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THE STOMACH AND ABDOMEN 
 
THE STOMACH AND 
 ABDOMEN 
 
 FROM THE PHYSICIAN'S STANDPOINT 
 
 BY 
 
 WILLIAM RUSSELL, M.D., LL.D. 
 
 EX-PKESIDENT ROYAL COLLEGE OF PHYSICIANS, EDINBURGH 
 
 PROFESSOR-EMERITUS OF CLINICAL MEDICINE, EDINBURGH UNIVERSITY 
 
 CONSULTING PHYSICIAN, ROYAL INFIRMARY, EDINBURGH 
 
 AUTHOR OF "arterial SCLEROSIS, HYPERTONUS, AND BLOOD PRESSURE" 
 
 AND " THE SPHYGMOMETER : ITS VALUE IN PRACTICAL MEDICINE " 
 
 NEW YORK 
 WILLIAM WOOD AND COMPANY 
 
 MCMXXI 
 
PRINTED IN GREAT BRITAIN 
 
 
i 
 fit 
 
 TO 
 THOSE BEYOND THE VEIL 
 
 TO WHOM I OWE MUCH 
 THIS WORK IS DEDICATED 
 IN REVERENT AFFECTION 
 
PREFACE 
 
 In submitting this work to the medical profession some words 
 of explanation seem to be necessary. The book is offered as 
 a contribution towards the elucidation of the disorders and 
 diseases of the stomach and other abdominal viscera as these 
 have to be dealt with by the family practitioner, and by the 
 hospital and consulting physician. 
 
 The writer was interested in these matters before the advent 
 of abdominal surgery, but the opening of that epoch gave a 
 motive and an impetus to abdominal diagnosis which had pre- 
 viously been lacking. That diagnosis could be tested on the 
 operating table, instead of the post-mortem-room table only, 
 gave a significance to abdominal diagnosis which had been 
 largely wanting. 
 
 As a teacher in a great medical school, and as a physician 
 to a great general hospital, where every type of disorder and 
 disease was admitted into the wards, it was a duty and a 
 privilege, not only to treat sick people, but to expound to 
 students the methods and the steps by which diagnosis was 
 reached, and on which treatment was based. The advent 
 of abdominal surgery opened up a new field for investigation, 
 and for teaching internal diagnosis, of which the writer took 
 as full advantage as circumstances allowed. 
 
 As time passed, and experience was tested and re-tested, 
 the problems became simpler and the points essential to 
 correct diagnosis clearer. This led to simplification in teach- 
 ing, and this book represents more or less fully the position 
 reached. There is little in it which has not been taught and 
 re-taught by the writer as abdominal cases were admitted to 
 his wards. Bits of clinical lectures and bits of cliniques, which 
 were written from time to time as new light arose, have been 
 
viii PREFACE 
 
 incorporated, and hence a certain amount of repetition has 
 been inevitable. 
 
 The records of cases by which the text is illustrated have 
 been deliberately restricted in number. Those which have 
 been used are sometimes of recent date, at other times of 
 earlier date ; they are used to illustrate the points which deter- 
 mined diagnosis — a diagnosis which in many of the cases was 
 checked in the operating room. 
 
 It is the hope of the writer that the book may be found 
 helpful in simplifying the problems of abdominal diagnosis. 
 
 WILLIAM RUSSELL. 
 
 Edinburgh, 
 April, 192 1 
 
TABLE OF CONTENTS 
 
 CHAPTER I 
 
 PAGE 
 
 The Relations of the Practitioner and the Physician to 
 
 AisDOMiNAL Diagnoses ....... ' 
 
 CHAPTER II 
 Examination of the Abdomen 5 
 
 SECTION L— THE STOMACH 
 
 CHAPTER III 
 
 Two Classes of Primary Disorder 8 
 
 Iiilroductoiy. Simplification of teaching. 
 
 CHAPTER IV 
 
 Disorders of Chemical Function ; that is of Digestion. Dimin- 
 ished Secretion of Gastric Juice, or Hypochlorhydria . 12 
 
 lutroductory: the relation of the stomach to carbohydrate and protein 
 food. Diminished secretion of gastric juice or hypochlorhydria. 
 Causes of diminished secretion. Clinical investigation and symptoms. 
 Illustrative cases. Complications of hypochlorhydria. Treatment of 
 catarrh and dilatation due lo hypochlorhydria. Treatment of hypo- 
 chlorhydria, 
 
 CHAPTER V 
 
 Increased Secretion of Gastric Juice. Hypersecretion or Hyper- 
 
 chlorhydria 33 
 
 Causation and pathology. The constitutional factor : an acid dyscrasia. 
 The determining causes of hypersecretion : food, alcohol, tea and 
 coffee, meat extracts. Symptoms ; the explanation of the symptoms. 
 An acid dyscrasia. Other immediate determining causes. Additional 
 comments. Illustrative cases : (a) acute, (d) longer duration. Com- 
 plications ; pyloric spasm ; atonicity and dilatation ; ptosis ; ulceration. 
 
TABLE OF CONTENTS 
 
 CHAPTER VI 
 
 PAGE 
 
 Air-Swallowing: commonly called Flatulent Dyspepsia . . 59 
 
 Illustrative cases. Abdominal rigidity in air-swallowing. Attacks of 
 severe cardiac depression. General remarks. Treatment. 
 
 CHAPTER VII 
 
 Method of Determining the Position and Size of the Stomach 
 
 IN the Recumbent Position ....... 68 
 
 Percussion — tympanicity. Auscultation and scratching. Bulging and 
 peristalsis. Palpation and splashing. Succussion. Auscultation- 
 succussion. The right border. The absence of physical signs of general 
 dilatation. Explanation of absence of succussion wave. X-ray exami- 
 nation. The right border in the recumbent position as a guide to 
 pyloric or duodenal lesion. 
 
 CHAPTER VIII 
 Dilatation of the Stomach — two Types 78 
 
 CHAPTER IX 
 
 Gastroptosis, or Dislocation of the Stomach .... 82 
 
 Definition. Anatomical considerations. Symptoms. Physical exami- 
 nation. Congenital pyloric stenosis as a cause of gastroptosis. Illus- 
 trative cases. Treatment, 
 
 CHAPTER X 
 
 Pyloric Stenosis, especially Congenital Stenosis in the Adult 97 
 
 Pyloric spasm. Effect of pyloric stenosis. Congenital stenosis a cause 
 of pyloric obstruction in the adult. Congenital hypertrophic stenosis 
 in infants. The medical position. The surgical position. The exist- 
 ence of the condition. Cases. Diagnosis: symptoms ; physical exami- 
 nation ; pyloric spasm or cramp ; chemical examination of gastric 
 contents. Summary. Treatment. The clinical pathology. Further 
 remarks on congenital stenosis and cases. 
 
 CHAPTER XI 
 
 Gastric Ulcer 
 
 Acute or recent gastric ulcer. Pathogeny. Preceding conditions. 
 
 Position of ulcer. Symptoms. Perforation. Reservations and wrong 
 
 diagnoses. Gastric ulcer heals. Treatment of acute ulcer. Chronic 
 ulcer. Illustrative cases. 
 
 117 
 
TABLE OF CONTENTS xi 
 
 CHAPTER XII 
 
 E StOI 
 
 Illustrative cases with comments. 
 
 PAGE 
 
 Malignant Disease of the Stomach 133 
 
 SECTION IL— THE PYLORUS AND DUODENUM 
 
 CHAPTER XIII 
 Introductory ........... 149 
 
 Hyperchlorhydria. Recurrence of attacks. Pain as a symptom. The 
 etiology of acute ulcer. Perforation. Healing of acute ulcer. Pyloric 
 and duodenal scar. Hyperchlorhydria and gastric atony. Effect of 
 scar and narrowing. Illustrative cases. 
 
 CHAPTER XIV 
 Duodenal Ulcer 159 
 
 Diagnosis : pain ; melaena. Absence of melaena. Persistent pain and 
 sagging. Symptoms masked. Illustrative cases. Causes of unsatisfac- 
 tory operation results : inefficient drainage ; continued haemorrhage or 
 pain ; recurrence of hyperchlorhydria or appearance of hypochlor- 
 hydria ; spastic stomach. 
 
 CHAPTER XV 
 
 Silent or Masked Duodenal Ulcer 170 
 
 Pain : its cause and its control. Cases. 
 
 SECTION III.— THE INTESTINAL TRACT 
 
 CHAPTER XVI 
 Enteroptosis : Splanchnoptosis or Visceroptosis . . . .177 
 
 Definitions. Occurrence in both sexes. Ptosis of transverse colon : 
 air-block. Ptosis of hepatic flexure. Complications. 
 
 CHAPTER XVII 
 Appendicitis 186 
 
 Pathology, diagnosis and indications for treatment. Anomalous 
 appendix cases. Cases illustrating wrong diagnoses. Conclusions and 
 summary. 
 
xii TABLE OF CONTENTS 
 
 CHAPTER XVIII 
 
 PAGE 
 
 iNfESTiNAL Obstruction: Malignant Disease of Rectum; Entero- 
 
 SPASM 212 
 
 Illustrative cases and comments. 
 
 SECTION IV.— THE CESOPHAGUS 
 
 CHAPTER XIX 
 The oesophagus 228 
 
 Obstruction. Symptoms. Etiology and diagnosis. Treatment. 
 Remarks. 
 
 SECTION v.— THE LIVER 
 
 CHAPTER XX 
 Jaundice or Icterus 233 
 
 Definition. Causes or varieties. Catarrhal jaundice : causes and 
 treatment. Obstruction by calculus. Gall-stone colic. Passing of 
 small stones. Treatment. Cholangitis or inflammation of bile ducts. 
 Cholecystitis and cholangitis due to gall-bladder calculi. Treatment. 
 Malignant disease of head of pancreas. Treatment. Hypertrophic or 
 biliary cirrhosis of liver. New-growths pressing on bile duct. New- 
 growth in duodenum at mouth of duct. Animal parasites leading to 
 obstruction. Illustrative cases. General considerations. Gall-stone 
 colic without jaundice. Illustrative cases. Conclusion. 
 
 CHAPTER XXI 
 The CiRRHOSES of the Liver 267 
 
 CHAPTER XXII 
 
 Malignant Disease of Liver 277 
 
 Cases. 
 
 SECTION VI.— THE SPLEEN 
 
 CHAPTER XXIII 
 
 Enlargement: Splenomegalv 280 
 
 Cases and comments. 
 
TABLE OF CONTENTS xiii 
 
 SECTION VII.— THE KIDNEY 
 CHAPTER XXIV 
 
 PAGE 
 
 Introductory : Movable Kidney. Perinephric Abscess . . 284 
 
 Movable, floating, and displaced kidney. Displaced and fixed kidney. 
 Symptoms. Pathology. Treatment. Acute perinephritis with abscess ". 
 Symptoms ; diagnosis ; treatment. Cases. 
 
 CHAPTER XXV 
 
 Renal Calculus and Renal Colic 292 
 
 Symptoms. Examination. Illustrative cases. 
 
 CHAPTER XXVI 
 Enlargemknt of the Kidneys 302 
 
 Hydronephrosis : examination and diagnosis. Pyonephrosis : cases and 
 diagnosis. Neoplasm : cases and diagnosis. The right kidney. 
 
 CHAPTER XXVII 
 Bacillus Coli Infection of the Urinary Tract 
 Illustrative cases and treatment. 
 
 324 
 
m: 
 
 THE 
 
 STOMACH AND ABDOMEN 
 
 CHAPTER I 
 
 THE RELATIONS OF THE PRACTITIONER AND THE PHYSICIAN 
 TO ABDOMINAL DIAGNOSES 
 
 In some quarters it has been thought that the time was not 
 far distant when the art of the physician would become 
 obsolete, and be replaced by the craft of the surgeon. If 
 this prediction be ever realized, the fault will lie at the door 
 of the physician and of the general practitioner. The latter, 
 however much more he may be, ought certainly to be a 
 physician, for to be a successful practitioner, in the only true 
 sense, requires that he should be a careful, and, as far as 
 possible, a skilful diagnostician. In no region has a more 
 debatable land arisen than in the domain of abdominal 
 disorder, and the cause of this is to be found in the following 
 considerations. 
 
 In the very nature of things, abdominal disturbances 
 come into the hands of the practitioner and the physician. 
 It is on them that the responsibility of diagnosis must 
 primarily lie, and it is imperative that they should rise to 
 their extended responsibilities in this department, and 
 devote themselves to the attainment of skill in the differential 
 diagnoses of abdominal diseases. That a gastric condition 
 may require a surgical operation no more removes it from the 
 domain of the practitioner and the physician than the diag- 
 nosis of an empyema lies with the surgeon because he is 
 called in to operate on it. The contrary idea is but an 
 illustration of what we have heard a good deal in other 
 
 I I 
 
2 THE STOMACH AND ABDOMEN 
 
 affairs — the want of clear thinking. The physician has 
 above all else, in the first place, to be a diagnostician ; and 
 the position assumed in some quarters that he is not to be 
 allowed to use his art in the disorders and diseases of- the 
 abdomen is as amusing as it is astounding. There is no 
 doubt that the opening up of abdominal surgery has made it 
 necessary to be more precise, more definite, more detailed in 
 diagnosis than formerly. We no longer ought to be satisfied 
 with such diagnoses as dyspepsia, hsematemesis, jaundice, 
 colic, intestinal obstruction, or peritonitis ; and the physician 
 ought to be the pioneer in that whole realm of diagnosis. It 
 is on him that the onus lies of indicating the paths and 
 methods of differential diagnosis in the abdomen, as he has 
 done in the thorax and in the brain. He is not justified in 
 abandoning his birthright in internal diagnosis. Whatever 
 difficulties there may be, or appear to be, they have to be 
 faced and solved. Not only ought he to be a pioneer in 
 differential diagnosis, but he ought to be more, for, however 
 much the surgeon's craft may be requisitioned by him, he 
 ought to know as well as the surgeon not only the diseases 
 which require operation, but also the kind of operation that 
 may or can be done in the various diseases with which he has 
 to deal. 
 
 Surgery is not an occult science, even such questions as 
 the advantages of anterior or posterior gastro-enterostomy 
 are copiously, not to say openly, discussed. The physician 
 knows, or ought to know, that if he diagnoses certain con- 
 ditions the treatment is gastro-enterostomy, although he 
 leaves it to the surgeon to select the method ; and that, if he 
 diagnoses other conditions, they are not worth meddling with 
 unless they can be removed entirely. Sometimes one gets 
 the impression that the physician thinks he ought not even 
 to know what the surgeon will do in any particular case, 
 which is as curious an affectation as if he professed ignorance 
 of how a broken leg or a dislocated shoulder is treated. If 
 the physician diagnoses gall-stones, he knows that the surgeon 
 to remove them has to use the knife ; the line of incision, and 
 whether catgut or silk be used, is no part of his responsibility ; 
 
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THE PHYSICIAN AND DIAGNOSIS 3 
 
 but it is absurd to affect ignorance of, or want of intelligent 
 appreciation of, the dexterity and skill of the surgeon in 
 carrying out all the details of the operation and the after- 
 healing of the wound. If the physician is confident of his 
 diagnosis he will not usually have any serious difficulty in 
 convincing his surgical confrere that operation is desirable. 
 
 Difficulty arises more frequently, perhaps, when the 
 surgeon recommends an " exploratory " operation, and the 
 physician does not agree with him. The " exploratory " 
 operation tends, indeed, to be so widely applied and advocated 
 that it threatens to be the bane of differential diagnosis. 
 It has its own place, but when it becomes the screen for 
 careless, ill-informed opinion, or for ignorance of methods, it 
 would be difficult to apply too damnatory criticism to it. 
 
 If the physician's first duty is diagnosis, his second is to 
 know enough of surgical methods and of surgical successes 
 to understand and appreciate what he recommends his 
 patient to submit to. These are essential for the physician, 
 whether he be a family practitioner or a hospital consultant, 
 for to him will assuredly come the vast majority of abdominal 
 cases. The responsibility is laid upon him of making accurate 
 and detailed diagnosis. There is really little difference of 
 opinion as to what treatment ought to be pursued in definite 
 conditions ; the whole difficulty lies in a weak diagnosis. 
 In abdominal disease and disorder there has been a large and 
 new demand upon the physician's skill, and there seems some- 
 times to be a tendency or a desire to shirk the new responsi- 
 bility. This is, no doubt, due to the idea that as abdominal 
 diagnosis was vague in the past it must remain so ; and the 
 champions of " exploratory " operation do little directly to 
 remove this idea. 
 
 It seems to me that not only for the sake of the physician's 
 reputation, but also for the maintenance of public confidence 
 in surgery, every effort ought to be made to secure increasing 
 accuracy in abdominal diagnosis — that is, in the differentia- 
 tion of conditions which present a certain surface-resemblance 
 to one another. The responsibility for such advance lies 
 chiefly with the hospital physician, for it is he who has the 
 
4 THE STOMACH AND ABDOMEN 
 
 material from which this can be made. When this is 
 done " exploratory " operations will be undertaken on 
 definite and enlightened principles. The practitioner and the 
 physician will then realize that the diagnosis of certain 
 conditions imperatively demands the recommendation of 
 surgical operation. It is not primarily a question of whether 
 to operate or not, but of accuracy and completeness of 
 diagnosis. " Exploratory " operation is really an acknow- 
 ledgment of failure ; and it is only by regarding it in this 
 light that advance can be made. 
 
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CHAPTER II 
 
 EXAMINATION OF THE ABDOMEN 
 
 Some introductory statement as to the general method of 
 examination of the abdomen seems to be necessary, but it 
 must necessarily be elementary. In the first place it may be 
 stated that the attention of the practitioner or physician is 
 drawn to the abdomen by the presence of symptoms referred 
 to this part of the body. The symptoms vary, however, so 
 greatly in different cases, and according to the organ affected, 
 that they cannot be referred to in detail here, but will be 
 dealt with when each organ is considered separately. 
 
 Physical Examination. — ^The physical examination of the 
 abdomen as a whole is carried out by means of inspection, 
 palpation, and percussion. 
 
 Inspection. — On inspection the following points are to 
 be noted: {a) the degree of fulness, or prominence, or of 
 localized protrusion ; {b) the movement of the abdominal wall, 
 or the absence of such movement, during respiration. When 
 fulness or distension is present the direction of bulging, 
 whether anterior or lateral, is noted. In persons with thin 
 abdominal walls the peristaltic movements of the stomach 
 or intestine may be visible, and the site and direction of such 
 movements ought to be noted. Such movements produced 
 by the stomach are frequently visible ; but the movements 
 of other parts of the intestinal tract may also be seen. These 
 movements can be stimulated by friction, by pinching, or by 
 tapping the skin. 
 
 The epigastric and abdominal reflexes may be taken at 
 this stage. 
 
 Palpation. — In palpating the abdomen the first point to 
 
6 THE STOMACH AND ABDOMEN 
 
 bear in mind is that there may be tenderness, either localized 
 or diffused. It is necessary therefore to begin palpation by 
 lightly passing the hand over the abdomen to determine 
 whether such tenderness is present or not. In some cases 
 there is marked general tenderness, giving rise to pain, no 
 matter how lightly the skin is touched. In such cases it 
 will be found that by passing the hand quickly but gently 
 over the surface the tenderness rapidly diminishes, and then 
 by pinching the skin at different points it can be determined 
 that the hypersensitiveness is a surface hyperaesthesia. 
 
 The measure of fatness of the abdominal wall can be 
 determined by grasping the wall between the thumb and 
 fingers, and it has to be remembered that the thickness of 
 fat in this position may be from three to four or more inches. 
 When this is the condition of the abdominal wall the palpation 
 of the viscera is attended with great difficulty and is some- 
 times impossible. When the abdominal wall is not loaded 
 with fat many points can be determined, and it is desirable 
 that a routine system of examination should be followed. 
 When pain is referred to any part of the abdomen, palpation 
 is usually begun there, but should never be confined to the 
 region to which the pain is referred. My usual procedure 
 is to begin in the right iliac region over the caecum : in 
 palpating here, as well as in the general palpation of the 
 abdomen, it is necessary to learn to palpate with the whole 
 hand flat on the abdomen, using the whole length of the 
 fingers as well as the palm of the hand in feeling for under- 
 lying structures. Rough and deep pressing with the points 
 of the fingers is to be carefully avoided. The reason for this 
 is that the structures to be palpated have not the consistence 
 of solid viscera. In the right iliac region the caecum can 
 usually be felt and its size and fulness can be determined. 
 By moving the hand upwards the ascending colon may also 
 be felt, especially if it contains faeces. The transverse colon 
 can, under similar conditions, be also frequently felt, and the 
 condition of the descending colon and pelvic colon may also 
 be determined. If tenderness be present at any point or 
 points, such points of tenderness are to be noted. The 
 
EXAMINATION OF THE ABDOMEN 7 
 
 central part of the abdomen is occupied by the small intestine, 
 and its coils cannot, as a rule, be felt. 
 
 The upper half of the abdomen requires careful examina- 
 tion, when the question of gastric or hepatic disorder has 
 to be considered : this includes the determination of the 
 position, size, and condition of the stomach, and the presence 
 or absence of local swelling or local tenderness of the body 
 of that viscus, of the pylorus, the duodenum, and the head 
 and body of the pancreas. The edge of the liver has also to 
 be investigated, to determine its position, its character, and 
 at the same time the character of the anterior surface of the 
 liver when the organ is enlarged. The gall-bladder is 
 investigated at the same time. In the left upper segment 
 of the abdomen it is to be noted whether or no the spleen' 
 can be felt projecting beyond the ribs. After these measures 
 have been taken, both loins ought to be palpated bi-manuallv, 
 with a view to determining the condition of the kidnej^ in 
 each loin, and in some cases to investigate the condition of 
 the hepatic and splenic flexures of the colon. 
 
 The hypogastrium is also to be palpated with a view 
 to ascertaining whether there is distension of the bladder, or 
 enlargement of any other pelvic organ. 
 
 Percussion. — Percussion ought to be carried out methodi- 
 cally, from above downwards, and then transversely at 
 the level of the umbilicus, and elsewhere as circumstances 
 may suggest. The points to bear in mind are the position 
 of such solid organs as the liver and spleen and the fact that 
 over the intestine the percussion sound varies as the bowel 
 is empty, or contains faeces, or gas. The percussion sound 
 may thus vary as the finger is moved from one coil to another. 
 When fluid is present in the abdominal cavity the percussion 
 sound is, of course, dull when percussion is made over the 
 fluid, and the note is altered as the position of the fluid is 
 altered by change of posture on the part of the patient. 
 
 Having made these introductory remarks, the detailed 
 examination of the different regions of the abdomen will 
 be dealt with as the organs occupying the regions are 
 considered. 
 
Section I.— THE STOMACH 
 CHAPTER III 
 
 TWO CLASSES OF PRIMARY DISORDER 
 
 Introductory. — Disorder of gastric digestion giving rise to 
 symptoms of less or more discomfort is one of the 
 commonest ailments to which men and women are subject. 
 In the consideration of these disturbances in the past clinical 
 enhghtenment was hindered by ignorance of gastric function, 
 and by the fact that surgical interposition was not even 
 dreamed of. The result was that gastric disorders had 
 crude names given to them — indigestion, dyspepsia, gastric 
 catarrh, gastritis ; and later gastric dilatation, nervous 
 dyspepsia, gastralgia, and so forth, were the terms used. 
 
 Within recent years knowledge and understanding of 
 gastric digestion has been put on a sound basis. Concur- 
 rently there has been a striking advance in the surgical view 
 of what the abdomen and its viscera will stand at the hands 
 of the expert operator. The change in surgical view and the 
 rapid application of a new faith and revelation to the varied 
 conditions inside the abdomen have amazed the world, and 
 given surgery a vast field for beneficent action. But it is 
 not necessary to enlarge upon what every one recognizes. 
 It is referred to now because of the great influence the appli- 
 cation of this recently acquired faith in the power of the 
 peritoneum and of abdominal viscera to tolerate surgical 
 manipulative skill, so long as it was aseptic, has had on the 
 remarkable advance which has been made in gastric and 
 abdominal diagnosis. The fact that the diagnosis of abdo- 
 minal conditions could be confirmed, or corrected, on the 
 operating table, instead of only on the post mortem table, 
 did much to stimulate precision in observation and gave it 
 
" SIMPLIFICATION OF TEACHING 9 
 
 a living interest which had been largely wanting. At the 
 outset of the abdominal epoch in surgery diagnosis was 
 so crude that the abdomen was often opened with the 
 deliberate object of making a diagnosis, and when practicable 
 of dealing with the condition that might be present. The 
 safety with which the mere opening of the abdomen was 
 attended encouraged and gave a measure of sanction to 
 the proceeding ; but it necessarily led to criticism, even if 
 it can hardly be said to have materially hindered progress. 
 The doctrine that the abdomen and all its diseases were in 
 future to be a region wholly in the hands of the operating 
 surgeon began to be promulgated even by physicians of 
 repute. This doctrine could not be accepted ; for internal 
 diagnosis in the abdomen belonged as much to the skiU and 
 art of the physician, and to the practitioner-physician, as 
 it did in the thorax and the head. It is here claimed that 
 it is the duty of the physician to make accurate abdominal 
 diagnosis. He ought to know which organ is giving rise to 
 symptoms and the disorder which the signs and symptoms 
 indicate. This also becomes the duty of the practitioner, for he 
 is usually the first to see sick people ; and he is not prepared 
 to open, or to advise to be opened, all abdomens which are 
 causing discomfort or pain. This book is written in the hope 
 that it may help towards the realization of this ideal of duty. 
 The indebtedness we owe to surgical skill and technique is 
 fuUy acknowledged, and will be referred to many times in 
 these pages. 
 
 Simplification of Teaching. — The stomach is the organ in 
 the abdomen which most frequently demands the attention 
 of the physician and the practitioner. We have reached a 
 stage when the teaching of gastric disorder and disease can 
 be put in line with recent knowledge ; when the investiga- 
 tions of physiologists can be applied to the interpretation 
 of the manifestations of disordered function ; and when 
 advance in surgical technique calls for reasoned accurate and 
 fuU diagnosis. The accuracy of diagnosis determines the 
 accuracy of prognosis ; and the experienced surgeon, so far 
 at least as the writer knows him, no longer wants to open an 
 
lo THE STOMACH 
 
 abdomen unless he sees a fair prospect of benefiting his 
 patient by so doing. B}^ the advances which have been made 
 in these directions the writer beheves that the teaching on 
 the stomach and on the whole abdomen can be greatly 
 simplified. Confining attention, in the meantime, to the 
 stomach, we must no longer lean upon such a term as 
 gastralgia, upon such a condition as dilatation, upon such 
 words as " indigestion " and " dyspepsia." These and other 
 words were good enough in their day as words for symptoms, 
 but they have no longer a diagnostic significance, for the 
 question now asked is, Why is there indigestion, or dj^spepsia, 
 or gastralgia, or even dilatation ? 
 
 The understanding of gastric disorder must be based, 
 firstly, on knowledge of normal function. And to that must 
 be added the recognition that all stomachs have not equal 
 functioning power or capacity. The practitioner of medicine 
 deals with individuals not with communities. Knowledge of 
 the average capacity of the community does not help him 
 unless he recognizes the individuals who are below the 
 average or above it. 
 
 The normal stomach performs two functions. It has a 
 secretion which disintegrates and transforms, that is digests, 
 protein foods. Its waves of muscular contraction mix the 
 food with the digestive secretions. 
 
 The secretions are the catalj^tic enzyme pepsinogen and 
 hydrochloric acid. The former only acts if the latter is 
 present, and hydrochloric acid by itself is of no use. 
 
 It has been shown that pepsinogen is not, as a rule, absent, 
 while it resembles other catalytic enzymes in being operative 
 in small quantity. On the other hand, experience has shown 
 there are great variations in the amount of hydrochloric 
 acid secreted. Here we get down to a basal fact, and we have 
 learnt that there may be too much or too little or none at all. 
 No other chemical deviation from normal occurs. It 
 becomes therefore a sound basis for the classification of 
 disordered function. We get a hyper and a hypo secretion. 
 The symptoms ranged round these are indigestion, dys- 
 pepsia, gastralgia, and so forth. Diagnosis and successful 
 
TWO CLASSES OF PRIMARY DISORDER ii 
 
 treatment are determined by the hyper or the hypo problem, 
 not by words of Greek or Latin derivation coined to give a 
 semblance of dignity to a feeling of discomfort or pain 
 consequent on taking food. 
 
 When we turn to such terms as atonic dyspepsia and 
 dilatation, we have terms which are commonly thought of 
 as applicable to failure on the part of the contractile mus- 
 cular coat of the stomach, which performs the mechanical 
 or mixing work of the viscus. All this class of term may be 
 used, but when gastric atonicity and dilatation are used as 
 diagnostic terms the position is unfortunate, Atonicity and 
 dilatation really depend on and are the result of error in 
 or deficiency in chemical function or power. 
 
 Two Classes of Primary Gastric Disorder. — The simple 
 proposition is thus reached that there are two classes 
 of primary gastric disorder, and that these two are deter- 
 mined by the amount of secretion of hydrochloric acid. 
 All other terms, which denote symptoms, become grouped 
 round disorder of the chemical function of the organ. 
 Believing that this is the basal fact upon which sound under- 
 standing of gastric disorder must rest, and the only founda- 
 tion on which our recent knowledge can be securely arranged, 
 the writer of these pages has long adopted and taught the 
 method of investigation which such a belief requires. It 
 is on this principle that the following pages are offered as a 
 contribution towards the simplification of gastric distur- 
 bances and the provision of a more scientific classification 
 than the text-books have hitherto entertained. 
 
 We begin, therefore, with the consideration of disorders 
 of function and deal with these under the two heads of 
 under-secretion and over-secretion. With these established 
 as clinical entities, it will be seen how they give rise to other 
 conditions, which are not in themselves entities, but have 
 been produced by primary disorder of chemical function, 
 and are in reality only symptoms, indicating the measure 
 of severity, or the duration of disordered function. 
 
CHAPTER IV 
 
 DISORDERS OF CHEMICAL FUNCTION ; THAT IS OF DIGESTION : 
 HYPOCHLORHYDRIA 
 
 Introductory : The Relation of the Stomach to Carbohydrate 
 and Protein Food. — ^The stomach performs two important 
 processes in the extended role of digestion. The principal 
 of these two is chemical, the other is mechanical. The latter 
 keeps the contents of the viscus moving and ensures their 
 thorough mixing with the chemical substances present in 
 the glandular secretions ; the one thus becoming the mechani- 
 cal complement of the other. 
 
 The chemical action of the gastric secretion is a strictly 
 limited action. It deals only with the protein elements of 
 the food. For some time after food is swallowed the ptyalin 
 of the saliva continues to act upon the carbohydrate of the 
 food, the act persisting until the gastric contents attain 
 a certain measure of acidity. This, however, appears not 
 to be an essential part of gastric function, the stomach 
 merely serving as a receptacle, while the necessary heat is 
 supplied as an integral factor of the living state. Disordered 
 gastric function, as will be presently seen, may interfere 
 with, and speedily arrest, ptyalin action ; but the stomach 
 secretion itself contributes nothing to the furtherance of 
 direct carbohydrate digestion, although it materially aids in 
 the disintegration of the carbohydrate food as it is received 
 into the stomach. It is of great importance to bear this 
 fact in mind, for it explains various of the phenomena 
 present in indigestion. 
 
 The motor function of the stomach plays an important 
 part in the trituration and churning of the soft carbohydrate 
 food ; but even this mechanical action has only a Umited 
 
DISORDERS OF CHEMICAL FUNCTION 13 
 
 effect upon such substances as lumps of potato, grains of 
 imperfectly cooked rice, the glutinous lumps of inefficiently 
 prepared sago or tapioca, and such like. It follows that 
 these substances, when introduced into the stomach in the 
 condition indicated, remain in the stomach practically 
 unaltered, and are often the direct cause of disorder and 
 discomfort. Their hurtful action is evidently a mechanical 
 one, for all observations go to show that lumps or masses of 
 food, of even relatively small size, not only do not pass 
 readily through the pyloric outlet, but by stimulating 
 the pyloric sphincter they lead to pyloric spasm, which 
 prevents, for the time, the passage of even the finely disinte- 
 grated and the partially digested portion of the stomach 
 contents into the duodenum. This is perhaps the most 
 important reason for insistence on the need of thorough 
 mastication, and explains the value of providing finely 
 divided, indeed minced, food, for many persons, who are often 
 erroneously regarded as suffering from primary gastric 
 disturbance. The pyloric sphincter is placed where it is to 
 prevent insufficiently disintegrated food from passing into 
 the intestine, and in this respect its action may be 
 accepted as necessary and beneficent. But while that 
 general proposition is true, it is necessary, in the considera- 
 tion of individuals, to bear in mind that, like all other 
 sphincters, the pyloric sphincter varies greatly in its sensi- 
 tiveness, quite irrespective of coarse local lesion, or demon- 
 strable local disturbance. It is one of the reflexes which in 
 some persons is readily called into action and readily becomes 
 exaggerated. Rough illustrations of this difference in 
 sensitiveness are available from the feeding habits of indi- 
 viduals, and of the effect upon them of common articles of 
 diet. Some persons swallow great lumps of potato without 
 conscious suffering as a result, while a similar proceeding on 
 the part of other persons is followed by discomfort, pain, 
 and other symptoms of severe gastric perturbation. This is 
 also true of many other carbohydrate foods, amongst the 
 more common of which are barley and rice. These cereals, 
 excellent and valuable as they are as foods, are often so 
 
14 ^ THE STOMACH 
 
 imperfectly cooked that they can be removed from the 
 stomach, unsoftened and unaltered, hours after they have 
 been partaken • of. This is more commonly met with in 
 the case of barley than in the case of rice ; and it is often the 
 essential cause of the indigestion so commonly complained 
 of as following a meal of which barley-broth formed a part. 
 The function of the stomach both as regards its treat- 
 ment of carbohydrate and of protein foods having been thus 
 defined, the consideration can now be taken up of the two 
 types of disorder of chemical function as these can be 
 determined by the physician. The first which will be 
 considered is under-secretion or diminished secretion of hydro- 
 cliloric acid, known also as h3^pochlorhydria, or even as 
 achylia ; while the second is known as over-secretion or 
 hyperchlorhydria, or as gastric succorrhoea. It will be seen, 
 as these two great types of gastric disorder are discussed, 
 that they give rise to secondary conditions, and that these 
 secondary conditions have hitherto been regarded as primary, 
 with the result that stomach disorder has been largely looked 
 upon from the standpoint of a S3rmptom such as " gastric 
 catarrh," with its furred or coated tongue, as " dilatation," 
 as " biliousness," as " chronic constipation," as " weak 
 digestion." It is here insisted upon that this way of looking 
 at stomach disorder has to be abandoned ; and that the 
 problems to be faced are, in the first place, the over activity 
 or under activity of gastric secretion ; in the second place, 
 the condition in which the carbohydrate and protein foods 
 enter the stomach ; and in the third place, the determination 
 of the normal digestive capacity of the individual with 
 whom we have to deal, and who is our patient, who has come 
 to us for relief and if possible for cure. 
 
 Hypochlorhydria 
 
 Diminished Secretion oJ Gastric Juice. — A diminished 
 secretion of gastric juice may be the result of a niunber 
 of different causes, and it is of practical importance to 
 determine so far as possible which cause has acted in the 
 
HYPOCHLORHYDRIA 15 
 
 particular case under consideration. While the recognition 
 of the determining cause occupies this position the 
 effect on gastric function is expressed in diminished or 
 arrested secretion, and slow and uncomfortable diges- 
 tion. The knowledge of this alteration in secretion not 
 only supplies the fact necessary for an intelligent under- 
 standing of the condition, but serves as the only reliable 
 guide in determining the nature of the remedial measures 
 to be taken. A diminution in the amount of secretion is 
 often found associated with catarrhal conditions of the 
 mucous membrane, in fact, so frequent is this association, 
 that it is often a matter, by no means easy to determine, 
 which of these has been the initial factor. The place of 
 catarrh as the causal factor will be considered later. At 
 present we have only to consider the condition in which 
 diminished secretion is the primary factor. In this connec- 
 tion it is necessary to postulate, what is so readily regarded 
 as a mere platitude, namely, that individuals differ greatly 
 in respect of gastric function, and the ease or efficiency with 
 which gastric digestion is performed. This embraces the 
 various factors included in the process, namely, the quantity 
 of secretion, and the relative proportions of pepsinogen 
 and of hydrochloric acid. Of pepsinogen and hydrochloric 
 acid the latter is the constituent which tends to be the more 
 variable in amount ; and the significance of this fact is 
 realized when it is remembered that the pepsinogen ferment 
 requires hydrochloric acid to activate it, that is, to develop 
 its digestive action. Further, a relatively small amount of 
 pepsinogen is sufficient for the conduct of gastric digestion 
 if it is supplied with abundant acid. Many observations 
 support this position. It follows as a consequence that 
 diminished secretion of gastric juice is rather a diminution 
 in acid than in pepsin, or at all events that deficiency in 
 acid is relatively greater and more important than deficiency 
 in pepsinogen. The gastric ferment in this respect corre- 
 sponds with other ferments or enzymes in possessing a 
 stronger action than might be expected from its bulk, if 
 placed in surroundings or under conditions favourable to 
 
i6 THE STOMACH 
 
 its action. Under unsuitable conditions its action is nullified 
 no matter liow large its quantity. When these facts are 
 applied to the individual it will be seen that the practical 
 aspect of diminished gastric secretion resolves itself into the 
 question of the quantity of acid secreted. 
 
 Individuals, however, differ not only in the amount of 
 gastric juice they secrete, but they also differ in the sensi- 
 tiveness of the secretion to conditions which are apparently 
 alike. Or, putting it differently, there are individuals whose 
 gastric secretion is so limited that influences which may not 
 be appreciable to the average person readily show with them. 
 The best illustration of this point is found in the effect of 
 milk in such individuals. Pawlow has shown in his wonder- 
 ful experimental work on digestion in dogs that milk has a 
 powerful inhibitory action upon the secretion of hydrochloric 
 acid. While allowing something for differences between 
 digestion in dogs and in man the observations on the former 
 have supplied facts which may with full assurance of their 
 accuracy be used for the explanation of some digestive 
 phenomena in man which are by no means uncommon. 
 There are for example, a considerable number of persons 
 who are conscious of stomach discomfort, with a sense of 
 fullness or of having a lump in the stomach, after taking 
 milk. The explanation of the feeling of discomfort is to 
 be found in the inhibition exerted by the milk on the gastric 
 secretion, particularly in the hydrochloric acid secretion, 
 and this to such a degree that the digestion of the milk is 
 much delayed, although not necessarily permanently 
 arrested. The milk-curdling ferment is present in sufficient 
 quantity to ensure the coagulation of the casein ; and it 
 is this coagulated casein, this milk-curd, and its undue 
 retention in the stomach which give rise to the discomfort 
 referred to. The disintegration and digestion of the curd 
 depends upon the peptonizing efficiency of the gastric 
 secretion, and, as has been already shown, this depends upon 
 the secretion of the gastric acid. We are thus provided with 
 the explanation of the fact known to every physician of 
 experience, that with some persons the administration of 
 
HYPOCHLORHYDRIA 17 
 
 milk becomes almost or altogether impracticable, either 
 because of the difficulty attending its digestion, or of a posi- 
 tive dislike to it on the part of the patient, due, not to some 
 stupid prejudice, as is not uncommonly thought, but to 
 an instinctive repulsion, almost certainly aroused by sen- 
 sitiveness to, or exaggeration of, the inhibitive action of this 
 particular food. Another interesting proof of the inhibitory 
 action of milk upon the gastric secretion is to be found in 
 the effect, readily produced in some persons, of taking 
 milk, usually by drinking it, along with flesh, particularly, 
 perhaps, beef and mutton. Many individuals have dis- 
 covered by painful experience that milk and flesh taken at 
 the same meal are a sure cause of indigestion to them. Such 
 persons, like many others, who have clear proof in their own 
 personal experience of the disastrous results of transgressing 
 certain clear laws, often seek to apply their law universally, 
 and with great insistence. Here, as in other departments of 
 popular knowledge, the individual experience, especially when 
 self-acquired, is commonly insisted upon as the universal law, 
 as the rule apphcable to every one, and obedience to which 
 will grant freedom from suffering to all. This, alas ! is not 
 the case. On the contrary, many persons take milk and meat 
 together with impunity, and even with greater comfort than 
 they take meat alone. The explanation of the difference is to 
 be found in the individual stomach constitution, in the chemi- 
 cal personality of the individual. Herein, indeed, lies at least 
 one broad line separating individuals as regards their digestive 
 functions ; and the interpretation of the difference is supplied 
 by Pawlow's investigations. One side of the line holds those 
 whose gastric secretion requires, and responds sufficiently, 
 but not over-much, to the stimulation of flesh, is not stimu- 
 lated by such a bland fluid as milk, but is inhibited by it. 
 The other side of the line holds those whose gastric secretion 
 is readily over-stimulated by flesh and by aU foods which 
 are at aU savoury, who as a consequence readily secrete 
 over-much acid ; with them milk seems to effect the restrain- 
 ing of hydrochloric acid secretion, while the degree of 
 restraint is only sufficient to prevent over-secretion. 
 
 2 
 
i8 THE STOMACH 
 
 Thus an equal balance is struck in such persons between 
 the food taken and the amount of secretion, and the combina- 
 tion, hurtful to others, is beneiicial to them. 
 
 This equilibrium is the normal standard for all, and its 
 maintenance implies digestive well-being, so far as the 
 stomach determines well-being ; and of its importance in 
 this respect there is no doubt. In the light of the foregoing 
 considerations it is easy to acknowledge the existence, 
 almost the necessary existence, of great individual differ- 
 ences. It is equally easy to say that these differences depend 
 upon, and are the expression of, chemico- vital idiosyncrasies. 
 The determining influences, or the steps of the chemico- 
 vital stimulation which result in over-secretion, may not, with 
 present knowledge, be readily followed in all cases, but this 
 side of the subject will be considered later. As regards 
 under-secretion it always seems more easy to explain it 
 than the contrary condition by simply assuming defective 
 stimulus, or lethargic functional activity. The point of 
 practical importance is the recognition of the facts indi- 
 cated, while their practical significance is that the individual 
 has to be considered individually ; it has at least to be 
 determined into which of two great groups he is to be 
 placed, and whether near the head or the foot of the group 
 to which he is relegated. 
 
 Causes oJ Diminished Secretion o! Gastric Juice. — The 
 causes of diminished secretion of gastric juice vary greatly 
 in their importance. At one efid stands malignant disease 
 of the stomach ; but this condition does not fall to be 
 more than mentioned at present. At the other end stand 
 the cases which are conveniently regarded as functional ; 
 cases in which deficiency differs in amount and is the 
 expression of a constitutional state which can be brought out 
 by dietetic causes such as have been already described, ^^'hen 
 this constitutional defect is present, it sometimes appears as 
 if there were an instinctive attraction to savoury foods, and 
 to pungent condiments, because of their stimulating influence 
 upon gastric secretion. This being the case the converse is 
 likewise true, namely, that partaking of the more bland and 
 
HYPOCHLORHYDRIA 19 
 
 imstimulating foods may be known to be followed by 
 symptoms of indigestion. Both the kind of food and the 
 quantity partaken of are factors of primary and fundamental 
 importance when dealing with persons in whom this idio- 
 syncrasy is pronounced. The next factor, the influence of 
 which is great, is the nervous factor, and this includes all the 
 numerous influences which act through the nervous 
 mechanism. Even the failure of certain foods to stimulate 
 gastric secretion is presumably a failure to initiate nerve 
 stimulation of sufficient energy to lead to secretion ; but, 
 putting this phase aside, there are other common nervous 
 influences which have a definitely inhibitory action upon 
 secretion. Various emotional disturbances are examples of 
 these. Grief, mental depression, anxiety, may all have this 
 effect. Physical or nervous exhaustion has a like result, so 
 has pain. Gastric catarrh, as has been already stated, is a 
 common cause of diminution in secretion no matter whether 
 the catarrh be acute or more chronic in type, while the cause 
 of the catarrh may be very varied, including over-eating as 
 well as the use of alcohol in excess. Lastly, there is the great 
 group of toxic conditions including the infective fevers, 
 embracing amongst others pneumonia, typhoid fever, 
 scarlatina, measles, malaria, and influenza. In all these 
 there is great lowering of gastric digestion due to arrested 
 or diminished secretion, which may, no doubt, be associated 
 with catarrh ; but even when there is no clear indication of 
 catarrh, the lowering or even arrest of gastric digestion is 
 present and is due probably to the definite influence of 
 toxaemic blood upon the secretory apparatus of the viscus. 
 If this common condition be overlooked, and the patient is 
 induced to partake liberally of nourishment, the result is the 
 speedy production of a gastric catarrh, which may seriously 
 complicate the original complaint, and embarrass its treatment. 
 The inability of the stomach to digest anything approaching 
 the quantities disposed of in health is accompanied with loss 
 of appetite, and this anorexia is in itself a safeguard to the 
 patient if ignorant although well-meaning officiousness does 
 not break down the valuable physiological barrier. 
 
20 THE STOMACH 
 
 Clinical Investigation and Symptoms 
 
 Before passing to a consideration of the symptoms 
 emphasis must be laid on the importance of subjective 
 phenomena — that is to say, the patient's history of his 
 experiences. This history is of first-rate importance in all 
 cases of stomach disorder, but it has to be obtained and 
 sifted with great care. It often requires tact, judgment, 
 and skill to get an intelligible story, and sometimes the 
 most expert skill as a sympathetic cross-examiner will 
 be baulked. In the great majority of cases, however, one 
 can succeed with patience, if the questions are put with 
 the understanding that there are the two great types of 
 digestive disturbance. 
 
 Symptoms. — The symptoms due to hypochlorhydria vary 
 within considerable limits, as might be anticipated, in view 
 of the fact that they result from delay or arrest of gastric 
 digestion and the retention of food in the stomach. The 
 presence of food which has not effectively stimulated secre- 
 tion soon gives rise to " a feeling of heaviness," or of a " load," 
 referred to the stomach. This discomfort is not a true pain, 
 although to begin with the patient may so describe it. Later 
 there is a feeling of distension also referred to the stomach, 
 and due evidently to accumulation of air or gas, the eructa- 
 tion of which gives temporary relief. If any other part of the 
 stomach contents is eructated there is usually an absence of 
 complaint of sourness or acidity In other cases the symptom 
 is described as " a lump " or " ball " referred to " the pit of 
 the stomach " — that is, to the epigastrium, or to behind the 
 sternum. The feeling of heaviness and of distension or 
 fullness usually comes on soon after food, but in other cases 
 it is delayed ; it may last for hours, and the sense of discomfort 
 and oppression may only get relief by vomiting. When the 
 condition has lasted for some time the tongue becomes furred, 
 the appetite impaired, and the bowels irregular and usually 
 constipated. There may be vomiting after every meal, but 
 only in severe cases. In such cases, although there is much 
 general discomfort, want of vigour, and of interest in all 
 
HYPOCHLORHYDRIA 21 
 
 things, there is not the same degree of mental and physical 
 inability as is met with in cases of hyperchlorhydria. 
 
 Symptoms Indefinite or Delayed. — In some x:ases the symp- 
 toms, while definitely digestive, are very indefinite. In 
 this respect they may be in striking contrast to those of 
 hyperchlorhydria. The times and duration of discomfort 
 are not only indefinite, but the patient's statements are 
 frequently so interlarded with views and explanations that 
 the utmost patience and tact on the part of the physician 
 may fail to elicit a history worthy or indeed capable of 
 record ; and yet the very indefiniteness, and the entire 
 absence of such a history as can usually be obtained from 
 a patient suffering from hyperchlorhydria, will often lead 
 to a provisional diagnosis of hypochlorhydria. In other 
 instances the symptoms are delayed, or do not become 
 intolerable until late in the day, and may continue and 
 even become more severe after the patient has gone to bed. 
 
 The following cases, taken from many, illustrate the 
 foregoing propositions. 
 
 Case 1. — This man was in the prime of life and looked 
 well nourished. He complained of weakness in the legs and 
 inability to walk any considerable distance, half a mile 
 tiring him. He also complained of discomfort after taking 
 food, and that recently he had vomited. 
 
 Symptoms and History. — On questioning him it was 
 ascertained that the gastric symptoms consisted of a feeling 
 of the food he took lying as a heavy load in the stomach ; this 
 continued all day. This discomfort led him to consult a 
 medical man of good repute living near where he was spending 
 a holiday on account of his health. The doctor put him on 
 " light diet." Before that his diet had consisted of porridge 
 and milk followed by tea for breakfast ; fish for mid-day 
 dinner three days a week, lentil soup and semolina the other 
 days ; a plain tea at night. He volunteered the information 
 that he had not taken butcher meat for six months. A week 
 after his first visit to the doctor he vomited about 8 p.m., 
 having only taken breakfast and dinner. The vomit 
 consisted of the bread and milk he had taken at i p.m. A 
 
22 THE STOMACH 
 
 fortnight later he vomited four times one day, the vomit 
 consisting of the food he had taken. At this point he was 
 sent to see me at the infirmary. There was no history of 
 flatulence, of eructations, or of constipation. The tongue 
 was fairly clean and moist. He had lost 28 lb. in weight 
 during the preceding six months. In spite of this loss he 
 was still a big, heavy man, rather soft looking, but not 
 cachectic. Examination of the abdomen gave no evidence 
 of gastric dilatation such as is present when there is pyloric 
 obstruction from any cause. The stomach was indeed 
 normal in size and position, the pylorus was not palpable, 
 and nothing abnormal was to be felt in any part of the 
 abdomen. 
 
 The leading points in this case were : (i) Food lying like 
 " a load " in the stomach ; (2) that he had dieted himself 
 along certain popular lines without benefit ; (3) that he 
 had lost 2 st. in weight in six months ; (4) that there had 
 been vomiting ; and (5) the absence of stomach dilatation. 
 
 The provisional diagnosis was (a) simple hypochlorhydria, 
 or {b) malignant disease of the body of the stomach. The 
 next step was the examination of the stomach contents. 
 These were obtained the following morning after a test meal 
 and showed an entire absence of free hydrochloric acid. 
 From the history of the case the diagnosis was the former of 
 the two alternatives. The patient got prompt and complete 
 relief from his troubles. 
 
 Case la. — Miss M., aged 30, was sent to me with a history 
 of headache, constipation, depression, and as a difficult 
 neurotic. She herself dwelt much upon her digestive 
 discomforts, and her strongly expressed opinion was that 
 life would be quite pleasant if her digestive system could be 
 put right. She had, as is common in digestive inefficiency, 
 beliefs about her liver being sluggish and so forth. The 
 symptoms, as dwelt on by her, pointed to stomach discomfort 
 with heaviness and flatulence, which did not present the 
 relationsliip to meals which hyperclilorhydria presents. 
 The fundus of the stomach was enlarged. The next step 
 was to get the stomach contents. A test meal was given. 
 
HYPOCHLORHYDRIA 23 
 
 and showed no free hydrochloric acid. On a second occasion 
 the stomach residuum was removed shortly before luncheon ; 
 it also showed entire absence of free acid. 
 
 This patient had been dieted on the lines commonly 
 adopted whenever digestive trouble is complained of, but 
 without benefit. She was now treated on the lines indicated 
 later, and the bowels were regulated by means of a simple 
 laxative. She improved rapidly, and lost all the neurotic 
 manifestations which had been so pronounced. Her friends 
 were surprised at the change in her appearance. In 
 three weeks she left the nursing home satisfied as to the 
 radical change in her condition. She continued to be well 
 when last heard of. 
 
 Case 2. — M. M., aged 23, from the North of Scotland, was 
 admitted to my ward at the request of a benevolent lady on 
 whose property the girl lived. She had been an invalid for 
 two years, and had been kept in bed most of the time. Her 
 own statement was that she had an " ulcerated stomach." 
 The stomach trouble had begun two years before, with pain 
 or discomfort after food ; later she began to vomit food, and 
 she stated that sometimes there was blood in the vomit. 
 There had been no blood for two months. She had been 
 treated by various doctors, and she had been in a local 
 hospital for two months, without apparent benefit. Her 
 domestic surroundings -were good ; she helped her mother 
 with the house work, and she used to walk and cycle a good 
 deal. She was intelligent, animated, fairly well nourished, 
 and not anaemic. The height was 5 ft. 2 in., and the weight 
 8 St. 6 lb. Appetite was good, but she was afraid to eat 
 because of the pain which followed. She lived largely on 
 Benger's food and Allenbury's diet, an occasional cup of 
 tea, and some toast. The pain was referred to the epi- 
 gastrium ; it was constant, but worse half an hour after 
 taking food. Vomiting usually took place when the pain 
 was most severe, and somewhat relieved it. Lately she 
 had vomited more, especially if she deviated from her 
 strict dietar}^ The vomit came up easily, and was not 
 preceded by nausea. She suffered from constipation, for 
 
24 THE STOMACH 
 
 which she took compound hquorice powder every few 
 da3^s. 
 
 On careful inquiry after admission, the S3niiptoms were 
 not definite enough to warrant a diagnosis of gastric ulcer. 
 With symptoms of this kind associated with constipation the 
 first procedure we adopt is to have the colon thoroughly 
 washed out by means of a douche can. She was given light 
 diet, consisting of fish, farinaceous foods, and milk. The 
 stomach discomforts continued, but there was no vomiting. 
 Examination of the abdomen revealed nothing abnormal ; 
 there was no gastric dilatation or ptosis, and not a suspicion 
 of tenderness in the caecal region. 
 
 A test meal was then given, and on removal showed entire 
 absence of free HCl. She was at once dieted and treated as 
 a hypochlorhj^dric. The sudden improvement in her con- 
 dition amazed her, and in a few days her discomforts and 
 pains had wholly disappeared. She was allowed out of bed, 
 and rapidly regained the health and vigour she had enjoyed 
 before her two years of invalidism. After a short stay in 
 hospital she returned home and has continued well. 
 
 Case 3. — This case was one of special interest, as it 
 occurred in a soldier during the war, the malady keeping him 
 at home when he wished to be at the front. He may be 
 designated Captain X., he was 30 years of age, and had been 
 a civilian. The story he gave was that for j^ears he had 
 suffered from stomach trouble, and had to be very careful 
 of his feeding. He had been dieted and treated by several 
 doctors and physicians without benefit. The main symptom 
 was discomfort and pain coming on about 10 p.m. and lasting 
 until 2 a.m. He was fairly comfortable in the forenoon and 
 the afternoon. There was no nausea or vomiting, but 
 considerable gaseous eructation. The bowels were regular. 
 He mixed up his symptoms with ideas about kinds of food, 
 and the way in which his food was cooked. WTien he tried 
 to live on army rations he got much worse, and the state of 
 his digestion was such that he was not allowed to go overseas. 
 He was kept at home as an instructor. He thought he 
 suffered less when living in his own house and with his own 
 
HYPOCHLORHYDRIA 25 
 
 cook to prepare his food. He complained bitterly of his 
 condition hindering his work and limiting his activities. 
 His bad nights made his day duties a burden which he often 
 felt to be more than he could bear, and yet by sheer force of 
 will he kept at it. 
 
 Examination. — He was poorly nourished, the cheeks were 
 slightly hollowed, and there was a dusky shadow under the 
 eyes. The abdominal wall was thin. The epigastric and 
 abdominal reflexes were active. No peristalsis was visible. 
 There was no tenderness on palpation in any region of the 
 abdomen ; but palpation promptly produced loud splashing 
 over the stomach, which extended to the level of the 
 umbilicus ; its fundal end was enlarged, but the right border 
 did not extend beyond the middle line. This was the 
 condition three hours after the midday meal, which had 
 consisted of cold chicken, farinaceous pudding made with 
 milk, and a tumblerful of milk. By means of the stomach 
 tube some ounces of stomach contents were withdrawn, which 
 consisted of finely divided starch, curd of milk, and pieces of 
 softened chicken ; it showed complete absence of free 
 hydrochloric acid. 
 
 Treatment. — ^The diet was regulated in accordance with 
 this finding, and a prescription was given containing dilute 
 hydrochloric acid, liquor strychninae hydrochlor., and com- 
 pound infusion of gentian. This visit was on May i6th. 
 
 He came to see me again on June ist. He looked much 
 improved, and his own account was that the pain had dis- 
 appeared, he had no discomfort after food, he was sleeping 
 well, and was more energetic and lively. The weight was 
 9 St. 12 lb. He was seen two hours after his midday meal 
 and the stomach splashed on palpation. 
 
 On June 6th I again saw him, at 1.15 p.m., before the 
 midday meal, and found the stomach empty. His own state- 
 ment was that he had not had " a touch of pain " since his 
 first visit to me, and that he was sleeping well. On June 27th 
 I saw him again. His weight was 10 st. 4^ lb., he was quite 
 free of gastric or other discomfort, and was full of gratitude 
 for increased vigour, and comfort in his work. 
 
26 THE STOMACH 
 
 The history in this case pointed to hypochlorhydria, but 
 the diagnosis from symptoms alone may be so unsatisfactory 
 that it is unwise to be guided by them, especially as the means 
 of attaining certainty are within easy reach when the stomach 
 tube can be used. In this patient I used the stomach tube 
 at our first interview, and a correct diagnosis was at once 
 established, as malignant disease of the body of the viscus 
 was not a reasonable proposition. The diet of white flesh, 
 as chicken and fish, farinaceous puddings, and milk, which 
 had been prescribed and conscientiously adhered to, under 
 the manipulative skill of an expert cook, was departed from. 
 The whole idea of bland and soothing nourishment was 
 revolutionized ; milk was stopped, farinaceous puddings 
 were to be taken with stewed fruit, all kinds of flesh were 
 allowed, but they were to be minced and eaten with stimulating 
 condiments and sauces. Acid and strychnine were also given 
 to help and to encourage gastric secretion. By these 
 measures stomach function and secretion were stimulated, 
 and the result was complete removal of the symptoms which 
 were making work a burden and life a struggle. 
 
 The next case illustrates a combination of hypochlor- 
 hydria and air swallowing persisting after removal of the 
 appendix. 
 
 Case 4. — Mr. W. C, aged 34, a mercantile marine officer, 
 had been at sea for fourteen years, and consulted me on 
 September 6th. His complaints were obstinate constipation, 
 the bowels never moving without a purgative, and frequent, 
 almost daily, vomiting. The vomiting had become more 
 frequent, and sometimes occurred two or three times a day. 
 His appendix had been removed in Bombay eighteen months 
 before I saw him, but without any relief to his symptoms. 
 
 On questioning him it was ascertained that he had a feeling 
 of weight and heaviness half an hour after food — " a feeling 
 like lead " in the lower half of the abdomen. There was no 
 pain. He often felt sick before breakfast, and if he did he 
 might vomit a quarter of an hour to half an liour after break- 
 fast. The vomiting occurred especially if he took anything 
 hot, cold not being so bad in this respect. He might vomit 
 
HYPOCHLORHYDRIA ,^,;[ ^^ 
 
 again after the midday meal. He never vomited after 4 p.m. 
 The vomiting was preceded by some degree of nausea, but 
 it did not appear to be great. The motions were dry and 
 lumpy. 
 
 Examination. — He was rather pale and flabby looking, 
 but stout. He had never had malaria or other fever in the 
 East. The scar of the appendix operation was good. The 
 fundus of the stomach was enlarged. The descending and 
 pelvic colon were felt small and contracted. The urine 
 contained neither sugar nor albumin. The brachial systolic 
 pressure was 135 mm. Hg. The apex of the heart was 
 slightly to the left of its normal position. From the fore- 
 going facts it looked as if it were only necessary to find a 
 suitable laxative to secure the removal of the symptoms. 
 With this object in view I prescribed a pill containing 2 
 grains each of extract of cascara and extract of taraxacum 
 with I grain of extract of belladonna, to be taken at night. 
 
 He returned to me on September 26th, when he informed 
 me that half a pill gave him a free motion every day, but 
 that there was no improvement in other symptoms ; that 
 he vomited daily, sometimes two or three times ; and had 
 much flatulence after taking food, feeling " blown up " with 
 it, and that he got relief when he got it up. From the account 
 he gave it seemed clear that he was an air-swallower. He 
 was examined by X-rays and watched by the screen. The 
 screen picture was not satisfactory, but the fact of air- 
 swallowing was estabhshed by his sense of distension after 
 the bismuth was swallowed, and by the visible and marked 
 projection of the stomach, the projection disappearing after 
 he belched up wind. I asked him to return to see me the 
 following day, September 27th, and to bring his vomit for 
 examination. On September 28th he brought me another 
 specimen. On both occasions the vomit consisted mainly 
 of disintegrated cereal food, some milk curd, etc. On both 
 occasions it contained no free acid. I prescribed dilute 
 acid, strychnine, and gentian ; stopped milk and farinaceous 
 puddings ; put him on meat and fish, to be eaten with 
 savoury sauces, and stewed fruits. He reported himself on 
 
28 THE STOMACH 
 
 October 2nd. He stated that the first dose of the mixture 
 I had prescribed had reheved him, that he had no more 
 vomiting or nausea, and practically no flatulence. He felt 
 quite well, and stated that the bowels were regulated by one- 
 fourth of the pill I had ordered for him. He was naturally 
 much gratified at the complete removal of symptoms, which 
 he had suffered from more or less for the fourteen years he 
 had been at sea. An interesting and important observation 
 made this day was that the brachial pressure, instead of being 
 135 mm. was only 115 mm. Hg. I saw him again on October 
 8th and was assured that complete relief was maintained. 
 
 Remarks. — The points of special interest in this case were 
 (i) the air-swallowing, which stopped when the hypochlor- 
 hydria was successfully treated ; (2) that it was not a case 
 of " appendicular dyspepsia," which presumably was the 
 diagnosis which led to the removal of the appendix ; and 
 (3) the fall of 20 mm. Hg when the gastric condition was 
 rectified. 
 
 Complications o£ Hypochlorhydria 
 
 The word complication is used here to mean certain 
 manifestations which result from the under-secretion of 
 what we may still speak of as gastric juice. It is, how- 
 ever, to be always borne in mind that when under-secretion 
 is spoken of by the physician he may mean in one case an 
 absolute reduction and in another case a secretion insuffi- 
 cient for the food which has been taken. Questions of 
 absolute amounts or of average amounts do not really 
 help him. To him the question is why has his patient the 
 symptoms of gastric disorder, or, to use the popular word, 
 of indigestion ? Is the indigestion the result of a diet larger 
 than the particular stomach is ever able to deal with ; or is 
 there merely a temporary failure of secretion ; or is there a 
 combination of both factors ? Whichever it be the results 
 upon the stomach are the production of catarrh with the early 
 supervention of dilatation. It is at this point that diagnosis 
 is made of " gastric catarrh," or "gastric dilatation," or of 
 a combination of the two conditions, when as a matter 
 
HYPOCHLORHYDRTA 29 
 
 of fact these terms merely indicate the recognition of a 
 consequence, and is not in itself the primary malady. It is 
 this way of looking at these cases which has to be changed. 
 It is the time-honoured way, no doubt, and it is wonderfully 
 persistent, but, in view of our increased knowledge of the 
 stomach and of digestive processes it is time these terms were 
 regarded as word-relics of the past, with the same value 
 as dropsy and jaundice and other words which indicate a 
 symptom or a sign of an antecedent malady. 
 
 Treatment 0! Catarrh and Dilatation due to Hypoehlorhydria 
 
 When this is realized, treatment is guided by the general 
 principles which underlie all intelligent therapeutics. Ca- 
 tarrh is the result of local irritation, for we leave out 
 of account here such causes as the general toxaemia of fevers 
 and other infective maladies. The irritation is caused by 
 what has been swallowed ; it may be alcohol in some 
 form; but it may be food, or what at least is within the 
 pale of dietetic substances. It may be caused by the bad 
 cooking of the food taken ; by the physical character in 
 which the food, even when well cooked, is passed into the 
 stomach ; and by the quantity being excessive for the 
 individual. The undue retention of undigested or partially 
 digested food leads to catarrh, and individual stomachs are 
 sensitive to this form of irritation. And at the back of all 
 these, and apart from them, is the question of a secretion 
 which may be temporarily, but may be always insufficient, 
 and definitely requiring stimulation and help for the due 
 performance of a reasonable amount of digestive duty. The 
 first principle in treatment is to remove or to alter dietetic 
 conditions which are associated with the catarrh, and here 
 elementary facts have to be enforced. The food has to be 
 reduced in amount, it ought to be finely divided, and, as we 
 are dealing with catarrh the result of hypoehlorhydria, milk 
 ought to be excluded from the dietary. The food ought to 
 be savoury and the meals may be followed by the administra- 
 tion of a mixture containing acid, strychnine, and an aromatic, 
 the acid ingredient of which may require to be increased in 
 
30 THE STOMACH 
 
 amount. If the catarrh is very pronounced, with thickly 
 furred tongue, treatment may be begun by giving compound 
 tincture of rhubarb, with small doses of the bicarbonate and 
 saUcylate of soda, half an hour before food, and it may be 
 given in hot water. The colon ought to be emptied, and 
 this can be effected by lavage if necessary, or by a laxative, 
 repeated at intervals of hours. Personally, I rarely use 
 salines for this purpose, preferring combinations of cascara 
 or phenol phthalein with taraxacum ; in other cases liquid 
 parafhn is given, and in still other cases small doses of castor 
 oil. When the catarrh has subsided, fuller doses of acid are 
 required with food and the diet has to be stimulating. 
 
 Dilatation is considerable but not usually great, and it is 
 mainly of the fundus. It is the result of atonicity of the 
 muscular coat due to the catarrh, or consequent on the too 
 prolonged retention of gastric contents. Atonicity and dila- 
 tation are the results of unduly retained contents in the 
 stomach, as is common in other hollow viscera. The condi- 
 tion is recovered from under the line of treatment indicated ; 
 but it may be slowly recovered from, and tonic treatment 
 must be combined with meals small in bulk and easily 
 digested. The treatment has to be persevered with until a 
 satisfactory result has been attained. 
 
 Treatment o£ Diminished Gastric Secretion 
 
 The treatment of the individual case hangs upon the 
 accuracy of the differential diagnosis. When the symptoms 
 of indigeston are due to such a constitutional state as has been 
 described all that may be necessary for the relief and cure of 
 the condition may be a reduction in the quantity of food 
 taken, especially of the more purely protein foods. Close atten- 
 tion ought to be paid to the condition of the bowels, especi- 
 ally to their daily complete evacuation. A tonic laxative such 
 as cascara may be used in small doses taken at each meal or a 
 single larger dose may be given at night. Most cases are 
 benefited by a course of acid and of bitter tonics taken before 
 meals. These include nux vomica, or its alkaloid strychnine ; 
 the various dilute acids as hydrochloric, nitric, and sulphuric ; 
 
HYPOCHLORHYDRIA 31 
 
 the vegetable bitters as quassia and calumba, or the more 
 aromatic bitters as gentian and cascarilla. All these tend 
 to stimulate gastric secretion and to favour digestion ; but 
 they are necessarily more efficacious if at the same time the 
 diet is regulated. As regards diet general principles only 
 can be laid down. The more purely protein food ought to 
 be finely divided, savoury in character, and small in amount. 
 The carbohydrate foods are usually well borne, if moderate in 
 quantity and if prepared in attractive and palatable ways, 
 and slowly and carefully eaten so as to be well mixed with the 
 saliva. Milk, for the reason already stated, has to be used 
 with caution, and never in association with fish or other 
 flesh. Pepsin preparations, as the acid glycerine of pepsin, 
 given after meals is often an efficient and pleasant mode of 
 administration. Extreme cases are occasionally met with 
 where large quantities of acid are not only well borne but 
 are even curative, A medical friend assures me that, when 
 he is seized with an attack of indigestion his invariable 
 remedy is large doses of acid, and that he always succeeds in 
 promptly curing the attack by this means. My own experi- 
 ence leads me to believe that this kind of case is not common, 
 but more will be said on this point when considering the reverse 
 condition, namely, hypersecretion. 
 
 In the toxic cases, that is in the cases where the gastric 
 inability is but an accompaniment of a general systemic 
 infection, nourishment has to be given in small quantities, 
 at regular and short intervals as the stomach can tolerate 
 it. The form in which nourishment is given is indeed of 
 great importance and requires care and judgment in its 
 determination. Milk stands at the head of the list as a model 
 food in such cases, but it often requires to be peptonized. 
 Skimmed milk can be tolerated sometimes when unskimmed 
 milk disagrees. Milk curdled with rennet is sometimes taken 
 willingly by patients who dislike or become tired of milk in 
 the fluid form. Milk may also be mixed with barley water, 
 which contains a small amount of nutriment ; or with soda, 
 potash, or seltzer water, which of course contain no nutri- 
 ment. The addition of any aerated water makes milk more 
 
32 THE STOMACH 
 
 acceptable to some palates. The milk itself may be aerated 
 by means of a sparklet or in an ordinary gasogene, and be 
 drawn off as required. Thin gruel made from oatmeal is a 
 valuable food and can be mixed with milk. Thin arrowroot 
 may also be given, prepared with milk ; both it and oatmeal 
 gruel ought to be well boiled and entirely free of lumps, and 
 their digestion may be facilitated by adding liquor pancreati- 
 cus after they are cooked. Beef-tea, chicken-tea and meat 
 essences generally may also be given for their stimulating 
 effect ; but they ought to be concentrated and given in 
 small quantity ; and it is to be remembered that they contain 
 very little, and sometimes no nourishment whatsoever. 
 Their action as stimulators of digestive processes and as 
 providing certain extractive materials whereby nutrition is 
 indirectly aided, gives them a value beyond their direct 
 nutritive value. Meat jellies occupy the same place. Jellies 
 can, however, have their nutritive value enhanced by pre- 
 paring them partly with milk or with white of egg. Egg 
 can also be used mixed with gruel, arrowroot, or milk, but in 
 no case ought egg to be added until the medium to which it is 
 added has cooled sufficiently to prevent the albumen coagu- 
 lating. \Vhen the digestive powers are returning both the 
 yolk and the white may be given, either whisked or mixed 
 with milk and cooked to form a custard pudding. 
 
CHAPTER V 
 
 increased secretion of gastric juice 
 Hypersecretion or Hyperchlorhydria 
 
 Introductory ; General Considerations. — The consideration of 
 increased secretion of gastric juice might theoretically be 
 taken up under the two headings of increase in the secretion 
 of pepsin, or of its immediate precursor pepsinogen, and 
 of hydrochloric acid. Practically, however, an increased 
 secretion of pepsinogen may be set aside, as little if 
 anything is known of the condition. 
 
 Notwithstanding this it may be assumed that the amount 
 varies in different individuals, being greater in some than in 
 others ; and that its free secretion will no doubt expedite 
 digestion if its activating acid be also freely secreted. On the 
 other hand, an increased secretion of hydrochloric acid is of 
 much importance, for it is usually if not always associated 
 with marked clinical manifestations requiring the attention 
 of the physician. It has been established that the gastric 
 secretion in health is called forth in proportion to the amount 
 of protein food which has to be dealt with ; and however 
 subtle the character of this arrangement may be, it is but 
 part of that wonderful chain of co-operation and adaptability 
 which Pawlow has shown to be linked all through the digestive 
 system. This normal state may, however, be disturbed so 
 as to lead to hypersecretion, that is to an amount of secretion 
 over and above what is required for immediate needs. In 
 these circumstances some of the acid remains free, that is 
 uncombined or unincorporated with the food, and it is this 
 free acid which gives rise to the discomforts which shall 
 presently be referred to. This over-secretion, that is secretion 
 
 33 3 
 
34 THE STOMACH 
 
 over and above the amount required for the digestion of the 
 protein taken, is known as hyperchlorhydria. The per- 
 centage of free hydrochloric acid is of comparatively little 
 importance from the practical side of clinical medicine, as 
 will presently be shown. Not only does secretion over and 
 above what is required take place, but secretion may be con- 
 tinuous, that is may continue when there is no food in 
 the stomach with which to combine. The term gastric 
 succorrhcea is confined to this condition. 
 
 The Causation and Pathology. — Gastric hyperacidity, as 
 manifested by heartburn, acid eructations, or water-brash, 
 has been long known as a common form of gastric derange- 
 ment, without definite knowledge being possessed regarding 
 its essential nature. At a later, and indeed at a compara- 
 tively recent date, the disorder came to be looked upon as 
 due to fermentation of the stomach contents. This explana- 
 tion was no doubt inevitable at a time when the profession 
 was learning its first lessons as to the true nature of fermenta- 
 tive processes, and of the part fermentation took in the 
 production of the processes and manifestations of diseased 
 or disordered action. It would indeed be still unwise to 
 regard this view as having been superseded in all quarters by 
 more accurate knowledge. Knowledge has, however, been 
 advancing both in regard to the physiology and the disturb- 
 ances of digestion. Part of this advance has shown that 
 there occurs a true hypersecretion of the normal acid secreted 
 by the organ, and clinical investigation has established this 
 as a morbid condition which can be differentiated and treated 
 as such. It is to this condition the appellation hyperchlor- 
 hydria or hyperchylia is applied, and which we are here 
 considering. 
 
 When we inquire into the cause of the hypersecretion it 
 is found that, as might be expected, there are many causes 
 which may be regarded as th-e determining agents or factors, 
 any one of which may be the particular factor in the individual 
 case. The marvel is that ordinarily the adjustment is 
 so accurate between the kind of food taken and the amount 
 of secretion poured out, for the normal state appears to be 
 
HYPERCHLORHYDRIA 35 
 
 very finely balanced. The causes of hypersecretion may be 
 considered as follows. There is first a predisposition, which 
 can only be regarded as constitutional. Free glandular 
 secretion, under moderate stimulation, is a character of 
 various glands in different individuals, and is by no means 
 confined to the gastric glands; just as, we have seen, a 
 sluggish or meagre secretion may be present in other persons. 
 It is important to bear this in mind, for it explains the readi- 
 ness with which some persons suffer from the symptoms of 
 over-secretion just as we have seen that other persons suffer 
 from the opposite condition. The immediately determining 
 causes may be placed in two great groups, namely, (i) direct 
 stomach stimulation, and (2) nervous influences, other, of 
 course, than those which are included under the former head. 
 The Constitutional Factor : An Acid Dyscrasia. — This 
 aspect of the subject requires further consideration. The 
 existence of a predisposition to an over-secretion of acid 
 seems to me to be bej^ond doubt : it is met with in early 
 adult life, even in a severe form, and may require prolonged 
 and persistent treatment for its subjection. This predis- 
 position I have ventured to call an " acid dyscrasia," and 
 the term has the merit of precisely defining the foregoing 
 contention. When the acid dyscrasia exists it is found that a 
 variety of circumstances determines its stomach manifesta- 
 tion. Nervous and mental influences will precipitate an 
 attack in such persons ; such influences having no such 
 effect in persons who are not the possessors of this special 
 constitutional characteristic. The relationship between 
 nervous influences and gastric disorder, particularly the 
 form due to over-secretion of acid, gave origin to the belief 
 in a " nervous dyspepsia." This form still holds a prominent 
 place in books devoted to stomach and digestive disorders. 
 The term precisely defines the underlying idea in the minds 
 of the authors of those works, which is that the condition 
 is a nerve condition, an abnonnal sensitiveness of sensory 
 nerve fibres, a neuralgia, in fact. It is indeed often caUed 
 " gastric neuralgia " or " gastralgia." We shall presently 
 show that there is another way of looking at this condition. 
 
36 THE STOMACH 
 
 which appears to be more correct, and the acceptance of 
 which leads to the adoption of therapeutic measures which 
 are much more beneficial to our patients than if we treat 
 them on the assumption that it is a neurosis we are dealing 
 with. Based upon, and necessarily following upon, the theory 
 of the nervous origin of the condition is the belief that this 
 form of dyspepsia manifests itself only in neurotic persons. 
 A further interesting, although extremely unfortunate, 
 development of this neurotic view has been that, if a patient, 
 who is beyond doubt neurotic, complains of digestive 
 discomfort or disorder it is at once taken as a confirmation 
 of the neurotic state, and that no special attention is to be 
 paid to the gastric derangement. The position comes to 
 this ; if you have a dyspepsia, which is thought to be 
 gastralgia, you are a neurotic ; and if you are a neurotic, 
 your dyspepsia is a mere gastralgia. A very simple argument, 
 but one which we hold to be seriously inaccurate. This 
 matter will be dealt with presently, and our contentions 
 regarding the true nature of the condition will be developed 
 as the whole question of hypersecretion is considered in 
 detail. With regard to the constitutional state which we 
 have termed " acid dyscrasia," it will frequently be found in 
 rheumatic and gouty people. It is not always possible to 
 determine this association, but it is sufficiently often present 
 to warrant the inference that these conditions are different 
 manifestations of a constitutional or vito-chemical pecularity. 
 
 The Determining Causes of Hypersecretion :' Food 
 AND Beverages 
 
 Food. — The first factors which fall to be considered as 
 determining hypersecretion are all substances which, when 
 taken into the stomach, directly stimulate secretion. They 
 include stimulating, and highly or full-flavoured foods, 
 condiments, and alcohol. The stimulating foods include 
 beef and mutton so cooked as to bring out their most 
 attractive and strongest flavours — in fact, flesh of all animals,^ 
 birds, or fishes possessing such flavours, or artficially flavoured 
 
HYPERCHLORHYDRIA 37 
 
 or seasoned to a high degree in the cooking. There is no doubt 
 that foods so prepared have this effect, and this is their value 
 to persons whose peptic glands require strong stimulation. 
 That this is a natural or congenital necessity is very 
 doubtful. It is probably to be regarded as an artificial and 
 acquired condition, the result of long habit, and is to be 
 viewed as a vicious or undesirable acquisition, unless the 
 view is adopted that the want of efficient response to all, 
 save the strongest impressions, is a desirable evolutionary 
 development. Such a position is certainly physiologically 
 unsound, and is practically injurious. We are meanwhile, 
 however, not concerned with this type of person ; but with 
 the fact that certain foods and condiments lead, in most 
 persons, to free secretion, and that this may imply that the 
 secretion of acid may be in excess, and lead to discomfort 
 some hours after the meal has been taken. There is another 
 element in this which occupies an important practical place, 
 namely, the ease or difficulty which the gastric secretion 
 experiences in disintegrating the meat which has been 
 swallowed. It is apparent, as soon as it is stated, that the 
 smaller the pieces of meat swallowed the more readily does 
 the gastric juice act upon them. The converse is equally 
 true, and thus it follows that, if the meat is present in the 
 stomach in large pieces, they continue to stimulate secretion 
 beyond the amount which is readily utilized and the acid, 
 instead of getting fixed, remains uncombined or free, and 
 accumulates in quantity sufficient to cause discomfort or 
 pain. When meat is finely divided the tendency to this 
 result is greatly lessened, and hence the value of finely minced 
 meats for those who suffer in this way. It will be found that a 
 given weight of flesh, eaten, say, as steak, may lead to intense 
 discomfort or pain, while the same quantity finely minced 
 will have no such effect. It may be argued that if the more 
 solid meat be carefully masticated there will be no bad result 
 from eating it ; but the fact is, that the necessary amount 
 of mastication to convert it into a degree of division 
 approaching to artificial mincing is practically beyond the 
 limits of education in the vast majority of our patients, and 
 
38 THE STOMACH 
 
 it is as well frankly to recognize and accept the position. 
 From this it is a simple step to understand that tough meat 
 is more difficult to digest than tender meat — a fact of common 
 knowledge to all who are liable to digestive discomfort. A 
 further illustration is provided by egg albumen : raw or 
 lightly cooked egg albumen is readily acted upon by the 
 gastric secretion, and if it be finely broken up by whipping it 
 is still more easily acted upon. On the other hand, if it be so 
 cooked as to make the white of the egg tough it will be found 
 that lumps of it escape mastication and are so swallowed. 
 Such lumps of tough white of egg may be found in the 
 stomach hours after having been eaten, and associated 
 with fluid containing much free hydrochloric acid of high 
 digestive value when tested by ordinary laboratory methods 
 on coagulated albumin. 
 
 The continued secretion of gastric juice under such 
 influences as have been described is of considerable interest, 
 as well as of great practical importance. Physiological 
 experiment on animals shows that the introduction of inert 
 substances into the stomach does not promote gastric 
 secretion, and Pawlow's experiments on dogs bears out this 
 view. From this it might be thought that the presence 
 of pieces of hard meat, or of tough white of egg, would, at 
 a given stage in digestion, be treated by the stomach as 
 inert substances. This, however, is not the case. What 
 happens is this ; the undigested lumps are not allowed to 
 pass out by the pylorus ; when they touch it the sphincter 
 contracts and they are swept back in the revolving mass of 
 stomach contents. So long as they are undigested the 
 gastric secretion continues, with the result that there is an 
 excess of secretion and the presence of free or uncombined 
 hydrochloric acid becomes manifest. The classical observa- 
 tions made through a gastric fistula have long been accepted 
 as proving the action of the pyloric sphincter in refusing to 
 allow pieces of solid or semi-solid material to pass from the 
 stomach. The correctness of this observation is fully 
 confirmed by clinical experience. 
 
 Passing from the food materials which ought to be digested 
 
HYPERCHLORHYDRIA 39 
 
 in the stomach, we have to consider in the next place those 
 which are not digested there, but are more or less broken up 
 and triturated by the movements of the gastric contents 
 as determined by the peristaltic contractions of the viscus. 
 The materials referred to all belong to the carbohydrate foods, 
 especially, and indeed exclusively, to starch-foods. These 
 include bread of all kinds made of wheat, potatoes, rice, 
 and porridge made from any of the cereals. These are 
 sufficient to illustrate the general principle which can be 
 laid down for guidance and practical application. The 
 potato may be taken from among these as most strikingly 
 illustrating our contentions. This useful article of food 
 may have deteriorated in quality within the last half-century, 
 but, whether it has or not, it is very frequently eaten in a 
 very unsuitable condition. Instead of being dr}/, floury or 
 mealy, it is sodden and waxy in appearance and consistence. 
 To pulverize it in the month, as it ought to be before it is 
 swallowed, requires a use of the teeth that few of our patients 
 have acquired, with the result that unmasticated lumps enter 
 the stomach. Such masses are not soon digested even by 
 amylolytic enzymes in the most favourable conditions ; in 
 the stomach this action has but little time to act. The gastric 
 juice has but a slight effect upon the lumps, but their move- 
 ment leads to a certain amount of trituration and disintegra- 
 tion. The breaking down process is, however, slow, so that the 
 lumps are often present in the stomach without being much 
 changed for hours, the pylorus refusing to allow them to 
 pass on ; the process by which retention is determined being 
 the same as was seen to be the case with lumps of protein 
 foods. Their presence also leads to continued secretion, with 
 the like result of much free acid being present. That lumps 
 of potato may remain in the stomach for hours is known to 
 every one who has had opportunities of seeing the vomit 
 of persons inside or outside hospitals. My own observations 
 lead me to believe that when vomiting does not indicate 
 anything more than a dyspepsia the vomit often contains 
 abundant free hydrochloric acid. The same is found to be the 
 case when the stomach contents are removed by the tube, 
 
40 THE STOMACH 
 
 although then there is difficulty in getting the masses out, as 
 they stick in and obstruct the tube. The demonstration of 
 the presence of potato is most striking when vomiting occurs. 
 Another food which I have seen in stomach contents removed 
 some hours after having been eaten is rice. I have seen whole 
 and half grains of quite unaltered rice in the contents 
 removed by the tube. I have also seen tough lumps of 
 tapioca. Of, perhaps, still greater interest is an observation 
 I have repeatedly made regarding oatmeal which has been 
 eaten in the form of porridge. It is necessary to state here 
 that oatmeal, which is, of course, prepared by grinding oats, 
 is sold of three grades, the grades being coarse, medium, and 
 fine. These terms indicate the size of the grains, that is the 
 degree of fineness of grinding, and not the quality of the meal. 
 The coarse-ground meal is very frequently preferred to either 
 the medium or the fine, and our remarks will be confined 
 mainly to it. This coarse-ground meal requires to be long 
 cooked to soften it and to make it easily disintegrated in 
 the stomach. This amount of cooking it very often does 
 not get. I have frequently found that on withdrawing the 
 stomach contents some hours after a meal partly consisting 
 of porridge, nothing of the meal remained but the coarse 
 grains of the oatmeal in a very acid fluid containing much 
 free hydrochloric acid. Along with the oatmeal porridge, 
 milk and egg may have been taken for the breakfast meal, 
 and yet no trace of milk curd will be present, and no trace of 
 egg. All has been digested and passed out of the stomach, 
 while the coarse grains of the oatmeal remain in an intensely 
 acid medium. These facts have only one possible explanation, 
 namely, that the coarse grains of the oatmeal act on the pyloric 
 sphincter as the other masses which have been already 
 described. It thus appears to me to be established that solid 
 and semi-solid masses, even of comparatively small size, do 
 not only not readily escape through the p3iorus, but that in 
 addition to this they continue to stimulate secretion, and thus 
 lead to an accumulation of free hydrochloric acid, with aU 
 its attendant discomfort. This is, then, the fact which has to 
 be given practical consideration to in the selection of the 
 
HYPERCHLORHYDRIA 41 
 
 food to be given to our patients. Above all the condition 
 in which the food is to be eaten demands much more attention 
 than is usually given to it. Flesh in one form may lead to the 
 most painful symptoms, in another form it may give rise to 
 no such symptoms. Starch-food in one form readily passes 
 the pylorus and has its digestion completed in the duodenum 
 and intestine, while the same food in another form will cause 
 the most severe dyspepsia. 
 
 Alcohol. — The effect of alcohol upon the gastric secretion 
 is of such wide interest that it has to be specially considered. 
 There is a consensus of opinion that alcohol stimulates gastric 
 secretion, and this fact is the warrant for its use at meal 
 times, at least by a certain number of people. Such persons 
 no doubt belong to the class who have a more or less sluggish 
 secretion ; but it is as unscientific, and as incorrect, to ignore 
 the existence of this class as it is to deny the existence of the 
 other class. The fact that alcohol stimulates the gastric 
 secretion is confirmed by what can often, if not invariably 
 be found to be its effect in persons subject to hyperchlor- 
 hydria. In them the taking of alcohol with food, either as 
 spirits or as wine, may determine an attack of acid dyspepsia 
 after a meal. In the same person taking whisky and water 
 at night, some hours after dinner, will often be promptly 
 followed by heartburn and acid discomfort. An interesting 
 practical fact in this connection is that this evil effect of the 
 alcohol can be prevented by adding an alkali to it ; the 
 ordinary soda-water being sometimes sufficient for this 
 purpose, while in other instances the soda-water is better 
 for being fortified by the addition of more bi-carbonate of 
 soda. The explanation of this effect is doubtless to be found 
 in Pawlow's observation that bi-carbonate of soda restrains 
 the secretion of acid : the soda may therefore be regarded 
 as counteracting and annulling the effect the alcohol would 
 have had without its addition. 
 
 Tea and Coffee. — The only other beverages which may 
 be considered are tea, coffee, and meat extracts ; a knowledge 
 of their influence upon the condition under consideration 
 being necessary on account of their extensive use. Tea may 
 
42 THE STOMACH 
 
 be taken first as it is the more used. The effect it has upon 
 gastric digestion has been much investigated and as the 
 result of these investigations there is no doubt that it has 
 an arresting influence. The precise degree of influence it 
 exercises depends upon the quantity taken and the strength 
 of the infusion. Taken in quantity or in strong infusion it 
 completely arrests gastric digestion by its direct effect upon 
 the digestive ferment ; in smaller quantity it reduces the 
 vigour of the digestive process, and correspondingly lengthens 
 the process. The action is, according to Roberts, due to the 
 tannin in the infusion, the theine and aromatic substances 
 present having a negative effect. This important action is 
 not without its beneficent side : it is not wholly and in- 
 variably or always an undesirable or hurtful action. This 
 other side is seen in the influence and effect it exercises in 
 hypersecretion. Clinical observation has convinced me that 
 the wholesale condemnation of tea drinking in all kinds of 
 dyspepsia is not warranted by the facts. What will be 
 found is that in h5^perchlorhydria, when the characteristic 
 symptoms of the condition begin to make their appearance 
 some time after a meal, the taking of a cup of tea often has a 
 very marked effect in relieving the symptoms, and preventing 
 their further development. A cup of hot water does not have 
 nearly the same effect, it may give temporary relief, but the 
 relief is often succeeded by an exacerbation of the symptoms. 
 The effect of tea infusion is due in the first instance to the 
 dilution of the stomach contents, leading to a corresponding 
 dilution or weakening of the acid present, acting in this 
 respect as hot water acts ; but its further effect seems to be 
 to arrest secretion. This seems to me to be the only possible 
 inference from what is undoubtedly a clinical fact, while it 
 bears out and explains the recognized injurious effect of tea 
 drinking in the opposite class of case. This in fact explains 
 what is so often to be noted in popular or common beliefs, 
 namely, that they have both a true and a false side. Tea is 
 hurtful in one form of dyspepsia, helpful in another, so that 
 the successful regulation of this, what might be deemed a 
 very simple matter, is determined by the correctness of the 
 
HYPERCHLORHYDRIA 43 
 
 differential diagnosis of the type of dyspepsia present in the 
 individual patient. 
 
 Coffee is regarded by Roberts and others as hav'ing the 
 same restraining and arresting action on peptic digestion 
 that tea has. It probably has the same influence as tea upon 
 the gastric secretion, but, owing to the much more limited use 
 of coffee, there is not the same amount of clinical observation 
 available regarding it. I have not been able so far to satisfy 
 myself regarding the effect of the small cup of cafe noir which 
 is sipped so commonly after dinner. Taken in the afternoon 
 it may arrest hypersecretion as effectively as tea. The 
 morning cafe au lait is preferable to tea, especially if that meal 
 is largely a carbohydrate meal. 
 
 Meat Extracts. — Passing next to meat extracts, of which 
 beef, mutton, or chicken-tea or soup may be taken as samples, 
 they have long occupied a prominent place in the sick-room, 
 and in the dietary of the invalid and convalescent. They 
 will doubtless continue to be much used because of certain 
 valuable properties they possess, although they may be 
 shorn of much of the value so commonly attributed to them. 
 They certainly serve as admirable and valuable stimulants 
 in some conditions. Turning to their effect on gastric 
 digestion, Roberts * showed that they delayed, embarrassed, 
 or practically arrested it ; the measure of the effect being 
 determined by the proportion or percentage of beef-tea 
 present in the digesting mixtiure. If this effect had been 
 definitely proved to take place in the stomach, or if this could 
 be shown to be the whole truth about its action in the 
 stomach, it would be difficult to regard its use with any favour 
 whatever. As to the correctness of the result when experi- 
 ment is made outside the body and in a flask there need be 
 no question. Practically there is this objection to the method 
 of investigation, namely, that beef -tea is not given to patients 
 when a considerable protein meal is in the process of digestion. 
 From the side of clinical observation it has often appeared to 
 me that beef-tea not infrequently caused s^miptoms of 
 indigestion due to the stimulating of gastric secretion while 
 
 * Sir William Roberts, Digesticti and Diet. London. 1S97. 
 
44 THE STOMACH 
 
 there was no food present in the stomach for it to act upon. 
 This chnical conviction is abundantly confirmed by Pawlow's 
 work. He found that meat extracts had a decided effect 
 in stimulating gastric secretion. In fact, he found that when 
 the psychic stimulus in dogs was abolished by division of the 
 vagus he could effect the digestion of solid food introduced 
 into the stomach by first stimulating secretion by introducing 
 meat broth. If this was not done the solid food introduced 
 began to decompose.* In short, all his experiments go to 
 show that meat extract is perhaps the most powerful chemical 
 stimulus that can be used for promoting gastric secretion. 
 This therefore warrants our contention that meat extracts 
 frequently lead to hyper-secretion, and that their use is to 
 be carefully watched if they are to be used at all in persons 
 suffering from or subject to hyperchlorhydria. 
 
 Symptoms and their Interpretation 
 
 In approaching the consideration of the symptoms, a 
 few general remarks may be made on what is recognized 
 as acid dyspepsia. The symptoms which characterize that 
 condition are burning pain at the cardiac orifice of the 
 stomach, acid eructations, water-brash, usually flatulence, 
 and constipation. The idea that these symptoms were 
 due to the presence of other acids — as lactic and butyric — 
 produced by fermentative processes in the stomach, is 
 presumably no longer more than a myth in medicine. The 
 acid which is present, and present in abundance, is HCl, 
 secreted by the oxyntic glands of the stomach. 
 
 Symptoms.! — As has been stated in a previous chapter, it 
 requires patience and method to obtain an accurate record 
 or a true picture of the symptoms in gastric disorder. The 
 plan I have developed is simple and practical, and gives 
 satisfactory results. I begin by inquiring how my patient 
 feels on getting up in the morning ; then the hour at which 
 he breakfasts, and of what that meal usually consists ; 
 how he feels after breakfast, and if any pain, discomfort, or 
 
 * T.oc. cit., p. 1 02. 
 
 I Reprinted from British Medical Journal of April i8th, 1903. 
 
HYPERCHLORHYDRIA 45 
 
 other symptom is experienced during the forenoon, and the 
 hour at which these come on, how long they last, and whether 
 they continue up to the time of taking the midday meal. 
 If symptoms continue up to the midday meal I ascertain 
 the effect that meal has upon them — whether they are at 
 once aggravated, or materially relieved, or entirely removed, 
 at least for the time. I then inquire as to the composition 
 of the mid-day meal. This is followed by inquiries as to the 
 symptoms during the afternoon and so on until bedtime, and 
 later if necessary. This method I have found to be the only 
 way to obtain exact knowledge of sjonptoms, and the 
 symptoms so obtained are of the greatest value in helping 
 to determine the part of the digestive process which is at 
 fault. Occasionally an observant patient gives all this 
 without detailed questioning, but such patients are rare ; 
 the majority give a description which is usually irrelevant 
 and confused, symptoms, times, and explanations being 
 intimately interwoven and mixed. 
 
 The history thus obtained is often so characteristic as to 
 warrant the diagnosis of hyperchlorhydria without the 
 chemical examination of the gastric contents. The facts 
 brought out in such a history are somewhat as follows : The 
 patient feels quite well in the morning, and has no discom- 
 fort until during the forenoon some time. He can often 
 state the hour at which discomfort begins — one to two, or 
 two and a-half hours after breakfast — the time varying in 
 different cases, and even in the same case. The pain after 
 lasting an hour or two may pass off, to reappear an hour 
 or longer after the midday meal. If the pain continue right 
 up to the time of taking the midday meal, partaking of this 
 meal removes it for a time, the period of relief varying from 
 half an hour to an hour or longer. The duration of the 
 interval of comfort depends upon the severity of the condition 
 and the composition of the midday meal. This sequence 
 of events — meals, intervals of relief, reciurrence of pain or 
 discomfort — may be maintained throughout the rest of the 
 day. If the last meal of the day be taken near bedtime, the 
 patient may be wakened from sleep by pain and other 
 
46 THE STOMACH 
 
 symptoms which may keep him awake for an hour or two. 
 The pain or discomfort varies within wide hmits ; it may be 
 severe and acute, and described as grinding, gnawing, 
 boring, burning ; or the sensation may be of dragging, 
 of weariness, of distension, or a hunger-discomfort. The 
 pain is usually referred to the epigastrium, but it may go 
 through to the back near the spine ; it may be present 
 behind either shoulder-blade, or be most marked in the 
 normal position of the pylorus, or over the liver behind. 
 The measure and the site of the pain depend upon the 
 duration and severity of the condition more than on any 
 neuropathic tendency in the individual. There is indeed 
 no department where so much is attributed to disordered or 
 disturbed innervation, as in gastric disorders, and the 
 exaggeration of this factor tends to relegate to a subsidiary 
 place the part taken by diet and altered secretion in the 
 production of the symptoms. Symptoms due to one or 
 other or both of these are referred to as nervous, as if a nerve 
 condition were the primary and essential factor, when it is 
 but the sensory index of disordered chemistry. In addition 
 to pain, there may be epigastric tenderness, but this is only 
 present in pronounced cases of considerable duration. The 
 tenderness is quite superficial, and is readily overcome by 
 gently rubbing or handling the skin, and then deep palpation 
 can be practised without causing pain. Other symptoms re- 
 ferred directly to the stomach are flatulent distension, gaseous 
 eructations, heartburn, acid eructations and water-brash. 
 The eructation of gas or of a small quantity of acrid material 
 gives relief, temporary usually, but often very marked and 
 out of all proportion, one would think, to the amount 
 eructated. The bowels are constipated, or, even if there be 
 daily action, the removal of the intestinal contents is incom- 
 plete. In severe cases there is sometimes great physical 
 and mental misery, coming on or attaining their worst when 
 other S3niiptoms are at their height. The most prominent 
 of these is a sense of physical and mental exhaustion, langour, 
 weariness, and weight in the lower limbs, and inability to 
 apply mind or body to any work. Another symptom has 
 
HYPERCHLORHYDRIA 
 
 47 
 
 been graphically described by Sir W. Roberts under the 
 designation of " paroxysmal pyrosis," and he regarded it as 
 an " abortive and incomplete act of vomiting." While 
 agreeing with him that this special symptom only occurs 
 during the presence of surplus acid in the stomach, I think 
 that, instead of its being an abortive act of vomiting, it is a 
 pyloric phenomenon. 
 
 Emphasis has to be laid on the fact that this disorder 
 of secretion is attended with very marked nervous phenomena. 
 Some of these have been mentioned, and they must be borne 
 in mind ; but in some instances the mental depression is 
 very great, and even a cause of anxiety, whilst in others 
 complete incapacity for work of any kind is experienced. 
 The severity of the nervous symptoms are not determined 
 by class differences, the manual worker may be more sensi- 
 tive than the brain worker, but the converse is equally true. 
 Some persons, irrespective of class, tolerate and bear pain 
 and discomfort much better than others, while other persons 
 are hyper-responsive. 
 
 The Explanation of the Symptoms. — To understand the 
 symptoms of gastric disorder it is necessary to postulate 
 precise knowledge and a clear comprehension of digestive 
 processes in the stomach. Our food consists of three great 
 classes of nutriment — starch, protein, fat. The main sources 
 of starch are cereals, including rice, and potatoes ; of protein 
 are meat, milk, eggs ; of fat are butter, milk, meat. The 
 starches are prepared for food by baking and boiling, 
 being unfit for human food in an uncooked state. The object 
 of cooking is to break the starch capsules and to disintegrate 
 the starch particles so as to expose them to the amylolytic 
 enzyme of the saliva and of other secretions. The longer 
 the cooking at a proper temperature is continued the greater 
 are the changes in the starch and the better the prospect of 
 its speedy conversion. The conversion is effected in the first 
 instance by the ptyalin of the saliva, and this under favour- 
 able conditions acts with vigour and promptness, converting 
 the disintegrated but insoluble starch into soluble starch, 
 a long chain of dextrins, and finally into maltose. This 
 
48 THE STOMACH 
 
 amylolytic process continues in the stomach until by the 
 pouring out of hydrochloric acid the gastric contents acquire 
 an acidity of o"oo3 per cent, according to Chittenden and 
 Smith. At all events when the acidity reaches a certain 
 degree the digestion of starch ceases, but the digestion of 
 proteins, which has already begun, is accelerated by the in- 
 creasing secretion of hydrochloric acid and pepsinogen. 
 These three chemical phenomena — starch digestion, arrest of 
 starch digestion, protein digestion — are those upon which the 
 unconscious comfort or the conscious discomfort of digestion 
 primarily and essentially depends. When the chemical 
 equilibrium and balance during this period is maintained 
 the stomach works without obtruding its existence on our 
 notice. The full significance of this equilibrium has, how- 
 ever, to be realized ; it means the existence of a " correct 
 relation " between the amount of protein food and the 
 amount of gastric secretion. There ought to be no more 
 gastric juice poured out than can satisfy the needs of — that 
 is, can be taken up by — the protein. When this is satisfied, 
 the secretion of gastric juice ought to cease, and we 
 cannot doubt that under normal conditions this must 
 be the case. If this arrest of secretion does not occur, 
 equilibrium is upset, and the resulting perturbation depends 
 upon the measure of the excess. The element in the secretion 
 which is the disturbing factor is the hydrochloric acid, and 
 not the special enzyme. The effect of this hyperchlorhydria 
 upon the gastric contents is noteworthy, and requires 
 explanation. The protein elements of the food are digested 
 with promptness and even with exceptional alacrity ; and it 
 might be thought that the other food substances, especially 
 the finely-divided starch food, as bread and oatmeal porridge, 
 would readily pass out of the stomach with the digested pro- 
 teins, but this is not what happens. What does occur is that 
 a considerable portion of unaltered starch is kept back and 
 retained in the stomach. This I have frequently found 
 to be the case. The effect of this retained and unaltered 
 starch is to keep up the gastric secretion while presenting 
 no constituent with which it can combine. The physiological 
 
EXPLANATION OF THE SYMPTOMS 49 
 
 concept is that the undigested starch is readily passed 
 into the duodenum, and its digestion completed in the 
 intestine. Even in such conditions as I am now con- 
 sidering, the undigested starch is, as a rule, ultimately 
 passed on, but this only after much local and often general dis- 
 comfort ; but it may be finally rejected by vomiting. Another 
 interesting observation I have made in this connection is that 
 not only the unaltered starch may be thus retained, but a 
 considerable amount of the fat of milk may also be retained. 
 I have several times noted this when all the casein of the 
 milk had disappeared. I have seen this both when plain milk 
 or peptonized milk had been taken. When it occurs the fat 
 of the milk is found diffused through the acid fluid removed 
 from the stomach, but partly floating upon it, presenting an 
 appearance as if it were a mass of mucus. When the fat of 
 milk is thus retained, it seems to me that it also keeps up the 
 gastric secretion, and, presenting no element with which the 
 hydrochloric acid can combine, the discomforts of hyperchlor- 
 hydria emerge. A third important factor in determining the 
 severity of the symptoms is the kind of protein food taken. 
 The general law is that the less stimulating and the more 
 easily digested proteins cause less discomfort than do those 
 of a contrary character. 
 
 In all three conditions there is the common factor of con- 
 tinued gastric secretion, continued beyond what is required, 
 therefore beyond what can be utilized. This continued secre- 
 tion, when the stomach contents are examined, provides 
 marked evidence of free hydrochloric acid, and a high per- 
 centage of acidity. At this stage the stomach contents may 
 only measure from one to a few ounces of very acrid material, 
 mainly fluid, containing starch, some milk fat, and shreds of 
 undigested material according to the kind of food which had 
 been taken. The main residue in ordinary cases is starch. 
 At this period the gastric s3niiptoms are very severe, and I 
 have frequently obtained the contents of the organ when the 
 symptoms were at their height, and have been amazed at the 
 smallness of the amount in view of the intensity of the 
 symptoms. Why a residuum of finely divided although 
 
 4 
 
50 THE STOMACH 
 
 undigested starch should remain in the stomach when other 
 material has passed the pylorus is difficult to explain. The 
 physiological position is roughly this, that the fate of starch 
 in the stomach is of relatively little importance, as it is 
 digested in the intestine ; and this, from the nutritive stand- 
 point alone, is true, and explains the fact that sufferers from 
 hyperchylia do not lose flesh unless they adopt a starvation 
 policy in regard to their food. But this physiological truth 
 is one of those truths which has led to a total misapprehension 
 of the phenomena of disordered function such as the physician 
 has to deal with. The interpretation which seems to me 
 to be in accord with clinical observations is that we have 
 to acknowledge that the unaltered starch is delayed in the 
 stomach, and that it is so even when broken up and digested 
 proteins have escaped. Being thus delayed it continues 
 to stimulate the gastric secretion, and there being no more 
 protein with which to combine the secretion accumulates and 
 leads to the hyperacidity in question. That this hyper- 
 acidity is due to a true hypersecretion is proved by the great 
 peptonizing power of the filtered contents when tested in the 
 usual way. Once the residuum in the stomach becomes 
 hyperacid its continued retention is explained by the fact 
 that the hyperacidity keeps the pyloric sphincter closed, or 
 even causes spasm of it. 
 
 An Acid Dyscrasia. — Looking, in the next place, at the 
 etiology of hyperchylia, we find ourselves face to face 
 with terms and designations which only obscure the position. 
 The favourite place in which to find it described is under 
 gastric neuroses, nervous dyspepsia, gastric irritation, gastro- 
 dynia, or gastralgia. It is not always clear what writers on 
 gastric disorders mean by some of these terms. Whether 
 the idea which is sought to be conveyed is that the pain and 
 discomfort are merely subj ective nervous phenomena, or that 
 an assumed neurotic diathesis determines an increased secre- 
 tion of hydrochloric acid. The underlying idea seems to be 
 that the nervous mechanism is the part of the system which 
 is primarily deranged. This conception I hold to be erroneous 
 and brimful of evil consequences. We all possess a nervous 
 
OTHER DETERMINING CAUSES 51 
 
 system, some more finely tuned and more responsive than 
 others, and we all grant and recognize the important role 
 played by it. All deviations of secretion from an average stan- 
 dard, aU increases of secretion, all modifications of chemico- 
 vital reaction, are not to-day accepted as explained or defined 
 by the word " neurotic," and it is time that the word and the 
 idea were relegated to a less prominent place when consider- 
 ing disturbances of stomach function. In opposition to this 
 neiurotic view I would submit as a result of clinical experi- 
 ence and the examination of gastric contents that certain 
 persons are prone to secrete over-much gastric juice, and that 
 the constituent which is primarily at fault is the hydro- 
 chloric acid. I have been impressed with the occurrence 
 of severe hyperacidity in some gouty and rheumatic subjects, 
 and by its occurrence in some persons as a consequence of a 
 diet rich in nitrogenous substances. I think, indeed, there is 
 little doubt that we might add to our list of constitutional 
 conditions an acid dyscmsia. To regard the intense misery 
 of severe hyperchylia as a mere neurosis is an impertinence to 
 some of the victims of the condition. Apart, however, 
 from that aspect of the case I hold the merely neurotic view 
 to be disproved by the following phenomena which are 
 frequently observed : the instantaneous relief obtained by 
 removing an ounce or two of acrid stomach residuum ; a like 
 relief obtained by neutralizing the acid by means of alkalies ; 
 and the measure of relief obtained by mere dilution. That 
 the over-secretion is more a chemical and a diathetic error 
 than a neurosis is further strongly supported by the ex- 
 perience that the mechanical removal of the hyperacid 
 residuum in severe cases more promptly overcomes the attack 
 than any dietetic or medicinal measure — as if the removal of 
 the acid removed an overflow which otherwise is difficult to 
 arrest, and which when not removed looks as if it were 
 absorbed and again and again resecreted. 
 
 Other Immediate Determining Causes.— While an acid 
 dyscrasia is held to be the foundation of hyperacidity, 
 there are determining causes which must at least be 
 enumerated. They are, in addition to unsuitable feeding 
 
52 THE STOMACH 
 
 or drinking, (i) worry or anxiety, (2) fatigue, (3) chill. 
 In these respects it resembles gout and rheumatism in 
 being a pronounced perturbation of chemico-vital idio- 
 syncrasy often determined by nervous influences. It is the 
 influence of these factors which presumably led to erroneous 
 conceptions of its nature. As will be seen later, it is the 
 upset of chemical balance which determines the symptoms, 
 and it is only by the recognition of this fact that a true 
 understanding of the condition is attained and a successful 
 therapy can be applied. 
 
 Additional Comments. — While the symptoms, and the 
 time of their appearance, in the most typical cases, are as 
 stated, they must not be taken too rigidly. In medicine 
 symptoms do not necessarily hold that place. The two 
 points upon which emphasis has been laid are (i) pain, and 
 (2) the time it comes on after a meal. With regard to the 
 first of these, namely, pain, it varies greatly in intensity. 
 In the third and fourth decades of life there may be, and 
 there often is, no definite pain ; a feeling of discomfort 
 referred to the stomach, and perhaps accompanied by a 
 general feeling of being " out of sorts," may be the complaint. 
 In the further decades the tendency is for the discomfort 
 to be described definitely as pain. Instead of pain the 
 discomfort may be a complaint of heartburn, or of acid 
 eructations, or of both together. These have been long 
 known as gastric acidity, or as acid dyspepsia ; even before 
 it was known that the acidity was due to over activity of 
 certain glands in the stomach. Pain, on the other hand, is 
 often present without any history of heartburn or of acid 
 eructations, and no doubt it was to this condition that such 
 terms as gastralgia, nervous dyspepsia, or even neuralgia 
 of the stomach, were applied. The second point is the time 
 after food when the pain or discomfort or the heartburn 
 appears. The pain or discomfort is what the late Professor 
 Wyllie called a " delayed pain," meaning thereby to 
 give it a place distinct from the pain that comes on in 
 other stomach disorders immediately after or soon after 
 taking food. The time of onset of pain or discomfort in 
 
ADDITIONAL COMMENTS 53 
 
 hyperchlorhydria is always some time after a meal ; it is 
 usually an hour or more, the time being determined by 
 the kind of meal and the size of the meal. A large meal 
 of porridge and milk may be foUowed by marked acidity 
 in an hour or even less. A breakfast of fish or bacon and 
 egg may be followed by discomfort or pain in an hour 
 and a half or two hours. A large protein meal at dinner 
 time may not give rise to discomfort for over two hours or 
 even three. 
 
 With regard to examination of the tongue, it is usually 
 clean but it may be furred. It is not coated as it commonly 
 is in hypochlorhydria. Constipation is the rule, but there 
 may be a history of daily and free bowel evacuation. I have 
 only met with one case of diarrhoea. In that case the 
 complaint was diarrhoea which was very troublesome, because 
 of uncertainty as to when an imperative demand might 
 arise to go to stool. At our first interview it was difficult 
 to find a cause for this. The diet and habits were above 
 suspicion, but I found the stomach dilated and splashing, and 
 a specimen removed by the tube showed much free hydro- 
 chloric acid. The matter was explained to the patient and 
 belladonna and bicarbonate of soda were given, with the 
 result that the diarrhoea and the irregular and imperative 
 calls were quite relieved. 
 
 The term " paroxysmal pyrosis " has been referred to at 
 page 47, as used by the late Sir William Roberts in his 
 valuable work on Digestion and Diet. He defines it thus : 
 " This symptom consists in a paroxysm, of which the chief 
 features are sudden cramp of the stomach, with profuse 
 salivation." He says that writers on dyspepsia exhibit 
 confusion in the use of the term, and suggests that the term 
 should be confined to these essentially characteristic attacks. 
 The present writer leans to the explanation that what 
 Roberts thought was a " sudden cramp of the stomach " 
 is a sudden relaxation of pyloric spasm and either the passage 
 of highly acid stomach contents into the duodenum or of 
 alkaline duodenal contents into the acid stomach contents. 
 However that part of the phenomena is to be explained, 
 
54 THE STOMACH 
 
 the concomitant profuse salivation is the result evidently 
 of a powerful reflex stimulation of the alkaline secretion of 
 the salivary glands which could be regarded as beneficent 
 were the secretion swallowed instead of being ejected from 
 the mouth. The salivary secretion in these circumstances 
 is, according to Roberts, characterized " by its unusual 
 degree of alkalescence." At the time of writing the case of 
 a patient, recently under my care, suggests such an 
 association. The patient, a retired army officer, had suffered 
 from slight cough and very copious expectoration, which 
 annoyed him all day and disturbed him all night. He was 
 thought to have bronchiectasis. The expectoration might 
 amount to eight or ten ounces during the night. It con- 
 sisted of a clear viscous fluid with lumps of white mucous 
 floating on the top. There was no evidence of anything 
 being wrong in the respiratory organs save very trifling 
 catarrh in the bronchi. The appearance of the expectorated 
 material at once suggested salivation, and fuller examination 
 showed it to be alkaline in reaction and to contain diastasic 
 ferment. It was, in fact, typical salivary gland secretion. 
 Dr. Logan Turner found nothing in the throat or posterior 
 nares to explain the condition. There were no symptoms of 
 gastric hyperacidity, but as the patient was rheumatic and 
 gouty it was decided to add bicarbonate of soda to the 
 belladonna which was clearly indicated. Under ten minims 
 of tincture of belladonna and twenty grains of bicarbonate 
 of soda thrice daily the secretion rapidly fell in volume and 
 finally became normal. Whether the " profuse salivation " 
 can be associated in this case with the same " acid dyscrasia " 
 as we hold gastric hyperchlorhydria to be associated with, 
 may be questioned ; but the case is referred to here as 
 suggestive, although it is, in the writer's knowledge, unique. 
 
 Illustrative Cases 
 
 A. Acute Cases. — The symptoms of hyperchlorhydria 
 not infrequently come on somewhat acutely in strong 
 vigorous persons who have not suffered previously from 
 
ILLUSTRATIVE CASES 55 
 
 digestive disturbance of any kind. As examples of this the 
 following cases arc given. 
 
 Case 5.— A gentleman, aged 37, who was sent to me 
 in November, had suffered for one month from pain and 
 flatulence. The pain came on about two hours after break- 
 fast, two hours after lunch, and two hours after an eight 
 o'clock dinner. He had sometimes been wakened in the 
 night with the pain. The pain lately had become almost 
 constant, but he had noticed that taking food put it away for 
 a time. The bowels had been constipated from the onset 
 of the symptoms, and he had for this taken an occasional 
 laxative. The tongue was furred. On examination of 
 the abdomen, succussion showed the lower border of the 
 stomach to be at the level of the umbilicus. There was 
 nothing to note in his other systems. He had no worries, 
 and he led the open-air life of a country gentleman. " Indi- 
 gestion was common in his family, and his father died 
 of it." 
 
 I advised a considerable reduction in the amount of food, 
 wine, and malt liquor he was taking, and gave him belladonna 
 and soda to take thrice daily. He saw me again at the end of 
 a week and of a fortnight ; he had had no pain since he began 
 the medicine, and by the latter date the dilatation of the 
 stomach had entirely disappeared. He remained perfectly 
 well, and has had no return of his symptoms up to the 
 present time. 
 
 Case 6. — A retired officer of the R.A.M.C, aged 54, 
 consulted me in August. He had been attacked by pain 
 between three and four weeks before, two hours or more 
 after lunch, and it had lasted for a couple of hours. This 
 pain kept recurring about two hours after taking food. He 
 dieted himself very strictly, and found that the pain kept 
 away if he lived on milk, biscuits, and lightly boiled eggs. 
 He was, as a result of this meagre diet, getting weak and out 
 of condition. The pain sometimes kept him awake at night. 
 He found that taking hot milk removed the pain. The 
 stomach was not dilated. There were no further points I 
 need refer to. 
 
56 THE STOMACH 
 
 I gave the patient belladonna and sodium bicarbonate, 
 and a laxative pill of cascara, belladonna, and nux vomica ; I 
 took off the restrictions on his feeding, but advised that he 
 should have red flesh and chicken minced. The belladonna 
 and soda were to be taken after food, as soon as the discom- 
 fort began. He reported himself to me in the end of Sep- 
 tember, and assured me that the medicine had very promptly 
 removed his symptoms. 
 
 He kindly reported himself in September of the following 
 year, when passing through Edinburgh, and informed me 
 that he had had occasional threatenings of a return of his 
 symptoms, but found that he had the remedy in the drugs 
 I had prescribed. 
 
 B. Cases of Longer Duration. — I select the following cases 
 for the illustration of this class. 
 
 Case 7. — The patient was a medical man, aged 47, 
 who consulted me in June. He had suffered off and on 
 with acidity for twenty years. The attack from which he 
 was suffering when he came to me had lasted for two weeks, 
 and was unusually severe. Pain came on about two hours 
 after food, and might continue up to the taking of the next 
 meal ; taking food relieved the pain. There was no vomiting, 
 and the bowels m oved daily and freely. There was no gastric 
 dilatation, but as there was something in his stomach 
 it was drawn off, and was found to be intensely acid from 
 free HCl, while the material removed consisted of fluid and 
 starch. The diet was regulated, and I recommended 
 belladonna before food and bicarbonate of soda after food, 
 as soon as the pain threatened. Ten days later he wrote 
 saying how much better he was, and that, " although the 
 weather has been simply atrocious, I have not suffered any 
 more." Three years later he assured me that he had been 
 able to restrain his old enemy as soon as there was a threaten- 
 ing of reappearance. He scouted any suggestion of having 
 either a gastric or a duodenal ulcer. 
 
 Case 7a. — Another medical man, aged 35, consulted me in 
 November. He had not suffered so long as our preceding 
 friend, but was finding his energy sapped and life burdened 
 
EFFECTS OR COMPLICATIONS 57 
 
 by his recurring attacks. He was cured, and has become 
 an able exponent of the chnical manifestations of hyper- 
 chlorhydria, and a curer of the condition in others. 
 These cases occurred in medical men. 
 
 Effects or Complications 
 
 The effects or results of h}'perchlorhydria have now 
 to be considered. They may be regarded as complica- 
 tions, in the sense that they constitute what have been 
 regarded hitherto as separate or independent conditions. 
 The view here taken is that so-called complications have 
 their origin in disturbance of normal gastric secretion 
 and are the result of that disturbance. This gives aberra- 
 tion of function its true position, as the forerunner of 
 anatomical changes, and accentuates the importance of 
 recognizing such aberrations from the supreme stand- 
 point of preventive medicine. Accepting this proposition, 
 the fact that functional disturbance is of two kinds, and that 
 each is amenable to intelligent treatment, puts gastric 
 disorders in a much simpler light than they have been 
 regarded hitherto. Not only this but it puts in the hands of 
 the practitioner the means of preventing the development 
 of some of the most disabling maladies to which civilized 
 man is liable. 
 
 These are (i) Pyloric spasm, (2) Atonicity and dilatation, 
 (3) Ptosis, (4) Ulceration, and they will be considered in thai 
 order. 
 
 (i) Pyloric Spasm. — It has been pointed out that the 
 pain in h3,'perchlorhydria is due to pyloric spasm. This 
 spasm may not be confined to the sphincter of the pylorus, 
 but may involve more or less of the pyloric antrum. If the 
 abdominal wall is thin and the abdomen easily palpated, 
 as it often is in these cases, the portion in spasm can occa- 
 sionally be felt and has frequently been diagnosed as pyloric 
 neoplasm. It is, however, only palpable when pain is 
 present, and cannot be felt in the intervals of pain. 
 
 (2) Atonicity and Dilatation. — In severe cases of hyper- 
 chlorhydria, which have lasted for some time, the stomach 
 
58 THE STOMACH 
 
 presents varying degrees of atonicity and of dilatation, 
 The atonicity is tlie result of undue retention of food due to 
 pyloric spasm ; the musculature of the stomach wall be- 
 comes exhausted, and exhaustion of involuntary muscle 
 always implies relaxation and consequent dilatation. This 
 is one of the forms of atonic dilatation and the tendency 
 is towards steady increase in the degree of dilatation and 
 atonicity. 
 
 (3) Ptosis.— Ptosis of the greater curve of the stomach, 
 or of both it and the lesser curve, may result from long- 
 continued or frequently recurring attacks of hyperchlor- 
 hydria. The phenomena produced will be dealt with 
 under the special heading of " The Position of the Stomach." 
 
 (4) Ulceration. — The occurrence of gastric and pyloric 
 ulceration will be dealt with in special sections. 
 
CHAPTER VI 
 
 AIR-SWALLOWING : COMMONLY CALLED FLATULENT 
 DYSPEPSIA 
 
 Air-gulping is a fairly widely recognized condition. It is 
 characterized and known not so much by the air-gulping 
 as by the great distension it may cause or by the great 
 belching up of wind from time to time. About twelve 
 years ago I had an extremely pronounced case of this kind 
 in the Infirmarj^ The patient was a girl in her 'teens and 
 the story we got was that the belching was so loud that the 
 neighbours heard the noise. WTien the case was being read 
 at the bedside I noticed that she kept steadily swallowing 
 air and when discoursing to the students on the condition 
 had no difficulty in getting the patient to blow up her 
 stomach by gulping air and then to belch it up. In animals 
 the condition is known as " air-sucking ; " it occurs in 
 cattle and horses, and in them it is a very serious condition 
 which may cause death. 
 
 The term " air-swallowing " I have used for the swallow- 
 ing of air when food is swallowed. This is a common 
 condition and yet it is not generally recognized. Although 
 it occurs specially when food is being taken it may be 
 continued during the period of gastric digestion, especially 
 if there be digestive disorder. The amount swallowed 
 varies in individual instances, and therefore the degree 
 of distension and of consequent discomfort caused by it 
 varies. In some patients discomfort is great because the 
 amount swallowed is large. It may be so great as to give 
 rise to visible distension ; it maj- lead to pronounced 
 
 59 
 
6o THE STOMACH 
 
 neurasthenia, and to grave mental depression ; it may 
 act reflexly on heart and vessels, leading to functional 
 angina pectoris. It may not only be associated with, but 
 apparently may be caused by, abnormal gastric secretion, 
 abnormal in the sense of the secretion containing too much 
 or too little hydrochloric acid. In my experience it is 
 more common and more pronounced in the latter, that is, 
 in hypochlorhydria. While it occurs in both conditions, 
 it also occurs independently of either, when it has to -be 
 regarded as an unfortunate faculty. It occurs in both 
 sexes and is probably fairly common in children. \Mien 
 the condition is present it can be demonstrated on the 
 screen, but the most pronounced cases give the most striking 
 picture. 
 
 The more extreme cases are not very common, and a 
 proportion of the cases seen have been seen in consultation, 
 where the cause of the symptoms had not been recognized. 
 
 The following cases illustrate the symptoms and the 
 phenomena which are present. 
 
 Illustrative Cases of Air-swallowixg 
 
 Case 8. — This man, J. I., aged 30, was sent to I\Ir. 
 Cathcart with a view to surgical treatment. 'Mr. Cathcart 
 did not think him a suitable case for operation and asked 
 me to admit him to my ward. He was transferred on the 
 3rd November, 1915. The history we got was that he 
 had enlisted on the outbreak of war, that he served in 
 Flanders, and was discharged in June, 1915, for " total 
 disablement." In April he began to have attacks of very 
 severe pain in the epigastrium. The pain came on after 
 food, lasted for several hours, and was often followed by 
 vomiting. The vomiting did not as a rule relieve the 
 pain. He lost appetite, became weak and sometimes giddy. 
 Restricting his diet alleviated the symptoms. He was in 
 an English county hospital for a time and from that hospital 
 was discharged from the army. He returned to his home in 
 cotland and sta3'ed in bed for five weeks, taking liquid 
 
ILLUSTRATIVE CASES OF AIR-SWALLOWING 6i 
 
 nourishment. Then he was sent to a convalescent hospital, 
 where his stomach was washed out twice a day, with slight 
 improvement in his symptoms. It was from this hospital 
 that he was sent to the Edinburgh Royal Infirmary for 
 admission to Mr. Cathcart's wards with a view to 
 operation. 
 
 On asking him carefully about his symptoms, it was 
 brought out that immediately after taking food he had the 
 feeling of being greatly blown-up, and that the feeling of 
 fullness and distension came up his chest into his throat. 
 On examination the abdomen was distended, the distension 
 being forwards. There were no peristaltic movements 
 visible ; there was some tenderness in the epigastrium and 
 in the right iliac region, but palpation was unsatisfactory 
 in its results as the abdominal wall was made tense as soon 
 as it was touched, the patient at the same time holding 
 his breath and arching his back. Immediately after a 
 meal the area of stomach tympanicity was increased. 
 
 Remarks. — This case in the first place illustrates the 
 value of careful and critical sifting of symptoms in abdominal 
 work. The patient was quite confident that the sense of 
 fullness and distension came on immediately after taking 
 food of any kind, and of its rapidly becoming so extreme 
 as to come up into his throat as if it would choke him. Now 
 no gastric lesion or disorder of gastric function causes 
 symptoms like these ; gastric ulcer, gastric carcinoma, 
 hyperchlorhydria, or other functional disorder never give 
 rise to the symptom which with care was fully established 
 as present in this patient. That being so, the next step 
 towards a diagnosis was determined by former experience, 
 and the simple explanation offered itself that the patient 
 was an air-swallower, that he swallowed air while taking 
 food and probably for some time after. By submitting 
 him to X-ray examination we were able at once to confirm 
 this opinion. Dr. Hope Fowler kindly carried out the 
 examination in our presence. The bismuth as it was 
 swallowed passed into the dependent part of the stomach 
 above the level of the umbilicus, while an air-space was seen 
 
62 THE STOMACH 
 
 at the fundus ; as he continued slowly to swallow the 
 bismuth, the air-space rapidly increased in size ; and when 
 he M''as asked to swallow without bismuth, the fundus of the 
 stomach was seen to rise up, and the air area to enlarge 
 until it attained the size of an adult head. The appearance 
 was well seen in the plate, but it has unfortunately been 
 lost. Now let me impress upon you that the patient did 
 not know he was doing this. The only way to cure such a 
 case is to explain to him what he is doing, and to tell him 
 that it will require watchfulness and perseverance to over- 
 come the habit. 
 
 Abdominal Rigidity in Air-swallowing. — Mention has 
 been made in the preceding case of the difficulty in 
 palpation of the abdomen owing to the abdominal muscles 
 becoming tense when the abdomen was touched. It was 
 difficult at the time to refrain from thinking that it was due 
 to a volitional act, although one did not see what motive 
 could underlie it. Its presence was striking and it was 
 invariably produced. Quite recently I have again seen this 
 phenomenon. The patient was seen in my consulting 
 room by appointment. He had travelled twenty miles. 
 He was seen at 2 p.m., and he had breakfasted at 9.30 a.m. 
 He had suffered considerably from his stomach for two 
 years, with intervals of relief. The history in part suggested 
 hyperacidity, but in parts this was obscured; in short, 
 symptoms were rather difficult to unravel. He stated that 
 on arriving in town he had tried to take a basin of soup, 
 but he could not swallow it. He was feeling very uncom- 
 fortable in the upper part of the abdomen, the discomfort 
 amounting to pain. On inspection the upper half of the 
 abdomen appeared to be full, and on placing the hand on 
 it the wall became rigid. In spite of every device this 
 phenomenon persisted and interfered with exploration of 
 the abdominal regions. The prominence in the upper half 
 suggested a distended stomach, and on percussion there 
 was a low-pitched tympanicity over it. No splasli could 
 be obtained. The patient was then given a tumblerful of 
 hot water to drink, after which, by means of the binaural 
 
ILLUSTRATIVE CASES OF AIR-SWALLOWITsG 63 
 
 stethoscope, a fine tinkle was heard clearly produced in 
 a resonating air-chamber. A stomach tube was passed 
 with its free end placed in a large basin of water. The 
 force with which the imprisoned air escaped was very 
 great and spilt some of the water out of the basin. After 
 the air had escaped, the residue of breakfast was recovered 
 consisting of finely granular toast : it was very rich in 
 free. HCl. This proceeding gave immediate relief. The 
 swelling in the upper part of the abdomen had disappeared, 
 and its place was represented by a depression. The abdomen 
 could be handled freely without inducing rigidity. The 
 sequence of events was recurring hj-perchlorhydria, the 
 discomfort of which led to unconscious air-swallowing, 
 possibly along with a stimulated salivary secretion. The 
 h\'perchlorh3-dria pain became overshadowed by the extra- 
 ordinary stomach distension and the depression it caused. 
 The patient was a medical man and the case is used to 
 illustrate how easy it is to misinterpret even such a phe- 
 nomenon as abdominal rigidity. 
 
 Case 9. — Mrs. B. was sent to me b}^ a medical friend in 
 the cit}^ as he feared she had some serious disease of the 
 stomach. Her complaint was stomach discomfort and pain. 
 When closely questioned about the " pain " we were able 
 to get the time of onset and the kind of discomfort defined. 
 The time of onset was immediately after eating, it occurred 
 after every meal, and she had suffered from it for months. 
 The kind of discomfort was ascertained by making certain 
 suggestions to her. When asked if the pain was severe the 
 reply was negative, and when asked if it were pain or an 
 uncomfortable feeling of tightness she readily replied that 
 it was a great tightness and fullness. On this definition 
 she became quite clear and decisive. As to the duration of 
 the feeling she thought the time varied. Asked if she 
 brought up much wind, the reply was that she brought up 
 " a lot of wind," and she was quite sure that the bringing 
 up of the wind gave her prompt relief. In other respects 
 the digestive sj^stem presented no abnormal symptoms ; 
 but she was emphatic as to the discomfort, anxiety, and 
 
64 THE STOMACH 
 
 depression the stomach condition caused. Nothing abnormal 
 was made out on examination of the abdomen ; there was 
 no stomach enlargement or ptosis, no tenderness at the 
 caecum or elsewhere. The abdomen was lax and easily 
 explored. 
 
 Such were the facts obtained by a carefully elicited 
 history and from physical examination. Note specially 
 the onset of the symptom of " pain," which was eon- 
 verted into " fullness and tightness," coming on with 
 the taking of food, increasing as food was swallowed, until 
 eating was stopped owing to the feeling of " fullness " — no 
 more could be swallowed. The history in this case is 
 quite different from the history obtainable in a case of 
 gastric ulcer, which is the only condition with which it 
 might be confused, if the history of the symptoms were not 
 carefully and critically examined. The statement of the 
 onset of pain " immediately after food " and of " flatulence," 
 must not be accepted at their bare word value ; not that a 
 patient means to mislead, but because patients do not 
 understand the physiology of digestion and use words 
 loosely. A history has to be sifted in the light of the 
 knowledge of normal digestion, of the aberrations to which 
 digestion is liable, and of the clinical knowledge we have 
 acquired of these disorders. 
 
 Case 10. — Mrs. M., aged 42, had a history of " gastric 
 ulcers " at the age of 22 years. For some weeks before 
 I saw her she had suffered from stomach pain after food 
 and frequent vomiting. She was well nourished and 
 the colour was good. There was a palpable swelling in 
 the epigastrium which felt like a thickened pylorus. The 
 gastric contents showed entire absence of free HCl. A few 
 days in a nursing home showed that there was no pyloric 
 obstruction. She was given dilute hydrochloric acid, milk 
 was stopped, and savoury food was given. The pain 
 and vomiting stopped, but after a few days there was a 
 return of discomfort which on careful questioning was 
 evidently due to air-swallowing, if not to air-gulping also. 
 An X-ray examination showed this view to be correct. 
 
[To face page 65. 
 
AIR-SWALLOWING— CARDIAC DEPRESSION 65 
 
 The condition was explained to her and she was instructed 
 to avoid the act of swallowing except when taking food. 
 She went home and remained well and learnt to recognize 
 the fact that there was a tendency to gulp at certain times, 
 and that it was difficult to resist doing so. She was quite 
 satisfied that she gulped air at these times. Fig. i is of 
 this patient and shows the air-ball at the fundus which had 
 appeared as the bismuth meal was being swallowed. 
 
 Fig. 2 is introduced to illustrate the condition in a more 
 pronounced case. 
 
 Air-swallowing causing Attacks of severe 
 Cardiac Depression 
 
 Case 11 (Mrs. R.). — ^This case is given briefly as it illustrates 
 the reflex effect the condition may have upon the heart. 
 The patient was between 50 and 60 years of age. She had 
 undergone hysterectomy some years before. She had some 
 oedema of the legs, the myocardium was wanting in tone, 
 there was no albumin, and she was considerably run down 
 and easily tired. In the nursing home she had an alarming 
 attack of what looked like collapse. She became pale, 
 cold, and almost pulseless, and she felt very ill. She was 
 treated with great promptness by means of stimulants 
 and heat and recovered. She informed us that she was 
 subject to attacks of this kind. On special inquiry it was 
 ascertained that the symptoms disappeared when she 
 brought up a lot of wind. She stated that this had 
 occurred in other attacks. From this it was evident that 
 our patient was an air-gulper, and that this was the explana- 
 tion of the heart attacks, which had been difficult to under- 
 stand. The condition was explained to her and she was 
 asked to avoid swallowing and to note whether she wanted 
 to swallow. She was an intelligent and observant woman, 
 and she soon told us that at times, and particularly at night, 
 she felt as if a ball were sticking in her throat, and that she 
 made repeated efforts to get rid of the feeling by swallowing. 
 She had difficulty in preventing herself doing this, but her 
 
 5 
 
66 THE STOMACH 
 
 common sense and will-power enabled her to restrain the 
 inclination. The result was that the obscure heart attacks 
 disappeared. 
 
 Cases of this kind are met with from time to time in 
 elderly people, and, when associated with a feeble myo- 
 cardium, the condition gives rise to very alarming symptoms 
 and may even be fatal. I have known the stomach tube 
 used to evacuate the air when it could not be otherwise 
 removed. 
 
 General Remarks. — Air-swallowing with food is a very 
 common condition. It occurs in all classes, and in both 
 sexes. The amount swallowed varies greatly in different 
 individuals. The commonest manifestation is merely a 
 feeling of fullness and distension, after a meal very moderate 
 in quantity, and which passes off as soon as the air is 
 eructated. The eructation is easily induced by some, 
 whilst in others it is only attained after a period of much 
 discomfort. In this latter type of case it is probable that 
 the discomfort leads to further gulping and the eructation 
 is only accomplished when the fundus has attained a certain 
 degree of distension. In some persons the mere act of 
 swallowing means air-swallowing. This fact can be demon- 
 strated by means of the X-ray screen. After a bismuth 
 meal has been swallowed in mouthfuls, and the passage of 
 air with it shown on the screen, the patient is then asked to 
 continue to perform the act of swallowing repeatedly, 
 the increase in the size of the air-ball at the fundus is very 
 striking and can be carried to quite an extraordinary degree 
 of fundal distension. This unfortunate faculty is possessed 
 by some young people. 
 
 The lesser and^moderate forms are commonly described as 
 " flatulent dyspepsia," the prevalent idea being that the 
 " gas " is generated in the stomach. Prevailing notions 
 of stomach fermentation with gas production is a relic of 
 the crude conception we had of stomach troubles and was 
 based upon the experiences of cases of malignant pyloric 
 obstruction. 
 
 The graver forms may be, and often are, associated with 
 
AIR-SWALLOWING— TREATMENT 67 
 
 grave nervous phenomena. Severe neurasthenia and 
 inabiUty for work of any kind along with great mental 
 depression are by no means uncommon. Their true nature 
 often escapes detection. 
 
 Treatment. — As regards treatment the first and the 
 essential point is to get the patient to understand the cause 
 of the symptoms. He or she has to be tactfully instructed 
 and informed that it is an unconscious act and a faculty 
 which some persons possess and others do not. The explana- 
 tion of it is not known, as to the fact there is no doubt. 
 ]\Iitigation or cure can only be effected with the co-operation 
 of the patient. A mixture containing valerian, nux vomica, 
 and acid is helpful. 
 
CHAPTER VII 
 
 METHOD OF DETERMINING THE POSITION AND SIZE OF THE 
 STOMACH IN THE RECUMBENT POSITION 
 
 The importance of care and patience in our endeavours to 
 elicit the real symptoms of gastric and other abdominal 
 disorders has been already dealt with and need not again be 
 dealt with in detail. It is mentioned again as it must never 
 be lost sight of as the starting-point in the investigation of 
 practically all cases. The next step is the determination of 
 the position and size of the stomach. The procedures to 
 be followed in this investigation wiU now be described and 
 explained. In this, as in many other examinations which 
 give phenomena based on simple physical principles, it is 
 necessary to understand that we have to learn not only to 
 recognize the presence of certain phenomena, but also their 
 absence. This statement is understood when it is realized 
 that the physical examination of the stomach depends on 
 its being a bag-like viscus, which varies in size and position ; 
 that it may be empty with its surfaces in contact, or may 
 contain more or less air, and a greater or less quantity of 
 fluid or semi-fluid material. 
 
 Percussion — Tympanicity. — The normal and empty stomach 
 usually contains some air, and when percussion is made over 
 the air-containing part, which is at the fundus, a tympanitic 
 note is elicited. This area, which measures two to three 
 inches in diameter, is above the costal margin on the left 
 side in the mammary line, and is known as Traube's 
 area. When the position of this area is determined the 
 exact extent of it is found by the size of the area of 
 tympanicity. 
 
 68 
 
BULGING AND PERISTALSIS 69 
 
 Auscultation and Scratching. — The limits of the area 
 can also be determined by scratching the surface with 
 the finger nail while the stethoscope is applied over its 
 centre. The scratching sound is well heard over the 
 tympanitic area, but is much diminished in intensity, or 
 quite lost, when the limits of the area are passed. This 
 method is seldom of any value in determining the size or 
 position of the viscus as a whole, for, when the body of the 
 stomach is either empty with its walls in contact, or full of 
 food or fluid, the scratching sound is lost over it. Occasionally, 
 with a patient lying flat on the back, the air in the stomach 
 may be anterior to the stomach contents while they, on the 
 other hand, lie in the more dependent and therefore the more 
 posterior part of the viscus. WThien these conditions are 
 present the whole anterior aspect of the stomach can be 
 mapped out by careful percussion or by combined ausculta- 
 tion and scratching. It is, however, by no means common 
 to find this distribution of air and fluid contents. The 
 point which has to be realized is that tympanicity means that 
 the air-containing part of the stomach is in contact with the 
 parietes, while the airless stomach, or the full portion of the 
 viscus, does not give either the tympanitic note or the 
 auscultatory phenomena mentioned. 
 
 Bulging and Peristalsis. — Even before percussion is used, 
 inspection is made. In normal conditions the stomach does 
 not reveal its position on inspection ; so that here again 
 there is an illustration of the value of the absence of 
 phenomena — what we may call " negative evidence." On 
 the other hand, if the stomach is visible by its bulging out 
 the abdominal wall, or if its contraction or peristalsis is 
 visible, it is frequently a sign of enlargement with some 
 difficulty at the pyloric outlet. The stomach can hardly 
 be said to bulge out the abdominal wall except when the 
 stomach contracts upon its contents, but when such con- 
 traction occurs the abdominal waU can often be seen to rise 
 up so that the outline of the part of the stomach in contact 
 with the parietes can be readily outlined. In other cases 
 not only is this bulging visible, but a quite definite peristaltic 
 
70 
 
 THE STOMACH 
 
 movement can be seen to pass along it. The position of the 
 stomach, of course, determines the position of the bulging 
 and the peristalsis — it may be above or below the level of 
 the umbilicus. The only part of the abdominal viscera 
 with which it may be confused is the transverse colon, and 
 this presents no serious difficulty, for as will be shown 
 presently other means of examination can absolutely 
 determine whether what is visible is or is not due to stomach. 
 
 If it is not due to stomach 
 
 © 
 
 © 
 
 Fig. 3. — S, stomach; TC, transverse 
 colon; U, umbilicus; ^u anterior 
 iliac spines. 
 
 there is usually no doubt 
 about its being transverse 
 colon. 
 
 Stomach and Transverse 
 Colon. — Fig. 3 illustrates 
 what is meant. In the 
 patient from whom the 
 figure was taken, peristalsis 
 was visible along the broken 
 line as soon as the abdomen 
 was looked at, and the first 
 impression made was that 
 it indicated the position of 
 the stomach. By means, 
 to be presently described, the position of the stomach was 
 determined to be as shown in the dotted line ; therefore 
 the peristaltic movement was not present in the stomach 
 but in the transverse colon. It is necessary to mention 
 here that the transverse colon always descends with the 
 stomach, and is to be found along its inferior border no 
 matter how low that border may be. 
 
 The converse is by no means always the case, for the 
 stomach may be normal in position, while the transverse 
 colon forms a great downward loop with its hepatic and 
 splenic ends attached in their normal positions in right and 
 left hypochondria. 
 
 In the preceding method of examination, and in the 
 following procedures, it is necessary to be on the right-hand 
 side of the bed or couch on which the patient is lying. 
 
SUCCUSSION 71 
 
 Palpation and Splashing. — By palpation alone the more 
 or less rounded form of the stomach can sometimes be 
 felt as it contracts on its contents ; but we do not reckon 
 on this as a phenomenon to be depended on to help our 
 examination. The production of splashing is, on the other 
 hand, of great value. It is elicited by tapping with the points 
 of two fingers, or by abrupt but gentle pressure of the four 
 fingers and equally sudden removal of the pressure. The 
 production of the sound depends upon the stomach being 
 in contact with the parietes and containing fluid and air. 
 It can be elicited in all cases of dilatation with sagging of the 
 lower border and in ptosis. The area over which splashing 
 is elicited can be marked with a pencil. The boundaries 
 which can be defined by this method are the lower border 
 or great curve, the lesser curve in the middle line, and the 
 right border, which may reach to the costal margin. If 
 the phenomena are not obtained because there is not sufficient 
 fluid in the stomach, it is obtained by giving a tumblerful 
 or more of hot water. This method is by itself of great 
 service, but the physical conditions present can be further 
 utilized by the two additional methods of succussion and of 
 auscultation-succussion. 
 
 Succussion. — When fluid and air are present in an 
 enlarged stomach a succussion wave can be felt when the 
 abdomen is properly manipulated. To do this the left hand 
 is placed flat over the lateral aspect of the lower ribs on the 
 left side while the right is placed across the epigastrium. 
 The left and right hands are alternately pressed with a jerk 
 inwards, in such a way as to produce a movement in the 
 stomach contents, and, when this is done efficiently and with 
 due intelligence, the wave is felt to impinge upon the hand. 
 In many cases the precise position of the lower border, and 
 of the right limit (which for convenience we call the right 
 border) , of the organ can be thus determined and marked ; 
 the position of the lesser curve can also be determined in 
 this way, and in many cases even the position of the fundus 
 can be confirmed by making the splash travel upwards 
 by the hand placed over the body of the viscus, while the 
 
72 THE STOMACH 
 
 other is over the fundus. The Hnes which succussion gives 
 are absolutely correct, but a certain amount of judgment has 
 to be exercised when the method is used : the position of 
 the hands has to vary with the position of the stomach ; 
 sometimes one kind of movement, at other times another 
 kind of movement will be found the best for producing the 
 succussion wave in different stomachs, li the contents 
 are not fluid enough a cup of hot water can be added to 
 them. If to judgment and common sense a measure 
 of patience is added, the succussion wave can always 
 be got. 
 
 Auscultation-Succussion. — This method of examination is 
 very interesting. It consists in listening with the stetho- 
 scope over the stomach when its contents are made to 
 splash. It is desirable to use a binaural stethoscope for 
 this purpose : it is applied over the stomach by one hand, 
 while with the other the splash is caused, or the splash may 
 be set up by alternating the movement of the free hand 
 with the movement of the hand holding the stethoscope in 
 position. The splash, however faint it may be, is readily 
 heard through the stethoscope, and, if the stethoscope be 
 moved from one point to another, it will be found that the 
 splash has a loudness and a tone when the stethoscope is over 
 the stomach quite distinct from the sound heard when the 
 stethoscope is no longer over it. This method of examination 
 is sometimes very helpful where succussion alone is not 
 satisfactory, or where the splash is not felt well. I have 
 frequently been able in this way to determine the right 
 border of the stomach when without it I might have been 
 in doubt. The upper limit of the fundus can also be thus 
 determined with accuracy. The variety of tone produced 
 by the sound of the splash in the air-containing fundus 
 will interest any one who is attracted by auscultatory 
 phenomena. 
 
 By these various methods the position in the recumbent 
 position of the enlarged stomach can be accurately deter- 
 mined. The common idea that the splashing referred to 
 may be in the colon has to be entirely abandoned. It is 
 
ABSENCE OF PHYSICAL SIGNS OF DILATATION 73 
 
 one of the relics of the days of ignorance to which currency 
 ought no longer to be given. 
 
 The Right Border.— The term " right border," as ap- 
 phed to the stomach, is a chnical term used to define the 
 right hmit of the stomach as it can be determined by the 
 methods which have been described. An explanation of 
 the term is necessary to enable its significance to be under- 
 stood, and it is as foUows. It was repeatedly noted at 
 operations on such cases as have been described, that the 
 dilated organ was carried or thrown to the right while the 
 pylorus remained in its normal position ; the result was that, 
 when the abdomen was opened, this portion of the stomach, 
 had to be drawn aside or out of the abdominal wound in 
 order to expose the pylorus. It is this folded-over portion 
 which gives the " right border." The fact that such a 
 definite border can be clinically determined in the recumbent 
 position becomes evidence of great dilatation and sagging ; 
 and it will be shown that the determination of the position 
 of this border is a great help in diagnosis, and in determining 
 whether surgical interposition is necessary. 
 
 The Absence of Physical Signs of General 
 Dilatation 
 
 The phenomena obtained by the foregoing method of 
 examination are absolute proof of general dilatation if the 
 examination is made when the contents of the stomach 
 are in sufficient quantity to make it reasonable to expect 
 the phenomena. The best time to make the examination 
 is from one to two or three hours after a meal, and, as already 
 stated, it often makes the phenomena clearer if the patient 
 drinks a tumblerful of hot water. The reason of again 
 emphasizing this is that, if the phenomena canjiot he obtained, 
 or are confined to the fundal part of the stomach, it means 
 that there is no dilatation of the pyloric half and no sagging 
 of the lower border of the viscus ; and it is this general 
 enlargement or dilatation which is of special and particular 
 clinical significance, as will be seen later. 
 
74 THE STOMACH 
 
 Explanation of Absence of Suceussion Wave. — Before 
 leaving this subject it is necessary to refer to cases 
 of dilatation in which the splash cannot be elicited right 
 across the abdomen from the left hypochondrium to 
 the right of the middle line, by the method described. In 
 a considerable number of cases of much enlargement it 
 will be found that a splash can be obtained to the left of 
 the middle line by smartly pressing with the fingers, but no 
 wave can be produced across the middle line ; while by 
 again smartly pressing with the fingers between the middle 
 line and the right costal margin, a separate splash or gurghng 
 or squelching can be obtained. The explanation of this is that 
 the stomach is not full, and, as the patient is lying fiat on 
 his back, the portion of viscus in front of the spine flattens 
 itself against the spine and the stomach is thereby divided 
 into two compartments. It thus becomes a physical 
 impossibility for the suceussion wave to pass from the one 
 side to the other. This explanation can be confirmed by 
 X-ray examination with bismuth. Illustrations will be 
 found in Figs. 4 and 6: in them the bismuth is shown in 
 two compartments, one the larger to the left of the vertebrae, 
 the other the smaller to the right. The appearance of two 
 compartments is, of course, lost when the patient is examined 
 in the upright position. When there is considerable air 
 present it occupies this central position in the recumbent 
 position, so that a tympanitic note is present over the spine, 
 while to left and right of it splash or gurgle is elicited. 
 
 X-RAY Examination 
 
 The clinician by the methods described can only deter- 
 mine the position of the stomach in the recumbent position ; 
 but he can determine it as accurately as X-ray examination 
 does. X-ray examination of the stomach after a bismuth 
 meal, however, not only gives its position in recumbency, but 
 also in the erect position. The great difference in the picture 
 of these two positions is to me one of the most interesting 
 and important revelations made by radiography. I never 
 
Fig. 4. — Showing stomach, in recumbent position, with 
 bismuth to right and left of the spine, and the air- 
 space at A. Black rectangle, umbilicus. 
 
 [To face page 74. 
 
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 ibent 
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 8'S M 
 
 
 4j <;^ 
 
 
 ^ .« 
 
 
 
 
 
 
 g- 5 
 
 spii 
 
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 cus. 
 
 
 fc ^ ^ s 
 
 
 as 
 left 
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 3 ^^.^ 
 
 
 C ™ &hSd 
 
 
 U} rfn Qj M-t 
 
 
 
 
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 h 
 
 [To face page 75. 
 
X-RAY EXAMINATION 75 
 
 forget the first time I liandled the abdomen with the patient 
 on a couch and the tube underneath it. On palpating the 
 Ciecum the bismuth-containing stomach and intestine 
 moved as if floating in fluid. The accompanying figures 
 show the remarkable difterence in the position of the stomach 
 in these two postures. Fig. 5 is taken erect, the lesser curve 
 being much dropped, while the greater curve is much below 
 
 O Q 
 
 Fig. 7. — Tracing of stomach, same as Fig. 6. 
 
 the iliac crests. Fig. 6 is taken recumbent and it is seen 
 that the greater curve is midway between the umbilicus 
 and the xiphisternum, while the lesser curve is up under the 
 ribs. Fig. 7 is my tracing taken in the recumbent position, 
 and it is to be noted how closely it corresponds to the X-ray 
 picture taken recumbent. Now the change here portrayed 
 can be so certainl}'- reckoned on that from the tracing obtained 
 in the recumbent position one can predict what the X-ray 
 picture will show when taken erect. In the earlier experiences 
 of radiography the picture in the upright position so misled 
 the surgeon that X-ray examination for this purpose became 
 temporarily discredited. It was at that time, or before it, 
 that I had worked out the methods described of determining 
 the position of the stomach with the patient recumbent, 
 
76 THE STOMACH 
 
 and my tracing gave the position of the stomach as the 
 surgeon found it when he opened the abdomen. The throwing 
 over of the dilated stomach to the right so as to cover 
 pylorus and duodenum, and thereby to give a right border 
 which becomes a guide to the clinician, is a fact of which 
 there is no doubt. Professor Caird informs me that he has 
 seen this prevent leakage from a duodenal perforation. 
 
 The Right Border in the Recumbent Position as a 
 Guide to Pyloric or Duodenal Lesion 
 
 Having thus shown that the size and position of the 
 stomach can be determined by ordinary methods of physical 
 examination, emphasis may be laid on certain conclusions 
 which follow upon the observations. In stomachs where 
 the fundus only is dilated the right border does not extend 
 to the right of the middle line. When the whole organ is 
 dilated the right border is found to the right of the middle 
 line in proportion to the degree of dilatation. When there 
 is dilatation and ptosis the right border is midway between 
 the middle line and the right costal margin, or right over to 
 the costal margin. From the position of the right border 
 the degree of dilatation and of ptosis may be estimated ; 
 and if this be watched hour by hour after a meal it can be 
 determined how long the stomach takes to empty. This 
 observation is of great value in checking and correcting 
 an opinion based on X-ray observations made after a 
 bismuth meal. It will be found that the bismuth meal is 
 got rid of in much shorter time than the ordinary meal of 
 mixed foods. By watching thus it can be shown that the 
 stomach contents are slowly got rid of, that, in short, there 
 is undue retention. When this is found it strongly suggests 
 the possibility, and indeed probability, of pyloric difficulty 
 being present, due to hyperacidity being associated with 
 duodenal ulcer, pyloric ulcer or scar, or congenital narrow- 
 ing. If undue retention can be shown to persist, and is 
 causing discomfort, it commonly means that a gastro- 
 
PYLORIC OR DUODENAL LESION ^^ 
 
 enterostomy is required for complete relief, and relief is 
 complete only when the new opening prevents the retention 
 of a residmmi of the food which has been taken. 
 
 This subject is referred to more fully in the introductory 
 chapter dealing with the pylorus and duodenum. 
 
CHAPTER VIII 
 
 DILATATION OF THE STOMACH — TWO TYPES 
 
 Dilatation of the stomach is not a primary disorder. It 
 is not a clinical entity and ought never to be regarded as a 
 disease by itself. It is, however, a sign or evidence of large 
 value in the consideration of gastric disorder and disease. 
 Its recognition is often the first step towards a diagnosis ; 
 and too much stress cannot be laid on the importance of 
 being able to recognize the existence of the condition. 
 The method of investigation has been described in the 
 preceding chapter. When dilatation is recognized the 
 next question which requires an answer is " what has led 
 to it ? " It is only when this question is answered that 
 the line which treatment ought to foUow is made plain. 
 
 Under the name of dilated stomach there has been much 
 confusion of thought, due apparently to its being regarded 
 as a specific and definite malady. 
 
 There are at least two conditions to which the name is 
 applied. The first and commoner form of dilatation is 
 characterized by enlargement of the fundus of the viscus 
 with extension of the great curve upwards and to the left, 
 and a corresponding increase in the antero-posterior diameter 
 of the organ. This type of dilatation is met with in big 
 feeders, and may sometimes be regarded merely as a big 
 stomach. It may or may not be associated with symptoms 
 calling for medical treatment. The other form of dilata- 
 tion is that in which the inferior border of the stomach 
 has fallen below the level of the pyloric outlet, when at the 
 same time there is enlargement of the cavity and atony, 
 although not immobilit}^, of the muscular coat. This 
 
 78 
 
DILATATION OF THE STOMACH 79 
 
 form can be conveniently called ptosis of the inferior border ; 
 this means that there is sagging of the great curve, without 
 ptosis of the viscus as a whole. 
 
 In this connection let me remind you that the position of 
 the pyloric outlet moves somewhat with the position of 
 the stomach ; it moves somewhat to the right and slightly 
 downwards, but it does not descend in proportion to the 
 degree of ptosis of the inferior border. One result is that, 
 when this form of ptosis occurs, the pyloric outlet is con-, 
 siderably above the level of the lower border ; and, as 
 ptosis is alwaj^s associated with considerable muscular atony, 
 the stomach takes long to empty itself, and in many cases 
 may never empty itself completely. This condition of 
 things is prone to occur in hyperchlorhydria ; it is the cause 
 of much discomfort ; it tends to increase, and the symptoms 
 to become more severe. When recognized early, the checking 
 of the hyperchlorhydria is followed by restoration of tone, 
 and by recovery from the ptosis. With the recurrence 
 of the hyperchlorhydria the ptosis, however, recurs also, 
 with its accompanying miseries. In a patient seen from 
 time to time during the last three years there have been 
 several outbursts of hyperchlorhydria with accompanying 
 ptosis, and a prominent feature in the case has been that 
 with the recurrence of the hyperchlorhydria extraordinary 
 quantities of fluid were poured out into the stomach. He 
 has been entirely without symptoms for as long a period 
 as eight months. When he is free of gastric symptoms 
 there is a relaxation of dietetic rules ; he is a busy and a 
 hard-working man, who will travel to London one night, 
 transact business during the day, dine, and return to Edin- 
 burgh b}^ the night mail, with the result that symptoms 
 may return. He can manage himself so well that he often 
 cuts the attack short ; but, if he does not succeed, I see 
 him again, and he has been warned that these recurring 
 attacks may leave the stomach in such a condition that he 
 will ultimately require a gastro-enterostomy. In this case 
 it is -probable that there are pyloric or duodenal adhesions 
 intensifying the mechanical difficulty, by keeping the pyloric 
 
8o • THE STOMACH 
 
 outlet in a fixed position, and that consequently there 
 is no movement of accommodation on its part. He is not 
 desirous of having an operation, as he has a friend who, 
 in spite of a gastro-enterostomy having been performed, 
 has still to exercise caution in his dietetic habits. 
 
 This leads me to point out that this condition of ptosis 
 of the lower border is more intractable, not only where 
 there are adhesions or narrowing from old healed ulcer, 
 but also in cases where there is congenital narrowing of 
 the pyloric outlet or where the pylorus is abnormally 
 high in position. I saw a case of the last description in a 
 medical man, who had suffered so long and so severely 
 from digestive miseries that I thought it quite likely that 
 his pylorus, which I determined was high in position, 
 might be fixed in its high position by old adhesions, and 
 yet at the operation it was shown that none existed. A 
 gastro-enterostomy was, however, done, with marked 
 benefit. In this patient, from the relation of the pylorus to 
 the lower border of the stomach, it was clear that the 
 stomach could not empty itself properly, and the new 
 opening afforded a channel which enabled it to do so. 
 Another patient, whom I saw some months ago, had a 
 like sagging of the lower border, which had not yielded 
 to treatment, and who also had symptoms indicating 
 pyloric difficulty from previous duodenal lesion. I at 
 once recommended gastro-enterostomy. At the operation 
 old duodenal lesion with adhesions was found of such a 
 kind that would have made an attempt at medical treat- 
 ment ridiculous. She also did well, and was much benefited 
 by the gastro-enterostomy. This patient had been diagnosed 
 a year before as a neurasthenic ; but blunders of this kind 
 are no more to be taken as the standard of the physician's 
 work than the blunder of opening the abdomen unneces- 
 sarily is to be taken as the standard of the surgeon's capacity. 
 The aim of the physician ought ever to be to reduce 
 the margin of error in internal diagnosis to vanishing pro- 
 portions. 
 
 Further illustrations of gastric dilatation will be given 
 
DILATATION OF THE STOMACH 8i 
 
 as the lesions which determine the dilatation are considered. 
 The subject has been meanwhile dealt with in this way to 
 emphasize its great importance as a demonstrable anatomical 
 change which has been produced in the viscus ; and that 
 the presence of the condition can be determined without 
 the assistance of X-ray examination. 
 
CHAPTER IX 
 
 GASTROPTOSIS, OR DISLOCATION OF THE STOMACH 
 
 Definition. — Gastroptosis is the modern designation of 
 what was formerly called " dislocation of the stomach." 
 It is a falling down or prolapse of the organ as a whole, so 
 that its body occupies a lower position in the abdominal 
 cavity than it does normally. As part of a visceroptosis 
 it is dealt with in Chapter XVI. 
 
 Anatomical Considerations. — The size of the stomach 
 varies within very wide limits, even in what is commonly 
 regarded as normal conditions. After starvation or after a 
 period of very spare diet small in bulk, the viscus is as small, 
 or even smaller, than the soda-water bottle with the egg- 
 shaped end. In many pictorial representations it is shown 
 as much larger than this by several times, indeed, many 
 of these representations have evidently been taken from 
 bodies in which the organ was dilated. When dilated its 
 shape and proportions are greatly altered, and also the 
 direction of its main axis. Full consideration has already 
 been given to degrees of dilatation, here it is only necessary 
 to recall some facts which bear upon gastroptosis. It is 
 in the first place to be remembered that the cardiac orifice 
 of the stomach is practically a fixed point, and that from it 
 the lesser curvature of the viscus runs downwards and to 
 the right to the pyloric orifice. This lesser curvature is 
 well under cover of the liver in the epigastrium in the normal 
 state. It is held in position with considerable firmness 
 by means of ligaments ; but also probably by a certain 
 negative pressure, as the liver is held in contact with the 
 
 82 
 
GASTROPTOSIS 83 
 
 arch of the diaphragm. The greater curvature is totally 
 different ; it varies in position with the size and the degree 
 of dilatation of the viscus. The greater curvature may 
 reach to a line far below its normal limits without dislocation 
 of the viscus being present, without there being any change 
 in position more than follows necessarily upon the enlarge- 
 ment of dilatation. Gastroptosis occurs when the lesser 
 curvature fails to maintain its position. When the lesser 
 curvature begins to sag gastroptosis has begun. This 
 sagging of the lesser curvature is due to dragging upon it 
 by the stomach and its contents. It is preceded b}^ stomach 
 dilatation, with atony and prolonged retention of food. 
 The result is due to the simple physical factors weight and 
 strain. The viscus may be regarded as a bag suspended in 
 the abdominal cavity, one end of which, the oesophageal 
 end, is firmly attached, while the other end, the pyloric 
 end, has a much less stable attachment. Along the lesser 
 curvature there is a delicate fold of peritoneum, which is 
 attached above to the liver, is known as the gastro -hepatic 
 omentum, and is presumably a factor of considerable value 
 in keeping the organ in position. The gastro-hepatic 
 omentum cannot, however, be regarded as likely to success- 
 fully sustain any prolonged increase of strain put upon it. 
 It is quite certain, moreover, that there must be greatly 
 increased strain when the hag becomes atonically relaxed 
 and its contents accumulate. There is no doubt that the 
 sequence of events is that the lesser curvature sags, stretches, 
 and is displaced downwards. This is the starting-point 
 of gastroptosis. So long as this has not taken place the 
 stomach is only dilated, no matter how great the dilatation 
 may be. Gastroptosis is, however, very liable to occur 
 when there is marked dilatation, with prolonged retention 
 of stomach contents. It is indeed, the strain of the weight 
 of the stomach which makes the gastro-hepatic ligament to 
 yield. While the essential factor is what has been indicated, 
 there is a predisposing factor which ought not to pass 
 unnoticed : that is, the condition of the abdominal wall 
 and of the intestine. When the muscles of the abdominal 
 
84 THE STOMACH 
 
 wall are firm, and the tone of the muscular coat of the intes- 
 tine good, the firmness of the packing within the abdominal 
 cavity forms a strong support to the stomach, preventing 
 its dislocation. The converse must be equally true, and it 
 is mainly, if not entirely, in lax abdomens that gastroptosis 
 commonly occurs. There is still another support which, 
 so far as the writer knows, has not been hitherto noted, 
 namely, the transverse colon. This part of the colon is 
 in contact with the greater curvature of the stomach and 
 moves with it, descending and retracting as it descends and 
 ascends. While this is true of the transverse colon, it is 
 not applicable to its ends, known to anatomists as the 
 hepatic and splenic flexures. These ends are firmly united 
 to the parietes so firmly that they may retain their position 
 in great measure even in extreme cases of gastroptosis. 
 Owing to this fixedness of the flexures, the transverse colon 
 must therefore provide an additional, and a considerable 
 measure of support to the stomach. 
 
 When, notwithstanding these various checks or hin- 
 drances, gastroptosis begins, it readily, and in some cases 
 rapidly, increases. The fact of its starting implies defect 
 in the various factors which have been mentioned ; and, 
 if the condition which starts it is not recovered from, but 
 persists, the inevitable sequence is a steadily progressive 
 degree of displacement. As the displacement has as its 
 determining cause dilatation or sagging, the persistence 
 of the dilatation not only continues to operate in increasing 
 the displacement but it also leads to increase of the dilata- 
 tion itself. The two conditions thus advance hand in hand. 
 
 The degree of displacement is measured by the position 
 of both the lesser and the greater curvatures. The former, 
 that is the lesser curvature, may reach at its most dependent 
 part to a point as low as from one to two inches below the 
 level of the umbilicus. I have never seen it lower than 
 this. In more moderate degrees it reaches to a point one- 
 third or one-half of the way between the ensiform and the 
 umbilicus. The greater curvature at its most dependent 
 part reaches to a correspondingly low position. I have 
 
Fig. 8.- — Gastroptosis. L, liver; S, stomach; P, pylorus; Dr, first part of 
 duodenum; D3, third part of duodenum ; PA. pancreas; C, colon; XX, 
 anterior ilica spine ; X, umbilicus. 
 
 [To face page 85. 
 
GASTROPTOSIS 85 
 
 seen it reach to the pubes and to an inch or two short of 
 that level. In such extreme cases the upper part of the 
 stomach is sometimes stretched so as to form a long tube- 
 like structure, the left edge being formed by part of the 
 greater curvature, while the right edge is formed by part 
 of the lesser curvature — these edges descend more or less 
 parallel with each other until they respectively reach their 
 lowest points and then turn upwards in such a way as to 
 convert the organ into a large U-shaped tube with a short 
 right-handed limb. In other cases, along with great ptosis 
 the cardiac end may be greatly dilated as is shown in Fig. 8. 
 In extreme cases the pylorus shares in the dislocation to a 
 very marked extent. In the accompanying sketch it 
 is seen almost at the level of the umbilicus, and in the same 
 sketch it will be found that the first part of the duodenum 
 has been so dragged upon and displaced that it forms the 
 upper part of the limb of the U-tube to the left.of the observer. 
 
 As the stomach descends it carries with it the transverse 
 colon while the small intestines also are pushed downwards. 
 So great may the displacement be that the small intestines 
 are packed into a clump in the true pelvis. The transverse 
 colon is stretched to an extraordinary degree and in the 
 stretching becomes extremely attenuated. So thin does it 
 become that it is rendered transparent so that any scybala 
 lying in it are plainly visible. The downward displacement 
 of the stomach exposes part of the pancreas, while in the 
 case from which the accompanying sketch was made the 
 third part of the duodenum was also exposed immediate^ 
 below the pancreas. 
 
 In gastroptosis there is, as stated, great displacement 
 of the small intestine and of the transverse part of the 
 colon, due entirely to the weight and pressure of the dilated 
 organ stretching the structures which act as moorings. 
 So great is the displacement that it is amazing the victims 
 of the condition can go on as long as they do. The purely 
 physical difficulties look as if they were unsurmountable. 
 Reference to Fig. 8 will illustrate what is here indicated. 
 In the upright position of the trunk the gastric contents fall 
 
86 THE STOMACH 
 
 by gravity to the dependent part of the U-tube, and nothing 
 can possibly pass into the duodenum unless the tube be 
 filled well up towards the cardiac end, which would mean 
 quarts of stomach contents. Passage into the duodenum can 
 only take place when the body is recumbent, either on the 
 back or inclined to the right side. Turning to the left side 
 throws the stomach contents into the left limb of the U 
 and away from the pylorus. In some of the cases I have 
 seen the passage of food from the stomach must for years 
 have been confined in the main to the hours of night which 
 were the hours set aside for sleep. 
 
 Symptoms. — The symptoms necessarily vary in intensity, 
 but in view of the great displacement of the gastro-intestinal 
 tract the marvel is that they are not much worse than they 
 are. There are symptoms of indigestion and of dyspepsia ; 
 the sense of a load in the abdomen, or a feeling of dragging ; 
 flatulence, eructations, pain. The symptoms are intensified 
 some time after taking food. There may be nausea and 
 vomiting from time to time. A sense of weariness, of 
 languor, and of inability for physical activity, and in women 
 for domestic duties, is present. When the condition has 
 become extreme and has lasted long, there ensues loss of 
 appetite, or even repugnance to food ; considerable thirst ; 
 vomiting, coming on on slight provocation ; progressive 
 asthenia, extreme emaciation, and death. 
 
 Physical Examination. — On examining the digestive 
 system the tongue is found to be more or less furred or 
 coated and moist. There is constipation, but the bowels 
 can be made to move by means of purgatives. The diagnosis 
 rests upon the physical examination of the abdomen. On 
 inspection, in extreme cases the part of the abdomen below 
 the level of the umbilicus is prominent, as compared with 
 the part above ; but this fullness may not reach to the 
 pubes. In less extreme cases the prominent part of the 
 abdomen is higher than this. It corresponds with the 
 position of the displaced organ. The prominence is usually 
 to be noted even with the patient lying on the back ; but 
 it is more pronounced when standing or sitting. In the 
 
GASTROPTOSIS 87 
 
 icciimbent position the contractions of the viscus can 
 sometimes be noted. The most important evidence is 
 obtained by palpation, and by this means the diagnosis 
 can be made with certainty. Using both hands the splash 
 or succussion sound and wave of the stomach contents is 
 readily produced, and as the viscus is never empty, but 
 always contains more or less fluid or semifluid contents and 
 air, the sign can be elicited almost at any time. The 
 succussion wave can be made to indicate with absolute 
 precision the inferior or most dependent part of the organ, 
 and can also be made to reveal with equal precision the 
 position of the lesser curvature. When these two points 
 are determined it is not difficult to determine the position 
 of the rest of the organ. Percussion will determine the 
 boundaries of the organ at the fundus. When there is 
 not sufficient air to distend this part it is usually little more 
 than a narrow tube, the position of which cannot be demon- 
 strated either by palpation or percussion, but can be correctly 
 inferred by determining the position of the lower part of 
 the organ, and bearing in mind that the cardiac opening 
 remains a fixed point. If the patient be turned from the 
 supine position to the left side, the stomach contents fall over 
 to that side, causing a marked projection, while the position 
 of the succussion wave is also changed. In cases of this 
 extreme degree of displacement care has to be exercised 
 that the position of the stomach is not entirely overlooked. 
 This sometimes happens by the examination being confined 
 to the upper half of the abdomen, particularly over the 
 normal gastric region, when, of course, the negative results 
 obtained will lead to a totally erroneous opinion of the 
 condition present. 
 
 Congenital Pyloric Stenosis as a Cause of 
 gastroptosis. 
 
 Not only may gastroptosis be due to prolonged reten- 
 tion of food in the stomach from acquired lesion at or 
 near the pylorus, it may also be the result of congenital 
 stenosis of the pylorus. When this stenosis exists it leads 
 
88 THE STOMACH 
 
 to conditions which are highly favourable to the production 
 of ptosis. The stenosis leads to a slow escape of the stomach 
 contents into the duodenum, even with the most perfect 
 gastric titration and digestion, and whenever there is delay 
 of this kind the stomach wall is liable to become exhausted. 
 Exhaustion leads to dilatation and to still more prolonged 
 retention of contents and also /favours the establishment of 
 catarrh. If lumps of food such as potato and bread crust are 
 swallowed they lead to much difficulty, for it is impossible for 
 such masses to pass through a congenitally constricted pylorus, 
 so here there is an additional factor favouring retention of 
 gastric contents leading first to atonic dilatation and secondly 
 to ptosis. Cases of congenital stenosis may long resist 
 marked ptosis, and the condition be only discovered when 
 the individual is well on towards middle life or even older. 
 
 A factor which, it has seemed to me, has a determining 
 mfluence on the time at which symptoms become pronounced 
 and continuous is the degree of mobility of the pylorus. In 
 some persons it seems as if the pylorus were congenitally 
 fixed, and even fixed abnormally high in the abdomen, 
 with the result that even moderate dilatation wiU at once 
 give rise to symptoms of retention. In other cases the 
 pylorus moves somewhat freely to the right or downwards 
 and, when this movement corresponds with and is determined 
 by the condition of the stomach, symptoms of retention 
 do not so readily assert themselves and the condition, as 
 a consequence, may be long overlooked. I have seen, as 
 m Fig. 8, with extreme ptosis of long duration, and due 
 seemingly to a congenitally small pylorus, the pylorus at the 
 level of the umbilicus. I have seen considerable ptosis with 
 the pylorus high up and apparently so fixed as not likely to 
 fall ; in these cases symptoms become prominent early. 
 
 It is possible that congenital stenosis may be the cause 
 of aU the extreme cases of ptosis ; but attention has not been 
 sufficiently long directed to these two conditions, either 
 separately or together, to determine whether or no this be 
 the case. Fig. 8 is from a case which occurred when 
 abdominal surgery was in its infancy. 
 
GASTROPTOSIS— ILLUSTRATIVE CASES 89 
 
 Illustrative Cases. 
 
 Congenital Pyloric Stenosis : Gastroptosis : 
 Operation Successful 
 
 Case 12. — Mrs. R., 33 years of age, was admitted to the 
 Ro3'al Infirmary on the 27th April, 1909. The history was that 
 in childliood she was subject to what was called " bilious 
 attacks," which were characterized by headache, which 
 confined her to bed for a day or so, was followed by vomiting, 
 which relieved her. From the age of 18 she had been 
 definitely troubled with her stomach. The symptoms 
 were flatulence, water-brash, and acid eructations. As a 
 riile there was no pain unless she had eaten vegetables, 
 soup, new bread, doughy puddings, or anything spiced. When 
 pain occurred it came on two or three hours after food and 
 was referred to the epigastrium and shot through to the 
 back. It lasted for half an hour or an hour, and was relieved 
 for a time by a hot drink. Patient did not vomit unless 
 the pain was accompanied by a " bilious attack," which it 
 occasionally was. After every meal she had a feeling of 
 weight in the stomach and flatulence (distension) so that 
 she wanted to loosen her clothing. The diet which she 
 found suited her best was stale bread or scones, soft-cooked 
 eggs, a mutton chop, porridge occasionally, strained soups, 
 and fairly strong tea. She continued in this way having 
 occasional exacerbations when the diet just mentioned 
 did not agree with her. For four years she had been 
 troubled with attacks of vomiting ; she would vomit every 
 day for eight or nine days, and then be free from it for 
 perhaps six months. The attacks of vomiting were preceded 
 by loss of appetite, by the feeling of " a great load in the 
 stomach," water-brash, and acid eructations. The vomited 
 material was clear and watery, had a very bad smell, and 
 was very great in amount. The vomiting occurred every 
 half hour or hour for three or four times. The vomiting 
 often occurred between three and four o'clock in the morning, 
 although neither tea nor supper had been taken. A year 
 
90 THE STOMACH 
 
 later, during the last two days of a five-day attack, the 
 vomit was black in colour. After this attack the hands 
 were apparently in a state of tetany. The vomit was not 
 black again until July, 1908. In December, 1908, she had 
 an attack of vomiting of clear fluid for four days, then an 
 interval of two days without vomiting, and then two days 
 of vomiting of very black material. After this attack she 
 had contracture (tetany) of both hands with numbness and 
 tingling in the lower limbs. In the first week of February 
 she had another attack, which lasted four days, and was 
 followed by tetany with stiffness in the jaw in addition to 
 stiffness in the limbs. She had another attack of vomiting 
 on the 31st March, and another on the 25th April. She 
 was admitted to hospital on the 27th. She had always 
 suffered from constipation. 
 
 Condition on Admission. — The patient was a spare 
 woman about 5 ft. in height, and weighing 5 st. li lb. 
 There was no abnormal condition in the thoracic organs. 
 The abdomen was scaphoid in shape and emaciated. 
 Peristaltic movements were visible over what appeared to 
 be, and was easily demonstrated to be, the stomach. When 
 the organ contracted, it made a visible swelling and pro- 
 jection on the abdominal wall, and in this swelling the 
 peristaltic movements were seen to pass from above down- 
 wards and to the right. The outline of the stomach as 
 determined by percussion and succussion was mapped out 
 from time to time and the two tracings given on opposite 
 page show the changes in its position and size, judging from 
 the position of the umbilicus. 
 
 On the day of admission and the following day the 
 patient vomited. She was kept in bed and put on peptonized 
 milk and peptonized arrowroot and milk, four ounces of 
 each every alternate two hours. The bowels were regulated 
 by a pill of cascara, nux vomica, and belladonna. The 
 stomach symptoms improved and the organ diminished in 
 size and was not so low in the abdomen, and we hoped that 
 she might go on improving, but when we got improvement 
 to a certain point the symptoms would all come back ; she 
 
GASTROPTOSIS— ILLUSTRATIVE CASES 
 
 91 
 
 became sick and vomited, and the ptosis and relaxation 
 became as bad as before. We worked away with this case 
 for nearl}^ two months, sometimes being encouraged with 
 the result of treatment ; but, as has been said, beyond a 
 certain point we could not carry improvement, and even 
 that point was too unstable to be of any value. I was 
 anxious to give this patient every possible chance of getting 
 well without operation, although I did not believe it could 
 be done. The reason for this scepticism lay in my belief 
 that there was almost certainly a congenital pyloric stenosis, 
 
 © 
 
 © 
 
 A 
 
 Tracings of Case 12. 
 
 Fig. 9. — U, Umbilicus; n. Ant. 
 iliac spine ; 0, Mammas. 
 
 Fig. 10. — U, Umbilicus; n, Ant. 
 iliac spine ; 0, Mammae. 
 
 or, at all events, a long-standing difficulty at or near the 
 pyloric outlet, which had led to this great measure of ptosis 
 in a woman of thirty-three years. She was quite willing 
 to submit to operation. My colleague, Mr. David Wallace, 
 now Sir David Wallace, opened the abdomen late in June, and 
 found the stomach and pylorus in the condition we have 
 indicated. He performed a gastro-enterostomy. The result, 
 however, was exceedingly disappointing for, after she was 
 allowed to take nutriment into the stomach, vomiting 
 became as bad and even worse than it had been before. It 
 
92 THE STOMACH 
 
 was evident therefore, that the new opening was not draining 
 the stomach. The patient's condition became critical, and 
 Mr. Wallace decided to re-open the abdomen and to repeat 
 the operation of gastro-enterostomy if it seemed desirable. 
 Another gastro-enteric opening was made, which proved 
 thoroughly efficient, and from this operation an excellent 
 recovery was made without any recurrence of gastric 
 trouble. She could eat any kind of food without discomfort 
 and rapidly put on weight. 
 
 Hyperchlorhydria : Gastric Ulcer : Ulcer Healed : 
 Ptosis : Successful Operation 
 
 Case 13. — Mrs. A., aged 47, illustrates this sequence of 
 events very clearly. She was admitted to the Royal Infirmary 
 on the 7th September, on the recommendation of Dr. Angus 
 McDonald. The history was that for about seven years 
 she had suffered from pain referred to the stomach, coming on 
 one, one and a half, or two hours after food. This pain 
 often passed off without anything being done for it ; at 
 other times it was more severe and relief was only obtained 
 by vomiting, which was induced by putting a finger into the 
 throat. The vomited matter consisted of part of the previous 
 meal and was usually very sour. She often relieved the pain 
 by taking baking soda in hot water, and she sometimes took 
 this three times a day. Pain might come on after any meal, 
 but the worst attacks occurred after dinner. Tea in the 
 afternoon did not increase the pain, indeed often eased it. 
 She was often for months on end free from stomach trouble, 
 whilst not dieting herself in any particular way, and indeed 
 when taking ordinary fare. The periods of pain lasted for 
 from two to four months, never under two. The year before 
 admission an attack came on in May and lasted until the second 
 week in October : during this period she would have a few 
 days of freedom from time to time. When the pain came 
 on it gradually became worse until she felt as if her " breast 
 (stomach) would split." An attack began by a lump rising 
 in her throat, and, if she could " break " it, water poured 
 from her mouth ; then she vomited, as a rule, and at once 
 
GASTROPTOSIS— ILLUSTRATIVE CASES 93 
 
 got relief ; the vomit always contained food. From the 
 middle of October to May she was quite free of pain or dis- 
 comfort and could eat anything, " soups of an}^ kind, suet 
 pudding, and potatoes. ' ' In May symptoms began again with 
 the feeling of a lump in the epigastrium, rising up into the 
 throat and making her feel as if she would choke ; then the 
 lump would break with a discharge of clear water from the 
 mouth. This would last for a few days and then the pain 
 would set in. If she took baking soda she felt as if " the 
 bowels rolled over," and she vomited quite easily, at other 
 times vomiting was induced by putting the finger in the 
 throat, while sometimes the pain passed off without 
 vomiting. These symptoms continued from May until 
 admission. She never vomited 
 anything suggestive of blood. 
 For twelve months there had 
 been constipation. She never 
 passed blood, or noticed the 
 motions black or brown in 
 colour. The pain was always 
 in the pit of the stomach and \ -... 
 
 never went through to the '^•*-..„ •''' 
 
 back. She usuahy became 
 
 very hungry after vomiting : ^ ^ 
 
 sometimes the hunger craving Fig. n.— Case 13. stomach re- 
 . , i.1 J. 1 11 cumbent; U, umbilicus. 
 
 was so mtense that she would 
 
 buy apples from a street vendor and eat them ; she said she 
 felt she would go crazy if she did not buy and eat ! Porridge, 
 oatcakes and tea, fish and potatoes, and potato soup always 
 made her worse during these months. 
 
 This patient was shown at a post-graduate clinic on the 
 15th September. The stomach projected and its peristaltic 
 movements were visible. K rough outline of the body of 
 the stomach was marked out by aid of percussion and 
 succussion : the outline is shown in Fig. 11. From this it 
 was evident that there was definite ptosis, but, as the 
 pylorus also was displaced downwards, I was of opinion 
 that a factor, in addition to ptosis, was required to explain 
 
94 THE STOMACH 
 
 the severity and the long continuance of the symptoms, 
 A cicatrized ulcer near the pylorus was, in my judgment, 
 the most likely additional factor. There was free hydro- 
 chloric acid in the gastric contents. I did not think it 
 worth while to spend time in trying to remedy the condition 
 by careful feeding, massage, and lavage, so advised her to 
 have an operation. To this she consented, and the operation 
 was performed by my colleague, Mr. Wallace, on 15th October. 
 The puckering caused by a healed gastric ulcer near the 
 pylorus was shown at the operation. Mr. Wallace performed 
 a gastro-enterostomy and the patient left hospital on the 
 2nd November feeling very well, able to take a good meal, 
 and very grateful for the relief she had obtained. 
 
 Remarks. — This patient was a most intelligent woman, 
 as was shown by the clearness with which the history of her 
 gastric troubles had been given. From that history it is 
 clear that her early symptoms were typical of hyperchlor- 
 hydria. During the year preceding the year of admission 
 the long duration of symptoms suggested that at that time 
 she probably had an ulcer near the pylorus, which must have 
 healed, seeing that the winter months had been so entirely 
 free of discomfort. Her functional troubles recurred, 
 associated with dilatation and ptosis, the symptoms being 
 intensified by the scar near the pylorus. Had she been in 
 a position to spend months over the restoration of the stomach 
 to the condition it had been in during the previous winter, 
 and had she been so placed socially that she could have 
 paid continuous attention to having a suitable dietary, 
 aided by equally suitable medical supervision, life might 
 have been made quite tolerable for her ; but, under the cir- 
 cumstances, the treatment advised was in my judgment 
 the only wise course. The stomach and duodenum were 
 of course examined with a view to excluding any fresh 
 ulceration, and in view of the negative result of the examina- 
 tion we consider that this case is an additional proof of 
 our contention that hyperchlorhydria may lead to gastric 
 ulcer, that that ulcer can heal, that symptoms may pass 
 away and return without any new ulcer having formed ; 
 
GASTROPTOSIS— TREATMENT 95 
 
 and therefore that the doctrine of hyperchlorhydria being 
 caused by ulcer is erroneous and misplaces cause and effect. 
 
 Treatment. — The treatment to be adopted will depend 
 upon the degree of displacement. In the lesser or moderate 
 degrees of the condition the treatment applicable to dilatation 
 is suitable. Food in small bulk, finely divided, and easily 
 and rapidly digested ought to be taken. The patient ought 
 to lie down for two hours or more after meals. Sometimes 
 benefit is obtained and comfort is afforded by an abdominal 
 belt, especially the obstetric type of belt with the pressure 
 on the lower part of the abdomen so applied as to help to 
 hold up the intestines, supplementing the support supplied 
 by the anterior abdominal wall. Massage of the muscles 
 of the abdomen will help to strengthen the muscles them- 
 selves, and if by the addition of prolonged rest and liberal 
 feeding the subcutaneous fat can be increased the benefit 
 may be still greater. It is most desirable that the condition 
 should be seriously dealt with in its earlier stages and such 
 measures as have been indicated taken to cure it. If 
 patient and wisely directed treatment on the lines indicated 
 does not lead to restitution of the organ to its normal 
 position and condition, gastro-enterostomy ought to be 
 advised. The advantage of the operation is that the 
 emptying of the stomach is facilitated. Still, if suitable 
 treatment be available it ought to have a reasonably long 
 trial before recourse is had to surgical measures. In extreme 
 cases, however, the outlook is gloomy, and it is very 
 doubtful if treatment at best can be more than palliative. 
 It may be more definitely stated that the relief and the 
 improvement which foUow on gastro-enterostomy when 
 cases are properly selected, are very striking. To my mind 
 the only possible explanation of the improvement is that the 
 gastric contents rapidly drain through the new opening 
 whenever the stomach wall relaxes from its peristalsis. 
 This almost certainly prevents further ptosis ; although to 
 what extent it may favour the return of the stomach to 
 normal size and position cannot be definitely predicted, for 
 these apparently varj^ in different cases. 
 
96 THE STOMACH 
 
 That the passage of the food from the stomach directly 
 into the jejunum does not lead to inefficient digestion is 
 shown by the great increase in weight that rapidly follows 
 upon the operation. 
 
 A point which is worthy of emphasizing is the necessity 
 of seeing that the lowest part of the stomach is the point 
 selected for communicating with the jejunum. In Case 12 
 it was shown that unless this was secured relief did not 
 follow ; while the relief that followed upon the second 
 operation proved that the efficient drainage of the stomach 
 is really the mechanical basis on which the therapeutic 
 success of the operation depends. Recently one of my surgical 
 colleagues asked me to examine a patient on whom he had 
 some time before performed a gastro-enterostomy with 
 success and with great relief to the patient. Owing 
 apparently to want of sufficient care some of the old symptoms 
 were reappearing and this seemed to me to be due to a 
 measure of gastric dilatation which brought the lowest part 
 of the stomach below the level not only of the pylorus but 
 of the gastro-enterostomy opening. He was again suffering 
 from symptoms of retained food residuum. The lesson 
 to be learnt was that with moderate care such dilatation 
 would not occur, and that, when dilatation was not present, 
 the artificial opening would efficiently drain the viscus. 
 
 Whatever theoretical contentions have been advanced 
 to show the unreasonableness of adopting a procedure which 
 seemed to run counter to our knowledge of the digestive 
 processes in the upper parts of the gastro-intestinal tract, 
 the results are such as to warrant fully the acceptance of 
 the treatment on empirical grounds. 
 
 The two cases to which reference has just been made 
 suggest the thought that some of the cases of " vicious 
 circle " which have been recorded may have had as their 
 true cause the failure of the artificial channel to act as an 
 efficient drain for the stomach contents. 
 
CHAPTER X 
 
 PYLORIC STENOSIS, ESPECIALLY CONGENITAL STENOSIS IN 
 
 THE ADULT 
 
 Pyloric Stenosis i 
 
 In approaching the subject with which this chapter deals 
 the generally recognized causes of pyloric stenosis may be 
 enumerated. They are (i) ulcer, (2) cicatrix, and (3) 
 malignant disease. 
 
 Pyloric Spasm. — That any of these three conditions may 
 cause recurring spasm contraction of the pylorus will not 
 be questioned by any sound clinical pathologist. That the 
 spasm is due to local irritation will be generally conceded ; 
 while the further proposition, that the spasm is an important 
 factor in occluding the pyloric outlet, will be readily accepted 
 by clinicians who have watched such cases with any reason- 
 able measure of interest. 
 
 That pyloric spasm may, in addition to the causes just 
 enumerated, be also determined by the direct stimulation 
 or irritation produced by the chemical character or 
 mechanical state of the gastric contents upon the unbroken 
 pyloric wall will not meet with such general acceptance ; 
 while probably only few clinicians have confirmed Lauder 
 Brunt on' s 2 observation that pyloric spasm may accompany 
 migraine, and be but an additional manifestation of an 
 explosive neurosis. 
 
 Effect of Pyloric Stenosis. — Without going into details, 
 which are unnecessary, it may be noted that the main 
 
 1 Reprinted from the British Medical Journal, nth July, 190S, with 
 some alterations. 
 
 - Lauder Brunton, AUbutt's System of Medicine, vol. iii. 
 
 97 7 
 
98 THE STOMACH 
 
 result or manifestation of stenosis is stomach dilatation 
 or ptosis. The size and position of the stomach can, as a 
 rule, be easily determined by physical examination ; while 
 the recurring vomiting demonstrates the retention in the 
 stomach of material which, under normal circumstances, 
 is readily passed on into the duodenum. 
 
 A further and a very important manifestation of pyloric 
 stenosis is visible stomach peristalsis. This, when present, 
 at once excludes the possibility of the dilatation or ptosis 
 being due to muscular atonicity resulting from catarrh, 
 anaemia, or nervous debility. It is only in pyloric obstruction 
 associated with the retention of considerable power in the 
 muscular wall of the viscus, that this symptom will be 
 noted ; and in my experience such a loss of power only 
 occurs in extreme cases, which are either cases in which 
 there has been a long history of gastric trouble, or are 
 malignant, with a relatively rapid progressive debility and 
 a correspondingly short history. Where definite pyloric 
 swelling is palpable the merest tiro in clinical medicine has 
 no difficulty in ascribing the gastric symptoms to pyloric 
 obstruction. 
 
 Congenital Stenosis an Additional Cause of 
 Pyloric Obstruction in the Adult 
 
 From the preceding summary I hope it may be con- 
 ceded that I approach the subject of congenital stenosis of 
 the pylorus in the adult with sound views regarding pyloric 
 stenosis in general, and I turn now to the special theme of 
 this communication. 
 
 We may begin with the historical side ; and we need 
 not too seriously concern ourselves with the question as to 
 who recorded the first case. John Thomson ^ ascribed it to 
 Williamson of Leith in 1841, Osier 2 has put it back to Dr. 
 Hezekiah Beardsley in 1788 ; further research may put it 
 back into the still darker ages of medicine. For our present 
 purpose it is not profitable to go beyond the years 1879 and 
 
 ^ John Thomson, Scot. Med. and Surg. Jottrn., June, 1897. 
 2 Osier, referred to by Cautley and Dent. 
 
CONGENITAL STENOSIS IN THE ADULT 
 
 99 
 
 1885. In the former year, 1879, Heinrich Landerer 1 
 published the thesis submitted by him for the doctorate of 
 medicine of the University of Freiburg. It was entitled 
 Congenital Stenosis of the Pylorus. After referring to the 
 hitherto known causes of pyloric stenosis and gastric 
 dilatation, he proceeded to show that there was an additional 
 condition to those he had enumerated — namely, one in 
 which the stenosis was congenital. He supported this 
 thesis by giving details of ten instances in which he noted 
 pyloric narrowing. The first case observed was a man of 
 45 years, who had been for years in the hands of doctors on 
 account of stomach disorder. After death it was found that 
 he had an enormously dilated stomach without structural 
 change, no thickening at the pylorus, and yet a pyloric 
 outlet so small as to measure only 2 mm. This led to the 
 careful examination of the condition of the pylorus in other 
 bodies. The result was that he collected other nine instances 
 of narrowing in persons ranging in age from 43 to 63 years. 
 The degree of stenosis varied. Although it was only in the 
 first case that a previous history was available, his clinical 
 acumen led him to realize that this was a condition which 
 must be of importance to the clinician. 
 
 In 1885 Professor Rudolf Maier 2 of Freiburg published in 
 Virchow's Archiv a contribution to the same subject. He 
 gave a short account of thirty- one cases in which he had 
 found a pyloric stenosis which he believed to be congenital. 
 The observations were made at post-mortem examinations, his 
 attention having been drawn to the matter by a striking 
 example of the condition having occurred in one of his 
 patients. The cases varied in age from 12 to 75 years. 
 The degree of narrowing of course varied considerably, 
 but in none was the narrowing associated with what we 
 would caU a coarse structural lesion. As the result of 
 these observations he separated his cases into two groups : 
 First, a simple form ; second,, a combined form. The 
 
 1 Landerer, Ueber angeborene Stenose des Pylorus, Tubingen, 1879 
 
 2 Maier, "Beitrage zur angeborenen Pylorus-stenose," Virchow's Arch., 
 1SS5, Bd. cii. S. 413. 
 
loo THE STOMACH 
 
 second group contained the cases in which, in addition to 
 stenosis, there was thickening of the pylorus. With regard 
 to the first group, where narrowing was present without 
 other change at the pylorus, he did not think there was 
 reasonable room for doubt that they were congenital ; 
 those in which there was pyloric thickening in addition to 
 narrowing he examined more fully and argued more closely 
 in support of their congenital nature. 
 
 This argument we need not follow now, for later develop- 
 ments have strengthened his contention that a combined 
 form is met with in the adult. At the same time, the 
 subject cannot be left without indicating that the description 
 of the changes he observed will be found well worthy of 
 attention from those specially interested in the exact 
 anatomical appearances presented by them. 
 
 Congenital Hypertrophic Stenosis in Infants 
 
 The next important step was the recognition that the 
 condition now known as hypertrophic pyloric stenosis in 
 infants was a pathological fact and a clinical entity. 
 Hirschsprung i in 1888 seems to have been the first to 
 describe the condition ; but many members of the profession 
 probably first had their attention drawn to the subject by 
 John Thomson's 2 paper published in 1897. Since those 
 dates the flood of literature on the subject has attained 
 portentous proportions. It is no part of my present purpose 
 to deal with that literature, or with the differences of opinion 
 which have risen up around the etiology of the condition — 
 that may be left in the hands of the protagonists already in 
 the field. It may, however, be taken as established that there 
 is met with early in infant life a stenosis of the pylorus due 
 to, or accompanied by, marked thickening of the muscle 
 of the pylorus ; that the condition is commonly regarded 
 as congenital, and is described as congenital hypertrophic 
 stenosis in infants. 
 
 1 Hirschspriing, quoted b}' Bloch, Jahrhuch fur Kinderheilkunde, 1907, 
 Ixv. S. 337. 
 
 2 John Thomson, loc. cit. 
 
HYPERTROPHIC STENOSIS IN INFANTS loi 
 
 It does not appear, so far as a cursory look through 
 some of the hterature has disclosed, that any other form 
 of stenosis has been observed in infants ; that is to say, 
 there are no examples of the class Maier called simple 
 stenosis. 
 
 The hypertrophic stenosis is much the same as Maier's 
 Combined Form. It is so easy of recognition in extreme 
 cases that one wonders now that clinicians had not recognized 
 it long before. 
 
 On that lack of observation on the part of clinical 
 pathologists it is not necessary to enlarge. It is, however, 
 necessary to claim that in a condition of this type there 
 must of necessity be degrees of stenosis and degrees of 
 thickening. AU infants with hypertrophic stenosis of the 
 pylorus do not die. Only the severe cases are seen by 
 the expert, and it is only for them that surgical aid is 
 required. 
 
 That aU cases have not the same measure of pyloric 
 narrowing, and therefore do not show equally urgent clinical 
 symptoms wiU presumably be granted as a sound proposition. 
 In support of the proposition there indeed emerges from the 
 literature what to my mind is an illuminating difference of 
 opinion. It is this : Controversy has arisen as to the part 
 that spasm of the pylorus takes in the production of the 
 hypertrophy and of the stenosis. Pfaundler i goes far 
 when he holds that the condition is entirely one of local 
 cramp or spasm, and that it can be successfully combated 
 by medicinal and dietetic measures. Pfaundler's contentions 
 are based on clinical observation, and, as such, they belong 
 to the data on which judgment has to be founded. At the 
 same time, if I do not question his observations, neither 
 do I question the observations of those who have had 
 experience of cases unrelieved by dietetic or medicinal 
 measures, and imperatively requiring surgical measures for 
 the relief of a permanent and structural obstruction. 
 
 From this it must be inferred that there are degrees of 
 stenosis, and that a pyloric stenosis is not incompatible 
 
 ^ Pfaundler, Wien. klin. Woch., Nr. 45, 1898, p. 1025. 
 
I02 THE STOMACH 
 
 with infant life ; that in spite of its presence hfe may be 
 continued into childhood and even onwards. 
 
 Simple Stenosis in Infants. — That, so far as I know, 
 there is no recognition in infancy of what Maier calls simple 
 stenosis is to me inexplicable, and when cases begin to be 
 recorded of simple stenosis of the pylorus being found in 
 children of 6 years when on the operating table, it is at 
 least suggestive that there is a clinical hiatus which ought 
 not to be difficult to fill. 
 
 The Present Medical Position 
 
 When we inquire into the position congenital stenosis of 
 the pylorus in the adult occupies in the realm of clinical 
 medicine at the present moment, there are facts to be noted 
 which have considerable significance. The article on 
 dilatation of the stomach i in AUbutt's System of Medicine, 
 is from the pen of the erudite editor himself, but there is no 
 mention of this condition amongst the causes of dilatation. 
 
 Sidney Martin ^ and Hemmeter ^ do not mention the 
 condition. Ewald,* quoting Landerer and Maier, includes 
 congenital stenosis amongst the mechanical constrictions 
 met with at the pylorus. Van Valzah and Nisbet ^ recognize 
 congenital pyloric stenosis in infants, and state that, with 
 the observance of a proper diet, they may live into adult life. 
 
 Lambert and Foster, 6 writing in 1907 on benign stenosis 
 of the pylorus, do not mention the congenital form. 
 
 Riegel,7 writing in 1908, only refers to congenital 
 narrowing of the pylorus as due to muscular hypertrophy 
 of the pylpric sphincter, and as leading to early death. 
 
 Boas,8 writing in 1907, merely mentions congenital 
 
 ^ Clififord Allbutt, System of Medicine, vol. iii. 
 ^ Sidney Martin, Diseases of the Stomach, 1895. 
 =* Hemmeter, Diseases of the Stomach, 1898. 
 
 * Ewald, Diseases of the Stomach, second German edition, 1892, p. 125. 
 "•' Van Valzah and Nisbet, Diseases of the Stomach, 1899. 
 
 * Lambert and Foster, "Benign Stenosis of the Pylorus," Amer. 
 Joitrn. Med. Sci., 1907, vol. 134, p. 335. 
 
 ' Riegel, Die Erkrankungen der Magens, 1908, II Teil, S. 220. 
 
 * Boas, Diagnostik und Therapie der Magenkrankheiten, II Teil, 1907, 
 S. 168. 
 
THE PRESENT SURGICAL POSITION 103 
 
 pyloric stenosis in the adult, and passes on to the consideration 
 of other causes of stenosis. 
 
 Osier 1 asks if some of the cases of dilated stomach with 
 thickening or hypertrophy of the pylorus may not be 
 congenital. 
 
 The Present Surgical Position 
 
 When we turn to the surgical side of the literature dealing 
 with the abdomen, the following may be quoted : 
 
 Cautley and Dent 2 refer to three cases as suggesting a 
 congenita] origin, occurring at the ages of 6, 11, and 22. 
 
 Mayo Robson and Moynihan,^ after reviewing and 
 discussing the literature on congenital hypertrophic stenosis, 
 conclude as follows : " There can be little hesitation in 
 affirming that a congenital abnormality of the pylorus of 
 some, at present indeterminate, character may after the lapse 
 of few or many years be so altered, or added to, as to cause 
 symptoms of pyloric obstruction. The conditions and 
 the frequency of such cases require further investigation." 
 Mr. Mayo Robson, in his large experience, had only operated 
 on one such case at the date of writing, the patient being a 
 young man of 24 years. 
 
 Maylard * of Glasgow in 1903 wrote a paper that has not 
 received the attention in this country to which it was 
 entitled, on " Congenital Narrowness of the Pyloric Orifice." 
 The paper is based upon observations made when the 
 abdomen had been opened for " chronic gastric derange- 
 ment." The condition of the pyloric orifice in those cases 
 was not only sufficient to explain the symptoms which 
 existed, but " to suggest that the condition itself was 
 probably of congenital origin." In 1904 he recorded another 
 case, a man aged 31, in whom at the time of operation he 
 found a hypertrophic stenosis of the pylorus, which he believed 
 
 ^ Osier, Practice of Medicine, igoi. ■ 
 
 - Cautley and Dent, Tratis. Roy. Med. and Chi. Soc, vol. Ixxxvi., 
 December, 1902. 
 
 3 Mayo Robson and Moynihan, Diseases of the Stomach, second edition, 
 1904. 
 
 * Maylard, Clin. Soc. Trans., vol. xxxvii., London, 1904- P- ^3- 
 
104 THE STOMACH 
 
 to be congenital, presenting the " funnel-shape " type 
 described by Maier. 
 
 In none of the cases recorded does it appear that any 
 attempt had been made at a differential diagnosis before 
 the patient was submitted to operation. 
 
 When Landerer and Maier wrote, the surgery of the 
 abdomen had not entered upon the brilliant operating 
 epoch included in the last twenty years ; and although they 
 both insisted on the great value of differential diagnosis, 
 the success of surgical operations on the stomach may be 
 said to have dulled the desire for diagnostic precision. 
 That phase has already nearly passed. 
 
 The Existence of the Condition 
 
 From all that precedes it seems to me that the occurrence 
 in the adult of congenital stenosis must be accepted as an 
 established fact. From the observations of Landerer and 
 Maier and from the experience of Maylard it might even 
 be predicted that, as soon as attention is definitely directed 
 to the condition of the pylorus, cases of pyloric narrowing will 
 be found to be a fairly common cause of intractable gastric 
 symptoms. To again quote Maylard : " There exists a 
 considerable class of patients in young adult life who owe 
 their chronic gastric trouble to a congenital narrowness of 
 the pyloric orifice." That both the simple and the hyper- 
 trophic forms will be found also seems to be probable. 
 
 Three Cases 
 
 As a contribution to the diagnosis of congenital simple 
 stenosis of the pylorus I submit the following three cases 
 which had fallen into my hands when this chapter was written. 
 
 Case 14. — Thomas C, aged 34, married, was admitted to 
 the Edinburgh Royal Infirmary on the 28th August, 1906. He 
 complained of vomiting and pain in the abdomen, and stated 
 that he had been very bad for the preceding six weeks. On 
 going into his history it was ascertained that he had been 
 troubled with his stomach for fifteen years, that is, since he 
 
ILLUSTRATIVE CASES 105 
 
 was a youth of 19 years. The general description of his 
 symptoms was that he had discomfort, fullness, and heaviness 
 in the stomach, coming on usually about an hour after food. 
 The discomfort was sometimes followed by and relieved by 
 vomiting. Sometimes the vomiting was at night. The 
 vomit when copious, he thought, consisted of what he had 
 taken for some days. The vomit had sometimes been dark 
 in colour and frothy. Twelve years previously he was treated 
 in the infirmary for dilated stomach, and for the same con- 
 dition two years later. Since that time he had been troubled 
 off and on with his stomach. For twelve months he had had 
 comparatively little trouble until six weeks before admission, 
 when discomfort, pain, and vomiting came on. The dis- 
 comfort and vomiting became very severe, and, he was 
 confident, worse than ever before experienced. He had lost 
 flesh and, of course, weight. Constipation had been extreme, 
 the bowels only moving once a week if left to themselves. 
 There was no history of melaena, nor of vomiting recently 
 poured out blood. The patient had a fresh complexion, 
 but was very lean. The stomach was greatly dilated ; the 
 fundus was at the level of the fifth rib, and the lower border 
 below the level of the umbilicus. The lesser curve was 
 lowered in position, while the pylorus was high up under the 
 liver edge. He on several occasions vomited as much as 
 three pints, and as much had been removed by the stomach 
 tube. The total acidity of the gastric contents was high, and 
 there was much free hydrochloric acid. From the symptoms 
 and from the stomach dilatation and ptosis there was no 
 doubt about pyloric obstruction. The chemical examination 
 of the stomach contents excluded malignant disease, and the 
 symptoms were not those of gastric ulcer. From the high 
 position of the pylorus I inferred that it was probably held 
 up by old adhesions, and that the fixity with the addition 
 of ptosis would so kink the outlet as to lead to obstruction. 
 The patient had a gastro-enterostomy performed by Mr. 
 Caird. At the operation no adhesions were found, and 
 there was no evidence of recent or of old ulceration. The 
 difficulty at the pylorus was due to an indurated and 
 
io6 THE STOMACH 
 
 apparently fibroid condition of the pyloric ring. The patient 
 made a speedy recovery and was entirely relieved of his 
 symptoms. It never occurred to me that the condition of 
 the pylorus found in this patient might be congenital until 
 Mr. Maylard, of Glasgow, wrote to me on the subject, 
 pointing out that the condition corresponded with cases he 
 had described. The suggestion at once appealed to my 
 judgment, and I was surprised it had not instinctively 
 occurred to me before. 
 
 Case 15. — James M., aged 42, married, was ad- 
 mitted to the Edinburgh Royal Infirmary on the 22nd 
 July, 1907. He complained of vomiting, constipation, 
 giddiness, and weakness. He stated that he had lost much 
 flesh during the preceding fortnight, and he was so ill that 
 he had been a week in bed before admission. Careful 
 inquiries into his history elicited the fact that he had suffered 
 more or less from his stomach all his life. Even when 
 he was a herd-boy he used often to vomit. The vomiting 
 attacks came on at intervals of a few weeks, at other times 
 after an interval of a few months. The attacks were 
 preceded by " sickness " (nausea). After vomiting he was 
 relieved, but the vomiting might continue for some days, 
 but after that he would be all right again for a while. When 
 asked about the character of the vomit, he said that he 
 " always minds that it was very, very sour." At that time 
 his food was the same as his brothers and sisters had, and 
 they did not suffer as he did. These attacks of stomach 
 disorder had recurred aU through life, and it was only by 
 great care as to his feeding that he was able to avoid their 
 more frequent occurrence. He usually breakfasted at g a.m., 
 and could not take another meal until 2, 3, or 4 p.m. His 
 afternoon meal commonly consisted of rice-soup made 
 with mutton, some of the mutton being cut up finely and 
 put into it ; or of fish or tripe with .bread. He gave up 
 taking potatoes and all other vegetables years ago, as they 
 " always came up." He drank a good deal of skimmed 
 milk and buttermUk. His symptoms had been severe 
 since the middle of June ; they were of the same type as 
 
ILLUSTRATIVE CASES 107 
 
 formerly, but were more persistent, and he could not depend 
 on any meal staying down. The stomach showed dilatation 
 and ptosis ; the greater curve was considerably below the 
 level of the umbilicus, while the lesser curve reached the 
 level of the umbilicus. The pylorus was in the right hypo- 
 chondrium, not far from the costal margin ; there was no 
 thickening. Handling the abdomen set up visible gastric 
 peristalsis. The gastric contents showed abundant free 
 hydrochloric acid. The diagnosis in this case seemed to me 
 to be perfectly clear, and I strongly advised the patient 
 to submit to operation. A gastro-enterostomy was performed 
 by Mr. Dowden. There was no evidence of recent or cica- 
 trized ulcer ; the pylorus had to my eye much the same 
 appearance as the former one, and Mr. Dowden could only 
 put the tip of a finger into, not through, it. This patient 
 also made an excellent recovery. 
 
 Case 16. — Mrs. H., aged 51, was admitted to the Edin- 
 burgh Royal Infirmary on the 25th October, 1907. She 
 was a small, spare, ill-nourished woman. Her complaints 
 were referred to the stomach. She had suffered all her 
 life from indigestion, but for the past four years her symptoms 
 had been more pronounced. In fact, during that period 
 her medical history was a varied one, although gastric 
 symptoms, as pain and vomiting, appear to have pre- 
 dominated. She had never been able to eat vegetables ; 
 there was a history of having vomited material like coffee 
 grounds shortly before admission to the infirmary. On 
 examination the stomach showed dilatation and ptosis, 
 both curves being displaced downwards, the greater one 
 reaching to considerably below the level of the umbilicus. 
 There was often visible gastric peristalsis. There was no 
 thickening of the pylorus. The gastric contents contained 
 no free hydrochloric acid. From the dilatation, ptosis, 
 and peristaltic movements there was no doubt as to the 
 existence of pyloric difficulty, but without pyloric thickening. 
 The symptoms were not those of gastric ulcer. The absence 
 of thickening at the pylorus led me to negative malignant 
 disease notwithstanding the absence of free hydrochloric 
 
io8 THE STOMACH 
 
 acid. In fact, the symptoms seemed to me to be due to 
 the retention of stomach contents ; and in view of the 
 lifelong history of indigestion and the need of extreme care 
 with regard to food and great moderation in the quantity 
 taken, I looked upon this case as another example of conge- 
 nital stenosis. I advised this patient to submit to operation. 
 Mr. Hodsdon operated. The case was, however, an unlooked- 
 for disappointment. The condition at the pylorus was as 
 I had judged it to be ; but there was in addition a malignant 
 growth high up at the fundus which could not be removed. 
 A gastro-enterostomy nevertheless was performed and gave 
 the patient complete relief from her gastric symptoms. 
 She made an excellent recovery, but the operation was 
 foUowed by that curious feeling of " having no mind " 
 which is one of the occasional and mysterious sequelae of 
 such operations. There was no constant pain, no pain on 
 the ingestion of food, no difficulty of deglutition, no mass 
 to be felt, to guide us to the suspicion of malignant growth 
 at the fundus. The absence of free hydrochloric acid 
 suggested malignancy, but being satisfied that the pylorus 
 was not malignant the idea was set aside. I concluded 
 that the absence of free HCl was an individual pecuHarity 
 which is not rare. 
 
 I heard of this patient in the beginning of June, 1908. 
 There had been no return of the gastric symptoms and no 
 further signs of malignancy. The mental condition had not 
 improved. 
 
 Diagnosis 
 
 The diagnosis may be briefly summed up under the 
 following heads : 
 
 History. — ^There is a long history of stomach trouble, or 
 of such digestive difficulties that the patient has learnt to 
 be very careful as to the character and the quantity of 
 food taken, and to allow a sufficient number of hours to 
 separate meals. On the intelligence with which diet has 
 been regulated depends the further history. There may 
 be a history of supposed bilious attacks dating back into 
 
DIAGNOSIS 109 
 
 childliood. In Case 15 the patient as a boy had at varying 
 intervals of time attacks of vomiting, which lasted for a 
 day or two. He had had these when his feeding was his 
 share of the food provided for the family, yet none of his 
 brothers or sisters had similar attacks. As he grew to 
 manhood he had learnt great abstemiousness in eating and 
 drinking, and thus saved himself from a frequent repeti- 
 tion of acute digestive disorder. In Case 16 the patient 
 had similarly learnt by experience how to regulate her 
 diet. In Case 14, where possibly the stenosis may have been 
 less pronounced, there was a definite history of preceding 
 attacks of severe digestive disorder with stomach dilata- 
 tion. In all three patients previous attacks had been over- 
 come by ordinary dietetic and medicinal means ; they 
 came to hospital because ordinary means had failed, and 
 ordinary means failed in our hands also. 
 
 Symptoms. — ^The symptoms are the symptoms of 
 stomach dilatation or of gastric dyspepsia, vomiting only 
 occurring in the more severe attacks. The attacks of 
 stomach disorder tend to become intensified as they are 
 repeated ; and as Mayo Robson has observed, something 
 happens, often not till life is fairly advanced, which brings 
 out the pyloric difficulty and leads to all the symptoms of 
 pronounced pyloric obstruction. 
 
 Physical Examination. — At the stage when these cases 
 are likely to come to hospital, stomach dilatation is easily 
 made out on physical examination. In two of my three cases 
 gastric peristalsis could be induced. In Case 14 the dilata- 
 tion and gastric atony were too pronounced to allow of this 
 sign being elicited. When gastric peristalsis can be induced 
 the pyloric end of the stomach also contracts and is easily 
 located. In my three cases there was no permanent — that 
 is to say, continuous — pyloric thickening. The cases 
 being examples of the simple form accounts for the absence 
 of this sign ; whereas in the combined or hypertrophic 
 form there is permanent thickening, although the degree 
 of thickening will vary from time to time. The absence 
 of continuous pyloric thickening is a most important 
 
no THE STOMACH 
 
 diagnostic point, but the negation, of course, assumes that 
 the pylorus can be located through the parietes. 
 
 Pyloric Spasm or Cramp. — ^This as a physical sign re- 
 quires a Httle special reference made to it. Kussmaul ^ 
 appears to have been the first to draw attention to it. It is 
 recognized by Ewald, Hemmeter, Van Valzah and Nisbet, 
 and Boas. It is a condition that I knew clinically long 
 before I knew that Kussmaul had noted it. When spasm 
 occurs, the pylorus hardens and thickens ; when spasm 
 relaxes, the pylorus softens. The two phases can usually be 
 easily followed by the hand placed over the pylorus, as the 
 patients are lean with a lax abdominal wall. The spasm 
 can be caused by the irritation of the stomach contents, by 
 structural lesion at or near the pylorus, or even by nervous 
 disorder. Spasm occurs both with and without permanent 
 hj^pertrophic or hyperplastic thickening of muscular and 
 fibrous tissue. Such permanent thickening is also no 
 necessary accompaniment of pyloric narrowing ; in fact, in 
 my three cases there was no thickening, and reference has 
 been made to similar observations by others. When spasm 
 is present there is thickening, and in this way spasm often 
 enables us to locate with certainty the position of the 
 pylorus, while the knowledge thus gained of its position 
 may enable us to definitely determine after spasm has 
 relaxed whether structural thickening has remained. 
 When structural thickening remains, the question of its 
 cause remains to be decided. 
 
 Chemical Examination of Gastric Contents. — The chemical 
 examination of the stomach contents, especially the 
 determination of the presence or absence of free hydro- 
 chloric acid, should, of course, never be omitted, for the 
 result materially influences the formation of an opinion. 
 
 Summary. — ^The diagnosis in the case of simple stenosis 
 is determined by the existence of pyloric difficulty, the 
 character and duration of the history, the absence of per- 
 manent pyloric thickening, the presence of free hydro- 
 chloric acid in the stomach contents, the exclusion of 
 
 ^ Kussmaul, Dent. Arch. f. kJin. Med., 1869, Bd. vi. p. 455. 
 
THE CLINICAL PATHOLOGY in 
 
 ulcer, of malignancy at the pylorus, and of a history that 
 would fit in with cicatrix from previous ulceration. \Mien 
 there is permanent thickening the benign causes, when we 
 exclude ulcer, are congenital hypertrophic stenosis, and 
 cicatrix from healed ulcer. The field for differential 
 diagnosis can thus be greatly circumscribed and simplified. 
 In fact, once the possibility of congenital stenosis occurring 
 in the adult enters the clinical field of vision, it will, I 
 think, be found to be quite within the differential 
 diagnostic skill of the physician. 
 
 Treatment 
 
 The treatment might be summed up in the words 
 of Lambert and Foster, i when discussing benign stenosis 
 of the pylorus, namely : (i) Control excessive secretions, 
 (2) reduce pyloric irritability, and (3) increase the muscular 
 activity of the stomach wall. Space does not permit of 
 these principles being elaborated here. \Mien dietetic 
 and medicinal measures are no longer sufficient to enable 
 a patient to nourish himself, the physician can, fortunateh' 
 with confidence, advise the patient to submit to surgical 
 operation. 
 
 The Clinical Pathology 
 
 I have not had the opportunity of examining post 
 mortem the character of the anatomical change at 
 the pylorus in simple stenosis. The changes in both 
 the simple and the hypertrophic form have, however, 
 been dealt with by Maier and Maylard. In the three 
 cases which have been in my hands I have only seen the 
 pylorus when it was exposed at the time of the operation 
 and when the surgeon was satisfied as to the smallness of 
 the opening and, at the same time, of the absence of ulcer, 
 new growth, or cicatrix to account for it. Under these 
 circumstances, I fail to see what view the clinical patho- 
 logist can hold but that the narrowing or stenosis is 
 
 ^ Loc. cit. 
 
112 THE STOMACH 
 
 congenital. There is, so far as I know, no pathological 
 process which produces this kind of change, while I am 
 told that a more or less corresponding congenital condition 
 occurs at the internal os of the uterine cervix, and a con- 
 genital tightness of the prepuce is common. That the 
 condition may, in some instances, be the true cause of the 
 attacks of indigestion or dyspepsia seen in young people 
 has to be kept in mind, for until the possibility of occur- 
 rence is present to the mind it cannot be diagnosed. In 
 young or later adult life symptoms are more likely to 
 become pronounced, for it is a common experience to find 
 digestive disturbances emerging during this period. It 
 must also be acknowledged that, if congenital narrowing 
 be present, gastric catarrh, hyperchlorhydria, or pyloric 
 spasm \n\l all tend to present exaggerated symptoms. 
 When, therefore, any one of these conditions is present, the 
 definiteness of pyloric difficulty may be a surer guide to the 
 existence of the congenital defect than we as yet know. 
 Another factor which Maylard lays stress on, probably 
 rightly, is that any condition which weakens the muscular 
 coat of the stomach, such as anaemia or general debility, 
 will bring out symptoms of digestive trouble, owing to the 
 pyloric narrowing effectively preventing the passage of the 
 gastric contents under the lowered pressure of weak 
 stomach contraction. There are thus several explanations 
 to account for the symptoms of congenital stenosis first 
 appearing prominently in adult life, or at least assuming 
 such prominence as to send the sufferer to seek medical 
 help. 
 
 Further Remarks on Congenital Stenosis 
 
 Since the preceding pages were written experience has 
 increased and a wider view of the relations of this condition 
 has been obtained. The condition does not appear to be 
 commonly recognized, yet it is possible that many persons 
 are the victims of this narrowing. Such persons early 
 learn to eat sparingly and carefully, as experience teaches 
 them that indulgence is followed by discomfort. Another 
 
FURTHER CASES AND REMARKS 113 
 
 interesting and important point in some of these cases is, 
 that pronounced symptoms may not appear until middle 
 life is reached, and that as life advances the symptoms 
 become more pronounced. The explanation seems to be 
 that under conditions of physical or mental stress, or of 
 both, the involuntary musculature of the stomach is 
 weakened and not so able to overcome the congenital 
 defect. This leads, of course, to atonic dilatation with 
 undue retention of food and consequent discomfort. In 
 other cases disordered secretion, particularly in the direction 
 of over-secretion of acid, supervenes, and, to the factor of 
 stenosis, pyloric spasm is added, leading to still longer 
 retention and to still further dilatation. I have recentl}^ 
 heard of a case of this kind successfully operated on, 
 although the patient was over sixty years of age. 
 
 This is in keeping with our experience of other gastric 
 disorders in younger people. In hyperchlorhydria, for 
 instance, the typical symptom in older persons, of recurring 
 pain does not in early life get beyond the stage of discomfort, 
 I recently saw a girl, twelve years of age, at the suggestion 
 of Sir Henry Dalziel of Glasgow, as there was a question 
 about the state of the appendix. That structure was giving 
 rise to anxiety, for there had been abdominal discomfort, and 
 the caecal region was tender, so its removal was recommended. 
 An X-ray plate showed a large stomach for a child, and 
 I suggested that it was congenital. The appendix was 
 removed by Sir Henry Dalziel, and he informed me that 
 in the family more than one member had a congenitally 
 narrow pylorus. Yet this child had so far not shown 
 gastric symptoms. 
 
 Two additional cases may be given, as they illustrate the 
 condition as present in youth and in middle age. 
 
 Narrow Pv'lorus: Ulcer and Stenosis 
 at duodeno-jejunal junction 
 
 Case 17. — C. L., a girl of 15 years, was admitted to 
 the Royal Infirmary on the 9th November, 1908. She 
 was under-developed and very thin. Six months before 
 
 8 
 
114 THE STOMACH 
 
 she had suffered from diarrhoea for two months, from which 
 she had to a great extent recovered. After this she developed 
 pain over the stomach and vomiting. Pain was alwaj^s 
 present but varied in intensity, sometimes reUeved by food, 
 sometimes made worse. Vomiting also occurred at irregular 
 times and once or twice daily. On examination of the 
 abdomen its wall was held tense, but no pain was elicited by 
 such palpation as was practicable. Stomach splashing 
 was easily elicited ; the organ was large, the right border 
 being at the right costal edge. The patient was sent to 
 me by one of my surgical coUeagues for observation and with 
 a view to her general condition being improved. We did 
 all we could for her by careful dieting and medication ; 
 the stomach contents removed on several occasions by means 
 of the tube showed no free acid. She became steadily 
 worse and died on the 15th December. Her condition 
 was discussed at the clinic and the conclusion was arrived 
 at that there was probably congenital pyloric stenosis, with 
 something in addition which did not appear to be ulcer 
 near the pylorus. There was no doubt that there was 
 extreme difficulty in passing on the stomach contents, that 
 there was an absence of hydrochloric acid, that there was 
 no palpable thickening of the pylorus, and that stomach 
 peristalsis of fair strength was present, for it could be seen 
 and felt. This case occurred before X-ray examination 
 with bismuth had attained the useful position it has now 
 attained, so that method of examination was not available. 
 Had the girl lived longer the abdomen would no doubt 
 have been opened with a view to gastro-enterostomy. The 
 post-mortem examination showed an enlarged stomach with 
 a distinct band of thickening at the pylorus, composed 
 principally of muscular tissue. There was marked dilatation 
 of the second and third parts of the duodenum. There was 
 an ulcer surrounding the gut at the duodeno-jejunal junction 
 which encroached so much on the lumen of the gut that 
 only a No. 6 catheter could be passed through the obstruction. 
 There were old and some recent tuberculous lesions in the 
 abdomen and old caseous changes in the thorax. This 
 
NARROW PYLORUS 115 
 
 case is briefly recorded here on account of . its unusual 
 character, and as an illustration of the advance which has 
 been made in methods of examination within the past 
 twelve years. 
 
 Indefinite SvMPtoMS : Narrow Pylorus : Pyloro- 
 plasty : Recovery 
 
 Case 18. — Annie D., aged 46, was admitted to the 
 Royal Infirmary on the 24th February, 1911. The 
 complaint was " pain in stomach." Eight weeks before 
 admission she began to suffer from burning pain in the 
 left hypochondrium which extended over the left side 
 of the chest. The pain was not severe, but was always 
 present and was not influenced by taking food. After 
 about a week the pain became more severe, coming on an 
 hour after food and lasting for two and a half hours. She 
 was put on light diet, but this did not lessen the pain. The 
 pain often prevented her sleeping. She came to Edinburgh 
 and was admitted to the Royal Infirmary. She did not 
 suffer from flatulence or acid eructations, and there had 
 been no vomiting. The bowels moved daily and easily. 
 She had lost weight. Twenty years before, she had suffered 
 much from indigestion, pain coming on immediately after food 
 and being often accompanied by vomiting. She was treated 
 at that time for " gastric ulcer," being put on milk diet 
 and kept in bed. In three weeks she completely recovered. 
 From that time she had occasionally experienced discomfort 
 after food, but not pain. On examination of the abdomen 
 the fundus of the stomach was found to be somewhat 
 enlarged, and there was slight tenderness in the right hypo- 
 chondrium. All her organs were sound, the urine presented 
 no important change, the blood showed a moderate anaemia. 
 The gastric contents removed on two occasions showed much 
 free hydrochloric acid. During the seven weeks she was 
 in my ward she was dieted with great care, first with milk, 
 then with egg and milk, then with gruel and milk, arrow- 
 root and milk, and occasionally with fish. Belladonna and 
 
ii6 THE STOMACH 
 
 an alkali were given and the colon was washed out. Later 
 small doses of morphine were added to the belladonna. 
 All these measures had no beneficial effect on the pain. 
 It persisted, although it varied in intensity, and sometimes 
 prevented her sleeping. The feeling of weight remained 
 stationary. ]\Iy surgical colleague, Mr. Miles, saw the patient 
 and it was decided to open the abdomen. The operation 
 was performed on the 4th April. There was no evidence 
 of present or past ulceration, but the pyloric outlet was 
 very small. A pyloroplasty was done. The patient made 
 an excellent recovery and was entirely cured and had 
 remained well when last heard of. 
 
 Treatment. — Individuals with pyloric narrowing who 
 have succeeded in keeping gastric discomfort in abeyance, 
 do not come under the notice of the physician, and only 
 incidentally under the notice of the general practitioner ; 
 yet it may be assumed there are many such persons. When 
 a case of congenital stenosis in early, middle, or later life 
 comes under observation the symptoms which have emerged 
 are due either to the supervention of a failure of muscle 
 compensation or to an attack of hyperchlorhydria. In the 
 former case the treatment ought to be directed to facilitating 
 and hastening gastric digestion, by supplying, not only 
 suitable food, but ensuring that aU food is either minced or 
 made into pulp in the mouth before being swallowed. And 
 in the second place by the administration of such tonics as 
 may be indicated, strychnine being the best, and, when 
 necessary, relief from the physical or mental strain which 
 may have contributed to the break down in compensation. 
 WTien, on the other hand, the symptoms result from too free 
 secretion of hydrochloric acid, treatment must be directed 
 to checking it. If these methods aU fail, recourse must be 
 had to surgical measures, and this can now be advised with 
 the utmost confidence. At the same time it must be in- 
 sisted on, that the presence of congenital narrowing cannot 
 be taken as necessarily requiring surgical interposition, and 
 that it is the duty of the physician to determine the cause 
 of the emergence of symptoms, and then to endeavour to 
 remove them by dietetic and medicinal measures. 
 
CHAPTER XI 
 
 GASTRIC ULCER 
 
 Simple Gastric Ulcer may for clinical purposes be divided 
 into two groups, namely, acute and chronic, or recent and 
 long-standing. The group in which the individual case is 
 placed will to a very important degree influence the prog- 
 nosis and determine the measures to be taken for the removal 
 of the symptoms and the repair of the ulcer. It will be 
 found to carry much the same significance as is attached to 
 the terms " acute " and " chronic " when applied to an ulcer 
 of the leg. 
 
 Acute or Recent Gastric Ulcer 
 
 Pathogeny. — ^The acute gastric ulcer presents a punched- 
 out appearance, with but little if an5' appreciable infiltration 
 of its floor or edges. There is a larger area of mucous 
 membrane destroyed than of the underlying coats, which 
 gives its section a terraced appearance. The exact etiology 
 is still a subject of speculation ; it does, however, appear 
 as if from one cause or another there must be, to begin 
 with, a localized area of greatly lowered tissue vitality, 
 or even of necrosis, from interference with, or complete 
 arrest of, the blood circulation at the affected spot ; and 
 that, as a result, the devitalized or necrosed tissue is rapidly 
 digested by the gastric juice, so that a clean-cut ulcer is 
 left. 
 
 Preceding Conditions. — In the great majority of cases 
 ulcer is preceded by definite symptoms of gastric and 
 digestive disorder. In young women, in whom gastric ulcer 
 
 "7 
 
ii8 THE STOMACH 
 
 is common, the stage of ulcer is often preceded not only 
 by a history of indigestion, but also of chlorosis. In men 
 ulcer is also preceded by a long history of indigestion or of 
 dj^spepsia. Even the form the dyspepsia assumes is known 
 to be the acid form, in which heart-burn, water-brash, acid 
 eructations, and flatulence are prominent phenomena. In 
 fact, gastric ulcer has come to be so closely associated with 
 hyperacidity that the acidity has come to be looked upon 
 as having an etiological significance, although the precise 
 part it takes in determining ulcer formation is not known. 
 In men it appears as if hyperchlorhydria were frequently 
 the precursor of gastric ulcer. This gains support from the 
 contentions which have emanated from certain quarters, 
 that aU cases of so-caUed hyperchlorhydria are really cases 
 either of gastric or of duodenal ulcer. This contention is 
 based upon the failure to recognize the existence of such a 
 condition as hyperchlorhydria ; but the diagnosis of this 
 form of altered function has been so fully discussed in an 
 earlier chapter, that it is unnecessary to deal with it again 
 here, while the contention is utilized to support our own 
 experience, that hyperchlorhydria may be followed by, or 
 even lead to, ulcer. 
 
 Position of Ulcer. — ^The position of ulcer may be at 
 almost any point of the gastric wall, although the frequency 
 with which it is found is not the same at all points. It is 
 more common in the pyloric half of the organ, and on the 
 lesser rather than the greater curve. It may, however, 
 be close to the cardiac opening. The symptoms are modified 
 and influenced by the position of the ulcer, as might be 
 anticipated ; and as pain is the leading symptom in all 
 cases it is this symptom which is mainly influenced. The 
 site of the pain and the time it comes on after taking food 
 are guides to the position. The nearer the ulcer is to the 
 pylorus the longer the interval between taking food and the 
 onset of pain ; but it is not usually longer than half an hour. 
 It often comes on immediately after taking food. 
 
 Symptoms. — In most cases of gastric ulcer there is a 
 history of longer or shorter duration of symptoms of gastric 
 
ACUTE OR RECENT GASTRIC ULCER 119 
 
 disorder. These symptoms are discomfort coming on some 
 time after taking food ; flatulence with eructation of air ; 
 heart-burn ; pyrosis, or the eructation of mouthfuls of acid 
 material ; perhaps pain, coming on an hour or two after 
 food has been taken ; occasionally vomiting. There is 
 usually a dehnite history of constipation with the bowels 
 moving only when purgative medicine has been taken ; or 
 moving without such assistance, but scantily and quite 
 inefficiently. 
 
 General symptoms are present, as well as local symptoms, 
 such as weakness and inability for exertion or even for 
 ordinary domestic duties. Languor and apathy are common. 
 
 All these symptoms may have lasted for months, indicating 
 disturbance of gastric function. 
 
 When ulcer has formed the main symptom is fain 
 referred to the stomach, not infrequently going through to 
 the back in the lumbar region. It comes on immediately 
 after or soon after food is taken. It continues until all food 
 has left the stomach, and it returns when food is again taken. 
 This sequence is so definite, even to the least observant of 
 persons, that as little food is taken as possible, with the 
 inevitable result of lowered health and strength and the 
 development of ancemia. There is almost always pro- 
 nounced constipation, an efficient motion being only obtained 
 by means of some laxative or purgative medicine. There 
 may be hcematemesis, the vomiting of recently poured-out 
 blood, or of material resembling coffee grounds or hare soup, 
 and consisting of blood which has lain in the stomach for 
 some time and has been acted upon by the gastric secretion. 
 When there has been a large haemorrhage part of the blood 
 passes into the duodenum, and when passed per anum is 
 black in colour, and known as melcena. The amount of 
 bleeding varies greatly, it may be so profuse, or repeated so 
 frequently, as to endanger life. 
 
 Perforation. — The ulcer may be of the acute perforating 
 type, when all the coats of the stomach wall are involved 
 in the morbid process. This is probably the more common 
 history of perforation ; but perforation may occur in an ulcer 
 
120 THE STOMACH 
 
 which has been present for some time, and even in an ulcer 
 of long duration. The diagnosis of perforation is difhcult 
 in some instances, especially if the perforation be small, and 
 be so situated that there has been little escape of gastric 
 contents. The guiding symptoms are sudden pain, collapse, 
 and acute tenderness over the whole abdomen. It is doubt- 
 ful if any other condition in the abdomen produces these 
 three phenomena so suddenly. No doubt perforation may 
 occur elsewhere, but with the pain referred to the upper 
 half of the abdomen the perforation is either in the stomach 
 or duodenum, — ^which it is, is of merely academic interest ; 
 whichever it is, prompt action is required. 
 
 Reservations and Wrong Diagnoses. — A reservation has 
 to be made when gastric ulcer is spoken of or thought of. 
 The mental picture is, or tends to be, of the full-blown and 
 classical acute perforating type. It is necessary, however, 
 to think of the mucous membrane of the stomach presenting 
 abrasions or excoriations, without extension into the deeper 
 coats, with little risk of such extension, and therefore with 
 no risk of perforation. That some bleeding occurs not only 
 from such an abrasion, but even from a limited area of 
 congested vessels, must also be accepted as reasonable and 
 requires a further reservation. The lurid picture evoked 
 by the diagnosis of " gastric ulcer and haematemesis " is 
 much modified if it can reasonably be thought of as excoria- 
 tion or congestion of the gastric mucosa with some blood 
 leakage, and this it must often be. 
 
 This explanation is offered to explain the large number 
 of cases of wrong diagnosis which were admitted to m}^ wards 
 in the Royal Infirmary. WTien a bed was available I never 
 refused to admit a case which was said to be gastric ulcer 
 with slight haematemesis, or indeed entirel}^ without a history 
 of haematemesis. A great many cases of this description 
 passed through the female ward. They were carefully 
 investigated as to history and symptoms. " Pain after 
 food " was often reduced to occasional pain, or pain after 
 a fairly large meal, which might only last for a short time. 
 The history was wanting in recurrence of pain after each 
 
ACUTE OR RECENT GASTRIC ULCER 121 
 
 meal and continuing until the stomach was empty. The 
 symptoms of gastric ulcer were found on careful investiga- 
 tion to be wanting, in many cases in which a history was 
 given of hsematemesis. The patients were often of poor 
 physique, often anaemic or chlorotic, and there was pro- 
 nounced constipation. The routine treatment adopted for 
 them was colon lavage by means of a douche can, instead 
 of by an enema syringe, at intervals of three or four hours, 
 using about 30 ounces at a time. The diet was in some cases 
 restricted at hrst to milk gruel made with oatmeal, in other 
 cases the ordinary light diet of the Infirmary was given. 
 Most of these cases got rapidly well and were entirely 
 relieved of gastric symptoms. In a few cases compound 
 tincture of rhubarb with bicarbonate of soda and chloroform 
 water were given, especially if the tongue were coated or 
 deeply furred. Before leaving hospital the regular action 
 of the bowels was attained by phenol phthalein or cascara, 
 to which taraxacum might be added or the three com- 
 bined. 
 
 My experience in Edinburgh of this common error in 
 diagnosis corresponds with Sir Berkeley Moynihan's in 
 Leeds, the difference being that the patients were sent to 
 him as a surgeon, to me as a physician. 
 
 Gastric Ulcer Heals. — That gastric ulcer which has 
 not been allowed to become chronic can and does heal, is 
 proved by the presence of scars in the stomach wall. In- 
 teresting experiments were recorded by Dr. C. A. Bolton, 
 in 1910. He produced acute ulcers in guinea-pigs by 
 injecting gastro-toxin into the stomach wall, and found 
 that the area was rapidly digested by the gastric juice. He 
 found that the ulcers healed, taking from two to four weeks 
 to do so. There can be no reasonable doubt that in the 
 human subject a like rapid healing can take place under 
 favourable conditions. 
 
 Treatment of Acute Gastric Ulcer.— In cases of severe 
 haemorrhage, when the surgeon did not think the patient's 
 condition permitted operation, or when it was decided 
 to wait and watch, the treatment adopted was the with- 
 
122 THE STOMACH 
 
 holding of food for a few days, then beginning with small 
 quantities of diluted milk to which some bicarbonate of 
 soda was added. In recurrence morphine and atropine were 
 given hypodermically, and in some cases chloride of calcium 
 by the rectum seemed to check the bleeding. The diet was 
 increased gradually by adding to the milk first oatmeal 
 gruel and then raw egg beaten up. The medicines used 
 were soda and belladonna to counteract acidity and to 
 inhibit its too free secretion. If, in spite of these measures 
 symptoms of ulcer continued, the question of surgical inter- 
 position was considered. Each case has to be judged of 
 separately. In some cases of severe haemorrhage the 
 patient's condition may not contra-indicate operation, and 
 if there has been a history of previous gastric trouble, 
 especially if there is evidence of gastric dilatation with the 
 right border considerably to the right of the middle line, 
 operation is indicated. If there is a recurrence of evidence 
 of bleeding, the indication is operation. 
 
 The following case illustrates what symptoms and signs 
 are present when the question of operation has definitely 
 emerged in a recently formed ulcer. 
 
 Hyperchlorhydria History for Ten Years : Recent 
 Gastric Ulcer with Pain and H^matemesis : 
 Dilated Stomach : Operation 
 
 Case 19. — John R., aged 45, was admitted to my ward 
 on the 12th October, 1914, complaint being " pain in stomach 
 and vomiting." 
 
 History. — He had suffered from his stomach for ten 
 years. Pain came on about three hours after food, and 
 might last until he took his next meal. The pain was very 
 severe, but was promptly relieved by taking food, even a 
 drink of water relieved it. He would be quite free of pain 
 for weeks or months, and then without any known reason 
 it returned. The season of the year had no apparent effect. 
 In August he had one of the recurrences, and on the morning 
 of the 8th he vomited a considerable quantity of " brown 
 
ACUTE OR RECENT GASTRIC ULCER 123 
 
 stuff." He went to work, but had to return home owing to 
 severe pain. On reaching home he vomited " half a gallon 
 of red blood." He was kept in bed for a fortnight, and at 
 the end of that time he again vomited " brown stuff mixed 
 with red." He remained in bed for three weeks. In the 
 second half of September he had another attack of vomiting, 
 the vomit being brown in colour. He remained in bed until 
 he was sent to the Royal Infirmary. He had noticed that 
 he was always constipated during his recurring attacks. 
 At 3 a.m. on the morning after admission, having had pain 
 and nausea up to that hour, he vomited sixteen ounces of 
 material like hare soup. This contained blood and much 
 free HCl. 
 
 Examination. — ^There was nothing abnormal to note on 
 inspection of the abdomen, and there was no tenderness. 
 The stomach was enlarged and splashed to the right costal 
 margin. He was transferred to Professor Caird on the 
 17th, and operated on at once. A large ulcer was present 
 near the pylorus on the lesser curve of the stomach. A 
 gastro-enterostomy was done. 
 
 Remarks. — It must I think, be accepted that in this 
 patient there had been a long pre-ulcer stage of hyper- 
 chlorhydria with stomach sagging. The symptoms of ulcer 
 appeared suddenly in the course of the last of his attacks, 
 and they never disappeared. Recurring haemorrhage, 
 vomiting, and a dilated stomach left no doubt in one's mind 
 that this was a case for prompt surgical treatment. 
 
 Chronic Gastric Ulcer 
 
 Symptoms. — ^The term " chronic gastric ulcer " is used to 
 indicate in the first place that symptoms are present which 
 warrant the diagnosis of ulcer, and in the second place that 
 the symptoms can be traced back for weeks, or months, or 
 years. Pain is again the outstanding symptom ; pain 
 caused by taking food, or coming on soon after it is taken, 
 and being worse the larger the quantity of food taken. 
 
 A history such as this is so definite that evidence has to be 
 
124 THE STOMACH 
 
 found that will disprove the a priori presumption. The pain 
 is different from the pain in hyperchlorhydria ; it comes on 
 sooner, and while it may be alleviated by such drugs as give 
 marked relief in hyperchlorhydria, it is not cured. A big 
 meal may lengthen the time before pain appears in hyper- 
 chlorhydria, it never does so when chronic ulcer is present. 
 Vomiting is not usual, although it may occur. Hcemorrhage 
 is common, but is not invariably present. If present in 
 considerable amount it is vomited as pure blood. If the 
 ulcer is near the pylorus, so that there is undue retention of 
 gastric contents, and slight bleeding occurs, vomiting is 
 common, and the vomit contains altered blood. There may 
 be melsena. The bleeding may be so persistent as to cause 
 death. A certain proportion of cases perforate with escape 
 of gastric contents into the peritoneal cavity ; but many 
 chronic ulcers have formed adhesions to surrounding parts 
 which prevent leakage into the peritoneal cavity. The 
 floor of a chronic ulcer on the posterior wall is often the 
 pancreas. 
 
 When the ulcer is at or near the pylorus marked dilatation 
 with undue retention of gastric contents is present, and can 
 be demontsrated by the methods already described. 
 
 Treatment. — If a diagnosis of chronic gastric ulcer has 
 been reached the fact has to be definitely faced that medical 
 treatment will not heal it. The diagnosis is not difficult if 
 the patient is intelligent. The margin of error is small. 
 The diagnosis ought not to wait for haemorrhage to occur, 
 for the haemorrhage may be fatal, from the involvement 
 in the chronic ulcerative process of a considerable artery. 
 As regards surgical measures the mere performance of a 
 gastro-enterostomy is unsatisfactory. The only satisfactory 
 treatment is to deal directly with the ulcer, and if the ulcer 
 is near the pylorus this implies a gastro-enterostomy as well. 
 When it is situated elsewhere this further procedure will not 
 be necessary. In bad cases of long duration, where the floor 
 of the ulcer is formed by an adjoining organ, and there are 
 extensive adhesions the difficulties the surgeon has to face 
 are great and may be insurmountable. It is important to 
 
CHRONIC GASTRIC ULCER 
 
 125 
 
 recognize this fact and to realize that it has become the duty 
 of practitioners and physicians to diagnose the presence of 
 gastric ulcer long before such changes have had time to be 
 produced. With surgical measures so eminently satis- 
 factory when in the hands of expert operators, it is to be 
 hoped that the deplorable cases of long-standing ulcer will 
 soon be no longer seen save as ancient relics in pathological 
 collections. 
 
 Hour-glass Constriction : Chronic Ulcer : Gastro- 
 plasty : Remarkable Relief 
 
 Case 20. — Miss M. had suffered for years from her 
 stomach. Pain was the prominent symptom. The taking 
 
 X 
 
 Fig 
 
 •Case 20. 
 
 C, the position 
 
 Stomach in upright position, 
 of the contraction. 
 This and the two following figures were kindly drawn by Dr. Hope 
 Fowler, from X-ray plates. 
 
 of food caused so much pain that it had been reduced to the 
 smallest possible amount and the blandest procurable. The 
 
126 
 
 THE STOMACH 
 
 result was that she was very lean, if not emaciated, weak, and 
 unfit for physical effort of any kind. A previous X-ray 
 examination was understood to show an hour-glass con- 
 striction of the viscus. Although the general condition was 
 such as this, there was no suggestion of cachexia, and the 
 symptoms had lasted so long that malignancy was regarded 
 as improbable. We only succeeded in obtaining a small 
 specimen of gastric contents, but it showed free HCl, which 
 strengthened the opinion that the condition was not malig- 
 
 FiG. 13. — Same case recumbent, showing at C contracture, at U bismuth 
 *in floor of ulcer. 
 
 nant. The X-ray picture of the stomach is seen in Fig. 12. 
 The hour-glass constriction is well shown. The bismuth 
 passed from the proximal to the distal segment, and after it 
 had left the former it will be seen in Fig. 13 that some 
 bismuth had remained behind at U. This further confirmed 
 the opinion that there was a chronic gastric ulcer, the bismuth 
 being retained in it. Mr. Dowden saw the patient, and 
 operation was agreed to. The hope was that the ulcer 
 could be excised. On examining the parts the channel 
 between the two sections of the stomach was found to be 
 
CHRONIC GASTRIC ULCER 
 
 127 
 
 much narrower than had been anticipated. The ulcer was 
 large, and its base was formed of adjoining structures, so 
 that its removal was not attempted. Mr. Dowden, however, 
 decided to enlarge the channel between the two sections of 
 the stomach, and this he effected by a gastroplasty. The 
 patient made a speedy and uninterrupted recovery. 
 
 Remarks. — ^This case gave great satisfaction to all 
 interested, and to some of us it was illuminating. The 
 patient not only recovered from the operation, but the 
 operation relieved her of all pain. She rapidly increased 
 
 Fig. 13A. — Same taken later; bismuth out of fundus, present in ulcer. 
 
 and extended her diet, for she found that food no longer 
 gave her pain. She put on weight, regained strength, and 
 was able to resume some of her former activities. 
 
 These were the facts, yet the ulcer was there, and would 
 remain, for its healing seemed beyond possibility. The 
 entire freedom from pain was very striking. The explana- 
 tion seems to be as follows. From Fig. 12 it is seen that the 
 proximal section of the stomach is quite definitely above the 
 distal section, so that when the patient is in the sitting 
 posture the food taken rapidly passes into the latter, where 
 it is digested and in due time passed on into the duodenum. 
 
128 TH?: STOMACH 
 
 The mere passage of food over the floor of the ulcer did not 
 cause pain, and there would appear to have been little 
 tendency for the contents of the distal section to pass back 
 into the proximal section. 
 
 Chronic Gastric Ulcer : Tender C^cum : Appendix 
 Removed : Ulcer Excised : Recovery 
 
 Case 21. — Isabella M., aged 23, was admitted to the Royal 
 Infirmary on the 24th September, 1915. The complaint 
 was of pain after taking food, vomiting, flatulence, heart-burn, 
 palpitation, and breathlessness on exertion. 
 
 History. — For four years she had suffered from attacks of 
 pain and vomiting after food. She had suffered also from 
 bloodlessness. For two months she had suffered from a 
 gnawing pain after taking food. The pain went through 
 to the back. Vomiting came on half an hour after taking 
 food, and vomiting gave relief. Twice or thrice before 
 going to her doctor she vomited a little dark brown material. 
 She suffered for a month before seeking medical advice, and 
 she was recommended to the Infirmary a month later. 
 
 Examination. — The patient was thin and ansemic : the 
 height was 4 ft. 6^ in., the weight 5 st. 12 lb. The tongue 
 was moist and clean. Inspection of the abdomen revealed 
 nothing abnormal. On palpation there was tenderness in 
 the middle of the epigastrium : there was also tenderness 
 on deep pressure in the right iliac region. Pressure in this 
 region relieved the pain in the epigastrium. 
 
 Treatment. — The treatment adopted was colon lavage, 
 and thereafter regulation of the bowels by means of a simple 
 laxative. Belladonna and bicarbonate of soda were given 
 to relieve the gastric pain. The treatment was persevered 
 with for nearly a month without any real improvement. 
 The diagnosis of a gastric ulcer that would not heal was 
 arrived at, and my surgical colleague, Mr. Dowden, saw the 
 patient with a view to operation. At the operation the 
 appendix was found to have a narrowed base and a narrowed 
 tip, but was otherwise healthy and there were no adhesions ; 
 
CHRONIC GASTRIC ULCER 129 
 
 it was removed. The stomach showed an indurated ulcer of 
 large size on the lesser curve near the cardiac end. The 
 ulcer was excised, the edges of the gap being brought together 
 transversely so as to make the lumen of the stomach as large 
 as possible. The operation was long and difficult, and the 
 patient suffered from shock, from which, however, she soon 
 rallied and made an excellent recovery. By the 12th of 
 November she was able to be out of bed. 
 
 Gastric Ulcer : Recurring Attacks of Pain imme- 
 diately AFTER Food : Vomiting : H^matemesis 
 
 AND MeL.ENA LATER : OPERATION 
 
 Case 22. — George R., aged 54, bricklayer, was admitted 
 to the Royal Infirmary on the 13th November, 1915. The 
 complaint was pain in the stomach, sickness and vomiting. 
 The history was that three years previously he began to have 
 discomfort and pain immediately after taking food, followed 
 by sickness and vomiting some hours later. The vomited 
 matter was very sour. Vomiting gave relief, and slowly 
 lessened the pain. He continued to have attacks of this 
 kind for eighteen months ; the attacks coming on at irregular 
 intervals and lasting a week or a fortnight, followed by 
 intervals of freedom lasting a few weeks or longer. For 
 eighteen months the attacks had been more frequent and 
 more severe. The attack from which he was suffering on 
 admission began a fortnight before. Pain of a burning 
 character came on immediately after taking food, it increased 
 in severity, was accompanied by a feeling of sickness and was 
 followed by vomiting two to four hours after food had been 
 taken. The vomiting gave relief. He seldom had pain 
 during the night. He had severe pain the evening before 
 admission, which continued until the morning of admission, 
 when he was relieved by vomiting. He had considerable 
 eructation of gas, especially after taking food. The vomited 
 matter he described as greyish-green in colour. 
 
 Examination. — There was nothing special to be noted on 
 inspection of the abdomen. Pain was referred to the centre 
 
 9 
 
130 THE STOMACH 
 
 of the epigastrium, and there was tenderness on palpation in 
 this region. The respiratory movement of the epigastrium 
 was quite free. The stomach was enlarged and splashing. 
 The stomach contents were intensely acid and contained 
 much free HCl. A week after admission he had hsemate- 
 mesis and melaena. He was transferred on the 22nd 
 November to my surgical colleague, Mr, Dowden. On the 
 25th he again had hsematemesis and melgena and was 
 operated on on the 26th. An ulcer was found near the 
 pyloric end of the stomach. 
 
 Chronic Gastric Ulcer : Recurring Hemorrhage : 
 Death. Remarks on Hemorrhage 
 
 Case 33. — Wm. C, aged 39, was admitted on thei6th June, 
 1918, in a very enfeebled and anaemic condition, after having 
 passed much blood from the bowel. The history was that 
 he had suffered from indigestion for several years, and had 
 been treated by his doctor. Patient had discomfort and 
 pain shortly after taking food, and he knew that taking 
 bicarbonate of soda or anything else did not relieve it. 
 He had never vomited blood, and only once had vomited 
 food. He had a haemorrhage on the day of admission, and 
 another on the 19th, which made his condition so unfavour- 
 able that operation was postponed. Another on the 22nd 
 was followed by death. The post-mortem examination 
 showed a large gastric ulcer situated about the middle of 
 the lesser curve and not adherent to adjacent structures. 
 
 Remarks. — This case is given to illustrate the problem 
 which gastric and duodenal haemorrhage presents and tends 
 properly enough to bias judgment. In this patient we had 
 a young man who had symptoms of gastric ulcer for some 
 time. There was haemorrhage with melaena, but without 
 vomiting, showing that the blood must have been poured 
 out slowly in the stomach and passed on into the duodenum. 
 The ordinary experience is that, under proper treatment, 
 the bleeding in these cases stops ; in this patient it recurred, 
 and finally led to death. This has not been common in 
 
CHRONIC GASTRIC ULCER 131 
 
 my experience. Bleeding commonly is arrested, and its 
 occurrence, and even recurrence, becomes part of a history 
 which determines diagnosis and the question of surgical 
 treatment. And yet a case of this kind comes into our 
 hands from time to time, and we regret that immediate 
 surgical treatment was not pressed. The position seems 
 to me to come to this : if there is hsemorrhage from a gastric 
 or duodenal ulcer, which from the history has almost cer- 
 tainly been present for some time, the wiser course is to 
 advise operation at once, not merely with the intention of 
 doing a gastro-enterostomy, but of securing, if possible, that 
 the ulcer will not again lead to hsemorrhage. The real 
 point being that a bleeding ulcer, unless definitely of quite 
 recent formation, ought to be operated on without unneces- 
 sary delay. Of course, this brings one back to the position 
 I have already expounded that the profession has to learn to 
 diagnose gastric ulcer correctly and to realize the desirability 
 of not allowing cases of this kind to drag on for years. 
 
 Pyloric Obstruction : Dilated Stomach : Gastro- 
 enterostomy : Recovery. No History of Pain or 
 OF Haemorrhage 
 
 Case 24. — Thomas W. T., aged 44, was admitted on the 
 nth July, 1917, complaining of vomiting and coldness of 
 legs and feet. The history given was that he had been in 
 hospital in the North of England six years before and was 
 treated for stomach disorder. He did not improve, and sought 
 advice elsewhere, and was then treated for " gall-stones." 
 He improved sufficiently to be able to resume work. Eight 
 months before admission patient began to suffer from 
 constipation — the bowels moving only every fourth day. 
 He also began to vomit, and vomited nearly every day ; the 
 vomit was pale in colour and sour. The vomiting usually 
 took place at night, between seven and eight o'clock. 
 When these symptoms had lasted a month, he consulted 
 his doctor, but received no benefit. He went into hospital 
 again, but after a seven weeks' stay felt no better. There 
 was an entire absence of complaint of pain in this patient. 
 
132 THE STOMACH 
 
 Examination. — There was considerable stomach dilata- 
 tion. The stomach contents contained much free acid. 
 X-ray examination showed that six and a half hours after 
 a bismuth meal none of it had left the stomach. 
 
 Diagnosis. — The diagnosis of non-malignant pyloric 
 obstruction was clear. My surgical colleague, Mr. i\Iiles, 
 operated on him on the 27th July, doing a gastro-enterostomy. 
 There was a cicatricial thickening at the pylorus. The 
 patient made a good recovery. 
 
 Remarks. — The entire absence of a record of pain in this 
 case must not be taken as absolutely correct. The patient 
 was in my ward when we were suffering from lack of efficient 
 assistance, and one had to be content sometimes with im- 
 perfect records not only of symptoms but even of the details 
 of examination carried out by oneself. That the patient 
 had suffered from pyloric ulcer six years before he was 
 admitted to the Edinburgh Royal Infirmary is almost 
 certain ; that the ulcer was chronic was shown by the 
 cicatricial induration. And yet there is the absence of a 
 history of pain in the record we have ; which is so unusual 
 that one is sceptical of its accuracy, although further ex- 
 perience showed that the case was not unique in this respect. 
 
CHAPTER XII 
 
 MALIGNANT DISEASE OF THE STOMACH 
 
 ^Malignant disease of the stomach as a primary lesion is 
 fairly common. It is usually of carcinomatous or adeno- 
 carcinomatous type. It may begin in any part of the 
 stomach, but it is probably more common at or near the 
 pylorus than elsewhere. 
 
 The phenomena revealed by examination of the abdomen, 
 and, indeed, the symptoms present, largely depend upon 
 whether the pylorus is or is not involved in the neoplasm. 
 It wiU simplify the subject with which this chapter deals 
 to begin with cases where the pylorus was involved. The 
 points which lead to diagnosis are most effectively illustrated 
 when considering individual cases. General principles 
 gleaned from case-experience will be summarized later. 
 
 Malignant Disease at Pyloric End of Stomach 
 
 Case 25. — Mrs. K., aged 43, was admitted to the Edin- 
 burgh Royal Infirmary on the 20th August, 1906, complaining 
 of uneasiness in the stomach and vomiting, the symptoms 
 having lasted since June. The history of the present illness 
 dated from early in that month, when she began to suffer 
 from sensations of uneasiness shortly after taking food, the 
 food often regurgitating, but there was no vomiting. The 
 sensations came on, as a rule, from half an hour to an 
 hour after each meal. She had also been constipated. 
 No history of any kind of gastric or digestive disorder before 
 June could be obtained by the most direct questioning. 
 She had become gradually worse — treatment giving her no 
 relief. The eructations increased, vomiting began and 
 
 133 
 
134 THE STOMACH 
 
 became more frequent. As she was rapidly becoming 
 weaker and losing flesh, she came to the Infirmary. She 
 had noticed for some time a lump in the upper part of the 
 abdomen. 
 
 Examination of the alimentary tract showed the gums 
 to be edentulous, the result of complete extraction ; and 
 the tongue was flabby, with a slight fur. The appetite was 
 fairly good. After meals there was a feeling of distension of 
 the abdomen, and she was conscious of movements and 
 rumblings in its upper part. She felt drowsy and heavy 
 after food. She vomited frequently after admission, the 
 vomit consisting of the food she had taken but little altered, 
 and when she was allowed bread the vomit contained great 
 pieces of undigested bread crust. Ultimately we minced 
 all her food, but that only led to a temporary diminution in 
 the frequency with which she vomited. The vomit never 
 contained free hydrochloric acid, nor did the gastric con- 
 tents withdrawn by the tube after a meal. There was a 
 pear-shaped lump to the right of the epigastrium ; movable, 
 and not seemingly adherent to deeper structures. The 
 smaller end of the lump was to the right. The stomach 
 was considerably dilated, its inferior border reaching to the 
 umbilicus and the fundus to the fifth rib. 
 
 Remarks. — In this case there was what is commonly 
 called a tumour in the upper part of the abdomen. It was 
 a somewhat pear-shaped swelling, running from above 
 downwards and to the right, the smaller end being its right 
 inferior end. The mass was usually hard, easily felt, and 
 to a small extent movable. The stomach was dilated, its 
 boundaries being easy to define by succussion and percussion. 
 The succussion wave could be felt right up to this mass. A 
 point of clinical interest was that the mass altered in cha- 
 racter ; it became so soft that it required the expert hand 
 to be sure of its existence. Further, waves of stomach contrac- 
 tion were often to be seen passing across the upper part of the 
 abdomen and ending in the mass. The mass was the thickened 
 -wall of the pyloric end of the stomach — its position, shape, 
 altering thickness, and its relation to the greater and lesser 
 
MALIGNANT DISEASE 135 
 
 curves of the stomach, all confirmed this. There had been 
 no haematemesis, no coffee-ground vomit, no melsena. There 
 had been an entire absence of gastric s^-mptoms until June, 
 but once they began there had been no material remission in 
 them ; discomfort and vomiting, especially vomiting, had 
 become pronounced. The vomit, and the stomach contents 
 removed by the tube, never showed a trace of free hydro- 
 chloric acid. That there was pyloric obstruction was shown 
 b}' the retention of food in the stomach. That the stomach 
 was not larger than it was, and that there was no marked 
 fermentation of its contents, was due to the ease and regu- 
 larity with which the stomach had hitherto emptied itself by 
 vomiting when discomfort became considerable. The dia- 
 gnostic points in the case were the " tumour," which varied 
 in thickness and hardness, and might be said at times to 
 disappear ; visible gastric peristalsis ; vomiting. These 
 three points indicated pyloric obstruction, with marked 
 spasmodic contraction of the pylorus. 
 
 The two conditions which give rise to pyloric spasm, as 
 marked as it was in this case, and to visible peristalsis, are 
 simple ulcer and malignant growth at the pylorus. There 
 was no history of simple ulcer, nor were the symptoms 
 those of simple ulcer near the pylorus, and therefore we con- 
 cluded that there was a mahgnant growth there. The onset, 
 the course, the condition on admission, the absence of free 
 hydrochloric acid, all supported this. A great part of the 
 difficulty commonly experienced in making differential 
 diagnosis in gastric and abdominal disease is really due to 
 a want of definite knowledge as to the lesions which occur 
 in different viscera, and as to the symptoms which are 
 practically inseparable from each. 
 
 In this case there was no doubt that the " tumour " was the 
 pyloric end of the stomach. I once, after a hurried examina- 
 tion, thought a " tumour " of this nature a displaced kidney, 
 but I speedily rectified my error. If we consider next its 
 nature, we conclude that much of it was due to muscular 
 contraction of the pyloric wall, for it went and came to a 
 considerable extent. This is not uncommon. As to the 
 
136 THE STOMACH 
 
 explanation of the muscular spasm, it is, in my experience, 
 due to irritation, caused either by a chronic open ulcer near 
 the pylorus, or to an infiltrating cancer in the same region. 
 We excluded simple ulcer, and when that was done there 
 was no escape from the alternative. If an ulcer is malignant, 
 there is only one method of treatment of any avail, and that 
 is removal. In advanced cases, where pylorectomy is not 
 practicable, gastro-enterostomy is often advisable for the 
 relief of symptoms. Which procedure is to be possible, can 
 sometimes only be determined after the surgeon has opened 
 the abdomen. In the above case, owing to the mobility of 
 the " tumour," we hoped it might be found removable. 
 
 This patient was operated on by Mr. Caird on the 29th 
 September, when a pylorectomy was done, followed by a 
 gastro-enterostomy. The pyloric end of the stomach showed 
 much thickening and contraction of the pyloric muscle, 
 while near the pyloric opening there was one of those large 
 circular growths, with a raised fungus-like margin and an 
 atrophied-looking centre, which experience has shown to be 
 malignant. There was no affection either of the lymph 
 glands or of the liver, so far as could be seen. Sections of 
 the removed pylorus made by Mr. Wade, F.R.C.S.E., one 
 of the assistant pathologists, showed the condition to be an 
 infiltrating cancer. 
 
 The patient made an uninterrupted and rapid recovery, 
 and was able to return to her home in the course of from 
 three to four weeks. She died two to three years later of 
 recurrence. 
 
 Case 26. — Mrs. C, aged 63, admitted on the 15th January, 
 1 916, was sent to me by Dr. Melville, Penicuik. She had 
 been under treatment for stomach symptoms for some months 
 without material improvement in her condition. 
 
 History. — During the summer before admission she had 
 suffered very greatly from flatulence, a nev/ experience to 
 her, for she had never been ill. In August, after a day in 
 Edinburgh, she was very " done-up." From the beginning 
 of September she rested and lived on milk, but without 
 improvement. It required very direct questioning to bring 
 
MALIGNANT DISEASE 137 
 
 out the significance of those early months. She denied having 
 suffered any pain or that fluid material was ever eructated. 
 When asked about her appetite, she granted that it was not 
 good at that time, that she had no desire for food, and that 
 therein lay a difference from her ordinary condition. When 
 asked if she felt she was weaker at that time, she granted 
 that she was "not going out so much," as she felt tired 
 after it. She then volunteered the information that she did 
 not always get up to breakfast. In fact, there was a clear 
 history to be wormed out of our patient of a definite and 
 progressive debility, which in her mind was so associated 
 with flatulence, that flatulence became the malady, and 
 progressive debility merely a side manifestation of it, and 
 inevitable. This was the part of the picture, or of the history, 
 which required some skill to fill in, and the importance of it 
 was great, for it gave a picture of the early weeks and months 
 of a stomach cancer in a patient of 63 years of age. This 
 phase continued until November, when vomiting was added 
 to the symptom of flatulence. For a fortnight she vomited 
 every second day, then the vomiting fell to every third or 
 fourth day, and at one time there was no vomiting for three 
 weeks. Then there were daily attacks for a fortnight, 
 followed by ten days of freedom. On the nth January 
 vomiting more severe than ever came on, and she was 
 admitted to the Royal Infirmary on the 15th. The descrip- 
 tion of the vomited matter was that it varied in quantity 
 from two to four breakfastcupfuls. It was either greyish 
 or brown in colour, of a bitter taste, and sometimes as thick 
 as gruel. There was no feeling of nausea and no pain before 
 vomiting. The vomiting removed a feeling of distension of 
 the stomach which preceded it. The bowels moved fairly 
 regularly, but the dejecta varied in colour and in consistence. 
 
 Family History.— The patient's mother died of " blockage 
 of gullet " ; a sister died of cancer at the age of 50. 
 
 Condition on Admission.^The patient was still plump, 
 although she had lost much in weight. The expression 
 was that of a calm, self-possessed, steadfast character. The 
 face colouring suggested cachexia rather than pure anaemia. 
 
138 THE STOMACH 
 
 Abdomen. — The abdomen was large, and showed consider- 
 able fat in its wall. There was a fulness in the right iliac 
 region, not present in the corresponding area on the left 
 side. On palpation in this region, there was a definite elastic 
 swelling, which felt so like a cyst that it suggested either a 
 right ovarian cyst or a displaced and cystic kidney ; it was 
 not tender. On examination of the epigastrium, there was 
 palpable what at first was thought to be the liver, but on 
 more careful palpation was clearly not liver. It was a 
 pear-shaped swelling, the thick end of which was to the left ; 
 it lay transversely in the epigastrium from the edge of the 
 ribs on the left side. It was not painful on pressure. On 
 percussion the area of normal fundus tympanicity was not 
 only present, but was considerably extended upwards and 
 to the left. During the few days the patient was in hospital 
 there was frequent vomiting, consisting of thickish, grey- 
 coloured material consisting of little pieces of curd of milk, 
 of gruel, or of the starch of bread she ate. At other times 
 it was more fluid and brown in colour. The vomiting was 
 not preceded by pain or nausea, and the vomit was brought 
 up without discomfort. No specimen of the vomited matter 
 contained free HCl. The bowels were easily acted upon by 
 means of water allowed to pass slowly into the bowel from a 
 douche-can. There were no enlarged glands above the clavicle. 
 
 Diagnosis. — The diagnosis was malignant disease of the 
 pyloric third of the stomach, and that the condition was 
 inseparable. The cystic-like swelling in the right iliac region 
 did not, in view of this diagnosis and in the absence of 
 symptoms which could be attributed to it, require further 
 measures of examination, such as cystoscopy or the collection 
 of urine from the individual kidneys. Both Dr. Haig Fergu- 
 son and Mr. Dowden kindly saw this patient with me. 
 
 Remarks. — The early history of this case as it has been 
 presented is not unique : it is a picture of what usually 
 happens in malignant disease of the body of the stomach. 
 Pain is often absent if considerable ulceration, or irritation 
 leading to adhesions to contiguous parts, has not occurred. 
 The failure of appetite ; the loss of desire for food ; the 
 
MALIGNANT DISEASE 139 
 
 slowly progressing debility without any blood lesion beyond 
 secondary an?emia ; the loss of weight ; the prominence of 
 a gastric symptom, such as flatulence was in this case ; and 
 the failure of medical measures to improve the appetite, to 
 stop the flatulence, to arrest the progressive weakness, all 
 suggest to the experienced physician that malignancy is 
 in the background, although there is nothing abnormal to 
 be made out on palpation of the abdomen. A test meal 
 and the examination for free HCl is valuable at this stage, 
 for, if free HCl be absent, it so strongly supports the 
 diagnosis of malignancy that the question of opening the 
 abdomen becomes urgent, in the hope that the condition 
 is early and sufficiently localized to allow of its removal by 
 the surgeon. In a case like this there are thus two practical 
 questions set to the clinician : (i) Is it malignant ? (2) Is 
 the surgeon likely to be able to remove it ? The second 
 question hangs upon the first, and this is why it is so important 
 to make an early diagnosis. The picture I have given of 
 the first few months of indisposition in a hitherto healthy 
 woman ; with no discoverable lesion in any other organ ; 
 and who does not respond to intelligent treatment, may 
 lead, ought indeed to lead, to this point, namely, that the 
 patient is so probably suffering from malignant disease that 
 one has to prove the negative ; and if that cannot be 
 done, one must remember that a cancer of the body of the 
 stomach can only be removed if taken early. This early 
 period in our patient lasted for fully three months. It was 
 not until November that vomiting became a symptom ; once 
 it started it continued, although at varying intervals — every 
 day or two, or even with a break of three weeks. The 
 vomiting latterly became more frequent and persistent, while 
 during the days she was in the Infirmary she vomited oftener 
 than once each day. There was no pain before the vomiting, 
 nor nausea, only a certain sense of fulness was relieved by it. 
 It seemed as if whatever nourishment she took accumulated 
 in the somewhat large fundus, and after lying there for a 
 time was simply ejected, while little of it passed along the 
 pyloric end to the duodenum. The state of nutrition 
 
140 THE STOMACH 
 
 warranted the assurance that some nutriment passed. From 
 the history I think it may be assumed that the mahgnancy 
 did not begin right at the pylorus ; had it done so there 
 would earlier have been evidences of pyloric obstruction. 
 As soon as malignancy occurs at the pylorus it gives rise to 
 pyloric spasm, with retention of gastric contents, early 
 gastric dilatation, and vomiting of retained contents. In 
 the present case vomiting was a later symptom, and when 
 it did appear it was so regularly and easily accomplished that 
 no great dilatation of the fundus had developed. By the 
 time she was admitted to the ward, the whole pyloric antrum, 
 judging by its uniformly thickened condition, was involved. 
 
 As to medical treatment, it is unfortunately confined to 
 amelioration of symptoms, and to giving as much concentrated 
 and predigested or readily digested food as possible. Our 
 first duty as physicians and practitioners is early diagnosis, 
 and I do not minimise the difficulty of early recognition. 
 The rule to guide us may be laid down as follows : — When 
 patients who suffer from gastric disturbance, and who have 
 been treated along sound lines without benefit, and especially 
 if they lose weight and complain of unwonted muscular 
 debility, it is our duty to no longer assume that the case 
 is only one of ordinary indigestion or dyspepsia, but to have 
 it thoroughly investigated with a view to determine whether 
 or no it is malignant. The methods of examination are 
 palpation, percussion, test meals, and X-ray examination, 
 and the exclusion of disease in other organs which might 
 simulate malignant disease of the body of the stomach. 
 In some cases malignant disease may be so situated in the 
 body of the stomach that palpation and percussion give no 
 data and where the diagnosis is determined by the history and 
 the phenomena grouped round it, and the absence of free 
 HCl. 
 
 Carcinoma of Pyloric Antrum without Pyloric 
 Obstruction 
 
 Case 27. — Mrs. S., aged 53, was admitted to the Infirmary, 
 as gastric ulcer with hsematemesis, in February, 1919. 
 
MALIGNANT DISEASE 141 
 
 History. — The history was that on the two days before 
 admission she had vomited blood ; on the first occasion 
 the vomit was red in colour, on the second it was chocolate- 
 coloured. She denied ever having suffered from indigestion 
 or stomach trouble of any kind. The appetite was good 
 and she " could eat anything." 
 
 After Admission. — She was put on our ordinary 
 regimen for gastric ulcer ; and the colon was cleared out 
 by lavage. The motions resulting from lavage were black 
 in colour (melccna) ; thereafter the colour became normal. 
 There was such a definite absence of gastric discomfort 
 that the diet was rapidly added to until she was taking 
 porridge and milk and fish and farinaceous pudding in 
 addition to bread and butter. 
 
 Cases of this kind are common and my attention was 
 not drawn to this case for some days. I then found on 
 palpation a sausage-shaped swelling lying transversely in 
 the middle of the epigastrium above the level of the 
 umbilicus ; it was not tender and it moved with respira- 
 tion. There was no dilatation of the stomach. After a 
 day or two the sausage-shaped mass lying in the middle 
 of the epigastrium was represented by an irregular mass 
 or lump lying to the left of the mesial plane at the same 
 level, which measured about two inches square. At this 
 stage it was apparent that the mass must be on the proximal 
 side of the pj^lorus, for the simple reason that with such 
 an entire absence of dilatation and of food retention the 
 pyloric outlet could not be encroached upon. That the 
 mass was a stomach neoplasm was almost beyond question. 
 An old gastric ulcer with thickening would certainly have 
 given a history of long stomach suffering. A test meal 
 showed entire absence of free HCl. 
 
 X-ray examination by Dr. Hope Fowler in the Electrical 
 Department was reported on as follows :— " J\Ieal given at 
 time of examination. Note that meal is filling the greater 
 part of the cardiac and pyloric portions of stomach, the 
 pyloric portion towards the distal end is seen to be deformed 
 (the opaque meal is seen to pass round something which 
 
142 THE STOMACH 
 
 deforms it). The whole of the duodenum is faintly out- 
 lined." 
 
 Mr. Dowden, one of my surgical colleagues, saw the 
 patient and agreed with the view that there was a neoplasm 
 not involving the pjiorus. The absence of free HCl indicated 
 in my experience that the neoplasm was malignant. Yet 
 the entire absence ot symptom, of any suggestion of cachexia, 
 the absence of loathing of food, and the occurrence of early 
 haematemesis and melsena were all so imusual that the hope 
 was expressed that it might be a simple growth associated 
 with absence of free HCl. The possibility of recurrence of 
 haemorrhage was the determining factor in favour of imme- 
 diate operation. At the operation it was decided that it was 
 malignant, so the part was resected and a gastro-enterostomy 
 done. The patient stood the operation well and made a 
 satisfactory recovery. 
 
 Combination of Gall-stones and Malignant 
 Obstruction of Pylorus : Operation 
 
 Case 28. — Mrs. B., aged 49, was sent to me for 
 opinion and advice as to treatment in September, 191 8. 
 She was well-nourished with no suggestion in her appear- 
 ance of cachexia. 
 
 The complaint was of vomiting, which occurred daily 
 and had lasted for three months or thereby. She had lost 
 weight, although still plump, and was weaker. 
 
 History. — The history was that four years before she had a 
 very severe attack of pain in the region of the liver, and 
 vomiting ; the attack was diagnosed as gall-stone colic. 
 The attack passed off and there was no recurrence until 
 three years afterwards when the same character of symptoms 
 appeared associated with jaundice ; the same diagnosis 
 was made. She again had an interval of freedom for about 
 a year until June, when she was again seized with pain 
 and vomiting but without jaundice. The pain passed off, 
 as the pain on the two previous occasions had passed, but 
 the vomiting persisted and had continued to the present 
 time. 
 
MALIGNANT DISEASE 143 
 
 Examination. — There was not a trace of jaundice. 
 The abdomen was lax but showed a considerable thickness 
 of fat. On palpation there was a mass palpable, under the 
 right costal margin and projecting from it, about the size 
 of a medium-sized pear and elongated in shape ; it was in 
 the vertical parasternal line, close to the abdominal wall, 
 and moved with the movements of the diaphragm on deep 
 breathing. It felt like a gall-bladder tightly contracted on 
 its contents, and it was thought to be the gall-bladder full 
 of calculi probably of a large size. This was also consistent 
 with the history of gall-stone colic extending back for 
 four years. This, however, could not be taken as the cause 
 of the persistent vomiting. On further examination it 
 was easily demonstrated that the stomach was much 
 dilated and that there was large retention of food. The 
 stomach succussion wave reached to the right of the middle 
 line and ended very abruptly and definitely. The stomach 
 contents, which were vomited soon after the examination, 
 showed no free acid, while the food was well broken up. 
 
 Comment and Diagnosis. — From the foregoing observa- 
 tions it was concluded that the attacks of gall-stone colic 
 had been caused by calculi in the gall-bladder which were 
 not escaping from it ; that, in addition, there was pyloric 
 obstruction with almost complete retention of gastric 
 contents. The absence of free HCl was regarded as of very 
 grave significance as indicating that the stenosis was almost 
 certainly malignant. Questions remained to be answered ; 
 the first was as to the palpable lump or mass. It seemed 
 to be the gall-bladder judging by its position, its outline, 
 and in view of the history. If it were the gall-bladder, was 
 it possible that it could press upon the pylorus ; and had it 
 formed adhesions leading to a constriction of the pylorus ? 
 Both these ideas were set aside as improbable. The other 
 question was : Is it not the pylorus ? This possibility could 
 not be set aside, although one had not previously felt a pylorus 
 like this or in this position. However that might be, there 
 was no doubt about the history of gall-stone colic, and there 
 was no doubt about the stomach dilatation due to almost 
 
144 THE STOMACH 
 
 complete stenosis of the pyloric outlet. The treatment was 
 clearly surgical. Before submitting the case to a surgical 
 colleague one completed the case by having the patient 
 screened and photographed after taking bismuth. The 
 X-ray examination was made by Dr. Hope Fowler ; it showed 
 the dilated stomach, and the abrupt right border, but no 
 trace of bismuth to indicate the position of the pylorus. 
 This plate was taken some thirty hours after the bismuth 
 had been taken, and it had all been retained. There was, 
 Dr. Fowler pointed out, a faint shadow between the stomach 
 and the liver edge, but the X-ray plate did not show it 
 to be pylorus rather than a distended gall-bladder. 
 
 Professor Caird saw the patient and had the history 
 and phenomena described, submitted to him, and he agreed 
 as to the necessity for surgical interposition. When under 
 the anaesthetic the lump in question was freely movable 
 and could be pushed to the middle line, which negatived 
 the possibility of its being gall-bladder. On the abdomen 
 being opened the mass was seen to be a greatly and uniformly 
 thickened pylorus, with abrupt ends, measuring fully three 
 inches in length, very freely movable without a single 
 adliesion. The stomach was very large. The gall-bladder 
 was full of calculi. The case seemed an ideal one for 
 pylorectomy, but the operation was a long one and proved 
 too much for the patient's strength, for she died the 
 following day. It would have been safer to have been 
 content with a gastro-enterostomy as a first step, but 
 even the physician could recognize the special attractive- 
 ness of the radical operation in view of a free pylorus and 
 the absence of metastasis. 
 
 The case illustrates the association of diseases which 
 had no apparent relation to each other, and the importance 
 of a complete diagnosis. It was of special interest, as I 
 had never seen a case in which the question : Was it gall- 
 bladder or pylorus ? was so difficult to answer satisfactorily. 
 Tlie question was, fortunately, purely academic and in no 
 way affected the decision that the stomach had to be given 
 an outlet for its contents other than by the oesophagus ; 
 
MALIGNANT DISEASE 145 
 
 and there was equally no doubt that there were calculi in 
 the gall-bladder. 
 
 Carcinoma Pyloric Antrum : Much Vomiting : 
 Relieved by Gastro-enterostomy 
 
 Case 29. — George M., aged 48, was admitted to the 
 Royal Infirmary on the 24th April, 1919. 
 
 History. — Six months before admission, he began to suffer 
 from indigestion and constipation. The indigestion showed 
 itself by pain and discomfort about an hour after food was 
 taken. There was loss of appetite. There was a sense 
 of general weakness and he soon got tired at work. Constipa- 
 tion was relieved by Epsom salts. He continued to work 
 for four months, when, after consulting his doctor, he began 
 to diet himself. Since then his diet had been gradually 
 reduced and for three weeks he had taken milk only. 
 He had become steadily weaker and had lost two stones in 
 weight in two months. During the last six weeks vomiting 
 had become more and more frequent, so that he was 
 afraid to take food. If he took solids he vomited at once, 
 but he could retain liquids for a variable time. If vomit- 
 ing was delayed he recognized food he had taken sixteen 
 or eighteen hours previously. Latterly the smell of food 
 had been sufficient to make him vomit. Thirst had been 
 very troublesome. He had constant nausea. 
 
 Examination. — ^The patient was very emaciated. The 
 abdomen was sunken. There was no visible peristalsis. There 
 was no tenderness anywhere. There was an indefinite 
 and ill-defined swelling in the epigastrium through which 
 the pulsation of the abdominal aorta was conducted. There 
 was an area of typanicity stretching from the fourth to the 
 seventh left space and lying between the costal margin 
 and the mid-axillary line. No splash was obtained. The 
 vomit contained no free acid, neither hydrochloric nor lactic. 
 The diagnosis was clearly malignant disease at the pyloric 
 end of the stomach. X-ray examination showed the 
 bismuth meal confined to the area of tympanicity described 
 above, which was, of course, the stomach fundus ; in the 
 
 10 
 
146 THE STOMACH 
 
 recumbent position this portion tapered to the right and a 
 
 trickle of bismuth was seen in it. 
 
 Remarks.^ — As has been stated there was no doubt 
 
 about the diagnosis, but the question was whether the 
 
 patient was to be left to get 
 worn out by the vomiting. The 
 position was explained to him 
 and he was willing to be 
 operated on. My colleague, Mr. 
 Miles, kindly saw him and 
 operated on the 24th April. 
 Neoplasm was found invading 
 the pylorus and the whole of the 
 
 FIG. i4-Case29.^^P, pylorus; antrum, extending further on the 
 
 posterior than on the anterior wall. 
 A posterior gastro-enterostomy was performed. He made a 
 good recovery and returned home freed from discomfort and 
 able to take nourishment. The annexed figure indicates the 
 area of involvement of the stomach wall. That surgical 
 treatment is known to be only palliative in cases of this 
 kind does not seem to me to contra-indicate operation, and 
 I have no hesitation in recommending it. The relief for 
 the time is great and later symptoms are less distressing. 1 
 
 The two following cases, which were seen as this book 
 was in the press, are added as they strikingly illustrate the 
 importance of early diagnosis, and as they prove how entirely 
 fallacious age incidence may be. 
 
 Case 29a. — Miss I., aged 33, was seen in consulta- 
 tion on the 17th April, 1920. The symptoms sug- 
 gested gastric ulcer near the pylorus. She went into a 
 nursing home, and was treated by her ordinary medical 
 attendant. The symptoms disappeared, and her general 
 condition improved. After leaving the home, she spent 
 the month of June at the seaside, and was reported to be 
 well. In July she went to the Highlands and symptoms of 
 gastric disturbance again appeared. She continued to 
 
 ^ The notes of this case were taken by my House Physician, Dr. Ross 
 Haddon. 
 
MALIGNANT DISEASE 147 
 
 suffer and became decidedly weaker and unfit for physical 
 effort. She consulted the local doctor in the middle of 
 August. He saw that she was weak and anaemic, and pre- 
 scribed iron. She felt some improvement under this treat- 
 ment. She returned to Edinburgh in the beginning of 
 September, and, notwithstanding the persistence of weak- 
 ness and of inability to take much nourishment, she did not 
 consult her medical attendant. For two or three weeks she 
 had vomited frequently. On the 29th of November she 
 came to see me, when I was shocked at her appearance, and 
 insisted that she must at once get her doctor to see her. I 
 saw her with him two days later, and could only confirm 
 his diagnosis of a malignant mass in the pyloric part of the 
 stomach. The mass was roughly nodulated, very hard, and 
 not movable. The hope was entertained that a gastro-enter- 
 ostomy might be feasible, although there seemed to be 
 no prospect that the mass which was felt could be removed. 
 >\Ir. Dowden opened the abdomen and found the stomach 
 so extensively affected and adherent to the liver that a 
 gastro-enterostomy could not be done. 
 
 Remarks. — This is a very tragic story and not a very 
 uncommon one. It teaches various lessons. In the month 
 of April the symptoms did not arouse any suspicion of the 
 possibility of malignancy, and the gastric contents were not 
 examined. After she left the nursing home late in May her 
 own doctor did not see her again until the end of November. 
 The responsibility for this lay entirely with the patient ; and by 
 the end of November an inoperable neoplasm had developed. 
 Had her doctor been seeing her, a malignant stomach would 
 have been diagnosed probably in July, when operative inter- 
 position would have held out a prospect of radical cure. In all 
 stomach cases which do not yield readily to treatment it is 
 essential to examine the gastric contents for free HCl, and 
 this would certainly have been done in this case had she been 
 under observation. When free HCl is absent the suspicion 
 of malignancy should never be airily set aside on account of 
 the patient's age. As has been already insisted on, a case 
 of hypochlorhydria which proves refractory to treatment is 
 
148 THE STOMACH 
 
 probably malignant. So strong is this probability that the 
 onus of proof lies with the contrary opinion. 
 
 Case 29b. — Miss S., aged 31, was seen by me on the 
 4th December, 1920, in consultation with her medical 
 attendant. The history was that in July she began to 
 feel her digestion to be out of order. She had a holiday 
 of some weeks in the month of August, which did not 
 benefit her. Appetite was very poor, she had a definite 
 dislike to food, and took very little. On returning home 
 she resumed her ofiice duties, and continued them until 
 quite recently, although she was living mainly on liquid 
 nourishment and taking very little. Her doctor saw her 
 shortly before I saw her, and found a lump in the epigastrium, 
 which varied in position and sometimes could not be felt. 
 When I saw her the " lump " was clearly the pylorus, and 
 the history, characterized by stomach discomfort, not pain, 
 continued repulsion to food, and loss of flesh, left no doubt 
 in one's mind that this was another malignant stomach, 
 near the pylorus, at a very early age, A test breakfast 
 the following morning showed entire absence of free HCl. 
 
 Professor Caird operated and was able not only to 
 perform a gastro-enterostomy, but to do a gastrectomy. 
 The disease, which was close to the pylorus, was quite cir- 
 cumscribed and there is considerable ground for hope that 
 it may not recur. The patient stood the operation well 
 and made an uninterrupted recovery. 
 
 Remarks. — The long history in this patient of gastric 
 disturbance, with not only loss of appetite, but positive 
 dislike of and repulsion to food, was very ominous. The 
 absence of symptom suggestive of chronic gastric ulcer 
 was another important point. The " lump," which changed 
 its position, was palpable sometimes, and could not be 
 found at other times, is characteristic of the pylorus ; some- 
 times in spasm contraction and palpable, at other times 
 relaxed and not palpable. No doctor had seen this patient 
 until her ordinary medical attendant saw her, and fully 
 investigated her condition. It is at this early stage that it 
 is so important to diagnose malignancy in this viscus. 
 
Section 11.— THE PYLORUS AND DUODENUM 
 CHAPTER XIII 
 
 INTRODUCTORY 
 
 We now pass to the consideration of matters concerning the 
 pylorus and the duodenum as they appear to me as a 
 physician. 
 
 We can never understand this important region unless 
 we begin at the right point, and here, as is so commonly the 
 case in medicine, the right point means functional disturbance. 
 The functional disturbance in this region round which 
 controversy lingers is hyperchlorhydria ; what symptoms 
 are to be referred to it, and which belong to gross anatomical 
 lesion ? It is not necessary again to argue that there is a 
 morbid condition called hyperchlorhydria. It is sufficient 
 to state that to me it is a clinical entity ; presumably an acid 
 dyscrasia, the manifestation of a metabolic diathesis on the 
 part of the individual. The acceptance of this proposition 
 is the starting point of any further knowledge we may acquire 
 concerning certain important conditions met with at the 
 pylorus or in the duodenum. On this as a foundation we 
 may at least hope to build securely : we may have to un- 
 build and to rebuild, but so long as we come back to it we 
 may hope that ultimately we shall find the building secure. 
 
 An attack of hyperchlorhydria may be determined by 
 such diverse causes as chill, fatigue, worry, or dietetic error. 
 Once, however, we accept the existence of the clinical entity, 
 and that it is a diathetic error, we are prepared for other 
 phenomena presenting themselves. 
 
 Recurrence of Attacks is one of these, in one person deter- 
 mined by worry, as surely, and perhaps more surely, than 
 
 149 
 
150 THE PYLORUS AND DUODENUM 
 
 in another it is determined by dietetic error. The story 
 of these recurrences can often be traced back for many years, 
 as we trace back a rheumatic or other well-recognized 
 diathesis. In one of my cases there was a history running 
 back for forty years. 
 
 Pain as a Symptom. — Assuming then the existence of the 
 condition, let us next consider its symptom — pain or dis- 
 comfort. This symptom comes on one to two hours or 
 longer after a meal ; it comes on after most if not all of the 
 protein food has been digested and has left the stomach. 
 The pain associated with duodenal ulcer comes on under 
 similar circumstances and presumably from the same cause. 
 It is evidently not caused by the mere passage of well- 
 digested gastric contents over the surface of the ulcer which 
 causes pain, but the spasm of involuntary muscle when the 
 gastric contents attain a high degree of acidity. The 
 phenomenon of pain coming on with a considerable interval 
 between its onset and the last meal is common to both 
 conditions, and in interpreting the phenomenon we must 
 begin with our knowledge of hyperchlorhydria, and our 
 experience of how it can be controlled and checked ; that 
 is our first step, and unless it is firm and secure the second 
 cannot be so, although, even then, a secure foothold is, 
 happily for some of our patients, not impossible. 
 
 The Etiology of Acute Ulcer. — ViQien we consider the 
 etiology of acute ulcer no one questions the association 
 of hyper-acidity with acute gastric, p3doric, or duodenal 
 ulcer ; it would almost appear to be established that hyper- 
 acidity precedes ulcer and in some way leads to it. If we 
 look at this subject a little more closely we shall find that the 
 latest experimental work has shown that acute ulcer is 
 readily produced by rendering a bit of stomach wall bloodless 
 by means of the local injection of adrenalin. Local blood- 
 vessel spasm is, in fact, all that is required to lead to acute 
 ulcer. We may carr}' our mental vision further and picture 
 to ourselves that when there is irritative spasm of the 
 musculature of stomach, pylorus, or duodenum, one limited 
 area may be so bloodless that necrosis results, followed by 
 
HEALING OF ACUTE ULCER 151 
 
 speedy solution of tissue by digestive fluids, with the result 
 that an acute ulcer is formed. If we regard the question 
 in this way the marvel is that ulcer in these parts is not more 
 common than it is. 
 
 Whatever picture we form of the mode of production 
 of such acute ulcers, it seems certain that they can be 
 produced suddenly, that is rapidly, and without having been 
 preceded by symptoms of digestive disturbance sufficient 
 to have given rise to any marked discomfort. One hears 
 of cases of perforated duodenal ulcer occurring in the middle 
 of the night, with but trifling preceding digestive disturbance 
 to help the diagnosis. Such acute cases cannot be regarded 
 as preventable, and the medical man's responsibility begins 
 and ends with prompt diagnosis and the prompt summoning 
 of surgical skill. That hyperchlorhydria may be the pre- 
 cursor of ulcer makes it all the more important to recognize 
 the disorder of function and to treat it promptly and 
 efficiently. 
 
 Perforation. — When ulcer is present, the accompanying 
 thought is, commonly, perforation, with all its dreaded results. 
 Yet perforation either of gastric or of duodenal ulcer is not 
 common. If I take my own experience I find that I have 
 seen many cases of ulcer but comparatively few of gastric 
 or of duodenal perforation, and my experience is not at 
 variance with the experience of others. 
 
 Healing of Acute Ulcer. — The next point that I would 
 draw attention to is that pyloric and duodenal ulcers 
 heal, probably as readily as gastric ulcer, if the conditions 
 are made favourable to their doing so. In support of this 
 statement let me remind you that the diagnosis of recent 
 duodenal ulcer is based, in the first instance, on the presence 
 of altered blood in the stools. The advent of severe pain 
 two hours or so after a meal is not pathognomonic of duodenal 
 ulcer ; but such pain associated with melsena has been long 
 regarded as justifying a diagnosis of duodenal ulcer. I have 
 seen many such cases, I shall here only mention one of 
 them ; a man sent with a diagnosis of duodenal ulcer to 
 my ward by one of my surgical cofleagues, with a view to 
 
152 THE PYLORUS AND DUODENUM 
 
 having his general condition improved before being operated 
 on. This patient had pain coming on after every meal and 
 persistent melaena. I treated him as I would have treated 
 a case of hyperchlorhydria, with the result that his pain 
 rapidly disappeared, and the bleeding stopped, even occult 
 blood not being demonstrable. He was soon allowed a 
 more liberal dietary and his general condition greatly 
 improved. He felt so well that he did not quite see why he 
 should undergo an operation, and my surgical colleague 
 was not prepared to press it. He therefore went home but 
 got instructions about his diet and habits generally, and was 
 advised to return, if pain or melsena returned. He had not 
 reappeared by the time I ceased to be in charge of wards. 
 
 I merely want to emphasize the propositions that duodenal 
 ulcer may heal, and that the danger of perforation may be 
 greatly exaggerated, and excite quite unwarrantable alarm. 
 I need not multiply cases ; this case is selected for evident 
 reasons — the diagnosis was not mine, although I entirely 
 agreed with it ; it was based upon the clinical phenomena 
 mentioned ; when these phenomena disappeared and 
 digestive comfort and vigour were restored the idea of the 
 continuance of the ulcer was not entertained. Without this 
 logical method internal diagnosis would cease to be a science, 
 and become an art of occult divination. Mere assertive 
 insistance that the ulcer is still there is outside the region 
 of scientific medicine. Diagnosis is based on phenomena ; 
 and accurate diagnosis upon, first, the power of determining 
 the presence or absence of certain phenomena ; and, secondly, 
 on the faculty of arranging the order and of estimating the 
 value of the facts ascertained. If phenomena disappear 
 we are bound to consider that their cause has disappeared. 
 If the phenomena reappear, the cause has presumably 
 reappeared. 
 
 Pyloric and Duodenal Scar. — I next draw attention to 
 the existence of pyloric and duodenal scar. I take these 
 two together, as they give rise to similar phenomena as 
 regards the stomach ; and I hope to show that the gastric 
 phenomena which can be demonstrated are of valuable 
 
EFFECT OF SCAR AND NARROWING 153 
 
 assistance in deciding the question as to what treatment the 
 patient ought to undergo. 
 
 In considering the phenomena of this stage we are again 
 thrown back on our initial contentions regarding hyper- 
 chlorhydria. By accepting these we form a working 
 conception of what occurs. We find a reasonable explanation 
 of the phenomena present. 
 
 Hyperchlorh3'dria, as has been stated already, commonly 
 precedes ulcer. It is moreover a recurring condition. The 
 addition of duodenal ulcer to the hyperchlorhydria can 
 frequently be dated to some one particular attack of hyper- 
 chlorhydria, definitely more severe, or more prolonged, than 
 other attacks, and not infrequently giving a distinct history 
 of melaena. Such an attack may date back many years ; 
 but between that time and the present there may be a history 
 of many lesser attacks. These lesser attacks give a history 
 of h;yperchlorhydria, but tend to run into prolonged gastric 
 discomforts, the reason for which is readily found. 
 
 Hsrperchlorhydria and Gastric Antonicity. — One of the 
 results of hj-perchlorhydria is gastric atonicity with sagging 
 of the lower border of the stomach. When the hyperchlor- 
 hydria is treated effectively this atonicity is recovered from ; 
 but with the recurrence of the hyperchlorhydria there is a 
 return of the sagging. With repeated recurrence of the 
 former the sagging becomes more marked and becomes more 
 chfhcult to correct. This is the course that might have been 
 predicted : hyperchlorhydria, pyloric spasm, atonic gastric 
 waU, sagging of lower border aU seem an orderlj^ pathological 
 sequence and such we may take them to be. That the 
 ultimate result should be such as is frequently found cannot 
 cause surprise when we know how little is thought of attacks 
 of so-called " indigestion " and how httle effort is made to 
 correct the symptoms. 
 
 Effect of Scar and Narrowing. — We may, however, carry 
 this a point further. And it is this : when there is a scar 
 at the pylorus or in the duodenum, and especially if there be 
 even slight narrowing of outlet or of duodenum, the atonicit}^ 
 with its consequent sagging, becomes more marked with each 
 
154 THE PYLORUS AND DUODENUM 
 
 successive attack of hyperchlorhj^dria and becomes more 
 difficult to correct b}^ ordinary means. The difficulty at 
 this stage hes, not in restraining the hyperchlorhydria, 
 but in getting the stomach completely to empty itself. 
 This is only effected by toning up the atonic lower border, and 
 by bringing the axis of the stomach into correct relation to 
 the channel of exit, which is, of course, the pyloric outlet. 
 This difficulty becomes greater as years pass, until a time 
 arrives when the discomfort has become almost intolerable, 
 and, on examination, the merest tyro can determine the 
 existence of a dilated and prolapsed viscus. 
 
 The point I msh to make is that here there is added to 
 S3^mptoms of pure hyperchlorhydria symptoms due to 
 retention of a residuum of the food taken. The retention is the 
 result of the sagging of the lower border to begin with. 
 Following upon this the pyloric antrum becomes more 
 dilated, and, in the recumbent position, the right border of 
 the stomach is carried more and more to the right of the 
 mesial plane. The dilatation, with this extension to the 
 right, is easy of determination. I have found that when it 
 occurs the stomach overlies the pylorus, that is, the pylorus 
 is behind ; so that when the abdomen is opened, it cannot 
 be seen until the stomach is pulled aside. 
 
 It seems to me that the determination of what for 
 convenience I have called " the right border of the stomach," 
 is of great help, especially when dealing with cases where there 
 is doubt as to the necessit}^ of having a gastro-enterostomy 
 done. 
 
 When the pylorus is overlain by the stomach in the 
 manner indicated, there is usually an organic difficulty at the 
 pyloric outlet. In the majority of cases this overlying only 
 occurs when there is a scar or some other anatomical cause 
 of difficult}^ The overlying is often of determining import- 
 ance. I have not seen it in the spasm and sagging due solely 
 to hyperchlorh}'dria. Certainly in all cases of long standing 
 I have invariably found the right border far beyond the 
 middle line, as the accompanying cases and figures show. 
 The only doubtful point is as to whether it can always be 
 
EFFECT OF SCAR AND NARROWING 155 
 
 taken as pointing to the existence of scar or of narrowing. 
 I am none the less assured that the position of the right 
 border is of much practical significance. I can go this far 
 that, if medical treatment does not remove the overlying, 
 the only relief obtainable is by means of a gastro-enterostomy. 
 In such cases it is found that there is a scar, or some pyloric 
 narrowing. 
 
 It is important to state that when cases of the kind are 
 seen early enough and their character is recognized, the 
 stomach position may be restored. It requires, however, 
 careful dietetic and other measures ; and even after restora- 
 tion has been effected, comparatively moderate indiscretion 
 may reproduce the condition. I followed a very instructive 
 case of this kind for three years and at last advised a gastro- 
 enterostomy. At the pylorus there w^as a scar but not, I 
 fancy, any greater narrowing than had existed for years. 
 The ulcer which had left the scar dated back some seven 
 years or more. 
 
 Another patient whom I saw more recently, presented 
 such stomach displacement as has been referred to. This 
 patient had been operated on a year before for perforated 
 duodenal ulcer. Without hesitation gastro-enterostomy 
 was advised, as I was of opinion that the stomach condition 
 was to be attributed to duodenal narrowing following upon 
 the previous operation, and, therefore, irremediable by 
 medical measures. The operation was agreed to, and the 
 conditions anticipated were found to be present. A gastro- 
 enterostomy was entirely successful and enabled the patient 
 to pursue an arduous life with fuU vigour. In this patient 
 the development of gastric symptoms had been progressive 
 and were, when I saw him, grievously interfering with his 
 capacity to carry through his daily duties. 
 
 If, on the other hand, to attain improvement, without 
 operation, it is necessary to put a patient to bed, and to use 
 dietetic and other expedients, I am not sanguine of obtain- 
 ing permanent well-being ; for experience shows that such 
 cases readily relapse. 
 
 The following tracings of stomachs such as have been 
 
156 
 
 THE PYLORUS AND DUODENUM 
 
 described were prepared as follows. The position of the 
 stomach is marked out on the surface of the trunk : a sheet 
 of tracing paper is placed over the trunk and the position 
 marked of themammse, of the costal margins, of the umbilicus, 
 of the anterior superior iliac spines, and of the pubes ; then 
 the stomach outline is traced. The tracing is photographed 
 and from that the figures were prepared. The advantage 
 of this method is that each figure shows the exact relation 
 of the stomach to the anatomical points mentioned. True 
 relations are by this means maintained. 
 
 Tracings of four stomachs are given as samples of many 
 and as they constituted the evidence on which stress was 
 laid when advising operation. The accuracy of the tracings 
 was constantly checked on the operating table. In this 
 way confidence was established in the accuracy of the 
 methods which have been described. 
 
 Case 30. — J. P., aged 29, had a gastric history of 12 
 years' duration. Eight years ago he had black stools. Three 
 
 years ago he was free of 
 
 © 
 
 ® 
 
 symptoms for a year. 
 Symptoms returned two 
 years ago, and at that 
 time he vomited black 
 material. He had the 
 power of vomiting when 
 he wished. He was in 
 hospital during the pre- 
 vious August and Sep- 
 tember without receiving 
 material benefit. He was 
 re-admitted the following 
 May. The annexed is the 
 outline of his stomach. 
 
 Mr. Miles did a gastro-enterostomy. There was cicatricial 
 
 thickening at the pylorus. The patient did well and was 
 
 relieved. 
 
 Case 31. — L. L., aged 39, had a history of stomach trouble 
 
 for seven years. For eighteen months he had no treatment, 
 
 Fig. 15. — Case 30. 
 
ILLUSTRATIVE CASES 157 
 
 then he began to take bi-carbonate of soda. The main 
 symptom was uneasiness coming on an hour after food. 
 There was occasional vomiting, which gave relief. The 
 symptoms got more pronounced, uneasiness becoming severe, 
 pain beginning an hour after food. For six months the 
 pain had not only been very severe but almost constant. 
 Vomiting was frequent and two months ago he vomited 
 half a pint of reddish-brown fluid, but there had been 
 no melaena. He had lost 5 st. in weight in eighteen 
 months having fallen from 15 st. to 10 st. Fig. 16 is the 
 
 © ® @ © 
 
 <5U 
 
 r\ /\ 
 
 r\ 
 
 Fig. 16. — Case 31. Fig. 17.— Case 32. 
 
 stomach tracing. Mr. Miles found cicatricial thickening 
 at the pylorus causing so much stenosis that the fingers 
 would not meet. A gastro-enterostomy was done and the 
 patient made a speedy and admirable recovery. 
 
 Case 32. — J. D., aged 45, was admitted on the 29th of July. 
 There was a history of what was thought to be gall-stone colic 
 in the previous February. He had gastric symptoms since 
 the middle of June, consisting of a feeling of fullness and 
 discomfort in the right hypochondrium. There was no 
 vomiting or nausea. The bowels were constipated. There 
 was no melsena. He was only taking about one-third of 
 his ordinary diet. There was no free HCl. Figure 17 is the 
 
158 
 
 THE PYLORUS AND DUODENUM 
 
 stomach tracing. Mr, Stnithers found the pylorus was the 
 seat of what was thought to be a cicatricial thickening with 
 so much stenosis that it would not admit the little finger. 
 A gastro-enterostomy was done. The patient did well, but 
 looking back on this case additional experience suggests 
 that the condition at the pylorus was malignant. 
 
 Case 33. — J. M., aged 43, was admitted with a history 
 of gastric trouble reaching back for eighteen years. It began 
 
 © 
 
 © 
 
 with pain coming on three to 
 four hours after taking food 
 and relieved by food. These 
 symptoms lasted for three 
 months. Ten years ago he 
 had a similar attack which 
 lasted for six months. Five 
 years ago he sought advice 
 at the Infirmary, and was 
 sent away with a prescription. 
 A fortnight later, when out 
 driving, he felt sick and ten 
 minutes later vomited a large 
 quantity of dark - brown 
 material. Nine months ago 
 pain came on again, and has continued off and on since 
 then, and for the last three weeks he has been off work on 
 account of it. Mr. Struthers did a gastro-enterostomy and 
 the patient made a good recovery. The above is the tracing 
 of this stomach. 
 
 eU 
 
 Fig. 18. — Case 33. 
 
CHAPTER XIV 
 
 DUODENAL ULCER 
 
 Diagnosis. — The diagnosis of duodenal ulcer may be made 
 very easily but it may present considerable difficulty. 
 
 Pain. — The outstanding symptom is pain in the upper 
 half of the abdomen in the middle line between the xiphi- 
 sternum and the umbilicus or to the right of it ; it may 
 radiate over the hepatic region, through to the lumbar 
 region, or upwards to behind the scapula. The pain comes 
 on two hours or more after food ; it may continue until the 
 stomach is empty, or until the next meal is taken, when 
 it is temporarily relieved by the closure of the pylorus and 
 the lowering of the acidity of the gastric contents. In 
 severe cases the pain is constantly present, but is most 
 severe some time after taking food. In the symptom of 
 pain ulcer closely resembles hj^perchlorhydria ; but from 
 this symptom alone the diagnosis of ulcer ought not to be 
 made. In the great majority of patients the symptom 
 means hyperchlorhydria. 
 
 Melaena. — The next sign of ulcer is melcena. When 
 this occurs coupled with such pain as has been referred to, 
 the diagnosis of ulcer is established. The diagnosis, how- 
 ever, ought not to lead to panic, as it seems to do in the 
 minds of some members of the profession as well as of the 
 laity. The ulcer if a recent one will heal under favourable 
 conditions. If gastric symptoms have for some time 
 preceded melaena the stomach will give the indications of 
 sagging which have already been fully described, and * the 
 right border will be found to the right of the middle line. 
 
 159 
 
i6o THE PYLORUS AND DUODENUM 
 
 Absence o£ Meleena. — But ulcer may be present with, a 
 total absence of a history of melaena. In cases of this kind 
 pain continues to be the prominent symptom, varying in 
 degree ; influenced by the kind and quantity of food taken ; 
 ameliorated up to a certain point by anti-hyperchlorhydric 
 remedies, but not usually wholly removed. On examination 
 there is found to be stomach sagging and dilatation with 
 the right border much to the right of the middle line and 
 often right over to the costal margin. 
 
 Haemorrhage is thus an inconstant sign of ulcer ; its 
 presence may be pathognomonic, whilst its absence is not 
 negative. 
 
 Pain and Sagging. — Persistent pain, not in the sense of 
 being constantly present, but constantly reasserting itself, 
 along with abundant secretion of hydrochloric acid, giving 
 evidence of much free HCl whenever the gastric contents 
 are tested, and stomach sagging and dilatation, with the right 
 border to the right, are as absolute proofs of ulcer, which is 
 not yielding and will not yield to medical treatment, as are 
 available to clinical medicine. The long-standing cases 
 may have a history of many attacks of melsena, and may 
 ultimately die of severe haemorrhage with haematemesis 
 as well as melaena. On the other hand a chronic ulcer may 
 ultimately lead to almost complete occlusion of the duodenum 
 from the thickening occurring round it, thereby rendering 
 the provision of a new channel for the passage of food 
 essential if life is to be continued, and yet there may be 
 no history of melaena. 
 
 Symptoms Masked. — In some cases there is no history of 
 melaena ; but there is pain coming on at varying intervals 
 after food ; there is a sagged and dilated stomach, which 
 takes long to empty itself of the previous meal ; always 
 much free HCl ; and yet the pain can be so controlled as to 
 be negligible even while the patient is on a liberal and 
 mixed diet. A case of this kind is given further on. The 
 uncertainty of this case was settled ultimately by the 
 appearance of melaena. It is of much importance to know 
 that 2inder treatment the symptoms may he masked in some 
 
ILLUSTRATIVE CASES i6i 
 
 cases so as to make it temporarily doubtful as to the necessity 
 for surgical interposition. This point will be more fully 
 dealt with under the cases which are given to illustrate the 
 different aspects duodenal ulcer presents. 
 
 Illustrative Cases 
 
 Pain : Recurring Helena : Fatal Hemorrhage 
 
 Case 34. — J. M., aged 58, had suffered from his stomach 
 for some years, the history being typical of hyperchlorhydria. 
 In 1914 he had melaena, and this recurred from time to time. 
 He suffered a great deal from pain. His medical attendant 
 thought the ulcer had healed as there had not been melaena 
 for some time. A sudden profuse bleeding with haema- 
 temesis and melaena, during which the patient fainted, was 
 followed by others, of which he died in 1919. The ulcer 
 was a chronic one with thickened edges. The patient 
 was from the outset strongly opposed to operation. 
 
 Persistent Pain : Dilated Stomach : Operation : 
 Complete Recovery 
 
 Case 35. — David D., aged 31, clerk, was admitted 
 to the Royal Infirmary on the 9th September, 1914, 
 The complaint was pain in the stomach at night for the 
 previous six months. 
 
 History. — About nine years before admission he had his first 
 attack of pain in the upper part of the abdomen. The pain 
 was sharp and stabbing in character and " doubled him up." 
 It came on about two or two and a half hours after food, 
 and was worst at night. The attack passed off in about a 
 week under treatment. For two years he was free from 
 pain. He then had a second attack of the same kind, which 
 lasted for two weeks. Since then he had had occasional 
 attacks of pain, but they were of short duration and never 
 severe. Seven months before (February, 1914), the third 
 severe attack occurred. Pain came on about two hours 
 after food, and continued to the next meal, which gave 
 relief. The pain was of a dull, burning character. It was 
 
 II 
 
i62 THE PYLORUS AND DUODENUM 
 
 always worst at night, from lo p.m. to 3 a.m. ; it was in the 
 upper part of the abdomen and to the right of the middle line 
 and went through to the left shoulder-blade. Since February 
 the pain had been practically constant except for a day now 
 ^ and then, and it had got gradually 
 
 worse, so much so that he could 
 
 not work or sleep. He had never 
 
 ..•••'•••-.,, vomited ; and only occasionally 
 
 ^.,.'*'' \ had heart-burn and water-brash. 
 
 ..'''*' i The bowels were regular up till a 
 
 • month ago and he never had 
 
 black motions. He had lost nearly 
 
 ''*-.. ®U .,-•*'** 2 St. since the beginning of the 
 
 """'" year. Lately he had lived on 
 
 Fig. 19. ~' ^ 
 
 Benger's food, chicken or veal 
 tea, toast and charcoal biscuits. Greasy and vegetable soups 
 were avoided, as they always caused severe pain. Bicarbonate 
 of soda gave temporary reHef, and taking food also gave 
 rehef. There had been flatulence. 
 
 Examination. — The abdomen was regular in outhne 
 and moved freely on respiration. There was no rigidity 
 but there was slight tenderness over an area 2 ins. above 
 the umbilicus and 2 ins. from the middle Hne. The stomach 
 was enlarged and splashing to the right of the middle Hne 
 as shown in the tracing, Fig. 19. 
 
 On the nth September the report was of pain the 
 previous night and of having vomited 16 ozs. before break- 
 fast. The vomit was Hght -green in colour, and consisted 
 almost entirely of clear fluid with some starch and fat 
 globules ; it showed much free HCl. 
 
 On the 15th September a test breakfast showed much 
 free HCl. 
 
 On the 1 6th September he was X-rayed six hours after 
 a bismuth meal, when a large amount of the meal was still 
 seen to be in the stomach but some had reached the caecum. 
 Twenty-four hours later all the bismuth was at the csecum. 
 
 On the 1 8th September he was transferred to Professor 
 Caird, who found a duodenal ulcer just beyond the pylorus, 
 
ILLUSTRATIVE CASES 163 
 
 and performed a gastro-enterostomy. He returned to my 
 ward on the 30th September and was discharged on the 
 14th October feeling quite well.i 
 
 Much Pain, no Helena, Large Gastric Dilatation : 
 Operation : Complete Restoration 
 
 Case 36. — C. R., aged 62, suffered some years ago 
 from h3'perchlorhydria, from which he had recovered under 
 appropriate treatment. The symptoms returned and 
 gradually became more pronounced until a time came when 
 no medicine gave much relief and what relief was obtained 
 was merely temporary. Diet had to be restricted to the 
 simplest and blandest of foods, and these were taken in 
 small quantity because everything caused pain. He neces- 
 sarily lost weight and found his work very trying during 
 the years of war, and only his great fortitude and endurance 
 enabled him to keep to his post. When pain was at its 
 worst he emptied the stomach by vomiting, which was 
 easily done by touching the pharynx. The stomach was 
 dilated and its contents could be splashed to the right 
 costal margin. This patient was also much opposed to 
 operation but ultimately consented. Professor Caird saw 
 him and the operation was done by Mr. Wilkie. An ulcer 
 was found an inch or more to the distal side of the pylorus, 
 the floor of which was so flimsy that it gave way when 
 handled ; after that was secured a gastro-enterostomy 
 was performed. The X-ray examination showed the stomach 
 to be very large and atonic with no appearance of the bis- 
 muth passing the pylorus. For various reasons this case 
 was specially observed, and the X-ray examinations were 
 found to confirm fully the observations made in advance 
 of the examinations. The position and size of the stomach 
 in the recumbent position was verified ; it was also seen 
 how in- this position part of the stomach was flattened against 
 the spine while the bismuth lay to left and right of it. This 
 phenomenon has been already referred to as explaining the 
 
 1 The notes of this case were made by my House Physician, Dr. G. M. Brown. 
 
i64 THE PYLORUS AND DUODENUM 
 
 failure to get a succussion wave unless the stomach is ver}- 
 full, while a gurgle or splash can often be obtained to left 
 and right of the spine. These phenomena were very pro- 
 nounced in this patient and frequently noted. 
 
 The operation was highly satisfactory in its results. 
 Pain was at once relieved. The patient rapidly regained 
 the weight which had been lost, and also his former strength 
 and vigour. 
 
 Gastric Symptoms for Twenty-three Years : Hyper- 
 CHLORHYDRiA : DuoDENAL Ulcer : Great Stenosis : 
 Operation Successful 
 
 Case 37. — Mr. W., aged 38, had suffered from his 
 stomach for many years. The trouble began when he was 
 15 years old. He clearly remembered that pain used 
 to come on two hours after taking food, and that it was 
 relieved by taking food. Before that time he " could 
 digest anything." The S3anptoms were not always present ; 
 they came and went and between the attacks he " could 
 eat anything without discomfort." The attacks gradually 
 became more frequent, more severe and more prolonged. 
 Taking bicarbonate of soda used to relieve, but this largely 
 lost its effect. The dose he took was three-quarters of a 
 teaspoonful. He had much flatulence both upwards and 
 downwards. The bowels were fairly regular, but he occa- 
 sionally took cascara or Gregory's powder and more recently 
 paraffin. He said he " had suffered more than anybody 
 would beheve." His ordinary medical attendant had not, 
 he stated, ever suggested to him that anything more could 
 be done for him than was being done. Owing to change of 
 residence he changed his doctor and fell into hands that 
 recognized the necessity for further treatment. 
 
 Examination. — He was of fair complexion, of good 
 colour, but very spare and there was no subcutaneous fat. 
 I saw him about one and a-half to two hours after he had 
 taken a meal consisting of fish and milk pudding. On 
 inspection of the abdomen the outline of the stomach was 
 visible and its peristaltic movements were easily stimulated 
 
ILLUSTRATIVE CASES 
 
 165 
 
 and visible through the thin parietes. Splashing was 
 readily obtained and the succussion wave felt to the right 
 costal margin. Fig. 20 is a copy on a reduced scale of 
 the outline of the stomach made at this time. He was sent 
 into a nursing home for 
 
 the night. I saw him six © ® 
 
 hours after the midday 
 meal referred to, and 
 found the stomach much 
 as it had been earlier, but 
 not quite so full. A 
 sample removed by the 
 tube showed much free 
 HCl. In the morning he 
 was X-rayed by Dr. Hope 
 Fowler and seen also later 
 in the day. This examina- 
 tion confirmed the opinion 
 that there was great py- 
 loric stenosis. The X-ray 
 plate taken in the re- 
 cumbent position corre- 
 sponded exactly with Fig. 
 
 20. The accuracy of the outHne was tested on the screen 
 and on the plate and showed the complete correctness 
 of the tracing in regard to fundus, the level of the inferior 
 border, and the position of the right border. The only 
 discrepancy was the lesser curve, owing to the stomach 
 having been fuller when the tracing was made than when 
 the X-ray plate was taken. Operation by Mr. Jar dine was 
 most successful. 
 
 0u 
 
 Fig. 20.— Case 37. Stomach tracing, 
 showing great ptosis of greater 
 curve. 
 
 Scar on Lesser Curve of Stomach near Pylorus, 
 
 ANOTHER IN THE DuODENUM NEAR THE PyLORUS, 
 
 AND Pyloric Stenosis 
 
 Case 38.— William G., aged 40, was admitted to the 
 Royal Infirmary on the 9th September, 1914. 
 
 History. — Since boyhood he had suffered from a " weak 
 
i66 THE PYLORUS AND DUODENUM 
 
 stomach " and had to be cautious in diet. Fat meat, 
 porridge, and potatoes were avoided, as they gave rise to a 
 feeling of distension. Six weeks before admission he began to 
 have pain after ever}' meal. It came on about an hour after 
 food and got gradually worse until relief was obtained by 
 vomiting. Pain was not related to any particular kind of 
 food, even water or milk induced it. At first he was 
 able to take Benger's food mthout pain or vomiting as a 
 result, but for five weeks he vomited after everything he 
 took. On several occasions after much retching the vomit 
 had been Uke coffee-grounds. He never vomited red blood. 
 The vomit was very bitter and " burnt the back of the 
 throat." The motions had never been black. The bowels 
 were constipated. Since the previous \vinter he had lost over 
 3 St. in weight. He had not suffered from heart-burn but 
 ^ ^ occasionally from water- 
 
 brash after eating oat-cakes. 
 Examination. — Teeth 
 were good and the gums 
 were healthy. Tongue was 
 moist and shghtly furred 
 
 \.^ -•''' in centre. Appetite was 
 
 ® U good but he could not retain 
 
 Fig. 21. — Case 38. food. The stomach was 
 
 much enlarged, as shown in 
 the tracing, Fig. 21 ; there was slight tenderness about the 
 normal position of the pylorus but nowhere else. On the loth, 
 the day after admission, he had pain about midday and 
 16 ozs. were withdrawn from the stomach, consisting mainly of 
 the food he had taken. There was much free HCl. On the 
 nth he had no pain, but the stomach was easily splashed. 
 On the 13th pain returned, which was removed by mth- 
 drawing the stomach contents. On the 14th he was examined 
 by X-rays in the erect position, when the stomach was shown 
 as low as the right iliac fossa. Examination six hours "after 
 the bismuth meal had been given showed that none of the 
 meal had left the stomach. Professor Caird operated on 
 the 1 8th and did a gastro-enterostomy. He found marked 
 
A RELIC OF THE NEAR PAST 167 
 
 pyloric stenosis, an old scar on the lesser curve of the stomach, 
 and another scar in the duodenum near the pylorus. The 
 patient made an excellent recovery and was relieved of all 
 his previous miseries. 
 
 A Relic of the Near Past : 
 
 Gastric Symptoms for Forty Years : Stomach Tube 
 
 Daily for Seventeen Years : Operation : Cured 
 
 Case 39. — John H., aged 60, was admitted to the Royal 
 Infirmary on the 21st October, 1910. The history of 
 his stomach symptoms covered a period of forty years. 
 At the age of twenty he began to suffer from a gnawing 
 pain which came on about two hours after meals but it was 
 not severe. It often began about midnight and would 
 last until he got up and took some baking soda. The pain 
 came on about two hours after breakfast and continued 
 until the midday meal, the taking of which gave rehef ; 
 two hours later the pain returned and was again put away 
 by taking supper. Pain was also removed by taking 
 bicarbonate of soda. A year later he had another attack 
 which lasted about a week. Up to the age of forty he 
 suffered off and on in this way. At the age of forty the 
 attacks became worse and blood was passed per rectum 
 on at least two occasions and he was unfit for work for 
 months. He also vomited stuff like coffee-grounds on one 
 or two occasions. He was admitted to the Royal Infirmary 
 suffering from severe pain and was treated by having the 
 stomach washed out. This relieved him, and he had evi- 
 dently been taught to use the tube, for he continued to use 
 it almost daily for seventeen years before he was admitted 
 to my ward in October, 1910. The stomach tube had ceased 
 to relieve him and vomiting had supervened. On admission 
 the stomach was found to be much dilated as shown in the 
 tracing, p. 168, Fig. 22. There was no tenderness on 
 palpation anywhere in the abdomen. There was no visible 
 peristalsis. The patient was transferred to Mr. Miles on 
 the 24th, and on the 28th a gastro-enterostomy was done. 
 An old duodenal ulcer was present with so much thickening 
 
i68 THE PYLORUS AND DUODENUM 
 
 around it that the duodenum was almost completely occluded. 
 Recovety was rapid and the patient left the infirmary 
 reheved of his miseries and continued so when last heard 
 of long after the operation. 
 
 Remarks. — This case is given as a connecting link before 
 the present and the recent past. The treatment of the 
 patient for gastric dilatation and vomiting b}^ stomach 
 
 lavage was as far as 
 medicine had developed 
 at the time. The discovery 
 b}^ surgery that the abdo- 
 men could be safely opened 
 and its \dscera freely 
 _ , , .••' handled has led us to the 
 
 "■•• ••■"" diagnostic accuracy now 
 
 attainable and to a re- 
 finement in operative pro- 
 '"• ^ cedure that leaves but little 
 
 more to ^^ish for. The 
 ,. , .,. case is instructive as 
 
 Fig. 22. — Case 39. L umbilicus. . 
 
 illustratmg a history of 
 recurring hyperchlorhydria for twenty j^ears ; then duodenal 
 ulcer being added, rendering him unfit for work until the 
 S3'mptoms were controlled for many years by using the 
 stomach tube daily. 
 
 Causes of Unsatisfactory Operation Results 
 
 The result of gastro-enterostomy in stomach and duodenal 
 cases is eminenth* satisfactor\' in cases properly selected 
 and in which the operation has fulfilled certain requirements. 
 The failures, or apparent failures, have been a small propor- 
 tion of the total and they can be placed in definite groups. 
 
 A. Ineflficient Drainage. — A striking example of this has 
 been given in Case 12, Chapter IX., where the only possible 
 explanation of the first opening being a failure, and the 
 second one an immediate success, must have been a matter 
 of drainage. Other cases occur where discomfort has not 
 
CAUSES OF UNSATISFACTORY RESULTS 169 
 
 been entirely removed ; and where it will be found that 
 there is a residuum of food in a portion of sagged stomach 
 which is below the gastro-enterostomy opening. Such a 
 residuum usually contains much free HCl. In one patient 
 with this condition there occurred from time to time attacks 
 of nausea and loss of appetite due to reflux from the duode- 
 num through the pylorus, and containing bile. 
 
 B. Continued Haemorrhage or Pain. — ^This is met with 
 in cases of gastric or duodenal ulcer when the ulcer has not 
 been dealt with directly by the surgeon. The behef that a 
 gastro-enterostomy will lead to the heahng of gastric or 
 duodenal ulcer in all cases is contradicted by experience. 
 That being the position the writer fails to understand why 
 ulcer in either region should not be dealt with directly 
 whenever practicable. Recurring haemorrhage from a 
 duodenal ulcer, after gastro-enterostomy, is a most unsatis- 
 factory sequel ; and continued pain from a gastric ulcer 
 is highly disappointing to patient and physician. 
 
 C. Recurrence of Hj^perchlorhydria or Appearance of Hsrpo- 
 chlorhydria. — Either of these conditions may make 
 their appearance ; and there may be no evidence to show 
 that it is anything more than a functional perturbation 
 such as occurs where there has been no operation. That 
 gastro-enterostomy is to cure an acid dyscrasia is perhaps 
 an unreasonable expectation. Certain it is that some 
 cases require from time to time to have treatment appli- 
 cable to hyperchlorhydria. Hypochlorhydria is much less 
 frequent, but it is met with, and when it is recognized it 
 can be successfully treated by the means emplo3-ed for the 
 counteracting of that defect. I have seen this emerge 
 eight years after a gastro-enterostomy. 
 
 D. Spastic Stomach. — In some cases continued discom- 
 fort seems to be due to an almost spastic contraction of the 
 stomach wall interfering with the gastro-enteric opening, 
 practically closing it, so that a residue of contents, in a 
 highly acid medium, is retained, and is evidently the cause 
 of the discomfort. 
 
CHAPTER XV 
 
 SILENT OR MASKED DUODENAL ULCER : THE EXPLANATION 
 OF PAIN AND THE CONTROL OF PAIN 
 
 Reference has already been made to the alleviation of the 
 symptoms of duodenal ulcer. In the first of the two f ollo^^ing 
 cases the symptoms were not only alleviated but were kept 
 in abeyance by the regular use of anti-h37perchlorhydria 
 treatment, so completely that the existence of ulcer was 
 obscured until a profuse melaena proved its presence. The 
 possibiKty of thus masking the symptoms must not be 
 lost sight of and it must be recognized that it adds to the 
 difficulty of diagnosis when there is no history of melsena. 
 This recurring masking of symptoms by treatment occurs 
 in cases of undoubted ulcer. I know a patient who has had 
 recurring attacks of pain ^^dth melsena for years and whose 
 attacks have so far been overcome by a few da3'S of very 
 careful dieting and the free use of belladonna and bicar- 
 bonate of soda. He is strongly and persistently opposed 
 to operation. 
 
 Pain : Dilated Stomach : Pain removed by Treatment : 
 Mel^na : Operation : Duodenal Ulcer 
 
 Case 40. — Mr. H., Indian Government servant, aged 39, 
 was sent to me on the 20th June. The history given was that 
 he had suffered from stomach pain off and on for the past 
 five years or so. The pain had been intermitting, attacks 
 occurring every three or four months. During the last 
 3''ear they had become more frequent and more severe. The 
 pain was usually worst about eight o'clock at night, but was 
 
 170 
 
MASKED DUODENAL ULCER 171 
 
 relieved by taking dinner, and there was no pain during the 
 night. Bicarbonate of soda relieved the pain. There was 
 troublesome and somewhat obstinate constipation. The 
 tongue was clean and moist. The general condition was 
 good, although there had been some loss of weight. On 
 examination of the abdomen the stomach was splashed to 
 the right costal margin ; there were fseces in the transverse 
 colon ; there was no tenderness at the caecal region on careful 
 and detailed palpation. He was seen a week later, three 
 hours after lunch, when the stomach was in much the same 
 condition, and a specimen withdrawn by means of the tube 
 showed abundant free HCl. He was treated from the outset 
 for hyperchlorhydria, and he faithfully carried it out during 
 the succeeding months. He was not seen again until he 
 returned to Edinburgh, seven months later. He looked 
 better and had kept himself free of pain although not 
 restricting his diet to any marked extent. On examination 
 the stomach was found to be as large as before, with the right 
 border at the right costal margin. The constipation had 
 continued obstinately troublesome in spite of phenol 
 phthalein, cascara, and taraxacum. The condition was so 
 unsatisfactory that he was again X-rayed. The examination 
 suggested the possibility of a duodenal ulcer retaining some 
 bismuth. He was advised to go into a nursing home for 
 observation, and he was again seen by Professor Caird. 
 The morning of the day on which we together saw him he 
 had a large melsena, which removed any doubt there may 
 have been as to the probability of ulcer. He was operated 
 on in a few days, when the presence of the ulcer was further 
 confirmed. He made a good recovery. 
 
 Pain : its Cause and its Control 
 
 This case provides a striking illustration of the control 
 of pain even when duodenal ulcer is present. It may be 
 used as a peg on which to hang some remarks and reflexions 
 which have an important bearing on the question of the 
 existence of duodenal ulcer in certain cases. In the fore- 
 
172 THE PYLORUS AND DUODENUM 
 
 going case there had been a period of fully three years during 
 which there had been recurring attacks of hyperchlorhydria ; 
 but, for a year or more, attacks became more frequent, more 
 severe and less tractable. There was no history of melaena. 
 When seen by me there was evidence of marked sagging of 
 the stomach as shown by the right border being at the costal 
 margin. Complaint of pain was not pronounced, nor indeed 
 at all definite, but at this stage the patient tended to belittle 
 his symptoms. By means of belladonna and bicarbonate 
 of soda he kept himself free of serious discomfort for seven 
 months while he was visiting friends in different places in 
 England. When again seen his general condition had 
 appreciably improved. Yet there was persistent delay in 
 stomach emptying : four and a half hours after a moderate 
 midday meal the stomach could still be splashed to the right 
 costal margin. The stomach had not lost any of the sagging 
 that was found seven months before. The question arose 
 whether there might be a congenitally narrowed pylorus. 
 He was again X-rayed and no such narrowing was 
 demonstrable and the stomach emptied the bismuth in 
 good time. In this business of emptying it has to be insisted 
 on very strongly that the emptying of a bismuth meal must 
 not be taken as representing what happens when ordinary 
 food is taken. The position of the right border, determined 
 by succussion, or by it and auscultation, is the only reliable 
 means of determining whether the stomach has passed on 
 or is unduly retaining the food which has been taken into 
 it. In this case, there was undue retention. The retention 
 could not be due to failure of gastric digestion, because 
 it was already known that the patient was an active 
 acid secretor. Moreover, he knew that he could coun- 
 teract his digestive pain by the free use of an alkali, 
 and I had encouraged him to use the alkali freely for this 
 purpose. 
 
 This is not the description of a unique case. The effect 
 of treatment, when it is pushed far enough, frequently has 
 this effect on the symptom of pain in the class of case we are 
 considering. It is during this period that healing of an 
 
PAIN: ITS CAUSE AND ITS CONTBOL 173 
 
 ulcer will take place if it is to heal. The phenomenon in 
 this case, as in others, throws a clear light, I venture to 
 hold, on the symptom of pain when ulcer is present. In this 
 case pain was not cured, if we may speak of the cure of a 
 symptom, it was merely kept in abeyance, certainly for 
 months. And yet the ulcer was there. There was no 
 anatomical cause of obstruction at the pylorus, and gastric 
 peristalsis was fairly good. Although there was delay, the 
 stomach contents finally passed through, and had never been 
 rejected by vomiting. It may be safely assumed that the 
 activity of acid secretion varied from time to time, and that, 
 when pain came on, the secretion was more active, but could 
 be counteracted and controlled by bicarbonate of soda. 
 This not only relieved the pain but allowed the gastric 
 contents to pass into the duodenum without causing 
 pain. 
 
 The explanation of this seems to me to be as follows. 
 The pain in hyperchlorhydria is due to spasm of the pyloric 
 musculature, but, at least when ulcer is present, instead of 
 this being a stimulus arising from the proximal side of the 
 pylorus, it arises from the distal side, that is the duodenal 
 side, and is the result of some of the super-acid contents 
 trickUng into the duodenum. That the presence of an 
 ulcer in the duodenum should accentuate this backward- 
 acting reflex can hardly be doubted. Certain it is that the 
 mere passage of gastric contents over a duodenal ulcer does 
 not necessarily or always cause pain. They require to be 
 unduly acid ; which is to be interpreted as free HCl. This 
 brings the condition into interesting relationship to the 
 phenomenon referred to earlier as the gastric phase of pyrosis, 
 described by Roberts, but which the writer believes to be a 
 pyloric phenomenon. 
 
 Accepting this explanation to be correct, it makes it 
 necessary to treat cases of hyperchlorhydria with intelligent 
 vigour so as, in the first place, haply to prevent the for- 
 mation of ulcer. If ulcer has formed it may heal, If, 
 however, pain is only kept in abeyance by treatment, 
 and if there is stomach sagging with retention, the 
 
174 THE PYLORUS AND DUODENUM 
 
 presumption is that there is ulcer, although there has not 
 been melcena. 
 
 Dilated and Sagged Stomach : No Pain : No 
 hemorrhage i diagnosis, " pyloric difficulty " i 
 Operation : Duodenal Ulcer 
 
 Case 41. — ]\Ir. B., aged 27, had served his country during 
 the war, but was latterly interned in Holland, where he was 
 poorlj- fed and had tr3dng experiences. When he returned 
 home in October, 1818, he was run down physically and 
 nervously. He was sent to me in the end of October, 1919. 
 Four and a half months before I saw him he began to suffer 
 from intense'stomach^discomfort with flatulence and consti- 
 pation. He also suffered from sleeplessness. 
 
 Examination showed him to be very lean. The tongue was 
 clean. The abdomen, examined two hours after breakfast, 
 revealed nothing abnormal on inspection save great leanness 
 of its wall. On examination the stomach fundus was found 
 to be large ; its greater curve was at the umbilicus ; and its 
 right border two inches to the right of the middle line. This, 
 of course, was in the recumbent position and was determined 
 by percussion, succussion, and succussion combined with 
 auscultation. A specimen removed from the stomach by 
 means of the tube showed the previous meal to be well 
 broken up. There was much free HCl. He was given 
 belladonna and valerian before meals and bicarbonate of 
 soda to be taken after food when discomfort began. A 
 laxative pill consisting of phenol phthalein, cascara, and 
 taraxacum was given for the constipation. 
 
 This treatment was continued more or less steadily until 
 I\Iarch, when I saw him again after an interval of two months. 
 His general condition had improved, but the gastric symptoms 
 had varied ; the most definite sj'mptom obtained was that 
 stomach discomfort became worse if he attempted to walk 
 much. Examination of the abdomen at different hours 
 showed no change in the condition of the stomach. He 
 could make it splash audibly at any time, and I never found 
 it empty. He could make it splash before breakfast, having 
 
MASKED DUODENAL ULCER 175 
 
 swallowed neither food nor fluid since 8 o'clock the previous 
 night. There was an entire absence of complaint of pain ; 
 he would not allow that it was more than " discomfort," 
 but it worried him and it was acting as a drag upon recovery 
 from his neurasthenia. I had had him X-rayed in November 
 by Dr. Hope Fowler as I thought he might have a congenitally 
 narrow pylorus which only asserted its presence after his 
 experiences in Holland. The bismuth, however, passed out 
 of the stomach in reasonably good time, whereas ordinary 
 food did not do so. My surgical colleague Mr. Wilkie saw 
 the patient with me /and Dr. Fowler again X-rayed him with 
 the special object of determining what evidence such 
 examination would give of pyloric difficulty and the nature 
 of the difficulty. That there was pyloric hindrance seemed 
 to me to be beyond doubt. At this second examination 
 it was seen that the duodenal cap was slow in appearing, 
 was small in size, and that the stem connecting it with the 
 antrum was small. The pyloric channel could not be 
 satisfactorily brought out by manipulation or by change 
 of position. It was agreed that pyloric difficulty was 
 present, and that it would be dealt with in accordance with 
 what should be found. Duodenal ulcer was not excluded, 
 although the symptoms did not definitely point to its 
 presence, but it seemed the only alternative to a congenital 
 stenosis. The differentiation of these was an academic 
 point, so far as the patient was concerned, for whichever 
 it was required to be dealt with surgically. The abdomen 
 was opened, when it was found that there was no stenosis, 
 but an ulcer in the first part of the duodenum, which 
 had not produced any appreciable narrowing of the 
 duodenum. 
 
 Remarks. — ^This case illustrates what may be termed 
 " silent duodenal ulcer " in so far that pain was not definitely 
 present. It, however, further illustrates what has been dealt 
 with fully in- a previous chapter, namely, the great value of 
 determining the position of the right border of the stomach. 
 It also shows that bismuth is expelled from the stomach in 
 much shorter time than an ordinary meal. Although there 
 
176 THE PYLORUS AND DUODENUM 
 
 was an absence of pain and of haemorrhage, the persistent 
 sagging of the stomach with the right border to the right 
 and retention, showed that there was pyloric difficulty which 
 was not yielding to medicinal treatment and required surgical 
 interposition for its relief. 
 
SectioxX hi.— the intestinal TPvACT 
 CHx\PTER XVI 
 
 ENTEKOPTOSIS : SPLANCHNOPTOSIS OR VISCEROPTOSIS 
 
 The term Enteroptosis means that there is ptosis or dropping 
 of nitestine. Splanchnoptosis or Visceroptosis means that 
 there is dropping of aU the abdominal organs, not only 
 stomach and intestine, but also of the liver and kidneys. 
 The bladder is, of course, excluded, although it may be pressed 
 upon by the weight of the other hollow viscera. The 
 differentiation is not above criticism, for it suggests a separa- 
 tion of conditions which are, in part at least, always associated. 
 In gastroptosis, for instance, the ptosis is not confined to 
 the stomach, it always carries with it ptosis of the trans- 
 verse colon ; so definitely is this the case that when the 
 position of the lower limit of the stomach is determined 
 it is certain that the position of the transverse colon is at 
 least lower than that, and that the coils of the small intestine 
 are correspondingly lowered. While the transverse colon 
 is thus lowered its hepatic and splenic flexures may remain 
 fixed approximately in their normal position so that the 
 transverse portion is U-shaped, an acute angle being there- 
 by formed at both flexures. In other cases both flexures 
 may be much below their normal position as is seen in 
 Figs. 27 and 28. Another very important point which 
 has to be determined in aU cases of gastroptosis is tJie position 
 of the pylorus and its relation to the axis of the stomach. 
 In some cases the pylorus, although it ma}- be considerably 
 to the right of and below its normal position, is not lowered 
 
 177 12 
 
178 THE INTESTINAL TRACT 
 
 in proportion to the lowering of the stomach. When 
 this occurs it can be readily understood that the stomach 
 has great difficulty in emptying and may be quite unable 
 to expel its contents into the duodenum, especially in the 
 upright posture, and that this leads to long retention of 
 food in the stomach. This retention leads to exhaustion 
 of the musculature and to consequent greater dilatation 
 and sagging of the lower border of the viscus. In other 
 cases the position of the pylorus is relatively as low as the 
 axis of the stomach. When this condition is present the 
 stomach empties satisfactorily, and progressive atony, 
 dilatation, and sagging does not take place. This latter 
 condition is probably congenital, for it is associated wdth a 
 long, straight aorta and a heart long, narrow, and low in 
 position. The liver and diaphragm are also lov/ in position. 
 Cases of this description are not uncommon, and it is usu'ally 
 so easy to make out that the stomach is below the level ot 
 the umbiUcus that the opinion may be formed that the patient 
 requires gastro-enterostomy. This opinion is stiU more 
 readily arrived at if the patient has an intercurrent attack 
 of gastric disturbance at the time when seen and examined. 
 Such cases are not exempt from functional gastric disorder 
 and if this has existed for some time there may have been a 
 loss of weight which further tends to lead to a wrong diag- 
 nosis. Operation in cases of this description is probably 
 one of the causes which has led to doubt in some minds as 
 to the value of a highly valuable operation when performed 
 in properly selected cases. It is here assumed that entero- 
 ptosis and visceroptosis are congenital conditions, although 
 they may become more pronounced as life advances. In 
 women there is a temptation to attribute it primarily to 
 tight lacing, but its occurrence in men throws doubt upon 
 this interpretation. The cases I have seen have been mostl}- 
 in persons in middle life. They belong to the lean type, 
 who never put on fat, and are small or moderate eaters. 
 They are usually seen when suffering from an intercurrent 
 disturbance of gastric function, associated as that often 
 is with atonicity and dilatation, or with a definite attack 
 
t 
 
 Fig. 23. — Case 42. Shows the upright position of the 
 stomach with the pyloric portion hook-shaped below 
 the level of the umbilicus. 
 
 d 
 
 
 ^K .*^ J^ 
 
 |^^|h 
 
 ^» ^mA 
 
 ^^^^S. 
 
 !» m 
 
 Fig. 24. — Same case, 4 hours later ; bismuth all out of 
 stomach. 
 
 [To face pa^e 178. 
 
Fig. 2^. — Same case, 24 hours later ; showing position 
 of hepatic flexure. 
 
 1 JG. 2',.- — Siime case, 4.S hours after; showing low position 
 of both flexures. 
 
 [To jace page i7q. 
 
VISCEROPTOSIS IN THE FEMALE SEX 179 
 
 of hyperchlorhydria. The intercurrent disturbance accen- 
 tuates the coarser evidences of displacement and dilatation 
 and readily leads to error in advising surgical interposition. 
 In enteroptosis when the stomach empties readily a gastro- 
 enterostomy can do no good and will probably do much 
 harm. 
 
 The following cases are examples of the condition. 
 
 Visceroptosis in the Female Sex 
 
 Case 42 (Mrs. R.). — Figs. 23 to 26 show the position 
 of the stomach and colon in this patient. As in all such 
 cases, there was much discomfort, a weary sense of dragging 
 and constipation. The position of the stomach in the 
 upright position is shown in Fig. 23. The pyloric portion 
 of the viscus is seen to be below the level of the umbilicus. 
 Notwithstanding this the organ emptied in good time. 
 Fig. 24 shows that the bismuth had completely passed out 
 of it in four hours. Fig. 25, taken twenty-four hours after 
 the bismuth was given, shows it heaped up in the caecal 
 region. It is, however, to be noted that the bismuth is 
 not only in the caecum, but in what represents the ascending 
 colon, the hepatic flexure, and the first part of the transverse 
 colon ; the hepatic flexure is seen to be below the level of 
 the iliac crest. Fig. 26 shows the position of the bismuth 
 at the end of forty-eight hours. Some of the bismuth has 
 passed along the transverse colon to the splenic flexure, 
 which, like the hepatic flexure, is below the level of the iliac 
 crest. This is a good example of enteroptosis in a patient 
 with visceroptosis. The slow progress of the bismuth 
 represented the constipation. As there was no undue 
 retention of food in the stomach all thought of using a 
 gastro-enterostomy was excluded ; and as there was no 
 known method of tacking up the abdominal viscera, she was 
 measured for a light abdominal corset and the constipation 
 was corrected bj^ means of a suitable laxative. The lady 
 became pregnant and, as happens in such circumstances, 
 the enlarging uterus served as an adiiiirable support to the 
 
i8o THE INTESTINAL TRACT 
 
 dropped viscera. After the child was born the abdominal 
 corset was adjusted, and the action of the bowels was 
 attended to. Her condition has continued to be most 
 satisfactory. 
 
 Visceroptosis in a Patient who had not worn Corsets 
 
 Case 43. — Mrs. M., aged 58, had borne six children. 
 She suffered from pains radiating all over the chest and often 
 referred to the precordia. She suffered from the conse- 
 quences of a lacerated perineum which, although healed, 
 had left an enfeebled anal sphincter and a tendency to 
 piles. The uterus was reported as normal. She had to be 
 careful of her feeding owing to abdominal discomfort, but 
 the view was strongly expressed that her symptoms were 
 all to be attributed to the state of the heart and circulation. 
 She had been seen by several doctors reputed to be specialists. 
 A doctor in America attributed her symptoms to a curvature 
 in the lower cervical region and sent her to an osteopath 
 for treatment. Another doctor told her she was suffering 
 from " spurious angina pectoris," the patient resenting 
 the word spurious as her pains were very real. Another 
 specialist said she was suffering from toxaemia from the 
 piles. On examination I found heart and vessels perfectly 
 sound. The abdominal wall was thin, fatless, and very lax. 
 The stomach was very low in position and the right kidney 
 was loose and half of it projected beyond the ribs. There 
 was no doubt that the condition was a pronounced viscero- 
 ptosis, but there was no evidence of food being unduly 
 retained in the stomach. The condition was explained 
 to the patient and her husband, and they agreed to a complete 
 X-ray examination in confirmation of the diagnosis. The 
 condition had not before been even suggested to them. The 
 X-ray examination in the upright position showed that the 
 stomach emptied in good time in spite of its low position. Its 
 inferior border was only two fingers' breadth above the pubes, 
 both the hepatic and splenic flexures were much below their 
 normal positions, and the right kidney was partly in the 
 iliac fossa. It is almost needless to say that this condition 
 
VISCEROPTOSIS IN THE MALE SEX i8i 
 
 of abdominal viscera was sufficient to account for all the 
 symptoms complained of. The patient had in earlier life been 
 verj' strong and vigorous and the only available explanation 
 of the condition was that the abdominal wall had been 
 allowed to remain lax after the various confinements. She 
 had never worn corsets. Surgical interposition was, of 
 course, out of the question, but it was hoped that an 
 abdominal corset applied before the patient got out of bed 
 would give much relief. This and the regulation of the 
 bowels gave great rehef. 
 
 Visceroptosis in the Male Sex 
 
 Case 44. — Mr. M., aged 42, had a dropped stomach which 
 did not interfere seriously with his business and public 
 activities. On my advice he wore an abdominal spirella 
 corset. During the time of the war, he was over- worked 
 and had a gastric and general physical breakdown in 1919. 
 I saw him with his ordinary medical attendant. He had 
 been kept in bed for three weeks and was fed on fluid nourish- 
 ment. He had lost weight and felt weak and unfit for work 
 before being confined to bed. He was very lean, but his 
 colour was good. The position of the stomach was visible. 
 The lesser curve was below the level of the umbilicus, while 
 the greater curve was still lower. Peristalsis was evidenced 
 by the varying degrees of prominence of the area referred 
 to. Epigastric and abdominal reflexes were active, and the 
 peristalsis of the stomach could be stimulated by flicking 
 the abdomen. Succussion was readily produced by the 
 hand placed over the organ. He was brought to a nursing 
 home and the limits of the organ traced and watched. 
 He was allowed a more liberal diet and the condition of the 
 stomach, soon after a meal and two or three hours later, 
 was watched for two days, and it was evident that emptying 
 took place satisfactorily. The liver was depressed and 
 from this combination of observations there was no reasonable 
 doubt that the condition was a visceroptosis. There was 
 no pain, and there had at no time been pain such as occurs 
 
i82 THE INTESTINAL TRACT 
 
 in ulcer. Congenital stenosis of the pylorus was excluded 
 by the absence of retention of food and by the shape and 
 size of the organ. Examination of gastric contents showed 
 abundant free HCl. To check the foregoing observations 
 he was X-rayed by Dr. Hope Fowler. 
 
 In the upright position the picture was a very striking 
 and unusual one : the bismuth meal filled and was grasped by 
 the proximal two thirds of the viscus, while the distal third 
 showed a narrow track of bismuth succeeded by an air- 
 containing area, the air having been carried down to the 
 pylorus by the weight of the bismuth meal. In the recum- 
 bent position, Fig. 27 shows the alteration in the position 
 of the stomach consequent on the change of posture ; while 
 the air had risen to the fundus and the bismuth occupied 
 the whole of the rest of the organ. This figure corresponded 
 sufficiently closely to the tracing taken in the nursing home 
 with the patient in bed. The X-ray examination confirmed 
 the presence of active peristalsis. Examined after a lapse 
 of three hours, it was seen that the large bismuth meal had 
 passed the pylorus with the exception of a small quantity. 
 Fig. 28, taken the following morning after the bowels had 
 moved, showed that both the hepatic flexure and the splenic 
 flexure were below the level of the crest of the ilium, and 
 thus fully confirmed the opinion that we were dealing with 
 an enteroptosis in a patient with visceroptosis. 
 
 Remarks. — ^This case illustrates very clearly the condi- 
 tion which has been described, and shows how entirely 
 unsuitable such a case is for gastro-enterostomy. The 
 question whether surgery is ever likely to be able to success- 
 fully deal with such a condition has, I venture to think, to 
 be answered in the negative. A visceroptosis like this must 
 be regarded as congenital, or as coming on early in life 
 from a congenital defect in the maintaining power of attach- 
 ments. Notwithstanding the lowering of the normal 
 anatomical position of the viscera, the stomach had ample 
 power in its musculature, the pyloric outlet was not narrowed, 
 nor was it so placed as to present a difficulty to the propulsion 
 of food from stomach to duodenum. There was no serious 
 
O 
 
 U5 
 
 O 
 
 S3 
 J O c« 
 
 
 
 [To /act; ^age iSz. 
 
PTOSIS OF TRANSVERSE COLON 1S3 
 
 difficulty to the passage of intestinal contents along the 
 colon, past the acute hepatic and splenic flexures, for not 
 only did the bismuth pass in reasonable time, but the patient 
 did not suffer appreciably from constipation. He suffered 
 from a measure of flatulence but not to a greater degree 
 than many persons whose viscera are normal in position. 
 An abdominal corset properly adjusted proved of great 
 value to the patient and enabled him to lead a strenuous 
 professional life. 
 
 Ptosis of Transverse Colon : Air-block 
 
 Case 45. — Miss C, aged 45, consulted me as she was 
 vomiting daily, had a feehng of great fullness after food, 
 referred both to the stomach and to behind the upper part 
 of the sternum, and of very obstinate constipation. She 
 thought that a gastro-enterostomy had been performed for 
 a gastric ulcer fifteen months before. The vomiting and 
 the constipation had been worse since the operation, and 
 she was unfit for work of any kind. 
 
 Examination of the abdomen showed the stomach to 
 be in practically the same position as in the previous patient. 
 The vomit consisted of softened and partially digested 
 food with much mucous. On chemical examination it 
 showed no free acid on three occasions. Bringing up 
 wind or vomiting, which was always accompanied by much 
 coming up of wind, gave great rehef. With a history such 
 as was given the presumption was that the gastro- 
 enterostomy opening was not functioning, but to test this 
 it was, of course, necessary to have recourse to X-ray exami- 
 nation. This showed the stomach to be in much the same 
 position as in the previous case, but there was no trace of a 
 gastro-enterostomy opening. I communicated with the 
 surgeon who had operated on her, when it was ascertained 
 that a gastro-enterostomy had not been done, but that a 
 gastric ulcer had been excised and the appendix removed. 
 The X-ray examination confirmed the position of the 
 stomach and showed air-swallowing. Air-swallowing, as 
 
i84 INTESTINAL TRACT 
 
 has been already pointed out, is prone to occur in hypo- 
 chlorhydria. The operative measures had not been effective 
 in removing the patient's symptoms ; in fact, she was 
 insistent in asserting that they had made her worse. On 
 following the bismuth in this case, as seen in Fig. 29, taken 
 nineteen and a half hours after it was given, the transverse 
 colon at its most dependent part was very low, a condition 
 which in some quarters is looked upon as pathological and 
 even called enteroptosis. In this patient, in spite of this 
 low position of the transverse colon, the hepatic and splenic 
 flexures were not nearly as low as in the other cases we have 
 given. The position of the bismuth in the caecal region 
 might mislead were it not shown, as is shown at B on the 
 figure, that there was a great block of air in the hepatic 
 flexure and in the colon on either side of it. This air space 
 evidently acted as a serious barrier to the passage of the 
 bismuth, for at the end of forty-eight hours little more 
 bismuth had passed it, as shown in Fig. 30. She was treated 
 as a case of hypochlorhydria with air-swallowing, and a 
 suitable laxative was given. 
 
 Ptosis of Hepatic Flexure only 
 
 Case 46. — Mr. S. was suffering from pain in the upper 
 half of the abdomen and constipation which was difficult 
 to overcome and was not getting less troublesome. On 
 examination there was a doughy mass to be felt in the right 
 hypochondrium which was neither liver nor a displaced 
 kidney and was therefore the hepatic flexure of the colon 
 full of faeces. It was tender on palpation. Faeces could be 
 felt in the transverse colon about an inch above the umbiHcus. 
 X-ray examination in the upright position showed marked 
 ptosis of the hepatic flexure, as seen in Fig. 31, taken twenty- 
 four hours after the bismuth was given. It will be noted 
 that there are two bends on the colon here instead of one, 
 but that the bismuth nevertheless was being propelled forward, 
 although slowly. At the end of forty-eight hours I examined 
 the abdomen with the patient on the X-ray couch and had 
 
QQ 
 
 QQ 
 
 [To /ace page 184. 
 
{To face page 185. 
 
COMPLICATIONS OF ENTEROPTOSIS 185 
 
 no difficulty in defining l^y palpation the position of the 
 hepatic flexure and of the transverse colon. The screen 
 showed these observations to be absolutely correct. The 
 position with the patient recumbent is shown in Fig. 32. 
 That the double bend of the colon was seriously interfering 
 with the passage of the bismuth was evident. To deal 
 surgically with the condition was out of the question, for 
 the time at least. After some trouble we arrived at a 
 laxative which promised to keep the flexure more or less 
 empty. 
 
 Complications of ENTERonosis 
 
 While enteroptosis is not suitable for operative interposi- 
 tion, conditions may emerge which require special treat- 
 ment. These are in my experience : (i) Hyperchlorhydria, 
 (2) hypochlorhydria, (3) appendicitis, (4) gastric or duodenal 
 ulcer. 
 
 Constipation is such a common accompaniment that its 
 correction becomes almost a matter of routine It can 
 be counteracted if sufficient care is taken to find the most 
 suitable laxative and the best time to give it. 
 
CHAPTER XVII 
 
 APPENDICITIS 
 
 The consideration of this common malady is begun by 
 reproducing the paper on its diagnosis and indications for 
 treatment prepared for opening a discussion on the subject 
 at the Edinburgh Medico-Chirurgical Society some years 
 ago. The reason for reproducing it here is that the state- 
 ments and argument submitted at that time are apphcable 
 to-day. Increased experience has given greater confidence, 
 and has put the questions surrounding the appendix in more 
 accurate and fixed perspective, as will be shown at the end 
 of the chapter. 
 
 Pathology, Diagnosis, and Indications for 
 
 Treatment - 
 
 Nothing is more valuable and nothing can be more mis- 
 leading in medicine than personal or individual experience. 
 This seeming paradox is perhaps specially applicable to the 
 clinical and therapeutic questions which surround the 
 caecum, for in this domain each individual physician, surgeon, 
 and general practitioner tends to base his views and methods 
 on his personal experience. One man calls in the knife the 
 moment he scents appendicitis ; another holds lingeringly 
 to the dying faith in a stercoral typhlitis and perityphlitis, 
 and each man is prone to continue to act in accordance with 
 the results of a limited personal experience. It is now 
 more than twenty years since the vermiform appendix 
 gained recognition as the main factor in what aforetime 
 
 ^ The opening paper read at the discussion on this subject before the 
 Edinburgh Medico-Chirurgical Society on Jan. 30th, 1904, 
 
 186 
 
PATHOLOGY AND DIAGNOSIS 187 
 
 was attributed to other causes. The predominance of the 
 appendix in this relationship has been steadily asserted 
 and hundreds of operations have afforded opportunities 
 for the confirming of its position and for a reasonable 
 classification of the morbid changes which affect it. In 
 this connection it will not be uninteresting to know 
 that in the medical statistics of the Edinburgh Royal 
 Infirmary for 1891-92 there are four cases of appendicitis, 
 three of t3^phlitis, and nine of perityphlitis. In 1894-95 
 the cases of appendicitis rose to twenty-one, while peri- 
 typhlitis has two, and typhlitis has disappeared from the list. 
 In 1901-02 both terms have disappeared and appendicitis 
 only is retained. Many writers have formally given the old 
 typhlitis and perityphUtis a place in the classical mythology 
 of medicine and assure us that no one has ever seen or ever 
 will see a simple perforation of the Ccecal wall or a peri- 
 t3^phlitis not due primarily to the appendix. Some writers 
 are more judicious and recognise a small percentage of such 
 cases, some even placing them as high as five per cent. 
 Were the statements of the former case to be taken as 
 correct I could claim a unique experience, for in a com- 
 paratively small experience I have had four such cases. 1 
 have had three cases of acute perityphlitis due to primary 
 lesion at the cacum ; one case at the operation showed 
 marked pericaecal inflammation, while the appendix showed 
 none, and a few daj^s later we had, unfortunately, the oppor- 
 tunity of seeing faecal ulcers in the caecum ; another fatal 
 case was the result of perforation of one of a number of 
 faecal ulcers ; the third occurred in an old man and proved 
 rapidly fatal without perforation or ulcer ; the fourth case, 
 also a fatal one, was of chronic peritjrphlitic burrowing 
 abscess in which the appendix was not involved and where 
 the diagnosis before I saw the patient was maHgnant disease. 
 I mention m}^ experience to accentuate one half of the seem- 
 ing paradox with which I opened — namely, that nothing may 
 be more misleading than the personal experience of any one 
 of us if taken by itself and not brought into relations with 
 the experience of others. Whatever hngering sentiment may 
 
i88 THE INTESTINAL TRACT 
 
 cling to the older views, the evidence is overwhelming that 
 in something between 95 and 100 per cent, of acute affections 
 at the caecum the primary seat of grave trouble is the 
 appendix, and that were it not for the appendix perityphHtis 
 would be a rare occurrence. 
 
 The Diagnosis of Acute Appendicitis 
 
 In approaching this question it is necessary to have a 
 clear conception of the condition we seek to diagnose. I do 
 not, however, propose to dwell in detail upon the varied 
 anatomical changes which are met with in the appendix as 
 a result of morbid action ; but there are some points which 
 materially assist us in our efforts at differential diagnosis. 
 It is important to bear in mind in the first place that the 
 appendix varies in length and in calibre, in its position 
 relative to the caecum, and in the form of its mesentery. 
 Moreover, the meso -appendix also carries its blood-supply. 
 In the second place two morbid conditions may arise in 
 connection with the appendix — namely, (i) inflammation 
 and (2) necrosis, going on to gangrene. The intensity of 
 the inflammation varies from a catarrh of its mucous mem- 
 brane to a parietal inflammation involving all its coats or 
 an inflammation accompanied by ulcers which may or may 
 not perforate. Necrosis or gangrene of the entire appendix 
 is sometimes, if not always, determined by a short mesentery 
 which gives the appendix a sickle shape or by some other 
 mechanism which interferes with the blood-supply. Van 
 Cott goes so far as to hold that the primary local condition 
 in appendicitis is a trophic one which makes it a point of 
 least resistance for the action of virulent organisms. The 
 fact that appendicitis is much less frequent in women than 
 in men is probably in part due to there being a second source 
 of blood-supply in women by way of the appendiculo-ovarian 
 ligament. This anatomical point is of important significance, 
 for various conditions at the caecum or of the appendix 
 itself may impede and even arrest the arterial blood-supply 
 so that necrosis and gangrene readily follow. The two 
 
DIAGNOSIS OF ACUTE APPENDICITIS 189 
 
 other anatomical points which seem to me of most importance 
 are the caUbre and perhaps the length of the appendix or 
 the relation between these and the relation of the lumen of 
 the appendix to the cavity of the csecum. I do not venture 
 to lay down definite rules, but it is by recognizing the exist- 
 ence of differences in the directions indicated that we are 
 able to understand how the appendix in certain persons, 
 from its shape, size, position, or curvature, is bound to give 
 trouble to its possessor on the slightest provocation, while 
 in others from birth to death it never indicates its existence, 
 no matter what the gastro-intestinal experience of the 
 individual may have been in other respects. 
 
 On this anatomical difference of position and of lumen 
 depends and hangs the question of inflammation. Why does 
 the appendix inflame and not the caecum ? I take from 
 A. O. J. Kelly of Philadelphia the idea, which I apply more 
 generally, that the question is essentially one of drainage. 
 Secretion from the mucous membrane of the appendix or 
 faecal matter entering from the caecum and not expelled form 
 an excellent nidus for the growth of the micro-organisms 
 of the intestine, but such conditions do more — they have 
 been shown experimentally to be the very conditions 
 which rapidly exalt the virulence of that otherwise harm- 
 less organism, the bacillus coH communis. Kelly, Deaver, 
 and others have shown by a large number of observations 
 that this organism is the most common bacterial agent, 
 although not the only one, in the determination of acute 
 inflammation in the appendix. It is important to realize 
 that the exaltation of virulence of the organism mentioned 
 takes place in other bowel conditions as obstruction, strangu- 
 lation, and volvulus, but for our present purpose it is still 
 more important to know that it also takes place in diarrhoeic 
 conditions and in constipation. The variability in the 
 measure of this exaltation of virulence determines the great 
 differences in the clinical manifestations and in the ultimate 
 issue in individual cases. But this question of drainage 
 requires further consideration, and in this connection 1 
 beheve that the condition of the mucous membrane of the 
 
190 THE INTESTINAL TRACT 
 
 caecum as a factor in causing the block is forgotten. We 
 never forget that a duodenal catarrh causes a block of the 
 common bile duct, but at the caecum we are so taken up 
 with the appendix that we ignore the possibiUty of the 
 block which determines and keeps up the inflammation 
 being caused by a like condition at its mouth. We must, 
 I think, accept this proposition. The block, however, may 
 be associated with a faecal concretion in the appendix and 
 this association is frequently present in the fulminating type 
 of appendicitis. Here also we have to be on guard against 
 unwarrantable conclusions. Faecal concretions are common 
 in the appendix without any trace of irritation, but if a 
 faecal concretion and a catarrh operate together then we 
 have the conditions which may lead to rapid perforation. 
 But even then the issue turns on the virulence of the organism 
 present. I have seen a faecal mass on a surgeon's finger tip 
 a second or two after he had introduced his hand into the 
 abdominal cavity and yet the patient never showed an 
 anxious symptom after the removal of the perforated 
 appendix. In connection with this question of faecal con- 
 cretion Fowler records a unique case in which gangrene of 
 the appendix was due to a gall-stone entrapped and stuck 
 at its orifice. 
 
 Following upon the foregoing considerations the first 
 point which appears to me to call for consideration is the 
 question of " appendicular colic " — is there such a condition, 
 and v/hat view do we take of it ? The sudden onset of severe 
 abdominal pain, perhaps vomiting, muscular rigidity of the 
 abdominal wall or of the lower right segment of it, and 
 tenderness are known to all of us. Talamon argues that 
 this sudden onset of pain is due to a scybalous concretion 
 formed in the caecum becoming suddenly engaged at the 
 mouth of the appendix. Fowler denies the occurrence of 
 appendicular cohc ; Hawkins questions it. Personally I do 
 not see how the manifestations referred to are to be other- 
 wise explained than by a temporary embarrassment to the 
 appendix drainage. We all know that an attack of the 
 kind indicated may come on in the night ; that after hot 
 
DIAGNOSIS OF ACUTE APPENDICITIS 191 
 
 applications and a dose of castor oil or of a saline laxative, 
 the individual may be well enough to be at business that 
 day or the following day. No medical man sees him, for 
 the condition is looked upon as indigestion or colic due to 
 constipation and only requiring domestic skill. We have 
 seen cases where a second and a third recurrence of this 
 experience formed the historical background to a tragedy ; 
 we have known it repeated over a period of many years and 
 no tragedy to follow. 
 
 This question of appendicular colic lies at the threshold 
 of the diagnosis of appendicitis ; from it you easily build 
 up the whole chnical story of acute appendicitis. You pass 
 from the mere mechanical and physical embarrassment of 
 cohc to the superadded inflammation, perforation, or necrosis. 
 The symptoms of acute appendicitis are common to various 
 abdominal illnesses — sudden onset of pain which may be of 
 extreme severity, vomiting, tenderness, rigidity, a measure 
 of shock with an accelerated and feeble pulse, and a varying 
 degree of elevation of temperature — so that appendicitis has 
 been mistaken for many things ; amongst them are acute 
 indigestion, gastric perforation, internal hernia, renal and 
 hepatic colic, while diaphragmatic pleurisy and croupous 
 pneumonia have been thought to be appendicitis. It would 
 be treating my readers with scant respect were I to 
 occupy their time with a reproduction of the points deter- 
 mining the differential diagnosis in all these. There are, 
 however, two phenomena which I venture to deal with — 
 namely, pain and tenderness. With regard to pain I am 
 often impressed by the undue significance attached to the 
 site of pain in abdominal conditions. In acute appendicitis 
 the pain is often referred to the umbiUcal, epigastric, or 
 other region, or it may be diffused all over the abdomen. 
 When pain is thus referred to regions at a distance from 
 the seat of lesion it frequently misleads. When such 
 referred pains are associated with surface tenderness in the 
 same regions they still more commonly lead to an error in 
 diagnosis. This surface tenderness or skin hypercesthesia 
 is a great stumbling-block in abdominal diagnosis, and 
 
192 THE INTESTINAL TRACT 
 
 accuracy of diagnosis need never be expected until we 
 have, by careful and patient examination, learnt to dis- 
 tinguish between it and the true tenderness of the diseased 
 organ. We need not discuss the paths of referred pains, but 
 it is well to remember that the nerves involved often carry 
 with them to their terminal distribution a surface hyper- 
 sesthesia. One point where the surface tenderness is 
 common has been engraved with the name of McBurney 
 and proves a trap to the unwary clinician. Surface tender- 
 ness must not be confused with deep tenderness. At the 
 outset of an attack the rigidity of the muscles may be a 
 barrier to deep palpation, but with sufficient patience it 
 is usually possible to make out the presence or absence of 
 deep tenderness, and if we are at all successful in our mani- 
 pulations pain can always be elicited by pressure on an 
 inflamed appendix. To indicate to you that this mode of 
 examination may be quite trustworthy, I may mention that 
 in one case I ventured to tell the surgeon into whose hands 
 I gave the patient that the appendix was lying behind the 
 caecum and the operation showed this to be correct ; in 
 other cases the point of marked tenderness is only to be found 
 by rectal examination. I saw with one of my brethren 
 some time ago a case in which tenderness was only elicited 
 in this way, and it was the only guide to the origin of the 
 lesion causing symptoms the extreme gravity of which it 
 was easy to estimate. The situation of the tenderness 
 in such cases is, of course, due to the position of the 
 appendix. 
 
 The importance of being able to elicit this direct tenderness 
 of the affected part cannot be exaggerated ; it is the key to 
 abdominal diagnosis ; it is recognized by all the authorities — 
 Hawkins, Fowler, and Deaver lay stress upon it. Deaver 
 says it is " always present." Fowler says " in the early 
 stage of the disease tenderness is only elicited when pressure 
 is made in the immediate neighbourhood of the appendix 
 itself." Fowler goes so far when considering diagnosis as 
 to say that " every case of colicky pains in the abdomen 
 suddenly developed ^^ith right-sided tenderness should be 
 
INDICATIONS FOR OPERATION 193 
 
 regarded as a case of appendicitis until this supposition is 
 disproved." Legueu denies difficulty in diagnosis save in 
 exceptional cases. Nothnagel refers one of the difficulties, 
 as I have done, to a false localization of the pain or an unusual 
 position of the appendix. Talamon holds that the diagnosis 
 of acute appendicitis is as easy as the diagnosis of pneumonia. 
 One warning I would add with regard to the state of the 
 bowels, and that is that while constipation is the rule it is 
 not the invariable condition. Some time ago I was looking 
 after a boy with diarrhoea, elevated temperature, some 
 tenderness in the right iliac region, and a history that sug- 
 gested tuberculous ulceration of the intestine. He was 
 seen for me by another physician, but it was left to me to 
 realize a couple of days later that we had both overlooked 
 an appendicitis. The patient fortunately recovered after 
 operation. In fact, the diagnosis of acute appendicitis hangs 
 upon and depends upon our skill in eliciting the essential 
 and distinguishing it from the non-essential and incidental. 
 
 Indications for Operation 
 
 At the outset of this part of the subject we have to face 
 two strong currents of opinion which cannot be called the 
 medical and the surgical, for the surgeons are found in both 
 camps. Indeed, the French surgeon, Legueu, divides even 
 his surgical confreres into radicals and opportunists or tem- 
 porizers. Probably the best designation for the two schools 
 is to be found in our own Uterature and we may accept 
 the terms ' ' radical ' ' and ' ' conservative ' ' as indicating the 
 point of distinction between them from the operative stand- 
 point. The radical school has attained its full effulgence 
 in America. Since the publication of Fitz's papers in 1886 
 and 1888 and the estabhshment of the appendix as the 
 dominant structure in the pathology of the right iliac fossa, 
 American surgeons have more and more adopted the practice 
 of routine excision as soon as appendicitis is recognized. 
 Fitz, Senn, Sands, McBurney, Price, Morris, and Deaver are 
 all names associated with this school. Legueu says : " Toute 
 
 13 
 
194 THE INTESTINAL TRACT 
 
 appendicite doit etre operee a temps." If this aphorism be 
 adopted the position is simple ; differential diagnosis 
 becomes a mere unpractical refinement and there is nothing 
 left to discuss. The argument in support of this position 
 is that the danger of perforation is great and that it is 
 impossible to determine which cases will perforate and 
 which mU not. This is the main point : there are also 
 minor although important points to which I need not 
 refer. This is the point which appeals to those of us who 
 have learnt to dread the possibiUty of an intense toxaemia 
 from peritoneal infection and who know how rapidly this 
 supervenes in some cases. I myself am so ahve to this truly 
 terrible aspect of acute appendicitis, and the cases which I 
 see are so often cases in which operation is clearly indicated, 
 that were I to take my personal experience of the last ten 
 years as my sole guide I should not be far from the radical 
 position. But here again our individual experience has to 
 be checked by the knowledge of the results of a wider 
 experience. 
 
 The conservative school is represented in this country by 
 Treves, Tubby, and Hawkins ; in France by Talamon ; and 
 in Germany by Nothnagel. Hawkins, on whose work Treves 
 leans, says of the American school that " the gravity of 
 disease of the appendix was measured by the rapidity 
 of death in a few fatal cases rather than by the actual 
 frequency with which a fatal event occurs." Referring 
 to some more recent contributions to the subject he says : 
 " They seem to be compiled by a surgeon for the use of a 
 physician concerning a disease which is in all its aspects 
 familiar to the physician, but of which the surgeon has seen 
 only the more severe form. They assume a rate of mortality 
 from disease of the appendix which has no foundation in 
 actual figures." Talamon says that the position of the 
 partisans of the extreme view would necessitate operation 
 for every attack of intestinal colic attended with intense 
 pain locahzed in the right iliac fossa, a rule he thinks 
 sufiiciently absurd in itself and not likely to be adopted. 
 Nothnagel speaks of the operation fanatics. Treves says : 
 
INDICATIONS FOR OPERATION 195 
 
 " It would be as wise to advise immediate operation in all 
 cases of ulcer of the stomach as soon as a diagnosis is made 
 because some cases of ulcer of the stomach end in a fatal 
 perforation." Tubby says : "I am strongly inclined to 
 think that no judicious surgeon is prepared to tie himself 
 down to the practice of routine early operation in all cases, 
 but would prefer to watch his cases closely and when in 
 doubt operate at once." The warrant for the conservative 
 position is to be found in the results of a wider experience 
 rather than in that embraced by the individual observer. 
 Some of these results are as follows. Furbringer in 120 
 cases had 10 per cent, of deaths. Renvers had from 91 to 
 92 per cent, of recoveries. Guttmann at the Moabit Hospital 
 had 96 per cent, of recoveries. Curschmann in 453 cases had 
 4 '5 per cent, of deaths and 9 cases sent to the surgeons. 
 Sahh, as the outcome of a collective inquiry, had a return of 
 7213 cases which showed that in 6740 cases not operated on 
 8-8 per cent, died and 91 '2 per cent, recovered. Nothnagel 
 in 130 cases had 115 cured or improved, four deaths without 
 operation, and 11 cases sent to the surgeons. Hawkins's 
 statistics of the cases at St. Thomas's Hospital, if we exclude 
 cases of perityphlitic abscess and of general peritonitis, show 
 190 cases with 190 recoveries and only one operated on. I 
 have collected from the statistics of the medical side of the 
 Edinburgh Royal Infirmar}^ from 1891-92 to 1901-02 (that 
 is, ten years, for one year is wanting) 268 cases, of which 
 189 were cured or relieved, 7 were unrelieved, 23 died, and 
 49 were sent to the surgeons. I regret that the only point 
 I could be sure of in the statistics of the surgical side was 
 that all the cases of appendicitis were not operated on, 
 showing that the conservative school is represented there 
 also. 
 
 It thus appears that in acute appendicitis recovery takes 
 place in from 90 to 95 per cent, of cases ^\ithout operation. 
 This is the position of appendicitis when it is judged of by 
 a wide experience, and it seems to me to be in accord with 
 the experience of many of our brethren in general practice 
 in the country and in the provinces who have not skilled 
 
196 THE INTESTINAL TRACT 
 
 surgical help at their call any and every hour of the day or 
 night as practitioners have in the cities. These figures may 
 well prove a comfort to our less favourably situated brethren, 
 but they throw a greater weight of responsibility on some 
 of us, for it becomes more and more imperative to watch 
 with the closest attention every individual case and to 
 learn to determine the one case in the ten which if it is to 
 be saved must be submitted to the surgeon's knife without 
 delay. 
 
 The first question which ought to be faced in every case 
 of acute appendicitis is : Is the appendix rapidly to perforate 
 or promptly to become gangrenous ? Early perforation and 
 early gangrene account for most if not for all of the cases of 
 early peritonitis with grave toxaemia. St. Thomas's Hospital 
 statistics show 36 in a total of 264 cases and of these 27 
 proved fatal. Perityphlitic abscess may be regarded as a 
 later development, but it supplies 38 cases with 28 deaths 
 in the statistics of the same hospital. The above question 
 ought to be formulated definitely in every acute case. The 
 chances as shown by statistics are fully nine to one against 
 perforation ; but differential diagnosis is not based on 
 averages, and it is equally poor comfort to be assured by 
 many authorities that the question cannot be answered until 
 the disaster we desire to anticipate has occurred. 
 
 As I understand the matter one great object which the 
 promoters of this dicusssion had in view was to elicit what- 
 ever there is of knowledge and of experience on this point 
 among us. I myself approach it with much diffidence, 
 but there are some points which I venture to submit. The 
 first is that if in an acute attack I find that there have been 
 one or two previous attacks, even mild ones, I do not hesitate 
 to advise removal of the appendix at once. My reason for 
 doing so is that I am satisfied that the anatomical relations 
 of certain appendices are such that appendicular trouble 
 is bound to arise. Recurrence is the clinical proof of this, 
 and in any recurrent attack the appendix may perforate 
 or necrose, so that the sooner such appendices are removed 
 the better. The second point is that if an acute appendicitis 
 
INDICATIONS FOR OPERATION 197 
 
 has an early rigor immediate removal is indicated. I have 
 seen early rigor followed speedily by gangrene. But this 
 only disposes of a small number of acute cases. When we 
 come to the remaining cases, and if we are not to adopt 
 routine removal in all instances, the questions necessarily 
 arise : What are we to do ? How long are we to continue 
 the medical treatment we may have adopted ? and, What 
 indications are to guide us in determining for or against 
 operation ? As regards the first of these it is quite clear 
 that something must be done and always is done. You all 
 know that purgatives are anathematized and that if perfora- 
 tion occur after the administration of such the medical man 
 who has ordered them is looked upon as a most culpable 
 person. I have not given purgatives in these cases for many 
 a day, but in the earlier years of practice I used repeated 
 doses of saline laxatives in what we called perityphlitis and 
 I had not then a single death. All of us have seen cases 
 where the so-called " fatal " purgative has been taken by the 
 patient on his own initiative and his appendix has not 
 ruptured. Such experiences have their due place. I have 
 referred to the point as I venture to think that statements 
 are made in this connection which are mere presumptions 
 and are based upon isolated and misinterpreted occurrences. 
 The next point that arises for consideration is the relief 
 of pain. This is sought for by either hot or cold local 
 applications ; these are at least harmless. When, however, 
 we go beyond local measures we at once enter a region 
 where there is a great difference of opinion. You all know 
 how opium and its chief alkaloid are condemned. Their 
 administration relieves pain and gives rest to the patient 
 and to the caecum. The main argument against their use 
 is that they " mask symptoms" and so they do to the in- 
 experienced and the unwary. Nothnagel is a great advocate 
 of opium, and while I am not prepared to follow his method 
 I have found, as he contends, that its previous administration 
 need not mislead, and I can hardly imagine the hospital 
 physician or surgeon being seriously misled by the mere 
 relief of pain consequent upon its administration. If given 
 
1 98 THE INTESTINAL TRACT 
 
 at all it ought certainly to be limited in its use to the allevia- 
 tion of intense suffering and as a temporary expedient. I 
 even go so far as to say that the call for the continued use 
 of opium is an indication that operation is desirable. Per- 
 sonally I prefer to use belladonna, which relieves spasm and 
 does not dull sensory centres. There is only one further 
 procedure which is worth referring to and that is lavage. 
 There exists in regard to its use some degree at least of the 
 same feeUng as exists about the giving of laxatives. The 
 reasons given against its use are open to question. That 
 lavage of the colon and csecum is dangerous and may cause 
 either perforation or gangrene is a mere arbitrary pre- 
 sumption and has no foundation in fact. Granting that the 
 essential factors in the production of acute appendicitis are 
 as I have represented, there is no measure which one would 
 more instinctively turn to than csecal lavage, owing to the 
 effect it would have upon the mucous . membrane at the 
 mouth of the appendix and the effect it might have in aid- 
 ing the re-establishment of appendix drainage. Professor 
 Bourget of Lausanne has published an important monograph 
 on this method of treatment. He uses it in all cases of acute 
 appendicitis which come under his care, and he only advises 
 operation after the acute symptoms have subsided and in 
 selected cases. In his monograph he gives the details of 
 twenty-three cases which occurred in his hospital practice 
 between January, 1901, and February, 1902, which he 
 treated on the lines indicated without a single death ; and 
 the clinical records show that some of the cases were of a 
 grave t^^pe. M3/ own experience of this method of treatment 
 is too limited to sa}^ more about it than that so far as I have 
 yet used it I am satisfied with the results. 
 
 Having thus indicated the medical measures which may 
 legitimately be used when brought face to face wdth a case 
 of acute appendicitis, the serious questions still remain : 
 How long are we to continue to use whichever measures we 
 may have adopted ? How long are we to wait for alleviation 
 of the condition at the appendix ? and, What are the indica- 
 tions that surgical interference is the wise course to adopt ? 
 
INDICATIONS FOR OPERATION 199 
 
 I can endorse the precept laid down by others that every 
 individual case ought to be regarded with great seriousness 
 and is to be closely watched for the appearance of any un- 
 favourable symptom. There are, however, definite indica- 
 tions which help us to determine those questions, and an 
 accurate mental picture of the steps of morbid processes in 
 the appendix materially aids us. Some of those indications 
 are as follows. The continuance of severe pains in spite of 
 local applications and the administration of belladonna 
 internally may be taken as an indication for operation, 
 for it mirrors almost certainly blockage and severe inflamma- 
 tion. The recurrence of paroxysms of pain indicates 
 operation, for it is a proof that the appendix drainage is 
 being recurrently interrupted and the sooner such an 
 appendix is removed the better for the patient. Great 
 importance is to be attached to the condition at the caecum 
 as revealed by careful and patient palpation ; locaHzed 
 tenderness and swelling are the two phenomena which 
 demand much more patient handling than they often get. 
 If the case has been ushered in by great pain and yet appears 
 to be a mild one as judged by cursory examination, be on 
 your guard ; that is the kind of case that can perforate within 
 forty-eight hours. If pain subsides and the appendix remains 
 very tender notwithstanding the use of local applications 
 and the internal administration of belladonna, do not wait 
 many hours for lessening of tenderness, for the appendix 
 may be already necrosed and will shortly be gangrenous or 
 a concretion may be completing a perforation. In these 
 instances of necrosis and of threatening perforation the 
 leucocyte count gives no sufficient warning of the threatening 
 disaster. Hubbard, Dunham, Da Costa, Wassermann, and 
 Brown have all dealt with the question of leucocytosis in 
 appendicitis, but on this important point no strong claim of 
 its value is made. I am very suspicious of severe onset, no 
 great local swelHng, only moderate tenderness over the caecum, 
 but a point where deep palpation reveals acute localized 
 tenderness. If it is reahzed that a blocked and inflamed 
 appendix accounts for such phenomena you will want proof 
 
200 THE INTESTINAL TRACT 
 
 within twenty -four hours that that appendix has clearly 
 lessened in tenderness, and if it has not you will want to have 
 it removed. I again lay great stress upon the cultivation 
 of abdominal palpation as a means of great value, not only 
 in diagnosing appendicitis but in estimating the progress of 
 an acute attack. In the less rapid, which is also the more 
 common, type of case, with marked swelling and tenderness 
 over the whole caecum, the temperature and the pulse are 
 an index of the measure of inflammatory reaction and the 
 blood examination shows a leucocytosis of somewhere about 
 15,000 as a rule. If the local and general symptoms do not 
 speedily subside under such measures as have been indicated, 
 and if on further blood examination it is found that the 
 leucocytosis reaches 20,000 or more, the case falls entirely 
 to the surgeons, for pus has almost certainly formed and the 
 condition has to be treated on general surgical principles. 
 
 I have sought in what I have said to formulate points 
 which present themselves before grave peritoneal infection 
 has taken place. When it has taken place the facies 
 abdominalis and the rapid and small pulse are indication 
 enough of what has happened. What the promoters of this 
 discussion want to bring out are the indications which will 
 enable us to anticipate this danger and by anticipation to 
 avoid it, and to this object my remarks have been directed. 
 When disaster has occurred there is Httle difficulty in 
 recognizing it and there are not two opinions as to the proper 
 course to adopt. Beyond sa3dng this I do not further pursue 
 this side of acute appendicitis. 
 
 Permit me in conclusion to reiterate the main points in 
 the Une of thought which I have endeavoured to present in 
 this paper, i. Certain appendices are so formed anatomi- 
 cally that they of necessity give rise to trouble. 2. Inter- 
 ference with the drainage of the appendix is an important 
 factor in determining inflammation. 3. The occurrence of 
 appendicular cohc may be taken as a warning that dangerous 
 anatomical conditions exist in connection with the appendix. 
 4. In all abdominal cases detailed palpation should be care- 
 fully and patiently carried out. 5. Too much emphasis 
 
INDICATIONS FOR OPERATION 201 
 
 must not be put on the site of pain or on superficial tender- 
 ness. Palpation should be directed towards ascertaining 
 the actual condition of the diseased part. 6. Statistics 
 show that from 90 to 95 per cent, of cases recover without 
 operation and the chances against recurrence are as three 
 to one or thereby. Therefore routine removal cannot be 
 accepted as necessary. 7, Operate at once in any case with 
 a history of previous attacks, also in all cases commencing 
 with a rigor. 8. The chief difficulty lies in the early recog- 
 nition of the cases in which the appendix will necrose or 
 perforate rapidly. In this connection suspect cases which 
 show constitutional disturbance with httle inflammatory 
 reaction round the caecum but with marked tenderness on 
 deep palpation and an ordinary degree of leucocytosis. 
 9. In cases which do not call for immediate operation pain 
 may be relieved by hot or cold local applications and by a 
 cautious and sparing use of opium or morphine or of bella- 
 donna. Lavage may give good results. 10. Medical treat- 
 ment should not be rehed on for more than from twenty- 
 four to forty-eight hours if severe pain continues or an acute 
 tenderness on deep palpation still remains. 11. Later in 
 the disease a continuance of the local and general symptoms 
 along with a high leucocyte count indicates the presence 
 of pus and the necessity for operative interference. 
 
 Bibliography. — Bourget : Typhliie, P/rityphlite, Appendicite. Brown : 
 International Clinics, vol. iv., twelfth series, 1903. Da Costa: American 
 Journal oj the Medical Sciences, November, 1901. Deaver : A Treatise 
 on Appendicitis, Philadelphia, 1900. Dunham : Annals of Surgery, 
 vol. xxxi., 1900. Fowler : A Treatise on Appendicitis, Philadelphia, 
 
 1894. Hawkins : On Diseases of the Vermiform Appendix, London, 
 
 1895. Hubbard : Boston Medical and Surgical Journal, vol. cxlii., 1900. 
 A. O. J. Kelly : Transactions of the College of Physicians, Philadelphia, 
 1899. Kelynack : A Contribution to the Pathology of the Vermiform 
 Appendix, London, 1893. Legueu : Traitement de V Appendicite, Paris, 
 1899. Nothnagel : Skolikoiditis und Perityphlitis, Specielle Pathologie 
 und Therapie, Band xvii., V^ien, 1S95. Talamon : Appendicite et Pe'ri- 
 typhlite, Paris, 1892. Treves : Allbutt's System of Medicine, vol. iii.. 
 p. 879 et seq. Tubby : Appendicitis, London, 1900. J. M. Van Cott, 
 junior, ibid. Wassermann : Miinchener Medicinische Wochenschrift, 
 Nos. 17 and 18, 1902. 
 
202 THE INTESTINAL TRACT 
 
 Anomalous Appendix Cases 
 
 What is included under this term are the cases in which 
 a wrong diagnosis has been made or a wrong view is included 
 in a right diagnosis. In the abdomen, perhaps more than 
 in other regions of the body, clear thinking and unambiguous 
 language are highly desirable. Wrong names not infre- 
 quently mean wrong views ; and when they do not the 
 words mislead and give rise to unnecessary controversy. 
 The first of the anomalies which may be referred to is what 
 has been called " appendix dyspepsia." 
 
 Appendix Dyspepsia. — That chronic trouble in the 
 appendix may reflexly affect gastric function would be 
 difficult to deny absolutely. It would, however, be less 
 difficult, I think, to advance evidence that dyspepsia can lead 
 to appendix trouble, manifested by local tenderness, which 
 disappears when the gastric condition is corrected. What I 
 specially want to represent here is that pain or discomfort 
 referred to the epigastrium is not necessarily dyspepsia, 
 and that, when it is present along with a tender caecum, the 
 term can be whoUy misleading. That dyspepsia and a 
 tender caecum may be contemporary there is no doubt, but 
 when this is found it must not be assumed that the removal 
 of the appendix is to cure the dyspepsia. In that direction 
 lies disappointment and sometimes discredit. Even opera- 
 tion misleads in another way, which has its own special 
 significance, namely, that the mere opening of the abdomen, 
 without doing anything else, may remove symptoms for a 
 considerable period of time. Many illustrations of this 
 might be given. The latest case was a patient, who had 
 been treated for recurring hyperchlorhydria, who took 
 acute appendix trouble which required the removal of the 
 appendix. For several months he was entirely free from 
 gastric trouble, and the hope was entertained that the cure 
 was to be permanent as the malady had apparently been 
 " appendix dyspepsia." The stomach symptoms, however, 
 slowly began to reappear and had fully reasserted themselves 
 in six months. The essential point in all cases is to be able 
 
ANOMALOUS APPENDIX CASES 203 
 
 to recognize that there is appendix trouble behind a patient's 
 complaint of " indigestion," " flatulence," " constipation," 
 and so forth. The opinion that " dyspepsia " is due to the 
 appendix may be totally wrong, but it is not comparable 
 in gravity to the mistake of diagnosing an appendix as a 
 duodenal ulcer, as colitis, or as dyspepsia. 
 
 The following deals with this aspect of the subject more 
 concreteh'. 
 
 Cases are met with in which the patient complains of 
 pain, referred to the epigastrium, coming on after taking 
 food. The interval between the meal and the onset of the 
 pain may vary from an hour to two hours, but may be 
 shorter. On examination there may be no evidence of 
 gastric dilatation, or of retention, and relief of pain is not 
 secured by the administration of an alkali as is usual in 
 hyper-acidity. On general examination of the abdomen 
 it is found that there is some tenderness in the caecal region ; 
 the tenderness is definite, and is judged of by the effect of 
 an equal amount of pressure apphed over other parts of the 
 colon. Every time the caecal region is palpated the tender- 
 ness is elicited, so that there remains no doubt as to its 
 presence. The caecum itself may be felt to be distended. 
 This in itself might not lead to the conclusion that there was 
 any direct connection between the epigastric pain and the 
 caecal tenderness, bu t in the class of case under consideration 
 it has been noted that when the local tenderness is brought 
 out by palpation pain is at the same time referred to the 
 epigastrium, and the patient may volunteer the information 
 that the kind of pain and the site of it are the same as had 
 been complained of. Under these circumstances it is reason- 
 able to regard the caecal region as the seat of disturbance, 
 and the caecum may be taken as implying the appendix. If 
 in spite of keeping the caecum well cleared of excrement the 
 pain and tenderness, but particularly tenderness, persist, 
 it is desirable to have the appendix removed, and of course 
 any ileocaecal difficulty from a band relieved at the same 
 time. The rehef to the symptoms is not always as im- 
 mediate as might be expected, but this need not cause undue 
 
204 THE INTESTINAL TRACT 
 
 disappointment. If continued attention is given to the 
 regular clearing of the colon the sensory reflex which had 
 established itself is finally controlled, and the fact that the 
 appendix can no longer be a source of anxiety materially 
 aids in the breaking of the nervous reflex. 
 
 The following cases illustrate the points upon which 
 emphasis has been laid : — 
 
 Patient sent to Hospital as an Obscure Stomach Case 
 
 Case 47. — John P., aged 38, miner, was sent in as a 
 stomach case which had resisted treatment. When asked 
 what he complained of the answer was " swelhng of the 
 stomach and pain." The history given was that he had 
 been troubled with flatulence all his hfe. For seven or eight 
 years he had suffered from " swelhng of the stomach and 
 pain," which usually came on when he had left the house 
 after having had dinner, and lasted for half an hour. For 
 the last six months the sj^mptoms had been getting worse. 
 On asking him to place his hand on the part of the abdomen 
 where he felt the pain he put it over the middle region, that 
 is the level of the umbiUcus, and indicated that it went 
 across the abdomen at that level. The pain was not 
 definitely related to the taking of food. On examination 
 the stomach was not enlarged, and there was no tenderness 
 in the upper half of the abdomen either on superficial or 
 on deep pressure. The pain was thus neither gastric nor 
 duodenal. Continuing the methodical examination, by 
 palpation it was found that on deep palpation of the 
 caecal region there was a definitely tender area of hmited 
 extent, and that whenever the fingers were brought back 
 to this point tenderness was ehcited. There was no other 
 tender point in the abdomen. After a httle he told us 
 in answer to a question that the pain produced by pressure 
 went up towards the navel. He was treated with colon 
 lavage once a day for eight days, and given a laxative pill 
 of cascara, belladonna, and nux vomica. The tenderness 
 entirely disappeared, and he left hospital quite well, and 
 with instructions to be attentive to his bowels. 
 
ANOMALOUS APPENDIX CASES 205 
 
 Appendix Simulating Dyspepsia : Sensory Reflex 
 
 Persisting 
 
 Case 48. — Miss M,, aged 31, was sent to me by a medical 
 relative of her own, who reported that from being a bright 
 and merry girl she had become listless, morbid, and imagina- 
 tive about herself. The bowels tended to be stiff, there 
 was a history of abdominal pains, and of pain in the back. 
 The only objective observation with regard to the abdomen 
 was that the succussion splash of the stomach reached to 
 the level of the umbilicus, and showed some dilatation with 
 ptosis of the lower border. The diet was regulated and the 
 gastric and intestinal conditions were attended to, but 
 without much improvement. After a considerable interval 
 of time I again saw her after she had had a somewhat severe 
 attack of abdominal pain. At this time there was definite 
 tenderness in the right ihac region, and pressure there caused 
 pain in the upper half of the abdomen. The history of this 
 attack left no doubt in my mind that it was to be attributed 
 to the appendix, and that instead of having a gastro- 
 enterostomy performed, the first step to be taken was to 
 have the appendix removed. Mr. Wallace saw her -with me 
 and her medical relative, and endorsed our view. The 
 operation was carried through without anxiety, and the 
 patient made a good recovery. It was, however, a number 
 of months before the effect of the operation became definitely 
 estabUshed, and she began to regain her earlier health and 
 vigour. 
 
 Appendix Diagnosed as Duodenal Ulcer 
 
 Case 49.— Mr. H. F., a student at one of the English 
 colleges, had suffered from attacks of abdominal pain for 
 a few years. He had been in London for a medical opinion, 
 and the opinion was that he had a duodenal ulcer. I saw 
 him as he was recovering from an attack similar to previous 
 attacks, and I failed to ehcit any facts to indicate the 
 existence of such an ulcer. There was, however, tenderness 
 in the caecal region ; but it was brought out onl}' on deep 
 
2o6 THE INTESTINAL TRACT 
 
 pressure through the caecum. The diagnosis in my judg- 
 ment was recurring appendicitis, with the appendix situated 
 retrocsecall}'. I suggested that he ought to be watched 
 carefully, with a view to testing the accuracy of this opinion, 
 and, were it found to be correct, the appendix ought to be 
 removed without delay. The patient was the son of a 
 medical man, and this was fully attended to. In the course 
 of a week or two he had another attack, and there was no 
 doubt as to its character, and surgical help was at once 
 summoned. The appendix, situated as had been stated, 
 was removed by Mr. Miles. An excellent recovery took 
 place ; the symptoms entirely disappeared ; the patient 
 put on considerable weight, and he was able to resume his 
 studies with renewed vigour, and has continued free from 
 abdominal trouble. 
 
 Appendix Diagnosed as Colitis 
 
 Case 50. — Mr. L. E., aged ig, preparing to become an 
 undergraduate at one of the Enghsh Universities, was sent 
 to me for advice. The history was of recurring attacks of 
 pain in the abdomen which were stated to be due to " cohtis," 
 from which he had recently suffered and was stiU suffering. 
 In the morning of the afternoon on which he was brought to 
 me he had had a specially severe attack of pain, and had 
 himself suggested seeing an Edinburgh physician. On 
 examining the abdomen the stomach was found to be normal, 
 and there was no tenderness along the course of the colon ; 
 but at the caecum, on deep pressure, pain could be alwaj'S 
 ehcited, it could also be elicited b}' bimanual palpation. 
 I expressed the opinion that the seat of the trouble was 
 the appendix, and that it was situated retrocaecally. I 
 represented the danger of allowing such a condition to 
 continue ; that it might become acute at any time, and even 
 if it did not do so there would be recurring attacks of pain, 
 which v.'ould certainlj- interrupt his studies. ]\Ir. Stiles 
 removed the appendix, which was found lying behind the 
 caecum and stretching far up behind the ascending colon. 
 
ANOMALOUS APPENDIX CASES 207 
 
 Appendix Diagnosed as Gall-stone Colic 
 
 Case 51. — James, S. This patient was admitted to my 
 ward with a history of a severe attack of abdominal pain 
 which was diagnosed as biUary cohc. On examination there 
 was no tenderness in the region of the gall-bladder, but there 
 was pronounced tenderness in the csecal region, and on going 
 more fully into the history it was evident that the attack 
 referred to had been due to the appendix and not to the 
 gall-bladder. The patient was transferred to the surgical 
 house and had his appendix removed successfully. 
 
 Appendix Diagnosed as Duodenal Ulcer : Double 
 Operation : a Freak Appendix 
 
 Case 52.^This case can only be referred to briefly. 
 The patient had suffered from recurring attacks of abdominal 
 pain which led to a provisional diagnosis of duodenal ulcer. 
 The abdomen was opened, but as the duodenum was found 
 to be sound nothing further was done. The symptoms 
 continued as they were before the laparotomy, and I had the 
 opportunity of examining the patient. The only objective 
 sign was the presence of a limited area of tenderness on the 
 edge of the liver in the position of the gall-bladder. This 
 and the recurring attacks of pain suggested biliary colic 
 with a tender gall-bladder, but when the abdomen was 
 opened it had been examined and found to be sound and no 
 stone in it. The late Dr. Price, from X-ray appearances 
 at the caecum, held that the appendix was not right ; but 
 what connection could exist between that and the pain 
 and tenderness in the hepatic region appeared to be inexplic- 
 able. The patient, however, had suffered so much that he 
 insisted on having the appendix removed. The abdomen 
 was again opened with this object in view and when it was 
 reached it was found to be of great size and ran upwards 
 so far that its tip reached the liver edge, to which it was 
 firmly attached at the point where tenderness could 
 always be elicited. The patient made an excellent recovery, 
 but the recurring pains were slow in disappearing. 
 
2o8 THE INTESTINAL TRACT 
 
 Calculus in Ureter mistaken for Appendicitis 
 
 Cases 53. — Cases of this description wiU be recorded in the 
 chapter on renal calculus, and the subject does not require 
 further consideration here. 
 
 C^cAL Tenderness accompanying Influenza 
 
 Case 64. — This combination of S3^mptoms presents an 
 anxious and a difficult problem. The combination may be 
 present at the first visit of the family practitioner. It occurs 
 at a time when mild cases of influenza are prevalent and the 
 S3^mptoms would warrant the simple diagnosis M^ere it not 
 that the careful medical man finds a tender caecum. This 
 local tenderness \vith considerable elevation of temperature 
 at once raises, in an acute form, the question whether the 
 patient is not suffering from a very acute appendix and not 
 at all from influenza. I have advised the removal of an 
 appendix under these circumstances, both in hospital and 
 in private, and the operation has been carried through 
 successfully, but mthout producing any effect upon the 
 temperature or the general sjonptoms. These ran on for 
 a week or more as a mild influenza after which rapid recovery 
 took place. I have seen an approximately similar case 
 where the same problem presented itself in the course of a 
 few daj^s after the onset of a mild influenza. In a few more 
 days it was clear to all concerned that the removal of the 
 appendix was imperative. The patient made a good 
 recovery. 
 
 Conclusions and Summary 
 
 This subject is so important that it may be useful to 
 briefly summarize what has been written and to indicate 
 clearly the conclusions the writer has reached after years 
 of experience of hospital and of private practice, and of the 
 mistakes which may be made. 
 
 The important part played by hindrance to drainage of 
 the appendix has been estabhshed by careful clinical and 
 
CONCLUSIONS AND SUMMARY 209 
 
 pathological observation, and has more recently been con- 
 firmed by X-ray examination. 
 
 Sufficient drainage may follow upon (i) swelling of the 
 mucous coat of the caecum or the retention of faeces there ; 
 and (2) on the anatomical position and character of the 
 appendix itself. 
 
 If there is recurring difficulty in its emptying, attacks 
 of pain occur, which were early spoken of as appcndictilar 
 colic. These cases may ultimately have a severe attack, 
 such as Mr. Wilkie described as acute obstruction of the 
 appendix, with rapid necrosis, gangrene and perforation. 
 
 There is no doubt that it is round this question of drain- 
 age that mistakes and misconceptions are most frequent. 
 Inefficient drainage readily sets up more or less irritation 
 in the wall of the appendix. When this has taken place, 
 in however small a degree, a point or small area of tender- 
 ness can be found by careful and proper palpation of the 
 caecal region. If the appendix is situated retrocsecally the 
 tenderness is only made out by deep and gentle pressure 
 exercised through the interposed caecum ; if the appendix 
 so situated is a long one the tenderness may only be made 
 out above the level of the caecum behind the ascending 
 colon. In these cases, and they are fairly common, the 
 recurring attacks of pain and the Hmited area of tenderness 
 are phenomena quite inconsistent with a diagnosis of 
 colitis, and that is the only condition with which an imperfect 
 or hurried examination could reasonably confuse it. In a 
 few cases the appendix hangs down into the true pelvis and 
 tenderness may be found only on rectal examination ; or 
 tenderness may be elicited indefinitely by palpating from 
 the surface and be very pronounced on rectal examination 
 when the finger is pressed towards the caecum. 
 
 There is no doubt that appendicular colic may be caused 
 by constipation and retention of faeces in the caecum ; and 
 that this type of disorder can be removed and prevented < 
 by getting the bowels properly regulated. Such appendicular 
 colic is not, however, usually severe ; there is only slight 
 tenderness, and no rise of temperature. 
 
 14 
 
210 THE INTESTINx\L TRACT 
 
 In this tj^pe, however, there may be and often is recur- 
 rence of attacks, with pain, some tenderness on deep pres- 
 sure, but no rise of temperature. This is a dangerously 
 insidious t3^pe ; it often leads the victim to think that he 
 is suffering " only from indigestion " or from cohc due to 
 constipation, for he can remove it by taking a dose of some 
 aperient medicine ; and this may go on until a severe attack 
 leads to the doctor being sent for. This severe attack 
 means a more pronounced obstruction, and, with the history 
 which I have indicated behind it, the appendix ought to be 
 removed without an hour's unnecessary delay. 
 
 In cases of this recurring type the fact to realize fully 
 is that the true significance of recurrence is that we are 
 in face of an appendix whose drainage is easily interrupted. 
 It may be due to one of several possible conditions, which 
 particular one need not concern us ; the important fact is 
 the recurrence of interrupted drainage. Such cases may 
 never have a really severe attack, and, after many attacks, 
 may cease altogether. On the other hand, the big attack 
 may come at any time and at the most awkward and 
 unfortunate time, and every one interested is faced with 
 possible tragedy. My own settled conviction is, and my 
 teaching has long been this, that an appendix of the type 
 indicated ought always to be removed, as soon as necessary 
 arrangements can be made. 
 
 When pain is sudden and severe in onset it must be 
 borne in mind that acute appendix obstruction has almost 
 certainly occurred, and, if that is not overcome in twelve 
 hours, time is given for the heightening of the virulence of 
 the imprisoned micro-organisms to be speedily followed bj/ 
 intense inflammation, necrosis, and gangrene. 
 
 Before concluding this summary there may be included 
 in it the results of years of experience in the use of colon 
 lavage, in this as well as in other abdominal conditions, as 
 Professor Bourget of Lausanne used it, and which is referred 
 to in the introductory part of this chapter. As to the 
 safety of this proceeding there is no question. As to its 
 efficacy in clearing out the colon and cleaning the csecum 
 
CONCLUSIONS AND SUMMARY 211 
 
 increased experience has strengthened first impressions. 
 Under this treatment a tender appendix may rapidly lose 
 its tenderness and if this does not take place operative 
 interposition becomes more clamant. The effect of colon 
 lavage has been very striking in cases coming into the wards 
 as acute abdomens with pain, rigidity, and tenderness all 
 over the abdomen. If colon lavage is at once resorted to and 
 repeated every hour or two, the surface hyperaesthesia 
 rapidly diminishes and permits of free palpation. The 
 procedure is of great assistance in some obscure cases when 
 the surgeon is not willing to open the abdomen until an effort 
 is made to reach a reasonable diagnosis. 
 
CHAPTER XVIII 
 
 INTESTINAL OBSTRUCTION : MALIGNANT DISEASE OF 
 RECTUM : ENTEROSPASM 
 
 Intestinal obstruction may be caused by a variety of 
 conditions. The first condition which ought to be thought 
 of and examined for is strangulation of an external hernia. 
 The importance of this is not to be underestimated, for the 
 neglect of it in children as well as in adults ends in tragedy 
 if not corrected in time. Internal hernia may occur of 
 any part of the intestine and is characterized by sudden 
 onset of pain, referred commonly to the site of the hernia, 
 and early onset of vomiting. Such cases require prompt 
 surgical intervention. And the physician does not see 
 many of them. In children the possibility of intussusception 
 has to be remembered and its special features recognized 
 when present. Many years ago, before the advent of general 
 abdominal surgery, I attended a fatal case of obstruction, 
 caused by a large gall-stone which had ulcerated out of the 
 gall-bladder. The stone had stuck in the small intestine 
 at the point where pain was present. 
 
 The cases to which special reference is here directed are 
 of a different type, in the circumstance of their providing 
 a history of intestinal difficulty before there is definite or 
 complete obstruction, meaning thereby an obstruction 
 which has not been relieved by medicinal measures in common 
 use. They include the cases of organic stricture in the 
 intestine. The small intestine is practically exempt from 
 such stricture. The large intestine, on the other hand, 
 is frequently affected. The symptoms and signs of obstruc- 
 tion will be dealt with later. It may, however, be stated 
 now that stricture of the large intestine is practically always 
 
INTESTINAL OBSTRUCTION 213 
 
 malignant, although the degree of malignancy varies in 
 individual cases. Stricture as a rule is confined to one 
 of several definite parts of the colon. The parts which may 
 be affected are the caecum, the hepatic flexure, the splenic 
 flexure, and the pelvic colon (the sigmoid flexure) where it 
 joins the colon and the rectum. The rectum itself may be 
 the seat of primary malignant disease. All these regions 
 can be effectively examined by the ordinary methods of 
 physical examination. That the regions mentioned are the 
 usual sites of stricture narrows the field of investigation, 
 and when the position of a stricture has been determined, 
 and the fact realized that it must be assumed to be maUg- 
 nant, the call for expert surgical assistance will not be 
 postponed indefinitely It is one of the conditions in 
 which early diagnosis and early operation give highly 
 satisfactory results. Waiting until a definite tumour 
 mass is felt, or until there is complete obstruction, is very 
 crude medicine. When complete obstruction supervenes, 
 it is due either to a blockage by hard fseces or to spasm at 
 the seat of lesion. 
 
 Symptoms and Signs. — There may be discomfort com- 
 plained of and referred to any one of the regions specified ; 
 there may be tenderness, but it may be absent. There is 
 usually a history of difficulty with the bowels, of recurring 
 periods of constipation requiring increasing doses of purga- 
 tives for relief. There may or may not be pain. On 
 examining the abdomen, if the art of palpation has been 
 acquired, it will be found that the colon is full behind the 
 seat of the stricture and empty beyond it. If the caecum 
 be the seat of obstruction the condition has often lasted 
 long enough to have produced a palpable swelling or tumour 
 mass, and the peristaltic movements of the small intestine 
 may be visible. In the other regions the stricture often 
 belongs to the annular type, whereas this type is perhaps 
 not common at the caecum. When the stricture is at the 
 junction of the sigmoid flexure and rectum it can be felt by 
 a long finger, and the mass of faeces above it may be mistaken 
 for a neoplasmic mass. 
 
214 THE INTESTINAL TRACT 
 
 ]\Iany attacks of such temporary obstruction may be 
 overcome by means of strong purgatives and the dihgent 
 use of the enema syringe ; but the patients ultimately 
 land in the surgeon's hands ; often when the conditions are 
 highl}^ unfavourable, and when removal of the part cannot 
 be attempted. Clear diagnosis at an early stage, and the 
 recognition of the fact that stricture is presumably mahg- 
 nant, would lead to mse counsel being given to a patient 
 at an early date. Waiting for a tumour to be felt, or for 
 complete obstruction, ought to be relegated to the methods 
 of a past time. 
 
 The following case and the remarks made on it formed 
 part of a clinical lecture on the subject dealt with in this 
 chapter. 
 
 Chronic Obstruction : Adhesions, Splenic Flexure 
 
 OF Colon 
 
 Case 65. — James McG., aged 41, labourer in iron works, 
 was admitted on the 17th September, 1915, complaining 
 of pain in stomach (abdomen) and vomiting. The history he 
 gave was that four 5''ears before, without previous symptoms, 
 he began to vomit everything he swallowed except milk 
 and switched egg. He was troubled also with flatulence. 
 He did not usually have pain after eating, but pain came on 
 with the wind or vomiting. The first attack lasted for a 
 month. For three months after that he could eat anything 
 without trouble; he then had another attack of the same 
 kind, which lasted for nine days ; and these attacks had 
 recurred at irregular intervals up to the time of admission. 
 The attack for which he was admitted had lasted for two 
 weeks, and for the last five days of this period he had vomited 
 everything he took, including milk. The vomit was some- 
 times green, at other times brown, " like tea." He said 
 that he had lost 3 st. in weight during the last few years. 
 He was unmarried ; he had syphiUs twenty years ago ; he 
 used to drink rather heavily until four years ago, and he 
 attributed his recurring attacks to his past habits in this 
 respect. 
 
INTESTINAL OBSTRUCTION 215 
 
 Condition on Admission. — He looked fairly well nourished, 
 but his weight was only 7 st. yl lbs. and his height 
 5 ft. 3 ins. The abdominal pain was referred to the left 
 hypochondrium and was always very severe after vomiting. 
 There was constipation, the bowels not having acted 
 for six days. That the abdominal pain was not gastric in 
 origin was shown by the following facts : (1) in the intervals 
 between the attacks pain was not brought on by taking 
 ordinary food ; (2) when the attacks were on, taking milk 
 even would bring on pain and vomiting ; (3) the pain was 
 not relieved but was intensified by the vomiting. On 
 inspection of the abdomen there were no abnormal appear- 
 ances, and abdominal respiratory movement was free. 
 On palpation there was pain in the left hypochondrium 
 on pressure over the lower ribs, and also tenderness 
 on deep palpation in the left loin. The treatment 
 adopted was colon lavage every four hours. The water was 
 allowed to flow in from a douche can, a syringe not being 
 employed. The result was that the colon was rapidly 
 emptied and the sickness and pain stopped. On the 22nd, 
 he was given a pill containing cascara, belladonna and 
 nux vomica, but the lavage was returned to from time to 
 time. The bowels were difficult to get into good working 
 order. Liquid paraffin was tried in addition to cascara, 
 compound jalap powder was resorted to, and even croton 
 oil in quarter-drop doses was given, all with unsatisfactory 
 results, and colon lavage had to be resorted to. This went 
 on until the 26th October, when in addition to the increasing 
 difficulty in getting the bowels to move severe vomiting 
 supervened, which continued day and night. The symptoms 
 clearly indicated intestinal obstruction, but, as this was 
 not the first attack of the kind he had had, we decided to 
 have him X-rayed before sending him for operation. The 
 large dose of bismuth necessary for this procedure stopped 
 the vomiting for a time, but it recurred. The screen examina- 
 tions showed a definite blockage at the splenic flexure. 
 Professor Caird kindly saw him with me, and the patient 
 was transferred to his ward for operation. Fortunately 
 
2i6 THE INTESTINAL TRACT 
 
 there ^^•as nothing more serious than adhesions which 
 only required to be released. The patient made a good 
 recovery. 
 
 Remarks. — This case illustrates a type of abdominal 
 case which is not very rare, and which it is of much import- 
 ance you should be able to recognize. I have often impressed 
 upon you the fact that you require to know the changes 
 which may be present, to visualize them mentally, before 
 you can reach a sound diagnosis. You cannot diagnose 
 a malady unless you recall the possibiUty of its presence. 
 The class which this case typifies is what we may call 
 recurring intestinal obstruction due to a local interference 
 with the mobihty or the lumen of the intestine. Inter- 
 ference with normal mobihty at a flexure, such as seems to 
 have been present in this case at the splenic flexure, would 
 appear to lead to obstruction after a period of constipation. 
 The colon contents get piled up behind the affected point, 
 and symptoms of complete obstruction supervene, with, 
 however, the absence of one important symptom, namely, 
 early pain. The absence of early and severe local pain 
 excludes such causes of acute obstruction as hernia, which 
 demands immediate surgical interference. The question, 
 however, which requires constant consideration, in the 
 cases where the symptoms of obstruction are pronounced, 
 is : How long is it safe to persevere with the various means 
 at our disposal which are directed to the reUef of the obstruc- 
 tion ? In some cases, where operation would be determined 
 on, and yet from some circumstance is not feasible. Nature, 
 aided by medical measures, ultimately removes the block 
 and the patient again enters on a period of time during which 
 the bowels can be kept going with ordinary laxatives. 
 Our decision on the question of operation is really largely 
 dependent upon our mental visuaUzing of the local condi- 
 tion ; and here the fundamental consideration is : Is the 
 obstruction malignant or not ? Some cases give a history 
 of constipation which has, up to a certain point, been 
 successfully overcome by the measures adopted by the 
 patient himself, perhaps with the assistance of his ordinary 
 
INTESTINAL OBSTRUCTION 217 
 
 medical attendant ; but a time comes when the constipation 
 does not yield to the measures which have hitherto been 
 sufficient and to this symptom the additional symptom of 
 vomiting is added. When the abdomen is examined it is 
 found that there is a localized sweUing with local tenderness. 
 Cases of this kind are so commonly malignant that they 
 must be assumed to be so, unless facts are available which 
 weaken the assumption. In such cases even when the 
 symptoms of complete obstruction are pronounced, rehef 
 may be obtained without operation ; and temporizing is 
 permissible if the local condition is so pronounced that there 
 is no hope of complete removal of the involved part being 
 possible. All that surgery can do in these cases is to estabhsh 
 an outlet for the bowel contents on the proximal side of the 
 obstruction, and thereby remove the symptoms of obstruc- 
 tion. The obstruction is not removed but the operation is 
 a valuable measure of amehoration. It is frequently one's 
 experience in consulting practice as weU as in hospital 
 practice that when the case is first seen the condition is 
 such as is here indicated. 
 
 This, however, leads to the consideration of the very 
 practical question of the recognition of a local and hmited 
 point of obstruction before it has advanced so far as is 
 portrayed above. In this connection it must be empha- 
 sized that, when constipation is a marked s^Tnptom, the 
 efficient examination of the abdomen ought always to be 
 undertaken. When there is evidence that the obstruction 
 is in some definite region as the rectum, splenic or hepatic 
 flexures, or caecum, the presumption is so strong that it is 
 malignant that advice to have it dealt with surgically ought 
 to be tendered. At the early stage the surgeon will probably 
 be able to completely remove the affected parts and to 
 estabhsh an effective anastomosis. 
 
 In the particular case with which we are deahng at 
 present there was evidence that the obstruction was at the 
 splenic flexure, but we had no evidence as to the cause of the 
 obstruction. The obstruction had recurred frequently 
 during the previous four years, with complete absence of 
 
2i8 THE INTESTINAL TRACT 
 
 symptoms in the intervals of the attacks of obstruction. 
 He was under our observation in hospital during a quiescent 
 interval and the most careful examination of the abdomen 
 revealed no tenderness or swelling. When an attack of 
 obstruction supervened the seat of obstruction as shown 
 by local tenderness and swelUng was placed at the splenic 
 flexure and this was confirmed by X-ray examination. 
 The presumption therefore was against malignancy. At the 
 same time, do not be led away by the academic aspect of 
 this diagnosis. The essential points were : (i) the recur- 
 rence of intestinal obstruction ; (2) the obstruction was at 
 the splenic flexure ; (3) the obstruction had to be relieved ; 
 (4) there was no evidence of extensive involvement, and it 
 was hoped therefore that the surgeon would be able to 
 remove completely the mechanical difficulty, I had not 
 even thought of adhesions as the cause of the obstruction ; 
 but, as I often point out to you, in diagnosis, especially in 
 the abdomen, there are practical questions and there are 
 academic questions, and the foregoing again illustrates this 
 distinction. Yet even here, although the immediate 
 necessity was operation for the relief of obstruction, the 
 academic question of malignant or non-mahgnant obstruc- 
 tion was a very practical question, although more remote, 
 but it could be allowed to wait until the necessary opening 
 revealed the precise cause. 
 
 The following cases illustrate the history which may be 
 obtained from patients and the physical signs which may be 
 present. 
 
 Colloid Cancer of Part of Pelvic Colon : Intussuscjep- 
 TioN OF Lower Part : Successful Removal 
 
 Case 56. — John G., aged 60, was admitted on the 23rd 
 September, complaining of diarrhcea and pain in abdomen. 
 The history as given to my Resident Physician, Dr. G. M. 
 Brown, was as follows. About twenty months ago he had an 
 
COLLOID CANCER OF PELVIC COLON 219 
 
 attack of ' ' diarrhoea. ' ' His bowels, which prior to this period 
 moved daily, became constipated, and two days later he was 
 seized with a dull pain in the left iliac region. The pain was 
 constant but varied in severity. A few hours later he began 
 to have frequent calls to go to stool and on every occasion 
 only a small amount of slimy material mixed with red blood 
 was passed. This continued for about a week and dis- 
 appeared after the passing of some stringy masses of blood- 
 stained mucus. The bowels, which had been constipated for 
 ten days, then began to move of their own accord, and the 
 pain, which had been gradually becoming less, disappeared. 
 There was no vomiting. He returned to work as an engine- 
 man and felt in his usual health. A fortnight before admission 
 the bowels again became constipated. He took opening 
 medicine without obtaining reUef. Two days later blood 
 and mucus were passed as on the previous occasion. A 
 week later pain reappeared in the left iliac region, of the 
 same description as before. The pain and rectal discharge 
 continued after admission. No fgecal matter had been 
 passed for fully two weeks, but much flatus had passed. 
 There was no vomiting. He stated that the bowels had 
 moved freely and regularly except during the two attacks 
 mentioned. He had not noticed blood in the stools nor 
 any change in the shape of the formed material he passed. 
 For the last month there had been much tenesmus and he 
 often went to stool without passing anything. He had become 
 thinner within recent months. 
 
 Examination. — The abdomen was somewhat distended 
 and tympanitic and gurgling sounds were heard. There 
 was tenderness in the left iliac fossa especially over the colon, 
 where there was a rod-shaped hard and tender swelling. 
 On rectal examination there was felt a firm mass low down 
 in the rectum ; it was freely movable, the finger could be 
 passed round it, and at its apex there was a central depression 
 which did not admit the linger. There was no connection 
 between the mass and the rectal wall. The mass was 
 congested and there was blood on the examining finger. 
 The surface was smooth and not specially tender. The patient 
 
220 THE INTESTINAL TRACT 
 
 was transferred to Professor Caird, who operated on him on 
 September 26th. The rod-like swelling was part of the 
 sigmoid flexure. It was resected and the cut ends united. 
 The mass in the rectum was an intussusception which had 
 become reduced just before operation. The removed portion 
 was the seat of a colloid cancer. The patient made a good 
 recovery. 
 
 Obstruction at Cecum : Successful Removal 
 
 Case 57. — William M., aged 60, was admitted on the 
 12th August. Up till two months before admission, 
 patient was in good health. At that time he began to suffer 
 from constipation, which gradually became more marked. 
 Prior to that the bowels moved daily. For no apparent 
 reason he became constipated and after going for three 
 days without a motion he took a dose of castor oil which 
 produced one small motion. This was followed by a week 
 without any relief. Epsom salts were taken without any 
 effect. Flatus was passing during this time. He began to 
 have abdominal pain referred to the epigastrium and he 
 noticed that the abdomen was becoming distended. He then 
 consulted his medical attendant and was treated by enemata. 
 These brought away a large amount of fsecal matter and 
 gave much relief. Enemata were continued up to the time 
 of admission. Two weeks after the enemata were begun 
 the distension and attacks of pain returned and for a week 
 he vomited every day. The quantity vomited was large, 
 it varied in colour, and had a sour taste. He was then given 
 nutrient enemata, and had no more vomiting. On examina- 
 tion the abdomen was distended and tympanitic. At intervals 
 of about five minutes a wave of peristalsis was visible which 
 began in the lower half of the abdomen on the left side and 
 passed across towards the caecal region, then up towards 
 the liver and from there across the upper part of the abdomen 
 to the left side. This was accompanied by loud gurgling 
 sounds. There was a well-marked " ladder pattern." 
 Between these periods of visible peristalsis the abdomen 
 
STRICTURE AT SPLENIC FLEXURE 221 
 
 was quite soft. There was no lump to be felt an5rwhere and 
 there was no pam on palpation. The abdomen moved 
 freely on respiration. Rectal examination was negative. 
 From all this it was evident that the obstruction was at the 
 caecum and X-ray examination confirmed this. My colleague, 
 Mr. Struthers, saw the patient and opened the abdomen on 
 the 25th September. The caecum and the terminal 8 ins. 
 of the ileum were removed and the severed ends united. 
 The small intestine was distended and hypertrophied. The 
 stricture was malignant. The patient made a good recovery. 
 
 Stricture at Splenic Flexure : C^cal Perforation : 
 Double Operation : Recovery 
 
 Case 58. — Mrs. M., aged about 50, was seen in consultation 
 with a doctor now deceased. There was a history of 
 recurring attacks of obstruction which had up till this 
 time been overcome. The abdomen was much distended. 
 There was visible peristalsis in the lower half, the movement 
 passing towards the caecal region. There was definite 
 tenderness in this region, and nowhere else. My opinion 
 was that there was malignant stricture at the caecum and that 
 the patient ought to be operated on. She was seen a week 
 later, operation not having been agreed to. The abdomen 
 was more distended and the patient stated that during the 
 previous night there had been a noise hke a pistol-shot in 
 her abdomen. She was an intelHgent person and there 
 was no reason to doubt the accuracy of her statement. In 
 view of this statement it seemed clear that there had been 
 a perforation at the caecum. She was transferred to a 
 nursing home, where Professor Caird saw her and opened the 
 abdomen. The transverse colon was found low down and 
 distended with faeces, which excluded the possibihty of the 
 caecum being the seat of the stricture. It was found to be 
 at the splenic flexure. The peristalsis which had been 
 visible was evidently produced by the prolapsed transverse 
 colon. When the caecum was investigated, as soon as it was 
 separated from the parietes, with which it was in close 
 
222 THE INTESTINAL TRACT 
 
 contact, there was a gush of liquid faeces from a caecal 
 perforation. The perforation was secured and made an 
 outlet for the contents of the colon. The patient did remark- 
 ably well and when matters had become stable the stricture 
 at the splenic flexure was removed and anastomosis of the 
 colon effected. The patient made a complete and perfect 
 recovery. Professor Caird informs me that the caecum is 
 apt to give way in cases of obstruction at the splenic flexure. 
 
 Obstruction at Lower End of Pelvic Colon : Colostomy 
 
 Case 59. — M. S., aged 56, was admitted to hospital on 
 the i6th October. In the previous May pain began in the 
 lower part of the abdomen and he suffered from constipation. 
 Action of the bowels was obtained by means of small doses 
 of cascara, but this did not remove the pain. The pain 
 was described as coming on gradually, increasing until it 
 became severe, and then passing off gradually. At these 
 times there might be a call to go to stool, but only a httle 
 blood might be passed. When faeces passed they were 
 usually formed and normal in colour. The symptoms varied 
 from time to time : if the laxative taken did not act the 
 appetite would fail and he might become actively sick. 
 The abdomen was much distended and tjonpanitic, so that 
 on examination nothing definite could be made out ; there 
 was no tenderness ; and nothing abnormal was felt on rectal 
 examination. X-ray examination showed the stricture 
 to be at the lower end of the pelvic colon. He was transferred 
 to Professor Caird's ward on the 22nd November, and, when 
 the abdomen was opened, it was found that only a colostomy 
 was practicable. This patient was ultimately removed and 
 died some time later. 
 
 Malignant Disease of Rectum 
 Malignant disease of the rectum, while it may affect any 
 part, is probably more common in the upper part than else- 
 where. It usually gives rise to pain when the bowels are 
 moving and both blood and mucus may be passed. There 
 may be tenesmus with discharge of small quantities of 
 
MALIGNANT DISEASE OF RECTUM 223 
 
 mucus and blood somewhat frequently. Such symptoms, 
 or indeed any discomfort, or frequent call to stool, or any 
 unusual complaint referred to this region ought at once to be 
 fully and carefully investigated both outwardly and by means 
 of a finger in the rectum. The possibiUty of early malignant 
 disease should never be lightly set aside. When present 
 its early recognition is of great importance and calls for 
 surgical interposition without undue delay. Without such 
 examination, cases are labelled "piles," "colitis," or some 
 equally misleading name, and their true nature is only 
 recognized when radical operation cannot be attempted. 
 Short notes of a few cases are given below to illustrate the 
 stage at which they are sent to the hospital physician, and 
 show how grievous the results are of misinterpreting the 
 bearing of symptoms or of neglecting to make a rectal 
 examination. 
 
 Case 60. — James M., aged 67, was admitted on the 30th 
 October, complaining of constipation with pain in the region 
 of the umbilicus. He attributed his condition to a chill 
 which he got a year ago which affected his bowels. Two to 
 three months later constipation became more marked and 
 for days he would pass nothing but brownish-coloured fluid. 
 About this time, he began to have recurring attacks of abdo- 
 minal pain. When pain was present he lost appetite, but 
 when he got the bowels properly moved appetite returned, 
 pain disappeared, and he felt quite well until the same series 
 of phenomena returned. These attacks had kept recurring 
 up till the time of admission. There was no vomiting. In 
 the attack shortly before admission there was a call to stool 
 every three or four hours and he only passed brownish- 
 coloured fluid. He noticed that he was getting thinner. 
 
 On palpation of the abdomen nothing could be made 
 out, but examination of the rectum revealed a malignant 
 mass at its junction with the sigmoid flexure. 
 
 Case 61. — C. P. was brought from Cumberland to the 
 Infirmary. For some months there had been abdominal 
 pain with constipation and the passage of blood and mucus 
 with considerable tenesmus. Colitis was diagnosed. On 
 
224 THE INTESTINAL TRACT 
 
 deep palpation in the left iUac region an indefinite lump 
 could be just reached. On examination of the rectum a 
 nodulated mass was felt at its junction \^dth the sigmoid 
 flexure, and firmly fixed. Mr. Wallace saw the patient and 
 considered the condition inoperable. The patient was 
 transferred to him and a colotomy gave much relief. 
 
 Case 62. — Walter H., aged 45, was admitted on the 22nd 
 September complaining of chronic diarrhoea. Diarrhoea 
 began about nine months earHer. There would be as man}^ 
 as eight motions a da}-. He continued at work until two 
 months ago. About that time he began to have pain in the 
 lower part of the abdomen. It came on about half an hour 
 after every meal, and was relieved when the bowels moved. 
 The hea\der the meal the worse the pain. Latterly the 
 motions had been shmy and chocolate-coloured He often 
 felt sick, but never vomited. He had never been consti- 
 pated. 'My colleague Mr. Hodsdon saw this patient and 
 kindly took him in charge, but decided later that the case 
 was inoperable, removal being impracticable. 
 
 Enterospasm 
 
 The name indicates the nature of this condition. It is 
 an interesting and important affection, not common and 
 sometimes very difficult of diagnosis. The following cases 
 illustrate it. 
 
 Case 63. — Mrs. W., aged 40. This patient provides 
 a concrete illustration of the bearing of certain principles 
 which underlie and determine the accuracy of abdominal 
 diagnosis. And I again accentuate the proposition that we 
 should aim at accuracy and completeness. 
 
 She was in my ward recenth^ being admitted with a 
 history of severe abdominal pain which had occurred oftener 
 than once. When admitted inspection of the abdomen 
 revealed nothing abnormal. Palpation revealed no swelling 
 or tenderness ; but the right kidney was movable, descending 
 with inspiration and slipping up with expiration : it was 
 slightly tender. The urine showed nothing abnormal : 
 and all the other organs were healthy. The patient was of 
 
ENTEROSPASM 225 
 
 the nervous, highly-strung type. When I was palpating and 
 speaking of the mobihty of the kidney she volunteered the 
 information that the doctor had told her there was a swelHng 
 there that would need operation. I assumed that the 
 swelling meant there had been a temporary hydronephrosis 
 due to the mobility of the organ. I accordingly had an 
 abdominal corset made for her, as the degree of mobility 
 did not seem to me to justify immediate operation. She 
 went home, but in a short time her doctor wrote and informed 
 me that the pain had returned, so she was re-admitted to the 
 ward. Her condition on this second admission was quite 
 different to what it had been during her former stay in the 
 ward. Now the abdomen was projecting and distended, 
 seemingl}^ from distension of the small intestine, and there 
 was abdominal pain but no tenderness at the caecum or else- 
 where, and there was nothing abnormal revealed on rectal 
 examination. The colon was certainly not distended. 
 There was no sickness and the bowels were relieved by 
 lavage. 
 
 The patient's medical attendant kindly came into town 
 and told us that this condition had recurred from time to 
 time and was characterized by pain and similar distension, 
 and that there had not been hydronephrosis as she had led 
 us to infer. 
 
 The condition suggested a partial block at the ileo-csecal 
 junction, although nothing was palpable in this region. The 
 next step was X-ray examination, and this was carefully 
 carried out by Dr. Hope Fowler in the electrical department, 
 but no point of blockage was shown. The only other 
 feasable explanation was enterospasm, and the abdomen was 
 examined from day to day. The pain and distension varied 
 from day to day, and I found that some days the ascending 
 colon could be felt strongly contracted, feeling no thicker 
 than one's thumb, while other days it would be two or three 
 times that size. This strengthened the view that the 
 symptoms were due to enterospasm of the colon. I ordered 
 belladonna internally and gave instructions that the dose 
 was to be increased until the physiological effect of the drug 
 
 15 
 
226 THE INTESTINAL TRACT 
 
 was obtained. There was no marked relief and the possibility 
 of an early organic lesion at the ilio-caecal junction, not 
 demonstrable by X-ray examination, obtruded itself, and 
 my surgical colleague who kindly saw the patient thought 
 the abdomen ought to be opened, as he thought there was 
 an organic stricture. The abdomen was opened and no 
 organic stricture or lesion of any kind was found. 
 
 Remarks. — The first point this case accentuates is the 
 necessity' of accuracy in the history of symptoms. If we 
 had seen the medical attendant earlier we would not have 
 been led into the error of diagnosing a hydronephrosis 
 because there was a movable kidney and from the statement 
 that the doctor had found a swelling there. In the second 
 place, the case is an added illustration of what becomes 
 more and more my experience, namely, that when it is not 
 quite clear that there is something definite for the surgeon 
 to do when he gets inside the abdomen, it turns out that there 
 is nothing to do. In this particular case the appendix was 
 removed and the caecum tacked down ; these measures, in 
 conjunction with the handling necessary for full examina- 
 tion, were likely to relieve the enterospasm at least for a 
 time. We must, however, face the fact that the abdomen 
 ought not to be opened for the relief of enterospasm until 
 it is quite clear that all possible medical measures have been 
 exhausted. 
 
 Case 64. — Miss S. The preceding case recalls the case 
 of a lady sent to me in June, 1917. She suffered from an 
 extreme degree of constipation, which became more and 
 more difficult to overcome. Some years previously she had 
 been operated on for a suppurating appendicitis, with 
 extensive peritonitis, and had at that time a long and severe 
 illness. The presumption therefore was that the constipation 
 was due to adhesions. On examination of the abdomen 
 there was no evidence of thickening in the csecal region and 
 the ascending and transverse colon could be traced as far 
 as the splenic flexure, and it was of good size ; while, from 
 the splenic flexure downwards, the colon was empty and 
 spastic. The question was whether there was an organic 
 
ENTEROSPASM 227 
 
 stricture at this point, but this did not seem to be probable 
 as the constipation had lasted for years and there had never 
 been any other symptom of true obstruction beyond the 
 very obstinate constipation. She was X-rayed and examined 
 by the screen, when it was seen that the bismuth got piled 
 up in the splenic flexure, while below it the colon was seen 
 to be spastic just as it had been felt. There was clearh' 
 no stricture at the point where stricture occurs. I suggested 
 that belladonna should be given in as large doses as the 
 patient could tolerate and I had the satisfaction of hearing 
 from the doctor that the drug had " acted like magic " and 
 that the constipation was entirely overcome. 
 
Section TV.-THE (ESOPHAGUS 
 CHAPTER XIX 
 
 THE (ESOPHAGUS 
 
 (Esophageal Obstruction. — ^This is the only condition in the 
 oesophagus requiring consideration here. It is not proposed 
 to deal with injuries due to swallowing hot or acrid fluids, 
 or with diverticula. 
 
 It might be thought that oesophageal obstruction gave 
 rise to such definite symptoms that it would be always 
 diagnosed at an early stage, and yet that is not my experience. 
 So far as the ultimate fate of the patient is concerned, the 
 failure to recognize its beginning, or its early manifestation, 
 does not carry the same grave responsibility as failure to 
 diagnose an early cancer of the stomach. The reason for 
 this statement will presently be shown. 
 
 Symptoms. — There is really only one sjrmptom. It 
 consists in some difficulty in swallowing food. It is not 
 usually a pronounced difficulty at first, it may not be 
 constant, and it may have been noted to occur only with 
 certain kinds of food. Whenever such a complaint is made 
 suspicion ought to be aroused, and careful inquiries made. 
 The patient ought to be seen from time to time and the 
 symptom asked about. The first complaint may be that 
 the first mouthful is felt to stick, but after a short interval 
 may pass, and the rest of the meal be swallowed without 
 difficulty ; drinking a little water may facihtate the passage 
 of the stuck portion. In some cases the stuck bit may be 
 brought up, and more careful mastication or taking smaller 
 pieces of food into the mouth prevents further difficulty for 
 
 228 
 
(ESOPHAGEAL OBSTRUCTION 229 
 
 the time. Very commonly the first article of food which 
 sticks is beef or mutton, which tends to be swallowed in too 
 large pieces and imperfectly masticated. A lump of potato 
 may also stick in this way. These symptoms may have 
 continued for some time before the doctor is consulted. In 
 fact, by the time he is consulted he may find that beef and 
 mutton have been already eliminated from the dietary, as 
 they could not be swallowed, or because "they would not stay 
 down." At this stage a difficulty arises, for the patient may 
 state that beef or mutton " made her sick ; " or that as soon 
 as it reached the stomach she vomited it just as it had been 
 swallowed. There is no better example than this of how 
 a doctor may be misled by a patient's statements, if he 
 accepts them at their medical face value. He has to get 
 behind his patient's use of the words " sick " and " vomiting," 
 for they are not used in the medical sense. He will find 
 that the stuck piece of food is brought up, either alone or 
 with some watery mucus. There is no true nausea ; there 
 is no true vomiting ; there is only a reversed peristalsis of 
 the oesophagus accompanied, perhaps, by a diaphragm 
 contraction. After beef and mutton and potatoes have been 
 discarded, fish, fowl, and rabbit follow. Then new bread, 
 toast, and indeed bread of any kind, save in small quantity 
 and very carefully masticated, have to be abandoned. 
 Fluids continue to pass and so may oatmeal porridge and 
 farinaceous puddings. Later the porridge and the puddings 
 have to be made thinner. Milk and beaten-up eggs, Benger's 
 and Allenbury's foods, and meat extracts may pass easily, if 
 swallowed slowly. The last phase is when fluid nourishment 
 even in small quantity passes slowly and may be brought 
 up. During all this time, which means some months, 
 there is progressive emaciation and advancing cachexia. 
 
 Etiology and Diagnosis. — Obstruction of the oesophagus 
 may be due to various causes. They are : (i) mediastinal 
 neoplasm or aneurism ; (2) spasm ; (3) malignant neoplasm 
 in the tube itself. 
 
 With regard to the first of these, obstruction is a late 
 phenomenon ; and mediastinal neoplasm or aneurism has 
 
230 THE (ESOPHAGUS 
 
 usually been alread}' diagnosed. Spasm occurs most 
 commonly at the cardiac opening ; it is characterized by 
 not being constant ; when not present ordinary food can be 
 swallowed. Persistently recurring spasm suggests the 
 possibility of a gastric ulcer, which may be very small, 
 close to the cardiac opening. \^'Tien these have been 
 excluded there remains only malignant neoplasm in the tube 
 itself. This is the commonest cause of obstruction, so 
 much so that it is not putting the matter too strongly 
 to say that a constant degree of obstruction, although some- 
 times less than at other times, has to be proved not to be 
 malignant. Clinically and pathologically an advancing 
 obstruction is maUgnant, when mediastinal pressure has 
 been excluded. If aneurism has been excluded a medium- 
 sized or a small stomach tube may be used to explore the 
 oesophagus and to judge of the degree of organic stenosis. 
 Spasm 3delds to the tube usually. Finally, obstruction 
 can be shown, beyond all question, to be present by radio- 
 graphy. 
 
 Treatment. — In cases of cardiospasm, belladonna and 
 valerian may be helpful. One patient with recurring spasm 
 required the passage of the tube at frequent intervals. In 
 malignant obstruction there is little that can be done. If 
 there is evidence of spasm belladonna may help. So long 
 as nutritive fluids pass into the stomach surgical interposition 
 is not to be advised. All that the surgeon can do is to make 
 a stomach opening through which nourishment can be 
 introduced. 
 
 Case 65. — Miss W., aged 51, was sent from the North of 
 England with a provisional diagnosis of malignant disease 
 of the stomach. The symptoms and the history were 
 clearly those of oesophageal obstruction. The main point 
 of interest in the history was that the earUest manifestation 
 of food sticking was hiccough. Fig. 33, the radiogram of this 
 case, shows the oesophagus in its lower part distended and 
 full of bismuth. The plate from which this figure has been 
 produced was taken by Dr. E. Price. This case is used as 
 it came under observation when this was being written. 
 
R.Diaplira3i 
 
 Fig. 33. — Case 65, showing dilated oesophagus filled with bismuth. 
 
 [To face page 230. 
 
(ESOPHAGEAL OBSTRUCTION 231 
 
 No useful purpose would be attained by loading this section 
 with a record of cases. They are monotonously alike when 
 the patient's use of words does not mislead the medical 
 attendant. The skill required is often confined to the power 
 to disentangle and interpret aright the symptoms as described 
 by the patient. 
 
 The following case is added as pain was a prominent 
 symptom. 
 
 Case 66. — Mr. R., aged 68, engineer, was seen in con- 
 sultation. 
 
 History. — Three months ago he began to suffer from pain 
 in the back, situated in the upper part of the lumbar region. 
 He had lost 3 st. in weight, since the beginning of his 
 illness. The pain was constant, it was not intensified by 
 movement of the trunk in any direction. About the same 
 time he began to have difficulty and pain on swallowing. 
 He described the pain as very severe until he brought up 
 "a lot of sUme." The slime came up when he attempted 
 to take food, after taking a mouthful, and after it came up 
 he could swallow his food. The explanation seemed to be 
 that spasm, giving rise to pain, occurred at the lower end 
 of the oesophagus, and that as a result mucus and saliva 
 accumulated above this ; that a mouthful of food determined 
 a reversed peristaltic movement, which led to the ejection 
 of the slime ; and that thereafter the bland food he was 
 taking readily passed into the stomach. Every mouthful 
 he swallowed caused an increase in the ordinary and constant 
 degree of pain, and this intensification persisted for fifteen 
 to twenty minutes after he had finished a meal, and then 
 subsided, leaving him with the amount which was constantly 
 present in the pit of the stomach and in the back. 
 
 On examination of the lumbar region no tenderness was 
 eHcited by pressure, and no pain was caused by movement 
 of the spinal column. Examination of the abdomen anteriorly 
 showed marked emaciation with hollowing. There was no 
 abnormal projection in the epigastrium, and on palpation 
 deeply in the epigastrium and under the left costal margin 
 no swelHng or undue resistance was present and no pain 
 
232 THE (ESOPHAGUS 
 
 was caused by the pressure. The stomach seemed to be 
 small. There were no enlarged glands to be felt in the 
 abdomen, above the clavicles, or elsewhere in the body. 
 The bowels moved regularly ; and other organs presented 
 nothing abnormal of importance. 
 
 Remarks. — ^The symptoms described above and the rapid 
 loss of much weight led inevitably to a diagnosis of malignant 
 stricture at the lower end of the oesophagus. The only 
 alternative was the presence of an aneurism causing spinal 
 erosion and oesophageal obstruction, but the absence of all 
 signs of erosion seemed to exclude definitely this as a 
 possibility With regard to treatment pain was being reheved, 
 as required, by belladonna or morphine. The patient was 
 able to swallow milk, porridge, lightly cooked eggs, soups, 
 and even fish and toast if he very carefully masticated them. 
 In view of this there was, of course, no need of surgical help. 
 
Section V.— THE LIVER 
 CHAPTER XX 
 
 JAUNDICE OR ICTERUS 
 
 Jaundice or icterus is the name given to the discoloration 
 of the tissues following upon the passage into the blood of 
 the bile formed by the liver. The skin becomes yellow in 
 colour while similar and early colouring of the conjunctivae 
 also appears. The urine contains bile, the presence of which 
 can be demonstrated by the ordinary tests. Jaundice is 
 not a disease ; it is a symptom, as dropsy is a symptom. 
 It always means that there is obstruction to the outflow of 
 bile into the duodenum. There are tintings of skin and 
 conjunctivae sometimes spoken of as jaundice, which are 
 not true jaundice. Here the term is confined to the colora- 
 tion produced by secreted bile passing into the circula- 
 tion and demonstrable in the urine. That the bile is not 
 escaping by its normal outlet into the duodenum is shown 
 by the white or grey colour of the motions and by their 
 putty-like or clay-Hke consistence. The determination of 
 the cause of the obstruction in the individual patient is the 
 clinical problem. It is not proposed to deal with jaun- 
 dice met with in certain infective maladies and poison- 
 ings, but to limit consideration to that which is most 
 commonly seen by the practitioner, and with regard to which 
 there still exist diflfiiculties and hesitations, in the hope that 
 differential diagnosis may be helped, for correct diagnosis 
 alone can indicate the line of rational treatment. It is 
 not " jaundice " which has to be treated but the condition 
 which has led to it. The immediate cause of jaundice in 
 
 233 
 
234 THE LIVER 
 
 these cases is purely mechanical. The pressure at which 
 bile is secreted and the pressure at which it passes into and 
 along the larger bile ducts is low, so that a relatively small 
 cause may completely prevent its escape into the duodenum. 
 The bile which has been produced by the liver ceUs is re- 
 tained and passes by way of the lymphatics, and perhaps 
 by blood capillaries also, into the blood. As a consequence 
 all the tissues, organs, and fluids of the body are stained or 
 coloured by it, while the bowel contents are wanting in bile 
 colouring. 
 
 The conditions which lead to this mechanical obstruc- 
 tion to the outpouring of bile are : (i) catarrh of the second 
 part of the duodenum, causing swelling of the mucous mem- 
 brane surrounding the orifice of the common duct or extend- 
 ing a short distance into the duct ; (2) calculus in the 
 duct ; (3) inflammation of the ducts due to an extension 
 from the gall bladder or consequent upon passing of a stone ; 
 (4) malignant disease of the head of the pancreas pressing 
 upon the orifice of the common duct ; (5) new-growth in the 
 liver so situated as to press upon the ducts ; (6) new-growths 
 outside the liver so situated as to compress the ducts ; 
 (7) new-growth in the duodenum so situated as to obstruct 
 the orifice of the common duct ; (8) animal parasites which 
 directly occlude the duct or by their presence determine a 
 duodenal catarrh which occludes the orifice of the duct ; 
 and (9) biliary or hypertrophic cirrhosis of the liver. These 
 causes have to be considered in detail, for the treatment and 
 the prognosis are determined by the accuracy of the differen- 
 tial diagnosis in each separate case, At the present time, 
 when surgery is so largely dominated by the newly acquired 
 sense of safety in operating on the abdomen, there is a 
 tendency on the part of many practitioners not to devote 
 sufficient attention and labour to the acquisition of skill in 
 differential diagnosis ; and to regard all cases in which the 
 differential diagnosis is not perfectly simple and readily 
 arrived at as cases in which exploratory incision is unhesi- 
 tatingly to be undertaken ; the extent of any further steps 
 being determined by the diagnosis made with the abdomen 
 
JAUNDICE 235 
 
 opened. This is a mental attitude and a practice from which 
 there is aheady a certain revulsion, and the reaction is not 
 only inevitable, but its acceleration is desirable. The per- 
 forming of unnecessary laparotomy is as reprehensible as 
 abstaining from operation in suitable cases ; and the 
 neglect to cultivate the skill necessary for differential 
 diagnosis is altogether unworthy of any branch of medicine, 
 while it reduces surgery to a mere expert handicraft. While 
 holding this view strongly, one recognises that there are 
 cases in which it may be impossible to differentiate finally 
 between two conditions, and in which it is right to give the 
 patient the chance that his malady may be the less of two 
 conditions. Of two possible conditions it not infrequently 
 happens that the one is curable b}^ surgical means, while 
 the other is quite beyond the skill of surgery to influence. 
 The aim of the physician and of the practitioner assuredly 
 is to reduce to a minimum the number of laparotomies which 
 begin with the abdominal incision and end with its immediate 
 suturing. This can only be reached by an earnest endeavour 
 after accuracy in diagnosis. That a high degree of accuracy 
 is attainable cannot be questioned. For its attainment 
 there are three lines of evidence to be developed, namely, 
 first, a clear and accurate account of the history of the 
 patient's symptoms ; second, a skilful examination of the 
 abdomen by the methods in general use ; third, a correct 
 knowledge of the morbid conditions met with in the various 
 viscera, and the relation of viscera or parts of viscera to 
 the abdominal wall. With the evidence culled from these 
 three sources the accuracy of the diagnosis depends upon 
 the measure in which the judgment and the judicial faculties 
 have been cultivated and developed. 
 
 The conditions, already enumerated, which lead to 
 jaundice may now be considered in order. 
 
 Catarrhal Jaundice 
 
 This is the term applied to jaundice due to obstruction 
 of the common duct by catarrhal swelling of the mucous 
 membrane surrounding its orifice or invading the duct 
 
236 THE LIVER 
 
 itself. A duodenal catarrh is therefore always present, 
 and is indeed the essential morbid condition. It is usually 
 preceded by symptoms of gastric disorder, with complaint 
 of " indigestion " or " dyspepsia." Discomfort after food, 
 flatulent distension, gaseous eructations are amongst the 
 common symptoms. A furred or coated tongue indicates 
 the catarrhal condition of the stomach, and when this 
 extends to the duodenum jaundice supervenes. It is the 
 commonest form of jaundice. In children and in young 
 adults it is the usual form, but it is not rare in later life. 
 The position of this question may be definitely stated to 
 be this, namely, that in the first half of life the presumption 
 is so strongly on the side of jaundice being catarrhal that 
 you have to prove that it is not. In later life there is greater 
 diihculty than in earlier life in determining that a jaundice, 
 which has come on without much previous history of definite 
 digestive disturbance, is catarrhal, and not due to early 
 malignant disease of the head of the pancreas, or to a primary 
 cancer affecting the duodenum where the common duct 
 enters it ; this latter condition, however, is very rare. As a 
 matter of fact and experience, the diagnosis really lies between 
 catarrh and malignant head of pancreas. 
 
 Treatment. — The treatment of the condition is the treat- 
 ment applicable to duodenal catarrh. The diet ought to con- 
 sist of skimmed milk and farinaceous foods. Care ought to 
 be taken to have the food very thoroughly mixed with the 
 salivary secretion so as to ensure its more easy digestion. 
 Medicinal treatment consists in the administration of 
 bicarbonate of soda, rhubarb, and small doses of salicylate 
 of soda. A small dose of calomel at night, followed by a 
 small dose of an effervescing saline aperient in the morning, 
 may be given for a few days in succession, or on alternate 
 days. It is better so to regulate the dose that free 
 movement is obtained without purging. The colour of 
 the motions shows when bile has begun to pass into the 
 bowel, and as soon as this is seen the diagnosis of catarrh 
 may be regarded as confirmed. If the condition does not 
 speedily yield to the above treatment the outlook becomes 
 
JAUNDICE 237 
 
 more serious, for it only too commonly indicates that the 
 cause of obstruction is beyond either medical or surgical 
 skill. 
 
 There is little to add to the foregoing beyond empha- 
 sizing certain points. Catarrh occupies the first place in 
 the consideration of the causation of jaundice. The cause 
 of the stomach catarrh which involves the duodenum is 
 commonly some error in diet. I have seen a small " epi- 
 demic " of catarrhal jaundice in the nurses of a hospital ; 
 but the error in the individual case may escape detection, 
 while in other cases the patient may attribute it to some 
 article of food which had produced a feehng of repulsion 
 or nausea when being eaten. The icteric tint shows first 
 in the conjunctiva. Bile soon appears in the urine and the 
 fseces lose their bile colouring. The duration of the obstruc- 
 tion varies from days to weeks, and there is only one test 
 that the obstruction has been removed and that is the 
 reappearance of the yellow colour of the faeces. Imagined 
 differences in the colour of the skin and urine have to be 
 put aside as absolutely unreUable guides as to the patient's 
 progress ; nothing but seeing the motions day by day is 
 reliable. After the motions resume the normal colour bile 
 rapidly disappears from the urine. The skin coloration 
 may take weeks to disappear and need not be regarded 
 seriously from the medical standpoint, although it may 
 offend the patient's aesthetic standards. It finally disap- 
 pears. 
 
 \Vhile the disappearance of jaundice as a result of 
 duodenal catarrh is the almost universal experience, I have 
 seen one instance in a woman past middle life in whom the 
 jaundice did not yield to any treatment directed to the 
 duodenum. The persistence and intractability of the 
 jaundice led to the opinion that it was due to malignancy of 
 the head of the pancreas. The patient died and the post- 
 mortem examination showed the lower inch or less of the 
 duct blocked with tough mucus. This possibility has to 
 be kept in mind and will be referred to again under jaundice 
 due to malignant disease of the head of the pancreas. 
 
238 THE LIVER 
 
 Obstruction by Calculus 
 
 Calculi are commonly formed in the gall bladder. For 
 obstruction to the outflow of bile to be caused by calculus it 
 is, of course, necessary that the calculus should be present 
 in the bile duct to the distal side of the point at which the 
 cystic duct opens ; that means that the stone has passed 
 along the cystic duct and has stuck in the ductus chole- 
 dochus. The obstruction leads to jaundice. 
 
 Gall-stone Colic — Gall-stone, or biliary, or hepatic colic 
 are the terms applied to pain caused by the presence of gall- 
 stone. The stone may be situated in the gall-bladder or 
 the larger ducts. When in the gall-bladder it only causes 
 coKc when it obstructs the mouth of the cystic duct. Gall- 
 stones are found on post-mortem examination when a history 
 of gall-stone cohc is awanting. The feature of all colic is 
 its sudden onset, and its sudden subsidence ; and the 
 appellation is confined to the abdominal viscera. The 
 passage of a gall-stone along the cystic duct or the ductus 
 choledochus always causes pain. The degree of pain 
 depends mainly upon the size of the stone. The pain may 
 be agonizing ; it may be so intense as to kill if relief is not 
 speedily afforded. If the stone or stones are small they 
 may pass with so little discomfort that their existence maj?^ 
 not even be thought of. When a stone sticks and causes 
 jaundice it is of larger size and yet not so large that it 
 failed to pass the cystic and enter the common duct. The 
 pain is usually sudden in onset, and may immediately 
 attain intense severity. It is referred to the abdomen, 
 either all over it, or mainly to the umbilical, epigastric, or 
 right hypochondriac region. In severe cases there may be 
 diffuse abdominal tenderness, which can easily be mis- 
 construed, and be regarded as a sign of general peritonitis. 
 It is in reality a surface hyperaesthesia, and has to be dis- 
 tinguished from the corresponding condition in perforation. 
 When jaundice is due to gall-stone there is always a definite 
 history of one or more severe attacks of pain such as has 
 been indicated. The jaundice may follow upon the first. 
 
JAUNDICE . 239 
 
 which may also have been the only attack of pain ; but there 
 may be a history of many attacks, which have not been 
 followed by jaundice, and which have passed without their 
 true nature ha\'ing been recognized. This history of 
 paroxysmal pain, or colic, is the key to the diagnosis when 
 jaundice appears. Whatever difhculty there may be in the 
 early stage of a case of abdominal pain the onset of jaundice 
 commonly sets the question of diagnosis at rest. The 
 differentiation of biliary from other forms of colic presents, 
 not infrequently, considerable difficulty. Care has to be 
 taken when the history of pain is being investigated that 
 the essential points are clearly and unequivocally determined ; 
 these are the mode of onset, whether gradual or sudden or 
 steadily developing in severity ; the intensity of the pain ; 
 and the site to which it is referred. Vague general questions 
 and answers are of no value in this inquiry, and it may require 
 patience and considerable tact to get the patient to answer 
 questions with approximate accuracy. The pain of gall- 
 stone colic has no constant relation to taking food, it is 
 erratic in its manifestations, usually sudden in its onset, 
 and as sudden in its cessation. Although having no constant 
 relation to taking food, it may be noted that attacks may be 
 determined by large meals. 
 
 The diagnosis that colic is hepatic in origin is simplified 
 by recalling and restating the causes which lead to the 
 sudden onset of pain in the abdomen ; they are constipation, 
 intestinal obstruction, hernia, internal or external, gastric 
 or intestinal perforation, renal colic, and hepatic or gall-stone 
 colic. This may be further simplified by stating that the 
 seat of pain is in the gastro-intestinal tract, in the kidney, 
 or in the hver. In the stomach acute severe pain may be 
 due to perforation ; but in perforation with considerable 
 escape of gastric contents into the peritoneal cavity there is 
 a degree of collapse not met with in hepatic or renal colic, 
 and the same is true of duodenal perforation. In the rest 
 of the intestinal tract primary ulceration with perforation 
 may be excluded. Intestinal obstruction from malignant 
 stricture occurs practically only in the colon and is preceded 
 
240 THE LIVER 
 
 by a history of constipation, more and more difficult to 
 overcome, while obstruction with pain and vomiting does 
 not set in precipitately. The seat of obstruction can 
 often be determined by physical examination. Internal 
 hernia gives rise to pain referred to the site of obstruction 
 and the pain leads to vomiting. In renal colic pain is 
 mainly lumbar, although in less degree it may be felt anter- 
 iorly ; on careful bimanual palpation the true seat of 
 tenderness is found to be the renal region. In hepatic 
 colic the pain is referred to the right hypochondrium as its 
 seat of origin, and by palpation the true seat of tenderness 
 is over the liver edge. The determination of the true seat 
 of tenderness has in all cases to be slowly and critically 
 determined when the surface hyperaesthesia has been over- 
 come. This can usually be effected by gentle friction 
 with the hand and by gradually making iirmer palpation. 
 If duodenal perforation and kidney are excluded, and they 
 usually can be excluded, there is no alternative to the 
 diagnosis of hepatic colic. The idea that hepatic colic 
 is not to be diagnosed until jaundice appears is deplorably 
 wrong. There is, however, a question in some cases of 
 diagnosis between chronic duodenal ulcer and gall-stone. 
 In duodenal ulcer pain has a definite relation in time to the 
 preceding meal, a relation which tends to repeat itself ; but 
 pain is not necessarily present after every meal. It is 
 influenced by the character of the meal which has been 
 taken. Recurring hepatic colic on the other hand is more 
 eratic in its manifestations, sometimes appearing to have 
 been determined by the preceding meal, but paroxysms 
 occurring apart from such relationship. 
 
 Passing of Small Stones. — Gall-stone colic must always 
 be considered from the standpoint that gall-stones are often 
 of small size, that one or many such stones may pass into 
 the duodenum and give rise to pain when passing. The 
 not uncommon idea that a colic was not hepatic because it 
 passed off without causing jaundice has to be definitely 
 abandoned both in practice and in teaching. It has been a 
 barrier to the recognition of many cases in which there would 
 
JAUNDICE 241 
 
 have been no difficulty in diagnosis but for its existence. 
 Many cases are seen in which there has been a single 
 attack of such colic ; or several attacks with intervals of 
 years of complete freedom. It cannot therefore be assumed 
 that an attack wiU not subside. The stone may pass, 
 but even if it remains in the gall-bladder it may cease for 
 long periods to cause pain. If a stone has been passed, 
 another may form at a later date, again cause pain, and 
 again be passed. These are foundation facts which ought 
 to influence our judgment in individual cases. They are 
 so fundamental that the position comes to be this, that it 
 has to be shown in the individual case that the stone is not 
 to pass without undue suffering and risk. 
 
 Treatment. — If the diagnosis of impacted gall-stone is 
 made, the expectant line of treatment may be adopted for a 
 limited time, in the hope that the stone may pass. The 
 bowels ought to be Icept moving easily, and belladonna be 
 given with a view to relaxing spasm. If these measures 
 are not followed by rehef, or if the patient continues to suffer 
 from recurring attacks of colic, the only remedy is the 
 surgeon's knife. 
 
 Cholangitis, or Inflammation of the Bile Ducts 
 
 Inflammation of the bile ducts leads to jaundice by the 
 blockage of the ducts with inflammatory products. While 
 inflammation may occasionally be an extension from a 
 primary duodenal inflammation, on the one side, or of a 
 primary inflammation of the gall-bladder on the other, 
 it is more commonly set up by calculus. The calculus may 
 have been arrested in transit from the gall-bladder, or it 
 may have passed, but in its passage have so injured the 
 duct that inflammation followed its passage. In other 
 cases there may be one or a number of calculi in the gall- 
 bladder, which indicate their presence by attacks of pain 
 consequent upon one of them becoming engaged in the 
 mouth of the cystic duct. During such an attack of cohc, 
 which may be very severe, a cholecystitis may be set up, 
 with the inflammation extending rapidly to the ducts, 
 
 16 
 
242 THE LIVER 
 
 leading to their blockage and to jaundice. In such cases 
 there is a like history of paroxysmal pain as was referred to 
 in the previous sub- section ; but along with pain there is a 
 rise of temperature, of the septic type. There may even be 
 slight rigors with sweating ; and examination of the blood 
 shows a polymorphonuclear leucocytosis. The diagnosis 
 in cases of this kind is simple as soon as the jaundice appears ; 
 any difficulty is in the pre- jaundice stage, when severe pain 
 and elevated temperature are the leading and indeed only 
 prominent symptoms. The combination of these symptoms 
 is, however, pathognomonic of cholecystitis or cholangitis, 
 or both combined, associated with calculus. The severity of 
 the S3niiptoms in this class of case varies very greatly and 
 can be best illustrated by brief reference to typical cases. 
 
 Case 67. — Male, aged 65, had one or two attacks of colic 
 which at the time of their occurrence had not been recog- 
 nized as of bihary origin. Some time afterwards fever 
 supervened and jaundice made its appearance. This state 
 of affairs was allowed to continue for some weeks, but finally 
 operation was agreed to. No calculus was found, but the 
 gall-bladder and bile ducts were inflamed. The gall-bladder 
 was drained and the patient made a good although a slow 
 recovery. 
 
 Case 68. — Female, in middle life, was deeply jaundiced, 
 emaciated, and exhausted when she came into my hands in 
 hospital. She had a septic temperature with occasional 
 slight rigors. The history indicated that there had been 
 attacks of coUc early in the course of the illness. In view 
 of this and of the fact that she was steadity losing ground, 
 I strongly advised her to submit to operation. This she 
 consented to, and Mr. Hodsdon, one of my surgical colleagues, 
 performed the operation. No stone was found, but the gall- 
 bladder was drained, with the result that the patient at once 
 began to improve ; the jaundice disappeared, she began to 
 take food readily, put on flesh, and in a few weeks was able 
 to be out of bed. 
 
 Remarks.— In these two cases there was definite history 
 of gall-stone colic before jaundice had appeared. Along 
 
JAUNDICE 243 
 
 with the onset of jaundice there was rise of temperature. 
 The rise of temperature indicated an inflammatory cause for 
 the jaundice, and this having been preceded by attacks of 
 pain pointed to calculus as setting up the inflammation. 
 The subsidence or disappearance of pain indicated either 
 that the calculus had passed or that it was still in the 
 gall-bladder although not so placed as to cause pain. It 
 must be remembered that the passage of a stone does not 
 necessarily cause cholangitis and jaundice. On the other 
 hand, jaundice due to cholangitis, following upon gall-stone 
 colic, if persistent, demands surgical interposition, yet a 
 stone may not be found when the parts are examined. If 
 there has been an absence of colic for some time, notwith- 
 standing the persistence of jaundice, the presumption is 
 that no stone will be found, but none the less the gall-bladder 
 ought to be opened and drained, for it is the only effective 
 method of dealing with the cholangitis. 
 
 Cholecystitis and Cholangitis due to Gall-bladder Calculi. — 
 It has been already stated that the presence of calculi in 
 the gall-bladder does not necessarily lead to attacks of colic. 
 On the other hand, however, there may be many and severe 
 attacks without jaundice. In some cases jaundice appears 
 after one or other attack and when it does so it is commonly 
 associated with a rise of temperature. In cases of this 
 kind it is found that cholecystitis has supervened, and 
 that the inflammation has rapidly extended to the ducts, 
 leading to partial or complete obstruction of them. The 
 facts are, whatever explanation may be advanced regarding 
 them, that stone or stones may be long present and cause 
 severe attacks of colic without causing cholecystitis, while 
 in some one attack cholecystitis may supervene with inflam- 
 mation spreading rapidly to the ducts. Without extension 
 to the ducts jaundice does not develop. The following 
 case illustrates several of the points referred to and speciall}/ 
 the fact that stones may exist without causing severe 
 pain; that a time comes when a mild cholec5/stitis and 
 angitis may supervene with jaundice, that this may subside 
 but be followed by still more severe attacks of colic, and yet 
 
244 THE LIVER 
 
 all the time the stones may be present and confined to the 
 gall-bladder. 
 
 Case 69. — A lady, aged 65, had for years suffered from 
 attacks of abdominal pain with a little rise of temperature, 
 which she thought were threatenings of a recurrence of an 
 appendicitis from which she had suffered many years 
 before. A day or two in bed and a dose of castor oil with 
 laudanum was followed by recovery. Quite suddenly one 
 day she was seized with very severe abdominal pain which 
 was only restrained by the subcutaneous administration of 
 considerable doses of morphine. She had several such 
 attacks of pain and the temperature rose somewhat. "When I 
 saw her that was her condition, but in addition there was 
 tenderness over the gall-bladder. There seemed to me to be 
 no doubt as to the cause of the symptoms and the onset of 
 jaundice fully confirmed my view. After full considera- 
 tion, it was decided to postpone the question of operation. 
 In the course of six weeks the temperature became normal, 
 the jaundice disappeared, and the patient was able to move 
 about. Not long afterwards there was another attack of 
 very severe pain, which was again made bearable only 
 by deep chloroform narcosis followed by morphine. The 
 temperature again rose, the region of the gall-bladder 
 became tender and slight jaundice supervened. 1 strongly 
 recommended operation on the ground that stones were 
 present, which were not escaping into the intestine, but 
 which when they got into the mouth of the duct caused 
 pain followed by cystitis and cholangitis. She was operated 
 upon by Mr. Cotterill and Mr. Hodsdon, and eight good- 
 sized stones were removed from the gall-bladder. No stone 
 was found in the ducts, but notwithstanding that the gall- 
 bladder was drained. Complete recovery followed, and the 
 lady enjoyed a degree of comfort, and a measure of strength 
 and vigour, which she had not experienced for years. 
 There was also no return of the attacks which were 
 previously reierred to the appendix. 
 
 Treatment. — In what has been already said the treatment 
 is indicated. If calculus with cholecystitis or cholangitis 
 
JAUNDICE 245 
 
 is diagnosed, time ought to be allowed to give the stone a 
 chance of passing and the inflammation an opportunity to 
 subside. These may be facilitated by giving the patient 
 a course of belladonna internally and applying belladonna 
 with hot fomentations or poultices locally. The bowels 
 ought also to be carefully seen to, and the diet ought to be of 
 the lightest description. 
 
 Malignant Disease of the Head of the Pancreas 
 
 Mahgnant disease of the head of the pancreas causes 
 jaundice by pressing upon and thus obstructing the opening 
 into the duodenum of the portion of duct common to the 
 pancreatic and biliary secretions. This affection of the pan- 
 creas leads early to obstruction. It commonly occurs after 
 middle life, being by no means common in the first four decades 
 of hfe. When the disease in the pancreas is secondary to 
 cancer of the pyloric end of the stomach the pyloric condition 
 has usually declared itself before jaundice appears, so that this 
 further development is regarded merely as a step in the down- 
 ward course of the patient. The same may be true of pancreas 
 involvement from other primary sites. When, however, 
 the pancreas is the primary site of the disease jaundice is 
 commonly the first symptom which attracts notice or receives 
 serious consideration. Primary cancer of the head of the 
 pancreas is not rare. Indeed, it is sufficiently common to 
 raise the question in all cases which have not been preceded 
 by any definite history of digestive disorder, whether it is not 
 the cause of an existing jaundice. The absence of evidence of 
 gastric or duodenal catarrh considerably deepens the suspicion 
 that Hes upon the pancreas in this kind of case. A further 
 deepening of the suspicion is induced by the experience that, 
 in spite of measures directed to the removal of any duodenal 
 catarrh which might have been present, the jaundice does 
 not lessen but, on the contrary, becomes more intense. 
 The failure to obtain improvement in spite of msely admini- 
 stered therapeutic measures becomes in itself a point of much 
 diagnostic significance. In fact, the persistence of jaundice 
 
246 THE LIVER 
 
 for some weeks, in spite of treatment, without a history 
 suggesting calculus, and wanting in unequivocal signs of 
 tumour, may quite reasonably be attributed to the pancreas. 
 Signs of tumour may not, however be so entirely absent. 
 If skill has been acquired in the palpation of the abdomen, 
 the hardened and somewhat enlarged head of the pancreas 
 may be felt in its normal position. 'V^'lien it can be so felt 
 it is in my experience definitely tender when moderate 
 pressure is made upon it. Palpation is facilitated as the 
 case goes on by the progressing emaciation of the patient, 
 and perhaps by the head enlarging. The head, however, 
 does not attain any striking enlargement, so a great tumour 
 mass must not be expected. Other points are regarded as 
 assisting in the differential diagnosis, such as an excess of fat 
 in the stools, from the absence of the pancreatic secretion ; 
 but all causes which lead to obstruction of the common duct, 
 be it calculus or catarrh or malignant disease, rob the 
 food of the benefit of the pancreatic secretion with its several 
 important and essential enzymes. Efforts have been made 
 by chemical analysis of the urine to determine the question 
 of the involvement or freedom of the pancreas from mahgnant 
 disease, but this method of investigation has not so far given 
 data which seem to be rehable. The diagnosis may be 
 regarded as practically dependent upon the considerations 
 which have been dealt with in the first part of this section. 
 
 Treatment. — ^This condition presents only one question 
 for consideration and that is whether we are to recommend 
 operation to give an artificial outlet to the bile. The misery 
 sometimes experienced from the distressing itchiness of the 
 skin seems to warrant the serious consideration of this 
 question. \Vhether the mental sjrmptoms caused by the 
 chol^mia ever warrant it is a consideration to be set against 
 the mode of death after effective and continuous drainage 
 has been secured. I have dehberately advised that the 
 gall-bladder be opened in the former class with a view to 
 drainage for the rehef of the itchiness, and the restless 
 irritability the patients experienced. In some cases the 
 operation was delayed too long owing to the patients 
 
JAUNDICE 247 
 
 declining at first to risk an operation which they were 
 informed would at the best be only palliative. Ultimately 
 their discomfort became so great that they desired to have 
 the operation performed. Another patient was operated on 
 at my suggestion in the hope that the cause of the jaundice 
 was removable, but at the operation it was found to be due 
 to malignant disease. The gall-bladder was, however, 
 attached to the surface incision so as to allow free external 
 drainage for the bile. She made an excellent recovery from 
 the operation, the jaundice cleared away, and she was 
 delivered from the distressing itchiness and general sense of 
 discomfort she had experienced from the jaundice. A case 
 of the second type was a woman, aged 55, who was admitted 
 to my ward on 27th September, 191 8, suffering from 
 jaundice which had lasted for three to four months. The 
 duration practically negatived its being due to duodenal 
 catarrh. There was no history of gall-stone cohc. There 
 was no elevation of temperature, so cholecystitis and cho- 
 langitis were excluded. The head of the pancreas was felt 
 indefinitely and it was tender. There was thus no reasonable 
 escape from a diagnosis of cancer of the head of that organ 
 pressing upon the common duct. The patient very much 
 resented the soporific and apathetic state into which she was 
 slowly but definitely slipping ; she was anxious to be reheved 
 and quite wilUng to be operated on. She was transferred 
 to my colleague, Mr. Miles, on the 19th October, and the 
 abdomen was opened on the 22nd ; the diagnosis was 
 confirmed, and an opening established between the gall- 
 bladder and the small intestine. She made an excellent 
 recovery, and was re-admitted to my ward on the 4th 
 November. She was entirely relieved from the cholaemic 
 symptoms, was greatly pleased with the result of the opera- 
 tion, and returned home on the 12th November. 
 
 The following is the record of the fiist patient who was 
 operated on for jaundice due to cancer of the head of the 
 pancreas at my instigation. The case was presented and 
 discussed at the Edinburgh Medico-Chirurgical Society, and 
 the following is reproduced from the Society's Transactions. 
 
248 THE LIVER 
 
 "Mrs. L. was admitted to Queensberry House Hospital, 
 as she had sustained an intracapsular fracture of the femur 
 which rendered her incapable of attending to herself in her 
 o^^^l house, as she had hitherto done. Her age on admission 
 was 85, and no measures by means of sphnts or extension 
 were taken with a view to bring about union of the broken 
 bone. In the course of some weeks she was lifted out of bed 
 to an easy chair for several hours almost daily, this being 
 beneficial to the general health and a preventive of back 
 irritation and bed-sores. Such was the life the patient 
 was leading in the early part of the year. She was rather a 
 short, plump woman, with a very contented and well- 
 balanced mind, not looking her age by fully fifteen years, 
 and with all her faculties intact and on the alert. Her 
 arteries were httle thickened ; in fact, they gave as httle 
 indication of her age as her general appearance and mental 
 faculties did. In April she suffered from shght dyspeptic 
 S5niiptoms, which were not thought much of until she began 
 to show a suspicion of jaundice, confirmed by finding bile 
 in the urine. The most careful physical examination of 
 the abdomen at this time revealed nothing abnormal, and 
 I hoped the bihary obstruction was due to duodenal catarrh. 
 This is the hope to which I usually give my adhesion in 
 such cases, although, as a matter of experience, I have not 
 found that jaundice from duodenal catarrh is usual in persons 
 over middle hfe. My experience has rather been that the 
 hope with which I first regard these cases has had to give 
 way before the development of evidence which puts the 
 diagnosis quite beyond the pale of doubt and of hope. In 
 young persons, and in younger adult life, on the other hand, 
 a diagnosis of catarrhal obstruction which has been carefuUy 
 made is usually correct. It soon became apparent that the 
 obstruction in this case was not to yield to the remedies 
 which are early successful when the cause is a duodenal 
 catarrh, and I watched very carefully for the first evidence 
 that might present itself which would throw distinct Hght 
 upon the cause of the obstruction. My attention was 
 necessarily most closely directed to the region of the pancreas. 
 
JAUNDICE 249 
 
 from the presumption that the cause would probably turn 
 out to be situated there. From time to time I therefore 
 carefully explored the abdomen in that region, and the 
 signs noted were the following : — The pulsation of the 
 abdominal aorta was, of course, evident and marked, but I 
 early noted that the pulsation appeared to become more 
 marked to palpation, as if the vessel had become larger at 
 that part, or as if there were something between the hand 
 and the vessel, and overlying it, and to which the pulsation 
 was communicated. This after a time could be fairly 
 satisfactorily resolved into an elongated structure mth a 
 somewhat firm or tough sense of resistance, which from its 
 position and shape was beUeved to be the pancreas. The 
 normal pancreas cannot, as a rule, be felt with any measure 
 of certainty, but when its consistence becomes increased 
 and its tissue hardened, it can be felt if the abdominal 
 parietes are not too tense or the abdominal wall not too laden 
 with fat. While the pancreas became thus palpable, the 
 absence of any palpable thickening above or to its right 
 made it improbable that either the pyloric outlet of the 
 stomach or the duodenum was the seat of material lesion. 
 That the pylorus was not affected was further rendered 
 probable by the absence of gastric dilatation, or any e\ddence 
 of marked derangement of gastric function. As time passed, 
 the right extremity of what was beUeved to be the pancreas 
 increased somewhat in size and at the same time in hardness, 
 forming quite a tumour-like body, which rendered it extremely 
 improbable that there was a mistake as to the structure 
 affected. As to the Uver, there was no greater enlargement 
 of it than could be explained by the obstruction to its biUar}' 
 outflow. No nodules or inequahties were felt on its surface. 
 The distended gall-bladder was felt as a pyriform elastic body, 
 not in its usual anatomical position, but in the axillary hne 
 immediately under the tenth rib at its most dependent 
 part. 
 
 "The jaundice had not existed long when the patient 
 began to complain somewhat bitterly of a general sense of 
 malaise and discomfort, and of aversion to food from a 
 
250 THE LIVER 
 
 persistent nausea. Owing to continuous discomfort, and 
 from the belief that the case was one of pure pancreatic 
 malignant disease, I represented to her the possibility of 
 having her symptoms alleviated and the jaundice removed 
 by means of an operation, while not holding out any expecta- 
 tion of complete and radical cure. She was hopeful that the 
 jaundice would pass off, and regarded her age— 85 years — 
 as too advanced to entertain the suggestion of operation, 
 and I made no further reference to it. Things went on thus 
 for some three months, the discomfort becoming greater, 
 the patient's strength necessarily progressively diminishing, 
 and emaciation slowly but steadily advancing. In fact, so 
 great was the general sense of discomfort, due to the deepen- 
 ing cholaemia, that she began to press me to have the opera- 
 tion undertaken. I was very loath to entertain the idea at 
 this stage, as her general condition had so deteriorated that 
 I doubted the possibility of the operation being moderately 
 or temporarily successful ; however, she was so anxious to 
 have it done, and both she and her friends were so willing 
 to run the risk which I quite plainly and clearly put before 
 them, that I asked my surgical colleague Mr. Cotterill if 
 he would be willing to give her what small chance there 
 was. 
 
 "Her admission to Mr. Cotterill's ward, on 25th September, 
 was necessarily followed by a reconsideration of the diagnosis, 
 and my position was that the case was one of primary 
 cancer of the head of the pancreas ; that there was an entire 
 absence of evidence that the stomach or liver was the seat 
 of further malignant disease ; that the tumour in the 
 axillary line was the gall-bladder, and not any other organ ; 
 that the disease appeared so confined to the head of the 
 pancreas that I did not think it had extended along the bile- 
 duct, so as to occlude the cystic duct ; that, therefore, to 
 tap the gall-bladder would effectively drain the retained 
 bile ; and that, if the operation could be performed with any 
 measure of surgical propriety, it might be risked. 
 
 "Unfortunately, after admission to the Infirmary various 
 untoward symptoms developed, which made the prospect 
 
JAUNDICE 251 
 
 of success still more doubtful ; and it was only after very 
 full deliberation, and with many misgivings, that the opera- 
 tion was performed. 
 
 " I need not dwell upon the care and manipulative skill 
 with which Mr. Cotterill did the operation. The steps of 
 and the method of operation in a case of this kind belong 
 entirely to the surgeon. Unfortunately, although not un- 
 expectedly, the patient only lived for thirty hours after 
 the operation, and it was at least doubtful if she would 
 have lived longer had she not been operated upon. At the 
 post-mortem examination the diagnosis was confirmed in 
 every detail, and the seat of operation showed that nothing 
 untoward had occurred there to hasten death. 
 
 " I would not have thought of submitting in some detail 
 a solitary case of unsuccessful operation upon the gall- 
 bladder, undertaken largely at my request, were it not 
 that it raises the important question whether this is an opera- 
 tion which we are to regard as legitimate merely as a paUi- 
 ative measure. The question might be regarded as being 
 answered in the negative, to judge from the meagreness 
 of the literature dealing mth it, at least so far as I have 
 been able to find. Operations upon the gall-bladder for 
 the removal of calcuh as a cause of jaundice or of colic have, 
 of course, been frequent in more recent years, and the 
 successes have firmly estabhshed the procedure as warrant- 
 able, and even necessary. Exploratory operations have 
 also been performed in cases which have been found to be 
 mahgnant ; but, as I have said, there is a dearth of records 
 of operations deliberately undertaken for the relief of the 
 jaundice caused by malignant obstruction. The point 
 is one on which it is desirable to form an opinion which can 
 be apphed in suitable cases, if, indeed, we are to grant the 
 operation to be at all a justifiable one. Personally, I am 
 decidedly disposed to favour it. I think an operation for 
 the rehef of the misery and discomfort of a deepening 
 cholcemia is as humane a procedure as tracheotomy in malig- 
 nant laryngeal disease, as gastrostomy for malignant 
 oesophageal stricture, or entered omy or enterostomy for 
 
252 THE LIVER 
 
 malignant intestinal obstruction ; and I do not see why we 
 should shrink more from the one than from the other. In 
 Mrs. L.'s case, had the operation been performed at the time 
 I recommended it, the patient's life might have been pro- 
 longed ; but, even if it had not materially lengthened life, it 
 would have made months of life more endurable, and have 
 saved her much of that languor, weariness, and nausea which 
 were a daily and hourly burden. The advisability of opera- 
 tion would, of course, depend partly upon the possibility of 
 making a diagnosis which could reasonably be regarded as 
 accurate and complete. If the obstruction to the bile- 
 duct were above the cystic duct, operative interference 
 would be ineffectual ; but with obstruction below that point, 
 draining the gall-bladder would remove the jaundice. A 
 distended gall-bladder would thus indicate and warrant 
 operation. 
 
 "Then there is the question as to the influence involve- 
 ment of the stomach should have upon the question, and I 
 should put it thus : If the gastric s3rmptoms are not only 
 prominent, but clearly attributable to gross involvement of 
 that organ, the removal of the jaundice would not give suffi- 
 cient relief to warrant the operation. If, on the other hand, 
 as was the case in my patient, the gastric symptoms appeared 
 to be due rather to the jaundice than to coarse lesion, the 
 relief of the jaundice would be followed by gastiic relief. 
 The presence of duodenal lesion would not contra-indicate 
 operation. Even clear involvement of the liver would not 
 necessarily be a contra-indication so long as the distension 
 of the gall-bladder showed that the hepatic ducts were not 
 blocked. The most perfect cases for the operation would, 
 of course, be those in which, as in my case, the lesion was 
 confined to the head of the pancreas, and these are by no 
 means uncommon." 
 
 Hypertrophic or Biliary Cirrhosis of Liver 
 
 This condition also gives rise to jaundice. It is not a 
 common affection of the liver, and it is not dealt with here 
 
JAUNDICE 253 
 
 as it is fully discussed in the chapter devoted to the considera- 
 tion of the various forms of cirrhosis of that organ. 
 
 New-growths in the Liver or Outside it Pressing 
 UPON the Bile Duct 
 
 These two conditions as a cause of jaundice can be 
 considered together. As regards malignant disease in the 
 liver it must not be thought, as is not uncommon, that it 
 always causes jaundice. The majority of cases of cancer 
 of the hver never develop jaundice. When jaundice is 
 caused by cancer of the liver it always indicates that one of 
 the cancer masses is so situated as to compress the hepatic 
 ducts and when it does so it will be found to be on the under 
 surface of the Hver near the hilum. A growth, developing 
 outside the liver and growing in the same direction has 
 a hke effect. In both cases there is seldom any great 
 difficulty in determining by palpation that a tumour exists. 
 There may be some special expertness required to deter- 
 mine with precision the exact part from which the tumour 
 may be growing, but that is not really a question of great 
 practical moment. One point, hoM^ever, is of practical 
 importance, namely, that it is desirable to be sure that the 
 swelling is not a hydatid cyst or a collection of pus. Both 
 these are doubtless rare, but the possibiHty of their occur- 
 rence cannot altogether be ignored. The examination of 
 the blood will determine the one, and the wise but bold use 
 of the exploring needle may determine either. In jaundice 
 from any of these causes the common duct may not be 
 occluded, so that, while the bile does not enter the duodenum, 
 the pancreatic secretion may, leading to a corresponding 
 difference in the character of the stools. 
 
 Treatment. — ^There is nothing to do in mahgnant cases 
 save to alleviate symptoms as far as possible on general 
 principles. In the case of hydatids the aspirator can be 
 used to empty a cyst and even surgical interference may be 
 warranted. In the case of abscess it has to be treated on 
 general surgical principles. If there is any doubt as to 
 
254 THE LIVER 
 
 whether the tumour can be removed a laparotomy is 
 permissible. \Vlien everything points to the condition 
 being malignant, and this view is supported by expert 
 medical opinion, I think the advising of exploratory opera- 
 tion fatuous in the extreme. I have myself consented in 
 times past to such a proceeding when it was the assured 
 conviction of myself and two other experts that the causation 
 was malignant and inoperable, but the possibility of being 
 wrong is in reahty too shadowy to vv^arrant our subjecting 
 patients to a profitless ordeal. The curious stories told of 
 strange cases of abdominal new-growth which have disap- 
 peared after an exploratory laparotomy are too rare to be 
 allowed seriously to influence our opinion or our advice. 
 The contention that an exploratory abdominal operation 
 makes no difference to the progress of the case tends to 
 become a surgical proverb, and, Uke many proverbs, is at 
 least as false as it is true. Unless there is a reasonable 
 presumption that benefit is to follow, a surgical operation 
 is not to be approved. 
 
 New-growth in the Duodenum Involving the 
 Mouth of the Common Duct 
 
 New-growth in this position is rare ; when it is present 
 it is practically always malignant. The growth may be 
 very small, and yet cause jaundice by obstruction if it is 
 close to the duct or in it. Cases of this kind can hardly 
 be differentiated from catarrhal cases in their earlier stage. 
 If there has been no history of gastric or digestive 
 disturbance preceding the jaundice the condition may be 
 suspected ; and if there continues to be an absence of 
 enlargement or tenderness of the head of the pancreas the 
 suspicion becomes greater. The effect of treatment directed 
 to the removal of duodenal catarrh will materially influence 
 the ultimate opinion. Further, if the obstruction is not 
 maHgnant, the patient will not emaciate as rapidly as if it 
 were, and he will not show the early cachexia. 
 
 Treatment. — Neither medical nor surgical treatment is 
 of any avail in this condition. 
 
JAUNDICE 255 
 
 Animal Parasites which Directly ok Indirectly 
 LEAD TO Occlusion of the Common Duct 
 
 The parasites which may possibly lead to jaundice are 
 not numerous when hydatids are excluded as they are here. 
 Liver flukes, tapeworms, and round worms are practically 
 the possessors of this field. The diagnosis, or the suspicion 
 of the nature of such a case, depends upon the presence of 
 jaundice, and the discovery that it is associated with any of 
 these parasites. In fact, when these are found to be associ- 
 ated it is justifiable to assume that the parasite is the cause 
 of the jaundice. Many years ago, I saw a Catholic priest 
 who suffered from time to time from jaundice which was a 
 great annoyance to him ; and it was only by clearing out a 
 tapeworm, which he harboured, that he was freed from this 
 recurring trouble. Round worms are perhaps a more 
 common cause of jaundice, especially in children. A round 
 worm may even occlude the bile duct by getting into it ; 
 but more commonly the jaundice is the result of a duodenal 
 catarrh set up by the parasite's presence there. 
 
 Treatment. — The treatment is that applicable to the 
 removal of the parasite knovv^n to be present and the subse- 
 quent allaying of the local catarrh. 
 
 General Considerations 
 
 When the various causes of jaundice are thus reviewed 
 it is apparent that surgical interference is only of limited 
 utility. If differential diagnosis is neglected the field of 
 surgical operation enlarges indefinitely. One's object, how- 
 ever, all through this book is to indicate the lines along 
 which differential diagnosis may be attained. It often 
 appears to be more difficult than it really is from the want 
 of precision in knowledge as to possible or probable causes. 
 When the jaundice is due to new-growth no operative inter- 
 ference is curative for the simple reason that it is practically 
 always malignant and irremovable. The cases in which 
 surgical interference is called for are gall-stone, and cholan- 
 gitis or cystitis, whether calculus be present or not. In 
 
256 THE LIVER 
 
 these operation is to be strongly recommended, and in the 
 hands of an expert surgeon much confidence may be reposed 
 in its completely curative result. Occasionally cases occur 
 in which there is a legitimate doubt as to whether gall- 
 stone is the cause of obstruction, and whenever this exists 
 the patient ought to be given the benefit of the doubt and 
 have operation recommended. In these cases if there is no 
 cholangitis, and no stone is found, it will only too commonly 
 be found that malignant disease is the casual factor. Calcu- 
 lus and malignant disease may be both present, while only 
 the calculus or calculi give evidence of their presence. Here 
 also the doubt, if doubt there be, warrants operation. In 
 all cases of jaundice where the obstruction can be satisfac- 
 torily shown to be below the origin of the cystic duct it 
 becomes a question whether the patient is to be advised to 
 have the gall-bladder drained, simply with the yiew of re- 
 lieving the great discomfort which results from the intense 
 cholsemia which ultimately develops. Each case has to be 
 decided by considering its individual characters. The de- 
 cision may be left to the patient after a frank explanation 
 as to what may be expected from operation under the 
 circumstances. If the operation is successful much rehef is 
 obtained for a time at least, and success may be confidently 
 looked for if the operation is not delayed until the patient's 
 condition is too unfavourable, and the operation is performed 
 by an experienced and capable surgeon. 
 
 Gall-stone Colic without Jaundice 
 
 When the presence of gall-stone leads to jaundice it 
 does so in one or other of two ways ; the one way is by the 
 stone being arrested in the common duct, after having left 
 the gall-bladder and passed along the cystic duct ; the other 
 way is, while remaining in the gall-bladder or in the cystic 
 duct, by setting up cholecystitis and cholangitis. The 
 symptoms which accompan}^ jaundice, resulting directly 
 or indirectly from gall-stone, have been considered in a 
 previous section, and do not require repetition here. It may, 
 
COLIC WITHOUT JAUNDICE 257 
 
 however, be noted that when gall-stone has led to jaundice 
 the diagnosis that colic is or was hepatic in origin is 
 assumed. Gall-stone does not cause jaundice without a 
 concurrent or recent attack of colic. 
 
 On the other hand, gall-stone may cause intense pain 
 without a trace of jaundice, or a trace of bile being demon- 
 strable in the urine. 
 
 The pain of gall-stone colic is very severe, and may be 
 so excruciating that the patient rolls about in agony. As in 
 all conditions in which pain is a symptom, the pain of biliary 
 coUc varies greatly in its intensity. It may be severe enough 
 to cause death from exhaustion, or from its reflex action 
 on the heart, especially if the heart be feeble. I have 
 known this to occur in an old man who was seized with coUc 
 during the night and died before he could be relieved. 
 In that case the stone was found in the ampuUa of Vater, its 
 end projecting into the duodenum. Ihe pain, however, is 
 not always so severe, but great severity is its ordinary 
 characteristic. The pain usually comes on suddenly, and 
 is at once intense, although it may take some time to reach 
 its maximum. 
 
 The pain is referred to the epigastrium, to the region of 
 the gall-bladder, or of the umbihcus : it may go right round 
 the Uver region to the back, and extend upwards or down- 
 wards. The pain is mainly and chiefly referred to the 
 anterior, rather than to the lateral or posterior aspect of the 
 abdomen. The abdomen is not held quite rigid but moves 
 with the movement of the diaphragm. There is some 
 degree of surface hyperaesthesia, but it is not extreme. 
 Hyperaesthesia may, however, be present over the greater 
 part of the abdomen. Here, as in other abdominal condi- 
 tions associated with pain, surface hyperaesthesia can be 
 judged of by pinching the skin between the thumb and 
 forefinger. There is muscular rigidity, but neither is this 
 extreme. On palpation, if it be done gently, not too 
 precipitately, giving time for the surface hyperaesthesia to 
 lessen, it will be found that there is deeply seated tenderness 
 along the hver edge and particularly over the gall-bladder. 
 
 17 
 
258 THE LIVER 
 
 The gall-bladder can sometimes be distinctly felt to be 
 enlarged, projecting to a variable extent beyond the Hver 
 edge, and more tender than any other part of the hver edge. 
 The pain is paroxysmal in character, that is, it is not 
 constant, it comes and goes, although in the intervals of 
 severe pain there may be some measure of dull aching 
 referred to the region of the gall-bladder. 
 
 The paroxysms of severe pain are presumably due to the 
 stone becoming impacted or fixed at the mouth of the cystic 
 duct in such a way as to obstruct the mouth of the duct 
 and so prevent the gall-bladder secretion escaping. The 
 secretion accumulates, and by distending the bladder 
 induces spasm contraction of its wall, this being the imme- 
 diate cause of the pain. The intermittent character of the 
 pain seems to indicate that it is caused by recurring spasm 
 of the muscular coat of the gall-bladder, and not by the 
 contact of the stone with a mucous surface which is probably 
 insensitive. The position of the stone blocking the mouth 
 of the cystic duct, while the irritated mucous membrane 
 is stimulated to hyper-secretion of mucus, almost certainly 
 causes painful spasm. This explanation is further sup- 
 ported by the fact that the presence of a stone in the 
 gall-bladder not only does not cause continuous pain, but 
 may never give rise to severe coHc. It is not very un- 
 common to find on post-mortem examination a gaU-bladder 
 containing several, or even many, calcuH, without any 
 record of attacks of coUc during a period of many years 
 before death. 
 
 An attack of colic is sometimes accompanied by an 
 abrupt rise of temperature of several degrees along with, 
 in some cases, a feehng of chilliness, or even of definite 
 rigor, and yet no jaundice develops. Pain itself is sufficient 
 to raise the temperature in some adults ; but it is a question 
 whether the pain alone, or its association with an inflam- 
 matory reaction of the mucous membrane and retained 
 secretion, is to be held responsible for the febrile disturbance. 
 Case 70 (Mrs. H.) illustrates this point. She had a 
 severe attack of pain on two successive nights, on each 
 
COLIC WITHOUT JAUNDICE 259 
 
 occasion accompanied by a sudden rise of temperature to 
 102° F., which as suddenly fell to normal when the pain 
 was relieved. AU evidence of inflammation subsided with 
 the disappearance of the pain, which no doubt also coincided 
 with the escape of the fluid contents of the gall-bladder by 
 way of the cystic duct. 
 
 In further confirmation of the correctness of the fore- 
 going explanation as to the immediate cause of the pain, 
 in the class of case under consideration, the case of a patient 
 sent to me by my colleague Mr. Cathcart may be mentioned. 
 The patient was a woman (Case 71, Mrs. A. D.) who had 
 been operated upon for gall-stones some time before. Several 
 months later she again developed symptoms similar to those 
 she had previously experienced. She was admitted to my 
 ward and I saw her during two or more attacks of pain of 
 great intensity. During the paroxysm of pain there was a 
 localized bulging, about the size of a plum, in the position 
 of the gall-bladder ; it was intensely tender. With the 
 disappearance of the pain this bulging disappeared also. 
 As, at the operation, the gall-bladder had been attached to 
 the abdominal wall there could be no doubt that the attacks 
 were attacks of hepatic colic and that the bulging was due 
 to distension of the adherent gall-bladder. Mr. Cathcart 
 again operated, opened the gall-bladder and removed the 
 stone which was causing the trouble. It would hardly be 
 possible to have a more definite proof and demonstration 
 of the true meaning of the pain in these cases. 
 
 Recurring Gall-stone Colic without Jaundice : One 
 Large Stone Removed : Recovery 
 
 Case 72. — Mrs. McB., aged 35, was admitted at the re- 
 quest of Dr. Badger, Penicuik, to the Royal Infirmary on 
 the 7th October, 1909. She had consulted me in the previous 
 July, on account of pain she had had in the abdomen. She 
 also spoke of " a lump " she had felt in the abdomen which 
 was very painful when touched, and was situated at a spot 
 situated to the right of the middle fine and about two inches 
 
26o THE LIVER 
 
 below the costal margin. Later it was ascertained that the 
 pain referred to had come on suddenly whilst at work and was 
 so severe that she had to go to bed. Laudanum internally 
 and hot local apphcations relieved her in the course of twelve 
 hours. On examination of the abdomen nothing abnormal 
 was discovered either in connection with the Hver or the 
 kidney at that time. She gave a history of dysmenorrhoea. 
 Shortly after I had seen her she had a similar attack and she 
 had several subsequent attacks, and her doctor informed me 
 that he had several times felt the " tumour " in the upper 
 right section of the abdomen. The attacks of pain had been 
 very severe. On questioning her after admission she was verj^ 
 confident that the attacks of pain were associated with her 
 menstrual periods. She was a very intelligent woman and 
 in view of the fact that no enlargement of the gall-bladder 
 was detectable, and but very sHght tenderness could be 
 elicited on pressure over the gall-bladder, Mr. Bre-wds was 
 asked to make a thorough examination of the pelvic viscera, 
 which he did under chlorofonn and reported that there was 
 nothing abnormal in that region. She was kept in hospital 
 and allowed to be out of bed. On the 15th October she had 
 an attack of pain and the house physician felt a tender lump 
 in the region of the gall-bladder associated with some tense- 
 ness of the right rectus muscle. On the 24th pain again 
 came on in the region indicated, although not severe, and 
 there was tenseness of the rectus as befoire, and the gall- 
 bladder could be felt beyond the liver margin. It was 
 painful on pressure. The pain continued on the following 
 days. The pain was not nearly so severe as during the 
 previous attacks ; there was no elevation of temperature ; 
 there was no jaundice and no bile in the urine. A diagnosis 
 of gall-stone was made and arrangements were made with 
 Mr. Wallace that she should be operated on. The operation 
 was performed on the 29th October. The gall-bladder was 
 found to project about an inch beyond the liver edge, it had 
 formed adhesions to the liver and its wall was considerably 
 thickened. One large stone was found and removed. She 
 made an excellent recovery. The case was of interest from 
 
COLIC WITHOUT JAUNDICE 261 
 
 the misleading nature of the patient's confident assertion that 
 the attacks of pain preceded the menstrual periods. Mr. 
 Brewis' examination, and Dr. Badger's confidence that he 
 had felt a tumour which might be the gall-bladder, led us to 
 wait for the reappearance of symptoms, and, in Httle over a 
 fortnight from the date of admission, the diagnosis was 
 practically assured ; and there was no longer any doubt as 
 to the necessity of having the stone or stones removed. 
 
 Recurring Gall-stone Colic for Four Months : No 
 Jaundice : Operation Successful 
 
 Case 73. — Mrs. M., aged 32, was sent to my ward on the 
 29th January, 1917. She complained of attacks of abdominal 
 pain and vomiting which frequently recurred. These 
 symptoms might continue for a week, after which there 
 would be a period of rehef, perhaps for three weeks, during 
 which time she could attend to her domestic duties until 
 another attack came on. Taking food seemed to have no 
 influence in producing an attack or remo\dng it. An attack 
 might come on late at night or early in the morning. The 
 pain was felt in the epigastrium and right hypochondrium 
 and went through to the back. For the rehef of pain morphia 
 had been given hypodermicaUy. There was and had been no 
 jaundice. My colleague Mr. Miles operated on this patient 
 and removed five gall-stones. She, of course, made a good 
 recovery. 
 
 Acute Cholecystitis with Calculus : No Jaundice 
 Necrosis of Gall-Bladder : Operation : Recovery 
 
 Case 74. — Mrs. W. was seen in consultation on the 24th 
 October. On the 21st she got chiUed when waiting at a 
 railway station and arrived home feehng pain in the right 
 hypochondrium and sick. Morphine reheved the pain and 
 made her feel well enough to go to church the following day. 
 On Monday pain returned and continued aU day and there 
 was vomiting. I saw her the following day and got the 
 
262 THE LIVER 
 
 preceding histor}^ There was no history of any previous 
 attack of the kind. There was no jaundice and no bile in the 
 urine. The abdomen was not tender all over. There was 
 no tenderness on deep palpation over the caecum. There 
 was pronounced tenderness under the hver edge where the 
 gall-bladder seemed to be felt. The temperature ranged 
 between ioo° and 102° F. The tongue showed a slight white 
 fur, and a dose of calomel had been given. My diagnosis was 
 cholecystitis \^ith gall-stone. The treatment suggested was 
 the administration of morphine and atropine to relieve pain, 
 hot appHcations to the hypochondrium, and the evacuation 
 of the colon by means of enemata. Operation seemed to be 
 inevitable, so Professor Caird's assistance was requested. 
 We agreed to postponement, but by the 27th it was clear 
 that operation was imperative for there was no abatement 
 in the cystitis and the pain continued. On opening the 
 abdomen the greater part of the anterior wall of the gall- 
 bladder appeared necrosed and almost sloughing. After 
 protecting surrounding parts the gall-bladder was opened and 
 twelve or more calcuh removed. The gall-bladder was cut 
 away. The prognosis, owing to the state of the gall-bladder, 
 was grave, but the patient made a perfect and a speedy 
 recovery. The case illustrates the fact that a cholecystitis 
 may not extend to the ducts, even when the inflammation is 
 so acute and so virulent as to lead to sloughing. It is the 
 only case of such severe cholecystitis the writer has seen. 
 
 Gall-stone Colic : No Jaundice : Stone Removed from 
 Bile Duct : Recovery 
 
 Case 75. — Mr. S. was sent from the South of Scotland 
 into a nursing home for observation. He had suffered 
 intermittently for months from severe attacks of abdomnial 
 pain, but as jaundice had never appeared there was the not 
 unusual hesitation in determining the cause of the pain. 
 Examination of the abdomen showed no stomach dilatation, 
 no epigastric tenderness at any point, no tenderness on 
 careful and deep manipulation of the caecal region, and no 
 
COLIC WITHOUT JAUNDICE 263 
 
 renal-region tenderness. There was no history of digestive 
 stomach disturbance ; the pain was referred to the hepatic 
 region, it was paroxysmal in character, coming on suddenly, 
 and of great intensity. There was no doubt that the attacks 
 were attacks of severe biliary colic. During a short stay in 
 the nursing home there was no attack and he returned to 
 his own home. I suggested to his doctor that the attacks, if 
 theyreturned, ought to be treated with morphine and atropine 
 for the relief of pain and spasm and that the stone might 
 pass. Some weeks later he was sent back to me as the 
 attacks of pain continued although no jaundice had developed. 
 There was still no objective phenomena save that some days 
 there was bile in the fseces, other days there was none. Mr. 
 Stuart, one of my junior surgical colleagues, saw the patient 
 at his own house, for the patient was able to walk there. 
 Mr. Stuart hesitated about the diagnosis, but a severe attack 
 of pain in his presence removed doubt. On the following 
 day the operation revealed a stone in the ductus choledochus. 
 It was removed with great skill, if a physician may be allowed 
 to form a judgment on the manipulative skill of a surgeon 
 faced by an operation that appeals to him as requiring great 
 care and nicety. The patient made an uninterrupted and 
 speedy recovery. 
 
 Remarks. — ^The entire absence of jaundice in this case was 
 explained by the bile, accumulated and retained behind the 
 stone, from time to time getting past the obstruction ; this 
 also explained the presence and the absence of bile from the 
 faeces. It was also notable that a stone of such a size 
 should have travelled so far without setting up cholecystitis 
 or cholangitis. It very strikingly illustrated what I have 
 laid so much emphasis on, namely, that bihary colic must 
 be diagnosed quite apart from jaundice. That jaundice is a 
 necessary accompaniment of, or sequel to, gall-stone colic 
 has to be given up in practical medicine. It also illustrated 
 the fact that a large stone may pass along the large bile ducts. 
 Reference has elsewhere been made to the case of an old 
 man who died in an attack of gall-stone colic, in whom, at the 
 post-mortem examination, the stone was found in the ampulla 
 
264 THE LIVER 
 
 of Vater, its end projecting into the duodenum. The stone 
 was about the size and shape of a date stone. In that case 
 there was no history of severe abdominal pain until the 
 paroxysm which killed him came on ; but he was an old man 
 who spent most of the time in bed. In this other case the 
 patient had no attack of pain when in bed in the nursing 
 home, but walking to seethe surgeon determined an opportune 
 attack in the surgeon's consulting-room. 
 
 AU this it is necessary to reahze, for it shows that pre- 
 cipitate surgical interposition, as soon as the diagnosis is 
 reached of bihary cohc, is not necessary. The history is 
 really the factor which ought to determine whether the time 
 for surgical assistance has or has not arrived. The case of a 
 lady whom I saw when writing the foregoing further illustrates 
 this point. 
 
 Case 76. — I was asked to see a lady about 60 years of age 
 who was in a nursing home. Her doctor, Dr. W. Elder, in- 
 formed me that she had her first attack of gaU-stone coUc 
 three years before. Until a week before I saw her she had been 
 entirely free of pain for two years, but for a week she had 
 suffered from severe pain, which had been controlled by the 
 administration of morphine. She had not been jaundiced. 
 She was sent into the nursing home with a view to operation. 
 When I saw her she had been free from pain for two or three 
 days. There was no abdominal pain and not the slightest 
 tenderness along the Hver edge or in any part of the abdomen. 
 The patient was highly intelligent, and when, going into the 
 history minutely, it was suggested to her that a stone often 
 passed, she promptly said that her feehng had been as if 
 something were passing and that she felt as if it had passed, 
 the rehef of pain was so instantaneous. This is a fairly 
 common experience, and the teaching of such cases is that a 
 stone passes, that another may form after a long interval and 
 it also may pass. I can look back upon cases free for many 
 years from biliary coHc after a single severe attack. In some 
 cases the stone is found in the faeces, but sufficient care in the 
 search for it cannot always be ensured. In the case at 
 present being considered 1 entirely agreed with Professor 
 
COLIC WITHOUT JAUNDICE 265 
 
 Caird that aU thought of operation had to be postponed. 
 The indication in cases of this description, is to use the 
 measures which are available to prevent the formation of 
 calculi. 
 
 The following case is added because the configuration of 
 the abdomen and the unusually low position of the gall- 
 bladder gave rise to doubt as to the nature of the lump which 
 was felt. 
 
 Case 77. — J. M., aged 59, was sent to the Infirmary in 
 December, 191 8. Five days before admission he was seized 
 with sudden and severe pain in the abdomen, which he located 
 between the anterior spine of the ihum on the right side and 
 the umbiHcus. The pain 
 lasted all night. WTien 
 his medical attendant 
 examined him he found 
 a " lump " in the posi- 
 tion indicated, and ad- 
 vised him to go to the 
 Infirmary. On inquiring 
 into the patient's his- 
 tory it was ascertained 
 that six years before he Fig. 34.— Case 77. G.B., gall-bladder; U, 
 
 had had an attack of |iS™-J: ^M^^^StKar^Tn: '■"- 
 pain in the abdomen, 
 
 which lasted only a short time, and the cause of which was 
 not clear. Three years and four years later he had similar 
 attacks of pain which lasted longer. He was a big, powerful, 
 well-nourished man. On examination of the abdomen the 
 " lump " was easily felt. It was not tender, and it moved 
 with respiration. The position of it is shown in Fig. 
 34. The figure is reduced from the tracing taken at the 
 time of examination, and taken in the manner described in 
 an earher chapter. At first it was not apparent that the 
 lump was connected with the Hver ; it was clearly not 
 connected with the caecum, and it was not a displaced kidney. 
 It was quite superficial. The possibihty of its being a 
 neoplasm in the great omentum suggested itself, while 
 
266 THE LIVER 
 
 the attack of pain could be attributed to a temporary twisting 
 of the pedicle of the neoplasm. Later it was decided that it 
 was connected with the liver and was therefore the gall- 
 bladder, and that the pain was due to calculus. That 
 operation was required in either case was not questioned. 
 Mr. Miles opened the abdomen and removed a large stone 
 from the gall-bladder. The patient made a good recovery. 
 
 Conclusions 
 
 The conclusions arrived at may be summarized as follows. 
 
 (i) The three most common causes of jaundice are : 
 {a) duodenal catarrh ; {b) gall-stone, either directly 
 or indirectly by setting up cholangitis, which may 
 be due to gall-stone injury to the ducts, or to exten- 
 sion from a cholecystitis set up by a retained stone ; 
 and (c) cancer of the head of the pancreas. 
 
 (2) The diagnosis of gall-stone coHc has frequently to be 
 
 made without the presence of jaundice ; and it is 
 usually easy to distinguish it from pain due to other 
 causes. 
 
 (3) Cholecystitis and cholangitis are preceded or 
 
 accompanied by gall-stone colic, and the tempera- 
 ture is raised. If there is no jaundice the in- 
 flammatorj^ action is confined to the gall-bladder, 
 and the stone or stones have riot left the gall- 
 bladder. 
 
 (4) Gall-stone may pass. 
 
 (5) If the stone or stones do not pass, and are causing 
 
 pain; or there is cholecystitis or cholangitis, 
 operation is necessary for removal of stone or for 
 drainage of the gall-bladder and the bile ducts. 
 
CHAPTER XXI 
 
 THE CIRRHOSES OF THE LIVER 
 
 The cirrhoses of the liver are commonly grouped in three 
 classes, namely, first, Laennec's atrophic cirrhosis — the 
 common cirrhosis producing the hob-nail Hver ; second, 
 Hanot's hypertrophic or bihary cirrhosis ; and, third, 
 syphihtic cirrhosis. These have synonyms based upon the 
 leading histological change they present ; thus the first is 
 polylobular cirrhosis, in virtue of the fibrous tissue surround- 
 ing several lobules ; the second is monolobular or biUary 
 cirrhosis, as the fibrous tissue surrounds individual lobules 
 and there is a seeming increase of bile ducts in the portal 
 spaces ; the third is pericellular or intralobular, because the 
 fibrous tissue appears simultaneously throughout individual 
 lobules and thus surrounds groups of liver cells. 
 
 On the clinical side it is commonly taught that these 
 have the following distinctive features : — Atrophic cirrhosis 
 shows diminution in the size of the organ as judged by 
 percussion ; a hard nodular edge or surface when within 
 reach of the palpating hand ; ascites, emaciation, and no or 
 but sUght jaundice, and this present only in the advanced 
 stage. Hypertrophic cirrhosis is characterized by enlarge- 
 ment of the organ as revealed by percussion ; a smooth 
 surface and edge revealed by palpation ; no ascites, marked 
 jaundice. Syphilitic cirrhosis may present the chnical 
 features of either of the preceding ; the liver may have a 
 lobulated surface from the development of fibrous strands 
 in it, and perihepatitis is common. 
 
 From the etiological standpoint the atrophic form is 
 usually attributed to the imbibition of alcohol which reaches 
 
 267 
 
26S THE LIVER 
 
 the Kver, and acts through the portal blood upon the fibrous 
 tissue of the portal spaces ; the hypertrophic is refen-ed to 
 
 influences acting from the bile ducts upon the surrounding 
 fibrous tissue, while the invoh'ement of the bile ducts is the 
 cause of the jaundice which is so prominent a feature in this 
 form. 
 
 Clinical and anatomical difficulties which have arisen in 
 connection ^^ith cirrhosis are to be attributed to the classical 
 descriptions given of the atrophic and hypertrophic forms 
 respectively. Speaking of Hanot's description of hyper- 
 trophic cirrhosis, Cheadle sa^^s (Lumleian Lectures, 1900, 
 On Some Cirrhoses of the Liver) : "It is surprising how a 
 definite observation of this kind, stated \rith authority, holds 
 swaj', and its general apphcation remains unquestioned, as 
 aU-comprehensive, -without further examination or inquiry." 
 This comment can ^\ith equal force be appUed to other 
 conditions and descriptions, and there is no doubt that the 
 first definitions of diseased processes may greatly hamper 
 the acceptance of later and more complete observations and 
 the inferences which foUow from them. Names become 
 associated 'S'sith definite clinical manifestations, and proposed 
 rearrangements are slowly accepted. Appl5ring this to the 
 matter at present under consideration, it appears to me that 
 the difficulties which have arisen centre round the term 
 '* h5-pertrophic " given by Hanot. The word is used to 
 designate an enlarged hver, in contradistinction to the 
 " atrophic " or smaU hver of Laennec. The two t^^es of 
 cirrhosis thus defined became fixed ; but, as experience has 
 viidened and investigations have multipHed, it has become 
 increasingly apparent that the terms atrophic and hyper- 
 trophic do not necessarily carry \^ith them either the chnical 
 manifestations or the histological characters which authority 
 associated with them. This divergence from the t\-pe as 
 originaU}- fixed is most marked in the enlarged or " h^T)er- 
 trophic ' ' form. A hver may be enlarged, and therefore 
 clinically, although strictty speaking inacciurately, be termed 
 " h3-pertrophic, " and this hj-pertrophic form may not 
 show jaundice, may be coarsely nodulated, may have 
 
CIRRHOSES OF THE LIVER 269 
 
 ascites, may not show an increase of bile canaliculi, and the 
 fibrous tissue may have a polylobular distribution. This 
 perturbs the equilibrium of both the cUnician and patho- 
 logist, and it does so because it is authoritatively taught that 
 an enlarged cirrhotic liver ought not to be a coarse polylobular 
 cirrhosis and ought to cause jaundice. Again, a liver is 
 met with which is small and atrophic, but the fibrous tissue 
 may be diffusely increased and mainly monolobular in 
 distribution, so that it is a finely granular instead of a coarsely 
 granular organ, and there may be a marked richness of bile 
 canalicuh in the fibrous tissue, yet there is no jaundice, and 
 there is ascites. Here, then, is an atrophic fiver with the 
 minute structure of a hypertrophic one, and the confusion 
 seems to become hopeless. 
 
 It has been shown by the published observations of various 
 inquirers that a hypertrophic fiver may exist without the 
 cfinical phenomena or the histological characters associated 
 with it in Hanot's classical description. Murchison, Saimdby, 
 FoxweU and Cheadle have aU shown this to be the case, and 
 others have reached a similar conclusion. In fact, the evi- 
 dence is so strong that the matter is no longer open to 
 question. But while this change of view has become neces- 
 sary, it is to be noted that the change attaches itself to the 
 question of size as expressed in the term " hypertrophic." 
 The standpoint of mere size is often a very unrefiable one 
 in medicine, and, as we have pointed out, it is so when hepatic 
 cirrhoses are considered. If, however, the standpoint be 
 altered, the whole question assumes a different aspect. If 
 instead of size being the standard the existence of marked 
 jaundice be taken, we arrive at a distinction w^hich is more 
 important and has a more sound etiological significance. 
 The cirrhoses without jaundice are those which are commonly, 
 and probably correctly, referred to blood changes in the 
 portal circulation, but the resulting cirrhosis may lead to 
 a large or a small liver, to a coarse or a finely granular surface, 
 to fibrous tissue, rich or poor in bile canaficufi. On the other 
 hand, cirrhosis associated with marked jaundice is a true 
 biliary cirrhosis ; that is to say, it has its starting-point, not 
 
270 THE LIVER 
 
 in blood changes in the portal circulation, but in conditions 
 in the excretory ducts of the liver in some part of their course. 
 These changes interfere mth the removal of bile, not with its 
 formation : to produce jaundice in cirrhosis, bile has to be 
 formed and then absorbed into the circulation as such. 
 Here then it seems to me is a crucial and essential distinction 
 both from a clinical and a pathological standpoint. A saving 
 clause has to be added here, as in so many other conditions 
 where boundaries are laid down, and the reservation in 
 cirrhosis is that the common cirrhosis may interfere with 
 bile ducts so as to cause a measure of jaundice, but this is a 
 secondary complication and not the initial change. Cheadle 
 says that of fifty- three fatal cases of cirrhosis of all kinds at 
 St. Mary's, marked jaundice was only noted in eight, and in 
 only four of these was the liver small, while in four it was 
 large [loc. cit. p. 17). 
 
 The proposition that the confusion regarding cirrhosis is 
 removed by abandoning the ordinary clinical concept based 
 upon size, and substituting for it another factor, namely 
 jaundice, requires some further consideration. 
 
 Hanot and Charcot both recognized a large hver with 
 jaundice, the cause of which was obscure. In this large 
 liver the cirrhosis was monolobular, and there were many 
 bile ducts in the fibrous tissue. Charcot and Gombault 
 further recognized a cirrhosis with jaundice due to obstruc- 
 tion to the outflow of bile and with the macroscopic and 
 microscopic characters of Hanot's hypertrophic biliary 
 form. Numerous experimental investigations have been 
 undertaken with a view to determine the effect of occlusion 
 by Hgature of the main bile duct. Wickham Legg {St. 
 Bartholomew's Hospital Reports, vol. ix. 1873) in this country, 
 Charcot in France [Arch, de Physiologie, 1876), Maffucci 
 of Naples in 1882, and more recently Vaughan Harley 
 {Brit. Med. Jour. 1898, vol. ii.), have all done so, and the 
 result has been to show that occlusion leads to enlargement 
 of the hver, jaundice, and a cirrhosis which is monolobular 
 in distribution and more or less rich in bile canalicuU. 
 Nicoti and Richard {Arch, de Physiologie, 1880) have 
 
CIRRHOSES OF THE LIVER 271 
 
 described an analogous condition in the liver of dogs due 
 to parasites obstructing the hepatic ducts. 
 
 From the clinical side Wickham Legg {Trans. Path. Soc. 
 Lond. 1874) , Charcot and others have shown that obstruction 
 to the bile outflow in man leads to corresponding Uver 
 changes. The former has also shown that in congenital 
 imperviousness of the common duct a Hke result is produced. 
 Ford of Montreal has recently {American Jour. Med. Sciences, 
 January, 1901) written an excellent resume on Obstructive 
 Biliary Cirrhosis, in which he records the results of a detailed 
 examination of three cases which occurred in that city, and 
 in which he confirms the observations made by the authors 
 already referred to. One of the points upon which he dwells 
 is that the so-called increase of bile ducts in the fibrous 
 tissue is not of that nature, but that the appearances which 
 have been so interpreted are caused by the fibrous tissue 
 surrounding groups and rows of cells which become altered 
 in appearance and thus give a false resemblance to bile 
 ducts. He on this point agrees with Findlay {Brit. Med. 
 Jour. 1900, vol. i.) and others. Ford's observations entirely 
 agree with my own, and I fully concur with him as to the 
 mode of formation of many of the so-called bile ducts. It 
 may, however, be that the appearance is in part due to the 
 persistence of rows of cells which contain a bile ductule, 
 while the cells not containing a ductule perish by compression. 
 This is practically what Cheadle refers to as the " exposure 
 of existing ones (ductules) by denudation through the 
 destruction of hepatic cells " {loc. cit. p. 8). The theory of 
 proliferation of bile ducts as a compensatory process to 
 obstruction has always seemed to me to be quite unreason- 
 able, and as having no analogy in any other organ. What- 
 ever view be held, it is, however, certain that the appearance 
 in question is not confined to cases in which there is obstruc- 
 tion to bile outflow. 
 
 From the foregoing it must be accepted that the changes 
 which result from obstruction to the outflow of bile are, as 
 Ford, and others before him, have pointed out, similar 
 and indistinguishable from those described in Hanot's 
 
272 . THE LIVER 
 
 h\'pertrophic biliary cirrhosis. Cheadle, strangely enough, 
 says " that in the majority of cases of obstructive jaundice, 
 even when prolonged, no cirrhosis follows " [loc. cit. p. 34). 
 My own experience is in opposition to Cheadle and in accord 
 witla. Ford. 
 
 This point being estabhshed, the question is suggested : 
 Is Hanot's h}"pertrophic biharj^ cirrhosis a clinical and patho- 
 logical entity apart from obstructive biliary cirrhosis ? It 
 is difl&cult to arrive at a perfectly satisfactory answer to this 
 question. Cheadle and others consider that it must be a 
 very exceptional condition, judging from their own 
 experience. This, I think, will be found to be the common 
 experience in Britain. The idea is that the true Hanot's 
 cirrhosis is a primary and probably infective inflammation 
 of the bile ducts. The acceptance of this view allows the 
 changes in the hver to be interpreted as due to obstruction, 
 but indicates piimar}' duct inflammation as the cause of the 
 obstruction. This, again, raises the question as to the 
 determining cause of the duct inflammation. There is 
 evidence to show that the passage of a calculus, which has 
 escaped into the duodenum, may leave behind an infective 
 inflanamation of the ducts which can cause a catarrhal block 
 of them o^^ing to the low pressure at which the bile flows. 
 I have seen a case where the draining of an inflamed gall- 
 bladder, where no stone was found either in it or in the 
 ducts, led to the recovery of the patient and the removal of 
 the jaundice, the jaundice ha^dng apparently been caused by 
 an inflammatory occlusion of the hepatic ducts, which was 
 cured by drainage of the inflamed gaU-bladder, this drain- 
 age draining the ducts also. From facts of this kind the 
 question ma}- be asked if Hanot's pure t3-pe is at all deserving 
 of a special clinical position, and if it is not possible that 
 most of the cases so classed were set up by a primar}^ coarse 
 lesion to a duct by the passage of a stone. At the same time, 
 the possibihty of a true primary infective choleangitis 
 cannot be entirely put aside as never occurring, especially 
 in \dew of the fact that the occurrence of a true primary 
 infective cholecystitis is, I take it, now clearly estabhshed. 
 
CIRRHOSES OF THE LIVER 273 
 
 If the foregoing argument is based on well-established 
 facts, which I believe it is, the questions surrounding liver 
 cirrhosis would be resolved as follows : — 
 
 The primary and most important phenomenon would be 
 the presence of, or the time of the development of, jaundice. 
 If there were no jaundice, or if it supervened as a late 
 symptom, the Hver might be large or small, and the terms 
 " hypertrophic " and " atrophic " may be applied as hither- 
 to. It ought, however, to be clearly understood that these 
 terms signify nothing more than size. 
 
 If, on the other hand, jaundice be an early and a marked 
 feature, and the liver be enlarged, then Hanot's term, 
 " hypertrophic biliary cirrhosis," ought to be applied to the 
 condition. This, according to the preceding argument, 
 is true biliary cirrhosis, and usually presents itself as a clinical 
 entity with early jaundice, enlargement, and no ascites ; 
 and as a pathological entity characterized by enlargement, 
 bile coloration, a finely granular surface, a monolobular 
 cirrhosis, and an increase of so-called bile ducts in the portal 
 spaces. This " biliary cirrhosis "is, I think, always " hyper- 
 trophic," meaning thereby enlargement. The condition 
 to which we would thus confine Hanot's term is, as we have 
 seen, identical in its cHnical and anatomical characters with 
 " obstructive biliary cirrhosis," as produced experimentally 
 in animals and as found not infrequently in man. It has 
 indeed been further shown in this connection that in the small 
 number of cases in which a cause for the jaundice had not 
 been determined that it was almost certainly due to blockage 
 of the bile ducts from a primary and initial inflammation 
 of them, or secondary to an antecedent and perhaps over- 
 looked history, indicating the passage of a gall-stone. The 
 infective nature of some cases of the typical Hanot's hj^er- 
 trophic biliary cirrhosis has been investigated recently by 
 N. N. Kirckow {St. Petersburger Med. Woch., No. 38, 1900) 
 and others, but the bacteriology of the condition cannot at 
 present be gone into. 
 
 All this, however, leads to a matter of very great practical 
 interest, and that is the clinical significance of the " atrophic " 
 
 18 
 
274 THE LIVER 
 
 and " hypertrophic " cirrhosis, as I have defined them, and 
 which are not associated with early and marked jaundice ; 
 or, in other words, the significance of cirrhosis with the 
 liver enlarged in one case and diminished in size in another. 
 The latest utterance on this question, so far as I know, is 
 to be found in Dr. Cheadle's Lumleian Lectures, to which 
 reference has already been repeatedly made. The outcome 
 of his experience is to show that if enlargement is due to 
 syphilis it can be treated with marked success ; further, 
 that cirrhosis with enlargement, even when unmistakably 
 alcoholic in origin, yields more satisfactory results from 
 repeated tappings and other approprate measures than 
 cirrhosis with atrophy. He holds that the enlarged liver 
 indicates a more acute cirrhosis, and that it is in virtue of 
 this fact that treatment is more successful than in the chronic 
 atrophic form. This gives a practical and a therapeutic 
 differential importance to the " atrophic " and the " hj^er- 
 trophic " cirrhosis if the term " hypertrophic " is to be 
 accepted as having this restricted application. 
 
 I have not dealt in detail with syphilitic cirrhosis, for it 
 does not occur as a diffuse condition in the adult. Hepatic 
 sj^mptoms due to syphilis are the outcome of gumma, the 
 cicatrices they leave, and of perihepatitis and the adhesions 
 and contractions caused thereby. 
 
 Clinical Manifestations o! Atrophic Cirrhosis.— The fore- 
 going discussion on the types of cirrhosis of the hver was 
 written a number of years ago, but it holds equally good for 
 the present. It is only necessary to amphfy somewhat the 
 clinical side of the commonest, namely, the atrophic form. 
 \Vhile this form is usually the result of the free use of alcohol, 
 cases are seen in which not only no history of alcohohsm can 
 be obtained, but the evidence is opposed to this as the cause 
 of the change. When alcoholism is the cause the earher 
 symptoms are not the early symptoms of cirrhosis but of 
 digestive disturbance due to the imbibition of alcohol. 
 The presence of gastric and other symptoms from this cause 
 ought to lead to very strong representations being made by 
 the medical attendant as to the absolute necessity of a change 
 
CIRRHOSES OF THE LIVER 275 
 
 of habit, if liver atrophy is to be prevented. WTien cirrhosis 
 is not alcohoHc it does not seem to be preceded by pro- 
 nounced symptoms of digestive disturbance. In hospital 
 practice cases of atrophic cirrhosis are not seen, usually, 
 until there is some fluid in the abdominal cavity, indeed the 
 amount of fluid may be great. Before fluid is poured out 
 cirrhosis has been already established, and the size of the 
 liver diminished. The diminution in size is, however, not 
 satisfactorily determined by percussion, unless it is pro- 
 nounced. The reason of this is the variable size of the 
 organ, and the variety of type of abdomen. The presence 
 of fluid, on the other hand, is of outstanding significance. 
 On the subject of ascites it is necessary to be somewhat 
 critical, as some of the teaching which has been handed down 
 from the past is not correct. The most pronounced cases 
 may be taken first. In these the abdomen is much dis- 
 tended and bulged anteriorly and laterally ; percussion 
 is dull from the flanks upwards, as far as the fluid has 
 risen, and also in the hypogastrium. A fluid wave can be 
 produced and felt wherever the fluid is ; and even from one 
 side of the abdomen to the other, by placing the hand over 
 one flank while the other flank is tapped by a finger of the 
 other hand. The level of the fluid changes with change of 
 position ; if the patient turns from the dorsal position to 
 one side, the fluid gravitates to that side, and the dullness on 
 percussion rises to a level nearer to the level of the umbilicus. 
 This time-honoured procedure is not necessary, however, and 
 is often inconvenient. The fluid wave is absolute evidence 
 of the existence of ascites. In small amounts of fluid the 
 wave cannot be produced across the abdomen ; but it is 
 easily produced when one hand rests on the surface of the 
 iliac region while the finger of the other hand taps the 
 abdomen above that. When fluid is present the wave 
 can be obtained from above downwards and from below 
 upwards. 
 
 There is frequently quite unnecessary hesitancy in diag- 
 nosing fluid, when the fluid \\-ave cannot be obtained across 
 the abdomen. The presence of a small quantity of fluid is 
 
276 THE LIVER 
 
 readily diagnosed after a little experience of the above 
 method of examining for its presence. 
 
 When an abdomen is distended, the distension is due 
 either to gas or air in the intestines, to fluid in the peritoneal 
 cavity, or to neoplasm. Neoplasm can be felt as a hard 
 mass. Fluid can be distinguished from gas and its presence 
 put beyond doubt by the method described. The importance 
 of being quite sure that an abdomen contains fluid, or does 
 not, is this, that if fluid be present we are then in a position 
 to consider the local causes which lead to fluid being poured 
 out here and nowhere else, that is to say the production of a 
 pure ascites, not ascites merely part of an anasarca from 
 heart or kidney disease. A pure ascites is a local condition 
 and has therefore a local cause. The diseases in which 
 ascites occurs may for ordinary clinical purposes be Umited 
 to three ; {a) tuberculosis of the peritoneum, [h) diffuse 
 malignant disease of the peritoneum, and (c) atrophic cir- 
 rhosis of the Uver. If the two first can be excluded there is 
 only cirrhosis to consider and one has practically reached the 
 position that ascites is due to cirrhosis, unless history and 
 symptoms point to malignancy or tuberculosis. 
 
CHAPTER XXII 
 
 MALIGNANT DISEASE OF LIVER 
 
 The liver is frequently the seat of malignant neoplasm. 
 The new-growth may be primary or secondary. Secondary 
 growths are more frequently seen than primary ; but this 
 fact must not be allowed to hamper or hinder diagnosis. 
 
 Secondary growth may be a metastasis from almost any 
 organ ; but most commonly the primary growth is in the 
 abdomen. Not infrequently a diagnosis of malignant 
 disease has been arrived at before there is any evidence of 
 the liver being involved. The primary growth is often in 
 the stomach, but it may be in any part of the intestine where 
 m^alignancy occurs. When malignancy has been diagnosed 
 elsewhere than in the Uver involvement of the liver may 
 determine whether or no surgical interposition is to be useful 
 or helpful. In, for instance, malignant disease of the body 
 of the stomach with secondary involvement of the liver no 
 useful purpose could be served by operation. In the case, 
 however, of malignancy at the pylorus with consequent 
 obstruction a gastro-enterostomy would give relief and 
 prolong hfe even in the case of involvement of the Hver. 
 
 When malignant disease has been diagnosed in some 
 other viscus than the Uver, signs of hver involvement may 
 or may not be present, but the absence of signs is no proof 
 that the hver is free. The reason of this is that many 
 nodules of new-growth may be present without appreciable 
 enlargement of the organ. And further, the nodules of new- 
 growth must be on the surface of the organ to render them 
 palpable, and they are by no means always so situated. It 
 follows that involvement of the hver can only be diagnosed 
 
 277 
 
278 THE LIVER 
 
 by enlargement, or b}^ nodules on the surface large enough 
 to produce palpable projections. 
 
 ^"\^len, on the other hand, malignant neoplasm is primary 
 in this organ the diagnosis does not follow quite such simple 
 Hnes, and it is this form which requires fuller considera- 
 tion. The onset of mahgnant growth does not seem to be 
 heralded bj- an}- definite s3Tnptoms. Its advance soon, 
 however, begins to produce an unwonted sense of weakness, 
 interpreted as being " run down," " out of condition," 
 " over-worked," as " needing a rest." The appetite may 
 have failed. There maj' be a complaint of " getting thin- 
 ner." The skilled eye may detect a suggestion of cachexia. 
 There is no stomach sjTnptom beyond the impairment of 
 appetite. There are no intestinal or rectal symptoms ; 
 none referable to thoracic structures ; none to the bladder. 
 If this has been the history for weeks, perhaps for two months 
 or longer, there are usually signs to be found on examination 
 of the abdomen. The Hver or part of it is palpable. It is 
 most important to realize this distinction, for enlargement 
 may be confined to the left lobe, or it may aAect only the 
 portion of the right lobe in contact ^ith the parietes. In 
 some cases, though rarely, the whole organ is enlarged. 
 With enlargement of any part there is nearly always a loss 
 of surface smoothness over the area affected. The degree 
 of this varies considerably^, and is determined by the number 
 and the rate of growth of individual nodules. Sometimes 
 there are numerous small nodules giving the affected portion 
 the feeling of a coarse cirrhosis, at other times the masses 
 are larger, or there maj^ appear to be only one great lump. 
 The growth may be on either side of the suspensory ligament 
 when the enlargement is found to be in the epigastrium and 
 the surface is uneven. As a rule there is no tenderness on 
 palpation. The involvement of only part of the liver may 
 lead to difficult}' in diagnosis. I have seen the left lobe so 
 much enlarged, distorted in shape, and reaching so far down 
 in the abdomen that it was difficult to persuade one's self 
 that it was liver and not something else. In the right 
 lobe a mass may be so situated as to raise the question 
 
MALIGNANT DISEASE OF LIVER 279 
 
 whether it is Hver or kidney. This point in diagnosis is 
 dealt with in a later chapter, in which kidney conditions on 
 the right side are discussed. With such phenomena and a 
 history of progressing debility there is practically no doubt 
 as to the diagnosis. 
 
 In making a diagnosis the only other conditions which 
 ought to be kept in mind are two in number. The first 
 of these is the presence of a gumma on the surface of the 
 liver giving rise to a projection. Such a lesion causes pain 
 and is tender on palpation. In these respects it differs 
 from malignant disease. If there is any doubt the use of 
 mercurial ointment locally will remove the one and have no 
 effect upon the other. The second condition is stiU more 
 uncommon in this country, namely, a large hydatid cyst. 
 This may lead to a large projection on the surface of the 
 organ which is not painful or tender to touch and has not 
 produced any constitutional disturbance. Such localized 
 swelling is almost certainly a hydatid cyst. The absence 
 of aU constitutional disturbance not only excludes malig- 
 nancy but also abscess. A hydatid cyst showing on the 
 surface can be successfully dealt with by the surgeon. 
 
 It is thus seen that the diagnosis does not present diffi- 
 culties of outstanding significance. 
 
 The malignant neoplasm enlarges rapidly and is accom- 
 panied by progressive cachexia. In a few cases the enlarge- 
 ment is very rapid and very great. In a case of " chorion 
 epithelioma " under my care the enlargement ended in 
 rupture, the patient dying of haemorrhage into the abdominal 
 cavity. 
 
 There seems to be an idea fairly prevalent that malignant 
 disease of the hver causes jaundice. It seldom does so. 
 Jaundice only occurs if the neoplasm is situated on the 
 under surface of the organ and in such a position as to press 
 upon the bile duct in the hepatic fissure. \Vhen it is situated 
 thus it presses also upon the portal vein and causes ascites. 
 
Section VI.— THE SPLEEN 
 CHAPTER XXin 
 
 ENLARGEMENT : SPLENOMEGALY 
 
 The spleen is enlarged in many conditions, but the degree of 
 enlargement varies. In typhoid fever and in pernicious 
 anaemia there is enlargement, but never to any great size. In 
 both varieties of leukaemia, on the other hand, the organ may 
 attain a very large size ; in chronic malaria it may also 
 become greatly enlarged. In so-called splenic anaemia, or 
 Banti's disease, the increase is pronounced. With the excep- 
 tion of these three conditions there is no other condition 
 in which great enlargement occurs. Considerable enlarge- 
 ment used to be met with in waxy degeneration, but 
 such cases have become very rare, at least in the adult. 
 When the organ is enlarged the enlargement is made out 
 by percussion and in more pronounced cases by palpation 
 as well. The organ for which it is most readily, and 
 perhaps commonly, mistaken is the kidney ; or, to put 
 it more directly, an enlarged spleen is thought to be kidney 
 and vice versa. This mistake is illustrated in a later chapter, 
 and as this was being prepared for the press I saw a patient 
 with a great mass on the left side of the abdomen which 
 was believed to be spleen, although physical examination 
 was not conclusive. The mass extended up under the 
 ribs, it had a definite anterior edge with two indentations, 
 but the upper part was uneven and nodular. There was 
 progressive loss of weight, no rise of temperature, and a 
 progressive increase in size of the mass. There were no 
 urinary symptoms. On examination of the blood it was at 
 once shown that the patient was suffering from an acute 
 
 280 
 
ENLARGEMENT: SPLENOMEGALY 281 
 
 lymphatic leucocythaemia. Before the blood was examined 
 in this case the question arose as to what other pathological 
 condition produced a spleen of such immense size ? Mahgnant 
 disease is often a ready answer ; but the question then is : 
 Does malignant disease ever appear primarily in the spleen 
 and, if it does, can primary or secondary growth ever lead 
 to such enlargement ? The answer for all practical and 
 clinical purposes is in the negative. If on blood examination 
 this mass had been found not to be associated with leucocy- 
 thaemia or marked anaemia, it could not be spleen, in spite 
 of its resemblance to that organ, and if not spleen there was 
 no organ it could be but kidney, in a male patient. In a 
 female it might have been a vagrant ovarian tumour. In 
 this patient all these questions were settled by a blood 
 examination. The same error may also be made in the case 
 of a moderately enlarged spleen. A moderately enlarged 
 spleen gives an increase in the area of normal percussion 
 dullness, the area extending upwards and forwards ; the 
 lower pole projects from under the left costal margin, is 
 ovoid in shape, has a smooth surface, and moves with 
 respiration. It is not palpable bimanuaUy with one hand 
 in the loin as a kidney of the same degree of enlargement 
 would be palpable, and the lower pole is in contact with the 
 parietes as it comes from under the costal edge, as a kidney 
 at this stage of enlargement never is. 
 
 The differentiation from neoplasm at the splenic flexure 
 of the colon has to be reached in the first place by the simple 
 fact that malignant disease at this flexure probably never 
 produces a mass that has any resemblance to the lower pole 
 of a spleen, and in the second place by the history. IMalignant 
 disease at this flexure never attains palpable size without a 
 history of recurring attacks of obstruction, or of attacks of 
 arrest of colon evacuation overcome with great difficulty, 
 accompanied sometimes by vomiting. On examination 
 evidence will be found of faecal accumulation in the colon 
 behind the seat of obstruction. 
 
 When all these points are taken into consideration there 
 is really no reasonable difficulty in recognizing a moderately 
 
282 THE SPLEEN 
 
 enlarged spleen ; it is only when there is great enlargement 
 that there is difficulty in distinguishing between a kidney and 
 a spleen. The differential diagnosis under these conditions 
 is dealt with in the section devoted to the kidney. 
 
 On the left side the problem is really narrowed to a 
 j udgment between spleen and kidney ; and when the clinical 
 facts are considered alongside the pathological possibilities 
 the problem solves itself. Pathological fancies and imagin- 
 ings, however, often become barbed-wire barriers to clinical 
 progress. 
 
 It is not necessary to enlarge upon the recognition of 
 enlargement of the spleen in malaria. An increase in the 
 area of normal splenic dullness, and an intensification of the 
 dullness when a patient has malaria, is at once accepted as 
 splenic without question ; and if the lower pole of the organ 
 is felt projecting from under the costal margin it is taken as 
 a measure of the enlargement of the organ. There is in this 
 case no doubt entertained, and every student trained in 
 physical diagnosis is expected to be able to make the 
 observations necessary for forming a judgment. Cases of 
 malaria need not therefore be recorded here. The follow- 
 ing cases illustrate some of the points dealt with or 
 referred to. 
 
 Case 78. — A man, aged 50, had the abdomen opened for 
 a " tumour " in the region we are dealing with. It was 
 believed to be either an enlarged kidney or neoplasm at the 
 splenic flexure of the colon. Nothing was found on laparo- 
 tomy but an enlarged spleen. He was later sent to my ward 
 in the Royal Infirmary. On examination there was no 
 doubt about the presence of " the lump " ; and it presented 
 the characters of a spleen projecting a couple of inches 
 beyond the costal margin. There was no history of malaria. 
 Examination of the blood showed the usual picture of an 
 early spleno-medullary leukaemia with 29,400 white cells. 
 The patient was put into the hands of the electrical depart- 
 ment for X-ray treatment. In the course of five weeks the 
 organ retreated up under the costal margin and the area of 
 dullness became practically normal, the leucocyte count fell 
 
ENLARGEMENT: SPLENOMEGALY 283 
 
 to 4250, and there were no abnormal cells to be seen in the 
 blood. Two years later he was in perfect health. This 
 case from the therapeutic standpoint is, unfortunately, in my 
 experience unique, and the question which it suggested was 
 whether it was possible that opening the abdomen had been a 
 factor in bringing about the result which had followed on 
 X-ray treatment. This question was suggested by (i) the 
 fact that X-ray treatment is not usually successful, and (2) by 
 the knowledge of the benefit following upon opening the 
 abdomen in tuberculous disease of the peritoneum and in 
 some other ill-defined cases. 
 
 Case 79. — Mrs. T., aged 31, was sent in by her doctor as 
 a case of enlarged spleen, the patient being definitely ill. 
 The details of this case need not be given here. The patient 
 was the victim of a very acute lymphatic leucocythsemia. On 
 admission the blood examination showed the red cells to be 
 3,392,000 and the white cells 42,000, of which go per cent, were 
 large lymphocytes and 7 per cent, polymorphs. The spleen 
 enlarged rapidly and the temperature began to swing to 102° 
 and even 104° ; the white cells rose to 137,600 and the reds 
 fell to a little over 2,000,000, and the patient died. X-ray 
 treatment could not be used as the first application made all 
 the symptoms worse. 
 
 Other cases of enlarged* spleen, in either lymphatic or 
 spleno-medullary leucocythaemia, need not be given, for it is 
 not the purpose of this book to dwell upon topics so well-worn 
 and familiar. What has been given here is given to lay 
 emphasis on the necessity for blood examination in all cases 
 where a mass in the abdomen is under observation. As has 
 been already stated, when such a mass is not associated with 
 leucocythaemia it has to be proved that it is not kidney. It 
 further must be borne in mind that a leucocytosis must be 
 carefully distinguished from a leucocythaemia. In some 
 inflammator}^ conditions of the kidney and its pelvis, and in 
 perinephric inflammation, there is a marked leucocytosis. 
 Under the heading of pyonephrosis the details of a case are 
 given in which presumably the blood examination led to 
 serious error in diagnosis. 
 
Section VII.— THE KIDNEY 
 
 CHAPTER XXIV 
 
 introductory : movable kidney : perinephric abscess 
 
 Introductory 
 In this section it is not proposed to deal with all the diseases 
 which occur in the kidneys. The various forms of nephritis 
 are excluded. The conditions in which palpation is an 
 essential part of the examination are mainly dealt with. 
 These cases are first seen either by the family practitioner, 
 or by the physician, and it is often of great importance to 
 the patient that an accurate and an early diagnosis be made. 
 It must not, however, be assumed that in some cases palpation 
 of the kidney region is unnecessary, for it ought to be part 
 of the routine procedure whenever a full examination of the 
 abdomen is made ; and this ought to be made in all abdo- 
 minal cases. 
 
 Ordinarily the kidney on neither side is palpable, although 
 occasional cases are met with in which the lower pole of one 
 or other organ may just be felt. Palpation is made by one 
 hand in the loin and the other over the corresponding region 
 in front. The hands ought to be gently and slowly pressed 
 inwards and upwards as if they were intended to meet, 
 while the patient is encouraged to breath easily, or to take 
 deeper breaths, using the lower part of the chest or upper 
 part of the abdomen in such a way as to ensure move- 
 ment of the diaphragm. This instruction is particularly 
 necessary in the case of women, as their breathing is largety 
 thoracic. 
 
 With regard to palpation it is to be remembered that the 
 
 284 
 
MOVABLE KIDNEY 285 
 
 kidneys are placed retroperitoneally and are thus outside 
 the general peritoneal cavity. One important result of this 
 is that when enlarged they extend downwards and usually 
 backwards, and thus tend to fill up the loin and to be readily 
 palpable by the hand in the loin when the hand in front is 
 pressed towards the loin. This is so definite that in many 
 cases there ought to be no doubt that the mass which is felt 
 is kidney and no other organ. It is only in cases of great 
 enlargement that doubt is reasonable, and that more detailed 
 examination and consideration are essential. The questions 
 which then require consideration, with a view to differential 
 diagnosis, are different for each kidney, but on both sides 
 they are few in number, and when this is realized the problem 
 is greatly simplified. Nothing has so much obscured, and 
 given an aspect of unmerited difficulty, to the diagnosis of 
 abdominal conditions, as the vague and false impression 
 that anything may occur in an}^ part of the abdomen. 
 
 When the problem is faced practically and formulated 
 the difficulties are at least defined, and will be found to be 
 few in number. On the left side the first question is : Is 
 the swelling kidney, or spleen, or splenic flexure of the colon ? 
 On the right side the question is the same, save that the Hver 
 takes the place of the spleen. The problem is no bigger than 
 this ; but it has to be approached definitely from this stand- 
 point. Here, as in all abdominal problems, the first question 
 is which soHd organ, or which portion of hollow viscus is 
 affected. When that is determined the disease or malady 
 in the affected part falls to be considered and a diagnosis 
 arrived at ; and it will be found at this stage also that the 
 problem is not so large, not so diffuse and ill-defined, as it is 
 commonly thought to be. 
 
 Movable, Floating and Displaced Kidney 
 
 Movable Kidney. — Movable kidney is a very common 
 condition. It occurs in men but much more frequently in 
 women. It is present in many women in whom it gives rise 
 to no symptoms and no discomfort. In them it is discovered 
 
286 THE KIDNEY 
 
 when the abdomen is examined for something else ; and it is 
 wise not to intimate the discovery to the patient, as it may 
 be a cause of mental anxiety, in view of the extreme opinions 
 entertained regarding the condition in some medical quarters, 
 and in sections of the community. If no symptoms are 
 referable to the kidney region the matter ought to be left 
 alone. The diagnosis of mobility is usually easy. With the 
 hands placed deeply, as stated in the Introductory part of 
 this section, an ovoid smooth body may be felt, which is 
 readily moved upwards and backwards under the pressure 
 of the hand in front. If the patient can be made to breathe 
 by means of the diaphragm, it moves down again, and can 
 again be replaced by the palpating hand. A kidney is 
 nearly always tender when palpated. The amount of kidney 
 felt varies, often only the lower half or third of the organ 
 is felt ; but the whole kidney may be felt. In other cases 
 the lower pole only of the organ is felt with each movement 
 downwards of the diaphragm, while it retreats with expira- 
 tion. The minor degrees of mobility may be missed and are 
 often missed by npt realizing that the organ only comes 
 down if the diaphragm is being actively used during 
 examination. 
 
 Floating Kidney. — ^The term Floating Kidney is applied 
 when the organ has a greater range of movement than has 
 just been described. It may be found lower than the iliac 
 crest and yet be easily pushed upwards and backwards into 
 its normal position. The shape and consistence, the smooth- 
 ness of surface, and the fact that it can be pushed up into 
 the loin make it quite certain that what is felt is kidney. 
 Nothing else at aU Uke this occurs in this part of the abdomen. 
 The range of movement of a floating kidney may not be 
 limited to this down and up movement ; it may slip towards 
 the middle line, and I have felt more than once a kidney that 
 could be moved towards the mesial plane until it partly rested 
 on the vertebrae. In other cases there is a forward displace- 
 ment, so that the organ may be felt under the edge of the 
 liver, especially if the patient is placed in the prone position. 
 
:movable kidney 287 
 
 Displaced and Fixed Kidney. — In this condition the kidney 
 is lixed in its abnormal position. The absence of mobihty 
 on manipulation makes diagnosis more difficult. When the 
 organ is as low as or below the iliac crest the possibiHty of the 
 mass being an ovary has to be considered and the opinion 
 of the expert gynaecologist may be required and is always 
 desirable. When it is fixed towards the middle line and lies 
 under the edge of the liver it may be mistaken for a distended 
 gall-bladder. The converse mistake has also been made, 
 a distended gall-bladder being diagnosed as an enlarged and 
 displaced kidney. Careful determination of the position of 
 the liver edge and the immobility of the mass when deep 
 diaphragmatic breathing is exercised will help in the 
 differentiation. 
 
 Symptoms. — In movable kidney there may be, as already 
 stated, no symptoms ; but when the mobility is sufficient 
 to warrant the term floating being applied there may be 
 marked discomfort and even pain. The pain is referred to 
 the half of the abdomen corresponding to the vagrant organ, 
 it may begin as a sense of dragging when the patient is 
 upright, increasing on moving about and rendering walking 
 any distance impossible owing to increasing pain. It leads 
 to symptoms commonly spoken of as neurasthenic, for, as 
 in all painful abdominal conditions, the general tone and 
 health suffer, appetite is impaired, and there may be reflex 
 disturbances of digestion leading to loss of weight. It 
 upsets the normal nervous equilibrium, the manifestations 
 varying greatly in different sufferers. It may lead to a 
 condition of chronic invalidism as trying to others as it is to 
 the patient. Another, although by no means an mvariable, 
 result is a kinking of the ureter due to an alteration in the 
 axis of the kidney. This may occur intermittently. It 
 causes attacks of pain, due to retention of urine in the pelvis 
 and calices of the kidney, and may lead to hydronephrosis. 
 Relief is obtained when the kink is corrected and the urine 
 escapes into the ureter. Hydronephrosis may be permanent 
 when a displaced kidney gets fixed in a bad position. 
 
288 THE KIDNEY 
 
 Treatment. — Floating kidney, or movable kidney which 
 gives rise to symptoms, may be kept in position by means of a 
 carefully adjusted abdominal corset. If this proves in- 
 effectual the patient requires surgical assistance. A fixed 
 hydronephrotic kidney which causes discomfort or pain can 
 only be dealt with surgically. 
 
 Pathology. — A few words may be added on the pathology 
 of the condition. It is usually stated that a floating or 
 freely movable kidney has a special mesentery. I have had 
 the opportunity of examining after death some cases of this 
 kind and was surprised to find that the kidney could be freely 
 moved downwards and towards the middle line behind the 
 peritoneum and without showing any drag on the peritoneum. 
 
 Acute Perinephritis with Perinephritic Abscess 
 
 Perinephritis is inflammation of the tissues surrounding 
 the kidney. The kidney, as has been already stated, is 
 placed retroperitoneaUy and lies against the lumbar muscles. 
 It is attached to surrounding structures by fibrous tissue 
 which usually fixes it firmly in its normal position in the 
 loin. In perinephritis it is this surrounding connective 
 tissue which becomes acutely inflamed. The inflammatory 
 process may involve the tissue right round the kidney ; it 
 may, however, be more circumscribed arid confined to the 
 tissue behind the kidney, when it becomes retrorenal, or above 
 the upper pole of the kidney, when it becomes suprarenal. 
 The kidney itself is not involved in the process. The cause 
 is the presence of one of the pyogenic micro-organisms ; but 
 whence it comes, and why it reaches this region, are not 
 known, although it is assumed that the infective organisms 
 have been carried in the lymph stream from lower down in 
 the abdomen or from the pelvis. It occurs on either side. 
 
 Symptoms. — The symptoms at the outset are a feeling 
 of chill or definite shivering with pain referred to the loin 
 affected. The temperature rises and there are the other 
 indications of an acute inflammatory process. The loin 
 
PERINEPHRITIS 289 
 
 is tender and, later, painful on palpation. The blood shows 
 a polymorphonuclear leucocytosis. The febrile condition 
 continues and on bimanual examination the loin becomes 
 resistant, filled up and projects backwards. There is no 
 change in the urine pointing to involvement of the kidney 
 itself in the acute inflammatory process. 
 
 Diagnosis. — The diagnosis is very simple. An acute 
 febrile condition with pain and tenderness in the loin ; no 
 change in the urine indicating acute inflammation of kidney 
 tissue ; continuation of the febrile phenomena ; the loin 
 remaining tender or pamful on manipulation while becoming 
 fuller, leaves no doubt as to the diagnosis. There is practically 
 no other explanation of such phenomena. The diagnosis 
 ought not to be delayed and treatment ought to follow in 
 due course. 
 
 Treatment. — The treatment belongs to the surgeon. 
 The part has to be incised to give free vent to the pus which 
 is rapidly produced. The treatment is completely curative. 
 
 Illustrative Cases 
 
 The following case of retronephric abscess is taken from 
 my earlier records as it had an unusual history. 
 
 Case 80. — J. P., aged 27, brass-moulder, was admitted 
 to the Royal Infirmary on the 4th October. The history 
 obtained showed that at the age of 19 he became a journey- 
 man brass-caster. Soon after that he began to have attacks 
 of pain in the left lumbar region shooting downwards to the 
 groin and testicle. These attacks did not prevent him from 
 following his occupation until eight months before admission, 
 when they had become so severe and so frequent that he 
 gave up his work as a moulder. He then worked for a few 
 months in a coal pit and improved somewhat in general 
 health and the attacks of pain lessened in frequency and 
 severity. The improvement continued until six weeks before 
 admission, when he was suddenly seized by a severe attack of 
 pain. For three weeks before admission he had been confined 
 
 19 
 
290 THE KIDNEY 
 
 to bed, attacks of pain occurring during the day as well as 
 the night. The pain was localized to the lumbar region and 
 he compared it to a " hot iron being thrust through the 
 part." During the long history of recurring attacks of pain 
 he stated that an attack always caused frequent micturition, 
 only a small quantity of urine being passed at a time. 
 
 On examination there was pain and great tende'rness in 
 the left loin, and this loin was distinctly fuller than the right 
 one ; it gave the impression of a tense, thick-walled sac. 
 It could not, however, be felt by bimanual palpation, and 
 pressure made deeply in front did not cause pain. The 
 temperature ranged from 99 -6° to loi -4° Fahr. He perspired 
 profusely during the paroxysms of pain and also during 
 sleep. The urine was practically normal. 
 
 Remarks. — ^There was no room for doubt that there was 
 suppuration in the left loin when he was admitted to hospital, 
 but the connection between that condition and the long 
 history of recurring pain in this region was not apparent. 
 The recurring attacks of pain, as they were described by the 
 patient, strongly pointed to renal calculus ; but this would 
 not give rise to retronephric suppuration. And retronephric 
 it evidently was, for had the swelling been in the kidney it 
 would have been palpable bimanuaUy, and had it been 
 perinephric it would also have been so, while in both 
 conditions there would not have been complete absence of 
 pain on pressing from the front. One of my surgical col- 
 leagues at the time incised the loin and evacuated a large 
 quantity of pus. The patient made an uninterrupted and 
 complete recovery. 
 
 The next case is the last one of this kind I had in my male 
 ward in the Royal Infirmary. 
 
 Case 81. — J. P., aged 46, was admitted in the autumn of 
 1 918. The complaint was of pain in the right loin, which had 
 lasted for six weeks. The pain had come on suddenly on 
 the right side below the costal margin. He had been confined 
 to bed since the onset of pain. The pain was intermittent 
 and was sharp and stabbing in character. There were no 
 urinary symptoms. On examination the abdomen moved 
 
PERINEPHRITIS 291 
 
 freely with respiration. Bimanual palpation of the right 
 loin revealed a hard mass projecting forwards towards the 
 anterior abdominal wall, which was tender. The temperature 
 was raised, and the pulse accelerated. The diagnosis was 
 perirenal suppuration. The patient objected at first to 
 operation, but finally consented and was transferred to 
 Professor Caird's ward. The loin was incised, the pus 
 evacuated, and the cavity scraped. The healing was very 
 slow, but the patient made a good recovery. 
 
CHAPTER XXV 
 
 RENAL CALCULUS AND RENAL COLIC 
 
 Calculi form in the pelvis or calices of the kidney and give 
 rise to symptoms which will be presently described. The 
 calculi vary considerably in composition, being formed of uric 
 acid, oxalates, phosphates, or of combinations of these. Their 
 mode of formation and the conditions determining their 
 formation need not be discussed here, but it is to be 
 remembered that alterations in the chemical contents of 
 the urine are determined by alterations or aberrations of 
 metabolism, and that these are often spoken of and placed 
 under the somewhat vague definition of a " gouty " or 
 " rheumatic diathesis," 
 
 Symptoms. — The first symptom produced by renal 
 calculus is pain. The pain is intermittent and paroxysmal 
 and is known as renal colic. The severity of the pain varies 
 greatly, but may reach an intensity that is agonizing. The 
 paroxysm which comes on suddenly may as suddenly subside 
 or completely cease. The pain is usually referred to the 
 kidney region in the loin ; it may be referred to the lateral 
 region of the abdomen, to the hypochondrium of the affected 
 side, to the umbilical region, or along the course of the ureter 
 to the upper part of the thigh, or in the male to the testicle. 
 An intense paroxysm may be the first symptom, indicating 
 the presence of stone. When this is the history it has to be 
 assumed that the forming of the stone gave rise to no 
 appreciable symptom, and that the sudden and severe pain 
 is the result of the stone having moved to the mouth of the 
 ureter, A large calculus may be fixed in a calyx, or in more 
 than one without causing pain ; but such cases are rare, 
 
 292 
 
RENAL CALCULUS AND RENAL COLIC 293 
 
 More commonly the stone is small or of moderate size and 
 lies free in the kidney pelvis. 
 
 Examination. — When the abdomen is examined in- 
 spection supplies no guidance. On palpation there is not 
 as a rule much surface tenderness, and I have never seen 
 calculus cause the diffuse surface hyperaesthesia which some 
 other abdominal conditions may produce. If surface tender- 
 ness be present it is usually present in the loin. When the 
 kidney region is to be explored by deep palpation both hands 
 are used — one in the loin, the other at the part in front 
 corresponding to the position of the hand in the loin. It 
 facilitates the examination to stand on the side which is 
 being explored. One hand is pressed slowly but firmly and 
 deeply into the loin in its upper part, remembering that the 
 kidney is normally under cover of the ribs ; the other hand 
 is applied in a similar fashion in front, and in such a position 
 that, were intervening tissues removed, the fingers would 
 meet. By this method of procedure the lower part of the 
 kidney may be felt, and as soon as it is thus felt the patient 
 will complain of pain. If the hands are relaxed the pain 
 ceases, and it can again be elicited by again grasping the 
 organ. The degree of tenderness, of course, varies : it is 
 most intense if the examination is made when an attack 
 of renal colic is present ; but it can be elicited between the 
 attacks of colic, and when without pressure no pain is 
 experienced. Along with the tenderness the kidney is often 
 enlarged. 
 
 The examination of the urine is the next proceeding. 
 There may be a definite history of haematuria, but a patient 
 sometimes speaks of the urine having been " like blood " 
 when it is merely high-coloured from concentration. Often 
 there is no such history. There may be a definite history 
 of having passed small calculi after attacks of pain. When 
 blood is present in considerable amount it may be recognized 
 by the smoky appearance of the urine as seen in a glass 
 vessel ; by the guaicum and ether test ; or the deposit 
 may on microscopic examination be found to contain 
 hgemocytes. When the amount of blood present is thus 
 
294 THE KIDNEY 
 
 easy of demonstration the urine will, of course, be found to 
 contain albumin. Blood may, however, be present in such 
 small quantit}' that its presence cannot be demonstrated 
 by any of these methods. It is then necessary to have 
 recourse to centrifuging the urine, and carefuUy examining 
 the sediment microscopically. When this is done a positive 
 result strengthens the diagnosis of calculus. The presence 
 of even a few haemocytes in the sediment indicates that there 
 has been sufficient irritation to cause bleeding. Crystals, 
 as uric acid and oxalates, may also be present. Leucocytes, 
 and epithelial cells from the pelvis of the kidney, if present, 
 still further indicate that there has been irritation ; even 
 tube casts may be found. The urine from each kidney may 
 be obtained by the separator and examined separately. 
 This procedure may supply valuable indications as to the 
 condition not only of the affected kidney but of its fellow. 
 
 Examination by X-rays may be made and when the 
 result is positive the evidence is unimpeachable. On the 
 other hand, if the evidence is negative it is unfortunately 
 of no value, for it does not disprove the presence of a calculus. 
 ^Diagnosis of renal calculus is thus determined by the 
 occurrence of paroxysms of pain referred mainly to the region 
 of the affected organ, by eliciting tenderness in the organ 
 by palpation, and by the condition of the urine. 
 
 In the great majority of cases there is no doubt about the 
 diagnosis. The situation of the pain and the result of 
 bimanual examination of the kidney region are sufficient to 
 warrant the diagnosis. If blood be present in the urine the 
 diagnosis is established. Here again the supposed difficulty 
 in diagnosis is the result of vague notions about abdominal 
 pains. A renal cohc could hardly be mistaken for intestinal 
 colic. Somewhat similar pain might be caused by a perforated 
 duodenal ulcer, but the collapse in that case is more sudden 
 and more pronounced, and there is usually diffuse surface 
 hyperaesthesia. Renal colic might also be mistaken for 
 gall-stone colic, but here the seat of tenderness is in the gall- 
 bladder region and not deep in the loin. There are no other 
 painful conditions with which it can be reasonably confused. 
 
RENAL CALCULUS AND RENAL COLIC 295 
 
 The further history depends on the size and the character 
 of the stone, and necessarily varies very greatly. If the 
 stone is large, it cannot pass into and along the ureter ; it 
 remains in the pelvis and its position varies with bodily 
 movements and posture. There are recurring attacks of 
 severe colic. These, as has already been stated, are due to 
 the presence of the stone at the mouth of the ureter, where 
 it is probably grasped, the involuntary muscle spasm causing 
 pain ; while the retention of urine in, and the consequent 
 dilatation of, the pelvis becomes a further factor in pain 
 production. As the result of these recurring phenomena the 
 kidney enlarges and is readily palpated, and a considerable 
 degree of pain is caused by manipulation. At this stage also 
 there is no reasonable doubt as to the diagnosis. An X-ray 
 examination may or may not confirm the diagnosis. Stone 
 of hard consistence is shown, while other stones do not show. 
 The result is that only a positive shadow is of confirmatory 
 value, while if a negative observation is accepted a grievous 
 blunder may be made, grievous both to the patient and to 
 the physician. Considerable irritation may be set up in the 
 pelvis by the stone leading to the presence of pus and blood 
 in the urine. In all such cases the only cure is surgical 
 interposition. When the diagnosis is made operation ought 
 to be unequivocally advised. If this advice is not acted 
 upon, life becomes embarrassed and its activities greatly 
 restricted. 
 
 Case 82. — Some years ago I saw a gentleman, who was 
 passing through Edinburgh, on account of hsematuria with 
 pain in the right loin. I was informed that he had suffered 
 from attacks of this description for years, and that he had to 
 be very careful as to the amount and kind of exercise he 
 took, as any little excess even of walking brought on an 
 attack. There was a large amount of blood mixed with the 
 urine ; the right kidney was large and tender. He had been 
 X-rayed and assured that there was no stone in the kidney. 
 I expressed the opinion that there was, and explained that a 
 negative X-ray examination could not be accepted, as some 
 kinds of stone did not show. I strongly advised operation. 
 
296 THE KIDNEY 
 
 When he returned to his home south of the Border he was 
 again X-rayed and assured there was no stone. I adhered 
 to my view, but could do no more, however much one 
 regretted that an otherwise hale man, occupying an influential 
 position, should continue to be hindered and handicapped 
 at every turn by a condition which was susceptible of suc- 
 cessful surgical interposition even if it meant the removal 
 of the organ. 
 
 This class of case is fortunately not now common in the 
 experience of the physician. On the other hand, the less 
 severe cases are fairly common. 
 
 Case 83. — A medical man, aged 28, had suffered for some 
 time from pain in the loins with a sense of weariness. The 
 urine contained oxalates and he had passed some very small 
 calculi without pain. Regulation of diet, particularly a 
 reduction in the amount of flesh he had been eating and an 
 increase in carbohydrate food, soon led to the relief of 
 symptoms and the disappearance of oxalates from the urine. 
 
 Reference has been made to pain and to tenderness in 
 the renal region with perhaps some blood in the urine. If 
 the stone is small enough to get into the ureter, severe pain 
 may be caused by its propulsion along the ureter, the pain 
 following the course of the ureter downwards towards the 
 groin, until the stone escapes into the bladder, such escape 
 giving immediate relief. From the bladder the stone may 
 be passed by way of the urethra painlessly, or with more or 
 less pain, according to the size, shape, and character of the 
 stone. It may be arrested for some time at the lower end 
 of the ureter, when, as will be shown in the following cases, 
 the question of diagnosis may present some difficulty. 
 
 Case 84. — A clergyman, well up in middle life and hving 
 in a country district far from a medical man, was seized at 
 night with pain in the abdomen and vomiting. The 
 temperature was raised two or three degrees. Suggestions 
 of indiscretion in diet were offered in explanation of the 
 symptoms. The pain began in the right loin, and extended 
 downwards towards the groin ; and there was a history of 
 attacks of " gravel." On examination of the abdomen there 
 
RENAL CALCULUS AND RENAL COLIC 297 
 
 was tenderness in the right ihac region, and the anxious 
 question arose as to whether the case was an acute appendix 
 or a renal calculus. The history suggested the latter, and 
 as the tender area was small, and it was known that pain 
 in this patient alwa3^s led to a rise of temperature, that 
 presumption was strengthened. A small injection of 
 morphine and atropine relieved the pain and the patient had 
 a good night. In the morning there was no pain or tender- 
 ness, and the temperature was normal. After a day or two 
 in bed he was able to be up. A day or two later he showed 
 me a couple of small calculi, smaller than grape seeds, which 
 had passed by the urethra without pain. 
 
 Case 85. — ^This patient was a young man, who had suffered 
 all night from severe pain in the abdomen, for which he had 
 been diligently treated by hot applications and enemata, on 
 the advice of his medical attendant. On asking him as to 
 where the pain began he referred it to the left loin, and stated 
 that it had extended down the left side of the abdomen. The 
 pain was constant with severe exacerbations. There was 
 tenderness in the left iliac region and nowhere else. The case 
 seemed to be one of renal colic, in which the stone had reached 
 the lower end of the ureter ; but again the question was raised 
 whether it might not be an appendix stretching across to the 
 left iliac region. Belladonna in full doses was recommended, 
 and it was arranged that the patient should be sent to the 
 Royal Infirmary to the ward of a surgical colleague. By the 
 time he arrived there the pain was much less, but there was 
 stiU local tenderness, and the surgeon had to be persuaded 
 to postpone operation. The patient rapidly improved 
 further, so that all thought of operation was abandoned, 
 and he was discharged. In a few days the patient brought 
 a smooth calculus, smaller than a coffee bean, which had been 
 passed by the urethra with trifling inconvenience. 
 
 Case 86. — M. W., aged 30, was admitted to my male 
 ward. He complained of pain in the right lower segment of 
 the abdomen. The history was that some time before 
 admission he was believed to have renal calculus, and that 
 operation for removal had been performed, but no stone was 
 
298 THE KIDNEY 
 
 found. There was a good lumbar scar. On palpation of the 
 abdomen there was a limitied area of tenderness on pressure 
 at the lower part of the csecal region. The peculiarity of 
 this area of pain on pressure was that movement of the thigh 
 on the trunk or of the trunk alone caused pain at the same 
 point. It was the pain on movement that sent him into 
 hospital as it prevented him working. The case thus presented 
 a history of diagnosis of renal calculus, and of a disappointing 
 operation in skilful hands. The localitj^ of the pain and 
 tenderness, when we saw him, definitely suggested appendix, 
 with this reservation, however, that one had never seen a 
 chronic appendix produce pain on movement. A surgical 
 colleague saw the case, and his opinion was that the tender 
 area was caused by the appendix. It was quite clear that 
 the cause, whatever it was, of this unusual type of pain had 
 to be removed. At the operation the appendix was shown 
 to be one of the S-shaped appendices which are prone to give 
 trouble, and it was removed After this the region was further 
 explored, especially the ureter, with the result that an ovoid 
 calculus about the size of a cherry stone was removed. The 
 stone, of course, explained the pain and its unusual character. 
 The patient made an excellent recovery and was cured. 
 
 The following case illustrates another aspect of renal 
 calculus. 
 
 Case 87. — Mrs. S., aged 50, had been subject for a few 
 years to attacks of " chill in the stomach and inflammation." 
 These attacks were characterized by abdominal pain, the 
 pain being referred to about the centre of the abdomen. 
 Five months before I saw her she had a severe attack which 
 confined her to bed ; after a time she got up, but this was 
 followed by a return of the pain. The doctor examined 
 the urine at this time and found blood in it. On more careful 
 inquiry it was ascertained that the pain was situated on the 
 right side of the abdomen, going as far down as the groin. 
 During paroxysms of pain she vomited. She was definite 
 in the statement that pain, vomiting, and the amount of 
 blood in the urine were in proportion one to the other. For 
 six weeks there had been no pain, and blood had gradually 
 
RENAL CALCULUS AND RENAL COLIC 299 
 
 disappeared from the urine. On examination of the abdomen 
 the kidney was not palpable, and therefore not enlarged ; 
 but there was slight tenderness on bimanual deep pressure 
 up under the right ribs. Ihe urine contained nothing 
 abnormal save that it threw down urates on coohng. In 
 other respects the patient's health was satisfactory. The 
 bowels acted easily and daily ; there were no symptoms of 
 indigestion ; and the circulation was satisfactory. The 
 patient was, however, taking too little fluid. The opinion 
 I expressed was that the calculus had passed along the 
 ureter, and might have been passed from the bladder without 
 the patient noticing it. I suggested that she should be 
 instructed to take more fluid, and that it might be taken as 
 lithia water. For nine months there has been no recur- 
 rence of calculus symptoms. 
 
 Case 88. — Two Uric Acid Calculi removed from Kidney. — 
 James H., aged 29 years, was admitted into the Royal 
 Infirmary, Edinburgh, with a history of having seen 
 several doctors and of having been in at least two 
 other hospitals for symptoms corresponding to those which 
 led to his being sent to the Infirmary. The history was 
 that for the preceding three months he had had severe 
 attacks of pain in the abdomen ; the right intermediate 
 third of the abdomen being the position to which the pain 
 was referred. The paroxysms of pain came on suddenly and 
 at any time. He had been seized in the street, he had been 
 seized when at work so severely that he had had to go home. 
 His wife stated that the pain might last for twenty-four hours 
 or longer, and that his cries could be heard outside the house. 
 When the pain was severe he often vomited. For three 
 months he had had an attack of pain almost every week. 
 On questioning him closely as to the beginning of his attacks, 
 it appeared that he had had his first attack many years 
 before, but he could not give a date. The last three months, 
 however, covered the period during which they had been a 
 serious factor in his life. The pain neither went down towards 
 the thigh nor up into the chest, but it sometimes went round 
 into the loin. The pain went away as suddenly as it came 
 
300 THE KIDNEY 
 
 on. Inquiring as to the effect of taking food, he thought 
 that a heavy dinner was apt to bring on an attack, whilst 
 light food had no bad effect. He had no pain when passing 
 water, and he was not'aware of ever passing blood. When the 
 pain was present he found that lying on the right side, or 
 still better resting on his elbows and knees, gave relief. He 
 had been given morphia hypodermically for the relief of the 
 pain. He had been told that he was suffering from " neuralgia 
 of the kidney," but he definitely asserted that it had not been 
 suggested to him that he had a stone in the kidney. Dr. 
 Carruthers, who had sent him to the Infirmary, had, however, 
 been of opinion that he was suffering from renal calculus, 
 and it was this opinion which led him to send the patient to 
 the Infirmary. 
 
 Condition on Admission. — He was a well-nourished man 
 with a somewhat florid complexion. 
 
 Examination of Abdomen. — ^There was nothing abnormal 
 to note on inspection of the abdomen. On palpation the 
 liver edge was felt, but there was no tenderness over it nor 
 over the position of the gall-bladder even on deep palpation. 
 The liver was not enlarged. The caecal region was then care- 
 fully explored and no tenderness was elicited in that region 
 on deep palpation. Hepatic colic or appendix colic were 
 therefore excluded. The region of the right kidney was then 
 examined bimanually, and soon after I began to approximate 
 the two hands he winced and complained of pain. The 
 hand in the loin specially brought out the pain when it 
 was pressed deeply. The kidney was felt between the 
 two sets of fingers, and a moderate degree of pressure made 
 him make a very wry face. The urine contained some red 
 blood corpuscles, some pus cells, hyaline casts, and oxa- 
 lates. Examination by X-rays was negative. The patient 
 was transferred to the surgical side of the hospital with the 
 diagnosis of renal calculus on the right side. The urine from 
 the two kidneys was separated, when it was found that there 
 was less urine coming from the left kidney than from the 
 right one and that it was from the left that the blood was 
 coming. In view of these facts the surgeon under whose 
 
RENAL CALCULUS AND RENAL COLIC 301 
 
 care he was did not think him a favonrablc or even a suitable 
 case for operation, and he was sent out. He returned shortly, 
 beseeching that he should be operated on as the pain was 
 becoming worse and was quite unbearable. He was 
 accordingly operated on and two calculi were removed from 
 the pelvis of the right kidney. He got on satisfactorily for 
 a day or two, but he became drowsy and died evidently of 
 uraemic coma. The lesson to be learnt from this case is the 
 necessity of early operation. Had the diagnosis been made 
 three months earlier the result of operation would probably 
 have been the reverse of what it unfortunately was. 
 
 Remarks. — The foregoing cases illustrate the clinical 
 phenomena of renal colic and the questions to which it may 
 give rise. The main object of this section has been to show 
 that renal colic is readily diagnosed once vague notions 
 regarding abdominal phenomena are put aside, and the fact 
 is accepted that the right and the left loin belong to the 
 kidney ; and that, when the diagnosis is difficult, it has to be 
 proved that the symptoms are not renal. Pain and tender- 
 ness in this region are renal in origin in the vast majority of 
 cases ; and in the minority of difficult cases it has to be 
 proved that the pain and tenderness are not renal. This point 
 is further illustrated in the following chapter. It has also 
 been shown that a small stone may give rise to pain beginning 
 in the loin which extends along the line of the ureter as the 
 stone passes, and that there is an area of tenderness at the 
 point where the stone is arrested. 
 
CHAPTER XXVI 
 
 ENLARGEMENT OF THE KIDNEYS 
 
 In this chapter the conditions dealt with are hydronephrosis, 
 pyonephrosis, and mahgnant neoplasm. 
 
 I. Hydronephrosis 
 
 Hydronephrosis means distension of the pelvis and 
 calices of the kidney by retained urine, the result of obstruc- 
 tion to its escape by way of the ureter. It leads to pressure 
 upon and destruction of the essential tissue of the organ ; 
 and to enlargement of the organ in different degrees. In 
 advanced cases the kidney is so completely destroyed that 
 it no longer performs its excretory functions. The main 
 causes of obstruction are renal calculus, permanently or 
 intermittently blocking the outlet ; and freely movable or 
 floating kidney. In the latter case retention is caused by 
 such an alteration in the position of the axis of the organ to 
 the ureter that sufficient kinking or twisting of the ureter 
 occurs to prevent outflow. This also may be intermittent. 
 When kinking occurs the urine is retained, and causes 
 much pain. It leads to much distension and enlargement, 
 which lessens when the kink is removed and the retained 
 urine escapes. By repetition of this process not only does 
 enlargement result but the entire kidney structure is practi- 
 cally destroyed. ' Many years ago I saw a typical case of 
 this kind on the right side in a woman who declined operative 
 interference. It was at a time when abdominal surgery had 
 not attained its present excellence, and operation was not 
 pressed as it would be to-day. 
 
 302 
 
ENLARGEMENT OF THE KIDNEYS 303 
 
 Lesions in the pelvis, particularly in women, may 
 involve the lower end of the ureter so completely that hydro- 
 nephrosis and great distension and thickening of the affected 
 ureter result. I have seen both kidneys become progressively 
 involved in this way. 
 
 Diagnosis. — Diagnosis is determined, firstly by the history, 
 although this may be misleading ; secondly, by palpation, 
 the resilience of the mass being that of a cyst and not of a 
 soUd body ; and thirdly, by collecting separately whatever 
 fluid escapes from the ureters. 
 
 The following case is an example of a hydronephrotic 
 cystic kidney, the cause of which seemed to have been 
 mobiUty. The case was examined and fully discussed with 
 the students attending my clinic, and the hne of argument 
 is reproduced as illustrating the method employed in teaching. 
 
 Case 89. — T. L., aged 33, was admitted on the 23rd 
 August, 1918, to the Royal Infirmary. 
 
 History. — The patient was in the Reserve when the War 
 broke out in August, 1914. He was called to the colours 
 and sent to France. He was soon on the sick hst, was 
 invaUded home, and discharged in January, 1915, after being 
 two and a half months in hospital. He did light work for a 
 year, and then worked for two years as a labourer. Two 
 years before admission to my ward he was in a surgical ward 
 for a few days for observation. A year later he was admitted 
 to a military hospital, where he was X-rayed. He under- 
 stood that nothing was found ; in this hospital, however, 
 he learnt that there was blood in the urine. For a year before 
 admission to my ward he had worked as a dock labourer. 
 He had suffered from pain in the abdomen since he had 
 returned from France. The pain was on the left side and 
 went round to the loin. In addition to a constant dull 
 aching in this region, he had severe attacks of pain, the pain 
 being worse in front, with a feeling of tightness in the loin. 
 He had had about three of these attacks each year, since the 
 end of 1914. Each attack lasted about a week. He 
 associated these attacks with constipation, for they had 
 been relieved by getting the bowels freely moved. The 
 
304 THE KIDNEY 
 
 attack for which he was admitted to my ward had lasted for 
 a week. 
 
 Examination. — He complained of a dull aching pain 
 with a feeling of tightness referred to the left loin. There 
 was blood in the urine, sufficient in quantity to be recognized 
 by the unaided eye. In the course of a few days the urine 
 became normal. On palpation of the abdomen there was 
 readily felt an abnormal mass, which extended from the rib 
 margin to the iliac fossa on the left side. It did not cause 
 any projection or bulging of the abdominal wall ; it was 
 longer than it was broad ; the surface was smooth and slightly 
 lobulated ; it was readily felt bimanually with one hand in 
 the loin ; the left loin was fuller and much more resistant 
 than the right ; there was no tenderness ; there was dullness 
 on percussion. The tympanitic note of the stomach fundus 
 was present in the usual position. There was no increase in 
 the area of splenic dullness such as is present when that 
 organ is enlarged and projects beyond the costal margin. 
 
 Remarks on Diagnosis. — The points in this case were 
 (i) the local pain directing attention to the abdomen, and to 
 the left half of it, including the flank and loin ; (2) the palpable 
 mass in this region ; (3) the temporary presence of blood in 
 the urine ; (4) the recurrence of attacks of pain associated 
 with constipation relieved by free colon evacuation. 
 
 The first problem this case presents is : What is this 
 mass ? And I ask you to realize that the number of possi- 
 bilities is limited ; you must not allow your brains to be 
 rattled with the idea that the field of possibilities is large, 
 vague, and indefinite. We are dealing with a human 
 abdomen, a cavity of the body of which we know the anatomy 
 and understand much of its pathology. For clinical purposes 
 I submit to you that a mass like this in this position is 
 pathological ; and that when you begin to consider what 
 part or organ is involved you are confined to spleen, splenic 
 flexure of colon, and kidney. Take these in order. When 
 the spleen is enlarged the normal area of splenic dull- 
 ness enlarges upwards, forwards, and downwards. There 
 is no extension of dullness upwards and forwards in 
 
ENLARGEMENT OF THE KIDNEYS 305 
 
 this case. The area of stomach fundus tympanicity is 
 present, in its normal position. With these facts before us 
 it may be confidently asserted that the mass is not an 
 enlarged spleen. Take next the splenic flexure of the colon. 
 This is one of the important parts of the colon. It is firmly 
 fixed up in this region, and it is one of the points where 
 malignant neoplasm occurs. Mahgnant neoplasm here may 
 grow to a considerable size before it gives rise to complete 
 intestinal obstruction. When such a neoplasm occurs and 
 attains much size it remains higher in position than this mass 
 has done, it projects more forward and towards the mesial 
 plane, it can be palpated under the costal margin, and if 
 big enough to be palpable it will give a dull percussion 
 sound over the lower ribs. It is not, however, common to 
 have a neoplasm attaining such dimensions in this region, 
 but it may presumably be met with. 
 
 \'\nien neoplasm occurs here there is a history available 
 of recurring symptoms of pronounced constipation, amount- 
 ing at times to temporary obstruction, and overcome with 
 difficulty. These sjmiptoms not being present, we pass to the 
 next possibility, namely, kidney. The position of the mass 
 suggests most readily that it is an enlarged kidney, enlarged 
 in length and in circumference ; it projects downwards much 
 beyond its normal limit ; it fiUs up the loin, and examined 
 bimanuaUy it is found to be several times larger than a 
 normal kidney. In text-books you wiU find it stated that 
 a mass like this will give a tympanitic note on percussing it 
 in front if it is kidney as the descending colon hes in front 
 of it. There is no such tympanitic note in this case. Let 
 me impress upon you that you have to apply common sense 
 to the examination of the abdomen. The absence of a 
 tympanitic note in front of this mass cannot be taken as 
 evidence that the colon is not in front of it, it only means that 
 the descending colon is not fuU of gas. Without gas or air 
 in it no part of the intestine gives a t3aiipanitic note, so this 
 test is not rehable. But this point can be carried even 
 further : if this is a kidney, as we beHeve it to be, the kidney 
 enlarging from behind the colon will press upon and compress 
 
 20 
 
3o6 THE KIDNEY 
 
 it, so as not only to prevent air or gas accumulating, but to 
 lead to difficulty in the passage of more solid colon contents. 
 The empty and contracted colon can in this patient be felt 
 running from above dowTiwards in front of the enlarged 
 kidney. This I submit is the explanation of the special 
 attacks of pain, accompanied by constipation, and reheved 
 by the emptjdng of the colon, referred to in the history of 
 the symptoms ehcited from the patient. This leads to the 
 next question : ^^'^lat change has the kidney undergone 
 which has led to the enlargement ? I again impress upon 
 you the necessity of recalhng and applying your knowledge 
 of pathology, and passing in mental review the common 
 causes of enlargement of this organ : they are neoplasm, 
 hydronephrosis, pyonephrosis, and congenital cj^stic kidney. 
 Take these in order. First, neoplasm ; neoplasm in this 
 organ may for cUnical purposes be regarded as always 
 malignant, either sarcoma or carcinoma. With a history of 
 four years' duration, the absence of cachexia, and the mass not 
 larger than it is, malignant growth may be set aside. Tuber- 
 culous disease does not lead to such enlargement as is present 
 here. The patient shows no constitutional reaction, and 
 the urine does not contain pus. This possibility may there- 
 fore be also put aside. There remains for consideration 
 cystic kidney, the result either of hydronephrosis, of p3^o- 
 nephrosis, or of increase in size of a congenitally cystic 
 kidney. The last mentioned is a very rare condition, 
 and usually affects both organs ; but in this patient there is 
 no e\ddence of enlargement of the right kidney. Hydro- 
 nephrotic cystic kidney may result from a calculus in the 
 pelvis blocking the ureter from time to time, but the pain 
 has never been of the description caused by such occur- 
 rences : hydronephrosis, however, occurs in movable kidney 
 when a change in the position of the organ leads to kinking 
 of the ureter with consequent retention of the renal excretion 
 in the pelvis and calices. Of the pre-existence of such 
 mobility in this patient we have no definite knowledge. The 
 intermittent presence of blood in the urine maj^ occur in 
 both conditions ; but a history of renal calculus is entirely 
 
ENLARGEMENT OF THE KIDNEYS 307 
 
 wanting, so we reach by the method of exclusion the diagnosis 
 of hydronephrosis due probably to mobiUty. 
 
 Treatment. — What can be done for the patient ? is a 
 question which need not be answered until our argument 
 has been checked by all the means at our disposal. He will 
 be X-rayed after bismuth with the object of showing the 
 condition of the splenic flexure, and perhaps of the descending 
 colon in relation to the kidney. The functional activity of 
 both kidneys will be investigated ; the object being to 
 determine whether the left kidney is worth preserving. 
 
 These examinations were duly made by Dr. Hope Fowler 
 in the Electrical Department and by Professor Caird on the 
 surgical side. The X-ray photograph showed the bismuth 
 piled up in and on either side of the splenic flexure, and 
 none in the descending colon, while later it passed to the 
 rectum. The explanation of the severe attacks of pain 
 with constipation was thus confirmed. Professor Caird 
 found that there was practically no urine coming from the 
 left ureter. This being so, there was no room for difference 
 of opinion as to the treatment to be followed, if the patient 
 wanted to be cured of the pain and discomfort which were 
 interfering with his work. The operation was performed 
 on the 19th September, and the kidney, a hydronephrotic 
 cystic one, was removed. The cause of the hydronephrosis 
 was not ascertained. The patient made an excellent 
 recovery. 
 
 2. Pyonephrosis 
 
 This term means distension of the pelvis and calices of 
 the kidney with pus causing enlargement of the organ and 
 destruction of the kidney tissue. The following is the most 
 striking case met ^vith in my experience, as presenting 
 unusual difficulties in diagnosis. 
 
 Case 90. — The patient, a boy of 12, was sent to my ward 
 by the family medical attendant because of an abdominal 
 tumour which had lasted for months and was enlarging. 
 The boy did not look ill, and he had no pain. There was no 
 rise of temperature and pulse and respirations were quiet. 
 
3o8 THE KIDNEY 
 
 On examination a very large mass was visible on the left 
 side of the abdomen ; on palpation it was hard and resistant ; 
 it extended from the costal margin to the iUac fossa ; it 
 seemed to occupy about one-third or so of the abdominal 
 cavity ; it was not tender ; it bulged the left loin and was 
 palpable bimanuaUy ; its surface was smooth with project- 
 ing parts ; its anterior and inferior margins were definite 
 and sharp. On percussion it was dull ; but the dullness did 
 not extend upwards under the ribs as the dullness of a large 
 spleen extends. On examination of the urine nothing 
 abnormal was found. A blood count gave 12,000 leucocytes, 
 mainly polymorphs. 
 
 There was no doubt that this great mass was renal. 
 The position of its upper Umit negatived any idea of splenic 
 origin. If then it was a renal tumour it was difficult to think 
 of any lesion but sarcoma. In any case surgical intervention 
 was obviously called for. My surgical colleague Professor 
 Caird saw the boy with me and he agreed in thinking it a 
 renal tumour and almost certainly sarcoma. The parents 
 were willing that the operation should be done, although we 
 did not hold out much hope that cure could be effected, in 
 view of the size of the mass to be removed and of what we 
 believed its character to be. At the operation it was found 
 to be a great pyonephrosis. The little fellow succumbed 
 to the shock of the operation. Had the patient been 
 operated on earlier the shock-element would have been less. 
 I learned later that the mass had been earlier diagnosed as 
 glandular and had been treated by intravenous medication. 
 Remarks. — Comment here is confined to the extra- 
 ordinary absence of symptoms in face of the increasing size 
 of the huge abscess sac. The leucocytosis present was not 
 more than might have been caused as the result of irritative 
 action round a malignant growth. And this leucocytosis 
 may possibly have led to the earher diagnosis of enlarged 
 glands. Had pyonephrosis even been suspected the sac 
 might have been tapped and emptied, thereby lessening the 
 shock of later removal. 
 
 The following case occurred many years ago and before 
 
ENLARGEMENT OF THE KIDNEYS 309 
 
 surgeons opened the abdomen with the freedom from anxiety 
 they now enjoy. The presence of symptoms in this patient 
 is in striking contrast to the absence of symptoms in the 
 previous case. 
 
 Case 91. — Displaced Kidney : Pyonephrosis : Operation 
 successful. — Mrs. J. F., aged 34, was admitted into the Royal 
 Infirmary on the 22nd September. She complained of pain 
 in the right iliac region, which had lasted for three weeks. 
 
 History of Illness. — The history obtained from the patient 
 was as follows : — The illness began three weeks before 
 admission with pain in the abdomen, and she indicated the 
 right iliac region as the site of the pain ; the pain was accom- 
 panied by retching and vomiting. These symptoms lasted 
 for from three to four days, the vomiting being continuous 
 during those days. The pain was constant day and night and 
 kept her awake at night. It continued in a mitigated form 
 until a few nights before admission, when she got sudden 
 relief from it, and she fell into a long sleep. She had several 
 shivering attacks which seem to have been rigors ; she 
 sweated freely during the three weeks, and said that her hair 
 was seldom dry during that time. The seat of the pain had 
 been tender to touch. There had been a bearing-down 
 sensation during micturition, and she stated that the urine 
 was then thick and high-coloured. She had a similar attack 
 to that just described, five years before. 
 
 She complained also of pain in the right lumbar region 
 which was always present ; this pain shot upwards to the 
 dorsal region. It came on somewhat gradually, and passed 
 off in Hke fashion. The attacks of pain were generally asso- 
 ciated with shivering or rigor. She had not noticed any 
 change in the character of the urine during or after the attacks. 
 
 Family History. — Unimportant. 
 
 Personal History. — She was a soldier's wife, and had been 
 married for thirteen years, but she had not had any children. 
 She had not been abroad. Five years before she had a 
 very severe attack of pain in the right loin which lasted for 
 three days. During that attack there was marked frequency 
 of micturition. 
 
310 THE KIDNEY 
 
 Alimentary System.— The appetite was usually good, but 
 the stomach was easily deranged. If she were not careful 
 in diet, she suffered from pain behind the sternum, 
 flatulence, and a sensation of weight in the epigastrium. 
 The bowels only moved every second or third day. 
 
 Abdomen. — The abdomen was of normal configuration ; 
 there was no abnormal bulging or retraction. The abdominal 
 walls were well nourished and moved freely. There was 
 markedly greater resistance over the right half of the 
 abdomen, the muscles being rigid. This side was tender on 
 pressure ; there was no dullness on percussion. On careful 
 palpation and gentle manipulation, to allow the muscular 
 spasm to subside, it was ascertained that there was a fuUness 
 on the right side which had its lower limit at the level of a 
 horizontal line drawn between the middle line and the 
 anterior superior ihac spine ; from there it extended up- 
 wards and apparently backwards, for a communicated 
 impact could be felt with one hand pressed into the corre- 
 sponding loin. It was not movable. The manipulation of 
 this body caused some pain. 
 
 The liver edge did not extend below the costal margin. 
 The area of spleen dullness was normal. There was no 
 gastroptosis. The circulatory and respiratory systems were 
 normal. 
 
 The temperature was subnormal, and the pulse was beating 
 from 76 to 80 per minute. 
 
 Diagnosis. — The swelling referred to was somewhat 
 soft and indefinite, and the question was, what was it ? 
 It seemed to me to be a displaced and enlarged kidney, for 
 the following reasons : — (i) its position ; (2) the level of its 
 lower end ; and (3) , most important of all, the fact that by 
 bimanual palpation a communicated impulse was perceptible 
 to the hand in the loin by pressing on the lower part of the 
 swelHng in the iliac region. The condition of the urine threw 
 no Hght on the diagnosis at this stage. 
 
 Progress. — The temperature was taken every four hours 
 and during the 22nd and 23rd it was subnormal, but on 
 the latter date at 9.30 p.m. the patient was seized with a rigor 
 
ENLARGEMENT OF THE KIDNEYS 311 
 
 and the temperature rose to 103-6° F. She had been free 
 from pain until about 6.30 p.m. of the 23rd, when there was 
 a slight return, and it continued to increase until about 10 p.m. 
 It was not specially severe during the rigor. The pain was 
 confined to the lumbar region. The abdominal wall was very 
 tense. The pain passed off towards midnight, and the 
 temperature fell and reached 97*4° in the early hours of the 
 morning. The pulse only rose to 90, while the temperature 
 was at its highest. 
 
 September 24th. — ^There was diffuse pain and tenderness 
 on the right side. The urine showed a deposit of one-eighth 
 of an inch of pus in the urine glass ; there were no blood 
 corpuscles. SHght pain continued all day but became 
 worse towards the afternoon, and the temperarure gradually 
 rose to 103° and the pulse to 109. The abdomen was tense. 
 There was no rigor. 
 
 September 2jth. — The temperature continued between 
 ioi"6° and 103°. The pulse varied from 112 to 120. There 
 was general abdominal tenderness. The right side of the 
 abdomen was tense and hard, and there was sUght bulging. 
 Palpation was difficult owing to the tense and tender con- 
 dition of the part, but there was a distinct increase in the 
 size of the tumefaction already referred to, and the impact 
 to the hand in the loin was more marked. 
 
 September 26th. — The temperature fell to 99°, but rose 
 to 102° at night. She perspired freely. The general 
 tenderness continued, but there was no acute pain. She was 
 very thirsty. The pulse rate was about 100. The urine 
 contained pus in quantity, but no blood. 
 
 The increase in the size of the sweUing in the right half of 
 the abdomen, extending into the loin, strengthened the view I 
 had formed that the swelling was a displaced kidney, while 
 the appearance of pus in the urine still further confirmed this. 
 It was evident that the displaced kidney was the seat of an 
 acute pyonephrosis. 
 
 On the following day the patient was transferred to 
 Professor Annandale's ward with a view to operation. 
 The swelling subsided considerably, but in view of the long 
 
312 THE KIDNEY 
 
 history it was decided to drain the kidney from the loin, and 
 to fix it, if practicable, more in its normal position. The 
 operation was performed by Professor Annandale. The 
 organ was incised, and the large sac formed by dilated pelvis 
 and calices opened and drained, and the organ was then 
 sutured to the parietes. The patient was much benefited by 
 the operation, and left the infirmary relieved of pain and 
 discomfort. 
 
 3. Neoplasm 
 
 Neoplasm is the next condition, in the organ under 
 consideration, which gives rise to enlargement. Not in- 
 frequently one or other kidney is enlarged by the time the 
 physician or the practitioner sees the patient for the first 
 time, or when the abdomen is examined for the first time. 
 In some instances there has been an entire absence of 
 symptoms nearly up to the time when the doctor is first 
 consulted. The complaint may then not be more than of a 
 feehng of discomfort or slight ache in the loin. There ma}' 
 also be a complaint of loss of strength or of vigour. No 
 observations may have been made regarding the appearance 
 of the urine and there may have been an entire absence of 
 discomfort or of appreciable alteration in connection with 
 urination. By the time the organ is enlarged examination 
 wiU usually reveal the presence of blood in the urine, visible 
 to the unaided eye, or to chemical or to microscopic examina- 
 tion. At this early stage, if there has been no history of 
 pain, and no active constitutional disturbance such as is 
 present in acute pyelitis, or in tuberculosis, there is unfortu- 
 nately no room for doubt as to the condition which is present. 
 Separation of the excretion from the ureters will show that 
 the function of the affected organ is gravely altered. It may 
 be that blood in the urine may be present before there is 
 appreciable enlargement, but I have not seen such cases. 
 There can, however, be no doubt as to the significance of 
 blood in the urine, coming from one kidney, along with the 
 absence of history of pain or of acute illness referrable to 
 the urinary tract. 
 
ENLARGEMENT OF THE KIDNEYS 313 
 
 The position is as simple as has been stated. An enlarged 
 kidney, with an absence of such history as has been indicated, 
 and the presence of even a small quantity of blood is a 
 malignant kidney. There is really nothing to confuse it 
 with, for no other pathological change occurs with which it 
 can be confused. One other point may be made, and that 
 is if there is blood in the urine and one kidney is enlarged 
 the kidney ought to be assumed to be the source until it is 
 proved not to be. The prompt recognition of an enlarged 
 kidney with blood in the urine lies with the general prac- 
 titioner in the first instance ; and the fate of the patient will, 
 in many cases, be determined by him. In the early stage 
 removal of the kidney may mean eradication of the disease ; 
 later removal cannot be expected to have this result, and the 
 judicially minded surgeon may at that stage advise against 
 operation. 
 
 Illustrative Cases 
 
 Case 92. — W. F., aged 63, cutler, was admitted to hospital 
 complaining of weakness and breath lessness. 
 
 History. — Two and a half years before admission he had 
 influenza and was in bed for eleven weeks. Since then he 
 had suffered from breathlessness and weakness. About 
 Christmas time the breathlessness became so bad that he 
 could hardly walk to work, although it was only three minutes' 
 walk distant. When working at his bench he used to get 
 pain in the " pit of the stomach " and also between the 
 shoulder blades. It was a dull aching and was relieved by 
 sitting down. He also had a constant pain across the small 
 of the back. He had to give up work, and had been attended 
 by his doctor, but as he was not improving he was sent to 
 the Infirmary, and was admitted. He had been a heavy 
 whisky and beer drinker. He was thin and somewhat 
 cachetic looking. The pulse was 70 and regular, the arteries 
 were thickened, and the systoHc pressure was 170 mm. Hg. 
 The heart sounds were faint. The lungs were emphyse- 
 matous, and there were rhonchi on both sides. On palpation 
 of the abdomen a mass was found on the left side evidently 
 
314 THE KIDNEY 
 
 an enlarged kidney. The urine contained sufficient blood to 
 give it the smoky appearance. 
 
 The diagnosis was bronchitis mth emphysema, a feeble 
 heart and sclerosed vessels ; and in addition a maUgnant 
 kidney. Professor Caird saw the patient, agreed with the 
 diagnosis and confirmed the opinion that operation was not 
 desirable. Professor Caird kindly separated the excretion 
 from the two ureters and confirmed the state of the left 
 kidney. 
 
 Cases of this kind need not be multiphed, for the diagnosis 
 is simple and the treatment is hmited to surgical measures. 
 For success early recognition, as has been already stated, 
 is the essential condition. There are, however, cases where 
 there is much greater enlargement, in which the diagnosis is 
 more complicated. The two follo^^ing cases illustrate this 
 on the left side of the abdomen ; while the third case illus- 
 trates the difficulty on the right side where the question was 
 whether the mass was formed bj' liver or kidney. 
 
 Case 93. — Wm. H., aged 23, in civil life engaged in a 
 wool mill. He \vas admitted to the Royal Infirmary on the 
 5th January, 1918. He complained of pain on the left side 
 in the region of the lower ribs, extending upwards to the 
 shoulder, and of discomfort after meals. The history 
 obtained from the patient was as follows. He was accepted 
 for the Army in September, 1914, although he had a shght 
 inguinal hernia. He went to France in the Scots Guards in 
 February, 191 5. In April he was sent home with the hernia 
 more developed. He was not operated on, but had to wear 
 a truss and returned to Belgium in August. At the end of 
 'Ma.y, 1916, he awoke one morning feeling unwell. He had 
 slight pain on the left side and headache, but attached no 
 importance to his sj^mptoms. He paraded for breakfast \rith 
 his section, but suddenly fainted and later he vomited. 
 The battaUon was on rest at the time. He was sent to the 
 C.C.S., and from there to Boulogne, where he remained in 
 hospital for three weeks and was kept on hght diet. At this 
 time there appears to have been blood in the urine. He 
 suffered from headache. He was sent to a hospital in London 
 
ENLARGEMENT OF THE KIDNEYS 315 
 
 where he suffered from headache and sharp pain in the small 
 of the back. In October, 1916, he felt much better and 
 was sent to a convalescent camp. At this time, although the 
 headache and pain in the back were less, he got breathless on 
 sHght exertion. After a few days he was sent to a reserve 
 battaUon and given light duty. He was medically examined 
 several times and discharged in December, 1916, with, it 
 was stated, the diagnosis of enlarged spleen. He had been 
 on full diet since leaving the hospital in London, and was 
 feeUng fairly well save for the pains in his side, which came 
 and went irrespective of what he did or what he ate. About 
 this time he noticed a lump on the left side of the abdomen. 
 He returned to his native place in Scotland and tried mill- 
 work of various kinds, but they all " took too much out of 
 him " and he had to give up trying to work. The pain was 
 meanwhile getting worse. By July, 1917, the pains had 
 become still worse, and he noticed there was blood in the 
 urine. He consulted the doctor, and after some days of 
 rest the red colour of the urine disappeared. He again 
 tried to work, but had to give it up. Since August, 1917, the 
 pain in his side had become much worse and more constant ; 
 it was dragging in character. The lump in his side was 
 much larger, but it was not painful when he handled it. The 
 pain often prevented sleep. In the end of 1917 he was 
 advised to go to the Infirmary, and he was admitted to my 
 ward at the request of the doctor. 
 
 Condition on Admission. — He was admitted on the 5th 
 January, 1918. The general condition was fairly good, he 
 was 6 ft. I in. in height, weighed 11 st. 10 lbs., but had been 
 13 St. 12 lbs. when he joined the Army. Pulse, temperature, 
 and respirations were normal. The blood showed the red 
 corpuscles to be 4,180,000, the whites 5,600, the haemoglobin 
 y^ per cent. , and the colour index '95 ; there were no abnormal 
 cells. The brachial pressure was 142 mm. Hg. There was 
 nothing abnormal in heart or lungs. Inspection of the 
 abdomen showed marked bulging on the left side and this 
 side did not move with respiration. On palpation a very 
 large solid mass was felt extending from the ribs downwards 
 
v> 
 
 i6 THE KIDNEY 
 
 into the iliac region ; it filled up the loin and at the 
 level of the umbiUcus extended i| ins. to the right of the 
 mesial Une. It was dull on percussion, the duU note extending 
 to the seventh rib in the axiUary hne. The surface of the mass 
 was smooth. It was closely in contact with the parietes. 
 It had a definite sharp edge, the hne of which was broken by 
 a notch. Pain was complained of when the mass was 
 pressed between one hand in front and the other in the loin. 
 Sixty-five ounces of urine were passed in twenty-four hours, 
 the specific gravity was 1027, there was a small amount of 
 albumin, the total urea for twenty-four hours was 604 '5 grains. 
 Pain was constantly present. The patient was easier lying on 
 the right side. The appetite was good, but if he took a large 
 meal he had discomfort ; and if the bowels were not acting 
 the pain became worse ; a purgative always gave rehef . 
 The mass increased in size and gave rise to increasing dis- 
 confort, with a feeUng of great weight ; and he was kept 
 awake at night by pain. 
 
 Remarks. — This patient came to hospital with a diagnosis, 
 seemingly passed on from hospital to hospital, of enlarged 
 spleen ; and the medical man attending him after he was 
 discharged did not challenge the diagnosis. There was also 
 a history of haematuria. When first seen and the abdomen 
 examined it was easy to accept the proposition that the mass 
 was a huge spleen ; it extended up under the ribs as a large 
 spleen extends ; its shape, smooth surface, somewhat sharp 
 anterior edge, and the notch in the edge aU contributed to this 
 fallacy. There was little doubt that the mass was mahgnant, 
 although I had never seen a mahgnant spleen of such large 
 size. The left kidney was practically functionless, but 
 even this was not absolute proof that the mass was kidney, 
 for we knew that a big spleen might press upon, flatten and 
 destroy the kidney as an excretory organ. Professor Caird 
 saw the patient several times. We both recognized the 
 gravity of removing a spleen of this size, and yet operation 
 seemed imperative unless the patient were left to suffer and 
 to die. The patient was anxious that something should be 
 done for his rehef and was wilHng to face the risk. Professor 
 
ENLARGEMENT OF THE KIDNEYS 317 
 
 Caird went into the history again and came to the conclusion 
 that it was kidney. This was confirmed when the abdomen 
 was opened and the mass was removed without very great 
 difficulty. It was as we expected malignant. The patient 
 stood the operation remarkably well and he made an excellent 
 recovery. In the summer of 1919, however, it was reported 
 that the abdomen had become widely affected. 
 
 Case 94. — W. P., a girl 16 years of age, was admitted to 
 my ward on the 19th May, 191 9. The complaint was pain 
 and swelling on the left side of the abdomen. The history 
 was that about the end of February or the beginning of 
 iMarch she began to be troubled with pain on the left side. 
 It did not come on at any definite time, but most frequently 
 it came on when she had been standing for some time at her 
 work. She was a grocer's assistant. She had attacks of 
 severe pain from time to time which lasted two or three 
 days. The pain was reheved by sitting down ; but Ipng 
 dovm on the left side was more effective in giving rehef. 
 After these attacks she would be free of pain for a fortnight. 
 On Monday, the 12 th May, when trjdng on a dress, her sister 
 noticed a swelling " over the stomach." She was sent to the 
 doctor, who advised her to go to the Infirmary. She was 
 seen on the surgical side, and sent over to my ward for 
 observation. 
 
 Examination. — The patient was a healthy-looking girl 
 with a ruddy complexion and pleasant expression. She was 
 well nourished. She had menstruated once, a year before 
 admission. On inspection the abdomen showed marked 
 bulging in the epigastrium extending towards the left flank. 
 On palpation a large mass was felt extending from the right 
 costal margin 2 ins. from midhne to | in. below the um- 
 biUcus, then in a straight hne to the left and then upwards 
 in the direction of the posterior axillary line. It was tender 
 on pressure along its anterior margin. The percussion note 
 over it was dull and the dullness was continuous mth the 
 Uver dullness to the right. The hmits of dullness and the 
 area defined by palpation are shown in Fig. 35, marked N. 
 The urine deposited urates but contained no albumin. Blood 
 
3i8 THE KIDNEY 
 
 examination showed slight impoverishment in haemoglobin, 
 and gave a leucocyte count of 15,000 mth 67 per cent, of 
 polymorphs ; later a differential count gave 50 per cent, of 
 pol3'morphs, 35 per cent, of lymphocytes, and 15 per cent, of 
 larger mononuclears. During the first days in hospital 
 she had no pain and slept and ate well. The mass increased 
 in size rapidly. The separator was used and showed marked 
 deficiency in the excretion from the left ureter. On the 3rd 
 June pain was very severe over the abdomen and small of 
 back ; the mass had further increased in size ; the circum- 
 ference of the abdomen where it projected most was 
 29! ins. A rise of temperature of from i to 3 degrees 
 was present for a week. She became pale and collapsed, 
 suggesting that haemorrhage had taken place into the mass. 
 Pain was relieved by means of herom given hypodermically. 
 Her condition continued to be critical for some days. By 
 the 14th June pain subsided so that only a small dose of 
 heroin or morphine was required to ensure comfort. The 
 mass was tender in its upper part, and the circumference of 
 the abdomen measured 31 ins. From this time onward there 
 was an abeyance of symptoms ; her general condition steadily 
 and markedly improved, her colour became ruddy, her cheeks 
 filled up, and she expressed herself as feehng quite well. 
 The mass became less, and it became a question as to what 
 was to be done. Was there to be surgical intervention ? 
 The separator was used again, early in August, and the fluid 
 obtained from each ureter carefully and fully examined in 
 the Department of CHnical Pathology. The amount of 
 fluid from the left ureter was much smaller than from the 
 right. The fluid from the latter showed nothing abnormal ; 
 the fluid from the left ureter contained a few red corpuscles, a 
 few pol3nTiorphs, and a small amount of albumin. No micro- 
 organisms were shown on microscopic examination or on cul- 
 ture. A differential leucocyte count, in a leucocytosis of 10,000 
 gave pol^anorphs 40 per cent., small l5miphocytes 36 per 
 cent., large lymphocytes 20 per cent., eosinophiles 3 per cent. 
 Discussion and Conclusions. — Both these cases were ex- 
 amined and re-examined and discussed with my students 
 
ENLARGEMENT OF THE KIDNEYS 319 
 
 freely. In the first place it was, of course, apparent that in 
 both cases there was a mass in the abdomen that could not 
 be overlooked by the veriest t3a'0. The next question was 
 not what was the character of the mass ? but, what organ 
 had given rise to it or in which of the abdominal organs had 
 it developed ? The importance of this being made, the next 
 question will presently appear. In the first of the two cases 
 the patient came with a diagnosis of enlarged spleen, and 
 from external examination of the abdomen there seemed to 
 be no reason to question it. The mass was extraordinarily 
 Uke a greatly enlarged spleen. The blood revealed no change 
 in its constituents beyond a slight anaemia. There was, 
 however, the history of blood in the urine the day he fainted 
 on parade. This point in the history of this and of other 
 cases nust be regarded as of prime importance. In this case 
 a diagnosis of enlarged spleen seemed to have been reached 
 early, but it is to be noted that this " enlarged spleen " was 
 associated with haematuria which probably led to his being 
 carefully and sparingly dieted when in hospital. It was at 
 this stage the mistake in the diagnosis originated, and it was 
 due to mistaking a big kidney for a big spleen. Whatever 
 difficulties the later history of a case of this kind presents 
 it must be insisted on that at the early stage such a mistake 
 is no longer inevitable and therefore it ought not to be made. 
 Confirmation of the diagnosis can be obtained by the use of 
 the separator. In the advanced stage at which we first saw 
 this patient the problem presented itself of spleen versus 
 kidney, and the warning has already been made as to the 
 great resemblance an enlarged kidney may offer to enlarged 
 spleen. Personally, I and others laid too much stress on the 
 resemblance both as regarded position and configuration. 
 The value of the separator must be emphasized, especially 
 when there is a history of early hsematuria, as was obtained 
 from this patient. At the outset the difficulty in regarding 
 the mass as splenic was that malignant disease of the spleen 
 was usually secondary, and that it did not attain such an 
 extraordinary size. Except mahgnant growth there was no 
 other conceivable change which could give rise to such 
 
320 THE KIDNEY 
 
 enlargement. The great lesson illustrated by the experience 
 of this case was that a mass in this region is almost certainly 
 of renal origin, and that the result obtained by the separator 
 may be taken as conclusive evidence against a splenic 
 tumour. The region of the loin belongs clinically and 
 pathologically to the kidney, not to the spleen. 
 
 The second case, that of the girl aged i6 (Case 94), was 
 not seen by a medical man until the mass had attained a 
 great size. She was under observation in hospital within 
 a week, and as soon as she was seen and examined the 
 question again was : Which organ is this ? The external 
 examination suggested left lobe of hver and perhaps spleen 
 as well. At first the kidney seemed to be excluded. The 
 mass was regarded as a rapidly advancing sarcoma not 
 suitable for operation. There was no history to help ; there 
 had been no S5miptoms of any kind. It may be that the 
 history of a single menstruation a year before was a mistake ; 
 that it may have been a temporary hsematuria and a mani- 
 festation of the early stage of the malady. Hsematuria may 
 be an early manifestation of malignant disease in the kidney 
 and is often the first symptom to attract attention. In 
 this patient the rapid growth of the mass was very striking, 
 and the collapse which occurred soon after her admission 
 seemed so definitely to be due to large haemorrhage into a 
 rapidly advancing sarcoma that there was no thought of 
 operation. She, however, rallied from this attack and the 
 mass shrank somewhat. The general condition improved 
 so much that it challenged the diagnosis of sarcoma. The 
 improvement again raised the question as to which organ 
 was affected. The separator was again used with the result 
 already mentioned. She was also examined by means of 
 X-rays. The result of this examination left no doubt that 
 we had to do \Aith a renal tumour, in spite of the extraordinary 
 resemblance of the mass to a greatly enlarged hver. The 
 extraordinary picture presented by the position of the 
 stomach as revealed by bismuth is shown in Fig. 35, taken 
 by Dr. Hope Fowler. The fundus containing air and marked 
 F is in its normal position, while the body marked S is 
 
FiG.''35- — Case 94. N, neoplasm; F, fundus of stomach containing air; 
 S, stomach containing bismuth; P, pylorus; L, liver; I, small in- 
 testine full of bismuth ; U, umbilicus. 
 
 [To face page 320. 
 
ENLARGEMENT OF THE KIDNEYS 321 
 
 stretched above the upper border of the mass and down its 
 right border to end in P, the pylorus. The liver is marked L, 
 while I shows the small intestine pushed into a clump and 
 containing bismuth. N marks the neoplasm, and U the 
 umbilicus. Operation was agreed to by the parents. The 
 operation was performed by Mr. Wade. It was exceedingly 
 difficult, but the patient soon raUied from the shock of it, and 
 recovered sufficiently to be able to return home. The 
 mass was a malignant kidney. 
 
 This case further strengthens the opinion already ex- 
 pressed that the result of observation made by means of the 
 separator is of leading importance in difficult cases in deter- 
 mining which organ is affected ; and that, when the function 
 of the kidney is so gravely involved as it was in these two 
 cases, the diagnosis of Iddney lesion becomes inevitable. In 
 the case of the girl the radiographic plate was conclusive 
 that the mass was kidney, and for the following reasons — 
 first, the fundus of the stomach would have been com- 
 pressed to the right by a large spleen, and to the left and 
 downwards by an enlarged left lobe of the hver, whereas it 
 was above the mass, occupied its normal position, and was 
 not lessened in capacity ; second, the body of the stomach 
 was stretched out over the upper hmit and down the right 
 limit of the mass as it could not have been were the mass 
 hepatic in origin. 
 
 Again it may be repeated that the question of diagnosis, 
 even in such cases as have been described, Hes between the 
 three organs indicated. A mass in this part of the abdomen 
 never arises from any other structure or tissue or organ. 
 When this is fully accepted the way to correct diagnosis is 
 greatly simplified, and in the great majority of cases is 
 comparatively eas}^ if reasonable skill in the examination of 
 the abdomen has been acquired. 
 
 The Right Kidney 
 
 All the conditions akeady dealt with occur on either side, 
 but on the right the question lies between hver and kidney 
 
 21 
 
322 THE KIDNEY 
 
 instead of spleen and kidney as is the case on the left. The 
 right kidney is, more commonly than the left, movable or 
 floating and difficulty arises more commonly on this side. 
 A displaced fixed kidney may be mistaken for a hver swelling 
 or for gall-bladder ; and a distended gall-bladder has been 
 diagnosed as kidney. The real difficulty is between kidney 
 and right lobe of hver. A palpable swelling in the loin, 
 palpable bimanually, may be either. The difficulty arises 
 usually in mahgnant disease, for mahgnant disease may give 
 rise to a mass projecting from the under surface of the right 
 lobe and very suggestive of enlarged kidne}/ ; while on the 
 other hand an enlarged kidney may suggest the right lobe 
 of the Hver. The history often helps in forming a correct 
 opinion. If there is any doubt, the use of the separator will 
 settle the point. In the great majority of cases no serious 
 difficulty arises, but cases occur in which diagnosis is difficult. 
 Some years ago 1 saw in consultation a man who had spent 
 his working days in India. There was a mass in the upper 
 right segment of the abdomen. He had been seen by more 
 than one consultant in London, and had been examined by 
 means of radiography. There had evidently been a difference 
 of opinion, but he came down to Scotland, with a strong 
 diagnosis of cystic growth in the hver. There was an 
 absence of urinary symptoms ; he had, however, lost weight 
 and deteriorated in strength. On examination there was 
 a large mass fiUing up the loin, readily palpable in front as 
 well as bimanually and which in parts had the resiUency 
 of a cyst. If it were a cyst and in the Hver, as had been 
 strongly insisted on, it could only be a hydatid cyst, and 
 hydatid cyst could be dealt with surgicaUy. At a later 
 conference with Mr., now Sir Harold, Stiles it was agreed 
 that the mass was renal and not hepatic ; that it was a 
 cystic sarcoma and inoperable. At that time the value of 
 the separator had not been estabHshed ; but it is evident 
 that its use in this patient would have saved much difference 
 of opinion, and if used early would have been of vital value to 
 the patient. The case is given here to iUustrate the kind of 
 difficulty which confronts the practitioner and the consultant. 
 
ENLARGEMENT OF THE KIDNEYS 323 
 
 The following case represents another difficulty in this 
 region. A patient, seen with Dr. Hunter, whose general 
 condition had deteriorated, and who had lost weight, was 
 believed to have mahgnant disease of the liver. There was 
 a swelling in the right loin with some pain on pressure, the 
 temperature had risen, and there was friction at the lower part 
 of the right lung. It seemed possible to explain the symptoms 
 and the signs by regarding the swelling as perinephric and 
 inflammatory with a secondary involvement of the pleura. 
 The diagnosis of mahgnant Hver could not, however, be 
 set aside in view of the skill and care with which the case 
 had been watched. Yet suclra febrile attack as was running 
 when I saw the patient seemed not to be satisfactorily 
 explained by pleural metastasis from the hver. The patient's 
 friends were anxious that any operative measures thought of 
 should be adopted, and the patient was Hke-minded. He was 
 accordingly sent into Edinburgh to Professor Alexis Thomson. 
 He leant to the mahgnant hver view, but recognized the 
 importance of the symptoms which had emerged. The 
 abdomen was opened and the sweUing in the loin was found 
 to be the right lobe of the hver showing mahgnant masses 
 on its under surface. The patient recovered from the 
 operation, and although no benefit accrued, every one con- 
 cerned was satisfied that everything possible had been done. 
 
 This case is referred to as it illustrates a principle which 
 sometimes serves as a guide in deciding what advice is to be 
 given. It is this, namely, that if after careful, fuU and 
 skilful examination there is a loophole of hope that a diagnosis 
 may be wrong, or if the opinion between two conditions is 
 balanced fairly evenly, the patient ought to be informed of 
 the doubt and be given the option of operation or of no 
 operation. 
 
CHAPTER XXVII 
 
 BACILLUS COLI INFECTION OF THE URINARY TRACT 
 
 This is one of the most important of the infective conditions 
 occurring in the abdomen. Its place as a clinical entity is 
 of comparatively recent date ; and this may be taken as the 
 explanation of the fact that it is not always diagnosed, nor 
 even thought of. Like other infective conditions the 
 symptoms vary wdthin somewhat wide hmits. Attention 
 may be directed early to the urinary tract by the patient's 
 complaint of frequency of micturition, of some discomfort 
 before, during, or after micturition, and by statements made 
 regarding the appearance of the urine. Examination of the 
 urine may reveal the presence of albumin and blood, and the 
 case be diagnosed as one of nephritis. In some of these 
 cases the temperature is raised several degrees and there may 
 be a history of shivering or rigor. A temperature degrees 
 above normal, rigor, blood in the urine, and no puffiness of 
 the face indicate urinary infection and not Bright's disease. 
 In other cases there is no complaint made which directs 
 attention to this tract, and, as a consequence, questions are 
 not asked which have any relation to it, and the true nature 
 of the case is entirely missed. 
 
 \Vhen knowledge of the phases of the malady is more 
 universal than it seems to be, failure to recognize its presence 
 wiU lessen. A malady cannot be diagnosed if it is not in- 
 cluded among the possibihties. And it is of high importance 
 that this infection should occupy a more definite place in 
 general practice than it apparentl}'^ does. 
 
 It occurs at aU ages, and it may be fatal at any period of 
 life. 
 
 324 
 
BACILLUS COLI INFECTION 325 
 
 In the cases briefly reported at the end of this chapter the 
 occurrence of the malady in a comparatively mild form in 
 children is illustrated. They show that the condition can 
 be easily overlooked in them. 
 
 In adults one's experience is the same. An adult suffering 
 from this infection was diagnosed as a " recurring gastritis ' ' 
 because of abdominal pain and vomiting. There was no 
 evidence of gastric or intestinal malady, but recurring rise 
 of temperature and a swelling in the right loin at once 
 suggested a bacillus coli infection of the urinary tract, which 
 led to a bacteriological examination of the urine and the 
 estabhshment of the diagnosis. Another adult, thought to 
 be suffering from " acute nephritis," presented phenomena 
 which one knew could not be caused by acute Bright 's 
 disease ; and this knowledge, combined with the fact that 
 certain definite phenomena were present, made it practically 
 certain that the patient was suffering from an acute baciUary 
 infection of the urinary tract. Bacteriological examination 
 of the urine established the diagnosis, and led to treatment 
 with an autogenous vaccine which was highly effective. 
 Some time ago I was asked to see a patient who was thought 
 to have pneumonia ; she was running a high temperature, 
 had indefinite phenomena in the limgs, and was semi- 
 comatose. Examination of the chest only revealed bronchial 
 catarrh with evidence of adherent pleura on one side. The 
 condition did not suggest to my mind pneumonia. On 
 examination of the abdomen I found the right kidney to be 
 enlarged and painful. I advised a bacteriological examination 
 of the urine as the case was probably one of baciUary infection. 
 This suggestion was found to be correct. Quite recently I 
 was asked to see a patient who had been confined to bed for 
 weeks Avith recurring attacks of periods of high temperature, 
 the cause of which had not been determined. Examination 
 of the chest revealed nothing abnormal in heart or lungs. 
 On examination of the abdomen the right kidney was found 
 to be enlarged and tender ; a baciUary infection involving 
 the pelvis of the kidney as the cause of the recurring pjTexia 
 was suggested. A bacteriological examination of the urine 
 
326 THE KIDNEY AND URINARY TRACT 
 
 showed this suggestion was correct ; the patient was treated 
 by urotropin and citrate of potash, Mith the result that the 
 recurring pyrexia was stopped. 
 
 Illustrative Cases 
 
 Case 95. — Mary G., aged i6, was admitted on the 29th 
 October, 1917. The child was sent to hospital without a 
 diagnosis. She was ill and had a temperature running between 
 normal and 100 "8° F. On the 2nd November the temperature 
 rose above this hmit, and, in view of the absence of discover- 
 able lesion in the thorax, the urine was fully investigated. 
 It contained pus in small quantity and was swarming v\dth 
 baciUus coli. She was given urotropine and later citrate of 
 potash. On the 3rd November, the temperature reached 
 104°, but by the 7th it became normal and remained normal 
 until she was discharged on 6th December completely 
 recovered. 
 
 Case 96. — Pat. G., aged 9 years, was admitted on the 
 26th Februar}/, 1918, as a case of hsematuria due to nephritis. 
 The urine was found to contain not only blood but pus and 
 bacillus coli. He was treated by urotropine and citrate of 
 potash ; and was discharged cured in April. In this patient 
 there were no symptoms. Three months before admission, 
 his mother had noticed that the urine was red in colour, and 
 took him to the doctor. He had been treated and not 
 allowed to go to school. The red colour of the urine came and 
 disappeared several times before the child was sent to the 
 Infirmary. There had been no complaint of any kind and 
 the boy appeared to be quite well. 
 
 Case 97. — Barbara H., aged 9, was admitted on the 20th 
 August, 1918, as a case of Bright's disease. The face was 
 puffy and there was albumin in the urine. This patient was 
 also found to have a bacillus coU infection. The temperature 
 rose to 101° and 102 '8°. She was treated by hexamine and 
 a bacillus coli vaccine and made a complete recovery. 
 
 Case 98. — Mr. S,, aged 60, was seen in consultation. He 
 had been on holiday for a few weeks and had been in his 
 
BACILLUS COLT INFECTION 327 
 
 usual state of health. The first symptom he observed was 
 increased frequency of micturition, which persisted for some 
 days and was a new experience for him. After a few days 
 of this he suddenly began to feel chilly and unwell, and this 
 was followed by a definite rigor and a rise of temperature to 
 104° and 105°. He returned home, and was seen by his 
 medical attendant. The frequency of micturition continued, 
 and became very troublesome. The temperature ranged daily 
 from normal to 104°. The urine contained blood, some pus, 
 and urates. He was thought to be suffering from acute 
 nephritis. The condition pointed so clearly to an infection 
 by bacillus coli that I suggested having the urine examined 
 and, if the diagnosis was correct, that an autogenous vaccine 
 should be prepared. The patient's temperature was speedily 
 controlled by the vaccine, and in due time complete recovery 
 followed, and the bacillus could no longer be grown from the 
 urine. 
 
 Case 99. — Mrs. McB., aged 56, was admitted, as a re- 
 curring gastritis, to \¥ard 27 on Tuesday, August 23rd, igio. 
 The history obtained from her was that she was well until 
 six weeks before admission. The first symptoms were pains 
 in the knees and legs ; but more severe pain in the lower part 
 of the abdomen (the hypogastrium) , the pain there being 
 continuously present although the severity varied. She felt 
 hot and perspired freely at that time, but did not vomit. 
 Her doctor saw her and kept her in bed for eight days. About 
 a fortnight after this patient had another attack of the same 
 kind, save that the pain was more definitely abdominal in 
 situation, and with the pain there was vomiting. The vomited 
 matter was green in colour and the vomiting came on after 
 taking food. She felt very hot and perspired freely during 
 this attack also. A fortnight after this she was able to be 
 out of bed. On Saturday, the 20th, three days before 
 admission, when attending to her household duties in the 
 forenoon, she felt chilly and shivered ; pain came on in the 
 abdomen, being again most marked in the hypogastric 
 region ; she vomited ; and headache developed. 
 
 Her doctor kindly gave us the information that, during 
 
328 THE KIDNEY AND URINARY TRACT 
 
 the six weeks referred to in the history obtained from the 
 patient, there had been three acute attacks, characterized 
 by abdominal pain, usually vomiting, and a temperature 
 reaching 104° F. in twenty-four hours, and continuing raised 
 for about eight days. 
 
 Such was the histor^r of the patient's illness up to the time 
 ot admission to the Infirmary. 
 
 On admission she complained of abdominal pain. The 
 pain was sometimes referred to the left h3rpochondrium, 
 sometimes passing round the right hjrpochondrium to the 
 back, while at other times it was most marked in the hypo- 
 gastrium with a feehng of distension in this region. A^omiting 
 occurred if she took food. The vomit was greenish in colour. 
 She also complained of headache. The pulse was 107, the 
 respirations 32, and the temperature 100"^ on admission, 
 and 101° in the evening. 
 
 On examination of the abdomen it was noted that there 
 was no rigidity of the abdomen save slightly of the right 
 rectus. There was no tenderness. There was a swelling 
 in the right lumbar region. On being questioned the patient 
 stated that she had difficulty in micturition at times ; that 
 there was a frequent desire to micturate ; that there was 
 pain during and after micturition ; and often a feeling of 
 distension in the region of the bladder. The swelling in the 
 right lumbar region was clearly the right kidney, enlarged 
 but not tender. On examination of the urine it was found 
 to contain pus, and on microscopic investigation showed 
 not only pus cells, but granular and hyaline casts. The blood 
 gave a count of 21,000 leucocytes — the leucocytosis being 
 polymorphonuclear. 
 
 The temperature rose above normal for the first four days 
 but then fell to normal and subnormal. There was a copious 
 deposit of pus in the urine ; the swelling in the lumbar region 
 became smaller and more definite in outhne. She was in 
 this condition when I first saw her. The kidney was large, 
 displaced considerably do\Miwards, and sHghtly tender, 
 A catheter specimen of the urine was obtained and sent to 
 the pathological department for cultural investigation. I 
 
BACILLUS COLI INFECTION 329 
 
 had little doubt that the case would turn out to be one of 
 coliuria. The pus in the urine, the three attacks of fever, and 
 the pain in the bladder all pointed to that conclusion. The 
 condition of the right kidney could be explained on the 
 assumption that there had previously existed a displaced 
 and movable kidney, the pelvis of which had become infected 
 from the bladder, and that owing to a change in the axis 
 of the organ, or to blockage of the ureter by purulent exudate, 
 a pyonephrosis had been determined. When the ureter 
 became patent again the pus escaped, and the swelling 
 rapidly subsided. The kidney retreated into its normal 
 position in the loin, so that ultimately only its lower pole 
 was palpable as the patient lay in bed. The cultural report 
 was that a pure culture of bacillus coU had been obtained 
 from the catheter specimen sent for examination. 
 
 The treatment consisted in administering 10 grs. each of 
 potassium citrate and potassium acetate every four hours 
 until the urine was rendered alkaUne, and then less frequently, 
 but in sufficient quantity to keep the urine alkahne. To this 
 urotropin gr. x. were added three times a day. The pus 
 speedily disappeared from the urine and also aU trace of 
 albumin. As she complained of some pain apparently in 
 the urethra the urotropin was stopped and some tincture 
 of hyoscymus given as a sedative. The patient made a 
 complete recovery. 
 
 Treatment. — The treatment of the condition, when it is 
 recognized is well known and need not be discussed here. 
 I may, however, state that my experience of treatment by 
 means of autogenous vaccine has been most satisfactory ; 
 but it has sometimes to be used in large doses. 
 
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