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DISEASES 
 OF THE INTESTINES 
 
 BY 
 
 Dr. I. BOAS 
 
 SPECIALIST FOR GASTRO-INTESTINAL DISEASES IN BERLIN 
 
 AUTHORIZED TRANSLATION FROM THE FIRST GERMAN EDITION 
 WITH SPECIAL ADDITIONS 
 
 BY 
 
 SEYMOUR BASCH, M. D. 
 
 NEW YORK CITY 
 
 " Nec ultra, nee infra scire' 
 
 IV [TH FORTY-SEl/EN ILLUSTRATIONS 
 
 NEW YORK 
 
 D. APPLETON AND COMPANY 
 
 1 90 1 
 
CoPYRIßHT, 1901, 
 
 By D. appleton AND COMPANY. 
 
AUTHOR'S PREFACE TO THE AMERICAN 
 TRANSLATION 
 
 It affords me great pleasure to make a few introductory 
 remarks to this translation of my recently published Diagnostik 
 und Therapie der Darinkrankheiten. 
 
 When the present book was written, the interest of the pro- 
 fession in the pathology of the alimentary tract had already become 
 very great. Owing to the ease with which diseases of the oesopha- 
 gus and stomach could be investigated, these had been exten- 
 sively studied. Because of their inaccessibility and the difficulty 
 of judging the effect of treatment, our knowledge of affections 
 of the intestine (exclusive, perhaps, of the rectum) was still very 
 meagre. 
 
 JSTotvdthstanding that the classical publications of Woodward 
 and Nothnagel, and the studies in ptomainology and the pathology 
 of metabolism have done much to further our knowledge of in- 
 testinal diseases, we have advanced but little since the days of 
 Henoch, Bamberger, von Leube, and their contemporaries. 
 
 Internal medicine must acknowledge a debt of gratitude to 
 surgery, for the surgeon has contributed most to the progress 
 that has been made. Our knowledge of appendicitis, intestinal 
 obstruction and stenosis, and benign and malignant tumours has 
 been greatly enriched by the results obtained from surgical treat- 
 ment, and this progress is still going on. It is universally con- 
 ceded that the American profession has contributed much toward 
 this end, and in many parts of this work I have acknowledged 
 this indebtedness. Numerous references to American authors will 
 be found throughout the book. 
 
jy DISEASES OP THE INTESTINES 
 
 It mii^ht be inferred from this that my treatise contains little 
 that is unknown in America, but I trust that the American reader 
 will find some useful diagnostic and therapeutic hints in the fol- 
 lowing pages. 
 
 I desire to express raj thanks to my former assistant, Dr. Basch, 
 for having undertaken and carried to a successful conclusion the 
 work of translation. 
 
 I trust that the American edition will meet with the same 
 success that has attended the original in Germany. If it will 
 aid the practitioner in solving some of the difficult problems in 
 intestinal pathology and assist him in the treatment of his patients, 
 the author will feel that his labours have not been in vain. 
 
 I. Boas. 
 
 Berlin, February, 1901. 
 
TRANSLATOE'S PREFACE 
 
 The popularity which Dr. Boas's treatise has enjojed abroad, 
 and the absence in the Enghsh language of any detailed and 
 exhaustive work on intestinal diseases, have led to the publication 
 of the present translation. 
 
 The book is intended more especially for the requirements of 
 the general practitioner, but on account of the exhaustive and con- 
 cise description of physiologico-chemical processes and laboratory 
 methods, it must also prove of value to other scientific investigators. 
 
 Additions have been made to the chapters on Appendicitis and 
 Hydrotherapeutics, a special account given of the intestinal gases, 
 and brief notes added in various parts of the book. These are 
 indicated by [ ]. 
 
 1 wish to express my sincere thanks to Dr. S. JSTeuhof, of this 
 
 city, for valuable assistance in the preparation of this work for 
 
 the press, and to the publishers, D. Appleton and Company, for 
 
 the many courtesies extended to me. 
 
 S. Basch. 
 48 East Sixty-third Street, 
 New York, March, 1901. 
 
PREFACE TO THE FIRST GERMAN EDITION 
 
 The present treatise is the final volume of the author's work on 
 the diagnosis and treatment of the diseases of the gastro-intestinal 
 tract. In this book I have closely followed along the lines laid 
 down in my earlier work on Diseases of the Stomach. It has 
 been my aim throughout to meet the requirements of the general 
 practitioner. 
 
 Without neglecting those diseases which are generally met with 
 in hospital practice, I have given special prominence to the affec- 
 tions which the private practitioner is called upon to treat — e. g., 
 intestinal catarrhs and ulcers, duodenal ulcer, chronic constipation, 
 rectal diseases, intestinal neuroses, etc. I have devoted no space to 
 the discussion of intestinal parasites, and would refer the reader 
 to standard text-books of medicine or the numerous monographs 
 on the subject. 
 
 In many of the chapters I have drawn upon my own experi- 
 ence as gained both in a large polyclinic and hospital practice. I 
 hope that I have been able to add some new and j)erhaps valuable 
 facts to the pathology and treatment of intestinal diseases. 
 
 "While physical methods have been so thoroughly studied that 
 only technical differences remain, examination of the fgeces has 
 heretofore been very much neglected. Whereas putrid sputa, 
 badly smelling lochia, offensive secretions of uterine cancer in 
 themselves no longer offer serious objection to examination, most 
 physicians cannot accustom themselves to the analysis of the 
 intestinal dejecta. This may in part be due to the circumstance 
 that deductions can be drawn only after repeated careful exami- 
 nations. This latter consideration should not, however, influence 
 
PREFACE TO THE FIRST GERMAN EDITION vii 
 
 the conscientious physician, for urine and sputum, too, are very 
 often examined with negative results. 
 
 Since many intestinal diseases may require surgical interference 
 at any moment, I have felt it necessary in a number of chapters to 
 define my position in this respect. As an internal practitioner I 
 have naturally little sympathy with extreme radical measures, and, 
 with increasing experience, beheve with conservative surgeons 
 that we have almost reached the limits of possibility in intestinal 
 surgery. 
 
 As in diseases of the stomach, abdominal surgery has also made 
 considerable advance within the last decade in diseases of the in- 
 testines. If the medical practitioner wishes to keep abreast of 
 progress he must follow these advances with the greatest con- 
 scientiousness, and consider carefully the changes made from time 
 to time in surgical technic, noting the results obtained there- 
 from. Should he have the good fortune to be associated with 
 a skilful abdominal surgeon, he should use every opportunity to 
 witness operations upon the intestine. This sharpens the judg- 
 ment, demonstrates the knowledge or ignorance of surgery, and 
 indicates to us, even better than cumbersome and frequently col- 
 oured statistics, the manner in which we must proceed in serious 
 cases. As I have already stated in another place, I must again 
 emphasize that the indications for operative procedures in diseases 
 of the stomach and the intestines, as well as of the liver and gall 
 bladder, is a matter which rests mainly with the medical practi- 
 tioner. He should bear the responsibility for the operative inter- 
 ference, while the surgeon should be responsible for the technic. 
 The placing of the responsibility in one's hands implies the 
 greatest confidence on the part of the patient and his family, and 
 the medical practitioner can only accept such responsibility when 
 he has recognised the disease in time, and is in a position to judge 
 whether or not a surgical procedure is indicated, and with what 
 prospects of success. 
 
 In discussing these difficult and very important questions, I 
 have agreed in most respects with the views of early writers. 
 
yi-ji DISBASES OF THE INTESTINES 
 
 In stating my views I have endeavoured to include theirs. In 
 this connection I feel called upon to express mj admiration for 
 the epoch-making treatise on intestinal diseases of Professor 
 Nothnagel, of Yienna, and my appreciation of his classical 
 studies on the physiology and pathology of the intestines. 
 
 Finally, I take great pleasure in acknowledging my thanks to 
 my publisher, Mr. George Thieme, of Leipsic, for the careful 
 preparation of the work. I desire also to thank Miss Paula 
 Günther, of Berlin, and my former assistant. Dr. Reitzenstein, 
 of Nürnberg, for the excellent execution of the drawings. 
 
 The Author. 
 
 Berlin, July, 1899. 
 
CONTENTS 
 
 PAGE 
 
 Author's preface to the American translation iii 
 
 Translator's preface t 
 
 Preface to the first German edition vi 
 
 INTRODUCTOEY 
 
 CHAPTER 
 
 I. — Preliminary anatomical and histological remarks ... 1 
 
 Appendix. Displacements of various segments of the intestines 20 
 
 II. — Preliminary physiological and physiologico-chemical remarks , 24 
 
 [The intestinal gases] 46 
 
 PART I 
 
 GENERAL DIVISION 
 
 III. — The history 55 
 
 IV. — The examination of the patient 67 
 
 Appendix. The* employment of Röntgen rays in the diagnosis of 
 
 intestinal diseases 88- 
 
 V. — Examination of the f^ces 90 
 
 VI. — Diagnostic value of the examination of stomach contexts in 
 
 intestinal diseases 129 
 
 VII. — Diagnostic value of urinary examinations in intestinal dis- 
 eases 132 
 
 GENERAL THERAPEUTICS OF INTESTINAL DISEASES 
 
 VIII. — The dietetic treatment of intestinal diseases .... 139 
 IX. — The hydrotherapeutics of intestinal diseases [including mineral 
 
 WATERS OF THE UnITED StATES] 158 
 
 X. — Massage. Electro- and hydrotherapeutics in intestinal diseases 170 
 XL — Injections (enemata. intestinal lavage, and douches), inflation, 
 
 and gastric lavage in intestinal diseases 177 
 
 XII. — Medicinal treatment of intestinal diseases 186 
 
 ix 
 
DISEASES OF THE INTESTINES 
 
 PART II 
 SPECIAL DIVISION 
 
 CHAPTER PAGE 
 
 XIII. — Acute and chronic intestinal catarrh 205 
 
 XIV. — Habitual constipation. Displacements of the intestines . . 240 
 
 XV. — ulcers of the intestines . . . 261 
 
 XVI. — Round ulcer of the duodenum 280 
 
 XVII. — Intestinal neoplasms 296 
 
 XVIII. — Intestinal stenosis and intestinal obstruction .... 342 
 
 XIX. — Typhlitis, perityphlitis (appendicitis) 430 
 
 [Brief resume of the American views on appendicitis] . . 466 
 
 Appendix. Sigmoiditis and pericolitis 473 
 
 XX. — Diseases of the rectum » = . . 482 
 
 XXI. — Nervous diseases of the intestines ...... 521 
 
 List of subjects ; . . . 543 
 
 List of authors 557 
 
LIST OF ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 1. Anterior view of the abdominal viscera 3 
 
 2. Perpendicular section of adult human jejunal mucous membrane . . 6 
 
 3. Intestinal epithelium 7 
 
 4. Section of mucous membrane of human duodenum 7 
 
 5. Surface of mucous membrane of the small intestine 9 
 
 6. Cross section of intestinal mucous membrane 9 
 
 7. Section of mucous membrane of the small intestine thi'ough a Peyer's 
 
 patch 10 
 
 8. Anterior view of the abdominal viscera after removal of the jejunum and 
 
 ileum 11 
 
 9. Opening of the ileum into the large intestine 13 
 
 10. Male pelvic organs, viewed from the i-ight side 17 
 
 11. Herzstein's rectoscope 81 
 
 13. Spirals of undigested meat fragments in faeces 98 
 
 13. Different vegetable substance found in faeces 114 
 
 14. Fatty stools, showing a large amount of fatty acid crystals . . . 115 
 
 15. Fatty soaps in fasces 116 
 
 16. Normal and degenerated epithelial cells from the mucous shreds of a 
 
 case of membranous enteritis 118 
 
 17. Faeces from a case of chronic enteritis, showing sarcina^ .... 130 
 
 18. Bacillus butyricus {Clostridium biityricum) stained with iodin . . 132 
 
 19. Charcot-Leyden crystals from fiBces 138 
 
 20. Yellow calcium salts from fasces 135 
 
 31. Bismuth crystals from fjeces 126 
 
 32. [Position of hands and direction of movements in abdominal massage] . 171 
 
 23. Electric rectal tube 174 
 
 24. Vermiform appendix in contact with the under surface of the liver . 357 
 
 25. Vermiform appendix lying behind the right lobe of the liver . . . 257 
 
 36. Double looping of the transverse colon 358 
 
 37. Double looping of the sigmoid flexure 858 
 
 38. Multiple looping of the sigmoid flexure 359 
 
 39. Tuberculosis of the ca?cum 365 
 
 30. Multiple polypi of the rectum 335 
 
 31. Ulcer of the duodenum, with secondary stenosis of the second portion 
 
 and dilatation of the flrst portion 351 
 
 33. Strangulation by a broad peritoneal band passing between two adjacent 
 
 coils of ileum 371 
 
 33. Strangulation of small intestine by a solitai-y band attached at either end 
 
 to the mesentery 371 
 
xü DISEASES OF THE INTESTINES 
 
 PAGE 
 
 FIGURE 
 
 34. Strangulation of a small intestinal coil by a long ligamentous strand . 372 
 
 35. Internal strangulation of an intestinal coil by a strand passing from the 
 
 omentum or transverse colon to the anterior abdominal wall . . 372 
 
 36. Internal strangulation of a loop of small intestine by a Meckel's diver- 
 
 ticulum coiled about it . . . ^ 373 
 
 37. Sigmoid flexure showing a tendency to volvulus formation . . . 377 
 
 38. A. Type rectum en arriere. B. Type rectum en avant .... 377 
 
 39. Schematic drawing to illustrate a knotting together of ileum and sig- 
 
 moid flexure 379 
 
 40. Schematic drawing to illustrate a simple intestinal invagination . . 383 
 
 41. Ileo-cfecal intussusception 385 
 
 ^. Complete rectal fistula 488 
 
 43. Incomplete internal rectal fistula 488 
 
 44. Incomplete external rectal fistula 488 
 
 45. Tubercular anal and rectal ulcer, with hemorrhoidal nodule . . . 495 
 
 46. Rectal support . 508 
 
 47. Peristaltic restlessness of the small intestines and descending colon . 526 
 
INTRODUCTORY 
 
 CHAPTER I 
 
 PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS* 
 
 The intestinal canal is that portion of the alimentary tract which 
 is situated below the pylorus. The small intestine has for its main 
 function the digestion of unassimilated food ; the large intestine 
 serves for the reception and propulsion of undissolved and waste 
 food products until their expulsion from the body. Occasionally 
 the large bowel, especially the rectum, is called upon to digest and 
 absorb nourishment, but this vicarious process of nutrition is not 
 adequate to support life a long time. 
 
 SMALL INTESTINE 
 
 The small intestine, a small, thin-walled tube about 1 metres 
 long, extends from the pylorus to the right iliac fossa, where, after 
 becoming extremely convoluted, it finally opens into the large intes- 
 tine. It is divisible into three portions, which vary as regards length 
 and calibre — viz., duodenum, jejunum, and ileum. 
 
 1. Duodenum 
 
 The duodenum, about 30 centimetres long and 4 to 6 centimetres 
 wide, is the widest and at the same time least movable portion of 
 the small intestine. It describes a horse-shoe curve, the convexity 
 of which is directed toward the right and downward, its concavity 
 embracing the head of the pancreas. Owing to its peculiar form 
 the duodenum is divided into three segments : superior horizontal 
 portion {pars horizontalis stoperior)^ a descending portion {2)ars 
 descendens)^ and an inferior ascending portion {pars horizontalis 
 inferior) {seu oblique ascendens, seu transversa). 
 
 The pars horizontalis superior., the shortest division (5 centi- 
 metres long), commences at the pylorus at the level of the first 
 
 * In writing the present chapter use has been made of the more popular text- 
 Ujooks of anatomy, especially A. Rauber's Lehrbuch der Anatomie, Leipzig, 1892. 
 
DISEASES OP THE INTESTINES 
 
 lumbar vertebra. From here it passes slightly upward, backward, 
 and to the right, thus gaining the right side of the vertebral column. 
 Ascending to the neck of the gall bladder, it then bends abruptly 
 
 Fig. 1.— Antekior View of the Abdominal Viscera ("/s). 
 (The liver is turned upward, thereby drawing the stomach and duodenum slightly 
 upward and to the right.) i, left lobe of liver; 2, lobus quadratus; S, right lobe of liver; 
 4, gall bladder ; 5, round ligament of liver ; 6, fundus of stomach ; 7, greater curvature ; 8; 
 lesser curvature ; 9, horizontal portion of duodenum ; 10, descending portion of duodenum ; 
 il, lesser omentum ; i^, spleen; i,?, jejunum ; i.^, ileum ; i5, ascending loop of ileum ; Iff, 
 ca3cum ; 17, vermiform appendix ; 18, ascending colon ; 19, hepatic fle.xure ; 20, transverse 
 colon ; 21, splenic fle.xure ; 22, descending colon ; 23, sigmoid flexure ; 24, bladder. ( Rauber.) 
 
 dowuM^ard, and is continued as the pars descendens. The superior 
 horizontal portion is invested by peritoneum, both anteriorly and 
 posteriorly, and behind is in relation with the hepatic duct and the 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 3 
 
 blood-vessels passing to the liver (the portal vein and the hepatic 
 artery). This part frequently is found stained with bile. 
 
 The fars descendens duodeni, which begins at the neck of the 
 gall bladder, is twice as long as the first portion. It passes almost 
 vertically downward in front of the right kidney and to the right of 
 the vertebral column, about as far as the third or fourth lumbar 
 vertebra. The transverse colon crosses at right angles in front of 
 it. The common bile duct opens into the descending portion just 
 before the latter merges into the pars horizontalis inferior. The 
 duct descends behind the left border of the descending portion, and 
 then, together with the pancreatic duct, which accompanies it for a 
 short distance, penetrates the wall of the gut. Thus a kind of 
 longitudinal swelling is formed, at whose lower end the common 
 opening of the ducts is situated. This opening is frequently hol- 
 lowed out — the diverticulum Vateri. 
 
 The lower transverse portion — the pc(/rs horizontalis inferior.^ 
 or, more correctly, the pars ascendens — equals or even exceeds in 
 length the portion just described. It ascends obliquely from right 
 to left, reaching the left side of the second lumbar vertebra, where, 
 making a sharp bend — the flexura duodeno jejunaUs — it merges 
 into the jejunum. It passes behind the origin of the transverse 
 mesocolon and the mesentery, while the abdominal aorta and the 
 vena cava lie in front of this division. A short, fibrous, muscular 
 strand, derived from the left crus of the diaphragm (the suspensory 
 muscle of the duodenum), retains this portion of the duodenum in 
 place. Thus, in contrast to the stomach, and especially to the large 
 intestines, the duodenum is usually fixed ; nevertheless, as a result 
 of marked distention and traction, it may descend to a greater or 
 lesser degree. 
 
 2. jEJinsruM and Ileum 
 
 The jejunum and ileum, which together have received the name 
 of intestimitn niesentericum, merge into each other without any 
 sharply defined line of separation. Formerly the term jejunum was 
 applied to those portions of the small intestines which lie in the 
 umbilical region and in the left iliac fossa, while the ileum included 
 the portions in the right half of the abdomen, in the right iliac fossa, 
 and in the pelvis. There are no marked differences in the structure 
 of these two divisions. According to Hyrtl, three fifths of the 
 small intestine below the duodenum constitute the jejunum and the 
 remaining two fifths the ileum. The great mobility of the small 
 
4 DISEASES OF THE INTESTINES 
 
 intestines does not permit of any constant position of the coils, but 
 in general the upper coils lie more transversely and the lower more 
 vertically. This mobility, however, is of the greatest practical im- 
 portance ; it allows of the adaptation of the intestines to the most 
 ■diverse conditions of the abdominal cavity, and also of their gliding 
 aside when the cavity is filled with serous or other effusions. 
 
 The mesentery, which binds the ileo-jejunum to the spinal col- 
 umn, is of great importance. Fan-shaped, it spreads from its origin 
 {radix meseriterii) and lies in many folds. Its edges are attached to 
 the small intestines by means of a small slip, the mesenteric border. 
 
 Blood-vessels, lymphatics, and nerves run between the two layers 
 of the mesentery. They enter the wall of the intestines at the 
 mesenteric border and terminate at the opposite free side. 
 
 The arteries supplying the duodenum are derived partly from 
 the coeliac axis and partly from the superior mesenteric artery, as 
 follows : The coeliac axis gives off the hepatic artery, which sup- 
 plies the liver. The gastro-duodenal branch of the hepatic artery 
 passes behind the stomach at the junction of the pylorus and the 
 horizontal portion of the duodenum, and in turn gives off the pan- 
 creatico-duodenalis superior, which supplies the duodenum and the 
 pancreas. In addition to the latter vessel the duodenum is also 
 supplied by the pancreatico-duodenalis inferior, a branch of the 
 superior mesenteric artery. The latter vessel passes beneath the 
 pancreas, while its branch (the pancreatico-duodenalis inferior) 
 winds upward and to the right, passing between the lower half of 
 the duodenum and the head of the pancreas, and ultimately anasto- 
 moses with the pancreatico-duodenalis superior. 
 
 The jejunum and ileum are supplied by branches of the superior 
 mesenteric {artericB hitestinales). They pass between the layers of 
 the mesentery, dividing forklike, and finally form a rich capillary 
 network throughout the entire intestinal wall. The lower end of 
 the ileum alone receives its blood supply from branches of the ileo- 
 colic (colica-dextra), which latter, in part, also supply the cfiecum and 
 the vermiform process, and, in conjunction with the superior mesen- 
 teric, the lower end of the ileum. 
 
 Thus, we see, a dense network of the most delicate blood-vessels 
 extends throughout the entire mesentery of the small intestines, 
 piercing the muscular layers of the gut and penetrating to the sub- 
 mucosa, where a second network is formed which supplies the 
 mucous membrane, the folds, vilH, and glands of the mucosa. 
 
 The veins which carry the blood from the intestines into the 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 5 
 
 portal vein have a course differing somewhat from their correspond- 
 ing arteries ; viz., the branches corresponding to the gastro-duodenal 
 artery (i. e., the gastro-epiploica and the pancreatico-duodenal) empty 
 into the superior mesenteric vein. 
 
 The lyinjyhatics may be divided into two sets, a superficial and 
 a deep. The superficial originate in the muscularis (subserous 
 lymphatics), while the deeper originate in the mucous membrane, 
 the villi, and the solitary follicles (submucous lymphatics). Both 
 sets unite at the mesenteric border of the small intestine and then 
 pass between the layers of the mesentery. Owing to their physio- 
 logical significance, they are called lacteals. 
 
 The nerves of the small intestines are derived chiefly from the 
 superior mesenteric plexus of the sympathetic. The hepatic plexus, 
 an offshoot of the coeliac plexus, gives branches to the duodenum. 
 Furthermore, the small intestine is supplied by the abdominal por- 
 tion of the vagus ; viz., the anterior and posterior gastric plexuses. 
 The nerves, which are for the most part non-medullated, accompany 
 the branches of the sujDcrior mesenteric artery to the intestinal wall, 
 and there form a subserous meshwork ; they then pierce the longi- 
 tudinal muscular layer, forming between the latter and the circular 
 layer a network consisting of numerous multipolar cells — the mes- 
 enteric plexus of Auerbach. 
 
 From the latter delicate nerve branches supply the muscularis ; 
 others penetrate the circular muscular layer to the submucosa, 
 where they form the submucous or Meissner nerve plexus — a very 
 fine network of nerves containing small ganglion-cell groups. 
 Bundles of nerve fibres pass from this plexus to the muscularis 
 nmcosse and to the muscularis of the villi, and are then lost in the 
 mucous membrane. 
 
 Histology of the Small Intestines 
 
 The wall of the small intestines is composed of four coats : 
 tunica serosa, muscularis, submucosa, and mucosa (Fig. 2, page 6). 
 
 The serous coat (peritoneum), as has been already mentioned 
 (page 2), does not uniformly invest the small intestines. Practically 
 speaking (and this is especially of surgical interest), the descending 
 portion of the duodenum is covered only upon its anterior surface 
 by the serous layer, while the superior and inferior horizontal por- 
 tions are inclosed by both folds of the mesocolon. The serous layer 
 is most adherent at the free border of the intestines, and but loosely 
 adherent at the mesenteric border. 
 2 
 
6 
 
 DISEASES OF THE INTESTINES 
 
 The muscularis of the intestines consists of two layers of un- 
 striped muscle fibres: a thick inner circular, and a thin external 
 longitudinal layer. Toward the ileum the layers gradually become 
 thinner. 
 
 Artifacts 
 Perpendicular section of the villi^ 
 
 Epithelium- 
 
 Tunica 
 propria- 
 
 Tunica 
 propria. 
 
 Muscularis 
 mucosce- 
 
 Submucosa,'' ~ \ / ' j 
 
 Intestinal glands Oblique section of intestinal glands 
 
 Fig. 2. — Perpendicular Section of Adult Human Jejunal Mucocs Membrane ( x 80). 
 During fixation the tunica propria of the villi retracted and became separated from the 
 epithelium, thus causing a space at a and a tear at h. The dark spots in the villi, at the 
 right-hand side of the figure, are goblet cells. (After Stöhr.) 
 
 The submucosa is composed of loose retiform tissue, and sup- 
 ports the above-described numerous blood and nerve plexuses. 
 The muscularis mucosm consists of smooth muscle fibres, an inner 
 circular and an outer longitudinal layer. From it fibres pass per- 
 pendicularly and inwardly, almost reaching the apices of the intes- 
 tinal villi. By their contraction they may cause shortening of the 
 villi. 
 
 The epithelium of the mucosa (Fig. 3) consists of a single layer 
 of cylindrical cells. We may distinguish two forms : cylindrical 
 epithelium with a basement membrane, and the goblet cells. The 
 significance of this basement membrane is still a matter of contro- 
 versy. According to the latest investigations, we must here recog- 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 
 
 A B 
 
 Fig. 3. — Intestinal Epithelium ( x 560). 
 A, goblet cells of rabbit (at x protrusion of mucus) ; 
 B, portion of a section of human small intestine ; b, a goblet 
 cell between cylindrical cells. (Stöhr.) 
 
 nise a very delicate skeletal framework with free interspaces ; througli 
 tliese latter, very fine protoplasmic prolongations of the epithelial 
 cells can be thrust 
 and again withdrawn. 
 Thus, the chief seat of 
 absorption is evident- 
 ly in the basement 
 membrane of the epi- 
 thelial cells. The 
 goblet cells have an 
 oval, not infrequent- 
 ly a gobletlike, form, 
 the upper (free) part 
 being more or less filled with mucus, which results from a proto- 
 plasmic metamorphosis, while the nucleus lies at the base of the 
 cell. They have no basement membrane, but have a sharply 
 
 defined opening at their free border, 
 through which the mucus is poured 
 into the intestines. Leucocytes are 
 present in varying numbers between 
 the epithelial cells. 
 
 The tunica projpria consists main- 
 ly of reticular connective tissue, with 
 here and there numerous leucocytes. 
 Owing to the size and number of the 
 glands of the large intestines, the 
 tunica propria is insignificant form- 
 ing little more than the intervening 
 substance between the glands and a 
 narrow strip of basement substance. 
 In the small intestines the tunica pro- 
 pria forms numerous cylindrical pro- 
 jections from the inner surface of the 
 gut, the projections being 0.5 to 0.7 
 millimetre in height and 0.1 to 0.2 
 millimetre in width ; these are the 
 so-called intestinal villi (Fig. 4). In 
 the duodenum they are leaflike in 
 shape. To a certain extent their 
 functions are like those of the roots of trees, inasmuch as they dip 
 directly into the nutritive material in the intestinal canal, and absorb 
 
 ah a. 
 
 Fig. 4. — A. Section of Mucoits Mem- 
 brane OF Human Duodenum 
 (xlO). 
 a, villi ; b, basement substance of 
 the mucous membrane ; c, Brunner's 
 glands ; d', deepest layers of the sub- 
 mucous tissue. 
 
 B. Transverse Section of Isolated 
 Glands. 
 a a, with lumen ; J, without lu- 
 men. (Eauber.) 
 
8 DISEASES OF THE INTESTINES 
 
 all of it thereof tliat can be taken up (A. Kauber). The total num- 
 ber of villi is estimated as over ten million. Each villus contains a 
 central chyle space, or villous sinus, which is a club-shaped expan- 
 sion of the lacteals of the intestinal mucous membrane, and is lined 
 with endothelium. The larger villi contain several of these spaces. 
 The blood-vessels of the villi spread out in the reticular tissue 
 between the external and internal endothelium. This rich capillary 
 network may cause erection of the villi, while the previously men- 
 tioned offshoots from the muscularis mucosee cause their rhyth- 
 mical contractions. TJius the villi act as simple and yet complete 
 suction pumps. The villi are most numerous in the duodenum, 
 gradually diminishing in number in the ileum. Each villus receives 
 its blood supply from one or more arterial branches which, dividing, 
 form a meshwork near the epithelium, from which meshwork the 
 corresponding vein arises. 
 
 A similar arrangement, intended for the greatest possible absorp- 
 tion and a uniform distribution of nutritive material, is found in the 
 so-called folds of Kerckring {valvulce conniventes Kerchringii). 
 These occupy one half to two thirds of the transverse circumference 
 of the mucous membrane, and are found close together in the upper 
 third of the small intestine. They are absent in the upper third of 
 the transverse portion of the duodenum. They number about eight 
 hundred, and the distances between the individual folds, according 
 to Sappey, average 15 millimetres. In the upper third of the small 
 intestines their height and the intervals between them are uniform ; 
 in the middle they diminish both in height and breadth, and finally 
 disappear in the lowermost coils of the ileum. 
 
 Glands form another constituent of the mucous membrane of 
 the small intestines. The liver and the pancreas should be reckoned 
 among these, since their secretions form an important — indeed, an 
 indispensable — part of the intestinal juices. Since these are inde- 
 pendent abdominal organs, their structure can not be entered into 
 here. We have already discussed the openings of the ducts of these 
 glands (page 3). The glands proper of the intestines are of two 
 varieties: secretory and agminated. The first variety includes 
 Brunner's and Lieberkiihn's glands; the second variety includes 
 the so-called solitary blind follicles and Peyer's agminated glands 
 (Peyer's patches). Brunner's glands (Fig. 4), which are found 
 almost exclusively in the upper part of the duodenum, are spread 
 over an area of from 8 to 10 centimetres from the pylorus. They 
 are conglomerate tubular glands whose bodies lie within the sub- 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 9 
 
 Fig. 5. — Surface of Mucous Membrane of 
 THE Small Intestine. 
 i, openings of Lieberkiihu's glands ; f , villi. 
 (Eauber.) 
 
 mucosa. Their terminal portions are lined with cylindrical cells 
 having a lightly coloured granular protoplasm and an oval nucleus 
 which lies near the periphery. The cells are best found by dissect- 
 ing away the muscularis from without. 
 
 In structure, Lieberkiihu's glands (Figs. 5 and 6) resemble closely 
 the tubular glands of the stomach ; they are evidently the true se- 
 creting glands of the small in- 
 testines. They are present in 
 enormous numbers throughout 
 the mucous membrane of both 
 small and large intestines. They 
 are club-shaped and rounded off 
 both above and below. Like the 
 glands of the stomach, they are 
 also seldom branched. They 
 measure from 0.3 to OÄ milli- 
 metre in length, their total num- 
 ber being estimated by Sappey 
 at forty to fifty million. Ac- 
 cording to Drasch, the glands 
 
 are surrounded by a fine network of capillaries" and nerves. They 
 generally terminate in circular openings between the villi, and when 
 viewed with a lens give the mucous membrane a honeycomb appear- 
 ance. As is well known, the solitary lymph nodules (solitary fol- 
 licles) are also met with in the 
 oesophagus and stomach. They 
 are quite uniformly distributed 
 throughout the surface of the 
 small intestine. They have an 
 elongated oval shape and are as 
 large as millet seeds, but under 
 pathological conditions may reach 
 the size of a pea, or even larger. 
 They extend deeply below the sub- 
 mucosa. As regards their finer 
 structure, this consists of adenoid 
 tissue and usually contains a ger- 
 minal centre. The leucocytes so 
 frequently present in the follicles 
 may pass into the lymphatic vessels or, by piercing the epithelium, 
 may enter into the lumen of the intestines. 
 
 Fig. 6. — Cross Section of Intestinal 
 Mucous Membrane ( x 150). 
 Showing Lieberkühn's glands with 
 their epithelial cell-lining embedded in 
 the adenoid tissue of the raucous mem- 
 brane, from which the cells are partially 
 absent. (Rauber.) 
 
10 
 
 DISEASES OF THE INTESTINES 
 
 Peyer's patclies occur in the ileum as elongated plaques, from 
 2 to 10 centimetres in length and from 1 to 3 centimetres in 
 breadth, their long axis corresponding to that of the gut. They 
 are never situated at the mesenteric border. Occasionally they are 
 met with in the jejunum, or even higher up, in the duodenum. 
 Usually twenty to thirty such plaques are present. They are made 
 up of groups of soHtary nodules spread out over a flat surface (Fig. 
 7) ; occasionally they become flattened from pressure. The mucous 
 membrane covering the glands is, as a rule, thrown into folds, but 
 it has no viUi. Yilh are, however, frequently present as flat folds 
 upon the intervening elevations (Henle). 
 
 Y\v,. 7.— Section of Ml-cocs Membrane of the Shall Intestine through a Peyer's 
 Patch, the Chyle Vessels being Injected. 
 a, villi; c, follicles: fZ, projections of the latter toward the surface; </, //., «, lymphatic 
 network around the follicles ; h^ efferent blood-vessels. (Frey.) 
 
 The branches of the chyle vessels form numerous meshes about 
 the glands, and communicate with them by means of very delicate 
 projections. These projections permit the passage of newly formed 
 lymph cells into the lymph channels, for Peyer's patches are breed- 
 ing places for lymph cells (A. Raul)er). 
 
 LARGE INTESTINE 
 
 The large intestine (Fig. 8, page 11), the lower division of the 
 intestinal canal, commences in the right iliac fossa, and thence 
 ascends along the right posterior wall of the abdomen to the right 
 hypochondrium. Here it comes in contact with the under surface 
 of the liver, and, bending to the left, passes transversely and slightly 
 upward to the spleen. There, in the left hypochondrium, it bends 
 downward and descends along the left side of the abdomen to the 
 left iliac fossa, and thence onward into the jDelvis. The large intes- 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS H 
 
 tine measures about 1.5 metres in length (according to Sappey, 
 exactly 1.68 metres), and varies in diameter from 5 to 8 centimetres. 
 Its diameter gradually diminishes from the csecum downward. The 
 
 Fig. 8. — Anterior View of the Abdominal Viscera after Eemoval of the Jejunum 
 
 AND Ileum ( x Ys). 
 (Liver and stomach are turned up, the jejunum and ileum, excepting their two ends, 
 removed, the mesentery is retained), i, left lobe of liver ; 2, lobus quadratus ; <?, right lobe 
 of liver ; 4-, gall bladder ; 5, round ligament of liver ; 6, fundus of stomach ; 7, greater curva- 
 ture; ^, lesser curvature ; S, pylorus ; iO, duodenum ; i7, pancreas ; I^, spleen; iJ, jejunum; 
 14-, mesentery ; i5, ileum ; 16, csecum ; i7, vermiform appendix ; 18, ascending colon ; 19, 
 hepatic flexure ; 20, transverse colon ; 21, splenic flexure ; 22^ descending colon ; 23, sigmoid 
 flexure ; ;g.^, bladder. (Eauber.) 
 
 dimensions just given may be greatly altered by pathological con- 
 ditions. 
 
 The large intestine differs from the small not only in calibre but 
 
12 DISEASES OP THE INTESTINES 
 
 also l)y having tliree narrow longitudinal bands of unstriped muscle 
 fibres iligamenta or tcenia coli). These begin in the csecum at a 
 point corresponding to the insertion of the vermiform appendix. 
 Through them the intestine is thrown into numerous sacculi {hcmstra 
 coli), separated from one another by deep folds {sulci transversi). 
 These folds and pouches do not exist in the rectum, hence the 
 latter is readily distinguished from the other portions of the large 
 intestine. 
 
 As regards its course, the large intestine is divisible into 
 
 1. A bhnd, pouchlike commencement, the ccecum, with the 
 vermiform appendix. 
 
 2. An ascending portion, colon ascendens. 
 
 3. A transverse portion, colon transvcTsum. 
 
 4. A descending portion, colon descendens. 
 
 5. The portion within the left iliac fossa, flexura sigmoidea 
 {S. romamim). 
 
 6. The rectum. 
 
 Each of these subdivisions requires separate consideration. 
 
 1. C^CUM AND YeKMIFOEM ApPENDIX 
 
 The blind gut is that portion of the large intestine lying imme- 
 diately below the termination of the ileum. Its length is subject to 
 wide fluctuations, variously estimated from -± to 12 centimetres. 
 According to Henle, the average length is 5.5 centimetres. Its 
 width almost equals its length. The ciBCum lies in the right iliac 
 fossa above the middle of Poupart's ligament, and is in contact 
 anteriorly with the abdominal wall. When immoderately long, it 
 may extend into the small pelvis. In the majority of cases the 
 caecum is completely invested by peritoneum (the mesocsecum). 
 This would account for its great freedom of motion and the fre- 
 quency with which it forms one of the contents of femoral and 
 inguinal hernia. In rare cases the peritoneum is absent from its 
 posterior surface. Attached to the anterior surface of the lower 
 middle division of the caecum we find the vermiform appendix, an 
 organ of extreme practical importance, but of whose physiological 
 functions we at present know nothing. It varies in length from 2 
 to 20 centimetres ; its width is about -J to 1 centimetre. Usually it 
 is spiral-shaped, and is directed from the right iliac fossa toward the 
 border of the small pelvis, or it may even dip into the small pelvis. 
 It has a small mesentery {rnesenteriolum) and, like the caecum, it 
 is freely movable. The appendix is hollow up to its apex, and 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 13 
 
 communicates with the caecum through a small opening, the ostiura 
 processus vermiformis. This opening is sometimes guarded by a 
 small crescentic fold, the valvxila processus vermiformis. 
 
 The terminal opening of the small intestine is found at the junc- 
 tion of the caecum and ascending colon. This opening, which leads 
 from the ileum into the large 
 intestine, is guarded bj a valve 
 formed of two crescentic folds, 
 the valvula coli or Bauhini 
 (Fig. 9). The two folds, superior 
 and inferior, are united at their 
 ends, but in the centre form an 
 aperture at right angles to the 
 long axis of the colon. I^ormal- 
 Ij this valve permits the passage 
 of contents from the small intes- 
 tines into the large, but not con- 
 versely. It will not even allow 
 the passage of gases insufflated 
 into the large intestine. Only 
 the combination of extreme 
 pressure with a* relative insuffi- 
 ciency of the valve, such as oc- 
 curs in paresis of the intestinal 
 wall, can eifect a passage of in- 
 testinal contents into the ileum. 
 
 Fig. 9. — Opening of the Ileum into the 
 Laege Intestine. 
 (Perpendicular section through the caecum 
 and ileo-csecal valve.) p. «., vermiform ap- 
 pendix, whose opening into the caecum is 
 visible. (Gegenbaur.) 
 
 2. Ascending Colon 
 
 The ascending colon passes almost vertically upward from the 
 right iliac fossa to the under surface of the liver, upon which latter 
 surface it produces the impressio colica. In the region of the gall 
 bladder the ascending segment of the colon leaves the posterior ab- 
 dominal wall and passes sharply forward and to the left, thus becom- 
 ing more superficial ; then, forming the hepatic flexure, the gut 
 continues on as the transverse colon. The hepatic flexure of the 
 colon is connected with the liver by a short, taut band, the ligamen- 
 tum hepatico-colicum. In front, the ascending colon is in relation 
 with coils of the small intestines; behind, with the lateral border 
 of the quadratus lumborum and with the transversalis abdominis, as 
 well as with the lower anterior surface of the right kidney. There- 
 fore it is possible to have nephro-colic abscesses without peritonitis. 
 
l^ DISEASES OF THE INTESTINES 
 
 The remainder of the ascending colon is completely surrounded by- 
 peritoneum. 
 
 3. Tkaistsveese Colon 
 
 The transverse colon passes from the right hypochondrium up- 
 ward and to the left behind the anterior abdominal wall to the left 
 hypochondrium ; then, bending acutely, it continues as the descends 
 ing colon. The angle thus formed is known as the splenic flexure. 
 At this flexure the colon leaves its superficial position and passes 
 sharply downward and backward. The flexure is connected with 
 the diaphragm by the ligamentuhi jjhrenico-coliciiin. The trans- 
 verse colon is provided with a very long mesentery, the mesocolon 
 transversum, and is therefore freely movable. This point will 
 again be referred to. 
 
 •i. Descending Colon 
 
 The descending colon passes from the sjilenic flexure vertically 
 downward through the left hypochondriac and lumbar regions to 
 the left iliac fossa, where it forms an S -shaped fold, the sigmoid 
 ßexure. The splenic flexure is in contact above with the spleen. 
 Anteriorly, the descending colon is covered for the most part with 
 coils of small intestine. The descending colon, like the ascending, 
 has no mesentery of its own, and it therefore is not freely mov- 
 able. It is invested only laterall}" and anteriorly by peritoneum. 
 Its posterior surface is in relation with the costal portion of the 
 diaphragm, with the left kidney, the transversalis abdominis and 
 quadratus lumborum muscles, as well as with the iliac fascia, to all 
 of which structures it is connected by loose connective tissue. 
 
 5. Sigmoid Flexure (S. Romanum) (Fig. 10, page 17) 
 
 This is formed by a double loop of the colon, and has the ap- 
 pearance of an inverted S. We may distinguish an upper (colon) 
 segment whose convexity is directed toward Poupart's ligament, and 
 a lower (rectal) segment which projects more or less into the pelvis. 
 As a rule, the transition to rectum occurs at the sacro-iliac synchon- 
 drosis. 
 
 The sigmoid flexure is entirely covered by peritoneum, which 
 forms a rather long mesentery, the mesocolon flexuroB sigmoidece. 
 On this account the flexure is freely movable. In the newly born 
 the sigmoid flexure has a very long mesentery, and it may therefore 
 lie on the right side near the caecum, especially if defecation has 
 not yet occurred and the flexure is still filled with meconium. 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 15 
 
 Blood-vessels, Lymphatics, and Nerve Supply of the Large 
 
 Intestine 
 
 The blood supply of the large intestine is derived from the 
 three colic vessels, the left colic artery, a branch of the inferior 
 mesenteric artery, and the middle and superior colic arteries, 
 branches of the superior mesenteric artery. 
 
 The veins, which have a course parallel to that of the arteries, 
 empty into the superior and inferior mesenteric veins. 
 
 According to Sappey, the lymphatics of the intestinal wall are 
 numerous and form two sets — a deeper, beneath the glands of 
 Lieberkühn, and a more superficial, which forms a network ramify- 
 ing in all directions in the submucosa. 
 
 The 7ierves which supply the caecum, ascending colon, and the 
 right half of the transverse colon are derived from the superior 
 mesenteric plexus, which is given off by the coeliac plexus. The 
 left half of the transverse colon, the descending colon, and the sig- 
 moid flexure receive their nerve supply from the inferior mesenteric 
 plexus, which in its turn is derived from the plexus of the abdomi- 
 nal aorta. 
 
 Histology of the Large Intestine 
 
 Like the wall of the stomach and small intestines, that of the 
 large intestine is composed of four layers : serous, mucous, sub- 
 mucous, and muscular. 
 
 The sercms coat has already been considered in speaking of the 
 separate segments of the intestine. 
 
 The muscular coat consists of an external longitudinal and an 
 internal circular layer. The longitudinal layer is not found through- 
 out the entire gut, but appears as three broad longitudinal bands, 
 tcenia {ligaTnenti) coli, which are each 10 millimetres in width and 2 
 to 3 millimetres in thickness, and are all visible through the serosa. 
 Beginning at the attachment of the appendix, they continue as 
 separate bands as far as the rectum, where they unite to form a 
 continuous muscular layer. 
 
 One of these bands is seen at the attachment of the gastro-colic 
 omentum of the transverse colon ; at its mesenteric border is a 
 second, while the third band is free. Hence they are known as the 
 tmnia omentalis, mesenterica and the libera. Between them there 
 is a triple row of alternately protruding and receding areas. The 
 protruding parts are termed the haustra coli ; the depressions, which 
 
IQ DISEASES OP THE INTESTINES 
 
 are parallel to each otlier and perpendicular to the plane of the wall 
 of the gut, are known as the pockets. Wherever haustra and taenia 
 cross, we find projections of the serous coat, rich in fat, called ap- 
 pendices epiploiccB. 
 
 The circular coat extends over the entire colon ; it is strongest 
 between the haustra, which it surrounds by folds of considerable 
 thickness {pliccB sigmoide(M). _ 
 
 The submucosa is entirely like that of the small intestines. 
 
 The mucous membrane diifers from that of the small intestines, 
 above all, through the absence of Kerkring's folds and of villi. It 
 is thicker than that of the small intestine. The muscularis mucosa, 
 a thin layer of crossed muscular fibres, lies beneath the mucosa. 
 The glands of Lieberkühn lend a sievelike appearance to the 
 mucous membrane of the large intestine. These glands resemble 
 the glands of the small intestine, but are longer and more frequently 
 branched than the latter. The mucous membrane between Lieber- 
 kiihn's glands contains cylindrical epithelium, goblet cells, and 
 numerous solitary lymphatic nodules. 
 
 6. The Rectum 
 
 We include in the term rectum the lower segment of the large 
 intestine from the sigmoid flexure to the anus. The rectum com- 
 mences at the sacro-iliac synchondrosis, and therefore lies entirely 
 within the pelvis. It varies in length from 18 to 22 centimetres 
 (according to other authorities, 25 to 33 centimetres). Its lumen is 
 narrower than that of the sigmoid flexure ; immediately above its 
 termination there is a normal dilatation, the ampidla recti, which 
 even normally varies largely in size. Contrary to its name, the 
 rectum is not straight, but presents curves, three of which can be 
 distinguished. Beginning at the sacro-iliac articulation, it at first 
 passes slantingly downward and to the right, then runs forward in 
 front of the lower portion of the sacrum and coccyx, being (in men) 
 behind the Ijladder, the seminal vesicles, and the prostate, or (in 
 women) behind the cervix of the uterus and the vagina. Behind 
 the last-named organs (or the prostate) the rectum again curves 
 downward and backward and terminates at the anus. 
 
 For practical purposes we distinguish between the rectum proper 
 and the anal portion — i. e., the part surrounded by the sphincter 
 ani. 
 
 The upper portion only of the rectum is covered by peritoneum, 
 the mesorectum, a direct continuation of the mesocolon sigmoidea. 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 17 
 
 Like the sigmoid, the upper portion of the rectum has also some 
 range of motion. Farther down, tlie peritoneum recedes from the 
 rectum and is reflected on to the bladder in the male, or on to the 
 
 Fig. 10. — Male Pelvic Organs, viewed from the Right Side ( x »/g). 
 (The right ilium and a portion of the ischium and the pubic bone, together with their 
 soft parts, have been removed.) i, auricular surface of the sacrum ; ^, tuberosity of the 
 sacrum; 5, ischium; 4, pubic bone: 5, psoas muscle; 6, erector spins ; 7, glutei muscles; 8, 
 obturator muscles ; 9, external sphincter of anus ; 10, rectum ; 11, sigmoid flexure ; 1£, blad- 
 der ; 13, ureter ; I4, vas deferens ; 15, seminal vesicles ; 16, prostate ; 17, penis ; 18, prepuce ; 
 19, scrotum ; SO, lateral vesical ligament ; SI, hypogastric artery ; SS, hypogastric vein ; 23, 
 external iliac artery; S4, abdominal aorta. (Rauber.) 
 
 vaginal vault and uterus in the female. Above the point of reflec- 
 tion two crescentic folds, inclosing smooth muscle fibres, pass from 
 the sides of the rectum to the bladder or to the uterus (the folds of 
 
IQ DISEASES OF THE INTESTINES 
 
 Douo-las). The space beneath these folds is known as the j^ecto- 
 vagi7ial,Sind the one above as the recto-vesical, ßouch. 
 
 The relative position of these peritoneal folds is not constant, 
 however, but varies according to age and sex, as well as to special 
 conditions of the neighboring organs. The above subdivision is 
 therefore of an anatomical rather than a practical value (von Es- 
 march). 
 
 The muscular coat of the rectum consists of an inner circu- 
 lar and an outer longitudinal layer. The circular layer, which is 
 directly continuous with that of the colon, constantly increases in 
 thickness toward the lower end of the gut, finally forming a ring 
 1 or 2 centimetres in length, the internal sphincter of the anus. 
 The external, the longitudinal, layer is continuous with the three 
 longitudinal bands of the colon. In the rectum it forms a uniform 
 layer, interrupted here and there by small intervals. The fibres 
 become thinner in the lower part of the rectum, and finally merge 
 with those of the external sphincter. 
 
 Contrasted with the feeble muscular coat of the upper portion 
 of the rectum, the anal portion contains two powerful bands of cir- 
 cular fibres which secure closure of the anus. They are the exter- 
 nal and internal sphincters {sphincter ani externus et internus). 
 
 The external sphincter, whose action is voluntary, arises by a 
 tendinous origin from the apex of the coccyx, and separates into 
 two divisions which surround the anal orifice. In front of the anus 
 it is connected, in the male, with the musculus bulbo-cavernosus, or 
 transversus perinei, and in the female with the constrictor cunni. 
 
 The internal sphincter of the anus, a ring or girdle of smooth 
 muscle fibres, is the direct prolongation of the circular layer of the 
 rectum ; these fibres gradually increase in strength as they approach 
 the anus. Connected with the internal sphincter are two muscular 
 fasciculi, 4 millimetres in width, which spring from the anterior 
 surface of the coccyx and sui'round the lower end of the rectum (the 
 musculi recti-coccygei). 
 
 A short distance below the middle of the rectum fabout 8 centimetres above 
 the anal orificej we sometimes find a prominent collection of circular fibres, to 
 which the name ^^ sphincter ani tertius'''' has been given (Hyrtlj. This "sphinc- 
 ter," however, is nothing more than the transverse rectal fold increased by some 
 circular fibres. 
 
 The mucous membrane of the rectum is thicker, redder, and 
 more succulent than that of the colon. It presents many folds, 
 varying in size and directions, and disappearing when the organ is 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 19 
 
 strongly distended. They are most distinct when the rectum is 
 empty. One deep, transverse fold alone does not disappear even 
 with the greatest possible distention of the rectum. This fold — the 
 ßyica transverscdis recti — is about 6 to 8 centimetres above the 
 anus, and can be distinctly seen through a speculum. It is a sickle- 
 shaped reduplication of the mucous membrane, and does not include 
 the entire circumference of the rectum, l^ear the anal opening 
 the folds are usually longitudinal, and have received the name of 
 rectal or columns of Morgagni. The pockets between the folds are 
 known as sinuses of Morgagni ; they are favourite lodging places 
 for intestinal parasites and for swallowed pointed foreign bodies. 
 The mucous membrane covering these folds and pockets differs 
 from that of the rest of the rectum by the absence of glands and by 
 the presence of moderate-sized papillae, partly agminated. The 
 epithelium is stratified, and consists of large pavement cells. Thus, 
 the lower portion of the rectum forms a transition from mucous 
 membrane of the intestinal canal to skin (Henle). The mucous 
 membrane of the upper portion of the rectum differs in no respect 
 from that of the remainder of the large intestine. 
 
 The rectum receives its blood from five arteries, branches of 
 three arterial trunks. The largest of these five, the superior h?em- 
 orrhoidal artery, is given off by the inferior mesenteric ; the middle 
 hsemorrhoidal arteries, two in number, come either from the hypo- 
 gastric or from the common pudendal ; the two smallest vessels, the 
 inferior hsemorrhoidal arteries, come from the common pudendal. 
 
 The blood is carried away from the rectum for the most part 
 by the portal system through the superior hsemorrhoidal vein, and 
 the remainder by the middle and external hsemorrhoidal veins, 
 which empty into the infei'ior vena cava. 
 
 The lymphatics form an extensive network with wide meshes, 
 which sends some branches to the retrorectal glands and others to 
 the left lumbar plexus. 
 
 The nei'ves are derived mainly from the sympathetic. They 
 come from the inferior mesenteric plexus, the sacral plexus (inferior 
 and middle hsemorrhoidal nerves), and from the superior hypogastric 
 plexus. 
 
20 DISEASES OF THE INTESTINES 
 
 APPENDIX 
 
 Displacements of the Various Segments of the Intestines 
 
 As a consequence of congenital or acquired anomalies, the va- 
 rious segments of the intestines maj undergo alteration in posi- 
 tion. These displacements are verj important for the diagnos- 
 tician, and in order to prevent serious error it is necessary that he 
 be acquainted with or at least consider them. The portions most 
 frequently affected are the duodenum and the entire large intes- 
 tine, exclusive of the rectum ; much less frequently, and usually as 
 a consequence of the above anomalies, the remainder of the small 
 intestine. 
 
 The superior horizontal portion of the duodenum is so closely 
 connected with the stomach that it would naturally be affected by 
 alterations in position of that organ.* Should the stomach be 
 pushed toward the left side, the superior horizontal portion of the 
 duodenum would be on a line with the pylorus. If the pylorus be 
 dragged to the left of the median line of the body, the first portion 
 of the duodenum will then lie upon the vertebral column. Should 
 the pylorus be within the median line or to the right thereof, the 
 same portion of the duodenum will curve around the vertebral col- 
 umn (Hertz). The gut thus becomes more superficial, and the 
 superior flexure of the duodenum is bent almost at a right angle. 
 "Where there is a fish-hook-shaped ptosis of the stomach, the first 
 portion of the duodenum will also be drawn downward, and will 
 assume an almost vertical position. A sharp bend is thus given to 
 the flexure, and it may be so pronounced as to even cause a partial 
 obstruction of the contents. Again, where the stomach in toto is 
 sunken, it will drag the first portion of the duodenum, or even the 
 entire duodenum, down with it. Under other conditions the duo- 
 denum can preserve its normal position. 
 
 The descending portion of the duodenum is less freely movable, 
 because of its close connection with the pancreas. Despite this, 
 both organs may be simultaneously displaced. Bi'aune observed a 
 case in which this portion of the duodenum was dislocated to the 
 left. Displacement of other organs, especially of the stomach, the 
 liver, transverse colon, etc., naturally causes displacement of the 
 
 * See Hertz. Abnormitäten in der Lage und Form der Bauchorgane, etc., 
 Berlin, 1894, S. 33. 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 21 
 
 duodenum as well. Nevertheless, the tendency of the descending 
 portion to become dislocated is limited. 
 
 The inferior horizontal portion is subject to slight alterations in 
 position alone, and these are brought about by the same conditions 
 as those of the remainder of the duodenum. We wish here to call 
 attention to the large number of adhesions which occur in the region 
 of the gall bladder and the duodenum, and which may create great 
 difficulties in diagnosis as well as in treatment. 
 
 Alterations in position of the colon are most common. Cursch- 
 mann ^ has recently called attention to their clinical importance. 
 The following statements are taken largely from Curschmann's 
 excellent treatise. 
 
 1. The C^cum and the Ascending Colon 
 
 The caecum may be abnormally long, and thus give rise to vol- 
 vuli, kinking, and flexures. In such cases the fundus of the csecum 
 is directed toward the diaphragm, and covers a part of the ascend- 
 ing colon. Thus we may at times have a total occlusion of the 
 gut. It should be remembered that such a dislocated caecum, to- 
 gether with the appendix, may be the seat of a perityphlitis. 
 
 In those very rare cases in which the ascending colon is con- 
 genitally entirely absent, the caecum with its appendix lies very 
 close to the edge of the liver, or behind that organ. Perityphlitis 
 has been observed under such conditions, but the clinical diagnosis 
 is very difficult, if not impossible. 
 
 2. The Teansyeese Colon and the Flexuees 
 
 It is a well-known fact that the transverse colon [especially in 
 the female] is subject to the greatest variations in position. This is 
 probably due to the habit of lacing, through which one portion of 
 the abdominal contents is forced upward and the other downward. 
 When its mesentery is excessive in length, the transverse colon may 
 be dislocated upward and lie in the epigastrium in front of the 
 liver, or in the left hypochondrium in front of the stomach (Hertz). 
 In other cases, the transverse colon may be entirely concealed by 
 coils of small intestine ; we then find it low down in the posterior 
 portion of the abdomen (Hertz). 
 
 Absence or shortening of the flexures may give rise to condi- 
 tions of special interest. For example, the colon may pass from 
 the right side upward and toward the median line ; thence trans- 
 versely for a short distance ; then, abruptly bending to the left, con- 
 3 
 
22 DISEASES OP THE INTESTINES 
 
 tinue downward as the descending colon. Again, in a verj long 
 colon, both flexures may be shortened or absent. The transverse 
 colon in such cases forms a large loop, whose segments lie close to 
 each other and in dii*ect contact with the liver, and may cover the 
 entire anterior surface of that organ. Here we would get apparent 
 diminution in liver dulness in front, but percussion of the lateral 
 and posterior surfaces should save us from mistakes. 
 
 Marked increase in length of the large intestine may give rise 
 to the coiling together of the intestines, or even to the formation 
 of a volvulus. 
 
 3. The DescendijStg Colon and the Sigmoid Flexure 
 
 The sigmoid flexure is the most movable segment of the large 
 intestine, because its length is subject to the greatest variations. 
 Its displacements, as well as those of the descending colon, have 
 been noted by the older anatomists. Recently Schieiferdecker^ 
 and von Samson^ have made a close study of the subject. 
 
 Schiefferdecker distinguishes the following alterations in position of the 
 descending colon : 
 
 I. The end of the descending colon lies to the side of the sigmoid flexure. 
 
 (a) The flexure projects into the small pelvis, and the small intestines lie in 
 front and above it. 
 
 (b) The flexure lies upon the posterior abdominal wall, and is directed up- 
 ward ; a, it lies within the left half of the body ; ß, it extends to the right iliac 
 fossa. Between these extreme left and right positions the greatest variations 
 occur. 
 
 (c) Other portions of the intestines separate the sigmoid flexure from the 
 posterior abdominal wall, with the result that a greater or lesser portion of that 
 gut lies directly behind the anterior abdominal wall. These variations can 
 only occur with a free mesosigmoideum, and the higher the lateral point of 
 fixation of the sigmoideum, the greater will be the predisposition to these dis- 
 placements and their extent upward. The apex of the sigmoid flexure may 
 move from the extreme left side of the body to the extreme right. 
 
 II. The termination of the descending colon lies to the median side of the 
 sigmoid flexure. This is extremely rare. 
 
 Curschmann, who has given special attention to the clinical im- 
 portance of the anomalies of the sigmoid flexure, lays particular 
 stress upon the striking differences in its length (60 to 80, or even 
 100 centimetres). Sometimes there are two coils instead of one. 
 A more frequent anomaly is the formation of an abnormal loop be- 
 tween the lower end of the sigmoid and the beginning of the rectum. 
 In such cases we almost always find the lower end of the colon far 
 
PRELIMINARY ANATOMICAL AND HISTOLOGICAL REMARKS 23 
 
 down in tlie pelvis and over to the right side. Under such circum- 
 stances, the commencement and termination of the large intestine 
 lie side by side. It is very apparent how gross errors in diagnosis 
 may occur. This has been very aptly illustrated in one of Cursch- 
 mann's cases. The position of the coils of the sigmoid may also be 
 greatly altered. ÜSTormally, they are in the centre of the abdomen, 
 their long axis being parallel with the linea alba. The upper bor- 
 der is in contact with the transverse colon. With increase of 
 length the coils may even reach the vault of the diaphragm, and 
 completely cover the stomach and liver. This abnormality in posi- 
 tion may make it difficult to determine the limits of the liver and 
 stomach. It appears that almost invariably the base of the coils is 
 covered by small intestine. If volvulus should occur in these 
 cases, we should then find tympanitic intestinal coils at all points, 
 excepting the one at which the volvulus is situated — i. e., the region 
 of the sigmoid flexure. 
 
 LITERATURE 
 
 1. Curschmann. Deutsch. Archiv für klin. Medicin, Bd. liii, H. 1 u. 3. 
 
 2. Schiefferdecker. Archiv für Anatomie u. Physiologie, 1886 u. 1887. 
 
 3. V. Samson. Zur Kenntniss der Flexura sigmoidea coli. Inaug. -Dissert., 
 
 Dorpat, 1890. (Complete literature.) 
 
CHAPTER II 
 
 PBELIMINABY PHTSIOLOGICAL AND PEY8I0L0GIC0- 
 CHEMIGAL BEMARE8 
 
 The digestive process in the intestines is far more complicated 
 than in the stomach. In the latter the digestive act is but a pre- 
 paratory one, affecting only the proteid bodies (and gelatinoid sub- 
 stances) and the starches. Absorption, as we now know, takes 
 place but to a limited extent (v. Mering, Brandl, Moritz, Hirsch, 
 and others). The digestive task of the intestines consists princi- 
 pally in converting all food stuffs, brought to it from the stomach, 
 into a form suitable for assimilation ; in absorbing the useful por- 
 tions, and gathering together in a solid form and excreting from 
 the body all waste material. The intestines, however, have another 
 function, heretofore but little appreciated by physiologists and clini- 
 cians — i. e., the removal in the form of flatus of noxious gases devel- 
 oped in the intestinal canal. This might be termed intestinal ven- 
 tilation. 
 
 All the functions of the intestines harmonize like the component 
 parts of a score ; interference with one deranges all. Strictly speak- 
 ing, then, these functions should not be considered separately. If, 
 nevertheless, we do so in the following, it is because the entire pro- 
 cess of digestion — the influence exerted by a single function upon 
 the whole, and vice 'versa — is not well enough understood either in 
 man or in the lower animals. 
 
 In the following we shall first treat separately of intestinal secre- 
 tion, absorption, and motility, and then of the entire course of intes- 
 tinal digestion. As by-products of intestinal activity, we have cer- 
 tain fermentation substances, some useful, others harmful. They 
 also will be considered in the section on intestinal digestion in its 
 entirety (page 43). 
 
 THE SECRETING FUNCTION OF THE INTESTINES 
 
 The secretion furnished by the intestines themselves plays but 
 an insignificant part in the digestive process. The main work is 
 24 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 25 
 
 accomplished bj the secretions from the two glands emptying into 
 the small intestine, viz., the liver and the pancreas. 
 
 1. The Intestinal Juice 
 
 This is a mixture of secretions from Brunner's and from Lieber- 
 kühn's glands. Grützner ^ ascribes the faculty of secreting pepsin 
 to Brunner's glands ; this would give them functions analogous to 
 those of the pyloric glands. They certainly do not secrete any 
 diastatic ferment. Other investigators regard Brunner's simply as 
 mucous or salivary glands. 
 
 Our information regarding the secretion of Lieberkühn's glands 
 is more definite, for this has been studied in animals by the aid of 
 the Thiry or Yella fistula, and also in individuals with fsecal fistulae 
 (Dumont, Turby and Manning). Observations thus made showed 
 the secretion to be pale yellow in colour, highly albuminous and muci- 
 form, and containing about 0.5 per cent, of sodium chlorid and a 
 like amount of sodium carbonate. Hoppe-Seyler^ lays special value 
 upon this mucosity, since mucin forms a protective coating for the 
 intestinal epithelium, and makes possible as well as facilitates the 
 passage of the solid masses within the intestines. 
 
 Another very important factor is the presence of the carbonate 
 of soda. This affects the rapid neutralization of the acid stomach 
 chyme. Bunge,^ in fact, ascribes the importance of the intestinal 
 secretion mainly to its carbonate of soda.* 
 
 In dogs, the solids of the intestinal juice equal 12.2 to 21.1 
 grams per 1,000 ; in sheep, 46 to 47 grams. According to Thiry, 
 the specific gravity of the secretion varies in dogs from lOlO to 
 1017. 
 
 It is generally conceded that the fermentative action of the in- 
 testinal juice is very slight. It has been shown that starch after a 
 long time is converted into glucose, and cane sugar is inverted 
 through the action of the intestinal secretion (Demant *, Brown and 
 Heron % K. B. Lehmann ^, Frick, Turby and Manning ', and Miura ^). 
 Similarly F. Röhmann and Lappe ^ have found that an extract of 
 mucous membrane from the small intestine of the calf or dog can 
 convert milk sugar into glucose. The secretion from Lieberkühn's 
 glands has no action whatever upon albuminoid bodies and fats 
 
 * In diseased conditions, marked odourless eructations may occur some time after 
 eating. It appears very probable to me that this results from decomposition of the 
 hydrochloric acid of the stomach by the alkaline intestinal secretion. 
 
26 DISEASES OF THE INTESTINES 
 
 (Frick ^% Ellenberger and Hofmeister ^\ K. B. Lehmann ^, Wenz ^^, 
 and others). The secretion from Lieberkiihn's glands in the large 
 intestine appears to be mostly mucous. 
 
 2. The Panceeatic Juice 
 
 The action of the pancreatic secretion has been studied princi- 
 pally upon animals in whom fistulse have been made. A few 
 observations have been made with the secretion from fistulse fol- 
 lowing the extirpation of pancreatic tumours, particularly cysts. 
 I have myself made a few such observations. The credit for 
 most of our knowledge of the function of the pancreas is due 
 to CI. Bernard, C. Ludwig, Bidder and Schmidt, Heidenhain and 
 Bernstein. The fundamental studies of v. Mering and Minkowski 
 first brought out the importance of the pancreas in diabetes. 
 
 In experiments upon animals two varieties of fistulae, the temporary and 
 the permanent, are employed. If a fistula be made in a dog after a hearty 
 meal, the secretion which flows will be profuse, viscid, and very active. Activ- 
 ity ceases, however, after a few days — sometimes after a few hours — and it is 
 succeeded by a thin, watery, inert secretion, very poor in albuminoids, and 
 resulting very probably from inflammatory changes. In a few cases it has 
 been possible to obtain an active secretion from a permanent fistula. It is 
 therefore easily understood that analyses of the secretion vary very much. 
 
 The normal secretion of the pancreas is a clear, colourless, and 
 odourless, viscid fiiiid, of a strongly alkaline reaction. The alka- 
 linity is due to sodium carbonate which is present in from 0.2 
 to 0.4 per cent. The secretion is highly albuminous and coagu- 
 lates strongly upon boihng. In addition to the above, it contains 
 leucin, fats, fatty soaps, and the following mineral ingredients : 
 Alkaline chlorids and carbonates, phosphoric acid, and some cal- 
 cium, magnesium, and iron. 
 
 In the secretion from a temporary fistula of a dog, C. Schmidt ^* 
 once found 9.92 per cent of solids, and at another time 11.56 per 
 cent; while Zawadsky^", in examination of pancreas fistula of a 
 man, found 13.25 per cent of solids, of which 9.2 per cent were 
 Proteids and 0.34: per cent mineral substances. Herter^^ found 
 24.1 per cent solids in the secretion of a man; this secretion, 
 though very active, seems to have been pathological in other 
 respects. From the above analyses, we may regard 10 per cent as 
 the average amount of solid matter. 
 
 The most important pancreatic ferments are the proteolytic, the 
 amylolytio, and the fat-splitting. 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 27 
 
 (a) At the proper temperature the proteolytiG f'enne7it, trypsin 
 (Kühne), is capable of converting proteids in a A'ery short time into 
 albumoses and peptones. This ferment does not exist preformed 
 within the gland, but is there instead as trypsinogen (Heidenhain 
 and Podolinski ^^), Trypsinogen is changed into trypsin through 
 bacterial influences, contact with air or water, or with dilute acids 
 (e. g., 1 per cent acetic acid). Trypsin is most active in a 0.2- or 
 0.4-per-cent solution and at 40° C. Small amounts even of free 
 mineral acids retard its action, but organic acids must be present in 
 stronger concentration. The kind of albuminous matter is not 
 without influence. Thus, as in gastric juice, fibrin is digested 
 much quicker than is coagulated egg albumen. 
 
 The initial stage of proteid digestion with trypsin differs very 
 much from that with the gastric juice. Whereas in the latter 
 there is a preliminary swelling of the albuminoid substance fol- 
 lowed by gradual solution, in trypsin digestion there is a breaking 
 up, or, more properly speaking, a melting away. 
 
 As in the stomach, so, too, in trypsin digestion the metamor- 
 phosis of the albuminoids is not a . sudden but a gradual one. 
 According to Kühne, who has studied the proteolysis of trypsin 
 digestion more carefully than any one else, the albuminoids are 
 first converted into deutero - albumoses, but after a very short 
 time peptones are also present. One portion of these peptones — 
 Kühne's antipeptones — remains unchanged throughout the entire 
 digestion, even though this may continue for several days, while 
 another portion — Kühne's hemipeptones — yields products of decom- 
 position, the most important of which are the crystalline amido- 
 acids — leucin, tyrosin, and aspartic acids. These latter products 
 have been well known for a long time ; of late, E. Drechsel and 
 Iledin" have succeeded in isolating two additional products of 
 trypsin digestion, lysin and lysatinin. Finally, a chromogen, tryp- 
 tophan, is regularly formed during tryptic action upon albumi- 
 noids^^. With bromin or chlorin water, or with chlorate of potash 
 solution, tryptophan yields a violet colouring matter, readily absorbed 
 by amylic alcohol. 
 
 Trypsin also acts upon the gelatins, causing them to lose their 
 gelatinous qualities and to be converted into gelatin peptones. 
 Kühne's and Roberts's ^^ investigations with the trypsin of pigs' 
 pancreas have shown that this ferment curdles milk. My own 
 investigations^ have proved that milk is not curdled by the biliary 
 juice contained in the duodenum (a mixture of bile, pancreatic 
 
28 DISEASES OP THE INTESTINES 
 
 juice, and tlie secretions of Brunner's and Lieberkühn's glands), 
 but that it is immediately peptonized. If the gelatin-yielding sub- 
 stance of connective tissue is previously svrelled by the action of 
 acids, or shrunken through the agency of heat, it will be dissolved. 
 Elastic membranes, as well as the membranes of fat globules, are 
 immediately dissolved. Chitin and keratin apparently are not 
 dissolved by trypsin. 
 
 (h) Pancreatic Diastase. — This ferment has the property of 
 converting starch and glycogen into sugar, the end products being 
 mostly maltose, together with small quantities of dextrose (Muscu- 
 lus and Gruber ^^ and v. Mering^). This conversion is a hydration 
 process, and the intermediate products are the same as those occur- 
 ring in the diastatic action of ptyalin, with which ferment pancreas 
 diastase is in all probability identical. Taken in their order of 
 occurrence these intermediate products are : first, soluble starch, 
 which still gives a blue colour with Lugol's solution of iodin ; next, 
 erythrodextrin, which gives a violet colour ; and, finally, one or 
 more of the achroodextrins, which remain nncoloured upon addition 
 of Lugol's solution. 
 
 In addition to diastase, pancreatic juice also contains invertin, 
 although in much smaller quantities than does the intestinal secre- 
 tion. It is assumed that this ferment gradually completely con- 
 verts maltose into dextrose (glucose). In like manner cane sugar 
 and milk sugar are also converted into glucose by invertin. Glyco- 
 gen is first converted into a maltoselike sugar, and then gradually 
 also changed into glucose. 
 
 (c) The Fat-splitting Ferment {Steapsin). — This ferment splits 
 up fats into fatty acids and glycerin. In the presence of alkalies 
 these fatty acids combine to form soaps ; furthermore, they aid 
 very much in the emulsification of fats. We shall return to this 
 when we come to speak of bile. Steapsin has not yet been iso- 
 lated, and the attempt has therefore been made to refer the spht- 
 ting up of fats in the intestines to the action of bacteria. The 
 researches of Neneki ^^ have, however, shown the positive existence 
 of a fat-splitting ferment in pancreatic juice. In my own investi- 
 gations ^ with the small intestinal juices of man I have observed 
 marked fermentative dissolution of fat. 
 
 According to ISTencki and Baas^^, pancreatiq ferment decom- 
 poses other esters besides the neutral fats. We shall speak of the 
 part played by the pancreatic juice during digestion when discuss- 
 ing intestinal digestion in its entirety. 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 29 
 
 3. The Bile 
 
 The importance of the bile in digestion was formerly very 
 much overestimated. At the present day bile may be looked upon 
 as possessing more of an excretory than a secretory importance, 
 since it has to render innocuous the products of body metabolism 
 stored up in the liver and safely conduct them from the body by 
 way of the intestines. It would be going too far, however, to 
 assign but this one function to the bile. Without doubt it has an 
 important part in intestinal digestion, especially in regard to the 
 fats. This will be referred to again later. 
 
 The composition of bile varies with different animals ; that of 
 the dead body is different from that of the living, and that flowing 
 from the biliary passages is not the same as that contained within 
 the gall bladder. 
 
 Human bile, such as is obtained immediately after death from 
 executed persons, is usually of a golden-yellow colour with a shade 
 of brown. Greenish-coloured bile has also been seen, especially 
 during operations. Bile such as I have seen regurgitated into the 
 stomach in numerous cases of deeply situated duodenal stenoses was 
 almost always green ; in a very few eases where there was a normal 
 condition of the duodenum, I saw bile of a golden-yellow colour. 
 The taste of bile varies in different animals ; that of man and of 
 cattle is bitter and has a sweetish after taste, while that of the rab- 
 bit and the pig has a purely bitter taste. The specific gravity of 
 that in the gall bladder varies from 1001 to 1004. The reaction is 
 faintly alkaline, due to the presence of the carbonate of soda (.02 
 per cent) and of alkaline sodium phosphate. The amount of solids 
 in bile obtained from fistulas varies so largely that figures are value- 
 less. This holds true, too, for the total quantity in twenty -four 
 hours of bile from fistulse, for an appreciable but immeasurable 
 portion must flow into the small intestine itself. Besides, as Stadel- 
 mann has correctly shown, marked variations in the biliary secre- 
 tion may occur under normal conditions. Bile contains very much 
 mucin as well as mucoid nucleo-albumin. 
 
 The most important constituents of bile are the two biliary acids 
 and their salts — the glycocholate of soda and the taurocholate of 
 soda — Cholesterin, and a number of biliary colouring matters. In 
 addition there are small quantities of lecithin, neutral fats, soaps, 
 urea, and mineral salts. 
 
 As regards the two biliary acids, it should be stated that glyco- 
 
30 DISEASES OF THE INTESTINES 
 
 cholic acid (C26H43]Sr06), wliicli is combined witli sodium and traces 
 of potassium, is more abundant in man ; while taurocholic acid 
 (C26H4ö^S07) is found in Carnivora and in goats and slieep. As 
 can be seen from the formula, taurocholic acid contains both nitro- 
 gen and sulphur, whereas neither of these substances is present in 
 gljcocholic acid. Both acids have a bitter taste and are dextro- 
 gyrous ; they are decomposed upon boiling with caustic potash, 
 glycocholic acid splitting up into glycin and cholic acid, and tauro- 
 cholic acid into taurin and cholic acid. 
 
 The biliary colouring matters met with under normal conditions 
 are bilirubin (reddish yellow) and biliverdin (green), and one col- 
 ouring substance closely related to hydrobilirubin (urobilin). 
 
 Biliruhin (identical with heematoidin) is found in the golden- 
 yellow bile of man, and is present to a marked degree in biliary 
 concretions as bilirubin-calcium. It is insoluble in water, sparingly 
 soluble in ether, a little more so in alcohol, and readily in chloro- 
 form, especially if warmed. Upon evaporation it may be obtained 
 partially in crystalline form, partially as an amorphous substance. 
 Solutions of bilirubin in chloroform yield reddish-yellow rhombic 
 scales which are exactly like h^matoidin. For other properties of 
 bilirubin, as well as for its chemical reactions, we refer the reader 
 to works on chemical physiology. 
 
 Biliverdin results from oxidation of bilirubin, and is met with 
 in the bile of man, of the lower animals, and also in the urine of 
 jaundice, and to a less extent, too, in gallstones. It is an amor- 
 phous substance readily soluble in alcohol, sparingly in ether, and 
 insoluble in chloroform, thus differing widely from bilirubin. 
 
 Hydrobilirubin results from the reduction of bilirubin, and is 
 constantly present as colouring matter in normal faeces. It is in all 
 probability identical with urobilin and the so-called stercobilin. 
 
 Cholesterin is held in solution by the bile salts. . It crystallizes 
 in colourless rhombic plates, is insoluble in water, but soluble in 
 hot alcohol, in ether and chloroform. 
 
 It is claimed that in addition to the above-described constituents, 
 there is also a diastatic ferment present in bile ; but very probably 
 it is the diastase of the salivary and intestinal secretions. 
 
 Importance of Bile in Intestinal Digestion. — Apparently the 
 principal function of the bile is to promote the absorption of fat. 
 This is readily seen from the fact that dogs with biliary fistulse 
 absorb far less fat than do normal animals. Whereas a normal 
 dog, according to Yoit^", given 150 to 250 grams of fat will absorb 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 31 
 
 99 per cent of it, one witli a biliary fistula given 100 to 150 grams 
 can absorb but 40 per cent, the remaining 60 per cent passing off 
 with the faeces. Röhmann ^"^ arrived at similar conclusions. On the 
 other hand, it may be stated as an actual fact that no disturbance of 
 digestion occurs when the bile is conducted externally, provided, 
 however, that the amount of fat partaken of be not too large.* 
 There is still much doubt as to the manner in which bile promotes 
 fat absorption. We know that it favours the emulsification of fats. 
 This action, according to IS[eumeister ^^, results from its cholates, 
 which dissolve the potassium and magnesium soaps that are insol- 
 uble in the other fluids of the small intestine. According to the 
 more recent views of physiologists, especially those of Heidenhain ^^, 
 bile promotes the entrance of fat into the epithelial cells by favour- 
 ing fat emulsification, and by imparting to the surface of the cells a 
 capillarity toward fat. Further characteristics ascribed to bile are 
 antiputrefactive qualities and stimulation of intestinal motions (dogs 
 with biliary fistula and human beings with occlusion of the bile 
 passages are obstinately constipated). f The latter results from the 
 free bile acids which normally are always present in the small intes- 
 tine. The fseces of dogs with biliary fistula have a most decided 
 stench, resulting from the decomposition of carbohydrates. Bile 
 has no digestive action upon albuminoid bodies. 
 
 INTESTINAL PERISTALSIS 
 
 (Motus peristaltictis) 
 
 The object of intestinal peristalsis is to secure a mingling of the 
 contents and their onward propulsion. Thus not only is the pabu- 
 lum brought into intimate contact with the digestive juices, but as 
 soon as this is accomplished the contents are further conducted 
 through successive portions of the intestines, and thereby thorough 
 absorption is secured. From this it follows that the small intestines 
 are mostly concerned with peristalsis, and that peristalsis takes place 
 almost exclusively during the act of digestion. 
 
 * Compare, for example, Mayo Robson, Proc. Roy. Soc, vol. xlvii, 1890, pp. 
 499-524 ; Copemann and Winston, Jour, of Physiology, vol. x, 1889, pp. 213-231 ; 
 Noel Paton and John Balfour, Laboratory Reports issued by the Royal College of 
 Physicians, Edinburgh, 1891, vol. iii, pp. 191-240 (cited from Gamgee, Physiolog- 
 ische Chemie der Verdauung, 1897, p. 288). 
 
 f As far as man is concerned, I can not, in general, personally confirm this rule, 
 which we find laid down with the greatest certainty in almost all text-books on 
 physiology. 
 
32 
 
 DISEASES OP THE INTESTINES 
 
 The excellent investigations of Braam-Houkgeest ^, of Sanders- 
 Ezn, and of I^otlmagel ^^, who studied peristaltic movements in ani- 
 mals placed in physiological salt solution, have acquainted us fully 
 witli all the details. We may distinguish three types of normal 
 intestinal movements : peristalsis proper, pendulum motion, and 
 rolling motion. 
 
 1. In ^peristalsis jproper there is a widening of the lumen of the 
 gut, followed by a narrowing — a wavelike motion, which passes with 
 moderate speed over a certain length of intestine toward the anus, 
 and thereby causes a visible onward propulsion of intestinal con- 
 tents. In the colon the peristaltic wave is represented by depres- 
 sions and prominences of the haustra following each other in regu- 
 lar succession. 
 
 2. Pendular motions are always limited to a short portion of the 
 gut. In these the gut is moved to and fro without any perceptible 
 change in the width of its lumen. There is no propulsion of the 
 contents, but, instead, a mingling of the same. Propulsion takes 
 place only where peristalsis is associated with pendular motions, a 
 combination which has been observed. According to Nothnagel, 
 pendular motions may be seen particularly^ in the middle and lower 
 segments of the intestines when these are tilled with pabulum. The 
 motions may last as long as fifteen minutes, when they suddenly 
 cease, to begin again after a long time (one hour to an hour and a 
 half) without any special cause. This period of cessation is said to 
 be shorter in the lower portion of the ileum only. Braam-Houk- 
 geest observed pendular motion in empty as well as filled intestines ; 
 Nothnagel in the latter only. 
 
 3. Rolling motions occur where a segment of the gut is strongly 
 distended by gas and at the same time has fluid contents. Such a 
 segment is from 10 to 20 centimetres long. Its contents are pro- 
 pelled with a rapidity closely resembling a condition known as 
 violent peristalsis. The following is I^othnagel's classical descrip- 
 tion : 
 
 " A circular constriction constantly progresses behind the dis- 
 tended intestinal coils, causing such a propulsion of the fluid and 
 gaseous contents toward the csecum that the widely distended in- 
 testinal parts roll about like a wheel quickly revolving in water. 
 And now a surprising occurrence is often observed : without the 
 slightest external cause, the peristalsis may suddenly cease at any 
 segment whatever, to begin very strongly again after an indeflnite 
 interval." 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 33 
 
 An analogy to these movements is furnished us by the familiar 
 violent peristalsis {tormina intsstinorum) often experienced very 
 soon after a serious dietetic error. But, as JS^othnagel distinctly em- 
 phasizes, these movements do not involve the entire length of the 
 small intestine ; they completely cease after rapidly passing along a 
 limited portion, and suddenly and without apparent cause begin 
 anew in another portion. They are most active in the duodenum 
 and jejunum ; movements in the duodenum being excited by the 
 bile and pancreatic secretion. Farther down in the small intestine 
 the peristaltic waves are less frequent and slower. 
 
 In consequence of the peristaltic action of the small intestine, 
 the pabulum from a large meal passes in from two and a half to 
 three hours from the j^ylorus to the ileocecal valve; whereas, owing 
 to slowness of peristalsis in the large intestines, food requires at 
 least twelve hours to pass through the much shorter distance be- 
 tween the caecum and the rectum. 
 
 According to investigations of Braam-Houkgeest, which have 
 been fully verified by Nothnagel, peristaltic movements in normal 
 intestine with free lumen proceed always toward the anus and never 
 toward the pylorus. ISTothnagel therefore rejects the occurrence 
 of antiperistalsis, such as has been described by older investigators, 
 particularly Engelmann, as taking place physiologically. There 
 appeared, however, to be two exceptions : When ]^othnagel intro- 
 duced active irritative fluids (e. g., concentrated solutions of sodium 
 chlorid, of potassium nitrate or bromate, or weak solutions of sul- 
 phate of copper) into the rectum of rabbits, he observed antiperi- 
 staltic movements as far as the caecum, but these movements could 
 be induced from the rectum alone ; they were never evoked by irri- 
 tative solutions of salt introduced through the stomach. Even after 
 artificially produced acute intestinal obstruction in animals, ISToth- 
 nagel did not observe antiperistalsis. There was, indeed, a backward 
 movement of the intestinal contents ; this resulted, however, not 
 from antiperistalsis, but rather from a procedure which ISTothnagel 
 has designated " recoil contraction." In consequence of the lively 
 peristalsis and of the increase in intestinal secretions above the 
 stenosis, there is a large accumulation of the contents in the supra- 
 stenotic part. As the wall of the gut becomes distended, the por- 
 tion immediately above the stenosis contracts strongly; this may 
 result in forcing the contents upward. JiSTothnagel does not believe 
 that the regurgitation of intestinal contents in intestinal obstruction 
 is brought about in this manner, but maintains that it results from 
 
34 DISEASES OF THE INTESTINES 
 
 pressure of the abdomen upon the distended paretic wall of intes- 
 tines above the stenosis. 
 
 The above-mentioned investigations of Nothnagel show that no 
 backward peristaltic waves can be observed in the physiologically 
 functionating intestine. 
 
 A different condition can be observed when we employ mild 
 irritants, such as injections of normal salt solution, which to a cer- 
 tain extent are still physiological. Thus Grützner ^^ has lately 
 called attention to the interesting fact that the injection of physio- 
 logical salt solution into the rectum of man and the lower animals 
 produces antiperistaltic movements, which involve not only a short 
 segment, but also the entire intestine up to the duodenum ; further- 
 more. Grützner showed hereby that small solid particles (starch 
 granules, haii's, charcoal, etc.) which are suspended in the injected 
 fluids are carried up to the duodenum, or even in part to the stom- 
 ach, being found in the wash water from the latter organ. 
 
 Simultaneously with these antiperistaltic movements, which 
 pass immediately next to the mucous membrane, there also occur 
 peristaltic movements by which faeces and chyme are brought down- 
 ward. 
 
 Thus far control examinations by others do not entirely confirm 
 Grützner's conclusions. Christomanos^, Dauber^, and Wendt^ 
 think positive results were obtained because the animals licked 
 their own intestinal evacuations ; where this was carefully guarded 
 against, negative results were obtained. By experiments upon 
 human subjects, Swiezynski^ was able to demonstrate that lycopo- 
 dium introduced into the rectum passed upward into the stomach. 
 He, however, was unable to determine with certainty the part which 
 sodium chlorid played in this experiment. Be this as it may, the 
 investigations of Grützner do not prove the occurrence of a true 
 antiperistalsis, but only show that food stuffs introduced into the 
 rectum may pass upward within the intestine. We fully coincide 
 with Riegel ^\ who regards the superficial epithelium of the intes- 
 tines as the chief causative factor in this upward movement. 
 
 Wherein lies the impulse for intestinal movements ? Investiga- 
 tions made thus far upon this point show that the intestinal wall has 
 automatic movement centres similar to those of the heart, and, 
 furthermore, that the central nervous system exerts an important 
 influence upon physiological and pathological intestinal movements. 
 The principal seat of the automatic centres is very probably the 
 nerve and ganglion plexuses of Meissner and of Auerbach. ]^oth- 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 35 
 
 nagel could elicit intestinal movements bj touching various spots in 
 the intestines with a sodium or a potassium salt, and thus proved 
 beyond all doubt the jjresence of nerve centres within the wall of 
 the intestines. 
 
 The relations between the cerebro-spinal nervous system and 
 intestinal movements are very complicated. The pneumogastric 
 undoubtedly plays a certain part here, for irritation of that nerve 
 causes or increases a movement throughout the entire small, and 
 the upper portion of the large, intestine. The entire large intestine, 
 according to the latest researches of Pal ^, receives motor fibres from 
 the pneumogastric. We know from Piiüger's celebrated experi- 
 ments that the splanchnic nerve inhibits intestinal peristalsis. This 
 inhibition may be direct, or it may be brought about indirectly by 
 the anaemia which results from irritations of the splanchnic. Ac- 
 cording to the most recent experiments of S. Mayer and von Basch, 
 the splanchnic nerve exerts an inhibitory influence only as long as 
 the blood in the capillaries is not venous ; when the blood becomes 
 venous, then stimulation of this nerve causes increased peristalsis. 
 Investigations of Nasse show that the splanchnic also contains direct 
 motor fibres, but PaP^ concludes from his experiments that the 
 action obtained is a reflex one. In like manner, stimulation of the 
 cortex of the brain and of the optic thalamus may inhibit or accel- 
 erate intestinal movements : the acceleratory stimulus passes through 
 the pneumogastric, the inhibitory through the spinal cord (Bechte- 
 rew and Mislowski ^). 
 
 J. PaP^ has furthermore shown that the splanchnic centre is not 
 the only inhibitory one of the small intestines, but that there are 
 others lower down in the spinal cord. 
 
 Contrary to the small intestines and the upper part of the large, 
 the lower part of the large intestine and the rectum receive inhib- 
 itory as well as acceleratory fibres from the sympathetic. 
 
 In connection with innervation of the rectum, Fellner " has called attention 
 to a remarkable antagonism existing between the nervi erigentes and the nervi 
 hypogastrici of the dog. Whereas the former nerves contain motor fibres for 
 the longitudinal and inhibitory for the circular muscles, the reverse is true of 
 the hypogastric. L. Exner *^ disputes the evidences lent by Fellner's experi- 
 ments, but they have recently been confirmed by Pal *^. 
 
 l^ormal peristalsis may be increased or diminished through ex- 
 ternal as well as internal agencies. The external agencies include 
 cold, massage, and the faradic current ; the internal, mechanical, 
 chemical and thermal, vaso-motor and central stimulation. Those 
 
36 DISEASES OP THE INTESTINES 
 
 mechanical agencies which cause an increase in normal peristaltic 
 movement are foreign bodies, stenoses, parasites, and particularly 
 indigestible foods ; the chemical agencies include laxatives and 
 tainted food stuffs, with their accompanying products of decomposi- 
 tion. The thermic excitants of peristalsis are cold, especially in the 
 form of cold drinks, ice, or of cold injections. Circulatory disturb- 
 ances resulting from congestion of the portal system may cause an 
 increase or a slowing of peristalsis. Finally, we may have increased 
 peristalsis resulting from certain conditions of the central nervous 
 system — e. g., crises enteriques of tabes, tormina ventricuh nervosa 
 (Kussmaul), in neurasthenics, hysterics, etc. 
 
 Conversely, similar conditions may cause the peristalsis to dimin- 
 ish, or to cease entirely. Mechanical causes are very frequently 
 found in women; retroflexion of the uterus is one of the best 
 knoAvn, although not the only example. 
 
 As examples of thermal sedatives, we have warm, moist applica- 
 tions (cataplasma) and warm enemata. Where we have increased 
 intestinal movements, the diet employed may, from its nature, act 
 as a chemical sedative — e. g., gruels in diarrhoeas. The narcotic 
 drugs (opium and its derivatives, belladonna, etc.) should be classed 
 with those chemical agents which diminish intestinal peristalsis. 
 The latter may also be indirectly influenced by remedies which 
 tend to diminish intestinal secretion (the so-called astringents). 
 
 In the course of many diseases of the intestinal mucous mem- 
 brane there is a gradual decrease in normal intestinal excitability. 
 In intestinal stenosis we may have a temporary or a permanent 
 paralysis, resulting from paretic effects of fluid or gaseous prod- 
 ucts. Disturbances of intestinal circulation (haemorrhoids, con- 
 gestion accompanying uncompensated valvular affections, etc.) 
 frequently cause a decided slowing of peristalsis. Furthermore, 
 central nervous impulses may not only accelerate, but may weaken 
 or even inhibit intestinal movements — e. g., meningitis, cerebral tu- 
 mours, etc. In functional neuroses (neurasthenia, hypochondriasis, 
 and hysteria) there may be a marked diminution in the peristaltic 
 movements. Lastly, feeble peristalsis has been observed as a con- 
 genital inherited condition. 
 
 INTESTINAL ABSORPTION 
 
 The intestinal canal is the principal seat of food absorption. 
 As has been proved by the most recent researches of von Mering, 
 
PHYSIOLOarCAL AND PHYSIOLOGICO-CHEMICAL EEMARKS 37 
 
 Moritz, Hirsch, and Brandt, the absorption of substances (even 
 in solution) from the stomach is very limited. It has been dem- 
 onstrated that besides water, the intestines also absorb peptones 
 (or albumoses) as well as the various saccharins, salt solutions, 
 and fats, and give up these substances to the lymph and blood 
 channels. 
 
 Formerly absorption was regarded as a purely physical process — 
 for the most part one of simple diffusion. But since colloids (albu- 
 mins and gelatins) have very poor osmotic properties, this explana- 
 tion would apply to crystalloid substances only (salt and sugar). 
 Furthermore, this theory does not account for the entrance of the 
 fats into the chyle. The view which is now accepted is that absorp- 
 tion of food particles results mainly from a specific function of the 
 living protoplasm. This theory has sprung up within recent years, 
 and has been evolved from the studies of Iloppe-Seyler, Heiden- 
 hain, I. Munk, and others. 
 
 We shall now briefly describe the manner in which absorption 
 takes place in the intestines. First, as regards the absorption of 
 peptones. It is well known that peptones do not enter the blood 
 current as such, but in the form of albuminoids. This change is 
 essential, for it has been proved that peptones injected into the 
 blood are quickly excreted by the urine (Plosz and Gyergyay'**, 
 Hofmeister ^^). Consequently peptones must be converted into 
 albuminoid bodies before they enter the blood. Opinion is divided 
 among physiologists as to where this conversion takes place. Thus 
 Hofmeister ^^ ascribes the greater importance in assimilation and 
 absorption of the proteids to the leucocytes found so plentifully 
 upon the surface of the intestine during digestion ; whereas Heiden- 
 hain ^^ credits the leucocytes with but a very minor part in the 
 reconversion of albuminoids from peptones, and ascribes this rather 
 to the epithehal layer of the villi. 
 
 It is important to inquire into the utilization of albuminoids 
 where pancreatic juice is entirely absent. After complete extirpa- 
 tion of the pancreas in dogs. Abelmann*''' and Minkowski found 
 an average utilization of 44 per cent of albumin ingested, while, 
 after partial extirpation, 54 per cent was utilized. Similar experi- 
 ments of Sandmeyer^ showed a utilization of from 62 per cent 
 to 70 per cent, which was markedly increased by the administration 
 of raw beef pancreas. In the latter instance, figures coinciding 
 fully with those from normal animals were obtained. 
 
 As regards absorption of the carbohydrates, that of glucose 
 4 
 
38 DISEASES OF THE INTESTINES 
 
 levulose and galactose is direct, while maltose and cane sugar are 
 iirst converted into glucose within the intestines, and as such are then 
 absorbed. Experiments of Ludwig and von Mering^^ upon lower 
 animals, and of I. Munk and Rosenstein ^ upon man, tend to show 
 that carbohydrates are not absorbed through the chyle vessels, but 
 pass directly into the blood. Should there be an excess of blood 
 in the intestine, some of the sugar will pass directly into the chyle 
 vessels and into the thoracic duct (Ginsberg ^^). It appears from 
 the investigations of Hoppe-Seyler^, von Mering^**, and Otto^^, that 
 cane sugar as well as dextrinlike substances may be found in the 
 blood, though only in small quantities. 
 
 There is also a limit to the amount of sugar which can be con- 
 veyed to the blood-vessels of the liver ; when this limit is exceeded, 
 the excess in all probability passes directly into the lymphatic sys- 
 tem and is not brought to the liver at all. A portion of it readily 
 appears in the urine (alimentary glycosuria). The so-called "limit 
 of assimilation " varies with the individual person as well as with 
 the variety of sugar.* Sugar is stored up in the liver and to a less 
 extent in the muscles and glands, in the form of glycogen, a non- 
 oxidizable substance. The pancreas is the main though not the 
 only factor in the digestion and absorption of sugars. Although 
 Minkowski and Abelmann ^'^ found that only 5Y to 61 per cent of 
 starches were absorbed after total extirpation of the pancreas in 
 dogs, the experiments of Fr. Müller ^^ on man have nevertheless 
 shown that, even with total occlusion of the pancreatic duct, starches 
 are absorbed with hardly any loss whatever. 
 
 Fats are absorbed in the intestines after previous emulsification 
 by the pancreatic secretion and the bile. Owing to the great abun- 
 dance of alkalies present, the fatty acids are converted into soaps. 
 Fats are very probably absorbed through the lymphatics. This has 
 been proved by the investigations of Munk and Rosen stein ^^ in 
 their case of lymphatic fistula. In their experiments they found 60 
 per cent of the fats originally given in the chyle, and only 4 to 5 
 per cent of that amount was saponified. Furthermore, upon feed- 
 ing with erucic acid, a fat entirely foreign to the body, they again 
 obtained 37 per cent, and this in the form of neutral fat. It follows 
 from this that the fatty acids do not enter the lacteals in their orig- 
 inal form, but as neutral fats. I. Munk assumes also that fatty soaps 
 are for the greatest part converted into neutral fats before entering 
 the lymphatics. 
 
 * Compare von Noorden, Pathologie des Stoffwechsels, Berlin, 1893. 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 39 
 
 To sum up, absorption of the fatty portion of the food takes 
 place as follows : 1. Finely emulsified fat, as such, is either taken up 
 by the migratory lymph cells lying upon the free surface of the 
 intestinal wall (Zawarykin^* and Wiedersheim^^), or else it passes 
 directly into the villi, entering between the spaces at the base of the 
 cylindrical epithelia (Heidenhain). 2. Fatty acids are converted 
 into neutral fats, and. are likewise taken up by the lymphatics. 
 3. Fatty soaps are reconverted into neutral fats and taken up by 
 the lymphatics. Since fatty acids, as such, are not found again in 
 the chyle, we must assume with I. Munk^^ and von Walther^*^ that 
 they are converted within the intestinal wall into neutral fats by the 
 addition of glycerin, or even upon the intestinal surface itself (von 
 Walther). 
 
 As regards the soajjs, it would appear as though they could 
 combine with glycerin to form neutral fats within the parenchyma 
 of the villi. We must, however, admit the impossibility of explain- 
 ing the source of the glycerin necessary for this change. Possibly it 
 may be a portion of that made free in the splitting up of fat by the 
 pancreatic secretion ; at all events, the investigations of Perewozisn- 
 koff ^^, and the later ones of WilP^ and C. A. Ewald ®'^, have shown 
 that the living intestine is capable of forming neutral fats when 
 the component parts, fatty acids and glycerin, or fatty soaps and 
 glycerin, are introduced into it. Neumeister ^ quite correctly 
 points out that the epithelial cells play an important part in this 
 conversion. 
 
 Variety and constituency of the fats are of great importance in 
 determining their digestibility. I. Munk^^ and Arnschink^^ have 
 shown that fats with a high melting point (mutton tallow, stearin, 
 etc.) are not so completely absorbed as the more easily melted fats 
 (lard, goose fat, olive oil, butter, etc.). According to Munk and 
 Rosenstein ^, a firm fat like mutton tallow is more slowly absorbed 
 than a fluid like lipanin. Besides this, a free fat is more readily 
 absorbed than one which, like lard, is inclosed in an envelope 
 (Rubner^^). I find interesting the fact mentioned by Fleischer^, 
 that Hippocrates had already referred the difiiculty in the digesti- 
 bility of eels to the stearin contained in them. 
 
 How does occlusion of the pancreatic duct or extirpation of the 
 pancreas affect fat digestion ? The absence of pancreatic juice is 
 certainly of great importance in this connection. According to 
 Minkowski and Abelmann ^''', all fats (neutral as well as mixtures 
 of fatty soaps and fatty acids) fed to dogs under these conditions 
 
40 DISEASES OP THE INTESTINES 
 
 appear in the feces. Milk forms the only exception; over half 
 of its fat is absorbed. An increase in the absorption of fat was 
 observed when pancreas of beef or pig was added to the food. 
 Other experiments upon the absorption of fat, especially in man, con- 
 trast with the results just cited. Thus Sandmeyer^ found great 
 variations in the absorption of unemulsified fats in his dogs (0-78 
 per cent). "Where emulsified fats in the form of milk were given, 
 42 per cent was absorbed. Teichmann ^ found no altei-ation in 
 fat absorption in rabbits in whom the pancreatic duct had been 
 tied. Fr. Müller ^ found rather abundant fat absorption in a case 
 of pancreatic fistula consequent upon the extirpation of a cyst. 
 
 Though the results just enumerated are so very contradictory, it 
 is not incorrect to assume that disturbances in the assimilation of 
 fat arise wherever there is a long-continued exclusion of pancreatic 
 juices, and (as is usually the case in man) also of the bile. From 
 this it by no means follows that these secretions are indispensable 
 to the support of life, for there are apparently vicarious forces which 
 to a certain extent can offset the disturbances occasioned by the 
 absence of these digestive secretions. 
 
 Absorption from the large intestine is relatively unimportant. 
 However, when the activity of the upper portions of the absorptive 
 system is in abeyance, the large intestine may for a time act 
 vicariously. This we learn from the employment of rectal nutri- 
 tion. Water, especially, is very readily absorbed from the large 
 intestine. As proved by Eichhorst ^^, Yoit and Bauer % Leube^, 
 Ewald ®^, Huber^'', and Kohlenberger'''^, albuminoids and albumoses 
 are also absorbed from the rectum and the large intestine. My 
 own experience with milk has taught me that it is almost entirely 
 absorbed from the lower segment of the large intestine. Starch 
 which has not been converted into sugar is slowly acted upon by the 
 bacterial ferments, and ultimately decomposed into lactic acid, buty- 
 ric acid, etc. 
 
 Eats, especially emulsified fats, are slowly absorbed from the large 
 intestine (Kobert'''^ Munk and Rosenstein ^^, P. Deucher"^^). The 
 amount taken up is, however, comparatively slight, only 10 per 
 cent of that present in a rectal injection being absorbed (Deucher). 
 The absorption of oils may be increased by the addition of normal 
 salt solution. 
 
 The immediate result of a liberal absorption of food constituents 
 from the intestines is a gradual increase in the consistency of the 
 residue, which slowly assumes the form of normal faeces. At the 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 41 
 
 same time the acid reaction of the masses becomes gradually neutral 
 or feebly alkaline. 
 
 THE EXCRETORY FUNCTION OF THE INTESTINAL 
 
 CANAL 
 
 Besides absorption and secretion, the intestinal canal, like the 
 stomach, has also the function of excretion. It may thus rid itself 
 of superfluous substances' as well as of waste materials from the 
 blood, all of which it excretes with the fseces. This function of the 
 intestines, which has been closely studied within the last few years, 
 is also of clinical interest, and therefore deserves brief mention. 
 
 We know from Hermann's experiments''^* with animals, but 
 even more so from Fr. Müller's experiments''^, in connection with 
 Senator, Lehmann, I. Munk, and Salkowski, upon the two profes- 
 sional fasters Cetti and Breithaupt, that during fasting the faeces 
 contain a number of organic and inorganic substances, a portion of 
 which, at least, must be regarded as excreted matter. Kobert '^^ de- 
 serves credit for having made similar studies upon the isolated large 
 intestine of men, and for having thus determined the share taken in 
 excretion by that portion of the intestinal canal. He found that in 
 twenty-four hours an inactive large intestine excreted an average of 
 0.9684 grammes dry substance, the percentage of whose ingredients 
 varied from 3.35 per cent inorganic and 96.65 per cent organic 
 ingredients, to 57.52 per cent inorganic and 42.48 per cent organic 
 substances. The inorganic ingredients were sodium, calcium, mag- 
 nesium, iron, and phosphoric, sulphuric, and hydrochloric acids; 
 the organic, mucin, albumin, keratin, fatty acids, soaps, and neu- 
 tral fats. A large proportion (12.793 per cent) of the inorganic 
 substances consisted of calcium and of phosphoric acid (44.52 per 
 cent). This substantiates the results of Fr. Müller's experiments 
 on dogs, as well as those of von Noorden and Belgardt '^^ on man, in 
 which they found large amounts of calcium and phosphates in the 
 excretions, particularly in those from the large intestine. From 
 investigations in a case of fistula of the ileum, Honigman '^'^ recently 
 arrived at the same conclusions. Particular interest lends itself 
 to the discovery made by Kobert, that the large intestine can also 
 excrete fat. He found that the total amount varies from 9.32 per 
 cent to 6.48 per cent of the dried substance ; 90 per cent of this 
 total amount being fatty acids, 9 per cent neutral fats, and the 
 remainder fatty soaps. From this it may be seen that intestinal 
 
42 
 
 DISEASES OF THE INTESTINES 
 
 excretion constitutes an important auxiliary to tlie functions of 
 the kidney. The occurrence of profuse diarrhoeas in extensive 
 parenchymatous changes of the kidneys is in all probability an 
 attempt on the part of the organism to vicariously rid itself of waste 
 material through the intestinal canal. From investigations thus far 
 made, we would regard the large intestine as most actively partici- 
 pating in this vicarious action. 
 
 THE NATURE AND COMPOSITION OF THE F>CCES 
 
 The fseces are made up partly of food which is either indiges- 
 tible or has not been acted upon by the digestive juices, partly of 
 the secondary products of digestion, and lastly from the remnants 
 of the secretions and excretions of the digestive tract itself. In 
 this latter connection it should be remarked that the empty intes- 
 tine may produce faeces through its secretions and its exfoliated 
 epithelium (so-called RingJcoth of L. Hermann '^^). 
 
 The composition of the fseces naturally varies very much accord- 
 ing to the nature and range of the diet. Under a vegetable diet 
 the fjecal masses are much bulkier than under an animal one. As 
 an example of this, Yoit "'^ states that the excrements of a man under 
 a mixed diet amounted to 120-150 grams, vnth 30-37 grams solids 
 in twenty -four hours ; while those from a vegetarian equalled 333 
 grams, with 75 grams solids. The colour of the fseces is to a cer- 
 tain degree also dependent upon the diet. Under mixed diet it 
 is dark brown ; under milk diet, brownish yellow ; and brownish 
 black, or even deep black, under meat diet. 
 
 Among the food ingredients found in normal fseces are muscle 
 fibres, connective tissue, casein particles, starch fragments, fat, vege- 
 table remnants, horny substances, nuclein, etc. The intestinal mu- 
 cous membrane and its secretions contribute mucin, cholic acid, 
 dysalin, and Cholesterin. The products of intestinal putrefaction 
 found in the fseces include skatol, indol, volatile fatty acids (acetic 
 acid is said to be constantly present in fseces), calcium, and magne- 
 sium soaps. Of the inorganic salts in the fseces, the readily soluble 
 alkaline chlorids occur but rarely, while the insoluble combinations 
 — ammonium magnesium phosphates, calcium carbonate, neutral 
 calcium phosphate, and magnesium phosphate — are, on the con- 
 trary, very frequently met with, being for the most part derived 
 from the food. 
 
 Bacteria and other micro-organisms occur in large numbers in 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 43 
 
 the fseces ; according to Woodward ""^j thej constitute a very con- 
 siderable portion of the faeces. The only bile pigment found under 
 norncial conditions is urobilin (stercobilin) ; the occurrence of biliru- 
 bin or biliverdin is pathologic. 
 
 Careful quantitative analyses of the faeces have often been made, 
 but, as might have been supposed, they have given widely varying 
 results. We would therefore desist from mentioning them. 
 
 INTESTINAL DIGESTION IN ITS ENTIRETY 
 
 In attempting a description of intestinal digestion in toto, we 
 encounter serious obstacles; for our knowledge of this subject in- 
 cludes a number of isolated processes which can not be grouped 
 together without the aid of some hypotheses. 
 
 What impulse excites intestinal secretion ? The opening of the 
 pylorus acting reflexly very likely causes an increased secretion of 
 bile and of pancreatic juice. Concerning the pancreatic secretion, 
 we know from the experiments of Heidenhain ^° and Bernstein ^^ 
 that it begins to flow simultaneously with the ingestion of food, and 
 reaches its maximum in from two to three hours. Thereupon the 
 amount declines till the fifth to the seventh hour, increasing anew 
 from the ninth to the eleventh, and then gradually declining again 
 from the seventeenth to the twenty-fourth hour, when it finally 
 ceases. 
 
 As regards the bile, we know that it decreases during fasting, • 
 and is secreted again after ingestion of food. According to Heiden- 
 hain, two maxima in rapidity of its secretion are observed in dogs : 
 the first from three to five hours after food ingestion, and the 
 second from thirteen to fifteen hours. Investigations of Rossbach ^ 
 yielded similar results. In all probability, therefore, the chyme 
 meets with an active digestive juice when it enters the intestinal 
 canal. 
 
 The action of the intestinal juices upon the products of stomach 
 digestion is still a matter of controversy. Physiologists, particu- 
 larly Kühne, ascribe to bile the property of precipitating and 
 destroying not only the albumin and gelatin, but also the pepsin 
 of the stomach contents. From this it would seem as though 
 the precipitation of the pepsin within the small intestines was of 
 extreme importance for digestion. However, my own investiga- 
 tions ^° made with the pure mixed secretions from the intestines 
 of man (i. e., mixtures of bile, pancreatic juice, and probably also 
 
44 DISEASES OF THE INTESTINES 
 
 tlie secretion from the glands of Lieberkiilin) have shown that these 
 views are incorrect. What does occur is rather as follows : The 
 first faintly acid portions of the chjme occasion alterations in the 
 intestinal juices onlj in so far as they acidify these to a slight 
 degree, whereby, as we have already seen (see page 27), no de- 
 struction of the active intestinal ferments occurs. It is true that 
 with the entrance of strongly acid chyme into the small intestine 
 a precipitation of the albuminoids — but not of the gastric ferments 
 — follows. However, a mixture of duodenal juices and stomach 
 contents with the latter in such proportion that free hydrochloric 
 acid is present exhibits solely and distinctly the characteristics of 
 a pepsin-hydrochloric-acid solution. Kennet ferment also is pre- 
 served intact in such a mixture. If we alkalinize such a mixture 
 with dilute soda solution, we may — for a short time at least — be 
 able to observe tryptic action. Later this action can not be brought 
 out because the trypsin is destroyed by the continued action of 
 the gastric acid. It is therefore very probable that in the first 
 stages of intestinal digestion there is simply a continuation of the 
 gastric digestion. Gradually, however, as the intestinal juices in- 
 crease and the amount of strongly acid stomach chyme poured into 
 the duodenum diminishes, pepsin digestion gives way to that of 
 trypsin. My observations have recently, in great part, been con- 
 firmed by Fleischer^ and Meltzer. 
 
 In spite of the differences of opinion between physiologist and 
 clinician, the above observations show that the reaction of the con- 
 tents of the small intestines varies according to the stage of diges- 
 tion. Even in the lowermost portion of the small intestines— as 
 JSTencki, Macfadyen and Sieber^ found in a fistula in the lowest 
 portion of the ileum — the reaction of the contents was acid, the 
 acidity averaging one pro miille (basis of acetic acid). 
 
 As soon as the intestinal ferments can act with full force the 
 digestion of food takes place, the individual ferments acting as 
 already described. Proteids which have not yet been converted 
 into albumoses are peptonized, with the additional formation of 
 leucin, tyrosin, and of aspartic acid ; unconverted carbohydrates are 
 at first altered into maltose and (a little) glucose, and finally com- 
 pletely into glucose ; fats are split up into fatty acids and glycerin, 
 and are in part emulsified — i. e., brought into an absorbable con- 
 dition. 
 
 In addition to these fermentative changes there are also bacterio- 
 logical changes which to a certain extent affect the proteids and 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 45 
 
 gelatinous substances, but to a far greater degree the carbohydrates. 
 Their existence has been proved by the above-mentioned instructive 
 investigations of JSTencki, Macfadyen and Sieber ^ upon their case 
 of fistula of the ileum. The chyme vs^as of a yellowish or yellowish- 
 brown colour and had an acid reaction. As a rule, excepting for a 
 somewhat burnt smell reminding one of the volatile fatty acids, or 
 still more rarely excepting for an odour of decomposition very like 
 indol, this yellowish mass was entirely odourless. Besides acetic 
 acid, fermentation as well as musclelactic acicl, volatile, fatty, suc- 
 cinic, and bile acids were also present. In large quantities of this 
 chyme it was impossible either through sense of smell or through 
 chemical examination to detect the merest traces of the character- 
 istic decomposition products, such as indol, skatol, phenol, methyl 
 mercaptan, or of their combinations, phenylpropionic acid, paraoxy- 
 phenyl-propionic acid, and skatolacetic acid. 
 
 Without doubt the real seat of intestinal putrefaction is in the 
 large intestine. The role in food digestion assumed by the large 
 intestine is markedly less than that of the small. The experiments 
 of Nencki, Macfadyen and Sieber showed that 85 per cent of the 
 albumin ingested is digected by and absorbed from the stomach and 
 small intestines, so that but about 15 per cent remains for the large 
 intestines. Undoubtedly digestion does take place in the large 
 intestine, but it is more bacterial than fermentative. Another chief 
 difference from small intestinal digestion is the formation not only 
 of useful products, but also of others harmful to the economy. It 
 is questionable, however, if all bacterial by-products are utterly use- 
 less in intestinal digestion — if, for example, certain products are 
 not capable of favourably exciting peristaltic motion. 
 
 The best-known decomposition products are those of albumin. 
 They have been studied by many investigators, above all by l^encki. 
 Baumann, Brieger and H. and E. Salkowski. The most important 
 are indol, skatol, paracresol, phenyl-propionic acid, phenyl-acetic 
 acid, hydroparakumaric acid, the volatile fatty acids, carbon-dioxide, 
 hydrogen gas, methyl mercaptan, and sulphuretted hydrogen. 
 
 Of these, the most important from a practical standpoint, are 
 indol and skatol, because, as has been shown by the investigations 
 of E. Baumann, they combine with the sulphates of the food (pre- 
 viously oxidized to indoxyl and skatoxyl sulphates) to form ethereal 
 sulphuric acids (indoxyl-sulphuric acid and skatoxyl-sulphuric acid), 
 and are excreted as such in the urine. They thus form a gauge 
 (though not a constant one) for the putrefactive processes within the 
 
46 DISEASES OP THE INTESTINES 
 
 intestines. Phenol passes into the urine as phenol-sulphuric acid ; 
 the oxy-acids pass off unaltered with the urine. 
 
 The carbohydrates, like the albuminoids, are also subject to 
 bacterial decomposition. At the present time we recognise a large 
 number of bacteria, which through fermentative action may on one 
 hand convert starches into sugars, and on the other cause these 
 very sugars to ferment. For example, the bacillus subtilis and the 
 spirillum of cheese are both capable of converting starch into sugar ; 
 but further long-continued action of the subtilis on this sugar 
 results, according to van den Yelden, in fermentative production of 
 lactic, butyric, and succinic acids. " Some bacteria and yeasts can 
 produce invertin, etc. ; others, again, such as the bacillus butyricus, 
 convert lactic acid into butyric acid. As final products of carbo- 
 hydrate fermentation we have a number of gases, the most important 
 of which are carbon dioxid, hydrogen and marsh gas. 
 
 Cellulose fermentation results mainly from the action of certain 
 bacteria or vibrios. 
 
 Fats are capable of fermentation, especially when in the form of, 
 fatty acids, but the special organisms as well as the different steps 
 of the process are entirely unknown to us. 
 
 [THE GASES OF THE INTESTINES 
 
 The gases occurring within the intestinal tract are derived from 
 three sources : 
 
 1. They enter the bowel from the stomach. 
 
 2. They pass from the blood into the intestines by diffusion. 
 
 3. They are formed within the intestinal canal. 
 
 Of these three sources the third is by far the most important 
 and active. 
 
 1. The gases that may enter the bowel from the stomach 
 are : 
 
 a. Air swallowed during or independently of the ingestion of 
 food (oxygen and nitrogen). 
 
 h. Gases contained in food, beverages, and medicated liquids. 
 These consist mainly of carbonic acid, but small qaantities of other 
 gases may be introduced with the mineral waters (e. g., sulphuretted 
 hydrogen in sulphur waters, etc.). 
 
 c. Gases originating within the stomach. These are partly 
 absorbed, partly escape from the body through eructations, but a 
 certain portion passes into the intestines. In the early stages of 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL EEMARKS 4:7 
 
 normal gastric digestion, micro-organisms swallowed with the food 
 cause some fermentation of the stomach contents with a result- 
 ing formation of carbonic-acid gas and hydrogen. According to 
 Miller,^^ this fermentation ceases as soon as a large amount of hydro- 
 chloric acid has been produced. Schierbeck ^ has demonstrated 
 that during digestion carbonic-acid gas is produced by the secreting 
 cells of the gastric wall. Strauss ^^ and Rosenheim ^^ found ammo- 
 nia present in very small amounts. 
 
 Under pathological conditions (stagnation with or without the 
 presence of hydrochloric acid, abscess of the wall, ulcerating carci- 
 noma, etc.), in addition to the above-mentioned two gases, hydro- 
 gen, sulphuretted hydrogen, ammonia, marsh gas, and other hydro- 
 carbons may be produced. It is but natural to assume that with a 
 patulous pylorus and fair or good gastric motility these abnormal 
 gases may enter the intestines. 
 
 2. Bunge ^ states that nitrogen, and l^othnageP^ that carbonic- 
 acid gas, enter the intestinal canal by diffusion from the blood. 
 
 3. Throughout the entire intestinal canal gases are formed from 
 digestive fermentation and bacterial decomposition of the food ; in 
 the uppermost portion of the small intestine, from the action of acid 
 gastric chyme and of the free acids of the fats upon the alkaline 
 intestinal and pancreatic juices. The amount and kind of gas 
 formed vary according to the diet and the segment of bowel in 
 question. Gas formation is most rapid wherever active fermentative 
 changes occur — i. e., in the upper segments of the small intestine. 
 Accordingly, less gas is produced in the lower portion of the small 
 intestine and very little in the large bowel. In the large intestine 
 gas formation has almost or entirely ceased, and putrefactive decom- 
 position and inspissation of the fseces take place. 
 
 From the decomposition of the alkaline carbonates of the intes- 
 tinal juices by the gastric chyme and fatty acids in the uppermost 
 portion of the small intestine carbonic-acid gas is formed. After 
 the acids have been neutralized, intestinal fermentation and decom- 
 position begin. 
 
 Of the solid food stuffs, the carhoJiydrates yield hydrogen, car- 
 bonic-acid gas, and a small quantity of marsh gas, varying propor- 
 tionately to the digestibility of the carbohydrates. Starchy foods 
 result in the formation of but very little marsh gas, while, as we 
 know from the experiments and investigations of Huge,*' Tappei- 
 ner,^^ and Planer,^^ those rich in cellulose yield more marsh gas than 
 any other variety of food. Since cellulose is not altered by the gas- 
 
48 DISEASES OP THE INTESTINES 
 
 tro-intestinal secretions of man, tlie formation of marsh gas is no 
 doubt due to bacterial action. 
 
 The gases that result from the digestion and decomposition of 
 proteid material are formed more slowly than those from the car- 
 bohydrates. These ai-e hydrogen, carbonic acid, marsh gas, ammo- 
 nia, sulphuretted hydrogen, and, according to Lehmann, Hagemann, 
 and Zuntz,^^ nitrogen under certain specific conditions. 
 
 As already mentioned, the fats, by the action of their fatty 
 acids upon the alkaline intestinal juices, produce carbonic-acid gas. 
 
 Considering the large quantity of gases normally present in the 
 intestine* and the comparatively small amount passed as flatus, 
 their absorption must be a very active one. Eegnault and Eei- 
 sert,^* Tacke,^^ Zuntz,^^ and others, have demonstrated the pres- 
 ence of marsh gas and other intestinal gases in the expired air. 
 
 Under pathological conditions the quantity and composition of 
 gases in a given segment will vary from the normal. It will depend 
 upon the nature of the contents (amount of fermentative material 
 and of fermenting agents — i. e., bacteria, moulds and yeasts), the 
 motility of the bowels, and the condition of the circulation. 
 
 In sluggishness or total arrest of the contents (e. g., atony, 
 paralysis, obstruction, occlusion, etc.) there will at first be the prod- 
 ucts of fermentation, later those of putrefactive decomposition. 
 By his experiments Kader^^ showed that excessive formation of gas 
 within the intestinal lumen was largely dependent upon the circula- 
 tion in the mesentery. In those experiments in which the mesen- 
 tery was ligatured, marked meteorism developed ; in those in which 
 the gut alone was tied, very little gas developed, (See also page 363 
 of this work.) 
 
 Certain catarrhs, by offering conditions favourable to bacterial 
 and fungoid growth, favour the increase of gases (l^othnageP^). 
 The same holds true also for ulcerative and sloughing conditions 
 (carcinoma, dysentery, abscess, gangrene, etc.). 
 
 On the other hand, in abnormally rapid peristalsis the contents 
 pass so quickly through the intestine that only easily assimilated 
 food stuffs are decomposed. The starches and sugars and carbon- 
 ated beverages yield gaseous products within the body ; the more 
 resistant carbohydrates, the fats, the proteids, connective tissues, 
 
 * [A faint idea of the active formation that goes on may be gained by mixing a 
 small amount of fresh faeces (about 5.0 grams) with a^ little water, placing the 
 mixture in any kind of a fermentation tube, and allowing the tube to remain for a 
 short time in an incubator at 37° C. — Te.] 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMARKS 49 
 
 and cellulose pass out very slightly or not at all altered. Hydrogen 
 and carbonic-acid gas are mainly formed ; the fseces are often passed 
 in a state of active starchy and saccharin fermentation — Te.] 
 
 LITERATURE 
 
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 3. Hoppe- Seyler. Physiolog. Chemie, Berlin, 1877-'81, S. 374. 
 
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 1887, S. 183. 
 
 4. Demant. Virchow's Archiv, Bd. Ixxv, S. 419. 
 
 5. Brown u. Heron. Annal. Chem. und Pharm., 1880, Bd. cciv, S. 338. 
 
 6. K. B. Lehmann. Arch, für die gesammte Physiologie, Bd. xxxiii, S. 180. 
 
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 ö. 945. 
 
 8. Miura. Zeitschr. f. Biologie, Bd. xxxii, S. 366-387. 
 
 9. Röhmann u. Lappe. Berichte d. deutsch, chem. Gesellschaft, Bd. xxviii, S, 
 
 3,506 u. 3,507. 
 
 10. Frick. Arch. f. wissensch. u. prakt. Thierheilkunde, Bd. ix, S. 148. 
 
 11. EUenberger u. Hofmeister. Ibid., Bd. x, S. 437. 
 13. Wenz. Zeitschr. f. Biologie, N. F., Bd. iv, 1886. 
 
 13. C. Schmidt. Annal d. Chemie, Bd. xcii, 1854, S. 34. 
 
 14. Zawadsky. Centralbl. f. Physiologie, 1891, Bd. v. 
 
 15. Herter. Zeitschr. f. physiolog. Chemie, Bd. iv, 1880, S. 100. 
 
 16. Podolinski. Pflüger's Archiv, Bd. x, 1875, S. 557 u. Bd. xii, 1876, S. 433. 
 
 17. S. G. Hedin. Du Bois-Reymond's Archiv, 1891, S. 373-378. 
 
 18. R. Neumeister. Zeitschr. f. Biologie, N. F., Bd. viii, 1890 ; and Winter- 
 
 nitz, Zeitschr. f. physiolog. Chemie, Bd. xvi, 1893, S. 463. 
 
 19. Maly. Jahresbericht, Bd. ix, S. 334. 
 
 30. Boas. Zeitschr. f. klin. Medicin, Bd. xvii, Heft 1 u. 3, 1890. 
 
 31. Musculus u. Gruber. Zeitschr. f. physiolog. Chemie, Bd. ii, 1878, S. 177. 
 33. von Mering. Zeitschr. f. physiolog. Chemie, Bd. v, 1881, S. 185. 
 
 33. Nencki. Arch. f. experiment. Pathologie u. Pharmakologie, Bd. xx, S. 
 
 367. 
 24. Boas. Deutsch, med. Wochenschr., 1891, No. 38. 
 
 35. Baas. Zeitschr. f. physiol. Chemie, Bd. xiv, S. 416. 
 
 36. Voit. lieber die Bedeutung der Galle f. die Aufnahme der Nahrungs- 
 
 mittel im Darmcanal. Festschrift, München, 1883. 
 27. Röhmann. Pflüger's Archiv, 1883, Bd. xxix, S. 509. 
 38. Neumeister. Lehrbuch der physiolog. Chemie, 1893, Theil i. 
 
 29. Heidenhain. Pflüger's Archiv, 1888, Bd. xliii, S. 91. 
 
 30. Braam-Houkgeest. Pflüger's Archiv, Bd. vii, 1872, S. 366. 
 
 31. Nothnagel. Beiträge zur Physiologie u. Pathologie des Darms, Berlin, 
 
 1884. 
 
 32. Grützner. Deutsch, med. Wochenschr., 1894, No. 48. 
 
 33. Christomanos. Wiener klin. Wochenschr., 1895, Nos. 12 and 13. 
 
 34. Dauber. Deutsch, med. Wochenschr., 1895, No. 34. 
 
50 DISEASES OF THE INTESTINES 
 
 35. Wendt. Munch, med. Wochenschr., 1896, No. 19. 
 
 36. Swiezynski. Deutsch, med. Wochenschr., 1895, No. 32. 
 
 87. Riegel. Die Erkrankungen des Magens, Wien, 1896, S. 246. 
 
 38. J. Pal. Wiener klin. Wochenschr., 1895, Nos. 29 and 30. 
 
 39. J. Pal. Ibid., 1897, No. 2. 
 
 40. Bechterew u. Mislawski. Arch. f. Anat. u. Physiol., 1889, Supplement- 
 
 band. 
 
 41. Fellner. Oesterr. med. Jahrbücher, 1883, S. 571 ; and Pflüger's Archiv, 
 
 Bd. Ivi, 1894. 
 
 42. L. Exner. Pflüger's Archiv, Bd. xxxix, 1884, S. 310. 
 
 43. J. Pal. Wiener klin. Wochenschr., 1895, Nos. 39 and 40. 
 
 44. Plosz. u. Gyergyay. Pflüger's Archiv, Bd. vi. 
 
 45. Hofmeister. Zeitschr. f. physiol. Chemie, Bd. v. 
 
 46. Ibid. Archiv für experiment. Pathol, u. Pharmakol., Bd. xix, xx und 
 
 xxii. 
 
 47. Abelmann. lieber die Ausnützung der Nahrungsstoffe nach Pancreasex- 
 
 tirpation. Inaug. -Dissert., Dorpat, 1890. 
 
 48. Sandmeyer. Zeitschr. f. Biologie, 1895, Bd. xxxi, S. 12. 
 
 49. von Mering. Du Bois-Reymond's Archiv f. Physiologie, 1877, S. 379. 
 
 50. I. Munk u. Rosenstein. Virchow's Archiv, 1891, Bd. cxxiii, S. 230. 
 
 51. Ginsberg. Pflüger's Archiv, Bd. xliv, S. 306. 
 
 52. Cited from Maly's Jahresb. f. Thierchemie, Bd. xvii, S. 134. 
 
 53. Fr. Müller. Zeitschr. f. klin. Medicin, 1887, Bd. xii. 
 
 54. Zawarykin. Pflüger's Archiv, 1883, Bd. xxxi ; 1885, Bd. xxxv. 
 
 55. Wiedersheim. Freiburger Festschrift zum 56. Naturforscherversammlung, 
 
 1887. 
 
 56. I. Munk. Virchow's Archiv, Bd. Ixxx. 
 
 57. von Walther. Du Bois-Reymond's Archiv, 1890, S. 329. 
 
 58. Perewozisnkoff. Centralbl. f. d. med. Wissenschaften, 1876, No. 47. 
 
 59. Will. Pflüger's Archiv, Bd. xx, 1879, S. 255. 
 
 GG. C. A. Ewald. Du Bois-Reymond's Archiv, 1883, Supplementband, S. 302. 
 
 61. I. Munk. Virchow's Archiv, Bd. Ixxx, S. 10 ; Bd. xcv, S. 407. 
 
 62. Arnschink. Zeitschr. für Biologie, Bd. xxvi, S. 434. 
 
 63. Rubner. Ibid., Bd. xv, S. 115 et seq. 
 
 64. Fleischer. Lehrbuch d. inneren Medicin, Bd. ii, Theil 2, S. 1,077. 
 
 65. Teichmann. Mikroskop. Beiträge zur Lelire von d. Fettresorption, luaug.- 
 
 Dissert., Breslau, 1891. 
 
 66. Eichhorst. Pflüger's Archiv, 1871, S. 570. 
 
 67. Voit u. Bauer. Zeitschr. f. Biologie, Bd. v, 1869. 
 
 68. Leube. Deutsch. Archiv f. klin. Medicin, 1872. Bd. x. 
 
 69. Ewald. Zeitschr. f. klin. Medicin, 1887, Bd. xii. 
 
 70. Huber. Deutsch. Archiv f. klin. Medicin, 1891, Bd. xlvii. 
 
 71. Kohlenberger. Münch. med. Wochenschr., 1896, No. 47. 
 
 72. Kobert. Deutsch, med. Wochenschr. 1894, No. 47. 
 
 73. Deucher. Deutsch. Archiv f. klin. Medicin, 1897, Bd. Iviii, S. 21G. 
 
 74. Hermann. Pflüger's Archiv, 1890, Bd. xlvi, S. 93. 
 
 75. Fr. Müller. Virchow's Archiv, 1893, Bd. cxxxi, Supplementheft. 
 
 76. von Noorden u. Belgardt. Berliner klin. Wochenschr., 1894, No. 10. 
 
PHYSIOLOGICAL AND PHYSIOLOGICO-CHEMICAL REMAKKS 51 
 
 77. G. Honigmann. Archiv f. Verdauugskrankheiten, 1896, Bd. ii, S. 296. 
 
 78. Voit. Zeitschr. f. Biologie, 1889, Bd. xxv, S. 264. 
 
 79. Woodward. Med. and Surg. Report of the War of the Rebellion, vol. i. 
 
 Part 2, 1879. 
 
 80. Heidenhain. Pflüger's Archiv, Bd. x, S. 557. 
 
 81. Bernstein. Arbeiten aus der physiolog. Anstalt zur Leipzig, 1869. 
 
 82. Rossbach. Deutsch. Archiv f. klin. Medicin, Bd. xlvi, S. 296. 
 
 83. Nencki, Macfadyen u. Sieber. Archiv f. expei-imentelle Pathologie u. 
 
 Pharmakologie, Bd. xxviii, S. 311-350. 
 [84. Miller. Deutsch, med. Wochenschrift, 1885, No. 49.] 
 [85. Schierbeck. Scand. Arch, of Physiol., vols, ii and iv. Quoted from Ham- 
 
 marsten's Lehrb. d. physiolog. Chemie., 1895, 3te Aufl., S. 246.] 
 [86. Strauss. Berl. klin. Wochenschr., 1893, No. 17.] 
 [87. Rosenheim. Centralbl. f. klin. Medicin, 1892, No. 39] 
 [88. Bunge. Lehrbuch, etc., S. 268.] 
 [89. Nothnagel. Darm u. Peritoneum, 1898, S. 64.] 
 
 [90. Ruge. Sitzungsber.d. Wiener Akademie d. Wissenschaften, 1861, Bd. xliv.] 
 [91. Tappeiner. Zeitschr. f. Biologie, 1893, Bd. xix, S. 223.] 
 [92. Planer. Sitzungsber. d. Wiener Akad. d. Wissensch., 1860, Bd. Ixii, S. 307.] 
 [93. Hagemann, Lehmann u. Zuntz. Landwirthschaftliche Jahrbücher, 1894, 
 
 S. 125.] 
 [94. Regnault u. Reisert. Quoted from Nothnagel, loc. cit., p. 64.] 
 [95. Tacke. lieber d. Bedeutung d. brennbaren Gase im mensclilichen Orga- 
 nismus. Inaug.-Dissert., Berlin, 1889.] 
 [96. Kader. Deutsch. Archiv f. Chirurgie, 1891, Bd. xlii, S. 57, etc.] 
 
DISEASES OF THE Ü^TESTH^TES 
 
 PART I 
 GENERAL DIVISION 
 
CHAPTER III 
 
 THE HI8T0BY 
 
 In diseases of the intestines the history is of almost greater 
 importance than in gastric affections. In the latter the diseased area 
 is very limited ; in the former it is far more extensive. Whereas 
 in gastric disease we can determine the condition through physical 
 and functional examinations alone, in intestinal diseases we are com- 
 pelled to rely mainly, sometimes even entirely, upon the statements 
 of our patients. Too much care, therefore, can not be expended in 
 obtaining as complete a history as possible. 
 
 ISTaturally here, as elsewhere, our first inquiry should not be con- 
 cerned with the local disturbances, but with the patient's previous 
 general health. Hereditary tendencies must be taken into account. 
 Our view of a case may be radically influenced by the existence of 
 special dyscrasias, as syphilis, tuberculosis, etc., or by learning of 
 the habitual employment of poisons which we know from experience 
 to be injurious to the gastro-intestinal tract (alcohol, tobacco, lead, 
 mercury, tin, zinc, argenic, antimony, etc.). Special interest is 
 imparted to a case by a previous history of infectious diseases, par- 
 ticularly such as have local manifestations in the intestines — e. g., 
 typhoid, cholera, dysentery, intestinal tuberculosis, etc. Owing to its 
 etiological relations to cancer, a traumatism received prior to the 
 development of a disease merits special consideration. In the 
 female, the sexual apparatus should receive due attention, since it is 
 frequently a cause of intestinal troubles. "We should inquire par- 
 ticularly into the menstrual condition, childbirths, previous opera- 
 tions, as well as regarding any special symptoms the patient may 
 have noticed (leucorrhoea, menorrhagia, metrorrhagia, pains, pres- 
 sure, etc.). In men, too, there is frequently a direct connection 
 between diseases of the sexual organs and those of the intestines, so 
 that careful inquiry ought never to be omitted. I need but recall 
 diseases of the prostate gland. It is only after having thus obtained 
 a clear and complete oversight of any other local or general affec- 
 
 55 
 
56 DISEASES OF THE INTESTINES 
 
 tions, which at first seem to have no cpnnection with the present 
 symptoms, that we ought to inquire into the details of the affec- 
 tion in question. 
 
 Regarding those points referable to gastric digestion, the reader 
 is referred to Pai"t I (general section) of my work on Diseases of 
 the Stomach. There the most important facts bearing upon intes- 
 tinal disturbances are discussed. 
 
 Whenever there is a suspicion of intestinal disease a most 
 thorough local examination is indispensable. We may begin with 
 the symptoms complained of by the patient, or, preferably, we can 
 pursue a definite plan of inquiry which shall include all the anam- 
 nestic data that can be gained from the history of a case. 
 
 The following scheme has been of great service to me for many 
 years : 
 
 1. Pai:s" along the Course or the Intestines 
 
 (a) Seat of the pain. 
 
 (5) Origin of the pain ; acute or chronic ; paroxysmal. 
 
 (c) Character of the pain ; burning, boring, stabbing, tearing, 
 colicky, lancinating. 
 
 {d) Duration of the pain. 
 
 (e) Kelation of pain to digestion ; how influenced, if at all, by 
 quantity and variety of food. 
 
 (y) Does the attack of pain cease with the passage of wind or 
 of stool ; or have these no influence upon the pain ? 
 
 (g) How do rest and motion affect the pain ? 
 
 {h) What is the effect of manual pressure upon the painful 
 area? 
 
 As a rule, the statements of the patient regarding the seat of the 
 pain are not conclusive for the physician ; for it requires very good 
 powers of observation to properly describe to the physician the 
 point of origin of the pain, its extent, etc. Should the pain become 
 intense, the patients naturally think less of its exact situation than 
 they do of its severity. Pain in one region of the intestines alone — 
 that of the vermiform appendix or of the caecum — is so very char- 
 acteristic that even the layman can localize it quite well. Its distinct 
 localization indeed differentiates CEecal from similar pains. If the 
 patient tells us that the pain is continuous, that it increases upon 
 motion and diminishes with rest, that the painful area is sensi- 
 tive to pressure, that the attack began with fever, and perhaps 
 that similar attacks have already occurred, the diagnosis of appen- 
 
THE HISTORY 5Y 
 
 dicitis or typhlitis is almost certain. Similarly, at least in well- 
 developed cases of round ulcer of the duodenum, we find a strictly 
 circumscribed area of tenderness.* This pain is characterized by 
 its situation in the prolongation of the right parasternal line some- 
 what below the gall bladder. Usually the pain begins three or 
 four hours after a meal, and rarely or never radiates toward the 
 back ; it is worse after the ingestion of solid food and less after 
 a fluid diet ; rest diminishes and bodily movements increase it. If 
 the patient be of the male sex, and his statements coincide with 
 what has just been said, there is at least a well-grounded suspicion 
 of duodenal ulcer, and we should keep this in view in making our 
 examination. 
 
 Typical cases with pronounced symptoms, such as are described 
 in text-books, are very rare. These are the classical cases which 
 every physician knows. In the great majority of cases a probable 
 diagnosis of the real condition can only be arrived at after repeated 
 questions as to the location, character, and intensity of the pain. If 
 the patient be seen during his attack of pain, we may sometimes 
 come to a rapid conclusion concerning the nature of the case from 
 the general behaviour, the facial expression, the character of the 
 patient's crying or groaning, etc. For exam]3le, the painfully 
 anxious and depressed facial expression of peritonitis, with the 
 increased respirations, the rapid small pulse contrasting with a high 
 temperature, the instinctive dread of the slightest contact and of 
 pressure even of the bedclothes, are so characteristic that an expe- 
 rienced physician, simply from hearing such symptoms described, 
 will at once recognise a serious condition, although he may not be 
 certain as to the exact diagnosis. 
 
 The pain accompanying acute or chronic intestinal stenosis or 
 occlusions is not so well characterized. Treves^ makes the general 
 statement that the pain of complete obstruction is constant (although 
 subject to exacerbations), while that of partial obsti'uction is inter- 
 mittent, alternating with intervals of freedom from pain. My own 
 views coincide fully with Treves's, although, as he himself admits, 
 exceptions to the rule occur. In other respects the pain which 
 accompanies intestinal occlusion and stenosis offers nothing diag- 
 nostic. From this, however, it should not be inferred that the 
 pain of ileus is like that of volvulus of the sigmoid, or like that of 
 
 * Round ulcers of the jejunum or the ileum are very rare, and, as a rule, can not 
 
 be diagnosticated. 
 
58 DISEASES OF THE INTESTINES 
 
 an invagination or even of an obstruction caused by a foreign body, 
 but ratlier that it is difficult, or even impossible, to make use of these 
 distinctions in the differential diagnosis. We shall return to this 
 point in the special part of this work. Similar difficulties are 
 encountered where there is a history of periodic attacks of pain. If 
 a long interval has elapsed between the time of the last attack and 
 of our examination, the statements of the patient will be uncertain, 
 and for the most part guesswork. In such a case we must seek to 
 establish a connection between the paroxysms of pain and the intes- 
 tinal functions — viz., to learn if obstinate constipation ordinarily 
 precedes the attack, if the abdomen is full and distended, and, finally, 
 if the passage of gas from above or from below, or of a copious stool, 
 causes the paroxysms to cease. These phenomena very probably 
 point to flatulent colic, although they may also occur with chronic 
 intestinal stenosis. Even in the absence of constipation, more or 
 less severe colicky pains may also be caused by decomposed food 
 which remains for some time within the intestinal canal. Even 
 though we may not at first discover any etiological factor, obstinate 
 constipation complicating intestinal colic should lead us to think of 
 lead colic (colica saturnica). Our inabihty to establish any connec- 
 tion between the paroxysms of pain and the gastro-intestinal func- 
 tions by no means justifies our declaring the pains purely "nervous," 
 and thereupon, as careless examiners or novices so frequently do, 
 construing a picture of hysteria or of neurasthenia from answers 
 which the patient makes to' leading questions. "We should first 
 examine those other organs which frequently cause paroxysms of 
 pain — above all, the liver, kidney, pancreas (?), and the bladder — 
 since stone colics occur in these organs. In women, the uterus, 
 adnexa, etc., must be examined. 
 
 One who knows from experience that severe gastralgias and 
 enteralgias may be caused from very small supraumbilical or crural 
 hernise, and by apparently insignificant prseperitoneal lipomata, will 
 be very careful before making the diagnosis of " nervous intestinal 
 pain." At all events, I wish to state here that " enteralgias," as 
 purely functional neuroses, occur much more rarely than, for exam- 
 ple, gastralgias. (For further details, see chapter on Intestinal 
 ISTeuroses in the special part of this work.) It is scarcely necessary 
 to mention that whenever we have a well-grounded suspicion of 
 enteralgia the central nervous system should be most carefully 
 examined (crises enteriques of tabes, of myelitis, and of progressive 
 paralysis). 
 
THE HISTORY 59 
 
 The individual causes which may occasionally give rise to intestinal pain 
 are too numerous to mention. I simply wish to state that we should remember 
 that this pain may be due to swallowed foreign bodies (needles, fish bones), to 
 entozoa,* or more so even to poisonous metabolic products such as occur, for 
 example, after death, or disease of tapeworms and other intestinal parasites. 
 Lastly, we must consider the possibility of nicotin poisoning. 
 
 It is of great diagnostic importance to give a careful description 
 of rectal pain. The jiature of these pains varies considerably with 
 their cause. When limited to the rectum, the pains may be press- 
 ing, boring, burning, or even colicky in character. They may be 
 continuous, or may occur for a short time only, before, after, or 
 during a fsecal evacuation. These rectal pains may be caused by a 
 simple coprostasis in the ampulla recti (the latter sometimes acquir- 
 ing enormous dimensions). They may be due to haemorrhoids, to 
 fissures or fistulse, to rectal ulcers (tuberculosis, fsecal ulcers, degen- 
 erated syphiloma), or, finally, to stenoses of the rectum from tumours 
 or cicatricial contractions. It is best not to spend too much time 
 upon the consideration of these different possibilities. In most cases 
 we can at once discover the condition present by digital examina- 
 tion, aided perhaps by further examination with the speculum. 
 
 Anal pains may likewise be due to strangulated haemorrhoids, to 
 fissures of the mucous membrane, to fistulse, or to periproctitis. 
 Here, too, direct inspection is the surest means of ascertaining the 
 cause of the symptoms. 
 
 2. Meteoeism, Tympanites 
 
 (a) Acute, chronic, or paroxysmal. 
 {b) Local or general. 
 
 Meteorism is a symptom which, when developed to a marked 
 degree, may be complained of by the patient. To be sure, a so- 
 called " meteorism " not infrequently turns out to be an ascites. 
 Meteorism is of diagnostic significance only when taken in connec- 
 tion with the rest of the symptoms. It may be caused solely by the 
 ingestion of food abnormally rich in gases, or which forms gases 
 (carbonated liquids, sauerkraut, the so-called " bloating substances "). 
 The statement that meteorism has suddenly occurred in connection 
 
 * Recently I have observed a case referred to me by Dr. Perel, of Odessa, in 
 which very severe and constant intestinal pains were caused by the taenia nana. 
 As is well known, the pains caused by the taenia solium or mediocanellata are mild, 
 or altogether wanting. 
 
60 DISEASES OP THE INTESTINES 
 
 with constipation is important, for this association maj speak for a 
 simple coprostasis ; we may, however, have to deal with retention 
 of gases in a commencing obstruction, an incarcerated hernia, an 
 invagination — in short, with any condition which can obstruct the 
 downward passage of gases, or even with an acute diffused or cir- 
 cumscribed peritonitis. It may even be one of those singular 
 gaseous distentions occurring in hysterical persons, which may 
 prove a souröe of great anxiety and of error to the novice. 
 
 Before beginning the objective examination, close questioning 
 may enable us to form a correct idea of the true condition present. 
 
 Chronic meteorism, more or less circumscribed, is also a symp- 
 tom of manifold significance which can not be correctly valued 
 without thorough investigation. Where the meteorism is circum- 
 scribed, we must think of adhesions, or of stenosis, from tumours 
 situated either within the intestines or external to them, and partly 
 connected with other abdominal organs — in women especially with 
 the genital organs. 
 
 3. Constipation 
 
 {a) Acute, chronic, habitual, or periodic. 
 
 (5) If acute, when was the last movement ? 
 
 (c) If chronic, does it alternate with diarrhoea ? 
 
 {d) Duration of the entire trouble. 
 
 {e) Are the movements retarded, or spontaneous, or do they 
 occur only after laxatives ? If the last, what is the nature 
 of the laxative ? Are enemata employed ? 
 
 Constipation may at times be a harmless condition ; at other 
 times it may be extremely severe and dangerous, frequently causing 
 death. The first question which presents itself is : Have we to do 
 with acute constipation in a case in which up to the present time 
 there were normal movements ? Such a condition may naturally 
 be brought about by various causes — e. g., sudden change in habits 
 of life or in climate, errors in diet, mental excitement, diarrhoeas 
 lasting for days and weeks, the administration of opium,* bismuth, 
 tannin, morphin injections, or of other drugs which cause temporary 
 arrest of intestinal peristalsis. Intestinal occlusion or stenosis may 
 
 * For a long time I have had under observation a female patient who has suf- 
 fered from obstinate constipation since an attack of perityphlitis. The cause of 
 her constipation is most probably the use of large doses of opium. (C/. further 
 remarks as to this in the chapter on Perityphlitis, Part IT.) 
 
THE HISTORY Qi 
 
 be present, or the constipation may be an accompanying symptom 
 of an acute affection of the central nervous system (basilar menin- 
 gitis) or an acute lead colic. Here, again, only a careful general as 
 well as local examination can demonstrate the true underlying con- 
 dition.* 
 
 Where we have to deal with a case of chronic habitual constipa- 
 tion, the existence of a functional intestinal weakness (intestinal 
 atony), or of an organic condition, will come into question. This, 
 again, can only be determined by a detailed examination. Where 
 there is constipation lasting for many years and not associated with 
 disturbances of the general bodily conditions, one generally thinks 
 of " functional intestinal weakness " (atony) or of intestinal catarrh. 
 It should never be forgotten, however, that habitual constipation 
 and chronic enteritis also predispose to the development of intes- 
 tinal cancer with subsequent stenosis (see chapter on Cancer). Even 
 at the present day the view so often expressed, that many years' dura- 
 tion of a disease speaks against cancer, is only correct when greatly 
 modified. The frequent development of cancer upon a coprostasis 
 of many years' duration should teach us to be more cautious. Fur- 
 thermore, in women we should always examine for some genital 
 disorder as a cause of existing constipation (retroflexed uterus, dis- 
 ease of the ovaries or of the appendages, etc.). Where the entire clin- 
 ical picture is unlike malignant disease, an exact knowledge of the 
 duration and the previous treatment are important. Constipation 
 is sometimes congenital or inherited (intestinal atony), or it may be 
 acquired during earliest childhood. This is important for the prog- 
 nosis and the treatment of the case. A knowledge of the nature 
 and effect of the various therapeutic measures employed is essential 
 for the proper appreciation of the diseased condition. The j>oot'er 
 the reaction of the intestines to laxative measures, the more difficult 
 the treatment, and vice versa. 
 
 Where constipation alternates with diarrhoea, we must first of all 
 decide which is the primary or dominating condition. It is by no 
 means easy for a patient who has doctored much, and who has alter- 
 nated between laxatives and astringents, to answer this question. 
 To appreciate the real functional disturbance, it is best for the pa- 
 tient to stop all medication for a few days. Should diarrhoea regu- 
 
 * In this connection it might be remarked that regular movements of the bowels, 
 or even diarrhceas, do not at all exclude intestinal occlusion. Cases with undoubted 
 intestinal obstruction have been described in which faecal vomiting as well as the 
 passage of wind from below, or even fajcal movements, occurred. 
 
62 DISEASES OF THE INTESTINES 
 
 larlj follow constipation, organic stenosis of some kind in some part 
 of the intestines, or else an intestinal catarrh, may be present. Here, 
 again, without a most careful examination, especially of the rectum, 
 it is absolutely impossible to come to a conclusion. Finally, should 
 repeated examinations constantly yield negative results, the ques- 
 tion of a nervous enteropathy or of hysteria may, with the greatest 
 reserve, be considered. 
 
 4. DiAEEHCEA 
 
 {a) Acute or chronic ; during intervals ? 
 
 (b) How frequently during the day ? 
 
 (c) With or without pain ; if present, its character and situation. 
 {d) Does constipation follow the diarrhoea ? 
 
 A sudden attack of diarrhoea may result from a simple error in 
 diet, or, on the other hand, may initiate a severe, acute, infectious 
 disease (typhoid, dysentery, cholera nostras, and asiatica, ptomain 
 poisoning from decayed meats, etc.). In these cases the disease 
 presents a number of other symptoms, which, together with the 
 objective examination, sooner or later clear up the diagnosis. We 
 may, however, have to deal with one of those frequent cases of 
 infectious enteritis which originate especially during the summer 
 months, from bacterial or other direct local sources (dyspeptic diar- 
 rhoea, ISTothnagel). 
 
 Chronic recurring diarrhoea occurs as a symptom of organic 
 intestinal disease, of local intestinal neuroses (i. e., secretion neuroses, 
 reflex neuroses of tabes and other systemic diseases, crises ente- 
 riques), or of nervous enteropathies. If the diarrhoea is a symptom 
 "of the first-named affections, it may be due to catarrh, atrophy, 
 ulceration, or amyloid disease of the intestinal mucous membrane. 
 In stenoses of the intestine there are generally, every few days, 
 watery, pasty, or partially fluid, partially solid stools. Under pre- 
 disposing conditions, patients with stenosing, ulcerating carcinoma 
 of the ileum may have continual diarrhoeas, usually of a purulent 
 character. I have observed and performed post-mortem examina- 
 tions on two such cases (for particulars, see Part II of this work). 
 Finally, chronic diarrhoeas may occur as a symptom of nephritis 
 (ursemic diarrhoea), of the uric-acid diathesis, of congestion in the 
 portal system, etc. The symptom " diarrhoea," therefore, is so 
 closely connected with apparently widely differing conditions that a 
 satisfactory diagnosis of its cause and nature can not be reached 
 without a careful general and local examination. 
 
THE HISTORY 63 
 
 5. Chaeactee of the Evacijations 
 
 {a) Consistency, quantity, and colour, 
 
 {h) Pathological admixtures (mucus, fragments of membrane, 
 blood, pus, tumour detritus, parasites). 
 
 (c) Odour (feculent or putrid). 
 
 In most cases the physician should not be satisfied with the 
 description of the stools as given him by the layman, but should 
 inspect them himself, and eventually examine them under the 
 microscope. If necessary, a chemical examination should also be 
 made. Where the patient's statements are positive, or where they 
 can not be personally controlled, the descriptions as given can not 
 be entirely ignored, for occasionally the statements are of the great- 
 est importance. Sometimes a careful account of the consistency 
 and calibre of the stools is of decisive value in arriving at a diag- 
 nosis by exclusion. Thus, persistent cylindrical stools of normal 
 calibre would generally exclude a stenosis of the intestines. 
 
 Conversely, stools of an abnormally small calibre do not speak 
 with any degree of certainty for a stenosis of the intestines ; in 
 this case the diagnosis must rest upon the presence of other symp- 
 toms. The stools may be pasty, semisolid, or fluid in consistency. 
 The first two of these characteristics may be present in the normal 
 individual ; the last is always indicative of an abnormal condition 
 and calls for a most careful examination. Scybalous stools indicate 
 a long retention of the faeces in the haustra coli, and this is a fre- 
 quent cause of attacks of intestinal colic (spastic contraction of the 
 intestines). 
 
 The patient's statement of the quantity of faeces passed in 
 twenty -four hours is generally correct. I say generally, because I 
 have often had neurasthenics declare that they have had insufiicient 
 evacuations, although they actually passed large quantities of faeces. 
 In many cases the quantity is not commensurate with the amount 
 of food ingested ; this may be due to the kind of food taken (espe- 
 cially meat), or to deficient peristalsis. Probably intestinal absorp- 
 tion is increased after a period of fasting, so that even normally 
 in the first few hours after eating again the amount of undigested 
 matter is disproportionate to the amount of food ingested. 
 
 The colour of the movements may vary considerably from the 
 normal. The patients are most apt to notice the clay-coloured 
 stools that occur with icterus, or sometimes without icterus (see sec- 
 tion on Faeces). But since icterus is only a symptom, the diagnosis 
 
64 DISBASES OF THE INTESTINES 
 
 of tlie primary trouble is impossible without further knowledge of 
 the cause of the disease. 
 
 The pathological admixtures in the fseces which may at times 
 be seen and correctly described by the patients are mucus, mucous 
 membrane, blood, pus, fragments of new growths, undigested food 
 remnants, and parasites. 
 
 Where imicus is present in large quantities, or is passed alone, 
 it is usually noticed by observant patients. Sometimes these move- 
 ments of mucous membranes are so characteristically described that 
 the diagnosis — membranous enteritis (colica mucosa) — is readily 
 made. In general the patient's descrij)tion very seldom yields use- 
 ful data. 
 
 Blood may be mixed with the stools, in a fresh fluid or decom- 
 posed state. The latter lends an intensely tarry or pitchy appear- 
 ance to the stool. However, the description, or even the micro- 
 scopical appearance, is decisive only in a very few and these other- 
 wise absolutely clear cases (see section on Fseces). It is important 
 here to know if symptoms of severe internal hsBmorrhage (collapse, 
 syncope, pallour of the visible mucous membranes, systolic murmur 
 at the apex of the heart, etc.) accompany the intestinal haemorrhage. 
 The darker the appearance of the blood the more correct are we 
 in assuming that the bleeding is located very high up (stomach or 
 upper portion of small intestines). Tar-coloured blood comes only 
 exceptionally from the lower portions of the intestines. Fluid blood 
 comes mostly (but not always) from the large intestine, including 
 the rectum. By rectal palpation, or by use of the speculum, it can 
 frequently be determined whether the latter is the seat of the bleed- 
 ing or not. If the rectum can be excluded, various diseased pro- 
 cesses may come up for consideration — acute or chronic dysentery, 
 fsecal ulcers, tubercular ulcers, tumours of the large intestine (be- 
 nign or malignant), and acute or chronic intussusception or other 
 forms of intestinal obstruction. 
 
 The admixture of pus with the stools, or the discharge of pus 
 from the rectum, is always a striking symptom. The pus may come 
 from the rectum itself (ulcerating tumours or ulcers, rectal fistulse), 
 or it may come from intestinal segments above the rectum. We 
 can only determine the seat and cause of the pus formation by 
 means of repeated careful examinations of the entire intestinal 
 canal and of the fseces {^ide Chapter Y). 
 
 The fragments of new growths which may be noticed by the 
 patients are broken-off pieces of cancerous tumours (veiy rare), or 
 
THE HISTOßY 65 
 
 exfoliated intestinal polypi. For obvious reasons, it requires a per- 
 sonal examination to pass an opinion uj^on these. In intussuscep- 
 tion, the intussusceptum may become gangrenous and be passed. 
 
 Parasites, especially segments of the tapeworm, may be recog- 
 nised by the layman, but may at times be also confounded with a 
 number of other things. 
 
 The importance of the presence of food remnants will be dwelt 
 upon in the chapter on Faeces. 
 
 The odour of the normal stools is feculent, but not putrid. 
 Should it be offensive, however, and should the statements of the 
 patients upon this point be very positive, a personal examination of 
 the stools and of the intestinal canal may be necessary. Putrid ad- 
 mixtures with the fseces are always a serious symptom, and are 
 generally due to the breaking down of malignant tumours or of 
 ulcers, to abscesses, perforations from neighbouring organs, etc. 
 
 6. Tenesmus 
 
 As a rule, tenesmus indicates an affection of the large intestine. 
 Apart from dysentery, which is almost always accompanied by te- 
 nesmus, and from acute intestinal catarrh with copious diarrhoea, the 
 greatest variety of intestinal disorders come into question when 
 tenesmus is complained of. For this symptom may be occasioned 
 by excessive coprostasis, more frequently, however, by proctitis and 
 periproctitis, rectal ulcers or catarrh, haemorrhoids, prostatitis and 
 prostatic hypertrophy, injBLammations and malpositions of the uterus, 
 ovarian tumours, etc., and, finally, by foreign bodies which have 
 entered the rectum from above or below. Especially in children is 
 tenesmus a frequent symptom of acute and chronic intussusception. 
 The condition in each individual case must be determined through 
 inspection and palpation of the rectum and of the rest of the intes- 
 tinal canal. 
 
 7. Gasteic Disturbances 
 
 It can be readily understood that gastric affections are frequently 
 associated with intestinal disturbances. The converse is also true. 
 As regards acute intestinal affections, especially those accompanied 
 by fever (acute infectious enteritis, perityphlitis, etc.), these require 
 no further explanation. Fsecal vomiting from ileus need only be 
 mentioned in this place, as it will be treated of more in detail in the 
 chapter on Ileus in the special part of this work. 
 
 In chronic intestinal diseases, even in those of a malignant nature, 
 
66 DISEASES OF THE INTESTINES 
 
 the appetite, as well as the other functions of the stomach, maj be 
 entirely normal. In intestinal tuberculosis, however, the stomach is 
 often affected. Here the fever which is generally present is an 
 important factor in decreasing the appetite. Frequently, and with- 
 out special cause, a well-marked chronic gastritis may complicate 
 enteritis (Einhorn, Biedert, Oppler). On the other hand, however, 
 hyperacidity may occur under the same circumstances. Chronic 
 constipation may be associated with glandular gastritis. The peri- 
 odic vomiting which accompanies intestinal stenoses, especially 
 those of a severe type, is very remarkable. With l!^othnagel, we 
 may look upon this as a " regurgitive contraction." (For further 
 details, see chapter on Intestinal Stenoses, special part.) ISTausea 
 and vomiting may also occur reflexly, or during long-continued 
 intestinal colics. 
 
 Continued bilious vomiting is a very important symptom of 
 deeply seated duodenal stenosis, and will be spoken of at length in 
 the special part of this work. 
 
 8. Subjective Abdominal Sensations 
 
 Patients sometimes declare their main symptom to be a feeling 
 of pressure and weight in the abdomen. Occasionally they are able 
 to fairly accurately locate the seat of this abnormal sensation. Such 
 subjective symptoms are naturally only of value when combined 
 with the results of the objective examination. 
 
 9. Peristaltic Movements 
 
 Many patients will state either of their own accord or in reply 
 to direct questions that they occasionally or constantly experience 
 "a crawling, wormlike sensation," sometimes accompanied by 
 severe pain ("peristaltic unrest"). The diagnostic importance of 
 this symptom will be discussed in the section on Inspection. 
 
 LITERATURE 
 
 1. Treves. Intestinal Obstruction. German translation of Dr. Arthur Pollak. 
 Leipzig, 1888, p. 354. 
 
CHAPTER lY 
 
 THE EXAMINATION OF THE PATIENT 
 
 1 . Inspection 
 
 In diseases of tlie intestines the entire body, inclusive of the ex- 
 ternal anal parts and the rectum should be inspected. Since inspec- 
 tion of the anal region and the rectum is usually associated with 
 palpation of the rectum, it will be considered under that heading. 
 
 After we have inquired into the general physical condition and 
 nutrition of the patient, we should inspect his mouth, to ascertain the 
 condition of his teeth, his tongue,* and his pharynx. The patient 
 is thereupon told to disrobe, and is at first examined in a standing 
 position. Any striking variations from the normal §hould at once 
 be noted (colour of skin, scars, growths, spinal curvatures and pro- 
 tuberances, or depressions of any part of the chest, etc.). 
 
 Direct inspection of the abdomen should now begin. The 
 patient should either lie in bed or upon a good elastic couch, with 
 his head extended and the legs and abdominal muscles as fully 
 relaxed as possible. The illumination must be good; dajdight is 
 best, but in its stead we can employ gas or electric light, either 
 direct or properly reflected. Like palpation (q. v.), inspection is 
 carried on in two ways : during shallow and during deep respi- 
 rations. 
 
 As regards the shin over the abdomen, we have here to look for 
 striae and venous engorgements. Besides ascites, venous engorge- 
 ment of the skin results from new growths of the abdomen when 
 these compress the portal system. This condition is not without 
 importance in the diagnosis of abdominal tumours which are deeply 
 seated and palpable only with extreme difliculty. Inspection also 
 enables us to readily detect protrusions or depressions of the abdo- 
 men. Protrusions may be localized, or they may extend over the 
 
 * The condition of the tongue in intestinal diseases is of less importance than 
 in gastric diseases. On the other hand, bad condition of the teeth may be a defi- 
 nite etiological factor in gastric or intestinal catarrhs. 
 
 67 
 
68 DISEASES OP THE INTESTINES 
 
 entire abdomen ; they may result from abnormal accumulation 
 of gas or fluid. We sliould note small differences in the level of 
 the abdominal surface, especially if some segments of intestines 
 are more prominent than others. Herniae of the abdomen (umbili- 
 cal, linea alba, ventral, femoral, and inguinal) are readily recog- 
 nised, especially when the patient coughs, usually simple palpa- 
 tion is all that is required to make the diagnosis. The prominence 
 above the general surface of the abdomen of any nevi^ growth is very 
 important. On deep inspiration we may convince ourselves of any 
 mobility of these neoplasms, which is a consideration of great value 
 not only for the diagnosis but also for the treatment of the case 
 (operation). It appears important to me, therefore, to point out 
 that even small new growths are much more readily detected hy care- 
 ful inspection with a good light {a very important point) than they 
 are through palpation. 
 
 Under especially favourable circumstances (e. g., descensus), and 
 particularly where there is a marked coprostasis, it is possible to 
 recognise isolated segments of the large and «mall intestine. We 
 find both abnormal abdominal depressions and prominences. Basilar 
 meningitis and lead colic present well-known classical examples of 
 depressed abdomen. Abnormal depressions also occur in marked 
 cachexias, inanition, esophageal and cardial cancers, as well as in 
 other non-stenosing growths in the upper portion of the digestive 
 track. Much interest attaches itself to visible peristaltic move- 
 ments. These normally occur in very emaciated persons, particu- 
 larly in women who have frequently borne children {vide special 
 part of this work), and are then, as E^othnageP correctly points 
 out, limited to the small intestines. Yisible peristalsis of the large 
 intestine is therefore a pathological condition. It may be an intes- 
 tinal neurosis {tormina ventriculi nervosa))^ as illustrated in a strik- 
 ing case which I have recently demonstrated^, or may constitute an 
 important and, if well developed, a decisive symptom of a chronic 
 intestinal stenosis. Since the peristaltic waves are most marked 
 above the point of stenosis, we can in a general way determine the 
 seat of the obstruction. Besides these forms, which really represent 
 but an exaggerated and for the most part a painless type of normal 
 peristaltic movement, there is a second form, the tetanic intestinal 
 contraction ; this varies according to the emptiness or fulness of 
 the intestines. As instances of tetanic contraction with empty 
 intestines, Nothnagel mentions cerebral meningitis and lead colic. 
 He thinks that in rare cases the contracted coils are visible. This, 
 
THE EXAMINATION OP THE PATIENT 69 
 
 however, has never been my experience ; on the other hand, tetanic 
 contractions with filled intestines are more frequent, and constitute 
 an exceedingly important diagnostic symptom. One may see a 
 rounded elevation suddenly appear in a circumscribed portion of the 
 intestine and accompanied by most severe pain, gradually become 
 more and more prominent, become rigid, and then suddenly sink 
 back again. This is often accompanied by loud gurgling and rum- 
 bling sounds and a subsidence of the pain, l^othnagel ^ has very 
 aptly applied the name " intestinal rigidity " to this condition. The 
 gradual increase in intensity, the pause at the acme, and the sudden 
 subsidence may all be better appreciated by placing the hand over 
 the part than by inspection. This form of tetanic contraction 
 always points to an obstruction of the intestinal passage ; however, 
 it gives us no information regarding the nature of the obstruction 
 — i. e., whether within or without the intestinal canal, whether caused 
 by a foreign body or by disease of the mucous membrane, etc. The 
 causes of "intestinal rigidity" will be referred to in the special 
 part of the present work. 
 
 2. Palpation 
 
 A. Palpation of the Abdomen 
 
 The great importance as well as the difficulties of palpation 
 have^ been dwelt upon elsewhere^. What has there been stated 
 applies to a greater degree, if possible, to the intestines. In the 
 following the most important points in regard to the technic of 
 palpation are again given. 
 
 1. A good couch, not too soft, and accessible from all sides, 
 should be used for the examination (a lounge is preferable to a bed). 
 
 2. The patient should lie in the horizontal position, with the 
 head extended and as low as possible. 
 
 3. The legs as well as the rest of the body should be as fully 
 relaxed as possible (anaesthetic posture). I have very seldom seen 
 any advantage from the drawing up of the lower extremities which 
 is still often recommended. 
 
 4. Palpation should be conducted in a warm room, and only 
 with warm hands, for otherwise the abdominal walls will contract 
 at the slightest touch, and deep exploration become impossible. 
 
 5. The attention of the patient is to be distracted from the ex- 
 amination by questioning him regarding his age, heredity, etc., and 
 by having him stretch out his tongue, raise his arms, etc. 
 
 6 
 
YO DISEASES OP THE INTESTINES 
 
 6. Palpation at first should include the superficial portions of 
 the abdomen, and only very gradually should the deeper parts be 
 explored. 
 
 T. The condition of fulness of the abdominal cavity at the time 
 of examination is very important. The distention of the abdominal 
 cavity with gas or fluid, of the stomach with food, of the large in- 
 testine with faecal masses, and of the bladder with urine, may at 
 times interfere with the examination, but, as will be later shown, 
 this is not always the case. We should therefore make it a rule 
 never to make a diagnosis at the first visit, but should point out the 
 necessity of a further examination after removal of the above-men- 
 tioned conditions. 
 
 8. Always palpate in the right and left lateral positions, as well 
 as in the dorsal, for frequently growths of the stomach, of the intes- 
 tines, or of other organs, can not otherwise be palpated. Bimanual 
 palpation is especially to be recommended for the examination in 
 the lateral position. 
 
 9. For the better recognition of tumours, enlargements, or alter- 
 ations in position of abdominal organs, differentiated otherwise with 
 great difficulty, Y. Chalapowski, Lennhof, G. See, Schuster, Berk- 
 han, and others, have recently strongly recommended palpation in a 
 warm full bath. Although I have had no personal experience with 
 this method, in spite of its inconvenience, it appears to me to 
 possess a number of advantages which would justify a more exten- 
 sive trial. 
 
 In palpating the abdomen we may proceed in one of two ways : 
 Either fix upon and at once explore some point that attracts atten- 
 tion, or examine systematically. The former method is to be rec- 
 ommended only to the experienced, while the latter is to be recom- 
 mended to the beginner. I would advise the following method of 
 procedure : Examination of the abdominal wall for oedema, emphy- 
 sema of the skin, excessive fat, lipomata, etc. ; examination of the 
 epigastrium, paying special attention to splashing and succussion 
 sounds, etc. ; examination of the right and left lobes of the liver, 
 the region of the small intestines from the pylorus downward to 
 the umbilical region. The hernial canals should be palpated ; also 
 the region of the caecum (McBurney 's point midway between the 
 anterior superior spine and the umbilicus). From the caecum the 
 examination is to be continued along the ascending, transverse, 
 and descending colon, and the sigmoid flexure. The ascending 
 and descending colon are best palpated in the right and left lateral 
 
THE EXAMINATION OF THE PATIEKT Yl 
 
 postures respectively. At the same time tlie condition of the kid- 
 neys (dislocation, fluctuation, and tumours) and of the spleen may- 
 be determined. 
 
 This plan is of course, to a certain extent, schematic, and assumes that the 
 intestines are in their normal position. We must, however, reckon upon jaossible 
 anomalies of single segments, especially those of the very mobile j^ortions of the 
 large intestines. (Compare further remarks upon this on page 21 et seq., and also 
 the chapter on Displacements of the Intestines, in the special part of this work.) 
 
 Under favourable conditions it is undoubtedly possible to pal- 
 pate certain segments of the intestines. Obrastzow "*, who has thor- 
 oughly studied the technic of this subject, has obtained remark- 
 able results by palpation. He was able to locate the caecum in 
 51.47 per cent of the men and in 58 per cent of the women he 
 had examined ; the transverse colon in 23 per cent and the sigmoid 
 flexure in 65 per cent of all his cases, unfortunately these results 
 are not accompanied by post-mortem records, and therefore they 
 lose much of their statistical value. As pointed out in the oft- 
 quoted instructive treatise of Curschmann, the greatest caution must 
 be exercised in accepting palpatory results of the large intestines, 
 since the latter are so frequently displaced. ]S[evertheless, we may 
 safely assert that the sigmoid flexure is the most easily palpated 
 segment, the transverse colon the most difficult, while the caecum 
 occupies a position between the two. It is frequently possible to 
 palpate the sigmoid flexure and the ascending colon from their be- 
 ing filled with scybalae ; upon palpating the lower portion of the 
 ileum or csecum, the impression is conveyed as if of a thin pasty 
 mass under the fingers, and one can hear and feel the gurgling 
 sounds, formerly considered an important symptom of typhoid 
 fever. These signs, however, are to be accepted in a diagnostic 
 sense only after most careful consideration. Abnormal thinness of 
 the abdominal walls and distention of the bowel by fseces render 
 palpation of the large intestine much easier. In the presence of 
 such conditions, it is, I believe, possible to map out the entire large 
 intestine. To determine intestinal displacements it might even be 
 advisable to bring about an artificial coprostasis. 
 
 Kecently, Edebohls^ has claimed that the vermiform appen- 
 dix, especially in women, is often palpable, and that from the con- 
 dition found one can tell whether in a given case the appendix is a 
 normal or an abnormal one. He recommends that one should 
 press as deeply as possible toward the posterior wall of the abdo- 
 men and floor of the pelvis, keeping to the outer side of the iliac 
 
72 DISEASES OP THE INTESTINES 
 
 artery. I have never succeeded in satisfactorily palpating the 
 appendix. In my experience, it is easier to palpate isolated coils of 
 the small intestines, particularly in enteroptosis. 
 
 This, however, is of no practical advantage, for it will rarely be 
 possible to recognise what particular segment is felt. I would here 
 remark that Obrastzow ^ points out the importance of palpation of 
 the ileum for the diagnosis of typhoid, claiming that the gut appears 
 thickened, uneven, and painful. 
 
 As in the stomach, so also in special palpation of isolated intes- 
 tinal segments the following points come up for consideration. 
 
 (a) Sensitiveness to Pressure ; Pain {CirGumscrihed or Diffuse) 
 
 We shall first give a few practical preliminary remarks. All 
 portions of the intestines are painful upon rough handling, the 
 caecal region more so than the rest ; furthermore, owing to the 
 adjacent sympathetic fibres, pressure over the large blood-vessels 
 causes pain, especially in women whose abdominal walls are relaxed 
 from frequent childbirths, and in very emaciated men. In the 
 palpation of isolated intestinal areas of anxious and excited indi- 
 viduals I have frequently met with a " pseudo-painfulness." It is 
 well to have the painful areas pointed out and to re-examine them 
 after a few moments. We can thereby convince the patients them- 
 selves of their error. In this connection I wish also to call atten- 
 tion to a general hyperalgesia of the abdominal wall not infre- 
 quently met with in neurasthenics. 
 
 Practically, we should distinguish between pressure sensitiveness 
 and pain. Thus, an acutely inflamed appendix, or, in acute dysentery, 
 the sigmoid flexure and the descending colon are painful, whereas 
 in chronic enteritis the large intestine is but slightly sensitive to 
 pressure. The differentiation of such degrees of sensitiveness must 
 be carefully practised and studied. Yery important, too, is the 
 differentiation between a localized and a diffuse pressure sensitive- 
 ness. In ulcer of the duodenum we meet with a very circumscribed 
 area of pain, beyond whose limits pressure made with the necessary 
 precaution is absolutely painless ; on the other hand, in appendicitis 
 with diffused peri-appendicular abscess the entire region of the 
 csecum, or even the entire ascending colon, may be painful on 
 pressure. Again, in general peritonitis the entire abdomen is pain- 
 ful even to the slightest touch. Multiple circumscribed sensitive- 
 mess is found in catarrh of the small intestines complicated by fol- 
 llcvular ulcers (for the most part tubercular) ; it may, however, be 
 
THE EXAMINATION OF THE PATIENT 73 
 
 absent. When present, it can, when viewed with a certain amount 
 of reserve and in connection with other symptoms, acquire a diag- 
 nostic value. I have often observed a diffuse pressure sensitiveness 
 in chronic sigmoiditis. This I regard as an important symptom to 
 which little attention has been paid. I will refer to it more in detail 
 in the chapter on Enteritis (special part). A pressure sensitiveness, 
 at first localized, but later diffused, may coexist with malignant 
 growths, stenosis from other causes, intussusception, and volvulus. 
 Further details of this subject must also be reserved for the special 
 part of this work. 
 
 (b) Splashing Sounds {Clapotage) • Succussion Sounds 
 
 In my experience, intestinal splashing sounds occur only in the 
 large intestine, and only under certain conditions. As far as I can 
 learn from the literature, this subject has received but little atten- 
 tion ; it therefore seems proper to consider it more in detail. A 
 certain relaxation of the intestinal walls as well as the presence of 
 fluid or thin pasty contents are necessary for the production of 
 splashing sounds. Furthermore, the abdominal walls must be suffi- 
 ciently yielding, so that the wave of contact may be readily trans- 
 mitted to the intestines. Thinness of the abdominal wall and lax- 
 ity of tbe intestines are normally present in women who have born& 
 many children. It is different, however, with regard to the physi- 
 cal state of the intestinal contents. From the investigations of 
 Macfadyen, I^encki, and Siebers (p. 45) we know that normally the 
 contents of the lower part of the ileum are of a thin pasty consist- 
 ency ; as such they enter the caecum, and there gradually assume 
 a firm cylindrical shape. Normally^ therefore, a splashing sound is 
 never elicited beyond the caecum, or the ascending colon. 
 
 To make certain whether or not substances of pasty consistency can cause 
 splashing sounds in the large intestines, I directed my former assistant, Dr. 
 Ehrlich, to ascertain whether splashing sounds could be elicited in the large 
 intestine after injections of large quantities of thick pasty soups. It was found 
 that these sounds could be distinctly elicited in the sigmoid flexure, and in two 
 cases in the caecum, and more particularly in the transverse colon. Marked 
 liquefaction of the contents of the large intestines is still more favourable for 
 the production of splashing sounds ; under such circumstances they may be 
 heard even over extensive areas. 
 
 It appears possible, therefore, without special preparation, to 
 determine approximately, the position of one or more segments of 
 the intestines by means of the splashing sounds, l^aturally, this 
 
Y4 DISEASES OF THE INTESTINES • 
 
 can only be accomplished with normal situation and an absence of 
 gastric succussion sounds. 
 
 I was the first to recommend methodical filling of the large 
 intestine with measured amounts of water for determination of the 
 splashing sounds'''. This method is somewhat cumbersome, and as. 
 yet not well known ; it does, however, give us some diagnostic data. 
 If after thoroughly emptying the intestines of a healthy individual, 
 we allow lukewarm water to flow slowly into the rectum through 
 a soft-rubber tube and funnel, all segments of the large intestine 
 will gradually fill up. After 500 to 600 cubic centimetres have been 
 introduced, a splashing sound, more or less distinct, may be obtained, 
 at first in the region of the sigmoid fiexure, but later also in the 
 transverse colon, and finally in the caecal region. Under favourable 
 conditions a slight succussion sound can be heard upon changing 
 the position of the body. In marked atony of the large intestine 
 we will obtain a splashing sound in the above-mentioned places after 
 only 200 to 300 cubic centimetres have been introduced. Should, 
 however, the splashing sound be heard at a point other than where 
 it normally ought to be (e. g., far below the umbilicus), it would 
 indicate displacement of the segments of the large intestine in ques- 
 tion. As in the stomach, downward displacement or a dislocation 
 of the segments of the intestine frequently coexists with atony. 
 J. Friedenwald^ has also employed this method and confirms its 
 diagnostic value. 
 
 Just as we can obtain splashing sounds in the intestines filled 
 with water by striking them with the tips of the fingers, so we may 
 also readily elicit succussion sounds wherever there is an excessive 
 relaxation or a dilatation of the intestinal walls by shaking the 
 patients or by having them rapidly change their position. Suc- 
 cussion sounds are very readily heard in the sigmoid flexure or the 
 descending colon. 
 
 (c) New Growths ; Fcecal Tumours; Adhesions 
 
 ]^ew growths occur in all parts of the intestinal canal, but 
 increase in frequency as we go downward. Malignant tumours 
 (cancer, sarcoma, lymphosarcoma, tubercular tumours) are met with 
 more often than benign tumours (myomata, fibromata, polyps, ade- 
 nomata, angioraata, syphilomata, etc.). If in the following discus- 
 sion we speak of tumours in general, we nevertheless have the 
 malignant new growths principally in view. 
 
 When a new growth is found in the abdominal cavity and ques- 
 
THE EXAMINATION OP THE PATIENT 75 
 
 tion of its connection with the intestines is raised, we should first 
 of all consider all those other organs to which the tumour might 
 possibly belong. Palpation alone is generally not sufficient ; other 
 methods of examination — the examination of the stomach contents, 
 inflation of the stomach and intestines, injection of water, as well as 
 other clinical phenomena (urine, blood, and especially examination 
 of the genitals) — must be brought to our aid. As in other abdominal 
 tumours, in intestinal tumours the jpositioii, mobility, size, consistency, 
 sensibility, and respiratory mobility, have to be determined. 
 
 As regards the position of a new growth, that is determined in 
 the first place by the normal position of the intestinal segment with 
 which it is connected. The position will depend very much upon 
 the mobility of the intestinal segment in question. For instance, a • 
 cancer of the pylorus may be found in the region of the caecum, or 
 a perityphlitis below the right lobe of the liver. 
 
 To begin with the small intestines, the duodenum is compara- 
 tively firmly fixed, so that its tumours can very seldom cause marked 
 alterations in its position. 
 
 Owing to their large and more freely movable mesentery, tumours 
 of the jejunum and of the ileum have a somewhat greater mobility. 
 As JN^othnagel ^ very correctly observes, this may lead to great diffi- 
 culty in the differentiation between tumours of the large and small 
 intestines. The csecum and the ascending and descending colon are 
 the least movable segments of the large intestine, while the trans- 
 verse colon and the sigmoid flexure have the widest range of motion. 
 In tumours of these segments there will very probably be a disloca- 
 tion of the parts. The tumour itself may tug upon the portion of 
 the intestine, dragging it laterally or downward ; or else the bowel 
 may become distended above the site of the stenosis, and becom- 
 ing abnormally loaded, may drag the intestinal segment at first par- 
 tially, later completely downward ; finally, in consequence of begin- 
 ning emaciation, there may be a relaxation of the fixation bands 
 with a resulting alteration in position of the intestinal segments. 
 
 Furthermore, we must distinguish between passive and active 
 (manual) mobility. I have found passive mobility of intestinal 
 tumours to be rare ; active motion occurs either not at all, or else to 
 a very striking extent. The mobility of the tumour will depend 
 principally upon whether a ptosis of the bowels has taken place, and, 
 further, upon the presence or absence of adhesions. The nature of 
 the tumour itself is also very important. Regarding the sise of 
 the tumour, this, as hi the stomach, will vary considerably, accord- 
 
Y6 DISEASES OF THE INTESTINES 
 
 ing to the stage of the process. I have seldom observed intestinal 
 growths acquire such dimensions as those of the stomach ; usually 
 they are very much smaller. Sarcomata and benign growths form 
 an exception ; they may reach enormous dimensions. 
 
 The consistency of the growth depends upon its origin and 
 malignancy. Cancers are hard and nodular; sarcomata hard and 
 smooth, and they not infrequently have a central soft or even fluctu- 
 ating area. Benign growths, as well as intussuscepted portions of 
 the intestines, are smooth and uniform, while abscesses and cysts 
 always impart the feeling of fluctuation to the examining finger. 
 
 The sensitiveness of intestinal growths is likewise subject to the 
 greatest variations. They are, perhaps, never entirely painless ; the 
 pressure sensitiveness of benign growths is very much less than that 
 of malignant ones. Upon the whole, however, no great weight 
 need be attached to the degree of sensibility of the intestineo. 
 
 All parts of the intestines are more or less movable with respira- 
 tion, most so where the intestinal wall is thin, and poor in fat ; on 
 the other hand, adhesions of organs directly connected with the 
 diaphragm (liver, stomach, and spleen) may have a disturbing influ- 
 ence. Yery little diagnostic significance attaches itself to the 
 respiratory mobility of intestinal growths. The question of exist- 
 ing adhesions is best determined under narcosis. 
 
 FoBcal tumours play such an important part among intestinal 
 growths, and so frequently give rise to errors and confusion in 
 intestinal diseases, that they require special consideration. They 
 may give rise to errors in two ways : first, in simulating new 
 growths, and, secondly, in causing existing new growths to appear 
 larger than they really are. In such cases, usually, the diagnosis 
 can not at once be made; we should allow ourselves more time and 
 observe the effect of internal and external laxative measures. As a 
 rule, the consistency of the growth in question will give us a useful 
 diagnostic hint. Apart from the so-called enteroliths, fsecal tumours 
 are generally of a somewhat doughy consistency, and retain the 
 impression of the finger, especially after rectal enemata of oil or of 
 soap (which tend to soften them). Even after such enemata the 
 peripheral portion of the fseces may remain hard {Randkotk) 
 and simulate a tumour, notwithstanding that frequent voluminous 
 evacuations {Centralhoth) have taken place. This experience, which 
 has been that of absolutely reliable clinicians, calls for the greatest 
 caution in the determination of the nature of doubtful tumours. 
 The situation can usually be determined, especially upon repeated 
 
THE EXAMINATION OP THE PATIENT 77 
 
 examinations, altliougli a very instructive case described by Noth- 
 nagel shows that even then errors can not always be excluded. 
 The history, the status, the clinical course, in short, everything in 
 Nothnagel's case, indicated cancer of the caecum, while the autopsy 
 showed an ulcerative tubercular stricture in the beginning of the 
 ascending colon. 
 
 Gersuny ^° believes that the difficulties in diagnosis so often caused 
 by faecal tumours have been overcome by the discovery of a peculiar 
 symptom which he describes as " the adhesive sign " (Klebesymp- 
 tom) ; viz., if the finger be very firmly pressed upon the faecal mass, 
 the intestinal mucous membrane will become adherent to the vis- 
 cous faeces, becoming free again when the pressure is discontinued. 
 Gersuny states that we can feel the mucous membrane loosening 
 itself, and that such a sensation is characteristic of a faecal tumour. 
 HofmokP^ could not, however, convince himself of the existence of 
 this " adhesive sign," and, like myself, regards the impressibility of 
 the faecal tumour as the most characteristic symptom. 
 
 Under favourable conditions adhesions between the portions 
 of the intestines may be palpated and recognised as cicatricial 
 strands ; more frequently, however, they are suspected rather than 
 recognised. 
 
 B. Inspection and Palpation of the Region of the Anus 
 AND Rectum ; Examination with Rectal Bougies 
 
 Palpation is the most certain method of acquainting ourselves 
 with diseased conditions of the rectum ; in many cases, however, it 
 must be supplemented by inspection and the use of bougies. Pal- 
 pation of the rectum should be preceded by inspection of the anus. 
 The patient is to be examined either in the lateral or in the knee- 
 chest position. Personally, for complete examination of the rectum 
 and anus I prefer the latter position. With good illumination we 
 can inspect external haemorrhoids, fissures, intertrigo, pruritus ani, 
 furuncles, phlegmons, external fistulae, etc. At the same time we 
 can at once learn whether or not any pathological secretions (blood, 
 pus, or mucus) come from the anus. Inspection is best followed 
 immediately by palpation. When a patient complains of rectal 
 trouble, rectal palpation should never be neglected. It not infre- 
 quently happens in very timid or prudish persons, especially women, 
 that we meet with opposition, and we should then, quietly but firmly, 
 explain the absolute impossibility of forming an opinion without 
 
78 DISEASES OP THE INTESTINES 
 
 direct local examination. Even in apparently harmless cases I do 
 not hesitate to point out the possible existence of serious disease of 
 the rectum. This very quickly has the desired effect.* Palpation 
 of the rectum is also absolutely unavoidable in other chronic stomach 
 and intestinal affections, which at first glance may appear to have 
 nothing in common with the I'ectum. 
 
 In my Diagnosis and Therapeutics of the Diseases of the Stomach 
 (Part I, p. 72) I have emphatically stated that we ought never to be 
 satisfied with the mere diagnosis " hsemorrhoids," but should always 
 explore the rectum very carefully. Sometimes a human life Tnay 
 he lost through such utterly inexcusable negligence. 
 
 Tbchnic of Rectal Palpation 
 
 As a rule, the examination is conducted in the knee-chest or lat- 
 eral position (see above). 
 
 The finger should be well anointed with borovaselin (oil or 
 glycerin are less commendable). f The examination itself must 
 never be a forcible one, and should consist in gentle rotatory move- 
 ments, and where the patient already complains of rectal pain 
 should be carried out with particular care. In some cases cocainiza- 
 tion of the rectum may be advisable, though I find it can generally 
 be dispensed with. 
 
 Passing the examining finger slowly forward, we learn the con- 
 dition of the mucous membrane, the presence of foreign bodies or 
 of new growths, and the patency of the rectal lumen ; furthermore, 
 the condition of the prostate, and in women, such anomalies of the 
 sexual organs as can be recognised by palpation through the rectum. 
 
 If the disease process be situated high up, and is entirely inac- 
 cessible, or accessible only with great difficulty in either of the two 
 mentioned positions, we may reach it with the patient in the dorsal 
 
 * Other circumstances may at times lead to difficulty in the exploration of the 
 rectum. Kelsey, the experienced New York rectal specialist, relates the following 
 characteristic story: " A foreigner told me, when I proposed it [rectal examination], 
 that he had entirely too great respect for me to allow such a thing. My only 
 answer was that 1 had too great respect for myself to treat him without knowing 
 what was the matter. That helped, and, " Kelsey concludes," we parted amicably." 
 
 [f To prevent the faecal odour from clinging to the finger after a rectal examina- 
 tion, it is a very effectual plan before the " preliminary anointing" to liberally 
 scrape ordinary soap under the free edge of the finger nail and between the cuticle 
 of the finger and the matrix of the nail. The so-called " finger cots " protect the 
 examining finger from infection and faseal smell, and when made of the proper 
 thinness do not interfere with the palpatory sense. — Tb.] 
 
THE EXAMINATION OF THE PATIENT 79 
 
 position and by suitable pressure in the left iliac region. In like 
 manner w^e may succeed with the patient in a standing position, 
 when the examiner should be on one knee and support the elbow 
 of the examining hand upon the other knee bent at a right angle. 
 At the same time the patient should be asked to make strong pres- 
 sure downward. 
 
 At the time of the first examination it is very desirable to make 
 the digital exploration of the rectum as carefully and fully as pos- 
 sible, so that we ascertain all that can be learned through palpation. 
 
 In some cases the introduction of one finger is not sufiicient to 
 palpate the entire diseased area. For this class of cases Simon, 
 many years ago, recommended the introduction of the entire hand 
 into the rectum. This procedure, which is by no means harmless, 
 can of course be carried out only under general ansesthesia. In 
 consequence of the resulting relaxation of the sphincter, one or two 
 fingers usually suffice for the exploration, and the entire hand is 
 necessary in isolated cases only. In rare cases, however, bloodless 
 distention, or even slitting up of the sphincter (sphincterotomia pos- 
 terior recti), must be undertaken. Since both of these are usually 
 preparatory to operations on the rectum, we must refer the reader 
 for further details to surgical text-books. 
 
 Examination under narcosis is also indicated, either where the 
 nature of the disease can not be otherwise determined because of 
 excessive painfulness of the exploration, or else where the disease, 
 being known (e. g., cancer), the determination of its extent, particu- 
 larly upward, is attended by great difficulties, or, finally, where new 
 growths are barely accessible to the finger. 
 
 If inspection or examination with bougies is also required, it is 
 best to proceed with these immediately after palpation. The patient 
 is thus spared the excitement attendant on every rectal examination, 
 and, what is most important also, the uncertainty of diagnosis. 
 
 Ocular inspection of the rectum is best conducted on an operat- 
 ing table, in the lithotomy position, whereby the sacrum lies on a 
 level with the examiner's chest. The knee-chest position may also 
 be used. The examination should be made with the aid of a suit- 
 able speculum. The number of these specula almost equals those 
 for the vagina. They are all best described in the catalogues of 
 instrument makers. For practical purposes most of them are too 
 complicated and clumsy. With the observance of the precautions 
 described below, one usually succeeds with a simple Sims's, Simon's, 
 or a Czerny's speculum, the latter having given me excellent serv- 
 
80 DISEASES OP THE INTESTINES 
 
 ice on account of the shortness of the one end. A bivalve specu- 
 lum is also very good. With proper illumination, one obtains a. 
 satisfactory picture of the internal rectum. 
 
 Palpation should always precede the introduction of the specu- 
 lum. The presence or absence of fseces in the rectum can thus be 
 determined. If present, they must be removed through irrigation 
 with lukewarm water or weak lysol solutions, or else manually. 
 
 The introduction of a speculum is very much facilitated by the 
 relaxation of the rectum. This is readily accomplished by the knee- 
 chest position, in which the abdominal organs fall forward and nega- 
 tive pressure in the rectum results ; the latter fills with air and 
 its walls stand apart. I have convinced myself that deep inspira- 
 tion combined with passing the finger into the rectum very much. 
 facilitates the passing of the speculum. If the instrument be uni- 
 formly and liberally anointed with a fatty substance, its introduc- 
 tion will be attended by no difficulty. With a good natural or 
 artificial light one can carefully inspect all pathological conditions 
 of the rectum. This has recently led Kelly ^^ to recommend the 
 introduction of cylindrical specula with a uniform diameter of 22 
 millimetres and a length varying from 14 to 35 centimetres, and 
 furnished with obturators. They are introduced with the patient 
 in the knee-chest position. As soon as the speculum has passed the 
 sphincter the rectum fills with air, and an entirely unobstructed view 
 of the rectal cavity is thus obtained. 
 
 Attempts have been made to illuminate the rectum just as in 
 other cavities in the body. J. Leiter, of Vienna, constructed an 
 instrument for this purpose ^^, which, however, appears to have 
 been put to little practical use. After introducing the speculum 
 into the rectum, one may employ either reflected electric illumina- 
 tion, or more simply, direct electric illumination. 
 
 Herzstein has lately constructed an instrument which I have 
 found very useful for the examination of the rectum (Fig. 11). It 
 consists of several metal tubes (A), varying in length from 10 to 34 
 centimetres, and furnished with metal obturators (£) for the pur- 
 pose of easier introduction. The screw (d) fastens the obturator to 
 the metal tube. The illumination is supplied by the well-known 
 Caspar electroscope (C). The longest tubes enable one to reach the 
 sigmoid flexure. The field of vision is kept clear of mucous frag- 
 ments or fseces by cotton applicators 20 and 35 centimetres long. 
 To facilitate the introduction of this instrument I have had the 
 obturators made conical, and in order to determine which portion of 
 
THE EXAMINATION OF THE PATIENT 
 
 81 
 
 the rectum the speculum has reached I have had a centimetre scale 
 marked upon the tubes. 
 
 Inspection of the rectum, in the first place, enables one to detect 
 acute and chronic inflammations of the mucous membrane. In 
 acute cases the mucous membrane has not the normal pale appear- 
 ance, but appears swollen and strongly injected ; in chronic inflam- 
 
 FlG. 11. 
 
 mations it appears relaxed, swollen, and velvety, is covered with firm 
 mucus, and easily bleeds. With good illumination the follicular 
 swellings become distinctly visible. In well-pronounced cases, a 
 muco-purulent secretion trickles over the surface. As a rule, these 
 inflammations are not primary, but occur in connection with other 
 rectal diseases. Furthermore, on inspection one can distinctly see 
 ulcerations (fsecal, dysenteric, tubercular, gonorrhoeal, hemorrhoidal, 
 syphilitic, etc.), and, in children, follicular ulcers, When typically 
 developed, these different forms can be distinguished from one an- 
 other. Rectal fistulse (internal and external), hemorrhoidal veins, 
 polyps and other growths, strictures, etc., can also be seen. Since 
 these various affections are treated of at length in the second por- 
 tion of this work, we may here content ourselves with this brief 
 reference to the subject. 
 
 By bougieing of the rectum and of the parts above, we may 
 sometimes learn whether or not that gut and the sigmoid flexure 
 are patent. For this purpose we employ either soft-rubber bougies,* 
 or else the so-called English [known here in the United States as the 
 French sounds] or hard-rubber bougies, or, finally, though more 
 
 * Those with a spiral obturator, as devised by Haha, are particularly good, be- 
 cause they combine great elasticity with firmness. 
 
82 DISEASES OF THE INTESTINES 
 
 rarely, the so-called Trousseau's sounds, with olive-shaped ivory 
 points that can be screwed on and off. The softer the iustrament 
 employed for diagnostic purposes the less the danger. When 
 sounding the rectum for the first time, I use only soft-ruljber 
 sounds or bougies. The question how far a bougie may be intro- 
 duced is very important. Some authorities state that it can not be 
 passed beyond the sigmoid flexure. According to my own investi- 
 gations this is incorrect, for by abdominal palpation of sounds which 
 1 had introduced I have been convinced that, if the colon be pre- 
 viously distended by water or air, even soft J^elaton sounds can be 
 passed into the descending colon. I purposely employ the word 
 caw, for our success depends principally upon the sound passing 
 through ]S"elaton's sphincter into the sigmoid flexure. In some 
 cases this is accomplished very readily, in others only by the aid of 
 one or two fingers in the rectum acting as a guide to the instru- 
 ment. Should this last precaution be neglected, flexible instru- 
 ments curl up in the wide ampulla or impinge against its walls, 
 thus making forward passage impossible. On account of the acute 
 bend which the splenic flexure makes at the junction of both seg- 
 ments of the colon, passage into the transverse colon, on the con- 
 trary, is impossible. 
 
 Bougies and sounds should be thoroughly oiled before intro- 
 duction ; the latter procedure must be attended by the greatest 
 precaution. All force must be carefully avoided. This rule ap- 
 plies particularly to all sounds which are not absolutely soft, for 
 during simple sounding of the normal rectum perforations have 
 occurred. 
 
 The diagnostic value of rectal bougieing is not great. We can 
 not learn more from bougieing, at least of the rectum, than we can 
 from digital and ocular examinations. On the other hand, only 
 through sounding can constrictions of the sigmoid flexure or of the 
 descending colon be diagnosed with certainty. Such examinations, 
 however, require the greatest possible care, and I would again recall 
 the advantages of the above-mentioned rubber bougies.* A stric- 
 ture can he diagnosticated with certainty only when, npon rejpeated 
 examinations, the passage of a sound itnparts the impression of its 
 
 * Kuhn, of Giessen, recently devised metallic spiral sounds for the sounding 
 of the stomach, pylorus, duodenum, and the large intestine. From these sounds 
 he hopes to learn much of value for the diagnosis and therapeutics of the said organs. 
 Since no evidences of the merits of this method have as yet been advanced, we wiU 
 not discuss it, nor the method of Hemmeter for the intubation of the duodenum. 
 
THE EXAMINATION OF THE PATIENT 83 
 
 always having to overcome a resistance at the same jpoint, and 
 when, after the suspicious point is passed, the withdrawal of the 
 sound also gives one the iinpression of passage through a narrow 
 portion. 
 
 Aside from diagnostic purposes, rectal bougies are also em- 
 ployed for the dilatation of strictures. This will be referred to in 
 the proper place in the second portion of this work. 
 
 3. Percussion 
 
 In general, percussion gives us less tangible results than palpa- 
 tion. ISTevertheless it is of value as completing and controlling the 
 latter procedure, and it should therefore never be omitted. 
 
 Percussion of the intestines should always be finger percussion, 
 never hammer percussion, for with the latter finer distinctions are 
 very easily overlooked. We should always percuss lightly, for 
 then only, if at all, can differences in tone be clearly brought out. 
 In the empty state of the intestines percussion gives the best 
 results. It is sometimes of importance to compare the result of 
 percussion of the empty with that of the full intestines (and stom- 
 ach). I^ormally, as in the stomach, the percussion note is tym- 
 panitic, but varies in pitch in the different segments. On account 
 of the descending colon being filled with solid matter, palpatory 
 percussion, according to Leo ^^, almost constantly gives a dull tym- 
 panitic tone in the left hypochondrium as compared to that obtained 
 on the right side. The diagnostic value of percussion is limited to 
 those cases in which we find distinct variations from the normal 
 tone. This occurs with free or encapsulated fluids in the abdomi- 
 nal cavity, and also in excessive meteorism. The results from per- 
 cussion in ascites ai-e so well known that detailed discussion is 
 unnecessary. We wish, however, to speak of the differentiation of 
 air in the abdominal cavity from that in the intestines. Whereas 
 in the former instance the percussion note has everywhere a uni- 
 formly tympanitic sound, and hepatic and splenic dulness disappear, 
 in intestinal meteorism the percussion note varies from place to 
 place and from time to time. 
 
 The percussion note over large tumours of the intestines (includ- 
 ing fsecal tumours) is flat, provided they are not covered by intes- 
 tinal coils that contain air. In the presence of moderate amounts 
 of fluid in the abdomen, tumour percussion in various postures of 
 the patient may also yield useful results. If the abdomen be tapped 
 before percussion the results will naturally be more satisfactory. 
 
34 DISEASES OF THE INTESTINES 
 
 By filling the intestines with air or water we can establish condi- 
 tions favourable to percussion (see pages 74 and 85). 
 
 In ileus, in order to distinguish between widely distended intes- 
 tinal coils and those of smaller calibre, a few authors, particularly 
 Curschmann ^^, have recommended pleximeter percussion, 
 
 4. Auscultation 
 
 Of all physical methods of examination, auscultation has the 
 least diagnostic value. It is true that sounds (borborygmi, gur- 
 gling, etc.) are heard in the most varied diseases of the intestines, 
 but the nature of their production is so atypical that little can be 
 learned from them. In stenosis of the large intestines we meet 
 with intestinal sounds (especially frequently recurring intestinal 
 sounds) on a most extensive scale, but compared with the data 
 obtained from palpation, or even inspection, their diagnostic value is 
 minimal. On the other hand, the absence of all intestinal sounds, 
 together with total absence of all intestinal movements, is of diag- 
 nostic value in perforative peritonitis (E. Wagner ^^ ). 
 
 The well-known ileo-csecal gurgling of typhoid fever to-day 
 p)Ossesses an historical value only. All experienced physicians 
 agree that it has no practical value. Kegarding succussion and 
 splashing sounds, compare above (page 73). 
 
 5. Inflation of tine Intestines 
 
 Inflation of the intestines can be accomplished either through 
 the introduction of mixtures which form carbonic-acid gas (bicar- 
 bonate of soda and tartaric acid, von Ziemssen " ), or of carbonic- 
 acid gas from fluids in retainers (O. Rosenbach ^^ ), or else from 
 inverted siphons of carbonic-acid gas ^^, or finally through the intro- 
 duction of atmospheric air by means of a double balloon bulb, such 
 as is used with a spray apparatus (E-uneberg ^° ). Of all these meth- 
 ods the last mentioned is certainly the simplest and best ; we can 
 inflate the intestines with as much or as little air as we wish. 
 Should there be any occasion for measuring the amount of air 
 introduced, we may employ a syringe of known volume and intro- 
 duce the air from this (Damsch ^^ ). 
 
 How far can the air be introduced ? Most authors, particu- 
 larly von Ziemssen and O. Rosenbach, claim that the air can not 
 pass beyond the ileo-csecal valve ; whereas Damsch has shown that 
 with slow inflation and the employment of more than one metre 
 of air, the valve may be overcome and even the small intestines 
 
THE EXAMINATION OF THE PATIENT 85 
 
 inflated. In view of similar successful attempts made with large 
 quantities of water (von Genersich^^) we must at once admit the 
 possibility of overcoming the resistance of the valve with air. 
 Both methods are very heroic, and have, besides, no advantage over 
 the introduction of small quantities of air or water. 
 
 Upon the whole, therefore, we shall have to remember that, as 
 ordinarily practised, the introduction of air distends the large intes- 
 tine only. 
 
 The technic of rectal inflation is very simple. For this pur- 
 pose a soft stomach or i-ectal tube, or, in case of necessity, even the 
 rubber tube of an irrigator, may be used. A well functionating 
 double balloon bulb is attached to the tube. Before introducing 
 the rubber tube we must see whether there is much faecal matter 
 in the rectum ; if so, it must be removed. Small quantities of fseces 
 need not be taken into account. To learn if air passes into the 
 intestines, we should auscultate in the left iliac region ; a hissing 
 sound made by the entering air can here be distinctly heard. Prac- 
 tically it is very iinportant not to inflate the intestines too greatly, 
 for finer shades of difference in sound are best apj)reciated with 
 slight inflation. It is often useful to combine inflation of the stom- 
 ach with that of the intestine. 
 
 Inflation of the intestines has a threefold practical diagnostic 
 signification ; it enables us to diagnose stenoses with a certain 
 amount of probability, sometimes even with certainty ; further- 
 more, it makes clear displacements of the intestines, especially of 
 the movable portions ; finally, it is of value in locating tumours and 
 in determining their mobility. 
 
 Regarding the diagnosis of stenoses, we may remark that nor- 
 mally, in compliance with physical laws, the entire large intestine 
 forms a uniform prominence ; in stenosis of a segment the infra- 
 stenotic portion only can be inflated, and will therefore appear more 
 prominent, while the supra-stenotic portion will be very little or not 
 at all distended. Furthermore, if the inflation be continued, the 
 air will return and pass out per anum alongside of the tube, and 
 severe pain will be apt to follow. The results obtained from per- 
 cussion in intestinal stenoses are also important ; while we still have 
 the usual tympanitic sound above the stenosis, we will get a deeper 
 and more sonorous one below it, and after all the air has passed 
 out both sounds will again be uniform. When the inflated air 
 presses upon the stenosed parts it is sometimes possible to hear a 
 peculiar long-drawn sound that may also be of diagnostic value. 
 7 
 
86 DISEASES OF THE INTESTINES 
 
 Great as may be the value of this method, for the development 
 of which much credit is due to von Ziemssen, it should nevertheless 
 be remarked that reliable results are obtained therefrom only in 
 very marked stenoses. In these cases, however, the other symp- 
 toms of intestinal obstruction are so well characterized, that, after 
 all, intestinal inflation should be employed mainly as a confirma- 
 tory method. For obvious reasons it frequently gives negative 
 results in the beginning of a stenosis. 
 
 A further advantage of the method lies in the possibility of 
 diagnosticating, with more or less certainty, changes in the position 
 of various segments of the large intestine. If, for examj)le, after 
 moderate distention of the large intestine a transverse protrusion 
 is seen below the umbilicus, or even immediately above the sym- 
 physis, and the same result obtains after repeated examinations, we 
 are safe in assuming that a sinking of the transverse colon {colojjto- 
 sis) has taken place. The sigmoid flexure sometimes becomes en- 
 larged or dislocated, or both, so that the greatest difficulty may be 
 experienced in differentiating it from the transverse colon. 
 
 Finally, as is well known, in inflation of the intestines we have 
 a means of ascertaining with certainty the position of questionable 
 intestinal tumours, and of distinguishing between these and tumours 
 of other organs (e. g. the kidney), since the latter disappear gradu- 
 ally with inflation, whereas the former (tumours of the intestine) re- 
 main as perceptible as before. J^evertheless, this symptom can 
 only be taken into account where a tumour previously perceptible 
 completely disappears. In like manner intestinal tumours may fre- 
 quently be very clearly differentiated from those of the liver. 
 
 6. The Injection of Water per Anum 
 
 The injection of water per antinn is principally employed to 
 locate an intestinal stenosis (Simon), or to establish the relation of a 
 new growth to surrounding organs (Minkowski ^^). In the latter 
 case it is well to combine the procedure with inflation of the 
 stomach. 
 
 , Here, according to Minkowski, the abdominal tumour slips back 
 into the position normally occupied by the organ to which it be- 
 longs. Here, also, it is frequently well to combine the distention 
 of the stomach by air or water with similar distention of the large 
 intestine. The recognition by means of distention of a stenosis — 
 especially one occurring far down — is based upon the fact that 
 under normal conditions 2 to 5 (!) litres can be passed into the intes- 
 
THE EXAMINATION OF THE PATIENT 8Y 
 
 tines, whereas in deep stenosis very much less can be introduced. 
 This method is unreliable if for no other reason than because the 
 toleration of the rectum for quantities of water varies considerably 
 (at least according to my experience). The water is introduced by 
 means of an irrigator armed with a calibrated tube or else by means 
 of a Hegar's funnel. 
 
 7. Test Lavage of the Intestines 2* 
 
 By this I mean a uniform irrigation of the mucous membrane 
 of the entire large intestine with water, for the purpose of recog- 
 nising anomalies of the same (mucus, pus, blood, or even fragments 
 of tumours) in the returning water. 
 
 Technic. — The following rules are given for test lavage of the 
 intestine. It is best carried out with the patient in the lateral posi- 
 tion, the intestines being previously emptied. 1 use a soft-rubber 
 tube, not too small in calibre, and from about 70 to 80 centimetres 
 in length, armed, as in lavage of the stomach, with rubber tubing 
 and a large funnel. The tube is well greased, and after its intro- 
 duction into the anus is gradually pushed forward, while the funnel, 
 filled with lukewarm water, is at the same time slowly raised. In 
 suitable cases — as can be proved by palpation through the abdom- 
 inal wall — we are sometimes able to introduce the tube into the sig- 
 moid flexure, or even beyond. As soon as marked tenesmus occurs 
 (not infrequently after more than a half litre has been introduced) 
 the funnel should be lowered, and the water thus siphoned off should 
 be carefully inspected and preserved in clean vessels for macroscopic 
 and microscopic examination. I^ormally, the water returns clear, 
 or only slightly cloudy from admixture of very minute particles of 
 mucus, epithelium, or small particles of faeces. It is very differ- 
 ent, for example, in catarrh of the large intestine. Here the wash 
 water to a greater or less extent contains large and small shreds 
 of mucus. Their quantity serves as a good criterion of the progress 
 and the extent of the disease. We have no simple or easier method 
 than this for diagnosticating membranous enteritis. This proced- 
 ure, which I have used for a long time, has also given me excel- 
 lent results in detecting suppurative and ulcerative processes accom- 
 panied by haemorrhage. I have often found pieces of exfoliated 
 mucous membrane in the wash water, and though I can not speak 
 from personal experience, it apjDears possible to readily obtain in this 
 manner fragments of tumours for examination. Where it is desir- 
 able to make a microscopical examination, this procedure possesses 
 
88 DISEASES OF THE INTESTINES 
 
 the advantage of absolute cleanliness, a fact which is very advan- 
 tageous considering the offensive smell of faeces. Besides, the isola- 
 tion of pathological substances (free from fgecal matter) makes the 
 microscopical examination much easier. 
 
 8. Electric Trans-illumination of the Large Intestines 
 
 Herjng and Reichmann ^ were the first to employ diaphanos- 
 cope for the determination of the limits of the large intestine. 
 They used a black elastic intestinal bougie, to the end of which a 
 small Edison lamp was fastened. Before introducing the bougie, 
 1,500 centimetres of lukewarm water were poured into the rectum. 
 By using a lamp of 25 volt amperes (equal to eight standard candle 
 power), the contour and course of the transverse colon were dis- 
 tinctly mapped out. With the development of the method, Heryng 
 and Reichmann hoped it would be possible to approximately deter- 
 mine doubtful tumours of the abdominal cavity, but thus far this 
 expectation has not been realized. 
 
 APPENDIX 
 
 The Employment of Röntgen Rays in the Diagnosis of 
 Intestinal Diseases 
 
 Hitherto the results in general from skiagraphy in the diagnosis 
 of abdominal diseases have not been very promising ; especially has 
 it been impossible to positively diagnosticate abdominal tumours 
 that could not also be diagnosed by the usual methods. On the 
 other hand, the location of metallic foreign bodies in the large 
 intestines by means of the Röntgen rays appears to me to be very 
 plausible. I am convinced that we can see certain portions of the 
 large intestine — e. g., the descending colon — and especially dis- 
 tinctly recognise the haustra coli. It is therefore not beyond the 
 limits of possibility that we should be able to render displacements 
 of the intestines visible to the eye. It remains to be seen how 
 much more favourable conditions will be created through the intro- 
 duction of metalKc sounds and the like into the rectum. Since the 
 kidney (particularly the left) and the spleen can frequently be dis- 
 tinctly recognised by the fluoroscope, it might be possible, under 
 favourable conditions, to make the differential diagnosis between 
 tumours of the kidney and of the intestine, or of the liver and the 
 spleen. 
 
THE EXAMINATION OP THE PATIENT §9 
 
 LITERATURE 
 
 1. Nothnagel. Die Erkrankungen des Darnas u. des Peritoneums. Wien, 
 
 1895, S. 5. 
 
 2. Boas. Verhandlungen des XV. Congresses f. innere Medicin, 1897, S. 479. 
 
 3. Boas. Diagnostik u. Therapie der Magenkrankheiten, Th. I, 4te Aufl., 1897, 
 
 S. 71 u. f. 
 
 4. Obrastzow. Archiv f. Verdauungskrankheiten, Bd. i, S. 263. 
 
 5. Edebohls. Amer. Journal of the Medical Sciences, May, 1894. 
 
 6. Obrastzow. Loc. cit., p. 274. 
 
 7. Boas. Loc. cit., p. 105. 
 
 8. J. Friedenwald. Med. News, August, 1894. 
 
 9. Nothnagel. Loc. cit., p. 248. 
 
 10. Gersuny. Wiener klin. Wochenschr., 1896, No. 40. 
 
 11. Hofmokl. Wiener med. Wochenschr., 1896, No. 43. 
 
 12. Kelly. Cited from Centralbl. für Chirurgie, 1895, p. 961. 
 
 13. R. Lewandowski. Das electrische Licht in der Heilkunde. Wien u. Leip- 
 
 zig, 1892, S. 211. 
 
 14. Leo. Diagnostik d. Krankheiten der Bauchorgane, 2. Aufl., 1895, S. 109. 
 
 15. Curschmann. Deutsch. Archiv f. klin. Med., Bd. liii, 1894, S. 30. 
 
 16. E. Wagner. Ibid., 1886, Bd. xxxix, S. 72. 
 
 17. von Ziemssen. Ibid., 1883, Bd. xxxiii, S. 235. 
 
 18. O. Rosenbach. Berl. klin. Wochenschr., 1889, No. 28. 
 
 19. Schnetter. Deutsch. Archiv f. klin. Med., 1884, Bd. xxxiv, S. 638. 
 
 20. Runeberg. Ibid., Bd. xxxiv, S. 460. 
 
 21. Darnsch. Berl. klin. Wochenschr., 1889, No. 75. 
 
 22. von Genersich. Deutsche med. Wochenschr., 1893, No. 41. 
 
 23. Minkowski. Berl. klin. Wochenschr., 1888, No. 31. 
 
 24. Boas. Deutsch. Aerzte Zeitung, 1895, No. 2 u. 3. 
 
 25. Heryng u. Reichmann. Therapeut. Monatshefte, März 1892. 
 
CHAPTER Y 
 
 EXAMINATION OF THE F^GES 
 
 Preliminary Remarhs. — The examination of the faeces is an 
 integral factor in the diagnosis of intestinal diseases. We learn 
 from it pathological changes in the secretive, absorptive, and motor 
 functions of the stomach and intestines, and ascertain the foreign 
 substances that are mingled with the intestinal contents. Fre- 
 quently also the nature and location of intestinal diseases can thus 
 only be correctly appreciated and diagnosticated. The diagnosis of 
 entozoa must be made almost entirely from the microscopical 
 examinations of the dejections. 
 
 In spite of all tliis, we are safe in stating that even at the pres- 
 ent day clinical examination of the faeces is not universally prac- 
 tised. The cause for this is very clear. In the first place, the rejDul- 
 sive nature of the material itself, so disagreeable to the olfactory 
 nerves ; then, again, the unpleasant manipulations that the trans- 
 port and examination of the material entail upon the layman and 
 the physician ; and last, but not least, the fact that faecal exami- 
 nations rarely yield decisive diagnostic results. The first two 
 objections mentioned are undoubtedly justifiable ; the latter objec- 
 tion is also valid to a certain degree. But the principle, sahis mgroti 
 2yrima lex esto, should help us to overcome all hesitancy and diffi- 
 culties. As regards the diagnostic value of faecal examinations, it 
 must be admitted that a single examination is only rarely sufficient 
 to make clear the nature of the disease. Still, this applies equally 
 well to all other secretions and excretions — e. g., sputum, stomach 
 contents, urine, and vaginal secretions. 
 
 In clinics and dispensaries the facilities for macroscopical and 
 microscopical examination of the faeces are usually very easily 
 arranged. In private practice, on the contrary, it is usually best 
 to make the first gross examination in the dwelling of the patient. 
 Should we find anything unusual, or should we for any other rea- 
 son wish to make a microscopical examination, we can select the 
 90 
 
EXAMINATION OF THE P^CBS 91 
 
 parts whicli appear pathological, and preserve them in a small wide- 
 mouthed bottle with a glass stopper. Only where exact chemical 
 analysis (perhaps for nitrogen or fat) is required, will large quanti- 
 ties of fgeces be necessary. In some cases — for instance where we 
 suspect amoebae — it is very desirable to examine the faeces fresh and 
 at the body temperature, if possible. This is readily accomplished 
 by warming the bedpan and bringing the material into a bottle, also 
 warmed, and wrapped for safety's sake in cotton. If we have an 
 incubator we can place the material in it until we are ready to make 
 the examination, otherwise some artificial means for maintaining the 
 warmth of the faeces can easily be devised. In some cases it is inter- 
 esting to follow the development of gases from thin stools placed in 
 a warm atmosphere, and to note the influence exerted by certain 
 internal medication upon such gaseous formation. For this pur- 
 pose we may use the so called "fermentation tubes" of Einhorn 
 and Fiebig, such as are also used in determining the gases of the 
 stomach contents. Should we have to deal with ulcerative processes 
 of the rectum, we can obtain the secretion directly upon a glass rod 
 or a platinum loop — best with the use of a speculum and good illu- 
 mination. 
 
 From what has been said, it will be readily seen that the exami- 
 nation of the fgeces is divisible into the macroscopical, the micro- 
 scopical, and the chemical. 
 
 1 . The Macroscopical Examination 
 
 In the last chapter a few striking changes were briefly men- 
 tioned and their diagnostic importance dwelt upon. This was 
 necessary because, notwithstanding the best intentions, we can not 
 at the time of the first consultation always obtain test material, and 
 for the time being are compelled to rely upon the statements of the 
 patient. In the following discussion it is intended to give as com- 
 plete a review as possible of the macroscopical changes of the stools. 
 Consistency and form, appearance, quantity, colour, smell, as well as 
 abnormal ingredients, will have to be considered. 
 
 ]^ormally, the f^ces are cylindrical in form, with great variations 
 in the calibre of the individual cylinders, or else they are homoge- 
 neous, and of a thick, pasty consistency. This difference in con- 
 sistency depends, among other things, upon the mode of life of the 
 individual and upon the nature of the diet. Under certain condi- 
 tions variations from the types just mentioned may still be normal. 
 
92 DISEASES OF THE INTESTINES 
 
 This fact, often overlooked, is of great practical importance. The 
 following will serve as an example : A patient who has just passed 
 through typhoid fever is constipated. The evacuations occur only 
 after enemata, and resemble the normal faeces of the sheep (" schaf- 
 kothartig"). In view of the careful diet of reconvalescence, and 
 the lack of exercise which is necessarily associated with a cured case 
 of typhoid, such a condition of the stools is entirely physiological, 
 and it would be a mistake to speak here of atony of the intestines 
 following typhoid. Cases like this occur almost daily, and where 
 constipation and changes of the stool are complained of, it behooves 
 the physician to inquire carefully into the manner of living, and 
 above all into the diet of the patient. Conversely, the occurrence 
 of diarrhoea with a diet consisting for the most part of milk or of 
 milk preparations, or after unaccustomed drinking of sour wines or 
 partaking of too much fruit or sweets, is an entirely normal condition. 
 
 Since we have frequently observed false therapeutic measures 
 instituted because of a failure to properly recognise the conditions 
 in question, we believe it best to state these facts, which, without 
 doubt, are known to the experienced physician. Variations in con- 
 sistency admit of two possibilities : the stool may either be abnor- 
 mally hard and passed in small lumps (scybala, " sheep stool," 
 " hazel-nut " stool), or in long, thin cylinders ; secondly, the opposite 
 condition may occur — the stools are passed in a thin, pasty, or even 
 fluid state. 
 
 Yery hard faeces with occasional furrows (evidently impressions 
 from the tgenise coli) indicate only long retention within the intes- 
 tine, and consequent desiccation. Such an appearance speaks for 
 intestinal stricture as little as does the so-called lead-pencil stool. 
 In these cases there are, very probably, spastic contj-actions of the 
 intestines, such as are often observed in chronic constipation. I 
 would lay more stress, however, upon a different form of stool, 
 which I have frequently seen in stenoses of the intestine. This 
 consists of a homogeneous, thick, pasty, or curdlike evacuation, in 
 which several short cylinders, of the thickness of the small finger, 
 float about. The diagnostic importance of this stool formation must 
 not be overestimated, and only repeated observation of the same 
 condition is of significance. 
 
 Thin stools may also vary in two ways : they may be very watery, 
 as in cholera nostras, or asiatica, or they may have a certain admix- 
 ture of mucus, which can be easily recognised, since it clings 
 to the sides of the glass when the contents are poured out. The 
 
EXAMINATION OF THE F.EOES 93 
 
 microscopical and chemical examinations confirm the presence of 
 mucus. 
 
 The quantity of stool passed is seldom of any practical impor- 
 tance. In stools of firm consistency the quantity voided is impor- 
 tant, if it remain considerably below the normal. It should be 
 remarked, however, that depending upon the nature of the diet 
 (vegetable, animal, mixed, milk, soup, starvation, etc.) the greatest 
 variations occur. There may be repeated small watery evacuations, 
 accompanied by marked tenesmus. Such evacuations indicate in- 
 flammatory processes in the lowermost segments of the intestine. 
 Among other conditions, stools of this kind occur very frequently 
 with haemorrhoids, in acute and chronic dysentery, proctitis, inflam- 
 mations of the prostate, rectal carcinoma, etc. 
 
 The colour of the fseces bears a certain relation to the con- 
 sistency. Even the normal colour may show variations ; thus in 
 purely meat diet it is dark brown (from hseraatin and ferrous sul- 
 phate) ; in a mixed and vegetable diet, although much lighter, it is 
 still brown from urobilin (according to Fleischer^, also hilijprasin) \ 
 it is lightest of all where the diet consists mainly of milk. The 
 longer the stool remains in the intestines the firmer will be its con- 
 sistency and the darker its colour. Under these conditions it may 
 even assume a tarlike appearance, which I know has led inexperi- 
 enced persons to believe there have been gastric or intestinal haem- 
 orrhages. Where the intestinal contents pass rapidly through the 
 canal, bilirubin may appear unaltered in the stools ; in fact, some 
 stools give bilirubin reaction only. As a result of the absence of 
 reduction of the bile pigments, we frequently find unaltered bile 
 pigments in children's stools. In itself, a green colouration of 
 stools is by no means indicative of bilirubin, for substances contain- 
 ing chlorophyl, when partaken of in large amounts, colour the 
 faeces green. Besides these, there are other alimentary colour 
 changes in the stool that are not without practical significance. 
 Thus the stools are coloured more or less of a brownish red by 
 cocoa, a dark brown with a shade of green by huckleberries and 
 preparations containing them, and also, though not so intensely, by 
 red wine. Iron and manganese salts give to the stools a darker 
 shade than they ordinarily have. According to Quincke^, in this 
 case the iron is not converted into a sulphate, but, owing no doubt 
 to the action of intestinal bacteria, the iron salts ai"e reduced to iron 
 oxydyl. Similarly, bismuth colours the stools very darkly, though 
 by no means a jet black. As Quincke has recently shown, and as I 
 
94 DISEASES OP THE INTESTINES 
 
 have been able to confirm through numerous control observations, 
 the cause of this is not the formation of bismuth sulphate, but, like 
 the iron, the bismuth is reduced to bismuth oxydyl. Calomel fre- 
 quently, though by no means always, imparts a greenish tinge to the 
 stool. According to examinations of Hoppe-Seyler and Wassiljeff, 
 this results from a reduction of a portion of the bilirubin to urobilin. 
 The anti-fermentative action of the calomel depends apparently upon 
 this change. Besides the drugs mentioned there are many others 
 which also cause colour changes in the stools ; thus senna, santonin, 
 gamboge, rhubarb and its preparations, colour the stools yellowish. 
 
 Acholic stools are very characteristic, and, in view of the phenom- 
 ena attending their appearance, can not fail to be recognised. Owing 
 to their importance they will be considered in a separate section, to 
 which the reader is referred (see page 103). 
 
 The normal odour of the stool results from the presence of ska- 
 tol, and to a lesser degree also of indol. Under pathological con- 
 ditions the odour depends largely upon the nature of the sickness, 
 and, furthermore, upon the length of time that the faeces have re- 
 mained within the intestinal canal. As a rule, the longer they stag- 
 nate in the large intestine the stronger will be the f secal odour ; 
 conversely, after a rapid passage the odour may be very slight or en- 
 tirely absent. The rice-water stools of cholera asiatica and nostras 
 are the best examples of the last-mentioned condition. In very 
 acute intestinal catarrhs and dysentery the odour may be very 
 slight or entirely absent. In chronic catarrh of the small intestines, 
 too, I have noticed entire absence of any odour. The stools of 
 nursing babies often have a sour and slightly fsecal smell. The 
 evacuations of adults containing large amounts of fat, particularly 
 milk fat, may lack the fsecal odour, but instead take on an offensive 
 smell like fatty acids or even cheese. In amoebic enteritis the faeces 
 have a peculiar gelatinlike odour. This was first observed by Quincke 
 and Roos^, and later confirmed by myself^. 
 
 Closure of the common bile duct is frequently attended by obsti- 
 nate constipation, and, as a consequence, the evacuations smell very 
 strongly ; this condition, however, changes upon the administration 
 of agents which increase intestinal peristalsis. Fetid-smelling evac- 
 uations occur in ulcerating carcinoma of the large intestine or of 
 the rectum, etc. 
 
 Ahnorinal admixtures in the stool occur very frequently, and at 
 times may constitute invaluable diagnostic symptoms of the existing 
 intestinal disease. 
 
EXAMINATION OP THE F^CES 95 
 
 Blood. — Fresh unclotted blood, when mixed with the stool, must 
 come from the lower portion of the intestines. It will require local 
 examination of the rectum or lavage of the large intestines to 
 determine its exact source. Blood may also appear altered and 
 decomposed, and impart a colour of tar or wagon grease to the evac- 
 uations. We have already stated what is most important in this 
 connection on page 64. 
 
 Pu8. — Pus may appear with the dejections and be recognised 
 by the naked eye. It almost invariably comes from the lower por- 
 tion of the intestines, for pus from the higher parts, unless voided 
 in very large quantities, is mixed with the faeces, and undergoes 
 physical and chemical changes which make it macroscopically and 
 microscopically unrecognisable. 
 
 The appearance of mucus in the stools is of special importance. 
 Its significance in the diagnosis of intestinal diseases, and especially 
 of intestinal catarrh, has been taught us by Nothnagel's classical 
 studies^. Although in what follows I base my remarks mainly on 
 JSTothnagel's teachings, I differ with this clinician in a number of 
 important points, and shall discuss the subject in the light of my 
 own quite extensive experience. In the first place, it must be 
 remembered that in itself mucus represents a normal product, inas- 
 much as it is always possible with chemical reagents to demon- 
 strate its presence in the stools.* The mucus covering, which is 
 found in very minute quantities partly upon the surface of the 
 faeces and partly mingled with them, is also a normal constituent, 
 being no doubt only a cohesive agent. Hence I can not indorse 
 the statement of ISTothnagel, that every macro- and microscopically 
 recognisable admixture of mucas with the stool indicates a change 
 from the actual physiological condition. 
 
 Even after a single administration of an active cathartic like 
 castor oil we frequently find a large amount of mucus in the 
 evacuations. We can not here speak of a pathological condi- 
 tion. Furthermore, we know that there is a physiological or, 
 more properly speaking, alimentary constipation and diarrhoea (see 
 above, pages 95 and 96). And here also we can not without 
 definite reason regard mucous admixtures in the stools as patho- 
 logical. Apart from these restrictions ISTothnagel's view is fully 
 correct. 
 
 * On the other hand, Hoppe-Seyler's view that the main ingredient of all feces, 
 normal as well as abnormal, is mucin, is certainly not correct. 
 
96 DISEASES OF THE INTESTINES 
 
 MacrosGOjoically recognisable mucns appears under four differ- 
 ent forms : 
 
 1. As pure, thick or glistening mucus which is voided as such — 
 i. e., unmixed with the faeces. This points with certainty to a dis- 
 eased condition of the lowermost segments of the intestines — the 
 rectum, or, at most, the sigmoid flexure. It should, however, be 
 remembered that absence of such mucus does not at all speak 
 against catarrh of the lower intestinal segments. 
 
 2. As mucous shreds, or membranes with or without amorphous 
 mucous masses, indistinguishable from that just described. It occurs 
 with any of those intestinal aifections so frequently referred to, 
 which we designate as membranous enteritis ; these will be spoken 
 of more in detail when we come to the description of this affection 
 in the special part of this work. 
 
 3. As tenacious, sticky, gummy, brownish-yellow mucus, inti- 
 mately mixed with thin pasty faeces. If stirred with a glass rod it 
 adheres in dense, sticky masses, and is separated from the basic 
 mass only with great difficulty. 
 
 4. As small shreds of mucus scarcely macroscopically visible. 
 These shreds are best seen by shaking up the fsecal mass in a glass 
 vessel. 
 
 With the exception of the variety that accompanies membranous 
 enteritis, and which at times develops in nervous individuals {colica 
 mucosa^ Nothnagel), all the other forms indicate catarrh of the large 
 intestines. 
 
 Although for years I have carefully looked for those frog- 
 spawn or sagolike bodies in the stool whose vegetable origin was 
 first recognised by Yirchow, and which are mentioned by l^oth- 
 nagel in the above investigations, I have thus far never seen them 
 in typical form. Kitagawa, on the contrary, thinks that sagolike 
 bodies of mucous character are met with in enteritis and in intes- 
 tinal ulcers. Research into this matter is not yet concluded, though 
 if for no other reason than their rarity these bodies can have but 
 slight diagnostic interest. 
 
 Mucus in the form fisrt observed and described by l^othnagel 
 as yellow mucous granules is barely visible macroscopically. As 
 described by this author, these bodies consist of yellow or brownish 
 yellow or even of dark green granules varying in size from poppy 
 seeds to peas, and having the consistency of butter. Microscopical 
 and micro-chemical examinations have shown that their colour is 
 due to unaltered bilirubin, and it can be readily demonstrated that 
 
EXAMINATION OF THE F^CES 97 
 
 the ground substance of tliese bodies consists of mucin or of a body 
 similar to it. According to JN^otlmagel, these bodies point to catarrh 
 of the small intestines. They may occur in the stool singly or in 
 large numbers. Although I make it a rule to examine the stools in 
 every case of intestinal catarrh, I have never seen these yellow 
 mucous granules. One of our best authorities upon mucoid bodies 
 (Ad. Schmidt) also questions their existence and their diagnostic 
 significance. According to Nothnagel, mucus can be recognised 
 by the microscope exclusively, only under the following condition : 
 Where the faeces are formed, are of a firm pasty consistency, and 
 have intimately mixed with them numerous small particles of 
 mucus, which appear under the microscope as small homogeneous, 
 hyaline, grayish-white refractive islets. IS^othnagel regards their 
 presence as indicative of a catarrh of the uppermost portion of 
 the large or of the lowermost portion of the small intestine. I 
 have never seen these hyaline mucous " islets " of !N^othnagel, and 
 Ad. Schmidt^, who regards them as dead amcebse, doubts their mu- 
 cous structure. At all events, no positive diagnostic importance 
 can be attributed to their presence in the faeces. 
 
 Important as is the appearance of mucus in the stools for the 
 diagnosis and location of a catarrh, its absence does not, as I have 
 already remarked, exclude catarrh. For example, as JSTothuagel 
 mentions, and I, too, have been able to show in a very typical case 
 (see Part II, Intestinal Catarrh), mucus may be entirely absent in 
 jejunitis. Furthermore, mucus may be entirely absent in intestinal 
 atrophy — so-called lienteritis of old persons. In both these in- 
 stances the clinical picture is so ty]3ical that with careful observa- 
 tion the diagnosis should present no difficulties. Undigested food 
 remnants are visible in the faeces. The opinions even of scientific- 
 ally educated and experienced physicians differ so widely regarding 
 the significance of this, that I desire to state my own views on the 
 subject. 
 
 Per se isolated or occasionally macroscopically recognisable 
 food remnants in the faeces do not indicate disease, for they may 
 result from poor preparation of the food or from insufficient chew- 
 ing ; or else, owing to utter insolubility, these remnants may have 
 entirely escaped the action of the digestive juices. To judge from 
 my own experience, this would apply almost entirely to vegetable 
 substances (fruits, potatoes, legumes, etc.). Macroscopically visible 
 remnants of meat, on the contrary, point to a serious disturbance in 
 the function of the digestive tract, the exact location being only 
 
98 DISBASES OF THE INTESTINES 
 
 jjossible through the entire clinical observation, especially in com- 
 bination with the examination of the stomach contents.* 
 
 The constant appearance of large amounts of the above-named 
 vegetables in the faeces points with great probability to anomalies 
 of secretion in the gastro-intestinal canal. In particularly severe 
 cases of chronic intestinal catarrh in which the stomach, as a rule, 
 
 ^ 
 
 ^ 
 ^ 
 
 Fig. 12. — Spieals of undigested AIeat Fragments in F^ces. (Natural size.) 
 J, pieces of bronchi. (Original observation.) 
 
 is also involve'}, we may regularly find large amounts of undigested 
 meat, as well as of vegetables, fruits, etc., in the faeces. These sub- 
 stances may take on an extraordinary appearance, such as shown in 
 Fig. 12, drawn from a fresh specimen. This important form of 
 enteritis will be again referred to in the special part of this work. 
 
 * [Recently, in a very interesting and instructive paper, A. Schmidt (Deutsche 
 med. Wochenschr., 1899. No. 49) has sought to formulate the principles which 
 govern the appearance of meat remnants in the faeces. By experiments he shows 
 
EXAMINATION OF THE P^CES 99 
 
 Occasionally, fragments of new growths (polyps, ulcerated carci- 
 noma, etc.) are seen, although their appearance in the faeces is usu- 
 ally accidental. As is well known, entozoa (ascarides, segments of 
 tapeworm, oxyuris, anchylostomum, trichocephalus, anguillula, etc.) 
 as well as echinococcus are sometimes also found in the stools. The 
 diagnostic importance of these bodies requires no special mention. 
 
 2. The Chemical Examination 
 
 The practical object of this book prohibits us from describing 
 all chemico-physiological tests. In the following, therefore, we 
 treat only of the more important methods, and at the same time 
 shall discuss the diagnostic importance of each. We shall consider 
 
 1. Reaction of the Fjeces 
 
 The normal reaction of the faeces is neutral or slightly alkaline, 
 changing to feebly acid only when the diet is largely a vegetable one. 
 The reaction becomes very strongly acid on occlusion of the flow of 
 bile into the intestines, being principally due to the presence of fatty 
 acids which have been incompletely or not at all saponified. The 
 qualitative test of the reaction of the stool is made in the usual 
 manner with litmus paper. It should be remarked, however, that 
 the surface of the faecal masses may give a different reaction than 
 the inner portions. To make a quantitative determination, 20 to 50 
 centimetres are mixed in a mortar with about ten times their amount 
 of distilled water, and a few drops of jL Phenolphthalein solution or 
 of a good litmus solution are added as an indicator ; or litmus paper 
 itself may be used instead. Decinormal NaOH or decinormal 
 Ba(0II)2 (Eubner) are added drop by drop until a neutral reaction 
 
 that the connective tissue is digested by the gastric juice and the muscle fibres and 
 nuelein by the pancreatic juice. The ingestion pro die of about 100 grams of 
 finely chopped and lightly fried beef should result in no meat remnants in the 
 stools. From his researches Schmidt concludes : 
 
 1. That the appearance under such circumstances of macroscopically visible 
 connective tissue (or of a large amount under a free diet) indicates some disturb- 
 ance of gastric function (either secretory, i. e., hyper-, sub-, or anacidity, or else 
 motory, i. e., hyper- or submotility). 
 
 2. If, in addition to the connective tissue, there are also macroscopically visible 
 muscle fibres present, there must also be a disturbance of intestinal digestion. 
 
 3. If visible muscle fibres appear without any connective tissue, there must be 
 a serious disturbance in intestinal digestion, but whether dependent upon 
 anomalies of the pancreatic secretion or upon interference with the secretory or 
 absorptive functions of the intestine itself, it is impossible to state. — Tr.] 
 
100 DISEASES OF THE INTESTINES 
 
 is obtained. The amount of alkaline solution added to obtain neu- 
 tralization can be expressed in percentage, as is done witli the stom- 
 ach contents. For example, if it requires 3 centimetres to neutralize 
 50 grams of fresh fseces, the percentage acidity of the latter will 
 be equal to 6 decinormal ]^aOH. Conversely, the alkalinity may 
 be determined in suitable cases with decinormal HCl. 
 
 As Nothnagel has pointed out, no diagnostic significance attaches 
 itself to the reaction of the intestinal evacuations. 
 
 2. Determination of Albuminoid Bodies in the Fjeces 
 
 The albuminoid bodies which may occur in the faeces are mucin, 
 albumin, and peptones (albumoses). 
 
 {a) Determination of Mucin 
 
 Either the fseces themselves or some mucoid masses mixed with 
 them may have to be analyzed. In the first instance the fseces 
 should be rubbed up with water, and an equal volume of lime- 
 water added ; after the mixture has stood for several hours the 
 filtrate is to be tested for mucin. Where mucoid bodies themselves 
 are to be analyzed, they should first be dissolved in weak potas- 
 sium or sodium-hydrate solution and then tested with acetic acid. 
 Insolubility in an excess of the acetic acid would speak for mucin. 
 To avoid confusion with mucinlike nucleo-albumin, the precipitate 
 must be further tested by boiling mth dilute mineral acids. 
 Should a substance which reduces oxid of copper be readily thrown 
 do^vn, the precipitate may be regarded as being mucin. It must, 
 however, be shown that, after repeated reprecipitation, the sub- 
 stance in Cjuestion is still free from phosphorus. 
 
 A much simpler and an equally effective test, in my opinion, 
 is the macroscopical staining of the mucus by means of Ehrlich's 
 triacid solution. A small piece of mucus is broken up in sublimate 
 alcohol and allowed to stand a short time ; the sublimate solution 
 is then replaced by distilled water, and a few drops of triacid solu- 
 tion added. If the fragments are coloured green, they are com- 
 posed mostly of mucus, and if red, there is an excess of albumin 
 (Ad. Schmidt*', Pariser"^, J. Kaufmann^). The diagnostic impor- 
 tance of mucus has already been dwelt upon. 
 
 (5) Determination of Albumin 
 
 In testing for albumin in the faeces, the latter are to be extracted 
 with a large amount of water to which a trace of acetic acid has 
 
EXAMINATION OP THE F^CES 101 
 
 iDeen added, and the watery extract filtered a number of times. 
 The filtrate should then be tested with the same reagents as used 
 in testing the urine for albumin ; of these, acetic acid and ferro- 
 <jyanid of jDotash are particularly to be recommended. For the 
 ■quantitative determination of the albumin, Magnus Blauberg ^ 
 recommends the following procedure : 3 to 5 grams of dried faeces 
 are repeatedly (three or four times) digested in ten times their 
 volume of thymol water '^' (each time for three or four hours), and 
 the clear supernatant fluid filtered each time through the same 
 filter. To these combined filtrates are added one half their volume 
 •of a saturated solution of sodium chlorid and an excess of Dragen- 
 dorf's tannin mixture (tannin, 20 grams ; glacial acetic acid, 37.5 
 grams). After a while the filtrate that forms is brought upon a 
 previously washed filter, then dried, and the amount of nitrogen 
 determined by the well-known Kjeldahl method. In typhoid diar- 
 rhceic evacuations and in two cases of acholic stools von Jaksch^" 
 found demonstrable quantities of albumin. 
 
 (c) Deter7ni)iatio)i of Alhu7noses and Pejptones 
 
 Yon Jaksch ^^ employs the following method : The faeces are 
 mixed with water until they have acquired a thin, pasty consis- 
 tency ; the mixture is then boiled, filtered while still hot, and the 
 clear filtrate tested for albumin with acetic acid and ferrocyanid 
 of potash. Usually a slight cloudiness follows the addition of 
 the acetic acid (mucin), and does not increase upon addition of 
 the potassium ferrocyanid. If such be the case, the mucin must 
 be precipitated by a solution of acetate of lead and the filtrate 
 further treated with phospho-tungstic acid. The fluid which finally 
 remains should be tested for the biuret reaction (caustic soda and 
 copper sulphate). If, after the boiling, albumin is still present, it 
 must be removed by combining it with acetic oxid of iron, and we 
 then proceed in the above-described manner. Magnus Blauberg ^ 
 simply precipitates the combined watery extracts of the fseces with 
 phospho-tungstic acid, collects the precipitates which he dilutes 
 with water, and then carefully floats caustic soda and very weak 
 solution of copper sulphate upon it (biuret test). To separate albu- 
 moses from peptones, the former should be removed by " salting " 
 them out with ammonium sulphate. 
 
 * Made by shaking distilled water with a saturated alcoholic solution of thymol 
 ior a long time, and then filtering. 
 
^02 DISEASES OF THE INTESTINES 
 
 In normal stools von Jakseh never found peptones. In patho- 
 logical stools he found them under most varying conditions — fre- 
 quently in typhoid fever, and wherever much pus was produced 
 (dysentery, tubercular ulcers, and peritonitis, with rupture into the 
 intestines). In affections of the liver the relations were extremely 
 varied. In the stools of nurselings Blauberg almost constantly- 
 found protein substances. 
 
 3. Deteemixation of Caebohydeates in the F^ces 
 
 Hoppe- Seyl er ^^ recommends the following procedure for the 
 determination of carbohydrates : The fasces are distilled, the residu- 
 um extracted with alcohol and ether, the extract boiled with water, 
 then filtered, the filtrate partially evaj)orated, and then tested for 
 reducing substances by boiling with dilute sulphuric acid, supersat- 
 urating with caustic soda, and then adding sulphate of copper solu- 
 tion. If we wish to test for sugar, the faeces should be extracted 
 with water, the albuminoid bodies in the extract precipitated with 
 acetate of lead, the solution freed from lead by means of a current 
 of CO2, then filtered, and the filtrate tested for sugar by Trom- 
 mer's or Xylander's test, etc. The quantitative determination of 
 sugar is made with dried faeces, after the manner of AUihn and 
 Liebmann. 
 
 It has been already stated (page 38) that the carbohydrates 
 are more completely digested and utilized than any other variety 
 of nutritive substances. This accounts for their being so constantly 
 absent (at least in large quantities) from the faeces. In numerous 
 examinations of watery extracts of the f feces, I have only twice ob- 
 tained a distinct Trommer reaction ; with Lugol's solution I have 
 never obtained a reaction. 
 
 4. DETERMINATIOiSr OF FaTS 12^ THE FjECES 
 
 For the determination of fat it will, as a rule, be sufficient to 
 shake the faeces with large amounts of ether until nothing more can 
 be extracted, and then to evaporate the ether over a water bath. 
 The ether takes up only the neutral fats and the fatty acids, but not 
 the soaps. The latter are demonstrated by splitting up- with acids 
 and then extracting -with ether. For the quantitative determina- 
 tion of the total amount of fat in the stools as should be made, and 
 as are indispensable in careful examinations of the so-called " fatty 
 stools," we must first estimate the amount of the neutral fats and the 
 fatty acids, then the fatty acids alone, and from the difference we 
 
EXAMINATION OF THE F^CES 103 
 
 learn the amount of neutral fats. Finally, through the agency of 
 acids, the fatty soaps in the remainder of the first portion are split 
 up into fatty acids, and as such are directly estimated. It would 
 lead too far to enter into a detailed description of the methods in- 
 volved in these examinations. To those who wish to better acquaint 
 themselves with them we recommend Fr. Miiller's Studien über 
 Icterus, Zeitschrift für klinische Medicin, Bd. xi, S. 45-113, and 
 von ISToorden's Beiträge zur Lehre vom Stoffwechsel, Heft 1, S. 
 109 u. f., Bejiin, 1892.' 
 
 In addition to the fixed fatty acids, volatile ones — succinic, 
 butyric, propionic, acetic — also occur. They are isolated, and deter- 
 mined by fractional distillation. For details the reader is referred 
 to the works of Iloppe-Seyler — Thierfelder, Hammarsten (Hand- 
 buch der Physiologischen Chemie), and von Jaksch (Klinische 
 Diagnostik, p. 280). I^o diagnostic significance attaches itself to 
 the determination of the volatile fatty acids. 
 
 N^ormally, fat, especially when taken in large quantities, may 
 appear with the fgeces. It is met with partly as free fat, in the 
 form of fatty acids, and partly as soaps of calcium and magnesium. 
 A good example of the limitation of fat assimilation is found in the 
 taking of large quantities of olive oil, such as are at present em- 
 ployed in cholelithiasis. In these cases we may frequently find in 
 the faeces fat in lumps varying from the size of peas to hazel nuts ; 
 but when taken in a form difficult of solution (pork, mutton, tal- 
 low, etc.), it will appear in the dejections even though the amount 
 partaken of be small. We speak of fatty stools only when the 
 faeces are so loaded with fat that this is even macroscopically visible. 
 This variety of stools has a light silver-grayish appearance, and if 
 allowed to stand in the cold, especially after being previously stirred, 
 two layers — a lower waxy yellow and a fascal one — will form. In 
 other and less marked cases we will still be able to recognise fatty 
 particles or yellowish translucent fatty plaques, which may be 
 isolated for further examination, 
 
 A priori^ it is evident that fatty stools may result from two 
 causes : either an incomplete absorption of fat well split up and 
 saponified, or an insufficient splitting up, whereby its absorption 
 into the lymph and chyle channels is rendered difficult. Finally, 
 both causes may act simultaneously. There can be no doubt what- 
 ever as to the occurrence of the first possibility. Biedert ^^ and 
 Demme^* have shown this in catarrh of the small intestines in 
 children, and Fr. Müller ^^ in adults with caseation of the mesen- 
 
104 DISEASES OF THE INTESTINES 
 
 terial glands. According to ]Srothnagel,* fatty stools occur also in 
 atro]3liy, amyloid disease, and tuberculosis of the intestines. 
 
 It is more difficult to explain the second cause of fatty stools — 
 i. e., anomalies in the splitting up of the fat which result from 
 pancreatic disease or from insufficient excretion of bile. Although 
 the investigations of Abelmann ^^ and Minkowski have shown that 
 in animals after extirpation of the pancreas absorption of fat no 
 longer occurs, control investigations of Sandmeyer^'^ and Teich- 
 mann^^ have also shown that, in spite of exclusion of the pan- 
 creatic secretion, absorption of fat will still take place. In two 
 cases of complete intestinal obstruction, and in one case of cystic 
 degeneration of the pancreas where large amounts of fat had been 
 given, Fr. Müller ^^ could find no increase of fat in the stools. 
 
 Absence of pancreatic juice, therefore, does not prevent the 
 digestion of fat. On the other hand, the careful and thorough 
 examinations of Fr. Müller have shown that in these cases an 
 insufficient splitting up of fat occurs. Whereas with a normal secre- 
 tion of pancreatic juice or in icterus the greater portion (84 per 
 cent) of fat in the fseces was split up, only 40 per cent (in round 
 numbers) was split up in the absence of the pancreatic juice. 
 Should this fact be confirmed, it would constitute an important sign 
 for diagnosing disturbances of the pancreatic secretion or occlu- 
 sions of the pancreatic duct. This would be all the more important, 
 since the other symptoms of these conditions — mellituria or mal- 
 tosuria, multiple muscle fibres in the stool, and ptyahsm — occur 
 very rarely, and are only conclusive when all three are present. 
 Conversely, since thorough sphtting up of fat may result from 
 bacterial action, it does not at all speak against occlusion of the 
 pancreatic duct. Yery much interest also attaches itself to those 
 acholic stools wdthout icterus, which Bamberger ^^ and Gerhardt ^*^ 
 described, and which have been particularly studied by jSTothnagel ^^, 
 von Jaksch,f Berggrün, and Katz^ and Pel.^^ I have observed 
 five cases of this kind. These acholic stools ^vithout icterus are 
 characterized by containing a large percentage of fat or of fatty 
 acids. Their reaction, therefore, is strongly acid. Urobilin has 
 been repeatedly found in these colourless stools (in one of my own 
 cases also). In the majority of cases the acholia was only tempo- 
 rary. In one case under my observation the acholia continued for 
 fourteen days ; unfortunately, further observation of the case was 
 
 * Nothnagel, loc. cit., p. 30. f Von Jaksch, Ice. cit., p. 292. 
 
EXAMINATION OF THE F^CES 105 
 
 impossible. The large amount of fat present is very probably due 
 to insufficient absorption. It is unnecessary to repeat that the rice- 
 water stools of cholera nostras and asiatica are also acholic ; the 
 cause is very probably an entire absence of intestinal secretion. 
 
 The class of acholic stools under discussion has been observed 
 under the most varied conditions in severe as well as in light cases. 
 Thus Nothnagel observed acholia in leukaemia, in cancer of the 
 stomach and intestines, in simple intestinal catarrh of children and 
 adults, and most frequently of all in advanced cases of pulmonary 
 tuberculosis. Yon Jaksch found acholic stools in intestinal tuber- 
 culosis, chronic nephritis, anaemia, and scarlet fever. Berggriiu 
 and Katz observed and ascribed great importance to them in 
 tubercular peritonitis in children. I myself have found acholic 
 stools in cholelithiasis, where the icterus appeared a few days later. 
 I have also seen it in a very feeble patient who suffered from 
 stricture of the esophagus, and after the use of Carlsbad water and 
 salts in a young lady suffering from chronic catarrh of the large (and 
 small ?) intestines ; furthermore, in a patient with cancer of the pan- 
 creas, and finally in a severe case of chronic constipation, where, on 
 account of other clinical manifestations, the probable diagnosis of 
 cancer of the large intestines had been made. 
 
 At present our ideas as to the causes of this form of acholia have 
 a purely theoretical basis. ^Nothnagel believes it is occasioned by 
 a temporary cessation of biliary secretion. Yon Jaksch thinks the 
 lack of colour is due to the non-formation of urobilin from bile pig- 
 ments, or else that colourless products of decomposition of bilirubin, 
 " leukourobilin " (von l^encki), are formed from the bile pigments. 
 The absence of colour is very probably due to a large percentage of 
 fat. We can readily imagine that, owing to certain influences (at 
 present unknown), the fat, or rather the fatty soaps, are only par- 
 tially or not at all absorbed from the small intestines. On the other 
 hand, it can not be denied that the abnormal excretion of fat from 
 the intestines may be caused by temporary or permanent disturb- 
 ances of pancreatic or biliary secretions. Owing to the numerous 
 possible causes of this form of acholia we can not at present assign 
 any great diagnostic value to it. 
 
 5. Determination of Blood and BLOOD-coLOURiNa Matter in 
 
 THE FiECES 
 
 With fresh blood, such as comes from the lower portion of the 
 intestines, the macroscopical appearance of the fseces is so char- 
 
IQQ DISEASES OF THE INTESTINES 
 
 acteristic that a microscopical control examination will seldom or 
 never be required. Well preserved red and white blood-corpuscles 
 may be demonstrated. Where the coloring matter of the blood has 
 undergone changes the condition is quite different. The presence 
 of blood-colouring matter may be demonstrated by microscopical, 
 chemical, and spectroscopic analyses, which will now be collectively 
 considered. 
 
 {a) Blood, when present in the fseces, can seldom be demon- 
 strated by microscopical examination. Even where the stools were 
 still intensely red coloured, Nothnagel never could find erythrocytes 
 in the fresh haemorrhages of typhoid fever. In these cases, how- 
 ever, we can observe clumps of pigment which, according to von 
 Jaksch,* are composed of hsematoidin. 
 
 {})) The Micro-clieinical Demonstration {Hcemin Test). — A small 
 particle of fseces that appears to contain blood-colouring matter is 
 dried, then pulverized, and together with a minute particle of com- 
 mon salt and one drop of glacial acetic acid brought upon a glass 
 slide, and the whole mixed carefully for a few moments. A cover 
 glass is then placed over the mixture and glacial acetic acid allowed 
 to flow under the cover glass until the latter uniformly touches the 
 slide. Thereupon the slide is held over a Yery small flame, care 
 being taken that the glacial acetic acid does not reach the boiling 
 point ; the heating may be repeated with the addition of fresh gla- 
 cial acetic acid. When the specimen has cooled it is examined with 
 the high power for hsematin crystals.f 
 
 {c) Chemical Demonstration ( Weber'' s Test ^^). — The faeces are 
 extracted with glacial acetic acid and ether, and to a few cubic cen- 
 timetres of this extract 10 drops of the tincture of guaiac and 30 
 drops of oil of turpentine are added. In the presence of hsematin 
 we can observe a pretty blue or violet colour, which, after the 
 addition of water, can be extracted with chloroform. 
 
 {cl) Spectroscopic Demonstration. — A portion of the most 
 darkly coloured part of the faeces is stirred with a little water, 
 and, after the addition of a few drops of concentrated acetic acid, 
 shaken with one fifth its volume of ether ; after a few moments the 
 ether separates, and, if the fseces contain blood, is coloured "a brown- 
 ish red (due to the haematin). The ethereal haematin solution shows 
 four spectroscopic absorption bands : one in the red, a second in 
 
 * Von Jaksch, loc. eit., p. 232. 
 •|- For unknown reasons the hajinin test with faeces does not always succeed. 
 
EXAMINATION OF THE FiECES lOY 
 
 the yellow, a third between the yellow and the green, and a fourth 
 between the green and the blae. That in the red is by far the 
 darkest and most clearly defined. 
 
 In most cases the demonstration of blood in the faeces is easj', 
 but the determination of its origin is more difiicult. In the first 
 place, we must remember that blood may be pliysiologically intro- 
 duced into the fteces through raw meat and some varieties of sausages. 
 If these can be excluded a large amount of blood in the faeces is 
 always a pathological condition. The causes are so numerous and 
 varied that only through general and local examinations can the 
 source be determined. The diseases of the intestines which fre- 
 quently or occasionally cause haemorrhages include ulcers, neo- 
 plasms, haemorrhoids, amyloid disease, intussusception, stenosis, 
 ileus, anchylostomum, bothriocephalus, trichocephalus disjDar, etc. 
 
 6. Demonsteation of Biliary Mattee in the F^ces (Bile 
 Pigments, Biliaet Acids) 
 
 As previously mentioned, the brown colour of normal stools is 
 due to colouring substances formed through reduction of the bili- 
 rubin or of the biliverdin of the bile. In adults, unaltered bile 
 pigment (bilirubin, biliverdin) appears under pathological conditions 
 only. Hence the demonstration of normal as well as of abnormal 
 faecal colouring matter may have some diagnostic value. 
 
 {a) Demonstration of Bile Pigments in Toto {Hujpjperfs Test) 
 
 Thio fluid feces (or artificiallj' thinned fseees) are placed in a flask, an equal 
 volume of milk of lime is added, and after repeated shaking the mixture is 
 poured upon a small filter; the precipitate which remains upon the filter con- 
 sists of hydrobilirubin lime. This should be washed, and, w^hile still moist, 
 placed into a boiling flask with a very long neck, together with 20 cubic 
 centimetres of alcohol to which sulphuric acid has been previously added to 
 distinct acid reaction. The mixture is heated to boiling; in the presence of 
 biliary colouring matter the fluid will acquire an emerald green or a bluish 
 green colour. Positive reaction with Huppert's test simply indicates the pres- 
 ence of bile pigment in the faeces, but tells nothing of its nature. 
 
 (jb) Test for Tfrobilin 
 
 1. Mehu's test. The f«ces are extracted with water and sulphuric acid 
 in proportion to 2 grams to the litre and ammonium sulphate in substance 
 are added to the watery extract. The resulting precipitate is separated by 
 filtration, washed with a warm saturated solution of ammonium sulphate, 
 dried over a water bath, and then extracted with hot ammoniated alcohol. 
 Spectroscopic examination of this extract shows an absorption band between B 
 
108 DISEASES OF THE INTESTINES 
 
 and F. The precipitate may be otherwise treated ; it may be dissolved with 
 ammoniated water and a 10-per-cent solution of chlorid of zinc added. In the 
 presence of urobilin the fluid will show a very pretty fluorescence. 
 
 3. A. Schmidt's test.^' With a glass rod a fragment of f«ces about the 
 size of a bean is rubbed up in a beaker or porcelain dish with a concentrated 
 watery sublimate solution. If urobilin be present the mixture immediately, 
 or after a short time, acquires a rose colour ; or if biliverdin be present, a green 
 colour. According to the experiments of Dr. Hari in my laboratory, the 
 reaction can be more quickly obtained by shaking the faeces with concentrated 
 sublimate solution, filtering, and then adding chloroform to the filtrate. In 
 the presence of urobilin a very pretty rose colour appears at the point of contact 
 of the two fluids. 
 
 3. Fleischer's method.'"' If a small quantity of faeces be placed in a 
 small flask or a test tube and alcohol (to which hydrochloric, sulphuric, or 
 acetic acid has previously been added) be poured over it and the whole allowed 
 to stand a short time, it will be coloured yellowish or brownish, according to 
 the proportion of urobilin contained. If the alcohol be then poured off and a 
 few drops of caustic soda or ammonia solution added, and then chlorid of zinc 
 solution, a green fluorescence with direct light and a rose-coloured or yellowish 
 with transmitted light will be obtained. The degree of colour reaction is 
 proportionate to the amount of urobilin present in the stools. If ammonia 
 solution be added to a watery extract of the faeces, and, after filtration, chlorid 
 of zinc solution, we will obtain a beautiful rose red or a dark red precipitate 
 in the presence of urobilin ; in the absence of urobilin, however, this precipi- 
 tate will remain uncoloured. If this precipitate is brought upon a filter and 
 washed with ammoniated alcohol, we will obtain a more or less marked green- 
 ish fluorescence. 
 
 (c) Determination of Unreduced Bile Pigments {Bilirubin, 
 Biliverdin), Gmelhi's Test 
 
 If nitroso-nitric acid be added to the faeces, the characteristic 
 colours — red, violet, and green — will appear (in most cases only a 
 green colour is seen). In like manner, after filtration of the faeces, 
 we can obtain this test with the dried filter paper. In order to 
 demonstrate bile pigment micro-chemically, a drop of the same acid 
 is added to a small particle of faeces placed upon a glass slide. The 
 reaction can be obtained either with the entire faeces or else with 
 some of the ingredients — viz., mucus, epithelium, muscle fibres, etc. 
 
 {d) Determination of Bile Acids 
 
 A small quantity of the faeces is extracted with alcohol, the 
 latter evaporated, and the residue dissolved in a very weak watery 
 solution of soda. Upon addition of cane sugar and a few drops 
 of sulphuric acid the characteristic red and purple colours of the 
 bile acids appear (Pettenkojffer's test). Since the greater portion of 
 
EXAMINATION OF THE F^CES 109 
 
 bile acids normally disappear by absorption, their presence in the 
 dejections is always pathological. 
 
 The diagnostic significance of the tests for biliary pigment in the 
 fseces hes mainly in the fact that their presence proves a completely 
 unobstructed flow of bile into the intestines, while their absence 
 speaks for an obstruction to the flow of bile. According to Noth- 
 nagel,^ normal biliary pigment can be demonstrated only in thin, 
 pasty, and fluid evacuations by Gmelin's test. If in such evacua- 
 tions distinct reaction for bihary pigments is obtained, and the 
 biliary pigment clings to the mucus or to the cylindrical epithelium, 
 it points to catarrh of the small and of the large intestines. With a 
 well-marked reaction we are justified in assuming that catarrh of 
 the upper part of the small intestine is also present. 
 
 7. Absence of Bile Pigment (Acholia) and Colourless Stools 
 
 Whenever there is an obstruction to the flow of bile, colourless, 
 clay -coloured stools result; also absolutely colourless stools may 
 occur when there is no obstruction in the biliary passages. In 
 obstruction to the flow of bile lack of colour is, on the one hand, 
 due to an absence of bile pigments, and on the other to the pres- 
 ence of abnormal amounts of fat and fatty acid in the stools. 
 
 Bunge " has pointed out that the clay colour is due not to the absence of 
 bile pigment but to the presence of large amounts of fat. If we extracted such 
 acholic stools repeatedly with ether, they would assume a brownish colour, 
 which, according to Bunge, results from the presence of hsematin and sulphate 
 of iron. Guided by this, Fleischer'''* examined for and actually found ha^ma- 
 tin in the three acholic stools; in a fourth he did not succeed. In all four 
 stools urobilin was entirely absent. From these investigations Fleischer 
 hopes for a better understanding of the causes and the nature of acholia in 
 the faeces. 
 
 Acholic stools occurring simultaneously with icterus point to an 
 affection of the liver, the nature of which can only be determined 
 by a closer examination. 
 
 8. Determination of Aromatic Substances in the F^ces 
 (Phenol, Indol, and Skatol) 
 
 These aromatic bodies occur normally as well as pathologically. 
 
 (a) Phenol. — To demonstrate the presence of phenol a portion 
 of fseces must be distilled, and the distillate made alkaline with 
 caustic potash and again distilled. The phenol then remains, and 
 is purified by distillation with sulphuric acid. By the addition of 
 
110 DISEASES OP THE INTESTINES 
 
 bromin water it can be demonstrated in the distillate as tribromo- 
 phenol. Upon beating the distillate with Millon's reagent a red 
 colour is obtained. A violet colour is obtained bj the addition of 
 chlorid of iron. 
 
 {h) Indol and SJcatol (Brieger). — To separate these bodies from 
 phenol, the distillate of the faeces, after being made alkaline, is again 
 distilled. Indol and skatol then pass over Avith the vapour of water. 
 Indol forms colourless scales, and is soluble in hot water and in 
 alcohol. Skatol also forms colourless scales, but is soluble with 
 much more difficulty in water, and has a disagreeable penetrating 
 odour. Unlike indol, it is not decomposed by caustics. With nitroso- 
 nitric acid indol gives a distinct red colour ; when more concentrated 
 a red precipitate may result. Pine shavings moistened with muri- 
 atic acid are coloured red in a short time by an alcoholic solution 
 of indol. Skatol gives neither the first nor the second test. At 
 present these substances have no diagnostic significance, but a 
 suitable method for their quantitative determination would very 
 probably enable us to recognise different degrees of putrefaction 
 within the intestines. 
 
 9. Detkeminatios' of Fekments in the F^ces 
 
 For the purpose of demonstration, the ferments may be extracted 
 with glycerin, and the glycerin extract used ; or, what is simpler, 
 the fgeces may be stirred with thymol or chloroform water, then fil- 
 tered, and the tests made with the filtrate. For f^ces, Leo^^ also 
 recommends the use of blood fibrin, which has the property of 
 absorbing ferments (discovered by Wittich). For this purpose faeces 
 are mixed with chloroform water until they form a thin, pasty mass. 
 In this mixture we suspend 2 to 5 grams of finely divided, pre- 
 viously boiled blood fibrin, which is inclosed in a gauze bag tied 
 with a thread. After twenty -four hours the gauze bag is taken out 
 of the faeces, the fibrin washed a number of times with water, and 
 then tested for the various ferments. To test for diastase, a small 
 piece of fibrin is placed with some thin starch paste in an incubator, 
 and after a while is tested with diluted Lugol's solution for the pres- 
 ence of sugar or the disappearance of starch. 
 
 To test for trypsin, a few pieces of fibrin in a 1-per-cent solution 
 of soda are placed for a while in the incubator, and then tested for 
 albumoses with caustic potash and very dilute sulphate of cop- 
 per solution. If albumoses are present a pretty rose-red [or onion- 
 red] colour is produced (biuret reaction). Yon Jaksch^^ and Leo^^ 
 
EXAMINATION OP THE FiECES HI 
 
 have demonstrated the presence of ferments in the dejections ; 
 diastase and invertin were found in children by von Jaksch, in adults 
 by Leo. In normal and in many pathological conditions Leo was 
 unable to find tryptic ferments, but he did, however, find them in 
 many cases of diarrhoea. In a case of jejunal diarrhcea I found 
 both amylolytic and tryptic ferments. 
 
 10. Deteemination of Biliaky Geavel and Gall Stones in 
 
 THE F^CES 
 
 As is well known, biliary gravel and gall stones very often appear 
 in the stools after attacks of cholelithiasis. They are very readily 
 recognised in some cases, particularly where the stones are of large 
 size, or are j)assed in large numbers. On the other hand, the macro- 
 scopical recognition of biliary gravel is more difiicult. Cholesterin 
 is the principal ingredient of these concrements. In addition, they 
 contain bile pigment combined with calcium (bilirubin-calcium), and 
 bile acids combined with calcium, calcium soaps, and the carbonate 
 of calcium. Appearance, colour, consistency, and size of the stones 
 vary according to the proportion of the different ingredients. We 
 differentiate especially between Cholesterin stones which are hard 
 and concentrically formed, and dark pigment stones which are not 
 concentric, and are soft, small, and composed principally of bilirubin 
 calcium. 
 
 Chemical Examination.- — This includes principally the demon- 
 stration of Cholesterin and biliary pigments. The concrements 
 are pulverized in a mortar, and in order to remove all biliary 
 components are boiled in water. After drying, the residue is 
 extracted with a mixture of equal parts of alcohol and ether. This 
 extract is then poured off, evaporated over a water bath, and under 
 the microscope shows Cholesterin in large rhombic plates with step- 
 like notches. Chemically, Cholesterin can be demonstrated by dis- 
 solving a portion of the residue in chloroform and adding an equal 
 amount of concentrated sulphuric acid. The chloroform solution 
 then shows the following play of colours : blood-red, purple-red, 
 and after longer exposure to the air, blue, green, and finally yellow. 
 The micro-chemical demonstration of Cholesterin is still easier. If 
 to the crystalline mass on a glass slide concentrated sulphuric acid 
 be added, the edges of the crystals will assume a carmin colour, 
 which upon the addition of Lugol's solution changes to violet. 
 
 To demonstrate gall-stone fragments we add dilute sulphuric 
 acid to the residue left after boiling with water [vide above). The 
 
11^ DISBASES OF THE INTESTINES 
 
 formation of gas shows tlie presence of a carbonated salt. The 
 mixture is heated, and after cooling is extracted with chloroform. 
 With this chloroform extract Gmelin's test (see page 108) is to be 
 made. 
 
 For further tests for the various ingredients of bile concrements, 
 the reader is referred to text-books on physiological chemistry. 
 
 11. Panceeatic Stones 
 
 Pancreatic calculi are very rarely passed in the stools. These 
 stones have a rough surface, are friable, and can be broken off in 
 facets. They are readily soluble in chloroform, and, according to 
 Minich,^" when heated evolve an aromatic odour. In one of Leicht- 
 enstern's^^ cases chemical examination showed only carbonate and 
 phosphate of calcium, but no bile pigment or Cholesterin. The 
 finding of pancreatic stones is of considerable diagnostic interest,, 
 for it proves conclusively the existence of a calculus. Unfortun- 
 ately, owing to their great friability we rarely find these stones. 
 We would, however, recommend that the dejections be examined in 
 cases of cholelithiasis without icterus, and particularly in cases of the 
 so-called "neuralgia of the hver." 
 
 12. FiECAL Stones (Copkoliths) and Intestinal Stones 
 
 (Enteroliths) 
 Fsecal stones or coproliths are formed from inspissated masses 
 of faeces and may acquire a size and firmness sufficient to cause 
 obstruction of the intestine. They develop in portions of the 
 large intestine in which the outward pro]3ulsion of the contents is 
 attended with difficulty — i. e., at the flexures and in the ampulla 
 of the rectum. As is well known, the vermiform appendix is a 
 special point of predilection for fgecal stones (see chapter on Ap- 
 pendicitis, in Part II). Keal enteroliths, on the other hand, are 
 much smaller bodies, and only very seldom give rise to intestinal 
 obstruction. According to Leichten stern's investigations, we may dis- 
 tinguish three forms of enteroliths, viz. : 1. Heavy, brown, con- 
 centric concrements of stony consistency, composed mainly of phos- 
 phates of calcium and magnesium, and containing some foreign body 
 in their interior (e. g., pieces of bone, hairs, fruit seeds, ascarides, 
 ova, etc.). 2. Stones, light in weight, composed of a fungoid mass 
 of undigested vegetable matter. They occur in poor people who 
 eat much oatmeal (oat stones). 3, Stones resulting from long-con- 
 tinued use of certain drugs (calcium carbonate, magnesia, sodium 
 
EXAMINATION OP THE FiECES 113 
 
 "bicarbonate, salol, alcoholic solutions of shellac, etc.). This variety 
 
 may acquire a considerable size. For the chemical character of 
 
 these stones the reader is referred to text-books on physiological 
 and pathological chemistry. 
 
 13. Determination of Inoeganic Substances in the F^ces 
 
 The faeces contain inorganic salts in amounts varying from 1 to 
 8 per cent. These consist principally of earthy phosphates ; in 
 addition, there are also small amounts of iron, silicic acid, sodium 
 chlorid, sodium sulphate, etc. Of the soluble inorganic substances, 
 sodium chlorid, at all events, possesses practical interest. To dem- 
 onstrate its presence, the faeces should be mixed with water and 
 a,llowed to stand a few hours and then filtered. The filtrate is 
 acidulated with nitric acid, and if a cloudiness results should be again 
 filtered. Thereupon a few drops of silver nitrate are added and a 
 white precipitate forms (silver chlorid). For the quantitative de- 
 termination of sodium chlorid, see the text-book of Hoppe-Seyler 
 and Thierfelder.^'^ 
 
 3. The Microscopical Examination 
 
 Teehnic. — Thin, pasty, or fluid faeces may be examined with- 
 out special preparation.* For the better examination of the insol- 
 uble portions, fluid faeces may be poured into a conicall_y shaped 
 glass, or, still better, centrifuged (Herz^^). In the case of firm 
 stools, a small particle is taken and mixed with physiological salt 
 solution. For very exact examinations it is best to take only par- 
 ticles the size of a pin's head. The ingredients to be microscop- 
 ically examined for are : 
 
 1. Food remnants. 
 
 2. Elements derived from the intestines. 
 
 3. Micro-organisms. 
 
 4. Crystalline bodies. 
 
 1. The following food remnants are met with normally or 
 pathologically : 
 
 {a) Muscle Fibres. — These occur not only in excessive meat 
 diet, but also in mixed diet. They may have well-preserved striae, 
 or more frequently they are seen as prismatic bodies with indis- 
 tinct or obliterated striae. JSTothnagel,^^ however, states that with 
 
 * The addition of 1- or 2-per-cent formalin solution effectively deodorizes faeces. 
 
114 DISBASES OF THE INTESTINES 
 
 the very high power even in these cases he could observe trans- 
 verse striations. Occasionally the muscle fragments can be readily 
 recognised raacroscopically, or even singled out as brown spots. 
 Under most diverse conditions muscle fibres are found in increased 
 
 ? / 
 
 f 
 
 *w 
 
 Fig. 13. — Diffekent Vegetable Substances found in F^ces. 
 (Original observation.) 
 
 numbers ; in diabetics, who, as is well known, eat very much meat, 
 in persons sufiiering from fever, particularly when there is increased 
 peristalsis (e. g., typhoid) — in fact, in any condition in which there 
 is a marked increase in the peristalsis of the small and large 
 intestines. In general the appearance even of large numbers of 
 muscle fibres in the fseces has no diagnostic significance. Only 
 their constant increase has any definite value. In the following 
 sentence E'othnagel very carefully formulates this law: "Only 
 where, in the absence of fever and in the presence of definite symp- 
 toms of catarrh (mucus, etc.), we find an abnormally large amount 
 of muscle fibre in the fgeces, is it permissible to conclude that 
 catarrh of the small intestines is very probably also present." 
 
 I fully agree with this statement, and would complete it by 
 remarking that the macroscopical rather than the microscopical 
 examination is decisive. Should we constantly observe undigested 
 masses of meat, together with large quantities of mucus in the 
 faeces of patients under moderate meat diet and with well-preserved 
 teeth, the diagnosis, catarrh of the small intestines, is almost cer- 
 tain. The reverse of this statement is not true. Although it is true 
 that in pancreatic disease large quantities of muscle fibres fre- 
 quently appear in the stools, we may to-day regard as entirely 
 
EXAMINATION OF THE F^CES 115 
 
 disproved the opinion defended by Friedreich ^^ a number of 
 years ago, viz., that abundance of muscle fibres in the faeces indi- 
 cates pancreatic disease. 
 
 (h) Starch. — formally, and also in disease, starch is so com- 
 pletely digested that the appearance in the faeces of numerous 
 vegetable remnants, and especially of well-preserved, concentrically 
 arranged starch granules, is of pathological significance. According 
 to my investigations, the following differences have been noted : 
 Upon the addition of iodin to the faeces, in many cases a blue col- 
 our is obtained, while in others again a more violet or even a rose 
 colour appears. Without doubt the first colour (blue) is indicative 
 of a more serious interference with starch digestion. Besides iso- 
 lated starch granules we may also find vegetable remnants that con- 
 tain starch, and which appear either as threads, particularly spirals, 
 or as large, square, meshlike bodies (Fig. 13) frequently contain- 
 ing chlorophyl, or, finally, as large striated globules similar to those 
 
 Fig. 14. — Fatty Stools, showing a Large Amount of Fatty Acid Crystals. 
 (Original observation.) 
 
 that I have described and pictured in the stomach contents.^"^ It 
 is very remarkable that starches, unlike muscle fibres and fats, are 
 never stained by bile pigment. 
 
 (c) J^ats. — Fat appears either in the form of drops or of col- 
 ourless, occasionally yellowish, clumps. Fat crystals consist either 
 
116 
 
 DISEASES OF THE INTESTINES 
 
 of fatty acids or of fatty soaps. Fatty acids (Fig. 14) are short, 
 delicate, partly curved needles, whereas the soaps (Fig. 15) are 
 formed as long needles arranged in clusters or fan-shaped. When 
 heated oyer a flame the fatty acids dissolve, but the soaps remain 
 unchanged. Fatty acids are soluble in ether ; soaps are only soluble 
 in ether after previous sphtting up by acids. These characteristics 
 enable us in every case to determine the nature of fatty crystals. 
 
 Rieder^ has recently recommended a new colour reagent for 
 fats, suitable for clinical purposes. It is known as Sudan III, and 
 
 Fig. 15. — Fatty Soaps in F^ces. 
 
 Taken from a case of chronic catarrh of the small and large intestines. 
 
 (Original observation.) 
 
 is a diazo-colouring substance with the formula C22II10N4O. It is 
 employed in concentrated alcoholic solution, filtered just before 
 using. In fatty stools the fat drops are stained from an orange to a 
 blood-red colour, while fatty acid needles and calcium and mag- 
 nesium soaps remain uncoloured. 
 
 {d) Coagulated Alhuinen. — In diarrhoeal stools, especially after 
 excessive dieting with milk, we may, according to ITothnagel, see 
 lumps of casein varying in size from half a lentil to a pea, and fre- 
 quently stained externally with bile, while internally they are as 
 
EXAMINATION OF THE P^CES 117 
 
 white as milk. In like manner, after eggs have been partaken of 
 in large quantities, small fragments of them may be observed in 
 the dejections. 
 
 2. The substances derived from the intestines themselves in- 
 clude red and white blood cells (pus cells), epithelium, mucus, and 
 tumour fragments. 
 
 {a) Blood and P%is Cells. — Regarding the red blood cells I 
 would refer the reader to what has been already said on page 106. 
 Although exceedingly rare, white blood cells do appear normally in 
 the stools ; they are more frequently met vtdth in pathological stools, 
 and are most frequent in catarrhs. Their appearance in great num- 
 bers indicates ulcerative processes within the intestinal canal. The 
 most important facts concerning this subject have already been 
 considered on pages 64 and 95. 
 
 (J) EpiiJielium. — This is usually of the cylindrical and but sel- 
 dom of the pavement variety. Yery rarely in diseases of the rec- 
 tum (rectal cancer, proctitis) we find pavement epithelium. It is, 
 however, of no symptomatic importance. Cylindrical epithelium 
 is more important. It may be unaltered, or more frequently can 
 assume the greatest alterations in form. The cells may or may 
 not retain their nucleus (degenerated epithelium). Microscopically 
 we may observe all possible changes from the normal appear- 
 ance of epithelium to that of degeneration. Minute fat globules 
 are also frequently seen in the epithelial cells. A. Schmidt ^^ has 
 indisputably proved that mucous shreds, too, may contain a consider- 
 able amount of fat. Fig. 16 explains all this much better than any 
 description could. Epithelial cells are best studied in fresh mucus, 
 such as is obtained in test lavage. In a few instances I have also 
 noticed goblet cells, occasionally with intact basement membrane. 
 Large quantities of cylindrical epithelium with mucus usually indi- 
 cates a desquamative catarrh, whose location must be determined by 
 other symptoms and signs, some of which have already been men- 
 tioned. In addition to these formed structures in normal and 
 pathological fseces, we may also find large and small bodies that can 
 be diiferentiated with difiScnlty and that are extremely resistant to 
 reagents. This detritus is derived in part from the food as Avell as 
 from the secretions and excretions of the intestines. 
 
 (ö) Miicin. — Mucin is mainly characterized by its striated base- 
 ment substance, in which epithelial cells are embedded in varying 
 numbers. In some cases the cells predominate to such an extent 
 that the striated structure of the macin becomes indistinct or is 
 
118 
 
 DISEASES OF THE INTESTINES 
 
 apparently absent. Still, in some portions of the specimen it will 
 always be recognisable by its lay er like appearance. In doubtful 
 cases its presence can be determined by the Hoyer-Elirlich thionin 
 colour test. Mucus is here coloured a reddish violet, and all other 
 proteid bodies blue. According to Sven Akerlund,^^ eosin, safranin, 
 methylene blue, and hsematoxylin also colour mucus very satis- 
 factorily, but not so as to admit of any differentiation from other 
 proteid bodies. We have already discussed the significance of 
 mucus in the faeces (page 95). We would, however, repeat that 
 
 Fig. 16.- 
 
 -Normal and Degenebated Epithelial Cells from the Mucous Shreds of a. 
 Case of Membranous Enteritis. (Original observation.) 
 
 pure, macroscopically visible mucus, such as is obtained in intes- 
 tinal lavage, can only come from the large intestines. 
 
 3. Micro-organisms. — The faeces contain a greater number of 
 micro-organisms than any other excretion of the body. They cer- 
 tainly play a great physiological and pathological role. jS^otwith- 
 standing that the important investigations of ]N"encki,- Macfadyen, 
 and Sieber,^^ as well as of Thierfelder and N^uttal,^ have shown that 
 normal digestion is possible without the aid of bacteria, we can not 
 deny them some significance. Their activity need not be limited to 
 action upon digestive matter, })ut may also include reciprocal action 
 on other pathogenic organisms. As usual in bacteriology, we here 
 distinguish moulds, yeasts, and schizomycetes (bacteria). 
 
EXAMINATION OP THE F^CES 119 
 
 (a) I have but once observed mould fungi in faeces (aspergillus 
 filaments). The oidinm albicans has occasionally been observed in 
 the stools of children. 
 
 (b) SaccharoTYiyces. — Of these the yeast is the most important. 
 It is a frequent constituent of normal and quite commonly of patho- 
 logical stools. It appears either as single cells or in pearly chains. 
 It frequently shows budding. Usually the cells are oval, more 
 rarely they are round. We find them both in firm and in diarrhoeal 
 evacuations, although they are more common in the latter variety. 
 The reaction of the fseces seems to have no influence upon their 
 growth, for I have met with them in alkaline as well as in acid 
 stools. With Lugol's solution they are stained a yellowish or 
 mahogany brown. Yon Jaksch quite correctly calls attention to the 
 occurrence in the faeces of bodies very similar to yeast cells, but I 
 have noticed that they are for the most part smaller than yeast 
 cells and have no double contour and do not bud. Furthermore, 
 they differ from yeast cells in giving the same reaction as starch 
 with Lugol's solution. They should very probably be classed with 
 the Clostridien (page 121). 
 
 (c) Sarcina (Groodsir) (Fig. 17). — Strange to say, the occurrence 
 of genuine, fully developed sarcinse in the faeces appears to be but 
 very little known. They are not infrequently found in the stools 
 of patients suffering from gastrectasia. Several times I have thus 
 had my attention directed to an existing gastrectasia with masked 
 symptoms. In one case, however, in which I found them in the 
 evacuations there was no gastrectasia present. Usually the evacua- 
 tions in which sarcinse appeared in very large numbers were of a 
 diarrhoeal nature, and the question therefore suggests itself whether 
 or not the migration of sarcinae en masse into the intestinal canal 
 can not give rise to fermentative processes in the latter. As already 
 remarked, sarcina intestini in no wise differs from the sarcina ventri- 
 cuh. As in the latter we also find, in addition to well-formed, brown- 
 ish yellow or lighter coloured bundles, those small coccous forms 
 whose constriction is indicated only by a loose cementing mem- 
 brane. Like the sarcina ventriculi, the sarcina intestini also shows 
 a distinct cellulose reaction with iodin and chlorid of zinc solution. 
 
 {d) Bacteria. — Undoubtedly bacteria form the gi-eater percent- 
 age of the micro-organisms occurring in the intestines, or rather in 
 the fgeces. They consist both of micrococci and bacilli. Accord- 
 ing to von Jaksch, thin stools as a rule contain more bacilli and firm 
 ones more micrococci. Some of these organisms are motile. 
 
120 
 
 DISEASES OP THE INTESTINES 
 
 1. Bj far the most numerous are those bacilli first described by 
 Escherich as belonging to the group of bacterium coli. They are 
 quite thick, short rods, in part motile and partly, immobile; in 
 appearance and growth upon most nutritive media they very much 
 resemble the typhoid bacilli. Unlike the typhoid baciUi, they do 
 not curdle sterile milk and develop gases (CO2 and II) in nutritive 
 media containing sugar. Their size varies widely, ranging between 
 0.5 and 3yLt. 
 
 Careful study of this variety of bacteria has shown that they 
 are really made up of several groups resembling one another, and 
 
 Fig. 17. — Fj:ces from a Case or Chronic Enteritis, showing Sarcin.e. 
 A, starch granule ; K, fractured triple phosphate crystal ; M, muscle übres ; E^ epithelial 
 cells ; B, goblet cells; P. vegetable cells and fibres. (Original observation.) 
 
 which, as it appears, can merge from one into the other, thus per- 
 mitting the formation of pathogenic organisms from innocent sap- 
 rophytes. Thus a large number of diseases have already been 
 observed in which it is suspected that the bacteriuni coli plays 
 an important role — e. g., cholecystitis and cholangitis, appendicitis, 
 acute dysentery, peritonitis, etc. 
 
 The addition of one per cent of iodid of potash to the culture 
 media, as advocated several years ago by Elsner,^^ but more particu- 
 larly the well-known Widal's test,**' enables us to distinguish typhoid 
 bacilli from the colon and other bacilli. 
 
EXAMINATION OP THE P^CES 121 
 
 2. Bacillus Siibtilis (Hay Bacillus). — This bacillus, first observed 
 in the faeces by N'othnagel, is very often met with under normal 
 as well as pathological conditions. It forms either long, motile fil- 
 aments with spores, or isolated bacilli with spores, or, finally, groups 
 of spores. It is readily recognised by its thick contours as well as 
 by its strongly refractive spores. It stains yellow or yellowish 
 brown with Lugol's solution. It has no special significance. 
 
 3. Bacterium, Lactis JErogenes. — These are thick, short rods, 
 1-2/A in length and 0.5/a in width. They are immotile. They are 
 characterized by their property of causing milk to curdle and to 
 ferment with the formation of gas within sixty hours. On potatoes, 
 also, the bacterium lactis forms gases. Besides milk sugar, they 
 also cause cane sugar to ferment. It is possible that owing to its 
 active gas-forming properties the bacterium lactis plays an impor- 
 tant part in the etiology of meteorism ; but of this we know noth- 
 ing certain. 
 
 4. Bacillus Putrificus Coli (Bienstock). — These are slender 
 rods about 3/* in length, which frequently form long threads. The 
 spores are marginal, and develop at one or both ends ; if at one end 
 only, they give the bacillus a drumstick appearance. The bacil- 
 lus, especially in the presence of air, causes a rapid decomposition 
 of albumin with the formation of ammonia, amin bases, amido- 
 fatty acids, tyrosin, phenol, indol, etc. I have very often observed 
 the bacillus in stomach contents as well as in fseces, but, unlike 
 Bienstock, would not consider it as a regular parasite of the faeces. 
 
 5. Organis7ns that Stain Blue with lodin. — Nothnagel has ob- 
 served a number of micro-organisms which stain blue with iodin, 
 and he regards one variety as identical with the Clostridium huty- 
 ricum of Prazmowski. The bacillus butyricus (Fig. 18) forms rods 
 from 3/i to 10/x in length and Ifx in width, and frequently occurs in 
 chains. It is sometimes said to form long filaments which are quies- 
 cent sometimes, at other times mobile. Usually the bacillus butyricus 
 is lemon- or lozenge-shaped and forms large clusters. It gives a very 
 pronounced iodin reaction. The bacillus is anaerobic. It causes 
 an active fermentation of starches, dextrin, sugar, lactates, and cel- 
 lulose. The bacillus butyricus is very probably the chief agent in 
 the formation of butyric acid and of gases in the intestines. Ac- 
 cording to von Jaksch, with whom I fully agree, the bacillus buty- 
 ricus is found in especially large numbers in pathological conditions 
 of the intestines. In almost every normal stool we find it in 
 smaller numbers. It does not have any pathological significance. 
 
122 DISEASES OF THE INTESTINES 
 
 The pathogenic organisms occurring in the faeces include the 
 cholera, typhoid, and tubercle bacilli. Since a work like the pres- 
 ent one can not include a discussion of the acute infectious diseases, 
 the tubercle hacillus is the onlj one we shall speak about. 
 
 Fig. 18.— Bacillus bütyricus {Clostridium hutyricum) stained with Iodin. 
 (Original observation.) 
 
 Assuming its morphology to be well known, we would simply 
 say regarding its demonstration, that the technic differs in no 
 manner from that of sputum examinations, and it is entirely super- 
 fluous to enter here into the details of that procedure. As to the 
 diagnostic significance of tubercle bacilli in the fseces, it may be 
 summed up as follows : It is conclusive of a tubercular process in 
 the intestines when we know positively that the material examined 
 comes directly from the intestines — as, for example, in tubercular 
 rectal ulceration. Otherwise the question of intestinal tuberculo- 
 sis must remain in doubt. 
 
 The diagnosis, intestinal tuberculosis, can, however, be made 
 with certainty where there is an entire absence of sputum, and 
 tubercle bacilli constantly appear in stools that are of a thin, bloody, 
 or purulent character. 
 
 Cocci are also found in the fseces, though not as frequently as 
 bacilli. Since they are of much less practical importance, we shall 
 
EXAMINATION OF THE F^CES 
 
 123 
 
 refrain from their discussion, referring the reader to Mannaberg's 
 able description in Nothnagel's work on Intestinal Diseases. 
 
 6. Crystalline Bodies. — These may be organic or inorganic, and 
 are seen very often in the faeces. With the exception of the biharj 
 concrements previously mentioned (see page 111), the diagnostic 
 importance of crystalline bodies is very slight. Since they may 
 be mistaken for other similar substances it is necessary to be able 
 to recognise them. The follovring are the principal crystalline 
 bodies which come into consideration : 
 
 io) HcBmatoidin Crystals. — Yon Jaksch has observed these in 
 long-continued catarrhs follovidng stasis, and also in many cases in 
 which intestinal hsemorrhages had but a short time previously 
 occurred. Usually hsematoidin shows an indistinct crystalline struc- 
 ture ; the crystals are in part free and in part embedded in a lustre- 
 less, mucoid mass. I have never been able to find the bodies men- 
 tioned by von Jaksch. ^° 
 
 (h) Cholesterin. — It is extremely rare to find Cholesterin pres- 
 ent as fully formed rhombic plates. This appKes as well to normal 
 as to pathological stools. Only once after the administration of 
 nutritive enemata have I seen them in large quantities. ]^othnagel 
 has seen them after nutritive rectal enemata of peptone, wine, and 
 eggs. This author quite correctly calls attention to the very decep- 
 tive similarity between fragments of triple phosphates and Choles- 
 terin scales. Indeed, the resemblance 
 is so close that I have frequently 
 only learned my error through ob- 
 taining a negative Cholesterin reac- 
 tion. Cholesterin also undoubtedly 
 appears in normal faeces in an amor- 
 phous form ; neither form has any 
 diagnostic significance. 
 
 (c) Charcot- Ley den Crystals (Fig. 
 19). — These are by no means ex- 
 tremely rare. They are identical 
 with the crystals found in asthmatic 
 sputum. In the same specimen they 
 may vary very much in size. Some- 
 times they can be distinctly seen only with the highest power lenses. 
 They are insoluble in alcohol, ether, and chloroform, but very 
 soluble in hydrochloric acid and alkaline solutions. This permits 
 of their ready distinction from fatty acid crystals. They stain with 
 
 Fig. 19. — Chaecot-Leyden Crystals 
 FROM F^CES. (Original observation.) 
 
^1^24 DISEASES OF THE INTESTINES 
 
 carmin, and can then be preserved for a long time. ISTothnagel ^ 
 has observed their aj^pearance under most varied conditions — viz., 
 reconvalescence from typhoid, typhoid at the height of the disease, 
 phthisis, in dysenteric disturbances of the large intestines, in a 
 rachitic child with fii'm stools, and in a child with profuse evacua- 
 tions resulting from chronic catarrh of the large and small intes- 
 tines. Perroncito*^ and Bäumler "^ first discovered the crystals in 
 persons suffering from anchylostomal disease. This was the status 
 of the question when Leichtenstern, in 1892, called attention to the 
 coincident occurrence of these crystals with various intestinal para- 
 sites (ascaris, anchylostomnm, trichocephalus, oxyuris, taenia, etc.), 
 and stated that entozoa, whatever be theh- nature, were the most 
 frequent cause of the formation of Charcot-Leyden crystals in the 
 intestines, and of their subsequent appearance in the fseces. From 
 this it follows, therefore, that the crystals possess great diagnostic 
 value ; if found in the fseces we may with the greatest probability, 
 perhaps certainty, conchide that tTie patient in question is suffering 
 from intestinal entozoa of some hind (Leichtenstern ^). 
 
 Conversely their absence does not in any manner exclude ento- 
 zoa. Leichtenstern based his views on the significance of the 
 coincidence of the Charcot-Leyden crystals and entozoa, especially 
 upon the fact that at autopsies he was always able to find them 
 in those portions of the intestines in which, from experience, we 
 know the parasites in question are usually found. In anchylos- 
 tomiasis, in particular, these crystals are found with such con- 
 stancy that he states ttiat they are distinctly pathognomonic of that 
 disease. Strange to say, little attention has been paid to this 
 important discovery of so great a clinician as Leichtenstern, who 
 has made excellent researches, esj^ecially regarding entozoa. The 
 question has only been discussed in Roesen's dissertation ^, where, 
 after an examination of seventeen cases of entozoa, an entirely 
 negative result was reached. My own experience in the matter 
 is too slight to demand recognition, but from the study of one case 
 I have gained the impression that the value ascribed to them by 
 Leichtenstern is correct. 
 
 The case in question was that of a gentleman thirty-six years old, who suf- 
 fered from chronic catarrh of the large intestines, and whose stools I used fre- 
 quently to examine very carefully. During one examination I found, in the 
 mucous portions of the stool, Charcot-Leyden crystals both of moderate and 
 very large size. Although not attaching much importance to my observation, 
 I took note of it, and upon repeated examinations the same condition was 
 observed. After three or four weeks the patient brought me taenia proglottids, 
 
EXAMINATION OF THE F^CES 
 
 125 
 
 whereupon a taenia mecliocanellata was readily removed. In spite of most 
 careful examination tapeworm eggs could never be found. 
 
 This case needs no further comment.* Leichtenstern's discovery 
 is certainly worthy of greater attention than it has heretofore 
 received. 
 
 {d) Fatty Acids and Fatty Soap Crystals. — We have ah-eady 
 touched upon the most important points in this connection (pages 
 115 and 116). We here wish to add that the opinion expressed 
 
 Fig. 20.^Yellow Calcium Salts feom F^ces. 
 In some the concentric arrangement of the layers is well seen. (Original observation.) 
 
 by Gerhardt ^^ a long time ago, that the crystalline bodies occurring 
 in acholic stools might be tyrosin crystals, has been wholly refuted 
 by the investigations of Oesterlein ^^, Stadelmann ^^, Fr. Müller ^^ 
 and von Jaksch '*'. 
 
 {e) Phosphate of Calcium.— This occurs in the faeces as neutral 
 phosphate of calcium and as yellow calcium salts. The former con- 
 sists of small or large wedge-shaped bodies, arranged for the most 
 
 * It struck me as strange that when entozoa eggs were present the crystals were 
 freqiiently missing. Besides numerous eases of taenia, ascaris, and oxyuris under 
 my own observation, I would also mention a case of trichocephalus dispar in which 
 Charcot-Leyden crystals were vainly looked for repeatedly by both my assistants 
 and myself. 
 
^26 DISEASES OP THE INTESTINES 
 
 part in groups with converging apices. This variety does not 
 absorb bile. Yellow calcium salts (Fig. 20) (whose acid has not yet 
 been determined) usually assume irregular, oval, or circular forms. 
 They are frequently fissured, and in some cases are arranged in con- 
 centric layers. The yellow colour comes from imbibition of bile, 
 JSTeither form has any diagnostic significance. 
 
 {f) Oxalate of Calcium. — This occurs in the well-known en- 
 velope form. The crystals may be small or large. They are 
 found especially in patients under largely vegetable diet. These 
 crystalline bodies are met with in normal as well as in pathological 
 stools. 
 
 {g) Ammonium-magnesium Phosphates (Triple Phosphates). — 
 These crystals are one of the most frequent crystalline elements of 
 
 normal or pathological stools, espe- 
 cially fluid stools. They appear 
 most frequently in the well-known 
 coffin - cover shape, more rarely 
 feather- shaped. The coffin-cover 
 fragments frequently show tears 
 and fractures (Fig. lY), and thus 
 may occasionally resemble Choles- 
 terin crystals. The solubility of the 
 triple -phosphate crystals in acetic 
 acid enables us to avoid error in 
 diagnosis. They have no diagnostic 
 
 Fig. 21. — Bismuth Crystals fkom VaiUe. 
 
 F^cEs. (Original observation.) (A) Sulphate of Calcium^. — The 
 
 appearance of sulphate of calcium 
 in the faeces is said to be extremely rare. I have never seen it in 
 the dejections themselves, but once by the addition of sulphuric 
 acid to faeces obtained some very pretty sulphate of calcium 
 needles in the sediment, which consisted principally of bilirubin- 
 calcium. 
 
 (^) Bismuth Crystals. — Yery soon after administration of bis- 
 muth, irregular shaped, rhombic, dark brown or black crystals are 
 excreted (Fig. 21). Until recently these have been" regarded as 
 sulphate of bismuth, but, as previously mentioned, Quincke showed 
 that they consist of bismuth oxydyl. 
 
EXAMINATION OP THE FAECES 127 
 
 LITERATURE 
 
 1. Fleischer. Lehrbuch d. inneren Medicin, Bd. ii, 2te Hälfte, S. 1139. 
 
 2. Quincke. Münchener med. Wochenschr., 1896, No. 36. 
 
 3. Quincke u. Roos. Berl. klin. Wochenschr., 1893, No. 45. 
 
 4. Boas. Deutsch, med. Wociienschr., 1896, No. 14. 
 
 5. Nothnagel. Beiträge zur Physiologie u. Pathologie des Darms, Berlin, 
 
 1884. 
 
 6. Ad. Schmidt. Zeitschr. f. klin. Medicin, 1897, Bd. xxxii, Heft 3 u. 4. 
 
 7. Pariser. Deutsch, med. Wochenschr., 1893, No. 41. 
 
 8. J. Kaufmann. New Yorker med. Wochenschr., November, 1895. 
 
 9. Blauberg. Experimentelle u. kritische Studien über Säuglings-fäces, u. s.w., 
 
 etc., Berlin, 1897, S. 37, u. f. 
 
 10. von Jaksch. Klinische Diagnostik, 4te Aufl., S. 277. 
 
 11. von Jaksch. Ibid., S. 278. 
 
 12. Hoppe-Seyler — Thierfelder. Handbuch d. physiolog. u. patholog. -chem- 
 
 ischen Analyse, 5te Aufl , S. 479. 
 
 13. Biedert. Jahrbuch für Kinderheilk., 1878, 1879, u. 1881. 
 
 14. Demme. 12ter Jahresbericht des Jenner'schen Kinderspitals in Bern, 
 
 1874. 
 
 15. Fr. Müller. Zeitschr. f. klin. Med., 1887, Bd. xii, S. 45-113. (Here will 
 
 also be found a resume of previous literature.) 
 
 16. Abelraann. Inaug.-Dissert., Dorpat, 1890. 
 
 17. Saudmeyer. Zeitschr. f. Biologie, 1895, Bd. xxxi, S. 12. 
 
 18. Teichmann. Inaug. Dissert., Breslau, 1891. 
 
 19. Bamberger. Die Krankheiten d. ChylojDöetischen Apparatus. Virchow's 
 
 Handbuch, Bd. vi. 
 
 20. Gerhardt. Zeitschr. f. klin. Med., Bd. vi, 1883. 
 
 21. Nothnagel, loc. cit., S. 127, and Die Erkrankungen d. Darmes u. Peri- 
 
 toneum, S. 17. 
 
 22. Berggrün u. Katz. Wiener klin. Wochenschr., 1891, S. 158. 
 
 23. Pel. Centralbl. f. klin. Med., 1887, S. 297. 
 
 24. H. Weber. Berl. klin. Wochenschr., 1893, No. 19. 
 
 25. A. Schmidt. Verhandlungen d. Congresses f. innere Medicin, 1895. 
 
 26. Fleischer. Lehrbuch der inneren Medicin. 2ter Th., 2te Hälfte, 1896, S. 
 
 1160. 
 
 27. Bunge. Lehrbuch d. physiolog. u. patholog. Chemie, Leipzig, 1887, 
 
 S. 192. 
 
 28. Leo. Diagnostik d. Krankheiten d. Bauchorgane, 1895, 2te Aufl., S. 348. 
 
 29. von Jaksch. Zeitschr. f. physich Chemie, Bd. xii, S. 116, u. Klinische 
 
 Diagnostik, 4te Aufl., S. 286. 
 
 30. Minich. Berl. klin. Wochenschr., 1894, No. 8. 
 
 31. Leichtenstern. Penzoldt-Stintzing Handbuch d. speciellen Therapie, Bd. 
 
 iv, Abth. vi, 15, S. 206. 
 33. Herz. Centralbl. f. klin. Medicin, 1892, p. 883. 
 33. Friedreich. Krankheiten des Pankreas in von Ziemssen's Handbuch d. 
 
 spec. Pathol, u. Therapie, Bd. viii. 
 
128 DISEASES OP THE INTESTINES 
 
 34. Boas. Diagnostik u. Therapie d. Magenkrankheiten, Bd. i, 4te Aufl., S. 
 
 281, Fig. 26. 
 
 35. Rieder. Deutsch. Arch. f. klin. Med., 1898, Bd. lix, H. 3 u. 4, S. 444. 
 
 36. Sven Akerlund. Arch. f. Verdauungskrankheiten, Bd. i, S. 396 u. f. 
 
 37. Nencki, Macfadyen u. Sieber. Arch. f. experiment. Pathologie u. Pharma- 
 
 cologic, Bd. xxviii, S. 311-350. 
 
 38. Thierfelder u. Nuttal. Zeitschr. f. physiol. Chemie, Bd. xxi, 1895, S. 
 
 109-129, and Bd. xxii, 1896, S. 62-73. 
 
 39. Eisner. Zeitschr. f. Hygiene, Bd. xxi, 8. 25, 1895. 
 
 40. Widal. Semaine medicale, 1896, No. 33. 
 
 41. Perroncito. Revista della Accademia di Torino, II Morgagni, 1881. Cen- 
 
 tralbl. f. d. medicin. Wissenschaften, 1881. 
 
 42. Bäumler. Correspondenzbl. f. Schweizer Aerzte, liter Jahrg., 1881, No. 1. 
 
 43. Leichtenstern. Deutsch, med. Wochenschr., 1892, No. 25. 
 
 44. L. Roesen. Inaug. -Dissert., Bonn, Crefeld, 1893. 
 
 45. Oesterlein. Mittheilungen a. d. med. Klinik in Würzburg, Bd. i, 1885. 
 
 46. Stadelmann. Deutsch. Arch. f. klin. Med., Bd. xl, S. 373, 1887. 
 
CHAPTEE Yl 
 
 THE DIAGNOSTIC VALUE OF THE EXAMINATION OF THE 
 STOMACH CONTENTS IN INTESTINAL DISEASES 
 
 In the diagnosis of difficult intestinal diseases an analysis of the 
 stomach contents is sometimes very important, or may even be 
 decisive. In the first place, it enables ns to exclude diseases of 
 the stomach itself. Thus, for example, if we find a poorly defined 
 tumour, from whose location alone it would be impossible to say 
 whether it belongs to the stomach, the intestines, or the omentum, 
 and where, in addition, there are general evidences of a serious dis- 
 eased condition, the finding of normal stomach contents would in all 
 probability speak against gastric cancer. On the other hand, abnor- 
 mal stomach contents does not signify absence of the disease of the 
 intestines. As an illustration of this by no means " rare complica- 
 tion," I may cite a very interesting case reported by Pulawski^ in 
 which the clinical picture was that of a dilatation of the stomach and 
 a tumour in the epigastrium, while the autopsy revealed a primary 
 cancer of the csecum. The gastric tumour felt was occasioned by 
 an aggregation of carcinomatous lymphatic glands which com- 
 pressed the pylorus and caused a stenosis. The mucous membrane 
 of the stomach was entirely normal. The reverse of this case is 
 more frequently met with — i. e., a gastric tumour becomes displaced 
 and simulates an intestinal neoplasm. Here, at times, examination 
 of the gastric contents may clear up the diagnosis. What has 
 always struck me as remarkable, and what also speaks for the diag- 
 nostic value of these examinations, is the fact that in cancer of the 
 intestines, excepting where the tumour is very near to the pylorus, 
 the gastric secretions may still be normal even in the most extreme 
 stage of cachexia. Examination of the stomach contents may also 
 give conclusive evidence for the diagnosis of a stenosis ielow the 
 duodenum. It can, however, only indicate the existence of a ste- 
 nosis, the nature of which must be determined by other means. In 
 these cases the stomach contents are always bile tinged, especially in 
 
 129 
 
130 DISEASES OF THE INTESTINES 
 
 the fasting state. I was the first to show that, besides bile, pan- 
 creatic, and very probably, too, intestinal secretion, pass into the 
 stomach. Hence we may sometimes observe the paradox, duodenal 
 digestion occurring within the stomach. This can happen only where 
 the gastric secretion, as is frequently the case, becomes weakened or 
 entirely suppressed through the action of the intestinal fluids, espe- 
 cially of the bile. As has already been shown on page 44, when the 
 gastric juice remains sufiiciently acid no variations from the nor- 
 mal occur. We may even find an alternating reaction of the gastric 
 contents, according as intestinal or gastric factors predominate. 
 Cohn, Kiegel, Hochhaus, Schule, Herz, and I, have published 
 examples of this last-named condition. 
 
 The presence of pancreatic juice in the stomach can be readily 
 demonstrated by its tryptic action. Its demonstration, I believe, 
 might be of importance in determining the etiology of a stenosis, 
 for with a palpable tumour in the region of the ascending portion 
 of the duodenum, the occurrence of pancreatic ferments in the 
 stomach contents would s-peak for, and the absence of such ferments 
 against, the existence of a pancreatic tumour ; still, I can not sup- 
 port this statement by actual cases.* 
 
 Besides the deeply situated duodenal stenoses, the much rarer 
 ones of the jejunum can, I think, also be diagnosed through exam- 
 ining the gastric contents. In these cases the latter no longer con- 
 tains pure bile, but a yellowish brown, slightly feculent material, 
 which has the appearance and composition of jejunal chyme. Care- 
 ful examinations of this, but more especially its constant appearance 
 in the stomach contents, should give us a clew to the existing con- 
 dition, particularly if we can exclude a fistula between the stomach 
 and the small or large intestines. We would add that, unlike 
 deeply seated duodenal stenoses, the suprapapillary variety can not 
 be diagnosticated by examinations of the stomach contents, for the 
 latter are exactly the same as in benign or malignant pyloric stenosis. 
 
 In some cases the determination of the acidity of the stomach 
 contents may be imjjortant for the diagnosis of an intestinal affec- 
 tion — e. g., in the differential diagnosis of ulcer of .the duodenum 
 and of the stomach. Leube^ states that he found normal acidity of 
 the stomach contents in a case of duodenal ulcer, while, from the 
 investigations of Jaworski and Riegel, we know that the acidity in 
 
 * It is well worth repeating, although obvious to one well acquainted with the 
 subject, that the finding of bile once, or even repeatedly, in the gastric contents pos- 
 sesses no diagnostic value. 
 
VALUE OF EXAMINATION OF THE STOMACH CONTENTS 131 
 
 gastric ulcer is very often increased. Too much value, however, 
 must not be attributed to this symptom. 
 
 Oppler^ has lately and quite correctly directed attention to the 
 total cessation of gastric secretion in chronic diarrhoeas, a condition 
 which has more of a practical than diagnostic value. As I can state 
 from repeated personal experience in these cases, we may meet with 
 severe forms of gastritis with entire absence of all the secretive 
 factors (hydrochloric acid, pepsin, and rennet). I have no doubt 
 that a distinct connection exists between the anacidity of the 
 stomach and the chronic diarrhoea and intestinal catarrhs. 
 
 The condition of the gastric contents indirectly aids us in under- 
 standing certain intestinal disturbances, among others the chronic 
 constipation that so often follows atony or ectasia of the stomach. 
 In like manner, in displacements of the stomach, particularly when 
 well marked, we can, as a rule, assume that a displacement of the 
 intestine, especially of the large intestine, exists. The methods by 
 which these intestinal displacements can be recognized have already 
 been described. 
 
 LITERATURE 
 
 1. Pulawski. Berl. klin. Wochenschr., 1892, No. 42. 
 
 2. von Leube. Specielle Diagnose innere Krankheiten, 1889, S. 274. 
 
 3. Oppler. Deutsch, med. Wochenschrift, 1896, No. 32. 
 
CHAPTER YII 
 
 THE DIAGNOSTIC VALUE OF URINARY EXAMINATIONS IN 
 INTESTINAL DISEASE 
 
 The examination of the urine is just as important in diseases of 
 the intestines as it is in almost all other internal and many external 
 diseases. It may in many cases substantiate and even clear up the 
 diao^nosis. Thus, to cite one instance, the discovery of an amyloid 
 kidney may serve as a useful argument for the existence of amyloid 
 disease of the intestines, a condition very difficult to diagnose. An 
 attempt to dwell on all existing relations between the intestines and 
 the urine would mean an account of almost the whole pathology of 
 the urine. In the following recapitulation we confine our remarks 
 solely to the clinical connection between intestinal diseases and cer- 
 tain abnormal substances found in the urine. These substances in- 
 clude : 
 
 1. The jrroditcts of intestinal putrefaGtion^ especially of albu- 
 minous putrefaction, the greater number of which, as we know, ap- 
 pear in the urine as aromatic combinations. These include indoxyl- 
 and skatoxyisulphuric acids, as well as the ethereal sulphuric acids 
 (skatoxyl, parakresol, and phenol ethereal sulphuric acids). 
 
 From the fundamental investigations of Jaffe \ E. Salkowski ^, 
 Baumann ^, Brieger'*, and Senator^, we know that the indoxyl- 
 sulphuric acid of the urine is regarded as a derivative of the indol 
 formed within the intestinal canal. In the intestines indol is 
 already oxidized to indoxyl, and the latter combines with the sul- 
 phuric acid, or with the sulphates derived from the food. Indoxyl- 
 sulphuric acid (indicanj appears in the urine in the form of the last- 
 mentioned combination. From this it follows that indican is an 
 entirely normal product of intestinal metabolism, and that only its 
 increase is to be considered as pathological. "Whereas the nor- 
 mal daily excretion of indican varies from 5 to 20 milligrammes 
 (Jaffe), in increased intestinal putrefaction it may reach 100 to 150 
 milligrammes. Fr. Müller^ and Ortweiler ''^ very correctly con- 
 133 
 
THE DIAGNOSTIC VALUE OF IJRINARY EXAMINATIONS 133 
 
 sider as necessary for increase in the urinary excretion of indican 
 a certain percentage of albumin within the intestines, marked 
 stagnation of the intestinal contents, and finally a certain absorptive 
 faculty on the part of the bowel. According to the animal experi- 
 ments of Jaffe (which have been fully verified in man), increased 
 excretion of indican occurs mainly in obstructions of the small, and 
 to a less extent of the large, intestines. Nevertheless, we may also 
 have an increased indican excretion in stenoses of the large intes- 
 tines associated with long-continued putrefaction of their contents. 
 Should suppuration coexist, the indicanuria will equal in amount 
 that of the small intestines. 
 
 As may be readily seen, increased indicanuria is largely depend- 
 ent upon intestinal peristalsis ; other things being equal, the slower 
 the peristalsis the greater will be the amount of indican in the urine, 
 and vice versa. The more putrefactive products carried off by the 
 intestines, the less will be brought to the kidneys. But this rule 
 holds good only in a general sense : for Jaffe, Vries, Ortweiler, 
 and von Pfungen (with whom ISTothnagel agrees) have shown that 
 there may be no indicanuria in obstinate constipation of the worst 
 type. The reason very probably is that, in consequence of increased 
 desiccation of the fseces, few putrefactive products are absorbed, 
 and the fseces therefore very rapidly undergo further decomposition. 
 
 The above considerations indicate that the presence of indican 
 in the urine is of decisive value only when taken in connection with 
 all other clinical symptoms. Indicanuria may be of importance in 
 the differential diagnosis between stenoses of the large and small 
 intestines, or between benign and malignant pyloric stenosis, etc. 
 The almost constant increase of indican in suppurative peritonitis 
 is also important. 
 
 Besides indigo blue there is a second urinary colouring sub- 
 stance, indigo red (" indigrubin," Kosin ^). Rosenbach's well-known 
 reaction depends upon its presence. As shown by control tests of 
 E. Salkowski ^, C. A. Ewald ^% Abraham ^\ Rumpel and Messter ^% 
 and others, Kosenbach's reaction, like a pronounced indigo-blue 
 reaction, indicates nothing more than an increase in the excretion 
 of indigo — i. e., albuminoid putrefaction. To a certain degree, the 
 ethereal sulphuric acids of the urine are indicative of putrefaction. 
 As with indoxyl, it has been shown that albuminoid putrefaction of 
 stagnating intestinal contents is also an important factor in the pro- 
 duction of the etherial sulphuric acids (E. Salkowski, C. A. Ewald, 
 Baumann, Käst and Baas). A second undoubted factor is disturb- 
 10 
 
l^^ DISEASES OF THE INTESTINES 
 
 ances in function, sucli as occur in ileus, incarceration of the small 
 intestines, lead colic, peritonitis, intestinal tuberculosis, and cholera. 
 Finally, Brieger's^^ investigations have shown that in such acute 
 infectious diseases as diphtheria, scarlet fever, and facial erysipelas 
 there is an increase of ethereal sulphuric acids, while in typhoid, 
 recurrent and intermittent fevers, variola, and meningitis there is a 
 decrease. 
 
 Increase in the ethereal sulphuric acids has also been observed 
 in foul-smelling and putrid processes in various portions of the 
 body. Furthermore, we may mention that even in healthy persons 
 the amount of ethereal sulphuric acids excreted is subject to great 
 fluctuations, and also that very much depends upon the nature of 
 the food ingested. It therefore follows that the excretion of the 
 ethereal sulphuric acids occurs under various conditions ; that it de- 
 pends as much upon their formation within the intestines as it does 
 upon their absorption ; furthermore, that it is to a large extent de- 
 pendent upon the diet, and that even normally it is subject to the 
 greatest variations. In the present status of the subject it would 
 be very risky to form any positive diagnostic conclusion from an 
 increased excretion of the ethereal sulphuric acids. Only where 
 there is a marked abnormal increase can any conclusion be drawn, 
 and then only in conjunction with other signs. 
 
 2. Acetonuria and Diaceturia. — Fetters ^^ and Kaulich^^ pointed 
 out the connection between digestive disorders and acetonuria. 
 Later, Litten ^^ described the occurrence of acetonuria in dyspeptic 
 conditions. Acetonuria in diseases of the digestive tract has 
 been most carefully studied by Lorenz ^''. He found this con- 
 dition present in diseases of the stomach, as well as in the greatest 
 variety of intestinal disorders — e. g., gastro-duodenal catarrh, 
 gastro-enteritis, intestinal obstruction (from marked coprostasis), 
 teenia, peritonitis, and perityphlitis. As fever was present in the 
 last-named conditions, febrile acetonuria could not be positively ex- 
 cluded. In almost all these cases, in addition to the aceton, diacetic 
 acid was also found. At present no diagnostic significance can be 
 attached to acetonuria. 
 
 3. Albuminuria. — Maixner^^ and Pacanowski^^ first called atten- 
 tion to the occurrence of an enteric peptonuria (more correctly 
 albuminosuria), and Ilobitschek^°, who employed improved methods, 
 confirmed their discovery ; nevertheless, the doctrine of an enteric 
 albuminuria rests upon a very weak basis. Chvostek and Stro- 
 mayr's'^ recently published investigations upon the occurrence of 
 
THE DIAGNOSTIC VALUE OF URINARY EXAMINATIONS 135 
 
 alimentaiy albuminosuria in ulcerative intestinal tuberculosis are 
 deserving of greater attention. A few hours after such patients had 
 received large amounts of drj peptones or of somatose, albumoses 
 were found in the urine, Devato's^^ and Salkowski's^ methods 
 being employed for their detection. In some positive cases of 
 ulcerative intestinal tuberculosis albumoses were not found, so that 
 a diagnostic value can only be attached to a positive result of the 
 test. 
 
 LITERATURE 
 
 1. Jaffe. Centralbl. f. d. medicin "Wissenschaften, 1872, S. 481, and Virchow's 
 
 Archiv, Bd. Ixx, S. 73. 
 
 2. E. Salkowski. Bericht d. deutsch. Chem. Gesellschaft, Bd. ix, S. 138 u. 
 
 408. 
 
 3. Baumann. Pflüger's Archiv, Bd. xiii. 
 
 4. Baumann u. Brieger. Zeitschr. f. physiol. Chemie, Bd. iii, S. 254. 
 
 5. Senator. Centralbl. f. die medicin. Wissenschaften, 1877, S. 357. 
 
 6. Fr. Müller. Mittheilungen a. d. Würzburger Klinik, Bd. ii, S. 341. 
 
 7. Ortweiler. Ibid., S. 153. 
 
 8. Rosin. Virchow's Archiv, Bd. cxxiii, 1891, S. 519. 
 
 9. E. Salkowski. Berl. klin. Wochenschr., 1889, No. 26. 
 
 10. C. A. Ewald. Ibid , 1889, No. 44. 
 
 11. Abraham. Ibid., 1890, No. 27. 
 
 13. Rumpel u. Messter. Centralbl. f. klin. Med., 1891, S. 527. 
 
 13. Brieger. Zeitschr. f. klin. Med., 1881, Bd. iii, S. 468. 
 
 14. Petters. Prager Vierteljahrsschrift, 14. Jahrgang, 1857. 
 
 15. Kaulich. Ibid., 17. Jahrgang, 1860. 
 
 16. Litten. Zeitschr. f. klin. Med., Bd. vii, Supplementheft, 1882. 
 
 17. Lorenz. Ibid., Bd. xix, 1891, S. 19. 
 
 18. Maixner. Zeitschr. f. klin. Med., Bd. viii, 1884, S. 534. 
 
 19. Pacanowski. Ibid., Bd. ix, 1885, S. 428. 
 30. Robitschek. Ibid., Bd. xxiv, 1894, S. 536. 
 
 21. Chvostek u. Strohmayr. Wiener klin. Wochenschr., 1896, No. 47. 
 
 23. Devoto. Zeitschr. f. physiol. Chemie, Bd. xv, Heft 5. 
 
 33. Salkowski. Centralbl. f. d. medicin. Wissenschaften, 1894, No. 7. 
 
GENERAL THERAPEUTICS OE 
 INTESTINAL DISEASES 
 
 " Non medicamentis confidere sed therapiie." — von Liebeemeistee. 
 
CHAPTEE YIII 
 
 THE DIETETIC TREATMENT OF INTESTINAL DISEASES 
 
 The fundamental principles laid down in the general section of 
 my book on The Diagnosis and Treatment of Diseases of the Stom- 
 ach apply equally to the general dietetic treatment of intestinal dis- 
 eases. To avoid repetition, we refer the reader to that work. Sev- 
 eral of the rules of procedure there described — e. g., those for the 
 treatment of gastric ulcer and acute gastritis — may with slight 
 changes be apj^lied to cases of ulcer of the small intestine and acute 
 enteritis. The conditions are, however, far more complicated in 
 many other intestinal diseases. According to the pathological con- 
 dition in the intestines, the stomach contents must have a varying 
 influence upon the intestinal contents ; these latter are acted upon 
 by three distinct secretions, each of which may vary in its effect 
 upon the intestines. Absorption from the intestines and intestinal 
 peristalsis may vary considerably. Some excrementitious substances 
 from the blood exert an undoubted action on the iutestines. 
 ISTervous and vaso-motor influences can hasten or retard digestion. 
 From a consideration of all these conditions it is evident that intes- 
 tinal digestion is a very complicated process. The principles of 
 feeding in gastric affections are based to some extent on the results 
 gained from an analysis of the stomach contents which can be 
 readily obtained. On the other hand, we have as yet no satis- 
 factory and practical general method of obtaining and analyzing 
 the intestinal contents. Sometimes an idea of the changes which 
 the food has undergone in the bowel may be gained from an 
 analysis of the faeces. Hence the pathologist and physiologist 
 have for many years paid great attention to the examination of the 
 fseces. 
 
 The first fundamental fact was discovered by Eubner, who 
 showed that the digestion of food stuffs depends principally upon 
 their chemical and physical composition. 
 
 139 
 
140 DISEASES OF THE INTESTINES 
 
 The following table is taken from Eubner's ^ work 
 
 Food stuffs. 
 
 ■WEIGHT OF SAME 
 IN GRAMS. 
 
 
 ABSORBED 
 
 IN PER CENTS OF 
 
 
 
 Fresh. 
 
 Dried. 
 
 Dried 
 substance. 
 
 Albumin. 
 
 Fat. 
 
 Carbo- 
 hydrates. 
 
 Ash. 
 
 Meat 
 
 884 
 
 984 
 
 2,470 
 
 2,490 
 
 860 
 
 1,360 
 
 695 
 
 750 
 
 638 
 
 600 
 
 3,078 
 
 3,880 
 
 2,566 
 
 376 
 
 247 
 315 
 420 
 753 
 765 
 626 
 641 
 780 
 553 
 521 
 819 
 406 
 352 
 
 95 
 95 
 92 
 94 
 95 
 85 
 96 
 93 
 96 
 96 
 91 
 91 
 85 
 79 
 
 97 
 97 
 94-99 
 96 
 81 
 68 
 83 
 85 
 93 
 80 
 83 
 68 
 82 
 61 
 
 95 
 
 95 
 
 95-97 
 
 97 
 
 94 
 83 
 91 
 93 
 
 96 
 94 
 
 94 
 
 ioo 
 
 100 
 99 
 89 
 99 
 97 
 96 
 99 
 96 
 92 
 85 
 82 
 
 82 
 
 Kp'CtS 
 
 82 
 
 Milk 
 
 51 
 
 Milk and cheese . . 
 
 White bread 
 
 Black bread 
 
 Macaroni 
 
 Indian corn 
 
 Corn and cheese. . 
 Rice 
 
 74 
 93 
 64 
 
 76 
 70 
 81 
 85 
 
 Peas 
 
 68 
 
 Potatoes 
 
 84 
 
 Cabbage 
 
 81 
 
 Carrots 
 
 76 
 
 
 
 This table is very instructive in that it shows that the albumi- 
 nous substances contained in meat, eggs, and milk are almost totally 
 used up in the intestines. ISTone of the vegetable matters, with the 
 exception of Indian corn, are so completely absorbed. Yery little 
 of black bread, potatoes, and carrots is absorbed. The greater paj-t 
 of the carbohydrate materials is, however, absorbed in the intes- 
 tines. Thus milk loses 100 per cent ; white bread, macaroni, In- 
 dian corn, rice, and peas almost as much ; potatoes and carrots lose 
 little of their carbohydrate matters in the intestinal canal. Intes- 
 tinal absorption of the fatty matters is also very active ; thus milk 
 loses very much of its fat, as do also meat, eggs, macaroni, rice, 
 potatoes, cabbage, and carrots. 
 
 The digestibility of food stuffs can be further heightened by the 
 manner of preparing them. Thus, according to Rubner, Boeck, 
 Praussnitz, Weiske, and others, 72 per cent of the albuminous mat- 
 ters are absorbed in the intestine from boiled peas as against 82 per 
 cent from ground-up peas, and 68 per cent of boiled potatoes as 
 against 80 per cent of mashed boiled potatoes. The addition of 
 spices to the food is also of undoubted benefit in this respect. The 
 above-mentioned figures apply only to healthy persons. Unfortu- 
 nately, our knowledge of the digestibility of food stuffs in diseased 
 individuals is very limited. The investigations of Fr. Müller^, so 
 frequently referred to, have shown that in intestinal diseases the 
 absorption of fats is early disturbed, and the absorption of nitroge- 
 nous matters is interfered with only in some intestinal catarrhs. 
 
THE DIETETIC TREATMENT OF INTESTINAL DISEASES 141 
 
 The absorption of carbohydrates is almost never interfered with, 
 although it is probable that some of the carbohydrates are lost 
 through fermentative processes in the intestines. 
 
 The food stuffs exert an important influence upon many of the 
 intestinal putrefactive processes. Thus Eubner ^ observed that 
 after a diet of bread the products of albuminoid putrefaction dis- 
 appeared from the urine, and in their stead there appeared a butyric 
 acid fermentation. 
 
 Hirschler ^ demonstrated that a direct antagonism existed be- 
 tween albumin and carbohydrate putrefaction. Ortweiler ^ showed 
 that a free diet of carbohydrates is apt to be followed by the com- 
 plete disappearance of indican from the urine. It is evident that 
 the food stuffs vary in their proneness to decomposition, and that 
 in disease there may be a greater or less tendency for the occur- 
 rence of putrefactive processes of the albuminous, carbohydrate, 
 or fatty matters. Unfortunately, our knowledge of the principles 
 of dietetics is so meagre that no deductions can be drawn from this. 
 
 In the absorption of food stuffs from the diseased intestine an- 
 other factor is of importance, viz., the influence exerted by the food 
 upon the intestinal functions. Thus, for example, in some diseases 
 of the intestines milk causes constipation, in others diarrhoea. Eggs, 
 to take another example, are not well borne in diarrhoea, but are 
 always prone to cause flatulence. The idea that some substances 
 are easier digestible and others not so is gradually losing many ad- 
 herents, for we are gradually coming to the conclusion that the 
 digestibility of foods varies in each individual case. This illustrates 
 the uselessness of basing our dietetic measures solely upon the diges- 
 tibility of various foods. Clinical experience must teach us the 
 principles of dietetics. From my observations and those of others 
 the following rules may be laid down : 
 
 1. In a number of intestinal diseases a change of diet is un- 
 necessary, or may even be harmful. 
 
 2. In some cases special dietetic restrictions are directly indi- 
 cated, but these should be as few as possible. 
 
 3. In another series of cases an abundant heavy, not easily diges- 
 tible or absorbable diet is indicated. 
 
 4. The general aim of our treatment should always be to so 
 manage the case before us that digestion of a normal diet will 
 always occur in the alimentary canal without any subjective or ob- 
 jective disturbances. Under these circumstances only can the case 
 be considered cured. 
 
14:2 DISBASES OF THE INTESTINES 
 
 The reasons which have led me to adopt the above principles of 
 treatment will be given in what follows, which will contain a gen- 
 eral description of the principles of feeding in diseases of the intes- 
 tines. For simplicity of understanding, intestinal diseases are classi- 
 fied * as 
 
 1. Diseases of the mucous membrane (ulcers of the duodenum, 
 jejunum and ileum, acute and chronic enteritis, carcinoma, intestinal 
 ulcers in general). 
 
 2. Functional disturbances (increased or diminished peristalsis). 
 
 3. Stenosis or occlusions. 
 
 4. Localized peritonitis (appendicitis) ; diffused peritonitis. 
 
 5. ISTeuroses. 
 
 1. Diseases of the Intestinal Mucous Membeane 
 
 In diseases of the mucous membrane the principles of feeding 
 are similar to those laid do^vn for the treatment of affections of the 
 body in general — i. e., rest for the affected part. The temporary 
 withdrawal of all foods constitutes the greatest possible amount of 
 rest for the digestive tract, and one that is often followed by bril- 
 hant therapeutic results. This method comes up for a special con- 
 sideration in acute bleeding from the stomach or intestines, in acute 
 gastro- enteritis, and in rebellious forms of gastric or duodenal ulcer- 
 ation. The importance of the latter disease is worthy of special 
 consideration in this place. That the absolute withdrawal of food 
 is the best therapeutic measure in acute intestinal haemorrhage 
 (exclusive of bleeding from haemorrhoids) is not as yet, according 
 to my experience, generally acknowledged. I emphasize the word 
 absolute, because I believe that in these cases even water by the 
 mouth is harmful. In such a patient the physician, and especially 
 the relatives and friends, are but too apt to give the patient large 
 quantities of fluid to drink to compensate for what has been lost 
 by the bleeding — a procedure which I consider absolutely wrong. 
 Food should not be given by the mouth until twenty-four to thirty- 
 six hours after the haemorrhage has ceased. By that time the 
 bleeding vessels have probably been closed by a thrombus. If the 
 weakness of the patient calls for immediate feeding, nutrient ene- 
 
 * In this classification it may occur that some diseases might, during their 
 course, come under another heading than they would at first ; thus, a carcinoma 
 of the intestines might be at first considered a disease of the mucous membrane, 
 later, as the symptoms of obstruction come to the foreground, as a stenosis. The 
 same is true of many other intestinal affections. 
 
THE DIETETIC TREATMENT OP INTESTINAL DISEASES 143 
 
 mata should be ordered.* During the following few days the 
 patient should be kept on a fluid diet. After eight to ten days 
 the diet may be gradually increased according to the well-known 
 plan of Leube. 
 
 In acute hsemorrhage from the large intestines (as in haemor- 
 rhoids, dysenteric ulcers, and neoplasms) the danger of profuse 
 bleeding is not great, and hence the entire withdrawal of food is 
 unnecessary. It will generally suffice to restrict the patient to a 
 soup diet for a few days. 
 
 In chronic bleedings, which are apt to be small ones, it is very 
 important so to arrange the patient's diet as to prevent the symptoms 
 of exhaustion which are apt to appear. The choice will largely 
 depend upon the nature and character of the illness. In the spe- 
 cial part of the present work more attention will be paid to this 
 subject. 
 
 In violent haemorrhages from large blood-vessels (embolism of 
 the mesenteric artery, rupture of varicose veins, etc.) we are 
 usually powerless. Diet has but little influence upon these haemor- 
 rhages. 
 
 The treatment of acute gastro-enteritis or enteritis alone is far 
 simpler. In these afliections the loss of appetite facilitates the 
 withdrawal of food. In very acute diarrhoeas we must provide 
 against the severe thirst which is so apt to be present, by giving the 
 patient diluted claret, oatmeal soups, cocoa boiled in water, and tea 
 without sugar. In chronic duodenal ulceration the same diet as in 
 gastric ulcer is to be ordered. The patient should remain in bed 
 for several weeks, poultices should be applied to the abdomen, and 
 he should partake of a bread -and-milk diet. This diet should be 
 continued until subjective and objective sensitiveness have disap- 
 peared, when the patient should abstain for a long time from inju- 
 rious diet — that is, food digested with difficulty (ice cream and iced 
 dishes, raw fruit, hard bread, all kinds of cabbage) — and improper 
 drinks (iced drinks, acid fruit juices, carbonated beverages). 
 
 In very obstinate forms of duodenal or jejunal ulceration the 
 treatment is similar to that of gastric ulceration — i. e., abstinence 
 from all food for ten to fourteen days, and rectal alimentation. In 
 nine undoubted cases of this class I found that the above-outlined 
 treatment was always sufficient. 
 
 * Concerning the composition and method of giving nutrient enemata, see 
 Boas, Diagnosis and Treatment of Diseases of the Stomach, fourth edition, 
 Part I, p. 293. 
 
144 DISEASES OF THE INTESTINES 
 
 The diet in chronic enteritis varies greatly, according to the sit- 
 uation, intensity, extent, and duration of the disease. It is diffi- 
 cult, therefore, to lay down any general rules, and we will limit 
 ourselves to a few suggestions, reserving fuller details for the second 
 part of this work. The treatment will depend mainly upon our 
 being able to «locate the intestinal catarrh. 
 
 Catarrhal affections of the small intestines call for a particularly 
 cautious diet. In long-standing diseases it is clear that the intesti- 
 nal secretions are deficient in quality, and hence can not act in a 
 normal manner upon the chyme. It can be readily understood that 
 if, in place of the normal strongly alkaline intestinal juice, a weakly 
 alkaline one containing large quantities of mucus is secreted (in 
 which cases the acidity of the chyme is not sufficiently neutralized), 
 the pancreatic juice will be acted on in an abnormal manner. In 
 the presence of the strong acidity the pancreatic juice loses its tryp- 
 tic, diastatic, and fat-splitting properties ; the emulsification of fats 
 is delayed, or does not at all take place ; the action of the bile is 
 likewise interfered with by the hyperacidity of the small intestines. 
 Where, as is usually the case in intestinal catarrh, there is diarrhoea, 
 the greatest care must be exercised in the selection of a suitable 
 diet. If the diet does not contain sufficient nourishment, the 
 patient may suffer from a transitory loss of albumin. JSTeverthe- 
 less, this plan must be carried out. The more numerous the 
 evacuations, the greater is the need for restriction of the diet. In 
 the beginning, gruel, cocoa, tea, beef tea, nutrose,* and claret, or 
 cognac diluted with water, may be ordered for the patient. The 
 diet must be varied according to the number and consistency of 
 the movements. Regarding a diet of milk and eggs in diarrhoea, 
 the most important facts have already been given ; as the patient 
 improves, an egg may be stirred into the soup, and according to 
 the manner in which the patient stands this the diet can be still fur- 
 ther increased. We may then gradually let the patient take milk. 
 Its effects should be carefully noted ; very often it will have to be 
 entirely excluded. It is obvious that all substances that increase 
 peristaltic motion (fruit, cider, certain wines, [organic] acids, honey, 
 sugar) must be avoided. It is not correct, however, as is still often 
 done, to give general instructions according to the above-mentioned 
 principles. Exact instructions as to the diet must be given in 
 treating each individual case. 
 
 * In all diarrhoeal conditions somatose must be avoided, because it is apt to 
 aggravate them. 
 
THE DIETETIC TREATMENT OF INTESTINAL DISEASES 145 
 
 In catarrh of the large intestine dietetic principles are quite 
 different. There is present either constipation, or constipation 
 alternating with diarrhoea, or diarrhoea alone. In the last-named 
 variety the diet is the same as that of catarrh of the small intes- 
 tines. In the other forms our aim should be to regulate the move- 
 ments without injury to the inflamed intestinal mucous membrane. 
 In these cases digestion in the stomach and the small intestines is 
 usually normal, and therefore the patient may from the very begin- 
 ning be placed upon a full and nourishing diet. We may begin 
 with a free diet (meat, fish well prepared, soft-boiled eggs, fat such 
 as butter, chicken fat, cocoa butter). Yegetables in puree form and 
 carefully prepared pastry may also be allowed. Conversely, experi- 
 ence has shown that soups tend to arrest peristalsis ; they, as well as 
 other physiological astringents (rice, farina, cocoa, red wine, huc- 
 kleberry wine, etc.), are to be avoided. Physiological laxatives 
 (honey, milk, sugar, glucose, grapes, stewed fruits, and sweet pas- 
 try) are especially to be recommended. In these cases milk, and 
 particularly such of its derivatives as contain acids (buttermilk, 
 koumyss, sour milk), may be employed to great advantage. We 
 should strictly forbid the use of all substances which from experi- 
 ence resist all action of the intestinal secretions, such as the cellu- 
 lose of cabbage, beets, and root vegetables, as well as indigestible 
 seeds which are contained in many fruits (huckleberries, cranber- 
 ries, currants, and gooseberries), A very similar diet is to be 
 ordered in that form of intestinal catarrh that manifests itself in 
 diarrhoea alternating with constipation, for here the con8ti]3ation 
 must be looked upon as the predominant and primary factor. In 
 these cases our judgment of the results of the treatment instituted 
 should not be governed by the effect upon the constipation alone, 
 but from the appearance of the evacuations, and particularly from 
 the amount of mucus contained in them. At the same time the 
 above-named general principles must not be lost sight of. In pri- 
 mary catarrhs of the lowermost portion of the intestine (sigmoid 
 flexure and rectum) the same general principles also apply. 
 
 In secondary catarrh, we may under favourable circumstances 
 achieve successful results by removing the cause of the congestion 
 in the intestinal blood-vessels. Generally we will have to content 
 ourselves with a symptomatic treatment of the intestinal disturb- 
 ances, following the above-mentioned underlying principles. 
 
 The dietetic treatment of intestinal ulcers also varies much, 
 according to their nature and situation and the influence which they 
 
146 DISEASES OF THE INTESTINES 
 
 exercise upon the movements. Tlius, according to J^othnagel, 
 ulcers of the small intestine or of the ascending colon only cause 
 diarrhoea when they occur simultaneously with other conditions 
 (catarrh, amyloid disease, etc.), while ulcers of the lower division 
 of the large intestine are usually accompanied by diarrhoea. Natu- 
 rally the diet in ulceration of the upper portions of the small intes- 
 tines will have to be a very cautious but highly nutritive one, and 
 in ulcers of the lower portions of the small intestine we should by 
 all means avoid all irritation of the mucous membrane from indi- 
 gestible food masses. For the rest, the condition of the evacuations 
 (consistency, number, admixtures such as pus, blood, etc.) will have 
 to guide us in the choice of the diet. 
 
 As regards tumours, the malignant ones alone require special 
 dietetic measures. We will have to take into consideration the pres- 
 ervation of the patient's life, and, if possible, the improvement 
 of his general condition, the local (intestinal) damage (secondary 
 catarrh, stenosis). Since our dietetic measures will ultimately de- 
 pend upon these complications, they will, to avoid repetition, be 
 detailed in the section on " Intestinal Stenosis " (Part II). 
 
 2. Diet in Functional Distuebances of the Intestines 
 {Iietardatio7i or A cceleration of Peristalsis) 
 
 Under this heading, in the first place, we include habitual con- 
 stipation and habitual diarrhoea. Both conditions may be accom- 
 panying symptoms of other diseases, or they may occur as inde- 
 pendent functional intestinal disturbances ; they therefore deserve 
 to be discussed separately. In the second portion of this work fur- 
 ther consideration will be paid to this subject ; in the present place 
 we wish to discuss the dietetic treatment of simple, uncomplicated 
 constipation and diarrhoea. 
 
 In habitual constipation the diet must be a plentiful as well as a 
 mixed one, and should contain substances that are known to stimu- 
 late peristalsis. Conversely, as already stated, dietetic astringents 
 must be avoided. The first indication is frequently disregarded. 
 We have already seen that foodstuffs are divisible into those well 
 utilized and those poorly utilized by the economy. The first group 
 includes all fluids and substances dissolved in them, meat, fish, 
 wheaten bread and the like, light pastry, etc. The second group 
 includes those foodstuffs that leave more or less of an indigestible 
 residue — as, for example, fruit, rye bread, cabbage, potatoes, salad, 
 and other vegetables rich in cellulose. 
 
THE DIETETIC TREATMENT OF INTESTINAL DISEASES I47 
 
 The main feature in the treatment of habitual constipation is 
 the employment of this last-named variety of foodstuffs. Were a 
 vegetable diet as nutritious as a mixed diet, and were its exclusive 
 employment not frequently associated with objective (gastric and 
 intestinal dilatation) and subjective disturbances (abnormal flatu- 
 lence), it would be the ideal one in constipation, since it leaves 
 behind a considerable indigestible residue. In general, therefore, 
 sufferers from constipation should be given a mixed diet containing 
 a minimum amount of totally digestible foodstuffs and a preponder- 
 ance of those that contain much indigestible material. With such 
 a regime we may accomplish much, but not all we wish to. The so- 
 called " physiological laxatives " must also be given. We know a 
 number of them ; they act either chemically or thermically. The 
 chemical ones include the organic acids, the mineral salts, and 
 numerous sugars as well as fats. The organic acids include lactic, 
 butyric, acetic, and probably also a number of other acids devel- 
 oped in the body from carbohydrates (formic, caproic, caprylic, pro- 
 prionic acids, etc.). As the investigations of A. Bokai^ have shown, 
 these acids are important factors in peristaltic action. It is a ques- 
 tion whether the acids introduced as such, or those which develop 
 from fermentation in the intestines, are the main causes of normal 
 peristalsis ; for many reasons the latter variety should be regarded 
 as the main cause. It is certain, however, that these acids do excite 
 intestinal peristalsis very strongly — more strongly, for example, than 
 do many vegetable cathartics. 
 
 Among the foods which contain these acids are buttermilk, sour 
 milk, kefir, and koumyss. In the latter two substances the carbonic- 
 acid gas is also an efficient factor, for this gas excites intestinal 
 peristalsis. 
 
 We know from animal experiments and observations upon man 
 that the mineral salts also stimulate peristalsis. Upon this fact are 
 based our ideas of the action of the muriated and Glauber salts. 
 This has taught us to give patients suffering from habitual con- 
 stipation plentifully salted food, such as sardelles, herring, caviar, 
 smoked and boiled ham, and smoked beef. 
 
 The sugars have long been known as home remedies in habitual 
 constipation. The sugars have not, however, a common action on 
 the organism. Thus milk sugar, and probably also levulose and 
 dextrose, have a greater influence upon peristalsis than has cane 
 sugar. The physiological action of the sugars may be due to either 
 the products of the decomposition of sugar in the body — i. e., lactic 
 
^48 DISBASES OF THE INTESTINES 
 
 acid, butyric acid, acetic acid, etc. — or tlie sugars may exert an influ- 
 ence upon the intestinal mucous membrane by causing an active 
 transudation from it. The investigations of Strauss ^ have shown 
 that after the ingestion of sugar considerable transudation from the 
 gastric raucous membrane occurs — a condition which I found pres- 
 ent years ago in experiments on the gastric digestion of sugars. 
 
 The sugars have, therefore, a similar action to the saline cathar- 
 tics (magnesium sulphate, sodium sulphate). Any one of a large 
 variety of saccharin foodstulfs can be made use of instead of sugar 
 itself. Among these may be mentioned sweet fruits, grapes, honey, 
 sweet milk (also that sweetened with milk sugar), condensed milk, 
 sweet wines (Tokay, Marsala, Sauterne, pasteurized graj)e juice, 
 young wine, etc.). 
 
 Finally, the thermic methods should be mentioned. It is a fact 
 of daily observation that cold appHed externally or internally stimu- 
 lates peristaltic action. Many of the laity, being cognizant of this 
 result, are accustomed to drink cold water on an empty stomach in 
 order to stimulate the activity of the bowels. It is advisable, there- 
 fore, in these cases to order cold instead of warm or hot, and prefer- 
 ably fruit soups, cold tea, coffee, sweetened lemonade, etc. 
 
 By means of these substances we are able to increase the intes- 
 tinal activity at will. In rebellious cases of constipation one must 
 not, as is so often done, expect too much from one particular 
 remedy. Since these agents are adjuncts one to the other they 
 must often be combined. I am accustomed to name a diet of this 
 kind a " constipation diet," and I shall speak of it more in detail in 
 the second part of this work. In the selection of appropriate food, 
 the location of the trouble, its duration, and the condition of the 
 patient have to be considered, but the principles upon which this 
 diet of constipation is based must never be lost sight of, and always 
 be applied in the proper manner. 
 
 As already stated (page 145), it is of prime importance to 
 exclude all physiologically constipating remedies from the diet. 
 Thus I have often seen patients for whom the diet had been pre- 
 scribed correctly in all respects, except that they were allowed to 
 partake of one half or even one bottle of claret daily — an absurd 
 allowance. For similar reasons, cocoa, rice, farina, and foods pre- 
 pared from flour, unless freely sweetened with sugar, should be 
 forbidden. I have little doubt that a diet based on principles as 
 above described and varied for each individual case, will result in 
 a permanent cure of even rebellious and long-standing cases of 
 
THE DIETETIC TREATMENT OP INTESTINAL DISEASES I49 
 
 constipation — a cure which will satisfy the conditions already 
 mentioned (page 141), that even with ordinary diet the bowels 
 will move in a normal manner. In those cases where the 
 patients have been dosed with cathartics many years, only a care- 
 fully prescribed diet, strictly followed out for years, may result 
 in a cure. 
 
 Besides the regulation of the diet, other therapeutic measures 
 have to be observed in habitual constipation. Of equal importance 
 are the regulation of the amount of exercise, stated hours for meals, 
 a regular and sufficiently long time for defecation, a stimulation of 
 the weakness of the intestinal muscle by exercise of the muscles in 
 general, in particular those of the abdominal wall, etc. These con- 
 siderations belong rather to the special treatment of habitual consti- 
 pation, and will be discussed in detail in the second part of this 
 work. 
 
 The choice of diet in chronic diarrhoea depends, as has been 
 mentioned above (page 144), upon the number and consistency of 
 movements and the duration of the affection. The most important 
 principles of treatment have already been considered in speaking 
 of catarrh of the small intestine. The mechanical, chemical, and 
 thermal agents which stimulate peristaltic action in habitual consti- 
 pation have, on the other hand, an unfavourable influence on diar- 
 rhoea. In regard to the first agent mentioned, we would therefore 
 carefully avoid all coarse, indigestible, or not easily digested sub- 
 stances, and particularly those containing much cellulose, such as 
 cabbage, salad, pickles, beets, and other root vegetables. Of the 
 chemical agents, all organic acids and sugar are to be avoided. 
 Where the food or drink has to be sweetened, it is best to use sac- 
 charin — a substance which Gans ', in his investigations made in my 
 laboratory many years ago, showed was also to a certain degree an 
 intestinal antiseptic. That good fats even in large quantities are 
 generally well home in chronic diarrhoea^ is worthy of mention. 
 Experience has taught me that even in severe cases one can prevent 
 exhaustion hy adding fats to the food. All cold drinks, ice water, 
 seltzer water, and other carbonized beverages (beer, champagne, 
 etc.), and even cold water, should be avoided. Hot drinks, on the 
 contrary (tea, soups, and claret), have a tendency to diminish peri- 
 stalsis. As has been mentioned on page 144, milk is not, as a rule, 
 well borne, and is apt to increase the number of stools. Cold milk 
 has a very unfavourable influence on diarrhoea, while hot milk may 
 not be harmful. Sometimes milk even in large quantities is well 
 11 
 
150 DISEASES OF THE INTESTINES 
 
 borne when cognac, limewater, powdered lime, talcum, ground bar- 
 ley, rice, Indian meal, or oatmeal, etc, are added to it. In a very 
 few but convincing cases I have seen good results from systematic 
 milk cures, and I believe that a careful trial may be made of them. 
 It is hardly necessary to add that in these cases salts (table salt, 
 nitre, and other spices) should be forbidden. If eggs (even 
 poached) or foods containing them are not well borne they should 
 be excluded from the diet. Generally, at least in the beginning 
 of the treatment, eggs should be sparingly or not at all given. 
 
 In addition, those kinds of foods or drinks should be recom- 
 mended which from experience^ or from whose composition, we 
 know tend to lessen peristaltic activity. In this category we may 
 mention the cereals which contain much mucin (farina, rice, barley, 
 oatmeal, porridge, etc.). These may be ordered in the form of soups, 
 or, better, as thick, unsweetened gruels.* Other articles of diet 
 which should be mentioned here are those which are characterized 
 by containing more or less tannic acid. Among these may be men- 
 tioned " eichel cacao," " eichel coffee," infusion of nut leaves (e. g., 
 butternut), of bearberry leaves (folia uva ursi), decoctions and jel- 
 lies of fresh huckleberries, and a number of red wines containing 
 much tannin, of which huckleberry wine is most useful. 
 
 A good old Bordeaux wine, the Greek wines (particularly Cama- 
 rete), the Italian red wines, and Simaruba wine may be also 
 given. 
 
 If the patient will adhere strictly to this diet not only during 
 the whole course of treatment, but even, though not so strictly, for 
 many months thereafter, his intestinal disturbances may be much 
 improved or entirely cured. In modern society, with its dissipation 
 and excesses, this plan of treatment will be adhered to only by a 
 small proportion of the patients. Diet, however, is not all-suffi- 
 cient. It must be remembered that other conditions (cold, consti- 
 tutional disturbances, sexual excesses, overexertion) may have con- 
 siderable influence upon the affection. This will be treated of more 
 in detail in Part II of this book. 
 
 3. The Diet in Cheonic Stenosis and Obsteuction of the 
 
 Intestines 
 
 Chronic stenosis occurs in different portions of the intestine, 
 either as a benign (adhesive peritonitis, contracting scars of ulcers, 
 
 * In these cases saccharin may be used with much advantage instead of sugar. 
 
THE DIETETIC TREATMENT OP INTESTINAL DISEASES 151 
 
 benign tumours) or as a malignant process (carcinoma, sarcoma). 
 No matter wliere the location of the disease and how great its 
 severity, the main therapeutic object must consist in the removal 
 of the causal factor. Diet will naturally have some influence upon 
 this. Even if its location be recognised, we are often able to remove 
 the cause of the obstruction only by operative means ; still, the 
 proper regulation of the diet may contribute much toward amelio- 
 rating or removing subjective or objective symptoms. In such cases 
 two points have to be considered before beginning the feeding : the 
 location and the degree of the obstruction. The location of the 
 disease may be discovered in many if not all of the cases. The 
 severity of the symptoms, the shape, consistency of the stools, the 
 visible or palpable peristaltic restlessness and intestinal rigidity 
 (Nothnagel), the appearance of meteorism, vomiting, etc. — all 
 these signs and symptoms indicate, though sometimes falsely, the 
 amount of obstruction. Since there are always processes of putre- 
 faction above the stenosed portion of the intestine, the direct bear- 
 ing of the amount of obstruction upon the diet to be prescribed is 
 not to be underestimated. The diet will differ according to situa- 
 tion of the obstruction in the large or in the small intestine. The 
 chyme remains fluid or semifluid until it reaches the lowest part 
 of the ileum, and hence can pass through a greater obstruction here 
 than below this point. Abnormal processes of fermentation and 
 13utref action are less apt to occur. The diet should be so arranged, 
 therefore, that only fluids or foods prepared in liquid form are 
 taken, while solid, indigestible, or not easily soluble matters are 
 to be avoided as far as possible. It is hardly necessary to point out 
 that food that ferments easily, or is already in a state of fermenta- 
 tion, should be excluded from the diet. 
 
 When the obstruction lies in the large intestine the conditions 
 are far more complicated. In this part of the bowel the faeces lose 
 most of their water, and in conditions of obstruction this loss of 
 water is further increased because of the lack of fluid in the sur- 
 rounding tissues. It matters not how large an amount of fluid the 
 patient imbibes, the fgeces are always firm when they reach the 
 site of obstruction. One often has to ask himself the question 
 whether it might not be advisable to order solid instead of liquid 
 food. Under a solid diet, however, there might be danger of 
 increased fermentation and putrefaction because of the large quan- 
 tities of easily putrefactive material which would reach the site of 
 obstruction, and furthermore, on account of the spasmodic peristal- 
 
152 DISEASES OF THE INTESTINES 
 
 sis, solid indigestible substances might become lodged in the stenosed 
 portion of the bowel. Lentils, peas, beans, asparagus, fruit, etc., in 
 short, those vegetables which contain much cellulose, would be most 
 apt to create such a condition — one very similar to that which occurs 
 in a typical manner in stenosis of the pylorus. A number of cases 
 have been reported in which moderate errors of diet have caused a 
 decided increase or an acute exacerbation of mild or quiescent 
 symptoms. 
 
 The diet in stenosis of the large intestines will therefore have 
 to be based on the following principles : 1. It should contain a 
 plentiful amount of solid material. 2. These solid materials must 
 be free from mechanically irritating ingredients. 3. The diet must 
 contain laxative ingredients. 4. These must not be excessively prone 
 to undergo fermentation. The first two points need no explana- 
 tion ; some attention must, however, be paid to the last two. That 
 substances which tend to make the stools less solid are advan- 
 tageously added to the diet has been already clearly shown (page 
 147). unfortunately, however, some of these substances, and among 
 them the sugars, form a good substratum for the occurrence of fer- 
 mentative processes above the site of the obstruction ; hence they 
 must be avoided. Experience has taught me that organic fatty acids 
 and the acids of fruits are generally well borne. The same is true 
 of salts, which probably diminish and certainly do not increase fer- 
 mentation in the intestinal canal. A plan of diet based on such 
 principles may be given in short resume in the following : Mixed 
 food — meat, fish, vegetables, etc. — should be prepared in puree 
 form; well-salted and pickled meat or fish are especially recom- 
 mended. Fat may be given in moderate quantities. Sweet milk is 
 not well borne, but buttermilk, thickened milk, kefir (free from 
 carbonic acid and two days old), koumyss (free from carbonic acid) 
 are permissible. No, or only small quantities of, sweet stewed 
 fruit, in which saccharin may be used instead of sugar, should be 
 allowed. A diet suitable for each individual case may be con- 
 structed on these principles. It is of prime importance to counter- 
 act the tendency to severe grades of constipation ; and if, as is often 
 the case, the regulation of the diet will not sufiice, one must occa- 
 sionally order mild vegetable laxatives. It would be a palpable 
 error to order a constipating diet for — or, what is still worse, to give 
 opiates to- — a patient who has partial intestinal obstruction. An 
 exception to this statement is furnished by those cases of spas- 
 modic tetanic intestinal peristalsis, in which opium not only quiets 
 
THE DIETETIC TREATMENT OF INTESTINAL DISEASES 153 
 
 tlie contractions, but even acts as a laxative. This subject will, 
 however, be treated of in another place. 
 
 The diet to be used in complete intestinal obstruction differs 
 essentially from that in partial obstruction. In complete obstruction 
 the diet must be very limited. Obviously this is of paramount 
 importance when the obstruction is in the small intestines, for in 
 these cases the entry of food into the stomach or intestines causes 
 immediate vomiting. When the obstruction is in the large intes- 
 tines (invagination, volvulus, foreign bodies, fsecal impaction) this is 
 also, though in a less degree, true. Only small quantities of very 
 easily digestible foods, preferably fluids, should be given at long 
 intervals, and, when possible, nourishment by some other path 
 should be at once begun (nutrient enemata, subcutaneous saline 
 infusion, salt-water enemata). Weakness, with cardiac exhaustion, 
 is to be greatly feared, since it will prevent the one therapeutic 
 curative method in the disease, namely, operation. 
 
 When the obstruction is in the small intestine, or in the upper 
 part of the large intestine, the patient should be given nutrient 
 enemata. If in the lowermost portion of the large intestine or the 
 rectum, the best one can do is to attempt to prevent threatening 
 collapse by injections of salt or glucose under the skin. In most 
 of the cases the result is unfavourable unless surgical aid is early 
 called in. 
 
 4. The Diet in Typhlitis and Appendicitis 
 
 By appendicitis we mean those inflammations which start from 
 the appendix vermiformis and either remain localized or extend to 
 the peritoneum or retroperitoneal cellular tissue, or through perfo- 
 ration attack a part or the whole of the peritoneal cavity. A pri- 
 mary typhlitis caused by fsecal impaction or foreign bodies, and 
 often followed by perityphlitis with its symptoms, does occur. 
 With this short statement of my position on an affection which has 
 been the cause of much clinical difference of opinion, I shall close 
 this subject and turn to the dietetic treatment of the condition, 
 reserving the details for discussion in another place. 
 
 It is exceedingly difficult to lay down any general rules of diet, 
 because in these affections the food must vary with the character, 
 severity, and course of the disease, as well as with the varying com- 
 plications and relapses. In stercoral typhlitis the question is easy ; 
 in appendicitis it is more difficult. For simplicity, I think it best 
 to adhere to the classification proposed by Sonnenburg, into the 
 
154: DISEASES OF THE INTESTINES 
 
 catarrhal, the perforative, and the gangrenous forms of appendi- 
 citis. 
 
 In typhlitis due to fsecal impaction the diet must be so arranged 
 as to aid in the softening and discharge of the faeces. The use of 
 laxatives (castor oil) or of enemata can be advantageously combined 
 with a suitable diet. 
 
 In most cases catarrhal appendicitis gets well of its own accord, 
 and the treatment must be so directed as neither to irritate the 
 intestines mechanically nor to increase peristalsis. This is best 
 accomplished by means of a fluid diet, continued until the rise of 
 temperature, the exudate, and the sensitiveness to pressure in the 
 ileo-csecal region have disappeared. Judging from my experience, 
 I believe that Sahli^, Quincke^, and Penzoldt^^ are too extreme 
 when they recommend that for one or more days all food should 
 be at once withdrawn. 
 
 After the acute inflammatory symptoms have disappeared, we 
 may for the next week allow the patient, in addition to fluids, to 
 partake of gruels (rice, barley gruels, vegetables in puree form, etc.). 
 After another week meat, beginning with the tender varieties, may 
 be added, together with foods made of flour and various stewed and 
 preserved fruits. After four weeks have elapsed the patient may 
 return to his normal diet, which should be so arranged as to coun- 
 teract the tendency to constipation which is always present in these 
 cases. 
 
 In the second variety, the suppurative form of appendicitis, the 
 danger to life is much greater, and the main question is when 
 to interfere surgically. Diet is of secondary importance. Even 
 in these patients I do not believe that an absolute withdrawal of 
 food is advisable, because, on account of the high fever, the patients 
 generally suffer from severe thirst. Penzoldt permits his patients 
 to drink water, and hence I do not see why they may not also take 
 small quantities of tea, milk, wine, and gruels. It seems to me that 
 the fear of a "dangerous stimulation" of peristalsis is exaggerated, 
 all the more as the opium treatment is more thoroughly carried 
 out.* This does not mean, of course, that one should not withdraw 
 all feeding by the mouth where there is severe vomiting or symp- 
 toms of intestinal obstruction, and use in its stead frequently 
 repeated nutrient enemata. In general, however, in acute or sup- 
 
 * [Within recent years, here in the United States, routine opium treatment — for- 
 merly so popular — has been almost entirely abandoned, even in those cases treated 
 without operation. — Tb.] 
 
THE DIETETIC TREATMENT OF INTESTINAL DISEASES 155 
 
 purative stages of the affection, rectal alimentation must be desisted 
 from, if possible, since it necessitates moving the patient about and 
 naturally disturbs the inflamed intestine. If the critical stage of 
 the disease is passed, or if an operation has freed the patient from 
 danger, the diet must be arranged according to the principles above 
 mentioned. 
 
 The same general principles apply also to the gangrenous variety 
 of the disease, but the diet must be still more carefully managed. 
 The bowels should be regulated, and by this means the occurrence 
 of relapses prevented. Only in very resistant cases should laxatives 
 be made use of, and one should endeavour to regulate the bowels by 
 means of the appropriate diet for constipation which has already 
 been described. 
 
 As the rarer forms of tubercular and actinomycotic appendicitis 
 do not differ essentially from the forms above described, it will be 
 unnecessary to detail the principles of feeding in these cases. 
 
 5. The Diet in Intestinal I^eukoses 
 
 The practical importance of the dietetic treatment of intestinal 
 neuroses is that by its means we may improve the general condition 
 of the patient or remove prominent symptoms of the affection (con- 
 stipation, diarrhoea, pain, flatulence, etc.). If the diagnosis is abso- 
 lutely certain, it is questionable whether any special regiine is neces- 
 sary at all. Many errors are made in this direction. I have seen, 
 for example, a strict diet cause or increase constipation, tympanites, 
 and colic, which symptoms had presented almost a typical picture 
 of nervous dyspepsia. Such patients tell us that they can not even 
 partake of soup without being troubled with belching or with severe 
 tympanites and abdominal pain. Often the patient will be imme- 
 diately cured by partaking of a full diet. I would therefore 
 emphatically warn physicians against restricting the diet too quickly 
 when they have patients who complain of intestinal symptoms with- 
 out discoverable physical signs. In some cases, as in the so-called 
 nervous diarrhoea, this is to some extent necessary. But even in 
 these cases one should in some degree be guided by the sensations 
 of the patient, and should not order all possible sorts of restrictions 
 at once. The patients may make strange assertions which contra- 
 dict all the acknowledged laws of physiology and pathology, but 
 these statements must not be absolutely ignored.* 
 
 * Thus, I have a patient in whom even the best kind of claret always causes 
 diarrhoea, although Moselle wine promptly counteracts the effect of the red wine. 
 
156 DISEASES OP THE INTESTINES 
 
 This class of patients is best treated in a sanitarium, where 
 observation will soon show the appropriate diet for the indi- 
 vidual case. 
 
 The treatment of nervous flatulence — a condition whose treat- 
 ment, in the experience of every busy practitioner, gives very unsat- 
 isfactory therapeutic results — must be considered in this place. 
 The attempt to determine the cause of the flatulence meets with 
 many difiiculties. In more than one case, even after long obser- 
 vation, I have been in doubt as to the nature of the process, and 
 more especially whether or not there was abnormal fermentation in 
 the intestines. N^ot only do the patients not improve under strict 
 dietetic treatment, but they often become distinctly worse. Tym- 
 panites and constipation, when they occur together, may be regu- 
 lated by an appropriate but not a bland diet ; diarrhoea may, how- 
 ever, be accompanied by tympanites, and a constipating diet then 
 becomes necessary. Above all, fluid food should be avoided, as 
 such a diet will make the patient's condition almost unbearable. 
 Yery many practitioners are afraid to give so-called gas-forming 
 remedies, but these are often indicated. In the same manner that 
 the sense of pressure in the epigastrium must be relieved by the 
 taking of bicarbonate of soda, so we can often, by means of a diet 
 rich in gas-forming foods, make it easier for the patient to expel 
 gas from his bowel. Many patients of mine who are very sceptical 
 on this point have, to their great surprise, been benefitted by this 
 kind of a diet. But even in these cases individual predisposition 
 must be taken into consideration. 
 
 6. Diet in Diseases of the Rectum 
 
 I^ot all affections of the rectum require a special regulation of 
 the diet. Thus, no special diet is necessary in fistulse, ulcers, or 
 foreign bodies in the rectum. This statement does not mean that 
 in none of the affections of the rectum — especially the surgical dis- 
 eases — is a regulation of the diet necessary. In some affections of 
 the rectum — stenosis and strictures, hemorrhoids, and fissures — a 
 systematic regulation of the diet is indicated. As regards the first 
 of these affections, the diet to be ordered is the same as that for 
 obstructions of the intestines situated higher up in the alimentary 
 canal. 
 
 Special treatment is necessary for hemorrhoids because of the 
 tendency to constipation, alternating perhaps with diarrhoea, and on 
 account of the bleeding which may occur. The bowels should be 
 
THE DIETETIC TREATMENT OP INTESTINAL DISEASES 157 
 
 regulated, and for this purpose tlie " constipation diet " will usu- 
 ally suffice. Where both patient and physician are impatient, mild 
 laxatives may be used. 
 
 Where the tendency to profuse hemorrhages exists, substances 
 whicb increase the discharge of fluids from the intestines — i. e., 
 acids, alcohol, spices — should, if conditions permit, be excluded from 
 the diet. 
 
 The diet in fissures of tlie rectum and proctitis should be so 
 arranged that the movements are retarded as mucb as possible ; if 
 necessary, opium may be used. Generally this treatment is very 
 satisfactory to the patients because every movement is apt to be 
 followed by severe pain. I keep these cases on a soup diet from 
 eight to ten days. When the fissure bas healed and there is no more 
 pain during or after movements, a dose of castor oil should be given. 
 Gradually the patient may be permitted to return to bis usual diet. 
 In proctitis the diet should be managed in such a manner that all 
 irritating substances are excluded, and that the movements are soft 
 and easily passed. When the movements are very painful the patient 
 should be placed on a bland diet, and, until the inflammation has dis- 
 appeared, the intestinal peristalsis should be diminished by means of 
 opiates. Similar treatment is also called for in periproctitis, and is 
 rendered more easy of accomplishment because the appetite of the 
 patient is diminished through the severe pain and the high fever 
 characteristic of the affection. In other cases, a careful empty- 
 ing of the colon (by means of injections and intestinal lavage) is 
 indicated. 
 
 LITERATURE 
 
 1. Rubner. Zeitschr. f. Biologie, Bd. xv, S. 115. 
 
 2. Fr. Müller. Zeitschr. f. klin. Medicin, Bd. xii. 
 
 3. Hirschler. Zeitschr. f. physiol. Chemie, Bd. x, S. 306. 
 
 4. Ortweiler. Mittheilungen aus d. medicin. Klinik in Würzburg, 1886, 
 
 Bd. ii. 
 
 5. Bokai. Arch. f. experira. Pathol, u. Pharmakol., Bd. xxiii. 
 
 6. Strauss. Zeitschr. f. klin. Medicin, Bd. xxix, 1896, S. 221. 
 
 7. Gans. Berliner klin. Wochenschr., 1889, No. 13. 
 
 8. Sahli. Verhandl. des Congresses f. innere Medicin, 1895. 
 
 9. Quincke. Ibid. 
 
 10. Penzoldt. Handbuch d. spec. Therapie innerer Krankheiten, Bd. iv, S. 724. 
 
CHAPTER IX 
 
 THE HYDRO THERAPEUTICS OF INTESTINAL DISEASES 
 
 In tlie treatment of affections of the intestines, hydrotherapy 
 plays almost as important a part as in that of the stomach. It is, 
 however, very difficult to give a good account of the action of hydro- 
 therapeutic measures, be the water taken internally or as baths, or 
 both together, or to determine exactly what effects climatic influ- 
 ences have upon the patient. The number of factors that have to 
 be taken into account is so large that in the greater number of cases 
 it is hard to say what part of the results obtained is due to rest and 
 exercise, to diet, to the change in surroundings, or to the treatment of 
 the physicians at the watering place visited by the patient. We are 
 often in the position of the physician who has given a prescription 
 containing four or five drugs ; the patient is improved, but the physi- 
 sician is unable to say to which one of the drugs the result was due. 
 
 The employment of mineral waters is to a certain extent empiri- 
 cal, for we really have little positive knowledge concerning the action 
 of these waters on the healthy or diseased intestines that we could 
 use as a basis for a systematic treatment. Every busy practitioner, 
 therefore, is accustomed to formulate therapeutic principles for him- 
 self according to his experience with these agents. As in my Dis- 
 eases of the Stomach, I shall also here give an account of the impres- 
 sions which I have gained from an experience vrith a large number 
 of carefully observed cases. 
 
 Eor simplicity, hydrotherapeutic measures may be divided into 
 the drinking of waters, hydrotherapeutic baths, seashore, and moun- 
 tain-air cures. The hydrotherapeutic procedures proper will be 
 considered in the Special Part of this book. 
 
 1. The DrmTcing of Waters. — The influence of a course of waters 
 is based upon their action upon the intestine. They may stimulate 
 or diminish peristalsis; they may, so to say, wash out the entire 
 alimentary canal and remove mucus, bacteria, and various toxic 
 products from its interior. The Avaters may have only an indirect 
 action upon the intestines ; for example, in those cases where an 
 improvement of an affection of other organs (gastric, hepatic, or 
 158 
 
THE HYDßOTHBRAPEUTICS OF INTESTINAL DISEASES I59 
 
 cardiac disease) is followed by an improved condition of the intes- 
 tinal functions. 
 
 We will limit ourselves to a consideration of the direct action of 
 waters upon intestinal diseases, and shall first give an account of the 
 mineral waters which increase peristaltic action. These are : 
 
 («) Alkaline carbonated waters (main constituents, bicarbonate 
 of soda and carbonic acid). 
 
 (5) Alkaline mnriated-carbonated waters (main constituents, so- 
 dium carbonate and chlorid, carbonic-acid gas). 
 
 (0) Sodium sulphate waters (main constituent, sodium sulphate). 
 
 {cT) Muriated waters (main constituent, sodium chlorid). 
 
 {e) Bitter waters (main constituents, sodium and magnesiuai 
 sulphate). 
 
 As regards the first group, they have only a very slight effect in 
 increasing the activity of the intestines. Owing to the sodium bicar- 
 bonate and carbonic acid contained in them, they may act as laxa- 
 tives when given in very large doses. Their use would be limited 
 to very mild cases of constipation, and to those diseases in which a 
 very slight laxative action is desired in addition to the general tonic 
 effect of a mineral water. It need hardly be mentioned that the 
 cold waters have more effect than the warm waters. 
 
 Cold alkalme carbonated waters may be arranged, according to 
 their percentage of bicarbonate of soda, into * Yals, Bilin, Fachingen, 
 Fellathalquelle, Preblau, Salzbrunn, Geilnau, and Giesshiibl. Ther- 
 mal alkaline carbonated waters are Yichy and JSTeuenahr. 
 
 [In the United States we have the following springs of this 
 class (arranged in the order of their percentage of bicarbonate of 
 soda) : Cold springs : The California Seltzers, Azula Springs (Cali- 
 fornia), Bladon Springs (Alabama), Adam's Springs (California), 
 and Waukesha (Wisconsin). Thermal springs : Ukiah Yichy (Cali- 
 fornia), Howard (Excelsior Spring) (California); and, as an example 
 of the hot alkaline carbonated, we have Skagg's Hot Springs in 
 California (temperature = 120° to 140° F.).] 
 
 The second group of waters, the alkahne muriated, have a similar 
 action to that of the first group, except that the high percentage 
 of sodium chlorid which some of them contain may make them par- 
 ticularly useful in the treatment of constipation. Of course the 
 
 * The detailed account of these mineral waters may be found in my work on 
 the Diagnosis and Treatment of Diseases of the Stomach (Part I, p. 282 et seq., 
 fourth edition). 
 
160 DISEASES OP THE INTESTINES 
 
 temperature of the water lias its due influence. Among the cold 
 muriated springs I may mention Sczawnicza (Magdalen Spring, 
 4.61 grams of ISTaCl per litre), Luhatschowitz (Yincenz Spring, 3 
 grams ISTaCl per litre), Gleichenberg (Constantin Spring, 1.85 grams 
 ^aCl per litre), Selters (2.3 grams J^aCl per litre), Tönnistein (1.4 
 grams per litre). Among thermal chlorid waters may be men- 
 tioned Ems (Fürsten Springs, 1 gram JSTaCl per litre). 
 
 [The most celebrated springs of this group in the United States 
 are those of Saratoga in IsTew York. In all, there are between 
 twenty and thirty springs at this famous watering place. The amount 
 of sodium chlorid found in them ranges from 1.86 grams (Flat 
 Rock Spring) to 12.04 grams (Champion Spouting Spring) per 
 litre,* Between these two extremes there exists a most varying 
 percentage. Other cold alkaline muriated-carbonated waters are 
 those of the Tolenas Springs, California (3.3 grams per htre) ; the 
 Pacific Congress, California (2 grams) ; the Dixie Springs, Tennessee 
 (1.9 grams) ; the St. Clair (Salutaris) Springs, Michigan, the Litton 
 Seltzer, California (each containing about 1.4 grams to the litre) ; 
 the ^tna Soda Springs, California (0.5 gram to the litre) ; Mani- 
 tou, Colorado (0.41 gram) ; the Medical Lake, Washington State, 
 and the Plymouth Eock, Michigan (each with about 0.26 gram) ; 
 and the Cresson Magnesia Springs, Pennsylvania, which contains 
 but 0.021 gram to the litre. As examples of thermal and hot 
 springs of the group under discussion we have the Las Yegas Hot 
 Springs of Kew Mexico (temperature from 110° to 140° F.), whose 
 largest spring (ßo. 6) contains 0.26 gram of J^aCl to the litre ; 
 the Ojo Caliente Hot Springs (temperature 90° to 122° F.), fifteen 
 in number, and containing 0.38 gram to the litre ; the Aguas Cali- 
 ente (Coahuila Yalley, California), which contain 0.53 gram to the 
 litre, and whose temperature varies from 58° to 142° F. Finally, 
 there is the Fountain Geyser of the Yellowstone K^ational Park 
 (temperature 1Y9.6° F.), whose water is estimated to contain 0.54 
 gram of I^aCl to the litre.f ] 
 
 The third group of waters contains a greater or less quantity 
 of sodium sulphate and a small percentage of sodium bicarbonate 
 and chlorid, and carbonic acid. Gold water springs are Marienbad, 
 
 [* These figures and most of those herein stated are taken from the tables of 
 analyses given in Crook's Mineral Waters of the United States, etc., the latest and 
 undoubtedly the best work on the subject. — Tr.] 
 
 [f The waters of these hot springs are employed mostly for bathing pur- 
 poses. — Te.] 
 
THE HYDROTHERAPEÜTICS OF INTESTINAL DISEASES 161 
 
 Tarasp, Elster (Salt Spring), Rohitsch, Franzensbad (Salt Spring). 
 Thermal springs are Carlsbad and Bertrich. 
 
 The cold sodium sulphate waters have a greater cathartic action 
 than the warm ones. Carlsbad is vaunted for its special good effects 
 on chronic catarrhs of the small and large intestines. Marienbad 
 and the Salt Springs of Franzensbad and Elster are particularly rec- 
 ommended for hemorrhoidal affections and abdominal plethora with 
 constipation. 
 
 [Very few of the cold springs of the United States of which we 
 have a trustworthy analysis contain a preponderance of sodium sul- 
 phate over the other mineral ingredients. Such are the Lineville 
 Mineral Springs of Iowa, which contain 3.1 grams of sodium sul- 
 phate to the litre ; the Rocky Mountain Springs of Colorado, with 
 1.8 grams of sodium sulphate to the litre ; the Aqua de Yida of 
 California, the Lower Spring with 0.25 gram, and the Upper with 
 0.3 gram to the litre. The Upper Spring also contains magnesium 
 sulphate. Porter Springs, Colorado, contain 0.47 gram of sodium 
 sulphate to the litre. 
 
 The thermal and hot springs are more numerous. As examples 
 we have the Arrow Head, the San Bernardino, and the Great Pa- 
 raiso Hot Soda Spring of California ; the Pagosa and the Middle 
 Park Hot Springs of Colorado ; the Ferris of Montana ; and Wal- 
 ley's Hot Springs and Gibson's Mineral Well of Texas. The sodium 
 sulphate in these waters varies from 0.021 gram (Walley's) to 4.4: 
 grams (Gibson's) to the litre.] 
 
 The m,uriated waters contain more or less sodium chlorid and a 
 considerable quantity of carbonic acid. Cold springs are ISTauheim 
 (Kurbrunnen), Neuhaus (Bonifacius Spring), Homburg (Elizabeth 
 Spring), Mergentheim, Kissingen, Soden. Thermal springs are 
 Wiesbaden (Kochbrunnen) and Bourbon les Bains. 
 
 [Many cold waters of this group are found in the United States ; 
 some have too high a percentage of sodium chlorid to render them 
 suitable for anything but bathing. Such are the l^eptune Spring 
 (Glen Springs, ISTew York), which contains 109.18 grams, and 
 Clark's Red Cross Mineral Well, containing 223.81 grams per litre. 
 The best known of the drinking waters are those of Ballston Spa 
 in Kew York (United States = Y.29 grams sodium chlorid and 
 Sans Souci = 1.46 grams to the litre) ; Sheboygan Mineral Well in 
 Michigan, with 5.24 grams ; and Glen Springs in I^ew York (Salu- 
 bria = 3.37 grams ; Deer Lick = 1.99 grams). Less generally 
 known, but enjoying an excellent local reputation, are the Louis- 
 
1(52 DISEASES OP THE INTESTINES 
 
 yille Artesian Well (Kentucky), the Lodi Artesian Well (Indiana), 
 the Sweet Springs of Missouri, the Spring Lake Well of Michigan, 
 the Wasatka Mineral Springs of Utah, and the Coronado Springs 
 of California. A number of otherwise excellent muriated waters 
 contain large amounts of sulphuretted hydrogen, so that, strictly 
 speaking, they do not belong in this class. These include the 
 Tipper and Lower Blue Lick and the Olympian Springs of Ken- 
 tucky, the Akesion (Sweet Springs) of Missouri, the Cincinnati 
 Sulpho-saline Spring, etc. 
 
 There are fewer hot and apparently no thermal muriated 
 springs. The Utah Hot Springs (131° to 140° F.), the Yampa 
 (Glenwood Springs) (Colorado), and the Koyal George Hot Springs 
 (Colorado), used for bathing purposes, are to be classed with this 
 group of waters.] 
 
 The muriated waters improve the appetite, and in large doses 
 increase intestinal peristalsis and thus clear the organism of excre- 
 mentitious material. 
 
 The main action of the bitter waters is cathartic, and hence they 
 may be used to clear the blood and general system of useless sub- 
 stances. We may mention Franz Joseph Spring in Buda-Pesth (24 
 grams of magnesium sulphate and 23 of sodium sulphate per litre), 
 Hunyadi Janos in Buda Pesth (16 grams of magnesium sulphate 
 and 15 of sodium sulphate per litre), Piilna in Bohemia (12 grams 
 of magnesium sulphate and 16 of sodium sulphate per litre), Fried- 
 richshall (5 grams of magnesium sulphate and 6 of sodium sulphate 
 per litre), Apenta, etc. 
 
 [There are between twenty and thirty cold and thermal bitter- 
 water springs in the United States. Although none have as high a 
 percentage of magnesium or sodium sulphate as the above-mentioned 
 European waters, still many of them are excellent cathartic waters. 
 At the head of the cold springs stand the B. B. Mineral Springs of 
 Missouri, which contain 11.5 grams of magnesium sulphate and 1.04 
 of sodium sulphate per litre ; the Estill (Purgative) Springs, 4.5 
 grams of magnesium and 1 of sodium sulphate ; the Epsom Spring 
 (Crab Orchard, Kentucky), 3.5 grams of magnesiuni and 1 of 
 sodium sulphate per litre ; the Harrodsburg Springs, Kentucky 
 (Saloon Spring = 3.8 grams and Grenville = 2.2 grams magnesium 
 sulphate per litre) ; Sowder's Spring (Crab Orchard) has 3 grams 
 of magnesium and 0.4 of sodium sulphate ; Foley's Spring, 3.4 
 grams of magnesium and 1 of sodium sulphate ; Mono Lake (Cali- 
 fornia) contains 2.1 grams of magnesium and 0.3 of sodium sul- 
 
THE HYDROTHERAPEUTICS OF INTESTINAL DISEASES 163 
 
 pliate ; the American Carlsbad Springs* (Illinois), 1.8 grains of 
 magnesium and 0.1 of sodium sulphate, and the Gypsum Springs 
 of Arizona have l.T grams of magnesium with 0.5 of sodium sul- 
 phate. The remaining springs contain magnesium sulphate in 
 amounts varying from 0.02 gram to 0.9 gram to the litre. Men- 
 tioned according to their percentage of magnesium sulphate, they 
 are the Alleghany Springs of Virginia, the Mineral Park Bitter 
 Spring (Arizona), the Greenbrier (West Virginia), the Bedford 
 (Magnesia and Bowling Alley) Springs (Pennsylvania), Seigleris 
 (Magnesia) Spring (California), and the Mountvale Springs (Ten- 
 nessee). Others charged, however, with sulphuretted hydrogen 
 are the Avon Sulphur and Sharon Springs f of 'New York, the Salt 
 Sulphur Springs of West Virginia, the French Lick Springs (Pros- 
 erpine and Pluto) of Indiana, and the Indian Springs of Georgia. 
 
 As examples of thermal and hot bitter waters we cite the Soda 
 (drinking) Spring (Virginia Hot Springs), temperature = 74:° F. ; 
 the Idaho Hot Spring (Colorado), temperature = 85° to 115° F. ; 
 the numerous Catoosa Springs of Georgia, temperature = 212° F.] 
 
 There are some mineral waters which diminish peristalsis. All 
 the waters mentioned above, except the bitter waters, when they are 
 taken warm and in small doses, have this action. Especial mention 
 nmst be made of Carlsbad Sprudel water, which has a great reputa- 
 tion in chronic diarrhoea. In addition, the waters which contain 
 lime and iron must be considered in this connection. 
 
 Of the lime waters, particularly those which contain calcium 
 carbonate, Germany has the following varieties : Wildungen (König's 
 Spring), Driburg (Herster Spring), Lippspringe (Arminius Spring), 
 Eappoldsweiler (Carola Spring), Marienbad (Eudolf's Spring), Co- 
 burg (Mariannen Spring) ; the last-named water is generally used for 
 exportation. The table below gives the composition of these waters : 
 
 Wildungen (König's Spring, temperature 10° C). • • 
 Driburg (Herster Spring, temperature 10.6° C.) . . • 
 Rappoldsweiler (Carola Spring, temperature 18° C.) 
 Lippspringe (Arminius Spring, temperature 21.2 G.) 
 Coburg (Mariannen Spring) 
 
 Carbonate of lime 
 
 Free CO,. 
 
 and carbonate of 
 
 Cubic 
 
 magnesium in litres. 
 
 Centimetres. 
 
 2.23 
 
 1.323 
 
 1.51 
 
 1,043 
 
 0.77 
 
 
 0.61 
 
 646 
 
 0.3463 
 
 343 
 
 [* The name " Carlsbad " is inappropriate, for the waters of Carlsbad in Bohe- 
 mia contain large quantities of sodium sulphate, and no magnesium sulphate 
 whatever.] 
 
 [f This is essentially a sulphuretted and sulphate of calcium spring.] 
 
Iß4: DISEASES OF THE INTESTINES 
 
 [Tlie list of carbonate of calcium springs in the United States is 
 too long to be even detailed here. A number of tliem contain 
 considerable quantities of this salt. All the Saratoga waters have 
 it in amounts ranging from 0.72 gram to the litre (Empire and 
 Eureka Springs) to 2.9 grams (Geyser Spouting and Hathorn) and 
 3.9 (Champion Spouting).* Other waters of this class are the 
 Americanus Mineral Well (formerly Michigan Congress), with 1.4Y 
 grams per litre; California Seltzer, with 1.25 gram; Montesano 
 (Missouri), 1.2 grams; (Tolenas (California), 0.85 gram; Sans 
 Souci Springs (Ballston Spa, N. T.), 0.74 gram ; Akesion (Sweet 
 Springs, Mo.), 0.69 gram; and the Soda (Summit Springs, Cal.), 
 0.65 gram to the litre. To mention a few others with lesser 
 amounts of calcium carbonate, there are the Geneva Lithia, the 
 Adirondack, and the Avon Sulphur (Lower) Springs of Xew York ; 
 the Kickapoo and Indian Springs of Indiana ; the Sheboygan and 
 Leslie of Michigan ; the Boiler (bathing) and Soda (drinking) of 
 Yirgiuia Hot Springs ; the Koyal George of Colorado, Waconda of 
 Kansas, Crocker of Tennessee, Old Sweet of "West Yirginia, the 
 Upper and Lower Blue Lick of Kentucky, the Bartlett of Cali- 
 fornia, etc.] 
 
 The Iron or Chalybeate Waters. — These contain carbonates as 
 well as sulj)hate of iron, and have a tendency to diminish secretion 
 in the body. They are especially useful in chronic diarrhoea or 
 intestinal catarrhs with diarrhoea, of which anaemia is the causative 
 factor. The best known carbonated chalybeate waters are Franzens- 
 bad, Elster, Driburg, Reinerz, Rippoldsau, Pyrmont, Schwalbach, 
 and Cudowa. Of sulphate-of-iron waters we may mention Konneby 
 in Sweden, Levico and Koncegno waters, and the Guber Spring. 
 
 [Many waters of this countiy have been found upon analysis to 
 be very good chalybeates. Combining, as many of them do, a 
 goodly proportion of other minerals (sodium, magnesium and cal- 
 cium, chlorids, carbonates, and sulphates), they are seen to be most 
 excellent mineral waters. But a limited number can be mentioned ; 
 an analysis and other details will be found in works devoted to the 
 subject of mineral waters (Crook, A. ]^. BelP, Walton^, etc.). 
 Xamed in the order of their percentage of carbonate of iron, we 
 have the Iowa White Sulphur Springs ; the Chittenango Sulphur 
 Springs of ISTew York (Magnesia Spring) ; the Owasso Spring 
 
 [* In addition to the amount of calcium carbonate here stated, the Saratoga, as 
 well as all the other waters of this class, contain considerable proportions of mag- 
 nesium carbonate. — Tr.] 
 
THE HYDROTHERAPEÜTICS OP INTESTINAL DISEASES 165 
 
 (Michigan) ; the Pacific Congress (Cahfornia) ; the Sparta Mineral 
 Wells, Wisconsin (Magnetic Mineral Well) ; ISTapa Soda Springs 
 and Mono Lake of California ; Fruit Port Well (Michigan) ; Sara- 
 toga Springs, New York (Putnam, Columbia, Hamilton, Excelsior, 
 and Eureka Springs) ; Wilhoit's Soda Springs (Oregon) ; Ballston 
 Spa (Sans Souci) and the Adirondack Spring of 'New York ; 
 Arrington Springs (Nos. 1 and 2), Kansas; Americanus Mineral 
 Well (Michigan) ; Massanetta Springs (Virginia), etc. 
 
 The following are the principal waters containing the sulphate 
 of iron ; they are arranged according to amount of that salt found 
 in them : The Overall Mineral Wells (Nos. 2 and 1) of Texas ; the 
 Oak Orchard Acid Springs (No. 2) of IN^ew York ; Gaylord and 
 Garlick's Mineral Springs of Pennsylvania ; Bath Alum Springs (Xo. 
 2) of Yirginia ; Indian Springs (Indiana); Bedford Alum Springs 
 (Virginia) ; Texas Sour (or Caldwell's) Springs ; Austin's Springs 
 (Tennessee) ; Iron Lithia Springs (Yirginia) ; Wilbur's Springs 
 (California) ; Fauquier's White Sulphur Springs (Yirginia), etc. 
 In addition, sulphate of iron has been found in a number of the 
 California geysers in amounts ranging as high as 0.49 gram to the 
 litre. 
 
 jFree sulphuric acid is found in the Oak Orchard Springs (about 
 2.25 grams per litre) ; the Texas Sour Springs (0.124 gram per 
 litre) ; the Gaylord and Garlick, the Iron Lithia, and Bath Alum 
 Springs (about 0.086 gram per litre) ; the Bedford Alum (about 
 0.068 gram per litre) ; and owing to its acid reaction is probably 
 also present in the Overall Mineral Wells (Crook).] 
 
 In some cases — I believe in far too few — enemata of mineral 
 water are made use of. For this purpose the thermal waters of 
 Carlsbad, Ems, Wiesbaden, and ISTeuenahr are especially appro- 
 priate, particularly if there exist a catarrhal affection of the lower 
 segments of the intestines. Pollatschek^, more than any one else, 
 has reported very favourable results from small enemata (100 to 
 200 cubic centimetres) of warm mineral waters in chronic catarrh 
 of the large intestine and in ulcerative processes and intestinal neu- 
 roses. I should think that small quantities of chalybeate waters per 
 rectum might be useful in these cases in which iron is not well 
 borne by the stomach. 
 
 If, after this brief resume, we next ask ourselves what practical 
 benefits are to be derived from the use of the above-named mineral 
 waters, we shall find it very difficult to answer our question satis- 
 factorily. 
 12 
 
IQQ DISEASES OF THE INTESTINES 
 
 As already mentioned, so many subsidiary factors are to be 
 taken into account that it is difficult, if not impossible, to clearly 
 define their individual action. Notwithstanding this, the following 
 statements are probably correct. To simplify matters let us classify 
 the most frequent intestinal affections as chronic catarrhs of the 
 large and small intestines, chronic constipation, and chronic diar- 
 rhoea. It would be correct also to distinguish between mild and 
 severe types, but such a division depends largely upon subjective 
 impressions. 
 
 In the milder catarrhs of the small intestine I have seen excellent 
 permanent as well as temporary results from the thermal waters of 
 Carlsbad. These cases are unsuitable for the cold sodium sulphate, 
 the muriated, or the carbonated springs. The warm Carlsbad 
 waters are also most beneficial in mild catarrhs of the large intes- 
 tine^ associated with constipation or with constipation alternating 
 with diarrhoea. l!^ext to these waters, the cold sodium sulphate and 
 the warm and cold muriated waters give the best results. Good 
 results are sometimes obtained from the waters of Ems. 
 
 Positive benefit may be expected in hemorrhoids from the use 
 of the Glauber salt watei's (particularly Marienbad), as well as from 
 the cold muriated waters (especially Kissingen, Homburg, and Mer- 
 gentheim). The effect is frequently permanent ; usually, however, 
 the course of waters must be repeated. Water treatment in mild 
 cases of habitual constipation is fairly satisfactory. These are 
 sometimes permanently relieved by the sodium sulphate and muri- 
 ated waters, but generally the relief is only temporary. 
 
 Improvement may be expected in chronic diarrhoea from the 
 use of the Carlsbad waters (the Sprudel in small amounts), the 
 muriated waters (small doses warmed), and from the waters of Ems. 
 
 The above-mentioned calcareous waters are very useful in 
 chronic diarrhoea, although, strange to say, they are very little used 
 for this purpose. In combination with a suitable diet I obtain 
 good results from their use. From an extended personal experi- 
 ence I can warmly recommend the Marienbad Rudolfsquelle, the 
 Coburg Mariannenquelle, and the Lippspringer Arminiusquelle. 
 
 Seigere forms of intestinal catarrh, constipation, and diarrhoea 
 are less likely to be benefitted by a course of mineral waters. The 
 results are either temporary or entirely negative. Of the many 
 hundreds of private patients who have drunk the sulphated or the 
 muriated waters at the original springs, I have not yet seen one 
 who has derived any permanent benefit from the waters themselves. 
 
THE HYDROTHBRAPEUTICS OF INTESTINAL DISEASES 167 
 
 I could note an inaprovement only in those patients wlio had other 
 treatment, and for whom, therefore, the drinking of the waters 
 was really superfluous. 
 
 The cause of failure in these cases is very clear. Proper regu- 
 lation of the diet is the main factor in the treatment of the severer 
 types, and not even in a place so well organized as Carlsbad is this 
 feature as thoroughly attended to as is necessary. Rest in bed for 
 a longer or shorter period is essential to the cure of the severer 
 forms of chronic diarrhoea and of the intestinal catarrhs that cause 
 them. It is very difficult or even impossible to obtain this in a 
 watering place, unless the latter contains a sanitarium such as have 
 of late been successfully introduced in various watering places. 
 From this it follows that only mild and very recent cases are 
 adapted to a course of water treatment ; all others should be 
 treated in a sanitarium or a hospital. Since a number of mineral 
 watering places (e. g., Kissingen, Wiesbaden, Carlsbad, Baden- 
 Baden, etc.) have now well-conducted private institutions in which 
 proper regulation of the diet can be, wherever necessary, combined 
 with mechanical therapeutic measures such as massage, intestinal 
 irrigations, etc., we can now send even severe and protracted cases 
 away. There are more such private sanitaria throughout Germany 
 and Switzerland, but as it is impossible to commend them all in 
 this place we refrain from mentioning any.* 
 
 Is the benefit to be derived in mild cases sufficient to warrant a 
 patient in moderate circumstances incurring the heavy expenses of 
 such a cure ? Where a permanent cure can not be anticipated — and 
 this is true in the majority of cases — it is best to advise against such 
 treatment. With the wealthier classes it is quite different, for they 
 visit the baths every year, either from custom or in order to recu- 
 perate from the trials of winter society. It matters, therefore, very 
 little to them whether they derive any benefit from the course of 
 waters or not. At all events, it is wrong to promise any patient a 
 permanent cure of his intestinal trouble from a four weeks' course 
 at a mineral spring. Unfortunately, the physician is too optimistic 
 regarding the effects of mineral waters, and it is not surprising, 
 therefore, that failure to obtain such results is explained upon the 
 ground that " the wrong spring was selected." 
 
 Mineral waters are often drunk at the home of the patient. This 
 
 * A fairly complete list will be found in Penzoldt-Stintzing's Handbuch d. spe- 
 ciellen Therapie innerer Krankheiten, 1. Aufl., Bd. iv, S. 274. 
 
Ißg DISEASES OF THE INTESTINES 
 
 is advisable, if at the same time it can be combined with proper 
 dieting and also a certain amount of rest and freedom from daily 
 occupation. It is also useful as a preliminary test in doubtful cases, 
 
 2. Baths. — Yery often baths are given in connection with a 
 coarse of mineral waters and may even constitute the main part of 
 the treatment. They are classed as natural baths, iron, salt-water, and 
 mud [" moor"] baths. The last-mentioned variety are very impor- 
 tant in the treatment of chronic exudative processes about the intes- 
 tines. The mud baths of Marienbad, Franzensbad, and Elster are 
 the most popular ones.* Salt-water baths are found inland in low as 
 well as in mountainous regions (Reichenhall, Kosen, Salzungen, etc.) 
 and at the seashore (Colberg, Swinemünde, etc.). There can be no 
 doubt as to the favourable influence of these baths upon many cases. 
 Thus in perityphlitic exudations I have occasionally observed re- 
 markable benefit follow the use of salt-water baths. For a com- 
 bination course of mineral waters with salt-water bathing Kissingen 
 and Wiesbaden are good ; for a course of waters with mud baths, 
 Marienbad, Elster, Franzensbad, and Pyrmont are best. 
 
 3. Climatological Treatrnent (Seashore and Mountain Air). — 
 This may be recommended alone, or may also be combined with a 
 <30urse of mineral waters. Without doubt climatic treatment is best 
 adapted to nervous affections of the intestines. It is very often also, 
 and quite correctly, advised as an after treatment to a course of 
 waters. The physician will very frequently have to decide for his 
 patient between seashore and mountain air. This question can 
 only be considered for the individual case ; very frequently, indeed, 
 equally valuable results may be obtained from either region. As a 
 rule, patients whose ordinary vocation inclines them to sedentary 
 habits should be sent to the mountains ; while those living in large 
 inland cities and accustomed to excitement and running about, and 
 to gross irregularities in eating and drinking, should be sent to the 
 seashore. On the other hand, those suffering from organic intesti- 
 nal disorders should not be sent to the seashore or to the moun- 
 tains. I would warn against permitting patients suffering from 
 chronic intestinal catarrhs to partake of tahle (PhSte meals such as 
 are ordinarily served at the seashore or in the mountains. As al- 
 ready mentioned, it is often possible to combine cold-water treat- 
 
 [* In the United States mud baths are given, among other places, at the 
 Arkansas, Virginia, and Las Vegas Hot Springs, At these resorts elaborate bath- 
 ing establishments, modelled after those in vogue at the most celebrated European 
 watering places, have been established. — Tß.] 
 
THE HYDROTHERAPEUTICS OF INTESTINAL DISEASES 169 
 
 ment witb a sojourn in the mountains, and in suitable cases we 
 ought to take advantage of this. Owing to the enormous number 
 of seaside and mountain resorts in Germany and in foreign coun- 
 tries, it is impossible to give even a partial list of them. 
 
 LITERATURE 
 
 1. Pollatschek. Wiener med. Wochenschr. , 1891, No. 23. 
 
 [3. A. N. Bell. Climatology and Mineral Waters of the United States, New 
 
 York, 1885.] 
 [3. Walton. Mineral Springs of the United States and Canada, 1873.] 
 
CHAPTER X 
 
 MASSAGE. ELECTRO- AND HYBUO THERAPEUTICS IN 
 INTESTINAL DISEASES 
 
 1 . Massage 
 
 In intestinal diseases massage is employed to stimulate the re- 
 laxed muscles of these organs, and to cause diffusion and absorption 
 of local inflammatory and peritoneal processes. 
 
 The most frequent indication for massage is furnished by atony 
 of the intestines. 
 
 Technic of Intestinal Massage* 
 
 In order to relax the abdominal walls we begin with rotary 
 efleurage (stroking). In stout persons this is followed by petris- 
 sage (kneading), the object being the crushing of individual fat 
 globules. Petrissage of the deeper tissues is the most important 
 manipulation in intestinal massage. 
 
 " With both hands we grasp the intestines through the abdominal 
 walls, and as though we were handling a muscle that we wished to ex- 
 press, we make the same zigzag forward and backward movements 
 that we would in kneading such muscle. We thus proceed over the 
 entire abdomen. The next step is to stroke the fsecal masses out of 
 the intestines. We begin with the ascending colon, pass upward, 
 follow to the left along the transverse colon, and then continue 
 downward until we reach the sigmoid flexure. At first, stroking 
 movements are made ; later, rotary petrissage is substituted, for this 
 acts more energetically in mechanically removing faecal contents." 
 Hoffa describes "rotary petrissage" (kneading) as follows: "With 
 the hands held at an acute angle to the abdominal wall, and with 
 the finger tips of the left hand resting upon those of the right and 
 
 * We here follow the description given by Hoffa in his Technik der Massage 
 (Stuttgart, 1893), to which work the reader is referred for all further details. (Com- 
 pare also the section on Massage in my Diagnostik und Therapie der Magenkrank- 
 heiten, Part I, p. 324, fourth edition.) 
 170 
 
MASSAGE 
 
 m 
 
 directed upward toward the chest, rotary movements are made in 
 the ileo-csecal region [Fig. 22]. Since sudden pressure would result 
 in rigidity of the abdominal walls, the rotary movements must be 
 gentle, the deeper parts being very gradually approached. The 
 movement is the same that we make in palpating deep-seated ab- 
 dominal tumours. The patient is told to breathe deeply, and with 
 
 [Fig. 22.— Position of Hands and Direction of Movements in 
 Intestinal Massage (Hoffa). — Tr.] 
 
 each expiration we press deeper. The advancing movement on the 
 part of the operator proceeds directly from the shoulder joint, while 
 the finger, wrist, and elbow joints should be held almost rigid." 
 
 Tapotement {percussion) and vibrations of the abdominal wall 
 follow the deep petrissage. These tend to stimulate the smooth 
 muscles of the intestines, and to promote alterations in the circula- 
 tion in the blood-vessels. 
 
 Besides atony of the intestines (especially that associated with 
 flatulence), massage is beneficial in localized peritonitic processes 
 about the intestines, particularly in perityphlitis or appendicitis after 
 the acute stage has passed. In these cases the greatest care must be 
 taken. Above all, we should make it a strict rule never to begin 
 massage until weeks after all inflammatory manifestations have dis- 
 appeared. The regions of the caecum must no longer be sensitive 
 to pressure. It is hardly necessary to state that if there is the least 
 suspicion of an abscess or of tubercular appendicitis massage should 
 never be attempted. 
 
 This last precaution applies also to new growths of the intestinal 
 
172 DISEASES OF THE INTESTINES 
 
 tract, benign as well as malignant. I would also warn against 
 employing massage in intestinal obstruction. As a rule, it can only 
 add to the gravity of the condition. 
 
 Each sitting should last ten minutes, and no single manipulation 
 should require more than two or three minutes. The treatment 
 should lirst be conducted daily for four weeks; after that every 
 two or three days for four to six weeks. In constipation the results 
 from massage will vary largely, for they depend upon the degree of 
 the intestinal difficulty, as well as upon the patience of the subject, 
 and above all upon the skill of the masseur. My own experiences 
 in the matter have led me to form the following conclusions : A 
 permanent result (i. e., regular and sufficient intestinal evacuations) 
 can be obtained from properly conducted massage combined with 
 therapeutic measures which tend to bring about the same result — 
 i. e., diet, gymnastics, electricity, rowing, turning, and other bodily 
 exercises. 
 
 On the other hand, in some cases of intestinal atony I doubt very 
 much whether massage alone can give more than temporary relief. 
 Yery soon after the discontinuance of the massage, even though 
 applied for weeks by an experienced person, the intestine usually 
 fails to properly perform its functions. This result is quite con- 
 trary to that obtained from the above-mentioned diet (page 000), 
 where in the vast majority of cases a permanent effect is secured, 
 continuing even when the diet regime is no longer strictly followed. 
 We do not deny that exceptions do occur, but these do not alter the 
 general rule. 
 
 Regarding massage in localized peritonitis, I can say but very 
 little, for my experience has not been extensive. I am, however, in 
 favour of a trial under the above-mentioned precautions. At times 
 considerable benefit may be derived from the combination of mas- 
 sage with indoor gymnastics, such as have been introduced by G. 
 Zander. This is not the place to enter into a description of such 
 gymnastics, especially as they can only be learned through practical 
 experience. 
 
 2. Electrical Treatment 
 
 This includes the use of the faradic, the galvanic, and the 
 galvano-faradic (mixed) currents. The application, as in the stom- 
 ach, may be either external or intra-abdominal, or, more correctly 
 speaking, rectal. At present opinion is very much divided as to 
 whether galvanism or faradism, or their combination, is more bene- 
 
ELECTRICAL TREATMENT 173 
 
 ficial, and also as to whether the extra-abdominal or intrarectal 
 method gives the best results. In fact, some authors regard the 
 application of electricity to the intestines as utterly useless. 
 
 Our scientific knowledge regarding the action of the electric 
 current upon the intestines is very limited. We know that visible 
 and palpable intestinal movements can be produced in persons with 
 thin abdominal walls or with inguinal Hernia (von Ziemssen). In a 
 case of peristaltic restlessness under my observation we could detect 
 a temporary increase of the intestinal peristalsis. The only sys- 
 tematic experiments were those of Schillbach ^ upon exposed rab- 
 bits' intestines kept in a bath of normal salt solution. His results 
 would seem to indicate that the faradic and the galvanic currents 
 differ in their effects upon intestinal peristalsis, inasmuch as a faradic 
 current of medium strength causes — particularly in the small intes- 
 tine and less so in the large — ascending and descending waves of 
 contraction of a few centimetres of the stimulated bowel. With the 
 galvanic current he observed localized contractions at the cathode, 
 and peristaltic waves of contraction at the anode. In view of these 
 observations, Leubuscher^ and Schillbach particularly recommend 
 the employment of intrarectal galvanization (anode on the abdom- 
 inal wall, cathode in the rectum), and from their experience they 
 believe galvanization gives better results than faradization. There 
 is considerable discrepancy between the views of authorities on the 
 efficiency of electro -therapeutic measures. I^othnageP considers 
 electrization of the intestine less beneficial than massage; Ewald*, 
 too, sees little or no use from electricity in intestinal diseases. On 
 the other hand, Eichhorst ^ reports a case in which unsuccessful 
 attempts were made for eight days to secure a movement of the 
 bowels, and in which a single application of the faradic current was 
 followed by copious evacuations and complete cure of the patient. 
 Unfortunately, the nature of the obstruction (fsecal impaction ?) can 
 not be determined with certainty from the published reports of these 
 cases. 
 
 I should like to describe the technic of intestinal electrization 
 before speaking of the results gained from my own experience. 
 For external application either broad electrodes are to be employed 
 or electric rollers or brushes. As in the electrical treatment of the 
 stomach, so in intrarectal electrization, I have many years employed 
 a soft-rubber tube, with numerous perforations near its tip and with 
 a platinum spiral in its interior (Fig, 23). In addition to the switch 
 for making and breaking the current, the upper part also is provided 
 
174 
 
 DISEASES OF THE INTESTINES 
 
 with a small tube for the in- and outflow of water. The filling of 
 the rectum is accomplished in the usual manner bj a funnel and 
 rubber-tube attachment. From 100 to 200 cubic centimetres of 
 lukewarm water are allowed to flow into the bowel. The other elec- 
 trode is placed upon the abdomen and is moved along the entire 
 course of the large intestine. Each application should last ten 
 minutes. The faradic current can be applied strongly enough 
 to produce distinct visible muscular contractions ; the patient 
 should experience a definite and barely painful prickling sensa- 
 tion. Twenty to thirty milliamperes of the galvanic current will 
 sufiice. 
 
 My personal experience is limited almost entirely to intrarectal 
 faradization. My conclusions are to be considered all the more 
 
 trustworthy because I resort to intesti- 
 nal electrization only when other means 
 have failed (i, e., in the most obstinate 
 cases), and I seldom combine different 
 methods of treatment. I can state that 
 intrarectal treatment succeeds in tnany 
 of the cases in which nothing at all 
 could he accomplished by massage^ diet^ 
 or gymnastics. The patients have well- 
 formed movements daily. We can ex- 
 clude any possible action from the water, 
 for, aside from the fact that it is with- 
 drawn through the tube at the termina- 
 tion of each electrical application, those 
 cases of constipation in which I employ 
 intrarectal faradization are of such an 
 obstinate nature that small enemata of water have no effect what- 
 ever. Besides this, defecation does not immediately follow rectal 
 faradization, but frequently occurs only after many hours. In 
 some cases a permanent benefit is obtained, in others the patients 
 are compelled for months to use the electric rectal sound. Aside 
 from the so-called auto-massage, which is hardly deserving of seri- 
 ous attention, electrization has the advantage over massage that any 
 intelligent patient can employ it for months on himself. 
 
 The use of the electric current is therefore generally indicated 
 in paresis of the intestinal muscle ; its most important sphere, how- 
 ever, lies in those forms of habitual constipation in which over-dis- 
 tention of the ampulla recti had gradually led to paresis of the rectal 
 
 Fig. 23. — ^Electrtc Eectal Tube. 
 
HYDROTHERAPEUTIC MEASURES 175 
 
 muscles and sphincters. In this condition, skilfully applied elec- 
 trical treatment will, as I have repeatedly convinced myself, result 
 in permanent benefit to the patient. 
 
 3. Hydrotherapeutic Measures 
 
 In diseases of the intestines, use is made of external and inter- 
 nal hydrotherapeutic measures. The internal ones are mostly 
 limited to the use of water in the rectum, and owing to their great 
 practical importance will he treated of separately elsewhere. In 
 the following we will consider external hydrotherapeutics only. Of 
 these we employ : 
 
 1. Moist Apjplications. — These may be cold, warm, so-called 
 " Priessnitz " (moist) applications and poultices. The former class 
 exert a stimulating, the latter a sedative, action on the bowel. The 
 Priessnitz pack while cold stimulates, and later exerts a sedative 
 influence on the gut. Hot bran poultices relieve pain, probably 
 owing to the fact that the heat causes a momentary paralysis of the 
 sensitive nerve-endings. Hot or cold water bottles or water bags 
 may be used instead of moist applications ; in general practice, clay 
 bottles filled with hot water and wrapped in flannel or some such 
 impermeable material sufiice. In place of hot bran poultices, I 
 have long used pieces of felt dipped in hot water and then covered 
 with an impermeable material. 
 
 2. Baths. — These are classed^ as full baths, half baths, and sitz 
 baths, all of which can be given at varying temperatures and com- 
 bined with other hydriatic measures. 
 
 3.. Douches. — These are given in the form of cold or warm or 
 of alternating hot and cold (Scotch) douches. They are classed as 
 shoimr, needle, jet, and vapour douches. 
 
 4. Cold or Lukewarm Applications, with Friction, etc. — In most 
 cases these different procedures are combined in various ways, and 
 frequently electricity or massage is given in connection with them. 
 It would be out of place to enter into a detailed description of these 
 here. External hydrotherapeutic measures are mainly indicated in 
 chronic and benign intestinal affections— i. e., catarrhs and neuroses. 
 Intestinal neurasthenia in particular is often very much benefitted 
 \)j hydriatic treatment. At the present day hydrotherapeutic treat- 
 ment is applied almost exclusively in institutions, and its results are 
 in part due to the water applications, but more so, in many cases, to 
 the personality of the conductor of the institute. It can be readily 
 
-[Y6 DISEASES OF THE INTESTINES 
 
 understood that those institutions are best which provide an indi- 
 vidualized diet regime. 
 
 LITERATURE 
 
 1. Schillbach. Virchow's Archiv, Bd. cix, 1887, S. 278. 
 
 2. Leubuscher. Centralbl. f. klio. Medicin, 1887, No. 25. 
 
 3. Nothnagel. Die Erkrankungen des Darms. Wien, 1895, S. 42. 
 
 4. Ewald. Berliner Klinik, Heft 105, 1897. 
 
 5. Eichhorst. Handbuch d. speciellen Pathologie u. Therapie, 4te Aufl., 
 
 1890, Bd. ü, S. 264. 
 
CHAPTER XI 
 
 INJECTIONS (ENEMATA, INTESTINA! LAVAGE, AND DOUCHES), 
 INFLATION, AND GASTRIC LAVAGE IN INTESTINAL DIS- 
 EASES 
 
 1. Injections (Enemata, Intestinal Lavage, and Douches) 
 
 Injections are employed for various purposes : 
 
 1. To stimulate peristaltic action, or by softening hardened faeces 
 to facilitate their removal. 
 
 2. As intestinal lavage, {a) for the removal of pathological sub- 
 stances (mucus, blood, and pus); (5) for the purpose of irrigating 
 the mucous membrane with watery solutions of medical substances. 
 
 3. Mechanically to remove concrements and foreign bodies. 
 
 4. As douches, to strengthen and stimulate the paretic intestinal 
 muscle. 
 
 Technic. — Nowadays enemata are given either by means of an 
 irrigator consisting of a reservoir of varying material (rubber, glass, 
 or metal) connected by rubber tubing, the so-called rectal tube ; or 
 else by means of Hegar's apparatus, in which the reservoir is 
 formed by a glass or rubber funnel. The irrigator is better adapted 
 for use by the patient himself than is Hegar's apparatus, but the 
 latter is far more preferable for the giving of an enema by a second 
 person, since it permits him to regulate the pressure, and in case of 
 too much distention, by simply lowering the funnel, to let any 
 desired amount of water or air out of the intestine. For auto- 
 irrigations I recommend an irrigator holding 3 litres, which is 
 fastened to a support, and, like the well-known Leube-Eosenthal 
 apparatus for gastric lavage, is also furnished with a T-shaped tube. 
 According to Quincke, the rectal tube is best made of soft rubber ; 
 the English [French] stiff or hard-rubber tubes are decidedly infe- 
 rior to it, and if employed at all, should be thick and rounded off at 
 their lower end and provided with two or three large [lateral] open- 
 ings. To avoid injury to the parts, all rectal instruments should be 
 
 177 
 
178 DISEASES OP THE INTESTINES 
 
 smooth and free from cracks. For this reason soft-rubber tubes 
 are to be preferred. 
 
 In place of the above-mentioned apparatuses there are others 
 adapted to auto-injections per rectum (e. g., the so-called injection 
 pumps, alpha syringes, etc.), all based upon the principle of forcing 
 water into the rectum under a certain degree of pressure. All in 
 all, the value of these and similar apparatuses described in the cata- 
 logue of instrument makers is not very great. Even their advantages 
 for use during travel is questionable. I would emphasize, better re- 
 sults are not obtained with these than with the irrigator or funnel. 
 As regards the technic of giving or taking an enema, in the first place, 
 one must have a definite idea of the object in view. If it be desired 
 to act upon the colon in order to stimulate peristalsis, this is best 
 done with the rectum as empty as possible. The method employed 
 is similar to that used in giving an intestinal douche, to the discus- 
 sion of which we refer the reader for technic and indications. 
 
 For the removal of hardened faecal masses from the intestine, 
 we employ thermal, mechanical, chemical, or electrical methods, 
 singly or combined. 
 
 Thermal stimuli consist in the injection of cold fluids of a tem- 
 perature of 18° C. [65° F.] or less. Sometimes irrigations of ice 
 water are recommended — e. g., in bleeding from hemorrhoids — but 
 such measures are not without danger. 
 
 The mechanical effect is obtained, in the first place, from the 
 introduction of the instrument itself, and, secondly, from the in- 
 jected water. 
 
 The purpose of chemical agents is either to exert an infiuence 
 upon the intestinal wall or to soften hardened faeces. 
 
 The effect of intrarectal electrical treatment has already been 
 described on page 174. 
 
 It is not easy to state which of these methods is the best. In 
 some cases— i. e., in certain stages of constipation — one apparently 
 obtains good results from any one of them. Without doubt, indi- 
 vidual idiosyncrasies play an important role here just as they do 
 in the medicinal treatment of constipation. I shall not, therefore, 
 enter into a discussion of the relative value of the various methods 
 in use, but shall confine myself to those which my experience has 
 taught me are best. 
 
 The quantity of fluid that should be injected into the rectum is 
 a question of primary importance. It is clear that 1 or 2 litres 
 of fluid, when injected into the lower portion of the bowel, will 
 
INJECTIONS lY^ 
 
 cause an acute extreme distention of the intestine and a resulting 
 tenesmus, so that the greater part or the whole of the fluid is expelled 
 without sufficient purgative action. It is immaterial whether one 
 uses cold or warm water, oil, vinegar, soapsuds, or glycerin. Even 
 the more active irritant remedies exert an insufficient influence 
 upon the bowel when they remain in it for a short time only. If 
 the lowermost portion of the intestines contain fsecal masses, these 
 will be forced out mechanically with the water. 
 
 The general rule to be followed in the majority of cases is this : 
 the quantity of fluid used should be small, not exceeding 300 c. cm., 
 and should be slowly injected under slight pressure. It is best to 
 have the patient lying on the left side with the pelvis raised. 
 This amount of fluid should be retained for several hours, so as 
 to cause a gradual softening of the intestinal contents or a stimula- 
 tion of the smooth muscle fibers of the bowel wall. I generally 
 leave orders to have these enemata given at night, so that the bowels 
 move the next morning, or else given in the morning, so as to obtain 
 a movement in the evening. Glycerin, soap, sugar, honey, etc., 
 added to the enema increase the softening effect upon the faeces. 
 Penzoldt's^ experience, which I can substantiate throughout, was 
 that soap acted most energetically in this respect, and oil somewhat 
 less so. Others have recommended limewater for the same pur- 
 pose. As a rule, I order the following as an effectual enema : One 
 teaspoonful of soap shavings, or of good glycerin soap, dissolved in 
 a quarter of a litre of lukewarm water to which is added one to 
 two tablespoonfuls of glycerin. As a result of Fleiner's ^ recom- 
 mendation, oil injections of from 400 to 500 c. cm. are very fre- 
 quently used. Fleiner believes that it is very important to use 
 only the purest oil, and for this purpose he has especially recom- 
 mended sesame oil. The disadvantage of the method is that fre- 
 quently the patient's clothes are soiled by the oil. For this reason, 
 and also because the oil partly adheres to the walls of the irrigator 
 and tube, I order the oil to be used in the form of an emulsion, and 
 recommend the following procedure : A piece of soda the size of a 
 bean is dissolved in a quarter litre of water ; to these are gradually 
 added two tablespoonfuls of commercial cod-liver oil and the mix- 
 ture thoroughly shaken ; two tablespoonfuls of castor oil are then 
 added, and the whole mixture shaken until an emulsion has been 
 formed. The resulting emulsion readily flows through the irrigator, 
 is well retained by the patient, and even in the most obstinate 
 cases will succeed in softening hardened faeces. In an experience of 
 
180 DISEASES OP THE INTESTINES 
 
 almost ten years I have never seen any irritation, pain, or other 
 unpleasant symptoms from them, and I therefore warmly recom- 
 mend them. 
 
 In this place it is proper to discuss " high enemata," concerning 
 which mnch is said in daily practice, and to the mechanism of 
 which due consideration is seldom paid. We have already noted 
 that rectal tubes can seldom be introduced beyond the sigmoid 
 flexure or the descending colon, since they are generally arrested in 
 the sigmoid flexure, and further attempts result in a bulging of the 
 intestinal wall. It is no better with rigid French or English tubes 
 than with the soft JSTelaton tubes ; the former pass more readily into 
 the sigmoid flexure, although they are very apt to be arrested by the 
 folds of this portion of the intestines. We see, therefore, that the 
 whole question of the so-called high enemata is in many respects an 
 illusion. 
 
 Even for extensive lavage of the upper portions of the intestines 
 it is not necessary to introduce the tube very high. By means of 
 auscultation one may convince himself that even when the tube lies 
 in the rectum and the patient is properly placed (lying on his [left] 
 side with raised pelvis, or in the knee-chest position), fluids pass as 
 far as the caecum. 
 
 Irrigations of the bowel by means of a funnel are especially use- 
 ful for the removal of fsecal masses and tightly adherent mucus 
 from the large intestine. In obstinate constipation I have had very 
 good results from enemata consisting of several litres of soapsuds 
 (with the addition of glycerin, castor oil, and cod-liver oil if neces- 
 sary). 
 
 Indications for Enemata and Irrigations of the Intestine. — Ene- 
 mata are most frequently used in acute and habitual constipation. 
 Regarding their usefulness or disadvantages there is a diversity of 
 opinion among physicians and laymen. We cannot here enter into 
 this question. From my own experience, I believe that enemata 
 have a wide fleld of application both in acute and in habitual con- 
 stipation ; when properly given they are generally successful. They 
 are said to have the disadvantage of distending the large intestine 
 and thus increasing its atony. This is certainly true where very 
 large enemata are given. When given as recommended by us this 
 result need not be feared. Therefore, whenever possible in habitual 
 constipation enemata should be given preference to laxatives. An 
 internal laxative is best in acute constipation complicated by acute 
 gastric catarrh. The second most frequent indication for enemata 
 
INJECTIONS 181 
 
 is chronic catarrh of the large intestine with profuse diarrhoeas or 
 excessive mucus formation. Here one should use lukewarm water, 
 or, better still, physiological salt solutions or solutions of medicinal 
 agents. The latter should be chosen according to the eifect desired ; 
 thus we may use antiseptics such as lysol, boric acid, salicylic acid, 
 salicylate or benzoate of soda, thymol, etc, or astringents such as 
 tannin, aceto -tartrate of aluminium, and nitrate of silver,* or mucus 
 solvents such as boracic acid, or bicarbonate, carbonate, or acetate 
 of soda,f or limewater. Here intestinal lavage is much better than 
 enemata, for it enables us to first cleanse the bowel and then imme- 
 diately thereafter apply our medication. If tenesmus occurs, it may 
 at once be allayed by lowering the funnel. The lavage should be 
 repeated once or twice daily. 
 
 A further indication for lavage is furnished by chronic stenoses, 
 where these are not caused by extensive ulcerations or tumours 
 which tend to perforate. Since we have no general diagnostic crite- 
 rion for these conditions, great care must always be exercised — 
 i, e., avoid great pressure, and give only small enemata, frequently 
 repeated. Syringes which force fluids into the gut should never be 
 used. While the effect from these irrigations is mainly palliative, 
 skilful application may occasionally enable us to relieve a sudden 
 and dangerous total intestinal obstruction arising from dietary error 
 — e. g., impaction of indigestible food remnants. 
 
 It is sometimes possible to loosen and wash out gallstones, cop- 
 roliths, or swallowed foreign bodies causing an obstruction. In 
 obstruction from gallstones I would recommend the employment 
 of injections of chloroform water (10 : 1,000) in order to dissolve 
 small fragments of these concrements. This should be done under 
 anaesthesia, as it is then possible to pass beyond the ileo-csecal valve. 
 I have not had any practical experience in the matter. 
 
 Furthermore, enemata are indicated in acute and chronic invagi- 
 nations : in the acute, in order to reduce the invagination ; in the 
 chronic, to prevent or relieve coprostasis above the invaginated 
 portion. J^othnagel especially recommends injections of 5 to 8 per 
 cent saline solutions, and bases his recommendation upon animal 
 experiments, in which he found that physiological invaginations are 
 overcome by saline injections. 
 
 * We use one teaspoonful of tannin, boric acid, and aceto-tartrate of aluminium, 
 or one half to one gram of silver nitrate to the litre of water, 
 
 f Bicarbonate, carbonate, or acetate of soda are used in the strength of one 
 dessertspoonful to the litre, 
 13 
 
182 DISEASES OP THE INTESTINES 
 
 Intestinal Douche. — In the intestinal douche we have a means 
 of stimulating and strengthening the neuro-muscular apparatus of 
 the lower portion of the large intestine. Here, as in the stomach, 
 we employ a funnel and rubber tube armed with a short, soft, Nek- 
 ton rectal tube, the end of which contains ten to fifteen small open- 
 ings. The tube is introduced as far as possible, preferably under 
 the guidance of the finger. Ordinary cold water, or cold water 
 alternating with hot, is employed, or we may also use water charged 
 with. CO3. As already mentioned, it is best to have the rectum 
 emptied before giving the douche. 
 
 In a series of cases of atony of the large intestine, especially in 
 those in which scybala were retained in the recesses of the sigmoid 
 flexure and the amj^ulla of the rectum and caused marked tenes- 
 mus, this procedure has proved a very valuable one. 
 
 2. Inflation of Air 
 
 Inflation of air, the diagnostic value of which has already been 
 discussed, is warmly recommended by some writers as a means of 
 relieving obstructions, especially of the lowermost portions of the 
 intestine. Curschmann^, in particular, has often spoken in favour 
 of intestinal insufflation in cases of volvulus of the sigmoid flexure 
 and intestinal stenoses, and he prefers it to the injection of water. 
 He recognises, however, that there are dangers connected with the 
 procedure, and therefore advises that it should be employed with 
 great caution in specially selected cases. The recommendation of 
 Curschmann, to use a tube of such a form as to permit the entry 
 and exit of air at will, is certainly worthy of consideration. It is 
 more difficult to fulfil Curschmann's second condition — namely, the 
 selection of suitable cases. Thus, it is often impossible to determine 
 whether ulceration of a carcinoma of the colon has occurred and if 
 there is danger of rupture. It is often exceedingly difficult to de- 
 termine the nature of a stenosis. I believe that all stenoses due to 
 ulceration or tumours constitute a contra-indication to insufilation 
 with air. It is also advisable not to attempt this procedure in 
 invaginations low down, as one can never determine with certainty 
 how far the process has advanced (beginning gangrene). Careful 
 insufflation may be done in simple volvulus of the sigmoid flexure 
 when the diagnosis is certain. 
 
INJECTIONS 183 
 
 3. Gastric Lavage in Intestinal Diseases 
 
 Gastric lavage in intestinal diseases comes up for consideration 
 in stenosis or stricture of the bowel, above wbich faecal matter has 
 collected ; also where fermenting stomach contents exercise an 
 unfavourable influence upon the intestines. In the latter case, how- 
 ever, the retention of stomach contents in itself constitutes an 
 indication for gastric lavage. Lavage may be advisable, though not 
 necessary, in patients in whom an excessive production of acid or 
 of mucus in the stomach causes an irritation of the mucous mem- 
 brane of the small intestine, and frequently a resulting diarrhoea. 
 
 In general, lavage of the stomach is done for stenosis or stricture 
 of the small intestine ; but in obstruction or occlusion of the large 
 intestine, according to numerous writers, it is often a life-saving pro- 
 cedure. The credit for having first tried and recommended gastric 
 lavage in obstruction must be given to Kussmaul and his disciple 
 Calm*. From the observation of three cases, they showed that by 
 means of this procedure cases of ileus with a bad prognosis could 
 sometimes be cured. Soon after Senator- Hasenclever ^, Küster^, 
 Henoch '', Ewald ^, Kauffmann^, Kuhn^*', Curschmann^, Pollak^^ 
 and others reported successful cases, and at the present time we 
 are justified in considering gastric lavage as a useful procedure, 
 scarcely less important than opium. 
 
 As Nothnagel ^^ quite properly observes, we must not expect too 
 much from gastric lavage ; indeed, that procedure at times may not 
 only be ineffectual, but even harmful, since it can further diminish 
 the already exhausted strength of the patients. The results from 
 lavage would depend upon the nature of the obstruction and our 
 ability or inability to overcome it by diminishing the pressure 
 above. Since the nature of the obstruction in acute cases can 
 usually not be determined, it can be readily understood that gastric 
 lavage may be a life-saving procedure in one case, while in another 
 case its effect will be an entirely negative one. 
 
 One point, however, shoul'd always be borne in mind : Gastric 
 lavage should always be resorted to in the early stages of ileus. 
 The more violent and f secal the vomiting, the greater the indication 
 for gastric lavage. For we recognise in fsecal or feculent vomiting 
 a certain sign of a marked putrefaction of the stagnating contents 
 above the site of strangulation, and only through the relief of this 
 condition can we check the violent peristalsis of the bowel and the 
 stagnation of its contents. As a rule, therefore, lavage is only in- 
 
184 DISEASES OP THE INTESTINES 
 
 dicated in those cases of ileus wliicli have not progressed for more 
 than twentj-four to forty-eight hours. In exceptional cases, the 
 period when the general condition of the patient is a good one, 
 lavage may be tried at a later period of the affection. Where there 
 is already beginning heart failure, a miserable, rapid pulse, and 
 possibly, too, impending death, the chances of accomplishing any 
 benefit whatever with the procedure are very slim indeed. If a case 
 such, as that of Pollak * is now and then reiDorted, in which, under 
 most desperate conditions, a cure was effected, it only demonstrates 
 the utmost extreme in which lavage may be of benefit. In private 
 practice it is not always easy to resist the urgent wishes of those 
 interested in the patient, who want every measure tried w^hich can 
 possibly save the patient, particularly if nothing can be lost and 
 possibly much gained thereby. It will always be well, however, 
 to point out the fact that such a mechanical procedure in the late 
 stage of the affection may hasten the fatal termination of the case. 
 
 The condition which presents itself in chronic stenoses, and the 
 indication for its relief, is much simpler. Of these stenoses, those of 
 the small intestine, particularly of the duodenum (supra- and infra- 
 papiEary), call for washing out of the stomach. The conditions are 
 so much like those of stenoses of the pylorus that they are to be 
 treated just like the latter. We must not wait, therefore, wdth 
 lavage until vomiting becomes incessant, but should begin as soon 
 as the stomach contents give evidence of stasis (in infrapapillary 
 stenosis, bile-stained or feculent). 
 
 It is quite evident, however, that only in rare cases can we secure 
 permanent relief of the stenosis by lavage. 
 
 Technic of Gastric Lavage ik Intestinal Obstruction and 
 
 Stenosis 
 
 This differs in a few points from ordinary methods of lavage. 
 In the first place, the stomach must be washed out several times 
 daily (two to five), and the washing must be continued each time 
 until the stomach is entirely empty. The succeeding lavage must 
 not be delayed until vomiting again occurs, but must be done as 
 soon as fsecal matter again enters the stomach. This will be shown 
 by renewed distention of the stomach, which has become less promi- 
 nent immediately after the former lavage. The fact that only clear 
 water flows away with the first washing must not deter us from fur- 
 
 * Loc. cit. (Case IV). 
 
INJECTIONS 185 
 
 ther lavage, particularly where the patient lias previously vomited 
 large quantities. I usually give a centigram of morphin subcutane- 
 ously before washing out the stomach, I have never had occasion 
 to cocainize the pharynx. A hypodermic injection of caffein or 
 camphor may be necessary previous to the lavage. Skilful technic 
 (compression of the tube upon its withdrawal (Ewald) ) will enable 
 us always to avoid aspiration. The pulse is to be carefully watched 
 in very weak individuals. The technic of gastric lavage in chronic 
 stenoses differs in no wise from that of stenoses of the pylorus. 
 Here, too, once a day, best in the morning, is sufficient ; or in the 
 evening, where rest is disturbed by the decomj)Osition of the stag- 
 nating products. 
 
 LITERATURE 
 
 1. Penzoldt. In Penzoldt-Stintzing's Handbuch, Bd. iv, S. 520. 
 
 2. Fleiner. Berliner klin. Wochenschr., 1893, No. 3 u. 4. 
 
 3. Curschmann. Deutsche med. Wochenschr., 1887, No. 21, and Verhand- 
 
 lungen d. VIII. Congr. f. innere Medicin, 1889. (Compare the instructive 
 discussion recorded there.) 
 
 4. Cahn. Berliner klin. Wochenschr., 1884, S. 669. 
 
 5. Hasenclever. Berliner klin. Wochenschr., 1885, S. 65. 
 
 6. Küster. Ibid., 1885, No. 27 u. 28. 
 
 7. Henoch. Ibid. 
 
 8. Ewald. Ibid. 
 
 9. Kauffmann. Vereinsbl. der Pfälzer Aerzte, iii, S. 185. 
 
 10. Kuhn. Bulletin general de Therapeutique, 1885, 15 Juliet. 
 
 11. 8. Pollak. Wiener med. Wochenschr., 1892, No. 51, and 1893, No. 1 u. f. 
 
 12. Nothnagel. Die Erkrankungen des Darms u. Peritoneum, S. 406. 
 
CHAPTEK XII 
 
 MEDICINAL TREATMENT OF INTESTINAL DISEASES 
 
 1 . Cathartics 
 
 By cathartics we understand those remedies which are capable of 
 ridding the intestines of their contents within a short time. Since 
 earhest times these have been divided into mild {eccoprotica sive 
 lenitiva) and powerful cathartics {drastica). Between these classes 
 there is a middle class, the so-called neutral salts, which belong to 
 one or the other classes according to dosage employed and the indi- 
 vidual effect obtained. 
 
 In spite of numerous investigations (confined for the most part, 
 however, to animals), our knowledge of the action of cathartics is 
 very limited. The effect of an individual cathartic varies in all 
 probability with its chemical state. This accounts for the variety 
 of action observed. Thus castor oil acts only after emulsification 
 by the pancreatic juice and the bile ; gamboge, elaterium, jalap, and 
 scammony act similarly. 
 
 Calomel is changed in the small intestines ; a portion of it is 
 converted into corrosive sublimate. "We do not know in what man- 
 ner this substance acts ; all mercurial salts cause increased catharsis. 
 It is probable that the action of this drug begins in the upper part 
 of the intestines, while other cathartics, such as senna, aloes, and 
 colocynth, exert their main action upon the large intestine (Nasse, 
 Radziejewski). 
 
 The action of the neutral salts appeared easiest of explanation. 
 It was natural to suppose that their action was due to a transuda- 
 tion. As great an authority as Liebig supported this theorj^ ; he 
 was followed by French investigators, chief among whom was Pois- 
 seuille. Later Aubert ^ opposed this theory, while Moreau ^ advo- 
 cated it. Eadziejewski ^ regards the influence upon peristalsis as 
 the main principle in the action of cathartics. Brieger^ showed 
 that the action of laxatives is due to stimulation of peristalsis ; neu- 
 tral salts in addition cause an increased secretion of water and a 
 larger secretion from the glands of the intestinal mucous membrane; 
 186 
 
MEDICINAL TREATMENT OP INTESTINAL "DISEASES 187 
 
 finally, that drastic cathartics in small doses act like laxatives, while 
 in larger doses they cause an inflammatory exudate and a hyper- 
 secretion. 
 
 These unsatisfactory results include all that we know of the 
 theory of the action of cathartics, and we must therefore place our 
 dependence upon experience gained in daily practice. 
 
 In this connection my experience leads me to emphasize that 
 every cathartic, or group of cathartics, has clinically a distinct action, 
 and therefore distinct indications. For example, in acute constipa- 
 tion, castor oil, which acts rapidly and painlessly, is first to be con- 
 sidered ; in acute indigestion, with or without bacteriological basis, 
 calomel in large, rapidly repeated doses is useful. The use of the 
 neutral salts or bitter waters is indicated in bilious individuals with 
 hemorrhoids. Between these two are a whole series of other cathar- 
 tics whose use is not especially indicated, but which are valuable 
 only when varied, since most of them lose their action after a time. 
 The physician should, however, have a knowledge of the main 
 and secondary action of these remedies, and make his own indi- 
 cations. 
 
 Opium and belladonna occupy a special position among cathar- 
 tics. We shall recur later to the effect of these substances upon 
 the intestines. In this connection it need only be mentioned that 
 they should be used where spastic contraction prevents the intes- 
 tine from emptying itself. Lead colic is a typical example of this. 
 In spastic affections of the intestine, flatulent colic, stenosis of the 
 intestines, and in ileus, one can accomplish more by overcoming 
 the spasmodic contraction of the bowels than by the use of cathar- 
 tics themselves. 
 
 A large number of cathartics, once very much in favour, have 
 now become obsolete. Among these substances we may mention 
 agaricus, euphorbium, fructus colocynthidis, gamboge, hellebore, 
 herba gratiolss, leptandra virginica, metallic mercury, elaterium, 
 croton oil, scammonium, and jalap tubers. A number of other 
 remedies might with justice meet with the same fate. The follow- 
 ing, on the contrary, are recommended if used under proper indica- 
 tions : castor oil, olive oil, calomel, magnesium salts, cascara sagrada, 
 rhubarb preparations, tamarinds, podophyllin, precipitated sulphur, 
 tartrate of soda, frangula bark, senna leaves. 
 
 With the exception of glycerin, subcutaneous and rectal admin- 
 istration of cathartics (aloes, etc.) has heretofore been but little 
 employed in medicine, although the subcutaneous employment of 
 
188 DISEASES OP THE INTESTINES 
 
 physostigma for cathartic purposes lias been well established in 
 veterinary practice. 
 
 Indications foe the Use of Cathaetics 
 
 We must here differentiate between acute and chronic (habitual) 
 constipation. The employment of cathartics in the first-named 
 condition will depend principally upon the cause of the consti- 
 pation — acute gastric catarrh, initial stage of acute infectious dis- 
 eases, acute intestinal obstruction, typhlitis, appendicitis, invagina- 
 tions, etc. 
 
 The employment of cathartics is indicated only where we can 
 exclude inflammatory processes and displacements of the intestines. 
 As long as there is any doubt, and there is no indication for active 
 treatment of the acute constipation, one should limit himself to 
 enemata, which can never do much harm. When there is a neces- 
 sity for cathartics in acute constipation, a rapidly acting and certain 
 cathartic should be used. If there are many stomach symptoms, 
 calomel is to be recommended ; where there are none such, castor 
 oil is preferable. The various rhubarb preparations are valuable, 
 but these lack the thorough action of the cathartics just named. 
 No others need be considered in these cases. 
 
 In treating these conditions it should be remembered that cathar- 
 tics should be stopped as soon as possible ; it is therefore advisable 
 not to give too small doses. If after one or more doses the con- 
 stipation recurs (Avhich is frequently the case), it is advisable to 
 treat the patient according to the principles previously laid down — 
 i. e., by dietetic measures. 
 
 In chronic {hahitual) constipation the indication for the use of 
 a cathartic, and the selection of the one to be used, depend upon 
 the nature of the affection. We must distinguish between condi- 
 tions in whicli the patency of the intestinal canal is diminished, 
 whatever be the situation or the cause, and those in which the lumen 
 of the bowel is unobstructed. 
 
 In the former class of cases, especially in stenoses of the intes- 
 tine, cathartics are generally indispensable and symptomatically 
 useful. Since a stasis of fsecal contents which is favourable to 
 decomposition processes develops above the point of stenosis, cathar- 
 tics are preferable to enemata, even when stenosis is situated low 
 down. Enemata are generally without result. 
 
 The kind of cathartics to be used is a question of great impor- 
 tance ; those only should be selected which do not cause painful 
 
MEDICINAL TREATMENT OF INTESTINAL DISEASES 189 
 
 spasmodic contraction and thus create a danger of perforation. 
 These are the mildly acting preparations of rhubarb, compound 
 licorice powder, magnesia usta, sodium phosphate, preparations of 
 tamarind and cascara sagrada, tea of frangula bark, etc. Prepara- 
 tions of aloes, bitter waters, podopliyllin, and the senna preparations 
 are to be used with caution. 
 
 In the second class of cases— i. e., those in whicli the permea- 
 bility of the bowel is preserved — the character of the disease deter- 
 mines the method of treatment to be pursued. In my opinion 
 cathartics should be used only in desperate cases of constipation, 
 and in old people in whom the normal reflex excitability of the 
 intestinal muscle has disappeared. Here one should endeavour to 
 use small doses of the milder aperients. Aided by a stimulation of 
 intestinal activity by proper diet, this procedure will often, though 
 not always, be successful. 
 
 The habitual use of cathartics in young persons is to he 
 avoided. After a misuse of these for years, it is very difficult to 
 succeed in bringing back normal peristalsis. I have already men- 
 tioned (page 149) that even in such cases one can sometimes obtain 
 good results. 
 
 CONTKA-INDICATIONS TO THE UsE OF CaTHAETICS 
 
 In acute affections, in which the diagnosis of occlusion of the 
 intestine is certain, the use of cathartics is contra-indicated. In 
 the early stages of an acute intestinal affection, which later proves 
 to be a case of intestinal obstruction, one can not blame the physi- 
 cian for having given a cathartic. In the later stages, where the 
 symptoms of intestinal obstruction are clear, it is an error to give a 
 cathartic. The same holds true for acute inflammatory affections 
 of the type of an appendicitis. Our present knowledge of the 
 nature of this disease (appendicitis) allows us to diagnosticate a 
 typhlitis stercoralis in exceptional cases only, so that it is always 
 advisable to keep in mind the possibility of a primary disease of 
 the vermiform appendix. If, notwithstanding, there is reason for 
 emptying the bowel, enemata are indicated (see page 180). When, 
 in exceptional cases, there is a particular reason for one dose of a 
 cathartic, castor oil is by all means the surest and best drug to 
 use. It is far preferable to the saline cathartics, bitter waters, 
 or rhubarb. In this connection we must mention that cathartics 
 are also contra-indicated in the habitual constipation which so fre- 
 quently follows appendicitis. In most cases the patients do well 
 
190 DISEASES OF THE INTESTINES 
 
 with proper feeding, or good results may be obtained from enemata, 
 glycerin suppositories, etc. 
 
 Cathartics are contra-indicated in young people who have 
 been constipated for a short time only. In children cathartics 
 are absolutely contra-indicated, and their employment can not be 
 too strongly condemned. In these cases continued and energetic 
 care in feeding, combined, perhaps, with massage and gymnastics, 
 gives good results. One should try dietetic measures for several 
 weeks before resorting to the constant employment of cathartics. 
 These drugs are contra-indicated in chronic gastric and intesti- 
 nal catarrhs. As regards the former, I have gained the .impres- 
 sion that cathartics have an unfavourable influence upon the 
 secretion of the gastric juice. This seems to me to be the 
 reason why we more frequently meet with insufficiency of gastric 
 secretion in women than in men, though the latter are more apt 
 to acquire gastric affections on account of their use of alcohol and 
 nicotin. 
 
 Still more important is the contra-indication to the continued 
 use of purgatives in chronic enteritis, affecting either the small or 
 the large intestines. A careful observer who is accustomed to 
 make frequent examinations of the fgeces will doubtlessly have 
 recognised that a slight enteritis of short duration, unnoticed by 
 the patient, results not only from continual use of cathartics, but 
 may also follow one or two doses of a mild laxative. This is much 
 more marked where drastic cathartics are habitually emplo^yed, and 
 I feel I am not exaggerating when I maintain that the more fre- 
 quent occurrence of membranous enteritis in women is due to care- 
 less employment of laxatives. This is already shown from the 
 fact that the mucous secretion ceases at once, and in most cases 
 permanently, when intestinal functions are regulated by physio- 
 logical laxatives. In the special part of this work I shall illustrate 
 this by a series of histories.^ 
 
 2. Antidiarrhoeal Remedies 
 
 Since earliest times medicinal remedies have played an important 
 role in the treatment of chronic diarrhoea. They are believed either 
 to inhibit peristaltic action, thereby creating better conditions for 
 
 * von Noorden, in a very remarkable article upon membranous enteritis (Zeit- 
 sehr. für prakt. Aerzte, 1898, No. 1) takes a stand which I maintained a number of 
 years ago (cf. Deutsch, med. Wochenschr., 1883, S. 1000). 
 
MEDICINAL TREATMENT OP INTESTINAL DISEASES 191 
 
 the absorption of nutritive material from the intestinal canal, or 
 restrict the production of intestinal secretion, or finally to cause 
 neutralization of certain fermentative processes in the intestines. 
 Antidiarrhoeal drugs are furthermore employed to furnish a pro- 
 tective covering for intestinal ulcers, in so far as these are the cause 
 of the diarrhoea and thereby to exert a curative effect upon the 
 latter. Some remedies (calomel, tincture of rhubarb, belladonna, 
 etc.) are laxative in large doses but binding in small ones. There 
 are some drugs, too, which exert a beneficial influence in diarrhcea 
 without our being able to explain their action. 
 
 The correctness of the above statement of the action of drugs 
 in diarrhoea may be disputed ; certain it is, however, that acute and 
 chronic diarrhoea frequently are cured when drugs are administered. 
 
 1. Kemedies which inhibit peristalsis : 
 
 These include opium and its alkaloids (morphin, codein, nar- 
 cein, and papaverin), as well as atropin and the belladonna prepara- 
 tions (particularly in small doses). 
 
 2. Remedies which act upon the intestinal mucous membrane 
 (astringents) : 
 
 These include tannic acid (tannin) and its preparations, tannigen 
 (diacetyl tannic acid) and tannalbin (tannin albuminate). Among 
 other remedies which contain tannic acid may be mentioned Colombo, 
 catechu, hsematoxylon, cascarilla, ratania, oak bark, cotoin, and 
 paracotoin. Nitrate of silver should also be classed with the intes- 
 tinal astringents. 
 
 3. The antifermentative remedies include calomel, salicylate of 
 bismuth and beta-naphthol bismuth (orphol), nosophen, paraform, 
 tannoform, creosote, salol, beta-naphthol, etc. 
 
 4. The remedies which furnish a protective coating include 
 carbonate and phosphate of calcium and similar chalk preparations 
 (pulvis cretse, talcum pi-eparations, bismuth, etc.). 
 
 The Indications foe and Use of Antidiaeehceal Remedies 
 
 Antidiarrhoeal remedies are administered by mouth or as sup- 
 positories (opium, morphin, belladonna, etc.), or finally as rectal 
 injections. Only rarely are they given subcutaneously. For rectal 
 injection, tannin, nitrate of silver, aluminium (preferably the aceto- 
 tartrate salt) or boracic acid are best. They are useful in diseases 
 of the large intestine only, while the internal remedies are to be 
 used in catarrhs of all parts of the bowel. 
 
 In some cases it is easy to determine which remedy to employ ; 
 
192 DISEASES OF THE INTESTINES 
 
 in others the difficulty of correctly interpreting the action of the 
 remedies makes the selection of the proper one in a given case 
 less easy. 
 
 Thus the use of antidiarrhoeal remedies is clearly indicated in 
 acute affections following exposure or errors in diet. The question 
 arises in these cases : Should the remedy he given at once, or only 
 after the bowels have been sufficiently emptied ? In weak individ- 
 uals the immediate administration is in general the better proce- 
 dure ; but where the general condition is very good, we should not 
 be too eager to check a diarrhoea, particularly if this be accompanied 
 by fever (beginning typhoid, infectious gastro-enteritis, etc.), or if 
 there be an epidemic of cholera. On the contrary, it is much better 
 to keep up the diarrhoea for several days by the administration of 
 calomel — large doses at first, smaller ones later. 
 
 If none of these complications be jDresent, we must give a 
 rapidly acting and certain astringent remedy. Opium is the only 
 one to be considered, and should be given in the form of the tinc- 
 ture, the powder, or the extract, combined, perhaps, with the tincture 
 or the extract of belladonna. All other drugs, as well as any other 
 combination with opium, are superfluous. As a rule, it is better to 
 give the opium by the mouth than by the rectum ; only where there 
 is pronounced nausea or marked tenesmus should opium be given 
 jper rectum, and then in the form of suppositories combined, perhaps, 
 with belladonna extract. Morphin, codein, papaverin, and other 
 alkaloids of opium are inferior to the mother drug in their action. 
 l^oi enough is known about subcutaneous injections of the watery 
 extract to allow one to express an opinion as to their efficiency. 
 
 Opium, whenever indicated, should be given in effective doses, 
 but continued for a short time only. I would strongly w^arn against 
 small divided doses. The correct amount for an adult is twenty 
 drops of the tincture two or three times a day, or two or three doses 
 of the extract, each equal to 0.05 gram. With this and proper feed- 
 ing an acute intestinal catarrh is generally cured. For eight to ten 
 days the patient must be instructed in rules of diet (see section on 
 Diet). The main use of opium is in acute gastro-enteritis ; it is 
 not a remedy for prolonged employment. 
 
 The other drugs above mentioned are used in a variety of ways 
 and combinations in subacute and chronic diarrhoeas, especially in 
 those affecting the small and upper part of the large intestine. If 
 we were to believe the pi'aises which have been sung in medical 
 literature about these drugs, especially during the last decade, the 
 
MEDICINAL TREATMENT OF INTESTINAL DISEASES 193 
 
 treatment of chronic intestinal catarrhs, even those of a tubercular 
 variety, would seem to be as promising and simple as anything in all 
 internal medicine. The critical physician would naturally doubt 
 this statement if for no other reason than for the fact that new 
 pharmaceutical remedies are being continually produced and recom- 
 mended. 
 
 I have not seen any lasting influence upon chronic diarrhoeas 
 from any of the newer antidiarrhoeal remedies. My experience in 
 this respect has been a large one. My results in the treatment of 
 these conditions on exclusively or almost exclusively dietetic prin- 
 ciples (about which the most important facts have already been 
 stated) have been just as good as when the newer remedies were 
 used. The so-called antiseptic astringent remedies would be ideal 
 if they exerted an influence upon the disease without simultaneous 
 dietetic treatment, and if they were able to influence the mucous 
 membrane in such a manner that the intestine would gradually 
 become able to bear almost normal regime without difiiculty and 
 without the occurrence of diarrhoeas. There is no real value in a 
 constipating action jper se of drugs. 
 
 It is true, I believe, that we can use antiseptic or astringent 
 drugs as adjuvants to our dietetic and hygienic methods. The heal- 
 ing of an intestinal catarrh can be accomplished only by long-con- 
 tinued care of the intestines as has been described above, and in 
 connection with long-continued absolute rest in bed. Whoever 
 looks for impressive results will without doubt find great satisfaction 
 from modern antiseptics and astringents ; but whoever desires to 
 make a permanent cure of a chronic diarrhoea can not place a very 
 high value upon these remedies. 
 
 The indication for the application of astringent remedies per 
 rectum is limited to chronic catarrhs of the large intestine. I 
 have sometimes seen favourable results from tannin and nitrate of 
 silver, but have obtained much better results from aceto tartrate 
 of aluminium (one teaspoonful to the litre of water). It must be 
 mentioned, however, that astringent remedies can not only cure 
 catarrhs, but may cause or aggravate them. Great care in the 
 administration and close observation of the reaction following such 
 astringent injection is imperative. It is advisable to follow an 
 enema of nitrate of silver by a neutralizing injection of salt solu- 
 tion. 
 
194 DISEASES OP THE INTESTINES 
 
 CONTEA-INDICATIONS TO THE UsE OF AnTIDIAEKH(EAL EeMEDIES 
 
 Above all, antidiarrhoeal remedies are contra-indicated where the 
 apparent symptoms are those of diarrhoea, but the real condition is 
 one of constipation. These remedies should not be employed in 
 the diarrhoea which accompanies intestinal stenosis. In carcinoma 
 of the rectum there are frequent apparent diarrhoeas which must be 
 considered as decomposition products of stagnating intestinal con- 
 tents. Cathartic measures would be indicated in such a case. It 
 is also best to administer them to patients with alternating diar- 
 rhoea and constipation. In these it is advisable to wait several days 
 before giving drugs, in order to come to some conclusion as to the 
 nature of the intestinal disturbance. Several years ago I had occa- 
 sion to observe a case in which the conditions were so complicated 
 that careful observation for several weeks was necessary before it 
 could be determined that the patient had chronic constipation, and 
 not chronic diarrhoea. The patient, who was very ill, was cured 
 when the constipation was overcome. Among the remedies contra- 
 indicated in chronic diarrhoea, opium and calomel should be men- 
 tioned, as they are frequently wrongly used. Although I place a 
 high value upon opium as a remedy in many diarrhoeas, I always 
 hesitate before using it in the chronic form. It is true, one gains 
 the advantage of placing the bowels at rest for a short time, but 
 meanwhile they become filled with putrefying decomposed material, 
 which only reproduces a severer diarrhoea as soon as the opium 
 effect has passed off. I allow the use of opium preparations as a 
 palliative method only during travel, in society, etc., but even then 
 with the greatest reserve. I need hardly mention that when there 
 is a suspicion of ulcerations of the intestines calomel must not be 
 used, or, if so, only under restrictions. 
 
 3. Sedative Remedies 
 
 Owing to the great importance of these in the therapeutics of 
 intestinal affections, it is necessary to dwell briefly, upon their 
 significance and use. They include mainly opium and its principal 
 alkaloid, morphin (which in this respect is superior to codein, 
 papaverin, narcein, etc.), and belladonna with its alkaloid, atropin. 
 
 From experimental investigations very little has been learned 
 regarding the manner in which opium and its alkaloids act. l^oth- 
 nagel's^ opinion that the intestinal paralysis results from stimulation 
 
MEDICINAL TREATMENT OF INTESTINAL DISEASES 195 
 
 of the inhibitory fibres of the splanchnic is directly opposed to that 
 of Jacob] ^ and Pohl ''', who, after extensive researches, have come 
 to the conclusion that the paralyzing effect of opium is brought 
 about by diminished excitability of the intestinal wall. The latest 
 investigations of Z. von Yamossy^ tend to show that there is a 
 benumbing of the brain centres which prevents transference in the 
 brain of centripetal impulses of the pneumogastric to those centrif- 
 ugal nerve paths that control intestinal movements. 
 
 We can not here give more than this brief reference. It shows 
 sufficiently well, however, that we still have had no satisfactory 
 explanation of the action of opium. 
 
 As regards belladonna and atropin, it is assumed that they cause 
 paralyses of the intestinal wall, and thus relieve abnormal contrac- 
 tions of the intestinal coils. 
 
 We know more, however, about the clinical application of nar- 
 cotics. The following are the indications for their use : To allay 
 inflammation, to relieve painful contractions, to arrest increased 
 intestinal peristalsis accompanied by profuse evacuations of contents, 
 and, finally, to secure rest of the entire intestines, so as to permit of 
 a correction of intestinal knottings, invaginations, incarcerations, and 
 volvuli. 
 
 Appendicitis furnishes the best example for the use of opium in 
 inflammatory processes. We should, however, make a careful dis- 
 tinction between the various stages of this affection. In appendi- 
 citis, opium is only indicated when symptoms of irritation, fever, 
 pain, and meteorism are present, and the patient's condition is still 
 satisfactory. If these symptoms disappear after repeated large 
 doses of opium (e. g., tinct. opii gtt. xx every three hours, or extr. 
 opii 0.03 gm. t. i. d.), its further use, though not harmful, is no 
 longer necessary. If the opium is continued the dosage should be 
 reduced one half. If symptoms of irritation have been present for 
 three or four days, opium is contra-indicated, for then there de- 
 velop intestinal paralyses, which are overcome only with the great- 
 est difficulty. 
 
 If symptoms of irritation continue and those of collapse (rapid, 
 compressible pulse, general depression, etc.) begin to appear, opium 
 must at once be stopped. This is the stage in which opium, as sur- 
 geons very correctly claim, masks the disease and gives rise to false 
 hopes. 
 
 A similar rule applies to acute intestinal occlusions. Here also 
 opium is indicated in the early stage with symptoms of reaction. 
 
196 DISEASES OF THE INTESTINES 
 
 If opium does not then yield the desired results, a curative action 
 can no longer be expected from it ; it can only induce euthanasia. 
 The same objections against the giving of large doses apply as in 
 appendicitis, undoubtedly large doses of opium temporarily relieve 
 the seriousness of the condition, but actual benefit can no more be 
 expected than from an infusion of digitahs in a cardiac case with 
 impending paralysis. The pulse and general condition should guide 
 us in the management of acute intestinal obstruction. If these are 
 good and the features " composed " (von Leyden), opiates will at least 
 do no harm ; if these are not good, then opium can only help seal 
 the patient's fate. 
 
 A few words regarding the treatment of enteralgias, intestinal 
 colic, peristaltic restlessness, and acute diarrhceas. Whatever may 
 be the etiology of these conditions, narcotics will always be of bene- 
 fit, for they quiet the excessive peristalsis, relieve pain, and thus 
 enable solid contents to pass through the intestinal canal, and fiuid 
 contents to become more solid. 
 
 In a given case it is by no means immaterial whether we admin- 
 ister opium or one of its alkaloids (particularly morphin) or bella- 
 donna (or atropin). This has been sufficiently shown by clinical 
 experience. Opium is far superior to any of its alkaloids in quiet- 
 ing the intestines or in arresting peristalsis. Morphin has only the 
 analgesic property of opium. In any case in which we desire a 
 sedative effect upon the intestines, as well as a slowing or an arrest 
 of peristalsis, opium will be found superior to all other narcotics. 
 
 On the other hand, extract of belladonna in doses of 0.01 to 
 0.03 gram, and its alkaloid, atropin, in doses of from 0.005 to 0.001 
 gram, are indicated in all colicky and painful crises. Like the opi- 
 ates, they may in such cases even have a laxative action. In gen- 
 eral, their action is weaker than that of the opiates ; their long-con- 
 tinued employment is always attended by danger of poisoning. 
 Opiates are frequently combined with belladonna. 
 
 4. Remedies for Flatulence 
 
 Since early times a large number of remedies have had the 
 reputation of allaying flatulency, either through combination with 
 the gases or excitation of the intestinal motility, or through 
 other unknown ways. As regards the power to combine with 
 gases, the magnesia salts, especially magnesia usta, play an impor- 
 tant part. It is well known that outside of the body magnesia usta 
 
MEDICINAL TREATMENT OF INTESTINAL DISEASES 197 
 
 can absorb a large quantity of carbonic-acid gas (1 gram absorbs 
 about 1,100 cubic centimetres). To what extent this substance can 
 absorb gas in the gastro-intestinal canal is still a matter of ques- 
 tion. In the stomach, magnesium chlorid is formed by combina- 
 tion with hydrochloric acid ; in the intestines only the residue of the 
 magnesia usta can be converted into magnesium carbonate. It is 
 very probable, too, that this formation of carbonate of magnesia 
 does occur in the intestinal canal, for, after the ingestion of mag- 
 nesia, patients frequently have borborygmi and expel much gas. To 
 a certain extent, however, the laxative action of the magnesia may 
 cause such symptoms. 
 
 The second group of remedies — i. e., those which excite intes- 
 tinal motility — is said to act by increasing the muscle tone. It 
 includes nux vomica and its preparations (the tincture, the fluid 
 extract, and its alkaloid, strychnin), as well as extract of physo- 
 stigma. We will speak of these more in detail in the next division. 
 
 Yery little is known of the action of the so-called carminatives. 
 But here, as everywhere in science, experience is the best guide, 
 and it has shown us that in flatulency very great benefit is often 
 derived from the use of carminatives. 
 
 The carminative remedies include various so-called carmina- 
 tive teas, such as valerian, fennel, peppermint, caraway, anise, 
 thyme, and the oils obtained from these substances, the most fre- 
 quently employed being oils of menthol, caraway, and fennel. These 
 remedies very probably have mild antiseptic properties, such as the 
 oil of menthol has been shown to possess. Based on this antiseptic 
 property, menthol (0.1 to 0.2 in gelatin capsules) has been recom- 
 mended for the relief of flatulency.* The following sums up the 
 latest ideas regarding the relative value of the various preparations. 
 With teas made from the fruit or leaves there is the additional 
 effect derived from the heat. We know from experience that 
 heat when applied externally, or hot solutions taken internally, 
 exert a beneficial action on acute colic and flatulency. The oleo- 
 saccharates and the oils are more in place in the chronic forms 
 of flatulency. The oils are to be given singly or combined, in 
 doses of 3 to 5 drops thrice daily, and the oleosaccharates in 
 amounts varying from very minute quantities to a teaspoonf ul, also 
 thrice daily. The combination of magnesia usta with the so-called 
 
 * To insure solution it is necessary to drink an alcoholic mixture (cognac or 
 wine) after the dose is taken, 
 14 
 
]^98 DISEASES OP THE INTESTINES 
 
 oleosacchai-ates is very effectual where constipation exists. For 
 example : 
 
 j^ Magn. ustse 15.0 
 
 Olseosaccli. menthae 5.0 
 
 M. Pulv. Sig. : A quarter to a teaspoonful thi-ee times a day. 
 
 In a number of cases of chronic flatulency, pulverized caroway 
 fruit in tablet form, in doses of from 0.5 to 1 gram, has proved 
 very serviceable to me. 
 
 Charcoal in the form of freshly burnt animal or wood charcoal 
 is still very frequently given as a gas-absorbing remedy. In France, 
 especially, the " pastilles de Bellocq," which consist mainly of char- 
 coal, are very generally used. "We can hardly expect any benefit 
 from charcoal, however, since it only absorbs gases while it is in a 
 dry state. 
 
 5. Tonic Remedies 
 
 Are there any remedies which may rightly be called intestinal 
 tonics ? Concerning this subject httle has been learned from ani- 
 mal experiments. Although there are no exact indications for their 
 use, and no convincing results have been obtained, drugs are often 
 employed for this purpose. They include the numerous bitters 
 which, according to the investigations made by Hamm ^ and Kobert, 
 stimulate intestinal as well as gastric peristalsis ; furthermore, the 
 preparations of nux vomica are also given (tincture of nux vomica, 
 gtt. x-xv, extract of nux vomica 0.01 to 0.03, or nitrate of strych- 
 nin 0.001 per dose, preferably subcutaneously). The other bitters 
 (tinct. amara, gentian, creosote, etc.) also enjoy considerable repu- 
 tation as intestinal tonics. Besides these remedies, I have fre- 
 quently obtained good results in painful flatulency from the use of 
 the extract of calabar bean. Attention was first directed to this 
 drug by Subbotin ^°, and later by S. Schaef er ^\ 
 
 5. Extr. physostigmge 0.05 
 
 Glycerin ad 10.00 
 
 M. Sig. : Ten drops three times a day. 
 
 Or the same remedy may be given in pill form in doses of 0.005 
 gram. It has no laxative action. I have never seen any injurious 
 effect result from the extract of calabar bean, and I am convinced 
 that in atony of the intestines this drug is as worthy a trial as nux 
 vomica. 
 
MEDICINAL TREATMENT OP INTESTINAL DISEASES 199 
 
 6. Intestinal Antiseptics 
 
 Owing to the numerous investigations of Bouchard and Dujar- 
 din-Beaumetz and their scholars, the idea that it is possible to 
 disinfect the intestinal canal in fermentative and putrefactive con- 
 ditions has been widely accepted, especially in France. These inves- 
 tigators have evolved a method of treatment which has been named 
 " antisepsie intestinale." Although it had many enthusiastic fol- 
 lowers in Germany, this movement has been reluctantly taken up. 
 Recently a marked reversal of opinion has taken place in France ^^, 
 for the lack of results spoke too strongly against the dogmatic 
 certainty with which the new teaching had been proclaimed. 
 
 Regarded critically, the idea of intestinal antisepsis really rests 
 upon a very weak foundation ; for we have httle knowledge con- 
 cerning the manner in which putrefactive products originate in the 
 intestines, as well as the factors which increase or diminish them ; 
 and, furthermore, we do not know which of these products are 
 absorbed and which are not, nor how the various foodstuffs influ- 
 ence them. Through the investigations of Eovighi^^, Schmitz ^^, 
 Winternitz ^^, and Albu^^ one fact has been established — that milk 
 and its products (kefir and pot cheese) cause a diminution in the 
 ethereal sulphuric acids in the urine. Furthermore, it must be 
 remembered that inhibition of normal intestinal motility results in 
 an increase of putrefactive products. If we compare the conditions 
 existing in the stomach -with those in the intestines — more complex, 
 it is true — we will have a basis upon which to study the question of 
 intestinal disinfection. We know to-day that the best way in which 
 to disinfect the stomach is to restore to it its normal motility. 
 Therefore it must be recognised that by the mechanical evacuation 
 of the stomach, numerous fermentative products and their causes 
 are removed, and by this means a more favourable condition is 
 created. Objectively this is noticeable in a demonstrable increase 
 in the strength of the distended organ. If the normal motility be 
 lost, permanent disinfection of the stomach, filled as it is with micro- 
 organisms, is impossible. 
 
 The knowledge gained from these experiences may be applied 
 to the far more complicated conditions in the intestines ; here also 
 the best antiseptic remedy is the restoration of normal peristalsis. 
 Therefore Albu^''' is perfectly correct if, in his numerous publica- 
 tions upon this subject, he regards catharsis as the main weapon 
 with which to combat intestinal putrefaction. 
 
200 DISEASES OF THE INTESTINES 
 
 A second scarcely less important means of mechanically com- 
 batting the causes and results of intestinal putrefaction is careful, 
 systematic intestinal lavage. It is well known, and we, too, have 
 repeatedly pointed out, that decomposition takes place mainly in the 
 large intestine ; the utility of careful and repeated intestinal lavage 
 is therefore very apparent. By this procedure we do not attempt to 
 sterilize the intestine, nor do we thereby make it impossible for new 
 microbes to develop, but we obtain at least a relatively clean con- 
 dition of the organ. Intestinal lavage is beneficial also from an- 
 other standpoint : a portion of the water is absorbed, causes an 
 increase in the excretion of urine, and thus, as Sahli was the first 
 to show, numerous products of decomposition are washed out of the 
 system. 
 
 For intestinal lavage a number of antifermentative substances 
 may be added to the water : salicylic acid, boracic acid, resorcin, 
 creolin, lysol, creosote, ichthyol, tannic acid, and perhaps also for- 
 maldehyde and its preparations (amyloform, dextroform, paraform, 
 tannoform, etc.). Yery little has been published regarding the 
 last-named preparations. Undoubtedly disinfection of the intestine 
 is best accomplished by means of lavage. As regards the techuic, 
 the only point to be remembered is that the irrigation must be con- 
 tinued until the water returns clear. As in gastric lavage, so after 
 apparent cleansing of the intestines, a change in the position of 
 the body will often cause fresh fsecal masses to appear and be 
 washed away. 
 
 In spite of the numerous remedies which have been recom- 
 mended and tried within the last decade, no important results have 
 been obtained for the disinfection of the intestinal canal by way of 
 the stomach. Nevertheless, it seems to me that Albn goes too far 
 when he says that internal antisepsis, in the broadest sense of the 
 word, is an unsolvable problem. The solution certainly will not 
 be found in a chemical agent, but rather in a proper selection and 
 preparation of the ingested food. In the future, therefore, it should 
 be our duty to study more closely than heretofore the effects of the 
 various foodstuffs npon decomposition processes in normal and 
 abnormal conditions. We must cease to place any . value upon 
 methods for the estimation of proteid decomposition from the 
 amount of ethereal sulphuric acid found, or upon the relation be- 
 tween preformed and total sulphuric acid. Tliis method has led to 
 the utmost confusion. 
 
 After what has just been said, it will be unnecessary to enumer- 
 
MEDICINAL TREATMENT OP INTESTINAL DISEASES 201 
 
 ate and discuss the numerous intestinal antiseptics wliich have been 
 recommended. A few of them, however (salol, orphol, nosophen, 
 bismuth salicylate, etc.), have, as already mentioned, a distinct 
 value in the treatment of chronic diarrhoea. This subject will be 
 treated of in detail in the chapter on Diarrhoea, in the second 
 part of this work. 
 
 LITERATURE 
 
 1. Aubert. Zeitschr. f. rationelle Medicin, 1852. 
 
 2. Moreau. Memoires de Physiologie. Paris, 1877. 
 
 3. Radziejewski. Arch. f. Anat. u. Physiol., 1870, S. 37. 
 
 4. Brieger. Archiv, f. experiment. Pathol, u. Pharmacol., Bd. viii, S. 335. 
 
 5. Nothnagel. Virchow's Archiv, Bd. Ixxxviii, 1884 ; and Beitrage zur Phys- 
 
 iol, u. Pathol, des Darms, 1884. 
 
 6. Jacobj. Archiv f. experiment. Pathol, u. Pharmacol., Bd. xxix, 1891. 
 
 7. Pohl. Ibid., Bd. xxiv, Heft 1 u. 2, 1894. 
 
 8. von Vämossy. Deutsche med. "Wochenschr., 1897, No. 29. 
 
 9. Ramm. Ueber Bittermittel. Robert's histor. Studien II, S. 1, cited from 
 
 Virchow-Hirsch Jahresber., 1890, Bd. i, S. 442. 
 
 10. Subbotin. Deutsch. Arch. f. klin. Med., 1869, Bd. vi, S. 285. 
 
 11. Schaefer. Berliner klin. Wochenschr., 1880, No. 51. 
 
 12. Bardet. Comptes rendus de la Societe de therapeutique, 1895. 
 
 13. Rovighi. Zeitschr. f. physiolog. Chemie, Bd. xvi. 
 
 14. Schmitz. Ibid., Bd. xix, S. 378. 
 
 15. Winternitz, Ibid., Bd. xvi. 
 
 16. Albu. Deutsche med. Wochenschr., 1897. No. 32. 
 
 17. Ibid. Loc. cit. and Berliner klin. Wochenschr., 1895, S. 9. 
 
PART II 
 
 SPECIAL DIVISIOI^ 
 
CHAPTEK XIII 
 
 ACUTE AND CHEOmC INTESTINAL GATARBE 
 
 {Enteritis acuta et chronica) 
 
 1. Acute Intestinal Catarrh 
 
 Preliminary Remarks. — Acute intestinal catarrh owes its im- 
 portance not so much to the gravity of its symptoms as to the 
 frequency of its occurrence. It affects persons at all ages, more 
 particularly, and to a very dangerous degree, children during the 
 first two years of life. There is no difference as regards sex. Cer- 
 tain periodic variations, dependent upon atmospheric and climatic 
 influences, exist. 
 
 The causes of acute enteritis, as of acute catarrhal gastritis, are 
 very numerous. Its various forms, however, may, on the whole, be 
 traced to the following four primary causes : 
 
 (1) To infection (infectious catarrhs). 
 
 (2) To injurious substances in the ingested food (alimentary or 
 
 ingestive catarrhs). 
 
 (3) To cold (refrigeration catarrhs). 
 
 (4) To the action of medicines or poisons (medicinal or toxic 
 
 catarrhs). 
 
 Infectious catarrhs, according to our present knowledge, are due 
 to bacteria or to their metabolic products. The sole primary mani- 
 festation of the disease may here be limited to the intestinal canal, 
 or the intestinal catarrh may form the chief or accompanying symp- 
 tom, or be a complication of other acute infectious diseases (typhoid, 
 cholera nostras et asiatica, pneumonia, malaria, anthrax, influenza, 
 sepsis, etc.). 
 
 We are here concerned only with the first-named variety. A 
 priori, it seems probable that in infectious catarrhs a specific bac- 
 terial flora does not exist, and, despite manifold studies in that 
 direction, the demonstration of a specific micro-organism as the 
 cause of intestinal catarrh has been only partially successful. In 
 this connection we would mention Gaffky's^ demonstration of the 
 
 205 
 
206 DISEASES OF THE INTESTINES 
 
 bacillus enteritidis (probably identical with the bacterium coli) in a 
 severe case of infectious intestinal catarrh. An important though 
 not necessarily the sole factor in the etiology of acute enteritis is 
 the bacterium coli. 
 
 Alimentary enteritis is the most common form met with. 
 Decomposed food, or else wholesome nourishment ingested in 
 improper combination or in excessive quantities or of unsuitable 
 physical character, may give rise to violent intestinal disturbances, 
 which assume the character of an acute intestinal catarrh. Among 
 the foods which most frequently excite intestinal catarrh are water, 
 ice, milk and its products (butter, cheese, whey), meat and its deriv- 
 atives, sausages, fish, fruit, etc. It has been justly assumed that 
 poisonous organic bases (ptomains) play an essential part in these 
 cases. Some of these have already been determined (Yaughan's 
 tyrotoxicon. Firth's lactotoxin, and the ptomains muscarin, guani- 
 din, methylguanidin, dimethylamin, methylamin, sethylamin, beta- 
 lin, mytilotoxin, etc., isolated by Brieger). In consequence of 
 improper combination or excessive ingestion of otherwise whole- 
 some food, injurious products of fermentation (lactic, butyi'ic, pro- 
 pionic, acetic, caproic, formic, succinic acids, etc.) may be formed, 
 which, innocuous in ordinary quantities, may under the above- 
 named condition cause violent irritation of the intestinal canal. 
 
 Undoubtedly we also meet with diarrhoeas due to exposure to 
 cold, in which, perhaps owing to reflex vaso-motor influences, a 
 marked stimulation of the excito-motor nerves is produced. When 
 the irritation is violent or the patient careless, an acute intestinal 
 catarrh may follow. 
 
 Finally, intestinal catarrh may result from the action of drugs, 
 either through the use of abnormally large single doses or from 
 the long-continued use of small amounts. Among these are the 
 mercurial preparations (calomel, corrosive subhmate), arsenic, anti- 
 mony ; the emetics — tartar emetic, ipecacuanha, sulphate of copper, 
 apomorphin; the strong drastic purgatives (croton oil, colocynth, 
 senna, jalap, gamboge, etc.). Many other medicinal agents, admin- 
 istered in unsuitable manner or dosage, may produce intestinal 
 catarrh; those named above, however, are the most frequent 
 offenders. 
 
 As rare causes of acute enteritis we may mention traumatism, 
 the presence of numerous entozoa, and acute coprostasis. 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 207 
 
 Symptomatology and Diagnosis 
 
 The following description relates solely to acute primary intes- 
 tinal catarrh ; all secondary varieties of enteritis — e. g., those tliat 
 occur in the course of typhoid fever, cholera, tuberculosis, malaria, 
 pneumonia, etc., carcinoma of the intestines, congestion of the por- 
 tal circulation, intestinal ulcerations, intestinal strictures, entozoa, 
 etc. — will not here be considered, because foreign to the present 
 discussion. As regards the intensity and extension of the process, 
 the symptomatology of acute enteritis presents a variety of gradu- 
 ated stages, so that it is difficult to faithfully describe all grades and 
 forms of the disease. The following description applies to a moder- 
 ately severe case of enterocolitis. Of especial importance are : 
 
 1. The commencement of the process. 
 
 2. The gastro -intestinal disturbances. 
 
 3. The patient's general condition. 
 
 4. The course of the disease. , 
 Certain other symptoms, which will be discussed below, may 
 
 complete the clinical picture. 
 
 As a rule, the symptoms appear suddenly and without prodrom- 
 ata, almost immediately following the exciting cause. Tormenting, 
 dragging, and boring pains are felt in the abdomen, usually accom- 
 panied by general discomfort, nausea, and occasionally even by 
 attempts at vomiting. Diarrhoea soon develops. The number and 
 character of the evacuations vary according to the localization, 
 intensity, and etiology of the disease. Thus in very mild cases 
 there may be two to three, in severe cases iifteen to twenty or 
 more passages. The first evacuations may still be solid or pasty, 
 but the more numerous they become the more fluid and odour- 
 less will they be. Should the catarrh involve the upper portions of 
 the small intestine, we may recognize its site from the greenish- 
 yellow colour of the dejecta and from the presence of unchanged 
 bile pigments (Gmehn's reaction). If the catarrh is limited to the 
 large intestine this test can no longer be employed, since the bili- 
 rubin has already been converted into urobilin. 
 
 All the stools- of acute enteritis contain an admixture of muctis, 
 partly in the form of exceedingly small, barely visible gelatinous 
 particles or minute specks intimately mixed with the stool, partly 
 in the form of isolated masses which consist of small or large shreds. 
 Besides mucus, blood is not infrequently present, partly as small 
 streaks usually adherent to the particles of mucus, partly in the form 
 
208 DISEASES OP THE INTESTINES 
 
 of larger bright red or coagulated masses, also generally mixed with 
 the latter. In my experience copious hemorrhage is very rare 
 in acute enteritis. In the majority of cases of uncomplicated 
 enteritis, unlike those of dysentery, ])us is not present in the evac- 
 uations. Owing to the active gas formation within the intestines, 
 the faeces may present a marked frothy appearance. Besides mucus, 
 the microscopical picture reveals red and white blood-corpuscles, 
 and frequently partly fresh but mostly disintegrated epithelium. 
 We also find various kinds of food remnants, particles of casein, 
 muscle fibres, starch granules, renmants of cellulose, and other acci- 
 dental constituents of food. 
 
 Gastric digestion is frequently interfered with along with the 
 intestinal disturbance. The appetite is generally absent, direct 
 aversion to food is occasionally present ; in other cases, gastric dis- 
 turbances — nausea, vomiting, epigastric pressure — are so prominent 
 that the case resembles one of acute gastritis. The tongue is 
 usually coated ; a disgusting fetor is present ; thirst is frequently 
 tormenting. There is an inverse relation between the number of 
 stools and the thirst on the one hand, and the urinary secretion on 
 the other. 
 
 The general condition depends essentially on the severity of the 
 enteritis and the number of evacuations. Only in very few cases 
 does it remain undisturbed ; in the greater number of cases the 
 patient complains of considerable lassitude, which in children, in 
 the aged, or in otherwise weakened individuals not infrequently 
 develops into sym.ptoms of grave prostration. Under these circum- 
 stances, a condition of acute hydrocephalus, as described by Marshall 
 Hall, may supervene, due to the copious intestinal discharges and 
 the resulting cerebral anaemia. 
 
 In the vast majority of cases, especially in adults, the disease 
 runs a favourable course and is of relatively short duration. N^ever- 
 theless, we occasionally observe, especially in colitis, quite severe 
 and protracted forms, in which convalescence is long delayed. 
 Other cases are characterized by a persistent vulnerability of the 
 intestine, so that under predisposing conditions relapses frequently 
 occur ; the process does not go on to perfect recovery,, a chronic 
 enteritis gradually develops, or a more or less intractable atony of 
 the large intestine, accompanied by constipation, remains. 
 
 Certain complicating conditions may be added to this typical 
 picture. The disease, which usually runs an afebrile course, may 
 be accompanied by more or less severe fever, so as to awaken the 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 209 
 
 suspicion of a beginning typhoid, tlie more so as enlargement of 
 the spleen is occasionally observed. The urine is generally con- 
 centrated and dark; in rare instances anuria may develop. It 
 has been observed by various authors, first by Kjellberg ^ and soon 
 after by Hermann^ and Mühlhauser ■*, that albuminuria may oc- 
 cur in cholera diarrhoeas ; and Kobler ^ has recently reported two 
 cases of cholera nostras, in which for a long time there was a 
 marked diminution of urine with albumin and large quantities 
 of hyaline and epithelial casts. In one case granular casts and 
 renal epithelium could also be demonstrated. Even in the milder 
 forms of diarrhoea, as first shown by Fischl ^ and corroborated by 
 Stiller'', temporary albuminuria and cylindruria may occur. I re- 
 cently made the same observation in an elderly patient, in whom 
 on the second day of an acute gastro-enteritis I found an appre- 
 ciable amount of albumin in his urine (without casts). With the 
 improvement of the intestinal catarrh the albuminuria soon dis- 
 appeared. 
 
 In exceptional cases in children, according to Turner^, fatal 
 Bright's disease may follow an acute gastro-enteritis. 
 
 Several authors (Strümpell^, Fleischer ^*^) report the occurrence 
 of acute pains in the joints and muscles, as well as tumefaction of 
 the joints, as a complication of acute enteritis. Herpes labialis has 
 also been observed in infectious intestinal catarrh. 
 
 As a rule, the diagnosis of an acute enteritis is not difficult, espe- 
 cially where a positive etiological factor (errors in diet, cold, etc.) 
 points to the origin of the disease. The diagnosis is based on the 
 acute onset, the characteristic gastro-intestinal disturbances, and the 
 course of the disease. Compared with these data, the objective 
 abdominal symptoms are of subordinate importance. Inspection 
 may reveal a slight distention, although this may be absent; in 
 greatly emaciated persons, isolated spasmodic intestinal contractions, 
 especially of the small bowel, are occasionally observed. If the colon 
 is especially affected, palpation elicits some tenderness on pressure, 
 particularly pronounced in the region of the descending colon and 
 the sigmoid flexure, and thus may indicate the Hmits of the inflam- 
 mation. In diffuse enteritis, the whole abdomen, especially the cir- 
 cumbilical portion, is the seat of more or less decided tenderness. 
 1^0 practical data are obtained by percussion. Auscultation enables 
 us to hear loud borborygmi and other intestinal sounds even at a 
 distance, and better still when the ear is directly applied to the 
 abdominal wall. If we except the gastro-duodenal catarrh accom- 
 
210 DISEASES OP THE INTESTINES 
 
 panied by jaundice which, will be considered later, the localization 
 is more difficult than the diagnosis of the diseased process. In my 
 opinion, the only determination of some practical value is whether 
 the seat of the catarrh is in the large or small intestines. The 
 absence of large appreciable masses of mucus and blood from the 
 stools and the presence of unconverted bile pigment is diagnostic 
 of catarrh of the small intestine, while, conversely, the presence of 
 a larger quantity of mucus and blood in the feeces argues in favour 
 of disease of the colon. K we go still further, and attempt to localize 
 the catarrh in the different intestinal segments, we are no longer 
 treading upon scientific ground. 
 
 In view of the symptoms above mentioned we will meet with 
 diagnostic difficulties only in exceptionally complicated cases. Thus, 
 for example, during the first days of febrile gastro-enteritis* the 
 differentiation from typhoid, as already stated, may be exceedingly 
 difficult, and may only become possible after careful observation 
 of the course, of the disease. This same difficulty confronts us in 
 cholera asiatica, particularly when that disease is epidemic. In both 
 instances the bacteriological and the serum examination (WidaPs 
 reaction) may materially assist the formation of a diagnosis. 
 
 The diagnosis of duodenal catarrh conforms completely with 
 that of acute and subacute gastric catarrh, and only becomes possi- 
 ble with the onset of catarrhal jaundice. Its symptom-complex 
 is generally so pronounced that a special description seems super- 
 fluous. 
 
 In my opinion, the differential diagnosis between acute colitis 
 and the milder forms of dysentery is exceedingly difficult ; I be- 
 lieve that we are as yet unable to satisfactorily discriminate between 
 these two diseases.* In pronounced cases, and particularly during 
 epidemics, the diagnosis is probably less difficult. In tro]3ical dys- 
 entery, the presence of the amoeba coli (Loesch) in the f^ces and in 
 the pus of the liver abscesses is of diagnostic importance. 
 
 The treatment of acute intestinal catarrh is based upon the fol- 
 lowing principles : 
 
 1. The removal of noxious material from the intestinal canal 
 
 (indicatio causalis). 
 
 2. The greatest possible protection of the gastro-intestinal canal 
 
 (indicatio symptomatica). 
 
 * That this same difficulty has been encountered by other authors is obvious 
 from the fact that in literature we not infrequently meet with the designation 
 " dysenteroid intestinal catarrh." 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 211 
 
 We are not always able to carry out the first rule, since only in 
 a certain proportion of cases are the noxious materials of a sub- 
 stantial nature. Where this indication can be fulfilled, recovery, as 
 a rule, immediately follows the removal of the undigested masses. 
 Frequently this result is also brought about by the products of 
 decomposition themselves, which accumulate in the intestinal canal 
 and excite increased peristalsis. Further treatment is then hardly 
 necessary. Where, however, in spite of the obvious presence of 
 noxious material, the evacuations are arrested or insufficient, the 
 removal of this material by a suitable purge is of primary impor- 
 tance. For this purpose, calomel (0,2 to 0.3 grams, every three 
 hours) [until the desired effect is obtained] or castor oil (in doses of 
 one to two tablespoonf uls) is preferable. 
 
 Since the early days of medicine it has been customary to give 
 calomel preferably in "infectious" catarrhs, and castor oil in cases 
 due simply to errors in diet ; still, the superiority of the one over 
 the other is by no means established. In my opinion, both act as 
 disinfectants by rapidly and thoroughly emptying the bowels. 
 
 The second indication — protection of the gastro-intestinal canal 
 — must be considered after the first has been fulfilled, or where, 
 owing to the absence of recognisable etiological factors, this is unat- 
 tainable. This second indication is principally fulfilled by complete 
 rest in bed for several days, by constant and uniform application to 
 the abdomen of heat in the shape of warm fomentations, and most 
 especially by a proper diet. For the first two or three days the 
 diet should consist of fluids only. All liquids, however, are not 
 suitable ; for example, milk is contra-indicated in all forms of acute 
 enteritis. Cold drinks as well as carbonated waters should also be 
 avoided, excepting when severe vomiting is also present for ex- 
 perience has shown that ice and iced drinks tend to check the 
 nausea. In acute cases the diet should therefore be limited to the 
 following : watery gruels, thin bouillon without salt or spices, tea 
 or cocoa made with water alone (no sugar, but in its stead saccha- 
 rin), claret with or without water, q^^ albumen, decoctions of arrow- 
 root and hygiama gruels, etc. Carminative teas are also frequently 
 useful — e. g., peppermint, valerian, fennel, anise seed, thyme, cara- 
 way, marsh mallow, etc. 
 
 Only after the intestine has become absohctely quiescent, and 
 tenderness to pressure has disappeared, may we increase the diet by 
 adding one or more softened zwiebacks, next permitting the lightest 
 forms of meat and fish, with some boiled rice or mashed potatoes, 
 
212 DISEASES OF THE INTESTINES 
 
 gradually approaching the ordinary diet. The patient should be 
 instructed to carefully abstain from excesses in food and drink for 
 a number of weeks, to avoid all indigestible, fatty, tough foods, 
 and also those rich in cellulose, for, as previously stated, the intes- 
 tine is very vulnerable for a long time. 
 
 These measures are all that are required for the cure of a large 
 number of cases. It will only exceptionally be found necessary to 
 control excessive diarrhoea, or, on the other hand, to combat a reac- 
 tive constipation or to stimulate a failing appetite. The first is 
 accomplished by the administration of opiates in the form of tinc- 
 ture of opium (10 to 15 drops, repeated one to four times) or 
 the extract of opium (0.03, repeated two or three times a day), in- 
 ternally or in suppositories. I regard the continued administration 
 of opiates not only as unnecessary but even as injurious. When, 
 as frequently happens, constipation occurs after the diarrhoea 
 has subsided, this must not he treated by purgatives, but only 
 by suitable enemata of oil or of soapsuds. The appetite gen- 
 erally returns in due course of time. It may be stimulated by 
 the well-known stomachics (the fluid extract or decoction of con- 
 durango, the tincture of nux vomica, the compound tincture of 
 cinchona, etc.). 
 
 In conditions of grave collapse we may endeavour to arouse the 
 heart's action by stimulants administered internally (e. g., wine, 
 cognac, ether) or subcutaneously (e. g., oil of camphor, citrate of 
 caff ein). 
 
 2. Chronic Intestinal Catarrh 
 
 Preliminary Remarlcs. — Chronic enteritis may result from 
 acute intestinal catarrhs in which recovery has taken place only 
 incompletely or not at all, or from long-continued and various 
 kinds of injuries of the intestinal canal. Among the injurious 
 agents which conduce to chronic intestinal catarrh, those which 
 directly affect the gastrointestinal mucous membrane are the most 
 important and the most frequent. These include improper food, 
 frequent colds, abuse of purgatives, constipation, etc. The pjri- 
 mary forms of enteritis are caused in this manner. As distin- 
 guished from these, the secondary forms are those which develop 
 either in connection with gastric diseases (e. g., catarrhs, carcinoma, 
 fermentation, etc.) or from intestinal diseases (tumours, ulcerations, 
 stenoses, adhesions, displacements, etc.). The intestinal catarrh is 
 often overshadowed by the other predominant symptoms, or it 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 213 
 
 may be so prominent that the etiological factor is only of second- 
 ary clinical importance. Nothnagel ^^ correctly remarks that a con- 
 gestive enteritis, in the true sense of the word, does not exist ; at 
 the most, we may concede that hyperaemia of the intestinal tract 
 creates conditions favourable to the development of chronic catarrhs. 
 As a matter of fact, I believe they occur very rarely as secondary 
 catarrhs dependent upon the main disease ; and when they do occur, 
 who can prove that they have developed in this way, and are not 
 accidental complications ? 
 
 Clinical observation combined with post-mortem examination 
 teaches us that we must distinguish between different grades and 
 forms of enteritis, and that these affect various intestinal segments. 
 For the better understanding of this I preface my remarks with a 
 short description of the pathologico-anatomical changes that are 
 found. 
 
 On macroscopical examination of such a diseased bowel the attention is 
 immediately arrested by a brown or black pigmentation of the mucous mem- 
 brane, which particularly affects the region of the villi and that of the fol- 
 licles. Peyer's patches may also present such discolourations, caused by old 
 hemorrhages. The histological changes involve chiefly the mucosa ; they may 
 also involve the submucosa, or the muscularis. The changes may consist of 
 a cellular infiltration of the interstitial connective tissue (leucocyte infiltra- 
 tion), from which a genuine hypertrophy of the connective tissue may develop 
 and this may occur to such a degree that the intestinal lumen becomes nar- 
 rowed for quite some distance. In other cases there is a polypoid prolifera- 
 tion of the tissues. In still other instances there are cystic dilatations (enteritis 
 chronica cystica), produced by strangulation of conglomerations of glands. 
 Usually the cysts are small and hardly visible to the naked eye, but they may 
 attain the size of a pin's head or a lentil. Their contents consist of a peculiar 
 slimy, viscid fluid, whose clinical nature has not as yet been positively de- 
 termined. In contrast to these plastic inflammatory processes a degenerative 
 form can also be distinguished. This affects the glands rather than the con- 
 nective tissue, destruction and atrophy of the glands gradually occurring as a 
 result of the marked epithelial desquamation. At the same time the other 
 layers of the mucous membrane generally lose their powers of resistance. The 
 mucosa becomes thin and lamellated, the villi atrophied, so that on section we 
 are only able to recognise isolated remnants projecting from the general level 
 of the mucous membrane. Besides these changes, the process especially affects 
 the intestinal follicles, which are swollen at first and are surrounded by a hyper- 
 semic zone ; later they I'upture, and thus give rise to so-called follicular (len- 
 ticular) ulcers. In addition to these last, other erosions result from desquama- 
 tion and loss of epithelium. At first they are superficial, but through their 
 confluence and deeper extension true catarrhal ulcerations may gradually be 
 formed. 
 
 15 
 
214 DISEASES OF THE INTESTINES 
 
 Pathological anatomy not only distinguishes between the variety, 
 but also between the situations of morbid processes, and hence 
 speaks of a duodenitis, jejunitis, ileitis, colitis, and j)rocUiis. 
 Clinically, these fine distinctions can not be made, and we must be 
 content with a division into catarrh of the small and catarrh of 
 the large intestines. 
 
 Since catarrhs of the small and of the large intestines, however, 
 frequently coexist, we must also consider this combination clinically. 
 In an anatomical sense the one will naturally preponderate over 
 the other, while the one intestinal division is extensively diseased, 
 only a small portion of the other will be affected. In the present 
 state of our knowledge these fine gradations can scarcely be made, 
 and in view of the great number of variations met with they are of 
 little practical value. The clinical diagnosis, therefore, will have 
 to deal mainly with the following two questions : 
 
 1. Is an intestinal catarrh really present ? 
 
 2. Does it involve the small or large intestine alone, or 
 both ? 
 
 In the following we will first outline the general symptoms of 
 intestinal catarrh, and then will consider its localization. 
 
 General Symptomatology and Diagnosis of Chkonic 
 Intestinal Catarrh 
 
 In chronic intestinal catarrh the clinical picture is mainly formed 
 by the subjective symptoms, or by objective abdominal manifesta- 
 tions — especially, marked variations in the number and character 
 of the stools. 
 
 The subjective symptoms vary greatly in degree. They may 
 be absent, or may only manifest themselves by disturbances of def- 
 ecation ; they may be only just felt, or may constitute the main 
 complaint of the patient ; they are constant or periodical, may 
 disappear with or without the objective symptoms, or vice versa ; 
 they may persist, notwithstanding the cessation of the characteristic 
 intestinal symptoms. Daily observation furnishes numerous ex- 
 amples of all the variations. "We will have to refrain from de- 
 scribing them all, since an exhaustive description would not be pos- 
 sible. We shall, however, describe a few forms of chronic enteritis 
 that are of practical importance. 
 
 In typical cases of chronic intestinal catarrh the symptoms con- 
 sist in feelings of discomfort or pressure, pain or soreness in the 
 abdomen, combined with intestinal rumbling and hyperperistalsis, 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 215 
 
 followed usually by copious alvine evacuations. In marked cases 
 these symptoms may be constant, or they may occur only in parox- 
 ysms — e. g., following a slight cold, excessive mental or bodily exer- 
 tion, dietetic errors, mental excitement, etc. The patient at the same 
 time has a sense of intense discomfort, of bodily and mental depres- 
 sion, to which are sometimes added salivation, retching, or actual 
 vomiting. Where the intestinal catarrh is situated very far down, 
 painful tenesmus is also present. In atypiGal or less marked 
 cases the symptoms are confined to uncomfortable painful sen- 
 sations which involve the whole abdomen, or else are limited 
 to certain areas — e, g., the umbilical region or portions of the 
 large intestine. When gas or fseces are passed these sensations 
 may rapidly disappear. I would call particular attention to the 
 frequent occurrence of this form of intestinal catarrh, for I am 
 convinced it is only rarely recognised, since it may be accompa- 
 nied by apparently normal faecal evacuations. By careful observa- 
 tion and questioning of the patient, but especially from an exami- 
 nation of the dejecta, we may convince ourselves that these patients 
 are affected with a slight or only partially healed intestinal catarrh. 
 This will be again referred to in discussing the diagnosis. In 
 another form of intestinal catarrh — the coprostatic — the subjective 
 symptoms are entirely different. The above-mentioned symptoms 
 are either entirely absent, or they appear as periodic intestinal colics, 
 with spastic obstipation, or else in the form of a constant or very 
 frequent feeling of pressure in the dependent portions of the intes- 
 tines, or even as meteorism accompanied by more or less marked 
 flatulency. 
 
 Between these two extremes we meet with cases in which the 
 lirst-described combine in the most diverse manner with the last- 
 described varieties. 
 
 The general condition of patients suffering from chronic enteri- 
 tis varies very markedly. As a rule, it is only slightly altered from 
 the normal in constipating enteritis, but very much more so in that 
 form accompanied by copious diarrhoea, especially where the upper 
 portions of the intestine are principally affected. Occasionally, 
 however, we meet with chronic diarrhoeas in which there is no 
 deterioration of the general health, while, on the other hand, it is 
 not rare to find cases of constipating enteritis in which the bodily 
 weight and general condition have been gravely affected. This 
 variable behaviour can not in all cases be explained alike. In a 
 great number the psychic factor — i. e., the general depression — no 
 
216 DISEASES OF THE INTESTINES 
 
 doubt exerts an unfavourable influence upon the ingestion of food ; 
 in others, again, the loss of fluids is the main cause ; in still others 
 an irregular mode of life, errors of diet, excessive bodily or mental 
 work, will cause a loss of streng-th and weight. The longer the dis- 
 ease exists and the more frequently curative measures fail to bring 
 relief, the sooner will the patient present a certain neurasthenic 
 tendency, which may even to the most experienced physician 
 obscure the true cause of the malady. 
 
 The objective examination is divided into that of the abdomen 
 and that of the dejecta. In the flrst, jpalpation alone possesses posi- 
 tive value. Percussion and auscultation may perhaps demonstrate 
 the existence of meteorism, of accumulated faeces, of abnormally 
 increased intestinal sounds, but they do not of themselves permit 
 of any conclusions as to the existence, location, or extent of the 
 intestinal catarrh. On the other hand, palpation may sometimes 
 be of value in determining a tenderness of certain intestinal areas, 
 thus, as will be later explained, indicating the seat of the intestinal 
 catarrh. The evacuations vary very much, according to the natm-e 
 and seat of the disease. The movements may be tardy, or may 
 occur at regular intervals ; they may occur too frequently or in 
 excessive amount, or after several days of constipation there may 
 suddenly be a single or repeated diarrhoeal movement ; or, finaEy, 
 after, a period of days or weeks of perfect health, suddenly, and 
 often without any recognisable cause, ä normal stool may assume a 
 diarrhoeal character. 
 
 Of stiU greater importance are the changes in the composition 
 of the faeces, as well as the presence of abnormal admixtures, par- 
 ticularly the constant occurrence of mucus. The change in com- 
 position may be due to an increased amount of undigested foodstuffs, 
 which can sometimes be recognised macroscopically, but better still 
 microscopically. 
 
 The presence of mucus is the most frequent and most charac- 
 teristic symptom of intestinal catarrh. The amount of mucus 
 voided varies greatly, however, according to the seat of the disease ; 
 this will again be referred to in the discussion on the localization 
 of intestinal catarrh. The presence of mucus in one movement 
 does not conclusively prove the existence of an intestinal catarrh, 
 neither does its absence exclude the same. The first statement will 
 scarcely be denied ; it is important, however, to emphasize the fact 
 that severe catarrhal conditions may exist without the production 
 of mucus. Thus, since Nothnagel's^^ investigation on this subject. 
 
ACUTE AND CHRONIC INTESTINAL CATAREH 21Y 
 
 it has generally been accepted, and I believe with perfect justice, 
 that in atrophy of the intestine (which, by the way, frequently 
 eludes a positive diagnosis) mucus is entirely absent from the 
 dejecta. An admixture of blood is not one of the characteristics 
 of primary enteritis ; it, as well as pus, represents only one of the 
 complications. 
 
 The course of chronic enteritis is tedious and protracted. 
 Undoubtedly a functional cure is sometimes achieved. If we con- 
 sider analogous conditions of other organs (the stomach, the urethra, 
 the larynx, the uterus), it is at least doubtful whether there are ever 
 any cures in an anatomical sense. The following experience, which 
 undoubtedly other physicians have also had, is very interesting, 
 viz. : after a catarrh lasting for many years, a sudden change in its 
 character may occur — i. e., chronic diarrhoea may gradually give 
 place to a marked tendency toward constipation, or vice versa. In 
 these cases there have been changes in the mechanism of innerva- 
 tion, the nature of which is as yet entirely unknown to us. 
 
 If we consider the picture outlined in the foregoing pages, the 
 diagnosis of chronic enteritis in marked cases is not especially dif- 
 ficult. It is more difficult, however, in atypical cases, and particu- 
 larly its differentiation from simple functional diarrhoeas is an 
 extremely delicate problem. There is no objective symptom in 
 the latter that may not also be present in catarrh. From numer- 
 ous personal observations, I can state that mucus, undigested food 
 remnants, and bile pigment may be present in nervous diarrhoea as 
 in intestinal catarrh. An analysis of such cases shows — and this 
 is perhaps the key to the proper understanding of these compli- 
 cated conditions — that, in consequence of a continued chemical and 
 mechanical irritation of the intestinal mucous membrane, a true 
 intestinal catarrh may be developed from a purely functional diar- 
 rhoea. For the elucidation of these diflacult questions, an exact 
 previous history and status praesens, particularly as to the nervous 
 system, are very necessary. We thus learn that the disease occurs 
 paroxysmally, that it is frequently increased by psychic excitement 
 or mental and bodily fatigue, that during rest it subsides or inter- 
 mits, and that also in the latter case an occasional dietetic error is 
 borne without injurious results, etc. Objectively, other signs of 
 hysteria or neurasthenia may be present : increased reflexes, local 
 hyp- or hyperalgesia, autographia, vasomotor disturbances, etc. 
 
 In spite of all these diagnostic auxiliaries, we entirely agree 
 with ^Nothnagel that the diagnosis can frequently be made only 
 
218 DISEASES OF THE INTESTINES 
 
 ex juvcmtihus et nocentihus. In discussing nervous diarrlioea, we 
 shall again refer to the individual symptoms. 
 
 As indicated above, the abortive or ill-defined cases of intestinal 
 catarrh are also of practical interest. These may occur with appar- 
 ently normal intestinal evacuations, and manifest themselves by 
 occasional painful abdominal sensations. A careful examination of 
 the faeces will, however, reveal the characteristic signs of intestinal 
 catarrh, now to be described. 
 
 For the diagnosis of intestinal catarrh, aside from the less posi- 
 tive data obtained from physical examination of the abdomen, there 
 are in reality only two other methods of examination : test lavage of 
 the intestine (see page 8Y) and the examination of the dejecta. 
 The first method at once shows whether the large intestine is the 
 seat of a chronic irritation attended with hypersecretion of mucus, 
 and should for this reason never be omitted in any [suspected] case 
 of intestinal catarrh. Under certain circumstances examination of 
 the dejecta may decide the diagnosis ; it may show the presence of 
 abnormal undigested matter or of certain admixtures (especially 
 mucus) as prominent constituents of the f^ces. Regarding the 
 undigested foodstuffs, we must at present be satisfied with the 
 gross differentiation derived from the comparison of the normal 
 with the abnormal stool. A positive functional test of the intes- 
 tine alone will furnish us with an exact knowledge of the devia- 
 tions from the normal. 
 
 For the examination of mucus and other abnormal constituents, 
 see above, page 96 et seq. 
 
 Diagnosis of Catarrh of the Small Intestine 
 
 The main symptom of catarrh of the small intestine is the 
 anomalous condition of the faeces. The subjective symptoms pre- 
 viously mentioned are also of some value. 
 
 With the exception of the dejecta (soon to be described), the 
 most important, at times the most diagnostic objective symptom, is 
 the presence of a well-defined pressure sensitiveness. In my 
 experience, catarrh of the small intestine may sometimes, at first 
 sight, be differentiated from that of the large intestine by this 
 means. While objective tenderness is either entirely absent in the 
 former, or, when present, is usually elicited only in the mesogas- 
 trium above or below the umbilicus (especially in tuberculous diar- 
 rhoea), diffuse tenderness on pressure is frequently found in chronic 
 catarrh of the large bowel; although rare in the region of the 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 219 
 
 caecum, it is well-pronounced over the sigmoid flexure and descend- 
 ing colon. 
 
 In these cases the evacuations are usually diarrhoeal. But, as 
 Ils^othnagel has conclusively shown, they may be semisolid or even 
 quite firm. Where they are fluid or semifluid, the admixture of 
 mucous shreds, as well as the presence of bile pigment and of bile- 
 tinged epithelial cells and muscular fibres, indicate an affection of 
 the small intestine. Where the evacuations are firm, the question 
 of disease of the small or of the large intestine is most readily and 
 positively answered by means of a test lavage of the bowel. If the 
 irrigation repeatedly brings away large quantities of membranous or 
 viscid mucus, there is undoubtedly a catarrh of the large intestine 
 present; whether catarrh of the small intestine coexists can not be 
 determined by this procedure. If the test lavage results nega- 
 tively, the diagnosis is very difficult in case the stool is firm or 
 semisolid. JS^othnagel has stated that the presence of so-called 
 yellow mucous granules or of hyaline mucous islets is characteris- 
 tic of catarrh of the small intestine, or of catarrh of the upper- 
 most portion of the large intestine (page 96). The existence of 
 these formations has, however, been denied by Ad, Schmidt, whose 
 opinion I must corroborate on the ground of numerous personal 
 examinations of faeces. 
 
 It will thus be seen that, aside from the subjective symptoms, 
 which are for the most part uncharacteristic, the diagnosis of that 
 form of catarrh of the small intestine which is accompanied by 
 constipation or by normal dejecta, rests upon the demonstration of 
 abnormal products — i. e., unchanged bile pigment (demonstrable 
 either macro- or microscopically), the constant presence of exceed- 
 ingly numerous muscular fibres, of well-developed starch cells, of 
 fat in the form of globules or needles (fatty acids or fatty soaps) in 
 the faeces. 
 
 As has been previously remarked, the localization of a catarrh 
 of the small intestines (duodenum, jejunum, ileum) is very difiicult, 
 and usually impossible. ISTevertheless, according to my experience, 
 we occasionally meet with cases in which the diagnosis may be ven- 
 tured. The following case is an illustration : 
 
 EmilB., sixty-two years of age, cabinetmaker, has always been perfectly 
 healthy. He was taken ill in the summer of 1892 with a feeling of pressure in 
 the epigastrium and violent diarrhoea (about seventeen evacuations in twenty- 
 four hours). From October, 1893, to March, 1893, his condition improved. At 
 this time there was a recurrence of his diarrhoea (four liquid stools a day), to- 
 
220 DISEASES OP THE INTESTINES 
 
 gether with painful sensation of pressure in the region of the stomach. The 
 patient complained also of shortness of breath and bodily weakness. His con- 
 dition, as recorded at the time, was as follows : Examination of the abdomen, 
 negative ; lungs emphysematous ; diffuse bronchitis ; heart dulness partially 
 obscured by the lungs ; cardiac sounds clear. Test lavage of the intestine 
 yielded numerous large shreds of mucus. Microscopic examination of faeces 
 negative. Treatment dietetic. Improvement. On July 18, 1895, the patient 
 returned, complaining again of diarrhoea. The first stool in the morning is the 
 only one of a somewhat firm consistency; the others (six to ten) are always 
 fluid. After the principal meal there are always two to three stools at short 
 intervals. No pain or tenesmus is present ; rumbling of the bowels is felt. 
 The appetite is fair; there are no eructations, no vomiting ; the diarrhoea is said 
 to be unaffected by the kind of nourishment taken. 
 
 Condition on July 18, 1895. The patient is a well-nourished man, with 
 a normal colour of the skin. The mucous membranes are somewhat pale. The 
 lungs are emphysematous. The area of cardiac dulness is somewhat dimin- 
 ished ; heart sounds are clear, though somewhat muffled. The radial artery 
 rigid. The abdomen is well rounded, the abdominal muscles tense. There is 
 no tumour present, no tenderness, no splashing sounds, oedema, or eruptions of 
 the skin. The urine is free from albumin and sugar, but contains indican in 
 moderate amount. 
 
 The dejections are fluid, of a brownish-yellow colour ; their odour is pun- 
 gently acid, but not at all faecal. Reaction, decidedly acid. They give a posi- 
 tive reaction for bile pigment. A digestive test was made with a filtrate of the 
 stool, by means of a scale of albumin (serum albumin), without any further addi- 
 tion. At the expiration of three and a half hours the albumin scale was per- 
 fectly dissolved. 
 
 Microscopical examination showed little mucus, much starch in well-pre- 
 served granules, many muscular fibres, strongly tinged with bile. Examina- 
 tion of further specimens of faeces gave the same result, excepting that the 
 digestive test (with albumin) was negative. Test lavage of the large intestine 
 yielded jellylike mucus. 
 
 My opinion that this case was one of catarrh of the upper por- 
 tion of the small intestine (with probable catarrh of the colon) is 
 based upon the pronounced biliary character of the brownish-yellow 
 fluid evacuations, which were quite free from fsecal admixture. 
 Although the digestion test only gave positive results on a single 
 occasion — something very unusual in my experience — yet this, when 
 taken in connection with the other features of the case, serves as an 
 additional support to the diagnosis. As far as I have seen, Noth- 
 nagel ^^ is the only one who has called attention to the peculiarities 
 of the stools in such cases, and to the difficulties of a differential 
 diagnosis between these diarrhoeas (jejunal diarrhoea) and the true 
 catarrhs. 
 
 Special mention should be made of a form of dyspeptic diarrhoea 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 221 
 
 which I have frequently met with, and which is of extreme prac- 
 tical importance. It is associated with severe types of chronic 
 gastric catarrh, such as, following the nomenclature of Einhorn, 
 are now called achylia gastrica. Biedert ^^ published minute and 
 valuable personal observations, and subsequently Einhorn^*, and 
 especially Oppler^^, have called attention to this condition. It is 
 characterized by a subsidence of the subjective gastric symptoms 
 and the appearance of chronic intestinal disorders, severe diarrhoea 
 being especially complained of. As a rule, while the motor func- 
 tion remains intact, the gastric secretion completely disappears. 
 Examination of the stools shows a disturbance in digestion, abun- 
 dant unaltered food residues, remains of animal tissues, espe- 
 cially connective tissue, vegetable products, and also, but less often, 
 fatty elements are present. Of the numerous observations of this 
 sort which I have collected in the course of years I will quote 
 but one, and that notable for the extent of the functional disturb- 
 ances. 
 
 Max G., nurse, forty-one years old. Underwent an operation for hemor- 
 rhoids six years ago, after which — doubtless because of a stricture of the rectum 
 — rectal bougies were passed for several weeks. From that time until two years 
 ago the patient remained well ; then he began to have occasional attacks of 
 diarrhoea. The patient denies any, even slight, gastric symptoms at this period, 
 excepting perhaps acid eructations. At all events, he could eat any kind of 
 food without discomfort. In the last two months the diarrhoea has mark- 
 edly increased, so that he now has four or five thin fluid movements each day, 
 without tenesmus. 
 
 Examination of the abdomen and rectum is quite negative. On the other 
 hand, repeated examination of the gastric contents shows absolutely undigested 
 food with a good deal of mucus, and neither free nor combined hydrochloric 
 acid. Examination for pepsin gives negative results ; that for rennet ferment 
 shows that only when undiluted is the gastric juice capable of coagulating 
 milk. In order to ascertain the digestive capacity of the intestine, the patient 
 was given a test meal on the evening of December 19, 1898, consisting of a 
 quarter of a pound of uncooked beef cut into small pieces. On the following 
 morning the fseces consisted almost exclusively of undigested meat, particularly 
 the connective tissue. 
 
 At a second test, in which the same quantity of beef was given in minced 
 form, numerous undigested fragments of connective tissue were again found, 
 and on microscopic examination a moderate quantity of muscular fibres. This 
 stool was a thin fluid of brownish colour; its filtrate gave a flocculent precipi- 
 tate with nitric acid, and with caustic potash and sulphate of copper (in very 
 dilute solution) a decided biuret reaction. The examination was repeated on 
 several occasions with the same result, except that the biuret reaction varied in 
 intensity. 
 
222 
 
 DISEASES OF THE INTESTINES 
 
 This case is therefore one of those which the older writers used 
 to call lientery {\€tov, slippery, and evrepov, bowels). It would be 
 difficult to decide in this case whether we have to deal with a true 
 enteritis or with a partial atrophy, but doubtless a marked functional 
 disturbance in the secretion of the intestinal glands and the pancreas 
 must be thought of. The latter feature has acquired special inter- 
 est from the fact, long since known, but recently confirmed by 
 Pawlow^^ (who has demonstrated it in a way worthy of imitation by 
 other investigators), that the hydrochloric acid of the gastric juice 
 is the most important excitor of pancreatic secretion. Thus, if we 
 may transfer the results of animal experiments to human physi- 
 ology, a new light is shed upon the origin of this form of intestinal 
 dyspepsia. 
 
 Diagnosis of Cheonic Catareh of the Laege Intestine 
 
 In well-marked cases the diagnosis of uncomplicated catarrh of 
 the large intestine seldom offers difficulties. The subjective signs 
 are essentially those which depend on the function of defecation, 
 and are not characteristic, unless it may be the tormenting feeling 
 of pressure or pain, above mentioned, or, in diarrhoeal cases, the 
 colicky pains, to which tenesmus may be added, if the process ex- 
 tends to the lower segments of the bowel. 
 
 The objective signs consist in tenderness on pressure and changes 
 in the faeces. The tenderness on pressure, which has already been 
 described, is by no means constant. When present, it seldom 
 extends over the entire length of the large intestine, but affects 
 localized segments, most frequently the descending colon and sig- 
 moid flexure. The sensitiveness may be of various degrees of 
 intensity ; occasionally even the slightest pressure is disagreeable. 
 Patients with well-marked tenderness usually complain of pain in 
 the corresponding portion of the bowel, particularly after being 
 seated for a long time, or after walking, bending, or riding, etc. 
 
 The nature and form of the mucus evacuations is of great impor- 
 tance in determining the regional extension of catarrh of the large 
 intestine. The lower the portion affected, the purer and more 
 unmixed are the mucus dejections. Thus the passage of pure 
 mucus points to catarrh of the- rectum, the sigmoid flexure, or the 
 lower segment of the descending colon. Similarly, hard masses of 
 fseces coated with mucus indicate that the disease is situated in the 
 lower portions of the bowel. 
 
 The examination of the stools gives the following results : 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 223 
 
 (a) With Constipation. — The stools frequently show mucus 
 either gelatinous or in strips (membranes), but not so constantly as 
 after irrigation. In other respects the formation may be normal or 
 diarrhoea], or of the consistence of pulp, or like sheep dung. For 
 the microscopical peculiarities, see chapter on the Examination of 
 the Fgeces. 
 
 (b) With Dian'hma. — In these cases the diagnosis as to localiza- 
 tion is best reached by exclusion — that is to say, by observing the 
 absence of unchanged biliary pigment. In other respects the stools 
 in this, as well as in the previously described form, show only scanty 
 food residues, in particular very little unchanged muscular fibre, 
 starch, or fat. The mucus is usually found intimately mingled 
 with the stool, or in the form of little shreds visible when the vessel 
 is rotated. 
 
 Diagnosis of Mixed Foems of Intestinal Cataeeh 
 
 The diagnosis can be made solely from the peculiarity of the 
 stools, which in such cases are almost always diarrhoeal. As before, 
 the recognition of biliary pigment, undigested food residues, espe- 
 cially muscular fibres, points to a localization in the small intestine, 
 while the results of irrigation will show whether or not the large 
 intestine is involved. The character of the stools as regards mucus 
 resembles that of catarrh of the large intestine. 
 
 Although in the preceding pages we have described the clinical 
 characteristics of intestinal catarrh with especial reference to the 
 determination of the regional extent as fully as our present knowl- 
 edge permits, we must not forget that such a delineation is largely 
 schematic. When we consider that hypertrophic catarrhal pro- 
 cesses are frequently associated with atrophic changes that can 
 not be diagnosticated, that catarrhs may arise from neurotic con- 
 ditions, that disturbances in intestinal absorption must be con- 
 sidered and may markedly infiuence the clinical picture, we must 
 exercise the greatest caution in expressing an opinion in those 
 cases where the existing conditions permit of more than one 
 interpretation. 
 
 Teeatment of Cheonic Enteeitis 
 
 In the treatment of primary chronic intestinal catarrh, as in all 
 catarrhs of mucous membranes, the same principle that we have 
 insisted upon in acute enteritis holds good : Protection of the dis- 
 eased organ. 
 
224 DISEASES OP THE INTESTINES 
 
 Especially must the nature, the seat, and the extent of the 
 underlying disease be considered in this connection. In the absence 
 of better criteria the character of the stools will serve as an indi- 
 cator, in all essential features, of the morbid processes going on 
 within the intestine. 
 
 For all practical purposes we are called upon to treat but three 
 conditions : Diarrhoea, constipation, and constipation alternating 
 with diarrhoea. 
 
 1. Diarrhoea 
 
 The most important part of the treatment is to insure complete 
 bodily rest and protection. In the milder cases, moderate physical 
 exertion or intellectual work may be permitted, but in the severer 
 forms these should be absolutely prohibited. Such patients should 
 be put to hed and kept there for at least several weeks. 
 
 Absolute rest in bed has the advantage that, once for all, it puts 
 a stop to the external influences so often conspicuous in chronic 
 diarrhoea, namely, cold, wet, mental or physical exertion, and, above 
 all, dietetic excesses or transgressions. As the other diagnostic 
 and therapeutic procedures are difficult to carry out at home, the 
 treatment — especially of advanced cases — is best conducted in hos- 
 pitals or in private sanitaria, in which dietetic arrangements are 
 well managed. 
 
 During the stay in bed, continuous warm fomentations may be 
 used with advantage. An appropriate diet is absolutely essential. 
 There are three points to be observed : 1. To avoid injurious sub- 
 stances which might increase the intestinal catarrh. 2. To select 
 such nutrients as will be assimilated in the particular case. 3. To 
 combine the greatest variety of those nutrients whose physiological 
 action is astringent or which reduce secretion — in other words, those 
 which have a tendency to constipate. 
 
 The details of such a diet have been given in extenso in the 
 General Section (page 149). For those physicians who have had 
 little experience in prescribing a special dietary, the follomng may 
 be of assistance : 
 
 8 A. M. — " Eichel cocoa " (in water), one saccharin tablet (or 
 crystallose), toast and butter (20 to 30 grams). 
 10 A. M. — One cup (200 grams) rice gruel, buckwheat or oat grits 
 in veal bouillon (avoid salt). In addition, 50 grams 
 roasted veal or beef (scraped), or fried fish or cold 
 meat (avoid salt or strongly pickled ham). 
 
ACUTE AND CHRONIC INTESTINAL CATAHRH 225 
 
 1 p. M. — Soup of peas or beans or puree of oatmeal, farina, or 
 corn starch, etc. (addition of nutrose, tropon, or eucasin 
 allowed ; somatose forbidden). In summer, huckleberry 
 soup (with saccharin, if desired). Two hundred grams 
 of rice bouillon (avoid rice with milk),^ or farina bou- 
 illon, well thickened by cooking. 
 
 Green vegetables or potatoes in puree form (50 to 
 100 grams). 
 
 Meat and fish (fat excepted), 50 to 100 grams. 
 (Butter sauce allowed ; cream sauces or highly seasoned 
 sauces forbidden.) 
 
 Stewed fruits, with the exception of huckleberries 
 and cranberries, forbidden. 
 
 Custards (corn starch, with a little yolk of ^^^ and 
 saccharin) allowed. (Avoid fruit juices.) 
 
 As beverages : Huckleberry wine. Burgundy, Cama- 
 rite, Simaruba wane, old Bordeaux. (Sweet wines, white 
 wines, and effervescent beverages forbidden.) 
 4 p. M. — Tea (without milk), with saccharin or cocoa. Cakes, 
 
 toast, zwieback (with butter). 
 7 P. M. — Strained gruel (oatmeal, etc.). Cold or warm meat 
 (50 grams), toast, butter (20 grams). 
 
 One or two glasses of huckleberry wine. 
 
 9 P. M. — One glass of huckleberry lemonade,f warm, or hot 
 
 mulled wine (saccharin), or tea, with red wine. 
 
 It may be necessary to cut out many articles from this dietary. 
 It should only be relaxed when the general and local conditions are 
 satisfactory, and the stools have been formed for at least four 
 weeks without any relapses having occurred. 
 
 Sugar, pastry, milk, organic acids, salt, beer, effervescing bev- 
 erages, cold drinks, and fruit ices should be positively avoided for 
 months, and in many cases for years. 
 
 The value of such a diet, taken in connection with absolute rest 
 in bed, can not be overestimated. Indeed, I know of nothing 
 which can replace this treatment. ^Nevertheless, in some cases the 
 use of medicines will be required. 
 
 Medicinal Treatment. — We know of no drug which will cure 
 
 * As to avoiding milk, see page 144. 
 
 f Huckleberry lemonade is made by adding one or two teaspoonfuls of huckle- 
 berry jelly to boiled water. 
 
226 DISEASES OF THE INTESTINES 
 
 an intestinal catarrh^ l>ut one of the symptoms, cliar'rh(Ba, may 
 sometimes he fa/oourdbly influenced hy ajpjprojpriate medication. 
 
 There is nothing to add to what has been said in the General Sec- 
 tion (page li9 et seq.). We can only repeat that we have little faith 
 in the value of the numerous astringent and antiseptic remedies 
 which have recently come to notice. Yet there is one drug that 
 should not be forgotten, because it combines a certain degree of util- 
 ity with the absence of any objectionable feature. I refer to chalk. 
 It should be given as a mixture of equal parts of carbonate of 
 lime and phosphate of lime. For several years I have preferred to 
 treat cases in which diarrhoea has persisted in spite of dietary regu- 
 lation, by giving a teaspoonful of this powder three times a day. 
 
 Jaworski^''^ has recently recommended chalk dissolved in carbon- 
 ated water for diarrhoeal cases. He uses two formulas, a stronger 
 and a weaker, as follows : 
 
 ]^ Calcii carbon 2.0 
 
 Calcii salicyl 2.0 
 
 Dissolved in one litre of highly charged carbonic water. (Aq. 
 calcii mitior.) 
 
 Y/, Calcii carbon 4.0 
 
 Calcii salicyl 3.0 
 
 In similar sohition, (Aq. calcii fortior.) 
 
 One half a glass of the stronger is to be taken fasting, in the 
 morning, and a half glass of the weaker, three times a day, after 
 meals. In severe cases Jaworski recommends that the above be 
 taken mixed with a half glass of warm Carlsbad Sprudel water. 
 
 The use of preparations of chalk is specially valuable when there 
 are eructations of hydrochloric acid, for here the sodium prepara- 
 tions are contra - indicated on account of their laxative tendency. 
 A combination of the above-mentioned chalk mixture with bis- 
 muth has been highly recommended. I prefer the beta-naphtholate 
 (orphol). The following formula is unobjectionable and appro- 
 priate : 
 
 'fy Calcii carbon. 
 
 Calcii phosph., ää 25.0 
 
 Bismuthi beta-naphthol 5.0 
 
 M. One teaspoonful three times a day. 
 
 Besides the preparations of lime just mentioned, the natural 
 mineral waters containing lime are useful as adjuvants [see 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 227 
 
 pp. 163 and 164]. Thej are especially suitable as table beverages. 
 I have often ordered them (warm, one glass morning and evening) 
 with good results, and can heartily recommend this treatment.* 
 
 Concerning the other hydrotherapeutic methods, see General 
 Section, page 158 et seq. 
 
 For the functional diarrhoeas that occur with achylia gastrica, 
 Oppler ^^ has found hydrochloric acid in large doses (20 to 30 drops, 
 and even more) very satisfactory. 
 
 If there are gastric disorders, and especially loss of appetite with 
 chronic intestinal catarrh, I particularly recommend the use of 
 wine of calumbo (a dessert glassful three times a day, before 
 meals), or the fluid extract of calumbo (a teaspoonful three times 
 a day, in a wineglass of lukewarm water or in a wineglass of the 
 above-mentioned solution of chalk). 
 
 The treatment of chronic diarrhoeas by enemata is suitable in 
 catarrhs of the colon and the rectum. In addition to those already 
 described (page 181), I have seen excellent results from enemata of 
 bismuth (a teaspoonful in 250 cubic centimetres of water). This is 
 analogous to Fleiner's method for the treatment of gastric ulcer. 
 
 2. Constipation 
 
 In the treatment of constipation, bodily and mental rest may 
 contribute toward a good result ; only in very severe cases is abso- 
 lute rest in bed indicated. Experience shows that warm, frequently 
 repeated fomentations have a favourable effect upon the pain. 
 
 The chief indication to be met in catarrh of the intestine accom- 
 panied by constipation is the removal of this symptom by appro- 
 priate diet. In all essential features it is the same diet as that to 
 be fully described in the chapter on Constipation, but with this 
 important exception, that all foods which are rich in cellulose^ 
 or other indigestible substances, must be avoided. If, as is usually 
 the case, we succeed in regulating the evacuations by the diet, the 
 abnormal secretion of mucus gradually disappears without further 
 treatment (see chapter on Membranous Enteritis). In these cases 
 I do not believe purgatives should be given ; indeed, I have a 
 suspicion that their use may cause, or at least aggravate, an intes- 
 tinal catarrh. If directions as to diet do not suffice, I recommend 
 
 * It is much to be regretted that the treatment of chronic intestinal catarrhs has 
 not been undertaken at the above-mentioned springs. With appropriate installations 
 for providing suitable diet (somewhat after the manner of Carlsbad), these springs 
 would, in my opinion, take a prominent [)lace in the treatment of intestinal catarrh. 
 
228 DISEASES OF THE INTESTINES 
 
 mild enemata of rape-seed oil, oil of sesame, or olive oil ; of neutral 
 soap (5 grams to 250 cubic centimetres of water), castor oil, cod- 
 liver oil, soda, etc. (see page 179). Irrigation for the purpose of 
 cleansing the intestine of mucus is a very useful adjuvant. The 
 following solutions are to be recommended for this purpose : Lime 
 water (3 to 4 tablespoonfuls to 1 litre of water), carbonate of soda 
 (1 dessertspoonful to 1 litre of water), Carlsbad salt (in the same 
 proportion). Other desirable agents for the same purpose have 
 been mentioned on page 181. 
 
 3. Constipation, alternating with Diarrhcßa 
 
 The same principles hold good as in the form just described. It 
 is only necessary to decide which is the primary or predominating 
 feature, and this can readily be ascertained by the use of a test diet 
 for a few days. 
 
 3. Membranous Enteritis 
 
 Preliminary Considerations. — By membranous enteritis, or, 
 still better, membranous colitis, we understand a form of catarrh of 
 the large intestine which is characterized by three cardinal symp- 
 toms : (1) A peculiar mucous formation ; (2) anomalies of intestinal 
 function ; (3) painful spasm of the intestine. In addition, there are 
 a few other collateral symptoms, which, however, have nothing to 
 do with the clinical picture proper of the disease. 
 
 The classification of membranous colitis with chronic enteritis 
 does not altogether correspond to the views which prevail at the 
 present time, especially among German authors. The predominant 
 conception is that which Siredey ^^ seems to have been the first to 
 advance in 1869 — that the membranous mucous formation was the 
 result of a peculiar secretory neurosis. Da Costa ^^, to whom we 
 owe its first classical description, looked upon membranous colitis as 
 of nervous origin. The German authors, in so far as they have 
 expressed themselves concerning the pathology of the disease, do 
 not agree, von Leube ^ and Eosenheim^^ are inclined to regard it as 
 a neurosis of secretion. Ewald ^^ takes a middle ground, and ISToth- 
 nagel^ makes a sharp distinction between mucous colitis and mucous 
 colic, one having an anatomical and the other a functional basis. 
 The standard French authors (G. See 2^, Potain ^s, Alb. Mathieu '^, 
 de Laugenhagen 2^) rather incline to the view that there is a superfi- 
 cial catarrh. On the other hand, American authors (Mendelson '^ 
 Einhorn ^^ and others) have recently laid stress on the nervous char- 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 229 
 
 acter of the affection. Yanni^ also speaks of a myoangioneurosis 
 of the intestine with hypersecretion of mucus. As far as I have 
 seen, the latter idea has made a deep impression in medical circles, 
 and has had an undeniable influence upon treatment. 
 
 From personal observation I can say that it is difficult to come 
 to a decision. There are cases in which the nervous, restless char- 
 acter of the affection is very prominent, so much so that it is diffi- 
 cult to believe that it has a material basis. On the other hand, 
 there is no doubt in my mind that membranous colitis is frequently 
 found in patients who are not at all neurotic, or in whom the neu- 
 rotic stigmata are positively or probably the results of the disease. 
 An unprejudiced estimate of the frequency of the two groups leads 
 me to the opinion that the latter predominates. 
 
 This much is certain : the idea that membranous enteritis is one 
 of the phases of hysteria or neurasthenia must be rejected as too 
 sweeping. 
 
 Unfortunately, neither experimental pathology (Yanni ^, Aker- 
 lund^^) nor pathological anatomy affords us much assistance as 
 to etiology. We have but two clinical observations followed 
 by autopsy — those of O. Eothmann^ and of M. Eothmann^l In 
 the former, although the entire intestinal tract was carefully 
 examined by C. Rnge, nothing abnormal was found ; while in the 
 second case, reported by the younger Rothmann,* all the character- 
 istic lesions of a catarrh of the large intestine were demonstrated by 
 a very thorough histological examination. Although it may seem 
 venturesome to draw any conclusion from two findings so diamet- 
 rically opposed to each other, yet there is no doubt that the posi- 
 tive result has much greater significance than the negative one. 
 
 Aside from the main question whether we are dealing with 
 a functional or an inflammatory condition, there are a number of 
 other etiological factors to be considered. First of all, the influ- 
 ence of habitual constipation must be emphasized. According 
 to the experience of most authors, habitual constipation is one 
 of the most constant affections occurring together with mem- 
 branous enteritis. A few (Ewald ^, Einhorn ^9, and others) call 
 attention to an antecedent diarrhoea as a cause. I have also seen 
 such cases, but only after the use of astringent enemata. In addi- 
 tion, numerous observers (Glenard ^, A. Mathieu ^^, Ewald ^, Boas ^% 
 Akerlund ^\ de Langenhagen ^', Einhorn ^, and others) have accen- 
 
 * The report of 0. Rothmann does not state whether a histological examination 
 was made. 
 
 IG 
 
230 DISEASES OF THE INTESTINES 
 
 tuated the relationship between coloptosis and membranous enteri- 
 tis. This etiological factor has a certain influence, but only in so 
 far as it favours the establishment of habitual constipation. 
 
 Attention has been called by French investigators to the rela- 
 tion between membranous enteritis and uterine diseases (Ozenne % 
 Letcheff ^, and others) ; but these observations seem rather to relate 
 to accidental complications. It is well known, moreover, that uter- 
 ine diseases, as well as abnormal conditions of the adnexse, may 
 cause constipation by compression or adhesions, and thus predispose 
 to membranous enteritis. 
 
 Finally, at a recent date, various French investigators (A. Ma- 
 thieu ^^, de Langenhagen ^^, Chevalier ^) have laid stress on a certain 
 connection between membranous enteritis and intestinal lithiasis. 
 The periodical formations of gravel, accompanied by severe colic, 
 which had already been recognised and which was recently rede- 
 scribed by Dieulaf oy ^\ are supposed by Mathieu ^^ to be a constant 
 feature of membranous enteritis. All that has been published on 
 this subject simply goes to show a possible coexistence of intestinal 
 lithiasis with the disease under consideration, but no proof has yet 
 been offered that there is any etiological relation. 
 
 Artificial membranous enteritis is a very important condition, 
 which from a practical standpoint has received much less attention 
 than it merits. I have frequently observed it after enemata of tan- 
 nin, alum, glycerin, and nitrate of silver. In some cases the clinical 
 picture of membranous enteritis already existed (see Case lY) ; but 
 I have become convinced that the symptoms may be kept up and 
 increased by irritant injections. Membranous enteritis is also ob- 
 served as a sequel to acute enteritis. It is doubtful whether this con- 
 dition is altogether identical with the one now under consideration. 
 
 After these preliminary remarks, we will proceed to 
 
 Symptomatology and Diagnosis 
 
 When we analyze closely the description of the symptoms of 
 membranous enteritis, as given by the most prominent authorities 
 (Da Costa ^^, von Leyden^, ]S"othnagel ^^, Kitagawa^, Krysinski*^, 
 A. Mathieu ^^, Germain See^, de Langenhagen^''', and others), we 
 find such a lack of agreement that the question arises whether 
 these authors are dealing with the same affection. In some of the 
 cases it can be shown with certainty that the clinical picture be- 
 longs essentially to the group of colica mucosa. Others are com- 
 plicated by gastric atony, intestinal prolapse, appendicitis, etc. In 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 231 
 
 still others uterine complications exist. In one case, recently de- 
 scribed by Henschen ^^, larvae of the fly were present in the intestinal 
 canal. Others were undoubtedly due to artificial influences such 
 as have been just mentioned. Finally, there are several cases (Mar- 
 chand ^^, O. Rothmann ^^, Richardiere '^'^) which, as far as concerns 
 the bowels, gave no symptoms during life. 
 
 'Nor does this exhaust the list; it would take too long to allude 
 to all of them. We can only say that for diagnostic purposes mem- 
 branous colitis is sometimes an independent disease, and sometimes 
 is found in conjunction with other afEections. It is thus easy to un- 
 derstand that the clinical picture presents manifold exceptions and 
 variations. 
 
 I have thought it advisable, therefore, to select the following 
 from the large number of cases which I have recorded, and in con- 
 nection with them to discuss the diagnosis : 
 
 Case I. A case of membranous enteritis^ with severe disturbances of nutrition, 
 which had existed for many years. Permanent cure. 
 
 Mrs. Regina B., twenty-seven years old, born in Poland, and for several years 
 a resident of Berlin. 
 
 The patient states that for seven years she has suffered from loss of appe- 
 tite, eructations, pains in the stomach after the ingestion of food, flatulence, 
 and persistent constipation. For some time past enemata have nearly alvpays 
 been required to obtain movements from the bowels, and the patient has often 
 noticed membranous and tubular masses of mucus in the stools. These have 
 sometimes appeared in such abundance that the stools consisted of almost 
 nothing but them. The patient asserts that during this period she was very 
 nervous and uneasy. She does not, however, remember having had any marlced 
 pain immediately before such mucous stools. At her first visit to the polyclinic 
 (March, 1893) she looked very ill, was extremely emaciated, so that incipient 
 phthisis was suspected, but not confirmed by examination. She was treated 
 by irrigations of the intestine; the washings frequently showed masses of 
 mucus, membranes of mucin, and tubular casts of various calibres. The sub- 
 sequent treatment was wholly dietetic ("constipation diet"). 
 
 Under the latter treatment and a course of waters the patient's condition 
 improved materially ; she gained in weight to a considerable extent, and began 
 to get a healthy colour. 
 
 At my request she presented herself in March, 1895, and again in February, 
 1899, for examination; she stated that her health had continued good, and 
 that there was no longer constipation. Irrigation showed that the mucous 
 masses were no longer present. 
 
 Case II. Severe form of membranous enteritis, complicated by dism^ders of 
 the stomach and bladder. Cure. 
 
 Mrs, B., widow, Kloster Lehnin, near Brandenburg, thirty-six years old. 
 The patient states that since the death of her husband and a sixteen year-old 
 
232 DISEASES OF THE INTESTINES 
 
 daughter she has been very nervous and irritable, sleeps badly, complains of 
 tremor and spots before the eyes. 
 
 The patient has suffered from extreme constipation since childhood ; has 
 always used enemata and laxatives. In the last three years disorders of the 
 stomach have appeared : poor appetite, nausea, but no vomiting, discomfort, 
 and pressure in the epigastrium. Gradually she began to have attacks of se- 
 vere pain in the epigastrium after eating, which came on even after a spoon- 
 ful of milk. This x)ain radiated toward the sides and back, and was more 
 severe after food not easily digested. The constipation increased so that 
 four tablespoonfuls of castor oil and an enema of oil produced only a small 
 evacuation. There was marked emaciation, and the patient was confined to 
 bed for months. In the winter of 1895-96 she first noticed that after ene- 
 mata pure mucus was passed, sometimes in the shape of little shreds, and 
 sometimes larger aggregations in tubes or bands as long as half a metre. 
 After passing these the patient used to feel better. With these complaints 
 there icas associated pain in the Uadderfrom time to time, ending in the passage oj 
 a light-coloured tirine of low density. On admission to the clinic in May, 1897, 
 she complained of debility, weakness on walking, pains along the spine, ano- 
 rexia, slight eructations, severe constipation, and the passage of mucus in the 
 stools. 
 
 Condition on admission. May 5, 1897 (with the omission of unimportant 
 features) : Floating kidney on the right side ; fundus of the stomach at the level 
 of the umbilicus. Loud splashing sounds in both iliac fossae, and to some 
 extent also in the epigastrium. 
 
 An evacuation followed irrigation of the intestine ; it resembled sheep dung, 
 and was covered with small shreds of mucus ; it was small in quantity, and of 
 a brown, or perhaps greenish brown colour. 
 
 Palpation of the abdomen showed that the left iliac region was very tender; 
 there was also slight tenderness in the ejjigastric region. 
 
 A second irrigation on the same day showed abundant masses of mu- 
 cus, several of the shreds measuring a few centimetres in length. They were 
 white or yellowish brown in colour, some membranous, and some vitreous in 
 appearance. 
 
 Repeated irrigations gave the same result. The microscopical examination 
 gave the usual findings. The stools were in other respects normal. Treat- 
 ment: constipation diet and intestinal irrigations. 
 
 In spite of these measures the constipation was not entirely relieved. Ene- 
 mata could not be dispensed with. In the further history of the case the 
 pains in the stomach and spine disappeared and the patient gained in weight. 
 The abdominal pains were felt occasionally. The evacuations obtained by ene- 
 mata frequently contained large shreds of mucus. The neighbourhood of the 
 sigmoid flexure was still sensitive to pressure, but much less so than formerly. 
 Treatment, aside from diet, consisted in pulv. glycyrrhizse comp., one tea- 
 spoonful twice daily. 
 
 June 2Jf, 1898. — The patient now has regular movements from the bowels; 
 the pains have almost entirely vanished ; weight and strength have increased. 
 The evacuations are free from mucus. The region of the sigmoid flexure only 
 slightly sensitive. 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 233 
 
 Case III. Membranous enteritis, with severe constipation and occasional 
 acute colics. Previous history of ulcer of the stomach {or duodenum ?). 
 
 Mrs. B., resident of G., forty-one years old. In her nineteenth year, four 
 weeks after marriage, the patient suffered from acute peritonitis fgonorrhoeal 
 infection ?). She was confined to bed for seven weeks, and had pains in the 
 abdomen for some time afterward. 
 
 As a girl she suffered from constipation, which became worse after the 
 attack of pelvic peritonitis. Two years later she had an attack of pleurisy on 
 the right side, following which she began to have a persistent gastric pain. In 
 the year 1885, after the appearance of tarry blood in the stools, a gastric ulcer 
 was diagnosed. In 1887 there was another attack of melaena, and in 1890 
 vomiting of blood. She underwent von Leube's treatment for ulcer, at 
 Würzburg. Improvement resulted, but only under the strictest diet. Mucus 
 was first noticed in the stools in 1888, the bowels being extremely constipated. 
 The same fact was noted during the treatment for ulcer in 1890. Gradually 
 severe pains developed on both sides of the abdomen at the level of the umbili- 
 cus; these were only relieved by a free movement of the bowels. Sometimes 
 nothing but mucus was passed, and at other times it was accompanied by faeces. 
 "When mucus only was passed there was no alleviation of the symptoms. Such 
 mucous evacuations occurred every four to six weeks. In the intervals mucus 
 was either absent or only found in small quantity. 
 
 Present condition : Sensitiveness on pressure localized at 1^ centimetres to 
 the right of the median line at the junction of the middle and lower thirds of 
 the space between the xiphoid cartilage and the umbilicus. Intestinal area 
 quite free from sensitiveness. Irrigation of the intestine on two occasions gave 
 only a very small quantity of mucus. 
 
 Case IV. Development of membranous colitis during pregnancy, tcith severe 
 pyrexia. Normal lcd)our. Cessation of the fever. Continuance of the colitis. Cure 
 by producing regular movements of the bowels. 
 
 Mrs. H., twenty -five years old. The patient, who was healthy, with the 
 exception of a varying degree of constipation, suddenly took sick in the sixth 
 month of pregnancy, on June 19, 1898, with a chill and a fever reaching 39.6" C. 
 [103.3° F.]. She complained of pain in the lower part of the abdomen on the 
 right side, which pain radiated to the lumbar region and down the right leg. 
 Examination yielded no positive results. The illness during the following four- 
 teen days presented the picture of a septic infection. 
 
 In the beginning of July the fever and chills abated, followed on the 10th 
 by symptoms similar to those at the onset. About the middle of the month 
 the stools for the first time showed mucous casts, which were both tubular and 
 ribbonlike, and 10-13 centimetres in length. 
 
 For the following particulars I am indebted to her family physician, Dr. 
 Laux, of Oldenburg : 
 
 On the 18th of July, having just returned after an absence from town, I saw 
 these evacuations for the first time. Though quite fresh, they had a penetrat- 
 ing odour, as if in a state of decomposition, which was also suggested by their 
 dirty, grayish green colour. By means of two or three large enemata, I succeeded 
 in removing more or less abundant masses of fjeces, with a resulting subsidence 
 
234 DISEASES OF THE INTESTINES 
 
 of the strong odour, and a return to the usual colour. Under this treatment the 
 chills and fever disappeared, and the subjective symptoms improved to some 
 degree. On August 1st delivery occurred, setting in with a chill and fever, but 
 otherwise normal in its progress. The puerperal period was uneventful. Since 
 then there have been, off and on, evacuations of mucous shreds, but finely broken 
 up and in small quantity. On the day before such passages there is pain, which 
 is relieved by the evacuation. Persistent constipation exists, but is controlled 
 by enemata. Regulation of the bowels by constipation diet in my clinic 
 resulted in a complete arrest of the mucous discharge. 
 
 The reported cases of membranous enteritis show an extraor- 
 dinary preponderance of the female over the male sex. All the 
 authors agree on this point. Litten foimd 80 per cent and Kita- 
 gawa 90 per cent in women ; Einhorn found, in a total of 20 cases, 
 2 men and 18 women, or about the same relation as the last-named 
 author. This is not surprising when we consider the prevalence of 
 coloptosis and constipation among women. 
 
 The greatest number of cases of membranous enteritis occur 
 during the second, third, and fourth decades of life ; it is only rarely 
 found during the later years of life, and rarest of all in childhood. 
 A few cases have been reported in the newborn (Longuet ^, Ull- 
 mann^^) and in the early years of childhood (Löwenstein ^). 1 have 
 seen a well-marked case in a two-year-old girl of very nervous 
 temperament. 
 
 The chief com]3laints of the patients relate to disturbances of 
 the intestinal functions. Constipation is, as I have repeatedly 
 said, the condition in the majority of cases ; diarrhoea is certainly 
 atypical. Paroxysmal pains are a very frequent symptom. They 
 usually mark the onset of attacks, and are of an exceedingly acute 
 cohcky type, so that they often cause symptoms of collapse. The 
 attack ends with the passage of faeces and membranous mucus, or 
 of the latter alone. The stools have the usual appearance of spastic 
 dejections. These intestinal colics are, however, by no means a 
 necessary symptom ; they may be slight, or entirely absent, or 
 there may be colicky pains without passage of mucus ; or, finally, 
 membranes may be passed with or without attacks of pain. If we 
 are successful in regulating the bowels, the painful intestinal spasm 
 and the mucous evacuations usually cease, or appear only occasionally 
 and to a limited extent. 
 
 Together with these symptoms there may be various other com- 
 plaints, partly of a nervous and partly of an organic origin ; these 
 have nothing to do with the disease as such ; they are nothing but 
 accessory symptoms or complications. 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 235 
 
 In typical cases the objective signs are sensitiveness over the 
 colon or portions of it, and the passage of mucus. 
 
 In the majority of cases the sensitiveness is noted over the 
 descending colon or the sigmoid flexure ; in other cases over the 
 caecum and ascending colon, and apparently very much less fre- 
 quently over the transverse colon. This sign alone is not character- 
 istic of membranous colitis, since, as we have noted above, it is met 
 vfith in ordinary catarrh of the large intestine ; but in the former 
 affection it is much more pronounced than in simple catarrh. The 
 tenderness which under certain circumstances is not much less than 
 in appendicitis, seems to bear a positive relation to the process, for 
 it disappears or diminishes as cure or improvement occurs, to return 
 in a surprising way when a relapse occurs. 
 
 The expulsion of mucus or membranes is the most decisive 
 clinical sign. It is hardly conceivable that these formations should 
 be mistaken for tapeworm, food residues, etc., or anything else, or 
 that the affection should be confounded with croupous enteritis, if 
 careful macroscopic and microscopic examination is made. Three 
 kinds of mucous formation can be distinguished: 1, unformed, struc- 
 tureless mucus ; 2, hyaline, tubular formations, which under cer- 
 tain conditions form a cast of the internal surface of the intestine ; 
 3, membranous mucus, sometimes firm and sometimes spongy in 
 consistence. The chief constituent of these secretions — for there is 
 no doubt on this point at the present day — is mucus and an albu- 
 minoid body, the latter depending upon the varying admixture of 
 cellular elements. According to careful investigations of Kita- 
 gawa^, M. Eothmann^, Akerlund^^, Ad. Schmidt ^^, and Pariser ^2, 
 there is no fibrin present, and they are thus differentiated from the 
 exudates in intestinal diphtheria. 
 
 In doubtful cases a microscopic examination is a useful supple- 
 ment to the results of the macroscopic investigation. Even without 
 the addition of acetic acid, but better with it, there will be found 
 the peculiar threadlike substance in which cells, nuclei, and detritus 
 are embedded in variable quantity. Most of the cells have lost their 
 characteristic appearance (see Fig. 16, page 118), fresh, unchanged 
 cells being rarely found. Opinions differ as to the cause of this 
 degeneration. J^othnagel^^ thinks it is due to desiccation. Kita- 
 gawa regards it as a degeneration process (coagulation necrosis). 
 As Ad. Schmidt ^^ has recently shown, it is due to an infiltration of 
 fatty soaps, on the removal of which the cells regain their bright, 
 transparent appearance. There are also found a greater or less 
 
236 DISEASES OF THE INTESTINES 
 
 number of leucocytes, occasionallj Charcot-Leyden crystals, and 
 micro-organisms of various kinds. ISTone of these have any special 
 significance. 
 
 CompKcations are very frequent. Associated disease of the 
 uterus and adnexse and intestinal lithiasis have already been men- 
 tioned. The literature of the subject shows that albuminuria, 
 pyrexia, epileptic attacks, tachycardia, dyspnoea, neuralgia, tremor, 
 somnolence, amblyopia, and melancholia are occasional accompani- 
 ments. Einhorn ^ found that out of twelve cases achylia gastrica 
 was present in five, and in several cases the gastric motor function 
 was increased. 
 
 The course of membranous cohtis, like that of habitual constipa- 
 tion, is exceedingly chronic, but like it, shows marked remissions 
 and intermissions. The general nervous symptoms follow very 
 closely the increase or diminution in the colicky attacks. 
 
 The diagnosis of membranous colitis can be made in most cases 
 from the symptoms which have been detailed, especially from the 
 results of repeated intestinal irrigation. This should not be post- 
 poned in any case. It will show — and I particularly insist upon this 
 — that the membranous formation does not appear occasionally or 
 suddenly, but that smaller or larger masses of mucous or tubular 
 formations may often be identified during the intervals between the 
 attacks. Some difficulty exists in the differentiation between simple 
 colitis and the membranous variety, for we meet with cases which 
 might with equal propriety be put in either class. In general, those 
 cases in which actual membranes are passed should be put in the 
 present class, and the remainder classed with the other forms of 
 enteritis. The other fact already mentioned, that membranous 
 enteritis may arise from artificial causes, must again be emphasized 
 and should always be borne in mind. 
 
 Teeat^iext 
 
 Until recently very unfavourable or doubtful results were ob- 
 tained from the treatment of membranous colitis, and at the pres- 
 ent time the disease is frequently obstinate, and yields reluctantly 
 to therapeutic influences. This is especially true of those cases in 
 which a hysterical element is prominent. 
 
 In cases of a conspicuously catarrhal type much more may be 
 expected from treatment. 
 
 In accordance with our conception of the nature of the disease, 
 chief stress is to be laid upon the treatment of the enteritis, with- 
 
ACUTE AND CHRONIC INTESTINAL CATARRH 237 
 
 out underestimating the importance of such elements as neuras- 
 thenia, enteroptosis, anaemia, or faulty nutrition. 
 
 We have already said, and it has been recently emphasized by 
 von I^oorden^^, that the chief feature of the treatment of mem- 
 branous enteritis consists in the relief of the constipation by an 
 appropriate diet, von IS^oorden^ rather recklessly states that one 
 rich in coarse constituents, with abundance of butter and fats, is 
 appropriate. I have not had any experience with this method, but 
 I can not suppress the thought that such a coarse diet may gi'adu- 
 ally set up intestinal irritation. I still believe in the view, expressed 
 some time ago ^^, and repeated recently, that a constipation diet, with- 
 out husks or cereals, is the only suitable and successful dietary in 
 membranous enteritis. Einhorn ^^ has very recently taken a similar 
 position. 
 
 It is not necessary to enter here upon the details of this diet, as 
 it differs very little from that to be described in the chapter on Con- 
 stipation. We agree with von Noorden as to the cardinal impor- 
 tance of an abundant supply of nutriment, since the patients are 
 generally individuals who are depreciated by ansemia, faulty nutri- 
 tion, or frequent pregnancies. I have seen excellent results from 
 the employment of forced nutrition, always, of course, with due 
 attention to the question of constipation. 
 
 In those cases in which the constipation is overcome by diet, 
 local treatment of the intestinal tract is superfluous ; in other cases 
 it may be of advantage. According to Fleiner, enemata of oil are 
 very successful, but I have not had sufficient experience with them 
 to be able to say whether their effect is lasting. Careful irrigation 
 with unirritating substances, such as physiological salt solution, so- 
 dium carbonate, or Carlsbad salt, may be of material assistance. On 
 the other hand, caution must be recommended in the use of astrin- 
 gent solutions which are apt rather to increase the difficulty (tannin, 
 alum, nitrate of silver, etc.). For the same reason I consider the 
 stronger purgatives contra-indicated, while the milder laxatives, such 
 as rhubarb, tamarinds, liquorice powder, and preparations of sagrada, 
 may be of use if dietetic measures are not sufficient. Other drugs 
 (ext. fl. hydrast. canadensis, bromids, opiates) have been recommended, 
 but a real influence upon the morbid process is hardly to be ex- 
 pected from them. Perhaps the painful colics may be ameliorated 
 by suppositories containing codeia, belladonna, or opium. In gen- 
 eral, the continuous or intermittent application of moist, warm, or 
 hot poultices, in connection with aromatic infusions, will suffice. 
 
238 DISEASES OF THE INTESTINES 
 
 In cases of membranous colitis with prominent nervous disturb- 
 ances hydrotherapeutic procedures are very valuable (half baths, 
 shower baths, douches, wet packs, etc.). Change of air and a warm 
 climate sometimes contribute to a cure. The mineral waters do not 
 promise great or permanent results. 
 
 Among the curiosities of treatment, I may mention that the sur- 
 geons have attempted to cure membranous colitis by the establish- 
 ment of an artificial anus (Hale White and Golding Bird ^, F. 
 Franke ^^). They claim to have had successful cases. 
 
 LITERATURE 
 
 1. Gaffky. Deutsch, med. Wochenschr., 1893, No. 74. 
 
 2. Kjellberg. Nordiskt med. Axkiv, 1869, Bd. i. 
 
 3. Hermann. Wiener med. Wochenschr., 1890, S. 1044. 
 
 4. Mühlhäuser. Berliner klin. Wochenschr., 1873, S. 595. 
 
 5. Kobler. Wiener klin, Wochenschr., 1890, No. 28-31. 
 
 6. Fischl. Prager Vierteljahrsschrift, 1878, Bd. cxxxix, S. 37. 
 
 7. Stiller. Wiener med. Wochenschr., 1890, No. 78 u. 79. 
 
 8. Turner. Practitioner, October, 1894. 
 
 9. Strümpell. Lehrbuch d. spec. Pathologie u. Therapie, Bd. i, 1883, S. 565. 
 
 10. Fleischer. Krankheiten d. Speiseröhre d. Magens u. Darmes, S. 1336. 
 
 11. Nothnagel. Darmkrankheiten, S. 98. 
 
 13. Nothnagel. Beiträge zur Physiologie u. Pathologie d. Darms. Berlin, 
 1884, S. 191. 
 
 13. Biedert und Langermann. Diätetik u. Kochbuch. Stuttgart, 1895. 
 
 14. Einhorn. Archiv f. Verdauungskrankheiten, Bd. i, S. 158, 1895. 
 
 15. Oppler. Deutsch, med. Wochenschr., 1896, No. 33. 
 
 16. Pawloff. Die Arbeit d. Verdauungsdrüsen. Wiesbaden, 1898. 
 
 17. Jaworski. Therapeutische Monatshefte, 1898, Heft 3. 
 
 18. Siredey. Union medicale, 1869. 
 
 19. Da Costa. Amer. Jour. of the Medical Sciences, p. 331, 1871. 
 
 30. von Leube. Specielle Diagnose innerer Krankheiten, 1889, S. 370. 
 
 31. Rosenheim. Pathologie u. Therapie d. Krankheiten d. Darms, 1893, S. 133. 
 
 33. Ewald. Nineteenth Century Practice of Medicine, 1897, p. 365. 
 23. Nothnagel. Darmkrankheiten, S. 139. 
 
 34. G. See. Bullet, medic, 1893, p. 1167. 
 
 35. Potain. Semaine medicale, 1887, p. 341. 
 
 26. Alb. Mathieu. Gaz. des hopitaux, 1894, 37 Oct. Cfr. also Therapeutique 
 des maladies de l'intestin. Paris, 1895. 
 
 37. de Langenhagen. Semaine medicale, 1898, No. 1. 
 
 38. Mendelson. New York Med. Record, Jan. 30, 1897. 
 
 39. Einliorn. Archiv f. Verdauungskrankheiten, Bd. Iv, Heft 4, 1898, and 
 
 New York Med. Rec. 
 
 30. Vanni. Rivista clinica, 1888, No. 4. 
 
 31. Akerlund. Archiv f. Verdauungskrankheiten, Bd. i, S. 396, 1895. 
 
ACUTE AND CHRONIC INTESTINAL CATARRH £39 
 
 32. O. Rothmann. Deutsch, med. Wochenschr. , 1887, No. 27. 
 
 33. M. Rothmann. Zeitschr. f. klin. Medicin, 1893, Bd. xxii. 
 
 34. Ewald. Deutsch, med. Wochenschr., 1893, No. 41, 
 
 35. G16nard. De l'Entöroptose, 1889. 
 
 36. Boas. Deutsch, med. Wochenschr., 1893, No. 41. 
 
 37. Ozenne. Journal de Medecine, 31 Dec, 1893. 
 
 38. LetchejBf. De la colite muco-membraneuse chez les uterines. These de 
 
 Paris, 1895. 
 
 39. Alb. Mathieu. Soc. medic, des h6pit., 22 Mai, 1896. 
 
 40. Chevalier. Contribution ä l'etude de la lithiase intestinale. Paris, 1898 
 
 (with literature). 
 
 41. Dieulafoy. Presse medic, 1895, 10 Mars ; and Acad. medic, 1897, 23 
 
 Mars. 
 
 42. von Leyden. Deutsch, med. Wochenschr., 1882, No. 16 u. 17. 
 
 43. Kitagawa. Zeitschr. f. klin. Medicin, Bd. xviii, 1890. 
 
 44. Kryainski. Enteritis membranacea. Inaug. -Dissert., Jena, 1884, 
 
 45. Henschen. Wiener klin. Rundschau, 1896, No. 33. 
 
 46. Marchand. Berliner klin. Wochenschr., 1877. 
 
 47. Richardiere. Union medicale, 1895, No. 1. 
 
 48. Longuet, Rec de mem. de med. milit , 1878, 
 
 49. Ulimann, Deutsch, med. Wochenschr., 1894, No. 2. 
 
 50. Löwenstein. Ibid., 1889, No. 2. 
 
 51. Ad. Schmidt. Zeitschr. f. klin. Medicin, Bd. xxxii, Heft 3 u. 4, 1897. 
 
 52. Pariser. Deutsch, med. Wochenschr., 1893, No. 41. 
 
 53. von Noorden, Zeitschr. f. prakt. Aerzte, No, 1, 1898. 
 
 54. Boas, von Leyden's Handbuch d, Ernährungstherapie, 1898, Bd, ii, Ite 
 
 Abth., S, 309. 
 
 55. Haie White and Golding Bird. Clinical Society, 1896. 
 
 56. F. Franke, Mittheilungen aus d. Grenzgebieten, etc., Bd, i, 1896, S. 379. 
 
CHAPTER XIY 
 
 HABITUAL CONSTIPATION. DISPLACEMENTS OF TEE 
 INTESTINES* 
 
 A. HABITUAL CONSTIPATION 
 
 Preliminm^y Remarks. — By habitual constipation we understand 
 a condition in which the intestine irregularly or incompletely 
 evacuates its contents. An estimate of the normal frequency of 
 defecation is intentionally omitted from this definition, for this may 
 be greater or less without giving rise to a morbid condition. Every 
 physician of experience knows, and every text-book of special pa- 
 thology mentions, examples of extraordinary infrequency of defeca- 
 tion without disturbance of health. Less known and appreciated, 
 and doubtless not so common, is the physiological occurrence of 
 the opposite condition — that is, an unusual frequency of defecation, 
 the stools being otherwise normal. Of this I have observed several 
 examples. 
 
 There is a sharp line to be drawn between this condition and 
 morbidly retarded defecation with its train of consequences. The 
 latter is sometimes an acute and sometimes a chronic condition ; it 
 may be artificial, or it may result from alimentary causes ; occasion- 
 ally it accompanies or is the sequel of other not wholly intestinal 
 disorders ; finally, it may be idiopathic, or, to speak more accurately, 
 be independent of any recognisable organic cause. 
 
 Of the forms just mentioned, alimentary constipation, on account 
 of its great practical importance, deserves a few remarks. It owes 
 its origin, no doubt, to a perverted or insufficient diet. It is specially 
 observed among the higher classes where there exists a very obstinate 
 traditional preference for what is called a " nourishing diet " (meat 
 and fish), or, in general, for very easily digested food. Deficient 
 
 * lUoway : Constipation in Adults and Children, New York, 1897, is a very- 
 useful and complete monograph on constipation, which we can recommend to the 
 reader who is interested in details. 
 240 
 
HABITUAL CONSTIPATION 241 
 
 bodily exercise and work is often an associated cause. Further fac- 
 tors consist in irregnlarity of life in every sense — in time of meals, 
 of sleep, of work, and, of course, in the act of defecation itself. 
 
 As a secondary condition, habitual constipation is found in con- 
 nection with a great variety of diseases belonging to every depart- 
 ment of medicine and surgery, and no attempt will be made to 
 enumerate them. Constipation, as a complication or sequel of other 
 intestinal affections, will be treated of under the headings of these 
 affections. 
 
 As to the other form of habitual constipation, that to which, in a 
 strict sense, Nothnagel^ applies this term, it is difläcult to decide 
 whether it is due, as he supposes, to a functional abnormality of the 
 intestinal nervous apparatus ; or, as Emminghaus ^ has recently an- 
 nounced on the basis of careful histological research, to changes in 
 the splanchnics; or how far the condition is, according to Dunin^, 
 one of the features of anomalies of the central nervous system 
 (neurasthenia, hysteria) ; or, finally, as Glenard * has endeavoured 
 to show, whether it is dependent upon displacements of the intes- 
 tines (enteroptosis). 
 
 It must be admitted that each of these hypotheses has a basis in 
 clinical experience, but no single one will serve to explain the mani- 
 fold varieties met with in daily practice. As Dunin has elucidated 
 in his excellent paper, there is evidently in many cases a vicious 
 circle, which when well developed may obscure the initial cause of 
 the malady. For illustration, let us suppose a case such as we see 
 almost every day, A woman who has previously been healthy be- 
 gins to suffer from constipation and uses laxatives ; gradually these 
 lose their effect, and defecation becomes more and more difficult 
 and less complete. Hand in hand with this goes a failure of nutri- 
 tion, either as a result of the abuse of laxatives or from therapeutic 
 measures (an " easily digested diet "), or as a result of the general 
 failure of health or of anaemia or gastric disorders (atony, for ex- 
 ample). The natural result is emaciation, prolapse of the viscera, 
 and with it increase of the constipation, and finally, as the climax 
 of all these symptoms, the clinical picture of well-marked neuras- 
 thenia. 
 
 Every one of experience will recognise that in this case the en- 
 teroptosis is not the cause but the result of the habitual constipa- 
 tion, and the same is true of the neurasthenia. On the other hand, 
 emaciation from any cause may lead to prolapse of the viscera and 
 thus cause constipation, or, more accurately speaking, favour it; and 
 
242 DISEASES OP THE INTESTINES 
 
 in this manner, as Dunin had in mind, pure neurasthenia may lay 
 the foundation for the most obstinate kind of constipation. 
 
 Sympto^^tatology and Diagnosis 
 
 Habitual constipation occurs in several grades of severity and 
 in several clinical forms, the differentiation between which is of 
 practical importance. 
 
 "We may distinguish the mild, medium, and severe types. But 
 what do we understand by this ? That a certain accord exists 
 between the duration and intensity of the disease is undeniable, and 
 this would be a good diagnostic test if experience did not show that 
 there are many exceptions. In patients who have become con- 
 stipated from any cause, the condition may in a very short time 
 run an obstinate course, and be very rebellious to treatment. Nev- 
 ertheless, the duration of the disease, as well as the existence of 
 an unmistakable hereditary or, perhaps more accurately, a family 
 tendency which has shown itself in the development of the con- 
 dition in early childhood, has a significance not to be underesti- 
 mated. 
 
 As previously mentioned, I have found that we can judge of 
 the intensity of the process by the results obtained from the usp 
 of purgatives. When the most severe drastics, used in large doses 
 for years, fail to produce their effect, it is safe to assume that the 
 case is a severe one, and, from a therapeutic standpoint, not a very 
 promising one. 
 
 In badly neglected cases, especially in women, the faecal accu- 
 mulations may form tumours. These are sometimes situated in 
 the large intestine, usually in the csecum or the neighbourhood 
 of the sigmoid flexure, and may cause the outline of the intestine 
 to stand out in relief ; or they may be located in the rectal pouch 
 and attain such a size as to dilate the latter like an aneurismal 
 sac. It is well known that fsecal tumours may exist and yet the 
 defecation be apparently normal or even diarrhoeal in character, a 
 byway having been formed through which the dejections pass. 
 Under certain unfavourable circumstances symptoms of obstruction 
 which may require surgical intervention, may develop. These cases 
 will be discussed in the chapter on Intestinal Stenosis. 
 
 Yery convenient for clinical purposes is Fleiner's^ division into 
 two classes, the atonic and the spastic forms. My own experience 
 would lead me to add a third, which might be called the fragmen- 
 tary. 
 
HABITUAL CONSTIPATION 243 
 
 The atonic variety is the usual form of constipation that depends 
 upon simple weakness of the intestine, such as usually develops 
 under improper habits of living and eating. According to Fleiner, 
 the stools are drier and firmer than usual, and consist of compressed 
 and desiccated lumps or cylinders of large calibre, or of distinct 
 particles or scybalse bearing the impress of the sacculations of the 
 colon. 
 
 The spastic form is due, according to Fleiner, to the retention 
 of firm masses of ffeces within segments of spastically contracted 
 intestine, somewhat as in lead colic. It is found chiefly in neuras- 
 thenics, hypochondriacs, and in women with pelvic disorders. The 
 stools have the following characteristics : long or short cylinders 
 of small calibre, often no thicker than a pencil or the little finger, 
 or spherical masses of faeces of the size of a hazel nut. The latter 
 formation is not characteristic of spastic constipation, as it is also 
 found in the atonic form ; it is only when constantly present that 
 it is significant. 
 
 I can confirm Fleiner's observation that there are numerous 
 transition forms and combinations, and that both varieties may be 
 associated with catarrh of the large intestine. 
 
 As I have said, my experience leads me to distinguish a third 
 form, fragmentary evacuation^ on account of the peculiar subjec- 
 tive and objective symptoms. 
 
 These patients have regular spontaneous movements of the 
 bowels, but the evacuations are incomplete, and therefore the call 
 to defecation is frequently repeated. They are obliged to go to 
 stool every two to three hours, and each time, with great straining, 
 pass small quantities of cylindrical, or pointed, spherical, or pulpy 
 fgeces. The patients may have a sense of pressure and tenesmus 
 in the rectum, or complain of a feeling of fulness in the abdomen, 
 so that they make renewed attempts to empty the bowels, which 
 may result in the evacuation of more of such fragments, or be quite 
 fruitless. This variety seems to be especially frequent in men, and 
 depends, I believe, upon a sluggishness of the lower segments of 
 the large intestine, or sometimes of the rectum alone. On palpa- 
 tion the latter may be found full of faeces shortly after one of these 
 evacuations. 
 
 Although this form may merge into the others or be combined 
 with them, yet I think it is entitled to separate recognition on 
 account of its significant symptoms. 
 
 The -following case is a good example of fragmentary stools : 
 
244 DISEASES OP THE INTESTINES 
 
 Paul P., merchant, of Berlin, thirty-nine years old. Has been somewhat 
 nervous ever since academic and university study. He suffers frequently from 
 neuralgias, nervousness, and praecordial distress. When he takes physical and 
 mental rest there is temporary improvement. At the present time he complains 
 chiefly of intestinal symptoms. He has six to eight movements of the bowels 
 daily. Each time the evacuations are small, and of either firm or pulpy con- 
 sistence. Defecation is preceded by an uncontrollable tenesmus. No mucus 
 or blood in the stools. The evacuations which occur during the night are espe- 
 cially troublesome. There is a marked sense of hunger after each passage. 
 Examination of the intestines, particularly of the rectum and of the stools, 
 shows nothing abnormal. 
 
 A prominent symptom of habitual constipation, particularly of 
 the spastic form, is intestinal colic. Attacks of most violent abdom- 
 inal pain occur with or without noticeable meteorism. They some- 
 times involve the entire abdomen, and sometimes only limited areas, 
 occasionally lasting for hours, and subsiding suddenly after the ex- 
 pulsion of much gas . or an evacuation of fseces. These colics are 
 present not only in constipation, but also, though less frequently, 
 when the bowels move regularly. Perhaps in the latter case the 
 evacuations are incomplete. Nothnagel * has also called attention 
 to this fact. 
 
 In habitual constipation Kobler® finds that albuminuria or cyl- 
 indruria are not infrequently found ; with the cessation of the intes- 
 tinal symptoms they vanish. 
 
 The question already briefly discussed, as to the relationship 
 between habitual constipation and certain cerebral manifestations — 
 such as headache, sense of pressure in the head, psychic depression, 
 which we designate at the present day by the comprehensive term 
 neurasthenia — can be disposed of in a few words. 
 
 An unprejudiced consideration leads us to divide the patients 
 into three groups : (1) Severe intestinal hypochondriacs, whose every 
 thought and aspiration is centered upon the function of defecation ; 
 (2) neurasthenics, in whom the constipation is but one of many 
 complaints ; and (3) individuals who either have no nervous dis- 
 orders, or complain of nothing more than a sense of pressure in 
 the head, or pain, or mild general malaise. In my experience, the 
 last-mentioned category includes the great majority of cases. This 
 alone would show that clinical observation does not give support 
 to the trend of the doctrine of auto -intoxication which was ad- 
 vanced by Yötsch''' in the TO's, and during the last decade by 
 
 * Loc. cit., p. 34. 
 
HABITUAL CONSTIPATION 245 
 
 Eouchard ^ Feyat ^, Glenard \ and others. I may say that 1 have 
 been able to permanently cure the constipation in a large number of 
 neurasthenics and constipation-hypochondriacs, but the symptoms 
 -of neurasthenia do not vanish, and the attention is merely diverted 
 to some other disturbance. 
 
 The diagnosis of habitual constipation seems at first sight to be 
 an easy one. This is a great error. I feel bound to state that in 
 the early years of my practice I used to make a number of mistakes 
 in this direction. First of all, the rule must be laid down that when 
 .simple constipation is complained of a thorough general and local 
 examination should never be omitted. Under the latter head rectal 
 examination is certainly included, especially with reference to the 
 presence of hemorrhoids, tumours, fissures of the anus or of the 
 neighbouring integument, which, together with anomalies of the 
 genital tract, hypertrophy of the prostate, tumours of the uterus 
 or of the ovaries, retroflexions, etc., are often important etiological 
 factors. In the General Section we have already spoken (page T6) 
 of the frequent blunders made when fsecal tumours are present, and 
 we have pointed out how these errors may be avoided. But aside 
 from such mistakes, which can almost always be avoided by careful 
 examination, there are severe affections of the intestines which may 
 be concealed under the guise of simple habitual constipation. These 
 are, first, stenoses of the intestine of benign character ; secondly, 
 istenosing intestinal carcinomata. These cases, obscure in their early 
 .stages, but later often revealed in a sudden and very disagreeable 
 manner, will be described under their appropriate headings. The 
 following remarks are limited to a few points of practical impor- 
 tance. 
 
 Individuals of or beyond middle age, who have previously been 
 healthy and never have had any intestinal trouble, and who without 
 appreciable cause begin to suffer from habitual constipation, should 
 a priori be suspected of having intestinal stenosis (usually mahg- 
 nant). This suspicion is strengthened if there is progressive ema- 
 ciation. The occasional occurrence of attacks of coUc should attract 
 immediate attention. In such cases, even in the absence of a tumour 
 that can be felt, the chain of evidence is very nearly complete, and 
 it only remains to recognise the objective signs of stenosis by care- 
 ful clinical observation. 
 
 Next to these most frequent and dangerous mistakes, a perma- 
 nent and severe grade of obstruction may be caused by adhesions 
 between coils of the intestine, incomplete volvulus, chronic invagina- 
 17 
 
246 DISEASES OF THE INTESTINES 
 
 tion, etc. It will suffice to mention them here, as they will be dis- 
 cussed in the chapter on Intestinal Stenosis. 
 
 It is undoubtedly of importance to distinguish between a con- 
 stipation arising from insufficiency of the muscular coat of the 
 intestine and that of catarrhal origin. These can usually be diifer- 
 entiated from each other by inflation and methodical fiUing of the 
 intestine with water in one case, and by intestinal irrigation in the 
 other. The methods by which these may be accomplished do not 
 differ essentially from those described in the General Section and 
 in the chapter on Enteritis. 
 
 Tkeatment 
 
 The therapeutic problem in habitual constipation is that of 
 inducing regular and adequate evacuations of the bowels. It should 
 not be considered solved until the bowels move regularly without 
 the assistance of mechanical or medicinal co-operation, the diet 
 being normal or nearly so. The ways in which this may be accom- 
 plished are numerous, and it seems to me that the energy and con- 
 sistency with which any one of these is carried out counts for more in 
 obtaining a good result than the particular method itself. 
 
 Sometimes, when one method or another fails, several methods 
 may very often be combined, and we do not doubt that in this way 
 also something may be accomplished. In everyday practice such a 
 procedure may indeed be justifiable, for the physician takes what is of 
 advantage from any source ; but from a scientific standpoint I must 
 utter a protest against superfluous confusion of therapeutic methods. 
 
 In the introductory chapter of his Guide to Clinical Thera- 
 peutics, Penzoldt ^^ has very justly remarked that a combination of 
 methods makes the estimation of the value of any one of them 
 extremely difficult. When a good result has been obtained, it is not 
 clear which has been the active or most active agent, and too much 
 credit or discredit may l)e attributed to one or the other. Unsuc- 
 cessful results may be due to neglect or omission of the essential 
 feature while the patient is occupied with what is of no importance. 
 Besides all this, a multiplicity of methods or therapeutic procedures, 
 such as are observed in certain lay hygienic establishments as well as 
 in some managed by physicians, is by no means necessary for the 
 patient; he returns from them loaded with a confusion of false 
 ideas, which are difficult to eradicate by the authoritative opinion of 
 medical men. I think it proper to allude to this subject — which is 
 equally pertinent in other disorders than chronic constipation — as a 
 
HABITUAL CONSTIPATION 247 
 
 warning against the danger of the various physical or mechanical 
 fads which have begun to mark the reaction against the abuse of 
 prescription writing. 
 
 The methods for the treatment of chronic constipation which 
 will be considered are the prophylactic, the dietetic, the mechan- 
 ical, the electrical, the thermic, and the medicinal. 
 
 1. The p'rophylactic treatment of constipation, which I know 
 to be too Httle appreciated, should begin in childhood, and consist 
 in appropriate rules for the child. It is the mission and the duty 
 of parents to supervise the intestinal activity of children, to teach 
 them to have evacuations at a set time, and, when necessary, to 
 modify the diet under medical advice until such movements are 
 satisfactory. The habitual use of laxatives during the first few 
 years must, as has already been said (page 190), be prohibited. 
 Such measures are especially necessary in families which have an 
 inherited tendency toward atony of the intestine. It is hard to 
 exaggerate the importance of prophylaxis during pregnancy, a 
 condition which experience teaches us is often, chiefly on account 
 of the local conditions, associated with more or less constipation. 
 In these cases it is to be combatted by appropriate food (see below), 
 and, as von Wild" has urged in his excellent essay, by gymnastic 
 exercises, so as to endeavour to increase the strength of the abdom- 
 inal muscles. The same is true of pareses due to long rest in bed 
 during infectious diseases or after operations, etc. 
 
 2. The Diet. — We have discussed the essential principles of a 
 rational diet in chronic constipation in the General Section (see page 
 146 et seq.). These will suffice for the preparation of suitable special 
 dietaries. Detailed and very appropriate diet schemes have been 
 given by Penzoldt ^^, Kosenheim ^^, and Wegele '*. We prefer that of 
 Penzoldt, because it is very simple and practical : 
 
 7 A. M. — A glass of cold water. 
 
 8 A. M. — A liberal breakfast, with sweetened coffee, a good deal 
 
 of butter, honey, and Graham bread or pumpernickel, 
 
 after which the patient should go to stool. 
 1 p. M. — Midday meal of meat, a good deal of vegetables, salad, 
 
 stewed fruits, farinaceous food, half a bottle of light 
 
 wine (Moselle, or cider). 
 7 P. M. — Meat, with a good deal of butter ; Graham bread, stewed 
 
 fruit, and beer. 
 10 p. M. — Before retiring, fresh or stewed fruit. 
 
248 DISEASES OP THE INTESTINES 
 
 The dietaries of Rosenheim and Wegele differ from the above 
 in that they add, once or twice a day, 300 grams of buttermilk or 
 kefir, which in severe cases increases the effect of the diet. 
 
 In the great majority of cases a permanently good result is 
 obtained by the use of this method — that is, without systematic adher- 
 ence to the above regime the bowels will move under the usual diet, 
 provided it is rich in carbohydrates. Even in older, indeed in very 
 chronic cases, contrary to my prognostication, I have seen very ex- 
 cellent results from the use of this simple constipation diet. Some 
 cases soon have a relapse, partly because the patient is not persistent 
 enough, and partly because — as in the case of medicinal agents — 
 dietetic laxatives may lose their effect after a time. In the latter 
 cases, which in my experience are certainly unusual, supplementary 
 measures must be employed. 
 
 It may not be superfluous to remark that the diet above described 
 is only suitable for uncomplicated cases of chronic constipation. 
 When complications exist it can not be used, or must be materially 
 modified. For example, this diet is obviously contra-indicated in 
 diabetes mellitus, in obesity, or in a tendency thereto, and in well- 
 developed alimentary glycosuria. The discomforts which it occa- 
 sions (pyrosis, oppression, vomiting, pain, hemorrhages, etc.) in 
 gastric atony, hyperacidity, ulcer of the stomach, gastric dilatation, 
 carcinoma of the stomach, carcinoma of the intestine, etc., naturally 
 will forbid its use in these conditions. Undue flatulence may con- 
 tra-indicate such a large quantity of sweets and acids. A careful 
 choice of the foods which are well tolerated, as shown by prudent 
 variations and experiments, will accomplish the desired results. It 
 would lead us too far to go into particulars with reference to all the 
 considerations in question. 
 
 Everyday experience shows that the milder cases will get along 
 with much less change in diet. For example, it will suffice in very 
 many cases to give Penzoldt's advice as to the glass of cold water in 
 the morning, especially if a little common salt is added ; in other 
 cases the taking of fresh or cooked fruit on an empty stomach or 
 in ihe evening is sufficient ; or the morning cigar may set up intes- 
 tinal peristalsis. ISTor do these exhaust the possibilities. We can 
 occasionally utilize these facts in treatment, at the same time that 
 they throw light upon the wide individual variations in the irrita- 
 bility of the intestines in different subjects, and on the necessity of 
 taking this factor into account in each individual case. 
 
 3. Mechanical Treatment. — The most important of such meas- 
 
HABITUAL CONSTIPATION 249 
 
 ures is massage ; it has already been discussed in the General Sec- 
 tion (pages 170-1 Y2). To this may be added, in many cases, other 
 mechanical therapeutic agents. 
 
 The simplest of these are exercise, and various systems of gym- 
 nastics. 
 
 The value of the former should not be underestimated, although 
 experience teaches us not to expect too much from it. We often 
 enough meet with chronic constipation in people such as farmers 
 and officers who take active exercise. The fact that surprisingly 
 good results are obtained in the treatment of constipation in spite 
 of absolute rest in bed, shows that the importance of exercise has 
 heretofore been very much overestimated. For these reasons I 
 have been led to prescribe rest in bed, with suitable diet, in some 
 cases of severe constipation ; and I particularly remember the case 
 of a lady who was suifering from a severe type of constipation — 
 whose medical adviser, in his perplexity, finally felt compelled to 
 order her to take a bottle of bitter water every hour — who was com- 
 pletely and permanently cured by four weeks of absolute rest in bed, 
 with no other treatment than an appropriate diet. 
 
 Much more valuable than simple exercise are the various forms 
 of indoor gymnastics, calisthenics, rowing, bicycling, riding, tennis, 
 bowling, football, and the Swedish movements, when they are 
 carried out more or less methodically. But they are not all equally 
 useful. For example, my experience shows that bicycling does 
 not exercise any especial influence over intestinal activity ; indeed, 
 one of my most obstinate cases was in the person of one v^ho was 
 moderately addicted to this sport. The same is also true of riding. 
 Rowing seems to be more useful, but, unfortunately, it is not always 
 available. For the same purpose, the so-called rowing machines 
 have been extensively recommended by some writers. 
 
 The importance of calisthenics and systematic indoor gymnas- 
 tics, as explained in numerous books on this subject (Schreber, 
 Fromm, and others), should not be underestimated. One of the 
 most useful movements for strengthening weak abdominal muscles 
 consists in raising the trunk slowly from a horizontal to an upright 
 position without the assistance of the arras or legs, and then allow- 
 ing it to slowly drop back again ; this should be repeated several 
 times each day. It is best practised in a progressive fashion, very 
 gradually increasing the angle at which the trunk is maintained by 
 the muscular exertion. Ultimately the motion of rising may be made 
 against a slight resistance, such as that of the hand of an assistant 
 
250 DISEASES OP THE INTESTINES 
 
 laid upon the forehead (von Wild). Another useful exercise is 
 hi^h kicking of the knee, so that the anterior surface of the thigh 
 is brought into forcible contact with the abdomen. 
 
 As Williams ^^, Lauder Brunton ^^, and recently Ewald ", have 
 pointed out, the position of the body during the act of defecation, 
 belongs in a certain degree to this class of measures. These 
 authors emphasize the advantage of a squatting position, in which, 
 as is evident, the abdominal muscles act upon the rectum to best 
 advantage. Anyone who knows from experience how difficult it is 
 to have an evacuation in a sitting posture with the legs extended 
 (bedpan position), will concur in the advice of these authors, but, 
 unfortunately, there are practical difficulties in the way of carrying 
 it out. 
 
 4. Concerning the use of electricity, its indications and advan- 
 tages, see the discussion on pages 172-175. 
 
 5. With the thermic measures may be classed the various forms 
 of hydrotherapy, which have been described on page 158. Their 
 eifect depends chiefly upon an improvement in the general condition, 
 by which, as we have seen, nutrition and intestinal activity are 
 increased. Local or intestinal hydrotherajjy is also of importance 
 in the form of douches and enemata (page 177), the latter contain- 
 ing substances which soften faeces (oil, soap, glycerin, etc.). It is 
 also known that the sudden local application of cold will increase 
 intestinal peristalsis, and this fact may be taken advantage of in 
 therapeutics. The most simple and at the same time a very effi- 
 cient method, according to my experience, consists in the use of cold 
 water compresses (of course without an impervious covering). A 
 more powerful application is the use of cold, or alternate cold and 
 hot jets or sprays over the abdomen (Scottish douche). The ether 
 spray is another and very simple method, which I have used in 
 obstinate cases for a number of years. Once or twice a day, for 
 about five minutes, 100 cubic centimetres of sulphuric ether are 
 sprayed upon the abdomen with the Richardson apparatus. The 
 chilling so produced markedly stimulates the muscles of the abdom- 
 inal wall, and presumably also the intestine, for it soon gives rise to 
 an urgent desire to go to stool. I will merely select two of my case 
 histories in which the ether spray gave brilHant results: 
 
 Case I. Ohstinate constipation, not cured by diet alone. Complete cure by 
 ether spray. 
 
 B., resident of Berlin, fifty-four years old, has suffered for many years from 
 severe pyrosis and constipation. Was operated on for hernia in 1896, but with 
 
HABITUAL CONSTIPATION 251 
 
 little improvement in the constipation. Movements from the bowels occur 
 only after laxatives or enemata. The urine contains a good deal of uric acid, 
 but there are no other signs of gout. Examination of the gastric contents 
 shows a high degree of hyperacidity with atony. Rectum empty. Irrigation 
 does not show the presence of mucus. Constipation diet was first tried. A 
 passage resulted each day, but only with great difficulty, and the amount was 
 insufficient. In May, 1897, the ether douche was used twice daily for about 
 five minutes. The evacuations were from this time on softer and more free. 
 After a fortnight's use of the spray the stools were normal. Subsequently the 
 patient used it from time to time when there was delayed evacuation. Since 
 the year 1898 the bowels have been perfectly regular on simple constipation 
 diet. He has gained 6 kilos in weight since the beginning of the treatment. 
 The hyperacidity has been improved by the continuous use of citrate of soda. 
 
 Case II. Chronic constipation of three and a half years' standing. Great 
 abuse of drastics. Results from diet unsatisfactory. Regular action of the towels 
 results immediately from the use of the ether spi-ay. 
 
 MissL., of Frankfurt-am-Main, twenty-three years old. The patient has 
 suffered for the past three and a half years from severe atonic constipation, 
 with resultant anaemia and anorexia. Purgatives of the drastic order, which 
 the patient has used for a long time, always cause severe pain. At one 
 period membranous enteritis developed, but disappeared later. At first the 
 treatment in my private clinic consisted in constipation diet, but the bowels 
 would not move spontaneously. Evacuations only followed the use of enemata 
 of soapsuds, glycerin, or oil. Fourteen days after admission the use of the 
 ether spray was begun, for five minutes once daily. The bowels moved daily 
 thereafter, and after ten days of this treatment the spray was left off. The 
 patient gained 15 pounds in weight, and left after four weeks, the bowels being 
 perfectly regular. 
 
 Such favourable results are not obtained in all cases, but, be- 
 cause of its simplicity in obstinate cases, the ether spray should be 
 considered almost as important as the diet. 
 
 6. Medicinal Treatment. — In recent times there is a good deal 
 of diversity of opinion among authors as to the benefit or the harm 
 that may result from medicinal treatment — that is, from the use of 
 laxatives. Even if we ignore the exaggerations of " the doctor who 
 follows ISTature," and whose stock in trade it is to denounce all drugs 
 as poisonous and harmful, there still remains between leading clini- 
 cians and physicians a gulf difficult to bridge over. 
 
 As representing one set of opinions I may quote Dnnin ^, who 
 " most positively forbids the use of any sort of laxative whatever," 
 and of the other, the elder clinician v. Liebermeister ^^ who gives 
 the advice that when regular stools can not be obtained without too 
 much trouble by dietetic regulation, " suitable laxatives are to be 
 used with regularity each day." Of the standard authors, Pen- 
 
252 DISEASES OF THE INTESTINES 
 
 zoldt ^"j Nothnagel \ Fleischer ^^, Rosenheim ^^, Ewald ^"^ and others' 
 take a middle position. We can especially recommend Penzoldt's 
 thorough and clear presentation of the facts of the controversy. 
 
 In what follows I shall give the results of mj own experience in 
 this matter. I must concur in the opinion of other investigators 
 who deny that laxatives always, or in a majority of cases, have a 
 harmful action. I know numerous healthy people who have taken 
 a daily laxative for ten years — particularly rhubarb — without any 
 injury to the intestine or to their general health. These people 
 would with justice indignantly refuse to exchange their efficient and 
 simple pill for monotonous and burdensome dietetic regulations. 
 From this sort of case — one which seldom comes under professional 
 notice — are to be distinguished two other varieties : the first, in 
 which laxatives do have an eifect, but occasion gastric * or intestinal 
 discomfort, loss of appetite, emaciation, etc., and second, those in 
 which laxatives have either no action or only an inadequate one. 
 In both cases it is not a question of the further use of laxatives, for 
 by the time that the patients seek professional advice the milder 
 agents have ceased to act, and they have found that the more pow- 
 erful ones sooner or later become inert against the intestinal tor- 
 pidity, or augment the other discomforts just mentioned. 
 
 It is in these very cases that a rational diet, possibly in con- 
 junction with some of the above-described methods, achieves its 
 greatest triumph ; and, even when it is not fully successful — as some- 
 times happens in very protracted cases — a satisfactory result may 
 be obtained with the assistance of small, perhaps minimal doses of 
 some mild laxative, or, still better, by enemata of some suitable fluid 
 (oil, etc.). 
 
 Thus the question as to the indications for the use of laxative 
 drugs is virtually self-answered. [Aside from the above-mentioned 
 cases in which their long- continued use has produced no injurious 
 effects], we employ this class of drugs only when a constipation diet, 
 patiently persevered in, and if necessary assisted by other methods, 
 is found inefficient. 
 
 We have already expressed our views concerning the choice of 
 laxatives in the General Section (page 186 et seq.), and have pointed 
 out that each of them has its special use and indications. These 
 are essentially dependent upon the state of the stomach and, in cer- 
 
 * Wiczkowski has recently made the interesting observation (Archiv f. Ver- 
 dauungskrankheiten, Bd. iv, S. 407) that laxatives materially diminish, while 
 opiates increase, the acid secretion of the stomach. 
 
HABITUAL CONSTIPATION 253 
 
 tain cases, of the liver. For instance, calcined magnesia and 
 Carlsbad salts are also very excellent antacid remedies, and podo- 
 phyllin and euonjmin equally good cholagogues. In appropriate 
 cases advantage must be taken of such facts. 
 
 Laxatives may often be administered by the rectum in the form 
 of small enemata or as suppositories. The most popular and effi- 
 cient, especially in the milder cases, is glycerin in doses of 1 to 8 
 grams. It is evident that their effect does not extend beyond the 
 lowermost segments of the colon. Hiller^*^ and, more recently, 
 Kohlstock ^^ have recommended the use of the active principles 
 of approved laxatives per rectum. According to Kohlstock, the 
 most serviceable are aloin, cathartic acid, and, for especially obstinate 
 cases, colocynthin and citrullin. The following are the formulae : 
 
 ^ Aloin 1.0 
 
 Formamid 10.0 
 
 (A suitable dose is 0.4 to 0.5 of aloin.) 
 
 1^ Colocynthin 1.0 
 
 Spirit., 
 
 Glycerin ää 12.0 
 
 (A suitable dose of colocynthin is 0.01 to 0.04.) 
 
 ^ Acid, cathartinic. e senna 3.0 
 
 Aq. destillat 7.0 
 
 Sod. bicarb, q. s. ad react, alkalin. 
 (A suitable dose of cathartic acid is 0.6.) 
 
 ^ Citrullini 2.0 
 
 Spirit., 
 
 Glyceringe ää 49.0 
 
 (A suitable dose of citrullin is 0.02.) 
 
 Kohlstock states that these concentrated enemata are prompt 
 and painless in their action. The only obstacle to their more gen- 
 eral use is their high cost.* 
 
 Up to the present time the subcutaneous use of purgatives 
 (aloin, colocynthin, citrullin, etc.) has not been very successful. 
 Reference should be made at this point to the subcutaneous use of 
 magnesium sulphate in doses of 0.12 to 0.18, as recommended by 
 Wood^^ and by Eakins^^. Wood states that he has obtained results 
 in YO per cent of cases of constipation ; and Eakins, that even in a 
 case of faecal obstruction he obtained copious evacuations and cessa- 
 
 * The preparations mentioned are manufactured by Merck (Darmstadt). 
 
254 DISEASES OP THE INTESTINES 
 
 tion of the threatening symptoms after ten hours. Scarbinato ^ also 
 had positive results, although, as he mentions, the effect of subcuta- 
 neous treatment is neither marked nor constant. 
 
 My own investigations with doses as large as 0.5 of magnesium 
 sulphate were not productive of any distinctly noticeable laxative 
 effect. 
 
 In the same communication Scarbinato describes another pro- 
 cedure which is scarcely known, at least in Germany : the endermic 
 treatment of constipation by croton oil (6 to 10 drops in 15 to 20 
 gm. ol. olivae). In four patients with chronic constipation, this 
 procedure produced regular fluid movements, often accompanied 
 by abdominal pain. Oleum ricini, used in the same way, gave 
 negative results. 
 
 Those substances which set up peristalsis by mechanical irrita- 
 tion occupy a mid-position between medicinal and dietetic agents. 
 Among these are the preparations of linseed, of which a table- 
 spoonful is allowed to soak in water and taken as a drink on an 
 empty stomach. A particularly agreeable and, as I know, an effi- 
 cient variety is the linseed of Tarin, which is distinguished by its 
 large size and elegant shape. The large amount of oil contained 
 in these preparations seems to account for part of the effect. It 
 appears to me very possible for some of the seed husks to gain access 
 to the vermiform appendix and thus give rise to inflammation. This 
 may be a purely theoretical idea, but it has nevertheless deterred 
 me from a very extensive use of this simple and efficient remedy. 
 
 7. The Tiydi' other apeutic treatment of chronic constipation has 
 been discussed in the General Section (page 158). 
 
 Among the complications of chronic constipation, the treatment 
 of flatulent colic deserves a brief discussion. 
 
 As we are here dealing with a spastic condition of the intestinal 
 canal, the preference should be given to opium in small doses (ext. 
 opii, 0.01 to 0.02). Such doses will not only allay the pain but will 
 promote an evacuation. The use of laxatives, or, better still, of a 
 suitable enema, is indicated only after the painful contractions have 
 subsided. 
 
DISPLACEMENTS OF THE INTESTINES 255 
 
 B. DISPLACEMENTS OF THE INTESTINES 
 
 Symptomatology and Diagnosis 
 
 A short review of the most important anomalies of position of 
 the intestines has been given in the General Section (page 20 
 et seq.), and to this we refer the reader. In what follows, an 
 attempt will be made to discuss briefly the clinical manifestations 
 and the resultant therapeutic indications. For practical purposes, 
 dislocations of the large intestine need be alone considered. Those 
 of the small intestine produce appreciable symptoms only when 
 there is a marked interference with peristalsis, such as may arise 
 from acute kinkings, as caused by tumours, adhesions, compressions, 
 etc. We shall return to this subject in the chapter on Stenoses of 
 the Intestine. Malpositions of the large intestine may either exist 
 for a long time without causing any disturbance of well-being, or 
 may occasion manifold symptoms, or, finally, may disguise the clin- 
 ical picture to such a degree that only a lucky chance, or an autopsy 
 in vivo, or sometimes only a post-mortem examination, will show 
 the true condition of affairs. 
 
 The functional disturbances which, as has been said, are some- 
 times present were not unknown to the older physicians — Mor- 
 gagni, De Häen, Esquirol, and Ruysch. Yirchow^^, in his famous 
 treatise on the Diseases of the Abdomen, from an Historical, Crit- 
 ical, and Scientific Standpoint, has long ago and in a classical man- 
 ner described the importance of peritoneal fixation as affecting the 
 onward progress of faeces. The pathological importance of dis- 
 placements was at times quite forgotten or underestimated, and 
 at times unduly exaggerated (Esquirol, Yötsch), until recently the 
 subject has been given a new prominence by Landau's fruitful 
 researches on the subject of floating kidney and pendulous abdomen, 
 and Glenard's original though somewhat fantastic doctrine of en- 
 teroptosis. The valuable contributions of Leichtenstern ^^, Cursch- 
 mann ~', and Fleiner ^ have notably enriched our knowledge con- 
 cerning the origin and clinical significance of displacements of the 
 intestines. 
 
 According to Fleiner, displacements of the colon may owe their 
 origin to abnormal curves and angular flexures which interfere with 
 the fjBcal movements. These are favored by increased pressure 
 upon certain segments of the large intestine by ill-fitting corsets, 
 belts, or, in the case of men, by an habitual stooping carriage and 
 
256 DISEASES OP THE INTESTINES 
 
 sedentary mode of life. In this way dilatation of the affected seg- 
 ments occurs, f£eces and gas accumulate, and the clinical picture of 
 atonic constipation is developed. 
 
 Soon organic changes in the wall of the intestine occur. Catarrh 
 develops, and there is then added diarrhoea, or diarrhoea alternat- 
 ing with constipation, or constipation with membranous enteritis. 
 Neuralgic colicky pains set in, which, according to Fleiner, are 
 easily mistaken for intercostal neuralgia, biliary colic, renal colic, 
 spinal crises — even for duodenal ulcer. Fleiner has given the 
 details of several very instructive clinical histories which show how 
 difficult it is to avoid mistakes, especially in confounding these 
 paroxysmal pains with biliary colic. I can add from my personal 
 experience that it frequently happens, especially in women, that the 
 symptoms of gastrointestinal neurasthenia are present. There are 
 anorexia, oppression in the epigastrium, intestinal colic, flatulence, 
 constipation, mental depression, disinclination for work, loss of 
 weight, etc. Objective signs are ptosis of the stomach and colon, 
 displacement of the kidneys, liver, or spleen, and sometimes of the 
 uterus. 
 
 Many physicians are puzzled when they come to deal with this 
 condition. Some think of anaemia and prescribe iron ; others sus- 
 pect gastric or intestinal catarrh and prescribe bismuth or laxatives ; 
 others diagnosticate hysteria and attempt to cure with valerian, 
 bromids, or asafoetida. 
 
 Displacements of the intestine may, however, cause very dan- 
 gerous changes in the intestines, and may endanger life. Thus 
 Curschmann has described two cases of upward flexure of the 
 caecum with absolute occlusion of the intestine from the acute 
 bending. Both patients died with symptoms of acute obstruction. 
 When there are abnormal bends of the transverse colon and its 
 flexures, there may be an acute angle formed which causes partial 
 or total obstruction. 
 
 These changes of position are of clinical importance also, be- 
 cause they may lead to errors in diagnosis not liable to arise in any 
 other way. Curschmann has reported very interesting cases in 
 which the caecum was bent so as to bring the vermiform process 
 directly into contact with the liver (see Fig. 24). If the appendix 
 became inflamed in this situation the exudate would be close to the 
 right costal arch. 
 
 In case of congenital shortness or absence of the ascending por- 
 tion of the colon, the c^cum with its appendix might be close to or 
 
DISPLACEMENTS OF THE INTESTINES 
 
 257 
 
 behind the liver. In a case described by Curschmann (see Fig. 25), 
 a perforating perityphhtis was present while the clinical signs were 
 those of cholelithiasis. 
 
 Dislocations of the colon are especially liable to be confounded 
 with diseases of the liver, von Leube'^^ and subsequently Fleiner=« 
 
 Fig. 24* — Vermiform Appendix in Con- 
 tact WITH THE Under Surface of 
 THE Liver. (Curschmann.) 
 
 Fig. 25.— Vermiform Appendix lying be- 
 hind THE Right Lobe of the Liver. 
 
 (Curschmann.) 
 
 and Curschmann 2^ have called attention to the fact that abnormal 
 elevation and gaseous distention of the transverse colon may reduce 
 or abohsh the area of liver dulness. 
 
 I have often observed the absence of liver dulness in males. 
 As Curschmann observes, this may often cause difficulties in map- 
 ping out the edge of the liver in hepatic cirrhosis. The normal 
 position of the liver dulness in the anterior and posterior axillary 
 lines enables a decision to be reached. In one of the cases which 
 Curschmann has described and illustrated, a duodenal ulcer was 
 mistaken for a subphrenic abscess because the flexures of the colon 
 were absent, both limbs running almost parallel. According to 
 Curschmann, when the flexures are exaggerated into loops the 
 splenic dulness may be obscured. 
 
 It is well known that loops with coincident elongation are found 
 
 * Thanks are due to Professor Curschmann, of Leipzig, for permission to re- 
 produce Figs. 24-28. 
 
258 
 
 DISEASES OP THE INTESTINES 
 
 with especial frequency in the transverse colon and at the flexures. 
 They are chiefly single ; next in frequency come the M or V 
 shapes, and rarely the double looping seen in Fig. 26. If the 
 flexures become still further enlarged, they may dip down as far as 
 
 Fig. 26. — Double Looping of the Trans- 
 verse Colon. (Cursohmann.) 
 
 Fig. 27. — Double Looping of the Sig- 
 moid Flexure. (Curschmann.) 
 
 the brim of the pelvis. It has long been known that abnormal 
 loops of the sigmoid flexure may give rise to serious mistakes. 
 We have already mentioned (page 23) that when the sigmoid flexure 
 is strongly inflated, it almost always encroaches upon the right lower 
 quadrant of the abdomen, and therefore lies close to the caecum. 
 When there is a suspicion of volvulus in that region, the physical 
 signs of distention of the sigmoid flexure should be looked for. 
 The importance of abnormal loops of the sigmoid flexure when 
 operative procedures are in question, when an artificial anus is to be 
 constructed, or when a loop is to be exsected, is of course evident. 
 The difficulties may be very much increased when an abnormally 
 long sigmoid flexure is arranged in a double (Fig. 27) or in multiple 
 loops (Fig. 28). 
 
 The latter condition may be considered on the border line be- 
 tween normal and pathological ; it presents favourable conditions 
 for the formation of a volvulus. 
 
 The diagnosis of certain forms of intestinal dislocation, such as 
 
DISPLACEMENTS OF THE INTESTINES 
 
 259 
 
 Fig. 28. — Multiple Looping of the 
 Sigmoid Flexure. (Curschmann.) 
 
 the common depression or elevation of the transverse colon, offers 
 no special difficulty. In most instances gross variations of this kind 
 can be determined with probabili- 
 ty or certainty by inflation of the 
 intestines with air, by methodical 
 distention with water, or by care- 
 ful percussion. The case is quite 
 different with displacements of the 
 csecum, deformities and disloca- 
 tions of the sigmoid flexure, ab- 
 sence of the flexures, abnormal 
 looping, and other irregular con- 
 ditions. The possibility of an 
 anomaly of position must be taken 
 into consideration in making a di- 
 agnosis. Curschmann was fortu- 
 nate enough to do this in one in- 
 stance. Perhaps the capsule meth- 
 od, with the assistance of the Rönt- 
 gen rays, as recently described by 
 Levy-Dorn and myself ^'^, will have some value for the recognition 
 of these anomalies of position or form. Practical experience is, 
 however, still lacking. When the clinical signs are obscure, the 
 possibility of such variations must be taken into consideration. 
 
 Tkeatment 
 
 The description of the treatment of changes in position or form 
 of the bowel touches upon many chapters of intestinal pathology ; 
 it is not possible, therefore, to enter into details in this place.* 
 Prolapse of the transverse colon, however, which is usually only a 
 part of a general visceral ptosis, requires a few brief remarks. The 
 fundamental therapeutic maxims agree essentially with those in gas- 
 troptosis (see Diseases of the Stomach, Part II, page 183). They 
 consist primarily in complete rest in a horizontal position and in a 
 strengthenina; diet. The latter should not be a routine one, such 
 as Weir-Mitchell's, but should be adapted to the necessities of each 
 case, with reference to the functional disturbances of the alimentary 
 canal. 
 
 Constipation or colitis must be treated in the manner advised in 
 the chapters on these affections. By the use of massage, hydro- 
 therapy, and electrotherapy, the effects of the dietetic prescriptions 
 
260 DISEASES OF THE INTESTINES 
 
 may be enhanced and the general condition improved. A suitable 
 abdominal supporter is useful in assisting the weak abdominal 
 muscles. 
 
 Treatment in a sanitarium is far preferable to home or ambu- 
 latory treatment. 
 
 LITERATURE 
 
 1. Nothnagel. Darmkrankheiten, S. 27. 
 
 2. Emminghaus. Münchener med. Wochenschr., 1894, No. 5 u. 6. 
 
 3. Dunin. üeber habituelle Stuhlverstopfung, deren Ursachen u. Behand- 
 
 lung, Berliner Klinik, 1891. 
 
 4. Glenard. De TEnteroptose, 1889. 
 
 5. Fleiner. Berliner klin. Wochenschr., 1893, No. 3. 
 
 ■ 6. G. Kobler. Wiener klin. Wochenschr., 1898, No. 20. 
 
 7. Voötsch. Koprostase, 1874. 
 
 8. Bouchard. Legons sur les Autointoxications, Paris, 1887. 
 
 9. Feyat. De la Constipation et des Phenomenes qu'elle provoque, 1890. 
 
 10. Penzoldt. Klinische Arzneimittellehre, 3te Aufl , S. 20 u. f. 
 
 11. von Wild. Sammlung zwangloser Abhandlungen a. d. Gebiete der Frau- 
 
 enheilkunde u. Gebui-tshülfe, 1897, Bd. ii, Heft 3. 
 
 12. Penzoldt. In Penzoldt-Stintzing, Handbuch d. spec. Therapie innerer 
 
 Krankheiten, Bd. iv, S. 514. 
 
 13. Rosenheim. Pathologie u. Therapie der Krankheiten d. Darmes, 1893, 
 
 S. 511. 
 
 14. Wegele. Diätetische Behandlung d. Magendarmerkrankungen, 1896, S. 
 
 107. 
 
 15. Williams. Boston Medical Journal, Aug. 23, 1888. 
 
 16. Lauder Brunton. Wiener med. Blätter, 1896, Nos. 37-39. 
 
 17. C. A. Ewald. Berliner Klinik, 1897, S. 16. 
 
 18. von Liebermeister. Vorlesungen über specielle Pathologie u. Therapie, 
 
 Bd. V, ö. 168. 
 
 19. Fleischer. Lehrbuch d. inneren Medicin. 
 
 20. Hiller. Zeitschr. f. klin. Medicin, 1882, Bd. iv, S. 481. 
 
 21. Kohlstock. Charite-Annalen, 1893, Bd. xvii. 
 
 22. Wood. The Therapeutical Gazette. Jan. 15, 1895. (Cited from Arch. f. 
 
 Verdauungskrankheiten, Bd. i, S. 320.) 
 
 23. Eakins. The Australian Med. Gaz., Jan. 15, 1895. (Cited from same 
 
 source as 22.) 
 
 24. Scarpinato. Arch, fermacolog. e therap., March 1, 1896. (Cited from 
 
 Arch. f. Verdauungskr., Bd. ii, S. 396.) 
 
 25. Virchow. Virchow's Archiv, 1853, Bd. v, S. 281. 
 
 26. Leichtenstern. von Ziemssen's Handbuch, Bd. vii. Heft 2, Aufi. 2, S. 
 
 509 u. f . 
 
 27. Curschmann. Deutsches Arch. f. klin. Medicin, 1894, Bd. liii, S. 1. 
 
 28. Fleiner. Münchener med. Wochenschr., 1895, Nos. 42-45. 
 
 29. von Leube. von Ziemssen's Handbuch, Bd. viii, H. 2, Aufl. 2, S. 242. 
 
 30. Boas u. Levy-Dorn. Deutsch, med. Wochenschr., 1898, No. 2. 
 
CHAPTER XY 
 
 ULCERS OF THE INTESTINES 
 
 Introductory Remarhs. — An extraordinary variety of ulcers 
 occur in the intestinal canal. It is unnecessary to describe tlieni 
 all in this chapter, as many are only complications or localizations 
 of diseases which do not fall within the province of this work. 
 Such, for example, are the ulcerations accompanying acute infec- 
 tious diseases (typhoid fever, acute dysentery, diphtheria, anthrax, 
 sepsis, erysipelas, variola, puerperal fever, leprosy), as well as con- 
 stitutional diseases (gout, scurvy, leucsemia). The toxic ulcerations 
 from mercury, arsenic, antimony, as well as the so-called uremic 
 ulcers, bear such slight relations to intestinal pathology that there 
 is no necessity for describing them here. There remain only those 
 forms of ulceration which, from their clinical symptoms, pursue an 
 independent course. These are, naming them in the order of their 
 frequency: the catarrhal idcer, the follicular ulcer, the stercoral 
 ulcer, the tuberculous tdcer, the chronic dysenteric ulcer, the syphi- 
 litic ulcer, the amyloid ulcer, and finally the emholic and thrombotic 
 ulcer. The duodenal ulcer, a peculiar clinical type, will be de- 
 scribed separately, and in that connection a few remarks will be 
 made on ulcers due to burns. 
 
 Catarrhal and folUctdar ulcers are tolerably often observed in 
 intestinal catarrhs. "^ Their favorite location is the large intestine, 
 and it is only exceptionally that they are found higher up. They 
 owe their origin to slight losses of epithelium, which permit of the 
 entrance of organisms which excite inflammation, or of substances 
 which are chemical irritants. The superficial strata of the mucous 
 membrane break down and a superficial erosion develops ; if the 
 process goes on, an ulcer of more or less depth may be formed 
 which may penetrate to the serous coat, and terminate in perfora- 
 tion. Several small ulcers may become confluent and give rise to a 
 single large one. If the ulcer heals, subsequent cicatricial contrac- 
 tion may lead to intestinal stenosis. 
 
 18 
 
 261 
 
262 DISEASES OF THE INTESTINES 
 
 Tlie follicular ulcers originate primarily from an inflammation 
 of a folKcle (suppurative follicular enteritis), in wliicli the swelling- 
 gradually increases, su]3puration and rupture occur, with resulting- 
 loss of substance — the follicular ulcer. Sometimes these points are 
 so numerous that the mucous membrane presents a sievelike appear- 
 ance. From undermining of the mucous membrane, these ulcers, as 
 in the variety just mentioned, may coalesce to form larger ones of 
 sinuous form. 
 
 The stercoral ulcer, or the decubital ulcer of Grawitz, is found 
 almost exclusively in the large intestine, and especially at those 
 points at which the pressure of the faeces is most marked — at the 
 flexures of the colon, in the caecum, the sigmoid flexure, the rec- 
 tum, and very frequently in the vei-miform appendix. In the latter 
 situation it may, under certain circumstances, give rise to perityph- 
 litis. Stercoral ulcers are frequently seen to develop above ste- 
 nosed portions of the intestine. They may be superficial or deep, 
 and lead to extensive loss of substance with suppuration. If they 
 heal, stenosis may follow from cicatricial contraction, but extensive 
 strictures secondary to stercoral ulcers are of great rarity. 
 
 The tuherculous ulcer is by far the most important variety, and 
 the one which has been most carefully studied. A distinction is. 
 made between primary intestinal tuberculosis, which develops in 
 the intestine of an individual who has heretofore been free from 
 tuberculosis, and secondary intestinal tuberculosis, which arises in 
 connection with some other tuberculous afiection. The occurence 
 of primary intestinal tuberculosis is still disputed by Klebs ^ and 
 von Leube ^ ; but at the present day we must admit that unim- 
 peachable observations (Behrens^, Eisenhart*, Wyss^, Melchior^) 
 have demonstrated that it may rarely occur in older children and 
 adults. In earliest childhood intestinal and mesenteric tuberculosis 
 is of very frequent occurrence. Investigations, particularly those 
 of Bollinger and his pupils, give convincing evidence that this form 
 of tuberculosis should be regarded as dietary (milk and the flesh of 
 tuberculous cows). 
 
 Secondary intestinal tuberculosis, on the other hand, is one of 
 the most frequent complications of pulmonary tuberculosis. Ac- 
 cording to the statistics of Eisenhart *, based upon 1,000 autopsies, 
 it was present in 56.3 per cent. Other authors, such as Hamann''', 
 find the percentage to be higher ; and Herxheimer ^ states that in 
 58 cases there was only 1 in which tuberculous disease of the intes- 
 tine could not be found. The mode of origin of intestinal tubercu- 
 
ULCERS OF THE INTESTINES 263 
 
 losis, long ago attributed by Klebs to the swallowing of tuberculous 
 sputum, is now recognised to be an auto -intoxication with material 
 containing bacilli. This may even be proved in an indirect way 
 from the statistics of Eisenhart. In them it appears that out of the 
 1,000 autopsies on [all varieties of] tuberculous patients, of whom 
 567 were cases of intestinal tuberculosis, there were only 3 cases 
 in which the intestinal tuberculosis was not associated with puhiio- 
 nary tuberculosis. Infection of the intestine by the tubercle bacil- 
 lus naturally results if erosions are present ; the researches of Orth^ 
 are especially instructive on this point. But it is important to note 
 that, according to the investigations of Fischer ^°, Dobroklonsky ", 
 Tschitscho wisch ^^, and others, tuberculosis may be conveyed to the 
 mucous membrane of the intestine even when its epithelium is intact. 
 Tuberculous lesions are not distributed uniformly throughout 
 the intestines ; some regions — the lower part of the ileum and of the 
 caecum — show a special liability to invasion. The very slow move- 
 ment of the chyle in these regions is the chief cause why this is the 
 site of preference. Below the csecum and above the ileum the 
 development of tuberculous ulcers is much more infrequent. The 
 process usually begins in Beyer's patches and in the solitary follicles. 
 Small nodules are developed in them (miliary tubercles) and the 
 lymph follicles become smaller. By their rupture ulcers are formed. 
 Fresh eruptions of tubercle spring up from its base and in its 
 neighbourhood. The original lenticular ulcers increase in size by 
 coalescence, and, breaking through the muscular coat, reach the 
 serous covering and sometimes penetrate into the abdominal cavity. 
 The ulcers may lie with their longer axis parallel to the course of the 
 intestine (longitudinal), or at right angles to it (encircling). The 
 former develop in a Beyer's patch, the latter follow the course of 
 the vessels ; yet some have quite an irregular outline. Tuberculous 
 ulcers of the intestine exhibit in the main but a very slight tendency 
 to heal. Out of Eisenhart's * 56Y cases, only 10 showed ulcers which 
 had completely healed ; in 25 cases there was partial cicatrization. 
 In consequence of cicatricial contraction, intestinal tuberculosis 
 may produce simple or multiple stricture, in rare cases complete 
 occlusion ^^. In the chapter on Intestinal Stenosis this subject will 
 be taken up more in detail. Berforation of a tuberculous ulcer is 
 a rare occurrence (about 5 to 10 per cent). It usually takes place 
 in the csecum or vermiform appendix, and opens into a space shut 
 off by previous inflammatory adhesions, and only very rarely into 
 the general peritoneal cavity. 
 
264 DISEASES OP THE INTESTINES 
 
 A few remarks on ileo-csecal tuberculous tumours may be intro- 
 duced at this point, because they arise from tuberculous ulcerations, 
 although, strictly speaking, they fall under the head of tumours. 
 
 Our knowledge of ileo-csecal tumours is of recent date, and the 
 credit for it is chiefly due to the experience gained from the opera- 
 tive surgery of the intestines. Following Conrath ^*, Durante (1890) 
 was the first to point out the features of resemblance and the differ- 
 ences between carcinoma and tuberculous tumour of the caecum. 
 In 1891, he was followed by Billroth ^^, Henri Hartmann and 
 Pilliet ^^, and Salzer ^'^, who laid stress upon the tuberculous charac- 
 ter of the tumours in question. The excellent work of Czerny ^^, 
 König ^^, Körte ^°, Hofmeister ^\ and Conrath ^^ has so far advanced 
 our knowledge of the pathology and operative treatment of tuber- 
 culous tumours of the ileo-csecal region that at the present day our 
 clinical knowledge of them is complete in all essential details. 
 From the medical side, however, they have received very little 
 attention except in the paper of Obrastzow which will be alluded 
 to later, so that I think a detailed consideration of the subject is 
 indicated in this place. 
 
 The tuberculous tumour (see Fig. 29) is usually the product of 
 inflammatory infiltration from multiple tuberculous ulcerations. 
 These partially cicatrize, with the formation of a large amount of 
 scar tissue, which gradually contracts so as to cause a stenosis of the 
 lumen of the intestine. It is evident that such stenosis will favour 
 hypertrophy of the coats of the intestine. The contraction is 
 most marked in the vicinity of the ileo-csecal valve because the 
 tissue shrinkage is greatest at this point ; the valve itself is usually 
 involved in the process. 
 
 The ulceration may originate in the serous coat and extend 
 deeply. Conrath attributes this to a direct infection from local- 
 ized tubercular disease of the lymph glands ; while the mucous- 
 membrane form is considei*ed to be an auto-infection from tuber- 
 culous sputum, or as a primary tuberculosis — a tuberculosis from 
 ingesta in the stricter sense. Conrath traces the fact that caecal 
 tuberculosis usually remains localized, to several causes. One is, 
 that the tubercular deposits in the subserous layer do not contain 
 so many bacilli as those in the deeper strata, and thus general- 
 ization is hindered. For this reason the pulmonary phthisis ob- 
 served in connection with caecal tuberculosis is usually of mild 
 form, and in contra-distinction to fully developed phthisis, the oppor- 
 tunity for bacillary infection of the intestine is relatively small. 
 
ULCERS OF THE INTESTINES 
 
 265 
 
 Evidently we must not, even in this case, lose sight of the fact that 
 on account of its location the caecum affords a favourable seat for 
 the deposit of tuberculous products, and most unfavourable condi- 
 
 FiG. 29. — Tuberculosis of the Cecum. (Wölfler — Coneath.) 
 a, junction of CEecura and ascending colon ; b, junction of ileum and cfficum. 
 
 tions for their cure. The conditions are apparently very analogous 
 to those in primary tuberculosis of the appendix, which once estab- 
 
266 DISEASES OF THE INTESTINES 
 
 lished, in like manner and doubtless for the same reasons, and in 
 spite of any sort of treatment, leads to progressive changes. 
 
 The chronic dysenteric ulcer develops as a sequel of the acute 
 form. The symptoms may be those of an unusual prolongation of 
 the disease, or they may set in shortly after apparent cure by one or 
 more relapses ; or, finally, what was originally a catarrhal diarrhoea 
 may terminate in dysentery. In its essential features the ana- 
 tomical picture of chronic dysentery resembles that of the acute 
 form, and is characterized by the formation of a variable number 
 of deep-seated ulcers of the large intestine with raised and un- 
 dermined edges. Accompanying this there are the symptoms of 
 an intense catarrh of the large intestine. If the ulcers heal, the 
 intervening islets of mucous membrane become so much more 
 prominent that they may resemble true polypi. Contraction may 
 lead to stenosis, but experience shows that this is not of frequent 
 occurrence. It only exceptionally happens that dysenteric ulcers 
 perforate, for the serous coat over them is usually thickened by 
 inflammation. In less pronounced cases the intestine shows only 
 the signs of a severe catarrh with swelling or suppuration of the 
 follicles, or the formation of simple catarrhal ulcers. Between these 
 there exist a great variety of transition forms which sometimes fol- 
 low the type of catarrhal enteritis, and sometimes of true dysentery. 
 
 Syphilitic ulcers are extremely rare in the small intestine (they 
 are most frequent in the newborn); they are more common, but 
 still rare, in the large intestine ; they are most common in the rec- 
 tum. Syphilitic ulcers of the large intestine are usually formed by 
 the breaking down of gummata in the mucous or submucous coats. 
 They begin as superficial bulbous elevations, which break dov^oi 
 slowly and leave ulcers characterized by sharp borders and a yellow- 
 ish, flocculent, grayish-white base. Under certain conditions they 
 may coalesce, v^th extensive loss of substance, the tendency being 
 to superficial rather than deep ulceration. Perforation into the 
 abdominal cavity of a syphilitic ulcer of the large intestine has not, 
 as far as I know, been described, but perforation into some neigh- 
 bouring organ, especially from the rectum, is not at all infrequent. 
 Stenosis of the large intestine from syphilis is very rare. For 
 syphilitic ulceration of the rectum, see the chapter on Diseases of 
 the Rectum. 
 
 Amyloid ulcers^ according to some authors, are rare, and accord- 
 ing to others (Colberg, Courtois-Sufiit, etc.) they are frequent. 
 The pathological anatomists (Orth, Ziegler, Birch-Hirschfeld) speak 
 
ULCERS OF THE INTESTINES 26Y 
 
 witli great reserve concerning the occurrence of this form of ulcer. 
 At the present time they have no clinical importance. 
 
 Embolic or thrombotic ulcers arise from the occlusion of small 
 twigs of the mesenteric artery, as a result of endocarditis or of 
 atheroma of the large vessels. A small hemorrhagic infarct re- 
 sults from the embolism, and is followed by necrosis and ulceration. 
 The ulcers are located chiefly in the small intestine, from the duode- 
 num down to the caecum ; below this point they are very seldom met 
 with. The ulcers are of various sizes, depending upon the extent 
 of the infarction. Sometimes the ulceration is very considerable, 
 extending through the entire thickness of the intestinal wall, and 
 perhaps leading to perforation into the abdominal cavity. Septic 
 emboli from ulcerative endocarditis may cause either small hemor- 
 rhages or very minute embolic abscesses between the mucous and 
 submucous layers. These rupture into the interior of the intestine, 
 and give rise to multiple ulcerations. 
 
 Symptomatology of Intestinal Ulcee 
 
 The symptoms of intestinal ulcers are very varied, and depend 
 not only upon the kind, but upon the localization, the number, 
 and the extent of the ulcerative processes. It must be kept in 
 mind that, as a rule, a more or less intense catarrh accompanies 
 every form of ulceration. The changes in the stools thus produced 
 (constipation, diarrhoea, mucous stools, bloody stools) in turn favour 
 the progress of the ulceration and hinder cicatrization. We have 
 therefore to consider a variety of conditions which, to a very con- 
 siderable degree, must influence and modify the cHnical picture of 
 intestinal ulceration. In the first place, there are no distinctive signs 
 for the differentiation of the various kinds of ulcers. Even the 
 recognition of tubercle bacilli in the stools — to repeat what we have 
 already emphasized (page 120) — has only a very limited significance. 
 For this reason a separate symptomatology of the various forms will 
 be omitted, and the discussion will be limited to the characteristics 
 which they possess in common. 
 
 It is undoubtedly true that ulceration frequently occurs without 
 any symptoms whatever. Every physician who has been present 
 at many autopsies in cases of phthisis has observed intestinal ulcera- 
 tion, sometimes of considerable extent, which had caused no appre- 
 ciable symptoms during life. This is also true of amyloid degen- 
 eration of the intestine with ulceration, and especially so for stercoral 
 ulcers, as well as for the catarrhal and follicular forms. It is diffi- 
 
268 DISBASES OF THE INTESTINES 
 
 cult to determine whether there may not have been shght subjective 
 symptoms (constipation), and changes in the stools (admixture with 
 blood, mucus, or pusj. The clinical history gives us httle positive 
 information. In the majority of cases of ulceration, however, there 
 are symptoms which j)ermit the diagnosis to be made in some cases 
 with likelihood, and in others with certainty. 
 
 We shall next describe : 
 
 {a) The Subjective Symjjtoms. — The most important symptom is 
 pain. As has just been mentioned, pain may be entirely absent in 
 ulcer of the intestine. "When it is present, it does not give us any 
 clew to the variety or location of the ulcerative process. Though 
 the patient be intelligent, his statements as to the subjective sensa- 
 tions of pain are very vague, and it is only exceptionally that they 
 serve to indicate the location of the process. The objective sensi- 
 tiveness on pressure is more valuable. This tenderness seems to 
 me to be most marked in severe forms of intestinal tuberculosis, 
 and in some cases I have found it localized and very persistent in 
 the region of the umbilicus. It has to be distinguished from the 
 tenderness of chronic dysentery, which is more diffuse and extends 
 over the descending colon and sigmoid flexure. In my experience 
 this too may be absent. The intensity of the pain is of some impor- 
 tance in estimating the extent of the ulcer and the progress which 
 it is making toward the external surface of the intestine. In cases 
 of very decided tenderness deep ulceration may with circumspection 
 be thought of. 
 
 (h) The Objective Symjjtoms. — Of these, the nature and condi- 
 tion of the evacuations from the bowels are of chief importance. 
 
 In cases of well-marked ulceration of the bowel the passages may 
 be normal, or there may be constipation. It is important to re- 
 member this in passing judgment on individual cases. 
 
 The younger Frerichs describes two very instructive cases in his Contribu- 
 tions to the Study of Tuberculosis (1882). They were both cases of pulmonary 
 consumption. One of them had a profuse diarrhoea with elevation of tempera- 
 ture, so that a diagnosis of typhoid was made. The other patient was persist- 
 ently and obstinately constipated. In both cases the autopsies showed that the 
 cause of the bowel symptoms was a widespread intestinal tuberculosis. In the 
 second case, in addition to the tuberculosis of the ileum, there was exten- 
 sive tuberculous ulceration of the colon. 
 
 JS^othnagel advances a plausible hypothesis to account for these 
 cases, viz., that the destructive process has either completely de- 
 stroyed the nerves in the base of the ulcer, or that the continuous 
 
ULCERS OF THE INTESTINES 269 
 
 irritation has exhausted their sensitiveness to the usual stimuli. The 
 stools usually show marked deviations from the normal ; there is 
 diarrhoea, or diarrhoea alternating with constipation. It is very 
 probable that the seat of the ulceration has an influence in deter- 
 mining which of these conditions will predominate, since experi- 
 ence has shown that diarrhoea is less frequent when the ulceration 
 occurs high up than when it is below the ileum. As has already 
 been said, the existence of a simultaneous enteritis has an extremely 
 important, perhaps the most important, influence. For instance, 
 there is scarcely ever any severe diarrhcea in ulcer of the duodenum, 
 because the process is a localized one, and therefore the catarrhal 
 condition is limited to a very small portion of the intestine. 
 
 The presence of abnormal constituents, such as blood, pus, and 
 shreds of necrotic tissue, is more important than the consistence of 
 the stools. Blood may be present in various forms : as fresh or 
 decomposed blood, or intimately mingled with the dejections, yet 
 recognisable by the eye, or, Anally, only to be detected by the micro- 
 scope. The old maxim that blood from the upper part of the intes- 
 tinal canal is materially altered in appearance when voided is true, 
 as a rule, in ulceration of the intestine. But, as every one knows 
 from the pathology of typhoid ulcer, blood which is unchanged may 
 come from the subdivisions of the small intestine, provided it is 
 quickly expelled. Blood is always passed in an unchanged condi- 
 tion when it comes from the lower part of the small intestine or 
 from the colon, and, according to the amount of the hemorrhage, 
 appears as an enterorrhagia, or is intimately mingled with the 
 dejections. Smaller hemorrhages are usually easily recognised in 
 the same way ; minute ones only by microscopic, chemical, or spec- 
 troscopic methods. 
 
 Hemorrhages are not, however, a necessary symptom of intes- 
 tinal ulcer. In dysenteric and typhoid ulcers they are very fre- 
 quent, and in tuberculous and catarrhal ulcers relatively infrequent. 
 In tuberculosis of the intestine, according to Girode^^, the stools 
 often have a dark colour, similar to the coffee-ground vomit of gas- 
 tric cancer ; and this he attributes to repeated oozing of blood from 
 the ulcerations. I have observed the same appearances, but they 
 do not afford conclusive proof of the presence of blood. 
 
 Admixture of pus in the fseces is a very important symptom of 
 intestinal ulcer. However, the finding of pus is not absolutely con- 
 clusive, since it may come from some abscess in the neighbourhood 
 which has ruptured into the bowel, or may occur in croupous or 
 
'270 DISEASES OF THE INTESTINES 
 
 dysenteric conditions, or from ulcerating tumours of the bowel. 
 For this reason, as I know from personal experience, the diagnosis 
 may become extremely difficult. It is very important to ascertain 
 whether the pus is voided pure or mixed with blood. In the former 
 ■case it points to the presence of an abscess adjacent to the intestine, 
 while in the latter it indicates that the pus has originated in the 
 bowel itself. Aside from this consideration, it may be stated that 
 the presence of pus makes intestinal ulceration in the highest degree 
 probable. On the other hand, its absence does not negative the 
 ■existence of ulceration. 
 
 Like the gastric contents in ulcerating carcinoma, the passages 
 acquire a penetrating fetid odour when mixed with large quan- 
 tities of pus. This differs so characteristically from the normal 
 odour of the faeces that it can scarcely be forgotten by one who 
 has ever appreciated it. The importance of this sign lies in the 
 fact that purulent stools may often be detected in this way when a 
 iormal inspection has been neglected. In many cases the unaided 
 eye suffices to determine the presence of pus. Small quantities of 
 pus can only be recognised by the microscope ; but, if the fseces 
 are spread out on a black dish, yellowish-green specks, of the size 
 of the smallest millet seeds, will sometimes be seen and recognised 
 as pus. 
 
 Fragments of intestinal tissue^ when present, are always the 
 result of necrotic processes, and are found only in acute and sub- 
 acute dysentery. It has often been asserted that the presence of a 
 formation resembling frog spawn or sago grains is characteristic of 
 intestinal ulceration. But there is now no doubt that Yirchow was 
 right when he declared that these are vegetable products, which 
 may be found in the stools in a great variety of conditions. Of the 
 intestinal bacteria, the tubercle bacillus is the only one which has 
 any, and even that a very limited, significance. In the General 
 Section we have discussed the diagnostic value of the presence of 
 the tubercle bacilli, and it is sufficient to repeat that it is only 
 their continuous absence from the sputum and constant presence 
 in large numbers in the stools which justifies any positive conclu- 
 sion. In tuberculosis of the rectum a doubtful diagnosis may be 
 made certain by the removal of material containing bacilli from 
 the ulcer itself. 
 
 (c) Meteorism. — This may accompany intestinal ulceration, and 
 is seen fairly often in tuberculosis of the bowel and in dysentery. 
 In other forms of ulceration I have not found meteorism a con- 
 
ULCERS OP THE INTESTINES 2Yl 
 
 stant symptom, unless there existed also some narrowing of the 
 lumen of the bowel. In the above-mentioned varieties (e. g., tuber- 
 cular and dysenteric ulceration) meteorism may, of course, be con- 
 sidered a sign of intestinal paresis. 
 
 {d) Fever. — Fever is not present in simple ulceration of the 
 intestine — i. e., in the catarrhal or follicular forms. But irregular 
 fever is a very important clinical symptom of dysenteric and tuber- 
 cular ulcers. Sloughing carcinomata, as has been mentioned in the 
 chapter on that subject, may cause an irregular and sometimes very 
 marked pyrexia ; the same is true of para-intestinal abscesses. 
 
 (e) The Urine. — Up to the present time the examination of the 
 Tirine has not been of any special importance. The interesting rela- 
 tion that exists between ulceration of the intestine and albumosuria 
 after the administration of peptone in tubercular ulceration of the 
 intestine (see page 135) is worthy of further investigation. Under 
 some circumstances, the Ehrlich diazo reaction may be of service in 
 differential diagnosis (see p. 276). 
 
 {f) The general health may suffer markedly from the fever, 
 hemorrhages, and suppuration, as well as from the diarrhoea. I 
 have, however, seen patients who, in spite of frequent suppurations, 
 remained well nourished. That this feature depends chiefly on the 
 primary cause needs no explanation. 
 
 The symptomatology of ileo-ccecal tumours may be introduced 
 in this place. 
 
 The age and sex are of importance. According to Conrath's 
 collection of 85 cases, the frequency of tuberculosis of the caecum is 
 pretty nearly the same in both sexes. Much more than one half 
 (65 per cent) of the cases were between the ages of twenty and forty 
 years. Yery few were found in the fifth and sixth decades. From 
 -Oonrath's statistics there is a significant preponderance of females 
 between the ages of twenty and thirty, while in those between thirty 
 and forty the proportion of males is markedly greater. Csecal tuber- 
 culosis usually begins insidiously, or has no characteristic symptoms. 
 There may, for example, be constipation, alternating perhaps with 
 diarrhoea, but there is nothing to indicate that an incurable destruc- 
 tive process has begun. There is no change in the picture until the 
 characteristic phenomena of stenosis or a tumour become manifest. 
 The distinctive signs of chronic stenosis of the bowel develop — the 
 •occasional attacks of colic with nausea or vomiting, the visible 
 tetanic contractions of the intestine, the constipation persistent in 
 spite of the usual remedies, and, as a result, a severe loss of nutri- 
 
2Y2 DISEASES OP THE INTESTINES 
 
 tion. In prolonged cases the marasmus is as marked as the cachexia 
 of cancer. Occasionally there may be hemorrhages from the bowel, 
 or blood may be mixed with the stools. As the disease is usually 
 associated with a manifest or incipient pulmonary phthisis, irregu- 
 lar fluctuations of temperature are frequently observed. 
 
 The most important symptom of caecal tuberculosis is the 
 t u m our. Its size varies ; it is usually made more accessible to 
 palpation by filling the rectum with water. At fii-st the tumour is 
 more or less movable, but later it may become quite fixed by adhe- 
 sions or thickening of the mesentery. Under such conditions it 
 may lie immediately under the abdominal wall, and thus lead to 
 serious mistakes in diagnosis. Furthermore, it may suppurate, 
 break down, and ruj)ture externally, forming an artificial anus ; or 
 the abscess may perforate into the abdominal cavity, or into one of 
 the neighbouring organs. 
 
 The course of caecal tuberculosis is usually slow. Many cases 
 lasting two or three years have been observed. As the tumour 
 doubtless has a long period of latency, the beginning of the disease 
 evidently dates much farther back. 
 
 Under medical treatment the prognosis is unfavourable. The 
 stenosis of the bowel gradually increases until there is absolute 
 obstruction or perforation into the abdominal cavity or adjacent 
 organs. Death may be caused by pulmonary phthisis, peritoneal 
 tuberculosis, by disseminated tuberculosis of the intestine, by the 
 protracted suppuration of multiple abscesses, by amyloid changes in 
 the intestines or kidneys, or by other complications. 
 
 Diagnosis an^d Differential Diagnosis 
 
 The detection and identification of ulcers of the intestine pre- 
 sent many difficulties. One, already alluded to, is that many forms . 
 run a perfectly latent course or give but slight clinical symptoms. 
 A second difficulty, which has also been mentioned, is that the dif- 
 ferent forms have no specific characteristic signs. With few excep- 
 tions, a positive diagnosis can only be made when the other clinical 
 facts clearly show the relationship between and etiology of the symp- 
 toms. On the other hand, it occasionally happens that, although 
 the standard symptoms are absent, one may suspect ulceration of 
 the intestine when disorders of the functions of the bowels, pro- 
 nounced tenderness, diarrhoea, and marked impairment of the general 
 health are suddenly or gradually added to the previous symptoms. 
 Even in such a case, however, the disease may only be suspected. 
 
ULCEES OF THE INTESTINES 273 
 
 The recognition of ulcers of the small intestine, especially those 
 which are not tuberculous, is especially difficult. The changes in 
 the stools may perhaps consist in hemorrhage or melsena. The 
 presence of pus can not be depended u]3on because, as von Leube ^ 
 has shown, pus loses its characteristic appeai'ance in passing through 
 the colon. It is unnecessary to say that hemorrhages from the 
 intestinal canal may have a great variety of causes. In a few cases, 
 as in those reported by Nothnagel ^^, the diagnosis of embolic and 
 thrombotic ulcers has been successfully made, and is of course pos- 
 sible when the source of the embolus can be clearly traced. This 
 may be possible when endocarditis, pyaemia, or arterial sclerosis has 
 preceded, or when the symptoms of embolism of a branch of the 
 mesenteric artery (severe colicky pains, severe hemorrhage setting 
 in at once, meteorism, intestinal paralysis) have been present and, 
 what is of course very rare, have abated. 
 
 The prospect of recognising ulcers of the large intestine (ex- 
 clusive of the rectum) is better, because the excreted products are 
 accessible to direct and repeated examination. Aside from the 
 changes in the consistence of the stools and the local pain and ten- 
 derness (whose value must be estimated with care), the main factors 
 to be looked for are admixtures of blood, pus, mucus, and tissue 
 debris with the faeces. Naturally, the presence of both blood and 
 pus is of the highest importance, while, as already explained, either 
 of them alone leaves room for many possibilities. The diagnosis 
 is not complete until not only the presence of an ulceration is de- 
 termined, but its special causation made out. In a few instances, 
 in addition to pulmonary tuberculosis, dysentery, and typhoid fever, 
 there are no special difficulties in reaching a conclusion, but there 
 are varieties which present insurmountable difficulties. 
 
 I shall relate one case in which the diagnosis of tuberculous 
 ulceration of the large intestine was probable, and another in which, 
 although ulcer of the intestine was diagnosed with positiveness, the 
 etiology of the ulcer was never cleared up. 
 
 Case I. — Miss Clara St., of Radenickel, near Crossen ; twenty-eight 
 years old. 
 
 Previous History. — Father had chronic pulmonary disease — otherwise no 
 hereditary taint could be made out. The patient has been weak and sickly 
 from her youth. Began to menstruate at fourteen; is regular, with very profuse 
 flow. Six years ago, without any exciting cause, in particular without any 
 previous cough, moderate haemoptysis. This was repeated every four to six 
 weeks. Two years later began to have pains in the epigastrium, which her 
 physician attributed to gastric ulcer. She was sent to Carlsbad. Here she 
 
274: DISEASES OP THE INTESTINES 
 
 had hemorrhages from the stomach and melsena. In the following year 
 hsemoptj'sis returned every four to six weeks. No change occurred until Oc- 
 tober, 1896, since which time there has been no hsemojjtysis. 
 
 The present illness developed shortly before Christmas, 1897. It begaa 
 with a sudden attack of severe pain in the region of the umbilicus, lasting day 
 and night, not dependent upon the ingestion of food, and increased by pres- 
 sure. Six weeks later there was a sudden discharge of pus from the rectum, 
 preceding a normal passage. The pus coated the faecal masses superficially. 
 This discharge of pus was repeated four weeks later, the pains having mean- 
 while ceased. From that time on evacuations of pus continued at intervals of 
 four to six weeks. During this period there were attacks of pain in the region 
 of the intestines, but not simultaneously with the purulent discharge. These 
 attacks used to last for a few weeks and then disappear for a few months. 
 
 Since May, 1898, the purulent discharge has been constant. There has been 
 a normal painless stool every day. There ai-e frequent cramplike pains, occur- 
 ring only at night. By the end of May, bright fluid blood began to appear 
 with the pus. This gradually increased in amount. Since the middle of June, 
 1898, the stools have been preceded by clear blood, and followed by blood witk 
 a little pus. During the last few days, neither pus nor blood has been passed. 
 
 Present Condition. — The patient is poorly nourished; the cheeks and lips- 
 are pale. Pulse, 73, of moderate tension. No fever. Nothing of especial in- 
 terest in the lungs. The abdomen shows no abnormal resistance, no increased 
 meteorism, no tenderness anywhere. Urine, negative ; in particular, no indi- 
 can. Examination by the vagina and rectum, negative. 
 
 Stools, solid and of normal calibre. 
 
 Irrigation of the bowel gave a negative result. 
 
 On June 30, 1898, she had a movement consisting of well-formed faecal 
 masses coated with muco-purulent shreds, in which pus cells were demonstrated 
 in abundance by the microscope. Eepeated examination failed to show tuber- 
 cle bacilli. Digital and ocular examination of the rectum resulted negatively. 
 
 There is no doubt that ulcers were present in this case. It is 
 most probable that they were located in the descending colon or 
 the sigmoid flexure. In spite of the absence of signs of pulmonary 
 lesions and the failure to find bacilli, the diagnosis of tuberculous, 
 ulceration of the large intestine is probable from the previous his- 
 tory of repeated haemoptysis and the hereditary taint. 
 
 Case II. — Max B., clerk; age, twenty-eight years. Was perfectly healthy 
 until 1895. In July of this year he acquired gonorrhcea, followed by stricture, 
 which was treated with sounds and cured. In April, 1898, had another attack 
 of gonorrhoea which lasted three weeks. During this period he states that he- 
 had "catarrh of the bladder." He had a chancre at the same time, which 
 lasted fourteen days. Whether this was a soft chancre or an initial lesion, the 
 patient does not know positively; but, at any rate, he was treated without 
 mercurial inunctions by a specialist. 
 
 As early as January, 1897, the patient noticed for the first time bleeding 
 from the bowel, the cause of which he does not know. There had been no. 
 
ULCERS OF THE INTESTINES 2Y5^ 
 
 antecedent constipation of notable degree. During this period he had twelve 
 movements from the bowels each day, fluid, and mixed with blood. He does 
 not know whether they contained any pus. There was no pain, either sponta- 
 neous or during defecation; and the actual loss of blood, in his opinion, was 
 less than at the present time. Under the treatment which the patient received 
 from January until July, the diarrhoea gradually ceased, the blood continued to 
 appear from time to time, even when the stools were normal otherwise, and 
 finally even this ceased. From that time until October, 1898, he had no abnor- 
 mal symptoms. The treatment was by internal remedies. 
 
 The patient now appears, complaining that he has four to five diarrhoeal pas- 
 sages per day which contain blood and mucus. He has tenesmus, and a fluid 
 resembling bloody mucus frequently escapes without faeces. There is no pain. 
 He has a good appetite, is easily satiated, but hunger returns in a short time. 
 However, he does not feel in any wise ill. 
 
 Present Condition. — A moderately well-nourished young man of slender build,, 
 who looks healthy. An examination of the thoracic viscera shows them to be 
 absolutely normal ; there is no ground for suspecting pulmonary phthisis. The 
 abdomen is nowhere distended, gives no abnormal percussion resonance, and is- 
 nowhere sensitive to pressure. Digital examination of the rectum gives quite 
 normal results, confirmed by repeated visual examination. There are no signs. 
 of syphilis. There is no swelling of the glands, no leucoderma, no atrophy of 
 the base of the tongue, and there are no nodules. (In response to an inquiry, 
 the specialist who treated the case in 1898 says that it was undoubtedly a soft 
 chancre.) The urine contains neither sugar, albumin, indican, nor peptones. 
 The patient was directed to bring a sample of his passages at each visit. 
 
 The examination of the faeces, which was made on an average two or three 
 times in each of the following weeks, showed that they were of normal colour, 
 partly formed, but mainly pulpy. There was a slight superficial admixture of 
 bright-red blood and a large admixture of greenish-yellow pus which settled in 
 a thick layer at the bottom of the glass. There was no intimate mingling of 
 the pus and blood with the faeces, and no further abnormal changes could be 
 made out upon microscopic examination. Repeated examinations for gonococci 
 and tubercle hacilli were invariably negative. 
 
 The treatment consisted at first in suitable diet, all irritating substances, 
 being excluded. Under irrigation with chamomile tea, and subsequently with 
 a solution of tannic acid, the diarrhoea improved somewhat, but the blood and 
 pus continued in variable quantity. There was no pain, either spontaneous or 
 on pressure. Irrigations with a solution of nitrate of silver, 1 to 1,000, were tried, 
 but had to be abandoned before long because they increased the diarrhoea, and 
 the patient complained of burning sensations in the rectum and sigmoid 
 flexure. Illumination of the rectum, the patient being in the lithotomy posi- 
 tion, again failed to give any positive result. 
 
 December 10, 1898. — The blood and pus in the stools have increased. Pa- 
 tient says that on alternate mornings he has four or five movements of the bowels 
 following close upon each other ; they contain a considerable amount of pus; 
 and that on the intervening days the conditions are nearly normal. 
 
 December 18th. — Enema of subnitrate of bismuth in suspension, preceded 
 by a cleansing enemata of chamomile tea. 
 
276 DISEASES OF THE INTESTINES 
 
 JDeceniber 29th. — Has only one or two movements from the bowels daily, of 
 thin, pasty consistence and still containing blood and pus in variable quantity, 
 but always enough to be recognised by the naked eye. 
 
 January 17^ 1899. — Patient feels very well. One or two movements from 
 bowels daily. They still contain blood and pus, but in smaller quantity. No 
 pain. Abdomen not tender on palpation at any point. Slight meteorism on 
 jjercussion below the umbilicus. 
 
 In this case also, the diagnosis of ulceration of the large intes- 
 tine is a safe one; but it is not possible to determine the nature 
 of the process (whether chi'onic dysentery, f olKcular ulcer, or tuber- 
 culous ulcer). There could not have been a follicular or catarrhal 
 ulceration at the bottom of this case, for the suppuration was too 
 extensive; and there was besides an absence of a long-continued 
 antecedent catarrh to act as a predisposing cause. 
 
 In the diagnosis of ileo-ceecal tuberculosis, the following points 
 should be considered : The recognition of a tumour in the ileo- 
 cecal region, the youth or middle age of the patient, the presence 
 of pulmonary or other localization of tuberculosis, a long duration 
 of the symptoms, emaciation and pallor, the presence of tuberculous 
 processes in other organs (lungs, joints, etc.), and, finally, the exist- 
 ence of an intestinal stenosis having the features first described by 
 König ^^. They are the following : The abdomen is distended; fre- 
 quently there is visible peristalsis, accompanied by gurgling, splash- 
 ing, sometimes musical sounds, especially in the neighbourhood of 
 the caecum. Toward the end of an attack the sounds heard resemble 
 those produced by expelling the last drops from a syringe ; the ab- 
 domen collapses and the attack is over. According to König, these 
 peculiar manifestations depend upon the relation between the length 
 and the tightness of the stricture, the hypertrophy of the portion of 
 the intestine above the constriction, and the relaxation of the gut 
 below it. In such cases Ehrlich's diazo reaction gives important 
 confirmatory evidence, for the extended investigations of Krokie- 
 wicz^ have demonstrated that this reaction is almost invariably 
 negative in carcinoma of the digestive tract, while it is seldom 
 absent in tuberculosis. In addition, as Obrastzow ^^ has shown, the 
 finding of tubercle bacilli may fortify the diagnosis. Aside from 
 carcinoma, a diiferential diagnosis must take into consideration the 
 possibility of exudations in the ileo-csecal region, especially peri- 
 typhlitis, and also various rare forms of tumour (sarcomata, fibrom- 
 ata, foreign bodies, intussusception, fsecal tumours, actinomycosis, 
 pericolitis, tumours consisting of abnormally located or displaced 
 
ULCERS OF THE INTESTINES 277 
 
 segments of the bowel, etc.). It is impossible to enter into a full 
 discussion of all these sources of error, and these hints, although 
 thej by no means exhaust the possibilities, must suffice. The dif- 
 ferential diagnosis between carcinoma and tuberculosis of the caecum 
 calls for special notice. Experience teaches us that it is very diffi- 
 cult. None of the above criteria, even the Unding of tubercle 
 bacilli, insures us against error. Only a collective consideration of 
 the signs of caecal tuberculosis warrants a decision. The following 
 table will be of service, though, like all such schematic presenta- 
 tions, it has only a limited value : 
 
 Tuberculosis of the Gceeum Carcinoma of the Ccecum 
 
 Age : Usually the second to fourth Seldom before the fourth decade. 
 
 decades. 
 
 Duration : Extremely chronic. Duration that usual for carcinoma. 
 
 Lungs : Frequently more or less pro- Examination of the lungs negative. 
 
 nounced tuberculosis. 
 
 T-MmöMr; Considerable extension in the The tumour has a definite outline, 
 
 length of the intestine ; the infiltra- which is usually strictly limited to 
 
 tion can be shown by palpation to that of the caecum. The latter can 
 
 involve the bowel. not be felt as such. 
 
 Symptoms of stenosis : Always present ; Symptoms of stenosis may be entirely 
 
 distinguished by remarkable mur- absent; when present, are usually 
 
 murs. less pronounced than in caecal tuber- 
 culosis. 
 
 Condition of the stools : Blood and pus Blood and pus are not infrequently 
 
 very seldom ; tubercle bacilli very found ; never any tubercle bacilli. 
 
 often present. 
 
 Fever : Not infrequently observed. Fever exceptionally present. 
 
 Urine : Ehrlich's diazo reaction is Diazo reaction always negative. 
 
 present. 
 
 Tkeatmekt of Intestinal Ulcees 
 
 In the treatment of intestinal ulcers, other than those of the 
 rectum, the curative measures at our command are few in number. 
 The weapons which asepsis and antisepsis have furnished so abun- 
 dantly for the cure of external ulcers are useless in the treatment of 
 intestinal ulceration. Since we lack an agent which has an efficient 
 and lasting influence upon the intestinal juices and the intestinal 
 contents, we can not even fulfil the simple postulate of nihil nocere. 
 The only thing we can do is to avoid strong irritants, and restore 
 the functions which have been perverted by the ulceration or its 
 accompanying catarrh to normal. 
 
 This is especially true of ulcers of the small intestine, and among 
 19 
 
278 DISEASES OP THE INTESTINES 
 
 these of tlie tuberculous. Here our chief task lies in the control 
 of the diarrhoea, partly by diet (see page 224) and partly by the 
 astringent agents already described (page 191). We again call at- 
 tention to the favourable action of the preparations of chalk, either 
 alone or in combination with bismuth (dermatol, beta-naphthol- 
 bismuth, etc.). In some cases of severe tuberculous diarrhcea in 
 which the diagnosis of ulceration was made with as much positive- 
 ness as it can be at the present day, I have been able to keep the 
 profuse evacuations at least temporarily under control by rest in bed 
 and anti-diarrhoeal diet. It is hardly necessary to state that this 
 treatment is sometimes ineffectual. 
 
 In ulceration of the large intestine the results are more favour- 
 able, as we may supplement diet by direct local treatment with, 
 suitable irrigations. This measure, however, should not be valued 
 too highly, since the agent is only briefly in contact with the dis- 
 eased area, and the reaction of the bowel to various drugs is found 
 by experience to be very much increased. Besides, in chronic diar- 
 rhoea it is not possible to keep the intestine in a clean condition. 
 These are all factors which make the utility of local treatment, at 
 least in severe cases, to some degree problematic. IS^evertheless, the 
 indication in every case is to try suitable disinfecting and astringent 
 drugs : such are boric acid, 3 per cent ; salicylic acid, 3 per cent ; 
 salicylate of soda, 5 per cent ; nitrate of silver, 0.2 to 0.5 to 1 per 
 cent; tannic acid, 0,5 to 1 per cent. In some cases I have seen 
 decisive results from bismuth injections given in similar way to 
 Fleiner's method in gastric ulcer. I use one teaspoonful to one 
 quarter litre of water. On account of the absence of any irritating 
 quality, I prize this drug above all others, and recommend that it 
 be given the preference. 
 
 The treatment of ileo-cceoal tuberculosis is surgical. The re- 
 sults are temporary, of course, since no small number of the patients 
 sooner or later fall victims to pulmonary tuberculosis. Of 86 cases 
 reported by Conrath ^*, the 23 operated on were found to be in good 
 health one to four to eight years later. Judging from experience, 
 the dangers of the operation are not inordinately high. According 
 to Conrath, in 86 operations the mortality was only 16 per cent. 
 The surgical procedures that have been tried are the extirpation of 
 the tumour by resection of the intestinal wall, or by intestinal anas- 
 tomosis (after Maisonneuve), or without extirpation the complete 
 exclusion of the involved segment (division of the ends of the ex- 
 cluded portion of gut after the method of Salzer). Experience 
 
ULCERS OF THE INTESTINES 279 
 
 shows that entero-anastomosis offers the best chance of recovery 
 (Conrath's statistics give 10 cases without a death), and the results 
 otherwise are equally as good as after extirpation. In the future it 
 should be the operation of preference. 
 
 LITERATURE 
 
 1. Klebs. Pathologische Anatomie, 1869, Bd. i, S. 256. 
 
 2. von Leube. von Ziemssea's Handbuch, Bd. vii, Abth. 2, 2te Aufl., 1878, 
 
 S. 310. 
 
 3. Behrens. Ueber primäre tuberculöse Darminfection des Menschen. Inaug.- 
 
 Diss., Berlin, 1894. 
 
 4. Eisenhardt. Ueber Häufigkeit u. Vorkommen d. Darmtuberculöse. Inaug.- 
 
 Diss., München, 1891. 
 
 5. Wyss. Correspondenzbl. f, Schweizer Aerzte, 1893, No. 22. 
 
 6. Melchior. Cited from Virchow-Hirsch's Jahresber., 1890, Bd. i. 
 
 7. Hamann. Statistik der Tuberculöse im Alter von 16-19 Jahren. Inaug.- 
 
 Diss., Kiel, 1890. 
 
 8. Herxheimer. Deutsch, med. Wochenschr., 1885, No. 52. 
 
 9. Orth. Virch. Arch., Bd. Ixxvi, 1879. 
 
 10. Fischer. Arch. f. experiment. Pathol., Bd. xx, 1886. 
 
 11. Dobroklonsky. Arch, de Medecine experim., 1890, No. 2. 
 
 12. Tschitschowisch. Annales de l'Institut Pasteur, III Annee, No. 5, p. 222. 
 
 13. "Wittstock. Zur Klinik des Ileus durch Darmtuberculöse. Inaug.-Diss. 
 
 Berlin, 1893. 
 
 14. Conrath. Brun's Beiträge zur klin. Chirurgie, Bd. xxi, Heft 1, 1898. 
 
 15. Billroth. Cited from Conrath, loc. cit. 
 
 16. Pilliet. Cited from Conrath, loc. cit. 
 
 17. Salzer. von Langenbeck's Archiv, Bd. xliii. 
 
 18. Czerny, Brun's Beiträge z. klin. Chirurgie, Bd. vi u. ix. 
 
 19. König. Deutsche Zeitschr. f. Chirurgie, Bd. xxxiv, 1892, S. 65. 
 
 20. Körte. Ibid., Bd. xl, 1895, S. 523. 
 
 21. Hofmeister. Brun's Beiträge, Bd. xvü, S. 577, 1896. 
 
 22. Girode. Contribution a l'etude de l'intestin des tuberculeux. These de 
 
 Paris, 1888. 
 
 23. Nothnagel. Darmkrankheiten, S. 156. 
 
 24. Krokiewicz. Wiener klin. Wochenschr., 1898, No. 29. 
 
 25. Obrastzow. Arch. f. Verdauungskrankheiten, Bd. iv, 1898, S, 440. 
 
CHAPTEE XYI 
 
 ROUND TJLGEB OF THE DUODENUM 
 
 {Ulcus rotundum duodeni) 
 
 Preliminary Remarlcs. — Among the ulcerative processes of the 
 intestinal canal round ulcer of the duodenum demands careful atten- 
 tion — anatomically, because of its size and marked characteristics ; 
 clinically, because of its obscure symptomatology and diagnostic 
 signs ; and because of the severe complications which may mark its 
 course and appear with an extremely acute onset. 
 
 In its most important features the pathological anatomy and 
 pathogenesis of ulcer of the duodenum is the same as that of gastric 
 ulcer. The extremely voluble discussion which followed Cruveil- 
 hier's classic presentation of the latter subject has not solved its 
 numerous problems. With reference to the mode of origin of 
 chronic duodenal ulcer we also are obliged to fall back upon more 
 or less well-sustained hypotheses. 
 
 Referring the student of this subject to the text-books on dis- 
 eases of the stomach, as well as to the monographs of Krauss \ Chvo- 
 stek^, Boucquoy ^, Oppenheiraer^, Eeckmann ^, and Collin®, we shall, 
 in what follows, limit ourselves to a concise description of the most 
 important etiological factors which we have gathered from literature 
 and from our own experience. 
 
 In the first place, just as in the case of gastric ulcer, so pre- 
 disposing and immediate causes operate in the production of the 
 duodenal ulcer. As regards the predisposing causes, it is univer- 
 sally, and I believe correctly, held that the corrosive action of the 
 gastric acid, which is not neutralized to any essential degree until 
 it meets with the pancreatic secretion, plays an important part. 
 The fact that round ulcers of the small intestine occur almost exclu- 
 sively in the duodenum permits scarcely any other explanation. But 
 there are other predisposing causes. Dickinson ''', and shortly after- 
 ward Perry and Shaw ^, as well as Marmaduke Sheild ^, have called 
 attention to the appearance of duodenal ulceration in the course of 
 380 
 
ROUND ULCER OF THE DUODENUM 281 
 
 chronic nephritis. Thus, from the Hterature of the subject, Perry 
 and Shaw have collected 70 cases of duodenal ulcer, in no less than 
 12 of which typical Bright' s disease was present. In such cases 
 everything points to a necrotizing effect exerted by the retained 
 urea or its derivative, amTnonium carbonate. It is apparent that in 
 this case we have to deal with the same influences which produce 
 multiple uraemic ulcers in the lower segments of the bowel. The 
 toxic influence may act continuously or suddenly, perhaps after 
 extirpation of one kidney, or after a severe acute nephritis with 
 suppression of urine. 
 
 A different set of conditions underlie those forms of duodenal 
 ulcer which have been observed after extensive burns, after frost- 
 bite, and in erysipelas, pemphigus, and septicaemia. The most 
 likely explanation for the first-named condition seems to be that 
 soluble fibrin ferment gains access to the circulation and emboli are 
 formed, resulting in a partial necrosis of portions of the duodenal 
 mucous membrane. On the other hand, in the case of the infective 
 processes named, bacterial influences doubtless play an essential 
 role. In still other cases a traumatic lesion may with more or less 
 probability be looked upon as the original factor. Such cases have 
 been observed by Schulze ^°, Brambillo^^, Reckmann^, J. Pauly^^, and 
 others. Thus it may be seen that very varied causes may operate to 
 produce the same anatomical changes, and it is of importance clin- 
 ically to discriminate between them. 
 
 To these etiological memoranda may be added a few brief data on 
 the age and sex affected, and on the localization of duodenal ulcers. 
 
 As far as age and sex are concerned, the duodenal ulcer shows 
 striking variations from gastric ulcer. Collin, to whom we owe the 
 most complete collection of cases (2Y9), gives the following sum- 
 mary : 
 
 Under 10 years 42 cases. 
 
 From 11-20 years 24 " 
 
 " 21-30 " 43 '' 
 
 " 31-40 " 52 " 
 
 " 41-50 " 46 " 
 
 " 51-60 " 41 " 
 
 " 61-80 " 18 '' 
 
 " 81-94 " 13 " 
 
 Of the cases occurring in the first ten years nearly one half 
 (17) belong to the first year of life. Duodenal ulcer has even been 
 
282 DISEASES OF THE INTESTINES 
 
 observed in newborn children who have only lived a few hours, so 
 that an intra-uterine origin has been suspected. Landau ^^ has 
 ascribed them to thrombosis of the umbilical vein and embolism of 
 the vessels of the small intestine, with consecutive necrosis. 
 
 The infrequency of duodenal ulcer at puberty, its slow increase 
 during the third decade, its marked rise in the fourth and fifth, 
 and its slow falling oif again in the sixth, is noteworthy. 
 
 There is a striking unanimity among the various authors as 
 regards the preponderance of the affection among the male sex. 
 Collin found 205 cases out of 257, or 79 per cent, in males. This 
 fact is one of the most striking in the pathology of duodenal ulcer. 
 How shall we explain the fact that the male sex, which has so 
 marked an immunity from round ulcer of the stomach, should show 
 so peculiar a predisposition toward duodenal ulcer ? In my opinion 
 the explanation can only be found in the difference in the habits of 
 men and of women. Of especial importance is the fact that the use 
 of alcohol and tobacco more often causes a chronic gastritis with 
 marked hyperacidity in men than in women. This, however, would 
 not explain why the duodenum becomes the favourite seat of ulcer- 
 ation. In this connection the following considerations appear to 
 me to be worthy of notice. 
 
 Through investigations on dogs made by von Mering^^ and 
 Moritz ^^^ we know that the stomach expels water into the intes- 
 tine with extraordinary promptness ; and further, that alcohol, sa- 
 lines, dextrin, and acids, although they are absorbed by the stomach, 
 are only taken up by it to a very limited extent. It further 
 appears, from the investigations of von Mering, that the first dis- 
 charges contain these substances in very concentrated solution. 
 When von Mering poured 300 cubic centimetres of 25 per cent 
 alcohol into the empty stomach, 105 cubic centimetres of 10.5 per 
 cent alcohol flowed out within ten minutes. When he poured 200 
 cubic centimetres of 50 per cent grape sugar solution into the 
 empty stomach, the fluid which was carried into the duodenum 
 amounted to 120 cubic centimetres, with 32 per cent sugar. In 
 addition, we know from Moritz's investigations that the stomach 
 first expels the fluid portions of the chyme, while the sohd portions 
 follow quite slowly. Furthermore, the stomach protects itself from 
 highly concentrated solutions by secretion of water ; such a function 
 has not yet been demonstrated for the duodenum. It thus follows 
 that the duodenal mucous membrane has much less protection against 
 concentrated watery solutions than the stomach, whose mucous 
 
ROUND ULCER OF THE DUODENUM 283 
 
 membrane is relatively well protected against injury during the first 
 stage of digestion by the slip]3ery or solid contents. If, then, acids, 
 alcohol, and saline solutions act upon a duodenal mucous membrane 
 already irritated by an existing hyperacidity, it only needs an oppor- 
 tune cause to produce a partial necrosis of this unresisting tissue. 
 This explanation receives a further illustration from the observa- 
 tions of Boucquoy ^, Burwinkel ^^, and others, which I can confirm, 
 that ulcer of the duodenum occurs with especial frequency in ha- 
 bitual alcoholics. If I might cite the results of treatment as a guide 
 to an opinion in this matter, I would assert that duodenal ulcer, 
 although not always in classic form, is a very prevalent lesion in 
 alcoholics. I shall return to this point in the section devoted to 
 symptomatology and diagnosis. 
 
 Among the features worthy of notice, we would call attention 
 to the fact that duodenal ulcers, like gastric ulcers, are usually 
 single. Out of 233 cases in which Collin found the number noted, 
 the ulcer was solitary in 195 (83.6 per cent). Occasionally duode- 
 nal ulcer is found associated with gastric ulcer or with esophageal 
 ulcer. In the great majority of cases the ulcer is situated in the 
 upper part of the duodenum (242 times in Collin's table of 262 cases) ; 
 in not a few (74) it was adjacent to or in contact with the pylorus ; 
 in 14 cases the seat was the descending portion, and in only 6 was 
 it found in the inferior horizontal portion. 
 
 There is a discrepancy in the statistics as to the relative fre- 
 quency of involvement of the anterior and the posterior wall. 
 Oppenheimer states that it is as 18 : 16. Collin found that out of 
 12T cases in which particulars were given, the ulcer was on the 
 anterior wall 71 times, on the posterior wall 45 times, on the upper 
 edge 10 times, and only once on the lower edge (" Bord superieur ou 
 inferieur "). In the descending portion the inner wall was most 
 often involved, especially in the immediate vicinity of the papilla. 
 
 The duodenal ulcer not infrequently gives rise to numerous 
 and serious complications, which will be comprehensively considered 
 further on. 
 
 Symptomatology and Diagnosis 
 
 In the first place, it is to be noted that a duodenal ulcer fre- 
 quently runs its course without any symptoms, and that it may 
 cause death by perforation into the abdominal cavity at a time when 
 the patient seems to be in perfect health. Such a latent course is 
 apparently more common than it is with gastric ulcer. Whether 
 
284 DISEASES OP THE INTESTINES 
 
 in siicli cases there have not been slight symptoms extending back- 
 ward over perhaps a long period is difficult to determine, but the 
 fact remains that perforation is seldom preceded by severe gastric 
 or intestinal symptoms. Such cases have been termed acute ulcers. 
 The symptoms may be divided into subjective and objective. 
 
 A. Subjective Symjptoms 
 
 Pain. — The pain of duodenal ulcer closely resembles that of 
 gastric ulcer. It is of a burning, boring character, and radiates 
 downward or to the sides, seldom or (as Burwinkel says) never 
 toward the back. According to Oppenheimer, the pain is increased 
 by lying on the right side. A characteristic feature of the pain 
 is that it comes on several hours after the ingestion of food, and is 
 localized in the right hypochondrium at a point on the prolongation 
 of the parasternal line about two centimetres below the gall bladder. 
 There are many exceptions to this. The pain may be more to the 
 left in the pit of the stomach, in the umbilical region, or excep- 
 tionally it may be more or less below this point. Judging from 
 my own experience, I should also state that there is no relationship 
 between the nature of the food and the onset of the pain, and also 
 that the latter may persist, even begin during the fasting state — ^for 
 example, at night. 
 
 From observations which he made, Chvostek formulated a test 
 which might serve to differentiate duodenal from round gastric 
 ulcers. He found that pressing gastric pains coming on two and 
 a half hours after breakfast were permanently, and similar pains 
 about three hours after dinner were temporarily relieved by the 
 taking of wine. He concludes from this that when the ulcer is in 
 the duodenum, the taking of the wine causes a reflex closure of the 
 pylorus, and thus arrests the flow of the gastric contents into the 
 duodenum. This, in the case of the more abundant meal, causes a 
 temporary remission, and in the case of the lighter one a lasting 
 relief. But if the ulcer is situated in the stomach, the swallowing 
 of wine not only does not relieve the pain, but increases it. Simi- 
 larly Burwinkel ^^ reports a case in which " pain in the stomach," 
 beginning two or three hours after each meal, was relieved by the 
 taking of an acid wine or citric acid. 
 
 With certain limitations I have been able to confirm this sign 
 in several cases of duodenal ulcer. I believe that it is dependent 
 solely upon hyperacidity of the gastric juice, for we know that in 
 this condition the ingestion of fluid or food will cause a cessation of 
 
ROUND ULCER OF THE DUODENUM 285 
 
 the pain. "Whetlier this comes about, as Chvostek thinks, from a 
 reflex pyloric closure which for the time being prevents the passage 
 of the food into the duodenum, or, as I believe, from dilution of 
 the superabundant hydrochloric acid by the fluid and consequent 
 diminished irritation of the ulcerated surface, may be left an open 
 question. At any rate, it seems to me that the nature of the fluid 
 is of no importance except that substances such as milk or egg albu- 
 min, which have a strong tendency to combine with hydrochloric 
 acid, should act better than, for example, wine. 
 
 B. Objective Si/mptoms 
 
 1. Points of Tenderness. — The typical point of tenderness on 
 pressure coincides with the area of spontaneous pain above described, 
 but, like it, may exhibit numerous variations which may easily lead 
 to errors in diagnosis. As far as I know, a dorsal point of tender- 
 ness has never been observed. In several cases I have noted a 
 circumscribed tender point to the right of the spinal column and 
 close to the twelfth dorsal vertebra. 
 
 2. Yomiting. — When the pain is severe and long continued it 
 may lead to vomiting, which is probably of a reflex nature. Strange 
 to say, there are only scanty allusions to this symptom in recent 
 literature. Oppenheimer found it noted 17 times in the cases (over 
 100) which he collected. 
 
 The accounts given by older authors (Albers^''', Mayer ^^) do 
 not agree with our experience of to-day. Krauss more correctly 
 observes (loc. cit., p. 59) : " In the clinical histories which I have 
 collected it [vomiting] is very seldom mentioned ; it depends either 
 upon stricture of the duodenum or is the result of cardialgia. In 
 a few cases only is it seen in connection with dyspeptic phenomena." 
 Starke ^^ and Boucquoy ^ make similar statements. My own experi- 
 ence, as far as it is possible to draw conclusions from a few observa- 
 tions, confirms their views. 
 
 The vomited matter has been variously described. In one ob- 
 servation reported by Reckmann ^, which in my opinion is open to 
 some criticism, the vomiting occurred in three installments — the 
 first pale and watery, the second bitter and sirupy (bile), and the 
 third a sweetish mass (blood).* 
 
 3. Intestinal Hemorrhage and HoBmatemesis. — Profuse hemor- 
 rhages from the stomach or rectum are a frequent symptom of 
 
 * See under head of the Examination of the Gastric Contents (in Special Part). 
 
286 DISEASES OF THE IXTESTINES 
 
 duodenal ulcer (perhaps in one third of all the cases — Krauss, Chvo- 
 stek, Oppenheimer). It is probable that this figure is too low, as 
 many of the smaller hemorrhages no doubt escape observation. 
 In 34 cases of hemorrhage which Oppenheimer found recorded, 
 vomiting of blood occurred 8 times, malsena 10 times, and both 
 hsematemesis and meleena 16 times. In all the severe cases symp- 
 toms of collapse follow the escape of blood by the mouth or the 
 bowel. When very copious the hemorrhage may be the imme- 
 diate cause of death. It is very characteristic of duodenal ulcer 
 that the intestinal hemorrhages recur at fixed intervals coincident 
 with other phenomena of the ulceration. 
 
 4.- The Comjposition of the Gastric Contents. — There are only a 
 few observations on record (von Leube ^'', Reckmann ^, A. Robin ^, 
 and Devic and Roux^~). In the first two there was a condition of 
 subacidity. In the last mentioned, a case accompanied by progres- 
 sive pernicious anaemia and profuse diarrhoea, there was hyper- 
 chlorhydria. The latter condition was present in one of my cases, 
 though it should be stated that the examination was made a long 
 time before the occurrence of the intestinal hemorrhages. Until 
 more observations have been accumulated, a differential diagnosis 
 on the basis of the results of examination of the gastric contents is 
 not permissible ; the same opinion is expressed by von Leube. In 
 three cases Robin found an entire absence of free hydrochloric acid, 
 but an abundance of organic acids. Unfortunately no details are 
 given as to the kind of test meal used, nor of the motor activity. 
 I^evertheless Robin's results are very remarkable. 
 
 5. There is nothing characteristic in the urine or the dejections. 
 
 6. Icterus. — The jaundice which has been observed in a few 
 cases (according to Collin, 9 out of 262) is not a specific sign of 
 ulcer of the small intestine ; it belongs rather to the complications 
 (see below). 
 
 Of all these symptoms, not one jper se enables the diagnosis to 
 be made with certainty or even probabihty. Only the ensemble, the 
 entire clinical history, the consideration of age and sex, is signifi- 
 cant or decisive. Taking into consideration all of these symptoms 
 (which are not often associated in a single case), and excluding all 
 other possibilities, the diagnosis of an ulcer of the small intestine 
 may be clinically made with some degree of cei'tainty. In this view 
 I agree with Chvostek, Boucquoy, and Burwinkel, but there are 
 many authors who are of a different opinion (von Leube, Ewald, 
 Eichhorst, Nothnagel, Collin). It is indeed pushing scepticism to 
 
ROUND ULCER OF THE DUODENUM 28Y 
 
 the limit to say, as does Collin in his otherwise admirable thesis, that 
 the diagnosis of duodenal ulcer intra vitam is impossible. 
 
 What I have just said will be illustrated by two positive, one 
 probable, and one doubtful eases of duodenal ulcer. 
 
 1. Secretary of Police R., of Berlin, comes from a healthy family, in which 
 haemophilia has never been observed. No history of any previous illness. Took 
 sick about twenty years ago (1876) with anaemia and tarry stools. Previous to 
 that time there had been gastric and intestinal disorders. The patient sub- 
 sequently recovered, and aside from temporary attacks of indigestion, was fairly 
 well until 1891. At this time, after having suffered from a sense of oppression 
 in the region of the stomach, he suddenly had several evacuations of very black 
 stools. The patient fainted at the time. For several weeks he was under treat- 
 ment at the Augusta Hospital. Following this there was a long period of good 
 health, although from time to time there were attacks of pressure in the um- 
 bilical region or in the pit of the stomach, and several small hemorrhages, to 
 which little notice was paid by the patient. Another severe hemorrhage oc- 
 curred in 1896, also with syncope. This, like the other, was recovered from. 
 In 1897, while under treatment at Carlsbad, he had a return of the bleeding, 
 which, however, did not last very long. From this time the patient never fully 
 recovered his health. He has almost constantly a feeling of pressure and weight 
 in the stomach and abdomen, not dependent upon the ingestion of food, and 
 suffers from frequent eructations which are sour, but never putrefactive. In 
 November, 1897, he had another severe hemorrhage. During the summer of 
 1898 he took the Wildungen cure for a catarrh of the bladder. In October, 
 1898, had tarry stools to a moderate extent, and in December, 1898, a severe 
 hemorrhage. These were always preceded by a sense of pressure, fulness in the 
 abdomen, and eructations of gas. 
 
 The patient does not remember ever having vomited or having liad severe 
 pains in the stomach or the intestines. The appetite has generally been good, 
 but diminished after the attacks. 
 
 Present condition (abstract) : Very anaemic — general nutrition much depre- 
 ciated. Organs of circulation and respiration normal. Heart sounds clear, 
 no adventitious sounds. Abdomen markedly relaxed ; the integument may be 
 raised in folds. Under suitable illumination the stomach is appreciable ; it is 
 apparently displaced downward, giving marked splashing sounds as far as three 
 fingers' breadth below the umbilicus. The other abdominal conditions are nor- 
 mal, and in particular there is no tenderness either in the region of the stomach 
 or duodenum. Examination of the urine shows it to be normal. 
 
 2. Oscar S., dealer in wood, Berlin, thirty-seven years old. The patient's 
 mother was a chronic sufferer from gastric disorders, and was extremely emaci- 
 ated when she died. His father is healthy. Since he was nine years old the 
 patient has suffered from digestive troubles. At the beginning he used to have 
 occasional pains in the gastric region, coming on without apparent cause and last- 
 ing a quarter to half an hour. His appetite was good and the bowels regular. 
 When he was almost thirty years old the pains increased, radiated toward the 
 right side, especially toward the back and to the right shoulder blade, and 
 became more frequent. They usually came on three to four hours after eating. 
 
288 DISEASES OP THE INTESTINES 
 
 occasionally 't\'hile fasting, and very often during the night. The sort of food 
 ingested made no essential difference, for the pain appeared equally after either 
 fluid or solid diet. Rest in the dorsal position alleviated the pains, while active 
 exercise increased them. There was never any vomiting. Appetite and bowels 
 were always in good condition. 
 
 Under suitable diet, rest, and the use of Carlsbad water, sometimes at the 
 Springs and sometimes in Berlin, his condition gradually improved. In Janu- 
 ary, 1896, he again began to have severe pains of the character described 
 above ; they extended backward and came on several hours after eating. He 
 always felt well immediately after eating. This attack was followed by a 
 slow improvement. In January, 1896, while travelling, he had a sudden pro- 
 fuse JiemorrTiage from the intestine. The blood was at first diluted and mixed 
 with faeces, but subsequently there was clear blood of coal-black colour. At 
 the same time there was extreme prostration, so that the man, who was of her- 
 culean build, was obliged to take to his bed and remain there for thirty-six 
 hours. He was treated by rest in bed, and poultices, and later drank Carlsbad 
 Mühlbrunnen. Improvement was rapid, and for a year and a half he was per- 
 fectly well. In October, 1897, the pains returned in the right side several hours 
 after eating, and were relieved by the ingestion of warm food. The treatment 
 for ulcer, carried out for several weeks, was again followed by improvement. 
 In the summer of 1898 he took the Carlsbad treatment with good results. 
 
 The examination of the gastric contents on two occasions showed marked 
 hyperacidity (HCl 0.28-1.35 per cent). Besides this, there was a characteristic 
 tender point in the prolongation of the right parasternal line. At the last 
 examination, November, 1898, the duodenal region was absolutely free from 
 tenderness. 
 
 3. Joseph L., bookkeeper, born in Poland, thirty-one years old. The 
 family history has nothing of interest. At the age of sixteen the patient had 
 typhoid fever, and at eighteen cholerine. Since he was nineteen years old he 
 has had gastric symptoms, which consisted in pressure in the pit of the stom- 
 ach, frequent eructations, and marked constipation. For the past seven or 
 eight years he has had hemorrhages from the intestines, as he says, every 
 spring and fall. These are preceded by sudden extreme weakness, nausea, 
 perspiration, and a desire to defecate. The first movement is free from blood, 
 but those which follow are intimately mixed with blood of a coal-black colour. 
 Has never vomited blood. During the past year there were four such hemor- 
 rhages. In consequence of the frequent losses of blood the patient has become 
 very angemic, and has not recovered from them as he used to. 
 
 From the notes taken when he w'as seen for the first time, only the follow- 
 ing need be quoted: Palpation of the abdomen shows that on the right side 
 above the umbilicus, about two fingers' breadth below the region of the gall 
 bladder, there is a decidedly tender point, while the corresponding area on the 
 left side is absolutely painless. The patient identifies this point as the seat 
 of his pain, which is pressing in character, but never colicky. Aside from 
 poikilocytosis, no changes are noted in the examination of the blood. 
 
 It is perhaps worth recording that a few ova of the trichina spiralis were 
 observed, but this probably has no bearing on the present illness. 
 
 4. Mr. v., member of the Board of Accounts of Gross Lichterfelde, near Ber- 
 
EOÜND ULCER OF THE DUODENUM 289 
 
 lin, forty-one years old. Well until December, 1897. Since then, without any 
 evident cause, he has had a sense of fulness a few hours after meals. An exam- 
 ination which I made at that time gave absolutely negative results. On January 
 6, 1898, he was suddenly taken with severe syncope and melsena. On January 
 7th the syncope was repeated. On January 8th, after drinking milk, there was 
 a slight vomiting of blood. Rectal feeding was resorted to. There was no 
 further hemorrhage. Gradual return to health. Spent three months partly in 
 the sanitarium and partly in the mountains. 
 
 He still has occasional pains on the right side of the median line, usually a 
 few hours after eating or after physical exertion. The painful area varies : 
 it may be more to the right or toward the median line, and may even 
 pass over to the left side. The pain is cut short by taking more food or 
 alkalies. There are times when there is no pain. Appetite good, bowels 
 confined. Exaynination shows that tJiere is no sensitive area over the stomach, 
 or to the right or the left of it, nor is there any dorsal tender point. 
 
 The symptoms of the first and second eases fulfil all the require- 
 ments for an exact diagnosis. The chronic course, the repeated 
 attacks of hemorrhage per rectum, and the absence of any special 
 dyspeptic symptoms, leave scarcely any doubt as to the nature of 
 the trouble. The diagnosis of the other two cases is more difficult. 
 In the third, the repeated attacks of melsena without any special 
 gastric symptoms, and the sensitiveness on pressure to the right of 
 the pylorus, make duodenal ulcer probable. Some of the other 
 characteristic symptoms, such as occasional pain significantly local- 
 ized, are absent, so that some doubt remains. 
 
 The fourth case can not be decided offhand with any certainty, 
 because the painful area is not fixed, the objective signs are absent, 
 and there is hsematemesis as well as melsena. The nature of the 
 pain, coming on several hours after eating, might equally well be 
 ascribed to hyperacidity. 
 
 Differential Diagnosis 
 
 It will be seen from the above histories, and still more so from 
 the autopsy records of cases of this class, that the differential diag- 
 nosis is often very diflicult, especially when there is neither hsema- 
 temesis nor melsena. In such cases many physicians prefer not to 
 commit themselves to a diagnosis or to attempt a differential diag- 
 nosis. I think this is going too far. If we were to wait for the 
 appearance of hemorrhage in gastric ulcer, at least 30 per cent of all 
 the cases would remain undiagnosticated, and therefore uncured. 
 
 In my opinion the greatest difiiculty lies in distinguishing ulcer 
 of the duodenum from gastric hyperacidity. Yery often both dis- 
 
290 DISEASES OF THE INTESTINES 
 
 eases give the same symptoms : pain several liours after eating, 
 relieved by the ingestion of food or alkalies, and localized at the 
 pylorus or in the duodenum. The 23ylorus and duodenal region 
 may be more or less sensitive to pressure in hyperacidity. I think 
 that when the latter cases do not imj)rove uj)on a diet suitable to 
 that condition, it would be well to begin treatment as for ulcer as 
 soon as possible. I have done so several times, with the result that 
 from that time on the patients were free from their discomforts. 
 Just as in gastric ulcer, von Leube's treatment has a certain value 
 for the differential diagnosis of doubtful cases, so, in long-estab- 
 lished cases of hyperacidity with symptoms suggestive of ulcer of 
 the duodenum I would recommend that the treatment for the latter 
 condition should be instituted experimentally. 
 
 As in gastric ulcer, the differential diagnosis between duode- 
 nal ulcer and irregular cholelithiasis, with or without icterus or 
 cholangitis, may be exceedingly difficult. Icterus as well as intes- 
 tinal hemorrhage are not uncommon in cholelithiasis. In his Clin- 
 ical Study of Cholelithiasis (p. 130 et seq.), to which we refer the 
 reader for further information, Naunyn has described the various 
 conditions in which the latter ajffection may be associated with intes- 
 tinal hemorrhage. From a differential diagnostic standpoint the 
 following must be noted : enlargement, tenderness, and tumefac- 
 tion of the liver, the presence of a decided sensitiveness on pressure 
 over the posterior surface of the liver (in the neighbourhood of the 
 twelfth dorsal vertebra), and sometimes an intermittent pyrexia. In 
 complicated cases it is difficult to avoid mistakes. 
 
 If the pains are atypical with frequent remissions and exacerba- 
 tions, a correct diagnosis is merely a matter of accident. As an 
 illustration of this I will give one of the numerous mistaken diag- 
 noses which appear in clinical records — that pubHshed by Had- 
 ham^. A painter suffered from severe colicky pains with free 
 vomiting, which, as his gums showed the lead line, were taken to 
 indicate lead colic. Autopsy revealed an ulcer with sharp cut mar- 
 gins on the anterior wall of the duodenum. Two similar obser- 
 vations have recently been reported by Alvazzi-Delfrate^*. 
 
 When there are intestinal hemorrhages, the chances for a cor- 
 rect diagnosis are more favourable.' The hemorrhage in itself is, 
 however, not pathognomonic. The diagnosis can only be safely 
 made when all the chnical symptoms are present, but even then 
 it is often exceedingly difficult to distinguish duodenal from gas- 
 tric ulcer. If we arrange the differential features in the order 
 
EOUND ULCER OF THE DUODENUM 291 
 
 of their value, age and sex must be given first importance. Ulcer 
 of the duodenum occurs with preponderating frequency during 
 the third and fourth decades, ulcer of the stomach during the 
 developmental age ; ulcer of the duodenum is vastly more frequent 
 in men than in women. In duodenal ulcer there is an absence of 
 special gastric symptoms, such as anorexia and vomiting ; ingestion 
 of food does not increase the pain, but diminishes it if present ; 
 the pain is localized and does not radiate ; hemorrhage per os when 
 present at all, is scanty in comparison with the melsena ; the hemor- 
 rhages are repeated extremely often, while in gastric ulcer they are 
 not so common. 
 
 Although the treatment of both kinds of nlcers and the thera- 
 peutic results obtained are the same, an attempt should be made to 
 distinguish between the two conditions, if possible, for, aside from 
 the danger of perforation, the prognosis of duodenal ulcer is 
 much more favourable than that of gastric ulcer, since the tend- 
 ency to stenosis or carcinomatous formation (see p. 293) is mark- 
 edly less. 
 
 Complications 
 
 Duodenal ulcer is noted for the remarkable number of its com- 
 plications. Either because of their frequency or on account of 
 the peculiar symptoms to which they give rise, some of these are of 
 practical importance. The most important is : 
 
 1. Perforative Peritonitis. — In Collin's collection of 262 cases 
 this was observed 181 times, or 69 per cent. The seat of the perfo- 
 ration — and this is of especial importance to the surgeon — like 
 that of gastric ulcer, is usually on the anterior wall. The rupture 
 may occur into the abdominal cavity and thus cause death by per- 
 forative peritonitis,* or else neighbouring organs — the liver, the 
 pancreas, the gall bladder, or colon — may be encroached upon. In 
 this way permanent adhesions or fistulous openings into the gall 
 bladder or the colon are formed, or there may be an erosion of 
 an important artery or vein and death from hemorrhage, or a sub- 
 phrenic abscess with pyopneumothorax, may result. 
 
 Furthermore, a duodenal ulcer on the anterior or posterior wall 
 may cause an abscess, and ultimately, by perforation of the abdomi- 
 nal wall, result in a duodenal fistula ; or the ulcer may rupture 
 
 * As has been shown by a case reported by Bardeleben (Virehow's Archiv, 
 vol. V, p. 2), the perforation need not always cause peritonitis. The fatal result 
 may come about just as rapidly from shock, collapse, or hemorrhage. 
 
292 DISEASES OP THE INTESTINES 
 
 into a cavitj walled off bv previous adhesions, which, increase until 
 the abscess is so encapsulated as to produce a plastic resisting mass. 
 I have seen a case which I believe to have been of this sort. 
 
 All these possibihties are founded upon more or less numerous 
 chnical observations described in the above-mentioned monographs 
 on duodenal ulcer. Since it would take too long to describe each 
 of them, the reader is referred to these authors for details. There 
 are no specific sjmjDtoms which indicate the site of the perfo- 
 ration. The answer is most decidedly in the negative. There 
 are accounts of operations (Bryant^, Brissaud ^®, Sheild^, Lock- 
 wood^, Lennander^) undertaken for supposed perforating appen- 
 dicitis, in which the autopsies showed that the cause lay in a 
 duodenal ulcer that had perforated. The error was usually due to 
 the fact that the chief painful point was located in the ileo-csecal 
 region. It is hardly necessary to call special attention to the cir- 
 cumstance that a diagnosis of perforation is open to all the mistakes 
 that may be made in the diagnosis of perforation of an ulcer in 
 any other part of the intestine (strangulation, etc.). 
 
 2. löterus. — Icterus is occasionally observed as a complication 
 of duodenal ulcer, although Collin could collect only 9 cases in 
 which it occurred. It begins as a true duodenitis, which involves 
 the papilla of Yater. Cases of this kind have been seen by so 
 competent an observer as Henoch, so that there is no good rea- 
 son for doubting them. The jaundice has the well-known char- 
 acter of the catarrhal form, except that it is transient and does 
 not cause enlargement of the liver. In a case reported by Krauss, 
 the cause of the icterus was inflammatory adhesion of the duode- 
 num to the gall bladder. Another form, moi-e easily accounted 
 for by what will shortly be described, occurs when the ulcer is located 
 in the descending portion of the duodenum. 
 
 On account of its infrequency, icterus is of scarcely any impor- 
 tance for diagnostic or differential diagnostic purposes. Except 
 under some favourable circumstances, it rarely throws any light 
 upon the clinical picture. 
 
 3. Formation, of Stenoses hy Cicatrization of the Ulcer. — In a 
 small number of cases the cicatrization of a duodenal ulcer leads to 
 stenosis and consecutive dilatation of the parts lying above it — that 
 is, of the stomach, or the corresponding portion of the duodenum. 
 As the ulcer is most frequently in that part of the duodenum adja- 
 cent to the stomach, it is in the latter organ that ectasia is most 
 often met with ; according to Collin, 18 times in 262 cases. Duo- 
 
ROUND ULCER OF THE DUODENUM 293 
 
 denal dilatation was observed only 4 times. The symptoms of this 
 condition will be considered in the chapter on Intestinal Stenosis. 
 Lastly, in rare cases, when the ulcer is located in the neighbour- 
 hood of the amjmlla of Yater, obliteration of the common bile 
 duct and permanent jaundice may follow. This complication will 
 make the diagnosis and the treatment veiy difficult. 
 
 4. Carcinomatous Ulcer of the Duodenum,. — Carcinomatous de- 
 generation of the ulcer seems to be rare. Altogether, but 4 cases 
 have been observed (Eichhorst ^^, Ewald ^^, Mackenzie^, Schrötter^'). 
 Unless it be that many cases are overlooked, this would constitute a 
 striking variance from the frequency of carcinomatous ulcer of the 
 stomach. 
 
 Treatment 
 
 The treatment of ulcer of the duodenum differs only in a few 
 points from that of ulcer of the stomach. For the details of the 
 latter I would refer to my Diagnosis and Treatment of Diseases of 
 the Stomach, Part II, third edition, page 55, and will limit what 
 follows to a brief sketch of the plan of treatment. 
 
 If hemorrhage set in, absolute rest in bed is the first require- 
 ment. The stomach should be put at rest, and for several days ali- 
 mentation carried on by the rectum. Following this, the most prom - 
 ising course is von Leube's rest-cure treatment for ten to fourteen 
 days, with the application of warm poultices, and a milk diet. After 
 the cessation of the pain the diet may be cautiously increased week 
 by week. Alkalies or Carlsbad water, bismuth or nitrate of silver, 
 may be useful as adjuvants. In very obstinate cases it is advisable 
 to give the stomach a rest by exclusive rectal feeding, under careful 
 supervision, for a week or a fortnight. Opiates can not be dis- 
 pensed with when the pain is severe. Long-continued physical 
 rest, careful diet, and the avoidance of alcohol and tobacco are to be 
 insisted upon. 
 
 When a cure is not obtained by palliative measures, and life 
 is threatened by continuous pain or profuse hemorrhages, when 
 there are symptoms of cicatricial stenoses not relieved by lavage, 
 or when there is perforative peritonitis or subphrenic abscess, sur- 
 gical procedures may be indicated. Owing to the analogy which 
 these indications bear to those that arise in ulcer of the stomach, 
 we refer the reader to the latest work of Mikulicz ^^. 
 
 Up to the present time experience in the surgery of duodenal 
 ulcer has been scanty. In one case Codivilla^ excised the ulcer 
 20 
 
294 DISEASES OF THE INTESTINES 
 
 by a gastro-enterotomv with good result. Lange ^ performed a 
 plastic operation on the pylorus in a ease of cicatricial stenosis from 
 duodenal ulcer, with equally good result. 
 
 Operations for perforative peritonitis have been successfully 
 performed in several quarters (Herczl^, Landerer and Glücks- 
 mann ^^, Wannach ^''^ ). In three cases reported by Lennander^ a 
 fatal termination occurred in spite of the operation. 
 
 In view of the absolutely hopeless prognosis of ulcer of the 
 duodenum after perforation, surgical intervention should be un- 
 dertaken as soon as possible — within ten to twelve hours at least 
 after the diagnosis is assured and the primary shock has been recov- 
 ered from. 
 
 Subphrenic pyopneumothorax or other abscess formations, are 
 treated according to the prevailing surgical methods. 
 
 LITERATURE 
 
 1. J. Krauss. Das perforirende Geschwür im Duodenum, Berlin, 1865. 
 
 2. Chvostek. Medicinische Jahrbücher, Wien, 1883, Heft 1, S. 1-58. 
 
 3. Boucquoy. Archives generales de medecine, 1887. 
 
 4. Oppenheimer. Das Ulcus pepticum duodenale. Inaug. -Dissert., Würz- 
 
 burg, 1891. 
 
 5. Beckmann, üeber Ulcus duodenale u. seine Diagnose. Inaug-Dissert., 
 
 Berlin, 1893. 
 
 6. Collin. Etude sur I'ulcere simple du duodenum. These de Paris, 1894. 
 
 7. Dickenson. Royal Med. and Chirurg. Society, January 9, 1894. 
 
 8. Perry and Shaw. Guy's Hosp. Rep., p. 171, 1894. 
 
 9. Marmaduke Sheild. Internat. Med. Magazine, vol. iii, No. 12, 1895. 
 
 10. Schulze. Beiträge z. Kenntniss des perforirenden Duodenalgeschwürs. 
 
 Inaug. -Dissert., Greifswald, 1873. 
 
 11. Brambillo. Cited from Virchow-Hirsch's Jahresber., 1882, Bd. ii, S. 168. 
 
 12. Pauly. Aerztliche Sachverständigen Zeitung, 1897. 
 
 13. L. Landau. Ueber Meläna. der Neugeborenen u. Bemerkungen über d. 
 
 Obliteration d. fötalen Wege. Breslau, 1874. 
 
 14. V. Mering. Verhandl. d. Congresses f. innere Medicin, 1893. 
 
 15. Moritz. Verhandl. d. 65 Versammlung d. Gesellsch. deutscher Natur- 
 
 forsche u. Aerzte in Nürnberg, 1893. 
 
 16. Burwinkel. Deutsche med. Wochenschr., 1898, No. 52. 
 
 17. Albers. Die Darmgeschwüre, 1831. 
 
 18. Mayer. Die Krankheiten des Zwölffingerdarmes, Düsseldorf, 1844. 
 
 19. Stärke. Deutsche Klinik, 1870. 
 
 20. V. Leube. Specielle Diagnose, 2te Aufl., S. 274. 
 
 21. A. Robin. Cited frorn Collin (reference No. 6). 
 
 22. Devic and Roux. Province medicale, 44^7, 1895. 
 
 23. Hadham. The Lancet, February 18, 1871. 
 
ROUND ULCER OF THE DUODENUM 295 
 
 24. Alvazzi-D elf rate. Gaz. med. di Torino, 1897, No. 7. Cited from Cen- 
 
 tralbl. f. innere Medicin, 1897, S. 845. 
 35. Bryant. Semaine medicale, 1893, p. 335. Cited from Collin (reference 
 
 No. 6). 
 
 26. Lockwood. Transact. Med. Soc, vol. xv, p. 91, 1895. Cited from review 
 
 in Centralbl. f. Chirurgie, 1895, No. 26. 
 
 27. Lennander. Ueber Appendicitis, 1895, S. 29. 
 
 28. Eichhorst. Schmidt's Jahrbücher, Bd. ccxx, S. 23. 
 
 29. C. A. Ewald. Berliner klin. Wochenschr., 1886, No. 32. 
 
 30. Mackenzie. St. Thomas Hosp. Rep., vol. xx, p. 341, 1892. 
 
 31. Schrötter. Aerztliche Bericht des k. k. Allgem. Krankenhauses zu Wien, 
 
 1887, S. 27. 
 
 32. Mikulicz. Mittheilungen a. d. Grenzgeb. d. Medicin \i. Chirurgie, 1897, 
 
 Bd. ii. 
 
 33. Codi villa. Sperimentale, Mem. orig., vol. xlvii, pp. 4 and 6. Cited from 
 
 Landerer u. Glücksmann (reference No. 36). 
 
 34. Lange. Annals of Surgery, vol. xxxvi, p. 2, 1893. 
 
 35. Herczl. Orvosi Hetilap, 1895, No. 50. Cited from Arch. f. Verdau- 
 
 ungskr., Bd. ii, S. 251. 
 
 36. Landerer u. Glücksmann. Mittheilungen a. d. Grenzgeb. d. Med. u, 
 
 Chirurgie, 1896, Bd. i, S. 168. 
 
 37. Wannach. Arch. f. klin. Chirurgie, 1898, Bd. Ivi, Heft 2. 
 
 38. Lennander. Mittheilungen a. d. Grenzgeb. d. Med. u, Chirurgie, 1898, 
 
 Bd. iv, Heft 1, S. 91. 
 
CHAPTEE Xyil 
 
 INTESTINAL NEOPLASMS 
 
 A. MALIGNANT NEOPLASMS OF THE INTESTINES 
 
 I. Carcinoma 
 
 Preliminary Remarks. — Malignant tumours of the intestines 
 are so very frequently carcinomatous that, in discussions relating to 
 malignant new growths, cancer is almost exclusively the tumour in 
 question. The other malignant tumours (sarcoma, lymphosarcoma), 
 however, will require brief consideration because of the well-marked 
 cHnical pictures they occasionally present. 
 
 Regarding the absolute and relative frequency of intestinal car- 
 cinoma, there are many extensive and instructive statistics. 
 
 A. Zemann^ found, in 21,624 autopsies performed at the Vienna 
 General Hospital, 2,070 neoplasms directly causing death, of which 
 number 1,744 were cancers — ^i. e., 84 per cent of all neoplasms. 
 
 Of these 1,744 cancer cases, 912 (52 per cent) were tumours of 
 the gastro-intestinal canal, the " canal " in this sense beginning at 
 the tongue and including the anal orifice. 
 
 The various portions of the gastro-intestinal tract were affected 
 in the following proportion : 
 
 Tongue 37 
 
 Pharynx 34 
 
 (Esophagus 136 
 
 Stomach 540* 
 
 Duodenum 3 
 
 Ileum 6 
 
 Caecum 12 
 
 Vermiform appendix 1 \- 165 
 
 Colon 32 
 
 Sigmoid flexure 30 
 
 Rectum 81 
 
 * I. e., 2.5 per cent of all the autopsies. 
 296 
 
INTESTINAL NEOPLASMS 29Y 
 
 In his excellent work on the intestines, ISTothnagel tabulates like 
 statistics derived from a study of similar material. George Hei- 
 mann^ has recently published extensive tables which are very useful 
 in the study of the pathology of the alimentary canal. During the 
 years 1895 and 1896, 20,054 patients died of cancer in the gen- 
 eral hospitals of Prussia, of whom 10,537 were cases of cancer of 
 the gastro-intestinal tract. The different portions of the canal were 
 affected as follows : 
 
 Tongue 269 
 
 Pharyngeal and buccal mucous membrane . . 192 
 
 (Esophagus 1,011 
 
 Stomach 4,288 
 
 Intestinal canal in toto 1,706 
 
 Of these, the rectum 1,204 
 
 Liver and gall bladder 979 
 
 Pancreas 92 
 
 Of the cases of cancer of the intestines (exclusive of the rectum), 
 20 involved the small intestine and 224 the large intestine ; 49 of 
 the latter affected the sigmoid flexure ; in 258 cases the portion af- 
 fected was not mentioned. 
 
 These statistics (which in the main agree with others) demon- 
 strate the relative infrequency of intestinal cancer as compared 
 with cancer of the stomach. The striking disparity in numbers 
 between cancer of the small and that of the large intestine, and 
 the overwhelming frequency of rectal cancer, are noteworthy. 
 Finally, these statistics prove the frequency of cancer of the sig- 
 moid flexure, l^ext in frequency to these are the carcinomata of 
 the colon (especially at the flexures), and last of all those of the 
 caecum. 
 
 Eegarding sex, authorities differ. Some believe that females 
 are of tener affected (Berard ^, Kokitansky ^, P. Kiipp *) while others 
 regard intestinal cancer as more frequent in males (MaydP, G. 
 Heimann '^). It is certain, however, that cancer of the rectum occurs 
 more frequently in men. 
 
 The age of the patient is an important consideration. Most cases 
 occur between the fourth and sixth decades. As Maydl ^ I^othnagel, 
 and G. Heimann ^ correctly pointed out, intestinal cancer quite fre- 
 quently occurs in even the earlier periods of life ; particularly is this 
 true of cancer of the rectum, many cases of which have been ob- 
 served in young people. In partial contrast to the above, sarcoma and 
 
298 DISEASES OF THE INTEST^ES 
 
 lymphosarcoma occur usuallj during the first to the fourth decades, 
 and only very infrequently in the fifth and sixth. Regarding fre- 
 quency^ sarcoma, in contrast to carcinoma, is oftener situated in the 
 small intestine than in the large. (Compare chapter on Sarcoma.) 
 
 It will hardly be necessary to discuss at length the etiology of 
 cancer and sarcoma, since, with the exception of the bacterial and 
 protozoan theories, nothing of importance has been brought to light. 
 On the other hand, histological investigations by modern investi- 
 gators, particularly Yirchow, Thiersch, Waldeyer, Häuser,* ßib- 
 bert, Hansemann, Lubarsch, and others, have proved more fruit- 
 ful. A full description of these as yet incomplete investigations 
 would lead too far, hence we will mention only a few pertinent 
 facts. In the great majority of cases intestinal cancer is a primary 
 affection, very rarely metastatic. The most frequent form is cylin- 
 drical epithelial. It originates, as do all other forms of intestinal 
 cancer, from the cylindrical epithelial cells, and shows most often a 
 glandular type (hence " carcinoma adenomatosum cylindro-epitheli- 
 ale," Häuser, loc. cit.). The second most frequent form is the 
 medullary (carcinoma medulläre), which shows a decided tendency 
 to break down and form ulcerations (intestinal hemorrhages). Some- 
 what less frequent (most often in the rectum) is colloid carcinoma. 
 In striking contrast to the stomach, true scirrhous cancer occurs 
 very rarely in the intestine, in most cases in the rectum. 
 
 The histological construction of the different types is not with- 
 out its clinical significance. The soft, medullary type of cancer 
 generally forms a diffuse tumour, while the scirrhous is a different 
 growth, infiltrating the intestinal walls and being occasionally quite 
 circumscribed. There are, however, exceptions to both these forms. 
 
 In its early stages cancer of the large intestine produces but 
 slight changes in the mucous membrane ; only later does the growth 
 show its special characteristics — propagation and tendency to ulcera- 
 tion. Another characteristic is its growth in a circular, girdlelike 
 fashion. Isolated nodules (at times of large size), or long, diffuse 
 infiltration, rarely occur. 
 
 From the two above-mentioned characteristics (viz., tendency 
 to ulceration and circular growth of the tumour) we have the 
 following two clinical conditions : A tendency to hemorrhage to 
 
 * Compare Hauser's interesting and critical description of the diiferent theories 
 of cancer in Das Cylinderepithel Careinom des Magens und Dickdarms, Jena, 
 1890, p. 109. 
 
INTESTINAL NEOPLASMS 299 
 
 purulent disintegration, even to separation of portions of the tumour 
 and the development of stenoses. These symptoms will later be 
 discussed at length. 
 
 Because of this tendency to ulcerate, superficial layers of the 
 bowel may be involved in this destructive process, and perfora- 
 tion may occur. The development of a stenosis, which may at 
 times cause complete obstruction, produces dilatation and muscu- 
 lar hypertrophy of that portion of the intestine above the stricture. 
 Through overaction in this dilated and hypertrophied portion nor- 
 mal propulsion of contents is maintained, until a disproportion 
 between the power of the hypertrophied wall and the resistance 
 offered occurs, and an intestinal paralysis (ileus paralyticus), or, 
 from extreme overexertion of the hypertrophied part, a rupture 
 of the intestine at its weakest point results. 
 
 The peculiar characteristic of cancer to form metastases by way 
 of the blood and lymph channels is also present in intestinal car- 
 cinoma. 
 
 The mesentery is supplied with lymphatics which lead to the 
 mesenteric glands, and hence the latter are the first to become 
 diseased, further metastatic involvement depending upon the site 
 of the tumour. Thus, according to Riipp ^, the lumbar glands are 
 involved in cancer of the sigmoid flexure of the colon ; the omental, 
 and later the prevertebral glands, in cancer of the transverse colon. 
 
 Metastatic carcinoma of the lymph nodes may cause secondary 
 intestinal obstruction, a condition which I have twice observed in 
 cancer of the uterus. Disseminated carcinosis of the peritoneum is 
 relatively frequent. 
 
 The observations of MaydP and Hausmann ''^, confirmed by 
 Rüpp ^, are of extreme surgical interest. They assert that metas- 
 tases are observed only late in intestinal carcinoma ; this is partic- 
 ularly true of cancer of the rectum. Iverson ^ cites 47 autop- 
 sies of rectal carcinoma, of which 21 were free from secondary 
 involvement of glandular organs; Kraske®, in 12 cases, found 
 metastases in only 6. 
 
 According to Häuser (loc. cit.), there is a connection between the 
 type of carcinoma and location and variety of the metastatic for- 
 mations. Thus colloid carcinoma very rarely causes secondary 
 involvement of internal organs (e. g., the liver), but frequently 
 secondarily involves the serosa, lymph glands, and bones. Large 
 medullary carcinoma produces metastases principally in the re- 
 gional lymph glands, while the small scirrhus may cause a large 
 
300 DISEASES OF THE INTESTINES 
 
 metastatic deposit in the liver. Besides the lymph channels, cancer 
 may also spread by way of the blood-vessels. Tumour masses may 
 erode the vascular wall (particularly of the veins), and thus infec- 
 tious material enters the blood stream. Since its tributaries are 
 directly in the intestines and are often connected with the ma- 
 lignant growth, the portal vein is especially prone to carry infec- 
 tion, For this reason the liver is often secondaiily involved, while 
 metastatic deposits in the lungs, uterus, and ovaries are rarer. 
 
 The tumour frequently becomes adherent to the neighbouring 
 organs. Such adhesions may lead to complications, but they are 
 favourable in so far as they prevent perforation. The most fre- 
 quent complications of this kind are adhesions to and fistulous com- 
 munication with the stomach, bladder, other portions of the intes- 
 tines, the abdominal wall, genitals, etc. 
 
 General Symptomatology and Diagnosis of Intestinal 
 Carcinoma 
 
 The symptoms of intestinal cancer vary so much according to 
 its location that it seems judicious to consider separately cancer of 
 the small intestines, the colon, and the rectum. A description of 
 sarcomatous and lymphosarcomatous diseases of the intestines will 
 be found in another chapter. 
 
 All cancers have certain general characteristics, which, although 
 of no special significance individually, collectively complete the 
 clinical picture of the disease. These are the history, the deport- 
 ment of the body weight, the condition of the urine and blood, the 
 occurrence of oedema of the ankles or of ascites, and, finally, the 
 presence of infiltrated lymph glands. 
 
 1. Hereditary disposition to carcinoma is perhaps of value. 
 Many striking examples of such a tendency have been described 
 (e. g., family of ISTapoleon I). Traumatisms received during recent 
 years should be noted in the history. 
 
 2. In obscure or atypical cases of intestinal cancer the hody 
 weight is of great importance, but is frequently not sufliciently 
 considered. My experience has taught me that patients weigh 
 themselves only when there has already been quite an apparent 
 loss of weight, perhaps even as much as 10 to 20 pounds. At this 
 stage, too, there is beginning cachexia. By weighing the patient 
 at regular intervals the physician niay often note the degenera- 
 tive character of the disease much earlier. If the appetite be 
 good and the condition of the upper portion of the alimentary 
 
INTESTINAL NEOPLASMS 301 
 
 canal normal, forced feeding may be tried ; if the patient then 
 lose in weight there is probably some obscure malignant disease 
 of the intestine, nsuallj a neoplasm present. The progressive loss 
 in weight should neither be over- nor underestimated, but re- 
 garded as a warning to examine the patient with greater care and 
 frequency in order to recognise the obscure condition as early as 
 possible. It must be remembered, however, that increase in weight 
 does not by any means exclude carcinoma. 
 
 3. The examination of the urine, particularly the finding of 
 indican and of Rosenbach's colouring matter may aid in making a 
 diagnosis. The diagnostic significance of these bodies has already 
 been dwelt upon (see page 132). Kast and Baas^^ attribute special 
 value to the presence of ethereal sulphuric acids in the urine as a 
 sign of intestinal putrefaction. This has occasionally been impor- 
 tant to surgeons in determining whether a stenotic obstruction was 
 successfully removed by operation or not. Eommeläre ^^ and others 
 drew attention to a lessened excretion of nitrogen by the urine in 
 carcinoma, but the investigations of F. Müller ^^ and G. Klem- 
 perer ^^ have shown this conclusion to be deceptive. 
 
 4. Examination of the Hood in cancer is of little diagnostic 
 value. There is a diminution in percentage of haemoglobin, accom- 
 panied by a corresponding decrease in the number of red blood-cells, 
 and of the specific gravity of the blood. " Digestion leucocytosis," 
 recently claimed by Schneyer^^ as diagnostic for cancer of the 
 stomach, has been disproved by later investigations. As yet we 
 have no reports regarding its occurrence in intestinal cancer. 
 
 F. Henry ^^ has lately called attention to the differentiation between 
 cancer of the stomach and pernicious anaemia by means of a count 
 of the blood-cells. He has pointed out that in cancer the number 
 of erythrocytes is never less than 1,500,000 per cubic millimetre, 
 while in pernicious anseraia it is almost invariably below 1,000,000. 
 
 5. The early occurrence and disappearance of oedema of the 
 ankles might, with a certain amount of reserve, be accepted as a 
 contributory sign to the diagnosis of a malignant disease. I can not 
 recall ever having seen it in any of my cases of intestinal cancer, 
 and can find no mention of it elsewhere in the literature of the sub- 
 ject (cf. Intestinal Sarcoma, p. 332). Ascites is, of course, one of 
 the most frequent accompanying symptoms of advanced cancer of 
 the intestines. Once, during an operation for cancer of the caecum, 
 I observed slight ascites, which, because of its small quantity, it 
 had been impossible to diagnosticate before operation. 
 
302 DISEASES OF THE INTESTINES 
 
 6. Markedly enlarged inguinal or supraclavicular glands may- 
 lend support to tlie diagnosis. Swelling of the latter group is 
 very rare, while enlargement of the inguinal glands, though fre- 
 quent, occurs under most varied conditions. At all events, exci- 
 sion and histological examination may aid the diagnosis. 
 
 (a) CANCER OF THE SMALL INTESTINE 
 
 For the clinical diagnosis of cancer of the small intestine it is 
 best to distinguish between cancer of the duodenum and that of 
 the jejunum and ileum. 
 
 1. Cancer of the Duodenum, 
 
 According to their relation to the papilla of Yater, these tumours 
 of the duodenum are conveniently subdivided into suprapapillary, 
 infrapapillary, and circumpapillary, 
 
 (o) Suprapapillary Cancer 
 
 The symptoms of suprapapillary cancer are not well defined, and 
 it is exceptional to arrive at even a probable diagnosis. Of some 
 value are the subjective symptomis produced by the marked disturb- 
 ance of gastric motility : the f eehng of the tension and pressure or 
 pain in the epigastric region, eructations, nausea and vomiting, loss 
 of appetite, constipation, oliguria, marked thirst, and a decided 
 feeling of illness and increased debility, sometimes sufficient to 
 confine the patient to bed. 
 
 Of the objective symptoms^ the earliest is the ])resence of a 
 tumour. This lies in the right hypochondrium, is hard and 
 uneven, painful on pressure, and is entirely immovable or only 
 slightly movable. 
 
 The second objective symptom is the presence of a supraduode- 
 nal dilatation, which naturally leads to enlargement of the stomach. 
 Here it will not be sufficient to diagnosticate simply anatomical 
 dilatation of the stomach, but by repeated examinations of the 
 stomach contents we must seek for proof of stagnation. As a re- 
 cently published case of Czygan^^ has shown, the examination of 
 the stomach contents for the presence or absence of hydrochloric 
 acid, for lactic and other organic acids, for sarcinse and yeast, 
 lactic-acid bacilli, ferments, etc., may be of aid to the diag- 
 nosis. In the above-mentioned case, besides a tumour in the right 
 hypochondrium and all other symptoms of cancer, there was 
 found (except a few days before death) normal hydrochloric-acid 
 
INTESTINAL NEOPLASMS 303 
 
 secretion in the dilated stomach. I found the same chemical con- 
 ditions in a case which I had under observation, and which, because 
 of the absence of tumour, was diagnosticated as a benign pyloric 
 stenosis. Laparotomy disclosed a tumour of the first portion of the 
 duodenum as the cause of the stenosis. 
 
 We must, however, not lay too much stress upon the results 
 of chemical examinations, since hydrochloric acid is often present 
 for a long time in carcinoma of the pylorus, and, owing to the 
 stagnation which results from proximity to the stomach, may be 
 absent and lactic present in duodenal cancer. 
 
 Czygan ^^ mentions another point of possible diagnostic value : 
 the presence of splashing sounds, particularly hetween the tumour 
 and the free border of the ribs. Upon emptying the stomach 
 these sounds disappeared, but, upon filling the organ, were again 
 observed, especially in the region above mentioned. 
 
 If an immovable or slightly movable tumour be felt in the right 
 hypochondrium, by careful consideration of the above criteria we 
 may venture upon the probable diagnosis of duodenal cancer, or, at 
 any rate, arrive at the differential diagnosis between this disease 
 and cancer of the pylorus. When no tumour is palpable, one can 
 diagnosticate the gastrectasis, and, under favourable circumstances, 
 the pyloric stenosis also. 
 
 iß) IXFRAPAPILLAKY CARCINOMA 
 
 Subjectively, infrapapillary carcinoma differs but little from 
 the above-described suprapapillary type, excepting in one very 
 marked symptom, viz., the vomiting of bile. When this occurs 
 constantly it should arouse suspicion of an infrapapillary ste- 
 nosis. 
 
 Objectively.— We again have an immovable tumour situated 
 in the right hypochondrium, more or less distant from the free 
 margin of the ribs, and painful on pressure. In addition there 
 is the bilious vomiting, from which Leichten stern ^'^ was the first 
 to estabhsh the diagnosis of carcinoma of the descending portion 
 of the duodenum.* Examination of the gastric contents will fre- 
 quently show the permanent presence of bile even before vomiting 
 occurs. 
 
 As a result of the stagnation of contents, dilatation of the 
 stomach may gradually be established, but because of frequent 
 
 * According to A. Pie, Chomel is said to have recognised and interpreted, as 
 early as 1853, continued bilious vomiting. 
 
304 DISEASES OF THE INTESTINES 
 
 vomiting, mild stenosis, and early lavage of the stomach may be 
 overlooked. 
 
 At present it is impossible to state whether the examination of 
 the gastric contents is of diagnostic or only contributory value. 
 In an exhaustive study of a case, Herz ^^ constantly found lactic acid 
 present and hydrochloric absent in the strongly bilious stomach con- 
 tents. The diagnosis of carcinoma of the stomach was made, but the 
 constant presence of biliary matter might have attracted attention 
 to the real seat of the lesion. Moreover, a tumour was not palpable. 
 The presence of the tumour will not always verify a probable 
 diagnosis. Thus, for example, Gerhardi^^, Hagenbach ^'', Wilms ^^, 
 and others have shown that it is absolutely impossible at times 
 to differentiate between infrapapillary carcinoma and tumours of 
 the head of the pancreas. Diseases of the gall bladder — e. g., 
 adhesions to the duodenum, compression by retroperitoneal glandu- 
 lar tumours, cicatricial strands following peritonitis, etc. — are con- 
 ditions too complicated for differentiation.* 
 
 In isolated cases the history and chnical course of the disease 
 are of some assistance. Previous melsena or haematemesis, signs of 
 cholelithiasis or of an old duodenal ulcer, glycosuria, or fatty stools, 
 may favour the one or the other diagnosis. Weecke^ has pointed 
 out that irritations or ulcerations of the walls of the common bile 
 duct by gallstones may produce duodenal cancer, particularly the 
 form next considered. 
 
 In the absence of tumour the diagnosis becomes quite uncer- 
 tain. In such cases the age of the patient, emaciation, oedemse, or 
 ascites may point to the correct diagnosis, although the absence 
 of severe general symptoms and the slow development of the dis- 
 ease may lead to a more optimistic conclusion. Such favourable 
 conditions are, however, rare. 
 
 y. ClRCUMPAPILLARY CARCINOMA 
 
 In this the neoplasm develops in the neighbourhood of the 
 papilla of Yater and compresses the bile duct. Whether in these 
 cases we have to do with primary carcinoma of the papilla, or, 
 as Pic^^ contends, with cancer of the pancreas, is certainly of scien- 
 tific interest; from a clinical (particularly a diagnostic) standpoint 
 
 * A case from Kussmaul's clinic, described by Cahn in 1886, was diagnosticated 
 as duodenal cancer on account of the presence of a palpable tumour and continu- 
 ous biliary vomiting. The autopsy showed a retroperitoneal lymphosarcoma com- 
 pressing the descending portion of the duodenum. 
 
INTESTINAL NEOPLASMS 305 
 
 this distinction is almost valueless. As discussion on this point is 
 foreign to the subject at issue, it will not be further considered, 
 and we shall at once proceed to the symptomatology of papillary 
 Carcinoma. 
 
 Subjective Symptoms, — These are of secondary importance, viz., 
 pain in the region of the stomach or liver, noncharacteristic but 
 not biliary vomiting, constipation or diarrhcBa, loss of appetite, and 
 progressive loss of strength. One or all of these symptoms may be 
 present, but they are of less value than the objective symptoms. 
 
 Objective Symptoms. — The main and most apparent symptom is 
 icterus. Bard and Pic ^ have shown, however, that icterus may be 
 entirely absent, and maintain that when a tumour and icterus are 
 present the carcinoma generally has its origin in the pancreas. On 
 the other hand, Lannois and Courmont^ have published several 
 cases of undoubted ampullary cancer with icterus. I myself have 
 made two similar observations. According to my experience, the 
 manner of development of the icterus is extremely important. As 
 in catarrhal icterus, this is sudden, and usually without pain, but 
 as Janicke has shown, severe attacks similar to gallstone colic may 
 exceptionally occur, obscuring the true clinical picture. The diflB- 
 culty of diagnosis is also illustrated by a case which I observed 
 of cholelithiasis with a large gallstone in the common bile duct. 
 The stone was passed without any pain, and the whole condition 
 was accompanied only by chronic icterus. Unless sudden inter- 
 current complications — e. g., marked cachexia, hsematemesis, me- 
 Isena, and irregular fever — indicate the correct diagnosis, it vdll be 
 impossible, therefore, in the first few days or weeks of the disease, 
 to make a differential diagnosis between simple icterus, cholelithia- 
 sis, and beginning carcinoma 
 
 The longer icterus continues, the more resistant is it to the 
 usual methods of treatment, and the sooner the general condition of 
 the patient suffers, the more probable will the diagnosis of a malig- 
 nant neoplasm become, particularly when the above-mentioned symp- 
 toms occur in middle-aged patients. In two cases of absolute ano- 
 rexia under my observation, the total absence of response to cus- 
 tomary therapeutic measures aided the diagnosis, because such ex- 
 treme obstinacy is not found in either duodenal icterus or chole- 
 lithiasis. We also meet with this extreme anorexia in hypertrophic 
 cirrhosis of the liver (which is otherwise sufficiently distinguished 
 from circumpapillary carcinoma), and especially in pancreatic carci- 
 noma, soon to be described. To my knowledge, no examination of 
 
306 DISEASES OF THE INTESTINES 
 
 the stomacli contents in cases of circumpapillaiy carcinoma liave 
 been published. In one of my cases, despite absolute anorexia, 
 there was no disturbance in the chemical or the motor functions 
 of the stomach. 
 
 In circumpapillary carcinoma the liver is usually not enlarged, 
 and the gall bladder is decreased in size. A tumour is rarely 
 palpable, but when present it is too deeply situated to be distinctly 
 outlined, l^aturally, as in the case described by Kernig ^, the pres- 
 ence of a tumour is of great aid to the diagnosis ; it may, however, 
 be misleading, for it may simulate primary cancer of the gall blad- 
 der or liver. If icterus be absent, even in the presence of a 
 tumour the diagnosis will be extremely difficult. It may be 
 very difficult to differentiate between carcinoma of the papilla 
 and of the pancreas. Bard and Pic^ have recently published 
 a set of symptoms which, recognised sufficiently early, is said to 
 render the diagnosis of cancer of the pancreas as easy as that 
 of cancer of the stomach. The symptoms are well-marked, 
 constantly increasing icterus, with enormous dilatation of the 
 gall bladder, rapid emaciation and cachexia, usually accompanied 
 by subnormal temperature and absence of appreciable enlarge- 
 ment of the liver. For excellent reasons, in which I fully 
 concur, Oser^ has behttled the significance of this clinical syn- 
 drome. 
 
 Only the presence of sugar in the urine (according to Mi- 
 rallie ^^ this occurs in 26 per cent of all carcinomata of the pancreas) 
 or of certain intestinal symptoms (bloody evacuations, hsematem- 
 esis, diarrhoeas) may point to the one or other condition in ques- 
 tion. None of these symptoms are absolutely diagnostic. 
 
 2. Carcinoma of the Jejumtm and Ileum 
 
 On account of its rarity and because, as stated by Treves ^, it 
 very seldom forms a palpable tumour, carcinoma of the jejunum and 
 ileum possesses but httle diagnostic interest. Unlike cancer of the 
 duodenum, tumours of this portion of the intestine are extremely 
 movable. This characteristic may make it difficult to differentiate 
 them from cancer of the large intestine, the difficulty naturally be- 
 coming greater the nearer the tumour is to the colon. As soon as 
 stenotic symptoms appear, however, jejunal carcinoma may be diag- 
 nosticated. Enterorrhagia, when present, may be of value in mak- 
 ing the diagnosis. 
 
 The subjective symptoms are very similar to those of duodenal 
 
INTESTINAL NEOPLASMS 307 
 
 carcinoma : colicky pains, increasing marasmus, anorexia, nausea, 
 vomiting, and constipation alone or alternating with diarrhcEa. 
 
 (])) CARCINOMA OF THE LARGE INTESTINE (EXCLUSIVE OF 
 
 THE RECTUM) 
 
 Although cancer of the small intestine, on account of its infre- 
 quency, possesses comparatively little clinical importance the case is 
 entirely different with cancer of the large intestine. In the latter, 
 not only is there a question of diagnosis per se, but also of the ear- 
 liest possible diagnosis, so that a radical surgical operation may be 
 performed. For such early diagnosis it is necessary to have in 
 mind not only classical cases, but also atypical, irregular forms of 
 the disease. 
 
 1. Typical Cases of Carcinoma of the Large Intestine 
 
 Symptomatology and Diagnosis 
 
 Subjective Symptoms. — The most important are intestinal pain, 
 vomiting, and disturbances of intestinal function. In concur- 
 rence with Riipp, we distinguish the fixed or tumour pain from 
 colic or other similar paroxysmal pains. In general, tumour pains 
 are dull and localized; in some instances, however, they may 
 radiate toward the back or the sides, toward the thorax, and, if 
 the tumour be deeply situated, toward the legs. When not pal- 
 pable, the site of the tumour cannot be determined by the locali- 
 zation of the pains. 
 
 The paroxysmal pains are of greater importance. Even in 
 typical cases their situation, nature, intensity, and duration are ex- 
 tremely variable. According to my experience, the situation of the 
 pain often points to the site of the tumour ; occasionally, however, 
 the pain radiates toward the umbilicus or over the whole abdomen. 
 The pain is colicky in character, with remissions and exacerbations ; 
 it is slight at its beginning, becomes exceedingly severe as it reaches 
 its acme, but soon decreases, to reappear after a longer or shorter 
 interval. In one of my cases the remissions lasted precisely ten 
 minutes, so that the patient, watch in hand, could exactly foretell 
 the next attack. In other cases the paroxysms continue much 
 longer, sometimes lasting for hours, with short remissions induced 
 by eructations, passing of flatus, or by vomiting. In patients with 
 complete stricture the pain is constant. Symptoms of ileus then de- 
 velop. Rüpp * states that the pain is increased directly before def- 
 
308 DISEASES OF THE INTESTINES 
 
 ecation, especially in stenosis of the lower colon and when purges 
 are given. 
 
 The picture is different in cancer of the lower bowel — i. e., from 
 the lower portion of the descending colon downward. Tenesmus 
 is prominent and characteristic. Since this constitutes one of the 
 main symptoms of rectal cancer, further discussion will be deferred 
 until the chapter on Carcinoma of the Rectum. 
 
 Constipation and vomiting are very intimately related to the 
 paroxysms of pain. Constipation stands in direct relation to the 
 pain : the severer the pain the longer the duration and the more 
 obstinate the constipation. After a satisfactory evacuation the pain 
 disappears ; when the colon is refilled with faeces, paroxysms recur. 
 If, in spite of fsecal movements, pain persists, we may be positive 
 that the evacuation was insufficient. 
 
 In the first stage of the disease we sometimes find diarrhoea 
 alternating with constipation, so that diarrhoea follows after several 
 days' constipation. In still other cases constipation is entirely ab- 
 sent ; from the very beginning diarrhoea of a nature later to be 
 described is present. 
 
 The clinical picture of disturbed intestinal function is com- 
 pleted by the appearance of vomiting. The vomiting varies accord- 
 ing to the degree of stenosis. It may consist of mucus, stom- 
 ach contents, or of feculent or faecal masses. The different types 
 of vomiting demonstrate the amount of obstruction. With Rüpp, 
 I think feculent vomiting, even in severe intestinal stenosis, is 
 the exception. I am inclined to believe that the vomiting of 
 mucus and of stomach contents is reflex in character, similar 
 to that associated with impacted stone, cardialgias, disease of the 
 genitals, etc. 
 
 In one of my cases of increasing symptoms of stenosis, haematem- 
 esis occurred directly before the operation. The patient fortunately 
 ■withstood the shock of the hemorrhage. This is an extremely rare 
 complication. 
 
 Leaving the last-mentioned symptom (hsematemesis) out of con- 
 sideration, there are three cardinal diagnostic symptoms, viz., ob- 
 stinate constipation or constipation followed by diarrhoea, colicky 
 paroxysms, and vomiting. Increasing experience has shown me 
 that, even mthout the presence of a j^alpable tumour, these three 
 symptoms frequently denote intestinal cancer. The frequency of 
 the attacks, the characteristic increase of the paroxysmal pain, 
 increasing constipation, the presence of unmistakable cachexia even 
 
INTESTINAL NEOPLASMS 309 
 
 in this stage, and marked loss of body weight, all point toward 
 the correct diagnosis. 
 
 The condition of the remainder of the alimentary canal, particu- 
 larly of the stomach, is of secondary importance. In discussing the 
 objective symptoms we will describe the results of examination 
 of stomach contents. Here we will only mention that, excepting 
 during attacks, gastric digestion and appetite may be absolutely 
 normal. If there be a long interval between the attacks of colic, 
 the patients may gain so much in weight as to mislead one. This 
 was particularly true of one of my own cases. In other patients 
 — ^namely, those with increasing stenosis — the appetite very rap- 
 idly diminishes. This occurs partly in consequence of the frequent 
 paroxysms of pain which rob the patient of sleep, and partly, ac- 
 cording to Koenig, in consequence of auto-intoxication from the 
 stagnant fsecal masses. 
 
 Objective Symptoms. — These are : tumour, meteorism, visible 
 intestinal peristalsis, the character of the feeces, and, in some cases, 
 the nature of the stomach contents. 
 
 The palpability of a tuTnour, which^ according to Treves^, occurs 
 in JfO per cent of all cases of cancer of the large intestine, constitutes 
 one of the most im,j)ortant and decisive diagnostic symptoms. 
 
 The size of the tu7nour varies considerably, from that of a wal- 
 nut to that of a fist, or even of a child's head. It is hard, nodular, 
 incompressible, and more or less painful on pressure. According 
 to all observers, its main characteristics are active mobility, and in 
 connection therewith, change of location and position. The fol- 
 lowing limitations, however, must be remembered : the mobility of 
 new growths of the large intestine is particularly well marked in 
 those portions which, because of their long mesentery, themselves 
 possess great mobility : these are the transverse colon with its 
 flexures, and the sigmoid flexure. The cgecum and the ascending 
 and descending colon, on account of anatomical peculiarities — 
 namely, their short, tense, retroperitoneal mesenteries — are not 
 nearly as mobile. Motion of the movable portions of the intestines 
 may be restricted by adhesions. Passive and active mobility is 
 increased by the weight and pressure of the stagnant intestinal 
 contents above the tumour. At times the tumour is covered by 
 distended intestine, so that it may be hardly palpable or disap- 
 pear entirely ; hence repeated examinations are necessary. This 
 condition is very similar to that met with in carcinoma of the 
 stomach, in which the tumour may not be felt when the stomach 
 21 
 
310 DISEASES OF THE INTESTINES 
 
 is full, but becomes palpable when that organ is empty. Another 
 possible source of error is that the intestines themselves fre- 
 quently change their positions, and thus the tumour may often 
 be falsely localized. This subject, which is of great surgical im- 
 portance, will be considered later. I shall now describe the gen- 
 eral principles to be followed in the examination of intestinal 
 tumours ; the technic has already been considered (page 84). 
 
 Tumours of the large intestine are best palpated when the bowel 
 is empty. When in doubt concerning the site of the tumour, or its 
 differentiation from neighbouring organs (stomach, omentum, kid- 
 ney, etc.), some aid may be derived from filling the intestines with 
 air or water. As already stated (page 85), moderate inflation 
 gives us much "better information regarding the topography of 
 the tumour and the position of the affected segment than ex- 
 treme inflation. The latter procedure has its dangers in ulcer- 
 ating tumours. In stenosing cancer of the lower portion of 
 the large intestine, the fact that air or water repeatedly intro- 
 duced always returns, may clear up an obscure diagnosis. Meteor- 
 ism is another very important diagnostic symptom. It may be 
 localized or general. When localized, it may enable us to de- 
 termine the site of the stenosis ; when general, the relations 
 between the viscera become uncertain and obliterated. These 
 symptoms are more thoroughly treated of in the chapter on Intes- 
 tinal Stenosis. 
 
 The occasional occurrence of msihle intestinal contractions (" in- 
 testinal rigidity," ISTothnagel) is of great diagnostic interest. These 
 contractions vary from a hardly noticeable rigidity of the intestinal 
 coils to a plastic representation of one or more of these, and appear 
 synchronously with the paroxysms of pain previously mentioned 
 (page 307). Like these, they vary greatly in duration and occur- 
 rence. If contractions follow at frequent and regular intervals, 
 their recognition is easy. If, on the contrary, they occur at long 
 intervals, as in the beginning of stenosis, unless clinically observed, 
 their recognition is mostly the result of accident. (See chapter on 
 Intestinal Stenosis.) 
 
 The macroscopic appearance of the fseces may be of importance ; 
 its value, however, is negative rather than positive. The faecal masses 
 are generally not as long nor as thick as in normal stools. The 
 stool is passed in small, pointed, narrow, or rounded masses. 
 These characteristics are particularly noticeable in the stool from 
 enemata. To this there are, however, many exceptions. I have 
 
INTESTmAL NEOPLASMS 311 
 
 seen an operated case of extreme stenosis from cancer of the caecum, 
 in which the cahbre of the stool ' was absolutely normal. After 
 passing the stenosis, the faeces must have become increased in cali- 
 bre through additions. 
 
 The diagnostic importance of the passing of blood per anum 
 has, I believe, been overestimated. In only 1 out of 11 cases of 
 cancer of tiie large intestine did I observe blood in fairly large 
 quantity. Slight losses of blood, usually overlooked, may occur 
 more frequently. Treves ^'^, who has had much experience in 
 these affections^ has found hemorrhage in but 15 per cent of pa- 
 tients with cancer of the colon. Eüpp^, in a series of 20 cases, has 
 found this symptom present in 25 per cent. 
 
 As already mentioned, the dejections may be diarrhoeal in char- 
 acter. This occurs not only in cancers of the lower segment of 
 the large intestine, but, as soon as marked ulceration begins, also 
 in those situated higher up. I have had two opportunities to 
 make regular examinations of such stools. They are mottled red 
 in appearance, and at times contain macroscopic, easily recognis- 
 able admixtures of pus, which sometimes forms as a yellow sedi- 
 ment, sharply contrasted with the remainder of the dejection. The 
 evacuations were very foul, and always of a distinctly alkaline reac- 
 tion. Besides red blood-corpuscles, microscopic examination showed 
 many pus cells in every field, giving the impression of an abscess. 
 There may be 8, 10, or 20 such dejections daily. Occasionally the 
 pus may not be so prominent, and the stools are more bloody in 
 character, but careful examination will always reveal pus in macro- 
 scopic or microscopic quantities. 
 
 As shown by cases of Potain ^^ and Wunderlich^, fragments 
 of the tumour may very rarely be passed per rectum, a fact which 
 will at once establish a positive diagnosis. In a case reported by 
 Nicolaysen ^^, there was prolapse of a carcinoma of the sigmoid 
 flexure. These cases, however, are so extremely infrequent that as 
 a rule they may be left out of diagnostic consideration. Despite 
 careful search — both in spontaneously evacuated stool and in 
 that after rectal irrigation — I have never found any tumour par- 
 ticles. ]^evertheless, in all obscure diseases of the intestines in 
 which blood and pus are present in the evacuations, I would advise 
 frequent rectal irrigations for this purpose (see page 87). 
 
 The examination of the stomach contents may sometimes give 
 facts of diagnostic importance. In cancer of the colon, as far as 
 I know, no such examinations have yet been made. In three 
 
312 DISEASES OP THE INTESTINES 
 
 patients in whom I made the tests, the gastric motihty was con- 
 stantly normah In one case there was absence, and in the two 
 others an abundance of hydrochloric acid. I lay particular stress 
 upon the maintenance of good gastric motility in cancer of the 
 colon, since this, as is well known, suffers quite early in cancer of 
 the stomach. 
 
 2. Atypical Cases of Carcinoma of the Large Intestine 
 
 There are many atypical cases in which the clinical picture of 
 cancer of the large bowel is obscured ; but, since their detailed 
 knowledge may enable us to make a probable diagnosis, they 
 must be considered. As in cancer of the stomach, there is 
 often an entire absence of characteristic symptoms : the patient 
 emaciates, loses appetite, presents indefinite dyspeptic symptoms 
 and continues to lose strength, and finally dies. Autopsy shows 
 an intestinal cancer. Such obscure cases occur in all segments 
 of the gas tro -intestinal canal. Surgical literature contains many 
 examples. 
 
 In a second and fairly large variety of cases there is sudden, 
 absolute intestinal obstruction with all its serious sequences. I 
 believe these cases are more easily diagnosticated. As early as 
 1864: Bamberger^ described one. After a meal consisting of 
 lentils, the patient, till then an apparently strong, healthy man 
 of forty, was suddenly attacked with severe abdominal pain, marked 
 tympanitis, constipation, and vomiting. Death occurred on the third 
 day. The autopsy showed a circular, carcinomatous stricture of 
 the sigmoid flexure with only moderate stenosis, but the intestine 
 above the tumour was entirely occluded by the undigested lentils. 
 Rüpp* has described a series of similar cases coming under his own 
 observation, characterized by acute intestinal occlusion from cherry 
 stones, bone splinters, inspissated fsecal masses, and apple seeds. 
 Yery acute intestinal obstruction may also result from adhesions 
 of the tumour to other intestinal coils, whereby kinking or twist- 
 ing of the bowel is produced. 
 
 As exemplified by a case of Eiipp, impacted gallstones in the 
 small intestine may cause the sudden appearance of acute symp- 
 toms of obstruction in a latent cancer of the large bowel. Such 
 instances might be further multiplied. Even without such direct 
 mechanical causes, symptoms of complete obstruction may (at 
 least according to the patient's own statement) be induced by 
 dietetic errors in healthy or rather, apparently healthy Individ- 
 
INTESTINAL NEOPLASMS 313 
 
 uals. These acute attacks of intestinal obstruction are doubt- 
 lessly preceded by preliminary symptoms wbicb are only slight, 
 and impress the patient but little. As far as the patient's 
 serious condition allows, the physician must inquire for symp- 
 toms which may have had the character of an incipient intes- 
 tinal stenosis. 
 
 Differential Diagnosis 
 
 Without doubt the presence of a well-defined tumour gener- 
 ally facilitates the diagnosis ; although even then error may be una- 
 voidable. 
 
 The question whether the tumour is a real neoplasm or only 
 impacted fseces, may sometimes produce the greatest diagnostic 
 difficulties. In the general division (page 76) we have described 
 the various methods by which mistakes may usually be avoided. 
 We have there stated that fsecal accumulations above the stenosis 
 may make a neoplasm appear much larger than it really is. 
 
 Tumours of the coecum^ beginning like appendicitis, with fever, 
 pain on pressure, and resistance in the ileo-csecal region, often lead 
 to diagnostic errors. But these tumours do not disappear when the 
 acute symptoms have passed ; they become larger and more nodu- 
 lar, the patient emaciates, and dies in extreme marasmus, or he 
 may succumb to symptoms of acute intestinal obstruction. Several 
 such cases have been described by Bamberger ^ and Krausshold ^. 
 Schede^''' has observed a medullary cancer superimposed upon an 
 old, irregular perityphlitis. On the other hand, Schede and Eiche- 
 lot and Hartmann ^^ have operated on cases in which, instead of 
 an expected cancer of the csecum, they found only inflammatory 
 perityphlitic products. These cases demonstrate that, even where 
 a tumour can be felt there may be difficulties. 
 
 If there be an intestinal tumour the further question of malig- 
 nancy or benignancy will have to be determined. Kegarding 
 benign tumours, fibromata and myomata of the intestines are 
 very rare, and only exceptionally produce the severe symptoms 
 of malignant growths. The differential diagnosis between sar- 
 comata of the large and small intestines may also have to be made. 
 It is discussed under the heading Symptomatology, to which the 
 reader is referred. 
 
 We have already discussed the interesting and frequent question 
 of differentiation between cancer and tuberculosis of the caecum 
 (p. 277). 
 
314 DISEASES OP THE INTESTINES 
 
 Besides the difficulties already mentioned, tumours of other or- 
 gans may give rise to errors in diagnosis. For example, von Berg- 
 mann ^^ once diagnosticated a tumour as cancer of the c£3cum ; on 
 operation it was found to be a cancer of the stomach adherent to 
 the right iliac fossa. Hahn^ reports a case of a yonng man of 
 nineteen with a nodular tumour in the right side which was thought 
 to be an enlarged kidney. Laparotomy (Simon's incision) showed 
 the right kidney normal and in normal position. Upon opening 
 the peritoneum there was found a tumour of the ileum and cgecum 
 the size of a child's head. Examination proved it to be a small 
 round-celled sarcoma. Czerny ^'^ and von Esmarch ^ report similar 
 errors. In a doubtful case in a woman, in which the diagnosis 
 rested between tumour of the csecum and floating kidney, Salzer ^^, 
 on vaginal examination, was able to differentiate by involuting the 
 soft layers between his fingers and the tumour; he could intro- 
 duce his fingers into the ileo-csecal opening from the small intes- 
 tinal side, and thereby recognised the neoplasm as one of the csecum. 
 These examples, particularly abundant in surgical literature, might 
 be multiplied. 
 
 The diagnostic difficulties are increased when tumours of the 
 intestine (generally the large intestine) are complicated by displace- 
 ment of the different intestinal segments. The obstacles are so 
 great that sometimes even an operation will not clear up the 
 cases. Thus, Passier^ reports a case from Curschmann's clinic 
 in which a carcinomatous stenosis of the hepatic flexure of the 
 colon was clinically diagnosticated. Autopsy revealed a carcinom- 
 atous degenerated csecum, which was situated high up under the 
 liver, and, owing to a congenital absence of the ascending colon, 
 communicated directly with the transverse colon. During an oper- 
 ation for carcinoma of the large intestine, Israel ^^ thought he was 
 dealing with the descending colon, while, in reality, he was oper- 
 ating upon a displaced transverse colon. 
 
 Many more examples might be mentioned. They should teach 
 us to be very cautious in diagnosticating the site of a neoplasm. 
 It may be necessary to differentiate between cancer of the lai'ge 
 intestine and chronic intussusception. The following symptoms 
 point to intussusception : sudden onset, passing of blood per rectum, 
 shape of the tuaiour (smooth, cylindrical) and its spontaneous mo- 
 tility, the age of the patient. None of these symptoms is pathog- 
 nomonic, and only by careful consideration of the separate data 
 can a mistake in diagnosis be avoided. Diagnostic difficulties may 
 
INTESTINAL NEOPLASMS 815 
 
 become considerable when a tumour can not be palpated, and when 
 the usual characteristic symptoms are absent. However, when 
 there is a good clinical picture a probable diagnosis can be made. 
 To begin with, it is necessary to establish the existence of an intes- 
 tinal stenosis. If the symptoms of the latter are well marked, 
 we may generally arrive at the correct diagnosis by exclusion. 
 Aside from subjective symptoms, it is necessary to keep in mind, 
 first of all, the appearance of visible intestinal peristalsis ; one 
 single coil of intestine discovered in the act of peristalsis and 
 rigidity may clear up an otherwise doubtful condition. For the 
 different symptoms which occur in the several varieties of intes- 
 tinal stenosis I refer the reader to the chapter on Intestinal Ste- 
 nosis. 
 
 If intestinal stenosis is absent as a symptom, the diagnosis is 
 only possible from the presence of other objective signs, particularly 
 blood and pus in the stools. As Nothnagel * states, the only other 
 disease besides cancer which can come into question when bloody, 
 purulent matter is found in the dejections, is chronic dysentery. 
 " Since dysentery is generally easily recognised, the importance of 
 this type of dejection in the symptomatology of intestinal cancer is 
 quite manifest." 
 
 The differentiation is not always easy, as the following example 
 will show : 
 
 Mr. A., merchant, thirty-nine years old, from Hanover. Parents and grand- 
 parents died at an advanced age ; has one brother alive and well. Had measles 
 when a child. When thirteen years old had malaria (probably tertian type) 
 for eight to nine weeks, later disappearing entirely. At twenty-four had hem- 
 orrhoids, which were successfully ligated. Otherwise the patient was well 
 until 1896. At that time he suffered with bowel complaint— frequent tenesmus 
 without evacuations, abdominal pain, alternating constipation and diarrhoea. 
 Blood or pus had not been observed in the stool. There was then no marked dis- 
 turbance of general health ; the patient was not confined to bed ; he was able to 
 attend to his business. Following the use of hot enemata the stools regained 
 their normal consistency, and remained regular until November, 1897. Patient 
 then for the first time noticed the occurrence of frequent painful rectal tenesmus. 
 The dejections were liquid, had a very bad odour, and were mixed with blood 
 and mucus. The tenesmus and number of dejections gradually increased. 
 Patient began to have fever; he emaciated and lost his previous good appetite. 
 I first saw him on February 10, 1898; the status pmsens was as follows: Ex- 
 tremely pale, emaciated man, of medium size and cachectic facies. No enlarged 
 glands, no cedema, no exanthema; tongue dry, clean, red; throat showed notli- 
 
 * Log. cit. (ref. 6), p. 236. 
 
316 DISEASES OF THE INTESTINES 
 
 ing special; thorax long and narrow, percussion note normal; vesicular breath- 
 ing present all over the lungs. Heart sounds normal ; heart of normal size. 
 Pulse of very low tension, small, somewhat irregular, 130 beats per minute. 
 Temperature, 36° to 37° C. 
 
 Abdomen. — The entire abdomen unequally distended. There is distention, 
 particularly localized below the umbilicus. Occasionally there are seen indica- 
 tions of intestinal peristalsis without rigidity, particularly in the ileo-cajcal 
 region. No tumour can be felt. Palpation of the ileo-caecal region is very 
 painful. Hepatic and splenic dulness entirely absent, being obscured by the 
 tympanitic intestinal percussion note. Slight splashing sounds in the epi- 
 gastrium. Rectal examination negative. Rise of temperature between 38° 
 and 39° C. 
 
 Since his stay in Berlin the patient has had continual rectal tenesmus. 
 There are 6 to 8 stools daily, consisting at first mainly of pus and blood, with 
 only a small amount of faecal matter ; they have a very foul and fetid odour. 
 Microscopical examination shows innumerable large and small pus cells and 
 blood cells. No amoebse. Repeated examinations for tubercle bacilli are nega- 
 tive. Pus in the stool continues during the course of the disease. 
 
 Urine contains a moderate amount of indican. Quantity of urine, 500 cubic 
 centimetres in 24 hours ; it is brownish-red and of high specific gravity. 
 
 The course of the disease was as follows : There was quite apparent loss 
 of strength ; at first fever, later temperature is normal or subnormal. Despite 
 this the pulse is always 130-130, and very small; tongue clean but dry; abso- 
 lute anorexia, troublesome thirst ; the main subjective symptom is tenesmus; 
 the main objective symptoms are meteorism, pain in the ileo-csecal region, 
 purulent dejections, as well as the patient's general septic condition (septic 
 intoxication). With symptoms of increasing marasmus and occasional somno- 
 lence, the patient died, February 36, 1898. 
 
 Autopsy^ February 37th, performed by Dr. Hans Kohn, of Berlin. Very 
 much emaciated corpse, presenting nothing special externally. Abdomen mod- 
 erately tympanitic. The thin abdominal walls coloured green. Upon opening 
 the abdomen all the intestines were found to be distended with gas, and were 
 all in normal position except the sigmoid flexure, which lay parallel with the 
 pubic bone until it reached the right iliac fossa, where it was slightly adherent. 
 It was also adherent to the anterior circumference of the pelvic outlet. The 
 omentum was almost entirely free from fat and wreathlike in shape, and also 
 adherent to the pelvic outlet. After the omentum is thrown back the gen- 
 eral intestinal serosa is moist and pale, excepting over the sigmoid, where 
 it is very dark red. Attempting to loosen and free the sigmoid, the whole 
 intestinal wall easily tears, disclosing an abscess cavity filled with pus and 
 about the size of a hen's egg. The walls of the cavity are mainly formed 
 by the sigmoid flexure, and partly by the anterior pelvic floor. It communi- 
 cates directly with the lumen of the bowel; the size of the communication can 
 not be positively determined because of the extremely brittle condition of the 
 intestinal wall. The dark discoloration of the intestinal serosa extends up- 
 ward to about the beginning of the descending colon, whence it gradually 
 becomes pale and disappears. With the excejjtion of the beginning of the 
 ascending colon, which is filled with faecal matter, the large intestine is 
 
INTESTINAL NEOPLASMS 317 
 
 found to be empty, or rather to contain only gas. The mucous membrane 
 of the descending colon is pale yellowish- white in colour, and is uniformly 
 covered with thick pus. In numerous places there are ulcerations, irregu- 
 lar in shape, with smooth edges, and extending to the muscularis. Above, 
 the ulcers may be followed into the middle of the transverse colon, where 
 they become smaller. The smallest are the size of lentils, the largest the 
 size of a 50-cent piece. They are not round, but irregularly shaped. Below, 
 the ulcers increase in size, and the mucous membrane becomes gradually more 
 deeply injected. In the sigmoid flexure the greater part of the mucous 
 membrane is destroyed. Here there are areas of eroded mucous membrane 
 about 1.3 centimetres long, 1 to 2 centimetres broad, and about 1 to 3 cen- 
 timetres thick. 
 
 As just stated, areas of mucous membrane and muscularis are entirely 
 destroyed. Between these the mucous membrane is covered by reddish-yellow 
 thick pus. These changes extend into the rectum. The mucous membrane 
 of the upper portion of the large intestine, and of the whole of the small intes- 
 tine, is anaemic. The small intestine contains only small quantities of semisolid 
 masses; the contents of the caecum are of normal consistency, formed, rich 
 in fat; but in the middle of the ascending colon the contents become semi- 
 solid. As already remarked, the intestines situated farther down are empty. 
 
 Isolated lymph nodes the size of lentils are found in the walls of the 
 lower segments of the large intestine. Some of the mesenteric glands are 
 swollen to the size of beans. There is no thrombosis of the blood-vessels 
 supplying the descending colon. 
 
 The liver is quite small and soft ; on section it is pale, reddish-yellow, and 
 cloudy; it contains no abscesses. 
 
 The spleen is somewhat enlarged, bluish-red, and soft. 
 
 The right kidney, normal in size, but soft and grayish-red on section ; very 
 cloudy. 
 
 The clinical diagnosis lay between carcinoma, tuberculosis of 
 the large intestine, and chronic dysentery. Since tubercle bacilli 
 were never found, and since other signs of tuberculosis were absent, 
 the diagnosis was limited to the two other possibilities — carcinoma 
 and dysentery. 
 
 In my opinion, an epicritical examination of the case presents 
 no possibility of a positive differentiation ; as against cancer it 
 might be maintained that a tumour was absent. But a tumour, if 
 present, would have been obscured by the marked abdominal dis- 
 tention. As regards the fever, that would have spoken as much for 
 the one as for the other condition. As to the age of the patient, 
 there is no special limit within which cancer may occur, particu- 
 larly cancer of the large intestine. Finally, the course of the 
 disease and its acute invasion spoke rather for than against a 
 malignant neoplasm. 
 
318 DISEASES OF THE INTESTINES 
 
 I miglit describe an analogous case, very similar tlirougliont 
 except that toward the end of life there developed to the right 
 of the bladder a tumour, whose diagnosis caused ex23ert clin- 
 icians, as well as myself, many difficulties. These difficulties 
 were increased by the fact that the patient dated his symptoms 
 some fifteen years back. Operation showed a sloughing carci- 
 noma of the sigmoid flexure, which had displaced the latter to 
 the right. 
 
 From these two cases it follows that, in the absence of a tumour, 
 the differential diagnosis between dysentery and carcinoma may 
 cause great difficulties, which, so far as I can see, cannot, in the 
 present state of medical knowledge, be overcome. 
 
 Finally, cancer is to be differentiated from the intestinal neu- 
 roses. I have observed two cases which for a long time presented 
 symptoms of nervous intestinal disturbance, and whose malignant 
 character was revealed only late in the disease. Both patients had 
 suffered for years from habitual constipation, and both were marked 
 hypochondriacs on the subject of defecation. Contrary to my own 
 opinion, and quite correctly, they looked upon their last complaint 
 as of a very serious nature. Brinton's excellent dictum regarding 
 cancer of the stomach is also true of cancer of the intestine : 
 " Obscure in its symptoms, frequent in its occurrence, fatal in its 
 events." 
 
 (c) CANCER OF THE RECTUM 
 
 Cancer of the rectum is recognised more easily than cancer of 
 any other portion of the intestines, and offers the most favourable 
 chances for cure. 
 
 Symptomatology and Diagnosis 
 
 It is best not to separate the subjective from the objective 
 symptoms, but to consider them together. The subjective symp- 
 toms relate to the disturbances of defecation, and at the beginning 
 they may be so indefinite that the patient may not seek medical 
 advice.* 
 
 Defecation is interfered with ; evacuation occurs only after strong 
 action of the abdominal muscles, and the stools have no longer the 
 normal cylindrical form, but are flattened and of small calibre. 
 
 * Occasionally apparently remote symptoms may point to the real source of 
 trouble — e. g., obstinate sciatica. 
 
INTESTINAL NEOPLASMS 319 
 
 They resemble sheep dung, and are often fragmentary. It thus 
 happens that patients have frequent daily evacuations, but each 
 time these are small, unsatisfactory, and are accompanied by very 
 much straining. Closely related therewith is a feeling of fulness, 
 weight, and pressure in the small pelvis, which always impels the 
 patient to attempt to evacuate his bowels. The resultant move- 
 ments, though small, afford temporary relief. 
 
 Gradually painful tenesmus develops, together with the increas- 
 ingly frequent and scanty dejections. These may remain formed, 
 but usually consist of thin fluid masses with an exceedingly nau- 
 seating, fetid odour. At this time the dejections may contain mu- 
 cus, blood, and pus. 
 
 As the disease progresses the symptoms of a stenosis of the 
 rectum become more marked ; tenesmus is continuous, or has 
 only short remissions. The stools become more numerous, more 
 liquid and less in quantity, and admixtures of pus, mucus, and 
 blood are more often found. The symptoms continue during the 
 night and cause insomnia. The appetite decreases perceptibly, 
 the general health begins to fail, and the patient begins to look 
 cachectic. 
 
 The objective examination consists, first and foremost, of a digi- 
 tal exploration' of the rectum, and then of an examination of the 
 evacuations. 
 
 At varying distances from the anus the examining finger en- 
 counters irregular, nodular, thickened masses which are immedi- 
 ately recognised as neoplasms. A more careful examination will 
 distinguish two types. In cancers situated high up^ the finger has 
 the feeling as if entering a hard, rigid cylinder, above and to the 
 sides of which is attached, as it were, a vaginal vault. Generally 
 the finger cannot pass any farther through this pseudo-vaginal 
 opening ; with a little force it may enter a narrow irregular cylin- 
 der. On withdrawing the finger there are traces of blood and a 
 characteristic fetid odour. 
 
 Kraske^ states that where the carcinoma is limited to the wall 
 of the rectum, and is not adherent to the surrounding tissues, one 
 may obtain the sensation of ballottement with the end of the finger. 
 I have found this symptom only once, but this infrequency is pre- 
 sumably due to the fact that I generally see cases in the more 
 advanced stages of the disease. 
 
 In cancer situated low down in the rectum there is usually no 
 marked invagination. The finger enters a stiff walled cavity which 
 
320 DISBASES OF THE INTESTINES 
 
 is sliarplj defined against the smooth mucous membrane, both above 
 and below. In other cases there are circular or semicircular tu- 
 mours, with protuberant, serrated (cockscomblike) edges which pro- 
 ject beyond the normal mucous membrane. 
 
 The diagnosis of the presence of cancer of the rectum is not 
 sufficient ; it is also necessary to know the extent of the tumour, its 
 mobility, and the presence or absence of complications. The ques- 
 tion of mobility is of the greatest surgical significance. According 
 to Kraske, the question of operation depends more on the mobility 
 of the growth than on its size. 
 
 The main complication is rupture into the neighbouring vis- 
 cera (bladder, genitals). We will not discuss the rarer complications 
 here. 
 
 In every case of rectal carcinoma the liver ought to be examined 
 as a matter of routine. Metastases occur most frequently in this 
 organ, a fact which is naturally of great importance in the question 
 of radical operation. Ordinarily the examination of the faeces is 
 unnecessary; but in doubtful tumours, or in those reached with 
 difficulty, such an examination may, as I maintain in opposition to 
 Hochenegg ^, clear up the clinical picture to a considerable extent. 
 The external appearance of the faeces may either be that of stenotic 
 stools (e. g., ribbonlike, spiral, short cylinders embedded in a thin, 
 apparently homogeneous, bloody, or purulent ground substance), 
 or they may consist entirely of fluid or semifluid masses, or, in ad- 
 vanced cases, of pus and blood. In cases not far advanced, where 
 the cancer is situated high up or where the differential diagnosis 
 lies between cancer and benign neoplasm, the abnormalities of the 
 faeces just described are of less significance than the demonstration 
 of small, microscopic admixtures of pus. 
 
 The diagnosis, therefore, will not be difficult in the majority of 
 cases, particularly to the physician who makes it a rule to examine 
 the rectum digitally not only in patients with symptoms referred 
 to the rectum, but in every case of intestinal disturbance. There 
 are, however, isolated instances in which there will exist doubt re- 
 garding the nature of the rectal affection. These necessitate a short 
 discussion on differential diagnosis. 
 
 DlFFEREKTIAL DIAGNOSIS 
 
 By careful and repeated rectal and vaginal examinations it is 
 very easy to differentiate tumours of the rectum from tumours of 
 the prostate or of the female genitals, pelvic abscesses, etc. Polypi 
 
INTESTINAL NEOPLASMS 321 
 
 of the rectum will only exceptionally cause diagnostic difficulties. 
 Owing to their extreme rarity, myomata of the rectum will scarcely 
 come up for consideration. Differentiation from rectal sarcoma 
 may give rise to error ; in contrast to cancer, the sarcomatous 
 tumour has a smooth surface and there is no tendency to ulcer- 
 ation. 
 
 It may be somewhat more difficult to distinguish between 
 fibrous syphilitic stricture of the rectum and carcinoma. We shall 
 more fully discuss the symptomatology of syphilitic stenosis of the 
 rectum in the chapter on Diseases of the Rectum, and therefore 
 limit ourselves here to a few brief remarks. 
 
 With Kraske, I believe that the differentiation is not difficult. 
 With reference to the diagnosis, Kraske says the following, which 
 corresponds with my own experience : " In syphilitic proctitis the 
 stenosis is produced by cicatrization and is a real stricture. The 
 difference between the two forms of stenosis is also very evident to 
 the examining finger. The syphilitic ulcerations never have the 
 hard, protuberant edges that are found in the carcinomatous. In 
 contrast to cancer, syphilitic ulcers are generally multiple, and are 
 separated from one another by areas of healthy or cicatrized mucous 
 membrane. The syphilitic infiltration begins mainly as a diffuse 
 process, while cancer is for a long time more circumscribed. This 
 last fact is particularly evident in the condition of the surrounding 
 tissues and organs. Syphilitic ulcerations very often produce peri- 
 proctitis, external abscesses, and fistulse which rupture externally, 
 while this very rarely occurs with cancer. In my own experience 
 it has never occurred. It is true that in cancer situated low down 
 there may occasionally be a rupture through the skin in the neigh- 
 bourhood of the anus, but the character of such an opening, par- 
 ticularly its infiltrated margin, will at once show that it is not a 
 fistula arising from a periproctitic abscess, but is a direct rupture 
 due to the growth of the cancer toward the surface." If we add 
 further that syphilitic stenosis is essentially chronic, is more fre- 
 quent in women than in men, is present much earlier in life than 
 cancer, we have sufficient facts to assist us in most cases. Where, 
 despite the above, diagnostic difficulties are encountered, there is 
 the final recourse to excision of a piece of the growth for examina- 
 tion. Even this may not give positive results. 
 
322 DISEASES OP THE INTESTINES 
 
 Complications of Intestinal Cancer 
 
 The most important complications are produced by the tumour 
 itself. As already mentioned (page 300), the tumour may become 
 adherent to the bladder, uterus, ovaries, stomach, etc. There may 
 be a discharge of fetid or fsecal matter through these organs. I have 
 seen two cases of rupture of cancer into the bladder with the rapid 
 development of a parulent cystitis with extremely feculent urine. 
 When rupture into the uterus or vagina takes place, fsecal masses 
 empty themselves through the genital cloaca. Where a communica- 
 tion between the stomach and large intestine is established the condi- 
 tion of lientery, known to the older writers, develops. In consequence 
 of such a fistula there is fsecal vomiting, and the passing of entirely 
 undigested food per anum. Rarely, carcinoma may rupture through 
 the abdominal wall. Finally, there may be a rupture of the carci- 
 noma into the retroperitoneal tissue, with the formation of fsecal 
 abscesses. The latter may cause a general septic peritonitis, or 
 may lead to abscesses pointing at different places — e. g., Pou- 
 part's ligament, the lumbar region, etc. The perforation, per se, 
 is practically the most important as well as the most significant 
 complication. This may occur very suddenly, without any warn- 
 ing, when the patient seems to be im23roving. In one case per- 
 foration occurred during the time the attendants were giving the 
 patient an enema of water. Straining at stool may c^use this un- 
 expected accident. 
 
 Finally, death may be caused by rarer complications, viz., aspi- 
 ration pneumonia, embolism and venous thrombosis, ursemia, metas- 
 tases in other organs, peritoneal carcinoma, terminal hemorrhage 
 of the intestine, stomach, etc. 
 
 Treatment of Intestinal Cancer 
 
 In the ordinary sense of the word a real cure of an intestinal 
 cancer does not exist. Under favourable conditions, to be later 
 more fully described, extirpation of the tumour may prolong life 
 for months, or years, but even in these cases a fatal termination 
 cannot be prevented. With but few exceptions, surgical inter- 
 ference is the best and most practical of all the palliative, life- 
 prolonging remedies. In most surgical operations there is un- 
 deniably a direct relation between the object to be gained and 
 the severity of the operation. He who risks much may occa- 
 
INTESTINAL NEOPLASMS 323 
 
 sionally expect a successful result even under unfavourable cir- 
 cumstances ; he who does not take such risks cannot reckon on 
 great results. 
 
 In hopeless cases we must limit ourselves to palliative treatment. 
 The various palliative measures depend upon the site of the tumour 
 and the clinical syndrome. 
 
 They consist in 
 
 1. Increasing the patient's strength. 
 
 2. Kemoval of the stenotic symptoms present in the great ma- 
 jority of cases. 
 
 3. When the last object is only partially accomplished or im- 
 possible, relief of the pain and other symptoms caused by the ste- 
 nosis. 
 
 4. Treatment and relief of complications. 
 
 It is quite apparent that the above division is somewhat sche- 
 matic, since the several symptoms may change or become interde- 
 pendent. For the better survey of the subject we shall, however, 
 adhere to this grouping. 
 
 1. In many cases the attempt to increase the strength and 
 nutrition succeeds even though temporarily. For apparent reasons 
 we are least successful in cancer of the small intestine, and most 
 successful in cancer of the rectum, while cancer of the large intes- 
 tine occupies a middle ground. 
 
 In cancer of the small intestine the diet is similar to that 
 in cancer of the stomach. It consists in the frequent adminis- 
 tration of small quantities of fluid or semisolid nourishment of 
 the highest caloric value. To stimulate the appetite we must 
 consider the wishes and peculiarities of the patient. We should 
 not hesitate to give patients such food as may refresh and please 
 them, provided it does not aggravate the intestinal lesion (von 
 Leyden). 
 
 The underlying principles have already been given (page 151), 
 and it will only be necessary to describe several minor details. 
 In carcinoma of the duodenum those foods are most appropriate 
 which, because of their physical character, allow of a large con- 
 centration of soluble nourishment. Milk, albumin, carbohydrates, 
 and fats, percentages of which may be increased at will, occupy the 
 first place. 
 
 The albumin may be increased in amount by the addition of 
 commercial albumin preparations ; the carbohydrates, by the addi- 
 tion of flour in any of its many well-known forms ; the fats, by 
 
324 DISEASES OF THE INTESTINES 
 
 addition of cream in amounts depending upon the tolerance of the 
 stomach and the degree of stenosis. Both the albumin and car- 
 bohydrates can be simultaneously increased by adding leguminous 
 flour. 
 
 The artificial albumin preparations, often tiresome in dyspeptic 
 conditions, may be alternated with natural egg albumen. Yege- 
 table, meat, and fish soups in their many combinations may be given 
 to satisfy the patient's desire for change of diet without producing 
 an appreciable diminution of the general nutrition. Solid meat and 
 fish preparations should be administered in their most easily digest- 
 ible forms, or had better be avoided altogether. Vegetables and 
 fruits, white bread, zwieback, sweetened crackers, all of which have 
 been finely divided or thoroughly cooked, may be allowed. Raw 
 fruits, vegetables, tubers, and similar articles are to be absolutely 
 forbidden. We shall return to this subject. 
 
 The food given to patients with cancer of the rectum and other 
 portions of the large intestine may be much more varied. As we 
 have already seen, the stomach functions may be absolutely normal in 
 these cases, and a similar normal condition may be assumed to exist 
 in the upper part of the intestinal canal. The diet must be of the 
 greatest caloric value, but the food need not necessarily be given in 
 small quantities and with frequent intervals. With the exceptions 
 soon to be stated the foods may be given in their natural form. 
 Meat, when minced, is often easily digested. Soups, particularly 
 when concentrated, are good though by no means absolutely neces- 
 sary forms of diet. The same may be said of milk, though strength- 
 ening the patient. Unfortunately milk is not always well borne ; 
 in such instances it may be tried in its various preparations (kefyr, 
 sour milk, koumyss, etc.). 
 
 Vegetables, lohich in their natural form are not finely divided, 
 must alvKtys he strained, so as to jprevent any possihle mechanical 
 obst/ruction of the luTuen of the intestine. 
 
 For this reason vegetables which cannot be mashed should be 
 absolutely excluded ; in fact, I regard it as a distinct therapeutical 
 error to allow patients Avith intestinal stenosis to eat unstrained len- 
 tils, peas, beans, asparagus, raw fruit, cabbage, etc. This same is 
 true, possibly more so, when applied to raw compotes, or such as are 
 not rendered fully pultaceous, or compotes and fruit containing 
 small seeds. As shown above, the patients may pay for such in- 
 discretions with their lives. 
 
 2. Next to abundant nourishment, the physician must try to 
 
INTESTINAL NEOPLASMS 325 
 
 induce increased intestinal peristalsis, brought about, if possible, 
 bj dietetic means. We have fully described this in the General 
 Division (see page 151, etc.). 
 
 To a certain degree diet may remove the symptoms due to the 
 stenosis. The underlying dietary principles have already been con- 
 sidered in the General Division, and in the chapter on Intestinal 
 Stenosis. The functional disturbances from intestinal cancer re- 
 quire great caution, for to the putrefaction produced by the stenosis 
 there is often added that resulting from the intestinal ulcerations. 
 Thus, instead of the normal contents, the bowel contains a fetid 
 mixture, uninfluenced by intra-intestinal medication. It is advis- 
 able to get rid of this putrescent material as soon as possible by 
 lavage of the stomach in cancer of the upper intestinal segments, 
 and by appropriate laxatives when the cancer is in the lower seg- 
 ments of the intestine. 
 
 3. When the above measures fail to relieve the symptoms of 
 stenosis, the use of narcotics is oftentimes unavoidable. We must 
 again refer the reader to the chapter on Intestinal Stenosis and to 
 the General Division. 
 
 In the operative treatinent of intestinal carcinoma the following 
 indications are particularly to be considered : 
 
 1. Extirpation of the tumour. 
 
 2. The removal of stenotic symptoms. 
 
 3. Relief of intestinal obstruction which may develop during 
 the course of the disease. 
 
 Before discussing the indications, we must briefly narrate the 
 results of intestinal surgery, as found in the numerous clinical and 
 statistical reports. 
 
 The medical practitioner, even though thoroughly acquainted 
 with the various phases of the disease, will rarely have an extensive 
 personal experience therevdth. Hence, notwithstanding the well- 
 known and oft-repeated fact that statistics are not always complete 
 or reliable, it is necessary for him to study statistical reports. 
 
 In the first place, the results of operations for cancer vary 
 with the kind of operation. According to Wölfler *^, the latest 
 statistics on intestinal resection for new growths give the high 
 mortality of 54 per cent, while the entire mortality of intestinal 
 resections for all causes is only 39.5 per cent. As pointed out by 
 many writers (Mikuhcz and others), this mortality is influenced 
 by the nature of the disease. In this connection it is worthy of 
 notice that better technic shows no improvement in results. In 
 22 
 
326 DISEASES OP THE INTESTINES 
 
 1890 Billrotli^ reported a mortality of 50 per cent; Czerny^^, a 
 similar mortality in 1892. Nicolaysen ^ gathered together 121 cases 
 from literature, with a mortality of 48 per cent. My own expe- 
 rience is limited to 8 operations for cancer of the large intestine 
 (csecum, 5 ; hepatic flexure, 2 ; sigmoid flexure, 1), of which 3 
 were resected. One case, cured by resection, is now alive, four 
 years since operation ; 2 died several days after operation ; intes- 
 tinal anastomosis was performed in 2 cases (they lived eight or 
 nine months) ; in 2, enterostomy (colostomy) was performed during 
 an attack of acute intestinal obstruction ; in another, exploratory 
 laparotomy. 
 
 The chances for a permanent cure after resection, are evidently 
 more favourable in intestinal than in gastric cancer, because the 
 former has a lesser tendency to metastasis. Wölfler reports a 
 case of a man operated on for cancer of the sigmoid flexure in 
 1879 who was still well in 1896. Riipp* reports a case of a 
 patient from Krönlein's clinic, who after nine years had had no 
 relapse. From reports kindly sent me by Prof. Körte, of Berlin, I 
 learned that an almost hopeless case of cancer of the caecum had 
 been operated on and had now been well over nine years. There 
 are many other similar accounts of patients operated on for cancer 
 of the large intestine who remained cured for a number of years 
 (Billroth, König, Czerny, Wölfler, and others). 
 
 The results from incomplete enterostomy (the entero-anasto- 
 mosis of Maisonneuve) are much more favourable. Wölfler*''' 
 cites statistics of Schloffer, which show that in 4Y cases of intes- 
 tinal stenosis the mortality from this operation was only 30 per 
 cent. The duration of the cure seems on the whole to be favour- 
 able. In one case of Körte* (cancer of the splenic flexure) the 
 patient lived three and a quarter years after entero-anastomosis ; 
 he died finally of metastatic cancer of the liver. The result in 
 these cases is to be judged by the degree of restoration of function. 
 Unfortunately there are only a few useful reports in this connection. 
 In the two cases I have mentioned above the results were not satis- 
 factory. The patients gained in weight, although the intestinal 
 pains were in no wise decreased. In one of the cases evidences 
 of intestinal stenosis reappeared after a time. 
 
 The results of operative treatment of rectal cancer require 
 special mention. We distinguish the following methods : 
 
 * Personal report. 
 
INTESTINAL NEOPLASMS 327 
 
 1. Extirpation of the rectum by the perineal method, practised 
 in rectal tumours situated low down. 
 
 2. Extirpation by the sacral method, first introduced by Kraske^ 
 for rectal cancer situated high up ; the operation has been improved 
 by the further modifications of Hochenegg^^, v. Heinecke ^^, W. 
 Levy^^, Schlange^, [Bardenheuer] and others, 
 
 3. The vaginal method recently introduced by Eehn ^^ for the 
 removal of rectal cancer in women. 
 
 There are a number of statistics regarding the results from the 
 first of the above-mentioned surgical procedures. We limit our- 
 selves to the very extensive statistics from Czerny's clinic ^^, which 
 have the advantages of presenting the results of only one individual, 
 of covering a long period of time, and of including both methods 
 of operation. From 18Y8 to 1891 152 cases of rectal cancer came 
 under observation, of which number radical operation was per- 
 formed in 109, 21 were curetted, 12 were inoperable, and colotomy 
 was performed in 8. Of 83 cases operated by the perineal method, 
 3 died immediately (that is, 3.6 per cent). Of 66 cases operated on 
 by the sacral method, 9 died (13.61: per cent). The total mortality 
 of the 109 cases was 10, or 9.1 per cent. Of 99 patients radically 
 operated on, 21 lived two years or more ; 15 lived three years or 
 more ; 8, five years and over ; 1, eighteen years ; another, sixteen 
 years ; others, thirteen and three quarters, eleven and a half, eight 
 and three quarters, and six and three quarters years. The frequency 
 of recurrence after extirpation is very variously estimated by the 
 different authors. The percentage ranges between 41.6 per cent 
 (Kraske) and 73.3 per cent (Lövinsohn). According to Czerny^''^ 
 these figures underestimate the facts ; he claims that 20 to 25 per 
 cent of radically operated cases remain free from recurrence for 
 over two years, and that the majority of these remain permanently 
 cured. The danger of recurrence is diminished by the sacral method 
 of operation, since by this procedure the lymph nodes in the sacral 
 fossa can also be removed. But the value of extirpation of the 
 rectum is also determined by the functional results obtained. Un- 
 fortunately, there are not sufficient statistics in this connection to 
 permit of proper judgment. The functional results depend upon 
 whether the sphincter ani must be sacrificed or not. When the 
 sphincter can be saved the functional result is satisfactory, even 
 though the sphincter rarely contracts as well as the normal. When 
 the sphincter has been sacrificed, the condition of the patients is 
 extremely unfortunate, since they have absolutely no control over 
 
328 DISEASES OF THE INTESTINES 
 
 the flatus or fluid stools. Solid faeces can usually be controlled by 
 tlie formation of an elastic obstruction near the former third 
 sphincter, the rectum being then daily irrigated. 
 
 Regarding extirpation of the tumour, whether of the small in- 
 testine, colon, or rectum, the operation must be radically performed 
 in those cases in which the tumour is well circumscribed and mov- 
 able, and where no metastases are found. 
 
 As is well known, apparently favourable cases may, when 
 laparotomized, present evidences of metastases, ascites, and peri- 
 toneal carcinoma — conditions which make radical operation illu- 
 sory. When an early diagnosis has been made, it is inadvisable to 
 delay operation, for, aside from favourable local conditions, resec- 
 tion of the intestine requires endurance and strength on the part 
 of the patient. Unfortunately, the absence of these qualities fre- 
 quently renders radical operation impossible. 
 
 The second indication for operation is increasing stenosis. In 
 these cases a radical operation cannot be performed, either because 
 adhesions make the removal of the tumour very difiicult, or metas- 
 tases are already present, or the weakened condition of the patient 
 does not allow of a severe operation. In cancer of the small intes- 
 tine gastro-enterostomy or entero-anastomosis comes in question ; 
 in cancer of the large intestine (including the sigmoid flexure), 
 entero-anastomosis or colostomy ; while in cancer of the rectum 
 only colostomy. In rectal cancer some surgeons advise scraping or 
 electrolytic removal of the stenosing tumour masses, but others of 
 experience (among them Kraske and Czerny) advise against such 
 procedures. 
 
 When there is danger of intestinal obstruction or when it is 
 already present, enterostomy or colostomy is generally indicated. 
 
 Finally, regarding extirpation of rectal cancer, the indications to 
 operate are influenced more by the mobility of the tumour than by 
 its extent. In many cases examination under narcosis is necessary 
 to decide the question of operahility and the character of the sur- 
 gical procedure to be used. In all obscure cases it is best for the 
 medical practitioner and surgeon to consult, and together determine 
 the mo.de of operation. 
 
 The experienced medical practitioner can generally recognise 
 inoperable cases of cancer of the rectum ; the extensive, rigid, fis- 
 sured, ulcerated, absolutely immovable neoplasm leaves no room for 
 indecision. In these cases we must decide whether a colostomy is 
 
INTESTINAL NEOPLASMS 329 
 
 to be performed, or whether the patients are to be left to their 
 fate. The decision is by no means an easy one ; each individual 
 case must be carefully considered, not only respecting the condition 
 of the rectum, but also the personality of the individual. Consid- 
 ering the unfavourable cosmetic result, some surgeons strongly 
 advise against colostomy, and only resort to the operation vrhen an 
 almost complete stenosis is present. 
 
 Kraske^ says : " It is horrible, even for a person of phlegmatic 
 temperament, to witness daily the misery caused by tbe involuntary 
 evacuation of faeces, and to know besides that a progressive and 
 fatal disease is present." Frequently, however, patients are satis- 
 fied witb their condition after operation. 
 
 II. Sarcoma and Lymphosarcoma of the Intestine 
 
 According to Kundrat ^, the best authority on these neoplasms, 
 sarcoma and lymphosarcoma belong to the rarer intestinal tumours. 
 Out of the large material of the Vienna General Hospital, he could 
 collect only 3 sarcomata and 9 lymphosarcomata of the intestine 
 between the years 1882 and 1893. 
 
 Regarding the localization of sarcoma, l^othnagel * voices the 
 general opinion when he states that the majority of cases are found 
 in the small intestine, and only extremely rarely are they in the 
 large intestine. f This view is correct if we exclude the i*ectum, 
 where sarcomata are found as frequently as in the upper part of 
 the intestinal canal. This conclusion is drawn from the careful 
 work of Fr. Krüger ^^, who has tabulated all the known cases of 
 intestinal sarcoma reported up to the year 1894 — altogether 37. 
 These tumours were distributed as follows : 
 
 Small intestine 16 
 
 Ileum and caecum 1 
 
 Caecum 1 (2) :{: 
 
 Yermiforra appendix 1 
 
 Transverse colon 1 
 
 Small and large intestine 1 
 
 Rectum 16 
 
 * Loc. eit., p. 250. 
 
 f [Libman, American Journal of the Medical Sciences, September, 1900. p. 309, 
 publishes an interesting report of four cases with detailed discussion of the clinical 
 and histological aspects of sarcoma of the small intestine, together with an exten- 
 sive reference to the literature of the subject. — Tr.] 
 
 X A case reported by Carrington (cited by Baltzer, Archiv für klin. Chir., vol. 
 xliv, p. 744) has here escaped notice. 
 
330 DISEASES OF THE TNTESTINES 
 
 The ages of the patients were as follows : 
 
 3 cases in the first decade. 
 
 3 
 
 (( 
 
 
 second 
 
 6 
 
 u 
 
 
 third 
 
 .0 
 
 ii 
 
 
 fourth 
 
 5 
 
 u 
 
 
 fifth 
 
 6 
 
 ii 
 
 
 sixth 
 
 4 
 
 ii 
 
 
 seventh 
 
 If we may judge from these rather few statistics, we see 
 that the first decades by no means furnish so large a majority 
 of the cases as is commonly believed. Furthermore, in contrast 
 to cancer, the proportion of the male and female cases is striking 
 (31 : 6). 
 
 Regarding the type of intestinal sarcoma, all possible forms 
 may be observed — hard and soft, small and large spindle-celled, 
 small and large round-celled, alveolar and medullary, melano- and 
 cystosarcoma (Krüger). The round- and spindle-celled forms* 
 are the most frequent. They generally originate in the submucosa, 
 extending inwardly to the tunica propria and outwardly to the mus- 
 cularis. Some forms originate in the subserosa, and sj^read inwardly 
 from here. 
 
 The sarcomatous tumour is usually smooth and its size va.ries. 
 It is often enormous. At different places it presents softened 
 areas. It is not particularly painful, is frequently movable, and, in 
 contrast to cancer, is distinguished by its rapid growth. 
 
 Zy?njyhosareomata probably originate from the lymphatic sys- 
 tem of the intestines. As already indicated by the difference of 
 their development, the changes produced in the intestinal canal by 
 sarcomata and lymphosarcomata are quite different from those of 
 cancer. 
 
 In cancer there is a circular, relatively well-defined area of dis- 
 ease ; in sarcoma and lymphosarcoma the affected area is extensive 
 and indefinite. As a result of this circular form of the cancerous 
 tumour a stenosis results. In sarcoma, however, as pointed out by 
 Treves, and later also by Baltzer^ and Madelung^, there is almost 
 always more or less demonstrable stretching and dilatation of the 
 intestinal luinen. As demonstrated by Bessel-Hagen ^^ in a case he 
 
 * For further histological details I would refer to the text-books on pathological 
 anatomy ; also particularly to the article by Ackermann, Die Histogenesis und His- 
 tologie der Sarcome, Yolkmann's Samml. klin. Vorträge, pp. 233, 234. 
 
INTESTINAL NEOPLASMS 331 
 
 reported, the dilatation may become enormous. Sarcoma is much 
 more apt to form metastases than is cancer, but, on the whole, this 
 occurs late in the disease. Lymphosarcoma, on the other hand, 
 seems to attack only the surrounding lymph glands. 
 
 The question of the relation between tuberculosis and lympho- 
 sarcomata is a peculiar one and has recently caused lively discussion. 
 The observations of A. Müller ^^, Clans'^, Kicker^, Nothnagel,^ 
 Dietrich ^^, and Rud. Schmidt ^^, point to the possible coincidence of 
 tuberculosis and lymphosarcomatosis. 
 
 Hereditary tuberculosis is sometimes found in the family his- 
 tory. A direct connection between the two diseases seems to be 
 excluded ; still there is much in favour of the theory advanced, par- 
 ticularly by Rudolf Schmidt, that there probably exist hereditary 
 constitutional tendencies — that is, a sort of lessened power of resist- 
 ance of the entire lymphatic system. 
 
 The duration of intestinal sarcoma is shorter than that of can- 
 cer ; most patients die within one year of cachexia, metastases, etc. 
 
 Symptomatology, Diagnosis, and Differential Diagnosis 
 
 The suhjecti've symptoms of sarcoma of the small intestine pre- 
 sent but few characteristic features. They consist in diffuse ab- 
 dominal pain, nausea, vomiting (oftentimes said to be bilious m 
 character), and marked irregularity of the bowels — obstinate consti- 
 pation alternating with profuse diarrhoea. Where constipation 
 alone was present, complications were always found (invagination 
 or intestinal displacements). The most important objective symp- 
 toms are the tumour, intestinal symptoms, and rapidly developed 
 debility. In contrast to cancer the tumour is smooth, and often 
 softened areas are to be felt ; it is well defined and easily mova- 
 ble. Several cases have been reported (Madelung) in which there 
 was evident growth of the tumour within a few days. 
 
 As is apparent from the above, the absence of the symptoms of 
 stenosis is a characteristic of great diagnostic importance ; visible 
 intestinal peristalsis and intestinal impactions are also absent. On 
 the other hand, the extensive growth of the sarcoma may cause 
 severe intestinal paralysis. 
 
 To judge from a review of the histories of reported cases, the 
 absence of intestinal hemorrhage is of some diagnostic significance, 
 since this symptom is rather frequent in cancer. The very rapidly 
 
 * Loc. cit., p. 253. 
 
332 DISEASES OF THE INTESTINES 
 
 developed cachexia is a striking symptom ; it may become extreme 
 within a few weeks or months. 
 
 Other symptoms of possible diagnostic value are temporary 
 (Edema of the ankles, the early occurrence of ascites, and occa- 
 sionally an irregular fever (up to 39.5° C. in a case of Madelung's). 
 I find oedema of the ankles mentioned as a symptom in six of 
 Krüger's^^ cases. 
 
 The recognition of lymphosarcoma is very difficult, for, as 
 shown by a study of the cases published, its symptoms may be 
 quite different from those of sarcoma. Two examples of this are 
 reported from Neusser's cHnic in the above-mentioned work of 
 Rudolf Schmidt ^^. Despite the greatest care, a correct diagnosis 
 was not made. It is worthy of note that in the first of these two 
 patients attacks of painful colic, inaugurated by distressing intestinal 
 contraction and very loud borborygmi, were present. The diag- 
 nosis lay between intestinal sarcoma and cancer. The autopsj 
 showed a stenosis, which, however, was not produced by the neo- 
 plasm, but by adhesions of two sarcomatous degenerated coils of 
 intestine. In the second case, complicated by tuberculosis of the 
 pulmonary apices, the clinical picture was that of peritoneal tuber- 
 culosis. (Edema was present in both instances. 
 
 Naturally the presence of a tumour is indispensable for the 
 diagnosfs ; a tumour in the second case might have made diagnosis 
 possible. The above coincidence of pulmonary tuberculosis and 
 lymphosarcoma shows the importance of a careful history. When 
 a characteristic tumour is present, the diagnosis of sarcoma of the 
 small intestine presents no insurmountable difficulties, particu- 
 larly when the age, rapid development, and absence of stenotic 
 symptoms are taken into consideration.* When a well-defined 
 tumour is absent a correct diagnosis is only accidental, although 
 the course of the disease may justify the diagnosis of a malignant 
 affection. 
 
 When tuberculosis is present or suspected, particularly when 
 
 * [Even in a young person presenting a tumour the diagnosis is by no means 
 always possible. Two of Libman's cases (loe. cit.) very closely simulated appendi- 
 citis. In the one, M. G., age 18 years, there was a history of only one day's stand- 
 ing, with such acute symptoms that the case was thought to be a perforated appen- 
 dicitis. In a third case the diagnosis lay between sarcoma of the kidney, tubercu- 
 lar peritonitis, and sarcoma of the peritoneum, with possible primary tumour of 
 the intestine. It must be remembered, too, that cancer of the intestine is by no 
 means rarely met with in young individuals (see p. 297).— Tr.] 
 
INTESTINAL NEOPLASMS 333 
 
 a serous effusion is present, the diagnosis will often lie between 
 peritoneal tuberculosis and an obscure abdominal tumour (cancer, 
 sarcoma, lymphosarcoma). The coincidence of tuberculosis and 
 lymphosarcoma has already been mentioned. 
 
 Treatment 
 
 The treatment of intestinal sarcoma and lymphosarcoma is 
 not different from that of cancer ; we therefore refer to the sec- 
 tion on the therapy of intestinal cancer. Occasionally special symp- 
 toms (e. g., diarrhoea) require treatment other than that given under 
 cancer. 
 
 As shown by the observations of MicheP^, Gilford*^, Hahn^, 
 Engstrom™, and others, surgical treatment may at times be suc- 
 cessful, even though the sarcoma be situated in the upper seg- 
 ments of the intestinal canal. Favourable results are, however, 
 much more frequent in sarcoma of the rectum. Recurrences 
 generally occur sooner and more extensively than in intestinal 
 cancer. 
 
 Where operation is contraindicated, the systematic subcutaneous 
 injections of arsenic, according to the method of von Ziemssen'^^, 
 have given favourable results both upon the symptoms and the 
 general condition of the patient. 
 
 B. BENIGN NEOPLASMS OF THE INTESTINAL CANAL 
 
 Benign tumours of the intestine are extremely rare. Some 
 possess no clinical interest, since they produce no symptoms during 
 life. Others, however, are of greater importance from a diagnos- 
 tic, therapeutic, and especially from a prognostic standpoint. It 
 thus becomes necessary to describe these tumours. 
 
 Benign intestinal neoplasms include adenoma, lipoma, fibroma, 
 myoma, and myxoma. In some cases we have mixed tumours ; 
 sometimes there are combinations of malignant and benign tumours 
 (myosarcoma, fibro-sarcoma, myxosarcoma, adeno-carcinoma, etc.). 
 
 I. Adenomata and Polypi 
 
 The adenomata generally originate in the glands of Lieberkühn 
 and have a glandular structure. They occur on the mucous mem- 
 brane either as sessile or pedunculated growths (polypi) ; they may 
 be either isolated or multiple ; their size varies from that of a pea 
 to a fist. They are found in all parts of the intestinal canal, but 
 
334 DISEASES OF THE INTESTINES 
 
 their favourite seat is tlie rectum. They occur at different ages, 
 but the first years of Hfe contribute by far the largest number 
 of examples. In some cases these polypi are the starting points 
 for the development of malignant growths (sarcoma and cancer). 
 Their transition into tuberculosis has been described by Prochow- 
 nick'''^. 
 
 Multiple polypi of the rectum and large intestine present a par- 
 ticularly important type of adenomata. According to the observa- 
 tions of Luschka '^ Whitehead ^^ Häuser '^ Schwab''«, Port"", Holt- 
 mann"^, and others, they form tumours of various sizes which some- 
 times extend along the entire length of the large intestine from 
 the rectum to the iieo-csecal valve. Häuser and Port have shown 
 that they may even extend into the small intestine and the pyloric 
 orifice of the stomach. The interest in these cases lies particularly 
 in the severe bleedings which they cause, and in their tendency to 
 carcinomatous degeneration (Helferich — Port"", Bardenheuer ''^^, 
 Smith ^°, Handford ^^, Paget ^^, Hutchinson ^^, Makins^^, Häuser ''^, 
 Holtmann ''^). A very striking fact is a certain hereditary predispo- 
 sition, which was observed in no less than 4 of the 13 cases gathered 
 by Port. In view of the relatively small number of these cases, 
 I deem it proper to report one which I had under observation 
 several years ago. 
 
 Polyposis recti et coli ; partial extirpation of the polypoid masses ; death from 
 peritonitis. 
 
 Mrs. P. G., age 36, working woman. As a girl the patient suffered from 
 malaria, pneumonia, and pleurisy. Has had. five children ; severe metrorrha- 
 gia with the last. The beginning of the present illness dates back seven or eight 
 years. She then complained of marked tenesmus, and even then the stools 
 were always bloody. These symptoms ceased, for months, during which time 
 she felt well. The periods of remission became shorter from year to year, and 
 latterly her symptoms have remained constant. 
 
 Patient has about 20 evacuations a day, which are passed as follows : First, 
 "bloody water" with mucus is passed ; then normal, thin, or semisolid faeces ; 
 finally, often a large quantity of blood mixed with mucus. At times there are 
 absolutely no faeces in the evacuations. For several years, at the end of each 
 evacuation a nodule was protruded from the anus ; this finally fell off ; it 
 looked "as if composed of small growths." After this patient felt better 
 for a few days, except for the tenesmus and the hemorrhages. The general 
 condition of the patient is only very slightly disturbed. 
 
 Status Prmsens. — Anaemic woman ; normal circulatory and respiratory organs ; 
 ptosis and atony of the stomach ; displaced right kidney ; no other abdominal 
 irregularity on palpation ; intestines not sensitive to pressure. On rectal 
 examination there were found grapelike masses as large as peas or beans, which 
 
INTESTINAL NEOPLASMS 
 
 335 
 
 consisted of broad-based excrescences ; about 20 of these were easily removed 
 by the examining finger. After rectal lavage, blood and several pea-sized 
 polypi were found in the wash water. Microscojiical examination shows dis- 
 tinct adenomatous structure. Upon severe straining a deep-red tumour, about 
 the size of an ostrich egg, protruded itself. It consisted of numerous large 
 and small polypi, and of several hemorrhoidal nodules. 
 
 Since extirpation (see Fig. 30) of the rectum seemed impossible, the mass 
 was partially removed on July 35, 1893. During the operation the peritoneum 
 was opened. Death from peritonitis three days later. Autopsy showed that 
 the entire length of the large intestine was carpeted, as it were, with innu- 
 merable large and small polypi. 
 
 Adenomata, particularly of the rectum, are easily diagnosti- 
 cated, especially, when the protrusion of one or two polypi, as so 
 frequently happens, allows of a direct 
 macroscopic and microscopic examina- 
 tion. 
 
 Of the siibjeGtive symptoms hemor- 
 rhage and tenesmus particularly neces- 
 sitate a digital examination. If the 
 patient strains during such examina- 
 tion, the finger may draw down a sin- 
 gle or more often multiple polypi out 
 of the anus ; these may then be care- 
 fully tied and cut oif and their struc- 
 ture immediately studied. 
 
 Even when the tumours are situated 
 higher up, their recognition is not very 
 diflScult ; the soft consistency, the well- 
 defined limits, the pedicle, the absence 
 of ulcerations, particularly the sharp 
 localization of the process, are unmis- 
 takable. However, the fact that ma- 
 lignant processes may develop upon the 
 bases of such polypoid growths, of 
 which I myself have observed two in- 
 stances, must warn the physician to be guarded in the prognosis 
 If multiple rectal polypi are present we must suspect further exten 
 sion of the growths into the intestinal canal. 
 
 Fig. 30. — Multiple Polypi of the 
 Eectum. (Personal observation.) 
 
 II. Lipoma, Myoma 
 
 Lipoma is more frequent than myoma. There are scarcely two 
 dozen clinically observed cases of myoma, but since the advance of 
 
336 DISEASES OP THE INTESTINES 
 
 surgery the eases of intestinal myoma reported seem to have mate- 
 rially increased. The remaining benign intestinal tumours (angi- 
 oma, myxoma, teratoma, and others) possess as yet no clinical sig- 
 nificance. 
 
 Lipomata generally originate in the submucosa, their most fre- 
 quent seat being the large intestine and rectum. Their size varies 
 considerably ; generally, however, they are of an appreciable size 
 (up to that of a child's head). They occur either isolated or mul- 
 tiple. The diagnosis of lipoma is only possible vt^hen they are situ- 
 ated in the rectum and produce symptoms. In other cases where 
 no tumour is felt either by vaginal or abdominal examination, a 
 definite diagnosis is impossible. Occasionally expulsion of the 
 lipoma (Castelain^, Albrecht^, Link^, Paci^^, etc.) has revealed 
 the cause of the symptoms. 
 
 Myomata of the intestinal canal arise partly from the mucosa 
 and submucosa, partly from the subserosa. Following Yirchow, 
 those from the mucosa and submucosa are known as internal, and 
 those from the subserosa as external myomata. Steiner ^"^^ who has 
 made an exhaustive analysis of benign neoplasms of the gastro- 
 intestinal canal, reported 19 cases of internal and 15 of external 
 myomata. The tumour is usually situated in the small intestine, 
 and only exceptionally in the large intestine (inclusive of the rec- 
 tum). The duodenum is very rarely affected. Myomata vary 
 very much in size ; they may be as small as cherries or as large as 
 a man's head. As regards the age at which myomata may occur, 
 they are by no means limited to young individuals ; cases have 
 been reported in persons forty, fifty, and even eighty years of age. 
 
 Only when there is a definite tumour can the symptomatology 
 and diagnosis of myomata be considered. Such palpable tumours 
 are found in but a limited number of cases, but even then the 
 diagnosis will be made in very exceptional instances. The diagnosis 
 will be possible in internal myomata, when certain complemental 
 symptoms or complications which tend to clear up the clinical pic- 
 ture are present. Among these we might mention the develop- 
 ment of a more or less complete invagination, which, according to 
 Steiner, was observed no less than Y times in 18 cases. In a case of 
 this nature described by Fleiner ^, in view of the chronic course of 
 the disease, of the variation of the patient's condition from good to 
 bad, etc., the diagnosis of myoma was made with a fair degree of 
 probability. Besides an invagination, the gradual development of 
 an intestinal stenosis or an obstruction is of great diagnostic signifi- 
 
INTESTINAL NEOPLASMS 337 
 
 cance ; in such cases, days, weeks, months, or even years of abso- 
 lutely good health may intervene. 
 
 The symptoms of external myoiriata are only rarely sharply 
 defined. Evidences of stenosis may be present, thus making the 
 connection between the neoplasm and the intestinal canal more 
 probable. Complete obstruction by kinking, incarcerations, or 
 volvulus, appears to be still more infrequent. In several in- 
 stances the intestinal contents were bloody, and contained nmch 
 mucus. Death from profuse hemorrhages from the bowel has also 
 been described. 
 
 According to Steiner ^^ the following data indicate external 
 myomata : The presence of a slowly growing, intraperitoneal (some- 
 times also retroperitoneal) tumour, hard and nodular on its sur- 
 face, and having no connection with the genital organs ; passive 
 movements of this tumour cause dragging pain in the abdomen ; 
 there may be symptoms of an obstruction of the intestinal lumen, 
 and finally intestinal hemorrhages. 
 
 Despite these data we shall hardly be able to diagnosticate other 
 than the presence of an intestinal neoplasm of unknown nature. 
 
 Myomata of the rectum require a brief mention. According 
 to Steiner, only 6 cases have been observed. Here also we dis- 
 tinguish between the external and internal myomata. The symp- 
 tomatology of the former is quite similar to that of pedunculated 
 polypi — passing of blood and mucus, tenesmus, and, when of large 
 size, evidences of rectal stricture. The diagnosis of myoma recti 
 may be made when by rectal (and vaginal) examination a rather 
 smooth, movable tumour, with a more or less thick pedicle attached 
 to the mucous membrane is felt. 
 
 The clinical picture of external rectal myomata is much less 
 characteristic. When they reach considerable size they compress 
 the pelvic organs and become adherent to the latter. The only re- 
 maining diagnostic data are the occurrence of rectal hemorrhages 
 and the obstruction to evacuations. It would also be of diagnostic 
 importance to demonstrate that the tumour is not connected with 
 the genital organs. 
 
 Treatment 
 
 ISTo matter in what portion of the intestinal canal the benign 
 tumour may be found, internal treatment can be of little benefit. 
 We shall have to limit ourselves to the treatment of the symptoms 
 — pain, stenosis, enterorrhagia, etc. 
 
338 DISEASES OF THE INTESTINES 
 
 Expectant treatment may be successful, for benign tumours, 
 especially when situated in the lower intestinal segments, are some- 
 times spontaneously expelled. As already mentioned, this has been 
 observed in lipomata, adenomata (polypi), and myomata (Pellizari^^, 
 Heurteux ^). 
 
 Eegarding simple pedunculated polypi of the rectum, their 
 removal is easily accomplished with the scissors or the galvano- 
 cautery. The case is quite different, however, with larger myom- 
 ata of the intestinal canal. In many cases we shall have to be 
 content with palliative treatment. Should dangerous symptoms 
 occur (invagination, complete or beginning intestinal obstruction, 
 severe, repeated intestinal hemorrhages), operative extirpation of the 
 tumour is indicated. Successful operative results in internal my- 
 omata have been reported by Fleiner, Czerny, Lockwood, Albert, 
 Rosi, Fenger, and Holländer ^^ External myomata have also been 
 successfully operated on (Wölfler, Babes-lSTanu, Kukula, and Kru- 
 kenberg). 
 
 Internal rectal myomata offer no great difficulties to surgical 
 treatment, for ligation of the pedicle and removal of the tumour is 
 usually sufficient. The treatment of external myomata of the 
 rectum is the same as that of rectal cancer. Removal of the 
 tumour by laparotomy is indicated when its growth extends beyond 
 the small pelvis. Cure resulted in 3 out of 4 cases of external rec- 
 tal myoma (Berg, Senn, PfannenstieP^). 
 
 General intestinal j)olyposis is not favourable either for internal 
 or surgical treatment. Our therapeutic aim will be limited to 
 decreasing the hemorrhages by appropriate internal medication 
 (ergotin, hydrastin, witch-hazel), or by astringent enemata (fer- 
 ripyrin, tannin, aceto-tartrate of aluminum). Partial extirpation 
 of the growth may be symptomatically advantageous. Thus, in a 
 case of polyposis of the jejunum and ileum recently reported by 
 von Karajan^^, complete cure resulted from extirpation of 10 of the 
 largest polypi. In a case reported by Sklif assowski ^*, the forma- 
 tion of an artificial anus seemed to have been followed by some 
 benefit. 
 
 LITERATURE 
 
 1. A. Zemann. Bibliothek d. medicin. Wissenschaften (Dräsche), Bd. iii, H. 
 
 1 u. 2, S. 49. 
 
 2. G. Heinaann. Archiv f. klin. Chirurgie, 1899, Bd. Ivii, H. 4. 
 
 3. Berard, Rokitansky. Cited from Leube in v. Ziemssen's Handbook, p. 
 
 335, vol. vii, Part II, second edition. 
 
INTESTINAL NEOPLASMS 339 
 
 4. P. Rüpp. lieber den Darmkrebs mit Ausschluss d. Mastdarmkrebses. 
 
 Inaug.-Diss., Zürich, 1894, S. 10. 
 
 5. Maydl. Ueber den Darmkrebs. Wien, 1883, S. 10. 
 
 6. Nothnagel. Darmerkrankungen, S. 219. 
 
 7. Hausmann. These de Paris, 1883. 
 
 8. Iversen. Verhandl. des X. internationalen medicinischen Conoresses Ber- 
 
 lin, 1891, Bd. iii, S. 98. 
 
 9. Kraske. Erfahrungen über den Mastdarmkrebs. Volkmann's Sammlung 
 
 klinischer Vorträge, 1883, 1884, 1897, S. 787. 
 
 10. Käst u. Baas. Münch. med. Wochenschr., 1888, No. 4. 
 
 11. Rommeläre. Journ. de med., de Chirurgie, et de pharmacie de Bruxelles, 
 
 1883-1886. 
 
 13. Fr. Müller. Zeitschr. f. klin. Medicin, Bd. xvi, S. 146. 
 18. G. Klemperer. Berl. klin. Wochenschr., 1889, No. 40. 
 
 14. Schneyer. Internat, klinische Rundschau, 1894, No. 39. 
 
 15. F. Henry. Arch, für Verdauungskrankheiten, 1898, Bd. iv, H. 1. 
 
 16. Czygan. Ibid, 1897, Bd. iii, S. 83. 
 
 17. Leichtenstern. von Ziemssen's Handbuch, 1878, Bd. vii, 2, 3te Aufl., S. 
 
 418. 
 
 18. Herz. Deutsche med. Wochenschr., 1896, No. 23 u. 24. 
 
 19. Gerhardi. Virchow's Archiv, 1886, Bd. cvi, S. 303. Inaug.-Diss., Zürich, 
 
 1886. 
 
 30. Hagenbach. Deutsche Zeitschr. f. Chirurgie, 1887, Bd. xxvii, H. 1 u. 3, 
 
 S. 110. 
 
 31. Wilms. Beiträge zur klin. Chirurgie, 1897, Bd. xviii, H. 3. 
 
 32. Weecke. Inaug-Diss., Kiel, 1894. 
 
 33. Pic. Revue de m6decine, 1894, No. 13, and 1895, No. 1. 
 
 34. Bard et Pic. Ibid., 1888, vol. viii. 
 
 35. Lannois et Courmont. Ibid., 1894, vol. xiv. 
 
 36. Janicke. Würzburger Verhandlungen, 1877. 
 
 27. Kernig. Petersburger med. Wochenschr., 1881, No. 4. 
 
 38. Oser. Die Erkrankungen des Pankreas, Wien, 1898, S. 314. 
 
 39. Miralliö. Gaz. des hopitaux, 1893, p. 889. 
 
 30. Treves. Darmobstruction. Uebersetzt von A. Pollak, 1888. [Intestinal 
 
 Obstructions. New York, 1899.] 
 
 31. Potain. Cited from Maydl, Ueber den Darmkrebs, 1883, S. 51. 
 33. Wunderlich. Cited from Rüpp (see ref. 4). 
 
 33. Nicolaysen. Cited from Maydl (see ref. 5). 
 
 34. Bamberger. Krankheiten des Chylopoetischen Systems. Virchow's Handb. 
 
 d. spec. Pathologie u. Therapie, Bd. vi, Würzburg, 1864. 
 
 35. Bamberger. Zeitschr. f. prakt. Heilkunde, 1857, Bd. iii. 
 
 36. Krausshold. Ueber Krankheiten des Proc. vermiformes u. des Coecums. 
 
 Volkmann's Sammlung klin. Vorträge, No. 191. 
 
 37. Schede. Cited from Paul Wolff, Ueber Geschwülste d. Ileocoecalgegend. 
 
 Inaug.-Diss., Berlin, 1893. 
 
 38. Richelot u. Hartmann. Cited from Virchow-Hirsch's Jahresbericht, 1894, 
 
 Th. ii, S. 462. 
 
 39. von Bergmann. Deutsche med. Wochenschr., 1895, Vereinsbl., S. 54. 
 
340 DISEASES OF THE INTESTINES 
 
 40. Hahn. Berl. klin. Wochenschr., 1887, No. 25. 
 
 41. Czerny. Beiträge zur klin. Chirurgie, Bd. ix, S. 797, Fall 14. 
 
 43. von Esmarch. Cited from J. Mockenhaupt. Inaug. -Diss., Kiel, 1894. 
 
 43. Salzer. Arch. f. klin. Chirurgie, Bd. xliii, S. 149. 
 
 44. Pässler. Berl. klin. Wochenschr., 1895, No. 34. 
 
 45. Israel. Ibid., 1894, No. 11. 
 
 46. Hochenegg. Wiener klin. Wochenschr., 1897, No. 33. 
 
 47. Wölfler. Berl. klin. Wochenschr., 1896, No. 34. 
 
 48. Billroth. Verhandlungen des X. internationalen Congresses zu Berlin, 
 
 1891, Bd. iii, Abth. 7, S. 76 u. f. 
 
 49. Czerny. XII. Chirurgencongress, 1893. 
 
 50. Nicolaysen. Cited from Rüpp (see ref. 4). 
 
 51. Hochenegg. Wiener klin. Wochenschr., 1888, No. 14-16, 1889, No. 
 
 36-30. 
 
 52. von Heinecke. Münch. med. Wochenschr., 1888, No. 35. 
 
 53. W. Levy. Centralbl. f. Chirurgie, 1889, No. 13. 
 
 54. Schlange. Berl. klm. Wochenschr., 1893, No. 47. 
 
 55. Liermann. Beiträge zur klin. Chirurgie, Bd. xix, H. 3, and Arch. f. klin. 
 
 Chirurgie, Bd. iviii, H. 3. 
 
 56. Lövinsohn. Beiträge zur klin. Chirurgie, Bd. x, S. 308. Lobstein. Berl. 
 
 klin. Wochenschr., 1897, No. 30 u. 31. 
 
 57. Czerny. Berl. klin. Wochenschr., 1897, No. 36. 
 
 58. Kundrat. Wiener klin. Wochenschr., 1893, No. 13. 
 
 59. Fr. Krüger. Inaug. -Diss., Berlin, 1894. 
 
 60. Baltzer. Arch. f. klin. Chirurgie, Bd. xliv, H. 4. 
 
 61. Madelung. Centralbl. f. Chirurgie, 1893, No. 30. 
 63. Bessel-Hagen. Virchow's Archiv, Bd. xcix, S. 99. 
 
 63. Müller. Inaug. -Diss. , Zurich, 1894. 
 
 64. W. Claus. Inaug. -Diss., 1888. 
 
 65. Ricker. Arch. f. klin. Chirurgie, 1895, Bd. 1. 
 
 66. Dietrich. Beiträge zur klin. Chirurgie, 1896, S. 377. 
 
 67. Rud. Schmidt. Wiener klin. Wochenschr., 1898, No. 21. 
 
 68. Michel. Inaug.-Diss., Würzburg, 1889. 
 
 69. Gilford. The Lancet, 1889, 1893. 
 
 70. Engström. Cited from Arch. f. Verdauungskrankheiten, vol. iv, p. 219. 
 
 71. von Ziemssen. Deutsches Arch. f. klin. Medicin, 1895, Bd. Ivi, H. 1 u. 2, 
 
 S. 134. 
 73. Prochownick. Münch. med. Wochenschr., 1896, No. 49. 
 
 73. Luschka. Virchow's Archiv, Bd. xx, S. 133. 
 
 74. Whitehead. Brit. Med. Journal, p. 410, 1884. 
 
 75. Hauser. Deutsches Arch. f. klin. Medicin, Bd. Iv, S. 429, and Das 
 
 Cylinderepithelcarcinom d. Magens u. d. Dickdarms, Jena, 1890, S. 
 182 u. 191. 
 
 76. Schwab. Beiträge zur klin. Chirurgie, Bd. xviii. 
 
 77. Port. Zeitschr. f. Chirurgie, Bd. xlii, H. 1 u. 3. 
 
 78. Holtmann. Multiple Polypen des Colon mit Gallertkrebs. Inaug.-Diss., 
 
 Kiel, 1895. 
 
 79. Bardenheuer. Arch. f. klin. Chirurgie, Bd. xli, H. 4. 
 
INTESTINAL NEOPLASMS 
 
 341 
 
 '80. Smith. St. Barthol. Hosp. Rep., vol. xxiii, 1887. 
 
 •81. Handford. Transact, of the Pathol. Soc. of London, vol. xli, 1890. 
 
 82. Paget, Hutchison, and Makius. Cited from Port (see ref. 77j. 
 
 83. Castelain. Gaz. hebdom. de medecine et de Chirurg., 1870, No. 30. 
 
 84. Albrecht. St. Petersburger med. Wochenschr., 1880, No. 9. 
 
 85. Link. Wiener klin. Wochenschr., 1882, S. 247. 
 
 ■86. Paci. Le Sperimentale, 1882, p. 46. (Cited from Virchow-Hirsch's Jahres- 
 bericht, 1882.) 
 
 87. Steiner. Beiträge zur klin. Chirurgie, 1898, Bd. xxii, H. 1 u. 2. (Here 
 will be found extensive literary references.) 
 
 :88. Fleiner. Virchow's Archiv, 1885, Bd. ci, S. 484 u. f. 
 
 89. Pellizari. Societa medico-fisica florentina, 1874. (Cited from Steiner 
 
 ref. 87.) ' 
 
 90. Heurteux. Gaz. medic, de Nantes, 1884, p. 135. (Cited from Steiner, ref 
 
 87.) 
 
 91. Holländer. Cited from Steiner (ref. 87). 
 
 '93. Pfannenstiel. Allgemeine medicin. Centralzeitung, 1897, S. 56. 
 «3. von Karajan. Wiener klin. Wochenschr., 1899, No. 6. 
 M. Sklifassowski. Wratsch, 1881, No. 4. (Cited from Centralbl. f. Chirurgie 
 1881, S. 527.) 
 
 23 
 
CHAPTEE XYIII 
 
 INTESTINAL STENOSIS AND INTESTINAL OBSTRUCTION 
 
 {ILEUS) 
 
 A. INTESTINAL STENOSIS 
 
 ' Preliminary HemarTcs. — Of all disturbances of the intestinal 
 canal, the most serious are those which interfere with the normal 
 passage of the fseces. Where they do not directly threaten life, 
 such disturbances cause a number of extremely distressing sym.ptoms, 
 which, unless relieved, gradually undermine the constitution of the 
 patient and finally produce death. At first, the variety and situa- 
 tion of the obstruction seem of secondary importance to the dan- 
 gers arising therefrom ; for, with the single exception of faecal 
 impaction, the danger in all varieties of intestinal obstruction is 
 practically the same. It would thus seem that the trouble taken 
 in the study and classification of the various forms of intestinal 
 obstruction has but little practical value. A more detailed knowl- 
 edge and more careful study will show that this idea is incorrect. 
 The clinical features of intestinal obstruction are never the same, 
 and the recognition of the differences in different cases is im- 
 portant for diagnostic, prognostic, and therapeutic purposes, par- 
 ticularly in surgery. There are only a few, though perhaps very 
 important, varieties of intestinal obstruction which really offer in- 
 surmountable diagnostic difficulties. 
 
 In every case of intestinal obstruction the following facts must 
 be determined before a diagnosis can be arrived at : 
 
 1. First and most important, the establishment of the presence 
 of intestinal obstruction or stenosis. 
 
 2. Determination of its situation. 
 
 3. Determination of its anatomical causes. 
 
 In order to understand the symptoms of individual cases, and in 
 view of the practical purpose of this work, it appears to me prefer- 
 able to first give the general symptomatology of intestinal strictures 
 and occlusions, and then the symptomatology and diagnosis of the 
 several kinds of obstruction. The differential diagnosis will be 
 342 
 
INTESTINAL STENOSIS 343 
 
 treated of in a separate section, and, finally, the treatment of all 
 forms will be discussed together. Owing to their extreme rarity 
 and because of their lack of practical clinical significance, congenital 
 stenosis and occlusion will be left entirely out of consideration. 
 Stenoses of the rectum are described in the chapter on Diseases of 
 the Rectum. 
 
 General Symptomatology of Stricture of the Intestine 
 
 The idea embodied in the term " intestinal stricture " already 
 seems to imply a gradual development with well-defined symptoms 
 only in advanced stages of the disease. Patients, as a rule, complain 
 of the characteristic symptoms of stricture only when the process is 
 relatively far advanced. There are, however, important exceptions 
 to the usual course. In the first place, a chronic stricture may de- 
 velop shortly after a complete obstruction (pseudo-ligaments, hernial 
 orifices, partial obstruction by gallstones, foreign bodies, intestinal 
 concretions, intussusception, compression) (Leichtenstern ^). On the 
 other hand, the characteristic picture of chronic intestinal stenosis 
 may for a time be present ; then, either through muscular paralysis, 
 marked increase of the stricture, or through impaction of foreign 
 bodies (generally undigested food), the chronic stenosis suddenly 
 changes into a complete intestinal obstruction. In other cases, 
 again, the change is less acute. For example, a patient has passed 
 through several attacks of intestinal stenosis, each one more severe 
 than the preceding one, so that it is probable that the next attack 
 will be one of complete obstruction. 
 
 The clinical picture varies in accordance with the site and de- 
 gree of the stenosis. 
 
 Regarding the site, we may, in general, differentiate between 
 strictures of the upper and of the lower segments of the intestines, 
 the former including the portions from below the pylorus to the 
 jejunum inclusive, the latter those from the ileum to the rectum. 
 Both have this in common, that the normal onward movement of the 
 bowel contents is either delayed or entirely interfered with. As 
 a natural result a dilatation gradually develops above the stenosis, 
 and acts as a reservoir for the retained fluid or solid masses. It 
 is quite evident that this will occur to a lesser degree in stenoses 
 above the jejunum than in those lower down. It is clear that the 
 latter variety demands considerably greater expulsive power of the 
 intestinal muscles than does the former. Finally, in deep-seated 
 stenoses the recoil contraction can have little effect in causinö; a 
 
344 DISEASES OF THE INTESTINES 
 
 backward movement of the solid matters in tlie intestine ; in ste- 
 noses of the upper bowel, however, where the contents are fluid, 
 very little force is required for their regurgitation. 
 
 From these differences the chief symptomatological distinctions 
 between the two types arise. 
 
 Let us begin with the small intestine. In general the symp- 
 toms point rather to disturbances of gastric than of intestinal func- 
 tions. The subjective symptoms are those of chronic overdisten- 
 tion of the stomach from the backward pressure of the retained 
 duodenal and jejunal contents — viz., fulness, pressure, pains, eruc- 
 tation, nausea, vomiting. 
 
 iSTaturally this permanent stasis is not without its effect upon 
 the appetite and nutrition — both of these suffer more or less. The 
 increasing vomiting will also affect or retard the evacuations, but 
 not nearly as much as in stenosis of the lower intestinal segments. 
 In general, meteorism is very moderate and limited to the epigas- 
 trium. In marked stenosis the fluid chyme can pass downward 
 through the intestinal canal, or flnd its way upward to the stom- 
 ach ; therefore in stenoses of the upper part of the intestines, intes- 
 tinal peristalsis, or intestinal rigidity is rarely seen. For the same 
 reason severe paroxysms of pain are also absent. 
 
 The clinical picture of deeply situated intestinal stenosis, par- 
 ticularly that of the large intestine., is quite different. Here the 
 evidences of muscular insufiiciency become very prominent. In 
 the flrst place there is constipation, which may be the only symp- 
 tom in the beginning, or throughout the disease. But constipation 
 in itself allows us to draw no conclusion respecting the ominous 
 changes occurring within the intestinal lumen. Even this symp- 
 tom is sometimes absent. ISTothnagel ^ cites a case of cancer of the 
 sigmoid flexure in which natural firm evacuations occurred one day 
 before complete intestinal occlusion set in ; and every experienced 
 physician can cite similar instances. Although constipation is one 
 of the most frequent symptoms of stenosis of the large intestine, 
 we may, as in intestinal cancer (page 311), occasionally have the 
 reverse condition, namely, diarrhoea. The latter is caused either by 
 decomposition of the dejecta above the stricture, or by irritation of 
 intestinal ulcers (stercoraceous ulcers, distention ulcers (Kocher)). 
 Finally, constipation may alternate with diarrhoea. 
 
 In connection with obstinate constipation, spasmodic pains may 
 sooner or later develop. These pains are distinguished from those 
 of ordinary flatulent colic by their frequent recurrence and in- 
 
INTESTINAL STENOSIS 345 
 
 creased duration and intensity. At a late stage they may be con- 
 tinuous. 
 
 In contrast to flatulent colic, in which th« whole or greater part 
 of the abdomen is tympanitically distended, the meteorism even in 
 advanced stenosis of the large intestine is generally inconsiderable. 
 Only after complete obstruction with intestinal paralysis, do general 
 meteorism and simultaneous cessation of intestinal contractions occur. 
 When we consider that the gases developed by the accumulated in- 
 testinal contents are powerful stimuli to peristalsis, it is not difiicult 
 to understand why meteorism is absent as long as the functional 
 activity of the bowel is preserved. 
 
 The most important accompanying symptom of painful intes- 
 tinal contraction is the occurrence of msihle, spasmodic intestinal 
 peristalsis^ a phenomenon which Nothnagel^ appropriately called 
 "intestinal rigidity." These severe visible and palpable spasmodic 
 contractions of the intestines in their effort to force their con- 
 tents through the stricture, are analogous to the attempt of the 
 uterus to force the child's head through the relatively small out- 
 let by increased muscular action. This intestinal contraction is a 
 favourable symptom in so far as it proves that the hypertrophied 
 intestinal muscle still possesses a certain amount of power ; on the 
 other hand, it demonstrates that the stenosis is so great that extraor- 
 dinary efforts are necessary in order to pass the obstruction. 
 
 In the General Division (page 69) we have already discussed the 
 phenomena of intestinal rigidity. We shall return to its significance 
 and varieties in the section on diagnosis. 
 
 Formerly great value was laid upon the consistency of the stools. 
 It was believed that pointed, narrow- calibred stools were char- 
 acteristic of stenosis of the large intestine. This error has found 
 its way even among the laity, and every physician can cite cases of 
 imaginary stenosis in which the patients complain of constipation 
 and habitually examine their own stools. Laparotomy has been 
 performed in a number of these patients. 
 
 We now know that in intestinal stenosis the stools have no 
 characteristic appearance, for we find similar stools in spasmodic 
 constipation, intestinal atrophy, in membranous enteritis, and even 
 in ordinary intestinal catarrh. It appears to me that the idea of 
 so-called stenotic dejections has originated in great part from stric- 
 tures of the lower large intestine (from the sigmoid downward), for 
 in that part of the tract characteristic stools do actually occur. 
 Under certain conditions, blood, pus, and mucus may be mingled 
 
346 DISEASES OF THE INTESTi:^rES 
 
 with the evacuations. These anomahes, however, are not peculiar 
 to the clinical picture of intestinal stenosis as such, but depend 
 upon the underlying intestinal disease. 
 
 Special Symptoms and Diagnosis of Intestinal Stenosis 
 
 In well-marked cases the diagnosis of intestinal stenosis is easy ; 
 in other cases only a probable diagnosis can be made; in some 
 the diagnosis is impossible. This depends partly upon the site of 
 the occlusion and partly upon the prominence of the symptoms, 
 which vary in the different kinds of stenosis. 
 
 {a) Stenosis of the Small Intestine 
 
 Analogous to the classification of malignant disease of the small 
 intestine, benign stenoses are also divided into the suprapapillary 
 and infrapapillary, jejunal, and ileal forrns. As already stated in 
 the chapter on Intestinal Cancer (page 303), the diagnosis of supra- 
 papillary stenosis is rarely possible. Its clinical picture is so similar 
 to that of pyloric stricture, that, despite the most careful examina- 
 tion, a correct diagnosis is the exception and a false diagnosis the 
 rule. The diagnosis can be made with a fair degree of probability 
 only when the subjective symptoms point to the duodenum as the 
 certain site of the lesion. In the following case the diagnosis was 
 made with the greatest possible clinical certainty before operation. 
 
 Stenosis of the sujjerior i^ortion of the duodenum follotcing an incarcerated 
 gallstone. Tetany. Gastro-enterostomy . Death. 
 
 Mrs. N., fifty years old, has been suffering from attacks of gastric colic for 
 over twenty years. These would often cease for years, and later return accom- 
 panied by very intense pain. The attacks lasted minutes to. hours, and were 
 frequently accompanied by chills, fever, cold sweats, and vomiting. Twenty 
 years ago had jaundice and clay-coloured stools. She cannot remember wheth- 
 er this occurred in an attack of colic or not. 
 
 Patient has been free from attacks for the last eight years, and felt well till 
 Christmas, 1897. She then began to have a feeling of discomfort in the epigas- 
 trium, and foul-smelling eructations, generally toward evening ; of late there 
 have been acid burning eructations early in the morning, and regurgitation of 
 stomach contents. Since the end of January there has also been vomiting of 
 large quantities of fluid, foul-smelling masses, but not of blood. Patient often 
 has the feeling as if the stomach " works strongly " after meals. Always re- 
 lieved after vomiting. Marked loss of weight ; appetite good ; constipation 
 obstinate. 
 
 Status Prcesens. — No evidence of cachexia; skin of yellowish colour. Slight 
 emphysema; heart sounds normal. 
 
INTESTINAL STENOSIS 347 
 
 Abdomen. — Abdominal walls are moderately fatty; no visible gastric or in- 
 testinal peristalsis. When the stomach is empty loud splashing and succussion 
 sounds are present to almost a handbreadth below the umbilicus. Epigas- 
 trium not sensitive to pressure; no pathological dulness or resistance. The 
 border of the liver indistinctly palpable ; hepatic dulness diminished, and 
 begins at mammary line at upper border of the fourth rib. Spleen and kid- 
 neys negative. 
 
 The vomitus consists of undigested food remnants, is neutral in reaction, 
 contains large quantities of sarcinse, yeast fungi, muscle shreds, fat, starch, 
 stearic acid bundles. No long bacilli. 
 
 During the next few days the stomach contents were expressed during the 
 fasting condition. Each time food remnants rich in HCl, and showing micro- 
 scopically the above-mentioned substances, were obtained. The stools consisted 
 •of scybala, containing enormous numbers of fatty acid crystals. The quantity 
 of urine was between 400 and 900 centimetres in twenty-four hours, and con- 
 tained an abundance of indican. Otherwise it was normal. 
 
 Treatment. — Fluid and semisolid diet. Daily gastric lavage ; nutrient 
 enemata. 
 
 Course. — On March 17th, after comjilaining of nausea and a feeling of 
 abdominal distention, the patient suddenly had a spasmodic attack limited ex- 
 clusively to both hands. The fingers were flexed, but could be passively 
 extended. Patient was collapsed ; pulse could not be felt ; face cyanotic ; eyes 
 staring and glassy; complete consciousness retained throughout the attack, 
 which lasted for half an hour. 
 
 Two hours later, despite repeated examinations, neither Trousseau's nor 
 Chvostek's phenomena could be elicited. There was no muscular irritability, 
 no sensory disturbances. Repeated examinations always gave the same results. 
 
 On March 20th, after previous nausea and abdominal pressure, there was 
 numbness and stiffness of the fingers. 
 
 Since the stomach contents always increased, and renewed attacks of tetany 
 were feared, the patient was transferred to the private clinic of Professor Hahn 
 on March 28th. • 
 
 The probable diagnosis was duodenal stenosis, situated high up, consequent 
 upon incarcerated gallstones. 
 
 Operation on March 31, 1897, by Professor Hahn. Slight attack of tetany 
 during narcosis. 
 
 Laparoton).y . — The pylorus is free; underneath it is felt a large gallstone. 
 In order to reach the latter a horizontal incision is made in the region of the 
 gall bladder. Gall bladder and parts about the gallstone tightly adherent to 
 the duodenum. The gallstone partly compresses the duodenum and partly 
 protrudes into its lumen. The adhesions are separated and the stone lifted out 
 of its bed, during which manipulation the duodenum is torn. Intestinal 
 suture, then gastro-enterostomy. The stone is composed of Cholesterin. Col- 
 lapse and death the following day. 
 
 In a second case — a bookkeeper, fifty years old — the proba- 
 Vie diagnosis of bigh duodenal stricture and calculus, resulting 
 from cbolelitbiasis witb icterus wbich bad lasted many years, 
 
348 DISEASES OF THE INTESTINES 
 
 was made. Gastro-enterostomy was performed hy Dr. Hahn and 
 the diagnosis was confirmed. The patient was cured. 
 
 These two cases are interesting because thej show that the sus- 
 picion of calculous obstruction of the pylorus and duodenum may- 
 be awakened by the occurreuce of attacks of cholehthiasis for many 
 rears, and by the later occurrence of dilatation of the stomach. In 
 view of the close relation between the gall bladder and duodenum, 
 we are justified in suspecting the duodenum as the site of the ste- 
 nosis. 
 
 On the other hand, as demonstrated by a case recently described 
 by Wegele^, the diagnosis of a high calculous duodenal stenosis 
 may be very difficult during life, and even during the course of 
 operation. 
 
 The diagnosis of low (infrapapillary) duodenal stenosis may be^ 
 made with a much greater degree of probability. This has been 
 shown by the more recent observations of Leichtenstem ^, Cahn\ 
 EiegeP, Hochhaus", Schule^, Reiche^, Herz^'^, Pic", Eewidzoff^\ 
 and myself ^^. From the writings of the authors just mentioned, 
 the following may be considered typical symptoms of infrapapillary 
 stenosis : 
 
 The most important subjective symptoms are functional dis- 
 turbances of the stomach, like those which occur in gastrectasis — 
 viz., diminished appetite, feeling of pressure and fulness, or even of 
 intense pain after taking food, eructations, nausea, vomiting, con- 
 stipation, decreased diuresis, and marked loss of weight and strength. 
 If in conjunction with these symptoms there is evidence of previous 
 disease of the duodenum and its surroundings (enterorrhagia, duo- 
 denal ulcer, disease of the pancreas, gallstones, cholecystitis, cho- 
 langitis, and icterus), we must suspect disease of this segment of 
 the small intestine. If, furthermore, the vomitus is constantly bile 
 tinged, the suspicion becomes a probability, and, as regards the site 
 of the stricture, a certainty. 
 
 The objective symptoms chiefly depend upon the disturbed 
 stomach motility, the changes in the gastric secretion being of sec- 
 ondary importance. The stomach may be of normal size or dilated 
 (cases of Riegel, Schule, Herz, and others). 
 
 Slight visible peristalsis in the neighbourhood of the pylorus 
 may be present, but is generally absent (Schule). Meteorism, is 
 only moderate or may likewise be entirely absent. When present, 
 it rapidly disappears through the eructations and the vomiting 
 (Leichtenstern *, Herz). 
 
INTESTINAL STENOSIS 349 
 
 The constant presence of hile in the stomach is the most impor- 
 tant evidence of infra papillary stenosis. This is best observed in 
 the morning after the stomach had been washed out the previous 
 evening. With the bile the duodenal secretion {succus entericus 
 and pancreatic juice) is forced into the stomach, and thus it is some- 
 times possible to exclude severe disease of the pancreas by the pres- 
 ence of active pancreatic juice (Boas). That under diseased con- 
 ditions pancreatic digestion may still continue, is proved by a case 
 recently reported by Wilms ^*, of a deeply situated duodenal stenosis 
 resulting from compression of a pancreatic cancer. Pertinent con- 
 clusions can only be drawn when the digestive tests are negative. 
 
 In these cases the secretion of gastric juice depends upon the 
 amount of regurgitated duodenal contents, the duration, and per- 
 haps also upon the nature of the disease. Varying amounts of 
 HCl have been found in the different kinds of stenosis of the 
 descending portion of the duodenum. According to Riegel's and 
 my own experience, the same individual may at one time have 
 abundant hydrochloric acid in his stomach, and at other times none 
 at all. As I have demonstrated ^^, the presence of bile and of pan- 
 creatic juice interferes with the digestive properties of the gastric 
 juice only to the extent that the latter is neutralized. If the hydro- 
 chloric acid preponderates in the mixture, the gastric juice has t.s 
 active digestive powers as in the normal. On the other hand, in 
 such a mixture, even though it be made alkaline, the pancreatic fer- 
 ments will be destroyed (probably due to the acid). 
 
 Microscopic examination may show evidences of gastric fermen- 
 tation (yeast, sarcinse, bacteria of various kinds, etc.) ; it may also 
 show the long bacilli generally found in lactic acid fermentation. 
 
 Discolouration of the stools and increase of indican in the urine 
 (Boas) are of diagnostic significance. Both of these changes may, 
 however, be absent. According to Herz, bismuth administered l)y 
 the mouth does not reappear in the stool. This can only be the 
 case in very marked stenosis of the lower portion of the large intes- 
 tine. In connection with other symptoms, it might possess diag- 
 nostic value. 
 
 If palpable changes are not present (tumour of the duodenum 
 or of its surrounding tissue, adhesions, etc.), the diagnosis of the 
 underlying cause of the stenosis is very difficult. The age and sex 
 of the patient, and, as already mentioned, the clinical history, are of 
 value. In women in whom there is a history of frequent attacks 
 of stomach ache, or of icterus, we must suspect impacted stones, 
 
350 DISEASES OF THE INTESTINES 
 
 which have either ulcerated through the bile duct and produced 
 peritoneal adhesions with the duodenum and compression of the 
 latter, or small concretions which have passed through the common 
 duct into the lower portion of the duodenum, and produced a spas- 
 tic obstruction of the latter (cases of Hochhaus, Schule, Herz, and 
 others). 
 
 In men in the prime of life we must think of duodenal ulcera- 
 tions as the cause of stenosis, especially if the characteristic symp- 
 toms of this disease have been present. Several years ago I observed 
 and reported two cases of ulcer of the duodenum with resulting ste- 
 nosis of the descending portion. In one case, which I shall now 
 describe, the autopsy confirmed the diagnosis. 
 
 Deeply situated duodenal stenosis following cicatricial contraction from duo- 
 denal ulcer. Gastro-enterostomy . Death. 
 
 Patient, a shoemaker, says that since early childhood he has suffered 
 from intestinal disturbances (diarrhoea, anorexia, occasional biliary vomiting), 
 so that his development was much retarded. In his seventeenth year he 
 had typhoid, from which he very slowly recovered. He felt better for ä 
 time, but frequently thereafter suffered from obstinate vomiting, with diarrhoea. 
 Certain articles of food were said to be passed undigested. The patient also 
 complained of flatulence, headaches, inability to work, and lassitude. 
 
 Examination showed a poorly nourished man with normal organs of respira- 
 tion and circulation. Nothing special found in the nervous system. The 
 abdomen is somewhat tympanitic, but no new growth can be made out; liver 
 and spleen normal; kidneys cannot be felt. In the right hypochondrium, cor- 
 responding to a prolongation of the parasternal line, there is a resistance, which 
 is sensitive, particularly upon deep pressure. The limits of the stomach are nor- 
 mal. After large meals slight splashing can be made out in the epigastrium. 
 Distention of the stomach with air plainly shows the larger curvature at the 
 level of the umbilicus. The largest diameter obtained by extreme distention 
 is 13 centimetres. Rectal examination and insufflation yield nothing special. 
 
 The examination of the stomach contents, made more than 100 times in 
 three years, shows the permanent presence of bile and the absence of food 
 remnants during fasting. The reaction of the stomach contents was at first 
 alkaline; after a test breakfast they were occasionally slightly acid. The gas- 
 tric contents, both in the fasting condition and after eating, always possessed 
 peptic power — i. e., pancreatic juice was mixed with the bile. Later the pic- 
 ture changed; the gastric contents became acid and gave a decided hydro- 
 chloric acid reaction, though the contents were still bile-tinged. After some 
 time the first-mentioned condition was again present. There was again dis- 
 tinct HCl reaction. 
 
 The patient's condition varied. Diarrhoea was present. At times the pa- 
 tient complained constantly, however, of a painful pressure along the right 
 parasternal line, lack of appetite, headaches, fatigue, etc. 
 
 Since these symptoms recurred during the following months, the patient 
 
INTESTINAL STENOSIS 
 
 351 
 
 consented to a gastro-enterostomy ; this was performed in January, 1892. At 
 the laparotomy the pylorus was found extremely dilated, so that it was very 
 difficult to determine which was the duodenum and which the pylorus. Exter- 
 nally, besides a few adhesions of the duodenum to the liver, nothing noteworthy 
 was discovered. The patient died the following day. 
 
 Autopsy showed the condition of the stomach and duodenum 
 pictured below (see Fig. 31). The pyloric ring was extraordinarily 
 dilated, and toward the upper portion of the duodenum almost 
 obliterated. The first portion of the duodenum was also extremely 
 
 Pyloric portion 
 of stomach 
 
 Pyloric valve 
 
 ] 
 
 / 
 
 Round ulcers 
 
 \ 
 
 "Etat mamelonne '''' '' -y 
 of duodenum 
 
 Papilla of Vater 
 
 Small ulcers 
 
 -'.. First portion of 
 '~^'.jJl '' duodenum (consid- 
 erably dilated) 
 
 J'-^ 
 
 ""••SSffl^^^ 
 
 'X'lcatricial strand 
 from ulceration 
 
 ^■-Second portion of duodenum 
 
 Tig. 31. — Ulcer of the Duodenum, with Secondary Stenosis of the Second Portion 
 AND Dilatation of the First Portion. (Personal observation.) 
 
 dilated and showed several ragged, eroded ulcers. The descend- 
 ing portion also contained sev^eral similar small ulcerations, some- 
 what larger than lentils, with numerous cicatricial strands. The 
 latter had considerably narrowed the lumen of the descending por- 
 tion. 
 
 Where tubercular symptoms are present we must consider the 
 possibility of tubercular ulcerations, though, as shown by a case of 
 Herz,^*^ under these circumstances other factors may produce the 
 stenosis (e. g., in the case just mentioned, a peritoneal strand). 
 
 In advanced age we must first think of cancer of the duodenum 
 
352 DISEASES OF THE INTESTINES 
 
 and its surrounding parts as the cause of the stenosis. This ques- 
 tion is discussed in the chapter on Intestinal ISTeoplasms, to wliich^ 
 in order to avoid repetition, we refer. 
 
 The above list bj no means includes all the engendering causes 
 of duodenal stenosis. To desci'ibe them all would be of no value, 
 because the diagnosis is scarcely ever possible during life. It is 
 safficient to simply mention the other possibilities, so that they may 
 be taken into account in appropriate cases. These are lymphomata, 
 sarcomata, kinking, compression by metastatic tumours, pancreatic 
 cysts, fat necrosis of the pancreas, cancer of the pancreas, retroperi- 
 toneal tumours, etc. 
 
 Stenosis of the Jejunum and Ileum 
 
 Isolated stenoses of the jejunum and ileum are rare. The ma- 
 jority owe their origin to the adhesions and kinking produced by 
 inflammatory adhesions with the (female) genitals, the appendix, 
 inflamed and reduced hernia, etc. 
 
 In rare instances healed or partially healed tubercular ulcera- 
 tions are the cause of the stenosis. Fibrous stenosis, analogous, 
 to hypertrophic pylorus stenosis, is of anatomical interest only. 
 It has been studied j)articularly by French and English writers 
 (" enterite sclereuse,^^ " plastic linitis," " cirrhosis intestinalis "), 
 and affects partly the stomach and partly the liver, peritoneum, 
 and isolated portions of the intestine. Cases of stricture of the 
 small intestine from unknown cause (syphilis enteritis) have been 
 reported ; only a very few are of carcinomatous nature (Petrina,, 
 Chouquet, Letulbe, Broscn, E. Hahn, Keinke, Wernich, Kütt- 
 ner^^). Tubercular stenoses may occur isolated, but (more fre- 
 quently) are multiple. In a case described by E. FränkeP''', and 
 another by Hofmeister ^^, 12 strictures were found. The strictures 
 are usually situated in the ileum, occasionally in the caecum, and 
 but rarely above or below these parts. 
 
 On the whole, the clinical picture of jejunal and ileal stenosis 
 is but Httle characteristic. The higher the stricture in the jejunum 
 the more will the symptoms of disturbed gastric digestion (par- 
 ticularly vomiting) preponderate ; and the greater the degree of 
 the stenosis the more apt is the vomiting to be fascal or fecu- 
 lent in character. The nearer the stricture is to the caecum the 
 more marked are the actual intestinal symptoms — constipation, 
 or alternating constipation and diarrhoea, meteorism, severe colic, 
 visible and palpable intestinal contraction, particularly in the 
 
INTESTINAL STENOSIS 353 
 
 middle of the abdomen — symptoms which differ little from those 
 of stenosis of the large intestine. 
 
 As shown by the observations of Litten ^^ and E. Fränkel", 
 marked tubercular stenoses of the ileum may run their course en- 
 tirely, or almost entirely, without symptoms. If increasing debility 
 does not cause death, the condition becomes recognisable by the 
 development either of intestinal obstruction or of an acute perfora- 
 tive peritonitis. 
 
 In a case of multiple strictures of the small intestine, of unknown character, 
 reported by Faber '"', besides uncharacteristic intestinal disturbances, there 
 were marked symptoms of a severe pernicious anaemia from which the patient 
 died. Faber explained the pernicious anaemia by absorption of certain toxic 
 products which developed above the stenosis. The correctness of the ex- 
 planation may be questioned. At all events, the occurrence of progressive 
 anaemia in connection with stricture of the small intestine is interesting. 
 According to Faber the same observation had already been made by John- 
 son and Wallis ^^. 
 
 Since stenosis of the lower small intestine produces symptoms 
 only when very far advanced, the diagnosis is very difficult. If the 
 diagnosis of a jejuno-ileal stenosis has already been established by a 
 careful analysis of the history and of other data, it will not be dif- 
 ficult to determine its character. Moreover, as above seen, we must 
 always think of the possibility of multiple intestinal stenoses, the 
 clinical diagnosis of which, as far as I know, has never been made. 
 
 Differential Diagnosis 
 
 The differential diagnosis must first establish the fact of a steno- 
 sis of the upper part of the intestines, and then more exactly define 
 the situation as well as the cause of the same. 
 
 The clinical picture of high duodenal stenosis is so similar to 
 that of pyloric stenosis, that, as previously mentioned (page 346), 
 only especially favourable circumstances can make differentiation 
 possible. On the other hand, so far as known, the permanent 
 presence of bile in the stomach always points to the existence of 
 infrapapillary duodenal stenosis. It is questionable whether the 
 absence of bile from the stomach excludes the latter disease. In 
 his oft-quoted work Herz concludes that in dilatation of the stom- 
 ach the presence of bile may not be recognised, so that the symp- 
 toms of pyloric stenosis predominate in the clinical picture. But 
 it requires further confirmatory evidence to determine whether this 
 difficulty can be overcome by washing out the stomach in the even- 
 
354 DISEASES OF THE INTESTINES 
 
 ings and examining the contents of the fasting stomach, a pro- 
 cedure which I always recommend. 
 
 The above data apply to the differentiation between stenoses 
 of the upper segments of the small intestine and those of the 
 lower. There is generally great diificulty in distinguishing be- 
 tween a deep strictui'e of the small intestine and stricture of 
 the large intestine. Subjectively the occurrence of frequent diar- 
 rhoea and the gastric disturbances (nausea, vomiting, anorexia, etc.) 
 may be of diagnostic value, but constipation, and alternate con- 
 stipation and diarrhoea, may also occur in stenosis of the large 
 intestine. Objectively^ marked, visible peristalsis may lead to a 
 probable diagnosis of the obstruction. We vdll discuss this more 
 fully in the section on stenosis of the large intestine. The lower 
 the stenosis the more feculent will be the masses which are 
 regurgitated into the stomach. Finally, in deep stenosis of the 
 small intestine, particularly when far advanced, more or less me- 
 teorism develops. 
 
 In the determination of the cause of the stenosis we must first 
 decide whether the process is malignant or benign. If malignancy 
 can be excluded, we should look for an etiological connection be- 
 tween some previous disease and the benign stricture. In stenosis 
 of the upper j^ortion of the duodenum we ought examine for dis- 
 ease of the neighbouring organs — of the liver, gall bladder, pan- 
 creas, and right kidney. Lower dovra we must think of adhesions, 
 of kinking, of compression — conditions produced by disease of the 
 female pelvic organs, the appendix, and by other local peritonitic 
 processes. The other varieties of stenosis mentioned above are of 
 secondary importance ; although the clinical symptoms be very com- 
 plete their diagnosis is sometimes impossible. 
 
 (J) Stenosis of the Large Intestine 
 
 The subjective symptoms are constipation and colic associated 
 with nausea and vomiting. The constipation has significance only 
 in connection with other symptoms; it may deserve consideration 
 because of the manner of its occurrence. If a patient, particularly 
 one in advanced life, in whom the intestinal functions have always 
 been normal and who has not changed his diet or way of living, 
 suddenly develop constipation, it is always a significant symptom, for 
 habitual constipation is not a disease of advanced age, but of youth 
 and middle age. Furthermore, its course is to be observed. In 
 contrast to simple intestinal atony, this constipation does not develop- 
 
INTESTINAL STENOSIS 355 
 
 gradually, but very rapidly, and it reaches its highest point very 
 quickly. Laxatives become useless in a few weeks or months, and 
 the patient is soon forced to use drastic cathartics. I have already 
 called attention to the great practical importance of circumspection 
 in the use of laxatives in consti23ation. A one-sided view of this 
 subject should not, however, be taken, for exceptions are some- 
 times met with. 
 
 In other cases the constipation exists for years as a harmless 
 complaint, before it becomes more severe. The patient who for- 
 merly got along with rhubarb must now use aloes, bitter waters, or 
 colocynth, and these always in large doses. 
 
 In addition, spasmodic, paroxysmal intestinal pains call atten- 
 tion to the presence of an intestinal obstruction. In conjunction 
 with spasmodic intestinal rigidity (soon to be more minutely de- 
 scribed), these pains assume a significant character. 
 
 Yomiting is an important and, to my mind, not sufficiently 
 valued symptom in stenosis. It recurs with the intestinal colic, and 
 in itself presents nothing characteristic. It derives its importance, 
 however, from the fact that it is extremely rare in stercoraceous 
 flatulency. If the vomiting recurs with each severe attack of 
 colic, it ought to warn the practitioner and cause him to suspect 
 intestinal stenosis. 
 
 Objective Synipto'ms. — The most important objective symptoms 
 are meteorism, palpable and visible intestinal contractions occur- 
 ring at intervals, and changes in the character of the stools. 
 
 The meteorism varies according to the degree and seat of the 
 intestinal stricture. It is scarcely appreciable in strictures of the 
 rectum (to be described later), considerable in stricture of the 
 descending colon, and most extensive when the stricture is in 
 the upper segments of the large intestine. It also varies with 
 the amount of fulness of the suprastenotic intestinal segments. 
 It may be very moderate after abundant evacuation, and in- 
 crease considerably after a few days of obstinate constipation. 
 It depends upon the sufficiency of the hypertrophic intestinal 
 muscle above the stricture — so much so that we should always 
 regard increasing meteorism as a precursor of approaching intes- 
 tinal paralysis (eventually in connection with peritonitis). As long 
 as the lumen is to some extent permeable, the tympanites will 
 be inconsiderable, and limited to one or both iliac regions (" flank 
 meteorism," l^othnagel *), the mesogastrium, the umbilical region, 
 
 * Loc. cit., p. 375. 
 
356 DISEASES OF THE INTESTINES 
 
 or the hypogastriura. Therefore, with certain reservations we can 
 draw important conclusions regarding the site of the obstruction 
 from careful observation of the tympanites. 
 
 We can sometimes define the extent of the tympanitic area by 
 percussion, or better, by auscultatory percussion. IS'othnagel has 
 pointed out that in stenosis of the large intestine, instead of the 
 normal more or less marked dulness and low resonance in the 
 upper lumbar region posteriorly, there is often a loud and deep 
 percussion note ; this is present on both sides in stenosis of the 
 sigmoid flexure or of the descending colon, and only on the 
 right side in stenosis of the splenic flexure or of the transverse 
 colon. 
 
 Visible peristalsis associated with intestinal rigidity is much 
 more significant than tympanites. As has been already mentioned 
 (page 68), visible peristalsis as such not infrequently occurs nor- 
 mally in emaciated individuals, particularly in women with dias- 
 tasis of the recti muscles or ptosis of the abdominal viscera. 
 It has also been observed as a motor neurosis, which was first 
 described by Kussmaul under the name of " tormina ventriculi." 
 Both forms, however, are entirely distinct from visible intes- 
 tinal peristalsis, for in the latter the intestinal spasm and the 
 circular palpable and visible intestinal contraction and rigidity 
 are absent. 
 
 In every spasmodic peristaltic action several phases may be 
 distinguished : a gradual onset, which is accompanied by mo.d- 
 erate pain ; steady increase of the pain up to its point of greatest 
 severity while the bowel is contracted and rigid ; finally, rapid 
 abatement of the attack, with the occurrence of palpable and 
 audible intestinal sounds — i. e., sounds of gas forced through the 
 stricture. 
 
 The intestinal contraction may be limited to a small portion of 
 the gut, or whole coils may contract, become snakelike and swol- 
 len, and again relax. The former variety (limited contraction) is 
 observed principally in stenosis of the colon below the csecum, the 
 latter in stenosis of the csecum and small intestine. The degree of 
 the stenosis will naturally greatly influence the extent of the tetan- 
 ically contracting intestines involved, and the frequency of the 
 attacks. 
 
 Can any conclusions as to the seat of the obstruction be drawn 
 from the configuration of the intestinal rigidity ? 
 
 Based upon the experience of others and myself in this relation, 
 
INTESTINAL STENOSIS 357 
 
 this question must be answered in the affirmative. Thus it is 
 easy to recognise a caecal stenosis from the active peristalsis of the 
 small intestine. Stenoses lower down are also easily recognised if 
 rigidity of the large intestine is well defined. Nothnagel * cor- 
 rectly states that errors can only arise when the intestine adjoining 
 the stricture has lost its power of contraction, and the segment 
 immediately above acts vicariously for the latter. 
 
 The important facts regarding the character of the stools in 
 stenosis of the large intestine have already been described in the 
 chapter on Neoplasms (pages 310 and 311), as well as under the gen- 
 eral symptomatology of the present chapter (page 345). In both 
 places we have mentioned the slight significance of this symptom, 
 and we wish to repeat here that the absence of stenotic stools does 
 not exclude the diagnosis of stenosis of the large intestine. The ad- 
 mixture of pus and blood in the stools is not chamcteristic of intes- 
 tinal stenosis, but only indicates the presence of complications — 
 neoplasms, hemorrhoids, partial or chronic intussusception, ster- 
 coraceous ulcers, etc. 
 
 Very rarely all these symptoms are combined. In such instances 
 we must be content with a probable diagnosis. At all events, when 
 "well-defined symptoms of stenosis of the large intestine are present 
 the diagnosis will not long remain in doubt. 
 
 The question of the cause of the stenosis is a much more difficult 
 one. The history gives us considerable assistance. It may inform 
 us respecting previous dysentery, tubercular disease of the intes- 
 tine, or of other organs, occasionally of syphilis, appendicitis, peri- 
 tonitis, in women, puerperal fever and other diseases of the geni- 
 tal tract, incarcerated hernia, intestinal obstruction, abdominal 
 operations. In this manner we may gain valuable hints for the 
 diagnosis. 
 
 The examination per rectum, and in women per vaginam, is of 
 importance and should never be neglected. Thus in an otherwise 
 well-defined case of stricture of the large bowel, I was recently 
 able to distinctly palpate a contracting coil of small intestine in 
 the small pelvis. In some cases vaginal examination, or com- 
 bined rectal and vaginal examination, may give important informa- 
 tion regarding the situation and character of a suspected stenosis 
 of the large intestine. 
 
 The external examination of the abdomen is, however, most 
 
 * Loc. cit.. p. 376. 
 24 
 
358 DISEASES OP THE INTESTINES 
 
 instructive. If a tumour can be felt, and its precise nature is in 
 donbt, a careful examination is necessary, with especial considera- 
 tion of the age of the patient and the comparative frequency of 
 the various tumours (the rarity of benign, the much greater fre- 
 quency of malignant neoplasms). 
 
 Differential Diagnosis 
 
 A description of the etiology has already been given. When 
 spasmodic intestinal contractions are absent it will be difficult to 
 avoid diagnostic errors. This will be the case, for instance, in 
 intestinal stenosis when the obstruction is not as yet marked or 
 can be easily overcome by contraction of the intestine above the 
 stricture. If there is no marked disturbance of nutrition, as 
 in intestinal cancer, the patients do not as a rule present them- 
 selves for medical examination at this early stage of the disease. As 
 already mentioned, the presence of the initial symptoms of stricture, 
 be they ever so slight, should make us suspect a mechanical obstruc- 
 tion in the bowel. If, in addition, the history confirms our suspi- 
 cion and other objective signs of disturbed intestinal functions are 
 present (diarrhoeas, blood, pus, and loss of weight), it may be 
 possible to make an early diagnosis. It need hardly be men- 
 tioned that if tumours, adhesions, and infiltrations about the large 
 intestine are found, they offer important data for clearing up 
 the diagnosis. Despite these favourable conditions and because of 
 the many other etiological possibilities there will always be doubtful 
 cases. It is impossible to consider all the differential diagnostic data, 
 for we should become lost in the immense literature of the subject.. 
 
 B. INTESTINAL OBSTRUCTION (Ileus) 
 
 Intestinal obstruction is a condition in which the lumen of one 
 or more portions of the intestines is occluded, and the normal 
 forward movement of the contents entirely suspended. Since the 
 earliest days of medicine the resulting clinical picture has been 
 called ileus (from eiXeeco = misereor, or e/Aeco ^ torqueo). 
 
 In his book on intestinal diseases, Nothnagel advocates the discontinu- 
 ance of the term ileus. It is true that the ileus of the older physicians, with 
 its extremely vague meaning, has not the same significance as the ileus of 
 to-day. The word as used at j^resent may stand as a short and forcible desig- 
 nation for intestinal obstruction. For purely practical reasons we shall retain 
 the old classification, as accepted by Leichtenstern, of mechanical, dynamic,, 
 and mechanico-dynamic ileus. 
 
INTESTINAL OBSTRUCTION 359 
 
 Through interference with the normal course of the faeces at any 
 point, a number of severe symptoms soon develops. These gen- 
 erally begin suddenly, soon become very severe, and either cease 
 spontaneously, or, if not cured by internal or surgical means, cause 
 the death of the patient. 
 
 We shall describe those varieties of intestinal obstruction which 
 are especially important to internal medicine. The obstructions 
 produced by external hernia will be incidentally touched upon, since 
 they are treated of in surgical text-books. 
 
 General Symptomatology and Diagnosis of Intestinal 
 Obstruction 
 
 As a typical example, let us take an acute obstruction of the small 
 intestines due to strangulation : An individual, previously healthy, 
 is suddenly seized with severe colicky pains in the abdomen, vomit- 
 ing of the ingesta, partially or not at all digested. There is abso- 
 lute anorexia, the abdomen rapidly becomes distended, neither fseces 
 nor flatus are passed. Intense nausea is present even when the 
 stomach is empty. The urine is diminished, or there is anuria. 
 There is severe thirst, particularly after repeated vomiting. The 
 patient looks very ill as if sufEering from a severe acute disease. 
 
 The vomiting consists at first of food remnants, and when the 
 stomach is empty is bile-tinged or grayish-green ; gradually it 
 becomes feculent, and finally fsecal. 
 
 With the onset of the vomiting pain and meteorism may tem- 
 porarily cease, giving new hope to the patient and relatives, or 
 to the physician. The sym]3tonis very soon become aggravated ; 
 the pain reappears, the abdomen becomes more tympanitic, and 
 even by the laity the repeated severe fsecal vomiting is recognised 
 as a sign of intestinal obstruction. 
 
 There is also a marked change in the patient's general condi- 
 tion. The lack of nourishment, the loss of sleep produced by the 
 pain and vomiting, and, above all, the shock caused by the strangu- 
 lation, produce a condition of deep collapse. In sharp contrast to 
 the latter, the patient retains full consciousness, and only just before 
 death may delirium appear. This condition of extreme collapse, 
 which has not inaptly been compared to the algid stage of cholera, 
 is soon followed by dissolution. 
 
 This is a short description of a typical case of acute obstruc- 
 tion. The several symptoms, and particularly the objective clinical 
 picture, require a closer study. To avoid repetition it is best to 
 
360 DISEASES OF THE INTESTINES 
 
 analyze both together and to point out their significance. For 
 this purpose the general symptoms relating to intestinal ob- 
 struction will first be considered, and the special diagnosis of 
 the several varieties of obstruction will be reserved for later dis- 
 cussion. 
 
 The subjectwe symptoms are pain, nausea, vomiting, retention 
 of gas and faeces. 
 
 1. Pain. — This constitutes the main symptom of intestinal 
 obstruction. It is present in all forms, but it may vary in inten- 
 sity and other characteristics. 
 
 The pain is most intense and continuous in obstruction of the 
 small intestine, independent of its anatomical cause. Its severity 
 is such that even strong people are overcome. The pains are 
 more continuous in character than in stenosis. As I have already 
 mentioned in the general division (page 58), Treves ^'^ gives great 
 diagnostic importance to this sign. This is true, however, only 
 with certain limitations. The seat and type of obstruction are 
 doubtlessly prominent factors. In the first place, as several cases 
 of incomplete intestinal obstruction reported by Treves show, 
 the pain may be intermittent in character, and this may be the 
 case in well-marked obstruction of the small intestines provided 
 copious vomiting affords temporary relief to the occluded bowel 
 segment. The continuance or discontinuance of the pain may be 
 obscured by the use of narcotics and stomach lavage, but we must 
 in general agree with the conclusions of Treves ^^. It is important 
 to note whether the pain, which was continuous, shows marked 
 remissions, for with cautious reservations this would point either 
 to a favourable termination or to a transition from a complete to 
 an incomplete obstruction. 
 
 The localization of the pain possesses on the whole no great 
 significance. In the majority of cases the pain is localized in the 
 neighbourhood of the umbilicus, but, as Treves has demonstrated, 
 this by no means signifies that the site of the obstruction is to be 
 sought for in that region. 
 
 We must distinguish between abdominal sensitiveness to jpi^essure 
 and subjective pain. The former is generally absent in the begin- 
 ning of the disease ; in the later stages it may be either circum- 
 scribed or diffuse. Circumscribed pressure sensitiveness occasion- 
 ally occurs in the first days of the obstruction ; it then has a certain 
 significance, since it points either to an active inflammation of the 
 intestine in question or to a local peritonitis. Difl:use sensitiveness. 
 
INTESTINAL OBSTRUCTION 361 
 
 in connection witli other symptoms (fever, etc.), points to a 
 general peritonitis. Treves speaks of another form of sensi- 
 tiveness which is developed late in the disease, and which is 
 to be looked upon as the consequence of spasmodic intestinal 
 peristalsis. In contrast to diffuse peritonitis, this sensitiveness is 
 only moderate. 
 
 In all varieties of obstruction pain may cease toward the end of 
 the disease. ISTothnagel believes this is due to intestinal paralysis 
 or to perforative peritonitis, but it is probably also caused by the 
 ensuing collapse and lessened vitality. 
 
 2. Vomiting. — This is one of the most regular symptoms of 
 the disease. The initial vomiting is no doubt reflex in character, 
 analogous to the vomiting of acute peritonitis, of gallstone and 
 kidney-stone colic, or of pregnancy. In the beginning the vomited 
 matter almost always consists of the stomach contents or mucus, 
 and, if severe, contains bile. 
 
 The transition to stercoraceous vomiting is recognised by the 
 bringing up of brown, slightly fetid, or feculent masses. When the 
 obstruction has developed very acutely, the vomiting may be fsecal 
 from the very beginning. Fsecal vomiting consists of fluid, or 
 occasionally of fragmentary brownish-yellow or brown-coloured 
 masses. Yomiting of formed scybala, which is reported by well- 
 known clinicians (Rosenstein ^, Jaccoud^, Briquet ^^), is certainly 
 extremely rare. 
 
 Ever since the time of Galen the cause of stercoraceous vomit- 
 ing has been the subject of lively discussion. We shall briefly con- 
 sider some of the theories which have been offered. 
 
 The old idea that fsecal vomiting depends upon perfect or imperfect action 
 of the ileo-csecal valve must be given up, in view of the fact that such vomiting 
 occurs in obstruction of the small as well as of the large intestine. It must 
 be admitted, however, that in the latter instance there is an insufficienc\' of 
 Bauhin's valve, the valve being capable of offering only a certain relative resist- 
 ance to the pressure of the stagnant fsecal mass. For a long time the exist- 
 ence of antiperistalsis has been disputed. That antiperistalsis vxay occur, 
 has been proved by Nothnagel's experiments on rabbits with common salt, 
 but Nothnagel has never tested his theory in intestinal stenosis. The ex- 
 planation given by Haguenot in 1813, as reported by Leichtenstern^^, is ample 
 for the comprehension of faecal vomiting. It is briefly as follows : Strong pres- 
 sure is brought to bear upon the site of obstruction by the accumulating faeces 
 and gas, and this pressure is increased by every respiration, by every act of 
 vomiting, and by every active intestinal contraction. Since the stagnant intes- 
 tinal contents have no other avenue o^ escape, it is apparent that even the act 
 of vomiting, accompanied as it is by contraction of the diaphragm and abdom- 
 
362 DISEASES OP THE INTESTINES 
 
 inal muscles, will force these masses toward the stomach. In like manner, 
 the tympanitic intestines may act as stimuli in forcing the stagnant masses 
 toward the stomach. Henle appropriately called this an "overflow " of fluid 
 into the stomach. Haguenot's theory also explains why faecal vomiting occurs 
 much easier and more extensively in obstruction of the small than of the large 
 intestines. 
 
 Because it is easily recognised, fsecal vomiting is one of the most 
 important symptoms of organic intestinal obstruction. We shall 
 see later, however, that it may also be present in simple spastic and 
 paralytic intestinal obstruction (compare page 403). 
 
 3. Constipation. — In complete intestinal obstruction constipa- 
 tion is generally absolute, and continues as long as the disease. 
 Neither faeces nor gas are passed. To this rule there are a very few- 
 noteworthy exceptions. Rectal irrigations may wash out small faecal 
 particles from the intestines below the site of the occlusion, but 
 these are small, and always consist of faeces that were adherent to 
 the intestinal walls {Randkoth). It is important to note that, in 
 these cases, flatus is always absent. Besides such stools, Treves ^^ 
 has reported several cases with autopsies, in which more or less 
 abundant evacuations were present during the course of the disease. 
 Some of these cases he explained by sudden intestinal peristalsis from 
 an intercurrent peritonitis (?). The explanation is much clearer in 
 two of the cases. In the one instance there was an incarceration of 
 about 20 centimetres of the ileum produced by a strand running 
 from the transverse colon to the caecum. An intestinal ulcer had 
 perforated, the tension of the distended intestines was thus lessened, 
 and the incarcerated coil was thereby enabled partly to escape from 
 the constricting bands. 
 
 In partial volvulus of the small intestine or sigmoid flexure 
 some faeces may be passed. Abundant evacuations are by no means 
 rare in acute intestinal invagination. 
 
 In the article already cited. Litten ^^ describes a case of multiple 
 tubercular strictures of the small intestine, in which both profuse 
 diarrhoea and faecal vomiting were present. He correctly concludes 
 that there was very advanced though not complete obstruction of 
 the bowel. 
 
 Finally, J^aunyn has pointed out the paradoxical occurrence of 
 evacuations in obstructions by gallstones. When we come to de- 
 scribe the various kinds of intestinal obstruction we shall more fully 
 analyze these difl^erent features, which are so important for the semei- 
 ology of this affection. 
 
INTESTINAL OBSTRUCTION 363 
 
 Objective Signs. — These are tympanites, visible peristalsis, intes- 
 tinal liemorrhage, changes in the urine, and disturbances of general 
 health. 
 
 1. Tympanites is always present in intestinal obstruction, but its 
 amount varies. In acute obstruction of the small intestines, with 
 «udden onset, it is relatively slight. The tympanites is extremely 
 marked in obstruction of the large intestine, particularly in its most 
 frequent form — volvulus of the sigmoid flexure. In the present 
 state of our knowledge we may distinguish two forms of tympanites, 
 tympanites due to stagnation of contents and local tympanites. 
 The former develops in the large or small intestines when the 
 lumen is obstructed by foreign bodies, invagination, impacted faeces, 
 etc. Fluids and gas stagnate above the stenosis and distend the 
 bowel, and the less the amount of gas absorbed the greater the dis- 
 tention (Zuntz and Tacker). 
 
 In the beginning of the disease, when the intestinal wall is still 
 fairly intact, meteorisra will be only moderate ; it gradually increases 
 with destruction and over-distention of the intestinal wall. 
 
 Local tympanites., already reported by Kiittner^'^ and Hilton 
 Fagge^^, is very much more important than the above form. Its 
 importance as a diagnostic factor, however, is due especially to von 
 Wahl and his pupils, von Zöge-Manteuifel and Kader, as well as to 
 Obalinski and Schlange. Yon "Wahl ^^ first called attention to the 
 apparent paradox, that in intestinal obstruction where the tympa- 
 nites is most marked (volvulus, invagination, kinking) the coil in 
 which the obstruction exists is the most tympanitic, for it is this 
 very coil which, through disturbance of its circulation and putre- 
 faction of its contents, is the first to be distended by gas. The 
 formation of gas is accompanied by considerable distention of the 
 bowel wall, and very rapid complete paralysis. 
 
 This distended, resistant, and immovable por- 
 tion of the intestine is recognised by inspection 
 from the shape of the abdomen, and by palpation, 
 from its clearly increased resistance (von Wahl). 
 
 From extensive experiments on animals, Kader ^'^ has given us 
 conclusive proof of von Wahl's theories, and has explained satis- 
 factorily the occurrence of local meteorism. This experimenter 
 showed that the chief cause of the meteorism lies in the disturb- 
 ance of the circulation of the intestinal wall ; the tympanites is 
 explained by the increase in the size of the bowel, which is pro- 
 duced by the following three factors : infiltration of the intestinal 
 
364 DISBASES OF THE INTESTINES 
 
 wall, accumulation of fluids in the canal, and the development of 
 gases in the interior of the intestine. The bowel segment in ques- 
 tion soon becomes distended and tense, often within a few hours. 
 Changes in the intestinal wall (oedema, hemorrhagic infiltration^ 
 thickening of the intestinal wall and its mesentery) occur through- 
 out the obstructed segment and are limited to this part. Finally, 
 there is gangrene of the intestine, frequently with perforation into 
 the abdominal cavity. These perforations are often so minute that 
 they are only demonstrable by distending the bowel under water. 
 As to the diagnostic value of this fixed, distended coil of intestine, 
 when the clinical symptoms are well marked, its presence is doubt- 
 less sufficient, and occasionally even conclusive. Its recognition 
 necessitates a series of careful examinations. According to the 
 description of von Zöge-ManteuffeP^, the method of the examina- 
 tion of this tympanitic coil is as follows : " After the history has 
 been taken and the general condition of the patient noted, the 
 abdomen should be carefully inspected. The smallest asymmetry 
 must be taken into account. We should observe whether the asym- 
 metry remains constant, whether it changes with active peristalsis, 
 whether intestinal movements become apparent, or whether — and 
 this is very important — there be not abnormal quiet beneath the 
 tense, distended abdominal walls. Palpation, which follows inspec- 
 tion, must attempt to establish differences of resistance. On pal- 
 pation, a strangulated, tympanitic coil of intestine feels quite differ- 
 ent from the normal intestine containing fluid faeces. Requiring 
 more space, it forces itself against the yielding abdominal wall, and 
 is thus directly accessible to examination. If vomiting occurs, the 
 resulting relief of tension may enable one to grasp this resistant 
 segment. This is especially easily accomplished during chloroform 
 narcosis." 
 
 The diagnosis of internal incarceration, strangulation, or volvulus 
 is facilitated if such a distended immovable coil of intestine is pres- 
 ent. Based upon von Wahl's symptom, the diagnosis of these forms 
 of intestinal obstruction has repeatedly been correctly made, and the 
 cases thereupon successfully operated. But von Wahl's sign is 
 not absolutely trustworthy, when, for instance, as he himself 
 states, a larger intestinal mass is strangulated. Schede ^^ points out 
 that the fixed intestinal coil may be covered by distended intes- 
 tines lying above the obstruction. Despite all this, however, we 
 shall have to look for von Wahl's sign in every case of intestinal 
 obstruction. 
 
INTESTINAL OBSTRUCTION 365 
 
 2. Spasmodic Intestinal Peristalsis. — Though a classic symptom 
 of chronic intestinal obstruction, spasmodic intestinal peristalsis, 
 according to the opinion of all careful observers, is one of the rarer 
 symptoms of aciite intestinal obstruction. Fenwick^ denies its 
 occurrence; Nothnagel* mentions it, but directs attention to the 
 great contrast between the marked intestinal rigidity in stenosis and 
 its weak contraction in complete occlusion. Schlange ^, Obalinski ^^, 
 and ISTaunyn^''^ consider the slight peristalsis of the "fixed coil "a 
 very important symptom of acute intestinal obstruction. The 
 first two authors also consider it of practical significance for it 
 indicates vital irritability of the bowel ; but this statement is dis- 
 puted by von Zöge-Manteuffel. According to Schlange, peri- 
 stalsis of the intestine proximate to the obstruction is best ob- 
 served in strangulation of smaller coils and in obstruction by 
 obturation. Naunyn, who has described a case in point, states 
 that this phenomenon may also occur in volvulus without strangu- 
 lation. I myself have never observed intestinal peristalsis in acute 
 obstruction in the course of a chronic stenosis, and I consider the 
 absence of such peristalsis as an evidence of a coinplete intestinal 
 obstruction. 
 
 3. Intestinal hemorrhages may occur under several conditions. 
 They are most frequent in intussusception, but, as Henoch and 
 Wilms have shown, are occasionally found after herniotomy, after 
 reduction of the hernia (Schnitzler), in strangulation, gallstone 
 obstruction, and more frequently in vohoilus of the sigmoid flex- 
 ure and other portions of the intestines. As Tietze ^ has recently 
 demonstrated, hematemesis may occur in intestinal obstruction 
 as a result of severe destructive tissue changes in the proximal 
 segment. Intestinal hemorrhage is only of significance in con- 
 nection with the symptoms. "When present, it speaks rather for 
 strangulation of the small intestine than for obturation. We have 
 already mentioned, in the chapter on Intestinal Carcinoma (page 308), 
 that hematemesis may also occur in stenosis of the large intestine. 
 
 4. Changes in the Urine. — The excretion of urine is dimin- 
 ished on account of the very rapid collapse, the vomiting and the 
 little nourishment taken. This oliguria is not especially charac- 
 teristic, but the indicanuria which is frequently present may, 
 according to JafEe, have a certain diagnostic significance in re- 
 lation to the site of obstruction, Numerous examinations have 
 
 * Log. cit., p. 211. 
 
366 DISEASES OF THE INTESTINES 
 
 confirmed Jaffe's claims that marked indicanuria is present in 
 the first days of obstruction of the small intestine, and may be 
 of diagnostic value. If at such time marked indicanuria is ab- 
 sent, it would speak rather for occlusion of the large intestine. 
 Later in the disease pronounced indicanuria may also occur in 
 obstruction of the large intestine, and hence loses all significance. 
 If even then no indican is present it would point still more to an 
 obstruction of the large intestine. Indican may be increased in 
 other affections than intestinal obstruction, and its value must 
 always be cautiously accepted. 
 
 What is true of indicanuria is also true of Rosenbach's reaction. 
 I have never heard of a marked Eosenbach reaction that was not 
 accompanied by an increase of indican in the urine. 
 
 Besides indicanuria we may find albumin and casts, particularly in incar- 
 cerated hernise (Englisch^', Frank*"), and in severe intestinal stenoses (von 
 Engel*'); hemorrhagic nephritis vpas observed by Israel in a case of volvulus 
 of the sigmoid flexure *^. 
 
 5. General Condition. — In all varieties of intestinal obstruc- 
 tion the general condition of the patient suffers greatly. ITaturally 
 there are differences in the several forms of obstruction. Age, con- 
 stitution, and other factors have their infiuence here as they do in 
 other pathological conditions, all, however, being of secondary 
 importance to the shock. To a certain extent the degree of the 
 shock indicates the site and perhaps the nature of the obstruction. 
 Thus it is a well-known fact that in occlusion of the small intes- 
 tine, particularly its most frequent pernicious variety — strangula- 
 tions and incarcerated hernise — the clinical symptoms very rapidly 
 reach their greatest severity. Obstruction of the large intestine, 
 on the other hand, is more gradual in its development, and hence 
 the collapse is less severe and is more slowly developed. We can- 
 not here go into the details of the theory of collapse, in which 
 different factors require consideration (reflex action, loss of water, 
 intoxication, peritonitis, cardiac insufficiency, etc.). 
 
 6. Clinical Examination. — Clinical examination may give us 
 valuable aid. The well-known rule — very careful examination of 
 the external hernial orifices in cases of intestinal obstruction — should 
 never be forgotten. We must first of all determine whether an 
 incarcerated hernia has been actually or partially i-educed en masse. 
 Medical literature abounds with cases of obstruction due to incom- 
 plete or apparent reduction. Digital examination of the vagina 
 
INTESTINAL OBSTRUCTION 36Y 
 
 and rectum is quite important, and sometimes gives useful in- 
 formation. 
 
 In the general division we have mentioned the most important 
 considerations regarding inspection, percussion, auscultation, and 
 palpation. I would again mention the diagnostic value of auscul- 
 tatory percussion^ first described by Leichtenstern * and later by 
 Curschmann ^^, by means of which it is often possible to localize dif- 
 ferent portions of the intestines. 
 
 The significance of distention of the rectum with air and liquids 
 has already been treated of at length in the general division. We 
 again repeat that these methods may serve to confirm a diagnosis of 
 obstruction in the lower portions of the intestine, though they are 
 useless in obstructions higher up. 
 
 Differential Diagnosis of Intestinal Obsteuction 
 
 If the clinical picture of obstruction is well developed, and its 
 course can be followed from the onset, the diiferential diagnosis 
 between ileus and its related conditions is rarely diflicult. If, 
 however, the beginning be obscure, the symptoms not well marked, 
 or complications present, the diagnosis becomes very difficult. 
 Among the conditions which are generally easily differentiated 
 from intestinal obstruction are flatulent colic, cholelithiasis and 
 nephrolithiasis, poisoning, and cholera. 
 
 1. Flatulent Colic. — If observed in the earliest stages, differen- 
 tiation between intestinal obstruction and flatulent colic may be 
 difficult, particularly if the severe symptoms of obstruction have 
 gradually developed. The history, clinical examination, and the 
 further course of the disease are important in this connection. 
 The history shows that the patient has often suffered from similar 
 attacks as well as from irregular bowels. Symptoms of severe 
 shock are absent in intestinal colic. Though flatus is generally 
 not passed in such cases, some gas may be passed and thereby relief 
 obtained. Yomiting, one of the early symptoms of intestinal ob- 
 struction, is very rarely present in simple flatulent colic. Further 
 observation will scarcely ever leave any doubt as to the nature of 
 the disease. 
 
 2. Gallstone and Renal Colic. — In the beginning of the attack 
 biliary and renal colic may very much resemble intestinal obstruc- 
 tion, especially an obstruction situated high up. Here, again, the his- 
 
 * Loc. eit., p. 407. 
 
368 DISEASES OP THE INTESTINES 
 
 torj is important. Biliary and renal colics usually occur late in life, 
 intestinal obstruction is found at all ages. It may be possible to pal- 
 pate the gall bladder or an enlarged painful liver or painful kidney. 
 The presence of slight icterus or of urine containing a small amount 
 of bilirubin, or of cloudy urine containing a marked sediment, may 
 point to the correct diagnosis. Finally, the presence of very marked 
 indicanuria in the beginning of the disease may aid in the differen- 
 tiation. "With careful observation the diagnosis should soon be made. 
 
 3. Poisoning has several times been mistaken for obstruction. 
 On the whole, however, error can only occur when no history can 
 be obtained or when the disease runs a very atypical course. 
 
 4. As recent reports have shown, cholera nostras or Asiatica 
 may cause dangerous mistakes, especially during a cholera epi- 
 demic, and particularly when that rare complication of obstruction 
 first described by Malgaigne — obstruction with profuse diarrhoeas 
 (cholera herniaire) is present. However, careful bacteriological and 
 other examination should nowadays make errors of this kind im- 
 possible. 
 
 5. Peritonitis and Perityphlitis. — Here, again, the history is 
 the most important, occasionally the only, aid in differential diag- 
 nosis. J^o circumstance in the present or previous history that may 
 have some connection with the disease should be neglected. Thus, 
 a previous typhoid, hematemesis, dysentery, or appendicitis may 
 clear up an otherwise obscure case. If the history renders no aid, 
 the differentiation is very difficult in cases which are at all compli- 
 cated, particularly where the onset was not sufficiently observed. 
 Is there intestinal obstruction only, or obstruction and secondary 
 peritonitis, or primary peritonitis, and — what is always pertinent to 
 etiology — what is the nature and origin of the process in question ? 
 
 Positive differential signs do not exist, since mild peritonitic 
 symptoms may be present in the early stages of intestinal obstruc- 
 tion and thereby lead to error. By a consideration of all the 
 important symptoms of both conditions it will be easier to arrive at 
 a correct diagnosis. These include fever, sensitiveness to pressure, 
 tympanites, abnormal peristalsis, vomiting, ascites, and changes in 
 the urine. 
 
 Ko positive conclusions can be drawn from the presence or 
 absence of fever. In diffuse peritonitis it may be entirely absent, 
 whereas in intestinal obstruction the fever, when present, is apt to 
 be only moderate. High fever from the very onset (39° C. and 
 over) would, in itself, indicate acute, diffuse peritonitis. 
 
INTESTINAL OBSTRUCTION 369 
 
 The sensitiveness to pressure is sometimes of diagnostic impor- 
 tance, but may be absent in peritonitis and be very marked in 
 obstruction. Still, sensitiveness to pressure is generally much more 
 accentuated in peritonitis than in obstruction ; in the latter it is 
 severe only when peritoneal complications are already present. The 
 situation of the area of sensitiveness is also of significance. If from 
 the beginning it has been localized in the right iliac fossa and has 
 remained there, the assumption of a perforative peritonitis follow- 
 ing perityphlitis is much more probable. 
 
 In like manner the tympanites is to be cautiously employed 
 as a differential factor. In peritonitis, as in obstruction, it may 
 be extensive or entirely absent. When present in peritonitis it 
 soon becomes general. This is in sharp contrast to some forms 
 of obstruction (strangulation) in which, as we have already seen, 
 meteorism is distinctly localized as long as there is no intestinal paral- 
 ysis. But even this symptom becomes only a theoretical distinctive 
 characteristic when we are dealing with a large sacculated peri- 
 toneal exudate which may produce the same physical signs as a 
 distended coil of intestine in obstruction. 
 
 Well-marked, visible, and palpable intestinal peristalsis is a valu- 
 able symptom of intestinal obstruction, but unfortunately it is absent 
 in the greater number of cases. Besides, slight evidences of peri- 
 staltic motion may easily be overlooked. The absence of all intes- 
 tinal motion and sounds tends to support the diagnosis of peritonitis, 
 but even this is no convincing proof. 
 
 Vomiting is a symptom of both diseases, and may make difficult 
 or frustrate all differentiation. The early appearance of fsecal vom- 
 iting speaks rather for obstruction than for peritonitis. Though 
 feecal vomiting occasionally occurs in peritonitis with intestinal 
 paralysis, it is by no means as frequent as in intestinal obstruction. 
 The occurrence of a fluid exudate is found in peritonitis as well 
 as in several forms of intestinal obstruction (volvulus, strangula- 
 tion) ; this sign therefore possesses no differential significance. 
 
 The same is true of the amount of indican in the urine, which 
 may also be much increased in acute peritonitis. The absence of 
 marked indicanuria may, in connection with other signs, speak for 
 obstruction of the large intestine. 
 
 The greater part of what has been said above also applies to peri- 
 typhlitis, which is the most frequent cause of perforative peritonitis. 
 
 It is evident that those cases only ought to be differentially con- 
 sidered in which the clinical picture of severe intestinal obstruc- 
 
370 DISEASES OF THE INTESTINES 
 
 tion is present. Aside from the history of the case, which may give 
 us valuable information, distinct localized pain over McBurney's 
 point, even in a case of indirectly developed diifuse peritonitis, 
 moderate resistance, increased rigidity, or oedema of the abdomi- 
 nal muscles, may indicate the correct diagnosis. Where, as not 
 infrequently happens, these data are absent the diagnosis will long 
 be doubtful. 
 
 Symptomatology and Diagnosis of the Yaeious Kinds of 
 Intestinal Obstruction 
 
 I. External Intestinal Obstruction by Bands, Clefts, 
 Fenestra, and Internal Hernise 
 
 Of all types of obstruction the above variety is scientifically the 
 most interesting and the most frequent, but unfortunately diag- 
 nostically the most unfruitful. There are innumerable possibilities, 
 and it would require a monograph to carefully analyze and discuss 
 the different varieties of this type of obstruction. 
 
 We will therefore content ourselves with a brief description 
 of its most frequent forms. Since I have had but little experience 
 with these various types, I shall follow the excellent description 
 of Treves ^^. 
 
 Treves distinguishes five varieties of external intestinal obstruc- 
 tion. 
 
 1. Strangulation hy Isolated Peritoneal Adhesions 
 
 Since chronic local peritonitis is an extremely frequent condition, it is 
 apparent tiiat it is a prominent factor in the etiology of intestinal obstruc- 
 tion. Generally one peritoneal adhesion is jDresent (see Fig. 32j, rarely there 
 are several. This fact is of great surgical importance, for occasionally during 
 operation the obstruction is thought to have been overcome by ligation of a pseu- 
 do-ligament, but the continuance of the obstruction and autopsy show the jires- 
 ence of a second adhesion, the real cause of the constriction. The adhesions 
 in question are circular or in the form of strands, and vary considerably in 
 length and thickness ; they vary from the size of a thread to that of a finger. 
 According to Treves, the average length is 4 to 5 centimetres. Naturally, every 
 adhesion which strangulates the intestine must have at least two points of 
 attachment. One of its ends is very frequently connected with the mesentery. 
 In other cases both ends are thus attached, and then the points of insertion are 
 far apart (see Fig. 33, page 371). The number of possible attachments is as large 
 as the possible adhesions of the intestines with each other and with the remain- 
 ing abdominal organs. "There is scarcely any conceivable combination 
 of connected areas which is not illustrated in the history of these adhesions " 
 (Treves [p. 34]). 
 
Fig. 32. — Strangulation by a Broad Peritoneal Band passing between Two Adja- 
 cent Coils of the Ileum. (Treves.) 
 
 Fig. S3. — Strangulation of Small Intestine by a Solitary Band attached at Either 
 End to the Mesentery. (Ti-eves.) 
 
3Y2 
 
 DISEASES OP THE INTESTINES 
 
 It is a fundamental observation that some portion of the small intestines 
 is most frequently constricted, and that its most movable segment, the ileum, 
 is generally affected. 
 
 The organs from which the bands most frequently originate are the female 
 pelvic organs (pelvic peritonitis) and the caecum and 
 appendix. The number of possible variations still in- 
 creases vphen we consider the frequent anomalous dis- 
 placements of the several intestinal segments. 
 
 Besides strangulation by isolated peritoneal adhe- 
 sions, there is another form in which, because of peri- 
 tonitis, movable organs become fixed and thereby give 
 rise to obstruction. To this category belong particu- 
 larly the vermiform appendix, Meckel's diverticulum 
 (see opposite page), and in rarer cases the Fallopian 
 tubes, appendices epiploicse, and the mesentery, which 
 is changed into a strand. These organs form either 
 a band or an arch under which the intestine becomes 
 constricted, or they form a coil in which a portion of 
 the bowel is caught. The first is the more frequent 
 occurrence (see Fig. 34). 
 
 Fig. 84. — Strangtxlation 
 OF A Small Intestinal 
 Coil by a Long Liga- 
 mentous Strand. 
 
 practical 
 omentum 
 
 2. Strangulation through Clefts and Fenestra 
 
 This type of obstruction is rare and hence possesses only slight 
 importance. Clefts and fenestra are found most frequently in the 
 and mesentery. They may be congenital, but 
 are generally produced by trauma or by peri- 
 toneal inflammatory products, or they consist 
 of spaces which have been formed by peri- 
 toneal adhesions between different organs (uter- 
 us, ovaries, hernial canals, appendices epi- 
 ploicse, etc.). 
 
 Discussion of the several forms and varieties 
 is not appropriate to the scope of this work ; we 
 therefore refer to the thorough descriptions of 
 Treves ^^ and Leichtenstern \ 
 
 3. Strangulation hy Omental Bands 
 
 As strands are caused by peritonitis, so bands 
 may also develop from inflammation of the 
 mesentery. The latter (mesenterial bands) are 
 much larger in size than the former (see Figs. 
 34 and 35). They originate from traumatism, 
 pelvic peritonitis, or, in the majority of cases, 
 from peritonitis about a hernial sac, especially 
 femoral hernia. The left side is more apt to 
 be involved because the omentum generally lies 
 in that half of the abdomen,. As with peritoneal adhesions, so two or more 
 mesenteric ligaments may be present. 
 
 Fig. 35. — Internal Strangula- 
 tion of an Intestinal Coil 
 BY A Strand passing from 
 THE Omentum or Transverse 
 Colon to the Anterior Ab- 
 dominal Wall. fKönig.) 
 
INTESTINAL OBSTRUCTION 
 
 373 
 
 4. Strangulation ty MecTceVs Diverticulum 
 
 As is known, Meckel's diverticulum is due to a pervious or an incompletely 
 obliterated omphalomesenteric duct. The abdominal end of the diverticu- 
 lum is generally free ; only rarely is it adherent to the umbilicus as a solid strand 
 or pervious canal. It is evident that free mobility of the diverticulum is 
 the most frequent cause of knotting and volvulus, 
 but it sometimes forms a bridge under which 
 intestines become incarcerated. This type of 
 strangulation is generally the result of fixation of 
 the diverticulum by peritonitis. The diverticu- 
 lum is usually adherent to the mesentery, but it 
 may also adhere to other portions of the intes- 
 tines, the omentum, caecum, small intestines, or to 
 the pelvic organs, thereby possibly causing intestinal 
 incarceration. 
 
 When the diverticulum is abnormally long and 
 has a kind of club-shaped swelling at its free end, 
 a not infrequent type of obstruction may occur. 
 The diverticulum may form a sort of slipknot in 
 which the ampulla, being the thicker portion, tends 
 to tighten the knot (hence called by the French 
 ^'■clef de Vetranglemenf'') (see Fig. 36). We j)ass 
 over several other forms of obstruction which 
 are described by Treves, as they are more infre- 
 quent. 
 
 Fig. 36. — Internal Strangu- 
 lation OF A Loop of 
 Small Intestine by a 
 Meckel's Divektioulum 
 
 COILED about it. 
 
 a, attachment of the divertic- 
 ulum to the intestine, i, 
 its club-shaped end (Eeg- 
 nault-Beclard). 
 
 5. Strangulation from Internal Hernice, 
 
 According to Leichtenstern, internal hernise are those which lie either en- 
 tirely within the abdominal or thoracic cavities, or which are situated retro- or 
 subperitoneally, parallel to the abdominal wall and protrude into the abdomi- 
 nal cavity, but never, even by continued growth, appear externally. 
 
 By external hernise we mean those which push the peritoneum in an exter- 
 nal direction, and which, by continued growth, become externally visible 
 tumours. Leichtenstern, who has given us the most thorough description of 
 this subject, distinguishes three forms : 
 
 1. Very small, external hernise, which, particularly in fat individuals, may 
 remain latent throughout. 
 
 2. Interstitial herniae which run their course under the clinical picture of 
 an internal hernia. They originate from the different hernial canals, most fre- 
 quently from the inguinal. They occur either alone or in connection with 
 external inguinal or femoral hernise, whose subsidiary swelling they represent. 
 Interstitial herniae are generally the result of taxis and efforts at reduction. 
 Interstitial incarceration has often been observed in the presence of mobility of 
 the main hernia. 
 
 3. Finally, the following very rare herniae — important only surgically and 
 anatomically — run the course of the internal herniae, viz., obturator, sciatic, 
 perineal, rectal, vaginal, and lumbar herniae. 
 
 35 
 
374 DISEASES OF THE INTESTINES 
 
 With the exception of diaphragmatic hernia, true "internal hernise " can 
 hardly ever be diagnosticated. We therefore limit ourselves to the mention of 
 their names, and again refer to the exemplary description of Leichtenstern. This 
 author gives the following varieties of true internal hernia : hernia retro-peri- 
 tonealis anterior (hernia intra-iliaca, ante-vesicalis, retro-pubica, hernia interna 
 vaginalis testiculi, hernia iliaco sub-f ascialis) , hernia duodeno-jejunalis (Treitz's 
 hernia, of which about 50 cases have been described), hernia pericsecalis, hernia 
 intersigmoidea, hernia intra-epiploica, hernia ligam. uteri lati, hernia fora- 
 men Winslowii, and, finally, hernia diaphragmatica. 
 
 There are two forms of diaphragmatic hernia, the true and the false. The 
 former name is applied to those cases in which an abdominal organ or organs 
 have entered the pleural cavity through an opening in the diaphragm, and 
 which have as hernial covering either pleura or peritoneum, or both. The latter 
 name (false) is applied to those cases in which the abdominal viscera pass through 
 an opening both of the diaphragm and of the contiguous serous membranes 
 (pleura and peritoneum), the abdominal organs coming into direct contact with 
 the thoracic. Such visceral displacements must be looked upon rather as a 
 prolapse or ectopia than as a true hernia. Most diaphragmatic hernise are 
 "false." Of 254 cases, only 38 were true. 
 
 Entrance of the abdominal viscera into the chest cavity is caused either by 
 congenital defects of the diaphragm, by a physiologically preformed fenestrum, 
 or by an absence of continuity in the diaphragm from inflammation or (more 
 often) traumatism. 
 
 Congenital defects occur most frequently in the muscular portion of the 
 diaphragm, usually to the left side (in the proportion of 98 to 19), and occa- 
 sionally extend over an entire half of the diaphragm. Acquired diaphragmatic 
 hernife are also generally leftsided ; the place of entrance is more frequently in 
 the posterior than in the anterior portion of the midriff. 
 
 The preformed openings in the diaphragm which may give rise to hernige 
 are (1) the esophageal opening ; (2) the foramen of Morgagni (in that portion 
 of the midriff corresponding to the sternum and the seventh costal cartilage of 
 either side); (3) the foramen of Bochdalek (posteriorly between lumbar and 
 costal division of the diaphragm) ; (4) the point of entrance for the sympa- 
 thetic nerve (between the external and median crura). 
 
 The abdominal viscus most frequently displaced is the stomach; then follow 
 the transverse colon, omentum, small intestines, spleen, liver, pancreas, and 
 kidney. The greater curvature of the stomach is regularly found uppermost, 
 and the lesser curvature below. If the fundus alone be involved, and not the 
 pylorus, volvulus with incarceration of the stomach may follow. Two or more 
 organs are generally displaced. When only one viscus is displaced it is usually 
 the stomach, less frequently the colon, small intestine, or omentum. Most 
 cases of diaphragmatic hernia are accidentally discovered at the autopsy. They 
 sometimes produce significant symptoms, which under favourable circumstances 
 may lead to a diagnosis during life. Leichtenstern •**, who first successfully recog- 
 nised a case of diaphragmatic hernia, considers that the diagnosis may be made 
 if pneumothorax can be excluded, and if it can be proved that there are in the 
 thoracic cavity other air-containing organs, which upon auscultation and per- 
 cussion present differences depending upon their varying conditions of fulness. 
 
INTESTINAL OBSTRUCTION 375 
 
 Filling up the stomach or colon with air or water may aid the diagnosis. Dis- 
 placement of the heart to the right is also of diagnostic significance (P. Gutt- 
 mann^^ and Abel ^^). Finally, trans-illumination of the stomach, particularly, 
 its radiograph (by the introduction of a soft metallic sound), ought to make 
 diagnosis possible. 
 
 Symptomatology 
 
 Before discussing the individual symptoms of these forms of ob- 
 struction we must mention several facts of great practical impor- 
 tance. 
 
 First of all as to the seat of incarceration. In the overwhelming 
 number of cases the ileum is the segment affected ; the other intes- 
 tinal segments, both above and below the ileum, are so rarely affected 
 that they hardly come up for consideration. The cause of this fre- 
 quency of ileal incarceration lies in its anatomical position, and in 
 the possibility of its coming into contact with all those other organs 
 which are most apt to be incarcerated (mesentery, great omentum, 
 Meckel's diverticulum, vermiform appendix, pelvic organs, hernial 
 canals, etc.). 
 
 The age requires consideration. Though incarceration may occur 
 at all ages, yet statistics show that it is essentially a disease of early 
 life, that it is most frequent in the second decade, and that it occurs 
 only exceptionally in the later periods, or in the first decade. 
 
 Sex is also a factor, though the difference in this particular is 
 not sufficiently marked to allow of positive data to be based there- 
 upon. In women the puerperium and the diseases incidental thereto 
 are considered as predisposing factors. We find that appendix 
 affections, hernise, traumatism, and Meckel's diverticulum act more 
 frequently as predisposing factors in the male than in the female, so 
 that the proportion of incarcerations is, according to Leichtenstern, 
 180 males to 118 females. 
 
 In its important details the clinical picture of incarceration coin- 
 cides with that already given under general symptomatology. While 
 referring to the latter we again point out certain important symp- 
 toms which are particularly prominent in the clinical ensemhle. Thus 
 we would mention the acute onset in the midst of normal health or 
 after a slight illness, or occasionally after a traumatism, the violent 
 development of symptoms finally leading to death, the severe pain, 
 the vomitus rapidly becoming feculent, the complete retention of 
 stool and gases and contrasting strangely with the absence or only 
 slight presence of meteorism, the retention of urine, rapidly in- 
 creasing debility, collapse amid complete consciousness, and the 
 
376 DISEASES OF THE INTESTINES 
 
 absence of fever when the case is not complicated by peritonitis. 
 The few exceptions to this type are characterized by a less violent 
 development of symptoms. The course of the disease may be less 
 sudden and show deceptive remissions. These differences mainly 
 depend npon the form and degree of the obstruction. 
 
 Diagnosis 
 
 jS^ot only the presence of an incarceration or strangulation, but 
 also its location and nature must be determined. Occasionally, 
 favourable circumstances — a history which points directly to the 
 source of obstruction — allow of a correct diagnosis being made, 
 but in the large majority of cases the diagnosis is impossible. If 
 we have diagnosticated internal strangulation, we may assume the 
 site of the obstruction to be in the lower ileum, since that portion 
 is more frequently involved. Regarding the differentiation of this 
 (internal) from other forms of obstruction, we shall only mention 
 the most important points which enable us to recognise the condi- 
 tion in favourable cases : early period of life, a history of inflam- 
 matory processes in the abdominal cavity or of the pelvic vis- 
 cera, previous traumatism, previous laparotomy, very acute onset of 
 severe symptoms, absence of tumour, absence of marlied mete- 
 orism^ the jyresence of a fixed, inflated coil of intestine and per- 
 haps visihle peristalsis, hemorrhagic exudate, and the absence of 
 bloody stools. (Compare in this connection the differential diag- 
 nosis, page 407.) When the case is comphcated by peritonitis the 
 diagnosis, as a rule, cannot be made. 
 
 II. Volvulus 
 
 Preliminary Observations. — By volvulus we understand a tor- 
 sion of the intestine about its mesenteric axis, or the knotting to- 
 gether of two coils of gut. We must consider volvulus of the 
 sigmoid flexure (the most frequent and practically the most impor- 
 tant form), volvulus of the ascending colon, and volvulus of the 
 small intestine. 
 
 "Volvulus of the sigmoid flexure is found in two thirds of all the 
 cases, and occurs when the sigmoid is very long, and its mesocolon 
 long and narrow, so that the ends of the arch are brought nearer to 
 each other (see Fig. 37). It is quite apparent that under such con- 
 ditions volvulus, with the mesentery as the axis, may easily occur. 
 
 The causes of volvulus are direct and indirect (predisposing). 
 Of the latter the following may be mentioned : congenital predis- 
 
INTESTINAL OBSTRUCTION 
 
 377 
 
 i 
 % 
 
 )L 
 
 position (an abnormally long sigmoid with a long, narrow mesen- 
 tery), habitual constipation, a purely vegetable diet (which, accord- 
 ing to Lingen and Küttner, explains the frequency of volvulus in 
 the peasants of Eussia), and peritoneal inflammation in the neigh- 
 bourhood of the sigmoid flexure, with 
 consequent cicatrization of its mes- 
 entery (mesenteritis, see page 394). 
 Trauma, marked natural or artificial 
 intestinal peristalsis or its reverse, 
 acute intestinal paresis, errors of 
 diet, foreign bodies, gallstones, dys- 
 entery with consequent cicatrices, 
 tumours, laparotomies, etc., are di- 
 rect causes of volvulus. Undoubt- 
 edly f secal impaction is the most fre- 
 quent cause of volvulus. It occasions 
 a sinking of the upper limb of the 
 sigmoid flexure upon the lower, or 
 the lower limb gradually approaches the upper till finally the volvu- 
 lus is completed by severe peristalsis, induced perhaps by a strong- 
 drastic purge. In most cases there is a torsion of 180 degrees, more 
 rarely of 360 degrees. The torsion takes place about the mesenteric 
 axis, and also, to some extent, about its [intestine] own axis. In these 
 
 V. 
 
 -^ 
 
 f§ 
 
 iii\ 
 
 Fig. 37. — Sigmoid Flexure showing a 
 Tendency to Volvulus Forma- 
 tion. [Treves.] 
 
 Fig. 
 
 Type Eectum en Arriere. (Potain.) 
 
 Type Eectum en Avant. (Potain.) 
 
 cases either the descending colon lies in front of the rectum (type 
 rectum en arriere, Potain), or the rectum lies in front of the colon 
 (type rectum en avant) (see Fig. 38, A, B). The former type is by 
 
378 DISEASES OF THE INTESTINES 
 
 far the more frequent. If the volvulus be complete (i. e., torsion of 
 270 to 360 degi-ees), spontaneous untwisting is impossible, because 
 of the changes which soon occur in the affected limb of the sigmoid 
 flexure (accumulation of blood, exudation, formation of gas), and 
 in that lying above it (intense meteorism, intestinal paresis). Ac- 
 cording to experhnents of Melchioris ^'^, the resistance of the abdomi- 
 nal wall also prevents untwisting. Finally, peritonitis will contrib- 
 ute to the fixation of the volvulus. Spontaneous untwisting may 
 follow incomplete volvulus. 
 
 As already stated, volvulus of the other segments of the large 
 intestine (csecum, transverse colon) is extremely rare. The condi- 
 tions under which it occurs are similar to those of volvulus of the sig- 
 moid. Somewhat more frequent, though still quite rare, is volvulus 
 
 of siuD'le or several coils of small intestine. The amount of torsion 
 
 o 
 
 is generally about 180 degrees. Usually the upper end of the small 
 intestine lies below and to the left, and the lower end above and to 
 the right. The intestines and mesentery lying to the right are 
 transposed to the left, and mce versa. The intestinal obstruc- 
 tion need not be complete. Yolvulus of this kind occurs even in 
 earliest childhood. According to Leichtenstern ^, congenital mal- 
 formation of the mesentery, in which ileum, csecum, and ascending 
 colon have a common mesentery, seems particularly to predispose 
 to volvulus. Yolvulus of the small intestine occurs most fre- 
 quently in coils which have for a long time been either in a large 
 hernial sac or in its vicinity, or which have become adherent to pel- 
 vic viscera (Leichtenstern). 
 
 We have mentioned that the volvulus usually occurs about the 
 mesenteric axis of the bowel. Besides this there is a true torsion 
 about the intestinal axis ; such cases generally affect the large intes- 
 tines, particularly the csecum and ascending colon. Leichtenstern 
 considers most of them as kinking following displacements. These 
 volvuli need not produce complete obstruction ; this may only occur 
 when other changes are superadded — for example, when the mesen- 
 tery of a coil of small gut is thrown across the place of kinking. 
 
 Finally, we must briefly describe the knotting together of two 
 intestinal coils. The sigmoid flexure and the ileum are" most often 
 twisted about each other (see Fig. 39). Much more rarely there is 
 knotting or coiling together of small intestine, or a twist of the jejuno- 
 ileum, csecum, and ascending colon. In the first-mentioned instance, 
 according to Leichtenstern, the most frequent occurrence is the dis- 
 placement of small intestine across the narrow mesentery of the 
 
INTESTINAL OBSTRUCTION 
 
 579 
 
 sigmoid. Througli the space which is thus formed bj the posterior 
 abdominal wall and the roots of the crossed coil of small intestine 
 and sigmoid flexure, the superior 
 portion of the sigmoid enters, after 
 passing from below upward in front 
 of the small intestine. The clinical 
 course of this knot formation is 
 exceedingly acute ; it is fatal in 
 one or two days. Such forma- 
 tions are frequently ushered in by 
 violent diarrhoeas, which may re- 
 main pronounced throughout the 
 course of the disease, to which they 
 lend a certain similarity to cholera. '^' % If^^F ) III! I h f ^ J 
 
 Symptomatology 
 
 Fig. 39. — Schematic Drawing to il- 
 lustrate A Knotting Together of 
 Ileum (/) and Sigmoid Flexure {S). 
 B, rectum. (Leiehtenstern.) 
 
 In what follows we shall de- 
 scribe more especially the clinical 
 symptoms of sigmoid volvulus. Be- 
 cause of their rarity and the ob- 
 scurity of their symptoms the other 
 forms have but little clinical interest, and will be very briefly de- 
 scribed at the end of this section. According to most clinicians, 
 volvulus is a disease of late life (forty to sixty years). In 20 cases 
 Treves ^^ found the average age forty-nine years. In his statistics 
 Leiehtenstern ^ found only one case in the first decade. Men seem 
 to be more predisposed to this affection than women ; Treves gives 
 the proportion as 4 to 1. The occurrence of volvulus late in life 
 is explained by the fact already mentioned (page 3YY), that it 
 develops most frequently in connection with habitual constipa- 
 tion, which is most severe in the fourth to the sixth decades of 
 life. In view of the fact that obstinate constipation is so frequent 
 in women, it is rather striking that the majority of cases of volvulus 
 should occur in men. Perhaps more extensive statistics will show 
 that the female sex is after all more prone to this affection. 
 
 Except for occasional acute attacks, the varieties of intestinal 
 obstruction already described generally present no evidences of 
 previous intestinal disease ; chronic constipation really forms the 
 initial stage of an affection which finally ends with an attack of 
 volvulus. 
 
 The pernicious character of the constipation is often appar- 
 
380 DISEASES OF THE INTESTINES 
 
 ent from the history. The constipation increases steadily, and 
 increasing doses of drastic purges produce only incomplete evacua- 
 tions of a spastic or diarrhoeal character, accompanied by severe pain 
 and perhaps by nausea and vomiting. After a longer or shorter 
 period volvulus suddenly occurs. 
 
 As in other varieties of intestinal obstruction, the main symp- 
 toms are pain, vomiting, complete intestinal occlusion, disturbance of 
 general health. Excepting that they are less violent, all these symp- 
 toms differ but little from those of obstruction of the small bowel. 
 
 Pain, the first and most striking symptom, is quite marked, but 
 is not so severe or continuous as in incarceration or strangulation. 
 It is intermittent, and is relieved by small doses of opium. The 
 patient may be able to obtain sleep without narcotics, and other- 
 wise present a certain euphoria. The pain is usually most pro- 
 nounced about the umbilicus, more rarely it is found in the vicinity 
 of the sigmoid itself. Tenesmus may accompany the pain, but even 
 in well-defined cases of volvulus it may be absent. If peritonitis 
 sets in, the pain is increased and becomes more diffuse. 
 
 Sensitiveness to pressure may be absent in the beginning of the 
 affection ; later, the tenderness becomes easily demonstrable, and 
 is generally localized in the umbilical region. Marked increase 
 in the degree and area of this sensitiveness to pressure is always a 
 suspicious sign of beginning peritonitis. 
 
 In the beginning, the vomiting is reflex and accompanies the 
 paroxysms of pain. Occasionally vomiting is entirely absent, and 
 then nausea or severe explosive eructations occur, followed by 
 momentary relief. The vomitus is by no means very copious ; at 
 first it consists of the stomach contents mixed with mucus, later, 
 of grayish green or brownish masses with a slight " intestinal odour." 
 As stated by Treves,* the vomiting is veiy rarely stercoraceous. 
 If in the presence of well-defined symptoms stercoraceous vomit- 
 ing occurs quite early, it always indicates an unfavourable termi- 
 nation of the disease. 
 
 As in the other forms of intestinal obstruction, anorexia and 
 very severe thirst occur also in volvulus. 
 
 Usually, from the very beginning of the disease neither faeces 
 nor flatus are passed. Small quantities of fsecal masses come away 
 with the enemata or rectal irrigations, but, as already mentioned, 
 no flatus accompanies such evacuations. If purges or enemata do 
 
 [* Loc. cit, p. 299.] 
 
INTESTINAL OBSTRUCTION 381 
 
 produce stools accompanied bj flatus, incomplete volvulus should 
 be suspected. A single evacuation of this kind should not make 
 the physician too sanguine, for experience has shown that an incom- 
 plete volvulus may readily become complete through peristalsis. 
 Therefore the general condition of the patient is more significant 
 than the condition of the stool. Occasionally blood has been found 
 in the evacuations. 
 
 Local tympanites is a very important and characteristic symp- 
 tom of volvulus of the sigmoid ; in no other form of intestinal 
 obstruction is this symptom so prominent from the very beginning 
 of the disease. The meteorism is not limited to the neighbourhood 
 of the sigmoid flexure ; on the contrary, this latter region is gener- 
 ally occupied by coils of small intestine. As previously mentioned 
 (page 23), the tympanites extend toward the right in front and 
 upward. Curschmann^ has made the important observation that 
 in this disease one may find tympanitic intestinal coils over the 
 entire abdomen, but not at the site of the volvulus — i. e., in the 
 vicinity of the sigmoid. Here von Wahl's symptom of distended 
 intestinal coils may be very well demonstrated (page 363). If 
 peritonitis develops, the meteorism gradually becomes general, and 
 it is then impossible to determine the location of the volvulus. 
 When the meteorism is moderate, w^e may, in the lower abdomen, 
 at or to the right of the median line, occasionally palpate a resil- 
 ient tumour having the resistance of a tightly distended air cushion. 
 The tumour usually extends from the lower left side upward toward 
 the right hypochondrium ; there may be tympanitic or metallic 
 tinkling on percussion, but there may also be dulness if the sig- 
 moid flexure is very edematous, or contains large quantities of faeces. 
 
 Yisible peristalsis is rarely observed. Treves noticed this 
 phenomenon twice in 20 cases. Incomplete occlusion is probably 
 present in such cases. 
 
 In volvulus of the sigmoid flexure the general condition of the 
 patient also sufl;ers ; the reaction, however, is not as severe as in 
 obstruction of the small intestine. The pulse remains of good 
 quality for a long time, and is not immoderately frequent, the face 
 does not bear that collapsed expression (facies hippocratica) that is 
 seen, for instance, in strangulation of the small intestine. In one 
 of my cases, a woman of sixty-four years, three days after the onset 
 of symptoms of obstruction, the patient was able to descend two 
 flights of stairs without apparent effort. If diffuse peritonitis or 
 perforation occurs, the symptoms very rapidly change. 
 
382 DISBASES OF THE TNTESTINES 
 
 The clinical picture of volvulus of other segments of the large 
 intestine, and of the small intestine, is somewhat different from that 
 of the sigmoid flexure. For example, in volvulus of the upper por- 
 tion of the large bowel, both tenesmus and bloody evacuations are 
 absent and the pain extends more toward the back. In volvulus of 
 the small bowel, on the other hand, the segment below the point 
 of constriction may contain intestinal contents, and these may be 
 evacuated. A case described by Naunyn* was characterized by 
 the passage of large quantities of unaltered blood. The mete- 
 orism naturally is variously localized. A case of Nothnagel's f dem- 
 onstrates that the course of the disease is not necessarily violent, and 
 may for a time appear favourable. 
 
 Diagnosis 
 
 In diagnosticating volvulus of the sigmoid flexure, the history 
 and the subjective and objective symptoms require consideration. 
 
 The history will give valuable data. It informs us regarding the 
 existence of long-standing chronic constipation, and perhaps also 
 of a former incomplete attack of volvulus of the sigmoid flexure. 
 
 The subjective symjytoras to be considered are the pain, the 
 vomiting, the complete intestinal obstruction, and the general con- 
 dition of the patient. These have all been already described. Col- 
 lectively they indicate an intestinal obstruction. The manner of 
 their occurrence, which, as already mentioned, is characterized by 
 a certain benignancy and slow development, offers serviceable hints 
 regarding the nature and the seat of the obstruction. 
 
 The most important objective sign is local tympanites. If well 
 developed, if the sigmoid flexure can be differentiated from other 
 intestinal coils by auscultatory percussion, if the distended sigmoid 
 flexure can be grasped and distinctly palpated, and if the other symp- 
 toms above mentioned are present, the diagnosis is generally assured. 
 If only small quantities of air or water can be injected into the rec- 
 tum, and these are immediately returned, the diagnosis is made still 
 more certain. On the other hand, as Treves correctly observes, the 
 possibility of large quantities of injected water being retained by the 
 lowest bowel segment by no means militates against occlusion of the 
 sigmoid flexure. It seems to me important also that injections of 
 large quantities of water cannot produce splashing sounds in the 
 caecum or transverse colon. In the presence of severe general 
 
 * Loc. cit., p. 110. f Loc. cit., p. 351. 
 
INTESTINAL OBSTRUCTION 
 
 383 
 
 tympanites tlie demonstration of splashing sounds in the caecum 
 may not be possible, even though the sigmoid flexure be pervious. 
 
 The indican test may be used as a diagnostic aid. Indican, 
 if absent, or present only in very small quantities, speaks for ob- 
 struction of the large bowel. Free hemorrhagic fluid has some- 
 times been found in operations for volvulus, but with marked tym- 
 panites its recognition is extremely difiicult. 
 
 It is seldom possible to diagnosticate volvulus of the upper seg- 
 ments of the large or of the small intestine. 
 
 III. Invagination, Intussusception 
 
 Preliminary Remarhs. — Invagination is a condition in which 
 a portion of the intestine is pushed or inverted into the lumen of 
 that adjoining. Thus, three tubes are telescoped into one another 
 (see Fig. 40). The outer tube is termed the intussuseipiens or 
 sheath, and the two inner, 
 which are generally full of 
 folds, the intussusceptum or 
 invaginatum. The latter is di- 
 vided into the returning (exter- 
 nal) and the entering (internal) 
 tubes. The entering tube lies 
 against the sheath at the 
 "neck" of the invagination 
 and is continuous with the re- 
 turning tube at the lower (free) 
 end of the intussusceptum. 
 The point of junction of the 
 two internal layers is known 
 as the apex. Its relation to 
 these layers is fixed ; with them 
 it always advances farther into 
 the intussuseipiens. The mu- 
 cous surfaces of the outer and 
 
 middle tubes and the serous surfaces of the inner and middle tubes 
 are opposed to each other. The mesentery of the gut is invagi- 
 nated with it, and since the mesentery is compressed and dragged 
 upon by the outer layer, the intussusceptum becomes concave at its 
 mesenteric border, and hence is pulled eccentrically, and not axially, 
 toward the intussuseipiens. 
 
 Besides the ordinary forms, double, or more rarely triple, invagi- 
 
 FiG. 40. — Schematic Drawing to illustrate a 
 Simple Intestinal Invagination. 
 
384 DISEASES OF THE INTESTINES 
 
 nation, occurs. In the former there are five, in the latter seven, intes- 
 tinal tubes. It is necessary also to make a distinction between com- 
 plete and incomplete invagination. In the incomplete form only a 
 single portion of the intestinal wall projects into the lumen. Partial 
 invaginations are sometimes found when tumours (generally benign 
 in character) drag one or more coats of the intestines after them. 
 As observations of Böttcher ® and Fleiner^'^ have shown, invagi- 
 nations incomplete at the outset, may finally become complete. 
 Several years ago I observed a partial intussusception in a success- 
 fully operated case of cancer of the csecum. Besides simple invagina- 
 tion, D'Arcy Power, Birch- Hirschfeld, and Thomas have described 
 cases in which two intussusceptions were present in different por- 
 tions of the bowel. Such a condition is, however, extremely rare. 
 
 From an etiological standpoint we must distinguish two different 
 types of invagination : the physiological and the pathological (Noth- 
 nagel), or the agonal and the vital (inflammatory) forms (Leichten- 
 stern). 
 
 The first variety very probably occurs immediately preceding 
 death. At that time one intestinal segment may lose its power of 
 contracting before another ; when an adjoining portion of the bowel 
 then contracts an invagination of the second part into the lumen of 
 that ah-eady paralyzed may take place. This form of invagination 
 occurs almost entirely in the small intestine. There may be more 
 than one such invagination. They occur more frequently in children 
 than in adults, and are found both in an ascending and a descending 
 direction. They are further distinguished from the pathological 
 variety by the fact that the mesentery is never drawn into the in- 
 vagination. This form cannot be diagnosticated before death. 
 
 In contradistinction to the above variety, vital or pathological 
 invagination — the only form which is of practical importance — is 
 generally single and often of considerable size. The invagination 
 is almost always in a descending direction (Leichtenstern found only 
 8 ascending invaginations in 593 cases), and is constantly accom- 
 panied by invagination of the mesentery. 
 
 Intussusception may occur in all segments of the large and small 
 intestines, but with very varying frequency. In general, we distin- 
 guish invaginatio enterica (small bowel into small bowel), invagi- 
 natio ileo-Gcecalis (small bowel into large bowel), and invaginatio 
 colica (lai'ge bowel into large bowel). Special subdivisions are : 
 itivaginatio ileo-duodenalis, dtiodeno-jejunalis, jejunalis, jejuno- 
 iliaca, ileo-colica, iliaca-ileo-colica, colica, colica-rectalis, and rec- 
 
INTESTINAL OBSTRUCTION 
 
 385 
 
 talis. The most important variety is invagination of the small into 
 the large intestine (see Fig. 41), which, according to Leichtenstern, 
 from an analysis of 4Y9 cases, occurs in 52 per cent of cases at all 
 ages. During the first year of life the percentage is as high as 
 YO per cent. J^ext in frequency are iliac (30 per cent) and colic 
 
 B.M. 
 
 —Pr.v 
 
 Ca— 4- 
 
 —-li 
 
 XL Intussusception. 
 
 /, ileum ; /*, invaginated ileum ; 0, cfecum ; B. M., mesenteric base ; Pr.v, vermiform appen- 
 dix; Ca, ascending colon. (Taken from the collection of Prof. Langerhans, of Berlin.) 
 
 invaginations (18 per cent). The proportion is different in adults, 
 for the iliac and ileo-caecal varieties are of about equal frequency. 
 In invagination of the ileum the lower portion of this part of the 
 bowel is usually affected. Colic invaginations are more frequent 
 in the descending colon and in the sigmoid flexure than in the 
 other portions of the large bowel. 
 
386 DISEASES OP THE INTESTINES 
 
 Invagination occurs most frequently in cliildhood. According to 
 Leichtenstern, one half of all intussusceptions occur during the first 
 decade. In the first year of Hf e, and particularly between the fourth 
 month and the end of the first year, invaginations are very frequent. 
 
 Regarding sex, the majority of cases occur in males. The chronio 
 forms are found most often between the twentieth and fortieth 
 years of life (50 per cent) ; then follows the first decade with a 
 frequency of 25 per cent. According to Raffinesque^^ in 51 cases 
 of chronic invagination, 38 occurred in men and 33 in women. 
 
 At the present day opinions still differ regarding the etiology 
 of intussusception. Contrasted with each other are the spasmodic 
 (Dance, Cruveilhier, Beriton, Bristowe, Raffinesque, Nothnagel) and 
 paralytic theories, the latter upheld mainly by Leichtenstern. Ac- 
 cording to the former theory an energetic, circular tetanic contrac- 
 tion of an isolated portion of the intestine constitutes the starting 
 point of the inversion. This occurs in such a manner " that the 
 intestinal segment below and immediately adjoining the spastically 
 contracted portion is drawn up over the latter" (Nothnagel). 
 Leichtenstern, on the other hand, claims that the bowel segment 
 in question becomes paralyzed through certain intercurrent cir- 
 cumstances (diarrhoea, ingesta, traumatism, partial peritonitis) ; this 
 segment is then everted and becomes invaginated with the enter- 
 ing internal contractile bowel lying below. The latter forms the 
 vaginal portion of the intussusception. Again, D'Arcy Power ^^, 
 who has won renown because of his work in the pathology and 
 operative treatment of intussusception, believes that a disproportion 
 between the width of the ileum and caecum is the true cause. If 
 either congenitally or otherwise the circumference of the caecum 
 is considerably increased, a predisposition to invagination occurs. 
 The discussion of these hypotheses, which are thoroughly described 
 by Nothnagel, Leichtenstern, and Treves, would lead us too far. 
 Animal experiments and theoretical considerations incline me to- 
 ward the spastic theory. 
 
 The direct causes of invagination, according to the statistics of 
 593 cases gathered by Leichtenstern ^^, do not appear to be uniform. 
 In 111 apparently healthy individuals the disease began suddenly ; 
 in the remaining number of cases the following etiological factors 
 were found : intestinal polypi (30 cases), intestinal cancer and stric- 
 ture (6 cases), diarrhoea (21 cases), other abnormal intestinal func- 
 tions (25 cases), ingesta (28 cases), abdominal contusion (14 cases), 
 concussion of the body (12 cases), invagination during preg- 
 
INTESTINAL OBSTRUCTION 387 
 
 nancy or puerperium (Y cases), '' catching cold " (6 cases), various 
 acute and chronic diseases as well as indifferent and doubtful 
 factors (6Q cases). From these statistics we can only conclude 
 that we are absolutely in the dark regarding the real causes of 
 intussusception. 
 
 Symptomatology 
 
 The symptoms of intussusception are those of a severe intestinal 
 obstruction with all its characteristics. Because of their peculiarity, 
 the pain, vomiting, character of evacuations, the condition of the 
 abdomen, and the tumour formed by the invaginated bowel, must 
 be described in detail. 
 
 Spasmodic pain, the first and most prominent symptom, gen- 
 erally appears quite suddenly — in nurslings while at the breast, in 
 older children during play, in adults in the midst of work or per- 
 haps at night. From the beginning the pain is usually of an 
 extremely threatening character, so that in children collapse or 
 convulsions may usher in the disease, while in adults the sever- 
 ity of the pain causes the patient to writhe in agony. After 
 the initial paroxysm — which is probably caused by incarcera- 
 tion of the mesentery — the pain may become continuous, or, 
 as is often the case, may cease for one or several hours. Dur- 
 ing the intermissions the patient may take some nourishment 
 and for a very short time feel comparatively well. The pain 
 may cease before death in consequence of paralysis of the pain 
 centres, but there are many cases in which the pain continues 
 till death. If the acute invagination becomes chronic, the pain 
 may take on a marked paroxysmal character, just as has been 
 described in intestinal stenosis. The site of the pain depends 
 upon the part of the bowel affected, and varies considerably. 
 In children it is generally limited to the region of the umbili- 
 cus. In adults the pain may be localized in a portion of the 
 intestine which corresponds fairly well with the seat of invagi- 
 nation ; this fact can be of diagnostic importance. The pain 
 is generally accompanied by distressing tenesmus. The character 
 of the evacuations (to be described later) and the tenesmus may 
 at first view present a striking similarity to that of acute dysen- 
 tery. The tenesmus is much more severe in children than in 
 adults, so that paresis of the sphincters very soon results. The 
 higher up in the intestine the invagination the less marked is the 
 tenesmus, and vice versa. 
 
388 DISEASES OF THE INTESTINES 
 
 In cMldliood, vomiting accoin]3aiiies tlie pain from the onset, and 
 maj very rapid Ij run through all the various stages (already 
 described) up to feculent vomiting. In adults, vomiting is by no 
 means as constant as in the other forms of intestinal obstruction. 
 It may be absent throughout or may occur at certain intervals, or, 
 as in children, it may be very violent and continuous. These vari- 
 ous characteristics depend upon the greater or lesser completeness 
 of the obstruction, upon the amount of the mesentery invaginated 
 and the degree of its compression, and upon the site of the invagi- 
 nation. Unfavourable conditions are found in the iliac, ilio-csecal, 
 and ileo-colic forms, while invaginations of the large bowel gener- 
 ally run a comparatively mild course. As in intestinal stenosis, 
 vomiting is least prominent in the chronic forms. 
 
 The character of the evacuations is one of the most important 
 objective symptoms. Invaginations are distinguished from most 
 other forms of intestinal obstruction in that evacuations do not 
 immediately cease, but one or more stools, evidently deiived from 
 the distal intestinal segment, may be passed after the onset of the 
 intussusception. If real stools no longer occur, there may be 
 repeated evacuations of blood, blood and mucus, blood and pus, 
 or of gangrenous masses. In these cases the tenesmus is apt to 
 be very severe. The hemorrhages constitute one of the most con- 
 stant symptoms; they are absent in only W per cent of acute cases; 
 they vary in amount according to the site and extent of the 
 invagination. As soon as the process becomes subacute the hemor- 
 rhages may cease or temporarily disappear. On the other hand, 
 large, gangrenous, putrid pieces of intestine may be passed per 
 rectum. In chronic invagination, hemorrhage, although much more 
 frequent than in other forms of chronic intestinal stenosis, may be 
 entirely, or almost entirely, absent. Rarely is the hemorrhage large 
 in amount. The character of the evacuations varies very much in 
 chronic invaginations, and scarcely two cases are alike. 
 
 Aside from the tumour the abdomen presents no noteworthy 
 changes. Tympanites is rare ; when present, it is not well marked. 
 It is least when diarrhoea is present, somewhat more marked with 
 absolute constipation, and extensive only when peritonitis super- 
 venes. 
 
 Formerly the presence of a symptom known as the " signe 
 de dance" was considered important. It was said to consist in 
 a depression in the right inguinal region or in the right iliac fossa, 
 presumably caused by displacement of the caecum. This symptom 
 
INTESTINAL OBSTRUCTION 389 
 
 has lost all value after Raffinesque^^ showed that even in chronic 
 invaginations — those most favourable for this sign — it is present in 
 only about 4 per cent of the cases. 
 
 The invagination tumour is of much greater importance, and may 
 even be pathognomonic. It may be palpated through the abdo- 
 men, or through the rectum or vagina. It is present in about half 
 of all acute cases, but it can be more easily found and palpated in 
 chronic cases. The tumour is, however, not palpable with uniform 
 frequency in all varieties of invagination. According to Treves, it is 
 most often felt in intussusception of the ileo-caecal region and of the 
 caecum, least so in that of the small intestines and in the ileo-colic 
 form. The tumour is more clearly demonstrable in children than 
 in adults. This is due to the fact that in the former, because of 
 the softer abdominal walls, tumours can be more easily felt. As 
 Henoch ^ states, even in such favourable cases the tumour may be 
 obscured by distended coils of intestine. The tumour may vary in 
 size from a hen's eg^g to that of the adult forearm. It is smooth, 
 moderately hard, of varying consistency, sausage-shaped, and some- 
 what curved. The smaller tumours are the more frequent. The 
 size of the tumour that can be mapped out by palpation does not 
 always correspond to its real extent, for portions may be obscured 
 at the flexures of the colon. The tumour is found most frequently 
 over the ascending, next over the transverse colon. When lying in 
 the caecal region it indicates an ileal invagination. The invagi- 
 nation tumour, like all other intestinal tumours, is characterized 
 by relatively great mobility. It is therefore very difficult, from the 
 position of the invagination tumour, to correctly diagnosticate the 
 original seat and kind of invagination. Provided it is not fixed 
 by adhesions, the tumour can be moved from without, sometimes 
 even to a very marked degree. It may temporarily disappear, and 
 therefore Treves's warning, never to diagnosticate the absence of 
 a tumour unless the abdomen is examined during a paroxysm of 
 pain, is timely. Examination at the height of an attack of colic 
 offers the best opportunity for distinctly palpating the tumour, and, 
 at the same time, determining the existence of tetanic intestinal 
 rigidity. The latter is rarely found in acute invagination ; in 
 chronic forms it is quite readily demonstrable. 
 
 In acute as well as in chronic cases there may be prolapse of the 
 
 invagination tumour through the rectum. It generally occurs in 
 
 acute invagination, and is most frequent in the ileo-csecal and colic 
 
 forms. When prolapsed, it may be directly palpated, and is seen as 
 
 26 
 
390 DISEASES OF THE INTESTINES 
 
 a hypergemic or partly gangrenous tumour. Its origin is evident 
 by the appearance at one point of the ileo-csecal opening, and next 
 to it a second opening, that of tlie appendix. Simple as is the 
 demonstration of a prolapsed invagination tumour numerous errors 
 have been made. For instance, invagination tumours have been 
 mistaken for prolapse of the rectum, for polypi, or for hemori'hoids, 
 and have been excised. Treves reported several remarkable in- 
 stances in which, despite these operative errors, cures resulted. 
 The reverse has also occurred, viz., that other tumours (a false 
 diverticulum, at another time a blood coagulum) have been mis- 
 taken for an invagination tumour. Such confusion can generally 
 be avoided by careful and repeated examination, particularly under 
 narcosis. 
 
 Diagnosis 
 
 Of all forms of intestinal obstruction, acute intussusception offers 
 the most favourable opportuAities for early diagnosis. 
 
 Among the suhjective symptoms we must consider the sudden 
 onset in the midst of good health, the immediate occurrence of 
 intense pain of a convulsive or intermittent character, and the 
 vomiting (by no means so violent as in other forms of obstruction, 
 and feculent in only about 25 per cent of all cases). Tenesmus, 
 present in about 50 per cent of all cases, is of special diagnostic 
 significance. As, of all varieties of obstruction, it is found in 
 volvulus of the sigmoid flexure alone, and here relatively seldom, I 
 believe that well-defined, tenesmus is one of the most positive sub- 
 jective symptoms of invagination. Disturbances of general health 
 vary so much according to the age of the patient, the site, the special 
 type, and the condition of the invagination, that they need scarcely 
 to be considered in a diagnostic connection. 
 
 The most important of the objective signs is the presence of a 
 tumour. As already mentioned, a tumour is demonstrable only in 
 about one half of the cases. In obscure forms we would strongly 
 recommend repeated examinations, particularly during a paroxysm 
 of pain. At this time the invagination tumour approaches the ante- 
 rior abdominal wall. By careful consideration of the remaining 
 symptoms the character of the tumour will scarcely ever remain 
 unrecognised. 
 
 If the tumour projects from the rectum, its peculiarities will 
 immediately point to the diagnosis. The character of the evacua- 
 tions is also a significant and possibly diagnostic phenomenon. Ab- 
 
INTESTINAL OBSTRUCTION 391 
 
 solute constipation is generally absent. In addition, there is the 
 frequency of bloody evacuations, or evacuations consisting of blood 
 and mucus, or of pus mixed with gangrenous shreds. As already 
 mentioned, bloody evacuations also occur in incarceration and 
 strangulation, but the passing of purulent, gangrenous masses is 
 typical of acute intussusception. "When we suspect intussuscep- 
 tion, early examinations of the stools and search for small micro- 
 scopical amounts of pus should be made ; such examinations may 
 clear up an otherwise obscure clinical picture. For further diag- 
 nostic data see chapter on Differential Diagnosis. 
 
 The diagnosis of chronic intussusception is often quite difficult. 
 Raffinesque^^ mentions that in 55 cases collected by him the diag- 
 nosis was incorrect in no less than 2T. Here, again, pain is the 
 most important and occasionally the most valuable subjective symp- 
 tom. It is so often markedly intermittent (coliclike) in character 
 that it may indeed be taken as the type of colic pain. Accompany- 
 ing the pain, intestinal rigidity with all the characteristics of the 
 tetanic contractions of intestinal stenosis (see page 356) generally 
 occurs. The patients themselves are conscious of this rigidity. 
 
 Vomiting is not a reliable diagnostic symptom of chronic invagi- 
 nation. Its frequency and degree vary considerably. The stools 
 present nothing characteristic. As Treves * remarks, " the only cer- 
 tain feature in the state of the bowels in chronic invagination is 
 the feature of uncertainty." Of importance in this connection is 
 the experience of Eaffinesque^^, that diarhoea is present in about 
 one half of all chronic cases. I have found no reports in medical 
 literature concerning the presence of pus in the evacuations ; such 
 a condition is without doubt more rare than it is in the acute form. 
 
 Of the objective symptoms the most important is the invagina- 
 tion tumour. When well marked it is of greater diagnostic value 
 than any other symptom, Regarding the nature of the tumour, 
 we refer the reader to the section on symptomatology. In chronic 
 intussusception the invaginated bowel not infrequently extends to 
 the rectum (according to Raffinesque in about one third of the cases) 
 and may be felt there. This is rare in the beginning, but more 
 frequent in the later stages of the disease. Just as in acute cases, 
 meteorism is not well marked, and the course of the affection and 
 general condition of the patient present no special diagnostic char- 
 acteristics. 
 
 * Loe. cit., p. 100 [English edition, p. 420]. 
 
392 DISEASES OF THE INTESTINES 
 
 IV. Bending, Kinking, Adhesions, Mesenteric 
 Contractions, Compression 
 
 In previous sections we have described those forms of obstruc- 
 tion caused by clefts, fenestra, false bands, etc., which may pro- 
 duce severe incarceration or strangulation. There is, however, 
 another group, more infrequent and clinically less severe, in which 
 intestinal obstruction may be produced by isolated peritoneal adhe- 
 sions. They are distinguished from the above group in that both 
 small and large intestine are affected with equal frequency. The 
 same is true of compression of the bowel from without by other 
 conditions (e. g., new growths). 
 
 Treves,* who has carefully described these forms of obstruction, 
 distinguishes the following varieties : 
 
 1. Obstruction over a Band 
 
 "If several coils of a thin India-rubber pipe, through which 
 water was flowing, were thrown over a tightly-drawn wire, the 
 lumen of the tube would become more or less completely occluded 
 at the spot where the wire was crossed " (Treves). 
 
 Yery similarly we may imagine that if one or more coils of 
 intestine are drawn across a taut tissue strand, the intestinal lumen 
 will be narrowed. Through irregular peristalsis and partial adhe- 
 sion of the coil to the band more favourable conditions for such an 
 occurrence are created. Treves discovered only 4: of these cases. 
 
 2. Obstruction from Acute Kinking Due to Traction upon an 
 
 Isolated Band or an Adherent Diverticulum 
 
 In this instance a band attached to the bowel so drags upon its 
 point of attachment that the intestine is acutely bent at the latter 
 point, and is finally completely occluded. This condition is most 
 frequently met with in Meckel's diverticulum or in isolated bands 
 connected with the ileum. The ileum, because of its short mesen- 
 tery, is particularly predisposed to kinking. Owing to its tendency 
 to displacements, the large intestine may also become kinked or bent. 
 
 3. Obstruction from Adhesions which retain the Bowel in a 
 
 Bent Position 
 
 The site of these abnormal bands is either the abdominal or the 
 pelvic wall or the abdominal organs, as the liver, kidneys, and 
 
 * Loc. cit., p. 100, etc. [English edition (1899), p. 75, etc.]. 
 
INTESTINAL OBSTRUCTION 393 
 
 spleen. The etiological factors are traumatism, pelvic peritonitis, 
 perityphlitis, incarcerated and reduced hernise, etc. The kinking 
 may be single or multiple — a fact to be remembered at laparotomies. 
 The kinking may give no symptoms during life, may partially 
 obstruct the passage of the fseces, or, in consequence of some exter- 
 nal or internal influence, may suddenly cause all the symptoms of 
 an acute intestinal obstruction. The forms of intestinal obstruc- 
 tion so frequently observed after reduction of femoral hernise are 
 striking examples of this variety. 
 
 4. Obstruction hy Means of Adhesions of Intestinal Coils to Each 
 
 Other 
 
 This may occur both in the small and large intestines. In the 
 former it is most frequent with hernise. If, for example, a large coil 
 is markedly compressed in the neck of the hernial canal, adhesions 
 develop at this point ; after reduction of the hernia these remain. 
 Only the portions of the loop that were compressed become adher- 
 ent (open loop). In small incarcerated hernise, on the contrary, 
 the entire loop of the bowel in question is bound together by adhe- 
 sions (closed loop). Similar adhesive bands occur after intestinal 
 ulceration with consecutive local peritonitis, or, as Treves specially 
 points out, as the result of cheesy degeneration of mesenteric glands. 
 
 Adhesions between coils of the large bowel occur particu- 
 larl}^ after displacements or ulcers of this portion of the intestine. 
 Displacements have been discussed in detail in a previous chapter 
 (see page 255). From these changes in position accumulations of 
 faeces occur and catarrhal changes easily develop ; stercoral ulcers 
 may result, and cause local peritonitis and adhesions to the adjoin- 
 ing part of the bowel or other abdominal organs. 
 
 In recent years Kelling^^ and Westphalen^^ have shown that 
 adhesions between the transverse colon and the liver occur and 
 cause a number of intestinal disturbances (pain accompanying 
 peristalsis). 
 
 5. Obstruction due to Traction ttpon the Intestinal Wall by a 
 
 Diverticulum 
 
 Treves has called attention to a stricture which is characterized 
 by marked narrowing of the small intestine and by numerous ulcera- 
 tions of the mucous membrane above the stricture. Complete intes- 
 tinal obstruction may here result from distortion of the bowel wall 
 by a diverticulum. 
 
394: DISEASES OF THE INTESTINES 
 
 6. Narrowing of the Bovjel from shrinking of the Mesentery after 
 
 Inflammation 
 
 The affection first described by Yircbow under the name of 
 peritonitis chronica mesenterialis apparently plays a much greater 
 part in the etiology of intestinal obstruction than was formerly sup- 
 posed. In one year, for example, Riedel^''' observed no less than 
 8 cases resulting from such cicatrization. The usual site of mesen- 
 teric inflammation with subsequent cicatricial contraction is the 
 sigmoid flexure, where, as already stated, it may lead to volvulus. 
 This process also occurs at the ceecum, and, as Riedel has recently 
 shown, in the mesentery of the small intestine as well as in the 
 peritoneum of the posterior abdominal wall. Besides volvulus of 
 the sigmoid, mesenteric contraction causes a displacement through 
 traction of some part of the intestines and disturbances of intesti- 
 nal mobility ; such disturbances may present the picture of chronic 
 bowel stenosis, or in extremely severe cases they may lead to acute 
 intestinal obstruction, 
 
 7. Comjpression of the Bowel from Without 
 
 This term, in its narrowest sense, means the pressure produced 
 in an intestinal segment by a body adjoining it; such pressure 
 either narrows or completely obliterates the intestinal lumen. Com- 
 pression is generally caused by malignant or benign neoplasms, 
 which may belong to the most varied organs (stomach, intestines, 
 liver, pancreas, spleen, kidney, lymph glands, mesentery, pelvic 
 bones, uterus, ovaries, etc.). A tumour originating in the intestines 
 may compress a neighbouring segment. 
 
 Besides neoplasms, other pathological conditions may compress 
 the bowel from without ; for example, a retroflexed uterus, large vesi- 
 cal calculus, peri- and paratyphlitic abscesses, floating spleen and 
 floating kidney, tumours of the pancreas from hemorrhage or 
 cysts, etc. 
 
 Owing to its situation, the rectum is most often pressed upon, 
 usually by pelvic tumours. According to Leichtenstern, this occurs 
 in 60 per cent of all cases. Then follow in order of frequency the 
 sigmoid flexure, descending colon, the lower portion of the ileum, 
 duodenum, and, finally, the ascending colon and hepatic flexure, 
 middle portion of the ileum, and transverse colon. 
 
 In this connection it is important to remember the peculiar 
 compression of the small intestines (duodenum or ileum) recently 
 
INTESTINAL OBSTRUCTION 395 
 
 described by Schnitzler ^^. It is produced by the mesentery of coils 
 of the small intestine which have descended into the pelvic cavity. 
 In a similar manner, from traction of the pylorus in consequence of 
 extreme gastrectasia and by compression of the duodenum and other 
 portions of small intestine, the clinical picture of acute incarceration 
 may be produced (L. Meyer ^^). 
 
 Symptomatology and Diagnosis 
 
 The clinical symptoms of the above forms of intestinal occlu- 
 sion possess, on the one hand, the character of stenosis, and, on 
 the other, that of obstruction, and both conditions may suddenly 
 or slowly interchange with the other. The few differential diag- 
 nostic signs described in the literature of the subject are not suffi- 
 cient to distinguish these forms from other similar ones. We 
 shall therefore not give any detailed account of them. Aside 
 from several marked instances (obstruction after hernial reduc- 
 tion), one fact deserves mention — the course of the disease is gen- 
 erally milder and slower than the forms previously described. 
 
 Under certain conditions the diagnosis of these affections may 
 be made, i. e., where the cause of the occlusion is visible or pal- 
 pable (e. g., tumours, palpable adhesions), or where the history 
 points directly to the nature of the disease (obstruction following 
 hernial reduction, local peritonitis following traumatism, appendi- 
 citis with adhesions, previous operations, etc.). The fact that these 
 forms of obstruction affect adults rather than children, and also 
 that, as above stated, the symptoms are generally less severe than 
 in strangulation, incarceration, or volvulus, may sometimes possess 
 diagnostic importance. The exceptions are so numerous, however, 
 that in a given case the last-mentioned data must be cautiously 
 taken into account. 
 
 V. Internal Intestinal Stricture 
 
 Internal strictures are produced by ulcerations with consequent 
 cicatricial contractions, by cancerous strictures, and by inflammatory 
 (hypertrophic) conditions of the intestinal wall. 
 
 The ulcerations to be considered are the tubercular, stercoral, 
 dysenteric, typhoid, and syphilitic. Tubercular ulcers are among 
 the most frequent causes of intestinal stricture ; the other forms 
 have little practical importance. As is well known, syphilitic 
 ulceration is most frequent in the lowest portions of the bowel, 
 especially in the rectum, and is extremely rare in the upper por- 
 
396 DISEASES OF THE INTESTINES 
 
 tions of tlie intestine. Strictures due to previous ulcerative pro- 
 cesses also occur in incarcerated hernia and after traumatism. 
 Finally, tlie peculiar strictures accompanying pernicious anaemia, 
 to which Knud Faber ^° has recently called attention, must be men- 
 tioned. 
 
 Cancerous ulcerations are mainly found in the large bowel and 
 rectum ; they are characterized by a tendency to the formation of 
 stricture. Since ulcerations, neoplasms, and their sequelse have 
 already been discussed in a separate section, a detailed account of 
 these affections will not again be necessary. 
 
 Symptomatology akd Diagnosis 
 
 As regards the intestinal stricture or obstruction, the symp- 
 tomatology is the same as that described in the previous section. 
 Special symptoms, when present, are evidenced by the special 
 form of the underlying disease (tumour, syphilis, tuberculosis, dys- 
 entery, etc.). 
 
 This is true also of the diagnosis. Where constitutional changes 
 or a characteristic tumour point directly to the cause of the affec- 
 tion, the correct diagnosis can be made ; in other cases it may 
 only be possible to say that there exists a stricture or total occlu- 
 sion, or perhaps to determine approximately the portion of the 
 bowel affected. 
 
 In stricture of the small intestine we should, on account of its 
 frequency, first suspect tuberculosis as the probable cause. In 
 stricture of the large intestine, exclusive of the csecum, we must 
 think of cancer. Syphilitic stenoses and stenoses due to sclerotic 
 changes in the submucosa can not, in the present state of our knowl- 
 edge, be positively diagnosticated. 
 
 VI. Obstruction from Foreign Bodies 
 
 In this category are included gallstones, intestinal concretions, 
 instruments introduced per os or per anum, and inspissated faeces. 
 
 {a) Obstruction hy Gallstones 
 
 This may occur in all parts of the intestinal canal from the 
 pylorus to the rectum, but the different segments are not affected 
 with equal frequency. Those most frequently involved are the 
 lower portion of the ileum and the ileo-caecal valve — i. e., the 
 divisions which, for anatomical reasons (narrow lumen of the lower 
 
INTESTINAL OBSTRUCTION 397 
 
 ileum, short taut mesentery), offer most resistance to tlie passage 
 of large stones; next in frequency are tlie duodenum and jeju- 
 num. Obstruction by gallstones is rarer in the upper or mid- 
 dle portions of the ileum, and is extremely rare in the colon and 
 rectum. In the vast majority of cases the stone passes into the 
 intestine through a fistula which has resulted from inflammatory 
 adhesions between the gall bladder and the intestines. Commu- 
 nication between gall bladder and duodenum is the most fre- 
 quent occurrence, while that between small intestine and colon is 
 rarer. Stones have been known to enter the duodenum thi-ough 
 a choledocho - duodenal fistula. Gallstones may cause intestinal 
 obstruction in other ways. Thus, Mikulicz^ twice found gall- 
 stones, not in the intestinal canal, but in diverticuli of the cystic 
 duct which lay across and compressed the duodenum. The obser- 
 vations of J. Israel^ and Körte ^^ have shown that smaller stones 
 may produce intestinal obstruction, probably by exciting circular 
 spastic contraction of the bowel. When a stone has been impacted 
 for a long time, and is large and angular, it may produce inflamma- 
 tion and swelling of the intestinal wall, or even gangrene and peri- 
 tonitis with or without perforation. 
 
 Symptomatology 
 
 It is well known that obstruction by gallstones is met with 
 more frequently in women than in men. Regarding age, 
 l^anuyn^"* has found among 120 cases only 5 under the age of 
 thirty, and only 7 between thirty-one and forty years of age, 
 while there were 96 cases between the ages of forty-one and 
 sixty. After the latter period there is again a decided decrease 
 in frequency. 
 
 In many cases (according to Lobstein^^ 17 times in 90) there 
 is a previous history of attacks of biliary colic, or more rarely 
 of jaundice. It is important to inquire whether the patient has 
 suffered from paroxysmal attacks of so-called " stomach ache," 
 which, as a rule, are nothing more than ill-defined attacks of chole- 
 lithiasis. 
 
 In other cases the history may point to a local peritonitis as the 
 cause of the rupture into the intestines, or only a doubtful connec- 
 tion can be established. 
 
 The symptoms of intestinal obstruction vary widely according 
 to the location of the stone. As already mentioned (page 3^6), the 
 stone, when situated high up in the duodenum, produces symptoms 
 
398 DISEASES OP THE INTESTINES 
 
 of pyloric stenosis ; in tlie descending portion of the duodenum con- 
 tinued bilious vomiting is one of the characteristic symptoms ; still 
 farther down, the usual symptoms of obstruction of the small intes- 
 tines occur — reflex vomiting, which may very soon become fecu- 
 lent or even faecal, visible or palpable intestinal peristalsis, more or 
 less (generally less) meteorism, and finally retention of stool and 
 gases. I^^aunyn ^'', the greatest authority on cholelithiasis, observes 
 that in intestinal obstruction by gallstones the retention of stool and 
 flatus is not necessarily absolute. Collapse soon follows ; it is sel- 
 dom of the severe type met with in other forms of intestinal obstruc- 
 tion. In unfavourable cases death occurs between the fifth and tenth 
 days of the disease, rarely later. There may be a favourable ter- 
 mination if the stone has been forced through the narrowest part 
 of the gut — that is, if the stone has passed into the large intes- 
 tine ; here, however, it may remain for days before it is passed 
 per anum. On the other hand, a cure does not result in all cases 
 in which the stone has been passed. An intestinal lesion may 
 remain which may later produce death from perforative peritonitis. 
 'Not rarely, as ISTaunyn^' states, the lumen of the bowel may only 
 temporarily remain pervious, and after, days, or even weeks, again 
 become obstructed. Finally, two attacks of obstruction by gall- 
 stones have been observed in the same individual. Eeports show 
 that if there be a fistulous communication between the gall blad- 
 der and colon, large stones may pass without causing symptoms of 
 obstruction. 
 
 Diagnosis 
 
 In diagnosticating obstruction from gallstones it is necessary to 
 determine that there really is a calculous obstruction, and, if pos- 
 sible, the site of the stone. In favourable cases (i. e., where the 
 obstruction is situated high up) when evidences of former chole- 
 lithiasis or of a communication of the gall passages with the upper 
 intestinal tract are present, it is possible to estabhsh both the above 
 facts. If the history is not reliable, and if objective signs of pre- 
 vious cholelithiasis (enlargement of the liver, painful gall blad- 
 der, and pressure sensitiveness of the posterior portion of the Hver) 
 are absent, a probable diagnosis may be made by exclusion. We 
 must remember that incarceration, strangulation, volvulus, perito- 
 neal adhesions, and internal stricture of the upper part of the in- 
 testinal canal (duodenum, jejunum) are relatively rare. Mistakes 
 cannot, however, be avoided. If the stone is impacted lower down 
 
INTESTINAL OBSTRUCTION 399 
 
 in the bowel, the diagnosis may be easy when a well-defined history 
 is obtained, or when characteristic changes about the liver or gall 
 bladder are found. In all cases of intestinal obstruction, there- 
 fore, one should carefully examine and palpate the liver and gall 
 bladder. 
 
 Yery rarely a tumour is palpable on the left or right side 
 of the abdominal cavity (Kirmisson-Rochard ^^, Sick^, Köstlein^^, 
 Dessauer ^^). Maclagan ^'^ has observed two cases in which a pain- 
 ful tumour T/as felt in the neighbourhood of the liver, and when 
 this tumour disappeared symptoms of intestinal obstruction gradu- 
 ally developed. If none of the above-mentioned data can be 
 obtained the differential diagnosis from other forms of intestinal 
 obstruction will be difficult. When there is a suspicion of obstruc- 
 tion from gallstones repeated rectal and vaginal examinations should 
 be made, for gallstones have thus been demonstrated in the intes- 
 tines. Gallstones in the rectum may be digitally or instrumen- 
 tally removed. 
 
 Visible intestinal peristalsis may make possible the localization 
 of the obstruction, but it can seldom be observed, and is also found 
 in other forms of intestinal obstruction. 
 
 As previously mentioned, the large intestine is rarely occluded 
 by gallstones (1 case of Körte ^^ and 2 cases of Courvoisier ®^). 
 This may, however, occur in the rectum, when the peculiar symp- 
 toms (tenesmus, obstinate constipation, pain) will direct immediate 
 attention to the site of the trouble. 
 
 {b) Obstruction by Enteroliths 
 
 We have already described the different varieties of intestinal 
 concretions (page 112). They generally originate in the large 
 intestine, for in this situation conditions are most favourable for 
 the development of hard concretions. They are chiefiy situated in 
 the haustra coli or in the rectal ampulla. In the small intestine 
 concretions due to stagnation of the contents may develojj in the 
 so-called true or false diverticula They occur most often in young 
 persons, and particularly in the poorer classes who subsist mainly 
 on vegetables, rather than in the better classes, whose diet contains 
 more animal matter. Intestinal concretions form very gradually. 
 " They may, moreover, be dormant, as it were, for years, or excite 
 during that time but insignificant symptoms " (Treves).* 
 
 * Log. cit., S. 336 [and Intestinal Obstructions, page 199]. 
 
400 DISEASES OP THE INTESTINES 
 
 S TMPTOMATOLOGT 
 
 The symptoms of this variety of obstruction resemble those of 
 chronic stenosis, viz., constipation, attacks of vomiting, paroxysms of 
 pain, and disturoances of general health. In a few cases large con- 
 cretions have been felt through the abdominal walls or through the 
 rectum. Occasionally fragments have been passed with the stools. 
 By reason of its powerful muscular coat and its elasticity, the large 
 intestine permits of the passage of very large concretions ; hence 
 severe symptoms of obstruction have very rarely been observed 
 (case of Down ^^). Where the concretion is retained in the caecum 
 it may produce all the symptoms and sequel se of typhlitis or peri- 
 typhlitis. 
 
 Diagnosis 
 
 A positive diagnosis of an intestinal concretion can only be 
 made when the concretion can be felt per rectum. The diagno- 
 sis is perhaps most likely to be made when a tumour is palpable, 
 when symptoms of partial obstruction are present, when the gen- 
 eral condition of the patient and the very protracted course of 
 tlie affection speak against carcinoma, and when the customary 
 food of the patient has been such as to favour the formation of 
 concretions. 
 
 (c) Obstruction from Entozoa {Ileus Yerminosus) 
 
 Opinion is still divided as to whether entozoa (chiefly ascarides) 
 may cause intestinal obstruction. Leichtenstern ^, Davaine™, and 
 Heller''^ doubt its occurrence, while Mosler and Peiper"^^ answer 
 the question in the affirmative. In his Bibliographie d. klinischen 
 Helminthologie, Huber cites 13 cases of obstruction caused by a 
 large accumulation of ascarides in the intestines. It occurs almost 
 exclusively in children. The ileo-csecal valve is said to be the main 
 site of the occlusion. Whether the obstruction is of a mechanical 
 nature, or whether, as seems more probable, it is dynamic (reflex) 
 in character, is as yet undecided. In the vast majority of cases the 
 disease runs an unfavourable course. Held en reich ''^ has reported a 
 successful case of enterostomy and Simon '''^ one of colostomy for 
 this condition. Yery few of the observations heretofore made will 
 stand critical examination ; it is therefore impossible to describe the 
 characteristic symptoms. The diagnosis is only possible through 
 the accidental evacuation of ascarides, which is usually a result of 
 therapeutic measures. 
 
INTESTINAL OBSTRUCTION 401 
 
 {d) OhstruGtion hy Foreign Bodies which have heen Introduced 
 
 Foreign bodies that have been purposely or accidentally intro- 
 duced may reach the intestines through the mouth or anus. Most 
 remarkable bodies have thus found their way into the intestinal 
 canal. ISTeurotic patients have swallowed very dangerous arti- 
 cles, frequently with suicidal intent, but occasionally also when 
 mentally deranged. Both old and recent literature is replete with 
 such instances, which are simply medical curiosities and hence 
 need only be mentioned. We refer, however, to the recent thor- 
 ough article of Frikker'^^, who describes a unique case which oc- 
 curred in his own practice. Coins and similar articles, or false 
 teeth, are most frequently swallowed. 
 
 Symptomatology 
 
 If their size or length is not disproportionate to the lumen of 
 the intestinal canal, swallowed articles generally pass through the 
 bowels without trouble. This is also true of pointed or sharp 
 bodies (nails, files, needles). In the majority of instances their 
 expulsion is painless, and cause no symptoms of any kind. 
 
 If the foreign body is not passed, it is apt to be retained in 
 certain portions of the alimentary canal — the stomach, lower 
 segment of the ileum, duodenum, and more especially the caecum 
 and ampulla recti. Even then symptoms are not necessarily pres- 
 ent; they may appear only after the expiration of months or 
 years. There may be pain, colic, vomiting, more or less complete 
 constipation, ulceration of the mucous membrane with perforative 
 or local peritonitis, or with resultant stricture or abscess opening 
 externally. After having passed through the intestinal wall, nee- 
 dles may be carried to different parts of the body, and extrude 
 spontaneously or be artificially removed. 
 
 Diagnosis 
 
 The diagnosis of swallowed foreign bodies can be made either 
 from the history or from direct evidence. Eegarding bodies intro- 
 duced into the rectum direct evidence should by all means be 
 obtained. In all other intestinal segments such evidence is only 
 exceptionally obtainable by palpation. Metallic foreign bodies are 
 best demonstrated and located by radiography. 
 
 My experience has shown that patients often imagine they have 
 swallowed articles (needles, false teeth, etc.). I once " removed " 
 
402 DISBASES OF THE INTESTINES 
 
 a needle — presumably swallowed — from a hysterical female by show- 
 ing;' her a needle in the water of an enema. 
 
 {e) Obstruction from Fcecal Tumours 
 
 In marked habitual constipation accumulations of fsecal matter 
 may obstruct the lumen of the bowel. These tumours occur only 
 in the large intestine, and particularly where the faeces are apt 
 to be retarded — i, e., in the csecum, at the flexures, and especially 
 the sigmoid flexure. The longer the fsecal mass is retained, the 
 greater is its loss in water and its chances for increase in size from 
 further fgecal accumulation. ISTotwithstanding, these masses only 
 exceptionally produce total obstruction, for there is always suffi- 
 cient space for fluids and semisolid fseces to pass between the 
 tumour and the intestinal wall. 
 
 Obstruction of the kind just described may produce other and 
 occasionally serious consequences. The frequent development of 
 sigmoid volvulus from impaction has already been mentioned. 
 Furthermore, as described in the section on Cancer of the Large 
 Intestine, a fsecal mass may be impacted in front of a stenosis in 
 such a manner as to directly cause intestinal obstruction. As a 
 result of stagnation of faeces, there may be a descent of intestinal 
 coils, especially of the movable transverse colon, with consequent 
 kinking or the formation of stercoral ulcers, and, in extreme cases, 
 as a result of exhaustion of the muscular coat of the bowels, there 
 may be complete arrest of the faeces. (See Ileus Paralyticus.) 
 
 Symptoms 
 
 These are mainly those of chronic partial or complete intes- 
 tinal obstruction. Some differences arise from the varying situa- 
 tions of the fsecal tumour. Thus, when situated low down (sigmoid 
 flexure, rectum) there is tenesmus ; when higher up the latter is 
 absent. The most important symptom is the fsecal tumour itself, 
 whose special peculiarities have been discussed in the General 
 Division. 
 
 Diagnosis 
 
 It is usually easy to recognise fsecal tumours in the lower por- 
 tion of the large intestine by abdominal, rectal, or vaginal palpa- 
 tion. If the mass is situated in the upper portion of the large 
 bowel, the diagnosis is more difiicult, particularly when meteorism 
 obscures the tumour. In such cases the history and clinical course 
 
INTESTINAL OBSTRUCTION 403 
 
 alone, more especially, however, repeated observations of similar 
 more or less severe attacks, may lead to the correct diagnosis. 
 Even here, however, there must always be a lurking suspicion of 
 some organic hindrance, of incomplete or beginning volvulus, peri- 
 toneal adhesions, kinkings, or compressions. It is still more diffi- 
 cult to decide whether the palpable fsecal tumour is the cause or 
 result of the occlusion. Only complete, permanent relief from all 
 the symptoms warrants a good prognosis. 
 
 VII. Obstruction without Physical Changes in the Intestines 
 (Paralytic, Spastic, and Dynamic Obstructions) 
 
 Besides intestinal obstruction from mechanical hindrance, there 
 is a second form in which the symptoms of obstruction are pres- 
 ent without any discoverable cause. The older practitioners rec- 
 ognised this seemingly paradoxical condition. In 1865, Henrot, 
 in a thesis classical even at the ]3resent time, gave an exhaustive 
 description of these pseudo-etranglernents. 
 
 The conditions are most readily understood when the intes- 
 tines have been injured in some manner — e. g., by severe trauma- 
 tism or continued constipation or abnormally great meteorism. At 
 present we are unable to explain the origin of a sudden severe 
 intestinal paresis. It may be theoretically explained, however, 
 that there are marked changes in the innervating fibres of the 
 muscular coat of the bowels, and that these changes cause the 
 paresis. In other cases the paralysis is evidently due to reflex 
 action (the paralysie reflexe of the French). A classic instance is 
 that of the undescended testicle, which, when inflamed, may cause 
 symptoms of intestinal obstruction ; or, as recently demonstrated 
 by numerous examples, an operation has been performed on the 
 intestines, uterus, or ovaries, and there develops severe intes- 
 tinal obstruction without any discoverable lesion in the intestinal 
 wall itself. Whether the dynamic intestinal obstruction often 
 found in peritonitis, and particularly in perityphlitis, is reflex, or 
 whether, as Stokes maintained, it is caused by a serous infiltra- 
 tion of the bowel wall (collateral oedema), in which case modern 
 writers would claim toxins as etiological factors, or finally, whether 
 it is produced by lessened absorption (and hence accumulation) 
 of gases, is a question which cannot at present be answered with 
 certainty. 
 
 Based upon several observations, Leichtenstern ^^ has proposed 
 another theory to explain the intestinal paralysis of peritonitis. 
 
404 DISEASES OP THE INTESTINES 
 
 According to tliis author, when the patient is lying on his back 
 those distended intestinal coils which have long mesenteries are 
 lifted lip by the gases in them and pressed toward the ante- 
 rior abdominal wall, while coils with fluid contents, particularly 
 those with short mesenteries, cannot move or can move but little 
 from the vertebral column. Because of their weight, the stagnant 
 fluid contents of the duodenum or jejunum are much more likely 
 to flow back into the stomach than they are to pass into the dis- 
 tended, paralytic bowel, which lies higher up and is held in place 
 by the meteorism. This explanation, however, is suflicient only 
 for isolated cases, since the above condition is absent in many cases 
 of peritonitis with marked tympanitis. 
 
 Sjjastic obstruction {ileus spasmodica) is a second form of 
 dynamic ileus, and one whose importance has only lately been 
 acknowledged. 
 
 In spastic ileus there develops in any portion of the intes- 
 tines a " spastic obstruction " which may be followed by the same 
 changes as a mechanical obstruction. Heidenhain '''^, by his vivisec- 
 tion experiments, has again brought this subject into prominence. 
 Spastic obstruction occurs under the most widely different condi- 
 tions : as primary spastic obstruction without discoverable cause, 
 as a complication of hysteria (very remarkable instances have re- 
 cently been described by von Leube '" and Strauss), in gallstone 
 obstruction without mechanical intestinal occlusion (J. Israel^, 
 Körte ^^), as a reflex condition in mechanical ileus (Heidenhain), 
 in crises gastriques (Sandoz'''^), in tubercular intestinal ulcerations 
 (Strehl"*^), and with foreign bodies in the rectum which do not 
 entirely close its lumen (Grundzach ^). The case described by 
 the last-mentioned author appears to me to be an especially good 
 example of sjjastic intestinal obstruction ; I shall therefore briefly 
 describe it : 
 
 After eating a hearty supper a man, thirty years of age, complained of ab- 
 dominal pain, tenesmus, constipation, absence of flatus, and anorexia. Castor 
 oil and calomel were given without result. Stomach and intestines markedly 
 distended : abdomen sensitive to pressure ; face anxious. Beginning intestinal 
 obstruction was suspected. Rectal examination discovered a fishbone, 5 to 6 
 centimetres long, lying crosswise in the rectum. After extraction of the bone 
 the patient very soon passed flatus and fluid stools. 
 
 Leichtenstern ^ is of the opinion that the intestinal spasm is 
 simply a persistence of the muscle in a condition of elastic tension. 
 
INTESTINAL OBSTRUCTION 405 
 
 IN^othnagel - also considers this possible. There are cases (for exam- 
 ple, the one just described, and that of gallstone obstruction with- 
 out occlusion) which point more conclusively to a spasmodic con- 
 dition than to one due to intestinal paralysis. From a practical 
 standpoint, however, both conditions are the same. 
 
 Symptomatology 
 
 The clinical picture of functional intestinal obstruction is so 
 very similar to that of the various forms of mechanical obstruction 
 already described, that we should only have to repeat what has 
 been said. From this it will be seen that a demonstrable and ob- 
 jective differentiation between these two general forms is very diffi- 
 cult. It might be stated that visible peristalsis is absent in func- 
 tional occlusion, but then it is also quite often absent in mechanical 
 ileus. 
 
 Diagnosis 
 
 Under the above circumstances the diagnosis is extremely diffi- 
 cult. This is appreciable when, for example, we have to differen- 
 tiate between peritonitis with intestinal paralysis and mechanical 
 obstruction. In the introductory part of this chapter (page 368) 
 we have described the factors that have to be considered. When 
 there are symptoms of obstruction after operations upon the intes- 
 tines or the sexual organs, or after reduction of a hernia, the con- 
 ditions may be so favourable that a correct diagnosis is possible. 
 Everybody who is acquainted with the literature of this subject 
 knows that diagnostic errors are very apt to be made, for it will 
 scarcely be possible to exclude apparently insignificant mechanical 
 causes (slight adhesions, circumscribed peritonitis, intestinal com- 
 pression, and crushing). For these reasons many surgeons are 
 sceptical regarding dynamic obstruction. 
 
 Differential Diagnosis between the Seveeal Forms of 
 Intestinal Obstruction 
 
 In the majority of cases it is impossible to make a correct diag- 
 nosis of the variety and localization of the obstruction. In prac- 
 tice we must often be contented when we have approximately 
 determined the site of the lesion and the probable cause of the 
 occlusion. 
 
 The first question to be determined is whether the obstruction 
 
 * Loc. cit., S. 360. 
 27 
 
406 DISEASES OF THE INTESTINES 
 
 is in the large or the small intestine. In what follows, therefore, 
 we shall briefly describe the symptoms which indicate the localiza- 
 tion of the obstruction in one or the other parts of the intestinal 
 tract. 
 
 {a) Small Intestine. — Here objective signs to a slight degree, 
 but more especially the knowledge gained from experience, aid in 
 making the diagnosis. Experience may be of great service. "We 
 herewith give an example : Sudden intestinal obstruction occurs in 
 a young man who has always been well. ]^o hernia; very rapid, 
 extremely acute development, with vomiting soon becoming fsecal ; 
 no flatus or stool passed ; intense indicanuria from the very onset 
 of the disease ; no marked meteorism. In such a case we may, 
 without fear of error, diagnosticate obstruction of the small bowel. 
 A second example is the following : An elderly woman, well except 
 for obstinate habitual constipation, is attacked with symptoms of 
 slight obstruction. No stool or flatus passed, slight vomiting, not 
 faecal in character; marked localized meteorism; marked tenesmus. 
 Here we need have no great hesitation in diagnosticating an obstruc- 
 tion of the large bowel, probably a sigmoid volvulus. 
 
 No doubt there are cases in which from the very onset the symp- 
 toms are so obscure that the diagnosis of the site of the lesion is 
 only a matter of personal experience, or rather of personal equation. 
 Regarding such doubtful cases, it must be mentioned that occlusions 
 of the large bowel generally present better objective signs than those 
 of the small bowel. Rectal injections or inflation, recognition of a 
 large, fixed, distended intestinal coil by means of auscultatory percus- 
 sion, the possibility of palpating this intestinal coil, the previously 
 described lumbar symptoms of Nothnagel (page 355) ; the recogni- 
 tion of mild peristalsis — all these combined will in favourable cases 
 lead to comparatively certain conclusions. It has often been men- 
 tioned that examinations per rectum and vagina, and of the evacua- 
 tions, may yield important, and, under certain circumstances, deci- 
 sive results. Error is unavoidable in those apparently rare cases 
 of simultaneous obstruction of both large and small intestines, de- 
 scribed by Treves in his monograph, and lately, after several opera- 
 tions, by Hochenegg^^ (combination ileus). Furthermore, as already 
 mentioned, the occurrence of multiple invaginations, cicatricial stric- 
 tures, peritoneal adhesions, volvuli, etc., should be remembered. Such 
 conditions cannot be recos-nised during life. 
 
 After the local diagnosis has been made other difiiculties must be 
 overcome. We can, however, often reach a diagnosis by exclusion. 
 
INTESTINAL OBSTRUCTION 40Y 
 
 The differential diagnosis of the nature of the obstruction must 
 necessarily be limited to those conditions which are at all capable 
 of being diagnosticated. Hence we must exclude constriction by 
 omental bands, incarcerations by the appendix or by Meckel's diver- 
 ticulum, by pseudo-membranes, fenestra or clefts in the mesen- 
 tery, or by adhesions of several intestinal coils ; occlusion by kink- 
 ing or distortion, by the formation of knots, volvuli (excepting sig- 
 moid volvulus) ; internal hernise (with the possible exception of 
 diaphragmatic hernia). We do not wish to imply that the diag- 
 nosis of these forms of obstruction can never be made, but that 
 they can be recognised only under particularly favourable and 
 rather accidental circumstances. 
 
 Deplorable as this is, it enables us to restore order out of this 
 diagnostic chaos, by allowing ns to study more carefully the few 
 recognisable and distinguishable varieties of obstruction. For this 
 purpose a detailed history, a careful study of the patient's condi- 
 tion, and an accurate knowledge of the symptomatology of intes- 
 tinal obstruction are necessary. 
 
 As Gräser ^^ states, the history and the patient's daily condition 
 should always be noted in writing, and any changes should be 
 compared with previous observations. If careful observation at 
 home is not possible, doubtful cases should immediately be sent to 
 a suitable hospital. 
 
 I^aunyn rightly observes that in all forms of intestinal obstruc- 
 tion the first practical question is whether or not an incarceration 
 or a strangulation is present. In not a few instances this ques- 
 tion may be answered affirmatively because of the severe initial 
 symptoms — violent shock, almost constant intestinal jDain, early 
 vomiting soon becoming faecal, and collapse very rapidly reaching 
 the greatest possible severity. The important objective symptoms 
 of incarceration and strangulation are the distended, fixed intes- 
 tinal coil (occasionally with peristalsis), hemorrhagic exudate into 
 the dependent portion of the abdomen, meteorism, moderate or 
 absent, large intestinal hemorrhages (rare) (Kaunyn), and marked 
 indicanuria from the beginning of the disease. The first symp- 
 tom (von Wahl's) is the most important, but unfortunately it is 
 not always well marked. As previously mentioned, it is entirely 
 absent when the strangulation aifects a large part of the intestine. 
 In such cases it is impossible to diagnosticate more than the site 
 of obstruction. JN'othnagel's case (mentioned on page 382) shows 
 that there are exceptions even to these rules. 
 
408 DISBASES OF THE INTESTINES 
 
 Among the forms of obstruction of the small intestine that can 
 be diagnosticated we must consider obstruction by gallstones. The 
 facts that are of value for the diagnosis of doubtful cases — and these 
 alone are here considered — are the age of the patient (generally over 
 thirty- one years), sex (more frequent in the female), the history 
 (which may, however, leave us entirely in the dark), some change 
 (though but slightly indicated) in the liver, especially the pro- 
 tracted course, the passing of flatus, and, despite fsecal vomiting, of 
 stool, and, finally, the shght tympanites. Hemorrhages per anum 
 do not speak against gallstone obstruction. When the obstruction 
 is situated high up— i. e., in the vicinity of the papilla— the picture 
 is in itself very characteristic, although the cause of the occlusion 
 may remain obscure if the history does not contain data which 
 call attention to the possibility of intestinal obstruction by a gall- 
 stone. The case might, however, be one of obstruction due to 
 compression by neighbouring tumours (which need not necessarily 
 be palpable), by adhesions with surrounding tissues (gall bladder, 
 pylorus, mesentery, etc.), by ulcers with cicatrization (Yarr), and 
 by torsion of the mesentery (J. Schuitzler). 
 
 Foreign hodies impacted in the small bowel can be diagnosti- 
 cated only Avhen there is a history of their having been introduced ; 
 otherwise this is not distinguishable from other forms of obstruc- 
 tion, especially that by gallstones. 
 
 (b) As already mentioned, obstructions of the large intestine are 
 more readily recognised and their nature determined than are ob- 
 structions of the small intestine. There is less danger of an error 
 in intussusception than in any other form. Its occurrence in very 
 young children, its sudden onset, the severe but generally intermit- 
 tent pain, the tenesmus, the characteristic discharges (especially the 
 admixture of 23us and blood), the presence of a smooth, growing, and 
 wandering tumour which occasionally becomes tetanically contracted 
 and is sometimes directly palpable and visible per rectum, in some 
 cases the passing of a sloughing, gangrenous intussusception — all 
 these symptoms, taken together or separately, are so characteristic 
 that doubt as to the correct diagnosis can occur only under partic- 
 ularly unfavourable circumstances. In the differential diagnosis we 
 must consider rectal polypi with bloody stools (which are, however, 
 easily distinguished from invaginations), acute dysentery, and severe 
 intestinal colic. In the early stage of the disease it is sometimes 
 impossible to distinguish the latter condition from intussusception, 
 but the diagnosis is almost always cleared up by the further course 
 
INTESTINAL OBSTRUCTION 409 
 
 of tlie affection. On the other hand, it is usually impossible 
 to correctly diagnosticate an invagination accompanied by a neo- 
 plasm. 
 
 Generally, volvulus of the sigmoid, the second most frequent 
 form of obstruction of the large bowel, also presents a character- 
 istic picture. Its main diagnostic features are the occurrence late 
 in life and in persons suffering from obstinate constipation, the 
 sudden development combined with a relatively slow course, ab- 
 sence of faecal vomiting despite complete intestinal obstruction, 
 futility of rectal injections of large quantities of water '^ (less 
 than one half litre), marked meteorism, which may extend over 
 the whole abdomen or may become quite visible and be limited 
 to a fixed coil, but without peristalsis, frequent tenesmus, and 
 finally slight indicanuria. Bloody evacuations occur in volvulus 
 of the sigmoid flexure as well as of the small intestine, in in- 
 vaginations, and but rarely in obstructions from gallstones. The 
 other symptoms vary so widely that only rarely ought there to be 
 any difficulty in differentiating between these conditions. We 
 may, however, have to determme whether we are dealing with a 
 simple volvulus, or with a volvulus produced by a carcinomatous 
 stricture or a tumour. When a tumour is absent, it will generally 
 be impossible to make the differentiation. In itself the clinical 
 picture is not sufficiently characteristic to enable us to state whether 
 we are dealing with a complete volvulus of 360 degrees or with 
 one of 180 degrees. 
 
 Occlusions of the large intestine which develop in the later 
 stages of a stricture (generally carcinomatous or tubercular) are also 
 easily recognisable. If a tumour is present, there can only be doubt 
 as to its nature ; frequently the further course of the disease will 
 clear up the case (compare chapter on Intestinal Neoplasms). If 
 there is no tumour, we can arrive at more than a probable diag- 
 nosis only in the presence of other definite clinical data — tuber- 
 cular symptoms, pyrexia, age, metastases, caneer cachexia, etc. 
 Usually it is impossible to determine whether the obstruction is 
 caused by paralysis of the intestinal wall, or by foreign bodies or 
 fgeces impacted in front of the stenosis, or by other mechanical 
 factors. 
 
 Foreign hodies in the large intestine which have been swallowed 
 can be diagnosticated from the history ; others can only be recog- 
 
 * Compare, however, limitations, given on page 382. 
 
410 DISEASES OF THE INTESTINES 
 
 nised when found in the rectum, or when fragments of them are 
 accidentally passed per rectum. Of importance, too, is the fact that 
 enteroliths are generally found in the csecum, and produce symp- 
 toms of typhlitis or intestinal stenosis before the symptoms of 
 obstruction appear. Occasionally a tumour may be felt in the 
 caecum, but its nature will be doubtful. On the whole, however, 
 enteroliths will seldom have to be considered in the differential 
 diagnosis. 
 
 As mentioned in the general division (p. 76), fmcal tumours of 
 the large bowel have often given rise to error. One who has had 
 any experience with these pseudo-tumours will, I believe, scarcely 
 ever be misled. Even when these tumours consist of old residua, 
 their compressibility and elasticity will usually indicate the proper 
 diagnosis. Difficulty will only arise when, in addition to the fsecal 
 tumour, a real neoplasm is present, or when the clinical course 
 points to a neoplasm. The case taken from Kothnagel's Diseases 
 of the Intestines, and cited on page 77, is a very good example of 
 this. For the diagnosis of a fsecal tumour, the clinical course is 
 very important, and the history may give us valuable information. 
 Faecal tumours produce symptoms of occlusion very gradually, and 
 these, when present, are relatively mild. The general health is but 
 little affected ; there is absence of fsecal vomiting, of a fixed dis- 
 tended intestinal coil (a point of differentiation from volvulus of the 
 large intestine), and of visible peristalsis. This latter condition is 
 always present in stricture of the large bowel. 
 
 (c) Dynmnio Intestinal Ohsl/puction. — If we obtain a history or 
 other evidence of laparotomies or operations on the female genitals, 
 of traumatism, reduced hernise, the diagnosis of functional (dynamic) 
 obstruction ought not to be very difficult ; but even in these cases 
 a positive differentiation is sometimes not easy. For example, in 
 obstruction following hernial reduction it is hard to state whether 
 the obstruction is of a mechanical (incomplete reduction, adhesions 
 of incarcerated intestinal coils) or of a functional nature ; or, when 
 a volvulus has been untwisted, it is difficult to state whether the 
 intestine has not been twisted anew, or whether the volvulus was 
 the only obstructing factor; or whether we are not dealing with 
 an obstruction of a dynamic type. As will be seen when we shall 
 come to speak of the treatment, these questions are not purely hypo- 
 thetical. It is important for the physician to know them before he 
 begins treatment. The differential diagnosis can be made only by 
 a study of each separate case and by the most careful consideration 
 
INTESTINAL OBSTRUCTION 411 
 
 of all details. "When applied to a complicated case, every tabulated 
 scheme utterly fails. 
 
 We have already mentioned that in these cases we must also 
 think of hysteria, for the latter condition may cause much diagnos- 
 tic difficulty. 
 
 Since it has been thoroughly discussed (p. 368, etc.), we shall 
 not enter into the diiferentiation between mechanical and dynamic 
 ileus and acute peritonitis. 
 
 It is evident that the varieties of obstruction which permit of a 
 positive diagnosis are not numerous, and even this small group 
 presents new phases and abnormalities which may absolutely dis- 
 guise the typical clinical ensemble. 
 
 The Tkeatment of Strictures and Obstructions of the 
 
 Intestine 
 
 Although physicians differ in many points regarding the treat- 
 ment of these affections, all agree that we are concerned with one 
 of the most difficult and responsible fields of internal pathology. 
 This is owing, no doubt, to the uncertainty which attends all cases 
 which can be recognised clinically, but more especially those far 
 more numerous cases in which the diagnosis is obscure. Even in 
 so simple a condition as internal stenosis of the large bowel we can- 
 not be certain of the degree of obstruction or the condition of the mus- 
 cular layers of the gut above the seat of obstruction. We can note the 
 efforts of the hypertrophied intestinal segment to force f gecal matter 
 through the stricture, but who can say whether it will finally succeed, 
 and, if so, when ? What is the anatomical condition of the stricture ? 
 How far has it advanced peripherally ? Is rupture impending ? It 
 is almost impossible to answer any of these questions. This is also 
 true of intestinal occlusions. Let us take the simplest example, 
 that of volvulus of the sigmoid flexure. Is the volvulus complete, 
 or incomplete ? Is it primary, or caused by a cicatricial stricture 
 of benign or malignant character ? What is the condition of the 
 twisted bowel ? Is there danger of peritonitis ? Is it beginning, 
 or has it already begun ? These questions are of the greatest impor- 
 tance both as regards the treatment to be instituted and the life of 
 the patient ; still it is impossible to clearly and precisely answer 
 any of them. If, then, typical cases are so perplexing, how much 
 greater the difficulty in cases which do not even admit of localiza- 
 tion, let alone of an anatomical diagnosis. 
 
 The difficulty in the selection of a method of treatment is due 
 
412 DISEASES OF THE INTESTINES 
 
 not so much to the doubtfulness of the gross diagnosis, as to the 
 fact that we know so Httle of the condition of the occhided seg- 
 ment during any stage of the disease. Other considerations influ- 
 ence our action in individual cases — viz., the age of the patient, his- 
 tory of previous exhausting disease, general condition, comphcating 
 constitutional dyscrasise, etc. Owing to these difficulties, it is im- 
 possible to give a schematic account of the treatment of intestinal 
 obstruction. The efforts of both surgeons and medical men in dif- 
 ferent countries have hitherto been unsatisfactory, because they 
 have had no common facts on which to base their plans of treat- 
 ment. Only a most comprehensive collective study, such as has 
 been so well carried on by Sahli in perityphlitis, may clear up the 
 disputed points. At present we must be content to give an account 
 of what can be gathered from the rich surgical and medical litera- 
 ture of the subject, and from my own experience concerning the 
 different methods of treatment, 
 
 I. Treatment of Intestinal Strictures 
 
 Unless we are dealing with a foreign body which may be passed 
 per mas naturales^ it is impossible to cure an intestinal stricture by 
 internal medication. The medical practitioner can only assist in the 
 efforts already begun by nature to compensate for the obstruction. 
 We possess several means to attain this end : appropriate diet and 
 mechanical and medical remedies. 
 
 {a) Diet. — In the General Division we have described the appro- 
 priate nourishment in intestinal stenosis. In the section on Intes- 
 tinal Carcinoma (page 323) there are special comments which may 
 be directly applied to the other forms of chronic stricture of the 
 bowel. 
 
 While referring the reader to the above sections, we shall here 
 briefly recapitulate the most important facts. The caloric value 
 of the diet must be as great as possible. The lower the site of 
 the stricture the less will be the difficulty of carrying out these 
 principles. The higher the occlusion, the greater will be the 
 accumulation of undigested material. The condition is similar to 
 that in gastrectasia ; the same difficulties are encountered in 
 stenoses of the small bowel situated high up as in dilatation of 
 the stomach. 
 
 We must again call attention to the necessity of avoiding 
 food indigestible or difficult of digestion, especially if it contain 
 much cellulose. 
 
INTESTINAL OBSTRUCTION 413 
 
 In stenosis of the small intestine the food should be fluid or 
 semifluid, and should contain appropriate physiological laxatives. 
 We need not regard the general warning against so-called flatu- 
 lent food, which exists only in the imaginations of thoughtless peo- 
 ple ; we should outline the diet according to the individual case. 
 The practitioner who distributes printed diet sheets shows that he 
 has no conception of the importance of diet in modern therapy. 
 In far advanced stenosis of the small intestine nutrient enemata 
 may be required. For the details or technic of this procedure the 
 reader is referred to other works on this subject.* 
 
 {h) Mechanical Treatment. — This consists in the use of stomach 
 lavage and rectal enemata. The former is used only in stenoses of 
 the small intestine. Since its technic is quite similar to that em- 
 ployed in dilatation of the stomach, we refer the reader to text- 
 books on diseases of that organ. Rectal enemata may be employed 
 in stenosis of both the large and the small intestines when, as fre- 
 quently happens, laxatives must be avoided. They may be of great 
 value in stenosis of the small intestine, and in high stenoses of 
 the large intestine (occasionally in connection with mild laxatives). 
 Thorough irrigation of the rectum is most appropriate, or else small 
 enemata of oil or soap, with glycerin, oil, cod liver oil, etc., may be 
 given. (Regarding particulars, see Chapter XI.) 
 
 (c) Medical Treatment. — The first question to be considered is 
 the treatment by laxatives. They are indispensable in the therapy 
 of intestinal stenosis, for, with but few exceptions, the patients suf- 
 fer from constipation or from alternating constipation and diarrhoea. 
 We have discussed this subject in the General Division (page 189), 
 but must again emphasize that drastic purges are always contra- 
 indicated. 
 
 Ojpium and its alkaloids, as well as the belladonna preparations, 
 are used in intestinal stenosis either as sedatives or (and this can- 
 not be too strongly emphasized) as laxatives. This is especially 
 true where there is visible and palpable intestinal spasm. Thus, in 
 a case of stenosing cancer of the csecum which I had observed for a 
 long time, and in which symptoms of acute occlusion were impend- 
 ing, the use of a suppository of opium and belladonna was followed 
 by a daily well-formed stool. 
 
 * See Boas, Diagnostik u. Therapie d. Magenkrankheiten, 4te Aufl., 1897, Th. 1, 
 S. 293 ; and von Leube, in von Leyden's Handbuch der Ernährungstherapie, 1897, 
 Bd. i, S. 490. 
 
414 DISEASES OF THE INTESTINES 
 
 Surgical Treatment of Intestinal Strictures 
 
 As already remarked, internal medication cannot have a cura- 
 tive effect upon an intestinal stenosis unless the same be due to a 
 foreign body. In every case of intestinal stenosis we must there- 
 fore consider the advisability of operation. The question of the 
 cause of the stenosis vs^ill naturally play a very important part as an 
 indication. A malignant tumour, no matter where situated, offers 
 a worse prognosis than a cicatricial stenosis or a stricture produced 
 by a foreign body — for instance, by gallstones. The site of the 
 stenosis must also be considered. Owing to the immobility of the 
 duodenum, a carcinoma of its superior portion can scarcely be rad- 
 ically extirpated, while tumours of the ileum or of the colon offer 
 much better chances of complete removal. Benign tumours, though 
 of large size, are generally more amenable to radical treatment than 
 malignant ones. Extensive adhesions may make the removal of 
 the tumour much more difficult, and. after its removal may cause 
 intestinal obstruction. Autopsy often reveals multiple strictures, 
 whereas at the time of operation but one stricture was found and 
 removed (Hofmeister and others). It is never possible therefore 
 to accurately determine beforehand the nature of the operation re- 
 quired, or its result and the prognosis. 
 
 The indications for operation vary with the individual case. 
 Generally speaking, benign stenoses, unaccompanied by marked me- 
 chanical disturbances, are best treated by internal methods, while 
 severe stenoses, in which internal measures have been exhausted, 
 are proper subjects for surgical treatment. Mild stenoses of a ma- 
 lignant nature (tuberculous and carcinomatous) belong exclusively 
 to surgery. In these cases delay may be fatal. On the other hand, 
 we have seen that the diagnosis at this stage of the disease is ex- 
 tremely difficult. Patients with a beginning stenosis are very rarely 
 willing to be operated on. When complete obstruction supervenes 
 upon stenosis the treatment is in every respect the same as that 
 described under that affection. 
 
 II. Treatment of Intestinal Obstruction. 
 
 "When the practitioner is confronted with a case of intestinal ob- 
 struction he ought to have a clear idea of the limitations in our 
 knowledge of this most dangerous form of intestinal disease. It 
 would be of incalculable value for therapeusis if by some method 
 similar to radiography we could actually see how an intestinal seg- 
 
INTESTINAL OBSTRUCTION 415 
 
 ment is cauglit in a mesenteric fenestrum, or how a peritoneal 
 strand causes intestinal strangulation, or how an angular kinking of 
 the bowel is produced by a cheesy degenerated gland, or how a for- 
 eign body has obstructed the intestinal lumen. We could then 
 immediately exclude a number of cases in which internal treatment 
 is useless. These are the mechanical obstructions, most of which 
 can only be removed by mechanical means. 
 
 Since our present knowledge does not enable us to localize or to 
 recognise the cause of the obstruction in all cases, it is difficult to 
 lay down absolute rules for the physician's guidance. Is internal 
 treatment absolutely of no avail from the very beginning of the 
 case, or shall we wait ? How long shall we wait ? Or is it a case in 
 which we can expect so much from internal treatment that surgical 
 treatment is uncalled for ? In most cases it is scarcely possible to 
 answer these questions, and therefore our treatment must be some- 
 what schematic. We would not have it inferred that all cases of 
 obstruction are to be treated alike. On the contrary, we should try 
 to individualize as much as possible. 
 
 Internal Treatment of Intestinal Obstructions 
 
 This may be divided into dietetic, mechanical, and medical 
 measures. 
 
 {a) Diet. — Most clinicians agree that patients with intestinal 
 obstruction should have an " absolute diet " [withdrawal of all 
 food] (Goltdammer, Curschmann, Ewald, I^othnagel, etc.). I have 
 already expressed myself (page 152) as somewhat averse to this 
 opinion, and I would again explain my views on this subject.* In 
 my opinion the diet in obstruction of the large intestine must be 
 quite different from that in obstruction of the small bowel. As 
 Curschmann ^^ states, feeding jper os in the latter disease really im- 
 poses an additional burden on the intestine, and hence should be 
 limited as much as possible, if not entirely given up. It is different, 
 however, in obstruction of the large intestine. In these vomiting 
 does not always occur ; when present it is not usually very violent, 
 and, what is very important, it very rarely becomes faecal. The 
 view often expressed, that there is a suspension of the motor and 
 of the resorptive power of the intestinal segment lying proximal to 
 
 * Above all, we must discard, the idea that diet is of secondary importance in 
 intestinal obstruction. I believe that patients have lost their lives in consequence 
 of this misconception, which is directly opoosed to modern views. I consider 
 everything of calorie value consumed by the patient as so much gain for him. 
 
416 DISEASES OF THE INTESTINES 
 
 the obstruction, is true of the small intestine, but as regards the 
 large intestine is, so far as I can see, only a pure hypothesis, and 
 has never been experimentally proved. Accordingly, it is entirely 
 proper to have patients with obstruction of the large bowel con- 
 sume as much easily digested nourishment as possible. We must 
 proceed carefully and cautiously, and be led by the course of the 
 affection in each individual patient. 
 
 The nourishment must be regulated even in its smallest detail. 
 It should be a fluid or a semifluid diet, which is absorbed without 
 difficulty in the upper bowel and leaves no residue. The follow- 
 ing are particularly to be recommended : Iced milk, beef tea, cau- 
 dle, meat jellies, and the numerous albuminoid preparations found 
 in the market. We may also try small quantities of alcohol in the 
 form of cognac, Hungarian wine, sherry, etc. It is not a question 
 of a great nutritive result, but when we consider that during the 
 course of treatment an operation is often indicated, we must never 
 even for an instant forget the importance of stimulation of the 
 heart, and of giving the patient large quantities of fluid. 
 
 When from the onset, or from attempts already made, we know 
 that patients cannot be fed by the mouth, we should always employ 
 nutrient rectal enemata. Where for mechanical causes the enemata 
 are not retained, we may (as recommended by Curschmann) attempt 
 to obviate the threatening systemic loss of water and the cardiac 
 collapse by subcutaneous injections of salt and sugar solutions. 
 Many surgeons appreciate the value of the latter procedure, and 
 before beginning operations on patients with cardiac weakness are 
 in the habit of injecting saline solutions, 
 
 (b) Mechanical Treatment. — Gastric lavage^ introduced into the 
 therapy of intestinal obstruction by Kussmaul and Cohn, undoubt- 
 edly is the most valuable of our mechanical measures. Its effect is 
 to lessen the pressure above the occluded segment and thereby to 
 remove the great hindrance to compensation of the obstruction. 
 We have already described the value, indications, and technic of 
 stomach lavage (p. 184), and we would here again point out that 
 this procedure is indicated only in cases of obstruction of the small 
 bowel. Gastric lavage will scarcely ever be attended by any great 
 success in invaginations of the large bowel, in sigmoid volvulus, in 
 internal strictures of the large bowel, in dynamic ileus, in obstruc- 
 tion by impacted faeces or enteroliths. 
 
 Under certain conditions rectal injections may favourably influ- 
 ence the course of the intestinal obstruction, only, however, when 
 
INTESTINAL OBSTRUCTION 41Y 
 
 the latter is deeply situated. Invaginations may be relieved, im- 
 pacted foreign bodies loosened, and incomplete volvulus occasion- 
 ally reduced, inspissated fecal masses gradually softened, and the 
 paralytic large intestine excited to peristalsis. I consider thorough 
 rectal irrigations with soap or emulsified oil solutions (see p. 1Y9) 
 most appropriate. We must naturally not expect too much from 
 these procedures. 
 
 A few observers have recommended massage in intestinal ob- 
 struction. Except perhaps in positive obstruction [!] its use is not 
 sufficiently clear. Because of the danger of peritonitis, we would 
 further recommend the greatest caution in such manipulations. 
 
 Regarding puncture of the distended intestine by the Pravaz 
 syringe, opinions are very much at variance. This procedure has 
 lately been recommended particularly by Curschmann ^^, O. Rosen- 
 bach^*, Fiirbringer ^^, von Ziemssen^^, and others. On the other 
 hand, it has been condemned by almost all surgeons ; for example, 
 by Treves,'^ Körte ^^, Graser,f Kocher ^^, and others. Kocher calls 
 it an operation in the dark. 
 
 Curschmann ®^ recommends the following technic for puncture of the bowel 
 through the abdominal wall : A long needle, having a valve of the calibre of a 
 Pravaz aspirator, is thoroughly disinfected. After the valve has been closed 
 the needle is passed into the intestinal coil which is most distended, and which 
 in each case must be most carefully sought for. The needle is then immedi- 
 ately connected with a rubber tube, the latter is passed into a bottle containing 
 a watery solution of salicylic acid, and the bottle is turned over a basin con- 
 taining the same fluid. When the valve of the canula is opened the intestinal 
 gases rise into the bottle, at first in a continuous stream, later more slowly in 
 large pearls, finally intermittently. Fürbringer's advice not to hold the needle 
 tightly, but to allow its direction to be guided by the intestine itself, is im- 
 portant. The intestines may be punctured at various places. 
 
 This method has for its object the diminution of the tension 
 in one or more intestinal coils, thereby allowing the incarcerated 
 segment to free itself more readily. Curschmann and Fürbrin- 
 ger claim to have seen cures from the procedure. The method 
 requires great caution and should only be used in selected cases. 
 It is only indicated in cases with well-defined distended coils, most 
 frequently in strangulation and volvulus. It is strongly contraindi- 
 cated in intestinal paralysis, in invaginations, in peritoneal irrita- 
 tion, especially when a tendency to gangrene exists. 
 
 * Darmobstruction, S. 446 u. f. [Intestinal Obstructions, p. 471 et seq.]. 
 f Loc. cit., p. 603. 
 
418 DISEASES OF THE INTESTINES 
 
 Inflation with air has practically the same significance as ene- 
 mata of water. Many cures by this method, particularly in invagi- 
 nations, have been pubHshed. Impacted foreign bodies may also be 
 removed in this manner. Finally, inflation with air may tempora- 
 rily or permanently relieve intestinal kinking. In intestinal ulcera- 
 tion and peritonitis, however, it is strongly contraindicated. 
 
 Electrical Treatment. — By means of the rectal sounds already 
 described (page 178) the faradic or galvanic current may be used for 
 the relief of obstruction. Both currents have been employed with 
 marked success, Yery favourable results were obtained by Bodet, 
 of Paris, who reported 53 cures in 70 cases (!). In France electrical 
 treatment is considered of extraordinary value, and is preferred to 
 opium, Boudet^^ uses the galvanic current exclusively. After the 
 rectum has been filled with one litre of salt solution, the current is 
 applied by means of a soft-rubber sound, which in its interior con- 
 tains a metallic wire. The instrument is similar to the rectal sound 
 described on page 174. The negative pole is connected with the 
 sound, and the positive pole is applied to the abdomen or back by 
 means of a broad flat plate electrode. The current applied varies 
 from 10 to 50 milliamperes, and each application should last from 
 20 to 25 minutes. We would naturally hesitate to ascribe to the 
 electric current such marked effects in the removal of mechanical 
 obstructions, but the high percentage of the reported cures refutes the 
 objection that all these were cases of faecal impaction. This method 
 deserves more consideration in Germany than it has heretofore 
 received. 
 
 (c) Medicinal Treatment. — Practically this is limited to either 
 laxatives or sedatives. The relative value of these two classes of 
 remedies has been in dispute for more than a century, and only 
 within the last ten years has the conclusion been reached that laxa- 
 tives are contraindicated in all forms of obstruction except faecal 
 impaction and paralytic obstruction. Heidenhain ^"^ has recently 
 pointed out that after hernial reduction and operations for intes- 
 tinal obstruction the only proper treatment consists in cleansing 
 enemata or laxatives, particularly castor oil. In this we fully agree 
 \vith him. 
 
 In all other cases treatment by laxatives can only do harm. In 
 a case of chronic invagination reported from Kussmaul's clinic ^\ a 
 dose of castor oil was followed by marked abdominal pain and by 
 rigidity of the intussusception, which descended to the anus. After 
 morphin, on the contrary, the pains not only decreased, but the 
 
INTESTINAL OBSTRUCTION 419 
 
 tumour became less marked and the invaginated portion retracted. 
 When we consider that during the first stage of occlusion there is 
 an attempt to overcome the presenting obstacle by increased peri- 
 stalsis, it is evident that an artificial increase of these efforts is en- 
 tirely unnecessary and generally harmful. The further filling of the 
 distended intestine above the obstruction lessens the chances of 
 spontaneous cure. 
 
 With the exception of the two above-named instances, opiates 
 spulvus opii, 0.02 to 0.05 grams every three or four hours, or morphin, 
 0.01 to 0.03 [!] grams) act effectually. They quiet pain, control vio- 
 lent peristalsis, prevent initial shock, diminish vomiting, induce sleep, 
 and thus favourably influence the general health. Undoubtedly 
 opium, similar to digitalis, is a tonic in heart failure. By quieting 
 the intestines, and preventing dragging upon the inflamed perito- 
 neum, opium acts as a prophylactic against local peritonitis, which, 
 according to present views, may develop in the first stages of ob- 
 struction. Opium is best administered in the form of suppositories 
 (each containing 0.05 grams), or subcutaneously ( [extr. opii] 0.01 to 
 0.05 grams). I would recommend the latter method. This treat- 
 ment, however, has its indications and its limitations. I repeat that 
 opium is to be used only in the first stages of intestinal obstruction, 
 and not when general weakness or cardiac paralysis has appeared. 
 The latter instances may be those in which, as some surgeons be- 
 lieve, the narcotic temporarily masks the serious symptoms of ob- 
 struction. This justifies the advice given by some authors, that 
 after the therapeutic effect of opium has been obtained one should 
 stop its administration for a short time, so that the actual condition 
 may not be obscured by any medicine. Opium is also strongly 
 indicated when the occlusion is complicated by local or general peri- 
 tonitis. Though most of these latter cases die, opium therapy at 
 least presents the possibility of limiting the inflammation. 
 
 Thus we possess many remedies and methods for the internal 
 treatment of obstruction. So far as I can see, all are agreed upon 
 the means to be used, but not upon the manner of their adminis- 
 tration. Some advise using all measures at one time, others that 
 they be used in rapid succession. I believe everything depends 
 upon the diagnosis. For example, gastric lavage is not applicable ■ 
 to sigmoid volvulus or invagination ; here one should give air 
 insufflations or water enemata. Furthermore, we should advise 
 appropriate diet, methodical opium treatment, and always use the 
 constant electrical current. In strangulation of the small bowel we 
 
420 DISEASES OF THE INTESTINES 
 
 should place our main reliance upon opium and gastric lavage. The 
 cardiac power may be increased bj small rectal enemata, injections 
 of saline solution, etc. We should make it our duty to use each 
 remedy systematically and persistently, and not discard one method 
 before its favourable or unfavourable results have been demon- 
 strated. Misdirected overtherapeusis may do more harm than care- 
 fully planned expectant treatment. 
 
 Surgical Treatment of Intestinal Obstruction 
 
 IS'o surgeon, however experienced, can in every case of intes- 
 tinal obstruction state positively whether, and at what moment, an 
 operation may be necessary. Even if his judgment in one or more 
 instances was correct, the very next case might demonstrate that 
 this judgment was only accidental. 
 
 A general rule of procedure must be the result of principles 
 derived from many observations ; but even then it is almost im- 
 possible to formulate satisfactory principles. This is due, above 
 all, to the variability of the material upon which the private 
 physician, the hospital physician, and the surgeon must base their 
 judgment. In the majority of instances the surgeon sees only 
 the severest cases of intestinal obstruction and but few of those 
 which have been cured medicinally, while the hospital physician, 
 and more especially the private physician, frequently succeed in 
 curing cases by conservative treatment. In view of the large 
 number of cures (33 to 35 per cent, according to fairly well agreed 
 statistics), and of the rarity of obstruction from fsecal impaction, 
 the objection advanced by some surgeons that these are only cases 
 of simple impaction does not come into serious consideration. In 
 which forms of obstruction do medical cures occur ? They un- 
 doubtedly include cases of feecal tumour, gallstone obstruction, in- 
 vagination, and, as Curschman^ has shown by autopsies, kinking of 
 both limbs of a jejunal coil and volvulus of the sigmoid. This 
 2)roves nothing more or less than the possibility of curing even severe 
 forms of intestinal obstruction by internal therapeutics (not, hoio- 
 ever, as some surgeons claim, by the opium therapeusis). Thus the 
 extreme view of a few surgeons, that every case of mechanical ob- 
 struction requires operation, lacks confirmation. 
 
 It is certain, however, that operative procedures have saved 
 many lives which would otherwise have been lost. From statis- 
 tics of 288 cases, Naunyn '^'^ has demonstrated that the earlier the 
 operation the better the results obtained. Of those operated dur- 
 
INTESTINAL OBSTRUCTION 421 
 
 ing the first two days of the disease, Y5 per cent, and of those oper- 
 ated after the third day, 35 to 40 per cent, were cured. These 
 statistics do not refer to all cases of obstruction, but only to those 
 which were operated upon. They serve to emphasize the statement 
 that if operation is to be performed at all it should be done as early 
 as possible. 
 
 Since the results of internal treatment, though not exactly 
 favourable, are by no means hopeless, they may be compared with 
 those following operation. If we consider only the statistics of 
 individual prominent surgeons, we shall find that the results of 
 surgical interference are not particularly encouraging. Thus, in 
 about 110 cases of intestinal obstruction, Obalinski^^ had a mor- 
 tahty of 34.5 per cent — just as large a death rate as those cases 
 treated internally. Treves,* who reported 122 cases of laparotomy 
 up to the year 1888, had about the same mortality, 36.9 per cent. 
 Even Kocher^, whose results in abdominal surgery are equal to any 
 in the world, had as high a mortality as 38 per cent. Hence we may 
 conclude that improved antisepsis and technic have not improved 
 the unfavourable results of operation. We must therefore search 
 for another factor. In his discussion on intestinal obstruction (1889) 
 Schede has spoken so convincingly that I cannot but reproduce his 
 own remarks : " Every surgeon, particularly every abdominal surgeon, 
 must agree with me that these operations [for obstruction], if per- 
 formed upon healthy individuals, would only very rarely end fatally 
 — in 5 per cent, or at most 10 per cent, of the cases. But there is 
 scarcely any other condition w^hich so rapidly lessens and so severely 
 taxes the ability of a patient to withstand large operations and long 
 abdominal manipulations as intestinal obstruction. A few days are 
 often sufiicient to bring about a condition in which the much- weak- 
 ened patient is unable to bear the simplest operation — for example, 
 the search for and division of a pseudo ligament." 
 
 In his recent treatise Kocher has sought for the conditions 
 which produce these unfavourable results. He found them in the 
 changes which the intestine suffers in consequence of disturbances 
 in its circulation. The epithelium of the obstructed segment is 
 destroyed, allowing micro-organisms to find their way into the peri- 
 toneum, and cause peritonitis. Putrefying substances are more 
 easily absorbed from a mucous membrane denuded of its ejDithe- 
 lium, hence an auto -intoxication (or sepsis) results. Kocher has 
 
 * Darmobstruction, S, 461. 
 28 
 
422 DISEASES OF THE INTESTINES 
 
 likewise called attention to the danger of perforation from ulcers 
 whicli develop above the stricture (" distention ulcers "). 
 
 The chances of operative success are also considerably lessened by 
 the difficulty, even during operation, in recognising existing condi- 
 tions. Any one who has witnessed the efforts and the time required 
 to control and replace the distended intestines which continually 
 protrude from the abdominal cavity will understand that the 
 strength of the patient is often exhausted before the actual opera- 
 tion begins. 
 
 In addition, it is often impossible before operation to deter- 
 mine the site or the type of obstruction. 
 
 Where shall the incision be made ? Which intestinal segment 
 shall be sought for ? Is there one obstruction, or, as occasionally 
 happens, are there several, and, in the latter instance, which one 
 occludes the bowel ? From this it can be readily understood that 
 the suro-eon is often confronted with insurmountable difficulties. 
 
 If roe are to draw the ])ro])er conclusions frora this discussion, 
 we TTiust concede that the results and da/ngers of internal and oper- 
 ative treatment are alxmt the same. In any given case, therefore, it 
 will be the duty of the physician to carefully consider which method 
 — operative or internal treatment — offers the better chances for 
 recovery. 
 
 The special conditions of the case, the kind of obstraction, the 
 age and strength of the patient, and the results obtained by inter- 
 nal therapy, are factors to be considered. The sum total of ex- 
 periences reported, favourable as well as unfavourable, must also 
 influence us in our decision. Regarding this point the following, 
 statements may be made : 
 
 In the most severe forms of obstruction — strangidation and 
 incarceration — the chances of cure by internal measures are very 
 small indeed. If in the very beginning of the disease the symp- 
 toms are severe and the clinical signs of internal strangulation are 
 present, and if a short trial with opiates and gastric lavage has been 
 without result, operative interference is undoubtedly indicated. 
 
 In those cases of obstruction due to an old or recent external 
 hernia, the indication for operation is also very clear.- Statistics 
 show that here the chances of cure are much better than in any 
 other form of obstruction. According to Xaunyn, 72 per cent of 
 the cases are cured. These favourable results have been obtained 
 because the diagnosis can frequently be made before operation, and 
 the field of operation is limited. 
 
INTESTINAL OBSTRUCTION 423 
 
 In gallstone obstruction the results are not so satisfactory, and 
 we must be more guarded in our jjrognosis. The chances of spon- 
 taneous cure are comparatively good (according to Courvoisier, 56 
 per cent, Lobstein, 52 per cent, ISTaunyn-Schiiler and Dufort, 44 
 per cent), while for the operated cases IS'aunyn (23 cases) reports 
 a mortahty of TO per cent, and Lobstein (33 cases) a mortality of 
 60.1 per cent. 
 
 From this it follows that surgical treatment of gallstone ob- 
 struction does not as yet offer such favourable results that operation 
 ought be immediately advised. Since the symptoms of this form 
 of obstruction generally develop slowly, we should first carefully 
 try the internal therapeutic measures which have been described. 
 The time for operation must be decided upon in each individual 
 case. 
 
 Eegarding operation for other foreign bodies there are not at 
 present sufläciently extensive statistics from which to draw conclu- 
 sions. It is a well-known fact that even large bodies may pass 
 through the intestines without difficulty. Since in the majority 
 of these cases operation is followed by favourable results, we should 
 not too long employ internal therapeutic measures if intestinal 
 obstruction develops. Obstruction from ascarides (a rare form) 
 may also demand operation. 
 
 Most authorities agree that as soon as the diagnosis of invagina- 
 tion is made the case should be handed over to the surgeon. Sta- 
 tistics bear out the complaint of surgeons that patients with invagi- 
 nation are generally referred to them too late. Barker ^^, for exam- 
 ple, cured 7 out of 11 cases, a result which he declares is due to his 
 operating as early as possible. According to Gibson ^, who in his 
 article gave a table of all cases (239) operated on up to the year 
 1896, tlie general mortality is 53 per cent ; in those oj)erated on on 
 the first and second days the mortality is only 39 to 41 per cent ; on 
 the third day, 62 per cent ; on the fourth and fifth days, 72 per cent ; 
 and on the sixth day, 100 per cent. He explains these differences 
 by the fact that even as early as the second day 14 per cent of the 
 cases are already irreducible ; on the third day, 38 per cent ; on the 
 fourth, 57 per cent ; and on the seventh, 80 per cent. Gibson gives 
 the proportion of deaths in the reducible and irreducible invagina- 
 tions as 38 : 82. The age of the patient naturally plays a great part 
 in the indication for operation. Gibson's statistics show a mortality 
 of 82 per cent in jDatients less than three months old ; the mortality 
 gradually decreases up to the tenth year, when it is 37 per cent, 
 
424 DISEASES OF THE INTESTINES 
 
 increasmg again to the fifteenth year (68 per cent) ; after this it 
 approaches the adult mortality (62 per cent). 
 
 These figures show that, even in cases operated on early, the 
 death rate from invagination is considerable. The results of con- 
 servative treatment are still more unfavourable. 
 
 Since the above statistics demonstrate that early operations (up 
 to the third day) offer the most favourable chances, Tve should not 
 continue too long with palliative treatment. Surgeons state, how- 
 ever, that palliative treatment should not be entirely neglected. 
 
 For example, Eydygier^^, in his latest work, recommends non- 
 surgical treatment at fii'st — electricity, gastric lavage, rectal enemata 
 and distention with gas in the knee-chest position, massage, and at- 
 tempts at reduction of the invagination in deep narcosis. Only 
 when one or all of these measures fail is operation to be resorted to. 
 
 Chronic invagination is somewhat more amenable to conserva- 
 tive treatment, and the appropriate therapeutic measures may for 
 some time be tried. If these are ineffectual and the patient's con- 
 dition becomes alarming, it is best to operate at once. According 
 to Eydygier's rather small statistics, the mortality from operation 
 is only 24 per cent. 
 
 In volvulus, particularly of the sigmoid, the indications for opera- 
 tion are different. Xaunyn ^ advises delay and individual consider- 
 ation of the cases. The results of surgical treatment are by no 
 means excellent, though in 19 cases of volvulus of the sigmoid (in 
 14 of which the correct diagnosis was made) Obalinski cured 10 by 
 operation. ISTothnagel * does not agree with ISTaunyn's conclusions, 
 and pleads for active interference not alone in severe but also in 
 mild cases. For the following reasons I am inclined to agree with 
 ISTothnagel. It is not particularly difficult to diagnosticate sigmoid 
 volvulus, the surgeon can readily find the obstruction, and, if the 
 volvulus was not originally incomplete, the chances of spontaneous 
 reduction are very small. By manipulations through the rectum, 
 we shall only rarely succeed in producing a permanent cure. On 
 the other hand, we must remember that the symptoms of volvulus 
 usually develop slowly, that there is usually no fsecal vomiting, and 
 that the patient's general condition remains satisfactory for quite 
 a time. Accordingly, unless the disease assume an exceptionally 
 severe course, we may wait two or three days for a spontaneous 
 reduction. If within this time this has not occurred, operative 
 
 * Darmkrankheiten, S. 425. 
 
INTESTINAL OBSTRUCTION 425 
 
 interference is at once necessary. If, as is very often the case, a 
 carcinoma or other tumour is the underlying cause of the volvulus, 
 there will be all the more reason for surgical interference, since by 
 operation we not only relieve the volvulus, but also may remove 
 its cause. A spontaneous reduction will not permanently cure the 
 condition, as the volvulus is very apt to recur. 
 
 All authorities agree that the surgical is the only proper treat- 
 ment for internal intestinal strictures. Since these generally de- 
 velop slowly, the question of operation will have to be decided 
 before there is complete intestinal obstruction. Whether we ought 
 to delay or immediately take active measures, Avill depend upon the 
 site and type of obstruction, and. particularly upon the acuteness of 
 the symptoms. Even should spontaneous cure occur, it would only 
 be a respite, hence there is no reason for long delay. It is true, 
 however, that the results of operations for tubercular and carcinom- 
 atous strictures are only temporary, and in cases of multiple stric- 
 tures a fatal termination is unavoidable. 
 
 Intestinal obstruction by faecal impaction is not amenable to 
 surgical treatment. Here the internal measures already described 
 (purgatives, rectal injections of oil, soap and water irrigations, 
 intestinal faradization or galvanization) are in place. Unfortu- 
 nately, the diagnosis is often so extremely difficult that an operation 
 may be necessary. After the diagnosis has been established, even 
 in the severe forms, internal treatment alone is indicated. 
 
 Unless the intestinal paralysis is reflex in character (apparent 
 reduction of external hernia, inflamed, undescended testicle, etc.), 
 and its cause can be removed by operative or other methods, intes- 
 tinal paralyses are to be treated as expectantly as jDossible. A 
 serious result may often be averted by intestinal irrigation, electrici- 
 ty and purgatives. If these do not succeed, the best procedure is 
 the formation of an artificial anus as high up as possible. 
 
 In the foregoing we have described the indications for opera- 
 tive treatment of intestinal obstruction. Discussion of the opera- 
 tive technic belongs rather to surgical literature.* We shall briefly 
 call attention to a few of the principal points involved. 
 
 In every case of obstruction the aim of surgery is undoubt- 
 edly to remove the cause, and to attempt a permanent cure by lap- 
 arotomy. Unfortunately there are often exceptions to this ideal 
 
 * An excellent resume by E. Gräser may be fouiul in Penzolclt u. Stintzing's 
 Handbuch, Bd. iv. 
 
426 DISEASES OF THE INTESTINES 
 
 result. Either the strength of the patient is insufficient, or the sur- 
 roundings render i-adical operation impracticable, or existing condi- 
 tions are so complicated that direct removal of the hindrance is 
 too dangerous. In these cases enterostomy is the operation adopted 
 by almost all surgeons. 
 
 In the Congress for Internal Medicine, 1889, Schede ^^ warmly 
 advocated enterostomy. From his experience with two cases, he 
 pointed out that the formation of an artificial anus might not only be 
 a palliative but a curative operation. On the other hand, von Oet- 
 tingen^^, from more extensive statistics, showed that enterostomy has 
 not been successful in any case of volvulus with axial torsion, or in 
 severe incarceration and strangulation ; but that it had succeeded 
 in intestinal kinking. In acute invaginations also, Eydygier^, Gib- 
 son ^^, and Ludloff^^ would limit the formation of an artificial anus 
 to those patients whose strength does not allow of resection of the 
 invagination. If the condition of the patient improves, a radical 
 operation is later indicated. 
 
 From the above description it can be seen that there is a distinct 
 gap between the therapeutic principles of the physician and of the 
 surgeon, which will only be filled when the number of surgical 
 cures becomes much greater than the medical. Excepting with a 
 few surgeons, this at present is not the case. The changes pro- 
 duced in the obstructed intestinal segment and the resulting serious 
 general condition develop so rapidly, that, to employ a common 
 expression, the surgeon, even though operating at the earliest mo- 
 ment, generally operates too late. 
 
 LITERATURE 
 
 1. Leichtenstern. von Ziemssen's Handbuch, Bd. vii, 3, 2te Aufl., S. 416. 
 
 2. Nothnagel. Darmerkrankungen, S. 189. 
 
 3. Wegele. Münchener med. Wochenschr., 1898, No. 16. 
 
 4. Leichtenstern. von Ziemssen's Handbuch, Bd. vii, 3, S. 411 u. 418. 
 
 5. Cahn. Berl. klin. Wochenschr., 1886, No. 23. 
 
 6. Riegel. Zeitschr. f. klin. Medicin, 1886, Bd. xi, S. 187, and Deutsche 
 
 med. Wochenschr., 1890, No. 39. 
 
 7. Hochhaus. Berl. klin. Wochenschr., 1891, No. 7. 
 
 8. Schule. Ibid., 1894, No. 45. 
 
 9. Reiche. .lahrb. d. Hamburger Krankenanstalten, 1892, Bd. ii. 
 
 10. Herz. Deutsche med. Wochenschr., 1896, No. 23 u. 24. 
 
 11. Pic. Revue de medecine, Dec. 1894, et Jan. 1895. 
 
 12. Rewidzoff. Arch. f. Verdauungskrankheiten, 1898, Bd. iv, S. 369. 
 
 13. Boas. Deutsche med. Wochenschr., 1891, No. 28. 
 
INTESTINAL OBSTRUCTION 427 
 
 14. Wilms. Beiträge z. klin. Chirurgie, Bd. xviii, S. 2, 1897. 
 
 15. Boas. Zeitschr. f. klin. Medicin, Bd. xvii, H. 1 u. 2, 1890. 
 
 16. Küttner. Beiträge z. klin. Chirurgie, 1899, Bd. xxiii, H. 2, S. 505. (Here 
 
 "will be found the literary references indicated in the text.) 
 
 17. E. Frankel. Cited from Munch, med. Wochenschr., 1896, No. 28; Mit- 
 
 theilungen aus d. Hamburger Staatskrankenanstalten, 1897, Bd. i, S. 61. 
 
 18. Hofmeister. Beiträge z. klin. Chirurgie, 1896, Bd. xvii, S. 577. 
 
 19. Litten. Zeitschr. f. klin. Medicin, Bd. ii, 1881, S. 702, etc. 
 
 20. KnudFaber. Berl. klin. Wochenschr., 1897, No. 30. 
 
 21. Johnson and Wallis. Cited by K. Faber (reference 20). 
 
 22. F. Treves. Darmobstruction; translated by Dr. Arthur PoUak. Leipsic, 
 
 1888, p. 354. [Intestinal Obstruction; its Varieties, etc. New York, 
 1899, p. 294.] 
 
 28. Rosenstein. Berl. klin. Wochenschr., 1881. 
 
 24. Jaccoud. Traite de pathologic interne. 
 
 25. Briquet. Traitö clinique et th6rapeutique de Thysterie. Paris, 1859. 
 
 26. Leichtenstern. Verhandlungen d. Congresses f. innere Medicin, 1889. 
 
 (Cited from a report.) 
 
 27. Küttner. Virchow's Archiv, 1868, Bd. xliii. 
 
 28. Hilton Fagge. Guy's Hosp. Rep., vol. xiv, 1869. (Cited from Naunyn, 
 
 Grenzgebiete d. Chirurgie u. Medicin, vol. i.) 
 
 29. von Wahl. Centralbl. f. Chirurgie, 1889, S. 155; Archiv f. klin. Chirurgie, 
 
 1889, Bd. xxxvüi, S. 283. 
 
 80. Kader. Centralbl. f. Chirurgie, 1891, Beilage, S. 110; Inaug.-Diss., Dor- 
 pat, 1891; Arch. f. klin. Chirurgie, 1891, Bd. xlii; Deutsche Zeitschr. f. 
 Chirurgie, Bd. xxxiii. 
 
 32. von Zöge-Manteuffel. Verhandl. des 8. Congresses f. innere Medicin, 1889, 
 
 S. 93. 
 
 33. Schede. Verhandl. des 8. Congresses f. innere Medicin, 1889, S. 103. 
 
 34. Fenwick. Obscure Diseases of the Abdomen. London, 1889. 
 
 35. Schlange. Archiv f. klin. Chirurgie, 1889, Bd. xxxix, S. 429; Volkmann's 
 
 Sammlung klin. Vorträge, 1894, N. F. No. 101. 
 
 36. Obalinski. Arch. f. klin. Chirurgie, 1896, Bd. xlviii, H. 1. 
 
 37. Naunyn. Mittheil, aus d. Grenzgebieten, 1895, Bd. i, S. 98. 
 
 38. Tietze. Deutsche Zeitschr. f. Chirurgie, 1897, Bd. xlv, H. 1 u. 2, S. 17. 
 89. Englisch. Oesterr. medicin. Jahrbücher, 1884, No. 2 u. 8. 
 
 40. Frank. Berl. klin. Wochenschr., 1887, No. 38. 
 
 41. von Engel. Prager medicin. Wochenschr., 1899, No. 14. 
 
 42. Israel. Berl. klin. Wochenschr., 1892, No. 1. 
 
 43. Curschmann. Verhandl. des 8. Congresses f. innere Medicin, 1889. 
 
 44. Leichtenstern. Berl. klin. Wochenschr., 1874, No. 40. 
 
 45. P. Guttmann. Deutsche medicin. Wochenschr., 1884, No. 14; Berl. klin. 
 
 Wochenschr., 1893, No. 2. 
 
 46. Karl Abel. Berl. klin. Wochenschr., 1894, No. 4 u. 5. 
 
 47. Melchioris. Cited from Treves, Darmobstruction, p. 142. 
 
 48. Cursclimann. Deutsches Arch. f. klin. Medicin, Bd. liii, H. 1 u. 2, S. 1. 
 
 49. Böttcher. Virchow's Archiv, 1886, Bd. civ. 
 
 50. Fleiner. Ibid., 1885, Bd. ci. 
 
428 DISBASES OF THE INTESTINES 
 
 51. Eaffinesque. l^^tude sur les invaginations intestinales chroniques. These 
 
 de Paris, 1878. 
 53. D'Arcy Power. Some Points in the Anatomy, Pathology, and Surgery of 
 
 Intussusception. London, 1898. 
 
 53. Leichtenstern. Prager Vierteljahrsschrift, Bd. cxviii. 
 
 54. Henoch. Kinderkrankheiten. Berlin, 1881, S. 453. 
 
 55. Kelling. Arch. f. Verdauungskrankheiten, 1895, Bd. i, H. 2, S. 172. 
 
 56. Westphalen. Ibid., 1898, Bd. iv, H. 1, S. 63. 
 
 57. Kiedel. Mittheil, aus d. Grenzgeb. d. Medicin u. Chirurgie, Bd. ii, S. 528. 
 
 58. Schnitzler. Wiener klin. Rundschau, 1895, No. 37. 
 
 59. L. Meyer. Virchow's Archiv, Bd. xcv. 
 
 60. Mikulicz. Arch. f. klin. Chirurgie, 1895, Bd. li. 
 
 61. Körte. Arch. f. klin. Chirurgie, 1893, Bd. xlvi, S. 331. 
 
 62. E. Lobstein. Beiträge zur klin. Chirurgie, 1895, Bd. xiv, S. 394. 
 
 63. Kirmisson-Rochard. Archives generales. Mars, 1892. 
 
 64. Sick. Deutsche medicin. Wochenschr., 1891, S. 368. 
 
 65. Köstlein. Würtemb. Corresj)ondenzbl., 1876, No. 6. 
 
 66. Dessauer. Virchow's Archiv, Bd. Ixvi, S. 271. 
 
 67. Maclagan. Lancet, vol. i, p. 123, 1888. 
 
 68. Courvoisier. Casuistisch stat. Beiträge zur Pathol, u. Chirurgie d. Gallea- 
 
 wege. Leipzig, 1890. 
 
 69. Down. Quoted from Treves's Darmobstruction, S. 336 [and Intestinal 
 
 Obstructions, p. 197]. 
 
 70. Davaine. Traite de l]ntozoaires et de maladies ver-mineuses. 2"^ edit., 
 
 Paris, 1871. 
 
 71. Heller. Darmschmarotzer. Ibid., S. 586. 
 
 73. Mosler u. Peiper. Thierische Parasiten. Nothnagel's Handbuch, Bd. vi, 
 1894, S. 197. 
 
 73. Heidenreich. Semaine medicale, 1891, No. 42. 
 
 74. Simon. Revue medic, de I'Eto, 1892, No. 8. (Cited from Mosler and 
 
 Peiper.) 
 
 75. Frikker. Deutsche medicin. Wochenschr., 1897, No. 4. 
 
 76. von Leube. Naturforscherversammlung in Düsseldorf (from report in the 
 
 Munch, med. Wochenschr., 1898, No. 41). 
 
 77. Strauss. Berl. klin. Wochenschr., 1898, No. 38. 
 
 78. Sandoz. Correspondenzbl. f. Schweizer Aertze, 1887, S. 41. 
 
 79. Strehl. Deutsche Zeitschr. f. Chirurgie, 1899, Bd. Ivi, H. 5 u. 6. 
 
 80. Grundzach. Wiener medicin. Presse, 1895, No. 10. 
 
 81. Hochenegg. Wiener klin. Wochenschr., 1897, No. 51. 
 
 83. Gräser. Penzoldt-Stintzing's Handbuch d. speciellen Therapie, Ite Aufl., 
 Bd. iv, S. 568. 
 
 83. Curschmann. Reference 43 ; also Deutsche medicin. Wochenschr., 1887, 
 
 No. 31. 
 
 84. O. Rosenbach. Ibid. 
 
 85. Fürbringer. Verhandl. des 8. Congresses f. innere Medicin, 1889. 
 
 86. von Ziemssen. Ibid. 
 
 87. Körte. Berliner Klinik, 1891, No. 36. 
 
 88. Kocher. Mittheil, aus d. Grenzgebieten, 1898, Bd. iv, S. 3. 
 
INTESTIN'AL OBSTRUCTION 429 
 
 89. Boudet (de Paris). Progres medical, 7 et 14 Fevrier, 1885. 
 
 90. Heidenhain. Deutsche Zeitschr. f. Chirurgie, 1897, Bd. xliii, S. 201. 
 
 91. Asch. Inaug.-Diss., Strassburg, 1880. (Cited from Gräser in Penzoldt- 
 
 Stintzing's Handbuch, 1. Aufl., Bd. iv, S. 596.) 
 93. Barker. Quoted from Ludloflf, Grenzgebiete, 1898, Bd. iii, H. 5, S. 603. 
 
 93. Gibson. New York Med. Record, July 17, 1894. 
 
 94. Rydygier. Deutsche Zeitschr. f. Chirurgie, 1896, Bd. xlii. 
 
 95. Schede. Archiv f. klin. Chirurgie, Bd. xxxvi, H. 3. 
 
 96. von Oettingen. Inaug.-Diss., Dorpat, 1888. 
 
CHAPTEK XIX 
 
 TYPHLITIS, PERITYPHLITIS [APPENDICITIS) 
 
 Preliminary Hemarks. — Typhlitis is an inflammation of tlie 
 csecum and the surrounding peritoneum. Perityphlitis or appen- 
 dicitis* is an acute or chronic inflammatory process, which origi- 
 nates in the vermiform appendix, and may remain strictly local- 
 ized or spread to the surrounding parts. 
 
 At the present day we believe that in these inflammatory affec- 
 tions the csecum is much less involved than the appendix. Thus 
 the long-forgotten teachings of Louyer, Viller, ]S~ay (1824), Melier 
 (1827), Grisolle, and others,f which were so obstinately and success- 
 fully opposed, are now vindicated. From Talamon we gather that 
 Melier had evidently foreseen the possibility of removing a diseased 
 appendix. He plainly stated : " If it were possible to diagnose 
 these affections with certainty we might conceive of the possibility 
 of curing them by means of operation. Perhaps some day this 
 result may be achieved." 
 
 Only very recently have the old mistaken views concerning 
 appendicitis been overthrown. To a very great extent this advance 
 is due to modern surgery. As in many branches of gastro-intestinal 
 diseases, here also the autopsy in vivo and jpost-mortem have borne 
 rich fruit (Ribbert, Zuckerkandl, Matterstock, H. Einhorn, and 
 others). Internal medicine slowly yielded to modern views, and 
 has since added considerably toward extending this new field. The 
 
 * We will employ the terms perityphlitis and appendicitis, though the latter is 
 etymologically not exactly correct. Because of its peculiar pronunciation, skoli- 
 koiditis (from CKdiKr]^, worm), the name introduced by Nothnagel, will prob- 
 ably not come into general favour. The term epityphlitis, recently suggested by 
 Küster, though sounding better than skolikoiditis, is also objectionable, since the 
 appendix is not always upon, but may be behind, below, above, or to the side of 
 the Ciecum. 
 
 f Compare the interesting historical development of this question by Talamon, 
 Appendicite et Perityphlite, Paris. 1892 ; and by Grobe, Pathologie und Therapie 
 der Perityphlitiden, Greifswald, 1896. 
 430 
 
TYPHLITIS, PEKITYPHLITIS (APPENDICITIS) 431 
 
 excellent article of SaLli^ and the impressive discussion pertaining 
 thereto have accomplished much toward this end. 
 
 Surgery soon dominated this new field. In the middle of the 
 eighties, with the progress and development of aseptic methods, 
 the operative treatment of appendicitis made rapid advance in 
 England and America, and soon obtained brilliant results. 
 
 Gradually our ideas of this affection became moderated, and the 
 early radicalism was somewhat modified. Indications for internal 
 and for operative treatment began to be compared, the results of in- 
 ternal and surgical treatment given their proper value, and the occa- 
 sional bad effects of the operation (fistulse, abdominal sinuses, her- 
 nise, adhesions, etc.) were considered. Both scientifically and prac- 
 tically appendicitis was made the boundary between medicine and 
 surgery. Before proceeding to a consideration of the diagnosis 
 and treatment of this affection we shall, in what follows, state as 
 briefly as possible its present status, in so far as it concerns the clin- 
 ical view of the disease. 
 
 Typhlitis. — Does it really exist ? Has stercoral typhlitis the 
 significance attributed to it since Alber's time ? Yiews differ ; a 
 few authors (among the modern writers I cite only Talamon*) 
 go so far as to deny the occurrence of typhlitis. We may discuss 
 these conditions in various ways — e. g., by referring to pathological 
 anatomy, to clinical observations, or to the results of the many 
 surgical operations. 
 
 Pathological anatomy has long dealt with inflammatory processes 
 of the caecum. Ulcerative conditions, particularly, have been 
 known since autopsies have been systematically performed. Usually, 
 however, these ulcerative conditions were quite different from those 
 now in question. They were either typhoid, dysenteric, tubercular, 
 stercoraceous, or actinomycotic. As already pointed out in the 
 more extensive discussion of these ulcerations, they are by no means 
 limited to the caecum, but occur as often in the rectum, the flexures 
 of the colon, and the sigmoid flexure. Indeed, it is surprising that, 
 excepting the rare cases of pericolitis and sigmoiditis, inflammatory 
 processes similar to typhlitis are not found more often in other 
 segments of the large intestine. Etiologically, besides ulcerations, 
 we must also consider foreign bodies (needles, etc.) and neoplasms 
 (particularly cancerous and tubercular). 
 
 What is the status of clinical teaching regarding typhlitis ? The 
 
 * Loc. cit. 
 
432 DISEASES OF THE IXTESTmES 
 
 symptoms of typhlitis are described as follows : Obstinate constipa- 
 tion, tympanites, pain and sensitiveness in the right iliac fossa, 
 development of a sausage-shaped faecal tumour corresponding to the 
 l^osition of the csecum {boudin stercoral)^ moderate fever, and 
 increased indicauuria. A perforation of the caecum may occur, and 
 death from peritonitis follow. 
 
 It must be admitted that in itself this picture is characteristic, 
 but modern research has shown that it cannot be distinguished 
 from disease processes which originate in the appendix. There 
 is not one symptom which might not also be present in an ap- 
 pendiceal inflammation. We cannot jpresent an absolutely indi- 
 'vidualizing picture of typhlitis, and at the present time it is impos- 
 sible to syinptomatologiccdly separate appendicitis and typhlitis. 
 The results of operations, however, or, as I^othnagel once appropri- 
 ately called it, the results of " biopsy," can only determine the diag- 
 nosis during life. 
 
 Increased observations have demonstrated that, though rarely, 
 isolated inflammatory processes may affect the caecum or its vicinity 
 ^vithout involving the appendix. Such observations have been 
 reported by Harley^, Mariage^, Curschmann "^5 Lennander^, Porter^, 
 Ivrönlein '^, Menley ^, Meusser ^, and others. I agree with Borchardt^*' 
 that some of these observations will not stand critical investigation, 
 but among these there are several (I will only mention the case of 
 Lennander, where no appendix at all was to be found) which need 
 no forced interpretation, and which prove the occurrence of 
 typhlitis.* 
 
 The etiology of typhlitis shows certain variations. There may 
 be faecal impaction with suppuration, or there may be adhesions ; 
 sometimes there are ulcerations of the most varied kinds, with 
 more or less evident perforations. These variations prove that 
 typhlitis by no means gives the simple clinical picture that 
 appearances would warrant. It is necessary to give up the idea 
 of a purely stercoraceous typhlitis, for impacted faeces per se 
 rarely produce typhhtis; foreign bodies, ulcerations, adhesions, 
 and fixation of the ccecum may also cause inflammation of the 
 caecum. 
 
 * Grohe (loc. cit.) also reports an observation which belongs here. In a paralytic 
 wlio died of broncho-pneumonia, the cfecum was filled with ffecal masses. In the 
 portion of the intestinal wall opposite the mesenteric attachment there was found 
 a slight ulceration of the mucous membrane of the size of a half dollar, which 
 could only be explained by faecal impaction. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 433 
 
 Perityphlitis (Appendicitis). — It is now an absolutely estab- 
 lished fact that the inflammatory processes which start in the ap- 
 pendix greatly preponderate, and that the great majority of dis- 
 eases until recently designated as tyjMitis, perityphlitis, atid para- 
 typhlitis likeioise originate in the vermiform apjjendix. This fact 
 is supported not only by anatomical observations (Matterstock, Fen- 
 wick, H. Einhorn), but also by the great number of observations of 
 the foremost surgeons (Eoux, Sonnenburg, Kümmel!, Lennander, 
 Körte, Schede, Eotter, McMurtry, Reginald Fitz, McBurney, 
 Fowler, Treves, Beck, Kelynack, Dunn, and others). The abso- 
 lute agreement of these surgeons relieves us of the necessity of 
 presenting isolated statistics. The question arises as to which are 
 the most frequent causative factors. 
 
 To answer this, a brief anatomical description of the relation 
 and position of the appendix is necessary. 
 
 The length of the appendix varies from 2^ to 24 centimetres, the average 
 being about 9 centimetres. Its thickness is about that of a goose quill. In 
 the newly born the proportion of the length of the appendix to th'e large intes- 
 tine is as 1 to 10; in the adult, 1 to 20. Like the caBCum, the appendix has 
 a mesentery (mesenteriolum, mesovermium) in which the nourishing blood and 
 lymph vessels course. The caecal artery, the lowest offshoot of the superior 
 mesenteric, gives off a branch to the mesovermium — the appendicular artery; 
 the latter runs along the mesentery parallel to and a few millimetres away from 
 the appendix, giving off branches to that organ. The appendicular artery is a 
 terminal artery (in Cohnheim's sense), and this accounts for the severe changes 
 which may develoji in the course of apparently mild cases of appendicitis. The 
 mucous membrane of the appendix contains cylindrical cells, Lieberkuhn's 
 glands, blood and lymph vessels, and is distinguished from the other intestinal 
 segments by its striking abundance of lymph follicles. According to Ribbert '^ 
 the latter vary very much with the age. In childhood the lymph follicles are 
 very large and lie closely together; after the twentieth year they decrease in 
 size and become more separated. 
 
 At the insertion of the appendix the so-called valve of Gerlach, or, accord- 
 ing to Groh6, more properly the valve of Merling, is sometimes present, though 
 frequently absent (Clado, Lafforgue). This structure, however, cannot prevent 
 faeces from passing into the appendix. 
 
 Being a functionally unnecessary organ, the appendix presents involution 
 changes with increasing age (Ribbert). After disappearance of the epithelium 
 there develops a slow proliferation of the connective tissue of the mucosa, while 
 the submucosa and muscularis retain their structure. By this process the lumen 
 of the appendix becomes gradually narrowed, and in one third of all cases 
 absolutely obliterated. 
 
 The relation of the peritoneum is important to an understanding pf the 
 anatomical changes. As modern observation (Bardeleben, Luschka, Tuffier) 
 has shown, the entire circumference of the caecum is covered by peritoneum, so 
 
434: DISEASES OF THE INTESTINES 
 
 that in more than 96 per cent of all cases the appendix lies intraperitoneally 
 (Maurin --, Bryant ", F. Yon Sydow "). The appendix may accompany the 
 caecum in its various changes in position. We ^'ill discuss this point more 
 fully in the diagnostic section. 
 
 The manner of attachment of the appendix to the csecum is of great surgical 
 interest, and, as Krausshold '^ has long since shown, may vary considerably. 
 The most frequent insertions of the appendix are internally to, behind, below 
 and in front of the caecum, and finally in the small pelvis (Bryant). 
 
 Tlie causes of aj)pendicitis are direct and ^predisposing. 
 
 Of the direct causes fsecal concretions play an important part. 
 According to Ribbert ^^ they occur in 10 per cent of appendicitis ; 
 according to Kenvers ^^, Treves ^^, and Murphy ^^ in about one third 
 of all cases ; according to some authors (Matterstock) they produce 
 50 per cent of the cases. 
 
 Other foreign bodies are found, but they are more rare than 
 coproliths, being present in about 2 per cent of all cases. 
 
 The presence of fsecal concretions (which, by the by, have only 
 a central nucleus of faeces, the remainder consisting of several layers 
 of mucus (Ribbert ^^) ), by no means explains the entire etiology of 
 appendicitis, for there are many cases in which these concretions 
 are not present, but in which the appendix contains mucus or fluid 
 faecal masses. In view of this, we must ask whether faecal con- 
 cretions really play a considerable part in the etiology, or only 
 favour the development of an inflammation. This question has 
 been variously answered. In my opinion the concretion acts only 
 as a predisj)osing factor in conjunction with other conditions soon 
 to be considered. 
 
 We have already described the peculiar structure of the appen- 
 dix, its abundance of lymph follicles, the absence of smooth muscle 
 fibres, its extraordinary length in proportion to its narrow lumen, 
 its tendency to changes of position and form, and, finally, the ab- 
 sence of anastomoses in the appendicular artery. All these circum- 
 stances favor catarrhal inflammation, which, no matter what its 
 cause, leads to increase and stagnation of secretion. 
 
 The chief cause of appendicitis without doubt lies in the stagna- 
 tion of its secretion. The pathology of other organs demonstrates 
 the harmful effect of stagnating secretions in hollow viscera. In 
 the gastro-intestinal canal they are the main cause of severe nutri- 
 tive disturbances; in the gall bladder they are to a great extent 
 responsible for formation of stones ; and in the course of a surgical 
 wound the absence of sufficient flow of secretion constitutes one of 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 435 
 
 the most important complications. -Evidently all this also applies 
 to the appendix. As long as there is free and regular communica- 
 tion between the mucous membrane of the appendix and caecum, 
 even though virulent bacteria be present, no disturbance will fol- 
 low. The moment, however, the communication ceases, and the 
 outflow of secretion is prevented either by faecal concretions, ca- 
 tarrhal swelling, partial obliteration, or by compression or adhesion 
 of neighbouring organs, decomposition of the contents, inflamma- 
 tion, ulceration, gangrene, and suppuration occur. 
 
 As demonstrated by the careful studies of Tavel and Lanz^^, 
 Eckehorn^", Morris ^^, and others, bacteria, especially the bacterium 
 coli communis, undoubtedly play a prominent part in the above 
 processes. The destructive powers of the bacteria are only exer- 
 cised when a favourable medium for considerable development, and 
 perhaps also for their transplantation, is offered. 
 
 As already mentioned, this medium is furnished by the stagna- 
 tion of secretion, by loss of epithelium, by erosions, or by catarrhal 
 or pressure ulcerations, which, owing to the poor blood supply of the 
 appendix, develop only too easily. 
 
 If, therefore, the faecal concretions are given their proper, rather 
 large predisposing part in the etiology of perityphlitis, and if we do 
 not underestimate the influence of the bacteria natural to the appen- 
 dix, the direct development of the inflammatory process must be 
 sought for in the peculiar anatomical form and structure of the 
 appendix, M^hich produce and make possible the deleterious action 
 of both the above factors. 
 
 Another circumstance which speaks in favour of the above view 
 is the inf requency of perityphlitis in childhood. In the statistics of 
 Matterstock, of 474 cases of perityphlitis, there are only 46 cases 
 between the ages of one and ten years. Out of 228 cases Fitz 
 gives 22 of the latter age, and out of 130 Sonnen burg only 26. 
 Still more convincing are the statistics of the pediatrists. From 
 the excellent monograph of Karewski^^ on perityphlitis in child- 
 hood, we tind that Henoch, during the years 1890-1894, among 
 3,486 sick children, saw only 2 cases of appendicitis. Baginsky, in 
 1890-1891, of 494 cases, saw none ; of 415 cases in 1891-1892 he 
 also observed none; of 1,692 cases in 1892-1893, he observed but 
 3 ; in 1893-1894, of 2,234 cases, only 4; in 1895, of 2,580, 8 peri- 
 typhlitis cases ; altogether 15 cases out of a total of 7,413 diseased 
 children. 
 
 Again, from H. Einhorn's statistics from the Pathological Insti- 
 
436 DISEASES OP THE INTESTINES 
 
 tute of Munich, the number of cases of perityphlitis in proportion 
 to total autopsies was 5 per 1,000, the cases in children being 2 per 
 1,000. Since the diagnosis of this affection in children is quite 
 difficult, this proportion is rather too large than too small. In this 
 connection Nothnagel's^^ statistics are also of great value. Of 
 44,94:0 autopsies performed in the Vienna General Hospital in the 
 years 18Y0 to 1896, there were 148 cases of peri- and paratyphlitis 
 (0.3 per cent). Of these 148 cases only 2 were in children between 
 one and nine years of age. 
 
 The explanation of these facts is furnished by the investigations 
 of Steiner^*, Ribbert", and Zuckerkandl ^l These observers found 
 partial or total obliteration of the appendix with increasing age, 
 while obliteration was extremely rare in children, particularly before 
 the fifth year. In my opinion the large size of the lumen of the 
 appendix, whereby accumulations of secretions and pressure necrosis 
 are prevented, is of great importance in explaining the rarity of 
 appendicitis in children. 
 
 Besides these essential factors certain predisposing circum- 
 stances play an undoubted part. Talamon ^^ lays stress on hered- 
 ity. Some families present a predisposition to appendicitis. Sahli 
 also mentions such cases. Traumatism is mentioned as a factor 
 by some authors (Coley % Small ^, Körte-Borchardt ^*^, and others). 
 Various observers give chronic constipation as a predisposing 
 cause. In 209 appendicitis cases Fitz ^'~' found constipation only 
 38 times. 
 
 I believe we must differentiate between acute and chronic 
 recurring appendicitis. According to my experience chronic con- 
 stipation is quite often a factor in the latter, but much less so in 
 the acute form. Treves ^"^ regards bad teeth and insufficient chew- 
 ing of food as frequent causes of appendicitis. Dyspeptic con- 
 ditions are said to favour this disease. In English literature par- 
 ticularly, rheumatism and gout are mentioned as predisposing to 
 an attack. 
 
 Recently Golubeff ^^ has directed attention to the frequent si- 
 tnultaneous occurrence of perityphlitis in Moscow, and has therefore 
 attributed to it an epidemic character. From a study of cases 
 occurring in Erlangen during a period of nine years, Penzoldt^ 
 could not substantiate this conclusion. At times I have seen nu- 
 merous simultaneous perityphlitis cases in Berlin ; a number of 
 factors may here have acted together. 
 
 We might further increase the list of accidental causes of ap- 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 437 
 
 pendicitis, and add that affections of the female genitals also pre- 
 dispose to appendicitis. All these facts can not overthrow the real 
 practical etiological considerations that we have above attempted to 
 establish. 
 
 Perityphlitis of tuberciilous or actinomycotic origin presents a 
 certain individuality. The former not infrequently occurs as a 
 latent symptom of general and particularly of intestinal tuberculo- 
 sis. On the other hand, primary tuberculous disease of the appendix 
 with a characteristic picture of appendicitis is exceptional. From 
 a very large material Sonnenburg reports but 3 cases of this 
 kind. Borchardt^^ also reports 3 cases occurring in Körte's hos- 
 pital service. Karewski ^^ has operated on 4 cases in children, in 
 2 of which he thinks the disease was a primary isolated tubercular 
 appendicitis. According to Borchardt, tuberculosis may produce 
 perityjDhlitic abscesses which rupture externally and cause cfecal 
 fistulse. 
 
 Actinomycotic appendicitis is more infrequent. In his mono- 
 graph Sonnenburg could collect only 12 cases of this kind. Karew- 
 ski ^^ reports a further case. 
 
 In conclusion, we wish to discuss the relative frequency of this 
 disease in the various periods of life and its relation to sex. 
 
 "We have already dwelt upon the relative infrequency of 
 appendicitis in childhood. Numerous statistics (Matterstock, Fitz, 
 ISTothnagel, Sonnenburg) demonstrate that the second and third 
 decades of life present a very striking predisposition to appendi- 
 citis. According to the extensive tables of Matterstock, 63 per 
 cent of all cases of appendicitis occur during these periods. Ex- 
 cept those of H. Einhorn, the remaining statistics indicate a simi- 
 lar conclusion. 
 
 Regarding the relative frequency in the two sexes, according 
 to the tabulations of Yolz, Bamberger, Matterstock, Sonnenburg, 
 Rotter, ISTothnagel, Fitz, Pravaz, and Fen wick, appendicitis is 
 much more frequent in men than in women, while others (Ein- 
 horn, Lennander, and Kiimmell) could discover no material differ- 
 ences in frequency, l^othnagel correctly points to the greater 
 frequency of appendicitis in the male even in childhood. This 
 is also evidenced by Matterstock's extensive tables (51 male chil- 
 dren to 21 female). 
 
 29 
 
438 DISEASES OF THE INTESTINES 
 
 Symptomatology and Diagnosis 
 
 A. Acute and Chronic Typhlitis 
 
 We have already briefly described (page 432) the symptoms of 
 acute typhlitis, and have mentioned pain and sensitiveness to pres- 
 sure in the ceecal region, tympanites, palpable fsecal accumulation, 
 and fever. This description presupposes a simple stercoraceous 
 typhlitis. We have as yet no clear clinical picture of the remain- 
 ing forms of typhlitis, at least not of the acute forms. This is evi- 
 dent fi'om the fact that in almost all operations in which typhlitis 
 was found the diagnosis of appendicitis had been made. It is 
 therefore idle to lay down diagnostic rules and j^rinciples for these 
 other forms of typhlitis. But in the present state of our knowl- 
 edge even the differentiation between stercoraceous typhlitis and 
 appendicitis must be made with the greatest reserve. Under the 
 following circumstances the diagnosis of stercoraceous typhlitis 
 might be ventured. Sudden, obstinate constipation, moderate 
 sensitiveness over the c^cum, mild fever or none at all, and 
 absence of severe general symptoms. The intensity of the sponta- 
 neous pains appears to me irrelevant. Objectively, we should be 
 able to palpate a faecal tumour characterized by its compressibility 
 and perhaps extending high up along the ascending colon. There is 
 a dull percussion note over the tumour. Chnical course : Immediate 
 disappearance of the tumour and of all symptoms after a laxative or 
 enema. Only in the presence of a clinical ensemble as well marked 
 as this can the diagnosis of [stercoraceous] typhlitis be made with a 
 fair degree of probability. So typical a picture is certainly not 
 frequently seen in practice, because the majority of patients have 
 already taken laxatives before medical advice is sought. Even in 
 such typical instances it is impossible to positively differentiate the 
 affection in question from appendicitis or appendicular colic. We 
 shall recur to this point in the section on differential diagnosis. 
 
 Under appropriate circumstances chronic typhlitis can be more 
 easily diagnosticated than the acute form. The absence of violent 
 initial symptoms, the very slow onset, the palpability of a resist- 
 ance in the caecal region, all point toward the diagnosis. Since 
 chronic typhlitis is usually tuberculous, dysenteric, or carcinomatous 
 in character, the previous history or other clinical phenomena may 
 give important diagnostic data. The presence of stenotic symptoms 
 will often serve to make the etiology positive. As proved also by 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 439 
 
 surgical experience, it is very difficult to diagnosticate adhesions about 
 the caecum {perityphlitis sensu strictiori). Even admitting the very 
 rare instances in which the adhesions can plainly be felt, it will be 
 scarcely possible to prove their origin from the caecum. At most 
 this can only be surmised. 
 
 B. Perityphlitis (Appendicitis) 
 
 1. Acute Perityphlitis 
 
 In many instances the diagnosis of acute perityphlitis is as easy 
 as that of croupous pneumonia or of an acute monarthritis. Con- 
 versely, however, the clinical picture may be so complicated and 
 atypical that, despite great experience and ability, error is un- 
 avoidable. The statistics of Nothnagel, already given (page 436), 
 derived from the very extensive material of the Vienna General 
 Hospital, contain a number of such diagnostic errors. These cases 
 are the more instructive because they have been under most care- 
 ful clinical observation. 
 
 The diagnostic difficulty lies in another direction. Operations 
 have taught us the numerous and various changes which the appen- 
 dix may undergo : the diseased process may be limited to the mu- 
 cous membrane, or to the peritoneal coat, or may affect both ; rup- 
 ture may take place into a preformed encapsulated space, into the 
 general peritoneal cavity, praeperitoneally, retroperitoneal ly, into the 
 intestines or other hollow viscera. Even during laparotomy it may 
 be impossible to distinguish these various forms of appendicitis. 
 It is absolutely necessary, however, to understand the principal 
 types, and to be able to recognise the most important clinical com- 
 plications of the disease. 
 
 The variations in the clinical picture of appendicitis have led to its 
 classification. Sonnen burg ^ was the first to establish and methodic- 
 ally carry out such clinical divisions. His classification is as follows : 
 
 1. Simple, catarrhal appendicitis, with its acute, chronic, ob- 
 structive, and cystic forms. 
 
 2. Perforative appendicitis : («) with periappendicitis, (J) with 
 general peritonitis. 
 
 3. Gangrenous appendicitis : {a) septic peritonitis without per- 
 foration, (b) circumscribed or diffuse peritonitis accompanying 
 beginning perforation. 
 
 Rotter^ has divided perityphlitis more simply into the circum- 
 scribed and the diffuse forms. Kümmeil ^ divides the cases into the 
 
440 DISEASES OP THE INTESTINES 
 
 mild, moderate, and severe — an arrangement whicli is followed by 
 Körte. 
 
 ISTaturally all these classifications are schematic, and give only an 
 incomplete idea of the various phases and clinical courses of appendi- 
 citis. Rotter's arrangement seems to me the simplest and least pre- 
 judicial, but it also incompletely represents the varieties of the 
 disease. With much hesitation, we shall follow Sonnenburg's 
 nomenclature, discarding only those subdivisions whicli either go 
 too far or not far enough. 
 
 Though such differentiation cannot be made with certainty, we 
 shall also distinguish between simple perityphlitis and appendicular 
 colic. 
 
 (a) Simple Perityphlitis 
 
 The most prominent symptoms are sudden onset ; acute pain in 
 the ileo-csecal region ; sensitiveness to pressure in the region of the 
 appendix, and eventually of the tumour ; gastric disturbances ; the 
 condition of the pulse and the temperature. 
 
 Each of these symptoms requires detailed consideration. 
 
 1. Sudden Onset. — The patients are usually attacked in the 
 midst of general good health. Occasionally, constipation or diar- 
 rhoea precedes the attack. The attack very soon becomes so 
 marked that the patients are forced to take to bed. 
 
 2. Pain. — This is the most characteristic symptom, and rap- 
 idly reaches its greatest intensity. Adults can usually localize 
 the pain quite well, but children complain of general stomach 
 ache. Some patients locate the greatest area of pain in the centre 
 of the abdomen, in the umbilical or epigastric region.* The pain 
 is continuous, and shows slight or no remissions. It may radiate 
 to the right thigh, the back, the testicle, or the bladder. In the last 
 instance bladder symptoms may be present, and there may even be 
 retention of urine. The respiration is a useful gauge for the intensity 
 of the pain. In well-marked cases the breathing is rapid, superfi- 
 cial, and costal ; the patients anxiously avoid deep inspiration. The 
 patient feels most comfortable when lying quietly on his back ; every 
 movement increases his pain, absolute rest decreases it. 
 
 3. Sensitiveness. — Sensitiveness to pressure over McBurney's 
 point is the most valuable and reliable of the objective symptoms. 
 The sensitiveness varies in intensity, but in the beginning is fairly 
 
 * [Hartley" states that only in one fourth of the cases is the initial pain referred 
 to the right iliac fossa. — Tr.] 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 441 
 
 well localized. As Fowler^* points oat, there is a certain amount 
 of rigidity on palpation of the right rectus muscle. He also calls 
 attention to an interference with the function of the abdominal 
 respiratory muscles, evidently caused by the above-mentioned 
 superficial and rapid breathing, Regarding the possibility of 
 palpating the inflamed appendix, to which Edebolils ^^ in partic- 
 ular refers, views diifer. Sonnenburg, whose opinion is certainly of 
 great value, says " that the thickened appendix cannot be palpated 
 during acute attacks, but may be jDalpable in the intervals." 
 Fowler ^ speaks of " exceptional identification in cases of chronic 
 appendicitis." 
 
 Admitting the possibility of feeling the appendix, this fact is 
 on the whole of small practical significance. A circumscribed pain- 
 ful area in the ileo-csecal region is a sufiicient clinical symptom. 
 
 4. Perityphlitic Tumour. — Under appropriate treatment the 
 sensitiveness may disappear in a short time, or may increase with 
 the onset of high fever and the development of a perityphlitic 
 tumour. Of what does this tumour consist ? According to Sahli \ 
 it is mainly composed of a thickening of the intestinal wall, the vis- 
 ceral and parietal layers of the peritoneum, and the fascia trans- 
 versalis of the abdominal muscles; in addition, there are fibrous 
 adhesions of the intestines, not infrequently thickening of the 
 omentum, and stagnation of the intestinal contents. 
 
 In general, even small tumours of the iliac fossa are readily 
 palpable. In perityphlitis, because of the rapid onset of intestinal 
 paralysis, the intestines become distended with gases and the tumour 
 is thereby brought nearer to the surface. The tumour is felt either 
 as a circumscribed, easily defined mass, or as a diffuse, doughy 
 swelling (Roux). In other cases, especially when there is marked 
 meteorism, or when the appendix is situated behind the caecum, 
 recognition of the tumour by palpation is difficult. In all these 
 cases rectal or vaginal examination is of great value, especially 
 since the appendix is sometimes situated low down in the small 
 pelvis and may there give rise to abscesses. 
 
 In doubtful cases exploratory puncture may render important 
 diagnostic aid. At present the views regarding the value of this 
 procedure are contradictory. Some prominent surgeons (Sonnen- 
 burg, Roux, Karewski, Fowler, and Treves) have entirely given up 
 puncture, while Körte, Borchardt, Lauenstein, as well as the major- 
 ity of internal practitioners (v. Leyden, A. Fraenkel, Fürbringer, 
 Renvers, Curschmann, Sahli, Nothnagel, Penzoldt, and others), 
 
442 DISEASES OF THE INTESTINES 
 
 strongly recommend it.* Summing up the experience of the latter, 
 we may say that exploratory puncture is usually not a dangerous 
 procedure. Puncture of the intestines cannot always be avoided. 
 Penzoldtf believes he has occasionally punctured the bowel with- 
 out causing any trouble. Karewski saw two injuries of the intes- 
 tines from puncture during operation, which, he states, were not 
 followed by deleterious effects. In another case Karewski ascribes 
 a peritonitis (and subsequent operation) to puncture, but I am not 
 convinced of the correctness of his statements. 
 
 In my opinion, we should puncture only when an abscess is sus- 
 pected and its presence cannot otherwise be determined. I do 
 not consider it advisable to employ exploratory puncture for the 
 purpose of showing the patient the necessity of an operation, for 
 the patient may recover without operation — a fact which would 
 place the physician in a rather awkward predicament. 
 
 Regarding exploratory puncture, Penzoldt^*' has laid down sev- 
 eral excellent rules, which we here reproduce. 
 
 The needle must have as large a lumen as possible and still be fine, long, 
 and strong enough to withstand bending. Instead of the point having the 
 usual lancet-shaped tip and being sharpened laterally, it should be round and 
 only sharpened at its extreme tip, so that the lower end of the needle is not 
 larger than the upper, thus avoiding an unnecessarily large puncture. 
 
 If carbolic acid, or ether and alcohol, have been used to disinfect the nee- 
 dle, sterilized water should be drawn through the needle directly before punc- 
 ture, because any portion of the above disinfectants remaining in the syringe 
 may precipitate the albumin of the fluid aspirated and thereby give rise to 
 difficulties. (For the better conservation of the cell elements, I draw sterilized 
 salt solution through the syringe directly before and after aspirating.) The 
 needle must fit the barrel of the syringe well. The puncture is made at the 
 point of greatest resistance and dulness ; if necessary, several punctures may be 
 made. After puncture of the abdominal muscles, the piston is slightly with- 
 drawn ; if nothing be aspirated, the needle is pushed in somewliat deeper, the 
 piston being retained in the same position. The piston is then drawn out 
 somewhat further, and if again nothing be aspirated, the needle is thrust 
 deeper, the piston then further withdrawn, and so on till the piston has been 
 drawn out its entire length. The syringe should be large enough to hold 
 3 to 3 cubic centimetres, so that a large area may be explored through one 
 puncture. The needle is steadied slightly with the left hand, so that it may 
 follow the movements of the abdominal muscles. Puncture must never be 
 performed without a microscope near at hand, so that clear fluid may be imme- 
 
 * [Exploratory puncture is a procedure not generally practised in the United 
 States ; it is rare to find it mentioned in text-books and monographs, and when 
 mentioned it is usually condemned. — Tr.] 
 
 t Loc. cit., p. 671. ' 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 443 
 
 diately exnmined for cellular elements. The small amount of fluid hidden 
 in the needle may be easily identified. ("Where, as in private practice, especially 
 in the country, a microscope is not handy, it is better to send the entire syringe 
 in a properly stoppered container for examination.) 
 
 Compared with the above diagnostic data, percussion is of sec- 
 ondary importance. It is clear that in the presence of a distinct 
 exudate the percussion is dull or dull tympanitic ; but if the exudate 
 be situated very deeply, percussion will scarcely be of diagnostic aid. 
 
 The same is also true of auscultation. For the purpose of differ- 
 entiation between simple and septic paralysis of the intestinal mus- 
 cles, Richardson ^ states that intestinal sounds are present in th6 for- 
 mer and absent in the latter. 'The "rumbling" sound described by 
 Naumann ^^ as characteristic of abscess does not appear to have been 
 observed by others. In a case without suppuration Borchardt * dis- 
 covered this sound, which he considers an ordinary intestinal noise. 
 
 5. Gastric Disturiances. — These consist in loss of appetite and 
 occasionally of vomiting, especially in the beginning. In children 
 vomiting is often the ushering-in symptom, and may be productive 
 of diagnostic errors — e. g., acute dyspepsia, intestinal catarrh, etc. 
 In the further course of the disease the vomiting generally ceases, 
 but should it persist and become more marked, suspicion of severe 
 invasion of the peritoneum must immediately be aroused. Should 
 the vomiting become fgecal in character, we must think of the 
 possibility of mechanical or j)aralytic intestinal obstruction accom- 
 panied by peritonitis. 
 
 6, Temper attire. — Temperature is of great diagnostic and prog- 
 nostic importance. In simple catarrhal appendicitis the tempera- 
 ture is low and falls raj^idly, but in the purulent and perforative 
 forms it very soon becomes quite high, and remains so for a longer 
 or shorter time. To avoid repetition, we shall now discuss the 
 course of the temperature in all the different varieties and stages of 
 appendicitis. Rotter ^^ has made a careful study of the temperature 
 in the various forms of appendicitis, and although, as must be ex- 
 pected from its protean type, the disease contradicts all rules and 
 experience, the fever curves of Rotter are very important for the 
 recognition of the status of individual cases. Rotter arranges the 
 cases, according to their temperature, into five groups : 
 
 The first group is ushered in by marked fever (up to 40° C. and 
 over), with or without a chill ; after 3 or 4 days there is a tend- 
 
 * Loc. cit., p. 330. 
 
444 DISEASES OP THE INTESTINES 
 
 ency to defervescence. These cases are characterized by a smooth 
 and rapid convalescence. 
 
 In the beginning cases of the second group are not distinguish- 
 able from those of the first. The fever, however, lasts longer ; 
 after the fifth day the temperature is not higher than 39° C. These 
 cases also recover, though sometimes only after operation. 
 
 The third group is characterized by the fact that after the fifth 
 day the temperature remains above 39° C. From the time of onset 
 these cases present more or less high fever, and also slight remis- 
 sions followed by increase of temperature. Most of these cases 
 generally run a severe course and sooner or later require operation ; 
 of those not operated upon some recover and others die. 
 
 The fourth groiip includes those which present a remittent type of 
 fever. The initial fever is followed by defervescence, but after a few 
 days the temperature again rises. This second rise indicates suppura- 
 tion. Most of these cases required operation. Of those not operated 
 upon, one seemingly recovered, another died of diffuse peritonitis. 
 
 In the fifth group, which includes those with diffuse peritonitis, 
 temperature has no special significance. It may be high, normal, 
 or even subnormal. If a circumscribed abscess ruptures into the 
 general abdominal cavity, there is a sudden fall of temperature, 
 often subnormal and accompanied by collapse. 
 
 Y. Pulse. — ISText to temperature, the frequency of the pulse 
 and its possible irregularity are of the greatest value. There is a 
 special significance in a disproportion between temperature and 
 pulse. From numerous operations we know that severe peritonitis 
 may exist without any rise of temperature. It is in these cases, of 
 which I have observed several, that the character of the pulse 
 becomes the only diagnostic and prognostic indication.* On the 
 other hand, Lennander,t Karewski^^, and others, have shown 
 that in the severest cases of progressive, suppurative, fibrinous 
 peritonitis, both temperature and pulse may be almost normal 
 (Mikulicz). A distinct and continuously irregular, and at the same 
 time very small pulse, is almost always an ominous sign. 
 
 Finally, we would mention an interesting phenomenon pointed 
 out by Mannaberg ^, viz., the accentuation of the second pulmonary 
 sound. He discovered this symptom in cases of perityphlitis 
 offener than could be accounted for by mere accident. 
 
 * [In the United States the pulse is generally regarded as the most valuable 
 single prognostic and therapeutic indicator in appendicitis. — Tr.] 
 t Loc. cit., p. 27. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 445 
 
 (b) Appendicular Colic 
 
 Under the name of colique apijendiculaire Talamon * first de- 
 scribed a clinical picture characterized bj the following symptoms : 
 The patient is suddenly attacked by very severe pains, occasionally 
 accompanied by vomiting. The region of the appendix is extremely 
 sensitive to pressure ; fever is either very moderate or entirely ab- 
 sent ; a tumour never forms. The attack passes off very rapidly. 
 Spontaneously, or after morphin, the patients are absolutely well at 
 the end of twenty-four to thirty-six hours. Talamon explains this 
 condition by supposing that a fgecal concretion is wedged into the 
 appendix and thereby causes violent muscular contractions ; finally 
 the concretion falls back into the csecum, similar to a gall-stone fall- 
 ing back into the gall bladder after having reached the cystic duct. 
 
 Yon Hochstätter^^, Caspersohn *', Goldbach *i, Treves 1^, :N'oth- 
 nagel, Sonnenburg, and A. Pick^ have described such cases. I 
 have seen a large number of these cases, but in view of the sim- 
 plicity of the clinical picture I shall not describe any. In my 
 experience the patients are generally individuals who suffer fre- 
 quently from such attacks (every four to six weeks or offener). In 
 the interval they are absolutely well, but the attacks may finally be- 
 come continuous, and assume the character of chronic perityphlitis. 
 
 All authorities agree upon the symptoms, but there is a diver- 
 sity of opinion regarding the origin of this disease. Treves" 
 denies the possibility of muscular contraction of a healthy, let 
 alone a diseased, appendix, and characterizes this theory as " wholly 
 ridiculous." ü^othnagel admits the possibility of spasmodic con- 
 traction, but does not consider it proved that coproliths wedge 
 themselves into the appendix. Monod and Yanvers^^ express a 
 somewhat similar opinion. Opposed to these theories is the cited 
 case of Goldbach, observed in Wölfler's clinic in Prague. 
 
 The patient was a sixteen-year-old scholar, who for one j'ear had suffered 
 from jaundice and severe colicky pains under the right free border of the ribs. 
 He never had fever or vomiting during the attack. Always had obstinate con- 
 stipation. Later, pains were present in the evening and absent in the morning 
 He now has pain in the ileo caecal region, localized directly over McBurney's 
 point. No concretion was ever found in the stools. Palpation shows an oval, 
 fairly soft tumour (caecum ?), over which may plainly be felt a second longi- 
 tudinal sausage-shaped tumour. The entire mass appears movable, and is felt 
 either in the right hypochondrium or in the lower abdominal region. Liver 
 
 * Talamon, Appendicite et Perityphlite, Paris, 1892, p. 25 et 111; Colique 
 appendiculaire medecine moderne, 1890, p. 837. 
 
446 DISEASES OF THE INTESTINES 
 
 is not enlarged. At the operation two small fgecal stones were found in the 
 caecum. When these were pressed toward the appendix they easily slipped in, 
 and could just as easily be forced back into the csecum. The appendix was 
 absolutely normal. Extirpation of the appendix. Cure. 
 
 This case at least proves the possibility of foreign bodies slip- 
 ping into the appendix and again falling back into the csecum. It 
 is very questionable whether this is a constant or only frequent oc- 
 currence. From the fact that in most autopsies [and operations] 
 for recurring appendicitis (which the above case greatly resembles) 
 slight changes are found in the appendix, it would seem that these 
 are after all very mild forms of simple catarrhal appendicitis. 
 
 (c) Perforative Perityphlitis 
 
 Pathological anatomy and the results of operation agree that 
 perforations occur very frequently in appendicitis. It is therefore 
 important to be able to diagnosticate this complication. Sonnen- 
 burg gives certain symptoms as characteristic : Violent onset with 
 high fever ; severe abdominal pain beginning suddenly or imme- 
 diately after a meal, and very soon localized on the right side ; 
 vomiting, accompanied by diarrhoea or constipation ; small, fre- 
 quent pulse ; fever, rising rapidly and often ushered in by a chill ; 
 marked tympanites. Patient feels extremely ill. There is slight 
 cyanosis and persj)iration. Distinct resistance in the vicinity of 
 the suppurative area. 
 
 The diagnosis of perforation, however, cannot be positively 
 made from any of these symptoms, for suppurative appendicitis with 
 tumour, severe general disturbance, high temperature, and rapid 
 pulse may give a very similar picture.* 
 
 It will therefore be wiser not to attempt to make the diag- 
 nosis of perforative peritonitis, but to content ourselves with the 
 diagnosis of suppurative appendicitis. 
 
 (d) Diffuse Suppurative Perityphlitis 
 
 According to Rotter, diffuse suppurative perityphlitis originates 
 in two ways : either as a purulent perityphlitis, in which the adhe- 
 sions between the intestinal coils continue to extend,- or by per- 
 foration of a previously encapsulated abscess, whose contents spread 
 over the general abdominal cavity. In both cases the pus generally 
 gravitates toward the lower right side of the pelvis and Douglas's 
 
 * [A blood count might prove of great value in differentiating the two condi- 
 tions. Marked leucoeytosis would speak for suppurating appendicitis. — Tr.] 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 447 
 
 cul-de-sac ; if the process continue, the pus spreads to the left side 
 of the pelvis, and from there over the different abdominal organs. 
 
 The diagnosis of the various phases of this variety may be 
 extremely difficult. Temperature, pulse, and objective symptoms 
 may be deceptive, and easily lead to false conclusions. As al- 
 I'eady remarked, if high temperature is present, it is irregular and 
 remittent in character, becoming normal, again suddenly rising, etc. 
 The most reliable symptom is the general appearance. The pa- 
 tients are usually markedly collapsed, depressed, apathetic, the fea- 
 tures are pinched and sunken, and are pale, cyanotic, and without 
 congestion ; the eyes are staring ; there is absolute sleeplessness and 
 anorexia ; the tongue is dry and cracked ; occasionally there is 
 singultus. In a word, the patient makes a septic impression. 
 To this picture there are excöptions. The patient may feel well, 
 sit up in bed, his pulse and temperature be properly proportioned 
 and not high, and yet laparotomy will reveal a diffuse, septic perito- 
 nitis. In other cases, very grave symptoms are at first present ; 
 then suddenly the patient becomes better, "the suppuration be- 
 comes circumscribed" (Rotter). Contrary to expectation, the pa- 
 tient recovers, perhaps only after one or several abscesses have been 
 opened. ]S[umerous other varieties are seen in practice, but a 
 schematic description is impracticable, because every case presents 
 special peculiarities. We have here purposely given the clinical 
 picture, but not the diagnostic criteria of diffuse perityphlitis, be- 
 cause after all the general impression created by the patient is the 
 decisive diagnostic factor. 
 
 The diagnosis, and I may add the prognosis, often vary ex- 
 tremely, as the clinical picture changes from day to day. This 
 should warn us never to give a prognosis too early in the dis- 
 ease. 
 
 2. Chronic Perityphlitis 
 
 Chronic or recurring perityphlitis is that form in which, after a 
 longer or shorter interval, renewed attacks of the disease occur. 
 The American surgeons (Bull^^, Fowler % and others) designate 
 this form as " recurring " appendicitis, and distinguish it from those 
 cases in which the acute attack is recovered from, but a sensitive- 
 ness to touch persists in the ileo-csecal region. The last form has 
 been called "relapsing" appendicitis, though some, like Fenger 
 of Chicago, call it " postappendicitis." 
 
 The studies of surgeons, particularly Sonnenburg, Kümmell, 
 
448 DISEASES OF THE INTESTINES 
 
 Bull, Fowler, Körte, Treves, and Senn, have given us valuable in- 
 formation regarding clironic appendicitis. Tliis disease may develop 
 in many different ways. The most frequent mode is through the 
 formation of partial obliterations (appendicitis obliterans, Senn) and 
 strictures, with consequent stagnation of secretion, formation of cysts, 
 and occasionally of empyema of the appendix. More or less exten- 
 sive adhesions may develop about the appendix, and cause functional 
 irregularities of the intestine, bladder, and female genitals, and pro- 
 duce pain and other disturbances. The mucous membrane of the ap- 
 pendix may be diseased, and small swellings and suppurations exist in 
 or around the appendix ; fsecal concretions are sometimes present. 
 Under such conditions the appendix may perforate during a relapse. 
 
 If we limit ourselves to the diagnosis of a diseased process in or 
 about the appendix, we will scarcely ever meet with any difficulty. 
 The history may give us valuable information. More important, 
 however, are the typical symptoms (pain, even while at rest, but in- 
 creased by motion or straining ; constipation) and the discovery of 
 a circumscribed area of sensitiveness to pressure, and of infiltrations 
 about the ciECum or appendix. 
 
 In recurrent perityphlitis the patients have no symptoms be- 
 tween the attacks. From time to time, either without recognisable 
 cause or after strains, errors in diet, colds, or constipation, the 
 pain recurs, a palpable tumour in the appendix region, accompanied 
 by fever, nausea, and vomiting, appears, and in about one half the 
 eases perforation occurs. 
 
 As Treves has pointed out, and as is generally known, the recur- 
 ring attacks are usually not as severe as the primary one. In recur- 
 ring SiTp-pendidtis perityphlitio abscesses seem to develop very rarely. 
 Talamon * records a case in which an abscess, necessitating surgical 
 treatment, developed in each of four attacks. 
 
 In the vast majority of instances the proper diagnosis can be 
 made from the symptoms above enumerated. The diagnosis is 
 difiicult only in those cases in which appendicitis must be distin- 
 guished from disease of the female genitals. We shall discuss this 
 under differential diagnosis. On the other hand, it is almost impos- 
 sible to diagnosticate the individual pathological conditions in and 
 about the appendix ; it would therefore be useless to enter into a 
 discussion of the diagnosis of this point, which, moreover, is of 
 little practical value. 
 
 * Loc. cit., p. 151. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 449 
 
 Differential Diagnosis 
 
 The diagnosis of a typical case of appendicitis is simple ; it may 
 become quite difficult when the disease runs an irregular course, or 
 when the patient is first seen during the late stages of the disease. 
 It is impossible to consider all the numerous differentia] possibili- 
 ties ; in the following we shall discuss only the important ones. 
 
 Simple appendicitis gives rise to the least difficulty. Mis- 
 takes may occur if the pain is atypically localized, or if the objec- 
 tive symptoms are entirely or almost entirely absent. 
 
 In the former instance (i. e., the atypical location of the pain) 
 we must consider biliary and renal colic, and occasionally mucous 
 colic. In most cases careful observation will scarcely leave room 
 for doubt. According to ITaunyn, the examination of the urine 
 for indican may be of value. I^aunyn^^ states that indican is 
 never absent in appendicitis, while in biliary colic it is only occa- 
 sionally present. As another important diagnostic fact, it must be 
 mentioned that in cholelithiasis the posterior surface of the liver, 
 between the tenth and twelfth dorsal vertebrae, two to three finger- 
 breadths to the right of the vertebral column, is sensitive to pressure. 
 In nephrolithiasis, it will be necessary to carefully palpate the riglit 
 kidney and to examine the urine. 
 
 In children, and sometimes in adults, appendicitis may be con- 
 founded with " febrile gastro-enteritis." Karewski ^^, in particular, 
 has directed attention to these errors, and every physician will 
 appreciate his warning. If, as a result of this error, these cases 
 are treated with calomel and castor oil, serious danger may arise. 
 In children, in all cases of so-called febrile gastro-enteritis accom- 
 panied by acute pain, we should at once think of appendicitis. If 
 we then err, there can never occur the severe consequences that 
 may otherwise arise. 
 
 The diagnosis is far more difficult if the sensitiveness to pressure 
 or an exudate is localized, not at McBurney's point, but at other 
 places — e. g., in the right or left hypochondrium, the umbilical 
 region, the left iliac fossa, etc. 
 
 The experiences of surgeons, particularly the oft-quoted topo- - 
 graphical clinical studies of Curschmann, have shown us how the 
 caecum and the appendix may be found in various situations. In 
 one case, close to the right costal border, Curschmann ^"^ found a 
 hard superficial tumour the size of the palm of the hand. The 
 tumour lay in front of the intestines, and was connected with the 
 
450 DISEASES OF THE INTESTINES 
 
 inner surface of the abdominal wall. Judging from its origin, posi- 
 tion, and form, it was a peritonitic exudate. The patient died of 
 general peritonitis. At the autopsy the caecum was found turned 
 up in front of the descending colon, with the appendix touching the 
 Uver(see Fig. 25). 
 
 I herewith present a similar case described by Rotter : 
 
 A man, fifty-one years old, while under ambulatory treatment at Kissingen, 
 became ill with gangrenous appendicitis. Eight days after the onset of the 
 disease a tumour was found between the liver and the ascending colon. The 
 most striking feature was the great mobility of the tumour; it could easily be 
 moved across the middle line toward the left, whereas perityphlitic tumours in 
 general are diffuse, and attached to the posterior abdominal wall. 
 
 The diagnosis rested between a tumour of the colon and of the 
 kidney till an exploratory puncture showed feculent pns. The great 
 mobility of the tumour was due to the fact that it was not adherent 
 to the anterior or posterior abdominal wall, bat rested upon the right 
 side of the mesentery of the small intestine, the remainder of the 
 abscess wall being formed by coils of adherent intestine. In dis- 
 placing the tumour, the mesentery and adherent bowel moved 
 with it. 
 
 In his Clinic of Cholelithiasis, JSTaunyn mentions similar in- 
 stances. Almost all experienced surgeons (particularly Sonnenburg, 
 Lennander, Fowler, Körte, and Riedel) have reported similar cases. 
 The practical conclusion to be drawn is that, although an exudate or 
 localized sensitiveness be found in other than in the typical situa- 
 tion, we must always keep in mind the possibility of appendicitis. 
 
 Cases of pericolitis and sigmoiditis (later to be described) show 
 that inflammatory exudates, though indeed more rarely, may occa- 
 sionally originate from other sources than the appendix. 
 
 Exploratory puncture may be of diagnostic value. The with- 
 drawal of feculent pus indicates a perforating appendicitis. 
 
 It may be very difficult to differentiate between inßammatory 
 disease of the female adnexa and appendicitis. The differentiation 
 may be impossible when, as often happens, appendix and adnexa are 
 simultaneously diseased. I have seen several cases of this kind. 
 Accumulations of pus in Douglas's pouch may also give rise to diag- 
 nostic errors. Borchardt thinks that the differentiation can be made 
 by examining the pus for bacterium coli communis, the presence of 
 which would speak for appendicitis. 
 
 For further details of the subject the reader is referred to the 
 monograph of Sonnenburg. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 45 1 
 
 The differential diagnosis is quite difficult where the appendix is 
 in the small pelvis and there gives rise to an abscess. In these in- 
 stances the differential diagnosis between appendicitis and inflamma- 
 tory disease of the adnexa can rarely be made. 
 
 Tumours, particularly of the csecum, may be mistaken for 
 chronic appendicitis, and, much more infrequently, for acute appen- 
 dicitis. The tumours here to be considered are sarcoma, carcinoma, 
 actinomycosis, tubercular tumours of the caecum, occasionally also 
 ileo-c88cal invagination. 
 
 For purposes of differentiation, Sonnenburg ^'' recommends infla- 
 tion of the intestines. In perityphlitic exudates the intestines be- 
 come distended, in neoplasms they remain rigid. The mobility of 
 a questionable tumour speaks decidedly against an exudate ; but 
 immobility does not speak against neoplasms, since they may be 
 fixed by adhesions. Where symptoms of stenosis of the large 
 bowel are present the diagnosis may be easy. If these be absent, 
 the insidious course, the cachexia (in malignant tumours), the pres- 
 ence of blood or pus in the stools, will indicate the correct condi- 
 tion. Reports of cases show, however, that numerous errors are 
 made which are only cleared up by operation or autopsy. (Com- 
 pare with chapter on Intestinal Carcinoma.) 
 
 Finally, we have the rare occurrence of the inflamed appendix in 
 a hernial sac (inguinal or femoral canal) which has resulted from 
 foetal maldevelopment. This may occur on the left as well as on 
 the right side. These cases run their course as incarcerated her- 
 nise, and are of great surgical interest. The diagnosis is 9,lmost im- 
 possible. 
 
 Appendicitis in the stage of diffuse peritonitis may cause con- 
 siderable diagnostic difficulty. This originates under very differ- 
 ent circumstances. In the first place, diagnostic confusion may be 
 present when, in the midst of apparently normal health, or after 
 obscure premonitory symptoms, signs of perforative peritonitis 
 appear. It is difficult to determine the cause of the condition and 
 the proper site for the surgical incision, upon which considerations 
 the life of the patient may depend. In the chapter on Duodenal 
 Ulcer (page 293) we have seen that not infrequently a perforation 
 of the appendix is sought for, and autopsy reveals a perforating 
 duodenal ulcer. 
 
 Regarding the differentiation between perforations of duodenal 
 or gastric ulcers and perityphlitic abscesses, Marmaduke Sheild"*^ 
 ascribes great value to the fsecal smell of the pus and the gas bub- 
 
453 DISEASES OF THE INTESTINES 
 
 bles formed ; these would indicate disease of the appendix and 
 caecum. He also lays stress upon the reaction of the pus, which is 
 neutral or alkaline in appendicitis, and acid in the others. Mistakes 
 like the above will never be unavoidable, but they warn us not to 
 operate till the site and nature of the perforation have been deter- 
 mined with some degree of certainty. 
 
 I believe that the prominence given to perforative appendicitis 
 tends to keep all other etiological factors in the background. 
 
 What is true of duodenal ulcer is also true of gastric and the 
 other numerous and genetically different forms of intestinal ulcers. 
 The differentiation between perforating ulcer of the csecum and 
 of the appendix can only exceptionally be made. In sudden per- 
 foration this distinction naturally has no practical significance. 
 
 We are frequently called upon to differentiate between appen- 
 dicitis and intestinal obstruction. In the following section we shall 
 discuss chronic obstruction as a complication of appendicitis. In the 
 cases there cited the diagnosis was easy, since the previous attack of 
 appendicitis clearly indicated the original trouble. In acute cases 
 the differentiation is much more difficult. (Compare also the chap- 
 ter on Intestinal Obstruction, page 368.) The symptoms may be 
 due to a variety of causes. The intestinal obstruction may result 
 from reflex intestinal paralysis, from compression of a perityphlitic 
 exudate, from kinking produced by adhesions, or from any other of 
 the almost innumerable ordinary causes. If no palpable abscess be 
 present, the history not definite, the temperature normal or almost 
 so, the patient collapsed and vomiting faeces, I see no possibility of 
 distinguishing between perityphlitis and obstruction. The situation 
 is the more critical since the circumstances necessitate quick de- 
 cision, and do not allow of careful and thorough examination and 
 observation. 
 
 In these instances the laparotomy will clear up the diagnosis. 
 We must again emphasize the value of a careful history, which 
 may offer an etiological hint and enable us to reach the proper 
 diagnosis. The history does not entirely guard against error, as 
 proved by a case of Sonnenburg ^'^, in which the history indicated 
 perityphlitis, but laparotomy showed obstruction by gallstones. It 
 is hardly necessary to state that the above diagnostic difficulties do 
 not always exist, and that when the symptoms are typical the diag- 
 nosis may be made at sight. 
 
 Typhoid fever, particularly after perforation, and intestinal 
 tuberculosis may also be confused with perityphlitis. When com- 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 453 
 
 plications exist, intestinal tuberculosis can be differentiated with 
 difficulty from perityphlitis. Borchardt^" reports a case of this 
 kind. 
 
 The patient entered the hospital with a pleuritic effusion and diarrhoea. 
 Tuberculosis was diagnosed. During an illness of three weeks, symptoms 
 pointing to the appendix were so mild that they were overlooked. Before 
 death peritonitis occurred, which was shown by the autopsy to have originated 
 from a perforated appendix. 
 
 Where the local symptoms are obscure, the pain not well local- 
 ized, and the fever curve of a continuous type, we must think of 
 typJioid fever. All the characteristic symptoms of typhoid must 
 naturally be considered, and the Gruber- Widal serum test made.* 
 The differentiation between typhoid fever and j)erforative peri- 
 tonitis may be very difficult, especially in recent cases with obscure 
 symptoms. 
 
 Septic (cryptogenetic) forms of appendicitis may also give rise 
 to diagnostic errors. As shown by the cases of Heubner*^ and 
 Karewski^, the symptoms are generally not sufficiently well de- 
 fined, and the course of the disease so violent that the patient dies 
 before all diagnostic possibilities can be excluded. 
 
 The cases of " pseudo-perityphlitis " (ISTothnagel) and "appendi- 
 citis larvata" (Ewald) should also be mentioned. French observers 
 (Talamon ^^ and Rendu ^) have described cases of hysterical perito- 
 neal irritation which very closely resemble appendicitis, and which 
 have been operated on. ]^othnagel ^^ has recently described a simi- 
 lar clinical picture under the name of " pseudo-perityphlitis." Un- 
 der the name of "appendicitis larvata," f Ewald ^^ has described a 
 train of symptoms in which (as proved by subsequent operations), 
 despite apparent hysteria, distinct changes occur in the appendix. 
 
 Complications 
 
 These are not infrequent. They may obscure the clinical pic- 
 ture, and, after the patients have passed through the actual attack, 
 often cause death. 
 
 Bossard aptly compares the inflamed appendix to a bomb which 
 may explode at any moment. The comparison is still further true 
 
 * [The blood must also be examined for leucoeytosis. which is absent in typhoid 
 fever and present in appendicitis and suppuration. — Tr.] 
 
 f As correctly stated by many authorities (Gussenbauei', J. Israel, and Senator), 
 the designation "appendicitis larvata" may easily produce misunderstanding, be- 
 cause it contradicts the fact that all the clinical data are present. 
 30 
 
454 DISBASES OF THE INTESTINES 
 
 in tliat it indicates tlie many different directions in which such a 
 bomb may burst. 
 
 All complications arise in two ways : by means of thrombosis 
 and embolism, or by extension of the inflammatory process by con- 
 tiguity. The latter is decidedly the more frequent. As we have 
 already seen, the perityphhtic process spreads most rapidly down- 
 ward (forming pelvic and vaginal abscesses). It may also spread pos- 
 teriorly (causing lumbar abscesses, vertebral abscesses, etc.), toward 
 the diaphragm (subphrenic abscesses), toward the anterior abdominal 
 wall, the hollow viscera, and even into the thorax. If rupture 
 through the abdominal or thoracic wall takes place, a fistula may 
 result. It is not our purpose to discuss all the clinical symptoms 
 arising from these complications. The resultant conditions are un- 
 derstood with difficulty when weeks or months intervene between 
 the primary disease and the secondary complications^, especially 
 when the perityphlitic attack itself runs an exceedingly mild 
 course. 
 
 Gerhardt ^ in particular has called attention to the frequency of 
 pleurisy as a complication of appendicitis. He has observed it 
 in no less than forty-eight per cent of all cases of appendicitis. 
 In the great majority (forty-two out of fifty) the pleurisy was on 
 the right side, in seven cases on both sides, and only once on the 
 left side. The pleurisy was generally serous ; in a small number 
 there was dry pleurisy. These cases are most probably explicable 
 by the fact that the inflammatory process affects the retrocsecal 
 connective tissue ; from here the process continues upward through 
 the lymph spaces of the retroperitoneal cellular tissue, advancing 
 through the diaphragm to the right pleura. 
 
 The second class of complications originate through thrombosis 
 of the appendicular vein. Thence the thrombotic particles are swept 
 into the blood stream and reach a branch of the portal vein. Pyle- 
 phlebitis and multiple liver abscesses develop, and, as observed by 
 Gendron ^^, an abscess may rupture through the diaphragm, causing 
 suppurative pleurisy and pericarditis. Terrillon ^ has directed at- 
 tention to purulent pleurisy as a comparatively frequent complica- 
 tion of appendicitis. Thrombi may become loosened from some of 
 the branches of the inferior vena cava and be carried as emboli to 
 the heart and lungs. 
 
 Thrombosis of the iliac or femoral vein is a rare complication. 
 These thrombi originate through direct extension of the inflam- 
 matory process to the large venous vessels, or as the result of stasis 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 455 
 
 following compression. Under these conditions, as sliown by Fow- 
 ler, fatal hsemorrhages may occur. Arterial thrombosis is very 
 rare. Körte ^^ has reported one case. Bull and Fowler ^'^ have pub- 
 lished cases of rupture of abscesses into the iliac and femoral 
 arteries. Most of these conditions can be diagnosticated only on 
 the autopsy table. The cases of suppurative hepatitis, pleurisy, and 
 pericarditis, already mentioned, may be recognised during life, 
 but we are rarely able to establish the relation between them and 
 the causative appendicitis. 
 
 An important complication of appendicitis, to which attention 
 was called by Eotter^^, is chronic intestinal obstruction by angular 
 kinking of the intestine in consequence of adhesions. Two cases 
 were cured by division of the adhesions. A case of this kind, com- 
 plicated by numerous abscesses, was observed and brilliantly diag- 
 nosticated intra vitam by IS^othnagel ^. 
 
 The infrequent complication of pregnancy with perityphlitis 
 will be briefly discussed. Gynecologists (Abrahams, Munde, Hla- 
 wacek, Treub, McArthur, Marx, E. FränkeP^, and others) teach 
 that appendicitis during pregnancy is generally a very serious com- 
 plication. Fowler claims that this complication always leads to 
 abortion, miscarriage, and death. E. Fränkel regards this as too 
 pessimistic. As the result of his own observations and a study of the 
 literature of the subject, he has demonstrated that the gravity of 
 this condition depends upon the variety and severity of the appen- 
 dicitis. In mild cases the process may heal and the pregnancy run 
 its natural course ; in severe cases, localized or general peritonitis 
 will produce abortion and generally the death of the mother.* The 
 puerperal period may also be endangered by appendicitis. Accord- 
 ing to Fränkel, there are three possibilities : 1. In consequence of 
 uterine contraction there is a break in the continuity of the peri- 
 appendicular abscess wall, with subsequent rupture into the free 
 peritoneal cavity and general peritonitis. 2. Fresh invasion of a 
 former inflammatory area by the bacterium coli. This invasion 
 may produce peritonitis as well as puerperal infection of the uterus. 
 3. Parametritis may develop from extension of the appendiceal 
 process to the vessels coursing in the appendicnlo-ovarian hga- 
 ment (Clado and Durand), or in the retrocsecal tissue. In a case 
 
 * [Successful operations for appendicitis during pregnancy with subsequent 
 delivery at term have been reported by Kraft "'s, McCosh ", Johnson «o, Gerster^i 
 (two cases), and others. An instance of recovery without operation and subse- 
 quent delivery at term has been published by Bayley ^^. — Tr.] 
 
456 DISBASES OF THE INTESTINES 
 
 of probable induced abortion which came under my observation 
 there occurred a severe aj)pendicitis, which was cured by operation. 
 
 Treatment 
 Typhlitis 
 
 I believe that, therapeutically as well as diagnostically, typh- 
 litis should be considered apart from appendicitis. The treatment of 
 these two affections is so entirely different that a separate descrip- 
 tion is necessary. We have previously (page 431) discussed the 
 different forms of development of typhlitis. Most of these are 
 mainly of surgical interest, and their treatment is practically that 
 of appendicitis, to which we therefore refer the reader. Medical 
 practitioners are principally interested in stercoral typhlitis. If the 
 physician agrees with us that, although very rare, stercoral typh- 
 litis does occur, the therapeutic methods to be used become obvious. 
 
 The main treatment consists in the removal of the impacted 
 faeces. We should employ therapeutic methods which even in 
 appendicitis do no harm, for it is impossible to always exclude the 
 latter disease. As already mentioned (page 189), I am decidedly 
 opposed to the administration of laxatives. For the purpose of 
 softening the faeces I use cleansing enemata of oil, or mixtures of 
 castor oil, cod-liver oil, and soda. In severe cases intestinal irriga- 
 tion (page 179) may be used. By these means we generally suc- 
 ceed in softening the inspissated fascal masses. 
 
 Should satisfactory evacuation follow these procedures, the intes- 
 tine will require rest. For the reasons often stated, I would warn 
 against repeated enemata in the expectation of more thoroughly 
 cleansing the caecum. On the contrary, after the patient has had a 
 movement the bowels should be constipated by opium sujDpositories 
 (0.02 to 0.03 gms. [of the extract?]) or tincture of opium (twenty 
 drops given once). Some benefit may also be derived from cold 
 compresses. After three or four days, when the subjective pain 
 and the sensitiveness of the csecum have ceased and the patient's 
 general condition is satisfactory, another enema may be given. 
 
 During the inflammatory stage the diet must be fluid, and gradu- 
 ally increased as the inflammation subsides and disappears. Subse- 
 quent treatment consists in preventing faecal accumulations ; when- 
 ever possible, this is to be accomplished by dietetic means only, 
 aided perhaps by mild laxatives, or still better by enemata. In this 
 connection we refer the reader to the chapter on Constipation. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 457 
 
 There still remains an important question : Shall patients with 
 this form of typhlitis remain in bed ? Most decidedly they should. 
 The patient is allowed out of bed only when three days have passed 
 without pain, fever, or gastric disturbances, when the general con- 
 dition is good, and there is no longer sensitiveness to pressure in 
 the ileo-csecal region. After he has left his bed the patient must 
 be advised to take care of himself for several days. 
 
 Perityphlitis 
 
 (a) Acute Perityphlitis 
 
 A few observations regarding the possible prophylaxis of peri- 
 typhlitis will not be out of place. As far as I know, Sahli, in his 
 Congress Report, was the first to touch upon this subject. It was 
 later taken up and discussed by Penzoldt^'', and moi-e recently by 
 Ewald ^. Authors are fairly well agreed that, to prevent a relapse 
 and to provide against an attack of appendicitis, constipation must be 
 controlled. Where family predisposition toward appendicitis exists, 
 I agree with these conclusions. As regards care to prevent the swal- 
 lowing of seeds, fish and other bones, I consider these precautions 
 theoretical rather than practical. The findings of surgeons in ap- 
 pendicitis operations do not justify such precautions. As previously 
 mentioned, foreign bodies are found only In a small number of cases. 
 
 The treatment of perityphlitis requires some preliminary re- 
 marks, by which we hope to make our general standpoint more 
 clear. There is no doubt that autopsies and operations have 
 already produced a reaction in the treatment of appendicitis. This 
 reaction will certainly become greater in the future. 
 
 Thanks to a large literary and statistical material bearing upon 
 the subject, the condition of the appendix and its surroundings can, 
 in the majority of cases, approximately at least, be determined by 
 abdominal palpation. This distinct advance in diagnosis lends aim 
 and direction to present therapeusis, and at the outset demands 
 neither surgical nor internal therapy, but simply a plan which will 
 always keep in mind the anatomical relations of the diseased pro- 
 cesses and their influence upon the general system. This stand- 
 point permits at times a surgical view of the case on the part of the 
 medical practitioner, and vice versa. In the therapy of appendicitis 
 internal and surgical treatment should not and cannot be opposed ; 
 but when internal measures do not sufiice, surgical intervention 
 should be an aid to them. 
 
458 DISEASES OP THE INTESTINES 
 
 The internal treatment, wliicli we shall now consider, must be 
 based upon the following principles : 
 
 1. Absolute bodily rest. 
 
 2. Rest of the intestines. 
 
 3. Appropriate diet. 
 
 Absolute rest in bed is one of the oldest and most important thera- 
 peutic laws. From the moment appendicitis is diagnosticated the 
 patient must take to bed, and not leave it until the attack is entirely 
 over. Simple as are these regulations, they are frequently broken, 
 generally by the patient, but sometimes by the physician. In his 
 excellent treatise Rotter has reported a number of serious results 
 from non-observance of these simple rules. " 
 
 The most important remedy in perityphlitis is opium, which was 
 first employed by Yolz. It has a very pronounced immobilizing 
 action on the intestines, reducing their movements and reflex irrita- 
 bility to a minimum. In this manner salutary adhesions may form, 
 the peritonitis become circumscribed, and, according to Sahli, the 
 shock of the peritonitis be lessened. Opium has a favourable effect 
 upon vomiting, loss of sleep, muscular irritability, and, according 
 to Penzoldt, it also lessens the thirst. Finally, I would call atten- 
 tion to the little-known diuretic action of opium, which, in view of 
 intestinal decomposition, is not without importance. In the General 
 Division (page 195) we have already given the underlying princi- 
 ples of the opium treatment of appendicitis ; we shall here briefly 
 repeat them. 
 
 In the first days of appendicitis, when pain, fever, and an in- 
 creasing tumour are the most prominent symptoms, opium is espe- 
 cially appropriate. It should be administered systematically (tinct. 
 opii, gtt. XX, every three hours ; or ext. opii, 0.03 gm., t. i. d.). 
 Suppositories of opium, each containing 0.05 gm. ext. opii, to be 
 used t. i. d., are also applicable, especially where internal adminis- 
 tration causes nausea or vomiting. Provided a good and active 
 preparation be at hand, the same directions apply to opium given 
 subcutaneously (ext. opii, aquos. sterilizat., 0.3 gms. in 10.0 c. cm. — 
 dose, a Pravaz syringeful t. i. d.). 
 
 In opium therapy the main rule must be avoidance of its lavish 
 use. When the process has reached or passed its highest point and 
 defervescence begins, opium is to be discarded. I would especially 
 warn against giving opium during convalescence. There is no 
 apparent reason for continuing the drug, and it may produce intes- 
 tinal paresis, from which the patients often suffer for the remainder 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 459 
 
 of their lives, particularly, as is so often the case, if there liad been 
 a tendency to constipation. 
 
 Opium is indicated not only in the beginning of the disease, but 
 also in suppurative and perforative appendicitis and in marked diffuse 
 peritonitis. In these instances the doses must be increased until 
 the pulse is slow and full, the general condition satisfactory, and the 
 facies composed (page 195). In beginning collapse and in sepsis 
 opium is without efEect ; in fact, it must be changed for the exci- 
 tant class of remedies. 
 
 Some authors prefer morphin (subcutaneously) to opium. The 
 advantages of opium are quite evident. The treatment of ajDpen- 
 dicitis with preparations of belladonna, which has also been recom- 
 mended, has not yet been sufficiently tested. Ferrand ^^ prefers bella- 
 donna to opium ; he claims it has all the advantages and none of 
 the disadvantages of opium (suppression of intestinal secretion, fae- 
 cal accumulations, increase of putrefaction). The few cases I have 
 treated with belladonna are not sufficient for me to express an opin- 
 ion of its effect. 
 
 The contraindication to laxatives of all kinds follows directly 
 from the principle of absolute intestinal rest. In fact, there is sel- 
 dom occasion for a laxative. If such necessity should arise, an 
 oil enema is by far the most appropriate remedy ; in these cases, 
 as Penzoldt quite correctly recommends, the physician should give 
 the rectal injection himself. 
 
 It need not be emphasized that the greatest possible precautions 
 are required during the act of defecation. 
 
 Ice applications [in the form of the ice bag or the Leiter coil] 
 to the ileo-csecal region constitute a further immobilizing agent, 
 for the patient is then forced to lie absolutely quiet on his back. 
 The ice may also lessen the pain. We need not fear peristalsis 
 from the cold applications, for daily ex]3erience has shown that 
 this, in view of the powerful inhibitory action of the opium, is 
 scarcely to be considered. 
 
 Ice is indicated as long as inflammatory symptoms continue and 
 no fluctuating abscess has formed. In the latter instance ice is, to 
 say the least, superfluous. The physician is often asked whether 
 ice applications are to be continued during the night. This question 
 cannot be answered generically. If sleep be thereby hindered, the 
 ice may be removed and cold applications instead applied ; other- 
 wise there is no objection to the continuation of the ice during the 
 night. 
 
460 DISEASES OF THE INTESTINES 
 
 As regards diet, the principle of greatest possible intestinal rest 
 also applies. This finds its extremest exemplification in absolute 
 starvation during the stage of inflammation. I do not deny the 
 theoretical justification of the absolute withdrawal of food, but, as 
 already stated (page 151), I believe that it is too severe a measure. 
 It is justifiable only in an etiologically obscure case of peritonitis or 
 of intestinal obstruction with feecal vomiting. In these instances, 
 subcutaneous injections of salt or sugar solutions are the only means 
 of subsidiary nourishment, but, with Penzoldt and Ewald, and as 
 opposed to Treves, I do not, for obvious reasons, consider nourish- 
 ing enemata indicated. 
 
 The most important dietetic details have been described in the 
 General Division ; we can scarcely add to that description. 
 
 Besides treatment of the perityphlitic attack, many cases require 
 appropriate after-treatment or observation. Regulation of the bow- 
 els in particular demands attention. In this connection we refer to 
 the recommendations given in the chapter on Chronic Constipation. 
 After the acute attack has passed, inflammatory adhesions or more 
 or less exudations may remain ; the question then arises how these 
 may be best removed. In recent cases I think it wisest to treat 
 these exudations expectantly, and to advise rest and general bodily 
 care. If the swelling persists, artificial or natural saline or mud 
 baths are often beneficial, or even curative. 
 
 Massage is also often advised for the exudations following peri- 
 typhlitis. We have stated in the General Division that massage is 
 to be used only after the inflammatory symptoms have run their 
 course, and must be practiced only by a physician experienced in 
 this field of work. Other authors (e. g., l^othnagel) advise against 
 massage. 
 
 The question regarding gymnastics and sports must be carefully 
 decided. This question is the more apt to arise because appendi- 
 citis usually occurs at an age when exercise is an important factor. 
 May a mihtary ofiicer ride, a gymnast exercise, a bicyclist ride, an 
 oarsman row ? These questions must be answered individually and 
 with the greatest reserve. Under all circumstances, and for at least 
 several months, exercises like the above should be prohibited. If no 
 relapse occurs and no untoward symptoms set in, we may tenta- 
 tively allow the patient to follow his special sport. Mountain 
 climbing, either as a vocation or as a pastime, requires the greatest 
 caution, and should not be extensively attempted for at least six 
 months after the attack. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 461 
 
 We liave spoken of the use of batlis, jDarticularly of saline and 
 mud baths, in the after-treatment, especially whei*e there is consti- 
 pation. These may be combined with water cures (Kissingen, 
 Homburg, Marienbad, Carlsbad, Tarasp, Franzensbad, Rohitsch, 
 Elster, etc.). [For corresponding American mineral springs and 
 wells, see page 161. — Tk.] (Comjiare also the chapter on Hydro- 
 therapeutics in the General Division.) 
 
 Operative Treatment 
 
 In view of the newness of the operative treatment of appendi- 
 citis, and of the customary separation of internal and surgical ther- 
 apy, it is quite difficult for the internal practitioner to express an 
 opinion concerning the indications for and the significance of 
 operation. Our judgment will therefore depend upon the experi- 
 ence of surgeons who are acquainted with the results that can be 
 obtained by internal treatment. 
 
 At every one of the numerous discussions within recent years 
 there has arisen the preliminary question : How do the results of 
 internal treatment compare with those of surgery ? Sahli, Ken- 
 vers, Kleinwächter, Rotter, Curschmann, Aufrecht, and others, have 
 l)rought forward a very impressive material to show the curative 
 results of conservative treatment. They have thus doubtlessly 
 strengthened the cause of conservatism, and have contributed much 
 toward preventing too radical surgical measures. 
 
 We quote Sahli's statistics, because they are very large and 
 therefore most trustworthy. Sahli ^ collected the entire material 
 of Swiss physicians, and thus gathered Y,213 cases. Of these, 
 473 were operated on, with a mortality of 21 per cent ; 6,740 were 
 treated conservatively, with a mortality of 8.8 per cent. Relapses 
 occurred in 20.8 per cent. The figures of other medical practi- 
 tioners and surgeons only partly agree with these. For instance, 
 Kleinwächter gives a mortality of 7 per cent ; Curschmann and 
 Aufrecht of 4 to 5 per cent ; Rotter, 8.9 per cent ; Renvers only 3 
 per cent. The same is true of surgical statistics, which give a 
 varying mortality between 9.6 per cent (Murphy) and 2-4 per cent 
 (Richardson), the average being about 15 per cent. It is possible 
 that the mortality will be lowered by increased experience, early 
 operation, etc., but a mortality of 5 to 8 per cent will exist in ap- 
 pendicitis operations, no matter how timely and successfully the 
 operation is performed (Rotter). 
 
 It is useless to compare the mortality rates of internal and sur- 
 
462 DISEASES OF THE INTESTINES 
 
 gical treatment. We miglit at most compare tlie several groups of 
 appendicitis with each other (simple appendicitis, suppurative, 
 perforative, with or without diffuse peritonitis, etc.). Aside from 
 this consideration, as recently emphasized bj Borchardt, the value 
 of statistics in determining the good obtained from one or the 
 other method of treatment is extremely doubtful.* There are too 
 many incommensurable quantities to be considered, which in some 
 manner must lead to a false conclusion. After all, the comparison 
 of hospital death rates would seem the most reliable. Even here 
 great differences exist. Thus, as the result of internal treatment in 
 the St. Hedwig Hospital [Berhn], in 213 cases of appendicitis, 
 Rotter gives the low mortality of 8.9 per cent. In the internal 
 division of the Ui'ban Hospital [Berlin] the mortality of appendi- 
 citis (132 cases) was about 12 per cent (Borchardt ^°), but of the 16 
 that died, about 14 were admitted with an inoperable general 
 peritonitis. These statistics speak for themselves, and demon- 
 strate that even the cases which come under the observation of 
 one man are subject to many accidental variations. From this it 
 follows that special rules for individual cases cannot be laid down, 
 but that only underlying general principles can be given. 
 
 For the purpose of clearness we employ the usual subdivisions 
 of appendicitis into simple catarrhal, suppurative, and perforative. 
 We shall later, from the surgical standpoint, discuss chronic peri- 
 typhlitis. 
 
 Simple catarrhal appendicitis does not usually necessitate sur- 
 gical interference. Sonnenburg believes that in these instances 
 the perityphlitic attacTc, and not the perityphlitic process, is cured. 
 There is not, however, any ground for such conclusion. Simple 
 perityphlitis will always be a medical disease. 
 
 In circumscribed suppurative appendicitis we must distinguish 
 between cases with and those without abscess. In the former group 
 there exists a possible indication for operation. When the patient's 
 general condition is good we may await the absorption of the exu- 
 date, which undoubtedly takes place in a large number of cases. 
 At all events the operation is generally simple, without danger, and 
 usually cures the suppurative process in a short time. 
 
 It is quite a different question whether the appendix itself 
 should be removed in suppurative appendicitis. Surgeons hold 
 
 * Compare also the brilliant discussion of 0. Rosenbach regarding the value 
 of statistics in diphtheria, in the 31üneh. med. Wochenschr., 1898, No. 27. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 463 
 
 contradictory opinions on this subject. As far as I can see, Son- 
 nenburg is the only German surgeon who recommends radical ex- 
 tirpation in order to prevent relapses. Fowler and Murphy are of 
 the same opinion. The majority of the other surgeons — Körte ^°, 
 Schede ^'^^ Kotter ^^, Mikulicz "^j etc. — consider that simple incision is 
 the proper procedure, becaus-e the removal of the appendix is very 
 dangerous and sometimes technically impracticable. In a case of 
 Gerhardt's ^, after extirpation of the appendix there was a relapse. 
 The appendix may be removed when the patient is not thereby en- 
 dangered — i, e., when the abscess is very small and well encapsu- 
 lated, and also in those cases where the appendix is not walled oif 
 by adhesions from the general peritoneal cavity.* 
 
 Experimental studies (Wieland ^^, P. Grawitz ^'^) have demon- 
 strated that the peritoneum is capable of absorbing small quantities 
 of pus. Furthermore, Renvers has seen cases in which the pres- 
 ence of pus was shown by exj^loratory puncture, cured by con- 
 servative treatment. Finally, during operations, inspissated pus, 
 evidently from previous exudates (Kümmel, Körte, and others), is 
 often found in and around the appendix. 
 
 In addition to the above, pus may be eliminated in two ways : 
 (1) By self -drainage (Sahli) — that is, by the pus emptying through 
 the ostium of the appendix itself ; or (2) by perforation of an extra- 
 appendicular abscess. Pus can only rarely be discovered in the 
 evacuations of the patients, but this fact does not speak against 
 the theory of self-drainage, since pus in the stool soon undergoes 
 changes which may make its recognition impossible (Sahli). On 
 the other hand, extension of the suppurative process with diffuse 
 peritonitis is quite frequent. These cases are often cured by sur- 
 gical, and only exceptionally by conservative, methods. The ques- 
 tion is still further complicated by the fact that, according to Pot- 
 ter, even with general peritonitis the inflammatory process may 
 become localized, lead to the formation of an abscess, and therefore 
 heal spontaneously or after simple incision. 
 
 These complicated conditions make the decision regarding the 
 
 * [The operator will have to be guided by the condition present. Among 
 American surgeons, Deaver ^^ -and Morton ^^ favour the removal of the appendix 
 in every instance. McBurney ^^ BuU^^ Senn^', Murphy ^^ Mynter^^ Fenger^^ 
 Fowler^, and almost all other noted surgeons advocate a careful search for and 
 removal of the appendix when the patient's general condition permits of reason- 
 able delay, and when the location and extirpation of the appendix do not neces- 
 sitate dangerous dissection and endanger the continuity of the abscess wall. — Tr.] 
 
464 DISEASES OP THE INTESTINES 
 
 time for surgical intervention one of the most difficult and respon- 
 sible tasks of the physician. Should we operate while there is still 
 hope that the process will heal under conservative treatment ? 
 How long should conservative treatment be tried ? We must not 
 foro-et the deceptive similarity between convalescence and danger. 
 What shall determine the proper procedure in these cases : the un- 
 favourable result of internal treatment, or the successful results of 
 surgery ? JSTot a few cases have been reported in which, both under 
 conservative and surgical treatment, the disease unexpectedly took 
 a favourable or an unfavourable termination. 
 
 As a general principle for these cases, we would lay down Rot- 
 ter's rules regarding the course of the temperature. He says : " If, 
 despite proper internal treatment, the fever shows no tendency to 
 subside, or rises after the third day, or if, after a slight remission, 
 the temperature after the fifth day reaches 39° C. or over, opera- 
 tion should not be delayed." In such cases the patient's general 
 condition will usually be disturbed, and the seriousness of the con- 
 dition will be indicated by the vomiting, the frequent, soft, irregu- 
 lar pulse, tympanites, great bodily weakness, sleej^lessness, marked 
 sensitiveness to pressure in the ileo-cjecal region, and singultus. 
 Rotter also says that cases which at first run a favourable course, 
 but which after a number of days again have fever, should also be 
 operated on. In all these instances an abscess is present, and if not 
 incised may lead to serious complications. 
 
 Those cases which immediately, or after twenty-four to forty- 
 eight hours, have signs of diffuse septic peritonitis, are undoubtedly 
 surgical, and the sooner they are placed under the surgeon's care 
 the better. Here, as already mentioned, the great difficulty fre- 
 quently lies in the diagnosis. The majority of these patients can 
 scarcely stand narcosis, let alone operation ; hence the surgical re- 
 sults are not very encouraging. Thus, despite timely operation. 
 Rotter lost sixty-six per cent, Körte sixty-four per cent, and Son- 
 nenburg ^'^ fifty-eight per cent of such cases. Every successful re- 
 sult must be regarded as a direct gain. 
 
 (5) Chronic Perityphlitis 
 
 Concerning this affection a proper understanding is beginning 
 to exist between medicine and surgery. We have already studied 
 the two forms of chronic appendicitis : chronic appendicitis in its 
 narrower sense, and relapsing appendicitis. Under certain condi- 
 tions both forms may be accompanied by severe symptoms, which 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 465 
 
 disturb the patient and interfere with his abihtj to do work, or 
 even endanger his existence. 
 
 We must, liowever, remember that great care and tlie use of 
 appropriate remedies (baths, springs, and diet) will remove many 
 of the patient's symptoms, and that relapses are often much milder 
 and do not last as long as the primary attack. Finally, as Eotter ^^ 
 and Kümmell*^ have shown, relapses are much more frequent 
 within the first year following the primary attack, decrease in fre- 
 quency in the second and third years, and are very rare thereafter. 
 The results of surgical treatment are exceptionally favourable ; 
 Kümmell ^^ , who has had the most experience in relapsing appendi- 
 citis, does not consider removal of the appendix more dangerous 
 than an ordinary ovariotomy. 
 
 The social status and vocation of the patient are of great impor- 
 tance in deciding for or against operation, A patient so situated that 
 he may take every possible care of himself need not decide upon an 
 operation as rapidly as one who must work hard for a living. 
 
 Hence, the following indications for operative interference in 
 chronic appendicitis may be laid down : 
 
 1. If, after an acute attack of appendicitis, severe and other 
 disturbances (pain, sensitiveness, etc.) persist, operation is to be 
 performed as soon as possible in those whose vocation necessitates 
 work. In other cases operation is indicated only after other reme- 
 dies have failed. 
 
 2. In relapsing appendicitis, especially among the working classes, 
 operative interference is indicated when the attacks occur at short 
 intervals and become more and more severe. If the interval 
 between the primary and the next succeeding attack is more than 
 three years, operation may be delayed or advised against. 
 
 Borchardt gives two further indications which, for the purpose 
 of completeness, we here repeat : 
 
 {a) In women, operation is indicated when the adnexa are 
 affected by the inflammatory process. Early operation may pre- 
 vent infection of the adnexa of the left side. 
 
 (h) Operation is indicated when, as a consequence of adhesions 
 between the appendix and the female adnexa, severe symptoms occur 
 during pregnancy, which tend to produce abortion or miscarriage. 
 
 Finally a few remarks on the operative treatment of tubercidar 
 appendicitis are in place. We have previously stated that, accord- 
 ing to literature, this class of cases concerns individuals with a 
 tubercular constitution in whom the appendicitis is only a compli- 
 
4,eG DISEASES OF THE INTESTINES 
 
 cation. In my opinion, operation in these instances is as little indi- 
 cated as in a tubercular kidney with marked pulmonary phthisis. 
 The few cases which were operated (Körte and Sonnenburg) died 
 in a short time, Borchardt reports two cases of tuberculosis of the 
 caecum with fistulse in the ileo-csecal region. Both patients died 
 soon after operation. 
 
 The prognosis after operative treatment of actinomycotic appen- 
 dicitis is also unfavourable. Of the twelve cases reported in Son- 
 nenburg's monograph (to which we add another case recently 
 reported by Karewski ^^ ) only one was cured. 
 
 In conclusion, a few remarks on the relation between the physi- 
 cian and the surgeon appears to me appropriate. We consider it 
 very desirable that, wherever possible, in every case of apparently 
 severe appendicitis a surgeon shall be immediately consulted. It is 
 not necessary to operate at once, but the case is to be observed 
 and studied by both practitioners, and the proper time for surgical 
 interference watched for. In public hospitals this is readily accom- 
 plished, but in private practice it should be followed to a greater 
 extent. The surgeon who in a given case decides for conservative 
 measures instead of for operation, will not lose, but gain, in repu- 
 tation. 
 
 [The preceding chapter describes very fully the modern conti- 
 nental view of appendicitis, particularly from the standpoint of the 
 general practitioner. Whether from climatic, racial, dietetic, or 
 other influences, the type of the disease in Europe is a far milder 
 one than in the United States, or whether, because less prevalent, 
 its gravity is not so fully appreciated, certain it is that the medical 
 profession abroad regard appendicitis in a far more sanguine light 
 than we do in this country. It appears therefore in place to sum- 
 marize the American ideas of appendicitis as gathered from litera- 
 ture and personal experience. 
 
 Within recent times no other affection has been the subject of 
 so much discussion, demonstration, study, and writing. In this 
 country, appendicitis is of such frequency that almost every layman 
 is acquainted with its manifestations and dangers. Fitz's^^ masterly 
 monograph taught us the proper significance of, and gave the impetus 
 to, the further study of ileo-csecal inflammations. The brilliant 
 operative results of Morton % Sands ^■^, McBurney ^^, Weir^*, and 
 others demonstrated practically what Fitz theoretically tanght, 
 viz., the possibilities of surgery in this domain, ßapidly experi- 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 457 
 
 ences multiplied, definition in diagnosis, prognosis, and treatment 
 became more exact, and to-daj the clinical phases of the disease are 
 far better understood. We have come to regard appendicitis essen- 
 tially as a surgical condition, and one which must therefore be 
 treated upon strictly surgical principles. It is everywhere recog- 
 nised by general practitioners that each case of appendicitis ought 
 (at least in large cities) to be treated by, or in conjunction with, a 
 competent surgeon.* This fact is also understood by our general 
 public ; and once the diagnosis is made or suspected, the possibility 
 of an immediate or future operation is entertained. In all our 
 hospitals patients with appendicitis are assigned to the surgical 
 di vision. f 
 
 The terms typhlitis, csecitis, iliac abscess, pericsecal abscess, and 
 perityphlitis, though still mentioned in text- books and monographs 
 have been completely dropped in practice. That primary inflam- 
 matory (suppurative) conditions of the caecum may occur is not 
 denied, but if they do occur they must be exceedingly rare, and 
 clinically indistinguishable from appendicular processes ; ;{: there- 
 fore no practical value attaches to their separate consideration. 
 Clinically, at least, the diagnosis " appendicular (vermicular) colic " 
 is never made in this country, for that condition is regarded as 
 identical with a mild form of catarrhal appendicitis (Hartley ''"'', 
 Fowler *), 
 
 For the reasons stated at length in the main body of the present 
 chapter, and which, together with a few additional facts, shall now 
 be briefly recapitulated, aj)pendicitis differs essentially from other 
 inflammatory and ulcerative processes of the intestines. 
 
 The vermiform appendix in man, being in an evolutionary state, 
 has a natural tendency toward obliteration ; hence it can offer but 
 a feeble resistance to deleterious influences. Owing to its very rich 
 
 * [" It must be confessed that, according to our present views, appendicitis is a 
 surgical rather than a medical affection, particularly from the standpoint of treat- 
 ment " (Anders 9*).] 
 
 [" The disease is, properly speaking, a surgical one " (Lockwood '").] 
 
 [" In the majority of instances appendicitis is a surgical affection," wriies 
 Pepper^', one of the strongest advocates of the opium treatment.] 
 
 f [Osier ^8 remarks : " So impressed am I by the fact that we physicians lose lives 
 by temporizing with certain cases of appendicitis, that I prefer, in hospital work, 
 to have the suspected cases admitted directly to the surgical side."] 
 
 X [According to McBurney, 99 per cent of all typhlitic abscesses are of appen- 
 dicular origin.] 
 
 * [Loc. cit., p. 45.] 
 
468 DISEASES OF THE INTESTINES 
 
 lymphatic structure, excessive secretion readily results from irrita- 
 tion. The disproportion between the length and the diameter of 
 its lumen, the scarcity of contractile muscle fibres, the presence of 
 fsecal concretions and of Gerlach's valve, and of other physiological 
 strictures, and the pendent position of the organ, favour the stag- 
 nation of this excessive secretion. As a result, there is increased 
 pressure within the appendix. Concretions and other foreign 
 bodies produce erosions and ulcerations of the wall. The nutrient 
 vessels being terminal branches, there is no provision for the estab- 
 lishment of compensatory anastomosis, the circulation is readily 
 embarrassed, and, unless the stagnation within the lumen is relieved, 
 gangrene results. The presence of bacteria adds an infectious ele- 
 ment to the process, and may lead to the formation of an abscess 
 within the appendix (empyema), or (with or without perforation) to 
 suppurative processes in the surrounding parts. General sepsis 
 may also occur. 
 
 Usually the changes involve the entire appendix. Hartley'''' 
 states that some appendices which he had removed in the first 
 twenty-four to forty-eight or even seventy-two hours of the dis- 
 ease, showed changes only in the mucosa and submucosa. If the 
 serous coat becomes affected, a local peritonitis, with the formation 
 of more or less extensive adhesions, results. " These adhesions may 
 repeatedly form an efiicient protective wall, but often they are 
 powerless to prevent the further spread of a purulent peritonitis. 
 This is the most important phase of the pathology of appendicitis, 
 and is a condition which we will never be able to overcome " 
 (Stein ^^). The existence of such a condition is a strong argument 
 against waiting for an abscess to become absorbed, or against delay- 
 ing the operation until firm adhesions have formed. In very acute 
 cases the infective process may spread so rapidly that there is 
 no time for adhesions to form, and an acute general peritonitis 
 supervenes. 
 
 In addition to empyema, ulceration, and perforation, the appen- 
 dix may be the seat of other pathological changes, particularly 
 where there have been repeated attacks. Strictures and cystic con- 
 ditions may develop, the lumen may be obliterated, or the wall of 
 the appendix become thickened and indurated. Sometimes the 
 entire appendix is embedded in a mass of adhesions, and loses its 
 original appearance and character. 
 
 JSTo new facts relative to the conservative treatment can be added 
 to those described on page 458. It is well, perhaps, to briefly 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 409 
 
 define the position assumed in this country in regard to opium and 
 cathartics. 
 
 As in other countries, views differ regarding the propriety of 
 prescribing opium and its alkaloids in appendicitis. In private 
 practice there is a constantly increasing tendency to limit their 
 employment. Surgeons, as a rule, condemn their administration, 
 at least until the diagnosis has been made or operation decided U23on. 
 Even then opium should be used in minimum amounts, just sufficient 
 to relieve pain. It has been stated that a pain unrelieved by an 
 ice bag, etc., and severe enough to require large doses of opium, 
 constitutes in itself a sufficient indication for operation (Wiener ^*'''). 
 The objections to opium are : («) That it masks the symptoms and 
 produces a false euphoria, rendering it impossible to properly esti- 
 mate the attack ; {b) that it favours the development of a tympani- 
 tis which we may be unable to differentiate from that of a begin- 
 ning peritonitis (Wiener) ; and (c) that in large doses it is apt to 
 induce an intestinal paralysis. The points in favour of its use have 
 already been mentioned (page 458). Pepper^ considers opium in 
 full doses as " the great standby," and that it has greatly lessened 
 the mortality from appendicitis. Einhorn ^"^ considers oj)ium the 
 remedy par excellence. Deaver^"^ permits its use for the relief of 
 pain, but only after a purgative action has been obtained; he con- 
 siders the local use of ice much better than the administration of 
 opium. Lockwood ^^ also would give opium, but not to the extent 
 of semi-narcotism. 
 
 The use of cathartics is still a disputed question. Recently 
 salines were extensively employed and recommended by surgeons. 
 Deaver ^'^^ claims never to have seen any harm from catharsis. lie 
 certainly does not voice the general opinion when he says : " Pur- 
 gatives are capable of doing much more good under these circum- 
 stances than any other class of drugs. ... I am positive, after con- 
 siderable experience, that the good from purging will overbalance 
 by far the harm done by active peristalsis. The writers who oppose 
 the use of these drugs are evidently limited in their experience 
 with the disease, otherwise they would not so believe." Tiffany ^''^ 
 also favours free purging. In general, both medical and surgical 
 authorities condemn their use during an acute attack (Osier ^^, Mc- 
 Burney «^ Einhorn ^^\ McN'utt ^% Mynter ^\ Pepper ^', etc.). Tyson ^''^ 
 opposes their employment in advanced cases, but thinks their early 
 administration in mild or moderate cases may clear up the diagnosis, 
 or, by depletion of the circulation, diminish the danger of peritonitis. 
 31 
 
470 DISEASES OP THE INTESTINES 
 
 Against tlie use of cathartics it is urged that they are not needed, 
 •since the csecum is rarely filled with faecal accumulations ; that cathar- 
 tics tend to increase nausea and general unrest ; and that by exciting 
 peristalsis they prevent the formation of fresh adhesions, and break up 
 those already formed, but not yet firm. Finally, it must not be lost 
 sight of that, even in the very earliest stages of appendicitis, we can 
 never tell how near the appendix is to perforation. Hence, in gen- 
 eral, it is best to defer the administration of purgatives until after 
 operation, or until the attack has passed oif. If it be necessary to 
 empty the lower bowel earlier, an enema will answer very well. 
 
 What are the recognised indications for operation ? In endeav- 
 ouring to answer this question the writer has consulted the publica- 
 tions of recognised American authorities,* and has also drawn upon 
 personal experience in hospital and private practice. He finds that 
 there has been a considerable change of opinion since the clinical 
 and pathological manifestations of appendicitis have received more 
 direct attention. In the earlier days it was universally recom- 
 mended to wait until an abscess had formed. The discovery and 
 publication of McBurney's point ^°^ was a most decided advance in 
 the early diagnosis of acute appendicitis. Taught by sad ex- 
 periences, the American profession has come to appreciate the 
 dangers which attend postponement of operation, and, emboldened 
 by the success of modern surgical methods, has learned to be more 
 radical in its treatment of appendicitis. 
 
 We recognise that owing to anatomical peculiarities, an appen- 
 dix once the seat of a more than very slight inflammation will never 
 return to its normal state, and that this predisposes the organ to 
 fresh attacks. We believe that with each fresh attack the patho- 
 logical state of the appendix is aggravated. There are no specific 
 internal remedies for the cure of appendicitis. Treated conserva- 
 tively, mild cases often recover with a restitutio ad integrum, or 
 with no further changes than strictures of the lumen ; severer 
 cases may be attended by any of the processes already mentioned. 
 Exceptionally, an extra appendicular abscess ruptures externally or 
 into a hollow abdominal viscus (bladder, caecum, rectum, etc.), and 
 relief or spontaneous cure follows.f 
 
 The abscess has occasionally perforated the diaphragm and dis- 
 
 * [See Literature at the end of this chapter.] 
 
 f [Lloyd ^''■' reports a very interesting and instructive instance of acute appen- 
 dicitis occurring in a man in whom years before a peri-appendicular abscess had 
 ruptured and discharged into the rectum.] 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 471 
 
 charged tlirougli the lung. The danger and inconvenience of such 
 conditions are too apparent to call for any comment. 
 
 In the vast majority of cases we are unable, without laparotomy, 
 to determine the condition in the ileo-caecal region. We cannot 
 tell how near the appendix is to perforation ; whether there are any 
 adhesions, and, if so, how firm ; whether there will be any further 
 attacks, etc. To guide us in our disposal of a case, we must appeal 
 to our experience and the results of pathological research. 
 
 With but few exceptions the profession have therefore come to 
 regard appendicitis as a surgical affection. This applies as well to 
 the simple catarrhal as to the suppurative and other severer forms. 
 If, then, during a slight or moderately severe acute attack we resort to 
 rest in the recumbent position, an ice bag, restricted diet, and other 
 conservative measures, in the endeavour to tide the patient over the 
 attack, we are none the less fully alive to the possibility of an im- 
 mediate or the probability (almost certainty) of a future operation. 
 We watch our cases very carefully, and are prepared for immediate 
 surgical interference should indication arise. Experience has taught 
 that the period of quiescence between attacks offers the best 
 chances for operative success. The patient or his friends are in- 
 structed concerning the gravity of the situation, and such details are 
 explained to them as are necessary for their clearer judgment. For 
 with the family, after all, will rest the consent to operate. 
 
 Contraindications to Operation. — Besides the withholding of 
 the consent of the patient or those responsible for him, operation 
 may be impossible or inadvisable for other reasons. Such would 
 be inadequate surroundings, failure to obtain proper assistance, sur- 
 gical inexperience of the medical attendant, too far advanced con- 
 dition of the case (sepsis, extreme weakness, moribund state, etc.) 
 coincidence of other serious disease, etc. 
 
 In the absence of these adverse circumstances the following are 
 the generally accepted indications for operation : * 
 
 I. Interval operation. f 
 
 (a) In mild cases after two or more attacks. 
 
 * [The following indications apply only to patients residing in large cities or 
 otherwise accessible to immediate surgical interference. For those who travel 
 much, who live in the country, or who must perform severe physical labour, etc., it 
 is best to remove the appendix during or after a first attack.] 
 
 f [It is best to wait about two to four weeks after even mild attacks, until the 
 inflammation has become quiescent. The mortality under such circumstances, 
 even in difficult and unfavourable cases, is, in the hands of a good operator, 1 per 
 cent or 3 per cent (McBurney).] 
 
472 DISEASES OP THE INTESTINES 
 
 Willy Meyer ^"^^ advises the radical operation after recovery 
 froiQ any attack of appendicitis, mild or severe. Deaver^^, Myn- 
 ter^®, and a few other surgeons, favour immediate operation in all 
 cases of appendicitis as soon as the diagnosis is made. 
 
 (h) After recovery from an attack of ordinary or more than 
 ordinary severity. 
 
 Here general practitioners and surgeons are almost unanimously 
 agreed that it would be assuming too great a risk to expose the 
 patient to the dangers of a repeated attack. 
 
 II. Immediate operation. 
 
 1. In cases of ordinary severity with sharply defined symptoms. 
 (a) Whenever there is a tumour present in the ileo-cgecal region. 
 (h) Whenever there is sudden or progressive increase in the 
 
 gravity of the symptoms. 
 
 (c) When, after thirty-six to forty-eight hours, the case does 
 not show any tendency toward improvement, but the condition 
 remains stationary.f 
 
 {d) Whenever there is any doubt as to the existing condition 
 and the patient's improvement most authorities advise immediate 
 operation. In this instance timely operation is better than the un- 
 certainty and dangers which attend delay .:|; 
 
 2. In all the severer forms of appendicitis — i. e., those in which 
 the symptoms point to pus in or about the appendix (with or with- 
 out peritonitis), to perforation, or to severe systemic infection — we 
 cannot operate too early. It is wrong to delay and attempt to 
 determine the pathological conditions present, for we will rarely 
 arrive at more than a probable diagnosis, and every delay may cost 
 the patient his life. In all cases of acute appendicitis the earlier 
 the operation the easier its performance, the better the condition of 
 the patient, and the more certain are the chances of success. — Te.] 
 
 * [Willy Meyer reminds us that the first attack is really not the first pathologi- 
 cal symptom, but rather the " first explosion."] 
 
 f [Here one must be guided, in advising immediate or interval operation, by 
 the existing circumstances, particularly by the general condition of the patient and 
 the care with which the case can be watched.] 
 
 I [McBurney ^^, one of our greatest authorities on appendicitis, says, in referring 
 to this indication for operation : " No greater mistake can be made than to wait 
 for very clearly defined signs of advanced and grave disease before deciding to 
 operate. Operation, to be usually successful, must be done before grave disease is 
 well pronounced."] 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 473 
 
 APPENDIX 
 Sigmoiditis and Pericolitis 
 
 (a) Acute Sigmoiditis 
 
 Under this name A. Mayor ^^ has described a condition which 
 consists in an inflammation of the sigmoid flexure and occasionally 
 of the neighbouring peritoneum and cellular tissue ("iliac phleg- 
 mon"). Mayor believes that this affection is caused by faecal 
 impaction in the sigmoid or by irregular defecation. Both causes 
 may, however, be absent. Fever may or may not be present. The 
 region of the sigmoid is always indurated, swollen, and sensitive to 
 j3ressure ; suppuration and rupture into the intestine may occur. 
 All the cases were marked by rapid convalescence. Mayor leaves 
 it undecided whether the disease is produced by purely mechanical 
 factors or by specific infection (e. g., erosions). 
 
 To illustrate the clinical picture, it seems best to present a brief 
 analysis of the clinical histories reported by Mayor : 
 
 Case I. — A woman, thirty-two years old, who, excepting for constipation, 
 liad. always been well. On examination of the region of the sigmoid flexure, 
 tliere was felt a cylindrical swelling which was continuous with the descend- 
 ing colon above, and disappeared toward the pelvis. Rectal examination 
 showed nothing abnormal. Tliis condition developed without fever, and 
 disappeared under the use of cataplasms. 
 
 Case II. — Boy, fourteen years old, became ill with fever, pain in the left 
 side, and local symptoms similar to the above ; after fever for several days the 
 boy recovered. 
 
 Case III. — Boy, eleven years old, became ill with high fever; suppuration 
 occurred, and the abscess ruptured into the intestine. 
 
 Case IV. — Physician, forty-two years old, sudden, severe, paroxysmal 
 pains in the sigmoid region, accompanied by nausea; no constipation, no fever. 
 The sigmoid flexure was indurated, swollen, and sensitive. Recovery after a 
 few days. 
 
 In a case recently reported by Galliard,'"' there were severe general symp- 
 toms, with fever, and pain in the left iliac fossa. There was a tumour the size 
 of an orange, which disappeared after three weeks. 
 
 In the absence of autopsies, certainty regarding the pathogenesis 
 of the disease is scarcely possible. It seems very diflicult to differ- 
 entiate acute sigmoiditis from inflammation of the csecum, or an 
 appendix displaced to the left. Chronic enteritis with acute exacer- 
 bations may also be mistaken for sigmoiditis, especially since fever 
 is not a necessary symptom of the latter. Finally, inflammation of 
 the left female adnexa may also require diagnostic consideration. 
 
4Y4 DISEASES OF THE INTESTINES 
 
 Mayor deserves credit for having pointed out that inflammatory 
 processes may occur in the left ihac fossa. Further study of these 
 conditions, and the knowledge derived from operative procedures, 
 will be required before we can say that there is proper justification 
 for considering this affection as an inflammation of the sigmoid 
 flexure. 
 
 The same treatment must be applied as in typhlitis : rest in bed, 
 ice, or, when this is not well borne, warm applications, regulation of 
 the bowels, and opium (internally, subcutaneously, or in supposi- 
 tories) when the pain is severe. 
 
 (5) Chronic Sigmoiditis 
 
 By chronic sigmoiditis I mean an affection in which there is 
 constant pain and sensitiveness to pressure in the region of the 
 sigmoid flexure. Further symptoms are severe diarrhoea, accom- 
 panied by more or less mucus, or by attacks of constipation. 
 
 Yon Leube '^'^ and Rosenheim ''^^ also report chronic inflammatory 
 infiltration of the sigmoid flexure with a " smooth, regular, increased 
 resistance." Since chronic sigmoiditis is but little known, I will 
 briefly report two cases from my journal : 
 
 Case I. — Mrs. F. R., of Berlin, age thirty-nine. No hereditary disease ; 
 has had four severe labours and two abortions, produced, she! says, by falling and 
 jolting. Her present symptoms have lasted eleven years, and are ascribed by 
 her to the first confinement, which was an instrumental delivery with complete 
 tear of the perinseum. A recto-vaginal fistula remained, and caused the patient 
 much annoyance. Three years later the fistula was operated on by Prof. 
 Fritsch. Patient felt better for a few months after the operation, but the symp- 
 toms gradually returned, and at present they are at their greatest intensity. 
 They consist of pains in left lower abdominal quadrant, flatus, and morning 
 diarrhoea (two to four movements) with much mucus. Blood has never been 
 found in the stools. Frequent tenesmus, which only ceases after injections of 
 chamomile infusion. The diarrhoea alternates with normal stools for one to two 
 days. On such days the patient feels much better. The other gastro-intestinal 
 functions are absolutely normal. All treatment (oil enemata, opium, tannalbin, 
 etc.) has been without effect up to the present time. 
 
 Status Proesens. — Pale, well-nourished woman. Organs of respiration and 
 circulation normal. 
 
 AMomen. — Many striae, abdominal j)anniculus flabby (pendulous abdomen), 
 splashing and succussion sounds in the gastric region. Lower border of the 
 stomach (carbonic-acid inflation) reaches to the umbilicus. 
 
 The slightest palpation in the region of the sigmoid is extremely painful. 
 As the examining finger passes upward the sensitiveness becomes less, and at 
 the splenic flexure disappears entirely. No resistance to be felt. Rectal exam- 
 ination negative. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 475 
 
 Urine. — Normal; no indicanuria. 
 
 Stools. — Two to three stools daily, of semisolid consistency, and mixed 
 with viscid mucus. Microscopically nothing of importance, particularly no 
 blood, pus, or amoebae. 
 
 Stomach. — Motility normal, marked hyperacidity (0.28 per cent HCl). 
 
 During the clinical examination there were six to seven thin stools, accom- 
 panied by severe tenesmus. The treatment consisted in absolute rest in bed, 
 astringent diet, hot poultices over the sigmoid flexure, and rectal irrigations 
 with bismuth mixtures (bismuth, J ounce; water, 1 litre). 
 
 After four weeks of treatment patient showed considerable improvement ; 
 had one to two well- formed stools daily; painless defecation, and much dimin- 
 ished sensitiveness over sigmoid. 
 
 Case II. — Mr. S., of W., thirty-tw^o years old. In February, 1896, while in 
 India, he had a severe attack of acute dysentery, which slowly improved after 
 about four weeks. A sensitive area remained, however, in the left lower 
 portion of the abdomen. Pain was particularly evident while riding, so as to 
 necessitate the giving up of that exercise. After walking about for several 
 hours the patient usually felt more or less severe pain in the above-mentioned 
 area. Appetite good. Stools always show a tendency to diarrhoea. Examina- 
 tion reveals circumscribed sensitiveness and a feeling of light resistance over 
 the sigmoid flexure. Everything else normal. 
 
 These cases demonstrate that local inflammation of the sigmoid 
 does occur. In the first instance the etiology was very probably 
 an infection originating in the recto-vaginal fistula ; the second case 
 very probably originated from the previous dysentery. 
 
 The diagnosis is made from the catarrh of the large bowel, aixd 
 from the sharply defined sensitive area corresponding to the sigmoid 
 flexure. There need not be a demonstrable resistance. Differen- 
 tially, we must, in the first place, consider malignant neoplasms, and 
 then diseases of the female adnexa. By careful examination we 
 ought to be able to exclude both groups of diseases. 
 
 The treatment is the same as that of chronic catarrh of the large 
 intestine. 
 
 (c) Exudative Pericolitis • Primär?/ Submucous, Circtimscriled 
 
 Colitis (Pal) 
 
 Under the name of exudative pericolitis. Windscheid '^^, of the 
 Leipsic Clinic, first described a condition characterized by the de- 
 velopment of acute exudative peritonitis about the ascending colon. 
 This affection is distinguished from typhlitis and appendicitis in 
 that the right iliac fossa is entirely free, and from tumour by the 
 acute onset and constant fever. In the same year Eisenlohr ^^ re- 
 ported " a case of abscess behind the ascending colon." Since this 
 
476 DISEASES OF THE INTESTINES 
 
 is tlie only instance in which an autopsy was performed, its impor- 
 tant points are here briefly recapitulated. 
 
 A ferryman, thirty-one years old, alcoholic, with cirrhosis of the Hver, on 
 March 31st became ill with chills, vomiting, diarrhoea, and marked abdominal 
 distention. On examination, the right hypochondrium was found sensitive to 
 pressure, and painful ; pulse frequent ; diarrhoea ; vomiting bilious but not 
 feculent ; urine contains no albumin ; peptonuria found once. 
 
 March 24th. Fluctuation in the abdomen with disappearance of perito- 
 nitis ; later, ascites ; evening temperature 39° C. 
 
 Death on May 29th. Autopsy showed a small abscess cavity situated be- 
 low the upper portion of the ascending colon and between the hepatico-colic 
 ligament, the anterior surface of the kidney capsule, and the descending por- 
 tion of the duodenum. This cavity contained a scanty amount of semisolid, 
 inspissated, yellowish pus. The mass measured about ten centimetres verti- 
 cally, and somewhat less horizontally. Its position corresponded to the mesen- 
 tery of the upper portion of the ascending colon. The walls of the abscess 
 cavity were tough, and thickened by connective tissue ; the peritoneum of the 
 intestines, particularly that of the caecum and appendix, showed no trace of 
 previous inflammation. The entire mucous membrane presented no evidence 
 of previous ulcers, cicatrizations, or infiltrations. The abscess was entirely 
 outside of the intestinal wall. 
 
 In 1895 Fleiner''^ reported a case which he also described as a 
 pericolitic exudate. J. Pal'^*' recently published a series of such 
 observations, in which he thoroughly discusses the question. Pal's 
 cases include exudates about various portions of the large intestine, 
 five cases of ascending colitis, one of colitis of the left or both flex- 
 ures, one of colitis of the right flexure, and one of descending 
 colitis. He considers colitis as a submucous inflltration which is 
 developed from peculiar changes in the intestinal contents, and 
 which either suppurates and ruptures or is absorbed. 
 
 I also am in a position to report a case of this kind which, after 
 laparotomy, came to the autopsy table. 
 
 H. K., nineteen years old, student. As a child suffered from pertussis 
 and frequent pulmonary and intestinal catarrhs. In 1889 tubercular knee and 
 hip-joint disease, cured by extension and iodoform injections. After the 
 chloroform narcosis then necessary, for the first time there developed vomiting, 
 with colicky pains and marked sensitiveness in the left side of the abdomen. 
 Cure after eight days. Then absolutely well for six years. On' March 22d, 
 1397, another attack after drinking cold beer. Severe pain in the umbilical 
 region, marked vomiting, and constipation. These attacks were repeated five 
 times in four weeks, each time lasting one to tliree days. The last attack be- 
 gan April 20, 1897, with severe colicky pains to the left of the umbilicus, and 
 radiating to the back. Vomiting and constipation ; no fever (?). "When seen 
 in consultation (April 23d), to the left of the umbilicus there was felt an in- 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 477 
 
 tensely painful, incompressible resistance the size of an apple. Since the 
 attendant physician has given the patient laxatives and irrigations, faecal 
 tumour can be absolutely excluded. Neoplasms also, because of the intense 
 sensitiveness. The diagnosis of serous exudative pericolitis was therefore 
 made. 
 
 Treatment. — Rest in bed, ice bag, opium pei' Tectum., fluid diet. First 
 stool four days after these regulations. Resistance can still be felt. Four 
 days later, tumour can no longer be felt. May 5, 1897, tumour had entirely 
 disappeared ; no sensitiveness in the area above mentioned. General condition 
 good. Course of waters at Kissingen in the summer of 1897 followed by 
 favourable results. In autumn, 1898, new attacks at intervals of three to four 
 weeks ; at the last attack (end of October) there was absolute retention of 
 stool and flatus. On October 31st, laparotomy performed by Professor Riedel, 
 of Jena. The following facts are borrowed from his report of the case : 
 
 Incision shows the transverse colon moderately distended by gas ; isolated 
 white patches in the mesentery« To the left and above the cicatrized omentum 
 is adherent to the tip of the spleen, which is very movable. The splenic flexure 
 is extremely coiled, the individual coils being connected to one another by 
 glistening, white, cicatricial tissue. Loosening of the mesenteric adhesions. 
 Ether bronchitis ; death from diffuse peritonitis. 
 
 In mj opinion, these numerous scar tissue adhesions were the 
 remnants of many previous attacks of exudative peritonitis. 
 
 Despite the small number of cases which have been observed, 
 there is no doubt that, clinically, there do occur serous or purulent 
 exudates without involvement of the appendix. Their etiology is 
 difficult to determine. The explanation given by Pal is founded 
 upon a case of Eisenlohr's, but since the entrance point for the de- 
 velopment of the abscess is unknown, this case must be used only 
 with the m-eatest caution for the establishment of a new disease. 
 
 to" 
 
 Symptomatology and Diagnosis 
 
 According to Pal's description, the onset is sudden, with symp- 
 toms of inflammatory swelling of the large intestine, accompanied 
 by fever, nausea, or vomiting ; there soon develops a sensitive area, 
 painful to pressure, and, in a few days, a palpable resistance. The 
 resistance may rapidly increase in extent ; at this stage the tumour 
 is quite sensitive to pressure. When fever subsides the sensitiveness 
 also disappears. The rest of the abdomen is slightly or not at all 
 affected by the process. 
 
 The most frequent site of the disease is the hepatic, less fre- 
 quently the splenic flexure. The process may develop in other seg- 
 ments of the large intestine, particularly in the ascending colon. 
 When affectino; the descendino; colon or the sigmoid flexure, the 
 
478 DISEASES OF THE INTESTINES 
 
 clinical picture is tlie same as that of sigmoiditis (Mayor). Occa- 
 sionally, several intestinal segments may be simultaneously in- 
 volved. In the beginning the clinical picture may impress one as 
 that of a circumscribed peritonitis, but the rapidly developing cylin- 
 drical area of resistance points directly to the intestines as the origin 
 of the lesion. 
 
 The fever is generally of short duration and may be overlooked, 
 but when suppuration supervenes it may become quite marked. In 
 the beginning the bowels may be normal or constipated. Fre- 
 quently there is an accumulation of gas. There is often marked in- 
 dicanuria. 
 
 DrFFEEENTIAL DIAGNOSIS 
 
 Differentiation from typhlitis and perityphlitis is the first con- 
 sideration, particularly when the process is localized on the right 
 side in the neighbourhood of the c^cura. Pal places a certain value 
 on palpation and percussion for the separation of the cascum from 
 the diseased colon. He, however, seems to undervalue the dif- 
 ficulties of an exact differential diagnosis of this disease from peri- 
 typhlitis. When we consider the numerous variations in position 
 of the csecum, and the different localities of perityphlitic abscesses 
 and exudates, error would appear unavoidable. When the colitis is 
 situated in the vicinity of the right hypochondrium, cholelithiasis 
 may have to be considered, and, under complicating conditions, the 
 diagnosis may be very difficult. Perigastritis and perinephritis 
 may also come into question. 
 
 Tkeatment 
 
 In general the treatment embodies the usual principles employed 
 in all inflammatory processes of the intestine — rest in bed, ice, in- 
 testinal irrigations, and opiates when the pain is very severe. Dur- 
 ing the first few days fever diet should be given ; in the follomng 
 days the diet is that of appendicitis after the acute inflammatory 
 s^nnptoms have disappeared (see page 154). After the exudate has 
 fully developed and acute symptoms have diminished, warm appli- 
 cations are in place. Pal particularly recommends hot flaxseed 
 poultices. We may later attempt to aid absorption of the remain- 
 der of the exudate by massage, and iodin and mercurial oint- 
 ments. When a fluctuating abscess develops, incision should not 
 be delaved. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 479 
 
 Repeated attacks of pericolitis or signs of chronic adhesive, in- 
 testinal inflammation maj require surgical treatment, but at present 
 the success of such operations is doubtful. 
 
 LITERATURE 
 
 1. Sahli. Verhaodl. des XIII. Congresses f. innere Medicin, Wiesbaden, 1895. 
 
 2. Harley. St. Thomas Hosp. Rep., vol. xi, p. 128, 1881. 
 
 3. Mariage. Contribution ä I'etude de I'intervention chirurgicale dans les in- 
 
 flammations pericoecales, These de Paris, 1891. 
 
 4. Curschmann. Verhandl. des XIII. Congresses f. innere Medicin, Wies- 
 
 baden, 1895, S. 291. 
 
 5. Lennander. Ueber Appendicitis, Wien u. Leipzig, 1895. (Cases 70 and 
 
 71) ; of. also Volkmann's Samml. klin. Vorträge, 1893, No. 175. 
 
 6. Porter. Medical News, p. 209, 1895. 
 
 7. Krönlein. Vereinigung Schweizer Aertzte, 1893. 
 
 8. Manley. Cited by Borchardt, Grenzgebiete, 1897, Bd. ii, S. 310. 
 
 9. Meusser. Ibid., Bd. ii, H. 3 u. 4. 
 
 10. Borchardt. Ibid., Bd. ii, S. 312. 
 
 11. Ribbert. Virchow's Archiv, Bd. cxxxii, 1893. 
 
 12. Maurin. These de Paris, 1890. 
 
 13. Bryant. Cited by Fowler, Ueber Appendicitis, Berlin, 1896. 
 
 14. F. von Sydow. Cited by Lennander, Ueber Appendicitis, p. 17. (See 
 
 ref. 5.) 
 
 15. Krausshold. Volkmann's Samml. klin. Vorträge, No. 191, 1881. 
 
 16. Renvers. Deutsche med. Wochenschr., 1891, S. 177. 
 
 17. Treves. Perityphlitis and its Varieties, London, 1897, p. 9. 
 
 18. Murphy. Cited by Treves, loc. cit. 
 
 19. Tavel u. Lanz. Ueber die Aetiologie der Peritonitis, Basel, 1893. 
 
 20. Eckehorn. Upsala Lackareforen, Foerhandlingar, 1893. 
 
 21. Morris. Centralblatt für Chirurgie, 1895, S. 609. 
 
 22. Karewski. Deutsche med. Wochenschr., 1897, Nos. 19-21. 
 
 23. Nothnagel. Darmkrankungen, S. 639. 
 
 24. Steiner. Zur pathologischen Anatomie des Wurmfortsatzes, Basel, 1892. 
 
 25. Zuckerkandl. Ueber die Obliteration des Wurmfortzsatzes beim Menschen, 
 
 Wiesbaden, 1894. 
 
 26. Talamon. MMecine moderne, 1896, No. 9. 
 
 27. Coley. New York Med. Rec, Feb. 15, 1896. 
 
 28. Small. Ibid., Sept. 10, 1898. 
 
 29. Golubeff. Berl. klin. Wochenschr., 1897, No. 1. 
 
 30. Penzoldt. Penzoldt-Stintzing's Handbuch, Bd. iv, S. 666. 
 
 31. Sonnenburg. Pathologie u. Therapie d. Perityphlitis, 2te Auflage, Leip- 
 
 zig, 1897. 
 
 32. Rotter. Ueber Perityphlitis, Berlin, 1897. 
 
 33. Kümmell. Ueber Perityphlitis, Leipzig, 1896. 
 
 34. Fowler. Ueber Appendicitis, Berlin, 1896, S. 68. [A Treatise on Appen- 
 
 dicitis, Philadelphia, 1901.] 
 
480 DISEASES OF THE INTESTINES 
 
 35. Edebohls. Amer. Journal of the Med. Sciences, May, 1894. 
 
 36. Richardson. Ibid., January, 1894. 
 87. Naumann. Hygeia, 1891. 
 
 38. Mannaberg. Centralbl. f. innere Medicin, 1894, No. 10. 
 
 39. von Hochstätter. Beiträge zur Chirurgie, Eestschrift für Billroth. Cited 
 
 by Nothnagel, Darmkrankheiten. 
 
 40. Caspersohn. Münch.med. Wochenschr. , 1893, No. 43. 
 
 41. Goldbach. Prager med. Wochenschr., 1898, No. 16. 
 
 42. A. Pick. Vorlesungen über Magen- u. Darmkrankheiten, Leipzig u. Wien, 
 
 1897, S. 58. 
 
 43. Monod et Vanvers. L'Appendicite, p. 83. 
 
 44. Bull. New York Med. Rec, 1894, vol. ii, p. 30. 
 
 45. Naunyn. Klinik der Cholelithiasis, Leipzig, 1893, S. 8G. 
 
 46. Curschmann. Deutsches Arch, für klin. Medicin, Bd. liii, H. 1 u. 3. 
 
 47. Sonnenburg. Deutsche med. Wochenschr., 1897, No. 40. 
 
 48. Sheild. Internat. Magazine, January, 1895. 
 
 49. Heubuer. Congress f. innere Medicin, München, 1895. 
 
 50. Rendu. Gaz. des Hopitaux, 1897, No. 40. 
 
 51. Nothnagel. Wiener klin. Wochenschr., 1899, No. 15. 
 
 53. Ewald. XXVIII. Congress d. deutschen Gesellsch. f. Chirurgie, 1899; 
 Berl. klin. Wochenschr., 1899, No. 34. 
 
 53. A. Fraenkel. Deutsche med. Wochenschr., 1891, No. 4. 
 
 54. WoUberecht. Inaug.-Diss., Berlin, 1891 ; Conrad, Inaug.-Diss., Berlin, 
 
 1898 ; Croizet, These de Lyon, 1893. 
 
 55. Gendron. These de Paris, 1885. 
 
 56. Terrillon. Cited by Fowler (see ref. 34). 
 
 57. Bull and Fowler. Cited by Sonnenburg (see ref. 31), 
 
 58. Nothnagel. Darmkrankheiten, S. 699. 
 
 59. E, Fränkel. Volkmann's Samml. klin. Vorträge, 1898, No. 339. (Here 
 
 will be found complete literature.) 
 
 60. Ewald, von Leyden's Handb. der Ernährungstherapie, 1808. Bd. ii. S. 366. 
 
 61. Ferrand. Cited by Grohe, p. 100. 
 
 63. Schede. Deutsche med. Wochenschr., 1893, S. 523. 
 
 63. Mikulicz. Grenzgebiete, 1898, Bd. iii, H. 1, S. 163. 
 
 64. Gerhardt. Ibid., Bd. i, H. 3, S. 354. 
 
 65. Wieland. Mittheil, aus Kliniken u. medicin. Instituten d. Schweiz, 1895, 
 
 Bd. i, H. 7. 
 
 66. P. Grawitz. Charite-Annalen, 1886, Bd. xi. 
 
 67. Sonnenburg. Grenzgebiete, 1898, Bd. iii, p. 1. 
 
 68. Kümmell. Berl. klin. Wochenschr., 1898, No. 15. 
 
 69. A. Mayor. Revue m6dic. de la Suisse Romande, 1893, No. 7, p. 431. 
 
 70. Galliard. Traite de medecine (Brouardel-Gilbert), T. iv, .p. 603, 1897. 
 
 Gaz. des Hopitaux, 1897, No. 7. 
 
 71. von Leube. Specielle Diagnose d. inneren Krankheiten, Leipzig, 1889, 
 
 S. 381. 
 73. Rosenheim. Pathologie u. TherajDie d. Krankheiten des Darms, 1893, 
 
 S. 457. 
 73. Windscheid. Deutsches Arch. f. klin. Medicin, 1889, Bd. xlv, S. 333. 
 
TYPHLITIS, PERITYPHLITIS (APPENDICITIS) 481 
 
 74. Eisenlohr. Deutsche med. Wochenschr., 1890, No. 44. 
 
 75. Fleiner. Miincli. med. Wochenschr., 1895, No. 42 et seq. 
 
 76. J. Pal. Wiener klin. Wochenschr., 1897, No. 18 u. 19. 
 
 [77. Hartley, F. Dennis's System of Surgery, Philadelphia, 1896, vol. iv, 
 
 p. 385, etc.] 
 [78. Kraft, C. Revue med. de la Suisse rom., Geneve, 1893, T. xiii, p. 764. J 
 [79. McCosh and Hawkes. Amer. Jour, of the Med. Sciences, 1897, vol. ii, 
 
 p. 885.] 
 [80. Johnson, M. M. Jour, of the Amer. Med. Assoc, 1896, vol. xxvi, p. 
 
 1203.] 
 [81. Gerster, A. G. New York Med. Jour., 1890, vol. liii, pp. 6-14.] 
 [82. Bayley, N. B. New York Med. Rec, 1895, vol. xlvii, p. 342. J 
 [83. Deaver, J. B. A Treatise on Appendicitis, Philadelphia, 1900, p. 246, etc.] 
 [84. Morton, T. G. Jour, of the Amer. Med. Assoc, 1888, p. 733.] 
 [85. McBurney, Charles. Dennis's System of Surgery, Philadelphia, 1896, 
 
 vol. iv, p. 415, etc.] 
 [86. Bull, W. T. Annals of Surgery, 1896, p. 764.] 
 [87. Senn, N. Jour, of the Amer. Med. Assoc, March 6, 1896.] 
 [88. Murphy, J. B. Medical News, January, 1895.] 
 [89. Mynter, H. Appendicitis and its Surgical Treatment, Philadelphia, 1897, 
 
 p. 143.] 
 [90. Fenger, C. Amer. Jour, of Obstetr., 1893, vol. xxviii, No. 2.] 
 [91. Fitz, R. H. Amer. Jour, of the Med. Sciences, 1886, pp. 321-846.] 
 [92. Sands, H. B. New York Med. Jour., 1888, vol. xlvii, pp. 197-205 and 
 
 607.] 
 [93. McBurney, Charles. Ibid., 1888, vol. xlvii, p. 719.] 
 [94. Weir, R. F. New York Med. Rec, 1889, vol. xxxv, p. 449.] 
 [95. Anders, J. M. Text-Book of the Practice of Medicine, Philadelphia, 
 
 1900, fourth edition, p. 812.] 
 [96. Lockwood, G. R. Manual of the Practice of Medicine, Philadelphia, 
 
 1896, p. 514.] 
 [97. Pepper, W. American Text-Book of the Theory and Practice of Medi- 
 cine, Philadelphia, 1894, vol. ii, p. 823.] 
 [98. Osier, W. The Principles and Practice of Medicine, New York, 1898, 
 
 third edition, p. 530.] 
 [99. Stein, R. Erfahrungen über Appendicitis. Deutsche med. Wochenschr., 
 
 1899, No. 27, S. 442.] 
 [100. Wiener, J. New York Med. Rec, May 19, 1900.] 
 [101. Einhorn, M. Diseases of the Intestines, New York, 1900, p. 220.] 
 [102. Deaver, J. B. Annals of Surgery, 1897, p. 325.] 
 [108. Tiffany, L. McL. Reference Handbook of the Medical Sciences, 1900, 
 
 vol. i, p. 428.] 
 [104. McNutt, W. F. Amer. Syst. of Pract. Medicine, New York and Phila- 
 delphia, 1898, vol. iii, p. 311.] 
 [105. Tyson, J. The Practice of Medicine, Philadelphia, 1900, p. 404.] 
 [106. McBurney, C. New York Med. Jour., 1889, pp. 676-684.] 
 [107. Lloyd, S. New York Med. Rec, Feb. 10, 1900, p. 228.] 
 [108, Meyer, W. Ibid., Feb. 29, 1896.] 
 
CHAPTER XX 
 
 DISEASES OF THE RECTUM'' 
 
 1. Proctitis 
 
 Peoctitis is an inflammation of the mucous membrane of the 
 rectum. It maj be acute or chronic, circumscribed or diffuse, pri- 
 mary or secondary. Its causes are but little understood. Undoubt- 
 edly catarrh of the rectum may be caused by entozoa, particularly 
 parasites of the large intestine (especially oxyuris vermicularis). 
 The theory of an infectious proctitis in pruritus ani, hemorrhoids, 
 foreign bodies, neoplasms, prolapsus ani, mechanical irritation, etc., 
 is very plausible. The view constantly expressed, even in the most 
 recent text-books and monographs, that there exists a connection 
 between proctitis and the abuse of drastic purgatives, does not seem 
 sufiiciently proved. Among numerous observations^ I have found 
 but one instance of this kind. It is doubtful whether cooling of the 
 pelvic region may produce proctitis. 
 
 The most frequent cause of primary proctitis is best sought for in 
 the composition and character of the evacuations themselves. These 
 may both chemically and mechanically, and under certain circum- 
 stances also bacteriologically, produce acute or chronic catarrh of 
 the rectum. The most frequent causes of secondary proctitis are 
 foreign bodies (fruit seeds, meat bones, fish bones, etc.), ulcerations, 
 neoplasms, hemorrhoids (so-called mucous hemorrhoids), prolapsus 
 ani, and rectal flstulee. Infectious diseases (gonorrhoea, diphtheria, 
 dysentery) are also looked upon as etiological factors. 
 
 As shown by recent investigations, gonorrhoeal proctitis may 
 occur both in men and women. In men it results only from 
 sodomy. In women it is very frequently due to the carrying over 
 
 * The scope of this work only allows of a description of those rectal diseases 
 which are particularly interesting to the medical practitioner. Malformations of 
 the rectnm, wounds, and foreign bodies will therefore not be discussed. Rectal 
 cancer is found in the chapter on Intestinal Cancer (page 318) ; the neuroses of 
 the rectum are found among the Intestinal Neuroses. 
 483 
 
DISBASES OF THE RECTUM 483 
 
 of gonorrhoeal secretions to the anal region, and, more rarely, to 
 extension of inflammation from the Bartholinian glands, recto- 
 vaginal fistulse, etc. Jullien^ and. Baer^ have recently investigated 
 the existence and. nature of rectal gonorrhoea. The latter investi- 
 gator found this disease in thirty-eight per cent of all women 
 infected with gonorrhcea, though rarely with any subjective symp- 
 toms. Gonococci are constantly found in these cases. Proctitis 
 occurs frequently in women with extreme uterine displacements. 
 Disease of the bladder and prostate may also produce proctitis. 
 Buche ^ states that gout may also cause proctitis, but the connec- 
 tion between these two diseases has not been proved. 
 
 Symptomatology and Diagnosis 
 
 The symptoms of proctitis vary with the severity and extent of 
 the process. In acute cases the inflammatory symptoms predomi- 
 nate ; in the milder ones there is a feeling of fulness and pressure 
 in the rectum. When the inflammation is severe the patients may 
 complain of marked boring pain, accompanied by annoying tenes- 
 mus. The pain may be limited to the rectum, or may radiate 
 toward the back, external genitals, bladder, and lower extremities. 
 The movements are generally voluntarily repressed, and every 
 effort at evacuation produces spasm of the sphincter and levator 
 ani. If, after continued tenesmus, the patient finally has an evacu- 
 ation, the latter is always small and is scarcely ever purely fecu- 
 lent, but is mainly bloody and muco-purulent. 
 
 In the severest cases the general health is usually involved. 
 The pain keeps the patients in bed, appetite and sleep are markedly 
 diminished, and from the very beginning fever is generally present. 
 The finger introduced into the rectum feels the contracted sphinc- 
 ter, which allows further introduction only after very careful and 
 gradual dilatation. The mucous membrane feels hot, oedematous, 
 and swollen. Even when most carefully performed, digital explora- 
 tion is very painful. On withdrawal, the finger is generally found 
 smeared with blood or blood mixed with pus. 
 
 In cTironic proctitis the symptoms are much less characteristic. 
 There is a feeling of straining and pressure, which in the presence 
 of impacted fseces may amount to tenesmus. Digital examination 
 is less annoying to the patient. The mucous membrane feels swol- 
 len, soft, and velvety ; it bleeds easily, and occasionally secretes pus. 
 Sometimes the swollen solitary follicles may be felt as prominences 
 the size of millet seeds. Defecation may be painful. The stools 
 
484 DISBASES OF THE INTESTINES 
 
 are often mixed with blood or bloody mucus ; in isolated cases (e. g., 
 rectal gonorrhoea) thej may consist entirely of pus. In acute as 
 well as in chronic proctitis, a paralysis of the sphincter may result 
 from the marked and deep infiltration of the inflammatory process, 
 60 that there is a continual discharge of bloody pus or muco-pus. 
 
 Where the symptoms are well defined, the diagnosis of acute 
 proctitis is usually easy and may generally be made without digital 
 examination. For the diagnosis of the etiology digital exploration 
 is necessary. It should be performed with the greatest caution- 
 A very thin suppository of opium and cocain or eucain should be 
 previously introdnced. In place of this we may employ a collaps- 
 able tin tube to which a short piece of rubber tubing is attached. 
 The latter is well oiled and passed into the rectum. The collaps- 
 able tube is then slowly squeezed and some of the ointment thus 
 directly introduced into the rectum. The introduction of a specu- 
 lum, especially without narcosis, is an unnecessary procedure. 
 Fever, tenesmus, and bloody, mucoid, or purulent defecations with 
 very little faecal matter are also of diagnostic importance. 
 
 The diagnosis of chronic proctitis is best made by digital and 
 speculum examination. Thus foreign bodies producing this affec- 
 tion can scarcely escape discovery. Under certain circumstances 
 the diagnosis of the nature of the process may be very difficult. 
 If ulcerations are present, we must consider especially the tuber- 
 cular, syphilitic, gonorrhoeal, and stercoral ulcers. These must be 
 differentiated by clinical and, more particularly, by bacteriological 
 examination (gonococci, tubercle bacilli). 
 
 If no sufficient explanation for the occurrence of the disease is 
 found in the rectum itself, the etiology must be sought for by 
 examination of the remaining pelvic organs — in men, the bladder ; 
 in women, the genitals. 
 
 Teeatjment 
 
 Depending upon circumstances, the treatment of acute proctitis 
 should be either symptomatic or radical. The latter plan is appli- 
 cable when foreign bodies, inspissated faeces, diseases of the neigh- 
 bouring organs, etc., are the cause of the proctitis. Symptomatic 
 treatment must take into account those basic principles which 
 apply to acute inflammations of the intestinal mucous membrane — 
 above all, absolute rest and immobilization of the rectum. The 
 abdominal or lateral posture is often recommended for the relief 
 of the pain. If constipation is not the cause of the lesion, it is 
 
DISEASES OP THE RECTUM 485 
 
 advisable during the acute inflammatory stage to keep the bowels 
 constipated by opiates, given either per mouth or rectum. It is also 
 necessary to decrease the amount and kind of the nourishment taken 
 — an easy task in view of the diminished appetite of these patients. 
 When the inflammatory symptoms have subsided the bowels may be 
 moved by castor oil or by enemata of olive oil. After this expect- 
 ant treatment has been applied for eight or ten days, the symptoms, 
 in the vast majority of cases, disappear. In complicated cases the 
 process extends, the suppuration spreads to the periproctitic tissues, 
 and a periproctitis results (see below). 
 
 Tenderness and tenesmus are generally well controlled by the 
 above-mentioned narcotics. Leeches applied in the neighbourhood 
 of the anus are also useful, and often curative ; their action is 
 increased by warm sitz baths. 
 
 Only after the acute symptoms have subsided should local treat- 
 ment be begun, if at all. The utmost care must be exercised in the 
 choice of our remedies. The most appropriate treatment is rectal 
 irrigation with warm decoctions of chamomile or linseed, contain- 
 ing a few drops of laudanum. Where there is copious purulent 
 secretion, we may try irrigations with very dilute sohitions of 
 nitrate of silver (0.5 to 1 gram in 1,000); if these cause severe 
 reaction, they should be followed by an irrigation with a weak salt 
 solution. 
 
 The management of chronic proctitis differs somewhat from the 
 above. The first and leading principle is the recognition and treat- 
 ment of the primary disease. Symptom atically, we must regulate 
 the bowels, and keep the parts as clean as possible through copious 
 rectal irrigations. It is immaterial whether for this latter purpose 
 (of cleanliness) we use permanent rectal drainage with the apparatus 
 proposed by Hofmokl (with which, moreover, there seems to have 
 been no extensive experience), or the usual double-current cathe- 
 ters, or, as described in the General Division, a simple catheter with 
 a T tube similar to that used in stomach lavage. According to 
 my own observations, two, or at most three irrigations per day are 
 sufläcient. The permanent introduction of even a soft instrument 
 is so uncomfortable that patients are seldom willing to undergo this 
 procedure. 
 
 We have a large variety of antiseptics and astringents to choose 
 
 from : alum, or its double salt, aceto-tartrate of aluminium (2 to 3 
 
 grams per 1,000), sulphate and sulpho-carbolate of zinc (1 to 2 
 
 grams per 1,000), tannic acid (3 to 5 grams per 1,000), nitrate of 
 
 33 
 
486 DISEASES OP THE INTESTINES 
 
 silver (0.5 to 1 gram per 1,000), etc. A change of solutions some- 
 times seems to produce a more rapid cure. 
 
 These irrigations are undoubtedly the most effectual of our 
 therapeutic measures ; we may, however, obtain favourable results 
 with suppositories containing the above astringents. An ointment 
 syringe has been recommended for the same purpose, but in view 
 of the application of ointments by the collapsable tin tube (see 
 page 484), which has given me the most satisfaction, an "oint- 
 ment syringe " seems superfluous. We may in a measure conduce 
 to cleanliness, and thus indirectly to the cure of the disease, by 
 appropriate medicated sitz baths and by anal douches. In England, 
 internal medication vdth balsam of copaiba, extract of cubebs, or 
 oil of turpentine is highly recommended. I have not found it suc- 
 cessful in my cases. The use of sea baths and other balneothera- 
 peutic measures is practised by balneologists ; but thus far no con- 
 vincing proofs of their good effects have been adduced. 
 
 Some cases, especially resistant ulcerative and gonorrhceal proc- 
 titis, are extremely obstinate to all internal therapeutic measures. 
 
 2. Periproctitis 
 
 This is an inflammation of the loose cellular tissue about the 
 rectum. Since this tissue is continuous with the fatty tissue which 
 fills the ischio-rectal fossa on both sides of the termination of the 
 rectum, between the levator ani and the sacral origin of the gluteus 
 maximus muscles, the bulbous urethra and the perineal fascia, it is 
 evident that local purulent processes may spread extensively. The 
 etiological factors are the same as those already described under proc- 
 titis. Besides these, periproctitis may also, though now very rarely, 
 occur after opei'ations on the rectum which have not been suffi- 
 ciently aseptic. Traumatism is also regarded as a cause of periproc- 
 titis, particularly since Cruveilhier has described a very marked case 
 of this kind, resulting from a " fall on the gluteus." As far as I 
 can learn, modern literature — which certainly contains abundant 
 cases of accidents — does not present any instance similar to this. 
 
 The inflammatory process may be either acute or chronic, cir- 
 ' cumscribed or diffuse, the acute diffuse type being the most fre- 
 quent. 
 
 From the seat of infection, the pus burrows through the cellu- 
 lar interstices and extends into the ischio-rectal fossa. The perineal 
 fascia offers a slight barrier to the spread of the process, so that the 
 anal region is generally affected later than the upper rectal seg- 
 
DISBASES OF THE RECTUM 487 
 
 ment, about whicli the pus may spread freely in all directions. 
 Under these circumstances the abscess may rupture either exter- 
 nally or internally, and thus produce fistulse {q. v.). 
 
 Symptomatology and Diagnosis 
 
 The symptoms of periproctitis point directly to the seat of the 
 lesion. In acute periproctitis the most persistent subjective symp- 
 tom is the severe pain, and a feeling of fulness and tension in the 
 anus and anal region. The pain becomes unbearable duriug defe- 
 cation, so that patients voluntarily retard this act as much as pos- 
 sible. The disease generally begins with a marked chill, accom- 
 panied by high fever. When the process is very extensive — an 
 occurrence occasionally found in cases improperly treated — the fever 
 becomes septic in character. As might be expected, the general 
 health soon suffers ; the patients are considerably weakened by the 
 fever, anorexia, and loss of sleep, and present the picture of an 
 acute infectious disease. 
 
 The objectwe symptoms are usually very evident. There is 
 a more or less hard, reddened, sensitive infiltration about the rec- 
 tum. The introduction of the finger causes severe pain, and re- 
 veals a hot, swollen mucous membrane, which nai-rows the lumen 
 of the rectum. Bimanual examination elicits fluctuation relatively 
 early. In women a vaginal examination may also be made. 
 
 In chronic cases the symptoms are less defined. The abscess 
 may rupture without the patient even knowing of the existence of 
 a periproctitis or proctitic suppuration. In other cases, however, 
 pain during defecation, uncomfortable sensations in the rectal re- 
 gion, and a muco-purulent or bloody discharge indicate the char- 
 acter and seat of the lesion. 
 
 The diagnosis ought present no difiiculty. In every case of 
 periproctitis digital examination of the rectum should be made. 
 In this manner we may not only discover the cause of the disease — 
 e. g., foreign bodies — but its course may be favourably influenced. 
 When the sensitiveness is very marked we should always make a 
 digital examination in the manner previously described. ]S"arcosis 
 is generally unnecessary. If in doubt, we may wait till the time 
 of operation, when the whole field can be carefully examined. We 
 have already pointed out the importance of the bimanual examina- 
 tion (best in the knee-chest position) for eliciting fluctuation. 
 
 The diagnosis of chronic periproctitis is attended by much less 
 pain for the patient than the acute. A speculum may be employed. 
 
488 
 
 DISEASES OP THE INTESTINES 
 
 As in proctitis, so here also it may be difficult to establisli the cause 
 of the affection (ulcers, fistulse). In the section on Rectal Ulcers 
 we shall discuss the symptoms of diagnostic importance. 
 
 Treatment 
 
 The treatment is practically surgical. The well-known anti- 
 phlogistic remedies (ice and cold applications to the anal region, 
 leeches) are to be applied only in the beginning of the affection — 
 i. e., until the first signs of fluctuation appear. Pain is controlled 
 by injections of morphin, better by opium suppositories (each con- 
 taining 0.03 gram of the extract, introduced every two to three 
 hours), or by opiates given internally (tinct. opii, 10 to 15 drops 
 t. i. d.). 
 
 When fluctuation is present the abscess should be opened as 
 soon as possible. The teehnic of this procedure is to be found in 
 works on surgery. 
 
 3. Rectal Fistulse 
 
 Where an inflammatory process of the rectal mucous membrane 
 ruptures externally and produces a pervious canal, we speak of it 
 
 as a rectal fistula. This is the so- 
 called complete fistula. Where the 
 canal does not extend through to the 
 skin, we have an incomplete inter- 
 nal fistula. Whei'e periproctitic and 
 ischio -rectal abscesses perforate ex- 
 ternally, we have an incomplete 
 external fistula. The accompanying 
 illustrations (Figs. 42, 43, and 44), taken from Esmarch's excellent 
 work ^, illustrate these conditions. 
 
 The causes of fistulse are similar to those of proctitis and peri- 
 proctitis. Ulcerations or abscesses slowly extend through, and 
 
 Fig. 42. — Complete Kectal Fistula, 
 (von Esmarch.) 
 
 Fig. 43. — Incomplete Internal 
 Eectal Fistula. 
 
 Fig. 44. — 1^ complete External 
 Eectal Fistula. 
 
 finally perforate the different layers of the rectum. The process 
 may develop very acutely, and present the characteristic features 
 
DISEASES OP THE RECTUM 489 
 
 of purulent proctitis already described, or it may be very slow and, 
 as mentioned, proceed without the patient's knowledge. Accord- 
 ing to Allingham's extensive statistics, a large percentage of fistulse 
 (fourteen per cent) are tubercular. It is very important for the 
 diagnosis whether the fistula occurs in persons who are otherwise 
 well and free from hereditary taint, or whether the fistula is a 
 complication of a general, especially pulmonary, tuberculosis. For 
 the differential diagnosis and for purposes of treatment a careful 
 general examination is required. 
 
 Symptomatology and Diagnosis 
 
 If symptoms of an acute proctitis or periproctitis have been 
 present, we should search for rectal fistulse. The diagnosis is more 
 difficult when the fistula develops without any previous symptoms. 
 It very frequently happens that patients are only accidentally 
 prompted to have the rectum examined after the disease has lasted 
 a long while. Some discomfort, or a feeling of slight fulness 
 in the rectal region before or after defecation, is generally all 
 that is complained of. When the fistula is a blind one, and the 
 secretions cannot escape, these symptoms may be somewhat in- 
 creased in severity. There is a sensation of heat in and around 
 the rectum ; the patient has a feeling of painful tension, or even of 
 tenesmus. 
 
 The characteristic objective symptom which disquiets the patient 
 is the discharge of greater or less quantities of pus from the exter- 
 nal or internal fistulous orifice. The pus is generally thin and 
 serous, and is rarely mixed with blood or faeces. The discharge 
 may cause an annoying intertrigo. Patients occasionally declare 
 that they pass gas through the fistula. They are weakened by 
 the continual suppuration, feel tired, dispirited, and unwilling 
 to work. 
 
 In simple cases the diagnosis is easy; in complicated cases it 
 may be so difficult that the kind and extent of the fistulous tract 
 can be recognised only when the patient is under general ansesthesia. 
 A careful examination of the anal region and rectum should be 
 made. The external orifice of the fistula may be variously situated. 
 It is D-enerally in the direct vicinity of the anus, but may be at quite 
 some distance therefrom — e. g., at the perinseum or the gluteal promi- 
 nence. We occasionally meet with several fistulse ; in fact, the 
 whole region of the anus may be perforated by numerous orifices. 
 The blind external orifice may present a pouting mouth filled with 
 
490 DISEASES OF THE INTESTINES 
 
 granulations, or it may be a small, barely visible furrow bidden 
 between tbe anal folds, and scarcely admitting a small probe. The 
 internal opening is I'ecognised by its small indurated prominence, 
 or there may be only a feeling of diffuse infiltration, or no appreci- 
 able chanp-e in the mucous membrane. In rare cases there is an 
 ulceration at the internal orifice of the fistulous tract. Complete 
 fistulse are recognised by passing probes through the fistulous canal, 
 thus disclosing both its orifices. The best probe for this purpose is 
 the flexible one of zinc recommended by Esmarch ; this is gently 
 pushed forward, without the use of any force. Quenu and Hart- 
 mann* recommend thin, soft bougies, like those used in urethral 
 catheterization. The left forefinger is introduced into the rectum, 
 so that it may follow the direction of the instrument, and thus dis- 
 cover a possible internal opening. 
 
 If this does not succeed there may still be a complete fistula, for 
 the probe may have followed a false passage. In such cases a 
 speculum is introduced and a good light thrown into the rectum, 
 and milk or a carmine or eosin solution is injected into the external 
 orifice of the fistula. In this connection it is of practical importance 
 to know that the internal orifice is usually either in the region of 
 the sphincter or directly above it, and that only very rarely is it 
 higher than 5 centimetres above the anal orifice (von Esmarch). In 
 this manner, we may, by careful and perhaps repeated examinations, 
 recognise a complete fistula. This also applies to the incomplete 
 external fistulse. The diagnosis of an incomplete internal fistula is 
 sometimes much more diflicult. The finger when introduced may 
 encounter a small indurated, buttonlike prominence, which can, 
 however, quite easily escape palpation. At all events, where other 
 symptoms indicate fistula, we should not rest until a satisfactory ex- 
 planation for the symptoms has been found. In complicated cases 
 it will be necessary to make a careful examination under nai'cosis. 
 The diagnosis of rectal fistula alone is not sufiScient. As already 
 mentioned, we must determine its nature. We should search par- 
 ticularly for luetic and tubercular symptoms, which may change 
 both prognosis and therapy. 
 
 Treatment 
 
 The treatment of rectal fistulse is now purely surgical. In pre- 
 antiseptic times, when operative treatment of these conditions was 
 a dangerous proceeding, conservative treatment was attempted. 
 The oldest method, known even to Hippocrates and occasionally 
 
DISEASES OF THE RECTUM 49 1 
 
 used to this day, is ligation of the complete or artificially completed 
 fistula. The other methods — scarification, injections of iodin, nitrate 
 of silver, alum, etc. — are all obsolete. With modern asepsis and 
 antisepsis, the operation for fistula has lost all danger. The ad\dsa- 
 bility of operation is doubtful only when there is advanced tubercu- 
 losis, and when other tuberculous ulcerations exist in the rectum. 
 In these cases, despite splitting of the fistulous tract, the process 
 steadily progresses. The same caution also applies to carcinomatous 
 fistulse. In both these latter instances we shall have to limit our- 
 ■selves to symptomatic treatment, particularly to copious irrigation 
 of the diseased rectum. A description of the technic of the oper- 
 ation for fistula in ano does not belong to this work. 
 
 4. Fissures and Spasm of the Anus 
 
 Small tears or excoriations at the border of the anus may pro- 
 duce painful reflex spasms of the anal muscles. In the chapter on 
 Intestinal I^euroses we shall see that spastic conditions of the anus 
 may also be caused by hysteria, neurasthenia, or diseases of the cen- 
 tral nervous system. Fissures are more or less extensive, generally 
 oval losses of substance, which are usually superficial, but Avhich 
 may also aifect the deeper muscular tissues. They are often found 
 at the posterior commissure, and less frequently laterally, anteriorly, 
 or in the interior of the rectum. After having lasted a long time, 
 they increase in size, become indurated, and have a dirty gray base. 
 Fissures are generally idiopathic, but may occasionally be pro- 
 duced by gonorrhcea, syphilis, tuberculosis, hemorrhoids, etc. They 
 occur in both sexes, more often in women than in men, and are 
 not infrequently found in early childhood. 
 
 Habitual constipation predisposes to fissures, particularly when 
 there is a disproportion between the calibre of the faeces and the 
 anal opening. A soft, irritable skin also favours their development. 
 These conditions are more often present in women, hence the 
 greater frequency of fissures among the latter. According to von 
 Esraarch,* fissures frequently occur in women who suffer from ante- 
 version or retroversion of the uterus. The act of parturition, dur- 
 ing which the rectal region and anus are enormously stretched, may 
 easily produce fissures. 
 
 * Loc. cit., p. 148. 
 
492 DISEASES OP THE INTESTINES 
 
 Symptomatology and Diagnosis 
 
 Anal spasm is recognised by tlie paroxysmal pains which accom- 
 pany defecation. The patients liken them to that of a red-hot iron 
 boring through the anus. The pain may be limited to the anus, or 
 radiate to the bladder, the external genitals, or the legs. The pa- 
 tients try to suppress defecation and the passing of flatus, so that 
 these cases sometimes have marked abdominal distention. Rest 
 relieves the pain ; motion, or even sitting for a long time, may in- 
 crease it. 
 
 The fissure can be discovered by careful inspection or digital 
 exploration of the rectum. Where digital examination is very pain- 
 ful, or where the finger can with difficulty be passed through the 
 anal orifice, it is better to previously relieve sensitiveness by the 
 introduction of a thin suppository of opium and cocain, or by 
 Cocain ointment spread over the rectal mucous membrane with the 
 previously mentioned collapsable tin tube. According to von Es- 
 march, a small polypoid tumour or an edematous fold of the skin 
 of the anus is often found at the external extremity of the fissure. 
 The fissure becomes visible only when this growth or fold is drawn 
 aside. I can recall but one such instance. For the purpose of 
 more thorough examination, surgeons (von Esmarch and others) 
 advise narcosis. Personally I have always found the above-men- 
 tioned methods sufficient. It appears to me that narcosis is only 
 indicated in those rare forms in which the fissure is situated higher 
 up. It is of diagnostic importance to determine whether the fissure 
 is idiopathic, or secondary to gonorrhoea, lues, tuberculosis, or hem- 
 orrhoids. 
 
 Treatment 
 
 Prophylaxis is of the first importance. In those suffering from 
 habitual constipation, that condition must be treated upon the prin- 
 ciples already enunciated (see chapter on Constipation). The tis- 
 sues of the anal and rectal regions must be hardened by washing 
 with solutions of tannin and alum, or with soaps containing these 
 substances, and by sitz baths. The patients must avoid severe strain- 
 ing durino; defecation. 
 
 When a fissure has been discovered, the anal region must as far as 
 possible be immobilized ; the patient should remain in bed till cured. 
 A second preliminary condition to recovery is the artificial preven- 
 tion of defecation (see page 157). The patients are put upon a fluid 
 
DISEASES OF THE RECTUM 493 
 
 diet, and get ten drops of tincture of opium three times daily. Of 
 late I have returned to the use of opium suppositories. If the fis- 
 sure can be seen, it is best dusted with some dry powder (e. g., airol, 
 Xeroform, iodoform, orthoform, calomel, etc.), without directly 
 touching the fissure with the fingers. I have seen more harm than 
 good from washing with antiseptic solutions. 
 
 After a week of this treatment I give the patients a large dose 
 of castor oil, and advise them to attempt to pass stool only when 
 they feel that the faeces have become thoroughly softened. Under 
 all circumstances straining must be avoided. The first evacua- 
 tion is usually painless. Sometimes the entire treatment must be 
 repeated a second or even a third time. I can warmly recommend 
 this method, although some individuals cannot retain their stools 
 for a week ; in these treatment is generally unsuccessful. Of 12 
 cases of fissure whose histories I possess, 6 recovered within eight 
 to ten days, 2 were cured in three weeks, 2 in four weeks, and 
 only 2 had to be operated, I believe it incorrect to regulate the 
 bowels by purgatives. 
 
 Local treatment with various astringent, cauterizing, and anses- 
 thetic agents has been recomuiended. The most frequently used is 
 cauterization with the pure nitrate of silver, or with a ten-per-cent 
 solution of the same. Allingham ^ employs the following : 
 
 Calomel 0.25 
 
 Pulv. opii 0.10 
 
 Ext. bellad 0.10 
 
 Ung. sambuci 5,00 
 
 m 
 
 This ointment is to be frequently spread over the entire anal 
 surface. Yan der Willigen ^, and recently Conitzer ', recommend 
 pencilling twice daily with a brush dipped in pure Ichthyol. I have 
 twice seen good results from this method, but in a third advanced 
 case of fissure it was useless. Cases which are not cured by any of 
 the above methods require radical treatment. A Ijloodless method 
 consists in stretching and massaging the anal sphincter under narco- 
 sis. This procedure, which is often employed in France, and is also ^ 
 highly recommended by Allingham^ and von Esmarch V^ i"fii*ely 
 used in Germany. The most certain method is the splitting of the 
 fissure with a knife or thermocautery [Paquelin], after which heal- 
 ing is usually quite rapid. 
 
494 DISEASES OF THE INTESTINES 
 
 5. Ulcers of the Rectum 
 
 Ulcers of the rectum occur under the most varied conditions — 
 primary, secondary, Kmited to the rectum, or involving other seg- 
 ments of the large intestine. 
 
 Primary rectal ulcers are traumatic (from enemata or foreign 
 bodies), gonorrhoeal, and syphilitic (both from sodomy). Gonor- 
 rhceal and syphilitic ulcerations may also develop indirectly (Bar- 
 tholinitis, recto-vaginal fistula, breaking down of large condylomata, 
 etc.). Among secondary ulcerations are the tubercular, which always 
 result from auto-infection. Finally, there are the dysenteric and 
 follicular ulcers, which also occur higlier up in the intestines. These 
 various types require a brief individual description. 
 
 1. Dysenteric ulcers result from chronic dysentery, ulcerative 
 destruction of the rectal mucous membrane, or from a follicular 
 catarrh. By destruction of the follicles and confluence of the 
 destroyed areas there gi-adually develop deep and extensive ulcera- 
 tions. The rectal lesion is always secondary to involvement of 
 other portions of the large intestines. The ulcers may extend into 
 the serous coat, and produce perforative peritonitis, abscess, and 
 fistula, or subsequent cicatricial stenosis. 
 
 2. Follicular ulcers develop in the rectum and large bowel 
 where there is catarrh with marked swelling of the follicles. When 
 these follicles rupture, a small flat ulcer results. Several such 
 ulcers coalesce and produce larger ulcerations, which, by the persist- 
 ence of the catarrh or through other unfavourable circumstances, 
 may become quite deep, and even rupture into neighbouring organs. 
 As von Esmarch ^ states, these ulcers are sluggish in character, heal 
 badly, and lead to the formation of cicatrices and polypi. Accord- 
 ing to this authority, most cases occur toward the end of exhaust- 
 ing diseases or after severe injuries and operations, and produce 
 death by colliquative diarrhoeas. 
 
 Follicular ulcers are frequent in children with chronic diar- 
 rhoea. I have never observed this form of ulceration in adults, not 
 even in those suffering from severe catarrh of the large intestine. 
 On the other hand, I have repeatedly seen chronic follicular swell- 
 ing, with pain and other disturbances, in catarrh of the large intes- 
 tine and rectum. 
 
 3. Tuhercular ulcers (see Fig. 45). These result from swal- 
 lowed tubercular sputum, from tubercle bacilli which have reached 
 the rectum by means of the blood and lymph channels, or from 
 
DISEASES OF THE RECTUM 
 
 495 
 
 mechanical insults to the anus or rectum. In tlie case from which 
 the accompanying illustration is taken, the probable cause of the 
 lesion was continued contact of the anal mucous membrane with 
 mechanically and chemically irritating evacuations. The patient 
 suffered from intestinal tuberculosis. The ulcers are formed by the 
 breaking down of tubercular nodules (lenticular ulcer). Similar to 
 tubercular ulcers of the rest of the intestine, those of the rectum are 
 
 PlO. 45. TUBEKOULAK AnAL AND EeCTAL UlCEE, WITH IIeMOKKIIOIDAL NuDULE. 
 
 (Original observation.) 
 
 characterized by a circular arrangement. ISTear the ulcers fresh 
 tubercular, grayish, globular nodules occasionally develop, undergo 
 the same necrotic process (softening, fatty and caseous degenera- 
 tion), and produce secondary tubercular ulcers. We have already 
 mentioned that tubercular ulcerations tend to spread, and to cause 
 periproctitis and rectal fistulse. 
 
 4. Syphilitic ulcers of the rectum occur in the most varied 
 
496 DISEASES OF THE INTESTINES 
 
 forms. They are found as soft chancres (primary, from coitus 
 per anum ; secondary, from infection by chancroidal secretion) or 
 as hard chancres, either as a primary infection (very rare), or more 
 frequently by the breaking down of broad condylomata in the 
 neighbourhood of and spreading toward the anus. They may occur 
 as gummatous ulcers. Gummata may be found in various stages : 
 true gumma, degenerated gumma, superficial ulcer, or scar tissue 
 from old healed ulcerations. Frequently we can also distinguish 
 the more recent processes (rounded nodules with beginning ulcera- 
 tive degeneration, and containing necrotic, brownish-red masses) 
 from the older, deep, irregular ulcerations. 
 
 In constitutional syphilis there may be a proliferation of the 
 deep layers of the connective tissue, a condition von Esmarch ^ des- 
 ignates as gummatous or syphilitic polypi. Unlike true rectal 
 polypi, these do not originate in the mucous membrane, but from 
 a proliferation of the submucous, submuscular, or subserous cellular 
 tissue. Yirchow has therefore called them granulation tumours 
 (granulomata). When these heal, cicatrices, which may produce 
 extensive stenosis, develop ; these will be described later. In 
 marked cases the entire rectum is changed into a rigid, immovable 
 funnel with immensely thickened walls. If the lowermost portion 
 of the rectum is affected, complete destruction of the sphincter 
 may result. 
 
 5. Gonorrhmal ulcers. Opinion is divided as to whether rectal 
 ulcers may be gonorrhceal or not. While Jullieu^ believes in their 
 existence, Baer^ considers them complications (post-gonorrhoeal 
 ulcerations), particularly since no gonococci have been demonstrated 
 in the excised portions. According to Baer, these ulcers are usually 
 situated upon the anterior or posterior wall of the anal orifice upon 
 a protrusion of its mucous membrane or of a hemorrhoidal fold. 
 The surface of the ulcer is always directed toward the lumen of the 
 rectum. 
 
 Symptomatology and Diagnosis 
 
 The first symptom observed in uncomplicated ulcer of the rec- 
 tum is a change in the evacuations. The stools are generally thin 
 and fluid, are mixed with blood and pus, have a very fetid odour, 
 and may consist only of blood and pus. In addition, there is more 
 or less marked tenesmus and pain radiating to the bladder, back, 
 legs, and genitals. The subjective symptoms may be absent, or 
 may not be prominent. As a result of hemorrhage and suppura- 
 
DISEASES OF THE RECTUM 497 
 
 tion, and occasionally from fever, the patients lose considerable 
 flesh and strength. From the symptoms above enumerated we may 
 assume the presence of ulcerative processes in the rectum. For 
 positive diagnosis a local examination is, however, necessary. 
 
 Careful digital exploration, wherel)y the situation and nature 
 of the ulcers can be fairly well determined, is the best method of 
 examination. It is also desirable to inspect the mucous memljrane 
 by means of a speculum, the rectum being meanwhile irrigated 
 with water. In this manner the diagnosis of tubercular, syphilitic, 
 or catarrhal ulceration can usually be made although great diflicul- 
 ties may be encountered, 
 
 A thorough history and careful study of the other clinical symp- 
 toms are of the utmost importance, particularly in the differentiation 
 between syphilitic, dysenteric, and tubercular ulcers. We must 
 always search for other signs of syphilitic or tuberculous disease. 
 When ulcers appear gonorrhoeal, the secretion should be examined 
 for gonococci. Similarly the tubercle bacillus must be looked for. 
 Small portions of the ulcers may have to be excised for microscop- 
 ical examination, although positive results are not always obtained. 
 Since ulcerations may also occur from ruptured al)scesses (salpin- 
 gitis, Bartholinitis), vaginal examination must never be omitted. 
 
 Treatment 
 
 The treatment of ulcers of the rectum is very tedious. The 
 reason is evident. The rectum offers the best chances for the 
 propagation of ulcerative processes, but the worst for their cure. 
 The long; list of remedies that have been recommended bears out 
 the above assertion. 
 
 Ä priot'i, the aim of our therapy would seem simple enough — 
 viz., wherever possible, to eradicate the underlying cause. Where 
 this is not possible, energetic local treatment should be instituted. 
 
 Prophylactic treatment is often employed in tuberculosis and 
 syphilis, but, unfortunately, with little success. The chief cause 
 for this is that patients regard the first phases of their rectal affec- 
 tion too lightly, and therefore present themselves for treatment 
 when the disease is already far advanced. In tubercular rectal 
 ulceration the patients usually have ])ulmonary or intestinal tuber- 
 culosis, so that treatment will be of little avail. 
 
 The conditions are more favourable in ulcerating chancres; 
 these may be healed by appropriate anti-syphilitic treatment (Köb- 
 ner). Although occasionally cured by enei-getic use of iodids by 
 
498 DISEASES OF THE INTESTINES 
 
 mouth and rectum, gummatous ulcers do not as a rule respond well 
 to treatment. 
 
 The treatment of gonorrhceal ulcers is the same as that of anal 
 gonorrhoea — i. e., astringent and antiseptic solutions. According 
 to Baer and others, the results are not more satisfactory than in 
 chronic urethritis. 
 
 SymptomaÜG treatment should be directed toward the increase 
 of general health and strength and the regulation of the bowels. 
 The most difficult therapeutic problem is the cure of the ulcers by 
 local treatment. The number of preparations recommended for 
 this purpose is so large that we can only mention the most impor- 
 tant and usual ones. These include nitrate of silver, sulphate of 
 zinc, tannin, aceto-tartrate of aluminium (Boas), zinc-chlorid solu- 
 tions, and carbolic acid. They are best applied in the form of rec- 
 tal irrigations. AUingham recommends the use of soft ointments 
 applied by a specially constructed ointment spray. 
 
 The difficulty in local treatment lies in the fact that in advanced 
 cases constrictions and dilatations almost always prevent remedial 
 agents from reaching the main seat of the disease. Surgical meth- 
 ods have therefore been attempted. In marked stricture of the anal 
 orifice, in order to render the diseased area more accessible, poste- 
 rior sphincterotomy has been proposed. In ulcerations higher 
 up, the most appropriate treatment would seem temporary colos- 
 tomy, mth subsequent local treatment through the intestinal fistula. 
 Except in cases of stenoses (see below), but little experience with 
 this operation has been gathered. When, as in rectal stenosis, the 
 disease is very extensive and obstinate, and remains uninfluenced 
 by all palliative measures, the only remaining procedure is resec- 
 tion of the ulcerated portion. 
 
 6. Strictures of the Rectum 
 
 The causes may be external or internal. External conditions 
 are disease of neighbouring organs, neoplasms, plastic exudates, and 
 vesical calculi. Internal stricture may be produced by simple 
 obstruction of the lumen of the rectum, by fsecal masses, foreign 
 bodies, enteroliths, prostatic hypertrophy, and tumours, or by 
 inflammatory conditions of the rectum itself. The latter are 
 undoubtedly the most frequent causes of stricture, and therefore 
 merit thorough discussion. 
 
 All lesions of the rectum which heal by granulation must pro- 
 duce narrowing of its lumen. Wherever a stricture has developed, 
 
DISEASES OF THE RECTUM 499 
 
 •its increase is favoured by continued irritation of the adjacent 
 tissues or by an extension of the underlying disease. 
 
 We have previously described (page 494) the various kinds of 
 ulcerations of the rectum. Syj)hilitic and dysenteric ulcers are far 
 more apt to produce extensive stenosis than are tubercular. To 
 what extent gonorrhoeal processes produce stenosis is still a dis- 
 puted question. 
 
 No doubt there is an inflammatory rectal stenosis similar to 
 inflammatory pyloric hypertrophy or to the so-called multiple 
 submucous sclerosis of the French. In his latest work, Bushe * 
 describes a very characteristic case. Rieder^ also believes in the 
 existence of a chronic inflammatory proctitis with destruction of 
 the mucosa and proliferation of the submucosa and muscularis. 
 
 The stricture is usually situated directly above the anal orifice, 
 but may even be as high up as the sigmoid flexure. (Several years 
 ago I saw an instance of this latter condition in a young woman. 
 The etiology of the case could not be determined.) The strictured 
 segment may be either straight, corkscrew shaped, or arborescent. 
 The wall of the canal may consist of thick, indurated mucous mem- 
 brane without ulcers, or there may be numerous primary or sec- 
 ondary erosions. In the most complicated cases all possible patho- 
 logical changes may be combined— »viz., proctitis, periproctitis, fis- 
 sures, hemorrhoids, fistulse, etc. 
 
 The greatest number of rectal stenoses are found in women with 
 present or previous syphilitic symptoms. In the former instance 
 syphilitic ulcers or gunmiata may be found on the genitals and in 
 the rectum, or in the rectum alone. These conditions are not dif- 
 ficult to diagnosticate, although the manner in which the syphilitic 
 virus infects new areas may not be apparent. According to Quenu 
 and Hartmann \ the lower group of rectal veins anastomose directly 
 with branches of the external pudendal, which latter originate in 
 the posterior commissure of the vulva, the chief seat of syphilitic 
 infection. 
 
 The question of post-syphilitic strictures has caused very much 
 discussion, and at the present time all etiological factors have not 
 been agreed upon. We can, however, safely say that syphilis is 
 undoubtedly the cause of a large number of rectal strictures. The 
 fact that the above lesions frequently occur with other syphilitic 
 stigmata (exostoses, amylosis, endarteritis, syphiloma of the liver, 
 
 * Log. cit., page 109. 
 
500 DISEASES OP THE INTESTINES 
 
 etc.) indicates their close association with constitutional syphilis. 
 The objection of the opponents of this theory (JSIickeP, Polchen ^"j, 
 that rectal stenoses are refractory to specific treatment, is hardly 
 convincing. The theory that rectal ulcers are produced by trauma- 
 tism does not ex23lain their greater occurrence in women. We ad- 
 mit that, besides syphilis, gonorrhoea and catarrhal inflammations of 
 the rectal mucous membrane may produce strictures. Rieder ^ has 
 recently demonstrated that there is a proliferation of the intima of 
 the rectal veins, even to complete obliteration, while the arteries 
 remain intact. This condition he considers characteristic of syph- 
 ilitic rectal stenosis. 
 
 Symptomatology ajstd Diagnosis 
 
 Obstruction to defecation is the foremost symptom of stricture 
 of the rectum. 
 
 As in carcinomatous strictures (already discussed on page 318), the 
 early symptoms of these rectal strictures are obscure and generally 
 escape observation. The patients first present themselves for treat- 
 ment when symptoms of ulceration or of increasing rectal stenosis 
 become prominent. In the former instance there is a bloody, mu- 
 cous, or purulent discharge ; in the latter, painful tenesmus with 
 fragmentary, scybalous, small-calibred or semifluid dejections. The 
 symptoms of ulceration may be accompanied by those of stricture. 
 Above the stricture (in the sigmoid flexure or higher) abdominal 
 palpation reveals fsecal masses, which soon produce a sacculated 
 dilatation of this part of the large intestine — an important symptom 
 of low strictures. There may be so-called " false diarrhoeas," which 
 are easily mistaken for intestinal catarrh. 
 
 The general health is gradually undermined by the tenesmus 
 and loss of blood and pus. It is surprising, however, to note how 
 long the general condition of patients with non-malignant strictures 
 remains good. This applies also to malignant strictures, though 
 here we may generally detect the characteristic cachexia. Acute, 
 complete stenoses or perforations into the neighbouring organs may 
 take place, but are rare. The lower the stenosis the more infre- 
 quent these perforations. 
 
 Continued ulceration may cause extensive destruction of the 
 sphincter ani. The symptoms of rectal incontinence then appear, 
 tenesmus ceases, and there is a profuse, continuous discharge of 
 blood, pus, and mucus. 
 
 The diagnosis of rectal stricture is readily made. Upon intro- 
 
DISEASES OF THE RECTUM 501 
 
 auction, the finger immediately strikes an obstacle; at the same 
 time we are informed of the degree of the stenosis, at least of its 
 lower (anal) portion. To determine the size of the stricture and 
 the condition beyond, the introduction of rectal bougies is indis- 
 pensable. As already mentioned (page 81), we may use various 
 instruments for this purpose. "We should always remember that 
 we are introducing the instrument into a cavity whose length, 
 direction, and lateral recesses are unknown, and that by this pro- 
 cedure we cannot determine the condition of the rectal wall and 
 the presence, extent, and depth of the ulcerations. Considering all 
 these facts, we may ask whether the diagnostic value of instrumen- 
 tation is as great as its dangers. It is plain, however, that thera- 
 peutic bougieing has to reckon with other factors. Bougieing is 
 only absolutely necessary in strictures beyond the reach of the 
 examining finger, for here the diagnostic difiiculties cannot other- 
 wise be overcome. Thus the previously mentioned case of sigmoid 
 stricture (page 494) had passed through many hands before the cor- 
 rect diagnosis was made. We have already pointed out the charac- 
 teristics of stricture of the sigmoid flexure and of the upper part 
 of the rectum (page 82). I agree with experienced clinicians that 
 the use of a speculum is generally unnecessary for the diagnosis of 
 low-seated strictures, although one may thus obtain a better idea of 
 their character. 
 
 The examination of the dejections, their form, and more espe- 
 cially the admixture of purulent, fetid, bloody masses, completes 
 the clinical picture and diagnosis. As already stated, changes in 
 the stools are often the first symptoms to alarm the patient, and 
 should always lead to careful local examination. 
 
 DiFFEKENTIAL DIAGNOSIS 
 
 The etiology of strictures is much more difiicult to determine 
 than is their diagnosis. Since they will scarcely escape a careful 
 examination, we need not here consider external tumours, exudates, 
 etc., which constrict the rectum. Prostatic tumours and enlarge- 
 ments will likewise rarely cause error in diagnosis, but differen- 
 tiation between malignant and benign rectal strictures, particularly 
 between carcinomatous, luetic, gonorrhoeal, and dysenteric varieties, 
 is quite difiicult. 
 
 In distinguishing between malignant and non-malignant ste- 
 noses, the history and clinical course of the disease are frequently of 
 value. The existence of syphilitic infection or of a previous dysen- 
 33 
 
502 DISEASES OF THE INTESTINES 
 
 tery can nsuallj be established. Tbe course of tlie affection is more 
 important. The patients may state that their symptoms date back 
 several years — a fact of great significance as regards the kind and 
 character of the stricture. The age of the patient and the absence 
 of cachexia may to some extent speak for one or the other type of 
 stenosis. 
 
 As we have seen in the section on Cancer of the Rectum (page 
 321), digital examination may give us useful information — e. g., in 
 the differentiation between carcinomatous and syphilitic strictures. 
 ISTevertheless, errors may occur. In such cases excision and micro- 
 scopical examination of a rather large piece of the new growth may 
 make the diagnosis positive. 
 
 The differential diagnosis between syphilitic and dysenteric rec- 
 tal strictures is very difficult. In his work on tumours, Yirchow ^^ 
 states : " Gummatous ulcers resemble diphtheritic, and more espe- 
 cially dysenteric, ulcers. This similarity is so marked that I have 
 often been in doubt as to whether the destructive process in a given 
 case was syphilitic or dysenteric. The same is also true of stric- 
 tures. The site of the lesion may to a certain extent guide us. In 
 dysenteric processes the lesions are more frequently found in the 
 sigmoid flexure ; in syphilitic, in the ampulla of the rectum or close 
 to the anus. In addition, the more even and broader ulcerations of 
 syphilis contrast with the eroded, irregular, superficial and deep 
 ulcerations of dysentery." In view of the rare occurrence of 
 dysentery in our country [Germany] the clinical differentiation will 
 usually be easy. 
 
 Tubercular rectal stenoses are rare, and are generally accom- 
 panied by signs of tuberculosis in other portions of the body (lungs, 
 peritoneum, other intestinal segments, genito-urinary system, etc.) ; 
 the etiology of the ulcers may be determined by examination of the 
 secretion for tubercle bacilli. When suspecting gonorrhoeal stric- 
 ture, gonococci should be sought for. It must not be forgotten, 
 however, that, especially among prostitutes, the simultaneous occur- 
 rence of syphilis and gonorrhoea is by no means rare. 
 
 From the above data we may (perhaps after a long-continued 
 observation), in many cases, make a probable or even a positive 
 diagnosis. 
 
 Treatment 
 
 Whatever the nat-ure of the underlying process, internal treat- 
 ment of strictures of the rectum is useless. Most experienced 
 
DISEASES OF THE RECTUM 503 
 
 clinicians agree upon the futility or slight value of antisjphilitic 
 treatment. According to dermatologists, in order to prevent cica- 
 tricial contraction, radical antisjphilitic treatment is always in- 
 dicated in fresh gummatous syphilis. In the majority of cases we 
 must alleviate stenotic symptoms by laxatives. Drastic drugs are 
 to be avoided. Rhubarb, frangula, flowers of sulphur, compound 
 licorice powder, or magnesia usta, in conjunction with the so-called 
 " constipation diet " (see page 14:6), are usually sufficient. If, as 
 determined by external palj^ation, there is long-standing cojorostasis, 
 the safest procedure is the administration of large doses of castor 
 oil (2 to 3 tablespoonf uls, repeated, if necessary, for several days). 
 
 The best palliative measure is methodical dilatation of the 
 stricture by rectal bougies. Views differ widely regarding the 
 value of this method. Most surgeons do not adopt the extreme 
 view of Schuchardt, Eieder, and others, that bougieing should be 
 entirely discarded. In several cases of very advanced luetic stric- 
 ture I have achieved remarkably favourable results with sounds, 
 although the treatment had to be carried out three times a week for 
 several months. I consider proctitis or periproctitis positive con- 
 traindications to the use of bougies. In a dissertation upon the clin- 
 ical material of G. Lewin, Alderhot ^^ also speaks in favour of bou- 
 gieing. Before beginning treatment, it is advisable to point out to 
 the patient the length of time required, as well as the possibility of 
 relapses after bougies have been discontinued. If the patient is 
 intelligent, he may after a few weeks be intrusted with the instru- 
 mentation himself, and the result occasionally controlled by the 
 physician. We begin with the smallest bougie that will pass the 
 stenosis, gradually increasing the size. The instrument should be 
 left in situ several minutes, and, to aid in the dilatation, should be 
 given gentle rotary movements. 
 
 The best bougies are solid soft-rubber ones, purchasable every- 
 where, or Hahn's hollow bougies containing a spiral frame. The 
 latter are not soft enough to give way when they encounter the 
 obstruction, but are sufficiently elastic not to cause laceration. If 
 properly curved (Bushe), the following instruments are also rec- 
 ommended : French bougies, hard-rubber or glass bougies (von Es- 
 march), and olive bougies fashioned after Trousseau's sounds. Crede 
 and Körte prefer curved, hard-rubber bougies. Because of their 
 lack of danger soft instruments are to be preferred. Where dis- 
 charges of blood or pus weaken the patient, we may try astrin- 
 gent irrigations (aceto-tartrate of aluminium, tannin, nitrate of 
 
504 DISEASES OF THE INTESTINES 
 
 silver) ; for obvious reasons, however, sucli irrigations are of little 
 benefit. 
 
 If the above palliative measures cannot be applied, or have 
 proved futile, we should advise operative treatment. There are 
 several methods ; opinion regarding their respective value is as 
 yet divided. 
 
 These methods are the following : («) Lateral incision with a 
 scalpel in order to render bougieing easier. This has not met 
 with great favour, since superficial incisions are of little use and 
 deep ones dangerous, (h) In annular cicatricial stenosis of the 
 anus, Dieffenbach advocated extirpation of the stricture and draw- 
 ing down and suture of the distal mucous membrane to the lower 
 edge of the wound, (c) In very marked stenosis of the anal region 
 and of the lower portion of the rectum, Pean recommended that 
 the canal should be cut longitudinally and the cut edges sutured 
 transversely, similar to the pyloroplasty of Heineke-Mikulicz. 
 This method, however, presupposes a stenosis of equal degree 
 throughout and the absence of fistulae, and hence will be of use 
 in only a limited number of cases, (d) Colostomy. This is usually 
 not dangerous, but is functionally unsatisfactory. The method first 
 used by Thiem^^ — temporary colostomy and subsequent bougieing 
 of the stenosis — gives much better results. As soon as the stenosis 
 is cured (cure naturally proceeding much more quickly under these 
 circumstances) the artificial anus may be closed. At present this is 
 the best and undoubtedly the most preferable procedure, because it 
 is not dangerous, and gives the best functional results. It is doubt- 
 ful, however, whether the majority of stenoses can be sufficiently 
 dilated to permit the normal passage of faeces within a reasonable 
 time. Further experience in this field is necessary. 
 
 Sonnenburg ^*, and recently Kotter ^^, have proposed two methods 
 whose value can only be determined by future operations. 
 
 (e) In very extensive syphilitic (and gonorrhoeal) strictures, 
 which, owing to their high situation and extent, cannot be extirpated, 
 Sonnenburg recommends extirpation of enough of the coccyx and 
 sacrum to lay bare the callous stricture and its surroundings. On 
 account of the extensive adhesions present, the peritoneum is not 
 endangered. The whole length of the stricture is then divided 
 from without inward ; the sphincter is not divided. The wound 
 is tamponed, and heals slowly. Later, long-continued bougie- 
 ing is necessary. Sonnenburg calls this operation " external rec- 
 totomy" 
 
DISEASES OF THE RECTUM 505 
 
 (/) Following the principle recommended bj the American sur- 
 geon Bacon, Rotter connects the intestinal segment above the stric- 
 ture (the sigmoid flexure portion) with the normal segment lying 
 between the stricture and sphincter ani. In two out of three cases 
 this operation was successful, and was accompanied by good func- 
 tional results. Rotter calls his operation '■'■ sigmoid rectotomy T 
 Aside from the fact that this procedure circumvents but does not 
 remove the stricture, it has a limited application, for it can only be 
 used when there is enough healthy rectum above the sphincter ani 
 for implantation of the sigmoid flexure and it is no longer possible 
 to treat the stricture. 
 
 {g) The most thorough and at the same time most severe opera- 
 tion is resection of the rectuwj^ first performed by James Israel in 
 1885, and since then repeatedly by Schede ^^ and many others. 
 When we consider the difiiculties of this operation, the results 
 achieved by Schede are quite satisfactory. In lY cases from 
 Schede's clinic, recently reported by Rieder^, none died from the 
 operation. Permanent results were obtained in 10 cases; of these, 
 5 remained cured and free from recurrence ; the remaining 5 had 
 either relapses or fistulse. Of the 5 cured cases (4 of them were 
 positively syphilitic) 1 was well since one year, 2 others since two 
 years, and 2 since six years. It is very diflicult to obtain a good 
 functional result after the operation. 
 
 It is only from rectal examination that we can, in a given case, 
 determine which of the above operations is the most appropriate. 
 Besides, the surgeon is swayed by his preference for one or the 
 other operation, and by his own results. 
 
 7. Prolapse of the Rectum {Prolapsus Recti) 
 
 The rectum is so closely connected with surrounding tissues that 
 only under special conditions is this attachment loosened. Such 
 conditions are for the most part found in children. According to 
 the statistics of Bokai '^'^, of 350 cases of prolapsus recti, the greatest 
 number occurred in children in the second and third years of life, 
 the first and the later years showing a markedly diminished predis- 
 position to the affection. Other prominent etiological factors are 
 poor general health, constipation, respiratory diseases (especially 
 pertussis), and catarrh of the larger intestine (particularly of the 
 rectum) with severe tenesmus. 
 
 In adults, besides the above factors, there are dysuria, unnatural 
 coitus, senile atrophy of the muscles of the pelvic outlet (levator 
 
506 DISEASES OF THE INTESTINES 
 
 ani, rectal sphincters, and retractors) ; in women, overdistention of 
 the muscles of tlie pelvic floor, etc. 
 
 The prolapse generally develops gradually; at first the anal 
 mucous membrane protrudes (as it does physiologically in the horse 
 during defecation) ; later there is a protrusion of all the layers of 
 the rectal wall. In extensive rectal prolapse the peritoneal fold of 
 Douglas is also drawn down. The sac formed in this manner may, 
 in rare instances, contain intestine, ovaries or bladder — a condition 
 known as rectal hernia. True rectal is to be sharply distinguished 
 from hemorrhoidal prolapse, the latter being easily differentiated 
 by the well-marked bluish nodules. "We shall later return to the 
 subject of hemorrhoidal prolapse. 
 
 Symptomatology and Diagnosis 
 
 The first symptoms are usually not well marked, and hence 
 have rarely been observed. The patient's attention is directed 
 to the lesion only when large portions of the rectum prolapse and 
 are not spontaneously reduced. On straining, we may then dis- 
 tinctly see the rosettelike protrusion of the mucous membrane with 
 the central opening from which faeces are emptied. When the pro- 
 lapse is reduced the examining finger can easily recognise the relax- 
 ation of the sphincters. At first the prolapse occurs infrequently, 
 and only from severe straining at stool ; gradually the resistance of 
 the sphincters is more easily overcome, so that coughing, laughing, 
 sneezing, and even walking, cause protrusion. 
 
 In consequence of mechanical irritation, particularly in the be- 
 ginning of the disease when the rectum is unaccustomed to any for- 
 eign influences, inflammation with subsequent catarrh of the mucous 
 membrane develop. A copious discharge of viscid mucoid secre- 
 tion follows. Accompanying this condition there may be hemor- 
 rhages, ulceration, and, where long-continued incarceration exists, 
 gangrenous inflammation with necrosis of the prolapsed segment 
 and serious sequelse. In this manner spontaneous cure often re- 
 sults. In the last stages of thö disease, having gained a certain 
 amount of practice in the rapid reposition of the prolapse, the pa- 
 tient becomes more or less accustomed to the condition. 
 
 We can gauge the age of the prolapse by its characteristics. 
 During the first stages it is succulent, soft, covered with mucus, and 
 rich in blood supply ; later it becomes tough, smooth, and resembles 
 epidermis. This latter condition favours easy reduction. 
 
 The occurrence of prolapse with simultaneous descent of abdom- 
 
DISEASES OF THE RECTUM 507 
 
 inal contents is of clinical importance. In sucli cases tlie prolapse 
 increases in size ; the orifice of the rectum is then pushed toward 
 the coccyx, and does not regain its axial position till the hernial 
 contents are reduced. If, as the result of marked distention or 
 inflammation of the rectum, or of abnormal tension of the sphincter 
 or levator ani, the intestinal contents become incarcerated, all the 
 sequences of intestinal strangulation may ensue. 
 
 The diagnosis of prolapsus recti is rarely difiicult. Careful ex- 
 amination will nearly always prevent error in differentiating between 
 rectal and hemorrhoidal prolapse. In extreme rectal prolapse it is 
 often difiicult to determine whether or not intestinal contents, etc., 
 are present in the peritoneal sac. There are numerous reports of 
 unsuccessful operations due to this error. Careful and repeated 
 examinations (preferably under ansesthesia) are therefore necessary. 
 
 Intussusception of the colon must be considered, as it frequently 
 occurs during the earlier periods of life. There is considerable 
 difference in the course of these two diseases (see page 387), and 
 difiiculty in their differentiation can only arise when we have 
 neither reliable history or observation to guide us. In intestinal 
 invagination the examining finger can feel the rectum outside the 
 intussusceptum without meeting the point of reduplication. It is 
 important also to note that in prolapse thei'e is a sort of furrow 
 between the base of the prolapsed portion and the anal ring, which 
 furrow disappears only in long-standing cases. In a prolapsed and 
 invaginated colon a bougie may be introduced for a long distance, 
 while in rectal prolapse the instrument's progress is soon stopj)ed. 
 
 Treatment 
 
 This is most successful during the early stages. At such times 
 cure may be obtained by regulation of the bowels, careful avoidance 
 of straining, and by local tonic treatment (cold irrigations with astrin* 
 gent solutions, etc.). Unfortunately we usually see cases for the 
 first time when they are far advanced, and when they are much less 
 amenable to conservative treatment. 
 
 The age of the individual and the duration of the prolapse have 
 an important bearing upon the treatment. In very old prolapses, 
 where operation is declined, internal treatment can only be symp- 
 tomatic. In children in whom the prolapse is not very far ad- 
 vanced, active internal or surgical measures are always indicated. 
 
 Besides careful regulation of the bowels (one semisolid move- 
 ment daily) and thorough regional treatment with astringents, local 
 
508 
 
 DISEASES OF THE INTESTINES 
 
 subcutaneous injections of ergotin (0.1 gm. to 0.2 gm. per dose) or 
 strychnin (0.001 to 0.002 gm.) may be given. This treatment has 
 often been successful, and is worthy of systematic trial. Should 
 
 it fail, surgical measures must 
 be employed. The rectal sup- 
 port of von Esmarch (see Fig. 
 46) is the best means of con- 
 trolling the prolapse in pa- 
 tients who complain mainly of 
 the discomfort. 
 
 In my opinion, the indica- 
 FiG. 46.-EECTAL SuppoKT. (von Esmarch.) tion for surgical treatment, 
 
 which nowadays has entirely 
 superseded the former bloodless methods (actual cautery,* cauteri- 
 zation with mineral acids, etc.), depends upon the severity of the 
 symptoms. The prolapse j?er se is certainly no indication for opera- 
 tion, for I have seen patients become entirely accustomed to their 
 condition. 
 
 The question of operation is quite different where there is diffi- 
 culty in replacing the prolapse, where there is any inflammation or 
 hemorrhage, and where the bowel protrudes in the interval of 
 defecation. We should lose no unnecessary time with palliative 
 treatment, especially since the present state of surgery has robbed 
 this operation of its dangers. Unfortunately, operation does not 
 always guard against relapses. For the various operative procedures 
 the reader is referred to surgical text-books. 
 
 8. Hemorrhoids 
 
 These are diffuse or circumscribed dilatations of hemorrhoidal 
 veins situated in the subcutaneous tissue of the outer anal region and 
 in the submucous tissue of the lower rectal segment. The old 
 classification of hemorrhoids into external, internal, arid mixed 
 groups still holds good. In mixed hemorrhoids the extra-rectal 
 portion is usually small and the intra-rectal portion well developed. 
 We find the statement, particularly in older literature, that hemor- 
 rhoids may extend over the entire rectum and even into the sigmoid 
 flexure. If this condition occurs at all, it certainly is extremely 
 
 * [This certainly is a surgical procedure — in fact, the cautery operation at the 
 present time is the favourite method in the United States for uncomplicated rectal 
 prolapse. — Tr.] 
 
DISEASES OP THE RECTUM 509 
 
 rare. For the most part hemorrhoids are undoubtedly caused by 
 hindrance to the return of blood to the vena cava and portal vein. 
 We distinguish, 
 
 1. Internal causes, within the rectal mucous membrane. 
 
 2. External causes, which act by compressing the hemorrhoidal 
 plexus. 
 
 3. Disturbances of the general circulation. 
 
 Internal factors produce three quarters of all hemorrhoidal for- 
 mations. Faecal stasis is the most important and frequent of these 
 causes. A vicious circle develops ; coprostasis, pressure on the 
 hemorrhoidal veins (further increased by straining of the abdominal 
 muscles), and formation of hemorrhoidal nodules, followed by 
 mechanical intestinal stenosis, stasis, proctitis, increased constipa- 
 tion, etc. 
 
 Other changes in the mucous membrane of the rectum and other 
 parts of the large bowel (stenosis, new growths, foreign bodies, 
 prostatic enlargement), by preventing the normal passage of faeces, 
 may give rise to hemorrhoids. As in cancer of the rectum, we 
 may observe the paradox of a diarrhoea due to coprostasis above 
 a stenosed segment. Hemorrhoids are also found in chronic 
 diarrhoea, particularly in catarrh of the large intestine. In such 
 cases the hemorrhoids may be caused by the tenesmus, hyperaemia, 
 and perhaps also by the inflammation of the rectum and lower seg- 
 ments of the large intestine. 
 
 The external causes of hemorrhoids are tumours of the neigh- 
 bouring organs which retard the rectal circulation. The simplest 
 example of this is pregnancy, during which, according to Budin^^, 
 35 per cent of all hemorrhoidal cases develop. These disappear 
 after the puerperium. Tumours of the uterine adnexa, retroflexion 
 and tumours of the uterus, disease of the urethra and bladder, par- 
 ticularly such as affect the contractility of the latter organs, may 
 also produce hemorrhoids. 
 
 Formerly disturbances of circulation (third cause) were regarded 
 as the chief source of hemorrhoids. Even at present similar 
 statements are found in almost all text-books of special pathology. 
 ISTothnageP^ mentions the rarity of hemorrhoids in stasis of the 
 portal system, and in diseases of the heart and lungs. He states 
 that in cardiac insufiiciency the pathological increase of pressure is 
 spread over so large a vascular area that it would scarcely affect the 
 hemorrhoidal plexus in the manner formerly assumed. My own 
 experience also speaks against the theory of hemorrhoids from gen- 
 
510 DISEASES OP THE INTESTINES 
 
 eral vascular congestion. Even if the two conditions coexisted it 
 would still have to be demonstrated that the hemorrhoidal compli- 
 cation was not due to the constipation present. 
 
 Bouchard found hemorrhoids in 28 per cent of cases of chole- 
 lithiasis. 'No comment on this is found in the classical monograph 
 of Naunyn, and, as far as I know, this observation has not been 
 confirmed. It does not agree with my own experience. That 
 hemorrhoids may occasionally occur in choleHthiasis is not remark- 
 able, for it is well known that a large proportion of these patients 
 suffer from constipation. 
 
 Reredity is often mentioned as a predisposing factor in hemor- 
 rhoids, but in all probability there is really hereditary intestinal 
 atony, a condition not at all infrequent. 
 
 It has often been demonstrated that a sedentary hfe predisposes 
 to hemorrhoids, but here again the hemorrhoids result from 
 habitual constipation. 
 
 Age and Sex. — That hemorrhoids is really a disease of advanced 
 life follows both from the underlying conditions producing tlie dis- 
 ease, and from the lessened elasticity of the vessels at this time of 
 life. (I might mention that Lannelongue ^"^ reports a case of hemor- 
 rhoids in a newly born infant.) It is quite striking (and my obser- 
 vations upon numerous cases confirms this) that in the majority of 
 instances hemorrhoids are more frequently found in men, whereas 
 habitual constipation occurs oftenest in women. Besides this, the 
 occupation of women is more restful and quiet than that of men. 
 I can only explain this fact by the numerous venous plexuses in 
 the female genitals, which, while not entirely preventing, certainly 
 make the occurrence of varicose conditions very difficult. 
 
 In my opinion, the oft-mentioned distinction between stout and 
 thin auEemic hemorrhoidal patients will as little withstand scientific 
 criticism as the distinction between stout and lean persons with dia- 
 betes or constipation. This theory is a remnant of the old teaching, 
 that hemorrhoids exert a beneficial infiuence upon the general sys- 
 tem. It is true, as Nothnagel says, that we find hemorrhoids much 
 more rarely in stout individuals, but this is solely because the tense, 
 firm connective tissue here present greatly retards the development 
 of venous dilatation. Conversely, in cachectic individuals who do not 
 suffer from severe constipation we may often observe hemorrhoids. 
 
 Anatomically we differentiate between diffuse dilatation of the 
 rectal veins and true hemorrhoidal nodules. The first generally form 
 a visible rosette, consisting of dilated, often spirally twisted veins, 
 
DISEASES OP THE RECTUM 511 
 
 under the skin or mucous membrane. Hemorrhoidal nodules, on 
 the other hand, vary greatly in size, and are single or multiple. 
 When multiple, they surround the anus circularly or wreathlike, 
 and are either sessile or pedunculated. Inflammatory adhesions 
 may produce a confluence of the hemorrhoids, and, as a result, large, 
 almost angiomatous masses are formed. The hemorrhoids may, 
 however, atrophy, and become covered with epidermis. Their ori- 
 ginal character can then only be recognised by their bluish colour, 
 their consistency, and their characteristic arrangement. By throm- 
 bosis and calcification of the veins so-called phleboliths may be 
 formed. 
 
 At present our views regarding the histological character of 
 these varices differ. We shall not enter into a minute discussion 
 of this subject, but only mention that Reinbach ^\ who has recently 
 carefully studied the histological structure of hemorrhoids, concludes 
 that they are not varicose veins, but true benign tumours — i. e., 
 angiomata. 
 
 Hemorrhoidal may conduce to rectal catarrh, with more or less 
 marked mucous secretion (so-called " mucous hemorrhoids "). Fis- 
 sures and excoriations occur quite frequently, and may lead to 
 abscesses, fistulse, and (rarely) to very severe inflammation and peri- 
 tonitis. 
 
 ■ Symptomatology 
 
 The former view that hemorrhoids was a constitutional disease 
 (even nowadays we speak of a " status hemorrhoidalis "), explains 
 whv the description of this disease was unnecessarily extensive. 
 Many indefinite abdominal disturbances and circulatory and re- 
 spiratory symptoms were attributed to hemorrhoids. Venesection, 
 which prevailed even to the middle of this century, was one of the 
 consequences of these theories. 
 
 At present hemorrhoids are viewed from a purely local stand- 
 point ; we treat the hemorrhoidal nodule, and not the hemorrhoidal 
 diathesis. We must not entirely relinquish the old theory of a gen- 
 eral disturbance brought about by the " status hemorrhoidalis." We 
 must admit that certain definite symptoms closely associated with 
 altered blood pressure are produced by the hemorrhoidal varix; 
 but many mild and (particularly in cachectic persons) severe cases 
 run their course without symptoms. When present, the symptoms 
 are generally limited to the diseased area, although, as already inti- 
 mated, they may extend to other regions of the body. 
 
512 DISEASES OF THE INTESTINES 
 
 The local symptoms are constipation, a feeling of pressure and 
 heaviness in the rectum, tenesmus, and itching and burning in the 
 anal region. Defecation usually brings relief. In external hemor- 
 rhoids there is also more or less discomfort in sitting, even upon a 
 soft pillow, and in riding, bicycling, jumping, and gymnastics. 
 
 These symptoms may be accompanied by hemorrhages, slight in 
 amount or (rarely) sufficiently severe to cause the most profound 
 anaemia or even death. The bleeding may recur periodically. 
 Hemorrhages are often preceded by increased hemorrhoidal symp- 
 toms — feeling of congestion, tenesmus, severe pains radiating to the 
 bladder, etc. With the onset of the bleeding these symptoms dis- 
 appear. 
 
 Strangulation of protruding hemorrhoidal nodules constitutes 
 one of the most painful complications. The masses which have 
 been protruded from the anal fold by straining usually return 
 easily, either spontaneously or by manipulation. They may, how- 
 ever, remain prolapsed, and become swollen and inflamed ; an in- 
 flammatory cedema then develops about the anus ; the patients 
 suffer unbearable pain, and, as in strangulated hernia, may collapse. 
 If strangulation is not relieved, the nodules may become gangre- 
 nous and necrotic, or a purulent inflammation with its serious 
 sequences may result. 
 
 In very old cases, in consequence of paresis of the sphincter, 
 the nodules may prolapse in walking, bending, coughing, laughing, 
 sneezing, etc. 
 
 As already mentioned, inflammation of intra-rectal hemorrhoids 
 may produce symptoms of acute proctitis — severe pain, repeated 
 and increasing tenesmus, sphincteric spasm, etc., and occasionally 
 fever. 
 
 General disturhances are more apt to occur in chronic hemor- 
 rhoidal disease. Besides chronic anaemia many patients suffer from 
 abdominal fulness and pressure, necessitating the loosening of 
 clothing. The passing of flatus affords temporary relief. There 
 may also be severe pain in the back, increased by bending or other 
 active motion. Some patients complain of sciatica, and resort unsuc- 
 cessfully to bath treatment. Certain nervous symptoms are also 
 present — a feeling of fulness in the head, dizziness, nausea, floating 
 bodies before the eyes, etc. 
 
 These symptoms may be considered neurasthenic, or, to be more 
 modern, evidences of auto-intoxication, or perhaps as the result of 
 habitual constipation. "We must admit that there remain symptoms 
 
DISEASES OP THE RECTUM 513 
 
 which can only be explained by changes in blood pressure in the 
 vena cava and portal vein. If we remember that an accumulation 
 of gas in the stomach or intestine not only gives rise to local dis- 
 comfort, but also to general disturbances — pressure in the head, 
 feelings of fear, palpitation, etc. — and if we recall the disturbances 
 that occur in the beginning of menstruation, we must acknowledge 
 the correctness of this view. The disappearance of these symp- 
 toms, with the relief of the constipation is no proof that they 
 depend upon that condition, for the hemorrhoidal affection is at the 
 same time favourably influenced. 
 
 Diagnosis and Differential Diagnosis 
 
 In the great majority of cases the diagnosis is easy. Under no 
 circumstances must it be based entirely upon the statements of the 
 patient. Inspection of the anal region alone is not sufficient ; the 
 rectum must always be included, and, in women, the genital organs. 
 Treatment and prognosis are considerably influenced by the 
 results of such examination. If internal hemorrhoids are sus- 
 pected, they are best brought to view by having the patient strain 
 strongly. It is best to first give an enema of warm salt water, 
 and then to have the patient strain while sitting upon a chamber 
 filled with warm water. If this does not succeed, a rectal specu- 
 lum must be used. We should avoid the tubular speculum, which 
 pushes the hemorrhoidal nodes aside, but, under the precaution men- 
 tioned in the General Division, use the grooved instrument (page 
 80). Erosions, ulcerations, proctitis, fissures, fistulas, etc., must also 
 be looked for. 
 
 The diferential diagnosis is rarely difficult. Broad condylom- 
 ata can only be mistaken for hemorrhoids when neither has before 
 been seen. It may be more difficult to distinguish hemorrhoids 
 from beginning carcinoma and ulcerations. Since hemorrhoids 
 ulcerate very readily and leave deep lesions, error can only be 
 avoided by careful consideration of all accompanying circumstances. 
 The distinction between rectal polypi and hemorrhoids is readily 
 made, although polypi may closely resemble thrombosed varices. 
 In most instances careful and repeated examination will scarcely 
 leave room for doubt. This is also true of the differentiation between 
 prolapse of hemorrhoids and of the rectum. 
 
514 DISEASES OP THE INTESTINES 
 
 Treatment 
 
 Wherever possible, treatment should be directed toward the 
 underlying cause. 
 
 Since constipation is the most frequent etiological factor, we 
 begin with its discussion. In referring to the regulations previ- 
 ously described for the treatment of this condition, we have only to 
 point out special peculiarities which exist in the constipation of 
 these patients. Proper diet is of the greatest importance. We 
 must distinguish, however, between hemorrhoids with and without 
 bleeding, and between insignificant and profuse hemorrhages. 
 
 The diet must be carefully regulated in patients with severe 
 and habitual or with profuse and periodical hemorrhages. Spiced, 
 sharp, piquant foods and drinks, as well as alcoholic beverages, 
 particularly those of stronger concentration, must be avoided. 
 Further dietetic restrictions are unnecessary. It is obvious that 
 over-action, excessive walking, horseback riding, gymnastics, bicy- 
 cling, etc., are to be forbidden. If there are no hemorrhages, or if 
 they are insignificant, the diet should be that of chronic constipa- 
 tion, with due consideration to the general health and nutritive 
 condition of the patient. A so-called " bland diet," still advised in 
 many text-books, is absolutely wrong. The favourable influences 
 of diet may be further increased by active and passive motion, 
 rowing, room gymnastics, billiard playing, bowliug, tennis, Swedish 
 movements, and massage. Owing to the continual local friction 
 and increased circulatory disturbances, horseback riding, and prob- 
 ably also bicycling, act unfavourably. 
 
 If diet alone does not produce sufficient evacuations, it must be 
 aided by appropriate laxatives. For this purpose, the sulphur 
 preparations (flowers of sulphur, one teaspoonful t. i. d), and laxa- 
 tives containing them (compound licorice powder, one teaspoonful 
 morning and evening), have been long and deservedly valued. 
 They operate in accordance with the tenets of the old school : 
 " Cito., tuto et juGundeP Whenever a change of remedies is indi- 
 cated, the other laxatives mentioned in the chapter on Habitual 
 Constipation may be used, though the above preparations will gen- 
 erally sufiice for a long time. The drastic cathartics are said to be 
 harmful in the treatment of this constipation. Recently they have 
 been added to the causative factors of hemorrhoids (Rosenheim ^^), 
 It is certainly an exaggeration to regard drastics as productive of 
 
DISEASES OF THE RECTUM 515 
 
 hemorrlioids, but in some instances it does no harm if the physician 
 supports such theories. 
 
 Enemata are rarely indicated in hemorrhoids, for manipulations 
 with the usual rectal tubes are apt to irritate, lacerate, and inflame 
 the hemorrhoidal nodules. Chemical agents, including oil, added 
 to enemata, also act harmfully. This applies particularly to glyc- 
 erin, which causes severe pain and tenesmus. 
 
 Almost all text-books advise avoidance of sexual excesses, and 
 claim they may produce hemorrhoids. This statement is true, in so 
 far as these should be avoided by healthy as well as diseased indi- 
 viduals. That sexual excesses are especially harmful to those with 
 hemorrhoids seems to me to be based on mere speculation, and not 
 upon scientific experience. I cannot comprehend how a temporary 
 congestion of the genitals can produce the serious results described. 
 
 The use of baths and mineral waters must be briefly touched 
 upon. Only those watering places which contain both appropriate 
 baths and appropriate laxatives (sodium chloride or sulphate) come 
 into consideration. First and foremost are the cold saline springs 
 of Kissingen and Homburg, then the sodium sulphate waters of 
 Marienbad, Tarasp, Elster (" Salt Spring "), Franzenbad (" Salt 
 Spring "), Rohitsch, and others.* In some watering resorts (Elster, 
 Marienbad, Franzenbad) persons ansemic from loss of blood may 
 also use an iron spring. In recent times — even medicine follows 
 fashion, as proved by the yearly increasing number of people who 
 visit these springs — great health-giving properties have been attrib- 
 uted to mineral waters. Convinced by numerous excellent results 
 from a sojourn at these springs, many patients visit them on their 
 own account and recommend their use to others. As physicians, 
 we must as far as possible consider the wishes of our patients, but 
 we should also know the limits of the action of these cures, and not 
 promise greater results than actually occur. We must admit that 
 these springs generally affect the hemorrhoidal disease very favour- 
 ably. This is quite natural, for the patients find themselves in 
 almost ideal surroundings for the treatment of their disease. The 
 use of aperient waters, the necessary exercise, the appropriate diet, 
 and, not the least, the hygiene of the anal region secured by numer- 
 ous baths, all combine to produce a condition never, even under the 
 best of circumstances, obtainable at home. But with this, however, 
 
 * [For corresponding springs and wells in the United States, see pp. 161 and 
 162.— Tr.] 
 
516 DISEASES OP THE INTESTINES 
 
 balneotlierap}^ finds its limitations. As soon as the patients resume 
 their usual habits of life the old condition returns, and the dearly 
 bought sojourn at the springs loses its magic. It is therefore the 
 duty of the physician to explain to the patient what benefit he may 
 expect from his course of waters, so that gain in health and neces- 
 sary sacrifice of time and money may be properly proportioned. 
 Permanent good often results from repeated yearly visits to the 
 baths and sj^rings, but this cannot be determined beforehand. 
 
 Of the symptomatic remedies for external and mixed hemor- 
 rhoids, the first is the toilet of the anus. The patient is to keep the 
 anal region absolutely clean. After every act of defecation, this 
 region and the hemorrhoids themselves are to be carefully washed 
 with absorbent cotton (not sponges) dipped in a cold three-per-cent 
 boric-acid solution, or, what I especially recommend, a tannin solu- 
 tion (teaspoonful to a quart of water). Cold antiseptic or astrin- 
 gent washings are very agreeable to the patient, and are to be re- 
 peatedly used. We should, however, always study our patients 
 before giving directions. I know from experience that in neuras- 
 thenics such regulations may lead to quite unpleasant consequences. 
 The patients examine their anus all day long by means of mirrors 
 and reflectors, just as tongue h^^pochondriacs do their tongues. 
 
 The most important complications of hemorrhoids are severe 
 periodic or marked chronic hemorrhages. In milder bleeding treat- 
 ment is scarcely necessary. In severe hemorrhage it is best not to 
 delay too long with ineffectual remedies such as the introduction of 
 ice, injections of tannin or liquor ferri into the rectum. By means 
 of a speculum we tampon the rectum with gauze or cotton dipped 
 in liquor ferri or ferripyrin solution. As in uterine hemorrhages, 
 hot irrigations (35° to 40° C.) have been recommended by several 
 authors (Sandowski and others). If these measures do not control 
 the bleeding, the bleeding vessels or tissue must be sought for and 
 tied off.* 
 
 In continuous hemorrhages, particularly where there is ansemia 
 and general weakness, I would recommend witch hazel. I use the 
 
 * [Firm packing of the bleeding area with dry gauze (if necessary under general 
 anfesthesia) is the simplest and surest of the non-operative means of arresting 
 hemorrhage. The hard clot and the dirty, slowly healing slough after the applica- 
 tion of the liquor ferri, make its employment undesirable. I have seen rapid and 
 permanent arrest of rectal hemorrhage follow the direct application of cotton 
 swabs soaked with fifty-per-cent antipyrin solution to the bleeding surface. Per- 
 haps, too, the local use of solutions of suprarenal extract would be effectual. Ab- 
 solute rest is of course essential to arrest of hemorrhage. — Tr.1 
 
DISEASES OF THE RECTUM 5I7 
 
 fluid extract exclusively in teaspoonful doses three times daily. I 
 have had no experience with the dry extract " hamamelin " (dose, 
 ■0.05 to 0.06 gram) recommended by Soulier^ for the same purpose. 
 Since the different preparations in the market vary in strength, we 
 should use a reliable one. After an extended experience I do not 
 s,t all doubt the action of hamamelis in hemorrhoidal hemorrhage. 
 The remedy may be taken for weeks and months without producing 
 untoward symptoms. In continuous hemorrhages I have the pa- 
 tients take the drug regularly six to eight weeks. 
 
 Ergotin, hydrastis canadensis, liq. pot. arsenites, glycerin, and 
 other remedies have been recommended in hemorrhages of this 
 character, but no definite proof of their favourable action exists. 
 Personally, I have had no experience with them. 
 
 Reposition is the chief measure in strangulation of varix nodules. 
 This is best carried out with the patient lying on his side, and the 
 hemorrhoidal mass and the parts about freely smeared with an oint- 
 ment containing cocain, eucain, or opium, or with olive oil. Gentle 
 pressure must be made. IS^arcosis, when possible, is preferable. 
 Schleich's local anaesthesia, however, is even better. Leeches aj)- 
 plied to the anus (but not to the varices) are very useful in reposi- 
 tion. After an abundant hemorrhage the hemorrhoids are easily 
 replaced. When gangrene has occurred the nodules should be 
 dusted with an antiseptic powder (iodoform, airol, xeroform, etc.).* 
 
 Besides these important complications, there are inflammatory 
 swellings and excoriations of external and internal hemorrhoids. 
 In the former, anaesthetic suppositories (cocain, eucain, opmm, 
 belladonna, and morphin) are generally useful. Unna, Kosso- 
 budskji^, and MacdonakP^ recommend the following suppositories : 
 
 5i Chrysarobin 0.08 
 
 Iodoform ^-^^ 
 
 Ext. bellad 0.01 
 
 Butyr. cacao ^-00 
 
 D. t. dos. 1^0. X. 
 
 S. : Apply one suppository two to three times daily. 
 
 * [If the patient refuse ana?sthesia or operation, and reposition otherwise is im- 
 possible, rest, local application of ice, and free inunctions with gallic ointment, 
 with opium, cocain, belladonna, etc., are in order. Under these, reduction in size 
 often follows and reposition is then possible. It would be interesting to try the 
 suprarenal extract in these conditions. Occasionally gangrene and a spontaneous 
 •cure occur. — Tr.] 
 34 
 
518 DISEASES OP THE INTESTINES 
 
 It would be interesting to know which of these three remedies^ 
 ehrysarobin, iodoform, or belladonna, is the effectual one. 
 
 As may be seen from their composition, styptic properties are 
 attributed to these suppositories. For a like purpose, Rosenheim * 
 recommends the injection of a very weak solution of nitrate of sil- 
 ver (one gram of a one-half-per-cent to one-per-cent solution) into 
 the rectum by means of a specially devised syringe. Anaesthetic 
 ointments may also be applied with the collapsable tube, previously 
 described. 
 
 In external hemorrhoids the various ointments again come into 
 consideration. Chrysarobin enjoys a special reputation. The oint- 
 ment recommended by Kossobudskji is as follows : 
 
 !^ Chrysarobin 0.8 
 
 Iodoform 0.3 
 
 Ext. bellad 0.6 
 
 Yaselini 15.0 
 
 D. S. : To be freely applied several times daily. 
 
 We will not enumerate the numerous other salves which prob- 
 ably act only through the anaesthetic drugs they contain. Preis- 
 mann ^^ praises the action of extei'nal applications of iodin-glycerin 
 very highly, and gives the following : 
 
 ^ Kali iodati 2.00 
 
 lodipuri 0.20 
 
 Glycerini 35.00 
 
 Later in the disease he increases the strength of the applica- 
 tion, thus : 
 
 ^ Kali iodati 5.00 
 
 lodi puri 1.00 
 
 Glycerini 40.00 
 
 Esmarch's rectal support is also to be recommended in prolapsed 
 hemorrhoids (see Fig. 46). 
 
 We must distinguish between " bloodless " and " bloody " sur- 
 gical measures. The former include stretching of the sphincter, 
 particularly recommended by French authorities (Yerneuil and 
 others). It may be carried out in one or in several sittings by 
 forced dilatation with fenestrated speculum, the blades being sepa- 
 rated by a special mechanism. The same result can be more sim- 
 
 * Log. cit., p. 236. 
 
DISEASES OF THE RECTUM 5I9 
 
 ply accomplished by passing two fingers into the rectum after pre- 
 vious introduction of a grooved speculum and eversion of the rec- 
 tum. The second bloodless method, used and recommended more 
 especially in England and America, is the fixed or elastic ligature 
 (von Dittel). As far as I know, this procedure is but little used in 
 Germany. Destruction of the nodules with fuming nitric or carbolic 
 acid is also practiced ; the skin of the anal region and tlie peri- 
 neum is protected from the action of the acid by a thick coating of 
 vaselin. 
 
 In 1887, Lange ^^, of New York, recommended local injections 
 of carbolic acid and glycerin, in concentration of 1 : 5 to 1 : 2. In 
 numerous cases, even of large nodules, this method has proved suc- 
 cessful in my hands. I usually proceed as follows : 
 
 The patient is told to press out the nodules. For this purpose 
 it is best to give him a warm enema beforehand, or to have him 
 sit on a bed-chamber filled with hot water. The rectum and the 
 anus are then carefully cleansed with a one-half -per-cent lysol solu- 
 tion. The skin about the anus is smeared with borated vaselin. 
 As an injection I use fifty-per-cent carbolic-acid glycerin, employ- 
 ing an accurately graduated syringe. The needle is introduced at 
 the border of each nodule, about three drops injected into each, 
 and the needle is allowed to remain in situ for a few minutes. 
 After it has been withdrawn and the parts again cleansed, the other 
 nodules are successively treated in the same manner. If possible, 
 the prolapsed nodules are replaced, a large cotton pad and T-bandage 
 applied, and, to produce constipation, fifteen drops of the tincture of 
 opium and a bland diet given. Eest in bed from two to three 
 days. Castor oil on the third day. Limited activity for sev- 
 eral days. 
 
 In only one of my cases did acute inflammation follow ; under 
 appropriate treatment the inflammation soon disappeared. All the 
 cures resulted without much pain. This operation does not guard 
 against relapses, but it has the great advantages of simplicity and 
 lack of danger.* 
 
 The "bloody" methods of operation seek destruction of the 
 hemorrhoids by the production of scar tissue by means of either the 
 actual or thermo-cautery [Paquelin], the galvano-caustic loop (von 
 Bardeleben), or by extirpation of the nodules and subsequent suture 
 
 * Roux^ä very appropriately says of this method: "Compared to the bloody 
 operations it has only one disadvantage : it is no longer an art to rapidly and care- 
 fully operate hemorrhoids." 
 
520 DISBASES OP THE INTESTINES 
 
 (Whitehead's operation). These are the operations generally per- 
 formed in Germany ; they will be found described in surgical text- 
 books. 
 
 LITERATURE 
 
 1. Jullien. Beiträge zur Dermatologie u. Syphilis. Festschrift für G. Lewin, 
 
 1895. 
 
 2. Th. Baer. Deutsche med. Wochenschr., 1896, No. 8, and 1897, No. 51 
 
 u. 52. 
 
 3. Bushe. Cited by von Esmarch, Die Krankheiten d, Mastdarms u. d. 
 
 Afters. Stuttgart, 1887, S. 72. 
 
 4. Quenu et Hartmann. Chirurgie du Rectum. Paris, 1895, p. 188. 
 
 5. Allingham. The Diagnosis and Treatment of Diseases of the Rectum, 
 
 p. 269, sixth edition, 1896. 
 
 6. Van der Willigen. Neederl.-Tijdschr. v. Geneeskunde, 1893, i, No. 17. 
 
 Cited from the Centralbl. für Gynäcologie, 1895, S. 481. 
 
 7. Conitzer. Munch, med. Wochenschr., 1899, No. 3. 
 
 8. Rieder. Archiv f. klin. Chirurgie, 1897, Bd. Iv, S. 730. 
 
 9. Nickel. Virchow's Archiv, Bd. cxvii, S. 279. 
 
 10. Pölchen. Ibid., S, 189. 
 
 11. Virchow. Die krankhaften Geschwülste, 1864-1865, Bd. ii, S. 416. 
 
 12. Alderhot. Beiträge zur Kenntniss der Rectumsyphilis. Diss.-Inaug. 
 
 Berlin, 1896. 
 
 13. Thiem. Verhandl. der deutschen Gesellschaft für Chirurgie, 1893, Bd. i, 
 
 S. 49. 
 
 14. Sonnenburg. Ibid., 1897. 
 
 15. Rotter. Archiv f. klin. Chirurgie, Bd. Iviii, S. 334. 
 
 16. Schede. Verhandl. d. deutschen Gesellschaft f. Chirurgie, 1895. 
 
 17. Bokai. Krankheiten des Mastdarms u. des Afters. Gerhardt's Handbuch 
 
 der Kinderkrankheiten, vi, 2te Abth. 
 
 18. Budin. Cited from Galliard, Maladies de Tintestin. Traite de Medecine, 
 
 t. iv, p. 698. 
 
 19. Nothnagel. Darmkrankheiten, S. 469. 
 
 20. Lannelongue. Cited by Galliard (see reference 18). 
 
 21. Reinbach. Beiträge zur klin. Chirurgie, 1897, Bd. xix, H. 1. 
 
 22. Rosenheim. Die Pathologie u. Therapie d. Krankheiten des Darmes, 
 
 S. 219. 
 
 23. Soulier. Cited from Mathieu. Therapeutique des maladies de l'intestin, 
 
 second edition, p. 91. 
 
 24. Kossobudskji. Cited from the Centralbl. f. Chirurgie, 1889. 
 
 25. Macdonald. Cited from the Wiener med. Presse, 1892, S. 1886. 
 
 26. Preismann. Weiner med. Presse, 1891, No. 22. 
 
 27. Lange. Verhandl. der deutschen Gesellschaft f. Chirurgie, 1887. Cited 
 
 from the Centralbl. f. Chirurgie, 1887. 
 
 28. Roux. Therapeutische Monatsh., März, 1895. 
 
CHAPTER XXI 
 
 NERVOUS DISEASES OF THE INTESTINES 
 
 Preliminary Remarks. — In the General Division (page 34) we 
 have given a brief and incomplete description of intestinal innerva- 
 tion. From this it is seen with what complicated conditions we 
 must deal in describing the pathology of intestinal neuroses. 
 
 The few anatomico-pathological investigations of Jürgens \ 
 Blaschko^, Sasaki^, Schleimpüug *. and Emminghaus^ point the 
 way to future investigators ; in themselves they are not sufficient 
 for clinical purposes. 
 
 The uncertainty of the study of intestinal neuroses is further in- 
 creased by the unstable transition between organic intestinal disease 
 and the so-called neuroses. Just as cystitis may develop from vesi- 
 cal paralysis of spinal origin, so organic changes in the intestinal 
 mucous membrane may arise from disturbances of intestinal inner- 
 vation. At certain stages we can recognise changes, but not their 
 origin. Disturbances of intestinal innervation probably do not fol- 
 low one course, but secretory-motor and vaso-motor disturbances 
 combine. 
 
 Under conditions so little understood, our only resource is clini- 
 cal observation and experience. 
 
 Like gastric neuroses, intestinal neuroses may be divided into 
 motor, sensory, and secretory. There is also a mixed or " com- 
 plex" form of intestinal neurosis, which appears as general intes- 
 tinal neurasthenia. 
 
 1. Motor Neuroses 
 
 {a) Enterospasm and Proctospasm 
 
 While spastic conditions of the bowel are most frequent and 
 prominent in organic intestinal disease (particularly stenosis), entero- 
 spasm is very seldom observed as a jpurely functional neurosis. 
 
 521 
 
522 DISEASES OF THE INTESTINES 
 
 J^Jothnagel ^ denies its existence entirely. This seeras to me 
 somewhat farfetched, although experienced physicians must admit 
 the rarity of primary, spastic intestinal contraction. Few cases have 
 been reported, and these (including the one of Talma cited by 
 IS^othnagel *) are not entirely free from objections. Proctospasm is 
 usually secondary to local affections of the rectum or of the pelvic 
 organs. It is met with as a functional condition (occasionally com- 
 bined with anal crises) in tabes dorsalis, and as a symptom of gen- 
 eral hysteria and neurasthenia. 
 
 Symptomatology and Diagnosis 
 
 The principal symptoms of enterospasm are painful intestinal 
 contractions which the patient feels, and which are accompanied 
 by rumbling and borborygmi, and by the passage of fragmentary 
 scybalse, with marked rectal tenesmus. 
 
 These symptoms generally occur at intervals, and are often 
 started or increased by excitement. The following is an example 
 of enterospasm of nervous origin : 
 
 Miss H., sixty years of age, has for many years suffered from the following 
 attacks : Every four to eight days, without apparent cause, sxidden severe pain 
 is felt in the umbilical region. At the height of the attack there is an urgent 
 desire to defecate. Three to five times a day she passes many small, thin faecal 
 masses. Each act of defecation is followed by one or two hours of ease. 
 
 During these attacks (which often last a whole day) the patient is confined 
 to her room. The abdomen is frequently distended. Except for mild consti- 
 pation, the patient is subjectively well. She ascribes her affection to overworry. 
 The first attacks began twenty-five years ago. Besides slight hemorrhoids, this 
 very robust and well-nourished woman presents no objective symptoms. 
 
 In cases like this the diagnosis is readily made, but where the 
 etiology is less clear it may be very difficult to distinguish between 
 this affection and organic stenosis. The following points are impor- 
 tant : the long duration of the affection, the good general condition, 
 normal health in the interval between attacks, and the presence of 
 neurasthenic or hysterical stigmata. 
 
 The symptoms of proctospasm consist of severe periodical, some- 
 times almost unbearable pain in the rectum, accompanied by sphinc- 
 teric contraction. 
 
 The following cases will illustrate and explain the clinical pic- 
 ture of the disease : 
 
 * Loc. cit., p. 463. 
 
NERVOUS DISEASES OF THE INTESTINES 523 
 
 I. (Observation of Peyer''.) Sexual neurasthenic, aged fifty, suffers from 
 various severe neuralgias, joarticularly of the testicle. His proctospasm shows 
 itself at first as a marked, painful tenesmus of the rectum, necessitating an im- 
 mediate attempt at defecation, but neither stool nor wind passes. With this 
 tenesmus there is a very severe spasm of the sphincter, so that the patient can- 
 not force even the narrow canula of an irrigating syringe into his rectum. Af- 
 ter some time the pain leaves suddenly and radiates to the bladder or testicle. 
 
 II. (Personal observation.) Mr. K., merchant of Prague, aged fifty-two, 
 good family history, had a mild attack of syphilis six years ago. Later, articu- 
 lar rheumatism, which his physician ascribed to. the syphilis. Irregular stool 
 during the confinement to bed necessitated by the rheumatism. Though he gen- 
 erally sleeps well, and has a good appetite, he has become very nervous through 
 much overwork. There is constipation, and occasionally mild tenesmus. 
 When tenesmus is severe, diarrhoea ensues ; normal, cylindrical stool is very 
 rare. 
 
 During the last few years he suffers from anal spasms every two or three 
 "days, and more recently every three to five days. These generally come on at 
 night. The patient is suddenly awakened by severe pain, as if the sphincter 
 ani were spasmodically drawing itself together. The finger can be introduced 
 only with great difficulty. The spasm may be controlled by the successive 
 introduction of the larger fingers. In a few minutes the entire attack ceases. 
 The proctospasm is generally preceded by constipation, and never occurs after 
 satisfactory defecation. 
 
 In the interval between attacks the calibre of the rectum is normal. No 
 symptoms of tabes.* 
 
 The diagnosis of proctospasm is not difficult. In order to estab- 
 lish the nervous character of the disease it is always necessary to 
 make a rectal or vaginal examination. 
 
 Treatment 
 
 Where appreciable lesions of the rectum or genitals exist, or 
 v^^here the symptoms are produced by spinal disease, appropriate 
 measures must be apphed. In purely functional entero- and procto- 
 spasm it will be necessary to treat the underlying nervous basis of 
 the disease. For this purpose cold hydrotherapeutic measures, ene- 
 mata (perhaps with the rectal cooler), mild galvanization of the rec- 
 tum and abdomen, and systematic passing of elastic bougies are best. 
 The attack may be checked by bromids, or by opium, morphin, 
 belladonna, codein, and cocain, internally or in suppositories. Con- 
 stipation, if present, should be treated dietetically, with or without 
 the addition of mild purgatives and enemata. 
 
 * We must always remember the possibility of this being an initial symptom of 
 tabes, which, analogous to gastric crises, may antedate the ataxia by many years. 
 
524 DISEASES OF THE INTESTINES 
 
 {b) Peristaltic Restlessness {Tormina Intestinorum Nervosa) 
 
 KussmauP, in 18T8, was tlie first to call attention to the occur- 
 rence of visible peristalsis of ttie stomach and intestine in neuro- 
 pathic individuals. These contractions may affect stomach and 
 intestines together or each separately. They occur in paroxysms,, 
 particularly after nervous excitement. They are usually observed 
 in women with flabby abdominal walls and enteroptosis. Peyer'^ has 
 observed several cases in male sexual neurasthenics. 
 
 St:mptomatologt A2sd Diagnosis 
 
 The chief symptoms are a feeling of movement and of drawing 
 together in the abdomen, which may increase to spasmodic pain. 
 In marked cases there may be simultaneous rumbling sounds. These 
 attacks are independent of the time of food ingestion, but may be 
 visibly increased by certain agents — carbonated beverages, laxa- 
 tives, etc. They frequently occur at night, and deprive the patient 
 of sleep. 
 
 On inspection, the lively peristaltic wavelike motion of the 
 intestine is usually immediately apparent. Where the j)icture is 
 not well defined, hyperperistalsis may be induced by abdominal 
 friction, pouring ether upon the abdomen, faradism, and distention 
 of the stomach or intestine with air or carbonic acid. The peristal- 
 sis mainly involves the small intestine, but, as shown by the case 
 described below, the large intestine may also be affected. Noth- 
 nagel^ maintains that evacuations always accom]j)any the latter 
 condition. In my case this was not so ; the patient always had 
 normal stool. 
 
 The attacks vary considerably in intensity and duration. In the 
 same individual I have sometimes seen mild peristalsis last for hom-s, 
 and violent actions decrease after a few minutes. 
 
 In my work on Diseases of the Stomach (Part II, third edition, 
 p. 236) I have described a case of this kind. I demonstrated a 
 second much more typical patient at the Congress for Internal 
 Medicine^. As the latter case is very interesting I repeat it here: 
 
 Pauline R., sixty years old, peasant's wife, has had considerable trouble 
 and worry throughout her life. Her father, a teacher, suffered from nervous- 
 ness during the last few years of his life, and committed suicide in his fifty- 
 second year. Patient has a brother who is quite well. No other sickness in 
 the family. 
 
 Patient herself, when a young girl, was always anaemic, and had "liver 
 
NERVOUS DISEASES OF THE INTESTINES 525 
 
 trouble," but was never confined to bed, and never had jaundice. Present ill- 
 ness began about eight years ago, when, after passing through a severe illness 
 and after the death of her husband, she spent many weeks in mental suffering. 
 Her syrüptoms then consisted of an occasional wavelike motion in the ciMomen, 
 which disappeared whenever she felt contented or happjy. 
 
 The death of her only son aggravated her condition. Since then (three 
 years) her condition has remained about the same. She is sometimes entirely 
 well for weeks and months, then, generally after some psychic disturbance, she 
 suffers for days or weeks. Since March of this year the symptoms are almost 
 continuous-, this she ascribes to the severe illness of her son-in-law. 
 
 She complains of a feeling as of a dead weight in the abdomen and a wave- 
 like sensation, which occur usually at night. The attacks are independent of 
 work, and are frequently relieved by eating. Appetite good; bowels regular. 
 Patient does not otherwise feel ill. Has had five children ; no miscarriages. 
 
 Status prcEsens. — Frail woman, good colour, poorly developed muscular sys- 
 tem and fat. Pupils react well to light, but not so well to accommodation. 
 Triceps and patellar reflexes cannot be elicited. Skin reflexes markedly dimin- 
 ished. Lungs and heart normal. Abdomen is hemispherically distended, the 
 greatest prominence ajjpearing below the umbilicus. When the patient raises 
 the upper portion of her body the intestines press forward through a broad dias- 
 tasis of the recti muscles, which reaches from the umbilicus to the symphysis. 
 Abdominal walls are thin and flabby. 
 
 Liver: Upj)er border begins at the seventh rib in the mammary line. As 
 determined by paljiation and percussion, the lower border of the liver corre- 
 sponds to a line beginning two fingerbreadths above the right anterior inferior 
 spine of the ilium, passing through the umbilicus, and reaching the eighth left 
 costal cartilage. Above this line there is uniform dulness. The sharp border 
 of the liver may be jilainly felt in the right half of this line, less so in the left 
 half. The spleen is slightly movable, and its border may be felt in the left 
 hypochondrium. 
 
 Kidneys are palpable. 
 
 As determined by palpation of an introduced sound, distention, and trans- 
 illumination in the fasting condition, the greater curvature of the stomach 
 extends a handbreadth below the umbilicus. During fasting the stomach is 
 empty. Test breakfast shows normal gastric functions. The urine contains 
 no albumin, sugar, or indican. Microscopical and macroscopical examination 
 of the stools shows no changes. 
 
 Through the thin, flabby abdominal walls one can plainly see the peri- 
 staltic movements (Fig. 47). Three types may be distinguished ; they vary in 
 position, form, and course. 
 
 During rest, one sees two or three parallel sausage-shaped protuberances 
 lying quite closely together. These periods of rest last but a very short time. 
 Soon each protuberance is seen to contract at one end. The wave of contraction 
 passes along the entire segment, while behind it the protuberance again reforms. 
 The whole action is slow and vermicular. There is a continuous alternation of 
 contraction and protuberance, and, following the simile of Nothnagel, the sur- 
 face of the abdomen may be compared to that of a bag filled with potatoes. 
 
 In the left side of the abdomen, from the free border of the ribs to about 
 
526 
 
 DISEASES OF THE INTESTINES 
 
 the anterior superior iliac spine, five — occasionally six — parallel swellings, each 
 about the thickness of a stout lead pencil, may be seen. They are somewhat 
 farther apart than the sausage-shaped tumours before described, and approxi- 
 mately one half the length of the latter (about 4 to 5 centimetres). Several 
 of these swellings disappear and reappear one after the other, thus giving 
 the impression as of the whole mass suddenly springing forward ("harmonica 
 motion "). Seemingly independent of the motions just described, a line of 
 shadow passes about midway between these tumours, oscillating from left to 
 right and mce versa. 
 
 In the epigastrium a semicircular arching may be seen, the lower border 
 corresponding exactly to the greater curvature of the stomach. Along this 
 border a deep contraction passes from left to right, and is immediately suc- 
 
 Fig. 47. — Peeistaltic Eestlessness of the Small Intestines and Descending Colon. 
 
 (Original observation.) 
 
 ceeded by a protrusion. One or two flngerbreadths below the liver the con- 
 traction continues somewhat longer, so that we see two protrusions separated 
 by a depression ; from this point the contraction again takes place more ener- 
 getically, till the line of liver dulness is reached. The series then begins anew 
 and continues uninterruptedly. The direction of motion is always from left to 
 right. Each series lasts from fifteen to eighteen seconds. 
 
 The patient does not feel these motions. Throughout the examinations she 
 has pain only when the peristalsis becomes severe. A pulsation can also be seen; 
 it may be mistaken for peristalsis. The pulsation evidently originates in the 
 
NERVOUS DISEASES OF THE INTESTINES 527 
 
 great arterial trunks, and is transmitted through the flabby abdominal walls. 
 It can be seen, and not felt, and is synchronous with the radial pulse. 
 
 These peristaltic movements may be increased to a slight extent by faradi- 
 zation, friction, and cooling the abdomen. 
 
 The diagnosis of the condition is not difficult. We must always 
 consider the possibility of intestinal stenosis or partial adhesions. 
 Several years ago I observed a large, fixed umbilical hernia com- 
 plicated by hyperperistalsis. The condition of the general nervous 
 system, the alternate disappeai-ance and reappearance of the peri- 
 staltic movements, and its dependence upon excitement, are useful 
 diagnostic facts. 
 
 Teeatment , 
 
 We must first attempt to strengthen the general nervous sys- 
 tem through appropriate climatic and hydrotherapeutic measures. 
 Kussmaul has achieved good results from the intragastric and ex- 
 ternal use of the faradic current. 
 
 Internally, we may give the alkaline bromid salts, narcotics, and 
 perhaps also antipyretics (antipyrin, phenacetin, lactophenin, etc.). 
 In one case I saw good results from codein and belladonna. Rosen- 
 heim ^° recommends chloral hydrate (1 gram, evenings, in gruel). 
 
 In the case described the attacks ceased when the patient was 
 admitted to my private clinic for closer observation. Bodily and 
 mental rest and appropriate nursing evidently contributed consider- 
 ably to this favourable result. 
 
 (c) Paresis {Ato7iy) and Paralysis of the Intestines 
 
 Paresis or atony of the intestines (" intestinal insufficiency," 
 O. Eosenbach) is a functional debility of the intestinal muscular 
 system ; paralysis is an absolute loss of the motor power of the 
 intestines. Both conditions affect the large bowel only. Pareses 
 of the muscle of the small bowel are unknown. In the chapter on 
 Intestinal Strictures and Intestinal Obstruction we have described 
 paralytic conditions of mechanical origin. In what follows we shall 
 discuss only their functional phases. 
 
 (1) Atony op the Large Intestine 
 
 This is closely related to and as frequent as constipation. All 
 the factors which produce constipation may in time produce flabbi- 
 ness or muscular fatigue of the bowel, and, as a result, partial or 
 general distention, or even actual dilatation of the intestine. Con- 
 
528 DISEASES OF THE INTESTINES 
 
 stipation is here the primary factor. Much more difficult is the 
 determination of other conditions which produce primary paresis 
 of the nervous muscular apparatus. By the previously described 
 experiments of Emminghaus, it was shown for the first time that 
 degenerative processes of the splanchnic nerve may produce consti- 
 pation ; this constipation must be considered as an example of 
 neuropathic intestinal atony. The artificial or toxic intestinal 
 pareses following the use of opium, morphin, and belladonna must 
 be placed in the same category. In a case under my own observa- 
 tion, a woman who within a few weeks had taken more than one 
 kilogram [2.2 pounds] of bismuth for symptoms resembling gastric 
 ulcer, there developed most marked intestinal paresis and dilatation. 
 It is well known that individuals who suffer from neuroses and 
 psychic disturbances (neurasthenia, melancholia, hysteria, hypochon- 
 dria, etc.) frequently develop paretic or subparetic conditions of 
 the intestinal muscular apparatus. Thus, in persons predisposed to 
 habitual constipation, I have occasionally observed acute intestinal 
 paralyses from sudden fear, anger, or other excitement. We may 
 explain these phenomena by reflex irritation of the nerves tliat in- 
 hibit intestinal peristalsis (splanchnics). In view of analogous con- 
 ditions in the stomach, we must also admit that traumatism and 
 shock may produce an inhibitory action upon the motor apparatus 
 of the large intestine. Congenital atony of the intestine has also 
 been observed. Intestinal paresis may result from the continuous 
 use of large rectal enemata. 
 
 Clinical observation has led to the differentiation between gen- 
 eral and partial atony. In a series of articles Federn ^^ has called 
 attention to the latter condition. According to this author, partial 
 atony plays a large part in general pathology. He finds this condi- 
 tion not alone in intestinal diseases, but also in arterio-sclerosis, car- 
 diac asthma, pulmonary tuberculosis, neurasthenia and hysteria, and 
 Basedow's disease. Federn even states that partial intestinal atony 
 is connected with the development of the last-named disease. He 
 maintains that the diagnosis of partial atony can be made from the 
 strikingly pungent smell of the stools, and from the fact that gentle 
 percussion of the intestines elicits dulness over some- areas, while 
 deep percussion of the same areas elicits a tympanitic percussion 
 note. 
 
 It needs no special demonstration to prove how little defined 
 and characteristic are the symptoms described by Federn. ISTever- 
 theless, there is a grain of truth in Federn's observations, a truth 
 
NERVOUS DISEASES OF THE INTESTINES 529 
 
 of which experienced physicians have not been as ignorant as this 
 author would have us beheve. At several j)laces along the intes- 
 tines, as the result of faecal stagnation, partial ballooning may de- 
 velop, and despite the presence of diarrhoea (stercoraceous diar- 
 rhceas), fsecal stagnation may exist. As is well known, the sites of 
 predilection for faecal accumulations are the csecum, the hepatic and 
 splenic flexures, the sigmoid flexure, and the ampulla of the rectum. 
 M. Herz ^^ has recently directed attention to a further type of 
 intestinal insufiiciency — that of the ileo-csecal valve, l^ormally, the 
 large intestine is shut off from the ileum by this valve. From in- 
 flammation or by flattening of its lower fold there may result a 
 relative insufiiciency of the valve, as shown by tympanites, consti- 
 pation, flatulency, and neurasthenic and other nervous symptoms. 
 
 Symptomatology and Diagnosis 
 
 These have in greater part been described in the chapters on 
 Habitual Constipation and Chronic Enteritis. Atony is frequently 
 associated with the latter condition. 
 
 Atony is most easily demonstrated by the method described in 
 the General Division of this work (page 74). It consists in the 
 injection of measured quantities of water per rectum and the elicit- 
 ing of splashing sounds in the corresponding segments of the large 
 intestine. Upon distending with air, we find that the amount re- 
 quired is far above the normal ; this also speaks for abnormal flab- 
 biness of the intestine. Herz believes that proof of ileo-csecal 
 insufficiency is demonstrated when gas under pressure can be forced 
 from the csecum into the ileum. The changes in the percussion 
 note are best obtained by percussing with the edge of the finger- 
 nail of one hand upon the nail surface of the other. 
 
 The clinical aspect of diifuse atony is so characteristic, that 
 its diagnosis will rarely be difficult. In every case, however, 
 we should think of the possibility of an underlying mechanical 
 cause. 
 
 As long as we have no more definite data than that obtained 
 from percussion, we shall not be able to diagnose partial intestinal 
 atony. 
 
 Treatment 
 
 This is identical with that described under Habitual Constipa- 
 tion and Chronic Enteritis {q. v.). It is unnecessary to repeat the 
 detailed regulations there given. In ileo-csecal insufficiency, Herz 
 
530 DISEASES OP THE INTESTINES 
 
 recommends massage of the large bowel. In partial atony, besides 
 massage, Federn advises faradization of the large intestine. 
 
 (2) Paresis and Paralysis of the Rectum 
 
 In describing paralytic ileus (page 403) we also discussed paral- 
 ysis of the large intestine. It still remains to describe paresis of 
 the rectum. 
 
 Chronic paresis of the rectum generally results from local rectal 
 affections (prolapse, tumours, proctitis, hemorrhoids, etc.), but occurs 
 also as a symptom of some spinal and cerebral lesions (locomotor 
 ataxia, progressive paralysis, myelitis, etc.). Straining during defe- 
 cation and urination in prostatic hypertrophy and stricture of the 
 urethra may likewise produce rectal paralysis. As a purely neurotic 
 affection this condition is extremely rare. I have once seen it in 
 a boy of nine years who was convalescing from diphtheria. 
 
 Several degrees of rectal paralysis are met with. In mild cases 
 the rectum is only relatively incontinent ; in the severe it is abso- 
 lutely so. 
 
 Symptomatology and Diagnosis 
 
 The main symptom is loss of voluntary control of evacuations. 
 In mild cases the sphincter is incontinent only when there is diar- 
 rhoea; in the severe, formed stools are also involuntarily passed. 
 Active movements of the body, slight straining of the abdominal 
 muscles, coughing, laughing, and sneezing may cause involuntary 
 evacuations and thus distress the patient. 
 
 The diagnosis can at once be made by digital examination of 
 the rectum. The question of etiology is more difficult. We must 
 search for not only disease of the rectum and of intestinal segments 
 higher up, but also for spinal disease. As shown by the following 
 history, it may not be easy to arrive at the proper explanation of 
 some of these cases. 
 
 F. S., aged twenty-two years, book gilder, has lost control over his stools 
 for the last two years. As soon as there is a desire to defecate, no matter 
 whether the stools be solid or fluid, an involuntary evacuation immediately fol- 
 lows. The patient also complains about urination; he must wait some little 
 time before the urine begins to flow. The act of urination is normal and does 
 not indicate stricture. Denies gonorrhcBa and other sexual diseases. 
 
 Patient works considerably with metallic dust which does not contain lead. 
 
 Status Praesens. — Healthy-looking young man; internal organs normal. 
 Anus very flabby, readily admitting two fingers. Proctoscopy shows nothing 
 special. Patellar reflexes markedly increased; no disturbance of sensibility. 
 
NERVOUS DISEASES OF THE INTESTINES 531 
 
 The diagnosis of beginning spinal lesion was made. This was concurred in by 
 Professor Oppenheim, who, in view of the intact sensibility, diagnosticated a 
 lesion in the motor centres of the bladder and rectum. 
 
 Tkeatment 
 
 Where the rectal paresis is secondary, treatment must be directed 
 toward the underlying cause. Where this is impossible, or where a 
 primary neurosis is present, we should endeavour to imjDrove the 
 functions of the incompetent sphincter. For this purpose, faradiza- 
 tion of the rectum is of the first importance, and must be carried 
 out thoroughly and systematically. The diet should vary with the 
 degree of the paralysis. 
 
 If involuntary evacuations occur only when there is diarrhoea, 
 the latter must be prevented by suitable dietetic regulations (astrin- 
 gent diet). If involuntary evacuations occur when the stools are 
 well formed, we must prevent faecal accumulation in the lower 
 intestinal segment. By diet we should attempt to have the stools 
 semisolid, so that a complete daily evacuation follows. The patient 
 must be particularly impressed with the importance of attending to 
 defecation regularly, at a certain fixed time of the day. 
 
 Where, despite these precautions, fseces accumulate in the rec- 
 tum, they should be got rid of by enemata of oil or soap water. 
 The diseased region should also be stimulated by cold sitz baths 
 and frequent irrigations. Of medicinal remedies, injections of 
 strychnin (0.001 to 0.002 gram per dose), or suppositories of nux 
 vomica (0.03 gram twice a day) are best. 
 
 {d) Nervous Flatulence 
 
 This consists of alternating expulsion from and reaccumulation 
 of air within the bowel, similar to nervous eructation. It is seen 
 mostly in hysterical girls and women and in neurasthenics, but also 
 occurs in healthy individuals. 
 
 The aifection may be acute, chronic, or periodical. As yet it is 
 but little understood. The best theory is that which attributes it 
 to rhythmical contraction and dilatation of the intestine. Anal- 
 ogous to what Oser believes to take place in nervous eructation, 
 after the air has been expelled from the lower bowel, renewed con- 
 tractions draw more air from the upper segments ; this leads to dilata- 
 tion, and when the bowel is quite distended the air is expressed, 
 etc. In well-marked cases the expressed air is odourless, or only 
 slightly mixed with offensive gases. 
 
532 DISBASES OP THE INTESTINES 
 
 Symptomatology and Diagnosis 
 
 A feeling of tension and pressure predominates ; this may 
 increase to severe colicky pain. Occasionally the air is heard rum- 
 bling through the gut. The abdomen may be more or less dis- 
 tended ; in my cases, however, despite repeated complaints of the 
 accumulation and passing of air, abdominal distention was scarcely 
 appreciable. Passing of wind affords but little relief. Gases reac- 
 cumulate, and the patients are disturbed throughout the day and 
 sometimes at night. The symptoms are aggravated by mental dis- 
 turbances. 
 
 The diagnosis is made from the clinical phenomena, the course 
 of the affection, and the negative abdominal symptoms. 
 
 Treatment 
 
 This should be directed toward the underlying hysterical or 
 neurasthenic basis. The forbidding of foods which produce flatu- 
 lency is usually ineffectual. Since the patients are generally poorly 
 nourished, anemic individuals, a mixed diet rich in fats is espe- 
 cially beneficial. Fluids and soups should be avoided, since they 
 often increase the flatulence and the feeling of weight in the stom- 
 ach and intestine. Warmth, both internal (valerian, peppermint, 
 and caraway teas) and external (warm fomentations), brings relief 
 and quiets the excited peristalsis. Of the many remedies recom- 
 mended for nervous flatulence, the best are the nux vomica prep- 
 arations (extract of nux vomica, 0.01 to 0.03 gram per dose, in 
 powder or pills), or extract of Calabar bean (0.05 gram to 10.00 of 
 glycerin, 5 to 6 drops t. i. d., or pills, 0.005 to 0.01 gram per dose). 
 
 Where constipation coexists, diet and the magnesia preparations 
 (especially magnesia usta) are to be recommended. 
 
 2. Sensory Neuroses 
 
 Enteralgia {Neuralgia Plexus Mesenterici) 
 
 This is a periodic, painful irritation of the intestinal nerves, 
 occurring without apparent anatomical cause. Thus enteralgia is a 
 true neuralgia, and, as stated by Nothnagel,* must be distinguished 
 from the colic of intestinal contraction. The cause is said to be in 
 the large nerve plexuses (mesenteric, hypogastric, and coeliac). 
 
 * Loc. cit., p. 489. 
 
NERVOUS DISEASES OP THE INTESTINES 533 
 
 Eomberg has tried to establisli separate types of the affection for 
 the different plexuses affected. When carefully examined, how- 
 ever, the symptoms are so similar that it is almost impossible to 
 differentiate these groups. The very assumption that enteralgia 
 is due to disease of the mesenteric plexus is purely theoretical. 
 Malaria, lead poisoning, and locomotor ataxia are cited as causes of 
 entei'algia. This condition is also found in hysterical and neuras- 
 thenic individuals, and Peyer has very often observed it in sexual 
 neurasthenics. 
 
 S TMPTOM ATOLOGT 
 
 Enteralgia presents itself as mild or severe, drawing, cutting, 
 boring, and burning pains in the abdomen, particularly in the meso- 
 gastrium. The patients take to bed, writhe with pain, and seek 
 relief by evacuations or the passing of wind. In severe cases vomit- 
 ing may occur and afford the patient temporary relief. 
 
 We shall not discuss in detail the enteric crises of locomotor 
 ataxia, but mention that they constitute the purest and most instruc- 
 tive types of enteralgia. 
 
 The attacks may cease after several minutes, or, with slight 
 remissions, last for hours or days (as in visceral crises). They gen- 
 erally cease or become less acute during the night. 
 
 In one of my patients, a man of fifty, whose nervous system was upset by 
 intense excitement, severe pain followed each act of an otherwise normal defe- 
 cation. Careful clinical examination showed normal intestinal functions and 
 stools. 
 
 Galvanism improved his condition, and a sojourn in the mountains entirely 
 cured him. 
 
 Ohjectively, there may be slight tympanitis and local points of 
 pain, particularly in both hypochondria (A. Peyer). According to 
 my experience, the severe pain complained of is in marked contrast 
 with the normal condition of the abdomen. 
 
 Constipation may accompany enteralgia, but, unlike stercora- 
 ceous colic, does not constitute a necessary feature of the attack. 
 That constipation accompanies enteralgia of longer duration (e. g., 
 enteric crises) is explained by the vomiting usually present, and the 
 abstinence from food. 
 
 The diagnosis of enteralgia is easily made when its etiology is 
 apparent (e. g., locomotor ataxia, arthritis, lead intoxication, hys- 
 teria, and neurasthenia). When the etiology cannot be discovered 
 the diagnosis is always uncertain. 
 35 
 
534 DISEASES OP THE INTESTINES 
 
 Hepatic, renal, and cystic calculi must first be carefully excluded. 
 An irregular cholelithiasis may closely resemble enteralgia. Care- 
 ful examinations of the anterior and posterior regions of the liver, 
 questioning regarding icterus, and the finding of concretions may 
 aid in the differentiation. In distinguishing from nephrolithiasis 
 and cystolithiasis, we must consider the data obtained from palpa- 
 tion of the kidney and bladder, examination of the urine, and cys- 
 toscopy. Enteralgia can usually be distinguished from flatulent colic 
 by the presence of f secal accumulations, or by the irregular char- 
 acter of the stools in the latter and by the cessation of the attack 
 when large quantities of flatus have been passed. 
 
 Differentiation from true colitis can generally be made by re- 
 peated and careful inspection of the stools and by intestinal irriga- 
 tion. In this connection we would mention hernias of the linea alba, 
 which are easily overlooked, and which often cause gastralgia or 
 enteralgia. Adhesions of the intestinal segments may produce all 
 the symptoms of severe intestinal neuralgia. 
 
 In some text-books (Rosenheim and A. Pick) peritonitis and 
 perityphlitis (A. Peyer) are also considered in this connection. 
 When the patient is examined not only during the attack but also 
 after its completion, error is almost impossible. 
 
 Tkeatment 
 
 ■ As enteralgia is not a primary affection, its curability depends 
 upon the underlying disease. In lead colic, complete cure is ac- 
 complished by removal of the toxic cause and by the administra- 
 tion of appropriate remedies (iodin preparations, sulphur baths, 
 etc.). Up to the present time the visceral crises of locomotor ataxia 
 have remained rebellious to treatment. The crises of gout are like- 
 wise extremely obstinate. In these latter instances, as well as in 
 idiopathic enteralgia, we must treat the paroxysms symptomatically 
 with hot fomentations, warm enemata, and narcotics (best subcuta- 
 neously or in suppositories). Invigorating general treatment is in- 
 dicated in neurasthenical or hysterical enteralgias. Galvanization 
 of the abdomen and rectum may also be tried. 
 
 3. Secretory Neuroses 
 
 («) Nervous Diarrlioßa 
 
 This condition, first minutely described by Trousseau, is charac- 
 terized by more or less numerous thin, watery, generally periodic 
 
NERVOUS DISBASES OF THE INTESTINES 535 
 
 evacuations. The diarrhoea may result from some ceutral disturb- 
 ance (the irritation being carried along the course of the vagi and 
 sympathetic), from peripheral irritation (alimentar}'^ diarrhoea), it 
 may be reflex (disease or displacement of the genital organs, en- 
 tozoa, thermic causes, etc.), or may be due to the absorption of toxic 
 products. 
 
 In a limited sense, nervous diarrhcea is usually an accompany- 
 ing symptom of general nervous debility. This fact must be kept 
 in mind, since only by its careful consideration can a positive diag- 
 nosis be made and favourable treatment instituted. A more ex- 
 tended experience enables us to distinguish several types : The first 
 group is characterized by the fact that under the influence of emo- 
 tions, or after partaking of certain food or drink, these individuals, 
 whose intestinal functions are otherwise normal, suddenly have one 
 or several quickly repeated fluid evacuations. 
 
 In the second group the intestines are unstable, a tendency to 
 diarrhcea exists, but the patients are otherwise healthy. From 
 mental excitement or variations from their ordinary mode of liv- 
 ing, sudden severe diarrhoeal evacuations occur, which cease after 
 the patient is placed under normal conditions. 
 
 A third group is characterized by diarrhoea under special condi- 
 tions—for example, when opportunity for defecation does not exist, 
 or is surrounded by certain embarrassing difiiculties. At other 
 times the intestinal function is normal. 
 
 Symptomatology and Diagnosis 
 
 Apart from the etiology and the periodicity of its occurrence, 
 nervous diarrhoea presents no specific features. The number of 
 dejections varies largely. The subjective symptoms are the usual 
 ones of tenesmus, rumbling, severe thirst, etc. The stools are not 
 characteristic. The patients tell us that food has been passed com- 
 pletely undigested, but since there is rarely an opportunity for ex- 
 amining the stools during an attack this statement must be accepted 
 with great reserve. We shall again refer to the question of mucous 
 admixture of the evacuations. Blood is never or very exceptionally 
 present. Pus is always absent. 
 
 These diarrhoeas are, so to speak, explosive in character. A 
 feeling of intestinal quietude very soon follows an attack developed 
 with inconceivable rapidity, and then, aside from a slight weari- 
 ness, the patient is relieved and well. In other cases the attack 
 begins very suddenly, but if left untreated it may continue 
 
536 DISEASES OP THE INTESTINES 
 
 many hours or days. I have recently seen a very typical case of 
 this kind. 
 
 The etiological factors of the attacks vary, and depend chiefly 
 upon the particular psychic idiosyncrasy of the individual. In an 
 excellent article on Gastric Keuroses, Fleiner ^^ relates how students 
 before their first duels, and physicians before applying forceps dur- 
 ing labour, previously visit the water closet.* These are examples of 
 very acute emotional diarrhoea (diarrhoea produced by fear). In 
 chronic cases, occupation frequently determines the attacks. For 
 example, I have often observed nervous disorders in bankers and 
 stock speculators under the influence of sudden great financial 
 crises. In actors, a debut, a gala or a first performance may in- 
 duce peristaltic hypermotility. Canstatt^^ reports the case of a 
 physician who was attacked with watery diarrhoea before every 
 large operation. Numerous other examples might be given. 
 
 Before proceeding to the diagnosis I shall describe several cases 
 which illustrate the above remarks. 
 
 I. — Mr. S., wine merchant of Berlin, forty-six years of age; comes from 
 a nervous family, and, as he himself says, has been nervous for years. Was 
 formerly addicted to excessive drinking, especially of champagne. Patient is 
 married to a very nervous and jealous woman. He complains of the following 
 attacks which occur from three to five times yearly : After any great excite- 
 ment he is suddenly attacked by severe gastric colic, together with profuse 
 diarrhoea. Even the blandest nourishment is passed in a few minutes. The 
 attacks last three or four days, during which time the appetite is very poor. 
 The patient improves gradually. In the interval between the attacks the gastric 
 functions are normal. 
 
 The last attack occurred on June 3, 1898, in consequence of great agitation 
 at his home. The patient suffered intense pain, causing him to toss about and 
 to break out into a cold perspiration. The pain always begins during the day, 
 but ceases at night. It is independent of food ingestion. There are twenty to 
 thirty almost watery stools per day, accompanied by severe tenesmus. 
 
 Status Pr mens. — Muscular, florid-looking man; pulmonary organs normal. 
 Marked diffuse sensitiveness to pressure in the gastric region, disappearing 
 when the patient's attention is withdrawn. Posteriorly, alongside the verte- 
 bral column there are numerous scattered pressure points. Patellar and pupil 
 reflexes are somewhat sluggish. No disturbances of sensibility, no Romberg's 
 symptom. 
 
 This case gives the impression of a visceral crisis, and we cannot 
 exclude the possibility that the above symptoms represent begin- 
 
 * In his celebrated novel Debacles, Zola has forcibly described the reflex action 
 upon intestinal peristalsis resulting from the enemy's artillery fire. 
 
NERVOUS DISEASES OP THE INTESTINES 537 
 
 ning locomotor ataxia. At present, however, corroborative symp- 
 toms are absent, so that we may regard the case as one of secretory 
 neurosis. The etiology also speaks in favour of this diagnosis. 
 
 II. — Mrs. L. T., of Berlin, aged thirty-three; teacher. For years patient 
 has suffered from nervous disturbances of the stomach and intestines; for 
 example, vomiting and diarrhoea occurred frequently at examinations. Later, 
 this condition improved, but about three months after an operation for fistula 
 in ano it returned. Since that time diarrhoea frequently occurs after the 
 slightest excitement ; thus the thought of consulting a physician or of meeting 
 strangers produces intestinal hyperperistalsis. There is also a predisposition to 
 diarrhoea when the patient makes a social call and cannot reach the toilet room 
 unobserved. In her own home, however, such attacks do not occur. Diet has 
 absolutely no effect upon the attacks — e. g., the stools may be quite normal 
 after eating fruit, vegetables, rye bread, or cake. Appetite always good. Pa- 
 tient is anaemic, has cold extremities (mains serpentines). Except for mild 
 sphincteric paresis all organs are normal. 
 
 Treatment. — Arsenic, which, according to patient, is very successful. 
 
 III. — Mr. L., fifty years old, director of a chemical factory in Boston; 
 antecedents of both parents nervous. The sisters of the patient are more or 
 less neurotic, but severe diseases of the nervous system have never appeared 
 in the family. The patient himself is easily excitable, but is of happy tem- 
 perament. 
 
 Has had his present trouble for ten years. It shows itself in occasional 
 diarrhoea, which occurs particularly when the patient is prevented from or 
 embarrassed in seeking the toilet. This is specially the case during railroad 
 trips. He must always ride in a railroad coach containing a toilet. When the 
 patient is invited to dinner it often happens that he must leave because of 
 sudden intestinal hypermotility. When going to the theatre he always takes 
 an end seat, so as to be able to leave quickly if necessary. Otherwise the 
 stools are entirely regular; the appetite is fair; sleep and general condition 
 good. 
 
 The patient is a strong, well-nourished man. Objective signs (including 
 examination of the faeces) are normal. 
 
 IV. — Mrs. G., of Moscow, aged twenty-nine; merchant's wife. The pres- 
 ent affection dates back six years, and began with her puerperium. It com- 
 menced with severe intestinal colic and rumbling and fluid stools mixed 
 with mucus and blood. Improvement after three or four days. Since then 
 there has been marked sensitiveness of the intestines, particularly when the 
 patient is excited. For example, the colic and diarrhoea begin when she is 
 frightened or worried; once an attack occurred when her child was sick, and 
 again when she had toothache and migraine. Rest has a favourable effect. 
 Diet has no appreciable influence. In the intervals between the paroxysms 
 the patient has normal stool daily or every second day. During pregnancy and 
 after labour the attacks are more severe and frequent. 
 
 On June 19, 1898, the patient was admitted to my private clinic for careful 
 observation. 
 
 I pass over unimportant details and mention only the intestinal phenomena. 
 
538 DISEASES OF THE INTESTINES 
 
 There is marked sensitiveness along the entire course of the Irrge intestine, 
 particularly over the caecum, the descending colon, and the sigmoid flexure. 
 
 Examination of the Fmes. — These are formed and covered with thick, tena- 
 cious mucus. Microscopically there is much degenerated epithelium, in several 
 places striated ground substance, in which, by the addition of acetic acid, 
 numerous nuclei are seen. Test lavage of the intestine also shows small shredded 
 or gelatinous masses of mucus. 
 
 Treatment. — Astringent diet as in chronic diarrhoea. Improvement. On 
 June 2oth, after a long visit of a relative from Leipzig, she had five fluid evacu- 
 ations accompanied by severe pain. Despite fluid diet she had continuous 
 tenesmus and about twenty movements during the night of June 35th. The 
 stools were brown and watery; microscopically they showed nothing special. 
 Tincture of opium and warm fomentations were ordered. On the next day a 
 feeling of marked tension in the abdomen and of great weakness. The stools 
 soon became firm and less frequent as the patient rapidly recovered, and left 
 the clinic on July 5th. After a course at Franzensbad she was completely 
 cured. 
 
 The diagnosis of nervous diarrhoea may be simple or difficult. 
 TThere, as in the second and third cases, the nervous factor is pre- 
 dominant, the affection occurs periodically with normal conditions 
 during the intervals, the diet has no influence upon the course of the 
 disease, the clinical examination shows other symptoms of neuras- 
 thenia, and the stools exhibit no signs of catarrhal enteritis, the 
 diagnosis can readily be made. 
 
 If, however, the condition becomes chronic, the diagnosis is less 
 simple. Thus, in the fourth case there is as much ground for as 
 against the assumption of a nervous origin. The absence of mucus 
 in the dejections — a point on which Nothnagel lays great stress — is, 
 according to my own experience and that of von Engelhardt ^^, by 
 no means a positive differential fact. Despite the nervous basis of 
 the disease, a catarrh may develop, or an otherwise mild clinical 
 enteritis may, from mental excitement, suddenly become worse and 
 present symptoms of a severe intestinal catarrh. There will be 
 mucus in the stools, and yet in both instances the diarrhcBa is 
 neurotic. 
 
 In his excellent treatise von Engelhardt attempts to introduce 
 other facts for the differentiation between true enteritis and intes- 
 tinal neuroses. He distino-uishes between these two conditions as 
 follows : 
 
 Chronic Intestinal Catarrh. — There is generally loss of weight 
 and anaemia. When diarrhoea takes place it is usually during the 
 night or in the early morning, and comes on at irregular intervals 
 during the day. Diet has a marked effect upon the character of 
 
NERVOUS DISEASES OP THE INTESTINES 539 
 
 the stool and upon the patient's general condition. There is sensi- 
 tiveness to pressure over the colon. 
 
 Intestinal Neuroses. — No loss of weight ; frequently robust 
 appearance despite diarrhoea for many years. The diarrhoea gen- 
 erally occurs at the usual time of defecation or immediately after 
 eating. Evacuations follow one another rapidly, and then cease for 
 a long time. Diet has almost no effect upon the attacks, or they 
 may cease after a mixed diet. Sensitiveness to pressure over the 
 aorta and the iliac arteries. 
 
 The facts cited by von Engelhardt are doubtless of diagnostic 
 value, as the clinical histories just given illustrate. In individual 
 cases, however, his points of differentiation may leave us in the dark. 
 For example, I have repeatedly seen morning diarrhoeas in typical 
 neurasthenics whose intestinal functions were otherwise normal. 
 Again, the general condition of a patient with intestinal neurosis is 
 not, as von Engelhardt maintains, always excellent. In the second 
 case I have described I find in my journal " the patient lost 5 kilo- 
 grams within a short time." It follows, therefore, that in view 
 of the innumerable possible combinations of the protean picture of 
 intestinal neurosis, all scientific considerations may occasionally 
 mislead. A clear conception of the disease is possible only from 
 systematic and most careful observation ; often we can only estab- 
 lish the diagnosis from the course of the aifection, or from the 
 results of treatment. 
 
 Treatment 
 
 This will vary with the type of the disease. The classification 
 previously made (page 535) shows that in the intervals between 
 attacks the intestinal function is sometimes normal. In such cases 
 treatment will be directed toward the general condition, the gen- 
 eral and local neurotic irritability, and the diarrhoeas tliemselves 
 when these become excessive. For the last-named condition opium 
 is undoubtedly the most appropriate remedy. Dietetic treatment 
 is of secondary importance. In continuous intestinal irritability the 
 treatment should be different. A diet similar to that of chronic diar- 
 rhoea (see pages 224 and 225) will frequently, though not always, 
 prevent an attack. In chronic neurotic diarrhoea the same princi- 
 ples apply. In addition, hydrotherapeutics, and in some cases 
 electricity (galvanism), may be beneficial. For obvious reasons the 
 best results are achieved by sanitarium treatment. 
 
 Of medicinal remedies, the bromid preparations (bromid of soda. 
 
540 DISEASES OP THE INTESTINES 
 
 0.5, one powder t. i. d.) deserve first consideration. According to 
 JSTothnagel (see also Case II), the arsenical preparations (Fowler's 
 solution, 3 to 5 drops t. i. d., in peppermint water) may liave a 
 favourable effect. For anaemic patients, iron springs (Franzensbad, 
 Elster, Pyrmont, Cudowa, Rippoldsau) may be of benefit. Carlsbad 
 thermal water taken hot and in small doses is sometimes followed 
 by good results.* 
 
 (b) Mucous Colic 
 
 In discussing membranous enteritis (page 228) we mentioned 
 mucous colic and the different theories regarding its origin. There 
 can be no doubt that periodical membranous dejections are frequently 
 observed in neurasthenic and hysterical women. But — and this is 
 the distinguishing characteristic — they scarcely ever occur without 
 simultaneous habitual (generally spastic) constipation. Since we 
 know that in predisposed individuals conditions of obstinate con- 
 stipation form the basis for all kinds of nervous and hysterical 
 symptoms, we do not consider mucous colic as a symptom of 
 hysteria or neurasthenia, but only of constipation. When the 
 latter is well marked mucous colic occurs, and it ceases when the 
 constipation is no longer present. I do not know of a single 
 instance, either from personal observation or from literature, in 
 which the mucoid dejections did not cease when the bowels were 
 regular. In view of these facts, the theory still maintained by sev- 
 eral authors that mucous colic is a secretory neurosis is incorrect. 
 
 It is therefore unnecessary for us to give a separate description of 
 this affection ; that in the section on Membranous Enteritis sufiäces. 
 
 4. Complex Intestinal Neuroses 
 
 Intestinal Neurasthenia 
 
 We have stated (page 521) that abnormal disturbances of func- 
 tion may frequently find their outlet along the course of different 
 nerves, so that motor, sensory, secretory, and probably also vaso- 
 motor disturbances of innervation may be variously combined. In 
 this manner there result intestinal conditions similar to those pro- 
 duced in the stomach by nervous dyspepsia. 
 
 Cherchewski ^^ was the first to give a detailed description of 
 
 * [For corresponding springs and wells in the United States, see pp. 161, 164, 
 and 165.— Tr.] 
 
NERVOUS DISEASES OP THE INTESTINES 541 
 
 intestinal neurasthenia. He directed special attention to tliree 
 characteristic symptoms, viz. : 
 
 1. Habitual constipation, rarely alternating with diarrhoea. 
 
 2. Abdominal distention, particularly in the region of the false 
 ribs. 
 
 3. Loud, tasteless, odourless eructations which only exceptionally 
 are acid. 
 
 These symptoms are also found in spastic constipation, in nerv- 
 ous flatulence, and in membranous enteritis. (Instances of the 
 latter condition doubtless figure among the author's cases.) 
 
 Under the term " nervous digestive weakness," Möbius ^'*' some 
 years ago described a widely different type. In this, despite excel- 
 lent appetite and abundant nourishment, the patients, without suf- 
 fering any subjective digestive symptoms, become more and more 
 emaciated. Their evacuations are apparently normal, but really 
 are overabundant, and a large part of their nourishment undoubtedly 
 passes away unabsorbed. 
 
 It is well known that, notwithstanding sufficient nourishment, 
 individuals may persistently emaciate, but it is questionable whether 
 we are not dealing with minute, as yet unknown, anomalies of food 
 metabolism. In my opinion, there is at present no reason for a 
 special description of intestinal nenrasthenia as an individual clin- 
 ical picture such as is found in the text-books of Rosenheim and 
 Pick. If we possessed a more or less complete clinical syndrome, 
 we would be justified in separating this from the other forms of 
 intestinal neurosis. Since such is not the case, we must limit our- 
 selves to the statement that functional disturbances of the most 
 varied kinds may be combined with one another, and thus produce 
 an ensemble whose individual traits are entirely dissimilar. 
 
 LITERATURE 
 
 1. Jürgens. Verhandl. des III. Congresses f. innere Medicin, 1884, S. 252 ; 
 
 Berl. klin. Wochenschr., 1893, S. 357. 
 
 2. Blaschko. Virchow's Archiv, Bd. xciv, S. 136. 
 8. Sasaki. Ibid., Bd. xcvi, S. 387. 
 
 4. Schleimpflug. Zeitschr. f. klin. Medicin, 1885, Bd. ix, S. 40, 
 
 5. Emminghaus. Munch, med. "Wochenschr., 1894, No. 5 u. 6. 
 
 6. Nothnagel. Darmkrankheiten, S. 482. 
 
 7. Peyer. Die nervösen Affectionen des Darms bei der Neurasthenie des 
 
 männlichen Geschlechtes, Wiener Klinik, 1893. 
 
 8. Kussmaul. Volkmann's Samml. klin. Vorträge, 1878, No. 53. 
 
 9. Boas. Verhandl. des XV. Congresses f. innere Medicin, 1897, S. 479, etc. 
 10. Rosenheim. Pathologie u. Therapie d. Krankheiten d. Darms, S. 492. 
 
542 DISBASES OF THE INTESTINES 
 
 11. Federn. Ueber partielle Darmatonie, Wiener Klinik, 1891 ; Blutdruck u. 
 
 Darmatonie, Wien, 1894; Ueber Darjmatonie, Wiener med. Presse, 
 1895, No. 25-28. 
 
 12. M. Herz. Wiener med. Wochenschr., 1897, No. 36 u. 37. 
 
 13. Fleiner. Archiv f, Verdauungskrankheiten, 1895, Bd. i, S. 243. 
 
 14. Canstatt. Prager Vierteljahrschrift, 1849, iii, 99. Cited from Henoch, 
 
 Klinik d. Unterleibskrankheiten, iii, S. 176. 
 
 15. R. von Engelhardt. Petersburger med. Wochenschr., 1895, No. 48. 
 
 16. Cherchewski. Revue de medecine, 1883, p. 876, etc., and 1033, etc. 
 
 17. Möbius. Centralbl. f. Nervenheilkunde, Bd. vii, S. 4. 
 
LIST OF SUBJECTS 
 
 Abdomen, inspection of, in intestinal dis- 
 eases, 67. 
 Abscess, perityphlitic, 448. 
 Absorption, intestinal, 86. 
 
 from large intestine, 37. 
 
 from small intestine, 40. 
 
 from rectum, 40. 
 Acetonuria, 134. 
 Acholia. See Stools. 
 Achylia gastrica, relation to dyspeptic 
 
 diarrhoea, 221. 
 Acid, acetic, 42, 103, 206. 
 
 biliary, 29, 30, 108. 
 
 butyric, 46, 103, 206. 
 
 caproic, 206. 
 
 carbonic, 45-48. 
 
 ethereal sulphuric, 45, 133. 
 
 fatty, 42, 102, 103, 125. 
 
 formic, 206. 
 
 hydroparakumaric, 45. 
 
 lactic, 46, 206. 
 
 oxy-, 46. 
 
 phenyl-acetic, 45. 
 
 phenyl-propionic, 45.- 
 
 phenyl-sulphuric, 46. 
 
 propionic, 103, 206. 
 
 succinic, 46, 103, 206. 
 Adenomata, 333. See Polypi. 
 Adhesions, obstructions produced by, 
 392, 393. 
 
 strangulation produced by, 372. 
 Albumin, determination of, in fasces, 100. 
 
 digestion of, 37, 140. 
 Albuminuria, 134. 
 Albumoses, determination of, in fjeces, 
 
 101. 
 Ammonia, 47. 48. 
 Antipepton, 27. 
 Anti-peristalsis, 34. 
 Antiseptics, intestinal, 199. 
 
 Anus, inspection of, 77. See Inspection, 
 Rectal. 
 
 palpation of, 77. See Palpation, 
 Rectal. 
 Appendicitis, 430. 
 
 actinomycotic, 437 ; operation in, 466. 
 
 American views of, 466. 
 
 as a surgical disease, 467, 471. 
 
 bacteria in, 435. 
 
 complications of, 453 ; chronic intes- 
 tinal obstruction, 455 ; emboli 
 and thrombi, 454; empyema, 454; 
 mode of origin, 454 ; pleurisy, 
 454; pylephlebitis, 454 ; pregnan- 
 cy, 455 ; secondary abscess, 454, 
 470 ; suppurative pericarditis, 454; 
 thoracic and abdominal fistulae, 
 454. 
 
 etiology, 434. 
 
 faecal concretions in, 435. 
 
 frequency of, 435, 437. 
 
 larvata, 453. 
 
 operation, contraindications to, 471 ; 
 indications for, 470. 
 
 pathologico-anatomical considerations, 
 434, 467. 
 
 pseudo-perityphlitis, 453. 
 
 septic, 453. 
 
 synonyms of, 430. 
 
 treatment, 457, 468 ; conservative, 457, 
 468; surgical, 461,470. 
 
 tuberculous, 437 ; operation in, 465. 
 Appendicitis, acute, 430, 433. 
 
 diagnosis from biliary and renal colic, 
 449 ; from cjecal tumours, 813, 
 451 ; from disease of the female 
 adnesa, 450 ; from intestinal ob- 
 struction, 368, 452 ; from typhoid 
 fever, 458 ; in unusual positions 
 of the appendix, 449, 451. 
 543 
 
544 
 
 DISEASES OP THE INTESTINES 
 
 Appendicitis, acute, diffuse, 446 ; causes, 
 446; diagnosis, 447; difEerential 
 diagnosis, 453 ; surgical treatment 
 of, 462, 472. 
 
 perforative, 446; differential diagno- 
 sis, 452. 
 
 prophylaxis of, 457. 
 
 puncture, intestinal in, 441. 
 
 simple, catarrhal, 440 ; differential 
 diagnosis, 449 ; symptoms, 440 ; 
 gastric disturbances, 443 ; onset, 
 440; pain, 440; pressure sensi- 
 tiveness, 440 ; pulse, 444 ; tem- 
 perature, 443 ; tumour, 441 ; treat- 
 ment, 458 ; surgical measures in, 
 462. 
 
 suppurative, circumscribed, 462 ; sur- 
 gical treatment of, 462, 472. 
 
 treatment, 457 ; after-treatment, 460 ; 
 conservative, 458, 468 ; bodily rest, 
 458 ; diet, 154, 460 ; ice. 459, 469 ; 
 laxatives, 189, 459, 469 ; opiates, 
 154, 194, 458, 469 ; prophylaxis, 
 457 ; surgical, 461 ; indications for 
 operations, 464, 470, 471. 
 
 varieties of, 439. 
 Appendicitis, chronic, 430, 483. 
 
 diagnosis, 448. 
 
 diet in, 154. 
 
 etiology, 447. 
 
 massage in, 171. 
 
 obliterans, 448. 
 
 recurring, 447. 
 
 relapsing, 447. 
 
 treatment, 464 ; internal, 465 ; opera- 
 tive, 465. 
 
 varieties of, 447, 453. 
 Appendicular colic, 445, 467. 
 Appendix, vermiform, 13. 
 
 palpability of, 71. 
 
 surgical anatomy of, 433. 
 Applications, moist, 175. 
 
 indications for, 175. 
 Atony, intestinal, 527. 
 
 etiology, 527. 
 
 symptoms, 529. 
 
 treatment, 170, 198, 529. 
 
 varieties of, 528. 
 Auerbach's plexus, 5. 
 Auscultation, abdominal, 84. 
 
 diagnostic value of, 84. 
 Axial torsion. See Volvulus. 
 
 Bacteria in fa3ces, 119. 
 
 bacillus putrificus coli, 121. 
 
 bacillus subtilis, 121. 
 
 bacterium coli, 120. 
 
 bacterium laetis ferogenes, 121. 
 
 cholera bacillus, 122. 
 
 Clostridium butyricum, 121. 
 
 cocci, 122. 
 
 decomposition by, 45. 
 
 tubercle bacillus, 122, 267. 
 
 typhoid bacillus, 122. 
 Ballottement, 319. 
 Bands, obstructions produced by, 372. 
 
 omental strangulation produced by, 
 372. 
 Baths, 168. 
 
 classification of, 168, 175. 
 
 in conjunction with mineral waters, 
 168. 
 
 therapeiatic indications for, 168, 515. 
 Bauhin's valve, 13. 
 Belladonna, in intestinal diseases, 187, 
 
 195, 415. 
 Bile, 29. 
 
 characteristics and composition, 29. 
 
 functions of, 29. 
 
 in stomach contents, 130. 
 
 relation to digestion. 30. 
 Biliary acids, 29, 30, 108 ; determination 
 of, in faeces, 108. 
 
 gravel in fasces, 111. 
 
 pigments, 30, 93, 107; demonstration 
 of, in fa?ces, 107, 108, 111. 
 Bilirubin, Biliverdin. See Biliary Pig- 
 ments. 
 Blood, condition of, in cancer, 301. 
 Blood in fa?ces. 64, 95, 105, 269, 311, 319, 
 496, 500, 512. 
 
 appearance, microscopical, 106, 117. 
 
 demonstration, chemical, 106; micro- 
 chemical, 106 ; spectroscopic, 
 106. 
 
 determination of, 105. 
 
 importance of, in the history, 64. 
 
 sources of, 107. 
 Bougieing, rectal, 81. 
 
 diagnostic significance of, 81, 82, 
 501. 
 
 precautions to be observed in, 82. 
 
 therapeutic employment, 83, 503. 
 Bougies, rectal, A^arieties of, 81. 
 Brunner's glands, 9, 25. 
 
LIST OP SUBJECTS 
 
 545 
 
 Cfecum, 12 ; tuberculosis of. See Tuber- 
 culosis, Ileo-caecal. 
 tumours of, 271, 312. 
 Carbohydrates, determination of, in faeces, 
 102. 
 digestion of, 37, 102, 141 ; in the ab- 
 sence of pancreatic juice, 42. 
 Carcinoma, intestinal, 296. 
 ascites in, 301. 
 body weight, 300. 
 complications, 322. 
 condition of blood in, 301. 
 cylindrical epithelial, 298. 
 diet, 151, 323. 
 etiology, 298. 
 frequency of, 296. 
 
 general symptoms and diagnosis, 300. 
 glandular enlargements, 302. 
 heredity in, 300. 
 medullary, 298. 
 metastasis, 299. 
 oedema of ankles, 301. 
 pathological anatomy, 298. 
 scirrhous, 298. 
 
 treatment, 322 ; palliative, 323 ; surgi- 
 cal, 325. 
 urine in, 301. 
 varieties of, 298. 
 Carlsbad Water, in duodenal ulcer, 293^ 
 Carminatives, 197. 
 
 Catarrh, acute intestinal, 205. See En- 
 teritis, Acute, 
 chronic, 212. See Enteritis, Chronic, 
 duodenal, 210. 
 
 of large intestine, 222 ; diagnosis of, 
 222 ; diet in, 145 ; mucus in, 222. 
 of small intestine, 218 ; diagnosis of, 
 
 218; diet in, 144; stools of, 219. 
 mixed forms of, 223. 
 Cathartics in intestinal diseases, 186. 
 action of, 186. 
 administration, endermic, 254 ; rectal, 
 
 187; subcutaneous, 187, 250. 
 contraindications to the use of, 189. 
 in appendicitis, 189, 459, 469. 
 in children, 190. 
 indications for the use of, 188. 
 in hemorrhoids, 514. 
 in membranous enteritis, 190. 
 in obstruction and stenosis, 413, 418, 
 in typhlitis, 189, 456. 
 Centralkoth, 76. 
 
 Chlorophyl in the faeces, 93. 
 Cholesterin, 30. 
 
 determination of, in faeces. 111, 123. 
 Clefts, strangulation produced by, 372. 
 Colic, appendicular, 445, 467. 
 
 flatulent, 244 ; diagnosis from intesti- 
 nal obstruction, 367; opiates in, 
 196; treatment, 254. 
 mucous, 540. 
 vermicular, 445, 467. 
 Colitis, primary, 475. See Pericolitis, 
 
 Exudative. 
 Colon, ascending, 13. 
 descending, 14. 
 displacements of, 86, 255, 257. 
 transverse, 14. 
 Coloptosis, 86. 
 Colouring matter, biliary, 30. 
 
 of fiBces, 30, 107. 
 Compression of bowel, producing ob- 
 struction, 394. 
 Constipation, 60, 240. 
 acute, 60 ; cathartics in, 188 ; causes 
 
 of, 60. 
 alternating with diarrhcea, 61, 228. 
 chronic, 240; alimentary, 240; atonic, 
 243; cathartics in, 188, 251; 
 causes of, 61 ; diagnosis, 245 ; diet 
 in, 146, 227, 247; electricity in, 
 250; fragmentary, 243; in carci- 
 noma, 308 ; in chronic enteritis, 
 223, 227; in obstruction of large 
 intestine, 361 ; in stenosis of large 
 intestine, 354 ; massage in, 249 ; 
 mineral waters in, 159, 161, 162, 
 166 ; opium in, 187 ; predisposing 
 to intestinal cancer, 61 ; prophy- 
 laxis of, 247; rectal examination 
 in, 245; spastic, 243; symptoms, 
 242 ; treatment of, 168. 227, 246. 
 habitual, 240. See Chronic, 
 mineral waters in, 159. 
 significance of, as a symptom, 60. 
 Coproliths, 112. See Stones. 
 Crystalline bodies in faeces, 123. 
 ammonium - magnesium phosphates, 
 
 126. 
 bismuth, 126. 
 calcium oxalate, 126. 
 calcium phosphate, 125. 
 calcium sulphate, 126. 
 Charcot-Leyden crystals, 123, 236. 
 
546 
 
 DISEASES OF THE INTESTINES 
 
 Crystalline bodies in f;eces, Cholesterin, 
 123. 
 fatty acids, 125. 
 fatty soaps, 125. 
 liaematoidin, 123. 
 
 Decubital intestinal ulcer, 262. 
 Diaceturia, 134. 
 Diarrhoea, 62. 
 
 acute, 62, 192, 207; diet in, 143, 211; 
 remedies in, 192. 
 
 chronic, 62 ; causes of, 62 ; diet in, 149, 
 224; in chronic enteritis, 219, 223, 
 224; medicinal remedies in, 192, 
 226; mineral waters in,163,164,166. 
 
 dyspeptic, 62, 220. 
 
 false, 500. 
 
 nervous, 534; diagnosis, 538 ; from 
 chronic enteritis, 538 ; diet in, 155, 
 539 ; etiology, 535 ; symptoms, 
 535 ; treatment, 539 ; varieties, 535. 
 
 significance of, as a symptom, 62. 
 
 subacute, 192. 
 Diet in intestinal diseases, 139. 
 
 fundamental principles of, 139, 
 
 general rules for, 141. 
 
 in acute enteritis, 143, 211. 
 
 in appendicitis and typhlitis, 153, 456, 
 460. 
 
 in cancer of large intestine, 325. 
 
 in cancer of small intestine, 323. 
 
 in chronic constipation, 146, 227, 247. 
 
 in chronic diarrhoea, 149, 224. 
 
 in chronic enteritis, 144. 
 
 in diseases of mucous membrane, 142. 
 
 in duodenal ulcer, 143, 293. 
 
 in functional disturbances, 146. 
 
 in hemorrhoids, 514. 
 
 in membranous enteritis, 237. 
 
 in neuroses, 155. 
 
 in rectal diseases, 156. 
 
 in stenosis and obstruction, 150, 153, 
 412, 415. 
 
 in ulcers, 293. 
 Digestion, intestinal, 43. 
 
 of albuminoid bodies, 37. 
 
 of carbohydrates, 37. 
 
 of fats, 38. 
 
 of foods in general, 140. 
 Disinfection, intestinal, 199. 
 Displacements, intestinal, 20, 255. 
 
 complications, 256. 
 
 Displacements, intestinal, diagnosis, 258. 
 
 etiology, 255. 
 
 symptoms, 255. 
 
 treatment, 259. 
 Disturbances, gastric, in intestinal dis- 
 eases, 65. 
 
 in acute appendicitis, 443. 
 
 in acute enteritis, 208. 
 
 in cancer, 302, 304. 
 
 in duodenal ulcer, 285. 
 
 in stenosis and obstruction, 344, 348, 
 355, 381, 388. See also Vomit- 
 ing. 
 Diverticulum, strangulation produced 
 
 by, 373. 
 Douche, rectal, 182. 
 Duodenum, 1. 
 
 anatomy of, 1. 
 
 carcinoma of, 302 ; bilious vomiting, 
 303 ; circumpapillary, 304 ; diag- 
 nosis, 302, 304; diagnosis from 
 pancreatic cancer, 306 ; from py- 
 loric cancer, 302 ; from pyloric 
 stenosis, 346, 353; emaciation in, 
 306 ; gastric disturbances, 302, 303 ; 
 icterus, 305 ; inf rapapillary, 302 ; 
 pain in, 303 ; splashing sounds, 
 303; suprapapillary, 302; symp- 
 toms, 302, 303, 305 ; tumour, 306, 
 308 ; vomiting in, 303 ; treatment, 
 see Carcinoma, Intestinal. 
 
 catarrh of, 210. 
 
 stenosis of, 346 ; diagnosis, 346, 349 ; 
 etiology, 351, 352 ; gastric con- 
 tents in, 349 ; gastric disturbances, 
 348 ; indicanuria, 349 ; inf rapap- 
 illary, 348; meteorism, 348; stools 
 in, 349 ; suprapapillary, 346 ; 
 symptoms, 346, 348; treatment, 
 see Stenosis, Intestinal. 
 
 ulcer of, 280. See Ulcer, Duodenal. 
 Dysentery, chronic, diagnosis from can- 
 cer of large intestine, 315. 
 
 Electric trans-illumination of intestines, 
 
 88. 
 Electricity, 172. 
 action of, 173. 
 results from, 174. 
 technic of, 173. 
 
 therapeutic indications for, 174, 250, 
 418, 425. 
 
LIST OP SUBJECTS 
 
 547 
 
 Emaciation, in chronic constipation, 245. 
 in intestinal cancer, 300. 
 in rectal cancer, 319. 
 Enemata, rectal, 177. 
 antiseptic, 193, 278, 485. 
 astringent, 193, 278, 485. 
 high, 180. 
 indications for, 177, 180, 413, 416, 456, 
 
 515, 531. 
 mineral waters in, 1C5. 
 oil, 178. 
 
 technic of, 177, 179. 
 Enteralgia, 532. 
 diagnosis, 533. 
 differential diagnosis, 534. 
 etiology, 532. 
 opiates in, 196. 
 symptoms, 533. 
 treatment, 196, 534. 
 Enteritis, 205. 
 acute, 205; alimentary, 206 ; complica- 
 tions of, 208; diagnosis, 207; diet, 
 143, 211 ; etiology, 205 ; faeces in, 
 207; infectious, 62, 105; medicinal, 
 206; refrigeration, 207; symptoms, 
 209 ; toxic, 205 ; treatment, 210. 
 amoebic, odour of fiBces in, 94. 
 chronic, 212; cathartics in, 190; course, 
 217; diagnosis, 217; diet, 144, 145; 
 etiology, 212; feeces in, 216 ; forms 
 of. 214; mineral waters in, 164, 
 166 ; pathological anatomy of, 213 ; 
 symptoms, 214 ; treatment, 223. 
 membranous, 228; artificial, 230; ca- 
 thartics in, 190 ; complications, 
 230, 236 ; course of, 236 ; diagnosis. 
 236; enemata in, 237; etiology, 
 229; stools in, 234; symptoms, 
 230 ; treatment, 236. 
 Enteroliths, 112. See Stones. 
 Enteroptosis, 255. 
 Enterospasm, 521. 
 diagnosis, 522. 
 symptoms, 522. 
 treatment, 523. 
 Enterostomy in malignant growths, 326, 
 333. 
 in obstruction, 426. 
 Enterorrhagia. See Hemorrhage, Intes- 
 tinal. 
 Entozoa, obstruction by, 400. 
 Epithelium, in faeces, 117, 235. 
 
 Evacuations, intestinal. See Faeces and 
 
 Stools. 
 Examination, rectal, 77. 
 
 digital, 79, 319, 357. 
 
 instrumental, 79. 
 
 manual, 79. 
 Excretion, intestinal, 41. 
 
 auxiliary to renal excretion, 42. 
 
 during fasting, 41. 
 
 Faecal tumours. See Tumours, Faecal. 
 Faeces, 42, 63, 90. See also Stools. 
 
 admixtures, pathological, in, 64. 
 
 albuminoid bodies in, 100. 
 
 bacteria in, 42. 
 
 biliary matter in, 107, 219. 
 
 bilirubin in, 93. 
 
 blood in, 64, 95, 105, 117, 269. 
 
 calcium salts in, 125, 126. 
 
 carbohydrates in, 102. 
 
 chlorophyl in, 93. 
 
 Cholesterin in. 111. 
 
 colour of, 42, 63, 93. 
 
 colouring matter of, 30. 
 
 consistency of, 63, 93. 
 
 crystalline bodies in, 123. See Crys- 
 talline Bodies. 
 
 effect of diet upon, 42, 93. 
 
 epithelium in, 117, 219. 
 
 examination of, 90 ; arrangements for, 
 91; chemical, 99; diagnostic value 
 of, 90; macroscopical, 91; micro- 
 scopical, 113. 
 
 fats in, 102, 219. 
 
 ferments in, 110. 
 
 food remnants in, 42, 65, 97, 113. 
 
 form of, 91. 
 
 frog-spawn bodies in, 96. 
 
 gallstones in. 111. 
 
 importance of careful examination of, 
 63. 
 
 indol in, 42, 94, 110. 
 
 inorganic substances in, 42, 113, 114. 
 
 intestinal elements in, 117, 270. 
 
 leukourobilin in, 105. 
 
 micro-organisms in, 42, 118. 
 
 mucin in, 117. 
 
 mucus in. 64, 92, 207. 
 
 muscle fibres in, 97, 113, 219. 
 
 nature and composition of, 42. 
 
 odour of, 65, 94. 
 
 odourless, 94. 
 
•548 
 
 DISEASES OF THE INTESTINES 
 
 Faeces, pancreatic stones in, 111. 
 
 parasites in, 65, 99. 
 
 phenol in, 109. 
 
 pus in, 64, 95, 117, 269. 
 
 quantity, variations in, 42, 63, 93. 
 
 I'eaetion of, 99 ; determination of, 99 ; 
 diagnostic significance of, 100. 
 
 significance of, in the history, 63. 
 
 skatol in, 42, 94, 110. 
 
 soaps, fatty, in, 103. 
 
 starch granules in, 115, 219. 
 
 tumour fragments in, 64, 99, 311. 
 
 urobilin, 107. 
 
 yellow mucous granules in, 96, 218. 
 Fats, determination of, in faeces, 102. 
 
 intestinal digestion of, 38, 104. 
 Ferments, determination of, in faeces, 
 
 110. 
 Finger cots, 78. 
 Fissures, anal, 491. 
 
 diagnosis, 492. 
 
 etiology, 491. 
 
 location, 491. 
 
 symptoms, 492. 
 
 treatment, 492. 
 Fistula, rectal, 488. 
 
 diagnosis, 489. 
 
 etiology, 488. 
 
 symptoms, 489. 
 
 treatment, 490. 
 
 varieties of, 488. 
 Flatulence, nervous, 531. 
 
 diet in, 156. 
 
 etiology, 531. 
 
 symptoms, 532. 
 
 treatment, 196, 532. 
 Flexure, sigmoid, 14. 
 
 displacements of, 23, 258. 
 
 volvulus of, 376. 
 Fold, transverse rectal, 18. 
 Folds, Kerckring's, 8. 
 Food remnants in faeces, 42, 65, 97, 113. 
 
 significance of, 97. 
 Food stuffs, intestinal digestion of, 140. 
 
 See also Digestion, Intestinal. 
 Foreign bodies producing obstructions, 
 396, 401. 
 
 Gallstones, obstruction by, 396. 
 Gases, intestinal, 46. 
 
 during disease, 48. 
 
 during health, 47. 
 
 Gases, intestinal, influence of mesenteric 
 circulation, 48, 363. 
 influence of peristalsis, 48. 
 sources of, 46 ; from carbohydrates, 47 ; 
 fats, 49 ; proteids, 48. 
 Gastric disturbances. See Disturbances, 
 Gastric, 
 lavage. See Lavage, Gastric. 
 Gastro-enteritis, diet in, 143. 
 
 opium in, 192. 
 Granules, yellow mucus, in faeces, 96. 
 Growths, intestinal. See Tumours. 
 Gurgling, ileo-caecal, 84. 
 
 Haematemesis. See Hemorrhage, Gastric. 
 Hemorrhage, intestinal, 143, 157. 
 diet in, 142. 
 gastric, in cancer of large intestine, 
 
 308 ; in duodenal ulcer, 285. 
 in cancer of large intestine, 310. 
 in duodenal ulcer, 285. 
 in hemorrhoids, 512, 516. 
 in ileo-C£ecal tuberculosis, 272. 
 in obstruction, 365, 388. 
 in ulcerations, 265. 
 Hemorrhoids, 508. 
 diagnosis, 513. 
 etiology, 509, 
 sequelae, 511. 
 strangulation of, 512. 
 symptoms, 512. 
 
 treatment, internal, 514; baths, 515; 
 diet, 514 ; enemata, 515 ; laxatives, 
 514; mineral waters, 515 ; of hem- 
 orrhage, 516 ; of inflammatory 
 conditions, 517 ; of strangulation, 
 517; toilet of the anus, 516. 
 treatment, surgical, 518 : " bloodless," 
 518; "bloody," 519 ; cauterization, 
 519 ; ligature, 519 ; local injec- 
 tions, 519 ; methodical dilatation 
 of the sphincter, 518. 
 Hernia diaphragmatica, 374. 
 
 obstruction from, 370. 
 History, the, 55. 
 importance of, in intestinal affections, 
 
 55. 
 scheme for obtaining, 56. 
 Hydrobilirubin, 30. 
 Hydrogen, 45-48. 
 
 sulphuretted, 45, 47. 
 Hydrotherapeutic measures, 158, 175, 250. 
 
LIST OF SUBJECTS 
 
 549 
 
 Icterus, in duodenal ulcer, 286, 292. 
 
 in intestinal cancer, 305. 
 Ileum, 3. 
 
 cancer of, 306. 
 
 stenosis of, 352. 
 Ileus, 358. See Obstruction, Intestinal. 
 Ileus, verminosus, 400. See Obstruction 
 
 by Entozoa. 
 Iliac plilegmon, 473. 
 Indicanuria, 132, 365, 383. 
 Indigo red, 133, 366. 
 Indol, 43 ; in the tseces, 45, 94. 
 
 determination of, 110. 
 Inflation, intestinal, 84. 
 
 diagnostic importance, 85, 86, 310, 367, 
 383. 
 
 methods of, 84. 
 
 technic, 85. 
 
 therapeutic employment, 182, 418, 
 Infrapapillary carcinoma and stenosis. 
 
 See Duodenum. 
 Injection of water, 86. See Water, In- 
 jection of. 
 Injections, rectal, 177. See Enemata. 
 Inspection in intestinal diseases, 67. 
 
 abdominal, 67. 
 
 rectal, 77; importance of, 77; objective 
 results from, 81 ; technic of, 79. 
 Intestines, absorptive functions of, 36. 
 
 adenoma of. See Adenoma. 
 
 anatomy of, 1. 
 
 atrophy of. See Atrophy. 
 
 carcinoma of. See Carcinoma. 
 
 catarrh of. See Catarrh and Enteritis. 
 
 contraction of, regurgitive, 66 ; tetanic, 
 68. 
 
 disinfection of, 199. 
 
 displacements of. See Displacements. 
 
 electric transillumination of, 88. 
 
 excretory function, 41. 
 
 gases of. See Gases. 
 
 hemorrhage of. See Hemorrhage. 
 
 histology of, 3. 
 
 inflation of. See Inflation. 
 
 insufficiency of, 527. 
 
 intussusception. See Intussusception. 
 
 invagination. See Intussusception. 
 
 irrigation of. See Irrigation, Rectal. 
 
 large, 10. See Intestine, Large. 
 
 lavage of. See Lavage. 
 
 lymphosarcoma of. See Sarcoma. 
 
 massage of. See Massage. 
 36 
 
 Intestines, movements of. See Peristal- 
 sis. 
 
 myoma of. See Myoma. 
 
 neoplasms. See Tumours. 
 
 neuroses of. See Neuroses. 
 
 obstruction of. See Obstruction. 
 
 paresis and paralysis of. See Paresis. 
 
 peristalsis of. See Peristalsis. 
 
 physiology of, 24. 
 
 polypi. See Polypi. 
 
 puncture of, in appendicitis, 441 ; in 
 obstruction, 441. 
 
 resection of, in malignant disease, 326, 
 333. 
 
 sarcoma of. See Sarcoma. 
 
 secreting function, 24. 
 
 small, 1. See Intestine, Small. 
 
 stenosis of. See Stenosis. 
 
 strangulation of. See Strangulation. 
 
 syphilis of, 266. 
 
 tuberculosis of. See Tuberculosis. 
 
 tumours of. See Tumours. 
 
 ulcers of. See Ulcer, Duodenal, and 
 Ulcers, 
 
 urine in diseases of. See Urine. 
 Intestine, large, absorption from, 40. 
 
 anatomy of, 10. 
 
 atony of. See Atony. 
 
 blood supply, 15. 
 
 carcinoma of, 307 ; appetite in, 309 ; 
 atypical forms, 312 ; constipation 
 in, 308; diet in, 151, 324; differ- 
 ential diagnosis between caecal 
 tumours and appendicitis, 313 ; be- 
 tween malignant and benign intes- 
 tinal growths, 313 ; from chronic 
 intussusception, 314; from dysen- 
 tery, 315 ; from floating kidney, 
 314 ; ileo-C£ecal tuberculosis, 277 ; 
 from intestinal neuroses, 318 ; from 
 tumours of other organs, 314 ; evac- 
 uations, 310 ; hajraatemesis, 308 ; in- 
 testinal rigidity, 310; pain, 307; 
 palliative treatment, 323 ; stomach 
 contents, 311 ; surgical treatment, 
 325; symptoms, 307, 312; tenes- 
 mus, 308 ; tumours, 309 ; typical 
 forms, 307 ; vomiting, 308. 
 
 catarrh of, 222. See Catarrh and En- 
 teritis. 
 
 displacements of, 30, 255. 
 
 electric transillumination of, 88. 
 
550 
 
 DISEASES OF THE INTESTINES 
 
 Intestine, histology of, 15. 
 
 lymphatics of, 15. 
 
 nerves of, 15. 
 
 obstruction of, 359, 408. 
 
 physiology of, 24. 
 
 sarcoma of. See Sarcoma, Intestinal. 
 
 stenosis of, 354. 
 
 ulcers of, 273 ; diagnosis, 273 ; treat- 
 ment, 278. See also Ulcei's, Intes- 
 tinal. 
 Intestine, small, absorption from, 36. 
 
 anatomy of, 1. 
 
 blood supply, 4. 
 
 carcinoma of, 302; diet in, 151, 323; 
 treatment of, 322, 325. See also 
 Duodenum, Carcinoma of. 
 
 catarrh of, 218. See Catarrh and En- 
 teritis. 
 
 digestive functions of, 43. 
 
 displacements of, 20. 
 
 histology of, 5. 
 
 lymphatics of, 5. 
 
 nerves of, 5. 
 
 obstruction of, 359, 406. 
 
 physiology of, 24. 
 
 sarcoma of, 329. See Sarcoma, Intes- 
 tinal. 
 
 stenosis of, 346. See Stenosis of Small 
 Intestine. 
 
 ulcers of, 273 ; diagnosis of, 273 ; treat- 
 ment, 277. See also Ulcer, Duo- 
 denal, and Ulcers, Intestinal. 
 Intussusception, 383. 
 
 diagnosis, 390 ; differential diagnosis, 
 314, 408, 506. 
 
 etiology, 384, 386. 
 
 frequency of, 385, 386. 
 
 symptoms, 387 ; evacuations, 388; me- 
 teorism, 388 ; pain, 387 ; tenesmus, 
 388 ; tumour, 389 ; vomiting, 388. 
 
 terms employed in, 383. 
 
 treatment, internal, 415 ; surgical, 
 423. 
 
 varieties of, 384. 
 Invagination, 383. See Intussusception. 
 Invertin, 46. 
 Irrigations, rectal, 180. 
 
 indications for, 180, 456, 485, 503. 
 
 Jejunum, 3. 
 cancer of, 306. 
 stenosis of, 352. 
 
 Juice, intestinal, 25. 
 
 gastric, in duodenal ulcer, 280, 286. 
 
 pancreatic, 26 ; influence upon intesti- 
 nal absorption of albuminoids, 37 ; 
 of carbohydrates, 38 ; of fats, 39 ; 
 in stomach contents, 130. 
 
 Kerckring, folds of, 8. 
 
 Kinking, intestinal obstruction due to, 
 
 392. 
 Klebesymptom, Gersuny's, 77. 
 
 Lavage, intestinal, 177. 
 
 gastric, indications for, 183 ; in car- 
 cinoma, 325 ; in obstruction, 416 ; 
 technic of, 184. 
 
 in intestinal putrefaction, 200. 
 
 test, 87. See Test lavage. 
 Laxatives, 186. See also Cathartics. 
 
 chemical, 147. 
 
 physical, 147, 190. 
 
 thermic, 148. 
 Leucocytosis, in differential diagnosis, 
 
 453. 
 Leukourobilin, 105. 
 Lieberkiihn's glands, 8, 16, 25. 
 Lientery, 222. 
 Lipoma, intestinal, 335. 
 Lymphosarcoma, 329. See Sarcoma. 
 
 Marsh gas, 47, 48. 
 
 Massage in intestinal diseases, 171. 
 
 dangers of, 171, 172. 
 
 indications for, 171, 249, 460, 517. 
 
 technic of, 170. 
 Meckel's diverticulum, strangulation by, 
 
 373. 
 Meissner's plexus, 5. 
 
 Mesenteric contraction producing ob- 
 struction, 394. 
 Meteorism, 59. 
 
 diagnostic significance of, 59. 
 
 in carcinoma of large intestine, 310. 
 
 in intestinal stenosis, 344, 348, 352, 355. 
 
 in intestinal ulcers, 270. 
 
 in obstruction, 363, 381,' 388. 
 Methyl mercaptan, 45. 
 Micro-organisms in faeces, 118. 
 Mineral waters and springs, 158. See 
 
 Waters, Mineral. 
 Movements, peristaltic, 31. See Peri- 
 stalsis. 
 
LIST OF SUBJECTS 
 
 551 
 
 Mucin, determination of, in faeces, 100, 117. 
 Mucus in ffeces, 64, 95, 319. 
 
 diagnostic significance of, 95. 
 
 in acute enteritis, 207. 
 
 in catarrh of the large bowel, 222. 
 
 in catarrh of the small bowel, 219. 
 
 in chronic enteritis, 216. 
 
 in membranous enteritis, 235, 
 
 macroscopic appearance, 96. 
 
 microscopical appearance, 117. 
 Muscle fibres in fteces, 97, 113, 219. 
 Myoma, intestinal, 335. 
 
 diagnosis, 336. 
 
 location, 336. 
 
 origin, 336. 
 
 rectal, 337. 
 
 symptoms, 336. 
 
 treatment, 338. 
 
 varieties of, 336. 
 
 Neoplasms, 296. See Tumours. 
 Nervous digestive weakness, 541. 
 Neuralgia plexus mesenterici, 532. See 
 
 Enteralgia. 
 Neurasthenia, intestinal, 540. 
 Neuroses, intestinal, 521. 
 complex, 540. 
 diet in, 155. 
 
 motor, 521. See Atony and Paralysis 
 of the Intestine, Enterospasm, 
 Flatulence, Proctospasm, and Tor- 
 mina Intestinorum Nervosa, 
 secretory, 534, See Diarrhoea, Nerv- 
 ous, and Colic, Mucous, 
 sensory, 532. See Enteralgia. 
 Nitrogen, 48. 
 
 Obstruction by bands, clefts, fenestra, 
 and internal hernise, 370. 
 
 diagnosis, 376. 
 
 symptoms, 375. 
 Obstruction, intestinal, 358. 
 
 by adhesions, bendings, compressions, 
 kinking, and mesenteric contrac- 
 tions, 392 ; symptoms and diagno- 
 sis, 395. 
 
 by enteroliths, 399. 
 
 by entozoa, 400. 
 
 by faecal tumours, 402. 
 
 by foreign bodies, 396. 
 
 by gallstones, 396. 
 
 by introduction of foreign bodies, 401. 
 
 Obstruction, intestinal, cathartics in, 189. 
 
 diagnosis, 367 ; from appendicitis, 368 ; 
 biliary and renal colic, 367; chol- 
 era nostras and Asiatica, 368 ; flat- 
 ulent colic, 367; peritonitis, 368; 
 poisoning, 308. 
 
 differential diagnosis between the dif- 
 ferent forms of, 405. 
 
 dynamic, 403, 410. 
 
 large intestinal, 359, 408. 
 
 paralytic, 403. 
 
 small intestinal, 359, 406. 
 
 spastic, 404. 
 
 symptoms, 359; constipation, 361; 
 general condition, 366 ; hemor- 
 rhage, 365 ; meteorism; 363, 388 ; 
 pain, 360 ; peristalsis, 365 ; pres- 
 sure sensitiveness, 360 ; tympani- 
 tis, SO."? ; urine, 365 ; vomiting, 361. 
 
 through volvulus. See Volvulus. 
 
 treatment, 411, 415; diet, 153, 415; 
 electricity, 418, 425 ; enemata, 416, 
 425 ; gastric lavage, 416 ; intestinal 
 inflation, 418 ; intestinal puncture, 
 418 ; medicinal, 418, 425 ; opiates, 
 195, 419 ; surgical, 420. 
 
 von Wahl's symptom in, 363. 
 
 without physical intestinal changes, 
 403 : diagnosis, 405 ; etiology, 403 ; 
 symptoms, 405 ; treatment, 425. 
 CEdema of the ankles in carcinoma, 301. 
 
 in sarcoma, 332. 
 Opiates, action of, upon tlie intestines, 
 194. 
 
 in appendicitis, 154, 194, 458, 469. 
 
 in constipation, 187. 
 
 in diarrhoea, 192, 196. 
 
 in proctitis, 485. 
 
 in stenosis and obstruction, 195, 413, 
 419. 
 
 Pain and pressure sensitiveness, 72, 
 as a symptom, significance of, 56. 
 in appendicitis, 56, 72. 
 in central nervous diseases, 58. 
 in duodenal ulcer, 57, 72. 
 in intestinal carcinoma, 303, 308, 307. 
 in intestinal ulcers, 268. 
 in peritonitis, 57, 72. 
 in rectal carcinoma, 319. 
 in stenosis and obstruction, 57, 344, 361, 
 388. 
 
552 
 
 DISEASES OP THE INTESTIIN'ES 
 
 Pain, nervous, 58. 
 
 periodic, 58. 
 
 qualities and characteristics of, 56. 
 
 rectal, 59. 
 Painfulness, pseudo-, 73. 
 Palpation, abdominal, 69. 
 
 importance of, 69. 
 
 in a warm bath, 70. 
 
 of individual intestinal segments, 71. 
 
 technic of, 69, 70. 
 Palpation, rectal, 77. 
 
 importance of, 77. 
 
 technic of, 78. 
 Pancreatic juice. See Juice, Pancreatic. 
 
 diastase, 28. 
 
 stones, 112. 
 Papillary carcinoma and stenosis. See 
 
 Duodenum. 
 Paraeresol, 45. 
 Paralysie reflexe, 403. 
 Paresis and Paralysis of Intestine, 527. 
 See Atony, intestinal. 
 
 rectal, 530 ; etiology, 530 ; symptoms, 
 530; treatment, 531. 
 Peptones, determination of, in fsBces, 101. 
 
 intestinal absorption of, 37. 
 
 occurrence in fasces, 102, 
 Percussion, abdominal, 83. 
 
 objective results from, 83. 
 
 palpatory, 83. 
 
 precautions to be observed in, 83. 
 
 value of, 83. 
 Pericolitis, exudative, 475. 
 
 diagnosis, 478. 
 
 pathology, 476. 
 
 symptoms, 477. 
 
 treatment, 478. 
 Periproctitis, 486. 
 
 acute, 487; symptoms, 487; treatment, 
 488. 
 
 chronic, 487 ; diagnosis, 487 ; symp- 
 toms, 487 ; treatment, 488. 
 
 etiology, 486. 
 
 sequelse of, 486. 
 Peristalsis, intestinal, 31. 
 
 agents which influence, 35, 146. 
 
 felt by the patient, 66. 
 
 in disease, 36. 
 
 nervous mechanism of, 34. 
 
 rapidity of, 33. 
 
 varieties of, 32. 
 
 visible, 68, 345, 365, 381. 
 
 Peristaltic restlessness. See Tormina In- 
 
 testinorum Xervosa. 
 Peritonitis, localized, massage in, 171, 
 172.' 
 
 perforative, in duodenal ulcer, 291. 
 Perityphlitis, 430. See Appendicitis. 
 Peyer's patches, 10. 
 Phenol, determination of, in f.Tces, 
 
 109. 
 Polypi, intestinal, 333. 
 
 diagnosis, 335. 
 
 location of, 333. 
 
 metamorphosis of, 334. 
 
 multiple, 334. 
 
 rectal, 335. 
 
 symptoms, 335. 
 
 treatment, 338. 
 
 varieties of, 333. 
 Polyposis, general intestinal, 338. 
 Postappendicitis, 447. 
 Pressure sensitiveness, 72, 222. See also 
 
 Pain. 
 Proctitis, 482. 
 
 acute, 483; diagnosis, 483 ; symptoms, 
 483 ; treatment, 484. 
 
 chronic, 483; diagnosis, 484; symp- 
 toms, 483 ; treatment, 485. 
 
 etiology, 482. 
 
 varieties of, 482. 
 Proctospasm, 521. 
 
 diagnosis, 522. 
 
 etiology, 522. 
 
 symptoms, 522. ^ 
 
 treatment, 523. 
 Prolapse, rectal, 505. 
 
 diagnosis and differential diagnosis, 
 506. 
 
 etiology, 505. 
 
 symptoms, 506. 
 
 treatment, 507. 
 Pseudo-perityphlitis, 453. 
 Pus in fajces, 64, 95, 117, 269, 311, 319, 
 496, 500. 
 
 significance of, in the history, 64. 
 Putrefaction, intestinal, 45. 
 
 bacteria in, 45. 
 
 of carbohydrates, 46. 
 
 of cellulose, 46. 
 
 of fats, 46. 
 
 of Proteids, 45. 
 
 products of, in the urine, 132. 
 
 remedies against, 199. 
 
LIST OF SUBJECTS 
 
 Kandkoth, 76, 363. 
 
 lleaetion, Rosenbach's, 133, 366. 
 
 Keetura, 16. 
 
 anatomy of, 17, 18. 
 
 carcinoma of, 318; appetite in, 319; 
 ballottement, 319 ; cachexia, 319 ; 
 complications, 330 ; diagnosis, 330 ; 
 differential diagnosis between car- 
 cinomatous and syphilitic stric- 
 ture, 331; diet, 334; digital ex- 
 ploration, 319; evacuations, 318; 
 metastases, 330; pain, 319; palli- 
 ative treatment, 323; surgical 
 treatment, 326: symptoms, 318; 
 tenesmus, 319 ; tumour, 319. 
 diet in diseases of, 156. 
 diseases of, 482. 
 examination of. See Examination, 
 
 Rectal, 
 fissures of. See Fissures, Rectal, 
 fistula of. See Fistula, Rectal, 
 histology of, 19. 
 illumination, electric, 80. 
 inspection of, 77. 
 myoma of, 337. 
 paralysis and paresis of, 530. See 
 
 Paralysis, Rectal, 
 polypi of, 335. 
 
 prolapse of, 505. See Prolapse, Rectal, 
 stricture of, 498 ; diagnosis, 500 ; dif- 
 ferential diagnosis, 501 ; etiology, 
 498; palliative treatment, 502 
 surgical treatment, 504, 505 
 symptoms, 500; syphilitic, 499 
 varieties of, 499. 
 support, 508. 
 
 ulcers of, 494 ; diagnosis, 496 ; dysen- 
 teric, 494 ; etiology, 494 ; follicular, 
 494 ; gonorrhoeal, 496 ; symptoms, 
 496 ; syphilitic, 495 ; treatment, 
 497 ; tuberculous, 494 ; varieties 
 of, 494. 
 Remedies, mechanical, 170 ; in chronic 
 constipation, 348 ; in intestinal 
 obstruction and stenosis, 413. 
 medicinal, 186 ; antidiarrhceal, 190 ; 
 antiputrefactive, 199 ; contraindi- 
 cations, 194; for flatulence, 196; 
 indications for, 191 ; sedative, 194 ; 
 tonic, 198. 
 Reactions. See Test. 
 Rectoscope, Herzstein's, 80. 
 
 Rigidity, intestinal, 09, 310, 345, 356. 
 Röntgen rays, 88. 
 
 Saccharomyces in faeces, 119. 
 Salts, inorganic, in fasces, 43, 
 Sarcina, in faeces, 119. 
 Sarcoma, intestinal, 339. 
 diagnosis, 333. 
 duration of, 331. 
 frequency, 339. 
 location, 339. 
 metastases, 331. 
 relation to tuberculosis, 331. 
 symptoms, 331 ; absence of stenosis, 
 331 ; cachexia, 333 ; gastro-intes- 
 tinal disturbances, 331 ; intestinal 
 paralysis, 331 ; oedema of ankles, 
 333; rapid growth, 331. 
 treatment, 333. 
 tumour in, 330, 331. 
 varieties of, 330. 
 Schafkoth, 93, 319. 
 Sedatives, 194; indications for the use of, 
 
 195, 413, 418. 
 Sensations, subjective, 66, 
 Sensitiveness, pressure, 73. See Pres- 
 sure Sensitiveness. 
 Sigmoid flexure. See Flexure. 
 Sigmoiditis, 473. 
 acute, 473 ; symptoms, 473 ; treatment, 
 
 474. 
 chronic, 474 ; symptoms, 474 ; treat- 
 ment, 475. 
 Sign, adhesive, Gersuny's, 77. 
 Signe de dance, 388. 
 Skatol, 43, 44, 94. 
 
 determination of, in faeces, 110. 
 
 Skolikoiditis, 430. See Appendicitis. 
 
 Soaps, calcium, 42. 
 
 fatty, 103, 125. 
 
 magnesium, 43. 
 
 Solitary follicles, 9. 
 
 Sounds, rectal, 81. See Bougies, Rectal, 
 splashing, 73, 303, 539 ; conditions ne- 
 cessary to produce, 73 ; method of 
 determination, 74 ; significance of, 
 73, 74. 
 suecussion, 74. 
 Spasm, anal, 491. See Fissure, Rectal. 
 Speculum, rectal, 79. 
 cylindrical, 80. 
 Czerny's, 79. 
 
554 
 
 DISEASES OF THE INTESTINES 
 
 Speculum, rectal, Herzstein's, 80. 
 
 introduction of, 80. 
 
 Kelly's, 80. 
 
 Simon's, 79. 
 
 Sims's, 79. 
 Sphincter ani, 18. 
 Spray, ether, in constipation, 250. 
 Steapsin, 28. 
 Stenosis, intestinal, 342. 
 
 chronic, diet in, 150. 
 
 from duodenal ulcer, 292. 
 
 inflation, rectal, in, 85. 
 
 percussion, abdominal, in, 86. 
 
 symptoms, 343 ; constipation, 344 ; di- 
 arrhoea, 344 ; evacuations, 92, 345 ; 
 gastric disturbances, 344 ; meteor- 
 ism, 344 ; pain, 344 ; stasis, 344 ; 
 visible peristalsis, 345; vomiting, 
 355. 
 
 treatment, 412; diet, 150, 412; me- 
 chanical, 413 ; medicinal, 413 ; 
 surgica,l, 414. 
 Stenosis of large intestine, 354. 
 
 differential diagnosis, 357. 
 
 etiology, 357. 
 
 symptoms, 354 ; colic, 354 ; constipa- 
 tion, 354 ; evacuations, 357 ; gastric 
 disturbances, 355 ; meteorism, 355 ; 
 visible peristalsis, 356 ; vomiting, 
 355. 
 
 treatment. See Stenosis, Intestinal. 
 Stenosis of small intestine, 346. 
 
 diagnosis of location and cause, 354. 
 
 differential diagnosis, 353. 
 
 duodenal, 346. See Duodenum, Steno- 
 sis of. 
 
 jejunal and ileal, 352 ; causes, 352 ; 
 diagnosis, 353 ; frequency, 352 ; 
 symptoms, 352. 
 
 treatment. See Stenosis, Intestinal. 
 Stomach contents in intestinal diseases, 
 129. 
 
 bile in, 130. 
 
 in carcinoma of large intestine, 311. 
 
 in duodenal carcinoma, 302, 304. 
 
 in stenosis of the small intestine, 349. 
 
 pancreatic juice in, 130. 
 Stones, faecal, 112. 
 
 gall-. 111. 
 
 intestinal obstruction by, 399. 
 
 pancreatic, 112. 
 Stools. See also Fteces. 
 
 Stools, acholic, 94 ; causes of, 105 ; deter- 
 mination of, in ffeces, 109 ; diag- 
 nostic significance of, 105 ; with- 
 out icterus, 104. 
 fatty, 102 ; causes of, 103. 
 in acute enteritis, 207. 
 in carcinoma of large intestine, 310. 
 in catarrh of large intestine, 222. 
 in catarrh of small intestine, 219. 
 in chronic enteritis, 216. 
 in hemorrhoids, 512. 
 in intestinal stenosis and obstruction, 
 
 345, 349, 357, 380, 388. 
 in membi-anous enteritis, 234. 
 in mucous colic, 540. 
 in nervous diarrhoea, 534, 539. 
 in rectal carcinoma, 319. 
 in rectal strictures, 500. 
 in rectal ulcers, 496. 
 lienteric, 222. 
 Strangulation, by internal hernise, 373. 
 by isolated intestinal adhesions, 370. 
 by Meckel's diverticulum, 373. 
 by omental bands, 372. 
 of hemorrhoids, 512. 
 through clefts and fenestra, 372. 
 treatment of, 432. 
 Stricture, internal intestinal, 395. 
 causes, 395. 
 diagnosis, 396. 
 
 intestinal, 342. See Stenosis, 
 symptoms, 396. 
 Stricture, rectal, 498. 
 diagnosis, 500. 
 differential diagnosis, 501. 
 etiology, 498. 
 symptoms, 500. 
 treatment, 502. 
 palliative, 502. 
 
 bougies, 503 ; cathartics, 503. 
 irrigations, 503. 
 surgical, 504, 505. 
 Substances, inorganic, in faeces, 113. 
 Succussion sound, 74. 
 Support, rectal, 508. 
 Suprapapillary carcinoma and stenosis. 
 
 See Duodenum. 
 Surgical treatment. See Individual Dis- 
 eases. 
 
 Teeth, in relation to gastro-intestinal 
 catarrh, 67. 
 
LIST OF SUBJECTS 
 
 555 
 
 Temperature, types of, in acute appendi- 
 citis, 443. 
 Tenesmus, 65. 
 
 in cancer of large intestine, 808. 
 
 in intussusception, 388. 
 
 in rectal diseases, 483, 496, 500, 512, 
 532. 
 
 significance of, as a symptom, 65. 
 Test lavage, 87. 
 
 diagnostic value of, 87, 218, 219, 
 
 technic, 87. 
 Test, Chvostek's, 284. 
 
 digestion, 110. 
 
 Fleischer's, 108. 
 
 Gmelin's, 108. 
 
 hsemin, 106. 
 
 Hoyer-Ehrlich's, 118. 
 
 Huppert's, 107. 
 
 Mehu's, 207. 
 
 Pettenkoffer's, 108. 
 
 Rieder's, 116. 
 
 Rosenbach's, 133, 366. 
 
 Schmidt's, 108. 
 
 urobilin, 107. 
 
 Weber's, 106. 
 
 Widal's, 120, 210, 453. 
 Thymol water, 101. 
 Tongue, in intestinal diseases, 67. 
 Tonics, intestinal, 198. 
 Tormina intestinorum nervosa, 33, 68, 
 524. 
 
 diagnosis, 527. 
 
 etiology, 524. 
 
 symptoms, 524. 
 
 treatment, 196, 524. 
 Toxins, in acute enteritis, 206. 
 Trans-illumination, electric, 88. 
 Treatment, mechanical, medicinal, sur- 
 gical. See Individual Diseases. 
 Trypsin, 27. 
 Tryptophan, 27. 
 Tube, electric rectal, 173. 
 Tuberculosis, intestinal, 262. 
 
 ileo-cfecal, 271 ; diagnosis, 276 ; diag- 
 nosis fi'om carcinoma of caecum, 
 277 ; prognosis, 272 ; symptoms, 
 272 ; treatment, 278. 
 
 ulcers in, 263. 
 Tumours, intestinal, 74, 296. 
 
 benign, 333; adenoma, 333: lipoma, 
 335 ; myoma, 335 ; polypi, 333. 
 
 consistency of, 76. 
 
 Tumours, intestinal, diagnosis of nature 
 and situation, 75. 
 
 diet in, 146. 
 
 fajcal, 76, 245 ; diagnosis of, 76, 410 ; 
 frequent source of error, 76 ; ob- 
 struction by, 402. 
 
 fragments of, in the fasces, 64, 99, 311. 
 
 frequency of, 74. 
 
 ileo-cajcal, 271, 312. 
 
 in carcinoma of large intestine, 309. 
 
 in circumpapillary cancer, 306. 
 
 in intussusception, 389. 
 
 in suprapapillary cancer, 302. 
 
 malignant, 296; carcinomatous, 296; 
 sarcomatous, 329. 
 
 palliative treatment, 323. 
 
 relative mobility of, 75. 
 
 respiratory mobility of, 76. 
 
 sarcomatous, 330. 
 
 sensitiveness of, 76. 
 
 size, variations in, 76. 
 
 surgical treatment of, 325. 
 
 tuberculous, 264. 
 Tympanites, 59. See Meteorism. 
 Typhlitis, 430. 
 
 diagnosis, 438. 
 
 diet in, 154. 
 
 etiology, 432. 
 
 existence of, 431. 
 
 stercoral, 431. 
 
 symptoms, 432, 438. 
 
 treatment, 450. 
 
 Ulcer, duodenal, 280. 
 
 abscess in, 291. 
 
 alcoholism as a factor in, 283. 
 
 carcinomatous, 293. 
 
 complications, 291. 
 
 diagnosis, 286. 
 
 diet, 143, 293. 
 
 diiferential diagnosis, 289 ; from chole- 
 lithiasis, 290 ; from gastric ulcer, 
 289 ; from hyperacidity, 289. 
 
 etiology, 280. 
 
 gastric juice in, 280. 
 
 hfematemesis, 285. 
 
 icterus, 286, 292. 
 
 intestinal hemorrhage in, 285. 
 
 location of, 283. 
 
 pain in, 284. 
 
 perforation of, 291. 
 
 stenosis from, 292. 
 
556 
 
 DISEASES OP THE INTESTINES 
 
 Ulcer, duodenal, symptoms, 283. 
 
 treatment, 293. 
 
 vomiting in, 285. 
 Ulcers, intestinal, 261. 
 
 amyloid, 266. 
 
 catarrhal, 261. 
 
 decubital, 262. 
 
 diagnosis, 272. 
 
 diet in, 143, 145. 
 
 dysenteric, 266. 
 
 embolic, 267. 
 
 evacuations in, 268. 
 
 follicular, 261. 
 
 hemorrhage from, 269. 
 
 large intestinal, 273. 
 
 purulent evacuations in, 270. 
 
 small intestinal, 273. 
 
 stercoral, 262. 
 
 symptoms of, 267. 
 
 syphilitic, 266. 
 
 thrombotic, 267. 
 
 treatment, 277. 
 
 tuberculous, 263. 
 
 varieties of, 261. 
 Urine, in intestinal diseases, 132. 
 
 abnormal substances in, 132. 
 
 ethereal sulphuric acids in, 134. 
 
 importance of examination of, 132. 
 
 in acute enteritis, 209. 
 
 in intestinal cancer, 301. 
 
 in obstruction, 365. 
 Urobilin, 30, 107. 
 
 determination of, in faeces, 107. 
 
 Valve, ileo-csBcal, 13. 
 
 insufficiency of, 529. 
 Villi, intestinal, 7. 
 Volvulus, 376. 
 
 diagnosis, 382. 
 
 etiology, 376. 
 
 frequency, 376, 378, 379. 
 
 indicanuria, 383. 
 
 injection of water in, 883. 
 
 intestinal inflation in, 382. 
 
 Volvulus of sigmoid flexure, 376. 
 
 symptoms, 379 ; constipation, 379 ; 
 evacuations, 380 ; gastric disturb- 
 ances, 380 ; general condition, 381 ; 
 meteorism, 381 ; pain, 380 ; visible 
 peristalsis, 381. 
 
 treatment, internal, 415 ; surgical, 424. 
 
 varieties of, 377. 
 Vomiting, in carcinoma of large intes- 
 tine, 308. 
 
 in carcinoma of small intestine, 303, 
 307. 
 
 in duodenal ulcer, 285. 
 
 in intussusception, 388. 
 
 in obstruction, 361. 
 
 in stenosis of large intestine, 355. 
 
 in stenosis of small intestine, 348, 352. 
 
 in volvulus, 380. 
 
 stercoraceous, 361. 
 von Wahl's symptom, 363, 376. 
 
 Water, injection of, per anum, 86. 
 
 diagnostic value of, 86, 310, 367, 382. 
 Waters, mineral, 158. 
 
 alkaline carbonated, 159. 
 
 alkaline, muriated-carbonated, 159. 
 
 bathing, 168. 
 
 benefits derived from use of, 158, 165. 
 
 bitter, 162. 
 
 calcareous, 163. 
 
 chalybeate, 164. 
 
 classification of, 159. 
 
 drinking of, 158. 
 
 effect of, upon peristalsis, 159, 163. 
 
 enemata of, 165. 
 
 free sulphuric acid in, 165. 
 
 in chronic enteritis, 164. 
 
 in constipation, 159, 161, 162, 166. 
 
 in diarrhoea, 163, 164, 166, 227. 
 
 in hemorrhoids, 515. 
 
 in nervous diarrhoea, 540. 
 
 in postappendicitis, 460. 
 
 muriated, 161. 
 
 sodium sulphate, 160. 
 
LIST OF AUTHORS 
 
 Abel, 375. 
 
 Abelmann, 37, 38, 39, 104. 
 
 Abraham, 133. 
 
 Abrahams, 455. 
 
 Ackermann, 330. 
 
 Akerlund, 118, 229, 235. 
 
 Albers, 285, 431. 
 
 Albert, 338. 
 
 Albrecht, 336. 
 
 Albu, 199, 200. 
 
 Alderhot, 503. 
 
 Allihn, 102. 
 
 AUingham, 489, 493, 498. 
 
 Alvazzi, 290. 
 
 Anders, 467. 
 
 Arnsehink, 39. 
 
 Asch, 457. 
 
 Aubert, 186. 
 
 Aufrecht, 461. 
 
 Baas, 28, 133, 301. 
 
 Babes, 338. 
 
 Bacon, 505. 
 
 Baer, 483, 496, 498. 
 
 Bäumler, 124. 
 
 Baginski, 435. 
 
 Balfour, 31. 
 
 Baltzer, 330. 
 
 Bamberger, 104, 312, 313, 
 
 437. 
 Bard, 305, 306. 
 V. Bardeleben, 291, 433, 
 
 519. 
 Bardenheuer, 327, 334. 
 Barker, 423. 
 V. Basch, 35. 
 Bauer, 40. 
 
 Baumann, 45, 132, 183. 
 Bechterew, 35. 
 
 Beck, 433. 
 
 Behrens, 262. 
 
 Belgardt, 41. 
 
 Bell, 164. 
 
 Berard, 297, 
 
 Berg, 338. 
 
 Berggrün, 104, 105. 
 
 V. Bergmann, 314, 
 
 Beriten, 386. 
 
 Berkhan, 70. 
 
 Bernard, 26. 
 
 Bernstein, 26, 43. 
 
 Bessel-Hagen, 330. 
 
 Bidder, 26. 
 
 Biedert, 66, 103, 221. 
 
 Bienstock, 121, 
 
 Billroth, 264, 326. 
 
 Birch - Hirschfeld, 266, 
 
 384. 
 Bird, 238. 
 Blaschko, 521. 
 Blauberg, 101, 102. 
 Boas, 27, 28, 43, 68, 74, 87, 
 
 89, 94, 130, 139, 143, 159, 
 
 170, 190, 229, 237, 259, 
 
 348, 413, 498, 524. 
 Boeck, 140. 
 Böttcher, 384. 
 Bokai, 146, 505. 
 Bollinger, 262. 
 Borchardt, 432, 436, 437, 
 
 441, 443, 450, 453, 462, 
 
 466. 
 Bossard, 453. 
 Bouchard, 199, 245, 510. 
 Boucquoy, 281, 283, 285, 
 
 286. 
 Boudet, 417. 
 Braam-Houkgeest, 32, 38. 
 
 Brambillo, 281. 
 Brandl, 24, 37. 
 Braune, 20. 
 Brieger, 45, 110, 132, 134, 
 
 186, 206. 
 Brinton, 318. 
 Briquet, 361. 
 Brissaud, 292. 
 Bristowe, 386. 
 Brosch, 352. 
 Brown, 25. 
 Brunton, 250. 
 Bryant, 292, 434, 
 Budin, 509. 
 
 Bull, 447, 448, 455, 463. 
 Bunge, 25, 47, 109. 
 Burwinkel, 283, 284, 286. 
 Bushe, 483, 499, 503. 
 
 Cahn, 130, 182, 304, 348, 
 
 416. 
 Canstatt, 536. 
 Carrington, 329. 
 Caspersohn, 445. 
 Castelain, 336. 
 Cherchewski, 540. 
 Chevalier, 230. 
 V. Chlapowski, 70. 
 Chomel, 303. 
 Christoraanos, 34. 
 Chuquet, 352. 
 Chvostek, 134, 284, 285, 
 
 286. 
 Clado, 433, 455. 
 Claus, 331. 
 Codivilla, 293. 
 Cohnheim, 433. 
 Colberg, 266. 
 Coley, 436. 
 
 557 
 
558 
 
 DISEASES OF THE INTESTINES 
 
 Collin, 280, 281, 282, 283, 
 286, 287, 291, 292. 
 
 Conitzer, 493. 
 
 Conrad, 481. 
 
 Conrath, 264, 271, 278, 
 279. 
 
 Copemann, 31. 
 
 Courmont, 305. 
 
 Courtois, 266. 
 
 Courvoisier, 399, 423. 
 
 Crede, 503. 
 
 Croizet, 481. 
 
 Crook, 160, 164, 165. 
 
 Cruveilhier, 280, 386, 486. 
 
 Curschmann, 21, 22, 23, 
 71, 84, 182, 183, 255, 256, 
 257, 259, 367, 381, 415, 
 416, 417, 420, 432, 441, 
 449, 461. 
 
 Czerny, 264, 314, 326, 327, 
 328, 338. 
 
 Czygan, 302, 303. 
 
 Da Costa, 228, 230. 
 Damseh, 84. 
 Dance, 386. 
 Dauber, 34. 
 Davaine, 400. 
 Deaver, 463, 469, 472. 
 Delfrate, 290. 
 Demant, 25. 
 Demme, 103. 
 Dessauer, 399. 
 Deucher, 40. 
 Devic, 286. 
 Devoto, 135. 
 Dickinson, 280. 
 Dieffenbach, 504. 
 Dietrich, 331. 
 Dieulafoy, 230. 
 V. Dittel, 519. 
 Dobroklonsky, 263. 
 Down, 400. 
 Dragendorff, 101. 
 Drasch, 9. 
 Drechsel, 27. 
 Dufourt, 423. 
 Dumont, 25. 
 Dunin, 241, 242, 251. 
 Dujardin-Beaumetz, 199. 
 Dunn, 433. 
 
 Durand, 455. 
 Durante, 264. 
 
 Eakins, 253. 
 Eckehorn, 435. 
 Edebohls, 71, 441. 
 Ehrlich, 73, 118, 271. 
 Eichhorst, 40, 173. 286, 293. 
 Einhorn, H., 430, 433, 435, 
 
 437. 
 Einhorn, M., 66, 91, 221, 
 
 228, 229, 234, 236, 237, 
 
 469. 
 Eisenhart, 262, 263. 
 Eisenlohr, 475, 477. 
 Ellenberger, 26. 
 Eisner, 119. 
 Emminghaus, 241, 521, 
 
 528. 
 V. Engel, 366. 
 V. Engelhardt, 538, 539. 
 Engelmann, 33. 
 Englisch, 366. 
 Bngström, 333. 
 Escherich, 119. 
 V. Esmarch, 18, 314, 488, 
 
 489, 491, 492, 493, 494, 
 
 496, 503, 508, 518. 
 Esquirol, 255. 
 Ewald,39,40,133,173,183, 
 
 185, 228, 229, 250, 252, 
 
 286, 293, 415, 453, 457, 
 
 460. 
 Exner, 35. 
 
 Faber, 353, 396. 
 Fagge, 363. 
 Federn, 528, 530. 
 Fellner, 35. 
 Fenger, 336, 447. 
 Fenwick, 365, 433, 437, 
 
 463. 
 Ferrand, 459. 
 Feyat, 245. 
 Fiebig, 91. 
 Firth, 206. 
 Fischer, 263. 
 Fischl, 209. 
 Fitz, 433, 435, 436, 437, 
 
 466. 
 Pleiner, 179, 227, 237, 242 
 
 243, 255, 256, 257, 278, 
 
 336, 338, 384, 476, 536. 
 Fleischer, 39, 44, 93, 108, 
 
 109, 209, 252. 
 Fowler, 433, 441, 447, 450, 
 
 455, 463, 467. 
 Fraenkel, A., 441. 
 Fränkel, E., 352, 353, 455. 
 Frank, 366. 
 Franke, 238. 
 Frerichs, 268. 
 Frey, 10. 
 Frick, 25, 26. 
 Friedenwald, 74. 
 Friedreich, 115. 
 Frikker, 400. 
 Fromm, 249. 
 Fürbringer, 417, 441. 
 
 Gaffky, 205. 
 Gallia"rd, 514, 555. 
 Gamgee, 31. 
 Gans, 149. 
 Gegenbaur, 13. 
 Gendron, 454. 
 V. Genersich, 85. 
 Gerhardi, 304. 
 Gerhardt, 104, 125, 454, 463. 
 Gerster, 455. 
 Gersuny, 77. 
 Gibson, 423, 426. 
 Gilford, 333. 
 Ginsberg, 38. 
 Girode, 269. 
 
 Glenard, 229, 241, 245, 255. 
 Glücksmann, 294. 
 Gmelin, 108, 109, 207. 
 Goldbach, 487. 
 Goltdammer, 415. 
 GolubefE, 436. 
 Goodsir, 119. 
 Graser, 407, 417, 425. 
 Grawitz, 262, 463. 
 Grisolle, 430. 
 Grohe, 430, 432, 433. 
 Gruber, 28, 453. 
 Grundzach, 404. 
 Grützner, 25, 34. 
 Gussenbauer, 453. 
 Guttmann, 375. 
 Gyergyay, 37. 
 
LIST OF AUTHORS 
 
 559 
 
 Hadham, 290. 
 de Häen, 255. 
 Hagemann, 48. 
 Plagenbach, 304. 
 Haguenot, 361, 3G2. 
 Hahn, 314, 333, 347, 348, 
 
 352, 503. 
 Hall, 208. 
 Hamann, 262. 
 Harnmarsten, 103. 
 Handford, 334. 
 Hansemann, 298. 
 Häri, 108. 
 Harley, 432. 
 Hartley, 440, 467, 408. 
 Hartmann, 264, 313, 490, 
 
 499. 
 Hasenclever, 183. 
 Hauser, 298, 299, 334. 
 Hausmann, 299. 
 Hedin, 27. 
 Hegar, 177. 
 Heidenhain, 26, 27, 31, 37, 
 
 39, 43, 404, 418. 
 Heidenreich, 400. 
 Heimann, 297. 
 Heineke, 327. 
 Helferich, 334. 
 Heller, 400. 
 Hem meter, 82. 
 Henle, 10, 12, 19, 361. 
 Henoch, 183, 293, 365, 389, 
 
 435. 
 Henry, 301. 
 Henschen, 231. 
 Herczl, 294. 
 Hermann, 41, 42, 209. 
 Heron, 25. 
 Herter, 26. 
 Hertz, 20, 21. 
 Herxheimer, 262. 
 Heryng, 88. 
 Herz, 113, 130, 304, 348, 
 
 349, 350, 351, 353, 529. 
 Herzstein, 80. 
 Heubner, 453. 
 Heurteux, 338. 
 Hiller, 253. 
 Hirsch, 24, 36. 
 Hirschler, 141. 
 Hlawacek, 455. 
 
 Hochenegg, 320, 327, 389, 
 
 406. 
 Hochhaus, 130, 348, 350. 
 V. Hochstätter, 445. 
 Hoffa, 170. 
 Hofmeister, 26, 37, 264, 
 
 352, 414. 
 Hofmokl, 77, 485. 
 Holländer, 338. 
 Holtmann, 334. 
 Honigmann, 41. 
 Hoppe-Seyler, 25, 37, 38, 
 
 94, 95, 102, 103, 113. 
 Hoyer, 118. 
 Huber, 40, 400. 
 Iluppert, 107. 
 Hutchinson, 334. 
 Hyrtl, 3, 18. 
 
 Illoway, 240. 
 
 Israel, J., 314, 366, 397, 404, 
 
 453, 505. 
 Iversen, 299. 
 
 Jaccoud, 361. 
 
 Jacob], 195. 
 
 Jaffe, 132, 133, 365, 366. 
 
 V. Jaksch, 101, 102, 103, 
 
 104, 105, 106, 110, 111, 
 
 119, 121. 123, 125. 
 Jan icke, 305. 
 Jaworski, 130, 226. 
 Johnson, 353, 455. 
 Jullien, 483, 496. 
 Jürgens, 520. 
 
 Kader, 48, 363. 
 V. Karajan, 338. 
 Karewski, 435, 437, 441, 
 
 442, 444, 449, 453, 466. 
 Käst, 133, 301. 
 Katz, 104, 105. 
 Kauffmann, 100, 183. 
 Kaulich, 134. 
 Kelling, 393. 
 Kelly, 80. 
 Kelsey, 78. 
 Kelynack, 438. 
 Kernig, 306. 
 Kirmisson, 399. 
 Kitagawa, 96, 230, 234, 235. 
 
 Kjeldahl, 101. 
 Kjellberg, 209. 
 Klebs, 262, 263. 
 Kleinwächter, 461. 
 Klemperer, 301. 
 Kobert, 40, 41, 198. 
 Kobler, 209, 244. 
 Kocher, 344, 417, 421. 
 Kühner, 497. 
 König, 264, 276, 309, 326, 
 
 372. 
 Körte, 264, 326, 397, 399, 
 
 404, 417, 433, 436, 440, 
 
 441, 447, 450, 455, 463, 
 
 404, 466, 503. 
 Köstlein, 399. 
 Kohlenberger, 40. 
 Kohlstock, 253. 
 Kohn, 316. 
 
 Kossobudskji, 517, 518. 
 Kraft, 455. 
 Kraske, 299, 319, 320, 321, 
 
 327, 328, 329. 
 Krauss, 280, 285, 286, 292. 
 Krausshold, 313, 434. 
 Krönlein, 326, 432. 
 Krokiewicz, 276. 
 Krüger, 329, 330. 332. 
 Krukenberg, 338. 
 Krysinski, 230. 
 Kühne, 27, 43. 
 Kukula, 338. 
 Kümmel, 433, 439, 447, 463, 
 
 465. 
 Küster, 183, 430. 
 Küttner, 352, 363, 377. 
 Kuhn, 82, 183. 
 Kundrat, 329. 
 Kussmaul, 36, 183.304, 356, 
 
 416, 418, 524, 527. 
 
 Lafforgue, 433. 
 Landau, 255, 282. 
 Landerer, 294. 
 Lange, 294, 519. 
 deLangenhagen, 228, 229, 
 
 230. 
 Langerhans, 385. 
 Langermann, 238. 
 Lannelongue, 510. 
 Lannois, 305. 
 
560 
 
 DISEASES OF THE INTESTINES 
 
 Lanz, 435. 
 
 Lappe, 25. 
 
 Lauenstein, 441. 
 
 Lehmann, 25, 26, 40, 48. 
 
 Leiehtenstern, 112, 124, 
 125, 255, 303, 343, 348, 
 358, 361, 367, 372, 373, 
 374, 378, 379, 385, 386, 
 394, 400, 403, 404. 
 
 Lennander, 292, 294, 432, 
 433, 437, 444, 450. 
 
 Lennhof, 70. 
 
 Leo, 83, 110, 111. 
 
 Letcheff, 230. 
 
 Letulle, 353. 
 
 V. Leube, 40, 130, 143, 177, 
 228, 257, 263, 273, 286, 
 290, 293, 404, 413, 474. 
 
 Leubuscher, 173. 
 
 Levy, 327. 
 
 Levy-Dorn, 259. 
 
 Lewandowski, 89. 
 
 Lewin, 503. 
 
 V. Leyden, 196, 230, 323, 
 441." 
 
 Libman, 329, 332. 
 
 Liebig, 186. 
 
 Liebmann, 102. 
 
 V. Liebermeister, 251. 
 
 Lingen, 377. 
 
 Link, 336. 
 
 Litten, 134, 234, 353, 362. 
 
 Lloyd, 470. 
 
 Ijobstein, 897, 423. 
 
 Lockwood, 293, 338, 467, 
 469. 
 
 Lösch, 210. 
 
 Lövinsohn, 327. 
 
 Löwenstein, 234. 
 
 Longuet, 234. 
 
 Lorenz, 134. 
 
 Louyer, 430. 
 
 Lubarseh, 298. 
 
 Ludloff, 426. 
 
 Ludwig, 26, 38. 
 
 Luschka, 334, 433. 
 
 McArthur, 455. 
 McBurney, 70, 370, 433, 
 
 463, 466, 467, 469, 470, 
 
 471, 472. 
 
 McCosh, 455. 
 McMurtry, 433. 
 McNutt, 469. 
 Macdonald, 517. 
 Macfadyen, 44, 45, 73, 118. 
 Mackenzie, 293. 
 Maclagan, 399. 
 Madelung, 330, 331, 332. 
 Maisonneuve, 278, 326. 
 Maixner, 134. 
 Makins, 334. 
 Malgaigne, 368. 
 Manley, 432. 
 Mannaberg, 123, 444. 
 Planning, 25. 
 Marchand, 231. 
 Mariage, 432. 
 Mars, 455. 
 
 Mathieu, 228, 229, 230, 520. 
 Matterstock, 430, 434, 435, 
 
 436. 
 Maurin, 434. 
 Maydl, 297, 299. 
 Mayer, 35, 285. 
 Mayor, 473, 474, 478. 
 Mehu, 107. 
 Melchior, 262. 
 Melchioris, 378. 
 Melier, 430. 
 Meltzer, 44. 
 Mendelson, 228. 
 T. Mering,24,26, 28, 36,38, 
 
 282. 
 Messter, 133. 
 Meusser, 432. 
 Meyer, L., 395. 
 Meyer, W., 472. 
 Michel, 333. 
 Mikulicz, 293, 325, 397, 
 
 444, 463. 
 Miller, 47. 
 Minich, 112. 
 Minkowski, 26, 37, 38, 39, 
 
 86, 104. 
 Mirallie, 306. 
 Mislawski, 35. 
 Miura, 25. 
 Möbius, 541. 
 Monod, 445. 
 Moreau, 186. 
 Morgagni, 255. 
 
 Moritz, 24, 36, 282. 
 Morris, 435. 
 Morton, 463, 466. 
 Mosler, 400. 
 Mühlhäuser, 209. 
 Müller, 38, 40,41,103, 104, 
 
 125, 132, 140, 301, 331. 
 Munde, 455. 
 
 Munk, L, 37, 38, 39, 40, 41. 
 Murphy, 434, 461, 463. 
 Musculus, 28. 
 Mynter, 463, 469, 473. 
 
 Nanu, 338. 
 
 Nasse, 35, 186. 
 
 Naumann, 443. 
 
 Naunyn, 290, 362, 365, 382, 
 397, 398, 407, 420, 422, 
 423, 424, 449, 450, 510. 
 
 Nay, 430. 
 
 V. Nencki, 28, 44, 45, 73, 
 105, 118. 
 
 Neumeister, 31, 39. 
 
 Nickel, 500. 
 
 Nicolaysen, 311, 336. 
 
 V. Noorden, 41, 103, 190, 
 237. 
 
 Nothnagel, 33, 33, 34, 47, 
 62, 68, 69, 75, 77, 95, 96, 
 97, 100, 104, 105, 106, 
 109, 113, 114, 116, 121, 
 123, 124, 133, 146, 173, 
 181, 183, 194, 213, 216, 
 217, 219, 220, 228, 230, 
 235, 241, 244, 252, 268, 
 273, 386, 397, 310, 315, 
 339, 331, 344, 345, 355, 
 356, 357, 358, 361, 365, 
 383, 384, 386, 405, 406, 
 407, 410, 415, 434, 430, 
 433, 436, 437, 439, 445, 
 453, 454, 460, 509, 510, 
 522, 524, 525, 532, 540. 
 
 Nnttal, 118. 
 
 Nylander, 102. 
 
 Obalinski, 363, 365, 421, 
 
 424. 
 Obrastzow, 71. 72.264,276. 
 Oesterlein, 125. 
 V. Oettingen, 426. 
 
LIST OF AUTHORS 
 
 561 
 
 Oppenheimer, 280,283,284, 
 
 285, 286. 
 Oppler, 66, 131, 221, 227. 
 Oppolzer, 468. 
 Orth, 263, 266. 
 Ortweiler, 132, 133, 141. 
 Oser, 306, 531. 
 Osier, 467, 469. 
 Otto, 38. 
 Ozenne, 230. 
 
 Pacanowski, 134. 
 
 Paci, 336. 
 
 Pässler, ol4. 
 
 Paget, 334. 
 
 Pal, 35, 476, 477, 478. 
 
 Pariser, 100, 235. 
 
 Paton, 31. 
 
 Pauly, 281. 
 
 Pawlow, 222. 
 
 Pean, 503. 
 
 Peiper, 400. 
 
 Pel, 104. 
 
 Pellizari, 338. 
 
 Penzoldt,154,167,179,246, 
 
 247, 248, 251, 252, 436, 
 
 441, 442, 457, 458, 459, 
 
 460. 
 Pepper, 467, 469. 
 Perewoznikoff, 39. 
 Perroncito, 124. 
 Perry, 280, 281. 
 Petrina, 352. 
 Pettenkoffer, 108. 
 Petters, 134. 
 
 Peyer, 523, 524, 5-33, 534. 
 Pfannenstiel, 338. 
 Pflüger, 35. 
 V. Pfungen, 133. 
 Pic, 303, 304, 305, 306, 
 
 348. 
 Pick, 445, 534, 541. 
 Pilliet, 264. 
 Planer, 47. 
 Pl(5sz, 37. 
 Podolinski, 27. 
 Pölchen, 500. 
 Pohl, 195. 
 Poisseuille, 186. 
 PoUak, 183, 184. 
 PoUatschek, 165. 
 
 Port, 334. 
 Porter, 432. 
 Potain, 228, 311, 377. 
 Power, 384, 386. 
 Praussnitz, 140, 
 Pravaz, 437. 
 Prazmowski, 121. 
 Preismann, 518. 
 Prochownick, 334. 
 Pulawski, 129. 
 
 Quenu, 490, 499. 
 Quincke, 93, 94, 126, 154, 
 
 177. 
 
 Radziejewski, 186. 
 Raffinesque, 386, 389, 391. 
 Ramm, 198. 
 Rauber, 1, 8, 9, 10, 17. 
 Reckmann, 280, 281, 285, 
 
 286. 
 Regnault-Beclard, 48, 373. 
 Rehn, 327. 
 Reiche, 348. 
 Reichmann, 88. 
 Reinbach, 511. 
 Reinke, 352. 
 Reisert, 48. 
 Rendu, 453. 
 
 Renvers, 434, 441,461,463. 
 Rewidzofe, 348. 
 Ribbert, 298,430, 433, 434, 
 
 436. 
 Richardiere, 231. 
 Richardson, 250, 443, 461. 
 Richelot, 313. 
 Ricker, 331. 
 Riedel, 394, 450, 477. 
 Rieder, 116, 394, 499, 500, 
 
 503, 505. 
 Riegel, 34, 130, 348, 349. 
 Roberts, 27. 
 Robin, 286. 
 Robitschek, 134. 
 Robson, 31. 
 Rochard, 399. 
 Röhmann, 25, 31. 
 Roesen, 134. 
 Rokitansky, 297. 
 Romberg, 533. 
 Rommelare, 301. 
 
 Roos, 94. 
 
 Rosenbaeh, 84, 133, 301, 
 
 417, 462, 527. 
 Rosenheim, 228, 247, 248, 
 
 252, 474, 514, 518, 527, 
 
 534, 541. 
 Rosenstein, 38, 39, 40, 47, 
 
 361. 
 Rosi, 338. 
 Rosin, 133. 
 Rossbach, 43. 
 Rothmann, 229, 231, 235. 
 Rotter, 433, 437, 439, 443, 
 
 446, 447, 450, 454, 458, 
 
 461, 462, 463, 464, 465, 
 
 504, 505. 
 Roux, 286, 433, 441, 519. 
 Rovighi, 199. 
 Rubner, 39, 99, 139, 140, 
 
 141. 
 Rüpp, 297, 299, 307, 308, 
 
 311, 312, 326. 
 Rüge, 47, 229. 
 Rumpel, 133. 
 Runeberg, 84. 
 Ruysch, 255. 
 Rydygier, 424, 426. 
 
 Sahli, 154, 200, 412, 431, 
 436, 441, 457, 461, 463. 
 
 Salkowski, 40, 45, 132, 133, 
 135. 
 
 Salzer, 264, 278, 314. 
 
 V. Samson, 22. 
 
 Sanders-Ezn, 32. 
 
 Sandmeyer, 37, 40, 104. 
 
 Sandowski. 516. 
 
 Sandoz, 404. 
 
 Sands, 466. 
 
 Sappey, 8, 9, 11, 15. 
 
 Sasaki, 521. 
 
 Searbinato, 254. 
 
 Schäfer, 198. 
 
 Schede, 313, 364, 421, 426, 
 433, 463, 505. 
 
 Schiefferdeeker, 22. 
 
 Schierbeck, 47. 
 
 Schillbach, 173. 
 
 Schlange, 327, 363, 365. 
 
 Schleimpflug, 521, 
 
 Schloffer, 326. 
 
562 
 
 DISEASES OP THE INTESTINES 
 
 Schmidt, Ad., 97, 108, 117, 
 319, 235. 
 
 Schmidt, C, 26, 98, 99, 100. 
 
 Schmidt, R., 331, 332. 
 
 Schmitz, 199. 
 
 Schnetter, 89. 
 
 Schneyer, 301. 
 
 Schnitzler, 365, 395, 408. 
 
 Schreber, 249. 
 
 Schrötter, 293. 
 
 Schuchardt, 503. 
 
 Schule, 130, 348, 350. 
 
 Schüler, 423. 
 
 Schulze, 281. 
 
 Schuster, 70. 
 
 Schwab, 334. 
 
 See, 70, 228, 230. 
 
 Senator, 40, 132, 183, 453, 
 463. 
 
 Senn, 338, 447, 448. 
 
 Shaw, 280, 281. 
 
 Sheild, 280, 290, 451, 
 
 Sick, 399. 
 
 Sieber, 44, 45, 73, 118. 
 
 Simon, 79, 86, 400. 
 
 Siredey, 228. 
 
 Skliffassowski, 338. 
 
 Small, 436. 
 
 Smith, 334. 
 
 Sonnenburg, 153, 433, 435, 
 437, 439, 440, 441, 445, 
 446, 447, 450, 451, 452, 
 462, 463, 464, 466, 504. 
 
 Soulier, 517. 
 
 Stadelmann, 29, 125. 
 
 Starke, 285. 
 
 Stein, 468. 
 
 Steiner, 336, 337, 436. 
 
 Stiller, 209. 
 
 Stöhr, 6, 7. 
 
 Stokes, 403. 
 
 Strauss, 47, 148, 404. 
 
 Strehl, 404. 
 
 Stromayr, 134. 
 
 Strümpell, 209. 
 
 Subbotin, 198. 
 
 Suffit, 266. 
 
 Swiezynski, 34. 
 
 V. Sydow, 434. 
 
 Tacke, 48, 363. 
 
 Talamon, 430, 431, 436, 445, 
 453. 
 
 Talma, 522. 
 
 Tappeiner, 47. 
 
 Tavel, 435. 
 
 Teichmann, 40, 104. 
 
 Terrillon, 454. 
 
 Thiem, 504. 
 
 Thierf elder, 103, 113, 118. 
 
 Thiersch, 298. 
 
 Thiry, 25. 
 
 Thomas, 384. 
 
 Tietze, 365. 
 
 Tiffany, 469. 
 
 Treub, 455. 
 
 Treves, 57, 306, 309, 310, 
 330, 360, 361, 362, 370, 
 372, 373, 379, 380, 381, 
 382, 386, 389, 390, 391, 
 392, 393, 399, 406, 417, 
 421, 433, 434, 437, 441, 
 445, 447, 460. 
 
 Trommer, 102. 
 
 Trousseau, 503, 534. 
 
 Tschitschowisch, 263. 
 
 Tuffier, 433. 
 
 Turby, 25. 
 
 Turner, 209. 
 
 Tyson, 469. 
 
 Ullmann, 234. 
 Unna, 517. 
 
 V. Vämossy, 195. 
 
 Vanni, 229. 
 
 Vanvers, 445. 
 
 Varr, 408. 
 
 Vaughan, 206. 
 
 van den Velden, 46. 
 
 Verneuil, 518. 
 
 Virchow, 96, 255, 270, 298, 
 
 394, 496, 502. 
 Villerraay, 430. 
 Vötsch, 244, 255. 
 Voit, 30, 40, 42. 
 Volz, 437, 458. 
 Vries, 133. 
 
 Wagner, 84. 
 
 V. Wahl, 363, 364, 381, 
 407. 
 
 Waldeyer, 298. 
 Wallis, 353. 
 V. Walther, 39. 
 Walton, 164. 
 Wannach, 294. 
 Wassiljeff, 94. 
 Weber, 106. 
 Weecke, 304. 
 Wegele, 247, 248, 348. 
 Weir-Mitchel, 259. 
 Weiske, 140. 
 Wendt, 34. 
 Wenz, 26. 
 Wernich, 352. 
 Westphalen, 393. 
 White, 238. 
 Whitehead, 334, 520. 
 Wiczkowski, 252. 
 Widal, 120, 210, 453. 
 Wiedersheim, 39. 
 Wieland, 463. 
 Weir, 466. 
 Wiener, 469. 
 V. Wild, 247, 250. 
 Will, 39. 
 Williams, 250. 
 van der Willigen, 493. 
 Wilms, 304, 348, 365. 
 Windscheid, 475. 
 Winston, 31. 
 Winternitz, 199. 
 Wittich, 110. 
 Wittstock, 279. 
 Wölfler, 325, 326, 338, 445. 
 Wollbrecht, 480. 
 Wood, 253. 
 Woodward, 43. 
 Wunderlich, 311. 
 Wyss, 262. 
 
 Zander, 172. 
 
 Zawadsky, 26. 
 
 Zawarykin. 39. 
 
 Zemann, 296. 
 
 Ziegler, 266. 
 
 V. Ziemssen, 84, 86, 173, 
 
 333, 417. 
 V. Zöge - Manteuffel, 363, 
 
 364, 365. 
 Zuckerkandl, 430, 436. 
 Zuntz, 48, 363. 
 
A TEEATISE 
 
 ON" DISEASES OE THE 
 
 RECTUM, AI^US, a^d 
 
 SiaMOID FLEXURE. 
 
 By JOSEPH M. MATHEWS, M.D., 
 
 of louisville, kt., 
 
 Professob of the Peinciples and Peactice of Surgery, and Clinical Lectceeb 
 
 ON Diseases of the Rectum, in the Kentucky 
 
 School of Medicine, etc. 
 
 With Six Cliroinolithographs and numerous Illustrations in the Text. 
 SECOND EDITION, REVISED. 
 
 8vo, 537 pages. Cloth binding, $5.00. 
 
 SOLD ONLY BY SUBSCRIPTION. 
 
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 rectal specialist. ... A careful perusal of Mathews's work can not fail to give the practi- 
 tioner all the knowledge that is desirable to successfully diagnosticate and treat any case of 
 rectal disease that may come before him, if he possesses a modicum of the dexterity that an 
 ordinary surgeon should have. . . . The book is rich in clinical material, and, in the writer's 
 opinion, is the best work on this specialty yet published. The publishers have done their 
 work well, the six chromolithographs being artistic." — Chicago Medical Recorder, 
 
 "._ . . The work is a most practical and classical presentation of the vast and varied 
 experience of a painstaking observer and worker. The specialist will buy it and read it, 
 otherwise he would not be progressive. The general practitioners, above all, should procure 
 and read this book, for the reason that it will at least assist them in making a correct 
 diagnosis ; and, if they care to treat these diseases, it gives them all that is newest and 
 best." — Medical Mirror. 
 
 " This book we think is decidedly original in many of its features. The author has not 
 taken other men's opinions as his guide, for the reason that in his fifteen years' experience 
 as a rectal specialist he has learned ' that many things that are taught are not true, and that 
 many true things have not been taught.' He has therefore accepted as truths only those things 
 which could be substantiated by facts, and has here recorded' them. Several chapters new 
 to books on this subject have been introduced by him, among which wül be found the follow- 
 ing : Disease in the Sigmoid Flexure, the Hysterical or Nervous Eectum, Anatomy of the 
 Rectum in Relation to Reflexes, Antiseptics in Rectal Surgery, and a New Operation for Fistula 
 inAno. . , . Illustrated with six excellent colored plates and numerous cuts ; clearly printed 
 with large type, and nicely bound, it presents a most attractive appearance. We do net 
 know of any work on the subject wMgii more thoroughly meets our approval." — Memphis 
 Medical Monthly. 
 
 D. APPLETO]!^ AND COMPANY, NEW YORK. 
 
A TREATISE ON THE 
 DISEASES OF WOMEN. 
 
 By ALEXANDER J. C. SKENE, M. D., 
 
 PROFESSOR OF GYNECOLOGY IN THE LONG ISLAND COLLEGE HOSPITAL, BROOKLYN, N. Y. ; FOR- 
 MERLY PROFESSOR OF GYNECOLOGY IN TEE NEW YORK POST-GRADtTATE MEDICAL 
 SCHOOL AND HOSPITAL, ETC. 
 
 Third Edition, revised and enlarged. 8vo, 991 pages. With 290 Fine 
 
 Wood Engravings, and Nine Chromolithographs, prepared 
 
 especially for this work. 
 
 SOLD ONLY BY SUBSCRIPTION. 
 
 THIS attractive work is the outcome and represents the experience of a long and 
 active professional life, the greater part of which has been spent in the treat- 
 ment of the diseases of women. It is especially adapted to meet the wants 
 of the general practitioner, by enabling him to recognize this class of diseases as 
 he meets them in every-day practice and to treat them successfully. 
 
 The arrangement of subjects is such that they are discussed in their natural 
 order, and thus are more easily comprehended and remembered by the student. 
 
 Methods of operation have been much simplified by the author in his practice, 
 and it has been his endeavor to so describe the operative procedures adopted by 
 him, even to their minutest details, as to make his treatise a practical guide to the 
 gynaecologist. 
 
 While attention has been given to the surgical treatment of the diseases of 
 women, and many of the operations so simplified as to bring them within the 
 capabilities of the general surgeon, due regard has also been paid to the medical 
 management of this class of diseases. 
 
 ■ Although all the subjects which are discussed in the various text-books on 
 gynecology have been treated by the author, it has been a prominent feature in 
 his plan to consider also those which are but incidentally, or not at all, mentioned 
 in the text-books hitherto published, and yet which are constantly presenting 
 themselves to the practitioner for diagnosis and treatment. 
 
 "In the preface of the first edition of this work the author states : 'This work was written for 
 the purpose of bringing together the fully matured and essential facts in the science and art of 
 gynsecoloo-y, so arranged as to meet the requirements of the student of medicine, and be convenient 
 to the practitioner for reference.' The demand for a second edition has demonstrated how fully 
 this purpose has been accomplished. The reader can not fail to commend the conservatism and 
 honesty of the author 's opinions, and the care with which the material has been collected and 
 arranged. The second edition contains new chapters on Ectopic Gestation, Diseases and Injuries 
 of the Ureters, and Vesical Hernia. The first of these subjects receives in this edition a careful 
 exposition, the want of which was among the few defects of the former edition. The author's 
 work in the positional disorders of the uterus and laceration of the perinasum stands pre-eminent 
 among the contributions to this subject. His discussion of the use of pessaries throws much light upon 
 a subject which has suffered from the want of caretul treatment, both pro and cow. The publishers 
 deserve great credit for the illustrations and general style of the woti^s..'''— Medical News. 
 
 "We have very little to add to what we said of it on its first appearance, and we still regard it as 
 one of the few foremost books in this department in the English language. The addition of 
 chapters on Diseases and Injuries of the ureters, and on Ectopic Gestation, make it more complete. 
 Too much praise can not be given to the illustrations, which are models of clearness, and, as is not 
 always the case, show what is meant." — Boston Medical and Surgical Journal. 
 
 D. APPLETON AND COMPANY, NEW YORK.