COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 33311 RC801 .C66 Diseases of the dige RECAP f?C-^o\ C «o(o Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofdigestOOcohn DISEASES OF THE DIGESTIVE CANAL (CESOPHAGUS, STOMACH, INTESTINES) BY Dr. PAUL COHNHEIM SPECIALIST IN DISEASES OF THE STOMACH AND INTESTINES IN BERLIN FROM THE SECOND GERMAN EDITION EDITED AND TRANSLATED BY DUDLEY FULTON, M.D. LECTURER ON MEDICINE, UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES ILLUSTRATED PHILADELPHIA ^^ LONDON J. B. LIPPINCOTT COMPANY CoPYKiGnx, 1909 By J. B. LippiNCOTT Company Printed by J. B. Lippincotl Company Tlie Waslmipton Square Press, Philadelphia, V. S. A. DEDICATED TO HIS HIGHLY ESTEEMED TEACHER Professor Dr. I. BOAS OF BERLIN WITH THE GRATITUDE OF THE AUTHOR TRANSLATOR'S PREFACE Perhaps the most distinctive feature of the present volume is the discussion of the subject-matter purely from the clinical point of view. Dr. Cohnheim considers the anamnesis the most impor- tant part of the examination in the diagnosis of diseases of the gastro-intestinal canal; and throughout the volume he so defines the significance of subjective symptoms that the reader will scarcely fail to be impressed with the value of the art of interpreting these rather than applying himself to complicated details of laboratory work. The author frankly disclaims any attempt to review the literature, or to compile the views of others, or to present any pathological details and theoretical discussions; every subject is attacked with directness and all non-essentials are ignored. The volume is, in fact, a succinct record of his everyday experience with gastro-intestinal diseases of every kind, and this is perhaps the most valuable asset of the book. Those who have attended Dr. Cohnheim's clinic know quite well that he has no hesitation in dissenting from con- ventional theories which have not proven successful in practice. All of the above-described features are strongly presented in the German editions, and I have endeavored to preserve them intact in the Enghsh version; in order to retain this characteristic quality, I have made but few editorial emenda- tions, all such data being enclosed in brackets. I wish to thank the publishers for their unfaiUng courtesy, Mr. W. Halven and Miss Ruby Archer for their assistance in the preparation of the manuscript, Dr. Malcolm Lloyd for the drawings which have been added to the English edition, and Mr. Leroy Baumberger for his careful stenographic work and preparation of the index. Dudley Fulton, M.D. Los Angeles, December^ 1908. PREFACE TO THE ENGLISH EDITION Since the first German edition of this medical work made its appearance, many American and EngHsh physicians who attended my cKnic, but who were not sufficiently con- versant with the German language to understand all the details, have repeatedly expressed the wish that an English edition of my work be published. I have finally decided to act upon this suggestion, and am especially willing to do so at this time for the reason that my esteemed colleague, Dr. Dudley Fulton, of Los Angeles, — who has studied the modern methods of diagnosis and thera- peutics of the diseases of digestion in my polycHnic and is thoroughly familiar with the principles upon which my book is based, — consents to prepare the English edition. I gladly authorize him to do so, and am exceedingly obliged to him, as well as to the publishers, the J. B. Lippincott Company, of Philadelphia, for their manifold courtesies. Encouraged by many cordial expressions of English- speaking friends, the author trusts that the present edition will supply a need of the general practitioner, and that it will find a friendly reception and kind criticism among its new circle of readers. Paul Cohnheim. Berlin, February 16th, 1908. PREFACE TO THE SECOND GERMAN EDITION The demand for a new edition of this work, — after scarcely two years have elapsed, — is evidence, I believe, of its friendly reception by the profession. The medical press has criticized my book in a favorable way, and has given me helpful hints for improvement in the second edition. To all kind censors, many thanks! I am especially grateful to all that have assisted me by suggesting recent developments in the knowledge of digestive disorders; and I desire to thank particularly my fellow specialists. Dr. F. Hoppe, of Hanover, and Dr. F. Ehrlich, of Stettin. The general plan and arrangement of the book, and the restriction of its contents to a consideration of only practical measures, remain unaltered. I have merely added some of the newer diagnostic and therapeutic methods, and with these changes I present the second edition to the profession. Paul Cohnheim. Berlin, September 1st, 1907. PREFACE TO THE FIRST GERMAN EDITION In compliance with the urgent desire of my students, I have finally decided to publish the present volume. My hesitation will be understood when one considers the numerous well-known text-books available on stomach and intestinal diseases. But as my little book contains the essence of what I have used for years in presenting and demonstrating patients and specimens to physicians attending my polyclinic, it offers only the practical points of view. In order that it might not be over-burdened, I have been obliged to exclude physiological, pathological, and anatomical subject-matter, as well as frequent reference to the literature. Since this book is intended for the use of the general practitioner, I believe I am justified in having done so. With the same object in view, everything has been omitted that could be spared in the clinical portion of the book. At the outset, I wish to defend myself against any suppo- sition that the present volume is a compilation from other text-books, and I beg leave to emphasize the fact that it contains the record of personal experience during my many years of work as the assistant of Dr. I. Boas, whom I desire to thank publicly for his aid and scientific guidance. The book likewise includes knowledge gained in my private and polyclinic experience; and since my practice has always been a general one, it has made me familiar with those points that are essential to the general practitioner, and, therefore, to be dealt with in such a work. Although the reading of any treatise can scarcely replace the advantages of clinical instruction and laboratory demon- strations, yet I believe that this manual will be a trustworthy xii PREFACE TO THE FIRST GERMAN EDITION guide to the physician in the difficulties of diagnosis and treat- ment of diseases of digestion. With this desire I offer it to the public, and hope for a kind reception on the part of its readers. I owe the execution of the microscopical drawings to the kindness of Miss Paula Guenther. Paul Cohnheim. Berlin May Lst, 1905. TABLE OF CONTENTS GENERAL SECTION PAGE Anamnesis and Subjective Symptomatology 1 Physical Examination 5 Inspection 5 Percussion 8 Palpation 8 Auscultation 21 Internal Chemical and Microscopical Examination of the Stomach. . 21 Introductory Remarks 21 Qualitative Examination 23 Quantitative Examination 25 Ferment Tests 29 Motility Tests 35 Jlicroscopical Examination of the Stomach-contents 36 Examination for Blood 41 Technic, Indications .\nd Contraindications in the Use of the Stomach-Tube 42 Laboratory Apparatus 46 SPECIAL SECTION Diseases of the CEsophagus 48 Cancer of the (Esophagus 48 Ulcer of the (Esophagus 50 Benign Stenosis (including Strictures and Spasms) 57 Dilatation of the (Esophagus (Diverticulum) , 60 Chronic Cardiospasm 61 Foreign Bodies 67 Neuroses of the CEsophagus 68 Diseases of the Stomach 71 Clinical Remarks 71 Organic Diseases of the Stomach 82 Acute and Chronic Gastric Catarrh 82 Acute Gastritis 83 Chronic Gastritis 87 Ulcer of the Stomach^ 108 Appendix: Erosions and Fissures of the Pylorus 127 Carcinoma of the Stomach 133 xiii xiv TABLE OF CONTENTS PAGE Diseases of the Stomach: Organic (Continued) Epigastric Hernia 150 Gastrectasis 151 Perigastritis 167 Hypersecretion 168 Hyperchlorhydria 172 Functional Diseases of the Stomach 177 Ana^mic-Gastroptotic Dyspepsia (Atony) 180 Remarks on Enteroptosis 190 Phthisical D3'spepsia 196 Nervous Dyspepsia 199 Special Forms of Neuroses of the Stomach 209 Diseases of the Stomach in Connection with Diseases of Other Organs. 223 The Stomach and Disorders of Metabolism 223 Acute and Chronic Infectious Diseases 225 Central Nervous System 225 Stomach and Circulatory System 228 Stomach and Diseases of tlie Lungs 229 Stomach and Genito-urinary Apparatus 230 Stomach and Liver, Pancreas and Spleen [Gail-Bladder] 231 Stomach and Intestinal Diseases 235 Stomach and Sexual Organs 236 Diseases of the Intestine 237 Introduction 237 Examination of the Patient 242 Chemical and Microscopical Examination of the Stool 245 Primary Organic Diseases of the Intestine 253 Acute Enteritis 253 Chronic Catarrh of the Intestine 257 Appendix: Membranous Enteritis, Meteorism and Flatulence. 265 Ulceration of the Mucous Membrane of the Intestine 271 Typhlitis and Appendicitis 275 Tumors and Neoplasms of the Intestine 281 Displacements of the Intestine 283 Secondary Organic Diseases of the Intestine 285 Stenosis and Dilatation of the Intestinal Canal 285 Intestinal Obstruction 289 Acute and Chronic Peritonitis 294 Functional Diseases of the Intestine 299 Chronic Constipation 299 Appendix: Relationship between Constipation and Diarrhoea. 318 Neuroses of the Intestine 319 Atony of the Intestine 321 Intestinal Spasms (Lead Colic) 321 Nervous Diarrhoea . 323 Peristaltic Unrest of the Intestine 323 Intestinal Neurasthenia 324 Intestinal Disturbances in Diseases of Other Organs 325 TABLE OF CONTENTS xv PAGE Diseases of the Intestine: Functional (Continued) Parasites of the Intestine 325 Diseases of the Rectum 330 Catarrh and Inflammation of the Rectum 331 Ulceration of the Rectum 334 Fissures and Erosions of the Anus 335 Neoplasms of the Rectum 337 Hemorrhoids 337 Malignant Neoplasms of the Rectum 341 Benign Stenoses of the Rectum 344 Nervous Diseases of the Rectum 345 Appendix 347 Diagnostic Table '. 347 Outline of Dietetic Treatment 348 Outline of Balneotherapy 356 Indications for Hydrotherapeutic, Mechanical and Electrical Treat- ment 359 Clinical A B C of the Most Important Disturbances of the Digestive Tract 361 Index 367 LIST OF ILLUSTRATIONS FIG. PAGE 1 . (A) Diagram of normal habitus 6 2. (B) Diagram of habitus enteropticus 6 3. Palpation of the abdomen 10 4. Obrastzow's palpatory percussion method for determining the borders of the stomach 12 5. Palpation of the right kidney 15 6. Typical pressure point in gastric ulcer 17 7. Typical pressure zone in liver and gall-bladder affections 18 8. Pressure areas in nervous affections of the stomach 19 9. Separating apparatus suitable for making test for lactic acid (Strauss 's) 24 10. Microscopic findings from fasting stomach containing free HCl, but no food remnants 37 11. Microscopic findings from fasting stomach containing neither HCl nor food 38 12. Microscopic findings from fasting stomach which contains both HCl and food 39 13. Microscopic findings from fasting stomach which contains food and lactic acid but no HCl 40 14. (A) American stomach-tube; (B) Riegel's stomach-tube 43 15. (A) Modified Jacques stomach- tube ; (B) Ewald's stomach-tube 44 16. Method of introducing the stomach-tube 45 17. Trousseau's oesophageal bougie 50 18. Cardiospasm dilator and mercurial manometer 64 19. 1. Obturator; 2. CEsophagoscope; 3. Coin catcher and foreign-body forceps 68 20. Diagram showing different positions of the stomach 73 21. Normal mucous membrane of the stomach (pylorus) 88 22. Mucous membrane in interstitial and atrophic gastritis (alcoholic) 88 23. Diagram showing the development of the various forms of gastritis. ... 89 24. Typical pressure point in gastric ulcer 114 25. Hour-glass contraction of the stomach, cicatricial stenosis of the pylorus and cardia with a dilatation of the oesophagus 118 26. Carcinomatous degeneration of an ulcer of the pylorus 134 27. Diagram showing the development and progress of cancer of the stomach 138 28. Cancer of the cardia producing stenosis 142 29. Gastrectasia secondary to ulcer of the pylorus 157 30. Diagram showing the development and course of hypersecretion 169 31 to 33. Various forms of abdominal belts 192 34. Stengel's kidney belt 192 x\ai xviii LIST OF ILLUSTRATIONS FIG. PAGE 35. Diagram of Rose's adhesive plaster belt marked for cutting 193 36. Diagram of Rose's adhesive plaster belt 193 37. First step in the application of the adhesive plaster belt 194 38. Second step in the application of the adhesive plaster belt 195 39. Microscopic findings of the normal stool 247 40. Microscopic findings of a stool containing bismuth, fat-cells, etc 248 41. Microscopic findings of the stool in enteritis 249 42. ^licroscopic findings in a stool containing taenia solium, eggs of ascarides, Charcot-Leyden crystals, etc 250 43. Ulcer of the duodenum 273 44. Rectal irrigator (Strauss) 333 45. Tuttle's rectoscope 334 INTRODUCTION A BOOK, to be a practical guide for the physician in the diagnosis and therapy of stomach and intestinal diseases, must avoid complicated methods which require special experi- ence and the apparatus of a laboratory. I have, therefore, laid the greatest stress upon a thorough and rational anamnesis in making the examination. The varying complaints and discomforts of patients, as well as the symptoms of the different forms of dyspepsia, are modi- fied so largely by rest, exercise and occupation, by the amount and character of the food, and by the condition of the bowels, that the skilled examiner will be able to form a correct diag- nosis in most cases from the answers to his questions. For this reason, I cannot sufficiently emphasize the need of mak- ing a provisional diagnosis while obtaining the history of the patient, which the physical, chemical and microscopical findings will either confirm or reject. When considered alone, the physical findings are far more liable than the clinical history to mislead one in making the diagnosis. For example, the diagnosis of ''dilatation of the stomach" is frequently made when the greater curvature of the stomach is found to be below the umbilicus. Now, since vomiting is never absent in actual dilatation of the stomach, and the history of the patient would establish the presence or the absence of this symptom, a careful anam- nesis would thus prevent this wrong diagnosis. I have been very careful, throughout, to emphasize the difference between organic, or anatomical, and functional, or nervous, stomach and intestinal diseases. All other points are of lesser importance in comparison with this cardinal information, since the accuracy of this knowledge determines the therapy. Organic, or anatomical, stomach and intestinal diseases require local treatment; while functional, or nervous, XX INTRODUCTION secondary, or reflex, stomach and intestinal affections, which are s3'mptoms of some constitutional disorder, or are second- ar)^ to a disease of some other organ, are to be treated with reference to the primary cause. I shall give only one example: Phthisis produces very often, at first, a loss of appetite and pressure in the stomach, which arc frequently attributed to chronic catarrh of the stomach; and such patients are often prescribed a liquid diet for a long period, in the supposition that an organic stomach trouble exists; when, in fact, only the treatment of the primar}^ disease, — in this case, phthisis, — would cause a disappearance of the symptoms of dyspepsia. It is appropriate to mention in this place that persons afflicted with lung, heart, kidney, liver and nervous disorders are very frequentl}^ sent to the specialist for treatment of dyspepsia. The examiner must, therefore, in every case of stomach or intestinal disease, make it his absolute duty to examine all the internal organs and also the central nervous S3'stem. The epigastrium, with its numerous sympathetic nerve- ganglia, offers a focus toward which the diseases of all possible organs throw their rays. This explains the fact, not com- monly known, that a large percentage of ''stomach troubles" are of a functional nature; and therein is found the explana- tion of the surprising truth that a great many patients suffer- ing from chronic stomach trouble obtain relief through "quacks," after having vainl}" sought relief for years in the regular schools of medicine. Indeed, the physician who, in clinical instruction in the universities, comes in con- tact with organic maladies almost exclusively, is naturally inclined to consider most stomach and intestinal affections as organic. Stomach pathology, more than any other department of medicine, shows the influence of bad habits, excesses "in Baccho et Venere," non-hygienic living, worry, anxiety and the restless haste and strenuousness of modern business life. In every rational therapy, therefore, it is of the greatest INTRODUCTION xxi importance to establish the cause of the dyspepsia by investi- gating the occupation, home environment, habits, diet, and general physical condition of the patient. An exact anamnesis is always the most difficult and prolonged and also the most important part of the examina- tion, because the clews thus obtained furnish not only the best fulcrum for the diagnosis, but also the best indication as to the causal therapy. The contents of the book are arranged in the following manner : In the General Section on Stomach Diseases tliese topics are considered: 1. The anamnesis, with the different subjective symp- toms; 2. The methods of physical examination, particularly palpation; 3. The chemical and microscopical methods of examina- tion. The Special Section on Stomach Diseases is divided into three parts: 1. The organic, or anatomical, local diseases; 2. The functional disorders, or atony, neuroses, etc.; 3. The symptomatic stomach disorders, secondary to diseases of other organs. The same arrangement is employed in the Section on Intestinal Diseases, except that the presentation is much shorter, in order to avoid repetition. In the beginning of the Special Section on Stomach Diseases, I have given a short abstract on the Diagnosis and Therapeutics of Diseases of the Oesophagus. As an appendix, I have added a diagnostic and thera- peutic glossary, which will be convenient for the practitioner. At the end of the book are outlines of balneotherapy, electrotherapy, diet, etc., appropriate to our subject. DISEASES OF THE DIGESTIVE CANAL GENERAL SECTION Anamnesis and Subjective Symptomatology Patients are unable to differentiate between the important and the unimportant symptoms of disease. Therefore, in ob- taining the history of a gastro-intestinal affection, it is essential that the physician should not allow the patient to enumerate aimlessly all his subjective disturbances, but should require him to give short, precise answers to the following questions: 1. How long have you been ill? Indefinite statements, such as "'A long time," or ''Several months," are without value. The physician must ascertain exactly how many weeks, months, or years the patient has suffered from indigestion, when the symptoms first appeared, whether the trouble developed suddenly or gradually, and whether the disease has been intermittent or progressive. The information derived from these answers immediately enables him to differentiate acute from chronic affections. 2. Do you suffer constantly or only occasionally? This question is important, because the course and pro- gress of the disorder, and the variations of its intensity, are significant in every primary disease of the stomach and intes- 1 2 DISEASES OF THE DIGESTIVE CANAL tine. For example, gastric pains which occur periodically are typical of peptic ulcer or of the gastric crises of tabes, etc.; while, on the other hand, sA'mptoms which are constant are characteristic of chronic gastritis, nervous dyspepsia, etc. It is especially necessary to determine whether periods of normal digestion have alternated with periods of dyspepsia. 3. Can you s w a 1 1 o \^• all kinds of food w i t h o u t d i f f i c u 1 t y ? With this ciuestion, the physician begins the incjuiry concerning the symptoms pertaining to diseases of the different portions of the digestive tract. If the patient answers this question in the negative, some affection of the oesophagus exists. More detailed questions will determine whether solids only are swallowed with diffi- culty, whether such are vomited, and whether the impediment to deglutition is constant or periodical. (See details in special chapter on Diseases of the Qilsophagus.) 4. Have you actual pain or only pres- sure? This question is of the greatest possible significance, because a purely functional dyspepsia never causes actual pain. Pain occurs exclusively in organic diseases of the stom- ach (ulcer, stenosis, carcinoma, etc.), or some neighboring organ (gall-bladder, appendix, colon, etc.). It should always be kept in mind, that unless patients are very careful on this point they usually say they have "pain," no matter what may be the exact nature of their discomfort, and it also frequently happens that they are really unable to distinguish between actual pain and other sensory disturbances. I include as painful all sensations of a crampy, colicky, cutting, stabbing, boring, or burning nature. Among those that are not painful, I would classify sensa- tions of pressure, fulness, discomfort, distention, nausea, weight, heaviness, or globus hystericus. ANAMNESIS AND SYMPTOMATOLOGY 3 5. If only pressure and discomfort are felt, are they constant or do they occur only after meals? Constant pressure in the abdomen, which is independent of the nature of the food, is characteristic of a gastric neurosis or of pressure from a distended intestine, or of encroachment upon the abdominal space from ascites, enlargements of the liver and spleen, etc. When pressure is located at the epigastrium, inquiry should be made as to whether this pressure is accompanied, as is usually the case, by fulness, distention, flatulence, the rapid satiation of appetite, lassitude after eating, heartburn, regurgitation, or vertigo. When pressure occurs after eating, it is essential to determine whether it is independent of the quality of the food. Pressure which occurs only after taking solid food indi- cates chronic gastritis. Pressure which occurs after a meal of either solid or liquid foods is characteristic of a functional dyspepsia. 6. If you have actual pain, what is its character, and when and where does it occur? Is it of a cohcky, cutting, boring, or burning nature? Where does it begin, and does it radiate? Is it intermittent, or does it persist with the same intensity for hours or for days? Does it recur every few months? (Cholelithiasis, Gastric Crises.) Or does it occur daily at a definite time after meals? (Ulcer.) Is the pain relieved by warm drinks? (Hy- perchlorhydria.) Or is it relieved by the escape of gases or by defecation? (Intestinal Colic.) Is vomiting induced by the pain, and does relief follow vomiting? Do you artificially produce vomiting to experience alleviation of the pain? (Pyloric Stenosis.) 7. Doyouvomit? If so, at what time? Do you vomit early in the morning, or only after meals? Do you vomit certain foods, — for 4 DISEASES OF THE DIGESTIVE CANAL example, vegetables or grapes,— which 3-011 have eaten a few days previously? (Stenosis of the Pylorus.) Do you vomit only mucus? (Gastritis.) Do j^ou vomit only an acid fluid? (Hypersecretion.) Are all foods vomited immediatch- after eating? (Reflex.) Or do you vomit very profusely every few days and are you thereb}" relieved? (Ectasia.) Does vomiting recur ever}^ few weeks or months, and are you then for a period comparatively well? (Gastric Crises.) Is the vomiting associated with attacks of migraine; and if so, do you vomit until bile is present in the vomitus? (Reflex.) Do 3'ou vomit a short time after eating rich, indigestible foods, such as cabbage, cheese, smoked meat, hard boiled eggs, etc. (Gastritis.) 8. What is the condition of 3- o u r bowels? Are 3^our bowels regular or irregular? How often do they move? Are the stools formed, semi-solid, or liquid? If the stools are formed, have they a large or small calibre? Are the stools hard and knotted or pasty and spongy? Do 3"ou pass mucus? If so, is the mucus free or is it mixed with the feces, or are the latter enveloped by membranous mucus? Have 3'OU observed sections of tapeworms in the stools? Have 3^ou much gas, and is it associated with abdominal pain? If the pressure of gas is associated with pain, does the escape of gas give relief? (See details in the section on Intestinal Diseases.) 9. What are 3^ o u r general symptoms? The physician must ascertain whether lassitude, emacia- tion, loss of appetite, excessive hunger, abnormal thirst, nervous irritability, insomnia, or mental depression is present. 10. From what diseases have you pre- viousl3^ suffered, and what is your family history? It is very important to ascertain whether the patient has previousl3' suffered from serious affections like apical PHYSICAL EXAMINATION 5 tuberculosis, venereal infections, inflammatory rheumatism, or typhoid fever; and whether he has been jaundiced, or has masturbated for a long time; and above all, whether he has been physically or mentally over-worked. In addition to obtaining a careful personal history, it is always the duty of the physician to inquire whether the parents or brothers and sisters of the patient have suffered from tuberculosis, diabetes, carcinoma, gout, or other con- stitutional diseases. The exact and complete answers to all these questions are invaluable in arriving at the correct diagnosis. Not until the anamnesis is obtained with the most patient care, as outlined above, and not until the physician has there- by formed a provisional diagnosis of the disease, should he proceed with the physical examination of the patient. The frequency with which patients consult a physician with regard to digestive disturbances, when the actual trouble is of an entirely different nature, emphasizes the importance of using the greatest care in the anamnesis, so as to avoid being misled at the outset of the examination. Physical Examination Inspection. — Since the physician must make it his duty in chronic stomach and intestinal diseases to make a thorough examination of the entire body, he should begin by carefully noting the color of the skin, the general nutrition, the facial expression, and above all, ''the habitus." All these things are of the greatest importance, because they often determine the differential diagnosis between functional and organic diseases of digestion. Since I assume the methods of inspection to be known, I shall merely remind the examiner of the need of noticing whether the patient is anaemic, pale, cyanotic, jaundiced, bronze-colored, or cachectic; and whether he appears to be well-nourished, moderately, or very badly nourished. I will here go into detail in the consideration of the habitus only. DISEASES OF THE DIGESTIVE CANAL According to Stiller, the normal habitus, or broad thorax, is differentiated from the so-called "habitus enter opticus," which is identical on the whole with the paralytic or phthisical habitus. The chief characteristics of the habitus enteropticus are the following: A long, small and usually flat thorax; a narrow costal angle, so that the xiphoid process is the apex of an Sicu\e angle. In patients with a normal habitv^, this angle amounts to 120 degrees or more. Where habitus ente- ropticus occurs, the angle amounts to perhaps 60 degrees. The more acute this angle, the more marked is the habitus enteropticus, which is accompanied by a loosening of the costal cartilages, so that usually the tenth right and left ribs fluctuate ; and in severe cases, the cartilages of the ninth right and left ribs also fluctuate. Fig. 1. Fig. 2. QUmbilicus ^Umbilicus A, diagram of normal habitus; B, diagram of habitus enteropticus. In habitus enteropticus, a vertical line drawn between the ensiform process and the umbilicus would be much longer than a line drawn at right angles to this vertical line and extending to the anterior axillary line. In normal habitus, on the other hand, this vertical line would be shorter or of about the same length as the line perpendicular to it, extending to the anterior axillary line. Therefore, in habitus enteropticus the epigastrium and hypochondrium have a greater longitudinal than transverse diameter, while in normal habitus the transverse diameter of these regions considerably exceeds the vertical. This explains why it is that the organs occupying the epigastrium and the hypochondrium must assume a more nearly vertical position than normally. (See Figs. 1 and 2). If relaxation of the abdominal wall and diastasis of the recti muscles occur in women with habitus enteropticus after pregnancy, the intestine loses its support, so that the stomach PHYSICAL EXAMINATION 7 also sinks downward and forward with the greater curvature below the umbilicus, without the stomach itself being dilated. Normally, the transverse colon is usually two or three finger-breadths below the greater curvature of the stomach. If the latter assumes an abnormally low position, it is natural that the colon should also occupy a correspondingly lower position. In women who have borne children, the colon is rarely found in the normal position, — namely, one or two finger- breadths above the umbilicus. In habitus enteropticus the right kidney is almost always palpable, the left less often, though the latter is more fre- quently displaced in men. The right kidney is often palpable, even in emaciated children with habitus enteropticus. Only in the rarest cases are the liver and the spleen displaced. The significance of habitus enteropticus in diseases of the abdominal organs, especially of the stomach, is, that persons with habitv^ enteropticus are predisposed to functional diseases of the stomach and intestine; that is to say, a given irritation would produce disturbances in a person with habitus enteropticus which would not affect a person with normal habitus. All causes that lead to insufficient nutrition and to a disappearance of fat from the mesentery and abdominal walls weaken the natural supports of the abdominal organs and produce in the enteroptotic individual some active disease which has, up to that time, been latent. This disease, how- over, is only of a functional nature, that is, not leading to a demonstrable anatomical change. With respect to its import, Stiller has designated this entire habitus as ^'asthenia universalis congenita." This term indicates that individuals with such habitus are predisposed to all possible functional diseases. From the above-cited principles appears the extra- ordinary significance of habitus enteropticus in affections of the stomach and intestine. The examiner, therefore, should never neglect to make an absolutely correct diagnosis of the habitus. 1 need not emphasize that inspection should detect any distention or retraction of the abdomen, tumors, circum- scribed swellings, hernia, or diastases of the recti muscles, should any exist. 8 DISEASES OF THE DIGESTIVE CANAL It is especially important to recognize abnormall}^ in- creased peristalsis, the so-called "stiffenings" of the stomach, small intestine or colon. These are especially significant as indicating stenosis of the pylorus, or of the colon. Visible peristalsis of the small intestine, which is not pathological, is found in old women in whom well-marked diastases of the recti muscles have remained after pregnancy, and who have become extremely emaciated. The peristaltic action of the coils of the small intestine is shown in a relief- like manner upon the thin abdominal wall around the umbil- icus. It is necessary to guard against considering this as pathological, or as "nervous peristaltic unrest" of the intestine, for the visible peristalsis in these cases is attributable merely to extreme emaciation of the patients. In the course of the examination, the tongue should also be observed. Its appearance has only an indirect relation, however, to diseases of the digestive organs ; for the less thoroughly the patient chews his food, the more thickly the tongue will be coated, and mastication in turn depends largely upon the appetite. Percussion. — In the examination of the abdomen, per- cussion is of minor value as compared with palpation. There- fore, the physician who can palpate well scarcely needs per- cussion at all, and it would better be dispensed with, for the reason that it is so often a source of error. In the determination of the borders of the stomach, the examiner will need to make use of it, if he does not succeed with palpation; for instance, in a patient whose stomach lies so high that it cannot be defined by palpation. Since distention of the stomach with air or carbon dioxide gas, which were formerly much used and considered very important, is dispensable in practical diagnosis, except when localizing abdominal tumors, it may be mentioned here and will be described briefly in the following discussion of the topography of neoplasms of the stomach and intestine. Palpation. — In examining a patient, one should always palpate the organs and parts in the following order: PHYSICAL EXAMINATION 9 1. The epigastrium and stomach. 2. The caecum and appendix, the ascending colon, the transverse colon, the sigmoid flexure, and the small intestine. 3. The liver and gall-bladder. 4. The spleen. 5. The kidneys. 6. The abdominal rings. 7. The rectum. 8. The abdominal cavity for tumors, ascites, etc. Palpation is most successfully and easily performed in the four positions described below, — the examiner sitting on the right side, or if left-handed on the left side, of the patient: 1. In the dorsal position of the patient, the epigastrium, transverse colon, caecum, sigmoid flexure, small intestine, liver- border, and gall-bladder are to be examined. 2. In the right-side position of the patient, the spleen, the left kidney, the sigmoid flexure, and tumors of the ascend- ing colon are to be examined. 3. In the left-side position of the patient, the right kidney, the liver, the ascending colon, and possible tumors are to be examined. 4. In the knee-elbow position of the patient, the anus and the rectum are to be examined. Although I am well aware that palpation must be learned through practice, I should like to mention the following points which have best served me in palpation of the abdomen. Above all, it is essential to palpate systematically, — not haphazard, as is so often done. The accompanying pictures will illustrate the art of palpation. Stomach and Epigastrium. — The examiner should lay both hands upon the epigastrium,' absolutely flat side by side, not using the thumbs (see Fig. 3), and should ask the patient to use the diaphragmatic breathing, — inhaling and exhaling deeply, — during the palpation. Patients who breathe thoracically should be shown how to breathe abdominally, — the examiner laying his hand on 10 DISEASES OF THE DIGESTIVE CANAL his own abdomen and ck'nionstrating to the j)atient that during the inspiration the hantl is raised, and during the expiration it is lowered. It is clear that only through diaphragmatic breathing may the patient effect the desired displacement of the organs of the abdomen, — namely, the stomach, liver, spleen, kidneys, and colon, or of possible existing tumors. Fir,. Palpation of the abdomen. While the patient inspires and expires as deeply as possi- ble, the hands of the examiner should remain absolutely quiet on the epigastrium; and only at the moment of the beginning of the expiration should the finger-tips be pressed somewhat deeply downward. In this way, all the organs dur- ing their elevation must come into contact with the finger-tips and are in this manner best palpated, since the finger-tips have a most delicate sense of touch. The examiner should attempt to palpate even any slight irregularities which may be present. PHYSICAL EXAMINATION 11 During palpation of the epigastrium, the physician should keep in mind the possibility of existing tumors, irregularities of the liver, abnormal pulsations, epigastric hernise, sensitiveness to pressure, arteriosclerosis of the aorta, and palpability of the pylorus, which occurs not infrequently. Of course, the most important question is, whether a tumor is palpable or not. Determination of the Borders of the Stomach by Palpa- tion. — The patient hes flat on a reclining chair with the upper part of the body shghtly raised, and is given from one to two glasses of water (200 to 400 c.c.).* The examiner should place on the epigastrium of the patient the fingers of his right hand, spread out claw-shaped (see Fig. 4), and should palpate without raising the finger- tips, by a short pushing stroke, centimetre by centimetre, beginning from below and passing upward, until he feels the splash of the water under his fingers. He should not assume, however, that the lower border of the stomach is as low as where the splashing sounds are heard. While this is often the case, such a premise sometimes leads to error. The lower border of the stomach reaches only as far as the palpating fingers feel the water. For the purpose of accomplishing the palpatory percussion introduced by Obrastzow, the examiner should require the patient to render the diaphragm tense by a deep inspiration, so that the stomach is pushed downward. The examiner can also assist this downward movement of the stomach by a strong pressure of his left hand upon the epigastrium of the patient just below the xiphoid process. But we must always take into consideration the fact that the lower border of the stomach lies perhaps two or three finger-breadths lower dur- ing inspiration than when the lungs are passive. In enteroptosis the greater curvature, i.e., the lower border of the stomach, lies, as a rule, as low as from one to two finger-breadths above the level of the umbilicus; while * Persons with enteroptosis require one glass of water, while patients with normal habitus need two. 12 DISEASES OF THE DIGESTIVE CANAL in individuals with noniicd Jiabitus, the lower stomach-border lies a h-and's breadth above the umbilicus, so that only a small portion of the stomach is in contact with the anterior abdominal wall so as to be palpable. When habitus enteropticus occurs in women who have borne children, the greater curvature frequently lies below the umbilicus as much as four finger-breadths, without there being in any sense actual dilatation of the stomach. Fig. 4. Obrastzow's palpatory percussion method for determining the borders of tlie stomach. On the oase-card of the patient, the physician should enter the findings in the following manner: For instance, if the greater curvature lies two finger-breadths above the umbilicus, he should record G.C. -§ ; or if the greater curvature lies three finger-breadths below the umbilicus, he should record G.C. ^ . If the greater curvature extends to the umbilicus, he should record G.C. at U. He may- add to the above whether the findings were during inspiration or expiration. These formulae express briefly and clearly the position of the stomach. When the patient has a very broad thorax and strong ab- dominal wall, the examiner cannot palpate the greater curva- ture, even after the patient has taken a half litre of water, — in which case the position of the stomach is considered normal. PHYSICAL EXAMINATION 13 Besides this method of Obrastzow's, there are quite a number of other means for determining the greater curvature, as well as the position and size of the stomach. Among these I will consider only distention of the stomach with air by means of a stomach-tube and a Davidson syringe, or by carbon dioxide gas produced by administering effervescent mixtures.* Either of these methods, however, is disagreeable to both patient and physician, and may be dispensed with. They are to be used only in special cases; for instance, when it is essential to demonstrate whether a tumor which is felt in the epigastrium is situated in the anterior wall of the stomach, or whether it lies behind the stomach. Tumors lying behind the stomach naturally become inaccessible to palpation when it is inflated. The Boas "sound" palpation for the determination of the posi- tion of the greater curvature is dispensable in general practice; likewise the illumination of the stomach (gastrodiaphany) introduced by Einhorn. All of these methods are explained in detail in well-known text-books. For practical work, the best of the above-mentioned methods is that of Obrastzow. In patients with enteroptosis, the examiner can often palpate the normal pylorus, which might easily be mistaken for a tumor by the inexperienced. It generally lies at or near the umbilicus, and resembles a tumor about the size of a walnut. It will be recognized by the follow- ing characteristics: 1. Its consistency continually changes; it is sometimes as hard as a board, sometimes so soft that it is inaccessible to palpation. 2. The expulsion of chyme from the pylorus can be heard, as well as felt. The Spleen. — The patient should lie on his right side on the examining table, with the arm not thrown upwards but lying over the chest slightly flexed, so that the abdomen is reHeved of tension. The physician should sit with his right side to the patient, laying his right hand upon the left costal arch and placing the finger-tips of his left hand on the costal cartilage. The patient should now be required to take a deep inspira- tion, and the examiner should press strongly downward and inward only at the moment of inspiration. By this procedure [ * The latter is best performed by dissolving about one dram of tartaric acid in a half glass of water, which the patient is requested to drink; this is followed by an equal amount of sodium bicarbonate dissolved in a hke quantity of water.] 14 DISEASES OF THE DIGESTIVE CANAL the- spleen is pushed below the edge of the ribs so that the finger-tips which are pressing downward slip over the level differences and detect any enlargement of the spleen. Several repetitions of this mode of palpation will convince the examiner of the correctness of his findings. Simultaneously it should be determined whether the spleen is moderately or greatly enlarged, whether it is soft or hard, and whether the edge is sharp or dull. The fact that an enlarged spleen occasionally reaches even as far as the caecum need only be mentioned here. Percussion of the spleen is quite valueless; and a spleen which cannot be palpated must, in general, be considered as normal in size. The Liver. — The liver should be first palpated in the right mammar}^ line. If it extends below the edge of the ribs, the examiner should palpate again with the hand applied absolutely flat upon the abdomen, and should exert pressure as soon as expiration begins. Then the finger-tips should slide over the liver-border into the soft tissues of the abdomen. The examiner should determine whether the liver is hard, soft, smooth, or knobbed; whether it has a sharp or a rounded edge; whether it is sensitive to pressure; whether the left lobe is especially enlarged; whether the entire liver is con- tracted; and moreover, whether the gall-bladder is sensitive to pressure, and whether or not it is swollen. When the liver is only slightly enlarged, the examiner should palpate somewhat differently. He should place the eight fingers of both hands almost perpendicularly on the eleventh costal cartilage and should press the eight finger- tips (naturally with short nails) as deeply as possible down- ward toward the posterior abdominal wall as far as the patient can bear it, and should request the latter to inspire as deeply as possible. If the liver now projects below the edge of the ribs, it will strike against the finger-tips producing a fcehng of sudden resistance both to the examiner and to the patient. Naturally, this palpation method is possible only with persons whose abdominal walls are not too rigid. In a great number of patients, the palpation of the liver is not successful, and the examiner must resort to percussion. PHYSICAL EXAMINATION 15 There are only a few pathological conditions in the liver inaccessible to palpation that need to be considered in a dis- cussion of diseases of the stomach and intestine. One word more concerning the contracted liver: The consideration of this affection is important in order to avoid confounding it with malignant tumors. The contracted liver is met with almost exclusively in women who have never, or at least rarely, worn corsets, but who have always fastened Fig. 5. Palpation of the right kidney. their clothes around the body wi.th draw-strings. For the diagnosis it is necessary to demonstrate that the supposed malignant tumor exists in connection with the rest of the liver. The Kidney. — It is well known that the right kidney in quite a large number of women and girls is palpable; in men, on the other hand, rarely so except in individuals with habitus enteropticus. The right kidney should be palpated in the left- side, and the left kidney in the right-side, position; and always bimanually, the examiner placing one hand on the region of the kidney and the other on the corresponding anterior region. (See Fig. 5.) ' 16 DISEASES OF THE DIGESTIVE CANAL After the patient has taken a deep inspiration, the exam- iner should press in deeply with the right hand at the mo- ment when expiration begins. If he can palpate the entire kidney and push it here and there from the umbilicus to its normal position, this indicates "displaced" kidney. If the entire kidney or only a portion is felt during expiration, and if it returns during inspiration to its normal position, the condition should be designated as ''movable" kidney. The left kidney is palpable in exactly the same manner. Even experienced examiners have difficulty in differentiating a movable left kidney from a displaced spleen, as it is often impossible to decide whether the organ lying in this position is the spleen or the left kidney. In men, the left kidney is found loosened more frequently than the right. Only when the kidney returns during expiration to its previous position is the examiner justified in diagnosing ''mov- able" kidney, and not "displaced" kidney. Three degrees of movable kidney are differentiated: The first degree is present only when the lower part of the kid- ney is palpable; the second degree, when half of the kidney is palpable; the third degree, when the entire kidney is palpable. The Intestine. — Normally, the colon, the csecum, the appendix, and the sigmoid flexure can be palpated only under the most favorable conditions. The small intestine is too soft to be palpated. The examiner should always begin with palpation of the sigmoid flexure by placing the fingers of the right hand upon the abdomen at right angles to the direction of the course of the sig- moid, and attempting to roll the sigmoid back and forth under the fingers by pressing downward against the iliac fossa. During this rolling movement, the examiner will deter- mine whether the sigmoid is empty or is moderately well filled; whether it is hard or soft, contracted or relaxed; whether it is sensitive to pressure; and whether a tumor is present. These differentiations naturally require some practice. The transverse colon is palpated in the following manner: The physician should place both hands (thumbs excepted) PHYSICAL EXAMINATION 17 close to each other on the middle of the abdomen, the finger- tips extending somewhat above the umbilicus; and, while the patient inspires and expires deeply with diaphragmatic respiration, should roll up and down with the tips of his fingers Typical pressure point in gastric ulcer. and at the beginning of each expiration press downward lightly. (See Fig. 3.) In this way he is able to differentiate, unless the colon is completely relaxed, as to whether the transverse colon is soft or hard, sensitive or insensitive to pressure, or whether it feels like a cord, more or less filled. As a rule, a pathologically altered transverse colon only can be felt, except in cases of habitus enteropticus, with descent of the 18 DISEASES OF THE DIGESTIVE CANAL intestine and relaxation of the abdominal walls after pregnancy. In this .latter case, a normal colon is, as a rule, palpable. In the normal habitus, the colon lies three or four finger- breadths above the umbilicus ( 'u'^ ). In habitus enteropticus, the Fig. Typical pressure zone in liver and gall-bladder affections. transverse colon lies at the level of the umbilicus or one finger- breadth above or below it. In "hang-belly," the middle por- tion of the transverse colon may reach to the symphysis pubis. The palpation of the colon is of double importance: first, for determining the position of the intestine and of possible existing tumors; and second, as a means to assist in the differential diagnosis between the two forms of habitual PHYSICAL EXAMINATION 19 constipation, — atonic and spastic. Only in the spastic form can one feel the hard and contracted transverse colon. The examiner should make it a rule to lay the palpating hands on the abdomen at right angles to the course of the Fig. 8. 'lii^'.ii^s's Pressure areas iii nervous allecUoiis of the stomach. colon. If the transverse colon assumes an arched form, as frequently occurs, with the convexity downward, the right half should be palpated in a different direction from the left half. It often happens that the transverse colon forms an arch which extends to the symphysis, so that the right and left sides of the arch are almost vertical. (U-form of the transverse colon.) 20 DISEASES OF THE DIGESTIVE CANAL The examination of the remaining portion of the large intestine should then be made. The palpation of the csecum is easily accomplished by the following method: The examiner should sit at the right side of the patient, placing his left hand over the ca?cum at right angles to its course and pressing downward with a rolling movement. Usually a gurgling murmur is heard, which, by the way, is of only slight importance. The examiner should attempt simultaneously to palpate the appendix. With practice, this is possible in a large number of cases. It lies generally in a direct Hne from McBurney's point to the symphysis. If the attention is directed continually to this point, the examiner will find by experience that the normal appendix is easily felt, by the rolling pressure of the finger, to be a cord about the size of a lead-pencil and as long as the little finger. He will also discover by this method any sensitiveness to pressure or thickening of this organ. The ascending and descending portions of the colon are less frequently accessible to palpation. The}^ are to be pal- pated exactly as the other portions, bimanually, by laying the hand upon the abdomen always at right angles to the course of the portion under examination, and ascertaining the condition by a rolHng movement combined with downward pressure. It is important, in making the diagnosis, to ascertain whether these organs are sensitive to pressure ; whether they are contracted or distended; or whether they contain fecal masses. For the sake of completeness, it must be ackled here that in sup- posed stomach-diseases, the urinary bladder can often be palpated; for instance, in patients suffering with prostatic affections. If the examiner will remember that unusual resistance above the symphysis may be caused bj'' distention of the urinary bladder, no confusion should occur in the diagnosis. I need scarcely mention that the examiner should always keep in mind the necessity of palpating for possible existing ascites. One other affection should also be mentioned that is often overlooked in practice. I refer to epigastric hernia in the hnea alba, — ''rupture," as it is called by the laity. INTERNAL EXAMINATION 21 The abdominal rings should always be palpated. The examiner should also look for a sensitiveness to pressure in the abdomen, and indeed in the skin, muscles, plexuses, and intestines. Pinching of the skin is usually not painful; in hysteria, however, or when there are inflammatory conditions of the intestinal organs, — such as occur in colitis, appendicitis, or cholelithiasis, — even a slight pinching of the skin will be quite painful. Head explains this by assuming that there is a projec- tion of pain to the skin overlying the inflamed organs. Finally, the examiner should test the back of the patient for sensitiveness by means of pressure and striking of the muscular parts on both sides of the spinal column. According to Boas, in gastric ulcer the skin to the left of the tenth, eleventh, or twelfth dorsal vertebra will be found sensitive to pressure. In cholelithiasis, on the contrary, the skin to the right of the corresponding vertebra is sensitive to pressure. In general neurasthenia, the entire area along both sides of the spinal column is sensitive to pressure, espe- cially in the interscapular and sacral regions. Having done all this, the examiner should not fail to pal- pate the anus and rectum. This is best done in the knee-elbow position. (See details in the section on Intestinal Diseases.) Auscultation. — In the examination of the abdominal organs, auscultation may be almost entirely dispensed with, so far as practical purposes are concerned. Internal Chemical and Microscopical Examination of the Stomach Introductory Remarks. — The Boas-Ewald test- breakfast is used almost exclusively in the examination of the gastric juice. This consists of from 60 to 70 grams of dry wheat bread and 400 c.c. of cool water. The test-break- fast should be eaten by the patient on an empt}^ stomach, and exactly one hour afterwards should be siphoned from the stomach by an ordinary soft stomach-tube. (See technic, page 42.) 22 DISEASES OF THE DIGESTIVE CANAL • Before filtering the contents of the stomach, the physician should note : a. The appearance; whether the meal has been well or poorly digested. h. The odor; whether normal or fetid. [Sour or rancid.] c. Whether blood, pus, or stagnant remnants of food are mixed with the test-breakfast. d. Whether free hydrochloric acid is present; this is done by moistening a strip of congo paper with the stomach-contents. In the well-digested test-breakfast, there should be a layer of finely-divided bread on the bottom of the glass con- taining the stomach-contents, and over this should be a layer of semi-transparent gastric juice. If the test-meal is poorly digested, as occurs in achylia gastrica, the stomach-contents will consist of only a small quantity of fluid and many coarse lumps of bread. With a little practice, the examiner will easily recognize the macroscopical differences between the normal and the impaired digestion. He will also observe that in cases -which have a normal acidity or a hyperacidity, the stomach-con- tents are easily removed; and that when anacidity exists, considerable effort and retching on the part of the patient are required to obtain the necessary quantity of gastric juice for examination. The examiner must sometimes utilize even the small quantity of stomach-contents which has remained in the lumen of the stomach-tube. In such cases, the stom- ach-tube should be quickly withdrawn and the contents blown into a glass. When necessary, even this small quantity will suffice to determine whether hydrochloric acid is present. I have never made use of an aspirator for removing the test-break- fast from the stomach, although I recommend its use to beginners. It consists of a large rubber bulb connected with the stomach-tube by a short glass tube. By pressing the air out of the bulb, a vacutun is pro- duced which readily aspirates the gastric contents. The test-breakfast should be filtered through a folded filter-paper; but if only a very small quantity of the test-meal INTERNAL EXAMINATION 23 has been obtained, the examiner would better use instead the unfiltered stomach-contents. The following determinations should be made from the filtrate : a. Total acidity. — T.A. b. Free and combined hydrochloric acid (F.HCl and C.HCl). c. Rennin and pepsin, in cases in which the reaction of free hydrochloric acid is negative, i.e., when congo paper is not colored blue by contact with the gas- tric juice. (See below.) Qualitative Examination. — For practical purposes, congo paper is used almost exclusively. [Congo red in solution is even more sensitive than congo paper.] Its red color is changed to blue by contact with free hydrochloric acid. The more free hydrochloric acid the gastric juice contains, the more nearly sky-blue will be the color. If only a small quantity of free acid is present, a weak, blue-black coloration will result. If free acid of any kind is present in the test-breakfast, the change of color is always indicative of free hydrochloric acid, and never lactic or other acids, because the Boas-Ewald test-breakfast contains only free hydrochloric acid. Lactic acid is found present only in test -dinners or in conditions in which there is food stasis. It is, therefore, quite superfluous to resort to the Uffelmann test when the ordinary Boas-Ewald test-breakfast has been given. (See below.) The examiner should determine whether the congo reac- tion is normal, weak, or strong. It should be noted that the mixture of mucus with the stomach-contents often disturbs, or even prevents, the reaction. In these cases, hydrochloric acid may be found in certain parts of the test-breakfast, while the reaction is negative in other parts. After practice, the examiner will be able to form quite accurate conclusions concerning the degree of acidity of the gastric juice by the intensity of the coloration of the congo paper. Normal gastric juice changes congo paper to a sky-blue. 24 DISEASES OF THE DIGESTIVE CANAL Fig. 0. i — 25 cj Lactic acid should be tested for only in cases in which there is stagnation of the stomach-contents. The test is made as follows: One drop of liquor forri chloridi is added to from 8 to 10 c.c. of water in a test-tube. The gastric filtrate is then added drop by drop. If the resulting color is a yellowish-green, about the shade of Esbach's reagent, lactic acid is present. The foregoing is Kelling's modification of Uffelmann's test. [Strauss's test is more accurate as a qualitative test than Uffelmann's, as the latter is usually made; and since the for- mer permits a rough estimate of the quan- tity of lactic acid present, it is preferable to Uffelmann's in clinical work. (See illustration.) A small separating funnel should be employed, graduated to hold o c.c. and 25 c.c. The funnel should be filled to the 5 c.c. mark with the filtered stomach- contents and then to the 25 c.c. mark with ether. The combination should be thoroughl}^ shaken for two or three minutes and then allowed to stand until the ether separates as a clear layer above the milky gastric juice. The stopcock at the lower M ~T ^ (,T^f_\ Qf -the funnel should then be opened l/ll T'"-' '^-^ -^ ^^^^^ ^^^ stomach-contents and the ether ' allowed to run out until the 5 c.c. mark is reached. This leaves 5 c.c. of the ethereal extract of lactic acid in the funnel, which should then be filled with distilled water to the 25 c.c. mark. Two drops of a 10 per cent, solution of ferric chloride should be added, and the whole gently shaken. 5C.' Separating apparatus suitable for making test for lactic acid. (Strauss's.) INTERNAL EXAMINATION 25 If 0.1 per cent, of lactic acid is present in the stomach- contents, an intense yellow-green color will appear; 0.05 per cent, will show a slight green color; quantities smaller than this, which are of little clinical importance, give no reaction.] Quantitative Examination. — In practical work, the de- termination of the total acidity of the gastric juice is usually sufficient, for the reason that the same test-break- fast is always given, the albuminous contents of which vary only within narrow limits. The examiner should have a normal sodium hydrate solution or a normal potassium hydrate solution, which can be obtained in any pharmacy. Every normal solution con- tains, dissolved in one litre of distilled water, a quantity of the ingredient equal to its molecular weight in grams. A normal sodium hydrate solution, for instance, contains 40 grams of sodium hydrate to one litre of water (Na -F + H = 23 + 16 + 1=40); a normal HCl solution, 36.5 grams to the litre (H + CI = 35.5 + 1 = 36.5). A decinormal solution contains, naturally, a tenth part of a normal solution. Therefore, one litre of a decinormal NaOH solution contains 4 grams of sodium hydrate, and one litre of a decinormal HCl contains 3.65 grams of HCl; it follows therefore that: 1 c.c. decinormal NaOH contains 4 milligrams =0.004 NaOH. 1 c.c. decinormal HCl contains 3.65 milligrams =0.00365 HCl. One c.c. of decinormal HCl solution should exactly neutralize 1 c.c. decinormal NaOH solution. To prepare the decinormal solution in the best manner, the examiner should himself place 10 c.c. of a normal solution in a graduated beaker and dilute with distilled water to 100 c.c. The examiner should now fill a 50 c.c. burette with a decinormal hydrate solution and titrate the filtered stomach- contents as follows: Five c.c. of filtered stomach-contents should be placed in a beaker or large test-tube. Two or three drops of a one per cent, alcoholic phenol- phthalein solution should be used as an indicator. The decinormal sodium hydrate solution is now added, drop by drop, until the contents of the beaker remain a permanent red color. It should be remarked here that the 26 DISEASES OF THE DIGESTIVE CANAL reading of the column of the deoinormal XaOH sokition in the graduated burette should always be made from the lowest point of the concavity of the fluid. The examiner should avoid shaking the beaker containing the stomach-contents; for if this were done too vigorously, a portion of the added alkali might be neutralized by the carbon dioxide of the air, which would be a source of error in the test. Example. — If for the neutralization of 5 c.c. of gastric juice, 3 c.c. of decinormal NaOH solution were required, the fluid level in the graduated burette would be lowered from 16.5 to 13.5. For the neutralization of 100 c.c. of gastric juice, twenty times as much decinormal solution w^ould be needed; therefore, 60 c.c. of decinormal NaOH. The total acidity (T. A.) has been generally accepted as representing the amount of decinormal NaOH solution required to neutrahze 100 c.c. of gastric juice. In our example, therefore, 100 c.c. of gastric juice contains as much acid as 60 c.c. of decinormal NaOH will neutralize. The total acidity of the test-breakfast is the sum of the following four factors: 1. Free hydrochloric acid. 2. Combined hj^clrochloric acid. 3. Acid phosphates. 4. Traces of organic acids (COj, lactic acid, acetic acid, butyric acid, etc.). The total acidity does not express, therefore, the per- centage of hydrochloric acid in the gastric juice, but merely the degree of acidity of the latter. To determine in a given case the proportion of free and of combined hydrochloric acid, it is necessary to deduct from the total acidity the sum of the acid phosphates and the organic acids. The acid phosphate and organic acid present in the test- breakfast amount, on an average, to from 4 to 8; but in con- ditions which cause stasis of food in the stomach, to consider- ably more. If, for example, the total acidity of the gastric juice is 50, then the sum of the free and the combined hydrochloric acid would be 50 — 6 = 44; that is to say, 100 c.c. of the gastric juice in such a case holds exactly as much HCl as is contained in 44 c.c. of decinormal HCl solution. Therefore, 44 X 0.00365 gram of HCl = 0.01606 gram HCl, or (since 100 c.c. = 100 grams) = 0.1606 per cent. = 1.606 per mille. INTERNAL EXAMINATION 27 Another Example. — The total acidity of the filtrate = 68 The total phosphates and the organic acids = 6 62HC1 The difference represents HCl, which is 62. Therefore, 62 X 0.00365 gram of HCl in 100 c.c. of gastric juice = 0.2263 per cent. = 2.263 per mille HCl. By common agreement, the total acidity of the test-meal is indicated in clinical records of cases by the number of cubic centimetres of decinormal NaOH solution required to neutralize 100 c.c. of gastric juice, rather than in percentages of acidity. It is proper to mention here that values of 40 to 65 in the Boas-Ewald test-breakfast (about 60 grams of white bread and 400 c.c. of water) constitute normal acidity; more than 65 is considered hyperacidity of the gastric juice; and under 40, subacidity. Although the physician might approximately estimate the total acidity by noting whether the congo reaction is positive or negative, weak or strong; yet it is more exact in the qualitative and quantitative examinations of the gastric juice to determine accurately the different component parts of which the total acidity of the gastric juice is composed. Topfer's Method. — By this method the total acidity, the free hydrochloric acid, and the combined hydrochloric acid, are determined in the following manner: 1. The total acidity is determined, as previously described, by using phenolphthalein as an indicator. 2. Free HCl is estimated by the same procedure, using as an indicator two or tliree drops of a one-half per cent, alcoholic solution of dimethyl- amidoazobenzol, a coloring matter which, in the presence of free HCl, appears yellow. The decinormal NaOH solution is added to the gastric juice, di'op by drop, until the solution is permanently yellow. Reckoning on the basis of 100 c.c. of gastric juice, the number of c.c. of decinormal NaOH solution used denotes as much free HCl as is present in the specimen. 3. The combined HCl is titrated with the use of two or thi'ee drops of a one per cent, aqueous solution of ahzarin [sodium alizarin sulphonate] as an indicator. Alizarin is a red-violet pigment which turns to j^ellow all acid factors of the gastric juice, with the exception of combined HCl, which 28 DISEASES OF THE DIGESTIVE CANAL is immune to this transformation. The alizarin value represents, therefore, the sum of all acid values of the gastrie juice, except that of combined HCl. To ascertain the value of combined HCl, the examiner nuist subtract the alizarin value from the total acidity of the specimen. Example of an Examination of the Stomach-Contents by Tupfer's Method 1. The ix^tient, i\Ir. Mailer, was given the Boas-Ewald test-breakfast, consisting of from 60 to 70 grams of bread and 400 c.c. of water. After one hour, this was removed from the stomach. It was easily obtained and was well digested. It settled in two layers. The lower, in the bottom of the glass, was a fine, flaky, crumbly mass of bread. The upper layer was a somewhat opaque fluid, upon which floated small ciuantities of sputum, saUva and mucus. On pouring the gastric contents from one glass into another, it w^as noted that very little mucus was present, also that it Avas not tenacious, the fluid contents leaving the glass drop by drop. The odor of the test -breakfast was sour, but not offensive. The macroscopic examina- tion did not reveal the presence of blood, pus, fibres of meat, or remnants of vegetables. Congo paper, brought into contact with the stomach-contents, turned sky-blue. Titration gave the following values: 1. Total acidity (phenolphthalein as an indicator) = 60 2. Free HCl (dimethylamidoazobenzol as an indicator) = 36 3. Combined HCl (alizarin as an indicator) = 20 4. Sum of free and combined HCl (36 + 20) = 56 5. The remaining acids, consisting of acid phosphates and organic acids (60 — 56) = 4 The examination gave, therefore, the quantitative value of each com- ponent part of the gastric juice. If the percentage of HCl is desired, the HCl value should be multiplied by 0.00365; therefore 56 X 0.00365 == 0.204 per cent. = 2.04 per mille HCl. 2. Patient, Mr. S. Diagnosis: Atrophic Gastritis. One hour after eating the Boas-Ewald test-meal, the stomach-con- tents were removed, but with considerable difficulty, as they were quite thick. The upper layer of gastric juice, which normally is present, was lacking. The specimen contained mucus and traces of fresh blood. None of the food eaten by the patient on the previous day was found in the stom- ach. The odor of the stomach-contents was that of bread-pap. The test with Congo paper was negative. The total acidity was 10. Tcipfer's method was not adaptable, because there was no free HCl present. INTERNAL EXAMINATION 29 Clinical Significance of HCl. — As already mentioned, the normal total acidity of the Boas-Ewald test-breakfast is from 40 to 65. In hyperchlorhydria, the acidity amounts to from 65 to 120. After the test-dinner, the acidity is even higher. Gastric juice, the total acidity of which is under 20, does not react positively to congo paper, since, as a rule, no free hydrochloric acid is present. The above values are constant because the bread of the Boas-Ewald test-breakfast contains a nearly constant percentage of albumen. The absence of free hydrochloric acid from the gastric juice is spoken of as ''anacidity." This is not logical, since combined hydrochloric acid may still be present. The total acidity is never below 5 or 6, because the Boas-Ewald test- breakfast always contains traces of acid phosphates and of organic acids. The total acidity of the gastric juice, when in excess of 8, indicates that the gastric mucous membrane has not lost its secretory function. The physician may nearly always assume that atrophy of the gastric glands has occurred if the total acidity does not exceed from 5 to 8. He may also assume the presence of an interstitial gastritis which has not yet led to atrophy when the total acidity amounts to from 10 to 15, and when traces of hydrochloric acid are present. When the total acidity exceeds 16, and in those cases of subacidit}^ in which free hydrochloric acid is secreted in quan- tities as high as from 20 to 24, the existence of a simple gastric catarrh or of a gastric neurosis may be indicated, as either of these affections may be associated with subacidity or anacidity. Ferment = Tests. — When the stomach -contents show an absence of free hydrochloric acid, and when the total acidity is 20 or less, it is desirable to determine quantitatively the ferments of the stomach, since this procedure furnishes a valuable diagnostic differentiation between neuroses of the stomach and gastritis. The quantitative test need be made in those cases only in which anacidity exists. It is super- fluous and therefore absurd to examine the gastric juice for 30 DISEASES OF THE DIGESTIVE CANAL the presence of ferments when the normal amount or an excess of hydrochloric acid is secreted, for in these cases the quantitative estimation of the ferments of the gastric juice is of scientific value only. As a working rule, it may be said that the amount of the gastric ferments — rennin and pepsin — corresponds with the amount of hydrochloric acid secreted. In general work, an exact determination of the total acidity of the gastric juice will enable the examiner to estimate with sufficient accuracy the amount of ferments present, provided, of course, he always uses the same test-breakfast. Rennin-Test. — The qualitative examination of ren- nin has but little diagnostic value. On this account, I always use Boas' quantitative test for rennin in cases where there is an anacid gastric juice This test depends upon the dilution- principle and shows the degree to which the gastric juice can be diluted without losing its property of coagulating milk. Boas neutralizes the gastric juice before making the test. I consider this unnecessary for two reasons: first, because only anacid gastric juice is examined; and second, because the gastric juice, being poor in acids, becomes so weakened by dilution that its ability to coagulate milk is completely lost. (The fear of this is the reason some authors neutralize the gastric filtrate.) I prefer, in performing the test, to use test- tubes and a water-bath heated to 40° C. [102° F.], rather than beakers and an incubator. The details of the rennin-test are as follows : The examiner should, vnth a pipette, introduce 1 c.c. of the gastric juice into a graduated cylinder of 10 c.c. capacity. The cylinder should then be filled with tap-water to the 10 c.c. mark. This mixture should be shaken several times, and half of it should then be poured from the graduated cylinder into a test-tube, which should be marked "1 to 10" with a wax pencil, and should then be set aside. The examiner should now add water to the 5 c.c. which remain in the gi-aduated cyhnder until it again reaches the 10 c.c. mark and should mix the solution by inverting the cylinder several times, as before. Five c.c. of the contents of the graduated c^'linder should again be poured into a second test-tube marked "1 to 20." The dilution of the original 1 c.c. of the gastric juice should be repeated INTERNAL EXAMINATION 31 several times in like manner, and the test-tubes containing the respective dilutions should be marked "1 to 40/' "I to 80," "1 to 160," "1 to 320," etc. The examiner should then add to each test-tube 5 c.c. of boiled [or raw] milk and 2^ c.c. of a one per cent, calcium chloride solution. After the contents of each test-tube are properly mixed by shaking, the test- tubes containing the specimens should be placed in the water-bath, which has been heated to 40° C. [102° F.]. It is usually best to use a control speci- men of only milk and calcium chloride solution in the same proportions in which they are used in the test-tubes containing the specimens. This con- trol specimen should remain uncoagulated. Normally, the milk in the test- tube which is marked " 1 to 160" should show a firm, cake-hke coagulation; and the next specimen, which is marked "1 to 320," should show a fine, flaky coagulation. All the preceding dilutions should show a solid, cake- like coagulation. The examiner should discriminate between strong, or cake-like coagulation, and weak, or flaky coagulation. In higher dilutions than the above, except in cases of hypersecretion of gastric juice, coagulation of the milk does not occur. In hypersecretion, coagulation has been obtained in a dilution of 1 to 800. Since the examiner can easily prepare a water-batli in any home, and since the entire procedure requires, at most, fifteen minutes, this test is very suitable to general practice. The clinical value of the rennin-test is as follows: If the examiner finds normal rennin-activity in a case in which the gastric juice is anacid, he may conclude, as a rule, that the cause of the anacidity is a gastric neurosis. The prognosis is good in such a case, as it is probable that the secretion of hydrochloric acid will return. If the secretion of rennin is diminished, — for instance, when coagulation does not occur in a specimen which is diluted 1 to 100, — -catarrhal gastritis is generally present. Here, also the prognosis may be favorable, as the secretion of hydrochloric acid will again be established by rational treatment. (See Special Section.) If, on the other hand, the examiner finds an absence of rennin-activity in the specimens or if, at best, a positive reaction is obtained only when the dilution is as low* as 1 to 10, he should always assume that total atroph}^ of the glandular structures of the stomach is present. If he finds a positive test only in a dilution of 1 to 20 or 1 to 40, a diagnosis of interstitial gastritis may generally be made. 32 DISEASES OF THE DIGESTIVE CANAL It should be mentioned here that rennin is not always secreted as an active ferment, but that it is secreted from the mucosa as an active lab-enzyme, which is transformed into the active rennin-ferment by the action of hydrochloric acid. The calcium chloride solution exerts practically the same influence upon the lab-enzj^ne as does hydrochloric acid. Although this transformation of the lab-enzyme into rennin by the action of the calcium chloride is not positively proven, the fact nevertheless remains that the examiner can conven- iently measure the milk-coagulating power of the gastric juice by this method. To prove that the coagulation of the milk was not caused by traces of combined hydrocliloric acid, which might still be present in the diluted specimens, the following test should be made: The examiner should prepare two test-specimens of gastric juice, each of which is diluted 1 to 100. One of these is then boiled. The examiner should then add 5 c.c. of milk and 2^ c.c. of one per cent, calcium chloride solution to each specimen, after which he should place them in a water-bath or incubator, heated to 40° C. [102° F.]. The boiled specimen will remain uncoagulated, because the rennin-ferment is destroyed by boiling; while the unboiled specimen will be coagulated within a few moments. In benign gastritis, provided total atrophy of the glands of the mucous membrane has not yet occurred, it will be found that with improvement of the condition there will be an increase in the production of rennin and hydrochloric acid. In malig- nancy, on the other hand, it will be found that the production of rennin will gradually sink to nil. Pepsin-Test. — Although a carefull}" performed rennin-test renders it unnecessary to make the pepsin-test, the latter should, nevertheless, be described, for the reason that in many cases it is the deciding factor as to whether a malignant affec- tion is present; and after treatment for a period, an increase or a decrease in the secretion of pepsin has the same signifi- cance as an increase or diminution of rennin-activity in indicat- ing whether the anacidity in a suspicious case is caused by a malignant disease or by a simple inflammatory affection. There are several tests for the c|uantitative estimation of pepsin, such as the methods of Oppler, Mette and Ham- INTERNAL EXAMINATION 33 rnerschlag, — the simplest and most practical, in my opinion, being that of Hammerschlag, which is performed as follows: The examiner should have on hand a one per cent, solution of albumin which contains about 4 per mille of hydrochloric acid. Experience has taught me that this is most easily prepared in the following manner: To make I litre of Hammerschlag's solution, I use: 1. 30 to 35 c.c. of fresh white of eggs. 2. 4 c.c. of concentrated hydrochloric acid. 3. 250 c.c. of tap-water. This solution should be renewed every two or three weeks, because the amount of albumin gradually decreases through decomposition. Ham- merschlag uses dry egg-albumin, which, in my opinion, is not so convenient as the above. The examiner should place the 30 c.c. of egg-albumin in an open glass receiver and should then add the HCl solution slowly while stirring. (The HCl solution is easily prepared by mixing 4 c.c. of the concentrated 25 per cent. HCl with 250 c.c. of tap-water.) The mixture should then be filtered through a linen cloth properly arranged in a funnel. The entire procedure should not require more than 5 to 10 minutes. In case the examiner does not use this test frequently, it is needless to keep more than one-quarter of a litre of Hammerschlag's solution on hand. The preparation of a full litre of the solution naturally requires four times the indicated amounts of the ingredi- ents; that is to say, 1000 c.c. of tap-water, 120 to 140 c.c. of egg-albumin and 16 c.c. of concentrated hydrochloric acid. The technic of the pepsin-test should be as follows: Five c.c. of the gastric juice should be placed in a test-tube, which is appropriately marked with a wax pencil; 5 c.c. of tap-water should be placed in a second test-tube [which is marked "W"]; 10 c.c. of Hammer- schlag's solution should then be added to each test-tube. If necessary, the examiner may carry on several albumin-tests simultaneously. The speci- mens should now be placed in an ordinary drinking-glass containing water at a temperature of 38° to 40° C. [98° to 102° F.], and then placed in a water- bath or an incubator, which should be kept at a temperature of 38° to 40° C. [98° to 102° F.], by means of a small gas flame, or by the addition of hot water. The specimens should remain in the incubator or water-bath exactly one hour. Should they be placed in the incubator or water-bath immediately, a considerable space of time would elapse before the specimens could reach the temperature at which digestion occurs. To avoid inaccuracy in the test, therefore, the examiner should place the specimens already heated, as 3 34 DISEASES OF THE DIGESTIVE CANAL above directed, in the incubator or water-bath. After one hour, the speci- mens should be removed and immediatel)'^ placed in cold water for two or three minutes to interrupt pepsin-digestion. The examiner should now take two Esbach tubes, one of which is to be marked with the name of the patient and the other with the letter "W" (water), and should fill these with the respective specimens up to the letter "U." The remainder of the specimens may be thrown awa3\ The Esbach tubes should then be filled up to the mark "R" with Esbach 's reagent, then shaken well, closed with rubber corks, and put aside to stand for twenty-four hours. After this time has elapsed, the examiner should note the height of the albumin-column in each tube. Example. — If the column in the Esbach tube which contains the gas- tric juice stands, for instance, at 1 per mille, and in the tube containing the water, at 5 per mille, there would necessarily be 4 per mille of the 5 per mille of the albumin peptonized, that is, i digested, which equals SO per cent. The examiner should enter in the clinical record of the patient, there- fore, that the pepsin-digestion, according to Hammerschlag, is 80 per cent. Second Example. — In a case of hyperchlorhydria, the column of albumin in the tube co^ntaining the gastric juice was \ per mille; the tube containing the w^ater was 6 per mille. Therefore, 5^ per mille was peptonized; or out of 12 parts, 11 parts were digested, therefore, \\ digested, or 91f per cent. According to Hammerschlag, normal pepsin-digestion is from 70 to 80 per cent.; in hyperchlorhydria, 90 per cent.; while in cases of subacidity or anacidity, there are values as low as 10 per cent., or even smaller. As a rule, the intensity of pepsin-digestion coiTesponds to the amounts of hydrochloric acid and rennin secreted by the gastric juice. When there is normal acidity or hyper- acidity, the tube which contains the gastric juice is usually cloudy, because the albumin of the gastric juice remains in suspension, since it is not affected by Esbach's reagent and is not precipitated as a sediment. In general work, the pepsin-test is employed only in cases of subacidity or anacidity. From the practical stand- point the rennin-test suffices, however, when there is anacidity of the test-breakfast; but it is advisable to perform Ham- merschlag's pepsin-test to demonstrate the presence or absence of the peptonization of food in cases in which there is stagnation of the contents of the stomach, in order to assist in making a diagnosis of the nature of the lesion. INTERNAL EXAMINATION 35 The following table indicates the corresponding amounts of hydrochloric acid, rennin, and pepsin, in the various organic diseases of the stomach: Atrophy. Interstitial Gastritis. Simple Catarrh. Subacidity. Hyperchlor- hydria. Total Acidity 5-6 6-12 14-20 25-40 70-100 1-1 to 1-10 1-10 to 1-40 1-80 to 1-160 1-200 1-200 to 1-800 0-5 10-25 30-60 70-80 90-98 Motility Tests. — Test-dinner : To test the motility of the stomach, the Riegel test-meal is sufficient. This consists of a plate of soup, 150 grams of beefsteak, a roll of bread, a small dish of potato-puree, some stewed fruit and one glass of water. Seven hours after the meal, the stomach should be washed out. It will be found empty if the motility is normal. If remnants of food are present, there exists a weakness of the muscles of the stomach, the so-called atonia ventriculi, and sometimes also hypersecretion of the gastric juice. Test-supper: To test gross motor disturbances I use a combination of the methods of Boas and Strauss. About 8 o'clock in the evening, the patient should eat a plate of por- ridge, cooked with rice or raisins, and one or two slices of bread and butter. The next morning before breakfast, or about twelve hours after eating, the stomach of the patient should be lavaged. A gross disturbance of the gastric motility is present if remnants of food are found, for instance, rice or raisins, which are easily recognized macroscopically. Such a disturbance is usually caused by some mechanical obstruc- tion at the outlet of the stomach, the nature of which will be considered later in detail. It need scarcely be mentioned that the examiner will be obliged to make use of the micro- scope to recognize food-remnants in the sediment of the lav- age-water, when only minimal amounts of food are retained. The Remnant-Test of Mathieu-Remond. — This test is used to detect the milder disturbances of motility and to ascer- 36 DISEASES OF THE DIGESTIVE CANAL tain the results of treatment in such cases. I do not discharge from ni}' chnic any patient suffering from dilatation of the stomach until the remnant-test has shown an approximately normal motility of the stomach. The test is made as follows: Exactly one hour after the Boas-Ewald test-breakfast, the examiner should remove a portion of the stomach-con- tents, "a," with an ordinary stomach-tube. The portion remaining in the stomach is the unknown quantity and is designated "x." To determine ".r," the physician should dilute the unknown quantity, ''.r, " with a known quantity of water, "q," which should be introduced into the stomach through the stomach-tube and mixed thoroughly with "x," according to the following equation: flj : Oj = x + g : X i.e., the first acidity, " a^" (before the mixture with "q," therefore, the acidity of "a," since "a" and "x" have the same acidity), is inversely proportionate to the second acidity, ''03" (after the mixture with "g"), as the respective quantities are proportionate to each other, because the acidity of " tto" is as much smaller than the acidity of ''a/' as the addi- tion of water, "q," is larger. The formula, therefore, is: Example: — 45 c.c. of stomach-contents (a) are removed one hour after the test-breakfast, the total acidity of which is 60 (aj. The acidity of the portion remaining in the stomach after mixing with 400 c.c. of water is found to be IS (a.,). Therefore, "'- 60 — 18 -'^^■ In normal acidity, the total remnants of the Boas-Ewald test-breakfast amount to from 180 to 200 c.c; in achylia gastrica, to about 120 c.c; in atony and in hypersecretion, to from 220 to 280 c.c; and in motor insufficiency of the stomach, to from 300 to 400 and over. Microscopical Examination of the Stomachi=Contents. — This examination, which is very important in diagnosis, must INTERNAL EXAMINATION 37 be made exclusively with fresh unstained material obtained from the fasting stomach. Although the examination of the test-breakfast reveals only starch-granules, and now and then some yeast-cells, squamous epithelium and swallowed sputum, all of which 'are of no diagnostic value, the examination of the contents of the fasting stomach is of the utmost importance. Fig. 10. X, free nuclei; piperittr, oviss 200.0 M. Sig. — One tablespoonful every hour. As an after-treatment, I prescribe pure hydrochloric acid every two hours, 6 drops in a wineglassful of lukewarm water. In this affection, I have found this mixture useful, to which, in some cases, I add 8.0 [5ii] of the tincture of bella- donna, together with menthol and valerian, as follows: I^ TincturEB belladonnse foliorum, Spiritus menthse piperitse, aa oii a^'i 8.0 Tincturae valerianse., 3iv 16.0 • M. Sig. — Thirty drops in a cup of peppermint and valerian tea, three or four times daily. Diet. — The dietetic treatment consists in the "starva- tion" diet. Nothing but peppermint tea, or black tea with cognac, and oatmeal gruel, should be given for the first two days of the illness. After nausea and vomiting have com- pletely disappeared, the patient may be given beef tea, gruels, soups, and tea to which sweet cream has been added; and in case of diarrhoea, cocoa, and spiced wine which is prepared by cooking a red wine with cinnamon and cloves and diluting with water. Solids should not be permitted until after the disappear- ance of diarrhoea; then gradually may be added rice broth, oatmeal porridge, stale white bread softened in liquids, and fresh butter; and later, pigeon broth, calves' brain, and by degrees more solid foods, such as pike, perch, roast filet, veal, etc. If the bowels have been constipated for a few days, light vegetables, — spinach, carrots, cauhfiower, asparagus,, and peas, — should be prescribed; and later, potatoes, bread, etc. Fruit should not be allowed for some time; nor acids for still longer. Acute gastritis is entirely curable if the patient will ad- here strictly to the proper diet; relapses, however, easily DISEASES OF THE STOMACH 87 occur if he assumes his ordinary habits of eating as soon as the first stormy symptoms of the disease have disappeared. People who hve at hotels and restaurants are especially exposed to this danger, as it is difficult for them to adhere to a rational diet. It is proper to mention here, however, that at the present time there are dietetic restaurants in most of the large cities, to which the physician may send such patients. Chronic Gastritis General Remarks. — Formerly most of the chronic dyspep- sias were called "chronic gastric catarrh"; but since Leube's epoch - making work, only that gastric affection is called ''chronic gastritis" in which there occurs the characteristic anatomical alterations of the mucosa. Every chronic stomach-disease which the anamnesis shows not to be a case of ulcer, carcinoma, or dilatation of the stomach, should be designated at first as chronic dys- pepsia. Further examination will determine whether an organic or a nervous-functional gastric affection exists. Chronic gastritis is one of those diseases of the stomach in which no positive diagnosis can be made without exam- ination of the secretions, because its subjective symptoms are so manifold and so frequently similar to those of other chronic affections of the stomach. By the anamnesis alone the physician can establish, as a rule, only a probable diag- nosis; and besides, the test-breakfast is indispensable in differentiating between the various forms of chronic gastritis. The anatomical changes in chronic gastritis are analo- gous to those of nephritis,* in which either the parenchy- matous or interstitial tissues are involved. The pathological process in gastritis rarely extends to the muscularis. It is now a well-known fact that besides the usual diminu- tion, or absence, of the gastric juice in gastritis, there are * From a pathological and anatomical standpoint the classification is some- what different, and approximately that of the nephritides, of which Hayem has given a practical classification. 88 DISEASES OF THE DIGESTIVE CANAE cases in which there is an increase in the secretion of hydro- chloric acid; indeed, it is even probable that there is an in- creased activity of the glandular structures in the first stages of all cases of chronic gastritis. This period of the disease rarely comes under the observation of the plwsician, for the reason that the symptoms are then usually latent. Fig. 21. Fig. 22. mm '■MM^^ Normal mucous membrane of the stomach Mucous membrane in interstitial and atrophic (pylorus).* gastritis (alcoholic).* In i^ractical work, the following clinical forms of gastritis should be differentiated: 1. Acid and hyperacid gastritis (acid catarrh of stomach). 2. Subacid gastritis. 3. Anacid gastritis. a. Catarrhal, or simple gastritis. 6. Interstitial gastritis. c. Atrophic gastritis. 4. Stenotic gastritis or cirrhosis pylori. * Specimens furnished through the courtesy of Dr. Ethel L. Leonard, Los Angeles, Cal. DISEASES OF THE STOMACH 81) The old view that stasis of the stomach-contents fre- quently occurs in 'chronic gastritis, is an error. On the con- trary, the motihty of the stomach in gastritis rather exceeds the normal, i.e., the stomach propels the food into the intes- tine as soon after eating, or perhaps sooner, for the reason that normally the stomach must propel the food as well as its own secretions. Stasis occurs only in stenotic gastritis; this form is ex- ceedingly rare. In gastritis, therefore, the secretory rather than the motor functions are impaired. Fig. 23. 120 »I20 Hyperacid G^sfrihs ascending / \ Hyperacid Dgstritis descending 80/ XsO — Evolution of Gastritis in Gourmonds — Evolution of Gastritis in Women and Alcoljolics. Diagram showing the development of the various forms of chronic gastritis. The general nutrition of the patient suffers only when the appetite is lost, the motihty disturbed b}^ some complication, or the functions of the intestine become secondarily involved. Etiology. — Chronic gastric catarrh arises, primarily, from the direct effects of injuries to the mucous membrane of the stomach; or, secondarily, as a complication of other diseases of the stomach or other organs of the body. 1. Primary chronic gastritis is produced from excesses in eating, drinking, and smoking; from the misuse of laxatives, especially of salines, such as Carlsbad salts; from continued improper mastication of food, irregular and hasty eating, or defective teeth; from insufficient nourish- 90 DISEASES OF THE DIGESTIVE CANAL mcnt,— as for instance, in persons who live on bread and coffe(> only and who eat no meat, year after 3'car. The misuse of alcohol and tobacco is especially important in men, and in women the other causes in question. According to Martins, a congenital insufficiency of the gastric glands is possible. There are frequently cases in which the etiolog}' of the disease cannot be established. Whenever possible, the causative factors should be care- fully traced and the treatment directed toward their removal. Excesses in smoking, meat-eating, and wine-drinking are generally the cause of hyperacid catarrh of the stomach, — the so-called ''acid gastritis;" while the misuse of whisky produces a subacid or anacid gastritis, — a clinical fact which has recently been experimentally established by Kast.* Acid gastritis occurs, therefore, most frequently in obese men, and scarcely ever in women. Chronic gastritis, like acute catarrh of the stomach, may also be caused by occupation poisons and by the use of irrita- tive drugs, such as salicylic acid, vermifuges, etc. 2. Second ar 5^ chronic gastritis may appear as a complication of carcinoma of the stomach itself, or in the course of cancer of other organs of the body, — for instance, the uterus, lungs, or intestines, — as soon as general cachexia has developed. On the same principle, atrophic gastritis develops almost without exception in patients suf- fering from progressive pernicious anaemia. I cannot agree with those authors who consider that atrophy of the gastric glands is the cause and not the result of the pernicious anaemia. Milder secondary gastric catarrhs are caused by passive congestion in either the greater, the lesser, or the portal circulatory systems; for instance, in chronic diseases of the heart, lungs, liver, and kidneys. These are usually of the anacid form of gastritis. Secondary acid gastritis, or gastritis hyperpeptica, oc- curs in ulcer or stenosis of the pylorus, in which event the *Arch. f. Verdauungskr., Bd. 12, p. 487. DISEASES OF THE STOMACH 91 irritation of the gastric mucosa has been caused by the stag- nating food-contents of the stomach. Symptomatology. — As in every other disease of the alimentary tract, there are present both general and local subjective symptoms, and both general and local objective findings. 1. The general subjective symptoms are lassitude, disinclination to work, and frequently loss of appe- tite or perversion of taste. The local subjective sj^mptom is pressure in the stomach, especially after eating solids, — which is a general symptom of all forms of gastritis. After the patient has taken soups or other liquids, except cold drinks, this pressure does not occur. Pressure in the stomach is characteristic of gastritis, especially if it occur after the patient has eaten such foods as beef, hard bread, cabbage, cheese, hard-boiled eggs, fried potatoes, meats, etc. Actual pain, as well as vomiting, rarely occurs in chronic acid gastritis. In advanced forms of atrophic gastritis, gnaw- ing pains and vomiting usually occur several hours after indiscretions in diet. In stenotic gastritis caused by hypertrophic stenosis of the pylorus, vomiting and pain set in regularly after errors in diet. Food-stasis occurs exclusively in this form of gastritis. Pyrosis, so-called ''heart-burn," occurs in hyperacid gastritis. 2. The general objective findings are : In- dividuals suffering from chronic gastritis may be well or badly nourished, according to the amount of food they are able to take, which is in turn dependent upon the appetite, and upon whether they suffer much or little after eating. It has already been mentioned that nutrition does not suffer from deficient gastric digestion alone, but rather from a diminution in the amount of food which enters the body. The majority of patients suffering from chronic gastritis are aneemic, under-nourished, and have the appearance of 92 DISEASES OF THE DIGESTIVE CANAL being ill, although there arc quite a large number of patients suffering from ehronic gastritis that are well nourished. The administration of the test-supper (see Special Sec- tion) will show that the motility of the stomach in gastritis is quite normal. The examination of the test-breakfast always shows characteristic deviations from the normal. In hyperacid gastritis, the total acidity is increased, on the average, to 80, but in some cases it may reach to as high as 120. The diagnosis of gastritis may be established if the patient gives the characteristic symptoms and etiology of the disease, even when the total acidity is normal, i.e., T.A. 40 to 60 (gastritis acida orthochlorica) . In subacid gastritis, the total acidity amounts to less than 40. Free hydrochloric acid is still present, however, as will be shown by the blue reaction of red congo paper. The test- breakfast shows that the chymification of food is but little reduced. In this form of gastritis, the diagnosis is estabhshed only by the general ensemble of sj^mptoms. In acid gastritis, free hydrochloric acid is entirely absent, Congo paper is not colored blue, and the total acidity amounts to 20 or less. The production of ferments is diminished or entirely absent, as has been explained in the General Section. All references to the total acidity of the gastric juice apply to the Boas-Ewald test-breakfast, which consists of 60 to 65 grams of dry white bread and 400 c.c. of water. Since white bread ahvays contains practically the same proportion of albumen, the amount representing the total acidity in which free hydi-ochloric acid is present must always be approximately the same. In general, it may be said that free hydrochloric acid is secreted when the total acidity of the gastric juice amounts to 20 or more. Atrophic gastritis exists when there is permanent cessa- tion of the secretion of gastric juice. The total acidity amounts to from 5 to 8; in interstitial gastritis, from 10 to 16. In simple catarrhal gastritis, the total acidity amounts to from 16 up to the occurrence of the secretion of free hydrochloric acid. The diminished secretion of gastric juice in atrophic gastritis is accompanied by a corresponding decrease in the amount of rennin and pepsin. (See General Section.) DISEASES OF THE STOMACH 93 The less the test-breakfast is mixed with the gastric secretions, the less digested is its appearance. If there is total absence of gastric juice, the test-meal has the appearance of having been chewed and immediately eructated. This con- dition has been designated by Einhorn, " achylia gastrica." The amount of mucus in the stomach-contents is sub- ordinate to other signs, in making the diagnosis, for the reason that a pharyngitis almost always exists simultaneously. The appearance of the tongue in chronic gastritis is entirely dependent upon the appetite, which, in some cases, is very good. The less the patient masticates his food, the more the tongue will be coated, because the latter does not receive the mechanical cleansing which results from mastication. The vomiting of mucus early in the morning, so-called vomitus matutinus, occurs very frequently, as is well known, in alcoholic gastritis. Boas has shown, however, that this depends upon co-existing pharyngitis and oesophagitis; the large amount of mucus produced by catarrh of the pharynx, and the sputum, pass into the oesophagus during the sleep of the patient, and cause him to awaken early in the morning with tickling and irritation of the throat, spells of nausea, and usually vomiting of the swallowed mucus. Only in rare cases does the mucus in the matutinal vomit- ing have its origin in the stomach itself. Another objective symptom is sensitiveness to pressure in the epigastrium. This is never so localized and intense as in ulcer of the stomach, but is more diffuse. Pyrosis, which occurs in hyperacid gastritis, will be spoken of below. Prognosis and Course. — The prognosis of chronic gas- tritis, so far as life is concerned, is very good, while the chances for complete recovery are poor. Most cases are clinically cured; that is to say, by adhering to a rational diet, such patients are freed from suffering and enjoy good health. The physician, however, is never able to guarantee the patient exemption from relapse, should errors in diet be made, for a sufferer with chronic gastritis must, in a measure, during his entire life, "cut the garment according to the cloth." 94 DISEASES OF THE DIGESTIVE CANAL Complete restoration can result only if treatment is sought during the initial stages of the disease, i.e., in hyper- acid gastritis, subacid gastritis, or catarrhal gastritis, in which forms few or no interstitial alterations of the mucosa of the stomach have occurred. Chronic gastritis may exist for years without symptoms, which will then appear gradually. Later in the disease, the intestine may become involved from the irritation to which it has been for a number of years subjected by the introduc- tion of undigested food. In other cases, the same etiological factors, — such as, for instance, the abuse of alcoholic stimulants and overeating, — may simultaneously produce an inflammation of the stomach and of the intestine. It is for this reason that a large number of patients suffer from gastritis and chronic diarrhoea at the same time; while in other cases, intestinal symptoms precede stomach-indigestion. It should, therefore, be emphasized here that examina- tion of the stomach-contents is absolutely essential in all cases where patients suffer from chronic diarrhoea, although they may not complain of trouble in the stomach after eating. The nutrition in gastritis suffers very considerably when it is associated with diarrhcea, otherwise these patients are well nourished until there is a diminution of the appetite. .The prognosis of chronic gastritis is, therefore, dependent upon whether the patient is able to bring about a change in his usual customs and habits; whether he continues to smoke and drink; whether he persists in hasty and irregular eating; and whether, if poor, he has the advantages of a suitable dietary and sufficient rest. Hyperacid gastritis gradually progresses into the sub- acid and anacid forms of the disease, if the causa morhi remains active. Diagnosis. — The diagnosis of chronic gastritis is usually easy if the physician, in addition to the anamnesis and the physical examination, gives the test-meal. Diagnosis should be formed from the complaints of the patient and the findings DISEASES OF THE STOMACH 95 of the examination, but never from either of these alone, if the examiner would avoid being frequently led into error. The most important subjective symptom is pressure which occurs after eating soHds. Objectively, the most im- portant diagnostic sign is a pathological alteration in the secretions of the stomach. Besides these, an etiological factor must be ascertained by the anamnesis. Differential Diagnosis. — Gastric neuroses and functional dyspepsia are the most frequent stomach-affections to be differentiated from gastritis. In these affections, the general statement may be made, that pressure occurs after eating any kind of food, — after liquids as well as solids, — and that the gastric secretions are normal, or else variable from day to day. Besides this, gastric neuroses occur principally in persons with habitus enter ovticus, while gastritis is found usually in persons with normal habitus (see above). Hence the differential diagnosis is difficult only when, on account of nervous influences, the secretion of hydro- chloric acid is also diminished. The physician will be assisted in estabhshing an exact diagnosis by an accurate examination of the gastric fer- ments, — rennin and pepsin, — which, in neuroses, should be found present in normal amounts; and also by a consideration of the general condition and symptoms of the patient. Gastritis is, as a rule, easily differentiated from ulcer of the stomach, because in ulcer the patient suffers from epi- gastralgia rather than from pressure. This epigastralgia sets in, as a rule, one or two hours after the principal meal, and the acidity of the gastric juice is almost always increased. The differentiation will be difficult only wdien there are erosions or fissures of the pylorus in hyperacid gastritis. In such cases, Hkewise, burning or gnawing pains occur in the epigastrium some time after eating. In these cases, the physician is no longer concerned with pure gastritis, but with the combination of erosions or ulcer with gastritis. In general this is rare, and occurs only in patients who smoke to excess. 96 DISEASES OF THE DIGESTIVE CANAL Gastritis is very easily differentiated from dilatation of the stomach, because in gastritis no stagnation of food occurs. Only in stenotic gastritis (cirrhosis pylori) does one find a combination of ectasia and chronic gastritis. The inflam- matory process produces, in these cases, a hjq^ertrophic stenosis of the pylorus, with secondary motor insufficiency and dilatation of the stomach. It is seldom possible to differentiate gastritis from the initial stage of carcinoma. If the cancer is not located at the pjdorus or at the cardia, no obstructive symptoms are present; and if no tumor is palpable, the physician will find objectively nothing more than the same evidences of achylia gastrica as occur in benign atrophy of the mucous membrane. The subjective symptoms of the initial stage of carcinoma are also the same as the subjective symptoms of gastritis. Only by a microscopical examination of the stomach-contents, obtained several hours after eating, may the diagnostic points be learned for the differentiation of these doubtful cases. The presence of many pus- and blood-corpuscles in the stomach-contents is an evidence of cancer. The failure of the Rhodankalium reaction in the saliva (appearance of a red color after adding one drop of ferric chlo- ride), according to Schmidt, of Vienna, is an evidence of cancer. The many varieties of gastritis are, as a rule, easily dif- ferentiated by the examination of the gastric juice and by making the ferment-tests (see page 29). Treatment. — The treatment of chronic gastritis is: (1) hygienic; (2) dietetic; (3) medicinal; (4) mechanical; and (5) balneological. 1. Hygienic. — In alcoholic gastritis (hyperacid and anacid forms), drinking and smoking are to be especially limited, or, if possible, entirely prohibited for a long time. When gastritis has originated from insufficient mastica- tion, in consequence of defective teeth, the patient should be referred to a dentist. The great value of eating leisurely, and the disadvantages of hasty eating, are to be strongly impressed upon the patient. DISEASES OF THE STOMACH 97 Compression of the epigastric region }3y tight clothing must also be condemned. If the disease is attributable to the misuse of saline lax- atives, evacuation of the bowels should be obtained by sub- stituting dietetic and mechanical measures. 2. Dietetic. — The dietetic treatment is similar in all forms of chronic gastritis. A few exceptions, which will be separately considered, are to be observed in acid gastritis. The dietetic treatment of gastritis is dependent upon the principle that the inflamed mucous surfaces should be spared as much as possible, and that the diet must be adapted to the altered functions of the gastric mucous membrane. Soft, pulpy foods, therefore, must predominate in the diet, while solids should be largely eliminated. A. Diet in Subacid and Anacid Gastritis. — The follow- ing foods should be forbidden: hard bread, pumpernickel, and hardtack; coarse vegetables, like cabbage and fried potatoes; raw fruit, stewed acid fruits, such as currants or gooseberries, and fruits containing seeds; legumes and nuts, of milk products, hard cheese and sour milk; of meats, bacon, goose, duck, fat ham, mutton and pork; smoked fish, such as red herring and salmon; also hard-boiled eggs, ma3^onnaise, and all forms of fat except butter. The following foods are allowed: a. Soups in every form and consistency, beef tea, with the addition of eggs, cereals, noodles, macaroni, and soft vege- tables; oatmeal, flour, milk, and bread soups, etc. 6. Rice, sago, millet, tapioca, oatmeal, — cooked in broth or milk; puree of potato, Brussels sprouts, spinach, carrots, green peas, asparagus, and cauhflower; fruit gelatins and sweet stewed fruit, such as apple sauce, plum sauce, straw- berries and raspberries. c. White bread, toasted white bread, zwieback, "Force," and in mild cases, small amounts of English white bread. d. Milk, cream, and butter. e. Chicken and pigeon, — boiled or broiled in butter; veal, — boiled or broiled medium rare; calves' brain and sweet- 7 98 DISEASES OF THE DIGESTIVE CANAL breads; beef and ham free from fat, which may be roasted or grilled. In severe cases, such as atrophic gastritis, only the most tender meats and lean fish, such as pike, perch, flounder, and shell-fish; roe, pheasant, partridge; but never hare, deer, nor any smoked game. /. The following relishes and beverages are allowed: tea, small amounts of cofTee, diluted wine, mineral water, with or without the addition of fruit juices; cocoa, chocolate, caviare, sardines, and spices. g. Artificial foods: puro, sanatogen, somatose, meat jellies, meat juices, and calves'-foot jelly. In the treatment of chronic gastritis, the condition of the bowels and the general health of the patient must be carefully taken into account. For instance, if constipation exists purees of fruits and vegetables, fruit juices and koumiss are to be pre- scribed. On the other hand, if diarrhoea or a tendency toward diarrhoea is present, all foods that stimulate peristalsis should be avoided and only those prescribed that have an astringent effect, — such as cocoa, red wine, huckleberry wine, etc. Very frequently, in gastritis, it is necessary to combine the gastritis and the diarrhoea dietaries; or the gastritis- constipation and the gastritis-fattening dietaries. (Special diet-lists will be found in the Dietetic Outlines.) B. Diet in Hyperacid Gastritis. — The diet in this form of gastric catarrh differs from the diet in chronic gastritis, in that all fats and spices, and other strongly irritating foods, as well as strong coffee, tobacco, and cold drinks, — such as beer, champagne, and white wine, — must be absolutely for- bidden. Sweetmeats and rich dinners, especially for patients who have thus brought about acid gastric catarrh, should be avoided. Warm drinks are to be recommended, such as hot milk, warm Vichy water, etc., to relieve the burning pains and pyrosis of the stomach. From the practical standpoint, the remaining thera- peutic procedures in the different forms of gastritis should be sepaTately considered: DISEASES OF THE STOMACH 99 I. Hyperacid Gastritis (Acid Catarrh of the Stomach. Gastrite Hyperpeptique.) 3. Medicinal Treatment. — a. Belladonna preparations are prescribed for the sup- pression of hypersecretion. b. Bitters are used for the stimulation of the appetite. c. Antacids should be symptomatically given after eating, to neutralize the acidity of the gastric juice. Belladonna is to be given in the form of the extract, the tincture, or as atropine in solution or tablets. Of the bitters, condurango bark is the most effective; either a teaspoonful of the decoction or of the fluid extract should be given before meals. Other bitters are the tinctures of rhubarb or gentian, the compound tincture of cinchona, the fluid extract of calamus, or bitter almond water, which may be given before meals, in doses of one-half to one tea- spoonful. Resorcinol and creosote are also recommended. The antacids should be prescribed according to the fol- lowing principles: 1. If the bowels are normal, sodium salts, sodium citrate, bi-carbonate or phosphate should be given. 2. If constipation exists, magnesium salts, — calcined magnesium or magnesium-ammonium phosphate, — should be prescribed. 3. In diarrhoea, the salts of calcium, — calcium carbonate and calcium phosphate, — should be used. As a rule, the following prescriptions are all I have needed: 1. I^ Tincturse belladonnae foliorum, ttl Ixxx-oiiss 5.0-10.0 Tincturae gentianas, (or calami, rhei, or cinchonae), oi 30.0 M. Sig. — 30 to 40 drops, 5 to 15 minutes before meals on sugar or in a wineglassful of water. 2. I^ Extracti beUadonnse foliorum, gr. iii-ivss 0.2-0.3 Sodii bicarbonatis, Magnesii oxidi, aa, 3v 20.0 M.ft.pulv. Sig. — One teaspoonful 2 or 3 times daily, 1 to 3 hours after meals for cramp-like or burning pains in the epigastrium. 100 DISEASES OF THE DIGESTIVE CANAL 3. I^ Extracti condurango fluidi, oiss 50.0 - Sig. — One teaspoonful t.i.d., 5 to 15 minutes before eating, for loss of appetite. 4. I^ Solution argenti nitratis — gr. viiss : oviss 0.5 : 200.0 Sig. — One tablespoonful (porcelain) in a wineglassful of distilled water 15 minutes before eating, for pyrosis. In acid gastritis, if, besides the usual pressure, there also occur burning pains in the epigastrium two or three hours after a heavy meal, the physician must always think of the possible complication of erosion and catarrh. If the pains are of a crampy nature, the erosion is most probably located at the pylorus. In such cases, the physician should prescribe belladonna combined with an alkali. (See above.) In addition to these remedies, the following medica- ments are very useful: 1. I^ Bergmann's or Belloc's mastication tablets. Sig. — One to tliree tablets after meals. 2. J^ Extracti belladonnse foliorum, gr. iiss 0.15 Bismuthi subnitratis, 5iv 15.0 M. Sig. — One knifepointful three times daily after meals. These "mastication tablets" should be chewed as thor- oughly as possible and dissolved in the mouth; this will cause the patient to swallow a large amount of sahva, which will tend to iieutraHze the hyperacid gastric juice. The Bergmann tablets are effective almost entirely through this mechanical effect of stimulating the secretion of saliva; while the Belloc tablets contain belladonna, char- coal, and magnesia. The chewing of hard bread-crusts, or taking a hot drink about an hour after meals, relieves the pain by introducing an increased amount of sahva into the stomach and by dilut- ing the gastric juice. Medicaments for the relief of pain should always be given about one-half hour before the attack usually occurs. 4. Mechanical Treatment. — In acid gastritis, lavage is usually superfluous, unless stagnation of the stomach-con- tents occurs as a complication. DISEASES OF THE STOMACH 101 It must be said, however, that irrigation of the gastric mucous membrane with a 1 to 1000 solution of silver nitrate is decidedly beneficial in cases of acid gastritis complicated with erosions. Irrigations with a solution of sodium bicar- bonate or Carlsbad salts are also recommended. Bourget has recently advised lavage with a one per cent, solution of liquor ferri chloridi in stubborn cases of acid gas- tritis. One hundred c.c. of this solution are introduced and afterwards washed out with warm water. The idea that the mucous membrane must be cleansed of its adherent mucus in every case of chronic gastritis is now obsolete. The use of hot mud-poultices or Priessnitz compresses is recommended if erosions of the mucosa are suspected. 5. Balneological Treatment. — The physician should pre- scribe Carlsbad or Neuenahr water for patients who are strong and rugged, and Vichy for those who are delicate. These waters should always be taken hot, about 35° to 40° R. [110°- 112° F.] The direct use of the water at the springs is most effective. As home treatment, these mineral waters may be given at the same temperature; while with patients of the poorer classes, it is advisable to prescribe either the natural spring-water salts or the artificially prepared salts dissolved in water. Three or four glasses, each containing 200 c.c. of water, should be given daily before meals, — one or two glasses early in the morning before breakfast, one glass at mid-day and one in the evening. This treatment should continue six or eight weeks. n. Subacid and Anacid Gastritis The (1) hygienic and (2) dietetic treatment has already been considered, and for the suitable dietary the reader is referred to the Dietetic outlines. 3. Medicinal Treatment. — In these forms of gastritis, actual pain almost never occurs, except after gross errors in diet. Narcotics and antacids are therefore not required, because hyperacidity does not exist. 102 DISEASES OF THE DIGESTIVE CANAL On the other hand, bitters (see above) are more freely prescribed; for the reason that tho appetite in these cases is generally much decreased. As a rule, the use of hydrochloric acid, either alone or in combination with a bitter, should be in amounts propor- tionate to the atrophic process of the mucous membrane of the stomach. The following prescriptions are suitable: 1. Acidi hydrochlorici off., oi 30,0 Sig. — Eight to ten drops in a wineglassful of water three times daily im- mediately after meals. (In severe cases, repeat the dose in half an hour; and in total atrophy with enterocolitis, repeat the dose a third time.) 2. I^ Acidi hydroclilorici diluti, ,5ss 2.0 Tinctura; gentiana? (rhei, etc.), oi 30.0 Sig. — One-half teaspoonful three times daily. 3. R All Bitters. Sig. — One-half to one teaspoonful tliree times daily before meals. In general practice, the following remedies are especially valuable in atrophic gastritis: Pepsin, papain in tablets of 0.3 to 0.5 [5 to 8 gr.], or pancreatin in knifepoint doses. Re- cently the use of pancreon in tablets of one-half gram, or as a powder combined with sodium bicarbonate in knifepoint doses, has been found beneficial. Pepsin should be administered in combination with hydrochloric acid, because it is active only in an acid medium. The other preparations should be administered without hydro- chloric acid, because of the well-known fact that, with the exception of papain, they are able to digest albumin only in an alkaline medium. In the medical treatment, the examiner must very fre- quently take into consideration the condition of the intestine, because there is often a co-existing intestinal catarrh with diarrhoea or, more rarely, with constipation. For a detailed consideration of this subject, the reader is referred to the section on Enterocolitis. DISEASES OF THE STOMACH 103 4. Mechanical Treatment. — Lavage and irrigation of the mucous membrane of the stomach with normal alkahne solu- tion is beneficial, but not absolutely necessary. A positive indication for lavage does not exist. Neither can favorable results be expected from electrical treatment, for the reason that motility in this form of gastritis is nearly always normal. 5. Balneological Treatment. — The sodium chloride mineral water of the Rakoczy spring at Kissingen, the Kochbrunnen of Weisbaden, and the EHzabeth spring at Homburg, as well as those at Baden Baden, Ems, etc. [Champion, Congress, and Hawthorn springs at Saratoga, N. Y., or Blue Lick springs, Ky.], are indicated in subacid or anacid gastritis. Whenever possible, the patient should be sent to one of these places to follow out the treatment, or, if necessary, he may drink the bottled waters at home. Patients who are in limited circumstances may, however, be given the artificially pre- pared salts, dissolved in warm water. If this form of gastritis is associated with constipation, the water should be drunk slightly warmed. If there is a tend- ency toward diarrhoea, on the other hand, it should be drunk as hot as possible, and in smaller doses. III. stenotic Gastritis This form of gastritis is exceedingly rare. It is caused by hypertrophy of the musculature of the pyloric end of the stomach, as a compensatory process brought about by the increased demands made upon the organ in atrophic gastritis; for it is evident that more muscular power is demanded of the stomach to propel foods not sufficiently chymified into the duodenum than foods which are well digested and mixed with an abundance of gastric juice. Hypertrophy of the pars pylorica frequently simulates the symptoms of a tumor of the pylorus, since besides the thickening of this part of the stomach, there is, — in con- sequence of the hjqDertrophic stenosis of the pylorus, — stagnation of the stomach-contents, with lactic-acid fer- mentation. 104 DISEASES OF THE DIGESTIVE CANAL In these cases, only by a long observation of the patient is the physician able to differentiate stenotic gastritis from cancer of the pylorus. (For further details concerning the differential diagnosis, the reader is referred to the chapter on Microscopic Examination of the Gastric Contents.) Treatment. — The hj^gienic, dietetic, and mechanical treat- ments are the same as in stenosis of the pylorus. The physician is referred, therefore, to that subject for the details in the management of these cases. It need only be mentioned that in stenotic gastritis, a total atrophy of the gastric glands is present. Meats, therefore, should be pre- scribed in the form of purees only. This precaution is not needed in the other forms of benign stenosis of the pylorus, for the reason that in these the gastric juice is secreted in amounts sufficient to peptonize meat. All hard or coarse foods and, in fact, all foods not of a liquid or semi-liquid nature should be strictly forbidden. Mechanical and Medicinal Treatment. — Olive oil, milk of almonds, hydrochloric acid, pepsin, and the bitters are to be prescribed as detailed in the chapter on Treatment of Ulcer of the Stomach, to which the physician is referred. Balneological therapy is contraindicated, since this form of treatment would cause an overtaxing of an already dilated stomach. In general, the treatment of stenotic gastritis is identical with that of cancer of the pylorus. In severe forms, which have produced a high degree of stenosis, the physician is in duty bound to advise operation (gastro-enterostomy ) . IV. Secondary Gastritis The rational treatment of secondary gastritis is naturally that of the primary disease; for instance, in affections of the heart, digitalis should be used, etc., etc. If the primary disease is incurable, the physician must treat the gastritis symptomatically, in the same way as he would treat gastritis of any other form. Especial emphasis should DISEASES OF THE STOMACH 105 be given to the great Value of free diuresis and regular evacua- tion of the bowels in gastritis produced by passive congestion of the mucous membrane. Under this treatment, the gastric symptoms very frequently disappear. In the following I will add the historips of a number of clinical cases, which will illustrate the various forms of gastritis : CLINICAL CASES 1. Acid Gastritis Case 1. — F. A., a policeman, 25 years old, entered the clinic November 8, 1902. For four months he had suffered from severe pyrosis, most marked an hour and a half after meals; and from pressure and burning in the epi- gastrium,, especially after eating fatty foods. He was very strong, rugged, and corpulent. The test-breakfast showed a marked increase in the hydro- chloric acid of the stomach, — the total acidity being 114. Treatment. — The patient was given a teaspoonful of Sprudel salts, dissolved in a glass of warm water, early in the morning before breakfast, and a teaspoonful of the following prescription twice daily, one hour after meals: I^ Extracti belladonnBe foliorum, gr. ivss 0.25 Magnesii oxidi, Sodii bicarbonatis, aa oviss 25.0 Smoking and drinking were forbidden. Under this treatment the symptoms disappeared entirely in ten months, when the total acidity was 70. Case 2. — Carl V., a laborer, 29 years old, entered the clinic December 31, 1902. For a year and a half or two years, the patient had suffered from pressure in the stomach, especially after drinking beer and eating coarse solids, — such as cabbage, rye bread, potatoes, etc. Soft foods and warm drinks, on the contrary, had produced no discomfort. Pressure in the stomach was so great at times that the patient sought relief by artificially produced vomiting. Appetite was good. Stools were dry and hard. The patient gave a history of excessive eating and drinking (ten to twelve steins daily), and smoking. Physical examination negative. Total acidity of the test-breakfast, 108. Treatment. — This consisted in the administration of Carlsbad salts, belladonna, tincture of valerian, and a mild diet. Ten days later the patient was much improved, and the total acidity was 80. After one month's treat- ment, the pressure in the stomach had absolutely disappeared. In pre- senting the case three months later, the patient stated that he was entirely free from gastric discomforts. 106 DISEASES OF THE DIGESTIVE CANAL 2. Suband Gastritis Case.I. — Carl J., a joiner, 54 years old, entered the clinic October 14, 1902. For years the patient had suffered from pressure in the stomach, ^Yhich was preceded, for some time, by frequent vomiting of mucus in the morning. The patient had a tendency to diarrha^i. There was a history of alcoholism. He was poorh' nourished. Physical examination was nega- tive. Total acidity, 24. There was only a weak reaction to congo paper. Treatment. — Rakoczy water, hj'drochloric acid, and a pm-ee diet, resulting in improvement. Case 2. — Emily H., 48 years old, the wife of a laborer, entered the clinic April 1st, 1903. She had suffered from stomach trouble for twenty years, with gastric pressure in the epigastrium from one to one and one- half or two hours after eating solids, — such as tough meats, potatoes, bread, cheese, etc. Of late she had suffered much from diarrhoea, associated with crampy pains. There was always a tendency to vomiting. The teeth of the patient were in poor condition. She had undergone many privations, with irregular, impoverished meals. Total acidity of the test-breakfast, 34. Treatment. — Rakoczy water, belladonna to combat the crampy pains, and a constipating diet. The improvement was only temporary, as after errors of diet.^for instance, after eating meats, etc., — the patient suffered again from pressure in the stomach, instantaneous diarrhoea and distention of the abdomen. 3. Anacid Gastritis 1. Catarrhal Gastritis Case 1. — Frederick B., a tailor, 31 years old, had for two years suffered from pressure in the stomach after eating solids, and had an inclination to diarrhoea. There had been an exacerbation of the symptoms for two weeks, after he had eaten currants. Patient's appetite was poor, except for highly seasoned foods. He was emaciated and pale. He had catarrh of the apex of the right lung. The greater curvature of the stomach reached to the umbilicus. The microscope showed the test-breakfast to be poorly digested. The total acidity was 20. Treatment. — Kissingen water; a diet of semi-solids; and hydro- chloric acid. Five weeks later, pressure in the stomach had almost entirely disappeared, and patient was discharged. Case 2. — Herman B., a railroad laborer, after an accident about one year previous, had suffered from severe pressure in the stomach, loss of appetite, emaciation and constipation. There was a histor}^ of alcoholism. The total acidity of the test-breakfast was 20. Rennin was positive, giving a cake-like coagulation in a dilution of 1 to SO, and a flaky coagula- tion in a dilution of 1 to 160. Pepsin-digestion ecjualed 50 per cent. After the use of Kissingen water for several months, with a semi-solid diet and hydrochloric acid, the patient was greatly improved in health. DISEASES OF THE STOMACH 107 2. Interstitial Gastritis Case 1. — August M., a laborer, 41 years old, had suffered from pres- sure in the stomach, especially after eating such hard foods as peas, beans, cabbage, cheese, and meats. After soups and liquids there was an absence of all symptoms. He had occasional diarrhoea. The appetite was poor. There was a history of alcoholism. Patient had a good physique, but was anaemic and emaciated. He had an ulcer of the rectum. Greater curvature 3-4 of the stomach . The total acidity was 14. Rennin-ferment was positive in a dilution of 1 to 20. Pej)sin-digestion equaled 1.5 per cent. After a treatment with Rakoczy water, hydrochloric acid, and suit- able diet, patient slowly improved. Case 2. — Carl B., a teamster, 34 years old, had suffered from a feeling of fulness in the epigastrium and loss of appetite for seven years. He had never vomited. There was no history of alcoholism. On account of his occupation, he had eaten hastily and irregularly. He had had frequent diarrhoea. The total acidity was 15. The rennin-test was positive in a dilu- tion of 1 to 40. There was no improvement; on the contrary, the total acidity diminished to 8, the inflammatory process gradually producing atrophy of the gastric mucosa. 3. Atrophic Gastritis Case 1. — Dr. H., an American physician, had for years eaten hastily and irregularly. He had used purgative remedies a great deal. There was always pressure in the stomach after meals. The test-breakfast was entirely achylous. The total acidity was 6. The lab and pepsin ferments were absent. After the rest-cure and the use of pancreon, and a gastritis-fatten- ing laxative diet followed in a sanatorium, the symptoms entirely disap- peared. The achylia gastrica was not improved. Case 2. — Therese B., a widow 67 years old, had for two years suffered from pressure in the stomach after eating solids, but experienced no dis- comfort after eating soups or liquids. There had been an inclination to diarrhoea, especially after taking cold. She had masticated insufficiently for years,- because of having no teeth. Total acidity of the test-breakfast was 8. There were traces of rennin and pepsin. Treatment. — Kissingen water, hydrochloric acid, and gastritis diet. A subjective clinical cure soon resulted. Case 3. — Selma S., a dressmaker, 40 years old, had for eight years suffered from stomach trouble, with frequent and irregular vomiting, which was not dependent upon meals. Bowels had been regular. The appetite was good. There was no gastric discomfort immediately after meals. Dur- ing the menstrual period the vomiting was more severe. The patient had suffered privations for years, and had lived largely on coffee, bread, and 108 DISEASES OF THE DIGESTIVE CANAL lard. She was very pale and emaciated. The physical examination was negative. The test-breakfast was entirely achylous. The total acidity was 8. There was no rennin nor pepsin. Treatment. — llakoczy water, hydrochloric acid, and semi-solid diet. Ten days later, there was an improvement in the general condition of her health. She vomited a stale liquid only once during the menses. After twenty days' treatment the patient was absolutely free from discomfort and had gained in weight. Ulcer of the Stomach Clinical and Pathological Remarks. — An ulcer of the stom- ach represents a loss of substance in the mucous membrane, and varies in size from the head of a pin to the palm of the hand. It is generally situated on the lesser curvature, in the pyloric antrum, or in the pjdorus; and, more rarely, in the other parts of the stomach. Ulcers which are found outside of the stomach in the cardiac end of the oesophagus and in the duodenum are, because of their well-known etiology, also called "peptic" ulcers. The above-mentioned breaks in the continuity of the mucous membrane vary in quality as well as in size. For instance, erosions of the pars pylorica occur (similar to erosions of the lips, nose, and mucous membrane of the mouth and rectum), which very frequently produce the same clinical phenomena as ulceration of the stomach. Still further distinctions should be made in the pathology of ulcers, such as between the mucous ulcer occuring in chlorosis, the simple peptic ulcer without indurated edges, and the chronic indurated ulcer. Multiple ulcers may exist at the same time. Etiology. — The etiology of ulceration of the stomach is so obscure that the exact cause is often impossible to estab- lish; but in every individual case, the ability to do this would be most desirable, so that the therapy might be properly directed. Aside from infectious diseases, such as tuberculosis and syphilis, there are two great etiological factors : 1. Disturbances of the circulation, which appear in chlo- rosis, at the beginning of menstruation, and at the climacte- rium or the cessation of the menses. DISEASES OF THE STOMACH 109 2. Mechanical influences. Besides these, acid gastritis and syphilis are important etiological factors which demand special consideration in men. Concerning the etiology of ulcer of the stomach, Rosen- heim gives the following summary: "The predisposing causal factor of ulceration of the stomach is a local reduction in the resistance of the walls of the stomach, caused by some disturbance in the circulation that weakens the resistance of the stomach-wall against the digestive power of the gastric juice. " I agree with Rosenheim in that he, contrary to other authorities, does not assume hyperacidity to be the cause of ulcer, for the reason that normal as well as hyperacid gastric juice has the ability to digest the mucous membrane, the resistance of which has been weakened. According to the above principles, therefore, most ulcers of the stomach may be classified, according to their etiology, in either the chlorotic or the climacteric group of ulcers, or as ulcers caused by mechanical or catarrhal influences. Such a classification naturally explains why ulcers of the first group are most frequent in the female sex, and especially in young girls; and why ulcers of the second group usually affect men, especially those who have indulged in excessive eating, smoking and drinking, and particularly those whose occupation requires chronic pressure upon the epigastrium. To this last group belong shoemakers, locksmiths, street- cleaners, masons, bookkeepers and, in short, all those whose occupation calls for the pressure of solid objects against the epigastrium, or who sit in a bent position. The same bad effects may be attributed to corsets and tight bands around the body. The assumption which was formerly so popular, — that ulcer was the result of chemicothermic influences, wdiich partly explained the frequency of ulcer in cooks, for example, — is now seldom considered. Ulcers may naturally be caused by the corrosive action of the various intoxications, especially ulceration of the oesophagus. These acute ulcers may become chronic. 110 DISEASES OF THE DIGESTIVE CANAL Acute traumata also play a role in the development of ulceratioii of the stomach. Violence upon the epigastrium causes either a necrosis of the mucosa by pressure against the spinal vertebrae, the formation of hipmatoma, or from suggil- lation of the submucosa. In any of these instances, the gastric juice digests that portion of the mucosa whose resistance has been lowered by injury. This form of ulcer may, under unfavorable conditions and improper treatment, become chronic and lead to cicatricial formation, as well as other complications and sequela^, and even to carcinomata, as in the case of any other kind of ulcer. Hyperchlorhydria, as such, never causes peptic ulcer. It is very frequently rather the result of an ulcer of the pylorus, for the reason that the latter causes a spastic stenosis of the pjdorus with food-retention, and a consequent irrita- tion of the gastric glands. Not until the mucous membrane of the stomach has been weakened in some way, — for example, by inflammatory processes, in acid gastritis, — may there be, besides the hyper- chlorhydria, a development of erosions of the mucosa. In comparison with the extreme frequency of hyper- acidity, there are but few cases of ulcer. As an example, symptoms of ulcer never appear in cases of nervous hyper- acidity, even if the latter should exist for decades. In many cases it is very difficult to differentiate between actual ulcers and erosions or fissures of the mucosa. Concern- ing this. Boas says: "CUnically, the view is thoroughly estabhshed that hemorrhagic erosions can produce exactly the same symptoms as ulcer, even fatal bleeding." In doubtful cases, therefore, treatment must always be that of ulcer. Sijmptomatology.—l, Subjective; 2, Objective. 1. Patients complain of actual pain in the epigastrium which is of a crampy, cutting, boring, or burning character. It begins anteriorly and radiates along the sternum or around both sides of the body to as low as the sacrum or as high as the DISEASES OF THE STOMACH 111 left shoulder. The pain scarcely ever occurs immediately after swallowing, but from one-half hour to four hours after eating. This symptom - complex should, according to Buch, be designated as epigastralgia rather than gastralgia, to prevent the assumption in the mind of the physician that the source of the pain is in the stomach. Attacks of pain always occur at the same hour after eating in each case, although different patients may suffer at different intervals after eating, — for instance, in case ''X, " one hour after raeals; in case ''Y," two or three hours after; and in case "Z," several hours after eating, when the stomach is empty, etc. Epigastralgia occurring at a definite time after eating is the most positive symptom of gastric ulcer. Gastric hemorrhage is even less diagnostic as a symptom, for the reason that it may occur as well in diseases of the liver, and in passive congestion in disturbances of the greater circulatory system; while gastric pain occurring at a definite time after meals occurs exclusively in ulcer of the stomach. The intensity of the pain always depends upon the quality of the food eaten; the coarser the food, the more severe the pain. After liquid foods, there may be no pain; or there may even be, in slight cases, a mitigation of . pain immediately after eating, because the food combines with and neutralizes the excessive amount of acid of the stomach. In ulcer of the pylorus, pain does not occur, as a rule, for some time after eating, — from two to four hours; and is frequently accompanied by vomiting of the acid gastric juice, after which it is relieved. The patient sometimes artificially produces vomiting by tickling the pharynx with the finger in order to obtain this relief. These are the cases in which, in addition to the organic lesion of the pylorus, there occurs at the height of digestion a pylorospasm, as we will give in greater detail below. Such attacks of pain cease after the acid contents of the stomach are vomited, which generally occurs in the evening 112 DISEASES OF THE DIGESTIVE CANAL between 6:00 ami 7:00 o'clock, and at night between 1:00 and 3:00 o'clock, at a time when there should be no food- remnants in the stomach. Frequently in these cases the ulcer is already partially cicatrized,— which sometimes causes the food-stasis. If not rationally treated, many such cases sooner or later lead to a dilatation of the stomach, secondary to the pyloric stenosis. It would, therefore, be a great mistake to assume that pain occurring before eating was due to a gastric neurosis, and to conduct the treatment accordingly. As a result of such irrational therapy, a fatal hsematemesis might occur. The periodicity of an epigastralgia is also characteristic of ulcer. Patients may suffer for weeks at a time from gastral- gia after eating, and then feel perfectly well for several months. These periods of pain, for reasons which are unknown, very frequently occur in the spring and autumn. They are to be naturally explained by the fact that they are dependent upon the return of the ulcer, disappearing as soon as it is cured by suitable treatment, and returning if errors in diet are committed. Menstruation and pregnancy also modify the pain of ulcer, — which fact is explained by the increased amount of blood in the pelvic organs at these times. The pains of ulcer are, in general, decreased in profuse menstruation and increased when there is a lessened menstrual flow; while in pregnancy, pain is sometimes entirely absent. It is also worthy of mention that vicarious menstruation sometimes occurs from the stomach. Kuttner and other authors have pointed out that these cases represent a diagnostic predisposition to ulcer, as exhibited by the locus minoris resisteniice in the mucous membrane of the stomach. Only when a peptic ulcer is situated at the cardia does epigastralgia occur immediately after swallowing. The appetite is, as a rule, quite good in ulcer-patients, but very frequently the fear of eating causes emaciation, which is inversely proportionate to the amount of food eaten. The bowels are generally constipated in ulcer of the stomach. DISEASES OF THE STOMACH 113 Vomiting is not a common symptom, although it usually occurs in severe cases a few hours after eating, if the food is too irritating in character. In regard to htematemesis and melsena: according to the statements of patients, these symptoms by no means occur in every case of ulcer, but, on the contrary, are relatively in- frequent. The history of patients to the effect that they have vomited blood, or have passed tarry stools, is of pathological value only when the blood vomited is of a dark color, or when epigastralgia has preceded the vomiting for a long period. Vomiting of blood without a preceding epigastralgia is typical, rather, of hemorrhage from passive hypersemia of the gastric mucosa, or of cancer. 2. The objective symptoms include, first of all, hemor- rhages, — provided that the physician has the opportunity to observe them; or the demonstration of occult blood in the vomitus or faeces, according to the method of Boas, which has been described in the General Section (see page 41). The second objective symptom of ulcer is a circumscribed tenderness in the epigastrium. To demonstrate this, the physician should exert strong pressure with the forefinger upon every part of the epigastrium, from the ensiform process to the umbilicus. From the state- ments, and from the facial expression of pain of the patient, the physician will usually locate the sensitive area. The sensitive area to the left of the tenth dorsal vertebra, which was first pointed out by Boas, is also an important finding which helps to establish a positive diagnosis. Diffuse sensitiveness to pressure o>n the back is without significance. The third objective symptom is hyperacidity of the gastric juice, which occurs in most cases of ulcus ventriculi. After the Boas-Ewalcl test-breakfast, it amounts to from 70 to 100, and to considerably more after the test-dinner. There are, however, a number of cases that have a normal acidity, especially recent cases, — which goes to prove, contrary to the assumption of many, that the ulcer is primary to the hy- perchlorhydria and that it is also the cause of the epigastralgia. 114 DISEASES OF THE DIGESTIVE CANAL A marked reduction of the total acidity of the Boas- Ewald test-breakfast, in cases of ulcer, should always awaken a suspicion of malignant degeneration of the ulcer. Ulceration of the duodenum causes precisely the same symptoms as ulcer of the pylorus, so that an absolute difTer- FiG. 24. Typical i)re-~\ire point in gastric ulcer. entiation is rarely possible. From a practical standpoint, however, this is not actually essential, because the treatment is the same in both diseases. Jaundice, appearing in a case of probable ulcer, renders the diagnosis more certain. Diagnosis. — In uncomplicated cases, the diagnosis of ulcer of the stomach from the symptomatologj^ is usually very easy. DISEASES OF THE STOMACH 115 In women in the chlorotic or climacteric periods of life, the diagnosis of ulcus chloroticum and dimactericum may always be made when epigastralgia occurs at a definite time after taking food, especially solids. These cases should be treated as ulcer, whether hsematemesis has occurred or not. Compression-ulcer, or ulcus decubitale, is diagnosed: (1) When the anamnesis gives an etiological factor; (2) when severe, cramp-like pains occur one to three hours after eating. The diagnosis of catarrhal ulcer is made in drinkers, smokers, and gormands, who present the above symptoms. The diagnosis of ulcer of the stomach is made certain if hsematemesis and melsena occur, or if the analysis of the gastric juice shows hyperacidity. The latter condition, in cases of chlorotic ulcer, cannot be determined, since it is unsafe to introduce the stomach- tube on account of the danger of perforation. All other symptoms are entirely accessory and subordi- nate to the above, with the exception of localized points of tenderness in the epigastrium, and in the area to the left of the tenth to the twelfth dorsal vertebra. , Differential Diagnosis. — In the differential diagnosis, hem- orrhage should be first considered. As already mentioned, hemorrhage from passive congestion in diseases of the heart, cirrhosis of the liver, vicarious menstruation from the gastric mucosa, and hsematemesis in pulmonary affections, must be differentiated from the hemorrhage of peptic ulcer. In connection with epigastralgia, we should especially consider the pain which occurs in three other affections: 1. Angina Pectoris. — The pain associated with this affection is fre- quently described by the patient as "stomach cramps." It occurs chiefly in advanced age, and in those with arteriosclerosis. The pain usually sets in after overloading the stomach, especially with flatulent foods ; after using coffee or tobacco; or after over-exercise. The pain in this disease, however, radiates to the left arm behind the sternum and the region of the heart. It does not occur with regularity, as in ulcer, and is generally independent of the nature of the diet. 2. Cholelithiasis. — In cholelithiasis, epigastralgia is paroxj'smal and sporadic. It comes on like a thunder-bolt from a clear sky; usually after 116 DISEASES OF THE DIGESTIVE CANAL mental excitement or errors in diet. The anamnesis in this disease also shows that there has been no regularity in the attacks. Patients suffering from cholelithiasis often describe such attacks of pain as "stomach cramps." [See editorial note on dyspei)tic symptoms of gall-bladder disease.] 3. Intestinal Colic. — The pain in intestinal colic is dependent upon the condition of the bowels. It occurs in constipation as well as in diar- rhoea, and the pain is usually relieved by a movement of the bowels, or by the escape of gas. (See details in the section on Intestinal Diseases.) In patients who suffer from chronic gastritis and intestinal catarrh, intestinal colic sometimes occurs a .short time after the partaking of indigestible food and cold drinks; it is produced reflexly and may easily be confused with the epigastralgia of ulcer. It persists, however, for a short time only and is always associated ivith disturbances of the intestine. There are, in addition, a considerable number of other affections that must always be considered in the differential diagnosis of epigastralgia, such as pancreatic calculi, emboli of the blood-vessels of the mesentery, lead colic, etc. The lim- ited space of this work will not permit a more detailed consid- eration of the diagnosis of these affections. The vomiting which occurs in ulcer of the stomach must be frequently differentiated from nervous vomiting, and from that which accompanies the gastric crises of tabes dorsalis. A great many other affections produce symptoms similar to ulcer, which explains why ulcer is so frequently diagnos- ticated when it does not exist, and vice versa. The most important diagnostic sign of gastric ulcer is the occurrence of severe, cramp-like, boring, or cutting pains in the epigastrium, which radiate to the sides and back and which ap- pear regularly at a certain time after meals. This is the only symptom of ulcer that may not be simulated by other diseases. Complications of Ulcer of the Stomach 1. Perforation. — This occurs but rarely, and then mostly in cases of chlorotic ulcer. It is for this reason that we advise the physician not to introduce the stomach-tube. The danger of perforation is proportionate to the amount of food in the stomach at the time of perforation; therefore, the earlier it occurs after eating, the more urgent the need of surgical treatment. DISEASES OF THE STOMACH 117 Perforations which occur in the empty stomach, how- ever, may be treated expectantly, for the reason that the empty stomach contains relatively few pathogenic micro- organisms.* [The improved surgical technic in the treatment of per- foration of gastric and duodenal ulcer, and the remarkable success in this field of surgery, scarcely justify the dependence upon expectant treatment in any case. If perforation of an ulcer occurs, it becomes a surgical affection, and operation should be resorted to within twelve hours, if possible. In data collected by Musser, the mortality following 182 cases, in which operation was performed from one to twelve hours after perforation, was 26.3 per cent.; while the general mor- tality in 481 operations performed from one hour to four weeks after perforation, was 34.3 per cent. In 55 cases without operation, the mortahty was 54.5 per cent.f] The most striking symptom of perforation is sudden abdominal pain. 2. Pyloric Spasm. — This is a very frequent compHcation of ulcer of the pylorus, and is caused in the same way as spasm of the sphincter ani in fissures of the anus. Pyloric spasm causes motor insufficiency, hypersecretion of gastric juice, and dilatation of the stomach, as will be described below. 3. Cicatricial Formation. — If scars occupy the region of the pylorus, and are situated in the duodenum, they also produce motor insufficiency of the stomach, hypersecretion, and ectasia. "Hour-glass stomach" also results from scar -formation [see Fig. 25]. 4. Perigastritis. — If the ulcerative process extends to the serous coat of the stomach-wall, adhesions to neighboring organs result, i.e., perigastritis. Such adhesions may impair * Perforation of the empty stomach occm-s, for instance, in clilorotic female servants who perform heavy labor, such as scrubbing, wasliing, cleaning windows, etc., early in the morning before breakfast. [t Musser. — Medical vs. Surgical Treatment of Gastric Ulcer. — "Trans- actions of the Congress of American Physicians and Surgeons," 1907, Vol. vii.] 118 DISEASES OF THE DIGESTIVE CANAL the motility of the pars pylorica, which in turn causes motor insufficienc}' and dilatation of the stomach. Adhesions between the fundus of the stomach and the neighboring organs, as a rule, do not cause any symptoms of importance. Fistula3 between the stomach and the trans- verse colon, and the formation of subphrenic abscesses also result from perigastritis. Fig. 25. SlefiosLso/' /^:/ori/A- Df/alaiio/i '^f\^^ S Hour-frlass contraction of the stomach, cicatricial stenosis of the pylorus and cardia with dilatation of tlie cc^^ophagus, secondary to multiple round ulcer of the stomach. [Courtesy of W. A. Edwaxds, M.D., Los Angeles.] 5. Malignant Degeneration of Ulcer. — Carcinomatous de- generation of ulcer often occurs in persons of advanced age. Ulcers of the pylorus and of the smaller curvature most fre- quently undergo malignant degeneration; and ulcers of the cardia, less freciuently. Ulcers caused by acute traumata of the stomach may also undergo carcinomatous changes; such cancers are, therefore, of traumatic origin. Cases are naturally observed, however, in which there is no positive evidence of the origin of cancer after trauma. DISEASES OF THE STOMACH 119 Treatment 1. Hygienic and Dietetic Treatment. — First of all, the causes which were responsible for the development of ulcer should be removed. Corsets and skirt-bands are forbidden; and the clothing should be supported entirely from the shoulders. Occupations which require constant pressure upon the epigastrium, and sitting in a bent-over position, must be given up. Diet: Leube's ulcer-diet is, at the present time, highly- esteemed. In the dietetic treatment of ulcer, four forms of food should be used; liquid, pappy, soft, and semi-solid. Each of these forms should be continued from seven to ten days. In addition, it should be mentioned that in persistent cases of ulcer, a prolonged fast must be observed. The nourishment in these cases should be given in the form of nutritive enemata. The following nutritive enema of Boas should be given three times daily: One-quarter litre of milk at the body-temperature; the yolks of two eggs; one tablespoonful of white flour; one tablespoonful of red wine, and a pinch of table salt, — to be well mixed by stirring. It is usually found that rectal nourishment cannot be continued indefinitely, as intertrigo ani is likely to occur. The first of the above mentioned forms of diet should be prescribed while the patient is at absolute rest in bed, for the reason that this diet will not furnish a requisite number of calories of food for the maintenance of the body. There are, naturally, severe cases of ulcer in which the individual forms of diet should be continued from two to three weeks, instead of the period mentioned above. As a rule, six meals should be given daily; two forenoon meals, a mid-day meal, two afternoon meals, and supper. Every patient, even the least intelligent, can easily follow out this treatment for himself. 120 DISEASES OF THE DIGESTIVE CANAL 1st Form. — The first form of diet should include the following foods: milk, milk and bread soups, tea with cream, or cocoa cooked with cream; the various cereals, — oatmeal, rice, wheat and corn-meal. Butter may be used with all foods. Patients of the better classes may, in addition to the above, use sanatogen, puro, malted milk, malted nuts, and the various artificial preparations of casein as substitutes for meat. In many cases very good results are obtained with the milk-diet, — two or three litres being used daily. 27id Form. — In the second period of the tlict, the patient may be given calves' brain, chicken and pigeon, as well as scraped ham; rice and sago in beef tea, various broths made from cereals, softened zwieback; and a liberal quantity of butter at every meal. Srd Form. — Fillet, mutton chops broiled or cooked rare in butter, boiled veal, roast chicken and pigeon, soft eggs, and purees of potato, spinach, carrots, green peas, asparagus and cauliflower with butter, and white bread. 4th Form. — This form consists of light breads, grits, cereals, rice pud- ding; such fruit sauces as raspberry juice and cherries; deer, partridge, and lean fish,^such as pike, perch, and trout. Sweet sauces prepared as purees may be used in this form, as well as in the second and third forms of diet. When all of these forms are well borne by the patient, he may gradually be given the ordinary mixed diet. It is necessary, for several months, however, to avoid coarse breads, fried potatoes, acids, pastries, cabbage, cheese, goose, duck, fat pork, ham, bacon, eel, salmon, legumes, and in short, all hard, indigestible foods. Small amounts of wine, slightly warmed and diluted with water, are allowed, as well as lemonade or raspberryade; while beer, and all other forms of alcohol, are interdicted. There are still a large number of patients who, on account of social conditions, are unable to have the advantage of the rest-cure, to carry out the proper dietary. In these cases, ambulatory treatment must be given in order that they may retain their vocations, etc. Patients undergoing an ambulatory treatment for ulcer, will, of course, become considerably reduced in weight during the first period of treatment. 2. Medicothermal Treatment. — Lavage is an unnecessary procedure in uncomplicated ulcer of the stomach, although DISEASES OF THE STOMACH 121 a few clinicians have attempted to control hemorrhage by lavaging the stomach with ice-water. Applications and compresses have long been used exter- nally. In acute exacerbation of ulcer, and in hemorrhage from the stomach, ice-compresses are indicated; while in chronic cases, hot applications, such as seed-meal poultices, etc., as well as thermal coils, offer good service. The compresses should be apphed during the entire day, as hot as possible, and replaced at night by a Priessnitz bandage. Should blistering occur from the hot applications, soothing salves and powders should be used. The physician will determine whether the compresses have been properly applied if the skin of the epigastrium shows a brown coloration. 3. Balneological Treatment. — In all forms of benign ulceration of the stomach, Carlsbad, Neuenahr and Vichy waters are indicated. Whenever it is possible, the patient should be sent direct to these watering-places. If this is not practicable, these waters may be used at home at a tempera- ture of about 35° R. [112° F.], — two glasses each containing about 200 c.c. in the morning, and one glass before the mid- day and one before the evening meal. Patients in poor cir- cumstances may be given the genuine spring-water salts or the artificially prepared salts in the same manner. Vichy water and salts should be given to those with weak constitutions. The mineral waters are to be used before meals, in order to affect directly the glands of the mucosa, rather than to neutralize the excessive acidity of the stomach, to accomplish which, alkalies should be given after meals. If there is a suspicion of malignant degeneration of the ulcer, i.e., if there are symptoms of ulcer combined with sub- acidity, — the mineral-water cure may be dispensed with. 4. Medicinal Treatment. — In the treatment of gastric ulcer, there are two drugs of especial value, — nitrate of silver and subnitrate of bismuth. As a general rule, the former should be given for acute chlorotic ulcer; and bismuth, in the other forms of ulcer, as per the following prescriptions: 122 DISEASES OF THE DIGESTIVE CANAL 1. J\ Sol. argenti nitratis — gr. viiss: oviss 0.5:200.0 M. ad. vitr. nigr. Sig. — One tablespoonful (porcelain) in a wineglassful of water, J to i hour before meals. 2. rj Bismuth! subnitratis, oiiiss 100.0 Sig." — One leaspoonful in a glass of warm water, stirred well, before breakfast. Lie on right side one-half hour after taking. These drugs generall}'' suffice in the treatment of patients who are able to take proper care of themselves. If pain is not relieved by the above treatment, it is best to prescribe belladonna combined with bismuth or an alkali, one or two hours after eating, as follows: 1. I^ Extract! belladonnse foliorum, gr. iii-v 0.2-0.3 Magnesii oxidi, Sodii bicarbonatis, fifi, 5vi 25.0 M. ft. Sig. — A teaspoonful one or two hours after meals, two or three times daily. 2. I^ Extracti belladonnre foliorum, gr. iii 0.2 Bismutlii subnitratis, 5iv 15.0 M. Sig. — A knifepoint of the powder after meals. If spasms of the pylorus complicate the clinical course of ulcer, from one-half to one wineglassful of olive oil should be given in the morning before breakfast, and from one to two teaspoonfuls before the mid-day and evening meals. The oil may be prescribed in the following manner to patients who have fastidious palates: I^ Tincturse belladonna? foliorum, oi-iss 5.0- 6.0 Olei amygdalae dulcis, oi-iss 30.0—10.0 Vitelli ovi unius or duo, Aqufe destillatse, q.s. adoviss 200.0 M. ft. emulsio. Sig. — A tablespoonful before eat- ing, t.i.d. (Hoppe, of Hanover.) I have successfully treated many cases of ulcer by the olive-oil treatment after other measures had been exhausted, especially in patients who had not taken the rest-cure.* * Good results from this oil-treatment, which I introduced, have been obtained in chronic ulcer, by Hoppe of Hanover, Wygodzinski of Beuthen, Van Lauwe of Roulers, Walkow of Prag, Roder of Berlin, and many others. DISEASES OF THE STOMACH 123 To neutralize the hyperacidity of the gastric juice, the mastication tablets, mentioned on page 100, should be used immediately after eating, — as well as sodium bicarbonate or magnesium ammonium phosphate, one or two hours after eating. According to the experience of Bourget, the follow- ing prescriptions are suitable: 1. I^ Sodii sulphatis, Sodii phosphatis, aa, gr. xxx 2.0 Sodii bicarbonatis, oii 8.0 M. ft. pulv. No. X. Each powder should be dissolved in one litre of water. The patient should drink 100 c.c. of the warmed solution, one or two hours after each meal. 2. I^ Extracti belladonnee foHorum, gr. iss 0.1 Magnesii oxidi, gr. Ixxx ,5.0 Sacchari, oiiss 10.0 Sodii citratis. oxi 40.0 M. ft. pulv. Sig. — A teaspoonfiil t.i.d. I have obtained very good results in the after-treatment , of ulcer by this method. Of the various alkalies, bicarbonate of soda would be preferably used if the patient's bowels are regular; while the salts of magnesia should be used in case of constipation, and calcium salts for diarrhoea, just as in acid gastritis (see page 99). ^ 5. Surgical Treatment. — Surgical procedures are to be resorted to in ulcer of the stomach in perforation and in per- sistent hemorrhage. On the other hand, surgical measures must very frequently be employed, as we shall see below, in the treatment of the various complications of ulcer, such as the removal of scar-tissue formation, and for the relief of the resulting complications. OUTLINE OF THE TREATMENT OF ULCER OF THE STOMACH I. Period of healing, about six weeks. A. Leube's rest and liquid-diet cure; when pos- sible, combined with the use of Carlsbad water, or its salts, and suitable medication. 124 DISEASES OF THE DIGESTIVE CANAL B. Ambulatory treatment, when Leubc's ulcer-treat- ment is not feasible. a. In chlorotic ulcer, silver nitrate from four to six weeks. 6. Subnitrate of bismuth from four to six weeks, in cases of chlorotic ulcer which have existed as long as a year, and also in the other forms of ulcer. c. Olive-oil treatment in severe epigastralgia and hyperchlorhydria, for several weeks. Milk of almonds may be used in lieu of the oil-treatment. Silver nitrate and subnitrate of bismuth and the oil-treatment should be given before meals; and the remaining medicaments, particularly belladonna and antacids, after meals. II. After-treatment, about forty days. A. Mineral-water cures at Carlsbad or Vichy, or conducted at home. Three or four glasses of water should be taken daily for from four to six weeks, combined with a bland, non-irritating diet. In this period, the secondary acid gastritis should be largely cured. B. Iron therapy in cases of chlorotic ulcer. III. Prophylactic period; about two or three months. For the prevention of the recurrence of ulcer, the use of milk of almonds before meals, three times daily, is indicated for a period of two or three months. The milk of almonds is prepared as follows: A tablespoonful of powdered sweet almonds is emulsified with one-quarter litre of hot water. When taken it should be warmed to 30° R. [100° F.] Patients with less fastidious tastes may use, instead, three times daily before meals, one teaspoonful of linseed oil, to which one drop of the oil of mentha has been added; or one- half wineglassful of oil may be given in the morning before breakfast. DISEASES OF THE STOMACH 125 I have arrived at the conclusion that relapses frequently occur unless after-treatment and prophylactic measures are strictly observed. IV. Acute hemorrhage: Rest in bed, application of ice-bags, swallowing of small pieces of ice, no food by mouth for two or three days, during which time nutrient enemata may be given. Iced milk may then be used and Leube's first diet-form may gradually be substituted. Of medicaments: lead acetate and opium, 0.3 (| gr.) of each, four times daily; stypticin, 0.3 (h gr.), three times daily; and liquor ferri, three to five drops in oatmeal gruel. In very severe hemorrhages, a subcutaneous injection of gelatin should be given. Hydrastinin and adrenalin may be tried internally. The newest remed}^ for hemorrhage, according to Klemp- erer, is estalin, an albumin preparation. Four or five tablets of estalin are dissolved in 100 c.c. of water and taken early in the morning on an empty stomach. 1. I^ Gelatini, oiss 50.0 Eleosacchari citri, 5 xi 45.0 Suprarenin (of a one per mille solution), gtts. Ixxx 5.0 Aquae destillatse, o xvss 4.50.0 Sig. — A tablespoonful every three hours. 2. R Hydrastininse hydrochloridi, gr. xlv 3.0 Aquae destillatse, iiss 10.0 M. Sig. — Fifteen to thirty drops several times daily. 3. R Ergotini, gr. xxx 2.0 Aquae destillatae, ii S.O M. Sig. — Fifteen to thirty drops several times daily. The further treatment of acute ulcer should be the same as that of chronic ulcer of the stomach. CLINICAL CASES 1. Chlorotic Ulcer Case 1. — Louise L., 19 years old, had suffered from violent gnawing, boring and burning epigastralgia, which radiated to the back, a half -horn- after eating solids. The pain continued for about one houi-. It did not occur l!26 DISEASES OF THE DIGESTIVE C.\NAL after taking liquids. Lying on the left side increased the pain, while the right-side position lessened it. There was a point in the epigastrium exces- sively sensitive to pressure. The patient was chlorotic. The appetite was good, but the patient was afraid to eat on account of the resulting pain. Treatment with Leube's ulcer-diet and bicarbonate of soda produced a permanent cure. Case 2. — Elsie G., a servant, 32 years old, had been chlorotic for the past four or five years. During this time she had periodical attacks of crampy, colic-like i^ain in the epigastrium. For about fom* weeks the patient had suffered from epigastralgia, which radiated to the left shoulder. The attacks of pain occurred one hour after the mid-day and evening meals. She had a good appetite. Physical examination revealed points of excessive tenderness below the xiphoid process and posteriorly to the left of the ninth dorsal vertebra. 2. Climacteric Gastric Ulcer Case 1. — Augusta P., a widow 49 years old, soon after the cessation of menstruation, began to suffer from hsematemesis, meltena, and regularly occurring epigastralgia one hour after a meal, especially of solids. Painful pressure-points anteriorly and posteriorly. Total acidity, 88. Case 2. — Adeline K., a laboring woman, 51 j^ears old, had passed the menopause eight years previous, since which time she had suffered from epigastralgia one hour after eating; had had frequent vomiting, and one attack of hipmatemesis. Total acidity, 102. Case 3. — Henrietta S., a cook .50 years old, who, previous to twenty years ago, had suffered from chlorosis and "stomach-cramps," but had remained healthy until the menopause. Five months later, the patient had experienced typical attacks of epigastralgia. Upon one occasion she vomited blood until she became unconscious. Meliaena followed. There was no hyperchlorhydria. 3. Pressure Ulcer, or Ulcera Decubitalia Case 1. — August K., a basket-maker, 52 years old, had suffered from epigastralgia two or three hours after the principal meal of the day, for the past two or three years. Upon one occasion there was melsena followed by unconsciousness. The attacks of epigastralgia were reheved by sodium bicarbonate and warm drinks. For several years, the patient's occupation had demanded that he sit in a bent position, with heavy pressure exerted against the epigastric region. The total acidity was 90. Cure resulted from rest in bed, the ulcer-diet, and the use of bicarbonate of soda and milk of almonds. Case 2. — Richard S., a shoemaker, 52 years old, had in his occupation subjected the epigastrium to heavy pressure ever since he was a young man. Eleven years previous to this time, the patient began to suffer from his DISEASES OF THE STOMACH 127 stomach. The first symptoms were epigastralgia and hscmatemesis. He resumed his work and there was temporary improvement. One year ago, he began to suffer from gnawing, cramp-Hke pains in the epigastrium four hours after meals, which were reheved by hquids. The appetite was good. He was unable to have rest during the treatment. The patient was put on an ulcer-diet and was given from two to three tablespoonfuls of olive oil before meals. There was an immediate improve- ment, and he did not suffer from acid eructations during the night. Eight days after commencing the oil-treatment, epigastralgia had ceased, in spite of the fact that the patient had continued his occupation, After errors in diet and after having given up the use of the oil, on account of the hot weather, there was a return of the ulcer-symptoms, which again immediately disappeared after the re-establishment of the oil-treatment.* 4. Ulcers and Erosions Following Acid Gastritis Case 1. — Ijeopold B., a merchant, 35 years old, gave a history of excesses in eating, smoking, and the use of alcohol. He had a good appetite and regular bowel-movements. For thirteen months he had suffered from violent attacks of epigastralgia one hour after light meals, and two to three hours after heavy meals, which were always immediately controlled by drinking warm milk. No improvement followed treatment with Carlsbad salts, belladonna and antacids. Total acidity of the test-breakfast was 125. The oil-treatment was then instituted, the patient taking one-half wineglassful in the morning, and a tablespoonful before luncheon and dinner. Following this, there was immediate relief. The patient was free from pain for six weeks, when there was a return of the symptoms after a meal containing Irish stew and griddle-cakes. After beginning the oil- cure again, the symptoms disappeared. The after-cure was carried out at Carlsbad. Appendix Erosions and Fissures of the Pylorus. — As has already been mentioned, erosions and fissures may occur in the mucous membrane of the stomach, just as in the mouth, lips, nose, cardia, and anus, which present clinical symptoms very similar to those of ulcer. These are not merely hypo- thetically present, but may be anatomically demonstrated. They are located chiefly in the pars jjylorica, or directly within the circumference of the pylorus. Proportionate to their min- uteness, they have a correspondingly greater tendency to heal * I could tabulate a long list of ulcer-cases among shoemakers, locksmiths, basket-makers, masons, etc. 128 DISEASES OF THE DIGESTIVE CANAL than ulcers of the stomach. Surgeons, especiall}', have demon- strated that erosions of the pylorus are frecjuentl}' the causes of {ndorie spasm, with secondary dilatation of the stomach. Etiology. — Fissures and erosions of the gastric mucosa are caused by the same factors as ulcers: on the one hand, chlorosis and circulatory disturbances; on the other, mechan- ical factors, — such as pressure exerted from without, and thermal influences. They occur, not infrequently, as compli- cations of acute infectious fevers, and they are especially freciuont in chronic acid gastritis caused by excesses in eating, drinking, and smoking. (See above.) Symptoms. — The most important symptom of erosions and fissures is a burning, drawing, and often cramp-like pain, which is felt some little time after eating. Patients, as a rule, experience relief immediately after the introduction of food into the stomach, or there may be a complete disappearance of the pain until from one to three hours after the meal, at which time gnawing, tormenting, burning pains recommence in the epigastrium. There is extreme sensitiveness to pressure, especially in smokers, which is frequently so intense as to result in actual parox3'sms of colic, which are not relieved until the patient vomits, either naturally or artificially, or unless he takes milk or an alkali to neutralize the excessive acidity of the stomach. While in ulcer, pain occurs, as a rule, only after eating sohds, the symptoms of erosion arise some little time after foods of any kind, even liquids, have entered the stomach. Pain is especially likely to appear after the enjoyment of a heavy cigar, or cold drinks such as beer and wine. Cases which have been cured relapse very frequently through just such errors. The physician may assume the location of the patho- logical lesions to be extra-pyloric when the epigastralgia is only of a burning character. If, on the other hand, the attacks are of a cramp-like nature, the location of the affection is usually in the pylorus. The eructation of acid fluids several hours after eating, at the time when the stomach should be quite empty, — ^there- DISEASES OF THE STOMACH 129 fore late in the afternoon or at night, — is a frequent symp- tom of erosion. All such patients suffer from pyrosis. Diagnosis. — The clinical differentiation between ulcer and erosions of the stomach is often very difficult and some- times impossible. It is made only ex juvantihus. Erosion of the stomach may be assumed, as a rule, if pain occurs several hours after eating, and is relieved by introducing any kind of food into the stomach, even a piece of bread. This does not occur in actual ulceration of the stomach. The estimation of the total acidity offers no criterion by which erosion may be separated from ulcer, since in the former the secretion is almost always above normal. The increased acidity is caused by two factors: In the first place, from the irritation of the glandular structures of the stomach caused by food stasis, resulting from spasm of the pylorus, two or three hours after meals; and secondly, the hyperchlorhydria occurring in acid gastritis, which may precede the erosion or be simultaneous with it, as the result of the inflammatory process of the mucous membrane. Hemorrhages also occur in erosions of the stomach, just as in ulcer, and may lead to a fatal termination. Many cases have been reported in the literature where erosions of the gastric mucous membrane were scarcely demonstrable, and yet were the cause of fatal hsematemesis. Complications. — When the erosion is situated directly in the pylorus, and causes pyloric spasm, hypersecretion and dilatation of the stomach will result, for the same reasons as in ulcer of the pylorus. Although these comphcations are caused more frequently by cicatricial stenosis of the pylorus, we shall see below that dilatation occurring as a result of pylorospasm is by no means rare. Scar-formation and perforation never result from ero- sions or fissures of the stomach, and there is not the same tendency toward malignant degeneration as in ulcer. Treatment. — The treatment is etiological and symp- tomatic. 9 130 DISEASES OF THE DIGESTIVE CANAL The etiological treatment deals with the removal of the factors which have caused the disease, especially smoking, cold drinks, and excesses in eating, particularly meat. Com- pression of the epigastrium should be avoided, such as is caused by wearing tight clothing, abdominal bands, or any factor through which pressure of hard objects is brought to bear against the epigastrium, as occurs in various occupations. Chlorotic girls demand, first of all, treatment of chlorosis, such as could be obtained by a stay at a chalybeate spring, such as Flinsberg, Pyrmont, Schlangenbad, etc. Patients who suffer from erosions and fissures caused by acid gastritis, should be sent to such a watering-place as Carlsbad, Neuenahr, or Vichy, where they may receive the treatment specifically suitable to their condition; or they may use the bottled water or the artificial salts in their homes. In persistent cases of erosions or fissures, the mineral water should be used uninterruptedly for from three to six months. For further details concerning these cases, the reader is referred to the chapter on Acid Gastritis. Erosions or fissures which are not caused by acid gastritis should be treated as light cases of ulcer. The treatment may be ambulatory, consisting of a bland, non-irritating diet and the use of antacids and olive oil. For this purpose, the physician should prescribe one-half to one wineglassful of olive oil at a temperature of 30° R. [100° F.] early in the morning before breakfast, and a tablespoonful before luncheon and dinner. In all cases suffering from epi- gastralgia during the night, the oil should also be given in the evening before retiring. The clinical records of patients given at the end of the chapter demonstrate that in persistent epigastralgia, when all other treatments have proved ineffectual, the use of olive oil has resulted in relief and final recovery. The use of oil would be less applicable in those cases of erosions in which the lesion was not situated at the pylorus and in which, therefore, the patient did not suffer from epigastralgia, but only from the burning sensation in the epigastrium. DISEASES OF THE STOMACH 131 For those who have a repugnance toward the use of the oil, the milk of almonds, which they can prepare at home, may be substituted (see page 124). The symptomatic treatment of erosions and fissures consists in the administration of an antacid before meals, such as bicarbonate of soda, magnesium salts, etc., in tea- spoonful doses, with or without the addition of the extract of belladonna. Bergmann's or Belloc's mastication tablets, one to three after eating, are also helpful. Great relief is obtained from the symptoms by the thor- ough mastication of hard bread-crusts after meals, whereby a large quantity of saliva is secreted and swallowed, which tends to neutralize the excessive acidity of the gastric juice. CLINICAL CASES Case 1. — Mr. S., a business man, 35 years old, had suffered periodically for five years from pressure and burning in the epigastrium after eating. Very late in the afternoon, he had cramp-Hke pains. The stools were regular. He had lost 14 pounds in weight. The patient traced his affection back to a period when he indulged in "over-nourishment." There had been fre- quent vomiting of acid liquids and food. The physical examination was negative. The test-breakfast, upon removal, contained much fluid, and its total acidity was 80. Remnants of ham which had been eaten the evening before were found. The treatment consisted in the ulcer-diet, the use of milk of almonds three times daily before eating, and belladonna combined with an alkaU three times a day, two hours before eating. It was impossible for the patient to go to bed for treatment. Ten days later he returned to the clinic, having suffered no pain and having gained one and one-half pounds in weight. After one month of treatment, he had gained three pounds, and had been entirely free from pain, except on one occasion when, after partaking of cakes and coffee, he had suffered from a burning sensation in the stomach. He had not been using any medication. The use of milk of almonds was advised, and later on Vichy water. Six months later the patient had gained six pounds in weight. Clinical Diagnosis. — Acid gastritis, with erosions of the fundus and pylorus. Hj^perchlorhydria, with occasional spasm of the pylorus, which led to temporary retention of food. Case 2. — Alphonse M., a merchant, 38 years old, was a hea\^ smoker, eater, and drinker. He was obese. For four or five years the patient had 132 DISEASES OF THE DIGESTIVE CANAL suffered from severe pjTOsis and burning pains in the stomach. For two or three years, he had had cramp-Hke pains in the epigastrium and behind the sternum quite frequently. Treatment. — Oil was prescribed in the morning before breakfast, and mastication tablets and an alkali after meals. Four weeks later, the patient reported that he still had occasional cramp-like pains. Then Vichy water, belladonna in pill form, and later on, milk of almonds, were prescribed, which caused the disappearance of the symptoms. On account of frequent errors in diet, the patient still suffered occasionally from heartburn. Case 3. — Mr. R., a merchant, 27 years old, was a heavy smoker. The patient had suffered periodically for a year and a half, from cramp- like pains in the stomach, two or three hours after meals, which were alwaA^s relie\'ed by eating again. He had always had a hearty appetite. Treatment. — Half a wineglassful of olive oil was prescribed in the morning and a cup of milk of almonds at noon and in the evening before eating. Belladonna, combined with an alkali, was given t'wice daily after meals. The patient was immediately free from discomfort in the stomach. The after-treatment consisted in the use of Vichy water. Permanent cure resulted. Case 4. — Mr. M., a business man, 43 years old, was a very heavy smoker, using twelve to fourteen cigars daily; a heavy eater, and obese. For four or five years the patient had suffered from burning in the epigas- trium after heavy meals. Temporary improvement had followed two mineral- water "cures" at Carlsbad. The physical examination was negative. The patient was given a bland, non-irritating diet, Vichy water, and the mastication tablets. He remained free from discomfort unless he indulged in smoking, the use of cold beer, greasy foods, heavy meats, — ^goose, etc., — which, in every instance, caused a return of the burning pain in the stomach. After another course of treatment at Carlsbad, and with a continued careful mode of living, the patient remained well. Case 5. — Inspector K., 39 years old, and very obese, in his history disclosed excesses in beer-drinking, eating, and smoking. For several weeks, the patient had suffered from burning and pressure in the epigastrium and oesophagus two or three hours after eating. Dn-ectly after meals, he would be free from discomfort. Total acidity of the test-breakfast, 112. jMeteorism. Thirty-two c.c. of gastric juice, with a total acidity of 80, were obtained from the fasting stomach. A complete clinical cure was effected by the use of Carlsbad salts, two or three teaspoonfuls daily before eating; and by giving up beer, tobacco, and heavy, greasy foods. Clinical Diagnosis. — Acid gastritis, with erosions of the mucosa (burn- ing pains), not located at the pylorus, since epigastralgia was not a symptom ; and also hypersecretion caused by the irritation of the digestive glands. DISEASES OF THE STOMACH 133 CLOSING REMARKS I am very well aware that often an exact diagnosis of erosions of the stomach cannot be made, beyond a probability. The existence of erosions and fissures of the pylorus is denied by many, in spite of which, for practical purposes, I should like to maintain the above-mentioned facts. At all events, I do not think that simple hyperchlorhydria, as such, in the absence of an anatomical lesion, — for instance, a gastric neurosis, — produces burning and cramp-like pains in the epi- gastrium. When these symptoms are present, an organic affection of the stomach or of a neighboring organ should always be thought of, and the therapeutic measures directed accordingly. Carcinoma of the Stomach General Remarks. — The etiology, the pathological anat- omy, the occurrence, frequency, hereditary influences, age- limits, etc., of cancer of the stomach, will not be discussed here. We shall consider only the significance and the relation- ship of gastric ulcer and traumata to gastric carcinoma. Malignant degeneration of chronic ulcer is quite fre- quent, especially in patients of advanced years. Beside the ulcer, the cicatricial formation of ulcer frequently gives rise to the development of cancer. The well-known carcinoma- tous ulcer, the symptomatology of which will be considered in detail later on, begins in this way. Cancer attacks individuals who have not previously suf- fered from stomach trouble or, as has already been mentioned, persons who have previously had ulcer. As a rule, patients suffering from other chronic stomach-affections are exempt. Concerning carcinomata, it may be said with certainty that acute, as well as chronic, injury exerts a decided influence in the development of gastric carcinoma. As a rule, the evolution of such a process is as follows: As a result of an injury to the stomach, a pressure-necrosis with an ulceration of the mucosa occurs, which later undergoes a carcinomatous degeneration. 134 DISEASES OF THE DIGESTIVE CANAL I emphasize this, for the reason that frequently [in Germany] the expert testimony of the physician must estab- hsh whether a carcinoma of the stomach is the result of traumatism or not. It is possible to trace the origin of a cancer to trauma, if the first symptoms of malignant disease of the stomach occur within a year or a year and a half after injury, — the patient having previously had good Fig. 2fi. Carcinomatous degeneration of an ulcer of the pylorus. [Courtesy of Dr. Stanley P. Black, of the Hendry.K Laboratory, University of Southern California.] digestion, and the injury having affected the region of the stomach itself ; in such a case, the physician may often state that it is his conviction that trauma has been an etiological factor in the production of the cancer. On the other hand, it would not be possible to associate an injury received several years previously, especially to some other part of the body, with a subsequent carcinoma of the stomach. General Symptomatology and Diagnosis. — Cancer some- times develops acutely, but as a rule, almost always slowly and without warning, beginning with loss of appetite, repug- nance toward meats, feeling of nausea, lassitude, lack of DISEASES OF THE STOMACH 135 desire to work, increasing weakness, emaciation, anaemia, and cachexia. The tongue is always coated, proportionate to the poor- ness of mastication and the diminished amount of food eaten. Later on, pressure in the epigastrium occurs, especially after eating hard foods, just as in chronic gastritis. And still later on occur cramp-like pains, depending upon whether the car- cinomatous lesion is located at the pylorus, or not. In these cases, there is vomiting, — the vomitus, on ac- count of the mixture of the food with blood, presenting a black-brownish, ''coffee-ground" appearance. In the terminal stage of cancer of the stomach, — when cachexia is marked, — fever, hydrsemia, and with these albu- minuria and oedema of the ankles occur. The physician must always keep in mind the fact, how- ever, that in individual cases the appetite may be retained for a long time; and especially that the patient may not experi- ence a repugnance toward meat; and above all, that fre- quently in carcinoma, vomiting is not a symptom. These are the cases in which neither the inlet nor the outlet of the stomach is involved. Likewise, haematemesis or melsena may never occur. When the cancer involves the pylorus, symptoms of pyloric obstruction, with stagnation of the stomach-contents, naturally occur. Whether gastrectasis follows malignant obstruction of the pylorus or not, depends largely upon the appetite. Patients with good appetites, who eat freely and vomit little, are the ones most likely to suffer from secondary dilatation of the stomach; while, on the other hand, there often occurs a contraction of the entire stomach in those patients who eat little, and especially if the food is vomited. Atrophy of the stomach is especially frequent in carcinoma of the cardia. The secretion of gastric juice in cancer of the stomach is, as a rule, totally lost, so that from the clinical standpoint the findings are exactly those of atrophic gastritis. Hydrochloric acid, rennin, and pepsin are almost, or completely, absent. The test-breakfast furnishes the picture of achylia gastrica. 136 DISEASES OF THE DIGESTIVE CANAL An exception to these findings occurs in carcinoma result- ing from malignant degeneration of an ulcer, in which free hydrochloric acid ma}^ be demonstrable up to the end of life. Lactic acid is found only in those cases of cancer in which there is stagnation of the stomach-contents, resulting from carcinoma of the pjdorus, as soon as the atrophy of the mucous membrane has progressed far enough so that measurable amounts of hydrochloric acid are no longer secreted. Uft'elmann's [or Strauss's] lactic acid tests are, therefore, not positive in all cases of cancer of the stomach, because not all such give rise to food-stagnation; and besides, the motility of the stomach may be normal if the cancer docs not involve the pylorus. The Boas-Ewald test-meal has a total acidity of from 6 to 8 in cases of carcinoma unassociated with food-stasis. But if there is stagnation of food, the total acidity is higher, for the reason that the fermentation acids, — especially lactic and acetic acids, — are also present. The bowel-movements are usually sluggish, correspond- ing to the lessened consumption of food. Diarrhcea occurs only if a complication develops, such as a fistula between the stomach and the colon. Diagnosis. — In the beginning of the affection, diagnosis is very difficult; and in many cases, only a probable diagnosis can be made. Naturally, the diagnosis becomes quite posi- tive if a large, irregular tumor can be palpated in the epi- gastrium. There are, however, many cases of cancer in which no tumor can be felt during the entire life of the patient. This occurs most frequently in men who have normal habitus, with a wide costal angle and firm abdominal walls. In these cases, if the tumor is not situated in the left hypochondrium behind the ribs, it will usually be hidden behind the left lobe of the liver and so closely adherent to the latter that it cannot pro- ject below the fiver-edge far enough to be subject to palpation. In case the physician is able to palpate a tumor, he must, first of all, determine whether it is hard, knotty, and irregular, or whether it is smooth, and if he can outline its borders. DISEASES OF THE STOMACH 137 Benign tumors of the epigastrium, — such as cysts, dis- tended gall-bladders, and hypertrophy of the pylorus, — are, as a rule, smooth and not very hard. It is important, above all, to determine the respiratory movability of the tumor; whether it is fixed, i.e., whether it rises and falls during respiration. In case it rises during expiration, it is very probable that the tumor is adherent, especially to the liver. Tumors which are limited to the stom- ach are usually stationary. In the latter cases, surgery offers better chances for cure than in the former; and the physician should, therefore, advise early operative procedures. Close attention should, of course, be given to the degree of sensitiveness to pressure of such tumors, and the physician must never neglect to examine closely the liver and the regional lymph glands of the groin and clavicle for possible metastases. Differential Piagnosis.— Tumors in the epigastrium, in the majority of cases, are carcinomatous. There are, how- ever, also benign tumors of the stomach, pancreas, and liver, such as cysts, polyps, gummata, concretions, and hydatids; and besides these, the physician must always keep in mind the possible existence of malignant tumors of the neighbor- ing organs, such as the pancreas, colon, liver, and the retro- peritoneal lymph glands, although these, on the whole, are quite rare. DIAGNOSIS OF CARCINOMA OF THE STOMACH BEFORE IT IS POSSIBLE TO LOCALIZE THE TUMOR BY PALPATION Carcinomata of the stomach, from the standpoint of practical diagnosis, are divided into three large groups: pyloric, cardiac, and extra-ostial. Each of these groups presents such characteristic signs and symptoms that their differentiation is proportionately easy. Cancer usually has its origin in some point of the lesser curvature, which agrees with the hypothesis of the mechanical theory of the etiology of cancer, because the lesser curvature is most exposed to mechanical, thermal, and chemical injuries from the swallowed ingesta. 138 DISEASES OF THE DIGESTIVE CANAL The accompain'ing illustration (Fig. 27) explains the developmcjit and progress of carcinoma of the stomach. Assuming that the tumor begins at a point in the lesser curvature, the proliferation of the cancer may extend in three different directions: first, toward the pylorus, which happens most frequently; second, toward the anterior or the posterior wall of the stomach; third, toward the cardia, which is rela- tivel}' the most infrequent of the three. It is self-evident Fig. 27. Diagram showing the development and progress of cancer of the stomach. that there are many cases of carcinomata in which the lesion involves, primarily, the pylorus, its neighborhood, or the cardia. It is very easy to point out how these forms develop quite different and characteristic symptoms. 1. The Tumor Beginning at or Proliferating toward the Pylorus. In these cases, stagnation of the stomach-contents is the dominating feature of the clinical picture. Food-stasis manifests itself by the vomiting of large quantities of. food, and especiall}^ of food which the patient has eaten on preceding days. For instance, when the patient vomits such food as rice, fruit, or remnants of vegetables, which he states he has eaten several days previously, the diagnosis of stasis, and therefore of narrowing of the stomach outlet, may be made. The diagnosis of stasis will be more DISEASES OF THE STOMACH 139 certain if the physician is able, by the use of the stomach- tube, to obtain food-remnants from the stomach of the patient early in the morning before breakfast. a. Stagnating Foods which Contain Free Hydrochloric Acid. — In these cases, there exists either a benign obstruction or an obstruction caused by a carcinomatous degeneration of chronic ulcer. Sometimes the differential diagnosis between these is only possible by long clinical observation. As a rule, in obstructions due to carcinomatous ulcer, there is a lessened or rapid diminution in the amount of hydrochloric acid secreted; while in benign stenosis, there is an increase in the amount of hydrochloric acid. In both conditions, a microscopical examination will show the presence of sarcinse and yeast-cells. In primary carcinoma of the pylorus, hydrochloric acid will also be found in the stagnating contents of the stomach, b. Stagnating Stomach-Contents which Contain Lactic Acid, hut no Free Hydrochloric Acid. — In these cases congo paper shows only a weak, dark coloration, but never the blue tone given by free hydrochloric acid. The lactic-acid test is positive (see above). Microscopically, sarcinae are absent, but the field of the microscope is overrun with the long, thread-like Oppler- Boas bacilli. In rare cases both bacilli and sarcinse are present. Stagnating stomach-contents containing lactic acid are obtained almost exclusively from patients suffering from carcinoma of the pylorus, or carcinoma of some of the neigh- boring organs, which, from pressure, narrows the stomach- outlet. An exception to these is the stenotic gastritis of Boas, a form of chronic catarrh of the stomach, which has already been discussed in the chapter on Chronic Gastritis. Stenotic gastritis is extremely rare, and, so far as diagnosis is concerned, demands little consideration, and for treatment scarcely any, because this form of gastritis, just as carcinoma of the pylorus, requires resection, or gastro-enterostoni}^, etc., if the life of the patient is to be prolonged. 140 DISEASES OF THE DIGESTIVE CANAL Summary. — If, in a suspected case, a tumor is palpable and renuiants of old food are obtained from the fasting stomach, the ph^'sician may assume, with the greatest prob- ability, the presence of carcinoma of the pylorus or pars pylorica, especiall}^ if the contents of the stomach show either lactic-acid fermentation, as in primary carcinoma, or con- siderable diminution in the secretion of hydrochloric acid, as in carcinomatous ulcer. Such cases should be, as earl}" as possible, referred to the surgeon, who, after opening the abdominal cavity, will decide which operation or procedure is indicated. II. Carcinomata Developing Extra-ostially, Producing There- fore no Symptoms of Stenosis at the Pylorus or Cardia In these cases, as a glance at the diagram will show, no obstruction at the pylorus exists, therefore there is an absence of symptoms of stasis or motor insufficiency of the stomach. The findings of the test-breakfast can scarcely be differen- tiated from the contents obtained from the stomach in atrophic gastritis. In both, hydrochloric acid, rennin and pepsin are nearly or completely absent. The test-breakfast is achylous. The microscopical examination of the material obtained from the fasting stomach usually gives, however, suggestive points in regard to the lesion, viz., the presence of large numbers of red and white blood-corpuscles; sometimes also of amoeba, infusoria and fetid material, besides the sputa, histological constituents of the mucous membrane of the mouth and oesophagus, such as epitheha, etc. Therefore, in suspected cases, in w^hich there have been progressive cachexia, loss of appetite, pressure in the stomach, though wdth no stagnation of the stomach-contents, and where achylia gastrica is present, the physician should examine the contents obtained from the fasting stomach with the greatest care. As a rule, only a few cubic centimetres will be obtained from the stomach in introducing the stomach- tube, and these contents should be blown out of the end of the stomach-tube into a receptacle for examination. DISEASES OF THE STOMACH 141 Mistakes arc also possible here, for the reason that blood- and pus-corpuscles also occur in benign atrophic gastritis, though not in so great numbers. In malignant cases, the pus can usually be seen macroscopically. The RhodankaHum reaction of the saliva is also said to be absent in carcinoma (see page 96). According to Boas, the examination of the faeces for occult blood is very important in all such cases. If the exam- iner finds a positive test for occult blood in the feeces of a patient with achylia, who has for three days been on a hsema- globin-free diet, it is in the highest degree probable that a latent extra-ostial carcinoma of the stomach exists. In the examination for occult blood, — the technic of which is given on pages 41 and 252, — it is scarcely necessary to mention that it is essential to exclude the origin of the blood from hemorrhoids, etc. III. Carcinomata Developing at the Cardia or Prolifer- ating toward It In these cases, difficulty in swallowing always occurs, in addition to the general symptoms of cancer. Upon introducing the stomach-tube, an obstruction is en- countered about 40 cm. from the incisors. On being removed, the tube is frequently covered with blood and fetid pus. In these cases, stagnation of the stomach-contents and lactic-acicl fermentation are absent, for the same reasons as in extra-ostial carcinomata. Stasis of food within the oesophagus with lactic-acid fermentation may, however, occur. A tumor of the cardia can rarely be palpated, because of its position behind the liver and the costal cartilages. A close clinical observation of all these symptoms makes it possible for us to follow, accurately, the progress and development of cancer of the stomach, even in those cases in which we are unable to palpate a tumor. It is self-evident, however, that there will always be cases in which the symptoms are only those of achylia gastrica m DISEASES OF THE DIGESTIVE CANAL and general cachexia, when the diagnosis of cancer cannot be established bej^ond a certain probability. With the application of these diagnostic i)rinciples, we have shown, therefore, that even in cases in which a tumor is not pali)ablc it is relatively easy — first, to make a diagnosis Fig. 28. Cancer of the cardia producing stenosis. [Courtesy of Dr. Stanley P. Black, of the Hendryx Laboratory, University of Southern California.] of gastric cancer as such; and second, to determine its loca- tion, the knowledge of which is always essential to the internist in establishing the correct indication for medical treatment or surgical interference. If the tumor is palpable in the epigastrium, the physician can determine, by the distention of the stomach with gas or air, whether it belongs to the anterior or the posterior wall of the stomach, or whether it lies behind the stomach. Tumors DISEASES OF THE STOMACH 143 of the anterior wall of the stomach become more distinct after distention, while those of the posterior wall entirely disappear. To inflate the stomach, the physician should use, by preference, a thin stomach-tube with a diameter of 8 or 9 millimetres, with an ordinary inflating bulb. Distention of the stomach with the well-known effervescent powders should be avoided, for the reason that the carbon dioxide gas gener- ates so suddenly and violently that syncope and perforation of the stomach-wall might easily occur. THE CLINICAL COURSE OF CANCER OF THE STOMACH Carcinoma of the stomach generally causes death from exhaustion within one or two years. Carcinoma of the pylorus causes a fatal termination sooner, on account of the resulting obstruction at the pylorus, which prevents the chyme from entering the intestine. Emaciation in these cases is, therefore, more rapid, and death naturally occurs much earlier. Sudden and fatal termination may also result from severe hemorrhage. The clinical symptoms of some cases of cancer of the stomach are so latent, and so few of a localized nature appear, that the disease closely resembles progressive pernicious anaemia. The autopsy findings alone will establish the diagnosis. COMPLICATIONS OF CANCER OF THE STOMACH Apart from metastases into the liver and the regional lymph-glands, and adhesions with neighboring organs, which almost invariably occur in carcinoma of the fundus of the stomach, fistulse sometimes form between the greater curva- ture and the transverse colon. With this complication, either feculant vomiting or a lienteric diarrhoea occurs. The forma- tion of secondary abscesses in the peritoneum with external perforation is sometimes observed, as well as subphrenic abscesses. We have sufficiently emphasized the fact that secondary dilatation of the stomach frequently results from cancer of the pylorus. 144 DISEASES OF THE DIGESTIVE CANAL TREATMENT OF CANCER OF THE STOMACH a. Internal Treatment. — The internal therapy of carci- noma of the stomach is not so ineffective as might ap})ear, considering the malignant nature of the affection. Although we are not in a position in any sense to bring about a cure or to lessen its progressive tendency, we are, nevertheless, able at the present time to remove or lessen the suffering of the patient and considerably to prolong life by maintaining the physical strength of the patient, provided his financial condi- tion permits of his having the best care and treatment. The treatment is dietetic, mechanical and medicinal, and should be directed entirely according to the location of the lesion. Dietetic Treatment. — In carcinoma of the pylorus, if the resulting stenosis is not already of sufficient severity to demand operation, the diet must be adapted to the degree of obstruction, in order to prevent the patient from starvation. It should, therefore, be of liquid or semi-solid consistency, and rich in liquid fats. (Butter, cream and olive oil.) In carcinomata not involving the pyloric region, the treatment will not differ from that of atrophic gastritis. In these cases, an operation is generally useless, — not only useless, but a surgical error, since the attempt at a radical removal of the cancer is usually hopeless in such conditions. When the motility of the stomach is quite normal, excel- lent results are obtained through dietetic measures, the patient still being able to enjoy many of the pleasures of the table. An increase in weight of from 10 to 20 pounds by adherence to a rational diet is not unusual, even after a posi- tive diagnosis of cancer has been made. I have seen such a result in several cases. For instance, a recent patient, after a few months of treatment and a rational diet, was able to indulge in such pastimes as hunting. Of course, such improve- ment was only temporary, continuing at the very longest for from six to nine months, when the progress of the disease and cachexia again took place. 9; :15 (I 12:00 M. 3; ;00 P.M. 5: :30 11 DISEASES OF THE STOMACH 145 The dietary in such cases shouhJ be directed about as follows : 7:00 .\.M. Milk soup, cooked with cream and butter. Biscuits with butter. Tea and cream, butter-rolls, scraped ham and a soft egg. Rice broth or soup; puree of spinach, carrots, or peas; chopped chicken, boiled calves' brain or fish; and some sweet fruit-sauce. Cocoa with cream, and butter-cakes. A cereal soup or broth, containing much butter. 7:15 " Tea with plenty of cream, scraped ham, and butter-rolls. The art of the chef will be taxed to arrange suitable variations in the diet. For instance, — lean fish, cooked in butter, makes a pleasing substitute in the well-known repug- nance of cancer-patients toward meats. In carcinoma of the cardia, the semi-solid and liquid forms of diet should be given, as in cancer of the pylorus. A gain in weight is no more to be expected here than in cancer of the pylorus, because the patient cannot be properly nourished. Mechanical Treatment. — Mechanical treatment is to be resorted to only in carcinom^a of the pylorus. The stomach should be washed out every morning, after which 75 to 100 c.c. of warm olive or almond oil should be introduced. If the stenosis is not of a high degree, the stagnation of the contents of the stomach will soon be lessened by this treatment, pro- vided the diet is adapted to the degree of stenosis present. The most important indications to be fulfilled by lavage and the oil-treatment are the relief of pyloric spasm, boring pains ill the stomach, and offensive eructations, — by which changes the appetite of the patient is often greatly improved. Cardiac and extra-ostial carcinomata require no mechanical treatment, especially since former attempts, — to dilate malig- nant stenosis of the cardia and to introduce a permanent cannula, — are no longer resorted to. Medicinal Treatment. — The medicinal treatment has in view, first of all, the iricreasing of the appetite, the improving of the digestion, and the relief of the suffering. 10 146 DISEASES OF THE DIGESTIVE CANAL These indications arc accomplished, as a rule, by the use of the- following prescriptions: 1. TJ Extract! condurango fluidi, oii 00.0 Sig. — One-half to one teaspoonful before meals, t.i.d. 2. !> Extracti cinchonce fluidi, oi 30.0 Sig. — Twenty drops t.i.d. 3. I^ Tincturse belladonna? foiiorum, oiiss 10.0 Tincturae gentianse, 5>^i -lO.O M. Sig. — One-half teaspoonful before meals, t.i.d., in carcinoma of the pylorus. 4. I^ Acidi hydrochlorici diluti, oiiss 10.0 Tincturse rhei, ov 20.0 M. Sig. — Thirty drops in a wineglassful of water after eating. The artificially prepared foods, — such as somatose, eucasin, puro, Valentine's meat-juice, sanatogen, etc., — are satisfactor}^ substitutes for meat. Three or four teaspoonfuls of an}^ of the above should be given daily, preferably cooked in milk or soup. The various infant-foods are also valuable. In general practice, I frecjuently prescribe pancreon, just as in benign atrophy of the mucous membrane. b. Surgical Treatment. — Three surgical procedures should be considered, — namely, gastrotomy, resection of the pylorus, and gastro-enterostomy. Gastrotomy should be performed in carcinoma of the cardia or of the lower portion of the oesophagus, when the cancer has caused almost complete atresia and the patient vomits eveiy thing that is eaten, including liquids. In extra-ostial carcinomata, operative procedures are generally contraindicated, for the reason that the life of the patient is maintained equally as long by internal treatment; furthermore, cancers which do not involve either orifice of the stomach are not often recognized at a time when total extirpation is possible. The proper domain of the surgeon is carcinoma of the pylorus, — which, unfortunately, is too often not operated on early enough, at a time when radical removal is possible. DISEASES OF THE STOMACH 147 The physician is in duty bound to consider operation in every case of cancer of the stomach in which there is stagna- tion of the stomach-contents with lactic-acid fermentation. By so doing, he will avoid merited censure for culpable delay and neghgence. It is unfortunate that patients so frequently refuse operative measures until internal treatment, — such as lavage, etc., — have proved ineffective, when it is often too late. It should always be left to the decision of the surgeon, after he has opened the abdominal cavity, whether he will perform a radical operation, — such as resection, — or a gastro- enterostomy, as a palliative measure. If the tumor has not proliferated, and no metastases into the liver and lymph- glands have occurred, resection should be attempted; other- wise, gastro-enterostomy is the proper procedure. It is now well known that such patients, if they survive the operation, often increase in weight from 30 to 40 pounds within a few months, and even live several years without gastric discomfort. Cases have been reported in which no return of the symptoms occurred five or six years following operation. [Both Kocher's and Robson's mortality in gastrectomy, up to the present time, is 15 per cent.; while the Mayos have a mortahty of only 10 per cent. In their last twenty- five cases of gastrectomy, there was only one death. Robson has recently collected data on 27 cases of gastrec- tomies, of which 10 were living at periods of 8, 7, 6, and down to 2 years after operation.* In view of the fact that such results are being obtained by the surgical treatment of gastric carcinoma, it would appear that the internist who fails to give his patient the advantage of early operation is assuming an unwarranted responsibility. Early diagnosis and good surgery are the requisites in the treatment of cancer of the stomach.] * [Keen 's ' ' Surgery, " 1 907 .] 148 DISEASES OF THE DIGESTIVE CANAL CLINICAL CASES Extra-ostial Carcinoma Case 1. — Von M., an editor, 50 years old, had for five or six years suffered from dyspepsia which was diagnosed as "atrophic gastritis." The mineral water "cure" at Kissingen had proved highly beneficial, and the patient had remained in good health until eight months ago, since which time he had experienced loss of appetite, pressure in the stomach, no pain, occasional vomiting, and emaciation. Tumor was not palpable. There was extreme emaciation. The fasting stomach contained blood and pus, but no food. The patient was put to bed, and he improved on a puree diet rich in butter, and the use of hydrochloric acid. He gained in weight from 1.52 to 1G7 pounds, was able to resume his work and even to enjoy the sport of hunting. One year later, however, the patient died from cachexia. Case 2. — Bertha H., a housekeeper, 49 years old, had been sick with "catarrh of the stomach," jaundice, loss of appetite, diarrhoea, and gradual aggravation of the symptoms for one year. At the time of examination, the patient had severe gnawing and cramp-like pains in the epigastrium after eating. She was markedly emaciated and cachectic. No tumor was palpable. The fasting stomach contained mucus and pus-corpuscles. The test-breakfast was achylous, the total acidity being 5. The treatment consisted of a puree form of diet, rich in butter; and the use of hydrochloric acid. During the following month, the patient improved and increased 20 pounds in weight; but died seventeen months later from cachexia, at which time a tumor was palpable. Carcinoma of the Pylorus Case 1. — Ernst S., a merchant, 55 years old, had been healthy until five weeks before the first symptom, since which time he had had a poor appetite and had suffered from frequent vomiting after eating solid foods. The stagnating stomach-contents, — for instance, grapes, which had been eaten a few days before,— were also vomited at times. The bowels were regular. He had suffered from pressure and a gna^\^ng sensation in the epigastrium after eating solids. Previous to his illness, the patient had always had good digestion. The physical examination showed that the patient was a strongly-built man. He was sallow and emaciated. No tumor was palpable. The greater curvature extended to the level of the umbilicus. Stagnating foods were obtained from the stomach which had an odor of hydrogen sulphide gas. Free hydrochloric acid and also sarcina? were present. The total acidity was 52. Lactic acid was absent. The treatment consisted of a suitable diet, the use of condurango, and lavage of the stomach. After ten days, there was no stasis of food, and pain had disappeared. Free hydrochloric acid was present. No tumor DISEASES OF THE STOMACH 149 was palpable. Six weeks later, the patient had increased seven pounds in weight. He remained in good condition on a puree diet without lavage treatment, and resumed his occupation. Two months later, the test-supper was given and lavage in the morning showed that there was stagnation of the stomach-contents, with lactic-acid fermentation. Oppler-Boas bacilli and a few sarcina? were present. During the next four weeks, the patient increased three pounds in weight. During the summer after indulging in errors in diet, he suffered from diarrhoea and lost ten pounds in one week, after which he improved again and gained six pounds in weight. While travelling and taking his meals in restaurants, he ate a meal of veal cutlets, returned to his home ill, and died within two weeks, — just eleven months after commencing treatment. There was atresia of the pylorus. A tumor, after considerable emacia- tion had occurred, was palpable. Carcinomatous Ulcer Case 1. — Ernst H., a laborer, 58 years old, had had hsematemesis, preceded and followed by cramp-like pains in the epigastrium, with vomit- ing. He had remained well until two weeks previous. The present illness began with pain in the stomach, vomiting, and icterus. The patient was emaciated aud cachectic. A tumor, the size of the fist, was palpated in the epigastrium. There Avas no stagnation of the stomach-contents. Case 2. — Carl T., a teamster, 52 years old, had suffered three years previous from epigastralgia, ha^matemesis, gastrosuccorrhcea, and hyper- chlorhydria. (Total acidity was 90.) Symptoms had disappeared through dieting and the oil-treatment. Four weeks ago, the patient suffered a relapse, with stagnation of the stomach-contents and vomiting. At first, lavage and the oil-treatment were beneficial. In the course of the following six or eight weeks, the hyperacidity of the gastric juice passed into subacicUty. Sarcinte, which had been present, were then absent. Patient at first refused to undergo an operation, and died six days after surgical treatment was finalh^ resorted to. The autopsy showed the presence of a carcinomatous ulcer of the pylorus. Case 3. — Ernst P., an inspector, 44 years old, had had periodical attacks of epigastralgia for twenty years, usually in the spring and autumn. Three years previous, patient had metena. For six months past, he had suffered constantly from gnawing and cramp-like pains in the epigastrium, which were especially severe after eating sohds. No tumor was palpable. Blood, pus, and mucus were obtained from the fasting stomach. The test-breakfast was entirely achylous. The patient was cachectic. Case 4. — Emma S., a laboring woman, 37 years old, had had symp- toms of gastric ulcer, — gnawing, cramp-hke pains, vomiting of blood, and heartburn, — for fifteen years. She had been temporarily relieved by Leube's 150 DISEASES OF THE DIGESTIVE CANAL ulccr-curc. A cicatrization of the ulcer had occurred, which caused food- stasis. Castl'o-onterostoniy was performed, which was followed by a dis- appearance of all symptoms for two or three years, patient gaining consider- ably in weight. But after this period, a tumor, as large as two fists, gradually developed behind the laparotomy cicatrix. She died later from cachexia. Epigastric Hernia The epigastric hernia? are found in the hnea alba, vary- ing in size from a pea to a hazel-nut. These herniic usually consist of only the fatty tissues of either the greater or the lesser omentum. It is very rare for a coil of the intestine to be a part of such a hernia. Epigastric hernise result from direct blows against the abdomen, lifting heavy weights, or subjecting the abdominal muscles to sudden tension, or severe coughing spells. The fis- sure occurring in the fascia is always transverse, never vertical. Symptoms. — The most prominent symptom of epigastric hernia is the occurrence of severe pain when lifting, coughing, sneezing, straining, etc. This pain is caused by strangulation of the omentum, and generally disappears when the patient assumes a recumbent position. Frequently these hernise produce no symptoms. Objectively, the physician can diagnose the hernia very easily if he directs the patient to cough during the examination. Diagnosis. — The diagnosis of epigastric hernise is usually very easy, if the phj^sician has in mind the possibility of the occurrence of such hernise. The affection may be confused with other kinds of hernia?, attacks of colic, appendicitis, and particularly ulcer of the stomach, especially when in epigastric hernia the lesser omentum becomes incarcerated in a fissure of the fascia in the neighborhood of the pylorus. In this condition, the pains, which are similar to those of ulcer, occur regularly two or three hours after eating, at a time when the omentum is subject to the greatest traction and disturbance from the active movement of the pylorus. Careful inspection, however, will usually prevent confusion in the differential diagnosis of the two affections. DISEASES OF THE STOMACH 151 Treatment. — The physician should first reduce the hernia and then apply a hernia bandage, or adhesive plaster, as in fracture of the ribs, using care to avoid strong tension of the abdominal muscles. It may be necessary to give morphine to prevent attacks of coughing. Naturally, irreducible hernise are frequently encountered, from which rehef can be obtained only by surgical treatment. CLINICAL CASES Case 1. — Otto G., a merchant, 30 years old, had suffered for six or seven weeks from pains in the region of the stomach, especially after lifting, bending, or reaching high. Nothing that the patient ate disagreed with him. There was a sm.all gastric hernia, which was treated by bandaging and the application of iodine, and a cure resulted. Case 2. — Mr. 0., a shipping clerk, 40 years old, had suffered for two years from violent pains in the region of the stomach, about two hours after eating. The pains always disappeared if he assumed a recumbent position. The patient had hyperchlorhydria, the total acidity of the test-breakfast being 70. Two epigastric herniae, about the size of peas, were found. The subsequent history of the case is unknown, as the patient did not retm-n to the clinic, — having been advised to undergo a surgical operation. Qastrectasis (Stenosis of the Pylorus, Mechanical Insufficiency, Vitium Pylori or Duodeni) Definition. — At the present time, we understand the expression, "dilatation of the stomach," to mean that form of gastric disturbance in which the stomach is unable to empty itself of its contents, with a resulting persistent stagnation of food. The location of the greater curvature is, in itself, irrel- evant in the diagnosis of dilatation of the stomach. The question is not as to the size of the stomach, but only as to its motor function. The term "gastrectasis" originated at a time when physicians had not learned to recognize the initial stage of the affection, but only its final stage, — dilatation of the organ, — and this was considered the most significant symptom of the disease. When we use the expression, ''dilatation of the stomach," therefore, we must from the outset be clear that we mean only the symptom of an actual disease, rather than a disease per se. 152 DISEASES OF THE DIGESTIVE CANAL To make the condition quite clear, a comparison of the stomach \yith the heart is very appHcable; for just as acute dilatation of the ventricles of the heart ma}' arise from valvular insufficiency, so acute dilatation of the stomach may occur from overloading this organ, as a result of errors in diet, or from paralysis of its nerve-muscular apparatus. On the other hand, chronic dilatation of the stomach is, without exception, the result of an obstruction at the pylorus or duodenum, just as hypertrophy and dilatation of the ventricle result from valvular affections. Hence the primar}'' factor is always an obstruction which causes stagnation of the food, this in turn producing dilatation of the stomach. Every dilatation of the stomach is, therefore, a vitium pylori or duodeni (obstruction), in the stage of disturbed compensation. . As has already been mentioned, it is necessary to differ- entiate between acute and chronic forms of motor insufficiency of the stomach. Acute dilatation is extremely rare and, in general, corresponds to acute gastritis after indigestion, or to ileus which is located high up in the intestine. Its details, therefore, will be described in the chapters on these affections. Etiology. — The cause of actual dilatation of the stomach is a mechanical obstruction at the stomach-outlet, the so- called vitium pylori. The assumption of the existence of primary muscular weakness of the stomach, as a cause of chronic dilatation, has now been quite generally abandoned. Apart from malignant stenosis of the pylorus, with second- ary gastrectasis, which has been considered in detail in the foregoing chapter on Carcinoma of the Stomach, there are two general groups of a benign nature that cause a narrowing of the stomach-outlet, the accurate understanding and knowl- edge of which are indispensable to a clear recognition and treatment of this affection. The first group includes those causal factors which pro- duce an organic and irreparable change of the entire 'pars pylorica, or of the pylorus itself. DISEASES OF THE STOMACH 153 These alterations may be caused by pathological lesions from within, such as cicatricial contraction of the pylorus following ulcer; or from without, such as perigastritis, chole- lithiasis, adhesions with the pancreas, liver, and the anterior abdominal wall, and finally compression-stenosis and the kinking of the duodenum in enteroptosis. The second group includes those causative factors that have produced a reparable, functional stenosis of the pylorus. Of these, spasm of the pylorus is most important, which occurs in fissures, erosions, small ulcers, and scars of the pylorus. It is never observed in neuroses. A transitory narrowing of the stomach-outlet, which gives rise to a temporary dilatation of the stomach, is some- times the result of inflammatory swelling of the tissues of the pylorus surrounding an ulcer. Likewise, acute traumata of the epigastrium may, by resulting ulceration of the pylorus, lead to stenosis and ulti- mate gastrectasia. Such a trauma causes either a necrosis of the mucosa or the formation of a hsematoma between the mucosa and the muscularis. From the digestion of the necrotic areas, an ulcer results which may lead to a mechanical obstruction of the stomach- outlet, either from spasm of the pylorus or from the formation of scar-tissue in the pylorus. Obstruction of the stomach-outlet with dilatation of the organ is also caused by peritoneal adhesions around the pylorus, following traumatism to the epigastrium. Ectasia of traumatic origin is, however, of rather rare occurrence. The diseases which ultimately lead to gastrectasis are, in the order of their frequency, the following: Ulcer of the pylorus and of the antrum of the pylorus, .erosions and fissures, perigastric adhesions, duodenal ulcer, gall-stones with pericholecystitis, enteroptosis, gastric hernia, traumata, and foreign bodies which have been swallowed and which obstruct the stomach-outlet. It is self-evident that a swelling of any kind within the pylorus, malignant or benign, as well as the enlargement of adjacent organs which 154 DISEASES OF THE DIGESTIVE CANAL may compress the stomach-outlet, — such as the hver, gall- bladder, pancreas, and duodenum, — may be capable of caus- ing dilatation of the stomach. "We have therefore, etiologically, two forms of gastrec- tasis, according to whether the obstructions are irreparable or organic, and reparable or functional. In both forms, apart from malignant cases, hyperchlor- h3'dria and h3"persecretion are almost alwa3''s present, provided the disease has already existed long enough for the gastric glands to have been subjected to sufficient irritation from the stagnation of the stomach-contents. Hyperchlorhydria associ- ated with stenosis of the pylorus is, therefore, never the cause of gastrectasis, but the result of it, with the exception of the above- mentioned acid gastritis associated with erosions of the pylorus. The spastic forms of gastrectasis, which often run an intermittent course, are worthy of special mention; for just as often as there is a recurrence of the ulcers or erosions of the pylorus, just so often will occur inflammatory swelhng and spastic stenosis of the p^dorus, which cause motor insuf- ficienc}^ of the stomach. Thus, patients who once or twice during every year, especially in the spring or autumn, suffer a few weeks from dilatation of the stomach will be reheved of the dilatation as soon as the lesion of the p^dorus is cured, by adherence to suitable treatment and diet; and will remain free from the trouble for several months, until there is a recur- rence of the erosion or ulcer from errors in diet or from some mechanical cause. It should be mentioned here, that stenoses resulting from organic lesions are frequently aggravated by spasm of the pylorus; for instance, pyloric spasm results from inflam- mation and irritation of the old cicatrix of an ulcer. Symptoms. — The most significant symptoms obtained in the anamnesis of patients suffering from gastrectasis is copious vomiting, which in severe cases occurs daily, and in light cases only now and then. The vomiting of food which has been eaten on one of the preceding da^^s, is characteristic of dilatation of the stomach. DISEASES OF THE STOMACH 155 It sometimes happens that fruits, cereals, and vegetables, especially grapes, raisins, rice, and other heavy ingesta which easily sink to the bottom, are not vomited for several weeks after they are eaten. In mild cases, sometimes only a sour fluid (gastric juice) is vomited several hours after meals, — therefore late in the afternoon or at night. These are the cases caused by a slight cicatricial stenosis, in which there is only a relative stenosis of the pylorus. In order to obtain relief, these patients frequently produce artificial vomiting by tickling the palate with the finger. After vomiting, the patients with gastrectasia usually feel very well and eat with a good appetite until the stomach is again over-filled, which induces vomiting anew. The subjective symptoms that most frequently annoy the patient with ectasia are gnawing, cramp-hke, burning, boring pains in the epigastrium, similar to those in ulcer, which are relieved only when the patient either naturally or artificially empties the stomach of its contents. Other subjective disturbances are heartburn, the feeling of fulness, and constant distention of the abdomen, except immediately after vomiting or lavage. The appetite in benign ectasia is generally good, although the nutrition of the patient usually suffers considerably because of his being afraid to eat. (Constipation and general emacia- tion set in for the same reason.) In addition to this, the assimilation of food is much impaired because it is not pro- pelled into the duodenum normally. This is the chief factor in producing impairment of nutrition. Patients suffering from ectasia are frequently seen emaciated almost to mere skeletons, so that the physician at first thinks, naturally, that he has cancer to deal with. The decrease in weight of the patient in ectasia must be ascribed in part to the deprivation of the organism of water; and the thirst, corresponding to the diminished absorption of water, is usually very great. In extreme stages of gastrectasis, where a high degree of drying of the tissues has occurred, there frequently develops 156 DISEASES OF THE DIGESTIVE CANAL the symptom-complex of tetany, a neurosis characterized by tonic spas-ms of the extremities, usually resulting in death. A portion of the fatal cases of gastrectasis is to be attributed to this affection. In gastrectasis there is almost always a diminution in the amount of urine secreted. The higher the degree of p3doric obstruction, the smaller the amount of urine secreted, — a fact which is sufficiently explained by the physiological fact that water is not absorbed in appreciable amounts from the stomach. The amount of urine secreted is, therefore, a direct measure of the degree of the obstruction at the pylorus. In carcinoma of the pylorus, in which a complete clinical atresia often occurs, the amount of urine secreted in twenty- four hours does not exceed 400 to 500 c.c. Objective Symptoms. — The external demonstrable signs of ectasia are the low position of the greater curvature of the stomach, and the " stomach-stiff enings, " first defined by Boas, which are increased peristaltic waves of the stomach running from the cardia to the pylorus, externally perceived on the abdominal wall. The "stomach-stiffenings" are an abso- lute symptom of stenosis of the pylorus, and are very easily recognized, because such a patient usually has a very thin and relaxed abdominal wall, and the wall of the stomach lies in al- most direct apposition to the skin covering the abdominal wall. The low position of the greater curvature, which the examiner will usually recognize by means of Obrastzow's method (see General Section, page 11), often leads the inexperienced into error, because of the fact that the low position of the greater curvature also occurs in ptosis and in the vertical position of the stomach, and in megalogastria, — the so-called phj^siologically enlarged stomach, — as well as in the case of large eaters and heavy drinkers. The significance of the splashing sounds in the epigastrium below the umbilicus is often misinterpreted as indicating dilatation, because they occur quite as frequently in gastrop- tosis and associated conditions, the details of which are considered in the chapter on Atony of the Stomach. DISEASES OF THE STOMACH 157 Since the splashing sounds may be produced by heavy palpation when only small quantities of secretion are present in the fasting stomach, it is evident how slight a value this symptom possesses in estimating the degree of stagnation of the stomach-contents. P'iG. 29. Gastrectasia secondary to iiloer of the pylorus. The stomach-stiffenings were easily recognized in this case. [Courtesy of Dr. W. W. Hitchcock, Los Angeles.] The use of the stomach-tube and an examination of the fasting stomach furnish the only absolute proof of the presence of dilatation of the stomach. If remnants of food are found in repeated examinations by this method, gastrectasis may be diagnosed. If no food-remnants are obtained from the fasting stom- ach, dilatation may be excluded from the diagnosis, — whether the greater curvature stands above or below the umbilicus. 158 DISEASES OF THE DIGESTIVE CANAL If considerable amounts of gastric juice, — for instance, 40 to 50 c.c, — can be obtained from the fasting stomach, the examiner may assume the i)resence of hypersecretion, — which will be considered in detail in a special chapter. In benign stenosis of the pylorus, hydrochloric acid is always present; and in almost all cases, there are both hyper- chlorhydria and hypersecretion, — the result of increased irrita- tion of the gastric glands from the stagnation of food. Occasion- ally the physician will find a normal or a subacid gastric juice, when stagnation has existed so long that the functional ability of the gastric glands has become exhausted from over-activity. In gastrectasis, the total acidity of the contents removed from the fasting stomach usually exceeds 100, since, in addi- tion to the normal acids of the stomach, there are present the acids resulting from fermentation and those introduced with the food, especially sarcolactic acid. Total acidities amount- ing to from 150 to 160 are not at all rare. In malignant stenosis of the pylorus, free hydrochloric acid is not found in the stagnating contents of the stomach; fermentation-acids only are present, especially lactic acid. In the early stages of a primary carcinoma of the p3dorus, free hydrochloric acid is also encountered. If the examiner finds a stenosis of the pylorus in which there is a diminished hydrochloric acid secretion in the stag- nating food, and the anamnesis points to the presence of an ulcer, this combination of symptoms should always awaken his suspicion of a malignant degeneration of the ulcer. Such a patient should, as already mentioned, be referred to the surgeon at the earliest possible moment. In benign stenosis, sarcinse and yeast-cells are always micro- scopically present, while in malignant stenosis there are always enormous numbers of lactic acid bacilli, besides yeast-cells. For further details see the chapter on Microscopical Examination of the Contents of the Stomach. Diagnosis. — The diagnosis of dilatation of the stomach is very easy. It is much more difficult to determine which form of dilatation is present in an individual case. DISEASES OF THE STOMACH 159 If stagnating foods are obtained from the fasting stomach, it is certain that there is a mechanical obstruction of the pylorus; and if the greater curvature of the stomach lies below the umbilicus, this obstruction has caused, in addition to food-stasis, an enlargement of the stomach. Unless the patient states definitely in the anamnesis that he has frequently vomited food eaten one or several days before, the chnician can never make a diagnosis of gastrectasis before he has introduced the stomach-tube into the fasting stomach and has demonstrated thereby that foocl-stasis exists. To determine the character of the obstruction is often very difficult. If the occurrence of dilatation has been preceded by periodical epigastralgia (see chapter on Ulcer), and if, besides this, hsematemesis has been observed, it is extremely probable that a cicatrized ulcer of the pylorus is the cause of the gastrectasis. If gall-stone colic with icterus, or an injury to the epi- gastrium, can be clearly established, the diagnostician will naturally think of the presence of adhesions from perigastritis which compress the pyloric outlet. If the dilatation has existed only a short time, in an otherwise previously healthy individual, a malignant neo- plasm of, or near, the pylorus should be suspected, especially if examination shows that there is a diminished secretion of hydrochloric acid. Gastrectasis due to spasm of the pylorus should always be thought of, if colicky pains occur regularly at certain periods of the day, especially four to six hours after meals, at five or six o'clock in the afternoon and from one to three o'clock at night. An exact diagnosis of the etiology of dilatation of the stomach will usually require a prolonged clinical observation of the case. Slight or latent cases of relative stenosis of the pylorus are recognized by the administration of the test-supper (see page 35). 160 DISEASES OF THE DIGESTIVE CANAL Differential Diagnosis. — No other affection can be easily confused with chronic dilatation of the stomach, if the examiner has obtained stagnating food from the fasting stomach. A low position of the greater curvature, as already men- tioned, is equall}' frequent in enteroptosis, in vertical position of the stomach and in megalogastria. If the physician gives the test-supper and finds the stomach empty in the morning before breakfast, gastrectasis maj^ be eliminated from the diagnosis. Acute gastrectasia, which is a form of ileus, high up in the bowel, results from sudden kinking of the duodenum, incarceration of a gall-stone, and paralysis of the stomach following laparotomies and abdominal injuries. Acute dilatation ma}^ be confused with the dyspeptic symptoms of acute gastritis. The low position of the greater curvature best protects the examiner from confusion in the differential diagnosis of these two diseases. Prognosis. — The prognosis of gastrectasis depends entirely upon the nature of the original disease. Gastrectasis due to chronic pylorospasm offers a favor- able prognosis, since an absolute cure is possible, the stomach regaining its normal motor power. On the other hand, chronic ectasia caused by organic obstruction at the pylorus can only be relatively cured, that is, the patient must occasionally have lavage treatment and use a stenosis-diet, i.e., a semi-sohd diet rich in fats. An absolute cure can be expected only through surgical intervention. The prognosis of gastrectasis must be very guarded in every case until the physician is convinced of the nature of the obstruction. The greater the stagnation of food, and the smaller the amount of urine secreted, the poorer are the chances for recovery. The prognosis is always bad if symp- toms of tetany are present. Treatment. — The indications for treatment in the dif- ferent forms of dilatation are as follows: In the spastic form of ectasia, the object of treatment should be to reduce the inflammatory swelling of the pylorus, DISEASES OF THE STOMACH 161 or to heal the erosion or ulcer. If the treatment is successful in these, the pylorospasm relaxes and the gastrectasis dis- appears of itself. In dilatation of the stomach due to organic stenosis, on the other hand, the task of the physician should be to reduce the obstruction of the pylorus to the stage of com- pensation, on the principle that every dilatation due to ob- struction represents a gastric disturbance in the stage of disturbed compensation. The treatment is (1) Dietetic, (2) Mechanical, (3) Medicinal, and finally (4) Surgical. 1. Diet. — The diet should be suitable to the anatomical conditions present, the food being of such a consistency as will pass through a sieve, the perforations of which are about the size of a knitting-needle, so that it can readily pass through the narrowed stomach-outlet. It must, therefore, be liquid or semi-liquid, and should be as rich in fats as possible, so as to contain the sufficient number of calories for the main- tenance of the body. Only after advanced improvement has taken place will it be safe for the physician to enlarge the dietary to foods of pulpy and semi-solid consistency. Meats and albuminous foods need not be given in a finely divided form, because the gastric secretions are usually pres- ent in amounts sufficient for normal chymification. Only in the malignant forms of stenosis of the pylorus need the food be given in a liquid or semi-solid form, because in these, gastric secretion is deficient. Of foods suitable in gastrectasis, the following should be especially mentioned : cream, butter, olive oil, milk, butter- milk, meat soups, raw eggs, scraped beefsteak, beef juice, meat-gelatins, purees of potatoes, carrots, peas, spinach, and also apple and orange sauces; and for drinks, — wine or fruit juices diluted with mineral water. Detailed diet-lists will be found in the Dietetic Outlines. 2. Mechanical Treatment. — The mechanical treatment of gastrectasia consists in lavage of the fasting stomach, which 11 16^2 DISEASES OF THE DIGESTIVE CANAL should be continued daily, until it no longer contains stag- nating food. In the beginning, the treatment should be given daih', then twice or three times a week, and finally only once a week. The patient may soon be able to lavage the stomach himself. Two or three litres of pure lukewarm water, about 30° R. [100° F.], are required in each treatment. The addition of medicinal substances to the lavage water is quite superfluous. After the lavage, from 50 to 100 c.c. of warm olive oil should be introduced into the stomach, or if preferable, the patient may drink the oil, in order that the narrowed, rough- ened and fissured portion of the mucosa may be lubricated. Besides its usefulness in this direction, the oil also effectively reduces hyperchlorhydria, and at the same time increases the number of calories furnished the body. 3. Medicinal Treatment. — Especially deserving mention are silver nitrate, bismuth, the alkalies, and atropine. Remedies such as bismuth, silver nitrate and atropine, which are directed toward the removal of the etiological factors, should be given before meals; while such drugs as antacids, whose effect is purely symptomatic, should be given after eating. As a rule, for the treatment of spasm of the pylorus, I first administer the oil- treatment; and later, give a tea- spoonful of bismuth in the morning on the fasting stomach, just as in ulcer; and at noon and in the evening, one-half hour before meal-time, a ^ milligram [gr. y^-o] tablet of atropine sulphate. Boas has recently recommended the use of ten drops of a one per mille solution of eumydrin, instead of atropine. One or two hours after meals, a teaspoonful of magnesia usta, magnesium carbonate, magnesium ammonio-phosphate, bicarbonate of soda, or Vichy salts, should be given. When indicated, the physician may prescribe the extract of bella- donna mixed with the alkalies in powder form. 4. Surgical Treatment. In case the internal treatment is ineffectual, if in spite of the stenosis-diet, stagnation of the DISEASES OF THE STOMACH 163 stomach-contents still persists, and the daily amount of urine secreted amounts to only 500 or 600 c.c, and if the strength of the patient is gradually failing, the physician should advise surgical treatment. The operator, after opening the abdominal cavity, should ciecide whether pyloroplasty, resection of the pylorus, or gastro- enterostomy is indicated. As a rule, the latter will usually be the most suitable. The clinician must be all the more ready to advise opera- tion, if the stenosis of the pylorus is of a mahgnant nature. If the operation is successful, the patient often takes a new lease of life, and an increase of from forty to fifty pounds in weight in a comparatively short time is frequently observed. Congenital Hypertrophic Stenosis of the Pylorus In addition to the above forms of gastrectasis, one other should be mentioned, — congenital hypertrophic stenosis of the pylorus with secondary gastrectasis. This condition manifests itself soon after birth, by the most persistent vomiting and dilatation of the stomach. A cure is to be expected only through surgical methods. [The cHnical course of congenital hypertrophic stenosis may extend over a period of many years, into adult life. The most characteristic symptom is the copious vomiting of food eaten several days previous. After the stomach is emptied and relieved of its stagnating contents, the patient is in good health and without any gastric discomfort. These attacks of vomiting appear at more or less regular intervals, varying in point of time from a few days to several weeks or months. Corresponding to the degree of stenosis present, there is impairment of the general health and nutrition of the patient. Lavage, for removing the stagnating stomach-contents, and the administration of alkahes, belladonna, etc., for the hj^per- acidity which is usually present, are suitable as paUiative treat- ment in cases presenting infrequent symptoms of the disorder.] 164 DISEASES OF THE DIGESTIVE CANAL • CLINICAL CASES r. Cicatricial Stenosis of the Pylorus with Gastrectasis Case 1. — Emily A., a dairyman's wife, 40 years old, suffered from cicatricial stenosis of the pylorus following ulcer, with secondary extreme dilatation of the stomach accompanied by symptoms of tetany. The oil- treatment was given, which was followed by marked improvement in a very short time. Patient gained 30 pounds in weight in two months. At the end of treatment, her total increase in weight was 45 pounds. A relative cure of the stenosis resulted, that is, the patient enjoyed good health and suffered no inconvenience while she continued to use the stenosis-diet and the oil-treatment. October 9, 1901 : The patient had previously suffered from chlorosis, at which period she suffered also from cardialgia for two or three weeks at a time. In 1894 she had vomited blood, with melsena, and a second time in 1897. Between these attacks of hsematemesis, she had suffered frequently from cardialgia. At that time an operation had been advised, which was declined. The patient made quite marked improvement until one and one-half years ago, since which time she had copious vomiting, with frequent gastric hemor- rhages. At this time the hemorrhages were occurring about every eight to ten days, and for the past eight months had appeared once or several times daily. There were extreme emaciation, oedema, and mild symp- toms of tetany. Patient was urgently advised by several different physicians to undergo operation, but refused. The stomach was washed out several times. Physical Examination. — Patient was extremely debilitated and as pale as wax. She weighed only 81 pounds. CEdema of the lower extremi- ties extended to the calf of the leg. The abdomen was very much relaxed and strong splashing sounds as low as the csecum could be produced. At the right of the median line, just below the Hver, in the region of the gall- bladder, a hard, irregular tumor as thick as the thumb was palpable. This was thought to be the pylorus. The urine contained some albumin. The greater curvature of the stomach extended to within two finger-breadths above the symphysis. Enormous quantities of material were obtained from the fasting stomach, which contained a great deal of free acid, sarcinte, and yeast-cells. During the lavage, the patient had a slight attack of tetany. She was put on absolute rest in bed, with liquid diet, enemata, and the introduction of oil following the lavage. October 11th: Condition of the patient was much improved. The gnawing and cramp-hke pains in the abdomen had entirely disappeared. 150 c.c. of oil were introduced. October 12th: Patient had no pain. There was a spontaneous, soft, well-formed stool. There were no eructations, and the thirst was less; DISEASES OF THE STOMACH 165 no gastric discomfort of any kind. There were only a few globules of oil obtained from the stomach in the morning before breakfast. 120 c.c. of oil were introduced. October 13th: Patient had another slight attack of tetany, which was less severe. October 14th to 17th: The patient was absolutely free from pain, and the bowel movements were regular. Treatment continued and dietary increased; she was even given chicken, wine soup, and grits. October 23rd: In the meantime, the patient had performed the lavage and oil-treatment at home. Evei'y evening before retiring she had drunk 100 c.c. of oil. Small remnants of food were still obtained from the fasting stomach, which contained sarcina? and yeast-cells. No other attacks of tetany had occurred. The abdomen of the patient was soft, a slight oedema of the legs was still present, and only traces of albumin were found in the urine. Patient was allowed to eat chicken, filet, and puree of potatoes with butter. November 1st: The patient weighed 104 pounds, having gained 17 pounds in four weeks. CEdema had disappeared, from which fact we know that the actual increase in weight was greater than the apparent. The appetite was good. The greater curvature of the stomach was three to four finger-breadths below the umbihcus. The right border of the stomach extended 10 cm. beyond the median line. The adiposis panniculus seemed considerably thicker. The patient had no repugnance toward the continued use of the oil. Diet now consisted of tender meats, eggs, milk, cream, and white bread. She was instructed to wash out her stomach every second day. November 8th: Only a very few remnants of food, — consisting mostly of rice, fruit-seeds, etc., — were obtained from the fasting stomach. The general health of the patient was very good. November 14th: Sarcina;, yeast-cells, muscle-fibres, and other rem- nants of food were obtained from the fasting stomach. Total acidity of the gastric juice, 105; free hydrochloric acid, 68. December 11th: Patient weighed 111 pounds, which was a gain of 30 pounds within two months. She was allowed to leave her bed. January 3, 1902: Greater curvature of the stomach was at the level of the umbihcus. General health of the patient was good. December 17, 1902: The patient weighed 126 pounds, an increase of 45 pounds. Examination showed that she was in quite good condition, although lavage and the oil-treatment are necessary from time to time. 2. Traumatic Ectasia Wm. B., a locksmith, 24 years old, had had previous good health until he received a severe contusion of the epigastrium in falling, after which he suffered from symptoms similar to those of ulcer, followed a few weeks later by typical signs of gastrectasis or motor insufficiency of the second degree. There were stagnation of the ingesta, copious vomiting, hyper- 166 DISEASES OF THE DIGESTIVE CANAL chlorhydria, a fj:reat number of sarcinrc and yeast-cells in the contents obtained from the fasting stomach. In addition, patient suffered from A-iolent cramp-like pain in the epigastrium, which occurred regularly at a certain time of day, and was usually accompanied by vomiting. He was given the ordinary treatment for dilatation of the stomach, — lavage, etc., — which failed to give any imp!-o\'ement ; but instead, he continued to grow worse. He therefore gave up lavage-treatment and sought i-elief by arti- ficially producing vomiting by irritating the palate with the finger; every three or four days he would produce vomiting as thoroughly as possible in this way. One evening, on the advice of an acciuaintance, after having thus emptied his stomach, he drank a glass of linseed oil, — which he continued to use three times daily for several weeks. According to the statement of the patient, the results were quite astonishing. Epigastralgia ceased im- mediatel}^ and there was only one recurrence of vomiting. After several months of this treatment, the patient had regained normal health. He was able to eat all kinds of food without any discomfort and was able to per- form the same heavy, manual labor as befoi'e his illness. The fasting stomach was always found to be free from food and contained no secretions. The motor insufficiency was, therefore, completely cured. 3 Spastic Stenoais of the Pylorus Leopold K., 28 years old, an engineer from Mexico, had suffered from severe epigastralgia and vomiting of blood five years previous. He had been given the "ulcer-cure," after which he had remained well for two years. He then suffered from a recurrence of the ulcer, accompanied by copious vomiting, heartburn, and cramp-like pain, occurring especiall)^ at night. Relief from epigastralgia was obtained by the use of alkalies. He was repeatedly advised to undergo an operation. Physical Examination. — Patient was extremely emaciated, his weight being only 106 pounds. Food-remnants and sarcinjE were obtained from the fasting stomach. There was hyper chlorhydria, and the total acidity was 100. Treatment. — In the beginning of treatment, the stomach was washed out daily, then two or three times a week, and then only once. One hundred c.c. of olive oil were given every morning. At the beginning of treatment, the patient was placed on an absolute liquid diet, and later on semi-solids. Alkalies with atropine were given after meals. One month later, pain and stagnation had entirely disappeared, and the patient had increased in weight to 120 pounds. He returned to Mexico cured. 4. Operated Case Mrs. K., 60 years old, had suffered from gastric ulcer for 30 years. She had vomited blood several times, and for several years had suffered from food-stagnation so that lavage was a necessity. In this case, the internal therapy, including the oil-treatment, was unsuccessful. She was. therefore, DISEASES OF THE STOMACH 167 advised to have a gastro-enterostomy, which resulted in a complete cure. At the operation the lumen of the pylorus was found to be contracted to the size of a lead-pencil. Perigastritis Etiology. — As has been shown in the previous chapter, perigastritis results chiefly from an extension of ulceration of the mucosa to the serous coat of the stomach-wall, or from acute and chronic trauma to the stomach region, or finally from inflammatory processes of the serous coats of neighbor- ing organs, — especially the gall-bladcler in cholelithiasis and empyema. Peritoneal adhesions and bands are formed by these inflammatory processes, just as in diseases of the uterus and its aclnexse. In ulcer of the duodenum, periduodenitis naturally arises in the same way. Symptoms. — The symptoms of perigastritis may be latent for years, and may become active only after some sudden twist or movement of the body. Sometimes, however, an exacerbation of the inflammatory process occurs, which causes the persistent, boring, stabbing pain in the epigastrium aggravated by movements of the body and especially by distention of the abdominal wall, coughing, sneezing, pressing, lifting of heavy weights, or bending the body backwards. In addition to these symptoms, forceful downward pressure upon the costal cartilages is, according to Pariser, especially painful. Diagnosis. — A diagnosis of perigastritis can never be made beyond a probability; and a positive diagnosis, never. In persons who have been injured, symptoms are often de- scribed which may be attributable to perigastritis; and it is necessary to add that such a history w^ould open the door freely to simulation in a person desiring to obtain damages after injury. Prognosis. — As already mentioned in the previous chap- ter, perigastritis frequently gives rise to gastrectasis. Bands of adhesion constrict either the pylorus or the duodenum, or interfere with the normal peristaltic movements of the pars pylorica, in such a way that the function of expelling the contents of the stomach into the duodenum is interfered with. 168 DISEASES OF THE DIGESTIVE CANAL Treatment. — The treatment of an acute exacerbation of perigastritis is identical with that of acute circumscribed peritonitis, — namel}'', rest in bed, hijuid diet, ice and opiates. If the course of the disease, in chronic perigastritis, presents no febrile symptoms, the condition should be treated in the same manner as chronic ulcer, — with hot applications, rest in l)ed, liquid diet, and bismuth. (See chapter on Gastric Ulcer.) If the perigastritis has already led to complications, — for instance, to motor insufficiency and secondary dilatation of the stomach, — the condition should be treated surgically. Hypersecretion (Gastrosuccorrhcea, "Reichmann's Disease") The term "hypersecretion" was introduced into the literature by Reichmann in 1882, as a clinical entity. By this term is understood the pathological condition of the glands of the stomach in which they constantly secrete gastric juice. In this affection, considerable amounts of gastric juice, which may have a normal acidity or a hyperacidity, can be obtained from the fasting stomach before breakfast. There is no uniformity in the opinions of the various authors as to what quantity should constitute hypersecretion. Since slight amounts of gastric juice may frequently be obtained from the stomach of healthy persons, it is better, — according to my experience, — to assume the presence of hyper- secretion only when at least 20 to 30 c.c. of gastric juice are obtained from the fasting stomach. So far as my experience goes, hypersecretion never occurs from a purely nervous affection of the stomach, — as some authors assume, — but is always an expression of an acid gastritis resulting from different causes, the most frequent factor being either an ulcer, an erosion, a fissure, or a scar at the pylorus, which occasions a delay in the emptying of the stomach, and, thereby, a constant irritation of the gastric glands. It is for this reason that in benign stenosis of the pylorus there is almost always a hypersecretion, which is the forerunner of motor insufficiency of the stomach. DISEASES OF THE STOMACH 169 The next most important etiological factor is primary acid gastritis which leads to hypersecretion. The following diagram illustrates clearly the origin and the influence of hypersecretion in gastric pathology. (Fig. 30.) In this diagram, the patient is represented as being in good health at the point "G;" an ulcer of the pylorus has developed at "U," which at "S" is represented as having given rise to hypersecretion, and to stagnation at ''St." Ectasia is the last stage of the process, represented at ''E," which, when rationally treated, leads to recovery. Fig. 30. Health line. G. G. Diagram showing the development and course of hypersecretion. Hypersecretion, therefore, precedes the motor insuffi- ciency of the stomach, and disappears with it by the institution of curative measures. Hypersecretion is a rudimentary or incomplete dilatation of the stomach. Periodical hypersecretion of gastric juice is almost always a symptom of tahes dorsalis, as will be pointed out below. Symptoms. — The subjective symptoms of hypersecretion consist of burning, boring, and, rarely, cramp-like pains in the epigastrium, which may extend to the throat, — all of which are relieved by eating, the use of warm drinks, and especially by alkalies. Objectively, there occurs vomiting of the gastric juice, which is often so sour that the patient feels as if his teeth were covered with acid. The most important objective symptom, however, is the discovery of considerable amounts, — from 30 c.c. up to a half-litre, — of gastric juice in the fasting stomach. The total acidity of the gastric juice in hyper- 170 DISEASES OF THE DIGESTIVE CANAL secretion amounts to from 70 to 110. Bile is frequently present and mixed with the gastric juice. In uncomplicated hypersecretion, there are neither macro- scopical nor microscopical evidences of food-remnants, and sarcina3 are absent. Should any of these be found in a case of hypersecretion, the assumption is safe that an insufficiency already exists which may lead to dilatation of the stomach. I am very well aware that different authors assume that hyperchlorhydria and hypersecretion are primary factors, and that pyloric spasm,— which is the immediate cause of the irritation of the mucous membrane of the stomach, — is secondary. But such a view can scarcely be correct, for the reason that after the cure of the obstruction at the pylorus, by either medical or surgical treatment, the hypersecretion spon- taneously disappears; while, on the other hand, very many cases of hyperacidity run their course without clinical symptoms. In the cases of hypersecretion which are the immediate forerunners of motor insufficiency, starch-cells are sometimes obtained from the fasting stomach early in the morning; while if meat-fibres are entirely absent, the clinician should not be surprised, because the proteid foods may have been digested during the night by the action of the hyperpeptic gastric juice. Diagnosis. — An exact diagnosis of hypersecretion is possible only by the use of the stomach-tube and the exami- nation of the fasting stomach. If considerable amounts of gastric juice are constantly present, in which there is no ad- mixture of food-remnants, the diagnosis is positive. The subjective symptomatology frecjuently leads to confusion with such associated conditions as ulcer, fissures, and erosions. In the differential diagnosis, the physician should always eliminate the periodically occurring gastric crises of tabes dorsalis, and the vomiting which is frequently associated with migraine. Treatment. — The treatment of hypersecretion should be directed exclusively toward the primary disease. The therapeutic procedures instituted, therefore, depend upon DISEASES OF THE STOMACH 171 whether an ulcer or a hyperacid alcohoHc gastritis, etc., is the cause of the trouble. A tablespoonful of olive or almond oil should be given three times daily, or the milk of almonds (see page 124) may be substituted before meals, if the condition is complicated by pylorospasm. Alkalies should be administered after eating. The diet should be semi-lic|uicl and rich in fats. If the primary lesion is an acid gastritis with erosions of the pyloric mucosa, large doses of Carlsbad or Vichy water should be given before meals, or the patient should be sent to one of these watering-places. Gormands and heavy smokers belong especially in this category of patients. The mastication tablets of Bergmann or Belloc may be used symptomatically to great advantage, just as in similar lesions of the stomach. The treatment of hypersecretion is of especial importance as a prophylactic agent against gastrectasis, since we must always consider hypersecretion as a preliminary or initial stage of dilatation. Since every case of hypersecretion is the result of an anatomical lesion of the stomach, and should never be con- sidered a nervous affection, anti-nervous treatment is useless. CLINICAL CASES Acid Gastritis Case 1. — Maurice K., a merchant, 50 years old, had indulged in the use of fatty foods, smoking, and beer-drinking. His appetite was very good, but he had begun to be afraid to eat because of a burning pain in the epi- gastrium several hours after eating, vi^hich had occurred regularly for the past two or three months. Pyrosis was frequent. He was a very strong, obese man. In every examination of the fasting stomach, 30 to 40 c.c. of secretion were obtained, the total acidity of which was 80 to 100. The patient was cured at Carlsbad. CavSE 2. — Heinrich B., a brewer, 30 years old, presented the same etiological and clinical course as in Case 1, hj^^ersecretion resulting from a relative stenosis of the pjdorus. (For other clinical cases, the reader is referred to case-histories described at the end of the chapter on Gastrectasia, in the course of which the symptom of hypersecretion is frequently mentioned.) 17 > DISEASES OF THE DIGESTIVE CANAL Hy perchlorhyd ria Hj'perchlorhyclria and hyperst'cri'tion are not the same. Hypersecretion indicates an increase in the secretion of gastric juice of normal acidity, while hyperchlorhydria is the secretion of an excessively acid gastric juice.* In hypersecretion, the test-breakfast is alwaj's found to be well digested and of a fluid consistency, or nearly so; on the other hand, in hyperchlorhydria, the test-breakfast is only moderately well digested and rather semi-solid in consistency. As a matter of course, both of the above-mentioned anomalies of secretion may occur at the same time. Although, as we have seen in the foregoing chapters, hj^peracidity is not a disease sui generis, being merely a symptom of various affections, yet it is so frequently and prominently associated with disorders of the stomach and intestine that it is deserving of special consideration in a practical work of this kind. According to its etiology, there are four different forms of hyperacidity that clinically may be very well classified, diagnosed, and causally treated. These four forms are: (1) hyperacidity in acid gastritis; (2) hyperacidity in ulcer and stenosis of pylorus; (3) hyperacidity in neurasthenia; (4) hyperacidity in chronic constipation. The first and second forms are the expression of organic, anatomical diseases; while the third and fourth are expressions of functional affections. The physician will be able to differentiate the various forms by the following characteristics: 1. Hyperacidity Occurring in Acid Gastritis The test-breakfast has a total acidity of from 70 to 120 and is of a thick, pulpy consistency, while frequently there is a diminished secretion of gastric juice. *According to the most recent examinations of the Pawlow's school, it appears that the concentration of the gastric juice is always the same, and its total acidity amoimts to about 120. The acidity, therefore, depends only upon the number of cubic centimetres secreted. In case "A," for instance, there are secreted in one hour 200 c.c. while in case "B," only 100, etc. DISEASES OF THE STOMACH 173 The anamnesis of such patients, — and this is of the great- est importance, — shows a history of abuse of tobacco, wine, beer, and excesses in eating. As a rule, the patients will be found to have felt sub- jective pressure and discomfort after eating heavy foods; but in cases where the formation of erosions of the mucosa has already occurred, the patients suffer from burning pain in the epigastrium two or three hours after eating, which is relieved by again taking food into the stomach. In individual cases,, if the erosions are located in the pylorus, the pain is of a cramp-like character, the so-called "epigastralgia," which, however, rarely occurs immediately after eating, but usually several hours later, especially if the patients have indulged in errors in diet, beer-drinking or heavy smoking. Besides the burning in the region of the stomach, pyrosis is very frequent. Obese and strongly-built individuals with hearty appe- tites are usually predisposed to this disease. 2. Hyperacidity in Ulcer and Stenosis of the Pylorus In these affections, the stasis of the ingesta causes an irritation of the gastric glands and, thereby, an increase in the amount of gastric juice secreted, i.e., hypersecretion and hyperchlorhydria occur. Concerning the symptoms of this form of hyperchlor- hydria, the reader is referred to the chapters on Ulcer of the Stomach and Gastrectasis. The therapy likewise needs no further consideration. Anatomical changes of the gastric glands, consisting of hypertrophy of the acid cells and atrophy of the chief cells, are present in both of these forms of hyperchlorhydria. In acid gastritis, the glands become irritated from excesses in eating; while in ulcer and stenosis of the pylorus, the hyperchlorhydria is the result of the disturbance of the motility of the stomach. In the first form, the hyperchlorhydria is primary; and erosions, should they occur, are secondary. 174 DISEASES OF THE DIGESTIVE CANAL All other cases of hyperchlorhydria that can be objec- tivel}' diagnosticated are of a functional nature. They may be clinically differentiated from the hyper- chlorhydria of organic disease by the absence of actual pain. The chnical course of such is either entirely without symptoms, and hyperchlorhydria is only discovered as an accidental or associated condition; or they produce, at most, only mild pressure in the stomach, or heartburn, discomfort and feeling of fulness in the epigastrium. 3. Hyperchlorhydria Occurring in Neurasthenia This form of hyperchlorhydria is found most commonly in neuropathically disposed individuals, and especially in such as have the habitus enteropticus. The s3^mptoms consist of pressure in the stomach after heavy meals, especially if the patient has not had the neces- sary amount of rest. In this form of hyperchlorhydria, actual pain never occurs. The treatment should be directed toward the removal of the primary disease, therefore should combat the general nervous condition of the patient. A full discussion of the details of the therapy will be found in the section on Func- tional Diseases of the Stomach. 4. Hyperchlorhydria Occurring in Chronic Constipation This exists very frequently without causing the patient any discomfort, or there is only a feeling of unpleasantness and fulness after eating. This form of hyperacidity is also of a functional nature, and disappears as soon as chronic constipation has been cured by proper treatment. The cause of hyperacidity in chronic constipation is not quite clear. One factor may be that the mucous membrane of the stomach is irritated by the abuse of purgatives and laxatives; and another cause may be that when there is a stasis of the intestinal contents, the peristaltic action of the musculature of the stomach is similarly affected. DISEASES OF THE STOmIcH 175 According to the above consideration of hyperchlorhydria, it is evident that there is as httle uniformity in the etiology of the different forms of the disease as in its treatment. It is, therefore, illogical for some authors to enthusiastic- ally recommend a meat-diet for hyperchlorhydria, and for others to insist upon the necessity of a vegetarian diet. Nor is it to be wondered at that under either of such dietetic regimes there occur as many absolute failures as successes in the treatment; for the treatment of hyperchlorhydria must always be planned according to its etiology. Besides the four forms of hyperchlorhydria already mentioned, there is still a fifth, which occurs acutely as the so-called " Gastroxynsis, " of Rossbach, which begins suddenly and continues from one to several days, with an extraordinary increase in the secretion of gastric juice, accompanied by boring pains and vomiting. It is probable that in most of these cases we have to do with gastric crises of tabes dorsalis ; and it should be pointed out here that the gastric crises may occur as the first symptom of tabes. I saw such a case in a man twenty-three years old, three years after syphilitic infection. The transient duration of hyperchlorhydria in these cases prevents the physician from confusing the condition with ulcer of the pylorus, in which pain also occurs periodi- cally; but in this instance each period has a duration of several weeks, when the pain occurs regularly at a certain time after eating. Hyperchlorhydria continues throughout the entire life of some individuals. Indeed in some families it is hereditary, — nearly all the members being affected, and is especially frequent in families where obesity is a characteristic. Prognosis. — The prognosis is very good in the functional forms of hyperchlorhydria. The prognosis is generally favorable if the patient is able and willing to confine himself to hygienic living, to forego smoking, drinking, and excessive eating, and to wear suitable clothing which will not constrict the epigastrium, etc. 176 DISEASES OF THE DIGESTIVE CANAL Hyperclilorhydria, if it has existed for several years, grad- ually terminates in normal acidity and finally in sub-acidity, of the gastric juice; this is especially the case in acid gastritis. I have personally observed patients during the evolution of this disease, in whom the total acidity was at first 80, then ()0, and later as low as 40. In stenosis of the pylorus, the hyperacidity gradually decreases after the obstruction has been removed. Treatment. — The method of treatment in a case of hyper- chlorhydria should always depend upon the cause. In hyperacidity caused by acid gastritis and ulcer, there- fore, the treatment should be local; while the therapeutic measures in hyperchlorhydria occurring in neurasthenia and constipation should always be general. The physician should prescribe a lacto-vegetable diet in the first two forms ; in the neurasthenic form, a mixed diet, combined with forced feeding; and in the last form, a vegetarian diet, — in order to obtain regular spontaneous evacuations of the bowels. CLINICAL CASES Histories of patients illustrating the first two forms of hyperchlor- hydria will be found at the end of the chapters on Gastritis and Ulcer of the Stomach, respectively. 1. Nervous Hyperacidity Case 1. — Ernst E., a teacher, 61 years old, had suffered discomfort and pressui-e in the epigastrium for six months, after eating. The appetite was poor. Patient had an aversion against fatty foods. He presented the typical fear-phenomena of neurasthenia. The bowels were sluggish. The patient had had nervous shocks caused by two deaths in the family, and he slept poorly. Treatment in a sanatorium had been unsuccessful. Patient was given bromide, digitalis, asafetida, and iron, without improvement. He lost 22 pounds in weight. He had suicidal intentions. Physical examination of the patient was negative. There was no sugar in the urine. Examination of the stomach showed the presence of hyperchlor- hydria. The total acidity was 80. The motility of the stomach was normal. Treatment consisted in the rest- and fattening-cure and the use of bit- ters. He gained fourteen pounds in weight. Improvement was very slow, and not until three and one-half years later was he quite cured. For clinical cases illustrating hyperchlorhydria in chronic constipation, see the section on Diseases of the Intestine. DISEASES OF THE STOMACH 177 FUNCTIONAL DISEASES OF THE STOMACH General Remarks. — It should not be concluded, from the considerable space devoted to the organic diseases, that they necessarily exceed, in their frequency, the functional diseases of the stomach. On the contrary, the functional diseases deserve equal space and interest in gastric pathology. We include, under functional or nervous dyspepsias, all those diseases in which no pathological anatomical change of the stomach is demonstrable; in which, therefore, the organ is diseased only in the pathological-physiological sense. Although functional diseases of the stomach are often very stubborn in yielding to treatment, still by suitable meas- ures they may usually be brought to complete cure and recovery. The successful results from the application of thera- peutic measures in the diseases of the digestive tract depend upon the physician's being able to classify correctly each individual case in either one or the other group of digestive diseases, — o rganic or functional , — and when a combination of both exists, to determine which of the two is primary, in order that he may know where to begin the appli- cation of the therapeutic measures. It is clear that frequently a patient suffering from an organic disease of the stomach. — for instance, ulcer, — will if neuropathically inclined pre- sent evidences of nervous dyspepsia in addition to the ulcer-symptoms. This occurs with especial frequency, as we shall see below, in diseases of the intestines. The opposite is also true, — that a functional affection, — for instance, nervous anorexia, — may lead to an organic disease of the stomach in con- sequence of the disturbances induced by malnutrition. Etiology. — The factors which favor the development of a functional disease of the stomach are both inherited and acquired. Among the inherited tendencies is the habitus, which, according to the admirable examinations of Stiller, has been designated as the so-called habitus enter opticus, or asthenia universalis congenita. This habitus, which plays a prominent 12 178 DISEASES OF THE DIGESTIVE CANAL part in the diagnosis of the diseases of the stomach and intes- tine, has .ah-eady received sufficient and appreciative mention in the introduction. In habitus cntcropticus, all of the abdominal organs assume a position more nearly longitudinal than transverse, — especially the stomach, which while normal lies almost diagonally from left to right, but in habitus entcrop- ticus takes an almost vertical position. It is easy to understand that the abdominal organs in enteroptosis assume a lower position if the patient becomes emaciated or the abdominal walls are relaxed. So long as persons with habitus enteropticus are well nourished, or are obese, and in women so long as the abdominal walls are not weakened and relaxed by pregnancy, no symj^toms are caused by the presence of habitus enteropticus. It is not until some cause, — such as loss of appetite or some nervous affection, — lowers the nutrition of an enteroptotic individual, that the fully-developed sym^Dtoms of enteroptosis appear. Enteroptosis is, therefore, a disease, while habitus enteropticus repre- sents only the predisposition. If the physician is in doubt in a given case as to whether the patient is suffering from an organic or a functional dyspepsia, he should, as a rule, determine the habitus of the patient. This will very often prevent his being misled in the diagnosis. Organic diseases, — such as ulcer, gastritis, etc., usually occur in individuals with normal habitus. Functional dyspepsia, on the other hand, occurs almost without exception in persons with the habitus enteropticus. This generalization does not debar the fact that the reverse of these general principles is sometimes true. All conditions that are capable of weakening the consti- tution of the patient, affecting his entire muscular and ner- vous system, and, in fact, all factors leading to neurasthenia, — hysteria, anemia, or malnutrition, — predispose the individual to functional diseases of the stomach. Tuberculosis, sj'phihs, and insufficient nourishment, especially in persons who are physically or mentally over-worked, lead to anaemia and mal- nutrition, which may also simultaneously cause neurasthenia. The nervous system is also debilitated through excesses in Baccho et Venere, from sexual abuses of any kind, and especially from masturbation. DISEASES OF THE STOMACH 179 Emotional strain from business and family troubles, depression, worry, disappointment in love, continuous excite- ment, death of relatives, and fear of contagion in caring for the sick, — all play an etiological role in the functional dys- pepsias. It is not possible to mention in detail all of the factors that weaken the general health of the individual. Only one other factor will be emphasized; that is, trauma, which is sometimes the cause of a functional stomach affection (traumatic neuroses). If any of the above factors have already caused a disturb- ance of the functions of the stomach, this in itself will result in a further aggravation of the trouble, for the reason that the patient eats less, and is therefore insufficiently nourished, which still further depletes his general force and vitality. This fact best explains the reason why such patients are irrationally put on a limited diet of liquids for years, — -the attending physician mistaking the functional dyspepsia for one of an organic nature. Diagnosis. — The diagnosis of functional diseases of the stomach is, as a rule, easy. The physician is, in most cases, able to differentiate these troubles from organic diseases by the anamnesis, as has been shown in detail in the description of the diagnosis of ulcer, carcinoma, and catarrh of the stomach. The fact that in functional diseases of the stomach actual pain scarcely ever occurs, is of the greatest practical import- ance in the diagnosis. The symptoms are, instead, only general dyspeptic disturbances, a feeling of fulness in the stomach, loss of appetite or rapid satiation of hunger, eructation, pyrosis, regurgitation, salivation, and constipation, — with general lassitude, weakness and lack of desire to work. Prognosis. — The prognosis of a functional disease of the stomach is in itself good. Cure always results if the disease which caused the dyspeptic symptoms can be removed. Unfortunately this is often impossible, because in the struggle for existence many patients lack the time and money to afford themselves the necessary rest and care. 180 DISEASES OF THE DICxESTIVE CANAL It need scarcely be mentioned that very frequently it is absolutely essential to a cure, that the patient be sent away for change of scene and climate in order that his mind may be diverted by new surroundings. If ho is able to fulfil these requirements for a sufficient length of time, a cure generally results. But it is to be expected that relapses will frequently occur if the patient resumes his former habits of living, because like causes produce like effects. Treatment, — Treatment should be almost exclusively directed to the removal of the primary disease, and should be, therefore, general, in contradistinction to the treatment of organic disease of the stomach, which is local and directed to the stomach itself. It is often very difficult to distinguish the different vari- eties of functional dyspepsia, in none of which are there pathological alterations of the gastric mucosa. They often merge gradually into one another and, in general, have many symptoms in common. The following classification, which is arranged according to etiological principles, has served me so well in practice that I do not hesitate to retain it in a book which is designed to serve as a guide to the general practitioner, although I am well aware that such a classification is not in accordance with that given in most of the text-books on stomach diseases. AnaBmic=Gastroptotic Dyspepsia (Atonia, or Myasthenia Ventriculi, Mechanical Insufficiency of the First Degree, Nervous Dyspepsia) As the name indicates, we understand anaemic-gastroptotic dyspepsia to be that affection of the stomach in which the most characteristic symptom is the low position of this organ in a poorly-nourished individual. Since this condition has been discussed in the Introduc- tion, I will here briefly cover only the etiological points. The predisposition to this form of dyspepsia is either a congenital hahitns enter oyticus, or an acquired enteroptosis following pregnancy; while the exciting causes of the disease DISEASES OF THE STOMACH 181 may be any condition that loads to anscmia, neurasthenia, or malnutrition of the individual. Gastroptotic dyspepsia, commonly known as atony, is extraordinarily frequent, being perhaps the most common disorder of the stomach. Its accurate recognition, therefore, is of great practical importance. It very frequently happens that not only the laity, but physicians also classify this very ordinary affection erroneously under the title, ''chronic gastritis." This explains why it is that so many patients suffering from functional disorders of the stomach are not cured, and why it is that they ultimately fall into the hands of "neuropaths," who, by the establishment of hygienic measures and by the use of hydrotherapy, very often effect brilhant cures. Symptomatology. — The symptoms of the disease are divided into subjective and objective. The former are far more characteristic than the latter, so that it is usually possible to make a correct diagnosis if the anamnesis is obtained with accuracy and care. Subjective Symptoms. — Subjective symptoms consist of all kinds of dyspeptic disturbances, but especially of pressure in the stomach after heavy meals and, in severe cases, even after a plate of soup or a glass of milk. Other symptoms are a feeling of fulness and distention in the epigastrium, rapid satiation of appetite, or anorexia, gaseous and acid eructations, regurgitation of food a short time after eating, sluggish bowels, water-brash and nausea, general lassitude and distaste for work, especially after meals. On the other hand, actual pains never occur in uncom- plicated anaemic-gastroptotic dyspepsia, as has already been stated in the discussion of Ulcer and Stenosis. Objective Symptoms. — The objective symptoms are general emaciation and anaemia, in addition to the presence of habitus enteropticus, evidenced by an acute costal angle, the long, narrow thorax, and fluctuation of both tenth costal ribs. The abdomen is relaxed, and the splashing sounds are easily produced. 182 DISEASES OF THE DIGESTIVE CANAL The lower border of the stomach frcquentl}' Ucs at the level of the umbilicus, or two or three finger-breadths below it. Frequenth', in women who have borne children, the greater curvature extends a hand-breadth ])eh)w tlie umbilicus, or even to the sj'mphysis pubis. The position of the greater curvature is easily determined by Obrastzow's method, which has been described in detail in the General Section. If there is not a sufficient amount of fluid in the patient's stomach at the time of examination, the ph3^sician should have him drink one or two glasses of water and should then determine the location of the fluid by palpatory percussion. The various ingenious methods for ascertaining the position of the greater curvature, — such as the carbon dioxide distention of the stomach by the use of effervescent powders, and inflating the stomach with air by means of the stomach-tube and a rubber bulb, and the illumination of the stomach by Einhorn's diaphane, — are not essential in general practice, and are besides very annoying to the patient. A detailed description of these methods may be found in any text-book on Diseases of the Stomach and Intestine. In addition to gastroptosis, there is generally a ptosis of the transverse colon and a dislocated right kidney, — the left kidney being less frequently movable. The examination of the stomach with the stomach-tube gives the following findings: The fasting stomach is alwaj's found entirely empty the morning after the test-supper, or at most contains only a few cubic centimetres of gastric juice mixed with mucus and epithelium from the mouth, oesophagus and bronchi. Should remnants of food be found, contrary to the expec- tation of the physician, atony may be excluded from the diag- nosis, the condition being more probably that of gastrectasis. An hour after the Boas-Ewald test-breakfast, the stomach- contents will be found well digested, with a total acidity of from 40 to 65, although transient hjq^eracidity and sub- aciclity also sometimes occur, — to which, however, no great importance should be given. It would be incorrect to assume the presence of a gas- tritis, should the total acidity amount to only 20 or 30, if DISEASES OF THE STOMACH 183 otherwise the clinical symptoms of the case were those of ansemic-gastroptotic dyspepsia. The remnant-test of Mathieu-Remond (see page 35) usually amounts to from 220 to 270 c.c. one hour after the test-meal. Although this exceeds the normal, it is as likely to be due to an increase of the gastric secretions as to impair- ment of the motor powers of the stomach. Seven hours after the Riegel test-dinner (see page 35), the stomach will usually be found empty. In cases, however, of extreme physical debility, some of the test-dinner may still be present in the stomach seven hours after eating. These cases, however, do not differ in any other factor from the usual ansemic-gastroptotic dyspepsia. It has been thought necessary by some to designate such cases as motor insufSciency of the first degree, or atony. The authors who share this view ascribe the delay in the expulsion of food into the duodenum to a primary muscular weakness of the stomach. I am of the opinion that the find- ing of small remnants of food seven hours after the test- dinner is as frequently the result of excessive secretion of the gastric juice, and that it is occasionally caused by diminished innervation of the musculature of the stomach. That the authors who consider the cause of the trouble to be a primary muscular weakness of the stomach cannot be in the right, is best proven by the therapeutic resuhs of forced feeding in this affection. If this theory were correct, such patients would suffer from gastrec- tasis or motor insufficiency of the second degree when their stomachs were excessively overloaded by the forced feeding. Since this is never the case, but on the contrary, such patients recover their health through the forced feeding cure, the theory of primary muscular weakness in ana^mic-gastrop- totic dyspepsia is evidently incorrect; and the cause of the affection is to be found in a general or constitutional disease. Consequently, I never have any fear of resorting to forced feeding in cases where remnants of the test-dinner are still present in the stomach seven hours after eating, if the patients present only the chnical symptoms of a purely functional affection of the stomach. It really amounts to malpractice to resort to gastropexy, — which frequently has been done, — for the relief of this condition, since this procedure exposes the patient to danger without obtaining more relief than is possible by forced feeding and rest. 184 DISEASES OF THE DIGESTIVE CANAL Diagnosis. — The diagnosis of functional ana^mic-gas- tropt(3tic dyspepsia is made from the above-mentioned symp- tom, — namcl}', pressure in the stomach, especially after meals, whether fluids or sohds; and the larger the meal, the greater the disturbances. In the objective examination, the physician usually finds normal secretions and normal motility of the stomach. In severe cases, there is sometimes a slight delaj^ in the expulsion of the test-dinner into the duodenum, but in no ease is there stagnation of food. The total acidity may be slightl}" increased or decreased, or free hydrochloric acid may be entirely absent. Usually, however, there is a variation in the acidity; for instance, one day there will be a total acidity of 60 and a few days later of 30, and vice versa. In this disease, there are, naturally, enteroptosis and impaired nutrition. Differential Diagnosis. — Ulcer and ectasia are easily differentiated from functional dyspepsia, since in both of these diseases vomiting is a symptom; while in ulcer, epi- gastralgia is prominent. Carcinoma is also easy to exclude from the diagnosis, for the reason that in carcinoma the gastric secretions are per- manently reduced, and the course of the latter disease would be malignant. Only in chronic gastritis is it sometimes impossible to make a differential diagnosis from antemic-gastroptotic dys- pepsia without the use of the stomach-tube, since in this affection pressure in the stomach also occurs after meals. In contradistinction to functional dyspepsia, however, this pressure does not occur after the patient has taken liquid foods. In addition to this clinical differentiation, the examiner may prevent confusion in his diagnosis by giving the patient a test-breakfast. In chronic gastritis, the secretions are persistently increased, diminished, or entirely absent. The anamnesis, the habitus, and the ptosis of the ab- dominal organs in enteroptotic dyspepsia give further clews for a differential diagnosis. DISEASES OF THE STOMACH 185 Prognosis and Course. — The clinical course of the disease is eminently chronic, often extending over decades, for the disease may exist from youth to old age. It generally attacks those individuals who have weak stomachs, and is hereditary in the same sense as is habitus enteropticus, i.e., the predisposition is inherited, while the dis- ease itself is brought on by unfavorable influences and factors.* The disease shows remissions, — healthy periods alter- nating with illness, — according to whether the patient is taking the proper care of himself, or must work hard. It is worthy of mention that the symptoms of ansemic- gastroptotic dyspepsia in women usually disappear during pregnancy, — which is very simply explained from the fact that the abdominal organs, which normally have a low posi- tion, are then supported by the growing uterus; and there is also the favorable influence of gravidity upon the metabolic process of the body. This fact is usually observed in multiparse. The disease may become serious through complications; for instance, pulmonary tuberculosis may develop in the patient who is malnourished and weakened by the disease. Habitual constipation is a very frequently resulting phenomenon of functional dyspepsia, because the patient, in consequence of his dyspeptic disturbances, eats such small amounts of food that there is not sufficient to maintain the normal intestinal peristalsis. Enteroptotic dyspepsia never develops into gastrectasis without the occurrence of a complication, such as ulcer of the pylorus. Many patients of insufficient financial means, or who lack the necessary time for treatment, are never cured. Treatment. — The treatment of ansemic-gastroptotic dj^s- pepsia can naturally be only a general one, to strengthen the weakened constitution and to increase the nervous, muscular, and circulatory vigor of the patient, through good care, forced feeding, rest, and plenty of fresh air. * Of atony, one might say with Goethe, "What thou hast inherited from thine ancestors, thou must win in order to possess." 186 DISEASES OF THE DIGESTIVE CANAL In many cases, a change of scene is all that is required to add tone to the nervous system of the patient, and to increase his appetite, therein' improving the nutrition and regulating the digestion. The symptoms of the disease will disappear under this regime, without the institution of other therapeutic measures. Such patients, therefore, do not require the treatment given for organic affections of the stomach at such places as Carlsbad, Kissingen, etc., and should in general avoid the use of the various mineral waters. A sojourn at some health resort, high in the mountains or at the seaside, is more suitable. Three other forms of hydrotherapeutic procedures are generally useful, which, if necessary, may be carried out at home; these are cold friction or the cold pack, the half-bath, and the cold douche. These stimulating treatments should not be used if the nervous system of the patient is in an irritable condition, as evidenced by exaggerated knee-jerks, excitement, and loss of self-control on slight provocation. Protracted lukewarm baths, or the pine-needle baths are preferable in such a case. As a household treatment, I usually begin with applications of cold moist towels. After the patient has become accustomed to this treatment, the cold wet sheet-pack should be applied to the entire body, accompanied by vigorous friction, given by an expert nurse, if possible. In summer, the patient should take cold shower-baths or plunges in a lake or river. A weaker patient may be given half-baths instead, sitting in water up to the epigastrium, at a temperature of 25° to 20° R. [88° to 78° F.), and having water poured over him at a temperature of 20° to 15° R. [78° to 68° F.], the patient meanwhile rubbing himself vigorously to avoid becoming cold. The entire procedure of the half-bath should not exceed five minutes, and the best time for its use is early in the forenoon. More complicated hydrotherapeutic procedures may be carried out in a sanitarium or a water-cure establishment ; although in most cases of func- tional dyspepsia, the necessary hydratic procedures may be given at home. Excessively severe treatment is harmful and should be avoided in hysterical and irritable patients, and naturally in cases when it is doubtful whether an organic or a functional dyspepsia exists. There are numeious ex- amples of cases where the patient was made worse by the use of water, applied \vith the assumption that a nervous affection was present, when in reality the trouble was due to an ulcer or some other organic disease of the stomach. DISEASES or THE STOMACH 187 Diet. — In every case, the dietetic treatment is the most important part of the therapy. It effects the most brilhant results, but these can be fully obtained only in connection with other hygienic factors, such as fresh air, pure water, and the avoidance of fatigue. The diet in ansemic-gastroptotic dyspepsia must, above all things, be such as will improve the nutrition of the individ- ual. It should be strengthening, and contain considerably more calories per clay than are necessary for the maintenance of the organism. In other words, the patient should be given the rest- and fattening-treatment, such as has been perfected by Playfair and S. Weir Mitchell. Whenever possible, the patient should absent himself from his usual occupation for about six weeks, and spend the first two or three weeks of treatment in bed. It is preferable that such cures be carried out in a sani- tarium. There are, however, a large number of patients who do not have the necessary time nor sufficient financial means at their disposal to avail themselves of the advantages of institutional treatment, so that it is often necessary to at- tempt the cure by ambulatory treatment at home. The diet-scheme suitable for ambulatory fattening-cure should be arranged about as follows: The articles named in the parentheses are suitable if the patient is at the same time suffering from chronic constipation. 7:00 a.m. Tea with cream, butter-rolls. (Stewed fruits, mar- malade, honey, whole-wheat bread.) 9:00 A.M. Cereal or flour soup cooked with cream, bread and butter, eggs or scraped ham. (Koumiss or butter- milk.) 12:00 M. Vegetables cooked with butter, boiled or roast meats, sweet fruit-sauces, mild pastries. (Cider.) After this meal the patient should rest in a recumbent position with loosened clothes for one or two hours. 3:00 P.M. Tea with cream, etc., as at 7:00 a.m. 5:30 P.M. Flour soup, etc. 7:30 P.M. Tea with cream, bread and butter, cold meats or eggs. 9:00 or 10:00 p.m. Fruit. 188 DISEASES OF THE DIGESTIVE CANAL As might be expected, patients have more digestive disturbances while the increased amount of nourishment is being taken during the first two or three weeks of the fatten- ing-treatment, than the}' had when on the previous Htiuid diet. The physician must not, however, let himself be influenced by the complaints of the patient, but should energetically insist upon his adhering strictly to \\\v above- mentioned diet-regime. The physician should always assure himself, by means of a pair of scales, whether or not the patient is increasing in weight; and as soon as there is a gain of two or three pounds in weight, the patient will be easily convinced that his stomach is not so much at fault as he had supposed, but that, on the contrary, his digestion is quite good; and as he gains in con- fidence, he wall be much more walling to bear the possible discomforts of forced feeding. Nausea and regurgitation, which frequently occur after meals, should not be given too much attention. It is only when cramp-like pain and diarrhoea set in, that the amount of food should be lessened. The physician should then once more carefully examine the patient to deter- mine whether or not an organic affection exists which had been previously overlooked. After about two weeks' treatment, when the metabolism has been improved, the dyspeptic disturbances generally begin to disappear; and they cease entirely after about three or four weeks of treatment. As a rule, the patient will have gained in weight a-bout eight or ten pounds, and will feel strong and healthy and able to enjoy the ordinary household diet without any discomfort. With sanitarium-treatment, there is often a greater increase in weight, and a still more rapid and striking improve- ment in the condition of the patient. An actual and permanent cure is obtained by this plan of treatment if the dyspepsia was caused solely by anaemia and enteroptosis. The abdominal organs, especially the capsules of the kidneys and the mesentery, regain their normal DISEASES OF THE STOMACH 180 amounts of fat, which helps to cstabhsh the normal equilib- rium and position of these organs, while the general treat- ment has also improved the quality of the blood and led to functional energy of all the abdominal organs. The rest-fattening cure, however, cannot restore all cases of dyspepsia of a functional nature. Those patients whose nervous systems have been injured by over-work, dissipation and worry, generally have only the nutrition restored to the normal by the fattening-cure, their dyspeptic symptoms not always disappearing. For these cases, mental diversion and change of scene are absolutely necessary. Medicinal Treatment. — The drug-treatment of ana^mic- gastroptotic dyspepsia is useful only in so far as it assists in carrying out the diet-treatment, by stimulating the appetite and suppressing the hypersesthesia of the gastric mucosa, etc. These indications are best fulfilled by bitters given before meals. The following prescriptions are examples: 1. I^ Tincturae nucis vomicse, gtts. xc-giiss 5.0-10.0 Tincturse gentianse (or tincturae rhei), ovss-viss 20.0-25.0 M. Sig. — Thirty drops 10 to 15 minutes before meals in a wineglassful of water or on sugar, t.i.d. 2. I^ Tincturae cinchonae, 3iss 50.0 or extracti calami fluidi, ^iss 50.0 or tincturae quassiae, 3 iss 50.0 or extracti condurango fluidi, 3 iss 50.0 M. Sig. — A teaspoonful, t.i.d. 3. I^ Acidi hydroclilorici diluti, rt\xl 2.5 (Tincturse nucis vomicae), TTLxxxii 2.0 Vini condurango, ^iiiss 100.0 M. Sig. — A teaspoonful, t.i.d. 4. I^ Extracti cinchonae, §1 30.0 Sig. — Twenty drops, t.i.d. 5. I^ Tincturae belladonnae foliorum, 3 iss 5.0 Extracti condurango fluidi, ^viss 25.0 M. Sig. — Twenty-five drops t.i.d., for hypersesthesia of the gastric mucosa. 190 DISEASES OF THE DIGESTIVE CANAL 6. I^ Extract! nucis vomicre, Extract! belladonna* foiionun, fia gr. !vss 0.3 ' Pulveris glycyrrhizjE composili, gr. xxiv 1.5 M. ft. pil. XXX. S!g. — A pill after eating, t.i.d. 7. I^ Ferr! reducti, oiss . 6.0 Extract! nucis vomicte, gr. vi 0.4 Quinina) hydrochloridi, 5ss 2.0 Acid! arseno.si, gr. ! 0.06 Extract! rhei, gr. xv 1.0 Mass. pill. q.s. ut f. pill. No. Ix. Sig. — Two pills t.i.d. (Biermer.) Massage of the stomach, and also of the intestine when constipation exists, usually affords the patient considerable relief during the rest-cure. It should consist chiefly in strok- ing the epigastrium with the flat hand after meals for five or ten minutes. This produces a pleasant and agreeable feeling of warmth. In organic affections of the stomach, on the contrary, massage usually produces unpleasant results and often pain. For very relaxed patients, the physician may also advise massage of the entire body, in order to stimulate the general metabolism, while the local massage of the stomach is per- formed by the physician personally with the best of results. Remarks on Enteroptosis (Gastroptosis, Nepliroptosis, and Pendulous Abdomen) Glenard was the first to appreciate correctly the relation between the sinking of the abdominal organs and disorders of the digestive tract. He showed that a large number of the nervous affections of the stomach may be traced to this ana- tomical condition. Stiller recognized that the fundamental cause of enterop- tosis is the habitus enteropticus. Owing to the fact that persons with habitus enteropticus generally possess weak constitutions, Stiller has designated this entire type of individuals as having "asthenia universalis congenita." The habitus enterojjticus is, therefore, congenital, — while enteroptosis, or Glenard's Disease, is acquired through various factors incident to modern life. DISEASES OF THE STOMACH 191 It is possible that habitus entcropticus is to be attributed to avatism, and can be traced to the time when human beings had not yet assumed the upright posture; for in no animal is the thorax so wide as in man, and it has probably developed only gradually. This is why a person with a broad thorax is scarcely ever affected with enteroptosis, since his organs are miich more firmly fixed and held in place. In addition to congenital or constitutional enteroptosis, there is an acquired or local form which occurs in women after pregnancy when the abdominal walls have been very much distended. The following abdominal organs may assume an abnor- mally low position : the stomach to a hand-breadth below the umbilicus; the transverse colon to the symphysis; the liver, and more rarely the spleen; and both kidneys, especially the right kidney. There are three degrees of nephroptosis: The first degree, when the lower portion, the second degree when half of the organ, and the third degree when the entire kidney is palpable during deep inspiration. If the kidney remains in its abnormal position during expiration and the quiescent respiratory period, the condition is described as dislocated, floating, or movable kidney of the fourth degree. Uncomplicated floating kidney may perhaps cause some discomfort to the individual, but never actual pain. Treatment. — Therapy, to be suitable for the congen- ital or constitutional enteroptosis, can be only such as will tend to strengthen the weakened constitution of the patient; while acquired .enteroptosis, produced by local condi- tions, must, in addition to the above, be treated locally. In this form, therefore, the application of suitable abdominal bandages is indicated; these serve to restore the sunken abdominal organs to their normal positions. This purpose is fulfilled by most of the abdominal bandages purchasable in large instrument-houses. To prevent the upward displacement of the bandage, thigh-bands should be used, just as in hernia trusses and bandages. 192 DISEASES OF THE DIGESTR^E CANAL Corsets arc absolutely forbidden in enteroptosis. Women with entei'optosis should wear "health-waists," to which Fig. 31. Fig. 32. Fig. 33. Various forms of abdominal belts. Fig. 34. Stengel's kidney belt. the skirts are buttoned, or the skirts may be supported by straps over the shoulders. Street-clothes should also be worn DISEASES OF THE STOMACH 193 supported from the shoulders, so that all pressure at the waist may be avoided. [The above statement of the author, in which he says that corsets should be forbidden in enteroptosis, evidently refers to the older form of corset which constricted the epi- gastrium and crowded downward the viscera of the abdominal and pelvic cavities. The more recent "corrective straight front" corset, if properly made and fitted by a corset-maker, presses inward and upward on the lower abdomen, serving to restore to their Fig. 35. Diagram showing the adhesive plaster marked for cutting.* Fig. 3G. Diagram showing the adhesive plaster belt. normal position organs which are displaced downward. Since no constriction of the lower thorax and of the epigastrium is caused the wearer, such corsets may be used in lieu of an abdominal bandage in many cases of enteroptosis.] In women with normal habitus, however, corsets are not forbidden; it is even better to wear them if properly fitted, since without corsets the skirts are simply tied around the waist, sometimes causing constricted liver and other disturbances. The use of adhesive plasters as a substitute for abdominal bandages has been recommended by two American authors, Rose and Rosewater, to be applied in the following manner: *[The sections indicated by the dotted lines, and marked (see Fig. 35), are separated from the bandage A, and laid upon it in reversed position so as to overlap (see Fig. 36) .] 13 194 DISEASES OF THE DIGESTIVE CANAL The ends of three broad strips of adhesive plaster are applied to the lower part of the abdomen, just above tlie symphysis; the otlier end of the middle strip is then brought upward and applied to the sternum. The right and left strips, respectively, are drawn obliquely around the sides of the patient and adhere to the spinal column. A fourth transverse strip of the plaster may also be applied across the abdomen above the umbilicus. In certain cases, this adhesive plaster bandage has given me good results, although its coatiiuied use is generally mipleasant to the patient, Fin. 37. The first step iu the application of tlie adhesive plaster belt. causing discomfort during the night, producing eczema and sudamina, and rendering it imj)ossible for him to bathe. The necessity of changing the plaster every three or four weeks makes it rather more expensive to the patient in the long run than an abdominal bandage. [The Rose adhesive plaster bandage may also be applied in the manner shown in Figs. 3.5, 36, 37, 38. A strip of " mole-skin " plaster seven inches in width and of sufficient length is cut as in Figs. 35 and 36, and then applied as in Figs. 36 and 37. The disagreeable itching and skin irritation which sometimes result from the use of Rose's adhesive plaster belt may be largely avoided if certain precautions mentioned by DISEASES OF THE STOMACH 195 Rose * and confirmed by experience are observed. The so-called "mole-skin" plaster, 7 inches wide, is preferable to any other. Before applying the plaster, the abdomen should be thoroughly washed with alcohol and ether to remove the fats and moisture of the skin. In my practice, patients have frequently worn one belt three or four weeks without causing any irritation of the skin. Fig. 38. Tlie second step in the application of the adhesive plaster belt. I usually apply the adhesive plaster belt preliminary to prescribing the ordinary abdominal belt, in order to more accurately estimate the amount of disturbance caused by the enteroptosis, and to more intelligently select a belt which will be adaptable for prolonged use. (See illustrations.)] Persons who have enteroptosis with the normal habitus, especially women, have quite a number of unpleasant symp- toms, particularly the feeling of heaviness, backache, weight, and even of a complete prolapsus of the uterus, also drawing- *"Atonia Gastrica," by Rose and Kemp, Funk and Wagnalls Co., 1905. 196 DISEASES OF THE DIGESTIVE CANAL pains in the sacrum and in the costal arches, especially after hard physical labor or standing for a long time. It need not be especially mentioned that both ileus and hernia of the anterior abdominal wall sometimes occur in severe cases of enteroptosis. Either congenital or acquired enteroptosis may exist without symptoms as long as the nutrition of the affected individual is good. Sometimes the physician accidentally discovers gastroptosis or a movable kidney when examining children or adults with good digestion. According to Stiller, such a finding should always be regarded as an indica- tion that such individuals are predisposed to functional disturbances of the stomach and intestine. Phthisical Dyspepsia Although dyspepsia caused by phthisis belongs to the large group of ansemic-enteroptotic dyspepsias, the subject will be given separate consideration on account of its great practical importance. Its symptoms are exactly the same as those of anaemic- gastroptotic d3'spepsia, — persistent loss of appetite, pressure and fulness after meals — whether solid or hquid food, — regurgitation, lassitude and weakness. Objective symptoms are ptosis and easily obtained splash- ing sounds in the epigastrium, while both the motility and secretion of the stomach may be normal or only slightly deviating from the normal; besides severe anaemia, emacia- tion may be present, as well as the symptoms of lung-affection. The physician should make it his absolute duty to examine the lungs of every young person that suffers from a persistent dyspepsia, and he will doubtless be surprised to find how frequently tuberculosis of the lungs is responsible for what has been treated months or years as chronic gastritis. Treatment. — The therapy, naturally, should deal with the primary disease. A very full, rich diet should, therefore, be advised in spite of the dyspeptic complaints of the patient. If the diet is such as to improve the nutrition, the stomach- symptoms will disappear of themselves. DISEASES OF THE STOMACH 197 As a supporting treatment, creosote combined with a bitter may be prescribed, and is best given in the form of the well-known creosote-tincture, which contains one gram of creosote to four drams of tincture of gentian. The effect of this medicament is almost specific in phthisical dyspepsia. In the beginning, I prescribe 8 drops three times daily after eating, in a teaspoonful of red wine; every day increasing the dose one drop, in such a manner that on the fourth, fifth and sixth days the patient takes 9 drops three times daily, and on the seventh, eighth and ninth days 10 drops three times daily, etc., until 20 drops are taken three times daily, which should be continued for about three months. In well-marked advanced cases of phthisis accompanied by dyspepsia, the physician will obtain very good results with codeine. In regard to the relation between phthisis and dyspepsia, it should be remarked that the opposite of what has been said above is sometimes the case, when dyspepsia is primary and phthisis secondary. CLINICAL CASES Because of the importance and frequency of functional dyspepsia, I have added quite a number of illustrative cases. 1. Congenital Cases Case 1. — Mr. M., a business man, 33 years old, who had led a dissi- pated and reckless life. For two years he had suffered from a feehng of fulness and pressure in the epigastrium, and from eructations, after each meal. The appetite was good and the bowels regular. He had never suffered pain in the epigastrium. Patient was anaemic and thin, weighed 111 pounds and had the habitus enteropticus. The test-breakfast showed that the gastric secretions were normal. The treatment consisted of forced feeding and the use of bitters. In six weeks, the patient had gained .10 pounds in weight and later was completely cured, and was able to eat all kinds of food without discomfort. Case 2. — Hedwig Z., a governess, 30 years old, for four years had suffered from a feeling of fulness after each meal, and from constipation, but never pain or vomiting. The appetite was poor. The patient was ansemic, emaciated, and had ptosis of the abdominal organs. The test- meal showed normal acidity of the gastric juice. 198 DISEASES OF THE DIGESTIVE CANAL Tho treatment consisted of a fattcninpi-oonstipation diet, and bitters and massage; and within a short time the patient was free from all discomfort. Case 3. — Gertrude E., a teacher, 23 years old, had been mentally over-worked foi" o\'er a year, and had felt exhausted and weak for five months past, with no appetite and with constant pressure and fulness in the epigastrium after eating any kind of food. Occasionally she had gone se^'eral days without any gastric distiu'bances. The patient was ^'ery anaemic and emaciated. She had the habitiis enteropiicus. The test-break- fast was well digested, and the total acidity one and one-half hours after the test-meal was 78. (Her father likewise had had hyperacidity.) The treatment consisted in forced feeding, bitters, and rest from work. She gained four pounds in weight in three weeks and the dyspeptic complaints soon ceased. 2. Cases of Acquired or Mixed Forms of Ptosis Case 1. — Clara M., 30 years old, had been pregnant twice. Her father had died three months previous from "large spleen," since which bereavement the patient had been ill from loss of appetite, rapid satiation, and the feeling of pressure and fulness in the epigastrium after eating any kind of food. The bowels had been regular and she had suffered from no pain nor vomiting. Patient was very anaemic and emaciated, and weighed 114 pounds. She had both the inherited and the acquired forms of ptosis. Her right kidney was movable to the third degree, the spleen slightly enlarged, the colon sunlcen, and loud splashing sounds could be easily obtained in the epigastrium. The treatment consisted of ambulatory forced feeding, bitters and massage. In two and one-half months, patient had gained IS pounds in weight, was fully restored to health, did her work without fatigue, and was able to eat any kind of food without discomfort. Case 2. — Mrs. W., 30 years old, had been pregnant eleven months previous. For six months she had suffered from pressure, but no pain, after eating. The patient had been much worried for the past six weeks. Stools were regular. Patient was very anaemic and emaciated, weighing only 107 pounds. She had both congenital and acquired ptosis. Both kidneys were movable to the third degree. Loud splashing sounds in the epigastrium were easily produced. Treatment. — Rest in bed, forced feeding, and bitters. In two months she was free from all discomfort and had gained 5 pounds in weight; after six weeks, her weight had increased to 117 pounds, and she was entirely well. 3. Phthisical Ffyspepsia Case 1. — Louise W., 31 years old, the wife of a merchant, had at one time been pregnant. Nepliroptosis had been diagnosticated ten years pre- vious. For the past seven or eight weeks, she had had poor appetite, sluggish stools, pressure and fulness after eating, which were relieved by assuming a DISEASES OF THE STOMACH 199 recumbent position. She had night-sweats, had lost 20 pounds in weight, and was very anaemic and emaciated. She had the habitus enteropticus and relaxed abdominal walls ; both kidneys were movable to the second or third degree, and there was a slight catarrhal involvement of the right apex. No benefit was obtained from forced feeding and the use of bitters. Patient was, therefore, sent to a sanitarium for treatment. Case 2. — Heinrich M., an engineer, 23 years old, had had occasional stabbing pains in the epigastrium, distention, and diarrhoea for two years. For six or eight weeks he had had pressure in the stomach after meals and poor appetite, besides quite frequent slight chills, expectoration and night- sweats. He had been treated for gastric catarrh with a light liquid diet. He was very thin and anaemic, and had the habitus enteropticus. Rales were heard in the apices of both lungs. His temperature was 38.3 C. The test- breakfast was deficient in acids, the total acidity being 22. Strong splashing sounds in the epigastrium were obtained. The patient was sent to Gorbers- dorf, where he was cured. Case 3. — Carl P., a farmer, 39 years old, had for six months had pres- sure in the stomach after eating, but no pain. His appetite had been good. The patient had habitus enteropticus, with loosening of the tenth costal cartilages, and inflammatory involvement of the right apex. The treat- ment consisted of the administration of creosote and gentian. The pressure in the stomach disappeared, his appetite improved, and he gained four pounds in weight. Case 4. — Mrs. T., 28 years old, had lost her mother from tuberculosis, and one sister was phthisical. Two years previous, the patient had been treated in Wehrawald for tuberculosis of the lungs. Nine months ago she gave birth to a child, since which time she had been exhausted, without appetite, had suffered from pressure and fulness in the epigastrium and regurgitation, after eating any kind of food. Patient was very much emaciated. She had both the congenital and acquired forms of ptosis, and the abdominal walls were very much relaxed. Both kidneys were dislocated. There was catarrh of both the apices. No benefit was obtained from the forced feeding, bitters and massage. Patient was sent to a sanitarium, where she died in about a year. Nervous Dyspepsia Nervous dyspepsia is very closely associated with and related to ansemic-gastroptotic dyspepsia. There are, how- ever, a few points so essentially different, that in most cases a distinction between the two affections is possible. In neither form of dyspepsia are there anatomical lesions of the mucosa of the stomach; at least, we are unable to detect any with our present methods of examination. 200 DISEASES OF THE DIGESTIVE CANAL While, as has been sufficiently emphasized, the habitus enteropticiL§ together with emaciation and anirmia arc the predominating signs of ana^mic-gastroptotic dj^spepsia, we do not always find these present in a purely nervous dyspepsia. The latter may develop in persons with the normal hahitus if the nervous system becomes unstable and irritable from any cause. The same thing occurs in persons who are well nourished — only more rarely — if they arc mentally over- worked or suffer from psychical disturbances. Etiology. — Nervous d3^spepsia is caused by disturbance of the vegetative nervous S3'stem, — the sympathetic nerve and its abdominal branches, the splanchnic nerves; since the sympathetic nerve stands in intimate relationship with all the organs of the bod}', the affection of any organ may cause nervous dj'spepsia, as soon as the sympathetic nervous system is in a condition of unstable equilibrium, as, — for example, in hysteria. Nervous dyspepsia is, therefore, always a local evidence of a general nervous condition. A pathological alteration, — limited to the nerves supplying the stomach, the splanchnic nerve or Auerbach's plexus, — is not probable, as the symptoms of a general neurasthenia or hysteria are alwa3^s present in such cases. Mental over-work, especially hurried nervous activity, emotional depression from death, sorrow, and care, or the fear of contagion while caring for cancer- or tuberculosis- patients, or fright, or trauma, — all form a large group of etiological factors. Another large group of causative factors is associated with disease of the sexual organs, occurring most frequently in men with phosphaturia, prostatorrhoea, spermaturia and, in short, in those of perverse sexuality and those who indulge in masturbation and in coitus interruptus; while in women, the chronic diseases of the pelvis, which need not be men- tioned in detail, induce a like result. Nervous dyspepsia is also frequently found in persons who suffer from chronic constipation or diarrhoea. DISEASES OF THE STOMACH 201 Any of these factors, as we shall sec later on in the clinical cases, may be associated etiologically with nervous dyspepsia. Symptomatology. — Actual pain, as also in ana3mic- enteroptotic dyspepsia, never occurs in nervous dyspepsia, but only general dyspeptic disturbances, such as pressure and fulness after meals. At times, these symptoms begin after eating only light, easily-digested foods; while at other times there is no discomfort, even after heavy, indigestible foods. Additional symptoms are distention of the epigastrium, eructation, and regurgitation. Actual vomiting does not occur, but there is usually an irregular, perverse, or complete loss of appetite. Very frequently there is a persistent pressure in the epigastrium and behind the sternum, similar to the sensation of globus hystericus. The dyspeptic symptoms throughout the cHnical course of this disease are dependent upon the condition of the ner- vous system. With physical and mental rest, the symptoms disappear, but to return after any kind of excitement. The objective examination in nervous dyspepsia usually reveals the fact that the stomach is normal in both its secre- tory and motor functions. The fasting stomach is either en- tirely empty or contains only a few cubic centimetres of gastric juice; and no remnants of the Reigel test-dinner are to be found in the stomach seven hours after eating. An hour after the Boas-Ewald test-breakfast, the meal is found well digested; and the total acidity, as a rule, amounts to from 40 to 70. It is peculiar to nervous dyspepsia that there occur great variations in the secretory functions of the stomach. In the same patient, the examiner may find a total acidity of 60, which a few days later may be 40 and at another time 20, while the fourth exami- nation may again show 60. Free hydrochloric acid may be entirely absent, or hyperchlorhydria and an excessive secretion of gastric juice may occur. In short, the condition of the stomach varies with that of the nervous system. On the other hand, gastric ferments are always present in nervous dyspepsia, even when there is an absence of free hydrochloric acid. 202 DISEASES OF THE DIGESTIVE CANAL For further details in regard to this point, the reader is referred to. the chapter on Gastric Ferments in the General Section. Diagnosis. — From the facts that the subjective symptoms of nervous dyspepsia are so manifold and variable, and that objective symptoms are either entirely absent, or take definite shape only after prolonged observation, it is, in many cases, impossible to arrive at an immediate diagnosis; and the physician should withhold his opinion until repeated exami- nations have been made. Of first importance is the variation of the stomach- secretions and the dependence of the dj'speptic s3miptoms upon the conditions of the nervous system. Differential Diagnosis. — The differential diagnosis is very easy in individual cases when the secretions and the motor- power of the stomach are normal. In other cases it is very difficult, because the affection may be easily confused with chronic gastritis. Gastric ulcer may be excluded from the diagnosis with positiveness by the occurrence of epigastralgia at an almost regular interval after eating; while in nervous dyspepsia, actual pain in the stomach does not occur. One of the sequelae of ulcer,— namely, perigastritis, — more frequently leads to confusion in the diagnosis than does ulcer. The details of the symptomatology of this affection are given in the chapter on Gastric Ulcer. It need only be mentioned here, that in perigastritis the symptoms and discomforts of the patient are largely dependent upon his physical activity and are but slightly influenced by the condi- tion of his nervous system. Gastric hernia sometimes gives rise to a mistaken diag- nosis, because the symptoms of this condition are often so atypical and vague that the physician may classify the affec- tion as ''nervous dyspepsia." Occasionally, cancer of the stomach is not recognized as such, and is considered by the phj^sician to be nervous dyspepsia. DISEASES OF THE STOMACH 203 Nervous dyspepsia is differentiated from ana^mic-enterop- totic dyspepsia, — first, by the etiology; and second, and more significantly, by the variabihty of its symptoms. Anaemic-gastroptotic dyspepsia occurs in very anaemic and under-nourished individuals who have congenital or acquired enteroptosis. The symptoms appear acutely after each meal, and persist unchanged for years at a time, dis- appearing only when the patient is provided with improved hygienic conditions. In contrast to this, the clinical symptoms of nervous dyspepsia may appear also in well-nourished individuals with normal habitus, if the equilibrium of the nervous system has been disturbed. If hyperacidity, subacidity, or anacidity is present in a case of nervous dyspepsia, confusion with hyperacid gas- tritis or anacid gastritis is possible, especially if only a single chemical examination of the stomach has been made. If the examiner can demonstrate sudden variations in ■the secretory functions of the stomach, gastritis is naturally excluded. Unfortunately, from the standpoint of diagnosis, there are cases of nervous dyspepsia associated with constant hyperchlorhydria or subacidity of the gastric juice, when confusion as to the nature of the condition can be prevented only by the ensemble of all symptoms of the disease, and by accurate determination of the etiology. For instance, in acid gastritis there is usually a history of excesses in drinking, smoking, and eating; and in subacid or anacicl gastritis, a history of prolonged alcoholism, hasty eating, imperfect mastication and the misuse of laxatives. The rennin and pepsin ferments are almost always present in normal amounts in nervous dyspepsia. This finding alone, however, is not a positive differential point, because these may also be present in approximately normal amounts in mild cases of gastritis. The determination as to whether any given case is one of nervous dyspepsia or not, is of utmost importance in the indications for treatment. 204 DISEASES OF THE DIGESTIVE CANAL In doubtful cases, it is always better for the physician to prescribe a treatment which is suitable for an organic affection, since this, under no condition, can injure the patient; for instance, if the typical ulcer-cure has been given without obtaining positive results, the clinician may then regard the case as one of nervous dyspepsia and may proceed with a treatment directed toward restoring the nervous S3^stem to its normal condition. Prognosis and Course.— Nervous dyspepsia scarcely ever progresses into an organic disease of the stomach, and then only in consequence of loss of appetite and malnutrition of the patient, which latter leads in turn to severe anaemia and emaciation (a loss in weight amounting to as much as 50 pounds has been observed), tuberculosis, and very frequently to chronic constipation, with its sequela?, — hypochondriasis, secondary intestinal catarrh, membranous colitis, etc. On the contrary, gastrectasia, gastritis, ulceration, cancer, and hypersecretion never develop from nervous dyspepsia. The clinical course is often tedious, — improvement alternat- ing with relapses, — depending upon the condition of the general nervous system. If the disturbing factors cannot be eliminated from the lives of these patients, cure is often impossible. On the other hand, a sHght psychical improvement in the patient, especially in women, often enables the physician to obtain within a few days surprisingly favorable results. Treatment. — Contrary to the treatment of organic dis- eases of the stomach, the therapy of nervous dyspepsia should not be directed to the removal of local complaints, but to the improvement of the general condition of the patient, which involves the restoration of the nutrition and the toning up of the entire nervous system. The dyspeptic symptoms often disappear simply through prolonged rest in bed, better nourishment, and the removal of those factors which weaken and irritate the nervous system, — such as noises in the streets, etc. A. Dietetic Treatment. — The dietary should always be adaptable to the physical constitution of the patient. Forced DISEASES OF THE STOMACH 205 feeding, which was described in the previous chapter, is suit- able only for those cases of nervous dyspepsia in which mal- nutrition is an associated condition. A patient with normal nutrition, — for instance, one with thick panniculus adiposus, — naturally does not require forced feeding, and only rarely should a rest-cure be instituted. Obese persons with nervous dyspepsia should be given a diet which will bring about a decrease in weight, — starches and fats being avoided as much as possible. For constipated patients, a rational constipation-diet, such as is described in the chapter on Chronic Constipation, should be prescribed, for the reason that very frequently constipation aggravates the symptoms of nervous dyspepsia or may even be the cause of the affection. In individual cases, mild laxatives may be used if spontaneous evacuation of the bowels does not result from the diet alone; the most suitable in such instances being regulin, tamarinds, purgen, etc. (See below.) In order to convince the patient that it is not his stomach that is dis- eased but his nervous system, the physician should insist, at the very begin- ning of treatment, that he give up the bland, non-irritating diet-regime which he has been wrongly following, either of his own accord or upon the advice of the attending physician, under the misconception that his trouble was chronic catarrh of the stomach. As soon as the patient is shown that a full diet produces no greater discomfort than a mild diet, he gains con- fidence and more readily follows the advice of the physician. Since in severe cases of nervous dyspepsia, the rest-cure and forced feeding may not be sufficient to bring about recovery, it may be preferable for the patient to be treated in a sanitarium which is well equipped with the necessary hydro- therapeutic apparatus, and which has beautiful surround- ings and is distant from a large city. In the dietetic treatment, it must again be strongly emphasized that in doubtful cases, that is, if the physician is not sure as to whether an organic or a nervous affection of the stomach be present, he should at first prescribe a diet which is suitable for the organic disease; also in cases where a neu- 206 DISEASES OF THE DIGESTIVE CANAL rosis is combined with an organic disease of the stomach, — as for instance, nervous dyspepsia with acid gastritis. B. Hygienic Treatment. — This Hne of therapy includes all those adjuncts necessary for the treatment of nervous affections in sanitariums and watering places, — namely, rest-cure, diversion, baths, gymnastics, massage and electricity. We cannot enter into the details of these measures, since they do not concern the practicing physician so much as those conducting such institutions. It is often very difficult for the physician to decide upon the most suitable sanitarium or bathing resort. The follow- ing general rules may serve to guide him: Patients with relaxed and depressed nervous systems who are in a fair condition of nutrition should be sent to the seaside, unless there is present a marked degree of auEemia. The Baltic Sea is, as a rule, more suitable for women and the North Sea for men. Nervous dyspeptics with an irritable condition of the nervous system should be sent to the mountains; those who are well nourished to the higher ranges, such as the Tyrol or the Bavarian Alps; while ansemic patients should be sent to mountains of medium altitude, such as the Black Forest, the Hartz, Thuringen, and the Riesengebirge. The deciding factors, therefore, in the choice of the sanitarium or resort are the state of the general nutrition, — obesity, angemia, etc., — and the condition of the nervous system, which is best indicated by the reflexes. Ansemic and very nervous patients should not be treated with cold-water procedures, but with protracted, lukewarm, full baths,— such as are given, for example, in Landeck, Elster, Badenweiler, etc. The same principles should govern their home treatment. Massage also should be used, with caution. As a rule, fight massage with friction of the epigastrium and the abdomen are indicated. AH of the more severe procedures, such as heavy massage, clapotement, etc., only aggravate the dys- peptic symptoms; while the mild stroking movements give considerable aUeviation. This mild massage with friction is what the ''quacks" designate as "magnetism." C. Suggestive Treatment. — This consists of verbal sugges- tions and the influence of the personafity of the physician DISEASES OF THE STOMACH 207 upon his patient, and in the personal trust which the patient has in the physician's assurance that no severe stomach- affection exists and that only an atonic condition of the nerves supplying the stomach is causing the trouble. The mere frequent repetition of these facts is often productive of actual improvement and even cure of the nervous dyspepsia. More susceptible and ignorant patients should be treated with electricity and effleurage of the epigastrium, for they often believe that the "magnetic" treatment which they are receiving has great curative powers. In practice this method works wonders with such patients. Treatment by electricity also belongs to the realm of suggestive therapeutics. It may be dispensed with as a rule, and is generally more suitable for sanitarium-treatment; although in chronic cases very good, though transient, results are often obtained by its use. It is beneficial only to those who believe in its heahng power and who have the utmost confidence in the physician. It need scarcely be mentioned that in irritable cases of nervous dys- pepsia the galvanic current, and in relaxed patients the faradic current, should be used. The electricity should be applied externally by means of two moistened electrodes, — one placed on the back and the other on the epigastrium. If the physician prefers, endofaradization may be given. A flat electrode is placed upon the epigastrium; and after the patient has drunk a glass of water, a stomach-electrode (which may be obtained in any large instrument-house) is introduced into the stomach. Instead of the regular stomach-electrode, an ordinary stomach-tube may be used. No. 8 or 9 [Am. No. 20-21], closed at the upper end by a small cork through which a copper wire has been pushed. The copper wire should extend to the blind end of the stomach-tube, and the proximal end should then be connected with the electrical apparatus. The current should be weak at first and gradually increased in strength as long as it can be borne by the patient. The duration of an endofaradization treatment should, as a rule, be about 5 minutes, while the external electrical treatment should last 10 to 15 minutes. D. Medicinal Treatment. — Sedatives, — such as bromides, — are the most general medicinal agents to be used in the treatment of nervous dyspepsia. The physician may pre- scribe either a glass of effervescent bromide-salts night and morning, or one of the following prescriptions: 208 DISEASES OF THE DIGESTIVE CANAL 1. T^ Validol, 3iv 15.0 Sig. — Six to ten drops t.i.d. 2. I^ Sodii bromidi, 5i 30.0 Sig. — A knifepoint twice a day, or fifteen grains in a cup of valerian tea. 3. J\ SjTupi hypophosphitum, 5ii 60.0 Sig. — A teaspoonfiil t.i.d. 4. 1^ Extracti cannabis indicse, gr. I 0.05 Sacchari, gr. viiss 0.5 M. ft. pulv. No. X. Sig. — One powder twice daily (or 8 to 10 drops of the tincture). 5. I^ Chloral hydratis, oi 4.0 Syrupi aurantii corticis, Aquae, aa, oi 30.0 M. Sig. — A teaspoonful t.i.d. Bromides are suitable for nervous dyspepsia of the excit- able type only. In the depressed form of the disease, with a diminution of the appetite, general despondency and hypo- chondria, bitters should be given, just as in ana^mic-enterop- totic dyspepsia; and they are equally successful in causing the disappearance of many of the annoying symptoms. The following are the clinical histories of a few cases of nervous dyspepsia, which serve to illustrate the character- istics of this disease better than prolonged detailed description. CLINICAL CASES Case 1. — Mrs. Ida A., 27 years old, had always been very nervous and subject to hysterical crying. She had inherited a neurotic tendency from her father, and had frequently been subject to tremors, headaches, nausea, and vomiting. She had been married for three years but had had no children. Menstruation had always been irregular, often not occurring for months. According to the statement of the patient, both ovaries had been prolapsed. She complained of loss of appetite and a feehng of great pressure in the epigastrium, which was often entirely independent of both the quality and quantity of food eaten, as sometimes she could eat any kind of food, and at other times she suffered from dyspepsia even after liquids. The bowels were sluggish. Stools were formed, of large caliber and hard. The use of lax- atives was often necessary. DISEASES OF THE STOMACH 209 Examination showed that she was well nourished, with an alternating paling and flushing of the skin. The patient had a typical habitus enter- opticus, the right kidney was movable, and the patellar reflexes were remark- ably exaggerated. The treatment consisted of a fattening-constipation diet, warm baths, and a large knifepoint of bromide of potassium three times daily, together with a glass of valerian tea. After one week of treatment, the patient had normal evacuations of the bowels, the pressure in the stomach had dimin- ished, and three weeks later had entirely disappeared. The patient had gained four pounds in weight and was in good health. In this case, much benefit was obtained from suggestive therapy. Case 2. — Oswald K., a teamster, 26 years old, had masturbated for years. For several months previous he had had constant pressure in the stomach, more intense after heavy meals. He had never had epigastric pain or vomiting. Stools were fairly regular. Patient was emaciated and pale. He had habitus enteropticus. The test-breakfast showed the gastric juice to be subacid, the total acidity amounting to 36. Treatment. — Bitters, fattening-constipation diet, and cold frictions. Within three or four weeks the patient was absolutely free from all of his former trouble and remained entirely well during the whole two years that he was under observation. Case 3.— Harry T., a business man, 27 years old, had for two years had dyspepsia, with fulness and pressure in the epigastrium after meals, loss of appetite, eructations, and constipation. Since this period he had lost 35 pounds in weight. The patient had for years over-worked in attending to his business. He was very anaemic, and habitus enteropticus was marked. The test-breakfast was well digested, with a total acidity of 74. After six weeks of treatment in the sanitarium at Thalheim, the patient returned completely cured of his dyspeptic troubles, and having gained 20 pounds in weight. Special Forms of Neuroses of the Stomach In the modern text-books on gastric diseases, by Ewald, Boas, Rosenheim, Riegel, etc., the gastric neuroses are sche- matically classified into secretory, sensory and motor neuroses, according to the individual functions of the stomach. In a book such as this, however, which is intended as a practical guide in the diagnosis and treatment of digestive diseases, it would be impracticable to conform to this classi- fication. Such a work can discuss in detail only the more common forms, not mentioning those which are rarely en- countered, and whose treatment had better be left to the 14 210 DISEASES OF THE DIGESTIVE CANAL attention of a specialist. With tliese preliminaiy explanatory remarks, the following text will be better understood and appreciated by the reader. 1 . Nervous or Reflex Vomiting (Including Nervous Eructation and Regurgitation) By the term ''nervous vomiting" we define that form of gastric neurosis which is accompanied by vomiting of all food eaten, — this being due to a purely nervous irritation, especially of the gastric nerves, without there being any demonstrable pathological changes of the stomach. Nervous vomiting occurs most commonly in women, especially at the beginning of menstruation and in the meno- pause. Men are very rarely affected. Nervous vomiting always occurs in a neuropathic in- dividual, and is due to some such exciting cause as over- work, agitation, anger, sorrow, masturbation, trauma, etc. The patient vomits all foods, — liquids as well as solids, — almost immediately after eating. The determination of this fact in the anamnesis is of exceptional importance, because vomiting occurring within the first ten or fifteen minutes after eating is not met with in any other disease, if we exclude stenosis of the oesophagus and cerebral affections. Nervous vomiting is not associated with pain. The sub- jective symptoms consist rather of pressure in the stomach, feeling of fulness, loss of appetite, and sometimes repugnance toward food, just as in other forms of functional dyspepsia. It is a striking symptom of nervous vomiting that patients, in spite of their frequent vomiting, are usually but slightly emaciated, although they very often become anaemic. Differential Diagnosis. — A large number of affections come into question in the differential diagnosis of nervous- hysterical vomiting. First of all, the vomiting of pregnancy must be excluded, which is sometimes a difficult task; likewise other abnormal- ities of the generative organs, — especially displacement of the uterus, — which very frequently cause reflex vomiting. DISEASES OF THE STOMACH 211 The periodical vomiting associated with the gastric crises of locomotor ataxia, which will be spoken of in another chapter, should also be eliminated from the diagnosis, and likewise all other affections with which vomiting might be associated. I will mention only migraine, cerebral affections, acute peritonitis, chronic nephritis, nephrolithiasis, and above all, helminthiasis in children. Vomiting in children, the so-called '' juvenile vomiting," is quite frequently observed in nervous and antemic children, and represents a special form of gastric neurosis. It appears from the eleventh to the thirteenth years in children who have previously been healthy, about the time they enter school. In some of these cases, early masturbation is the cause; while in others, worms are the exciting factor. In these cases the stools should be carefully examined for ova of intestinal parasites, the details of which will be given in the chapter on Microscopical Examination of the Faeces. It is well known that the vomiting may also occur from the intestinal irrita- tion resulting from ascarides, oxyuria, and other small worms, as well as from the presence of tapeworms. Both chronic and subacute gastro-enteritis in children is also frequently the cause of vomiting. In these conditions, it is characteristic that the vomiting is always dependent upon the quality of food, and occurs after eating such heavy foods as potatoes, bread, acids, or fruits, etc., but not after liquids. An incomplete or rudimentary vomiting, — the well- known regurgitation of food a short time after eat- ing, — should be discussed here. It occupies a middle position between simple eructation and vomiting and is, as a rule, associated with eructations of chyme, the mouth becoming full of stomach-contents which have a bitter, acid taste, due to the presence of gastric acids and peptone. After regur- gitation the food is expelled from the mouth. This condition should be chnically differentiated from an associated one known as rumination, which is most frequently observed in men who have indulged in irreg- ular and hasty eating for years. 212 DISEASES OF THE DIGESTIVE CANAL These patients regurgitate food soon after tlie meal, and, instead ofspitting it out, chew it and swallow it again. Nervous eructation occurring in diseases of the oesophagus, as has already been mentioned, is sometimes observed with nervous vomiting. These affections are often seen one after the other in the same individual. Heartburn, or pyrosis h y d r o c h 1 o r i c a , is associated with nervous vomiting, although it is also a symp- tom of such organic affections of the stomach as gastric ulcer and acid gastritis. For details, see the chapter on Hyperchlorhydria. Prognosis. — The prognosis of nervous vomiting is, — as a rule, — good, although its chnical course covers a long period of time. The affection disappears spontaneously after the nervous system has been restored to its normal tone. Treatment. — The therapy should be directed chiefly to the removal of those factors in the life of the neuropathically inclined individual which have given rise to the neurosis. Usually we have to do with the removal of various mental conditions; although it is self-evident that such factors as diseases of the genital organs, particularly in women, should be excluded to prevent confusion of nervous vomiting with the reflex vomiting of pregnancy, etc. The therapy should, therefore, be largely of a suggestive nature, and should include bromide and valerian preparations, just as in nervous dyspepsia. I generally give the test-breakfast in such cases, following m}^ rule of systematically examining every patient. The advantage of doing this with such patients is, that the}^ feel that the physician is interested in their indi- vidual affection and they are afterwards more easily assured that the stomach is performing its normal functions and that only the nerves are affected. This assurance and conviction tend considerably toward the quieting of the nervous sj^stem, which indirectly brings about a cure. On the same basis of suggestion, I sometimes lavage the mucous membrane of the stomach of such a patient with luke- warm water, using Rosenheim's irrigation-tube, and some- DISEASES OF THE STOMACH 213 times also resort to endofaradization, as has been mentioned in the previous chapter. I have had much better resuhs from effleurage of the epigastrium, which should be carried out as follows: The physician should lightly stroke the region over the stomach with both hands, the right alternating with the left, using a gentle and slightly vibratory movement; and it so happens that ignorant and susceptible patients often think they are being "magnetized." By this procedure I have often seen the most striking results after three or four treatments, so that patients who had a short time previously vomited everything they had eaten were able to digest the heaviest foods without any trouble. The appended histories of clinical cases best represent the clinical course and treatment of nervous vomiting. Naturally, the treatment must always be selected and adapted for each individual case. For instance, the ''magnetizing" treatment would be quite unsuitable for the intellectual class of patients. There are numerous cases of nervous vomiting in which the nervous system has been so disturbed through over- work for a number of years that all therapeutic measures are without effect. In these cases only prolonged residence in other climates, as in the Riviera, or the high altitudes, or a lengthy stay at a suitable sanitarium, will be of benefit. In nervous vomiting, as in nervous dyspepsia, the same principles governing the hydrotherapeutic and balneological therapy are applicable. Since in almost all cases we are dealing with an irritable form of neurosis, prolonged residence at the northern seaside is generally inadvisable, although re- sorts along the Mediterranean may sometimes be recommended. CLINICAL CASES Case 1. — In the case of Frieda F., 19 years old, the daughter of a mid- wife, menstruation wliich had begun at the age of 16 had been irregular. For one year there had been sluggishness of the bowels, and for five weeks previous, the patient had been obliged to use enemata because purgative remedies had become ineffectual. For five months patient had had loss of appetite, pressure in the stomach after heavy meals, and often vomiting after eating, which had recently occurred several times daily. Patient was fairly well nourished. The habitus enteropticus was present. The appendix was palpable. Otherwise the physical examination was negative. 214 DISEASES OF THE DIGESTIVE CANAL Treatment. — The therapy consisted in suggestive treatment and mas- sage which was called "magnetism," also belladonna and codeine pills, and a heavy constipation-diet, in spite of which no pressure in the stomach or vomit- ing occurred. After two and one-half weeks, the patient could bear the heaviest diet without the use of narcotics. Massage was continued and endo- faradization begun. After three treatments of the latter, the stools were evacuated spontaneously, since which time the patient has been entirely well. Case 2. — Emma R., 34 years old, the daughter of an army officer, had suffered from chlorosis and occasional stomach-trouble for the past few years. For two weeks jDrevious, the patient had loss of api^etite, vertigo, and persistent vomiting immediately after eating. Only slight interruptions in the vomiting spells occurred, followed by some improvement. The patient had constant ]:)ressure in the stomach, but no pain. She was of slight phy- sique, had the habitus cnteropticus, a small goitre, and a movable right kidney. Bromides and faradization were ineffective. I\Iassage was, therefore, sub- stituted, which proved of great benefit. For instance, she was soon able to eat such food as herring and potatoes without any discomfort. In the course of five years, during which time she was under observation, she had only two periods of vomiting, which were removed each time by effleurage of the epigas- trium, and verbal suggestion. The total acidity of the gastric juice was 46. Case 3. — Gertrude P., a sales-girl, 16 years old, gave a history of sexual perversion and early sexual relations. She had had gonorrhoea and had been subject to severe mental strain. For one or two years, the patient had at periods vomited everything she had eaten, immediately after meals, and had felt severe pressure in the stomach. She had been treated unsuc- cessfully for ulcer several times. Patient was well nourished. She had the habitus enter opticxis. The acidity of the test-breakfast was normal, total acidity being 64. After one week of daily massage, softly stroking the epi- gastrium, the pressure in the stomach and the vomiting completely ceased, and the patient was able to eat meat, potatoes, etc., without any discomfort. Her health remained normal for several months, at which time she suffered a relapse, and was again cured by the same treatment. Later on, the patient developed hysterical writer's cramp, for which she was treated two months with cold baths, etc., in a sanitarium for nervous diseases. The writer's cramp disappeared but the patient still complained of pressure in the stomach, which was again removed by one week's treatment with massage. The condition subsequentl)^ recurred, associated again with writer's cramp, for which she was again sent to a sanitarium. 2. Gastric Vertigo B)^ the term ''gastric vertigo" is understood the frequent occurrence of a feeling of dizziness about the end of the mealtime. DISEASES OF THE STOMACH 215 It is most commonly observed in young persons who are extremely nervous, in consequence of masturbation or other causes. Except for this symptom, the patients feel well. The objective signs of the stomach are negative. The secretion shows normal or fluctuating values. Motility is normal. The diagnosis is made from the history of the subjective disturbances and from the negative objective findings. The prognosis is favorable. The affection generally disappears soon after the causal factors have been removed. Therapy. — The therapy consists in the abolition of those factors which have weakened the nervous system, the admin- istration of bromide and valerian preparations, massage of the entire body, and the employment of half-baths. If the condition occurs in a patient with poor nutrition, a mild fat- tening-diet is indicated. CLINICAL C4SES Case 1. — Julius S., a joiner, 55 years old, had had influenza for three years, and for two years had suffered from stomach-trouble, a feeling of dizziness and loud eructations after each meal. He had no pain, his appetite was poor, and he was ill-nourished. Stools were irregular; and he frequently complained of pressure in the head. The test-breakfast showed a slight sub- acidity. x\fter treatment with bromide and valerian tea, the patient improved. Case 2. — Marie V., 40 years old, had been healthy up to three months previous, since which time she had suffered from heartburn and a feeUng of vertigo, generally one hour after a meal,- — even of liquids. If she had suf- ficient rest the above symptoms did not appear ; but they invariably retiirned after hard labor. The patient's bowels moved once or twice a day; stools were soft. The appetite was good. Physical Examinolion. — Patient was pale and emaciated; the right kidney was palpable. Total acidity of the test-breakfast was 30. After treatment with bromides the patient improved. Oxyuria had been noted in the stools for the past three months, therefore the case was not a simple gastric neurosis, but reflex vertigo. 3. Nervous Anorexia Great variations in the appetite may occur from purely nervous influences; it may be considerably increased or totally lost. 216 DISEASES OF THE DIGESTIVE CANAL Bulimia (ox-hungcr), or c y n o r c x i a , hj which is meant an abnormal increase of the feeling of hunger, occurs quite frequently. The fundamental reason for this condition is probably an abnormal increase in the motility of the stomach whereby its contents are propelled into the tluodenum in considerably less than the normal time. Such patients experience an imperative need of food, which, if not gratified, results in phenomena resembling an attack of fainting, which disappear immediately after eating. The actual cause of the affection is unknown. The prognosis is not especially favorable, since the trouble will often persist many 3^ears, and causes exceeding discomfort and annoyance. Every case of bulimia should naturally be examined for diabetes, since a ravenous appetite is often the first symptom of this disease. Gastralgokenosis. — Closely associated with this affection is the so-called '^ gastralgokenosis," a form of gastric neurosis which was introduced into the pathology of the stomach by Boas, and is characterized by a painful emptiness of the stomach. Patients with this affection do not experience the same insane, irresistible desire to eat as do those with bulimia; but several hours after meals an unpleasant feeling of con- traction in the pit of the stomach occurs, which disappears immediately after taking any kind of food. This symptom is very frequently considered as '^ heart-pain" by the laity. Patients suffering from gastralgokenosis feel a need to eat, yet lack the desire. They have an abnormal feehng of hunger but no appetite. This neurosis need not be confused with ulcer or erosions of the pylorus, in which severe pain occurs several hours after eating, — so-called epigastralgia, — which immediately disap- pears after taking food or drink. Whenever a cramp-like pain occurs at a definite time after meals, the examiner should always think of an ulcer DISEASES OF THE STOMACH 217 associated with hyperchlorhydria, — which has been discussed in detail in the section on Gastric Ulcer. Treatment. — Gastralgokenosis may be easily and suc- cessfully treated by having the patient eat every two or three hours, thereby removing the factors of malnutrition and ansemia, when the condition will disappear of itself. In contradistinction to this, the physician is quite help- less in the treatment of bulimia. In individual cases, arsenic and silver nitrate offer good service. 1. T^ Liquoris potassii arsenitis, Aqu£e menthse piperitse, aa, 5iiss 10.0 M. Sig. — Six to ten drops after meals, t.i.d. Add one drop to the dose each week. 2. I^ Argenti nitratis, gr. vi 0.4 AquEB, oviss 200.0 M. Sig.- — A tablespoonful (porcelain) in a wineglassful of water fifteen minutes before meals. Nervous Anorexia.— In contrast to bulimia is nervous anorexia, or total loss of appetite. Before the examiner makes a diagnosis of nervous ano- rexia, it is necessary first to exclude other diseases of the stomach or of other organs which produce the same symptom, especially incipient tuberculosis, early carcinoma of the stomach or other organs, typhoid fever, Basedow's disease, etc. Etiology. — The causes of nervous anorexia are, as a rule, emotional disturbances from bereavement, loss of property, fright, railroad and steamship accidents, etc. A patient suffering from nervous anorexia may become considerably emaciated, losing as much as fifty pounds or more, so that the suspicion of the presence of a malignant neoplasm will at first occur to the examiner. The other functions of the stomach, — secretion and motility, — are either quite normal or offer variations typical of nervous dyspepsia. Frequently there is a marked dimi- nution in the amount of hydrochloric acid in the gastric juice which renders the differential diagnosis between nervous ano- rexia and latent carcinoma of the stomach especially difficult. 218 DISEASES OF THE DIGESTIVE CANAL It is not at all rare for hyperchlorhydria to be associated with nervous anorexia. Treatment. — The therapy consists in the administration of bitters. The following have proven useful in my experience: Fluid extract of quinine, 20 drops before meals, t.i.d. Tincture of gentian, or rhubarb, a teaspoonful before meals, t.i.d. Fluid extract of calamus, a teaspoonful before meals, t.i.d. Orexin, 4 or 5 grains (0.3) in capsules, t.i.d. In most cases, a change of scene is essential, though not to any special health resort, it being sufficient for the patient to go to any kind of summer resort or to visit relatives in the country or at the seashore, or to go anywhere that offers the necessary change and diversion, for in this affection we almost always have to do with a depressed condition of the nervous system. Acoria. — By way of addendum, I will mention the condi- tion known as acoria, a neurosis in which the patient has lost the sense of satiation of hunger. The condition is encountered especially often in women in the climacteric. The treatment of acoria is wholly ineffectual, and it often exists for several years. The therapy is largely limited to send- ing the patient to a health resort, administering symptomatic remedies, and waiting for the neurosis to disappear of itself. CLINICAL CASES Case 1. — Dora P., an artist, 54 years old, had for ten years had attacks of nausea, gnawing pain in the epigastrium, and vomiting of water during periods occurring from two to four times each year. The appetite was good, but the patient was afraid to eat. The attacks occurred only after she had not eaten for several hours, and were usually terminated by the regurgita- tion of liquids. The patient had several times been treated for tapeworm. She had been constipated from twenty to thirty years, and had been under a severe nervous strain in caring for her paralytic husband. Patient was pale, poorly nourished, had the normal habitus, and relaxed abdomen; the right kidney was movable to the second degree; the transverse colon and the sigmoid flexure were contracted and palpable. There were no symptoms pointing to disease of the central nervous system. The test-break- fast showed the stomach-contents to be normal, the total acidity being 54. DISEASES OF THE STOMACH 219 Treatment consisted in the administration of belladonna pills and a constipation-fattening diet, with oil enemata twice a week. After two weeks of treatment, the stools were spontaneous and the painful emptiness of the stomach and the vomiting of water had entirely ceased. During the following few months, the patient increased twenty pounds in weight, and remained in good health. Case 2. — Pauline C, a dancer, 30 years old, had had occasional stomach-trouble during her childhood, after which period she had been healthy until one year previous, since which time she had had considerable discomfort in the epigastrium several hours after a meal, which would cease immediately after eating even a mouthful of food. Patient had occasionally vomited mucus. There had been a loss of ten pounds in weight. Some days the patient had felt free from the symptoms. On account of her occupation, she had been irregular in her meals for several years. Examination showed that she was emaciated and had habitus enter opticus. She was treated with bromides and valerian without results. The test-breakfast was normal, total acidity being 50. The painful emptiness of the stomach frequently recurred, and improvement was obtained only after prescribing the ulcer- diet and the use of mastication tablets ; so in this case there probably existed an ulcer of the stomach rather than a gastric neurosis. Case 3. — Anna R., a house\yife, 28 years old, had for two and one- half months suffered from painful contracting sensations in the epigastrium whenever the stomajch became empty, — these attacks generally occurring early in the morning and at 2:00 or 3:00 o'clock in the afternoon, as the patient did not eat anything between the hours of 8:00 o'clock in the morning and 3:00 o'clock in the afternoon. Soon after eating, the pains disappeared. After treatment with belladonna, valerian, and regulation of the diet, improvement occurred without resorting to treatment for ulcer. Case 4. — Clara H., a capitahst, 46 years old, had had an operation for hemorrhoids seven years previous. For five years the patient had never ex- perienced the sensation of satiation of hunger. Improvement resulted from treatment at Franzensbad, which was followed by a recurrence of symptoms, and the weight was reduced from 168 to 110 pounds. At the time of the ex- amination, the patient was constipated, and the appetite poor, but hunger was not appeased by eating. She was treated with belladonna, etc., and with massage to regulate the bowels. The acoria was not influenced by treatment. Observation of the patient gave the impression that she was hysterical. Nervous Hyperacidity, Subacidity and Anacidity In the section on Nervous Dyspepsia, it was stated that the gastric secretions might be increased, diminished or entirely lost through purely nervous influences. The subject merits, therefore^ a somewhat detailed consideration. 220 DISEASES OF THE DIGESTIVE CANAL The diagnosis of an}' of these conditions is possible only after a prolonged observation of the patient. In the differential diagnosis of nervous hyperacidity, the physician should especially eliminate acid gastritis and gas- tric ulcer. A detailed consideration of the differential points has already been given in the chapter on Hyperchlorhyclria. In making the diagnosis of nervous anacidity, this affec- tion is most likely to be confused with anacid gastritis and incipient carcinoma. The chapter on Nervous Dyspepsia presents the question in detail. Many authors assume that total achylia may occur on a purely nervous basis and that the functions of the gastric glands are depressed even to complete cessation in the pro- duction of the gastric ferments, without being associated with any anatomical change of the mucosa. In my opinion, this is an error. An anatomical process is probably always the cause of a diminution in the total acidity of the test-breakfast, when it is as low as from 6 to 8. It is not essential to account for such diminution by an alcoholic gas- tritis alone, since a parenchymatous inflammation of the gastric mucous membrane may arise from other causes, such as years of privation, hasty, irregular eating, bad teeth, and the misuse of laxatives. The total acidity of a purely nervous anacidity is rarely found to be below 18. There is an absence of only free hydro- chloric acid. The combined acids and the ferments are present. The treatment is that of the primary disease, as in ner- vous dyspepsia. In hyperacidity, the belladonna preparations are indi- cated; and in subacidity and anacidity, strychnine, as in the following prescriptions : 1. I^ Tinctura^ belladonnse foliorum, oiiss 10.0 Tincturse Valerianae, 5v 20.0 M. Sig. — Twenty-five drops, t.i.d. 2. I^ Tincturse nucis vomicae, oiiss 10.0 Tincturae rhei, ov 20.0 M. Sig. — Twenty-five drops, t.i.d. Hypersecretion is also held by some authors to be a nervous affection, especially by Riegel and his school, who DISEASES OF THE STOMACH 221 assume that the gastric glands respond to purely nervous influences with an alimentary hypersecretion in slight cases, and with continuous secretion of gastric juice in more severe cases. According to the view held by the majority of author.s, hypersecretion is always of an organic nature and rightfully belongs to the chapters which discuss Acid Gastritis and Stenosis of the Pylorus. The gastric glands become irritated and hypertrophied, and respond with a continuous hypersecretion of gastric juice, from the irritating effect of poisons, alcohol, nicotine, excessive meat-eating, and over-eating. The glands of the stomach are subject to the same irritation if stagnation of the stomach-contents results from stenosis of the pylorus caused by scars or ulcer. If the irritation of the gastric glands is removed, — as may result from suitable treatment, from the healing of the ulcer, or by gastro-enterostomy, — the glands gradually resume their normal functions. It very often requires years, however, to bring this about, since the causative factors have also been operative for many years. Nervous Cardiospasm and Pylorospasm The diagnosis of these conditions is very often wrongly made in general practice. As has been mentioned in discuss- ing the differential diagnosis of Gastric Ulcer, all kinds of affections are diagnosticated under these terms; while as a matter of fact, spasm of the cardia or of the pylorus very rarely occurs as a neurosis. Generally the conditions taken for cardio- and pyloro- spasm are cases of gall-stone colic, gastric crises of tabes, angina pectoris, intestinal colic and — the most frequently — ulcer of the pylorus associated with hyperchlorhydria. My opinion is, that there is practically no nervous affec- tion of the stomach in which actual pain is a symptom. When- ever a pain does occur, the physician should always think of an organic lesion of the mucous membrane of the stomach. Although there are certain unpleasant sensations in the epigas- trium in neurasthenia and in nervous dyspepsia, neither actual pain nor cramps ever occur. The absence of real pain, in fact, differentiates functional from organic disease of the stomach. If pain suddenly occurs as a symptom in a patient who has been suffering from a nervous affection of the stomach for years, the physician should at once think of a complica- 222 DISEASES OF THE DIGESTIVE CANAL tion. For example, I saw a case of severe neurasthenia with hyperacidity which had for years presented symptoms of nervous dyspepsia, — loss of appetite, pressure and fulness after eating, etc. Gastralgia suddenly developed, occurring several hours after meals. It was pronounced by a specialist to be due to a nervous affection of the stomach, and was so treated. The sudden occurrence of hsematemesis, however, gave evidence of the true nature of the affection, namely, gastric ulcer. The somewhat exceptional association of an organic disease of the stomach with nervous dj^spepsia was charac- teristic of this case. I must state that I have never yet observed an undoubted case of nervous spasm of the pylorus or cardia. Painful cardiospasm is generally caused by some organic lesion, such as small erosions of the mucous membrane around the cardia. When otherwise caused, the symptoms produced by the spasm are more like unpleasant sensations in s wallo wing-than actual pain. [See discussion of chronic cardiospasm, page 61.] CLINICAL CASE Rosalie G., 48 years old, had given birth to nine children, and had been subject to much grief and care, — her husband being an inmate of an asylum. Menstruation had been irregular. For two years, the patient had had a feehng of contraction in the epigastrium every ten or fifteen minutes, which was independent of eating. Patient had never vomited, and the bowels had been fairly regular. She was considerably emaciated, had habitus enter ojiticus, and relaxed abdomen. The pylorus was palpable, of about the size of a walnut, and was felt by the palpating hand to be alternately soft and hard. Both the secretions and the motility of the stomach were normal. Patient made temporary improvement under bromides, valerian, and mas- sage, during which time she increased in weight and felt no discomfort. After renewed trouble and worry, the above symptoms always returned. Patient was seen five years after the first examination, and was in practically the same condition; so that malignant or benign stenosis of the pylorus could be excluded in this case. With this I close the discussion of Functional-Nervous Affections of the Stomach. They are extremely diverse in their manifestations; and the art of the physician, his ability to improvise, and his ingenuity in the treatment and manage- DISEASES OF THE STOMACH 223 ment of these cases, find a large field in this form of dyspepsia. Those of the largest experience in these cases will naturally obtain the greatest number of cures. It may be mentioned once again that in doubtful cases the patient should at first be treated as if he had an organic disease of the stomach; and only after this method of treatment has been unattended with favorable results should the affection be assumed to be a neurosis and general treatment instituted. DISEASES OF THE STOMACH IN CONNECTION WITH DISEASES OF OTHER ORGANS Stomach-Affections Secondary to Diseases of Other Organs of the Body (Symptomatic Affections of the Stomach) Although the relationship between diseases of the stomach and constitutional diseases and affections of other organs of the body has been mentioned quite often in the foregoing chapters, there are a few especially frequent and important reflex stom- ach-conditions that should be individually considered. 1. The Stomach and Disorders of Metabolism Anaemia very frequently produces dyspepsia, as we have seen in the section on Functional Diseases of the Stomach, no matter what the origin of the anaemia is; and especially, if enteroptosis and malnutrition are associated conditions. Pernicious anaemia, — or any other form of wasting disease, — such as carcinoma of any of the internal organs, — frequently causes atrophy of the gastric glands. In regard to anaemia, it is also true that the atrophy of the gastric glands may be primary, and pernicious anaemia the secondary affection, if at the same time the absorptive ability of the small intestine is much impaired. Anaemia leads only exceptionally to anatomical, but very frequently to functional, disturbances of the stomach. In regard to the diagnosis and treatment, the reader is referred to the chapter on Anaemic-Gastroptotic Dyspepsia, for the details. Chlorosis is frequently associated with organic affections of the stomach, such as erosions and ulcers. It is only in the 224 DISEASES OF THE DIGESTIVE CANAL minority of cases, however, that such comphcations as per- foration, adhesion, cicatricial formation, and stenosis of the pylorus occur; for the reason that only small superficial breaks in the continuity of the mucous membrane of the stomach are present, which heal without scar-formation. This explains why it is that, in proportion to the fre- quency of ulcer, fewer women are affected with stenosis of the pylorus and secondary dilatation of the stomach than men, in whom ulcers arise from other causes, such as chronic gastritis and compression of the epigastrium in various occupations. In chlorotic dyspepsia, especially in young girls, the symptoms are often very vague and indefinite; at one time there is pain, at another time pressure, and at still another time, burning in the epigastrium, which in most cases the physician will be able to ascribe to chlorotic erosions of the mucosa. These disturbances, as a rule, are stubborn to treat- ment, persisting often two or three years, and disappearing only with the chlorosis. The treatment does not differ in any way from that of ordinary ulcer. It should consist in the administration of silver nitrate, as long as pain is present in the epigastrium. No iron should be given until all local gastric symptoms have disappeared. It is preferable to send patients, who can afford the expense, to some chalybeate spring, such as Flinsberg, Pyrmont, etc. [Sharon Chalybeate Spring, Schoharie County, N. Y., Churchill Alum, Virginia, Cresson Alum Springs, Pennsylvania, Santa Clara Vichy, Cahfornia.] It is well known that diabetes very frequently causes dyspeptic symptoms, — especially acoria, ravenous appetite, and disagreeable fetor ex ore. Stomach disturbances are frequently associated with gout and obesity. Hyperchlorhydria with its symptoms is usually present with the former; while pyrosis and burning pains in the stomach and the symptoms of acid gastritis are usually present in obesity, as a result of immoderate eating. The treatment of all these conditions is that of the pri- mary disease, the details of which cannot be entered into here. DISEASES OF THE STOMACH 225 2. Acute Infectious Diseases Gastric symptoms, loss of appetite, and vomiting occur especially often in meningitis, scarlet fever, influenza, and typhoid fever. The vomiting is usually reflex, while the loss of appetite is due to the febrile process, although it is often, — for instance, in influenza, — an expression of an acute parenchymatous gastritis which is demonstrable at autopsy. 3. Chronic Infectious Diseases Tuberculosis of the lungs frequently causes disturbances of gastric digestion, as has already been mentioned in detail in the chapter on Phthisical Dyspepsia. Tubercular lesions limited to the mucous membrane of the stomach are very rare. Syphilitic lesions are also very rarely found in the stomach, although syphilitic ulcers are now and then found post mortem. Specific affections of neighboring organs, such as the liver and the lymphatic glands accompanying the portal vein, may indirectly produce gastric disturbances by narrowing the pyloric outlet and by producing jaundice. The well-known gastric crises of tabes, and the dyspepsia associated with paralysis, may also be mentioned. It should be recalled, as well, that nervous dyspepsia is often caused directly from fear of syphilitic infection. 4. Central Nervous System The relationship between diseases of the stomach and dis- turbances of the sympathetic nervous system has been suggested in the chapters on Nervous Dyspepsia and Gastric Neuroses. The important association existing between diseases of the stomach and the central nervous system should also be considered. The very frequent occurrence of vomiting in diseases of the brain, — particularly in meningitis, and cerebral tumors, — is well established. Cerebral vomiting is characterized by its occurring independently of the nature of the food; and it is 15 226 DISEASES OF THE DIGESTIVE CANAL particular!}' likely to occur whenever the patient assumes an upright position. The correct diagnosis is usually possible from the associ- ation of symptoms, or if the physician is able to prove that the functions of the stomach are normal. I recently had occasion to observe a patient who vomited profusely whenever he assumed an upright position. While one would at first naturally think of carcinoma of the pjdorus, the microscopical examination of the contents of the stomach showed that no stagnation of food existed, — which therefore excluded the existence of pyloric stenosis. Free hydrochloric acid was present, but neither sarcinse nor lactic acid bacilli. From the associated symptoms, therefore, I made a diagnosis of cerebral vomiting. The patient, a man about fifty years old, died soon afterwards, and a cerebral tumor was found at autopsy. The vomiting which results from disease of the fifth nerve may also be properly mentioned here. Headache usually precedes vomiting in these cases, as in the wTll-known symp- tom-complex of migraine. Less often recognized is the fact that gastric crises may be the first symptom of locomotor ataxia; the loss of the patellar reflexes, and the presence of the Argyll-Robertson pupil not being evident until two or three years later. The crises usually occur in patients with a syphilitic history who have had insufficient medication, or none at all. In almost every case, examination reveals the scar of a venereal ulcer. The gastric crises usually occur six to seven years after the specific infection, although I have seen cases in which the crises developed in two or three years. The gastric crises are characterized by periodical attacks of vomiting all food. These attacks are often accompanied by most severe pain. Later, mucus and bile are vomited. Every case of periodical vomiting should be examined for tabes. In some instances, the gastric crises recur every month, lasting two or three days; while in other cases they return at intervals of months or even years; and in still other cases they disappear permanently after two or three paroxysms. The occurrence of gastric crises is at present DISEASES OF THE STOMACH 227 unaccounted for. Following an attack, the patient is again entirely well and digests everything he eats, just as if he had never experienced any stomach-trouble . The diagnosis is generally easy, although mistakes are frequent, because the true nature of the disease is unsuspected by the examiner. The treatment is unsatisfactory. If the attacks occur from five to seven years after infec- tion, mercurial inunctions followed by iodide treatment should be tried. Generally, however, it is then too late to be successful. In doubtful cases, the decision as to whether specific treatment should be instituted would better be left to the opinion of an expert neurologist. Symptomatic treatment consists in the use of strychnine, morphine and other narcotics. The following prescriptions will be found serviceable: 1. T^ Cerii oxalatis, gr. |-iss 0.5-0.1 Sig.— T.i.d. 2. I^ Morphinse hydrochloridi, gr. J 0.02 Sig.— T.i.d. 3. I^ Atropinje sulphatis, gr. jh^ 0.0005 CLINICAL CASES Case 1. — Constantino G., a waiter. 35 years old, had a chancre eighteen years previously, which was treated by injections. He had gonorrhoea several times, and for three years had had attacks about once in two months when he vomited everything he ate, in addition to bile, and suffered from violent pains in the epigastrium, head, and chest. These attacks usually lasted for about seven days. In the intervals, patient ate and digested all foods without discomfort. The bowels were regular, except that two days previous to the attack there was always constipation. The examination showed the patient to be well nourished. He had exophthalmus, the Argyll-Robertson pupil, slight ataxia, and the loss of the patellar reflexes. The secretory and motor functions of the stomach were normal. Case 2. — Gustav P., a weaver, 47 years old, had contracted syphilis twenty-five years previously. For the past four years he had suffered from attacks of vertigo and vomiting which occurred without any apparent cause and lasted for several days. In the intervals, the patient was in good health. The pupils reacted to accommodation but not to light. The patellar reflexes 228 DISEASES OF THE DIGESTIVE CANAL were absent, and there was no ataxia. Motility and secretion of the stomach were both normal, and the total acidity of the gastric juice was 64. The administration of cerium oxalate gave temporary improvement. Case 3. — Adolphe L., a servant, 26 years old, had had syphilis seven years previously. For the past six months he had suffered from attacks of vomiting without any apparent cause. These lasted four or five days, and were usually accompanied by severe diarrhoea. The left patellar reflex was diminished, and the pupils reacted to light. There was no Romberg symp- tom. The diagnosis of tabes was confirmed in Professor Oppenheim's clinic. No improvement resulted, the attacks of gastric crises recurring. Case 4. — August W., a mason, 30 years old, had contracted syphiUs ten years previously and had had typical attacks of gastric crises with severe pain for about one year. As nothing but morphine would give relief, he contracted the morphine habit. The attacks occurred about every month during the two and one half-years' observation of the patient. 5. Stomach and Circulatory System In valvular diseases of the heart and in arteriosclerosis, gastric disturbances occur which are the result of congestion in the general circulation, causing plethora abdominalis, con- gestion of the liver, etc. Such patients complain most frequently of loss of appe- tite, and of constant pressure and fulness in the epigastrium. The pain in angina pectoris is frequently confused with spasm of the pylorus. In arriving at a diagnosis, the existence of marked arterio- sclerosis, as well as the dependence of the attacks of pain upon physical activity, overloading the stomach, or the advanced age of the individual, should protect the examiner against mistaking the condition for spasm of the pylorus. Also, the pain of angina pectoris occurs behind the upper portion of the sternum, and radiates generally to the left arm; while during the attack the patient has a feeling of great depression and fear of impending death, which symptoms are very characteristic of this disease. The gastric disturbances associated with disease of the heart disappear as soon as the circulatory compensation has been established. The therapy, therefore, should be suitable to the primary lesion which is causing the circulatory disturbance. DISEASES OF THE STOMACH 229 1. R Infusi digitalis, ^iv 124.0 Liquoris potassii acetatis, 51 Ii'O.O Syrupi aurantii, ,^v 20.0 Aquae destillatse, q. s. ad 5viii 200.0 M. Sig. — A teaspoonful every 2 or ."5 liours. 2. R Tincturse strophanthi, Sig. — Five to eight drops in a wineglassful of water t.i.d. CLINICAL CASE Dr. C, 69 years old, had had no appetite for three months and suffered from a feehng of fuhiess in the epigastrium, especially after eating. Physical examination showed advanced arteriosclerosis, irregular action of the heart, and oedema. Treatment consisted of rest in bed, and the giving of a diuretic mixture and juniper tea, after which the oedema and gastric disturbances disappeared. The patient had come to me for treatment, fearing that he was suffering from carcinoma of the stomach. 6. Stomach and Diseases of the Lungs The essential points concerning the relationship between pulmonary tuberculosis and dyspepsia have already been considered in the chapter on Phthisical Dyspepsia, so it is unnecessary to reconsider this particular subject again. The connection between vomiting and severe bronchitis is less fully appreciated, especially when such vomiting occurs in adults. Vomiting is regularly present in children with whoop- ing-cough. Adults, however, suffering from bronchitis, often consult the physician for relief from the vomiting, — instead of from the bronchitis which is the cause of such vomiting. In these cases, the vomiting usually follows a severe attack of coughing early in the morning, shortly after break- fast. If the physician is able to determine, from the state- ments of the patient, the dependence of the vomiting-attack upon the bronchitis, both the diagnosis and the therapy of this form will easily be established. Either Ems or Salzbrunner salts should be given in hot milk; and codeine or morphine, in the usual way. The following clinical cases will illustrate the connection between attacks of vomiting and bronchitis: 230 DISEASES OF THE DIGESTIVE CANAL CLINICAL CASES Case J. — Margaret H., 28 years old, the wife of a merchant, had for four months suffered from vomiting of a green-colored mucus with a bitter taste, which occurred early in the morning soon after rising. By a very carefully obtained anamnesis, it was established that the patient had first suffered from a spasmodic cough, which soon produced nausea and vomiting. After meals, the patient experienced no discomfort, and the bowels were regular. The total acidity of the test-breakfast was 44. The examination of the vomitus proved it to consist of sputum. Improvement followed treatment with Ems salts and codeine. Case 2. — Franz K., a locksmith, 46 years old, had had no appetite for three weeks. Every morning after breakfast the patient had an attack of coughing, which was almost invariably followed by vomiting, but during the rest of the day he had no stomach-trouble. The bowels were regular, and the motor and secretory functions of the stomach were normal, the total acidity being 50. Rales were present in both lungs. The patient entirely recovered under an anti-bronchitis treatment. 7. Stomach and Qenito=Urinary System Apart from nephritic colic, which may be confused with spasmodic conditions of the stomach, and chronic nephritis, — which sometimes leads to passive congestion, pressure in the stomach, and finall}' to. urinic phenomena, — the diseases of the prostate require special consideration. As the result of inflammatory conditions of this gland, distention of the bladder and a feeling of fulness in the abdo- men occur. Such patients usually seek the advice of the phj'sician on account of the gastric pressure. The following clinical cases may serve to illustrate: CLINICAL CASES Case 1. — Herman S., a capitalist, 61 years old, had for about six months suffered from loss of appetite, occasional vomiting, and from pressure and a feeling of fulness in the epigastrium, as well as bladder trouble, — dribbling of urine, etc. The total acidity of the test-breakfast was 50, and the motor powers of the stomach were normal. The physical examination revealed a tumor about the size of the head, which was found just above the symphysis, — midway between the umbiUcus and the symphysis, — and which proved to be a distended bladder. Catheterization caused a dis- appearance of the "stomach-troubles." DISEASES OF THE STOMACH 231 Case 2. — Rudolph H., a tailor 32 years old, had been without appetite for three weeks, and had a feeling of fulness in the entire epigastrium. The bowels were regular, but the patient was occasionally nauseated and ex- perienced some trouble in urination. He remembered having taken a severe cold prior to his illness. A tumor above the symphysis proved upon exam- ination to be a distended urinary bladder. Treatment consisted of belladonna suppositories, sitz-baths, and a diuretic; after which the micturition became normal, and dyspeptic symptoms ceased, 8. Stomach and Liver, Pancreas and Spleen [Gall= Bladder] Enlargement of the liver, -from inflammatory processes and from stasis in the portal circulation, often manifests itself subjectively by a constant feeling of fulness in the epi- gastrium, caused by the consequent crowding upon the abdominal space, — especially when there is a simultaneously existing ascites. The same subjective symptoms are produced by enlarge- ment of the spleen. It has already been repeatedly mentioned that gall- stone colic may often be confused with spasmodic pain of the stomach. The sporadic occurrence of gall-stone colic, and also the enlargement and sensitiveness of the liver and gall- bladder in acute cases, should readily protect the physician from making a wrong diagnosis. [The advances made in early diagnosis and treatment of diseases of the biliary passages, — due largely to American and English surgery, — deserve a fuller consideration of the subject than the author has given. The early symptoms of gall-bladder disease are very often of a. dyspeptic nature. Such patients have been treated for weeks, months and years for stomach-trouble; and only the development of active and positive signs of gall-bladder disease has caused the correct diagnosis to be made in many of these cases. Thanks largely to the opportunities which surgery has offered of making comparisons between the clinical symptoms and the pathology of the earlier inflammatory affections of 23^2 DISEASES OF THE DIGESTIVE CANAL the biliary tract, the clinician is now able to recognize such by the subjective and objective symptoms of the patient. But cases are still too frequent where, owing to complica- tions, — such as adhesions, etc., — the symptoms are so indefinite and the symptomatology so confusing that the differential diagnosis of organic gastric disease is difficult and perplexing. In the differential diagnosis between organic stomach- affections and diseases of other organs of the abdomen, includ- ing the gall-bladder, the cardinal point is that the symptoms of organic stomach-diseases are dependent upon food and that the symptoms of organic diseases of other organs of the abdomen are not. In peptic ulcer, for example, the pain which occurs from one to four hours after eating is the most characteristic symp- tom of that disease, — all other symptoms, such as vomiting, hyperacidit}'', gas, and even hemorrhage, being present in diseases of other organs of the abdomen; but the pain phe- nomenon of ulcer differs from the pain caused b}^ disease of other organs, in that, although sometimes temporarily eased by foods, warm drinks, soda, etc., it recurs regularly after eating, usually two to four hours, throughout the ulcer-period. In contrast to this, the pain in gall-stone disease is inde- pendent of eating, is not modified by food, is irregular in relation to meals, and is periodical in occurrence; like the pain of ulcer, it is located in the epigastrium, but it has a wider field of radiation, usually extending to the right costal arch and scapular region, and is generally of a more sudden onset. In cystic duct-obstruction and in cholecystitis, pain is occasionally more or less constant in the epigastrium, and is for this reason more likely to be confused with gastric pain than is the pain of cholelithiasis. But here again, the pain is independent of and not modified by the kind and amount of food eaten, which fact excludes the pain as being of gastric origin. Tenderness to pressure in the epigastrium may be either present or absent in cholelithiasis, but in cholecystitis it is a more constant physical sign. It is located usually more to the right of the median line in the region of the gall-bladder DISEASES OF THE STOMACH 233 than otherwise. There is quite frequently a tenderness to pressure at the right of the ninth to the twelfth dorsal verte- brae in both gall-bladder and liver disease, and heavy per- cussion over the posterior hepatic area is more painful than over the corresponding area of the left dorsum. In gastric ulcer, the point of tenderness is sharply defined, and is almost always minutely localized by the patient to a small area throughout the ulcer-period. In a considerable number of ulcer-patients, the area lying to the left of the ninth to the twelfth dorsal vertebrse is sensitive to pressure. Vomiting is common to both cholelithiasis and peptic ulcer, although not so frequently a significant factor in the former. In gall-stone disease, vomiting appears soon after the initial pain and may give some relief. It is profuse only when the attack comes on after a meal, and then the normal food and the normal acidity of the vomitus will be recognized. In gastric ulcer, vomiting occurs from one to four hours after meals, at a time when the pain and hyperacidity are most intense, and it is usually followed by relief from pain. In uncomplicated gall-stone disease, the gastric contents will be found normal. In organic stomach-disease, the gastric analysis will show characteristic variations from the normal, depending upon the nature of the disease, — as in ulcer, dilatation, car- cinoma, etc. In chronic disease of the gall-bladder, adhesions so frequently exist between the gall-bladder and the pylorus and other structures, and so disturb their functions, that a differential diagnosis is possible only when an intelligent early history is obtainable.* Graham says that in the study of these cases, ''there is nothing so important as the carefully developed history, and that when this can be clearly obtained, errors in diagnosis will be at a minimum." [ * For helpful suggestions in this editorial, I owe my thanks to Dr. Chris- topher Graham, of the Rochester Clinic, who, in a recent letter, discussed the general diagnostic principles of early gall-bladder disease.] 234 DISEASES OF THE DIGESTIVE CANAL He considers the most important differential points of gall-bladder dyspepsia to be: ''Little stress laid on food as a cause of pain; the irregularity of symptoms, as to time of attack; the period over which the attack runs; the dis- comforts and pain depending little, if any, upon the amount or kind of food; and the distress being epigastric."] A few suggestions concerning the therapy of chole- lithiasis will be parenthetically offered. In the acute attack, the physician should prescribe strict rest in bed, and the application of hot linseed poultices and one or two leeches in the region of the gall-bladder, with the internal administration of 0.03 [{ gr.] extract of belladonna, or 0.001 [^^j gr.] of eumydrin, three to four times daily. In case there is a tendency to vomiting, either morphine may be given subcutaneously, or the above-mentioned remedies may be given in suppositories per rectum. The nourishment should be limited to tea, milk, and cereal soups. Chronic cholelithiasis, as well as the after-treatment of an acute attack, should receive attention preferably at Carlsbad, where the hot mud-poultices may be used to great advantage. The Carlsbad water should be drunk as hot as possible, in amounts of three or four glasses daily, — three in the morn- ing and one in the afternoon, — for a period of about four weeks. For very stubborn and severe cases, the physician should prescribe rest in bed and the use of the hot poultices from four to six weeks, befoi'e advising operative measures. If the Carlsbad regime proves ineffective, the oil-treatment should he prescribed. A wineglassful of olive or almond oil sliould be drunk every morning for about four weeks. Recently chologen* has proved useful in individual cases. It should be given for a period of from six to ten weeks. Eunatrol, salicylic acid, and i^robilin pills, — which consist of sal- icylic acid, sodium oleate, phenolphthalein and menthol, — should be taken before breakfast and in the evening, in doses of three or four pills, with one-third to one-half litre of hot water. The patient should be referred to a surgeon when internal therapy fails, or when attacks of cholelithiasis are frequent. [The medical treat- ment of gall-stone disease is A-ery uncertain in its results and owing to the pathological conditions present it can scarcely be more than palliative. Early sm-gical treatment should therefore be advised unless contraindications to an operation exist.] * There are three strengths, — No. 1 for Kght, No. 2 tor medium severe, and No. 3 for severe cases. The physician should prescribe two tablets before the dinner the first day, and two tablets before luncli and dinner on the second day, and on the third day two tablets before each meal; while on the fourth day, the patient should begin over again, etc. DISEASES OF THE STOMACH 235 Neoplasms of the pancreas, — such as cysts, carcinomata, etc., as well as other disorders of the pancreas, — such as concretions and hemorrhages, — are frequently confused with gastric diseases. A carcinoma of the pancreas, which causes stagnation of the contents of the stomach by compressing the stomach- outlet, cannot be differentiated in some cases from a cancer of the pylorus. In suspected cases of pancreatic disease, the physician must never neglect to examine the urine carefully for sugar, and also the stools for an increased fat-content. Fortunately, so far as therapy is concerned, a differenti- ation between the two affections is unimportant. 9. Stomach and Intestinal Diseases Numerous sufferers from intestinal diseases believe their real trouble is of gastric origin. Especially is this the case with those who have the so-called "intestinal dyspepsia." By the term "intestinal dyspepsia" is understood the occurrence of all kinds of dyspeptic symptoms, such as pres- sure, fulness in the epigastrium, loss of appetite, nausea, and even vomiting, flatulence, distention, and a more or less severe intestinal catarrh, — the functions of the stomach mean- while being normal. In 'addition to the above symptom, griping pains occur in those cases where an organic intestinal affection exists. Since such complaints have their origin mostly in the colon, which runs transversely through the epigastrium, its close inti- macy with the stomach may very easily confuse both the patient and the physician as to the exact nature of the affection. Disturbances of the functions of the intestine are always objectively evident. Either persistent constipation or diarrhoea, or alternating constipation and diarrhoea, will be found present. With these symptoms, cramp-like pains, which are a sign of spasm of the intestine, very frequently occur. Occasionally, the movements of the bowels are normal, the patient suffering only from impaired absorption and gaseous disturbances. 236 DISEASES OF THE DIGESTIVE CANAE Improvement naturally results in these cases only through treatment of the intestine. It is often very difficult to determine the location and intensity of a catarrhal condition of the intestine. If consti- pation exists, it is almost always of a spastic nature, reciuiring the use of belladonna, — 0.01 (J gr.) of the extract, or 10 drops of the tincture, — three times daih', also a non-irritating diet and Vich}' water. If diarrha?a is present, with only occasional constipation, the patient should be given a non-irritating diet, cond:)ined with intestinal astringents, such as tannocol, bismuth, etc. Fuller details will be given in the section on Chronic Intestinal Catarrh. CLINICAL CASES Case 1. — Otto G., a business man 42 years old, had for fifteen years suffered from attacks of -v'ertigo after errors in diet. He had also been troubled with heartburn and a feeling of fulness in the epigastrium and in the entire abdomen. There had been much flatulence, and the stools were lumpy and of a spongy consistency. He had occasional diarrhcea, and had lost 26 pounds in weight. There was no hyperchlorhydria. The liver and spleen were enlarged. Treatment consisted of a bland, non- irritating diet, the use of Vichy water and the calcium salts, with subni- trate of bismuth, — after which the stools became regular, and the flatulence and dyspeptic sjonptoms disappeared. He gained 10 pounds in weight, but noticed that he still suffered from vertigo whenever he ate eggs. Case 2. — Miss L., a singer 26 years old, had been constipated twelve years, so that purgatives were necessary. For six months she had suffered from languidness half an hour after dinner, and nausea in the morning, followed by vomiting of mucus and bile. The appetite was poor, and the patient slept badly. Physical examination was negative. The patient was given a coarse constipation-diet, after which the bowels became immediately regular, and in three weeks all the dyspeptic symj^toms had disappeared. 10. Stomach and Sexual Organs The co-relation between the female sexual organs and the stomach is generally recognized, especially the vomiting asso- ciated with uterine colic before or during the menses, and also the vomiting caused by retroflexion of the uterus, and by pregnancy. DISEASES OF THE INTESTINE 237 It is therefore essential, before making a diagnosis of nervous vomiting, to examine the pelvis carefully, in order to determine the condition of the uterus, since the statements given in the anamnesis of these cases are so often unreliable and misleading. Chronic metritis, perimetritis, ovarian disease, prolapsus of the uterus, etc., are extremely often the cause of nervous dyspepsia, nervous eructation, etc. In regard to the male sexual organs, it may be mentioned that diseases of the semen-producing organs are closely related to disorders of digestion. The dyspepsia caused by sexual neurasthenia following masturbation, prostatorrhoea, sper- matorrhoea, or phosphaturia, has already been spoken of in sufficient detail in the chapter on Nervous Dyspepsia. Diseases of the Intestine Introduction. — Diseases of the intestinal tract are even more extensive and common than those of the stomach. An enormous number of people suffer from irregularity of the bowels, — diarrhoea, constipation, or flatulence; so prevalent are these, indeed, that in civilized man, particularly in adults, a normally functioning intestine is rarely found. The causes of these prevalent disturbances of the bowels are the use of artificial "foods" during the first few years of childhood; and in adult hfe, unhygienic living, — such as sedentary occupations, insufficient exercise, mental over-work, frequent overloading of the digestive tract, irregular meals, alcoholic excesses, etc. The great length of the intestinal canal, amounting on an average to from 7 to 8 metres, frequently makes the diag- nosis of the exact location and character of any special disease very difficult. Our present knowledge of the individual dis- eases of the intestine is much less advanced and accurate than our knowledge of the stomach, because it is much more diffi- cult to examine the functions of the intestine than those of the stomach, by means of a so-called test-meal. Only very 338 DISEASES OF THE DIGESTIVE CANAL recently, following the initiative of Schmidt and Strasburgcr, clinicians have begun to use the test-meal, subjecting the stool formed from it to a chemical and microscopical examination. Unfortunately, this method of examination can be utilized only in the clinic and in hospital practice, being scarcely adaptable to the every-day use of the general practitioner. To be carefully performed, it requires a trained nurse and considerable routine on the part of the physician; and in consideration of these factors, is better left to the use of the specialist. In this book, we cannot go into the anatomical and physiological details of the intestinal tract, especially since it is taken for granted that such knowdedge is already famihar to the physician. A few remarks concerning the characteristics of a normal stool only will be made. From a person on a mixed diet, it is always of large caliber and semi-solid consistency. Clumps of yellowish-brown mucus, but never membranous mucus, may be adherent to its superficial surface. The normal color may be any of the shades from light yellow to dark brown; it is black-brown only after certain foods, — such as red wine, blueberries, spinach, etc. In twenty-four hours the stool will amount to about 170 grams. With vegetarians and those who have temporarily eaten largely of fruit and vegetables, it may be normally unformed and of pulpy consistency. After the eating of much milk and butter, the color may be a decided light yellow without being pathological. Every stool that differs from the above-indicated normal stool is pathological, as we shall see below in describing stools of hard consistency and those of small calibre, or of unformed, semi-liquid, or fluid consistency, etc. Etiology. — In general, the causes of disease of the intes- tine are the following: 1. Diseases of the Stomach. — Impairment of gastric diges- tion is frequently the cause of disturbances of the intestine. DISEASES OF THE INTESTINE 239 Chronic gastritis, especially, gives rise to a secondary chronic intestinal catarrh, although it should be mentioned that both diseases are often caused by the same etiological factor, such as excess in eating or drinking. The secretion of too much as well as of too little gastric juice will disturb the intestinal digestion. If a hyperacid gastric juice enters the duodenum, the bile and the pancreatic juice are unable to normally neutrahze the acid chyme after it has entered the bowel. On the other hand, when chyme which is deficient in acids enters the duodenum, there is insufficient stimulation for the secretion of bile and pancreatic juice of a normal quality and quantity. In both of the above instances, intestinal digestion suffers; and catarrh of the smaller, and later of the larger, intestine results. Diarrhoea first sets in after some error in diet; and after existing for several years, it becomes chronic. In simple gastric dyspepsia, when the appetite is much reduced and when even hght, easily assimilated foods cause disturbances in peptic digestion, the functions of the intestine become implicated, because normal peristalsis cannot be maintained with a deficient amount of nourishment. It is in this way that chronic constipation most commonly develops. An organic disease of the stomach will disturb the func- tions of neighboring organs, such as the transverse colon, and especially the duodenum. For example, hyperacidity of the gastric juice may cause the development of a peptic ulcer in the duodenum, or adhesions may form between the stomach and the transverse colon from perigastritis, giving rise to the formation of fistulse, and thereby to severe disturbances in the functions of the intestine. The converse may occur; that is, primary intestinal disease, especially catarrh of the bowels, may cause second- ary disturbances of the stomach, as we have seen in the chapter on Nervous Dyspepsia. 2. Frequent Indigestion. — This is, especially in children, one of the most common causes of chronic disease of the 240 DISEASES OF THE DIGESTIVE CANAL intestine, for the reason that insufficient care is maintained to produce an anatomical cure following acute conditions. Such cases are usualh' considered cured, if the violent symj)- toms have ceased, or if the pain and tliarrha^a, with the help of an anti-diarrha?a remedy, such as opium, have disap- peared; then the patient is not observed long enough, nor a sparing diet adhered to for a sufficient time, to allow the intestine to be restored to its normal anatomical condition. Opium is given entirely too often in sueh cases. In diseases of the intestine, it would be better if it were entirely dispensed with. Evcr}^ case of acute diarrhoea requires the most careful treatment in order to prevent permanent ana- tomical alterations of the mucous membrane of the intestine. Inherited tendencies toward alimentary troubles are recognized, and there are undoubtedly families in which an alteration in the functions of the intestine is a prevalent trait. Several members of one family will have a tendency toward diarrhoea; while in another family, a corresponding inclination exists toward constipation. 3. Infections and Intoxications. — Both acute and chronic affections frequently cause acute and chronic disturbances of the intestine. I need mention only lead, copper, arsenic, phosphorus, opium, and ptomaine poisoning,— besides dysen- tery, diphtheritic and syphilitic infections, — which may be associated with an inflammatory condition or ulceration of the intestine. 4. The General Constitution. — The general constitution has the greatest influence on the occurrence of functional intestinal diseases, — especially of hereditary constipation. Persons with the habitus enteropticus, — especially women after pregnancy who have relaxation of the abdominal walls, and in addition to the congenital, have acquired enteroptosis, — are predis- posed to atonic constipation, the existence of which for several years will give rise to a large number of disturbances and will finally lead to an organic disease of the intestine, as we shall see further on. 5. Neighboring Organs. — Hemorrhoids may be either the result or the cause of chronic constipation. DISEASES OF THE INTESTINE 241 Diseases of the neighboring organs, such as the peri- toneum, liver, spleen, kidneys, or heart, are also detrimental to the normal functions of the intestine. Passive congestion in either the greater, the lesser or the portal circulation causes stasis of the blood in the mesenteric veins, producing a passive congestion of the blood-vessels of the intestinal mucous membrane, with its clinical result. The bands formed from peritonitis, and further acute and chronic peritonitis, may give rise to the most severe intestinal disturbance. 6. Nervous System. — Besides the above-mentioned etio- logical factors, there are a large number of purely nervous affections of the intestine, the exact nature of which we do not understand. It is of the utmost importance that the physician seek and remove the causa morbi, so as to produce a permanent cure in every case of acute and chronic intestinal disease. Symptomatology. — The symptomatology in intestinal diseases, just as in affections of the stomach, is divided into subjective and objective. The subjective symptoms consist of pressure, feel- ing of fulness, distention not merely in the epigastrium but in the entire abdomen, flatulence, nausea, the tendency to vomit, and vomiting; also cutting, gnawing, cramp-like, recurrent pain in the region of the umbilicus and radiating to all sides, the so- called ''mesogastralgia, " which may increase to the sensation of oppressive constriction and finally to severe colic. Besides the above, constipation and diarrhoea occur as two subjective symptoms which merge into the objective. The objective signs and symptoms in disease of the intestine must, as a rule, be obtained from the statements of patients alone, since such cases are usually ambulatory and not under the constant observation of the physician. The most common symptoms are irregularity in the evacuation of the bowels, constipation, diarrhoea, and fever; besides meteorism and the escape of flatus, mucus, blood, pus, concretions, substances resembling gravel, foreign bodies, etc. 16 242 DISEASES OF THE DIGESTIVE CANAL The significance of the individual subjective and objec- tive symptoms will not be discussed until later on. Examination of the Patient. — The examination of a patient suffering from intestinal trouble should consist in the following: 1. Anamnesis. 2. Ph3''sical Examination. 3. Chemical and Microscopical Examination of the Stools, and if necessary of the Stomach-Contents. 1. In obtaining the anamnesis, the physician should proceed exactly as in Diseases of the Stomach, to which chapter the reader is referred, in order to avoid repetition. The differential diagnostic points, however, may properly be given here: Pressure, fulness and distention throughout the entire abdomen, which are independent of eating l^ut which are, on the other hand, dependent upon the evacuation of the bowels, are indicative of an intestinal affection, especially when they occur early in the morning before food has been eaten, or when the symptoms are associated with irregularity of the bowels. If, on the other hand, these symptoms occur only after eating, and are limited to the epigastrium, the physician should suspect that their origin is in the stomach. While in the stomach, pressure is alleviated by eructations; in the intestine, it is relieved by the escape of gas. In chronic affections of the intestine, actual pain is rarely associated with eating; while in disease of the stomach, pain is directly dependent upon the quality and quantity of food, — as has been shown in the chapter on Gastric Ulcer. Intestinal pain, as a rule, lasts for only a few minutes, — very rarely for hours, except in such cases as lead colic, — and it is usually relieved by the escape of gas. The mistaking of spasm of the pylorus for intestinal colic is notably frequent in diagnosis. The point just men- tioned, — that in intestinal colic the pain is of only temporary occurrence, — will guard against such an error, especially if DISEASES OF THE INTESTINE 243 the physician bears in mind that the pain of pyloric spasm occurs regularly at certain times after meals. If the physician determines from the anamnesis that the patient is suffering from an irregularity of the bowels, he will have much less difficulty in differentiating whether stomach trouble or disease of the intestine is present. I would not mention this matter in so much detail, had I not so fre- quently seen conditions, which were in reality intestinal colic, diagnosed as a spasmodic affection of the stomach. And again, when the physical exam- ination has determined that the patient has a congenital or an acquired enteroptdsis, the diagnosis of dilatation of the stomach, secondary to spasm of the pylorus, was assumed. Accurate observation, however, would soon reveal the fact that the alleged pylorospasm was in reality intestinal colic resulting from spastic constipation, and that the alleged dilatation of the stomach was nothing more nor less than gastroptosis. 2. Physical Examination. — The technic of palpation has already been considered in the Introduction to Diseases of the Stomach. The following, however, must be particularly mentioned in this place as requiring the close observation of the physician: The hahitus, the degree of nutrition of the patient, his color, the condition of the abdominal wall, and whether dias- tasis of the recti muscles is present, as well as visible peri- stalsis of the coils of the small intestine. An attempt should be made to palpate the colon from the C2ecum to the sigmoid flexure. This is best done by a rolling movement with the palmar surfaces of the extended fingers placed at right angles to the course of each portion of the colon. It is also frequently possible to palpate the appendix. When the abdominal walls are thick and rigid, the colon is not palpable; but, on the contrary, it can almost alwaj^s be felt when the abdominal walls are relaxed, especially in women who have given birth to several children, or in men who were formerly stout and have become emaciated. It is especially easy to palpate the transverse colon when it is contracted and hard; while it is almost impossible to differ- entiate a soft, empty colon from the neighboring structures. 244 DISEASES OF THE DIGESTIVE CANAL The palpation of the colon cannot be theoretically learned, but requires considerable practice and experience. Beginners should select, for examination, individuals who are emaciated or those who have relaxed abdominal walls. Particular attention should be given to the investigation of areas of the colon that are sensitive to pressure. Some- times the entire organ is sensitive, especially in a catarrhal condition associated with spasmodic contraction. The abdomen should be carefully palpated, also, for possibly existing tumors. The inexperienced may easily mistake fecal accumulations or Irregularities in the bellies of the recti muscles for new growths. The latter are hard, nodular, and resistant to the palpating hand; while fecal tumors yield under the fingers and give the so-called Ger- suny's symptom, that is, a feeling, after pressure on the mass, that the finger still adheres to the tumor; besides, fecal tumors usually have a knotted formation and shape, and are limited largely to the descending colon and the sigmoid flexure. As a rule, the coils of the small intestine are not palpable, but the examiner may often observe its peristalsis around the umbilicus, especially in women who have relaxed abdominal walls and who, after repeated pregnancies, have diastasis of the recti muscles extending from a finger's to a hand's breadth. These visible peristaltic movements of the small intestine are not in themselves pathological, and are unassociated with neuroses or stenoses of the small intestine. The only patho- logical features in such a case are the above-described condi- tions of the abdominal wall. While palpating the C2ecum, a gurghng sound is fre- quently heard, which is merely a sign that the intestinal con- tents are of a fluid consistency, and undergoing fermentation. Hard, irregularly-formed tumors are frequently palpated in this region, and are usually of either a tubercular or a car- cinomatous nature. To palpate the vermiform appendix, the physician should first locate McBurney's point, — which lies midway between the umbihcus and the anterior-superior spine of the ilium. He should place the palmar surface DISEASES OF THE INTESTINE 245 of the fingers of the left hand just below this point, at right angles to the line from the umbilicus to the anterior-superior spine of the ilium. By a slow, downward pressure of the fingers, accompanied by a rolling move- ment, the appendix will frequently be felt as a cartilage-like band, about the length of the little finger and as thick as a lead pencil, which can be rolled here and there under the palpating finger. In this way, with ex- perience and practice, it is frequently easy to demonstrate whether the appendix is SAVollen and sensitive, or elongated, or if it has assumed or is retaining an abnormal position. Palpation should not be concluded until the abdominal rings also are carefully examined for hernia; and finally, the rectum and anus should be palpated in all doubtful cases. Percussion should be used by the physician to outline tympanitic areas of the abdomen. 3. Chemical and Microscopical Examination of the Stool No detailed nor complicated methods of examining the de- jections will be described in this book, but only such procedures as are important and essential to the practical physician. a. Macroscopical Examination. — This is fully as valu- able as the microscopical examination of the stool; and indeed, for the general practitioner, it is often the only possible method, if the microscope and the necessary chemical re- agents are not at his disposal. With a little practice, and by keeping the following points in mind, the physician will be able to diagnosticate correctly the majority of chronic affections of the intestine by the examination of the faeces with the naked eye alone. 1. The Form of the Dejection. — It has already been men- tioned that the normal stool is formed, of large caliber, and sausage-shaped; and also that with vegetarians it may nor- mally be of a semi-solid consistency. All other stools are pathological, such as those that are spongy, semi-solid, liquid, abnormally hard, or of small caliber. 2. Color. — The color of normal faeces may range from yel- low to brown. Black stools are caused by the presence of blood, or medicaments such as iron and bismuth. The light-gray stool is indicative of liver-affections; and the green, of acute enteritis. 246 DISEASES OF THE DIGESTIVE CANAL 3. Consistencii. — The normal consistency of the stool is about that of butter at room-tcmperaturc. Fieces that are hard are most frequently observed in atonic constipation, while they may l^e still liarder in spastic constipation. The stools are doughy, s})ongy, or cream-like in mild cases of intestinal catarrh; semi-fiuid to fluid, in severe cases; and finally of watery consistency, in Asiatic cholera. 4. Food- Remnants. — Food-remnants are frequently recog- nizable with the naked eye; for instance, bits of potato or other vegetables, or of whortleberries, mushrooms, etc., all of which are less significant in diagnosis than undigested remnants of meat, connective tissue, and fats; since vegetable- remnants are found in every normal stool, while the presence of large amounts of meat and connective tissue is indicative of disturbed gastric digestion. 5. Pathological Constituents. — The pathological constitu- ents which are recognizable with the naked eye are blood, pus, and mucus. The blood varies in color from bright red to tarry black. If the former, it is usually free and not mixed with the faeces; when of the latter color, its origin is in the upper portion of the gastro-intestinal tract, and it is found closely admixed wath the stool. Red bloocl-cells are microscopically demon- strable only in the former instance, when the blood is fresh and of a red color. In the latter instance, the presence of blood must be chemically proven. Bright red blood in the stool almost always comes from ruptured hemorrhoids or from a rectal polyp. When blood and pus are found in the stool, even in teaspoonful amounts, a suspicion should always be aroused in the mind of the physician that a malignant chsease of the rectum is present. Carcinomata of the rectum are often treated for weeks as hemorrhoids. Pus. — In tuberculosis and dysentery of the colon, and in mahgnant growths of the colon and rectum, pus generally occurs in connection with blood. To best detect pus, the examiner should spread the entire stool as thinly as possible upon a smooth, black surface and look for small gray points with the aid of the dissecting- DISEASES OF THE INTESTINE 247 needle or a wire loop; the specimen should then be examined microscopically for leucocytes, tubercular bacilH, etc. Mucus. — Small amounts of mucus are present on the surface of the normal stool. In chronic catarrh of the colon, mucus surrounds the entire stool like a membrane. A light- brown mucus is often evacuated, together with semi-solid, unformed dejections, which should be considered as an objec- tive sign of severe enteritis. Fig. 39. Normal stool. M, muscle-fibres; H, plant-hairs; F, fat-globules; B. Z, pear-cells; Sj), plant- spirals; P. Z, plant-cells; P, Phosphate. The membranous form of mucus is always from the colon; and it may be said that the more typical the membrane, the lower down in the colon is its origin. Mucus from the ascending colon scarcely ever exceeds the size of a pea. When mucus is first evacuated, it generally has the appearance of an amorphous, clumpy mass, but its membranous character will be revealed if it is separated with forceps or a needle and shaken out in water. Mucus from the small intestine is not seen macroscopically. In catarrh of the small intestine, the stools look as if they had been varnished, if they have passed rapidly through the colon without undergoing changes in that portion of the gut. In such a case, the superficial surface of the stool appears 248 DISEASES OF THE DIGESTIVE CANAL smooth and reflective after it has stood for some time. In this affection, the stool is often soft, porous and sponge-like. For further details, see the chapter on Intestinal Catarrh. 6. Concrements and Foreign Bodies.- — The stool should always be examined for these in a case of gall-stone colic. The entire stool should be stirred with warm water and washed through a fine sieve, b}' which procedure gall-stones are usually recognized. The Boas stool-sieve may be used to good advan- tage for this purpose. Fig. 40. Stool containing fat and bismuth. M, muscle-fibres; A'^, fat-needles; F, fat-droplets; B.K, bismuth-crystals; O.K, calcium o.'ialate crystals; Ka, calcium salts. The physician must always guard against confusing vegetable-remnants, and especially fruit-seeds, with gall- stones. The suspected bodies should be placed in a watch- crj^stal containing a solution of liquor potassse, which softens the vegetable tissue, so that when they are crushed between two cover-glasses they may be easily recognized with the microscope. On several occasions, poppy seeds have been brought to my clinic by patients who thought them to be biliary concretions. Often the debris formed from pears very closely simulates concrements, since the pear-tissue contains hard, cellulose material which may form the so-called intestinal gravel, whose retention might produce colic. DISEASES OF THE INTESTINE 249 It would be impossible to enumerate the various foreign bodies, — such as coins, buttons, teeth, pieces of bone, fruit- seeds, etc., — that are sometimes found in the stool. 7. Parasites. — Tapeworm, Ascaris lumbricoides, etc., can- not escape the careful macroscopical examination of the stool. h. Microscopical Examination of the Stool. — Technic. — For a proper examination of the stool, at least three preparations should be made; Fig. 41. Enteritis. M, muscle-fibres; H, yeast-cells; E, epithelium; CI, Clostridia. 1. Dry. 2. With the addition of a little water or acetic acid. 3. With the addition of Lugol's solution. 1. A portion of the stool, about the size of a half a pea, should be pressed as flat as possible between two cover- glasses until it becomes transparent, and should then be examined with the low power of the microscope. By this method, the physician will inform himself con- cerning the digestion of meat, fats, and connective tissue. Muscle-fibres are easily recognized by their yellow color and regular surface. They are present in every normal stool and should not be considered as pathological, unless almost the entire field of the microscope is covered with them, or unless 250 DISEASES OF THE DIGESTIVE CANAL large masses of the muscle-fibres appear grouped together. In siich a case, the physician may assume that the gastric digestion, — one of the chief functions of which is to dissolve connective tissue, — is poor. If a large number of isolated muscle-fibres are present in the microscopical fiehl, it sliould l)c' inferred that digestion in the small intestine is not normal. Fig. 42. T. E., Taenia solium; Ch, Charcot-Leyden cry.stals; M, muscle-fibres; F, fat-droplets; A.E., eggs of ascarides; //, yeast; E, epithelium; A'', fat-needles. An intense yellowish-green color of meat-fibres is indica- tive of catarrh of the ileum. In normal conditions, only a few fat-droplets will be found in the stool. But in cases in wdiich there is catarrh of the large or of the small intestine, disease of the pancreas or any pathological conditions in which there is an obstruction of the ductus choledochus which, because of the absence of bile, gives a gray-white color to the stool, — the entire field of the microscope may be full of fatty-acid crystals, needles, fat- droplets, and even clumps of fat. Connective-tissue fibres are recognized by their shining surface and their tortuosity. They are often much swollen. An enormous number is indicative of the diminution or the entire absence of hydrochloric acid in the gastric juice. DISEASES OF THE INTESTINE 251 In this preparation, the eggs of intestinal parasites are also recognized, especially those of tapeworms, ascarides, and the trichocephalus. The accompanying cuts will illustrate the above findings. 2. A portion of the fasces, about the size of the head of a pin, should be mixed with a drop of normal sodium chloride solution and examined with an objective of higher magnifica- tion. In this specimen, the examiner will likewise observe the degree of digestion of meat-fibre, fat, and connective tissue, and will also note the presence of pus, amoebae, infusoria, Charcot- Leyden crystals, epithelia, and red and white blood-corpuscles. In stools of fluid or semi-fluid consistency, the physician should examine the specimen for mucus, without the addition of a sodium chloride solution or acetic acid. Charcot-Leyden ciystals in the mucus are quite typical of helminthiasis. An enormous amount of epithelia is characteristic of chronic intestinal catarrh. If a severe inflammatory condition of the intestinal mucosa is pres- ent, numerous white blood-corpuscles, in addition to epithelia, will be found. 3. A portion of the faeces about the size of a pin-head should be mixed with a drop of Lugol's solution. Under high magnification, the examiner should determine whether free starch-corpuscles and Clostridia, — which are both colored blue by the iodine in Lugol's solution, — are present in profuse numbers. Free starch-cells are always a sign of a catarrhal condition of the small intestine. Normally, starch is only found enclosed in cellulose. Clostridia are always a sign of fermentation; the more cellulose the food contains, the more profuse is the development of Clostridia, which give a sour odor to the stool. When they are present therefore in large numbers, the examiner may assume a pathological condition of the small intestine. In many cases, he should make a fourth or a fifth prep- aration from parts of the stool presenting some unusual appearance; for example, bloody or purulent portions (see Figs. 40 and 41). Frequently it happens that crystals, — such as , triple phosphates, calcium oxalates, etc., — as well as large numbers of bacteria, and the most diverse kinds of plant-cells, which 252 DISEASES OF THE DIGESTIVE CANAL are easily recognized by the thick, ghstcning membrane, are observed under the microscope. In dilatation of the stomach, sarcinir are also found in the firccs, which arc, consequently, of especial importance in the diagnosis. The microscopical examination of the faeces allows us, therefore, to form conclusions concerning the following: 1. The digestion of meat, fat, connective tissue and starch. 2. The presence of blood, mucus, and pus. 3. The presence of concrements, crystals, ova of the various parasites, and Charcot-Leyden crystals. The microscopical examination will lead to a correct diagnosis only in connection with the macroscopical findings. c. Chemical Examination. — 1. Test for Occult Blood. — A positive reaction to this test is of value only when very few meat-fibres are present in the stool. To obtain a significantly positive result, it is necessary that, for three days before making the test, the patient be kept on a diet which does not contain blood or iron. Either the Aloin-test may be made, which has been described in Part I; or the more simple and sensitive test, — recently introduced by 0. and R. Adler, and modified by Schlesinger and Hoist,— may be made in the following manner: 1. Dissolve a knifepoint of pure benzidin in two or three cubic cen- timetres of glacial acetic acid. II. Add 2 c.c. of Hp^ to ten or twelve drops of "I." III. Boil a portion of the faeces the size of a pea, which has been thor- oughly mixed with five or six cubic centimetres of water, in a test-tube closed with a wad of cotton. IV. Add two or three di-ops of the solution of boiled faeces to "II." If blood is present, a green or bluish reaction will occur in from one to three minutes. 2. Schmidt's Biliruhin-T est. — A portion of fseces about the size of a bean should be placed in a watch-crystal containing a 5 per cent, sublimate solution, and alloAved to stand for twenty-four hours. At the end of this time, ptfi'tions of the stool containing bilirubin will have become green, while those containing hydro-bilirubin will be yellowish-red. Positive reactions of either are indicative of a catarrhal condition of the small intestine. DISEASES OF THE INTESTINE 253 CLOSING REMARKS AND DIRECTIONS Patients whose bowels move normally may bring the stool to the physician's office in a closed glass receptacle. Constipated patients should produce an evacuation of the stool by using a soap suppository, the stool being left in a vessel half- filled with water, for the inspection of the physician. In office-practice, the stool may be conveniently obtained and preserved by the use of the apparatus previously described. PRIMARY ORGANIC DISEASE OF THE INTESTINE Acute Enteritis. General Remarks. — In considering acute intestinal catarrh, which occurs with great frequency, we shall discuss the sub- ject as briefly as possible, since nearly every physician is familiar with the symptoms and treatment. It is only the severe, chronic cases that come to the physician for treat- ment, as the milder and more acute ones are usually relieved by home remedies. Acute enteritis becomes serious, as a rule, only in children, or in old and decrepit, or arteriosclerotic, persons. It occurs epidemically during the summer months, as is well known. The entire intestinal tract may become affected or only individual portions of it, such as the duodenum and jejunum, when the inflammatory process extends from the stomach, and when the causative agent passes through the stomach without producing inflammation of its mucosa, as is the case with certain poisons that are soluble only in the alkaline intestinal juice. The mucosa may be so severely inflamed that ulceration occurs, the stools then becoming bloody in character. Etiology. — The causes of acute enteritis, in the order of their frequency, are the following: Indigestion, infections, intoxications, and exposure to cold. Foods which are especially injurious in acute enteritis are raw fruit, ice-cold beer, fresh cucumbers, sour potatoes, and meat-dishes, especially in summer; while overloading the stomach with fancy dishes, such as goose, liver, patties, ra- gouts, etc., is the most frequent causal factor in the winter. 254 DISEASES OF THE DIGESTIVE CANAL Besides the intoxications resulting from attempted sui- cide, murder, criminal abortions, etc., there should be men- tioned, as causative factors, vermifuge remedies and the occupation-poisons, such as copper, lead, etc. Exposure to cold causes acute catarrh of the intestine, especially when the resistance of the mucosa has been weak- ened by previous catarrhs. Symptomatology. — The chief symptom is diarrhoea, which occurs with almost explosive suddenness and with colic. It is not rare for twenty stools to be passed in .24 hours, al- though in some cases constipation results from spasm of the colon, — -first, when only the small intestine is affected; and second, when the offending material, — for instance, undigested remnants of food, such as cucumbers, sour potatoes, etc., — lodges in the folds of the mucous membrane of the colon, producing spasm, accompanied by severe pain from the result- ing irritation. Colic, — that is, gnawing, boring, contracting pain, — begins in the mesogastrium, radiates in all directions, and disappears with a movement of the bowels or the escape of gas; it recurs repeatedl}^, and accompanies nearly every case of enterocolitis. Fever occurs, as a rule, only in infectious enterocolitis. Indeed, it is characteristic of this form, and will amount to 40° C, [104° Fahr.] or more. The other causative agents produce either no fever at all, or at most 38.5° C. [101° Fahr.]. Vomiting and nausea exist only when the stomach also is involved. The general condition of the patient, even in moderately severe enteritis, is poor. In very severe cases, there are great weakness and lassitude, caused by the violent pain. The spleen is generally swollen and sensitive to pressure, especially in infectious enterocohtis. Indeed, the whole abdomen is sensitive to pressure, especially over the course of the transverse colon. Icterus is often an accompanying or subsequent symptom. The stool is of a semi-solid or fluid consistency^ and mixed with large shreds of mucus which are often tinged with blood. Old, hard scybala may also be DISEASES OF THE INTESTINE 255 passed. The odor of the stool is at first very penetrating or acid, later it is stale and fiat. The color may be brown, green, yellow or light gray. Late in the affection, mucus only is passed. Microscopic examination shows the presence of epithclia and in severe cases of red and white blood-corpuscles, rem- nants of food, bacteria, etc. Diagnosis. — The diagnosis is made from the sudden onset of the above-mentioned symptoms, — namely, diarrhoea, fever, colic, mucus and blood in the stools, — and by the establish- ment of an etiological factor. Differential Diagnosis. — Typhoid fever, crises enteriques, and acute yellow atrophy of the liver are the most common diseases to be differentiated from acute enterocolitis. There are cases in which only a prolonged observation of the disease will differentiate enterocolitis from typhoid fever, although the roseolse, splenic tumor, and the general condition will usually protect the physician against mistake. Treatment. — The tasks of the physician are largely limited to protecting the mucosa of the intestine from further injury as much as possible, and to controlling the pain and diarrhoea. Rest in bed is essential as long as there is fever. In cases in which the latter is high, — 39° to 40° C, — cold applications should be used on the abdomen. In moderate fever, — 38° to 38.5°, — the Priessnitz compresses are indicated; while febrile cases are best relieved by the application of moist, hot com- presses wrung out of chamomile infusion, etc. The dietetic treatment for the first two or three days is the same as in acute gastritis, — peppermint tea, black tea with cognac, gruels, soups, cocoa cooked in water or red wine, and the gradual institution of rice and cereals added to pigeon or chicken broths, and finally chicken, veal, white bread, etc. Meats, raw fruits, cold drinks and vegetables should be forbidden for some time. Medicinal Treatment.— BeWadonna should be used for tlie suppression of the cramp-like pain; and styptics for the control of tlie diarrhoea, as in the following prescriptions: 256 DISEASES OF THE DIGESTIA E CANAL 1. I^ Extracti belladonnte fouorum, gr. l-\ 0.02-0.03 Sig. — Three or four times daily. 2. r^ Extracti belladonnte folioruin, gr. J 0.02 Tannocol, gr. xv 1.0 Sig. — One powder three or four times daily. 3. ^, Tannalbin, tannigen or tannoform, gr. xv 1.0 Sig. — Three or four times daily. Opium and its preparations should be strictly forbidden, because they paralyze the peristalsis of the bowels, and thereby prevent the evacuation of the materia peccans. In contrast to the effect of opium, belladonna relaxes the painful contraction of the intestine, while leaving the peristalsis undisturbed. I administer a laxative only when the fever is higher than 38.5° C, and has continued more than three days. In children or adults w^th good teeth, I prefer to give 0.03 to 0.2 [h gr. to 3 gr.] calomel three times, at about one-hour intervals, or until the desired effect is produced. In other cases, I administer either a teaspoonful of castor oil or a heap- ing teaspoonful of Carlsbad salts. In cases in wdiich there is no fever, I do not prescribe a laxative unless the cramp-like pain does not disappear. Otherwise, I prescribe muriatic acid mixture. Constipating remedies should not be given unless the fever has entirely disappeared, or is only slight, since other- wise the inflammatory process and the clinical symptoms would be prolonged. Prophylaxis. — Individuals who seem to have a pre- disposition to enterocolitis should be warned against raw fruit, cold beer, cucumbers, sweets, over-eating, etc. Prognosis. — The prognosis of the disease is generally good, although there always remains a certain weakness of the mucous membrane of the intestine. It should finally be mentioned that repeated attacks of acute catarrh often lead to chronic enterocolitis. DISEASES OF THE INTESTINE 257 Chronic Catarrh of the Intestine (Chronic Enterocolitis) General Remarks. — Chronic catarrh of the intestine is very frequent in old people, and less so in children. Men are more often affected than women, because they are exposed to a greater number of injurious influences. The disease may extend over several decades. Indeed, severe cases are never cured in the anatomical sense; and several years of the most careful treatment are required to produce even a clinical cure. As a general thing, the beginning of the affection is generally entirely neglected, so that the disease gradually becomes worse until finally, on account of the suffering due to constant pain, flatus, and diarrhoea, the patient consults a physician. Etiology. — Primary intestinal catarrh is caused by direct injury to the intestinal mucous membrane, while secondary catarrh is caused by passive congestion brought on by venous stasis in the greater or the lesser circulatory systems, or by the continuity of inflammation from neighboring organs. Primary catarrhal enterocolitis arises from indigestion, infections, — such as tuberculosis, dysentery, etc., — intoxica- tions, exposure to cold, misuse of laxatives, entozoa, habitual constipation, and mechanical irritation from scybala. Secondary enterocolitis results from cardiac diseases, affections of the kidneys, sclerosis of the liver, and from ulceration, tumors, and stenosis of the intestine. The most common cause of chronic enterocolitis is fre- quent indigestion, in consequence of which chronic catarrh of the stomach and of the intestinal tract both occur. As a rule, chronic gastritis precedes chronic enterocolitis. It very frequently happens that catarrh of the intestinal tract is secondary to atrophy of the gastric glands, the so- called achylia gastrica, when the food enters the duodenum non-chymified, and this in the course of years produces chronic inflammation. 17 258 DISEASES OF THE DIGESTIVE CANAL Naturally, both affections may arise at the same time and from the same cause, — as, for instance, from the excessive use of alcohol. For this reason, the gastric juice should be examined in every case of chronic enterocolitis. Symptomatology. — The subjective s3''mptoms are loss of appetite,* nausea, feeling of fulness, and distention of the entire abdomen which, in contrast to the same sj'mptoms in gastric diseases, appear earl}' in the morning, are of only short duration, and are, except for flatuous foods, independent of eating. Other symptoms more characteristic of this disease are flatulence, colic or the so-called mesogastralgia, and frequent tenesmus. Lassitude, weakness, lack of desire to work, and nervous irritabilit}^ are present in enteritis. Objective Symptoms. — By palpation and an accurate examination of the stools, the physician will find the most typical signs and symptoms. The whole abdomen is frequently distended and sensi- tive to pressure, especially over the entire course of the colon, whose sensitiveness in a localized inflammation of the large intestine is characteristic. Enlargement of the spleen is sometimes found in a catarrh which has existed for years. The condition of the stools depends upon the intensity and the localization of the inflammatory process of the intes- tinal tract. In mild cases, the stools are of firm consistency, have a small caliber, and are surrounded with membranous mucus. In cases of moderate severity, their condition is variable, — solid and liquid stools alternating with each other, or with those of a pulpy consistency. In the more severe cases, the stools are persistently semi- solid, semi-fluid, or liquid, and are mixed with large shreds of mucus. The superficial surface of the stools, of pulpy con- sistency is reflective, having a varnished appearance. * This does not occur in some cases; for instance, in gormands suffering from intestinal catarrh, the appetite is often excellent. DISEASES OF THE INTESTINE 259 When ulcerations or erosions arc associated with catar- rhal inflammation, the stools are often mixed with bloody, purulent mucus. There are cases of enterocohtis in which the clinical course is characterized by periods of complete constipation alternating with severe diarrhoea. Further details have been given in a previous chapter on Macroscopical Examination of the Stools. Diagnosis. — The diagnosis of catarrh of the intestine is, in general, very easy. The statements of the patients often suffice as to whether they have a diarrhoea which is persistent or frequently recurrent, whether it occurs only after eating certain foods, whether mucus is present in the stools, and whether or not they suffer from colic. The Localization of the Lesion.— This is often very difficult, and in many cases quite impossible, although the following suggestions will generally be found appHcable in the diagnosis. Inflammation Hmited to the small intestine causes loss of appetite, borborygmus, a gnawing sensation in the middle of the abdomen, meteorism, or flatulence; while actual pain and diarrhoea occur but rarely. The stools contain much fat and sometimes free starch-cells and many muscle-fibres, while mu- cus is scarcely ever recognized, even with the microscope. The condition is aggravated by the use of flatuous foods, cold drinks, raw fruit, and by overloading the stomach. The diagnosis of catarrh of the ileum is arrived at largely from accurate statements made by the patient in the anam- nesis. The stools are formed, are of soft consistency, and the bowels are regular. Catarrh limited to the colon runs a clinical course, as a rule, with constipation, or a sluggish condition of the bowels with the evacuation of spastic stools, unless an ulcerative process is present. Only in severe cases are the stools of large cahber and of a pulpy consistency, when they are surrounded by membranous mucus, which is frequently not recognized until the stool has been placed in a vessel of warm water. In the event that the stool is brought to the physician in a dry ^260 DISEASES OF THE DIGESTIVE CANAL glass receptacle, the mucus may no longer be recognizable, because of its having become dry. If constipation is present, it will be necessary to insert a soap-suppository in the rectum of the patient in order to obtain the stool for examination. Catarrh of the entire intestinal tract, that is, of the large and small intestine, almost always runs a clinical course with diarrhcea. The more extensive and severe the inflammatory process, the more severe is the diarrhoea, — there being often from two to six stools in twenty-four hours. If the dejections are still more frequent, the clinician should think of ulceration of the intestine, and should direct the examination of the patient accordingly. In chronic cases, a movement of the bowels is especially frequent early in the morning, probably caused by the fermentation of the faeces during the night. Mucus in large or moderate amounts is almost always present in the dejections, and in fluid stools is detected in pea-sized portions, and may be removed with a teasing-needle or forceps and shaken out in water, when it is easily recognized. The so-called ileoctecal catarrh, which at the same time attacks the greater part of the ascending colon, runs a clinical course with the above-mentioned symptoms and with persist- ent sluggishness of the bowels, sometimes complete constipa- tion, or profuse diarrhoea accompanied by severe pain. Objec- tively, the examiner will find gurgling murmurs in the ileocsecal region. Catarrh of the large intestine almost invariably runs a clinical course with cramp-like pain, mucus in the stools, and "wind-cohc." In general work, the physician must be satisfied with the determination as to whether slight, moderate, or very severe catarrh of the intestine is present, because an exact localization of the lesion is often possible only after pro- longed clinical observation and a microscopical and chemical examination of the faeces. Differential Diagnosis. — Nervous diarrhoea is almost the only affection that might be confused with chronic entero- colitis. This is extremely rare, however, and can only be DISEASES OF THE INTESTINE 261 diagnosticated: jSrst, when the dejections contain no macro- scopically visible mucus; and second, when diarrhoea occurs invariably after any excitement. In almost every case of nervous diarrhoea, there exists a latent catarrhal condition as the basis of the trouble, which fact should always be kept in mind in the treatment, because many so-called nervous diarrhoeas are cured only by anti-catarrhal therapy. Ulcers and erosions of the mucous membrane may be differentiated from chronic enterocolitis by the absence of blood and pus in the dejections of the latter. In every instance, the etiological factor should be ascer- tained if possible, and the following three points should be given especial attention: 1. Whether the gastric secretion is normal; or whether there is present, for instance, achylia or hyper- secretion. 2. Whether the catarrhal condition is due to venous congestion. 3. Whether there is a malignant affection accompanying the enterocolitis. Treatment. — The first task in the therapy is, naturally, the removal of all etiological factors, so far as possible, and the careful study of the functions of the heart, liver, and stomach. An examination of the contents of the stomach must be made, when possible, in every case of chronic entero- colitis. Otherwise it often happens that for months the thera- peutic measures will produce no result. Concerning this point, the reader is referred to the section on Chronic Gastritis. In the following discussion, I have divided cases of chronic enterocoHtis into three groups: 1. Mild cases, with either constipation or normal stool, and with many disturbances of the small intestine. 2. Moderately severe cases, with alternating constipa- tion and diarrhoea. 3. Severe cases, with persistent diarrhoea. 262 DISEASES OF THE DIGESTIVE CANAL Hygienic and Dietetic Treatment. — In all forms of intes- tinal catarrh, any sudden exposure to cold and chilling of the abdomen, feet, or entire body should be avoided. The patient should wear woolen underclothing and a woolen abdominal bandage during the day and a Pricssnitz compress at night. Workingmen should avoid, as much as possible, occupations which give rise to intestinal catarrh, especially those in which they come into frequent contact with arsenic, lead, copper or mercury. Only a limited amount of smoking should be allowed. The diet in chronic enterocolitis must be bland, non- irritating and easy of absorption; and in severe cases, it should be, in addition to the above, astringent in character, and consist of the following: Tea with one tablespoonful of cream, red wine, cocoa or blackberry wine; cereal soups, gruels, rice, sago, noodles, macaroni; the broth of white meats, fresh soft eggs, toasted white bread, Leibniz's cakes, butter; and milk diluted one-half with cereal soups or cocoa, but never undiluted. In cases of moderate severity, the patients may be allowed, in addition to the above, light vegetables, — such as spinach, carrots, cauUflower, asparagus, peas, potato purees, and red meats cooked in butter or broiled. In Kght cases, the dietary may include whole-wheat bread, stewed fruit-sauces, meats, fish, and the like. In this form, it is unnecessary to adhere strictly to any special dietary. Only the following foods are forbidden: cold drinks, strong coffee, plain milk, sour milk, all acid foods, raw fruits, — such as sweet oranges, dates, figs, and apples — legumes, cheese, cabbage, smoked meats and fish, fat meats, fresh bread, and pastries. Special diet-tables will be found in the Appendix. The mechanical treatment consists in warm or hot injections. In severe cases, associated with diarrhoea, in which treat- ment per mouth is not successful in controUing the bowels, I generally prescribe the following enema, night and morning: One teaspoonful of tannin, 1 tablespoonful of starch and 1 ntre of water 32° to 33° R. [104°-10()° F.]; or a solution DISEASES OF THE INTESTINE 263 of silver nitrate, 0.5 to 1.0 [gr. viiss to xv] to 1000, or one tablespoonful of the extract of blackberry to |- litre of water. Since many astringent preparations should be employed with considerable caution, their use is limited to the chnic; but the tannin-starch enema may be prescribed without hesitation for home treatment. In moderate cases, an injection of one litre of hot Carls- bad water or a htre of hot water containing a teaspoonful of the artificial Carlsbad salts, should be given every morning. Under this treatment, the cramp-like pain and the diar- rhoea disappear with surprising quickness in a great number of cases, because of the soothing effect upon the irritated membrane. In mild cases, enemata are unnecessary. . Massage is contraindicated in all cases. However, a very gentle stroking massage may be allowed if there is neurasthenia. Balneological Treatment. — Balneological treatment depends first upon the condition of the stomach; and second, upon the intensity of the enterocolitis. If there is a deficiency of gastric secretions, the sodium chloride waters of Homburg, Wiesbaden, or Kissingen [Cham- pion and Hawthorn Springs, Saratoga, N. Y., and Blue Lick Springs, Kentucky], are indicated. In mild cases, when there is either a normal or a sluggish condition of the bowels, the above-mentioned waters should be given lukewarm; in moderate cases, at the temperature of the body; and in severe cases, as hot as possible, but in very small doses. On the other hand, when there is normal acidity of the gastric juice, or hyperchlorhydria, — as in acid gastritis, — the waters of Carlsbad, Neuenahr, Franzensbad, Marienbad, or Vichy [Tate Epsom Water, Tennessee; French Lick Springs, Indiana; Buffalo Lithia Water, Virginia; Crab Orchard, Kentucky], should be prescribed in the same quantities and at the same temperature as described above. Well nourished indi- viduals should be sent to Carlsbad, while anaemic and badly- nourished patients should be given the milder Vichy water. ^204 DISEASES OF THE DIGESTIVE CANAL Two or three glasses of the water shoiihl be drunk each da}', — two glasses on the empt}' stomach early in the morn- ing, and one glass before the evening meal. The spring- water salts, or the artificially prepared salts dissolved in plain water, may be used as above indicated, by patients who are travelling or those who cannot afford the luxury of a visit to one of these watering places. In enterocohtis associated with constipation, either | of a teaspoonful of Carlsbad salts or H teaspoonfuls of Vichy salts should be dissolved in I litre of water and taken on the empty stomach early in the morning. These mineral water treatments should be continued from four to six weeks and begun again after an intermission of two or three months, and so on for several consecutive j^ears; for it is impossible to produce a complete cure in one course of treat- ment when an intestinal catarrh has existed for several years. Medicinal Treatment. — The control of pain and the regu- lation of the bowels are the indications for medicinal treatment. I prescribe astringents only in cases of persistent diarrhoea. The most suitable of such preparations are tannin and bismuth, although tannocol, tannalbin, tannoform, and tannigen have given very good results in doses of a knifepoint to one-half a teaspoonful three times daily. Bismuth subnitrate, bitannate of bismuth, bismutose, and nosophen may also be useful, while dermatol is particularly suitable in tuberculosis of the intestine. For cases in which the stools are persistently of a pulpy, semi- solid consistency with marked fermentation, calcium salts combined with bismuth are the most effective. Good results are obtained from the use of the following prescriptions: 1. I^ Calcii carbonatis, Calcii phosphatis, aa, ovi 25.0 Bismuthi salicylatis, gr. Ixxx 5.0 M. Sig. — One teaspoonful after meals. 2. I^ Tannocol, or Tannalbin, or Tannigen, or Bismuthi subnitratis, gr. viiss-xv 0.5-1.0 Sig. — T.i.d. DISEASES OF THE INTESTINE 265 The most efficient sedative and anodyne remedies are belladonna, menthol, valerian, and the carminatives. I administer them in the following prescriptions : 1. I^ Extract! belladonna3 foliorum, gr. vii 0.5 M. ft. pil. No. XXX. Sig. — One pill after meals, t.i.d. 2. I^ Menthol, gr. iss 0.1 Ft. pil. i. Sig.— T.i.d. 3. I^ Spiritus menthse piperitse, gtt. Ixxx 5.0 Tincturse belladonnse foliorum, oiiss 10.0 Tincturge valeriana3, oiv 15.0 M. Sig. — Thirty drops in a cup of hot water or fennel tea, t.i.d. 4. I^ Extracti belladonnse foliorum, gr. ivss 0.3 Menthol, gr. xv 1.0 Tincturse Valerianae, q.s. ad oi 30.0 M. Sig. — Twenty-five drops t.i.d. The treatment of chronic intestinal catarrh, because of its diversity of symptoms, requires much experience and the art of individualizing. The physician must not change from one line of treatment to another merely if there is no apparent improvement in two or three weeks; for instance, having given the mineral water for this length of time, he should not change to astringents, nor vice versa, as the first line of treatment has not been given a sufficiently thorough trial. Prognosis and Course. — The treatment of chronic intes- tinal catarrh should extend over several years; indeed many patients must adhere strictly to a suitable dietary for the rest of their lives if they are to remain free from intestinal disturbances, as relapses are likely to occur after the slightest error in diet or exposure to cold. As a rule, improvement is only very gradual. All patients suffering from chronic enteritis become nervous and hypochondriacal, which further modifies the prognosis and complicates the course of the disease. APPENDIX 1. Membranous Enteritis. — Membranous catarrh of the colon, which is still designated by some authors as "myxo- neurosis intestinalis, " is in reality a simple, chronic, reparable, 266 DISEASES OF THE DIGESTIVE CANAL superficial catarrh of the colon which accompanies chronic constipation, as will be shown in its clinical description. Since constipation is associated with neurasthenia in a large majority of cases, especially women, it follows therefore that membranous enteritis is also met with in hysterical and neurasthenic patients. Membranous enteritis disappears as soon as constipation is cured, which fact is the best refutation of the theory of its nervous origin, since notwithstanding the cure of constipa- tion, the hysteria and neurasthenia often become still more aggravated and persistent. Mucous colic, or the colica mucosa of Nothnagel, is an acute exacerbation of chronic membranous colitis. For further details, see the subsequent chapter on Chronic Constipation. 2. Meteorism and Flatulence (Intestinal Flatulent Dyspep- sia). — By meteorism, we designate the acute abnormal distention of the abdomen; by flatulence, the chronic abnormal fermentation and evacuation of gas. Although both are often observed in nervous, and especially in hyster- ical, individuals, they are, — with the exception of obstruction of the bowels, — symptoms of catarrh of the intestine and not of a nervous affection. The escape of gas from the bowels is, in itself, normal; we speak of a pathological flatulence onl}' when the patient suffers from discomfort, such as cutting pains, disagreeable distention, and fulness in the abdomen, — especially when unable to expel the gas. The retention of gas causes very unpleasant conditions and symptoms, — such as mental clulness, palpitation o£ the heart, dyspnoea, mental depression, insomnia, irregularity of the appetite, inabihty to work, and griping pains in the entire abdomen, especially in the flexures of the colon. Whether these symptoms are of a reflex nature, — caused by the .irritation of the splanchnic nerve, — or are the result of a so-called autointoxication — as many authors assume — I shall not attempt to decide. DISEASES OF THE INTESTINE 267 The cause of abnormal accumulation of gas in the intes- tine is the stagnation and fermentation of liquid faeces, which are mixed with a pathological secretion of the intestine, — namely, mucus. In simple constipation without catarrh, such as atonic constipation, flatulence does not occur, nor in cases of severe catarrh with profuse diarrha-a, for the reason that in each of these affections there is present only one of the two conditions essential to the formation of gas, — namely, constipation and mucus. Flatulence, however, becomes a symptom in catar- rhal conditions of the jejunum, ileum, and large intestine as soon as the colon becomes spastic, as is very frequently tte case. The spasm of the colon does not permit the gas to escape at all, or only with great difficulty, and then associated with pain {colica flatulenta) ; and the same condition of the colon offers a hindrance to the expulsion of the fermenting liquid contents of the ileum into the colon, or out of the caecum and ascending colon into the transverse portion of the large intestine. The principal locations of fermentation and the accumu- lation of gas are the caecum and the ascending colon, where the pathological faeces stagnate. If the fermenting contents of the bowels enter the transverse or the descending colon, the}^ are either rapidly evacuated or become so thickened by absorption that the fermentation-process is entirely absent, or slight, for the reason that fermentation is present only to a minimum degree in dry faeces. The well-known meteorism which occurs in hysterical patients arises from spasm of the colon and fermentation of the stagnating catarrhal and liquid contents of the ileum. It generally occurs in hysterical persons with enteroptosis, who have suffered for years from chronic constipation, in consequence of which, as we shall see in the chapter on this subject, secondary catarrh of the intestine has developed. It is an indication of flatulent dyspepsia, when distention and pain are reheved by the escape of gas. It is often neces- sary to question the patient carefully concerning this point, 268 DISEASES OF THE DIGESTIVE CANAL since he usually considers and explains the pain to be due to "stomach-cramps" and ''pressure in the stomach." Flatulence is especially marked after the use of flatuous foods, such as all kinds of fresh fruits, cabbage, legumes, coarse bread, pastry, fresh beer, and other cold drinks. The more cellulose the food contains, the more troublesome is this symptom. That persons in normal health have more or less flatu- lence is, of course, well known, and has no especial significance. Diagnosis. — The diagnosis of flatulence- cannot be mistaken if the examiner will keep in mind, in a case of acute meteorism, the possibility of intestinal stenosis or obstruction. Treatment. — The therapy of this symptom-complex, — - which is not sufficiently appreciated nor considered in the text-books on the subject, — is as difficult as it is important in general practice. The first task of the physician should be to cure the chronic catarrh of the intestine, or rather to mitigate its symptoms, since he can scarcely hope for a complete cure of chronic enteritis; second, to limit the use of fermentable foods; third, to facilitate the removal of intestinal gases. These indications are best fulfilled by the following treatment: 1. It should be emphasized that, in cases where all the above indications are estabfished, we invariably have to do with sfight or only moderately severe enterocohtis, — and never the severe form of the disease; for in the latter, owing to persistent diarrhoea, there is no stasis of the intestinal contents, while in slight and moderately severe cases, the enterocolitis is associated with constipation of a spastic nature, or with alternating diarrhoea and constipation. Anti-catarrhal mineral water should be prescribed, — small doses of Carlsbad, Vichy, or Homburg waters, accord- ing to the principles set forth in a previous chapter; or else the anti-fermentative remedies that are, at the same time, astringent to the mucous membrane of the intestine, ^such as tannocol, tannalbin, menthol, resorcinol, vegetable charcoal DISEASES OF THE INTESTINE 269 (one teaspoonful three times daily), or the calcium salts, — according to the following prescriptions: 1. I^ Tannalbin, oiiss 10.0 Sig. — Four to eight grains, t.i.d. 2. I^ Calcii carbonatis, Calcii phosphatis, aa, 5vi 25.0 M. Sig. — One teaspoonful, t.i.d. When there is constipation, mineral water should be given at a temperature of 28° to 30° R. [96° to 100° Fahr.]. When there is a tendency to diarrhoea, it should be given hot. The use of the mineral water should be continued for several months. Warm abdominal poultices should be worn during the day and the Priessnitz compresses at night, as in enteritis. 2. The above-mentioned foods of a flatuous nature should be strictly forbidden, while the following are recommended: white bread, stale whole- wheat bread, meats (excepting goose, duck, fat pork, and ham), fresh eggs, spinach, cauli- flower, asparagus, carrots, peas, rice, sago, noodles, macaroni, butter, baked potatoes (one or two tablespoonfuls), tea, weak coffee, cereal soups, red wine, sweet fruit-sauces, espe- cially apple sauce, marmalades and lemonade. Potatoes and milk should be allowed only in small quantities. 3. Carminative remedies which relax the spasm of the colon are always indicated. Belladonna and menthol in the following prescriptions are the most effective: 1. I^ Menthol, gr. xlv 3.0 Extracti belladonnse foliorum, gr. ivss 0.3 M. ft. pil. No. XXX. Sig.--One pill, t.i.d. 2. I^ Extracti belladonnse foliorum, gr. ii 0.15 Tannocol, 5iiss 10.0 Sig. — -One small knifepoint, t.i.d. 3. I^ Tincturse belladonnas foliorum, 5iiss 10.0 Tincturse valerianse, ov 20.0 M. Sig. — Twenty-five drops in a cup of hot peppermint tea, t.i.d. 270 DISEASES OF THE DIGESTIVE CANAL In mild cases, the following carminatives are sufficient: 1. I) Valerian, Peppermint, Fennel, Caraway, aa, 5vi 25.0 M. Sig. — One tablespoonful to a cup of hot water, morning and evening. Eight or ten drops of the tincture of belladonna may be taken with the above. CLINICAL CASES 1. Catarrh of the Stnall fntestine Case 1. — Geo. B., an officer 19 years old, had had an attack of diar- rhoea six or seven weeks previous, at which time he was jaundiced for two weeks, since when he has suffered from distention and a feeling of fulness around the umbilicus, which was especially troublesome in the morning, and was relieved by the escape of gas, which was sometimes painful. The appetite was poor. He defecated a soft, sausage-like stool once daily. In the evening the patient was often troubled by borborygmus and gnawing pains in the abdomen. All the above symptoms were increased after eating such foods as cabbage, baked potatoes, bread, etc. The patient was pale and emaciated. The liver was enlarged and the umbilical region was sen- sitive to pressure. After treatment with Carlsbad sprudel salts, a non- irritating diet and menthol combined with calumba, the patient made rapid improvement. 2. Enterocolitis Case 1. — Wm. F., a stone-mason 50 years old, had suffered for many 5^ears from profuse diarrhoea, jDressure in the stomach after eating hard foods, and griping pains in the epigastric region. The test-breakfast was achylic, — total acidity being 6. The stools were of fluid consistency and contained much mucus. Improvement followed rest in bed, the use of hot poultices, a constipating diet, and the internal administration of belladonna, tannocol, hot teas, Rakoczy water and hydrochloric acid. Whenever the patient returned to his occupation, at which he worked half-naked, there was always a relapse. Case 2. — Bertha L., 38 years old, had for four or five years suffered from pressure in the stomach after eating hard foods, and for two or three years from diarrhoea. She had four or five stools daily, especially after taking flatuous foods and cold drinks. There was a catarrhal condition of both apices. The stomach was completely achylic, and the stools contained much mucus. The patient was much improved by a constipating-diet and tannocol, which was continued for about six years. DISEASES OF THE INTESTINE 271 Case 3. — Emil R., a coachman 41 years old, had for two months suffered from pressure in the stomach after eating hard foods; and from gnawing sensations in the abdomen, and diarrhoea, after the use of flatuous foods. The total acidity of the test-meal was 8. After he was put on a constipating-diet, with hydrochloric acid, and Rakoczy water, all the symp- toms disappeared. The rapid improvement in this case was due to the fact that it was of relatively short standing. The above three cases were associated with achylia gastrica. The following are cases with hyperchlorhyclria and acid gastritis. Case 4. — Carl K., a druggist 40 years old, had drunk a great deal of beer when a student at the university, since which time there had been a tendency toward diarrhoea and vomiting. For one year, the patient had suffered from pyrosis earlj'- in the morning, and also from vomiting, cramp- like pain, and diarrhoea. The stools had been of a semi-solid consistency for several years, and of a liquid consistency for the past year. The bowels moved from one to three times a day and the fseces were admixed with mucus, especially after the use of milk. The patient was not emaciated, since his appetite was good, and he ate heartily. The total acidity of the Boas- Ewald test -breakfast was 70. The physical examination was negative. Treat- ment consisted of small doses of hot Vichy water, and the use of tannocol. The patient was permanently cured. Case 5. — Siegmund T., a merchant 45 years old, stated that he had been nervous for four or five years, and had suffered every three or four months from burning sensations in the stomach and griping pain in the epigastrium (flatulent colic) for two or three weeks at a time. The stools were unformed and of a semi-solid consistency, or when formed were the size of the little finger and made up of short, sponge-like nodules of fecal matter, which the patient thought usually resulted from errors in diet and excessive smoking. At these times the patient was very nervous, and had a frequent desire to go to stool, but without results. After escape of gas from the intestine, the patient was always relieved of distress. Treatment at Carlsbad resulted in a cure. Owing to the innumerable variations in the clinical history of chronic enterocolitis, it is impossible to introduce clinical cases illustrating the different types of the disease. Ulceration of the Mucous Membrane of the Intestine Ulcers of every form and extent, — varying from erosions no larger than a pin-heacl to deep ulcers the size of a dollar, — may occur anywhere in the intestinal tract, from the duo- denum to the anus. 272 DISEASES OF THE DIGESTIVE CANAL Etiology. — The etiology is widely diversified, there being peptic, catarrhal, decubital, toxic, embolic, iiraniiic, and malignant and infectious ulcers, — such as tubercular, sj'philitic, typhoid, d3^sentcric, etc. Peptic ulcers are found in the duodenum, and after gastro- enterostomy, in the jejunum. (See chapter on Gastric Ulcer.) Catarrhal ulcers result from an increase in the severity of an inflammator)^ process of the mucosa, just as erosions and small ulcers of the gastric mucosa occur in acid gastritis. Decubital ulcers arise from pressure of hard scybala, especiall}^ in the csecum and in the hepatic and sigmoid flex- ures of the colon; also from pressure of neighboring organs, such as the uterus and gall-bladder, and from traumata. Tubercular ulceration may involve the entire ileum and colon; and it seems to select, by preference, the csecal region, where irregular tumors resembling neoplasms are found. Diagnosis. — The diagnosis is usually made from the following symptoms, which I quote from Nothnagel: "Ulcer- ation of the intestine often runs a course without symptoms. Even when a number are present, or when the ulcer is very large, the clinical symptoms are frequently not at all propor- tionate to the intensity of the anatomical changes. Signifi- cant signs .... only are pus and fibrous tissue in the stools. A very important objective sign, also, is the presence of blood in the stool, although this must be interpreted with great caution. On the other hand, the number of stools passed, or the fact that they are of liquid consistency, will not aid in forming any direct conclusions as to the condition present." As a general thing, the physician should suspect intes- tinal ulceration if more than six or eight stools are passed in the twenty-four hours, and especially if the patient is suffer- ing from tuberculosis of the lungs. [This statement does not apply to ulceration of the duodenum, since constipation is often an early symptom in this condition, being indeed the symptom for which the patient frequently consults the physician. DISEASES OF THE INTESTINE 273 Further attention should be given to the symptomatology of duodenal ulcer. The most frequent symptoms, according to Graham,* are pain, gas, vomiting, hyperacidity, hemor- rhage, general weakness and nervous irritability. The pres- ence of this combination of symptoms should always suggest the possibility of the presence of duodenal ulcer. Fig. 43. Ulcer of the duodenum. [Courtesy of Dr. Stanley P. Black, Hendryx Laboratory, University of Southern California. In the differential diagnosis, gall-bladder disease and peptic ulcer are most likely to lead to diagnostic confusion, for the reason that the symptoms of these affections so nearly parallel those of duodenal ulcer that the disease is most difficult of recognition. In a general way, it may be said that the symptoms of duodenal ulcer simulate those of gastric ulcer very closely, — the pain being largely dependent upon food and occurring from * [The Journal of the American Medical Association, February 9, 1907.] 18 274 DISEASES OF THE DIGESTIVE CANAL two to five hours after meals, and being relieved temporarily by food, vomiting, bicarbonate of soda, or anything that neutral- izes or removes the acid-acrid chyme from the ulcer-area. Vomiting is less common in duodenal ulcer than in gastric ulcer, although when present it occurs most commonly from two to five hours after meals. It does not so frecjuently pro- duce cessation of pain as in gastric ulcer. Gas is a distressing sj^mptom of duodenal ulcer. This symptom also is most marked from two to five hours after meals, and is relieved by the same factors that cause cessa- tion of the pain. The stomach-analysis furnishes about the same findings as does the gastric juice in ulcer of the stomach. For the differential diagnosis between duodenal ulcera- tion and gall-bladder disease, see editorial note, page 231.] The physician should examine the stool microscopically or chemically for the presence of blood. It is necessary, before performing the test for occult blood, to place the patient on a meat-free diet for two or three days, so that there can be no ha?moglobin introduced in the food, which might give rise to confusion in the diagnosis. I have found the aloin and benzidin tests for occult blood the most reliable (seepages 41 and 252). If either of these tests gives a positive reaction, and gastric ulcei' is excluded from the diagnosis, ulceration of the intestine may be considered as cjuite probable. For the macroscopical and microscopical examination of the intestinal contents, the physician should spread out the entire stool over a black plate and examine its different parts with a magnifying glass for any small substances of a grayish or reddish color, the examination of which will often reveal large numbers of leucocytes and tubercular bacilli. Pain, in ulceration of the intestine, may be entirely absent, and there is less mucus than in simple enteritis. If ulceration is associated with enterocolitis, involving a greater part of the intestinal mucosa, there will be severe diarrhoea, amounting to as many as twenty stools in 24 hours. DISEASES OF THE INTESTINE 275 Prognosis. — The prognosis depends, naturally, upon the primary disease, and as a general rule, is not absolutely bad, since even in tubercular ulceration a clinical cure is often obtained, — frequently leaving, however, stenosis of the bowel at the scar of the ulcer. Treatment. — The therapy is largely symptomatic. The diet should be the same as in the most severe forms of enter- itis, — consisting, therefore, of cocoa, chocolate, rice, grits, blackberry wine, blueberry extract, cereal soups, etc. Medicinally, 1.0 gram [gr. xv] of dermatol, three times daily; tannocol 1.0 to 3.0 grams [gr. xv to xlv], three times daily; bismuth subnitrate 1.0 gram [gr. xv], four times daily; bismutose ^ teaspoonful, or calcium carbonate and cal- cium phosphate, equal parts, 1 teaspoonful three times daily. Mechanical Treatment. — The bowels should be irrigated with J to 1 htre of the following solutions at body-temperature: silver nitrate, 0.2 to 0.3 [gr. iii-ivss] to 1000; salicylic acid 1 : 300; or thymol 1 : 1000; or an enema consisting of a teaspoon- ful of tannin and a tablespoonful of starch in one litre of water. Opium is indicated for the amehoration of pain and its styptic action, especially in cases offering a poor prognosis. I give 0.06 [gr. i] of the extract three times a day in pills. Bella- donna may be used for the relief of the same symptoms, prefer- ably the extract, 0.02 [gr. |] or the tincture, three times daily. Codeine or heroine may be substituted for either of the above-mentioned drugs. For severe cases, rest in bed and warm compresses are indicated. With cases in which a fatal termination seems imminent, it may be necessary to resort to surgery to produce an artificial anus in the ascending colon, in order to relieve the colon of all its functions. Typhlitis and Appendicitis Typhhtis and appendicitis are specific forms of inflamma- tion and ulceration of the intestine, influenced by special anatomical conditions. We cannot discuss the pathological anatomy of the subject at this place. 276 DISEASES OF THE DIGESTIVE CANAL From the clinical standpoint, it is first of all desirable to differentiate typhlitis stercoralis from appendicitis, and to classify the latter into the catarrhal, the purulent, and the perforative-gangrenous forms of appendicitis. Etiology. — The most frequent causes of the above affec- tions are acute and chronic enteritis, in which the caecum and appendix are implicated and become filled with fluid fa?ces, a portion of which remains in the narrow lumen of the appendix, and leads to the formation of concrements, or to ulceration and stenosis, which in their turn cause dilatation, empyema, perforation, or gangrene of the organ. Symptomatology. — The symptoms are so well known that their description may be omitted from a book de- signed for physicians in general practice. Diagnosis. — In making a diagnosis of appendicitis, the following four symptoms are the most significant: a, pain; h, tumor; c, fever; d, condition of the bowels. Differential Diagnostic Points. — From the clinical stand- point, the physician should always decide upon two questions : 1. Does typhlitis stercoralis — or appendicitis — exist? 2. Is the affection a severe form, which requires operation? In a case of appendicitis where an operation is indicated, it is vital to recovery that the operation be not postponed too long; while it is equally important to remember that in simple typhlitis no operation should be performed at all. It is well known that, owing to the surgical tendencies of the present time, the contrary has been done from what has just been stated as indicated, — which error has aroused consider- able prejudice in the minds of the laity against operative procedures for the relief of appendicitis. The differential diagnosis is often very difficult. On this point. Boas remarks, ''The diagnosis of typhlitis sterco- ralis, and its differentiation from appendicitis, must be made only with the greatest reserve, on account of the present status of our knowledge. " DISEASES OF THE INTESTINE 277 The following diagnostic points have generally proven practical and reliable for me. 1. Typhlitis Stercoralis Acuta a. Pain. — The pain is of a dull, stabbing or stinging character, and seldom colicky. Its location is apparently superficial, and it extends upward along the ascending colon. It is considerably relieved by the apphcation of hot com- presses, by movement of the bowels, or by the escape of flatus. The skin-area overlying the affected region is more sensitive to pinching than to deep pressure. b. Tumor. — The tumor is usually sausage-shaped, corre- sponding to the caecum or colon; in case diarrhoea is present, however, no tumor is palpable, and only a gurgling murmur is heard in the right iliac fossa. c. Fever.— A febrile reaction is either entirely absent, or quite mild, corresponding to the temperature of a co-existing enteritis, and being about the same as is found in summer diarrhcBa. d. The Condition of the Bowels. — The bowels are rarely constipated. In typhlitis, diarrhoea, — which is rare in appen- dicitis, — is almost always present, although there are frequent exceptions to this. 2. Typhlitis Stercoralis Chronica (Pseudo-appendicitis) a. Pain. — The pain in chronic typhlitis is of variable intensity, and may continue for years. Pressure and tension are rarely severe; they are more often located behind than at McBurney's point, and are reheved by rest in bed, hot compresses, the escape of gas, and gentle upward stroking. h. Tumor. — A sausage-shaped tumor may be palpated when the bowels are constipated. c. Fever. — Fever is absent. d. Condition of the Bowels. — The bowel-movements are alternately constipated and diarrhoeic. There is much flatu- lence, the increase of which aggravates the pain. 278 DISEASES OF THE DIGESTIVE CANAL 3. Catarrhal Appendicitis a. Pain. — The pain in catarrhal appendicitis is intense and of a cutting or boring character, radiating in all direc- tions. It is increased b}^ pressure over McBurney's point, or by hot applications, but is relieved by the ice-bag. b. Tumor. — A tumor is usualh' present about as large as the fist, but it varies in size, and is extremely painful. c. Fever. — The temperature is generally very high, being rarely lower than 40° C. [104° F.], but a chill is commonly an early symptom. d. Condition of the Boivels. — There is usually constipation. 4. Suppurative and Gangrenous Appendicitis a. Pain. — The pain in this form of appendicitis is very severe, resembling that of peritonitis. It radiates, and is generall}' of a tearing quality, relieved by the ice-bag, but intensified by hot apphcations. 6. Tumor. — A tumor as large as the fist is usually present, which increases rapidly in size, and is very painful to pressure. c. Fever. — The disease is often ushered in with a chill. The temperature is extremely high, reaching to 40° C. [104° F.] and more. d. The bowels are usually constipated. 5. Appendicitis Larvata of Ewald a. Pain. — The pain is indefinite, and is often entirely absent in the ileocsecal region. h. Tumor. — No tumor is present. The appendix is often thickened, palpable, and sensitive to pressure, especially during an acute exacerbation. c. Fever. — There is no fever. d. Condition of the Bowels. — There is periodical diarrhoea. 6. Recurrent Appendicitis a. Pain. — The pain is periodical, continuing for months with variable intensity, according to the character of the chronic appendicitis. DISEASES OF THE INTESTINE 279 b. Tumor. — ^A tumor is either constantly present, — diminishing in the interval between attacks, and increasing again during a recurrence, — or it may be entirely absent. c. Fever. — There is fever is nearly all cases. d. Condition of the Bowels. — The bowels are generally sluggish. Summary. — Diarrhoea, and also constipation, when fever is absent, are generally indicative of typhlitis. Constipa- tion with high fever is indicative of appendicitis, as is also constipation with or without fever when a tumor is present, — as extracsecal tumors and also high fever are almost always indicative of appendicitis. Pain, alone, is of only a slight characteristic value in the differential diagnosis. Treatment. — The treatment of typhlitis and appendicitis simplex should be conservative. In suppurative, perforative, or gangrenous appendicitis, it should be operative during the attack. In appendicitis larvata and in recurrent appendi- citis, when the symptoms are annoying and attacks frequent, surgical treatment should be given in the interval. A. CONSERVATIVE THERAPY Diet. — Only fluids should be allowed, such as tea, milk, cocoa, cream, broths, oatmeal gruel, and wine with the yolks of eggs. Medicinal. — Of the extract of belladonna 0.02 to 0.03 [h~i gi"-] should be given three or four times daily; or if there is a tendency to vomiting, double this quantity should be given per rectum. If pain is very severe, 0.06 to 0.1 [gr. i to iss] of the extract of opium, or 15 to 20 drops of the tincture, should be given three or four times a day. If there is diarrhoea without fever, the various styptics are indicated, for instance, tannocol; if with fever, a mixture of muriatic acid. For constipation, oil enemata are prescribed. In case of high fever, ice-bags should be apphed exter- nally; with moderate fever— 38° to 39° C. [100.4 to 102.2 F.]— the Priessnitz compresses. In the absence of fever, hot 280 DISEASES OF THE DIGESTIVE CANAL poultices, thcniial coils, etc., should be used. In chronic appendicitis or typhlitis, the mud-baths or the niud-i)oultices, such as are given at Franzensbad, are useful. B. SURGICAL TREATMENT Under this heading, naturally, only the indications for surgical intervention will be spoken of. Operation should be performed immediately in young persons when the attacks begin with fever of 39° C. [102.2° F.] or more. With older patients, it is preferable to wait one or two days before operat- ing, because in these cases adhesions usually exist which prevent the rapid spread of pus. If purulent appendicitis has already given rise to peritonitis or a subphrenic abscess, operative procedures are usually without avail. C. DIFFERENTIAL DIAGNOSIS In the differential diagnosis, it is only necessary to mention that certain other pathological conditions need to be thought of, especially invaginatio ileocolica, neoplasms, renal colic, incomplete inguinal hernia, pyosalpinx, and other right-sided diseases of the adnexa, [gall-bladder diseases], etc. CLINICAL CASES A cute and Chronic Typhlitis Case 1. — Rosa E., 32 years old, had suffered from colic two weeks previous, after partaking freely of pears and beer. There was a boring pain in the csecal region, and constipation, but no fever. Treatment consisted of the application of thermal coils, hot compresses, rest in bed, belladonna, and oil-enemata, — after which the patient gradually improved. Later, however, there was a recurrence of the trouble, following errors in diet. Case 2. — Mrs. H., 23 years old, had suffered for years from constipation associated with colic. For several weeks she had complained of dull pressure in the ileocsecal region, and for the past five days had suffered from colicky pains in the right iliac fossa. She was constipated. A fecal tumor was jDal- pable. There was sensitiveness to pressure, but no fever. Recovery occurred after rest in bed for eight days and the use of hot applications to the abdomen. Case 3. — Gustav L., a merchant 40 years old, had for one or two years suffered frequently from pain in appendix region, especially when obliged to stand for a long time. Temporary rest in bed always produced improvement. Later, an inguinal hernia developed ; and after the application of a suitable hernia-truss, all evidences of the "appendix pains" disappeared. DISEASES OF THE INTESTINE 281 Tumors and Neoplasms of the Intestine If we except tumors of the rectum, — which will be con- sidered separately, — neoplasms of the intestinal canal are com- paratively infrequent. According to Von Leube, 80 per cent, of intestinal carcinomata are located in the rectum; 15 per cent., in the caecum and colon; and only 5 per cent., in the small intestine. Diagnosis. — ^The lower the location of a tumor in the intestinal canal, the greater is the possibility of an early diag- nosis. A carcinoma of the ascending colon produces obstruc- tion-phenomena much later than does a tumor of the sigmoid flexure; because, for instance, in the former case the intestinal contents are of a fluid consistency and therefore have less difficulty in passing the obstruction. The diagnosis is easily made from the following symptoms: 1. Cachexia and the other general symptoms of cancer, which cannot be accounted for by a carcinoma of the stomach, rectum, or other organ, may naturally suggest malignant disease of the intestine. 2. Pain. — If there is no stenosis, there are only indefinite painful sensations in the abdomen. If, on the other hand, stenosis of the intestine is present, there is intense pain of a colicky, contracting character, particularly if the tumor is located in the splenic flexure of the colon. 3. Constipation or Pseudodiarrhcea. — If the latter occurs, the patient must often go to stool from 6 to 10 times daily. Generally, nothing passes from the bowels but mucus, which may be mixed with blood and pus; and the stools if formed have a caliber about that of a lead pencil. 4. Intestinal Hemorrhage. — Hemorrhage, which is either microscopically or macroscopically demonstrable, occurring in a patient who has never had any previous intestinal trouble, — if hemorrhoids, etc., can be excluded, — is very suggestive of a malignant disease of the intestine. 5. Intestinal "Stiffening." — Intestinal ''stiffening," that is, a visible peristaltic contraction of the colon above its narrowed portion, most freciuently occurs in the transverse colon. 282 DISEASES OF THE DIGESTIVE CANAL G. Tumor. — Tumors of the intestine arc usually movable. They are palpable only relatively late, when the patient becomes cachectic and the abdominal walls relaxed. In entcr- optotic individuals, or those with pendulous abdomen, a tumor is palpable considerably earlier than otherwise. Mahg- nant neoplasms are hard and irregular in shape. Differential Diagnosis.— The differential diagnosis is some- times very hard to make, since we must exclude tubercular and stercoral tumors of the caecum, scybala in the sigmoid flexure and the transverse colon,, gall-stones, neoplasms of the stomach, tumors of the gall-bladder or pancreas, retro- peritoneal cysts, carcinomata and echinococcic cysts of the kidnej^s, movable kidney or spleen, foreign bodies, etc. Treatment. — The treatment is of a surgical nature, and operation should be resorted to as early as possible. In the event that the patient refuses operation, the treatment must become symptomatic, — care being taken to produce stools of soft consistency by the use of castor oil, Carlsbad salts, or rhubarb, every two or three days; or by oil enemata, contain- ing I litre, to be given every second or third day. Diet. — The diet should be such as will furnish as httle intestinal debris as possible, and should consist of milk, cream, butter, cereal soups and gruels, eggs, tender meats, fish, broths, stewed fruits, fruit-juice, honey, etc. In private practice, some of the artificial food-prepara- tions may be used to great advantage,— such as somatose, roborat, puro, eucasin, sanatogen, etc. Medicinal Treatment. — Medicinal treatment is indicated for the reHef of coUcky pain; 0.02 of the extract of bella- donna, when given three times daily, is one of the most suitable medicaments for this purpose. If preferred, 0.05 of the extract may be given three times daily, per rectum. The use of opium is less satisfactory than the above. CLINICAL CASE Case 1. — Carl H., a laborer 56 years old, had for about six months suffered from indefinite pains in the abdomen. He had passed from 12 to 15 stools daily, of a chocolate color and a semi-solid consistency, which often DISEASES OF THE INTESTINE 283 contained brown and grayish-red particles. There had been a gradual aggravation of the symptoms, with increasing cachexia. Physical examina- tion was negative, except that there was some blood in the stools. There was no tumor. The patient was cachectic. He grew gradually worse and died. An extensive ulcer which had undergone carcinomatous degeneration was foUnd in the splenic flexure of the colon. Displacements of the Intestine (Pendulous Abdomen, Hang-Belly, etc.) A. Congenital Malpositions, Anomalies, etc. Apart from situs inversus, the displacements of the caecum, with the appendix and the sigmoid flexure, — in consequence of extraordinary length of their mesenteries, — are of special importance. Such congenital anatomical conditions account for appen- dicitis in the left iliac fossa and for volvulus of the sigmoid flexure. The caecum has been found in the hernial sac of a congenital scrotal hernia; and as a curios'ity, we may mention that congenital hernia of the diaphragm has been discovered at autopsy, when the stomach was found in the thoracic cavity. In habitus enteropticus, which has already been discussed in detail in the section on Diseases of the Stomach, the position of the transverse colon corresponds to the abnormally low position of the greater curvature of the stomach, and gradually becomes lower with the age of the patient. The transverse colon, in this affection, is usually found at the umbilicus or a finger's breadth above or below it. B. Acquired Displacements of the Intestine 1. Total: a, constitutional; h, due to local conditions. 2. Partial, such as herniae, tumors, etc. 1. General Enteroptosis a. A general displacement of the intestine results from a congenital habitus enteropticus if the abdominal walls have become relaxed following pregnancy, or from i-mpairment of the general nutrition, or from absorption of the accumulations of adipose tissue in the abdominal cavity. 284 DISEASES OF THE DIGESTIVE CANAL b. Pendulous abdomen is sometimes present without hahifus entei'opticus after pregnancy; or when rapid emacia- tion has occurred in a previously obese person, as in cases of phthisis, carcinoma, etc. 2. Partial Enteroptosis a. Individual portions of the intestine may assume an abnormally low position, either from their own weight or from the extra weight given them by the presence of tumors or fecal accumulations. In chronic constipation, or in relaxa- tion of the abdominal w^alls, the colon may assume the shape of a capital letter '^M, " — the middle portion of the transverse colon standing immediatel}^ above the symphj'-sis. I have seen several such cases. b. In this category of partial displacements of the intes- tine belong external hernia, which, however, cannot be properly discussed in a work on internal medicine. Diagnosis. — Anomalous positions of the intestine, as such, usually run a course without symptoms, and are occas- ionally discovered when palpating the abdomen of a patient suffering from other affections. Quite frequently, however, — as a result of such displacements of the intestinal tube, — ileus arises, whose exact diagnosis is generally impossible. It can be arrived at only with a certain degree of probability, because, in addition to internal hernise, there is an unlimited number of other affections that may produce ileus. Only the autopsy in vivo or post mortem explains such anatomical abnormalities. Treatment. — The treatment consists chiefly in the appli- cation of suitable abdominal bandages, supports, and abdom- inal corsets. In every case of "hang-belly," when there are unpleasant drawing sensations in the costal arch and a feeling of fulness in the abdomen, especially after eating, or when the patient is more uncomfortable in a horizontal position, I prescribe such abdominal support. Achilles Rose, of New York, has recently made use of the appHcation of four strips of adhesive plaster, 8 to 9 cm. DISEASES OF THE INTESTINE 28.5 wide, for this purpose. The first strip, about 4.5 cm. hjng, extends from the symphysis to the sternum; the second and third strips, .50 cm. long, are applied from the symphysis diagonally around the left and the right thoracic walls to the spinal column; the fourth strip is applied across the abdomen above the symphysis from one iliac fossa to the other. The adhesive plaster may be worn for three or four weeks, when it should be renewed, to prevent disagreeable perspiration, eczema, etc., — especially in warm weather. [See illustrations and further details, page 194.] In addition to the above means, the physician should always devise treatment which will strengthen the muscu- lature of the abdomen, such as heavy massage of the abdominal muscles, physical culture, and gymnastic exercises, such as raising and lowering the legs or trunk of the body. The con- dition may also be improved by a course of forced feeding, by which the relaxed condition of the musculature is improved and the abdominal space is made smaller by the deposition of adipose tissue. The treatment of hernia is surgical. SECONDARY ORGANIC DISEASES OF THE INTESTINE Stenosis and Dilatation of the Intestinal Canal (Not Including the Rectum) General Remarks. — Just as stenosis of the pylorus and dilatation of the stomach are the results of some primary or- ganic disease of the stomach, — such as peptic ulcer, carci- noma, perigastritis, etc.,— stenosis and dilatation of the in- testinal canal may develop more or less quickly from similar primary affections, — such as ulceration, compression, new growths, adhesions, etc. As a sequel to ulcer, cicatricial stenosis results, which in turn gives rise to hypertrophy and dilatation of that portion of the intestinal tube lying just above, — according to the general law of compensatory concentric hypertrophy. Stenosis of the intestine is a chronic affection; although any aggravating cause, — such as the lodging of hard and 286 DISEASES OF THE DIGESTIVE CANAL irritating remnants of foods or the inflammatory swelling of that, portion of the gut, — may lead to the acute stage of total obstruction of the intestine. Stenoses of the duodenum and of the pylorus have been discussed together in a previous chapter. The treatment is practically the same in both affections. Acute dilatation of the intestinal canal without stenosis re- sults from paralysis of the intestinal musculature, which will be considered in detail in the chapter on Intestinal Obstruction. Etiology. — The stenotic factors are as follows: 1. Intestinal. — Neoplasms, cicatrices following tubercular, syphilitic, and decubital ulcers, hard scybala lodged in the folds of the intestine, partial volvulus, moderate invagination of the intestinal tube, or incomplete hernia. 2. Peritoneal. — The congenital and acquired formation of adhesion-bands, especially following trauma, laparotomies, cholelithiasis, peritonitis, appendicitis, and perimetritis. 3. Neighboring Orgaiis. — Compression by a distended gall-bladder, enlarged lobe of the liver, echinococcic cysts, retroverted gravid uterus, abdominal and pelvic tumors, and especially ovarian cj'sts. Symptomatology. — A stenosis, especially if located in the small intestine, or in the colon as low as the hepatic flex- ure, may exist for quite a long time without producing any symptoms, for the reason that: 1. The Hquid faeces of these portions of the intestinal canal may pass through a relatively narrowed portion. 2. H3^pertrophy of the musculature tends to overcome the effect of the obstruction, since the former increases pro- portionately to the diminution in the size of the lumen of the intestine. In this way, even a stenosis of the sigmoid flexure may be compensated for quite a while, until some excessive demand suddenly brings about a compensatory disturbance, and thereby introduces the evident signs and symptoms of intestinal obstruction. The first subjective symptoms are a sluggish condition of the bowels, griping, a feehng of tension in the abdomen, DISEASES OF THE INTESTINE 287 and severe recurrent attacks of colic which disappear for two or three days after a very free evacuation of the bowels. Usually the patient is nauseated and has a tendency to vomit, besides a general feeling of anxiety. Objectively, the physician will observe that the stool is of small caliber, — about the size of a lead-pencil, — and is made up of broken, irregular, or square fragments of fecal matter. Diarrhoea is sometimes present if a secondary catarrh develops above the stenosis, which causes a hquefaction of the stagnating faeces. Another very important objective sign is the so-called "stiffening" of the intestine, which was first described by Nothnagel, and consists of visible and palpable tonic con- tractions of that portion of the intestine above the stenosis. A third sign is meteorism. All the above-mentioned symptoms will disappear after a free evacuation of the bowels. Diagnosis. — In any given case, the following points must be decided: 1. Does a stenosis actually exist? 2. What is its location? 3. What is its pathology? "Sometimes," says Nothnagel, "the diagnosis of stenosis of the intestine may be made with absolute certainty, and sometimes this is simply impossible; between these extremes there exists a large number of cases in which the diagnosis can be made with greater or less probability." 1. We may assume the occurrence of a more or less rapid narrowing of the intestinal lumen, when a person who has formerly had normal functions of the bowels begins to suffer from constipation, coHcky pains and meteorism, or when intestinal "stiffenings" are observed, or when the stool itself is of small cahber and composed of broken fragments of hard fecal matter. 2. If "stiffenings" of the colon are visible, the location of the stenosis is usually in the region of the sigmoid flexure; 288 DISEASES OF THE DIGESTIVE CANAL while a strong peristalsis of the small intestine, — commonly observed only when there is a diastasis of the recti muscles or relaxation of the abdominal walls, — usually indicates that the lesion is in the ileocaccal region. 3. Only long observation will make clear the nature of the stenosis. Blood and pus in the stool, as well as the pal- pabilit}' of a tumor, are indicative of a malignancy. In order to diagnose a compression stenosis, it is necessary to make an accurate examination of all the neighboring organs of the abdo- men and pelvis, especially the rectum and the female genital organs. (See discussion on Palpation, in the General Section.) Differential Diagnosis. — Practically one condition only will give rise to confusion in the diagnosis, i. e., spastic consti- pation, when hard stools of small caliber are passed, associated with colicky pains. The following points will assist in the differentiation of this affection from stenosis of the bowel : Preceding spastic constipation, there is almost always a long period of atonic constipation. In spastic constipation, the stool is surrounded by membranous mucus, and the entire colon is palpable as a sensitive, hard, band-hke stricture about the size of the little finger. After suitable diet and oil enemata for three or four weeks, there is usually an improvement. Sausage-shaped stools of large caliber are then passed without difficulty, and the intestinal "stiffenings" entirely disappear. Treatment. — The internal treatment has already been detailed in the chapter on Ulcer of the Intestine. The diet should be as free as possible from foods leaving a heavy residue in the intestine, but should be rich in butter and fats, and should contain a large amount of stewed fruit. Laxatives, antispasmodic remedies, — such as 0.02 to 0.03 [\-\ gr-] of the extract of belladonna per mouth, or 0.03 to 0.05 [^-| gr.] per rectum, — and oil enemata, should be administered. Frequent and repeated attacks are an indication for surgical treatment; and in any case where the abdominal pathology is doubtful, it is the duty of the physician to obtain the opinion of an experienced surgeon. DISEASES OF THE INTESTINE 289 Recently, the use of thiosinamin has been recommended in cicatricial stenosis of the intestine; ^ to 1 c.c. of the fol- lowing solution should be subcutaneously injected daily in the interscapular region. I^ Thiosinamin, 3ii 8.0 Glycerini, oiii 12.0 Alcohol dil., 5v 20.0 M. Sig. — To be used by the physician. Whenever syphilis is suspected, sodium iodide should, of course, be prescribed. Intestinal Obstruction General Remarks. — Ileus, or acute intestinal obstruction, above all other diseases of the intestine, demands a wide per- sonal experience for its early diagnosis, and for the selection of the proper therapeutic procedures. One of the most difficult tasks in the diagnosis and therapeutics of these conditions is to decide, in a given case, whether a purgative or a narcotic should be prescribed, whether ice or hot com- presses should be used, and whether an operation is indicated. In any case, the responsibihty is so great that no physician should neglect to have consultation with either a clinician or a surgeon of experience as early as possible, in order that through mutual and repeated observations the developments of the case may be carefully followed and the indications thoroughly established before secondary symptoms have developed which might cloud the picture of the disease in such a way that it would become unrecognizable. In addition to this, it is always best, if possible, to have an experienced nurse in constant attendance upon the case. Etiology. — Precisely the same etiological factors as lead to stenosis of the intestine will lead also to the gradual aggravation of stenosis until intestinal obstruction results. The importance of the subject justifies a repetition of these etiological factors. The most frequent causes are external or internal herniae; malignant or benign stenoses of the intestinal lumen; volvulus and acute flexures from bands of omentum; invagination, 19 290 DISEASES OF THE DIGESTIVE CANAL spasmodic contracture or paralysis of the intestinal muscula- ture; and the compression produced by a pathological con- dition of some neighboring organ, — among which the retro- flexion of the gravid uterus must not be forgotten. The subject will be more clearly comprehended after classifying it into three principal groups of cases: 1. Ileus resulting from mechanical occlusion of the bowel. 2. Compression ileus. 3. Strangulation ileus. Symptomatology. — An absolute retention of faeces and gases develops more or less acutely; while nausea, eructa- tions, meteorism, singultus, colicky pains, fecal vomiting, cold perspiration, peritonitis, fever and collapse gradually appear; in short, there arises the well-known clinical picture of miserere, with the so-called fades Hippocraiica. Diagnosis. — Nothnagel, in speaking of intestinal obstruc- tion, says, "Even the most expert surgeon, as well as the most experienced internist, must acknowledge that every new case may bring with it unexpected developments. All care in the examination, all diagnostic discrimination, and even all personal experience, will frequently leave one in the lurch. The difficulties in such cases are simply insurmountable." Before proceeding with an analysis of a concrete case, two points should be carefully considered: 1. The hernial rings, the rectum, and the uterus should be carefully palpated in order to determine: whether there is a possibly existing strangulation hernia, or a rectal stricture which has previously run a latent clinical course, or whether a retrofiexed gravid uterus is giving rise to the symptoms. 2. Whether there is an accumulation of fseces resulting from spasmodic contraction or paralysis of the intestine, without the presence of an anatomical lesion. Spasm of the intestinal musculature occurs in lead colic, and in spastic constipation, which has been mentioned above and will be described in detail later on; and it also occurs in acute coHtis caused by the lodgment of irritating food-remnants, — such as cucumbers or pears which have been poorly masti- cated, — in the folds of the mucous membrane of the intestine. DISEASES OF THE INTESTINE 291 Such patients have, as a rule, suffered for a long period from chronic constipation. The internal administration of atropine and the use of high rectal enemata of oil will gener- ally give relief in these cases. The causes of paralysis of the intestinal musculature are as follows: Opium-poisoning; peritoneal shock following trauma to the abdomen; laparotomy; ruptured tubal pregnancy; perforation of the stomach or intestine ; the same causes as produce peritonitis ; and finally, chronic atonic constipation. The presence of fever is always suggestive of peritonitis as a cause of paralysis of the bowels; and especially when it is associated with persistent vomiting, diffuse pain in the abdomen, — especially when vomiting, — and generalized sensitiveness to pressure over the abdomen. These symptoms are significant of peritonitis as a causal factor, even if fever is absent. If, from employment of the above-mentioned principles, the physician can exclude, as etiological factors, — hernial rings, peritonitis, affections of the rectum or uterus, and spasmodic contraction or paralysis of the intestinal muscu- lature, he may then naturally assume the presence of an anatomical obstruction, the exact nature of which will fre- quently not be recognized before operation or autopsy. If the patient has been under observation since the beginning of the illness, the location of the trouble can usually be established with a fair degree of success. A consideration of the following symptoms will best serve to diagnose the position of the lesion: 1. Pain. 2. Meteorism. 3. Vomiting. 4. The effect of enemata. 5. Temperature. 1. Pain. — In obstruction of the colon, there is a fre- quently-recurring colic, — resembling labor-pains, — of from one to five minutes' duration, which, according to the loca- tion, begins on the right or the left side, and radiates in all 292 DISEASES OF THE DIGESTIVE CANAL directions, especially toward the back. The affected portion of the colon is especially sensitive to pressure. In obstruction of the small intestine, distress is more constant and is associated with rumbling of gases in the middle of the abdomen in the region of the umbihcus, — which parts are also sensitive to pressure. In peritonitis, there is constant cutting or boring pain. In paralysis of the intestine, there is no pain, but a dull feeling of pressure, fulness and distention, corresponding to the meteorism. 2. Meteorism. — When a stenosis of the intestine, which has been gradually developing, suddenly becomes a complete stenosis, or ileus, it gives rise to visible and palpable localized meteorism. In this condition, the so-called intestinal "stif- fenings" also become manifest above the point of obstruction. This is rarely present in cases of sudden obstruction of the bowels, for the reason that hypertrophy of the muscles has had no time to develop. If, within 24 or 36 hours after the onset, the peripheral region of the abdomen which corresponds to the course of the colon becomes tympanitic and distended, and the middle portion of the abdomen is sunken, the conditions are indica- tive of an obstruction of the colon, and especially of the sig- moid flexure or descending colon. If, on the other hand, the peripheral portion of the abdomen is not distended, and the middle portion is tym- panitic, this is indicative of an obstruction at some point above the ileocsecal valve, provided that this symptom corresponds with the character of the pain. This is equally true, even if gas still escapes from the intestine, and if enemata are successful in showing the presence of some fecal matter. Two or three days after complete stenosis has set in, the entire intestinal tube will be distended, so that by this time meteorism will be of no value in localizing the lesion. 3. Vomiting. — Constant, non-feculent vomiting of every- thing eaten, and of bile, is indicative of either peritonitis or DISEASES OF THE INTESTINE 293 an obstruction located high up in the intestinal tube, — for instance, in the jejunum or the duodenum. If fecal vomiting occurs within twenty-four or thirty- six hours after the onset of the trouble, it is significant of obstruction of the small intestine; and if after two or three days, it indicates an obstruction of the large intestine. In a deeply located obstruction, — for instance, one between the sigmoid flexure and the rectum, — vomiting may be entirely absent, or it may appear six or seven days after the illness, or not until a short time before death. 4. Enemata. — If the injected fluid, — water or oil, — returns after the injection of from five to seven hundred cubic centi- metres, it is probable that the obstruction is located low in the large bowel, or that there is insufficiency of the sphincter ani. If, on the other hand, one or two litres can be injected, it is quite evident that the seat of the occlusion lies above the colon. 5. Temperature. — Fever at the beginning of the illness is indicative of peritonitis; while if the febrile reaction occurs at a later period, it indicates some other condition which is complicated by peritonitis. It is self-evident that one may establish a fairly accurate diagnosis only when all of these five symptoms harmonize with one another. Differential Diagnosis. — It is impossible to describe in detail, in this book, all of the many varieties of ileus. Treatment. — Internal medication is ineffective in volvu- lus and strangulation; but in mechanical occlusion and invagi- nation of the gut, it will often produce good results. Laxatives should be given only when there is neither coUc nor fever. Three or four tablespoonfuls of castor oil, or one tablespoonful of Carlsbad salts, dissolved in a pint of lukewarm water, should be given, besides using high enemata, consisting of two or three Htres of warm water at a tempera- ture of 30° to 32^^ R. [100°— 104° F.], since in such cases it is highly probable that there is only a fecal impaction. If colic, with or without moderate fever, is a symptom, 0.001 to 0.0015 [eV-To gi"-] of atropine sulphate should be 294 DISEASES OF THE DIGESTIVE CANAL given every three hours by mouth, or subcutaneously if there is vomiting; and an enema of one to one and one-half Htres of warm sesame oil should be introduced, if a movement of the bowels does not follow enemata of water. If fever is present from the onset of the illness, the ice- bag should be used, and suppositories containing 0.1 [gr. issl of the extract of opium and 0.05 [§ gr.] of the extract of bella- donna should be introduced into the rectum three times daily. Diet. — The only foods allowed are champagne, ice-cold milk, cream, lemonade, peppermint-tea, and egg-cognac. It is safe to continue the above-mentioned therapy for five or six days, in case no alarming symptoms occur, — such as stercoral vomiting, singultus, fever, severe sensitiveness to pressure, thread-like pulse or collapse. The physician should always, under the last-named con- ditions, advise operative treatment, unless it is evident that an inoperable cancer is the cause of the obstruction, in which case, — to prevent pain, — opium or morphine should be given by mouth, or subcutaneously if there is vomiting. In some instances it may seem advisable, as a palliative measure, to create an artificial anus. Since the clinical picture of ileus presents such A^aried phases, I consider it quite useless to attempt to illustrate the disease by clinical cases, for two given cases will very rarely run the same clinical course. Acute and Chronic Peritonitis Since the peritoneum is so often diseased as the result of acute and chronic organic affections of the digestive tract, it seems advisable to discuss briefly the clinical character- istics of peritonitis, especially since it must be differentially diagnosticated from ileus, as has been mentioned in the pre- vious chapter. Etiology, — ^With the exception of the rare idiopathic form, peritonitis is always secondary to an inflammatory affection of the serous membrane covering any of the abdomi- nal or pelvic organs. DISEASES OF THE INTESTINE 295 First to be discussed is Circumscribed Peritonitis, which is limited to a^relatively small area of the peritoneum. Circumscribed peritonitis, — as has already been men- tioned above in discussing perigastritis, — results from deep- seated ulceration of the stomach or intestine, from malignant neoplasms of the intestine, from pericolitis, perityphlitis, periduodenitis, pericholecystitis, perisigmoiditis, from trauma, or from inflammation of the uterus and its adnexa. The adhesions which form between the serous membranes of the various organs often prevent the diffusion of an inflammation, even after perforation. Diffuse General Peritonitis results from perforation at a time when there are insufficient adhesions or none at all, to prevent the spread of the infection. Chronic Circumscribed Peritonitis accompanies chronic ulceration of the stomach or intestine. Generalized Chronic Peritonitis is usually of a tuber- cular nature. In peritonitis, as in pleurisy, there is a dry, adhesive form, and also an exudative form. The exudate in the latter is either serous or purulent, according to the type of the infection. Finally, there may be both circumscribed and diffuse general peritonitis, as in subphrenic abscess, associated with a generalized purulent peritonitis. Diagnosis. — The symptoms in the different forms of the disease are often so atypical, that an exact diagnosis is some- times impossible. 1. Localized Peritonitis of the Adhesive Type The onset is gradual. The first symptoms usually appear after sudden and active exercise, heavy lifting, coughing or straining; later, pain becomes spontaneous, especially if the patient hes on the side opposite to the seat of the lesion, which produces traction upon the adhesion. Pain is increased by pressure over the seat of the disease, as well as by active peristalsis, or distention of the bowels by gas. There is no fever, and nausea and vomiting are rare. 296 DISEASES OF THE DIGESTIVE CANAL Sometimes the abdomen over the diseased portion of the peritoneum, — especially in patients with relaxed abdominal walls, — appears thickened on palpation. IMany times, such patients are mistakenly considered to be hypo- chondriacal or hysterical, — notwithstanding the fact that actual and severe pain in the abdomen occurs only in organic diseases. The above-described circumscribed adhesive peritonitis occurs with especial frequency in perigastritis, pericolitis, or following strangulated hernia? and laparotomies. Rest in bed, hot apphcations, and treatment which con- trols meteorism and lessens peristalsis, will relieve the pain incident to this form of disease. 2. Circumscribed Exudative Peritonitis The exudation may be serous or purulent, as in fecal abscesses, and may rupture into the lumen of the intestine, the urinary bladder, or externally. The onset of the affection is usually quite sudden, with severe pain over a localized area, — so severe that the patient must immedi-ately assume a recumbent position; this pain is increased by pressure, and there is a distinct, balloon-like resistance to palpation. Certain movements or positions of the body, and also hot compresses, will increase the pain, which however is reUeved by the ice-bag. Either moderate or high fever is present. Vomiting is generally absent, al- though nausea is a common symptom. This form of peritonitis is associated with chronic ulcer- ation of the stomach and intestine, which have perforated through adhesive inflammation into an already encysted cavity; and it also occurs after trauma which has ruptured some internal organ, when, under favorable circumstances, adhesions rapidly form. 3. Diffuse Exudative (Serous or Purulent) Peritonitis This is characterized by intense, constant, cutting, boring, but rarely cohcky pain in the entire abdomen, which is most intense at its point of origin, — for example, in the DISEASES OF THE INTESTINE 297 appendix or gall-bladder. It radiates in all directions, and is increased by the slightest touch or movement. Vomiting is very frequent. Usually there are, — besides a small, thread- like pulse, — singultus, and the fades Hippocraiica. Scarcely any relief from suffering is obtained by the use of the ice-bag or by moderate doses of narcotics. Micturi- tion is painful, and meteorism gradually develops to enormous proportions. There is almost complete paralysis of the bowels, so that neither faeces or gas can escape from the rectum. The temperature is rarely high, and may fall to normal in collapse, as it always does before death. This form of peritonitis is caused by perforation of any part of the gastro-intestinal canal, gall-bladder, Fallopian tubes, etc., when no adhesions are present to limit the spread of the inflammation. 4. Diffuse Chronic Peritonitis This is usually of a tubercular nature, and is character- ized by stabbing, cutting pain which occurs now in one part of the abdomen, now in another, and which is caused by intestinal peristalsis, and is increased by heavy movements or pressure. Alleviation of the pain is usually experienced from the use of the ice-bag and the administration of bella- donna, — which lessen the peristaltic action of the gut. The amount of exudate is usually moderate, and is fre- quently encapsulatecj. There is little or no fever, the stools are regular or moder- ately constipated, and there are occasional nausea and vomit- ing. Other signs of tuberculosis are usually present. The course of the disease may extend over a period of several months or a year, sometimes resulting in recovery, but usually in death from debility. TREATMENT 1. The treatment of Circumscribed Adhesive Peritonitis consists in absolute rest in bed, the application of hot oatmeal compresses, mud-poultices, a thermal coil, etc.; the internal administration of 0.03 [gr. ^] of extract of belladonna three 298 DISEASES OF THE DIGESTIVE CANAL times dail}', administered bj' mouth or rectum, according to the location of the affection; and the apphcation of one or two leeches over the seat of the lesion. Proph3'lactic treatment consists in the use of abdominal bandages, suitable hernia trusses, and the avoidance of violent demands upon the musculature of the abdominal wall, as in hard manual labor, sports, etc. 2. Fecal Abscess. — In this condition treatment should consist of rest in bed and the use of the ice-bag; belladonna as above indicated; the apphcation of one or two leeches; and eventual incision. 3. Diffuse Purulent Peritonitis. — Internal treatment should be limited to the use of anodyne remedies, — of which the best is morphine, given three times daily in doses of 0.02 to 0.03 [^-^ gr.], or atropine sulphate 0.001 [gV gr.], given subcutaneously three times daily. Ice-compresses are pref- erable to the ice-bag. Sometimes painting the abdomen with oil of turpentine is helpful. The decision as to whether an operation should be attempted should be left to the judgment of the surgeon. 4. Chronic Peritonitis. — The treatment giving greatest relief to the patient consists in the apphcation of towels wrung out of ice-water, the internal administration of 0.02 ih gi'-] of belladonna, or 0.0005 [j^^ gr.] of atropine sulphate three times daily, the occasional use of leeches, and smearing the abdomen with green soap. Incision should eventually be made, in case the exuda- tion is circumscribed. Diet. — In the first two forms of peritonitis, the diet should be Hmited to assimilable and nourishing foods of hquid or semi- sohd consistency, — such as broth, tea, or coffee with cream, beef-tea, fruit ices, lemonade, egg-cognac, and champagne. In the third form, the diet should be stimulating, — con- taining wines, etc. In the fourth form of the disease, the food should be non-irritating, but strengthening, in order to increase the patient's resistance against the infection; the most suitable DISEASES OF THE INTESTINE 299 dietary consisting in the daily use of a pint of cream in tea or coffee, three or four yolks of eggs, 100 to 150 grams of butter, puddings with fruit-sauces, besides chicken, pigeon, white bread, rice, noodles, or light vegetables in puree form, caviare, and Hungarian wine. FUNCTIONAL DISEASES OF THE INTESTINE Chronic Constipation We speak of chronic, habitual obstipation, or constipa- tion, when there is a diminution or a complete cessation of spontaneous evacuations of the stool. There are, therefore, complete and incomplete forms of chronic constipation, accord- ing to whether the patient must constantly, frequently, or only occasionally resort to the use of a laxative or an enema. The incomplete, associated with the formation of so- called residual faeces, is generally the forerunner of complete constipation. There are many individuals that have used laxatives for decades, even from childhood, and have never be;en ill nor suffered any serious consequences, — satisfactory results having been obtained from the use of one laxative after another, recommended by physicians or by the laity. Patients have rarely consulted me for constipation at a time when laxative remedies were still, even to a slight degree, effective. There comes a time, early or late, however, when all laxative remedies and enemata become ineffective. It is then that such persons, having formerly considered their condition as unimportant, realize that they are ill, and consult a physician. It is self-evident that the earlier the patient has rational treatment, the more successful will be the results. Cases which have existed for several years, or for decades, often require many months' treatment in a sanitarium to be cured. The therapy depends entirely upon the variety of con- stipation, and upon the physician's ability to find the etio- logical factors in each individual case. When these are 300 DISEASES OF THE DIGESTIVE CANAL established, it is eas}!- to determine the rational therapy, which results successfully in by far the majority of cases. In the following discussion, therefore, I have laid the chief emphasis on these two points. Etiology. — The causes of chronic constipation are natur- ally grouped as follows: 1. Bad Habits; Neglect; Prudery; Lack of Time; Indolence, etc. In this group belong many school-girls and women living in boarding-houses, who, on account of prudery, do not go to stool regularly; also office-people and business men, who, at the time when the need manifests itself, are too busy to respond. In such persons, the normal sensation of the rectum has gradually been lost through the unnatural suppression of the desire to go to stool; hence they resort to purgatives and laxatives, as a matter of convenience, and so habituate themselves to their use that they are gradually obliged to employ stronger and stronger remedies, until finally all have lost their effect. 2. Insufficient Exercise, Sedentary Occupations and Obesity To this group of patients belong many officials, book- keepers, coachmen, students, etc., who are seated the greater part of the day, and also obese persons who take too Httle exercise and who do not go to stool as frequently as they should, because of the inconvenience or because it is difficult for them to use the abdominal muscles at stool. 3. Diminution of Power of Expulsion of the Intestinal Musculature and Abdominal Pressure To this group belong patients with congenital or accjuired enteroptosis, especially women who have borne children and who have diastasis of the recti muscles and pendulous abdomen, and also those who have a relaxed peritoneum, following lacerations. DISEASES OF THE INTESTINE 301 Whether in these cases the musculature of the colon is indeed anatom- ically weakened, or only badly innervated, cannot be determined with positiveness. It is most probable that the condition of the colon corresponds to that of the rest of the body in such patients as are under-nourished and anaemic. Since, however, the constipation entirely disappears by proper therapy, it may be quite positively assumed that the trouble was of a functional nature. To this group belong a large majority of patients suffer- ing from chronic constipation. Very frequently the physician is able to trace the beginning of the trouble to the first preg- nancy and puerperium. But this form of chronic constipa- tion occurs equally often in nulliparce and in men who have the habitus enteropticus, associated with a general malnutrition. This intestinal condition corresponds to ansemic-gastrop- totic dyspepsia. It need only be mentioned here that the stomach and intestine are often involved simultaneously, or an affection of the one follows that of the other, as a result of these disturbances of the functions of the gastro-intestinal tract. 4. Insufficient and Unsuitable Food Most of the patients in this group are those with poor or perverted appetites, — such as phthisical or neurasthenical individuals, or those who through ignorance have subsisted largely on proteid foods, avoiding vegetables and fruit because they did not consider them nourishing and strengthening. Children especially suffer from constipation as the result of such a diet-error. 5. Disease of the Stomach in which the Nourishment taken is either too Limited in Amount or Too Bland and Non- Irritating in Quality In this group should be mentioned first the organic dis- eases of the stomach, — such as chronic gastritis, ulcer, ectasia, and carcinoma, — in which the patient, partly on account of the loss of appetite and partly from fear of eating, or because the motiUty of the stomach is disturbed by an organic obstruction, has, upon the advice of a physician, avoided those foods which give bulk to the faeces, and this in turn has caused constipation. 302 DISEASES OF THE DIGESTIVE CANAL In functional diseases of the stomach, patients suffer from constipation as a result of taking insufficient amounts of food, because they fear the resulting pressure and fulness in the epigastrium, — sjaiiptoms which they often consider due to chronic catarrh of the stomach. 6. Diseases of the Intestine, such as Catarrh, Inflammation in the Ileoccecal Region, and the Misuse of Laxatives In this group we should first mention typhlitis and appendicitis, because they are often treated with large doses of opium, which frequently leaves behind a persistent con- stipation. Laparotomies have the same effect, for in addition to the paralyzing influence of narcptics and anaesthetics upon the intestine, there is a weakening of the muscles involved in the downward abdominal pressure. Another common disease of this group is chronic catarrh of the intestine, which frequently causes chronic constipation, as a result of a spastic condition of the musculature of the colon, as has been pointed out in the chapter on Enterocolitis. 7. Nervous Influences: Hysteria, Tabes Dorsalis, Lead Intoxications, etc. Chronic constipation occurs in hysteria from impair- ment of the innervation of the intestinal wall. The muscula- ture may be either too much relaxed or too strongly con- tracted. A period of atonic constipation usually pre- cedes the spastic stage, which does not appear until pathological alterations in the mucous membrane of the colon have occurred. In general, it may be said that the stage of spastic con- stipation occurs earher in hysterical individuals than in those who have no neurotic tendencies. Disturbances of intestinal innervation which lead to chronic constipation frequently occur in cases of tabes dor- salis, because such patients have largely lost the normal desire to go to stool. Chronic leacl-poisoning also causes spastic constipation. DISEASES OF THE INTESTINE 303 It is assumed, at the present time, that this occurs as a result of paralysis of the splanchnic nerves, which are the inhibitory nerves of the automatic ganglia of the intestinal wall. In severe cases of lead-poisoning, the spastic condition of the bowels frequently develops into the well-known lead colic, which represents merely an acute exacerbation of the intoxication. 8. Local Obstructions, — Stenoses, Dilatations, and Neoplasms of the Intestinal Tract In such cases, the constipation is merely a symptom of the pfimary disease. In any given case, the presence of a tumor which narrows the lumen of the intestine from within, or compresses it from without, should always be thought of, as well as hypertrophy of the prostate gland, displacements of the uterus, and also peritonitic adhesions with neighboring organs, — such as the liver, the anterior abdominal wall, and the female genital organs. Laparotomies and traumata also produce the same results. That portion of the intestine above the seat of the ob- struction becomes dilated, just as does the stomach when there is a stenosis of the pylorus. The atonic dilatation of the sigmoid flexure should be mentioned here, since it is observed with especial frequency in children and may lead to enormous sack-shaped dilatation of this portion of the intestine. The exces- sive length of the mesentery is responsible for this condition, since it allows a kinking of the colon at this place. This condition has been given the name of "Hirschsprung's Disease," after the clinician who first described it. THE DEVELOPMENTAL STAGES OF CHRONIC CONSTIPATION To be successful in the treatment of any given case of constipation, it is essential for the physician to be able not only to find its etiological factor, but also to recognize the stage of its development. I recognize that the classification of constipation wdiich I shall present in the following pages is somew^hat schematic, and the arrangement of the different forms may not, in some 304 DISEASES OF THE DIGESTIVE CANAL instances, be strictly correct; yet the plan of the subject as outlined has proven so satisfactory to me in practice, that I do not hesitate to adhere to it in this book. 1. Atonic Stage Except in neurasthenically-disposed individuals, chronic constipation always begins with this stage, in which the mus- culature of the colon is relaxed. [It appears, from the investigations of Schmidt and Strassburger, that this stage of constipation is due, not to atony of the intestinal musculature, but to too complete digestion and absorption of food in the intestine. As a result of this, the intestinal bacteria have not food enough left for their growth, and are therefore unable to form gases, acids, and other substances which appear to be normal stimulants to the intestinal wall; and the intestine, lacking this stimu- lation, fails in its peristaltic action. Lohrisch*has under- taken the systematic investigation of the stools of patients suffering from constipation, while on the test-diet. He found that the normal dried substance of the stools of three days' diet averaged 59.3 grams, while in constipation it averaged but 33.9 grams. This indicated that the digestion and absorp- tion had been too perfect. He found that when he gave opium to normal persons, — which would produce a condition sim- ulating atony of the bowels,— only the watery elements of the stool were reduced, while the dried substance was not altered. This indicates that lack of peristalsis cannot, of itself, produce the condition that has been called atonic constipation. No doubt, weakness of the muscles of the bowels plays some part in the production of constipation, but it does not appear to be the most important factor. The most prominent causes seem to be a too perfect digestion and absorption of food, poor growth of the normal bacteria of the bowel, and a consequent lack of the normal products of fermentation.] {*Deutsch. Arch. f. klin. Med., 1904, Bd. 79, p. 383.] DISEASES OF THE INTESTINE 305 2. Catarrhal Stage This follows after the atonic stage has existed for years or decades, as a result of the irritating effect of the scybala upon the intestinal mucosa, or from the abuse of laxatives. The diagnosis of this stage is made possible by the presence of membranous mucus surrounding the scybala. We do not accurately know the real condition of the small intestine at this stage. We must assume, however, on the occurrence of flatulence during this period, that a catarrhal con- dition is gradually developing in this part of the intestinal canal. 3. Sjjastic Stage This stage of constipation occurs as soon as the secondary enterocolitis, or the abuse of laxatives, has irritated the colon so that a persistent hypertonicity of its musculature has developed. In nervous, and especially in hysterical, individ- uals this stage sets in considerably earlier than in a person whose nervous system is in a normal condition. 4. Membranous Enteritis This stage of constipation is still designated by a few authors as a "myxoneurosis" of the intestinal canal; but, as has already been mentioned, it is merely an advanced stage of chronic colitis. The more marked is the stagnation of scybala in the colon, the more active is the secretion of mucus from Lieberkiihn's glands of the mucosa; and since the faeces are often retained for several days, on account of the contracted condition of the colon, there is produced a large amount of mucus as a result of the absorption of the fluid constituents, as well as from the astringent effect of the acid faeces, and the mucus assumes a membranous formation which may be evacuated as an isolated cyUnder of mucus, or may be expelled together with the faeces, completely surrounding the latter. 5. Mucous Colic The so-called "mucous coHc" is merely an acute exacer- bation of membranous colitis. When the contraction of the 20 306 DISEASES OF THE DIGESTIVE CANAL colon is too strong, obstructing the lumen of the gut, nature attempts to expel the mucus by violent peristaltic contractions of the colon, which cause great pain. During these attacks, the patient often expels a glassful of mucus, which, when suspended in water, reveals its mem- branous formation. After the evacuation of large masses of mucus, the patient is generally free from pain for some time, and presents during this period only the picture of simple spastic constipation, until another attack occurs. 6. Stercoral Diarrhopa In very advanced cases of secondary catarrh of the intes- tine, chronic constipation may develop into diarrhoea. Such patients then generally suffer from alternating constipation and diarrhoea; for instance, after diarrhoea has existed for about a week, there is a period of absolute constipation. These clinical cases are rather rare, but are found with some frequency in neuropathic individuals, or in patients who have been improperly treated for constipation. The secondary catarrh occupies the foreground in the chnical symptoms so prominently that only by the most careful anamnesis and examination can the physician trace its origin to a previous chronic constipation. DIFFERENTIAL DIAGNOSIS OF THE VARIOUS STAGES OF CHRONIC CONSTIPATION Atonic. — In this period of the disease, patients complain of nothing more severe than constipation, a dull feeling in the head, lack of desire to work, etc. Enemata and laxatives are both effective, but the latter must be changed frequently. There is no pain, flatulence, nor meteorism. In the objective examination, the physician will find the stool of normal form and consistency, i.e., of large caliber, and covered only with the normal amount of mucus. The sigmoid flexure, and usually the transverse colon as well, will be found filled with faeces which may usually be palpated. DISEASES OF THE INTESTINE 307 Catarrhal. — This stage is recognized subjectively by the occurrence of flatulence after the use of irritating foods, such as flatulent vegetables, pastries, fat meats, cold drinks, etc. Objectively, it is recognized by the admixture of mucus with the stool. Spastic. — This stage of chronic constipation occurs almost simultaneously with membranous enteritis, and is easily differentiated from the atonic stage by the following signs and symptoms: 1. Colic is a frequent symptom. In shght cases, patients have flatulent colic; and in severe cases, mucous colic. Every case of chronic constipation that runs its course with attacks of pain belongs to the spastic variety, in which inflammatory and catarrhal changes of the intestinal tube are demonstrable. 2. Laxatives are either not effective at all, or only so when given in very large doses, which produce great pain, Enemata likewise are usually ineffective. 3. Objectively, on palpation, the contracted transverse colon and the sigmoid flexure of the colon are found to resemble a hard cord, about the size of the little finger. The colon in this condition is sensitive to pressure. 4. Digital examination of the rectum reveals the fact that it is either entirely empty and contracted, or else is filled with faeces the size of the little finger; while in atonic con- stipation the rectum is, as a rule, entirely filled. In spastic constipation, the physician can frequently feel the contraction of the intestinal tube around the palpating finger. 5. The stool is of small caliber, — about the size of the little finger. It is sometimes ribbon-shaped, or its transverse section may sometimes be quadrangular. It would be an error, however, to assume from this that an organic stenosis exists in the lower portion of the colon, since these configur- ations of the faeces may likewise be caused by a spastic con- traction of the intestinal musculature. In many instances, the stool consists of individual, short segments; while in the atonic form it is of large caliber and tubular. 308 DISEASES OF THE DIGESTIVE CANAL ,6. Very frequently, besides the above symptoms, the physician- will observe the above-mentioned membranous mucus. In a doubtful case, to demonstrate whether this is present, the patient should insert a soap suppository into the rectum and examine the resulting stool, placing it in warm water, when the mucus will spread out upon the surface of the water and thus be easily recognized. Or the examiner may follow the procedure of Boas,— flushing the intestine with one or two litres of water, small amounts at a time, and examining the return lavage-water for mucus. The lavage-apparatus described by Zweig may also be used for this purpose.* By these subjective and objective signs and symptoms, it is possible in most cases to determine the stage of the disease in any given case of chronic constipation. Mucous cohc is very easily recognized, especially since the patient will frequently bring the characteristic defecations to the physician, with the mistaken idea that he has a tapeworm. The stage of mucous diarrhoea, or so-called stercoral diarrhoea, is also easy of recognition. It is necessary, however, to prove by the anamnesis that constipation has existed for several years previous to the diarrhoeal stage. TREATMENT For the rational treatment of chronic constipation, it is unqualifiedly necessary to have, in every concrete case, a clear understanding of the etiological factors and the stage of the disease from which the patient is suffering. Atonic Stage of Constipation. — The sole indication for treatment of this period of constipation is to produce spontaneous movements of the bowel. The application of the following fundamental principles will accompHsh this in the majority of cases: Hygiene. — The physician should regulate the life of the patient by written directions, so that all causative factors of constipation, such as sedentary habits and occupations, may * Therapie der Gegenwart, April, 1906. DISEASES OF THE INTESTINE 309 be avoided; and the patient should be advised to take up gymnastics, swimming, riding, walking to and from business or school, etc. Gymnastic exercises are especially suitable for women with relaxed and weakened abdominal muscles. Exercises should be carried out night and morning, as follows : With the hands clasped behind the head, the patient should raise and lower the trunk six to ten times, and then bend the trunk forwards and backwards, besides rotating the trunk and flexing and extending the legs. Mechanical Treatment. — Patients with enteroptosis, ''hang belly," and diastasis of the recti muscles should wear a suitable abdominal bandage or support, and should have massage, — at first daily and later only two or three times a week. As a rule, 25 or 30 treatments are required, which should be given as follows : The hand should be lubricated with vaseline and placed flatly extended upon the ileocgecal region, and the entire colon should then be stroked along its course to the sigmoid flexure, over which quite strong downward pressure should be exerted, when the hand should be returned to the caecum and the routine movement repeated. The treatment should last from five to eight minutes. * In the first one or two weeks of treatment, it will generally be necessary to resort to the use of enemata, consisting of | litre of lukewarm water, every second clay after breakfast. It must be emphasized, however, that laxatives should be strictly forbidden and patients should be directed to go to the toilet every morning after breakfast. Hydrotherapy. — Hydratic treatments, — such as cold friction, douches, half-baths, and fresh -water baths, — are useful only in the atonic form of constipation. Electrotherapy. — In cases which respond to treatment stubbornly, it is often useful to apply a strong faradic current for about five minutes, using a flat electrode upon the abdo- rnen, and a rectal electrode in the rectum. One of the older and most useful methods was that of introducing into the * I have not entered into the remaining movements and details, for the reason that massage cannot be theoretically learned. 310 DISEASES OF THE DIGESTIVE CANAL lower bowels 100 to 150 c.c. of lukewarm water, through a glass funnel and Naunyn's intestinal tube, in order to estab- lish a contact between the membrane of the rectum and the metal of the electrode. I have obtained espcciall}^ good results in the constipa- tion of tabes dorsalis by this treatment. Diet. — The diet must be such as will furnish an abundance of waste matter in the intestine, and should therefore be rich in cellulose and of such a character as will mechanically stimulate the mucosa. In arranging the dietary for such patients, cold drinks should be included, such as a glass of cold water upon arising in the morning, soda water, Apolli- naris, etc., with or without fruit-juices, such as raspberry, lemon, etc.; also tea and malted coffees (bean coffee being excluded), buttermilk, sour milk, sugar of milk, koumiss (twice daily), butter, all kinds of fruits and vegetables in every form, — cooked or raw, — legumes, pumpernickel, honey-cakes, and meats of all kinds, but in limited amounts; the only wines allowed should be the white varieties, such as Moselle, Rhine, or White Bordeaux, Hautes Sauternes, etc. Constipating foods,— such as red wines, cocoa, cereal soups, rice, grits, sago, etc., — are contraindicated. For full details, the reader is referred to the special diet-tables in the Appendix. Medicaments. — Only in cases in which chronic constipa- tion is not the primary trouble, but only a symptom of some other disease of the intestine, stomach, or other organs of the body, may the patient be allowed to avoid a severe dietetic regime and resort to the use of laxatives. Such is the case in arteriosclerosis, diseases of the heart, kidney affections, marked obesity, diabetes, and especially in habitus apojjlecticus, diseases of the female genital organs, and naturally also in chronic appendicitis and stenosis of the intestine. For temporary rehef, the most suitable remedies are castor oil in doses of two or three tablespoonfuls or 8 or 10 capsules, in a glass of one of the laxative mineral waters, or a teaspoonful of Carlsbad salts dissolved in a glass of lukewarm water, to be taken on the empty stomach. DISEASES OF THE INTESTINE 311 The following preparations are the most desirable lax- atives for extended use: 1. Grillon's or Kanoldt's tamarind tablets, I- to. 1 tablet in the evening. 2. Wine of cascara sagrada, one or two teaspoonfuls in the evening. 3. Compound licorice powder, | to 1 teaspoonful in the evening. 4. Rhubarb tablets, each containing 0.5 [gr. viiss], in the evening. 5. St. Germain tea, 1 tablespoonful to a cup of hot water, in the evening. 6. Cortex frangulse, 1 tablespoonful in a cup of water in the evening. 7. Cascara tablets. 8. Marienbad and Schweizer pills. 9. Extract of rhubarb 10.0 [oiiss], sodium sulphate 20.0 [5v], and bicarbonate of soda 20.0 [5v], taken in J to 1 teaspoonful doses in the evening. 10. As alternatives: Purgen, exodin, regulin, etc. For acute cases, aloes and jalap may also be recommended. Spastic Stage of Constipation. — -The treatment of this form of constipation is essentially different from that of the above, for the reason that in addition to the constipation, the membranous enteritis and mucous colic must also be simul- taneously treated. The cases associated with mucous or ster- coral diarrhoea require anticatarrhal treatment. In the therapy of the spastic variety of constipation, it must be kept in mind that the intestine is in an irritable condition, that the mucous membrane is inflamed, and that the intestinal musculature is in a state of hypertonicity. Hygiene. — ^As much rest as possible should be prescribed, especially after eating. In severe cases, especially in neuro- pathically-inclined individuals, two or three weeks' rest in bed, — preferably in a sanitarium, — is absolutely essential if the patient is unable to secure the necessary rest at home. Natur- 312 DISEASES OF THE DIGESTIVE CANAL all}', this requires freedom from all worry and anxiety, — other- wise favorable results will not be obtained from the treatment. Mechanical Treatment. — Massage is contraindicated, be- cause its use would aggravate the spasmodic contraction of the colon. The abdomen should be kept warm by woolen ban- dages, while abdominal supports are necessary only in cases associated with enteroptosis or "hang-belly." In this stage, Fleincr's oil-treatment is of great value. My usual procedure is to introduce 300 to 400 c.c. of sesame or olive oil, at body-temperature, into the rectum about 10 o'clock in the evening, just before the patient retires. The patient should assume the left-side position, and the oil should be allowed to enter the bowel slowly through a Naunyn's rectal-tube connected with a glass funnel. After the intro- duction of the oil, the patient should lie on the abdomen for about a quarter of an hour. The introduction of oil into the rectum with an ordinary hard rubber syringe is ineffective, since the oil does not reach high enough. The physician should never neglect to advise the patient to protect the bed from becoming soiled by the treatment, since otherwise, because of its uncleanliness, he might become disgusted and refuse to carry it out. The oil should be retained in the intes- tine at least until the following morning. In the beginning of treatment, oil should be introduced every other day; and later, every third day. I generally instruct patients to omit the treatment on those days when there has been a spontaneous evacuation of the stool, and to resort to its use again in the evening of the first day when the bowels have not moved. The oil dissolves the hard scybala which have remained in the folds of the colon, often for several days, and which have maintained the spasm of the musculature. In addition to this, the oil is decomposed into fatt}^ acids, which excite peristalsis and produce both mechanical and chemical stim- ulation of the bowels. Hydrotherapy. — Cold procedures are contraindicated. To benefit the general neurasthenical condition, I advise pro- DISEASES OF THE INTESTINE 313 tracted lukewarm baths, at a temperature of about 25° to 30° R. [88°-100° F.], lasting about I hour; or the pine-needle baths, containing { litre of the extract in each bath; besides moist, warm abdominal bandages, consisting of a wet towel covered first by oiled paper or oiled silk, then by a woolen bandage, and worn during the night. Diet. — -In contraindication to the coarse constipation- diet indicated in the atonic form, the mild constipation-diet should be used in this stage of the disease, for the reason that the coarse foods, rich in cellulose, would aggravate the spasm of the colon, and might easily cause secondary membranous enteritis of the intestine, or give rise to very frequent or persistent diarrhoea. The mild constipation-diet consists of the following: Tea, malted coffee, and fruit-juices, which should never be taken cold; milk, white wines, white Bordeaux, — such as Hautes Sauternes, — cream, koumiss, buttermilk, sour milk, soft cheese, and a tablespoonful of sugar-of-milk three times daily dissolved in liquid foods ; only light vegetables, — such as peas, carrots, asparagus, cauliflower, spinach, and Brussels sprouts, chestnuts and pota- toes, — all to be served in the puree form. The patient should eat freely of sweet fruit-sauces, honey, and marmalades made from the raspberry, orange, plum, grape, apple, date, etc. The diet in spastic constipation should stimulate peristalsis chemically; in atonic constipation, mechanically. The following foods should be forbidden: Coarse breads, acids, sour fruits, flatuous vegetables, — such as cabbage, peas and beans, — red wine, goose, duck, eel, salmon, and sardines in oil. Balneological Treatment. — Treatment at a mineral-water resort need be considered only in severe cases of spastic constipation. Before sending a patient to such a place, it is advisable to examine the gastric contents by means of a test-breakfast, in order to determine whether hydrochloric acid is secreted in normal, diminished, or increased amounts. When the hydrochloric secretion is normal or increased in spastic constipation, with a secondary membranous enteritis and gas or mucous colic, I send the patients to Carlsbad, Fran- 314 DISEASES OF THE DIGESTIVE CANAL zensbad, Ncucnahr, or Vichy, where they (h'ink the thermal watcTS and have the hot mud-poultiecs apphed to the abdomen. AVhcn hydrochloric acid is diminished or absent, such patients should be sent to Kissingen, Homburg, or Wiesbaden. The details of treatment should be directed by the attending phj'sician at the watering-place. Medicinal Treatment. — Purgatives are contraindicatcd, because they are very often the cause of the trouble, because they increase the secondary catarrh of the intestine, and because they are effective only in very large doses. Sedatives, on the contrary, just as in lead colic, are indicated as in the following prescriptions: 1. I^ Extract! belladonnse foliorum, gr. ivss-vij 0..3-0.5 M. ft. pil. No. XXX. Sig. — One pill after meals, t.i.d., in simple spastic constipation witli gas and mucous colic. 2. I^ Tincturse belladonnge foliorum, gtt. Ixxx-oiiss 5.0-10.0 Spiritus menthse piperitiE, gtt. Ixxx 5.0 Tincturse valerianse, 5iv-ov 15.0-20.0 M. Sig. — Thirty drops in a cup of hot carminative tea, t.i.d. 3. 1^ Extracti belladonnge foliorum, gr. ivss-viiss 0.3-0.5 Extracti opii, gr. vi-xii 0.4-0.8 M. ft. pil. No. XXX. Sig. — One pill t.i.d. for very- nervous patients. 4. I^ Extracti belladonnge foliorum, gr. ivss 0.3 Spiritus menthce piperitse, gtt. xv 1.0 Tincturse valerianse, oi 30.0 M. Sig. — Twenty-five drops t.i.d. A cup of carminative tea, as hot as possible, taken morn- ing and evening for several months is very helpful. One tablespoonful of equal parts of valerian, peppermint, fennel and caraway, steeped in a cup of hot water, is a very suitable preparation. A glass of hot water taken night and morning also tends to relax the spasm of the bowels. For patients who suffer very severely from colic, and for those who travel, I prescribe a compressed tablet of atropine sulphate containing 0.0005 [yj-^ gr.], twice daily after eating, the temporary use of which is not injurious. Morphine should not be prescribed in these cases. DISEASES OF THE INTESTINE 315 PROGNOSIS AND COURSE Successful results are obtained in most cases, the patient being permanently cured, or at least remaining well for a number of years. I have obtained the least satisfactory results in treating persons who were excessively obese, or very nervous, or in the case of women in the climacterium. Very successful results are quickly obtained from diet and massage, in enteroptotic and under-nourished patients suffering from the atonic form of constipation. It is very frequently the case, that after the first week of treatment their bowels become normal. Cases of spastic constipation are more difficult to treat, for the reason that, in addition to the constipation, there is the catarrhal factor to combat, as well as the injcreased reflex- ibility of the nervous system. I have, however, obtained most satisfactory results, — even after constipation had existed for fifteen years or more, — through rest, hot apphcations, belladonna, oil enemata, and a suitable mild constipation-diet. It is particularly necessary in this disease to individualize in the selection of the proper therapy. Until the physician's experience is large, it is well for him to follow the above- mentioned differential diagnostic principles, namely: Constipation without pain indicates atonic constipation; constipation asso- ciated with gas and mucous colic indicates spastic constipation. The therapy directed according to the above will usually be correct. To treat atonic cases with oil enemata is superfluous; and to treat spastic constipation with a coarse constipation-diet is an error, since it would aggravate the associated catarrhal condition of the mucosa. PROPHYLAXIS Only the family physician, who knows accurately the pathogenesis, the symptoms, and the course of the disease in the individual, is in a position to prevent the later stages by 316 DISEASES OF THE DIGESTIVE CANAL the timely institution of suital)l(' theraiKnitic measures. For instance, in enteroptotic in(li^•i(l^lals he can prescribe a suf- ficientl}^ iiourishing diet, exercise, fresh air, and a yearly outing and vacation. CLOSING REMARKS There are few diseases so strikingly the result of our over-refined civilization, and directly attributable to insuf- ficient exercise, diet containing too little waste matter, loss of appetite, and disturbances of the stomach, as chronic constipation. It would be interesting to know whether this disease is as widely prevalent among the wild tribes who subsist largely on raw foods. It may safely be assumed that such is not the ca.se. CLINICAL CASES 1. Atonic Constipation Case 1. — Minnie F., 45 years old, had been constipated from 15 to 20 years and had used all kinds of laxatives, which had lately been ineffective, unless taken in very large doses. She Jiad suffered no pain, but had expe- rienced lassitude and loss of appetite. The physical examination was negative. The patient had a normal habitus. The treatment consisted of massage, a coarse constipation-diet and faradization. After two weeks, the stools became normal and remained so for the five years the patient was under observation; and during this time she increased 15 or 20 pounds in weight. Case 2. — Clara B., 30 years old, had for ten years been unable to obtain any action of the bowels by natural means, always having resorted to laxatives or enemata. For one year the patient had complained of pres- sure in the epigastrirmi after eating, for relief of which she sought treatment at the polyclinic. The patient had never suffered from pain in the abdomen. Examination showed her to be enterojDtotic, and suffering from emaciation and anaemia. Otherwise the findings were negative. The patient was prescribed a heavy fattening-constipation diet, bitters and massage. After eight daj^s the stools became normal. The patient afterward gained 12 or 15 pounds in weight and remained permanently well. Case 3. — Mrs. H. W., 38 years old, had not had a spontaneous evac- uation of the bowels for 10 or 12 years. The abdomen was large and pen- dulous. After two or three weeks of treatment, the patient wa spermanently cured, since which time she has increased considerably in weight. DISEASES OF THE INTESTINE 317 2. Spastic Constipation Case 1. — Mrs. O. S., 40 years old, had been constipated for 15 or 20 years, during the early part of which period she had never had abdominal pains. For the past several years she had suffered from colicky pains, vomit- ing, and the evacuation of mucus and gases from the bowel. The patient alleged that on several occasions she had had stercoraceous vomiting, and that she was sent to the hospital for operation for ileus, should the latter become necessary. At this time laxatives were effective only when given in very large doses, and then accompanied by violent colicky pains. Enem- ata were unsatisfactorj^ The patient was very anaemic and emaciated, and there was a marked gastroptosis. In palpation, the colon was of the size of the little finger, and very sensitive. The bowel-movements consisted either solely of membranous mucus, or of mucus admixed with faeces, of the caliber of a lead-pencil. Treatment consisted of the administration of oil enemata, at first every third day, and later less frequently, continued for three or four months. 0.015 [i gr.] of the extract of belladonna was given three times daily and a mild constipation-diet used. The patient was under observation for three or four years, during which time she remained entirely well. Case 2. — Mrs. Emily P., 55 years old, had had a laparotomy performed, twelve years previously, since which time she had been con- tinuously constipated. For the past four or five years, the patient had passed much mucus from the bowels, and suffered a great deal from "wind colic." She was permanently cured by the treatment outlined in the previous case. Case 3. — A coachman 50 years old had suffered for years from slug- gishness of the bowels, being obliged to resort to the use of laxatives very frequently. After errors in diet, — such as eating cucumbers and heavy cheese, — the patient always suffered from violent colic. After treatment for two weeks, — consisting of rest in bed, hot applications, oil enemata, and the mild constipation-diet, — the patient was permanently cured. 3. Mucous Colic Case 1. — Mrs. Clara B., 30 years old, had for several years suffered from constipation ; and for one or two years, from mucous colic and periods of mucous diarrhoea. The latter would continue about eight days, when it would be succeeded by about one week of complete constipation. The patient was an hysterical subject. Enormous quantities of mucus and epithelial cells were mixed with the faeces, and the stools had a caliber about that of a lead-pencil. Treatment with atropine gaA'e some relief, but the patient was not cured. Temporary improvement followed residence in the country. 318 DISEASES OF THE DIGESTIVE CANAL APPENDIX The Relationship between Constipation and Diarrha'a Although constipation and diarrhoea appear to be two diametrically opposed symptoms, they are sometimes observed either simultaneously in the same individual, or the one fol- lowing the other, — which will not seem paradoxical to the careful reader of the previous chapter. For a clear and correct understanding of the relationship between the two, however, a few remarks should be made. The factor by which both constipation and diarrhoea are associated in the same individual is a chronic catarrhal condition of the colon. Colitis of a mild degree runs a course with constipation, as a result of hypcrtonicity of the musculature of the bowels, caused by an irritation of the mucosa. If, at this time, any such factors as indigestion, exposure to cold, or irritation caused by the stasis of faeces in the bowels appear, the in- flammation of the mucosa is increased, which causes diarrhoea. I have had under observation a business man 40 years old, who was treated for acid gastritis and a mild catarrh of the small and large intestines. When the patient was on a non-irritating diet, two or three stools partly- formed and partly of semi-solid consistency were passed daily. Whenever the patient indulged in errors in diet, such as over-loading the stomach, the use of acids, or eating fried potatoes, etc., there was constipation for two or three days, associated with meteorism; while after gross errors in diet, — such as the free use of cold beer, — gnawing, stabbing pains immediately appeared in the abdomen, accompanied with diarrhoea. Another patient, a manufacturer, 54 years old, who suffered from achylia and intestinal catarrh, was ordinarily constipated. Profuse diarrhoea always occurred immediately after eating food containing coarse meat-fibres. In ileocsecal catarrh, the alternation of constipation and diarrhoea is the rule. In spastic constipation with membranous enteritis, a period of four to six weeks of constipation is frequently fol- lowed by an attack of mucous diarrhoea. In chronic intestinal catarrh associated with diarrhoea, a period of total constipation often follows an improvement in the former condition. DISEASES OF THE INTESTINE 819 Stercoral diarrhoea occurring in the course of habitual constipation has already been mentioned, and is well known to every practitioner. Diarrhoea alternating with constipation can scarcely be caused by purely nervous influences. An exception to this condition may perhaps be mentioned here, namely, the intes- tinal symptoms which occur in exophthalmic goitre. Naturally, patients suffering from paradoxical symptoms should receive anticatarrhal treatment, consideration and attention being given at the same time to the irritabihty of the sympathetic nervous system usually present in these cases. Neuroses of the Intestine When compared with gastric neuroses, purely nervous affections of the intestine are relatively less frequent, if we except habitual constipation, the nature of which has been described in detail in the foregoing chapters. In an affection which, in individual cases, is greatly modified by the irrita- bility or weakness of the intestinal nerves, the nervous factor often determines whether the constipation will assume the atonic or the spastic form. In a neurasthenical or hysterical individual suffering from an intestinal neurosis, a great variety of symptoms in the mesogastrium and hypogastrium are complained of. It is an interesting fact, however, that an accurate exam- ination of the faeces will reveal the presence of an anatomical lesion, usually of a catarrhal nature, in the majority of these cases. As a further proof that these cases are due to organic alterations of the mucosa rather than to neuroses, the fact may be mentioned that such patients improve if given a treatment adapted to an organic affection, while no improve- ment of the symptoms results from purely antinervous treatment. It seems certain, at the present time, that such conditions as arteriosclerosis and syphilis also play a causative role in the production of many of these vague disturbances in the abdo- men, which were formerly considered as of nervous origin. Our 320 DISEASES OF THE DIGESTIVE CANAL present methods of investigation, however, are too imperfect to inform us fully as to the exact anatomical changes present. The phj'sician must, for these reasons, use the greatest caution in making a diagnosis of a neurosis of the intestine, and should arrive at such a conclusion only when, (1) all evidences of an organic disease are absent, and (2) when in any given case the symptoms are not influenced in any way b}" dietetic treatment; while, on the other hand, depending upon the condition of the nervous system, the patient's con- dition is better or worse. It is self-evident that a neuropathic individual with markedly increased reflex irritability will react more strongly to slight pathological irritations than an individual with a stable nervous organization. Also the fact that habitus enteropticus, which has already been frequently mentioned, is of considerable importance in the diagnosis of intestinal conditions, need not be especially emphasized. It is a fact that severe enterocolitis, with its unpleasant symptoms of flatulence, meteorism, colic, etc., is observed with especial frequency in enteroptotic and neurasthenical individuals. That in such cases we have an organic disease of the intestinal mucosa to deal with is proven by the presence of mucus in the fseces in most of these cases. One may even go a step further, and maintain that a great number of the nervous symptoms are dependent upon the organic affection of the bowels, the treatment and removal of which almost always cause a complete disappearance or an amelioration of the nervous symptoms. The diagnosis of ''nervous diarrhoea" is often erroneously made along the same line. This is an extraordinarily rare affection; in by far the majority of cases we have to do rather with a combination of neurasthenia and intestinal catarrh. The intestinal neuroses may be conveniently divided into: (a) motor, (6), sensory; and (c), secretory. From the practical standpoint, only the following are of importance and significance: DISEASES OF THE INTESTINE 321 Atony of the Intestine. — We have considered chronic atony in the chapter on Habitual Constipation; and the acute weakness of the intestine, in the chapter on Intestinal Ob- struction. The latter occurs primarily only in either marked congenital or acquired enteroptosis, and secondarily after trauma, laparotomy, peritonitis or shock, which cause acute paralysis of the intestine. The diagnosis of acute intestinal paralysis, or the so- called paralytic ileus, is made from the absence of violent pain, fever, and intestinal ''stiffenings." Chronic intestinal atony is identical with atonic consti- pation, the diagnosis and therapy of which have already been discussed. The therapy of the acute form consists in the adminis- tration of laxatives and in high irrigations of the colon. The following combination is the most suitable for use in the latter: Castor Oil, 2 tablespoonfuls; Cod-Liver Oil, 1 tablespoonful; Bicarbonate of Soda, J teaspoonful; Warm Water, 1 to 2 litres. The above should be well emulsified and introduced with the patient in the knee-elbow position. The best laxatives are castor oil, laxative mineral waters, rhubarb, and jalap. Intestinal Spasms. — Spasm as an intestinal neurosis is extremely rare; much more frequently we find a catarrhal condition associated with it, as evidenced by the presence of mucus in the stools, and the occurrence of diarrhoea after errors in diet, taking cold, etc. I wish to emphasize again, as has already been mentioned in the chapter on Constipation, that in nervous individuals an enterocolitis will produce a contraction of the intestinal musculature earlier than in non- nervous persons. Symptoms. — Patients have a feeling of pressure or tension across the abdomen, similar to the "girdle-sj^mptom" of locomotor ataxia, in consequence of spasm of the transverse 21 32^2 DISEASES OF THE DIGESTIVE CANAL colon. This spasm is usually associated with frequent colicky, cutting, and sometimes cramp-like pains around the umbilicus, generally radiating from right to loft, lasting a few minutes, and disappearing after the escape of gas. By palpation, the colon, and cspcciall}' the transverse colon and the sigmoid flexure, will be found to resemble a hard cord or band about the size of the little finger, and sensitive to pressure. Intestinal obstruction, or the so-called spastic ileus, may result from a very severe spasm of the intestinal musculature (see below). Treatment.— Since intestinal spasm is usually a symptom of intestinal catarrh, the latter should alwa3^s be treated as the primary condition; although sedatives and antispas- modics, such as bromide and belladonna, are indicated, from the fact that the spasmodic feature is more frequent in hysterical and neurasthenical subjects. 1. I^ Potassii bromidi, oi 30.0 Sig. — A knifepoint in milk or water night and morning. 2. I^ Extracti belladonna; foliorum, gr. J-J 0.01-0.02 Ft. pil. or chart, i, No. xii. Sig. — One t.i.d. 3. I^ Extracti opii, gr. J-i 0.02-0.03 M. ft. pil. i, No. xii. Sig. — One t.i.d. The dietetic, balneological and hydropathic treatment is the same as in mild enterocolitis associated with constipation. The patient should, therefore, be put on a light consti- pation-diet and Wiesbaden or Vichy mineral water, and the use of mud-poultices applied to the abdomen, and a Priessnitz bandage at night. Nervous patients should be given Carlsbad water, — which contains Glauber's salt, — with caution, and then only in small doses. Lend Colic. — Lead colic is the result of an actual spasm of the intes- tinal musculature, occurring in painters, plumbers, boxmakers, etc. A diagnosis of the condition is very readily made if constipation asso- ciated with colicky pains occurs in one engaged in any of these occupations. Patients with lead colic have usually passed dry hard stools of very small caliber for a long time, until they have finally become completely constipated. Severe mesogastralgia occurs, which is intensified by the use of laxatives. DISEASES OF THE INTESTINE 323 The intestine is contracted and the blue line on the gums is usually demonstrable, or at least the anamnesis generally shows that the patient is engaged in some occupation in which he comes into contact with lead. The treatment of lead colic consists in the use of hot compresses, oil enemata, or 0.06 [gr. i] of the extract of opium three or four times daily, and the later use of potassium iodide and sulphur baths. Nervous Diarrhcea. — Acute nervous diarrhoea is the result of greatly increased peristalsis, caused by intense emotional excitement, especially fright. At first the stools are formed, and later they consist only of watery evacuations in which almost the entire contents of the bowels may be expelled in from half an hour to an hour, without any evidence of their being pathological. Chronic or frequently recurring diarrhoea is hardly ever of purely nervous origin, but is generally associated with a catarrhal inflammation of the intestinal mucosa, with the exception of the diarrhoea which occurs in Basedow's disease. Acute nervous diarrhoea does not require treatment, while the chronic form should be treated with a catarrhal diet and catarrhal medication. The catarrh of Basedow's disease should be treated in connection with the primary disease. Peristaltic Unrest of the Intestine. — This condition is treated by various authors as an intestinal neurosis. I must say, however, that I have never seen an undoubted case of this sort. The peristalsis of the small intestine, which is so frequently seen in women with pendulous abdomen or with broad diastases of the recti muscles, is normal; on the other hand, the so-called intestinal "stiffenings," considered by Nothnagel as a symptom of stenosis or obstruction of the intestine, are pathological. Borborygmus is a sign of abnormal fermentation of food in catarrh of the small and large intestines. From the practical standpoint, peristaltic unrest of the intestine is of no importance. Flatulence and Meteorism. — I have already shown that these conditions are symptoms of enterocolitis. The fact that they occur very frequently in hysterical persons is no evidence that the affection is not of a catarrhal nature. They are 324 DISEASES OF THE DIGESTIVE CANAL frequent in nervous women with cntcroptosis who have suffered, from habitual constipation for a number of years, which in turn has caused a sccontlary membranous enteritis and a spasmodic condition of the colon. It is cjuite clear that, through a rapidly developing spasm of the colon, stagnation of the fluid faeces occurs, which gives rise to meteorism. Membranous Enteritis. — This condition, which is still regarded by some authors as an intestinal neurosis, must be considered at the present time as merely a colitis secondary to habitual constipation. Mucous colic is an acute exacerbation of a chronic colitis. The same relation exists between chronic colitis and m.ucous colic as between cholecystitis and gall-stone colic. For further details concerning membranous enteritis, the reader is referred to the special chapter on Chronic Constipation. Intestinal Neurasthenia. — In this condition it is more accurate to speak of the neurasthenia which occurs in patients suffering from intestinal affections. The subject requires a special consideration. Hypochondriasis and melancholia are accompanying phenomena in many cases of chronic constipation. Such patients have their minds continually upon their intestinal functions, anxiously and accurately noting all symptoms, almost despairing if the chosen purgative does not produce the expected results, etc., etc. Actual psychoses may develop in this way, which may even lead to suicide. If constipation has already existed for several years and has led to enterocolitis, or to its incipient stage, the abdomi- nal symptoms of fermentation will cause much anxiety and suffering. The patients complain of tremor, of their hands' being hot, of cerebral congestion, a feeling of heaviness in the extremities, tension in the abdomen, lack of desire to work, insomnia, anorexia, nausea, emaciation, sensations of fear and mental depression. These secondary symptoms are most frequently associated with enterocolitis which runs a DISEASES OF THE INTESTINE 325 course with spastic constipation. They occur more rarely in other forms of the disease, because the fermenting fiL'ces are rapidly evacuated by the associated diarrhoea. This entire symptom-complex has been designated as Flatulent Intestinal Dyspepsia. These symptoms must be explained as a reflex irritability of the splanchnic nerve; I will only mention the fact that many authors assume autointoxication as their cause, and while this is quite possible, it has not yet advanced beyond the stage of a hypothesis. Treatment. — The therapy of intestinal neurasthenia con- sists in those measures which will cure the constipation and the resulting flatulence. If the physician is successful in doing this, the hypochondriasis disappears and the vasomotor and reflex troubles become considerably better, being often entirely relieved. The tendency to relapse, however, generally remains in these cases. It would be a great mistake to endeavor to cure the neurasthenical affection solely by hydrotherapy, electricity, massage, etc., without taking into consideration the asso- ciated intestinal condition. INTESTINAL DISTURBANCES IN DISEASES OF OTHER ORGANS In the absence of anatomical affections of the intestine, the latter shows much fewer symptoms than does the stomach, when other organs of the body are diseased. The diarrhoea which occurs in exophthalmic goitre and tabes dorsalis need only be mentioned. If diarrhoea or intes- tinal hemorrhage occurs in tuberculosis, arteriosclerosis, cardiac disease, nephritis, cirrhosis of the liver, pericarditis, or diabetes, these are the result of secondary catarrh or ulceration of the intestine, — both of which have already been described. Parasites of the Intestine It is not one of the tasks of this book to give a systematic discussion of the parasites of the intestine. For a full con- sideration of this subject, the reader is referred to the larger 326 DISEASES OF THE DIGESTIVE CANAL works of Hosier and Peipcr, Braun, Von Jacksch, etc. Some of Ihc diagnostic and therapeutic suggestions, merely, will be given here. Diagnosis. — The subjective symptoms of intestinal para- sites in children are nausea, vomiting, loss of appetite, and itching of the nose or anus, particularly at night. The presence of a tapeworm, or of a large number of smaller worms, may produce colicky pains, although these are generally of rare occurrence. Adults who have tapeworms frequently expe- rience unpleasant sensations after such foods as herring, sour pickles, coffee, light beer, etc. The above-mentioned symptoms are, however, so un- certain and are observed in so many other affections, that the physician should never undertake the treatment of tape- worm without objective proof of the presence of the parasite. The objective symptoms are as follows: The macroscopic demonstration of the worms them- selves, or of some of their mature segments, or the micro- scopical demonstration of their ova or of Charcot-Leyden crystals in the stool (see illustration, page 250). The segments of the worms are generally brought to the physician, who, in order to best examine them, should press the segments out fiat between two cover-glasses fastened at both ends. But few ramifications of the uterus will be observed in the tcenia solium of pork; while a great many, numbering from 30 to 40 on both sides, are observed in the tcenia saginata of beef. A person infected with the ttrnia solium is in constant danger of infecting others, so that unless precautions are used, both the patient himself and his family are liable to cysticercus. For this reason, the differentiation between the two tape- worms is of considerable practical importance. In children who are suspected of having worms, the examiner should wipe the anal mucous membrane with a spatula and examine the specimen microscopically, when oxyurides or their ova are frequently found. DISEASES OF THE INTESTINE 327 If nothing is observed from the macroscopical examina- tion of the stool, the latter should be examined for ova and Charcot-Leyden crystals, according to the methods outlined in the General Section on the Examination of the Faeces. The microscopical examination is of especial value to ascertain, in cases of tapeworm, whether the head has been found or not, as it is only by this means that the physician may anticipate a recurrence. It should be mentioned that occasionally, for some unknown reason, the ova are not detected, even when the tapeworm is present. If the examiner does not have access to a microscope, and desires to assure himself whether or not a worm is present, he should administer castor oil or worm-lozenges before insti- tuting the actual cure. TREATMENT 1.' The Smaller Worms, such as Ascarides, Oxyurides, etc. — The most certain vermifuge is santonin, which should be given alone in troches, or in powder form combined with calomel, as in the following prescriptions: 1. I^ Santonini, Calomel, iia, gr. ^-iss, 0.03-0.1 Saccharianin, q.s. M. ft. pulv. Dos. vi. Sig. — A powder night and morning. 2. I^ Olei chenopodii, Mucilaginis acacise, aa, gtt. xc Aquae destillatae, Syxupi aurantii corticis, aa, gtt. xc M. ft. emulsio. Sig. — One-half teaspoonful t.i.d. 3. I^ Olei chenopodii, Bi 30.0 Sig. — Eight to fifteen drops t.i.d., after a laxative. This treatment should be i;epeated every three to six months in children, until the worms are expelled; and it is more effective if irrigations are given every evening while the remedy is being taken, so that the benumbed parasites of the 328 DISEASES OF THE DIGESTIVE CANAL colon may be washed out before they again become active. The most suitable preparation to be used in this way is an infusion of three or four garlic leaves in a cu}) of water. ' In cases of oxyuris, it is useful to anoint the anus every evening with gray salve, which will kill the worms that escape from the rectum during the night. The tincture of absinthe is also effective when taken in doses of ^ to 1 teaspoonful three times daily. 2. Tapeworms. — It is often verj^ difficult to bring about the expulsion of tapeworms, especially in patients who vomit the administered vermifuge. As a general rule, I conduct the treatment as follows: At 8:00 o'clock in the morning, the patient is given a dry roll; at 12:00 o'clock a plate of soup and a small amount of vegetables, but no meat; at 4:00 o'clock, a cup of coffee; at 7:00 o'clock, some herring, or an Italian or herring salad; at 10:00 o'clock in the evening, he should take two table- spoonfuls of castor oil, which will usually oblige him to go to the toilet during the night. The next morning about 6:00 o'clock, he should take four or five capsules, each containing 1.0 [gr. xv] of the fresh oleoresin of aspidium. At 6:30 o'clock, a.m., the patient should again be given four or five capsules; and at 8:30 a.m., two tablespoonfuls of castor oil, a glass of mineral water, or a tablespoonful of an infusion of senna every half-hour. The movements of the bowels resulting from the above treatment should be deposited in a closed vessel and thoroughly examined for the head of the tapeworm. If the physician does not wish to conduct the examination personally, he may instruct the patient that the head is a nodular thickening on the tapering end of the worm and that it shows four dark points. If only segments of the worm are passed, or if only one end of the worm protrudes from the anus after the second dose of castor oil, a thorough irrigation with two or three litres of lukewarm water should be given, when usually the head of the worm, which has been lying benumbed in the intestine, will be obtained. During the treatment, the patient should remain in bed. If the results are negative after one or two ''cures" have been given, the patient should place himself under the imme- DISEASES OF THE INTESTINE 329 diate observation of the physician, who should supervise the irrigation and procedures of treatment at the correct time. The expulsion of a tapeworm is especially difficult in children. The extract of male fern should not be administered simultaneously with oil, as the latter renders the constituents of this poison soluble, which if absorbed might cause hepatitis and intoxication. In addition to the above-mentioned extract of male fern, the administration of which should always be tried first, the following vermifuges may be used: 1. I^ Extract! filicis maris sether., gtt. xlviii to Ix .3.0-4.0 Chloroformi, gtt. vi Olei ricini, Mucilaginis acaciae, aa, oi 30.0 Aquse destillatse, q. s. ad oviss 200.0 M. ft. emulsio. Sig. — Introduced through a stomach-tube early in the morning. 2. I^ Granati corticis, oi-oiss 30.0-50.0 Mac. per hor. xii cum 200-300 aq. dest. deinde coque ad remanentiam 150.0 Sig. — Drink the above or, preferably, introduce it through a stomach-tube, early in the morning. Contraindications. — The contraindications against the use of the tapeworm remedies are gastro-enteritis, or a con- dition of emaciation and weakness, because the tapeworm treatment is extremely exhausting to the patient, and not only aggravates the existing catarrh but also is frequently the cause of a gastro-enteritis, which might become permanent. Since the life of the tapeworm is about six or seven years, it is always better to await the death of the parasite than to weaken an already enfeebled patient by a radical cure. I have several times observed the final disap- pearance of a worm in cases where two or three inefficient treatments had been given and the trouble had always recurred. There should be an interval of three or four months between two treatments for tapeworm, to allow the mucous membrane of the intestine to return to its normal condition, — otherwise the tapeworm would be the lesser evil. 330 DISEASES OF THE DIGESTIVE CANAL Complications. — Complications in the treatment of tape- worm are intoxications. Death has resulted from the use of male fern, but usually only after excessive doses of 15 to 20 grams or more. Symptoms of intoxication are a severe, painful, and even bloody diarrhcra; enlargement of the liver, jaundice, fever, coma, albuminuria, amaurosis, and collapse. The treatment consists in the administration of stim- ulants. If the patient survives immediate danger, the condition should be treated as any other toxic gastro-enteritis or hepatitis. Poisoning from santonin causes vertigo, cramps, yellow vision, etc. REMARKS Concerning the other parasites of the intestinal canal, we cannot go into detail. A discussion of the various infusoria is of no practical impor- tance, for the reason that a patient thus infected ahvays suiters from intes- tinal inflammation or ulceration, which should be treated as such. Ankylostomiasis should also be treated with male fern, while tricho- cephaliasis, in which the eggs are frequently found in the stools, should be treated with santonin. The remaining parasites are curiosities in Germany. DISEASES OF THE RECTUM Although exactly the same diseases affect the rectum as the other portions of the intestinal tract, I will, for practical purposes, devote a special chapter to their consideration. Here again we have primary, organic diseases, — such as catarrh, inflammations, ulcerations, and new growths, — and secondary organic conditions, — such as stenoses, dilatation, fistula?, abscesses, prolapsus of the rectum; and finally func- tional-nervous diseases of the rectum, — such as relaxations, spasms, crises, etc. I have considered only the individual affections that are of interest to the internist. Many of the diseases of the rectum must be left to the treatment of the surgeon. One of the most important things to emphasize in this place is, that the physician should never permit himself to neglect making a digital examination of the rectum. For an accurate examination, a rectoscope, — preferably that of Strauss, — is essential. DISEASES OF THE INTESTINE 331 1. Catarrh and Inflammation of the Rectum Inflammation of the rectum is found in widely varying intensit}'', from the simple hypersecretion of mucus to the formation of erosions. Very mild cases may run a clinical course without symptoms; while severe cases present very striking objective and subjective symptoms, which may even progress to ulceration. Etiology. — Acute proctitis is usually caused by gonor- rhoeal infection from using rectal tubes, etc.; or it may simply be a local symptom of severe gastro-enteritis. The causes of chronic proctitis are: Fecal accumulations in chronic constipation, especially when the patient has hem- orrhoids; too frequent enemata of various solutions; and the presence of parasites, especially oxyurides. Intense catarrh, i.e., that which is associated with frequent tenesmus and the passage of mucopurulent faeces, with or with- out blood, is the symptom of a general catarrh of the intestine. The condition is likewise a symptom of other severe affections of the intestine, — such as ulcer, carcinoma, and stenosis. Symptomatology. — In acute proctitis, besides diarrhoea the patient has tenesmus, with passages of purulent, bloody mucus. The mucosa of the rectum is reddened and swollen. In mild cases of chronic catarrh, the scybala that are passed are covered with opaque or yellowish-brown clumps of mucus in which many epithelia are found, but few leucocytes. In severe cases of chronic proctitis, the patient is obliged to go to stool from six to ten times in twenty-four hours, usually, however, without results, except the passage of one or two tablespoonfuls of a turbid fluid in which large clumps of white corpuscles and isolated red cells are found. The mucous membrane of the rectum, which is normally ■quite smooth and of a rosy color, presents itself in the recto- scope as puffed, wrinkled and cyanotic, often covered with small erosions which bleed easily if stroked lightly with the apphcator. Chronic eczema of the anal margin is frequently observed in proctitis. 332 DISEASES OF THE DIGESTIVE CANAL Diagnosis. — The diagnosis of catarrh of the rectum is made from the tenesmus, from the frequent escape of muco- purulent secretion, and from the examination of the rectum with a tubular rectoscope, such as that of Strauss or Herzstein. Differential Diagnosis. — The physician should always think of the insidious dovelopment of a new growth when the patient suffers from chronic or subacute proctitis. A recto- scopic and digital examination must be made to eliminate such conditions from the diagnosis. Treatment. — Acute proctitis responds readily to rest in bed, a non-irritating diet, prolonged warm sitz-baths, hot compresses, and antispasmodic remedies. Sitz-baths should be taken for a half-hour three times daily, of a temperature of 30° R. [100° F.]. If tenesmus is severe, the following suppositories will be found helpful: 1. I^ Extract! opii, gr. i. 0.01 Extracti belladonnse foliorum, gr. | 0.05 Olei theobromatis, gr. xxx 2.0 Ft. suppos. i. Sig. — To be introduced t.i.d. The application of leeches to the anal region also affords the patient considerable relief. Rosenheim recommends irriga- tion with a mucilaginous solution or with a linseed decoction to which 10 drops of the tincture of opium have been added. The following should be given in gonorrhoeal proctitis: Zinc sulphate, gr. iii-v to oviss, 0.2-0.5 to 200; Silver nitrate, gr. iss-ivss to oviss, 0.1-0.3 to 200; or alum or tanin solution, 0.5 to 2.0 per cent. For certain cases, where all the above treatment has proved ineffective, Rosenberg has recently employed the following powder, sprayed through the rectoscope: Tannic acid, oiv 15.0 Magnesia usta, oiiiss 100.0 (or bismuth subnitrate or xeroform.) In erosions or ulcers of the rectum or of the sigmoid flex- ure, after the diseased areas have been cleansed with hydrogen peroxide solution, they should be cauterized with | to 1 per DISEASES OF THE INTESTINE 333 cent, solution of silver nitrate, after which they should be touched lightly with a solution of sodium chloride. Slight cases of chronic proctitis do not require any special treatment; they disappear when the etiological factor, such as habitual constipation or intesti- nal parasites, has been eliminated. Severe cases of chronic proctitis require local treatment. It is best to try, at first, irrigations with chamomile tea or normal saline solution, morning and evening. If these produce no suc- cessful results, irrigations should be made v/ith at least 200 to 250 cc. of the following solutions : Tannin, 5 to 1000; silver nitrate, 1 to 1000; bismuth emulsion, 8 to 250. In very stubborn and persistent cases, silver nitrate 1.0-5.0 [gr. xv- Ixxv] to 100 should be locally applied. A well-oiled Nelaton catheter and the ordinary rubber syringe should be used for irrigations and to be most effective, the fluid should be retained in the intestine for a few moments. Irrigations should be continued once or twice daily for a few weeks. During this time, the patient should have as complete physical rest as possible, and a mild constipation-diet, to which he should occasionally add mild laxatives, — such as rhubarb or licorice powder, — if the diet is ineffectual in causing spon- taneous evacuations of the bowels. Fig. 44. — Rectal irrigator (Strauss). The irrigator is inserted and the rubber balloon is introduced past the sphincter and then inflated, which prevents the escape of the irrigation solution. 334 DISEASES OF THE DIGESTIVE CANAL In very stubborn cases, Rosenheim resorts to treatment with salves, applying zinc or bismuth ointment with the Am- erican ointment-injector, which the patient can use himself. Franzensbad, Elster, and other chalybeate watering-places are indicated. 2. Ulceration of the Rectum Ulcers of the rectum are of the most varying intensity and extent, from flat, pea-sized erosions to deep ulcerations as large as a five-cent piece. Fig. 45. ^ Etiology. — Severe irritation of the rectum may lead to erosion and ulceration, as ma}^ be seen in the previous chapter. The most frequent causes of ulceration are infections from gonorrhoea, syphilis, tuberculosis, dysentery, typhoid fever, pyaemia, etc. Gonorrhoeal infection occurs most frequently in women through taking enemata with an infected syringe. The causes of infection in tubercular and syphilitic ulcer- ation are less clear, although in tuberculosis an ulcer frequently arises from the breaking through of a peritoneal abscess. Ulcers of the rectum rarely result from intoxications. Symptomatology. — The subjective symptoms consist of tenesmus and severe pains in the rectum which radiate to the sacrum. Objective signs are muco-blood}' and purulent discharges, hemorrhages, and the macroscopic demonstration of ulcers through the rectoscope. DISEASES OF THE INTESTINE 335 Diagnosis. — Fissures, erosions, and ulcers situated in the anal margin may be easily recognized; while to discover those located higher in the intestine, a rectoscope is required. An accurate diagnosis, — especially a differentiation from severe inflammation, — is not possible without direct inspection of the mucous membrane of the rectum. Treatment. — The treatment of catarrhal ulceration, which usually consists of superficial erosions, has been given in the previous chapter. Excoriation and ulceration from gonorr.hoeal infections should be treated with warm sitz-baths, injections of alum, tannin, silver nitrate, or other astringent solutions, and cauterization with zinc chloride, 20 to 100, applied with a cotton applicator through the rectoscope. 3. Fissures and Erosions of the Anus Erosions and fissures are located in the circumference of the anus. The fissures present flat breaks in the mucous membrane, sometimes about the size of a bean, with swollen edges and purulent bases. Etiology. — These lesions most frequently arise from one of the following causes : Inflammation of hemorrhoidal tumors; rupture of the mucous membrane caused by straining at stool, or the passage of extremely large-sized stools; or the above-described gon- orrhoeal proctitis. Symptomatology. — Erosions usually cause nothing more than itching and burning around the rectum; while the fis- sures, in spite of their small size, very frequently produce extreme pain around the anus and its region, this pain often radiating to different parts of the pelvis. Usually after def- ecation, spasm of the sphincter ani occurs, which ma}^ persist for hours; so that patients, from fear of this suffering, delay going to stool as long as possible. Small amounts of blood and pus frequently appear in the stool. Diagnosis. — The symptoms are so characteristic, — espe- cially the spasmodic contraction after defecation, — that they 336 DISEASES OF THE DIGESTIVE CANAL immediately suggest the necessity of examining the rectum. A fissure is often very difficult to see, because it is painful for the patient to press down sufficiently to expose the fissured surface. But by carefully drawing out the anal folds, when the patient is in the knee-elbow position, the fissures may usually be brought to view. They often lie deeply within the folds of the mucous membrane. Treatment. — The stools should be kept soft by the use of a suitable diet, laxatives, and irrigations of oil. Before defecation, the rectum should be lubricated with oil as thor- oughly as possible with the finger. It is best at first to tr}^ two medicaments, — silver nitrate and pure ichthyol. After cocainizing or anaesthetizing the patient, the fissure should be thoroughly cauterized with caustic potash, after which the patient should stay in a recum- bent position for two or three days, during which time con- stipation should be induced by the administration of opium. Ichthyol should be applied twice daily to the fissure, using a match or an applicator wrapped with cotton. A great many of the milder cases may be cured in a few weeks by the use of ichthyol alone. Boas treats stubborn cases as follows: After a thorough evacuation of the bowels by the use of castor oil, the patient should he in bed for eight days and be given 10 to 15 drops of the tincture of opium three times daily. The diet should be light, such as will furnish as httle intestinal debris as possible. After the eight days, the patient should be given a large dose of castor oil. Rosenbach recommends that the patient himself dilate the rectum with the little finger, when in the squatting position. This treatment should last about one-quarter of an hour, and should be performed night and morning. Chronic cases that re- fuse operation should especially make use of this dilatation- treatment, because the spasmodic contraction of the sphincter is thereby relieved. Finally the dilatation and incision of the sphincter comes into question. Under narcotics, the rectum should be thor- DISEASES OF THE INTESTINE 337 oughly stretched by means of the two thumbs introduced into the rectum. Incision should then be made, after which the fissure will generally be completely healed in from one to two weeks. Erosions and anal eczema are best treated with dusting powders, such as orthoform, xeroform, or with an ointment composed as follows: Orthoform, Xeroform, aa, gr. xv 1.0 Zinc oxide, 5 iiss 10.0 Vaselinol, 5 iiss 10.0 (or Thigenol, gr. xlv 3.0) Lanolin, oiv 15.0 After cleansing the affected areas at night, a bit of oint- ment the size of a bean should be thoroughly rubbed in. 4. Neoplasms of the Rectum Of the benign tumors of the rectum, the polyps have especial clinical significance, from the fact that they may lead to profuse hemorrhage. Rectal polyps are most frequently found in women after gonorrhoeal infection. Very frequently the bleeding which results from these polyps is for a long time considered to be of hemorrhoidal origin, until digital examination renders the diagnosis clear. The treatment is surgical. The other benign tumors, — such as cysts, fibromata, etc., — rarely occur; the only ones deserving especial con- sideration being the angiomata, i.e., hemorrhoids. Hemorrhoids Hemorrhoids are caused by the dilatation or the new formation of blood-vessels, brought about by sedentary habits, obstruction of the portal circulation, or chronic con- stipation (see Etiology of Chronic Constipation). Symptoms. — Slight cases very frequently run a clinical course accompanied by no pain, and perhaps by only a little itching; the patient notices only that sometimes the toilet- paper is colored bright red with blood. 22 338 DISEASES OF THE DIGESTIVE CANAL The symptoms of the disease begin acutely when the hemorrhoidal nodules become inflamed, before which time the patients rarely consult a physician. The pain is of a burning, boring, pricking, and occasionally cramp-like character, — especially after stools, — and is usually increased by the sitting posture. The anal mucous membrane is swollen and of a bluish-red color. By pressing clown, tense nodules ranging in size from that of a bean to that of a hazel-nut are caused to protrude from the anal margin; while the finger will usually palpate similar hemorrhoids situated within the bowel. Profuse hemorrhage often occurs. If there are breaks in the continuity of the mucous mem- brane, spasm of the rectum is a prominent symptom. Diagnosis. — In the diagnosis three tasks should be fulfilled : 1. To demonstrate the source of the bleeding; whether it is actually caused by hemorrhoids or by a polyp, carcinoma, or ulceration. 2. Whether isolated hemorrhoids exist; or whether the entire mucosa, both internal and external, is diseased. 3. Whether the hemorrhoids are inflamed or not. It is scarcely possible for confusion to occur in the diag- nosis if accurate inspection and careful digital examination of the rectum are made. Therapy. — There are three indications for treatment: 1. To reduce the inflammation of the hemorrhoids. 2. To bring about a contraction of the hemorrhoids. 3. To prevent their recurrence. I generally institute the following measures, and have thus obtained permanently good results in a large number of cases: 1. For three to six days, I have the patient apply cold compresses to the rectum when in the dorsal position with hips elevated. In mild cases, this should be done three times daily for one-half hour, — early in the morning, at mid-day, DISEASES OF THE INTESTINE 339 and in the evening; while in severe cases, the compresses should be worn the entire day. Lead and opium water, or aluminum acetate, one tablespoonful to a cup of water, may be added to these compresses. During the treatment, the patient should expose the hemorrhoids as much as possible by downward pressure. During this period the bowels should be regulated by low enemata. After three or four days of this treatment, the hemorrhoids are no longer swollen and painful. To control the bleeding from external hemorrhoids, tannin 1 to 2 per cent, and alum 1 to 3 per cent., should be applied; while for internal hemorrhoids, the same preparation should be injected with a rectal syringe. Prolapsed hemorrhoids should, according to Rosenheim, be touched with the following: I^. Potassii iodidi, gr. xxx 2.0 lodi, gr. iii 0.2 Glycerini, oxii 40.0 Erosions should be painted with zinc amylum paste. 2. To reduce the size of the hemorrhoids, I have found extract of hamamelis the most suitable. I usually prescribe twelve suppositories, each containing the following: Extr. of hamamelis virg., gr. ivss 0.3 Orthoform (if painful), gr. ivss 0.3 Cocoa butter, gr. xxx 2.0 M. Sig. — Suppository, introduced night and morning. For three or four weeks, I prescribe ^ teaspoonful of the fluiclextract of hamamelis, to be taken after meals. For frequently recurring or for chronic hemorrhages from internal hemorrhoids, cold irrigations with Arzberger's "re- frigerator," as employed in diseases of the prostate, are very useful. The diet throughout the treatment should be the coarse constipation-diet if atonic constipation is present; or the mild constipation-diet, if there is spastic constipation. If rectal spasms are troublesome, oil enemata should be given every other night. 340 DISEASES OF THE DIGESTIVE CANAL . 3. To prevent recurrence, the patient should take a cold sitz-bath every day, lasting ten minutes, and use the Hautel pessary with a central perforation for the escape of gases. The hamamelis suppository treatment should be repeated every three months, with the diet adapted to the nature of the constipation; when it is atonic, I occasionally prescribe compound licorice powder, rhubarb tablets, laxative mineral water, or Glauber's salt; when the constipation is of the spastic variety, — oil enemata, and the mineral-water treat- ment at Kissingen, Marienbad, Carlsbad, Franzensbad, Elster, Tarasp, Homburg, etc., or the grape-cures afforded at the health-resorts along the Rhine near Lake Geneva, — at Vevey, Montreux, Territet, etc. The injection of carbolic acid in the treatment of hem- orrhoids should be discarded, because of the clanger of embolism. Boas has recently recommended the use of a 10 per cent, solution of calcium chloride, 10 c.c. of which he injects once or twice daily. For the relief of painful, itching and bleeding hemorrhoids the following prescriptions are recommended: 1. I^ Chrysarobini, gr. IJ 0.08 lodoformi, gr. J 0.02 Extract! belladonnse foliorum, gr. J 0.01 Olei theobromatis, gr. xxx 2.0 M. ft. suppos. i, No. XV. Sig. — Use one or two suppositories daily. 2. ^ Clirysarobini, gr. iss 0.1 Acidi tannici, gr. iss 0.1 lodoformi, gr. iii 0.2 Extracti belladonnse foliorum, gr. J 0.02 Olei theobromatis, gr. xxx 2.0 M. ft. suppos. i, No. xii. Sig. — Use two or three daily. 3. 1^ Chrysarobini, gr. xii 0.8 lodoformi, gr. ivss 0.3 Extracti belladonnse foliorum, gr. viiiss 0.6 Vaselini, oiv 15.0 M. ft. unguentum. Sig. — Apply several times daily. DISEASES OF THE INTESTINE 341 A large number of old, persistent cases have improved by this treatment in my clinic to such a degree that all the synij)- toms disappeared. Plowever, there are always cases that can be cured only by operation, — especially internal hemorrhoids. Prognosis. — The prognosis of hemorrhoidal affections is good. The sufTerer generally becomes weakened only by loss of blood or by severe continuous pain. Otherwise, the general condition of the patient rarely suffers, although in some cases the hemorrhoids become so severe and the constitutional re- action is so marked that the patient has a cachectic appearance. Complications. — The most important comphcations are inflammation, fissures, erosions, rectal fistulse, or abscess, occasionally thrombosis and embolism, and finally prolapsus of the mucous membrane of the rectum, with hemorrhoidal tumors. Sometimes hemorrhoids are the result of constipation, and sometimes its cause. When the disease has existed for years, the patient frequently becomes hypochondriacal and neurasthenical. CLINICAL CASE Case 1. — Mrs. S., a widow 36 years old, had suffered from constipation for ten years. Purgatives and enemata had been effective only when taken in large amounts. For about nine months, the patient had had severe rectal pains and hemorrhages. Every four or five weeks, she lost three or four teaspoonfuls of blood daily. Examination showed the presence of external and internal inflamed hemorrhoids. Treatment. — The patient was given rest in bed for one week, with the application of lead and opium water compresses; every second day oil was introduced through a Nelaton catheter; hamamelis suppositories were used during the second week of treatment; the third and fourth weeks, a teaspoon- ful of the fluidextract of hamamelis was given three times daily. A mild constipation-diet and oil enemata were continued for three months, after which the patient was completely cured. Malignant Neoplasms of the Rectum From the practical standpoint, only carcinomata of the rectum need be considered, for the reason that other neoplasms of a mahgnant nature are very exceptional. 342 DISEASES OF THE DIGESTIVE CANAL Cancer of the rectum most commonly attacks persons whose previous tligestion.has been almost faultless. The dis- ease begins insicliousl}', the patient generally coming to the physician too late for operation, The general health of the patient may be undisturbed, the appetite remaining excellent. Symptomatology. — The subjective symptoms are ag- gravated tenesmus, drawing, boring pains in the rectum and left side of the abdomen, and painful distention. When going to stool, instead of fecal matter, only mucus, — or sometimes blood, — will appear after hard straining; the patient fre(|uently believing he has hemorrhoids. Objectively, a malignant neoplasm is revealed by digital examination and the use of the rectoscope. It is generally crater-shaped in advanced cases, and of the form of a ring. It may involve any part of the rectal mucosa.. The cancerous growth is usually found to be more extensive than appears on palpation. The diagnosis is very difficult when the new growth is located high up in the bowels between the rectum and the sigmoid flexure. The most important part of the physical examination, even in slightly suspicious cases, is to make a digital explor- ation of the rectum, with the patient in the knee-elbow position; and when necessary to resort to the rectoscope. If the attend- ing physician is in doubt as to the nature of a lesion, he should always consult with a specialist in rectal diseases as early as possible. It is very suggestive of cancer of the rectum to find a bloody, purulent mucus-discharge of a dirty brown color and of the consistency of cream. Cachexia does not occur until the last stages of the disease. Sometimes colonic "stiffenings" are observed in the region of the sigmoid flexure, as in obstruction of the bowels from any other cause. Diagnosis. — The diagnosis of cancer of the rectum can be made only by the actual inspection and palpation of the mahgnant ncoplasni, because the other symptoms are found in a number of other affections of the rectum. DISEASES OF THE INTESTINE 343 Prognosis. — The prognosis is, quod vitam, naturally absolutely bad; but in regard to prolonging life, it is not so unfavorable as one might assume, even when operative treat- ment is refused. I have seen quite a number of patients that were able to attend to their business and felt relatively well, had a good appetite, and only occasionally needed to resort to the use of a purgative, for a period of one to one and one- half years after a positive diagnosis of cancer of the rectum had been made. Treatment. — A carcinoma of the anterior wall of the rectum, which is in close intimacy with the prostate gland and the bladder, should not, as a rule, be operated, especially if the malignant neoplasm is adherent and is already as large as a dollar. It is more conservative to produce an artificial anus at a later period in the disease, — which is more favorable for both the comfort and the life of the patient than a premature radical operation, the outcome of which is always uncertain. Small carcinomata of the entire rectum and cancers of larger size, when not adherent and located on the lateral or posterior wall of the rectum, should be immediately referred to a surgeon for operation. In addition, it should be said that in every case the physi- cian should, early in the disease, consult a surgeon to decide whether or not an operation is indicated. Extensive carcinomata situated in the anterior wall of the rectum should be treated symptomatically, with the possible creation of an artificial anus, if indicated, later in the disease. The internal treatment is the same as for Stenosis of the Intestine, to which chapter the reader is referred. I generally prescribe a diet as non-irritating as possible, and rich in fruit and fats. Vegetables should be used only in purees. There should be plenty of fruit, besides butter, cream, tender meats, eggs, white wine, and lemonade. Lax- atives should be given every second evening, — either castor oil or salts with rhubarb; besides oil enemata, each containing ^ litre, twice a week. 344 DISEASES OF THE DIGESTIVE CANAL If the affection is painful and tenesmus marked, one to three suppositories, — each containing 0.04 to O.OO [| to 1 gr.] of the extract of belladonna, — should be given one to three times daily. Complications. — The most important complication of carcinoma of the rectum is the formation of the rectovaginal and rectovesicular fistuhr, the treatment of which is surgical. 5. Benign Stenoses of the Rectum A constriction of the lumen of the rectum occasionally results from external compression, as by retroflexion of the uterus, pelvic tumors, or from the accumulation of an exudate. The most common stenoses of the rectum result from cicatricial formation following ulceration, — especially of a venereal nature. S3'philitic strictures of the rectum are most frequent in women, and are a very severe affection. They develop insid- iously and may lead to total atresia of the rectum, by the formation of a diaphragm-like, radiating scar just above the anal opening. Symptomatology. — The symptoms of benign stenosis of the rectum consist of pressure, tenesmus, mucous diarrhoea, hemorrhage, and borborygmus. Objectively, the stenosis itself may easily be palpated. The scar-formation is usually ring-shaped, resembling a funnel whose end presents a round opening, the lumen of which varies in thickness from the diameter of a knitting-needle to that of the finger. The mucosa above the strictured area is reddened and inflamed. The stool is, of course, delayed in expulsion; and in advanced cases, the stricture may develop into complete ileus. Diagnosis. — The diagnosis is easily made by palpation. Treatment. — When a benign stenosis is of recent forma- tion, and the little finger can still be introduced, the stricture should be dilated with the well-known Enghsh bougie, which has a receding conical end. The dilatation should be made every day for several weeks. There is always a tendency toward relapse when the dilatations are discontinued. DISEASES OF THE INTESTINE f345 As an additional treatment, a tablespoonful of a 6:200 solution of iodide of potassium should be given three times daily, if the scars are recent and still have some elasticity. Injections of a ten per cent, solution of thiosinamin (see page 289) into the tissues around the anus may be tried if other therapy seems hopeless. For the relief of pain, suppositories of cocaine and bella- donna should be given; and as laxatives, castor oil or saline mineral-waters should be used in connection with oil enemata two or three times a week. Mild cases respond quite favorably to this treatment; but in severe cases, the patient has no choice but to submit to either the extirpation of the stenotic area, or the creation of an artificial anus. 6. Other Organic Diseases of the Rectum In addition to those already discussed, there are many diseases of the rectum, — such as abscess-formation, fistulse, prolapsus, and congenital malformation, — -the treatment of which belongs so naturally to the domain of the surgeon that their discussion may reasonably be omitted in a work on internal medicine. 7. Nervous Diseases of the Rectum The rectal symptoms that sometimes occur in the course of locomotor ataxia need be only briefly mentioned, — the most important being incontinence of the rectum and the so- called rectal crisis, which is characterized by periodically occurring tenesmus, unassociated with anatomical lesions of the rectum. Rectal incontinence should be treated with cold sitz- baths and endofaradization. As accompanying phenomena in diseases of the entire intestinal canal, relaxation and spasmodic contraction of the rectum occur, which may lead to functional dilatation or stenosis. The reflex irritability of the rectum in hysterical patients is sometimes so pronounced that the anal sphincter strongly 346 DISEASES OF THE DIGESTIVE CANAL contracts upon the palpating finger. Such cases should be treated with irrigations of warm oil or chamomile tea, and with belladonna suppositories. Relaxation of the rectal sphincter should be treated with prolonged cold enemata, of 100 to 150 c.c. of water, cold sitz-baths, carbonic-acid full- baths, rectal douches, etc. Sensory neuroses of the rectum are so very rare that their discussion may be omitted. APPENDIX TABLE TO ASSIST IN THE DIAGNOSIS WITHOUT THE USE OF THE TEST-BREAKFAST. General Findings. Pain. Pressure. Vomiting. Stool. Habitus. Gastritis In the beginning, good, especially in acid gastritis; later, debility with variable ap- petite. Only in gas- tritis asso- ciated with stenosis of the pylorus. Aftersolids Unusual, except after errors in diet. Irregular, with frequent diarrhosa. Normal. Ulcer Appetite very good, except during the period of pain. Gen- eral state of health may be good. Violent yk to 41ioursafter eating. None. After im- proper diet. Sluggish. Normal. Dilatation Appetite good, except in dilata- tion due to cancer. General health good except ditring acute attaclis. Of gnawing character, which is relieved by vomiting. Constant. Copious, 5 to 6 hours after eat- ing. Sluggish. Normal. Carcinoma, without ste- nosis. Poor, aversion toward meats. None. Aftersolids None. Sluggish. Normal. Atony Poor. None. After all kinds of food. None. Sluggish. Enterop- totic. Nervous stom- ach affections Poor or variable. None. Most of the time. Often im- mediately after eat- ing. Sluggish. Enterop- totic. Enteritis Poor. None. Constant in the entire abdomen. None. Soft, spongy consist- ency. Either nor- mal or enterop- totic. Poor. Colicky. Tension across the abdomen. Unusual. Pulpy, thin or mucous. Either nor- mal or enterop- totic. Atonic consti- pation. Fairly good. None. None. None. Hard and large, resembling sausage. Usually en- teroptotic. Spastic consti- pation. Poor. Colicky. Distention and pres- sure. Unusual. Surrounded by mucus. Usually en- teroptotic. 347 348 APPENDIX Outline of Dietetic Treatment of Diseases of the Stomach and Intestine and of Metabolism Although the dietary has ah'eady been considered in the individual chapters, the subject will once more be briefly outlined. In general, the following ten Diet-Forms are sufficient for the treatment of the diseases of the digestive tract. If there is a complication, rather than a single affection, the physician should combine the diets; as an example, he will sometimes find it necessary to combine a constipation-diet with one suitable for gastritis, or a forced-feeding diet with one suitable for constipation, etc. Ever}' patient should be given a diet-list showing the exact time, quality and quantity of his meals; the time for baths, walking, gymnastic exercises, massage and enemata; the hour of rising in the morning and of going to bed at night, the periods of rest during the day, and the hours for taking medicine or mineral-waters. The arrangement of the list should always be compatible with the occupation of the patient and the time he has at his disposal; working people must naturall}' have their meals at certain hours, while those who have no occupation can be at home any time. The choice of foods also depends a great deal upon the financial circumstances of the patient. The physician must never, therefore, prescribe foods which the patient is unable to buy, — otherwise his directions will not be followed. I. Stenosis=Diet Indications. — In benign and malignant stenoses of the cardia, pylorus and duodenum. [CEsophagus.] Principle. — The diet must be of fluid consistency and rich in fats and albumins. In stenosis of medium degree, the diet may be semi-sohd. In benign stenosis of the pylorus, 12: :00 Noon 3: 00 P.M. 5: 30 P.M. 8: 00 P.M. DIETETIC TREATMENT 349 where hyperpepsia exists, tender meats may be allowed, — which are contraindicated in malignant stenosis associated with achylia: 7:00 A.M. A wineglassful or 1 to 2 tablespoonfuls of olive or almond oil. (If there is a repugnance toward these, the patient may be given milk of almonds or butter.) When stag- nation is present, these should be taken immediately after lavage. 8:00 A.M. One cup, or 200 to 250 c.c, of coffee, tea or cocoa with milk or cream. 10:00 A.M. Bouillon with 1 or 2 yolks of eggs, or a cereal soup rich in butter. Broth thickened with a finely-ground cereal, butter and the yolks of eggs. Same as 8: 00 a.m. Same as 10: 00 a.m. Same as 12:00 Noon, with perhaps the addition of sana- togen, etc. As refreshments, — lemonade, wine with the yolks of eggs, egg-cognac, fruit-ice, especially vanilla ice, puro, meat-jellies, calves'-foot jelly, buttermilk, and raw eggs, — as desired. In stenosis of moderate degree, in addition to the above, the following are allowed: Finely-prepared purees of potato, spinach, carrots and peas, hght puddings, scraped ham, chopped chicken, anchovy, butter, etc. 2. Gastritis=Diet Indications. — Hyperacid gastritis, subacid gastritis, anacid gastritis, and carcinomata located extra-ostially. Principle. — Such a diet should be non-irritating, of semi- solid consistency, and arranged according to the state of nutrition of the patient and the degree of constipation present. Obese persons should be given but httle butter; emaciated persons, a great deal. Constipated persons should be given much fruit and vegetables; while patients with diarrhoea should, on the contrary, be given constipating articles of food. 350 APPENDIX 7:00 a.m. Mineral water: In hyperacid gastritis, Carlsbad or Vichy; and Homburg, Kissingen, or Wiesbaden waters in subacid or anacid gastritis. 7:30 to 8:00 a.m. Tea with milk or cream, white bread and butter; or if diarrhoea is present, cocoa or chocolate with bread or toast. 10:00 to 11:00 a.m. Cereal soup or broth, white bread, butter, one egg cooked two minutes, and scraped ham. 12:30 P.M. Mineral water. 1:00 P.M. Dinner: Soup. Puree of peas, carrots, spinach, asparagus or cauliflower, cooked in butter; noodles, macaroni, or rice cooked in soup. The tender white meat of chicken; pigeon, veal or fish, — such as pike or perch; sweet fruit purees, served warm; and rice or sago pudding. 4 : 00 to 5 : 00 p.m. Same as at 7 : 00 or 8 : 00 a.m. 6: 30 P.M. Mineral water. 7:00 to 8:00 p.m. Gruel or cocoa cooked in milk; white bread, butter with a white meat or two soft eggs. Strictly Forbidden Cabbage, legumes, smoked meats of all kinds, goose, duck, animal fats, salmon, acids, pastries, and cold drinks. Condiments are forbidden in hyperacidity, but indicated in conditions associated with subacidity. 3. Ulcer=Diet Indications. — Ulcers and erosions. Principle. — A non-irritating diet which will leave the stomach quickly and excite the secretions as httle as possible. There are four forms, each of which should be continued from eight to ten days: (1) fluid; (2) semi-hquid; (3) soft, orsemi-soHd; (4) non-irritating soHds. The subject is discussed in detail in the chapter on Ulcer of the Stomach. Carcinoma, dilatation, and hyperchlorhydria need no special dietary. A stenosis-diet is indicated for ostial carcinomata; a gastritis-diet, for extra-ostial carcinomata. Dilatation should always be treated at first with the stenosis-diet. DIETETIC TREATMENT 351 In hyperchlorhydria (see below), a diet suitable to the primary disease is indicated; for instance, an acid-gastritis diet, an ulcer-diet, a constipation-diet, or a forced-feeding diet. 4. Diarrhoea=Diet Indications. — Intestinal catarrh with diarrhoea, or a strong tendency toward diarrhoea. Principle. — A diet which is non-irritating, astringent, free from food-debris and easily absorbed. The diet-hst is as follows: 7: 00 A.M. Mineral water; hot, and taken in small doses of 75 to 150 c.c. The choice of the water depends upon the state of the gastric secretions. (See previous chapter.) 7:30 A.M. Eiehel cocoa (2 teaspoonfuls to a cup) in water, and toasted white bread and butter. 10: 00 A.M. A cereal soup with butter, toast with butter, eggs and scraped ham. 1: 00 P.M. Broth with grits, noodles, macaroni, and white meat; in mild cases, vegetable purees, and one glass of blueberry wine. 4:00 p.m. Same as 7: 30 a.m. 6: 00 P.M. Mineral water. 7 : 00 to 8 : 00 p.m. Tea with red wine or blueberry wine, toast, butter, and cold white meat. 9: 00 to 10: 00 p.m. A cup of hot peppermint-tea. In mild cases, when the stool is of a pulpy consistency, — • or after improvement in severe cases, — white bread, carrots, filet, and baked fish may be allowed. Strictly Forbidden Cold drinks; any kind of coarse vegetables, like cabbage or potatoes; cheese, acids, cakes, coffee, all legumes (except when served in soups); goose, duck, salmon, animal fats, gravies, and raw fruits. 5. Forced=Feeding Diet Indications. — Anaemia, general malnutrition, atony of the stomach (ansemic-gastroptotic dyspepsia), enteroptosis, and pulmonary tuberculosis. 7: 00 A.AI. 9: 30 A.M. 12: :00 Xoon 3: :00 P.M. 5: :00 P.M. 352 APPENDIX Principle. — With rest in bed, the patient shoukl be given much more nourishment than he needs for the reparation of tissue-waste, in order to increase the amount of adipose tissue. The diet, therefore, should be rich in carl)ohydrates and fats. During the first two or three weeks of the fattening-cure, the patient shouhl remain in bed and the stomach shoukl be massaged once daily after the heaviest meal. One pint of milk, bread and butter. Tea or cocoa with cream, one piece of bread and butter, and ham. If constipation exists, koumiss and Graham bread should be given instead, with butter. Vegetables cooked in butter, a small amount of meat, pudding with fruit-juice, and mineral water. Same as at 7: 00 a.m. One plate of cereal soup or broth, or cocoa with cream if the bowels are regular. 7: 00 P.M. Tea with cream or milk, white or whole-wheat bread, butter, two soft eggs or cold white meat. On this diet, even in the ambulatory treatment, the patient, as a rule, gains two or three pounds a week. A bitter for the excitation of the appetite should alwaj^s be given from 15 to 30 minutes before eating. 6. Constipation=Diet Indications. — Habitual atonic and spastic constipation, and mild enterocolitis which runs a clinical course with constipation. Contraindications. — Cardiac disease, habitus apoplecticus, abdominal plethora, diseases of the female generative organs. Priiiciple. — In the atonic variety, a diet rich in food- debris which chemically and mechanically excites intestinal peristalsis; in the spastic variety, a diet non-irritating in character, which chemically excites peristalsis. A. DIET IN ATONIC CONSTIPATION 7 : 00 A.M. One glass of cold water. 7: 30 A.M. Malt coffee or tea with milk, one teaspoonful of milk-sugar, whole-wheat bread with butter, honey or marmalade. DIETETIC TREATMENT 353 10:00 a.m. Buttermilk two days old, kefir, koumiss, or sour milk, whole-wheat bread, butter and ham. 12:00 to 1:00 p.m. Vegetables, including cabbage, small amounts of meat, an abundance of sweet fruit sauces, and one glass of cider sweetened with one tablespoon- ful of milk-sugar. 4:00 p.m. Malt coffee or tea with milk, whole-wheat bread and butter. 7:00 p.m. i litre of two days' old kefir or koumiss. Pilsner beer, bread and butter, eggs or cold sliced meat. 9: 00 to 10: 00 p.m. Fruit or honey cakes. Strictly Forbidden Rice, gruel, sago and cereal soups. B. DIET IN SPASTIC CONSTIPATION 7:00 A.M. One glass of hot peppermint and valerian tea. 7:30 A.M. Tea with cream and a tablespoonful of milk-sugar, and fine white bread with butter and raspberry jelly. 10:00 A.M. Koumiss or kefir two days old, white bread and butter, and one egg. 12:00 to 1:00 p.m. One small plate of soup, tender vegetables cooked in butter, meat, stewed fruits, and one glass of raspberry lemonade. 4: 00 P.M. Same as 7: 30 a.m. 6: 00 p.m. \ litre of kefir or koumiss. 7:00 to 8:00 p.m. Tea with cream, one tablespoonful of milk-sugar, white bread, butter, and cold meat. 9: 00 to 10: 00 p.m. Puree of fruit. Forbidden Cabbage, coarse bread, goose, duck, and all raw fruits, — except sweet apples, oranges and grapes. 7. Obesity=Diet Indication. — Obesity. Principle. — Small amounts of fats and carbohydrates, a liberal supply of proteids, and muscular exercise. Four meals daily: 23 354 APPENDIX 7:00 A.M. One gfass of foUl water, if constipation exists; gym- nastic exercises. 8:00 .\.M. Coffee with a small amount of milk, ^ pound of lean roast beef, some toast and cheese. 12:00 Xoon Green vegetables cooked w'ith salt, lean ^•eal and beef, sour salads, — such as cucumber, — red whortleberries, and one glass of cider. 4:00 P.M. One cup of coffee with milk, toasted whole-wheat bread with plum sauce or cheese. 7: 00 to 8:00 p.m. Beef-steak or other lean meat, 1 or 2 pieces of toast, or 2 tablcspoonfuls of baked potatoes, tea with lemon, or 1 glass of Pilsner beer. Forbidden Fats, rice, farinaceous food, hot breads and potatoes. 8. Diabetes=Diet The amount of carbohydrates allowed depends upon the severity of the disease. Under no circumstances should all carbohydrates be excluded, since otherwise acidosis and dia- betic coma would develop. I allow, in all cases, small amounts of toast,, baked potatoes, and green vegetables. 7:00 A.M. One teaspoonful of Vichy salts dissolved in a glass of warm water. 8:00 A.M. Tea or coffee with milk, toast with plenty of butter, and two eggs. 10: 00 A.M. Cocoa with cream, bouillon, one piece of toast, butter, ham or lean meat. 1 : 00 P.M. Consomme, green vegetables, — such as spinach, peas, carrots, asparagus, Brussels sprouts, sauerkraut, ' cabbage cooked in butter, meat of all kinds, salads and one glass of wine. 3: 00 P.M. One teaspoonful of bicarbonate of soda. 4: 00 P.M. Same as at 8: 00 a.m. 7:00 P.M. Tea, cream, butter, cold meat or filet, chicken and fish. 9: 00 to 10: 00 p.m. One teaspoonful of bicarbonate of soda. Strictly Forbidden Bread, potatoes (unless baked), rice, grits, noodles, macaroni, farinaceous foods, milk, sugar, honey, cake and legumes. DIETETIC TREATMENT 355 9. Qout=Diet Forbidden. — All raw meats and the glandular organs, such as the liver, thymus, spleen, lungs, etc., in order to avoid the formation of the purin bodies. Allowed.— Q\i\Q.kQn, squab, veal, lean fish, milk, carbo- hydrates in every form, fruit and vegetables. 10. Nutrient Enemata Indications. — Corrosive strictures, malignant atresia of the oesophagus and pylorus, severe ulcers of the stomach, hyperemesis in pregnancy, and hysterical vomiting. Method of Employment. — An enema of the following composition, recommended by Boas, should be given three times daily, preceded by a cleansing enema: 250 c.c. of milk; 1 or 2 yolks of eggs; 1 tablespoonful of white flour; 1 to 2 tablespoonfuls of red wine; 1 knifepoint of salt; 6 to 8 drops of tincture of opium. The nutrient enema is best given with a Naunyn rectal tube, connected with a glass funnel. 356 APPENDIX Outline of Balneotherapy The choice of a suitable health-resort is one of the most difficult tasks of the physician. If patients woultl take the time and money for a trip to a suitable place of this kind, they would at least obtain some beneficial results. If, for any reason, an aggravation of the symptoms of the disease should occur, the attending physician is usually held responsible. In the choice of a resort there are so many factors involved, — such as expense, distance, attractions, the divergent interests of the different members of the family, etc., — that advice is sometimes very difficult. For example, if the hus- band has acid gastritis and the wife neurasthenia, there is nothing to do but send them both to some quiet summer resort, where the husband may have access to a suitable mineral water. In the following, we can touch only upon the principles that will assist the physician in selecting a resort most likely to prove satisfactory to the patient. The details and routine of the treatment should always be left to the resident physician. A. ORGANIC DISEASES OF THE STOMACH AND INTESTINE 1. Carlsbad, Neuenahr, Vichy, Bertrich, Franzensbad, Marienhad, Elster or Tarasp [Buffalo Lithia Springs, West Virginia, Crab Orchard, Kentucky], the waters of which contain principally sodium bicarbonate and sodium sulphate. Indications. — Acid gastritis, ulcer of the stomach, all forms of hyperchlorhydria, gastrosuccorrhoea, perigastritis, cholelithiasis, cholecystitis, enlargement of the liver, catarrhal icterus, diabetes, and enterocolitis when the gastric juice has a normal acidity or hyperacidity. Contraindications. — Ectasia, carcinoma, subacid and anacid gastritis. Special Indications. — Obese or vigorous persons should always be sent to Marienbad, Tarasp or Carlsbad; emaciated patients to Vichy; and those who are at the same time BALNEOTHERAPY 357 nervous, — particularly women, — to Bertrich or Franzensbad; while Neucnahr is the most suitable for diabetics. 2. Kissingen (Rakoczy, Spring), Homhurg {Elizabeth Spring), Wiesbaden (Kochbrunner) , Ems, Pyrmoni, and Baden- Baden [Cha7npion, Congress, and Hawthorn Springs, Saratoga, New York, and Blue Lick Springs, Kentucky], the waters of which contain sodium chloride as their principal mineral ingredient. Indications. — Subacid or anacid gastritis, catarrh of the small and large intestines when the gastric juice has a sub- acidity or anacidity, chronic constipation (on account of the carbon dioxide baths), and hemorrhoids. Special Indications. — Kissingen is recommended for patients with hemorrhoids and constipation; Homburg is more suitable for those with gastritis; Wiesbaden for cases of enteritis with a tendency toward diarrhoea; while Pyrmont is best adapted for very anaemic and nervous patients. Contraindications. — Hyperchlorhydria, ulceration, car- cinoma, ectasia, neurasthenia and hysteria. 3. Marienbad, the waters of which contain sulphate of magnesium and sulphate of sodium. Indications.— Ohesiij associated with constipation. 4. Franzensbad, Pistyan, Nenndorf, Polzin, or Muskau, for mud-baths used in conjunction with the local application of hot mud-poultices. Indications. — Chronic appendicitis, perigastritis, and circumscribed peritonitis. If the drinking of some other spring water is indicated during a residence at one of these resorts, a bottled water, such as Carlsbad, may be prescribed. 5. Flinsberg, Pyrmont, Franzensbad {Eger Salts Spring) [or Sharon Chalybeate Springs, New York, Schuyler Chalybeate Springs, Illinois, New Almada Vichy, California], the waters of which are rich in iron. Indications. — The after-treatment in diseases of the gastro- intestinal tract, associated with chlorosis and other anaemic conditions. 358 APPENDIX B. FUNCTIONAL DISEASES OF THE STOMACH AND INTESTINE General Indications Patients with enervated and relaxed nervous sj'stems should be sent to the seashore or to the high mountains. Well-nourished individuals should be sent to the North Sea, and ana?mic women and children to the Baltic, — especially to those resorts surrounded by forests. Patients with marked irritability of the nervous system should be sent to mountain ranges of only moderately high altitude. 1. Westerland, Norderney, Borkum, Eiigadin, Berner Oherland. Indications. — For individuals who have become enervated and over-worked, such as bankers, physicians, lawyers, etc. 2. Kolherg, Swinemiinde, Rilgen, Zoypot, Warnemilnde, Haupten, etc. Indications. — For anaemic, emaciated patients, — especi- ally women and children. Patients with increased reflex irritability of the nervous system should be sent to some quiet resort in a forest, with an elevation of from 1000 to 1500 feet. Schreiberhau and other resorts situated at the foot of the Riesen Mountains fulfil these conditions, as do also Oberbayern, Thiiringen, Harz, and the resorts in the middle of the Black Forest; as well as Genfersee, where the grape-cure is given, and Abbazia. For many diseases of the stomach and intestine, a vaca- tion in the country or in the forest, combined with a simple outdoor life, is all that is required. INDICATIONS FOR TREATMENT 359 Indications for Hydrotherapeutic, Mechanical and Electrical Treatments Hydrotherapy Cold Procedures. — Sea bathing, fresh-water bathing, cold wet packs, friction, half-baths, the Scotch douche, and carbon dioxide baths. Indications. — Enteroptosis, nervous dyspepsia, and general neurasthenia, with a relaxed condition of the nervous system. Warm Procedures. — Lukewarm tub-baths, pine-needle extract baths and saline baths. Indications. — Hysterical dyspepsia and a general weakness of the nervous system. Hot mud-baths, hot mud-poultices, hot gruel or flaxseed poultices, thermal coils, etc. Indications. — Chronic inflammatory conditions of the large and small intestines, appendicitis, cholecystitis, ulcer of the stomach. In acute inflammatory conditions of the stomach, intes- tine, and appendix, without fever, — hot, moist poultices of chamomile, etc. The ice-bag in ulceration with hematemesis, or acute appendicitis, with high fever; and ice-compresses in diffuse peritonitis. Priessnitz moist abdominal bandage, which consists of the application of a moist towel covered with oil paper or oil silk, bandaged with a woolen cloth, and worn during the night. Indications. — Chronic enterocolitis, spastic constipation, and chronic appendicitis. Mechanotherapy Abdominal bandages and supports in enteroptosis, "hang- belly," or large hernia of the linea alba. The Hantel pessary, in prolapsus of the anus and hemorrhoids. Umbilical hernia-truss, for small hernia of the epigastrium. 360 APPENDIX Massage Indipations. — Heavy massage of the stomach and intes- tine is indicated in atonic conditions, such as atonic consti- pation, enteroptosis and relaxed abdominal walls; light massage, — such as stroking, — in nervous dyspepsia, nervous vomiting, and spastic constipation; and massage of the entire body, in general relaxation of the musculo-nervous system. Lavage Indications. — Lavage of the stomach in stasis of the gastric contents from any cause, in severe dyspepsia, for the relief of nervous anorexia, vomiting, etc. Irrigation of the Intestine. — Lukewarm irrigations are indicated in atonic constipation; hot irrigations and oil enemata, in spastic constipation and catarrh of the colon; astringent enemata, in chronic uncontrollable diarrhoea. Electrotherapy Endofaradization of the rectum is indicated in atonic constipation; endogalvanization of the stomach, in nervous eructations, nervous vomiting, and hysterical disease of the stomach; endogalvanization (1 to 2 M. A.) of the rectum, in spastic constipation. CLINICAL ABC 361 Clinical A B C of the Most Important Disturb= ances of the Digestive Tract Chronic Acid Gastritis Pressure in the stomach after eating soHds, epigastralgia only in complications. Pyrosis. Gastric analysis shows hyperacidity, — T. A. from 60 to 120. Carlsbad, Vichy, semi-solid diet, antacids, belladonna. Smoking forbidden. Subacid Gastritis Pressure in the stomach after eating solids, but not after liquids. Pyrosis absent. Vomiting only after gross errors in diet, — such as cheese, cabbage or smoked meats. Tendency to diarrhoea. Homburg, Wiesbaden, Kissingen, soft diet, hydrochloric acid and bitters. Ulcer of the Stomach The appetite may be good, but the patient is often afraid to eat. Epigastralgia j hour to 4 hours after eating, which is often relieved by warm drinks, or vomiting of the gastric juice. The localized point of tenderness in the epigastrium is to the left of the tenth to the twelfth dorsal vertebrae. Leube's rest and fasting-cure. When this is impossible, the use of silver nitrate in recent chlorotic ulcers, and bismuth subnitrate in chronic ulcer. Oil for severe epigastralgia; Carlsbad water for ulcer following acid gastritis. After-Treatment. — Carlsbad or Vichy water for six wrecks, followed by the milk of almonds for three months. In chlo- rotic ulcer, iron spring water. Cancer of the Stomach This occurs in previously healthy stomachs, or follows chronic ulcer. The onset is insidious, beginning with loss of appetite, repugnance toward meats, anaemia and weakness. Cancer of the Cardia Difficulty in swallowing, obstruction at the cardia. 362 APPENDIX Cancer of the Pylorus Stagnation of the stomach-contents with lactic acid fermentation, or hydrochloric acid present in carcinomatous degeneration of ulcer of the pylorus. Extra=ostial Carcinoma The gastric juice is achylous; blood and pus are found in the fasting stomach. Suitable therapy, either that of stenosis of the pylorus or achylia gastrica. The treatment of carcinoma of the pylorus is surgical. Gastrectasis Acute dilatation following acute paralysis of the stomach, severe indigestion, or ileus of the jejunum or upper ileum. Chronic dilatation is caused only by obstruction of the stomach-outlet. Vomiting of stagnating foods; gnawing and cramp-Hke pains in the epigastrium; heartburn. Remnants of food with hydrochloric acid and sarcinse are always found in the fasting stomach. Lavage, oil-treatment, stenosis-diet. If stasis of food persists after medical treatment, and the daily quantity of urine secreted is below 500 c.c, the treatment should be surgical. Atony (Aneemic-Enteroptotic Dyspepsia) General ana?mia, neurasthenia, hysteria, hahitus enter- opticus, and often tuberculosis. Weakness, loss of appetite, feehng of fulness and pressure after eating any kind of food, rapid satiation of appetite, regurgitation, but no vomiting; constipation. Secretory and motor functions of the stomach normal. Low position of the greater curvature of-the stomach. Loud splashing sounds in the epigastrium. General, rather than local treatment, forced feeding with rest in bed, change of scene, hydrotherapy, massage, and bitters. No special health-resort is indicated. CLINICAL ABC 363 Nervous Dyspepsia Secondary to hysteria or neurasthenia, even in patients who are well nourished. Periods of normal digestion alter- nate with a constant feeling of pressure in the epigastrium. Objectively, the stomach is normal. There is frequently a disturbance in the genito-uririary system. Change of scene, and suggestion; bromide of potassium and valerian, and the treatment of the primary disease. Gastric Crises These are usually caused by syphilis, which have received insufficient or no mercurial treatment. In this affection there are periodical attacks of pain and vomiting, following which the patient has a period of normal digestion. The symptoms of tabes are usually present, although they sometimes do not appear until two or three years later. Treatment should include morphine, cerium oxalate, and gastric lavage. If tahes has not yet positively developed, inunction treatment with mercury. Cholelithiasis Generally with obesity, and following pregnancy. There are sporadically occurring epigastralgia, — located principally on the right side, — vomiting, and frequent jaundice. Fol- lowing the attack, the patient digests ordinary food without trouble. There is a tendency to relapse, following errors in diet and emotional disturbances. In an acute attack the treatment includes leeches, mor- phine subcutaneously, or the extract of belladonna, and hot fomentations. In chronic cases the treatment should include Carlsbad water, Neuenahr, Vichy, or Bertrich at these places, or the water used at home; olive oil, chologen or eunatrol. The treatment is also surgical. Angina Pectoris Arteriosclerosis, myocarditis, cramp-like pain after over- loading the stomach or after violent physical exercise, — the 364 APPENDIX pain being behind the sternum and in the cardiac region, radiating into the left arm. The treatment shouhl consist of rest, iodide of potassium, nitroglycerin and diuretin. Nervous and Reflex Vomiting This is variousl}' caused by retroflexion of the uterus, masturbation, helminthiasis in children, bronchitis, or emo- tional disturbances. Vomiting follows immediately or within 10 or 15 minutes after eating. It is independent of the quality of food eaten. There is no pain. The secretion and motihty of the stomach are normal. The treatments most effective are suggestion, mild mas- sage, and bromide of potassium and valerian. Catarrh of the Small Intestine Caused by repeated indigestion or gastritis. There is a feeling of fulness and distention in the entire abdomen, espe- cially around the umbilicus, after excesses in eating, and often in the morning before breakfast. There is much flatulence, which is relieved by the escape of gas. Generally the colon is simultaneously inflamed. The stool is of a semi-solid con- sistency, or alternately hard and semi-solid, or often of a liquid consistency. In shght catarrh of the small intestine, the stools often present no objective findings. Microscopical findings are fat-needles and free starch-cells. Catarrh of the Colon This is most frequently caused by over-loading the diges- tive tract, and constipation of several years' standing. a. Slight Cases. — Constipation with membranous enteritis. h. Moderately Severe Cases. — Alternating constipation and diarrhoea, with shreds of mucus in the stool. c. Severe Cases. — Persistent pulpy or liquid stools con- taining much mucus. Therapy a. Laxative mineral water, mild constipation-diet, Priess- nitz compresses, belladonna. CLINICAL ABC 365 b. Bland diet, hot mineral water in small doses. c. Constipating diet, tannocol, etc., hot compresses, hot enemata of a solution of tannin or of Carlsbad water. Atonic Constipation Insufficient amounts of food on account of anorexia or disturbances of the stomach, enteroptosis, etc. The only symptom is constipation. The stool is of large caliber; the sigmoid flexure is well- filled with faeces; laxatives and enemata are effective. A heavy diet, rich in cellulose, strychnine, cold hydro- therapeutic treatments, massage and endofaradization. Spastic Constipation The result of atonic constipation, especially in neuro- pathic individuals. Laxatives and enemata ineffective. Feeling of tension and cutting pains in the abdomen. Stools of small cahber, surrounded by membranous mucus. The sigmoid flexure is palpated as a contracted, painful cord. Hot apphcations, belladonna, oil enemata, mild diet, and hot aromatic teas. Typlilitis Pain in the ileocsecal region, generally diarrhoea, and gurgling sounds in the right iliac fossa; fever rare. Hot compresses. Appendicitis Diffuse pain and the presence of a diffuse, painful tumor. Generally fever. No diarrhoea. Ice-bag, opium, operation. Peritonitis Tympanites. The shghtest movement, — especially cough- ing and urinating,— excrutiatingly painful. Fever. Constant gnawing and cutting pains in the abdomen. Ice-compresses, opium, operation. 366 APPENDIX Stenosis and Obstruction of the Intestine Intonnittont pains, resembling labor pains. No fever, or not until late. T3'mpanitcs. Vomiting. Fecal vomiting. Enemata ineffective. If pain is absent, and there is only a simple temporary constipation, — laxatives. If colic exists, large doses of bella- donna, or the subcutaneous use of atropine and high oil enemata. If medicinal treatment is ineffective, — operation. The uterus, rectum and abdominal rings should be carefully examined. Hemorrhoids At first, lead- and opium-water compresses, followed by hamamelis per rectum and mouth. After-Treatment. — That of habitual constipation, — Hom- burg, Kissingen, etc. (see above). INDEX ABC, clinical, 301 Abdomen, auscultation, 21 inspection, 5 palpation, 8 pendulous, 190 percussion, 8 Abdominal bandage, 191, 193 Achylia gastrica, 22, 93, 220, 223 Acidity, qualitative estimation, 23 quantitative estimation, 25 Acids, combined bydrochloric, 26 free hydrochloric, 26 lactic, 23 organic, 26 phosphates, 26 total, 26 Acoria, 218 treatment, 218 Adhesive plaster abdominal belt, 193 Alimentation, forced, 351 Alkalies, indications for use, 199 Almonds, milk of, 124 Aloin blood test, 41 AmcEba in gastric contents, 38 Anacidity, 29 nerA^ous, 19 Anaemia and disorders of digestion, 223 pernicious, and achylia gastrica, 223 Ansemic-gastroptotic dyspepsia, 181 Anamnesis, 1 Angina pectoris. 111, 228 Ankylostomiasis, 330 Anorexia, nervous, 215, 217 etiology, 217 treatment, 218 Anus, 335 erosions, 335 fissures, 335 Appendicitis, 275 catarrhal, 278 diagnosis, 276 etiology, 276 gangrenous, 278 larvata, 278 recurrent, 278 suppurative, 278 surgical indications, 280 symptoms, 276 treatment, 279 Appendix, palpation, 20, 244 Ascarides, 327 Atony, 180 Atony of intestine, 321 of stomach, 180 Atrophy of gastric glands, 29 Auscultation in diseases of digestion, 21 Bacilli, lactic acid, 41 Balneological treatment of atrophic gastritis, 103 of chronic gastritis, 104 of constipation, 313 of enterocolitis, 263 of gastric ulcer, 121 of hyperacid gastritis, 101 of pyloric stenosis, 101 Balneotherapy, outlines, 356 Belladonna, use of, in acute enteritis, 85 Belloc's mastication tablets, 100 Benzidin occult blood test, 252 Bergmann's mastication tablets, 100 Bilirubin test, Schmidt's, 252 Blood in gastric contents, 38 tests, aloin, 41 benzidin. 252 Boas-Ewald test-breakfast, 21 pressure point in gastric ulcer, 21 rennin test, 30 sound palpation, 13 Bougie, (Esophageal, Trousseau's, 50 Breakfast, test-, Boas-Ewald, 21 Bronchitis, relation to stomach, 229 Bulimia, 216 treatment, 217 Caecum, palpation of, 20 Caloric value of foods, 82 Carcinoma of cardia, 137 symptoms, 141 of oesophagus, 48 of rectum, 341 of stomach, 133 Carcinomatous degeneration of ulcer, 118, 136 Cardiospasm, 61 diagnosis, 62 dilator, 64 nervous, 221 symptoms, 61 treatment, 63 Carminatives, 269 Catarrh, 82 of intestine, 253 acute, 253 chronic, 257 367 368 INDEX Catarrh of rectum, 330 of stomach, 82 Chlorosis and dyspepsia, 224 and peptic ulcer, 223 Cholelithiasis; 1 15, 234 treatment, 234 Cicatrix of duodemini, 117 of pylorus, 1 1 7 Circulatory system and diseases of digestion, 228 Cirrhosis pylori, 41 Colic, intestinal, 78 lead, 302, 322 mucous, 2()(), 305 Colitis (see Enteritis), membranous, 305, 324 Colon, 7, 16 diseases, 253, 257 palpation, 16 position, 7, 17 " stiffenings, " 8 U-form, 19 Congo-paper test for HCl, 23 Constipation, 299 atonic, 304 diet, 310 treatment, 308 catarrhal, 305 diagnosis of different stages, 306 etiology, 300 prognosis, 315 prophylaxis, 315 relation to diarrhoea, 318 spastic, 305 diet, 313 treatment, 311 Corsets, use of, in enteroptosis, 192 Creosote-tincture, 197 Cynorexia, 216 Deglutition murmurs, 51 Diabetes diet, 354 Diarrhoea (see Enteritis), ner^'ous, 323 relation to constipation, 318 stercoral, 306 Diet in constipation, atonic, 310, 352 spastic, 313, 353 diabetes, 354 diarrhoea, 351 enteritis, acute, 255 enterocolitis, chronic, 262 flatulent intestinal dyspepsia, 269 forced feeding, 351 gastritis, acute, 86, 349 chronic, 97 hyperacid, 98 stenotic, 104, 348 subacid, 97 gout, 355 intestinal obstruction, 294 ulcer, 275 Diet in nervous dyspepsia, 204 obesity, 353 oesophagus, cancer of, 53 ulcer of, 56 peritonitis, 298 pyloric stenosis, 161 stomach cancer, 144 dilatation, 161 stenosis, pylorus, 103 ulcer, 119. 3.50 Dietetic outlines. 348 Dilatation of intestine, 285 of oesophagus. 60 of stomach, 151 Dilator, cardiospasm. 64 Distention of stomach, methods, 13, 143 Diverticulum of oesophagus, 61, 64 Duodenum ulcer, 272 Ectasia of stomach (see Dilatation), 151 traumatic, 165 Electrotherapy, 360 Enema, nutritive, 119, 355 Enteritis, 253 acute, 253 diagnosis, 255 diet, 255 etiology, 253 prognosis, 256 symptoms, 254 treatment, 255 chronic (see Enterocolitis), 257 diagnosis, 259 diet, 262 etiology, 257 prognosis, 265 symptoms, 258 treatment, 261 membranous, 265, 305, 324 Enterocolitis, 257 Enteroptosis. 6, 190, 283 diagnosis, 284 general, 283 partial, 284 treatment, 191, 284 Enteroptotic dyspepsia, 180 hygienic treatment, 187 medicinal treatment, 189 Epigastralgia, diagnostic significance, 77 Epigastric hernia, 20, 150 Epigastrium, palpation, 9 Erosions, 335 of rectum, 335 of stomach, 127 complications, 129 diagnosis, 129 etiology, 128 symptoms, 128 treatment, 129 Ewald-Boas test-breakfast, 21 INDEX 369 Faeces (see Stool), 238 examination, 245 Fat cells and droplets in gastric contents 39 Fatty acid crystals, 39 Feeding, forced, 351 Ferment tests, 29 pepsin, 32 rennin, 30 Fissures of rectum (see Rectum), 335 of stomach (see Stomach), 127 Flatulence, 266 Flatulent dyspepsia, 266 diagnosis, 268 treatment, 268 diet, 269 medicinal, 269 Fleiner's oil treatment in constipation, 312 Foods, artificially prepared, 146 caloric value of, 82 Foreign bodies in oesophagus, 67 treatment, 67 Functional diseases of intestine, 319 of stomach, 177 Gall-bladder dyspepsia, 231 Gastralgokenosis, 216 treatment, 217 Gastrectasis (see Dilatation), 151 acute, 160 chronic, 152 Gastric crises, 169, 226 glands, atrophy, 29 juice, acidity, 27 component parts, 26 ferments, 29 pepsin test, 32 rennin test, 30 qualitative examination, 23 quantitative examination, 25 Topfer's method, 28 Gastritis, acute, 83 diagnosis, 84 diet, 86 etiology, 83 prognosis, 84 symptoms, 83 treatment, 84 chronic, 87 atrophic, 92 treatment, 99 classification, 88 diagnosis, 94 diet, 97 etiology, 89 hyperacid, 92, 99, primary, 89 prognosis, 93 secondary, 90, 103 stenotic, 96 24 Gastritis, chronic, subacid, 92 symptoms, 91 treatment, 90 Gastrodiaphany, 13 Gastroptosis, 190 Gastroptotic dyspepsia, 180 diagnosis, 184 differential diagnosis, 184 prognosis, 185 symptoms, 181 treatment, 187 diet, 187 massage, 190 medicinal, 189 Gastrosuccorrhcea (see Hypersecretion), 168 Genito-urinary diseases and dyspepsia, 224 Glc^nard's disease (see Enteroptosis), 190 Gout and dyspepsia, 224 diet in, 355 Habitus enteropticus, 6 normal, 6 Hang-belly, 190 Heart disease and dyspepsia, 228 Hemorrhage, gastric, 125 treatment, 125 Hemorrhoids, 337 complications, 341 diagnosis, 338 prognosis, 341 symptoms, 337 treatment, 338 Hernia, epigastric, 20, 150 diagnosis, 150 symptoms, 150 treatment, 151 Hour-glass stomach, 117 Hydrochloric acid, clinical significance, 29 combined, 26 congo-paper test, 23 free, 26 qualitative estimation, 23 quantitative estimation, 25 Topfer's method of estimating, 28 Hydrotherapeutics, 186 Hydrotherapy outlines, 356 Hyperacidity, 170 nervous, 219 treatment, 220 Hyperaesthesia of skin in diseases of abdomen, 21 Hyperchlorhydria, 172 in acute gastritis, 172 in constipation, 174 in neurasthenia, 174 in stenosis of pylorus, 173 in ulcer, 173 prognosis, 175 treatment, 176 Hypersecretion, 168, 220, 221 370 INDEX HiTJersecretion, diagnosis, 170 symptoms, 109 treatment, 170 Hysteria, liypersesthesia of skin of abdomen, 21 ' (Esophageal spasm, 70 Ileus, 290 Infectious diseases and dyspepsia. 225 Infusoria in gastric contents, 38 Intestine, atony, 321 colic, IIG dilatation, 285 diseases, 237 anamnesis, 242 etiology, 238 examination, physical, 243 sjTnptomatology, 241 displacements, 283 acquired, 283 congenital, 283 enteritis, acute, 253 enterocolitis, chronic, 257 flatulent dyspepsia, 266 neurasthenia, 324 treatment, 325 neuroses, 319 obstruction, 289 diagnosis, 290 diet, 294 etiology, 289 sjTnptoms, 290 treatment, 293 palpation, 16 parasites, 325 peristaltic unrest, 8, 323 relation to stomach diseases, 235 spasms, 321 symptoms, 321 treatment, 322 stenosis, 285 diagnosis, 287 etiology, 286 symptoms, 286 treatment, 288 " stiffenings, " 8, 323 tumors, 281 ulceration, 271 diagnosis, 272 diet, 275 etiology, 272 prognosis, 275 treatment, 275 Jaworski's nuclei, 37 Kidney, displacements, 7, 16, 191 palpation, 15 Kronig's treatment of corrosion of a:sopha- gus, 57 Lab ferment, test for, 30 zymogen, 32 Laboratory equipment, 46 Lactic acid, 23 bacilli, 41 tests, Kelling's modilication of Uffel- mann's, 24 Strauss's, 24 Lavage, indications, 100, 103, 360 Laxatives, 311 Lead colic, 302, 322 Leube's ulcer diet, 119 Leucocytes in gastric contents, .39 Liver, displacements, 7 palpation, 14 relation to dyspepsia, 231 Lungs, relation to dyspepsia, 229 Manometer for treatment of cardiospasm, 64 Massage, stomach, 190, 3G0 Mathieu-Rcmond motility test, 35 Mechanotherapy outlines, 359 Membranous colitis, 305, 324 Menstruation, effect of, on gastric secretion, 46 Metabolism and dyspepsia, 223 Meteorism, 266, 292, 323 Microscopic examination of fa?ces, 249 of gastric contents, 36 Milk of almonds, 124 Motor functions of stomach, disturbances (see Dilatation of stomach), 72 tests, Mathieu-Rdmond's, 35 test dinner, 35 test supper, 35 Mucous colic, 266. 305 Mucus in gastric contents, 40 Murmurs, deglutition, 51 Muscle fibres in gastric contents, significance, 40 Myasthenia of stomach, ISO Myelin spirals, 38 Nephroptosis, 190 Nervous diarrhcra, 323 diseases of rectum, 345 dyspepsia, 199 diagnosis, 202 diet, 204 etiology, 200 prognosis, 204 sjTuptoms, 201 treatment, 204 eructation, 69 hyperacidity, 176 system and dyspepsia, 225 vomiting, 210 diagnosis, 210 prognosis, 212 symptoms, 210 INDEX 371 Nervous vomiting, treatment, 212 Neurasthenia, intestinal, 324 Neuroses, intestine, 319 oesophagus, 68 rectum, 345 stomach, 209 Nuclei, Jaworski's, 37 Nutritive enema, 119 Obesity and dyspepsia, 224 Obrastzow's method of palpation of stomach, 11 Obstipation, 299 Obstruction of bowel, 289 Occult hemorrhage tests, aloin, 41 benzidin, 252 OEsophageal bougie. Trousseau's. 50 CEsophagoscope, 67 Qllsophagus, cancer, 48 complications, 51 diagnosis, 49 diet, 53 sjrmptoms, 49 treatment, 51 deglutition murmurs, 51 dilatation, 60 treatment, 60 diverticulum, 60, 64, diagnosis, 64 treatment, 64 foreign bodies in, 67 hypersesthesia, 69 neuroses, 68 stenosis, spastic, 68 diagnosis, 58 treatment, 58 stricture, 57 etiology, 57 symptoms, 57 treatment, 57 ulcer, 56 symptoms, 56 treatment, 56 Oil-treatment, 53, 122, 130, 312 Oppler-Boas bacilli, 41 Outlines of balneotherapy, 356 of dietetics, 348 of hydrotherapy, 359 of mechanotherapy, 359 Ox-hunger (see Cynorexia), 216 Oxyurides, 327 Palpation of epigastrium, 8 of intestine, 16 of kidney, 15 of liver, 14 of rectum, 21 of stomach, 9 Pancreas and diseases of digestion, 231 Parasites of intestine, 249, 325 Parasites of intestine, diagnosis, 326 treatment, 327 Pepsin tests, Ilammerschlag's, 32 clinical value, 34 Percussion of abdomen, 8 Perforation of stomacli, 116 treatment, 117 Perigastritis, 117, 167 diagnosis, 167 etiology, 167 prognosis, 167 symptoms, 167 treatment, 168 Peristalsis, visible, of colon, 8 of intestine, 8 of stomach, 8 Peristaltic unrest of intestine, 323 Peritonitis, acute, 294 chronic, 297 circumscribed, 296 diet, 298 diffuse, 296 etiology, 294 localized, 295 treatment, 297 Phthisical dyspepsia, 196 symptoms, 196 treatment, 196 Physical examination in diseases of diges- tion, auscultation, 21 inspection, 5 palpation, 8 percussion, 8 Pin-worms, 327 Proctitis, 331 Psychotherapy, 206 Pus in gastric contents, 38 Pylorus, cancer, 139 cirrhosis, 41 hypertrophy, 103 palpation, 13 spasm, 117 nervous, 221 stenosis, 103 treatment, 104 Rectum, cancer, 341 complications, 344 diagnosis, 342 prognosis, 343 symptoms, 342 treatment, 343 catarrh, 331 erosion, 335 fissure, 335 diagnosis, 335 etiology, 335 symptoms, 335 treatment, 336 inflammation, 331 372 INDEX Rectum, inflammation, diagnosis, 332 etiology, 331 ■ symptoms, 331 treatipent, 332 neoplasms, 337 neuroses, 345 stenosis, 344 diagnosis, 344 symptoms, 344 treatment, 344 ulceration, 334 diagnosis, 334 etiology, 335 symptoms, 334 treatment, 335 Regurgitation, 79 nervous, 210, 212 Reichmann's disease, 108 Remnant test of Matlueu-R(5mond, 35 Rennin test of Boas, 30 clinical value, 31 Rhodankalium reaction of saliva, 96 Riegel's test-dinner, 35 Rose's adhesive-plaster abdominal belt, 193 Rumination, 79 SarcinK, presence of, in gastric contents, 39 Seat-worms, 327 Sexual organs and dyspepsia, 236 Skin, hyperaesthesia of, in cliolelithiasis, 21 in hysteria, 21 in inflammation of abdominal vis- cera, 21 in nervous dyspepsia, 21 in ulcer of stomach, 21 Sodium hydrate solutions, 25 Spasm of cardia, 61 of intestine, 321 of pylorus, 117 of rectum, 345 Splashing sounds in stomach, 74, 156 Spleen, displacement, 7 palpation, 13 relation to dyspepsia, 231 Stagnation of food in stomach, 40 Stenosis of intestine, 285 of oesophagus, 58 of pylorus, 151 congenital hypertrophic, 163 spastic, 166 Stomach, 71 atony, 180 carcinoma, 133 classification, 137 clinical course, 143 complications, 143 diagnosis, 136 etiology, 133 lactic acid in, 136 Stomach, carcinoma, symptoms, 134 treatment, 144 cardiospasm, 01 symptoms, 61 determining borders of, methods, 11 dilatation, 151 distention with elTervescent mixtures, 13 erosions, 127 ferments, pepsin, 32 rennin, 30 fissures, 127 etiology, 128 symptoms, 128 functional diseases, 177 diagnosis, 179 etiology, 177 prognosis, 179 treatment, 180 gastrodiaphany, 13 hemorrhage, 125 treatment, 125 hour-glass contraction, 117 microscopic examination, 36 motility tests, remnant test of Mathieu- Rdmond, 35 test-dinner, 35 test-supper, 35 miotor functions, 72 neuroses, 209 palpation, 11 perforation, 116 position, 11 " stiff enings," 8 subacidity, nervous, 219 -tube, 42 indications and contraindications in use, 44 technic in use, 42 ulcer, 108 complications, 116 diagnosis, 114 diet, 119 etiology, 108 symptoms, 110 treatment, 119 Stool, normal, 238 chemical examination. 252 macroscopical examination, 245 blood, 246 color, 245 concrements, 248 consistency, 246 food remnants, 246 form, 245 microscopical examination. 249 Surgery of carcinoma of stomach, 146 of dilatation of stomach, 162 of perforation of stomach, 117 of stenosis of pylorus. 162 INDEX 373 Tabes dorsalis, gastric crises in, 169 Tapeworm, 328 complications, 330 contraindications in treatment, 329 diagnosis, 326 treatment, 328 Test-meals, Boas-Ewald test-breakfast, 21 test-dinner, 35 test-supper, 35 Tetany, 156 Thiosinamin, use of, 289 Tongue, significance of coating, 8, 80 Topfer's method of determining gastric acidity, 28 Traumata, role of, in diseases of stomach, 133 Trichoeephaliasis, 330 Trousseau's oesophageal bougie, 50 Tuberculosis, dyspepsia in, 196 Tumors, abdominal localization, 7 of cardia, 141 of intestine, 281 diagnosis, 281 treatment, 282 of stomach, 136 diagnosis, 136 Typhlitis, 275 acute, 277 chronic, 279 diagnosis, 276 etiology, 276 Typhlitis, chronic, surgical indications, 280 symptoms, 270 treatment, 279 Ulcer of duodenum. 114 symptoms, 114 of intestine, 271 of oesophagus, 56 of rectum, 334 of stomach, 108 Urine, diminution of, in dilatation of stom- ach, 156 Vertigo, gastric, 214 treatment, 215 Vomiting, diagnostic significance of, 78 cerebral, 225 in bronchitis, 229 in gastric crises, 226 in migraine, 226 juvenile, 211 nervous, 210 reflex, 210 Worms, intestinal, 325 ascarides, 327 oxyurides, 327 seat-, 327 tape-, 328 Yeast cells in gastric contents, 39