COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 33630 RC801 .K32 Diseases ofthestonT; n/ Columtiia ®nibersit|? in ttje Citp of ^eto |9orfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofstomacOOkemp DISEASES OF THE Stomach and Intestines BY ROBERT COLEMAN KEMP, M.D. Professor of Gastrointestinal Diseases in the New York School of Clinical Medicine; Visiting Gastro-enterologist to the New York Red Cross Hospital ; Gastrologist to the West Side German Dispensary ; Consulting Physician, Gastro- intestinal Diseases, to the Manhattan State Hospital ; Meinber American Medical Association WITH 280 ILLUSTRATIONS, SOME IN COLORS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY I 9 I o Copyright, 1910, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANV PHI LADEl-PMIA TO Wxiimm % ®I|omaott, M, i., fCIC. i., CONSULTING PHYSICIAN TO THE ROOSEVELT AND RED CROSS HOSPITALS AND LATE PRESIDENT OF THE NEW YORK ACADEMY OF MEDICINE, THIS VOLUME IS INSCRIBED AS A TRIBUTE TO HIS HIGH PROFESSIONAL ATTAIN- MENTS AND IN REMEMBRANCE OF HIS MANY ACTS OF KINDNESS, BY THE AUTHOR PREFACE In view of the excellent works on diseases of the stomach and intestines that have been placed before the medical profession, the publication of a new book on these subjects might almost seem to be superfluous. From a great accumulation of material, it is often difficult for the general practitioner to select simple and practical methods, and it is the endeavor that this volume should render service in this special direction. Many physicians have neither time nor opportunity to devote to a practical clinical course, and next in value to this for the pur- pose of instruction is the employment of photography to demon- strate the methods of diagnosis and treatment. Of this I have endeavored to take advantage. Many of the illustrations are from photographs of patients at the Manhattan State Hospital, taken by Mr. Hill, the official photographer, for whose services I am indebted to the courtesy of Dr. Wm. Mabon, the Medical Superintendent. Some of the illustrations have been made by my artist from models. As visceral displacements have recently assumed an important position, their symptoms, diagnosis, and treatment, notably by me- chanical methods, are specially described. Typhoid fever is included in this volume on account of its intestinal complications and for the purpose of differential diagnosis. A chapter is devoted to Diverticulitis , which has become an important subject. The endeavor has been made to indicate as clearly as possible the conditions which call for surgical procedure. ROBERT COLEMAN KEMP. New York City, February, 1910. CONTENTS Part I CHAPTER I PAGE Anatomy op the Stomach and Intestines 17 Anatomy of the Stomach 17 Anatomy of the Intestines 22 Histology of the Large Intestine 33 CHAPTER II Physiology op Digestion 34 The Gastric Juice 35 Intestinal Digestion , 36 CHAPTER HI Interrogation of the Patient (History) 42 CHAPTER IV General Methods of Physical Examination ■ 45 General Inspection 45 Topographic Anatomy 55 Physical Examination of the Liver and Gall-bladder 57 Part II DISEASES OF THE STOMACH CHAPTER V Methods of Physical Examination of the vStomach 71 Rontgen Rays (x-Rays) •'^7 Radium Transillumination of the vStomach SS Radium Photographs of the vStomach NS Conclusions -SI^ 9 lO CONTENTS ' CHAPTER VI Examination of the Functions of the Stomach 90 Test Meals 91 Method of Aspiration of the Gastric Contents 91 Examination of the Ingesta 95 Abnormal Constituents of the Stomach Contents 113 Microscopic Examination of the Gastric Contents 116 Determination of the Absorptive Function of the Stomach 121 CHAPTER Vn Diet 124 Diet in Health . 1 24 Diet in Disease 138 CHAPTER VIII EocAL Treatment of the Stomach 140 Lavage 140 Stomach Powder-blower 159 Electricity 161 CHAPTER IX Massage, Vibratory Massage, Hydrotherapy, Counterirritation, Orthopedic Appliances 165 Massage 165 Vibratory Massage 165 Local Hydrotherapy 168 Counterirritation 1 70 Orthopedic Methods 170 CHAPTER X Catarrh op the Stomach 180 Acute and Chronic Gastritis 180 Acute Gastritis 1 80 Simple Acute Gastritis 180 Toxic Gastritis 185 Phlegmonous Gastritis 188 Chronic Gastritis 189 CHAPTER XI Achylia Gastrica 203 CHAPTER XII Hematemesis, UIvCER of the Stomach, Exulceratio Simplex, Acute AND Chronic Erosions 211 Gastric Hemorrhage -. 211 Ulcer of the Stomach 212 Exulceratio Simplex (Dieulafoy) or Superficial Ulceration of the Stomach 235 Gastric Erosions 236 Acute Erosions (Hemorrhagic Erosions) 236 Chronic Erosions •. 237 CONTENTS I I CHAPTER XIII PAGE Cancer of the Stomach (Carcinoma Ventricuu), Other Tumors of THE Stomach, Apparent Tumors of the Stomach, Foreign Bodies in the Stomach 240 Cancer of the Stomach (Carcinoma VentricuH) 240 Other Tumors of the Stomach 275 Apparent Tumors of the Stomach 277 Foreign Bodies in the Stomach 277 CHAPTER XIV FuNCTiONAi, Diseases of the Stomach 279 Hyperacidity (Hyperchlorhydria) 279 Gastrosuccorrhea (Continuous Secretion of Gastric Juice) 291 Gastrosuccorrhea (Continua Periodica) 292 Gastrosuccorrhea (Continua Chronica) 296 CHAPTER XV Disturbances of the Motor Function of the Stomach, Acute Atony, Chronic Atony, Acute Dilatation of the Stomach, Chronic Dilatation of the Stomach 303 Atony of the Stomach 303 Acute Atony of the Stomach 303 Chronic Atony of the Stomach 304 Acute Dilatation of the Stomach 306 Chronic Dilatation of the Stomach 320 Atonic Dilatation of the Stomach 322 Obstructive Type (Stenotic) of Ectasia 325 Diagnosis 326 Treatment 329 Treatment of Stenotic Dilatation (Benign Stenosis) 335 Treatment of Malignant Stenosis 336 Complications of Chronic Ectasy 336 Gastric Tetany ' 336 Convulsions, Epilepsy 338 CHAPTER XVI Anomalies in the Position and Form op the Stomach, Hour-glass Stomach, Dislocations, Gastroptosis 340 Hour-glass Stomach 340 Dislocation of the Stomach 341 Gastroptosis, Enteroptosis, Glenard's Disease 341 CHAPTER XVII Nervous Affections of the Stomach 359 Sensory Neuroses of the Stomach 360 Bulimia 360 Parorexia (Perversion of Appetite) 361 Polyphagia 362 Akoria 362 Nervous Anorexia (Anorexia Nervosa) 362 12 CONTEXTS PAGE Nervous Affections of the Stomach: Sensory Neuroses of Stomach — Sensations \\'ithin the Stomach 363 Abnormal Sensations 364 Hyperesthesia of the Stomach 364 Gastralgia 365 Gastralgokenosis (Boasj 369 Motor Neuroses of the Stomach 369 HypermotUity of the Stomach 369 Peristaltic Restlessness of the Stomach (Kussmaulj 370 Antiperistaltic Restlessness of the Stomach 371 Incontinence of the Pylorus 371 Spasm of the Pylorus (Pylorospasmus) 372 Atony of the Stomach 372 Hypanakinesis Ventriculi (Einhorn) 372 Hyperanakinesis \'entriculi (Einhorn) 373 Spasm of the Cardia (Cardiospasmusj - 373 Pyrosis (Heart-burn) 375 Regurgitation 37^ Rumination 376 Nervous Vomiting (Vomitus Nervosa) 377 Periodic Vomiting (Von Leyden) 378 Cyclic ^'omiting in Children 37^ Juvenile Vomiting 379 Reflex Vomiting 379 Idiopathic Nervous A'omiting 379 Pneumatosis 380 Secretory Neuroses 380 Nervous Dyspepsia (Leube) 381 CHAPTER XVIII Dyspeptic Asthma 385 CHAPTER XIX The Stomach Functions in Diseases of Other Organs 387 Functions of the Stomach in Acute Febrile Diseases 387 Chronic Febrile Conditions 388 Condition of the Stomach in Pulmonary Tuberculosis 388 Chlorosis and Anemia 389 Heart Lesions 389 Diseases of the Liver 39° Aneurysm 390 Diseases of the Kidneys ■ 39° Diabetes 39° Arthritis Deformans 39^ Gout : 391 Malaria '• 39 ^ Diseases of the Skin • 39^ Syphilis of the Stomach 392 Gastric Ulcer (Syphilitic) 393 Syphilitic Tumor of the Stomach 393 Syphilitic Pyloric Stenosis 393 Syphilitic Cirrhosis of the Stomach 393 CONTENTS 13 Part III DISEASES OF THE INTESTINES CHAPTER XX PAGE Methods of Examination of the Intestines; Examination of the Feces; Mechanical Procedures 394 Physical Examination of the Intestines 395 Inspection of the Rectum — Proctoscopy and Sigmoidoscopy 396 Transillumination of the Intestines 404 Inflation of the Intestines with Carbonic Acid Gas or Air 406 Lavage of the Bowel for Diagnosis 408 Examination of the Feces 4^9 Testing the Intestinal Functions 420 Mechanical Procedures 428 CHAPTER XXI Diet, Intestinal Dyspepsia, Indicanuria, Saccharobutyric Putre- faction, Botulism, Hydrogen Sulphid Auto-intoxication, Enterogenic Cyanosis, Meteorism, Enteralgia, Visceral Arteriosclerosis, Anomalies, Intestinal Sand 442 Diet 442 Intestinal Dyspepsia 444 Indicanuria 445 Saccharobutyric Type of Intestinal Putrefaction 447 Botulism 449 Hydrogen Sulphid Auto-intoxication 449 Enterogenic Cyanosis 450 Meteorism; Tympanites 45 1 Intestinal Pain (Intestinal Colic, Enteralgia) . • • ■ 453 Visceral Arteriosclerosis 455 Anomalies in the Position and Form of the Intestines; Enteroptosis. . 456 Intestinal Sand 45^ CHAPTER XXII Constipation and Diarrhea 458 Constipation 45^ Diarrhea 47^ Diarrhea Due to Irritation of the Bowel Contents 473 Diarrhea Due to Irritants Transmitted in the Blood 474 Diarrhea Nervosa (Nervous Diarrhea) 474 Diarrhea from Exposure to Cold and Wet 475 Treatment of Diarrhea 475 CHAPTER XXIII Intestinal Catarrh, Enteritis, Colitis, Catarrhal Sigmoiditis, Proc- titis, Phlegmonous Enteritis 47^ Acute and Chronic Intestinal Catarrh 47^ Acute Intestinal Catarrh ■ 478 Chronic Intestinal Catarrh (Chronic Colitis) 4^7 Proctitis 49S Phlegmonous (Purulent) Enteritis 500 14 CONTENTS CHAPTER XXIV page Dysentery 501 Diphtheritic Dysentery 501 Location 502 Amebic Dysentery 503 Bacniary Dysentery 520 CHAPTER XXV Typhoid Fever 528 CHAPTER XXVI Intestinal Hemorrhage, Intestinal Ulcers, Diseases of the Blood- vessels (Embolism and Thrombosis) 542 Intestinal Hemorrhage 542 Ulcers of the Intestines 543 Simple Duodenal Ulc^r 543 Intestinal Ulcers from Cutaneous Burns 546 Embolic and Thrombotic Ulcers 547 Amyloid Ulcers 547 Tubercular Ulcers and Intestinal Tuberculosis 548 Secondary Tubercular Ulcers of the Intestines (Tuberculosis) . 549 Catarrhal and Follicular Ulcers 55° Ulcerative Colitis 55° Stercoral or Decubital Ulcers 55° Ulcers in Acute Infectious Diseases 55° Ulcers in Constitutional Diseases 55° Toxic Ulcers 55° Syphilitic, Gonorrheal, and Cancerous Ulcers 55 1 Intestinal Myiasis 55^ General Symptoms of Intestinal Ulceration 55 1 Treatment -^^S Diseases of the Blood-vessels; Embolism and Thrombosis of the Mesenteric Arteries and Veins (Infarction of the Bowel) 554 CHAPTER XXVII Neoplasms of the Intestines • 559 Malignant Growths 559 Carcinoma of the Intestines 559 Sarcoma and Lymphosarcoma of the Intestines 57° Benign Tumors of the Intestines 57 1 Gas Cysts of»the Intestines 573 CHAPTER XXVIII Hemorrhoids, Prolapse of Rectum, Fissure 574 Hemorrhoids 574 CHAPTER XXIX Appendicitis •" 59^ CONTENTS 15 CHAPTER XXX PAGE Diverticulitis, Peridiverticulitis 620 CHAPTER XXXI Intestinal Obstruction, Acute axd Chronic 635 Acute Intestinal Obstruction 635 Chronic Intestinal Obstruction 657 CHAPTER XXXII Nervous Diseases of the Intestines 666 Motor Neuroses of the Intestines 666 Sensory Neuroses of the Intestines 669 Secretory Neuroses of the Intestines 671 Intestinal Neurasthenia 671 Mucous Colic (Membranous Enteritis) 672 CHAPTER XXXIII Intestinal Parasites 681 Protozoa 68 1 Amebse '. 681 Sporozoa 681 Intestinal Psorospermiasis 681 Infusoria 681 Vermes 685 Index DISEASES OF THE STOMACH AND INTESTINES PART I CHAPTER I ANATOMY OF THE STOMACH AND INTESTINES ANATOMY OF THE STOMACH A BRi^P description will be given of the anatomy of the stomach, but for a complete exposition of the subject the reader is referred to any standard anatomy. The stomach lies in the epigastric and left hypochondriac regions, about five-sixths of it to the left of the median line. The larger end, the fundus, fits into the concave left vault of the diaphragm. It is a pyriform sac, with longitudinal diameter slightly oblique, and lying traUvSversely across the abdomen (Fig. i). The cardiac orifice (C), the junction of the esophagus and stomach (the esophageal orifice), is fixed and lies behind or a little to the left of the sternal junction of the left seventh cartilage (seventh rib), or about 1 1 inches from the edge of the sternum, in the left parasternal line, on a level with the spinous process of the ninth dorsal vertebra. The cardia is situated ^.h inches from the anterior surface of the abdomen. The point of communication with the small intestine is called the pylorus (P), and shows a furrow on the outer surface and within a protruding fold (the valve of the pylorus). The pylorus (P) lies between the right sternal and parasternal lines, slightly below the tip of the ensiform process, and corresponds to the spinous process of the twelfth dorsal vertebra. It descends slightly when the stomach is distended and moves somewhat to the right. A line (-f ), drawn in the axis of the esophagus through the stomach to its lower border, cuts off about one-fourth of the organ to the left. This portion is called the greater cul-de-sac or fundus (/-"). The fundus (F) rises as high as the lower border of the left fifth rib in the mammillary line, slightly above and behind the apex of the heart, and from i to 2 inches higher than the cardia. It is in contact with the diaphragm above, and to the left with the spleen and left kidney. i8 DISEASES OF THE STOMACH AND INTESTINES The lesser curvature (L) lies to the left of the vertebral column, passes downward and parallel with it, and then crosses it to the upper border of the pylorus. The greater curvature (G) forms the fundus and lower border of the stomach and extends to the lower border of the pylorus. The lower border, when the organ is distended, lies about two to three fingers' breadth (i^ to 2| inches) above the umbilicus. Fig. I. — The stomach: C, Cardia; F, fundus; P, pylorus; L, lesser curvature; G, greater curvature (modified from W. J. Mayo). The volume of the stomach varies according to its contents. Dehio has shown that the healthy stomach when empty is contracted and hidden away in the left cavity of the diaphragm, and it is the colon that we then demonstrate by percussion. The pancreas and splenic vessels lie behind the stomach. The anterior surface is overlapped above by the liver, the left lung, and the seventh, eighth, and ninth ribs. Below it is in relation with the abdominal wall. ANATOMY OF THE STOMACH AND INTESTINES 19 The pyloric end, the lesser curvature, and the cardia lie behind and beneath the quadrate and left lobes of the liver. Traube's space is the area in which the stomach lies in direct contact with the ribs, and is bounded above by the liver and left lung, externally by the spleen, and the inner border is formed by the free costal margin. Both here and in the epigastric region pure gastric tympany can be elicited. When the stomach is distended, the lesser curvature is directed obliquely backward toward the spine, the posterior wall looking somewhat downward and the anterior wall slightly upward. The transverse colon, if distended, may overlap the greater curvature, and the latter tends to fall away from the abdominal wall when the patient is in the dorsal position. The transverse colon lies ordinarily below the greater curvature. With moderate distention, the average length from fundus to pylorus is 10 to 12 inches; from the lesser to greater curvature, 4 to 5 inches; from the anterior to the posterior wall, about 3 to 3 J inches. The average capacity is vari- able. It may contain even as much as 2 quarts. A plane drawn transversely through the base of the lesser curvature will lie parallel with the plane of the diaphragm. The lesser omentum extends from the lesser curvature to the liver above, and the great omen- tum is suspended from the greater curvature, protecting the viscera. The blood-vessels enter the upper and lower borders, and thus divide the surface into two equal parts. They mark the greater and lesser curvatures. Structure of the Stomach. — The stomach consists of four coats: serous or peritoneal, mus- cular, submucous or areolar, and mucous. The peritoneal coat forms a thin, transparent, elastic membrane, and closely covers the organ except along the curvatures, where it is more loosely attached for the passage of the blood-vessels. The muscular coat consists of three sets of fibers (Fig. 2), dis- posed in layers, the outer or longitudinal, middle or circular, and inner or oblique. The last is a continuation of the circular fibers of the esophagus and the fibers descend obliquely from the cardia Fig. 2. — Vertical sttii'Mi of the stomach: i. Mucosa; 2, submucosa; 3, 4, muscuiaris; 5, serosa. 20 DISEASES OF THE STOMACH AND INTESTINES upon the anterior and posterior surface, and, spreading out like a fan, terminate at the greater curvature. The submucous coat consists of areolar tissue, connecting the mucous and muscular coats. The blood-vessels subdivide therein. The mucous membrane is soft, smooth, somewhat pulpy, and of pink color, thickest in the pyloric region and thinnest at the fundus. It constitutes the glandular layer of the organ. It is covered by columnar epithelial cells, which extend for a variable distance into the mouths of the glands. There are about five million glands in the stomach, tubular in form, and perpendicular to the surface. They are surrounded by fibrous tissue and lymphoid cells and by a thin muscle layer (muscularis mucosae). The glands are composed of a mouth, neck, body, and base; and several tubules, from two to even four or five, may end in one mouth. On microscopic examination, the dots appearing on the surface of the mucosa are the openings of the glands. There are three varieties of glands in the stomach: Cardiac or fundus glands. Pyloric glands. Mucous glands. Cardiac or fundus glands are the most numerous. They fill the greater part of the stomach and are characterized by the shortness of their mouths and the length of the glands. They contain two varieties of cells. Cells bordering on the lumen of the tube, which are small, granular, and pol3^hedral or columnar, the chief or principal cells, and' which only stain to a slight extent with anilin dyes. The other cells, parietal or oxvntic, lie between the principal cells and the membrana propria (Fig. 3). They are most numerous in the necks of the glands, larger than the chief cells, are oval or angular and finely granular in structure. The}^ have strong affinity for anilin dyes. Pyloric Glands. — These are characterized by the greater length of their mouths, which are lined b}' cylindric epithelium. They are found only in the region of the pylorus. The body or secretory portion of the gland is represented b}^ a single layer of short and finely granular colunmar cells, resembling the chief cells of the fundus glands. There are also a few isolated cells (Nussbaum) which resemble, in structure and in their behavior to anilin dyes, the parietal cells of the fundus glands (Fig. 4). Besides these specific glands, a number of vmcous glands are found near the pylorus. The hydrochloric acid is secreted by the parietal cells; pepsin and the milk-curdling ferment by the principal cells of the fundus and pyloric glands. Some consider the mucus to be also a product of the cylindric goblet-cells lining the stomach and the wider portions of the glandular ducts. The ferments do not exist as such in the cells, but as zymogens, which are transformed into ferments through the activity of the free hydrochloric acid. Blood-vessels , Lymphatics, and Nerves of the Stomach. — The ANATOMY OF THE STOMACH AND INTESTINES arteries of the stomach are derived from branches of the ceUac axis; the gastric and pyloric branch of the hepatic artery supplying the upper curvature and forming the superior ventricular arch and the right gastro-epiploic from the hepatic, and the left gastro-epiploic and vasa brevia from the splenic form the inferior ventricular arch. They reach the stomach between the folds of peritoneum and ramify between the muscular coats, giving oflF a number of capillaries and dividing into small vessels in the submucosa, and finally enter the mucous membrane, and pass between the tubuli, where they / \»^SSi Fig. 3. — Cardiac gland: o, Parietal cells; b, principal cells. Fig. 4. — Pyloric gland : a, Mouth; h, neck; c, fundus. form a plexus of fine capillaries both on the walls of the tubules and around the mouths of the glands. The veins arise from this capillary network and pass nearl\- straight through the mucous membrane between the glands. The> pierce the muscularis mucosae and form a plexus in the submucosa. and finally form the coronary and pyloric veins empt>-ing into the portal vein, the right gastro-epiploic vein emptying into the superior mesenteric vein, and the left gastro-epiploic vein emptying into the splenic vein. The lymphatics extend directly to the surface of the mucosa. They form a dense network of lacunar spaces between and among 22 DISEASES OF THE STOMACH AND INTESTINES the gland tubuli, which they enclose, as well as the blood-vessels, with sinus-like dilatations. The lymph is collected near the surface of the mucous membrane into vessels which form loops and possess dilated extremities. They are less superficial than the capillaries, though the lacunar spaces extend as far as the basement-membrane of the surface. The lymphatic glands extend along the lesser curva- ture to the cardia, while they are present on the greater curvature from the pylorus to only about one- fourth to one-third of the distance. This fact is of important consideration in gastrectomy for carcinoma, as the lesser curvature must, therefore, be entirely removed. Nerves. — The left vagus supplies the anterior surface of the stomach. The right vagus supplies the posterior surface with only one-third of its fibers, the remainder passing to the other viscera. Branches of the S3^mpathetic nerves pass from the celiac plexus and anastomose with the vagi. These nen,^es with numerous ganglia form a network in the submucosa. ANATOMY OF THE INTESTINES The intestinal canal is divided into two parts : the small intestine and the large intestine; the former about 7.6 meters (25 feet) long, and the latter 1.5 to 1.8 meters (5-6 feet) long. The small intestine is subdivided into three portions: the duo- denum, jejunum, and ileum, and lies, excepting the duodenum, to the inner side of the large intestine, and is connected to the posterior abdominal wall by the mesenter}^, which last encloses the jejunum and ileum throughout. The Duodenum. — The duodenum, which is about 10 to 12 inches (25.5-30.5 cm.) long, is not suspended by the mesentery and is the most fixed and widest part of the small intestine, having a diameter of 1 1 to 2 inches (3.81-5.08 cm.). It is curved like a horseshoe, surrounds the pancreas, and is divided into four parts (Fig. 5). The superior horizontal part of the duodenum is about 2 inches (5.08 cm.) long, begins at the pylorus at the level of the first lumbar vertebra, and passes slightly upward and to the right of the gall- bladder. It is the most movable portion, is surrounded by the peritoneum, and suspended chiefly by ligaments from the hilus of the liver and neck of the gall-bladder. The quadrate lobe and neck of the gall-bladder lie above it ; below it is the pancreas, and behind it the common bile-duct and hepatic vessels. The descending portion of the duodenum, about 3 inches (7.5 cm.) long, commences at the neck of the gall-bladder and runs vertically to the third or fourth lumbar vertebra on the right side and touches the right kidney. The transverse colon passes in front of it ; on the left side is the pancreas, and the common bile-duct lies a little poste- rior. At its inner and back part, about 4 inches from the pylorus, the common bile-duct and pancreatic duct enter it and form the diverticu- lum or ampulla of Vater. ANATOMY OF THE STOMACH AND INTESTINES 23 The third or transverse portion of the duodenum, about 5 inches (12.5 cm.) long, extends from the right side of the body of the third or fourth lumbar vertebra across the spine, and slightly ascends to the left side of the spine. The superior mesenteric vessels cross it, as does the mesentery. The lower layer of transverse mesocolon lies in front. The pancreas and superior mesenteric artery lie above, and the aorta, vena cava, and crura of the diaphragm behind it. It is the most fixed portion of the duodenum. Fig. 5. — Stomach and duodenum, liver and intestines removed, and showing anatomic relations of the duodenum (after Testut). The fourth or ascending portion of the duodenum, about i to 2 inches (2.54-5.08 cm.) long, ascends vertically along the left side of the spine from the third or fourth lumbar vertebra to the side of the second or first lumbar vertebra. It is firmly fixed by the suspensory muscle of the duodenum (muscle of Treitz), which descends from the left crus of the diaphragm. Anteriorly are the transverse colon and transverse mesocolon (lower layer). It terminates in the jejunum (usually opposite the second lumbar vertebra) and forms the duodeno- jejunal flexure. Jejunum and Ileum. — They form the continuation of the 24 DISEASES OF THE STOMACH AND INTESTINES duodenum. It is hard to determine where the one ends and the other begins. The jejunum occupies the upper two-fifths of the remaining small intestines, or about 9 feet, 7 inches (2.9 meters) ; the ileum the lower three-fifths, or about 14 feet, 5 inches (4.3 meters), and ends at the ileocecal junction. Their position is not fixed, but the jejunum is more apt to occupy the left side of the abdominal cavity, with the loops more transverse; while the ileum is usually found on the right side and in the pelvis, with the loops more vertical. The coils of the jejunum and ileum are very movable and are completely invested by peritoneum. They are supported and attached to the posterior parietes by the mesentery, w'hich is attached above to the left of the vertebrae on a level with the lower border of the pancreas. The mesentery runs downward and to the right and presents the form of a fan, the intestines hanging on it in the form of coils. The diameter of the jejunum is about ij inches (3.81 cm.), and this gradually diminishes in size to the ileum; and in this, in turn, the diameter decreases until its entrance into the large intestine. The ileum passes nearly perpendicularly into the ascending colon, its mucosa forming a double valve (valvula Bauhini). The jejunum and ileum are the most movable parts of the intes- tinal tract. They are often met with in hernias, and if pregnancy, a tumor, or ascites are present, the intestines move up and escape compression. Occasionally Meckel's diverticulum (the remains of the vitelline duct), a process 2 or 3 inches long, is given off from the ileum, on an average of i to 2 feet above the ileocecal junction. It is of import- ance in reference to intestinal obstruction. Arterial Supply of Small Intesti'ne. — The duodenum is supplied by the pyloric branch of the hepatic, by the superior pan- creaticoduodenal branch of the gastroduodenal branch of the hepatic and by the inferior pancreaticoduodenal branch of the superior mesenteric, and the jejunum and ileum by the superior mesenteric artery. They branch into small vessels which run through the intestinal wall, ramify in the submucosa, and form the capillary system of the villi and glands. Veins. — The venous blood flows partly into the superior gastric vein and partly into the superior mesenteric vein and empties into the vena porta. Lymphatics. — The lymphatics are divided into those of the mucous membrane and muscular coat, and form plexuses. They run between the folds of the mesentery and end in the mesenteric lacteals, and so on into the intestinal lymphatic trunk and thoracic duct. They are provided with valves to prevent a backward flow. Nerves. — The duodenum is supplied by the hepatic plexus, a branch of the celiac plexus, with branches of the right vagus. The superior mesenteric plexus, formed by nerves from the ANATOMY OF THE STOMACH AND INTESTINES 25 celiac plexus, the semilunar ganglia, and right vagus, supph- the jejunum and ileum. The nerves enter the intestinal wall with the blood-vessels and form a subserous net. They then penetrate the longitudinal muscu- lar fibers and form between these and the circular muscular fibers ramifications consisting of numerous groups of multipolar cells (Auerbach's plexus), from which fine branches supply the muscular tissue. Other branches penetrate the circular muscular layer to the submucosa, where they form the submucous nerve plexus (Meissner's plexus), and branches supply the muscularis mucosae, the muscles of the villi, and end in the mucosa. Structure of the Small Intestine. — The small intestine is composed of four coats : serous or peritoneal, muscular, submucous, and mucous (Fig. 6). Fig. 6. — Longitudinal cross-section through the wall of the small intestine: I, Mucous layer; 2, muscularis mucosae; 3, submucous layer; 4, muscular layer; 5, subserosa; 6, serous layer; 7, intestinal villi; 8, intestinal glands (Lieber- ktihn); 9, blood-vessels; 10, solitary lymph nodule; 11, center of same. The serous coat is formed by the visceral layer of the peritoneum. The muscular coat consists of an internal circular layer and an external longitudinal layer, the former being considerably the thicker. They consist of bundles of unstriped muscular tissue supported by connective-tissue fibers. The submucosa consists of connective tissue in which blood-vessels, lymphatics, and nerves ramify. The mucous membrane comprises a thin muscular layer (muscu- laris mucosae), containing circular and longitudinal fibers and the tunica propria of the mucous membrane, which is made up principally of reticular connective tissue, with leukocytes, glands, villi, and an epithelial covering. The mucosa is of a grayish-red color, appears velvety, and forms crescentic folds, set transversely to the long axis of the intestine (valvulae conniventes of Kerkring, Fig. 7). Each valve extends from one-half to two-thirds of the circumference of the gut, and they may be 2 inches long and } inch wide. They begin a short distance below the pylorus, at the middle of the jejunum commence to diminish 26 DISEASES OF THE STOMACH AND INTESTINES in size, and gradually disappear at the lower part of the ileum. They serve to increase the absorptive surface of the mucous membrane. muscular coat mesentery x Tular folds (+ intestinal villi) Fig. 7. — A portion of the jejunum showing the circular folds or valvulae con- niventes of Kerkring (Sobotta). Microscopic Anatomy of the Small Intestine. — The inner surface of the small intestine is composed of villi and glands, the surface being covered by a layer of columnar epithelial cells, with striated borders and some goblet- cells. The villi are formed chiefly by elevations of the tunica propria of the mucous membrane. They are from .5 to .7 mm. in height and about .1 to .2 mm. in width, and number about ten millions (Fig. 8). Each villus has a central space for chyle, which cavity is covered with endothelial cells and connects with the lymphatics of the mucosa. The villus has blood-vessels and muscular fibers which are derived from the muscularis mucosae. It expands when filling up with blood, and when the muscle contracts it shrinks. Fig. ileum; —Mucous membrane of Intestinal glands (Lie- berkiihn); b, intestinal villi; c, solitary lymph nodule (follicle) . ANATOMY OP THE STOMACH AND INTESTINES 27 The villi thus have an action of suction and pumping, and also form the chief organs for absorption in the small intestine. Around the villi are numerous glands; the tubular glands of Lieberkiihn and the acinous glands of Brunner. The latter are confined to the duodenum. The glands of Lieberkiihn resemble in structure the tubular glands of the stomach, and cover almost the entire surface of the small and large intestine. Each tubule is from .3 to .4 mm. long, and opens without ramifications. They form the chief organ of intestinal secretion and number over forty millions. Brunner's glands are found only in the duodenum and are most abundant at its commencement, diminishing in number lower down. They He beneath the mucosa, being embedded in the submucosa. They resemble the pyloric glands of the stomach, but are more Fig. 9. — Longitudinal cross-section through wall of duodenum: i, Mucous layer; 2, muscularis mucosae; 3, submucous layer; 4, circular muscular layer; 5, longitudinal muscular layer; 6, intestinal villi; 7, intestinal glands (Lieber- kiihn); 8, Brunner's duodenal glands; 9, serous layer. branched and convoluted, and their ducts are longer. They are lined with columnar epitheHum. The duct of the gland passes through the muscularis mucosae and opens on the surface of the mucosa (Fig. 9). Solitary follicles (or glands) are scattered throughout the mucous membrane of the small intestine and are most numerous in the lower ileum. They have a diameter of 2 to 6 mm. (Fig- 10). The follicles consist of a dense retiform tissue packed with lymph- corpuscles and permeated by capillaries. They have no ducts. The spaces in this tissue are continuous with lymph-spaces at the base of the gland and the base of the follicle is in the submucous tissue. The gland enters the mucous membrane, causing a slight projection of its epithelial layer. Lvmph-cells develop in these follicles. There are no villi on their surface. 28 DISEASES OF THE STOMACH AND INTESTINES These follicles are scattered singly through the intestine as solitary glands, or collected into groups, known as Peyer's patches or mesentery x '''■i'' circular folds solitary lymphatic nodules Fig. lo. — A portion of the ileum showing solitary lymphatic nodes (Sobotta). ■-K circular ^folds ^'---i^nrj:" aggregated lymphatic nodules mesentery x ■ (Peyer's patch) Fig. II. — A portion of the ileum, cut open along the line of attachment of the mesentery, showing Peyer's patch and solitary lymphatic nodes (a) (Sobotta"). plaques, or as the agminate glands. These last may be from i to 3 inches long and h inch wide, usually oval, with the long axis parallel ANATOMY OF THE STOMACH AND INTESTINES 29 with that of the intestine. They He generally opposite the attach- ment of the mesentery, are twenty to thirty in number, and are found chiefly in the ileum, though a few are present in the jejunum (Fig. u). Anatomy of the Large Intestine. — The large intestine, which is about 5 to 6 feet (1.5 -1.8 meters) long, extends from the termina- tion of the ileum to the anus, and is divided into the cecum (or caput coli) , the colon, and the rectum. Its caliber is largest at the cecum, and this gradually decreases until it reaches the ampulla of the rectum, when it again increases in size. Fig. 12. — Partial section of colon: 1, Free tenia; 2, tenia mesocolica; 3, appen- dices epiploicae; 4, mucosa; 5, semilunar folds; 6, mesocolon.- The large intestine, excepting the rectum, is characterized by three longitudinal unstriated muscular bands or teniae (Fig. 1^2), with sacculation of the walls between these bands and by the appen- dices epiploic^, or external pouches formed by the peritoneal covering and containing fat. The circular muscular fibers also accumulate in bands with intervals between them, thus forming expansions or semilunar folds across the colon (haustra coli) (I'ig. 13). The cecum (caput coli) is that part of the colon lying below the ileocecal valve (Fig. 14). It is about 3 inches (7.5 cm.) broad and 30 DISEASES OF THE STOMACH AND INTESTINES 2§ inches (6.3 cm) long, and lies in the right iliac fossa above the outer half of Poupart's ligament, being completely covered by semilunar folds lumen omental __ band ~ 'free band Fig. 13. — A segment of the colon (Sobotta) ; Haastra coli. peritoneum. When filled, it is situated close to the abdominal wall. The vermiform appendix, a small blind tube, hollow nearly to the free band ascending colon post, frenulum of valve. upper lip of valve.. semilunar folds lower lip of valve vermiform process Fig. 14. — The cavity of the cecum (SobottaV tip, is given off generally from the posterior and inner portion of the caput coH, about \\ inch (1.7 cm.) below the ileocecal valve. ANATOMY OF THE STOMACH AND INTESTINES 3 1 Its average length is 3^^ inches (9.2 cm.). It may be much shorter or longer. The diameter is about \ inch (6 mm.) at base and y^^ inch (5 mm.) at apex. It may be slightly larger at the middle. It is usually guarded by a valve (crescentic fold) where it enters the cecum. It has a meso-appendix (mesentery) only extending about two-thirds its length. The position of the appendix is not fixed and it may point in various directions. The colon is depicted in Fig. 2 1 . The ascending colon, about 8 inches (20 cm.) in length, extends vertically upward from the cecum to the inferior surface of the right lobe of the Hver to the right of the gall-bladder, at which point it bends to the left (hepatic flexure). It passes along the posterior abdominal muscles and lower part of the right kidney, and is in relation to the abdominal wall in front. It is bound posteriorly by connective tissue to the muscles, and is only covered by peritoneum anteriorly and laterally. The transverse colon, with an average length of 20 inches (51 cm.), extends from the hepatic flexure beneath the liver transversely across the abdominal wall, with a slightly downward and forward convexity at its center, to the spleen in the left hypochondrium (splenic flexure). It has a long mesentery, transverse mesocolon, connecting it with the posterior abdominal wall, and is the most movable part of the large intestine. It usually corresponds to a line separating the umbilical and epigastric regions. The liver, gall- bladder, greater curvature of the stomach, and lower end of the spleen lie above it; the small intestine lies below; the descending duodenum and small intestine behind; the great omentum and abdominal wall in front. At the splenic flexure below the lower end of the spleen, the colon turns downward (descending colon). This is about 8^ inches (21.5 cm.) long, and extends from the splenic flexure vertically through the left hypochondriac and lumbar regions to the sigmoid flexure. It is covered anteriorly and laterally by the peritoneum, and passes down in front of the left kidney and quadratus lumborum and iliac muscles, to the left iUac fossa into the sigmoid flexure. The sigmoid flexure of the colon (S. romanum) is an S-shaped curve, about 13 inches (31 cm.) long, beginning at the iliac crest and ending at the brim of the true pelvis opposite the left sacro-iliac articulation. The upper, or colic, limb tends down, inward, and forward toward Poupart's ligament, while the lower, or rectal, limb hangs down into the true pelvis, where it joins the rectum. The sigmoid flexure has a complete peritoneal covering, or mesentery, is very movable, and is the narrowest portion of the large intestine. The rectum, which is about 8 to 9 inches (20-23 cm.) long, passes from the left sacro-iliac junction obliquely to the middle of the sacrum, and follows it down to the bottom of the pelvis to about I inch (2.5 cm.) below the tip of the coccyx, where it passes downward and backward to end in the anus. It is divided into three portions. 32 DISKASES OF THE STOMACH AND INTESTINES Only the first part, 35 inches (9 cm.), of the rectum is completely- invested with peritoneum (mesorectum) , and it is attached to the sacral vertebrae. The second part is partially invested with peri- toneum (pouch of Douglas), which lies anterior and ascends over the bladder or vagina. The third part has no peritoneal investment. The lower half of the rectum passes between the organs occupying the pelvic floor and is adherent to them by connective tissue. The rectum is surrounded by connective tissue below the pouch of Douglas. It is widest at the point opposite the prostate, there forming the ampulla of the rectum. The outer longitudinal muscular fibers of the rectum are not arranged in teniae, as in the colon, but are present in all parts of its circumference. The inner circular layer of muscle-fibers increases in density from above downward and forms a thick ring at the anal opening (the internal sphincter). The w^alls of the rectum are connected at the anus with the sphincter ani and levator ani muscles, which are of importance in defecation. Arterial Supply of the Cecum and Colon. — They are the ileocolic, colica dextra, and colica media from the superior mesenteric artery; the colica sinistra and sigmoid from the inferior mesenteric artery. Veins of the Cecum and Colon. — These are the superior and inferior mesenteric, emptying into the portal system. Lymphatics of the Cecum and Colon. — Those of the sigmoid colon empty into the lumbar glands; those of the rest of the colon into the mesenteric glands. Nerves of the Cecum and Colon. — The cecum, ascending colon, and right half of the transverse colon are supplied by the superior mesenteric plexus, a branch of the celiac plexus. The rest of the colon, including the sigmoid flexure, is supplied by the inferior mesenteric plexus, a branch of the aortic plexus. Arterial Supply of the Rectum. — They are the superior hemor- rhoidal (of the inferior mesenteric) ; the middle hemorrhoidal (of the internal iliac) ; the inferior hemorrhoidal (of the internal pudic) ; branches from the sacromedia (of the abdominal aorta) ; branches from the sciatic (of the internal iliac) ; in the female, branches from the vaginal. Veins of the Rectum. — They are chiefly from the superior hemorrhoidal, passing to the inferior mesenteric and to the portal system; part of the other hemorrhoidal veins empty into the internal iliac veins, and so enter the general venous system. Anastomosis thus occurs in the rectum between the portal and the general venous system, and there is a communication also with the other abdominal veins. Lymphatics of the Rectum. — They empty into the sacral and lumbar glands from the rectum; from the anus into the inguinal glands. ANATOMY OF THE STOMACH AND INTESTINES 33 Nerves of the Rectiim. — The cerebrospinal nerves come from the sacral plexus ; the sympathetic nerves from the inferior mesenteric and superior hypogastric plexus. HISTOLOGY OF THE LARGE INTESTINE The large intestine (colon), like the small intestine, consists of four coats: serous, muscular, submucous, and mucous. The longitudinal muscular fibers of the large intestine, however, are arranged in three bands (teniae) running along the wall, as already described. The serosa and submucosa resemble those of the small intestine in structure. The mucosa of the large intestine differs from that of the small intestine in that the villi and circular folds of Kerkring (valvulae conniventes) are absent. The glands of Lieberkiihn are somewhat longer and at times curved. The mucous membrane of the rectum is thicker, redder, and more generously supplied with blood-vessels than that of the colon. When the rectum is empty the mucous membrane of the upper part is thrown into a multitude of superficial transverse velvety folds. From two to seven folds (Houston's valves) are made more prominent by distention (Gant). Just above the anus are a number of longitudinal folds (columns of Morgagni), extending for | to -f inch (8.46-15.23 mm.). The mucous membrane of the rectum consists of columnar epithelium, except at the lowest portion, a narrow la)-er of stratified pavement-like epithelium, transitional between skin and rectal mucosa. The upper part of the rectum resembles the colon. 3 CHAPTER II PHYSIOLOGY OF DIGESTION ■ The stomach and intestines form an important part of the diges- tive tract, and in order to understand their functions it will be neces- sary to review briefly the process of digestion. This term includes those processes which convert the food into such condition that it becomes fit to enter the circulation and afford nutrition to the human organism. These changes are brought about by means of certain ferments contained in the saliva, gastric juice, bile, pancreatic juice and intestinal juice, which are a part of the human organism at birth. There are certain fermentative and putrefactive processes which take place in the gastro-intestinal canal, the result of bacterial invasion, which play an important part in the physiolog}^ and pathology of this tract. The first ferment (ptyalin) with which the food comes in contact by the act of chewing, is found in the saliva. The latter is alkaline in reaction, of low specific gravity (1.002 to 1.0009), and contains water, ptyalin, mucus, epithelia, albumin, and salts. The ptyalin, which converts starch into maltose, or sugar, begins its action on the food already in the mouth, but the principal uork is done during the first period of digestion within the stomach. Under normal conditions during this early stage of gastric digestion the free hydrochloric acid is becoming combined acid, and the action of the ptyalin continues; but if the free hydrochloric acid be exces- sively secreted, further digestion of the starch is interfered with; this physiologic fact has a bearing on the treatment of hyperchlor- hydria. We must remember that thorough mastication of the food, which promotes salivary secretion, and the care of the teeth have an important bearing on digestion. It has been demonstrated that acid fermentation in the mouth interferes with the action of the saliva, and that cleansing the mouths of nursing infants will diminish fermentative processes in the gastro-intestinal tract. Hemmeter has apparently recently demonstrated on dogs that the salivary glands secrete a chemical substance during mastication which passes into the blood and starts up the secretion of the gas- tric juice. After extirpation of the glands, HCl and rennin were much reduced. Intravenous injection of salivary gland extracts partially restored gastric secretion. 34 PHYSIOLOGY OF DIGESTION 35 THE GASTRIC JUICE Hydrochloric acid was discovered in the gastric juice by Prout in 1824; and Beaumont, in 1833, by his experiments on St. Martin with his gastric fistula, greatly advanced our knowledge. Schwam, in 1836, discovered the pepsin ferment; and Bedder and Schmidt, in 1854, showed that the acid of the gastric juice is hydrochloric acid. The gastric juice is a clear, colorless fluid, of an acid reaction and a specific gravity of 1.002 to 1.003. It contains w-ater, salts, inorganic matter, proteids, h3'drochloric acid, pepsin, rennet, and recently a fat-splitting ferment has been discovered. The quantity of this secretion in twenty-four hours is estimated to be about 3 pints. The degree of acidity varies from o. i to 0.2 per cent. Pepsin and rennet when first secreted are inactive bodies, known as pepsinogen and rennet-zymogen, but on coming into contact with the hydrochloric acid become converted into active pepsin and rennet. Various theories have been advanced to explain the production of the gastric juice, hew an inorganic acid comes to be secreted by the blood which is of alkaline reaction. We are so far forced to accept the view that the secretion of the gastric juice must be due to the specific action of the cells. Through the combined action of hydrochloric acid and pepsin, it converts the albuminates into propeptones and peptones, which are more soluble. The rennet ferment curdles the milk. A small percentage of fat is split into fatty acids. It has the property of converting cane-sugar into grape-sugar, and gelatin into a soluble peptone which does not coagulate. Some of the substances contained in the Hquefied chyme are absorbed through the stomach-walls, such as peptone, sugar, salts, and possibly propeptone. Meltzer has demonstrated that only a small quantity of water is absorbed in the stomach. The residue of the gastric contents passes into the small intestine, where further digestive processes occur through the action of the other ferments and the principal absorption takes place. The motor function of the stom.ach is of importance in the process of digestion, as by its active and passive movements physical changes are brought about in the ingesta. The food is brought more closely in contact with the stomach-walls and becomes more Hquefied. The pylorus opens and closes at intervals, and allows the entrance of the chyme into the small intestine, the exact intervals of which we do not know. About two to three hours after a small meal and six to seven hours after a large meal the stomach is empty. Cannon^ has studied the movements of the stomach by the rc-rays, by administering food mixed with bismuth, and by observa- tion with a fluoroscope. He found that the contractions start in the middle of the stomach and pass toward the pylorus at regular intervals. The pyloric end of the stomach lengthens out and the 1 American Journal of Physiology, 1898. 36 DISEASES OF THE STOMACH AND INTESTINES peristaltic waves increase during advanced digestion. At intervals the pylorus relaxes and the contraction squeezes part of the chyme into the duodenum. Cannon^ finds that carbohydrates pass out soon after ingestion and require only about one-half the time that proteids do for gastric digestion. Fat when taken alone remains for a considerable time in the stomach, and if combined with other food its exit is dela)^ed. It is believed that chemic stimuH, such as hydrochloric acid, control the opening and closing of the pylorus. If atony of the stomach be present, motor insufficiency and stasis result, and the latter favors fermentation and putrefaction. It has been demonstrated that the presence of hydrochloric acid in con- siderable quantities does not prevent these conditions if stasis be present. INTESTINAL DIGESTION Under normal conditions, when the chyme enters the duodenum its reaction is acid. It is here subjected to the influence of the bile, pancreatic juice, and intestinal secretions, all of which, in their action, have a more or less close interdependence upon each other. Bile. — The bile in the intestine precipitates the pepsin from the chyme. This, however, is soon dissolved. Others hold that albu- minoids are precipitated from the chyme, together with the pepsin, and are then more readily absorbed. It does not have a deleterious effect on the pancreatic digestion. The bile is one of the chief factors in gradually altering the reaction of the chyme to neutral or alkaline, and it strongly supplements the action of the pancreatic juice in emulsifying fats, and its absence or diminution lessens this function. Pawlow believes that it may augment slightly the effects of the other pancreatic ferments. One of its chief functions is undoubtedly excretory, and through it many of the useless products of metabolism are eliminated. When absorbed into the system it acts as a poison and produces a definite toxemia. The bile is a clear, tenacious mucoid fluid with an alkaline reaction, consisting of water, bile-acid salts (glycocholic and taurocholic acid), pigments (bilirubin and biliverdin), mucin, cholesterin, lecithin, soaps, fats, etc. ; about 500 to 600 cc. are excreted in twenty-four hours. Wm. H. Porter^ believes that the precipitation of the pepsin from the chyme through the action of the bile is necessary for the action of the pancreatic ferments, and the enterokinase of the intestinal juice, as the pepsin, as long as it remains active, inhibits their action. Some consider that it has antifermentative and antiputrefactive powers, and that it helps to maintain the nutrition of the epithelial 1 American Journal of Physiology, 1904. - Indicanuria a Danger Signal, Postgraduate, 1907. PHYSIOLOGY OF DIGESTION 37 cells. Lindenberger has shown experimentally that a small amount of bile combined with .05 per cent, of lactic acid prevents putrefac- tion in an infusion of pancreas, while lactic acid alone has no effect. Von Noorden holds that bile has no antiseptic action. Clinically, we at times see cases of indicanuria with the presence of bile in the urine, with light-colored stools in \vhich there is no permanent disappearance of indican, though there is a temporary improvement after the use of calomel, etc., until the biliary excretion into the intestine is restored to normal. The internal use of the bile-salts, which can be given as inspissated bile, seems to be of some value. Bile possesses slightly purgative qualities. The liver has special functions. Many of the substances taken up by the digestive process are stored there until used in the system, namely, some of the peptones and sugar in the form of glycogen. It excludes some poisonous matters from the circulation. Thus it is the chief organ for the removal of indol and poison, such as curare or of various autotoxins. Urea is also formed in the liver. Pancreatic Juice. — The pancreatic juice is the principal factor of digestion in the intestinal canal. It is clear, colorless, alkaline, sticky and odorless, quite albuminous, containing water, solids, proteids, and inorganic matter. The most important constituents are the three ferments: Amylopsin, an amvlolytic enzvme, which converts starch into- maltose, and still further into glucose. Cane-sugar is converted into grape-sugar, while milk-sugar is unchanged. Some of the cellulose ferments form marsh-gas and various acids. The activity of pancreatic diastase is increased by very small quantities of acids (Chittenden). Steapsin, a lipolytic ferment. This acts upon fats by splitting them into fatty acids and glycerin; and this action is increased by the bile. The fatty acids combine with the alkalis in the intestine to form soaps, which aid in the emulsifying of fats, and thus promote their absorption. The emulsification occurs in an alkaline medium, or in contact with the alkaline secretion of the mucous membrane. Trypsin, a proteolvtic ferment, changes the proteids into albu- moses and peptones. There is probably a rennet-zymogen also. The fermicnt acts in a neutral or alkaline medium, though slight degrees of acidity seem to favor it. Indol is a product of intestinal putrefaction, and not from the action of the pancreatic ferment, as was formerly supposed. The same is true of hypoxanthin. The secretion of the pancreatic juice is not reflex, but is due to direct excitation of the cells of the pancreas by secretin (Starling). This is formed in the mucous membrane of the duodenum and jejunum and reaches the pancreas bv the blood-stream. The passage of the chyme over these portions of the small intestine stimulates the production of secretin or, rather, splits it off from " presecretin," which is present in the mucous membrane. 38 DISEASES OF THE STOMACH AND INTESTINES The intestinal juice (succus entericus) consists of water, albumin, mucin, and salts. Ptyalin and an inverting enzyme have been discovered therein. It seems to neutralize the acids formed by the fermentation of the carbohydrates and the presence of mucin shows it to be of service in aiding peristalsis. Pawlow's experiments demonstrate that it augments the activity Qi the pancreatic ferments, especially of trypsin. The fat-splitting and amylolytic pancreatic ferments are augmented by the succus entericus from all parts of the small intestine, while that from the duodenum augments chiefly the proteolytic ferment. Pawlow found enterokinase, a ferment of other ferments, which is believed to be necessary to excite intestinal ferments into activity. Erepsin, another ferment, is also present, which transforms hemi-albuminose into other bodies. Organized Ferments. — There exist in the intestine fermentative and putrefactive changes produced by micro-organisms.^ At birth the gastro-intestinal tract is sterile, but rapidly, by the ingestion of food and through the air and by the anus, bacteria of various types enter this tract. Herter^ has estimated their number at one hundred and twenty- six billions for the daily human excreta. Many of them are no longer living. He considers the chief function of the obHgate bacteria (Bacillus lactis aerogenes, Bacillus coH, and Bacillus bifidus) to be their capacity for checking the development of other types of organ- isms capable of doing injury, though they themselves under certain conditions may produce much harm. Many other varieties are described. Some observers believe that there is a so-called normal fermentative process which aids -in the digestion of cellulose, though Bergman claims there are enzymes (intracellular) which decompose it. The fermentative processes in the small intestine caused by the action of bacteria on the carbohydrates (Bacillus lactis aerogenes) leads to the formation of ethyl alcohol and various organic acids, such as lactic, acetic, paralactic, succinic, biliary acids and albumin, peptone, mucin, sugar, etc. These organic acids are believed to prevent putrefaction within the intestine, to partly check the decom- position of the carbohydrates, and to aid in producing intestinal peristalsis, which render putrefaction less likely. The lactic acid in koumyss, matzoon, bacillac and lactone milk, and even in plain milk (to a slighter degree), is believed to lessen putrefaction. In the lower jejunum and ileum the reaction is acid. When the intestinal contents pass into the colon the reaction becomes alkaHne, fermentation stops, putrefaction begins, and the 1 Proceedings American Medico-Psych. Association, April 21, 1905. Some Observations on the Relations of the Gastro-intestinal Tract to Nervous and Mental Diseases (Kemp). 2 Bacterial Infections of the Digestive Tract. PHYSIOI.OGY OF DIGESTION 39 fecal odor appears. The colon bacilli are marked factors in this process. The decomposition of the albuminates caused by bacteria goes much further than that produced by pancreatic digestion. Albumoses, peptones, lysin, ammonia, amido-acids, etc., are produced in both cases, but with putrefaction the process goes further and we have new products formed, such as indol, skatol, paracresol, phenol, various acids and gases, such as sulphuretted hydrogen, marsh-gas, carbon dioxid, etc. Some of these products of decomposition are eliminated unchanged in the urine, such as the oxyacids, others, like the phenols, after further oxidation, and others, like indol and skatol, after combination with ethereal sulphuric acids. For example, indol forms an indoxyl- potassium sulphate or indican, and is so eliminated in the urine; and thus may be an indication of the amount of putrefaction occurring in the intestine. The causes of indicanuria are various, such as excessive proteid diet, catarrh of the small intestine causing alterations in the mucosa and increased intestinal putrefaction therefrom, typhoid, cholera, a pus-cavity, constipation, alimentary putrefaction, decrease of normal digestive fluids, intestinal obstruction, and peritonitis. Certain drugs, such as salol, salophen, and creosote, will give nearly similar reaction, while urotropin will cause its disappearance. These possible conditions must all be considered. As the intestinal contents pass through the large intestine they become thickened through the absorption of fluids and are at last eliminated as feces. These comprise the remains of undigested material, excretory material from the intestines, and man}- micro- organisms. The quantit}^ of feces depends upon the character of the food, being greater after a vegetable diet. The average amount after a mixed diet is about 100 to 150 gm. The reaction of the feces is ordinarily alkaline, though occasionally variable. The odor is chiefly due to skatol, and the color is a light or dark brown. Absorption from the Intestines. — Absorption chiefly occurs in the small intestine. The proteids are usually changed into albumoses and peptones before absorption occurs. Albumin may be absorbed as such, though not as quickly. Absorption of the albumoses and peptones takes place by the capillaries and not by the lacteals. They are reconverted into albumin before reaching the blood-current, probably either b}^ the epithelial cells or leukocytes. It has been shown experimentally that they do not reach the blood as peptones. Albuminates from animal food are more completely absorbed than those from vegetable food, on account of the indigestibility of the cellulose and the increased peristalsis caused by the latter. 40 DISEASES OF THE STOMACH AND INTESTINES Absorption of the Carbohydrates.- — These are chiefly absorbed as monosaccharids through the capillaries of the villi, enter the liver through the portal vein, and are retained as glycogen for use in the animal economy. If sugar is absorbed in excess, it may enter the general circulation and be excreted by the kidneys, so-called alimentary glycosuria. It may also cause diarrhea. Carbohydrates, as starch, are absorbed without difficulty. Glucose, levulose, and galactose are absorbed as such, while cane-sugar and maltose are first changed to these products. Milk- sugar is unchanged and absorbed as such, or undergoes lactic-acid fermentation. Absorption of Fats. — The greatest amount is absorbed as an emulsion (both fats and fatty acids), though some absorption takes place in the form of soaps. They become neutral fats after absorp- tion. They enter the lacteals probably through the action of the epithehal cells of the intestinal wall and reach the thoracic duct. The absorptive power for fat in the small intestine is considerable, probably over 300 gm. per day. Olive oil and butter (fats with a low melting-point) are absorbed more quickly than mutton fat, for instance (fat with a high melting-point), and a free fat, such as butter, is taken up more quickly than bacon, which contains considerable connective tissue. Water, salts, some of the secretory juices, and bile are readily absorbed. Disease or removal of the pancreas stops the absorption of fats, except of milk, of which part is absorbed in emulsified form. Absorption in the Large Intestine. — Water, fluids, and salts are well absorbed, in fact, markedly absorbed, as is noted by the change in the character of the intestinal contents. Albumin and carbohydrates are absorbed in considerable amount and fats in small quantities. Advantage is taken of this fact for the employment of nutritive enemata. Intestinal Peristalsis (Motor Function). — The contents are thoroughlv mixed by the movement of the intestines, and the residuum left after digestion is expelled through the anus. There are three types described : The intestine contracts at a certain point and then relaxes, and continues this in successive segments progressively toward the anus, pushing the contents forward {ordinary peristaltic movements). Oscillating movements, by which the coil is moved to and fro along the mesentery, with no particular contraction. The contents are mixed up by these movements and not propelled forward. Rotary movements, by which a coil contracts in a circular direction rapidly along the intestine for 15 or 20 cm. in a violent manner. The last is usually pathologic and occurs when there is con- PHYSIOLOGY OF DIGESTION 4 1 siderable gas, after indiscretions in diet, or in stenosis. It is observed only in the small intestine. Peristaltic action is much more rapid in the small intestine. After ingestion of a small meal the stomach becomes empty in about two hours, the small intestine in the same length of time ; but in the large intestine it takes at least twenty hours before the contents are expelled. Nothnagel has never seen a physiologic antiperistalsis (reversed peristalsis) beginning from the anal direction upward toward the stomach, though some^ describe an intermittent antiperistalsis occurring in the ascending colon. It is said that strong injections of salt water into the colon will produce this effect. Nervous Control of Peristalsis. — Auerbach's and Meissner's plexuses are probably the automatic centers for peristalsis, but there are central agencies. For example, fright or excitement may cause diarrhea. The splanchnic nerve contains inhibitory fibers for the control of intestinal peristalsis. Ehrmann claims that the longitudinal muscles are stimulated by the splanchnics and inhibited by the vagus, and the circular muscles stimulated by the vagus and inhibited by the splanchnics. The ch3'me acts as the normal stimulus to peristalsis through the nerves. Toxic material that has been ingested or developed in the intestinal canal, indigestible food, organic acids from excessive fermentation, and too hot or too cold drinks, may overstimulate the peristaltic action and be the cause of diarrhea. 1 W. B. Cannon, Amer. Jour. Physiol., vol. vi., p. 253, has demonstrated by the Rontgen rays that antiperistaltic movements occur normally in the cecum, ascending and transverse colon, thoroughly churning and mixing the food, and bringing it in more perfect contact with the absorbing surface of the colon. CHAPTER III INTERROGATION OF THE PATIENT (HISTORY) In every case suffering from symptoms pointing to the gastro- intestinal tract, before the physical examination is undertaken, the patient should be carefully interrogated as to his general history and the past and present symptoms. I shall briefly indicate the form of taking and preserving the history of such cases : Date Diagnosis No. of patient Name Nativity Age Occupation Sex Family History Tuberculosis: Rheumatism: Syphilis: Malaria: Diphtheria: Influenza: Scarlatina: Nephritis: Typhoid : Heart disease : Gout: ' Disease of liver: Habits Tea — cups: Sexual excess: Coffee — cups: Mastication: Tobacco: Character of food : Alcohol: Past History of Present Complaint Began : Duration : Onset — Sudden: Gradual : Probable cause: Symptoms — Progressed : Same in character: Changed in character: Loss of flesh — Present: Increasing: Absent : Bowels — Constipation: Mucus: Diarrhea: Blood: Alternating: Odor: Regular: 42 INTERROGATION OF THE PATIENT (HISTORY) 43 Present Condition and History Headache — Character: Location: Time of: Vertigo — Nervousness: Drowsiness: Sleeplessness: Appetite — Good: Bulimia (canine hunger) Anorexia (loss): Polyphagia: Time: Akoria: Parorexia (perversion) : Thirst: Taste — Normal: Sour: Bitter: Sticky: Time: Deglutition: Dysphagia — With solids: With liquids: Abnormal sensations — Bloating: Pressure: Fulness: Weight: Time : Belching — Quantity: On empty stomach : Time of: Odor: On full stomach: Regurgitation— Water-brash : Sour: Time : Rumination: Pyrosis (heart-burn) — Time: Duration: Pains— Location : Circumscribed : Cardialgia: Diffuse: Gastralgia: Radiating: Character : Sudden : Time of appearance: Slow: Duration : Relieved by pressure: Affected by position: Increased by pressure; Affected by food or drink: Local tenderness — Position: Nausea — Time: Affected by food : 44 DISEASES OF THE STOMACH AND INTESTINES Vomiting — Time : Frequency: Quantity : Character of: Odor: Taste : Stools — Regular: Constipation: Diarrhea: Alternating constipation and diarrhea: Number of movements: Blood and its character: Bile: Mucus: Easy: Difficult: Relief of pain by: Time of appearance: Undigested food: Mucus: Blood: General character: Bile: General health and strength — Loss of weight: Symptoms Referable to Circulatory System Symptoms Referable to Nervous System Chief Complaint After the physical examination has been made, the results should be incorporated with the history, as should also the data secured from examination of the gastric contents and stool. General Physical Exam,ination Comprises — Tongue: Uvula: Tonsils: Pharynx: Teeth: Eyes — as to difficulty in reading or headache therefrom; exophthalmos. Nose — as to nasal discharge. Ears — as to deafness. Heart: Lungs: Liver: Tenderness: Motor function: Typanitis: Gastric analysis: Tumor : Stomach — Position: Normal : Dilated: Gastroptosis: Spleen: Kidneys — Position : Urine : Intestines — Position : Tender points: Thickening: Rectum — Local examination: In some cases microscopy and fermentation test of stool. Nervous system: Weight of patient: Examination of genital organs — in some cases. Tympanitis: Borborygmi : CHAPTER IV GENERAL METHODS OF PHYSICAL EXAMINATION As patients who complain of digestive disturbances may suffer from disease of other organs which may be the cause of the symptoms, a thorough physical examination should be made in everv case. The first step should be an examination of the heart and lungs. The character and rapidity of the pulse and respiration should be noted and a specimen of urine requested for analysis. In all acutely commencing processes pointing to the digestive tract, the temperature should be taken. GENERAL INSPECTION The general appearance of the patient may afford valuable information. With cancer, there is often the sallow and emaciated appearance (cachexia) with anemia ; with gastric neurosis, the patient may often appear rosy and well nourished; while with ulcer there is frequently marked anemia and the face may have the appearance of suffering. Protrusion of the eyeballs, with inability of complete closure of the lids, taken in connection with tachycardia, are suggest- ive of Graves' disease, even though no thyroid enlargement be present. The skin should be inspected for eruptions and the exanthe- mata. Oral Cavity. — This should be carefully inspected. Defective and carious teeth or inflammation or abscess of the gums may give rise to gastric disorders. Disease of the posterior nares or middle ear, with resulting discharges passing into the pharynx, may be factors. The tongue was formerly regarded as a mirror of the stomach, but it can, hardly be so considered, as there are some gastric affections in which the appearance of the tongue is normal; while in smokers, for example, the tongue may be coated and yet no gastro-intestinal disturbance be present. A thick gray or grayish-yellow, moist, coated tongue showing indentations is suggestive of chronic gastritis; while with ulcer it may be dry and red with a white median stripe, or sm.ooth and moist, or slightly furred. The condition of the mouth, smoking, drinking, and the teeth, have a decided bearing on its appearance. This is true in reference to the odor of the breath. I hardly deem the tongue diagnostic in diseases of the gastro-intestinal tract except in association with other symptoms. 45 46 DISEASES OF THE STOMACH AND INTESTINES AVith the typhoid state, we have the narrow tongue, with the deep median fissure, thickly furred, the tip and edges being red and denuded, or the dry brown, fissured, and tremulous tongue; while with scarlet fever and in some other acute specific infections there is the so-called strawberry or raspberry tongue, with bright red projecting papillae. The uvula is sometimes elongated, and may cause reflex digestive disturbances. In the pharynx and tonsils there may be inflammatory conditions of an acute or chronic type which influence the case. Inspection of the neck is important. Enlarged thvroid with tachycardia is diagnostic of Graves' disease, and a swelhng to the left of the larynx, which increases in size after the ingestion of food, is suggestive of a diverticulum of the esophagus. Examination of the Esophagus. — The cardinal svmptom of esophageal disease is dysphagia, with or without regurgitation. The object of examination is to determine whether a stricture or a diverticulum is present. Palpation of the esophagus is possible in the neck, usually on the left side behind the trachea. A tumor found here mav be a diverticulum distended with food or fluid. It is sometimes possible to empty it by the exertion of pressure. A brawny swelling, in some cases with subcutaneous emphvsema, may result from perforation or rupture of the esophagus, with inflammation, which proceeds to suppuration. An abscess in this locality may be due to caries of the vertebrae. Auscultation of the esophagus is often of ser^'ice. Place the stethoscope posteriorly, to the left of the spine, at the level of the sixth dorsal vertebra, and at a signal let the patient swallow a mouthful of water. At the instant of swallowing . the deglutitorv sound is heard, followed in six or seven seconds by the esophageal bruit, which resembles the sound one hears when swallowing saliva. Three to five seconds later there is a second sound caused by the fluid entering the stomach or by regurgitation of air. If the first sound is dela3'ed longer than seven seconds, or replaced by a splashing or gurgling noise, or if the second sound is delated longer than five to twelve seconds, partial stenosis may be suspected. If both sounds are absent, there is probably nearly complete or complete stenosis. Gurgling sounds lasting several minutes and heard along the left side of the spine are probably due to contractions in a diverticulum, or in the dilated portion of the canal above a stricture. Instrumental examination of the esophagus is made by flexible stomach-tubes of various sizes, the safest method, or by flexible solid bougies or sounds. • The esophagoscope is of chief value in locating foreign bodies and aff"ording direct means of removal. In the use of the sound one must remember that it is 6 inches from the incisors to the commencement of the esophagus at the GENERAL METHODS OF PHYSICAL EXAMINATION 47 cricoid cartilage; 9 inches to the crossing of the left bronchus, and 16 inches to the cardiac orifice of the stomach. There is normally some constriction of the esophagus at these three points. Obstruction to the passage of the tube may be due to esophageal spasm, but by waiting this will usually subside. I have found that in some of these cases a large tube can be passed more readily than a small one. If the tube pass readily on one occasion and refuses to pass on another, it has probably slipped into a diverticulum, or the latter has filled up and by pressure prevented the passage of the instrument. If the obstruction is permanent, one must decide whether it is due to stricture (narrowing) or external pressure, such as from aneurism, tumor, or enlarged glands. Syphilis, cancer, and con- traction following burns from acids or alkalis are the principal causes of stricture. Congenital stricture is rare. If stricture be present, the locality, caliber, and permeability must be determined. Locality. — Pass the tube to the strictured point, nip it close to the incisor teeth, and measure the distance from here to the entering tip of the tube after withdrawal. Caliber. — Sounds of varying diameters will determine the caliber by finding one which will pass the obstruction. By the esophageal bruit and the use of a somewhat rigid sound one can tell whether or not the obstruction is permeable. Occasionally small portions of new growth may be found in the openings of a fenestrated tube. Blood shows ulceration or erosion. Contra- indications. — The tube should never be passed if there is aneurism of the thoracic aorta or recent vomiting of blood. Examination of the Abdomen. — The special methods of physical examination of the stomach and intestines are described in the parts of this volume devoted to these subjects. It seems advisable to refer to the general methods of examination of the abdomen and the other viscera. Anatomic Landmarks. — The ensiform appendix and down-curved arches of the ribs constitute the upper bony landmarks. The iliac crests, anterior superior spines of the iha, and the symphysis pubis in the median line are the lateral and lower boundaries. The linea alba lies between the recti muscles in the median line, runs from the ensiform appendix to the pubic symphysis, and is visible as a groove above the umbilicus. The umbiHcus is somewhat variable in its position, though usually lying about 2 inches above the bispinal line drawn transversely between the anterior superior spines of the ilia. The recti muscles lie on each side of the linea alba and are bounded externally by the lineae semilunares, which run with an outward curve from the lowest part of the seventh rib to the pubic spines. These lines lie on each side about 3 inches from the umbilicus. 48 DISEASES OF THE STOMACH AND INTESTINES Topographic Areas. — In order to describe the situation of organs or lesions, the surface of the abdomen is divided into regions, of which the method depicted in Fig. 15 is in general use. There are nine regions divided off by four lines, two horizontal and two vertical. The horizontal lines are the infracostal or sub- costal, drawn transversely at the level of the inferior borders of the tenth ribs, and the bispinal line, connecting the anterior superior spines of the ilia. The vertical lines pass through the center of Poupart's ligament on each side and are downward prolongations of the mammillary lines of the thorax. The boundary lines between the epigastric and hvpochondriac regions correspond with the costal margins, and the iliac regions correspond to the so-called inguinal regions. Fig. 15. — Topographic areas of the abdomen. A second method of dividing the abdomen is by a vertical and transverse line through the umbilicus, forming four quadrants. - In reference to the various landmarks, one often measures dis- tances by the finger-breadth. The average finger-breadth is f inch; two, i\ inches; etc. A hand-breadth averages 3^ to 4 inches. Preparation of the Patient and Technic. — The patient should preferably lie in bed in the dorsal position, quite flat, with the head on a single thin pillow. The same posture should be assumed if the examination be made on the office table. The bedclothing should be drawn well down, except the sheet, under cover of which the nightdress or undershirt should be drawn up to the lower sternum, and the sheet then folded down to a short distance above the pubes. GENERAL METHODS OF PHYSICAL EXAMINATION 49 The sheet may not be required in the office, though generally prefer- able. The patient should lie as symmetrically as possible, with the pubic spines at the same level and a good light secured. It is of value to make an observation also in the sitting or standing position, as pro- lapse of the abdominal ivalls or viscera can thus be more clearly seen. Inspection. — Inspection should be from the front, sides, and back. It is of great importance. With excessive abdominal distention the skin is smooth, shining, and stretched. Copper-colored, scaly, somewhat circular spots are significant of secondary syphiHs; and whitish streaks, or striae, of long-continued distention, such as from pregnancy or ascites. Typhoid eruption or exanthemata may in some cases be in evidence. Glandular enlargements in the groin or old scars are suggestive of venereal infection. Inguinal or femoral hernia may be observed. Inspection of the blood-vessels often affords valuable information. Enlarged veins radiating from the umbilicus (the caput medusae) are significant of portal obstruction, cirrhosis, or tumor of the liver. General enlargement of the abdominal veins may be present in similar conditions, or from pressure on the venae cavae by thoracic or abdominal tumors. If a dilated lateral vein is present running up the right midaxillar}^ line, it should be emptied by massage, and the method of its repUing carefully observed. If the portal vein, or the inferior vena cava, is obstructed, the direction is upward; but if the superior vena cava is pressed upon, the direction is downward. Distention of the veins in the pubic region alone shows some probable obstruction below the liver. Enlarged epigastric arteries are diagnostic of obstruction of the aorta or iUacs. An umbilicus that protrudes is suggestive of hernia, ascites, pregnancy, or some form of abdominal distention. Absence of respiratory abdominal movements, with accentuation of thoracic respiration, is significant of peritonitis. Peristaltic unrest (visible peristalsis) is usually diagnostic of stenosis of the pylorus or intestines or of intestinal obstruction. It may rarely occur normally in thin persons. One can at times infer the site of the obstruction by the location and character of the peristalsis. The waves run in the stomach from left to right and in the transverse colon from right to left. If the obstruction is near the ileocecal valve, the swollen and moving coils of the intestine lie one above the other in the central part of the abdomen (ladder pattern). If the constriction is lower down in the large intestine, the dis- tention is chiefly visible in the course of the colon (in the circumfer- ence of the abdomen). A recurring protuberance at one point, disappearing with a loud sound, is probably near the point of stenosis. 4 50 DISEASES OF THE STOMACH AND INTESTINES Protrusion from tumor can at times be observed. Method of Abdominal Palpation. — The right hand should be warmed and laid flat upon the surface of the abdomen, the physician sitting to the right of the patient (Fig. i6). Palpation should be at first by somewhat circular pressing movements, sliding the skin over the parts beneath, and passing from one portion of the abdomen to another. One should not poke suddenly with the finger-tips. Gradually deeper localized palpation may be made with the finger-pulps to determine the presence of tender spots, or the shape, size, and mobility of existing masses or swellings. The facial appearance of the patient rather than the verbal expression tells whether true pain is present. Tender- ness suggests inflammation or ulceration. McBurney's point should always be explored for appendicitis. If firm pressure elicits ten- derness, it is apt to be real and deep seated, rather than a surface lesion or hyperes- thesia. If hysteria is suspected, the patient's attention can be diverted by pressing on a dif- ferent part of the surface with one hand, while the other hand explores the original seat of pain complained of. Absence of true tenderness is thus fre- quently revealed. If the abdominal muscles are contracted, the knees and thighs should be flexed and a pillow placed beneath the head and shoulders to secure relaxation. The flexion of the lower limbs I believe prefera- ble in every case. Deep and rapid respirations at the end of expiration relax the muscles momentarily and render examination more easy. This method aids in differentiation; whether the mass felt is due to contraction of the belly, of a muscle, such as of the rectus, and whether a tumor is movable with respiration. Howard Kelly recommends vibratory movements with the fingers while palpating. In some cases reinforced palpation, the left hand exerting pressure over the right, as in Fig. 17, is of value, especially in examination of the deeper organs. During examination forced respiration should be taken, and at each expiration the abdominal wall should be Fig. 16. — Abdominal palpation. GENERAL METHODS OF PHYSICAL EXAMINATION 51 pressed upon firmly, maintaining during inspiration the ground which has been gained. This method is of special service in determining a chronic enlarged appendix, as suggested by Edebohls and R. T. Morris. If there is fluid in the peritoneal cavity and one desires to palpate an organ which is obscured by its presence, sudden deep pressure wdth the finger-tips ("dipping") wdll displace the fluid. In some cases a general anesthetic may be necessary for a thorough examination. All the regions of the abdomen should be explored, the umbilical, the inguinal, and femoral regions being examined for hernia. When the lateral regions are examined, both hands should be employed, one being slipped under the body so as to make forward pressure between the last rib and iliac crest, thus pushing forward the structure against the examining hand in front. At times it may be of service to examine in the knee-elbow position, or with the patient standing and leaning forward, supporting himself with the hands by a table or chair. If he is very fat, it is often useful to have him turn partly on the side, thus ' ' spilling ' ' the intestines and fatty abdominal walls away from the region under investigation. Digital rectal and vaginal ex- amination are very necessary in manv cases, especiallv when the 1 • ' • •, i J • ii. 1 Fisr. 17. — Reinforced palpation. lesion IS situated m the lower ^ ' ' ' third of the abdomen. Rigidity of one or both of the recti muscles is of great diagnostic importance, being significant of peritoneal irri- tation, local peritonitis (if one muscle be involved), or general peri- tonitis if both recti and all the abdominal muscles are afTected. Occasionally a rigid rectus is found on the side of a pneumonia or diaphragmatic pleurisy. The upper segments of one or both recti may be rigid in abscess of the liver, or in subphrenic abscess, or of the right rectys in acute cholecystitis; the right rectus, especially the lower segment, in appendicitis; and the left rectus in diverticulitis, or in left-sided pelvic inflammation. Mensuration of the circumference of the abdomen at the level of the umbilicus and of the length of its anterior wall from the ensiform 52 DISEASES OF THE STOMACH AXD IXTESTINES to the symphysis, are of use in noting the increase of ascites or the growth of a large tumor. An uneven protuberant surface is char- acteristic of a malignant growth ; an even surface is more often found in benignant neoplasms or intussusception. A fecal tumor can usually be indented and as the finger is raised the intestinal wall slips from the mass. Percussion of the Abdomen. — With the exception of pulmonary resonance, which we note in defining the upper limits of the stomach and liver, and splenic and hepatic dulness, the normal abdomen is tvmpanitic. From the presence of food in the stomach or fecal accumulation in the intestines there are variations, with resulting dulness or even flatness. The percussion note over the sigmoid flexure and lower part of the descending colon is quite frequently dull, owing to the tendency to fecal accunmlation in these regions. In general, we mav say that the pitch of the resonant note varies w'ith the size of the air space and the degree of tension of the con- Simple percussion. taining cavity; the smaller the air space and the greater the tension, the higher is the pitch. Hence, the empty stomach and colon would afford a lower pitched note than the small intestine. The presence of food and liquid in the stomach modifies the results of percussion, as do also feces in the large intestine. For example, with an empty stomach we have tympanites; and then quite frequently a change in note over the transverse colon to dulness or even flatness; or with the partially full stomach and empty intes- tine, tympanites above, then dulness or flatness over the contents and intestinal tvmpanites below. It is well, therefore, to have the large intestine cleared out by enema before examination. Practically we find in many cases stomach tympanites with change in note over the colon due to some contents. Among the best methods of percussion are simple percussion with the finger or hammer, flicking percussion, auscultatory per- cussion, and the "scratch method" of auscultation. GENERAL METHODS OF PHYSICAL EXAMINATION 53 In simple percussion, the middle finger of the left hand should be laid flat on the abdomen (the pleximeter) and the mid-finger of the right hand, bent at right angles, should be employed as the plexor, as depicted in Fig. i8. The other fingers and thumb should be folded into the palm of the hand. Fig. 19. — Percussion hammer. In Fig. 19 is shown the method with the percussion hammer and the correct position. The finger is preferable as a pleximeter, as the rubber instruments interfere with the sounds. "Flicking percussion" is useful in detecting slight degrees of dulness. Fig. 20. — Flicking metliDd of pL-rcussiiJU. The forefinger or middle finger of the left hand should be placed nail downward on the surface; the middle finger of the right hand is well flexed, so that the nail is pressed against the palmar surface of the thumb. It is then suddenly allowed to escape, so as to strike sharply against the palmar surface of the finger lying on the abdomen (Fig. 20). 54 DISEASES OF THE STOMACH AND INTESTINES Auscultatory percussion is probably of greatest value in outlining contiguous air-containing viscera. The stethoscope is placed over the organ and the normal note secured by percussion close to the instrument. Then percussion is carried out, beginning at some distance, from above, below, and laterally, and the change of note observed. This method and the "scratch" method will be described later in outlining the position of the stomach and intestines. If the percussion note of a deep-seated mass is to be elicited, the pleximeter finger must be pressed slowly and firmly down in order to push aside or compress air-coils of intestine which would mask the note. If dulness is present where it should not exist, it should be ascertained whether it disappears or shifts with changes in the position of the patient, i. e., whether it is fluid. If the distention is due to ascites (fluid) , the center of the abdomen is flattened and the lateral and dependent portions bulge outward, providing the fluid is not excessive. If it is very great, the abdomen is arched and prominent, the umbilicus is bulging or stretched, and the shape is not changed when the posture is altered. On percussion, the flanks are dull and the center of the abdomen tympanitic, as the intestines float to the highest point. Unless the quantity of fluid is excessive the line of dulness changes its position, as the patient is turned on the side the fluid gravitating to the lowest point and being replaced by the tympanitic intestine. The upper flank, previously dull, is now tA^mpanitic. If a small amount of fluid is suspected, percussion in the umbilical region in the knee-elbow position will give dulness, when it was tympanitic in the dorsal position. Fluctuation may be elicited if there is considerable fluid. The ulnar edge of a nurse's or assistant's hand should be pressed firmly on the linea alba, to cut off muscular vibrations. One hand of the examiner is placed upon one lateral abdominal wall, while he should tap sharply with the fingers on the opposite side. If fluid is present, a transmitted wave — at times visible — will be felt by the palpating hand. With tumors, enlargement of the abdomen is not symmetric. Percussion does not show the uniform resonance of gas nor the lateral dulness and central tympanites of fluid, and palpation dem- onstrates the solidity of the mass. With gas, the abdomen is arched and tense, universally tym- panitic, and fluctuation cannot be obtained. Sources of Error. — The segments of the recti muscles when contracted may simulate a small tumor. By insinuating the tips of the fingers under the edge of the apparent tumor and having the patient raise the head and shoulders, the muscle is felt to contract and thicken. Fig. 21. — Relations of the viscera. Anterior view: L, L, Lungs; A, heart; B, liver; C, stomach; x, gall-bladder; D, colon; E, small intestine. / Fig. 22. — ^Relations of the viscera. Posterior view. GENERAL METHODS OF PHYSICAL EXAMINATION 55 A localized contraction of the abdominal muscles or a persistent gaseous distention of a portion of the intestines ("phantom" tumor) may be deceptive. These occur, as a rule, in hysteric women and • are dull or tympanitic, depending on the above conditions. They disappear during rapid forced respiration or under anesthesia. Fitz believes that some "phantom" tumors are congenital or acquired dilatation of the colon. Auscultation of the Abdomen. — Sounds in the Abdominal Cavity. — In the healthy intestines there are always bubbling or gurgling sounds heard on auscultation. The entire absence of sound is significant of intestinal paresis. With mechanic obstruction the sounds are usually increased in intensity and number. In intestinal paresis, usually due to peritonitis, the heart and respiratory sounds may be audible over the entire abdomen. This is not true in tympanites due to other causes. Crepitation or friction sounds are at times heard in peritonitis, as in perihepatitis in the right hypochondrium, or in the left h^^pochondrium with perisplenitis. The venous hum or aneurismal bruit of abdominal aortic aneurism can be appreciated, or occasionally a venous hum over the liver from pressure on the vena cava. If pregnancy is present, there are the fetal heart sounds. The sounds over the stomach are of little diagnostic value, except the duration of the swallowing sound. TOPOGRAPHIC ANATOMY The position and relations of the stomach and intestines have been described, but for the purpose of physical diagnosis we must briefly refer to the normal relations of the other abdominal viscera. In Fig. 21 are depicted diagram.matically the relations of the organs on the anterior surface of the body, and in Fig. 22 the relations on the posterior surface. The Liver. — The general shape is that of a wedge with its base in the right hypochondrium, the upper surface lyhig in relation to the vault of the diaphragm, and its lower surface with the stomach, duodenum, gall-bladder, transverse colon, and small intestines; its anterior, lateral, and posterior portions are in relation with the abdominal parietes and lower right ribs. Delimitation of the Normal Liver. — Mark a point i (Fig. 23) at the lower border of the fifth rib, between the left parasternal and mammillary lines, or about 2 to 2h inches from the left edge of the sternum. Point 2 lies in the fourth right intercostal space in the mammillary line. From 2 to i draw a connecting line, slightly convex upward on the right half and concave on the left, curving down at the lowest point to the base of the ensiform appendix. From 2 draw a line nearly horizontally to the right and pos- teriorly, which should cut the midaxillary line in the seventh space 56 DISEASES OF THE STOMACH AND INTESTINES and the scapular line in the ninth space, to the midspinal Hne. This Hne, front, side, and back, corresponds to the upper border of the Hver. To dehmit the lower border, mark point 4 in the median Hne (linea alba) about a hand-breadth (3^ to 4 inches) below the base of the ensiform process of the sternum. ]Mark point 3 at the lower edge of the ninth right costal cartilage, and another point 5 at the edge of the left costal arch on a level with the lower border of the sixth rib. A line should then be drawn from 3 to 4 upward and to the left. At 4 is indicated the notch between the liver lobes. From 4 a shghtly curved hne to i , passing through 5, should next be drawn. The line from 3 to i indicates the lower anterior border of the organ. Fig. 23. — Delimitation of the normal liver (diagrammatic): G, Gall-bladder. From point 3 draw a Hne backward and to the right, cutting the tenth intercostal space in the midaxillary line, from which point it joins the spine at a level of the eleventh rib (Fig. 24). This line demarks the lower border of the liver laterally and posteriorly, and is a continuation of the anterior inferior border. This illustration shows diagrammatically the relations of the lower borders of the lung, .pleura, and liver in the midaxillary Hne. The left lobe lies to the left of the linea alba and extends nearly to the nipple, the notch lying in the midline. In the right mammil- lary line the liver extends from just below the level of the nipple to the costal margin. GENERAL METHODS OF PHYSICAL EXAMINATION 57 The horizontal shadings in Fig. 23 show the portion of liver overlapped by lung, and the vertical shadings, that overlapped by the heart. Fig. 24. — Lower border of liver (midaxillary line). The gall-bladder, which is pear shaped, lies just internal to the ninth right costal cartilage. PHYSICAL EXAMINATION OF THE LIVER AND GALL-BLADDER Inspection. — The method advocated by M. Knapp I have found most practical. The patient stands with the abdomen uncovered facing a good light, the examiner slightly to the patient's right, so as not to interfere with the exposure to light. The lower edge of the enlarged liver shows on the abdomen as a linear transverse shadow, moving up and down with respiration and being especially prominent at the close of expiration, when there is a sudden check to the movement. Pulsation can occasionally be observed. Ex- treme enlargement may cause fulness in the right hypochondrium. An enlarged gall-bladder can be appreciated in the same manner. Inspection may also be made with the patient in the dorsal position, the examiner stooping so as to bring the eyes on a level with the abdomen. 58 DISEASES OF THE STOMACH AND INTESTINES Palpation. — The head and shoulders should be slightly raised and the knees and thighs flexed, the patient being in the dorsal position. The examiner, sitting on the right side of the patient, should lay the right hand flat on the abdomen below the right costal arch, the fingers pointing upward and obliquely inward just to the right of the right rectus. Depress the fingers and feel for the resistant edge of the liver. The patient should be directed to take deep respira- tions, and by pressing inward and upward with the fingers the edge of the organ can be felt to move up and down. As the liver may be enlarged, palpation for its lower edge must be begun from the level of the umbilicus upward. It is often neces- sary to feel for the notch of the gall-bladder or round ligament to determine whether it is the edge of the liver which is felt on palpation. One should note whether the edge is sharp or thick, or smooth or irregular. In some cases with thick abdominal walls the liver may Fig. 25. — Spilling the liver. be "spilled" against the latter by turning the patient on the right side, as in Fig. 25, thus rendering palpation more easy. The hand in this case may be in the reversed position. The surface of the liver should be palpated, the left lobe in the epigastrium and the portion projecting below the ribs, if it be enlarged. One should observe whether it is rough, smooth, nodular, or whether large tumor-like masses are present ; also whether it is hard or soft and fluctuating; or if there is a thrill (hydatid), or friction during respiration, or pulsation. If the abdomen is distended the "dipping" method of palpation may be necessary. The empty gall-bladder is not palpable. If distended it feels like a smooth pear-shaped tumor, moves with respiration, and is movable laterally, unless there are adhesions. If malignant growth is present, the gall-bladder is irregular and nodular. If there are many gall-stones, Hutchinson describes the feel as of a "bag of nuts." GENERAL METHODS OF PHYSICAL EXAMINATION 59 Percussion of Liver and Gall-bladder. — For anterior and lateral percussion the patient should lie down; for percussion pos- teriorly he should be sitting or standing. The upper part of the right lobe is overlapped by the lung, and of the left lobe, a small area is covered by the left lung and heart. Percussion over the covered part gives impaired pulmonary resonance, or modified dulness (deep, relative, or covered hepatic dulness). The part in contact with the parietes gives absolute dulness (superficial or exposed dulness). It is necessary to delimit the entire area. Percuss downward, first in the mammillary line, beginning at the second intercostal space; then in the midaxillary line from the fourth interspace, and in the scapular line from the angle of the scapula. Percussion should then be made from below upward, in the midline from the umbilicus and from lateral and posterior points below the ribs. Covered Hepatic Dulness. — Strong percussion should be employed, commencing above in the areas noted, and watching for the change from pure pulmonar}^ resonance to impaired resonance, which denotes the presence of the liver. Impaired resonance is found normally in the fourth space in the mammillary line; in the seventh space in the midaxillary line; and in the ninth space in the scapular Hne. Upper Limit of Exposed (Absolute) Hepatic Dulness. — Gentle percussion should then be employed and normally absolute liver dulness appears in the mammillary line at the sixth rib; midaxillary line at the eighth rib.; and in the scapular line at the tenth rib. Lower Limit of Hepatic Dulness. ^Gentle percussion along the lines previously indicated from below upward will differentiate between tympanites and hepatic dulness. The lower limit normally is in the median line anteriorly a hand-breadth (3J to 4 inches) below the ensiform; in the mammillary line, the tenth space. In the scapular line, it joins the dulness of the right kidney. The vertical width of liver dulness is normally in the mammillary line 4 inches; in the midaxillary, 6 inches; in the scapular, 3. inches. Percussion of the Gall-bladder. — This is only possible when it is distended x)r enlarged, in which event there is an area of dulness projecting downward and inward from the lower border of the liver and continuous with the dulness of the latter. In some cases the transverse colon may pass over the neck of the distended gall-bladder and separate its dulness from that of the liver by a tympanitic area. This is important to remember. Auscultatory Percussion of the Liver. — The stethoscope should be placed over the middle of the area of the liver anteriorly, laterally, and posteriorly, and percussion be carried out on the' lines already described. As a rule, simple percussion is sufficient; but the auscul- tatory method is of special value to determine whether a tumor is connected with the liver or not. 6o DISEASES OF THE STOMACH AND INTESTINES Thus in Fig. 26 the stethoscope is placed over point 5. The note over the tumor T resembles more closely in intensity and quality the percussion note over the liver at C than it does over the point A. General enlargement of the liver may be due to passive congestion, usually from valvular disease of the heart, amyloid disease, cancer, fatty infiltration, hypertrophic cirrhosis, leukemia, abscess, gumma, or, rarely, Weil's disease. Circumscribed enlarge- ment of the liver, i. e., of the left lobe, is usually due to abscess, hydatid cyst, gumma, or cancer. Downward displace- ment of the liver is caused by various intrathoracic lesions, such as emphy- sema, effusions, etc., by subphrenic abscess, or as a part of a general ptosis of Fig. 26.-Tumor of liver. the viscera. In downward displacement the upper surface, especially of the left lobe, is readily accessible to palpation and presents a rounded surface. A prolapsed liver does not move as freely with respiration, on account of its separation from the diaphragm. The consistence of the hver is somewhat diagnostic. It is abnormally hard, dense, and resistant in cirrhosis, carcinoma, amyloid disease, or syphilis. A fluctuating swelling at the lower border may be a distended gall-bladder, abscess, or hydatid cyst. The surface is smooth in fatty infiltration or degeneration, in passive congestion, and in amyloid disease; it is rough in tubercular peritonitis and granular to the feel in cirrhosis. Hard nodules, varying in size, are suggestive of cancer; smooth, elevated prominences occur with gummata. A smooth projection may be due to abscess or cyst. Topography of the Pancreas. — The pancreas (Fig. 27) lies about 3 inches above the umbilicus, midway between the navel and the ensiform appendix, corresponding to the level of the second lumbar vertebra. It is about 6 inches long and lies deep in the epigastrium, trans- versely across the spine, with its head resting in the cur^^e of the duodenum and its tail extending to the spleen. The stomach covers it in front. It is rarely accessible to direct examination. The head of the organ lies in close relation to the inferior vena cava, portal vein, and common bile-duct, which are posterior. A cancer or growth of the head of the pancreas may press upon these blood- GENERAL METHODS OF PHYSICAIv EXAMINATION 6i vessels and cause edema and ascites, or upon the bile-duct and produce persistent jaundice. Pain, fatty diarrhea, ascites, glycosuria, and jaundice may result from pancreatic disease. Physical Examination. — Normally the pancreas cannot be pal- pated unless the patient is extremely emaciated. An important physical sign of pancreatic disease is the presence oj a tumor in the median portion of the epigastrium, midway between the navel and ensiform process. It is deep seated and often nothing more than a sense oj resistance can be appreciated by the palpating hand. Fig. 27. — The pancreas. The diseases in which these conditions are present are acute hemorrhagic or suppurative pancreatitis, chronic pancreatitis, and tumor — either carcinomatous or cystic. Topography of the Spleen. — The spleen is oval, flattened in shape, and lies in the left hypochondriac region, measuring on an average 5 by 3 inches. It reaches from a point i^V inches from the midspinal line posteriorly nearly to the midaxillary Hne, lying along the ninth, tenth, and eleventh ribs, the long axis being parallel with the ribs and running obHquely forward and downward, as in Fig. 30. The lower two-thirds of its outer surface lie against the lateral abdominal wall, and the upper third is overlapped by the diaphragm, which separates it from the lower border of the left lung. The diaphragm lies above and the left kidney posteriorly, and it is in contact elsewhere with the stomach, pancreas, colon, and small intestine. 62 DISEASES OF THE STOMACH AND INTESTINES The anterior border is sharp and indented by two to four notches. Physical Examination of the Spleen. — Inspection. — If the spleen is greatly enlarged, it may be visible as a protuberance extend- ing from the left hypochondrium downward and inward, moving with respiration. Palpation. — With the patient in the dorsal position and the knees and thighs flexed, the examiner on the right side of the bed should lay the right hand flat on the abdomen and with the finger- tips exert pressure, pushing obliquely upward under the left costal margin at the tenth cartilage. The edge of the enlarged spleen can, as a rule, then be felt. If it is not palpable, then request the patient to take deep breaths, when the sharp edge of the organ, which is smooth and usually notched, moving with respiration, will be felt riding over the finger- tips and directed downward and inward. Fig. 28. — Examination of the spleen. " Spilling the spleen." The left hand may be placed posteriorly between the ends of the tenth and eleventh ribs and firm pressure be made, so as to tilt the organ forward and thus make palpation more easy. Normally the spleen cannot be felt. If the organ is enlarged a depression or space, into which the finger-tips can be sunk, can be detected at the posterior border of the enlarged spleen between it and the erector spinae. An excellent method of palpation of the spleen is shown in Fig. 28. By turning the patient on the right side, combined with posterior pressure, palpation is rendered easier. It is often necessary to differentiate between tumor of the left kidney or spleen. The spleen is oval, moves with respiration, is notched, has a sharp edge, a gap is present between it and the lumbar muscles, and it has no tympanitic resonance over it. GENERAL METHODS OF PHYSICAL EXAMINATION 63 The kidney is reniform in shape and rounded, has no sharp edge or notch, and is overlaid by tympanitic resonance (Fig. 29). Percussion of the Spleen. — The patient may be recumbent, partially turned to the right, midway between the dorsal and right lateral position, with the left arm extended over the head; or the examination may be m.ade in the sitting posture. Percussion should be light, except over the posterior portion near the kidney. :^f:; I^H 1 OF LUN G. P>i ^^V '•^MARGIN OP RIB3. ^^f. jmKf J^^r L >^"' ^^^0ii^'- 1 r 1 . 'i'fi*' ■ .. i« ■i^r^ i^., Fig. 29. -S, Tumor of spleen; K, tumor of kidney, by tympanitic colon. Kidney tumor overlaid It should be carried out along the lines .4, B, C, D in Fig. 30. Anterior percussion at the costal margin along the tenth rib, along A until the tympanites of the stomach is replaced by dulness usually at midaxillary line. From above percuss along B, commencing at the level of the angle of the scapula midway between the posterior axillary and scapular lines, passing vertically downward until pul- monary resonance is impaired, generally at ninth rib. Percuss from below upward along line C, commencing below the border of the ribs, in or sHghtly posterior to the posterior axillary line, and passing upward until tympanites becomes dull, usually at eleventh rib. Posteriorly percuss strongly from midspinal line at level of tenth rib and along the latter. Splenic dulness should commence i^ inches from the median spinal line. It is difficult to determine. The area of splenic dulness is oval, 2 to 2^ inches by 3 to 3I inches. Dulness of over 3I inches, on vertical percussion, shows enlargement. 64 DISEASKS OF THE STOMACH AND INTESTINES Pleuretic effusion, consolidation at the left base, and fecal accu- mulation in the splenic flexure, may obscure percussion of the spleen. Palpation is the most important method and the most accurate. Acute enlargement of the spleen occurs with infectious diseases, such as typhoid, malaria, etc., and in septic processes; chronic enlargement, with leukemia, malaria, cirrhosis of the liver, amyloid disease, pernicious anemia, etc. The organ m^ay be displaced downward by intrathoracic pressure. Fig. 3o.^Lines for percussion of spleen. Abscess, carcinoma, or hydatids may cause an unequal enlarge- ment. Liver and spleen may be enlarged together in passive con- gestion, cirrhosis of the liver, leukemia, and in amyloid disease. A floating spleen may occur as a result of congenital laxity of its ligaments or to overstretching from the increased size or weight. It may be part of a visceroptosis, usually in women. It is recognized by its mobility, shape, ' sharp edge, and notches. Topography of the Kidneys. — The two kidneys lie against the posterior abdominal wall, one on each side of the spinal column, in beds of fat and connective tissue. They are of reniform shape. The upper end of the right kidney is in contact with the liver, and GENERAL METHODS OF PHYSICAL EXAMINATION 65 the left kidney with the spleen. They are retroperitoneal, the ascending and descending colon respectively lying in relation in front. The right kidney lies about ^ inch lower than the left. Each organ is about 4 inches long, 2 to 2^ inches in breadth, and i inch thick. Surface Relations of the Kidneys. — Draw a horizontal line through the upper margin of the unibiHcus; prolong the mammillary lines on each side downward until they intersect this horizontal line. The points of intersection lie about 3 inches on each side of the median line. From the intersections measure upward i inch on the right and 1 5 inches on the left mammillary line, and draw on each side a short Fig. 31. — Anterior surface of kidneys. horizontal line. The lower ends of the kidneys He at these levels (Fig- 30- One can- measure 3 inches on each side along the horizontal line and then upward, without drawing the mammillary Hne. The kidneys extend upward and inward about 4 inches, one-third to the outer side and two-thirds to the inner side of the vertical lines. Posterior Surface Relations of the Kidneys. — Draw a horizontal line across the back at the level of the tip of the spine of the eleventh dorsal vertebra ; a second line at a level of the tip of the spine of the third lumbar vertebra. On each side draw a vertical line from the upper to the lower horizontal Hues, i inch from the median line of the spine, and second vertical lines 2-} inches away from the first vertical lines. Within these outer parallelograms lie the kidneys (Fig. 32). 66 DISEASES OF THE STOMACH AND INTESTINES The lower ends of these organs lie from i to i^ inches above the iliac crests, the right J inch lower than the left. About a third of the upper ends are covered by the eleventh and twelfth ribs; the liver overlaps the right kidney and the spleen the left. Physical Examination of the Kidneys. — Inspection is seldom of service; palpation is most valuable; percussion is often uncertain. Inspection. — A large tumor of the kidneys may be visible in the anterior lumbar regions, extending into the umbilical region, with outward bulging of the ribs on the affected side, such as in the case / \ Fig. 32. — Posterior surface relations of kidneys: A, Lower border of lungs; B, level of spine of eleventh dorsal vertebra; C, lower border of liver; Z?, level of spine of third lumbar vertebra; E, colon. of sarcoma, hydronephrosis, or cyst. A perinephritic abscess may become visible as a swelling in the posterior lumbar region. Palpation. — This is most important. There are several methods described, of which the two following are the most practical: Method I. — The patient lies in the dorsal position, with the knees and thighs flexed, and the head is slightly raised to secure perfect relaxation. If the right kidney is to be examined, the left hand is slipped under the back, so that it rests on the two lower ribs and the lumbar space below thern. The right hand is laid flat on the abdomen in front, resting below the costal margin to the outer side of the rectus, as in Fig. 33. GENERAL METHODS O^ PHYSICAIv EXAMINATION 67 The patient should take deep and slow respirations, and during expiration firm pressure should be made with the fingers in front against posterior counterpressure, so that the kidney may be grasped between the hands. If the kidney is normal in position and size, the extreme lower edge can be felt if the abdominal walls are not too thick. If the lower quadrant of the organ can be clearly palpated, it may be considered a movable kidney (of the first degree). Various classifications of mobility have been given, some con- sidering the organ when palpable in half its extent, mobility of second degree ; entirely palpable, mobility of third degree ; and when descend- ing into the abdominal cavity, mobility of fourth degree. Others consider it movable if the entire length be accessible, especially if it Fig- 33- — Palpation of kidney (older method)." can slip down as far as the horizontal umbilical fine ; and if it can be displaced below this or across the abdomen, as a floating kidney. I believe that any kidney which can be palpated to one-fourth of its extent should be considered movable, and the subdivision into various degrees of mobility to be excellent. A movable kidney from strain or traumatism is comparatively rare. Occasionally we find a congenital floating kidney with no visceroptosis. As a rule, I believe that in about 95 per cent, of cases of movable kidney the condition is merely part of a ptosis of the abdominal organs, and it may be considered to be practically pathognomonic of this condition. The right kidney is most frequently movable, though both may be so. If the kidney is not found at its normal site, it should be searched for in the abdomen. 68 DISEASES OF THE STOMACH AND INTESTINES In examination of the left kidney, the position of the hands is reversed. Method 2. — This is, from personal experience, the most practical method of palpation, and the varying degrees of mobility can be detected with greater ease than by the method described. For examination of the right kidney, the patient sits up in bed, and the left hand of the examiner grasps the right flank, the thumb resting under the costal margin, the fingers posteriorly. The patient breathes deeply, or coughs, or bears down, and the kidney can be felt to slip down between the thumb and fingers, like "a pea in a pod, " or the lower margin or part of the kidney may be felt (Fig. 34). If the organ slips be3^ond the thumb and fingers or is not found in its normal position, then the left hand grasps the flank more Fig. 34. — Palpation of kidney. Step i. firmly and upward palpation is made with the right hand, as in Fig. 35, the patient gradually assuming the semi-oblique and, finally, the dorsal position, the final step, as shown in Fig. 36. A similar method with the patient standing is employed b}' Goelet, but the technic described seems preferable. For palpation of the left kidney, the position of the hands is reversed, the right hand grasping the loin and the left hand anteriorly. Tumors, hydronephrosis, and cysts of the kidney may be detected by palpation of the abdomen, as already described. Brewer's Point. — Tenderness at the costovertebral angle is diagnostic of an acute inflammatory condition of the kidney, such as infarctions, etc., and aids in differentiation between this condition, appendix adherent to the liver, and acute cholecystitis. GENERAL METHODS OF PHYSICAL EXAMINATION 69 Percussion of the Kidney. — The lower and part of the outer border of the kidney may at times be determined by percussion, comparing the dulness with the tympanitic note of the colon which lies ante- riorly. As a rule, the thickness of the muscles, peritoneal fat, or fecal accumulation render the results uncertain. Fig- 35- — Palpation of kidney. Step 2. Patient in semi-oblique posture. Position for Perctission. — The patient may lie on the abdomen, with one or two pillows placed underneath, to arch the back; or on the side, midway between the lateral and prone position, the physician Fig. 36. — Palpation of kidney. Step 3 (Unal,. Patient in dorsal position. sitting facing the patient's back and percussing the uppermost kidney. One should commence percussion in the middle of the area in which the kidney Hes (Fig. 32), using heavy strokes, and percuss 70 DISBASBS OF THE STOMACH AND INTESTINES outward until the kidney dulness is replaced by tympanites; also percuss downward in the same way. Increased dulness shows enlarged kidney. To Differentiate a Movable Right Kidney from the Distended Gall-bladder. — The kidney is movable in all directions, can be carried downward, does not move with respiration. Tympanites is found between it and the costal margin, the shape is reniform, and it may be pushed back into its normal position. The distended gall-bladder moves with respiration, can only be moved laterally; if pushed away from the abdominal wall, it tends to resume its original position; and there is no tympanites between it and the liver dulness. The chief causes of enlarged kidney are pyonephrosis, perine- phritic abscess, hydronephrosis, cyst, echinoccoccus, carcinoma, and sarcoma. An enlarged kidney tends to develop toward the front ; an abscess, posteriorly, between the last rib and the iliac crest. With enlarged kidney, the colon overlays in front of the tumor. With splenic tumor, this does not occur (Fig. 29). If in doubt, inflate the descending colon with air through a colon- tube or catheter. PART II DISEASES OF THE STOMACH CHAPTER V METHODS OF PHYSICAL EXAMINATION OF THE STOMACH General Considerations. — For an intelligent understanding of the subject, it is necessary to briefly define those conditions which constitute an abnormality in the position of the stomach and to differentiate between them. The greater curvature of the normally distended stomach hes about 2 to 3 fingers-breadth (ih-^l inches) above the umbilicus. The normal position of the organ has been indicated in Chapter I. It must be remembered that some possess an abnormally large stomach; and that it can only be considered to be dilated if there are symptoms associated which point to this organ. If there is atony of the stomach, with motor insufficiency, the patient having gastric symptoms, while the lower border of the stomach is de-fined at the level of the umbiHcus or below it, the lesser curvature maintaining its relations to the diaphragm, we may consider the organ to be dilated. This constitutes the atonic type of dilatation, which is extremely common. Many of this class suffer from auto- intoxication with nervous sequelae, and are found in great numbers in our asvlums and among our nervous cases. Attention may be diverted from the gastric symptoms and they may even be slight. As a result of pyloric spasm, or benign or mahgnant stricture of the pylorus, or any obstruction in the pyloric region interfering with the egress of the gastric contents, we have the so-called stenotic type of dilatation of the stomach. In these cases the lesser curvature retains its relation to the diaphragm, while the lower border extends to the umbilicus or below . it, and gastric symptoms are present to a marked degree and of a special type. With gastroptosis (prolapse of the stomach) the suspensory ligaments of the stomach are relaxed and the entire organ sinks, the lesser curvature as well as the greater. In aggravated cases the lesser curvature looks inward to the right, and the greater curvature 71 72 DISEASES OF THE STOMACH AND INTESTINES outward to the left. The pylorus may often lie below the level of the umbiHcus. With this condition, movable kidney — especially of the right organ — is present, and may practically be considered pathognomonic in my opinion, as only in about 5 per cent, or less of cases is mobility due to strain or injur}*. The congenital floating kidney, without ptosis of other viscera, is excessively rare. There may be various degrees of gastroptosis, a loop-shape, or even a vertical stomach similar to that of the fetal period, which are pictured in the chapter on Gastroptosis. The change in position of the lesser curvature is, therefore, diagnostic of gastroptosis, and not the position of the lower border of the stomach. The presence of movable kidney is also diagnostic. It seems advisable to describe the methods generallv employed, and at the end of the chapter to briefly summarize those which are of most practical value. Preparation of the Patient. — On the day or night previous to examination, the bowels should, if possible, be thoroughly emptied by a cathartic. If there is much tympanites, it should be relieved by a hot enema of about i liter (i quart) of normal saline solution or soapsuds and water; or, if the condition is marked, then by entero- clysis at 110° to 120° F. with a recurrent tube (Kemp's) or two catheters. This carries off the gas in a satisfactory manner. The patient should be examined in the dorsal, semi-oblique, and standing positions. Inspection. — Examination in the dorsal position should first be made. A recognizable bulging, distinct from the epigastrium, especially if it occur in the umbilical or hypogastric region, may be due to a dilated stomach; the epigastrium under these conditions is usually hollow and depressed. Inspection is often of assistance in thin patients, especially after artificial distention of the stomach with carbonic acid gas. Peristaltic movements of the dilated stomach are at times observed. Kussmaul has noted very active peristaltic movements in the dilated stomach (peristaltic unrest), the waves passing from the linea alba below the umbilicus in an upward direction and to the right to the lower margin of the liver. This is found present in cases in which stenosis of the pylorus exists. We can facilitate inspection by placing the patient upon a raised table, the head toward the window, the shades being arranged so that the light enters on a plane only slightly above that of the patient, and is directed from tbe head toward the feet. The examiner, standing toward the foot of the table and bending from side to side, can at times make out shadows cast by the inequalities of the abdo- men. The shadows move with respiration. By this method the size, shape, and position of the stomach can often be made out. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 73 Knapp places the patient in the same position, but stands at the side or at the shoulders, and brings his eyes down to the level of the abdomen and observes the respiratory waves passing over its surface. After some experience one can detect delicate transverse lines or waves passing upward and downward with respiration. These lines correspond to the curvatures of the stomach. ]\Iore recently he places the patient facing a good light, and, standing slightly to the side, observes the movements of the trans- verse lines. I have seen good results from this method, especially for determination of the lower border of the stomach. The following signs I have found quite reliable: With the patient in the recumbent position, a marked concavity between the costal arches — extending from the ensiform process to or below the umbilicus, with a vertical median sulcus, wider above than below, the abdomen being flattened in the central part and bulging in the lateral regions — is significant of gastroptosis. In the erect position the epigastrium becomes still more depressed, while the umbilical and especiallv the pubic regions bulge outvv-ard. Tumors of the stomach may sometimes be obser\'ed, causing slight projection or protuberance on the abdominal wall. Palpation of the Stomach. — Inspection should be supplemented by palpation. Palpation should be performed gently and the hands of the operator should be warm. The patient should be in the dorsal position with the legs flexed, to relax the abdominal muscles. He should breathe naturally and keep the mouth open to aid relaxation. The physician should be seated on the right side of the bed and palpate with the right hand, which should be flat or slightly bent upon the abdomen, with the ulnar side down. One can stroke from above downward, and with practice it is possible, in some cases, to feel the stomach-wall and appreciate the position of the greater curvature, as the stomach gives a more uniform elastic sensation than do the intestinal walls. Some commence palpation from below and work upward, dipping in the ulnar edge of the hand rather deeply. By these means it is at times possible to determine the position of the greater cur- vature. By palpation we can discover if nephroptosis is present. Dias- tasis of the recti muscles and floating tenth rib can also be deter- mined These conditions are significant of gastroptosis. Under "Inspection" I have noted the signs that are significant of gas- troptosis. If we find a "movable kidney, " this renders our diagnosis conclusive. By gentle palpation one can frequently discover a tumor, its position, size, consistency, and mobility. Occasionally, more pres- sure is necessary and the palpating hand may be reinforced by the other hand, after the method described. Sensitive or tender points can be located by palpation; for 74 DISEASES OF THE STOMACH AND INTESTINES example, the circumscribed tenderness of an ulcer or the diffuse tenderness of the gastric region in acute inflammation. Boas has devised an algesimeter for indicating the degree of pain. T. Kilmer has also an instrument for the same purpose. Considerable care should be exercised in palpation in cases of suspected ulcer, and I prefer the hand for this purpose. Percussion of the Stomach. — The accurate determination of the position and size of the stomach is often difficult by simple percussion. The sound varies, according to whether the organ is empty or filled with air, food, and water. The position of the patient, whether lying dow^n, semi-oblique, or standing, modifies the findings. In order to obtain results the stomach should contain some air. Dehio has demonstrated, both on living subjects and on the cadaver, that if the stomach is empty the tympanitic sound which we produce on percussion is due to the colon and not to the stomach, since the latter is contracted into the left concavity of the diaphragm and is not in contact with the anterior thoracic wall. Hence the time at which the examination is made is important. Moreover, the lower curvature tends to fall awa}^ from the abdominal wall. The patient should first be examined in the dorsal position with the knees flexed. This method determines wdth fair accuracy the upper right and upper left portions. The percussion hammer is sometimes an aid. The absolute determination of the lower border by percussion is more difficult. It is rendered easier if the bowels have been thor- oughly emptied, since the colon is then less likely to ride over the greater curvature. The percussion sound over the colon is lighter and does not equal that over the stomach. The stomach sound is of greater intensity and clearness and of higher pitch. This, of course, refers to conditions when air is present as the factor. Food or fecal contents alter the result, w^hich is further modified by per- cussion in the semi-oblique and standing positions. As a rule, there are some contents in the transverse colon, so that we have the tympanites of the stomach merging into dulness or flatness. With gastroptosis, determination of the position of the organ b}^ simple percussion is often difficult. The presence of a tumor can frequently be determined by percus- sion. Auscultatory Percussion. — With this method we employ the stethoscope. The chest-piece may be placed above the seventh rib in the left mammillary line, or between the tip of the ensiform process and the left costal margin; or in the same vertical line, but slightly below these points. First percuss near the stethescope to fix the characteristic sound. The tympanites of the stomach is transmitted generally through the liver and lung. The percussion should be begun well distant from the possible location of the stomach, and METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 75 should be performed in the vertical direction, downward and upward, and also laterally. One should begin nearly at the symphysis and percuss in vertical lines upward (Fig. 37). Fig- 37- — Vertical lines of auscultatory percussion. Circles show positions of stethoscope. The patient should be in the usual position, as described, and should hold the stethoscope for the operator against the abdomen. Fig. 38. — Auscultatory percussion of tumor of stomach wall. A sound of greater intensity and clearness and of higher pitch denotes the border of the stomach. The greater bulk of the organ, when 76 DISEASES OF THE STOMACH AND INTESTINES dilated or in a condition of ptosis, lies to the left of the median line. We must remember that some cases of marked dilatation extend a great distance to the right of the abdomen. This method is of value in determination of a tumor of the stomach. Place the stethoscope at O, Fig. 38, and percuss toward the tumor from all directions. The sound heard over the tumor (C) differs in character from that heard over the stomach at D. If the growth involves the stomach wall, C resembles D much more nearly than A (percussion of liver) and B (percussion of intestine) resembles D (stomach percussion). Differential Diagnosis. — If a tumor Hes at D, near the margin of the liver (Fig. 39), tumor of the liver is excluded as follows: place stethoscope at S, over liver. Percussion note over D resembles note Fig. 39. — Differential diagnosis. over G more than it resembles that over F. Then to exclude intestines, shift stethoscope to K, over stomach. Percussion over D resembles that over M more closely than that over G resembles that over M. The tumor is, therefore, of the stomach. Reichmann's Rod. — This consists of a short ivory rod, with circular grooves and intervening projections, like the handle of an ivory knitting-needle. The rod is pushed firmly down over the stomach at a right angle to its surface (in a vertical line to the abdomen), and is gently stroked with the fmger. The stethoscope is applied over the organ and the "pitch " carefully observed. When the rod passes beyond the limits of the stomach, a change in "pitch" occurs. Scratch Method of Auscultatory Percussion. — This method I have found satisfactorv in manv cases. METHODS OF PHYSICAL EXAMIXATION OF THE STOMACH 77 The stethoscope is placed on the abdomen below the left border of the ribs, and with the index-finger of the right hand the abdominal wall is scratched gently by the examiner so as to secure the "normal pitch" over the stomach. The abdomen is then scratched lightly from below upward, commencing below the umbilicus, and the change in "pitch" is readily observed when the lower border of the stomach is reached. If gastroptosis is believed to exist, the stethoscope is placed more to the left, and the "scratch pitch" noted from left to right. The method is shown in Fig. 40. It is of special value in determining the lower border of the stomach. Fig. 40. — "Scratch method" of auscultatory percussion. Flicking. — This method was described and illustrated in the previous chapter. Inflation of the Stomach with Carbonic Acid Gas. — Carbonic acid gas inflation is employed to render the stomach visible to inspection; to aid the determination of the position of the lesser curA^ature. as well as the greater, and so enable a differential diagnosis between dilatation and gastroptosis. The method is to administer, first, one-half glass of water in which about i dram of tartaric acid is dissolved and, after this one-half glass of water containing from i to i^ drams of soda bi- carbonate. If small quantities are employed the stomach will not become visible and palpable. 78 DISEASES OF THE STOMACH AND INTESTINES There are certain objections to this procedure. At times there is considerable escape of gas through the cardiac orifice or pylorus and the small intestine may be distended. This is a possible source of error. There may be sudden hyperdistention of the stomach, with resulting pressure on the heart and lungs, and unpleasant or even dangerous symptoms result in the aged or in a patient suffering from cardiac or pulmonary disease. In the chapter on xVcute Dilatation of the Stomach the effects of sudden distention of the stomach on the heart and circulation are described by Thomas Satterthwaite and the author. When there has been a hemorrhage, or symptom^s of ulcer or cancer, or signs of peritonitis, the use of this method is contra- indicated. Several fatal accidents have occurred. It sometimes irritates the mucous membrane. One could employ a stomach-tube and Dr. Rose's carbonic acid gas generating-bottle as a substitute. Carbonic acid gas inflation is valuable in those who are in fair physical condition. In the determination of the position of a tumor, whether it hes on the anterior or posterior surface of the stomach, it is of service. A posterior tumor will disappear under inflation. This is fully described under Cancer of the Stomach. Inflation of the Stomach with Air. — This consists in introducing a soft stomach-tube and slowly pumping air into the stomach with a double-bulb or a Davidson's syringe. The tube should be intro- duced with the patient sitting up in bed, and he should then gently recline on the back, and inflation should be carried out. It possesses the advantage that the amount of air pumped into the stomach can definitely be regulated. Fill a vessel with i liter ( i quart) of water, invert it over a pail of w^ater, and note how many compressions of the bulb displace the given quantity of fluid. One can thus estimate the quantity of air pumped in at each compression. The first few squeezes of the bulb should be given rapidly, so as to cause spasmodic closure of the pylorus. The same indications and contra-indications exist as for the use of carbonic acid gas. There is the advantage of being able to regulate more definitely the degree of inflation. Some patients, however, object to the passage of the tube. If there are discomfort or unpleasant symptoms from either method of inflation, the con- dition should be immediately relieved by the passage of the stomach- tube. Fiirbringer suggests that when we inflate with air the tube should be introduced only to the middle of the esophagus, and air should then be pumped in. He -claims that this procedure prevents retching. Inflation of the Stomach with Water. — To Dehio we must give the credit of determining the position of the stomach by water inflation. He percusses over the patient's stomach, preferably w4th the organ empty and the patient in the erect position. He then METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 79 administers a glass of water (8 ounces), not too cold, and percusses the area of dulness. He follows this with a second, third, and fourth glass of water, percussing each time, and notes the position and extent of the dulness. The patient is then directed to lie on his back and tympanites will appear where dulness previously existed. This conclusively demonstrates that the area corresponded to the stomach. If there is pronounced dilatation or ptosis, a single glass of water will often cause dulness to appear below the navel or in the inguinal region. The results may be obscured in patients with much adipose tissue or if there is fecal accumulation in the colon. In this event, it should be cleared out by injection. I have also found the following method of value, especially if there be some gastric contents: first, place the patient in the semi-oblique position and percuss the stomach ; then administer 2 or even 3 glasses of water. We secure stomach tympanites above, then a band of stomach dulness and intestinal tympanites below. It is easier to differentiate between dulness and tympanites than between two types of tympanites. Fig. 41. — Kemp's stomach-whistle. There are numerous complicated methods by means of inflatable bags, manometers, etc., for determining the position of the stomach, which are scarcely of practical value. Leube introduces a stiff sound and determines the position of its lower end through the abdominal walls. This method does not seem to be safe. Others differentiate between the stomach and the colon by inflating the colon with air or carbonic acid, employing the same methods as in the stomach, only using twice the quantity of soda bicarbonate and tartaric acid. Rose's apparatus would prove of value to inflate the bowel. To further differentiate, water was given by the stomach. Some first empty the bowel thoroughly and then inflate the intestine with water. It is often difficult for the patient to hold the enema. There are two other methods for determining the lower margin of the stomach: First, the administration of small quantities of soda bicarbonate and tartaric acid, with the patient in the standing position. In some cases one can approximately map out the lower borde- of the stomach by listening to the "sizzling sounds" with the stethoscope. Second, the use of the stomach-whistle (Fig. 41). This consists of a rectal tube of small caliber, with a whistle in the 8o DISEASES OF THE STOMACH AND INTESTINES end. To the other extremity is attached an ordinary stomach aspirating bulb without valves. The tube is inserted into the stomach, the finger placed over the open end of the bulb, and a single bulbful of air is forced into and aspirated out of the stomach by rapid and short intermittent contractions. This entirely eliminates the possible chance of distending the stomach with air and the organ remains practically empty. A stethoscope is placed over the abdomen and the point of greatest intensity of sound is marked by a cross with a colored pencil. The tube is pushed in and out and the various points of sound are marked — the lowest is in the lower border of the stomach. The ear can be applied in place of the stethoscope. Transillumination of the organ was then performed and the lower margins absolutely corres- ponded. The method of administering water and then blowing air into the stomach through a tube, and producing "bubbling sounds," only gives the level of the fluid, and not accurately the lower margin of the stomach. The whistle will not differentiate between dilatation and gastroptosis. This experiment with the stomach-whistle demonstrated that in the standing position the stomach, when empty, descends to the full length of its suspensory ligaments, and its lower border is at a constant level or within about I inch of the same, whether the organ be full or empty. It was at the same level when a pint or more of fluorescent fluid had been ingested, as when demonstrated by transillumination. Splashing Sounds. — The splashing sounds of the stomach are produced when water and air in the organ are agitated together, when either the whole body or the stomach alone, is shaken. They are best demonstrated by rapidly tapping with the index- and middle fingers of the right hand over the stomach several times in succession without removing the fingers, as in striking chords on the piano. The patient should be in the dorsal position with the lower limbs flexed. The sounds resemble those produced by shaking a rubber bag containing air and water. They can be elicited in many people in ordinary good health shortly after meals, but if found at an abnormal time or in an abnor- mal position, are of diagnostic value. If present an hour after a test breakfast, the patient suffering from gastric symptoms and the position of the stomach being normal, they are significant of simple atony. This is true if they be found several hours after an ordinary meal or on an empty stomach. If the splash is present in an abnormal position at the level or below the umbilicus, it shows the lower border of the stomach lies abnormally low, and that either dilatation or gastroptosis is present. The presence of movable kidney demonstrates it is a ptosis. The upper border may be determined to be in an abnormal position by inflation or gastrodiaphany, as a further test. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH The splashing sound determines the position of the lower border of the stomach with greater accuracy than percussion. Some patients hold the abdomen rigid, so that it does not appear on exami- nation, but it can be produced artificially for examination purposes. The following is a simple method to differentiate between stomach and intestinal splash: In Fig. 42, if the splash be found at A, mark same on abdominal wall ; then give several glasses of water or, preferably, Vichy. If the splash at A be intensified, it is stomach splash. If, on the other hand, the splash appear at B, this is the true stomach splash and .4 is the intestinal splash. If no splash is present on examination, it can be created artificially by giving several glasses of water or, preferably, Vichy. Sometimes 3 or 4 glasses are required; the patient takes several deep breaths, the splash being determined during expiration. I find the determination of the lower border of the stomach most accurate by means of the splashing sound. Deglutition Sounds. — These were first described by Kronicker and Meltzer.^ When drinking, a sound is heard simul- taneously with the act of deglutition, which is termed the first deglutition sound. A second sound is noted about seven seconds later. Both sounds can be heard by placing the ear or stethoscope at theensiform process. As a rule, only the second sound is heard. If the first sound is heard, the second may be present or absent. The presence of these sounds assists in forming judgment as to the permeability of the cardiac orifice. If they are absent, the ingested liquid has remained in the esophagus, and hence a tight stricture is present. If the second sound is markedly delayed, there is probably partial obstruction. Other Sounds Have Been Described. — Dripping sounds, arising from the passage of fluid along the gastric wall, are sug- gested as a means of mapping out the stomach. The method is inaccurate. The succussion sound, obtained by shaking the body of the patient, is not as accurate a method as by tapping. Gurgling sounds occur from the contraction of the empty stomach about air or gas. Sounds are heard in the stomach due to movements imparted to the organ through the respiration, and also ringing sounds, imparted from the heart in gastric dilatation.^ These sounds are of no diagnostic value. Occasionally sizzling ^Centralb. f. die med. Wissensch., 1883, No. i. 2 Laker, Wiener med. Presse, 1889, Nos. 43 and 44. Fig. 42. — Splashing sound. Differential diag- nosis between stomach and intestinal splash. 82 DISEASES OF THE STOMACH AND INTESTINES sounds are heard on auscultation, which are produced by fermentation of the gastric contents. They resemble the sounds produced after the administration of soda bicarbonate and tartaric acid, with the resulting generation of carbonic acid gas. Esophagoscopy. — Mikulicz, Rosenheim, Kelling, Von Hacker,^ Einhorn," and many others have advocated this method. In the earlier instruments the source of illumination was outside the esophageal tube. The instrument with the lamp at the end of the tube near the point to be inspected, such as devised by Einhorn, is more practical. In Fig. 43 is depicted Einhorn's instrument, w^hich is readily understood. The obturator is inserted and held in place by the plug d and the wires connected with the battery. After introduction, the plug is removed, the obturator with- drawn, and the current turned on. Fig. 43. — Einhorn's esophagoscope. Technic. — The pharynx should be sprayed with cocain (5 per cent.). The patient sits on a chair with a straight back. The instrument with obturator inserted is immersed in warm water and inserted like a pen along the roof of the mouth to the posterior wall of the pharynx, the head being thrown backward on the shoulders. It is then pushed down in a vertical line into the esophagus without the exertion of any force. By this method it is unnecessary to press down on the tongue, and thus gagging is avoided. The lips of the patient should not be pressed upon by the instru- ment. The obturator is removed, the light turned on, and the eye of the operator applied to the opening. For complete inspection of the esophagus, the instrument is gradually withdrawn. This esophagoscope is made in several lengths and in two sizes. * Beitrage zur klinischen Chirur., Bd. 20, 1898, pp. 141, 275; Ibid., Bd. 29, 1901, p. 128. 2 New York Med. Journal, Dec. 11, 1897. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 83 Indications. — Esophagoscopy is of chief value for the removal of foreign bodies. It may be employed in cases of suspected ulcera- tion and for topical application thereto. In suspected cancer it should be used with caution. Conira-indications. — Aneurism or recent hemorrhage. Gastroscopy. — This method of examination of the gastric mucosa was inaugurated by ^Mikulicz in 1881.^ The general principle of the instrument is based on the cystoscope. Rosenheim has devised a new instrument, and Chevalier Jackson has carried on numerous investigations in gastroscopy. The latter has conclusively demonstrated that general anesthesia should be given for such an examination. I must confess that in cases of suspected cancer or ulcer I would not submit a patient to the certain degree of risk from the introduc- tion of an instrument of the present type; and in milder cases of gastric disturbances I can see no advantage, except for the purpose of scientific study. It would seem that a large number of normal organs, as well as mild types of gastric disease, should first be investi- gated as a basis for comparison, and that the instrument should be improved upon before the method can be generally recommended. Gastrodiaphany or Transillumination of the Stomach. — Casenave, in 1845, first applied the method of transillumination to living tissues. In 1867 Milliot succeeded in transilluminating the stomachs of animals and experimented with the stomachs of cadavers, but to Max Einhorn, of New York, the credit is due of being the first to demonstrate transillumination of the stomach on the living subject and the practical value of gastrodiaphany. His instrument, which he denominates a gastrodiaphane, consists of a soft-rubber stomach- tube, at one end of which is fastened an Edison lamp. Conducting wires run through the tube to the battery, and there is a current interrupter at some distance from the tube. The lamp is enclosed in a glass bulb, to act as a reflector and prevent the action of heat on the stomach. He has the patient drink only i or 2 glasses of water, so as not to distend the stomach, inserts the light, and examines the case in a dark room, either in the sitting or in the recumbent position. Heryhg and Reichmann employ a modified tube, with a water cooler about the lamp. Kutner and Jacobson, under Ewald's direc- tion, performed a great number of experiments. These experimenters, together with Meltzing, are the chief foreign investigators with gastrodiaphany. Manges, Stockton, and many others have employed it. Among various gastrodiaphanes are those of Hemmeter, Lincoln, Solis-Cohen, Koplik, and Lock wood. To Lockwood we must credit a decided advance in the type of instrument — a fine, wire-bound cable (rubber insulated) and a small Ught, no larger than a 5-grain capsule. The cut of my instrument, the "circumscribing gastrodiaphane," will sufficiently explain the ^Wiener med. Presse, 1881, No. 45. 84 DISEASES OF THE STOMACH AND INTESTINES Lock wood instrument, after which it is modeled, with certain additions. The Circumscribing Gastrodiaphane. — A series of observations with transillumination of the stomach suggested an improvement on the gastrodiaphanes in use. Manipulation of the tube after the electric light has entered the stomach frequently causes gagging and, at times, vomiting, interfering thus with the accuracy of the method. The cables of all the instruments were found unsatisfactory in cases of gastroptosis of great degree when we endeavored to explore care- fully the pyloric end of the greatly dilated stomach. It was impossi- ble to guide the light in a definite direction ; it would sometimes pass to the right, sometimes to the left, and often it was necessary to draw it in and out a number of times for a distance of several inches. The instrument I devised to overcome these drawbacks has a cable about 6 inches longer than the Lockwood gastrodiaphane, and Fig. 44. — Kemp's gastrodiaphane (circumscribing). is of about the same caHber (Fig. 44). The cable is more flexible for the space of I inch at about the same distance from the light — in effect, a joint at this point. At the base of the light is attached an extremely thin accessory cable, covered with rubber. This runs parallel with the main cable and increases the diameter only a very slight degree. After introduction of the instrument the main cable is held firmly and the accessory cable drawn upon. By turning the cable at the same time, the instrument can be directed in the desired direction. By manipulation of the accessory cable the main cable can be so bent that the light will explore the entire wall of the stomach anteriorly, and can be made to pass up to the pylorus and along the borders of the ribs. The lesser curvature is thus explored. Care should be taken that the cables, are parallel when passed into the stomach, and the accessory cable should be relaxed before withdrawal. The main cable, except at the joint near the light, METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 85 is stiffer than the Lockwood Hght. Eight dry cells are employed with a rheostat. Wappler manufactures a small pocket battery with six cells, which I have found excellent. An extra lamp should be carried. Water was the medium formerly employed. A great advance in the technic of gastrodiaphany is the employ- ment of fluorescent media. ^ There are three such media found to be of value: Bisulphate of quinin, gr. 10 (0.6), in a pint of water. The addition of Tn.5 (0.3) of dilute phosphoric acid intensifies its action. The same amount of dilute sulphuric acid may be substituted. The reaction of the quinin solution is acid and the fluorescence a very pale violet. Increased acidity intensifies its action and fluorescence disappears if the solution is rendered alkaline. Esculin. This is derived from the CEsculus hippocastanum (horse-chestnut), indigenous to Europe; 15-gTain doses have been used in malaria. One can employ small doses, gr. -§- to | (0.008- 0.032), in a pint of alkaline solution, which gives a blue fluorescence. This preparation is difficult to secure and is expensive. Fluorescein (phthalic anhydrid, 5 parts), a naphthalin product, and resorcin (7 parts), heated to 200 C. (392 F.). It is a reddish powder, faintly soluble in water, with a neutral action, and gives thus no fluorescence; soluble in alcohol and in alkaline media, it gives a green fluorescence like liquid opal. It has been employed to detect ulcers of the cornea. It can be secured from Merck & Co., and is extremely cheap. The addition of glycerin intensifies the fluorescence, and the hydrochloric acid of the stomach must first be neutralized. The patient should first be given a glass of water (8 oz. — 250 cc.) in which gr. 15 (i.o) of bicarbonate of soda have been dissolved. A second glass of water (8 oz. — 250 cc.) is then administered, in which are dissolved the same amount of sodium bicarbonate, i dram (4.0) of glycerin, and gr. i to | (0.008-0.016) of fluorescein; i or 2 ounces of lime-water may be substituted for the sodium bicarbonate. As we increase the fluorescein in strength, fluorescence diminishes and colorization begins. By means of fluorescent media I have found it -possible to illuminate the stomachs of fat or muscular subjects that were formerly unsatisfactory, and to examine for tumors and the location of the stomach with greater accuracy. The brilliancy of the illumination is markedly increased. Examination of the urine of patients Avho have taken fluorescein shows no deleterious effects — no albumin, no sugar, no casts. The fluorescein acts in an alkaline medium and free acid destroys fluores- cence, yet on catheterization of these patients greenish fluorescent urine is obtained one hour after the administration of fluorescein solution, and this condition persists for about four hours. The 1 New York Med. Journal; Philadelphia Med. Journal, Feb. 13, 1904; New York Med. Journal, August 6, 1904. 86 DISEASES OF THE STOMACH AND INTESTINES acidity of the urine is not due to the presence of free acid. In fluorescein solution we have an additional means of testing the permeability of the kidneys. The technic of gastrodiaphany is as follows: The patient's stomach should be empty. He is given a glass (8 oz.— 250 cc.) of the alkaUne solution, and then a second glass (8 oz. — 250 cc.) of the fluorescein solution. I frequently give an extra half or even two additional glasses of water, especially in the suspected cases of dilata- tion or ptosis, or in stout subjects. In the latter, gastrodiaphany is not as satisfactory, but by pressing on the abdominal wall the outlines can be secured. ■ -pig 45. — Gastrodiaphany: A, Normal stomach; B, dilated stomach; C, D, E, F, varying degrees of gastroptosis (Rose and Kemp). A dark room gives the only satisfactory results. It can be devised by pinning blankets across the windows. The patient can also be examined in a light room by covering him from neck to feet with a dark blanket or black gown, and the examiner looking through an opening therein. The gastrodiaphane is introduced by gaslight or candlelight, the patient sitting opposite in a chair, with the abdomen exposed. The electric current is turned on and the room darkened. The patient should then stand up, as this position is preferable. It is my custom to mark out the anatomic regions on the abdomen of each case with blue pencil, and then draw the outlines of the stomach during transillumination. With gastroptosis, the lesser curvature can be determined. In METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 87 Fig. 46. — Cancer of greater curvature. Gastrodiaphany, some cases the stomach will be bottle-neck above, with the base below; or somewhat pear shaped, the narrow part showing above, as the light disappears beneath the ribs. In a dilated stomach the transverse diameter of transillumination is nearly the same through- out; as we withdraw the light it begins to narrow just below the tip of the ensiform. If we illuminate in the dorsal position, the light hardly shows at all; it becomes clearer as the patient gradually sits erect, and is most marked in the standing position. This sub- stantiates the view of Meltzing, who states that in the dorsal position only a portion of the stomach is in contact with the abdominal wall, and it demonstrates the necessity of the standing position for accurate illumination. In Fig. 45 are shown a normal stomach, the dilated organ, and several degrees of gastroptosis. There is no question but that ptosis of the stomach exists from a very slight to an extreme degree. Tumors or thickenings of the anterior wall of the stomach, or the lesser or greater curvature, or anterior surface of the pylorus, appear as a dark area projecting into or surrounded by a light zone (Fig. 46). By the circumscribing gastrodiaphane the entire contour of the stomach is determined. The older instruments show only the lower segment clearly. RONTGEN RAYS (X-RAYS) The most valuable practical application of the x-rays^ in reference to the stomach is for the detection of a foreign body which is believed to be lodged within the organ and for demonstrating its location. The question often of operation and the location of the incision depend upon the information secured by this means. Cannon has made a valuable study of the motions of the stomach with the x-rays, to which I have alluded. Rontgenography of the stomach has been performed bv numerous observers for the purpose of locating the position of the organ. The patient on an empty stomach is given i pint of milk, in which I ounce or more of bismuth subnitrate has been thoroughly mixed. On exposure to the x-rays for about fifteen seconds, from a photographic plate placed direct!}^ over the abdomen, a picture can be obtained ; or with a fluoroscope the stomach can be inspected. This method is expensive for the patient, and no information can be secured that cannot be obtained by the physical examination, especially by transillumination. The Rontgen picture shows onl}'' ' Their use in carcinoma of the stomach and in stenosis of the esophagus are described under these topics. 88 DISEASES OF THE STOMACH AND INTESTINES the greater curvature and part of the body of the stomach; the lesser cur\^ature is not dehneated. This can be demonstrated by comparing the result with subsequent gastrodiaphany. By the administration of bismuth subnitrate capsules the lower border of the stomach can be delineated by the a[;-rays. RADIUM TRANSILLUMINATION OF THE STOMACH This method was first suggested by Einhorn.^ with his radio- diaphane (Fig. 47), a rubber-covered glass capsule, containing 0.05 gm. bromid of radium (Curie, 1,000,000 strength), an inflating bulb, and Kahlbaum's fluoroscope. The transillumination is very faint and the results not as clear as from gastrodiaphany. The Fig. 47. — Einhorn's radiodiaphane. expense is considerable. At the present stage of its development I would not recommend it as of practical value. RADIUM PHOTOGRAPHS OF THE STOMACH The same may be said of this procedure devised by Einhorn.^ The length of exposure to radium is never less than an hour and, preferably, longer to secure results. This is decidedly objectionable, as severe burns are possible from radium. If photographs are to be taken, the x-rays are safer and give more definite results. CONCLUSIONS The following methods I have found from experience to be most practical for general use: Inspection. — By this method the peculiar shape of the abdomen, suggestive of gastroptosis, can at once be determined. Palpation. — If movable kidney be present, it is pathognomonic of gastroptosis, especially if the lower border of the stomach lies abnormally low. Sensitive areas can also be determined and often the presence of a tumor. Percussion. — The scratch method of auscultatory percussion is serviceable in mapping out the stomach, as is also auscultatory percussion. ^ Medical Record, July 30, 1904. 2 Archives of Physiological Therapy, Sept., 1905. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 89 Splashing Sound. — If not present, it can be artificially pro- duced, and is most valuable in determining the lower border of the stomach. Dehio's Method. — Additional water can be given if desired, and by percussion the observations determined by the splashing sound can be substantiated for accuracy. Gastrodiaphany. — This can be employed to differentiate in doubtful cases between ptosis and dilatation, and is of value in accu- rately mapping out the stomach before surgical operation. By it one can at times determine the presence of a tumor at an early stage. Inflation. — This method, especially by distention with carbonic acid gas, is an aid in mapping out the stomach and in determining the position of the upper as well as of the lower border. CHAPTER VI EXAMINATION OF THE FUNCTIONS OF THE STOMACH The determination of the functions of the stomach — secretory, motor, and absorptive — is of importance for accurate diagnosis. Of the examination of the secretory function I will first speak. Ewald and Boas have demonstrated that gastric secretion begins as soon as food enters the stomach, and continues until the chyme has passed into the intestines. The secretion is diminished toward the last. Examination at various periods after taking food will give different results, and it is necessary to examine the gastric contents at a definite time, during the height of digestion. It is desirable that a definite test meal should be administered. TEST MEALS Riegel's Test Dinner. — Riegel's test dinner is the oldest advo- cated. This consists of a plate of meat broth (about 400 cc.) ; a beafsteak weighing from 150 to 200 gm. (5-7 ounces); 50 gm (ij ounces) of mashed potatoes; and a roll (35 gm.). The average time one should aspirate the stomach contents is about four hours after this meal. Ewald's Test Meal. — This consists of about 6 ounces (175 gm.) of finely chopped meat; stale bread, 35 gm., and butter, to be taken three hours before withdrawal of the stomach contents. This is practical as regards quantity, as by some the test meal of Riegel is considered large in amount. Test Meal of Germain See. — The patient is given 3 to 5 ounces (100-150 gm.) of white bread; 2 to 3 ounces (60-80 gm.) of finely chopped meat, and a large glass (300 cc.) of water; and the contents examined two hours later. Klemperer's Test Meal. — This consists of i pint (500 cc.) of milk and 2 rolls (70 gm.), given on an empty stomach. Examination two hours later. Test Breakfast of Ewald and Boas. — This is given in the morning in the fasting condition, and consists of i to 2 rolls (35-70 gm.) and i cup (300-400 cc.) of tea or water. Examination one hour later. Boas' Test Breakfast. — One ounce of rolled oats boiled in I pint of water, with salt to taste. Boas advocates this, as it contains no lactic acid, and believes it should be employed when an accurate test for this acid is desired. 90 EXAMINATION OF THE FUNCTIONS OF THE STOMACH 9 1 Two shredded wheat biscuits with water (300 cc.) or a pint bowl of granose have been recommended as a convenient substitute. The test meals that are in chief use are the Riegel test dinner and Ewald-Boas test breakfast. The latter is easily procured and can be administered during ofifice hours — which is the most accurate method. It is easy to recognize therein remnants of food from the previous day. The test dinner gives better results as regards the investigation of the microscopic appearances and the study of the motor functions. The test breakfast in many cases will be sufficient. It is often of service to administer a special test dinner at 7 p. m. and the test breakfast in the office at 7.30 to 8.00 a.m. It will be described under Testing the Motor Functions. I agree with Fleiner that tea is to some an irritant. In addition, it is not of stable strength, and water is preferable. The average slice of bread from the loaf weighs 30 gm. I employ usually 2 slices (60 gm.) of bread and 250 to 300 cc. of water. One must allow for a patient of small physique and poor nutrition, for in such cases he cannot or will not take this quantity. The diagnosis in most cases should not be made from a single examination of the gastric contents. METHOD OF ASPIRATION OF THE GASTRIC CONTENTS The selection of the proper type of tube is important. It should be of soft rubber, of a caliber of 30 to 32 French, to allow free exit ^ - -^ Fig. 48. — Aspirating tube. of contents; have an opening at the tip, and one or even two lateral openings, as in Fig. 48, or the Ewald's tube (Fig. 49). Fig. 49. — Ewald's tube. Position of Patijent and Operator. — The patient sits upright on a chair and is protected by a sheet or towel. False teeth should be removed. The operator stands in the position as depicted in Fig. 50, and passes the tube along the roof of the patient's mouth. The advantages of this method are described under Lavage. 92 DISEASES OF THE STOMACH AND INTESTINES The tube should be moistened in warm water and introduced about 20 inches until resistance ,is felt, when it should be slightly Fig. 50. — Correct position for passage of aspirating tube. withdrawn. In the event of gastroptosis or dilatation the distance would be greater. A Politzer bulb can be employed for aspiration. Fig. 51. — Boas' aspirating bulb. Boas' Method. — The Boas aspirator (Fig. 51), which consists of a rubber bulb having two soft-rubber ends and provided with a clamp, is attached to the stomach-tube by a piece of glass tubing. The clamp is fixed, the bulb compressed and then released, and EXAMINATION OF THE FUNCTIONS OF THE STOMACH 93 thus filled up; the clamp is opened, and the contents, by com- pression of the bulb, forced into a bottle, glass, or some other recep- tacle. This is a simple method of aspiration. Other devices with a Fig. 52. — Aspirating bulb vacuum bottle, mouth suction, forcing air through a double tube, etc., have been suggested, but they are more complicated. Fig- 53- — Filling the bulb. Ewald-Boas Expression Method. — This consists in having the patient exert pressure upon his stomach by means of his abdom- inal muscles. He should first inspire deeply, and then compress 94 DISEASES OF THE STOMACH AND INTESTINES the abdominal walls in the same manner as during defecation. The pressure expels the gastric contents through the tube into a recep- tacle. This method is considerably employed, and when successful is unquestionably excellent. In cases of marked atony, both of the stomach and abdominal walls, in excessive dilatation, and at times from plugging of the stomach-tube, the expression method is a failure. Author's Method. — It is my custom to attach to the stomach- tube a bulb without valves, such as is depicted in Fig. 52. The Fig. 54. — Second step of aspiration. patient is then directed to express the contents. If the tube becomes stopped, the thumb is placed over the open end, the bulb squeezed, and the obstruction immediately relieved. This obviates blowing through or removing the tube. If expression fails, then immediate aspiration is resorted to. The tube is pinched near the teeth, the bulb squeezed, and the thumb placed over the open end. The stomach-tube is then released and the vacuum in the tube allowed to fill with gastric contents, as in Fig. 53. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 95 When the bulb is filled the stomach-tube is again pinched, the thumb removed from the bulb, and the contents gradually expressed into the receiving vessel, as in Fig. 54. Fig- 55- — Final step of aspiration. The final step is depicted in Fig. 55. This process is repeated until the gastric contents are removed. EXAMINATION OF THE INGESTA Before chemic examination of the ingesta is begun, the quantity- aspirated should be carefully measured. After the Ewald-Boas test breakfast, one may expect to secure on an average 50 to 75 cc. of contents, and if 100 cc. or more be present, this would be suggestive of motor insufficiency. A large quantity of gastric contents (350 to 400 cc.) four hours after the test dinner would also be a suspicious circumstance, and further tests should be made, as described under Examination of Motor Functions. The quantity of the residue, therefore, has a chief bearing on the motor function, though in hypersecretion abnormal quantities are found. 96 DISEASES OF THE STOMACH AND INTESTINES Macroscopic inspection gives considerable information. After the test breakfast, in some cases large undigested pieces of bread are brought up; in others, remnants of bread that are nearly digested or only slightlv digested; and in others, a fine fluid mushy mass. These findings are at once suggestive. With Riegel's test meal the differences are more pronounced; the mass may be fine, uniform, and mushy, containing no coarse elements; or there may be coarse undigested meat-fibers. Mucus, blood, and bile are readily visible. In some cases the gastric contents when placed in a glass vessel forms three layers: at the bottom, fine starchy material ; next, cloudy fluid; and on top a foamy layer, which latter is evidence of gaseous fermentation. Chemic Examination. — The aspirated gastric contents should be filtered, preferably through filter-paper. If this is not at hand, several layers of cheese-cloth or gauze can be employed. From a practical point of view, the most important fact to deter- mine is, whether there is an excess of hydrochloric acid during the height of digestion. If free hydrochloric acid be present, it is then necessary to find out whether the secretion is normal or increased. If the hydrochloric acid is deficient in amount or absent, the digestive power of the stomach is deficient. When free hydrochloric acid is present, the determination of pepsin is unnecessary; in fact, it is often present, even if free hydro- chloric acid is absent. In such event, if the gastric contents are acidified with sufficient hydrochloric acid and digestion of albumin then occurs, this is evidence of sufficient pepsin formation. In cases complicated by the absence of free hydrochloric acid, the examination for pepsin should be carried out. For a complete chemic analysis the following tests should be performed : 1. Reaction. 2. Total acidity. 3. Free hydrochloric acid. 4. Combined hydrochloric acid. 5. Lactic acid. 6. Propepton. 7. Pepton. 8. Pepsin. 9. Rennet. 10. Dextrin. 11. Er3d:hrodextrin. 12. Achroodextrin. Before describing the tests, it is well to remember the findings of the normal gastric juice after the test breakfast for a basis of comparison. Normal gastric juice is of acid reaction; total acidity, 40 to 60 (o. 1 5-0.21) ; free hydrochloric acid, 25 to 50 (0.1-0.2 per cent, approxi- EXAMINATION OF THE FUNCTIONS OF THE STOMACH 97 mately) ; propepton, small amount; pepton more; pepsin and rennet present; sugar and achroodextrin, present; erythrodextrin present in small amount or absent; dextrin absent. Some patients may have free hydrochloric acid within the above normal Umits, and yet suffer from the symptoms of hyperchlor- hydria; while others may have free hydrochloric acid as high as 100+ and present no symptoms at all. Individual peculiarities must be considered. Reaction. — This is determined by means of blue and red litmus- paper. If the filtrate is acid, it turns the blue paper red; and if alkaline, the red turns to blue; neutral causes no change. Test for Free Hydrochloric Acid. — Numerous coloring-matters when exposed to the action of weak solutions of hydrochloric acid, undergo changes, and have been employed as tests for its presence. Those that are of greatest practical value I wdll describe shortly. There has been considerable dispute as to the respective superior- itv of these tests. Though organic acids, when present in considerable quantities, may give these color changes, yet they are not as sensitive to organic acids as to mineral acids. I agree with Riegel that this danger is practically negligible. As a precaution it is well to employ one of the following qualitative check tests, w^hich react only to free mineral acids, and not to the organic acids. In addition, the test for lactic acid should be performed. The Phloroglucin-vanillin Test (Glinzburg's). — This reagent consists of 2 grams of phloroglucin and i gram of vanillin dissolved in 30 grams of absolute alcohol. An equal number of drops, i or 2 each, of this and the gastric juice are placed on a porcelain dish and mixed with a glass rod. The dish is then held over an alcohol lamp and the fluid allowed to evaporate slowly. A cherry-red color appears, as in Fig. 56, if free hydrochloric acid be present. If there are only traces, then there is a rose tint at the margin. If hydro- chloric acid is absent, the color varies from yellow to brown. This test responds to free hydrochloric acid and not to organic acids. The solution is unstable, and should be preserved in a dark glass bottle. It is advisable to make a fresh solution frequently. The Resjorcin-sugar Test (Boas). — Five grams of resorcin and 3 grams of cane-sugar are dissolved in 100 cc. of alcohol. Equal drops of this reagent and gastric juice are slowly evaporated to dryness, without burning, in a porcelain dish or a butter dish. If free hydrochloric acid be present, a rose-red color appears, which fades on cooling (Fig. 57). It responds to hydrochloric acid only. It is nearly as delicate, more easily obtained, less expensive, and more stable than Giinzburg's test. After performing one of these check tests it is preferable in all cases to test quantitatively for acidity; and for this purpose I prefer Topfer's method. The qualitative method gives no basis for scientific accuracy. 98 DISEASES OF THE STOMACH AND INTESTINES Topfer's Method. — This method determines quantitatively: Total acidity; free hydrochloric acid; combined hydrochloric acid; total hydrochloric acid, and acid salts quite accurately for clinical purposes. In routine examinations it is rarely necessary to deter- mine more than total acidity and free and combined hydrochloric acid. If free acid is absent then the pepsin and rennet tests should be made. Solutions Required. — (i) One per cent, alcoholic solution of phenolphthalein (colorless). (2) One per cent, aqueous solution of sodi,um alizarin sulphonate (opaque brownish yellow). (3) Five-tenths per cent, alcoholic solution of dimethyl-amido- azobenzol (yellowish red). (4) Decinormal solution of NaOH to titrate the gastric juice; I cc. of tenth-normal XaOH neutralizes .00365 hydrochloric acid. Topfer's method depends upon the different sensitiveness of three- color end-reagents to the various constituents of the gastric juice. Method. — Though 10 cc. of the filtrate are usually employed, I have illustrated the method on the basis of 5 cc, as it is often practically found impossible to carry out all the tests when using larger quantities. The methods are equally correct. In each of the three beakers {A, B, and C, Fig. 58) are placed 5 cc. of the filtered gastric contents. To beaker A are added i to 2 drops of the phenolphthalein solution, which is used as an indicator of the total acidity. This body turns red pink or red as soon as the fluid becomes slightly alkaline, after the addition of the sodium hydrate. To beaker C we add 1 to 2 drops of the dimethyl-amido-azobenzol solution. A reddish-pink or cherry-red color develops if free hydrochloric acid be present, depending on the degree of acidity. After titration with sodium hydrate, the end-reaction is a pale orange yellow. To beaker B is added i to 2 drops of the sodium-alizarin-sidphonate solution. After sufficient sodium hydrate is added a violet color (the end-reaction) appears. The titration with sodium hydrate is performed from a graduated pipet or, preferably, a buret, supported on a stand. The latter should be graduated to i or, by preference, to -^^ cc. The elements combining the total acidity in beaker A, Fig. 58, are free h3-drochloric acid, acid salts, combined hydrochloric acid and organic acids, which respond to the phenophthalein test. In beaker B are free hydrochloric acid, acid salts, and organic acids, responding to the alizarin test. Hence, as Topfer claims, to find the combined hydrochloric acid, one must substract the acidity of B from the total acidity of A. In beaker C we have free hydrochloric acid alone, which responds to the dimethvl-amido-azobenzol test. Fig. 57. — Resorcin test. Color reaction. Fig. 56. — Phloroglucin-vanillin test. Color reaction. Sc.c.Gastric Juice Sc.c.GastricJuice Sc.c.GastricJuice PHENOLPHTHALEIN. 1. Frtf HCL 2. Acid Salts. j». Organic Acids, 4. Combined HCi. 1. Free HCL 2. Acid Salts. J. Organic Acids. Af/IIDO-BENZOL. YlLUrW Ams XXUTKA /. Free HCL Fig. 58. Fig. 59. — Phenolphtha- lein end-reaction. Total acidity. Fig. 61. — vSodium ali- zarin sulphonate end-re- action. Fig. 60. — Dimethyl- am ido-azobenzol end- reaction. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 99 In the absence of organic acids, the acidity of C substracted from the acidity of B will give the acid salts. Total Acidity. — The beakers being thus prepared, titration of beaker A (total acidity) is begun with the sodium hydrate solution. As this is added, the reddish color appears, but it disappears as the fluid is agitated. The procedure should be continued until a per- manent red-pink or reddish color is present, as in end-reaction (Fig- 59)- As the degree of acidity is expressed by the number of cubic centimeters of a decinormal solution of sodium hydrate required to saturate or make slightly alkaline 100 cc. of the gastric contents, and as only 5 cc. of the latter was employed (which is ^o of the total quantity) , the number of centimeters of the sodium hydrate necessary to produce the end-reaction must be multiplied by 20. Thus if 3 cc. sodium hydrate produced the end-reaction in 5 cc. of the filtrate, the total acidity would be 3X20, or 60 -H. iNIultiply this figure of acidity by 0.00365, and we have the percentage of total hydrochloric acid, or 60X0.00365 equals 0.219 per cent. Free Hydrochloric Acid. — Commence titration of beaker C, to which the dimethyl-amido-azobenzol solution has been added, and continue titration until the solution becomes a pale lemon yellow, as in Fig. 60. As saturation with the decinormal sodium hydrate solution was computed on the basis of 100 cc. of .gastric contents, and only 5 cc. or YW were tested, the number of cubic centimeters of sodium hydrate solution required to produce the end-reaction must be multiplied by 20. Thus, if 2 cc. of this alkahne solution will produce this result, we must multiply it by 20, and we say the free hydrochloric acid is 40 -|- . To compute free hydrochloric acid in percentage, multiply 40X0.00365=0.1460 per cent. Combined Hydrochloric Acid. — Commence titration of beaker B, to which the sodium-alizarin-sulphonate has been added, and con- tinue the process until the end-reaction, the violet color, as in Fig. 61, occurs. ' As only 5 cc. of gastric contents are employed, and again the computation is based on 100 cc, the number of cubic centimeters of decinormal sodium hydrate employed must be multiphed by 20. If, for example, 2.2 cc. were required, 2. 2X20 = 44-!- acidity. Topfer has shown that alizarin is sensitive for all the elements comprising acidity, except for the combined hydrochloric acid. The acidity 44, therefore, secured by this reaction nmst be substracted from 60, the total acidity; and this gives 16 acidity as the combined hydrochloric* acid. In percentage 16X0.00365 = .06 per cent, combined h3^drochloric acid. loo DISEASES OF THE STOMACH AND INTESTINES The total acidity, free and combined hydrochloric acid, are important to examine for as a matter of routme. As fractions of a centimeter must often be computed, I give an example in tabulated form : Beaker A, 5 cc. gastric contents; for total acidity, 3.2 cc. deci- normal sodium hydrate gives end-reaction. Beaker B, 5 cc. gastric contents; for alizarin test, 2.4 cc. deci- normal sodium hydrate gives end-reaction. Beaker C, .5 cc. gastric contents; for free hydrochloric acid, 1.5 cc. decinormal sodium hydrate gives end-reaction. 1. Total Acidity. Beaker A. — 5 cc. X20= 100 cc. 3.2 cc. X20 ^64 cc. 64X0.00365 = .23 per cent. 2. Free Hydrochloric Acid. Beaker C. — 1.5 cc. X2o = 30 cc. 30 X 0.00365 = . II per cent. 3. Combined Hydrochloric Acid= A-B. — B = alizarin reaction. A =64. 2.4X20 = 48. ^ = 48 A-S = i6 = combined HCl. 16X0.00365 = .06 per cent. 4. Total Hydrochloric Acid, Free and Combined. — .11 per cent. + .06 per cent. = .17 per cent. 5. Acid Salts = B — C (Organic Acids Absent). — 5 = 48 C = 3-0 B-C=i8 S-C=i8 18X0.00365 = .07 per cent. If 10 cc. of gastric juice be employed in the tests, then the number of cubic centimeters of sodium hydrate required to produce the end- reaction must be multiplied by 10. If 2 cc. of gastric juice is used, the multiple is 50, and so on. The further tests are as follows : Lactic Acid. — Ufjelmann's Test. — This reagent is the one most frequently employed and is sufhciently accurate, if necessary pre- cautions are observed. It should be freshly prepared before each test. It can be prepared as follows: 10 cc. of a. 4. per cent, carbolic acid solution is mixed with 20 cc. of distilled water, and to this is added i drop of sesqidchlorid of iron. A watery solution of carbolic acid (2 per cent.), to which is added i drop of liquor ferri sesqui- chlorid, is another method of preparation. These solutions have an amethyst-blue color. Other methods of preparation are recommended by Riegel: 20 cc. of distilled water, locc. of a 4 per cent, carbolic acid solution, and o.i cc. of neutral 10 per cent, iron chlorid solution; or, dilute the officinal iron chlorid solution with distilled water until the solution is about colorless, and then add a 2 to 4 per cent, solution of carbolic until the amethyst-blue color appears. Fig. 62. Fig. 63. Fie. 62. Fig. 63 -Uffelmann's test. -Congo red test. EXAMINATION OF THE FUNCTIONS OF THE STOMACH lOI A very dilute iron chlorid solution will also give the reaction, but the blue color acts as a contrast. The lactic acid reaction has been described as a canary-yellow or, more often, a canary-green color (Fig. 62). Fatty acids produce an ash-gray and inorganic acids decolorize the blue solution. As at times the phosphates may be present in the gastric contents, and they give the same reaction, a modification has been recom- mended, which is practical for general use. Modified Uffelmann. — ^Take 5 cc. of the fil- trate plus 10 cc. of ether, and shake in a test- ^ ^ tube for a few minutes; then allow it to stand until the ethereal solution has separated from watery solution. Pour the ethereal part into an- other test-tube and place it in a glass of hot water to evaporate. Add i cc. of distilled water to the remaining drops, and test for lactic acid with the Uffelmann solution. If the canary color occurs, lactic acid is positively shown. A larger quantity of the filtrate can be em- ployed with two or three times the quantity of ether. Fleiner does not evaporate the ether, but adds Uffelmann 's solution directly to it. The solution will appear yellow at the bottom of the tube if lactic acid be present. Strauss employs a mixing funnel with two markings, one at 5 cc. and the second at 25 cc. (Fig._64). Fill to 5 cc. with the stomach filtrate. Pour on ether (Squibbs) up to 25 cc. and shake the mixture well. Open the lower stop-cock and allow the fluid to run off until it reaches 5 cc, and then pour in distilled water to 25 cc. To this mixture add 2 drops of iron chlorid solution (1:9 distilled water), and shake the whole. Investigations by Strauss show that if one promillimeter of lactic acid be present, an intense green color occurs; if less lactic acid, the color is light green. Arnold^ suggests a new test : 1. A solution of gentian violet (0.2 cc. saturated alcoholic solu- tion in 500 cc. distilled water) and 2. Tincture ferri perchloridi, 5 cc. (U. S. P.), diluted with dis- tilled water (20 cc). A drop of the iron solution gives a blue color with i cc. of the gentian violet, which changes to yellowish green when gastric contents which contain lactic acid are added. 1 Journal of American Medical Association, 1898, vol. viii, p. 21. \^!Il Fig. 64. — Strauss mixing funnel. I02 DISEASES OF THE STOMACH AND INTESTINES Other methods have been suggested, notably that of Boas, which is rather compHcated. It is based on the oxidation of lactic acid into acetaldehyd and formic acid. The presence of aldehyd is demonstrated by the iodoform reaction with alkaline iodin solution, or of aldehyd of mercury with Nessler's reagent. Boas Method. — Take lo to 20 cc. of the gastric filtrate and evaporate it into a syrupy consistency over the water-bath. If free hydrochloric acid is present, an excess of barium carbonate is added. A few drops of phosphoric acid are then mixed in, and the carbonic acid is expelled by boiling. The fluid is then cooled and extracted two or three times with 5p cc. of ether. After half an hour pour off the clear ethereal layer. The ether is now evaporated and the residue washed in a flask with 45 cc. of water, well shaken and filtered. Concentrated sulphuric acid, 5 cc. (sp. gr. 1.89), and a pinch of manganese dioxid are added to the filtrate. The mixture is then distilled over a small flame, and the vapor conducted into a narrow cylinder containing 5 to 10 cc. of an alkaline iodin solution. This consists of equal parts of a decinormal iodin solution and the standard potassium hydrate solution. The vapor may be conducted into the same quantity of Nessler's reagent. If lactic acid is present it gives rise to the iodoform reaction (clouding and odor of iodoform) with the iodin mixture. If Nessler's reagent is used, yellowish-red aldehyd of mercury appears. This procedure is further elaborated for the quantitative estima- tion of lactic acid, but it is extremely complicated and clinically unnecessary. We may say that when a test breakfast or test dinner is taken imder proper conditio7is, only traces of lactic acid are introduced, and finding it in appreciable quantities in the gastric contents is of pathologic significance, showing subacidity and stagnation. It is not pathog- nomonic of cancer, but these conditions frequently exist in such cases. Quantitative Estimation of Lactic Acid. — The acidity of the filtrate is first determined ; 10 cc. of the filtrate are shaken up with ether in excess. The ether is then separated and the degree of acidity computed therein. Subtract this figure from the total acidity and multiply by .09, which gives the percentage. Volatile acids must be first tested for and eliminated by boiling. This method is only approximate. Volatile Acids. — Fatty or volatile acids are recognized by boiling a few cubic centimeters of the filtrate in a test-tube. A strip of moistened blue litmus-paper is held over the escaping vapors. The paper will turn red if they are present. Their quantitative determination is hardly necessary. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 103 Acetic Acid. — In large quantities acetic acid can be detected by its characteristic odor. For the detection of small quantities, Einhorn neutralizes the watery residue of the ethereal extract of the gastric filtrate with carbonate of soda, and then adds neutral chlorid of iron solution, when a red color is developed. Propepton. — Add to the gastric filtrate of, say, 5 cc. an equal quantity of a saturated solution of sodium chlorid. Propepton, if present, is precipitated. If none is formed, then add i or 2 drops of acetic acid, and precipitation will occur if propepton is present. On heating, the solution clears up, but again becomes turbid on cooHng. Pepton. — Preferably, after filtering out the propepton, take 2 cc. of the gastric filtrate and make strongly alkaline by adding sodium hydrate solution and then add a few drops of a weak i per cent, copper solution. Pepton gives a purple or violet-red color (biuret reaction). Pepsin. — A thin disk of the white of a hard-boiled egg, weight of about I gram (i cm. in diameter and i mm. thick), is placed in a test-tube containing 5 cc. of the gastric filtrate and kept at blood temperature. The tube can be placed in water at blood temperature in a Thermos bottle. If free hydrochloric acid is not present in the filtrate, add 2 drops of dilute hydrochloric acid. The presence of pepsin will cause disappearance of the albumin in from two to six hours. The methods for the quantitative determination of pepsin that have been recognized as practical for clinical purposes, are those of Hammerschlag and Mett. Henry Illoway has devised a simple method for determining the relative quantity of pepsin, which seems to the author of value: 10 cgm., exact weight, egg albumen (white of hen's egg) is coagulated in the following manner : The egg is placed in a small pot of cold water, which is then covered with a lid and put on to boil. It is allowed to cook for ten minutes after the water has begun to boil — in all, twenty minutes from the time it has been put on. The egg is then taken out and allowed to cool, either by setting it in a saucer or by putting it into cold water. To imitate the usual way, food is, or should be, ingested, the segment of albumin is divided into two parts. Observation has shown, as it has long been known cHnically, that thus subdivided the gastric juice can act upon it more quickly. The action being from all sides, it is m.ore effective when we have eight sides for a given quantity, than where we have only four. The coagulated albumin is put into 10 cc. of the gastric filtrate (from stomach contents extracted one hour after an Ewald-Boas test breakfast), and this is then placed in the thermostat, which is kept at 38° C. The time in which the 10 cgm. are digested, entirely, partially, I04 DISEASES OF THE STOMACH AND INTESTINES or not at all, will give us a correct idea as to the status of the pepsin secretion in the case under examination. Illoway by experiments shows that normal digestion of the albumin requires from five to five and one-half hours. He classifies as follows : Hyperpepsinia. — Digestion requiring only from three to four hours, not in any pathologic sense necessarily, but only to indicate a secretion of pepsin greater than usual; which may, however, be the normal for that case. Normal Pepsinia. — Digestion requiring from five to five and one-half hours. Hypopepsinia. — Digestion requiring more than the usual time. The degree indicated b}^ the number of hours required beyond the standard of time. Apepsinia. — No digestion at all. Jacoby-Solms Method to Determine Pepsin. — Ricin Test} — - Dissolve i.o gram of ricin in loo cc. of a 5 per cent, solution of sodium chlorid and filter. Mix 2 cc. of this filtrate with 0.5 cc. decinormal HCl solution ; i cc. of diluted stomach contents is added and allowed to remain at blood temperature for three hours. Ferments clear up the ricin deposit. The quantity of pepsin is determined from the amount of dilution in which the stomach contents will cause the ricin deposit to disappear. Solms designates the amount of gastric juice which is sufficient to clear up the 2 cc. of a 2 per cent, ricin solution in three hours, kept at the blood temperature, as one pepsin unit. The normal stomach contents contain about 100 pepsin units to the cubic centi- meter. Fuld employs a solution of edestin instead of ricin.- An ordinary Thermos bottle partially filled with water at a temperature of about 100° F. can be employed in place of a thermo- stat; test-tubes containing the solutions being tightly corked and placed therein. Einhorn^ employs a Thermos bottle with metal framework to hold the tubes. These last are graduated in milli- meters, so as to dispense with measuring glasses. Casein Test. — Gross* mixes a i : looo solution of casein containing 16 cc. of a 25 per cent. HCl to the liter with the filtrate or its dilutions, and leaves it for a quarter of an hour in the thermostat. He then adds a few drops of the concentrated solution of sodium acetate, which results in a precipitate if the casein has not been digested; otherwise the solution remains clear. ^ " Ueber eine neue methode der quantitative Pepsinbestimmung und ihre Klinishe verwendung," Zeitschr. f. klin Med., Bd. 64, Heft i and 2. 2 " Pepsinbestimmung vermittelst Edestins," Miinchener med. Wochenschr., 1907, No. 27, Vereinsbeilage. ^Einhorn "A simplification of the Jacoby-Solms Ricin Method for Pepsin Determination." Med. Record, Aug. 29, igoS. * " Die Wirksamkeit des Pepsins und eine einfache methode zu ihrer Bestim- mung," Berliner klin. Wochenschr, 1908. No. 13, p. 643. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 105 Melt's Method. — This consists in sucking fresh egg albumen into capillary tubes of i or 2 mm. diameter, coagulating the albumen by boiling, and then cutting off portions 3 to 5 cm. long of the filled tube and adding these pieces to the gastric contents. This should be kept at body temperature for ten hours in the incubator. At the end of this period each end of the tube will show a lack of solid albumen owing to digestion, while some will remain in the central portion. Both the empty portions and the portion that is full are measured, and the activity of the pepsin digestion is thus determined. The relative amount of pepsin varies according to the square of the length of the empty portion of the tube, the figures of the latter being expressed in millimeters; thus, 3 mm. of digestion equals 9 parts of pepsin; 2 mm., 4 parts of pepsin, etc. Rennet. — x\dd 5 drops of the filtered gastric contents, preferably neutralized with decinormal sodium hydrate solution, to 10 cc. of fresh neutral milk in a test-tube. Place this in a glass of warm water at a temperature of about 100° F., or in a thermostat. A Thermos bottle containing warm water is extremely convenient. Normal Rennet. — In about five to fifteen minutes coagulation will occur if the rennet be normal. If the same quantity of filtrate (5 drops) be added to 20 cc. of milk, Illoway finds, under normal conditions, coagulation will occur within fifteen to thirty minutes. He suggests a simple quantitative method. Deficient Rennet. — Add i cc. of gastric filtrate to 10 cc. and 20 cc. of milk, if the smaller quantity of filtrate (5 drops) gives no result^ If reaction occurs within the same period, rennet is deficient. More marked deficiency when no result is obtained with i cc. of gastric filtrate, but is obtained within the half -hour with 5 cc. of filtrate. Absence of Rennet. — When no reaction is obtained within half an hour with 5 cc. of gastric juice and 10 cc. of filtrate, no reaction will occur. It has been demonstrated by Illoway's experiments that rennet may be present in nearly normal amount, even if pepsin is markedly deficient ; it may be present even if pepsin is absent. Rennet is usually the last one of the elements active in the process of gastric digestion to disappear. Rennet Zymogen {Chymosinogen). — Add to the same specimen of milk 3 to 5 drops of a i per cent, solution of calcium chlorid and place in an incubator. Coagulation shows the presence of the enzyme ; otherwise it is absent. Examination of Starch Digestion. — The salivary ferment continues its action on starch in the stomach while the amount of hydrochloric acid is not too great. It is estimated that as soon as the total hydrochloric acid reaches 0.12, the action ceases. If the secretion of hydrochloric acid is abnormally great, starch diges- tion is soon stopped, and there is either no digestion of starch or I06 DISEASES OF THE STOMACH AND INTESTINES the end-products are not formed. The reverse is the case in sub- acidity. To determine the intermediary stages, a dilute iodin-potassium solution (Lugol's) is employed. It consists of iodin, o.i; potassium iodid, 0.2 ; aqua destillata, 200.0. A few drops of the filtered gastric juice are placed on a porcelain dish, and to it is added a drop or two of Lugol's solution. The reactions are as follows : Dextrin turns the fluid blue; erythrodextrin, a red purple; achroodextrin discolors slightly the yellow tincture of the Lugol; maltose does not change the color. For sugar or maltose, FehHng's or Trommer's test must be employed. In normal cases, sugar and achroodextrin are present; erythro- dextrin absent or present in small amount; dextrin absent. If blue or blue-violet color appear, saccharification is deficient. Other Methods for Determining Free Hydrochloric Acid. — It seems advisable to describe a few additional practical methods of determining free hydrochloric acid: 1. Tropdolin 00 (]\Ierck's) in a concentrated watery solution, as recommended by Riegel. Knapp employs a supersaturated alcoholic solution of the same. To 5 cc. of the filtered chyme add 2 drops of the tropaiolin solution. Free hydrochloric acid turns it a cherry-red. Titrate with decinor- mal sodium hydrate until it becomes amber — the end-reaction. As 5 cc. is 2V of 100, on which the calculation is based, and if it takes 3 cc. of the alkali to produce the end-reaction, free hydro- chloric acid therefore = 20 X 3 = 60. Multiply 60X0.00365 to secure percentage. 2. Mintz's Method. — For example, to 10 cc. of the gastric filtrate, decinormal sodium hydrate is gradually added, until i drop of the mixture no longer responds to the Giinzburg reaction (phloroglucin- vanillin test). A platinum loop should be employed as a drop carrier. The amount of the sodium hydrate solution in this case should be multiplied by 10 to give free hydrochloric acid. For example, if the reaction no longer appears after the addition of 3 cc. sodium hydrate, free hydrochloric acid = 30; percentage = 30X0.00365, or 0.109 per cent. 3. Boas and Moerner. — They estimate the free hydrochloric acid by Congo paper, or by a i per cent, watery solution of Congo red, which turns blue in the presence of this acid (see reaction. Fig. 63). Take 5 cc. of the filtrate and add 3 or 4 drops of the Congo red solution. More is unnecessary, though Boas adds 5 cc. of it. On the other hand, Congo paper can be moistened in the filtrate. A blue reaction results in each case. Decinormal sodium hvdrate is then added to the mixture, or the EXAMINATION OF THE FUNCTIONS OF THE STOMACH I07 paper is placed in a porcelain dish and the alkali added. Titration is continued until the blue begins to turn red. The estimation is performed in the same way as before. 4. RiegeVs Method. — Congo paper is employed in his test. Take 10 cc. of the gastric filtrate. The Congo paper is dipped in the filtrate, giving the blue reaction of free hydrochloric acid. It is then placed on a saucer. Decinormal sodium hydrate is allowed to drop slowly from the buret into the filtrate, and a drop of the mixture is removed from time to time with the platinum loop and applied to the Congo paper. As the change in color becomes indistinct, this is controlled by dropping distilled water on the same piece of paper. The alkali is dropped on the paper until it begins to turn a violet red. The number of cubic centimeters of decinormal sodium hydrate necessary to secure the end-reaction, say 3 cc, is multiplied by 10, giving free hydrochloric acid as 30. This is necessary, as the orig- inal figure is computed for 100 cc. of contents, and only 10 cc. were employed. To complete the analysis and estimate the total acidity, 2 drops of phenolphthalein solution are added to the same filtrate, and titra- tion with the sodium hydrate is continued until the color of the solution turns red (the end-reaction). The total acidity is indicated by the total quantity of decinormal sodium hydrate used from the beginning of the first titration. For example, if in both titrations 6 cc. of sodium hydrate have been employed, the total acidity is 60, as 10 cc. of filtrate were examined. Various modifications have been employed for these tests, which only serve to confuse the reader. Those described are the most practical. Small booklets of Congo paper can be secured from Merck. It may be prepared by saturating filter-paper with a watery solution. It is of a reddish-pink color. The qualitative examination for free hydrochloric acid can be made with this paper by dipping it into the filtered or unfiltered gastric contents. If free hydrochloric acid is present, it will turn blue. Determination of Hydrochloric Acid Deficit. — Honigmann^ and Von Noorden^ determine the degree of hydrochloric acid insuifi- ciency by adding a decinormal hydrochloric acid solution to the stomach contents until free hydrochloric acid can be detected by Congo paper or Giinzburg's test. Ten cc. of the filtrate are placed in a beaker and the decinormal hydrochloric acid solution allowed to flow into it gradually, the solution being well mixed. The test being continued until after repeatedly dipping the Congo paper into it it shows a bluish tinge. The more hydrochloric acid required to secure the reaction, the *less the amount of combined acid in the filtrate. 1 Berlin, klin. Wochenschr., 1H93, Nos. 15 and 16. 2 ibid., No. 19. Io8 DISEASES OF THE STOMACH AND IXTESTIXES Or, about 25 drops of Giinzburg's solution can be added to the filtrate, and then titration with the dilute acid follows until a red mirror appears on a porcelain dish as a couple of drops of this mix- ture are evaporated over an alcohol lamp. We know, however, that the average amount of combined hydro- chloric acid is 25, or o.i per cent.,- under normal conditions, and Tbpfer's method of testing will give the required data. The amount of pepton and propepton qualitatively are an indica- tion. When there is no biuret reaction, there will be no combined hydrochloric acid. Other Methods of Testing the Gastric Secretion. — There are several ingenious methods for testing the gastric secretion in order to obviate the unpleasant procedure of aspiration, or because some patients absolutely refuse the tube, or there is danger incurred from its passage, such as in cases of aneurism, angina, severe endocarditis, or after a recent hemorrhage from the stomach or lungs, or in the very debilitated. Sahli's Desmoid Test} — This consists in placing methylene-blue or iodoform in a small rubber bag and tying it tightly with thin raw catgut. The bag is swallowed after a large meal, and the urine is examined for methylene-blue, or the saliva for iodin. Methylene- blue colors the urine green or greenish blue. The iodin is tested for in the saUva by starch-paper and fuming nitric acid, giving a bluish or violet color. It is based on the fact that raw connective tissue, including catgut, is, according to Schmidt,- digested only b}^ the gastric juice and not by the pancreas. The reaction occurs in health}' persons usually six to eight hours after swallowing the bag. If it takes place later, or not at all, the secretory function is insufficient. An early reaction shows hyper- acidity, according to Kaliski. Einhorn,^ in some cases of achylia gastrica and cancer, has demonstrated that catgut is also digested in the bowel, so that the method is unsuitable. 2. Gunzburg's Method.^ — This is based on the same principle as Sahli's. The patient swallows 0.2 gm. potassium iodid, enclosed in a small rubber bag, which is tied with fibrin threads. After the fibrin is digested, the potassium iodid is set free and absorbed. The test of the saliva is made \vith starch-paper and fuming nitric acid, giving a violet or bluish color. This necessitates frequent examinations of the saliva, and the bag may escape and the fibrin be digested in the intestine. The objections are the same as to Sahli's test. 3. Spallanzani and Edinger's Method.'^ — They fasten a small 1 Correspondenzblatt fiir Schweizer Aerzte, 1905, Xos. 8 and 9. 2 Deutsch. med. Wochenschrift, 1899, No. 49. ^Journal of the American Medical Association, May 12, 1906. * Deutsch. med. AVochenschr., 1889, No. 4. 5 Deutsch. Arch. f. klin. Medizin, vol. xxviii, 1881. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 109 sponge to a silk thread. The patient swallows this, and after several minutes it is withdrawn and the contents squeezed out and examined. Some of the contents are squeezed out during removal, and secretions of the esophagus and pharynx are mixed with it. 4. Dunham's Thread Test} — The patient swallows a small tassel of test thread, colored with litmus, Congo, or dimethylamido-azo- benzol, attached to a silk thread about 30 inches long. After about five minutes it is withdrawn and the color reaction noted. There are the same objections as to the previous test. 5. Einhorn's Stomach Bucket? — This consists of a small silver capsule, open at the top, with a cross-piece as a handle, to which a silk thread is attached. Several sizes can be secured (Figs. 65 and 66). Fig. 65. — Einhorn's stomach bucket, three sizes. Fig. 66. — Stomach bucket set. The bucket is moistened in warm water and emptied. It is then placed on the root of the tongue and swallowed by the patient. The vessel should remain in the stomach for about five minutes. It is then withdrawn by the silk thread. During the act of withdrawal, if resistance is felt, the patient is told to swallow and the bucket is then readily removed. If there are mucus and saliva in the patient's mouth, he should first gargle with plain water and expectorate the mucus. The test breakfast should be given and the bucket administered an hour later. The gastric contents are poured from this instrument into a small beaker. Tests can then be made with blue litnms and Congo paper. A single drop can be tested with Giinzburg's solution.- Einhorn demonstrates that the amount of hydrochloric acid can be approximately determined by diluting i drop of the filtrate with water, until Gunzburg's reaction begins to disappear in the diluted 1 New York University Bulletin of the Medical .Sciences, vol. i, No. 178, Oct., 1901. 2 Medical Record, July, 1890. 4. P- no DISEASES OF THE STOMACH AND IXTESTIXES fluid. He finds that normally the drop can be diluted up to eight or ten times and give the Gtinzburg's reaction. The disappearance of the reaction after five times dilution or less shows subaciditv. The presence of the reaction after dilution of twelve times or more shows hyperacidity. Recently he has employed another approximate method with a strip of paper saturated with 0.5 per cent, dimethyl-amido-azo- benzol solution and with dilution. If the paper turns red after dilution of i drop of filtrate with 3 to 6 drops of water, free hydro- chloric acid is normal; if no color appears after 3 drops of dilution, it is subacid; and if red appears after over 6 drops dilution, it is hyperacid. If rennet is present, pepsin is also present; 2 drops of filtrate added to 2 cc. of milk placed at blood temperature in a tube in warm water will curdle in ten to twenty minutes in the presence of rennet. I employ this method in exceptional cases, when the stomach-tube cannot be passed. It is preferable to aspirate. Gas Fermentation. — The presence of free hydrochloric acid does not prevent the development of gas. It ma}^ occur in a soil that is non-acid, together with lactic acid fermentation. Stagnation is the chief factor favoring fermentation. A^arious gases may be formed, but from a practical point of view the determination of its occurrence, quantity, and the time necessary for its development are sufiicient. The unfiltered gastric contents should fill a tube such as is emplo^'ed for the determination of sugar in the urine (the Fiebig tube).' It should be placed in an incubator at 37° C. (98.6° F.), or if this is not at hand, in a uniform warm place. One can employ a test-tube, as suggested by ^loritz, closed by a rubber cork through which is passed a bent glass tube. The test-tube is filled with gastric contents and then closed with the cork, thus forcing some of them into the curved tube and preventing the entrance of air. The apparatus is inverted in a beaker. As at times the sugar may already be destroyed by fermentation, it is well to prepare a control tube of gastric contents to which a small quantity of powdered dextrose has been added, or it may be added at once. If no development of gas is noted after twenty-four hours, the tube should be allowed to stand for three or four days. Carbon dioxid mav be identified bv allowing a small amount of KOH to flow through a pipet to the bottom of the gas column. The carbonic acid is absorbed by it and the fluid moves up to take the place of the absorbed gas. The expressed test meal, or test breakfast, or vomitus can be employed. If fermentation is excessive, one can assume motor insufficiency. If rapid fermentation occurs within a few hours, pyloric stenosis should be suspected, as this produces the most severe degree of motor insufficiency. EXAMINATION OP THE) FUNCTIONS OF THE STOMACH III If the stomach contains a large amount of lactic acid and no free hydrochloric acid, carcinoma of the pylorus is probably the cause of this stenosis. Gaseous fermentation is usually more intense in cases of motor insufficiency in which free hydrochloric acid is present. It can occur, however, in any form of stomach disease in which there is a disturb- ance of gastric secretion. Lactic acid fermentation only occurs markedly in subacid conditions. Alcohol, various hydrocarbons, and sulphuretted hydrogen have been found as products of fermenta- tion. Boas finds H2S chiefly in benign ectasia. Determination of the Quantity of Chyme Within the Stomach. — Usually the quantity of chyme can be determined by emptying the patient's stomach by the expression method, especially with the addition of the aspirating bulb that I have described. Air can be forced into the stomach by covering the free end of the bulb and squeezing the latter. If no bubbling sound is heard, the organ may be considered empty. With marked dilatation from py- loric stenosis, it is at times difficult to completely empty the organ. Matthieu and Remond suggest the following method of deter- mining the total quantity: After removal of the contents, a funnel is attached to the tube and 200 cc. of water poured into the stomach. The funnel is moved up and down several times, and the patient shakes the abdomen so that complete mixture of the water and contents occurs. They are then removed by a combination of siphonage and expression. The quantity of liquid originally contained in the stomach is equal to the number of cubic centimeters of water poured into the stomach multiplied by the degree of acidity of the second portion removed, divided by the figure resulting by deducting the degree of acidity of the second portion from that of the first plus the portion previously withdrawn. Examination of the Vomit. — The same methods that are em- ployed in examination after the test meal, apply to investigation of the vomitus. The information, however, is not as positive, as the admixture of bile, saliva, etc., obscures the result. Important information is secured, but the physician should inspect the vomitus in person. If the vomiting consists chiefly of food, it should be learned when the last meal was taken and of what it consisted. If coarse morsels are found six or seven hours after a meal the conclusions are naturally different than if they were found directly after eating; and by this means we can often determine the digestive and motor powers of the patient. If food is vomited that was ingested the day before, marked motor insufficiency is present. In ulcer, vomiting usually occurs at the height of digestion. In some nervous diseases it usually takes place immediately after eating. 112 DISEASES OF THE STOMACH AND INTESTINES With ectasia, vomiting occurs late in digestion and often in great quantity. In dilatation, with hypersecretion, the fluid is abundant, and there are fine remnants of amylaceous material ; while with carcinoma of the pylorus undigested morsels of meat are present. In the former case free hydrochloric acid is present, and Congo paper will turn blue; in the latter case, no color change occurs. The presence of blood is important, and its appearance depends on the presence or absence of hydrochloric acid, on the rapidity with which it is poured forth, and on the length of time it has remained in the stomach. It may, therefore, look like chocolate brown, coffee-grounds, or fresh blood. Mucus is also readily discovered. Pus is rarely found, unless from perforation in phlegmonous gastritis, or from some neighboring focus into the stomach, or unless it has been swallowed. During violent vomiting, bile is frequently in evidence, or when vomiting occurs on an empty stomach. It may occur with pyloric stenosis, when the opening is kept slightly patent. With persistent vomiting of bile one would suspect some obstruction of the duodenum, such as carcinoma, torsion, gall-stones, etc. Parasites, such as ascarides or the oxyuris vermicularis, are occasionally found in the vomit, and very rarely a piece of gastric tumor. Examination of the Contents of the Fasting Stomach. — It may be necessary to investigate the contents of the fasting stomach, especially when disturbance of the motor function is present or when hypersecretion is suspected. Under normal conditions one might expect to find from 5 to even 1 5 cc. of gastric contents in the normal stomach. Anything over 20 cc. is considered pathologic. The examination should be made in all cases where one suspects an abnormal quantity of gastric contents will be found in the morning after fasting; also in all cases of suspected ectasia or aton}' of the stomach. The best method is to wash the stomach thoroughly the night before, both in the sitting and reclining posture, and then administer a test supper. The contents are aspirated, measured, and examined the following morning before breakfast. The chief purpose is to test the motor function of the organ, especially to determine whether motor insufficiency of a high degree is present. When hypersecretion is suspected, the procedure is sUghtly different. The stomach is thoroughly washed at about 10 p. m. and care taken that all the water is removed. No food or drink are allowed thereafter, and in the morning before breakfast the contents are aspirated and examined. A quantity over 20 cc. found repeatedly I would consider pathologic (hypersecretion). When there is permanent regurgitation of bile into the stomach, Riegel has shown that this method of examining is important. If EXAMINATION OF THE FUNCTIONS OF THE STOMACH II 3 bile and pancreatic juice enter the stomach, digestive processes are arrested. Bile, pancreatic, and probably intestinal juice are occasionally found in the empty stomach (duodenal juice, Boas). This material is grass green or yellowish, containing bile constituents, and converts starch into maltose and dextrose, proteids into peptones, and splits fats. If it is aspirated occasionally, it is probably not significant; but if there is constant regurgitation, it is suggestive of obstruction in the duodenum. When there is obstruction to the flow of the intestinal contents, or a communication between the stomach and intestine, intestinal contents are found in the stomach. ABNORMAL CONSTITUENTS OF THE STOMACH CONTENTS Abnormal products which are of importance for our diagnosis are quite frequently found in the gastric contents. They may con- tain mucus, blood, bile, intestinal juice, and pus. Mucus when present in considerable quantity is easily recognized. It generally occupies the upper part of the fluid, appearing in swollen glassy lumps or in flakes and shreds. It is also intimately mixed with the food. It can be readily lifted with a glass rod. If in small amount, a few drops of dilute acetic acid are added and it will be revealed by the characteristic precipitate. Bile and Intestinal Juice. — Small quantities of bile and intes- tinal juice may occasionally be met with normally. In the para- graph on "Examination of the Contents of the Stomach after Fasting" I referred to the presence of bile and intestinal juice and that their frequent occurrence is due either to relaxation of the pylorus or stenosis of the duodenum below the mouth of the bile-duct. Pure bile is golden yellow, but green if mixed with gastric juice. I believe that too often the diagnosis is made by simple inspection. Mould may produce a greenish color, and I have found it on several occa- sions. For accuracy, the tests should be made; Gmelin's for bile- pigment and Pettenkofer's for bile-acids. Einhorn suggests the following for the intestinal juice, which is recognized by its ferments, trypsin, amylopsin, and steapsin: Trypsin. — Mix the filtrate with i per cent, solution of sodium carbonate until the reaction is decidedly alkaline; add a flake of fibrin and keep in a warm place for several hours. Trypsin will dissolve the fibrin. Amylopsin. — Starch is changed into maltose. Steapsin. — Add i drop of blue litmus tincture and a few cubic cen- timeters of the neutralized filtrate to a small portion of milk and keep at blood temperature. Steapsin changes the blue color and the milk becomes slightly reddish from decomposition of the fat into fatty g^cids. Blood. — Blood in large quantities is easily recognized, as is fresh blood, even if in small amounts. 8 114 DISEASES OF THE STOMACH AND INTESTINES Fresh blood mixed with gastric contents presents a reddish appearance, while old blood is brownish or of a coffee-ground color. It may even appear blackish. When the blood cannot be detected microscopically and gastric hemorrhage is suspected, occult blood must be examined for. It is advisable to make the same examination of the stool. I. Benzidin Blood Test for Gastric Contents and Stool. — This is the most recent test devised by O. and R. Adler.^ They first applied it to test the feces. Schlesinger and Hoist" advise boiling the gastric filtrate and testing in the same manner as for feces. Gastric Contents. — Solution i. — Knifepointful of benzidin (Merck's) is added to 2 cc. of glacial acetic acid and allowed to stand and dissolve. Solution 2. — Ten to 12 drops of the benzidin solution are added to 2\ or 3 cc. of a 3 per cent, peroxid of hydrogen solution. Three or 4 drops of the gastric filtrate, which has been boiled for about half a minute, are added to Solution 2. In the presence of blood, a green or blue color results in from a few seconds to a minute. Stool. — The stool should also be examined. A small piece of feces about the size of a pea is mixed with 2 cc. of water and boiled in a test-tube closed with cotton for half a minute ; 3 or 4 drops of the boiled fecal solution are added to Solution 2. A green or blue color results if blood be present. Benzidin .Test Paper. — Einhorn^ has devised a benzidin testing paper as follows : Take a saturated solution of benzidin and glacial acetic acid; moisten filter-paper therein and dry it. Both in preparing the paper and making the test avoid contact with the fingers, as a drop of perspiration causes the reaction. When handhng the paper employ ivory-tipped forceps or protect the hand by a towel. Method. — Gastric Contents. — A piece of benzidin paper is first immersed in the gastric filtrate, and then a few drops of hydrogen peroxid are added. The paper is then placed on a piece of white porcelain and examined for the development of a blue color. If blood is present, a blue or green color occurs in a few seconds to a minute. Einhorn shows that if we wait longer periods, other sub- stances may cause the reaction, also in time the paper moistened with peroxid will become blue. Feces. — In testing for occult feces with the paper, a small piece the size of a pea is rubbed up with 2 cc. of water, the benzidin paper immersed therein, a drop of hydrogen peroxid added, and the blue color then examined for. The benzidin paper Einhorn recommends as a preliminary, and if there is immediately a strong reaction or none at all, he regards the 1 Zeitschr. fiir physiol. Chemie, Bd. 41, Heft i and 2, p. 59. 2 Deutsch. med Wochenschr., 1906, No. 36, p. 1444. ^ " A New Blood Test," Med. Record, June 8, 1907. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 115^ result as reliable. If at the end of a minute only a trace of reaction occurs, then the aloin-ether extract method may be employed as a check. In the fecal examination, ether extract of feces, as employed in the aloin test, makes the benzidin test more reliable. In examination of the gastric contents no meat products or iron preparations should be taken for at least twenty -four hours before the test, and in testing the stool tJie same rule must be osbervcd; but, prefer- ably, for a longer period if possible, at least two to three days as a precautionary measure. 2. Weber's Modification of Van Deen's Test for Occult Blood. — Dilute the stomach contents or, preferably, the filtrate thereof with I volume of glacial acetic acid, and extract with about 10 cc. of ef her. A few cubic centimeters of this acid ether extract are mixed with 10 drops of tincture of guaiac and 20 to 30 drops of ozonized oil of turpentine (old turpentine exposed to air). If blood is present, the mixture turns a blue or blue violet; if absent, it turns a reddish brown with a green tinge. The reaction is more distinct if a little water is added and the blue pigment extracted with chloroform. The Stool. — The test for occult blood is as follows: Treat 5 cc. of feces with 20 cc. of ether ; the latter is then poured off; 2 cc. of glacial acetic acid are added to the feces and thoroughly stirred. This mixture is again treated with about 10 cc. of ether and allowed to separate. To 2 cc. of the etherized extract add 2 to 3 drops of a fresh tinc- ture of guaiac. Then add 20 to 30 drops of ozonized oil of turpentine, or pure hydrogen peroxid, and shake well. If blood be present,, there appears a blue or blue-violet color. Meat and iron preparations should be avoided for from twenty- four to seventy-two hours before these tests. 3. Klunge's Aloin Test. — Feces. — In this test freshly prepared aloin is employed. Dissolve as much aloin as can be placed on the tip of a knife blade in 10 cc. of 70 per cent, alcohol; add 2 cc. of the aloin solution to 2 cc. of the ethereal extract of feces, prepared as above, and then the oil of turpentine or peroxid of hydrogen, as described. A cherry-red color appears in the fluid if blood be present. Gastric Contents. — Ethereal extract of the filtrate is prepared as in Weber's test. Rest of test is same as aloin test of feces. Einhorn at times employs aloin paper prepared with filter-paper saturated with a solution of aloin in 70 per cent, alcohol, the paper being then dried for future use. 1 prefer the benzidin or Weber's test. The spectroscopic test, hemin test, etc., have been suggested, but the ones described are the most practical. Pus is seldom found in the gastric contents and is recognized readily under the microscope. Excluding ingested pus and phleg- monous gastritis, pus shows ulceration of the gastric mucosa. Ii6 DISEASES OF THE STOMACH AND INTESTINES Fig. 67. — Fasting gastric juice con- taining mucus, snail forms, epithelial cells, and amorphous material. MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS The relative value of the microscopic examination of the gastric contents after the test meal, of the vomitus, and of the fasting stomach contents, as compared with gastric analysis, is still a matter of dispute. Some of the ardent advo- cates of the microscope go so far as to claim that their method is alone necessary. Un- doubtedly, in many cases the clinical symptoms, gastric anal- ysis, the test of the motor func- tion, and macroscopic inspection of the contents afford sufficient information for diagnosis. I do not wish, however, to depreciate the value of the microscope, as in some cases it is of funda- mental importance. Gastric Secretion. — When fasting, the gastric secretion shows normally under the micro- scope epithelial cells, cell nuclei, some mucus, amorphous material, and micro-organisms. Jaworski^ describes spiral or snail-like bodies in cases of hvperchlorhydria, but Boas believes they are quite common and that they are developed from the mucus by the action of the gastric juice (Fig. 67). Einhorn has found them in patients with normal secretion. Mucus. — Mucus from the bronchi and lungs is characterized by the pres- ence of alveolar cells and myelin drops; while the oc- currence of a great many columnar epithelial cells is evidence of the origin from the gastric mucous mem- brane. In doubtful cases the microscope will thus deter- mine the origin of the mucus, either by examination of the fasting contents or after a test meal. The clinical symptoms and macro- Fig. 68. — a, Nuclei of leukocytes; b, spiral bodies; c, nuclei of epithelial cells; d, striated mucus. 1 Miinch. med. Wochenschr., 1887, No. 30. EXAMINATION OF THE FUNCTIONS OF THE STOMACH II 7 scopic appearance of the contents, as described under chronic gas- tritis, will, however, generally give sufficient information. Paul Cohnheim holds that the presence of free nuclei of leu- koc^iies and epithelial cells is a positive evidence of hydrochloric acid and pepsin (Fig. 68). I believe that gastric analysis is much preferable for such deter- mination. Importance has been attached to the presence of two varieties of infusoria, the Trichomonas hominis and Megastoma entericum, notably by Cohnheim (Fig. 69). He beHeves that their .presence is pathognomonic of carcinoma, not affecting the motility of the stomach. Ameb^ are often associated with them. The development of these infusoria requires the absence of hydro- chloric acid, an alkaline medium, and the existence of deep folds in the mucosa. Previous to aspiration, the stomach-tube and receptacle should be warm^ed. Fig. 69. — a, Pus cells; b, trichomonas; c, megastoma; d, pavement epithelium. To differentiate between cancer and achylia gastrica, in the suspected cases, with emaciation, gastric distress, and achylia, special examination for these infusoria is advocated by Cohnheim. The presence of pus,' especially if associated with blood in the non- fetid gastric contents, he also believes aids in the early diagnosis before the tumor is palpable. Phlegmonous gastritis and the ingestion of pus from above must be excluded. Sarcinge and the Boas-Oppler bacillus can be examined for, both in the fasting stomach and after the test meal. The same is true as regards epithelial cells and pieces of the gastric mucosa. I will refer to them shortly. Gastric Contents. — The microscopic examination of the gastric contents after the test breakfast or dinner shows, under normal conditions, a few starch granules, many of which no longer appear in ^Microscopic pus in the gastric contents shows ulceration, not necessarily malignant in type. ii8 DISEASES OF THE STOMACH AND INTESTINES Spiral form. The muscular fibers do not show their diagonal stripes; globules of fat, plant-cells, and micro-organisms are present in small numbers. Many unchanged starch granules are found in hyperchlorhydria and h3'persecretion, and the muscle-fibers are well digested; while with hypochlorhydria (deficient secretion) unchanged muscle-fibers are present. The granules of starch are brought out clearly by the addition of one drop of tincture of iodin, giving a blue reaction. The microscopic findings are here confirmatory of macroscopic inspection. The varieties of micro-organisms have been thoroughly studied by DeBary\ Nencki,- Boas,^ and others. It has been demonstrated that they may be present even in hyperchlorhydria, showing that the hydrochloric acid does not always prevent fermentation. J. Kaufmann^ has described a case of hyperchlorhydria in which the motor function of the stomach was not markedly disturbed, but Fig. 70. — Benign ectasia. Yeast-cells and sarcinae are prominent: a, Muscle- fiber; b, plant-cells; c, sarcinae; d, starch granules; e, degenerated sarcin^; /, yeast-cells; g, fat crystals. which showed fermentative processes. He isolated eight varieties of micro-organisms in a specimen of the gastric contents. Boas has also described the development of sulphuretted hydrogen in a case of hyperchlorhydria. In general, we may say that fer- meniation develops in cases when the motility of the stomach is reduced. Minkowski' has shown that if free hydrochloric acid be abundant, yeast and thread fungi may be found; while if it is absent, numerous mould organisms are present. This last corresponds to the findings of A. Rose and myself. 1 Arch. f. Exper. Path, und Therap., Bd. 20, p. 243. . 2 Archiv. f. Exper. Patholog., Bd. 28. ^Deutsch. med. Wochenschr., 1892. ■* Berlin, klin. Wochenschr., 1895, No. 6. ^ See Naunyn, Mittheilungen aus der medicin. Klinik zu Konigsberg, Leipsic, e;xamination of the functions of the stomach 119 Yeast. — A few isolated yeast-cells are found in the normal stomach. In ectasia or atony of marked degree the yeast-cells are numerous, arranged in colonies, and are in active process of germina- tion (Fig. 70). Sarcinae. — These occur usually in cubes or bales, and are only pathologic if present in large numbers, as in benign ectasia or atony (Fig. 70), in the presence of hydrochloric acid. They are rare in ectasia from cancer, and, if present, occur usually in cancer developed on an ulcer. Their presence in large numbers is an aid to diagnosis. Boas-Oppler Bacilli. — They are unusually long, non-motile bacteria, and are characterized by their large size and end-to-end arrangement (Fig. 71). They must be differentiated from the Leptothrix buccahs, by Gram's solution, with which they stain brown, the Leptothrix, blue. Kaufmann's^ investigations prove the Boas-Oppler bacillus has the i? Fig. 71. — a, Boas-Oppler bacilli; b, leptothrix; c, potato-cell; d, yeast-cells. power of generating lactic acid from different sugars. Stagnation with lactic acid fermentation is not specific of pyloric carcinoma, but depends on the absence of hydrochloric acid and the presence of stagnation. These conditions exist in stenotic gastritis. These bacilli have been found occasionally in stomach contents that contain free hydrochloric acid (Rosenheim). Kaufmann has demonstrated them in 19 out of 20 cases of carcinoma. The presence of these bacilli, with pronounced lactic acid fer- mentation and taken in connection with clinical symptoms, is very significant. Epithelial Cells, Particles of Timiors, and Fragments of Gastric Mucosa. — Single cells cannot be diagnosed as cancer cells, but cell-nests nlust be found. These are rare. 1 Wiener klin. Wochenschr., 1895, No. 8. I20 DISEASES OF THE STOMACH AND INTESTINES Occasionally after aspiration of the fasting stomach, or test meal, or after lavage, or in the vomitus, small particles of tissue may be found, which on staining may reveal the nature of a tumor. Hemmeter recommends in suspected cases, first, thorough lavage and rectal feeding for a day; then, passing the tube, moving it about actively, and subsequent aspiration of the fasting stomach. This is to be followed bv lavage. All tissue fragments are to be examined. Einhorn finds, especially after lavage, or at times after aspiration, small pieces of mucous membrane which he stains and examines. Some point to erosions, others to other affections. The fragment may be normal mucosa, or there may be proliferation of the connective tissue, or of the glands, or atrophy (partial or complete), or vacuoliza- tion. These conditions are illustrated in their appropriate chapters. A positive judgment cannot be given from this examination, as only a small area may be actually involved and no changes obser^^^ed in the gastric secretion. On the other hand, a bit of normal mucosa may be aspirated from a dis- . eased organ. Mould. — Mould in the stomach has been little referred to in literature as a pathologic condition except by Talma, A. Rose, Naunyn, Einhorn,^ and Knapp.^ In an article on "Dilatation of the Stomach"^ I have already referred to it. Einhorn has found it in the wash-water of the empty stomach, as blackish-gray or brownish-green flakes of varying number; while Knapp describes it as coloring the chyme a yel- lowish green or dark red, and states that it has been mistaken respectively for bile or blood from its macroscopic appearance. He emphasizes the necessity for appro- priate tests for bile and blood, and not the diagnosis from appear- ances. I can substantiate this in one case at least, in which the reddish-brown material proved to be mould. The mould flocculi consist of clusters of spores and mycelia, sometimes mixed with mucus and epithelial cells. Crystals are also found, which Knapp considers to be segments of mould filaments. The mould generally found has been identified by E. K. Dunham as the penicillium glaucum, though Knapp reports in addition the oidium albicans and the aspergillus groups. These fungi probably ^ Medical Record, June 6, 1900. 2 Organacidia Gastrica, Sept. 6, 1902. ^Medical News, Aug. 16, 1904. Fig. 72. -Green mould follicle, mycelia, spores, and crystals. EXAMINATION OF" THE FUNCTIONS OF THE STOMACH 121 adhere quite closely to the mucosa and may involve considerable areas (Fig. 72). Einhorn reports mould formation in hyperchlorhydria, in some cases attended with hypersecretion, and also in gastralgia with normal or reduced gastric secretion. Knapp holds that the presence of organic acids in the stomach have a decided bearing, and that succinic acid and mould go hand in hand, the presence of the former being conclusive. His test for succinic acid is as follows: Extract i cc. of filtered chyme, with 4 cc. of ether, and float this extract on a solution of ferric chlorid (i drop of a 10 per cent, ferric chlorid to 2 cc. of distilled water) in a narrow test-tube. At the line of junction is a dark mahogany-red ring. He further describes symptoms in many respects resembling severe hyperchlorh3-dria with spasm of the pylorus, and believes the condition influenced by saccharine material in the chyme. In the experience of A. Rose and the author, diminished motility of the stomach is a marked factor in favoring the growth of mould. I have found it in cases of atonic ectasia, producing many of the symptoms of chronic gastritis, and again in benign stenosis with hypersecretion. The subject requires still further investigation. Rose finds the administration of TTLj (0.059 cc.) doses of beech wood creosote or carbonate of creosote gr. v (0.3) t. i. d. of value, and lavage is, of course, indicated, preferably with warm water — i liter, followed by lavage with nitrate of silver i : 2000, or spraying the stomach with the latter, as suggested by Einhorn. The general treatment should be according to the other conditions present. DETERMINATION OF THE ABSORPTIVE FUNCTION OF THE STOMACH The absorptive function of the stomach is usually tested by the method of Penzoldt and Faber, as follows: 0.2 of potassium iodid is administered in a gelatin capsule, and the saHva or urine examined every minute or two with starch-paper and fuming nitric acid. The strip of paper is moistened with saliva or urine and then touched with a drop of the acid. A violet or blue color is the reaction. It takes six and one-half to fifteen minutes before the reaction appears in normal conditions. In pathologic cases it is retarded. The test should be made on an empty stomach, as with the full organ it is retarded. It is self-evident that the gastric digestion of proteids — and hence their absorption — is delayed in cases of sub- acidity or anacidity, while these conditions are not so important for the digestion of carbohydrates. In some cases the absorption of iodid is normal, though we hnow proteid digestion is interfered with, so that I do not consider the test in every case reliable. Hershell gives a capsule containing 2 deci- 122 DISEASES OF THE STOMACH AND INTESTINES grams of powdered rhubarb. Under normal conditions the urine gives a red color with liquor potassae. They are, however, the best tests so far known. Motor Functions of the Stomach. — By this we mean the peristaltic action of the stomach which expels its contents into the intestine. The impairment of the motor power is fully as and in many cases more important than damage to the secretory functions. The best method of testing the motor power is by the test meal. Leube's is the oldest method. He administered a plate of soup, a beefsteak, and a roll. If the stomach was found empty seven hours later and nothing could be washed out, it indicated that its motor power is sufficiently active. If the food remains in the stomach longer, the motor power is reduced. We must remember that in pyloric stenosis the motor power may be reallv increased in endeavoring to overcome the obstacle, but that food remains in the stomach for an abnormal length of time ; strictly speaking, it is a relative motor insufficiency. If five hours after a test meal, a small amount of chyme is aspirated, the motor power is good. If large quantities are found six hours after the meal the motor function is absolutely (or if stenosis, relatively) decreased. Greater degrees of insufficiency may be present. For example, lavage is performed and a test supper administered, say, at 12 P.M. and the contents aspirated seven or eight hours later. In one case there may be a small quantity of food remaining, and in another case a large amount; while in another, none. I have found chopped spinach, a few raisins, or a piece of fig an addition to the test, as they are readily recognized. Boiled rice can be added. Boas recommends cold meat with rolls and butter and a large cup of tea. It may be more convenient to follow the same procedure, but give the meal at lunch time. Some employ the test breakfast. Two hours later the stomach shotdd he empty. If loo cc. or more are found at the end of an hour, or varying quantities at the end of two hours, it shows different degrees of motor insufficiency. The test meal is more accurate. I sometimes administer a test supper and aspirate in the morning to test the motor function, following immediately with the test breakfast to examine the secretory function. Salol Test (Ewald and Siever's Method). — Salol is not decomposed in the stomach, but in the alkaline medium of the intestine. Here it is split up, and the salicylic acid is absorbed and eliminated in the urine as salicyluric acid. The latter is recognized by testing the urine with neutral ferric chlorid solution, which gives a violet color with this acid. The patient takes salol i.o (gr. 15) in two gelatin capsules half an hour after a fight meal. The bladder is first emptied. Thereafter he urinates every half hour for about two hours, and the different specimens of urine are tested with the iron solution. Under normal EXAMINATION OF THE FUNCTIONS OF THE STOMACH 1 23 conditions the reaction appears in from thirty to seventy-five minutes. In retarded motiUty, it takes two hours or more. Ewald treats the urine with ether and examines the ethereal residue ; while Einhorn moistens a piece of filter-paper with the urine and touches the middle of it with the iron solution. Huber suggests to determine the time required for the complete disappearance of the reaction in the urine. The longer the time required for the salol to be absorbed and entirely eliminated through the urine, the longer it has remained within the stomach. He found that normally the excretion of the salicyluric acid after salol was administered lasted twenty-four hours; in patients with diminished motor function it lasted forty-eight hours or more. lodipin Test. — lodipin is decomposed in the intestine. Heichel- heim gives i.6.gm. iodipin in gelatin capsules at breakfast. The saliva is then examined every fifteen minutes for iodin by starch- paper and fuming nitric acid. In normal cases the reaction appears within an hour, Klemperer's Oil Test. — Oil is not absorbed in the stomach. After washing the stomach, 100 cc. of pure olive oil are poured into the empty organ. Two hours later the stomach is thoroughly aspirated. The difference between the original quantity of oil and that withdrawn indicates the condition of the motor function. Normally at this time only 20 to 40 cc. of oil should be aspirated. Einhorn's G a str ogr a ph. —^mhom has invented a deglutible ball, arranged wdth an electric circuit, so that the movements which mix and break up the food can be registered. Hemmeter-Moritz Method. — This method has been independently employed by Hemmeter and Moritz. A thin deglutible bag is attached to an esophageal tube. The bag is then blown up and connected with a tambour on the Ludwig kymograph, which registers all the movements with a pen. A pneumograph is tied about the chest to record the respiratory movements as a basis of comparison. The muscular contractions of the stomach are demonstrated on the record as independent of the respiration. These instruments are of interest scientifically, but their practical value has not been demonstrated. CHAPTER VII DIET The study of nutrition, both in health and disease, is important, but it will only be possible to enunciate the general principles. There are three groups of food stuffs — proteids, carbohydrates, and fats — procured from the animal and vegetable kingdoms, which in combination furnish the most suitable form of nourishment. Climatic conditions and environment have an influence on the requirements for nutrition. In extremely cold climates the Esqui- maux have lived for many generations on nearly an exclusively nitrogenous diet, in which fat, which produces the greatest number of heat units, predominates. In hot regions many of the races live principally on a non-nitrogenous diet. We also know that vege- tarians live and thrive on carbohydrates. A mixed diet is the most suitable form of nourishment. DIET IN HEALTH Voit has emphasized the fact that the smallest amount of proteid, with non -nitrogenous food added, that will keep the body in con- tinual vigor is the ideal diet. He holds that a healthy adult of aver- age weight should ingest loo gm. of albumin, 50 gm. of fat, and 450 gm. of carbohydrate in twenty-four hours; others place the requirement for proteid as considerably higher. A small proportion of the food serves the purpose of reconstructing the tissue waste, while the major part is used for generating the heat required for the maintenance of life. It is, therefore, customary to speak of the necessary amount of heat units during the twenty-four hours instead of the quantity of food. A calorie (or heat unit) may be defined as the amount of heat required to raise i gram of water i ° C. This is a small calorie. A large calorie is the amount necessary to raise i kilogram of water 1° C. Hence a large calorie equals 1000 small calories. I gm. carbohydrate yields 4.1 large calories. I gm. fat " 9.3 " I gm. proteid " 4.1 " " In order to calculate the calorie value of any kind of food, the num- ber of grams of albumin that are contained in it are multiplied by 4. 1 ; the grams of carbohydrate b}^ 4. i ; the grams of fat by 9.3. These are added together and give the total calorie value of the food. For example: 100 gm. albumin X 4.1 = 410 calories. 50 " fat X 9.3 = 465 " 450 " carbohydrate X 4.1 = 1845 " 2720 total calories. 124 DIET 125 The calorie value of vegetable proteid is slightly less than that of animal proteid; 50 gm. of fat about equal 113 gm. of starch in calorie value. Riegel holds that a human being at rest demands about 35 calories per kilogram of his body weight, and a person performing light work about 40 calories per kilo. From this estimate, the calorie value of the food of an individual weighing 50 kilos is from 1750 to 2000 calories. The weight of the patient must, therefore, be known in order to select the correct amount of nourishment. Rubner states that different articles of food can replace each other according to their calorie value, and that it is immaterial in what form the calories are introduced into the organism. This may be taken advantage of temporarily in certain pathologic condi- tions when it is necessary to limit some special variety of food, such as the carbohydrates. On the other hand, a certain amount of proteid is necessary for the organism, while unquestionable damage can be done by excess in this direction. The results of scientific study are opposed to the prevailing dietary standards, especially in regard to proteid foods. It is true that no other form of food can take the place of proteids, for a certain quantity is needed each day to replace the loss of tissue material broken down, and our choice of the varied articles of diet should be regulated by the amount of proteid they contain. It is not neces- sary, however, that they should exceed the other foods in amount or approach them in quantity. Russell H. Chittenden^ has clearly demonstrated by his scientific researches that the recommended dietary standards are excessive in quantity,^ especially in regard to proteids. They do not undergo complete oxidation in the body like non-nitrogenous foods, but there is left behind a residue of non-combustible matter, cr3^stalline nitrogenous products, which ultimately, if occurring in^ excess of the requirements of the body, prove injurious to the gastro-intestinal tract, liver, kidneys, and nervous system. The fats and carbohydrates are easily eHminated, becoming carbonic acid gas and water. Overfeeding with a tendency to obesity i^ an evil, as the fat acts as a mechanic obstacle to the activity of the body and interferes with the movements of the heart and other organs; and, in addition, fatty degeneration may occur. Potential energy, however, can be fully as advantageously met by the non-nitrogenous foods, carbohydrates, and fats. Fletcher has demonstrated on himself that deliberation in eating, necessitated by the habit of thorough insalivation, results in the occurrence of satiety on the ingestion of a comparatively small amount of food, and hence excess is avoided. It is clear that a man of 170 lbs. weight has more proteid tissue ^ Nutrition of Man. '^ Physiologic Economy in Nutrition. 126 DISEASES OF THE STOMACH AND INTESTINES to nourish than one of 130 lbs., and consequently what will suffice for the latter will not for the former. Dietary standards are merely approximate and depend on the physical work to be performed, the body weight, sex, age, climate, etc. There is doubtless a specific coefficient of nutrition characteristic of the individual. Chittenden demonstrated on professional men, soldiers, and athletes that they could perform their duties with greater vigor, and their strength as measured by tests, was increased under dimin- ished proteid diet; in fact, with about one-half the amount as compared with the standards suggested, CHITTENDEN'S TABLE Fuel value.i 60 gm. of proteid are contained in — Calories. J lb. fresh lean beef (loin) . 308 9 hens' eggs 720 I lb. sweetbread. ...'.... .^ 660 I lb. fresh liver 432 f lb. lean smoked bacon 1820 f lb. halibut steak 423 I lb. salt codfish (boneless) 245 2i lbs. oysters, solid 506 J lb. American pale cheese 1027 4 lbs. (2 quarts) of whole milk 1300 ■f lb. uncooked oatmeal 1550 i^ lbs. shredded wheat 2125 I lb. uncooked macaroni 1665 I -5 lbs. white wheat bread 1520 i\ lbs. crackers • 2381 if lbs. flaked rice 2807 f lb. dried beans 963 if lbs. baked beans 1 1 25 f lb. dried peas 827 i^i lbs. potato-chips 5728 f lb. almonds 2020 f lb. pine-nuts, pignolias. 1 138 I I lbs. peanuts 3584 ID lbs. bananas (edible portion) 4600 10 lbs. grapes 4500 1 1 lbs. lettuce 990 15 lbs. prunes 5550 33 lbs. apples 9570 The standards of 100 gm. of proteid or more mean the excretion of excessive nitrogen through the urine. Chittenden^ found bv experiment that the average need of proteid food by adults is fully met by a daily metabolism equal to an exchange of 0.12 gm. of nitrogen per kilogram of body weight. This means a cataboHsm of I gm. of proteid matter daily per kilogram. The intake of proteid food must be somewhat in excess of proteid cataboHsm, since not all of the proteid is available, and this is a variable amount depending on the proportion of animal and vegetable foods with their different degrees of digestibility and availability. The required intake of proteid Chittenden places at 0.85 gm. per kilogram of body weight, giving a maximum for safety. Hence, for a man weighing 70 kilos. ^ Fuel value of the quantity needed to furnish 60 gm. of proteid. 2 Physiologic Economy in Nutrition; Nutrition of Man. DIET 127 (154 lbs.) there would be required daily 59.5 gm. (say, 60 gm.) of proteid food to meet the needs of the body. This is about one-half the Voit standard, and far below that of many other so-called diets. As the specialist is so often consulted as to the proper diet to maintain the health of the body, I quote Chittenden at some length, being a firm believer in his principles. The daily proteid requirement of 60 gm. can be obtained from I pound of uncooked lean meat, of which loin steak is the tvpe. Lamb, veal, poultry, or lean flesh of any variety, of equivalent weight, will approximately furnish the same amount of proteid. Fish, such as halibut steak, and liver require | pound, and of sweetbreads |- pound are necessary. Of salt codfish h pound is equivalent to the same weight of fresh beef, while of lean smoked bacon | pound is necessary. Three hens' eggs furnish one-third the arnount of proteid required in twenty-four hours. Dried peas and beans, almonds, and pine-nuts are as rich in proteids as the above-mentioned animal foods, and essentially the same weight is called for to provide the daily require- ment of proteid. The same is true of cheese, the composition of J pound beiiig equivalent to the same amount of proteid, but of much higher calorie value than the equivalent weight of fresh beef. There are some differences in digestibility which tend to lower slightly the availability of the vegetable products, also of the cheese, which necessitates a slight increase in the amount of these foods to equal the proteid value of the equivalent weight of lean beef. Certain foods are poor in proteids, such as fruits, bananas, grapes, prunes, apples, etc., lettuce, and, to a less degree, potatoes. These are all palatable, but add little to the proteids, even when given in large amount. There is a radical difference between the animal foods and those of vegetable origin, in that the fuel value necessary to furnish the 60 gm. of proteid is small in the former, as compared with that of the vegetables; \ pound of lean beef with its 60 gm. of proteid has, for example, a fuel value of only 308 calories, while § pound of almonds has one of 2020 calories; ii pound of cheese has one of 1027 calories; h pound of dried peas, 827 calories. This is due to the proportion of fat or oil present. With fat meat, such as bacon, the calorie value rises in proportion to the increase of fat, the prot^d decreasing to a greater or less degree. A high proteid (animal) diet cannot serve for man. In a male, for example, with a weight of 70 kilos, and requiring 2800 calories,' it would necessitate the ingestion of 4^ pounds of beef to secure this result, or nine times more proteid than is necessary for the system. Certain vegetable foods on the diet list, such as flaked rice, crackers, and shredded wheat, contain proteids with carbolndrates and fat in such proportion that the energy requirement would be met with essentially by the same quantity as served to furnish the 128 DISEASES OF THE STOMACH AND INTESTINES necessary proteid. In potatoes and bananas the fuel value pre- dominates over the proteid. The ideal diet is an admixture, such as wheat bread with butter or fat bacon to add to its calorie value, shredded wheat with cream, crackers with cheese, bread and milk, eggs with bacon, meat with potatoes, etc. Two quarts of milk will furnish half the requirement of an average man, and reinforced b}' a i -pound loaf of wheat bread, gives the requisite amount. A better combination is I pound of lean beef, § pound of bread, and h pound of butter. According to Chittenden, for a man of average weight of 70 kilos. (154 pounds) to provide the requisite quantity of food — i. e., 60 gm. of proteid and 2800 calories — the following is a sample dietary: Proteid. Calories. Breakfast : Grams. I shredded wheat biscuit (30 gm.) 3.15 I teacup of cream (120 gm.) 3.12 1 German water roll (57 gm.) 5.07 2 i-inch cubes of butter (38 gm.) 0.38 I cup of coffee (100 gm.) 0.26 106 206 165 284 with J teacup of cream (30 gm.) 0.78 I lump of sugar (10 gm.) 12.76 51 38 Lunch : I teacup home-made chicken soup (144 gm.) 5 1 Parker House roll (38 gm.) 3 2 i-inch ciibes of butter (38 gm.) o I slice lean bacon (10 gm.) 2 I small baked potato (2 ounces — 60 gm.) i 1 rice croquette (90 gm.) 3 2 ounces maple syrup (60 gm.) I cup tea with i slice lemon I lump sugar (10 gm.) Proteid. Grams. 25 38 38 14 53 42 850 Calories. 60 no 284 65 55 150 166 38 16.10 Proteid. Dinner : Grams. I teacup cream of corn soup (130 gm.) 3.25 I Parker House roll (38 gm.) 3.38 I I-inch cube of butter (19 gm.) 0.19 I small lamb chop broiled, lean meat (30 gm.). . . . 8.51 I teacup of mashed potato (167 gm.) 3.34 Apple-celery lettuce salad with mayonnaise dress- ing (50 gm.) 0.62 I Boston cracker split, 2 in. in diameter (12 gm.) . . . 1.32 J-inch cube American cheese (12 gm.) 3.35 ^ teacup of bread pudding (85 gm.) 5.25 I demi-tasse coffee I lump sugar (lo gm.) • 29.21 928 Calories. 72 1 10 142 92 175 75 47 50 150 38 951 of The total with the dietary for the da)^ amount to 58.07 gra proteid and 2729 calories. These figures are to be considered only approximately correct. If a little more proteid is required without changing materi?llv the fuel value, a boiled &gg can be added to the breakfast. DIET 129 average egg of 53 gni. contains 6.9 gm. of proteid and increases the fuel value by 80 calories. If more vegetable proteid is desired, a soup of split peas can be introduced without changing to any great degree the calories; thus, one teacup of split pea soup (1.44 gm.) contains 8.64 gm. of proteid, while the fuel value is only 94 calories. The addition of i banana (160 gm). will increase fuel value 153 calories, but will only add 2.28 gni. of proteid. If the fuel value is to be increased without change in the proteid contents of the food, recourse can be had to butter, fat of meat, additional oil in salads, or to syrup and sugar. Wheat products abounding in starch still show a large proportion of proteid; thus, shredded wheat biscuit (i ounce), which is a type of many wheat preparations from bread and biscuit to various breakfast foods, yield about 3 gm. of proteid per ounce and 100 calories; ^ ounce of olive oil contains 100 calories. Potato, chiefly a carbohydrate, yields nitrogen the equivalent of about I gm. of proteid per ounce. If a large volume is desired without much increase in real food value, there are green foods, such as lettuce, celery, greens of various sorts; fruits, such as apples, grapes, oranges, etc. Meat augments largely the intake of proteid and adds relatively a small amount to the fuel value. In edible nuts the content of proteid is high, in some cases higher than in fresh beef; while carbohydrates and fat are large in amount, as in almonds and peanuts. In pine-nuts and Brazil nuts carbohydrates are small as compared with peanuts, almonds, and walnuts, an important fact where a vegetable rich in proteid is desired, but with freedom from starch (see table). Proteid present. Carbo- hydrate present. Fat present. Water present. 4.8 9.2 6.4 5-3 2.5 Mineral present. Fuel value per lb. Almonds (edible portion) .... Peanuts (edible portion) Pine-nuts (edible portion) . . . Brazil nuts (edible portion) . . Soft-shell walnuts 21.0 25.8 33-9 17.0 16.6 17-3 24.4 6.9 7.0 16. 1 54-9 38. 6 49-4 66.8 634 2.0 2.0 3-4 3-9 1-4 3030 2560 2845 3265 3285 United States Department Agriculture Bulletin No. 28. Green vegetables, such as spinach, help the bowel action. Natural sugars are of value, especialh' such as occur in oranges, grapes, prunes, dates, plums, and bananas, and to a less degree in apricots, peaches, pears, apples, figs, strawberries, raspberries, and blueberries. Apples when ripe and well masticated are good, and a baked apple is wholesome. There is occasionally an idiosyncrasy to strawberries, and some suffer from fermentation from various fruits. I30 DISEASES OF THE STOMACH AND INTESTINES A diet conforming to true nutritive requirements must tend toward vegetable food if excess in proteids is to be avoided. There is less need for food in hot weather, especially for fat, when lighter foods and less calories are required. We must also remember that the excessive use of salt strains the kidneys. The following table modified from that of Koenig and others, gives the chemic composition of different foods and the heat units which they produce: CHEMIC COMPOSITION OF COMMON FOOD SUBSTANCES I. Meats and Game. Beef (very fat) . . . . , Beef (lean) , Veal (fat) Veal (lean) Mutton (fat) Mutton (lean) Pork (fat) Pork (lean) Westphalia ham .... Salted ham Smoked beef Smoked beef tongue Pulverized meat. . . . Sweetbread Chicken (fat) Chicken (lean) Capon Duck (wild) Partridge Pigeon Hare Venison Per cent. Nitrogenous (proteid). 17.19 20.78 18.88 19.84 14.80 17. 1 1 14-54 20.25 23-97 22.32 27.10 24-31 64-5 22.0 18.49 19.72 23-32 22.65 25.26 22.14 23-34 19-77 Per cent. Fat. 26.38 1.50 7-41 0.82 36.39 5-77 37-34 6.81 36.48 8.68 15-35 31.61 5-24 0.4 9-34 1.42 3-15 3-" 1-43 1. 00 I-I3 1.92 Per cent. carbohydrate (nitrogen free). 50 Calories per 100. 315-81 99-15: 146.61 86.97 399-31 123.81 406.88 146.36 453-69 173-23 253-76 393-64 322.53 9392 167.58 99.10 135-II 131-36 116.85 100.02 107.08 105.44 II. Fish. Per cent. nitrogenous (proteid). Per cent, fat. Per cent. carbohydrate (nitrogen free). Calories per 100. Eel Pike Carp Shellfish Halibut Salmon Sardellen Oysters Fresh herring Salt herring. . Caviar 12.83 18.34 20.61 17.09 11.94 15.01 22.30 4-95 10.11 18.90 31-36 28.37 0.51 1.09 9-34 0.25 6.42 2.21 0.37 7.11 16.89 15.61 0.53 0.63 0.45 2.85 0.45 2.62 1.57 2.23 312.93 83.57 94.64 156.93 53-66 132.93 "3-83 34.39 106.15 247.61 279.76 DIET 131 III. Dairy Products Per cent, nitrogenous (proteid). Cows' milk Cream Buttermilk ....... Whey Kumyss (cows' \ milk) / Butter.-. .,; Cheese (cream) .... Cheese Eggs (hens') White of egg Yolk of egg 3.41 to 4.3 3.61 3.0 to 4.0 •85 3-65 0.5 16.28 34-99 12.5 12.67 16.24 Per cent, fat. 3.0 to 3.8 26.75 •93 to 1.3 -23 f I 2.07 90 41.22 11-37 12. 1 0.25 31-75 Per cent. carbohydrate (nitrogen free). 3.7 to 4.81 3-52 3.0 to 4.0 3-03 Lactic acid, .7 Alcohol, 1.9 Carbonic acid, 8. 0-5 1.90 5-40 0-5 0.12 Calories per 100. 56.41 to 71.93 276.01 33.08 to 43.63 18 1 32.99 823.1 449-54 269.06 165 54-22 355-99 IV. Cereals and Vegetables Per cent, nitrogenous (proteid). Wheat bread. . . . Rye bread Sago Wheat flour Rye flour Cakes Roll Zwieback Cauliflower ..... Potatoes Asparagus'. Carrots Rice Beans Peas Spinach Oatmeal Barley meal Brussels sprouts. Cabbage (white) . Pickles 6.0 6. II 0-5 8.5 10.0 II.O 6.82 9.5 to 13.0 2.0 to 1-5 2.0 1.04 5-5 ■19-5 19-5 2.49 12.05 8.31 4-83 1.89 1.02 5-0 Per cent. fat. 0.75 0-43 traces 1-25 2.0 4.60 0.77 i.o to 3.0 0.4 0.3 0.21 1-5 2.0 2.0 -58 5-26 o.Si 0.41 0.20 0.09 Per cent. carbohydrate (nitrogen free). Calories per 100. 52.0 46.0 86.5 73-0 69.0 73-30 43-72 75-0 4.0 20.0 2-5 6.74 76.0 52-0 54-0 4-44 66.77 75-19 6.22 4-87 0.95 245 217.56 356.70 345-78 342.50 387.09 213.87 3.56 (average) 35 88 20 33-85 348.10 311-75 319-95 33-67 338.80 323 49-05 29.52 8.81 132 DISEASES OF THE STOMACH AND INTESTINES V. Soups and Beverages Per cent. nitrogenous proteid. Per cent, fat. Per cent. I non-nitrogenous carbohydrate. Calories per loo. Meat broth Meat juice (expressed) . . . . Beef-tea ( Leube's meat solution . . -{ I I Malt extract Milk soup with wheat flour Barley soup Rice pap with milk Coffee Tea Beer Porter 0.4 6.0 to 7.0 0.5 9 to 1 1 albu- min and 1.7 to 6.5 pep- ton. 8.0 to lO.O 5-0 1-5 8.8 3.12 12.38 0.5 0.7 0.6 0.5 0.5 3-25 i.o 3-5 5-i8 5-25 6.0 0.5 550 15.0 II. o 28.6 0.3 0.3 7.10 31.20 (average) 6.6 ' 86.5 L (average) 258-30 112. 6o.g6 182.61 59-92 50.75 510 60. VI. Fruits, Nuts, and Sugar Apples Pears. ...... Plums Peaches Apricots. . . . Grapes Strawberries Chestnuts. . . Cane-sugar. . Beet-sugar. . Honey Per cent, free acid. 0.82 0.20 1.50 0.92 1. 16 0.79 0-93 Per cent. nitrogenous proteid. Per cent, fat. Chiefly sugar. Per cent. non-nitrogenous carbohydrate. 7.22 8.24 4.68 7.17 4.69 14-36 6.78 38.34 93-33 99-75 73.22 Calories per 100. 29.6 33-78 19.18 29-39 19.22 58.87 31.88 192. II 382.65 408.97 305.22 For the determination of the calorie value of each kind of food, the number of grams of albumin must be multiplied by 4.1, the grams of carbohydrate by 4.1, and the grams of fat by 9.3, and the multiples added will give the total calories as already described. The following diet Hsts of von Noorden^ demonstrate the method of calculating calorie values, and will be found useful to fulfil their indications : »Berl. Klinik, 1838, J. 55. DIET 133 I. A Chiefly Milk Diet with Addition of Carbohydrates in Liquid Form Albumin (per cent.)- Fat (per cent.)- Carbohydrate (per cent.). Calories per 100. Milk, 1 700 cc 70.2 10 7.0 66.3 5-5 71.8 69.7 30 40 1295 164 244 Soup of tapioca flour, 30 gm.and logm.albumose' Soup of 40 gm. wheat flour, with some of the milk, 10 gm. sugar, and one ess Total 87.2 139-7 1703 II. A Chiefly Milk Diet with the Addition of Carbohydrates and Fat in Mushes and Soups Albumin (per cent.). Fat (per cent.). Carbohydrates (per cent.). Calories per 100. Good milk, 1500 cc Soup of 15 gm. sago, 10 gm. butter, I egg, 10 gm. albumose 62 17 7 58.5 13-5 5-5 63 1.5 90 1056 257 Pap of 80 gm. corn flour, I egg, 10 gm. sugar (two meals) 198 Total 86 77-5 168 1711 III. Milk Diet with Addition of Solid Food, Pastry, and Broths, Icaviug little Residue Albumin Fat (per cent.). (per cent.). Carbohydrates (per cent.). Calories I)er 100. Milk 1250 cc 51 , J-O 5- 30 50 30 878 Meat broth with i egg, 10 gm. of butter, 50 gm. of fine toasted w heat bread 10 5 7 14 12 294 Cakes 70 gm., butter T ■; ffm 337 Soup of 30 gm. tapioca flour, I egg, 10 gm. 282 Total 73 89 162 1791 ])reparat 1 Ten gm. albumose is contained in 90 cc. (3 ounces) of Denayer's peptone )aration, in 22 gm. ( ovss) of Kemmerich's, or in 30 gm. (i ounce) of Koch's. 134 DISEASES OF THE STOMACH AND INTESTINES IV. Milk with Tender Meat, Solid Food (Pastry), Butter, and Soups Albumin (per cent.)- Fat (per cent.). Carbohydrates (per cent.). Calories per 100. Spring chicken, loo gm. . . Mashed potatoes, loogm. . Two eggs 19.6 2.0 14.1 7 193 51 2.8 4.0 II.O 0.5 23.0 2.1 49 20 55 52 106.4 127.4 160 I Toasted wheat bread loo gm Butter, 30 gm . 258.8 213.9 106.4 878 Trout, 100 gm MUk, 1250 CO. and soups in addition Total 113.0 92.4 127 1851 V. Abundant Non-irritating Diet Albumin (per cent.). Fat (per cent.). Carbohydrates (per cent.). Calories per 100. Tender meat, 250 gm.^. . . . Cacao, 20 gm 49 4 21 8 7 4 51 7.0 6.0 16.0 I.O 0-5 2-3 44.0 49 8 75 55 36 40 40 20 52 266 105 235 349-4 258-75 187 407 164 164 82 Three eggs^ 100 gm. Zwieback 100 gm. wheatbread 50 gm. cakes 50 gm. butter^.. 40 gm. tapioca flour*. . . . 40 gm. corn flour (mai- zena) 20 arm. susrar' 1250 cc. milk" 878 Total 144 125.8 326 3096.15 Digestibility of Food. — We may say that an article of diet is easily digestible if it makes small demand on the secretory and motor functions of the stomach, if it is readily absorbed, and causes no subjective disturbance. The scale of digestibility of foods has been arranged according to the length of time that they remain in the stomach, the motor and secretory functions in the healthy stomach acting together, and hence the length of time the material remains in the organ indicates its digestibility; good motor power for a definite food shows good digestion. In pathologic conditions the rule is not as absolute, for either secretory or motor functions may be 1 Meat of various kinds, finely chopped, raw, or broiled in butter, or roasted, cold or hot, given in two meals. 2 Egg in cocoa, one in soup and one raw or soft boiled. ^ Butter for starchy foods, soup, etc. * Tapioca flour to thicken soup. ^ Sugar for cocoa and cornmeal pudding. ® Milk for cocoa, pudding, and to drink. DIET 135 perverted alone or together, and sometimes in opposite directions. Gastric digestion may also be vicariously assumed by the intestines. Leube's experiments were conducted with digestion in diseased stomachs, and from these he constructed his diet scale of foods according to their digestibility. It especially forms the basis of the diet of ulcer (Leube's method) and is valid in many other conditions. Leube's Diet Scale. — Diet i. — ^With much reduced digestion, the following are most easily digested : bouillon, meat solutions, such as Leube-Rosenthal's ; milk; raw, soft-boiled, or poached eggs; zwieback; water, acidulous waters (Apollinaris, Seltzer). Diet 2. — Less digestible are boiled calves' brain, boiled thymus, boiled chicken and pigeon, boiled calves' feet (with some) ; gruels, milk, mushes made with tapioca and beaten white of ^^g. Diet J. — If Diet 2 is digested, then these can be given: Raw beef (chopped fine), or scraped meat with a dull spoon, and roast meat scrapings in fresh butter ; raw ham (chopped fine) ; a little mashed potato; stale white bread and a small amount of coffee or tea with milk. Diet 4.. — Roast chicken; roast pigeon; venison; partridge; roast beef, medium to raw (particularly cold) ; veal (leg) ; pickerel ; boiled shad; macaroni; bouillon with rice. Trout are hard to digest. Small quantities of wine one or two hours before eating. Gravies are contra-indicated. Young and finely chopped spinach is best. Asparagus may be tried, but Leube considers it risky. After the fourth diet the food is gradually increased, but very gradually. Vegetables, salads, preserves, and fruits should be refrained from for a long time. A baked apple is one of the first of these that can be taken. Penzoldt has formulated a scale of digestibility for the normal stomach. Various Food Stuffs. — It is important to remember that we can replace the albumin in food by carbohydrates, and at times by the fats, though the latter are not always well tolerated. In many cases the food should be concentrated, nourishing, and finely divided, so as not to irritate the organ. Milk is excellent in some cases, but in ulcer, too large quantities, at least 3 liters (1770 calories), would have to be given, which tend to overdistend the organ. Moreover, raw milk remains in the stomach longer than some other forms of nutriment, and when given alone may coagulate, and with some disagrees. In some experiments at the Manhattan State Hospital,^ in cases of dilatation of the stomach, it was conclu- sively shown that this organ emptied itself with greater rapidity in proportion to dilution of the milk with water. It is, therefore, preferable to give smaller quantities of milk and not to administer it alone, but diluted with barley-water, for example, or some other ^ Medical Record, June 20, 1908. 136 DISEASES OF THE STOMACH AND INTESTINES amylaceous material, such as rice-water or decoctions of tapioca, maizena, etc. One can add material, such as raw eggs, to increase the calorie value, a large amount of nutriment in small bulk, as described under the treatment of gastric ulcer. Gartner's fat milk, from which some of the casein has been removed, is of service. Buttermilk has small nutritive value. Kefir, koumyss, bacillac, and matzoon are often useful. Meat broth and bouillon have little nutritive value, while beef -tea and expressed beef-juice are of some service. The latter is best made from the rump of beef, cut in dice, cooked for five to ten minutes, and then the beef-juice expressed and pepper and salt added. Valentine's beef -juice and Armour's extract of beef can be recommended and are cheap. Gelatinous articles of food, such as gelatin in solution, jellies, calves' feet, etc., are easily digested, as are soups containing chicken or calves' brain finely macerated and forced through a sieve. Shellfish, pike, halibut, and carp contain the least fat and are digestible. Carbohydrates should be well masticated and carefully insalivated. If they contain much cellulose they are not as readily digested and should be ground thoroughly. If there is stagnation and so danger of fermentation, care in their use should be exercised. Ordinary bread (rye or domestic) is not as good. Zwieback, toast, maizena, tapioca, oatmeal, and LofHund's kindermehl are best. Aleuronat flour (Ebstein) contains 80 per cent, albumin. Legu- minose (Hartenstein's), Liebig's maltoleguminose, and Knorr's preparations are excellent. American veal has been found by experience to be not very digestible. Fat in the form of butter (50 to 100 gm.) usually agrees. Coffee and tea may be given in moderate amounts in many cases, but considerably diluted. Alcohol. — Wines are recommended by many as a mild stimulant to the stomach in certain cases, but from personal experience I advise against their use. There are other remedies which give better results. General Rules. — The teeth should be kept in good condition; thorough mastication and insalivation are important, and a brief period of rest after meals should be advised both in health and disease. Regularity of meals should be enjoined. Method of Feeding to Spare the Stomach. — In some cases it is necessary to administer nutriment in soluble or easily digested form. Appended is a short list : Hemmerich's pepton, somatose, sanatogen, tropon, Koch's pepton. Brand's meat preparations, Valentine's meat juice, Liebig's soup, and Gartner's fat milk. Leube- Rosenthal Meat Solution. — Chop i kilo, of beef into fine pieces, mixing it with water (i liter), and add 20 gm. of pure hydro- chloric acid and boil mixture ten to fifteen hours in a Papin pot. DIET 137 The mass obtained is crushed, boiled fifteen hours longer, neutrahzed with pure sodium carbonate, and evaporated to a mushy consistency. It is digestible, but contains relatively small quantities of peptone. Debove's Meat Powder. — Roast finely chopped lean beef on tin plates until it is entirely desiccated. Powder in a mortar. Haggard. — Cut lean meat into narrow strips, place for a few minutes in hot fat or lard until surface is browned, then place on a sieve for a short time. Fat is allowed to drip off, and meat is dried twenty-four hours in a baking oven at a moderate temperature. It can be ground to powder in a coffee-mill. Rectal Alimentation. — General R^lles. — ^The bowels should be emptied by enema ; injection of the nutritive enema should be given with the patient on the left side with a colon-tube several hours later; temperature should be about 100° F. (warm). A folded towel should be pressed against the anus and the buttocks pressed together for at least fifteen minutes after the injection. Milk shoidd always he peptonized, and alcohol, if injected, should not be stronger than i : 6 in the fluid enema. The addition of a small amount of salt aids absorption. Dextrose is readily absorbed. Occasionally it may be necessary to add a few drops of tincture of opium if there is much irritation. Raw eggs are readily absorbed. Sanatogen, pepton, and somatose are excellent additions. No more than 8 oz. (250 cc.) should be given at an injection. It can be administered four or five times a day. If the bowel is irritable, smaller quantities should be employed. The patient should remain quiet for one-half hour after the injection. Ewald suggests 3 to 5 raw eggs, mixed with 150 cc. of water and 30 gm. of grape-sugar, and a small amount of common salt. Boas uses 250 gm. milk; yolks of 2 eggs; salt, tablespoon of red wine; tablespoon of Kraftmehl. I have found the following useful: milk (peptonized), 125 cc. ; sanatogen, oiij (12.0); 2 raw eggs beaten up; water q. s., 250 cc. (oviij), and a little salt. Modifications will readily suggest them- selves. Leube's Meat Pancreas is Often Valuable. — To 150 to 300 gm. of scraped and finely chopped beef add 50 to 100 gm. of pancreas from cow or hog, free from fat, and finely chopped. The two substances are placed in a dish and 150 cc. of lukewarm water are added, and the mixture stirred till it forms a thick mushy mass. If fat is also to be digested, add 25 to 50 gm. of fat. Inject with a pressure syringe. Enemata of normal saline solution — .3j (4.0) salt to Oj (500 cc.) of water — are of value for thirst, or administered at a temperature of 110° to 120° F. as a stimulant. Proctoclysis is useful. If this quantity is not retained, a smaller amount should be employed. Subcutaneous injection of fats I would not recommend. vSierile 138 DISEASES OF THE STOMACH AND INTESTINES almond oil, 5ss (2 cc), might be given three times daily subcu- taneously in extreme emaciation for a brief period. Inunctions with preparations of oil or lanolin may at times be of service. DIET IN DISEASE General principles will be enmnerated. In acute diseases of the stomach, as in acute gastritis, the indication is to spare the organ as much as possible. In some cases no food is administered b}^ mouth for several days and rectal feeding is employed. If food is administered, it should be given in small quantities at first and in liquid form, weak broths, bouillon, barley- water, a small quantity of water. They should be neither exces- sively hot nor cold. Peptonized milk, milk and hme-water, white of raw egg beaten up; later, toasted bread, soft-boiled eggs, .etc., and a gradual return to full diet. Ulcer of the Stomach. — In this condition both mechanic and chemic irritation of the stomach should be avoided. Albumin solu- tions and finely divided proteid material are indicated, such as milk, beef-juice, somatose, tropon, or especially, sanatogen in solution. Einhorn allows barley-, oatmeal-, or rice-water in early treatment. Raw eggs beaten up aid in binding the free acid. Dextrose and butter aid nutrition and lessen acidity. Starch in any great quantity is not well borne on account of the acidity. Leube avoids all stomach feeding for several days after the hemorrhage, employing nutritive enema; while Lenhartz feeds immediately, binds the free acid, and endeavors to rapidly improve nutrition. Gelatin solutions are of value in these cases. Chronic Diseases of the Stomach. — In the chronic diseases it is extremely important to see that sufficient quantity is taken and to improve the nutrition of the patient, as frequently subnutrition is present. Carcinoma. — In malignant disease of the stomach or its orifices little can be accomplished by diet alone. The patient should receive frequent meals in small quantities, liquid or pultaceous in form. This is advisable, even if the cancer is so situated as not to interfere much with the m.otor function. I have seen cases improve tem- porarily in nutrition. Radical or palHative operation is indicated. Benign Stricture. — Stricture of the cardia can at times be dilated wdth bougies; but with pyloric stricture perfect recovery often follows operation. With benign pyloric stenosis, hyperacidity, at times with hypersecretion, and ectasia are present. The indications in these cases are to administer hquid or mushy foods, chiefly of albuminous type. There is relative motor insufficiency and increased secretion. Starchy food in quantity is not, therefore, well borne. The gastric secretion, motility, and sensibility of the stomach must be studied in every case. DIET 139 When there are disturbances of the motor function, food should be given so prepared that it will be most easily evacuated from the stomach, as in liquid or pidtaceous form. Among the disturbances of gastric secretion we have hyper- acidity and hypersecretion, an increase in the secretory function; and subacidity and anacidit}', an impairment of secretion. IMotor disturbances may complicate any of these conditions, and sensory disturbances are most frequent in the first class. In the hyperacid forms, a diet should be selected which stimulates hydrochloric acid secretion as little as possible and at the same time combines with it. Abundant albuminous diet should be adminis- tered, w'ith hyperacidity, in coarse form if the motor function is intact, otherwise in liquid or mushy form. With hypersecretion, smaller and more frequent meals are indicated, and fluids should be limited. Carbohydrates in any quantity are not well borne, though their digestion is better in hyperacidity than in hypersecretion. Solu- tions of dextrose are readily absorbed and lessen the secretion of hydrochloric acid. The diet of ulcer has been previously referred to. Fats are quite well borne, and in the form of olive oil lessen the hydrochloric acid. In cases of subacidity, as in chronic gastritis, meat must be diminished and carbohydrate material increased. Nutrition must be improved. Koumyss, matzoon, milk, and raw eggs must be taken wdth crackers and butter between meals. As an example of anacidity we have achyUa gastrica. This may be a temporary functional disturbance or a permanent condition W'ith organic changes. Chemic action has ceased and vegetable food (in which starch granules possess an albuminous coat) as well as animal food pass from the stomach unchanged and irritate the intestines. A rich carbohydrate diet is indicated, but it must be well pulverized. With ectasia and gastroptosis small and frequent meals are indicated, the character depending on the gastric secretion. With severer forms of motor insufficiency liquids and mushes are required. In nervous dyspepsia one must gradually increase the quantity of food. ' The administration of frequent small meals, koumyss, matzoon, etc., betw^een the chief meals is of value. The rest cure is often ser^dceable. One must individualize in every patient, and with the aid of the general principles described it will be possible to formulate a diet to suit the case. CHAPTER Vni LOCAL TREATMENT OF THE STOMACH LAVAGE Since the year 1867, when Kussmaul employed lavage in a scientific manner with his stomach-pump in the treatment of diseases of the stomach, there has been a gradual improvement in the type of instrument. The hard tube and the use of the stylet for intro- duction have passed into disuse, and the modern method is based upon the principle of siphonage with the soft-rubber tube. Funnel Method. — The one that is in most common use for washing the stomach is by means of the funnel. The latter may be of hard rubber, glass, or a flexible rubber funnel, attached to a piece 73. — Funnel and tube for lavage. of soft-rubber tubing about a yard long, the latter being joined to the upper end of the stomach-tube by a small connecting glass or hard- rubber tube (Fig. 73). The glass funnel is more readily broken and the soft-rubber funnel not as easily managed by a novice, so that for general use the hard-rubber funnel is preferable. One of. medium size, holding about 250 cc, is most convenient. The glass connecting tube, in one case to my knowledge, came near being the source of considerable danger to the patient. During the lavage he suddenly grasped the glass tube and managed to splinter off a portion of it, fortunately at the same time partially pulling out the stomach-tube. The accident was immediately noted and the tube entirely withdrawn. Fragments of glass were found in the tube. 140 LOCAL TREATMENT OE THE STOMACH 141 There is always the possibiUty of a similar accident to the glass funnel, and the use of a rubber instrument and metal or rubber attachment would seem to be preferable. Dangers. — There is one possible danger, namely, the stomach- tube may separate from the attachment to the funnel tube and slip down into the stomach. Leube^ reports such a case. On the ninth day after swallowing the tube — after an attack of coughing — the tube passed up into the esophagus and pharynx and was withdrawn therefrom. The connection between the stomach-tube and funnel- tube had become loosened and the water from the latter forced the tube into the mouth. Moreover, every stomach-tube should be tested before using to be sure that it is not cracked or weakened by some defect. Friedenwald" reports such an accident resulting from the use of a defective tube, with the result that two fragments were subse- quently removed by gastrotomy. At the Manhattan State Hospital, Ward's Island, among our nervous and insane patients, a long, continuous, single-piece stomach- tube (3 J to 4 J feet in length), with a rubber funnel at the end, is employed. This obviates all possible danger of swallowing the tube, which would be the most likely accident with this class of patients. For ambulance w^ork such a tube is decidedly to be recommended. Under ordinary conditions, with the two-piece tube, the patient or an assistant can hold the stomach-tube tightly at the point of junction with the connecting joint, or the operator can hold it firmly at the lips of the patient when he elevates the funnel. £ ^O Fig. 74. — Best tube for lavage. Selection of the Stomach-tube. — The selection of the stomach-tube may seem to be an unimportant matter, but from a varied experience there is undoubtedly a decided advantage in the choice of an instru- ment. The tube should be of value both for aspiration of the stomach contents and for lavage. Some prefer the tube closed at the end and with two lateral openings, claiming that there is less danger of traumatism from the smooth rounded end and less chance of aspirating the mucous membrane into the openings of the tube. In actual practice, one has to exercise more pressure with this type of tube in order to force it to take the cur\'ature of the stomach and He parallel with the same, if thorough aspiration or lavage is to be performed. This tube is, moreover, not so readily cleansed. The tube open at the end and with a large lateral opening is prefer- 1 Deutsch. Arch. f. klin. Med., vol. xxxiii, p. 6. 2 American Medicine, August 2, 1902. 142 DISEASES OF THE STOMACH AND INTESTINES able; a tube with two lateral openings is the best, though not abso- lutely essential (Fig. 74). It is much easier to thoroughly aspirate the stomach or perform lavage with tubes of this description. The pressure is so minim- ized by these large openings that in my own experience I have never seen damage result to the mucous membrane. For practical purposes a tube of from 28 to 30 (French) is thor- oughly efficient. I have seen physicians in their general practice employ tubes of very large caliber, irrespective of the size or age of the patient. This is about as sensible as using a large sound in every case, irrespective of caliber or conditions of the urethra. The tube of medium caliber that I have indicated will pass comfortably through any average or even small adult esophagus, unless stricture be present. The best tubes are marked at about 18 inches from the distal end (it is 16 inches from the teeth to the stomach), and by this means we know when the instrument has reached that organ. The tube should be inserted a little further until checked by the lower border of the stomach, and then with- drawn slightly until no resistance is felt by the operator. With ectasia or gastroptosis it may be necessary to pass it a considerable distance. If the tube is not marked it is easy to estimate the correct dis- tance and make a scratch mark on the tube with a pencil, or insert it until checked by the lower border of stomach, as just described. A pitcher, pail or large basin, towels, and rubber sheets are required. Special irrigating stands can be secured, but are un- necessary and expensive for the young physician. The correct method of lavage in office practice, without an assist- ant, is first described. False teeth should he removed. The patient should sit upright in a straight back chair, with a rubber sheet or towels about the neck and protecting the front of the body. His confidence should be gained. He should be told that the procedure is slightly disagreeable, but absolutely safe. He should be admonished that he is to breathe deeply and steadily all the time, as this will prevent the gagging and sensation of choking; and he should be directed, while the lavage is actually in process, to follow out this method. The stomach-tube should be lubricated by dipping it in warm water. Vaselin, cold cream, or olive oil may be used, but they are disagreeable and unnecessary. The irrigating fluid should be pleasantly warm to the hand. This is sufficient index to the tem- perature, though for absolute accuracy a thermometer may be employed; and about 100° to 10 1 ° F. is correct. Plain water or, preferably, normal saline solution — .5j (4-0) salt to I pint (500 cc.) of water — is employed in the average case for the purpose of cleansing the stomach. Special solutions will be appro- priately indicated in their places. LOCAL TREATMENT OF THE STOMACH 143 The patient should bend the head sHghtly forward and open the mouth, but not protrude the tongue. In rare cases a 2 per cent, cocain or 5 per cent, eucain spray may be required if the pharynx is irritable. Freezing the stomach-tube is also serviceable. The physician should never insert his finger into the mouth to depress the tongue or act as a guide to the tube, as it renders the operation more difficult, and will only cause gagging or vomiting. Fig- 75- — Correct method of passing the stomach-lube. Most of our text-books advise that the operator stand in front of the patient and pass the tube along the base of the tongue. The most practical method is the one shown in Fig. 75. The physician stands on the right side and a Httle back of the' patient and passes the left arm about the neck, the fmgers sttp- porting the tube at the lips, the little finger resting on the chin. This method prevents the patient from throwing his head back and struggling, and gives the operator perfect control. The stomach-tube should be passed into the mouth with the right hand, it being held about 2 inches from the lips and being 144 DISEASES OF THE STOMACH AND INTESTINES supported by the left hand against the roof of the mouth. It should then be rapidly forced in with the right hand, the index-finger and thumb of the left hand continuously aiding its introduction. The tube follows the arch of the mouth, and glides down the posterior wall of the pharynx (Fig. 76). Interference from the tongue is thus avoided. When its progress is checked, the patient should be told to swallow and it will enter the esophagus. It should now be rapidly fed into the mouth until the marked ring has been reached, and then more slowly to the bottom of the stomach. If the tube is checked during introduction, it is probably due to a spasm of the esophagus, and the act of swallowing or a deep inspiration will free it. There is practically no danger of its en- trance into the larynx. Sometimes the patient ma}^ become cyanotic and a beginner may fear that this has happened ; but this is due to the fact that the breath is held, and deep and regular breathing will immedi- ately relieve the condition. Occasionally the tube may slip out of the esophagus and coil in the mouth, but that is easily detected. Patients accus- tomed to lavage can often intro- duce the tube themselves. I prefer a funneP of a capacity of 250 cc. or about 8 ounces, and allow 2 funnelfuls to run into the stomach (in all about i pint) and to run out again at once. It is a bad practice to overdistend the stomach, just as it is the bladder. At times I emplo}^ i funnelful. Lavage is continued until the water is perfecth^ clear. The patient may move the body about so as to bring the water in more thorough contact with the stomach wall, or may lie down, as sug- gested by Kleiner, rotating to the right side and then to the left; but this is rarely necessary except in cases of marked dilatation with insufficiency. Lavage by a Single Operator. — During lavage the patient steadies the stomach-tube, holding it to the lips with one hand. He should be instructed not to bite the tube. 1 If the funnel is of smaller capacity, more funnelfuls should be used, total 250 to 500 cc. (8 ounces to i pint). Fig. 76. — Course of tube. LOCAL TREATMENT OF THE STOMACH 145 The operator holds the funnel in the left hand and pours the water into it from a pitcher in the right hand, then elevates the funnel to about the level of the patient's forehead (Fig. 77). As soon as it is empty, he pours in the second funnelful. Then before the latter is empty he quickly lowers it to below the level of the patient's stomach, and allows the fluid to siphon out into a pail or bowl placed on the floor to the right of the patient (Fig. 78). The rim of the funnel should be held upward. It should be allowed to fill before emptying it, as in this way it can be estimated fig. -J-. — Lavage by single operator: Position one. whether the amount of fluid that flows out equals that which was poured in. In emptying the funnel it should only be slightly tipped, so that the column of water is still visible in the bottom. This prevents the entrance of air and also the aspiration of the mucous membrane into the openings of the tube. When the washing is completed, the funnel should be rapidly 10 146 DISEASES OF THE STOMACH AiXD INTESTINES raised and the stomach-tube withdrawn in this position. The small column of water remaining in the tube flows back into the stomach and prevents the possibility of the accident just noted. The tube should not be pinched during the withdrawal, as mucous membrane might be aspirated in. If the water stops flowing during lavage, one should observe if the patient has not inadvertently withdrawn the tube slightly; and in this event, it should be pushed back. On the other hand, the tube may be bent and the flow stopped by reason of its being forced too far into the stomach. If so, withdrawing it slightly will correct the trouble. Pieces of food may occlude the tube by stopping up the stomach openings. By pour- ing more water into the funnel the instrument will usually be cleared out. By forcing air through the stomach-tube or by suction this can be accom- plished if the above method fails. Thus, a rubber bulb with metal attachments is in- serted between the stomach- tube and the funnel-tube, in place of the tube joining them. Close the end leading to the funnel and compress the bulb. This will force air through the stomach -tube; or first com- press the bulb, then close the distal end connecting with the funnel by making an angle or compressing the soft tube of the lat er then let the rubber bulb expand again. The last method described is that originated by FriedHeb. The stiff rubber bulb made by Tiemann, with metal attachments, is a better instrument than Friedlieb's, which has glass attachments. On rare occasions it may be necessary to remove the tube, clean it, and reintroduce it. In emergency in country practice one can employ an ordinary tin kitchen funnel and a piece of small red or even white rubber tubing. A fountain syringe with the long soft-rubber tubing has been used in poison cases. A stomach-tube can be improvised out Fig. 78. — Lavage by single operator: Posi tion two. LOCAL TREATMENT OF THE STOMACH 147 of a long colon-tube. The lateral opening can be cut with a pair of sharp scissors, and the rough edges of the window burned over an alcohol lamp, wiping them quickly with a wet cloth, thus making a smooth velvet eye. If the opening of the improvised tube is rough, it can be trimmed down and smoothed b)^ the above method. It is best to lubricate all such emergency tubes with ohve oil or vaselin, as they are less smooth and more difficult of introduction- Fig. 79. — Lavage by two nurses: Step one. With an intelhgent patient who will co-operate with the physician the method described is excellent. In nervous cases, when pos- sible, it is easier to have an assistant, or for two nurses to perform lavage, as in Figs. 79 and 80. The technic is the same as to passage of the tube, etc. One nurse steadies the tube at the patient's mouth and carries on the manipulation with the funnel, the other pouring the fluid. 148 DISEASES OF THE STOMACH AND INTESTINES 10 L Fig. 80. — Lavage by two nurses: Step two. Fig. 81. — Friedlieb's apparatus for lavage. LOCAL TREATMENT OF THE STOMACH 149 If the patient resist, nurse No. i both holds the tube and prevents interference by the patient's hands, while nurse No. 2 manages the funnel and pours the fluid. Friedlieb's apparatus is demonstrated in Fig. 81. In Figs. 82 and 83 we have two nurses performing lavage with a funnel, the modified Frtedlieb bulb connecting the stomach-tube and funnel-tube. This is a favorite method of mine. Fig. 82. — Nurses performing lavage with modified Fnedlieb bulb: Step one. It is best to close the bulb on the side joining the stomach-tube by pinching the latter with the fingers, then squeeze out the air and pour the fluid into the funnel, allowing the bulb to fill with water. This prevents aspirating air into the stomach. Lavage is then performed in the usual way. The advantage is that we have the bulb in position to employ air pressure or suction if the stomach-tube becomes occluded. Intermittent squeezing of the bulb also aids expulsion of the fluid. I50 DISEASES OF THE STOMACH AND INTESTINES The modified bulb made by Tiemann has metal connections (instead of glass) and is stiffer than Friedlieb's. Irrigation of the Stomach by Means of a Glass Y or T- — This method has generally been known as Leube-Rosenthal's, but R. H. M. Dawbarn has taught this plan for many years. It is useful for office work. A large glass irrigator, about 2-quarts capacity, is hung at a level slightly above the patient's head. This should be marked in Fig. 83. — Nurses performing lavage with modified Friedlieb bulb: Step two. 250 to 2000 cc.'s, or in otmces or pints. This irrigator is con- nected with a long soft-rubber tube by means of a Y" or J-shaped glass or, preferably, hard-rubber or metal tube; one branch with the stomach-tube and the other with a carry-off tube which passes down into a pail or basin. The irrigator tube should be closed with a clamp. This is- kept closed until after the introduction cf the stomach-tube and com- mencement of lavage. A second clamp on the outflow tube is LOCAL TREATMENT OF THE STOMACH 151 unnecessary, as all manipulation can be thereafter conducted by the operator, by alternately opening and closing the inflow and outflow tubes with the fingers. The stomach-tube is introduced in the way described. The outflow is pinched as in Fig. 84 and the clamp on the inflow tube opened. Only 500 cc. of fluid, or about i pint, is allowed to fl.ow Fig. 84. — Stomach irrigation hy the T-method; First step. into the stomach. I do not approve of employing the larger quanti- ties as recommended by some authors. While the fluid is still entering, the outflow tube is suddenly released and part of the current is diverted, thus starting the siphon action. The inflow tube is then pinched, as in Fig. 85. and the stomach rapidly empties itself. The outflow is then pinched and the inflow released, and so on. The patient may shake his abdo- men, so as to wash all parts more thoroughly. 152 DISEASES OF THE STOMACH AND INTESTINES This procedure must be continued until the wash-water returns clear. There are cases among the insane or when the patient is uncon- scious when the methods described cannot be used. It may be necessary to employ a mouth-gag, forcibly distend the jaws, and force in the stomach-tube. Under such conditions niuner- ous assistants may be required. Fig. 85. — T -method: Second step. The operation may be performed with the patient lying on the back, being properly restrained. The tube should be passed along the roof of the mouth, and the patient should lie on a sufficientlv high level, so that the funnel can be carried below the level of the body in order to secure the siphon effect. If no mouth-gag can be secured, the handle of a spoon, protected with gauze or a handkerchief, can be inserted between the teeth. turned, and the jaws forced apart, or some such instrument improvised. The director devised by Mark Knapp (Fig. 86) would be of value LOCAL, TREATMENT OE THE STOMACH 153 in sucTi cases. Being all metal, it can be left in situ during lavage, and acts as a gag. The simplest method in such cases is to introduce the tube through the nostril. The technic of lavage by this method is shown in Figs. 87 and 88. The tube is passed along the floor of the nostril, just as is the guide for posterior nasal tamponnade. It is fed directly through the nostril for about 20 inches, and no difficulty, as a rule, is experienced, as it passes down the posterior wall of the pharynx and so on into the esophagus. r1 J^Wmttl^^^^^ CL- Ja ai ^ 1 J" ^T ^ ' ('i "^^ \_^-|^ cZ — — --^ Fig. 86. — Knapp's director. The nares should be examined, and that nostril selected which is of larger dimensions. This is important, as there are frequently deflections of the septum. At the Manhattan State Hospital a stomach-tube of fair size (about 27, French) is employed. I frequently use this tube in my office lavage per orem. It is rarely necessary to employ the very small tubes so frequently recommended. For thorough lavage a fair caliber is preferable. Gavage is a different proposition and the small tubes are to be preferred.^ Hemmeter and others have employed double-current tubes for lavage, but 1 can see no advantage. Indications for Lavage. — i. In All Cases of Poisoning. — Some authors advise against it in cases of acids or alkalis, for fear of causing 1 Gavage or forced feeding is employed chiefly among the insane who refuse food, the tube being introduced as in lavage, the nasal route being preferable. 154 DISEASES OF THE STOMACH AND INTESTINES perforation; but there is greater danger of the latter by leaving the poison, since thorough emesis cannot be secured, especially if the Fig. 87. — Lavage through the nostril: First step. Fig. 88. — Lavage through the nostril : Second step. patient be unconscious; there is the increased danger of subsequent 'damage to the intestinal canal below and often to the other organs, LOCAL TREATMENT OF THE STOMACH 1 55 such as the Hver and kidneys, or cardiac or respiratory poisoning ■might result. 2. In acute and uncontrollable vomiting from any cause, as from acute gastritis, the value of lavage was first definitely shown bv our specialists in pediatrics. Bihous vomiting is included. 3. In chronic gastritis, with excessive production of mucus. 4. In dilatation of the stomach (atonic type), where there is marked fermentation and motor insufficiencv. 5. In dilatation of the stomach (stenotic type), with fermentation, motor insufficiency, gastritis, etc. 6. In acute dilatation of the stomach from all causes. 7. In vomiting due to vicious circle, after gastro-enterostomy. 8. At the end of anesthesia, to prevent post-operative vomiting, or to treat the same, if it has occurred. 9. In post-operative intestinal paresis (correctly, gastro-intestinal paresis) lavage should be employed together with enteroclysis. 10. In acute tympanitis of typhoid fever lavage is of great value to aid reduction of the same; especially when hemorrhage is occurring and enteroclysis is contra-indicated. 11. In intestinal ohstructio7i, especially in intussusception. Fre- quent lavage has so relieved abdominal distention above the point of obstruction that the condition has been spontaneously reduced. It also checks the vomiting in this condition. 12. Occasionally lavage with iced water has proved successful in uncontrollable hemorrhage from gastric ulcer. It should be used as a last resort and with great caution. 13. It is also of service in estimating the degree of motor itisuffi- ciency by washing out the residue after aspiration following the test meal. 14. In gastric tetany. 15. In the convulsions of young children which immediately follow the ingestion of improper food. Epileptiform convulsions occasion- ally occur in adults from overfeeding and lavage is indicated. 16. In vomiting of peritonitis. Centra-indications to Lavage. — i. Aneurysm of the aorta. 2. Gastric hemorrhage, as a general rule, except as in No. 12 above. 3. Marked heart lesions, when danger might be incurred, such as in angina, etc. 4. Last months of pregnancy. 5. Special conditions where it might damage the patient or be. dangerous. In cases of poisoning lavage would take precedence over all other risks. 6. Recent rectal, vesical, or renal hemorrhage. 7. Recent hemoptysis. 8. Extreme prostration from an>' cause. Stomach Douche. — This method was first described by Malbranc, 156 DISEASES OF THE STOMACH AND INTESTINES and the measure was first employed by Kussmaul. It consists in sprinkling the stomach with water under pressure. Ewald and Rosenheim^ have devised the most practical stomach-tubes for this purpose. The instrument, as in lug. 89, has numerous small lateral openings and a slightly larger hole at the end. This last is so that the water can run off more rapidly in emptying the stomach, and any mucus or food products can more readily escape. If the hole is too large, the bulk of the fluid will pass through this and no diffuse irrigation of the mucous membrane be accomplished. The tube is introduced in the manner already described, and the funnel method is employed. This is held quite high above the patient, so that the water is under considerable pressure and numer- ous small streams are forced out of the tube. Rosenheim recommends it on an empty stomach before break- fast or, if this is impractical, three or four hours after the first meal. It is applicable to mild motor insufficiency. Rosenheim- advises its use in mild cases of chronic catarrh and in irritation of the sensory and secretory apparatus. Fig. 89. — Stomach douche. Salt added to the irrigation fluid increases the hydrochloric acid production, nitrate of silver (in i : 1000 strength) reduces the secre- tion of gastric juice. Other observers have agreed with these findings, and Riegel advocates the use of the silver nitrate. Fleiner^ recom- mends the douche for stimulating the appetite. Thus, infusions of hops, quassia, condurango, or cinchona bark are valuable. Boracic acid, salicylic acid, sodium salicylate, thymol, gomenol, creolin, lysol, etc., may be employed in average strength (i: 1000) if antiseptic treatment is indicated. If medicated douches are employed, the stomach should first be washed with plain water; then the medicated fluid applied for one to three minutes and then siphoned out; the stomach should be rewashed ^vith plain water if toxic materials have been used. Gross has devised a doiihle-currcnt gastric douche, which is scarcely practical, and Einhorn an instrument with a ball-valve and hard- rubber tip. 1 Therapeut. Monatsch., August, 1892. - BerUn. Klinik, 1894, No. 71. 3 Samml. klin. Vortrage, New Series, No. 103. LOCAL TREATMENT OF THE STOMACH 157 The following simple addition to the Ewald -Rosenheim tube -gives satisfactory results. Employ a fountain syringe instead of a funnel and also a compression bulb (Fig. 90). The stomach douche is passed in the usual way and the bulb (aspirating) joins it to the fountain syringe, which contains the irrigating fluid at a temperature of 100° F. Clip X is previously closed. The tube is pinched tightly at A and the clip then opened. By squeezing the bulb B, all air is driven out through the fountain syringe C. The bulb is then released and fills with fluid. This prevents air from entering the stomach. The finger releases the tube at A and the fluid begins to flow into the stomach; and by inter- mittent pressure of bulb (B) the spraying effect can be intensified &UL Fig. 90. — The bulb-com- pression method of spray- ing the stomach. Fig. 91. — The Y-method of spraying the stomach. at the will of the operator. When the douching is completed the bulb is detached from the fountain syringe and with pressure of the same — the thumb over the end — sHght aspiration is commenced and the contents will then siphon out. In Fig. 91 is illustrated the Y-method of spraying the stomach. The technic is the same as the similar procedure in lavage. In Fig. 92 the use of the alternate hot and cold douche, with pressure bulb, is depicted. The addition of the bulb enables one to employ the spray with- out distending the stomach with air, and to reach much further than with simple hydrostatic pressure. When stronger medicaments are employed, the rapid emptying of the stomach within one to two minutes and immediate lavage eliminate all danger, especially in 158 DISEASES OF THE STOMACH AND INTESTINES view of the fact that by the compression method of spraying much less fluid is required, as compared with the older procedures. The temperature of the fluid should be about ioo° F. When stimulating effects are required it could be 103° to 105° F.; if cold, at 75 ° to 80 ° F. when used with the alternate douche. In atony, with or without commencing dilatation, the spray method, employing in all not over ^ pint to li pints, is at times of service to stimulate the organ. With this exception, I rarely use it. CUP Fig. 92. — The alternate douche. Gastric Spray. — This consists of an ordinary spray apparatus with a double bulb, to which is attached a soft Nekton tube 70 cm. long; within this is a fine central flexible tube, which connects the inner capillary tube with the nozzle (Fig. 93). Einhorn\ who devised the tube, recommends it highly, as therebv one employs a small amount of fluid to secure results; and hence, there is less danger w^hen toxic or irritating substances are used. ^ New York Medical Journal, Sept. 17, 1892. LOCAL TREATMENT OF THE STOMACH 1 59 The spray should be employed when the patient has fasted or after a previous lavage. The bottle is filled with the required amount of the antiseptic solution, the tube dipped in warm water, and introduced in the usual manner. The patient should hold the tube at the lips and the operator steady the bottle and compress the bulb. The spraying should be begun when the tube has entered to the mark (about 16 inches). It can be forced further in. Einhorn advocates it to disinfect the mucous membrane of the stomach; for the application of astringents; and to relieve pain in gastralgia, as from ulcer, cicatrix, or cancer. It is recommended in erosions of the stomach; in chronic gas- tritis, with marked production of mucus; in hypersecretion and hyperacidity, and in gastralgia. Fig. 93. — Einhorn's gastric spray. Riegel holds that the necessary insufflation of air distends the stomach, and on this account it is objectionable. I have found the spray of value in gastralgia and in the treatment of erosions. STOMACH POWDER-BLOWER A dry method for spraymg the stomach w'ith insoluble substances (powders) has been devised by Einhorn.^ His instrument consists of a flexible rubber tube about 28 inches long (Fig. 94), the distal end of which connects wdth an air suction-bulb. The extremity of the tube is attached to a hard-rubber piece c, which is hollow and has lateral openings. It is provided with a screw thread. To this is attached a capsule with numerous side holes. Capsules of several sizes are furnished. A capsule is filled with powder and screwed on to the tip piece. A small spoon is employed to fill the capsule. It is well to lubricate the latter with a thin layer of vaselin to prevent entrance of moisture. The tube is then dropped into warm 1 New York Medical Journal, Ai)ril i, 1899. i6o DISEASES OF THE STOMACH AND INTESTINES Fig. 94. — I. The stomach powder-blower: a, the tubing part; b, connection with the bulb; c, hard-rubber end with screw thread for capsule; 2, the capsule- shaped powder receptacles (natural size); 3, the small spoon for putting the powder into the capsule. Fig. 95. — New model powder-blower. water and inserted into the stomach in the usual manner. The bulb is quickly compressed several times and the air drives out the powder, opening up the vaselin layer over the holes. LOCAL TREATMENT OF THE STOMaCH i6i It has been recommended for ulcer of the stomach, employing bismuth subnitrate; in gastralgia, orthoform; and in erosions, pro- targol or suprarenal powder. I would not care to advocate the passage of the instrument in ulcer, but in the other conditions it is at times of service. Recently Einhorn has modified this instrument (Fig. 95). There is a double- bulb with a stop-cock. This last is closed. Bulb a is compressed several times, thus overdistending bulb b, which is without valves. The stop-cock is opened and a single blast of air distributes the powder ; about 15 gr. ( i .0) is the capacity of the capsule. ELECTRICITY From clinical experience it is found that the electric current exercises an influence on the secretory and motor functions of the stomach and also on its sensibility. Physiologic experiments and clinical experience do not always agree. ]\Ieltzer, experimenting on animals, passed strong induced currents through the fundus of the organ and noted no contraction of the pylorus. The influence of the anesthetic or of morphin or similar drugs would influence the experiment. Pepper demonstrated on a very thin patient that percutaneous electricity produced no peristaltic movements in the stomach. It is believed that it is through contraction of the abdominal muscles that this procedure influences the musculature of the stomach. The two methods for the application of the galvanic and faradic current are the percutaneous and the intraventricular. The latter seems preferable from a therapeutic standpoint, but the former is easier and is more readily submitted to by patients. Percutaneous Method. — Von Ziemssen employs two large plate- electrodes, one anteriorly between the pylorus and fundus, and the other from the fundus to spinal column, with a separating space of only 2 cm. The electrodes should be moistened and sufficient current employed to cause strong contraction of the abdominal muscles. If smaller sponges are used, they can be moved about in these regions. The seance should last ten to fifteen minutes, and be carried out at first ever}^ other day, depending upon indications, which are the same as for the intragastric method. Intragastric Method. — Kussmaul first suggested the internal application of electricity, and was the first to introduce the sound with a copper wire and olive point into the stomach. Bardet improved upon this, and employed an electrode which did not touch the stomach wall, the circuit being established by filling the organ with water. Numerous intragastric electrodes have been devised, of which the most practical are Einhorn's, Lockwood's, and Bassler's. Lockwood's Electrode. — This consists of a very small cable of conducting wire covered with rubber. The intragastric tip is oUve 11 l62 DISEASES OF THE STOMACH AND INTESTINES pointed and protected from the gastric mucous membrane by a rubber finistrated capsule (Fig. 96). The instrument in appearance is much Hke his gastrodiaphane. It is easy of introduction and of such small caliber that it does not incommode the patient. A glass or two of water is administered on the empty stomach, and the instrument is passed along the roof of the mouth, like the stomach- tube, about 18 inches or, preferably, until the resistance of the Fig. 96. — Lockwood's intragastric electrode. Stomach wall is encountered. It is then slightly withdrawn. The outer end of the instrument is furnished with a key which is inserted into the negative pole of the battery. The sponge which is connected to the positive pole is applied over the stomach. Einhorn's Deglutible Electrode. — The intragastric tip is similar in construction to Lockwood's. The conducting wire is much more flexible than Lockwood's and is covered with thin rubber. Fig. 97. — The deglutible stomach electrode. It is not introduced by the operator, but swallowed by the patient, being similar in principle to the stomach bucket (Fig. 97). The key is connected to the cord of the negative pole of the battery. The patient drinks about a glass of water. The deglutible electrode is placed on the root of the tongue and the patient is directed to swallow more water, which carries the instrument into the stomach. A mark can be placed on the cord, about 20 inches LOCAL TREATMENT OF THE STOMACH 163 from the electrode, to determine that it has reached the bottom of the stomach. The sponge is attached to the positive pole. If there is resistance to the withdrawal of the instrument, the patient should swallow to relieve the spasm. Bassler's Gastric Electrode. — This instrument is practically a combination of Figs. 96 and 97. It has the usual capsule with a cord-like conducting wire and also an introducer (Fig. 98). The latter is withdrawn after the introduction of the electrode. After the application is completed the electrode is removed by the flexible conducting cord. I have found Lockwood's electrode easy to introduce and unob- jectionable to the patient. All are good instruments. Gastrofaradization. — Duration ten to twelve minutes. The stomach electrode is attached to the negative pole. A plate elec- trode connected with the positive pole is placed in the epigastric region for four or five minutes, and later a sponge. The electrode Fig. 98. — Bassler's gastric electrode. is then moved from left to right several times in the gastric region ; and later, if marked constipation, from the caput coli to the sig- moid along the colon, and also overthe umbilical region. The appli- catioii over the stomach occupies about two minutes. The electrode is then placed to the left of the seventh dorsal vertebra for one to two minutes, and then returned to the front for the balance of the time. The current should be strong enough to cause contraction of the muscles, but not produce pain. Application of the sponge to the intestines occupies several minutes, in addition to the ten minutes over the stomach. I sometimes reverse the poles during the appli- cation, by changing their external attachments to the battery. Gastrogalvanization. — Duration eight to ten minutes. A small sponge electrode is placed on the epigastrium. The intragastric electrode is connected with the negative pole. The strength of the current should average 15 to 25 milliamperes. The full strength is not used at first. The application is two minutes to the epigas- 1 64 DISEASES OF THE STOMACH AND INTESTINES trium. It is then moved about over the gastric region for three to four minutes ; then for one to two minutes in the dorsal region as described, and the balance of the period in the gastric region. There has been some dispute as to the effects of these currents and the indications for their use. In general we ma}^ sa}' that direct faradization increases the gastric secretion, while galvanization decreases it. Faradization affects the musculature and galvanization the sensory field. The claims regarding increase in absorptive power from the use of electricity seem hardly to be substantiated, as it was so small as to be wdthin normal limits. Therapeutics. — The percutaneous method has proved of service in nervous anorexia and in motor insufficiency. The intragastric method is preferable when possible. It renders some patients more nervous, and in such should be avoided. Among the indications for gastrofaradization are: Atonic ectasia, atony, relaxation of the cardia and pylorus, and diminished secretion. Fig. 99. — Tiirck's latest gyromele. For gastrogalvanization they are: Gastralgias, especially of nervous type, ner\-ous anorexia, and hyperacidity. Faradization, however, has proved of benefit in gastric neuroses. Static Electricity. — This has been recommended especiall}^ in the atonic types of ectasia, claim being made that it causes con- traction of the organ. In neuroses it is sometimes of service. High-frequency Current. — This method is scarcely applicable by the general practitioner, but I believe it of some benefit in gastric neuroses and in atonv. Tiirck's Gyromele. — Turck has introduced this instrument for the local treatment of the stomach and colon. It consists of a cable with a sponge attachment, which can be made to revolve within an outer stomach-tube. There is an arrangement so that medicated fluids can flow into the stomach or colon through the outer tube, and also an attachment for a battery pole. He advocates its use for catarrhal gastritis to cleanse the mucous membrane. It can also be employed alone for internal massage of the stomach or combined with electricity. It is depicted in Fig. 99. CHAPTER IX MASSAGE— VIBRATORY MASSAGE— HYDROTHERAPY— COUNTERIRRITATION— ORTHOPEDIC APPLIANCES MASSAGE Massage of the stomach is indicated in atony or in the atonic form of dilatation and to temporarily aid in the removal of gas. The intestines should also be manipulated in these conditions. It is of value in stimulating the abdominal muscles in gastroptosis. I will briefly refer to a few simple methods. If massage is performed on the absolutely empty stomach it is contracted and cannot be palpated. It is preferable to perform it two or three hours after a meal. This aids in emptying the stomach. Earlier manipulation might cause vomiting. Counterindications are ulcer, recent hemorrhage, and acute inflammation. The patient should be in the dorsal position; lower limbs flexed. The left hand of the operator is placed on the right hypochondrium to exert counterpressure against the pyloric end. With the thumb and fingers extended the right hand performs stroking motions from left to right over the stomach. Then the stomach is kneaded. These procedures should alternate. This technic should be carried out daily for five to ten minutes. With dilatation or ptosis of the stomach the direction of the stroking must be adapted to the position of the organ in each case. Tapping (tapotement) or rapid vibratory movements with the fingers can be employed. It is often well to rotate the patient to the right side during massage, so as to aid in emptying the atonic stomach. VIBRATORY MASSAGE Various vibrators, especially electric, many of which are quite expensive, have been devised for this purpose. There is an instru- ment run by carbonic acid gas pressure. These necessitate the electric current or carrying a large tank. There is a small portable vibrator, the Vedee, manipulated by hand (Fig. loo), which is cheap, simple of manipulation, and efficacious. The strength of the vibration is regulated by changing the position of the rotating disk. The instrument can be employed, with the addition of electricity, by attaching a sponge arranged for battery connection and employ- ing the other pole with a sponge over the abdomen. Electric vibratory massage can thus be given over the stomach and intes- 1G5 1 66 DISEASES OF THE STOMACH AND INTESTINES Fig. loo.^ — Vedee vibrator (new model). tines (Fig. loi). In addition, one battery pole can be attached to Fig. loi. — Combined electricity and vibratory massage. the vibrator and the other to the intragastric electrode for treat- ment of atonv of the stomach. VIBRATORY MASSAGE 167 Vibratory massage should be given from left to right over the stomach for about three minutes, then two minutes to the left of the seventh dorsal vertebra, and three minutes more over the stomach. This should be performed daily. It is generally advisable to vibrate the intestines, following the course of the colon, especially over the sigmoid, and also over the small intestine. This last can be done before breakfast to stimulate the bowels. Two or three hours later the stomach should be vibrated. The patient's family can be taught to use this instrument. Fig. 102. — Massage roller with demonstration of alternating hot and cold electric massage: a, Screw cap; b, filling tube; c, funnel for filling; d, attach- ment for battery pole. Bassler has recently devised an excellent vibrator, but it requires the street current. Massage Roller. — Various instruments have been devised, but the following is simple. It consists of a revolving cylinder, which can be filled with hot or cold water, and which is furnished with a battery attachment. Heat or cold, or with an instrument attached to each battery pole, alternating heat and cold, combined with i68 DISEASES OF THE STOMACH AND INTESTINES electricity, can be applied (Fig. 102). This method can be employed for abdominal massage in some cases of chronic constipation. Fig. 103. — Combined application of electricity and roller massage with heat. I have found the method next depicted of some value in stimu- lating atonic conditions of the gastro-intestinal tract (Fig. 103). LOCAL HYDROTHERAPY Cold. — For hemorrhage or acute inflammation, the ice-bag is preferable to the Leiter coil. At times it relieves ulcer pain more than does heat. Priessnitz's Compress. — A towel folded several times is dipped in cold or warm water, then wrung out, and placed over the stomach. Oiled silk or gutta-percha is placed over it, and a flannel binder applied to keep it in place. A temperature of 50° to 75° F. or warmer if desired can be employed. This method is of value in nearly all painful diseases of the stomach. The compress can be changed two or three times a day. vSome patients do better with the cold, others with the warm com- press. LOCAL HYDROTHERAPY 169 Hot Applications. — Moist Heat. — In cardialgia, ulcer, vomiting, etc., hot moist applications are of value. Poultices can be made of linseed, flaxseed or bran, boiled in water, or of bread and milk. I have seen hot meal or hot mashed potatoes used in country practice. The poultice is wrapped in gauze or cheese-cloth and applied as hot as the patient can bear it. Fresh hot poultices are continually appHed. There is an apparatus which can be boiled in water, wrapped in a cloth, and then applied over the cataplasm. Jt will keep it constantly hot. A felt sponge dipped in boiling water, wrung out, and covered with oiled silk can be employed. r--,. fS."-^i~ii!;6« i=^-"----^^ T! V Sc?iew cap oyer apef/ure 'f~^ { ^ forfillin^j. ik [amp Fig. 104. — Continuous steam coil for the application of heat. "Dry Heat. — The hot-water bag, hot cloths, a light tin pieplate heated in the oven and covered with flannel, the Japanese hot box containing burning punk, are all useful. A continuous hot-water coil has been devised. In the illustration (Fig. 104) is shown a continuous steam coil ^ of my own. The steam passes through a metal coil plate and is recondensed. Only a small quantity of water is necessary in the boiler. The temperature can be regulated by the coverings of the plate and by the stop-cocks on the Y-branch at the top of the boiler, thus allowing less steam to enter the coil. The coil can be placed 1 Enteroclysis, Hypodermoclysis, and Infusion, 1900. lyo DISEASES OF THE STOMACH AND INTESTINES over a moist poultice to preserve its heat. In general, moist com- presses are preferable. The fan douche and the Scotch douche, played over the stomach region, alternating cold 55° F. and warm 95° F., for about three minutes, may have a tonic effect. Packs, rubs, baths, and the carbonated bath are at times employed for the general tonic effect. COUNTERIRRITATION Mustard and flour poultice (equal parts) ; or black or red pepper, 3j (4.0) to the pint (500 cc.) of boiling water, flannel to be wet therein, wrung out, and applied with an oil silk cover or a turpentine stupe, prepared by the same method, are of service. ORTHOPEDIC METHODS Mechanical support of the stomach and intestines is of great ser- vice. Many nervous symptoms referred to the gastro-intestinal tract can be imputed to ptosis of the viscera and relaxation of the ab- dominal walls. In simple atony of this tract the proper support frequently aids the bowel action. ""^v. I ^--'' n v m Fig. 105. — Pattern for cutting the Rose plaster abdominal binder: Dotted lines for section. Fig. 106. — Pattern for cutting the Rose plaster abdominal binder: Plaster after section. The indications for mechanical support are as follows: Ptosis of any or all of the -viscera from any cause; atony of the stomach; atonic dilatation of the stomach; stenotic ectasia as a temporary measure; atony of the intestines; pains from intra- abdominal adhesions dragging on the viscera ; hernia of the abdominal wall; after laparotomy as a temporary support; post-partum to prevent ptosis (Landau's disease), and also to enable -the patient to sit up in bed earlier and so drain the uterus. This last was sug- gested by me to Douglas H. Stewart, who has reported successful results. Cases of constipation in which atony is a factor. Pelvic disturbances which are associated with splanchnoptosis and result ORTHOPEDIC METHODS 171 from general prolapse. Mucous colic in which ptosis is a factor. Pertdulous abdomen, vomiting of pertussis (T. W. Kilmer), sea- sickness, and nervous vomiting. There are three methods: The use of adhesive plaster, the most scientific; elastic bandages, and a special corset. To A. Rose we must credit the best method of adhesive strapping. The author first suggested the use of zinc oxid on moleskin plaster, from experiments finding it most suitable, and this was adopted by the originator of the method. For a full description I would refer to our work on this subject.^ Fig. 107. — Rose's belt (under plaster): Step one. Fig. 108. — Rose's belt: Step two, left wing. The method is as follows: Adhesive plaster, zinc oxid on soft moleskin (Johnson and Johnson), preferably 7 inches wide, though 6 inches can be employed. A yard in length will suffice in most cases. The circumference of each patient should be measured, and the plaster should be long enough to encircle the waist. The plaster is folded over so that the free ends are in line and a curved line drawn in pencil from the lower margin of the point where it folds to the free margin, to about i inch below the upper border. The plaster is cut along this line, giving three pieces; or the plaster is stretched out and the dotted lines marked, as in Fig. 105, and cut along these lines, giving three pieces, / and the two lateral pieces, //, ///, as in Fig. 106. ^ Rose and Kemp, Atonia Gastrica. 172 DISEASES OF THE STOMACH AND INTESTINES Fig. 109. — Rose's belt: Complete. Fig. no. — Dorsal view: Under plaster with overlapping ends (Rose and Kemp). ORTHOPEDIC METHODS 173 / is applied to the abdomen, and the lateral pieces, //, ///, over- lap in front and are applied to the under plaster. These serve to draw up the abdomen. To avoid irritation of the umbilicus, I cut a V out of the upper border of the under plaster or invert a small portion of it. The sharp angle below should be cut off to avoid interference with the pubic hair. The curved portions of the lateral wings should look upward and somewhat inward and adhere to the lower ribs. The sharp Fig: -Dorsal view: Plaster dressing complete (Rose and Kemp). angles of the lateral wings at the symphysis may also be cut off to avoid the hair. Hair, if present on the abdomen, is shaved and the surface cleaned with ether or chloroform. The plaster is applied with the patient in the dorsal position, and preferably with hips slightly elevated. In the illustrations (Figs. 107-109) are shown the three stages of application of the belt, the under plaster, one wing applied, and the complete contrivance. In Figs, no and in are shown the rear view during application. 174 DISEASES OF THE STOMACH AND INTESTINES The plaster should remain on for four to six weeks, depending on the season of the year, irritation (which is rare), or its loosening. Fig. 112. — Application of narrow strips I'ig. 113. — Application of plaster: Sec- of adhesive plaster: First step. ond step. It should then be removed, a full bath given, talcum dusted on, and twenty-four hours later a new belt applied. Fig. 114. — Application completed. One patient sent me by Wm. H. Thomson, a severe case of splanchnoptosis, wore the belt fourteen months, gained 40 lbs. in weight, and was completely cured. ORTHOPEDIC METHODS 175 The device gives brilliant results. The method of support by a pad for the special organ is unscientific. Only on occasions when the material for Rose's belt was not at hand have I applied a method with narrow strips of plaster, as depicted in Figs. 11 2-1 14. They overlap at the linea alba in front and at the spine behind. As the final procedure, two transverse strips are applied in front. Rosewater Adhesive Belt. — A strip of zinc oxid plaster of sufficient length and two to three inches wide is fastened to the abdomen just above the pubes. This is drawn upon upward and fastened above to the lower end of the sternum. Diagonal strips Fig. 115- -Front view: Step one. Fi?. 116. — Rear view. Fig. 117. — Front view. Belt complete. Figs. 1 1 5-1 17. — Rosewater adhesive plaster belt (Rose and Kemp). crossing the lower end of the vertical strip, overlapping behind at the spine, are then applied (Figs. 115 and 116). A horizontal strip is fastened to one hip and stretched across the pubes to the other hip, overlapping the ends of the other plaster and acting as an additional girdle (Fig. 117). Plaster strapping affords continuous support during treatment, which other methods do not. Numerous modifications have been devised, but these are the most practical. Kihner's Abdominal Belt. — An ingenious belt was devised some years ago by T. W. Kilmer for the relief of vomiting in pertussis. The original instrument consisted of a stockinet band apphed as 176 DISEASES OF THE STOMACH AND INTESTINES Fig. ii8. — Kilmer's belt stockinet band: Step one. Fig. 119. — Kilmer's belt (complete): Elastic %vebbing, front. ORTHOPEDIC METHODS 177 in Fig. 118. Around this was wound a strip of silk elastic webbing, which could be pinned or sewed on, as in Figs. 119 and 120. Fig. 120. — Kilmer's belt (complete): Elastic webbing, rear. The apparatus extends from just above the hips and symphysis well up on the thorax. The relief of vomiting and cough was quite remarkable in pertussis. 12 178 DISEASES OF THE STOMACH AND INTESTINES Fig. 121. — Improved belt (front). Fig. 122. — Improved belt (rear). ORTHOPEDIC METHODS 179 Recently Kilmer reports a simplified belt^ made of linen, with strips of elastic webbing inserted on either side. It laces up the back (Figs. 121 and 122). The belt should measure slightly less (2 to 3 inches) than the circumference at the navel. The degree of constriction should be \ \ ^^..^ jS=^f== ^ x ""Wi ¥n m vd\l l|L AU Q| P ' B-^ "_ •«r^^ ! t > ' ' Fig. 123. — Teufel's abdominal supporter. determined in every case. The instrument is valuable for the prevention of seasickness, for nervous vomiting, and as an abdominal support. The cost is shght. Silk Elastic Belts. — Various types of silk elastic belts are employed. Figs. 123-125 show useful instruments. Storm's abdom- inal supporter is also excellent. \ V Fig. 124. — ^Abdominal supporter. Fig. 125. — Abdominal supporter. Special Corsets. — The most valuable support of this type is that of E. Gallant, which is depicted under Gastroptosis. The La Grecque surgical corset is also useful, and is illustrated in the same chapter (Fig. 161). ^ Archives of Pediatrics, February, 1907 CHAPTER X CATARRH OF THE STOMACH ACUTE AND CHRONIC GASTRITIS Acute gastritis Acute gastritis may be defined as an acute inflammation of the gastric mucous membrane with resulting disturbances of digestion. It is of different degrees of severity, being Hmited to the superficial layer of the mucous membrane, or it may extend to the glandular p'arenchvma or involve the interstitial tissues. It is subdivided into simple acute gastritis, toxic gastritis, and phlegmonous gastritis. SIMPLE ACUTE GASTRITIS {Synonyms . — Acute Gastric Catarrh; Acute Gastric Dyspepsia.) Etiology. — Simple acute gastric catarrh is one of the most frequent diseases met with by physicians. It occurs in all classes of society and at all ages. It may be primary or secondar}^ to another disease. One of its frequent causes is some irritant, mechanic, chemic, or thermal; thus errors in diet, or too large a quantity of food that has been imperfectly masticated, or rapidly bolted; too hot or too cold food or drink; too highly spiced or fer- mented foods; rancid butter; unripe or spoiled fruit; spoiled food or drink, or overindulgence in alcohol. Fermentation or putrefaction are most apt to occur in food during the summer, and these factors probably account for the epidemics occurring at that season, though infection has been suggested. Such cases generally occur as gastro-enteritis. Bacterial infection of food may be a cause, as the colon bacillus in milk, or meat, or sausage poisoning. Primary mycosis of the stomach, the favus fungus; schizomvcetes ; parasites, as the larvae of flies; ascarides, oxyuris and taenia, by entering the stomach, and abdominal burns are rare causes. Acute catarrhal or suppurative conditions of the nose and throat may produce acute gastritis from the ingestion of discharges. I have recently seen one such case and the patient suffering from acute gastritis, cured by treatment of the source. Some persons have a predisposition to a "weak stomach," and this condition seems almost to be hereditary. Others have been trained to such a simple diet, as the children of dyspeptics, that the 180 CATARRH OF THE STOMACH l8l stomach cannot perform its normal amount of work and readily becomes irritated. In old persons, invalids, or anemic women the organ is readily affected. Acute gastritis may be secondary to the acute infectious diseases, such as measles, typhoid, variola, pnuemonia, etc., or as a sequel of acute nephritis. I have seen an attack follow prolonged anesthesia. A diphtheritic or membranous gastritis has been met with in diphtheria, or as a secondary process in typhoid, typhus, pneumonia, etc. It cannot be diagnosed unless the membranes are vomited. Morbid Anatomy. — Acute gastritis is characterized by an acute inflammation of the superficial layers of the mucosa, with an increased secretion of mucus and a desquamation of the epithelial cells. The mucous membrane is reddened and swollen, less gastric juice is secreted, and mucus covers the surface. The swelling is diffuse or in circumscribed areas. There are sometimes slight hemorrhages and small erosions or sacculations of the mucous membrane. The submucosa may be edematous. The pyloric end is more frequently affected. Gastric secretion is weakly acid, neutral, or even alkaline and diminished in quantity. Beaumont, from his observations on St. Martin, has given an excellent description. Microscopic. — The superficial epithelial layer is partially loosened or in a condition of cloudy swelling. The parietal and principal cells cannot be distinguished apart; they are granular and in a condition of cloudy swelling and fatty degeneration, and are shrunken. The capillaries are dilated and round cells are found in the interglandular tissue, between the epithelial cells and on the surface. Karyokinesis may be present. Symptoms. — These vary according to the severity of the attack. There is loss of appetite, discomfort, fulness or pressure in the region of the stomach, belching of gas, which may taste sour, and occasional nausea. In some cases there are no rise of temperature and no vomiting, and the symptoms pass off in a da}' or two; the bowels are costive or diarrhea is present. In more severe cases there are pains in the gastric region, head- ache, nausea, vomiting (prolonged and excessive), first of food, then chiefly of mucus, at times streaked with blood, and frequently bilious vomiting. There may be considerable prostration. Often there is an acid taste in the mouth. There is generally a temperature, sometimes rising to 102° to 104° F., and at times chills, and the tongue is usually coated and swollen. The pulse is frequently rapid and feeble. In the cases due to ingestion of spoiled food, etc., auto-intoxi- cation undoubtedly results and aggravates the symptoms. Vomiting usually follows the introduction of the irritant, but is sometimes delayed for some hours, and food is found that was ingested twelve or fifteen hours before, a condition of acute motor insufficiency. Constipation or diarrhea is present. The early l82 DISEASES OF THE STOMACH AND INTESTINES vomitus often has a disagreeable odor and contains food remnants. The reaction is sHghtly acid and free hydrochloric acid is often absent. Lactic and other organic acids are at times present. Occa- sionally a duodenitis with jaundice is associated. Herpes labialis is quite frequent. Physical Examination. — The region of the stomach is usually distended and sensitive, and may be tender on pressure. Urine is scanty, dark in color, of high specific gravity, urates marked, and occasionally indican and albumin. Duration. — This is usually short, from two to three days, though at times prolonged to a week. Diagnosis. — Some of the infectious diseases, notably scarlatina, begin like the febrile form of acute gastritis, and one should always be on the watch for such an occurrence. In rare cases the symptoms are intensely severe, headache and even delirium being so marked as to have been mistaken for rAen- ingitis. In the latter case, Kernig's sign can be elicited. and lumbar puncture is an aid to diagnosis. In biliary coHc, with acute vomiting, the pain radiates to the right side or right shoulder, and pain over the gall-bladder is present. In cholecvstitis, with or without calculi, with Uttle or no pain and no jaundice,^ but vomiting, the diagnosis is more difficult. The previous history, tenderness over the gall-bladder, and the presence of leukoc\i:osis, especially the increase in the polynuclears, are significant. Hyperchlorhydria is frequently associated. With peritonitis, we have muscular rigidity, leukoc^iiosis, in- creased polynuclears, marked abdominal tenderness, and distention. With ner^^ous gastralgia, the material vomited is very acid (hyperchlorhydria), no mucus, and the nervous history. Y\'ith typhoid fever, we have the gradual rise of temperature, increasing daily, the splenic enlargement, frequently the eruption, often bronchitis, EhrHch's diazo and the Widal reactions; while, with acute gastritis, the rise of temperature is sudden and the fall equally sudden, and there is the absence of splenic enlargement and other symptoms. When jaundice is associated with acute gastritis, the duodenum has evidently become involved. The gastric crises of locomotor ataxia have been mistaken for acute gastritis, but the absence of knee-jerks, the Romberg symptom, and Argyll-Robertson pupil are diagnostic of tabes. Prognosis. — This is favorable, except in very old people and invalids. Treatment. — Prophylaxis. — In patients subject to attacks of acute gastritis, excess in eating, rich food, lobster, food and drink that are too hot or cold, or any articles for which they have an idiosyncrasy should be forbidden. Candy and cake should not be 1 The presence of Head's gall-bladder zone of cutaneous algesia aids diagnosis. CATARRH OF THE STOMACH 1 83 allowed. Unripe and dirty fruit should be avoided. With infants, care should be taken as to the storage of milk and its preparation. If the acute gastritis be due to ingestion of improper food, there are two principles to follow: Clear out the gastro-intestinal tract and give rest to the stomach. If there are other factors, the first consideration does not apply. In all cases rest in bed should be enjoined. In the mild cases, with nausea but no vomiting, castor oil, oj to iss (32.0-48.0) ; or, if there is doubt of this being retained, then calomel, gr. 2 to 5 (0.125-0.3), or blue mass, gr. 5 (0.3), followed in twelve hours by a saline, such as a wineglass of apenta, or citrate of magnesia (wineglass), or magnesia sulph., 5j to ij (4.0-8.0), should be administered. If much nausea, calomel, gr. -jV (0.006), with sodium bicarb., gr. h (0.0325), every hour for eight or ten doses, followed by a saline. Children should receive proportionately small doses of cathartics. For eructation of acid fluid (pyrosis), bismuth subnit., gr. 3 (0.2), with sodium bicarb., gr. 3 (0.2), every hour or two; or magnesia usta, oss (16.0), with sodium bicarb., oSS (16.0), as much as covers the point of a knife, every three hours. For nausea or vomiting, oxalate of cerium, gr. i (0.065), every hour for several doses, or bismuth subnit., gr. 2 to 4 (0.125-0.25), alone, or with sodium bicarb., same dose; or gelatin (i per cent, solu- tion), dose oj (4-o), every hour, given cold; or milk, oviij (250.0 cc), with oxalate cerium, gr. 10 (0.6), and sodium bicarb., gr. 10 (0.6), packed in ice; dose, 5j (4-0) every hour; or Fowler's solution of arsenic, HXj (0.06), every hour for four doses, are of value. Teaspoonful doses of hot water or, occasionally, a piece of cracked ice; or white of raw egg beaten up and given cold in i-dram doses (4.0), every half -hour to an hour, are useful. Cocain, carbolic acid, or creosote I strongly deprecate. Heat should be applied. Application of Heat. — A hot-water bag, one-third full to avoid weight ; a Japanese hot box, a hght hot salt-bag, a thin tin pieplate heated in the oven and covered with flannel ; or moist heat by means of a' flaxseed poultice, hot mashed potato or bread poultice in country practice ; mustard and flour poultice (equal parts) ; or black or red pepper poultice— 5j (4.0) to Oj (500 cc.) of boiUng water — and wring out flannel in the same and apply, covering with oiled silk. If the discomfort is marked, then give warm salt water, oss (2.0) of salt to oviij (250 cc.) of water, and tickle the fauces to promote vomiting, or lavage. Small doses of hot water may be given to relieve thirst and food should be avoided for twenty-four hours. If small quantities of nourishment be given, I have found §j (32.0) doses every hour of a 5 per cent, gelatin solution (in a glass 184 DISEASES OF THE STOMACH AND INTESTINES packed in ice) of special value, or small quantities of milk and lime- water (equal parts), or peptonized milk or kumyss. In severer cases, the stomach should be emptied, preferably by lavage, §j to ij (32.0-64.0) of Phillips' milk of magnesia to 2 quarts (liters) of warm water being excellent for this purpose. Plain warm water or normal salt solution may be employed. I frequently administer calomel, gr. 3 to 5 (0.2-0.3), ^nd sodium bicarb., gr. 5 (0.3), in a little water, through the stomach-tube after lavage before withdrawal of the tube. This is generally retained, with resulting thorough clearing of the bowels. Saline solution should not be employed for lavage if calomel is thus given. Later an enema of saturated solution — oij to iij (64.0-96.0) — of magnesium sulphate, or a recurrent enteroclysis with normal saline solution at 110° F. should be administered (several quarts — liters), or a soapsuds enema, i quart (liter), containing olive oil, §vj (200 cc), may be substituted. Even if the calomel be omitted, it is of great importance to move the bowels. If the case is not due to ingestion of irritating food, then bismuth subnitrate, oxalate of cerium, a few doses of gr. 75 (0.006) of calomel every hour, sodium bicarb., etc., may be tried for a brief period; and if these fail, lavage should be performed. Gelatin solution or white of egg often are of value in such cases. With bilious vomiting, lavage should be employed at once, as there is practically reversed peristalsis with an open pylorus, and the continuous accumulation of bile in the inflamed stomach keeps up the vomiting. Enteroclysis should be used after lavage (within one hour) to promote normal peristalsis. It may be necessary to wash the stomach several times, but it is the best method to check vomiting. In the severe cases, due to ingestion of improper food, it is my opinion that calomel should be given directly after lavage, even though some of it be vomited, as auto-intoxication is a factor. In addition to the milk of magnesia, if the vomitus is very foul, I add gr. 10 (0.6) resorcin to the fluid for lavage and wash with the patient both in the erect and lying-down position. I do not care for apormorphin, gr. ^ (0.006), ipecac, or tartar emetic to empty the stomach. If there is considerable prostration, enemata of hot normal salt solution (115° F.) and strychnin by hypodermic — gr. gV to -gV (0.00108-0.002) — may be necessary. In rare cases, when there has been much vomiting and the patient is exhausted, codein, gr. | to \ (0.008-0.016), by hypodermic, or the same amount of morphin may be used. I sometimes. employ a single dose after lavage to quiet the patient. A suppository — gr. I (0.064) opium, or gr. \ (0.016) morphin with gr. -Jr (0.021) extract belladonna — may be substituted. Diet. — Entire abstinence from food during the first twent3^-four CATARRH OF THE STOMACH 1 85 hours or longer is preferable; nutritive enemata may be given and injections (rectal) of hot saline solution to relieve thirst.* For the latter, oj (4.0) doses of hot water by mouth, or of a cold I to 2 per cent, gelatin solution are preferable to cracked ice. The gelatin seems to have an excellent effect. Later small doses of cold gelatin (5 per cent, solution) or milk and lime-water (equal parts) can be given, or milk, oviij (250 cc), with sodium bicarb., gr. 10 (0.6), and oxalate cerium, gr. 10 (0.6), in oss to j (16.0-32.0) doses, given cold, every two or three hours. White of egg beaten up and given cold ; barley-water alone or with milk (equal parts) ; rice gruel, very thin, made from rice flour (Park and Tilford) with milk may be added. Later add eggs (soft boiled), scraped raw beef, pigeon (boiled), calves' brains, zwieback, broths, soups, bouillon, boiled chicken, and gradually increase to full diet. If after the acute attack has subsided the patient suffer from a feeling of pressure and discomfort, dilute hydrochloric acid may be given to aid digestion. I^. Acid, hydrochlor. dilut oiiss (lo.o) ; Aq. destil q. s. ad. oij (60.0). Sig. — oj to ij (4.0-8.0), in water, t. i. d. The same combined with small doses of tincture of nux vomica, TTLv (0.3) in each dose; or with compound tincture cinchona, lUx (0.6) in each dose may be given. These remedies should be administered one-half hour after meals or the same time before. TOXIC GASTRITIS Etiology. — This most intense form of inflammation of the stomach is caused by the swallowing of concentrated mineral acids or strong alkalis, or by poisons, such as phosphorus or arsenic. Among such are nitric, sulphuric, hydrochloric, oxalic, and carbolic acids; the caustic alkalis, as caustic potash, caustic soda, soap lees, and strong ammonia; alcohol, phosphorus, arsenic, potassium cyanid, corrosive sublimate, and potassium chlorate. The effects are more severe on the empty stomach. Anatomy. — The acids and alkalis destroy the parts they come in contact with, causing various degrees of sloughing of the mucous membrane. They may penetrate the submucosa or the entire stomach wall and produce perforative peritonitis. Alcohol, phosphorus, or arsenic cause an acute inflammation of severe type, the mucous membrane becoming swollen and super- ficially necrotic, with hemorrhagic spots in the submucosa, and there is fatty degeneration of the epithelia of the glandular tubuli. Symptoms. — There are intense pain in the gastric region, violent and burning in character, and increased on pressure; and frequently 1 Proctoclysis is also excellent. 1 86 DISEASES OP THE STOMACH AND INTESTINES pain in the pharynx and esophagus (along the sternum). There are saHvation, difficulty in swallowing, and usually vomiting, con- stant and repeated, which fails to relieve the pain. This is generally immediate, though not always so. There may be food remnants in the vomit, mucus, streaks of blood, and even shreds of mucous membrane. The abdomen is tender, at times distended, though occasionally contracted. Symptoms of collapse often appear, the face pale and anxious, the skin pale and extremely cold, pulse rapid and feeble, respiration rapid and shallow. There are restlessness and sometimes convulsions. Albumin and blood often are present in the urine and petechias under the skin. Peritonitis, shock, or respiratory or cardiac failure may cause the fatal issue. Some cases are more protracted. There may be jaundice or hematuria, or intestinal ulceration, or degeneration of the liver or kidneys. Phosphorus-poisoning may produce hemorrhagic jaundice and symptoms simulating acute yellow atrophy of the liver. Stricture of the esophagus, pylorus, or cardiac orifice of the stomach can result from the damaged mucous membrane, with corresponding symptoms, such as dilatation of the stomach, etc. In rare cases, atrophy of the mucous membrane (achylia gastrica) follows, or hour-glass stomach, or perigastric adhesions. Diagnosis is usually easy. The sudden appearance of violent gas- tric symptoms in a perfectly healthy subject should excite suspicion. Inspection of the lips, mouth, and tongue will show the effect of corrosive poison, if such have been taken, and examination of the vomitus and odor of the breath may afford information. Inspection, if possible, of the receptacle from which the substance was taken, and examination of the latter, if any remain, are important. The patient often gives a clear history. Prognosis. — It is best to give a guarded prognosis even in appar- ently favorable cases. Treatment. — There are certain cardinal rules to follow in the treat- ment of toxic gastritis: first, administer fluid to dilute the poison, and at the same time give an antidote ; empty the stomach as rapidly as possible, preferably by lavage ; administer demulcents ; stimulate the patient and give a cathartic to clear the poison from the bowels. Though some advise against lavage in poisoning from acids and alkalis for fear of perforating the stomach, there is far greater danger of perforation by leaving the poison in the organ, with the additional risk of cardiac or respiratory failure, or subsequent damage to the intestines or other viscera. lyavage by siphonage of the stomach is indicated in all cases of poisoning. Warm water at about 101° F. should be employed and the organ washed until thoroughly clean. Any bland fluid, such as tea, coffee, soup, water, or milk, can be used in an emergency to dilute the poison and wash the stomach. CATARRH OF THE STOMACH 187 A gastric siphon can be improvised from a fountain syringe by removing the tip and clip and rounding the edges of the extremity; or from a kitchen funnel and rubber tube of small caliber. If lavage be impossible, then give a pint of lukewarm water with 5ij (8.0) of mustard dissolved therein, or warm salt water and tickle the fauces with the finger or a feather. Apomorphin, gr. xV (0.006), by hypodermic; zinc sulphate, gr. 30 (2.0), in oiv (30.0) of water; copper sulphate, gr. 5 (0.3), providing these latter were not the poisons ingested; or syrup of ipecac, oj to iij (4.0-12.0), can be employed. Among useful demulcents are whites of raw eggs, milk, olive oil, barley-water, flour boiled with water, and gum-arabic water. Fats and oils should be avoided in phosphorus-poisoning. The subsequent treatment is of acute gastritis, enteritis, and of special symptoms. Antidotes. — For Acid Poisoning. — Alkalis,^ such as calcined magnesia; powdered chalk in water; sodium carbonate (w^ashing soda), dilute; potassium cabonate; sodium or magnesium sulphate, Bss (16.0), in water; Carlsbad salts; soapsuds in water. For Carbolic Acid. — Alcohol (95 per cent.), oj to iij (32.0-96.0); raw whisky or brandy, or liquor with a large percentage of alcohol. The alkalis can be used subsequently or alone if alcohol or liquors are not obtainable. For Caustic Alkalis. — Dilute acids, such as dilute vinegar or lemon juice; tartaric or citric acid. For Tartar Emetic and Antimony and its Compounds. — Tannic acid or strong tea. For Arsenic and its Compounds. — ^Tincture of perchlorid of iron, §iss (48.0) in a wineglass of water, add Bss (16.0) sodium carbonate (washing soda) in half-tumbler of water, mix, and administer. This renders insoluble about gr. 5 (0.3) of arsenic. Repeat dose, or give dialyzed iron, tablespoonful doses. For Copper Salts. — Potassium ferrocyanid, 5j (4.0) to oiv (125 cc.) of water, forms insoluble copper cyanid. For lodin, lodids, and Iodoform. — Starch solution in cold water; sodiutn bicarbonate; lead acetate, 5ij (8.0) in oiv (125 cc.) of water. For Lead and its Salts. — Magnesium or sodium sulphate, or dilute sulphuric acid, Tri30 (2.0), in water. For Mercury and its Salts {Corrosive Sublimate, etc.). — White of raw egg; milk; form albuminate. For Silver Nitrate. — Salt solution. For Zinc Salts. — Sodium or potassium carbonate; tannic acid; tea; white of egg; milk. For Phosphorus (Rat Paste, Matches).— Copper sulphate, gr. 3 to 5 (0.2-0.3), in oiv (125 cc.) of water, a number of doses; forms insoluble phosphid of copper and acts as an emetic; old French 1 Soda bicarbonate, oj (16.0), or plaster scraped from the wall, dissolved in water oviij (250 cc.) can be employed. 1 88 DISEASES OF THE STOMACH AND INTESTINES turpentine. Avoid oils, fats, milk, and yolks of eggs. Avoid American or German turpentine. For Alcohol. — Ammonium carbonate, gr. 3 (0.2), in water. The stomach should receive rest after immediate treatment. Pain may be relieved by local heat, or codein or morphin, gr. i to J (o.oo8-o!^oi6),hypodermically. Large doses of bismuth subnitrate may be given if the bowels continue irritable. Retention or sup- pression of urine must be watched for. In the latter case, entero- clvsis, with hot normal salt solution at 115° to 120° F. Stenosis of the esophagus may be dilated if possible, if stenosis of the pylorus, appropriate treatment as for gastric dilatation, and in most cases subsequent operation. If atrophy of the gastric mucosa result, the treatment is for achylia gastrica. For perforative peritonitis, operation is indicated. PHLEGMONOUS GASTRITIS (Synonrm^.— Suppurative Inflammation of the Stomach; Gastritis Phlegmonosa; Abscess of the Stomach.) This is a rare disease and usually runs an acute course, though occasionally subacute. The process begins in the submucosa and sometimes extends to the muscular coat, and at times to the mucous or serous coats. It is more frequent in men. It is primary or idio- pathic, due to some micro-organism, especially the streptococcus, probably entering through some solution of continuity in the mucous membrane; or secondary (metastatic), due to pyemia, puerperal infection, or the exanthemata. Errors in diet, alcohoHc excess, trauma, etc., have been given as causes, but probably only are contributory by depressing the system. Traumatism might cause dam.age to the mucosa and render infection more easy. There are two forms met with: a diffuse purulent infiltration and a circumscribed abscess. Morbid Anatomy. — In the diffuse type a large area of the submucosa is frequently involved. It is thickened, infiltrated with pus, and multiple small abscesses are often present. The pyloric end is more frequenth^ attacked. The muscular wall is often involved or the pus may burrow through to the peritoneum. The mucosa is usually also affected and is swollen, and there is granular degenera- tion of the gland cells. Perforation of the mucosa may occur. In the abscess type there is generally a single circumscribed abscess of variable size, starting in the submucosa and involving the muscular layer. The mucosa and serosa are often involved. It may terminate favorably by perforating into the stomach (a rare event) or perforate into the peritoneal cavity. Symptoms. — The patient may have for a brief period a few dyspeptic symptoms, such as loss of appetite, thirst, and some burning in the stomach, but these are usually absent. CATARRH OF THE STOMACH 189 The attack is generally of an acute fulminating type : Severe pain or burning in the gastric region, a rapid rise of temperature to 103° to 105° F., with slight intermissions; frequently chills; often vomiting of mucus, bile, and food remnants, but no pus, unless the abscess breaks into the stomach, which is a rare event. The area over the stomach is very sensitive to pressure and there is some tympanites. There is constipation or, more usually, diarrhea. The pulse is rapid and feeble, occasionally there is jaundice. The patient presents all the aspects of a severe infection, with delirium and coma preceding death. The blood examination shows leukocytosis with increase in the polynuclears. There is muscular rigidity in the upper quadrant of the abdomen, of the recti muscles, due to peritoneal irritation even before perforation occurs. This is a valuable sign. With general peritonitis we have the usual symptoms — pain, distention, general tenderness on pressure, etc. With a circumscribed abscess the tenderness is more localized, the symptoms not so severe, and the duration longer. Percussion and palpation may locate the process if localized. Duration. — Three or four days, rarely one to two weeks. Diagnosis. — The temperature, chills, fulminating character, leukoc3^tosis, and early recognition of muscular rigidity — all point to an acute suppurative process. Abscess of the liver and subphrenic abscess are not of such acute type. Acute cholecystitis and acute pancreatitis are more apt to be confounded with abscess of the stomach. With acute pancreatitis the temperature at first may be low, tympanites is earlier and more marked, and there are circumscribed tenderness in the course of the pancreas and tender spots throughout the abdomen (Fitz). Constipation is usual; also the symptoms may resemble intestinal obstruction. Abscess of the pancreas is slower in its course and there is a longer history. Acute cholecystitis is a much more frequent condition than phlegmonous gastritis. The gall-bladder can at times be palpated, is tender, and we have the previous history. Treatment.— Laparotomy is advised, both to settle the diagnosis and afford relief if possible. Should this not be consented to, then the ice-bag, rectal feeding, enteroclysis, to relieve tympanites, and opiates are indicated. CHRONIC GASTRITIS {Synonyms. — Chronic Gastric Catarrh; Chronic Dyspepsia.) Definition. — A chronic inflammation of the mucous membrane of the stomach, with the production of mucus and changes in the gastric juice, causing disturbances in the act of digestion. Etiology. — This disease is more frequent in men than in women. It may follow the acute type, especially after recurrences of this condition. The same irritating agents that cause acute gastritis I90 DISEASES OF THE STOMACH AND INTESTINES can produce the chronic type when acting for a long period of time; notably, fast eating with imperfect mastication, overloading the stomach, indigestible food, highly spiced dishes, cold drinks in excess, over rich food, excessive use of tea or coffee, and overindulgence in alcohol (the so-called "drunkards' catarrh"); excessive use of tobacco, especially in tobacco-chewers and those who indulge in dry smoking (chewing the cigar-butt), an unhealthy condition of the mouth or teeth, and swallowing the products of decomposition. Habitual use of drugs may be a cause. Discharges from the nose or ear through the Eustachian tube, which are then swallowed, have been factors in several cases that I have observed. Thrush may cause mould in the stomach. Chronic gastritis may be secondary to the acute infectious diseases, such as typhoid fever. It is frequently associated with cancer of the stomach and is often present in the atonic type of dilatation of the stomach. It may be secondary to cirrhosis of the liver, pulmonary or cardiac disease, and chronic nephritis. Among constitutional causes are gout, diabetes, leukemia, and severe anemia. Classification. — Chronic catarrhal gastritis m.ay be classified as follows : 1. Acid gastritis (gastritis hyperpeptica, hypersthenic gastritis), or acid catarrh of the stomach, first described b}^ Boas. This is considered on the borderline and to be the initial stage of chronic gastritis. There is a slight increase in the hydrochloric acid and Boas believes this occasionally occurs in the early stages of chronic gastritis. There is also the presence of mucus. 2. Chronic catarrhal gastritis, under which is described mucous gastritis (Ewald), which is merely a severe type with great secretion of mucus. We must remember that occasionally from a long-continued chronic gastritis, other conditions may arise. (a) There may be a great thickening of the mucosa (hyperplasia), so as to produce thick folds, the so-called etat mamelonne, and this combined with swelling of the mucosa cause benign stenosis of the pylorus; or sometimes wart-like excresceiices (gastritis poHposa) develop, which if situated at the pylorus can produce partial obstruc- tion — a benign stenosis, with dilatation of the stomach; or a prolifera- tion of interstitial tissue occurs and muscular hypertrophy with resulting hypertrophic stenosis of the pylorus. Chronic gastritis may, therefore, produce and have associated with it benign stenosis and dilatation of the stomach. (b) On the other hand, a degeneration or atrophy of the muscular fibers due to hyperplasia of the connective tissues may cause atony, and atonic dilatation of the stomach may result, and these'conditions will improve with the improvement of the gastritis. They only occur in the more advanced cases. In the patients whom we are called upon to treat, the stomach is iisually of normal CATARRH OF THE STOMACH I9I size, non-atonic, and with normal or slightly diminished motor functions. 3. Atrophic gastritis (Anadenia ventriculi, Ewald), an atrophy of the mucous lining of the stomach, can result from chronic gastritis. Of these, there are two forms: (a) Phthisis ventriculi, a thinning of the coats of the organ, which may remain of normal size or be increased in size. (6) Cirrhosis, or sclerosis ventriculi, an enormous thickening of the muscular coat and a great reduction in the volume of the stomach. Atrophic gastritis is described under Achylia gastrica. Morbid Anatomy of Chronic Catarrhal Gastritis. — The mucous membrane is yellowish-gray or slate-gray in color, and in secondary catarrhal conditions produced by congestion may, in some parts, be intensely red. It is swollen and thickened and covered with a closely adherent tenacious mucus, which is usually cloudy and gray in color, due to various cells, epithelia, and leukoc}'tes, and occa- sionally is tinged with blood. Enlarged veins, patches of ecchymosis, and small hemorrhagic erosions may be present. The mucosa in some instances forms papillary projections (etat mamelonne). The pyloric portion is usually involved, though the inflammation may extend over the entire mucosa. The submucosa and muscular coats are at times hypertrophied or atrophied. Microscopically the following conditions appear: The glands are enlarged, sacculated, and dilated in cyst-like forms, the tubuli in many places being atypic and branching like the fingers of a glove; the gland-cells are cloudy, granular, and in a condition of fatty degeneration, and the principal and parietal cells cannot be differen- tiated. Abundant small cell infiltration presses the glands apart, being especially marked toward the surface of the mucosa. Exten- sions of connective tissue may be seen passing from the mucosa between the glands. The mouths of the glands are at times filled with mucus which projects against the lumen. Mucoid transforma- tion of the cells of the tubuli is a striking feature and may extend to the fundus of the glands and cells. Mucoid degeneration may replace the principal and parietal cells. The mucus fills part of these cells, or may crowd the protoplasm and nucleus against the base, or rupture the cell-membrane and escape into the duct of the gland. The pyloric region is usually thus affected. Ewald has described this condition. After a long period the inflammatory process ma}- lead to a total destruction of the glandular layer, or atrophy of the mucous mem- brane of the stomach — anadenia ventriculi (Ewald). Of this there are two forms, as heretofore noted: (a) Phthisis ventriculi, atrophy of the stomach, or anadenia ven- triculi (Ewald), is a thinning of the coat of the stomach, with a retention of or usually an increase in the size of the organ (dilatation). There are fatty degeneration and destruction of the glands, the 192 DISEASES OF THE STOMACH AND INTESTINES process progressing from the surface of the stomach inwardly. In the early stage no glands are found, but glandular cysts are present near the submucosa. Later these disappear and the mucous mem- brane consists chiefly of round cells. The submucosa is changed and the muscular layer is thinner. (b) In cirrhosis, or sclerosis ventriculi, the stomach coats are thickened and there is a great reduction in the volume of the organ ; in some cases it is no larger than a pear and the walls may be 2 to 3 cm. in thickness, the greatest increase being in the submucosa, where the process starts. The inflammatory process causes the for- mation of fibrous tissue, which progresses from the submucosa to the surface, spreading around the glands, constricting them, and finally replaces them with fibrous tissue. The hypertrophy extends to the muscular layer. This condition may coexist in the cecum and colon and so be difficult to distinguish from diffuse carcinoma. Proliferative peri- tonitis with perihepatitis and ascites are at times associated. Atrophy of the gastric mucosa is described under Achylia gastrica. Symptoms of Chronic Gastritis. — These develop slowly; the appetite diminishes or is irregular or easity satiated. There is a feeling of fulness or pressure in the gastric region after eating. Occa- sionally heartburn or cardialgia in the epigastrium or precordial region or behind the sternum occurs, generally at the height of digestion; while with hyperchlorhydria it is present on an empty stomach. Discomfort or pain on pressure over the stomach is present. Belching of gas is the most frequent symptom and it is usually odorless; water- brash (pyrosis) , a bitter or a tasteless fluid, may be brought up into the mouth (regurgitation) ; the stomach and intestines are often markedly distended with gas. Nausea is frequently present and occasionally vomiting. When the latter occurs it is frequent in the morning, when the stomach is empty, and consists chiefly of slimy mucus, and sometimes of partly digested food of the previous day with mucus. It may take place after breakfast. There is a sour, bad, or salty taste in the mouth. The patient in some cases complains of palpitation and shortness of breath (dyspeptic asthma or, more correctly, dyspnea). The pulse is small and sometimes slow. There are fulness in the head, insomnia, lack of energy, and distaste for work. Dizziness may be present. Sensation of fear, depression, melancholia, or hypochon- driasis occur in some patients. The tongue is usually covered with a thick gray moist fur, though not always so, and it cannot be said to be characteristic. The margins are at times indented. Odor of the breath is present when there is disease of the mouth or teeth, or atony of the stomach with fermentation. Headache is quite com- mon and a desire to yawn. There is at times the so-called stomach cough, doubtless due to pharyngeal irritation. The patient's appearance may be quite good and he may preserve CATARRH OF THE STOMACH 1 93 his weight. In severe cases he looks quite badly, and shows black rings under his eyes, has cold hands and feet, and chills easily. Some even lose considerable weight and become thin and emaciated. In the severe types with nervous symptoms, intestinal fermentation or putrefaction are often present and auto-intoxication is undoubtedly a factor. The bowels are, as a rule, constipated; though occasionally diarrhea or diarrhea alternating with constipation are present. Physical Examination. — Inspection. — The gastric region appears bloated. Percussion. — Tympanites is present, but the stomach is usually in the normal position. Palpation. — The gastric region is sensitive to pressure ; tenderness is rather diffuse. No real pain or sense of resistance. Splashing sound can be produced if liquid and gas are present. It is only abnormal if found at a time whe7i the stomach should be empty. It would then show atony. If found in an abnormal position (low), it is an evidence of dilatation or ptosis. With movable kid- ney ptosis can be diagnosed. Urine is scanty; contains phosphatic and urate deposits. Spe- cific gravity is increased. Diagnosis. — The presence of gastric mucus in the stomach con- tents is the chief diagnostic point in chronic gastritis, so that examina- tion of the vomitus or, preferably, of the gastric contents after a test breakfast is imperative. The diagnosis should not be made from clinical symptoms alone. Gastric Contents. — One hour after Ewald's test breakfast or the one I employ — 2 slices (60 gm.) of bread without butter and 250 to 300 cc. of water — the latter being slightly less than Ewald's, the con- tents of the stomach are withdrawn. The following are the condi- tions found present: Total acidity is diminished; free hydrochloric acid is markedly lessened or is small in amount or absent ; pepsin and rennet are present but diminished; erythrodextrin present in small quantities; achro- odextrin and sugar abundant ; quantity of gastric contents frequently normal (under 100 cc.) or may be sHghtly more (100 to 150 cc), which last would show some motor insufficiency. The pieces of roll are not as fine as normally, but larger and coarser. Mucus is usually intimately mixed with the food remnants and is adherent to the morsels of food. The stomach contents are thick, tough, and sticky, and difficult to filter, A glass rod dipped into them and lifted up will draw up strings of mucus with it. Acetic acid added to the filtrate produces turbidity. Mucus that has been swallowed is never mixed with the food remnants, but floats as isolated balls on the surface. Mucus in some cases is in large amount, while there may be very little in others. In the latter event, lavage of the empty stomach will determine its presence, in shreds or flakes. 13 194 DISEASES OF THE STOMACH AND INTESTINES In the fasting condition there are often only a few cubic centi- meters of turbid Hquid in the stomach, consisting chiefly of mucus of an alkaline, neutral, or slightly acid reaction. If no contents can be thus secured, lavage again will show the mucus. The vomitus shows the same characteristics already described, but the examination by the test breakfast is more accurate. Microscopically. — Mucus, round cells, and epithelial cells are found to be present. In doubtful cases the microscope may differen- tiate the types of mucus.^ If squamous epithelia be mixed with it, it probably comes from the mouth or pharynx ; if pigmented alveolar epithelia, probably from the air-passages. In acid gastritis, we find the total acidity and free hydrochloric acid slightly increased, and the presence of mucus. I had recently a case in which the total acidity averaged 90 + and free hydrochloric acid 70 + , with a large amount of mucus. The so-called cases of mucous gastritis merely contain an excessive amount of mucus, with little or no hydrochloric acid. In atrophic gastritis there is absence of hydrochloric acid, absence of pepsin and absence of rennet, as described under Achylia gastrica. If dilatation be present, we have the physical signs and gastric findings of such. Kinhorn finds small shreds of the mucosa present in the wash- water of some cases of chronic gastritis due, as he believes, to erosions. Motor function may be normal or slightly diminished, so that the ingesta escape before fermentation can occur. This is the usual course in the ordinary type of case. In some cases with hypertrophy the motor function may be increased. If atony or dilatation is present, there are motor insuffi- ciency and fermentation. In those with excessive mucus production, the action of the saliva and gastric juice is interfered with and though the motor function is good, the ingesta passes into the intestine with little change, and intestinal fermentation or putrefaction results. Absorption. — This depends on the severity of the case; in milder cases, with the iodid of potassium test, it seems normal; in severe cases it is interfered with. Course. — The duration of chronic gastritis is long, often extend- ing over many 3^ears. Marked improvement may take place, but relapses are apt to occur from indiscretions. Milder cases can be permanently cured. Differential Diagnosis. — Chronic Gastritis. — No severe pain; no circumscribed spot painful to pressure ; no hematemesis ; no cachexia ; no mxarked emaciation, except in severe cases of long duration; free HCl diminished or absent; gastric mucus present; slow course. Ulcer of the- Stomach. — Hyperchlorhydria, as a rule; severe pain in the epigastrium with intervals free from pain when the stomach 1 Columnar epithelia mixed with mucus show it is gastric. CATARRH OF THE STOMACH 1 95 is empty; local tenderness which is circumscribed; dorsal pain, hematemesis, or occult blood in the stool or gastric contents; no mucus ; patient has appearance of suffering ; no true cachexia. Cancer. — Age (usually over forty-five) ; rapid course; free HCl usually markedly diminished or absent; lactic acid present; mucus sometimes present; pain generally continuous, but not as acute as in ulcer; Boas-Oppler bacillus; cachexia; tumor on physical exami- nation; small amount of blood present in gastric contents; blood or occult blood in the stool; hematemesis much less than ulcer; foul odor to vomitus at times present. Achylia Gastrica. — Slow course; scarcely any gastric juice; acidity very low (2 + to 4 + ) ; absence of HCl ; absence of pepsin ; absence of rennet; usually no mucus; no lactic acid. In the early stage (transi- tional) Riegel holds that mucus may at times be present. Gastric Neuroses. — Symptoms not uniform; character of food makes little difference; indigestible food may be well borne and digestible food may cause symptoms ; no gastric mucus; HCl may be diminished or in some cases normal or increased, and the gastric findings often vary at different times in the same patient. Sub- jective symptoms are sometimes similar to chronic gastritis, but they disappear and reappear abruptly. Prognosis. — Some cases can be cured ; many improved. Relapses may occur. The affection is frequently a tedious one. Treatment. — This may be divided into: (i) Prophylaxis. (2) Hygiene. (3) Local treatment of the stomach. (4) Diet. (5) Mineral springs. (6) Medication. Acid Gastritis. — The borderline cases, acid gastritis, should receive the treatment of hyperchlorhydria ; also occasional lavage to remove mucus, say, twice a week, is advisable. In a recent case I have employed it daily, using several ounces of milk of magnesia (PhilHps) to the quart of water. Extract of belladonna, gr. -} (0.022), t. i. d. before meals and mag- nesia usta and soda bicarb., aa, gr. 10 (0.6), combined with resorcin resub., gr. 5 (0.3), in water, an hour after meals, as suggested by Theodorus Bailey, is excellent treatment. Milk of magnesia, 5j to ij (4.0-8.0), is also of value. Van Valzah and Hayes report cases. I. Prophylaxis. — Unquestionably, repeated attacks of mild so- called acute dyspepsia (acute gastritis) may ultimately lead to the development of chronic gastritis. The causes of both conditions are practically the same. The patient, therefore, should masticate thor- oughly, avoid bolting the food, overindulgence in alcohol, tobacco, very hot or very cold food and drink, indigestible food, etc. He should rest for fifteen to thirty minutes after meals before returning to busi- ness. The mouth and teeth should be kept in good condition ; and if there are aural or nasal discharges escaping into the mouth, or tonsillar or pharyngeal inflamrnation, treatment should be instituted. 196 DISEASES OF THE STOMACH AND INTESTINES Cardiac disease should be treated with cardiac stimulants, espec- ially if there is failing compensation; and diseases of the liver and kidney should receive appropriate diet and treatment, so as to lessen the chances of secondary gastritis. 2. Hygiene. — Slow eating, with subsequent rest; exercise, prefer- ably in the open air, driving, golf, rowing, walking, and horseback — all of which should be carried out in a leisurely manner and not overdone, so as to exhaust the patient, are useful. Moderate gym- nastic exercises five or ten minutes daily, as with an exerciser, with open windows, are of value. Avoid badly ventilated rooms and sleep with the windows open. Cold salt-water sponging morning and night, followed by friction with a rough towel, is of service. If the patient is excessively nervous, change of climate may be necessary. 3. Local Treatment. — The removal of the mucus is of importance. This can be done by two methods: By administering alkaline remedies that will dissolve the mucus and by lavage. In mild cases lavage is not alwa3's necessary and the use of alkalis, as advocated by Achilles Rose, is of service. They should be administered about an hour before breakfast and, if necessary, also before luncheon and dinner. For example, in ovj to viij (200 to 2.50 cc.) of hot water, soda bicarb., gr. 30 to 3j (2.0- 4.0), or lime-water, 16.0 (oss), or milk of magnesia (Phillips), 4.0 to 8.0 (3j-ij)._ Magnesia usta, 2.0 to 4.0 (gr. 30-0 j), is also of use, alone or combined wath equal quantities of soda bicarbonate. Penzoldt has demonstrated that mucus will adhere to bismuth. Rose takes advantage of this and gives a tablet consisting of 0.6 (gr. 10) magnesia usta and 0.6 (gr. 10) bismuth subnitrate, to be chewed with a full glass of water one hour before meals ; or two tab- lets, if required. The magnesia usta, milk of magnesia, or soda bicarb, are espe- cially useful. Lavage. — When the mucus secretion is more marked, lavage should be substituted; or if a mild case does not improve by the above method. This should be employed on the empty stomach before breakfast, so as to aid subsequent digestion. An alkali should preferably be added to the fluid to dissolve the mucus. The stomach should be washed with the patient both sitting and lying down and turning on the sides, to remove all mucus possible, and washed miiil the outflow is clear. The following are excellent: Milk of magnesia (Phillips), 30.0 to 60.0 (oj-ij) to the liter (quart) ; or lime-water the same quantity; or soda bicarb., 4.0 to 8.0 (oj-ij); or magnesia usta, 4.0 to 8.0 (5j-ij) — all to the liter (quart). CATARRH OF THE STOMACH 1 97 Normal saline solution — oj (4-0) salt to water Oj (500 cc.) — or boric acid, 4.0 (oj) to the liter (quart), may be employed. I use normal saline solution combined preferably with milk of magnesia or magnesia usta. Fleiner mixes 2 parts sodium chlorid and i part soda bicarb, and employs 4.0 (oj) to 2 to 3 liters of water. Frequency of Lavage. — Once a day before breakfast is often sufficient ; in some cases it may be necessary to repeat before supper. If dilatation with fermentation, resorcin (resub.), 0.3 to i.o (gr. 5-15), or the same quantity of salicylic acid or sodium salicylate; or gomenol, i.o to 2.0 (15 drops-oss) ; or potass, permang., o.i to 0.3 (gr. 1 2—5); or listerin, glycothymolin, or borolyptol, 4.0 (oj) — all to the liter (quart), can be employed. In such event, I wash with the alkali in the morning to remove mucus, and with the antifermentative at night. In some cases, lavage with nitrate of silver i : 5000 to i : 2000 is of value, used every two or three days, preceded by warm water lavage, to first remove nmcus. No saline should be used in the silver solution. Saline solution may subsequently be used if the silver cause pain or irritation. Pepper, in place of this, advocates an aqueous solution of silver nitrate, dose, gr. •§■ to | (0.008-0.016), internally three times a day for a short period. This should be kept in a dark bottle. Electricity. — Unless atony with lessened motor function of the stomach, or severe subjective symptoms, with little mucus are present, electricity is of no practical value. When there is little mucus, it may aid to stimulate gastric secre- tion. In such event the intragastric method is preferable to the percutaneous. Removal of the mucus is of the first importance. Electricity, however, is of service applied to the abdomen to increase intestinal peristalsis. Massage. — Vibratory Massage. — The same holds true of these methods. They are also of value over the intestines to promote peristalsis. Hydrotherapy. — In sensitive cases hot water compresses applied to the stomach are useful. 4. Diet. — This is an important feature, and its character depends on the severity of the symptoms. It is always preferable to give four or five light meals than three full meals a day. In severe cases give food in liquid and semihquid form (mushes), such as milk or matzoon with Vichy, kumyss, bacillac, lactone-buttermilk, barley, oatmeal, or rice soups prepared with milk ; or chicken soup or bouillon, with raw egg beaten up; sanatogen (plain or flavored), somatose, plasmon, or tropon can be added to the soups. Later, soft-boiled eggs, mashed potatoes, rice gruel, scraped raw or broiled beef, toast baked in the oven, stale bread (white), butter, cocoa, and weak tea. 198 DISEASES OF THE STOMACH AND INTESTINES The diet should be mixed, the albumin somewhat reduced; the carbohydrates should be given in suitable form, avoiding those that contain too much cellulose. Fats, such as butter and cream, are especially necessary when there is loss of nutrition. In the latter case I feed by the "scales," endeavoring to put on weight, improve assimilation, and at the same time ameliorate symptoms. The mere estimate of requisite calories and feeding by this method alone is of no value, as each patient is a rule to himself. For example: In severe cases, at first liquids and mushes. 8.00 A. M. Milk with oij (about 125 cc.) of lime-water, or pep- tonized milk, oviij (about 250 cc), with sanatogen, 5j (4.0). 10.30 A. M. ]\Iatzoon and Vichy equal parts, in all ovj to viij (200-250 cc). 1.30 p. M. Oatmeal soup or chicken soup, with an egg beaten in, Bviij (250 cc). 4.00 p. M. Same as at 10.30 a. m. 6.30 p. M. Same as at 8.00 a. m. 9.30 p. M. Milk and Vichy equal parts, in all oviij (250 cc). Additions can gradually be made to this diet. Alilk, however, does not agree with some, and soups and broths must be substituted. The following diet is useful in many cases for a w'eek or two, but must be modified to suit the individual. Calories. 8.00 A.M. I cup cocoa or tea, about two-thirds milk, approximately 100 1 lump of sugar 40 2 soft-boiled eggs 165 2 ounces zwieback, or toast, or stale white bread (2 slices) 150 ^ ounce butter 115 10.30 A.M. 8 ounces koumyss, matzoon, or milk (250 cc.) 168 2 ounces crackers or somatose biscuit 150 J ounce butter 115 1. 00 P.M. 2 ounces of steak, chicken, or chop 70 3 ounces of mashed potatoes or rice 130 2 ounces white bread (stale), or toast, or zwieback 150 I cup tea, about two-thirds mUk, approximately 100 ^ ounce butter 115 4.00 A.M. 7 ounces milk, mixed with i ounce top-cream (250 cc.) 210 1 ounce crackers 100 ^ ounce butter 100 6.30 P.M. 8 ounces hominy, rice, or cereal boUed in milk (250 cc.) 450 2 scrambled or poached eggs 165 2 slices bread average about 2 ounces 150 i ounce butter 115 2858 The above is for about three weeks, and the diet of each patient should later correspond, as nearly as possible, to the usual mode of living. There are things which it is necessary to forbid, such as fried food; meat with tough fibers or that is too old or too fresh, pork, sausages; lobster, salmon; chicken salad; mayonnaise; cucumbers, pickles, corn, radishes, celery, cabbage; hot breads, brown and CATARRH OF THE STOMACH 199 Graham bread; also fresh bread and all alcohoUc beverages, which last I believe do special harm to the inflamed mucous membrane. Foods which disagree should be interdicted. Sugar should be taken in small quantity and avoided by some. Soda-water and candy are forbidden ; also hot and cold drinks and ice-cream. Veal, as a rule, in this country is interdicted, as it is often tough. Salt is of value, as it aids the production of HCl. Beef, mutton, lamb, chicken, potatoes, hominy, rice, oatmeal, spinach, lettuce, asparagus, eggs, etc., are all admissible. Water should be taken in small amounts during the meal. S'mo/^'ing.^Excessive smoking should be stopped. It is chiefly the tobacco juice from chewing the cigar, carried by the saliva, that damages the mucous membrane of the stomach; chewing tobacco should be forbidden. If a cigar-holder or cigarrette-holder be employed, I can see no objection to two cigars or four cigarettes a day; otherwise it should be interdicted. If there is nasopharyngeal catarrh, smoking should be stopped. 5. Mineral Waters. — These dissolve the gastric mucus, hasten the emptying of the stomach, and often stimulate the mucosa. On account of the rest and regular life and diet the springs are often preferable, though the waters may be taken at home. The most useful are the saline and the saline-alkaline waters. (a) Saline Springs. — ^These contain chiefly sodium chlorid and varying quantities of carbonic acid gas, and stimulate the secretion of hydrochloric acid. The most notable are Kissengen, Homburg, Wiesbaden, Soden, and Saratoga (Congress Spring). Dose, glass of mineral water on arising. (6) Alkaline-saline Springs. — These contain sulphate of soda, sodium bicarbonate, sodium chlorid, and carbonic acid gas. The Carlsbad Springs are the most famous. Marienbad and Saratoga (Hawthorne Spring) belong to this group, also Glauber's Salt Springs and Glauber's salts. One can employ the imported Carlsbad salts or Glauber's salts; and by adding sodium bicarbonate to Glauber's salts imitate imported wa'ters more closely- Wolff's formula for artificial Carlsbad salts: I^. Sulphate of soda 30.0 Sulphate of potassium 5-° vSodium chlorid 30.0 Carbonate of soda 25.0 Biborate of soda lo.o.— M. Sig. — OSS to j (2.0-4.0) in warm water before breakfast. These springs are of value for the solution of large quantities of mucus and for constipation. Care should be taken not to purge the patient excessively, and nervous cases do not take them especially well. 200 DISEASES OF THE STOMACH AND INTESTINES 6. Medication. — The methods described will often be sufficient, but medication is of service as an accessory. Leube was the first to recommend the use of dilute hydrochloric acidV to supplement this deficiency of the gastric juice. Ewald advised the use of large amounts, 40 to 60 drops, taken in divided doses three times a day after meals. For example: The entire dose in a glass of water and com- mencing one-half hour after meals, a third of this being taken every fifteen minutes. I prefer a smaller dose, from 15 to 20 drops, in a small glass of water three times a day one-half hour after meals, and taken in three divided doses, as advised by Ewald. This is impossible to pursue with some patients, as they wiU not devote the time; so in such an event a single dose can be administered, commencing at 5 drops and gradually increasing to 15 drops. The following is an excellent prescription : I^. Tinct. nucis vomica 12.0 (oiij) Acid, hydrochlor^dilut. | -- ^g^ (gg^^ Comp. tmct. cinchona. . J Aq. destil q. s. ad. 125.0 (oiv).— M. gig, — 4.0-8.0 (3j to ij) t. i. d. in water one-half hour after food. Pepsin is present in considerable quantity in chronic gastritis, so it is hardly indicated; though some add 0.5 to i (gr. 7J-15) in combination. Papayotin, papain or papoid, or pancreatin, i.o to 1.5 (gr. 15-22J), with sodium bicarbonate, have been suggested; also the diastase combinations, wines of pepsin, etc. The use of artificial digestants would tend to weaken the gastric functions, and are not indicated. The bitter medicaments as stomachics, to stimulate the function and appetite, are often employed, and Riegel beHeves the hydro- chloric acid acts in this way. They should be used fifteen minutes before meals in i to 2 ounces of water. Among such remedies are tincture aurantii amara ; tinct. amara (bitter tincture, Squibb ' s) ; tinct. calumba; fluidextract calumba; tinct. cardamomi; tinct. hydrastis; tinct. gentian comp.; fluidext. hydrastis; fluidext. condurango; fluidext. quassia. The average dose for this purpose of any of these remedies would be from 15 to 20 drops; quassia, in 5 to 10 drops ; and tincture nux vomica, if given as a stomachic, in 5 to 10 drops. They may be given alone or in combination, with smaller indi- vidual doses. The alkaloidal form of administering stomachics is often of value. Thus: Condurangin (Abbott's), gr. -g-V (.001). Quassin (Abbott's), gr. -gV to ^2 (•001-.005). 1 Oxyntin, a derivative of HCl, combined with nux (tincture), 5 drops, given in capsules, gr. v (0.3), after meals, is of value. CATARRH OF THE STOMACH 20I Condurangin (Merck's), gr. jV to \ (.0065-016). Quassin (Merck's), gr. 3V to ^ (.002-.02). Hydrastin (Merck's), gr. { to h (.016-.032). Strychnin arsen., gr. j-J-q (0.00065), and quassin, gr. ro (0.0065), are a good combination. Orexin, gr. J to i (0.032-0.065), can be given in bouillon for the same purpose. In the gastritis of phthisis, carbonate of creosote or guaiacol carbonate, gr. 5 (0.3) each t. i. d. after meals, are of value. For Nausea and Vomiting. — Cerium oxalate, gr. i (0.065), alone or combined with soda bicarb, or bismuth subnitrate, gr. 2 (0.13), or any of the methods described under Acute Gastritis. Lavage may be necessary. For Belching. — ]\Iilk of magnesia, oss to j (2.0-4.0), or magnesia usta, gr. X (0.6). For Gas and Intestinal Fermentation. — Resorcin resub., 5iss (6.0); Aq. menth. piperit., q. s. oiv (125.0). Dose, 5ij (8.0) t. i. d. after food in water, or ichthoform or ichthalbin, gr. 5 (0.32) each, etc. For nervous symptoins associated with intestinal putrefaction 1 would refer to the chapter on the latter subject. Iron and arsenic can also be added to the treatment. For Constipation. — Patients under treatment with the Carlsbad waters require no treatment for constipation; otherwise attention must be paid to this condition. The patient should have a movement every day, go to the closet at a definite hour, and endeavor to secure bowel action. This can be assisted by a 2-ounce injection of olive oil, or by a glycerin or gluten suppository, or oij to oss (8.0-16.0) glycerin in oj (30.0) of water, by means of a small rectal syringe. Green vegetables, such as spinach, asparagus, lettuce, green peas, etc., are of service. Stewed fruits, such as prunes, apples, or pears, are often effectual. Some cases do well with food containing much cellulose and with rye bread, but many cannot take them. A glass of cold or hot water on rising is of value. If mild cathartics are necessary, cascara (fluidextract) , oss to j (2.0-4.0), or the aromatic fluidextract; or extract cascara, gr. i to 2 (0.065-0.13), or compound rhubarb pills; all at night. The following prescriptions are of service. P^. Aloin gr. \- (0.016) Podophyllin gr. ^ (o.oii) s/ryZi/""*} M gr. rf. (o.«»65, Cascara ext gr. J (0.016). — M. In one pill. I^. Ext. aloes Ext. nucis vomicae ]■ aa gr. J (0.008). — M. Ext. belladonnae In one pill. I 202 DISEASES OF THE STOMACH AND INTESTINES I^. Podophyllin gr. J (o.oi i) Ext. nucis vomicae 1 -. , / ,. ,, Ext. physostig. j ^^Sr. i (0.016) .-M. In one pill. I^. Aloin gr. I (0.016) Strychnin gr. ^ (0.00108) Ext. belladonna gr. ^ (0.008). — M. In one pill. Other remedies are described under Constipation. Olive-oil injections to be retained at night; an occasional enema of soapsuds, not over i quart (Hter) ; massage or vibratory massage or electricitv to the intestines are useful. CHAPTER XI ACHYLIA GASTRICA (Synonyms. — Atrophy of the Stomach; Atrophy of the Gastric Mucosa; Anadenia Ventriculi; Phthisis Ventriculi; Atrophic Gastritis; Catarrhus Atrophicans.) Definition. — Achylia gastrica (the term first suggested by Einhorn) may be defined as a functional perversion of the stomach, characterized by the absence of the gastric secretion (of hydrochloric acid, pepsin, and rennet). Introduction. — In many cases, atrophy of the mucosa is the cause, and the condition is permanent. Einhorn, however, has reported a case in which there was eventually some return of secre- tion, so that portions of the mucosa could not have been much altered ; and a case of achylia in a vegetarian, apparently an atrophy from disuse. Achylia gastrica may result from organic changes in the stomach, or may be a pure neurosis, so I prefer to place it in a special chapter. The loss of function may be temporary from nervous disturbances, and A. Rose^ and the author^ have observed achylia occurring in gastroptosis, with a return of secretion following the cure of ptosis. Temporary achylia is present occasionally in mucous colic. History. — Atrophy of the gastric mucosa was first described in connection with pernicious anemia by S. Fenwick,^ and later by Lewy,* Ewald,^ Osler,^ Kinnicutt,' Nothnagel, Boas, and others. It was believed to be the cause of pernicious anemia and productive of the fatal result. Herter has demonstrated the influence of intes- tinal putrefaction, chiefly through the gas bacillus (Bacillus aerogenes capsulatus), in the production of pernicious anemia, and favorable results produced by intestinal irrigation and lactic acid fermented milk diet. Stockton has called to our attention that achylia does not occur in the early stages of pernicious anemia, but only when it becomes severe. In view of these facts, achylia seems to be a sec- ondary and not a primary cause. Numerous non-fatal cases of achylia have been reported by 1 Atonia Gastrica, Rose and Kemp. 2 Observations on Dilatation of the Stomach and Gastroptosis, Medical News, August 6, 1904. Mucous Colic, American Medicine, March 4, 1905. 3 Lancet, July, 1877. < Berlin, klin. Wochenschr., 1887, No. 4. 5 Ibid., 1886, No. 32. 6 American Journal of the Medical Sciences, vol. xci, 1886, p. 498. 7 Ibid., 1887, p. 419. 203 204 DISEASES OF THE STOMACH AND INTESTINES Ewald/ Boas, Einhorn,' Jaworski, Jones, and Martins, and the latter has written a work on the subject. Etiology. — Severe chronic catarrhal gastritis, or toxic gastritis, may produce permanent destruction of the glands; atrophy from disuse, as in vegetarians; achylia, associated with cirrhosis of the liver (syphilis) ; or with carcinoma of the stomach, or, rarely, with carcinoma of other organs; occasionally with diabetes mellitus; achylia with pernicious anemia. Organic changes are present in these cases. Achylia may occur as a temporary functional disturb- ance in nervous conditions, neurasthenia, gastroptosis, and mucous colic. Achylia may also be secondary to a general infection, such as typhoid fever,-^ etc. It is quite common in the middle and later years of life, but has occurred in a number of 3"oung persons, especially in the transitory type. Morbid Anatomy. — When the achylia is of nervous origin, or associated with gastroptosis or mucous colic, there are no organic changes in the mucosa, and the condition is a temporary functional disturbance of secretion. Rose and myself believe the achylia in mucous colic due to the gastroptosis and not to the nerv'ous condition. Einhorn has shown that in cases where a portion of the mucous membrane has been aspirated, showing the organic changes of achyUa, there has been some return of secretory function under treatment, so that this is no evidence of permanent destruction of secretory power in all the gastric glands. Of the organic changes, there are the two types described under the terminal stage of chronic gastritis: 1. Phthisis ventriculi — round-celled infiltration and fatty degen- eration, with thinning of the stomach wall ; round cells taking the place of the glands ; and the stomach is normal in size or may be dilated (Fig. 126). 2. Cirrhosis, or sclerosis ventricuh, a fibrous inflammation, start- ing in the submucosa ; fibrous tissue takes the place of the glands, and the stomach is contracted and the walls thickened. Symptoms. — One can scarcely say that there are symptoms characteristic of achylia gastrica; it is the examination of the gastric contents which will alone determine the true diagnosis. In describing the symptoms it seems best to classify achylia under certain groups, some of which we may dismiss briefly. 1. Gastroptosis (splanchnoptosis), with its . symptoms ; gastric disturbances; achylia present in some cases. 2. Mucous colic, with its symptoms; occasional presence of achylia. 3. Patients with no symptoms and enjoying good health. 1 Berliner klin. Wochenschr., 1892, Nos. 20 and 27. 2 New York Med. Presse, Sept., 1888. 3 Stockton, American Journal of the Medical Sciences, Aug., 1909. ACHYLIA GASTRICA 205 Einhorn calls attention to this class, one of which had the habit of rumination, and achylia was found present, of forty years' duration. Patient had no other symptom. Clinically this class cannot be considered. 4. Cases with gastric symptoms of varying severity, associated with intestinal disturbances. These are the most common type. There are loss of appetite, a feeling of fulness or pressure in the epigastric or gastric regions, and in some cases severe paroxysms of pain, usually soon after eating and persisting for some time; vomiting Fig. 126. — Achylia gastrica: i, mucosa; 2, submucosa; 3 and 4, muscularis; 5, serosa; section shows round-celled infiltration of mucosa and absence of glands. may occur soon after the ingestion of food ; belching of gas; headache and occasionally vertigo; usually constipation. Some cases may remain fairly well nourished. In others there may be considerable loss of weight, which extends over a period of several years, and nervous symptoms may be present. In cases in which nutrition is preserved, the intestines perform the digestive functions of the gastro-intestinal tract. Einhorn describes cases whose symptoms resemble h^'perchlor- hydria, with pains one to two hours after eating, which are relieved 2o6 DISEASES OF THE STOMACH AND INTESTINES by food and drink, especially the latter, which prevents irritation of the mucosa by the coarse particles. This has been given as an explanation for the pain. 5. Cases with marked intestinal disturbances, especially diarrhea, or occasionally diarrhea alternating with constipation; quite fre- quently there may be no gastric symptoms or slight belching or feeling of pressure. Some of the cases lose considerable weight and strength and feel weak. I have recently treated a case suffering from these symptoms who was, in addition, markedly ner^^ous. At the end of four months' treatment gastric secretion returned and all symptoms disappeared, there being 15 pounds increase in weight — a case of nervous achylia. Some cases of this type may present symptoms (subjective) of diabetes, according to Einhorn. 6. Cases with severe anemia (described by Riegel) with diarrhea. Examination of the blood shows secondary anemia, and of the stomach, achylia gastrica. Diarrhea favors the production of anemia and the latter improves under treatment. These cases must not be confounded with pernicious anemia. The blood examination easily differentiates. 7. Ach^^lia developing during acute febrile conditions, such as influenza (Ewald). Riegel believes it probably pre-existed, and that the intestines, which formerly performed the digestive functions, are thus disturbed and achylia symptoms first appear in consequence. 8. Patients suffering from ner^^ous conditions, or neurasthenia, or gastric neuroses; achylia a temporary per^^ersion. ]\Iy case under the diarrheal class belonged to this type. 9. Pernicious anemia with achylia, in which the blood findings are typic; megaloc}i:es and nucleated red blood-corpuscles (normo- blasts and megaloblasts) , etc. Diagnosis. — ^The diagnostic feature of achyHa is the gastric analysis one hour after Ev:ald's test breakfast. The characteristics are as follows : Total acidity is 2 -f to 4 -|- , or even neutral ; HCl = O ; Pepsin = O ; rennet = (rennet zymogen .may be present); propeptone = O ; pep- tone = 0; lactic acid = O ; or faint trace ; er}'thro6dextrin = 0; sugar = + ; gastric contents have no odor, no eA'idence of fermentation; quantitv of liquid is very small, aside from that soaked into the particles of bread (this is quite characteristic) ; bread particles are not minutely minced, but rather coarse; absence of mucus. Schmidt and Riegel believe mucus to be present in some cases in the early stage of achylia, developed from chronic gastritis, while there are some glands remaining in mucoid degeneration, and that the presence of mucus does not signify that the case is not one of achylia. Some cases of old chronic gastritis certainly seem on the borderline. ACHYLIA GASTRICA 207 The small amount of fluid in achylia is explained by the fact that the liquid chyme rapidly leaves the stomach, leaving the solid particles, and that practically no secretion takes place in the stomach. Motor function is often normal or even increased. It is diminished where there is degeneration and dilatation of the stomach. Absorption. — Though this has apparently seemed normal by the iodid of potash test, in some cases it is evident that this test is often fallacious, in view of the fact of the general loss of nutrition in some patients. I agree with Riegel that from the pathologic condition present, absorption must be diminished. Course and Prognosis. — In nervous achylia, secretion may be resumed in a few months under proper treatment, and in gastroptosis and mucous colic the condition is dependent on the treatment of these diseases. In some patients the condition perhaps exists for years, with the patient in good health; while in others the subjective symptoms maybe removed or cured, while the objective symptom (the analysis) persists. Others run a long and protracted course. With pernicious anemia and carcinoma the prognosis of achylia depends on the primary disease. Diagnosis. — Repeated analysis of the gastric contents are necessary to arrive at the diagnosis. Achylia Gastrica. Cancer of the Stomach. Gastric contents: Gastric contents: Little fluid, no rnucus, low acid Mucus, acidity higher, lactic acid, reaction (2+ to 4 + ), no HCl, free HCl may be present, though no lactic acid, coarse particles, usually absent, contents more no blood. fluid, and odor and food less coarse, blood. Stool: No blood. Blood, or occult blood. Tongue: Often clean. Coated. Pain: At times. Constant. Motor power: Normal usually. Diminished. Course: Slow. Rapid. Loss of weight: Gradual. Rapid. Cachexia: None, or slow emaciation. Rapid and peculiar type. Tutnor: None. Present later. The possibility of achylia gastrica being the cause of various types of gastro-intestinal disturbances, of chiefly intestinal derangement or irregularities, or of severe anemia must be considered. Its associa- tion with pernicious anemia, gastric neuroses, various nervous symp- toms, gastroptosis, and mucous colic must be remembered. These facts further emphasize the importance of gastric analysis. 2o8 DISEASES OF THE STOMACH AND INTESTINES Treatment. — This depends on the cause. Rose's belt, if achyUa is due to gastroptosis or mucous coHc, is necessary. If associated with nervous affections, these conditions should receive treatment. Such patients should have their nutrition improved, and placed on the diet shortly to be laid down. As in these cases achylia is a func- tional disturbance, the secretion should be stimulated by — Strychnin, gr. gV to -gV (0.00108-0.002 1), t. i. d. before meals, or condurango (fluidextract) , lUxv to xx (0.88-1. 18), or tinct. nux vomica, ttlv to x (0.29-0.59), with the addition of hydrochloric acid, thus: I^. Tinct. nucis vomicae \ .. ,r--. / ^ Acid, hydrochlor. dilut. j ^^ ^"^ ^^^^^ Comp. tinct. cinchona j (30.0) Pure pepsin 5 iss (6.0) Aq. destil q. s. ad. oiv (125.0). — M. Sig. — 3ij in water t. i. d. before meals (preferably). Pancreatin, gr. v to x (0.3-0.6), with soda bicarb., gr. xv (i.o), or taka-diastase, gr. v (0.33), can be given after meals in cases with diarrhea to aid digestion of starchy food.^ In the general treatment of achylia gastrica endeavor: (i) To stimulate gastric secretion. (2) To arrange the diet so that the food is easily digested. To stimulate gastric secretion employ stomachics, such as nux vomica, condurango, etc., fifteen minutes before meals, as just described. The occasional use of lavage twice a week is of service in some cases. Litten advises the use of a 2 per cent, dilute hydro- chloric acid solution for this purpose. Intragastric faradization (preferably) - twice a week or percuta- neous faradization may be valuable. I would not advise this in the purely nervous cases. If the symptoms simulate hyperchlorhydria, the use of water, §viij (250 cc), or crackers and milk one to two hours after meals, as suggested by Einhorn, lessens the irritation. Diet. — This is very important. Food should be prepared so as to pass readily from the stomach, and should be finely divided and thoroughly masticated. Meat should be given in small quantity, finely chopped, scraped (rare or broiled), chicken, pigeon, raw scraped beef, calves' brain, steak, fish, and game. Starchy foods are excellent and should be thoroughly prepared; membranes covering any such should be removed. Starch is rapidly converted into sugar. Mushes and liquids are preferable. Pea and bean soup (strained), barley, oatmeal, rice, sago, and potato soups. Mushes from rice. potato, tapioca, oats, flour, etc.; puddings. Soft-boiled eggs; yolks. of eggs in soups; raw eggs beaten with water or milk; koumyss; matzoon; bacillac; bread; crackers; milk; plenty of cream and butter are indicated. 1 Cellasin tablets, gr. v (0.3) t. i. d., are also useful. ACHYLIA GASTRICA 209 Somatose, sanatogen (plain or flavored), and meat powder; Valen- tine's or Liebig's beef -juice; Armour's extract of beef. Cocoa possesses considerable nutritive power. Tea and cofifee well diluted with milk can be given. My personal view is that alcoholic beverages are objectionable, though some allow them in moderation. The second indication in the feeding is to employ it at frequent intervals, about every three hours, in small quantities, but so that the sum total shall be considerable. The object should be rather to overfeed and to increase the patient's weight by selecting those foods which best agree in each case. In diarrheal cases, constipating food, such as potatoes and rice, should be selected. Feed by the "scales" is my rule in cases where loss of weight has occurred. For the preparation of meat powder, either of the following methods is excellent : (i) Debove's Method. — Roast finely chopped lean beef on a tinplate until desiccated, then powder in a mortar. (2) Einhorn's Method. — Dry finely chopped meat three to six hours on a stove ; then pound in a mortar and grind twice in a coffee- mill. Butter, milk, cream, eggs (soft boiled or raw), potatoes, rice, peas,, and beans (strained through a colander), cocoa, chocolate, and a small amount of beef, chicken, or game, and crackers or stale bread always seem to agree. I have often given 4 to 8 raw eggs a day. For example: Calories. - 8 A.M. Oatmeal with cream, 150 gm 400 Cocoa with milk, 200 gm 135 Soft-boiled eggs-(2) 160 Toast (2 slices) 1 60 Butter, 20 gm 163 II A.M. 6 ounces (200 cc.) milk with raw egg 240 Crackers, 2 oz. (60 gm.) 1 50 Butter, 20 gm 163 2 P.M. Soup, bean or pea, 100 gm. (with i egg and 10 gm. of cane- sugar) 122 Rare meat scraped, 100 gm 215 Mashed potatoes, 50 gm 63 Spinach, 50 gm 30 Bread, 2 slices (60 gm.) 1 35 Butter, 20 gm 1 63 Tea and milk (2 lumps of sugar) 60 5.30 to 6 P.M. Soft-boiled egg (i) 80 Rice, 50 gm. ; milk, 200 gm 302 Bread ( i slice) 67 Butter, 20 gm 81 Tea and milk 60 9 to 9.30 P.M. 6 ounces (200 cc.) milk or koumyss 128 Zwieback, 50 gm 1 29 Butter, 20 gm 163 Total calories 3269 It may be necessary to modify this diet and give less, especially at first. 14 2IO DISEASES OF THE STOMACH AND INTESTINES In cases of severe anemia, rest in bed; arsenic in large doses, beginning with Fowler's solution Tllv (0.296) t. i. d. and increasing to TTlx to XV (0.59-0.88) t. i. d. ; or by hypodermic in sterile water atoxyl, gr. ^ to § (0.022-0.044), every other day, and, in addition, peptomangan (Gude), iron tropon, or other good iron preparation. Intestinal irrigation is of value in these cases when putrefactive processes are present in the intestine, for example, with §j to ij (30.0-60.0) peroxid of hydrogen or acetozone gr. xv (i.o) to the liter of water. Enteroclysis is especially advocated in pernicious anemia cases, with bacillac as diet. I have recently found urotropin, gr. v to x (0.3-0.6), combined with equal quantities of benzoate of soda, is of great service as a remedy for intestinal putrefaction. Resorcin and the other remedies suggested for this purpose under Chronic Gastritis and in the paragraph on Indicanuria are of value. The bismuth preparations, notably bismuth subcarbonate or sub- nitrate, gr. X to XXX (0.6-2.0) t. i. d., can be given if diarrhea is present, and in this type boiled milk, potatoes (mashed), and rice are serviceable. If there is dilatation of the stomach, lavage and the treatment for this condition must be carried out and Rose's belt applied. CHAPTER XII HEMATEMESIS-ULCER OF THE STOMACH— EXULCER- ATIO SIMPLEX— ACUTE AND CHRONIC EROSIONS GASTRIC HEMORRHAGE Vomiting of blood cannot be considered to be a proof of gastric hemorrhage, as it may come from the esophagus, nose, or mouth, or be coughed up and swallowed. On the other hand, gastric hemorrhage may occur and the blood only appear in the stools. The causes of gastric hemorrhage may be classified as follows: 1. Trauma over the stomach; injuries to the mucous membrane from foreign bodies, as bones or needles; damage from the stomach- tube, mineral acids, or caustic alkalis. 2. Thrombosis or emboHsm of the vessels; aneurism; varicosities; atheroma of a vessel, or fatty degeneration. 3. Venous stasis due to cirrhosis of the liver; tumors of the hver; pylephlebitis; compression of the vena cava. In case of cirrhosis the hemorrhage is from the mucous membrane or from esophageal varices. 4. Lesions of the heart or lungs, causing stasis in the vena cava. 5. Constitutional diseases, as leukemia; pseudoleukemia; per- nicious anemia; hemophiha; scur\^y; purpura; melena (morbus maculosus neonatorum). 6. Menstrual type, when amenorrhea is present. 7. Lesions of the central nervous system (brain or spinal cord). 8. Hysteria. 9. Ulcer of the stomach and carcinoma. 10. Acute infectious diseases, as yellow fever, scarlet fever, measles, small-pox, etc. 11. Weil's disease (epidemic jaundice) ; malignant jaundice (acute yellow atrophy). 12. Phosphorus-poisoning. 13. Acute jaundice with hemorrhage, following operation. 14. Erosions — postoperative hematemesis due to these ; the French describe them after appendicitis as vomito-negro-appendiculaire. 15. Exulceratio simplex (Dieulafoy), or superficial ulceration of the stomach. As it is the general tendency to impute cases of gastric hemorrhage chiefly to ulcer or cancer, it seemed desirable to classify all causes. Symptoms. — The chief symptoms are hematemesis and melena. Acute anemia develops if much blood is lost ; the patient feels dizzy 211 212 DISEASES OF THE STOMACH AND INTESTINES and weak and faints easily. The sight is blurred, pulse rapid and feeble, and extremities cold; rarely convulsions and death follow. Nausea and vomiting occur. The blood may be dark in color or coffee ground in appearance, or light if in a large amount. An evanescent rise of temperature may occur after the hemorrhage. At times the symptoms may take place with no hematemesis and nothing definite visible in the stool, when Weber's or the benzidin test may be necessary to determine the presence of blood. Prognosis. — The prognosis is rarely fatal from the hemorrhage itself, but depends on the primary disease. Treatment. — A h^'-podermic of morphin, gr. ^ (0.016), and locall}^ the ice-bag; ext. ergot 3ss (2.0) in solution by hypodermic, or ernutin Ttlv (0.3) by hypodermic, and in addition gelatin 10 per cent, solution, or Tremoliere's solution gelatin, 5 per cent, with calcium chlorid, 2 per cent. These gelatin preparations should be given from 5ij to oj (8.0-30.0) every half -hour to an hour by mouth. Tannic acid, gr. v (0.33), or lactate or chlorid calcium, gr. xv (i.o), should be given in solution (water 200 cc. or ovj) by rectum; lactate of strontium or magnesium, gr. xv to xxx (1.0-2.0) in 60 cc. (oij) of water can also be administered by hypodermic. Adrenalin chlorid (1:1000); 5 to 10 drops (0.291-0.582 cc), by mouth or hvpodermic is recommended, but it at times too rapidly increases pulse tension, especially if given hypodermically. Hypodermoclysis or the rectal injection^ of normal saline at 120° F. are useful. Ice-w^ater lavage in rare instances may be necessary. Stimulants, such as strychnin, gr. gV (0.00108), or camphorated oil, gr. 75 (0.5), camphor in IU20 (1.3) of sterile almond oil, by hypodermic, may be required. ULCER OF THE STOMACH {Synonyms. — Ulcus Ventriculi (Simplex); Peptic Ulcer; Ulcus Ventriculi Rotun- dum; Perforating Gastric Ulcer; Cruveilhier's Disease.) Ulcer of the stomach is characterized by a destruction of the mucous membrane of the stomach varying in degree, exhibiting no tendency to heal, and in typic cases attended with gastric s^^mptoras associated with pain, vomiting, and hematemesis. It was first described by Cruveilhier in 1829. Etiology. — Postmortem and Geographic Distribiition. — Brinton found evidences of gastric ulcer in 5 per cent, of persons dying from all causes, most frequent in London and on the Continent. Gerhardt Iiotes its frequent occurrence in Thuringia, and Von Sohlern its rarity in Russia, the Rhine region, and in the Bavarian Alps, believing this to be due to the vegetarian diet (rich in potassium salts) in these countries. This theor}^ lacks scientific confirmation. Sex. — Gastric ulcer occurs more in women than in men. Welch ^ Proctoclysis is of value. ULCER OF THE STOMACH 213 places it at 60 per cent, in women and 40 per cent, in men, while Brinton believes it twice as frequent in women. Age. — Cases have been reported in children under ten vears. It occurs most frequently between twenty and forty in females, and in males quite often between forty and fifty. Ewald places the highest mortality between forty and sixty. It may occur in old people. Occupation. — Cooks, shoemakers, and porcelain makers are most liable to this disease, but it seems a matter merely of coincidence. Traumatism. — Simple trauma probably cannot produce gastric ulcer unless other conditions are associated. Blows, falls, and the swallowing of foreign bodies, such as knives by jugglers, etc., have produced severe damage to the mucosa of the stomach and marked hemorrhage, without the ultimate production of ulcer. Griffini and Vassale have resected or burned out portions of the nmcosa of the stomachs of animals and perfect healing has taken place, with no ulceration. Traumatism may be a factor, as is shown in the following case of mine: Girl, age twenty-tw^o, with no gastric symptoms, was thrown from a trolley car, striking on the epigastric region. Pain and tenderness were present at this point and gastric symptoms developed. There was no visible hemorrhage, but pain and symp- toms continued for six weeks, apparently of hyperchlorhydria, but local tenderness persisted at the point of injury. The patient then had a sudden gastric hemorrhage of severe type and the ultimate course w^as of ulcer of the stomach. Cure resulted in eight months, the case being obser^^ed for several years subsequently, with no recur-, rence. This girl was anemic before the accident and probably hyperchlorhydria was present, though no symptoms were complained of. A hematoma was, I believe, produced in the stomach wall, inter- fering with its nutrition, and the other conditions favored ulcer devel- opment. The patient also had a hematoma of the thigh from the same accident. Traumatism under such conditions may be a factor. Anemia and chlorosis may predispose to ulcer, and Riegel and Charles Stockton have shown that hyperchlorhydria frequently accompanies these conditions, and that it has an influence in the prevention of the cure of ulcer or even in its production. Experi- ments on animals have been performed for the purpose of studying the etiolog}^ of ulcer. Quincke and Daettwyler made animals anemic by venesection and produced lesions in the gastric mucosa. Section of the spinal cord, with the introduction of h of i percent, hydrochloric acid solution in the stomach of a dog, has produced ulceration (Koch and Ewald). It has occurred after injury to the anterior corpora quadrigemina. Weinland recently maintains that there is formed in the gastric mucosa an anti- body, an antipepsin, which opposes the digestive action of the acid gastric juice. If the antibody is deficient in a certain area, this unprotected region is readily injured by the gastric juice. Rosenau has produced gastric ulcer by the injection of diphtheria toxin. Botton has produced gastric ulcer in animals by injecting the macerated gastric mucosa of other animals and of animals of other species. 214 DISEASES OF THE STOMACH AND INTESTINES The neurotrophic theory has been held by some. Stockton beHeves that nerve perturbation analogous to herpes may be a factor; and de la Verdora produced ulcer and hyperchlorhydria by injecting alcohol into the splanchnic and celiac plexus of a dog. Section of the vagi below the diaphragm has caused ulceration of the gastric mucosa. These experiments suggest that the nervous sys- tem may be a factor. Silberman introduced substances into the blood producing hemolysis (hemoglobinemia) with resulting anemia, and found that defects of the mucosa healed tardily. Turck has produced gastric ulcer by feeding dogs with pure cultures of the bacterium coli comnmne. It is known that burns of the abdomen may produce gastric ulcer, though usually the duodenum is affected, Pavy held the theory of diminished alkalinity of the blood, but this can hardly be accepted. Erosions have been considered by some to be the cause of ulcers, but Langerhans opposed this from his experience in autopsies, and Einhorn has demonstrated that gastric erosions are a clinical entity and that ulcer does not result. We know that autodigestion of the gastric mucosa occurs after death. The effect, therefore, of circulatory disturbances of the blood-vessels of the stomach in the development of ulceration is important. Virchow first suggested that ulceration may result from the plugging of a nutrient artery to part of the mucosa by a thrombus or embolus, and that the infarction is destroyed by the gastric juice. Panum supported this view by producing infarcts and ulcers of the stomach in a dog by injecting an emulsion of wax into the femoral artery. Occlusion of the portal vein or of some of the large veins of the stomach may cause gastric ulcer. Injection of chromate of lead into the gastric and splenic arteries (Cohnheim) has produced ulcer. Talma, by increasing the tension of the gastric wall by ligating the orifices of the stomach, has brought about ulceration. Artificial anemia by faradization of the stomach has caused ulcer. Local interference with the circulation, with resulting necrosis, associated with hyp^chlorhydria and changes in the blood are probably the most frequent causes. Hyperchlorhydria is present in about 95 per cent, of the cases,^ but occasionally there is subacidity or achylia gastrica, as reported by Einhorn and others. I have recently seen a case with very low acidity (Connor's case).^ Probably gastric ulcer is not always produced by the same factors, and several of the theories described may apply. Hyperchlorhydria undoubtedly has a bearing on most cases, and frequently anemia or chlorosis. Morbid Anatomy. — The peptic ulcer is found in the regions 1 Recent reports from Mayo's cases show there are quite a number without marked increase in HCl. 2 Frequent gnstric analyses showed free HCl trace or absent; lactic acid present; microscopic pus and occult blood. Multiple ulcers (non-malignant) were found by John Connor at operation. ULCER OF THE STOMACH 215 exposed to the gastric juice, in the stomach, lowest part of the esophagus, and upper duodenum. It is round or oval, occasionally oblong; is funnel shaped, the upper part being the larger; is of variable depth, its floor being formed by the subniucosa, muscular tissue, serosa, or by adjacent adherent organs. The acute ulcer is usually small, punched out, with clean cut edges and a smooth floor, with no thickening of the peritoneal coat ; occasionally the floor may be covered with a thick green or brown mucus. The chronic ulcer is of larger size, with callous margins, and the border may be sinuous. It is often markedly indurated, so if situated at the pylorus it may feel like a tumor on palpation. Embolism or endarteritis of the artery supplying the ulcerated region has been found, or a small aneurism on the floor of the ulcer. Microscopically. — The ducts of the glands are cut off toward the base, being eaten away or digested up to where the tissue offers sufficient resistant power to the gastric juice. Healing occurs by proliferation of the connective and glandular tissue near the margin of the gland. As the connective tissue con- tracts, the proliferation of the glands is stopped. If the stomach wall is adherent to an adjacent organ and the ulcer perforates, the neighboring tissue may grow into the hole and unite with the con- nective tissue growing from within. Muscle-fibers do not regenerate. This is true of the large deep ulcers ; the mucosa and m.uscularis roll in and adhere to the adjacent organ. There is further proliferation of tissue caused by irritation of the gastric juice, and the latter may cause erosion of vessels. The rest of the imicous membrane of the stomach, as a rule, remains normal. Extent of the Ulcer. — It may vary from the size of a pea to a diameter of 5 or 6 inches; the average being from a 5-cent piece to a 25-cent piece. Peabod}" reports one measuring 19 by 10 cm. Location. — It is commonly situated on the posterior wall of the pyloric end of the stomach, at or near the lesser curvature. Welch states that out of 793 cases, 288 were in the lesser curvature, 95 at the pylorus, 96 on the anterior wall, 50 at the cardia, 29 at the fundus, and 27 on the greater curvature. Other statistics are given. Number, — In about 80 per cent, of cases i ulcer is found; in a trifle over one-half the remainder, 2 ulcers; in the balance, 3 to 5 ulcers; Osier reports 34 ulcers in i case, and Lange i in which he could not count them. Progress of the Ulcer. — i. Cicatrization may occur, with formation of a connective-tissue scar, w^hich tends to depress and contract. Depending on its location, it may cause stricture of the pylorus, esophagus, or an hour-glass stomach. In other situations it may produce no trouble. 2. Progressive necroses may take place and there may result: (a) Erosion of a blood-vessel with severe or occasionally fatal 2l6 DISEASES OF THE STOMACH AND INTESTINES hemorrhage from perforation of a large vessel, such as the gastric, hepatic, or splenic artery, portal vein, etc. (b) Adhesions to neighboring organs or various perforations. The stomach may become adherent to the liver, gall-bladder, spleen, pancreas, or intestines, and there may be perforation into these organs. If the ulcer is on the anterior surface, then direct perforation and general peritonitis may follow. There is sometimes a circumscribed peritonitis when adhesions form with other organs and a local abscess, which may later perforate into the peritoneal cavity. The ulcer may perforate into the lesser peritoneal cavity and cause subphrenic abscess; the diaphragm may be perforated and a communication formed with the pleura, lungs, pericardium, and even with the left ventricle; or, rarely, an emphysema of the sub- peritoneal tissue occurs, which may pass into the posterior medias- tinum; or adhesions may form and a perforation of the anterior abdominal wall take place ; or general emphysema of the subcutaneous tissues may rarely result. In cases with adhesions to adjacent organs, with or without abscess, localized growing tumors, hard in consistency, may be formed, and Gerhardt notes the possibihty of mistaking these for carcinoma, but the history and gastric analysis make the diagnosis. Symptoms.^ — Some cases present typic symptoms, in which event the diagnosis is easy; others suffer apparently from a simple hyperchlorhydria for a long period of time with no special symptoms pointing to ulcer; while in others the condition is latent. In the latent cases the patient is sometimes apparently perfectly well, when there will suddenly develop hematemesis or symptoms of perforative peritonitis. Others may not vomit, but suddenly turn faint and weak, become pale with a feeble pulse, presenting the symptoms of internal hemorrhage. Examination of the stool for occult (concealed) hemorrhage by Weber's, the aloin, or the benzidin test is a valuable aid. Cases Simulating Hyperchlorhydria. — Kaufmann,^ of New York, has suggested that in cases of hyperchlorhydria not yielding to treatment and in whom the pain is of a gnawing or tearing character the suspicion of ulcer is justified. This is undoubtedly true, and repeated examinations of the gastric contents and stool for blood or occult blood are indicated. Typical Case. — As a rule, the symptoms of gastric ulcer develop slowly and are as follows: at first a feeling of fulness and pressure after eating; gradually increasing to pain in the epigastrium, which may become so severe that the patient is afraid to eat. Nausea, regurgitation, or vomiting may occur early. iNew York Medical Journal and Philadelphia Medical Journal, March ii, 1905. ULCER OF THE STOMACH 217 Pain occurs generally a few minutes after eating, though sometimes one-half to one hour later, and persisting during digestion. Coarse substances and large quantities of food increase it. It is of a burning or gnawing character. Epigastric pain is increased on pressure and the sensitive point is usually circumscribed. A few weeks later dorsal pain begins, gnawing in character, lying to the left of the spine, between the eighth and tenth vertebrae, alternating with the epigastric pain; at times there is sensitiveness on pressure in this region. The epigastric pain is not continuous, as in cancer, but there are periods of relief. Later, vomiting may occur, one to two hours after meals, of very acid watery material, mixed with food ; emesis generally relieves the pain; occasionally there is vomiting late at night or early in the morning if gastrosuccorrhea (hypersecretion) is associated with ulcer. Appetite is variable; at times the patient desires food, but fears to eat on account of pain ; constipation generally marked ; amenorrhea frequent in women; anemia marked in many cases. These symptoms continue, then hemorrhage suddenly occurs, and is visibly present in one-third to one-half the cases, and in a very large percentage when occult hemorrhage is included, as it should be. (i) Hemorrhage may he occult, no vomiting of blood, the patient turning pale and faint and in a cold sweat, and on the next day there are tarry stools, or occult blood is found in the stool by Weber's or the benzidin test. Progressive anemia may be caused by small repeated hemorrhages. (2) The patient may experience a sense of fulness after a meal and become nauseated and restless; then hematemesis occurs in large amount, of fluid blood, bright red, or of liver color, brown, or coffee grounds, mixed with food. Patient may feel faint, extremities cold, temperature subnormal, become collapsed and, rarely, even die from hemorrhage. Con- vulsions and unconsciousness may precede death. Death from internal hemorrhage can occur without vomiting. Blood is generally passed by the stools (melena) , black and tarry in color, and may be found in cases with no vomiting or in latent cases. Convulsions from cerebral anemia, or hemiplegia from thrombosis, or amaurosis (possibly permanent) have occurred. A temporary rise of temperature may follow the collapse. Persistent temperature shows complications. The vomitus usually shows hyperchlorhydria and no mucus. Tongue is clean and red, rarely coated. Often there are remissions and exacerbations of the symptoms, and they may be protracted ; from no apparent cause a relapse may occur. With an unhealed ulcer, complications or perforation may occur at any time. In others, ulcer symptoms may disappear, but those of gastric dilatation, adhesions, etc., may follow. In the long cases, from pain and self-starvation, marked emaciation takes place; 2l8 DISEASES OF THE STOMACH AND INTESTINES the suffering shows in the patient's face, but there is not the sallow- appearance of cancer. Tetanic attacks complicating chronic ulcer have been reported by Kaufmann.^ Pain. — The epigastric pain usually occurs about the center of this region, in the median line, just below the tip of the ensiform. Occa- sionally it is more to the right or left, and Hes in a circular area of i to 2 inches in diameter. Throbbing and pulsation may be felt in the epigastrium. Pain is usually increased on pressure, rarelv lessened. It is injurious to frequently manipulate the painful area or subject it to marked pressure. Testing with the algesimeter is not advisable. In place of vomiting, some patients regurgitate acid chyme, with pyrosis, or suffer from nausea. Motor Function. — In uncomplicated cases of gastric ulcer this is increased. If pyloric stenosis or adhesions compHcate, then the function is interfered with. Examination of the Stomach Contents. — If the diagnosis of ulcer has been positively determined, it is preferable not to pass the tube. If there is no hematemesis, but vomiting is excessive, it is well to give the test meal and examine, in addition, for occult blood. Lav- age after the contents are removed is of service, as it checks emesis, and thus renders a hemorrhage less liable. If the patient states there has been a hemorrhage, but the diagnosis is in doubt, the tube should not be passed earher than ten days to two weeks after the history of hematemesis. The stool can be exam- ined at once for occult blood. If vomiting occurs, the vomitus ma^/ be examined by preference, but the quantity and quality of the food and time of ingestion would influence the analytic findings and might lead to error. Immediate examination of the vomitus and stool for occult blood is important. In about 95 per cent, of uncomplicated cases of ulcer, hyper- chlorhydria is present; the total acidity is high, from 90+ to 150 + , and free hydrochloric acid 50+ to 60 -1- or even 90 + , and there is no mucus. There are cases of subacidity, or even of achylia gastrica, with ulcer. The Absence of Hyperchlorhydria Does Not Exclude the Presence of Ulcer. — In all doubtful cases gastric analysis and examination for occult blood in the stomach contents and stool should be carried out. In some cases we must think of the possibility of development of carcinoma on the base of an ulcer, but in such event tumor growth and increasing cachexia occur. Urtne. — The quantity is reduced when there is much vomiting and food is diminished. There are no characteristic changes. Complications. — Perforation and general peritonitis; circum- scribed peritonitis ; sacculated abscess ; adhesions with other viscera, with or without perforation of them ; pyloric stenosis ; stenosis of the ' American Journal of the Medical Sciences, April, 1904. ULCER OF THE STOMACH 219 cardia; perigastritis with adhesions; subphrenic abscess; perforation of the diaphragm, pleura, lungs, pericardium or heart; hour-glass contraction of the stomach; external fistulous opening; anemia of severe type; mediastinal emphysema, and subcutaneous emphysema may occur. Stenosis of the pylorus, due to stricture or hypertrophy from spasm, produce dilatation of the stomach and its symptoms; stenosis of the cardia causes dysphagia and regurgitation of food. Perforation. — This occurs in ulcers on the anterior stomach wall, or from perforation of a circumscribed abscess, with resulting general peritonitis. The symptoms are sudden pain, at times with a tearing sensation, shock, muscular rigidity, rapid distention of the abdomen; tenderness on pressure; disappearance of liver dulness; cold sweat; rapid and feeble pulse, followed by a rise of temperature, singultus; frequently vomiting ; anxious and sunken face (f acies Hippocratica) ; usually coma; then death. Leukocytosis, especially increase in the polynuclears, is present. In perforation, with circumscribed abscess formation, the symp- toms are less intense and are localized. Perforation of the stomach occurs usually after a full meal, or following coughing, sneezing, or local mechanic violence. If adhesions form with other organs, these may be perforated. Frequency of Perforation. — Brinton gives the frequency of per- foration as I in 8 cases. Others place it at 6 to 7 per cent. In women, Brinton places one-half the perforations at the age of fourteen to thirty, the average being twenty-seven ; while in men it is distributed up to fifty, the average age being forty-two. The chances of perforation of an ulcer on the anterior stomach wall are 5 to i in its favor, on account of its mobility which prevents adhesion formation, but ulcers are much less frequent .in this location. Subphrenic abscess (pyopneumothorax subphrenicus, when gas is present). Etiology. — The chief causes are as follows : Posterior perforating ulcer of the stomach (the most frequent cause) ; traumatism of the liver; abscess of the liver; retroverted appendix; and perforation of duodenal ulcer. The boundaries of the abscess-cavity are: above, the diaphragm; below, the stomach and liver; to the left, the spleen; to the right, the suspensory ligaments of the liver. The liver is pushed down and the diaphragm upward. Symptoms. — These are abrupt when due to perforation of gastric ulcer and are as follows : severe pain ; vomiting of bilious or bloods- material; embarrassment of respiration; subsequently chills, fever, and emaciation. Leukocytosis and increased polynuclears during the suppurative period. Physical signs depend on the quantity of air in the cavity and upon the presence or absence of a complicating pleurisy. 220 DISEASBS OF THE STOMACH AND INTESTINES Physical Signs (with Little Air Present). — Dulness or flatness in the lower part of the thorax, but cough and expectoration are absent; signs of pressure in the pleural cavity are absent or slight, the thorax not being much dilated, and there being scarcely any obUteration of the intercostal spaces; the lungs are intact and distensible, and on deep inspiration there is vesicular breathing. Physical Signs (with Much Air Present). — The lower part of the thorax protrudes and respiratory movements diminish; the heart is sometimes pushed upward and slightly to the right; the liver extends well down into the abdomen, occasionally as far as the umbilicus; the liver dulness in the back and lower part of the lung is replaced by a tympanitic zone; on auscultation the respiratory sounds are absent in this zone, and there are succussion sounds of a metallic pitch. When pleurisy complicates subphrenic abscess from ulcer, there are the signs of pleurisy. Senator gives the following diagnostic points : Violent pain in the epigastric and hypochondriac region ; pain in the back on sitting up; pain on belching; patients prefer dorsal position when abscess complicates; while in pleurisy alone, they lie on the diseased side; edema of the lower lateral and posterior tho- racic walls. Pfuhl suggests a diagnostic point between subphrenic abscess and pyopneumothorax. In subphrenic abscess, if an aspirating needle be inserted and a manometer be attached, the pressure is greater on inspiration and less on expiration. In pyopneumothorax the pressure conditions are reversed. Exploratory puncture is the accurate method of diagnosis, pus and food particles being aspirated. Terminations of Subphrenic Abscess. — Perforation of the diaphragm and pleura; perforation of the lung, with expectoration of pus ; or of the pericardium. ; or of the left ventricle ; or of the colon ; rarely perforation into the general peritoneum ; or perforation of the skin, with resulting fistula. Successful operations have been performed for subdiaphragmatic abscess, notably by Carl Beck.'^ Tuberculosis may occur in asso- ciation with ulcer. Some authors describe so-called atypic forms of ulcer, taking the most prominent symptom as a basis, such as : Gastralgic. Catarrhal or vomiting. Dyspeptic or latent. Hemorrhagic. Cachectic. Per- forative form. Diagnosis. — This is easy in the typic form characterized by hematemesis, the epigastric pain circumscribe'd, and present dur- ing the digestive process, the dorsal pain, local tenderness, and vomiting. 1 Medical Record, Feb. 5, 1896. ULCER OF THE STOMACH 221 T3 C 3 u c3 -■3^3 8 S &.C o-a £frt o o P I c c s '-' o o ■ I ri"2 C/) C X" X ?. ti 1- <" -- rt c 3 O I ,^ -^ y «J fi -^-r: r3 u r; 4J ■ rt 0^ 03 tu 03 C o^ _> .s 1 tn , "O '^ J:; OJ j^ c' l«-^3-|^ 2 5 o •"•4:! W) C^-3 3 H iH ^ ■r, 03 O 13 .■3 t« S -M <^ o -a ^ o TJ > W 3 03 B -d 3 03 (A U E 03 q3 3 tn 3 r3 c; r- 3 ;q .« o 03 j; J-C 3 00 > tu cu o3 i^ Ci,.3 _ 1-1 ^-1 i- .y o3 03--' ^ tn > (L) -r C O c; tn E-d o o aj o Ji; OJ j> . - -■ ^ 3 ti^ rH S"^ .2 j_,„3a;'->^ 'hfi.>.-1 22 ? be . >^^ tn a I' ?, o 5 3 "> 3 tn ^"*: R ?s t-^ ==73 rf > Z! y > (U r- ^ Vh *-^ en CJ G^ Oh > g3 OJ dJ TJ ?i t/l TJ •^^-?5 8|.^ 13 g § c -a 3 .0 c 4^ , 3 „. -^ = ., cti q ;:i 03 OJ ",-a O .^.H (u ^ o '^ (fi -^ .ti aj G > §0 0.2 '.B c g> o a 3 aa o 1 4..O) Aq. destil. J ^■'^ ^ by a large syringe subcutaneously have proved useful adjuncts; or fluidextract of ergot or hydrastis, 5j to ij (4.0-8.0), in 2 ounces of water by rectum. Chlorid of iron and acetate of lead are objectionable. Tremoliere has recently advocated a solution as a local styptic consisting of a 5 per cent, gelatin solution containing 2 per cent. chlorid of calcium. In a severe case I should not hesitate to give at once by mouth i to 2 ounces of a 10 per cent, gelatin solution containing 5 to 10 gr. (0.3 to 0.6) of chlorid or, preferably, lactate of calcium. The drug is dissolved in a little water and added to the gelatin solution while still warm and then rapidlv cooled off on ice. The plain gelatin solution should be admmistered in every case. Lactate, or chlorid of calcium, gr. x to xv (0.66-1.0), in oiv (125 cc.) warm water can be given by enema as an adjuvant. ULCER OF THE STOMACH 225 Lactate of strontium, or lactate of magnesium, gr. xv to xxx (i.o-2.o), in oij to iij (125 cc. to 200 cc.) of sterile water, are rec- ommended by hypodermoclysis, by Maas, to increase the coagulabilit)^ of the blood, and would be valuable in gastric hemorrhage. Calcium chlorid should never be so given, as it causes local coagulation necrosis, and the lactate of calcium never stronger than i : 20 by hypodermic, and even so there is danger. Adrenalin chlorid, 1:1000, TTLx to xv (0.66-1.0), have been recommended by hypodermic for internal hemorrhage, but the pulse tension is markedly increased thereby and I have seen secondary hemorrhage result. Five drops may be given by the mouth in oij (S.o) of w^ater for the local st^^ptic effect if other remedies are insufficient. Bismuth subnitrate, oss (2.0), in i ounce of water is at times of service. Ewald recommends cautious lavage with ice-water after cocainiz- ing the pharynx (2 per cent, solution of cocain is sufficiently strong by spray) , in cases in which death seemed imminent from continuous hemorrhage. I have never found the procedure necessary, though I have treated severe cases. If it is employed, the addition of 125 cc. (oiv) of a 5 per cent, gelatin solution, gr. xv (i.o) lactate of calcium, and HIx (0.66) adrenalin to the water for lavage would be of advantage. Wiel advises lavage with hot water at 42° C, but I doubt its advisability. When all methods fail and the hemorrhage continues, opening the stomach and direct suture of the bleeding ulcer has been advocated. For Thirst.— Th^ cold gelatin given for hemorrhage helps relieve thirst. A small piece of gauze dipped in cold water and held in the mouth, frequent washing of the latter; an occasional pellet of ice and enemata of normal saline solution at 105° F., oiv to vj (125 cc. to 200 cc), if no relief by other methods, and given every three hours. Proctoclysis, the administration of saline solution per rectum by the drop method, is also useful. Gollapse.—Q.2iMt\on must be employed not to overstimulate the heart, lest the coagulum be forced out and hemorrhage recur. Only collapse that is fairly marked — a pulse 120 or over — should be treated, as depression of the pulse favors clotting. Among the valuable methods are : External application of heat to the limbs by hot- water bags; rectal injections of i pint (500 cc.) to i quart (liter) of hot normal salt solution at 1 1 5 ° to 1 20 ° F. every two to three hours, also proc- toclysis can be employed. Hypodermoclysis with normal saline solution, .ovj (375 cc.) to Oj (500 cc), given at 105° V., through a large needle attached to a fountain syringe, preferably between the iliac crest and twelfth rib, is valuable and does not stimulate too rapidly. 15 226 DISEASES OF THE STOMACH AND INTESTINES In emergency I saved one patient by employing an ordinary hypodermic needle and elevating the fountain syringe 6 to 8 feet to obtain forcible flow. In this event a higher temperature (i i8° F.) should be employed, as the fluid cools in passing through the small . needle. In one case, having no time to perform infusion, I needled a large superficial vein with a hypodermic needle^ and infused by this method. Infusion with i liter normal saline solution at 120° F. in severe cases is indicated. Direct infusion of blood from donor to patient is generally impractical and the simple method is the best. Strychnin, gr. V^ to 3V (0.00108-0.002 1), every three or four hours by hypodermic or camphor, pulv., gr. v (0.3), in sterile almond oil, ITlxx (1.184 cc). A single dose by hypodermic and repeated in three or four hours, if necessary. Bandaging the extremities and elevation of the foot of the bed are of service. Whisky or brandy, o j to ij (30.0-60.0), may be added to the enema. The rational methods for the cure of acute or chronic gastric ulcer differ widely, the chief exponents being Leube-Ziemssen and Lenhartz. General Principles. — ^There are certain general principles to which I must first refer. Absolute rest in bed for a period of two to four weeks, even though the hemorrhage may not have taken place recently, gives the best results. Cruveilhier first recommended milk in gastric ulcer as an ideal food. Pure milk coagulates rapidly with some patients and does not agree. Boiled milk does not form large curds and leaves the stomach more rapidly. Ivime-water or milk of magnesia lessens milk coagulability. lycnhartz believes that the general nutrition should be improved as rapidly as possible to hasten the healing of the ulcer, and that sufficient milk to secure this result requires so large a quantity that it would overdistend the stomach. Though given in divided doses, he states that 2 to 3 quarts per diem are excessive, and limits the total quantity of milk to i liter, adding other materials to increase the calorie value. Riegel demonstrated the capacity of egg-albumen to bind free hydrochloric acid, and also the use of sugar solutions to lessen acid secretion, such as pure dextrose or even ordinary dextrose. These possess high calorie value. Soluble dry peptonoids — oj (30.0) — have a calorie value of 120.4. They dissolve in milk or water. Milk powder (gm, 100) ; Gartner's fat milk; casein nutrose, gm. 30 to 60; somatose, oiv to vj (16.0-24.0), and notably sanatogen, 20 to 30 gm. per diem, possess nutritive qualities. Among other foods are meat jelly, prepared by boiling chicken ^Manual on Enteroclysis, Hypodermoclysis, r.nd Infusion (Kemp). ULCER OF THE STOMACH 227 or beef with calves' feet (Fleming), Leube-Rosenthal's meat solution; flour soup boiled with milk; and barley-water or rice-water to dilute the milk. Protection of the gastric mucosa and lessening hyperchlorhydria by the use of olive oil — oss to j (16.0-32.0) — t. i. d. before meals is of service. Kaufmann^ has demonstrated that the normal gastric piucus exercises a protective influence and is absent in ulcer, and that silver nitrate both aids the healing of ulcer and stimulates mucous secre- tion. Turck substantiates this by showing the increase of mycogen cells during the process of healing. Large doses of bismuth act as a protective layer to the ulcer and prevent irritation. Neutralization of the free hydrochloric acid is important. Among the most valuable alkalis are magnesia usta, milk of magnesia (Phillips), and soda bicarbonate. Magnesia preparations are also of use for the constipation. If their action becomes excessive, bismuth can be combined. At times I employ soda bicarbonate in combination with magnesia. Bicarbonate alone is apt to produce too much carbonic acid gas and distend the stomach. In cases without dilatation, Carlsbad water or the salts are of service, as they lessen gastric secretion and empty the bowels. They form a permanent feature in Leube's cure. Belladonna is valuable when there is hypersecretion, gr. -^ (0.022) of the extract or TTLio (0.6) of the tincture three times a day. Iron and arsenic are imperative to improve the condition of the blood. Alcoholic drinks, coffee and tobacco, heavy salads, hot breads, acids, pastry, etc., should be excluded during the course of treatment. If nutritive enemata are given for twenty-four hours following Leube's method, plain milk should never be emploved, but should always be peptonized. This feature is often overlooked. An enema of saline solution should be administered an hour or more before the nutritive enema in order to cleanse the bowel. The following is of service: Peptonized milk, 125 cc. (oiv) ; raw egg, or whites of 2 eggs beaten up; salt, i.oo (gr. 15) ; sanatogen, 8.0 (5ij) ; water, q. s. 250 cc. (oviij). Somatose, 5ij (8.0), or dry peptonoids, 5j (4-0), or liquid pepto- noids, oj (32.0), may be substituted for sanatogen. Four nutritive enemata should be given during the day of sixteen hours. Metzger has shown that wine in the enema increases gastric secretion. Having enunciated the general principles of treatment, I will describe the chief meAods employed and the procedures with which I have been most successful in my own experience. ^ American Journal of the Medical Sciences, Feb., 1908. 228 DISEASES OF THE) STOMACH AND INTESTINES Riegel confines himself exclusively to rectal feeding for six or eight days at the commencement of treatment following hematemesis, giving only a few pieces of ice by mouth, and then follows with a mild, non-irritating diet and the use of Carlsbad water or salts; while others confine the feeding to the rectum for two to three weeks. Good results have been reported, but as the patient is suffering from subnutrition, these methods can be improved upon. Leube-Ziemssen Rest Cure. — This is substantially as follows: The patient is kept in bed for two to three weeks, not being allowed to rise for any purpose, either for defecation or urination; rectal feeding for several days if hematemesis has just occurred ; hot poultices (flaxseed) over the stomach by day and warm Priessnitz compresses at night. Then after the first two to three days the subsequent diet for ten days should consist chiefly of milk, or milk with barley-water, strained barley, oatmeal- or rice-water, tea and a little bouillon. For the next ten days boiled calves' brain, boiled thymus, rice and sago in milk, gruels and mushes, raw and soft-boiled eggs. This is followed by a little scraped rare or raw beef. Scraped raw ham and mashed potato for a week or so are added, and finally broiled chicken, venison or roast beef, pike and shad, etc. ; coarse bread, skin, tendons, fruits, alcohol, and acids should be avoided. Carlsbad water, a glass, or 5j to ij (4.0-8.0) Carlsbad salts in Bviij (250 cc.) of water should be taken half an hour before breakfast. This can be begun after the first week or ten days. Einhorn ^ employs nutritive enemata for a day or so after hema- temesis, and then milk as the basis of his diet for the first two weeks; for the first week giving 5v (150 cc.) every hour, adding barley-water and bouillon; and gradually increasing the quantities of milk, but giving it at longer periods, adding eggs, crackers, etc., at the end of ten days, gradually increasing the diet. Lenhariz's Method. — Lenhartz^ believes that many cases of gas- tric ulcer do not definitely improve, or but very slowly, under the method of entrenched milk feeding; that the high acidity is not measurably lessened ; and that if patients are in a poor physical condition consequent upon one or more hemorrhages, often, indeed, in collapse, the "starvation treatment" — the ice and nutrient enemata and insufficient milk feeding following — not only maintain the patient in his anemic state, but may even drag him into serious inanition, and such an undermined constitution hardly favors the speedy healing of an ulcer. Frequent nutrient enemata excite the gastro-intestinal tract into peristaltic activity and may thus induce renewed bleeding ; besides, very little nutriment is, after all, obtainable. Should more milk be given by mouth, merely enough to preserve the body weight — 3 liters for an adult — would overfill the stomach ^ New York Medical Journal, Nov. 20, 1909. This author now employs raw eggs and milk from the first day. ■ 2 International Congress at Wiesbaden, 1901; Therapeutic Gazette, Nov. 16, 1906. ULCER OP THE STOMACH 229 and stretch its walls, thus pre- venting a contraction of the ulcer and again offering the danger of renewed bleeding. He advises another dietary treatment, one that will especially combat the hyperchlorhydria and reinforce the enfeebled and anemic state of the patient. The concentrated egg-albumen diet was tried. In case after case the effect proved so gratifying that this method became the routine treatment. The sour regurgitation subsides, the vomit- ing immediately ceases, the pain and distress after eating, within a few hours to a few days, dis- appear, and finally an increase in the body weight is manifest as early as the first week. Be- sides, the improvement is com- paratively rapid, so that the patient can be dismissed as cured within a briefer time than formerly. The following is the tabu- lated regimen: "Absolute rest in bed for at least four weeks. All mental excitement to be avoided. An ice-bag is placed upon the stomach and kept there almost continually for two weeks. This prevents gaseous distention and promotes contraction of the stomach walls, thus tending to obviate hemorrhage, and eases the pain when present. On the first day, even when a hematemesis has occurred, the patient receives between 200 and 300 cc. (ovj-ix) of iced milk given in spoonfuls and from 2 to 4 beaten raw eggs within the first twenty-four hours. At the same time bismuth sub- nitrate is given twice or thrice a day, 2 grams (gr. 30) per dose, and •*000000iO oo<~o O CO O COOOOO-+ oo>^ lO O i^ O 10 Tf- o O ro O ^OOOOOOro OO" "0 O t^ O lO T}- rf O ro On CDOOOO^O CO« lO O I-- O lO -^ -t- O <0 ON OoOOOOOn 0000 O .y" o O O i H,^ <^ -S S -a - ^ ^d £i s s bo bO W M S O S N -^ o ho bo w ULCER OF THE STOMACH 233 If no recent hemorrhage, I start the diet after the method cor- responding to the third day in the table on page 232. An ice-bag is kept on for two weeks if there is hemorrhage or one within a week or ten days. Bismuth subnitrate, 2.0 to 4.0 (5ss-j), is given in oij (60.0) water t. i. d. before feedings, commencing on the second day after hemorrhage. At times I combine magnesia usta, i.o (gr. 15), or sod. bicarb., i.o (gr. 15), with the bismuth. Tr. belladonna, TTLx (0.66) in a teaspoonful of water can be given t. i. d. for pain. I prefer to move the bowels gently by a small soapsuds enema containing oij (60.0) of oHve oil on the third day after hemorrhage, and thereafter every other day. If no hemorrhage has occurred recently, then a daily movement should be secured. Milk of magnesia, 5j to ij (4.0-8.0) in oiv (125.0) water given on rising, or small doses of Sprudel salts, 5j (4.0) in a glass of hot water, are of service. On the seventh day after hemorrhage, or immediately if no hemorrhage, iron and arsenic should be given: 1^. Blaud's iron pill gf- v (0.3) (made fresh) Sod. arsen gr- 3*0 (0.0013) Pill made soft with honey and crumbled when taking, one pill t. i. d. after eating. The arsenic can be gradually increased to gr. 2V (0.0026) sod. arsen. t. i. d. I give no scraped beef until the commencement of third week after hemorrhage, and then increase the diet after Leube's method. The bismuth treatment should be continued, or one can substitute the nitrate of silver treatment. It is advisable to keep this up for several months as a precaution, and then continue the diet and alka- line treatment for hyperchlorhydria for a considerable period. At the end of three weeks the patient may be allowed to sit up for a short time daily; and at the end of four weeks to begin to go outdoors for a short time. In favorable cases it is advisable not to resume work under six weeks. Some of the chronic cases either will not remain in bed or cannot, for financial reasons. In such event we are obliged to employ careful, but liberal feed- ing; the use of Carlsbad salts, iron and arsenic tonics, and either the subnitrate of bismuth treatment with an alkali in addition, or nitrate of silver. The following prescriptions are of service : I^. Bismuth subnitrate, 2.0 to 4.0 (oss-j), suspended in 4 ounces (125 cc.) of water, and given t, i. d. half an hour before meals. This is preferable to pouring the bismuth suspension through a stomach-tube. As olive oil protects the surface and lessens the secretion, I sometimes employ the bismuth suspended in oj to ij (30.0-60.0) of olive oil instead of water. Alkalis should also be used. 234 DISEASES OF" THE STOMACH AND INTESTINES I^. Magnesia usta 2.0 (gr. 30), or Milk of magnesia 4.0 to 8.0 (3i-ij) In 3 or 4 ounces (100-125 cc.) of water alone, or combined with equal quantities of soda bicarbonate. T^. Soda bicarb., Magnesia usta aa lo.o (5iiss) Milk-sugar 2.0 (3 ss) Dose, 2.0 (5ss) in water t. i. d. an hour after eating. Nitrate of silver can be employed in place of the bismuth, to be given on an empty stomach t. i. d. half an hour before meals, as advocated by Boas and Kaufmann: ^. Argenti nitratis 0.2 (gr. 3) Aq. destil 180.0 (ovj) Keep in dark bottle. Tablespoonful in wineglass of water t. i. d. half an hour before eating. Occasionally lavage of stomach v/ith i : 5000 to i : 3000 silver nitrate has been advocated once or twice a week, if there has not been a hemorrhage for some weeks; but the internal administration is safer. It should be given for two to three weeks, then discon- tinued and the bismuth substituted. The alkali can be given in addition t. i. d. an hour after meals. The meals should preferably be frequent and in smaller quantities, as in hyperchlorhydria. Tincture of belladonna, TTLx (0.66) ; or extract of belladonna, gr. \ (0.022); or atropin, gr. yg-Q (.0006), may be given t. i. d. for pain or excessive secretion. It is a valuable remedy and lessens HCl. Rarely a hypodermic of gr. \ to \ (0.016-0.032) of codein or morphin, gr. i to ^ (0.008-0.0016), may be necessary for acute pain. In cases complicated by stenosis and ectasia lavage is necessary for the fermentation, and olive oil oj to ij (30.0-60.0) t. i. d. before the chief meals, to aid the passage of food. The application of Rose's belt, and the patient lying on the right side for half an hour after eating, both temporarily aid in emptying the stomach. . Hemorrhage is rare in this type, the ulcer being dormant and the chief symptoms due to stenosis. Surgery, gastro-enterostomy espe- cially, is advocated in these cases. If tetany, the same procedure is advisable. Vomiting. — In cases described by Lenhartz, this is relieved by neutralizing the acid, and this is the best treatment. Rarel}^ rectal feeding may be required for a few days. Bismuth subnitrate, gr. 2 (0.13), and oxalate of cerium, gr. i (0.065), should be given, or i-drop doses of Fowler's solution of arsenic, four in all, an hour apart. If the vomiting continue, a single cautious lavage is a safer procedure than the risk of recurrent hemorrhage from the strain of emesis. Pain. — Rose's belt will at times aid in alleviating the pain due to the dragging of adhesions, by the support afforded to the viscera. Perforation. — Temporarily, rectal feeding, a hypodermic of BXULCERATIO SIMPLEX 235 morphin, the ice-bag, and cautious lavage after cocainizing the pharynx, as suggested by Ewald. Immediate recourse should he had to laparotomy. Surgery. — The following are the indications for operation: Perforation with commencing peritonitis; local peritonitis, with or without abscess; subphrenic abscess; perigastric adhesions; ectasia due to stenosis from ulcer or spasm from its irritation; gastric tetany with ulcer. In recurring acute hemorrhages the Mayos advise opening the stomach, locating the bleeding point, suturing it firmly with catgut on the inner (mucous) side, and protecting the region by mattress sutures (musculoperitoneal). Gastrojejunostomy they have not found reliable. In 6 cases — i case of death from hemorrhage followed gastro- jejunostomy — 5 cases treated by primary operation on the bleeding point, with or without excision of the ulcer, recovered.^ In cases of chronic ulcer, with recurrent hemorrhages, after systematic treatment for eight months to a year by the methods I have described, and if the patient is still losing ground, I advocate resort to surgery. I am av/are that some surgeons are loth to operate on such cases unless there is pyloric stenosis, and claim that in such event the gastric contents will not pass through the new opening, but through the pylorus. Cannon and Blake have demonstrated this experimentally on animals. On the other hand, when a large anastomotic opening is made, this has been shown to be of practical value, especially by the posterior no-loop method. It has been demonstrated that the pancreatic juice and bile entering the stomach aid in neutralizing the hyperacidity, and this is of service. Wm. Mayo states that in chronic ulcer, where there is no mechanic obstruction, the result has not been as favorable. Unfortunately, we do find cases of multiple ulcers with hemorrhages from various areas and with an open and soft pylorus, such as Munro^ reports, in which the results of surgery are not favorable; but in any event the lessening of hyperacidity through gastro-enterostomy is of value. In cases of pyloric obstruction (stenosis) from ulcer with dilatation of the stomach, I always advocate surgical procedure, finding that though there may be temporary improvement at times quite marked under medical treatment, in every case there is subsequent relapse. EXULCERATIO SIMPLEX (DIEULAFOY) OR SUPERFICIAL ULCER- ATION OF THE STOMACH Small ulcerations of the mucous membrane of the stomach, so minute that they appear to be little more than erosions, have been observed, from which fatal hemorrhage has taken place. 1 Journal Amer. Med. Association, Sept. 22, 1906. 2 Annals of Surgery, June, 1907. 236 DISEASES OF THE STOMACH AND INTESTINES The usual symptoms of ulcer have been absent and no vomiting occurred prior to the hemorrhage. Dieulafoy was the first to minutely describe this affection. Anatomy. — There is a superficial round or elliptic loss of sub stance, involving merely the mucous membrane and the muscularib mucosae and some blood-vessels. It does not penetrate further into the coats of the organ. The defect may be from pinhead size to a quarter of a dollar in dimension ; the margins are not indurated, and it may be difficult to detect even on autopsy, being concealed in some of the folds of the mucous membrane. The stomach is healthy throughout. There may be a slightly reddened zone about the area and it may be in any location. Etiology is unknown. It may be the beginning of an ordinary ulcer, or possibly a toxic element is responsible. Age. — Chiefly in persons from twenty-five to thirt3^ Symptoms. — The patient is in perfect health, when he suddenly vomits 0.1 {h liter) to i quart (liter) of blood, accompanied by melena. The hemorrhage may prove fatal. The symptoms are those of any hemorrhage: dizziness, cold extremities, collapse, and the patient may become rapidly moribund. Occasionally the patient may recover and suffer from recurrences. Diagnosis. — Ordinary cases of gastric ulcer suffer from gastric symptoms, while these cases do not. From latent ulcer of the stomach it cannot be differentiated. In chronic erosions there are no hemorrhages. Treatment. — This is the same as in hematemesis from ulcer, morphin, gr. \ (0.016); ice-bag over stomach; 10 per cent, gelatin solution every half hour oij (8.0) by mouth; lactate of calcium, gr. X (0.66), by mouth and by rectum; ergot injections, hypoder- moclysis (2 per cent, gelatin), also of saline solution, etc. Dieulafoy recommends operative procedure, suturing the bleeding point, if medical remedies fail or if the hemorrhages are recurrent. GASTRIC EROSIONS These are subdivided into acute erosions and chronic erosions. Acute Erosions (Hemorrhagic Erosions) These are small (2 to 4 mm.) abrasions of the mucosa of the stomach, in character usually multiple, and extend partly or through the layer. There is hemorrhage (hematemesis) with this type. The}^ occur in the newborn ; in the cachexia of children ; in chronic heart and arterial diseases ; cirrhosis of the liver ; in acute infections with the pneumococcus (Dieulafoy); and with septic organisms; also in postoperative cases, and associated with the throbbing aorta in a considerable number of neurotic women. Treatment is of hematemesis and also of the cause. gastric erosions 237 Chronic Erosions (Erosions of the Stomach) An erosion is a small superficial exfoliation of the gastric mucous membrane. Erosions of the stomach have been quite frequently found at autopsy, and the subject has been discussed by Virchow, Ewald, Gerhart, and others. The latter found nothing characteristic. Riegel notes the frequency with which small fragments of mucous membrane are washed out of the stomach, and believes it due to the tearing from this procedure. He denies its significance as a special pathologic process, but believes that at times an examination of the fragments will demonstrate the general condition of the mucous membrane. There is even to-day some dispute as to whether the erosions of the stomach can be described as a separate clinical entity, in view of the fact that in the majority of cases there is a chronic gastritis, and only on lavage the bits of mucous membrane are secured, some believing it to be due to manipulation with the tube. We must credit Einhorn^ with first describing erosions of the stomach as a clinical entity. Pariser,^ Quintard,^ Mintz,* and others have described cases. Undoubtedly, not in every case in which bits of mucous membrane are washed out of the fasting stomach have we chronic erosions. I have noted in several cases of chronic gastritis — in which unques- tionably lavage was performed in an unscientific manner by the physician in attendance — the appearance of these small fragments, and yet the patient never subsequently suffered from the salient symptoms described. Traumatism was the evident cause. Erosions may occur in acute cases. I was recently called to attend a patient with acute gastritis, having severe and persistent vomiting streaked with blood, and though I washed the stomach with greatest care, in two washings several pieces of gastric mucous membrane were found, evidently exfoliation from the acute process and violent vomiting. The case made a rapid recovery with no further symp- toms. Unrecognized cases of chronic erosions occur, but those recog- nized intravitam by the clinical symptoms are, so far reported, com- paratively few. Etiology. — Chronic catarrhal gastritis is the chief factor, though Einhorn reports erosions associated with hyperchlorhydria, and I have seen them once with acid gastritis. Symptoms. — The diagnostic symptoms described by Einhorn are: Pain, emaciation, weakness and lassitude, and the finding in the wash-water after lavage of one or more small pieces of gastric mucous 1 New York Med. Record, June 23, 1894; also Journal Am. Med. Asso., May 20, 1894. 2 Berlin klin. Wochenschr., 1900, No. 43. ^ Arch. f. Verdauungskrankheiten, 1901. * Zeitschr. f. klin. Med., Bd. 46, 1902. 238 DISEASES OF THE STOMACH AND INTESTINES membrane. There is usually decrease in acidity and free hydro- chloric acid and considerable mucus (chronic gastritis). Pains. — These are not intense and occur directly after meals, irrespective of the character of the food. They last one or two hours and are never severe. There are usually intervals free from pain, though rarely the pains are constant. Emaciation. — The patients lose weight at first; the face becomes rather thin. They have not the cachexia of cancer nor the appear- ance of suffering as in ulcer. Weakness. — The patient feels weak and unable to work, and likes keeping quiet, most markedly so for a period after meals. Loss of appetite is present in some cases. If the stomach is washed out in the fasting condition one or more small pieces of gastric mucous membrane are found in the wash- water. They appear normal under the microscope, but are infiltrated with red blood-cells. This lesion is constantly found after lavage. Blood is rarely present, though occasionally the wash-water is slightly streaked with it. Einhorn believes the "erosions" resulting from the peeling off of the mucous membrane are responsible for the pain and tenderness, and that it has not yet been determined whether the exfoliation recurs at the same place after healing or in new regions of the stomach. Gastric Analysis. — The hydrochloric acid secretion is, as a rule, decreased and also the total acidity. Considerable mucus is usually found. Rarely, hyperchlorhydria is present and in one case I found acid gastritis. In washing the fasting stomach, one to four pieces of mucous membrane (0.3 to 0.4 cm.) are found. They are blood-red and under the microscope the gastric glands and red corpuscles are visible. Prognosis. — The disease is usually of long duration, with at times intervals of improvement. Treatment. — The diet depends on the gastric findings. The treatment is the same as for chronic gastritis, acid gastritis, or for hyperchlorhA'dria, depending on the case. Hydrotherapy and out-of-door exercise are of service. If deficient hydrochloric acid, nux, comp. tinct. cinchona, and condurango are indicated; if hyperacidity, the alkaUs, such as magnesia or sodium bicarbonate. There are three methods of local treatment: 1. Bismuth Treatment. — Lavage every other day with milk of magnesia to dissolve mucus, and t. i. d. gr. ^5 to 30 (1.0-2.0) bismuth subnitrate before meals. 2. Nitrate of Silver Treatment. — This is superior in manv cases. It may be administered internally, gr. \ (0.016) in solution t. i. d. three hours after eating; lavage with an alkali every two or three days depends on the mucus; or lavage every other day with i : 2000 to 1 : 1000 silver nitrate, preceding it by lavage with warm water. • GASTRIC EROSIONS 239 Einhorn recommends intragastric galvanization on one day, with nitrate of silver spray preceded by lavage on the following day, and so alternating. He first washes the stomach with warm water, which is all removed, and then sprays the stomach with his instrument, emploving 10 cc. of a 0.1 to 0.2 per cent, solution of nitrate of silver solution, employing most of it and moving the tube about. The bottle should be opened before removal of the spray. 3. The extract of the suprarenal gland (iVrmour and Co.) has been recommended by Einhorn. He employs it in his powder-blower and applies it every other day to the stomach, gr. 3 (0.194) at a time, instead of the silver nitrate spray. Good reports are given of this method. CHAPTER XIII CANCER OF THE STOMACH (CARCINOMA VENTRIC- ULD— OTHER TUMORS OF THE STOMACH— AP- PARENT TUMORS OF THE STOMACH— FOREIGN BODIES IN THE STOMACH CANCER OF THE STOMACH (CARCINOMA VENTRICULI) Frequency. — In an analysis of 30,000 cases of cancer, W. H. Welch, of the Johns Hopkins Hospital, finds the stomach involved in 21.4 per cent., standing next in frequency to uterine cancer. Osier states there were 150 cases of carcinoma ventricuU in 8464 patients admitted to the hospital wards. Haberlin gives 41. per cent, from 1877 to 1886 in his statistics, while Brinton places it at about 25 per cent. Haberlin demonstrated that gastric cancer is on the increase in Switzerland, and Joseph D. Bryant shows the same in the United States. Its frequency seems to vary in different countries, Griesinger having never observed it in Egypt. Age. — Welch finds that three-fourths of his cases occurred between the ages of forty and seventy. Osier analyzes 150 cases as follows : Between twenty and thirty years, 6 cases; from thirty to forty, 17; forty to fifty, 38; fifty to sixty, 49; sixty to seventy, 36; seventy to eighty, 4. Fifty-eight per cent, occurred between forty and sixty, the youngest case was twenty-two. Welch's statistics show the majority of cases between forty and sixty. The maximum liability to cancer of the stomach is, therefore, between the ages of forty and sixty. Two cases of congenital carcinoma have been reported and also a few cases under the age of thirty. Sex. — Welch finds cancer of the stomach shghtly more frequent among men, 1233 men to 981 women; and Osier in 150 cases, 126 males and 24 females. Statistics vary somewhat regarding per- centages, but it seems to preponderate in males. Race. — Among 150 cases at the Johns Hopkins Hospital, there were 131 among the whites and 19 among the blacks. The ratio of colored patients to white, however, in our hospitals is small. Heredity. — Since several members of one family have been afflicted with cancer, many are inclined to believe heredity plays a part. Delafield^ and Prudden hold that "while the influence of 1 Handbook of Pathologic Anatomy and Histology. 240 CANCER OF the; STOMACH (CARCINOMA VENTRICULl) 24 1 heredity is difficult to estimate, there are a few well authenticated cases of the remarkable prevalence of malignant tumors in families within a few generations." The statistics of Williams showed that in 235 cases of carcinoma of the uterus or breast, 9 per cent, gave a history of carcinoma in the father or mother, while in nearly 20 per cent, there was evidence of carcinoma in the family ; though such statistics are suggestive and indicate that an hereditary predisposition to the development of tumor may exist, this does not account for the immediate excitement of the growth of tumors and is, as Menestrier has urged, but one of the examples of hereditary disposition which is observed in many forms of disease, such as infections, cerebral apoplexy, etc. Williams cites the fact that the father, brother, and two sisters of Napoleon died of cancer of the stomach, to which he himself succumbed. William S. Bainbridge,^ who has extensively investigated the question, believes that the hereditary acquirement of cancer requires much more study before definite conclusions can be formulated, and in this I agree. Etiology. — Traumatism has been given as a frequent cause of cancer of the stomach, but Osier reports only i case in his series. Probably attention is drawn to this part by reason of the injury, and the tumor is thus recognized more early. Cider, sour wines, mental worry, and nervous strain have been suggested as predisposing causes, but they have no influence. As the muscular fibers of the cardia and pylorus undergo frequent expansion and contraction, and are subject to more work than other portions of the stomach, Brinton believes the necessarily increased nutrition of these parts may favor glandular proliferation and be productive of a neoplasm. Some consider" chronic inflammatory disease of the mucous membrane of the stomach to be a predisposing factor in the produc- tion of carcinoma, notably the polypoid form of chronic gastritis (Menestrier). As a rule, carcinoma develops without a previous history of long-standing gastric disturbance, and I agree with Ewald and Einhorn in believing these conditions have no influence. The gastritis found with cancer is a secondary condition. The development of cancer on an ulcer scar has been clinically demon- strated by Hauser. Haberlin places about 7 per cent, of cases as occurring in this manner, while Moynihan gives 60 per cent., and William Mayo 36 per cent. Regarding the parasitic origin of cancer and its infectious nature there is much dispute. Scheurlein beheved he had discovered a bacillus, but later researches demonstrated his error. Gaylord, Park, and Adami hold to the parasitic theory, and Gaylord states that in all the organs, including the blood taken from 1 Boston Medical and Surgical Journal, June 27, 1907. 16 242 DISEASES OF THE STOMACH AND INTESTINES cases dying of cancer, certain organisms (parasites) are found. He has inoculated guinea-pigs and dogs with peritoneal fluid from a human abdominal tumor and produced adenocarcinoma in the lung and liver. Coley has secured, in a few cases, good results in the treatment of cases chiefly of sarcomata and of a few cases of carci- noma by the injection of blood-serum of horses treated by erysip- elas cocci, and I have personally seen a favorable result in i case of kidney sarcoma. Psorosperms have been found in cancer cells, but it has not yet been proved whether they are real psorosperms or dried-up and changed cells. Beard's recent theory and his suggestion of the use of trypsin in the treatment of cancer is still in the experimental stage. We must confess, so far the origin of cancer has not yet been determined, though I believe it will eventually be demonstrated to be due to some bacillus or parasite. Morbid Anatomy. — Waldeyer demonstrated that cancer of the stomach originated from the glandular structure of the mucous membrane, being an atypic proliferation of the epithelium of the glands. Beginning in the mucosa, it infiltrates the submucosa, the muscular coat, and extends to the serosa. Early in the development of the disease the lymphatic glands become enlarged, especially those of the lesser curvature. Metastatic growths may take place. The cancerous growth, especially of a certain type, may slough and form irregular ulcers. Varieties. — The most common varieties of cancer are the cylindric-celled adenocarcinoma (or epithelioma) and the encephaloid or medullary carcinoma; next in frequency is the scirrhus, and least frequent, the colloid cancer. 1. Adenocarcinoma (Cylindric-celled) or Epithelioma. — This type forms soft tumors, of firmer consistency than the medullary type, and sloughing more slowly. Microscopically, the section shows elongated tubular spaces filled with columnar epithelium, and the intervening stroma is abundant. Gradually the tubular spaces develop into cell-nests. There is frequently infiltration of the connective tissue with white blood-corpuscles. Cystic degeneration is quite common. Metastases and hemorrhage may occur. 2. Medullary Carcinoma. — This occurs in soft, spongy, f ungating masses, which involve all the coats of the stomach and usually ulcerate early. It is large and often fiat, projecting above the mucous membrane and may form villous-Hke projections, or a cauliflower- like outgrowth. It is soft and grayish or yellowish white and contains many blood-vessels and cells. Microscopically, it shows scanty stroma, enclosing alveoli containing irregular polyhedral and cyHndric cells. It is often blackish in color, due to hemorrhage (melanotic) , and has a tendency to ulcerate. Metastases are frequent. 3. Scirrhus (Fibrous) Carcinoma. — This is characterized by great hardness, due to abundance of stroma and the limited amount of CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 243 alveolar structure. The large amount of connective tissue makes the tumor very firm and compact. It cuts almost like cartilage, and on section has a yellow or grayish-white appearance. There is little tendency to ulcerate, except at a late stage superficially, and second- ary metastases are not common. It is seen quite frequently at the pylorus, there being a diffuse thickening and hardening of the wall and then a contraction, being a common cause of stenosis. The tumor may be diffuse, involving all parts of the stomach, when it may be difficult to recognize it microscopically from cirrhosis ventric- uli. It has occurred in the stomach secondary to ovarian cancer, and as a part of a diffuse carcinomatosis, with involvement of the small and large intestines. It may be combined with the medullary form. 4. Colloid Carcinoma. — This type of cancer is peculiar from the fact that it invades widely all the coats of the stomach. It spreads with great frequency to the neighboring parts, and at times causes secondary growths of the same nature in other organs. The appearance on section is distinctive, shovving large alveoli filled with translucent gelatinous colloid material. This is often present, even to the naked eye. On scraping, no cancer juice exudes, but gelatinous fragments. Various transitional forms, from one variety to another, are often found. Rarely a carcinoma consisting of squamous epithelium may extend from the esophagus into the cardia. Brinton, in analyzing 180 cases of cancer, finds the scirrhus type to be most common (72 per cent.), the medullary next in f requeue v; though other observers, notably Osier, consider the epithelioma to be most frequent. Cancer of the stomach is usually primary, though secondary growths have been reported. Cancer may also extend from the liver. Types of Growth. — Medullary and colloid cancers involve large areas of mucous membrane, growing little above the surface, being somewhat flattened, with occasional rough nodulous masses. Blood extravasations and adhesions to neighboring organs are of frequent occurrence. The scirrhus variety extends usually only over a small portion of the mucosa and may develop extensively in thickness, growing in depth and height. The latter type, however, occasionally infiltrates the entire stomach, causing a contraction of the organ (cancer atrophicans). Secondary Changes in the Mucous Membrane of the Stomach. — Hammerschlag has investigated the gastric mucosa in cases of carcinoma by examining fresh pieces of mucous membrane removed in cases of resection of the pylorus at the time of gastro-enterostomy, examining also the section of the stomach. When the hydrochloric acid secretion was intact, there were no 244 DISEASES OF THE STOMACH AND INTESTINES changes in the mucous membrane. When it was absent and lactic acid present, changes occurred, and there were found destruction of the rennet glands in certain areas and small-celled infiltration and formation of connective tissue in the gastric mucosa, also mucoid changes or cystic degeneration; in effect, a secondary atrophic gastritis. Eosinophile cells are present. Hypertrophy of the muscular fibers and connective tissue has been observed. Ewald has also noted that the entire mucosa may show the lesions of chronic gastritis. It is interesting to learn that Fenwick has demonstrated that atrophic gastritis may occur in carcinoma of the breast and uterus. Location of the Cancer. — The development of the cancer may take place in various regions of the stomach, at the pylorus or cardia or within the organ, causing variation in the symptoms according to location, and in each case necessitating a special plan of treatment. Welch's analysis of 1300 cases is as follows: Pyloric region, 791 ; lesser curvature, 148; cardia, 104; posterior wall, 68; the whole or greater part of the stomach, 61 ; multiple tumors, 45; greater curva- ture, 34; anterior wall, 38; fundus, 19. In Brinton's cases, 60 per cent, were found at the pylorus. The latter is evidently the point of selection. Wm. Mayo believes 70 per cent, involve the pyloric region, and that 60 per cent, originate in the pylorus or within 3 inches of it. Changes in the Shape of the Stomach. — If the cancer is situated at the cardia, the stomach is usually retracted and small in size, while the esophagus above the stricture is dilated. If the tumor constricts the pylorus, the stomach will be dilated. Gastroptosis of varying degree may be present by reason of the weight of the tumor dragging down the pylorus, and it may even lie down in the pelvis. Adhesions may distort the shape of the organ, and Riegel reports an hour-glass contraction of the stomach resulting from cancer. Perforation. — Perforations into other viscera, through the skiti, or into the general peritoneal cavity are rare. The aorta has been perforated. Subphrenic abscess has been produced. Perforation, however, seldom occurs. Cancerous Metastases. — In an analysis of 1574 cases by Welch, metastases occurred in the lymphatic glands in 551; in the liver, 475; in the peritoneum, omentum, and intestine, 357; in the pan- creas, 122; in the pleura and lung, 98; in the spleen, 26; in the brain and meninges, 6; in other parts, 92. The abdominal lymph-glands are usually affected, but the cervical and inguinal glands are sometimes attacked. vSecondary growths occur sometimes at the navel or in the skin in the immediate vicinity. Infection occurs either by the blood- vessels or lymph-channels. Direct extension by continuity ma}^ take place. The medullary and colloid types of carcinoma are often associated CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 245 with metastases. Sometimes numerous small cancerous deposits occur in the pleura. The microscope will differentiate them from tuberculosis, though they have occurred together. Rarely metas- tases are found in the eyes. Symptoms. — There are general symptoms and special symptoms, depending on the location of the growth. General Symptoms. — Usually a patient of middle age, fifty to sixty years, up to a short time previous — a few months or so — being in perfect health and having had no gastric symptoms, will begin to complain of slight dyspeptic disturbance, loss of appetite, and fulness, pressure, and discomfort after eating. Belching occurs, also more or less loss of sleep and loss of strength — the symptoms looking much like a mild gastritis. The tongue is usually thickly coated. The symptoms gradually become more marked. Rarely the attack begins more acutely. The feeling of discomfort gradually merges into pain. This is generally not of the severe spasmodic type of ulcer, but is continuous in character, there not being the intermis- sions of freedom as in ulcer. It may remit somewhat. The pain is at times increased by the food, but is often intense at a later period after eating than in ulcer. With the belching there is at first regurgi- tation of food, later vomiting, usually not after every meal, but once or twice a day. This is a prominent symptom when the growth causes a stenosis of the pylorus. I have had a patient at the Red Cross Hospital with car- cinoma of the greater curvature and body of the stomach, an inoper- able case who has never vomited at all, the motor function being fairly good. Later, hematemesis occurs, generally several times in succession, and the vomitus is of coffee-ground appearance and not large in quantity. The tumor usually becomes palpable at this time, though often earlier. The patient has, meanwhile, been steadih' losing weight, and this loss becomes more and more marked and anemia and cachexia are prominent. He becomes more weak and prostrated and finally dies of inanition or of complications. These general symptoms are modified by the position of the growth. A brief analysis of the symptoms is advisable. Anorexia, or loss of appetite, occurs in about 85 per cent, of the cases, and it seems, as a rule, to be progressive. There is at times a special aversion to meat. Riegel believes that in the early stages while the motor power remains undisturbed, the appetite remains good. This would seem as if toxemia were a factor. Boas reports fair or increased appetite in some cases, believing loss of appetite to be due to lack of care of the mouth and tongue. The toxemic theory of loss of appetite seems most logical. Pain. — Pain is the most constant symptom, Osier reporting it in 130 out of 150 cases, Brinton finds it in 92 per cent, of his patients, and others report a higher percentage. It usually begins at an early 246 DISEASES OF THE STOMACH AND INTESTINES date, generally in the epigastrium, but may be referred to the hypo- chondriac regions, the sternum, or sometimes extends to the shoulders or back. It may be lancinating or of a dull, gnawing, or burning character. There may be tenderness on pressure in the epigastrium. The pain does not occur in paroxysms and is not relieved by vomiting, as in ulcer. It is continuous and never entirely disappears, though it may remit. As a rule, it is less intense than in ulcer. It is not relieved at the end of gastric digestion. In some cases it may occur more markedly after eating, though it is not especially influenced thereby. In other cases there may be more of a painful dull feeling and it is not circumscribed as in ulcer. Sometimes over the region of the tumor the pain is most intense, as is the tenderness. Head believes there are areas of skin tenderness between the nipple and umbilicus in front and the fxfth to the twelfth dorsal vertebrse behind. Exacerbations of pain are caused by ulceration of the growths or by formation of adhesions. Vomiting. — It may come on early, but more usually later. Osier reports it in 128 cases out of 150; and Brinton in 87 per cent. At first it occurs at rather long inter\^als, but later may be present several times a dav. It is more frequent when the pylorus is involved, and may come on some hours after the ingestion of food, or at times on rising, when there may be mucus or undigested food in the vomitus. It may be offensive in odor or contain changed blood, micro-organisms (Boas-Oppler bacilli), and isolated yeast-cells; but rarely sarcinae, which are ynost common in benign stenosis. Vomiting can occur, even if the orifices are not involved; if the cardia is affected, then regurgitation is characteristic. Extensive involvement of the anterior or posterior wall or fundus may be present without vomiting. Hemorrhage occurred in 36 of Osier's cases out of 150; w'hile Brinton places it at 42 per cent. Riegel believes these percentages too low, as hemorrhage may be occult, or often not examined for in the vomitus or stool. The blood is occasionally ejected in sufficient quantity to be visible. It is more frequently mixed with gastric juice, food and mucus, and presents a blackish, brownish, or coffee-ground appearance; is rarely bright red. Osier finding it in 3 cases. The quantity is much less than with ulcer, though frequent small hemor- rhages may occur. Blood in the stool (melena) may accompany it. though this is rarer than in ulcer. A fatal hemorrhage seldom occurs. Loss of Weight and Cachexia. — Progressive emaciation, especially if the disease is running a rapid course or has existed for some time, is a consistent feature. In the earlv stages we may occasionally see patients who appear fairly healthy, or have little loss of weight, or at times temporary improvement may occur under treatment. Unfortunately, this is evanescent, and progressive emaciation takes place. In the later stages this is marked, as are the sallow skin CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 247 and peculiar ashy and cachetic appearance, with loss of strength proportionate to the loss of weight. The Blood. — Anemia is present in a large proportion of cases; when pyloric stenosis occurs with dilatation and insufhcient water absorption, on account of the concentration of the blood the number of red cells may not be greatly reduced. The average count in 59 of Osier's cases was 3712, 186 per cmm. Average of the hemoglobin was 44.9 per cent. Schneyer^ has shown that normal digestive leukocytosis is absent in gastric cancer, and that the number of leukocvtes during diges- tion and fasting is the same. Osier claims that only 54 per cent, gave positive reaction. Leukocytosis is present in gastric carcinoma, usually of mild de- gree, and rarely above 12,000 to 15,000. Eosinophilia is usuallv pres- ent and suggestive. We find some cases without apparent tumor, in which the blood count is so low as to be suggestive of pernicious anemia, but the absence of megaloblasts and the presence of leuko- C5rtosis speak for cancer. Tumor. — In connection with the symptoms, the presence of a tumor in the gastric region is a reliable diagnostic point. If large and superficial, it is readily detected. In Osier's 150 cases, tumor w'as detectable in 115. The methods of determination are as follows : 1. Inspection. — Position should be dorsal and the knees flexed to relax the abdomen. In some cases a protrusion can be seen in the gastric region below the ensiform or at the margin of the ribs. If there is dilatation, the lower cur\'ature of the stomach may appear as an arched line below the umbilicus, moving up and dowri during respiration. Peristaltic movements are present w'ith stenosis. With gastroptosis, the lesser curvature may be seen at times and the tumor situated thereon moving during respiration. If the tumor is at the pylorus, it mav draw the stomach downward and the pro- trusion may be seen low down in the abdomen or even at the pelvic brim. Pulsation from the aorta may be transmitted to the tumor. Intrinsic movements in the hypertrophied muscularis may cause the tumor to appear and disappear. A subcutaneous umbilical nodule can at times be observed. Inspection with the patient standing, as suggested by Knapp, should be carried out in any case, as the tumor can at times be thus more readily appreciated. Frequentlv, simple inspection gives no information. 2. Percussion. — There is dulness on percussion, or a dull tym- panitic note over the tumor, which can be differentiated from the surrounding tympanites. Auscultatory percussion for its determina- tion is described and illustrated in Chapter X, pages 75 and 76. 3. Palpation. — This is usually quite reliable. It determines the ^ Berliner klin. Wochenschr., 1894, No. 41. DISEASES OF THE STOMACH AND INTESTINES position and size of the growth, whether hard and nodular, or smooth, its respirator 3^^ motihty, and whether it is painful. It is difficult to recognize a tumor on the posterior stomach wall unless it is thin and the stomach empty. On the lesser curvature, with the stomach in the normal position, it can only be felt on forced inspiration. 4. Respiratory Motility. — Tumors of the curvatures show greater respiratory motility than those of the pylorus. When the latter is adherent to the liver, it follows the excursion of the diaphragm. Tumors are smaller to the palpating finger than they are found to be on operation. 5. Inflation. — This is of value in aiding inspection and also in determining whether the growth is connected with the stomach, if it be adherent, and in some cases the position of the tumor in the organ. Air can be employed for the purpose or, more easily, carbonic acid gas by the method already described. If the tumor lies in close contact with the liver and moves away from it during inflation, the diagnosis of tumor of the stomach is evident, and the liver and gall- bladder are excluded. If this does not occur, there may be adhesions or involve- ment of both organs. If the tumor changes its position during inflation, there are prob- ably no marked adhesions with the neigh- boring organs, an important fact in refer- ence to operative procedure. A tumor of the pylorus generally moves to the right and downward on inflation; and if held in this position by the hand will not ascend during expiration — expira- tory fixation (Minkowski). If adherent to the liver, it will move upward. Tumors of the posterior wall and lesser curvature that are palpable before inflation are frequently no longer so thereafter. With gas- troptosis, however, the tumor would be palpable, but lie higher up. A tumor of the greater curvature descends when the stomach is inflated and occupies the lowest border of the area of inflation ; it is freely movable on respiration. The position of the tumor should be marked on the abdominal wall before inflation for a basis of comparison. Inflation of the colon sometimes aids in the location of the growth. 6. Transillumination of the Stomach. — This method is of value for the early recognition of tumors, but only if they lie on the anterior surface, on the curvatures, or at the pylorus. With the circum- scribing gastrodiaphane the lesser curvature can be explored. The Fig. 127. — Composite from three patients show- ing dark areas in trans- ihuminated stomach, pro- duced by carcinomata of the curvatures and pylorus. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 249 method with fluorescent media is preferable. The tumor being opaque, appears as a dark spot projecting into, or within, the trans- illuminated area; on top, when the lesser curvature is involved; below, if the greater curvature; to the right, if the pylorus (Fig. 127). Temperature. — This is not a regular symptom, but often appears in the later stages. It occurred in 74 of Osier's 150 cases. It is of an intermittent type and rarely runs over 101° F. Chills have occasionally been associated. Fever is probably due to some inflam- matory process, or to toxic absorption from the growth. Constipation occurs in the majority of cases and is obstinate and marked; occasionally there is diarrhea, due to food decomposition or to scybalae, causing irritation of the intestinal canal, or as a ter- minal symptom due to sloughing of the cancer. Coma similar to diabetic coma may occur, and is believed to be due to acid intoxication. Thrombosis of the femoral vein is an occasional symptom. Osier reports general thrombosis of the superficial veins in one case. Edema. — Swelling of the ankles frequently occurs toward the close, ascites and general anasarca sometimes are present, and the latter may appear early. Metastases have been described. A small nodule appearing at or near the umbilicus, though rather rare, may aid in the diagnosis. Multiple neuritis is an occasional complication. Perforation is rare. Tetany is a rare complication, but has occurred with malignant stenosis of the pylorus with ectasia. Urine. — Excessive nitrogen execretion has been found in some cases, but is not constant. Dimiinution of the chlorids is quite frequent, while indicanuria is common. Glycosuria, acetonuria, and peptonuria have been described. Peptonuria indicates absorption from an ulcerated area. Neph- ritis is often present, but would be expected in advanced age. Special Symptoms Produced by the Location of the Growth. — (a) Cancer of the Cardia. — One of the first and an important svmp- tom is dysphagia. The patient finds that there is some impediment to the entrance of solid food into the stomach and assists it by drinking water. The condition gradually grows worse. Later it is impossible to take solid food at all, as it sticks in the esophagus, causing much discomfort, and is finally regurgitated, often with considerable straining or retching. Finally, most of the fluid even is returned. There are often severe pains behind the end of the sternum and burning sensations. Mucus is sometimes ejected with the food, and occasionally blood. The cervical lymph-glands are often enlarged. Bronchitis or bronchopneumonia are frequent terminal events. Physical Examination. — The stomach is of normal size or, in some cases, contracted ; the swallowing sound is occasionally absent or 250 DISEASES OF THE STOMACH AND INTESTINES heard in fifteen to twenty seconds instead of in the normal period of seven, though this is not invariably true. Examination of the esophagus, preferably with soft stomach-tubes of different sizes , should be made. The position of the stricture can be noted by marking on the tube at the teeth when resistance to its passage is first encountered, and measuring the distance from the mark to the tip of the tube. Smaller tubes are then employed, until one of sufficiently small caliber is secured to enter the stomach. In this way the degree of stenosis can be determined. Much force should never be used. In some cases it may be necessary to employ a stiff er tube of silkworm or bougies of varying sizes, of which Einhorn's divisible instrument is convenient (Fig. 128). The soft stomach-tube, with openings at the tip and side, is of value for safety; by pinching the tube before withdrawal, blood, either fresh or decomposed, of foul odor or mixed with mucus, may be found within it, which in conjunction with the other symptoms is suggestive of malignancy. Occasionally a small tumor fragment Fig. 128. — Einhorn's divisible esophageal bougie. may be removed, which should be submitted to microscopic examina- tion. With malignant stricture of the esophagus, dilatation above the point of stenosis and retention of food are associated. It also occurs in benign stricture from syphilis or from traumatism from burns by acids or alkalis or with congenital stenosis of the esophagus, a rare condition. After the ingestion of suspended bismuth, examination with the x-rays and the fluoroscope will aid in determining the site of the stricture. This is of special value when it is not desirable to use the bougie. Aspiration of the esophagus above the seat of stricture after a small test meal, and then the passage of a smaller tube and aspiration of the stomach contents, and a differential examination of the contents are not necessary for diagnosis, though they have been recommended. The food removed from the esophagus would present the appear- ance as when swallowed, and there would be no hydrochloric acid ; while in the stomach the particles would be finer, the reaction acid, CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 25 1 and free hydrochloric acid might or might not be present. This is also true of the ferments. It has been demonstrated by Moore and Friedenwald^ that in cancer of other organs than the stomach, there may be diminution or absence of free hydrochloric acid in the gastric contents, and this occurs at times in cancer of the cardia. The presence of stricture and dysphagia , the age of the patient, and the general symptoms are diagnostic. With diverticula of the esophagus, which usually occur at the junction of the pharynx and gullet, there is generally a swelling in the neck, which can be diminished by pressure (the contents expressed), and symptoms of cancer are absent. Spasm of the esophagus usually occurs in nervous patients, and the tube when passed is temporarily arrested. Larger tubes often pass more readily than the small ones. There are no symptoms of malignancy. (b) Cancer of the Pylorus. — The chief subjective symptoms are pain, a full feeling in the stomach and other dyspeptic symptoms, and frequent attacks of vomiting. Just before emesis there are often severe exacerbations of pain, due to the contractions of the stomach and the effort to expel the contents through the pylorus. The vomitus is generally large in amount (i to 2 liters) and may consist of food taken the day before. Motor insufRciency is marked, the contents on aspiration being found to consist of more or less decomposed food, when the fasting stomach is examined. The particles of food are often quite large and obstruct the openings of the tube, and are difficult to remove by lavage. Physical Examination. — Peristaltic unrest is a frequent symptom. Dilatation of the stomach is present, as determined by the methods of examination described. Gastroptosis may be present. Fre- quently a tumor can be detected lying in the epigastrium to the right of the median line or, if ptosis is present, at a lower level. (c) Cancer of the Body of the Stomach. — -Pain, anorexia, and other symptoms are manifested. Vomiting occurs in some, but in many cases is absent. The vomitus contains food and occasionally coffee- grounds, the food is more fmelv divided. The tumor frequently lies to the left of the median line; but if on the upper curvature or posterior surface of the stomach, is not always detectable. There is motor insufficiency of a slight or moderate degree due to infiltration of the muscular tissue bv the growth, and occasionally, if the tumor be large and on the greater curvature, a slight dilatation. Laboratory Diagnosis. — In conjunction with cUnical symptoms, analysis of the gastric contents and microscopic examination aid in establishing the diagnosis of cancer of the stomach. Gastric Contents. — Golding Bird, in 1842, first refers to the diminution or absence of hydrochloric acid in gastric cancer, but ^New York Medical Journal, August 24, 1907. 252 DISEASES OF THE STOMACH AND INTESTINES Von der Velden, in 1879, first studied the question in a scientific manner. For accuracy the vomitus should be examined; analysis of the gastric contents and microscopic examination, after the test break- fast, should be made and the stomach washed out. If small frag- ments of mucosa are found, these should be examined, as suggested by Hemmeter and Einhorn. Vomitus. — Macroscopically, undigested meat-fibers and coarse food particles are found; the quantity is variable, depending upon the motor functions. Coffee-ground material is present in many cases and often a foul odor in advanced cases. Fig. 129. — Gastric contents in carcinoma. Dark ground illumination X 460: a, Leukocyte; b, Boas-Oppler bacilli; c, squamous epithelium; d, yeast; e, mucous membrane fragment with carcinomatous cells as rarely found in wash-water; /, bacilli; g, wheat starch grain; h, sarcinae (very rare); i, fat-droplet; ;, cocci. Microscopically, undigested muscle-fibers, remnants of vegetable material, starch granules, fat droplets, numerous fungi; sarcincB are rare; yeast-celis are found in stagnating contents, though usually as isolated specimens; and blood and Boas-Oppler bacilli (Fig. 129). Boas and Strauss report pus^ in some cases. Occult blood should be tested for by Weber's or the benzidin or aloin test, if none appear microscopically. Examination of Test Breakfast. — Ewald's or Boas' test breakfast should be given, and one hour later the contents aspirated and examined. Repeated analyses should be made. I. Hydrochloric Acid. — Out of 94 of Osier's cases of gastric cancer, in 84 free hydrochloric acid was absent; and in 40 cases, 1 Pus may be found in benign ulceration, as in Connor's case, as well as in malignant ulcer. CANCER OF THE STOMACH (CARCINOMA VENTRICULI) 253 Boas found it absent in 35. In the first stages of gastric carcinoma, however, free HCl is diminished, not absent. A progressive dimi- nution in the percentage of free HCl during the course of a month or more, as determined by frequent examinations, when taken in con- sideration with the other symptoms, is corroborative of cancer. Einhorn reports 6 cases of gastric cancer in which free hydrochloric acid was present in normal or excessive quantity. In gastric cancer, engrafted on gastric ulcer, free HCl (or hyper- chlorhydria) has been noted in the earlier stages, often with pro- gressive diminution accompanying the increased development of the cancer. I have seen hyperchlorhydria persist in quite an advanced stage, notably in a case at the Red Cross Hospital, which was deemed inoperable. The patient, aged sixty-eight, suffered with the symp- toms of gastric ulcer for a year, fall- ing off in weight from 240 to 200 lbs. There was then a slight gain. Later he lost steadily, and when admitted to the hospital weighed 149 lbs., was extremely weak and cachectic, with a tumor on the anterior surface of the stomach, involving the greater curvature, and with the clinical symp- toms of carcinoma, except the gastric findings, which were hyperacid, with a total acidity of 90 + , free hydro- chloric acid 70 -1- . The position of the growth is shown in Fig. 130. There was only slight disturbance of motor function and no vomiting. Anemia, leukocytosis, and eosinophilia were present. The patient gained 20 lbs. in weight under trypsin treatment and proper diet, and was able to go out daily. His strength markedly improved, as well as his appearance. The growth did not disappear. The patient returned to work and at the end of several months con- tracted pneumonia and died. We know that free hydrochloric acid is markedly diminislied, or even absent, in severe catarrhal gastritis, and is absent in achylia gastrica. Its absence is not pathognomonic to cancer, but taken in conjunction with the clinical symptoms is confirmatory. 2. Lactic Acid. — It has been known for some years that organic acids were increased in cancer of the stomach and lactic acid was present; but to Boas must be given the credit of attaching diagnostic significance to it and who first described exact quantitative and qualitative methods. Fig. 130. — Irregular type of carcinoma under trypsin treat- ment at Red Cross Hospital. Carcinoma of stomach, anterior wall involving greater curvature; slight reduction, of motor func- tion. Tumor evident by palpa- tion, percussion, and gastro- diaphany. History of ulcer with carcinoma engrafted. Hyper- chlorhydria present. 254 DISEASES OF THE STOMACH AND INTESTINES He washes the stomach and gives a plate of barley soup, which contains no lactic acid, and an hour later aspirates the contents. Lactic acid should be examined for by Uffelmann's test or by Boas' method. Ewald's test breakfast will generally suffice for practical purposes. In most cases lactic acid is present in considerable quantity, though occasionally it is absent when free hydrochloric acid is in evidence. In non-malignant stenosis with dilatation it has been found, so it cannot be said to be absolutely pathognomonic. The absence of free hydrochloric acid and the presence of lactic acid are confirmatory, in conjunction with other symptoms. Boas-Oppler bacilli are found. These are rods of considerable length, frequentlv joined at their ends, and form long angulated threads, stain- able by methvlene-blue or other ani- line dyes (Fig. 131)- They must be distinguished from the Leptothrix buccalis (found in the mouth). A drop or two of Gram's solution should be added to the specimen. The Boas-Oppler stains brown with the iodin, the leptothrix blue. Gram's solution consists of iodin, I part; potassium iodid, 2 parts; water, 300 parts. The Boas-Oppler bacillus is found in about 80 per cent, of cases of car- cinoma of the stomach; also rarely in non-malignant stenosis with dilatation of the organ. With absence of HCl, an alkaline medium, and absence of stagna- tion, Paul Cohnheim also holds that the trichomonas hominis, megas- toma entericum, with associated amebae, pus, and blood, are found in carcinoma of the stomach, not affecting its motility (page 117). Pus. — The detection of pus in the gastric contents by micro- scopic examination is of diagnostic value. The presence of blood, or occult blood, is also important before the tumor is palpable. Diagnosis. — -In a patient of forty-five to sixty or more years of age, suffering from recent gastric disturbances of six months' or a year's duration, or less, with a previous history of good health; there being continuous pain, frequently epigastric rigidity,^ rapid loss of weight and strength, anorexia with or without vomiting, motor insuf- ficiencv moderate, or great with marked ectasia, with diminution or absence of free hydrochloric acid, lactic acid present; Boas-Oppler bacilli present ; whether or not there be tumor detectable, or whether or not coffee-grounds are present in the vomitus, such symptoms ' Anders, N. Y. Med. Jour., Nov. 21, 1908. Fig. 131. — Boas-Oppler bacillus from near top of fluid from wash- ing in case of gastric cancer. Ob- servation at Pennsylvania Hos- pital (Boston). CANCER OF THE STOMACH (CARCINOMA VENTRICULi) 255 should be considered diagnostic of carcinoma of the stomach.^ As already noted the presence of pus and occult blood are important. Rontgen Rays. — Anders- and Pfahler ^ hold that the :r-rays aid in the early diagnosis of gastric carcinoma. The new growth makes itself evident by a change in the contour of the stomach wall ; by disturbance of the peristaltic waves at certain points; at times by rigidity and contraction of the stomach wall; by adhesions which prevent the free motility of the stomach when the abdominal walls are contracted, or when the position of the patient is changed; and finally, in some cases, by obstruction to the passage of food. The method requires great care even by an expert, and may be an aid later in connection with the clinical symptoms and phvsical and clin- ical examination. Differential Diagnosis. — Apparent Tumors of the Stomach. — Prolapse of the left lobe of the liver, or a pulsating aorta, or thickening of part of the abdominal muscles (recti) are referred to by Einhorn as being mistaken for a tumor or possibly for a carcinoma of the stomach. In view of the fact that with these conditions gastrop- tosis is usually associated, the history is a long one, emaciation is of long duration, and the symptoms of cancer are absent, the mistake can hardly occur. They are also apt to be present in younger patients. Simple adhesions of the stom.ach give a history most fre- quently of gall-bladder disease, or gastric ulcer, or localized peri- tonitis. Adhesions are frequently present with cancer, but the symptoms and gastric findings are of carcinoma. Grave Anemia in Carcinoma Ventriculi, without Palpable Tumor. — These cases must be differentiated from pernicious anemia. The type occurs with mild dyspeptic symptoms. The blood-count is rarely below 2,000,000 per cubic millimeter; there is absence of megaloblasts and leukocytosis is present, which speak for cancer. There is a lower color-index, as in secondary anemia. In addition, the acidity of the gastric contents is higher than \vith the achylia gastrica of pernicious anemia, and lactic acid is present in cancerous anemia. If, therefore, we have gastric symptoms, rapid loss of weight, and severe anemic s3^mptoms in an elderly patient, the diagnosis of cancer is most probable. In secondary anemia or chlorosis, hyperchlorhydria is usually associated. Syphilis. — This may present symptoms which may simulate carcinoma of the stomach, unless thorough examination be made. I have seen three types of this class. I. Sclerosis of the Stomach. — A male patient, aged sixty, had lost 30 lbs. in weight within a period of a year; was emaciated and weak, ^ Neusser and R. Schmidt hold that Boas-Oppler bacilli are more easily found in the stool than in the gastric contents and aid early diagnosis of cancer. Gram negative stools exclude cancer of the stomach; Gram ])ositive stools, uniform sized Gram positive bacilli (Boas-Op])ler bacilli), show cancer (Journal Am. Med. Assoc, Nov. 6, 1909, p. 1525, by P. K. Brown). I believe the Bacillus aerogenes capsulatus are found, and their deductions probably erroneous. ^ New York. Med. Jour., Nov. 21, 1908. ^ Ibid., Aug. 21, 1909. 256 DISEASES OF THE STOMACH AND INTESTINES suffering from gastric symptoms and constipation. On examination, a small hard mass is found in the epigastrium at the left border of the ribs (Fig. 132). It was demonstrated to be a hard and contracted stomach, giving the feel of a diffuse scirrhous carcinoma of the organ. The liver was diminished in size and hard. Free HCl were absent, the findings were of achylia gastrica. Syphilitic scars were in evidence and the patient acknowledged syphilis ^ and alcoholism. 2. Cirrhosis of the Liver {Left Lobe — Syphilitic). — ]\Iale, aged fifty-five, had lost 20 lbs. in a few mouths and suffered from gastric symptoms. A hard mass could be felt in the epigastrium, extending down from the lower border of the left ribs, apparentlv a tumor of Fig. 132. — Syphilitic sclerosis of stomach. Physical examination of stomach suggests scirrhous carcinoma (diffuse) of stomach. Fig- 133- — Syphilis. Enlargement of left lobe of liver overlapping stom- ach. Transillumination shows mass, which is readily palpable. Side view (gastrodiaphany) shows the mass not connected with the stomach. Free HCl trace; chronic gastritis. the lesser curvature of the stomach involving the anterior wall. Respiratory movements were present. Deep palpation elicited a free edge and gastrodiaphany showed an opaque mass, but on moving the instrument a lateral view demonstrated the mass over- lapping the stomach (Fig. 133). Gastric findings were a trace of HCl and much mucus (chronic gastritis). Syphilitic scars and history were elicited. Improvement followed treatment directed to the stomach and syphilis. 3. Syphilitic Stenosis of the Pylorus, Due to Gummatous Tnmor, Simulating Malignancy. — ]\Iale patient, aged thirty-eight. Weight, September, 1907, 196 lbs. At this time, anorexia, pain continuous in character, nausea, and occasional vomiting began. These symp- toms gradually grew worse and the patient steadily lost weight. Early in November he entered a local hospital, where he was under ^ The demonstration of Wassermann's reaction is diagnostic in doubtful cases. CAN'CER OF THE STOMACH (CARCIXOMA VENTRICULl) 257 tufttrof/iot' f^aJpable- /lor visible by , TratiSiflinnitiat/on treatment by lavage, etc., for eight weeks. His weight on leaving the institution was 137 lbs. He spent two months at a western sanitarium, where he grew steadily worse, having vomited small quantities of blood on several occasions. He was given morphin for pain and subsequently contracted the habit. At the end of March, 1908, or about six and a half months after the first appearance of symptoms, he entered the Red Cross Hospital. His weight w^as 119 lbs. a loss of 77 lbs., epigastric pain nearly continuous, increased some after eating, tenderness in the epigastrium, peristaltic unrest of the stomach, dilatation to one finger below umbilicus, daily vomiting. There were marked emaciation and considerable anemia, but not the cachectic appearance of cancer. No tumor was detectable by palpation or transillumination, but a sense of resistance at the pylorus. Frequent gastric analysis invaria- bty showed free HCl absent and abundant lactic acid. Morphin w^as shut off, and lavage, diet, and careful obser\'ations w^ere carried out. A syphilitic history w as secured. On account of the age of the patient, the syphilitic his- tory and the absence of true cachexia, in spite of the gastric findings, I believed the stenosis to be non-maUgnant (syphilitic) and advised operation. This was duly performed. There was a hard mass on the posterior wall of the p^'lorus, about the size of an English walnut, block- ing the passage; no glandular involvem.ent (Fig. 134). As the patient was in poor condition, rapid gastro-enterostomy was performed. He vomited once after operation. Mercurial in- unction a.nd iodids were given, and the patient left the hospital in good condition. He would unquestionably have died from inanition unless stomach drainage had been instituted, in spite of specific treatment. Cancer Engrafted on an Ulcer. — This condition I believe is a quite frequent occurrence. There is generally a gradual change in the symptoms and character of the gastric secretion, a gradual dimi- nution of free HCl, though Riegel has brought to our attention that in this type the excessive production of hydrochloric acid often per- sists for a long time, and in some rapidly fatal cases may be present ^tntil death. In these cases the diet and medication directed to the ulcer fail 17 Fig. 134. — Syphilitic stenosis of pylorus due to gumma simulating malignancy. Transillumination shows dilatation, but no tumor. Growth found at operation lying on posterior wall of pylorus. Gas- tric findings of carcinoma, but no ca- chexia. 258 DISEASES OF THE STOMACH AND INTESTINES faJ^ble Tumor - as soon as the malignant condition sets in. The pain increases and is continuous. There is a dislike or even loathing for food. There is rapid loss of weight and the typical cachexia appears — a change from the facies of ulcer. Hematemesis is more frequent, especially as occult hemorrhage. This type should be considered in order to avoid error. I have already referred to a patient of this class (hyperchlorhydria) , with a marked growth, cancer engrafted on an ulcer. Aneurism of the Celiac Axis Simulating Carcinoma of the Pylorus. — The possibility of this error is interesting. A negro patient, aged forty-five, was seen by me at Roosevelt Hospital several years ago at the request of William H. Thomson. The illustration (Fig. 135) shows the position of the stomach by inflation and that of the mass by palpation, it not being visible by transillumination. The tumor disappeared on inflation, diagnostic of a posterior position. There were vomiting, gastric symptoms, such as pain, anorexia, etc. , and a loss of weight of 40 lbs. in three months. The patient was very weak. Dilatation to below the umbilicus. Gastric analysis; no free hydrochloric acid; lactic acid was present. A palpable tumor, the size of a small egg, was present in the epigastrium, in which there was slight pulsation, but no bruit or thrill. From the history and results of examination it seemed to be a carcinoma on the posterior wall, involving the pylorus, with pulsation transmitted from the aorta. The possibility of aneurism was considered. Exploration by G. Brewer showed an aneurism of the celiac axis pressing on the pylorus posteriorly. The resulting occlusion of the pylorus and circulatory disturbances from the aneurism were responsible for the ectasia and changes in the gastric secretion. Syphilis and aneurism must thus be considered in our differential diagnosis. The following are the chief diagnostic points between cancer of the stomach and other conditions: Cancer. — Age, usually forty to seventy; tongue coated; symptoms progressive and of short duration — a few months to a year; emacia- tion rapid; cachexia; repeated small hemorrhages, but not always; pain continuous, not paroxysmal, with no periods of relief, and not referring especially to the digestion period ; anorexia ; vomiting once Fig. 135. — Aneurism of celiac axis with symptoms simiulating carcinoma of pylorus. No tumor visible by trans- illumination. Tumor disappears on inflation. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 259 or twice a day; later, coffee-grounds in vomitus; at times only occult blood in vomitus or stool ; ectasia if the pylorus is involved ; tender- ness over the gastric region; no relief of pain by vomiting; anemia; free HCl diminished or absent; lactic acid present, also pus; sarcinse rare and when present, few; Boas-Oppler bacilli in most cases; in some vomiting of blood (coffee-grounds), small in quantity and often repeated several times; melena slight. Leukocytosis moderate and eosinophilia present. Mucus present in some cases. Dysphagia and regurgitation if involvement is at cardia. Ulcer. — Age usually twenty to forty; pain paroxysmal and worse after eating; remissions of pain, and relieved by vomiting; pain in epigastrium and in the back; local circumscribed tenderness in the epigastrium increased by pressure, at times slight tender point in the back; loss of weight; anxious expression of suffering; no cachexia; anemia; vomiting at height of digestion; appetite good; hyper- chlorhydria usual; vomiting of blood in large quantity, at times of bright color ; melena. Blood at times only occult. Benign Stenosis. — Dilatation of stomach; peristaltic unrest and pain (spasmodic) preceding vomiting; long history; periods of improvement; hyperacidity usual; sarcinae present in number; emaciation but no cachexia; vomiting of large amount; usually no tumor, and if present very small and smooth on palpation; history of previous ulcer; usually no blood, as ulcer is practically healed or contracting; anemia present; no leukoc>i;osis. Malignant Stenosis. — Dilatation of stomach; peristaltic unrest; short history; no period of improvement; rapid loss of weight; pain continuous ; cachexia ; little or no free hydrochloric acid ; lactic acid ; Boas-Oppler bacilli; vomiting large amount and often odorous; at times coffee-grounds in vomit from ulceration of growth; anemia marked; leukocytosis. Chronic Gastritis. — Long history of dyspepsia ; absence of cachexia ; no lactic acid; less anemia; no leukocytosis; intense pain absent, more feeling of discomfort; no real pain on palpation; mucus in gastric contents, HCl diminished or absent. Achylia Gastrica. — Total acidity much lower than in cancer, from 4-f to 2-f or less; free hydrochloric acid, pepsin and rennet absent; no mucus ; scarcely any gastric juice ; food particles coarse and nearly dry; course long; no cachexia; no lactic acid; may be considerable loss of weight. In transitional stage (commencing) some claim mucus is present. Nervous Gastralgia. — Patient nervous or hysteric; pain irregular or relieved by pressure; free intervals from pain; appetite variable; no regularity of vomiting; secretory function is variable; no tumor; no cachexia ; character of food makes little difference as to symptoms. Carcinoma of the gall-bladder is found in location of gall-bladder; follows respiratory movements of the liver ; shows no lateral motility and does not allow expiratory fixation. Its position is unchanged 26o DISEASES OF THE STOMACH AND INTESTINES if the stomach is inflated with air. It rarely causes dilatation of the stomach unless adhesions form; and dyspeptic disturbances are not marked as a rule. Jaundice may be present. Head's zone. Enlarged lymph-glands can hardly be mistaken, as there is the absence of gastric symptoms; no gastric findings, as in carcinoma of the stomach ; and inflation of the latter organ enables a differentiation. Growths of the peritoneum or mesentery are more diffuse and rareh' movable on respiration, and gastric inflation and the symp- toms enable one to differentiate. Exudates or adhesions give none of the symptoms or gastric findings of carcinoma. Duration of Carcinoma of the Stomach. — Osier reports 15 cases with fatalit}^ under three months; 45, under a year; 4 cases tAvo years or over ; i case, two and a half years. The general average is about a 3'ear to a year and a half. Cases involving the cardia or the pylorus are more rapid, as subnitrition occurs more quickly. The medullary type is more quickly fatal. Complications shorten the disease. It is interesting to learn, however, that some cases of inoperable carcinoma of the stomach improve greatly after palliative gastro- enterostomy. Eleven such cases have been collected from Czernys' ^ clinic, in which the patients were well from two to fourteen years later. Prognosis. — This has been considered fatal, though recent results are more favorable. Surgery has relieved conditions tem- porarily and prolonged life, while medical treatment has failed, though it has helped to alleviate suffering. Kocher has reported i case in which the patient was in good health five and a half years after resection of the pylorus for car- cinoma; and Wolfler i in which the patient was well for five years when a metastasis occurred. Recently a few isolated cases of apparent cure have been reported. In an analysis of the results of operative treatment of gastric cancer at Braun's Clinic at Gottingen, Creite" refers to i case in which fourteen years after resection of the pylorus for carcinoma the patient was in perfect health. Recently more favorable results have been reported. Leriche^ has collected records of 89 patients on whom gastrectomy was performed, found in good health three years after operation; and of these, 34 no less than five to ten years after operation. Out of 79 cases treated by gastrectomy, Patterson* collected 33 (41.6 per cent.) who were free from recurrence three years or more after operation. 1 Wells, "Resistance to Cancer," Jour. Amer. Med. Assoc, May 29, 1909. 2 Journal American Medical Association, Aug. 24, 1907, p. 723. 3 Revue de Medecin, Jan., 1907. * International Medical Annual, p. 537, 190S. CANCER OF THE STOMACH (CARCINOMA VENTRICULi) 26 1 Deaver shows that we may expect 10 to 15 per cent, to be cured by radical operation. According to Kausch/ Makkas traced 92 of MikuHcz's patients operated on before 1902, and found 17, or 14.3 per cent., well more than three years after operation. Further statistics are unnecessary. The radical operation, gastrectomy, evidently affords results in some cases. Schlatter reported in 1897 the first successful case of total extirpa- tion of the stomach, with survival of the patient for a considerable period. Bernays, of St. Louis, and others have reported the survival of cases for some time after operation. The operation has been generally abandoned and we find that the so-called gastrectomies are generally not complete removal. Treatment. — There are two methods of treatment, surgical and medical, of which the only hope of cure lies in the former, medical treatment being only justifiable if the case is inoperable or refuses operation or as an adjunct to palliative operation. Surgery. — Before referring to the radical or palliative methods in surgery, I desire to call to my readers' attention the necessity of the education, not so much of the patient who will generally consent, if the matter is placed fairly before him, but of the physician and the specialist in gastric diseases, as to the value of early exploratory laparotomy for the purpose of diagnosis. William Mayo^ justly remarks that in an early exploratory incision we have the one diagnostic resource which is reliable and which must be resorted to in a large majority of cases before a surgical diagnosis can be made, and without it the truth is but slowly established at the expense of progressive hopeless involvement. It can be safely accomplished through a small incision. He further calls to our attention that the chemic findings of the gastric secretion gain in diagnostic importance with the progress of the disease and become of the greatest value when the patient is in a hopeless condition and that exploration should not be delayed by reason of the inconclusive nature of the results. He has further demonstrated that about 60 per cent, of cases of cancer begin in the pylorus and 70 per cent, in the pyloric region, and that the early diagnosis of cancer depends in a great measure upon the introduction of the mechanic phenomena from obstruction at the pylorus. It is the interference with gastric motility which first calls the patient's attention to his trouble and not the presence of the cancer itself. Moreover, a case with marked symptoms of cancer of the stomach, but without any evidence of pyloric obstruction, proves on exploration to be the victim of advanced and hopeless disease of the body of the organ, in which there were no symptoms during the operable period. The presence of a tumor does not demonstrate inoperability, as a small movable ' International Medical Annual, p. 5,^7, 1908. 2 Annals of Surgery, March, 1904. 262 DISEASES OF THE STOMACH AND INTESTINES tumor in the p3'loric region may be a favorable indication. Limita- tion to the pyloric end and mobility are the important factors, also the degree of lymphatic infection. Pyloric Stenosis is a Surgical Disease Whether it is Benign or Malignant. — It seems, therefore, especially sound doctrine in all cases with s^^mptoms pointing to pyloric stenosis, in patients of forty years of age or over, to perform exploratory laparotomy to settle the type of stenosis and immediately further operation of Fig. 136. — The lymphatics of the stomach (Moynihan, after Cuneo). greater or lesser extent, the character depending on the cause of obstruction. In elderly persons, previously in good health, with gastric symp- toms and rapidly developing emaciation, after frequent examinations both of the patient and gastric contents for several weeks, even if no definite results are secured by analysis and no tumor be detectable, exploratory laparotomy is indicated. vSome patients, of course, will not consent to any operation until even palhative operative procedure is too late. I have seen a number of abdomens opened and immediately closed as inoperable, in one case notably the entire stomach wall being CANCER OF THE STOMACH (CARCINOMA VENTRICULl) ?63 infiltrated. If the medical profession would recognize the value of exploratory incision, I believe many lives could be saved. Radical Operation. — Billroth, in 1878, was the first to prove the possibihty of resection of the pylorus for cancer, but it has been clearly demonstrated that this operation is insufficient. Mikulicz has pointed out that on the lesser curvature the blood and lymph- vessels He in the wall of the stomach itself, and that it is necessary Fig. 137. — W. J. Mayo's method of partial gastrectomy for cancer of the stomach. Ligation of gastrohepatic omentum and superior \'essels in such manner as to leave all the lymph-nodes attached to the part of the stomach to be excised; also lines of division of duodenum and stomach: a, Mikulicz-Hartniann line (Fow- ler). in every case of pyloric cancer to remove all the lesser curA^ature to the gastric artery. Cuneo has demonstrated that there are but few lymph-glands along the greater curvature and that these are con- fined to the pyloric region. The illustrations (Figs. 136-138) demonstrate the glandular relations, the correct line of incision, and the completed operation. In all cases of pyloric cancer a partial gastrectomv should be per- formed. If cancerous metastases or luarked adhesions are present, 264 DISEASES OF THE STOMACH AND INTESTINES radical operation is contra-indicated; as it is in the case of extreme debility or old age. Mayo's latest statistics show 11.45 P^r cent, mortality, and Deaver's 11. 11 per cent. The latter has tabulated 393 cases by various operators with an average 26.5 per cent, fatality. Palliative Operation. — This should be performed when radical operation cannot be carried out, to prevent death from starv'ation Fig. 138. -W. J. Mayo's method of partial gastrectomy for cancer of the stom- ach. Operation completed (Fowler). and to remove the irritating effect of food with the resulting pain. The operations are: (a) Gastrostomy is the formation of a fistulous opening into the stomach; indicated in cancerous stenosis of the cardia, with rapid loss of weight and severe pain. (b) Gastro-enterostomy is an anastomosis between the stomach and small intestine, in cancer of the pylorus with stenosis ; for similar reasons. These operations prolong life and give the patient considerable comfort, and there is often temporary increase in weight. They are less severe than the radical operations and are only contra-indicated CANCER OF THE STOMACH (CARCINOMA VENTRICULI) 265 in extreme debility or great age, with the patient in such condition that fatahty would be assured. Gastrostomy can be performed under cocain (local) anesthesia if necessary. I have already referred to the fact that in 1 1 of Czerny's cases the patients were living from three to fourteen years after gastro-enterostomy. Medical Treatment. — Diet. — The first important feature is the endeavor to relieve the condition of subnutrition and to give the patient food which he will most easily assimilate. If there is stric- ture of the pylorus or esophagus, it will necessitate the use of liquid food entirely, or mushes in addition, if there is less severe obstruction. If the cancer involve the body of the stomach alone, food of more solid character can be taken, as the motor functions are not as greatly interfered with. In the dietary we include milk, kumyss, matzoon, bacillac, farinaceous food; soups, with finely divided vegetables, such as pea, bean, and potato; broths, gruels, bouillon; raw or soft-boiled eggs; butter in plenty, tea, weak coffee, and cream; crackers softened in water and milk-toast. In some cases, chicken, squab, scraped meat, sweetbread, stale bread, oysters, fish, etc. Sanatogen (flavored) given in oij (8.0) doses up to I ounce a day; somatose, Wyeth's beef-juice, Mosquera's beef- jelly, soluble beef peptonoids, Armour's extract of beef, tropon, and rare beef -juice are all of value. I have employed as many as 8 raw eggs a day beaten up in milk, in addition to other foods. They possess great nutritive value. Russell's emulsion of mixed fats is of service. Food should be ad- ministered in divided small meals, four to eight a day. The calorie value can be estimated, but the chief criterion is their digestibility and the increase in the patient's weight, which should be carefully recorded. Temporar}^ increase in weight can often be secured. X-rays. — There have been various claims made for the value of the x-ray in the treatment of internal cancer, such as of the stomach or intestines, that it diminishes the size of the growth and relieves pain. I have seen cases in which the pain seemed to be somewhat relieved, but never any permanent results. In the treatment of skin cancer definite or even curative results have been secured. Beck's eventration treatment with employment of the .r-rays is described at the end of the chapter. Incidentally Morton has recommended the use of fluorescent media internally in connection with the x-rays, but Henry Piffard and S. Tousey have conclusively exploded his theory and shown that fluorescence does not occur. Direct light rays are necessary. The first researches with the internal administration and dosage of fluorescein were reported by me in connection with gastrodiaphany.^ Radium. — The radium treatment for cancer of the stomach and esophagus was first introduced by Einhorn.^ He employs for the 1 Medical News, April 10, 1904. 2 Medical Record, March 5, 1904. 266 DISEASES OF THE STOMACH AND INTESTINES stomach a hard-rubber capsule that can be unscrewed and which contains a glass radium flask (Curie 20,000 strength). To the rubber capsule is attached a silk thread, in which several knots are tied, indicating the distance from the lips to the cardia and how far the capsule lies from the cardia. The capsule is introduced Uke his stomach-bucket. The thread is tied to the lobe of the ear and the capsule left in the stomach for one hour. Binhorn states he has not yet formed definite conclusions as to results, but it seems to be of palliative benefit. There is no method of determining the relation of the capsule to the tumor, serious burns have resulted from prolonged exposure to radium, and no definite results are yet reported. I would, therefore, not recommend the method. A similar instrument, except that it is connected to a thin rubber tube in which a mandrin is slipped for the purpose of introduction Fig. 139. — Einhorn's radium receptacle for treatment of cancerous stenosis of the cardia: Tubing, mandrin, and receptacle. and then the latter removed, has been devised by Einhorn for the treatment of mahgnant esophageal stricture (Fig. 139). He recommends leaving it in the esophagus from half an hour to an hour, and claims an increase in the permeability of the stricture, less pain, and increased ability in swallowing. As in this case the radium can be directly applied and some definite results have been secured, the method might be of value. The question of damage from overexposure must be carefully considered. The method is evidently worthy of further investigation. Drugs. — Sodium lodid. — In stricture of the cardia, Boas has recommended sodium iodid, gm. 2.0 to 3.0 (30-45 gr.), in divided doses during the day, and claims that during a treatment of over six months the patient gained a little in weight and was relieved from some of the symptoms. Even though transient improvement occurs, it is worthy of trial if it adds to the patient's comfort. Admin- istration for a brief period would decide the latter question. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 267 Thiosinamin. — Sachs^ claims to have been successful with thiosinamin by hypodermic use in the treatment of 2 cases of pyloric stricture ; and Michaelis^ found it softened an esophageal stricture and enabled him to dilate it with bougies. Thiosinamin (fibrolysin) is moderately soluble in water, soluble in 3 parts of alcohol, and readily soluble in ether. Hypodermic injection of fibrolysin can be given in 15 per cent, alcoholic, or 10 per cent, glycerin, solution. The average dose is gr. | to i| (0.032-0.1 gm.). Einhorn advises its use by mouth. It is worthy of trial in stenosis of the esophagus or pylorus. The following is useful: IJi. Thiosinamin 0.5 (7^ gr.) ; Glycerini 6.0 (oiss.); SjTup. cort. aurant 20.0 ( o v) ; Aq. destU q. s. ad. 60.0 (oij). — M. Sig. — Teaspoonful in water t. i. d. Arsenic has been recommended, Fowler's solution, 3 to 5 drops (0.2-0.3) daily; or sodium arsenate, gr. 3V to ^V (0.002-0.0026), t. i. d., but their chief value is combined with iron, such as Gude's peptomangan, or iron tropon, to combat the anemia. I^. Blaud's iron pill (fresh) gr. v (0.32) ; Sod. arsen gr. -50 (o-OOi3)- — M. One pUl, made soft with honey, is an excellent combination given t. i. d. Condurango was first recommended by Friedreich in 1874 for the treatment of cancer, but it has no specific action. Alone or combined with dilute hydrochloric acid (suggested by Ewald), it is an excellent stomachic to improve the appetite, and at times increase of weight may result. It may be given as the fluidextract of condurango, 15 to 20 drops (i. 0-1.3), ill water t. i. d., with or without dilute hydrochloric acid, half an hour before meals; or the decoction of condurango may be employed: I^. Decoction condurango 20.0 to 25.0 gm. ; Water 200.0 to 250.0 cc. — M. Tablespoonful t. i. d. before meals. Other stomachics, such as are advised in chronic gastritis, are of service : T^. Acidi hydroch., dilute ojj (8.0); Tr. nuc. vomic __o ij (8.0) ; Comp. tinct. cinchona .' oSS (16.0); Aq. destil q. s. oiv (125.0).— M. Dose, one to two teaspoonfuls in water t. i. d. before meals. 1 Ther. d. Gegenw., 1907, No. i, 2 Med. Klin., 1907, No. 10. 268 DISEASES OF THE STOMACH AND INTESTINES When trypsin treatment is employed, the acids are contra-indi- cated. Methylene-hlue. — Einhorn^ has employed methylene-blue in capsules once or twice daily for some years past — gr. 3 (0.2 gm.)- In I case the tumor appeared smaller for a time and did not increase in size; for eight months the patient was free from pain and lost no further weight. Later it grew again and the case succumbed. He believes it exercises a beneficial action in some cases. A. Jacobi- advocates its use in inoperable intra-abdominal cancer, having used it for about fifteen years. He reports cases of various types and claims mitigation of symptoms, prolongation of Hfe for some years in several cases, and a temporary retrogression of the tumor. He does not claim to have absolutely cured a case. He believes that exposure to sunlight is an aid, as methylene-blue is fluorescent. He advocates doses (divided) , commencing at 2 grains a day and increasing to 6 grains, combining belladonna, and suggests the following : I^. :\Iethylene-blue gr. vj (0.4) ; Ext. belladonna gr. | (0.048) ; Arsen. acid gr. t^ (0.0065).— M. Di\'ide into foiir pills. Sig. — One t. i. d. after eating and at bedtime. Methylene-bhte treatment may be tried in inoperable cases as a palliative. Trypsin Treatment. — For the theory of Beard, on which he bases his so-called trypsin treatment, I refer my readers to his various articles. There have been cases of apparent cures reported, and others of complete failure. Rice=* reports a case of supposed cancer of the larynx with cure; while Wm. S. Bainbridge-* demonstrated a reported cure by ]\Iorton to be an absolute failure. Shaw-:Mackenzie^ and Carter*^ report cures in apparently hopeless cases, while Ball and Thomas' report unfavorably in 1 1 cases. There are manv other reports for and against its use. Cleaves beHeves this treatment to be justified, noting a reUef of pain, an improvement in metabolism, and improved mental condition. She described a tr3'ptoglycogenic reaction as occurring from its use, consisting of a moderate leukocytosis and eosinophiUa. 1 Deutsch. med. Wochenschr., i8qi. No. 18. -Journal Am. Med. Association, Nov. 10, 1906. ^Med. Record, Xov. 24, 1906. * Xew York Med. Journal, March 2, 1907 5 Med. Press, May 15, 1907. ® Med. Press, March 18, 1907. ^ Archiv. Middlesex Hosp., vol. ix, in Prac, August, 1907. CANCER OF THE STOMACH (CARCINOMA VENTRICUIj) 269 Wm. S. Bainbridge, of New York, has had under observation about 100 cases undergoing this method of treatment, which are reported in the Medical Record of July 17, 1909. Space will only allow me to insert a small portion of his sum- mary in which he deduced the following: 1. The internal medication with holadin and ox-gall aids digestion and increases elimination. 2. Aiding digestion, increasing elimination by skin, kidneys, and bowels, and decreasing local absorption are the most important features of the treatment. 3. The regime by increasing resistance may in some cases de- crease the rapidity of the malignant process. 4. Control cases given sterile water plus the regime, did as well as those on the full enzyme treatment. 5. Trypsin injection seems in some cases to cause disintegration of (Hquefy) the cancerous tissue in the center of the mass, but the periphery continues to grow. 6. Amylopsin injection seems to diminish cachexia in some cases. 7. In a small percentage of cases hemoglobin improves under trypsin injection. 8. A steady increase (6 to 12 per cent.) in the eosinophiles oc- curred in most cases during the trypsin injections, which lessens under amylopsin injection. There was no increase when they were given by mouth. 9. The claims for eosinophilia as a test were not substantiated. 10. Beard's enzyme treatment does not check the cancerous process. 11. It does not prevent metastases. 12. It does not cure cancer. ' The author's personal observations on this method of treatment will be shortly described. "Trypsin' Treatment for Cancer."— With sHght changes, I have followed Bainbridge's modification of Beard's method. I have added secretin to the treatment to stimulate the pancreas. Trypsin {Special). A solution of double strength is now employed (Fairchild's). . . For First Mon//?-.— Begin with 5 minims (0.296 cc.) deep mjection daily by hypodermic. Increase 5 minims daily up to 35 to 45 minims daily. For Second Mow^/^.— Trypsin one day 5 minims (0.296 cc). Amylopsin next day, 5 minims; and so on by hypodermic. Run each up with daily 5 minims, increase up to 35 to 45 mmims daily. . . For Third Mon//?.— Amylopsin daily. Commence at 5 mmmis (0.296 cc.) by hypodermic. Run up with daily 5 minims (0.296 cc.) ; increase to 35 to 45 minims daily. 270 DISEASES OF the; STOMACH AND INTESTINES If symptoms of reaction, temperature, or renal disturbance, reduce to small dose, ITL 5 to 20 (0.296-1. 184 cc), daily. If local irritation from injection, use ichthyol and ice-bag. Urine should be examined every two or three days. Examination for trypsin in the urine can be made, as described by Bainbridge. One holadin capsule with a secretin tablet, gr. i (0.06), should be given one hour t. i. d. before meals throughout treatment. Ox-gall pepules, dose, 2 each night. Avoid all acids. Give as little salt as possible. Give an alkaline mineral water one and a half hours after meals t. i. d. ; can employ glass of Vichy in which is dissolved J teaspoonful of soda bicarbonate. Give plenty of butter, milk, eggs (raw), nourishing food, etc. I have frequently substituted milk of magnesia, 5 j to 5ij (4.0-8.0), for the soda bicarbonate with Vichy, as it produces less gas and aids bowel action. I shall refer briefly to 5 cases: Case I. — At the Roosevelt Hospital. Carcinoma of the anterior wall of the stomach (inoperable). My technic for the first week was faulty, but was followed out correctly for four weeks, during which time I could see no improvement, but no apparent retrogression. The case passed out of my hands. Case II. — Same hospital. Carcinoma of the bladder, from which a villous process was removed and examined, confirming the diagnosis. The patient suffered from considerable bladder irritation. After ten days' trypsin injection, this condition was slightly improved, and several small fragments of the villi were passed in the urine. Beard claims a disintegration of the tumor. Whether the passage of this material was a coincidence or not, I am not prepared to state. At the end of three weeks' treatment the patient had apparently improved slightly and insisted on leaving the hospital. These cases were unsatisfactory, as further obserA'ation was impossible. Case III. — This patient I have already referred to as one of cancer engrafted on an ulcer. The patient, aged sixty-eight, whose weight two years ago was 240 lbs., for a year gave the history of ulcer of the stomach, with a loss of weight of 40 lbs., and subsequent improvement under treatment with an increase of 10 lbs. The pain during this period was increased on eating, and he had free periods. No hemorrhage as far as I can learn. A year ago, weight 210 lbs., he began to grow worse; the pain became continuous and no free periods. He became weak and more and more emaciated ; anorexia, no vomiting. When I first examined him, the early part of April, 1908, he was extremely weak, being hardly able to walk, markedly cachectic, and anemic. His weight had fallen from 210 to 149 lbs. There was a hard nodular mass to the left of the median line, extending from the CANCER OF THE STOMACH (CARCINOMA VENTRICUU) 27 1 greater curvature upward on the body of the stomach. This was readily palpable and showed clearly by transillumination. Motor insufficiency was slight. The gastric findings have always shown a total acidity varying from 90+ to 100+ and free HCl 65+ to 70+ (hyperchlorhydria) ; moderate leukocytosis 12,000, and a slight increase in the eosinophiles. I have already referred to the fact that hyperchlorhydria may be present in cancer and persist even to the time of death. The patient suffered from chronic nephritis. During the first month, under trypsin treatment, there was slight increase of leukocytosis and eosinophilia up to 9 to 11 per cent., averaging about 9 per cent. In the second month, with trypsin alternating with amylopsin, the eosinophilia slightly diminished to about 8 per cent. The patient, midway in the third month, with amylopsin alone injected, eosinophilia was 7 per cent. Holadin, alkalis, etc., continued as usual. No opiates and no alcohol or heart stimulants have been employed. The patient averages 8 raw eggs a day, milk, gruels, a moderate amount of bread with plenty of butter, sanatogen oj daily, etc. The weight increased to 160 lbs., a gain of 1 1 lbs., the pain, which was formerly continuous, occurred only occasionally at night. As nothing was given for the pain, I am forced to attribute the improve- ment to the specific treatment. The patient's strength, appearance, and mental condition were greatly improved, and he walked daily in the park. The growth did not increase in size and, in fact, slightly diminished. The forced feeding undoubtedly improved the nutrition. Treatment for hyperchlorhydria did not relieve the continuous pain, as it was carried out for a week before the trypsin treatment was begun with no results. A second course of trypsin treatment was administered, and the patient, on leaving at the end of August, weighed 169 lbs., and was in quite good physical condition, being able to exercise and having only occasional pain. I can substantiate, in this case at least, the statements of Cleaves as to leukocytosis, eosinophilia, the relief of pain, and the mental improvement. The tumor, apparently, diminished considerably in size, but did not disappear. The patient returned to work and died of pneumonia two months later. I could not attribute the improvement in nutrition in this case to the trypsin, as, in view of the location of the growth, the motor functions were excellent. Case IV. — This patient, aged thirty-eight, male, was a steady drinker. Two years before he had an attack apparently of gastric ulcer with several hemorrhages; then was in fair condition for some months with slight gastric symptoms. Six months previous to admission to the hospital he began to lose weight and strength, the gastric symptoms became more severe, and he began later to 272 DISEASES OF THE STOMACH AND INTESTINES vomit. His weight at the commencement of his last attack was 190 lbs. When I saw him in October, 1908, he weighed 120 lbs., anemia and cachexia were marked, vomiting six to eight times daily, ectasia with the lower border of the stomach three fingers below the umbilicus, a distinct hard mass palpable in the epigastrium, blood in the vomitus and stool. The pulse was very feeble, hardly detectable, and he was only able to walk with the aid of support. He was at once admitted to the Red Cross Hospital, where the visiting surgeon and one of the physicians in consultation with me agreed that even palliative gastro-enterostomy could not be risked. Lavage was per- formed twice each day, and forced feeding with 8 to 10 raw eggs daily, sanatogen, oj (64.0), in divided doses; iron tropin, 5j (4.0) t. i. d. ; pep- tonized milk in divided doses, i quart (liter) in all, butter, broths, gruels, etc. The patient only vomited twice after lavage was begun. Rose's belt was applied to elevate the stomach, and after each feeding the patient was turned on the right side, where he remained for half an hour to aid in emptying the organ. Olive oil, oij (60.0), was also given twice daily for the same purpose. On admission October, 1908: Gastric analysis, free HCl absent; lactic acid, large amount; Boas-Oppler; blood. Blood. — Slight leukocytosis, 11,000; red cells, 3,200,000; hemo- globin diminished; eosinophilia slight; nephritis, probably due to al- coholism. Trypsin injections were given for a month, then for the second month trypsin alternating with amylopsin. Leukoc3^tosis slightly increased; eosinophils, 9 to 11 per cent, during trypsin injection, 7 to 8 per cent, during the combination. There was a gain of i ,000,000 red cells in the course of the two months. At the end of this period a gain in weight of 20 lbs., the patient felt quite strong, and was able to walk about without assistance. His pulse was excellent. Operation was then performed (gastro-enterostomy) on account of adherency of tumor and of many glandular enlargements. Subsequent to operation, holadin, ox-gall pepules, and secretin with alkalis were continued, but no further injections. Forced feeding and tonics were resumed as soon as possible. The patient remained three months in the hospital after operation, gaining in all 38 lbs. Six weeks later he reported a further gain of 2 lbs. He con- tinued the internal medication with holadin, secretin, etc. It is now nearly a year^ since he entered the hospital in extremis, and the condition is the same as when he left the institution. There was no disappearance of the tumor, though the growth seemed slightly smaller after the injections. Case V. — Male, aged fifty-six, history of gastric symptoms of six months' duration, original weight 155 lbs. On admission to Red Cross Hospital weight 1 20 lbs. Occasional vomiting, anemia, cachexia. 1 This patient recently began to drink and neglect himself and has lost con- siderable weight, is anemic and cachectic, but no vomiting. Under resumption of forced feeding and tonics he is improving. CANCER OF THE STOMACH (CARCINOMA VENTRICUu) 273 Gastric analysis, free HCl absent ; lactic acid present ; Boas-Oppler ; no blood. Leukocytosis slight ; eosinophiles slight increase. Ectasia to one finger below umbiHcus. Tumor palpable in epigastrium. Pulse quite good. Immediate operation was advised. The growth was not large, but there was considerable glandular involvement and some nodules on the liver. Palliative gastro-enterostomy was performed. On the fourth day nutritive enemata were no longer retained and the patient was given strained broths, barley-water, white of egg, etc., by mouth; later, peptonized milk, and as rapidly ac possible forced feeding was begun. Two weeks after the operation trypsin treatment was commenced. The patient ultimately gained ^o pounds in weight. There was no change in the tumor, it apparently remaining the same size. Seven months later conditions were the same.^ There is no excuse for abscess formation during the trypsin treat- ment if proper aseptic precautions are taken. I have always ap- plied a 5 per cent, ichthyol ointment dressing over each fresh punc- ture for twenty-four hours thereafter as an extra precaution and have never had an abscess. The iliolumbar region, between the twelfth rib and the crest of the ilium, is the point of selection for the injections, alternating from one side to the other. It is not necessary to employ a special syringe and pain is avoided by using the ordinary hypodermic as follows : decant from the ampule the required amount of trypsin or amylopsin into a sterile glass. If, for example, 40 drops are to be injected, fill the syringe with 20 drops, and at the end of the injection unscrew the barrel, leaving the needle in situ. The syringe is then refilled, screwed on to the needle at the site of puncture, and the residue injected. Deductions. — The mental effect on the patient is excellent; pain was relieved in one case: eosinophilia was markedly increased by the trypsin injections, less by the alternating injections, and some in- crease by the amylopsin injections. I believe this feature shows increased body-resistance, just as the presence of eosinophilia in t}"- phoid is a favorable symptom. In 2 cases the growth seemed to decrease in size. There was no disappearance of the tutnor in any case. We must remember that the palliative gastro-enterostomy relieves irritation, and in some cases the growth becomes quiescent for a long period. The forced feeding improves nutrition. This should be con- tinued indefinitely, together with the holadin, secretin, ox-gall, iron, and arsenic. I consider trypsin treatment justifiable in inoperable cases and in those on whom palliative operation has been performed, as it seems to produce some benefit as an adjunct. Further investi- gations should be carried on. Thymus. — F. Gwyer^ reports the use of dried and powdered thymus of the calf in doses of oj to iv (4.0-16.0) three or four times 1- This patient, Nov. 27, 1909, is engaged in active business. 2 Annals of Surgery, July, 1907. 18 274 DISEASES OF THE STOMACH AND INTESTINES a day. He claims diminution of pain, reduction of size of growth, improved digestion, and diminution or arrest of the growth. EHmi- nation is through the secretory organs and considerable reaction occurs, so it cannot be used for over three weeks. There is a certain amount of danger from auto -intoxication and the method is still under experiment, so that I would not advise its employment. Coley's fluid (erysipelas toxin) might be tried, though the results have been more favorable in inoperable sarcoma and rarely in car- cinoma. I do not advocate its use. Bier has reported some improvement in superficial cancer by injection of heterologous blood of a pig (lo to 20 cc. at a dose) ; and Leyden and Bergel have experimented on animals suffering from cancer with the injection of liver extracts, but these methods are also experimental.^ Vomiting and Ectasia. — Systematic lavage is indicated for these conditions with normal saline solution or milk of magnesia, §j to oij (30.0-60.0) to the quart (liter) of water; if marked fermentation, resorcin, gr. xv (i-o), can be added; or glycothymolin or listerin, 3j (4.0) to Oj (500 cc.) of water, etc. Hemorrhage. — This is usually not severe. Morphin, gr. ^ (0.016), by hypodermic; the ice-bag; gelatin, 5 to 10 per cent, solution, by mouth, 3ij to ^ss (8.0-16.0), every one to two hours for twelve hours are useful; also hypodermics of ernutin, "Hlv (0.296 cc), or ergot fluidextract, and the methods described for hemorrhage under Gastric Ulcer, Tremoliere's Solution. — Gelatin (5 per cent, solution) with calcium chlorid (2 per cent.) therein. Dose, Sss to §j (30.0-60.0) by mouth, repeated every four hours, is of value. There are not the indications to relieve hyperchlorhydria as in ulcer, so rectal feeding may be instituted for twenty-four hours or longer. The ice-bag should be kept on for twenty-four hours. Gelatin thereafter (3 per cent, solution) should be used for several days, in divided doses up to 5xij (375 cc.) in twenty-four hours. White of egg is of value on the following day, and then fluid diet, and a gradual return to the usual feeding. Pain. — ^The application of heat b}^ the hot-water bag or hot poultices is indicated. Boas recommends 3 to 5 drops of chloroform on ice to be given occasionally. Chloral hydrate, 3 to 5 gr. (0.2-0.3) in water, has been recommended by Ewald, but if the patient be very weak it is a dangerous remedy. Lavage will often relieve acute attacks, especially if stenosis with dilatation are present. Orthoform or, preferably, orthoform hydrochlorid, which is more soluble in water, can be given t. i. d., gr. v to viiss (0.3-0.5). Tincture belladonna, Hlx (0.66) t. i. d., or extract belladonna, gr. ^ (0.022) t. i. d., are valuable. Heat, belladonna, lavage, and 1 Cancer vaccine (neoformans) has been recommended for injection, but further investigation is required as to its value. OTHER TUMORS OF THE STOMACH 275 orthoform should first be tried. If they fail, it may be necessary to employ codein, preferably, gr. ^ to 3 (0.008-0.032) by mouth, or gr. I (0.016) by hypodermic; or, as a last resort, morphin, gr. ^ to I (0.008-0.016). In terminal cases the opiates are indicated. Bowels. — For constipation, enemata of soap and water, with or without olive oil, bowel irrigation, injection of olive oil (Iviij to Oj (250 CC.-500 cc.) at night, to be retained, rhubarb pills, the cascara preparations, aloes and belladonna compound pills, purgen or phe- nolax tablets, and compound licorice powder, are all of service. For diarrhea, the bismuth preparations, subnitrate of bismuth, i.o to 2.0 (gr. xv-3ss), several times a day; or bismuth salicylate, gr. V to X (0.32-0.64), three or four times a day; or subgallate of bismuth, the same dose; or subcarb. bismuth, i.o (15 gr.), three or four times a day, are of value. Chalk mixture or comp. tinct. catechu or kino, in 3ss (2.0) doses, may be combined; or at times tinct, opii, 1Ux (0.892), or tinct, opii camphorat., Tllxv to xxx (0.888-1.7776 cc), may be required in addition. Stenosis of the Cardia. — This may require cautious dilatation, preferably with soft tubes, if possible. In conclusion, I desire to refer to an interesting communication by Carl Beck.^ In several cases of intra-abdominal cancer one (notably of the pylorus) incision was made over the growth, and the latter stitched to the skin, making it practically cutaneous. The x-TSLys were then applied, with apparent disappearance of the growth in several cases. In some the wounds were allowed to granulate, and in others the stomach was reduced after separation of adhesions. In some of the cases the report was certainly favorable. It would seem that in cases of cancer of the stomach in which extirpation is impossible, gastro-enterostomy combined with Beck's treatment, just described, the use of trypsin, and forced feeding to improve the resisting power of the patient, might give the best results. OTHER TUMORS OF THE STOMACH Other tumors of the stomach (excepting carcinoma) are com- paratively rare. Sarcomata, lipomatoma, fibromata, and myomata have been found, and also polypoid excrescences due to proliferation of the glands. Sarcoma is the most common of these varieties, and may be primary or secondary. Primary myosarcoma and fibrosarcoma are generally in the form of circumscribed nodules in the stomach wall, while lymphosarcoma is flatter and infiltrates. The tumors vary in size and form and are situated generally on the greater curvature. Metastases are frequent. Primary Ivmphosarcoma appears most frequently between t wenty 1 On External Rontgen Treatment of Internal Structures (Eventration Treatment), New York Med. Journal, March 27, 1909. 276 DISEASES OF THE STOMACH AND INTESTINES and thirty-five years of age, while the other types occur more fre- quently in older subjects. Symptoms of Sarcoma of the Stomach. — These appear somewhat insidiously, in some cases gradual emaciation being first noted; the stomach symptoms are practically the same as in carcinoma : loss of appetite, sour belching, a feeling of pressure and fulness, disagreeable taste, pain, vomiting, and, finally, coffee-grounds in the vomitus. Dilatation of the stomach, if pyloric involvement and tetany have been observed in this type of case. Gastric Analysis. — Absence of free hydrochloric acid; presence of lactic acid; Boas-Oppler bacilH are frequently present. In effect, we may say the gastric findings and symptoms are similar to carcinoma. The methods of physical examination are the same as in carcinoma of the stomach. Average duration is from one to one and a half years. Schle- singer and Kundrat have shown that certain factors may be utiHzed for the purpose of differential diagnosis. Metastases of the skin are more frequent with sarcoma, and excision, with examination of a cutaneous nodule, when such is present, will afford positive information. Metastases in the intestine occur more frequently with lymphosarcoma, and these do not pro- duce stricture, but dilatation; while carcinoma causes stenosis of the gut. The lymph-glands are more swollen in sarcoma. The spleen is also swollen in sarcoma, not so in carcinoma. The tongue folhcles are at times swollen and tumefied and infil- tration of the tongue may occur; there is a symmetric arrangement of the ridges, nodules, and papillae. Harlow Brooks beUeves the growth usually appears at the lesser curvature of the stomach, though it may occur in other regions. It may be multiple. Treatment. — Early surgical operation, if possible, the indication being the same as in carcinoma. Lavage is indicated if dilatation be present. Coley's fluid (ery- sipelas toxin) has proved of value, especially in some cases of sar- coma, and should be tried in inoperable cases. Severe reaction and renal disturbance may follow its use, so it should be employed with caution. The diet should be the same as in carcinoma, and the use of stomachics. Arsenic (Fowler's solution), beginning at TTLv (0.296) and grad- ually increasing to Ttlxv (0.888) t. i. d., can be tried in lymphosarcoma. Benign Tumors. — Benign tumors of the stomach are a rarity and practically impossible to differentiate in many cases. The cachexia and gastric findings of malignancy would be absent. With benign pyloric stenosis, a^ tumor (thickening) is palpable FOREIGN BODIES IN THE STOMACH 277 in some cases, but the s^^mptoms would be of benign stenosis, cachexia absent, and usually hyperacid gastric contents. Occasionally a small tumor has been noted lying on the greater curvature, due to enlargement of a lymph-gland secondary to an inflamed ulcer. APPARENT TUMORS OF THE STOMACH Einhorn^ has described cases of apparent tumors of the abdomen which have been mistaken for tumors of the stomach, notably, prolapse of the left lobe of the liver, exposure of the aorta (abdominal) , thickening of the abdominal muscles (recti), and adhesions of the lesser curvature. Enteroptosis of a considerable degree is usually associated with the first two conditions and the history is a long one. Pulsation of the aorta may be mistaken for aneurism. Cirrhosis of left lobe of liver may simulate cancer of the stomach on palpation. The gastric analysis and other symptoms will differentiate these conditions. With gastroptosis the pancreas has been palpated and mistaken for gastric tumor. In some cases a transient tumor in the region of the stomach dependent evidently on spasm, as from ulcer, has been noted. Schnitzler- observed such a case. Thickening of the recti is diagnosed as follows: The thighs and knees are well flexed, and the head and shoulders elevated so as to produce marked relaxation of the abdominal muscles. It will then be possible to slip the finger-tips beneath the edges of the relaxed and thickened rectus muscle. FOREIGN BODIES IN THE STOMACH These may be swallowed occasionally or purposely, or may be gradually deposited in the stomach. Among such articles are pins, needles, scarf-pins, knives, spoons, forks, artificial teeth, glass, hooks, pens, buttons, balls of hair, bits of iron, nails, lead, wood, and even the stomach-tube. Lunatics, idiots, and young children frequently swallow foreign bodies, as do trick knife-swallowers. Cases have been reported of patients who have worked with an alcoholic solution of shellac, and who had swallowed small quantities daily, with the ultimate formation of stones in the stomach. Sarcinae ventriculi have also accumulated in large numbers and formed a tumor. There may be local disturbances of severe type and vomiting, or if damage be done to the mucous membrane, then hemorrhage. On the other hand, there may be no disturbances at all and the foreign body, especially if of small size and smooth, may be evacuated from the bowels. The history of the case will generally give us information. If the tumor be of sufficient size and very movable, it can be at times appreciated by palpation. 1 Medical Record, Nov. 24, 1900. 2 Centralblatt f. Chir., vSept. 3, 1898. 278 DISEASES OF THE STOMACH AND INTESTINES The :x;-rays will give information as to its presence. Treatment. — The use of an emetic is objectionable, as a rule, unless the foreign body is extremely small and smooth. Personally, I never employ it. Mayou has recommended the use of an electro- magnet inserted in a stomach-tube, there being sufificient space at the end of the tube to draw in a small metallic object which can be located by the x-rays. Under usual conditions, the administration of constipating food, potatoes, rice, and the soft part of bread, and keeping the bowels costive for several days, so as to form a protective mass about the foreign body, is the best method of treatment. It is an error to immediately administer a catharic, as damage is done to the intestinal canal if there be any sharp edges to the object. Complications, such as perforation or inflammatory adhesions, are liable to occur if it be of any size. Intestinal obstruction may even result. If the body is of large size or serious symptoms ensue, early gastrotomy is indicated. CHAPTER XIV FUNCTIONAL DISEASES OF THE STOMACH Under functional diseases of the stomach we may classify those affections in which either the secretory or motor functions of the stomach are at fault. Anatomic lesions are present in some cases and are absent in others. The principal symptoms are due to the disorders of secretion or motility. Among these we classify hyperacidity (hyperchlor- hydria), hypersecretion (gastrosuccorrhea) , atony of the stomach, dilatation of the stomach, and achylia gastrica. Many cases of hyperacidity and of hypersecretion are pure secretory neuroses, atony may also result from nervous disorders; but there are other causes for these conditions. When there is dilatation due to stenosis of the pylorus, as from maUgnant tumor, the symptoms are due to the cancer and also to the relative motor insufficiency. It is difficult, therefore, to place any special disease of the stomach under a pure classification, owing to the diverse etiology. With achylia gastrica we have the loss of secretory functions of the stomach, and it may be classified under functional diseases. It is produced either by nervous influences or by anatomic changes in the gastric mucous membrane. As in rhany cases organic changes are present, I judged it advisable to devote to it a separate chapter. HYPERACIDITY (HYPERCHLORHYDRIA) {Synonyms. — Hyperaciditas Hydrochlorica; Superacidity.) ~ The term "hyperchlorhydria" should be used to designate an increased secretion of gastric juice or, more correctly, of hydrochloric acid, during the period of digestion; that is, an overproduction of this acid. Under normal conditions the free hydrochloric acid fluctuates in the stomach within certain limits, thus : Free HCl averages between 25+ and 50 + , or about .1 to .2 per cent., and the total acidity from 40 + to 65 + , or . 146 to .237 per cent. We speak of hyperchlorhydria when not only the total acidity is higher than normal, but when the excess of free HCl is above normal. It is not "sufficient to merely test for the total acidity, as it may be increased by organic acids. The free HCl should be determined quantitatively. 279 28o DISEASES OF THE STOMACH AND INTESTINES We might place a total acidity of 70 + , of which the greater part consists of free hydrochloric acid, on the dividing line. A patient with such a degree of acidity and complaining of clinical symptoms may be considered a case of hyperchlorhydria. A total acidity of 100 to 120, with free HCl, 80+ to 90+ , is quite common, and much greater degrees of hyperchlorhydria have been observed. We must remember that individual idiosyncrasies exist as to the susceptibility to free HCl. We occasionally find patients with a total acidity of 100 + , the greater part of which is free HCl, who have no subjective disturbances whatever and never suffer any discomfort. On the other hand, I have at present a patient under treatment with a total acidity of 60 + and free HCl 40 + , who has all the symp- toms of hyperchlorhydria. Frequency. — It was formerly thought that in most diseases of the stomach the gastric secretion was deficient, but it has been demonstrated that the gastric juice is increased in about one-half the cases. One does not see so many cases of hyperchlorhydria in hospital practice, except in connection wdth gastric ulcer, since the symptoms rarely become so severe as to require hospital treatment. As a concomitant of chlorosis it is frequently found. The gastric analysis in these cases is often neglected. Moreover, the general practitioner rarely examines the gastric contents in cases which present the symptoms of hyperacidity. It is, therefore, difficult to secure statistics as to its frequency. . Einhorn reports a trifle more than one-half his patients to be sufferers from hyperchlorhydria. Records of my private patients show that about 50 per cent, come to me for treatment for this condition. Etiology. — No age is exempt. It is met with in adults and quite frequently in young people. In some cases it is a neurosis. Nervous excitement, violent emotions, sorrow, worry, and severe mental labor may be direct causes. Neurasthenics and melancholies often suffer from it. It is a frequent concomitant of gastroptosis. In this condition the hyper- chlorhydria is not the result of the nervous condition alone, but in part due to the ptosis, with resulting circulatory changes. Its relief by Rose's belt is the proof, as reported in a series of cases at the Manhattan State Hospital.^ It occurs with mucous colic, in which case I believe gastroptosis is a factor. Chlorosis is a frequent cause. Irritation of the mucous membrane of the stomach may be a direct factor, as from bolting the food, large quantities of cold or hot drinks, alcoholic excess, pickles, rich condiments, and insufficient mastication. ^ Atonia Gastrica, Rose and Kemp. FUNCTIONAL DISEASES OF THE STOMACH 281 Special articles of food or drink are often productive of it, such as very strong coffee. Excessive smoking and chewing of tobacco are also factors. Cholelithiasis and nephrolithiasis are said to be causes. Hyperchlorhydria is the most frequent accompaniment of gastric ulcer. It is more frequent among the wealthy class, such as bankers, brokers, and professional men, though it occurs among the poor. There seems to be no special predilection for either sex. Symptoms. — They rarely appear suddenly, but usually develop gradually. They always come on after eating and never on an empty stomach, after the time for digestion has elapsed. At first the patient complains of a disagreeable sensation or an uneasy feeling about one to three hours after a meal. It may be a feeling of pressure or fulness, or of heat, or of tingling. This increases into a feeling of distress in the epigastric region, or a burning sensation after each meal. In the mild cases there is no actual pain. In severe cases pain may be marked, with acid belching and heart -burn, and the patients suffer severely and in some cases appear almost in a state of collapse. The burning may be felt in the esopha- gus or along the back and is due to the eructation of the acid contents. Violent headache often accompanies it. Some claim they can feel spasmodic movements in the stomach. This is due to contraction of the pylorus and an increased peristaltic action of the organ endeavor- ing to overcome the obstacle. Mild attacks of pain last for a brief period of time, while the more severe attacks persist for several hours. Vomiting occurs occasionally during the height of the cardialgic attacks. The vomitus is very acid and burning, and after its occur- rence relief, as a rule, results. In some cases the pain appears after eating certain articles of food, and patients seem to have idiosyncrasies, such as to coffee, etc. The attacks are not always directly dependent on the degree of the digestibility of the food, and at times they can eat indigestible material without discomfort; whereas at other times digestible articles of diet will cause pain. Probably the nervous element plays a part in these cases, causing undue irritation of the nerves of secre- tion. Some suffer more disturbance after a small meal, while after a large meal they have no distress. This is readily explained by the fact that the larger amount of food combines with a greater portion of the free HCl secreted. Patients when the symptoms first appear can ease their pain by taking nourishment, especially if rich in albumin, as the whites of eggs and milk or meat. It also disappears after the administration of an alkali, such as milk of magnesia (Phillips), Vichy, or soda bicarbonate. Persons living chiefly on a starch diet suffer more intense pain than those who live largely on meat and eggs; hence, the character of the food has frequently a relation to the pain. 282 DISEASES OE THE STOMACH AND INTESTINES Appetite. — In most cases the appetite is very good, and in some is greatly increased. Others are readily satiated, but the desire for food soon comes on again. Thirst is at times increased during the active attack, but in many cases is normal. If hyperchlorhydria is complicated by dilatation of the stomach, thirst is present. Bowels. — Constipation is, as a rule, present, though constipation and diarrhea may alternate. Headache. — Severe headache often occurs, or even attacks of dizziness, generally during the occurrence of gastric pain. Nutrition. — These patients generally do not lose in weight nor present the aspect of being very sick. They are rarely particularly well nourished and are often of nervous temperament or anemic. This is not invariable, as one has at times to treat stout, well- nourished men, high livers, and inveterate smokers and drinkers, who suffer from this complaint. Rarely, under improper diet loss of weight may occur. Nervous Symptoms. — Some patients are depressed, nervous, suffer from insomnia, and are neurasthenic. Migraine occurs in others. Urine. — Acidity of the urine may be reduced during the course of digestion. There are no characteristic features. Physical Examination of the Stomach. — During intervals between attacks there may be nothing in evidence. Percussion. — At the time of the attack the stomach may be distended. Palpation. — The greater part of the gastric region will be found to be tender on pressure or even painful in some cases. The tenderness covers a large area, generally over the greater part of the stomach, often in the region of the pylorus this tenderness is accentuated. Splashing Sound. — This can be produced after meals or after the ingestion of water, but is not present in the fasting condition. Examination of the Stomach Contents. — This is the decisive test. If the stomach is aspirated in the fasting condition, it is found to be empty, or only a few cubic centimeters of juice can be secured. One hour after Ewald's test breakfast or three to four hours after the Leube-Riegel test dinner the stomach contents show an extremely acid reaction, often two to three times higher than normal (from IOO+ to 150 + ). It is not sufficient to determine the total acidity, but the value of the free hydrochloric acid is the important feature. Only in hyperchlorhydria is it increased, and in this condition the free HCl causes the high degree of acidity; and Topfer's test (dimeth}'l-amido- azobenzol) shows that the free hydrochloric acid constitutes the chief content, and is often within 10+ to 15+ of the total acidity. Mintz's method is also excellent. FUNCTIONAL DISEASES OF THE STOMACH 283 The digestive power is very good ; a small disk of egg-albumen will be digested in a short time, sometimes within one-half to one hour. Three to four hours after the test dinner meat will be found to be perfectly digested, while starchy substances will be at times unchanged or little altered. Starch or erythrodextrin will be found, Lugol's solution giving a blue or dark red reaction. If, however, a small amount of starchy food be given with a large amount of albuminous material, while the HCl is entering into combination and before free hydrochloric acid appears, the normal reduction changes in the starch may occur. With large quantities of amylaceous material the brief period before the appearance of hyperchlorhydria will not allow a complete con- version of all the starch, and this tends to remain in the stomach an abnormally long time and to produce fermentation. Absorption from the stomach is not disturbed; potassium iodid appears, if anything, more rapidly in the saliva. Motor Function. — This is not impaired, but is often rather increased. Two hours after the test breakfast or six to seven hours after the test dinner the organ is found to be empty or nearly so. Salol appears as salicyluric acid in the urine an hour after its ingestion when tested for with ferric chlorid solution. We must remember that hyperchlorhydria untreated, with fermentation resulting from improper diet (excessive starch), may in some cases produce atony and resulting insufficiency. Hypersecretion, which may accompany hyperchlorhydria, is another factor. Course. — It may be rapid, coming on suddenly and lasting a short time, or chronic for months to years. It often varies in the early stages and may be intermittent in its character. The attack may last for days, weeks, or even months, and then there be a free interval for a considerable period of time. It can recur without any apparent cause, or result from some mental shock or worry, or from some dietary indiscretion. Gradually the hyperchlorhydria becomes more frequent and at last the condition becomes permanent. In rare cases the attacks appear to come on later than usual and vorhiting of an acid mass of undigested food may occur, showing the contents were retained an abnormally long time. This is undoubt- edly due to spasmodic closure of the pylorus from irritation by the acid contents. Atony and even atonic dilatation may develop from this type, and hypersecretion (gastrosuccorrhea) may result in some cases. Prognosis. — The prognosis is, as a rule, good. Many patients can be completely cured. In some very old or severe cases there is a tendency to relapses. The disease is not dangerous to life. Those in whom the nerv^ous element plavs a part often do not readily respond to treatment and are a source of discouragement to the physician. Relapses, in spite of the greatest care and for no apparent reason, are not infrequent. 284 DISEASES OF THE STOMACH AND INTESTINES If atony or dilatation of the stomach complicate the hyperchlor- hydria, the prognosis as to cure is not as favorable. Pathology. — As the cases are not fatal, it is hence unknown. In one case, dying of intercurrent disease, a few erosions were found. It is evidently a disorder of the secretory function. Diagnosis. — The diagnosis of hyperchlorhydria can be made from the examination of the gastric contents: 1. An hour after Ewald's test breakfast the acidity is found increased, due to the increased quantity of free hydrochloric acid. 2. In the fasting condition the stomach is found empty or nearly so. (This excludes gastrosuccorrhea.) Furthermore, the patient suffers from certain subjective symp- toms: 1. Discomfort or, more generally, a pain which comes on from one to three hours after a meal. This is directly dependent upon the ingestion of food. It is not a continuous pain and there are intervals of relief. The character of the food and the quantity have a bearing. Starchy food readily produces it and a light meal more than a full meal. The latter, when rich in albumin, often causes no disturbance. The pain may be "a dead, dull pain, with a gnawing sensation, " or may be of a burning character. The administration of an alkali, such as Vich}^ or sodium bicarbonate, relieves the pain by neutralizing the acid; or milk, raw eggs, or a meat sandwich, by binding the free acid, produces the same result. 2. In others there is more the feeling of a heat or burning in the stomach or the feeling of a sour stomach. 3. Appetite and thirst are generally normal. 4. No cachexia. 5. Marked constipation is the rule. 6. Some cases are quite nervous or even neurasthenic. Complications. — It is often necessary to determine whether atonv, dilatation of the stomach, or gastroptosis are associated with the hyperchlorhydria. Simple Atony. — Presence of the splashing sound and 100 cc. or more of gastric contents aspirated one hour or more after Ewald's test breakfast ; or the splash with the presence of food in the stomach six or seven hours after the test meal; the lower border is in normal position as determined by the splash and by percussion. Dilatation. — Splash at the umbilicus or below shows descent of lower border. Percussion alone or with inflation, or gastrodiaphany substantiate this finding; there is no descent of the upper border. Kidneys are normal in position. Gastroptosis. — Splash at the umbilicus and below shows descent of lower border. Movable kidney is diagnostic if found in addition. There is diastasis of the recti muscles; inflation or gastrodiaphany shows descent of the upper border of the stomach. FUNCTIONAI. DISEASES OF THE STOMACH 285 Differential Diagnosis.— Acid Gastritis. — Hyperacidity is pres- ent plus abundant stomach mucus. Hypersecretion (Gastrosuccorrhea) . — The stomach in the fasting condition contains 75 to 100 cc. or more of very acid gastric juice. The persistent appearance of 20 cc. of gastric juice in the fasting stomach is considered pathognomonic by many. Severe attacks of pain and vomiting generally occur during the night or early morning. Biliary Colic. — Pains are later (four to five hours after meals) or independent of meals. The pains of hyperchlorhydria are dependent on the meals. Pains of biliary colic are not relieved by alkalis and they extend over the right epigastrium and hypochondrium, and frequently to the right shoulder or right axillary region. A patient with biliary coUc or even after the attack has no appetite and cannot eat. The appetite is good in hyperchlorhydria. The gall-bladder is painful on pressure and at times swollen. Icterus may be present. Gall-stones at times are found in the stool. Leukocytosis is present in biliary colic if inflammation is associated. Sometimes the differential diagnosis is difficult. Gastric analysis may be necessary to determine it,^ though occasionally both conditions occur together. Ulcer of the Stomach. — Epigastric pain is intense, appears shortly after the ingestion of food; local tenderness on pressure and pain increased thereby. Pain disappears at the end of digestion. There are the dorsal pain and vomiting in many cases soon after meals. Hematemesis occurs or occult blood- is found in the gastric con- tents or stool. Ulcer is more frequent in women. Nervous Gastralgia. — More frequent in women from eighteen to thirty years. Pain appears without regularity, and is in no way dependent upon the meals or character of food. Is relieved by pressure. Intervals of perfect health ; nervous temperament always present. Gastric analyses often varies in the same case. Treatment. — The treatment comprises, first, the removal of the causes of hyperchlorhydria; and second, the cure of the condition itself. Removal of the Causes. — Interdict tobacco smoking and chewing. If a cigar or cigarette holder is employed, smoking once or twice a day I believe may be harmless, as it prevents swallowing saliva impregnated with tobacco juice, the chief source of irritation in my opinion. Alcohol in every form, including wines and beers, should be prohibited. All kinds of acids, such as acetic, tartaric, or citric, should be forbidden; and all foods prepared with them, such as with vinegar or lemon juice; and all acid or acidulated drinks. Condiments, such as pepper, ginger, horseradish, etc., pickles, 1 The presence of Head's gall-bladder zone may aid diagnosis. 2 The discovery of occult blood is often the determining factor in our diagnosis. 286 DISBASES OF THE STOMACH AND INTESTINES mustard, paprika, nuts, acid fruits, grapefruit, and radishes, should be prohibited. Avoid all extremes of heat and cold in food and drink. Thorough mastication of the food should be enjoined. Nervous conditions, when present, should be treated. Hygienic regulations are important. Overwork and mental anxiety are factors in the production of hyperchlorhydria. Brokers, professional, and business men must be relieved temporarily from overwork and worry by being sent into the country, where various open-air amusements, such as golf, horseback riding, driving, walking, etc., can be indulged in. If the patient have a taste for fishing or shooting, such diversions are excellent. I have seen a few weeks in camp work wonders. Those indulging in a continuous round of social festivities should be compelled to lead a quiet life. On the other hand, there are many people of wealth with no occupation whatever who become entirely self-centered and nervous therefrom, and for such a class of persons occupation is of great value. Hydrotherapy, such as sponge-baths, douches, etc., are of service; also a moderate indulgence in calisthenics (ten minutes morning and night). For the cure of the hyperchlorhydria there are practically two methods used, alone or in combination: We may bind the excess of free hydrochloric acid by the adminis- tration of large quantities of proteids or we may neutralize the excessive acid by the administration of an alkali. Clinical observa- tion has demonstrated that those articles of food which are capable of binding large quantities of HCl are borne the best. The burning feeling of distress or pain is relieved by the administration of albuminous food. Carbohydrates, if given in any quantity, cause distress. The diet is, therefore, of greatest importance. Diet in Hyperchlorhydria. — As noted under prophylaxis, all articles which are liable to overstimulate the secretory glands of the stomach should be forbidden. Among such are acids, all spices, as pepper and mustard, pickles, horseradish, olives, acid fruits, beers, and wines. The food should be rich in albumin, such as chops, steak, roast beef, mutton, game, eggs, milk, oysters, and fish. Bread and butter can be taken, the former in moderation. Green vegetables, such as spinach, asparagus, lettuce, peas and string beans, potatoes, rice, and other cereals should be given in small quantity. They should be taken in combination with large amounts of albuminous food. Alcohol in all forms, including beers and wines, I believe should be avoided, also coffee; though some allow a small amount of beer and very weak coffee. Fleiner has demonstrated that egg-albumen binds more free hydrochloric acid than any other food. Among other articles especially suitable for this purpose he recommends FUNCTIONAL DISEASES OP THE STOMACH 287 boiled veal, beef, mutton, raw ham, Leube-Rosenthal's beef solution, boiled ham, boiled pork, Swiss cheese, Roquefort, pumpernickel, milk, and cocoa. In my own experience I have found gelatin^ an excellent remedy, employing i or 2, or even 3 ounces of a 5 to 10 per cent, gelatin solution flavored with a pinch of sugar or a little vanilla, and given midway between meals. The value of egg-albumen and cocoa is marked. Starchy foods that have been well dextrinized, such as Zwieback and toast, are more readily digested. Strauss has shown that if carbohydrates are introduced in the form of sugars in solution they do not markedly increase HCl secre- tion. He gives 200 to 300 cc. of a 20 per cent, dextrose solution during the day. Considerable water should be taken during meals, or Apollinaris and seltzer, if no atony is present. Fats, such as butter and cream, are of value. Since the carbo- hydrates are restricted and additional calories must be secured, Strauss, Bwald, and others advise their use. Furthermore, fats seem to lessen the acidity or possibly the irritable tendency of the mucous membrane. Cream has been thus recommended. For some years I have been accustomed to administer olive oil once or even three times daily before meals in obstinate cases of hyperchlorhydria, using from oss to j (16.0-32.0), suspended in water. This has lessened the hyperacidity. In the same way, glycerin, oss to ij (2.0-8.0), mixed in water, may be used. Illo- way- employed it in one case. If we attempt to treat hyperchlorhydria by diet alone, we should give three additional feedings at a time after the regular three meals, such as would bind the excessive hydrochloric acid and prevent the symptoms. The extra feedings may consist of kumyss, matzoon and Vichy, bacillac, bouillon, a sandwich, milk, raw egg (especially the whites) and milk, with crackers or bread and butter. One can select a diet from the tables with a sufficient number of calories. For practical purposes an improvement in nutrition, i. e., some increase in weight, should be secured, even though slight, in addition to the amelioration of symptoms. This refers only to those of thin habit, not to the well nourished. The use of the scales, weighing at stated intervals, is of radical importance. Assimilation differs in individual cases, and though on paper the calories may be correct, a loss of weight shows a radical error in the treatment. The follow- ing is a sample dietary, such as is usually recommended for a patient of good physique and quite active. The content of pro- teid is very high as compared with Chittenden's scale, which I advocate in health. It is frequently advisable to diminish the quantity of meat and substitute milk, matzoon, kumyss, or ^ Calves' foot or chicken jelly are excellent. 2 New York Med. Jour., May 25, June i, 15, and 29, 1901. 288 DISEASES OF THE STOMACH AND INTESTINES bacillac. Ivactone-buttermilk is also excellent. Gelatin solutions bind the free hydrochloric acid in a satisfactory manner. Depend- ing on the normal weight, height, and occupation, the diet must be formulated in every case: Calories. 7.30 A. M. — 250 cc. milk, cocoa, 2 eggs, 3 zwieback, and butter (gm. 20) 690 10.30 A. M. — 200 cc. milk, with i raw egg, or matzoon and Vichy 125 cc, or kumyss 250 cc, or milk 250 cc, or bouillon with i raw egg (approximately) . 240 Bread 2 slices, or crackers 2 oz. (gm. 60) 160 Butter gm. 20, water, or ApoUinaris, or Vichy 250 cc, occasionally weak tea 163 1.30 p. M. — Chops, steak, beef, or mutton, 100 gm. (about). . 200 Mashed potatoes, 30 gm 37 Spinach, 30 gm 12 Bread (i slice), 30 gm 81 Butter, 10 gm 80 4.30 p. M. — Same as at 10.30 a. m 563 7.00 p. M. — Soup (barley), 200 cc 100 Meat, broiled, 100 gm 200 Spinach or peas, 50 gm 30 Potatoes mashed with milk, 50 gm 80 Weak tea, 100 cc. (three-fourths mUk) 64 Toast ( I slice) 75 Butter, 10 gm 81 10.00 p. M. — Milk and Vichy, aa 100 cc 64 Total calories 2920 Various modifications may be made. Coffee I interdict. All fried food should be forbidden, as should hot breads, hot biscuits, and rich desserts. The food should not be excessively hot or cold. The patient should eat slowly, masticate thoroughly, and rest after eating for at least twenty minutes to one-half hour. Illoway and Bouveret advocate only three meals a day, with a sandwich at bedtime in some cases. They believe the stomach should have an interval of rest so as to become perfectly emptied. Practically, Illoway's only medication is one-half glass of French Vichy, given at 10 to 11 a. m., at 4 to 5 p. m., and at night, if the sand- wich is omitted. They beheve that unless the stomach have some rest, atony or atonic dilatation may result. On the other hand, some patients can only eat a small amount of food at a time, have the desire to eat at frequent intervals, and feel better if they do so. Repeated feedings are difficult to follow out in some cases, so conditions vary. My method is to give the three regular meals a day with diminished carbohydrates, with the alkaHs an hour to an hour and a half or even two hours later. If it is necessary to improve nutrition, addi- tional feedings are given, a glass of kumyss, or milk and raw egg, or matzoon and Vichy or i to 2 ounces of 10 per cent, gelatin solution (sweetened) between meals or if pain comes on after the administration of the alkaH. These foods can be alternated. FUNCTIONAL DISEASES OF THE) STOMACH 289 Medication. — Among the alkalis that are of value are Vichy, imported or siphon, bicarbonate of soda, milk of magnesia (Phil- lips), magnesia usta, magnesia ammoniophosphorica, and biborate of soda (Jaworski). A little sugar of milk can be added to the soda or magnesia preparations to make them more agreeable. If the hyperchlorhydria is complicated by atony, then bicarbonate of soda (which generates considerable carbonic acid gas) would be objectionable. The following rule should be carried out as regards the adminis- tration of the alkalis: "Give them in ample time to anticipate the appearance of symptoms by a considerable margin." They should be administered t. i. d. after meals, depending upon the time of appearance of symptoms. Repeat the dose if the symptoms begin later, unless albuminous food is given as a substitute. The magnesia preparations have the tendency to move the bowels and hence are of special value. If the result is too active, combine the magnesia with varying proportions of soda bicarbonate or give the latter alone, or give bismuth subnitrate with the magnesia. Magnesia usta will neutralize about four times more acid than soda bicarbonate. The dosages are as follows, given from one to two hours after meals t. i. d. : Vichy 175 to 250 cc. (^i glassful). Vichy ^ to I glassful plus sod. bicarb. J to 1 tea- spoonful (2.0-4.0). Allow this to become fiat (effervescence to disappear). Sod. bicarb ^ to i (2.0-4.0) teaspoonful in one-third glass- ful of water. I^. Magnesia usta, Sod. bicarb aa Dose, i to 1 teaspoonful (2.0-4.0) in water t. i. d. A little sugar of milk or rr^j oU of peppermint may be added to flavor. If the bowels move too freely, diminish magnesia, then give: I^. Magnesia usta oSS (16. o") Sod. bicarb q. s. oij (64.0). — M. Dose, i to I teaspoonful (2.0-4.0) in water. If necessary, bismuth subnitrate, oij to Sss (8.0-16.0), may be added. I^. Sod. bicarb oj (320) Magnesia usta oss (16.0) Magnesia ammon. phos oss (16.0). — M. Dose, 2 to 1 (2.0-4.0) teaspoonful in water. I^. Magnesia usta 5ss (16.0) Pulv. rhu gm. 15 (i.o). Soda bicarb oss (16.0) Sugar of milk oss (16.0). — M. Dose, ^ teaspoonful (2.0) in water if costive or, Milk of magnesia (Phillips) 5 j to iv (4.0-16.0), in water t. i. d. 19 290 DISEASES OF THE STOMACH AND INTESTINES This I have found to be an excellent preparation, especially where constipation is marked. It is one of the most serviceable remedies for hyperchlorhydria. Sod. biborate gr. x to xv (0.6-1.0), in water (Jaworski). has been recommended. The use of Carlsbad water or a glass of the imported Carlsbad salts, 5j to ij (4.0-8.0), in warm water on rising, lessens acidity and helps the bowels. Wolff's artificial Carlsbad mixture consists of: I^. Sod. sulph 30.0 Sulph. potass 5.0 Sod. chlorid 30.0 Sod. carb 750 Sod. biborate lo.o. — M. He adds sod. biborate on account of Jaworski' s recommendation. Dose, 5ss (,2.0) in one-half glassful of warm water two hours before meals. In some cases I give olive oil, oss to j (16.0-30.0) or more, or glycerin, 3ss to ij (2.0-8.0), in a little water before meals, to lessen gastric irritability; bismuth subnitrate, gr. 15 (i.o), given with the olive oil is often useful. If the pain is severe the administration of belladonna before secretion commences, in order to lessen the gastric juice, is of value. At the time of pain it is too late. It is serviceable also in obstinate cases, thus before meals : I^. Tinct. belladonna oiss (6.0) Aq. destil q. s. oij (60.0). — M. Dose, J to I teaspoonful (2.0-4.0), or larger dose of tinct. belladonna, up to 10 drops, may be given. or Ext. belladonna gr. ^ to J (.01-.02). or Atropin gr. j^q (0.0006). Illoway suggests: I^. Tinct. aconite root 6 drops Tinct. belladonna 25 drops Aq. destil q. s. 5 j (30.0). — M. Dose, I teaspoonful (4.0) on rising and a second dose in half an hour. No -Tiore. If the pain is extremely severe and not relieved by an alkali, a small dose of codein, gr. |- to I (0.008-0.016), may be required. This may even be given by hypodermic with excellent results. Mor- phin in same dosage is rarely necessary and should only be given by the physician. The application of heat to the epigastrium by moist compresses, hot-water bag, or poultice is of service. If the patient is very restless and disturbed one of the bromids. FUNCTIONAL DISEASES OF THE STOMACH 29I strontium bromid, sodium bromid, or ammonium bromid, may be given in gr. x to xv (.06-1.0) doses for a brief period. In obstinate cases, silver nitrate, gr. i to ^ (0.008-0.016) t. i. d. or in solution, has been recommended to relieve gastric secretion, or occasionally a douche or spray with silver nitrate (i : 2000), followed by lavage with water. If the douche is used, lavage is unnecessary unless there is a complicating atonic dilatation. If one sees the patient during a severe attack of pain, aromatic spirits of ammonia, 5ss to j (2.0-4.0), diluted well with water; lime-water, oj to ij (30.0- 60.0), mist, cretae, oss to j (16.0-30.0), or bicarbonate of soda or the magnesia preparations can be given at once. Sometimes sodium bicarbonate distends the stomach and causes more pain. Emesis is often a relief, and at times, when other treat- ment fails, lavage may be used as a temporary method. Electricity has been recommended, especially by Einhorn, for the treatment of hyperacidity. Internal galvanization has been suggested for the relief of pain. It seems to be impractical. In cases when constipation is obstinate or when atony is present it might be of service, either the intragastric or, preferably, the percutaneous method of faradization. Bowels. — ]\Iassage, vibratory massage, and rectal injections of olive oil are of service, as well as out-of-door exercise, horseback riding, etc. Remedies such as cascara, aloes, phenolax, etc., may be at times temporarily necessary. If there is atony, dilatation, or ulcer, these conditions must be treated. Rose's belt is indicated for atony or atonic ectasia. To briefly recapitulate. I have found the following of value: Carlsbad salts on rising. Milk of magnesia (Phillips) or magnesia usta, alone or with soda bicarb., or Vichy and soda bicarb., one to two hours after meals; midway between the chief meals a little milk and raw eggs, kumyss, matzoon and Vich}^, or i to 2 ounces (30.0-60.0) of gelatin solution (5 to 10 per cent.). In some cases olive oil before luncheon and dinner, and belladonna extract or tincture when required. The proper diet must be followed. GASTROSUCCORRHEA (CONTINUOUS SECRETION OF GASTRIC JUICE) {Synonyms. — Hypersecretion; Parasecretion; Excessive Flow of Gastric Juice; Reichmann's Disease; Gastroxynsis — Rossbach.) Gastrosuccorrhea is a perversion of function in which the glands of the stomach secrete large quantities of gastric juice even when the stomach is empty, and hence when there is no irritation from ingested food. The diagnosis rests on the removal from the stomach in the fasting condition of a considerable quantity of gastric juice, with 292 DISEASES OF THE STOMACH AND INTESTINES the addition of symptoms which present a characteristic picture. To Reichmann the credit is due of having first called attention to this perversion of function. Gastrosuccorrhea may be classified in two types: 1. Gastrosuccorrhea continua periodica or the intermittent form of hypersecretion; the attacks occur at irregular intervals. 2. Gastrosuccorrhea continua chronica or chronic hypersecretion. Though some believe that hypersecretion is a purely secretory neurosis, other factors can also produce it. Unquestionably, nervous conditions, such as mental excitement or mental overexertion, may be the direct cause in some cases; hence, gastrosuccorrhea may be a pure neurosis. On the other hand, direct irritation of the mucous membrane can be the cause; in fact, the same factors that produce hyperchlor- hydria, such as rapid eating, indigestible food, spices and condiments, abuse of alcohol, bolting the food, excessively hot or cold food or drink, etc. Hyperchlorhydria of long standing, especially if neglected, may be a factor in the ultimate production of continuous secretion. In some of the gastric crises of locomotor ataxia gastrosuccorrhea is at times observed. Hypersecretion is also at times an accompaniment of dilatation of the stomach, either of the atonic type or, more frequently, in the form due to stenosis of the pylorus. It also may occur with ulcer of the stomach. It can even accompany acute dilatation of the stomach, especially in that form engrafted on a chronic stenotic dilatation, to which I refer under Acute Ectasy. Tetany may be rarely associated. In many cases of hypersecretion disturbances of the motor functions of the stomach are present in addition. GASTROSUCCORRHEA (CONTINUA PERIODICA) {Synonyms. — Intermittent Secretion of Gastric Juice; Intermittent Hypersecre- tion; Gastroxynsis; Periodic Continuous Flow of Gastric Juice.) This type of hypersecretion is characterized by an acute attack of continuous secretion of gastric juice associated with severe pains in the stomach, usually spasmodic in character, and by vomiting of acid fluid, the attacks usually occurring in the night or early morning and at irregular intervals; hence it is known as intermittent or periodic. Probably this condition is more frequent among nervous cases than we generally suppose. I have been able to absolutely determine in several cases of supposed intermittent attacks of acute gastritis, or so-called acute bilious attacks, that this condition of intermittent hypersecretion was present. History. — Reichmann^ was the first to describe this perversion of function, and Rossbach,^ under the nomenclature gastroxynsis, ^ Berl. klin. Wochenschr., 1882, No. 40. ZDeutsch. Arch. f. klin. Med., 1883, Bd. 35. FUNCTIONAL DISEASES OF THE STOMACH 293 described what is generally considered the same disease. Sahli, Riegel, and many others have written on it. Etiology. — In some cases it is a neurosis, or the result of mental overexcitement or of overexertion; irritation of the gastric mucous membrane, as from cold water, or smoking, spices, etc., may pre- cipitate an attack. It is associated with the gastric crises of locomotor ataxia in some patients, or with organic affections of the peripheral or central nervous system, with gastric ulcer, or with the stenotic form of ectasia or with acute dilatation of the stomach. These are not pure cases, but have the additional symptoms incident to the disease. Symptoms. — These usually begin during the night. The patient, who is generally apparently perfectly well, suddenly begins to feel discomfort in the gastric region, w^hich is rapidly followed by pain of severe type and generally spasmodic in character. There is nausea, a feeling of faintness, and the patient is obliged to assume the recum- bent position. He grows pale, the extremities become cold, and the abdomen at times is sunken and the pulse rapid and feeble. The nausea becomes worse and worse and soon a violent attack of vom- iting of a large amount of acid fluid takes place. There is temporary relief, but the symptoms begin again, and after a short period the patient again vomits up a large quantity of fluid, far out of proportion to the amount previously ingested. During the attack the appetite is lost and there is extreme thirst. Severe headache and constipation generally accompany these attacks. These attacks generally occur in the middle of the night or early in the morning, and awaken the patient by the pain, if he be sleeping. During the attack the stomach is tender on pressure and there is a good deal of heart -burn and acid belching, the urine is scanty, alkaline, and of high specific gravity. Character of the Vomitus. — The fluid is watery and ver}^ acid. It may be clear or somew^hat tinged with bile (yellowish green). There may be particles of food in the first vomit if motor insuf- ficiency is associated with the condition, but in many cases there is simply the clear gastric juice alone or mixed with bile. If this fluid be examined it will be found to contain free hydrochloric acid in considerable quantity, rennet, and pepsin. The desire to vomit frequently persists and generally several attacks of vomiting succeed each other. Even though the patient abstain from all fluid , in a few hours or less he will again vomit a large quantity of gastric juice. Rarely the vomitus may contain traces of blood, which does not necessarily mean an ulcer. This condition may last for several hours or for several days, when gradually the vomiting stops, the nausea and pain subside, and the patient begins to desire food. Gradually the appetite returns, the food is retained, in a few days 294 DISEASES OF THE STOMACH AND INTESTINES "he begins to feel nearly well, and in a brief time is apparently in perfect health. The patient may continue in good health for weeks, months, or a year, and then have a recurrence. The intermissions of good health, on the other hand, may become shorter until, finally, the intermittent gastrosuccorrhea becomes chronic. In many cases during the intermissions, if the gastric contents are analyzed, they will be found to be perfectly normal. On the other hand, some cases may suffer from mild symptoms of hyper- chlorhydria, and such a condition will be found to exist on examina- tion. Diagnosis. — This can be made by the characteristic symptoms beginning during the night, the vomiting of pure gastric juice occur- ring when no ingesta are present in the stomach. Analysis shows that it possesses all the properties of the gastric juice with an excess of free hydrochloric acid. If no food is given and the stomach be aspirated before the second attack of vomiting occurs, at the time of appearance of pain and nausea, or if the second vomitus be anatyzed and in either event be found to consist of a considerable quantity of pure gastric juice, the diagnosis is conclusive. The attacks are intermittent. All cases should be examined as to motor functions and dilata- tion, since attacks of gastrosuccorrhea occur with these conditions. One should also exclude organic disease, such as the gastric crisis of locomotor ataxia. In the latter case we have loss of patellar reflexes, the Argyll-Robertson pupil, and the Rhomberg symptom. Prognosis. — In pure cases of gastrosuccorrhea continua periodica the prognosis may be fairly good. It is often possible to lessen the severity of the attacks or in some cases even to effect a cure. Treatment. — Prophylaxis. — We must first endeavor to find the cause of these attacks, and by correcting it prevent their recurrence. In the interval between attacks the stomach contents should be examined after a test breakfast or meal, and we should determine whether or not hyperchlorhydria exists. The motor functions of the stomach should also be carefully tested, and any motor insufficiency if present should receive treat- ment. If there be excesses in smoking or drinking, tobacco and alcohol should be cut off. If there are errors in diet, they should be corrected. If mental overexertion or nei-\^ous excitement is a cause, such conditions should be corrected. If the patient is neurasthenic, he should receive careful treatment. Hygienic method of living, exercise out of doors, horseback riding, golf, etc., are ser\'iceable. Treatment of the Attack. — During the early stage, when the pain and nausea first begin, binding the free acid with the whites of several raw eggs beaten up in water or in milk, or the use of B j to ij (30.0-60.0) of 10 per cent, gelatin, or neutralizing the acid by the administration of an alkaH, such as oss to j (2.0-4.0) sodium bicarbonate in water, FUNCTIONAL DISEASES OF THE STOMACH 295 Siv (125.0), or Vichy; or milk of magnesia, oss (16.0), or magnesia usta, oss to j (2.0-4.0) , will at times mitigate the symptoms. Einhorn recommends a large dose of bromid at the appearance of the first symptom and claims that it will often cut the attack short or lessen its severity. About gr. 15 to 30 (1.0-2.0) of sodium bromid should be given, preferably in Vichy (an alkali). The patient should be kept recumbent, with the application of moist heat or dry heat (wet hot flannel compress or hot-water bag) applied to the gastric region. He will generally vomit in spite of treatment. The best method, I believe, is to perform lavage early, not waiting until vomiting occurs, if the pain and nausea are not relieved by administration of the albuminous food or alkalis. Wash the stomach thoroughly with an alkaline solution — i to 2 quarts (liters) of warm water in which Bij to iij (30.0-45.0) of milk of magnesia (Phillips) have been dissolved — or oss (16.0) of sod. bicarb, or oSS (16.0) of magnesia usta. Before withdrawing the tube after lavage, pour through it into the stomach 3ij (8.0) of milk of magnesia dissolved in oij (30.0) of water, to which is added TTLx (0.6) tincture of belladonna to check further secretion. Sod. bicarb., 3j (4-0), may be substituted for the magnesia. If the pain is very severe it may be necessary to give one or several hypodermics of morphin, gr. ^ to ^ (0.008-0.016), preferably combined with atropin, gr. ^-^o to j^-q (0.00032-0.00065), which last is of value to lessen h^^persecretion. Codein may be employed. To the use of cocain for nausea and vomiting I am opposed. It gives but temporary relief, is a marked cardiac depressant, many patients have an idiosyncrasy to even a small amount, and there is danger of the cocain habit. It may be necessary to repeat lavage several times. The bella- donna or atropin should be pushed to physiologic limits, with dilata- tion of the pupils and dryness of the throat, if one expects to have any effect in checking the hypersecretion. Some recommend washing the stomach with i : 2000 silver nitrate solution, and following it with plain warm water. ' Some patients will not consent to lavage, and in these cases we can simply give internally several large doses of the alkalis with belladonna every two to three hours, whether they vomit or not. If there is great thirst, a glass of hot water in which sodium bicar- bonate, oj (4-0), has been dissolved is of service, if taken in small amounts (teaspoonful doses). It often relieves the nausea and the alkali is of value; or a small piece of cracked ice or an occasional teaspoonful of cool water can be also employed. The raw white of eggs beaten up, placed in a cup and packed around with ice, or the 5 to 10 per cent, gelatin, two teaspoonfuls given every half -hour or so, both relieves thirst and binds the acid; or 296 DISEASES OF THE STOMACH AND INTESTINES Milk Sviij (250CC.) 1 Pack this Oxalate of cerium gr. x (0.6) \ dissolved > -^ ^^^ Sodium bicarbonate gr. 15 to 3ss (1.0-2.0) J therein. J Give I teaspoonful (4.0) every half -hour or so as to relieve thirst and bind the acid, and check nausea and vomiting. In some cases rectal enemata of hot normal salt solution at 11 5 ° F. , Oj (500 cc), relieve thirst and stimulate the pulse. It may be necessary to employ smaller quantities of saline solution or to use proctoclysis. It is best for the patient not to drink too much the first day of the attack, except the remedies noted, as an excessive amount of fluid favors vomiting. No food should be given except as above advised. On the next day small quantities of milk diluted with lime-water or matzoon and Vichy or albumen-water can be given, oss to j (16.0-32.0), every hour, and the gelatin can be kept up. The quantity of nourishment may then gradually be increased and, finally, soft-boiled eggs, scraped raw meat, and a subsequent diet such as is used in hyperchlorhydria. The bowels should be moved early in the attack by a soapsuds enema, i quart (hter), to which oviij (250 cc.) olive oil have been added, or by enteroclysis. To recapitulate. In the treatment of the acute attack I follow out the following method : Heat to the abdomen, the administration at once of an alkali by mouth ; the bowels are moved by enema, and the stomach, after a brief period of rest, washed with an alkali, pref- erably with milk of magnesia; oij (8.0) of milk of magnesia diluted with water oiv (125 cc), with tincture of belladonna, TTlx (0.6), being poured into the stomach through the tube before removal. A hypo- dermic of morphin is then given, the room darkened, and the patient kept perfectly quiet. This treatment is repeated if necessary. If the patient will not consent to lavage, then alkalis, gelatin and whites of raw eggs with belladonna should be administered. GASTROSUCCORRHEA (CONTINUA CHRONICA) (Synonyms. — Chronic Gastrosuccorrhea; Chronic Hypersecretion; Chronic Parasecretion ; Chronic Continuous Secretion of Gastric Juice; Reichmann's Disease.) Chronic continuous secretion of the gastric, juice is a per\^ersion of function which is characterized by the secretion of an excessive quantity of gastric juice, not only after the ingestion of food but also when the stomach is ernpty. The chief diagnostic point is the secretion of large quantities of gastric juice in the fasting stomach. Reichmann,^ in 1882, was the first to describe this condition. 1 Berlin, klin. Wochenschr., 1882, No. 40. FUNCTIONAL DISEASES OF THE STOMACH 297 We must make a distinction between the pure cases of chronic gastrosuccorrhea and those in which dilatation (atonic) of the stomach or dilatation from stenosis, especially with ulcer, exist, and with which hypersecretion is an associated symptom. After fasting, small quantities of gastric juice, as much as 5 to 10 cc. or 15 to 20 cc, on one or two occasions have been aspirated. Thus the possibility of a normal small secretion may exist. If, however, we find 20 to 30 cc. or more of gastric juice constantly in the stomach of a patient who has been fasting for some time, the finding we would consider to be pathologic and to be an evidence of con- tinuous hypersecretion. Frequency. — Cases of pure gastrosuccorrhea chronica without any associated organic lesions of the stomach I believe, with Einhorn, to be quite a rare disease, while those found in association with ectasia are not uncommon. Undoubtedly the latter class have been confused with the pure cases. Chronic hypersecretion is more rare than the periodic type. Etiology. — Chronic hypersecretion occurs more frequently in men than women, and in youth and middle life. Severe mental strain or worry seem to be factors, also the neurotic condition. The periodic type may develop into the chronic; persistent hyperchlorhydria or its causes, such as indigestible or irritating food or condiments, the abuse of alcohol or tobacco, or excessive hot or cold food and drinks, may be factors. Dilatation of the stomach, ulcer, or tetany may have chronic gastrosuccorrhea associated with them. Symptoms. — In most of the cases the patients state that the gas- tric symptoms began. gradually, a feeling of pressure, fulness, and sour eructation commencing a couple of hours after the ingestion of food, resembling the symptoms of hyperchlorhydria. Then pain occurs several hours after meals or shortly before the ensuing meal; it is most frequent on the empty stomach, just before the next meal is due. It ma}^ be spasmodic in character ; nausea and then vomiting follows. The vomiting may increase in frequency and, finally, occur several times a day after breakfast and supper. In some cases the attacks take place during the night between 12 and 2 o'clock, the patient being awakened by burning and pain in the epigastrium, acid eructa- tions, and, finally, vomiting of very acid fluid takes place; after vomiting the pain is relieved. The night vomitus is generally a clear fluid. Albuminous food, egg or milk, will often relieve the pain. The day vomitus is very acid (quite liquid), but some food is mixed with it; is often of a grass-green color. The appetite is generally good and often increased. Sometimes the patient develops excessive hunger ; loss of appetite is rather rare. Thirst is increased, the bowels are constipated, the urine dimin- ished and less acid than normal. 298 DISEASES OF THE STOMACH AND INTESTINES There may be some loss of weight, but no marked emaciation. The contrast between the physical condition of the pure type of chronic hypersecretion and that in which dilatation of the stomach accompanies it will be described under Differential Diagnosis. Palpation. — The stomach is more or less sensitive to pressure. Diagnosis. — The diagnosis of gastrosuccorrhea continua chronica can onlv be made hy examination of the stomach in the fasting condi- tion. To exclude error, the method suggested by Reichmann is the best. The stomach should be thoroughly washed out with warm water, preferably at night, all food and drink should be withheld for ten to twelve hours, and then aspiration of the stomach contents should be performed. Anywhere from 50 to 125 cc. of gastric contents is thus obtained. This secretion exhibits all the properties of the gastric juice. It contains no particles of food. The fluid is usually watery and clear in color or it may be yellowish green from admixture with bile. There is an increased degree of acidity, the values for free hydrochloric acid being, as a rule, pretty high. There are no starchy products contained therein. There are no evidences of fermentation and no organic acids present. Under the microscope no sarcinae are found. An hour after Ewald's test breakfast more liquid than usual is present and the acidity is quite high (75 to 125), higher than when the fasting contents are aspirated. A thin disk of egg-albumen will be digested at blood temperature in an hour or so. Lugol's solution gives a blue or violet reaction, showing the starch is unchanged or slightly so. Three to four hours after Riegel's test dinner hardly any meat fibers are found, whereas considerable starchy material is present. The acid content is high and the residue considerable. We must remember that the above description is a case of pure chronic gastrosuccorrhea, in which there is no motor insufficiency. These cases I believe to be quite rare. Differential Diagnosis. — Many of our writers do not properly distinguish between cases of pure chronic hypersecretion and those in which dilatation of the stomach is a complication. The examina- tion of the stomach as regards its size, position, and motor functions should always be carried out, and this will aid us. Ulcer of the stomach may be complicated by hypersecretion, and in a few rare cases gastric tetany is associated with it. Occasionally no symptoms pointing to a previous ulcer can be obtained, though there may have been a previous history of hyperchlorhydria, and at subsequent operation the stenosis will be found to be due to an ulcer not entirely healed. In ectasy from pyloric benign stenosis with hypersecretion we have excessive vomiting of a large quantity of greenish-yellow fluid, pain, cramp-like attacks, peristaltic unrest, excessive thirst, marked FUNCTlONAIv DISEASES OF THE STOMACH 299 loss of weight, skin over the abdomen dry and wrinkled, loss of weight which is often very great, and occasionally some tinge of blood in the vomitus. The patient presents almost a cachectic appearance, and there is in some patients the sense of resistance, or even a feeling of thickening at the pylorus. The vomitus or contents aspirated after a test meal will separate into three layers: an upper layer of foam, middle layer yellow or yellowish green, and a lower layer of sediment. Meat is digested, the sediment consists of starchy material. Acidity is markedly increased and content of hydrochloric acid is high. Pepsin digestion is rapid. Starchy materials, yeast-cells, and sarcinge are found under the microscope. Examination further shows marked dilatation of the stomach, with great relative motor insufficiency. Hyperchlorhydria with atonic dilatation must also he differentiated. The pain and vomiting present some of the symptoms of hypersecretion. For example, in one case a test meal given at night shows a. m. on aspiration 500 cc. of contents; separating into three layers, fermen- tation being present, stomach one finger below umbilicus. Reich- mann's method was then employed, i. e., the stomach was thoroughly washed out and nothing given for twelve hours. Morning aspiration showed the organ to be empty, no secretion, hence the diagnosis was clear. In many cases of marked stagnation of the stomach contents with dilatation, continuous secretion may be simulated. The method of testing the empty stomach will determine the diagnosis. If there have been hematemesis, melena, circumscribed tenderness, or dorsal tenderness ulcer will be suspected. Frequent examinations for occult blood in the stomach contents and stool are of service. Tetany may complicate hypersecretion with dilatation. The symptoms are characteristic. Prognosis. — In the cases of pure chronic hypersecretion the prognosis is fairly good. Most patients improve under treatment, but quite frequently there are relapses. Sometimes the condition persists for years. Hypersecretion pei' se is never fatal. When complications such as dilatation of the stomach are present the serious features are dependent on them. Treatment. — Prophylaxis. — The patient should not overwork, should be relieved of all mental oxerexertion, and lead a rational out-of-door life, with proper attention to exercise and hygiene. Nervous conditions when present should be treated. The patient should avoid bolting his food, should not eat any irritating sub- stances, such as mustard, pepper, spices, alcohol, and verv hot and very cold food and drink; in fact, he should avoid everything that will overstimulate the secretion of gastric juice. Albuminous food is digested well, and starchy food, badl)^; hence the latter should be reduced in quantity. 300 DISEASES OP THE STOMACH AND INTESTINES Diet. — This is practically the same as in hyperchlorhydria, except that very large quantities of fluid should be avoided. If the appetite and physical condition are good, it is just as well to give but three meals a day, so as to give the stomach a rest and not tend to keep up gastric secretion. In this event the excessive acidity can be neutralized between feedings by alkalis. Doses, 5ss to j (2.0-4.0) of magnesia usta, milk of magnesia, or soda bicarb, should be given, as in hyperchlorhydria, in water one to two hours after meals, and the hypersecretion and the pain relieved by tincture of belladonna, TTLx (0.6), t. i. d. On the other hand, some patients, as in hyperchlorhydria, readily feel satiated, and yet desire food frequently. They may also be losing some weight, especially in the cases complicated with dilatation; small meals, which are readily expelled from the stomach {i. e.,m soluble form or mushes), must be given, and yet the nutrition must be kept up, which last necessitates frequent feeding. The diet, for example, when given in small frequent meals would be as in hyperchlorhydria, but less fluid: 7.30 A. M. — Milk or cocoa, 250 cc. (oviij), 2 zwieback or toast and egg (i). 10.00 A. M. — Beef sandwich or ham sandwich. 1.30 p. M. — Soup, 250 cc. (oviij), with raw egg, steak (gm. 100), potatoes (gm. 50). 4.00 p. M.' — Same as 10 a. m. 7.00 p. M. — 2 eggs or meat (gr. 100), 2 slices toast, butter (gm. 20). If there is dilatation, more soluble food should be given (see Dilatation of the Stomach). Starches should be given thoroughly cooked, or predigested and in small amounts, and preferably in soups and mushes; potatoes should be mashed and alcohol avoided; also avoid cabbage, turnips, spices, pickles, mustard, etc. Medicaments.— ^ To lessen hypersecretion, Tinct. belladonna in doses of TTLx (0.6) or more, t. i. d. before meals, up to physiologic effects, or ext. belladonna, gr. | to | (.01- .02), will lessen secretion and subsequent hypersecretion. Atropin, gr. TW to 5^0 (0.0006-0.0013) t. i. d., by mouth or hypodermic, is also of value ; the pain and the spasm of the pylorus and the hy- persecretion are lessened by these remedies. One can administer a large dose of belladonna after lavage before withdrawing the tube. Bismuth subnitrate, gr. 30 (2.0) in Sij (60.0) water, t. i. d. half an hour before meals, or olive oil, oj (30.0), t. i. d. before meals, or the latter containing gr. 30 (2.0) of bismuth lessen secretion. Large doses of morphin, as have been recommended, I believe to be a pernicious method for obvious reasons. For Attacks of Pain. — Alkalis, such as milk of magnesia (Phillips), 5ss (16.0) in oij (60.0) of water, or magnesia usta, 5j (4-0). or soda bicarb, alone, oj (4-0), or combined with the above, are of ser\dce. FUNCTIONAL DISEASES OF THE STOMACH 3OI Albumen-water (white of raw egg) or gelatin, 5 to 10 per cent, solution (J3 — 30.0), are useful. Heat should be applied externally. Lavage, preferably with an alkaline solution, with oj (30.0) milk of magnesia in I quart (liter) of warm water, or with soda bicarb., oss (16.0), or magnesia usta, oss (16.0) in the same amount of water, is the best method. A small quantity may be left in the stomach and bella- donna, TUx (.06) , with an additional dose of the alkali poured in before removing the tube. In some cases it may be necessary to administer a hypodermic of codein, gr. ^ to ^ (0.0016-0.032), or morphin, gr. i to ^ (0.008- 0.016). They should only be given by a nurse or physician. Alkalis.— ~1{ there be no ectasy, a course at Carlsbad is of service, or artificial Carlsbad salts or the imported salts, or alkaline mineral waters, such as Vichy, can be taken at meals or just before meals. This lessens hyperacidity and thus aids digestion. To prevent subsequent attacks of pain an alkali should be given at the height of digestion, about two to two and a half hours after food; magnesia usta or milk of magnesia, 3ss to ij (2.0-8.0), alone or combined with soda bicarb, or ammonia magnesia phosp., as described under Hyperchlorhydria, are useful. Lavage. — Reichmann and Riegel were the first to recommend lavage for the treatment of this condition. Reichmann and Einhorn perform lavage in the morning with the stomach fasting, while Riegel washes it out six or seven hours after the heavy meal. My method is entirely dependent on the time of appearance of the symptoms. If the attack comes on at midnight or early in the morning, it seems most logical to perform thorough lavage at bedtime with an alkaline solution, leaving some of it in the organ, and also pouring into it a large dose of belladonna — Tllx to xv (0.6-1.0). If the attacks come on after breakfast or the noon meal, then the early morning lavage on the empty stomach seems best. I often recommend pouring Carlsbad salts directly through the tube before withdrawal. With severe pain it may be necessary to perform lavage again during the exacerbation. If there be dilatation and marked retention of food, lavage six hours after the full noon meal is necessary, then followed by a light supper; an alkali and belladonna should be given at bedtime. In some obstinate cases Reichmann recommends lavage with 1 : 1000 to 1 : 2000 silver nitrate solution. It is safest to wash the stomach with about 500 cc. of this solution, 150 cc. at a time, and then wash out the stomach with warm water. Normal salt solution may be substituted if there is much irritation. Some also recom- mend the internal administration of gr. ^ to ^ (0.011-0.016) of silver nitrate in pure form or in solution t. i. d. and at bedtime. Stomach Spray. — Einhorn claims excellent results from spraying the stomach with his gastric spray with nitrate of silver i : 2000 to 1 : 1000 after a previous washing with warm water. 302 DISEASES OF THE STOMACH AND INTESTINES Direct Galvanization. — The same author reports good results from internal galvanization of the stomach, employing it and the gastric spray on alternate days. Riegel finds no benefit from intra- gastric galvanization unless atony is present, and in this I agree. If the condition of chronic hypersecretion be complicated by dilatation, this condition must be treated. Rose's belt is of value for atonic ectasia. If there is pyloric stenosis, gastro-enterostomy is indicated. Lavage with an alkali, belladonna or atropin in large doses, the alkaline treatment, diet, and in some cases spraying or lavage with nitrate of silver, are the chief requirements. CHAPTER XV DISTURBANCES OF THE MOTOR FUNCTION OF THE STOMACH— ACUTE ATONY— CHRONIC ATONY- ACUTE DILATATION OF THE STOMACH— CHRONIC DILATATION OF THE STOMACH ATONY OF THE STOMACH Atony of the stomach may be defined as a relaxation and weaken- ing of the muscular wall of the organ, so that it cannot empty itself in the normal time, and thus motor insufficiency results. It is a perversion of motor function. With simple atony, the stomach is of normal size, but motor insufficiency exists. When the organ is enlarged, we speak of ectasy or dilatation, which is combined with motor insufficiency. There are two types of atony of the stomach : First, acute atony; second, chronic atony. Acute Atony of the Stomach Acute atony of the stomach may occur as a preliminary to acute dilatation of the stomach, just as may chronic atony to chronic atonic dilatation. Acute atony does not necessarily result in acute dilatation. Many of the causes which produce acute dilatation are the factors with acute atony, but the stomach has not become dilated. The early recognition of the condition is, therefore, important. The motor insufficiency which occurs with it may also lead to error in diagnosis. The condition takes place most frequently after overloading the stomach, bolting the food, or indigestible food, or alcohol. It may complicate acute gastritis, with belching, fulness or discomfort in the stomach, some distention, constipation, and delayed vomiting; in fact, merely discomfort for a considerable period of time and then the vomiting of food taken some hours before. The splashing sound is present. The stomach becomes distended, tympanitic, and often sensitive to pressure. A sudden attack of retention of chyme for an abnormal length of time is the salient symptom. In one case, because of motor insufficiency following a single dietary indiscretion, a diagnosis of ectasy with motor insufficiency was made. Examination demonstrated normal functions, the attack evidently being an acute atony (acute motor insufficiency) of temporary duration. 303 304 DISEASES OF THE STOMACH AND INTESTINES During typhoid or the infectious diseases, gastric disturbances with belching, discomfort, sudden distention of the stomach, consti- pation, or diarrhea, with delayed vomiting, the vomitus consisting of milk (curdled) or other food taken some hours previously, are significant of this condition. There may be evidences in the stool of nourishment taken forty-eight hours before. Treatment. — The immediate emptying of the gastro-intestinal tract is the indication. Lavage should he performed at once. A good cathartic, calomel, gr. 3 to 5 (0.2-0.3), or blue mass, gr. 5 (0.3), followed by a saline cathartic, should be given. Castor oil, oj to ij (30.0-60.0), is also excehent. Enemata, and especially rectal irrigation, are of value to produce intestinal peris- talsis. Acute atony may progress rapidly to acute dilatation or develop more slowly for ten to twelve hours, and then, if untreated, result in acute ectasy. Its early recognition is, therefore, important. Chronic Atony of the Stomach {Synonyms. — Motor Insufficiency; Gastric Insufficiency; ^Nlotor Insufficiency of the First Degree; Myasthenia Ventriculi; Atonia Gastrica.i) Chronic atony of the stomach, if untreated, may result in the atonic type of dilatation of the stomach. Its correction is, therefore, of great importance. We use the term "chronic" in distinction from the acute, evanescent form. In the pure cases no dilatation is present. Etiology. — Atony of the stomach may complicate many digestive disorders, such as chronic gastritis, hyperchlorhydria, neurasthenia gastrica, and diseases of the heart and lungs, as tuberculosis. It occurs in nen."Ous and hysteric subjects and may exist as a primary neurosis. It mav occur as a result of biliary colic or the crisis of tabes. Symptoms. — If atony occurs as a complication of some other affection of the stomach, its symptoms will be overshadowed by the primary disease. The characteristic symptoms of atony are : a feeHng of fulness after meals, sHght distention, belching of gas, dimi- nution of appetite, headache, and constipation. The resulting motor insufficiencv is productive of fermentation and gas production. Physical Examination. — There is generally some distention of the stomach with gas. The splashing sound is easily produced over the greater part of the stomach an hour or two after the test breakfast, or four or five hours after a full meal. If the splash extend to the umbilicus or helow it, this is evidence that dilatation is associated. If movable kidney is associated, gastroptosis is present. These are not pure cases. 1 Rose has called to our attention that atonia gastrica is an improper term, really meaning abdominal relaxation. It is so applied in our work to define splanchnoptosis. ATONY OF THE STOMACH 305 An hour after Ewald's test breakfast aspiration of the stomach contents will remove 100 cc. or more of gastric contents; an excellent test taken in connection with the symptoms. Six hours after Leube's test dinner aspiration and lavage show considerable ch^^me, 150 to 200 cc. The fasting stomach in the morning is found empty. Boas states that on filling the stomach with water, the greater curvature will descend as water is added. This is not reUable. The lower border will descend after a moderate amount of water, if the stomach is dilated. Prognosis. — This is good if proper treatment is instituted. Treatment. — If hyperchlorhydria or chronic gastritis is present, each should receive appropriate treatment; as should tuberculosis, endocarditis, nervous conditions, etc. In all cases of chronic atony of the stomach, Rose's plaster belt is indicated. Atony of the intestines is frequently associated, and the use of mechanic support lends tone to the general musculature of the abdomen, keeps the stomach well supported, and prevents atonic dilatation of the organ. Vibratory massage or massage over the entire gastro-intestinal tract is of value. It stimulates the muscles and lessens the tendency to con- stipation. Outdoor exercise, walking, golf, and horseback riding are indicated. In some cases douching the abdomen is of ser\dce; in this event one must employ a silk elastic abdominal support, which can be readily removed. I have secured the best results with Rose's belt. The patient should not overwork, either mentally or physically, and should eat slowly and masticate the food thoroughly; the teeth should be kept in good condition. An excessive quantity of fluid should not be taken — in all, including water, soups, tea, etc., not over I J Uters a day. It is best to give numerous divided meals of rather moderate size, four or even five daily; so as not to overburden the stomach with three large meals, and allow it to thoroughly empty itself. The diet may include bread (fresh and hot breads are inter- dicted) and butter, eggs in various forms, cereals, milk, soup, chicken, steak, chops, game, squab, fish, oysters, and green vege- tables, which are specially valuable for the constipation; cocoa, weak tea, occasionally weak coffee, with milk and sugar. The diet must be modified if hyperchlorhydria or chronic gastritis is present, or to suit the special idiosyncrasies of the patient. Alcohol should be interdicted. Medicaments. — Strychnin or nux vomica is of great service to tone up the muscular system. They ma}' be given alone, or I^. Tr. nucis vomicae TTtx (0.59 cc.) Comp. tinct. cinchona TTtxv (0.888 cc). — M. Sig. — Give in a wineglassful of water t. i. d. half an hour before meals. Some prefer it at the same time after meals. 20 306 DISEASES OE THE STOMACH AND INTESTINES or, if the patient is anemic, it may be combined with iron and arsenic, thus: I^. Strych. sulph gr- sV (0.0021) Sod. arsen gr. -gV (0.0013) Blaud's iron pill gr. v (0.3). — M. One pill; administer t. i. d. after meals. Strych. sulph., gr. ^0 to 3^0 (0.00x08-0.021), is excellent, or tinct. nux vomicae in combination with fluidextract of condurango, or comp. tincture of cinchona, thus: I^. Tinct. nucis vomicae, Fluidext. condurango aa 125 cc. (about Bij). — M. Dose, 20 drops in water, t. i. d. before meals. If hyperchlorhydria is present, I omit strychnin; though Musser advocates nux in the neurotic type. Other useful iron preparations are : Iron tropon j to ij (4.0-8.0), t. i. d. Peptomangan (Gude) 5j to iij (4.0-12.0), t. i. d. To be given in water or milk after meals. Electricity. — This is of service applied by the external method or, in some cases, by intragastric faradization. Static electricity or the high-frequency current may be useful in nervous cases. Lavage is not indicated. Massage or vibratory massage is especially useful. For Constipation. — The green vegetables, brown, rye, and Graham bread, and raw or stewed fruits are serviceable. A glass of water should be taken on rising. The patient should accustom himself to go to stool at a definite hour, and on the closet may gently massage the stomach and bowels to aid action. A small gluten or glycerin suppository, or the injection of i ounce (30.0) of olive oil, or 4 to 6 ounces (125-185 cc.) of warm water have a good effect in exciting peristalsis; or a soapsuds enema, but never of larger size than i liter (quart). Olive oil injection, i pint to i quart (500 cc. to I Hter), at bedtime, to be retained, is useful. It may be necessary to employ medication, such as extract of cascara, gr. i to 4 (0.065-0.26) , at bedtime, or fluidextract of cascara, 5j to ij (4.0-8.0), or pills, such as the lapactic, aloin, belladonna, podophylhn, phenolax, purgen tablets, etc. ACUTE DILATATION OF THE STOMACH Acute dilatation of the stomach may be defined as acute atony of the stomach, with resulting acute motor insufficiency, gradually merging into a paralytic condition, and accompanied by a distention of the organ to beyond its normal physiologic limits. Its lower ACUTE DILATATION OF THE STOMACH 307 border extends to the umbilicus or usually to below this point, and the stomach may even occupy the entire abdominal cavity. Brunton, Fagge, Boas, Hemmeter, notably Campbell Thomson,^ and Lewis A. Conner,^ have written on this subject. The fatal or most severe cases have been reported, but the condition occurs quite frequently. I have already referred to numerous types.'' Personal investigation demonstrates that five anatomic types of acute ectasy exist: 1. Acute dilatation of the stomach alone. 2. Acute ectasy, which supervenes on an existing chronic dilata- tion (due to stenosis of the pylorus). Thomson also reports one case. 3. Acute dilatation of the stomach and duodenum, the most fatal type. 4. Acute dilatation of the stomach engrafted on chronic atonic dilatation. 5. Acute dilatation of the stomach and intestines, a mixed t^^pe, so-called acute tympanites. This last is quite common, especially in the acute infectious diseases, such as typhoid fever and pneumonia. For a complete description of the theories of its mechanism and of the subject, I refer my readers to the "American Journal of Surgery, " November-December, 1908. Weston and the author found that the fibrous attachment of the transverse duodenum to the diaphragm (muscle of Treitz) and the pressure of the dilated stomach on the transverse duodenum were chief factors in the production of the gas- troduodenal type of dilatation. Mesenteric traction was chiefly pro- duced b}^ the downward pressure of the stomach on the intestines, which last exercised a countertraction against the muscle of Treitz. The collapsed intestines were the result of pressure. Mechanism of the Production of Acute Dilatation of the Stomach. — The nature of the condition as stated is undoubtedly an acute atony, with acute motor insufficiency , finally merging into a paralytic con- dition. Many factors in the production of acute dilatation have been described, namely: 1. Section of the vagi — by Carion and Hallion — producing acute dilatation of the stomach, thus demonstrating that an injury or in- flammation of these nerves may be a cause, as in cerebral injury, or pneumonia at the base. 2. Injury to the dorsal spine by stimulation of the inhibitory nerves. 3. Direct action of the agent on the musculature or its terminal nerve filaments; among such maybe chloroform, anesthesia, toxemia from fermentation, etc. 4. Traumatism. ^ Brochure. 2 Am. Jour, of the Med. Sci., March, 1907. ^Medical News, August 6, 1904. 3o8 DISEASES OF THE STOMACH AND INTESTINES /\formoe_ 5. Spasmodic stenosis of the pylorus, due to fermentation or hy- peracidity. 6. Acute gastrorrhea (]\Iorris) ; or possibly acute gastrosuccorrhea (Kemp) . 7. Kelling's and Conner's experiments on spasmodic closure of the cardia, and the demonstration of kinks in various parts of the duodenum, or of spasm of the pylorus. 8. Rotation of the pylorus. 9. Kelling's and Braun's experiments demonstrating that acute dilatation of the stomach is a paralytic condition, by producing it with animals under deep narcosis. ID. Rotation at junction of cardia and esophagus. II. Toxemia from infection, as from the toxins of typhoid, pneu- monia, etc, ; or auto-intoxication from improper diet, causing gastro- intestinal dilatation during the course of these diseases. Dietary in- discretions are the causes of acute ectasy of the milder types which I shall shortly describe. 12. Obstruction of the transverse duodenum is one of the frequent causes so far found in the fatal cases, producing acute gastroduodenal di- latation, the most dangerous type. There are a number of causes given for this condition, notably: (a) ]\Iesenteric obstruction of the duodenum from mesenteric trac- tion. Out of 69 fatal cases 19, or 27.5 per cent., Conner states were caused by this, and probably 33 to 50 per cent, is nearer the fig- ure, according to his view. Al- brecht first called attention to this condition, performing numer- ous experiments. {b) Pressure from the distended stomach on the transverse duo- denum, producing complete obstruction, is most frequently the cause in m}^ belief. (c) The firm fibrous band (muscle of Treitz) attaching the trans- verse duodenum to the crus of the diaphragm, a factor hereafter noted and demonstrated by Dr. Weston and myself, is also an important factor. Regarding mesenteric traction, Conner further believed that the conditions essential for this were the dorsal position, an empty intes- tine, and a mesentery of such length that the intestine can slip into the pelvis and yet hang free. He believes fasting, purges, and enemas after operation have a possible bearing. Accessory factors are suggested, such as a lax abdominal wall, Fig. 140. — Experiment: Acute dila- tation by CO2 distention. ACUTE DILATATION OF THE STOMACH 309 pressure from weight of hepatized lungs (in pneumonia), coughing and laughing paroxysms, lordosis, or an abnormal position of the duo- denum. It generally crosses the third lumbar vertebra ; the fourth is the most prominent, and more pressure would be exercised at this point. Clotted blood behind the transverse duodenum was a cause in one case. On the other hand, some believe the stomach dilatation is the primary factor and the mesenteric constriction is produced second- arily bv the stomach forcing down the intestines. T. Satterthwaite and the author studied the effects of acute gastric distention on the pulse and respiration by artificially dis- tending the stomachs of patients with carbonic acid gas and taking the blood-pressure before, during, and after the experiment. In Fig. 140 is illustrated the result in one of our cases. Physician Position dorsal. Pulse. Pressure. Respiration. Pulse. Before distention 72 135 18 Slightly irritable (to- bacco;. After distention 86 1 20 24 Irregular in force ; some intermission in the beats. Pain under the sternum and over the abdomen, sensation of suffocation and of flushing of the face, nausea, and discomfort accompany the acute distention. The stomach extends to one finger-breadth below the umbilicus; in all a distention of 3^ fingers- breadth. Aspiration of the contents relieved the symptoms. These facts emphasize the danger of overdistention of the stomach with carbonic acid gas for testing the position of the organ in patients with car- diac or pulmonary disease or in old age; also the danger of acute ectasy as a complication. ^Moreover, the true dimensions of the stomach may not be obtained by the method of carbonic acid gas distention. Etiology of Acute Ectasy, — It may be primary or secondary. The causes are as follows: Indigestible food; infectious diseases, such as typhoid, pneumonia, acute tuberculosis, and scarlatina; during convalescence from long-continued disease, as chronic tuberculosis, hip-disease, pneumonia, typhoid, sarcoma, and anemia; injury to the head or spine; traumatism to the abdomen; postoperative, in which manipulation of the viscera, shock, uremia, sepsis, and the anesthetic are factors; one case after gastro-enterostomy reported by the author; retroperitoneal abscess; disease and deformity of the spine, lordosis, etc. ; application of plaster jacket in spinal deformity ; par- oxysm of laughing supposedly (true cause undiscovered). Toxemia or auto-intoxication are, therefore, factors in many cases. 3IO DISEASES OF THE STOMACH AND INTESTINES Age. — It may 6ccur from infancy to old age. Three-fourths of the cases are developed during adolescence or early adult life (ten to forty years). - Aforatal "Position ./^cuM Dilatation Fig. 141. — Acute dilatation of the stomach during epileptic attack. Sex. — ^Is about equally divided. Clinically, we may classify acute dilatation of the stomach into cases presenting various clinical types, in this sense atypic, and into the typic cases, which are usually described. Fig. 142. — Acute dilatation of the stomach in migraine, August 29, 1902. Borders of stomach: i, August 16; 2, August 29, in the morning; 3, August 29, in the evening; 4, August 30, in the morning; 5, August 30, in the evening; 6, August 31, in the morning. Clinical Types of Acute Ectasy. — I shall briefly refer to these cases, which have already been fully reported by me.* 1 American Journal of Surgery, Nov.-Dec, 1908. ACUTE DILATATION OF THE STOMACH 311 I . Cases of A cute Dilatation of the Stomach with Symptoms Pointing to the Nervous System. — Convulsions in Infants and Young Children. — Auto-intoxication is the cause. I have seen a case in an infant two years of age in which the stomach extended 2 inches below the umbiHcus. Vomiting of bread and curds occurred, with immediate cessation of convulsions and return of the stomach to normal position. Repeated attacks may lead to chronic ectasy or epilepsy. '^'■''"V^ \. Fig. 143. — Acute dilatation of stomach with tachycardia. Epilepsy. — Mangelsdorf^ has demonstrated acute ectasy during the convulsive seizure and the gradual return to normal position (Fig. 141). Migraine. — The same author noted similar conditions during attacks of migraine (Fig. 142), and reports ^oo cases in epilepsy and migraine. Lauder Brunton- noted transitory dilatation in sick headache. Tetany. — Broadbent^ describes a case of acute ectasy with tetany, which ended in recovery. ' Atonia Gastrica, Rose and Kemp. 2 Allbutt's System of Medicine, vol. iii, p. 392. ^ Practitioner, igo8. 312 DISEASES OF THE STOMACH AND INTESTINES Chorea. — Acute ectasy has been reported as a terminal event in chorea.^ 3. Acute Ectasy Producing Acute Cardiac Symptoms. — Tachy- cardia. — Girl, age twenty-one, with chronic endocarditis, excellent compensation, no gastric disturbances. Tachycardia, 210 beats per minute, followed dietary indiscretion. Acute ectasy was found as in Fig. 143. Emesis occurred, the stomach contracted to normal size, and the tachycardia ceased. The patient suffered from several attacks, but has had no further trouble since she has exercised care in diet. Pseudo-angina Pectoris. — Female, age sixty-five, suffered from attacks of pseudo-angina, following dietary indiscretions, at times Fig. 144. — Acute dilatation of the stomach with symptoms of pseudo-angina pectoris. consciousness was lost. A number of attacks occurred and in every instance acute ectasy w^as present, as in Fig. 144. Emesis relieved both the dilatation and the attack. Ultimate cure resulted from proper diet. 4. Acxde Ectasy Complicating Infectious Diseases, Notably Typhoid and Pneumonia. — The tympanites of typhoid is frequently not purely intestinal. Acute gastro-intestinal dilatation is by no means rare; in fact, I have found it quite frequent. Systemic infection or im- proper diet cause this condition. Acute gastroduodenal dilatation has been reported. In the milder types of acute gastro-intestinal dilatation there is 1 Lancet, April 19, 1890. ACUTE DILATATION OF THE) STOMACH 313 often no romiting. There are cardiorespiratory symptoms which might suggest pulmonary involvement. Examination shows acute distention. Postural treatment/ by elevation of the head of the bed, enteroclysis, and lavage, will relieve the symptoms. The same mixed type of distention may occur wdth pain and shock and simulate perforation. After relief of the distention, examination shows absence of muscular rigidity (no peritonitis) . .-T^^&ST^ Fig. 145. — Acute dilatation of the stomach, with constipation (ten days' duration) a prominent symptom. In the acute distention of typhoid, with intestinal hemorrhage, lavage will relieve gastric distention and diminish intra-abdominal tension. I have never seen it recommended. Pneumonia. — We may have the gastroduodenal type of acute ectasy, of which several cases are reported. The mixed type is quite common and constitutes a serious danger. Undoubtedly sudden heart-failure has been precipitated by this condition. The etiology and treatment are the same as in typhoid fever. There is greater 1 See Treatment of Typhoid Fever. 314 DISEASES OP THE STOMACH AND INTESTINES danger to the heart from the pressure than from the passage of the stomach -tube. 5. Acute Ectasy with Coprostasis the Prominent Symptom. — Male, age fifty-five, following indiscretions in diet, complained chiefly of coprostasis, with occasional vomiting. Constipation had been present eight days when I saw the case. Fecal impaction was present in the sigmoid and caput coli. Frequent lavage, enteroclysis, and cathartics relieved the con- dition. In Fig. 145 is depicted the stomach before and after relief. Fig. 146. — Acute dilatation of the stomach engrafted on chronic dilatation. 6. Acute Dilatation Supervening on Chronic Ectasy. — Female, age forty-five, suffered from chronic ectasy due to pyloric stenosis from ulcer. Following a dietary indiscretion, acute ectasy resulted with gastrosuccorrhea, pain, vomiting, peristaltic waves, constipa- tion, and coljapse. In Fig. 146 is shown the acute ectasy, with return to the position of chronic ectasy after lavage. Subsequently gastro-enterostomy was performed with a gain of 100 pounds in the patient's weight. Symptoms of the Severe Cases. — The symptoms are charac- teristic, and are as follows: acute; dilatation of the stomach 315 Sudden abdominal distention, pain, tenderness, excessive vomit- ing, constipation, thirst, scanty urine, and collapse. It has been mistaken for intestinal obstruction or for peritonitis. Onset. — This is nearly always sudden. The patient may be well or suffer from some illness taking its usual course, when he suddenly complains of great distention, discomfort, or severe pain in the abdomen. This is rapidly followed by vomiting, which is the most constant symptom, begins early, and generally persists throughout the attack. Rarely there may be an intermission due to tem- porary cessation of secretion, or cessation of vomiting may be a terminal event, the abdominal muscles and diaphragm being no longer able to expel the contents. Cessation of vomiting is, therefore, not always a favorable symptom. The vomiting is profuse, in large amounts, and comes up in gulps without straining. In the early stage it may consist of the gastric contents, of food in various degrees of fermentation ; later, it becomes thinner and watery, and generally of a greenish hue. It is often described as bilious. It may be brownish, grayish, or even inky black; occasionally there may be a trace of blood. Often in the postoperative cases acute distention, pain, and greenish vomiting are the first symptoms. The vomitus may be sour or foul or even (rarely) feculent in odor. Character of the Vomitus. — Various constituents, such as bile, diastase ferment, hydrochloric acid, lactic acid and traces of blood, visible or occult, have been found. Pain is present in the majority of cases, usually in the epigastric and umbilical regions. In the gastro-intestinal mixed cases at the commencement it is more general and acute from sudden distention, being suggestive of peritonitis^; later there is a feeling of distention, not so acute, with accompanying cardiorespiratory- symptoms. It differs from the continuous pain of acute obstruction. Tenderness occurs in some cases. Muscular rigidity is absent. The urine becomes scanty and nearly suppressed during the last twenty-four hours. Anuria is diagnostic of obstruction high up in the intestinal tract, and does not occur with obstruction of the large intestine. It has been mistaken for uremia. The temperature is usually normal or subnormal, unless the patient has fever. Thirst is marked. Hiccough may occur as a terminal symptom, as may also delirium. General muscular cramps occurred in one case; and Broadbent reports a case of tetany. Physical Signs. — In the gastric or the gastroduodenal type there is distention of the abdomen, but the swelling is not uniform; it chiefly fills the left half and lower part of the abdomen, and the right hypochondrium appears to be flattened. There is often swelling in the epigastrium. The following is of service: Draw a line from the tip of the ' Sudden perforation may even be suspected. 3i6 DISEASES OF THE STOMACH AND INTESTINES ensiform to the junction of the middle and outer third of Poupart's Hgament (Fig. 147). The distention usually Hes to the left and below this oblique line. Occasionally it appears more below the navel and sometimes there is general distention. Splashing sounds (succussion) and the sense of fluctuation are an aid in some cases. They are not always present in the early period, when there is chiefly gas in the organ. They occur below the level of the umbilicus. Percussion will show the resonance increased, but will be interfered with when there is much fluid. It is important when the splash is absent. Peristaltic waves of contraction occur very seldom. They are found only before complete paresis takes place, or in the acute cases engrafted on the stenotic type of chronic dilatation. The general symptoms are those of collapse, a rapid and small pulse, fre- quent respiration, a clammy skin, and subnormal temperature. Dttration of the Attacks. — The dura- tion of the attack depends on its severity and type of case. In my case of tachy- cardia it lasted less than an hour. In the mixed cases it depends on the treat- ment accorded by the physician. Among the severe cases, 1 case of Conner's died within three hours after the onset of the pain, which, with disten- tion, was the first symptom. There was no vomiting. Several cases died within twenty-four hours, and sixteen days w^as the longest duration. The average was about five days. Some cases recur or several weeks may elapse before the dilatation entirely disappears. Prognosis. — In the severe cases it has been extremely bad, being a most formidable condition. There is a 72 per cent, death-rate recorded. In realitv many cases occur, and with our present know- ledge the mortality should be comparatively small. Morbid Anatomy. — The post-mortem appearance of the stomach is quite characteristic, being cylindric and bent into a horseshoe or V -shape. The cardiac portion is the longer (Fig. 148). The walls of the stomach are distended and thinned. A large amount of elasticity is retained, as shown by the shrinking that takes place after the distending force is removed.^ The stomach may occupy the entire abdomen or even reach into the pelvis. It has been mistaken on operation for cyst of the pancreas. Its color may be purplish red, grayish, or bluish white. 1 McEvitt, New York State Journal of Medicine, July, 1906. Fig. 147. — Line drawn from ensiform to Poupart's liga- ment. ACUTE DILATATION OF THE STOMACH 317 Microscopic Examination. — This has been made in a few cases. There was thinning of the musculature and no definite microscopic changes were noted, though in some there were small hemorrhages. Duodenum. — In a large number of cases — over 50 per cent. (Conner) — a part or the whole of the duodenum shared in the dilata- tion; in many the distention stopping where the mesentery crossed. Kinks have also been found in the duodenum. The coils of the intestines are flattened and collapsed in the pelvis. Diagnosis. — One should always think of the possibility that tachycardia, convulsions, epilepsy, migraine, anginoid symptoms, increased cardiac and respiratory rapidity, and even tetany may oc- cur with acute ectasy. Sudden gastro-intestinal dilatation is quite frequent in typhoid and pneumonia. Often vomiting is absent in the milder cases, and the chief symp- tom pointing to the abdomen is j, distention. AX times there may be acute pain in typhoid, simulating perforation. Examination in every ^- "'"" case should be made hy percussion, /, the splashing sound, and especially ' hy lavage, if there is any douht. Intestinal irrigation (recurrent) will often relieve distention when present, and aid in diagnosis. Postnarcotic vomiting may be- :|,\ , " come gradually persistent, and this mi- should be looked on with suspicion. Wf Pain, tenderness, distention, con- tinuous vomiting of bilious appear- ance are suggestive, especially with collapse, rapid and feeble pulse, Rg. .^g.-Post-mortem appearance urinary suppression, and obstinate of acute dilatation of the stomach. constipation. In the severe cases there may be occasionally no vomiting and no -pain, but only acute distention and some diarrhea. The use of the stomach-tube and determining the position of the stomach before and after its employment are of value in all cases. //, after lavage, the distention disappears and there is no distention of the intestines or only slight tympanites in the colon, the acute dilatation is of the stomach or of the gastroduodenal type. If intestinal distention persists, the dilatation is of the mixed type. If all the tympanites is reheved by enteroclysis, subsequent examination will determine the stomach not to be dilated. The presence of pancreatic juice, absence of fecal vomiting, and presence of bile show the gastroduodenal type. This is especially true if the abdominal posture affords relief. Bile, however, may be present with acute gastric distention alone. 3l8 DISEASES OF THE STOMACH AND INTESTINES True stercoral vomiting shows obstruction lower down, and muscular rigidity is a symptom of peritonitis. Treatment. — Prophylaxis. — Rapidity in operating, the minimum amount of manipulation of the viscera, a minimum quantity of anesthesia, and care in feeding after operation are important. The abolition of milk-diet in typhoid fever, pneumonia, and acute infectious diseases is advisable, with the substitution of broths, strained soups of various kinds, as barley, rice, and gruels. If the. patient has had an attack, then the conditions of the gastric secre- tion should be investigated, irregularities corrected, and proper diet instituted. In every case of acute ectasy the stomach should be immediately evacuated by lavage. It is an error to wait until the symptoms appear marked, or until the patient vomits, before lavage is insti- tuted. The stomach may redistend in the severe cases. It is advisable to repeat lavage within two hours or at times in three hours, and thereafter every four to six hours, during the first twenty-four hours, depending on the physical signs and symptoms. It may be necessary to perform it more frequently. At times it must be carried out for some days. It is safer to err on the side of frequency. No food or drink should he given by mouth. For severe thirst, saline enemata, proctoclysis, or even hypodermoclysis may be administered. They are also efficient in the collapse, and infusion may be required. Rectal feeding must be kept up for several days until symptoms disappear. If there is intestinal distention, continuous rectal irrigation is of value. It is advisable to promote peristalsis as soon as possible. Unless hemorrhage, peritonitis, or appendicitis complicate (as might occur in typhoid), or there be a suspicion of a true intestinal obstruction, after washing the stomach with plain water, in which milk of mag- nesia, 2 oz. (60.0), has been dissolved, I give calomel, gr. 3 to 5 (0.2- 0.3), in water, ^ss (16.0), directly through the stomach-tube before removal; and a saline cathartic by the same method four to six" hours later. In some cases I have given by preference a high enema^ of oiv (125 cc.) of a saturated solution of magnesium sulphate two hours after lavage. Tincture of belladonna is useful. It lessens the secretion, relaxes pyloric spasm, and has an excellent effect on the atony. It should be given in TTLv to x (0.296-0.592) doses on the tongue, with strychnin, gr. gV to aV (0.00108-0.002 1 2), every four to six hours by hypodermic injection. The latter stimulates the musculature, the heart, and respiration. Atropin, gr. i/jo (0.00065), ^nay be substituted h^^poder- mically for belladonna. Physostigmin sulph. (eserin), gr. tto (0.00065), has been recom- ^ This may be preferable, lest the patient vomit the saline cathartic. ACUTE DILATATION OF THE STOMACH 319 mended to promote evacuation of the bowel. I have recently employed gr. 5V (0.0013) every two hours for several doses with suc- cess. It is well to arrange to give strychnin, gr. jo to gV (0.00065- 0.00108), to guard the eserin. Rectal electric irrigations of the bowels are efficacious for obsti- nate constipation. The second most important therapeutic measure is postural treatment. The position depends on the anatomic type of the dilata- tion. (i) The semi-obHque or nearly sitting position, the head of the bed is blocked up as in the illustration under Typhoid Fever. The patient lies on an inclined plane. This is of value in the acute gastro-intestinal (or mixed) type, with general abdominal distention, so frequent in typhoid or pneumonia, where the cardiac and respi- ratory symptoms are pronounced jrovi abdominal pressure. By elevation of the head of the bed in one severe case of typhoid the tympanitic area in the thorax lowered 4 inches, and the pulse and respiration dropped 20 points each. A fatal issue may result from pressure-effects on the heart and lungs with this type. Frequent lavage and enteroclysis should be instituted in these cases, and later milk-free diet, substituting soups and broths. This method would be incorrect in the gastroduodenal type of dilatation. (2) Elevation of the foot of the bed to relieve pressure on the - duodenum. The objectionable feature is the danger from pressure on heart and lungs if the stomach should begin to redilate. (3) In the acute gastroduodenal type the lateral position, on the right or left side, has relieved the symptoms. The patient recovered. (4) The abdominal position {patient lying on the'belly) is the best m,ethod to treat the acute gastroduodenal type. That this position affords relief seems to me to show quite con- clusively that this type of obstruction is caused chiefly by the stomach pressure on the transverse duodenum. Baumler kept the patient fifteen minutes in the knee-elbow position in each two hours ; the balance of the time on the belly. Operations. — These have not generally proved successful. Among those performed or suggested were : The stomach opened and evacuated, and gastro-enterostomy. Gastric fistula might be tried. A kink at the duodenojejunal junc- tion was relieved in one case, and the patient recovered. Recovery has also been reported after one case of gastro-enteros- tomy. Frequent lavage, combined with postural treatment, enteroclysis, and securing bowel action as soon as possible are indicated. 320 DISEASES OF THE STOMACH AND INTESTINES CHRONIC DILATATION OF THE STOMACH (Synonyms. — Ectasy; Ectasia Ventriculi; Gastrectasy; Ischochymia — E inborn; Motor Insufficiency of the Second Degree — Boas.) The term "dilatation of the stomach" is employed for descriptive purposes, but in view of the existence of an acute type of dilatation of the organ, chronic dilatation of the stomach would seem a prefer- able nomenclature. Definition. — How may dilatation of the stomach be defined? Is it to be measured by the capacity of the stomach alone or by the increased capacity plus the alteration of its functions? The latter is correct. The capacity of the normal stomach is extremely variable. Ziemssen has shown that a stomach may be normal and only contain 8 ounces (250 cc), whereas another stomach, also normal, may pos- sess a capacity of 2 quarts (Hters). The large stomach ("megalogas- tria"), at times found during a physical examination, produces no symptoms. This may be congenital or acquired by large eaters or by those who live on vegetable diet. Such cases, however, can read- ily develop atony. As long, however, as the functions of the stomach are normal we cannot regard the conditions met with as pathologic, and hence cannot consider that dilatation exists. As already described, the lower border of the normal stomach when distended with food or liquid lies from ij to 2 fingers-breadth above the level of the umbihcus.^ If it descends to nearly the level of the umbilicus, to its level or below it, and symptoms accompany it, we must consider the organ dilated. One must not commit the error of mistaking gastroptosis for dilatation. With gastroptosis the upper border of the stomach descends as well as the lower border, and there are movable kidney and enteroptosis. The prolapsed stomach may, in addition, be dilated. There are varying degrees of gastroptosis. With dilatation the upper border of the stomach does not descend, but maintains its relation to the diaphragm, and the stomach is dilated chiefly in the direction to which the greatest force is applied, downward and laterally. The muscular fibers first elongate in the vertical direction and the distance between the lesser and the greater curvature is increased. Dilatation may also ensue in the transverse and anteroposterior dimensions and the pylorus may be a little further to the right and in a slightly lower plane, but the lesser curvature maintains its relation to the dia- phragm, and this is the differential point between dilatation and gastroptosis (Fig. 149). There is confusion as to the terms "atony," "ectasy," and "motor insufficiency," as they are often used interchangeably by different authors. 1 Examination of normal subjects, complaining of tio symptoms, will fre- quently show that the stomachs are abnormally large, or in an abnormal posi- tion. Such cannot be considered pathologic. CHRONIC DILATATION OF THE STOMACH 321 Atony oi the stomach may be defined, as aheady stated, as a loss of tone or contractile power of the muscles of the stomach, so that the organ does not contract about its contents, with a resulting motor insufficiency {inability to expel its contents within the normal limit of time). This condition has not progressed to dilatation. Ectasy may be defined as dilatation, an enlargement of the stomach permanent in character, combined with motor insufficiency. With the atonic type of ectasia, there is motor insufficiency. Relative Motor Insufficiency.— When there is dilatation of th2 stomach due to obstruction at the pylorus, the motor power of the stomach is not sufficient to expel the stomach contents within nor- mal time limits. This is spoken of as insufficiency. This should be considered a rela- tive insufficiency, as in this type the musculature of the stomach is hypertrophied, especially at the pyloric end, and the contractile power is often increased, but not sufficiently to expel the contents past the obstruction within the normal time. In the dilated stomach without pyloric obstruction we have the true atony of the musculature, with varying degrees of motor insuf- ficiency. Some claim that stenosis exists in all cases of dilatation of the stomach, but it is easy to demon- strate that there are two distinct types of chronic dilatation of the stomach differing in symptoms and pathologic findings: . (i) The atonic type of chronic dilatation of the stomach. (2) The stenotic (obstructive) type of chronic dilatation of the stomach. Differential Diagnosis.— A ton/c Type.— In the atonic type there may be few or no symptoms pointing directly to the stomach, the patient frequently suffering from nervous symptoms due to auto- intoxication and from intestinal disturbances. I have seen many such cases at the Manhattan State Hospital continue a year, or even four or five years, without vomiting. There are no peristaltic waves and cramp-like pains such as occur in the stenotic type followed by vom- iting; though some may have dyspeptic symptoms and rarely an attack of vomiting. The post mortem shows the stomach often enor- mously dilated, with thin walls and no evidence of pyloric stenosis. 21 Fig. 149. — Dilatation of the stomach. 322 DISEASES OF THE STOMACH AND INTESTINES Stenotic Type. — In the stenotic (obstructive) type of dilatation dyspeptic symptoms are marked, there are peristaltic waves and cramp-like pains preceding vomiting of large quantities of gastric contents, thirst, etc. In the benign type of long duration the patient often suffers markedly in nutrition, but the cachexia and other symptoms of malignancy are absent and the disease runs a long course. The post mortem shows considerable hypertrophy of the musculature at the pyloric end of the stomach, and elsewhere thinning and dilatation of the muscular wall with the evidence of stenosis at the pylorus, or constriction from some external factor. Atonic Dilatation of the Stomach Etiology. — As causes, we may have a primary reduction or loss of muscle power or impairment of it from overwork, for example, from the ingestion of too much material. It directly follows chronic atony of the stomach, which is the preliminary stage, and hence there are similar etiologic factors, such as wasting disease, tubercu- losis, chronic gastritis, heart disease, etc. Among other causes are bolting the food, frequent overloading the stomach, excessive drinking of large quantities of fluid, especially of those containing much gas ; it may rarely be congenital ; it is quite frequently associated with rickets, in which case gastroptosis is quite often also present. It sometimes follows repeated attacks of acute atony or acute dilatation. Nothnagel traces back some cases of chronic dilatation to improper methods of feeding during early life. Atonic ectasy we frequently find among the insane. I have found an enormous number of patients at the Manhattan State Hospital suffering from this condition, and quite a number of the women with gastroptosis, and frequently dilatation associated with it. Examinations of many hundreds of cases during the last five years show that very few stomachs were in the normal position or possessed normal functions. Many of these cases have never vomited and in very many no special symptoms directed attention to the stomach. Unquestionably the hahit of bolting the food common to such patients is a frequent cause of ectasy. Among the acute melancholies in whom some ultimate cures resulted, auto-intoxication, in some cases the result of ectasy ivith fer- mentation or putrefaction, was the primary factor in the production of the nervous symptoms. In the epileptic ward one case suffering from dilatation (atonic) with gastroptosis, and absence of free hydro- chloric acid, had suffered from numerous epileptic convulsions both day and night, averaging 140 seizures per month. Under simple diet, initial lavage, and at present diet and medication directed to the gastro-intestinal tract alone, she has had no convulsions for two years and a half, with the exception of one week, some fourteen months ago, during which period she was taken off diet and medication while in CHRONIC DILATATION OF" THE STOMACH 323 the general hospital ward with an acute nephritis. Bromids were only given two months at the commencement in small dosage to break the convulsive habit. I have also another case of epilepsy with atonic ectasia and hypochlorhydria, who has gone over a year with- out a seizure under gastro-intestinal treatment alone. Even in the incurable insane this atonic type of dilatation has a direct bearing on some of the symptoms. In a series of 13 paretics, examined for the late Dr. Dent at the Manhattan State Hospital/ I found II cases of atonic dilatation of the stomach and 2 cases of gastroptosis, and in all secretory derangements of the functions of the stomach ; 1 1 of these cases had at some time of the day a tem- perature of 99.5 ° F. and upward, in one 102.5 ° F. Under treatment directed to the gastro-intestinal tract the temperature was lowered in all II (in some to normal), the convulsions, which were present in 5 cases, were diminished in frequency, and in one patient suffering from attacks of syncope, cessation of attacks followed treatment. The atonic type of ectasy is quite common in many nervous cases and is undoubtedly, in some, the causeof the auto-intoxication, and the nervous condition is secondary. Atonic ectasy may, therefore, be in many cases the cause of various nervous conditions. On the other hand, ectasia resulting from insufiicient mastication and bolting of food among many of the nervous and insane may be a factor in the production of a vicious circle. Beer drinkers and diabetics suffer from this type of dilatation. Professional men, bankers, and brokers, from their irregular habits and rapid eating, are quite liable to this form. The musculature of the pylorus, as we know, is much thicker than other parts of the stomach wall, and the latter naturally gives way and distends more readily. This does not constitute, however, a stenosis at the pylorus. Ultimately, however, the pylorus itself relaxes in these atonic cases, which undoubtedly accounts for the usual absence of vomiting in these patients. This type of ectasy is extremely common. Symptoms are at times not referred to the stomach at all, and often point to the nervous system, or cause an exacerbation of a preexisting nervous condition. The patient is often neurasthenic or melanchoHc with the symptoms associated with these conditions. I have seen the lower border of the stomach in atonic ectasy reach nearly to the symphysis. The following symptoms are generally associated : Constipation usually marked, rarely diarrhea, coated tongue, fre- quently headache, and at times dyspeptic disturbances, such as belch- ing and pressure after eating, though often these symptoms are absent. In a few cases of extreme dilatation there may be occasional vomiting of large quantities of fluid. There are no spasmodic pains, no peristaltic waves, and no marked vomiting, as in the stenotic type. In atonic ectasia with chronic gastritis, the gastric symptoms 1 Proceedings of the American Psychological Association, Sixty-first Annual Meeting, April, 1905; also The Medical News, July 8, 1905. 324 DISEASES OF THE STOMACH AND INTESTINES of the latter may be present, in addition to the other symptoms already noted. More rarely there may be hyperchlorhydria^ with atonic ectasy. These cases suffer from the symptoms of hyperchlor- hydria, motor insufficiency is present, there may be spasmodic pains and vomiting of considerable severity, the vomitus being very acid. These cases, as already noted, have been mistaken for gastrosuc- corrhea. After lavage, and later by aspiration of the contents of the empty stomach, one readily demonstrates that hypersecretion is not present. The symptoms in this type are due to the extreme hyper- chlorhydria and to spasm of the pylorus resulting. Excellent results are secured by lavage and by the treatment of the hyper- chlorhydria. Most of the so-called cures of stenotic ectasia belong, I believe, to this class. The mild types belong to the atonic class, though they might be considered border-line cases. In the milder cases in which cure results without operation, organic changes at the pylorus, I believe, must necessarily have been slight, while the severe cases with peristaltic unrest and progressive symptoms should be classed under stenosis.^ Gastric Contents.— The gastric findings are variable; fermenta- tion is quite frequently present and hypochlorhydria or nearly com- plete absence of free HCl; chronic gastritis, occasionally hyperacidity ; mould has been found, and in cases with gastroptosis and dilatation at Ward's Island, I have even noted achylia. The usual manifestations are toxemic in character, with intestinal fermentation or putrefaction and indicanuria. Course. — The milder cases of atonic dilatation are quite amenable to treatment and can be cured. The severe cases do not run so favorable a course, and I have seen such among the nerv^ous and insane where the dilatation extended nearly to the symphysis. I believe that in this type drainage by gastro-enterostomy is indicated, since lavage and diet are only palliative. In the cases of ectasia due to benign stenosis there is at times, under treatment, a temporary improvement. The stomach, from an increased hypertrophy of the muscles and a subsidence of the hyper- emia at the pvlorus, may secure a certain amount of compensation and empty its contents fairly well for a time, but usually the symp- toms return and, finally, resection of the pylorus or gastro-enterostomy become imperative in order to save the life of the patient. I have known these cases to drag along twelve to fifteen years without operation. Thev become chronic invalids. Only by operative procedure can a practical cure of the case be accomplished. If the stenosis is malignant, then the course depends on the extent of the disease. Even in those cases where removal cannot be undertaken, gastro-enterostomy will relieve the symptoms. ^ I have found a number of such cases among the epileptics, there being no vomiting or rarely so, and no peristaltic unrest. 2 These last cases, which do not rapidly respond to treatment of the hyper- chlorhydria, should be referred to the surgeon. CHRONIC DILATATION OF THE) STOMACH 325 Obstructive Type (Stenotic) of Ectasia The stenosis causing this type of dilatation of the stomach may be in the gastric tissue at the pylorus or near the pylorus in the duodenum, or it may be external to the stomach — intrinsic and extrinsic causes. The factor causing constriction may be benign or malignant in character, which would modify the clinical symptoms. Etiology. — (i) Congenital stenosis of the pylorus. (2) Acquired stenosis, such as from ulcer, cicatrices following burns from acids or alkalis; from severe gastritis, causing hyper- trophy at the pylorus ; repeated spasmodic closure of the pylorus due to hyperacidity (spastic stenosis due to inflammation or irritation) ; benign tumors; pedunculated polypi; adhesions at the pylorus; external tumors ; pressure from large gall-stones (in the gall-bladder) ; perigastric adhesions; spider-web adhesions (Morris) from the gall-bladder; stenotic hypertrophic gastritis (Boas), a fibrous disease of the pylorus (hnitis plastica); sclerosis in the pyloric end of stomach (Ottinger) ; pressure from external tumor ; malignant dis- ease of the pylorus. (3) Stenosis of the duodenum from ulcers, cicatrices, carcinoma, external compressions, adhesions, kinks, or diverticula. It is the modern consensus of opinion that bile may regurgitate into the stomach even if the stenosis is present at the pylorus, as the cicatricial tissue holds it open in many cases ; so its presence or absence does not always aid us as to locating whether the stenosis' be pyloric or duodenal. Continuous regurgitation of bile and pan- creatic juice, however, is suggestive of obstruction of the duodenum below the common duct. Movable kidney I do not believe has any relation to ectasy, but when associated with so-called dilatation, it can be demonstrated that the latter is really a gastroptosis. Pathology.— In the stenotic type, the musculature at the pyloric end of the stomach is much thickened ; the fundus is much thinner than normal. The pathologic findings at the pylorus vary according to ^ the cause of the stenosis. The intestines are pushed downward and the liver slightly upward when marked ectasy is present. Symptoms.— The symptoms of dilatation of the stomach due to pyloric stenosis are quite characteristic, but are modified if the condition is cancerous, or in the special type described by R. T. Morris. The usual symptoms are thirst, dryness of the throat, dry skm, oppression, feeling of cramp-like pains of considerable severity, generally associated with peristaltic restlessness of the stomach, eructation of odorous gas, vomiting of considerable chyme, often containing remnants of food taken the day before. This may occur from once to several times a day. The bowels are extremely constipated. Emaciation may become very marked and the loss 326 DISEASES OF THE STOMACH AND INTESTINES of adipose on the abdomen so great that the skin is in dry wrinkled folds. The urine becomes markedly diminished in advanced cases ; its reaction is frequently alkaline. Intestinal fermentation and putrefaction with indicanuria are often present. Bradycardia and dyspnea (cardiac asthma) at tim.es are present, as are also stupor, headache, and so-called gastric vertigo. Tetany, or epileptiform attacks may complicate the condition. The benign type of stenotic dilatation is characterized by rather a long course, with often considerable temporary improvement under treatment, with a tendency to relapse. In the malignant type we have the marked cachexia and rapid loss of weight within a few months, the age of patient usually over forty or forty-five, and the character of the vomitus to be noted later. In my experience the cases characterized by attacks of gastro- succorrhpa are more frequently associated with ulcer at the pylorus with benign stenosis. Special Type. — In an interesting type, to which Robert T. Morris has called attention, there may be vomiting of considerable blood, pain, etc., suggestive of an active ulcer. Gall-bladder spider adhesions have been found to be the factor. The symptoms are probably explainable by circulatory interference. The history of previous gall-bladder disease should be looked into. Examination of the Gastric Contents in Malignant Pyloric Stenosis. — Coffee-ground vomit, or the presence of occult blood; free HCl markedly diminished or absent, lactic acid present; few or no sarcin(E and the Boas-Oppler bacilli present, in connec- tion with the clinical S3^mptoms, are diagnostic of malignant stenosis. Meat is undigested. Free HCl may be present, especially in the early stages, or when the carcinoma is engrafted on an ulcer. With benign stenosis we have: the gastric contents separating into three layers, the upper being gaseous; HCl is marked (hyper- acidity) ; yeast and sarcinae are abundant ; undigested starch is present. Mould may be found and occasionally bile or sulphuretted hydrogen. I agree with Einhorn that bile can enter the stomach in some cases of stenosis of the pylorus, the thickened tissue allowing a sUght patency. Diagnosis Ectasy means dilatation of the stomach combined with motor insufficiency. We must, therefore, first determine the position of the organ. Frequent errors have been made, in differentiating dilatation and gastroptosis. The position of the upper border of the stomach is the chief point. There is a simpler method which is dependent on whether or not a movable kidney be present. The movable kidney is almost invari- CHRONIC DILATATION OF THE STOMACH 327 ably part of a general ptosis of the viscera (splanchnoptosis), and movable kidney from traumatism is extremely rare. If we find a movable kidney with a stomach whose lower border is in an abnormal position (too low down) , the diagnosis is gastropto- sis. If no movable kidney is present and the greater curvature is low down, plus motor insufficiency and symptoms, the condition is one of dilatation. An extremely simple method of locating the lower border of the stomach is by the splashing sound (succussion). This has been fully described, and also the creation of the splash for diagnosis. Dehio's method can be used as a check. We may employ in addition : (i) Inspection, which will in some cases show the outline of the distended stomach, especially after distention with carbonic acid gas. Active peristalsis is also evident on inspection and is diagnostic of pyloric obstruction. (2) Palpation. — By this means the peristaltic movements may at times be felt, as can also the cushion-like resistance of the dis- tended stomach. Occasionally a small oval tumor can be determined in benign stenosis, though generally it is not appreciable. In carci- noma of the pylorus the hard resistant mass can often be appreciated. (3) Percussion and auscultatory percussion, especially before and after the addition of water, as already described, are useful. The "scratch method" is of service. (4) Inflation. — The stomach may be inflated with air or carbonic acid gas. The outlines can thus be more readily determined and the position of the upper curvature mapped out. Inflation with air or water renders a tumor, if present, more evident to percussion and palpation if it lie on the anterior wall. It disappears if posterior. (5) Transillumination. — This method, especially with the cir- cumscribing gastrodiaphane and fluorescein, readily determines the outline of the stomach and differentiates between dilatation and gastroptosis in disputed cases.^ The use of mensuration by means of stiff sounds is deprecated. " The determination of the motor functions is most important, as motor insufficiency is a salient feature. There are different degrees of this motor insufficiency, and this is best determined by the test breakfast or test meal. Test Breakfast. — Ewald's test breakfast. Aspirate the contents one hour later. (i) Normal position of the stomach, with a residuum aspirated of 100 cc. or over, and symptoms, show atony of the stomach. (2) Descent of the lower border of the stomach; 100 to 150 to 200 cc. residuum or more with symptoms and with kidneys in normal position show dilatation of the stomach. 1 The ar-rays give no additional information over the methods described, and the expense is an objection. 328 DISEASES OF THE STOMACH AND INTESTINES (3) If movable kidney, gastroptosis is present. Six or seven hours after Leube's test meal the healthy stomach should be found empty. If undigested food is found (200 to 600 cc. or more), insufficiency is present and the degree of insufficiency is indicated by the amount of residuum. It is always preferable to wash the stomach before the test meal, so as to get rid of the old residuum and make an accurate test. If considerable residuum be found at the end of seven hours, a further test should be made. Wash the stomach and directly thereafter give at 10 p. M. a light supper — a little soup, a slice of bread, a slice of beef, and a little chopped spinach; a small amount of boiled rice or a dozen raisins may be substituted for the spinach. Aspirate and wash the stomach twelve hours later before breakfast. In some cases there will be a marked residuum after seven hours, but none after twelve hours; in others there will also be considerable after twelve hours, showing different degrees of insufficiency. The stomach should be washed, as well as aspirated, to remove all the contents. The salol and olive oil tests are not as reliable. TABLE OF DIFFERENTIAL DIAGNOSIS Atonic Dilatation. Duration. Course. Tumor. Pain. Peristaltic lessness. Vomiting. Cachexia. Symptoms. Blood. Long unless recently ac- quired. Long, often. None. Absent, rest- None. Most frequently absent. None, but some loss of weight. Often toxemic, referred to ner- vous system and not spe- cially referred to stomach ; at times gastric. None in vomi- tus. Gastrosuccorrhea. Rare. Stenotic Dilatation. Benign stenosis of pylorus. Quite long, two years, generally considerably more. Generally intervals of quiescence or improvement. Occasional (sinall and smooth). Spasmodic attacks. Marked. Frequent. Malignant stenosis of pylorus. Short, few months to one year or one year and a half. Progressive. Present; later palp- able. Always present and exacerbations. Present and at times marked. Fairly frequent. None, but great Present. emaciation. Marked gastric. Marked. None except in gall- bladder adhesion cases. More frequent with ulcer. Coffee-grounds in Vomit or occult blood. 1 Generally absent, though occasional. 1 Blood or occult blood present in stool in cancer. CHRONIC DILATATION OF THE STOMACH 329 Gastric Contents Atonic Dilatation. Benign Stenosis. Malignant Stenosis. Total acidity. Lessened; more Increased. Generally dimin- rarely in- ished. creased. Free hydro- Often hypo- Generally increased. Usually absent. chloric acid. chlorhydria; more rarely hy- perchlorhydria. Lactic acid. At times pres- Absent. Present, marked usu- ent. ally. Fermentation. Often marked. At times marked. At times, depending on location of growth. Odor. Often present. Unpleasant. Fetid at times. Boas-Oppler ba- - Occasional. Rare. Usually present. cilli. Mucus. At times, if gas- tritis. At times, if gastritis. In some cases. Sarcinae. Present often. Present markedly. Usually absent. Yeast. Marked often. Often present. Pronounced yeast fermentation rare. Treatment The treatment of chronic dilatation of the stomach varies con- siderably, depending on whether it be due to atony or to benign or malignant stenosis. Atonic Dilatation, — This is by far the most frequent type of dilatation which we are called upon to treat, especially among bankers, brokers, and professional men, who habitually overeat, bolt their food, or are heavy drinkers. Associated with or having a direct bearing on this condition, we may find hypochlorhydria, hyperchlorhydria, or, at times, chronic gastritis. Some of these cases are, in their incipiency, of rather mild type, and prophylaxis, as regards avoiding rapidity of eating and eliminating indigestible food and overeating, is of value. If the patient is run down or anemic, iron and tonic treatment are indicated. Diet. — Though some have recommended a so-called dry diet in dilatation of the stomach, it is a well-known fact that liquids are first evacuated from the stomach, then mushy food, and finally solid food, and this scientific knowledge should be our guide in feeding such cases. Water and food soluble in water leave the stomach soonest of all. Large quantities of fluid should not be given at a time lest they overdistend the flaccid stomach, but if they are administered in smaller quantities at frequent intervals, a considerable amount can be employed. It has been demonstrated that alcohol, sugar, and dextrin cause a secretion of water into the stomach. Milk has been usually recommended as the standard diet in this condition as possessing highly nutritive properties, and the statement has been made that it does not stay in the stomach much longer than plain water. 330 DISEASES Olf THE STOMACH AND INTESTINES Penzoldt has demonstrated that water, cocoa, meat broth, soft- boiled eggs, and boiled milk (loo to 200 gm.) leave the healthy stom- ach within one to two hours, cooking altering the curd formation. Raw milk takes a considerably longer period, and curds have been found frequently in the normal stomach two or three hours after ingestion. Experiments have been conducted on my service at the Manhattan State Hospital in cases of dilatation of the stomach, and the periods for the raw milk to remain in the stomach were investigated. After three hours large masses of curd were aspirated. If the milk were diluted one-half with water, the residuum found at a certain period was just one-half as much as when pure raw milk was used, which formed curds. The higher the dilution, the greater the quantity passed from the dilated stomach within a definite time. Another objection is that i liter of milk only represents about 640 calories, and too large an amount would be required if sufficient nutrition is to be obtained from milk alone. Strained soups and strained gruels are evacuated more rapidly. If milk be given, it should, preferably, be combined with some strained gruel or the latter made with milk, so that the nutritive value may be increased. In the severer type of cases the diet suggested by Seibert in typhoid appeals strongly to the author. It possesses considerable nutritive value, namely : Strained rice, oviij (250 cc), barley or oatmeal soup containing the extract of J pound of meat and the yolk of a fresh egg. This can be spiced slightly to improve the flavor. It can be given five or six times daily. Strained pea soup, lentil, tomato, or potato soup can be used in addition. Rice flour is excellent in the form of a thin gruel, and can be made with milk which has been thoroughly boiled. The object should be to give frequent (five or six smaller) meals, so as not to overburden the stomach, and yet secure a sufficient amount of nutrition to improve the patient's physical condition. Cream, oij (60.0) in oiv (125 cc.) of water, possesses considerable nutritive value. Crackers heated thoroughly and well buttered can be rubbed up in the broth. Fat in the form of cream and butter should be administered. In the milder cases, scraped beef, rare beef, soft-boiled eggs thickened with a small amount of mashed potatoes, and rice strained through a colander, with plenty of butter, can be given, with a little asparagus and spinach. Other vegetables are more difficult to expel from the stomach. Matzoon, kumyss, bacillac, kefir, and milk prepared with lactone tablets (lactone-buttermilk) are of special value in cases suffering from auto-intoxication having nervous symptoms and indicanuria CHRONIC DILATATION OF THE STOMACH 33 1 (intestinal putrefaction). The matzooncan be diluted with one-third water or Vichy that has been allowed to become flat. This last avoids gaseous distention of the atonic stomach. It is also prefer- able to allow some of the gas to pass off from the kumyss. About I quart of one of these preparations can be used daily — additional water or Vichy one-third in volume being then added. These sour milk preparations, especially with the slight dilution, pass readily from the stomach. They do not curdle like plain milk. The yolks of several raw eggs, stale bread or crackers with plenty of butter and cream, strained vegetable soups, rice gruel, and sanatogen can be added. Meat preparations should be avoided in these cases. In cases with deficiency of hydrochloric acid, the meats are not well digested and should be given in smaller quantities; rice, barley, and tapioca (strained) or in purees, and mashed potatoes are of service, and in larger amounts. I have often found raw eggs beaten up in water or milk of great service, employing at times six to eight daily. The milk can be completely or partially peptonized to lessen curd formation.^ If thirst is marked, rectal enemata of hot normal saline solution are indicated,^ and in very severe cases the stomach may be given a rest and nutritive enemata be given for a few days. Sanatogen, preferably flavored, tropon, and somatose are useful adjuncts, given in divided doses in the broths. If anemia is pres- ent, iron tropon can be added, oj (4-0), three times a day. Always peptonize milk if given by enema. After eating the patient should lie down for from one-half an hour to an hour, preferably on the right side, so the stomach can empty itself more readily. Mechanic Support. — One of the most important methods of treatment is the use of proper support to the organ, and the ideal method is by Rose's adhesive plaster belt, a description of which has been given. It increases intra-abdominal pressure and the stomach is pushed upward, acting in effect like gastroplication. Transillu- mination was employed in one case (Fig. 150), the belt applied, and transillumination again carried out (Fig. 151). The illustration (Fig. 151) shows the result, the lower border of the stomach being elevated 4 inches. This belt should be worn four or five weeks and a new one then applied. It aids in the evacua- tion of the stomach contents. Silk abdominal belts may be sub- stituted, but the support is not continuous and the adhesive strapping is superior. General Hydrotherapy. — External douches — the fan douche and also the Scotch douche — applied to the region^ of the stomach and changing the temperature of the water has been serviceable 1 With the precaution noted, milk may be employed in the cases with not too marked motor insufficiency. It is a simple matter to test whether it leaves the stomach readily or not. 2 Proctoclysis is of value. ^ ^n adjustable silk belt is worn in this event. 332 DISEASES OF THE STOMACH AND INTESTINES in some cases. Cold compresses and cold sponging are at times useful. Local Treatment of the Stomach. — (i) Lavage. — In some of the milder atonic cases proper diet, mechanical support, and appropriate medication may suffice without or with occasional lavage. In the more severe cases lavage is indicated, and the time of its performance and frequency depend upon the degree of dilatation and the amount of residuum found after the test meal (degree of motor insufficiency). Fig. 150. — Dilatation of the stom- ach. Transillumination with fluores- cein before application of Rose's belt (Case i) (Ward's Island Gastro-intes- tinal Clinic, Manhattan State Hospital). Fig. 151. — Dilatation of the stom- ach, same patient (Case i). Trans- illumination with fluorescein after application of Rose's belt. By accu- rate measurement the stomach has been elevated and the lower border is 4 inches higher than it was before the belt was applied. The lower border now lies above the umbilicus (Ward's Island Gastro-intestinal Clinic, Man- hattan State Hospital). If there is not immediate im- provement if lavage is omitted, it must be added to the treatment. If a large amount of residuum is present after a test meal or test breakfast, or there are nervous symptoms, or in the morning before breakfast a residuum is present, lavage should be carried out. As to the proper hour for lavage, I believe Riegel holds sound views, and my own experience agrees with his; if the residuum is 200 to 500 cc. or more before supper, it is best to wash the stomach then and follow with a light meal; if this is not done the organ will contain fermenting food during the night which will increase the CHRONIC DILATATION OF THE STOMACH 333 atony. If food is present before breakfast a second lavage is then indicated. The washing should be performed with the patient both sitting and lying down, so as to remove all the irritating material. The stomach should be washed until the return is clear. Daily lavage is generally necessary at first. As the tone of the stomach improves, the residuum found will decrease and washing may be performed less often. The first part of the washing may be done with plain warm water, though normal saline solution is preferable. I have found milk of magnesia (Phillips), oij (60.0) to i quart (liter) of water, excellent for the preliminary lavage. It is well to employ antifermentatives in the final treatment, such as — Acid salicylic i : 1000 Sodium salicylate 1:1 000 Sodium benzoate i : 1000 Listerin 1 Glycothymolin >oj (4-o) to i quart (liter). Borolyptol J Resorcin or \ gr. 15 to 30 (1.0-2.0) to i Boric acid J quart (liter). (2) Electricity. — ^The intragastric faradic current (preferably) can be employed if there be no objection on the part of the patient, using Lockwood's instrument. In many cases the percutaneous method is advisable. Static electricity is claimed to be of value, and in some cases to reduce the size of the atonic dilated stomach. Massage or -vibratory massage are of service to tone the muscula- ture and aid in emptying the stomach. (3) The stomach douche has been recommended in the milder forms to stimulate the organ. The fluid should be at a temperature of 95° to 85° F. (gradually reduced). If hydrochloric acid is diminished, normal salt solution may be employed ; if HCl is increased, then use silver nitrate i : 3000 to i : 2000. -Bitter remedies, such as quassia (fluidextract) , 0.888 cc. (111 15) to 1.77 cc. (oss), or a cup of quassia-water (quassia cup filled with water and allowed to set for half an hour) ; or hops (fluidextract lupulin), 0.888 (TTLxv) to 1.77 cc. (.oss), or fluidextract of condurango, 1.77 cc. (oss) to 3.54 cc. (oj) to a liter of water, have been recommended for lavage as a stimulant, but I see no special value in their use. The stomach spray has also been suggested in place of the stomach douche, but it possesses the disadvantage of injecting considerable air. Medicines. — If there is deficiency of hydrochloric acid, the stomachics and hydrochloric acid should be administered, such as are employed in chronic gastritis. The following prescription is often valuable: 334 DISEASES OF THE STOMACH AND INTESTINES Acid hydrochloric, dilute J ^^ ^ " *^^ J-* Comp. tinct. cinchona 16.0 (oss) Aq. destil q. s. ad. 125.0 (oiv). — M. Sig. — One to two teaspoonfuls in a wineglassful of water t. i. d. half an hour before meals. If there is hyperacidity, magnesia usta, gr. xv to oss (1.0-2.0) or more, in water t. i. d. an hour after meals. Or milk of magnesia (Phillips), 5j to ij (4.0-8.0), in water. These are excellent remedies. If bicarbonate of soda be employed, it is better to combine it with magnesia usta, equal parts, as it readily generates carbonic acid gas. In the atonic type of dilatation I have always been inclined to employ nux vomica or its alkaloid as a stimulant to the musculature of the stomach, even though hyperacidity be present, which is rare; in the latter event combining belladonna with the nux, as a pill, before meals: "*■ Ext: SadoZl'" } »^ ^- i (°-°-^'-»- or I^. Strychnin gr. eV (0.00108) Atropin gr. too (0.00064).— M. If nux vomica is incorporated in the stomachic mixture, it should not be repeated. If the tincture of nux vomica is employed, it can be gradually increased to large dose — oss (2.0) t. i. d. For fermentation and intestinal putrefaction the following remedies are of service, given three times a day half an hour to an hour after meals: Sahcylate of soda, benzoate of soda, ichthoform, ichthalbin, bismuth salicylate, salol, resorcin, benzonaphtol, bismuth phenolate, or bismuth sulphocarbolate, all in doses of gr. v (0.3) each. Urotropin, gr. V (0.3), given in combination with sodium benzoate, gr. v (0.3), in water t. i. d. after meals is also useful. I have found resorcin an excellent remedy, alone or combined with bismuth subnitrate. If mould is present the creosote prepara- tions as suggested by A. Rose are preferable, such as beech wood creosote, Ttlj (0.059 cc), or carbonate of creosote (creosotal), gr. 5 (0.3), three times a day after meals. For constipation the olive oil injections at night, to be retained, Siv (125 cc.) to I pint (500 cc.) or more, as suggested by Fleiner; massage, electricity, the estabhshment of a regular hour for stool, the administration of a glass of water on rising, and, if required, the use of the cascara preparations or the aloin and belladonna pill, or one of the phenolphthalein preparations, such as phenolax, at night. The saline cathartics are objectionable. Gastrosuccorrhea is rare in the atonic type of dilatation. In the event of its presence, lavage with nitrate of silver (i : 2000) twice CHRONIC DILATATION OF THE STOMACH 335 a week and belladonna tincture, IfTlx (0.592 cc.) t. i. d., or extract of belladonna, gr. J (0.022) t. i. d., are indicated. For further treat- ment, the chapter on this subject should be consulted. For gastric tetany, which may occur in the atonic type of ectasy, but which is a rare condition, lavage is of service, but gastro-enteros- tomy is indicated. Moynihan has operated on 14 cases of gastric tetany, with cures in all. Surgery. — In atonic ectasy, when no improvement occurs under treatment or when the dilatation is of great degree and the patient's condition seems to be getting worse, operation is indicated — prefer- ably drainage of the stomach by gastro-enterostomy. Gastroplication — infolding the wall of the stomach and sewing it in pleats — has also been successfully reported. Coffey has sutured the greater omentum to the abdominal wall and thus supported the stomach in a hammock. He reports two favorable results. Treatment of Stenotic Dilatation (Benign Stenosis) In these cases, where there is a mechanical obstruction to the exit of the gastric contents, the muscular action is increased during the earlier stages and hypertrophy of the pyloric end of the stomach is present; later the fundus and body become distended and thinner. Gentle massage from left to right, or vibratory massage by the same method, the patient lying on the right side and the manipulations being performed an hour or two after meals, may aid in emptying of the stomach. Electricity is of slight or no value. I have seen no permanent benefit from these methods in the obstructive type of dilatation. Olive oil, oij to iv (60.0-125 cc), administered three or four times a day before meals will aid the passage of the food through the stenosed region, and Rose's adhesive plaster belt is also of service. The diet must be liquid in the worst cases and mushes may be employed in the less severe types. Raw eggs, six to eight a day, plenty of fat, such as butter and cream, sanatogen, somatose, and tropon, are all of service. The general method of feeding with small frequent meals is the same as in atonic ectasy. Improvement in weight must be secured. Solid food is objectionable. "The sour milks, such as bacillac, lactone-buttermilk, kefir, matzoon, and kum^^ss, administered after the manner described in atonic ectasy, are of value." lyavage is always necessary, and for the attacks of spasmodic pain is the most rapid method to secure relief. As hyperacidity is present, alkalis are indicated to correct this condition, as in hyper- chlorhydria. Tincture of belladonna in large doses, 10 to 15 drops t. i. d., will often relieve spasm and pain, also the application of heat. Vomiting.— For vomiting lavage is indicated, followed for several days by rectal feeding and then commencing with a small amount of liquid nourishment. 336 DISEASES OF THE STOMACH AND INTESTINES Rectal injections^ of normal saline solution, oviij to Oj (250- 500 cc), may be indicated to relieve thirst and collapse. Thiosinamin, gr. v (0.3) doses t. i. d. by mouth, or gr. iij (0.2) doses in 15 per cent, alcoholic or 10 per cent, glycerinated solution by hypodermic, may prove of service in fibrous contractures of the pylorus. Gastrosuccorrhea may occur in cases when there is an ulcer with stenosis at the pylorus and, rarely, hemorrhages. Temporary treat- ment as for hemorrhage of gastric ulcer is indicated, and then surgical procedure. The treatment for gastrosuccorrhea is described in the chapter on that subject. Gastric tetany may be a complication for which lavage is indicated temporarily, and then operation (gastro-enterostomy). I have seen cases of ectasy from benign stenosis lose 75 pounds in weight and regain 50 to 60 pounds under treatment, and ultimately relapse and come to operation. I have treated many so-called brilliant cures by specialists, the ultimate results being the same. These patients, even at the best, tend to become chronic invalids and always require treatment. The best physician for these cases is the surgeon. If the cause of the stenosis lies external to the pylorus, bands, adhesions, etc., can be separated. If it is intrinsic, resection of the pylorus can be performed in suitable cases, or drainage by gastro- enterostomy. The latter is usually the operation of selection. Divul- sion I do not approve. I have seen a patient gain 100 pounds in weight in eight weeks after gastro-enterostomy, and, from being a confirmed invalid, restored to perfect health. Malignant Stenosis In these cases early radical operation is indicated, as described under Cancer of the Stomach; otherwise, palliative gastro-enter- ostomy. If operative procedure be refused, then diet, lavage, and the treatment laid down under Carcinoma Ventriculi. COMPLICATIONS OF CHRONIC ECTASY Gastric Tetany Tetany is characterized by peculiar bilateral tonic spasm of the extremities, either paroxysmal or continued. Pathology. — In all cases there is dilatation of the stomach of a high degree, due generally to stenosis of the pylorus or the duodenum ; frequently the result of an ulcer; rarely from carcinoma. Gastrosuccorrhea has been associated with it in some cases. Tetany has also been reported with acute ectasy and in atonic ectasia. Etiology. — There are three theories as to its cause: 1 Proctoclysis is of service. COMPLICATIONS OF CHRONIC ECTASY 337 (i) Kiissmaul and, later, Fleiner believed its symptoms are due to the great loss of fluid in the system, the thickening of the blood, and the consequent drying of the tissues. (2) Friederick Miiller and Germain See consider it to be the result of some reflex action, as Miiller brought on an attack by tapping the epigastric region. Riegel has observed it on passing the stomach- tube ; and it has also occurred in cases of intestinal worms. (3) The third theory explains it on the ground of auto-intoxica- tion, since fermentation and putrefaction are present in the stomach. This last is probably correct, as the cases have been benefited by lavage and cured by stomach drainage (gastro-enterostomy). Amato reports a case of gastric tetany with death. He has introduced fermenting materials into the stomachs of animals and produced dyspnea, myosis, muscular contraction, and trismus. The liver and pancreas (post mortem) showed lesions, such as are usually found in poisonings and intoxications. Symptoms. — There are tonic and clonic bilateral spasms, which appear suddenly and are generally confined to the extremities, the flexor muscles being chiefly affected. The fingers are bent at the metacarpophalangeal joint, extended at the terminal joints, being pressed close together, and the thumb is contracted into the palm of the hand. The wrists are flexed, the elbows bent, and frequently the arms are folded over the chest. The knees are bent, the feet extended, and the toes adducted. In severe cases there may be trismus and the angles of the mouth are drawn up. There is sometimes edema of the hands and feet. The spasms are usually paroxysmal and last for a variable time. The eyes may be turned up. In the acute attack there may be a rise of temperature and elevation of the pulse. In some cases there may be involvement of the muscles of the back and of the thorax, with dyspnea and cyanosis. The attack may be acute, from a few minutes to several hours, but there may be some stiffness and contraction lasting several weeks. Diagnosis. — There are certain diagnostic features: (i) ''Trousseau's Symptom." — As long as the attack is not over, the paroxysms may be produced by compressing the affected parts, either in the direction of their principal nerve-trunk or over their blood-vessels, so as to impede the venous or arterial circulation. (2) "Chvostek's Symptom." — There is an increase in the mechanical excitability of the motor nerv^es. A slight tap over the facial nerve will throw the muscles to which it is distributed into active con- traction. (3) "Erb's Sign." — The electric irritability of the motor nerves, to the galvanic current especially, is increased. (4) "Hoffmann's Sign." — Heightened excitabiUty of the sensory 22 338 'DISEASES OF THE STOMACH AND INTESTINES nerves. The slightest pressure may cause paresthesia in the region of distribution. The prognosis of tetany is extremely bad. Frequency. — Moynihan believes it to be not so very rare, and reports 14 cases in which gastro-enterostomy was performed, with a cure in each case ; though some claim only 30 to 40 cases are re- ported. Tetany-like attacks with epileptiform attacks are more frequent, and will be referred to under Epilepsy. Treatment. — Bromids, and even chloroform inhalation during the acute attack. Lavage is beneficial. The chief indication is drainage of the stomach by gastro- enterostomy. REFERENCES 1. Smith, Med. Record, 1900, Iviii, 910. 2. Dujardin-Beaumetz, L'Union Medicale, 1884, Nos. 15 and 18. 3. Strong, Boston Med. and Surg. Journal, 1902, cxlvii, 561, 597. 4. Simpson, Pract., 1900, Ixv, 283. 5. Kussmaul, Deutsches Archiv. f. klin. Med., 1869, Bd. 6. 6. Moynihan, Pract., 1903, Ixx, 354. 7. Bouveret, Rev. de Medicine, 1892, p. 48. 8. Ewald, Berlin, klin. Wochenschrift, 1894, No. 2. 9. Fleiner, Arch. f. Verdauungskrankheiten, Bd. 1, Heft. 3. 10. Einhorn, Diseases of the Stomach. 11. Amato, La Riforma Med., Feb. 4, 1903. 12. E- Neumann, Deutsche Klinik, 1861. 13. Boas, loG. cit., 107, and others. CONVULSIONS— EPILEPSY Epileptic seizures occur both in cases of chronic ectasy and in other affections of the stomach. I have a case at present under observation at the Manhattan State Hospital who suffered from repeated attacks of epilepsy, 140 seizures a month. There is dila- tation of the stomach, with ptosis and hypochlorh^^dria. For the last two years, while having occasional lavage, dietetic treatment with medication directed to the stomach, no bromids, she has had no attacks, except for the period of a week, a year and a half ago, when the treatment was omitted. At the same institution there is another patient with atonic ectasia and hypochlorhydria, who had frequent epileptic attacks and who has had no seizures for over a year, as a result of treatment directed to the gastro-intestinal tract. I have reported a case of hyperchlorhydria,^ with epileptic seizures, apparently cured by appropriate treatment; and cases of dementia paralytica with chronic ectasy, in which the convulsions were diminished under treatment and the high temperatures returned to normal. I have also seen tetany-like convulsions in a case of dementia prsecox, with gastroptosis and marked ectasy, improve ^ Observations on the Relation of the Gastro-intestinal Tract to Nervous and Mental Diseases, reported April 17-21, 1905, American Medicopsychological Association, and in their proceedings. CONVULSIONS — EPILEPSY 339 after treatment of the stomach. Salt-free diet, the avoidance of meat, open air, and treatment appropriate to the gastric findings in each case are indicated. In conclusion I cannot recommend too highly the sour-milk diet in the treatment of these cases. Matzoon, kumyss, kefir, or the lactone-buttermilk can be employed after the manner indicated under Atonic Ectasy. I have found Wm. H. Thomson's formula for the preparation of matzoon of great value. It is as follows : " I. Place half a cake of yeast in i pint (500 cc.) of fresh milk in a pitcher covered with a towel in a warm place for twelve hours ; then " 2. , Add to this i quart (liter) of milk and keep in a warm place for twelve hours ; then "3. Take i pint (500 cc.) of No. 2, add to it i quart (liter) of milk and keep in a warm place for twelve hours ; then "4. Take i pint (500 cc.) of No. 3, add to it i quart (Uter) of milk and keep in a warm place for twelve hours. "This makes ij quarts (1500 cc.) of matzoon, the entire process occupying forty-eight hours. " One quart (liter) of this can be administered in divided doses daily, breaking in it stale bread or crackers and eating it with a spoon. The remaining pint (500 cc), with the addition of i quart (liter) of milk at the end of twelve hours, will furnish i^ quarts (1500 cc.) of matzoon. Fresh matzoon can be made daily from the former pint (500 cc.) of mother matzoon for about two weeks, when the process must be started over again. If larger quantities are to be used, I quart (liter) of No. 2 can be used with 2 quarts (liters) of milk, and so on." This method has been extensively employed by Thomson and the author in feeding our epileptics. One can also use oiv to vj (125- 185 cc.) of the ordinary bottled matzoon to i quart (liter) of milk, which will produce matzoon if kept twelve hours in a warm place. From this daily matzoon can be made from each previous supply for about a week, when a fresh bottle must be employed. CHAPTER XVI ANOMALIES IN THE POSITION AND FORM OF THE STOMACH— HOUR-GLASS STOMACH— DISLOCA- TIONS— GASTROPTOSIS Anomalies of form are frequently congenital. Fore-stomach is a dilatation of the lower end of the esophagus immediately above the diaphragm. Antrum cardiacum is a sacculated diverticulum of the esophagus situated below the diaphragm. In some cases no symptoms are present; in others food becomes lodged and causes serious results. Megalogastria is a congenital or acquired large stomach with normal functions. Microgastria is an abnormally small stomach with normal functions. Angustatio ventriculi is an ex- tremely small stomach due to stricture of the cardia or esophagus or cirrhosis ventriculi. Congenital Narrowing of the Pylorus. — This condition is due to hypertrophy of the circular muscles of the pylorus. It may be of so severe a type that ingestion of food may be impossible and the infant die within a few days after birth. In milder cases chronic ectasy may result. HOUR-GLASS STOMACH This condition may be congenital, but is more frequently acquired. The stomach has a peculiar sacculated outline, and is divided into two parts — the cardiac and pyloric (Fig. 152). In some cases the cardiac sac is larger, in others, the pyloric. Etiology. — Cicatrized tissue contrac- tion following an ulcer; less frequently peritonitic adhesions, corrosive gastritis, and carcinoma are causes. Slight forms may produce no characteristic symptoms. In advanced cases the division may be recognized. By the ingestion of bismuth and the use of the fluoroscope this con- dition can be demonstrated. The following diagnostic points have been given by Moynihan : With lavage, part of the fluid is lost; if the stomach is washed clean, a sudden reappearance of the stomach contents takes place, "paradoxical dila- tation"; when the stomach has been apparently emptied, a splashing sound may be elicited by palpation of the pyloric segment ; after dis- 340 Fig. 152.- -Hour-glass stom- ach. GASTROPTOSIS — ENTEROPTOSIS — GLENARD's DISEASE 34 1 tending the stomach, a change in the position of the distention tumor may be seen in some cases. Gushing, bubbhng, or sizzHng sounds are heard on dilatation with carbonic acid gas at a point distinct from the pylorus. In some cases, when both parts are dilated, two tumors with a notch or sulcus between are apparent to sight and touch. On both sides of the furrow there will be a loud tym- panitic sound which cannot be elicited in the middle. Stockton finds that if the first part of the stomach is aspirated, after manipulation, it is sometimes possible to force from the second into the first portion a gastric juice of different quality. Operative procedure is the only method of cure. DISLOCATION OF THE STOMACH The fundus may be dislocated upward. Among the causes are: Absorption of a pleuritic exudate on the left side ; after contraction of the lung or any process which is accompanied by upward dislocation of the diaphragm; excessive distention of the abdominal cavity, forcing the diaphragm upward, such as from pregnancy, ascites, tumors, and meteorism ; diaphragmatic hernia. The cardiac end of the esophagus may become bent. Lateral dislocation is rare, and may be caused by tumors of the spleen, distended colic flexure, or lateral pressure from an enlarged liver. As a rule, the latter forces the stomach downward. Downward dislocation (gastroptosis) is the common form. GASTROPTOSIS— ENTEROPTOSIS—GLENARD'S DISEASE (Synonyms. — Gastroptosia (Rose); Visceroptosis; Splanchnoptosis; Abdominal Relaxation or Atonia Gastrica (Rose) ; Atony of the Third Degree.) Definition. — Gastroptosis may be defined as a prolapse or downward displacement of the stomach, right kidney or both kidneys, and other organs of the abdominal cavity,^ which may be associated with disturbances of the gastro-intestinal tract and pelvic organs, together with various nervous symptoms. -Nephroptosis is a stigma of gastroptosis. Introduction. — I here use the term "gastroptosis" with the usual definition (ptosis of the stomach), though Rose has shown it correctly means descent of the belly (splanchnoptosis). The reader must remember that gastroptosis is a quite frequent condition, and that it may be accidentally discovered in some cases which have no symptoms whatever. On the other hand, there are various degrees of ptosis of the stomach, in some of which the symptoms are rather mild in character, while in others there may be the symptoms-com- plex of Glenard's disease. It is not the position of the lower border of the stomach which constitutes a ptosis, but that of the upper border; with the relaxation 1 Ptosis of the heart may also occur. 342 DISEASES OF THE STOMACH AND INTESTINES of the suspensory ligaments of the stomach the lesser curvature sinks as well as the greater, and we may have varying degrees of ptosis, from moderate obliquity of the upper border to a vertical stomach ; while on the other hand, the entire organ may sink and give the crescentic form of gastroptosis. The determination of the lower border alone is not diagnostic, since it may merely be evidence of a dilated stomach. Hundreds or even thousands of cases of nephropto- sis have been reported with dilated stomachs, the dilatation being imputed to pressure of the kidney on the duodenum, and no investi- gation has been made of the position of the lesser curvature. From my own experience, I do not hesitate to say that movable kidney (nephroptosis), with the lower border of the stomach lower than normal, is diagnostic of gastroptosis. Dilatation of the stomach^ is often associated with gastroptosis, but kidney pressure on the duodenum, in my opinion, has no bearing as to its production. Furthermore, treatment for gastroptosis will generally cure this condition. Ptosis of the stomach in some of these cases may be of extremely mild type. Anatomic Considerations.— It is necessary to briefly allude to certain anatomic features. The liver, as we know, is suspended from the diaphragm by ligaments derived from the peritoneum. The cardiac end of the stomach is held quite fixedly in position by the esophagus, and there is a peritoneal attachment to the diaphragm at this point, the gastrophrenic ligament. In this location the stomach lies in close relation to the diaphragm, while the lesser curvature is suspended from the liver by the lesser omentum (gastrohepatic). The spleen lies in close relation to the diaphragm, being attached thereto by ligaments (processes of the peritoneum), and to the stomach by the gastrosplenic omentum. It is thus readily understood how compression of the lower part of the thorax or effusions above the diaphragm may mechanically force down the latter and produce ptosis of organs so closeh^ asso- ciated. The descent of the intestines is a natural accompaniment. A tumor of the p^dorus may cause ptosis of the stomach, and prolapse of the transverse colon and of the other viscera follow. On the other hand, a severe type of dilatation of the stomach may be followed by ptosis of the organ and then general visceroptosis. These primary types of gastroptosis are not so very frequent. The transverse mesocolon surrounds the transverse colon and connects it with the back of the abdomen at the spine. The trans- verse colon is attached to the abdominal surface of the eleventh rib on each side by a fold of peritoneum. As the colon passes across the abdomen it sags somewhat, presenting a slightly concave surf ace superiorly. Glenard, whom we must justly credit as the first to describe splanchnoptosis as a pathologic entity, believes enteroptosis (ptosis of the transverse colon) to be the starting-point. He thinks 1 This combination has been found in cases at the Manhattan State Hospital. GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S DISEASE 343 the transverse colon is fastened to the pyloric end of the stomach by a band (ligament) and that the hepatic flexure first sags, followed by the transverse colon, causing thus a sharp flexion at the attach- ment of the ligament, and a hindrance to the progress of the intestinal contents, with resulting accumulation in the ascending and transverse colon. From the point of stenosis the transverse colon passes down- ward diagonally across the abdomen as a hard cord-like mass (corde colique transverse). The sagging of the transverse colon exercises traction on the pylorus and omentum, thus causing descent of the stomach and liver. The descent of the hepatic flexure, he believes, causes traction on the parietal peritoneum and encourages ptosis of the right kidney. The gastro-intestinal tract, he noted, was suspended in the form of loops, six in number, by means of ligaments; and he believed in the possibility of too great a bend at such an acute angle, that it might cause a partial obstruction to the passage of the contents. This might occur at the gastroduodenal, the duodenojejunal, transverse colon, or sigmoidorectal curves. The gastroduodenal and transverse colon ligaments Glenard holds to be the weakest, and if they give way, with resulting ptosis of the intestine, increased traction and angulation is produced at the next fixation point, causing an enterostenosis. Glenard found the transverse colon displaced and stenosed in numerous autopsies, and was the first to realize that many cases of so-called nervous dyspepsia were dependent upon these abnor- malities. Riegel has demonstrated that the hepatic flexure is not dislocated downward in the majority of cases, and Glenard's explanation I hardly believe tenable, as there are other very important factors which have a bearing. A tumor, however, of the transverse colon or adhesions may produce primary enteroptosis. We must remember there is one type of case, a congenital con- stitutional defect, the patient with long narrow thorax, who suffers from splanchnoptosis. The major number of cases of gastroptosis, however, are acquired from various causes; and in my opinion the development of the prolapse of the various organs generally occurs synchronously, the stomach, right kidney, and transverse colon most frequently pro- lapsing together; while in other cases the left kidney or the rest of the viscera may descend in addition. These following are the prominent factors which have a marked bearing in preserving the proper position of the viscera: (i) The abdominal muscles. (2) The maintenance of normal intra-abdominal pressure. (i) Abdominal Muscles. — In an interesting article, A Rose' calls 1 Surgery, Gynecology, and Obstetrics, November, 1906, Physiology and Pathology of the Abdominal Muscles. 344 DISEASES OF the; stomach and intestines attention to the fact that in addition to the usual functions described in the text-books, in assisting expulsion of the fetus, bowel action, urination, and vomiting, the abdominal muscles aid in the preserva- tion of the physiologic position of the abdominal organs. The cross- wise arrangement of the external and internal oblique and trans- versalis muscles — supported by the recti — effect a narrowing of the abdominal cavity and prevent visceral ptosis. Groddeck, of Baden-Baden, has, moreover, described the mechan- ical influence of healthy muscle, by the alternate contraction and ex- pansion, in assisting the circulation of the blood and lymph, and an atonic condition of the abdominal musculature would certainly interfere with the maintenance of the normal relations between the extra- and intra-abdominal circulation. Moreover, clinically, simple inspection will differentiate between normal conditions and the typic "pot-belly" of the gastroptosis patient. Acute or wasting disease may also cause changes in the muscles. (2) Intra-abdominal Pressure. — Normal abdominal muscles also maintain the normal intra-abdominal pressure necessary to preserve the position of the viscera. Walkow^ has made a very exhaustive study of this question and has demonstrated, for example, on the cadaver, with the upper part of the trunk elevated (the reversed Trendelenburg position), that after abdominal section mobility, of varying degrees, of the kidney is found, which did not previously exist. Stiirmdorf has found similar results after laparotomy on the living. Clinically, changes in the intra-abdominal pressure, the result of childbirth or tapping for ascites, have resulted in the production of splanchnoptosis, the thinned and distended musculature of the abdomen also being a factor. Rapid loss of weight from emaciation and absorption of omental fat is another example. Nephroptosis. — Movable kidney, in probably 95 per cent, of cases in my own experience, is one of the stigmata of gastroptosis. The congenital type, with long mesonephron, or those cases due to traumatism, are comparatively few in number. The right kidney has a longer pedicle and lies lower on account of the liver. Stiirmdorf refers to certain skeletal deformities as influencing the shape of the bony receptacle for the kidneys, and which in some cases predisposes to prolapse; but gastroptosis is associated with these same conditions. It has been claimed that there is a nephrocolic ligament connecting the kidneys to the ascending and descending colon, and that traction of the colon may influence its descent. Reversed peristaltic action occurring intermittently in the ascending colon, which does not take 1 Medical Record, January 13, 1906. GA5TROPTOSIS— ENTEROPTOSIS — GLENARD's DISEASE 345 place in the descending, is believed to have an influence, and the peritoneum over the left kidney is said to be thicker. The fact that the tail of the pancreas lies in front of the left kidney seems to me to have some bearing on the question. Absorption of the fatty capsule is probably another factor. The peculiar position of the right kidney and lessening of intra- abdominal pressure seem to be the chief causes of its more frequent descent. With gastroptosis we have also a relaxation of the gastro-intestinal musculature and of all the peritoneal ligaments. Changes in the posi- tion of the stomach and in its secretory and, at times, in its motor functions account for the gastric disturbances. The secretory func- tion one might expect to be influenced by circulatory disturbances following displacement of the organ. Associated are changes in the position of the duodenum produc- tive of stasis, and which readily account for gall-bladder symptoms simulating stone, so often attributed to nephroptosis. Similar disturbances in the intestine, constipation, diarrhea, mucous colic, or chronic appendicitis^ can thus be accounted for. There is a relaxa- tion of the broad ligaments and with it ovarian and uterine descent, and even descent of the pelvic floor, with dysmenorrhea and various pelvic symptoms. Occasionally Dietl's crisis from torsion of the kidney pedicle and, rarely, nephritis or hydronephrosis occur. More rarely the kid- ney may become adherent to the gall-bladder or appendix. In addi- tion, circulatory disturbances and marked neurasthenia, the latter due chiefly, I believe, to auto-intoxication, are present; and from the severe type of splanchnoptosis we have the symptoms-complex of Glenard's disease — all of which the "kidney experts" attribute to nephroptosis. Etiology. — We must remember that the vertical stomach is the fetal position of the organ and every infant is born with it in this position. After a few weeks or months, through the weight of the food and the action of the diaphragm, the position of the stomach becomes normal. Occasionally it may remain vertical, but I believe this is true more especially in those suffering from the congenital constitutional defect, to which I shall refer. The causes of gastroptosis may be divided into congenital and acquired : I. Congenital constitutional defect, the long narrow thorax, with the diaphragm and liver pushed down. In these, splanchnopto- sis is a constitutional defect. Stiller's floating tenth rib is usually present. 2. Other skeletal deformities, spinal curvature, rickets, ky- phosis, kyphoscoliosis. 3. Intrathoracic pressure on the diaphragm from effusions, tumor, etc. 4. Tumors of the liver. 5. Leukemic 1 1 do not agree with Edebohls' theory of compression of the superior mesen- teric vein by the kidney as a cause of congestion of the appendix. 346 DISEASES OF THE STOMACH AND INTESTINES enlargements of the spleen. 6. Tumor of the pylorus or adhesions (gastric). 7. Tumor of the colon or adhesions. 8. Chronic dilata- tion of the stomach. 9. Compression of the thorax by tight lacing, poor corsets, tight waist-bands, etc. 10. Relaxation of the abdom- inal muscles and diminution of intra-abdominal pressure. This may result from rapid emaciation in acute disease, with degeneration of the muscular tissue ; or the same condition in longer chronic wasting disease, or from loss of weight and muscular tone from any cause. Landau's disease, splanchnoptosis following confinement, is fairly frequent. Emptying of the uterus produces a sudden diminu- tion in intra-abdominal tension, and the tendency of the viscera is to fill the vacuum previously occupied by the uterus. The abdominal walls are lax and thin from uterine pressure. The accoucheur is often to blame for not properly supporting the relaxed abdomen. Tapping of ascites, with removal of all the fluid, may produce a similar condition; or removal of large tumors. Sex. — Meynert found in 50 girls, age twelve, 50 per cent, gastropto- sis, and about 80 per cent, females in his gynecologic clinic to 5 per cent, males among adults. From the study of various statistics it can be estimated that from about 20 to 25 per cent, of women complaining of digestive disturb- ances are affected with movable kidney and enteroptosis. Unques- tionably the percentage of gastroptosis among all women, including those who complain of no symptoms, will average at least 15 per cent, in our city population. The advocates of nephropexy find nephrop- tosis, disregarding the other ptoses, in 20 to 33 per cent, of all women, a satisfactory surgical viewpoint. The improvement following promiscuous nephropexy in gastro- intestinal and other symptoms can be often imputed to the post- operative rest in bed and to the increase in fat by proper feeding. The ratio of males complaining of digestive disturbances, with enteroptosis and nephroptosis, is about 2 to 3 per cent. The ratio in women is 8 or 10 to i male. Glenard finds a lower ratio, 70 women to 30 men in 100 cases. Age.— The most frequent age is from eighteen to forty, though between fifty to sixty the condition appears most marked. Symptoms. — Gastroptosis may exist without the production of any symptoms; while, on the other hand, it may be present with those of a mild character, or may finally present the aggravated type of Glenard. The following symptoms in part or whole may be present: Some cases complain chiefly of nervous, cardiac, gastro- intestinal or pelvic disturbances, or of special organs, such as the kidney or liver. There is usually anemia, a feeling of weakness or faintness, and fatigue on slight exertion and backache. The appetite in some cases is poor, while in others quite good. GASTROPTOSIS — ENTEROPTOSIS — GLENARD's DISEASE 347 Some patients have the symptoms-complex of hyperchlorhydria, while others complain of belching and discomfort immediately after eating. There is usually marked and obstinate constipation, rarely diarrhea; at times intestinal catarrh or mucous colic. Flatulence is present. They have headache, are frequently nervous and hysteric, and at times neurasthenic. There is often a feeling of weight or bearing down in the abdomen, which is relieved by proper support. Menstrual disorders are frequently present, dysmenorrhea quite often. At times the pain and discomfort are focused in the kidneys, especially the right ; and in addition . they may have attacks of Dietl's crisis. Pains in the region of the liver and gall-bladder occur in some, and there may be attacks of pain resembling gall- stones and occasional jaundice. There may be irritability of the bladder, with frequent inclination to urinate, and pains in the ovaries and appendical region. Various sensitive points are often found in other regions of the abdomen. Palpitation is frequently present and occasionally attacks of tachycardia may occur. Physical Examination. — Inspection. — ^These patients are usually thin and slender; the abdominal walls are generally flaccid. There Fig. 153. — Abdominal projection; lead-tape outline between anterior su- perior spines; curved line, when standing; fiat line, when lying on back (from Gallant) . is a concavity between the costal arches in the epigastrium from the ensiform to the umbilicus; and in some a vertical median sulcus between the recti muscles wider above than below. In the dorsal position the abdomen may be flattened below and bulge laterally; and when the patient is erect the epigastrium becomes more depressed; while the hypogastric regions from the umbilicus to the symphysis and the pubic region markedly bulge forward and outward (pot belly). Fig. 153 shows this clearly. Palpation. — Diastasis (separation of the recti muscles) can be readily appreciated. Stiller's floating tenth rib is present in some cases. Marked pulsation of the abdominal aorta is often met with, as it is uncovered by the stomach. Movable kidney of varying degrees can be readily appreciated, and this, taken in connection with the splashing sound found below the normal position of the lower border of "the stomach, is pathognomonic of gastroptosis. The corde colique transverse is generally found to be the pancreas, which may also prolapse. Splashing Sound. — This is the best method to determine the lower border of the stomach and has been thoroughly described. 348 DISEASES OE THE STOMACH AND INTESTINES If no splash can be originally detected, create it artificially by giving water, or if required, add a little Vichy, or tartaric acid and sodium bicarbonate. Inflation of the stomach with air or CO2 will settle doubtful cases, as the upper border is then to be seen on inspection, and percussion is an aid. Gastrodiaphany is an accurate method. Percussion. — ^There is at times dulness or flatness in the epigas- trium when the stomach is markedly depressed, the liver descending in such cases. It is difficult to differentiate by simple percussion unless CO2 distention has also been employed. The scratch method is of assistance. Gastric Secretion. — Examination of the Gastric Contents. — Ewald's test breakfast should be employed . and gastric analysis made in every case. Hyperchlorhydria, hypochlorhydria, or, more rarely, achylia gastrica (functional) may be present. Rarely the secre- tion is normal, and then usually in the cases found accidentally, pre- senting no symptoms. I agree with George R. Lockwood to this extent, that in many cases no evidences of fermentation can be found on test, and the gas also may be odorless. In hysteric women some of the air is swallowed. On the other hand, in some patients with associated marked dilatation (the latter probably being primary), such as I have seen among the nervous and insane at the Manhattan State Hospital, marked fer- mentation has been found. The treatment is modified by the gastric findings. It is evident, in some cases, that the secretory conditions are influenced by the misplacement, since Graham-Rogers, at the Ward's Island Clinic, found that in 4 out of 7 cases (6 of hyperchlorhydria and i of hypo- chlorhydria) improvement followed the use of Rose's belt^ alone, without medication or special diet. Motor Functions. — Motor insufficiency- is undoubtedly present in some cases. On the other hand, many cases exist with few or any gastric symptoms, and though there is relaxation of the musculature of the stomach, compensation takes place probably by relaxation of the pyloric ring, so that the contents of the stomach enter the intestine within the normal limit of time. Per contra on some occa- sions, or from some cause, this compensation may fail and then symp- toms develop. Motor functions appear only slightly diminished in other cases, or even normal, as just explained. This is the probable explanation for those cases which have existed for years without symptoms and in whom they suddenly develop. Stomach and Small Intestine. — Gastroptosis may occur in various forms and degrees, semi-oblique of different degrees, looped, 1 Rose and Kemp, Atonia Gastrica, p. 124. 2 Ibid., p. 79. GASTROPTOSIS — ENTEROPTOSIS — GLENARD's DISEASE 349 or, more rarely, crescentic, and even the vertical stomach (Figs. 154-158). In some cases we may have primary dilatation and then ptosis. These illustrations represent gastrodiaphany of various cases. As far as I can determine, from physical examination, post- mortem, and operative cases, especially in the marked semi-oblique or in the vertical stomach, there seems to be a straightening of the pyloric curve and some dilatation of the pyloric end and of the duo-, denum, probably with relaxation of the pylorus. The supports of the duodenum are relaxed and it crosses the spine at a lower level. I believe there is some relaxation with descent of the pancreas, and Fig. 154. — Slight gastroptosis. Fig. 155. — Gastroptosis. also relaxation of the mesentery and descent of the rest of the small intestine. The duodenal distention is to be expected from gravitation of the stomach contents, and as there is relaxation of the mesentery I am skeptical of the so-called ''chronic mesenteric traction" with dilatation as a result. Gastroptosis should favor acute dilatation of the stomach, on the mesenteric traction theor}^, but I have never seen such a condition associated with acute ectasy. Large Intestine. — Enteroptosis. — Descent of the transverse colon is most common (Fig. 159), as can be demonstrated by inflation with air or water, or with bismuth and x-rays ; but undoubtedly there may 350 DISEASES OF THE STOMACH AND INTESTINES Fig. 156. — Vertical stomach. Fig. 157. — Vertical stomach (extreme). be relaxation, with changes in the position of the sigmoid or even of the descending colon. I have seen a case of this type recently. Fig. 158. — Crescentic form of gastroptosis. Fig. 159. — Enteroptosis. Nephroptosis. — It seems important to further discuss this con- dition, though I have already described many of its features. Mov- GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S DISEASE 35 1 able kidney from traumatism or straining and the congenital floating kidney with a long mesonephron constitute, I believe, a comparatively small percentage of all cases — in my own opinion, about 5 per cent. ; while jMeynert places them at 10 per cent. The balance are con- comitants of enteroptosis (gastroptosis). It is most common on the right side. Einhorn, as well as many other authors, recognize movable kidney as an essential symptom of enteroptosis. Nephroptosis occurs at least six or seven times more frequently in women than in men. Nephroptosis exists in about 15 per cent, of all women examined, associated with gastroptosis; but in many cases no symptoms are present. No worse judgment can be shown than to tell a patient that she has a movable kidney. Edebohls finds it in 20 per cent, of his cases, disregarding asso- ciated ptoses, and some even place it at 33 per cent. The normal kidney is slightly movable during respiratory move- ments. The most accurate method of kidney palpation I have already described. Glenard classifies four degrees of movable kidney: First Degree. — The lower pole of the kidney is palpable on deep inspiration and slips back on expiration. It cannot be arrested. Second Degree. — The body of the kidney can be palpated and arrested, but not the upper border. Third Degree. — ^The superior border of the kidney can be palpated. Fourth Degree. — The entire kidney is palpable and it may be found in various regions of the abdomen, near the gall-bladder or as low as the appendical region. I have already referred to the various symptoms attributed to movable kidney, such as dilatation of the stomach due to pressure on the duodenum ; jaundice ; gall-stone symptoms, or stasis with the production of stone; gastro-intestinal and pelvic disturbances; chronic appendicitis as a result of congestion from compression of the superior mesenteric vein against the pancreas and spine (in 20 per cent, of cases, according to Edebohls). All these symptoms are referable to splanchnoptosis. Goelet believes that in 75 per cent, of nephroptosis of the third degree, or beyond, there is a pyelonephritis or interstitial nephritis. In 20 cases of nephroptosis of the third degree or more (with enteroptosis) at the Manhattan State Hospital, I requested LeRoy Broun to examine the gynecologic conditions, and in no case could any connection be found between the prolapsed kidney and the genital organs. Ferd C. Valentine' and Terry M. Townsend, as a check, made special examinations of the genito-urinary tract and urine, but found no evidence of nephritis or pyelonephritis in these 20 cases. ' Kemp, American Journal of Urology, January, 1906. 352 DISEASES OF THE STOMACH AND INTESTINES Such examinations should not be made immediately after palpa- tion, as Menge demonstrated that albuminuria appeared directly thereafter. Schreiber^ showed this in 39 out of 42 cases examined within ten to fifteen minutes after palpation, and that it sometimes lasted hours. Renal epithelium, red and white cells, but no casts were found. He believes it will furnish a method of differential diagnosis, as if, on palpation of a doubtful mass, this condition occurs, it will prove to be kidney. Of course, nephritis or pyelonephritis may occur in some cases; and after differential ureteral catherization, if both kidneys are prolapsed, nephropexy is indicated in the diseased prolapsed organ. Hydronephrosis, or adhesion of the kidney to the appendix or gall-bladder, may also occur occasionally. In some cases more marked or severe symptoms may be attributed to the movable kidney: (i) There may be a weight or special feeling of traction on that side, increased on standing or walking, and lessened in the recumbent posture. (2) The kidney may be increased in size, tender on pressure, and there may be pain and tenderness in the lumbar region, frequent urination, and burning headache. (3) Dietl's crisis, probably due to torsion of the pedicle, will produce severe abdominal pain, chills, nausea, vomiting, fever, and even collapse. The urine may be high colored and blood be present. Abdominal support should first be tried systematically in these conditions before operation is advocated. Floating Liver (Movable Liver). — Osier claims that in a considerable number of cases there is a m-istaken diagnosis. One anomaly is the tilting forward of the organ, so that the antero- posterior axis becomes vertical and not horizontal, and a consider- able part of the surface of the right lobe is in contact with the abdominal wall. In one type of lacing liver, the anterior part of the right lobe is greatly prolonged, a shallow transverse groove separating it from the rest of the organ. A slight grade of mobility (floating liver) is found in enteroptosis, but the cases reported are comparatively few. In some cases the upper surface may lie below the costal margin. G. E. Graham has collected 70 cases. The condition is rare in men. In some cases of enteroptosis with hepatoptosis, the symptoms may be fairly marked in the liver, there being pains in the hepatic region radiating toward the back and at times of a tearing character. There may be some local tenderness and attacks similar to hepatic colic, though usually no jaundice. Einhorn^ described several groups of cases, dyspeptic asthma 1 Zeitschrift fiir klin. Med., vol. Iv, No. 3. 2 Medical Record, September 16, 1S94. GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S DISEASE 353 among them, but from my own point of view this condition seems to be a part and parcel of the general syndrome "enteroptosis," with marked local symptoms, such as pain or colic, in some cases. In extreme cases the liver may drop down so that the upper surface is below the costal margin. Cardioptosis. — In my own experience, ptosis of the heart is present only in marked cases of splanchnoptosis, especially where there is skeletal deformity. Einhorn finds it associated wdth float- ing liver. The latter is more frequently a concomitant of skeletal deformity, I believe, and hence the two conditions are associated. Movable spleen may occur from below the rib even into the pelvis. There may be dragging pains in the side, torsion of the pedicle, swell- ing of the organ, with pain and fever associated. Diagnosis. — Curiously enough, the majority of wTiters pay chief attention to nephroptosis, refer to the stomach as dilated (a result of kidney pressure), and do not differentiate between gastrop- tosis and dilatation of the stomach. It is the position of the upper border which determines ptosis, but the following symptoms will usually settle the diagnosis. The peculiar conformation of the abdo- men heretofore described, the separation of the recti, movable kid- ney, and the determination that the lower border of the stomach is abnormally low, are sufficiently diagnostic of gastroptosis. Inflation or gastrodiaphany may be necessary in doubtful cases to settle the question. G16nard's "Belt Test." — If one stand behind the patient and, encircling him with the arms, lift up and support the lower pro- tuberant abdomen, and this gives relief, it suggests enteroptosis. Prognosis. — The cases of congenital type with funnel thorax or other skeletal deformities are the most unfavorable to treat; but even in these much can be done. The acquired type presents a favorable prognosis as to absolute cure, though some tend to relapse if continuous care, as to regulation of mode of life, exercise, and diet is not kept up. I have seen a number of cures, as has every other observ^er. Treatment. — Prophylaxis. — Much can be done to prevent the acquired type of gastroptosis. Improperly made corsets compress the thorax or waist. Tight lacing and the use of tight bands around the waist are productive of ptosis. These should be avoided. In my opinion, most of the Landau (post-partum) cases of splanch- noptosis are absolutely preventable, the fault frequently being due to the physician in attendance, the patient's abdomen not being properly supported, and she also being allowed to leave the bed too soon. There is a marked thinning and weakening of the abdominal wall during pregnancy, and after delivery immediate attention should be given to its support. For several years Douglas H. Stewart, of New York, has been employing as a routine post-partum method of support (at my 23 354 DISEASES OF THE STOMACH AND INTESTINES suggestion) Rose's plaster strapping, reinforcing it with lateral soft-rubber strips (an idea of his own). He states that it supports the organs perfectly, prevents abdominal relaxation, and enables the patient to sit up in bed earlier, with resulting improved drainage of the uterus, and to be about at an earlier period. Bassler^ treats of the necessity of abdominal support after confine- ment, and describes methods of strengthening the abdominal muscles and the value of forced feeding. Treatment of Existing Gastroptosis (Splanchnoptosis). — There are three chief principles involved: (i) The support and strengthening of the abdominal muscles, which also increase intra-abdominal pressure. (2) The increase of intra-abdominal pressure, by reducing the volume of the abdominal cavity through accumulation of fat, and thus lifting up the stomach. (3) Correction of the gastro-intestinal disturbances and the toning up of the nervous system. Fig. 160. — The proper way of adjusting the corset (after Gallant). (i) Abdominal Support. — The selection of a proper apparatus- for mechanical support to the abdominal muscles, which at the same time will increase intra-abdominal tension, is the first indication. I have employed, by preference for some time past, adhesive plaster strapping in the form of the belt devised first by Achilles Rose. I have already referred to the superiority of moleskin, first suggested in this country by me after numerous experiments. The Z. O. type should be used by the method already described. The support afforded is continuous, should never be kept on over three to five weeks, and on signs of loosening, a new belt should be applied; the patient, between belts, taking a full bath and employ- ing talcum powder over the surface during the twelve to twenty- four hours' intermission. My longest case wore the belt fourteen months, winter and summer, it being reapplied every four to six weeks, with a gain of 44 pounds and perfect cure. Some of the other types of adhesive strapping belts may be 1 Prophylactic Measures Against the Development of Landau Cases of Visceroptosis, Therapeutic Gazette, September 15, 1907. GASTROPTOSIS — ENTEROPTOSIS — GLENARD'S DISEASE 355 employed if the wide plaster necessary for Rose's belt cannot be procured. Pressure is exerted by the belt, from the symphysis to the umbilicus in front, the intestines are forced up, and hence the stomach; and the increased pressure aids in holding back the kidneys. Next in value to adhesive plaster is the Gallant corset, which also exercises upward pressure and support below, and is loose above. The method of its application is shown in Fig. i6o. The La Grecque corset (Von Noorden's), recently devised, is an excellent appliance. It well supports the spine and pelvis, is made in a single piece behind, and is subdivided in front, as in Fig. i6i, A. Fig. i6i. — La Grecque corset: A, Lower segment of corset; B, corset after adjustment. In Fig. i6i, B,'is shown the corset after application. It should be applied in the dorsal position, like the Gallant corset. The pressure is exerted like Rose's belt, from the symphysis to the umbilicus, and it is loose about the thorax and upper abdomen. Of late I use the adhesive strapping for several months and then follow it with this corset. The indications are the same as for Rose's plaster. If the patient will not consent to these methods, the silk abdominal bandages, as previously illustrated, are useful. In male cases Rose's belt and, later, the silk belt are indicated. Supports formed with pads for special organs are unscientific. Kilmer's belt, drawn snug below and lax above, or the Van Valzah-Hayes belt can be employed. 356 DISEASES OF THE STOMACH AND INTESTINES Exercise. — Massage. — Gymnastics. — There are marked inconsist- encies in many of the recommendations as to active exercise, flexion, and extension of the body by elevation of the legs, gymnastics, etc., to strengthen the abdominal muscles. There is no better way to take off abdominal fat and to reduce omental fat than by these means ; and in the cases with marked weight reduction it is impossible to put on fat if excessive exercises are employed. In moderation and properly directed, they are of service later when the weight has been increased. Driving or moderate walks in some cases are useful. Massage. — On the other hand, gentle abdominal massage and often general massage of mild type, taken several times a week, will improve the muscular tone. The use of Hght cannon-ball massage of the abdomen, taken five minutes once or twice a day, or mild vibra- tory massage, at home in bed, with the Vedee vibrator, I have found of service. In the severe type of case, absolute rest in bed for three to six weeks with the Rose's belt appHed, forced feeding, and mild massage, etc., give the best results; and if the patient is very much prostrated I omit massage at first. 2. Increase of Abdominal Pressure through Diet hy Fat Accumula- tion. — Diet. — There are certain general principles we must follow: If there is hyperchlorhydria, plenty of albuminous foods and fats and diminished starchy foods should be given; frequent feedings; avoidance of acids, spices, and alcohol. Often alkahs are required. If hypochlorhydria or achylia, little meat and abundance of carbohydrates and fats, with dilute hydrochloric acid, stomachics, etc. Not more than 8 oz. (250 cc.) of fluid should be taken at a time, and thorough mastication of the food should be enjoined. If the case is not confined to bed, a rest of fifteen to thirty minutes after each meal, if possible, is advisable. The patient should take the three chief meals daily at — !r 10.^0 A. M., U -^O P M with intermediate feedings at A -^'^^^ ^^^^^ ^^ [9.30 P.M. John Russell's method, as employed in tuberculosis, is of value in some cases. The foods especially of use to increase weight and which can be employed for the interval feedings are : Milk, raw eggs, cream, oj (30 cc.) in milk, Bviij (250 cc.) kumyss, matzoon, bacillac, lac tone-buttermilk, crackers or bread with plenty of butter, and sanatogen (preferably flavored). Raw eggs can be given, beaten up in milk. It is well to start with I or 2 daily, and increase gradually to 6 or 8 per day. They possess considerable value. One could give, for example, at the intermediate feedings: GASTROPTOSIS — EXTEROPTOSIS — GLENARD'S DISEASE 357 10.30 A. M. — Milk, oviij (250 cc), with 2 raw eggs. 3.30 p. M. — Kumyss, oviij (250 cc). 9.30 p. M. — Same as at 3.30 p. M., and vary the methods. Two soft-boiled eggs can be given for breakfast. Green vegetables and raw or cooked fruits should be given for constipation, depending on the gastric conditions. Strict attention to the bowels is imperative. I have seen the stomach elevated 3 or 4 inches by the increase of fat. Electricity. — In the ambulant cases the use of static electricity will prove of service with some patients to improve the general muscular tone, or it may be employed after the rest cure has been completed. The external application of galvanic or faradic elec- tricity I have used with good results in some cases, but never remove the belt. Intragastric faradization has been recommended to improve the atony of the stomach, and galvanization for the pain. I have had patients bitterly complain of the intragastric method; one case notably had been treated thus systematically, with increasing nervous symptoms being produced and marked nausea, stating she was worse after each treatment. The simple method of external application seems to me advisable in those cases. Massage of the Kidney. — Several methods have been recommended for treatment of the painful movable kidney: The operator, sitting on the side of the kidney to be massaged, places the left hand (if it is the right kidney) on the lumbar region, so that the organ rests on the finger, the thumb being supported by the ribs. With the finger-tips of the right hand he pushes on the kidney from in front and gently kneads it. Brandt places the patient in the lithotomy position, and having replaced the kidney, places both hands in front under the margin of the ribs, and makes vibratory movements backward and upward, allowing the finger-tips to slip around to the back. The patient aids in securing this position by lifting his buttocks. - As palpation alone will cause albuminuria, I do not approve of these methods, hut merely refer to them. It is sufficient to replace the kidney. Elevation of the Eoot of the Bed. — This method may be employed in those cases taking the rest cure who do not wear an abdominal support continuously. Elevation of the buttocks may be sub- stituted. They are unnecessary when Rose's belt is employed. Iron and arsenic are indicated in all cases, such as — Iron tropon, 5j (40). t. i. d.; or Peptomangan (Gude), oj to ij (4.0-2.0); with Fowler's solution of arsenic, Tn.3 to 5 (0.177-0.296 cc), t. 1. d, or any good combination of iron and arsenic. An excellent pill is Blaud's iron, gr. 5 (0.3), in which sodium arsenate, gr. -g-^g to ^'o (0.00108-0.002 1), has been incorporated. 358 DISEASES OF THE STOMACH AND INTESTINES If no hyperchlorhydria is present, strychnin, gr. q^^ to 3^0 (0.00108- 0.0021), can be included. Hyperacidity should be treated with the alkalis. Hypo-acidity with nux, strychnin, hydrochloric acid, and stomachics. Bromid, gr. 10 (0.6), or veronal, gr. 5 to yh (0.33-0.5), sulfonal, gr. 10 (0.6), or trional, gr. 10 (0.6), are valuable for sleeplessness, given an hour before retiring. Hydrotherapy.— The Scotch douche, one to two minutes over the abdomen, in convalescent cases has rendered service. The Priessnitz compress aids to relieve pain. A glass of cold water, Vichy or Carlsbad, on rising helps the bowel action. Dietl's Crisis. — Apply heat to the kidney ; employ fluid diet ; ele- vate the foot of the bed ; replace the kidney. Codein, gr. i to ^ (0.016-0.022), or morphin, gr. | to | (0.008- 0.016), may be required, by hypodermic. Constipation. — Olive oil enemata; cascara; comp. rhubarb, if required, are excellent. Complications,^ such as mucous colic or catarrhal colitis, must be appropriately treated. Surgery. — In splanchnoptosis, if all medical treatment after a year conscientiously applied prove a failure, suture of the recti (ab- dominis) and thus tightening the abdomen, as advocated by Robert T. Morris and by Charles Codman," is the most scientific procedure. If there is nephritis, pyelonephritis, or intermittent hydronephro- sis confined to the prolapsed kidney, then nephropexy is indicated. After repeated attacks of Dietl's crisis, when medical measures afford no relief, nephropexy may be advised. Hydronephrosis or pyelonephritis may be of such a character as to require nephrectomy. Operations on individual organs I am opposed to unless there be marked gastric dilatation with the ptosis. Gastroplication, shortening of the lesser omentum, attaching the lesser curve of the stomach to the abdominal wall, suture of the transverse colon to the abdominal wall, sewing the greater omentum to the abdominal wall, have all been recommended. Gastro-enterostomy may be indicated in gastroptosis with ectasia and marked fermentation, which does not respond to medical treat- ment. The spleen has been stitched up or rernoved if inflamed. Duodeno- enter ostomy has been advocated by Byron Robinson, but I see no indication for it. Elliot^ recommends anchoring the liver in hepatoptosis. In rare cases, gastroplication, with shortening of the lesser omentum ; or the latter with gastro-enterostomy might be necessary. ^ See under Constipation for other remedies. 2 Medical Record, October 19, 1907. ^ Medical News, November 12, 1904. CHAPTER XVII NERVOUS AFFECTIONS OF THE STOMACH Gastric neuroses may be defined as functional disturbances of the stomach without any discoverable anatomic basis, there being no organic lesion of the organ. Etiology. — These cases have either inherited a nervous con- stitution or, through indiscretions, have brought about a condition of nervous prostration. Sometimes the gastric disturbances have apparently a reflex origin, depending on disturbances in remote parts of the body, as in the sexual organs, appendix, eyes, etc., and these factors must always be searched for. They are divided into sensory, motor, and secretory neuroses, and may appear separately or in combination. They occur most frequently in women from puberty to menopause, and quite fre- quently at these special periods. In men they appear most often during middle life and most frequently in the higher classes. There is probably a predisposition to the condition. Worry, extreme mental exertion, excesses, and excitement may be predisposing factors. Organic lesions of the stomach must be excluded. Classification. — Neurosis of the stomach may present the appearance of some primary disease, or may be one of the symptoms of hysteria or neurasthenia, or may be a reflex symptom due to dis- ease of some other organ. In cases of this last description, though there is no organic change in the stomach and the disturbance in this organ is purely reflex, there is an anatomic cause elsewhere. They should, strictly speaking, be differentiated from the pure gas- tric neuroses, since treatment of a distant diseased organ may cure an apparently pure gastric neurosis. This emphasizes the necessity of thorough examination. - Peculiarities. — Generally the nervous system shows more or less deviation from normal conditions. Leube and Boas have probably best described the condition. There are headache, mental depression, lack of energy; at times fear, palpitation, dyspnea, and sweating. On the other hand, there may be excitement and sensi- tiveness. There are an increase or diminution of reflexes, local hyper- esthesia, paresthesia, or anesthesia. Polyuria may or may not be present. Some patients remain in comparatively good condition, while others emaciate. The digestive disturbances are usually independent of the quantity and character of the food, and are not always connected with the act of digestion. Errors in diet are often not followed by an exacerbation 359 360 DISEASES OF THE STOMACH AND INTESTINES of the symptoms, and sometimes they occur when the simplest food has been taken. The gastric secretion and motor functions are often variable. We may find hyperchlorhydria at one time and normal secretion at another, or, conversely, normal conditions may alternate with hypo-acidity or anacidity. At times the motor functions may be normal, at others, diminished. The condition of the bowxls also varies ; there may be constipa- tion alternating with diarrhea; or the bowels may be regular and a sudden diarrhea appear. Climate and surroundings may influence the condition. SENSORY NEUROSES OF THE STOMACH There may be abnormal sensations more or less general in char- acter external to the stomach, such as regarding hunger, appetite, or abnormal sensations within the stomach itself. Among the abnormal sensations of appetite are bulimia (or canine hunger) ; parorexia (perversion of appetite) ; polyphagia (excessive eating) ; akoria (absence of satiation) ; anorexia (loss of appetite). Bulimia Bulimia, hyperorexia, or canine hunger (cynorexia) denotes a marked increase of the sensation of hunger which may occur in attacks, either as an independent neurosis or as a secondarv affection, the result of some other disease. The attacks are paroxysmal. The hunger center is believed to be located in the medulla. This center is probably irritated when a certain degree of impoverishment of the blood takes place. On the other hand, if the latter is marked, the sensation of hunger may not be produced or may even be sup- pressed. The stomach is also concerned in its production, and the amount of food contained therein has an influence. For example, with hyperacidity and increased motor function, hunger is present. In a case of mine suffering from stenosis of the pylorus and dilatation of the stomach, while before operation anorexia was marked, the patient is now continuously hungry. Reflexly, the hunger center is often disturbed ; this loss of appetite may occur after fright or on the appearance of food that is greasy and badly served, whereas with food daintily prepared and of pleasant odor, the appetite is increased. The time at which hunger appears depends on the time the person is accustomed to eat. Pathologically the sensation of hunger may also be stimulated or inhibited in various ways. Etiology. — Bulimia may be a primary affection or may be second- ary to ulcer of the stomach, hyperchlorhydria, hypersecretion, epilepsy, hysteria, neurasthenia, tumor of the brain, tapeworm, intestinal diseases, rarely to diseases of the pancreas or to diabetes mellitus. NERVOUS AFFECTIONS OF THE STOMACH 361 Occurrence. — It is more frequent in women than in men and most frequent from eighteen years of age to menopause. Symptoms. — The patient may be in perfect health, when suddenly a feeling of intense hunger comes on which is extremely persistent and calls for food. There is frequently a gnawing in the stomach and a feeling of fear and anxiety. Unless the hunger is relieved, headache, trembling, and even fainting spells may occur. The attack may take place immediately after a large meal or come on in the night. In some cases small amounts of food will relieve the conditions; in others, enormous quantities are necessary. One patient recorded ate 23 eggs in forty-five minutes and drank i| quarts of milk and i quart of wine. Character of Attacks. — They may be severe or very sHght. In some cases they occur every few hours ; in others they last a few days, or they may exist chronically and last for years. The periodic form is generally more intense. Hypermotility is found in some cases. Prognosis. — In the secondary form it depends on the primary disease, though sometimes bulimia persists. The more frequent and violent the attacks, the worse the prognosis. Ordinarily it is difficult to give an absolute prognosis. Gastritis, atony, or dilatation may result in some cases. Treatment. — If bulimia is secondary, the primary disease should be treated, such as hyperchlorhydria, tapeworm, diabetes, or neuras- thenic or hysteric symptoms. For the bulimia we should give frequent light meals every two hours. The bromid of sodium, potassium, ammonium, or strontium may be given in gr. xx to oss (1.3-2.0) doses two or three times daily; for example: P'. Sod. bromid oiiss (lo.o) Aq. menth. piperit q. s. oiv (125 cc). — M. Sig. — Two teaspoonfuls in water t. i. d. after meals. Codein, opium, and cocain I strongly deprecate, though recom- mended by some. There is great danger of acquiring the habit. Tr. belladonna, tTlx (0.59 cc.) t. i. d., is a good substitute. Arsenic (Fowler's solution), TTLv (0.296 cc), or sodium arsenate, gr. -5V to 2V (0.0013-0.0026), or arsenous acid, gr. y^o (0.00065) t. i. d., are useful. Iron can be given, also strychnin, gr. gV (0.00108), for the nerves. Change of climate is of value. Food should be carried by those suffering from abnormal hunger for immediate use. Parorexia (Perversion of Appetite) Sometimes the appetite is manifested for special or peculiar kinds of food. There are three types: (i) Malacia, a desire for spiced foods, such as for mustard, vinegar, green fruits, etc. 362 DISEASES OF THE STOMACH AND INTESTINES (2) Pied, a desire for substances that are not foods, such as earth, chalk, ashes, sand, insects, etc. (3) Allotriophagia, a craving for disgusting and harmful sub- stances, such as fecal matter, pins, etc. Malacia is met with in disturbances of the stomach and neuras- thenia, while the other types occur chiefly in idiots, lunatics, or severe hysteria. The treatment is of the disease which is the cause of the perversion. Polyphagia Polyphagia is the demand for large quantities of food before satiation occurs. The cases do not feel hungry until the food is digested. It may occur as a primary condition in neurotics, or secondary to diseases of the gall-bladder, spleen, diabetes, or brain tumor. The attacks may be of short duration or as a chronic trouble. One case could eat 100 pounds of meat in twenty-four hours. Disease, if present, should be treated; neurotic conditions should be corrected. The general treatment is the same as of bulimia. Akoria Akoria is absence of satiety. Patients with akoria never feel satiated, and never know when to stop eating. It is at times com- bined with polyphagia. It is met with among the neurasthenic and hysteric. Bromids are of service and the general treatment of the nervous condition. Nervous Anorexia (Anorexia Nervosa) Anorexia is diminution or loss of appetite, with absence of the hunger sense, so that even aversion to food may be present. It occurs in most of the organic as well as in the functional dis- orders of the stomach, but the nervous type appears as a primary affection. It has been attributed to a depressed condition of the hunger center or to hyperesthesia of the mucous membrane of the stomach. Etiology. — Psychic shock, some mental depression, worry, a disagreeable odor, or some nauseating sight may cause transitory anorexia in a healthy person. It may, however, be more persistent in hysteria, neurasthenia, and the psychoses; morphin and excessive smoking may produce it. It is more frequent in women and may result from anemia or chlorosis. Symptoms. — There is at first loss of appetite, and the patient begins to eat less. These cases may first have ah aversion to meat, and later to bread and butter, vegetables and all solid food, and may finally live only on fluids, sometimes on very small quantities. They often vomit at the sight or smell of food and may, in severe cases, emaciate markedly. They will refuse to increase their nourishment NERVOUS AFI^ECTIONS OI^ THE STOMACH 363 ("siturgy"). The pulse becomes slow and the temperature sub- normal; they become pale, cyanotic, and the eyes sunken. Such cases may even terminate fatally. This condition may be mistaken for organic disease or for phthisis, and a careful physical examination and gastric analysis should be made. Treatment. — The patient should be impressed with the idea that he must take his food in sufficient quantity and eat everything put before him. He should not be questioned as to his desires. Frequent small meals with kumyss, matzoon, bacillac, lactone- buttermilk, butter, milk, and cream should be given to improve nutrition. Raw eggs are of service; also sanatogen up to Bj (32.0) daily in divided doses. The sour-milk products are of value, as auto-intoxication is an important feature in these neurasthenics. Stomachics, such as tincture of nux vomica, TTLx (0.59 cc.) t. i. d., and fluidextract of condurango, lUxx (1.184 cc), are of service. Fluidextract of Peruvian bark, oj (4.0) t. i. d., is excellent. I^. Tr. nucis vomicae \ .- ^.. ,„ . Acid hydrochlor. dil. / ^^ ^^J "^^^^ Comp. tinct. cinchona oss (16.0) Aq. destU q. s. 5iv (125.0). — M. Sig. — oj to ij (4.0-8.0) t. i. d. in water before meals. Basic orexin, gr. | to J (0.02-0.03) t. i. d., may prove of service. Morphin and tobacco, if they are factors, should be cut off. Sanitarium treatment and rest cure are important in severe cases, especially by the Weir-Mitchell method. Isolation from the family, strict supervision by the physician, massage, and electricity are valuable. Forced feeding (gavage) or nutritive enemata may be required. After a while the patient will be convinced she can digest food. Small quantities are given at first, and then they are increased, In milder cases change of climate is useful. Strychnin,' gr. -i^ to sV (0.001-0.002), Blaud's iron pills, pepto- mangan (Gude), or iron tropon are of service. Arsenic may be added. Fowler's solution, Hlv (0.29), sodium arsenate, gr. eV to -gV (0.001-0.002), glycerophosphates of soda, or Chapoteaut's glycero- phosphate of lime. These remedies should be given t. i. d. Sensations "Within the Stomach Under normal conditions we do not recognize that we have a stomach, and there are no sensations after the ingestion of food. The stomach is not devoid of sensation even normally, as excessive quantities of hot or cold material are noted by internal sensations, such as after the ingestion of a large quantity of ice cream on an empty stomach. Gastric sensation, however, may be increased to a pathologic degree and be a source of great discomfort. We must remember 364 DISEASES OF THE STOMACH AND INTESTINES that certain persons are peculiarly constituted and have idiosyn- crasies to particular foods. Idiosyncrasies. — For example, shell-fish, such as lobsters, crabs, and oysters, strawberries, bananas, onions, etc., will produce skin eruptions such as urticaria or erythema, and gastric symptoms such as pain, belching, pressure, and even nausea or vomiting. Talma and Einhorn have described cases having a peculiar idiosyncrasy to hydrochloric acid. I have seen several cases where the patient suffered from the symptoms of hyperchlorhydria, and yet the free hydrochloric acid found was well within normal limits. The adminis- tration of alkalis relieved the symptoms. The gastric nerves were evidently peculiarly sensitive to acid in these cases. If patients have an idiosyncrasy to special food, it must be avoided. Abnormal Sensations (Sensory Neuroses of the Stomach) The nervous and hysteric at times complain of sensations of heat, cold, or of some foreign body, such as the feeling of worms, etc., within the stomach. These symptoms are not dependent on the food or upon the gastric secretion. There may be in some a feeling of constriction, cramp, or "pulsation" within the stomach. The latter is probably due in many cases to hyperesthesia and the trans- mission of the aortic pulsation. Nausea.-^ -There may be a nervous type of nausea in such patients, either during the fasting condition or after meals, the treatment for which should be directed to the neurasthenia. Nausea may also be reflex, as from an affection of the genital organs or in organic disr ease of the stomach. Einhorn recommends intragastric galvanization. The indication, however, is to treat the hysteria or neurasthenia. Hyperesthesia of the Stomach This consists in an increased sensibility of the nerves of the stomach, so that the mucous membrane is abnormally sensitive even after ordinary food is taken. It differs only in degree from gas- tralgia. It may be secondary to organic affections, associated with secretory disturbances, or it occurs as a primary neurosis. Etiology. — It is present especially in the higher classes. Mental overexertion, excitement, alcohol, and venereal excesses, which weaken the constitution, are factors. It is associated with hysteric or nervous symptoms. Though anemia is given as a cause, hyper- chlorhydria with hyperesthesia occur with this condition, and this type is, therefore, not a pure sensory neurosis. Symptoms. — There is a sensation of fulness, weight, or pressure after meals, which may become real pain, and finally vomiting may occur. Sometimes considerable emaciation is present, as the patient fears to eat (sitophobia). Hyperesthesia occurs after excess of food or, in some, in cases of fasting. NERVOUS AFFECTIONS OF THE STOMACH 365 Physical Signs. — The epigastrium and region of the stomach are sensitive to pressure throughout, but there is no specially sensitive area as in ulcer. Certain articles of food, such as sugar, fat, starch, or coffee, may produce the condition. The secretory and motor functions are normal in the purely nervous cases. Diagnosis. — This is based on the absence of organic disease of the stomach, the absence of hyperchlorhydria or of other secretory disturbances, and the absence of motor disturbances. With hyper- chlorhydria and gastritis the gastric analysis and other symptoms will give us the requisite differential points. With ulcer, hyperacid- ity is the rule, and the degree of pain is dependent considerably on the character of the food, which is not generally so in hyperesthesia; the other symptoms also differ. With erosions small bits of mucous membrane are washed out and there are secretory changes. Prognosis depends on the result of the treatment of the nervous condition. Treatment. — In many of these cases, as when anemia is present, secretory disturbances are associated with the sensory neurosis, as hyperchlorhydria, so that the pure sensory condition is often com- plicated. Iron and arsenic are necessary in such cases and, in fact, have an excellent effect. Peptomangan, iron tropon, or any good iron preparation combined with Fowler's solution, TTLv (0.296 cc.) t. i. d., is excellent. The patient should be kept in bed in severe cases and warmth applied to the stomach, dry heat, or Priessnitz compresses. Fluid diet in rather small quantity should first be given. Milk and lime- water, sanatogen, broths, chicken soup, white of egg, later entire raw eggs beaten in water, calves'-foot jelly, scraped meat, zwieback softened in milk, butter, and gradually solid food. Tincture of belladonna, TTLv to x (0.296-0.592) t. i. d., is excellent for the pain. The use of opium and its derivatives and cocain are to be deprecated. Rarely an occasional dose of codein may be required. In some cases silver nitrate, gr. i to ^ (0.008-0.016), in aqueous solution t. i. d. before meals is of service. External galvanization to the stomach is of value. Bromids in some cases are serviceable. Baths and change of scene may be enjoined. Suggestion should be used by the physician. GASTRALGIA {Synonyms. — Gastrodynia, Spasm of the Stomach (Gastrospasmus) ; Cardialgia, Neuralgia of the Stomach.) Gastralgia may be defined as the occurrence of violent attacks of pain in the stomach, paroxysmal in character and alternating with free intervals. 366 DISEASES OF THE STOMACH AND INTESTINES Etiology. — We may have a number of forms of gastralgia originating from various conditions, and these must be referred to in order to differentiate them from the purely nervous type. Gastralgia Originating in the Stomach. — (a) Connected with organic affections, such as ulcer, cancer, stenosis of the pylorus, or gastritis, with hyperacidity, hypersecretion, peritonitic adhesions, or perigastritis. (b) Special varieties of food, as rich spices, or of drink, as strong coffee, or ice cream, etc., may produce it in people not accustomed to these substances. Spinal disease, as tabes, may cause gastric crises, or, more rarely, cerebral disease or various types of myelitis. Absence of patellar reflex, Argyll-Robertson pupil, and Rhomberg symptom are diag- nostic of tabes. Gastralgia as a Neurosis. — This occurs with neurasthenia or hysteria. It may appear before the nervous symptoms are in evidence. Reflex Causes. — Gastralgia of this type occurs most frequently in women. It takes place reflexly from disturbances in the female or in the male genital organs. Gastralgia may occur at the time of menstruation or in place of it. Disease of the liver, spleen, bladder, pancreas, and ptosis of abdominal organs may be reflex causes. Other Causes. — Malarial injection may be a cause of gastralgia. The latter may be associated with the usual symptoms of malaria or it may be substituted for the malarial cycle, appearing every day, alternate day, or third day at the same hour, as do other neu- ralgias. Gouty infection, lead- or mercurial poisoning, or excessive smoking may produce it. Exophthalmic goiter, anemia, or chlorosis with malnutrition may be a cause, although the attacks in many of these cases are the result of the associated hyperchlorhydria. Sex. — Most frequently in women and girls from fifteen to forty, and decreases in frequency with age. Symptoms. — The attacks usually appear suddenly and occur in paroxysms, though they may be preceded by nausea, with belching and distention, headache, or dizziness. There is a sudden extreme pain in the epigastric region of a boring, tearing, burning, and constricting character. It may radiate over the abdomen or to the back and shoulders. The attacks may occur independently of eat- ing and whether the stomach is empty or full, or at any hour {in the nervous cases). The face is pale and distorted with the pain, by which the patient is frequently doubled up, as with colic, and there is inability to lie straight, and often clammy sweating. Strong pressure on the abdo- men frequently relieves the pain, though it may be sensitive to lighter pressure. The gastric region is usually sunken. NERVOUS AFFECTIONS OF THE STOMACH 367 There are often hiccough and belching, with nausea and collapse. The pulse is generally rapid and feeble, though in some cases slow. . Duration. — Gastralgic attacks may last from a few minutes to an hour or longer. There may be several attacks in a day, every few days, or at intervals of weeks or months. The pain disappears suddenly and may be followed by hunger or even bulimia. In mild cases the patient may not be greatly affected and may be able to work immediately, while in the severe cases there is often prostration for several days. Prognosis is favorable as far as life, and depends on the removal of the primary cause. Differential Diagnosis. — The sudden onset, violent spasmodic pain in the stomach, general in character and lessened by pressure, nausea, vomiting, and headache— that these symptoms are inde- pendent of eating and frequently occur after mental overexertion or emo- tional shock and are associated with nervous hysteric symptoms — all point to the nervous type. We must exclude the secondary form by gastric analysis, and by the determination that no organic disease exists. A careful physical examination is necessary, thereby ehminatihg other conditions that may cause pain in the gastric region. U-lcer of the Stomach.— The pain at the height of digestion depends on the quantity and quality of food ; disappears when the stomach is empty; intervals free from pain; hyperchlorhydria present; circum- scribed spot in the epigastrium painful on pressure and increased by it; hematemesis present in some cases, or occult blood in gastric contents or stool. If these characteristic symptoms are absent it may be necessary to try one of the ulcer cures; which, if it fails, would rather point toward nervous gastralgia. Cancer of the Stomach. — Pains not as severe, but more continuous, never free from pain ; absence of hydrochloric acid ; lactic acid and Boas-Oppler bacilli present; cachexia; age of patient; tumor often present. Chronic Gastritis. — Intense pains are absent; are continuous and more a sense of discomfort after the ingestion of food ; no paroxysms ; mucus in gastric contents; hypochlorhydria. Stenosis of the Pylorus. — Attacks of pain (gastralgia), associated with peristaltic unrest and vomiting. Dilatation of the stomach is present; usually hyperacid contents if benign stenosis ; and lactic acid present with absence of free HCl and Boas-Oppler bacilli if malignant. Functional Disorders. — Hyperchlorhydria and hypersecretion; pains disappear after albuminous food or alkalis. Gastric analysis, hy- peracidity; and if hypersecretion, excessive quantity of secretion in the empty stomach. Achylia Gastrica. — Pains disappear when stomach is empty. Gastric analysis shows low acidity, 2 + or 4 + ; free HCl absent ; rennet = o ; pepsin = o. 368 DISEASES OF THE STOMACH AND INTESTINES Rheumatism and Myalgia. — Myalgia is muscular pain which may be due to exertion. In both conditions the pain is not paroxys- mal; corresponds to the course of the muscles, and is reUeved by abdominal relaxation; we have rheumatic history or that of over- exertion. Intercostal Neuralgia. — Pain is superficial and can be traced along the intercostal nerves, which are sensitive at numerous points on pressure. Renal Calculi. — Pain in the kidney (dorsal region) radiates to the ureter and bladder; testicle drawn up in the male; urine is acid and shows blood. Kidney is frequently tender on pressure. Gall-stones. — Pain over liver and gall-bladder; deep pressure increases the pain; rise of temperature; pain^ passes to right and often up into the right shoulder. Iveukoc3^osis frequently present. Jaundice at times and gall-stones in the stool are conclusive. // the motor or secretory functions of the stomach are normal, the attack of pain — especially if it is in the right h^^pochondrium and the patient has no nervous symptoms — is probably due to gall-stones. In gastralgia there is no pain and no fever. It is sometimes difficult to differentiate between the other conditions. Perigastritis. — A high position of the stomach, with the left lobe of the liver drawn down and covering that organ, is suggestive of perigastritis when pains come on regularly several hours after meals (Kaufmann).^ Intestinal Colic (Enteralgia) . — Pain changes its position in the abdominal cavity. Passage of flatus relieves pain. Bowels are irregular. Treatment. — In secondary gastralgia it is necessary to treat the primary cause. If it is due to tobacco, it should be cut off. Malaria should be treated with quinin or Warburg; and anemia, with iron and arsenic and the rest cure. Correct a gouty tendency, if present; or treat tabes, if this be found. Sexual disorders, ulcer, gall-bladder disease, or cancer should receive appropriate treatment. If hysteria or neurasthenia is present, tonics, isolation, the rest cure, massage, and hydrotherapy are of value. The galvanic current, the anode over the stomach, or intra- ventricular galvanization, with the cathode over the spinal column, is of service when repeated attacks of primary gastralgia occur. For the active condition, if moderately severe, hot applications (dry or moist heat) and hot drinks are useful. Tincture of belladonna, TTLx to xv (0.592-0.088), to relieve the spasm. Tincture of valerian, Tllxx to 3ss (i. 184-2.0), in water, or Hoffmann's anodyne, 3ss (2.0), may be given in water with sugar. 1 Head's gall-bladder zone often present. 2 American Medicine, vol. vi, No. 20, pp. 792, 794, Nov. 14, 1903. NERVOUS AFFECTIONS OP THE) STOMACH 369 Chloroform spirits, 2 to 3 drops in water at a dose, can be admin- istered. The bromids are also valuable. If there is retention of food during the attack, then lavage with hot water will relieve some cases. If the pain is unbearable, codein, gr. h (0.032), by hypodermic, or morphin, gr. \ (0.016), with atropin, gr. 1^^ (0.00065), can be administered. Suppositories of morphin, gr. \ (0.016), and extract of belladonna, gr. \ (0.016), or opium, gr. i (0.065), ^^id extract of belladonna, gr. \ (0.016), every two to three hours for several doses, are useful. Gastralgokenosis (Boas^) This is characterized by pain in the stomach when it becomes empty, and is relieved by food. It may be periodic or permanent. Frequent meals and nerve sedatives are required. MOTOR NEUROSES OF THE STOMACH Under normal conditions the cardia remains closed after the process of digestion has begun, while the pylorus opens at intervals to allow a certain amount of escape of chyme. The muscular movements of the stomach mix the ingesta with the gastric juice and aid in its disintegration by churning movements. Later they propel it into the intestine. These motor functions may be irritated (exaggerated) or depressed (diminished). Hypermotility of the Stomach {Synonyms. — Supermotility; Hyperkinesis; Hyperanakinesis Ventriculi — Einhorn). In this condition the stomach propels the ingesta into the intestine more rapidly than normally. It may be secondary to achylia gastrica or hyperchlorhydria or diseases complicated thereby, or the condition may exist as a primary neurosis. In some cases achylia and hyperchlorhydria exist as a secretory neurosis, and with this there is the motor neurosis, hypermotility. Supermotility may exist as a motor neurosis alone (primary neurosis) , due to some nervous influence or associated with nervous conditions, and is analogous to increased intestinal peristalsis from nerv^ous influence. In pyloric obstruction there is often actual increased motor power in the early stages, but the resistance to the exit is so increased that the final result is relative motor insuf- ficiency. In the secondary cases hypermotility will be relieved by treating the cause. Diagnosis. — Aspiration of the stomach contents will demon- strate the condition. For example, one may find the stomach empty thirty-five to forty-five minutes after the test breakfast, or only a minute quantity can be removed. 1 Boas, Krank. des Magen, II, Feb. 418, Auflage, S. 260, Leipzig, 1901. 24 370 DISEASES OF THE STOMACH AND INTESTINES Einhorn suggests the employment of the gastrograph, noting an increase of the "makes" and "breaks," but this method is complicated. Careful analysis of the gastric contents should be made to test the secretory functions, and an early aspiration would be necessary. Hypermotility in itself does not produce any special gastric symptoms. Peristaltic Restlessness of the Stomach (Kussmaul) {Synonyms. — Peristaltic Unrest; Tormina Ventriculi Nervosa.) This is really an exaggerated hypermotility in which the peristaltic action is unusually great, and is appreciated by the patient as a disagreeable sensation. It may even become visible through the walls of the abdomen, and waves of contraction can be seen running from left to right along the stomach, and may take from three- quarters of a minute to a minute or more. This condition usually occurs when there is obstruction at the pylorus or duodenum, with dilatation of the stomach, and is produced by the effort of the organ to overcome the obstruction. Kussmaul first described 2 cases of peristaltic unrest which were pure neuroses of motility. The movements began early in the empty stomach and became more violent after eating. Gastroptosis was present. Emotional shock and abuse from sexual excesses were the causes. Mechanical forms must be excluded. In these it occurs only when the stomach is full. In the nervous cases movements take place both when the stomach is full and empty. If the patient is well nourished and the stomach is in normal position it may be diffi- cult or impossible to see the movements, but the patient will com- plain of the contractions and wave-like movements, and borborygmi and gurgling may be heard. Nausea, vomiting, and cramp-like pains mav occur, especially in the obstructive type. Physical examination and gastric analysis will determine whether the peristaltic restlessness is primary (a neurosis) or secondary. Course and prognosis depend upon the cause and the nervous condition in primary cases. Cases may be continuous, when they may cause loss of sleep, or may be intermittent. Treatment. — This must be directed against the primary cause, such as stenosis of the pylorus, etc. If it is a pure gastric neurosis, resulting from mental overexertion, grief, sexual excess, or nervous or hysteric conditions, we must remove these factors. Iron, arsenic, and the glycerophosphates are indicated. Hydrotherapy, diet, and change of scene are valuable. The diet should be regulated, all irritants to the stomach should be NERVOUS AFFECTIONS OF THE STOMACH 371 avoided. The food should be digestible, non-irritating, and in moderate quantities at a time, especially at night. Locally, heat or cold to the stomach; galvanic electricity, per- cutaneous or intragastric. This last is of no value in stenotic cases, but does harm. Lavage is indicated if there are stenosis and dilatation. Antiperistaltic Restlessness of the Stomach In rare cases the peristaltic action is reversed, the waves running from right to left. These cases are generally of neurotic origin. Intestinal waves are of small caliber and move in different directions in various regions, while gastric waves are of large size and move in the gastric region. These waves may extend to the intestines and colored enemata have been voided from the mouth (Osier). Treatment should be directed to the neurosis. Incontinence of the Pylorus {Synonyms. — Insufficiency of the Pylorus.) This condition was first described by de Sere and Ebstein. It may be caused by some growth in the pylorus, keeping the opening patent, or by stenosis or other organic changes, or when the pylorus is relaxed (atonic) due to some nervous derangement, hysteria, or myelitis. Relaxed pylorus, 1 believe, to be frequently associated with atonic ectasy, and that this feature accounts for the absence of pain and vomiting. It is also present in some cases of gastroptosis. The relaxation in these cases is probably compensatorv. Ebstein^ has shown that if we attempt to inflate the stomach with air or CO2, it will rapidly pass into the intestine and distend it, and gastric tympany is absent. A diagnostic feature is"ihe regurgitation of the intestinal contents into the stomach. On aspiration or lavage in the fasting condition, intestinal juice and often a considerable quantity of bile will be found. It is sometimes present on aspiration of the test breakfast or test meal. Very little chyme is present in these cases, but regurgitation is in evidence. There are no distinctive clinical symptoms in most cases; though Knapp^ reports diarrhea alone or alternating with constipation, as sometimes associated, and also toxemic symptoms, as does Ebstein; and Einhorn refers to 2 cases in which there was associated cardiac relaxation, with belching as the chief symptom. My prolonged in- vestigations among the nervous and insane lead me to absolutely disagree with Knapp that achylia (functional or organic) and in- sufficiency of the pylorus are confounded. This author believes there is no functional achylia, and with this I entirely disagree. 1 The relaxation in these cases I do not believe to be a true incontinence, but merely atony with weakening of the pyloric musculature, with no regurgitation. - Philadelphia Medical Journal, May 24, 1902. 372 DISEASES OF THE STOMACH AND INTESTINES Treatment. — Occasional lavage; strychnin, gr. 4V (0.00146), and belladonna extract, gr. J (0.0 11) t. i. d., with intragastric faradization (every other day). Massage and douches are serviceable. Spasm of the Pylorus (Pylorospasmus) Spasm of the pylorus is usually a secondary occurrence, asso- ciated with hyperchlorhydria, hypersecretion, ulcer of the pylorus, or in its immediate neighborhood; and in the latter case must be considered a reflex neurosis. It may result from irritation of the stomach by indigestible diet, by food that is too hot or cold, or by strong spices, etc. It is rare with carcinoma with abundant lactic acid. Bentijac^ described a case who drank a glass of kerosene by mis- take, and who later developed all the symptoms of stenosis of the pylorus and dilatation. Operation showed the pylorus normal, but spasmodically con- tracted. Vomiting ceased after operation. Repeated spasm of the pylorus, in conjunction with hyperacidity or hypersecretion, is undoubtedly at times the cause of gastric dilatation ; and in some cases benign stenosis may result from hyper- trophy at the pylorus caused by repeated spasm. Symptoms. — Pain, increased peristalsis of the stomach, and occasionally vomiting are present. Pure nervous spasm of the pylorus is difficult to diagnose. All perversions of secretion and all mechanical obstacles must be ex- cluded. Nervous pyloric spasm is most likel)^ to be associated with the hysteric or neurasthenic condition. Treatment. — Belladonna is of value; the tincture, lUx (0.592) t. i. d., or extract, gr. ^ (0.016) three or four times a day. The nervous system must be treated. In the secondary cases, secretory perversions and other causes of the condition must receive appropriate treatment. Atony of the Stomach This is a condition in which the muscular action of the stomach is retarded and weakened, and moderate motor insufficiency results. It may be acute or chronic and secondary to other conditions, or as a primary neurosis. It has been already fully described. Hypanakinesis Ventriculi (Einhorn) is defined as a condition in which the mechanical function of the stomach is greatly reduced. There are no breaks, or few, in the gastrograph, an instrument to determine the churning movements of the stomach. It seems a minor degree of atony, and is of no Special clinical significance. 1 These de Paris, 1888. nervous affections of the stomach ' 373 Hyperanakinesis Ventriculi (Einhorn) This is an excessive mechanical action of the stomach. It seems to correspond to hypermotihty. Excessively active churning move- ments occur in this condition (Einhorn). It seems difficult to sepa- rate it from hypermotihty. Spasm of the Cardia (Cardiospasmus) Spasm of the cardia consists in a spasmodic contraction of the muscles of the cardia, with the production of pain and difificulty in swallowing (dysphagia). It may be secondary to other diseases (organic disease), reflex from local irritation, or as a primary neurosis, associated with nervous conditions. Etiology. — It may be produced by the passage of the stomach- tube or after rapid eating, by very hot or cold drinks, and by coarse or hard food. Among other causes are ulcer or carcinoma of the cardia. Hyper- acidity may occasionally cause it, though pyloric spasm is more frequent with this affection. Diverticula, or inflammation of the esophagus, are causes. It may occur in tetanus. It is quite frequent in hysteric or neurasthenic individuals, especially in air swallowers (aerophagia), in whom spasm of the pylorus may also occur with resulting distention of the stomach ("pneumatosis"). Violent psychic shocks may also produce it, so the condition may be a primary neurosis. Fermentative processes in the stomach, with the production of gas, may be a cause ; but organic disease is usually associated. Primary spasm of the cardia cannot produce gastric dis- tention unless spasm of the pylorus is also present. S5niiptoms. — As a pure neurosis the attack usually begins suddenly. The patient may be in perfect health, when an acute pain begins in the region of the cardia radiating tow^ard the chest or back. It occurs generally during the ingestion of food, and there is a feeling as if some of it were arrested. There is at times some interference with breathing. Slight dyspnea is present and the respiratory movements are more forcible. There may be regurgi- tation and the patient feels better thereafter. There is gagging and often vomiting. The attack can be acute and last only a short time or the con- dition may become chronic. The dysphagia in these cases, as a rule, increases; and though for a time the patient, by taking a deep inspira- tion and compressing the thorax while holding his breath, can force down the food, the deglutition of soHd food becomes more and more difficult, and finally only liquids can be taken. Emaciation may become quite marked, and after several years atonic dilatation of the esophagus may result similar in character to atonic gastric dilatation from pyloric spasm. Dilatation of the esophagus may also be produced by benign or malignant stenosis at the cardia; or by 374 DISEASES OF THE STOMACH AND INTESTINES paralysis of the dilator nerves of the cardia, from paralysis of the esophagus, or by loss of reflex relaxation of the cardia (Einhorn). Diagnosis. — In acute cases the existence of pain and dysphagia, the delay or absence of the swallowing sound, and the spasmodic resistance at the cardia on insertion of the stomach-tube, which can be overcome by pressure, together with the presence of neu- rasthenia or hysteria, settle the diagnosis. In the chronic type the history of the case, the fact that often the resistance to the large tube is less than to the small one in nervous cases, all aid the diagnosis. In true stenosis (organic stricture) the small sounds are more readily passed. The method of determining esophageal stricture has been described. If blood appears with the sound, ulceration is at once suggested. Cachexia is suggestive of mahgnancy, and aspira- tion of the gastric contents will settle the question. Dilatation of the esophagus can be further determined as follows : A slice of bread can be dissolved in 200 cc. of water to form a soft mass, and administered, the patient being instructed to employ forcing movements, so that it will enter the stomach. An hour later 200 cc. of water may be given, no forcing movements to be employed. In about three to five minutes an aspirating tube can be passed to the cardia, and if dilatation and spasm exist the water just ingested can be removed, and will be in the same condition as taken. The tube can then be forced on into the stomach and the true gastric contents can be removed. These can be tested. The administration of bismuth with the employment of the x-rays is also of value for the purpose of diagnosis. Prognosis is good in the acute cases, but as regards complete cure in chronic cases it is not so good, though there is no danger to Ufe. Treatment. — If the spasm occurs while eating and drinking, this should be performed slowly. The food should be well masticated or should be, preferably, soft in character; and excessively hot or cold food should be avoided. General tonics should be given. The employment of sounds, left in place for some time, is of value. Tincture of belladonna, TTLx (0.592), should be given t. i. d. to relieve spasm. The bromids are of service; thus, sodium bromid, gr. 15 to 30 (1.0-2.0) t. i. d. Opium or chloral should be administered with caution, or not at all. In the chronic cases soft or liquid food should be given. The patient should bear down to force the food thoroughly by the ob- struction. The stomach-tube should be introduced at least once a day to relax the cardia; if there is emaciation, food can be admin- istered through the tube; if the esophagus is dilated, it can be emptied and washed out. Rectal feeding must be enjoined for a time in severe cases. As improvement occurs the diet can be increased. nervous affections of the stomach 375 Insufficiency of the Cardia Under this we may classify eructation, pyrosis, regurgitation, and rumination. Eructation (Belching). — Eructation may be defined as the expulsion of gas from the stomach through the mouth. The condition may be secondary to various conditions of the stomach or may be a primary neurosis. Normal healthy subjects may eructate after drinking carbonated water, or those who eat rapidly without proper mastication, and thus swallow considerable air. Secondary Cases.- — Belching may be associated with acute or chronic gastritis or with fermentative processes in the stomach. The clinical symptoms, gastric analysis, and fermentation test will render a positive diagnosis. In fermentative processes the gas is often malodorous. Primary Cases. — Nervous Belching (Eructatio Nervosa). — We have cases in which belching occurs at short intervals, which is independent of the character of the food and clearly of nervous origin. It is noisy, as a rule, and may persist for a considerable period or occur in paroxysms. The gas consists of atmospheric air which has been swallowed (aerophagia) or aspirated into the stomach. Oser claims that the stomach acts as an elastic sac, and can aspirate the air without the effort at swallowing, and that it tends to fill after expulsion. Some of the air probably comes from the esophagus and has been swallowed just previous to the act of belch- ing. Bouveret considers it due to spasm of the pharynx. . Etiology. — This nervous type of eructation is observed in hysteric women and chiefly in neurasthenics, or after excitement, shock, or mental worry. It frequently occurs in children, often in several in a family. The belching may last for a long period and only occur during the day, and may be extremely annoying. Diagnosis. — Absence of fermentation, as shown by the test, the history of nervousness or of shock, and the gastric analysis show- ing normal secretion render the diagnosis conclusive. Treatment. — Massage, hydrotherapy, iron and arsenic, change of climate, the faradic current (extraventricular or intragastric), bromids, and suggestion to the patient are of service. Pyrosis (Heart-burn) This consists in the ejection of chyme from the stomach into the esophagus, with which is associated a burning sensation in the epigastrium. Etiology. — It most frequently occurs with hyperchlorhydria, but has been found with achylia. 376 DISEASES OE THE STOMACH AND INTESTINES It may occur as a neurosis, especially among the hysteric or neurasthenic, with normal gastric contents. It is of mixed type, motor and sensory. General tonics and electricity are of value in these cases. REGURGITATION Regurgitation denotes the condition in which after eating, some of the food ingested, Hquid or liquid and solid, rises from the stomach, enters the mouth, and is ejected. Occasionally small fragments are swallowed again. The act is usually involuntary, though it can be produced by some at will. Early regurgitation tastes of the food, later it is acid. The patients can suppress it at will, and in this way it differs from regurgitation due to cardiac stenosis or diverticula. The sound and chemic analysis also give aid in diagnosis. In some cases, if regurgitation is marked, considerable emaciation may result. Organic disease, such as stricture of the esophagus, must be excluded; also gastritis. Etiology.— Patients of nervous or hysteric type develop this condition; and mental worry and nervous strain may be the cause. Prognosis is good. Treatment. — The patient should eat slowly and masticate his food. Suggestion is good; also forbid the patient to spit out his food, and tell him to swallow it again. Massage, faradization (intra- and extragastric) ; strychnin, gr. -j^Q- (0.0016) t. i. d., and the treatment of the nervous condition are indicated. Rumination , {Synonyms. — Merycism, "Chewing the cud.") In this condition the food is returned from the stomach, without nausea, into the mouth, some time after meals, where it is chewed and swallowed again. Etiology. — It occurs more frequently in men than in women; and most of the cases reported belong to the higher classes, especially among professional men. Many of the lower class would not deem the condition abnormal and women would conceal it, so it may be said to belong to all classes. It occurs among hysteric persons, neurasthenics, epileptics, and idiots. Possibly heredity and, undoubtedly, imitation in many cases are factors. Occasionally there may be a pathologic condition of the stomach, with regurgitation, and rumination follows. Several cases have been reported of imitation among children. Shock, trauma, rapid eating, and emotional disturbances in nervous persons are at times accessory factors. NERVOUS AFFECTIONS OF THE STOMACH 377 Gastric Findings. — In some cases hyperacidity has been found, and rumination diminished after this was corrected. Diminished acidity has been found by Boas, and improvement followed after hydrochloric acid was administered. On the other hand, achylia gastrica has been present in such cases and also normal secretion. The motor functions are normal in most cases. Prognosis. — ^The habit may be corrected in part, but may persist for years, with no impairment of health. In some patients the attacks are periodic. Treatment. — Any secretory anomaly that exists must be cor- rected. The treatment should be by mental impression (psychic) on the part of the physician. The patient should be taught that he can readily suppress the condition. Small bits of ice after meals; lavage and gavage have been suggested. The nervousness should be corrected by iron, strychnin, and arsenic. Nervous vomiting (Vomitus Nervosa) Vomiting is a complex process. There is a contraction of the abdominal muscles and fixation of the diaphragm, with a contraction of the stomach, accompanied by closure of the pylorus and opening of the cardia; reversed peristalsis of the esophagus and closure of the larynx and posterior nares, with resulting expulsion of the stomach contents through the mouth. The vomiting center lies in the medulla near the vagus center. Vomiting may be due to some organic disease of the stomach or as a result of irritation due to the ingestion of food of abnormal character. Certain intoxications, as from uremia, cholemia, opium, morphin, tobacco, ether, or chloroform, may produce vomiting. Nervous vomiting is characterized by the absence of these con- ditions just mentioned, and may be either cerebral or spinal in origin, or due to reflex disturbance, overexertion, emotional shock, anger, fright, or neurasthenia. Among the cerebral causes are organic disease of the brain and its- meninges, concussion, and tumors. Spinal forms, such as tabes, or occasionally paresis, multiple sclerosis, and subacute myelitis. Reflex causes, such as from the pharynx, larynx, palate, liver, peritoneum, kidneys, genitals, etc. Juvenile vomiting and the periodic or cyclic vomiting (Leyden), also the cyclic vomiting of children (infants) are included. Characteristics of Nervous Vomiting. — Stiller calls attention to the following peculiarities: This type of vomiting seems to he independent of the character and quality of the food, and occurs generally without any premonitory symptoms. Sometimes digestible foods are vomited, while indiges- tible material is well borne. There seems at times to be a power of 378 DISEASES OF THE STOMACH AND INTESTINES selection to vomit certain nutrients, and the patients suffer from no inanition. Vomiting may also occur from the empty stomach, and the condition is associated with various nervous symptoms. Boas has noted that the motor and secretory functions are normal, though Bouveret and Einhorn have observed a diminution or absence of secretory function in some cases. Treatment. — Tonics. Correct disturbance of secretory functions. Mental impression on the part of the physician is important. Change of scene is at times of value. Periodic Vomiting (Von Leyden) There are several particulars connected with this type of vomiting. As a rule, no cause can be discovered, and the attack appears when the patient is in perfect health. The attacks occur at intervals of equal duration. After the attack the patient is immediately restored to health, and remains well until the next one occurs. They resemble somewhat the gastric crises of tabes, and are similar in suddenness of occurrence to violent attacks of migraine. They seem to be influenced by emotional disturbances. They begin with slight nausea and with a chilly feeling and headache followed by vomiting of the gastric contents, and later bile and mucus streaked with blood. The vomiting is very persistent, and all food or even small quanti- ties of water are ejected. In some cases there is pain. The patient becomes greatly prostrated, the abdomen sunken, and the face pale. The attack may last from a day to a week or longer. Suddenly the nausea and vomiting cease, the appetite returns, and the patient is rapidly restored to health. Gastric Juice. — This has been found to be normal in most cases, though Einhorn reports a case of achylia gastrica. Treatment. — Rest, ice pellets, morphin, gr. \ (0.016), by hypo- dermic, and belladonna tincture, Hlx (0.59), are useful. Cocain I deprecate. Tincture of hyoscyamus, 2 cc. (30 drops), and hot appli- cations during attacks. Oxalate of cerium in grain doses is of value. Between attacks, tonics, change of climate, and hydrotherapy. Cyclic Vomiting in Children This is probably due to faulty metabolism; occurs generally in those from two to four years of age, of a nervous type and gouty family history. There are premonitory symptoms; temperature but seldom over 100.5° F., anorexia, languor, followed by persistent and violent vomiting of food, mucus streaked with blood, and at times bile. Prostration is marked; the gastric contents very acid. Acetone, diacetic acid, and oxybutyric acid are present in the urine, and so it is believed it is a form of acid intoxication ; uric acid in the urine is diminished. It is possibly a lithemic manifestation. NERVOUS AFFECTIONS OF THE STOMACH 379 The attack resembles migraine in the adult. Antecedents are a neurotic and gouty family history. Carbohydrates in excess seem to have a bearing on its production, according to some; fatigue, excitement, or tonsillitis bring it on. Prognosis. — Good. Diagnosis. — Attacks are not brought on by indigestible food; the disease is self-limited, and the child rapidly returns to the normal state. The attacks are repeated. Treatment. — Calomel to abort it; food and drink should be stopped; enemata and enteroclysis are advisable. Hypodermoclysis may be necessary in severe cases and rectal feeding is indicated. Alkaline Treatment. — Sodium bicarbonate, gr. 15 to 30 (1.0-2.0), in divided doses may be given. Limit starchy food. Care must be taken not to tire the child thereafter. Juvenile Vomiting Overwork at school is often the cause. Cardialgia and vomiting occur. There may be headache, slow pulse, pallor, dilatation^ of pupils, etc. Treatment. — Tonics, proper diet, removal from school. REFLEX VOMITING Nervous vomiting is frequently reflex in character from disease of almost any organ. Among the causes are disease of the pharynx, elongated uvula, diseases of the abdominal organs, as hydronephrosis, movable kidney, kidney colic, ptosis of the liver or spleen, peritonitis, appendicitis, hernia, and disease of the sexual organs. These conditions should receive appropriate treatment. The vomiting of pregnancy belongs to this type. Belladonna tincture, TTLx (0.59), t. i. d.; cerium oxalate, gr. 2 (0.13), t. i. d.; Fowler's solution of arsenic, several doses i drop each; bromids, gr. 15 (i.o); codein, gr. ^ (0.016); or chloral, gr. 3 (0.194), t. i. d. I^. Menthol gr. x (0.6) Syrup o ij (60.0) Aq. destil q. s. giv (125.0). — M. Sig. — Two teaspoonfuls t. i. d. The use of cocain I deprecate. Lavage is temporarily of service. Abortion may occasionally be required in pregnancy cases. Change of scene may be necessary. Idiopathic Nervous Vomiting In some hysteric or neurasthenic persons (adults) vomiting will occur after meals without any apparent cause, more frequently in women and without showing the periodic type. Usually part of 380 DISKASES OI? THK STOMACH AND INTESTINES the meal is vomited. It may continue for a long period. Nutrition is frequently not disturbed. The vomiting may occur so quickly during the act of ingestion of food that it seems as if it did not enter the stomach, but was rejected by the esophagus. Other patients seem normal in this regard. Occasionally hysteric subjects may vomit blood. In all cases the gastric secretion must be studied, so as to exclude hyperchlor- hydria, hypersecretion, etc., and to observe whether vomiting complicates some other disease or is a reflex affection. Treatment. — Suggestion, the regulation of the mode of life, tonics, such as arsenic and iron, bromids; change of climate; gavage for about two weeks; lavage with i: 1000 nitrate of silver, have proved of value. Faradization, extra-abdominal or intragastric (Einhorn), has been of benefit. Pneumatosis Spasm of the cardia, combined with pyloric spasm, may produce pneumatosis (distention of the stomach with air), with a resulting sensation of tension and at times dyspeptic asthma. Hysteric or neurasthenic symptoms are associated. Aerophagia (air swallowing) is probably the cause. The upper part of the abdomen is markedly distended and tympanitic, and there is interference with respiration. As a rule, there is no belching. Diagnosis. — Organic affections of the stomach must be excluded, in which the gas has a foul odor and the contents ferment. Treatment. — Tonics and bromids are indicated. Aspiration of the stomach in the acute attack, so as to give exit to the air, is the best method. It may be necessary to repeat it. Extract physostigmatis, gr. ^ (0.008), or eserin, gr. jio (0.00065), or morphin, gr. I (0.016), or tincture of belladonna, 1TLx (0.59), or extract of belladonna, gr. | (0.016), may be required. SECRETORY NEUROSES The secretory function of the stomach is undoubtedly under the direct control of the nervous system. For example, in a hungry dog with a fistula the sight of meat will produce gastric secretion, and in the case of a man with impermeable esophagus, but with a gastric fistula, mastication produced gastric secretion. The vagus has been demonstrated to be the secretory nerve. The stomach itself, however, possesses some secretory power, since after section of the pneumo gastric and sympathetic nerves, secretion will occur after the application of an irritant. Hyperchlorhydria, gastrosuccorrhea (hypersecretion), and achylia gastrica may all be functional disorders of secretion, and have been described in special chapters. NERVOUS AFFECTIONS OF THE STOMACH 381 Subacidity (hyposecretion, hypochylia gastrica, hypochlorhydria) may be of nen^ous origin, and must be differentiated from cases occur- ring with organic disease of the stomach, especiahy gastric catarrh. Hydrochloric acid, strychnin, massage, and electricity are of service in these last cases. In the subacid cases sudden changes in the gastric findings (secretory) are in favor of a neurosis, according to Hemmeter. Disorders of secretion may accompany other diseases, such as tabes, or spinal lesions. Nervous Dyspepsia (Leube) {Synonym. — Neurasthenia Gastrica.) Leube originally described nervous dyspepsia as a disorder of the stomach, characterized by a variety of distressing subjective symptoms during the act of digestion, but in which it was normal as regards time and chemism. In effect, he originally considered "nervous dyspepsia" as a neurosis of sensibility. He has more recently extended his definition to other forms. Strictly speaking, nervous dyspepsia is a combined gastric neurosis in which the sensory disturbances (subjective symptoms) are the most prominent. It may be combined with secretory and at times even with motor disturbances. Gastric Juice. — The findings in the gastric juice are not char- acteristic. It may be frequently normal; it may occasionally be hyperacid, more frequently diminished acidity, or at times there may be variations in the same subject. In long persistent cases atony may be present. Some authors refer to the presence of enteroptosis or membranous colitis with neurasthenia gastrica. In this connection it is evident that frequently the diagnosis of "nervous dyspepsia" is made, when in reality gastroptosis (enteroptosis) is the basis of the difficulty. "With the ptosis of the viscera we have sensory, secretory, and frequently motor disturbances of the stomach, associated with nervous symptoms, but the correction of the ptosis will cure the condition. In pure nervous dyspepsia all organic lesions of Die stomach must be excluded and also ptosis of the viscera. The stomach must occupy the normal position. Etiology. — Neurasthenia gastrica may occasionally appear as an independent neurosis, but more usually with nervous symptoms, hysteria, or neurasthenia. Grip, pulmonary disease, anemia, chlo- rosis, malaria, or debilitating conditions predispose to it, as do also reflex irritation from the sexual organs, excessive venery, abuse of alcohol, or tobacco. This disease occurs more frequently in men than in women, especially among brokers and those subject to worry and mental 382 DISEASES OF THE STOMACH AND INTESTINES strain, and usually at the prime of life between thirty and fifty, though it may be present at other periods. Symptoms. — The patient usually complains of a feeling of fulness or pressure after eating, or even of shght pain or belching, loss or irregularity of appetite, a sleepy feehng, or even weakness or dizzi- ness. The tongue is usually clean. There is marked mental depres- sion, and the patients are nervous and anxious. One peculiarity is that the quantity and qiiality of the food seem to make 'little difference in their symptoms. At times indigestible food can be taken without discomfort, while at other times digestible food may produce the symptoms. Occasionally the pain and discomfort are present when the stomach is empty. There is often nausea and occasionally vomiting. Thirst is variable. There is usually tension or fulness of the intestines due to accumulation of gas, which is passed later per rectum. The bowels, as a rule, are constipated, with occasion- ally an alternating diarrhea. The movement may appear in narrow cylindroids or small balls in some cases. In addition to the feelings of depression, insomnia, palpitation, headache, and lassitude may be present; also vertigo, impotence, or emissions. The surroundings and general mood of the patient have a marked influence on the symptoms. The cases are often extremely dis- agreeable in their "home life." Circumscribed points, sensitive to pressure, have been described as diagnostic; one below the ensiform and the others near the navel, especially to the left, but Ewald has demonstrated "nervous dyspepsia" in which no such points could be found. Course. — The course of the disease is slow and the svmptoms vary; sometimes one symptom being prominent; at another time, another. The mood of the patient has a marked influence and in good company he may forget his trouble. They generally do not sufifer much in nutrition, but in cases with insomnia they at times lose considerable weight. Diagnosis. — The presence of general nerv^ous s^^mptoms, especially of those pointing to the stomach, without the presence of organic disease of the organ; the fact that the gastric secretion is often found to be normal, though at times hypochlorhydria and more rarely a mild hyperchlorhydria, and that we frequentlv obtain variable gastric analyses in the same patient; that there is lack of proportion between the gastric findings and the condition of the digestive organs, as compared with the severe complaints voiced by the patient; that the character of the food, whether digestible or indigestible, seems to make no difference as regards increasing or ameliorating the symptoms, and, finally, that change of scene or the mental condition of the patient has a decided influence on the condition — all these facts point to neurasthenia gastrica. Differential Diagnosis. — The chief differences are as follows: NERVOUS AFFECTIONS OF THE STOMACH 383 Neurasthenia Gastrica. — Character of the food makes no difference as to symptoms. There are sudden changes in the patient's condi- tion; well for a few days, and then marked symptoms; nervous symptoms marked. Gastric secretion often normal, and frequently variable in the same patient at different times. Chronic Gastritis. — Aggravated by errors in diet; symptoms constant; mucus in the gastric contents; reduction in hydrochloric acid is marked as a rule. Ulcer of the Stomach. — Painful area in the epigastrium, tender on pressure; hematemesis or occult blood, melena, and pain is increased markedly after ingestion of food. The character of the food influ- ences the pain markedly, even in the more obscure cases. Pain remits or disappears. Cancer. — Age of patient; tumor; cachexia; quality and quantity of the food may not markedly influence the pain; gastric analysis showing absence of free HCl, lactic acid, and Boas-Oppler bacilli present ; pain continuous ; progressive emaciation. Treatment. — If there are any sexual disorders which reflexly might affect the nervous condition, these should be treated; sexual excesses or overindulgence in alcohol or tobacco should be checked. Brokers and professional men who have mentally overexerted them- selves or are tired with the worry of business cares, lead an irregular life, or who are engaged too actively in social pursuits, if possible, should have a change of scene. Horseback riding, golf, yachting, fishing, shooting, camp life for a few weeks, a pleasure trip, all give excellent results. A short ocean trip south or abroad is of service. In those who cannot afford these methods, the lightening of business and professional cares is important. Hydrotherapy, massage, electricity, especially by the faradic current, combined with out-of-door life and proper exercise, mild gymnastics, so as not to tire the patient, are of value. The mental itnpression created by the physician ^'.s" important. Static electricity is at times of service. General faradization, the bare feet on one electrode, and the other being passed over the body, is useful (Rock- well). The diet should be abundant, the patient avoiding highly seasoned food, alcohol, strong coffee, and excessive smoking. Stomachics should be given if hydrochloric acid is deficient, such as nux vomica, compound tincture of cinchona, dilute hydrochloric acid, etc. If hyperchlorhydria, then the alkalis should be administered. The patient should secure the proper amount of sleep. Forced feeding and the Weir-Mitchell rest cure are necessary in severe cases. Milk and raw eggs are of value in reduced nutrition. Malbranc's gastric douche has been recommended in some cases, and Einhorn suggests the use of his gastric spray. Personally I do not employ such local measures. 384 DISEASES OF THE STOMACH AND INTESTINES The general tone of the patient should be built up by iron, such as peptomangan (Gude's), iron pills, iron tropon, arsenic, and strych- nin. Small doses of nux vomica combined with compound tincture of cinchona are excellent to improve the appetite : I^. Tr. nucis vomicse 3iij (12.0) Comp. tinct. cinchona oss (16.0) Aq. destil q. s. §iv (125.0). — ^M. Sig. — I to 2 teaspoonfuls t. i. d. in water before meals. Basic orexin, 2 decigrams (gr. 3) t. i. d., has also been recom- mended by Einhorn for this purpose. Sodium or ammonium bromid, gr. v to x (0.3-0.6) two or three times a day, lessens the nervousness. The bowels should be properly regulated by cascara, aloin pills, phenolax, etc. Iron springs, such as Franzensbad, or salines, as Kissengen or Wiesbaden, are of service. The carbonated bath (Nauheim, Triton) I have found — given every other day at home for a course of 12 baths at a temperature of 95 ° to 98 ° F. — to be of service in toning up the circulation and general nervous condition. CHAPTER XVIII DYSPEPTIC ASTHMA This type of asthma, due to digestive disturbances, was first described by Henoch,^ later by Silberman,^ Oppler,^ Boas,* Murdoch,^ and Einhorn.® Many others have described this condition. The symptoms first reported by Henoch were of an acute type and, according to his behef, were the result of reflex action starting from the stomach. It is noteworthy that the most severe symptom disappeared when the patient vomited. In his cases the breathing was rapid and shallow, pulse rapid and feeble, and at times so rapid that it could not be counted, extremities cool, the temperature sub- normal, and there were even symptoms of collapse. In all cases there was acute dyspepsia due to some error in diet. The region of the stomach was usually distended and painful. The greatest number of cases were observed in children. Numerous explanations have been given for this condition, and a variety of experiments have been performed. Henoch believes it to be due to reflex action, starting from the stomach and causing a vasomotor spasm; while Einhorn suggests reflex irritation of the vagus fibers. In view of the fact that the majority of cases occur after dietetic error, Riegel's suggestion of auto-intoxication as a factor seems to have a decided hearing on the subject. On the other hand, under acute dilatation of the stomach I referred to certain peculiar clinical types, in one of which many of the symptoms resembled angina pectoris, there being dyspnea and rapid and feeble heart action, and in some attacks loss of conscious- ness. These attacks followed indiscretion in diet. In view of this fact and also that Henoch describes distention of the stomach as present in most cases, and dietary indiscretion as a cause, it would seem to me that in this type at least acute gastric dilatation from auto-intoxication is a factor. Einhorn describes acute cases follow- ing excesses in eating, drinking or smoking, excitement, or from no discoverable cause. Even these facts do not mitigate distention. The second group which he classifies are more of a chronic type, appearing after meals, or after overexertion, or without apparent 1 Berlin, klin. Wochenschr., 1876, No. 181. 2 Ibid., 1882, No. 23. 3 Allgem. Med. Central. Zeit., 1890, No. 71, p. 849. * Arch. f. Verdauungskrank., Bd. 11, 1896, p. 444. 5 New York Med. Journal, Jan. 12, 1901. ^ Jour. Am. Med. Assoq., Feb. i, 1902. 25 385 386 DISEASES OF THE STOMACH AND INTESTINES cause, or those appearing several hours after meals spontaneously, or after exertion. In some of these cases a small amount of food would check the attack. The last type would seem to suggest reflex irritation from hyperchlorhydria, for example, which when relieved would stop the asthma. Some of the last group present, in some cases, symptoms suggest- ive of pseudo-angina pectoris. Secretory Functions. — Ach^-lia gastrica has been found in some patients and h3^perchlorh5^dria in others. Treatment of these con- ditions caused subsequent disappearance of the attacks of asthma. In achylia the coarse particles of food, Einhorn believes, might cause reflex irritation of the vagus. Asthma dyspepticum may also occur with chronic gastritis. On the other hand, these attacks have occurred in patients in whom the gastric secretion was normal; and Boas believes that hyperesthesia of the stomach with reflex irritation is the cause. Again, in my case of acute dilatation with some of the attacks similar to angina, the gastric secretion was normal; but dietary indiscretion produced gastric distention and the attack noted. It was immediately relieved by vomiting. Floating liver was noted by Einhorn in 5 cases, and this together with abdominal ptosis of other organs; and he believes that the pro- lapsed liver, by dragging down the diaphragm, may be a cause of this type of asthma. In my own opinion ptoses of the viscera have an influence on the secretory conditions in the gastro-intestinal tract, and only to this degree predispose to dyspeptic asthma. Probably these various factors to which I have referred may have a bearing in different cases. Treatment. — Disorders of the gastric secretion must be appro- priately corrected, and ptosis of the viscera supported by Rose's adhesive belt. Excesses in the use of alcohol and tobacco must be corrected, mental worry and strain be avoided, and the mode of life must be regulated. All indigestible food must be avoided and diet suitable to each case must be instituted. By this means many cases will be relieved and often cured. In acute cases with distention of the stomach lavage is indicated, also calomel, gr. 5 (0.3), followed by a saline cathartic. Catharsis is also indicated in cases following excesses in eating or drinking. CHAPTER XIX THE STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS Unquestionably there are few diseases, either constitutional or local, which are not attended to a greater or lesser degree by some disturbance of the digestive organs. These are dependent on the general disturbance of the organism and are appropriately discussed under the symptoms of each disease. In the present chapter I shall only briefly refer to those diseases in which disturbances of the gastric functions are particularly conspicuous. FUNCTIONS OF THE STOMACH IN ACUTE FEBRILE DISEASES Numerous investigations have been carried out both on animals and men, in some of which at least accurate quantitative gastric analyses were performed. Riegel concludes that we are probably justified in stating that in acute febrile infectious diseases the pro- duction of hydrochloric acid was more frequently reduced than normal, and the secretion of pepsin is, as a rule, unchanged. Prob- ably the fever is responsible and the condition is temporary. Von Noorden^ showed that hydrochloric acid reaction can be obtained in fever cases if pepper and salt are administered with the food. Some interesting researches have been carried out in numerous cases of typhoid and pneumonia. During the high temperature of these diseases there was a marked diminution, and in some cases an absence of hydrochloric acid. During defervescence an increase of the secretion was noted. During high tempratures pure milk was found in the stomach in a curdled condition several hours after the normal time for evacuation, and in one case, on autops}^ the stomach was found filled with the curdled milk of previous feedings, thus demonstrating a diminution of the motor function. Water alone was- then administered at this period. During lower temperatures foods freely soluble in water, such as broths and gruels, were found best. There was less fermentation and distention under this method of feeding and the stomach more readily emptied itself. In my own experience^ I can confirm the fact that during the high temperature of typhoid the free hydrochloric acid diminished, often markedlv, and the motor function is not as active. It has also been found that biliary secretion is disturbed during high fever. Stolmkow noted disturbances in the pancreatic secretion during high temperature. 1 Lehrbuch der Pathologic des Stoffwechseis, 1893. ^ American Medicine, May, 1909. 387 388 DISEASES OF THE STOMACH AND INTESTINES CHRONIC FEBRILE CONDITIONS Observers vary considerably in their findings in the gastric secretion in these cases, some noting no changes whatever. In my own experience the temperature, as a rule, caused disturbance in the secretory function of the stomach, lessening the HCl pro- duction. The type of disease, the physical condition, the personal equation of the patient, and, most important, the time at which the analysis is made, all have a hearing. I shall refer shortly to the work of Hildebrandt on this subject, under Tuberculosis. The power of absorption seems to be impaired in fever (Sticker).^ CONDITION OF THE STOMACH IN PULMONARY TUBERCULOSIS Phthisis quite frequently begins with dietetic disturbances, such as heart-burn, belching, pressure, nausea, loss of appetite, constipa- tion alternating with diarrhea, and even vomiting, with the lung symptoms so slight as to be at first overlooked. It has been called pre tubercular dyspepsia. In the later stages we may have the dyspeptic symptoms quite marked. Hildebrandt" found the following results: The cases in which free hydrochloric acid was present usually had no fever, while those in whom it was absent suffered from continuous fever. When it was absent at one part of the day, it was when the temperature was high ; and when present at another part, it was when the temperature was low. The temperature, therefore, exercised an influence. These findings were in advanced cases. Klemperer^ studied lo cases in the initial stage, 3 in the advanced, and i in the moderate. In the beginning the secretory power of the stomach was usually increased, often normal, and rarely reduced. In the terminal stages, always greatly reduced. Motor reduction slight in the initial stages, reduced in later stages. Brieger* analyzed 64 cases: 31 advanced, with continuous fever ; 37 moderate, with more or less fever; 6 incipient cases, with no fever. Gastric secretion normal in 16 per cent, of advanced cases, and in the others insufficiency of varying degrees; in 9.6 per cent, absence of free hydrochloric acid. In moderate cases, 33^ per cent, normal, and in all others perversion; and in 6.6 per cent, normal secretion absent. In the initial cases, normal secretion and perversion were equally divided. Einhorn' has shown in analysis of 1 5 cases that the appetite does not seem to correspond, as would be expected, to the gastric findings; and also that frequently the subjective symptoms do not harmonize with the objective findings. 1 Deutsch. med. Wochenschr., 1889, No. 15. 2 Berlin, klin. Wochenschr., i88s. 3 Ibid., 1889, No. 2. ^Deutsch. med. Wochenschr., 1889, No. 14. ^Loc. cit. THE STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 389 Treatment.-^The main indication is to improve the resisting power of the patient against the primary disease. Forced feeding, especiall}^ by Russell's method, rest in bed, and fresh air, with milk and vegetable juices, I believe the best treat- ment for the tuberculosis. I have seen a gain of 15 to 25 pounds in each case by his methods at Ward's Island in 12 cases in eight weeks. The heart and kidneys must functionate properly for success with his method. Functional disturbances of the stomach should be treated. Tuberculous ulcer of the stomach is occasionally met with in connec- tion with tuberculosis of the other organs. CHLOROSIS AND ANEMIA Among the gastric symptoms in these conditions are found gastralgia, anorexia, hyperesthesia of the stomach, hyperchlor- hydria, and chronic atony. These symptoms appear more frequently after eating than on an empty stomach, and occur, as a rule, in attacks at irregular intervals. There are often perversions of appetite. The atony, if neglected, may progress to chronic atonic ectasia. In chlorosis (primary anemia) the hydrochloric acid secretion is, as a rule, increased. In anemia (secondary), on the other hand, depending on the causative disease we may find variable results; hydrochloric acid decreased, normal, or (more rarely) increased. In this I agree with Riegel. The relation between achylia gastrica and pernicious anemia has already been described. The relation of intestinal putrefaction to this disease is described later. Many of the derangements belong to the neuroses and are depend- ent on the condition of the blood. The administration of iron is chiefly indicated, with the additional correction of the functional disturbance if such be present. HEART LESIONS ^ In general we may say that while compensation is present, in many cases the stomach functions are normal or nearly so; with imperfect or failing compensation, with resulting stasis and hyper- emia in the gastric mucous membrane, I have noted diminution in the amount of free hydrochloric acid with accompanying digestive disturbances, belching, pressure, anorexia, and at times nausea and even vomiting, with sick headache. These conditions improved after treatment was directed to the circulation. In severe cases free HCl may be absent. In one case with poor compensation and frequent gastric attacks, a course of treatment at Nauheim produced excellent results. Symptoms simulating heart lesions may be produced by gastric disorders, thus : Ulcer, chronic ectasy, and chronic gastritis may pro- 390 DISEASES OF THE STOMACH AND INTESTINES duce bradycardia or arhythmia; or tachycardia may occur with chronic gastritis, in nervous gastric disorders, or with atony. Tachycardia with acute dilatation of the stomach, especially with existing heart lesions, the author has described in the chapter on Acute Ectasy. DISEASES OF THE LIVER Diseases of the liver are generally accompanied by gastric symp- toms; with cirrhosis and the resulting circulatory disturbances of the viscera the gastric secretion (free hydrochloric acid) is more frequently diminished. The findings in other liver disturbances are not constant. ANEURYSM In a case of aneurysm of the celiac axis, referred to under Cancer, free hydrochloric acid was absent, lactic acid present, and the stomach dilated. Circulatory disturbances were responsible for the gastric findings and pressure for the dilatation of the stomach. DISEASES OF THE KIDNEYS Gastric disturbances are frequent in nephritis, and nausea and vomiting may be the first symptoms. In fact, Osier has reported death with these symptoms, and nephritis may be unsuspected until autopsy. The excretion of urea through the gastric mucous mem- brane or cerebral irritation from the poison are responsible for the vomiting. Variable conditions of the gastric secretion have been reported by various observers. Biernaki^ has studied 25 cases of nephritis, both acute and interstitial, and found in general the gastric secretion was diminished, and also that the quantity of free hydrochloric acid was reduced in proportion to the extent of the edema, the excretion of albumin, and the reduction in the quantity of urine excreted. Pepsin was reduced and the motor function was increased. Free hydrochloric acid was present in the mild cases in large or small quantities. Einhorn has observed achylia gastrica in a case of renal calculus, which disappeared after operation, and A. A. Jones^ has found achylia gastrica among patients with kidney disturbances. DIABETES Variable results have been secured. Atrophy of the gastric mucosa has been found in a few cases. The motor power was good. Rosenstein^ reports normal secretion in 4 cases and abnormal in 6, while Gans* found 6 normal and 4 negative. The findings are not constant, and both normial and abnormal conditions of the secretion have been observed. 1 Berlin, klin. Wochenschr., 1891, Nos. 25 and 26. " New York Medical Journal, January 19, 1895. ^Berlin, klin. Wochenschr., 1890, No. 15. * IX Congress f. innere Medicin, 1890, Wiesbaden. THE STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 39 1 . ARTHRITIS DEFORMANS In I case^ I found hyperchlorhydria marked ; and Einhorn reports I case of achylia. GOUT In 2 cases Einhorn reports achylia, and in several mild cases hyperchlorhydria. Grip. — Gastric disturbances are reported by Kaufmann in grip. MALARIA Gastralgia may occur as a substitute for the malarial paroxysms and has already been described, or vomiting may be present, asso- ciated with malarial symptoms. There are no characteristic features of the gastric secretion, but in the latter cases free hydrochloric acid may be diminished. Arteriosclerosis. — General arteriosclerosis may affect the gastric vessels and produce disturbances. Harlow Brooks refers to arterio- sclerosis occurring chiefly in the abdominal vessels. The possibility of this latter condition should be considered (see Visceral Arterio- sclerosis). DISEASES OF THE SKIN Eczema. — Various systemic conditions probably have a bearing, and in some few cases correction of the digestive disturbances seem to have an influence in improving the condition. In one case I found hyperchlorhydria, and in another deficient hydrochloric acid. Hyde^ believes that gout, dyspepsia, constipation, and scrofula have a decided influence. Acne Simplex and Acne Rosacea. — ^These are associated at times with gastric disturbances. Einhorn reports 2 cases of acne rosacea in whom chronic continuous gastrosuccorrhea was found. The correction of the latter benefited the skin affection. Psoriasis. — The treatment of gastric disorders in this affection does not seem to benefit the lesion, according to Einhorn. Urticaria and Erythema. — Some persons have an idiosyncrasy to lobsters, crabs, strawberries, etc., and develop therefrom poisonous substances which produce these eruptions, associated at times with acute gastric symptoms. These conditions seem to be due to auto- intoxication. Combe (" Intestinal Auto-intoxication") believes that acne, the seborrheic eczemas, urticaria, pruritus, strophulus infantum, and furunculosis to be chiefly due to intestinal auto-intoxication. He advises fresh brewers' yeast, oj (4.0) t. i. d., before meals for these conditions. Duncan Bulkley believes that cutaneous lesions are in some cases produced through cutaneous elimination of toxic substances. The author holds that the entire gastro-intestinal tract 1 The relation of intestinal putrefaction to arthritis deformans is described later. * 2 Twentieth Century Practice, vol. v. 392 DISEASES OF THE STOMACH AND INTESTINES should receive attention. Thorough catharsis should be carried out. These foods should thereafter be avoided. Pemphigus of the Mouth. — Einhorn has noted 3 cases in which there was hyperchlorhydria or neurasthenia gastrica, and in 2 cases improvement resulted from treating the gastric symptoms. In general, we may say that considerable investigation is still necessary to definitely determine the relations of gastric disturbances to skin diseases. SYPHILIS OF THE STOMACH Gastric symptoms quite frequently occur in the secondary and tertiary stages of syphilis. In the secondary stage they may often be attributed to fever (the constitutional condition) ; while in the ter- tiary stage there are anatomic changes in the stomach itself. Fenwick^ believes that syphilis may affect the stomach in three ways: By the formation of gummata, by producing endarteritis, and by a chronic inflammation of the mucous membrane. The symptoms arising subside under antisyphilitic treatment. Flexner" holds that syphilitic gastric ulcer is not rare, while Dieulafoy^ notes various lesions, such as hemorrhagic erosions, ecchymoses, gummata, infiltration of the submucosa and circum- scribed gummatous ulceration, and cicatrices of the latter. Pain, vomiting, hematemesis, and melena occur. RiegeP reports 12 cases in which they complained of gas, nausea, distress after eating and gastralgia, which responded promptly to antisyphilitic remedies. Death has resulted from perforation of a broken-down gumma. All doubtful cases should be examined for signs of previous syphilitic infection,^ for active syphilitic manifestation; also as to the history, and should be tested by specific treatment. Of course, many patients may have digestive disturbances without any con- nection with the old luetic condition. Hemmeter® has described syphilis of the stomach. Einhorn^ gives the following classification and describes cases: (i) Gastric ulcer of syphiHtic origin. (2) Syphilitic tumor of the stomach. (3) Syphilitic stenosis of the pylorus. To this I shall add a fourth type: (4) Syphilitic cirrhosis of the stomach. 1 London Lancet, Sept. 20, 1901. 2 Am. Jour. Med. Sciences, Oct., 1898.' ^Gaz. heb. de Med., 1902. * Diseases of the Stomach. 5 The test for Wassermann's reaction is important, both as confirmatory and for the diagnosis of doubtful cases. 6 Diseases of the Stomach, p. 556, 1897. ^ Ibid., p. 534, igo6. THE STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 393 (I) Gastric Ulcer (Syphilitic) A number of cases have been reported in which the usual treat- ment for ulcer failed, and which made complete recovery under specific treatment. (2) Syphilitic Tumor of the Stomach This condition is excessively rare. Einhorn has reported 2 cases, and refers to the fact that they may run their course like carcinoma. I referred to a case in this volume under Differential Diagnosis in Carcinoma of the Stomach. In this patient the gastric analysis showed absence of hydrochloric acid and lactic acid abundant. The patient had lost 77 pounds in eight months and was vomiting con- tinuously. The stomach was dilated to below the umbilicus, and though he had been on specific treatment for a time before I saw him, the pyloric obstruction was so marked that drainage of the stomach was necessary to preserve life. Palpation gave a sense of resistance at pylorus. A rapid laparotomy at the Red Cross Hospital disclosed a gummatous tumor at the posterior wall of the pylorus, nearly blocking it. Gastro-enterostomy was performed and specific treat- ment pushed. There was no more vomiting and the case has steadily improved. (3) Syphilitic Pyloric Stenosis Einhorn reports a case of pyloric stenosis cured by antisyphilitic treatment. In most of these cases, however, gastro-enterostomy is required in addition to the antiluetic treatment. (4) Syphilitic Cirrhosis of the Stomach This case has also been referred to under Cancer. The stomach was small, hard, and contracted, and on palpation felt like a cir- rhotic carcinoma, involving the entire stomach. The patient was an elderly man, had lost considerable weight, and was suffering from gastric symptoms. Examination demonstrated cirrhosis of the liver and evidences of old syphilis. Deficient HCl, or achylia, occurs in this type. These facts show that the syphilitic history, or evidences of the same, should be investigated carefully in gastric affections. Treatment should be for syphilis. Appropriate remedies may be given in addition for special symptoms, or secretory or motor disturbances. PART III DISEASES OF THE INTESTINES CHAPTER XX METHODS OF EXAMINATION OF THE INTESTINES; EXAMINATION OF THE FECES; MECHANICAL PRO- CEDURES. Special Interrogation. — We presuppose that the method of interrogation of the patient, as described in Part I, has been carried out. Disease of the stomach may produce secondary intestinal symptoms, aijd hence the condition of this organ must be inquired into, and in many cases the functions examined. Inquire, furthermore, whether abdominal pains are present, and also their position. In the right iliac fossa they suggest appendicitis or catarrh of the cecum; in the left iliac fossa, disturbances of the descending colon or sigmoid. With rectal pain, inflammation in that region is probable, while pains near the navel usually originate in the small intestine. Pains of short duration and sharp in character are generally due to colic, and are followed and relieved by the passage of flatus or feces. They often shift from one region to another. Pains of long duration are usually from some organic lesion, such as ulcer or from some affection of the sensory nerves. Abnormal sensations, such as feelings of heat or cold, may be experienced over different regions of the abdomen. Tenesmus is present in dysentery and in many rectal affections. The time of the pain, whether immediately after meals or later, or during the night or in the early morning, is important. The stool should be investigated — whether constipation, diarrhea, or alternating conditions exist, the number of movements, time of appearance, odor, color, and characteristics, as to whether mucus, blood, bile, pus, or undigested food are present. Do climatic changes or mental excitement influence the bowel action, or are headache, dizziness, or exhaustion associated with the movements? Is there distention of the abdomen with gas, localized or general? When does it appear? Is rumbling (are borborygmi) present? Do belching of wind or passage of gas from the bowel occur, and does this give relief? Total absence of flatus is important. Occurring with obstinate constipation, it would then suggest obstruction. 394 PHYSICAL EXAMINATION OF THE) INTESTINES 395 Continuous vomiting associated with intestinal symptoms suggests obstruction. With acute symptoms the temperature should be taken immediately. PHYSICAL EXAMINATION OF THE INTESTINES The reader is referred to Chapter IV for general methods. Inspection. — The retracted or trough-shaped abdomen occurs in stricture of the esophagus or cardia, basilar meningitis, lead- poisoning, and with long-continued inanition. The peculiar contour of enteroptosis has been described — the concave epigastrium, sulcus between the recti above the umbilicus, and the pot-belly below. On distention of the normal colon with gas (CO2), the ascending and descending portions are seen as elongated swellings in the lateral regions, and the transverse colon at or just above the um- biHcus. Protrusion oi the abdomen may.ue over a definite area or over the entire surface. It may assume the shape of a rounded hemi- sphere, or oval, slightly flattened, especially in atonic conditions of the intestines and in hysteria. Marked uniform distention with tense abdominal walls, absence of respiratory abdominal movements and increased thoracic respiration are present in peritonitis. There may be a general bloating with atony, but there is not the marked tension of the abdominal walls, and the other symptoms are absent. With ascites the abdomen is evenly protuberant above, with the center somewhat flattened, while the lateral and dependent parts bulge somewhat in the recumbent position; change of posture alters the shape of the abdomen. This applies to the milder types. With marked distention, as with meteorism, the enlargement is uniform. There is no bulging in any special location, except that the anterior portion is more prominent and change of position has no effect. Palpation aids under these conditions. There may be protrusion of the abdomen in cases of neoplasm, in fecal accumulation, and occasionally in abscess, as of the appendix, from diverticulitis or other intra-abdominal suppuration. Hernial protrusions at the umbilicus or in the inguinal regions may be observed. In patients with thin abdominal walls, small sausage-shaped protrusions are occasionally visible, which change their shape and position. This is due to peristalsis of the small intestine, occurs with no pain, and denotes no morbid condition. Similar waves may appear periodically and annoy the patient when caused by nervous -influences. There are sometimes violent contractions (peristaltic unrest) of the small intestine visible, caused by stenosis or obstruction. If it is near the ileocecal valve, the swollen and moving coils of intestine lie one above the other in the central part of the abdomen (ladder pattern). Intense pain accompanies these movements. 396 DISEASES OF THE STOMACH AND INTESTINES Marked distention may be visible in the course of the colon (in the circumference of the abdomen), and if associated with visible peristaltic contractions of the large intestine, passing along it from right to left, it is diagnostic of partial or total obstruction of the large bowel. In some cases a recurring protuberance is noted, disappearing with a loud sound. This is probabl}^ near the point of stenosis. INSPECTION OF THE RECTUM— PROCTOSCOPY AND SIGMOID- OSCOPY The anus can be inspected by having the patient lie on his side with thighs and knees flexed, and his back toward the examiner. Fig. 162. — Kelly's short rectal speculum. The buttocks should be held apart with the hands. Hemorrhoids, fissures, and fistulse may be discovered. For inspection of the rectum the introduction of a speculum (proctoscope) is necessary. Fig. 163. — Kelly's standard rectal speculum. Proctoscopy. — Various instruments have been devised, notably those of Howard Kelly, Sims, Kelsey, Gant, and J. P. Tuttle (Figs. 162-170). INSPECTION OF RECTUM — PROCTOSCOPY AND SIGMOIDOSCOPY 397 The bowels should preferably be thoroughly evacuated before the examination. If the region is sensitive, a few drops of a 2 to 5 per cent, cocain solution can be injected inside and along the sphinc- Fig. 164. — Kelly's proctoscope (} actual size). ters with a narrow-pointed rubber syringe. A suppository containing opium, gr. j (0.065), with extract of belladonna, gr. ^ (0.022), or cocain, gr. ■§• (0.008), can be substituted. Fig. 165. — Kelly's sigmoid speculum. Tuttle's pneumatic proctoscope is a valuable instrument. There is an electric lamp at the end of the inspection tube and an arrange- Fig. 166. — Sims' rectal speculum. ment for inflation of the rectum, so that it can be distended with air at the time of examination. With other specula, a head-mirror with electric-light attachment is most convenient, though an ordinary light can be arranged. The 398 DISEASES OF THE STOMACH AND INTESTINES patient lies on the side, with ■ thighs and knees flexed, with back toward examiner, or the legs can be elevated on a crutch, or in some cases the knee-elbow position can be assumed. The external sphinc- ter as well as the speculum should be lubricated with sweet oil or vaselin, to render introduction more easy. Fig. 167. — Kelsey's speculum. A long speculum (sigmoidoscope) may be required for examina- tion of the sigmoid. Palpation.— The technic of simple and reinforced palpation has been described in Chapter IV. Fig. 168. — Gant's examining speculum. The cecum, parts of the ascending and descending colon, the transverse colon, and the sigmoid flexure are often accessible to palpation, but not as readily so in obese or in muscular subjects. Fecal accumulation, tumors, thickening of the gut, or purulent col- lections connected with the intestine can often thus be recognized. INSPECTION OF RECTUM — PROCTOSCOPY AND SIGMOIDOSCOPY 399 An uneven protuberant surface is characteristic of malignant growth, while an even surface is more often found in benignant Fig. 169. — Gant's hinged speculum. neoplasm or intussusception. Volvulus occurs usually in the sig- moid. A fecal accumulation will, as a rule, "pit" on pressure (give a Fig. 170. — A, Tuttle's pneumatic proctosigmoidoscope. Two lengths — rectal 4 inches, sigmoid 10 inches — with window attachment to make instrument air- tight for bowel inflation; B, Tuttle's sigmoidoscope with Mercier curve. doughy feel). Hard scybalae occasionally feel like marbles under the fingers, but can be moved or slightly indented. Sometimes when raising the fingers from palpating, there may be a crepitating or 400 DISEASES OF THE STOMACH AND INTESTINES sticky sensation, or the intestinal wall can be felt to slip off from the fecal mass. This symptom was first described by Gersuny.^ Gurgling occurs on palpation in typhoid in the right iliac fossa, but is not diagnostic. Tenderness or pain on pressure can be readily determined by palpation, and are suggestive of inflammatory processes or ulceration. There may be the general tenderness of acute intestinal inflammation or the acute pain and tenderness of peritonitis, either localized or general. Circumscribed pain on pressure may be present at McBurney's point ( 1 2^ to 2 inches to the inner side of the anterior superior spine of the right ileum) on a line drawn from this process to the umbilicus. With ulceration of the bowels there may be circumscribed areas very sensitive to pressure; with hysteric manifestations there are often sensitive spots complained of in the abdomen, as for example, in mucous colic. By palpating simultaneously two distinct points, the supposed painful area and another region, with the different hands and at the same time distracting the patient's attention by conversation, one often finds an absence of true tenderness at the supposed seat of pain. Muscular rigidity shows peritonitic involvement. It may be localized, as of the right rectus in the region of the appendix or gall-bladder, or over the left rectus, as in diverticulitis or phleg- monous gastritis, or in abscess of the left lobe of the liver. General rigidity shows general peritonitis. Splashing Sound (Clapotage, Succussion). — If the intestines contain liquid material and gas, tapping over them with the fingers will at times produce the splashing sound. The method of differ- entiation between stomach and intestinal splash has been described under Splash of the Stomach in Chapter V. In the small intestine clapotage can usually only be obtained in the dilated portion of the gut above a stricture. It is not uncommon in the large intestine, and can be most often determined in the sigmoid flexure, caput coli, and the transverse colon. In case of atony of the bowel it is quite frequently present, also in the relaxed abdomen of enteroptosis, and often in patients with hysteric mani- festations. Boas^ first suggested injecting into the bowel 500 cc. (i pint) or more of water and then examining for the splash along the colon. It should be given with hips elevated. The splash will first be secured in the sigmoid, and by turning the patient on the right side it can at times be produced in the transverse colon and in the cecal region. It is possible to administer an enema of moderate size and cause it to gravitate to the caput coli by the method of rotation described under Enteroclysis. By the splash one can determine whether an 1 Wiener klin. Wochenschr., 1891, No. 4. 2 Diagnostik und Therapie der Magenkrankheiten, 1897. INSPECTION OF RECTUM — PROCTOSCOPY AND SIGMOIDOSCOPY 40I injection given for dysentery has passed through the entire colon to the cecum. In atony of the bowel, Boas produced the splash, even after the injection of only 200 to 300 cc. (ovj-x) of water. The position of the colon can be determined by the splashing sound when it is present; it can be produced artificially by the injection of water into the bowel, and be thus employed for locating the intestine. A little Vichy (siv — 125 cc.) can be added to the injection to increase the amount of gas. Palpation of the Rectum. — The rectum is preferably palpated with the index-finger. Soap should be placed under the edge of the nail to prevent fecal material lodging therein, and the finger lubricated with vaselin or olive oil. It is well to grease the external sphincter, as it renders entrance of the finger easier. It is more cleanly to encase the finger with a thin rubber cot, or to employ a rubber glove, well lubricated. ■1 Fig. 171. — A, soft rectal bougie; B, cylindric bougie. The patient lies on the side, with knees flexed and back to examiner, or may be in the knee-elbow position, or stand with the waist flexed — leaning forward over a chair and bearing down as if to defecate. Hemorrhoids, polypi, low-seated stricture, tender points suggestive of ulcer or fissure, malignant growths, rectal prolapse, abscess, fecal obstruction, foreign bodies, and intussus- ception are often within reach of the examining finger. The pros- tate or uterus should be palpated during the examination. If the difficulty is located beyond reach of the palpating finger, inspection with the proctoscope or sigmoidoscope will give the required infor- mation. Simon's method of dilating the sphincter under anesthesia and passing the hand and arm into the bowel for the purpose of palpation is a most dangerous procedure. Palpation of the Rectum by Sounds. — This is indicated when there is suspicion of stricture in the bowel not accessible to the fingers. Soft rectal tubes of various caliber may be employed. When the obstruction stops the passage of the tube, a mark is made at the 26 402 DISEASES OF THE STOMACH AND INTESTINES external sphincter, so that the distance of the stricture up the bowel can be estimated. Smaller tubes are then employed until one can pass the obstruction. Its caliber is thus estimated. The ordinary soft flexible rectal or colon-tube is the safest for diagnostic purposes in the hands of the general practitioner. In Fig. I J I, A and B, are shown an olive-pointed flexible and a cylindric bougie. The latter is somewhat stiff and can be softened in hot or boiling water before use. This last is also employed for dilatation of the stricture. Kuhn's metal spiral tube is of no advantage. Care should be exercised if stiff tubes are employed. \ Fig. 172. — Auscultatory percussion of the colon. Percussion should be gentle. Over empty intestinal coils or those containing gas or air, a tympanitic sound results, which is louder over the large than over the small bowel. As there may be considerable distention of the small intestine, it is sometimes difficult to delimit the large intestine by simple percussion. If the colon is emptied by enema, and then distended artificially with air or carbonic acid gas, the procedure is much easier. Intestinal coils which are filled with liquid or solid material give dulness on percussion. With meteorism there is tympanites of a deeper pitch than normal, and sometimes there is a metallic sound with auscultatory percussion. The meteorism may be localized or INSPECTION OF RECTUM — PROCTOSCOPY AND SIGMOIDOSCOPY 403 general. If local, in connection with visible peristalsis, intestinal stenosis is at once suggested. With local meteorism there will be dull areas elsewhere; with general meteorism, the entire abdomen is symmetrically distended, the anterior portion being most protruded, and there is the diffused tympanitic note of the peculiar type noted, and dulness over the region of the liver and spleen may dis- appear. With ascites, percussion shows dulness in the lower lateral regions of the abdomen and tympanites in the middle. The sounds change on altering the position of the patient (turning him on his side). The intestines ride up on the fluid, and the upper flank, pre- viously dull when in the dorsal position, is now tympanitic. Fecal accumulation, tumors, and abscesses give dulness on percussion. A %iscultatory Perciission. — This is the best method of deter- mining the position of the colon. If the small intestine is exces- sively distended it is difficult to differentiate the percussion "*', sounds. It may be necessary A)f to empty the colon by enema „.,_ J/ or irrigation and then inflate B — — ~~«.«_,>f»^ with air or CO2. Place the stethoscope at the circle (Fig. 172) over the cecum; begin percussion midway between the umbilicus and symphysis, and percuss to the right, to the left, and upward, in the direc- J tion of the arrows, until in each Fig. 173.— Differential percussion, direction the greater intensely altered quality and heightened pitch show that the inner border of the colon has been reached. These points can be marked on the abdomen with a pencil. Then percuss in the epigastric region (midway between the ensiform and umbilicus) downward, and from the lateral lumbar regions inward. The changes in pitch, quality, etc., should be marked, and thus the outer limits of the transverse ascending and descending portions of the colon are determined. The scratch method of auscultatory percussion ma}^ be carried out in the same lines. - Stengel claims that by auscultatory percussion it is possible to determine that a tumor found to lie in the course of the intestine originates in the wall of the colon. In Fig. 173, C represents the tumor; the circle O, the stethoscope placed over the colon near the tumor; B, percussion note over small intestine; A, percussion over normal large intestine near the stethoscope. X ^> 404 DISEASES OF THE STOMACH AND INTESTINES First percuss directly over the tumor, then toward it from every direction. The note over tumor, C, if it is connected with the colon, resembles the percussion note at A (colon) more closely than does percussion note at B (small intestine) resemble note at A (colon). Auscultation. — This is not of great significance in intestinal diseases. Palpation may elicit a gurgling noise in the right iliac fossa, formerly thought to be pathognomonic of typhoid, but it is found in many other conditions. Gurgling sounds (borborygmi) are at times heard. They may be due to fermentative processes or occur in neuroses, and are not specially significant. The entire absence of intestinal sounds may be significant of intestinal paresis. If the latter is due to peritonitis, cardiac and respiratory sounds may be audible over the entire abdomen. Friction sounds from perisplenitis or perihepatitis may rarely be auscultated. With chronic stenosis very loud noises are at times heard, caused by the sudden passage of fluid and gas through the stricture under pressure. Splashing sounds are at times distinguishable in the enlarged bowel above the stricture. TRANSILLUMINATION OF THE INTESTINES This method was first suggested by Einhorn^ and further practised by Heryng and Reichmann.^ Einhorn's technic is as follows: A high enema or irrigation of the bowel is first given. A quart of water is later injected per rectum and the illuminator, very similar to the gastrodiaphane, is inserted and gradually pushed up the intestine. The examination must be made in a dark room. Experiments were carried out by the author with specially devised illuminators at the Manhattan State Hospital. As the average adult rectum is 8 inches long, the sigmoid flexure 17^ inches, and allowance must be made for the sphincters, it requires an instrument at least J o inches in length to pass through the sigmoid into the descending colon. The 30-inch instruments, with which I experimented, on almost every occasion caught and coiled back, and rarely did I succeed in securing transillumination of the lowest part of the sigmoid, and even then the light was so faint that it was entirely unsatisfactory. Inflation of the bowel with water, with fluorescein solution, and with air were all tried before passage of the light, as were various positions of the patient. The experiments demonstrated practically the impossibility of passing a flexible instrument or tube through the sigmoid. The sigmoid is quite movable, and Howard Kelly has shown that the colon-tube readily pushes it up. My experiments demonstrated visually the impossibility of passing the long colon-tube through 1 New York Med. Monatsschrift, Nov., 1889. 2 Therapeutischc Monatshefte, 1892. TRANSILLUMINATION OF THE INTESTINES 405 the sigmoid flexure and showed that transillumination of the sig- moid has not been sufficiently certain to prove of practical value. Rontgen Rays ; (^-Rays).— For examination of the intestines the x-rays are of value for the following conditions: The determination of the presence of a foreign body in the intestinal tract, accurately locating its position, and hence the site for operation. Einhorn^ has recommended the internal administration of bismuth subnitrate in watery solution to locate the constriction in acute intestinal obstruction with the aid of the x-rays. The delay necessitated would be dangerous. For locating the seat of chronic intestinal occlusion the method may be of service. An ounce (30.0) of bismuth subnitrate or bismuth subcarbonate can be administered in oxij (375 cc.) of milk or water, and about twenty-four hours later examination should be made with the %- rays. With the fluoroscope or by a photograph one would see a distended area of intestine filled with bismuth, a region below with apparently no bismuth or a trace (the point of stenosis), and below this a small amount of bismuth that had passed through the stricture. If the stricture is apparently in the large intestine, a check test can be made as suggested by Einhorn." A few days later, when the bowel is free from bismuth, an injec- tion per rectum is given of 500 cc. (i pint) of water containing 30 gm. (about oj) of bismuth subnitrate. If the stenosis is in the large intestine it will be located by the Rontgen picture, there being the area apparently free from bismuth (the stricture) and the collections above and below the stricture. Location oj the Colon by the x-Rays. — Two quarts (liters) of water, in which 60 gm. (about 2 ounces) of subnitrate of bismuth are sus- pended by means of a little starch solution, are injected per rectum, with the hips elevated or in the knee-elbow posture. The position of the colon can be immediately determined by the Rontgen ray. One could administer the bismuth by mouth and examine at the end of twenty-four hours, but the enema method is preferable. Misplacements of the colon, enteroptosis, and angulations of the sigmoid can thus be determined. It has been claimed that a soft tube, in which lies a flexible wire, can be introduced per rectum, and the course of the colon determined by the x-rays, the wire showing a shadow. It is prac- tically impossible to insert the tube beyond the sigmoid, so the method is not accurate. The x-ray pictures shown of the long colon-tube — supposedly in the descending colon — are usually in the ampulla of the rectum. H. W. Soper^ has demonstrated, by means 1 New York Med. Journal, May 18, 1907. 2 Ibid. ^Jour. Am. Med. Assoc, Aug. 7, 1909. 406 DISEASES OF THE STOMACH AND INTESTINES of the jc-rays that it is impossible to pass the colon-tube into the sigmoid, except in the case of Hirschsprung's disease (congenital idiopathic dilatation and hypertrophy of the colon). For locating the position of the colon the Rontgen method is expen- sive and usually impractical, as it gives no more information than by inflation. Physiologic Investigations with Rontgen Rays. — Cannon^ has in- vestigated intestinal movements after administration of bismuth by means of the :r-rays. He experimented on cats, and claims there are periodic antiperistaltic movements in the cecum and ascending and transverse colon which aid in churning and mixing the contents, and so help absorption. He holds that some of the material may be forced back into the small intestine, and that this may occur with a high nutrient enema. Some investigators disagree with Cannon. Griitzner has shown that starch granules, lycopodium, powdered carbon, etc., in physio- logic salt solution, injected into the bowel under favorable circum- stances, will find their way upward into the stomach. By means of the rjc-rays Hemmeter observed that the upward movement of these particles goes on simultaneously with the down- ward movement of the feces, i. e., there is upward marginal current. He considers the epithelia and muscularis mucosa instrumental, and that it is not true antiperistalsis. INFLATION OF THE INTESTINES WITH CARBONIC ACID GAS OR AIR Von Ziemssen^ first employed inflation of the colon for diagnostic purposes by injecting in succession into the bowel solutions of tartaric acid and sodium bicarbonate, with the resulting development of carbonic acid gas. The bowel could then be recognized by the marked tympanitic sounds on percussion or, more rarely, by inspec- tion. Preferably, the gut should be previously emptied by enema. Inject into the bowel 5j (4.0) of tartaric acid, which has been dissolved in ovj to viij (200-250 cc.) of water, and follow it by the injection of the same quantity of soda bicarbonate in same amount of water. Preferably the hips should be elevated. Schnetter suggested attaching a flexible tube with rectal tip to the nozzle of an inverted soda-water siphon and driving out the CO2 by pressing the valve. The gas has also been injected by obtaining it from the liquefied gas in a sparklet and conducting the CO2 from a bottle into the rectum. One of the simplest methods to inflate the bowel by means of carbonic acid gas is by Rose's gas bottle. This consists of a moderate-sized bottle with perforated cork, through which passes a glass tube. To this is attached a soft-rubber tube and rectal tip (Fig. 174). The bottle is half -filled with water and 5j (4-00) each of tartaric 1 American Journal of Physiol., vol. vi, p. 253. 2 DeutschesArchiv. f. klin. Medizin, 1883, Bd. 38, S. 325. INFLATION OF INTESTINES WITH CARBONIC ACID GAS OR AIR 407 acid and soda bicarbonate added, and the cork tightly inserted. The accumulating gas is conducted off by the tube into the rectum. Inspection and percussion will determine the extent of distention. Runeberg^ recommended inflation of the intestines by air by means of a colon-tube, to which a compressible air bulb is attached. It is possible by this means to measure and regulate the quantity of air employed for inflation- An ordinary Davidson's syringe can be used to pump in the air, and its capacity can be determined as follows: Take a measuring glass of i pint (500 cc.) to i quart (liter) or a glass vessel of unknown capacity and measure its capacity when filled to the brim. Invert the filled vessel in a pail of water, so that the entire column of water is sustained in the inverted vessel. Then slip the colon-tube under water, so that its tip enters the inverted jar. Observe how many compressions of the bulb are required to Fig. 174. — Rose's carbonic acid gas generator. replace the water column with air, that is, to drive out all the water from the inverted vessel. If, for example, the jar contained 500 cc. (i pint) and it required sixteen squeezes of the bulb to replace this by air, then each squeeze of the bulb replaces i ounce of water by the air equivalent. Uses of Inflation. — It is of service to detect stenosis of the large intestine. Under normal conditions the injected air distends the colon evenly. If there is stenosis, the air will distend chiefly that part of the bowel below the stricture, while above it remains unchanged. This is true in marked strictures, but in those of mild type the air will pass through. Even in some such cases there will be less distention above than below the strictured point. The position of the colon can be determined by air inflation. Normally it passes with a slight downward curve across the abdomen with lower edge about touching the upper margin of the umbilicus. Enteroptosis is demonstrated by this method and the transverse 1 Deutsches Archiv. f. klin. Med., Bd. 34, S. 460. 4o8 DISEASES OF THE STOMACH AND INTESTINES colon may descend to a hand's breadth above the symphysis. It may assume a V shape. Angulations of the sigmoid may at times be determined by this means. For the diagnosis of the location of abdominal tumors inflation of the intestine is often of service. After inflation of the colon with air, tumors of the viscera become more distinct; while tumors of the kidney, retroperitoneal glands, spine, etc., tend to disappear. Minkowski^ holds that after filling the colon with air or water, abdominal tumors are shifted in the direction of the organ to which they belong. Sutton^ suggests inflating the bowel with air impregnated with ether for the diagnosis of intestinal perforation. He employs a bottle provided with a perforated rubber cork to which are attached two rubber tubes with stop-cocks. To one of these tubes is attached a bicycle pump or a Davidson's syringe; to the other an ordinary colon-tube by means of a short glass connecting tube. Two drams of ether are placed in the bottle. The air pumped into the bowel passes through the bottle and thus takes up the vapor of ether. With the stop-cocks the pressure of ether and air can be regulated. If perforation of the bowel is present, the ether escapes through the opening into the abdominal cavity and distends it equally in all directions. If there is no perforation, first the large intestine and later the small intestine become filled with air and ether, and finally ether vapor may be eructated and readily recognized. This method is useful in gunshot wounds of the abdomen. Inflation of the Colon with Water. — This can be performed with a graduated irrigating jar and a rectal tube. With a fountain syringe of known capacity it is easy to estimate the quantity injected. In stricture of the colon, especially in the lower portion, the quan- tity of water which can be injected is not great. Normally the colon will contain from 3 to 4 quarts, or occasionally 5, without dangerous distention. The injection should be given with hips elevated. Many people are unable to hold any quantity of water in the bowels without pain, discomfort, and rapid evacuation of the fluid. Determination of the position of the colon by inflating it with water is, therefore, often difficult. The air inflation is preferable for the above reasons. LAVAGE OF THE BOWEL FOR DIAGNOSIS Boas^ first recommended this procedure to be carried out in a manner similar to lavage of the stomach. The bowels should be previously evacuated. The patient should lie on the side with the knees and thighs flexed. The colon-tube is attached by a short 1 Berlin, klin. Wochenschr., 18S8, No. 31. 2 Journal Am. Med. Association, Dec. 30, 1899. ^Deutsch. Aertze-Zeitung, 1895, Nos. 2 and 3. EXAMINATION OF THE FECES 409 piece of metal or glass tubing to a long tube, provided with a funnel. The rectal tube is lubricated and inserted high up to its full length and about 500 cc. (i pint) to i liter (quart) gradually poured in through the funnel held i or 2 feet above the patient, until some discomfort is expressed. The funnel is then lowered below the anus and the contents siphoned off. They are then submitted to a thorough examination. Normally the contents are fairly clear or slightly stained with fecal matter and contain a little mucus and a few epithelial cells. With intestinal catarrh a large amount of mucus is present. Blood or pus may be found, showing hemorrhages or a suppurative process, such as an ulcer or abscess. ExfoHated portions of the mucous membrane may occasionally be found or, rarely, tumor fragments. Microscopic examination of such material is of diagnostic impor- tance. Intestinal worms are occasionally discovered. Lavage of the bowel is also employed for the removal of dysenteric discharge and mucus, for the purpose of examination for amebae. EXAMINATION OF THE FECES The Stool. — General Considerations. — ^The normal stool consists of changed and unchanged remnants of food, bacteria (estimated at about 126 billions daily), epithelial cells, salts, and traces of the digestive juices. The normal daily quantity under a mixed diet averages 100 to . even 200 gm. (3^ to 7 ounces). It may be increased by a vegetable diet. There is usually one movement daily of dark brown color, though diet and medicine have an influence. Milk gives a hght yellow; claret and huckleberries, a brownish black; salts of iron and magnesia, a blackish brown ; bismuth, black. Blue is given by iodids (long continued); green, by calomel; yellow, by santonin, senna, and rhubarb; violet, by salol and betanaphtol. The feces are slightly soft and of sausage shape. Abnormally they may appear in small balls, cylinders or tape-like, or as hard scybalae (dry in character), or they may be mushy or liquid. They may be very watery, as in choleraic conditions, or fluid and mixed with mucus. Odor.— This is normally caused by skatol and sHghtly by indol. It is increased when the feces have been retained an abnormal time. After a short sojourn in the intestines, as Avith rice-water move- ments, there is often no odor. The character of the food may affect the odor. Very fetid movements occur with ulcerative processes or with malignant growths. Macroscopic Findings. — Remnants of Food in the Feces. — Undigested remnants of food can often be seen in the stool. Nor- mally they consist of only small particles of vegetable material, such as potato, asparagus, spinach, and peas; while remnants of meat cannot be seen. Providing abnormal quantities of food have not 4IO DISEASES OF THE STOMACH AND INTESTINES been ingested, it is often possible to draw definite conclusions as to the state of intestinal digestion, from the excess of one form of non-digested material over another. The presence of large quantities of undigested starch indicates a catarrhal condition of the small intestine, and, indeed, more than traces of this material should be regarded with suspicion. If particles of meat are visible, this indicates a lesion of the intestinal tract. Connective-tissue fibers appearing unaltered in the feces indicate deficient gastric digestion, according to Schmidt, and the presence of nuclei, under the microscope, disturbance of the trypsin function of the pancreas. Blood. — Blood may be visible in the feces, either fresh (red) or dark in color and un coagulated, which shows its origin from the lower part of the large bowel. It may appear changed, giving the feces the appearance of tar, then originating from the small intes- tine or even from the stomach. Blood shows the presence of an ulceration or of an ulcerating cavity communicating with the gut. Pus. — Visible pus in the dejecta only occurs when pus exists in large quantities in the lower part of the large intestine. It shows ulceration or an abscess communicating with the gut. Pus in small quantity or from higher up the intestine can only be determined by the microscope. Fragments of tumor (polypi or cancer) may rarely be found in the dejecta. Microscopic examination will give important infor- mation. Mucus. — Mucin can always be detected in normal feces by chemic examination. The amount of mucus in the feces in health is so small and so intimately mixed as to be only recognized by chemic tests. Mucus in the stool, either macroscopic or microscopic, indi- cates some deviation from the normal physiologic condition. It does not invariably show an anatomic lesion. We may, for ex- ample, have a few flakes of mucus or an extremely thin layer adherent to scybalae, due to irritation of the mucosa from a fecal accumulation or impaction, or mucus, which is contained normally in the higher portions of the small intestine, may occasionally ap- pear in the stool as a result of increased peristalsis. Under other circumstances the presence of mucus is pathologic. Macroscopically, mucus may exist as follows: (i) An abundant coating in the form of a glassy layer may cover fecal masses. It may be gray or cloudy from epithelial or round cells. This usually indicates catarrh of the lower portion of the bowel. / (2) It may be intimately mixed with the feces in mushy move- ments, and may adhere to a glass rod if this is dipped in the stool. (3) It may float on top of watery movements. (4) It may be passed almost pure in large amount. Material resembling frogs' spawn or sago grains may occur in the feces. They were formerly considered due to follicular ulceration, 17 EXAMINATION OF THE FECES 4II but are now believed to be of vegetable origin. Kitagawa holds that some of them are pure mucus, but that they are not pathologic. Yellow or yellowish brown granules occur in the stool, from the size of a pinhead to a poppy seed, resembling butter in consistency. Some of these have been considered bile-stained mucus, while other frag- ments are believed to be albuminous or vegetable material or yellow calcium salts. Boas and Schmidt beUeve these yellow granules to be albuminous matter stained with bile-pigment. The presence of any one of the previously described types of mucus indicates intestinal catarrh. Mucus without feces or sur- rounding the feces shows the colon is inflamed. When mucus is mixed with the feces the upper colon or small intestine is inflamed. Mucus in the food residue shows catarrh of the small intestine. There are two exceptions to the rule that visible mucus indicates catarrh: (i) In mucous colic (membranous enteritis) pure mucus due to hypersecretion is evacuated in the form of a cast membrane or in long tape-like formation. (2) In intestinal dyspepsia with acid fermentation the patient has a jejunal diarrhea, with gelatinous, tenacious, semifluid stools. Mucus is present. Epithelial or round cells, which are abundant in catarrhal mucus, are absent from the mucus in dyspepsia of the small intestine. The stools are also green, acid, and give a bile-pigment reaction. Intestinal parasites may be visible in the feces. Chemic Examination of the Feces. — Reaction is normally neutral or slightly alkaline. Marked acidity results from occlusion of the bile-duct. Rich vegetable diet causes slight acidity. The simplest method to test the reaction is by litmus-paper (red and blue). Normal stools react slightly differently with different indicators. With pheriolphthalein they react slightly acid, while to litmus they would be neutral. If the phenolphthalein test is employed, take feces 5.0, rub up in a mortar, and add 30.0 cc. distilled water, after the modified Schmidt diet. Place 2 cc. of this in a test-tube, add 2 drops of I per cent, alcoholic solution of phenolphthalein. With this quantity titration with decinormal sodium hydrate never exceeds 1.5 cc. to secure end-reaction. Above this the stool should be considered acid, and if less than i cc. it may be considered alka- line (Kaplan^). For general use the litmus test is sufficient. Test for Mucin. — Mucin is normally present in the feces. Mix feces with water and an equal quantity of milk of lime and let the mixture stand for several hours. Then filter, add acetic acid to filtrate, and mucin precipitates if present. 1 New York Medical Journal, Dec. 7, 1907. 412 DISEASES OF THE STOMACH AND INTESTINES To Examine Separate Particles of Suspected Mucus. — Dissolve a flake of material in a weak solution of potassium or sodium hydrate and add acetic acid. If the precipitate is undissolved after adding the acid in excess, mucin is present. Heat the precipitate to the boiling-point in a dilute mineral acid ; if mucin is present the heated solution will reduce copper oxid. This last test excludes nucleo- albumin, which otherwise gives a similar reaction (Einhorn). Stain a flake of apparent mucus with a weak triacid solution (Ehrlich), mucus produces a green color; albumin, red. This test is of value in determining the presence of mucus in membranous specimens from mucous colic. The tests otherwise are rarely required. Albumin. — Treat the feces with water slightly acidified with acetic acid. Filter the watery extract and employ boiling test as for albumin in the urine. Normally no albtimin is present, but it has been found in typhoid, occasionally in acute enteritis, and in chlorosis. Propeptone and Peptone. — After the test for albumin has proved negative, the watery extract of the feces is treated with phospho- tungstic acid, the precipitate is diluted with water and sodium hydrate, and a small amount of a weak solution of sulphate of copper added. A purple red (biuret reaction) shows the presence of both propeptones and peptones. To determine the presence of peptones separately, first precipitate the propeptones by ammonium sulphate in large amount. Pathologically, peptone is found in typhoid, d^'sentery, tubercu- lous ulcer of the intestine, and in perforative peritonitis. Normally it is not present. Carbohydrates. — The feces are first subjected to distillation. The residue is extracted with alcohol and ether; the extract boiled with water, filtered, and again boiled, with the addition of dilute sulphuric acid. Trommer's or Nylander's test is then employed. Examination for Starch. — The watery extract of feces is examined with Lugol's solution, the presence of starch producing a blue color. For Sugar. — A watery extract of feces can be directly tested by Fehling's method. Normally, neither starch nor sugar are found. Gas Fermentation. — Schmidt's method will be described later. Fat. — The feces are treated with considerable ether, and the latter is separated and evaporated in a water-bath. The neutral fat, if present, remains visible. To show the presence of soaps which do not dissolve in ether, another portion of fecal matter is first treated with acids which split up the soaps, and then extracted with ether ; quantitative determina- tion is complicated. Normally, fat is never present macroscopically in the stools unless after ingestion of very large quantities. It may then be visible in very small portions, the size of a pea. Pathologically, EXAMINATION OF THE FECES 413 fat may exist in large quantities in the fecal matter and give the grayish-silver fatty stools, especially in disease of the pancreas and whenever lymphatic absorption is disturbed. Blood. — Fresh blood can often be recognized macroscopically. The tests for occult (concealed) blood are of importance. The best methods are the benzidin test (the latest) ; Weber's modification of the guaiac test ; and the aloin test. These are fully described under Tests for Occult Blood in the Stomach Contents and Stools in Part II of this volume. Neither meat nor iron preparations should be ingested for two to three days previous to the tests. The hemin test has been employed. A small particle of fecal material is dried, pow- dered, and placed on a slide. A trace of sodium chlorid is added and a drop of glacial acetic acid poured on and thor- oughly mixed. A cover-glass is placed over the specimen and the slide slowly pig. lys.-Hematin crystals. heated. After cooling, a microscopic ex- amination is made. In the presence of blood, hematin crystals are found (Fig. 175). These are reddish pink and rhomboid in shape. Bile-pigment. — Normally, no unchanged bile-pigment is found in the feces. In catarrh of the small intestine it has been detected. The presence of bile-pigment is determined as follows: A particle of the colored fecal matter is brought into contact with a drop of fuming nitric acid. The yellow color passes through the various colors of the spectrum, red, violet, to green; in some cases green appears at once; or liquid feces can be filtered through filter-paper, or a watery mixture can be made and then filtered. The paper is then dried and a drop or two of the fuming nitric acid poured, on it. The colors will appear in rings if bile is present ; or : A small quantity of the feces is treated with a concentrated watery solution of corrosive sublimate. Biliary pigments will turn the mixture green, or green appears in that portion where pigments are -present. Biliary Acids. — ^These usually accompany biliary pigments. They are revealed by Pettenkofer's test: A small quantity of feces is treated with alcohol and then the latter is evaporated. To the residue a weak watery solution of bicarbonate of soda is added, and to this mixture a small amount of cane-sugar and a few drops of sulphuric acid. Red or pink occurs when biliary acids are present. Urobilin. — Normally, the biliary pigment in the intestinal tract becomes changed to urobilin, which gives the brown color to the feces. A small piece of fecal matter is treated with a concentrated watery solution of corrosive sublimate and thoroughly mixed with a glass rod. Urobilin gives rise to a pinkish-red color; bilirubin, to a green 414 DISEASES OF THE STOMACH AND INTESTINES color. Urobilin is normally present and is absent in pathologic con- ditions, while bilirubin is present in the latter. Fleischer's Test. — Place a small quantity of feces in a test-tube with a small amount of alcohol to which has been added a few drops of h^'^drochloric or acetic acid. After a short time urobilin produces a yel- low^ or brown color. If the alcohol is then poured off and a few^ drops of sodium hvdrate wdth a small quantity of zinc chlorid are added, there appears a green fluorescence in direct rays of Hght, and in trans- mitted light, pink or yellowish red, greater or less in proportion. Acholic and Colorless Stools. — The acholic stool presents a grayish-white, ash-gray, or clay color due to absence of bile-pigment. The dejecta are of penetrating odor, buttery consistency, and on chemic and microscopic examination are found to contain much fat. The latter is present as needle-shaped crystals or in sheaves of crystals or, less generahy, in fat-droplets. This type of stool occurs in conditions such as occlusion of the bile-duct, when there is an exclusion of bile from the intestine. Stools may be entirely devoid of color or of a gra^dsh-white color resembling true achoHc stools, though there is no jaundice or occlusion of the bile-ducts. These stools are less putrid in odor and more acid. They contain enormous amounts of fat, Hke the true acholic stool, and urobilin has been demonstrated in them. Such movements occur in conditions when the absorption of fat is impaired, as in tuberculosis of the intestines and peritoneum. At other times abnormal quantities of fat are not present, and the lack of color is imputed to the presence of a colorless decomposition product of bilirubin, the leuko-urobilin of Mencki. The conclusion that a stool contains an excessive amount of fat because it is apparently acholic is not justifiable unless a microscopic examination is made. An apparently acholic stool may also be due to excessive fat and urobilin be present. Fatty Stools (Steatorrhea) . — This term is applied to all cases in which isolated masses of fat are present in the feces and can be recognized with the naked eye. It appears in whitish or grayish lumps, or it may cling around the feces or be adherent to the vessel. Ingestion of excessive fat even under normal conditions may produce an evacuation of superfluous fat. If the mucosa of the small intestine and the lymphatic system (mesenteric glands) lose their powers of absorption, fat must appear in the stools, as in tuberculosis of the small intestine, chronic tubercular peritonitis, intestinal catarrh, etc. In occlusion of bile from the intestines with acholic stools, the fat is revealed microscopically and by chemic analysis, but fatty stools are not then spoken of in the clinical sense. Steatorrhea is not per se diagnostic of pancreatic disease. In the absence of icterus and of demonstrable intestinal disease, fatty stool is probably due to pancreatic disease. Disturbed digestion of EXAMINATION OF THE FECES 415 fat is diagnostic of pancreatic disease. Miiller shows that qualitative changes in the fat (Hpolysis) is much sHghter, only 39.8 per cent, in pancreatic disease, where it is 84 per cent, in healthy subjects, or even in those with icterus, if the pancreatic juice has free access. Ferments. — A glycerin extract can be made of the feces or the fecal matter may be mixed with water containing a small proportion of thymol and filtered. To test for trypsin, the filtration extract is made alkaline by the addition of soda bicarbonate and a few flakes of fibrin added. The solutions are kept at a blood temperature for a few hours and then tested with potassium hydrate and a weak solution of copper sul- phate. If trypsin is present, there will be a pinkish-red reaction (biuret) in consequence of peptone. For Diastase. — A few cubic centimeters of the filtrate are mixed with about one-half the amount of a starch solution and kept at a Fig. 176. — Einhorn's stool sieve. blood temperature for about thirty minutes. The mixture is then subjected to Fehling's or Trommer's test. Normally, these ferments are absent,^ but in pathologic conditions, especially in diarrhea, they are frequently found. Wynhausen" describes a new test for the pancreatic activity. Further investigations are advisable. Concretions, Foreign Bodies, Worms. — To examine for such material the feces should be thoroughly mixed with water and poured through a sieve. This can be improvised — a circular wire rim can be fitted to a water-closet seat, and attached to the wire a network bag made of two thicknesses of cheese cloth, practically a dip net. The patient defecates in the net, and water can then be poured through several times until only the more solid parts remain. 1 Goldschmidt (Deut. med. Wochenschr., 1909, No. 12, xxv, 522) and Gross (Ibid., 1909, No. 16, xxv, 706), u.sing the latter's method for detecting trypsin, have discovered it in the feces of all normal persons examined. This, if con- firmed, will prove a great advance. 2 Berliner klin. Wochenschr., July 26, 1909; also Med. Record, Sept. 11, 1909. 41 6 DISEASES OF THE STOMACH AND INTESTINES Boas has constructed a stool sieve and Einhorn's, as in Fig. 176, is readily understood. Water is poured through and there is a stirring apparatus. Concretions. — Among such are gall-stones, pancreatic calculi, enteroliths, and coproliths. Biliary calculi are readily recognized when of any size. The principal constituents are cholesterin, bile- pigment, and lime. Tests for small biliary concretions (sand) are as follows: first, powder gr. 30 (2.0) of the mass and treat with ether, 3v (20 cc), mix and filter, evaporate, and test for cholesterin. Dissolve part of residue in hot alcohol and allow it to evaporate. Microscopic examination of the precipitate shows rhomboid crystals with ragged edge (cholesterin) ; second, another part of the residue is placed on a slide, a drop of concentrated sulphuric acid added and covered with a cover-glass, the cholesterin crystals become carmine at their edges, add i drop of Lugol's solution and a violet color arises; finally, a portion of the residue is treated with hydrochloric acid, a trace of iron chlorid, and then evaporated. If cholesterin is present, a blue color occurs. The residue of the original ether mixture is treated with dilute hydrochloric acid mixture, heated, and extracted with chloroform after cooling. The chloroform extract is tested with Gmelin's reaction (fuming nitric acid). Bile-pigment produces the rainbow play of colors. Pancreatic Calculi. — These usually have a rough surface, are brittle, and may be faceted. They are soluble in chloroform, and on evaporation produce an aromatic odor.^ Bile-pigment and choles- terin are absent. Enteroliths. — Calculi formed in the small intestine consist of inorganic salts (lime and magnesia). They are light in color and usually of small size. They form occasionally after the extensive use of lime and magnesia. Rarely they cause obstruction. Coproliths {fecal calculi) are found in the large bowel, chiefly where there is retardation to the passage of feces, as in the cecum, appendix, sacculi of the colon, sigmoid, and rectum. They are of stony hardness and sausage shape and show concentric rings on section. They may attain considerable size and even cause intestinal obstruction. Foreign Bodies. — Bodies which have been swallowed may pass through the entire bowel and be passed in the feces, such as bones, coins, marbles, needles, etc. Concretions of shellac have been found in the stools of patients who have drunk furniture polish. Hair- balls may be found. Microscopic Examination. — The microscopic examination of the feces is often of great assistance to diagnosis. For examination for amebae, the stool should be kept warm. 1 "■--h. Berliner klin. Wochensclir., 1898, No. 8. EXAMINATION OF" THE FECES 417 To diminish the disagreeable odor of a watery stool, place it in a conic glass and cover it with a layer of ether. If it is mushy or firm, it can be spread on a plate and covered with a layer of spirits of turpentine, or a 5 per cent, solution of carbolic acid or thymol, or 4 per cent, formalin. Diarrheal stools may be examined without further preparation. With solid fecal matter, a small piece of feces ma}^ be placed on a slide and mixed with a drop or two of normal salt solution. If there is odor, a i per cent, formalin solution may be added. The findings depend on the diet. With meat diet, no vegetable residue is found, and vice versa. With a mixed diet, in a normal stool, there will be plant cells, the remnants of various vegetables and fruits, no starch granules, meat-fibers changed beyond recognition, or with slight i // rTMMlW.MFW*W.>«U<3ITIV»MM|. Fig. 177. — General view of the feces: a, Epithelial cells and leukocytes; b, stone-cells; c, cuticular formations; d, crystals of ammoniomagnesium phosphate; e, fat-crystals; /, yeast-fungi; g, Amoeba coli; h. Trichomonas intestinalis; %, Cercomonas intestinalis; m, ovum of ascaris; n, ovum of oxyuris; o, ovum of trichocephalus; p, ovum of ankylostomum ; q, ovum of bothriocephalus; r, ovum of Tsenia saginata; s, ovum of Taenia solium (Jakob). striation (Fig. 177). More commonly they appear as oval yellow translucent masses with a high degree of refractibility. The presence of numerous meat-fibers striated and with nuclei is pathologic, showing deficient pancreatic digestion (tryptic). They may appear a'^- spirals (Fig. 178). Fat. — ^Fat appears microscopically as colorless small globules or as needle-shaped crystals (fatty acids) or in sheaves (soaps). The fatty acids disappear when heated or when ether is added ; soaps remain unchanged. Sudan dye-stuff, in concentrated alcoholic solution, stains plain fat bright red, while crystals of fatty acid and the soaps remain unchanged. In pathologic conditions these forms of fat are markedly increased, as in affections of the liver, pancreas, and intestines. Normally, they are scanty. 4i8 DISEASES OF THE STOMACH AND INTESTINES Crystals. — Oxalate of lime, calcium carbonate, neutral phosphate of calcium, and ammonium magnesium phosphate are found in normal as well as pathologic feces and have no diagnostic importance. Fig. 178. — a, Spirals of undigested meat-fibers in stool; b, pieces of bronchi. Bismuth, if administered, occurs as dark brown or nearly black rhomboid crystals. Hematoidin appears in rhombic crystals of orange or red color, shortly after intestinal hemorrhage. Charcot- Fig. 179. — Charcot-Leyden crystals (after Riegel). Leyden crystals (Fig. 179) are fine colorless, pointed octahedra. These when present excite the suspicion of helminthiasis (intestinal parasites), and their persistence after removal of the tenia shows the EXAMINATION OF THE FECES 419 head has probably not been removed. They occur occasionally in normal stools and in typhoid, dysentery, and phthisis. Epithelium. — Epithelial cells when present in large numbers always indicate an inflammatory condition of some part of the intestinal tract. Cylindric epithelial cells are found in abundance in inflammation of the intestinal mucosa (Fig. 180). They cause the cloudy appearance of the mucus. If bile-stained specimens of epithelia are met with, the small intestine is involved. Degenerative forms without nuclei are mostly seen, though well preser^^ed cylindric or goblet-cells are often found. Red blood-cells are rarely obser\^ed unless hemorrhage is from the colon or rectum, as in dysentery. Hemorrhage higher up gives a brownish-red color to the feces, and hematoidin rhombic crystals in some cases, and the cells cannot be recognized microscopically. Fig. 180. — Chronic intestinal catarrh: Fig. 181. — Intestinal catarrh: Con- Groups of epithelial cells, detritus, some siderable mucus, some plant cells, mus- muscle cells partly digested, bacteria, cle cells, and fat crystals. plant cells, and yeast cells. Pus occurs in the dejecta in ulcerative processes when an abscess communicates with the bowel or in dysentery. It presents the usual characteristics. Muciis when bile-stained indicates disease of the small intestine; and if colorless, catarrh of the large intestine or lower part of small intestine is present. Mucus also occurs with mucous colic, in which condition no catarrh exists. Mucus is thread-like in appearance, though occasionally amorphous (Fig. 181). Hyaline particles of vegetable residue must not be mistaken for mucus. lodin stains it blue. Thionin colors it reddish violet and other proteids blue. ■Mucus has no definite structure. Tiimor. — Fragments of tumor may rarely be found in the feces and its character determined by the microscope. Microorganisms.- —A large portion of the stool is constituted by bacteria, as already mentioned. Among the most important are the 420 DISEASES O'P THE STOMACH AND INTESTINES Bacillus coli, Bacillus lactis aerogenes, Bacillus bifidus, Bacillus aerogenes capsulatus (gas-forming), and Bacillus putrificus. The Bacillus coli is of importance in reference to the indolic t3"pe, and the Bacillus aerogenes capsulatus, to the saccharobutyric type of intestinal putrefaction. The Bacillus lactis aerogenes causes fermentation of milk and the production of lactic acid. The lactic acid producing bacilU are held to be antagonistic to putrefactive changes. For a description the reader is referred to any work on Bacteriology. Typhoid, tubercle, dysenteric, and the cholera bacilli are the chief pathogenic micro-organisms found in the feces which are of interest to us. TESTING THE INTESTINAL FUNCTIONS Boas has obtained intestinal juice by passing the stomach-tube into the empty organ and massaging the region of the liver, thus forcing the juice into the stomach. Hemmeter and Kuhn have passed the tube directly. These procedures are uncertain and pos- sess no advantages. Einhorn^ has devised a new method of obtaining the intestinal juice by means of a duodenal bucket.^ The quantity secured (and it is not always obtained) is infinitesimally small ; there is the possi- bility of an admixture of gastric juice and saliva during withdrawal, and the procedure requires three to five hours or even longer. It does not admit of the thorough technic as secured by Schmidt's test diet. The same holds true of Einhorn's bead test.^ Testing the motor function with foreign bodies (beads) is not a proper criterion; the food material attached to each bead is too infinitesimally small in amount to test the digestive capacity for an average diet; it may work loose from the beads, in which event it could not be recovered and wrong deductions might result. There is a slight element of risk from fish-bone escaping from the bead and damaging the mucosa. The author believes the stomach functions should be tested sepa- rately, and one should not depend on the connective-tissue test for the stomach, as suggested by Schmidt. 1 am indebted to E. E. Smith, of New York, for the following description of the tests of the intestinal functions: Tests of the Intestinal Functions. — The determination of the functional activity of the stomach is made with relative ease, com- pared to the similar examination of the intestines. Correspondingly, methods for such determination have long been applied to the former * New York Medical Journal, June 20, 1908. 2 Einhorn has recently suggested passing a soft tube along the duodenal bucket cord (on the principle of Gouley's tunnel sound along the filiform bougie), and then aspirating the intestinal contents with a bulb. Farr (Jour. Amer. Med. Assoc, Dec. 11, 1909) describes Boldireff's oil test meal to secure trypsin in the gastric contents, and the tests of Mett, Yolhard, and Gross. These tests are com- ])licated. Trypsin is not always secured. 3 Med. Record, Feb 10, 1906: Ibid., Oct. 26, 1907; Journal Am. Med. Associa- tion, Feb 2, 1907, Therapeutic Gazette, Jan. 15, 1908. TESTING THE INTESTINAL FUNCTIONS 42 1 organ, while they have recently found application to the latter; and even now the diagnostic determination of intestinal function by exact methods is only in its infancy. The problems presented are essentially these : (a) Is intestinal secretion, including pancreatic and biliary secretions, normal in quality and quantity ? (b) Is intestinal absorp- tion normal ? (c) Is the intestinal motor activity normal ? If not, in what respect is each of these processes abnormal? The investigation of these problems is made by the use of a test diet. While in the case of the stomach the diet is relatively simple and the digestive mixture withdrawn for examination within a few hours, in the case of the intestines only inferences as to the intestinal contents may be reached, and then indirectly from the conditions affecting the bowel contents after they have been ejected, perhaps in one or several days. The feces corresponding to the test diet may be indicated by a material administered for the purpose, usually soot in capsules. No. 00 hard gelatin capsules filled with soot accom- plishing this purpose; or carmin may be used, 0.3 gm. (5 gr.), in a capsule. Either of these is administered at the beginning of the first meal of the test diet. The subsequent appearance of a black or red stool indicates that the intestinal contents corresponding to the special diet are being ejected. The administration of a special substance to mark the stools is in a majority of instances not absolutely necessary, the diet being of a nature that gives rise to a stool sufficiently distinctive for recogni- tion. Until the observer is familiar with the examination, it is advisable to employ one of the substances mentioned. The test diet to be employed is selected to meet the requirement that it shall present a sufficient quantity of all classes of food stuffs to test the digestive capacity, that the digestive processes shall not be unduly anticipated in the preparation of the food, and that very little food residue shall be present in the ejected bowel contents. Naturalh', the stomach plays its usual part, so that the test is not limited to the intestinal tract proper, but applies to alimentation as a whole. The test diet made use of is a modification of the original Schmidt- Strasburger diets. Instead of three diets, as were originally employed in connection with the fermentation test of these observers, one diet is now advocated which presents the conditions essential for the meat test. This diet, as recently described by Schmidt, is as follows: In the Morning. — 0.5 liter milk or, if milk does not agree, 0.5 liter cocoa (pre- pared from 20 gm. cocoa powder, 10 gm. sugar, 400 gm. water, and 100 gm. milk), to this add 50 gm. Zwieback. In the Forenoon. — 0.5 liter oatmeal gruel — made frorn 40 gm. oatmeal, lo gm. butter, 100 gm. milk, 300 gm. water, i egg — (strained). At Noon. — 125 gm. chopped beef (raw weight), broiled rare with 20 gm. of butter, so that the interior will remain raw; to this add 250 gm. potato broth (made of iQO gm. mashed yiotatoes, 100 gm. milk, and 10 gm. butter). In the Afternoon. — As in the morning. In the Evening. — As in the forenoon. 422 • DISEASES OF THE STOMACH AND INTESTINES This diet consists of: 1.5 liters milk, 100 gm. Zwieback, 2 eggs, 50 gm. butter, 125 gm. beef, 190 gm. potatoes and gruel of 80 gm. oatmeal. It contains about: 102 gm. albumin, III gm. fat, 191 gm. carbohydrates, or a total of 2234 calories fraw calories). The test is generally given for three days, sometimes longer; at any rate until a stool is obtained, which comes with certainty from this diet. Steele advocates an arrangement of the diet to conform to American dietary habits, which still maintains the essential features of the above. It consists of: 2f pints milk, 3 ounces well-dried toast, 2 eggs, I J ounces butter, J pound tender rare steak, 6 ounces mashed boiled white potato, and gruel made from 25 ounces ordinary oatmeal, J ounce sugar. This may be given somewhat as follows: Breakfast. — 2 eggs, one-third of the amount of toast and butter, 2 glasses of milk, oatmeal, and sugar. Dinner. — The steak and potato, one-third of the amount of toast and butter, \\ glasses of milk. Supper. — 2 glasses of milk, remainder of toast and butter. For the collection of the stools, where they are not to be trans- ported for any considerable distance, an ordinary tin basin of 24-oz. capacity ser\^es well for a receptacle, as suggested by Prof. L. B. Mendel. This may be supplied with a cover, consisting of a cake tin of appropriate size; or, where this is not readily provided, a small pie tin may be used. This outfit is inexpensive (8 cents), adequate, and where a considerable number are to be kept, may be advanta- geously stacked. ^loreover, where the stools are to be weighed and dried for exact quantitative analysis, this may be directly done in the weighed basins, thus avoiding the transfer of the specimens. If the feces are to be transported for any considerable distance, a pint glass jar (with patent airtight top) sen.-es admirably for the collection. .The specimen may be hermetically sealed. If trans- ported in ordinary wide-mouthed bottles, the stoppers should be TESTING THE INTESTIXAL FUNCTIONS 423 tied on, as gas formation is quite likely to produce sufficient pressure to force out any stopper not securely fastened. The characteristics of the test diet stool, aside from the coloration given by the special marking substance administered, are the light brown color and uniform consistency. It usually appears at the second or third defecation after the beginning of the test diet. The period of time required for the passage of food through the entire alimentary tract is of importance and is readily obser\'ed. Normally it takes about twenty-four hours. It is not necessarily, though it is commonly, related to the frequency of defecation. In some cases the stool appears with regularity and is fairly copious, vet the patient suffers from fecal accumulation — a latent constipa- tion. The period of passage may suggest the seat of the intestinal disturbance in diarrhea, since it is only decidedly increased when the cause is high up. Strauss has shown that chronic colitis maybe accompanied by several watery movements a day with a normal period of passage. The examination of the collected stool should be ' made while the feces are perfectly fresh. Macroscopic Examination. — This is the most important part of the procedure. Experience with this part of the investigation may enable the observer to at once recognize some defect in alimenta- tion. Note the consistence, color, and odor. Inspect the surface of the formed stool for morbid products, notably for pus, blood, and mucus, which are to be removed for microscopic and bacteriologic examination. Bits of tissue from some diseased area may also be sought for, but their occurrence is so unusual that it is exceptional when they are found. The mass of feces is then well mixed, for which procedure a wooden or tin-plate spoon is useful; and a piece the size of a walnut trans- ferred to a mortar, in which it is thoroughly but not forcibly ground with distilled water added gradually until the whole is of a uniform fluid consistency and no small masses of fecal matter remain. The fluid feces is then examined in thin layers, conveniently in a Petri or similar larger dish, against a black background with the naked eye, or low-power magnifying glass, for all elements that may be differentiated. In normal digestion only a few brown points smaller than pin-heads will appear, these consisting of chaffy remains of oatmeal gruel and remains of cocoa, if this latter has been taken. Under pathologic conditions, there may be present: 1. :\Iucus, which appears usually as larger or smaller, soft, glossy, translucent flakes, often bile stained; infrequently, when from the large intestine, white or brown, with a gummy or almost leathery hardness. 2. Pus, blood, parasites, stones, and other foreign bodies. 3. Connective tissue and tendons, distinguished by their whitish- yellow color, thread-like appearance, and solid consistence. 424 DISEASES OF THE STOMACH AND INTESTINES 4. Muscular tissue, chiefly in very small, brown colored rods, like splinters of wood. 5. Potato, appearing like boiled tapioca grains, readily confused with flakes of mucus. The distinction is made with the microscope. 6. Large crystals of ammoniomagnesium phosphate, which grate when the specimen is ground. Microscopic Examination. — This serves chiefly to complete the gross inspection. In addition to the preparations of material selected during the macroscopic examination, three slide preparations are made. The first consists merely of a drop of the liquefied stool under the cover-glass. The second, a drop of the liquefied stool mixed with a drop of acetic acid, heated to the beginning of boiling and covered with a cover-glass. The third consists of a drop of the liquefied stool mixed with potassium iodid solution of iodin and covered with a cover-glass. Inspection of the first slide preparation by the aid of the micro- scope, using a high, dry lens, reveals finely divided material consisting of bacteria and mostly unrecognizable detritus, in which are imbedded : (a) Isolated fragments of muscle-fibers, usually bile stained, partially digested, but occasionally with the transverse striations recognizable. ih) Larger or smaller yellow crystals of the alkali earth salts of the fatty acids. (c) Colorless soaps. {d) Isolated potato cells, without distinguishable contents. (e) Particles of oatmeal and cocoa shells, where the latter is taken instead of milk. The second slide gives a general idea of the fat present in the stool. While hot, the fatty acids, liberated in the acetic acid, appear as drops; on cooling, these congeal to small needle-like crystals. In the third preparation potato remains have a violet color, while isolated fungus spores (Clostridium butyricum) may appear blue. The pathologic findings which the slide may present, in addition to those enumerated under the macroscopic examination, are: Slide I. — Muscle fragments in greater number and better state of preservation, particularly wiih retained nuclei; drops of neutral fat; needles of fatty acids and soaps; many groups of potato cells. Slide II. — Massive fatty acid drops and crystals. Slide III. — Blue starch grains, free or in the potato cells; oatmeal cells; any con- siderable number of blue-staining fungus spores or thread-like bacteria. Bacteriologic Examination. — The recognition of the tubercle, typhoid, Shiga, or cholera bacillus calls for technic which will be found described in special treatises. The selection of material to be examined for tubercle bacilli is best made from the surface of formed TESTING THE INTESTINAL FUNCTIONS 425 stools, since in soft movements morbid products from the diseased area will be so mixed with the feces as to easily escape detection. For amebae a saline^ should be given and the warm liquid stool examined. Mention has already been made of the detection of bac- teria and fungi which are colored blue by iodin (granulose reaction). Procedures that yield information of considerable value in the less specific forms of intestinal infection have recently been advocated by Herter. Of first importance is the preparation of smears of the mixed stools on microscopic slides, stained b}" the Gram method. The relative number of Gram-positive bacteria, as also their character, is of diagnostic value, since they are relatively few in health and in meat-free diet, while they are increased in some diseased conditions and when notable quantities of meat are eaten. Not only is it of value to note the actual increase, but the potential. The latter is determined by the observation of the relative number of Gram- positive bacteria in the residues in the sugar-bouillon tubes (see below), a predominance of Gram-positive bacteria indicating a pathologic tendency of the fecal flora. The sugar-bouillon tubes just mentioned are ordinary fermenta- tion tubes, containing i per cent, lactose-bouillon, i per cent, glucose- bouillon, and I per cent, saccharose-bouillon respectively. Normally, little fermentation occurs when the tubes have been incubated at 37° C for twenty to twenty-two hours. Active gas production, so that it accumulates to the extent of more than one- third of the tube capacity, is most frequently due to the predominance of a bacillus identical with or allied to the Gram-positive Bacillus aerogenes capsulatus, the growth of which replaces the Bacillus coli communis, the normal intestinal inhabitant. Chemic Examination. — The cheinic reaction is best determined by smearing one side only of moistened red and blue litmus-paper with the diluted (see Macroscopic Examination) fecal matter. After some time the reaction is noted on the opposite side. It is usually amphoteric, feebly acid, or alkaline. The sublimate test for unchanged bile-pigment is performed by add- ing some of the diluted fecal matter to a considerable excess of strong solution of bichlorid of mercury, allowing the mixture to stand over night. The normal feces are colored red ; more intensely, the fresher and less decomposed the excrement. Herter points out that this red coloration may be pathologically increased in excessive saccharobuty- ric putrefaction. In the presence of bilirtibin, a green coloration is pro- duced. This, even to the extent of microscopically small particles, is pathologic. A negative sublimate test suggests suppression of bile ; an incomplete test with fresh stools, abnormal processes of decomposition. The fermentation test of Schmidt and Strasburger for fermentable carbohydrate or putrescible proteid is performed in the Strasburger fermentation tube (Fig. 182). ^ Magnesium sulphate is an excellent saline cathartic to employ. 426 DISEASES Olf THE STOMACH AND INTESTINES V A 5-gram portion of the well-mixed, undiluted, fresh excrement, or proportionally more of the thinner material, is well mixed with sterile water; the chemic reaction noted; and then the mixture is introduced into the lower vessel of the apparatus. The bottle is entirely filled with water and stoppered, with exclusion of air. The adjacent upper tube is filled or nearly filled with water, while the distal tube remains empty. The apparatus is incubated at 37° C. for twenty-four hours. The extent of gas formation is indicated by the amount of water displaced by the gas from b' and which accumulates in the distal tube c'. Normally, there is practically no gas formation, and the chemic reaction of the fecal mixture remains about unchanged. Gas production to such an extent as to introduce an amount of water into the distal tube equal to one-third its capacity is pathologic. If coincidently with the gas production the chemic reaction has de- veloped a decidedly increased acidity, the gas production is due to carbohydrate fermenta- tion ; if alkalinity, albuminous putrefaction has occurred. When the proximal tube is opened it, gives off a butyric acid odor in the former case and a putrefactive odor in the latter. The color of fermenting feces is generally brighter; of putrefying feces, darker. The test is more especially applicable to the test diet stools. If the condition approximates the normal, a further test should be carried out for accuracy. In such event, the patient is placed on a diet which differs only from the first in the absence of meat and potato. If there is still a positive result, the diagnosis of "fermentative dyspepsia" is justifiable. Putrefactive Products. — Tests for indol and skatol may be applied to the distillate, using 10 gm. of the feces mixed with 120 cc. of water, the whole made alkaline, a bit of paraffin added to prevent frothing, and the first 50 cc. collected. A suitable apparatus for conducting the process consists of a 500-CC. capacity long-neck Kjeldahl digestion .flask connected with a I^iebig condenser. Distillation with steam is sometimes advantage- ous; 10 cc. of the distillate is rendered slightly alkaline with sodium or potassium hydroxid and an excess of a fresh solution of beta- naphthaquinone-sodium-monosulphanate added. The substance, in the course of a few minutes, reacts almost completely with the indol present, but not with the skatol; with the resulting formation of a bluish precipitate with much indol, and a mere coloration of the Fig. 182. — Stras- burger's tube. TESTING THE INTESTINAL FUNCTIONS 427 solution with little. If more than a trace is present, the reaction is conducted with the remaining 40 cc. of the distillate, the indol- naphthaquinone compound removed from the whole by filtration, and from the portion remaining in solution by distillation, after acidifying. The distillate containing the skatol, if necessary, freed from indol as described, is tested by the use of a well-marked excess of dimethyl- amido-benzaldehyd (Ehrlich's aldehyd), being boiled with a 5 per cent, solution in 10 per cent, sulphuric acid. Dilute hydrochloric acid is added to the point of the production of the maximum color intensity and the mixture rapidly cooled. The presence of skatol is indicated by the blue coloration. The color may with advantage be extracted with chloroform. If the process described is to be conducted quantitatively, 25 gm. of feces should be employed, and distillation continued till the distillate is free from substances reacting with the above reagents, the color shaken out with known volumes of chloroform, and the depth of color compared by the aid of the Duboscq colorimeter, with a similar chloroform extract obtained by starting with solutions of known strength of indol and skatol respectively. REFERENCES 1. Herter, C. A., Bacterial Infections of the Digestive Tract, 1907. 2. Herter, C. A., and Foster, M. Louise, Journal of Biol.Chem., i, p. 257; ii, p. 267. 3. Schmidt, A., translated by C. D. Aaron, The Test Diet in Intestinal Dis- eases, vol. Ixxvii, igo6. 4. Steele, J. Dutton, Medical News, 1905, p. 1158, vol. Ixxvii. Results. — In interpretation of results, we have to consider both the occurrence of pathologic admixtures and an increase of the con- stituents from the test diet. A thin coating of mucus is normally collected by the hardened fecal matter. Otherwise the appearance of this product indicates catarrh of the mucosa, the mucus containing many cellular elements. An exception is the overproduction of mucus in colica mucosa, with cellular elements less abundant and with the striking consistence. Pus, blood, masses of epithelia from the mucosa, and similar elements carry the pathologic significance of these products, and require investigation and interpretation, as when found elsewhere. Considering an increase of the constitutents of the test diet, a distinct connective-tissue increase indicates deficient gastric^ diges- tion. An excessive quantity of meat-fibers points to deficient proteid digestion in the small intestine. The albumin fermentation (putre- factive) test further indicates increased proteid in stools, frequently derived from pathologic secretions, probably associated with an abnormal putrefactive flora. The bacteriologic examination, espec- ially as to fermenting and Gram-positive bacteria, is of value along 1 The author advocates a separate test of the gastric functions. 42 8 DISEASES OF THE STOMACH AND INTESTINES these lines. Also tests for putrefactive products, if increased activity in this direction in the stool itself is to be investigated. Starch granules, revealed microscopically, show deficient starch digestion in the intestines, due either to rapid passage of the contents or disturbed secretion. Defective carbohydrate digestion is also indicated by an abnormal carbohydrate fermentation test. Only a considerable increase of fat is pathologic. Such a stool is indicated by the quantity of the stool itself, the light (whitish) color, and a marked acid reaction, as well as by the microscopic findings. A deficient flow of bile or of pancreatic secretion is the usual cause; in the former case the stool not containing pigment (sublimate test) ; in the latter showing an associated increase of meat-fibers, frequently with retained nuclei. Functional disturbances of fat digestion are said to occur, but other possibilities must be excluded in reaching this diagnosis. MECHANICAL PROCEDURES The Enema ; Intestinal Irrigation ; Proctoclysis. — For injection into or irrigation of the intestines there are four methods, all of which have their special applications. They are : 1. The enema. 2. Irrigation with a single tube. 3. Irrigation with a double-current tube or with two tubes. 4. Proctoclysis, the drop method of injection. Uses of irrigations or enemata are as follows : The local treatment of diseased conditions, as of catarrhal colitis. The relief of congestion or acute inflammation, as of the rectum or prostate. The relief of pain and irritability, as in spasm of the sphincter. The absorption of inflammatory products, as of postuterine adhe- sions. To replace the loss of fluid in the body, as in cholera. To dilute the poison of disease, as in uremia. To increase the flow of blood to a part, as in insufiicient men- struation. To check hemorrhage (extreme cold or heat). Locally, as in bleeding ulcers of the rectum; in an adjacent organ, as in uterine hemorrhage. Reflex effects through the sympathetic ganglia, on the circulator v apparatus, on the secretions, as a tonic stimulant, and the revulsive effects. On the circulatory apparatus, as in shock. On the secre- tions, as in the production of sweating, bowel action, and urinary secretion in uremia. As a tonic stimulant, as by use of the alternate hot and cold douche in diminution of erectile power. The revulsive effect, as the production of bowel action in apoplexy. The reflex effect on a distant organ, as from enemata in jaundice. The effect on the heat centers — the temperature can be raised MECHANICAL PROCEDURES 429 in shock by hot irrigation, or lowered in fever by cold irrigation or by enemata. Simple cleanliness, removing undigested food products, and preventing auto-intoxication. Antispasmodic, as by relieving spasm in colic. Mechanical, as in intussusception. Water as a vehicle — the nutritive enema. Physiologic Experiments. — In a series of experiments at Columbia University some years ago the author demonstrated on animals (Fig. 183), and latei clinically, that enteroclysis at 110° to 120° F. best stimulated the heart in shock; that renal secretion undergoes a double cycle of increase from enteroclysis at high temperatures Fig. 183. — Method of performing physiologic experiments. (110° to 120° F.), both from intestinal absorption and from the increased blood flow through the kidney; while with lower temper- atures the increase is merely from intestinal absorption. Normal saline solution has a specific effect in increasing renal secretion. Cold irrigations first stimulate, then depress. Body and blood temperature are increased by hot irrigations and diminished by cold. These experiments^ were completel}^ reported. I. Enema. — The enema may be high with a colon-tube (Fig. 184), which should be thoroughly lubricated and the water should flow while inserting. It should be administered with the patient on the left side,^ or for high injection in the knee-elbow posture, when a 1 Enteroclysis, Hypodermoclysis, and Infusion, Kemp; Hydrotherapy, S. Baruch; Enteroclysis, Reference Hand-book of the Medical Sciences, 1900. 2 The dorsal position, with the hips elevated, can be employed. 430 DISEASES OF THE STOMACH AND INTESTINES high enema can thus be given with a short tip. I prefer never to give more than i to i^ quarts (liters). Fig. 184. — Colon-tube. Milder medicated solutions can be employed in this way. The low enema is of more value for low impaction or to relieve local irritation in the rectum or adjacent organs. 2. Irrigation with a Single Tube. — There are four modifications of this method : Fig. 185. — Lee's cholera table. (a) A colon-tube is inserted into the bowel, a funnel attached, and by raising and lowering the funnel, the bowel is washed out- (6) A fountain syringe can be attached to the colon-tube, and when sufficient fluid has flowed in the fountain syringe the con- nection is detached and the fluid flows out through the colon- tube. MECHANICAL PROCEDURES 431 (c) The patient can void the fluid around the colon-tube or catheter during irrigation. This is the method usually employed Fig. 186. — Kemp's flexible recurrent rectal irrigator. with infants. Elmer Lee carried out this technic at the cholera stations (Fig. 185). An irrigating jar may be substituted for the rubber bag. Fig. 187. — Kemp's glass rectal irrigator (recurrent). Cork opening above for cleansing. (d) A glass Y is attached to the colon-tube, as in lavage of the stomach ; one branch is connected with the fountain syringe, the other Fig. 188. — Kemp's rectal irrigator. All metal tube. Fig. 189. — Electric attachment for electro-enteroclysis. Hard-rubber tube with metal center. is to a carry-off tube. By alternately pinching the soft-rubber outflow and inflow tubes the bowel can be irrigated. 432 DISEASES OF THE STOMACH AND INTESTINES 3. Double-current Irrigation with Two Tubes or a Recurrent Tube. — Advantages. — The quantity of the fluid is under the control of the Fig. 190. — Kemp's tube (ready for cleansing). Hard rubber with metal center. Fig. 191. — Enteroclysis (double current). Patient in dorsal position on bed-pan. Operator, since it can be regulated by manipulation of the outflow and inflow tubes. The labor is placed upon the operator and not upon the patient, MECHANICAL PROCEDURES 433 and there is no straining to overcome the resistance of the sphincter. The straining of self-evacuation is avoided, and mere mechanical cleansing of the bowel is employed. The temperature of the fluid entering the bowel can be kept constant. Tympanites is relieved best by this method, the return flow carries off the gas bv suction. With the enema the gas frequently Fig. 192. — Enteroclysis fdouble current). Patient in Sims' position. collects in the intestines behind the injection and it is often impossible to exert sufficient force to expel it with the enema. Two catheters or two small rectal tubes passed through a perineal pad can be improvised for this purpose. The illustrations of the author's tubes are shown (Figs. 186-190). They are readily under- stood. J. P. Tuttle's, Hemmeter's, and various recurrent rectal tubes are described by the author in his manual " Enteroclysis." The hard-rubber tube with metal center is the best. All metal tubes are good for hospital work. 28 434 DISEASES OF THE STOMACH AND INTESTINES The flexible tube is excellent for sensitive cases or for young children. To the middle tube of the irrigator is attached the tube of the fountain syringe; to the curved tube the outflow soft-rubber tubing is fastened. This last must be pinched, as it is the larger, in order that fluid may pass up the bowel. By alternately pinching the in- flow and outflow the quantity of fluid may be regulated. Fig 193. — Enteroclysis (double current) without the bed-pan. Position of the Patient. — Elevation of the hips is the important feature, not the length of the tube. The different positions of the patieiits are illustrated and are readily understood (Figs. 191-195). Method by Rotation. — Patient is placed on the left side with the hips elevated, and the descending colon is irrigated. Rotate the patient gradually to the dorsal position, and then to the right side, with the hips elevated ; the return tube being pinched. About 1 5 pints to 1 quart (750 to 1000 cc.) of fluid are allowed to run into the bowel. MECHANICAL PROCEDURES 435 The shoulders are then elevated to above the level of the hips, the patient being still on the right side. This is to make the fluid gravitate into the caput coli. The shoulders are then depressed to below the hip level, the patient on the right side ; he is then gradually rotated to the dorsal position and then to the left side, and as a final step the shoulders are elevated, etc. In other words, the process is reversed. The return tube is then released and the fluid is allowed to escape. Fig. 194.- -Enteroclysis (double current). Patient in semi-oblique position, as in pulmonary edema, etc., when dorsal position is impossible. I employ tnost frequently the dorsal position without the bed-pan. Temperature of the solution depends upon the conditions of its employment, an average of 101° to 105° F. in intestinal catarrh; at 110° F. in typhoid for an additional eliminative eff"ect, and for shock and uremia at 115° to 120° F. Solutions Employed. — Flaxseed tea {2 drams — 8.0 — of flaxseed to I quart — liter — of water, boiled twenty to thirty minutes and 436 DISEASES OF THE STOMACH AND INTESTINES strained). Temperature, ioi° to 103° F. This should be rather thin and oily in order to flow easily from a fountain syringe. Dilute it with boiled water if too thick. Normal saline solution with oil of peppermint, V([v to xv (0.296-0.88 cc), or oil of cinnamon, TTLv to XV (0.296-0.88), to I pint (500 cc). lyisterin, borolyptol, glycothy- molin, borax, bicarbonate of soda , tannic acid, and alum have been employed at a strength of 5] (4.0) to i quart (liter). Fig. 195. — Enteroclysis (double current). Self-irrigation of the prostate per rectum. Delafield has used bichlorid of mercury (1:10,000), 2 quarts (liters), for septic membranous colitis complicating typhoid fever, with a recurrent tube, with success. Gum-arabic solution is often of service. Special solutions are described appropriatelv. Normal saHne solution, Sj (4.0) of salt to i pint (500 cc.) of water, has a wide field of usefulness. Enema ta and enteroclysis are of value in d>senterv, intestinal hemorrhage,^ intestinal catarrh, typhoid, intestinal colic, tympanites, 1 This refers to hemorrhage in the large intestine, where an extremely hot 01 cold astringent enema is of service. MECHANICAL PROCEDURES 437 intestinal toxemias, thirst, constipation, impaction, intestinal paresis, and jaundice. They are extremely useful in shock, uremia, sepsis, renal colic, and in inflammatory conditions of the genito-urinary organs of both sexes. Proctoclysis. — In conclusion, I wish to refer to proctoclysis, the injection of normal saline solution into the rectum by the drop method, as first suggested by Dr. John B. Murphy of Chicago. This procedure is of special value in sepsis, and is of use as an adjunct to other treatment in postopera- tive shock, intestinal paresis, and uremia. In my experience the employment of con- tinuous (recurrent) irrigation, with a tem- perature of the saline solution at 120° F., is more efficacious in the latter conditions, followed by proctoclysis as an adjunct. One of the difficulties which the phys- ician must endeavor to overcome in the administration of saline solution by the rectum or by infusion is the maintenance of a constant temperature of the solution. Elbrecht's apparatus necessitates a special heating chamber in addition to the contain- ing reservoir, with the employment of an electric heater, an alcohol lamp, or a Bunsen burner. The method, though scientific, seems complicated and is quite expensive. I have recently employed the vacuum bottle^ with a specially devised attachment which has proved efficacious in preserving the saline solution at a constant tempera- ture. The device is readily understood irom the illustration (Fig. 196). Through the screw cap (B) , which closes the bottle, passes a small hard-rubber con- ducting tube, to which is attached the outflow tube (£). Parallel with this is the filiform tube (C), which allows the entrance of a fine column of air, so as to render the flow possible. This last tube passes through the solution to within about i inch from the bottom of the bottle. As the instrument is employed inverted, it would cor- respond to the same distance from the top of the bottle. This fili- 1 New York Medical Journal and Philadelphia Medical Journal Incorporated, Aug. 14, 1909. Fig. 196. — Heat -retaining proctoclysis bottle. 438 DISEASES OF THE STOMACH AND INTESTINES form tube is of hard rubber externally where exposed to the air as a non-conductor of heat. The part lying within the bottle is pur- posely made of metal, so that it is rapidly heated by the surround- ing solution and the entering air is thus, in turn, heated markedly. A series of experiments have demonstrated that there is only a loss of I ° to 2 ° F. in the temperature of the solution in the bottle during the administration of proctoclysis (the drop method) lasting half an hour, a negligible amount. The screw compression valve (D) is applied close to the bottle attachment, so as to avoid as much as possible the solution cooling in the soft outflow tube. This outflow tube (E) is joined to the catheter (G) by a short piece of glass tubing (F), for the purpose of observing whether the flow is constant. The catheter for rectal injection passes through a self- retaining rectal tip (H), and the former can be inserted to any length desired. The conducting tube (E) is especially thick, as in Elbrecht's apparatus. An asbestos tube surrounds the conducting tube from its junction at the bottle to the catheter. This lessens dissipation of heat and obviates the use of hot towels. The asbestos wrapping can be occasionally slipped off the glass connecting joint, so as to observe the flow. The vacuum bottle is filled in the usual manner and the special cap with attachment screwed on. The bottle is then inverted and suspended in a cord sling, as in the illustration. A small amount of fluid will escape from the bottle by the filiform air tube until the solution reaches the level of the tube, which now lies near the top of the bottle. The bottle is then suspended about 6 inches above the rectum or higher if desired, and the flow' tested for the proper speed before inserting the rectal tip and catheter. If flatus occur, lower the reservoir for a brief period to below the level of the abdomen, so the gas may escape into the bottle. At times, however, it may be necessary to remove the tube for a short period. The insertion of a T-tube between the reservoir tube and rectal catheter is of advantage. A short piece of rubber tubing is attached to the branch and immediately clamped. On occurrence of flatus, the lateral clamp is removed and the gas allowed to escape. It is then reclamped. This obviates removal of the tube. As al- ready stated, there is practically no loss of heat in the container, all of it occurring during the passage of the drops through the outflow, tube; the slower the speed, the greater the loss. At the start the speed is always more rapid and, though gauged to say 15 drops per minute, may in the course of two minutes drop to 5. A test of two to three minutes should, therefore, be made before inserting the catheter, so as to insure a constant flow at the desired rate. The following table will be found of service ; with Temperature of water Length of tube Number of drops Temperature in in bottle. (inches). per minute. rectum. 160° F. 30 20 or less 100° F. 150° F. 30 40 to 50 100° F. 138° to 140° F. 30 150 to 200 105° to 110° F, MECHANICAL PROCEDURES 439 If the injection is given at a greater speed than 200 drops per minute, the solution in the bottle should not be over 120° F., as there is practically no loss of temperature. This method by enema or recurrent enteroclysis would be of great value in shock. It could then be followed by proctoclysis as an adjunct. Hypodermoclysis. — There is a loss of 10° to 20° F. during the injection, depending upon the size of the hypodermic needle. Infusion. — Dawbarn advocates a temperature of 115° to 120° F., preferably the latter; time, ten minutes to the liter (quart). With the smaller vacuum bottle, containing about i quart ( liter), a glass V tube can be inserted between the conducting tube and the rubber tube for attachment to the infusion canula. By this means it is possible to tell when the bottle is empty and thus prevent the entrance of air. A clamp can be applied close to the V tube on the canula side and the bottle refilled, the v tube being refilled before the conducting tube is reattached, and the latter being done while the solution is flowing. A larger bottle can be secured for infusion, but the smaller one can be employed with these precautions. Fig. 197. — Tiirck's double-current needle douche for the sigmoid. The temperature of the saline solution does not practically change during the infusion and should be at 115° to 120° F. in the reservoir. Needle Douche ; Nebulizer ; Colonic Massage Bags ; Gyro- mele. — These instruments^ have been devised by F. B. Tiirck. The colon needle douche (Fig. 197) I believe of some value for local treatment by the alternate hot and cold spray in the atonic type of constipation. . The nebuHzer (Fig. 198) is recommended by its inventor for spraying oils of cloves or cinnamon into the colon for their antiseptic, analgesic, and vasomotor effect. He recommends distensible bags for massage of the atonic sig- moid and rectum, which I hardly advocate. The gyromele, already described, Tiirck recommends in the rec- tum and sigmoid for cleansing the mucosa and producing vibratory movements. I question the possibility of its entering into the sig- moid flexure except very rarely. Massage, Gymnastics, and Exercise. — The general methods of massage have been described. The course of the colon should be followed. The cannon-ball and vibratory massage are of service. ' Tournal American Medical Association, May, 1895. 440 DISEASES OF THE STOMACH AND INTESTINES The portable Vedee vibrator is a useful instrument for the general practitioner. It is illustrated in Part II of this volume. Gym- nastic exercises and out-of-door sports are valuable for strengthening the abdominal and intestinal musculature, especially in intestinal atony with constipation. Rowing with a sliding seat, golf, horse- back-riding, bicycling, and walking are useful. Mechanical Support. — Adhesive strapping (Rose's belt), abdom- inal supporters, etc., are indicated in enteroptosis, in atonic condi- tions of the intestines or of the musculature of the abdominal wall, in hernial protrusions, etc. Hydrotherapy. — The Priessnitz compress, poultices, and the application of heat or cold locally are useful. Fig. 198. — Tiirck's nebulizer. Sitz-baths and abdominal douches are employed as already described. Electricity. — Galvanic, faradic, and static electricity may be employed percutaneously. The faradic, chiefly in atonic conditions ; the galvanic, in painful neurotic affections. Static electricity can be used for both purposes. About ten to fifteen minutes is the average period of treatment. When externally applied the current should follow the course of the colon and then be given over the small intestine. Electric vibration may be used. Violet rays, the high-frequency current, etc., have been advo- cated for various conditions, but further investigation, I believe, is necessary before they can be recommended. The application of heat and Hght (electric -light bath) to the abdomen in painful con- ditions due to a gouty or rheumatic tendency, or in enteroptosis or MECHANICAL PROCEDURES 44 1 mucous colic its application to the sensitive areas may prove of service. Intrarectal Electricity. — Boudet's electrode presents the disadvan- tage that sometimes frequent evacuations necessitate withdrawal of the electrode. The author's instrument (Fig. 189) consists of a recurrent irri- gator, external tube hard rubber, internal tube metal, with an attachment for a battery pole; a sponge attached to the other pole is placed over the abdomen. Continuous enteroclysis is given with hot normal saline solution, the water carrying the current. The treatment should be given for five to thirty minutes, depending on the indications. It is excellent for simple atonic constipation and for intestinal paresis. The faradic current is preferable, as strong as the patient can bear. The galvanic may be employed, with nega- tive pole in the rectum, with a current of 10 to 15 milliamperes. CHAPTER XXI DIET; INTESTINAL DYSPEPSIA; INDICANURIA; SAC- CHAROBUTYRIC PUTREFACTION ; BOTULISM ; HYDROGEN SULPHID AUTO-INTOXICATION; EN- TEROGENIC CYANOSIS; METEORISM; ENTER AL- GIA; VISCERAL ARTERIOSCLEROSIS; ANOMALIES; INTESTINAL SAND DIET The; general principles of diet were described in Diseases of the Stomach. I will briefly mention a few general rules which should be applied. Acute intestinal disorders must be managed on the principle of rest. Ivight food (chiefly liquid) should be given, such as broths, barley-water, gruels, kumyss, matzoon, bacillac, lactone-buttermilk, and in some cases milk, but diluted with barley-water or Hme- water. It has been demonstrated that in the acute intestinal catarrh of infants and children, undiluted (or at times even diluted) milk will frequently pass undigested and intensify the inflammatory process, so that reli- ance is placed for a time on barley-water and similar preparations. Seibert has demonstrated conclusively that milk is not the ideal food for typhoid fever. In chronic intestinal disease, for a brief period, rest may be given to the intestines by means of a fluid diet, but feeding should soon be increased, the general nutrition improved, and the intestional tract gradually accustomed to a regular diet, if such be possible. Milk, cream, raw eggs, carbohydrates, and fats are of value to improve nutrition. In these chronic cases especially, and also in intestinal dyspepsia, all or some special digestive function may be disturbed, such as for proteids, fats, or carbohydrates. The presence of indicanuria, the test diet with stool examination, the fermentation test, together with the clinical symptoms, will determine the type of disturbance of the intestinal digestive function. The findings would modify the diet. Dietetic measures are of special value in reference to disturbances accompanied by constipation or diarrhea. I. Laxative foods are articles which increase intestinal peristalsis. Among such are fruit juices and raw and cooked fruits, such as apples, pears, plums, peaches, strawberries, gooseberries, dates, and figs. Salads, garden vegetables, due to water contained and indigestible residue, such as melons, cucumbers, spinach, tomatoes, pumpkins, and cabbage; cider, bonny-clabber, kumyss, matzoon, and bacillac, 442 DIET 443 through formation of acid products and gas, increase peristalsis. Some of the fruits and vegetables mentioned have a similar effect. Brown bread and oatmeal tend to move the bowels, also water or carbonated waters. Sugar has a laxative effect. Considerable fat, in the form of cream, butter, or olive oil, aids bowel action. 2. Constipating Foods. — Among such are substances containing astringent agents, especially tannic acid, such as tea, dried bilberries, French red wines, cocoa, the acorn preparations, such as acorn coffee, acorn cocoa; mucilaginous foods, such as sago, tapioca, rice, and barley; also foods which leave little residue and exert no irrita- tion, such as albumen- water (white of egg dissolved in water), scraped raw beef, mutton broth, etc. Pathologically, excess of carbohydrates may be a cause of diarrhea, as may excess of proteids. Milk is constipating in one person, laxative in another, and has no special effect on others. Boiled milk is usually constipating. Dietetics have changed markedly during the last few years. In chronic colitis with diarrhea the chief diet was formerly scraped meat. Modern methods allow a much greater variety, and the em- ployment of mashed potatoes and boiled rice lessen peristalsis and are often of considerable value. Certain foods, when taken under ordinary conditions, have no marked influence in increasing peristalsis ; among these are meats, fish, meat powders, artificial foods, such as peptone, nutrose, soma- tose, sanatogen, plain or flavored; eggs, well-baked bread (wheat), crackers, zwieback, and butter or fat in small amount. Marked seasoning of foods increases peristalsis. The finer the particles of food, the less the irritation ; the coarser they are, the greater stimulation the}^ produce on the intestines. Gelatin. — I have referred to the value of gelatin in ulcer of the stomach and in hyperchlorhydria. Gelatin does not build up new tissue, no matter how much is ingested, though it may diminish tissue waste (Voit).^ It cannot be reconverted into a proteid. Kirchmann^ shows that gelatin spares proteid in metahoUsw,. - The ingestion of 7.5 per cent, of the total heat'* requirement of the organism in the form of gelatin spares 23 per cent, of the body's proteid, while 60 per cent, gelatin reduces it 35 per cent. The small amount of gelatin has nearly as much effect as larger quantities. Its value in typhoid is, therefore, evident to lessen nitrogen excretion. Kaufmann* shows that when the lacking tyrosin, cystein, and tryptophan are mixed with gelatin in the proportion in which they occur in true proteid, and are given to a dog or man, nitrogen equilib- rium may be established. 1 Hermann's Handbuch Stoffwechsel, 1881, p. 396. ^ Zeitschrift fiir Biologie, 1900, Bd. xl, p. 54. 3 One gm. of gelatin furnishes 4.1 calories. About 50 gm. of gelatin repre- sents this requirement in a person weighing 154 pounds. * Pfliiger's Archiv., 1905, Bd. clx, jx 440. 444 DISEASES OF THE STOMACH AND INTESTINES Gelatin does not yield indol, and can be employed in the form of jellies as a nitrogenous substance to replace proteids in cases of indicanuria (Herter).^ In severe inflammation of the intestines artificial feeding may be necessary, by rectum or subcutaneously. Rectal alimentation has been described under Diet, in Part II. Sterile olive oil, oj to ij (30.0-60.0), may be injected subcu- taneously two or three times a day between the crest of the ileum and lower border of the ribs (preferably). Sterile almond oil in doses of oj to ij (4.0-8.0) may be substituted. I do not advocate, how- ever, the subcutaneous method. Normal saline solution, Oj (500 cc.) to i quart (liter), may be slowly injected in the same region in case of collapse or hemorrhage. INTESTINAL DYSPEPSIA With intestinal catarrh or biliary or pancreatic obstruction there is perversion of intestinal digestion. These conditions will not be considered here. Digestive processes in the intestine may become abnormal when the intestinal contents are no longer normal. This may occur even with intact mucosa and with sufficient bile and pancreatic juice. Indigestible food, or excess in some special types of food, may lead to fermentative or putrefactive processes in which bacteria take part, and may produce dyspeptic symptoms. Indicanuria or saccharobutyric putrefaction occur from these conditions. There may be functional disturbances of pancreatic digestion for the proteids, carbohydrates, and fats, or any one or two of these functions may be disturbed. Riegel describes cases with marked fermentation of the carbo- hydrates. There is a jejunal diarrhea of gelatinous semifluid char- acter, often quite green, with bile-pigment reaction and acidity. There is mucus in these movements, but no formed elements, such as epithelial and round cells, which occur in catarrhal conditions. Catarrh may ultimately result. Herter^ shows that there is an intestinal indigestion in children of marantic type, in which there is intolerance to carbohydrates, and light colored and gray or fatty stools occur. Indican and phenol are found in large amount in the urine. A great number of Gram- positive bacilli of the Bacillus bifidus type occur in these cases. Schmidt and Strassburger describe "intestinal fermentation" as dyspepsia in which the stools are light yellow, foamy, with the odor of butvric acid. Fatigue, discomfort, loose stools, or even diar- rhea may occur. Abdominal pains, distention, and some tenderness may be present. These cases correspond to saccharobutyric putre- 1 Bacterial Infections of the Digestive Tract, p. 267. ^ ibid., p. 285. INDICANURIA 445 faction (Herter).^ Dyspeptic symptoms may be due to the decompo- sition of proteids.^ Various symptoms, as stated, may be present with intestinal dyspepsia, such as distention, pain, borborygmi, passage of flatus, feeling of discomfort in the abdomen. Diarrhea or irreg- ularity of the bowels is present; loss of appetite, eructations, nausea, and even vomiting may occur. The best method of determining the intestinal functions is by the Schmidt test diet, with examination of the stool. Treatment. — That variety of food must be limited for which the particular disturbance exists. Liquid or semiHquid diet may be necessary. Indicanuria and saccharohutyric putrefaction must be appropriately treated. Lactic acid has been recommended in the form of ferm.ented milks, such as kumyss, matzoon, bacillac, kefir, or lactone-butter- milk; chicken, jellies, gruels, etc., can be given later. Calomel, gr. ^V (0.0016) four times a day, is suggested by Van Valzah^ for fermentation; or resorcin, gr. 5 (0.3) t. i. d., is excellent. Taka-diastase, gr. 5 (0.3) t. i. d., is valuable in am3daceous dyspepsia*; or pancreon, gr. 5 (0.3) t. i. d., in disturbances of fat and proteid digestion,^ and pancreatin, same dosage. In conclusion, I would advise that in the milder cases the special food stuff which causes dyspepsia should be limited in quantity, but not entirely cut off. Eggs, soft boiled or raw, vegetables in mashed forms, bread or crackers, stale and well broken up, and sanatogen are of service ; butter or cream according to indication. Later the diet is increased. INDICANURIA Indicanuria designates the presence of indican in the urine, as demonstrated by reactions with the formation of indigo, on using Jaffe's, Obermeyer's, or similar tests. Indol is absorbed from the intestines and forms in the liver indoxyl potassium sulphate or indican, an ethereal sulphate which is eliminated in the urine. There are various causes of indicanuria: excessive proteid diet, catarrh of the small intestine, causing alterations in the mucosa and increased intestinal putrefaction, typhoid, cholera, etc., constipation, alimentary putrefaction, partial or complete obstruction of the com- mon bile-duct, decrease of normal digestive fluids, intestinal obstruc- tion, and peritonitis. Certain drugs, such as salol, salophen, and creosote, give reactions which must not be mistaken for it, while urotropin causes its disappearance. 1 Bacterial Infections of the Digestive Tract, ]ip. 294, 300. 2 ibid., pp. 280, 306. 3 Medical News, Jan. 17, 1903. *Cellasin, gr. 5 to 10 (0.3-0.6), given t. i. d. an hour after meals in combina- tion with bicarbonate of soda, gr. 10 (0.6), has of late proved valuable in amyla- ceous and fatty dyspepsia. 5 True Intestinal Dyspepsia (Einhorn), American Jour, of Med. Sciences, No- vember, 1907; also Med. Record, September 4, 1909. 446 DISEASES OE THE STOMACH AND INTESTINES Intestinal indicanuria is an evidence of intestinal putrefaction. Excessive quantity of proteid, especially of meat, may be a cause. Any condition favoring stagnation in the intestines helps produce this condition. Imperfect action of a cathartic can produce indicanuria. In children little indican appears. IMany adults show indican and suffer from no symptoms, but this is true of constipation. Finally, persons with indicanuria show clinical evidences of intestinal disorder and sometimes symptoms of auto-intoxication, frequently affecting the nervous system. Neurasthenic and even melancholic symptoms may be dependent on this form of auto-intoxication. '^ Intestinal putrefaction^ may directly affect the liver and kidneys. "I have a patient with marked indicanuria with bile in the urine, albumin casts, cylindroids, and diminished urea. Treatment of the intestinal putrefaction cleared up this condition. This corroborates the view of W. H. Porter^ that excessive intestinal putrefaction may cause disturbance of the hepatic cells. There was no jaundice in this patient. The colon bacilli, through their activity in the decomposition of proteids, are chiefly responsible for the production of indol. The Bacillus aerogenes capsulatus and the Bacillus putrificus, when present, favor the putrefactive action of the colon bacilli on the proteids.* The following test is reliable : Place in a test-tube equal quantities (lo cc. of each) of urine and chemically pure concentrated hydro- chloric acid. To this mixture add 3 drops of i per cent, solution of potassium permanganate. Then add a small portion of chloroform, I or 2 more drops of the permanganate solution, and a few drops more of chloroform, or a total of 75 drops (5 cc.) of chloroform, and shake vigorously for a few seconds. Indigo-blue is deposited in presence of this indicator. Bile should be tested for even if there are no evidences of jaundice. W. H. Porter's scale (Plate I) is a basis of comparison in the ab- sence of bile test. The color scale of complex indicanuria is omitted. Rosenbach's test, which consists in boiling the urine with nitric acid, gives a Burgundy red if putrefaction is present. This may occur when no indican is found. It is due to substances of a like class. Taylor^ recently reports transient heart block due to indicanuria. Treatment. — Diet. — Matzoon, kumyss, lactone-buttermilk, bacil- lac ; later, stale crackers with butter, boiled rice, and jellies (gelatin) are to be added. Herter shows that clinically the carbohydrates have an influence, and the substitution of a quickly digested carbohydrate, like rice which has been well cooked and forced through a colander, 1 Headache, migraine, myasthenia, epileptiform seizures, early fatigue, cycli- cal vomiting, or progressive muscular atrophy may also be dependent on this condition (Herter). 2 This condition, I believe, further influences the production of arteriosclerosis. 3 The Post-graduate, Oct., 1902. * Herter, Bacterial Infections of the Digestive Tract. 5 Jour. Amer. Med. Assoc, April 18, 1908. -r«^ A ■sj -A r ^ n F"?f -^ J -^ docn -^ > < m (J > X AJ -/I SACCHAROBUTYRIC TYPE OF INTESTINAL PUTREFACTION 447 for large quantities of bread or sugar, will lessen the excretion of indican. Taka-diastase or cellasin can also be given. Medication. — Blue mass, gr. 5 (0.3); calomel, gr. 5 (0.3), once a week, and a saline (cathartic for a short period) daily. Urotropin, gr. 5 (0.3), with benzoate of soda, gr. 10 (0.6) t. i. d., has cleared up many cases, albumin casts, bile, and indican disap- pearing within a short time. This shows the improvement was not due to the mere interference with indican reaction. Lacto-bacillin tablets are useful. Those advocated by Metchnikoff are best. Aspirin, salicylate of soda, and salol, gr. 5 to 10 (0.3-0.6), are of service, as is also chologestin, oij to iij (8.0-12.0), t. i. d. Enteroclysis is valuable, especially the injection of i pint to i quart (500-1000 cc.) of a i : 1000 acetozone solution, with the patient in the knee-chest posture. This should be retained for a short time. This procedure can be carried out every day or few days. Gastric disturbances should be investigated and corrected. George A. Tuttle has shown that potassium iodid, especially in cases with arteriosclerosis, will lessen indican. Basham's tincture has been of benefit in some. Some have advocated acetozone solu- tion, (i : 1000), 500 cc. (i pint), in divided doses daily by mouth. SACCHAROBUTYRIC TYPE OF INTESTINAL PUTREFACTION This type of decomposition is produced chiefly by the Bacillus aerogenes capsulatus,^ Gram-positive. Bacillus putrificus or Gram- positive diplococci may at times be associated. The Bacillus aerogenes under anaerobic conditions can attack carbohydrates and proteids. Butyric acid is often formed in con- siderable amount, and often propionic, caproic, or valeric acids. The odor of the movements is often intense and characteristic of butyric or caproic. acid. Excessive gas is liberated. The seat of this process is chiefly in the large intestine and lower ileum. When proteids are attacked there is less gas liberated. With excessive gas production the feces have a low specific gravity and float on water. There are small bubbles in the contents and the feces are a light color. Patients who suffer from this condition do not tolerate well either carbohydrates or acids, flatulence and diarrhea occurring after use of cereals, starchy food, and especially sugar. The mucous membranes of the digestive tract are easily irritated, and there may be epithelial desquamation in the mouth. In the simple cases indol is generally absent. Combined Saccharobutyric and Indolic Type. — The Bacillus aerogenes capsulatus is also able to break down proteids into a suit- able form for the use of other putrefactive bacteria, among which are the indol-forming organisms. This last form, associated with the excessive production of indol, is the most severe type, and these cases are subject to auto-intoxica- 1 Herter, Bacterial Infections of the Digestive Tract. 448 DISEASES OF THE STOMACH AND INTESTINES tion, depressive mental conditions, and diminution in muscular power (muscle fatigue), according to Herter. In the severe types the anaerobic organisms, especially the Bacillus aerogenes capsulatus, produce hemolytic substances which are believed to have a bearing on the production of pernicious anemia. The results of intestinal irrigation in such cases have been favor- ably reported by Hollis^ and Ditman," as in Fig. 199, with marked improvement in the hemoglobin and red cells. - Nov. DeoenalDer January February in arch Hemo- globin Red Blood Cells 33 SO 3 15 SQ S 10 IS se X 7 13 SI 1 7 13 Indican Very StfOrg Stiong Modofale 100% 5,000,000 4,500,000 4,000,000 3,500,000 3,000.000 90% / /^ s 80% J / 70% / / /■» •^ 60% / / / 60% \ <^ 1 / / V 40% 2,000,000 1,500,000 1,000,000 500,000 \ y \ / / / 30% Y AJ 1 < \ \ N / / 20% / \ \/ V < \ \ ^S^ y 10% \ 0% 1 _^ 1 Fig. 199. — Chart of pernicious anemia demonstrating value of enteroclysis. Arthritis deformans^ has recently been imputed to putrefactive changes in the intestinal canal. At the Red Cross Hospital excellent results were secured by the author by enteroclysis and fermented milks, no medication; the swelling in the joints rapidly subsiding. Treatment. — Careful mastication of the food, cleanliness of the mouth, and correction of gastric disturbances are necessary. Sugars should be omitted, starchy food cut down, and meat diminished or eliminated if the mixed type with indican is present. Taka-diastase, gr. 5 (0.03) t. i. d., aids starch digestion. Pan- 1 Herter, Bacterial Infections of the Digestive Tract. 2 Medical Record, Feb. 2, 1907. 3 A Preliminary Report on the Relation of Albuminous Putrefaction in the Intestines to Arthritis Deformans by Andrews and Hoke, American Journal of Orthopedic Surgery, July, 1907. HYDROGEN SULPHID AUTO-INTOXICATION 449 creatin preparations may be tried. The fermented milks are of spe- cial value. Lactobacillin tablets are useful. Enteroclysis, or high enema, with saline solution, acetozone (i: 1000) or hydrogen peroxid (1:1000) are of service. The latter are of special value. Ichthoform, formidin, ichthalbin, aspirin, salol, salicylate of soda, gr. 5 (0.3) t. i. d., are useful;^ or urotropin, gr. 5 (0.3), with benzoate of soda, gr. 10 (0.6), t. i. d. This last combination, with the addition of the high enema of acetozone i quart (liter), strength 1 : 1000, I have found of great value. Surgery- may be indicated in extreme cases. BOTULISM This is a variety of meat-poisoning due to the Bacillus botulinus, isolated by Van Ermengen from raw ham. The symptoms resembled those of so-called sausage-poisoning. This same type of poisoning has occurred from eating beans that were imperfectly canned. These were probably infected through the manure of pigs. Meat may be extensively infected with the Bacillus botuHnus, and contain a large quantity of the toxins, without showing the signs of decomposition. The filtered toxins can produce the effects. Incubation. — The symptoms seldom appear before twelve to twenty -four hours after ingestion of the infected meat. They are : First, disturbances of the external muscles of the eyeball, such as ptosis, abducens paralysis, disturbances of associated movements with nystagmus; second, disturbances of the internal muscles of the eyes, such as enlargement and rigidity of the pupils; third, there are swelling or paralysis of the tongue, pharyngeal and laryngeal paral- yses, and disturbances of the heart and respiration; fourth, there may be weakness or paralysis of motion. Changes in sensibility and consciousness usually do not accompany these disturbances. Fever has frequently been absent and there has even been absence of disturbances of the stomach and intestines. This condition is not so rare abroad and occurs in this country. Treatment. — Evacuation of the gastro-intestinal tract. Treat- ment of symptoms. Herter recommends Kempner's antitoxin when procurable. HYDROGEN SULPHID AUTO-INTOXICATION In health the formation of hydrogen sulphid seems probably limited to the large intestine and a small adjacent portion of the small intestine. Under pathologic conditions it is formed in other 1 Permanganate of potash up to gr, i fo.o6) t. i. d. may be of service. Herter suggests the possible value of dioxid of manganese. 2 If dilatation of the stomach, not responding to medical treatment, is the cause, then gastro-enterostomy is indicated. With failure of medical treatrnent and progressive anemia and mental disturbances, Herter suggests appendicos- tomy followed by enteroclysis. I am opposed to shortening or short circuiting the large intestine for this condition. In extreme cases Gant's cecostomy, with irrigation of colon and ileum, might be of service. 20 450 DISEASES OF THE STOMACH AND INTESTINES parts of the digestive tract. In chronic ectasia hydrogen sulphid is at times liberated when putrefactive changes take place. Herter believes the eructation generally occurs from this viscus, so that no symptoms result. He holds that the stagnating stomach contents probably go on to the formation of cystin, and that the Bacillus lactis aerogenes, Bacillus coU, and other bacteria produce hydrogen sulphid therefrom. Senator^ reports a case of auto-intoxication from hydrogen sulphid (hydrothionemia). After an error in diet the patient became ill with gastro-enteric catarrh. On the third day vomiting accompanied with the odor of hydrogen sulphid occurred. The patient became dizzy and went into collapse, without loss of con- sciousness. The eructation of gas continued, and the first urine gave the reaction of hydrogen sulphid. The case recovered. Betz^ and Stefanio and Emminghaus ^ describe cases. Head- ache, dizziness, delirium, mental depression, drowsiness, stupor, and collapse were prominent symptoms. Treatment. — Catarrh of the gastro-intestinal tract, ectasia, and in- testinal putrefaction must receive appropriate treatment as required. ENTEROGENIC CYANOSIS This peculiar type of auto -intoxication was first described by Stokvis.* The patient, aged fifty-eight, suffered from severe enteritis with pronounced cyanosis of the skin and visible mucous membranes, together with a swelling of the terminal phalanges. Spectroscopic examination of the skin and mucous membranes showed a band corresponding to the absorption spectrum of methemoglobin. It was believed that poison substances were formed in the intestine which transformed part of the hemoglobin into methemoglobin. Talma^ reported 3 cases. Van der Bergh® reported 2 cases, one of which was evidently due to sulphemoglobin (from hydrogen sul- phid) in the blood, and in the other the blood contained nitrites. Van der Bergh also reports a case in a child nine years of age, who suffered from marked digestive disturbances with diarrhea. Anuria was marked. Child was very cyanotic and the ends of the fingers were clubbed; abdominal distention marked. Urine contained no albumin, no sugar, but a little indol. No cardiac affection present. Several cases of sulphemoglobinemia have been associated with obstinate constipation, the relief of which has been follov/ed by improvement. Treatment. — This should be directed to the intestinal tract. Proteids should be reduced ; sour milks given ; enteroclysis and the general treatment of intestinal putrefaction. 1 Berlin, klin. Wochenschr., v, p. 254, 1868. 2 Memorabilien, Ix, p. 145, 1864. ^Berlin, klin. Wochenschr., Ix, pp. 477, 491, 1872. * Festsch. f. V. Leyden, 1, p. 597, 1902. ' Tijdschrift voor Geneesk., li, p. 721, 1902. • Deutsch. Archiv. f. klin. Med., xciii, p. 86, 1905; also Berlin, klin. Wochenschr., No. i, p. 7, 1906. meteorism; tympanites 451 METEORISM; TYMPANITES This is defined as an accumulation of gas in the intestines. Flatulence is used to indicate a great formation of gases that are removed by eructations and flatus. Part of the gas thus accumulated is expelled and part is absorbed, and thus the volume of gas in the intestines is regulated. Etiology. — The causes of tympanites are as follows: 1. An increased introduction (ingestion) of gas. 2. The development of excessive gas within the intestines. 3. A diminution or impairment of the eliminative power of the intestines for gases. 1. The increased introduction of gases may be due to the excessive drinking of aerated beverages or the swallowing of air. Aerophagy (air swallowing) usually occurs in hysteric women, and may result from shock or emotional disturbance. It is generally involuntary, due to spasm of the pharynx. The symptoms are distention after food, loss of appetite, frequent noisy eructations, often insomnia or sleeplessness, constipation. Frequently mucous colic or gastroptosis (enteroptosis) coexist. Rapid deglutition' movements precede the eructations. The mucous colic or enteroptosis should be treated ; the hysteria combated; pharyngeal spasm checked by keeping the mouth widelyi open, applying cocain (i per cent.) locally, blisters externally, bella- donna, bromids, or valerian internally; hypnotic suggestion in some cases; strychnin to stimulate the muscular tone of stomach; food; should be concentrated. 2. Formation of Abnormal Quu.ntity of Gas in the Intestines. — ^This: may be due to fermentation of the carbohydrates or to putrefaction of the proteids. An excessive amount of fermentable or putrefactive material or food which cannot be assimilated are factors. Catarrhal conditions influence the activity of the ferment and putrefactive organisms. 3. Diminished Elimination of Gases from the Intestines. — This is due to mechanical obstruction or to a reduction or inhibition (paral- ysis) of the muscular power of the intestinal wall. Among the causes are stenosis, intestinal obstruction, paresis of the intestines in the infectious diseases, such as typhoid fever, pneumonia, cerebrospinal meningitis, peritonitis, etc. In pathologic conditions, where there is circulatory disturbance in the intestinal walls, as in peritonitis, etc., absorption of gases must be interfered with. It is difficult to estimate to what degree this is a factor. Nervous Meteorism. — This is most common in the hysteric, and usually occurs as a diffuse distention of the abdomen (tympanites hystericus), but also as a circumscribed swelling (phantom tumor)* Various factors have been suggested, such as swallowed air^ 452 DISEASES OF THE STOMACH AND INTESTINES insufficiency of the pylorus, allowing passage of air from stomach to bowels; or continuous contraction of the diaphragm (Talma). With narcosis the abdomen becomes flaccid, while with returning consciousness meteorism recurs, and air cannot be detected entering or leaving the tract, hence Talma denies that there is any increase of gas in the intestines. Some attribute the condition to acute general paresis, of sudden onset, passing off rapidly, analogous to other hysteric paralyses. Sjonptoms. — The shape of the abdomen is usually altered, a feeling of tension is almost always experienced. With general meteorism the abdomen is distended quite symmetrically, while with partial distention the affected parts stand out in marked relief. With local distention the coexistence of visible peristalsis, as with stenosis, simplifies the diagnosis. The degree of distention generally corresponds to the amount of gas present; but the weaker the muscles and the more reduced their tone, the greater is disten- tion. An example of this is marked tympanites in peritonitis. When the abdominal muscles are tense sometimes the diaphragm, heart, and lungs are forced upward, and severe dyspnea results, which occasionally may be followed by a fatal issue. In severe cases there is a constant feeling of pressure and a desire to pass wind, while colicky pains are sometimes present. As a rule, no flatus is passed, or in inconsiderable amounts at long intervals. Palpation shows the abdominal walls are very tense. They present an air-cushion resistance. The percussion note is abnormally low and loud, the tympanitic ring is usually lost. With auscultatory percussion a metallic sound is elicited. The liver dulness may be reduced and finally disappear. There are some cases of meteorism, in which the wind is passed almost constantly from the anus with considerable noise. Rosenheim believes, as these gases are odorless, that the air is pumped into the rectum and emitted again as flatus. Prognosis. — If occlusion of the intestines is present, the outlook is serious. Ordinary cases are favorable. Treatment. — This should be directed toward removal of the cause responsible for meteorism, such as peritonitis, typhoid, stenosis, etc. Drinks and foods known to produce flatulence must be prohibited. Avoid carbonated waters, beer, champagne, cider, excessive carbo- hydrates, rich pastry, etc. Intestinal fermentation or intestinal putrefaction, if they cause the meteorism, must he treated after the methods already described. Among the intestinal antiseptics are ichthalbin, ichthoform, formidin, salol, salicylate of soda, benzonaphtol, urotropin, and sodium benzoate, average dose of each, gr. 5 (0.3) t. i. d. after meals. They may be given in shellacked capsules. Bismuth salicylate and bismuth subnitrate, gr. 5 to 10 (0.3-0.6) t. i. d., are of service. INTESTINAL PAIN (INTESTINAL COLIC; ENTERALGIA) 453 Calcined magnesia, lime-water, and charcoal are suggested to absorb the gas. In mild forms of flatulency various carminatives have been employed, such as caraway seed, peppermint, mint, thyme, cinnamon, cloves, anise seed, nutmeg, sassafras, and fennel. These are best given as infusions. Asafetida and the oil of cloves are believed by Brunton to aid absorption of CO2 and H2S. Cathartics and laxatives may be necessary when there is no peritonitis or obstruction. Physostigmin salicylate, gr. joq- to -g-'g (0.0006-0.001), has been recommended in severe cases. Massage, abdominal douches, electricity, and electric enterocl3"sis are of service in cases where there are no anatomic lesions. Friction of the abdomen with spiritous, aromatic, or ethereal substances, such as camphorated oil, turpentine, oil of cajeput, etc., is serviceable. The introduction of a colon-tube may aid the escape of gas. Water enemata of soapsuds, containing spirits of menth. piperit., Zj (4.0), or oil of turpentine, 3j (4.0), are useful. Puncturing the intestines with a trocar is a dangerous procedure. Meteorism in the hysteric occasionally disappears without treatment. Attention should be paid to the nervous condition. Valerian and asafetida are useful by mouth or enema in such cases. Pill asafet., one t. i. d. ; emulsion (milk) asafet., oj to ij (30.0- 60.0), by enema. Zinc valer., gr. 2 (0.125), or ammon. valer., gr. 5 (0.3), t. i. d. Tinct. valer. with tinct. lavend. co., da oij (60.0). Dose, 3j (4.0) in water t. i. d. after food. Iron, arsenic, and strychnin are of tonic value in the nervous cases. Massage, friction, and a tight abdominal band are useful. INTESTINAL PAIN (INTESTINAL COLIC; ENTERALGIA) Intestinal pain can be distinguished as follows: 1. Pain originating from inflammation of the intestinal wall or of its peritoneal coat. 2. Pain of colic. 3. Nervous enteralgia, described under Neuroses. Colic is the painful stimulation of the intestinal ner\^es which is produced by severe tonic contractions of the intestines. G. F. Shiels^ holds that the pain is produced in the peritoneal coat. Kast and Meltzer have demonstrated by a series of experiments that the intestines are sensitive to pain. Etiology. — Organic lesions of the intestines, excess in or improper articles of food, cold drinks, substances causing marked gas formations, fecal accumulation, intestinal worms, foreign bodies, gall-stones, enter- oliths, tainted foods, large quantities of mucus, as in mucous colic, ex- posure to cold, occasionally ulcers, internal strangulation of the bowels, ■stenosis, purgatives, lead- and copper-poisoning may produce colic. 1 American Journal of Surgery, April, 1908. 454 DISEASES OF THE STOMACH AND INTESTINES S3rmptoms. — The pain of colic is peculiar — pinching, boring, or occasionally of a tearing character — it occurs in paroxysms which msLj last a few seconds or be prolonged several hours. It usually appears suddenly and disappears as rapidly. Its intensity may be so severe that fainting and collapse occur. If cohc begins from error in diet, there may be gastric disturb- ances, belching, nausea, and vomiting. Obstinate constipation and • flatulence may be present, or if the cause be from improper food, diarrhea. The pain frequently starts at the umbiUcus and remains localized or radiates in other directions. The face of the patient shows his suffering. Pressure over the abdomen relieves the pain in some, while in others it increases it. There may be straining sensations in the bladder and rectum and occasionally borborygmi can be heard. Peristaltic movements can be seen in thin patients. If accumulated fecal masses and gas are evacuated spontaneously or by injections, the attack rapidly subsides. Spastic contractions of the intestines may be encountered. If they involve a large part of the bowels, as in lead-colic, the abdomen appears trough shaped. In stercoral and wind-colic, it is usually tympanitic. Diagnosis. — In enteralgia due tp anatomic lesions of the intes- tines the pain is increased by pressure. There is frequently diarrhea and the stools contain blood, mucus, and, rarely, pus. With rheuriiatism of the abdominal muscles the pain is superficial and not within the abdominal cavity. It often changes its location. Pressure increases the pain, while rest and antirheumatic medicines diminish it. With peritonitis there are fever, tenderness on pressure, muscular rigidity, meteorism, absence of abdominal respiration, increase of polynuclears, and leukocytosis. Hyperesthesia of the abdominal wall usually occurs in hysteria and neurasthenia. The pains are superficial, lying chiefly in the skin. The faradic current often removes the pain. Biliary and renal colic are recognized by location of the pain and characteristic symptoms. Neuralgic pains are superficial and radiate. Prognosis. — These cases end in recover}^, with rare exceptions. Treatment. — For the relief of pain, morphin by hypodermic, gr. i to I (0.008-0.016), or codein, same or even double dose, or tincture of opium, TTLx (0.59 cc), heat to the abdomen, and hot saline enema or enteroclysis at 115° F. Squibb's mixture is useful. Later, the bowels should be thoroughly evacuated by enemata^ which may contain h pint (250 cc.) of olive oil and oj (4.0) of spirits of turpentine, and a cathartic — castor oil, .5iss (45.0), or calomel, gr. 5 (0.3) — be given, followed by a saline cathartic. The cause of the colic should be corrected, as should any errors in diet. Fluid diet should be employed. 1 The simple soapsuds enema, i quart (liter). VISCERAIv ARTERIOSCLEROSIS 455 VISCERAL ARTERIOSCLEROSIS Harlow Brooks^ calls to our attention that the presence of dimin- ished visceral function, with occasional and otherwise unaccountable elevations of the blood-pressure, should, particularly in connection with possible etiologic factors, lead to a suspicion of some localized, if not general, area of arterial disease. When associated with pain of peculiar anginal character, location in some special organ may be within the range of possibility. I feel quite certain that careful observ^ation of cases of obscure abdominal pain, paroxvsmal in character and associated with elevation of the blood-pressure, will eventually make it possible to diagnose these generally unrecog- ' nized types of arterial disease while in a stage when something may still be done for their alleviation or for the prevention of their further progress. ^ Some of these patients give a history of nervousness, gastric catarrh, and pain; vomiting and even hematemesis may occur. iVIeteorism and constipation are not uncommon. Pain over the pancreas and intestinal functional disturbances have been noted. When such symptoms occur in a patient with well-marked arterio- sclerosis, and are relieved by iodids and nitrates, one is justified in diagnosing abdominal arteriosclerosis. Etiology. — Alcohol, nephritis, syphilis, old age, tuberculosis, tobacco excesses, and toxemia are the chief causes. Perutz- shows we must differentiate between angina pectoris and angina abdominis due to arteriosclerosis: 1 have recently seen several cases who have complained of pain in the epigastrium, belching, constipation, and headache. The gastric analysis showed deficient hydrochloric acid secretion and the pulse the characteristics of arteriosclerosis. Treatment afforded no relief until the nitrites were administered. " Gilbride^ reports a number of cases with symptoms of pain in the epigastric or umbilical regions, rarely in the lower abdomen. This is increased by exertion and in some cases during digestion. Weakness, loss of weight, abdominal distention, and belching are present. Bowels are con- stipated or there is constipation alternating with diarrhea, or occa- sionally normal movements. There may be vertigo or disturbances of vision. The gastric analysis showed in most cases deficiency of hydrochloric acid; in one it was nearly absent and in one normal. Stomach motiHty normal or increased. Lactic acid and Boas- Oppler bacilli were absent. Cancer had been suspected. The radial pulse and blood-pressure may show arteriosclerosis. In some cases there are no evidences of this, but there are two symptoms ^ American Journal of the Medical Sciences. 2 Miinch. med. Wochenschr., !\Jay 2S and June 4, 1907. 3 Gast ro-intestinal Disturbances Due to Arteriosclerosis, Journal Amer. Med. Assoc, March 20, 1909. 456 DISEASES OF THE STOMACH AND INTESTINES significant of abdominal arteriosclerosis — tenderness of the abdominal aorta with epigastric pulsation. Some patients may have attacks of angina pectoris with pain referred to the epigastrium. The age of the patient is usually over forty." Ortner^ has contributed to the subject, demonstrating the disturbances of the motor, secretory, and absorptive functions of the intestines due to arteriosclerosis; and Akin^ has reported several cases. Nitrites afford the most relief, with the addition of potassium or sodium iodid. ANOMALIES IN THE POSITION AND FORM OF THE INTESTINES ; ENTEROPTOSIS Various anomalies in the position and form of the intestines occur ; in some cases congenital, and in others acquired, of which Koch and Curshman have made a study. They may be congenital in some cases, acquired through copros- tasis, the weight of a tumor, or the formation of adhesions, in the majority of cases the colon being affected. Various angulations of the sigmoid, especially due to adhesions, are described by J. P. Tuttle. Inflation with air and the use of bismuth injections with the x-rays aid diagnosis. Hirschsprung's disease, or congenital primary dilatation and hypertrophy of the colon, is found at birth. Dyspeptic symptoms, obstinate constipation, and colicky pains with great distention are present. By insertion of a finger or catheter into the rectum a movement will occur with relief of the distention. Enterocl^^sis, electricity, etc. , are of value. Idiopathic dilatation of the colon is a rare event, and enteroptosis, the most common displacement, is described under Gastroptosis. Idiopathic dilatation of the colon, in which there is no mechan- ical obstruction to the feces, mav be congenital, develop early or later after birth, or be acquired in adult life. Ner\^ous derange- ments, habitual constipation, rickets, or chronic colitis may be fac- tors. The colon and especially the sigmoid are greatly distended, so that the protrusion of the abdomen may justify the term " bal- loon man." Constipation or irregularity of the bowels, gaseous dis- tention, intestinal putrefaction, shortness of breath, etc., occur. Enteroclysis, regulation of the bowels, diet, and treatment of indi- canuria are indicated. Abdominal support is of service. Rarely, operative procedure is required. INTESTINAL SAND This material is gritty, contains organic matter, inorganic salts, especially calcium phosphate and carbonate, but no cholesterin, which distinguishes it from biliary sand. 1 Volkmann, Samml. klin. Vortr., No. 347. 2 Jour. Amer. Med. Assoc, June 5, 1909. INTESTINAL SAND 457 It has been considered by some as a manifestation of the arthritic diathesis. It is usually associated with mucous colic or possibly constipation. It occurs generally in women between thirty and forty years of age. The associated condition must be treated. Sodium bicarbonate and bismuth salicylate have been recommended. False intestinal sand, such as the residue of vegetable food, especially from pears, must not be mistaken for true sand. Symp- toms are absent. CHAPTER XXII CONSTIPATION AND DIARRHEA CONSTIPATION {Synonyms. — Obstipatio Alvi; Constipatio Alvi; Atony of the Bowel; Habitual Constipation.) HeaIvThy persons usually have one bowel movement daily, gen- erally about the same hour- Some normally have two actions a day, while others empty the bowels every other or every second day, and yet are in perfect health. Constipation is defined as a condition in which the feces are not passed sufficiently often. Another form is that in which defecation occurs daily, but the movements are insufficient in quantity. A stagnation of fecal matter may thus occur. The quantity of feces is somewhat variable, from loo to 150 gm., the average, even up to 250 gm., being greater after a vegetable diet and less after meats. Considerable of the evacuation is made up 6i micro-organisms, of which Herter^ has estimated the daily number as 126,000,000,000, which explains the fact that patients who eat little may pass con- siderable material. Constipation may be acute or chronic. The acute type is due to complete obstruction of the intestinal tract or to dynamic ileus (intestinal paresis). The chronic type is extremely common. Henry Illoway and Samuel Gant have written excellent works on this subject. My classification is slightly modified from their books. Etiology. — All possible factors must be carefully investigated. 1. Diseases of the stomach, such as hyperchlorhydria, ulcer, cancer, dilatation, simple atony, catarrhal conditions, and achylia gastrica may cause constipation. 2. Obstruction of the bowel by tumors of the intestine or tumors pressing on the bowel from some adjacent organ ; by stricture within the intestine; by external stricture, as by peritonitic adhesions; by chronic intussusception. 3. Catarrh of the small intestine alone; in some cases catarrh of the large intestine ; mucous colic ; atrophy after catarrh ; ulcers of the small intestine are occasionally attended by constipation; dysenteric ulcers at times produce constipation, though ulcers of the large intestine usually cause diarrhea. 4. Voluntary abstention from stool on account of the pain it pro- duces, by reason of disease of the rectum, such as from piles, fissure, ^ Bacterial Infections of the Digestive Tract. 458 CONSTIPATION AND DIARRHEA 459 or ulcer. Increased contraction of the sphincter ani also occurs from irritation and interferes with bowel action. 5. Obstruction to the entrance of bile into the intestine or deficiency of bile. 6. Diseases of the heart, lungs, liver, and kidneys. Intestinal hyperemia and congestion of the portal system are factors in these cases in retarding peristalsis, as in cirrhosis of the liver. 7. Disease of the pancreas. 8. Diabetes, anemia, and chlorosis. 9. In many diseases of the brain, spinal cord, and of the nervous system constipation is present. Among such are chronic insanity, diphtheritic paralysis, tabes, brain tumors, cerebrospinal meningitis, hemorrhage of the brain, chronic hydrocephalus, myelitis, neuroses, and psychoses. 10. Acute febrile conditions are usually accompanied by constipa- tion, as pneumonia, etc. This generally excludes those with special intestinal lesions. We must remember that constipation occurs in some cases of typhoid, and even of dysentery. 1 1 . Chronic constipation from foreign bodies. 12. Malformations, such as abnormally developed colon; undue size or length of the sigmoid flexure ; diverticula of the large intes- tine; a diaphragm partially closing the large intestine. 13. Defective development or essential primary atrophy of the colon. 14. Enter optosis; angulations of the sigmoid flexure due to adhesions; prolapse of sigmoid into rectum from long mesentery — in effect, slight intussusception. 15. Atrophy of the intestinal musculature following catarrh or fatty degeneration, as in consumption or in alcoholics. 16. Hypertrophy of Houston's valves. 17. Loss of power in the abdominal muscles may be a factor in some cases, as in the emaciated, with multiparous women with diastasis of the recti, etc. 18. Chronic constipation from impaired physiologic function. This type is due to disturbance of the motor function of the intestines, and is strictly classified under motor neuroses, under which we have: (a) Constipation due to retarded intestinal peristalsis (atony or relaxation of the bowel). (6) Spastic constipation, perverted action, or enterospasm. The constipation is due to a spasmodic contraction of a portion of the intestine. (c) Spasm of the sphincter is included under this type. Constipation Due to Disturbances of the Motor Function. — Habitual constipation due to impairment of the physiologic function {i. e., caused by motor disturbances) constitutes an important class of cases. It should be strictly classified under motor neuroses. There are the two types mentioned above: the atonic and the spastic forms of constipation. 460 DISEASES OF THE STOMACH AND INTESTINES Atonic Constipation. — Constipation due to atony (literally, relaxa- tion) of the bowels constitutes the majority of cases. Predisposing Causes. — The character and quantity of food and the amount of physical exercise influence bowel evacuation. Boas has laid stress upon the importance of the type of nourishment and its influence in the production of constipation (alimentary constipation). Albuminous diet consisting of meat and eggs leaves little residue, and eventually tends to constipate; while with vegetable diet there is more residue and the fermentation products excite peristalsis. A patient may diet by avoiding vegetables, butter, and fat, and thus constipation result which may become chronic. Repeated neglect of the call of nature is a frequent cause, such as in the case of young girls and children while at school, or among women at social gatherings, etc. Interruption of the habit of regularity, as on a railroad journey, or an attack of diarrhea with subsequent constipation, or of acute fever, may lead to habitual constipation. The same is true of mental conditions, such as depressing emotions. Prolonged exercise, such as long marches, has produced chronic constipation. Constipation is more frequently found among the wealthy than among the working class. The mode of living, sedentary life, etc., have a bearing. Worry and mental strain have an influence, and it occurs among neurasthenics and hypochondriacs. Habitual constipation is found in those engaged in active exercise and who are of strong constitution. In such persons the cause of this perversion of motor function is unknown, but it seems inherent to the patients that the bowels respond slowly to stimuli. In some cases there seems to be hereditary or congenital diminution of intes- tinal peristalsis (constipation). Riegel observed cases in which at autopsy the musculature of the large intestine was abnormally thin and was probably congenital. In some of these cases the skeletal muscles were strong. Nothnagel described similar cases in which the general muscular development was poor. These rare conditions cannot be recognized intra vitam. Enteroptosis is given as a cause of chronic constipation on account of the intestinal angulation which occurs. This is true in some cases. The general atony^ with enteroptosis is the chief factor. The musculature of the stomach, intestines, and also the abdominal muscles are relaxed, which have a bearing on the production of constipation. The abuse of cathartics, and repeated distention of the bowel from large enemata, may produce constipation. Spastic Constipation. — Spasmodic constipation of the bowels, or enterospasm, is produced by a perversion of the motor function of the intestine, taking the form of a spasmodic contraction of a portion of the intestines, which may involve both the circular and longitudinal muscles. ^ Atonia Gastrica, Rose and Kemp. CONSTIPATION AND DIARRHEA 46 1 This Spastic condition may be of variable duration and involve different segments of the intestines. Fleiner holds that the con- tracted portion retains its contents, while others believe that it is nearly occluded by the spasm, thus creating an obstacle to the passage of the intestinal contents. Diffuse enterospasm involving the small intestine occurs in spinal meningitis, in diseases of the pons and medulla, and in chronic lead -poisoning. In these cases the abdomen is retracted like a trough. Local or circumscribed enterospasm is more frequent, and it generally affects a portion of the large intestine. The abdomen shows no abnormality on inspection. Spastic constipation is more frequently met with in nervous persons, neurasthenics, the hysteric, and in those debilitated by long-continued disease. The constipation is quite obstinate, lasting for several days. The evacuation is somewhat painful and consists of small balls (goat feces) or pencil-shaped fecal material. There are spasmodic pains in the left lower abdomen or in the umbilical region which are relieved by the passages. Spasm of the Sphincter (Proctospasmus). — This condition really belongs to spastic constipation. There is painful spasmodic con- traction of the sphincter. I have seen cases, however, in which pain was not marked, but spasm occurred when defecation was attempted; in effect, spasmodic stricture was present. Such cases may be a direct factor in the production of constipation. Many cases of sphincteric spasm are secondary to fissure or ulcer of the rectum, or are reflex when there are inflammatory conditions in the neighboring organs, such as the uterus, bladder, etc. Some cases occur as a primary nervous affection and are chiefly met with in those with a nervous taint or disease of the spinal cord. Rectal examination is often extremely painful. In some cases there is simply reflex spasm on examination, and the sphincter is found to be extremely tight and evidently hypertrophied from frequent contraction. - It is important to consider the possibility of the last type in connection with chronic constipation. Symptoms. — In many cases constipation causes no subjective symptoms. Some have a stool every second or third day or even once a week. There is a classical case who had an annual movement. Nevertheless, chronic constipation should not be made light of. Some patients on the appearance of constipation immediately suffer from subjective symptoms, which may become at times quite severe. Among milder symptoms are sensations of fulness, tension, and discomfort in the abdomen; at times they are referred to the stomach; loss of appetite, occasionally belching, nausea, pyrosis, and a disagreeable taste in the mouth. Coated tongue and headache are often present. Colicky pains and distention may occur. 462 DISEASES OF THE STOMACH AND INTESTINES These symptoms disappear after thorough evacuation of the bowels. On inspection and palpation considerable fecal accumulation can be found in the intestines, especially in the colon. Some patients suffer from severe headache, dizziness, sleeplessness, despondency, palpitation, tachycardia, or irregular pulse. Such symptoms I believe due to auto-intoxication from the intestinal tract. Motor insufficiency, as in constipation, favors stagnation and putrefactive changes. Duprey^ reports extreme cases in whicTi the patients became un- conscious, but recovered after free bowel evacuation. One death also occurred. In most of my patients suffering from chronic constipation, with the symptoms just described, especially with nervous manifestations, marked indicanuria was present. Herter^ states that most children and many adults may fail to develop indicanuria with constipation, yet there are others in whom it is marked, and that a satisfactory explanation is not possible. In my report of 13 cases of dementia paralytica before the American Medicopsychologic Association^ marked constipation was noted in all the cases, and all suffered with considerable temperature. Rectal irrigation lowered the temperature in 3 cases, and under general treatment for the gastro-intestinal tract it was lowered in 8 more. Convulsions diminished in 5 cases. The bowels were freely opened. Bouchard's theory that no intoxication from the intestinal tract can take place when the feces are solid, I believe untenable. Dunin has shown that constipation may be the result of nervous conditions. There are many in which no nervous factor can be discovered, and others in whom constipation and intestinal auto-intoxication are factors in the production of nervous symptoms. Termination. — The bowels may act spontaneously, hard masses of fecal matter being passed covered with a thin layer of mucus. Feces are often passed in small balls or in rod shape. With the atonic type of constipation relief is usually felt after defecation; while with the spastic type movement is accomplished with great effort, and there is a feeling as if there were still material in the rectum. In some cases the constipation terminates in an attack of diarrhea due to hyperemia and the secretion of fluid from irritation of the mucosa by the hardened feces. In others, purgatives or enemata may be required, or removal of scybalge from the rectum by the fingers. ^Lancet, 1902, p. 1832. 2 Bacterial Infections of the Digestive Tract, p. 263. ^ Proceedings of the Sixty-first Annual Meeting, April, 1903. Some observa- tions on the Relations of the Gastro-intestinal Tract to Nervous and Mental Diseases. CONSTIPATION AND DIARRHEA 463 Slight catarrh may occur or, rarely, stercoral ulcers, local peri- tonitis, or even perforation and general peritonitis. Constipation has been a factor in the production of typhlitis, diverticulitis, catarrh of the cecum with secondary catarrhal appendicitis, volvulus, and subacute or acute intestinal obstruction. Fecal Colic. — ^When large masses of fecal matter accumulate, colic may occur. The patient is seized with violent colicky pains which may cause a fainting spell. The abdomen is distended and tender. Passage of flatus brings temporary relief. The symptoms do not disappear until thorough evacuation of the fecal accumulation takes place. Fecal colic may occur, with daily evacuation of the bowels. The detection of fecal accumulation by palpation is of chief importance. In obstinate cases of constipation cathartics may fail to produce movements and the patient go into marked collapse and vomit profusely, with symptoms resembling intestinal obstruction. Rectal irrigations or oil injections may relieve the condition. Rarely, in the insane, old, or weak total paralysis of the colon may take place and the patient die with the symptoms of obstruc- tion. In cases of fecal accumulation it is always safer to employ injections and irrigations before resorting to active catharsis. Fecal Tumors. — ^They occur most frequently in the cecum, sigmoid flexure, rectum, and hepatic and splenic flexures. They may cause dislocation of the transverse colon, and the mass be felt a short distance above the symphysis. In most cases the tumor is not of very firm consistency, is movable, and pits on pressure. On the other hand, it may be nodular, hard, or angular. In some cases the bowels may move every day, there evidently being a free central passage. Gersuny's Adhesion Symptom. — If the abdominal wall over the tumor is gradually depressed with the finger-tips, the pressure gradu- ally diminished, and the fingers slowly withdrawn, one can feel the mucous coat of the intestines loosening itself from the feces forming the tumor {i. e., the wall of the bowel separates from the tumor when palpating pressure is relaxed). If under intestinal irrigations, etc., the tumor diminishes in size, it is evidently fecal. Anesthesia may rarely be required for examina- tion. Some of these fecal tumors have developed into large size — over 4 pounds or more — and after the colon is dilated, stercoral ulcers, local or general peritonitis, or intestinal obstruction from kinking, compression, torsion, or internal occlusion may result. Hemorrhoids are a complication. They are described in a special section. I have referred to various nervous symptoms that are dependent on constipation. Leube describes intestinal vertigo, which he believes reflex and 464 DISEASES OF THE STOMACH AND INTESTINES due to pressure on the hemorrhoidal plexuses of the sympathetic, since the palpating finger in the rectum also produced it. Senator imputed dizziness and vertigo to absorption of poisonous gases, such as sulphuretted hydrogen; while Nothnagel assumes that nervous symptoms are due to absorption of ptomains, thus causing auto-intoxication. Auto-intoxication I believe to be the correct explanation. In persons of a neuropathic disposition auto-intoxication from chronic constipation is undoubtedly a contributory factor in the production of ner^-ous disease, especially melancholia. Fecal Fever. — This is generally due to some complication, such as inflammation, local peritonitis, or stercoral ulcer. With infants and young children fever may be caused by fecal accumulation. I have referred to the cases of dementia parahiiica with temperature, with disappearance of the latter after bowel action. Clark holds that chlorosis is the result of toxins absorbed from coprostasis. Hyperchlorhydria is generally present and this would have an influence on the bowels. Though diarrhea with marked multiplication of the Bacillus aerogenes capsulatus often occurs in common with severe primary anemia, and in some instances the cases present the blood-picture and clinical characteristics of pernicious anemia, yet Herter shows that advanced infection with the gas bacillus can occur^ without any diarrhea, in fact, with obstinate constipation. Stasis is favorable to putrefaction. The possibility, therefore, of stasis (constipation) favoring in some cases the development of poisons having a hemo- h^tic action on the blood should be considered. Diagnosis. — The irregularity of the movements and their character, occurring in small balls, pencil shape, or in small fragments, and abdominal palpation disclosing fecal masses are diagnostic- One must remember that daily incomplete evacuations may occur. Fecal masses are found most frequently in the caput coli, sigmoid, and the rectum. It is always well to examine the latter. All possible causes of constipation must be considered. If it is suspected to be due to anomahes of the functions of the stomach, gastric analysis must be performed and treatment directed toward the gastric con- dition. Diseases of the heart, lung, Hver, and kidneys must be treated if present. Rectal examination may disclose hypertrophy of Houston's valves; in such event, their division by the application of Gant's valve clamps is indicated. Prolapse of the sigmoid may be determined by inspection with the sigmoidoscope. Gant's suspensory operation is then indicated. Splanchnoptosis if present must be treated and Rose's belt applied. If none of these causes can be determined, the constipation must be pureh' functional (habitual), either of the atonic or spastic type. 1 Bacterial Infections of the Digestive Tract, p. 207. CONSTIPATION AND DIARRHEA 465 With atony of the bowels there are sUght bloating, evacuation of hard fecal matter, often in balls covered with a thin layer of mucus, at times dizziness and nervous symptoms. Severe pains are rare. With enterospasm there are uneasiness and pain at the time of evacuation or just preceding it, and at times spells of faintness. The fecal matter is not so hard and is evacuated after considerable straining in narrow tape-like or pencil-shaped pieces. There is no feeling of complete relief after evacuation, but as if more were present. The abdomen may at times be sunken and retracted and the intestinal coils can sometimes be palpated. Prognosis. — This is favorable in the majority of cases as regards life, though occasionally incurable lesions, such as diverticulitis, ulceration, or even peritonitis and death may result. These compli- cations are comparatively rare. The prognosis as to cure depends on the cause of the constipation. In the functional cases of halDitual constipation cures result, but many cases require more or less care for the balance of their lives. Treatment. — General Methods. — The cause of the constipation should be treated. Persons who for years have habitually had a movement every second or third day and are in good health should be let alone. Prophylaxis. — Never place a patient on a restricted diet for too long a period, excluding vegetables, fruits, starchy foods, and fats which would dispose to constipation. Abuse of cathartics should be avoided. A hygienic method of living, proper out-of-door life and exercise, diminution of strain and worry are necessary. As few purgatives as possible should be employed. Training of the Patient. — One should allay the patient's anxiety. He should be told not to worry if the bowels fail to act for a day or two. Meanwhile, rational methods should be undertaken by the physician to produce the desired result. Trousseau first advocated teaching regularity. The patient should be taught to endeavor to have an evacuation at a regular time every day, preferably half an hour after breakfast. He should go to the closet and try to have a passage, but should not exert himself for over five minutes. It is an excellent procedure to aid the return to the habit by insertion of a small gluten or glycerin suppository or, preferably, the injection of I to 2 ounces (30.0-60.0) of olive oil with a soft-rubber hand syringe. This is better than waiting twenty-four hours, as the desire is often thus stimulated. Regular habits could thus often be cultivated and the small injection then stopped. Diet. — The main object is the ingestion of foods which increase intestinal peristalsis and the avoidance of constipating material. A glass of cold water or, in some cases, of hot water should be taken on rising. Water should be taken on the fasting stomach and a moderate amount — 5viij (250 cc.) at least — of fluid at meals. 30 466 DISEASES OF THE STOMACH AND INTESTINES Total abstinence from liquid at meals tends to constipate. The following are of value: buttermilk, cider, sour milks, fermented milk, such as lactone-milk, kumyss, matzoon, bacillac, carbonated waters, raw fruits, such as grapes, oranges, grape-fruit, apples, prunes, pears, peaches, plums, mandarins, gooseberries, currents, straw- berries, raspberries, blackberries; cooked fruits, honey, lemonade, vegetables rich in cellulose, cabbage, cucumbers, spinach, green peas, cauliflower, green salads, syrup, sugar, salmon, sardines, herring, rye bread, Graham bread, brown bread, pumpernickel; fatty and highly seasoned foods, plenty of butter, cream. Excess of potatoes or rice constipate. Oatmeal is often of value. ]\Iilk is constipating with some and purgative with others. Whortleberries are constipating. Red wines, tea^ chocolate, and cocoa should be avoided. Beer and champagne are recommended by some. Chicken and red meats are given in moderation. We may say the diet should be mixed, with a preponderance of vegetable food. Some patients, of course, have idiosyncrasies to certain foods, and one would not give a patient with a deUcate stomach cabbage, cider, and brown bread. If the intestines are already overburdened with too much ballast and excess of cellulose has been given, such articles must be restricted. The internal administration of olive oil, oj to ij (30.0-60.0) or more, has often an excellent effect; to be given once or twice daily. If fermentative or putrefactive processes are present, they must receive attention. In very obese patients one would not give excessivel}^ fattening food. Often a few prunes with the morning glass of water and fruit for breakfast are sen.aceable. The administration of a raw apple thoroughly masticated at 9 p. m., and an hour later a large glass of Vichy, as suggested by Lewis K. Neff, I have often found valuable, a morning movement resulting. Physical Methods. — These are useful to strengthen the bowel and promote better action or to directly stimulate peristalsis. Alassage. — This is of use in the atonic cases, but not as much so in spastic constipation. It should, preferably, be administered by an expert and the treatment carried out for many months. Abdominal massage should be carried out in the course of the colon by short tapping motions (vibratory), or by kneading and rubbing. It is preferable to massage from the caput coli to the sigmoid. The small intestine should also be manipulated as well as the abdominal muscles. Illoway^ recommends massage for five to fifteen minutes in adults and three to five minutes for children, at least every other day for a period of six weeks, and then, if there is improvement, at longer intervals, but for a long period of time. It should be given preferably early in the morning in the fasting condition. ^ Constipation in Adults and Children. CONSTIPATION AND DIARRHEA 467 Automassage. — The patient sitting upright with the right hand should stroke the abdomen from the caput coU to the hepatic flexure, and then along che transverse colon. With the left hand he can then massage down the descending colon. Circular stroking movements should then be made over the median abdominal region. I often have the patient follow this out while endeavoring to have the morning defecation. Seances should last about five to ten minutes. Cannon-ball Massage. — A 3- to 5-pound cannon-ball rolled over the abdomen in the course of the colon and small intestine spir- ally is of value. The patient can employ this in the dorsal position. The hollow wooden cannon-ball with a screw cap, arranged so that shot can be placed therein, and thus different weights employed with the same ball, is an excellent instrument (Fig. 200). It is arranged with a handle and frame so that it can be more easily manipulated Fig. 200. — Cannon-ball with screw cap. Fig. 201. — Cannon-ball with handle. (Fig. 201). One should begin with a weight of 2 pounds and increase it gradually to 5 pounds. Vibratory Massage. — This is of great value. Special vibration should be given over the sigmoid flexure. The Vedee can be used alone or with electricity. Seances should last about ten to fifteen minutes in the course of the colon and over the small intestine. Hot and Cold Massage Electric Roller. — This instrument has been described and can be employed for the atonic cases. Gymnastic Exercises. — Exercises which bring the abdominal muscles into play are of value, such as gymnastics on the horizontal bar, horseback riding, hill climbing, skating, rowing, bicycling, golf, tennis, boxing, fencing. Overexertion and too abundant sweating should be avoided. Flexion and extension of the body and lateral rotation while in the sitting posture; bending downward and then 468 DISEASES OF THE STOMACH AND IXTESTIXES Upward in the standing position with the knees held stiff; Swedish movements and treatment by the Zander methods are all of value. Electricity. — Percutaneous electricity, especially faradization over the abdomen, is useful as an adjunct. The intrarectal method (one electrode in the rectum and the other over the abdomen) is recom- mended, especially galvanization. The author's method with recurrent electric irrigation is practical. With a glass Y attachment and two fountain syringes, alternate hot and cold electric douches can be employed for the atonic condition. I have used both the faradic and galvanic current. In obstinate cases of high impaction I have found hot normal saHne douches at 120° F. with the faradic current most efficacious, duration fifteen to thirty minutes. Kussmaul has suggested one electrode in the stomach and the other in the rectum. Electricitv is indicated in the atonic cases. Static electricity is also recommended. Doumer^ has employed it in the form of sparks, especially in the left iUac fossa. Hydrotherapy. — Frictions, cold douches, the alternating cold and w'arm fan douches, Scotch douches, short cold sitz-baths (five minutes at 12° C), the wet binder (Neptune's girdle) applied over night, and the Priessnitz compress are all recommended. Hydrotherapy must needs be conducted at a sanatorium. For practical purposes the sitz-bath and wet abdominal compress suffice the general practitioner. Injections; Enteroclysis. — Recurrent enteroclysis with hot nor- mal sahne solution at 110° to 120° F. for fifteen minutes three times a week, alone or combined with electricity (rectal method) or with the alternating cold douche at 60° F., may prove of ser^'ice in the Yery obstinate cases. Enteroclvsis with flaxseed tea has also proved A'aluable. The soapsuds and water enema alone — Oj to i^ quarts (500-1500 cc.) — or with olive oil, oviij (250 cc), or castor oil, oj to ij (30.0-60.0), included, or normal salt solution alone, may be required, depending on the conditions. Often a small enema of normal saline or soapsuds and water of Oj (500 cc), if given with the patient in the knee-elbow position, is more efficacious than the larger injections. The water injections may be employed at the same hour daily for a considerable time. The large injections, as recommended by some, overdistend the already atonic intestines. The Sims position is excellent for the injection. Klemperer recommends the injection into the bowel of small quantities of water at bedtime — only \ pint (250 cc.) — and the patient is told to retain the fluid. It is soon absorbed and evacuation occurs 1 Annales d'Electro-Biologie, 1898, p. 722. 2 Therapie der Gegenwart, 1899, p. 48. CONSTIPATION AND DIARRHEA 469 the following morning. These injections are given every night for three weeks, and then every other night. Kussmaul and Fleiner employ an injection of sweet oil into the rectum at bedtime, which is to be retained. I believe it advisable to start with a small quantity, only oiv to vj (125.0-200.0), heated to the temperature of the body and slowly injected through a colon- tube from a fountain syringe. The patient should retain the oil as long as possible (over night if he can). Gradually increase the quan- tity to oviij to Oj (250-500 cc), and in obstinate cases nearly to i quart (liter). As a rule, evacuation follows the next morning. I give the in- jection every night for a week, then every other night for several weeks, then twice a week, and, finally, once a week. The treatment should cover several months. This method is recommended especi- ally for the spastic type of constipation, but I have found it of value in other cases. Olive oil, oj to ij (30.0-60.0), by mouth once to three times a day is a valuable adjunct. Cottonseed oil can be substituted by enema. Glycerin Injections. — Glycerin, oj to ij (4.0-8.0), dissolved in Siij (95.0) of water and injected into the rectum is of service in some cases, or given as a suppository. It is somewhat irritating. Flatau^ inserts or insufflates into the rectum gr. 15 to 45 (1.0-3.0) of boracic acid powder. Bowel action results one-half to three hours later. Orthopedics. — I have found Rose's belt of value in chronic consti- pation, even if no ptosis is present. It lends strength to the ab- dominal muscles and so aids evacuation. Medication. — In many cases of constipation mild laxatives must be employed, sometimes only temporarily. More powerful cathartics are often required. In constipation of the spastic form, and in the atonic type with fecal impaction, belladonna is of great value. It should be given preferably as the tincture, in large doses, TTLx to xv (0.592-0.888 cc), and pushed three or four times a day, so that physiologic symptoms are apparent. In constipation due to atony, strychnin, gr. io to 3V (0.00108-0.002 1) t. i. d., or tincture of nux vomica in 5- to lo-drop doses are of value, even if no laxatives are given. They are often combined with a laxative. Among the milder laxatives are fluidextract of cascara sagrada and the aromatic fluidextract of cascara, of which the dose is 5 j to ij (4.0-8.0); extract of cascara, gr. i to 5 (0.065-0.324); laxophen, a solution of phenolphthalein, oj to iv (4.0-16.0); phenolphthalein (purgen),- gr. i to 5 (0.065-0.324) to gr. 15 (i.o); phenolax (i to 3 wafers); purgatin, gr. 15 to 30 (1.0-2.0), which is contraindicated in renal disease. 1 Berlin, klin. Wochensclir., 1891, p. 231. 2 Purgen tablets (Bayer), each tablet contains gr. \\ (o.i) of phenolphthalein; each phenolax wafer contains gr. 1 of the same. 470 DISEASES OF THE STOMACH AND INTESTINES Ad. Schmidt^ claims that the internal administration of agar-agar, cutting up the straws into small fragments and administering as much as 25.0 gm. a day, aids in softening the feces and also evacuation. He adds to it 25 per cent, of an aqueous extract of cascara sagrada. Schmidt recommends this combination, which is dispensed as "Regu- lin," as being of value in chronic constipation. Dose, i teaspoonful (4.0) to a tablespoonful (16.0) or more, mixed with stewed apples or mashed potatoes. It can be secured as tablets. Syrup of tamarinds, 5j (4-o), or a sauce of tamarinds; syrup of figs, 5 j to ij (4.0-8.0) ; compound licorice powder, 3j to iv (4.0-16.0). This last gripes some patients. Olive oil by mouth, oj to ij (30.0- 60.0), several times a day is valuable. Aloes does not lose its effect even when employed for a long time, and painless defecation results. It may be used alone or in com- bination. If hemorrhoids are present I do not advise it. Rhubarb is an excellent drug. Pil. aloes, dose, i to 2 pills at night. Tinct. rhei aromatici, 5ss to j (2.0-4.0). Tinct. rhei, oj to ij (4.0-8.0). The following are of value: I^. Tinct. nuqs vomicae oiss 6 Fl. ext. cascara oss 16 Pulv. ipecac gf- iv Pulv. rhei gr. xv i Sod. bicarb oiss 6 Aq. menth. piperit q. s. giv 125 Sig. — Shake. One to two teaspoonfuls (4.0-8.0) t. i. d. in water after meals as a mild laxative. 26 — M. B. Pulv. rhei 1 Magnes. usta V aa 3iv (16.0). — M. Sod. bicarb. J Sig. — One-half teaspoonful (2.0) t. i. d. after meals. ^. Pulv. aloes gr. xx Ext. belladonna "I aa gr. v Ext. nucis vomicae J "• Ft. pil. No. XX. Sig. — One to two pills at night. 3 3-— M. Podophyllin combinations are quite useful. I^. Podophyllin Ext. physostigmatis \ aa gr. v Ext. nucis vomicae Ft. pil. No. XXX. Sig. — One pill at night and in the morning if required. 3-— M. ^- P!|- colocynthi corap. j - - _ ^ (^^g ^ Pil. rhei comp. j o j v ^/ Ext. hyoscyam gr. ss (0.032). — M. One pill. Sig. — One pill before dinner. 1 Miinchener med. Wochenschr., No. 41, 1903. CONSTIPATION AND DIARRHEA 47 1 I^- Aloin gr. ^ (0.013) Strychnin sulph S^- is (0.00108) Ext. belladonna gr. i (0.008) Pulv. ipecac gr- tV (0.004). — M. One pill. Sig. — One to two pills at bedtime. I^. Resinse podophyllin gr. i (o.oi i) Pil. rhei comp gr. iiss (0.162) Ext. hyoscyam gr. i (0.032). — M. One pill. Sig. — One to two pills at night. I^. Ext. colocynth comp gr. j (0.065) Ext. jalap gr. ^ (0.032) Resin, podophyllin .gr. \ (0.016) Leptandra gr. | (0.32) Ext. hyoscyami I ..,, ^^ Ext. taraxaci | ^^gr.^ (0.016) 01. nienth. pepmt q. s. — M. One pill. Sig. — One to two pills at bedtime. Jalap^ and colocynth belong to the stronger remedies, and I only- employ them temporarily to empty the bowels. The same is true of castor oil and calomel. Hunyadi, Friederickshall, the Homburg Waters, Carlsbad salts, Pluto, Apenta, Rubinat, etc., may be necessary for a brief period, but should not be used for any length of time. In anemic patients with constipation the following pills are of service: I^. Pill (Blaud iron) gr. v (0.324) Aloin gr. 3jV (0.032).— M. One pill. Sig. — One to two pills t. i. d. after meals. or I^. Blaud' s iron pill gr. X (0.6) Pulv. capsici gr. i (0.016) Aloini 1 Strychnin sulph. >- aa gr. 3^5- (0.0022). — M. Acid arseniosi j One pill. Sig. — One pill t. i. d. after meals. Fecal Colic, Fecal Tumor. — It is an error to at once administer large doses of cathartics, and in some cases positive harm may result. The rectum should first be examined and all material found therein removed by the finger and then by enemata. High injections of soapsuds and water, in all, 1500 cc, containing olive oil .5 viij (250 cc.) to I pint (500 cc), should be given, in some cases in the knee-elbow posture, in order to soften and remove accumulation; L'requent injections and irrigation^ should be given to start movement for the first twenty-four to forty-eight hours. Ox-gall, oj to iij (4.0-12.0), with glycerin, 5ij to .^ss (8.0-16.0), added to the enema are of value. 1 Compound jalap powder, gr. 30 (2.0), with calomel, gr. v (0.6), is a good combination. 472 DISEASES OF THE STOMACH AND INTESTINES Olive oil, oij to vj (60.0-200 cc), can be given by mouth if neces- sary t. i. d- to soften the dejecta. Later, castor oil, calomel, or com- pound jalap by mouth, and saline cathartics. Frequent irrigations, in some cases with electricity, can be added to the treatment. Large doses of tincture of belladonna and strych- nin may later be of service. In some cases it takes several weeks for an old accumulation to be completely removed. Spasm of the Sphincter. — This should alwa5^s be examined for, especially in cases of spastic constipation. Gradual dilatation or rapid dilatation under an anesthetic are curative. Local disease should be treated. DIARRHEA Clinically, diarrhea may be defined as abnormal rapidity of in- testinal peristalsis, accompanied by frequent evacuations of the bowel contents, which are too liquid or are watery in character. Some patients normally pass solid dejecta several times a day, but this is not diarrhea; yet a single solid movement may possess pathologic significance. Diarrheal stools are caused by the excess of water in the feces, and may be due to the liquid contents of the small intestine being so rapidly hurried into the colon that little absorption is able to occur in the small intestine. Free transudation of water from the blood- vessels or the glands may be a factor. Rapid peristalsis in both the small and large intestines, or in the latter alone, is another cause. At times increased peristalsis is the only factor, and there are no chemic or physical changes in the bowel contents and no structural changes in the wall of the gut. Increased peristalsis usually involves the large intestine as well as the small. Pathologic increase of intestinal peristalsis may be produced in numerous ways. In the majorit}^ of cases it is caused by intestinal diseases in which anatomic changes are present, as in intestinal catarrh, ulcers, typhoid, etc. It may be present without any ap- parent anatomic lesions, as a result of irritants in the contents of the bowel; or when the contents are normal, but the irritability of the nerves of the intestinal wall is increased ; or when the muscular coats of the intestines are stimulated by an irritant circulating in the blood or affecting the central nervous system. Frequently there are several factors. The appearances of the evacuation, both macroscopic and microscopic,, in diarrhea vary ac- cording to the etiology of the disease and the anatomic changes in the gut, when such are present. In every diarrhea it is important to know whether it is produced by abnormal transudation or exudation, with increased peristalsis of the large intestine; or whether in addition the peristalsis of the small intestine is increased. In the last event large quantities of un- changed digestive fluids and undigested food remnants are evacu- CONSTIPATION AND DIARRHEA 473 ated, and nutrition is markedly impaired. Bile-pigment reaction in the feces shows involvement of the small intestine. We may classify two forms of diarrhea: first, with intestinal lesions ; second, diarrhea without lesions. The first group is described in the appropriate sections. The second group, with no intestinal lesions, is classified as follows: 1 . Diarrhea due to irritation from the bowel contents. Diarrhea dyspeptica, Diarrhea gastrica, Diarrhea stercoralis, and Diarrhea en- tozoica are subdivisions. 2. Diarrhea due to irritants transmitted in the blood, such as the uremic type. 3. Diarrhea nervosa (nerv^ous diarrhea), due to irritation of the nervous system. 4. Diarrhea Cathartica. — This type belongs in a class ^ by itself. The majority of purgatives stimulate the peristaltic action of the entire intestinal tract. The peristaltic action of the large intestine is chiefly affected, as by the aromatic laxative drugs. The move- ments in this case are thin and liquid, since increased peristalsis interferes with the absorption of the ingesta and intestinal secretions. With the alkaline laxative salts the action is not only to increase peristalsis, but they withdraw the water from the blood and stimulate the intestinal secretions. The prolonged use of drastic purgatives or excessively large doses produce an acute catarrh of the intestines. Diarrhea Due to Irritation of the Bowel Contents Diarrhea Dyspeptica. — Certain articles of diet may produce diarrheal evacuations, such as fresh fruit, cucumbers, pickles, cab- bage, turnips, beets, etc. Patients vary as to suceptibility. Milk produces diarrhea in some, while others it constipates. Excess of food or too great ingestion of water or beer with the food may prevent gastric digestion. The ingesta entering the intestines un- changed may cause diarrhea. Intestinal fermentation or putrefaction, spoiled food, and auto- intoxication may produce diarrhea. With the last the diarrhea is due to more than the mere local irritation. In neglected or severe cases of pure dyspeptic diarrhea, long-con- tinued irritation may give rise to true catarrh. Diarrhea Gastrica. — Einhorn and Oppler first called attention to diarrhea resulting from disturbances of the stomach functions. Hypochlorhydria and achylia gastrica are the most frequent causes of this type of diarrhea; more rarely hyperchlorhydria or motor insufficiency. In hypochlorhydria or achylia, diarrhea with intestinal symptoms such as flatulence, borborygmi, and colicky pains may predominate. The stools are often quite undigested. These cases, if prolonged, may develop intestinal catarrh. 1 This type, thus referred to by Nothnagel, is merely mentioned in passing. Colocynth and aloin in excess may also produce the condition. 474 DISEASES OF THE STOMACH AND IXTESTINES- Diarrhea Stercoralis. — Diarrhea with constipation. If consti- pation occurs in a person whose bowels usually are regular, diarrhea may follow the attack of constipation. The diarrhea is accom- panied 'by coUcky pains, bloating, and by the development of more or less offensive gases, such as sulphuretted hydrogen, etc. • It is beUeved that the diarrhea is caused by the development of these gases in the intestinal contents as a result of stagnation of the fecal matter. Hardened fecal matter may irritate the mucosa and produce secretion and peristalsis. With stercoral diarrhea the pas- sages are at first formed, then mushy, and finally liquid. Scybalae may be found in the dejecta. The passage of flatus affords temporary relief. Thorough evacua- tion of the bowels relieves all the symptoms. Neglected cases may cause intestinal catarrh. Diarrhea Entozoica. — Intestinal parasites, the tapeworm, for example, may in some cases cause persistent diarrhea. Like other types of diarrhea, there are probably at first no changes in the mucosa, but long-continued irritation will produce catarrh. Diarrhea Due to Irritants Transmitted in the Blood Diarrhea due to the hypodermic injection of certain drugs belongs to this class. The diarrheas of septicemia, nephritis, diabetes, cholera, malaria, etc., are explainable by this theory. Diarrhea Nervosa 'Nervous Diarrhea) This type depends on nen.-ous disturbances, without any morbid changes in the walls of the intestines. Trousseau first described nervous diarrhea. No impairment of digestive functions is present. It originates either from excessive stimulation of the nerves governing peristalsis (the motor function) or from the transudation of serous material into the intestinal canal (secretory function), produced by ner^'ous influences. In some cases probably both factors are concerned. The stimulus may arise from the nen.-e centers and be transmitted through the fibers of the vagus, sympathetic, or splanchnic ner\-es to the intestinal ganglia. As an example of nervous diarrhea, numerous watery evacuations may occur as the result of some emotion, such as fright or shock, in which cases the stimulus arises in the brain centers. These are more especially acute transitory attacks. Nothnagel and Peyer' report instances of chronic ner^^ous diarrhea: thus, some persons will be attacked with gurgling, abdominal pain, tenesmus, and diarrhea as soon as they find they can secure no access to a water-closet ; while with others the sight of the toilet produces 1 Wiener Klinik, 1893, Heft i. CONSTIPATION AND DIARRHEA 475 diarrhea. Some patients may have attacks at definite hours, without any relation to surrounding conditions. In others, nervous symptonis precede the diarrhea, such as vertigo, stupor, giddiness, congestion of the head, reddening of the face, hot flushes over the body, fear, oppression, palpitation, rapid breath- ing, etc. These symptoms often disappear after a few diarrheal movements. The number of stools varies; these may be from two to four, or even to fifteen, consisting of thin liquid contents, with mucus rarely present. At times the first movement is solid, the next mushy, and the subsequent movements liquid. Occasionally peristaltic unrest, borborygmi, and severe tenesmus may accompany the movements. This form of diarrhea is found as a symptom in hysteria or neurasthenia, in the nervous and debilitated, and even in healthy persons after a nervous shock. With Graves' disease and migraine this type may occasionally occur. Charcot^ describes attacks with tab^s (intestinal crisis). Peyer speaks of a reflex form of nervous diarrhea found in consequence of abnormal processes in the genito-urinary tract; for example, in uterine catarrh, emissions, spermatorrhea, and sexual excess. Fischl cites a case of diarrhea which persisted for several years and resisted all treatment. Replacement of a reflexed uterus cured the case. Vicarious diarrhea in pregnant women of the neuropathic type has been described by Condio. The diarrhea takes the place of vomiting. Nervous diarrhea has also been attributed to excessive smoking. Diarrhea from Exposure to Cold and Wet This occurs after a sudden or severe chill from exposure to cold, or wetting of the surface of the body, especially the feet or abdomen. Probably it is due to reflex irritation, transmitted from the cutaneous nerves. Accelerated peristalsis of the intestines occurs, whether due to reflex stimulation or secondary to hyperemia, it is uncertain. This type of diarrhea is usually transitory. At times it may assume the character of true intestinal catarrh. Treatment of Diarrhea The method of treatment depends on the cause. In the cases with anatomic lesions in the intestines, regulation of the diet and medication appropriate to each special type should be carried out. These methods are described under their special sections, such as under Intestinal Catarrh, Dysentery, etc. ^ Prager med. Wochenschr., 1891. 476 DISEASES OF THE STOMACH AND INTESTINES With diarrhea due to a laxative, heat to the abdomen and opium are indicated. Pilulae opii, gr. j (0.065), three or four times a day, or one of the other opium preparations, or I^. Tinct. opii oiiss Bismuth, subnit oiij Mist, cretae q. s. oiv Sig. — Shake. Two teaspoonfuls (8.0) four times a day. 12 125. — M. With dyspeptic and stercoral diarrheas thorough removal of the sources of irritation are indicated, such as the use of calomel or blue mass, gr. v (0.3), castor oil, oiss (45.0), or a saline cathartic^ such as magnesium sulphate, oss to oj (15-30 gm.), or Sprudel salts, apenta, etc. Intestinal irrigation is indicated in these types. For intestinal parasites an appropriate remedy and a cathartic. For Diarrhea Gastrica. — Treatment should be given for the existing condition in the stomach ; for hypochlorhydria, stomachics, dilute hydrochloric acid, intragastric faradization, etc. For achylia gastrica, chiefly vegetable food, finely divided, and the methods employed for this condition. For hyperchlorhydria, a rare cause, diet and the alkalis, etc., are indicated. For Diarrhea Due to Irritants Transmitted in the Blood. — The cause should receive treatment, thus, nephritis, malaria, etc. The general condition should be improved. Heat locally to the abdomen, liquid diet, rest in bed, the bismuth and astringent preparations, such as bismuth subnitrate, gr. 30 (2.0) t. i. d., bismuth salicylate, gr. 10 (0.6) t. i. d., or bismuth subgallate, gr. 10 (0.6) four times a day; or tannalbin, tannigen, tannopin, or tanocol, gr. 10 (0.6) each, three or four times a day. Opium preparations may be required, but should be used with caution. Nervous Diarrhea. — -If this depends on reflex action, such as from uterine disturbance, etc., the primary affection must be treated. In other cases the general condition of the patient must be built up. Neurasthenic and hysteric conditions must receive special treatment. Constipating food may be administered. Iron preparations, such as iron tropon, oj to ij (4.0-8.0), t. i. d. ; peptomangan (Gude), oj to oss (4.0-16.0), in water t. i. d. ; or Fowler's solution of arsenic, TTLv (0.296 cc), or smaller doses t. i. d. ; or sodium arsenate, gr. -gV to 2's (0.0013-0.0026), are of value as tonics. I^. Blaud's iron pill gr. v (0.6) Sodium arsenate gr. -^V (0.0013). — M. One pill. Make 30 such pills soft with honey and silver coat. Sig. — One t. i. d. after meals. The bromids of sodium, ammonium, or potassium, or bromid of strontium, given for a few weeks, gr. 15 to 30 (1.0-2.0) t. i. d., lessen irritability. CONSTIPATION AND DIARRHEA 477 Bismuth subnitrate or salicylate, in dosage already given, silver nitrate, gr. i to | (0.008-0.016), and the astringents noted above are useful. Heat should be applied. Opium and its derivatives are generally recommended for this, as well as other types of diarrhea, and are preferable to morphin. The general tendency to at once prescribe opiates in all diarrheas is to be deplored, especially in the nervous type, as the habit is readily gained. If other remedies fail, they may be used with caution. The following (Wm. H. Thomson) is a useful combination for such purposes. The dosage is small: ^- Pulv. opii ) aa er V (o ^) Silver nitrate J * ' ^ '"^^ Resin of turpentine oij (8.0) Liquor potass 3 j (4-o) Pulv. licorice q. s. to make pills soft. — M. Divide in pil. No. Ix. Sig. — Two or three pills t. i. d. I^. Tinct. opii camphor I aa ^ss deo^ Bismuth subnit. J aa oss (.ib.oj Mist, cretae q. s. 5iv (125 cc). — M. Shake. Sig. — Two teaspoonfuls in water every two or three hours. I^. Tinct. opii 3iij (12.0) Tinct. catechu comp oss (16.0) Aq. destil q. s. ad. oiv (125 cc). — M. Shake. Sig. — Two teaspoonfuls in water every three hours. Opium pills or other combinations can be employed. In nervous diarrhea the intestines should be trained in the normal direction. Suggestion by the physician is of value. The patient should be instructed that after his morning evacuation he should refrain from other movements except when absolutely necessary. Often he can thus control the desire. CHAPTER XXIII INTESTINAL CATARRH; ENTERITIS; COLITIS; CATAR- RHAL SIGMOIDITIS; PROCTITIS; PHLEGMONOUS ENTERITIS ACUTE AND CHRONIC INTESTINAL CATARRH (Synonyms. — Enteritis; Catarrhus Intestinalis.) Intestinal catarrh is one of the commonest conditions with which we have to deal, and is of importance, since in acute cases in the young or aged it may seriously endanger the life of the patient ; while the chronic cases are often obstinate and difficult to cure, and may impair the general health. It occurs in two types, the acute and chronic, and these in turn may be primary or secondary to some other disease. ACUTE INTESTINAL CATARRH (Synonyms. — Enteritis Acuta; Catarrhus Intestinalis Acutus; Cholera Nostras; Acute Diarrhea.) Acute intestinal catarrh is defined as an acute inflammation of the intestines, characterized by pains of considerable severity and accompanied by diarrheal movements containing an admixture of mucus. The disease may attack a portion of the bowel and we may have a duodenitis, jejunitis, ileitis, colitis, sigmoiditis, and proctitis. In many cases the entire intestinal tract is involved. Appendicitis is described in a separate chapter. Though Woodward^ held that the small intestine may not be involved alone, yet it unquestionably occurs. In many cases acute catarrh of the colon, on the other hand, gives the prominent symptoms, though there is frequently involve- ment of the ileum. The inflammation may also be confined to the large intestine. Etiology. — Age. — It may occur at all ages, and is frequently found in infants and children. Acute intestinal catarrh may be pri- mary (idiopathic) or secondary to some other disease. Primary acute catarrh is due to the following causes: i. An excessive quantity of food, so that a considerable portion remains undigested and acts as a source of irritation ; heavy and indigestible food; extremely cold drinks, or an idios^'ncrasy to certain foods. In others, who are suffering from slight intestinal disturbances, some articles of diet which otherwise would produce no difficulty may lead to the development of catarrh. Unripe fruit, tainted meat, milk or fish, or vegetables that are overripe or spoiled. Auto- intoxication with diarrhea may result from ingestion of such ma- ^ Medical and Surgical History of the War of the Rebellion. 478 ACUTE INTESTINAL CATARRH 479 terial, and catarrh is frequently produced if the source of irritation is not immediately removed. 2. Chemic irritants, both organic and inorganic substances, such as colocynth, croton oil, jalap, senna, podophyllin, spices, pepper, copaiba, mustard, garlic, cantharides, mercury, arsenic, lead, copper, tartar emetic, phosphorus, antimony, alcohol, chloro- form, ether, and some of the alkaloids, such as colchicin, veratrin, acids, and alkalis. With concentrated irritants the mucosa may be permanently damaged. Catarrh is caused when smaller quantities are ingested. 3. Mechanical irritants, such as hardened scybalae, enteroliths, biUary calculi, foreign bodies, such as seeds, fruit pits, coins, etc. 4. Exposure to cold or high temperature, especially in children and infants, or sudden variation in temperature, wetting the feet, are predisposing causes; these conditions probably favoring the development of micro-organisms and producing circulatory change. 5. Chemic irritants from the blood, such as in catarrhal nephri- tis, catarrh from mercurial inunction, or from abdominal burns. "^ Acute intestinal catarrh may be secondary : 1. To general infection, as in typhoid, dysentery, cholera, sepsis, influenza, pneumonia, scarlatina, measles, malaria, rheumatism, or other infectious diseases. In dysentery and typhoid the ulcerations are in part responsible. 2. Direct action of micro-organisms, as in infantile catarrhs due to the activity of numerous types, such as proteus vulgaris and streptococci. Bacillus enteritidis sporogenes,- colon bacillus, also Bacilli dysenterii. 3. Extension of inflammatory process from adjacent parts, as in peritonitis, invagination, hernia, tubercular or cancerous ulcera- tion, and thrombosis. 4. Diseases of the liver, heart, and lungs due to stasis and engorge- ment. 5. In cachexia of cancer, profound anemia, diabetes, Addison's and Bright's disease, intestinal catarrh may be a terminal event. _ Morbid Anatomy. — The entire gastro-intestinal tract may be involved or only portions of the intestines are affected. These differences depend on the extent of the catarrhal process and upon the cause and intensity of the inflammation. The anatomic changes are not always commensurate with the severity of the symptoms. The mucous membrane of the intestines is reddened uniformly or in spots, from light red to dark purple in color, especially marked around the follicles and plaques, on the summit of the valvulae conniventes and of the villi. If the inflammatory process is intense, 1 Elimination of the poisons through the bile and from the blood during intes- tinal secretion is the probable cause of the catarrh. 2 This was believed to be possibly an impure culture of the Bacillus aerogenes capsulatus, though possibly it is a distinct organism (Herter, Bacterial Infections of the Digestive Tract) . 480 DISEASES OF THE STOMACH AND INTESTINES extravasations of blood occur. The mucous membrane is swollen and edematous, and is often covered with tenacious glassy mucus, stained by bile or blood and more or less opaque. Desquamated epithelial cells and occasionally a few pus-cells are seen in the mucus under the microscope ; layers of epithelium may desquamate and form gray shreds. Fecal contents are usually liquid. The villi and soli- tary follicles are swollen and appear as whitish nodules surrounded by a red injected area (enteritis folHcularis sen nodularis). If the process continues, these nodules may rupture and give rise to follicular ulcers. Catarrhal ulcers are produced by loss of the epithelial covering and extension of the inflammation. Irritation in the neighborhood of these ulcers may in protracted cases give rise to polypoid growths. Microscopically, there are congestion and distention of the blood- vessels of the mucosa and submucosa and small extravasations are at times seen between the glands of Lieberkiihn. The spaces between the glands are frequently widened and contain abundant masses of round cells. They are also present in the superficial or deeper layers of the submucosa. The swelling of the solitary follicles is due to proliferation of their cells and to round-cell infiltration. This is also true of Peyer's patches when they are involved, which is rare to any extent. The epithelium of the mucosa is detached, especially in the large intestine, but this is believed to be chiefly a post-mortem change. The epithelium is undoubtedly involved in the catarrhal process, as degenerated epitheHal cefls are found in the mucus with the stool. The cells of the glands may be cloudy and swollen. Crypts of Lieberkuhn. — The glands are enlarged or the fundus is wider than normal, the opening is narrow, so that the crypt becomes bottle shaped. They may be detached from their base and raised, or protrude into the intestines, or even desquamate. The submucosa is hyperemic. The muscular and serous coats are unaffected. Symptoms. — They depend on the etiology, the location of the catarrh, and its severity, so that considerable variation occurs. The general symptoms of an ordinary primary attack are as follows: It usually begins with a feeHng of fulness in the lower part of the abdomen, with attacks of colicky pains and diarrhea. Nausea and vomiting may be associated with these symptoms at the incipiency of the attack. In the mild cases there may be no temperature, or it may be moderate, while in the severe types there may be a chill with rise of temperature to 103° to 104° F. In some cases there may be tympanites. There are gurgling sounds (borborygmi) and the abdomen is tender on pressure, at times over special regions markedly so. Loss of appetite occurs. The number of stools depends upon the severity of the case. There may be only two or three movements in twenty-four hours. ACUTE INTESTINAL CATARRH 48 1 or as many as fifteen to tv>renty evacuations. The first one or two movements usually contain fecal matter and are somewhat mushy in character. They rapidly become semifluid, and finally thin and liquid. Feces and scybalae may be found " later. The more the colon is involved, the greater is the diarrhea. Diarrhea does not always occur if the small intestine alone is the seat of inflam- mation. The early stools are frequently of a dark brown color sometimes of offensive odor, the latter condition being especially noticeable if dietetic errors are the cause. The amount of material passed exceeds the quantity of food ingested, due to the digestive secretions and catarrhal secretion, all of which are rapidly evacuated. When the stools consist of watery discharge and mucus there is often little or no odor. They are slightly acid in reaction and foam-like in appearance. The stools may be light yellow in color, grayish, or even greenish in young children, or colorless, resembling rice-water. These differ- ences in color are dependent upon the location of the catarrh. In the yellow fecal material Gmelin's reaction for bile-pigment can often be obtained, and this is also found in the green movements, demonstrating involvement of the small intestine. The colorless stools most frequently occur in the specific choleraic types. Mucus is contained in the stools. It may float on top of the dejections in shreds of various sizes and be of glassy appearance, or be stained in various colors, or mixed with the bowel contents and form a jelly-like mass; it may coat the feces or be mixed with it in small amounts; or the movement may consist chiefly of mucus. In some cases the mucus may only be determined by the microscope. The localization of the seat of the catarrh is shown by the charac- teristics of the mucus, to be described later. Microscopically, there are epithelial cells, numerous micro-organ- isms, mucus, occasionally a little pus and blood, and undigested food particles. Blood is found only in severe cases where there is marked congestion or ulceration, and pus when ulceration is present. Chemically, peptones and sugar may be present in the dejecta. Macroscopically, food remnants may be seen with the naked eye for several days, especially if dietetic indiscretion be a factor. Subjective Symptoms. — In the milder cases, except for the colicky pains, diarrhea, and the feeling of pressure and fulness, the patients may not feel very badly. In more severe cases they may feel chilly, feverish, dizzy, and weak, at times nauseated, and in some cases thev may vomit. Tenesmus may be present if the lower part of the colon or rectum are affected. Gas may be expelled. Borborygmi may be audible. With children and elderly persons the symptoms are often pronounced. Collapse may occur. With infants the hydren- cephaloid condition may occur, temperature 104° F. or more, sunken fontanels, rapid pulse, cold extremities, collapse, etc. General Physical Signs. — The abdomen may be bloated, but 31 482 DISEASES OF THE STOMACH AND INTESTINES when gas is expelled the distention lessens or disappears. Splashing sounds can often be elicited. Over the abdomen usually there is ten- derness on palpation, especially in the region of the navel, and fre- quently in the right or left iliac regions, or along the course of the transverse colon; gurgling sounds can often be heard on palpation. In thin subjects peristaltic movements of the small intestine may be visible either before or after palpation. If there is much gas, there is a tympanitic note on percussion; it may be dull in character if much fluid be present. Large accumu- lations of gas are not frequent. Fever. — There may be no temperature or only moderate fever. In severe types the temperature may be quite high (102 ° to 104° F.). In some cases there are chills associated with the fever, but the temperature has a tendency to fall after a few days and does not show the characteristic steady increase of typhoid fever. With tainted food or bacterial infection, fever is especially apt to occur. Such cases run an acute course with severe clinical symptoms. Undoubtedly auto-intoxication is a prominent factor in their production. With gastroduodenitis, jaundice is present, and often vomiting. Urine may become scanty and concentrated, especially in severe cases when there are frequent movements, and there may be found cylindroids, albumin in small amounts, and hyaline casts. Indican is often present, especially if the small intestine is involved. Rosenbach's reaction (Burgundy red), on boiling urine with nitric acid, is also found. This also shows intestinal putrefaction. Acetone has been found. Localization of Acute Catarrh. — Involvement of the small intes- tine alone is more uncommon, and usually associated with gastritis. I believe in actite cases the involvement of the intestines is the more frequent occurrence, though the intensity of inflammation may be greater in one portion, especially in the colon. Some believe the large intestine alone is most frequently involved. This is more so in chronic cases. In the rectum local involvement is quite frequent. Acute catarrh of the caput coli, due to fecal accumulation, at times occurs, and this must be difi'erentiated from appendicitis. The fecal tumor can be generally discovered by the doughy feel on palpation. The acute symptoms subside rapidly under intestinal irrigation and catharsis. This refers to a simple catarrh and not to a true typhlitis which involves the muscular tissue. Acute catarrh ma)'- occur in the sigmoid and should be classified as catarrhal sigmoiditis. In sig- moiditis or perisigmoiditis the musculature is also involved. The cases described by Mayor and Leube are evidently of this type. Diverticulitis belongs to this last class. The nomenclature should be very specific. Localized Physical Signs. — An acute duodenitis is usually asso- ciated with acute gastritis, and we have jaundice with local tender- ACUTE INTESTINAL CATARRH 483 ness on pressure in the right portion of the epigastric region. Inflam- mation of the duodenum with local tenderness may occur after cuta- neous burns. Tenderness on pressure (pain), confined to the middle of the abdomen and not laterally, shows the affection to be probably confined to the other portions of the small intestine ; but when the small intestine alone is involved, as diarrhea is usually absent, the diagnosis is difficult. The presence of a considerable number of undigested food particles and epithelial cells tinged with yellow bile- pigment in the feces; microscopic mucus mixed with the stool, with rarely a small amount of visible mucus, are a valuable aid to the diagnosis. Indican is usually present in the urine. Acute Colitis. — With acute colitis^ the pain and tenderness are most marked along the course of the colon, over the cecum, trans- verse or descending colon, sigmoid flexure, or over all together. The stools are diarrheal and contain considerable mucus. Proctitis is characterized by tenesmus and colicky pains in the left iliac fossa. There is a constant desire to defecate. The scybalae or stools are surrounded with mucus, sometimes tinged with blood, and the mucous membrane may prolapse during defecation and is red and tender. Rectal digital examination is accompanied by much pain, and the examining finger shows, at times, traces of blood. The most important method of diagnosis to localize the process is by examination of the feces, noting the character of the mucus. Macroscopic examination is often sufficient. When pure mucus is passed without any fecal admixture, catarrh of the rectum, sigmoid, or of the descending colon is indicated. If small masses of fecal matter or solid balls are passed covered with a layer of mucus, the same condition is indicated. If there is catarrh of the entire large intestine up to the cecum, even if the movements are thin, shreds of mucus are intimately mixed w'ith the fecal matter, and can be recognized by the naked eye. The close admixture of fecal material and mucus distinguish it from catarrh of the lower colon. In catarrh of the upper colon alone or of the small intestine, or small intestine and upper colon alone, usually no mucus can be seen with the naked eye, and hyaline microscopic lumps of mucus are found intimately mixed with the stools. Small amounts mixed in the feces are at times visible. Diagnosis. — If a colon-tube be introduced high into the rectum, and lavage be carried out intermittently with warm water through a funnel, by the same method as lavage of the stomach, the recovered fluid will contain visible mucus, and demonstrate that catarrh of the large intestine is present. This method was suggested by Boas. The presence of yellow mucoiis granules in the movements have 1 More properly, acute catarrhal colitis, to distinguish it from dysenteric and other types. 484 DISEASES OF THE STOMACH AND INTESTINES been considered diagnostic of inflammation in the small intestine, though Schmidt and Boas believe them to be structureless remains of muscle substance, casein, or egg-albumen, colored with bile-pigment. Bile-pigment. — If bile-pigment reaction can be obtained in the stool or in some of its constituents, this indicates an inflammation of the small intestine, and the more marked the reaction, the higher up the involvement. It may be found in the mucus, and this may be stained a dark orange, green, or greenish yellow. Cylindric epithelium, round cells, or rarely fat (droplets) may be stained yellow. An acid reaction of the stool also shows involvement of the small intestine. Boas has subjected a filtrate of the feces to the digestion test with a small piece of albumin, and when the result is positive, justly con- cludes that the condition originates in the small intestine. Duration. — Mild cases may rapidly recover in three to five days, while severe cases often continue for several weeks. The intestine remains susceptible to irritation for a considerable time, and errors in diet may cause a recurrence of the attack. The condition may become chronic. Constipation may follow the acute attack, and this should carefully be treated, lest habitual constipation develop. The acute attack may never be entirely recovered from, but gradually develop into a chronic catarrh. Prognosis. — These cases frequently recover within a short time, but in children or very old and enfeebled persons the disease may occasionally prove fatal. The prognosis as to cure depends upon the etiology of the disease ; thus, if due to chemic irritants, the condition may become chronic. Treatment. — Prophylaxis. — Particular articles of food or drink known to produce attacks of acute intestinal catarrh should always be avoided. Some are affected by ice-cream and ice-cold drinks, and these should be forbidden. Exposure to cold or wet should be avoided. Rest in bed should he enjoined. When tainted food has been ingested or indigestible or an excessive amount of food, even though there is diarrhea, a laxative should be given immediately to thoroughly empty the bowel. Calomel, gr. 5 to 10 (0.3-0.6), followed by a saline cathartic, preferably within six hours for rapid effect, or castor oil, o] to ij (30.0-60.0), should be given to an adult. Castor oil may be ad- ministered in coft'ee, sarsaparilla, ginger ale, or with orange or lemon juice. For infants and young children calomel, gr. ss to j (0.32-0.65), in divided doses, or 5 j to iss (4.0-6.0) of castor oil. If an acid chemic irritant has been taken, then an alkali should be given, and vice versa. Antidotes should be administered in the case of chemic poison. It is preferable also to administer a cathartic, so as to remove the poison from the intestinal canal. acute; intestinal catarrh 485 Knteroclysis with normal saline solution at 110° to 115° F. is indicated in all these cases, employing i gallon (4 liters) by the recurrent method, so as to thoroughly cleanse the large intestine. Calomel is useful when there are flatulence and indicanuria. I prefer a fairly large initial dose in these cases, and to repeat it within a few days, to the method of daily small doses. There is some danger of salivation from frequent small doses. Colonic irrigation once or twice a day is of great importance. These methods, combined with salol or beta-naphtol-bismuth (orphol), gr. 5 (0.3), three or four times a day, with the other bismuth preparations, or with urotropin, gr. 5 (0.3), and sodium benzoate, gr. 10 (0.6), are generally sufficient. Dilute hydrochloric acid in HXx (0.59) doses t. i. d. is an excellent adjunct, providing there be no nausea or vomiting, and resorcin, gr. 5 (0.3) t. i. d., may be employed for intestinal fermentation. One of the best remedies for diarrhea is bismuth. Bismuth subnitrate, gr. 20 to 30 to 40 (1.3-2.0-2.6), given four or five times a day is of service. It may be combined with sac- charated pepsin as a vehicle in mild cases in smaller doses. Bismuth subnitrate, saccharated pepsin, equal parts, ^ to ^ tea- spoonful every two or three to four hours during the twenty-four hours. Bismuth subcarbonate, gr. 15 to 30 (1.0-2.0), four times a day. Bismuth subgallate, gr. 5 (0.3), three or four times daily with the bismuth subnitrate is excellent. Bismuth salicylate, gr. 5 (0.3), four times a day is a good anti- fermentative; or ichthoform, gr. 5 (0.3) t. i. d., in combination with bismuth subnitrate. Ichthalbin, gr. 5 (0.3) t. i. d., is useful. Tannalbin, tannigen, or tannopin, gr. 5 to 10 (0.3-0.6), can be used in combination with bismuth. I^. Bismuth, subnit oss (16.0) Mist, cretse q. s. oiv (125.0). — M. Sig. — Shake. One to two teaspoonfuls in water every two or three hours. The same prescription with 10 to 15 drops (0.6-1.0) of tincture opii camphor is useful if the diarrhea continues excessive. The following represent single doses of remedies which can be taken every three or four hours in persistent diarrhea : I^. Tinct. opii IfTtx (0.59) Tinct. kino "1 "" ITl (' 8^ Comp. tinct. catechu ) ^ ^ " ^ Aqua destil q. s. oij (8.0). — M. . I^. Tinct. opii. TlXx (0.59) Mist, cretae 5j (40) Comp. tinct. catechu q. s. 5ij (8.0). — M. I^. Bismuth, subnit gr. x (0.6) Tinct. opii deodor HXx (0.59) Aq. cinnamomi q. s. oj (4-o). — M. 486 DISEASES OF THE STOMACH AND INTESTINES I prefer, however, to avoid opiates as much as possible in my treatment. Cotoin, 0.06 to 0.1 (gr. i to 2) ; tincture coto, TTLxv (0.888), or paracotoin, in double dose as compared to the cotoin, have been suggested for diarrhea. Codein, gr. i to ^ (0.008-0.016), or, rarely, morphin may be re- quired. Patient should be kept in bed. Dry or moist heat, or Priessnitz compress, hot-water bag, flaxseed, or milk or potato poultice, hot pieplate, hot salt-bag, compress of hot water, pepper poultice, weak mustard and flour poultice should be applied. If symptoms of collapse, warmth, hot drinks. Camphor hypodermics and strychnin are indicated. Hypodermoclysis may be required. Enteroclysis is useful to rid the bowel of irritating material, and for treatment of the acute catarrh when located in the colon. It may be given by enema ^ or, preferably, with the recurrent tube. When there is marked fermentation — Acetozone i : 2000 to i : 1000 Alphazone 1 : 2cxdo to i : locx) Peroxid of hydrogen 5 j (32.0) to 2 quarts (liters), or Salicylic acid (i : 1000) 2 quarts (liters) Boracic acid 3 j (4-o) to 2 quarts (liters) Permanganate of potash i : 3000. Irrigate with 2 or 3 quarts (liters) with a recurrent tube once a day. Soothing irrigations are flaxseed tea, gum-arabic solution in water at 110° F., slippery-elm water, or normal saline solution. Occasionally astringent irrigations may be necessary. First wash the bowel with warm water, then inject tannic acid, gr. 30 (2.0) to I Hter (quart), and 15 drops (0.888) of laudanum, and hold a while. Weak nitrate of silver, gr. 5 (0.3) to i quart (hter), has also been recommended, but is better in chronic cases. Gas- tritis, jaundice, and malaria should be treated, if present, or any disease to which the intestinal catarrh is secondary. Diet. — Cold drinks should be avoided. Sanatogen is useful. Warm teas, such as chamomile, fennel, anise seed, or plain tea and gruels (barley or rice), with or without milk, very dilute milk with lime-water, etc., should be given. Milk is often indigestible and barley broths preferable. Later, bouillon, water soup (bread softened in hot water with butter and salt), yelk of &gg or white, or entire egg (raw or soft boiled), stale bread, boiled water, etc. Avoid carbonated waters. As soon as the diarrhea is over, soft-boiled eggs, calves' brains, scraped beef, mashed potatoes, cocoa, weak coffee, chicken, chops, steak, stale bread and butter, potatoes mashed or baked can be given. Fruit, green vegetables, hot breads, fat, and acids should be avoided for a considerable period. 1 About I to i\ quarts (1000-1500 cc.) should be used by enema; hips elevated, injecting with a long tube. CHROiNIC CATARRH OF THE INTESTINES 487 CHRONIC CATARRH OF THE INTESTINES; CHRONIC COLITIS {Synonyms. — Enteritis Chronica; Chronic EnterocoHtis.) This disease is characterized by a chronic inflammation of the mucous membrane of the intestines, which gives rise to various functional disturbances of the bowels. iVny portion may be affected. Etiology. — Chronic intestinal catarrh may arise from an acute enteritis which shows no tendency to recovery, or more frequently from repeated attacks of acute catarrh which follow each other at short intervals before complete recovery occurs. Patients frequently pay no attention to an apparently mild attack and disregard the rules of diet prescribed. As a result, the condition becomes chronic. In other cases, however, chronic catarrh may have an insidious onset from the beginning. Fecal accumulation, notably scybalae, may be a cause of a subacute or chronic catarrh. Pressure of tumors narrowing the canal, as pressure from fibroids of the uterus, or adhe- sions, may be factors. The direct causes of chronic enteritis are the same as in the acute type, and chronic catarrh may be either primary (idiopathic) or secondary to other affections. For the complete etiology the reader should refer to the causes of acute intestinal catarrh. Chronic catarrh may be secondary to diseases of the lungs, espe- cially tuberculosis, and also diseases of the liver, heart, kidneys, and diabetes. Intestinal parasites, tapeworms, round-worms, seat- worms, etc., may be causes by producing irritation. I recently at- tended a case of splanchnoptosis, in which there was marked prolapse of the sigmoid flexure with a tendency to fecal accumulation therein. The patient never had an acute enteritis, but for five years has had discomfort in this region, and invariably every few days the passage of strings of mucus and scybalae. There were no symptoms of mucous colic. The case was one of chronic catarrh of the sigmoid. The symptoms disappeared under treatment for visceroptosis. The possibility of chronic locaHzed catarrh from visceroptosis, associated with fecal accumulation, is worthy of consideration. Chronic ap- pendicitis is suggested as a cause by G. R. Lockwood, and the cure of chronic colitis has followed appendectomy. The rectum should always be examined. Pressure on the rectum from a uterine fibroid I have seen produce partial stenosis with coprostasis above and resulting intestinal catarrh. Ulcer, fissure, or hemorrhoids may cause not only local manifestations, but catarrh higher up. I have seen a case with chief symptoms pointing to the descending colon and sigmoid, in which an ulcer high in the rectum was the cause. Morbid Anatomy. — The anatomic changes in chronic enteritis are similar to those in acute cases, being characterized by hyperemia, swelling of the mucous membrane, and increased secretion of mucus. The color of the mucosa varies from a dark venous red to a pale gray- 488 DISEASES OF THE STOMACH AND INTESTINES ish-red tint ; in some cases it may even be gray or slate colored from extravasation of pigment between the glands and at the tips of the villi. The last cases are those of long duration. The surface of the mucous membrane is covered with a trans- parent viscid mucus and the epithehal cells are cloudy, in a condition of fatty degeneration, and partly desquamated. In the majority of cases of chronic catarrh the accumulations of round cells (which are characteristic of the acute type) are not seen, but there is connective- tissue proliferation in the chronic form. Exceptions. — In some of the early cases of chronic enteritis the microscopic picture may be much the same as in the acute process; and in other mild cases the only abnormality determined is the accumulation of pigment between the glands or in the muscularis mucosae and a slight widening of the interstices. As a result of chronic enteritis, hypertrophy or atrophy of the intestinal mucosa may develop. Hypertrophy of the Intestinal Mucosa. — The glands of the mucosa are elongated, tortuous, irregular in shape, and may form diverticula. Their orifices may become occluded through connective-tissue proliferation and there will be a retention of secretion and the formation of cysts (enteritis chronica cystica). Connective-tissue proliferation leads to the formation of polypi (enteritis polyposa), which are more rare, and are usually found in the large intestine. In many cases the walls of the intestines may become thickened throughout, including the muscular coat, to the extent of several times its normal thickness. Woodward reports a few cases of proHferation of the intestinal mucosa with its glands. Atrophy of the Intestinal Mucosa. — ^The clinical entity of atrophy of the intestines has been in considerable dispute, and undoubtedly a pseudo-atrophy due to post-mortem change occurs. Riegel, Bwald, and Einhorn believe there is a true intestinal atrophy. In view of the existence of an atrophy of the gastric mucosa resulting from a chronic gastritis and from its occurrence in pernicious anemia, I am convinced that an atrophy of the intestinal mucosa may occur in advanced cases of chronic intestinal catarrh. The condition I believe to be rare. Such atrophy may originate in the glandular tissue in the glands of Lieberkiihn. There may be an infiltration of round cells, a fatty degeneration, a disintegration, and desquamation or atrophy. On the other hand, it may result from a connective- tissue proliferation compressing the glands. Musgrave believes an atrophic condition of the intestines may follow the chronic catarrh occurring w4th amebic dysentery. The villi degenerate with the atrophy of the glands, shrink, and become small. No ulceration of the soHtary or agminate follicles occurs, and it is a question whether atrophy to any extent ever takes place in them. CHRONIC CATARRH OF THE) INTESTINES 489 There is a degeneration of the muscular coat and some thinning of it. Jiirgens^ has described a fatty degeneration of Meissner's and Auerbach's plexus and of the muscular tissue, as a special type of intestin?^ atrophy; Sasaki records 2 similar cases dying with the clinical symptoms of pernicious anemia. These conditions probably are related to intestinal atrophy. Atrophy of the mucosa occurs more frequently in the colon, especially in the cecum, ascending colon, or ileum near the valve. Large portions of the intestines are rarely found atrophied, but the process generally involves certain parts. Ulcerative Processes. — As in acute enteritis, we may have ulcerative processes in chronic catarrh of the intestines. Superficial erosions of the mucosa may become deeper with the production of ulcers. Rarely they increase sufficiently in depth, and result in erosion of a blood-vessel with hemorrhage, or cause a local peritonitis with or without abscess, or even a perforative peritonitis. Generall)^ the ulcers remain unchanged for a considerable time or cicatrize; occa- sionally stricture of the intestines may result. The follicles may occasionally swell up and burst, producing small follicular ulcers. Frequently healing takes place. Extensive ulcerations are seldom met with in chronic enteritis, unless accompanying a tubercular process. The "sago grains" or frog spawn in the feces, formerly believed pathognomonic of follicular ulceration, are shown to be of vegetable origin. Kitagawa finds that some of these grains are mucous in character, but this in itself militates against ulceration, as ulcers do not discharge mucus, but pus. The presence of mucus merely indicates catarrh. Symptoms. — The chief diagnostic symptom of chronic intestinal catarrh is the abnormal character of the feces. It seems advisable to first describe the subjective and objective symptoms which occur in many cases. Some patients complain of no subjective symptoms whatever. The majority of cases complain of a feeling of discomfort or occasionally of slight pains in the abdomen. These symptoms are apt to be most marked after eating, usually several hours; or fre- quently just before or even after defecation. At times these sensa- tions may disturb the patient an hour or two before rising. There is a feeling of tension or bloating of the abdomen which may be relieved by the passage of flatus, and this tendency gives rise to considerable annoyance. Flatulence may become so severe as to cause shortness of breath, an asthmatic attack, palpitation, angina pectoris, or cerebral congestion and vertigo, all of which symptoms are alleviated by belching of gas. Flatulence is much more charac- teristic of chronic enteritis than of the acute type. Borborygmi are often present. Severe pains are usually absent, though slight colicky pains of rather brief character may be present. ' Berlin, klin. Wochenschr., 1892, p. 357. 490 DISEASES OF THE STOMACH AND INTESTINES These are often relieved by bowel movement or by the expulsion of flatus. In some cases the general health is not impaired; while in other cases it is undermined. General nutrition may become impaired, especially if the small intestine is also involved. In the latter case gastric symptoms, such as anorexia and nausea, and occasionally vomiting, may be met with. The patient may feel weak, disinclined to work, be irritable, depressed, and even hypochondriac or melancholic. There may be loss of weight, anemia, slow pulse, cold extremities, and attacks of severe headache. The nervous symptoms are due in part to depres- sion from an evidently chronic and persistent disease, and to a large degree to auto-intoxication. Physical Signs. — The abdomen may appear distended, especially a couple of hours after eating, with some tenderness on pressure. In chronic enteritis the colon seems to be more usually affected. Chronic Catarrhal Colitis. — There may be chronic catarrhal colitis, with tenderness over the caput coH and ascending colon, with the sensation of a hard mass which yields to the examining finger on pressure (fecal accumulation), or this part may be tympanitic and give the splashing sound from gas and Hquid. The same may be true over the descending colon, sigmoid flexure, or transverse colon. There is often tenderness on pressure along the entire colon. Pain is felt directly under the point of pressure, or occasionally at a dif- ferent point further along the colon, due to the passage of gas, which has been forced along by local pressure. In thin persons peristaltic movements of the intestines are occasionally observed, especially after palpation. In some cases there are no special objective symptoms. The diagnostic symptom in chronic intestinal catarrh is the abnormal character of the stool — the presence of mucus. The movements are irregular and the consistence of the stool is variable, hut the mucus is diagnostic. Diarrhea is not a constant symptom. There are four types of movements which occur in chronic enteritis : 1. In one set of cases there is marked constipation, and a solid movement occurs only once every two or three days and at times only after a cathartic. The feces are usually, hard. It is probably due to a diminished activity of the automatic nervous mechanism of the intestines produced by the catarrh (Nothnagel). 2. In others, constipation and diarrhea alternate; there may be hard movements for several days and these succeeded by five or six thin or mushy movements, mixed with mucus, and accompanied by severe colicky pains. These, in turn, will be followed by con- stipation, and so on. In some instances the evacuations will be fairly normal for several days and then diarrheal movements will CHRONIC CATARRH OF THE INTESTINES 49 1 occur and after this constipation. Constipation is the chief feature in these cases. The reflex irritabihty of the nervous apparatus, however, is quite good, and decomposition of the stagnating bowel contents eventually causes increased peristalsis with diarrhea. The periods of constipation or diarrhea, on the other hand, may continue for a long time; thus, constipation for several weeks or months, and then diarrhea for weeks or months. Probably in the latter class there is an acute exacerbation of the catarrh. 3. Rare cases occur in which there is a daily evacuation of unformed and mushy feces. 4. Cases in which for months the patients pass several diarrheal stools each day. The small intestine is involved as well as the large bowel, as there is a bile-pigment reaction, as a rule, or there are yellow fragments of mucus or epithelial and round cells tinged with bile. The food on account of the catarrhal process is not completely digested in the small intestine, and abnormal products, such as acids, etc., are produced, so that the undigested food and fermenting material give rise to increased peristalsis. In addition there are some in which the ner\^ous element is a factor combined with the catarrh, and movements occur during the night or early in the morning. F. Delafield^ describes this type. The presence of mucus in the feces is characteristic. The type of mucus in mucous colic (Enteritis membranacea) , which occurs in large amount, and the symptoms render the differential diagnosis comparatively easy. In other cases the presence of mucus demon- strates a true catarrh. In habitual constipation there may be a thin shellac-like covering of mucus over the scybalse, and this appearance is not found in chronic enteritis. With chronic catarrh with con- stipation, the quality of the dejecta may be nearly normal, except there is an admixture of mucus. In rare cases the mucus may be absent, or it may be very tough and adhere to the intestinal wall, or the scybalse may be too small to scrape it off. However, on most occasions mucus will be present, and if there is doubt, washing of the bowel by means of the tube and funnel will eventually bring it away. Besides the presence of mucus in mucous colic, in some cases of intestinal dyspepsia there is mucus in the stools. Intestinal Dyspepsia. Chronic Enteritis. Pure mucus alone. Stools gelatinous. Mucus with epithelial and round cells Mucus microscopic and seldom (diagnostic), visible. Green stools with acid reaction; bile- pigment gives pronounced reaction. No fecal odor. Alkaline stools. Fecal odor. The quantity of mucus varies greatly ; in most cases onlv a small or moderate amount. 1 Med. Record, May 11, 1905. 492 DISEASES OF THE STOMACH AND INTESTINES The various combinations of mucus with the stool and the local- ization of the catarrhal process have been described under Acute Enteritis (page 483), to which I refer my readers. We may have therefore : (i) Chronic catarrhal enteritis (alone), rare; (2) chronic catarrhal enterocolitis; (3) chronic catarrh of various portions or of the entire colon or of the rectum; thus, chronic catarrh of the caput coli, of the ascending, transverse, or descending colon ; or chronic catarrhal sigmoiditis, or proctitis. The colon is most frequently involved. When the movements are watery and thin the fecal matter is a light brownish yellow or grayish yellow, and may contain little biliary matter. Undigested meat or starch particles can often be seen in these cases. Microscopically. — Though nothing may be discovered macro- scopically, we may find with the microscope undigested meat-fibers, starch granules and fat droplets, also mucus and round and epithelial cells, at times yellow and shrivelled up. They indicate catarrh of the small intestine. Blood is never present unless due to ulcer or hemorrhoids. Pus is rarely found and only as isolated cells. Dejecta resembling pus dilated with water (Blennorrhoea intes- tinalis) shows diphtheritic inflammation when pus is seen in large amount under the microscope. Large masses of epithelial cells in various degrees of degeneration are present in chronic catarrh. They are responsible for the cloudiness in the mucous secretion. The character of the food and of the stool, and whether there is constipation or diarrhea, determine the consistence and reaction of the feces and the degree of fermentation. As a rule, alkaline reaction is present. The presence of fermentation and putrefaction can be determined by the abdominal tension, flatus, and character of the stool, which may be fetid and present a foamy surface. Fecal material may be placed in a fermentation tube and kept at blood temperature for several hours, and the degree of fermenta- tion or putrefaction will be shown by the quantity of gas in the tube. The method is described under ' ' Testing the Intestinal Functions." The presence of putrefaction will be shown by indican in the urine, and the Rosenbach reaction (Burgundy red) on the addition of nitric acid and boiling. A chronic catarrhal enteritis complicated with ulcers will show marked diarrhea with pus and blood in the stool. If the ulcers occur in the small intestine alone and there is no diarrhea, pus and blood often will not he present; but there will be more severe pain, more marked tenderness on pressure, and the clinical symptoms will be more severe. The diagnosis of the atrophic type of chronic enteritis is extremely difficult. Some question its possibility. There will be a previous history of intestinal catarrh of long standing. Later there will be CHRONIC CATARRH OF THE INTESTINES 493 diarrhea, no mucus, with gradual loss of weight, and at times symp- toms of pernicious anemia. Tuberculosis must be excluded. This condition is more frequent in the young. Course. — The course of chronic intestinal catarrh is usually very tedious. It may last for many years. There may be periods of perfect health, but there is a tendency to relapses from any slight indiscretion. Differential Diagnosis. — The method of localization of the catarrh, as previously stated, is the same as in acute enteritis (page 483). Irregular bowel action, with the presence of mucus in the stools of the character described, associated with abdominal symptoms of discomfort, suggest chronic catarrh. The discharge of mucous colic is characteristic, as are also the symptoms. In the mucus which is occasionally found with intestinal dyspepsia there is an absence of epithelial and round cells and the stools are green and acid, as I have already stated. In habitual constipation there is an absence of mucus in the move- ments. With marked fecal impaction I have frequently seen a small amount of mucus in the feces due to temporary irritation. After removal of the impaction and subsequent care of the bowels there is no further appearance of mucus. Impaction if neglected, or occur- ring in frequent attacks, may be a cause of local intestinal catarrh and, as heretofore noted, occasionally of stercoral ulcers. With malignant disease of the intestines, enteritis is often asso- ciated, but the cachexia is marked and other symptoms of the neo- plasm are present. With intestinal ulcers there are marked pains, local tenderness, and pus and blood in the stool. With enteroptosis we may have a prolapse of the sigmoid, fecal accumulation, and chronic catarrhal sigmoiditis. In every case of chronic intestinal catarrh, enteroptosis should be examined for. Rectal examination should be made in every case of chronic intestinal catarrh, as the focus occasionally starts from the rectum and pro- gresses up the bowel as, for example, from an ulcer. On account of its importance I shall devote a brief chapter to Proctitis. ~ A uterine fibroid may block the bowel, acting as a ball-valve, and from fecal accumulation above this point a marked catarrh of the mucous membrane may result. Chronic appendicitis may result from a chronic intestinal catarrh ; while in some cases a chronic appendicitis may act as a focus of irrita- tion for a localized chronic catarrh in the cecum. Removal of the appendix is curative in the last type. In certain diseases of the stomach there may be constipation or diarrhea, but the absence of mucus in the stools and examination of the gastric contents will settle the question. In chronic enteritis of the small intestine alone there are usually gastric symptoms, constipation, yellow tinged mucus in the stools, 494 DISEASES OF THE STOMACH AND INTESTINES generally microscopic and well mixed with the feces, and the biliary salts reaction. In chronic catarrhal colitis there is usually more constipation and more or less mucus of a grayish tinge, either covering or on the surface of the feces or in small strings. Pure mucus may at times be voided at the end of defecation if the lower bowel is affected. Palpation is of value in locating the position of the chronic colitis, as the affected area is apt to be sensitive to pressure. Chronic diarrhea is prominent in cases in which both the small and large intestines are involved, and the mucus ma}^ be yellow in color and considerable undigested food is often present. Prognosis. — This depends on the severity of the symptoms, the duration of the disease, and the physical condition of the patient. In the very young, very old, or those weakened by some other disease, such as endocarditis or tuberculosis, severe types of chronic catarrh may be accessory in producing a fatal result. As a rule, the prognosis as to life is favorable, but in the severer cases of long standing it is not so favorable as to perfect cure. The cases have a tendency to relapse, especially after indiscre- tions, though they may continue for a considerable time with com- parative comfort. The milder cases of not long standing may recover under appropriate treatment. Treatment. — The cause of the chronic catarrh should be care- fully sought, out and corrected. If, for example, endocarditis with resulting circulatory disturbances (which are a predisposing factor) be present, this should receive treatment. The Nauheim bath, even though taken at home by means of the Triton salts, would be of value in such cases. If enteroptosis be present, such as in the case I have described, where there was marked prolapse of the sigmoid, fecal accumulation, and local chronic catarrh, treatment by abdominal support (Rose's belt) and increasing the nutrition by the methods described under Gastroptosis would be indicated, in addition to the general treatment for chronic catarrh. I have seen one obstinate case cured by S. Gant by drawing up and suturing the sigmoid to the abdominal muscles. Angulations of the sigmoid should be cor- rected. If worms are present, they should be removed. These remarks will sufficiently illustrate the necessity for investi- gation of the cause of the catarrh. Hygienic and dietetic measures are of great importance. The patient should regulate his life carefully, not overwork nor be under too great business strain, eat slowly and at regular hours, and live in the open air as much as possible. In the constipated cases considerable exercise is of value. When the diarrhea is marked the patient should keep quiet during its active stage, and in some cases remain in bed until it has passed. Ner\^ous disturbances should be avoided. The patient should exercise care not to wet the feet or undergo exposure to cold, and should be properly protected in rainy CHRONIC CATARRH OF THE INTESTINES 495 weather. A flannel band about the abdomen is of value. Change of scene and climate are often sersdceable. Diet. — The patient should eat at regular hours, slowly, and masticate thoroughly. It is preferable to give small meals more frequently than three large meals, and sufficient nourishment should be administered so that there is an increase in weight. Fried foods, hot breads, rich pastries, desserts, and indigestible substances should be avoided. Though some allow the very moder- ate use of light wines, and occasionally beer or ale, in constipated cases, and the use of claret in diarrhea, in my own experience I find that patients with catarrhal conditions of the gastro-intestinal tract do much better by eliminating alcoholic beverages altogether. The character of the diet is dependent upon whether diarrhea or constipation is present. In diarrheal cases, if the type be severe, milk and Hme-water equal parts, or boiled milk, or milk and barley-water, or rice-water in combination often are efficacious; though some patients have an idiosyncrasy to milk. . Rest in bed for a brief period may be necessary. Kumyss, matzoon, bacillac, or lactone-buttermilk are often use- ful in such cases, though with some these preparations are objection- able, increasing the diarrhea. Sanatogen in 5j (4.0) doses, also raw eggs beaten in milk, may be of value. In milder cases of diarrhea the diet may be more liberal. Car- bonated waters, lemonade, fruits, salads, acids, cabbage, cauH- flower, rye bread, brown bread, ice-cream, pastries, oatmeal, green vegetables, corn and beans, turnips, carrots, beets, radishes, celery, and lobster should he avoided. Mashed and baked potatoes, rice, sago, macaroni, bread well baked and toasted, with a moderate amount of butter, cream soups, bouillon, soft-boiled or scrambled eggs, sweet-breads, calves' brains, chicken, lamb chops, lean fish, cocoa, tea and milk, or matzoon (with some) can be given. The drink should not be too hot or too cold, and an excess of liquid should be avoided. In constipated cases the diet must be more liberal. In addition to the food mentioned above, fruits, such as oranges, ripe pears, grapes, green vegetables, such as spinach, peas, lettuce, cauliflower, plenty of butter, cream, and fluids are of service. Cabbage, cucumbers, brown bread, sausages, lobster, mayon- naise dressing, and bran breads should be avoided in these cases also. The urine findings should modify the diet — if indicanuria, less meat or none for a time; if fermentation, less vegetables; if nephritis, an appropriate diet. Massage. — In cases characterized by chronic constipation, gentle massage over the course of the colon or the use of a light cannon-ball is indicated. No pressure should be exerted on the ball, but it should 496 DISEASES OF THE STOMACH AND INTESTINES be rolled along the colon for five minutes morning and night. Light vibratory massage is of value under similar conditions. Hydrotherapy. — Warm salt baths at 98° to 100° F., or Nauheim baths (artificial) eight to ten minutes every other day for two or three weeks, or pine-needle baths, bran baths, or mud baths may be of some service in some diarrheal cases. Cold baths should be avoided in diarrhea. A Priessnitz wet pack over the abdomen is of value when applied on retiring. Cold showers and cold sponges are of service in nervous cases. Cold sitz-baths and cold douches over the abdomen are of use in constipated cases, but should be preferably carried out at some sanitarium. I have rarely found the latter methods necessary, but use the artificial Nauheim, pine-needle, or bran baths, also the cold compress to a considerable extent. Mineral Waters. — A methodic course of drinking certain alkaline or saline mineral waters has proved beneficial in many cases. When taken at the springs, the patient is obliged to follow a rational method of life and diet and is free from worry, and thus receives additional benefit. Carlsbad is especially valuable when there is a tendency to diarrhea, and Vichy is next. In cases of marked constipation, Marienbad is of service, and also the Hawthorne and Congress Springs at Saratoga. Virginia Hot Springs are also to be recommended. Where neither diarrhea nor constipation, are prominent, Kissengen or Homberg; with constipa- tion and anemia, Franzensbad and Klster. Carlsbad water should be taken in small quantities, a wineglassful twice a day, or even in small amounts of the imported salts, gr. 30 to 60,^ three to five times a day. It is preferable to begin with small doses. Some do badly with this method. If the diarrhea increases so that the patient begins to lose weight, the treatment should be stopped at once. Medication. — The method of internal medication depends upon whether constipation or diarrhea is the existing condition. As a preliminary it is always wise to begin treatment with a thorough cleansing of the intestines by a single dose of castor oil, oiss (45.0), or a good dose of Carlsbad salts or magnesium sulphate. If there be marked fecal accumulation, it is better first to employ enteroclysis or enemata, to remove the impaction, and then follow with the single cathartic. In constipated cases, fruits, buttermilk, cold water (glass) on rising, stewed fruits, and a regular hour for attempted stool are all rational. An enema, olive oil, Siv (125.0), increasing to Oj (500 cc.) or more, given slowly by a long tube on retiring, and to be retained, is an excellent procedure. It may be necessary to employ soapsuds enema (never over i quart) or normal salt solution. Rhubarb pills, fluidextract of cascara in 5j (4.0) doses, or the same quantity 1 An equivalent of 2.0 to 4.0 of the salts. CHRONIC CATARRH OF THE) INTESTINES 497 of aromatic fluidextract cascara, or podophyllin pills are of service. Carlsbad water has been given by enema. Small doses of castor oil or olive oil combined with salol are of considerable value in all cases. Thus : Salol, gr. 5 (0.3) tablet; with it give castor oil.lUx (0.59), given in a gelatin capsule, coated with shellac, four times a day; or olive oil can be substituted. In the constipated cases larger doses of olive oil by mouth, oj to iv (30.0-125.0) t. i. d., are of service. The oil preparations seem to have an excellent effect on the mucous membrane. Lead and zinc preparations I do not employ. Nitrate of silver is sometimes of service. It can be given in aqueous solution, each 5j containing | to ^ gr. (0.0 11 -0.0 16), being kept in a dark bottle, or the same dosage in an enteric coating. The following pill, gr. ^ (0.008), of silver nitrate is excellent: Bf. Argenti nitratis gr. v (0.3) Resin turpentine "1 ..,-.,. Liq. potass. | aa o] (4.0) Pulv. licorice q. s. — M. Div. in pil. No. xl. Sig.— One pill t. i. d. Bismuth salicylate, gr. 5 to 10 (0.3-0.6) t. i. d., is of some value, but a movement should be secured every day if it is given in the con- stipated cases. The bismuth and tannin preparations are of special value in the diarrheal cases, the dosage being dependent on their severity. The movements should be reduced to one or, at the most, two a day. Opiates I always avoid, if possible. Bismuth subnitrate, gr. 10 to 20 (0.6-1.3) three or four times a day or more, alone or combined with chalk. Bismuth salicylate, gr. 5 to 10 (0.3-0.6) t. i. d., combined with subnitrate bismuth; or bismuth subcarbonate, gr. 10 to 20 (0.6-1.3) t. i. d. ; or bismuth subgallate, gr. 5 to 10 (0.3-0.6) t. i. d. Tannigen, tannalbin, or tannopin, gr. 5 to 15 (0.3-1.0) t. i. d. Beta-naphtol-bismuth, gr. 5 (0.3) three or four times a day, if there is fermentation. For some of the combinations with kino- catechu, etc., I refer to treatment of Acute Enteritis. Belladonna can be used for pains, but codein and morphin rarely should be employed. Local Treatment. — This is of great importance, especially when the large intestine is involved, which is usual. The method may be employed by an enema of i pint (500 cc.) to i or even 2 quarts (liters) of the solution, preferably employing several quarts (liters), with the recurrent tube or two tubes. If possible I use my own rectal irrigator of hard rubber or, if the rectum is sensitive, 'the soft-rubber tube or two catheters. Normal saline solution — oj (4.0) salt to Oj (500 cc.) water ^ — at 1 Oil of peppermint (10 drops) can be added to this. 32 498 DISEASES OF THE STOMACH AND INTESTINES 105° to 110° F. is excellent if there is much pain, or flaxseed tea at the same temperature is useful. Slippery elm solution and gum- arabic solution are excellent soothing applications. Listerin, glycothymolin, borolyptol, and boric acid, 5j to ij (4.0-8.0) to the quart, are of service. Tannin, gr. 10 to 20 (0.6-1.3) to the quart (liter); zinc sulpho- carbolate, gr. 10 to 15 (0.6-1.0); or borax, oj (4-0) to the quart, are good astringents; salicylic acid, gr. 15 (i.o) to the quart (liter); irrigation once a day or every other day is of value. I often employ flaxseed tea or gum-arabic one day, and one of the mild antiseptics or astringents the following day. In obstinate cases, nitrate of silver solution, gr. 10 to 20 (0.6-1.3) to a quart (liter), given once or twice a week, is a valuable adjunct. If the patient complains of pain, a subsequent injection of normal saline solution is of service. The bowels should be thoroughly emptied, preferably an enema given an hour or two before local treatment. Protargol or argyrol (i : 1000 or i : 1500) is of service in place of the silver nitrate. Surgery. — In cases with evident ulceration , if no benefit results from medical treatment conscientiously applied for a year, I would advocate appendicostomy or cecostomy with subsequent irrigations. In catarrh without ulcers I do not believe operation is indicated. PROCTITIS The rectum is very liable to bacterial infection, both from within and without, through the anal opening, so that ulcerations and peri- proctitis may occur. I will briefly refer to this disease, merely to serve as an index to the practitioner. Etiology. — As this condition is often a part of chronic enteritis, the etiologic factors may be identical. Local conditions may also produce it; thus, traumatism, as by a syringe-tip; sodomy; impacted feces ; worms ; foreign bodies introduced through the rectum or lodged there during their passage from above, such as fish-bones, pins, etc., hemorrhoids, polypi; prolapse, intussusception; tumors; pressure from other organs; displacement of the uterus; stone in the bladder; inflammation of adjacent organs, such as uterus, tubes, prostate, or seminal vesicles. Sitting on cold stones or wet seats may be a cause. Idiosyncrasies to certain foods seem to be a factor. Proctitis is classified as follows : 1. Acute simple catarrhal proctitis. 2. Chronic proctitis : Atrophic form ; hypertrophic form. 3. Specific forms: Gonorrheal, dysenteric, diphtheritic, erysipel- atous, and syphilitic proctitis. Pathology. — With simple catarrh there is no pus, except pos- sibly a minute amount. With ulceration there is pus and blood. PROCTITIS 499 The acute and chronic types of intestinal catarrh have aheady been described. It is preferable to examine pus (if such is present) for gonorrhea, especially if there be a gonorrheal vaginitis, and it may even pass by extension from Bartholin's glands. Erysipelas may extend from without. Pseudomembranes occur with the diphtheritic type. Amebse, or the bacilli dysenteric, are found with the dysenteric type. We may have the primary chancre of syphilis in the rectum, in which case relaxation of the sphincter will also be noted, or there may be secondary ulceration and catarrh. The test for Wassermann's reaction should be made if syphilis is suspected. Actinomycosis may rarely occur. Symptoms. — They have been described. They are: Marked straining and tenesmus; passage of mucus with the stool, or mucus alone with pus and blood if ulceration is present ; frequent micturi- tion ; throbbing heat and weight in the rectum. Constipation at first, later diarrhea; heavy and aching pain in the rectum and down the limbs ; often pruritus and prolapse of the rectal mucous membrane or hemorrhoids ; temperature ; coated tongue ; abscesses of the rectum may develop. The chronic cases present less severe symptoms. Digital examination is painful on account of spasm, and the rectum will be found to be very sensitive and hot to the feel. If the inflam- mation extend deeper into the tissues, it will feel hard and rigid. By speculum examination it will be seen to be a deep red, with hemorrhages and erosions. Often the condition is so painful that it is not advisable to use a speculum at first. The chronic cases run a less severe course. Complications : Periproctitis or ischiorectal ab- scess may occur. Treatment. — Recurrent rectal irrigation with hot normal saUne solution at iio° F., or in other cases with cold saline solution at 50° to 70° F., with the patient in the Sims posture for fifteen minutes' duration,' is of value, once or twice a day, to relieve inflammation. Flaxseed'-tea irrigation is also useful, or the other antiseptics described under Chronic Enteritis. Injection of hvdrastis, i to 2 per cent., or aqueous fluidextract of krameria (J. P. Tuttle), 5 to 20 per cent., several quarts, are of service in some cases. Carbolic acid solutions should never be employed. In the acute conditions I do not care to employ nitrate of silver at first, though later i : 2000 every day or two is of value. Argyrol or protargol (i : 500 or i : 1000) is less irritating. Tuttle suggests the use of the following by injection to quiet irritation after local treatment. R. Flaxseed tea o j (300) Opium gr. ss to J (0.032-0.065) Aqueous fl. ext. krameria Tdxxx (1.77).— M. A suppositorv of opium and iodoform may be substituted. 500 DISEASES OF THE STOMACH AND INTESTINES If there is marked purulent inflammation, then twice daily irri- gate with : Peroxid of hydrogen 8 to lo per cent., or i : looo acetozone or alphazone, or even i : 10,000 bichlorid of mercury once in twenty- four hours. The bowel should be irrigated well with saline solution after each movement and medicated solutions used once or twice a day. Injections of starch and laudanum should only be used once or twice a day in severe cases to relieve irritability. After the acute stage has passed, S. Gant recommends spraying the rectum with permanganate of potassium (1:3000), or with zinc sulphate, copper sulphate, or nitrate of silver, i per cent. In chronic cases irrigation with nitrate of silver (i : 2000 to 1 : 4000) is of value, every two or three days. I have seen an excellent result in a severe chronic case from the injection of the aqueous fluidextract of krameria, suggested by J. P. Tuttle. His formula is as follows: Macerate i pound of bark of krameria in a long percolating tube for twenty-four hours. After this a mixture of glycerin (20 per cent.) and w-ater (80 per cent.) is ahowed to percolate through it. The percolate should be constantly stirred and refiltered through the bark a second time. The filtrate is then evaporated down to i pound, thus obtaining an aqueous fluidextract containing gram for gram all the therapeutic properties of the bark. The preparation should be kept in a dark place and not exposed to air. A 10 to 20 per cent, solution of this can be used for irrigation or a local application of it pure. The diet and internal medication should be the same as described tinder Chronic Enteritis. Syphilis, if present, should be treated. Warm sitz-baths aid in relieving pain. PHLEGMONOUS (PURULENT) ENTERITIS This disease, a purulent inflammation of the submucous tissue of the intestines, is rare as a primary process. It is probably due to streptococcic infection, the jejunum being most frequently involved. Peritonitis is present, but the purulent enteritis cannot be diagnosed as the cause, in my opinion, until after operation. Phlegmonous enteritis may be secondary to intestinal ulceration, to intussuscep- tion, or strangulated hernia. MaragHano has reported septic infection of the ileum probablv bv the colon bacillus, with hemorrhage, ulcer- ation, and peritonitis. CHAPTER XXIV DYSENTERY Dysentery is defined as an infectious disease characterized by specific ulcerations of the large intestine. In typic acute cases it gives rise to bloody mucous or mucopurulent dejections, accom- panied by tenesmus and general symptoms. Dysentery was known to the ancient world, being first described accurately by Hippocrates 430 b. c, and later by Celsus, Aretaeus, and Galen. In 1506 the first records of post-mortem examinations of dysen- teric subjects were published in the posthumous work of Antonio Benevieni. Following these came many writers, among whom I shall mention a few of the most prominent of recent years : Cruveil- hier, Virchow, Woodward, Lambl, Loesch, KartuHs, Quincke, Roos, Mus'ser, Osier, Stengel, Stockton, Harris, Councilman, Lafleur, Ogata, Shiga, Russell, Flexner, His, Barker, Duval, Bassett, Yedder, Musgrave, Strong, Craig, and Thomas. It has been demonstrated that the disease is due to infections of a specific type — either to the ameba dysenteriae or to the Bacillus dysenteriae (Shiga) or one of its strains. The disease is transmitted in the same way as is typhoid fever. It sometimes assumes a diph- theritic type, in which case other bacteria are undoubtedly associated. The so-called acute catarrhal dysentery, the sporadic form, I believe, is undoubtedly due to the Bacillus dysenteriae or one of its strains. ' Diphtheritic dysentery (or, more strictly speaking, pseudo- diphtheritic, as Klebs-Ldffler bacillus is not present) has been shown in many cases to be due to the Bacillus dysenteriae. Undoubtedly mixed infections with other bacteria are found in this type. DIPHTHERITIC DYSENTERY This may be found in combination with amebic dysentery, and. in addition, in some of the amebic liver abscesses numerous other bacteria are present, which demonstrate mixed infection from other sources. Secondary diphtheritic dysenter>' is a common terminal event in many acute and chronic diseases; and Vedder and Duval have de- monstrated that the Bacillus dysenteriae is present in these cases. Diphtheritic dysentery in which the diplococcus pneumoniae has been isolated has been several times reported. In addition, mercu- rial poisoning or uremia may have this lesion associated. It is evi- 501 502 DISEASES OF THE STOMACH AND INTESTINES dent, therefore, that other bacteria either present in or entering the intestinal tract under favorable conditions may produce this lesion. In the ileocolitis of infants dysenteric bacilli of various strains have been discovered, and some of these cases, both clinically and pathologically, present the appearance of an acute catarrh. Many causes were formerly given for the production of dysentery, but we may say that they only predispose to infection on account of weakening the organism, producing intestinal disturbances. In the case of overcrowding in asylums and camps there is a tendency to unsanitary conditions. By inattention to the proper relation of the latrines, to the water-supply, for example, there may result a severe epidemic. LOCATION Dysentery is found in all parts of the world, but is endemic and often epidemic. It is most common in warm climates, such as the southern United States, Cuba, the Philippines, southern coast-line of Asia, Africa, Egypt, Mexico, Central and South America. It has been met with in cold climes, as in North Russia and Greenland; is sporadic in all parts of the United States and occasionally epidemic. Severe epidemics have occurred in the New England States. During the Civil War, Woodward collected 259,071 cases of acute dysentery and 28,451 of chronic dysentery in the Federal service. During the recent Spanish-American War the mortality from dysentery and typhoid was far in excess of that from battle; and in the African War the English troops suffered severely. In the Russo-Japanese War the deaths in the Japanese army from dysentery and typhoid were infinitesimal in number, demonstrating that by intelligent care of the water-supply and proper sanitation epidemics of dysentery can be absolutely stamped out. Dampness, overcrowding, and imperfect ventilation vitiate the system, and so predispose to subsequent infection. With over- crowding and necessarily insufficient and improper attention to sanitary conditions, infection from the dejecta can readily occur, if a sporadic case develop. Heat and moisture predispose to intestinal disturbances, and readily cause changes in fresh fruits or canned material, if improperly cared for, which in turn produce diarrheal disturbances, and cause susceptibility to infection. Sudden alternations from heat to cold produce the same result. Errors in diet are predisposing causes. No race or age is exempt from dysentery, and a person going from his native to a warm climate— with the sudden change in food and mode of life incident thereto — is probably more susceptible. Dysentery is more fatal among the poor and ill-nourished than among the rich, though the latter are not exempt. It is probably more prevalent in epidemic and endemic form in smaller country towns, villages, and farms, where one so frequently sees the well in close proximity to the privy, a stagnant pool, or the family cow-yard. DYSENTERY 503' Dysentery may be endemic, the so-called tropical dysentery; epidemic or diphtheritic ; and sporadic (the acute catarrhal dysentery). It is classified as follows: 1. Amebic dysentery, in which there is at times a mixed infection (diphtheritic process). 2. Bacillary dysentery (Shiga), or one of its strains, under which are included the sporadic type (acute catarrhal), which probably belongs to this classification, as a catarrhal type (ileocoUtis) exists in infants. . . . The diphtheritic type is included and also the secondary dtphtheritic type, which may be a terminal event in acute and chronic disease, and 'in which Vedder and Duval have demonstrated the presence of the Bacillus dysenterige. Undoubtedly other varieties of bacteria play a part in the diph- theritic type. AMEBIC DYSENTERY {Synonym. — Intestinal Amebiosis.) Definition.— A colitis, latent, subacute, acute, or chronic, caused by the ameba dysenteric. There is a special liability to formation of abscess of the liver. Often these cases occur without the clinical symptoms of dysen- tery at all. I agree with Musgrave that the condition should be more correctly given the name of "intestinal amebiosis." The 'disease is widely prevalent in Egypt, India, the Philippines, West Indies, Southern States, and in tropical countries. It occurs frequently in the United States, and much more in many of our cities than is generallv supposed. I have recently attended a case clearly infected in New York State, the patient having never been south. It is endemic, especially in warm climates, and often becomes epi- ■ demic. Sporadic cases occur in temperate climates. In Manila, Strong states that out of 1328 cases in the United States army, 561 were of the amebic type. At the Johns Hopkins Hospital, Osier reports most of the acute and chronic cases of dysentery were of the amebic variety; during the first fourteen years theie were 119 cases admitted, 95 of which came from Maryland — 108 males and 11 females. Source of Infection.— Chiefly from contaminated water or green vegetables and fruit. Musgrave has found the ameba in ice-cream and water-ices. Amebse Dysenterise.— Lambl first described amebse in the stools in 1859, and in 1875 Loesch investigated the stools of a dysenteric patient and described the amebae. He injected the stools into the intestines of dogs and produced ulceration. Osier, Councilman, Lafleur, Dock, Quincke, Roos, Musgrave, Strong, and manv others have carried on investigations. To obtain a specimen for examination little flakes of mucus or 504 DISEASES OF THE STOMACH AND INTESTINES pus should be selected, or the mucus may be secured by passing a soft catheter, or through a speculum. Preferably a saline cathartic should be administered, as suggested by Musgrave, and the fluid portion of the stool examined while -warm. Swollen, altered epithelial cells must be distinguished from the amebae. The cells are round with granular protoplasm. Ameba dysenteriae is from fifteen to twenty microns in diameter and consists of a clear outer zone, or ectosarc, and a granular inner zone (endosarc), and contains a nucleus and one or two vacuoles ^4: Fig. 202. — Amebae from a culture. Impression preparation. Borrel's stain ( Woolley and Musgrave) . (Fig. 202). The movements are similar to an ordinary ameba, consisting of a slight protrusion of the protoplasm. They vary somewhat and can be intensified by having the slide heated. They have a pale green appearance under the microscope. Red blood- corpuscles are at times contained in the amebae, and occasionally bacteria. Musgrave recommends Borrel's stain for study of amebae in the tissues. They may be in large numbers in the tissues. In the pus of a liver abscess, amebae may be abundant. In the sputum from a ■■.if ^ >■ ^ >v>V ¥'■ ^' ■'• i; -^.^ .W> ^ ' * /' / 4. >^^ Fig. 203. — Intestinal amebiasis. Cecum. Shows all stages of ulceration. The smallest black points indicate the positions of preulcerative lesions (Woolley and Musgrave). Fig. 208. — Intestinal nmebiasis. Rectum. Extensive ulceration and diphthe- ritis. Thick-walled gut (Woolley and Musgrave). DYSENTERY 505 pulmonary infection from an hepatic abscess they can be recog- nized. Quincke and Roos describe three varieties of amebae in the stools of healthy persons; and Strong two types, only one of which is pathogenic. Musgrave and Clegg do not think it has been proved there are amebse non-pathogenic to man. They hold that all such are, or may become, pathogenic. Amebae dysenterise can be grown in cultures from stools or intestinal ulcers, but not alone as a pure culture. A symbiotic organism is necessary for its development. It has been isolated as a pure culture, in combination with a pure culture of another organ ism. Fivea, Celli, and ^liller claim to have grown it pure, and that it multiplies by division. Resistant forms of the ameba have been described by Cunningham and Quincke. They are apparently analogous to the gamete forms of the malarial parasite. The "encvsted amebse" seem, under certain conditions, to be necessary for the transmission of the disease from one person to another, and are regarded by Musgrave and Clegg as the most dangerous type. Cultures of amebae have withstood drying for fifteen months. Location of Lesions. — The lesions are found in the large intes- tine, rarely in the lower end of the ileum ; and abscess of the liver is a common accompaniment, being present in 22 per cent, of Osier's cases. Pathology of Amebic Dysentery. — Intestines. — Thoughwriters refer to the classic undermined type of ulcer in amebic dysentery, three tvpes of lesions are described, which ma}- shade gradually into each other: 1. P re-ulcer ation. — This stage is characterized by the presence of the "small red dots" of Rogers, varying from 0.2 to 0.5 mm. in diameter, and which are intensely congested (Fig. 203). They consist of capillary hemorrhages into the intraglandular tissue. Erosion of the superficial layers of mucous membrane is usually associated. There is moderate injection of the mucous membrane and but little thickening of the submucosa. These lesions ma)- be seen in an>- part of the affected gut, and chiefly in the acute cases. 2. Ulceration {type of Harris), rarer than the classic type, and believed to be intermediate between the petechiae and ''under- mined" ulcer. They are probably the result of the superficial ero- sions, and are primarily confined to the mucous membrane, though they reach into the submucosa or to the circular muscle, but no deeper (Fig. 204). They spread laterally. The ulcer has a punched- out appearance and is round or oval, the edges thick and congested. Base is clean, gray, and edematous. They often lie at the apex of 506 DISEASES OF THE STOMACH AND INTESTINES the intestinal fold and tend to increase in the direction of the short axis of the bowel, and are found in all regions, but less often in the advanced or chronic cases. They are most common in the ileum. 3. Classic or Undermined Ulcers. — In the early stage they appear as minute yellow or gray spots in the mucosa, at times at the centers of the "Rogers' red dots, " and are usually surrounded by a congested area. These spots are the mouths of passages leading to cavities in the submucosa; the mouths and cavities are filled with necrotic material. Fig. 204. — Early iry:estinal lesion. Shows superficial necrosis, glandular dis- tortion, and round-cell infiltration. Borrel's stain. Zeiss obj. A, A, oc. comp. 4; bellows at 30 cm. (Woolley and Musgrave). As the ulcerative process extends, the cavity in the submucosa is enlarged, and though the necrobiosis eventually involves all the coats, the muscular layers and mucosa are affected less rapidly, and the latter may he markedly undermined. The ulcers may gradually coalesce on the surface, or quite frequently the cavities in the sub- mucosa may communicate with each other by tunnels, while the mucous membrane shows a catarrhal condition. The submucosa becomes thickened and edematous, as do often the muscular layers and peritoneal coat (Fig. 205). The ulcers may be from the size of a pin-head to the palm of the DYSENTERY 507 hand. In extensive ulceration the muscular layer may become necrosed or even perforated, and the base of the ulcer be formed by peritoneum or omentum. The omentum plays an important pro- tective part, being frequently, early in the ulcerative stage, found adherent to the surface of the intestines. Localized suppuration is, therefore, common. Ulcers may perforate into the subperitoneal Fig. 205. — Colon. A moderately thick- ened gut with various types of ulcers (Woolley and Musgrave). Fig. 206. — Colon. Thin-walled gut, with shallow ulcers, some slightly undermined, others punched out (Woolley and Musgrave). or retroperitoneal tissue. They are usually circumscribed, though they may burrow (Fig. 206). Healing Process. — In the case of the small ulcers there may be complete repair, the epithelium from the mucous membrane lining the ulcer, except its base. In larger ulcers there may be considerable scar tissue, which may lead to contraction. According to Musgrave 's obser\'ation there is established in cases 508 DISEASES OF THE STOMACH AND INTESTINES of long duration not systematically treated a chronic catarrJial condition with subsequent atrophy (enteritis chronica atrophicans), a thinness of the bowel, absence of normal folds, atrophy of the mucosa and increased length; and he places it in the classification of sprue or psilosis, believing untreated amebiosis to be one of the causes of this condition. There may be, on the other hand, in some cases localized hypertrophy with well-developed polypi. Location of the Lesions. — Harris believes that in fully one-half the cases the lesions do not extend beyond the beginning of the transverse colon; while Rogers holds that they are more frequently limited to the cecum and ascending colon. The ileum just above the ileocecal Fig. 207. — Amebae in a blood-vessel; X500. Heidenhain iron hematoxylin (Woolley and Musgrave). valve is rarely involved, and generally by only a few ulcers (super- ficial) and a slight involvement if diphtheritic inflammation compli- cates. The lower rectum is rarely involved. Strong and ]\Iusgrave, comparing 200 cases treated and untreated, find 159 cases involve the entire large bowel, excepting the lower rec- tum; 23, the cecum and ascending colon; 2, the transverse colon; the descending colon, sigmoid, and rectum, 9; unrecorded, 7; appendix ulcerated, 2 (amebic); with large intestine, 14; ileum with large intestine, 7. The presence or absence of irrigation treatment makes a differ- ence. In cases dying early from intermittent disease, ulceration in DYSENTERY 509 the cecum and ascending colon, 1 1 ; in descending colon, sigmoid, and rectum, 8 ; in the entire bowel, 6. Microscopic. — Mucous membrane between the ulcers is little changed. In the neighborhood of the lesions a tendency to hyper- trophy with mucoid degeneration and cyst formation. In the early lesions, congestion with capillary hemorrhages and edema of the mucosa; increase of lymphoid cells in the interglandular tissue. Ameba from 4 to 35/2 long are present in the glands, inter- glandular tissues and blood-vessels, muscularis mucosa, and in the veins of the submucosa (Fig. 207). In the more advanced condition there is necrobiosis (coagula- tion necrosis) in the ulcers, with lymphoid infiltration, congestion and thrombosis, and very little polymorpholeukocytic invasion. The amebse secretion and thrombosis both tend to produce the necrobiosis. If there is marked polymorphonuclear infiltration, pathogenic bacteria are playing an active part in the process; noticeably then there is diphtheritic inflammation (Fig. 208) or gangrene. When amebae are found in exudates rich in bacteria, they show evidences of active phagocytosis. In some cases there are many bacteria, but they are probably non-pathogenic, as marked leukocytosis was not present and no process could be seen to be attributed to them. " In effect, intestinal amebiosis may be said to be rather a subacute chronic inflammatory process, as was demonstrated by the character of the exudate and infiltration, by the early formation of granulation tissue and by the absence of leukocytic infiltration, a notable absence of purulent inflamination. This applies to the cases not complicated by diphtheritic process or gangrene" (Musgrave). If the diphtheritic process is associated, some strain of the bacil- lary type is probably responsible ; and if gangrene, some other bacteria (mixed infection). Lesions (Abscesses) of the Liver. — There may be local necroses of the parenchyma scattered throughout this organ due to probable chemic products of the am.ebae, and also abscesses. _ This is quite a common complication of amebic dysentery, and occurred in 27 out of Osier's 119 cases. Most of the so-called amebic liver abscesses are really local necroses and no pus at all. They may be single or multiple ; when single, the right lobe is most commonly affected on the convex surface hear the attachment to the diaphragm, or on the concave surface near the bowel* Multiple abscesses (small and superficial) miliary, containing amebae, may be scattered throughout the liver substance (Osier). The hepatic abscess, though it often occurs within the first two to three months after the onset of the dysentery, in some cases may not appear for several years. Some cases are reported as occurring when no dysenteric symptoms had apparently been complained of by the patient. 5IO DISEASES OF THE STOMACH AND INTESTINES In the early stage -the abscesses are a grayish-yellow color, sharply- defined in shape, and contain a spongy necrotic material, with more or less glairy semitransparent fluid in the interstices. The larger ab- scesses have ragged necrotic walls and contain a viscid greenish- yellow or reddish-yellow purulent appearing material, mixed with blood and shreds of liver tissue. Old abscesses of a chronic type have a dense fibrous wall. The outer zone is hyperemic ; the midzone shows proliferations of connec- tive-tissue cells, compression and atrophy of the .liver cells, and an inner necrotic zone. There is the same absence of true purulent inflammation as in the intestines, except where there is a secondary infection with pyogenic organisms. When the latter are present we have true purulent accumulations. The contents of the necrotic type of abscess show fatty and glandular detritus, necrotic hepatic cells, amebae, and occasionally Charcot- Ley den crystals. Amebae are also found in the abscess walls. Cultures are frequently sterile. Micrococci and bacilH may be found, notably the Staphylococcus aureus. Streptococcus pyogenes. Bacillus coli (with other organisms), Bacillus pyocyaneus, and Micrococcus lanceolatus. The abscess most frequently points upward and ruptures into the right lung. In some cases an empyema may be produced or a pyo- pneumothorax. Perforation may occur in other directions, into the pericardium, peritoneum, stomach, intestines, portal or hepatic veins, inferior vena cava, kidney, or externally. Symptoms. ^There has been a tendency to arbitrarily divide amebic dysentery into two clinical types, the acute and the chronic, and to create the impression that in acute and chronic dysentery we have necessarily diarrhea or diarrhea alternating with constipa- tion, the passage of blood and mucus, and the presence of tenesmus. Unquestionably latent and masked infections, with intestinal ame- biosis are by no means rare, and marked pathologic changes may be present without objective clinical symptoms. Councilman, Lafleur, Osier, Dock, Strong, and Musgrave have reported such cases. The latter notably refers to one case treated six months for constipation, in whom autopsy showed perforation of a liver abscess as the cause of death, with associated lesions (amebic ulceration) of the cecum and ascending colon. The early recognition of these irregular types is of great import- ance, especially when amebic dysentery is endemic. Unquestionably, some of our old cases of apparently simple catarrhal colitis are of this type. In fact, I have had one experience with such a case, where amebae were found present, y\dth ultimate recovery under appropri- ate treatment. vSince many of the cases may present no clinical symptoms of amebic dysentery, I believe Musgrave's' classification, under "In- 1 Journal of American Medical Association, September i6, 1905. DYSENTERY 511 testinal Amebiasis," to be the most scientific, which I have but sHghtly modified. 1. Latent and masked infections with the amebae. 2. Mild and moderately severe infections (subacute dysentery). 3. Severe infection, including gangrenous and diphtheritic types (acute dysentery). 4. Chronic dysentery. 5. Infection in children and in the aged. Latent Infection. — In these cases there is a pathologic amebic process in the intestines, without any diarrhea or any other s^'mp- toms that would indicate the infection. Musgrave has demonstrated that the symptoms pointing to dysentery may be absent for a long time, yet there are certain symp- toms which suggest the condition. Dull aching abdominal pains are present, which are attributed to catching cold. They first appear and are most active during the night or early morning. Indigestion, headache, lassitude, coated tongue, and a foul breath are present. There are loss of appetite, some loss of weight, loss of color, and at times a yellow skin. Physical examination discloses on deep palpation tenderness along the colon, especially over the cecum and ascending colon. This last is a significant symptom; occasionally thickened intestines can be made out. If a hydragogue cathartic be administered, there will be present in the stool amebae, mucus, tissue elements, and often old blood. Musgrave has demonstrated by autopsy on his fatal latent cases that the lesions are in the cecum and ascending colon. Any patient, therefore, living where amebic dysentery is endemic, suffering from the symptoms referred to, should be given a saline, and the stool •carefully searched for amebae. The possibility of amebic infection in chronic coHtis with no diarrhea should be considered in New York. I have already referred to a patient infected in that State. On the other hand, some of the latent cases, if untreated, may later de^'elop the symptoms of amebic dysenter}^ - Under the same class of cases (latent) in regions where amebiosis is endemic we may have patients in whom other symptoms, such as chronic constipation, gastric symptoms, or even appendicitis, may mask the intestinal amebiosis. Musgrave has reported such cases. Mild and Moderately Severe Cases (Subacute Dysentery). — Mild Cases. — These frequently develop from the latent type and often pre- sent the aspects of a diarrhea and not of dysentery. Abdominal pain, tenderness along the colon, headache, digestive disturbances, irrita- bility, melancholic condition, anemia, and loss of weight are present. Amebae are found in the diarrheal movements. Some of these cases never show dysenteric movements, even without treatment. This type Musgrave believes often becomes chronic; while, on the other hand, chronic gastro-enteritis or "sprue" may be the ultimate 512 DISEASES OF THE STOMACH AND INTESTINES outcome, giving their clinical pictures. The patient usually dies from intermittent disease or complications. Moderately Severe Cases {Subacute Dysentery). — In these cases with the symptoms just described there may be a diarrhea more marked in the morning, consisting of several semifluid stools, no mucus or blood, and passed without pain. This may intermit with constipation. Finally, the attack may increase in intensity, and mucus and blood will appear. In other cases they will occur from the onset. Usually the more acute the onset, the more rapidly the^ severe symptoms develop. Severe Cases {Acute Dysentery). — -These are the classical cases usually described. Diphtheritic and gangrenous processes, due to some secondary infection, are most common in this type. The onset is usually quite sudden, whether primary or following on a milder type. There are marked abdominal colic; diarrhea; tenesmus, which may be constant and very painful; straining, and then finally passages chiefly of small quantities of mucus and blood. In some cases the dejecta are hemorrhagic, consisting of pure blood or dark and coagulated blood. Sloughs are passed in others, con- sisting of gray or blackish masses of necrotic tissue of very foul odor. The temperature, as a rule, is not high. The patient rapidly emaciates, and the heart becomes rapid and feeble. Death may occur in severe cases within a week from the onset. Hemorrhage (intestinal) or perforative peritonitis may take place. Many cases recover, but some become chronic. In others extensive ulceration may remain after sloughing and the diarrhea continues, the patient rapidly emaciating, and finally dying exhausted within a couple of months. Emaciation is very marked in these patients. Corneal ulceration may occur. Stools. — As many as twenty to thirty may be passed in twenty- four hours, colicky pains usually precede them, and they are followed by straining and severe tenesmus. Movements at first are copious, later scanty, and chiefly mucus and blood. Intermissions and exacerbations of diarrhea occur, gangrenous dejecta, dark red brown and containing gray or black fragments of tissue (foul in odor), may be passed, or pure blood. Amebse are present in the stools. Abdominal Pains. — These are quite severe, chiefly before evacua- tion, and sometimes continuous. They are frequently located in the umbilical region and left iliac fossa ; at times in the right iliac fossa, and may simulate appendicitis. Pressure increases the pain. Tenesmus. — ^This consists of pressure and constriction in the rectum and a desire to go to stool. It may be continuous and accom- panied by dysuria or strangury. Other Symptoms. — ^Fever may occur, generally of moderate type, and it may be accompanied by chills at the onset. Temperature is irregular. Anorexia, nausea, and vomiting may occur. There DYSENTERY 513 may be severe prostration, cold extremities, delirium, stupor, drowsiness, and cerebral disorders. Chronic Dysentery. — This type of dysentery shows several forms. It may be rather mild, characterized chiefly by diarrhea, with no blood or tenesmus, following on the mild type previously described. This may continue a number of years. Dysentery in more marked cases is subacute from the onset or gradually passes into the chronic stage. There are generally alternating periods of diarrhea and constipation covering several years. During the exacerbations there are pain, passages of blood and mucus, tenesmus, and a slight rise of temperature. Many such cases do not feel especially ill between attacks and keep fairly well nourished. The appetite is often irregular in this type, and errors in diet are followed by exacerbations of the disease. The tongue is red, glazed, and beefy. In more severe cases emaciation may be extreme and the patient be confined to bed most of the time. There are loss of appetite and nausea ; diarrhea is quite persistent, there being mucus or mucus and blood in the stools, with attacks of colic and tenesmus. There may be some periods of improvement. Infection in Children and in the Aged. — Musgrave reports cases in children from the age of six months to ten years in the Philippines. Children seem to present a natural immunity, he believes, and when infection does occur it seems of a mild type and readily yields to treatment. The symptoms resemble those of the mild type in adults. In the aged there also seems to be a natural immunity, but when the disease was established it ran a severe and rapid course. Liver abscess is infrequent in the very young and aged ; Musgrave notes it is infrequent in the natives. The only certain method of diagnosis is by microscopic examina- tion of the feces or discharges and finding the amebae. Other parasites are found at times associated with the amebae, such as the trichomomedae, ova of uncinariae, embryo strongyloides, tenia, oxyuris, etc. Circulatory System. — The pulse may be of good quality at first; later, rapid and feeble. There are the changes of secondary anemia. Early, the blood is normal; later, the red cells are those of anemia. Still later, they may become irregular in size and shape and the count be reduced. Leukocytes. — An increase in polynuclears and eosinophiles. Hemoglobin decreases with the red cells. Spleen usually not enlarged. Temperature may be absent, moderate, or intermittent. In cases that are complicated, especially if there is diphtheritic inflammation of the colon, it may become quite high. With liver abscess tem- perature is frequent, but not constant. If there is mixed infection 33 514 DISEASES OF THE STOMACH AND INTESTINES in the liver, bacteria with the amebae, the temperature may be intermittent or remittent and resemble malaria or endocarditis. Sometimes it may be subnormal. Nervous System. — Neuritis and neuralgias may be present. Pain. — This varies in type and intensity. Tenesmus. — More often is an indication of secondary involvement or complications. It is never present in the latent forms, and is often absent or very slight in the moderately se\'ere cases. In acute cases with diphtheritic process or secondary infection, as from Bacillus dysenterise (Shiga), it may be severe. It is more likely absent when the lesions are in the cecum or upper colon. Colicky pains frequently occur, and at times severe colic. The dull, aching abdominal pain is often prodromic and persists during the course of the disease, at times interfering with the patient's rest. The greatest intensity is usually along the colon, as demon- strated by palpation. Sometimes it is confined to the cecum. It ma}^ be complained of in the back. It is probably due to the ulcera- tive process in the bowel and, as demonstrated in the latent cases, as shown by post mortem, is the only indication during life of serious lesions. These pains are often the worst at night. Burning pains ("heart-burn in the abdomen") ^lusgrave states may be general or local ; when the disease is in the sigmoid or rectum, these pains may be intense, and extend down the backs of the thighs to the calves, and old cases of sciatica may be started up. Musgrave holds that the beginning of sciatica, associated with such cases, is of sufficiently frequent occurrence to be suggestive. Appendicitis pains are at times stimulated, but examination will show that the tenderness is located in the caput coli. The differential method by IMorris' point would be of value in these cases, as described under Appendicitis. Neuralgia, myalgia' and arthralgia may be present. There is persistent dull headache in the back of the head and neck. The genito-urinary, respiratory, and special senses are rarely involved, as is also true of the joints and osseous systems, though complications may occur. Diagnosis. — In amebic dysentery there are so many clinical tvpes that the diagnosis is by no means easy, and can only be made absolutely by microscopic examination of the feces. In regions where the disease is endemic and the microscope is not available one can reasonably infer its presence by the most valuable symptom, to which I have already alluded, namely, "abdominal soreness which is increased on pressure and extends along the course of the colon, especially when there is maximum intensity over the cecum and ascending colon." If bowel movements are present, their odor and the appearance of blood are of chief diagnostic import. Indigestion, pain, nausea, and other symptoms are not as important. DYSENTERY §15, Often a thickened tender colon may be felt on palpation. These symptoms give the nearest approach to diagnosis without micro- scopic examination of the feces. Loss of weight is a guide to the infection. Musgrave believes that the presence of ameba in the stools in tropical regions should be considered diagnostic for purposes of treatment. Amebiosis should be treated, even if other complications are present. Prognosis. — The disease is generally milder iri children and in the natives of the tropics. The course is shorter and the mortality higher among the aged. Previous good health is a favorable factor. The shorter the duration of the disease and the earlier the local treatment, the better is the prognosis. The higher up the lesion, the greater the mortality and the less active the clinical symptoms of dysentery. Infections of the cecum are the most serious. Under proper treatment recovery is the rule in young and well- nourished adults if the disease is not of long duration. The early diagnosis and treatment are the important features, as otherwise the apparently mild cases may assume a dangerous character. Tend- ency to relapse or chronicity are characteristics. Abscess of the li\er is a serious complication. Treatment.— Afet^ica/.— The disease is contracted probably in. the same way as typhoid fever, and the same prophylactic measures should be used. Infection through the drinking-water is undoubtedly the chief method. Musgrave holds that the best rule to observe in countries where the disease is endemic is to "take nothing into the. gastro-intestinal tract which has not been sterilized." He has found the amebae in the drinking-water ; on dishes washed in tap-water ; in the soil from contamination; on the surface of uncooked vegetables, such as lettuce; on raw fruits; from hand contamination; and in ice-cream, water-ices, and milk. Prophylaxis, when the disease is endemic or during epidemics, is very important. All drinking-water should be boiled, and dishes should be washed in boiled water, also the hands. Raw fruits and vegetables should first be placed on ice, and then have scalding water poured over them, which kills the ameba?. Ice-cream and water-ices should not be taken. The vaginal douche and especially rectal enemata from tap-water should be avoided. The stools should be disinfected in carbolic acid (1:20) or m bichlorid of mercury (i : 1000), and the same precautions taken with linen— soaked in carbolic acid (1:20) and boiled. 5l6 DISEASES OF THE STOMACH AND INTESTINES Care of the hands and the prevention of fly infection (by screens) are necessary. We have aheady noted that mixed infection with the Bacillus dysenteriae (Shiga) may be present. The acid of the stomach lessens the chance of infection, and acid mixtures may be given, such as dilute hydrochloric acid. In acute dysentery the patient should be put to bed and placed on a liquid diet: barley-water, rice-water, bouillon, broths, gruels, white of raw egg, tea, also peptonized milk diluted with lime-water (at least 25 per cent, or more), or peptonized and diluted, or equal parts of milk and barley-water. With some sour milks agree, as kumyss, etc. Sanatogen is an excellent preparation and somatose is of service. Personally I prefer milk-free diet and only the strained broths, gruels, etc., and 10 per cent, gelatin solution flavored with vanilla, oiv to vj (125-185 cc). Give nourishment in divided doses (2 quarts daily) and a large amount of acidulated water. If the tem- perature is over 102.5 ^-y only water is given until defervescence to that point. Later the diet can be increased. Hot applications or poultices should be employed over the abdomen for the reUef of pain or colic. Internal Medication. — Musgrave and Osier both object to the use of bismuth preparations for the diarrhea, on the ground that they coat the ulcers and interfere with their local treatment. I believe this probably to be true as regards bismuth subnitrate or subcar- bonate, which would be required in large doses. I have occasionally employed bismuth subgallate, gr. 5 to 10 (0.3-0.6) t. i. d., in com- bination with other remedies, apparently with benefit. On the other hand, I have seen at times that, in spite of all treatment, too frequent movements continue either in the acute or chronic cases. In such event I have employed bismuth subnitrate as much as gr. 90 to 120 (6.0-8.0) in divided doses in twenty-four hours with good results. This is preferable to the use of opiates, and I only employ it to avoid such. I have never had nitrate poison- ing from large doses of bismuth subnitrate. It would seem a more likely occurrence in children. In the initial stage the patient should be given magnesium or sodium sulphate, oj to ij (4.0-8.0), one or two doses, so as to thor- oughly cleanse the bowels. Calomel, gr. 5 (0.3), may be given, or a single dose of castor oil, oiss (45.0). In young persons these remedies in smaller doses. Some recommend TTLxx (1.18) of laudanum, followed in half an hour by gr. 20 to 30 (1.3-2.0) of pulv. ipecac, after the saline treat- ment; but, like Musgrave, I believe this of no special service in these cases. Occasionally salol, gr. 3 (0.194), with guaiacol carb., gr. 3 (0.194), and gr. i (0.065) of pulv. ipecac, given several (three or four) times DYSENTERY 517 a day, with small doses of Dover's powder, gr. 2 to 3 (0.13-0. 194), have proved of service. Strong has reported good results in some cases by giving inter- nally acetozone (i : 5000 or i : 3000) in carbonated water, i to 2 Hters (quarts) in twenty-four hours in divided doses. I have recently employed i liter (quart) of acetozone (i: 1000), given in divided doses by mouth during the day with good results. Just before administering, the dose can be flavored with orange juice to make it more palatable. Among valuable astringent remedies are: Salicylate of guaiacol (guaiacol-salol), gr. 5 to 10 (0.3-0.6); tannalbin, gr. 10 (0.6) ; tannigen, gr. 10 (0.6) ; or tannoguaiaform, tannopin, and tannocol, given in doses of gr. 5 to 10 (0.3-0.6) three or four times a day. Hydrochloric acid with pepsin or alone, or nitromuriatic acid are of value. Musgrave recommends hydrochloric acid. Thus: I^. Acidi hydrochlor. dil. | aa ^iii (12 o) Comp. tinct. cinchona J <-> J ■ ■ 1 Aq. destil q. s. oiv (125.0). — M. Sig. — 3 j to ij (4.0-8.0) in water t. i. d. before food. Vomiting should be treated by the methods described under Acute Gastritis. Small doses of Dover's powder may be required for persistent diarrhea. Local Treattnent. — ^This is of extreme importance, not only in the acute but also in the latent and chronic cases. Extensive researches were conducted by J. B. Thomas, reported in Bulletin 32, Bureau Government Laboratory, Manila, who found the following solutions destructive to ameba or inhibiting their growth : Acetozone, i : 1000, most destructive to amebae, and alphozone, 1 : 1000, nearly as much so. They destroy other bacteria as well. Protargol and argyrol, i : 500, were excellent antiseptics. Sul- phate of quinin, 1:500, preferable strength, or bisulph-quinin ; nitrate silver, 1:2000, of service; thymol, 1:2500, readily destroys amebge; also permanganate of potash, i: 2000, is useful. Hvdrogen peroxid was recommended by Harris some years ago, and I have used it successfully for some time. Cold water (under a temperature of 45° F.) has been highly advocated by J. P. Tuttle as destructive to the amebae and also removing them from the bowel. He sometimes employs 5 to 10 per cent, hvdrogen peroxid in this injection, and places the patients in the knee-elbow position and has them retain the injection for a considerable time (one-half hour). A glass irrigator, attached to a colon-tube, with the opening preferablv at the end, can be employed; if the ulcers extend low 5l8 DISEASES OF THE STOMACH AND INTESTINES down into the rectum or there is extreme tenesmus, then an ordinary- rectal tip. The foot of the bed should be elevated 12 to 18 inches and the patient placed in the Sims position, or the hips can be elevated on a pan. The patient's position should be changed and he should be moved so the fluid will gravitate into the caput coli by movements described as "rotation method" under Enteroclysis. Musgrave recommends the injection of at least i to 2 liters (quarts) , which should be retained five to fifteen minutes, preferably the latter. At the commencement, if there is much irritation, often a smaller quantity must be used. The knee-elbow position advised by Tuttle is excellent in the latent or chronic cases, but I would not advise it in acute conditions. If there is much irritation one can precede the antiseptic injection one-half hour by a small enema of normal saline solution — Bij (60.0) containing gr. | (0.016) of morphin — or with tincture belladonna, ITLx (0.592), alone or together. This should only be done once or twice in the first twenty-four hours and not repeated. Musgrave has suggested taking advantage of the action of reversed peristalsis by giving occasionally a preliminary enema of a 7 to 8 per cent, salt solution, about i pint (500 cc), containing gr. I (0.016) morphin, one-half hour before the antiseptic injection. He then employs acetozone (i : 5000 to i : 3000), combined with quinin (i : 1000 to i : 750), or gives the injections alternately, employ- ing one to five enemata every twenty-four hours, according to the severity of the case. Alphozone, same strength, or hydrogen peroxid (i : 10) can be substituted. We must remember that quinin affects some cases badly, causing gastric symptoms, vomiting, and headache. It must be omitted or weaker solutions given to such patients. Quinin is much more efficacious in the strong solutions (i: 1000 to even i : 500). The usual solutions suggested are much too weak. One can take advantage at the same time of the cold injections, as suggested by Tuttle, unless the patient have an idiosyncrasy to cold or renal complications. In such event a hot injection at 120° F. is of service. An excellent method is to alternate, giving an enema of acetozone (i : 1000), and the next enema of quinin (i : 1000 to 1:500), cold, at 50° to 40° F. If the quinin disagrees, then alternate the acetozone or alphozone with thymol (i: 2500), or protargol or argyrol (1:500). The silver nitrate is at times found irritating in the acute cases. Permanganate of potash ( i : 2000) is also of service, or hydrogen peroxid, oiv (125.0 cc.) to i liter (quart). The local treatment is of chief importance to check the lesions DYSENTERY 519 and prevent liver abscess. In the latent cases the bowels should be opened freely with magnesium sulphate and daily injections of quinin and acetozone given. In cases of marked tenesmus, where the large or even small injections cannot be retained, recurrent irrigations with the antiseptic solutions, i or 2 gallons — i pint (500 cc.) being kept in the bowels, with marked elevation of the bed and the solu- tion of one-half strength — are of great service. Chronic Dysentery. — In the chronic cases the diet should be quite liberal, but indigestible and rich food should be avoided. Mashed potatoes, boiled rice, and constipating food are often indi- cated in the diarrheal cases, and the avoidance of fruits and green vegetables. Milk, eggs (raw), the sour milks, and fats are of value. Judgment must be used in each case as to what will agree, whether liquid, semisolid, solid food, or combinations. Sanatogen is of value, and the iron preparations are often indicated. The tannic acid preparations, as suggested in the acute cases, should be em- ployed. Occasionally large doses of bismuth subnitrate are neces- sar}^ Quinin and acetozone injections should always be employed; and nitrate of silver (i : 3000 to i : 2000) is of value, used once or twice a week to heal the ulcers. Change of climate is valuable. In all cases of fever, sponging (alcohol) is the best method of treatment. I deprecate the use of antipyrectics. If heart stimu- lants are required, small doses of strychnin, caffein, and spartein, or camphorated oil by hypodermic. I have, moreover, a suggestion which I believe may prove of value. Pififard and Tousey have demonstrated that IMorton's claims regarding the production of internal fluorescence by the x-rays after the administration of small doses of fluorescein or quinin are fal- lacious. However, the use of gr. | (0.016) fluorescein in ovj (200 cc.) of water,^ and placing the patient in the full electric-light bath for fifteen minutes or more, I believe, might prove of service in latent, chronic, or even in acute dysentery. There is great heat penetration from this light bath, as has been demonstrated in rheumatic and other conditions, and necessarily a certain penetration of light rays. The heat, light, and fluorescence are destructive to amebse. Musgrave demonstrated that violet light, x-ray light, and fluores- cence inhibit amebic action. Carbonic Acid Gas for Tenesmus. — Rose has demonstrated that the injection of CO2 into the rectum will relieve tenesmus. It is worthy of use as an adjunct and can be given by his bottle. Intestinal hemorrhage from dysenteric ulcers should be treated by high injections of 10 per cent, gelatin or, preferably, Tremoliere's solution, or, rather, a modification : Tremoliere. — Gelatin, 5 per cent, solution, containing calcium chlorid, 2 per cent. 1 The fluorescein solution should be given by high enema; soda bicarbonate, gr. XV, should be added before injection, and water, q. s. i quart (liter). 520 DISEASES OE THE STOMACH AND INTESTINES TremoUere (Modified). — Calcium lactate, gr. 20 (1.3); gelatin (10 per cent.), oviij (500 cc). Hot (120° F.) or cold (40° F.) astringent injections — oj (4.0) alum to I pint (500 cc.) — may be required. Avoid cold if there is shock. Morphin, gr. i to ^ (0.008-0.016), by hypodermic at once; ernu- tin, TTLv (0.296), hypodermically, or fluidextract of ergot, oj (4-0), internally; ice-bag locally; calcium chlorid or lactate, gr. 10 (0.6), by mouth every three hours, gelatin solution (5 per cent.) may also be taken by mouth. Hypodermoclysis may be required if there is marked shock, or even infusion. " Surgical Treatment. — In cases of chronic dysentery of long dura- tion which do not respond to medical treatment, or in such cases with repeated acute exacerbations, surgical procedure is indicated. This is true of either the amebic or bacillary type of dysentery. " Appendicostomy. — This operation was first suggested by Weir. It consists in suture of the appendix to the abdominal wall and skin, and removal of its apex. Subsequent irrigations of the large in- testine are carried out by means of a small tube or catheter, which is inserted through the lumen of the appendix. "Cecostomy. — An incision is made over the cecum and the latter brought into the abdominal wound. The cecum is incised and sutured to the abdominal wall. A catheter or drainage-tube is then inserted for the purpose of irrigation of the colon. Gibson has devised a valve operation, separating the abdominal muscles in a special manner so as to prevent leakage and ultimately secure a more ready healing. Cecostomy is indicated when the appendix is diseased or in an ab- normal position, so that appendicostomy is impossible. ' '5. G. Gant's Modified Cecostomy. — Gant^ makes his incision over the cecum nearer the ileocecal junction. After opening the cecum and suturing it to the abdominal wall by means of a special director, he inserts a drainage-tube or catheter through the ileocecal valve into the ileum. A second tube is inserted into the cecum. In cases where ulceration of the ileum is present, it is thus possible to irrigate both ileum and colon." Excellent results have been reported from these methods. BACILLARY DYSENTERY Definition. — A form of coUtis, frequently an ileocolitis, usually of an acute type; occurring sporadically and in severe epidemics; attacking children as well as adults, and characterized by pain, tenesmus, and the frequent passage of blood and mucus; the result of infection by a specific bacillus, of which there are various strains. Etiology. — Owing to improvement in sanitary conditions bacillary dysentery is less frequent. This is the type which has ' New York Med. Jour., Aug. 15, 1908. DYSENTERY 521 proved such a scourge, as epidemics in crowded asylums, institutions, and camps. It is one of the great camp diseases, and I have aheady referred to the fact that Woodward collected 259,071 acute cases during the Civil War. The disease prevails in the Phihppines, Porto Rico, Cuba, and in South Africa. In Japan a fatal type has prevailed, especially in summer and autumn, having a mortality of over 25 per cent. In 1899 there were 125,489 cases with 26,709 deaths, collected by Eldridge. Most of the severe epidemics in the tropics are of the bacillary type, and the same form prevails in the temperate climates. Bacillus Dysenterice. — In 1892 Ogata, during an epidemic of dysentery in Japan, isolated fine bacilli which when introduced by the mouth or rectum produced ulceration in the intestines of cats. In 1897, during a severe epidemic, Shiga isolated the Bacillus dysen- teriae and described its special characteristics, demonstrating it to be the specific cause of the disease. Flexner and Barker found in the dysentery in the Philippines an identical organism, and Strong, Musgrave, and Craig have made a careful study of it. It has been found in acute dysentery in Porto Rico. Out of 1328 cases of dysentery in Manila, Strong and Musgrave report 71 of the bacillary type, 51 suspected bacillary, and 561 amebic. ' Kruse, in Germany, has isolated an identical bacillus. Vedder and Duval demonstrated that sporadic cases in adults in Philadelphia, and also epidemics in the Lancaster County Asylum, Pennsylvania, and in the Almshouse, New Haven, were due to the Bacillus dysen- teriae. Duval and Bassett, during the summer of 1902 at Mount Wilson Sanitarium, first demonstrated that certain forms of summer diarrhea in infants were due to Bacillus dysenteriae, and under Flexner 's direction at the Rockefeller Institute investigation, into the cause of infantile diarrhea in New York, Boston, Philadelphia, and Baltimore, showed the Bacillus dysenteriae present in 63 per cent, out of 412 cases. Several strains of this bacillus have been found, and the Flexner- Harris type is the one most frequent in the United States. These strains have been determined by the relative agglutinative power of immune serum upon the bacilli isolated, and also by the action of the bacilli upon various sugars. Flexner recognizes three types :^ 1. "Shiga type" attacks glucose, without action on other sugars, including mannite and lactose. 2. "Flexner-Harris type" attacks glucose, mannite, and dextrin, not lactose. 3. "Bacillus" (Hiss and Russell) attacks glucose and mannite. No action on dextrin and lactose. The lesions produced by the diflferent strains are identical. The organism agglutinates with the blood-serum of cases with acute dysentery, as well as with the serum of immunized animals. The Flexner-Harris type agglutinates in dilutions of i : 1000 to i : 1500. 1 Hiss now recognizes four groups based on fermentative characteristics, and Shiga has added a fifth, intermediate between the acid and non-acid bacilli. 522 DISEASES OF THE STOMACH AND INTESTINES In two instances the organism has been isolated by Duval in the stools of healthy children. In dysenteric stools it is most readily isolated from the particles of mucus. The organism has not yet been isolated outside the human body, but the belief is that it is prob- ably water-borne, and that the same prophylactic measures should be taken as in typhoid fever. Camp epidemics clearly originate in this way, and the care taken by the Japanese in regard to the latrines and water-supply practically eliminated the disease during their recent war. Morbid Anatomy. — In acute cases, when death has occurred during the first week, the mucous membrane of the large intestine is swollen, hyperemic, of a deep red color, and presents elevated coarse ridges and folds. There are ecchymotic patches scattered throughout the swollen mucosa; over the surface there is usually a superficial necrotic la3^er, which can be brushed off lightly with the finger. This may be in patches or over large areas. There is no ulceration, but only the superficial general necrosis of the mucosa. They are, in effect, superficial erosions which give it a worm-eaten appearance. This superficial necrotic layer is, in effect, a fine pseudomembrane. The soHtary follicles are swollen and red, but their prominence is obscured in the involvement of the mucosa. In severe cases the entire coats of the colon may be stiff and thick, and the mucous membrane greatly increased in thickness, grayish- black in color, extensively necrotic, and in places gangrenous. The submucosa is often enormously thickened and edematous. The serous surface is often deeply injected and the vessels of the mesentery, especially near the sigmoid and rectum, may be distended. The ileum for lo or 15 cm.' is quite frequently involved (which is rare in amebic dysentery), having a deeply hemorrhagic mucosa with superficial necrosis. Peyer's patches and the solitary glands may be moderately swollen. The specific bacilli and various cocci^ are abundant in the necrotic mucous membrane, and are said by Strong to be seen in all the coats. In the subacute cases there is less thickening of the intestinal walls, there is less necrosis, the solitary follicles are more swollen, the mucosa less red, there are superficial erosions, and no ulcers. The disease, as suggested by the compHcations, is evidently characterized by a more or less acute general toxemia^ starting from a localized process. Symptoms. — The incubation period is not more than forty-eight hours. The onset is usually sudden and characterized by fever, pain in the abdomen, and frequent stools, first containing mucus, and later consisting chiefly of mucus and blood. The movements increase in frequency and are associated with tenesmus, which be- ^ Streptococci and various other types may be present. 2 The toxins of dysentery are probably excreted by the bile and also through the intestinal mucosa, thus aiding in the damage to the intestines. Probably the toxins are responsible for cerebrospinal lesions (HerterV DYSENTERY 523 comes very marked. The movements may occur as frequent!}' as every half-hour, and there is much straining. The tongue is coated with a white fur and there is excessive thirst; nausea and vomiting may occur. The abdomen is not distended, but there may be tender- ness, especially over the colon. There are cramp-like pains in the abdomen. The spleen is not usually enlarged. The temperature rises to 103° or 104° F. It may run an irregular course and rise or fall before death. The pulse increases in rapidity (100 to 120 or even to 150) and becomes rapid and feeble. Urine is decreased and may contain albumin. Liver not enlarged and no liver abscess; moderate leukocytosis may be present. In very acute cases the patient becomes seriously ill within forty-eight hours, the move- ments increase in frequency, the pain is of great intensity, severe headache, and the patient becomes delirious and dies on the third or fourth day. Lobar pneumonia, bronchopneumonia, acute bron- chitis, and fib rino purulent pleuris}^ may occur. In cases of moderate severity the symptoms abate, stools lessen, temperature falls, and within two or three weeks the patient is con- valescent. In the subacute cases the attack may last many weeks or even months, the patients have three to five bloody mucous stools in twenty-four hours, and become very emaciated. One of Strong's cases died on the sixty-fourth day. The Bacillus dysenteriae is found in the stools and agglutinates with blood-serum. Other Clinical Types. — The description just given applies to the types of bacillary dysentery such as seen in Japan, the Philip- pines, and the tropics, and the features of that in adults in temperate climates differ in no essential, except in many cases it is less severe. Duval, as noted, has found one of the bacillary dysentery strains in sporadic cases in Philadelphia and elsewhere, and the probability is that most cases of non-amebic dysentery belong to this type. The so-called acute catarrhal dysentery is unquestionably a sporadic form due to the Bacillus dysenteriae. This is the more probable when we consider that in ileocolitis (dysentery) in infants we find a catarrhal type. In infants there are four types of lesion found on autopsy (Holt) : FolHcular ulceration; catarrhal inflammation; catarrhal inflam- mation with superficial ulceration; membranous inflammation. This last differs from the membranous type in adults, in that there is little psuedomembrane and no deep sloughing. Holt has well described these varieties. Diphtheritic^ dysentery is a type of the bacillary form with great necrosis and infiltration of the mucosa. It is believed that other types of bacteria are also often associated in the process. 1 The pure dysentery bacillus, unlike the typhoid bacillus, does not lead to bacillemia or bacilluria (Herter, Bacterial Infections of the Digestive Tract). In the diphtheritic type, a mixed infection in which streptococci undoubtedly are prominent, the condition is unquestionably, in my opinion, a general infection, as shown by the complications. 524 DISEASES OF THE STOMACH AND INTESTINES The secondary diphtheritic dysentery is a common terminal event in many acute and chronic diseases. Vedder and Duval have demonstrated that the bacilli are present in these cases. Peritonitis is rare, either through extension or by perforation. When it occurs about the cecal region, perityphlitis results, or when low down, periproctitis. In io8 cases collected by Woodward, perforation occurred in ii. Abscess of the liver is very rare. A few cases occurred in the Civil or South African War. In the tropics malaria and dysentery may coexist, and typhoid and dysentery coexisted quite frequently in the Civil War. In ordinary practice it is very rare. Complications. — Acute bronchitis, pneumonia, bronchopneu- monia, pleurisy, gangrene of the lung, albuminuria, meningitis, paralysis, paraplegia, in many cases due to a neuritis, are not un- common ; thrombosis of cerebral sinuses, embolism (cerebral) , rheu- matic pains and swollen joints (analogous to gonorrheal arthritis), pericarditis, endocarditis, periproctitis, perityphlitis, and occasion- ally pyemic manifestations, such as pylephlebitis or abscess of the spleen, may occur. Anemic edema may be present in protracted cases. Chronic Bright's disease is an occasional sequel and intes- tinal stricture is rare. Persistent dyspepsia and irritability of the bowels may follow. Prognosis.. — -In the very severe cases the prognosis is bad, the patient often dying within one to two weeks. This is especially true in epidemics. In milder cases convalescence begins by the end of the second week. Chronic cases may run weeks or even months, the patient becoming very emaciated. They may die at the end of several months. Convalesence is slow in any but the mild cases. Treatment. — Prophylaxis. — The same precautions should be exercised as regards boiling drinking-water, avoiding green vege- tables, cleanliness of the hands, destruction of flies, disinfection of stools and linen, as are carried out in amebic dysentery and in typhoid fever. Medication. — The bowels should be at once thoroughly cleared with castor oil, oj to ij (30.0-60.0), or with magnesium sulphate or sodium sulphate, 5j to ij (4.0-8.0). Buchanan has had excellent results by the sodium sulphate treatment; he gives oj (4.0) sodium sulphate four to even eight times a day for two to three days until blood and mucus have disappeared. He has treated 855 cases with 9 deaths — an excellent record. The old ipecac treatment is still in considerable repute in tropical countries. No food is taken for three hours, then 20 drops of lau- danum are administered and one-half hour later gr. 20 to 60 (1.3-4.0) of pulv. ipecac. If this is vomited, the dose is repeated in a few hours. In South Africa the saline treatment was often given combined later with the ipecac, and Washbourne reported good results. DYSENTERY 525 Ringer recommends small doses of bichlorid, gr. tco" (0.00065), every two to three hours, and large doses of bismuth subnitrate have been used with success, at least oss (2.0) and sometimes as much as 5j (4.0) every two hours daily for the first few days. The fol- lowing I have found the most rational method of internal medication.^ The bowels should first be thoroughly cleared by the administra- tion of oiss to ij (45.0-60.0) of castor oil in the adult, or by several doses oj to ij (4.0-8.0) of magnesia sulphate or sodium sulphate; calomel, gr. v (0.3), may precede this. A hot appHcation should meanwhile be applied to the abdomen to relieve the pain, and if the latter be unendurable and there is considerable collapse, a very small hypodermic of morphin may be given, sufficient to render it endur- able and not large enough to interfere with peristalsis. It is pref- erable not to administer opiates until thorough cleansing of the bowels has been accomplished. In fact, it is my belief that opium is given too frequently and in too large doses, so that material accu- mulates in the bowel which had better be expelled. Bismuth subnitrate, which it is preferable, as a rule, not to use in the undermined ulcers of amebic dysentery, in this type is of great value. The dose should be large. After thorough clearing of the bowels, bismuth subnitrate alone or combined with equal parts of saccha rated pepsin should be given. At least gr. 20 to 30 (1.3-2.0) of this mixture or even gr. 20 (2.6) of bismuth subnitrate every two to three hours. Bismuth subcarbon^ ate, gr. 10 to 15 (0.6-1.0), can be substituted. Bismuth subgallate, gr. 5 to 10 (0.3-0.6) t. i. d., or bismuth salicylate, gr. 10 (0.6) t. i. d., can be substituted in place of some of the usual doses of the other preparations; thus, for example, bismuth subgallate and bismuth subnitrate could alternate. Bismuth subnitrate, gr. 30 (2.0), mis- tura cretae^ 5ij (8.0), is an excellent combination in one dose, given every three or four hours. The tannin preparations, such as were suggested in amebic dysentery, can be given, three doses substi- tuted for three of the bismuth in the course of twenty-four hours. Thus, if seven doses of bismuth were given in twenty-four hours, give three of tannin and four of bismuth. If the pain is severe, small doses of opium may have to be given, with the precautions noted. Children should receive proportionately small doses of all remedies. The opiates are described under Diarrhea. Tenesmus should be relieved first by thorough bowel irrigation, and after this, if it continue, by inflation with a small amount cf CO2 (Rose's method), or by a small injection of starch- water and lau- danum, Tltxv (0.888), with tincture of belladonna, Tllx (0.59). Opium should never be given first, thus tying up the foul secretions. ^ Urotropin, I believe, might be of service; urotropin, gr. v to x (0.3-0.6), combined with equal quantities of sodium benzoate, given three or four times daily. It might lessen the toxemia and be of service in the cases of mixed infection. 526 DISEASES OF THE STOMACH AND INTESTINES Stryclmin, nitroglycerin, or camphorated oil by hypodermic may be reqmred. Local treatment is of paramount importance. Zinc, sulphocarbolate of zinc, and silver nitrate are preferable in the chronic cases. Hypodermoclysis, or even infusion, may be required in shock or severe sepsis. If there is much tenesmus, a preUminary suppository of bella- donna ext., gr. ^ (0.022), alone or, rarely, combined with gr. ^ (0.008) cocain, or the injection of gr. ^ (0.008) cocain in oj (30.0) water, may rarely be necessary. The best method is to insert a recurrent tube and gently irrigate with normal saline solution at 110° to 115° F., or cold at 40° to 50° F., and then, forcing the tube in still further, continue the antiseptic irrigation. I have found the recurrent method of irrigation with a double tube (preferably) or two tubes (soft catheters) of great value in these cases, the patient's hips or foot of the bed being elevated. The patient is gradually accustomed to the fluid, and the quantity allowed to run in before permitting return can slowly be increased and there is not the endeavor to expel the solution. A single injection of any size can often not be given. On the other hand, i to i j Uters (quarts) can be injected by the method of Musgrave in amebic dysentery in some cases. In the acute cases acetozone, alphozone, hydrogen peroxid, and permanganate of potash are of especial value, in the same strength noted below as employed in amebic dysentery. Delafield has secured excellent results by the use of bichlorid of mercury (1:10,000), using 2 quarts (liters), but cautiously, with my recurrent tube. I have had good results by this method, but it should never be given by ordinary enema. Acetozone (1:1000), hydrogen peroxid (i : 10), alphozone (i : 1000), and permanganate of potash (i : 1000) are excellent. Mucol, .5j (4.0) to I quart (liter) or even stronger, has been employed. This preparation contains the chlorid, borate, bicar- bonate, and benzoate of soda, with zinc sulphocarbolate and essen- tial oils. Several irrigations or enemata may be necessary daily, depending on the tenesmus or character of the stool, one or two antiseptic, and the rest of normal saline solution, or flaxseed or gum-arabic. If mucus and blood increase, a cathartic is again indicated, and I believe it should be given every three days in any event. Carbolic acid should never he employed for irrigation. Chronic Dysentery. — Bismuth is of value. Nitrate of silver injec- tions are of ser\'ice — 10 to 30 gr. (0.6-2.0) to i pint (500 cc.) — and inject 2 to 3 pints if possible ; if there is irritation, follow it with an injection of normal saline solution. Protargol or arg\Tol (i : 500) are useful, and often preferable to silver nitrate. Normal saline or normal saline with oil of peppermint, TTlx (0.59), DYSENTERY 527 can be used between the antiseptic injections, or an injection of flaxseed tea or gum-arabic solution. The latter are soothing. Diet. — Acute Cases. — Fluid diet, broths, gruels, barley- and rice-water, beef juice, sanatogen, egg-albumen, and milk well diluted. Somatose is of use. Personally I prefer milk-free diet. In the chronic cases fruits and green vegetables should be avoided and constipating food given if there is diarrhea. The weight of the patient should be increased by administration of fats. The general diet rules should be similar to those in amebic dysentery. Serum Therapy. — Shiga immunized horses and produced a poly- valent serum from which he claims to have reduced the mortality of dysentery in Japan from 35 to 9 per cent. Flexner has prepared a serum, but Holt states results in children have proved disappointing. Complications should receive appropriate treatment. CHAPTER XXV TYPHOID FEVER A MERE outline of this disease will be given for the purpose of differ- ential diagnosis. Typhoid may be defined as a general infection caused by the Bacillus typhosus, characterized anatomically by hyperplasia and ulceration of the intestinal lymph-follicles, swelling of the mesen- teric glands and spleen, and by parenchymatous changes in the other or- gans, such as in the kidneys, liver, etc. CHnically the disease is marked by fever, rose-colored eruption, abdominal tenderness, tympanites, di- arrhea, and splenic enlargement, but these symptoms are inconstant. History. — Louis, in 1829, gave the name to the fever. Gerhard, in 1837, first clinically differentiated between typhoid and typhus. Etiology. — General prevalence. It prevails in temperate cli- mates. Imperfect sewage and contamina:ted water-supply favor the distribution of the bacilli; filth, overcrowding, and bad ventila- tion aid in lowering the resistance of the individual. Fingers, food, and flies spread the disease from the infected person. It is prevalent in England, Wales, India, parts of Germany, and in the United States, where it occupies about fourth place in the mortality list. It has been one of the great scourges of armies, more destructive than powder and shot. The mortality in the South African and Spanish- American wars was greater from typhoid than from bullet wounds; among the American troops, about one-fifth of the soldiers in the national encampments had this disease. The former inefficiency of our sanitary methods was a blot upon our government. In great contrast to this were the remarkable results secured by the Japanese in the recent Russo-Japanese War, where, in comparison with our own records, typhoid and dysentery were practically negligible factors. Season. — The disease is more prevalent in the autumn, though frequent cases occur during August. Sex. — Both sexes are equally liable, but males are more frequently admitted to the hospitals. Age. — ^Typhoid is a disease of youth and early adult life, the greatest susceptibility being between the ages of fifteen and thirty. Cases are rare over sixty. It is not infrequent in children. Infants are rarely attacked. Immunity. — Not all exposed take the disease. One attack usually protects; two attacks have been described, and occasionally three. Bacillus Typhosus. — The researches of Eberth, Koch, and others have shown that the disease is due to a special micro-organism. It is a short, thick, flagellated, motile bacillus with rounded ends, in one 528 TYPHOID FEVER 529 of which, sometimes in both, there can be seen a gHstening round body, probably an area of degenerate protoplasm. It grows readily on various nutritive media and must be differentiated from the Bacillus coli.^ The organism fulfils all the requirements of Koch's law. Cultures are killed in ten minutes by a temperature of 60° C. The direct rays of the sun destroy them in from four to ten hours' exposure. Bouillon cultures are destroyed by carbolic acid (i : 200) and by bichlorid (i : 2500) solution. Toxins have been isolated from the bacilli. Distribution in the Body. — The typhoid bacilli may be demon- strated in the circulating blood, and have been found in the urine, stools, sweat, sputum, and in the rose spots. They occur in the mesenteric glands, spleen, and gall-bladder, and have been found in almost all the organs, even in the muscles, uterus, and lungs. Cultures from the intestines show that few, and frequently none, can be cultivated from the rectum up to the cecum. Above this they are numerous. They have been found in the mucous membrane of the stomach, also in the esophagus, and on the tongue and tonsils, and have been isolated from endocardial vegetations, meningeal and pleural exu- dates, and from foci of suppuration in various parts of the body. They may be present in the stools of healthy people who have lived in close association with typhoid patients. Bacilli Outside the Body. — They retain their vitality for weeks in water. This is further demonstrated from infection by ice, in which they exist for several months, and live for some days in butter from infected cream. They may live in the upper layers of the soil for months; in street dust for a month or more; on linen for two months; and on Vv^ood for a month. Modes of Conveyance. — Aerial transmission is not probable. Fingers, food, and flies are the chief means. House infection is difficult to avoid unless finger contamination is carefully ehminated. Such epidemics have been reported at the Johns Hopkins Hospital. Epidemics have occurred from infection of water, milk, and food,^ such as celery and uncooked vegetables which have grown in infected soil. Raw oysters are recorded as a cause of epidemics. Bedbugs and fleas may be carriers. Water infection is the most common cause. Morbid Anatomy. — Intestines. — A catarrhal condition exists throughout the large and small intestine. Specific changes occur in the lymphoid elements, chiefly in the lower end of the ileum. Four stages are described : I. Hyperplasia, involving Peyer's patches in the jejunum and ileum and to a variable extent those in the large intestine. They are swollen, grayish white in color, and may project from 3 to 5 mm. The solitary glands may project to a variable extent. 1 Paratyphoid infection is referred to under Diagnosis. 2 There is some evidence that the digestive tract is not the only portal of infection for typhoid fever, but that the bacilli may enter by way of the throat, notably by the tonsils (Herter). 34 530 DISEASES OF THE STOMACH AND INTESTINES There is hyperemia of the folHcles; later an increase and accu- mulation of the cells of the lymph-tissue which may infiltrate the adjacent mucosa and muscularis ; the blood-vessels are compressed, which gives a white anemic appearance to the follicles. This process reaches its height from the eighth to the tenth day, and then undergoes either resolution or necrosis. 2. Necrosis. When the hyperplasia is marked, resolution is no longer possible. The blood-vessels become choked; there is a con- dition of anemia ; then necrosis and sloughs form, which must be sepa- rated and thrown off. This process is always more intense toward the ileocecal valve. The necrosis is variable, it may pass deep into the muscular coat, and even perforate the peritoneum. 3. Ulceration. Sloughing is effected from the edges inward, and results in the formation of an ulcer, the extent of which is directly proportionate to the amount of necrosis. The muscularis usually forms the floor of the ulcer. 4. Healing. The mucosa extends from the edge and a new growth of epithelium is formed, as are the glandular elements. The healed ulcer is depressed. Healing is never associated with stricture. Large Intestine. — The cecum and colon are affected in about one- third of the cases, and the solitary glands are sometimes enlarged. Perforation. — About one-third of the deaths, Scott's statistics state, are due to perforation. It occurred in 3.6 per cent, of all cases. The German statistics are much lower; in Munich only 5.7 per cent, of deaths are due to perforation. Among 1 500 cases at the Johns Hopkins Hospital there were 43 of perforation ; 20 were operated on, and 7 of these recovered. The site of the perforation is usually in the ileum, within 1 2 inches of the ileocecal valve. It may be from a pin-point to large size. Death from Hemorrhage. — This occurred in 12 of 137 deaths in Osier's 1500 cases. He could not find the bleeding vessels. Mesenteric glands are hyperemic and swollen. Necrosis is common; abscesses may occur, causing peritonitis or hemorrhages. Spleen enlarged, infarction not infrequent. Rupture may occur. Bone-marrow. — Same changes as in lymphoid tissue, and there may be foci of necrosis. Liver. — Parenchymatous degeneration. Liver abscess has been found, also acute yellow atrophy. Pylephlebitis may occur. Gall-bladder. — Acute cholecystitis may be present. Kidneys. — Cloudy swelling, with granular degeneration; less commonly an acute nephritis; miliary abscesses or diphtheritic inflammation of the pelvis may occur ; also infection by colon bacilli. With colon bacilli infection, chills, rise of temperature, and acute renal S)miptoms occur (W. H. Thomson). Bladder. — Cystitis or diphtheritic inflammation. Orchitis and acute mastitis are occasionally met with. Respiratory Organs. — Ulcer of the larynx; edema of the glottis; TYPHOID FEVKR 531 diphtheritic inflammation ; bronchitis ; pneumonia ; hypostasis ; pleu- risy; gangrene; abscess of the lung; hemorrhagic infarction and empyema may complicate. Circulatory Changes. — Endocarditis, pericarditis, and myocar- ditis, endarteritis, arthritis of a peripheral vessel with thrombus formation may occur. Venous thrombosis is more frequent, espe- cially of the left femoral. Nervous Symptoms. — Meningitis is rare ; optic neuritis may occur ; the cause of aphasia seen in children is not positively known. Paren- chymatous changes may occur in the peripheral nerves. Voluntary Muscles. — ^The muscular substance, especially of the recti, pectorals, and adductors of the thigh, may undergo granular degeneration or hyaline transformation. Rupture, hemorrhage, or abscess have been found. %^ \9A&..- DiTlston, Wari.i Temperatgre Chart Vo.Jf.. Fig. 209. — Typhoid chart. ' Symptoms.— Incubation, eight to fourteen days, occasionally to twenty-three days, during which period there is lassitude and inaptitude for work. Onset is rarely abrupt, with occasional chills, There may be cough (bronchitis), epistaxis, headache, anorexia, diarrhea in many cases, but frequently early constipation, abdominal pain, and distention; and in some cases there is pain in the right iliac fossa. At the onset the patient usually takes to his bed. During the first week there is in many cases a steady rise of temperature, the evening record rising a degree or more each day, and reaching 103° to 104° F. (Fig. 209). Variations of temperature are common. It may rise suddenly to 104° F. or may fall suddenly. It may be high a. m. and lower r. M. 532 DISEASES OF THE STOMACH AND INTESTINES The pulse is rapid, loo to no, full, but of low tension, and often dicrotic. The tongue is coated and white, the abdomen slightly distended and tender. Unless there is high temperature there is no delirium. The patient complains of headache and there may be mental confusion at night. The bowels are loose or may be con- stipated. At the end of the week the spleen becomes enlarged and the eruption appears in the form of rose-colored spots, seen first on the abdomen. They are raised, flattened papules, can be felt by the finger, and disappear on pressure. They come out in crops and may appear on the trunk or extremities. Desquamation may occur. In the second week the symptoms become aggravated; the fever remains high and the morning remissions are slight, the pulse is rapid and loses its dicrotism. There are mental torpor and dulness; the lips are dry and the tongue may become dry. Tympanites, tenderness, and diarrhea, if present, become aggravated. The stools are described as pea-soup. Death may occur at the end of this week from hemorrhage or perforation, but generally later. In the third week the pulse ranges from no to 130. The temperature shows marked morning remissions and there is a gradual decline in the fever. lyoss of flesh is more marked and weakness is pronounced. Diarrhea and meteorism may in some cases occur for the first time. Unfavorable symptoms are pulmonary complications, feeble- ness of the heart, delirium with muscular tremor, and acute tym- panites. The tongue may become brown or brownish black and the lips and teeth be covered with sordes. Special dangers are perforation and hemorrhage. The fourth week convalescence begins. Temperature gradually becomes normal; diarrhea stops; tongue cleans; the desire for food returns. In severe cases the fourth and fifth weeks present an aggravated picture of the third, the patient grows weaker, pulse more rapid and feeble, tongue dry, and abdomen distended. He lies in profound stupor with low muttering delirium and subsultus tendinum and passes the feces and urine involuntarily. Heart failure and secondary complications are the chief dangers. In the fifth and sixth weeks protracted cases show irregular fever, and convalescence may not set in until the fortieth day or longer. During this period, recrudescence of temperature may occur from errors in diet, constipation, or excitement; or a relapse (re-infection) mav occur. With relapse there is a repetition of the ascent of the original fever. A rise in temperature from a com- plication usually has leukocytosis associated. Modes of Onset. — As a rule, the onset is insidious. The following deviations may occur: Marked nervous symptoms, such as headache or cerebrospinal symptoms, with retraction of the head and convul- sions; or mania; or stupor. Pulmonary symptoms, such as bron- chitis, pneumonia, or pleurisy. Intense gastro-intestinal symptoms, with pain and vomiting, suggestive of poisoning, or in some cases TYPHOID fevBr 533 simulating appendicitis. Acute nephritis is the first symptom. Ambulatory form, in which the patient keeps about and attempts to work. This runs a severe course and often a fatal issue results. Chills may occur at the onset and may be followed by sweats, and they are present with complications. Variations from the typic tem- perature are common, the step-like ascent does not always occur, but the fever may rise suddenly. A sudden fall of temperature is sug- gestive of hemorrhage before blood appears in the stools. Peliomata, maculae cerulae — pale-blue or steel-gray spots — are sometimes present due to lice. Erythema may occur. Bed-sores are not uncommon and boils are a troublesome sequel. Blood. — ^Leukopenia (hypoleukocytosis) is present; lymphocytes are relatively increased. Eosinophiles disappear or are markedly diminished. The reappearance or increase of eosinophilia is a good prognostic sign. Leukopenia and absence of eosinophiles aid diagnosis. Hemoglobin and red corpuscles are reduced. Severe meteorism is a danger-signal and predisposes to hemorrhage or perforation. Acute gastro-intestinal dilatation or acute ectasia alone may occur. Acute distention may even simulate perfora- tion; and it is only possible to differentiate by relieving the dis- tention by enteroclysis and lavage. Symptoms of Perforation. — Sudden sharp pain, at times paroxys- mal, often in the hypogastric region to the right of the median line; tenderness, sudden distention, and muscular rigidity. This last is an important symptom. There are shock, fall of temperature, pallor, sweating, and the Hippocratic facies. The temperature then rises, pulse rapid and feeble, respiration increases. Vomiting is often present. Leukocytosis and especially increase in the polynuclears. Percussion may show a flat note in the flank, dlie to exudate. Obliteration of liver flatness may be caused by tympany. Abscess of the liver and cholecystitis may complicate. Gall- stones in many cases are probably associated with the presence of typhoid bacilli in the gall-bladder. Under Lesions most of the com- plications are referred to. Loss of hair may occur. Local neuritis, as in the arms, legs, or toes (tender toes), may occur. Multiple neuritis is a complication of convalescence. Polio- myelitis, tetany, and hemiplegia have been reported. Typhoid pyschoses may occur, also eye and ear complications, and retention of urine. Posttyphoid anemia may be severe. Ehrlich's Diazo-reaction. — This test is not absolutely diagnostic, as it occurs in miliary tuberculosis, in malaria, and occasionally in other acute disease, associated with high fever. It is of accessory value taken with other data. Bacilluria occurs in about one-third of the cases. Acute appendicitis may complicate. Osseous System. — Periostitis, osteitis, caries, and necrosis are trou- blesome sequelae of typhoid, as are arthritis and typhoid spine. Colitis, simple catarrhal or of a septic (diphtheritic) type, may complicate. 534 DISEASES OF THE STOMACH AND INTESTINES Posttyphoid septicemia and pyemia are not uncommon. Furun- cles, abscesses, and infarcts in various regions may occur. With chil- dren typhoid fever often runs a mild and irregular course. Diagnosis. — The type of temperature, splenic enlargement, eruption, absence of leukocytosis, disappearance of the eosinophiles, together with Ehrlich's reaction, are the chief signs. Isolation of the typhoid bacilli from the blood, stools, and urine is diagnostic. Widal's reaction is of positive value when foimd. It is generally not in evidence until the seventh to tenth day, sometimes not until convalescence, and occasionally not at all. Cabot claims over 90 per cent, reactions before the eighth day. Fortunately it is present in about 90 per cent, of cases. Blood examination will differ- entiate between t3^phoid and malaria. Ulcerative endocarditis has been mistaken for typhoid, but the presence of the heart lesion and the streptococci in the blood are diagnostic. With acute miliary tuberculosis the temperature is irregular or intermittent.^ Respira- tion is more rapid and there is more cyanosis. AVidal is negative, but leukoc^-tosis is common. With t^'phoid we have the Widal reaction; there is leukopenia, splenic enlargement is present, and the typic eruption. Intestinal grip may for a few days simulate typhoid, as may intestinal toxemia." The subsequent course, absence of AVidal reaction, etc., clear the diagnosis. Prognosis. — Mortality. Death-rate is variable, depending on the severity of the epidemic and when treatment has begun. Of recent years it has been from 5 to 20 per cent. Fat people stand typhoid badh^ ^leteorism, hemorrhage, high fever, and nervous symptoms give a bad prognosis. Prophylaxis. — Care in drainage and water-supply are most im- portant. Raw milk, raw oysters, and uncooked fruit and vegetables should be avoided during an epidemic. Raw oysters in Xew York should generally be avoided, unless the source of the supply is known. The urine, stools, and sputum should be disinfected. The sputum can be collected in cloths and burned, and bichlorid (i : 1000) or carbolic (i : 20) used to disinfect the other discharges. About twice the volume of the disinfectant should be mixed with the stools, and it should be left to stand for two hours before emptying. For dis- infection of the bath water, h pound of chlorid of lime will render an ordinary bath of 200 liters sterile in one-half hour (Babucke). The nurse should wear a rubber apron and should wash it frequently with carbolic or bichlorid. When giving baths, rubber gloves, or espe- cially rubber finger-tips, should be worn, and the hands thoroughly ^ Tubercle bacilli may be found in the fluid by lumbar puncture, and there is an absence of typhoid bacilli in the blood-culture. The tuberculin test (ocular) or by injection is of value. 2 The paralj'phoid bacilli A. and B. may produce symptoms like a mild typhoid, and paratyphoid B. may be productive of meat-poisoning. The Bacillus faecalis alcaligenes and Bacillus enteritidis (Gartner) may incite symptoms simu- lating mild typhoid (Herter). These bacilli differ from the typhoid bacilli in agglutination reactions, etc. TYPHOID FEVER 535 disinfected later. All bedding and the patient's night dress should be soaked two hours in i : 20 carbolic and then boiled. A special cup, dish, spoon, etc., should be used for the patient and disinfected on each occasion after using. It is best to keep them in the room and transfer the food from another vessel to the special cup or dish ; if in a ward, after each feeding they should be placed in carbolic (i : 20). After recover}', the room should be disinfected. Osier shows that 1. 8 1 per cent, of cases of typhoid at the Johns Hopkins have been of hospital origin. I have noted great carelessness in our hos- pitals as regards fly protection, seldom observing screening of the patient during the fly season. Typhoid cases should preferably be kept in a special ward to avoid the danger of infection of other patients through carelessness. Mabon demonstrated this at the Manhattan State Hospital. Chronic Typhoid Distribution. — Many cases are discharged from the hospitals while there are still typhoid bacilli in the urine and stools. Examinations of these discharges should be made. Urotropin, gr. 5 to 10 (0.3-0.6), with an equal amount of sodium benzoate t. i. d. is excellent to disinfect the urine. An interesting case of typhoid carrier of nearly seven years' duration, with five small epidemics to her credit, is reported by George A. Soper.^ Wright has introduced a method of vaccination against typhoid which proved of considerable value in South Africa. Treatment. — General Management. — The patient should be in a light, well-ventilated room, confined to bed. This should be single, - with a comfortable mattress, covered with a blanket, and a loibber cloth placed under the sheet. Nursing and diet are the essentials. Diet. — ^There is a tendency among many practitioners to endeavor to increase the resisting power to typhoid by increased feeding, and who hold that for this purpose the patient should lose as little weight as possible. In some cases solid food has been administered ; in others liquids, with considerable dextrose and cream.^ It has been thoroughly demonstrated that no matter what the intake, the nitrog- enous output in this disease is always markedly in excess.^ Typhoid is an acute general infection, and in such conditions all the digestive functions are abnormal. There is change in the charac- ter of the bile. Stolmkow* noted disturbances in the pancreatic juice ; and I recently referred to the diminution'' of motor power and the lessening or absence of hydrochloric acid during the high temperature of typhoid fever. The parenchymatous changes n the liver and 'Journal of American Medical Association, June 15, 1907. 2W. Coleman (Jour. Am. Med. Assoc, Oct 9, 1909) advocates milk, cream, milk-sugar, and eggs, giving from 4000 to 5500 calories per day, and reports good results. The author disagrees with a method which places upon diseased organs twice the labor which they perform in health, with the dangers incident to ex- cessive feeding. ^Finkler and Lichtenfeld, Centralblatt fiir die Allgemeine Gesundheitspflege, igo2. ■' Pfliiger, Archiv. Physiologic. 5 Medical Record, June 20, 190S, and American Medicine, May, 1909. 536 DISEASES OF THE STOMACH AND INTESTINES kidneys interfere with elimination by these organs, and the asso- ciated intestinal catarrh causes further interference with the digest- ive functions. Seibert, in 1889, noted that temperature and tympa- nites were lessened when milk was withheld, the fever falling to 99° or 100° F. on the ninth to twehth days. Rectal irrigations he found of great value. He^ gives rectal injections with 3 pints of warm normal saHne solution, preferably several times a day, depending on the case, thus irrigating the bowel. During the first day of treat- ment cold water only is given as food. From the second day on, J pint of strained rice, oatmeal or barley soup, containing the extract of ^ pound of meat and the yelk of a fresh egg, well spiced, are given every three hours, five times daily. From the fourth day on, strained pea, lentil, potato, and tomato soup with rice, were added to the menu. Two or three zwiebacks were given with the soup at the end of the first week. Orange juice was given in water three times daily. Egg-albumen was not given on account of the proba- bility of forming toxins. Before each meal 15 to 25 drops of hydro- chloric acid were administered in h ounce of water. No alcohol was given except to topers, and camphorated oil was employed by hypo- dermic if stimulation was required. Cold baths were never emplo^^ed, even in hyperpyrexia. Sponging was added if necessary. Opium was only used in bowel hemorrhage. Lesser^ has treated all fevers above 102.5 °F. with water alone, and below this point with broths, rice- and barley-water, also em- ploying enteroclysis. Good results were secured by these methods in typhoid during the Spanish- American War. The author's method is as follows: As gelatin^ lessens nitrogen excretion, and as it aids in preserving weight, and furthermore causes no putrefaction in the intestines, it is of some value as a food. It also lessens tendency to hemorrhage. Approximately, oiss (48.0) of gelatin in oxij (375 cc) of water, gives a 12 per cent, solution. This gelatin solution can be slightly flavored with lemon, vanilla, or with a pinch of sugar, and be given in divided doses. Strained rice, barley, oatmeal, and chicken broths, the sum total not over i quart (liter) , are also to be given in divided doses every three to four hours, the last feeding no later than 9 p. m. This makes in all about i^ quarts (Hters) of nourishment. The various foods are alternated for variety. The patient is not urged to eat. Whenever the temperature reaches 102.5° ^- or more, nothing but water is administered until it falls to that point. The juice of several oranges is given during the day. When the temper- 1 Medical Record, June 20, 1908. 2 j^-,i(j., October 19, 1905. 3 Xhe ingestion of 7.5 per cent, of the total heat requirement of the organism in the form of gelatin spares 23 per cent, of the body's proteid. Thus, in a total of 2800 calories required by a man of 154 pounds (Chittenden), 210 calories in gelatin are necessary; i gm. of gelatin contains 4.1 calories, so about 50 gm. of gelatin are required, or oiss (48.0). The gelatin and cereal gruels approximate 2000 calories, all that can be digested properly. TYPHOID FEVER 537 ature falls to 99-5° F., the gruels are thickened and the yelks of 4 raw eggs added. At least I ^ to 25 quarts (liters) of water, to which dilute sulphuric acid, TTLxx (1.184 cc), is added, are to be drunk by the patient during the twenty-four hours. Dilute nitromuriatic or dilute hydro- chloric acid may be substituted. For the advocates of milk, I would state that the sour milks, such as matzoon, bacillac, kumyss, and lactone-buttermilk, are preferable to plain milk. Effervescence should be allowed to a great extent to pass off from kumyss before administering, and it is preferable to dilute it some with lime-water or water. Matzoon and the thicker sour milks should be diluted one-half with plain water, or Vichy that has become flat, to avoid distention. Milk^ if administered should be diluted one-half, preferably with barley-w^ater or rice gruel. About 1^2 quarts (liters) of milk or sour milks thus diluted could be given in twenty-four hours. I do not advocate their use. Carbonated waters while effen,"escing add to distention. Sanatogen, as much as o j (32.0) in divided doses, is of value, given in the broths. The bowels are freelv opened by calomel, gr. 5 (0.3), or castor oil, oiss (45.0), on the first day, and thereafter hot sahne enemata, ij liters (1500 cc), at 110° to 115° F., or if gas, enteroctysis (recurrent), i gallon is given A. M. and p. M. as routine. Hemorrhage, perforation, or appendicitis ■ are the only contraindications. There is one exception to this rule: gentle bowel irrigation with a tube and funnel, with hot normal saline solution at 120° F. during hemorrhage, lessens tympanites and helps contract the vessels. Performed by the physician, if guarded by a hypodermic of morphin, gr. ^ (0.016), to prevent subsequent peristal- sis, I believe, with Kaufmann, the procedure to be of value. Sponging. — With diet and irrigation of the bowels iiib-baths are rareh^ necessary. Cold sponging with alcohol and water, combined with friction when the temperature is over 102.5 ° F., generally suffices. Baths. — I am not opposed to the Brand method as a scientific procedure for its additional effects on the pulse and on elimination. If the friction bath is given, it should be started at about 90° F., -never given below 70° F. Often the warm bath is preferable. Strychnin, gr. -gV to -gV (0.00108-0.002 1), or Hoffmann's anodyne, 3j (4.0), may be required in the bath. The average duration of the bath should be twenty minutes, longer if no reduction of high tem- perature. If the patient looks blue or shivers, he should be removed. The Nauheim bath (Triton salts), advocated by William H. Thom- son, especially if friction is combined, is superior to the Brand bath. In Fig. 210 is a portable tub, weight 5 pounds, excellent for private work. Medicinal Treatment. — Antipyretics should be avoided. Though 1 In 100 cc. of milk is contained only 64 calories, or 640 calories per liter; 4 quarts (liters) of undiluted milk would not give more than 2800 calories required for a man weighing 154 pounds. The fallacy of pure milk diet is thus demon- strated. Rice, barley, and oatmeal average about 750 calories per 100. If milk is given, its calorie value and digestibility are increased by these cereals. 538 DISEASES OF THE STOMACH AND INTESTINES Chantemesse has reported some results from serum-therapy, it is doubtful whether anything of value has yet been obtained, though interesting data have been reported on the injection of bacterial vaccines by Walters and Eaton. ^ Bismuth subnitrate or subcarbonate, in a dose of gr. 15 to 20 (i. 0-1.3), comxbined with the same quantity of saccharated pepsin, I employ every three hours, on an average of four doses a day. The bismuth helps control the ulcers. As urotropin causes disappearance of the bacilli from the urine, it would seem a logical remedy. Uro- tropin, gr. 5 to 10 (0.3-0.6), given preferably wdth equal quantities of sodium benzoate in Yichy w^hich' has become flat, is the best method. It should be administered three or four times a day. I have apparently seen some benefit in lessening the temperature and tympanites by this method. Acetozone (i : 1000), given in divided Fig. 210. — Chambers' portable bath-tub. doses, about i to ij quarts (Hters) per day, has been favorably re- ported in some cases; each dose is flavored with orange juice. Tympanites. — Hot fomentations and turpentine stupes are employed. The ice-bag is best in many cases. A rectal tube may be inserted, or an enema containing oil of turpentine, oj (4.0), be given. Spirits of turpentine, 'TTLx to xv (0.592-1. 184), can be given three or four times a day, or resin turpentine, gr. 3 (o.i94)> four times a day, or oil of cinnamon, ITLiij to v (0.178-0.296), every two hours. Charcoal, gr. 5 (0.3), bismuth subnitrate, gr. 15 (i.o), beta-naphtol, gr. 3 (0.194), or ichthalbin, ichthoform, or formidin, gr. 5 (0.3), every three to four hours may be substituted. Acute dis- tention is relieved by enteroclysis. As acute dilatation of the stomach 1 Medical Record, January 16, 1909. TYPHOID FEVER 539 is often associated, lavage is also of value. This is especially true in distention with active hemorrhage. A thorough bowel action should at once be secured if there is no hemorrhage. Eserin, gr. e^o (0.00108) by hypodermic, may be of value. As I order magnesium sulphate or citrate, oj (4.0); every second or third day in addition to the rectal irrigation, tympanites is rare. In Fig. 2 1 1 is illustrated the correct position to relieve pressure from tympanites ; pulse and respiration lessened 20 points as a result, and the tympanitic area in the thorax diminished 4 inches. Diarrhea. — The bismuth preparations, chalk, and occasionally a little opium (see chapter on Diarrhea) may be required, and the ene- mata stopped for twenty-four hours, if the movements are excessive. Constipation does not occur with the methods described. Fig. 211— Postural treatment for acute dilatation of stomach and intestines in typhoid fever. Hemorrhage.— Morphin, gr. { (0.016), by hypodermic, and the ice- bag immediately applied. Then lactate of calcium, gr. 15 (i-o), given with 5ij to iv (60.0-125.0) of 5 to 10 per cent, gelatin solution; chlo- rid of calcium, gr. 10 (0.6), may be substituted. Thereafter lactate of calcium, gr. 10 (0.6), with 5ij (60.0) of 10 per cent, gelatin every four hours. Ernutin, Vf[v (0.296), may be given by hypodermic. William H. Thomson recommends the following: I^. Pulv. opii \ aa gr. V (0.3) Argenti nitratis ( ' _.. , . Resin turjjentine oy A *^^ Liquor potassii ^J ^^ Licorice pulv. 1- s- •"■ Divide into 60 pills. , ■ r r ^^c-^c of Sig._Two pills every four hours. They may be given for a fev\ doses at two-hour intervals. 540 DISEASES OF THE STOMACH AND INTESTINES Large doses of opium should be avoided, as they obscure symp- toms. Adrenahn (i : looo), Ttl,v to x (0.296-1.592), has been advocated by hypodermic, but it may increase pulse tension too markedly. Hypodermoclysis, preferably in the iliolumbar region, as in Fig. 212, with normal salt solution, may be required, or even infusion. At any time, on the appearance of blood in the stool or of sus- pected hemorrhage, stop enteroclysis and baths (if being given) at once. Perforation and Peritonitis. — Early operation is indicated. Fig. 212. — Hypodermoclysis in the iliolumbar region. Heart Stimulants. — Strychnin sulphate, gr. -i^ to 3V (0.00108- 0.0026), every three or four hours by hypodermic, or I^. Pulv. camphor gr. viiss (0.5) Sterile almond oil TTLxJC (1.184). Sig. — One dose every four to six hours by hypodermic may be required, especially if there are complications. Aromatic spirits of ammonia or Hoffmann's anodyne, in oj (4.0) doses, are useful in emergency Caffein citrate, gr. i to 2 (0.065-0.021) every three or four hours, is of service. Some advise alcohol, oviij to xij (250-375 cc), in divided doses, but, like Seibert, I have not found it necessary. Large doses of tincture of digitalis may be added in the case of alcoholics. Careful stimulation with drugs, I believe, causes less strain on the kidneys. TYPHOID FEVER 54 1 The former views as to the value of alcohol as a food, or its power to increase the capacity for work, seem, by scientific research, to be pretty thoroughly exploded. Its use in the arctic regions, where food of high calorie value is at a premium, has been found to be deleterious. In sudden emergency, as a heart stimulant, it is of value, but its prolonged use as a circulatory tonic has been shown to be harmful. Proper individual dosage is difficult to estimate, and the strain on the already damaged eliminating organs in typhoid fever is severe. F. Lee has, moreover, demonstrated that the use of alcohol causes muscle fatigue. For Nervous Symptoms. — Warm or cool packs with ice-bag to the head, and at times bromids or opiates. For Sleeplessness. — Sulphonal, trional, or veronal, gr. lo (0.6). Bacilluria.^ — Uro tropin and benzoate of soda, of each gr. 10 (0.6) t. i. d. Care should be taken to guard against bed-sores. Tender toes should be protected from the weight of the sheets, and hyperexten- sion of the feet should be avoided. In some cases a water- or air-bed or an old sheepskin spread under the patient, as suggested by Thom- son, may be required. For Renal hisufpciency. — Cream of tartar lemonade: Cream of tartar, oj (4.0); juice of 2 lemons; saccharin, gr. j (0.063); water, I quart (liter). Drink in divided doses during the day. Recurrent enteroclysis with normal saline solution at 120° F. and proctoclysis are useful. Caffein citrate, gr. v (0.5) t. i. d., is of value. Hypo- dermoclysis may be necessary. Colitis should receive treatment as described in that chapter. Delafield^ has secured results in membranous colitis by irrigation with 2 quarts (liters) of bichlorid of mercury (i : 10,000) with the re- current tube. Complications should receive appropriate treatment. Convalescence. — It is usually preferable to have a normal tem- perature for a week before commencing with solid food. Soft-boiled eggs, milk toast, jellies, and a little scraped beef should be first tried. In some prolonged cases, with temperatures of 99° to 100° F., cautious feeding may be attempted with the above materials. I have seen temperature fall as a result. Bacilluria I believe a frequent cause of slight persistent tempera- ture. This should receive treatment as already described. The patient should first sit up for a brief period about the tenth day of normal temperature. 1 In infection of the kidneys by the colon bacillus, Wm. H. Thomson advises active catharsis, followed by frequent doses of urotropin and sodium benzoate, aa gr. x (0.6), every three hours. If not retained by mouth, give by enema. 2 Enterodysis, Hypodermoclysis, and Infusion (Kemp). CHAPTER XXVI INTESTINAL HEMORRHAGE; INTESTINAL ULCERS; DISEASES OF THE BLOOD-VESSELS (EMBOLISM AND THROMBOSIS) INTESTINAL HEMORRHAGE It would seem advisable to refer to the various causes of intes- tinal hemorrhage for the purpose of diagnosis. iVmong such are dysentery, tvphoid, yellow fever, malarial poisoning, ulceration from various causes, cancer scurvy, purpura, traumatism, volvulus, intussusception after reduction of a strangulated hernia, excessive use of laxatives, hemorrhoids, injury (traumatism), venous hyperemia of the intestines due to diseases of heart or lungs, stasis or obstruction of the portal system, such as cirrhosis of the liver, injury from dried scybalae, ankylostoma, isolated venous varicosities, arterial aneurysms of the intestinal wall, aneurysms in adjacent arteries, as of the hepatic, from which blood may enter the bile-passages and be passed by the bowel. A peculiar type of enterorrhagia occurs with no anatomic changes, but there is probably an alteration in the walls of the blood-vessels. Thus, intestinal hemorrhages have occurred in phthisis when there were no ulcers. Intestinal hemorrhages in pernicious anemia, leukemia, scur^^y, morbus maculosus, septicemia, icterus, phosphorus-poisoning, inter- mittent fever, and erysipelas probably belong to this class. Amy- loid degeneration may be complicated by intestinal hemorrhages. Some believe vicarious hemorrhage may take the place of menstrua- tion. There may be collapse, with all the symptoms of internal hemor- rhage, and blood may or may not pass from the rectum. The blood may be bright red, brown, or like coffee-grounds. No visible blood may appear in the stools and be detected only by tests for occult blood. Microscopic examination may show the presence of red blood - corpuscles and hematin. Treatment. — The immediate hemorrhage should be treated as described under Hemorrhage in Typhoid, and the cause should be determined and treated. 542 ULCERS OF THE INTESTINES 543 ULCERS OF THE INTESTINES Simple Duodenal Ulcer {Synonyms. — Duodenal Ulcer; Ulcus Duodeni Pepticum — Leube; Round or Per- forating Duodenal Ulcer.) This is characterized by a defect of the mucous membrane of the duodenum, usuahy tending to run a protracted course, though in some instances it may be acute. It presents the appearance' and characteristics of ulcer of the stomach. Etiology.: — This is practically the same as gastric ulcer, being caused by the action of the acid gastric juice upon the mucous membrane of the duodenum, whose nutrition and \dtality have previously been impaired as a result of circulatory derangement. Chlorosis, however, seems to play no part in its production. Duodenal ulcers occur from burns of the abdomen, but are not correctly classified under peptic duodenal ulcer. Duodenal ulcer is less frequent than gastric ulcer, but is much more frequent than is generally supposed. Undoubtedly many cases have been diagnosed as gastric ulcer when it was a duodenal ulcer, lying close to the pyloric ring. William J. Mayo has demonstrated that many pyloric ulcers are found to have their origin in the duodenum, and in many cases it is impossible to differentiate between the two conditions. Trier places it as i to 9 gastric in frequency; while Andral as i to 40 gastric ; while Starke places it at i to 1 2 gastric. Age. — It occurs more frequently between the ages of fifteen and sixty. The average age of death in 127 fatal cases w^as thirty-eight years (Rolleston), but the Fen wicks show that in the acute cases 68 per cent, prove fatal between fifteen to thirty years, and in chronic cases, between thirty and thirty-five. Duodenal ulcer occurs quite frequently in young . children of one to ten years, and has been found in the newborn infant. Gastric ulcers occur less frequently in young children. Sex. — The proportion of males affected by duodenal ulcer is greater than the females. Weir reports 30 women in 176 cases; Collins, 52 women in 257 cases; others give the rates from 5 to i to 3 to i. Pathology. — It resembles the gastric ulcer, having a punched- out appearance; it is oblong or oval, having a funnel shape, and extends to a variable depth. It is only irregular in shape when sev- eral ulcers have coalesced. It varie in size from a pea up to a silver dollar. William Mayo classifies them surgically as indurated and non-indurated. In the former case they have a callous margin. The base is formed usually of the intestinal wall (muscle), or at times by adhesions to adjacent organs. Site of the Ulcer. — It is usually present in the upper 2 inches of the duodenum, in the ascending part near the pylorus, or in the upper horizontal part; less frequently in the descending part, and rarely in the third horizontal part. If the ulcer is* situated 544 DISEASES OF THE STOMACH AND INTESTINES near the diverticulum of Vater, through cicatricial contraction it may occlude the orifices of the bile- and pancreatic ducts and produce complications. Usually there is one ulcer, more rarely, two to four. They vary in size from a lentil to a dollar. Complications. — Stenosis of the duodenum near the pylorus or at a greater distance ma}^ occur, with resulting dilatation of the stomach and symptoms of benign stricture, the same as in the ste- nosis of gastric ulcer. Jaundice, distention of the gall-bladder, and inflammatory conditions therein may result from stenosis blocking the common bile-duct. Atrophy of the pancreas may take place from closure of the pancreatic duct. Fatal hemorrhage may occa- sionally occur. The type of hemorrhage is usually severe. In acute cases quite frequently perforation and general peritonitis occur, with death from shock or peritonitis. If the process is more slow, there may be circumscribed peritonitis with abscess. There may be adhesions with other organs and ulceration involving the liver, gall-bladder, pancreas, aorta, portal vein, or hepatic artery. Sub- phrenic abscess may result. Thrombosis of the portal vein has also occurred through deep cicatrization of an ulcer. The blood-vessels in the upper and descend- ing duodenum have frequently been eroded. Cancer, developed on the base of a duodenal ulcer, has been reported by Arnold, Eich- horst, and S. Fen wick. Clinical Aspects. — Occasionally the cicatrix of an old ulcer may be found at autopsy, though there have been no symptoms during life. Other patients may be apparently in perfect health, when suddenly a severe and dangerous intestinal hemorrhage takes place, or perforation and peritonitis. Symptoms. — In some cases there are quite marked symptoms. The patient may complain of tension and pressure in the epigastric region that may occur without apparent cause, or after eating, or on palpation. In many cases there are paroxysmal attacks of pain that may be quite violent, which are difficult to distinguish from cardialgia or gall-stone colic. They are more frequently to the right of the linea alba and extend to the right, in a line below the liver. As a rule, the pains do not radiate to the back as in gastric ulcer, but rather downward in the abdominal cavity. There are interv^als free from pain. Pain usually occurs from two to three hours after meals. Some claim the period of pain is later, four to six hours after eating, which aids diagnosis. I have not found this to be so. Though the region near the pylorus is found to be slightly sensitive on pressure, there does not seem to be the usual circumscribed and very sensitive spot, as found in gastric ulcer. In some cases there may be continuous pain and tenderness, probably due to local peritonitis. ULCERS OF THE INTESTINES 545 In Others there is a boring or gnawing sensation in this region. Vomiting, which reUeves the pain of gastric ulcer, is said not to do so in duodenal ulcer. Fluid given at the time of pain is said to lessen it by causing reflex closure of the pylorus or by diluting the excess of acid. The appetite and stools may be normal. Con- stipation frequently occurs, diarrhea rarely. The general condition of the patient is often good and there may be no great loss of weight. Vomiting is rare, unless there is stenosis with gastric dilatation. Gastric Contents and Vomitus. — In my own experience I have generally found hyperchlorhydria present, which corresponds with Boas' findings. This is in the uncomplicated cases. Normal contents, hypochlorhydria, or even the absence of free hydrochloric acid and the presence of lactic acid have been reported. Hemorrhage is a very frequent symptom and occurs in at least one-third of the cases. The number is undoubtedly much larger, if care were taken to examine the stools and gastric contents for oc- cult blood^ by Weber's or the benzidin test. The blood is most fre- quently passed by the bowel and less frequently vomited. There may be severe hemorrhage retained in the bowel, with all the symptoms of collapse, or blood passed of a tar-like or coffee-ground appearance. The death-rate from hemorrhage is quite large, estimated at 13 to 33 per cent, in acute and chronic cases. Jaundice^ is rare. With perforation there are pain, distention, muscular rigidity, etc. William Mayo has shown that the onset of perforation is extremely acute, and the early pain is just to the right of the median line, while in gastric perforation it is usually to the left of this line. In duodenal perforation the contents gravitate at once to the appendical region, and simulate perforated appendix. The course may be very acute or very chronic. Hemorrhage and complications are common. Diagnosis. — In many cases differential diagnosis between duodenal and gastric ulcer cannot be made. Acute cases following burns are easv of diagnosis. The following are of ser^dce: Duodenal ulcer is much more fre- 'quent in males; pain is more frequent to the right of the median line and does not radiate to the back ; local circumscribed tenderness on pressure not as marked as in ulcer; vomiting rare, unless stenosis; melena quite frequent; hematemesis is rarer than in ulcer; patients generallv healthy in appearance; intestinal hemorrhage very fre- quent ; perforation verv frequent ; pain in some cases at a later period than with stomach ulcer; latent type with sudden hemorrhage more common than with gastric ulcer. Though Leube states that hyper- chlorhydria is present in gastric ulcer and normal acidity or dimm- 1 Occult blood at least can at some time be found in every case. 2 The development of icterus, in a case presenting some of the symptoms ot gastric ulcer, probably shows duodenal ulcer, if gall-stones can be excluded. 35 546 DISEASES OF THE STOMACH AND INTESTINES ished acidity in duodenal ulcer, so far in the uncomplicated cases I have found hyperacidity. Occult blood ^ in the stool is quite diag- nostic. The prognosis is quite serious, especially in the cases with frequent recurrent hemorrhage. Relapses may occur in the apparently cured cases, but I have seen complete recovery follow proper treatment. Treatment. — This is similar to ulcer of the stomach. For acute hemorrhage, ice-bag to epigastrium, morphin, gr. ^ (0.016). Tremo lie re's solution — calcium chlorid (2 per cent, solution) in gelatin (5 per cent, solution) — oj (30.0), every two to three hours. Gelatin (10 per cent.) by mouth, oj (30.0), or 2 per cent, subcu- taneously ; calcium chlorid or calcium lactate, gr. 10 (0.6) , by mouth or enema; or strontium or magnesium lactate by hypodermoclysis, gr. 15 to 30 (1.0-2.0), in oiv (125 c.c.) sterile water, or ernutin, TTLv (0.296). Adrenalin (i : 1000), lllv (0.296) or more, has been recommended by mouth or hypodermic. It may too markedly raise pulse tension. For collapse, rectal saline enema, proctoclysis, or hypodermo- clysis, with camphorated oil or strychnin by hypodermic. Rectal feeding for twelve hours and white of egg and gelatin (cold) by mouth. Subsequently, large doses of bismuth, and nitrate of silver should be given, as in gastric ulcer. Treat hyperchlorhydria, if present, and feed by Lenhartz's method, as for ulcer of stomach. Iron and arsenic for anemia. Regulate the bowels Surgery. — Perforation requires immediate operation; for fre- quently repeated large hemorrhages and for gastric dilatation gastro- enterostomy is indicated. Local abscess, adhesions, or obstructive jaundice require operation. Intestinal Ulcers from Cutaneous Burns Ulcers from extensive burns (cutaneous) generally occur in the upper transverse duodenum, seldom lower down. Rarely an ulcer may occur in the stomach or other part of the intestines. There may be a single ulcer or five or six of them. There is considerable loss of tissue in some cases, in others erosions, and at times inflamma- tion of the mucous membrane. The shape of the ulcer is irregular and dentate or long and narrow. The course is very acute, the result generally fatal; hemorrhage or perforation occurring within one to two weeks after the burn or even within two to three days. The condition is probably due to septic embolism. Operate if there is perforation. In viild cases treatment is that of duodenal ulcer. Intestinal hemorrhage and local tenderness are the salient symptoms. 1 The determination of occult blood in the stool, and at times occasionally in the vomitus, is of valuable diagnostic import. In an obscure case at the Red Cross Hospital, a positive diagnosis, ulcer of the duodenum, was made chiefly on this point and confirmed at operation by H. Haubold. It served to exclude gall- bladder disease and a gastric neurosis. ulcers of the intestines 547 Embolic and Thrombotic Ulcers Parenski^ first described this condition. These ulcers originate from emboli which are carried into the small branches of the mesen- teric arteries from an endocarditis or atheromatous degeneration of the aorta, from an abscess focus or foci, or from thrombosis, as a result of endarteritis. They occur in the jejunum, ileum, and colon. If the embolus is aseptic, infarction with hemorrhagic infiltration occurs and necrosis results with the production of an ulcer. The ulcers, as a rule, are small, circular, or irregular in outline. Occasionally the whole thickness of the intestines may become involved, so that peri- tonitis of a fibrinous or purulent type occurs, or at times perforation. These ulcers occur in the area of distribution of the occluded vessels. Infarction of the spleen and kidneys may be present. If the emboli are septic, numerous small abscesses are seen in the sub- mucosa, which may break down and form ulcers. Small nodules (miliary abscesses), consisting of round cells surrounding a blood-vessel, are at times found post mortem in fatal cases, not yet having broken down into ulcers. Colicky pains, tenderness, diarrhea with blood and pus, occurring in cases in whom embolic processes can be discovered in other organs, or when a cause for emboli can be found, render the diagnosis of embolic ulcer probable. Intestinal ulceration occurring with multiple degenerative neuritis probably belongs to the class of thrombotic ulcers, there being degenerative changes (arteritis) influenced by the neuritis (trophic). Fracture of the spine has resulted in intestinal ulceration. Amyloid Ulcers This type of intestinal ulcer is rare, and would only be suspected when associated with amyloid degeneration of other organs, such as of the liver, spleen, in cases suffering from long-continued suppuration, cachexia, tuberculosis, syphilis, rickets, or leukemia. There would be diarrhea, symptoms of ulcer, and deficient absorption from the intestines. Amyloid ulcers may be found in any part of the intestinal tract, though more usually in the small intestine. They are gener- -ally multiple and may involve large areas. They are from the size of a pea to large girdle ulcers, nearly circumscribing the bowel. Leube believes the ulcers originate from circulatory disturbances due to amyloid degeneration of the walls of the small arteries. The vessels of the mucous membrane are first affected, but the process may involve the entire coat of the bowel. The ulcers have no tendency to heal. Other areas of intestines between the ulcers ma$r be in a condition of amyloid degeneration. The mucous membrane is pale and waxy in appearance and some of the villi are missing. On post mortem a weak solution of iodin gives a mahogany- brown color, the test for amyloid degeneration. The addition of sulphuric acid turns it violet or blue. iWienermcd. Jahrl)uchcr, 1.S76, Heft. 3. 548 diseases olf the stomach and intestines Tubercular Ulcers and Intestinal Tuberculosis Tuberculosis is a quite frequent cause of ulceration of the intes- tines. The infection may be : (i) Primary in the intestinal mucous membrane; (2) most commonly secondary to diseases of the lungs; and, rarely, (3) secondary to tubercular peritonitis. Primary intestinal tuberculosis occurs most frequently in children, and with it may be associated tuberculosis of the mesenteric glands or tubercular peritonitis. R, Koch believes that bovine tuberculosis differs from human tuberculosis, and that infection from diseased milk or milk of tuber- culous cattle hardly ever occurs, and it is unnecessary to take any precautions. Von Behring takes the opposite view. In the Charite Hospital in Berlin there were only 10 cases in ten years. In 3104 cases of tuberculosis in children, there were 16 of primary infection. There have been investigations recently reported which are suggestive that infection through the intestines is more common than we suppose, notably, Macfayden found tubercle bacilli in the mesenteric glands of 5 out of 20 children post mortem, with no tubercular lesions elsewhere; and Ravenal in 8 cases out of 25. Recent consensus of opinion holds that primary intestinal infection occurs through tuberculous milk. Milk from an infected nurse or mother may also be a cause. The meat of tuberculous cattle probably plays a lesser role, as it is generally thoroughly cooked. There is no reason why other raw food products may not be occasionally a source of infection, especially if exposed to infection by flies or sources of contamination. In adults primary intestinal tuberculosis is rare (in the Munich Pathologic Institute i in 1000 cases). The lower ileum is usually first involved and then the rest of the small intestine and colon. Symptoms. — The condition may begin with irregular diarrhea, slight fever, and colicky pains. Rarely, hemorrhage may be the first symptom. At first the symptoms may simulate a chronic catarrh. Until subsequent emaciation becomes marked or an involve- ment of the lungs occurs, the condition may not be suspected. The stools in every doubtful case should be examined for Koch's tubercle bacillus, which is diagnostic. The tuberculin test, by injection or ocular, should be made. A deceptive condition is when the ulceration begins in the cecum, and there are symptoms suggestive of appendicitis, with tenderness ifi the right iliac fossa, constipation, or irregular diarrhea. Osier reports in his primary cases of intestinal tuberculosis occasional fatal hemorrhage or perforation, with the formation of pericecal abscess or perforative peritonitis, or, rarely, partial healing, with great thickening of the intestinal walls and narrowing of the canal (chronic hyperplastic tuberculosis). ULCERS OF THE INTESTINES 549 Secondary Tubercular Ulcers of the Intestines ( Tuberculosis j These are very common in chronic pulmonary tuberculosis. Frerichs^ found tuberculosis of the ileum in 80 per cent, of these cases. In 566 of 1000 Munich autopsies secondary tuberculosis was found in the ileum, cecum, or colon, and in all but 3 the lungs were involved. Swallowing tuberculous sputum is the cause. The lowest part of the ileum is the chief point of infection with ulcers. It often extends to the cecum, colon, or rectum, and upward to the jejunum or even duodenum. Tuberculous ulceration has even occurred in the stomach. At times tuberculous ulcers develop primarily in the colon. The development of the tuberculous ulcer is preceded by the formation of a mihary tubercle. It usually begins in the solitary or agminated follicles. Caseation and necrosis of the tubercle lead to ulceration. In Peyer's patches only isolated follicles are at first involved, while in typhoid and intestinal catarrh they are uniformly affected. Ulceration at first occurs in certain points of the plaque, but later it becomes entirely involved, and the ulcer, there- fore, may be ovoid. This occurs in the ileum. In the jejunum and colon they may be round, but usually lie transverse to the long axis. The chief characteristics of the tuberculous ulcer are as follows: It is irregular in shape, more rarely ovoid, and generally extends along the transverse axis (girdle ulcer) ; the margin is a light red color; the edges and base are infiltrated and often caseous. The submucous and muscular coat are usually involved, and on the serosa are mihary tubercles or a marked tubercular lymphangitis. The serosa is reddened and thickened, covered with layers of fibrin, and is often adherent to the mesentery or other loops of the intestines. As compared with the great frequency and number of tuberculous ulcers, perforation is, therefore, not frequent. There may be stenosis from cicatrization of the ulcers and this may be multiple. They do not, as a rule, show much tendency to heal. Swelling and tuber- culous 'infection of the mesenteric glands are often present. Secondary infection of the intestines from the peritoneum may pro- ducetuberculousulceration.Theaffectionmaybeprimarilymthe peri- toneum, or extend from the Fallopian tubes or mesenteric glands. The intestinal coils may mat together, containing caseous, suppurating foci. There may be the pecuHar localized form of tuberculous tumor from a chronic hyperplastic tuberculosis occurring in the ileocecal region, to which I have already referred. It may simulate a new growth and cause constriction of the lumen of the bowel. There may be a chronic hyperplastic tuberculosis of the intestines with thickening of the gut. There is no definite tumor to be felt, but the induration in the right iliac fossa, when it occurs there, is similar to a recurring appendicitis. It may attack other parts of the intes- tines. Tuberculosis of the rectum may occur, with fistula m ano. iBeitrage zur Lehre von dcr Tuberculosc, Marburg, 1882. 550 DISEASES OF THE STOMACH AND INTESTINES Tubercle bacilli in the stools are diagnostic of these conditions when found; otherwise they are difficult of diagnosis unless by operation. The symptoms and treatment of tuberculous ulcer (tuberculosis) of the intestines will be described at the end of this chapter. Catarrhal and Follicular Ulcers These types of ulcer occur in the course of catarrhal inflammation of the intestinal mucous membrane, and are described in that chapter. Ulcerative Colitis This special form of ulceration of the colon was first described by Hale White, colitis occurring especially in institutions and insane asylums. Probably the greater percentage of these so-called cases of colitis, such as occur in institutions, are true dysentery. Vedder and Duval,^ while working under Flexner, found that institutional outbreaks were due to Bacillus dysenteriae. Osier and J. P. Tuttle differ in this regard and classify it as non-dysenteric. The symptoms and treatment are of dysentery. Stercoral or Decubital Ulcers These ulcers are produced by the pressure of hardened and stagnating feces on the mucous membrane, resulting in necrosis and purulent inflammation. They develop particularly in the cecum, flexure of the colon (hepatic and splenic), sigmoid flexure, and the rectum, where stasis is most apt to occur. Fecal concretion in the appendix is fair-ly common and may produce ulcer and appendicitis. They sometimes develop in chronic intestinal stenosis above the seat of stricture. Ulcers in Acute Infectious Diseases Under this group are the specific ulcers of typhoid and dysentery; diphtheritic ulceration; ulcers of sepsis; rarely duodenal ulceration in erysipelas; in varioloid; ulcer of the duodenum in pneumonia, a rare occurrence. In acute pemphigus and in pellagra isolated cases have been reported. Ulcers in Constitutional Diseases In acute leukemia, lymphatic tumors may occur in the intestines, especially in the ileum, and break down, with the production of ulcers. This is rare in the chronic type. Intestinal ulceration has occurred in scurvy and a few isolated cases are reported in gout. Toxic Ulcers Intestinal ulcers occur in nephritis, with uremic symptoms associated with the intestinal catarrh. They He chiefly in the large intestine. 1 Journal Exp. Med., Feb. 5, 1902, vol. vi. ULCERS OF THE INTESTINES 55 1 In poisoning with mercury they are also found, even when it is not administered by mouth or rectum, but by inunction. Changes in the blood have been held responsible for these con- ditions. With nephritis the intestinal catarrh is probably a factor; it is believed by many that the mercury reaches the intestines by excretion in the bile, and produces direct inflammation with result- ant ulcer, in which decomposition or intestinal bacteria play a part, since we find in some cases a pseudodiphtheritic membrane. Syphilitic, Gonorrheal, and Cancerous Ulcers Syphilitic ulceration of the intestines is rather rare. In the small intestine it may be found in a young infant with inherited syphilis. Ulcers originate in the lymphatics or in the mucosa or submucosa, from a gumma which gradually breaks down. A few cases of syphilitic ulcer of the small intestine in an adult have been reported by Klebs, Osier, and Birch-Hirschfeld. These ulcers are rarely encountered in the large intestine, except in the rectum in its lowest part. Primary chancre of the rectum has been observed. If feasible, the test for the Wassermann reaction should be made to confirm the diagnosis. The physical examination and history of the case are important. Condylomata and gummata may break down, and by cicatrization give rise to stricture of the rectum. Virchow notes that syphilitic ulcers are of slight depth and have a smooth base. They are more frequent among women than men. Polchen^ found 190 cases of stricture among women out of 219 cases, but believes that many of these result from ulcerations caused by gonorrheal infection, from abscess of the Bartholin glands, or from fecal pressure (decubital ulcer), or local traumatism from the syringe-tip. Ulcers from gonorrhea, traumatism, and hemorrhoids occur in the rectum and are referred to under Proctitis. Ulceration of intes- tinal carcinoma may occur, or metastatic nodules may break down and ulcerate. Intestinal Myiasis A case of fatal ulceration of the colon due to maggots has been reported." General Symptoms of Intestinal Ulceration Our readers must take into consideration the special types of ulcer, their etiology, and the history of the case in making the diagnosis. In some cases this is quite difficult, as the symptoms are not constant. The salient diagnostic points of intestinal ulcer are as follows : ^ Virchow's Archiv., Bd. 127. 2 Schlesinger, Wiener klin. Wochenschr., January 9, 1901. 552 DISEASES OF THE STOMACH AND INTESTINES 1. The appearance of pus in the stool. This is frequently in small quantity and in the form of minute grayish-white lumps, which ap- pear under the microscope as closely aggregated masses of pus-cells, and are especially important. At times it is only microscopic. 2. Necrotic pieces of the intestinal mucosa, such as shreds of tissue from the intestinal wall, which must be differentiated from membranous or shred-like particles of food, occur in some cases. 3. The appearance more or less frequently of blood in the stool, unchanged and in large amount as pure blood, or changed, coffee- ground, or occult blood. In some cases blood is only shown under the microscope, or by hematin crystals, or by Weber's or the benzidin test. Gastric ulcer and vicarious hemorrhage must be excluded. 4. The constant appearance of tubercle bacilli in the stools in connection with diarrhea and increasing emaciation are diagnostic of tuberculous ulceration; also the tuberculin reaction. 5. Persistent diarrhea (with local tenderness) and pain of a greater or lesser degree over a definite region of the abdomen, extending over a considerable period of time, associated with the presence of pus and blood in the dejecta. 6. Tenesmus, with pus and blood in the stool, suggests ulcer, probably in the rectum, and visual examination makes the diagnosis. The presence of mucus is not diagnostic of ulcer. Diarrhea. — This is present in a large number of cases. It is dependent on the site of the lesions ; ulcerations of the small intestine, cecum, or ascending colon probably do not produce diarrhea unless there is a complicating catarrh, amyloid degeneration, or some special infection like typhoid fever. Even in the latter we have constipated cases. Ulcers of the lower colon and rectum usually produce diarrhea, but even here it may occasionally be absent. Blood. — -Pure blood may be passed in large amounts in simple duodenal ulcer from burns and in typhoid. Targe hemorrhages at times occur from dysenteric ulcers. The hemorrhages from catarrhal and tuberculous ulcers are, as a rule, not as large. The blood may be bright red or dark, or of coffee-ground color, or may be only determined microscopically as blood-corpuscles or hematin crystals, or by tests for occult blood. Intestinal ulcer may be present without hemorrhage, and other conditions may produce intestinal hemorrhage,^ such as liver cirrho- sis, etc. Pus is diagnostic of intestinal ulcer. It is also found in con- nection with ulceration accompanying neoplasms of the intestines, and in abscesses which open into the intestines. It is generally in small amounts. Occasionally no pus is found, as in the case of duodenal ulcer; or the ulcer may be single and high up, so that the pus will disappear. If small grayish-white specks are discovered in the stool and under microscopic examination they are found to be 1 Repeated examinations, however, will generally show occult blood. ULCERS OF THE INTESTINES 553 pus, the diagnosis of ulcer is established. Pus is often only found by the microscope. Mucus found mixed with the intestinal contents is the result of associated intestinal catarrh. We can draw some conclusion from the relative amount of pus, blood, and mucus. Mucus is never diagnos- tic of ulcer. Pure pus is also found in a diphtheritic process of the bowel or from perforating abscess. Blood, pus, and mucus occur in dysentery and in carcinoma of the lower colon or rectum. Shreds of Tissue. — They consist of mucous membrane and are differentiated from particles derived from food; they occur most frequently in dysenteric ulcer and not in the slower type, as in tuberculosis; or in the more rapid, as in typhoid. Tubercle Bacilli. — Generally diagnostic of tuberculous ulcer, in connection with the other symptoms. Rarely sputum may be swallowed and pass through without infection. Absence of bacilli does not always prove absence of tuberculous process. The injec- tion of tuberculin or the ocular test (conjunctival) aid diagnosis in the doubtful cases. Pain. — This is occasionally absent. If pain exists in a circum- scribed spot for a long time and is increased on pressure, it is probably due to ulcer. It may at times be caused by local peritonitis. Ulcers of the rectum produce tenesmus, which is quite charac- teristic. Rectal examination should always be made. Fever is present in the tuberculous type, dysentery, etc., but not in all types of ulcer, being dependent on the etiologic cause. General Nutrition. — This may not be disturbed by a few small ulcers, but marked ulceration, especially of the tuberculous type, leads to great emaciation, as the intestinal contents are rapidly propelled and also normal absorption is interfered with. Perforation with general peritonitis, local peritonitis, or encap- sulated abscess may occur. Stricture may result from ulcers. Prognosis. — ^The prognosis depends on the etiology. Treatment Hemorrhage should be treated as in that from duodenal ulcer. The primary cause should receive appropriate treatment; in uremic ulcers, the nephritis ; in syphilitic ulcers, by hypodermics of bichlorid of mercury; mercurial inunction; protiodid, bichlorid, and iodid of potassium. Heat or cold can be applied for the pain and rest in bed for the severe cases. In tuberculous ulceration, out-of-door life and change of climate are important. Beech wood creosote, Ttlij (0.118) t. i. d., guaiacol carbonate, carbonate of creosote, and creosal (tannosal) are useful. Average doses of these remedies are gr. 10 (0.6) t. i. d. 554 DISEASES OF THE STOIMACH AND INTESTINES Diet is important; it should be non-irritating and chiefly liquid, such as milk, kumyss, matzoon, bacillac, lactone-buttermilk, raw eggs beaten in milk; soft-boiled eggs, broths, chicken soup, mushes, etc. Fats, such as butter, emulsion of mixed fats (Russell's), cream, etc., are of value. Some cases can take sweetbread, scraped beef, calves' brains, cocoa, tea or weak coffee, milk-toast, etc. Sanatogen (flavored) and malt-tropon can be given in broths or soups. Compound tincture of catechu, chalk mixture, opium, etc., are useful for severe diarrhea. The fohowing are excellent: I^. Comp. tinct. opii ) aa oss (16.0) Bismuth, subnit. J Mist, cretse oij (60.0) Aq. destil q. s. oiv (125.0^ — M. Sig. — Shake. Dose, oij (8.0) every three hours. I^. Tr. opii Hlx (0.59) Mist, cretse 3 j (4-o) Comp. tinct. catechu q. s. 3ij (8.0). — M. Sig. — Dose, 5ij (8.0). Administer every three hours. Bismuth subnitrate, gr. 15 to 30 (1.0-2.0), three or four times a day, or bismuth subcarbonate or bismuth saHcylate, *r. 10 to 15 (0.6-1.0), may be substituted. Avoid opiates as much as possible. Tannigen, bismuth subgaflate, tannalbin, and tannocol are useful in average doses of gr. 10 to 15 (0.6-1.0) three or four times a day. High injections of silver nitrate, 1:3000; thymol, 1:2000; salic3'Hc acid, 1:300; boric acid, 1:500; tannic acid, 1:1000; and protargol, i : 1000, are of seri-ice in rectal and colonic ulcers. CarboHc acid should not be used, and bichlorid of mercury (i : 10,000) bv recurrent irrigation only in typhoid in the diphtheritic form of colitis. Special local treatment is necessary for proctitis, as already described. DISEASES OF THE BLOOD-VESSELS ? EMBOLISM AND THROMBOSIS OF THE MESENTERIC ARTERIES AND VEINS (INFARCTION OF THE BOWEL) Embolism and thrombosis of the mesenteric arteries are com- paratively rare aft'ections. When the mesenteric vessels are blocked by emboli or thrombi, infarction follows in the territory supplied by the vessel, which may continue to gangrene or perforation and peritonitis. If only a few small vessels are occluded there may be few if any symptoms, and the circulation may be re-established. Welch^ states that about 70 cases of embolism or thrombosis of the mesenteric arteries have been published, while Gallavardim has collected 83 cases, of which 63 were of embolism. 1 Allbutt's System of Medicine, vol. ii, 1S94; also vel. iv. -Gaz. des Hop., Paris, 1901, p. 929. DISEASES OF THE BLOOD-VESSELS 555 As the clinical symptoms of obstruction of the mesenteric arteries and veins can scarcely be differentiated during life, the symptoms being much the same, and since careful study of their etiology may aid in diagnosis, it is advisable to describe them together. Including both arterial and venous mesenteric obstruction, Jackson, Porter, and Quimby have studied about 30 cases in Boston, and have collected 214 cases in all. Etiology. — Embolism and Thrombosis of the Mesenteric Arteries. — In a majority of cases occlusion is due to embolism and rarely to thrombosis. The chief source of the emboli are traceable to endocarditis (valvular lesions) or atheroma of the aorta, or rarely from a pul- monary thrombosis or aneurism of the aorta. Thrombosis. — Local changes in the vessels, as endarteritis (described by lyitten), syphilitic endarteritis, injury and pressure from calcareous glands, have been given as causes. Rolleston refers to peri-arteritis nodosa, a rare condition in man, with the production of multiple aneurysms, which produces pain, colic and diarrhea, with ulceration. The superior mesenteric artery is more often affected. Verminous aneurysms cause infarctions in the horse. Etiology of Thrombosis of the Mesenteric Veins or the Portal Vein. — Welch^ has collected 32 cases and has demonstrated that the superior mesenteric vein is more often affected than the inferior mesenteric. Among the causes are pressure on the portal vein, as in cirrhosis or cancer of the liver; neoplasms of the abdomen; chronic peritonitis, with formation of constricting tissue; local pressure r incarceration of the intestines ; suppurative inflammation of the portal system as a result of infection, as in appendicitis, intestinal ulcer, or dysentery. Traumatism may produce inflamma- tion and thrombosis. Mayland- shows that it may occur after oper- ation; from tuberculous peritonitis, or diseased mesenteric glands. Hemorrhagic infarction of the intestines, as a rule, occurs with venous thrombosis, and the general symptoms are the same as due to arterial -occlusion; hence, the comparative study of the etiology of these different conditions is important for diagnosis. We would note that in a few rare instances Welch and Rolleston have reported exceptional conditions; the former, that acute portal obstruction has caused hemorrhagic infarction of the intestines, without thrombosis of the mesenteric vein ; and the latter, thrombosis of both veins without infarction.'' Pathology of Occlusion of the Superior Mesenteric Artery. — The changes resulting from occlusion of this vessel or its branches are hemorrhagic infarcts and peritonitis. If only small branches 1 Allbutt's System of Medicine, vol. v. 2 British Medical Journal, 1901, vol. ii. 3 Rolleston, Trans. Patli. Soc, vol. xlii. 556 DISEASES OE THE STOMACH AND INTESTINES are occluded the results are embolic or thrombotic ulcers of the intestines, to which article I refer my readers. The transverse duodenum, ileum, jejunum, caput coli, ascending and transverse colon are supphed by this vessel, and lesions of the intestines occur in that portion of the bowel supplied by the occluded branch or branches. It usually involves a continuous segment of the gut, quite frequently in the lower jejunum and ileum; but if smaller vessels or branches are occluded, there may be lesions scat- tered in several places over the bowel, with healthy segments between them. The superior mesenteric artery has such long and small branches that it acts functionally, Uke a terminal artery, so sufficient blood cannot be supplied to the intestines if it or one of its branches be occluded. Welch and Mall^ have demonstrated experimentally that if a branch be occluded, the blood which produces the hemorrhagic infarction is derived from anastomosing arteries and not from regurgitation from the portal vessels, as was formerly supposed. The following are the chnical appearances in the intestines: Arteries empty, except at obstruction. There are venous hyperemia ; edema and necrosis; hemorrhages in the mucous membrane and mesentery. The mucosa is a dark red and finally becomes necrotic, of a brownish-green appearance. The intestinal canal contains extravasated blood, either fresh or tarry looking. Necrosis of the intestines is present. The serous coat is inflamed, not only in the affected area but also over the healthy intestines, and the coils may become adherent and be covered with fibrin. There may be a blood-stained or purulent exudate in the peritoneal cavity. Occasionally gas may be present in the cavity due to the Bacillus aerogenes capsulatus or emphysema of the mucosa. Clinical Symptoms. — Kussmaul and Gerhardt^ first clearly described these some years ago. There are two types, the most frequent characterized by hemor- rhage from the intestines; the second, simulating intestinal obstruction, with or without peritonitis. Usually the onset is sudden, frequently with violent, colicky pains in the region of the umbilicus, which may gradually become diffuse, and at the same time there is tenderness on pressure over the abdomen. We must remember that in some cases there is an absence of pain. Vomiting may accompany the pain. Diarrhea may begin shortly after the pain and become extreme — mucous, watery, and at last bloody — or an intestinal hemorrhage may occur at the com- mencement, with dark-brown or tarry stools, which at times may have 1 Johns Hopkins Hosp. Reports, vol. i. 2 Wiirzburger med. Zeitschr., 1863 and 1864, Bd. iv and v. DISEASES OF THE BLOOD-VESSELS 557 a fetid odor. The blood may not always be voided, but retained, and the patient may have the symptoms of hemorrhage — collapse, cold extremities, rapid and feeble heart, and subnormal tempera- ture. In the other type of cases the patient may have signs of acute intestinal obstruction; a history of constipation for some days; distended and painful abdomen; vomiting, at times feculent; severe abdominal pains; collapse and peritonitis. The attack is clearly due to intestinal paralysis. Diagnosis. — The following may be of service: An intestinal hemorrhage from no apparent cause; colicky pains of great severity; tympanites and tenderness ; evidences of effusion into the peritoneal cavity; the discovery of simultaneous embolism in other vessels or of an endocarditis. In many cases, however, the salient symptoms are not all present; and in the type simulating obstruction the true cause cannot be determined. Prognosis. — ^This is generally fatal in occlusion of the superior mesenteric artery. In rare instances recovery may be possible. Treatment will be described at the end of the chapter. Embolism and Thrombosis of the Inferior Mesenteric Artery. — In 83 cases of Gerhardt, in only 5 instances was the inferior mesen- teric artery obstructed ; in 4 cases by emboli and in i by thrombosis ; and in 2 of these the superior mesenteric artery was also obstructed. This condition is rare. Symptoms. — ^The chief symptoms are pain, tenesmus, and bloody stools. Gerhardt states that the blood is bright red and that in ob- struction of the superior vessel it is darker, but I believe it generally dark. The descending colon, sigmoid, and rectum, or parts of these are affected, the mucosa becoming red, succulent, and containing effusions of blood. The mucous membrane may be loose and de- tached in places and hemorrhagic. There are not the serious lesions, as a rule, as in occlusion of the superior mesenteric artery. The artery (inferior mesenteric) is not an end artery functionally, and the circulation is generally re-established. Rarely there may be infarction or gangrene with perforation. Thrombosis of the Mesenteric Veins or Portal Vein. — This condition is extremely serious. Anatomic Findings. — ^The arteries are distended (thus differing from the superior mesenteric artery obstruction) ; thrombotic processes are found in the mesenteric vein or branches or in the portal vein. The intestines show similar conditions to obstruction of the arteries — infarction, necrosis, hemorrhage, peritonitis, etc. Symptoms. — The clinical picture may present the same t}'pe as in obstruction of the mesenteric arteries — colicky pains, tenderness, blood, diarrheal movements, etc. Rarely there may be hematemesis and occasionally constipation. The etiology, such as appendicitis, diseases of the liver causing pressure on the portal vein, abdominal 558 DISEASES OF THE STOMACH AND INTESTINES neoplasms or constricting bands, producing pressure, etc., and the exclusion of the causes of embolism, may aid our diagnosis. Treatment. — Temporarily, ice-bag to abdomen; stimulants, mor- phin, gr. \ (0.016), and ernutin, Hlv (0.296), by hypodermic; gelatin solution, calcium chlorid, or lactate of calcium to check hemor- rhage, as described in Dysentery. Immediate resort to laparotomy and resection of the diseased area is indicated, if possible. Cases of recovery after this procedure have been reported. ElHott resected 48 inches of intestines in one case with recovery. CHAPTER XXVII. NEOPLASMS OF THE INTESTINES MALIGNANT GROWTHS {Synonym. — Neopiasmata Maligna Intestini.) Though many have claimed that intestinal cancer is a com- paratively rare disease, recent statistics show that it has increased in frequency and is more common than has been generally supposed. Among the malignant tumors met with in the intestines, car- cinoma is by far the commonest. Sarcoma and lymphosarcoma are also found, and will be described in a separate section. CARCINOMA OF THE INTESTINES Etiology. — ^The cause of intestinal cancer, like that of cancer of other organs, is still unknown. There have been many theories advanced, such as the embryonal origin, parasitic infection, the theory of irritation, etc. The traumatic theory (irritation as the cause), in so far that it might hasten the development of the con- dition, is afforded a certain amount of plausible support, in view of the fact that the disease occurs most frequently in those parts of the bowels in which the feces are retarded, and hence act as a source of irritation. The points of selection for the development of cancer are the same as those in which the so-called decubital or stercoral ulcers most frequently develop, and we may assume they probably originate from the cicatricial tissue of these ulcers, in some cases at least, or on the base of other ulcers. Billroth has found a carcinoma in the scar of a dysenteric stric- ture, just as it occurs in the case of carcinoma engrafted on the scar of a stomach ulcer. It will probably eventually be shown to be due to some specific organism in my opinion. Sex. — Carcinoma of the intestines appears to be somewhat more common in men than in women. Age. — In general this lesion is most common between the fortieth and sixty-fifth year. Contrary to cancer developed in other regions, cancer of the intestines has been encountered quite frequently before the fortieth year. It has been found even in children ; several cases being reported at the ages of eleven to seventeen, and 2 cases in children of three years of age. Maydl, of Vienna, has calculated from records that one-sixth of all cases of intestinal carcinoma occur between thirty and forty 559 560 DISEASES OF THE STOMACH AND INTESTINES years, and one-seventh before the thirtieth year. It is important to remember that early occurrence is fairly frequent. Situation of the Carcinoma. — Cancer of the bowel is rare in the small intestine, occurs quite frequently in the colon, and most commonly in the rectum. From 1882-93, from autopsies in the Vienna General Hospital, Riegel states 5 cases were in the duodenum; 6 in the ileum; none in the jejunum; i in the vermiform appendix; 14 in the cecum; 63 in the colon; 40 in the sigmoid, and 114 rectal cancers. At the same hospital, during twelve years, out of 254 cases of cancer of the intestines, Maydl found in the living that 224 were cancer of the rectum. Bryant, in no autopsies, found carcinoma of the small intestine 6 times; 7 times in the cecum and ileocecal region; 19 times in the transverse colon, including its flexures; 78 times in the sigmoid flexure and rectum. Leichtenstern's data show that 80 per cent, of all intestinal cancers occur in the rectum. Other statistics are given. They all show the preponderance of rectal cancer. Intestinal cancers are almost always primary, and secondary growth by metastasis is extremely rare. It may occur through direct extension by continuity, as a cancer of the pancreas may extend to the intestines. Primary carcinomata of the intestines often give rise to metastases in other organs. These are most frequently found in the lymph- glands, especially in the neighborhood of the neoplasm. Secondary metastases in the liver are quite frequent, no matter where the situation of the carcinoma. The peritoneum, omentum, mesentery, and lungs may be involved, and occasionally the kidneys. Hauser calls attention to certain peculiarities regarding the metastases in different forms of carcinoma of the large intestine. Colloid carcinoma chiefly involves the serous coat and metastases of internal organs are rare. Medullary tumors involve adjacent lymph-glands, while simple and scirrhous carcinomata, even when small, frequently cause carcinoma of the liver. Morbid Anatomy. — Several varieties of carcinoma are found in the intestines, most often the cylindric epithelial-celled carcinoma (adenocarcinoma), starting in the cylindric epithelium of the intes- tinal glands (follicles of lyieberkiihn). It occurs most frequently in the large intestine, as do medullary carcinoma and colloid cancer. More rarely the scirrhous carcinoma is found. The epitheliomatous chancroid occurs in the lower rectum at the anus, and it may involve the perineum and vagina. In the small intestine the primary proliferation starts from the glands of Brunner; in cases developing from cicatrices, proliferation may start from glandular tubules which have grown deep down into NEOPLASMS OF THE INTESTINES 561 the tissue. The growth varies in consistency, depending upon whether connective tissue or cells predominate; if the former, then the tumor presents a hard consistence (scirrhous) ; and if the latter then it is less firm and occasionally soft and succulent. The colloid cancer contains a brown viscid fluid. The scirrhous show a tendency to ulcerate. The cancer may form a hard annular induration, as in the colon, or a circumscribed nodule or an ulcerating gangrenous, cauliflower growth, as in the rectum. The nodule may develop into a single large tumor or several smaller masses; the softer tumors usually grow to larger size. At other times the mass may protrude into the intestines, like a poh'pus; or may infiltrate a large surface of the bowel, so that it becomes stiff and rigid. In the majority of intestinal carcinomata the surface is ulcerating. The annular form of the growth is most common, tending to involve the circumference of the bowel. It may develop from a small nodule or, more frequently, on the base of an old annular cicatrix, due to former ulceration. Stenosis of the canal is often the result. Secondary changes develop ; the intestines become dilated through stagnating feces and gas, and the walls hypertrophied above the stenosis through overexertion to overcome the obstacle. Catarrhal inflammation and stercoral ulcers develop in the dilated portion of the gut and perforation may ultimately occur. Below the stricture the intestinal walls are thinner, and if the stenosis is narrow, the intestines may be empty and contracted. Stenosis of the bowel may be produced by a growth of the cancer into its lumen or by infiltration of the entire wall. Large masses of very hard scybalse often accumulate above the seat of obstruction and are difficult to distinguish from the carci- noma proper, so that on autopsy a small growth may be found which intra vitam was believed to be of large size. When stenosis of the bowel occurs, all the symptoms are present which are described under this condition. Narrowing of the bowel does not always take place. Sometimes "the symptoms of stenosis may gradually disappear, being due to ulceration of the neoplasm, so that the canal again becomes patent. As a rule, it tends to grow and fill up again. The necrotic process often causes more or less hemorrhage, and in rare cases, if a large vessel is eroded, there may be a fatal issue. The canal may become patent by a direct connection becoming established, through ulceration and adhesions, between two loops of the intestines. The muscular and serous coats are frequently involved, and peritoneal adhesions develop which may unite the diseased intestines to other portions of the intestines, or to some adjacent organ, which may constitute a serious obstacle to the removal of the growth. 36 562 DISEASES OE THE STOMACH AND INTESTINES Perforation may rarely occur before the formation of adhesions, with resulting general peritonitis, or there may be a circumscribed abscess formed within the adhesions. Marked displacement of the intestines may be caused by the formation of these adhesions. A carcinomatous peritonitis may be produced by extension from the serous layer of the intestines, accompanied by hemorrhagic exudation. Perforation into other organs which have become agglutinated to the bowel can occur; thus a fistulous opeiling forms between the colon and the stomach or bladder, or vagina or uterus, or between the large and small intestines, or from the bowel through the abdominal wall. The omentum and mesentery may become infiltrated with cancerous masses. A band may be formed by the stiffened omentum, which may cause a knuckling or a twisted bowel. The mesentery may kink and twist the intestines. Sjmiptoms. — ^The symptoms vary, depending on the position of the neoplasm, the rapidity of its growth, and the character of the cancer. There may be symptoms at first of habitual constipation or of hemorrhoids, or of stenosis of the intestines, or of peritonitis, or icterus, or of cachexia of uncertain origin. It seems preferable to first review the general and then the local symptoms, depending upon the position of the tumor, as occurring with — 1. Carcinoma of the duodenum. 2. Carcinoma of the small intestine. 3. Carcinoma of the colon (cecum to sigmoid flexure). 4. Carcinoma of the rectum. General S5rmptoms. — There are symptoms common to all cases of carcinoma, of which anemia and cachexia are the most important. As a rule they occur together, though one may develop before the other. In many patients weakness, pallor, and emaciation are the first signs noticed, and arouse the suspicion of a serious disease. There may be only slight local symptoms, moderate constipation, and a sense of weight or discomfort in the abdomen, with loss of appetite, coated tongue, and slight dyspeptic disturbances. There is loss of weight and a peculiar cachectic appearance. On the other hand, the local symptoms may be the more pronounced, or the local and general symptoms may occur together. Quite frequently, especially in those cases of carcinoma which run a rapid course, fever is present. I have seen a number of cases in which it is entirely absent. It probably depends upon an ulcera- tive condition in the growth and absorption of toxic products. The tumor may cause symptoms in adjacent organs by dragging upon them or constricting them. There may be radiating pains from compression of nerves and also disturbances of the circulation, such as edema of the lower extremities. Symptoms of chronic intestinal obstruction are frequently pres- ent, but not in all cases. The symptoms may develop gradually, NEOPLASMS OF THE) INTESTINES 563 the constipation increasing, or there may be a sudden stoppage, with all the signs of acute obstruction. The clinical symptoms of can- cerous obstruction are similar to those from stenosis of the intestines caused by other processes, and are described in Chapter XXXI. When acute obstruction suddenly occurs during the course of chronic stenosis a fatal result may ensue within a few days. Fecal retention has been reported in connection with malignant stenosis, lasting even over eighty days^ without the presence of fecal vomiting. Diarrhea is fairly frequent in carcinoma of the intestines. It is of assistance in clearing up the commencing obstruction, and in some cases alternates with constipation. In some patients the stools appear as small hard balls, cylindric, like a pencil, or fiat and tape-Hke, as if they had passed a strictured point. These are not always characteristic, as they may appear with nervous conditions. The stools frequently contain pus, blood, and mucus. The appearance of the first two (pus and blood) is significant. If the growth is ulcerating markedly, the stools have a most offensive odor. In this event particles of tumor may rarely be found in the dejecta, which show under the microscope the 'nature of the growth. They may be of fair size or very small, so that careful examination of the fecal matter may be necessary in order to find them. Irrigation of the bowel is of assistance if the neoplasm is situated in the large intestine. One of the most important factors in our diagnosis is the detec- tion of the physical signs of a tumor. The growth is from the size of a walnut to that of a child's head. It is often easily palpable, hard, and usually has an uneven nodular surface. A marked peculiarity of this type of tumor is its great mobility under the palpating hand of the examining physician. Even in the cecum and ascending and descending colon the tumor is distinctly movable as a rule. The mass is usually situated in the lower half of the abdomen, most frequently in the lower left iUac region, as unless there are marked adhesions, the intestines are dragged down there by their own weight. If the growth is in the cecum, the right iUac region is involved. I have already referred to the fact that on autopsy the tumor is frequently found to be smaller than it was apparent to palpation, this being due to the thickening of the gut above the stenosis and to the fecal accumulation. Abdominal pain is present, which will be described under Local Symptoms, and the tumor is at times tender. In some cases simple abdominal palpation is not sufficient, and it may be necessary to examine the patient under an anesthetic. In every case digital examination of the rectum and, if necessary, 1 Cooper-Foster, Med. Times and Gazette, Sept., 1867. 564 DISEASES OF THE STOMACH AND INTESTINES the passing of a rectal bougie or introduction of a speculum should be employed. In women a vaginal examination should also be made. I strongly deprecate the insertion of the entire hand into the rectum under anesthesia, as has been sometimes advised. When the cancer is fully developed we may have peritonitis, either local or general, as a complication. If the peritonitis is of a cancerous nature, a hemorrhagic exudation and the presence of nodules under the abdominal wall will indicate this fact. Acute perforative peritonitis will be indicated by the usual symptoms of this condition. On the other hand, we may have circumscribed adhesions with the presence of local fecal abscess. Perforation may occur into adjacent adherent organs which will present special symptoms. Among the chief communications are : 1. Communication between the colon and stomach. There may be a valvular communication or it may be free. If the direction of the passage is from the stomach into the colon, symptoms of lientery develop — undigested food, such as rice, potatoes, meat, etc., appear rapidly in the stools. Diarrhea occurs shortly after the ingestion of food with evacuation of solid contents. If the valvular action is in the opposite direction, feculent vomiting takes place. If the fistulous opening is perfectly free, then lientery and fecal vomiting occur together or may alternate. This combination of s5^mptoms is pathognomonic. Lavage, especially if the fluid be colored with methylene-blue or carmin, gr. 3 (0.194), will demonstrate that the liquid rapidly escapes from the stomach, and is expelled from the bowel without being decolorized or discolored. If the rectum is inflated with air or CO2 the stomach will be distended with gas, or after injection of i to 2 liters (quarts) of colored fluid into the bowel some can be secured from the stomach by aspiration. 2. Communication between the rectum and bladder. Fecal matter and gas escape into the bladder and are voided through the urethra. Severe septic cystitis results, or the urine may escape from the bladder and be discharged through the stools. A carmine solution injected into the rectum or bladder will demonstrate the condition, and will appear respectively in the urine or feces. 3. Communication between the rectum, uterus, and vagina are also met with, and give rise to the passage of fecal matter through these organs, and also to severe infiammatidn. Injection of weak carmin solution or methylene-blue into the rectum will demonstrate the communication. 4. Communication between the bowel and abdominal wall. There may be a feculent or fetid discharge, or even of particles of fecal matter, if the communication is with the lower small or large intestines. If the communication is high up, it may be chylous or biliary. This condition appears usually in the last stage of the NEOPLASMS OF THE INTESTINES 565 disease. Injection of carmin red solution through the fistula will appear in the stool. Ulcerative processes (tubercular) may produce similar communication. The urine is not characteristic, shows indican, occasionally acetone and diacetic acid. Albumin is present. Secondary anemia occurs. Leukocytosis is moderate and eosinophiles are increased. Symptoms Due to Position of the Cancer. — Cancer of the Duodenum. — ^This is a rare condition. There are the anemia and cachexia and pain usually in the right hypochondriac region; this last occurs in the midepigastric region or upper part of abdomen. The tumor, when palpable, is usually found in the right hypochon- driac region, near the middle line. If it is in the ascending part of the duodenum, there may be fair mobility; if in the descending or transverse parts, the tumor is only slightly movable. Nearly all the symptoms are referred to the stomach — anorexia, pains, belching, vomiting, and dilatation of the stomach — and if the mass is in the ascending part of the duodenum, it will hardly be possible to differentiate it from gastric tumor without operation. Blood may be mixed with the vomitus. Boas makes use of the terms suprapapillary, infrapapillar}^, and circumpapillary carcinoma, according to the position of the gro\\i:h relative to the papilla of Vater. If the carcinoma is suprapapillary, we have stenosis of the upper part of the duodenum, and, as already noted, symptoms identical with pyloric stenosis, from which it can hardly be differentiated. With infrapapillary carcinoma the gastric symptoms again predominate, but there is stasis of bile and pancreatic juice, and regurgitation of these secretions into the stomach; bilious vomiting is frequent. The vomiting is intermittent and the symptoms those of obstruction. Trypsin should be tested for in the vomit by observ- ing whether fibrin is digested in an alkaline solution. This would differentiate from a gastrohiliary fistida. Circumpapillary carcinoma. In the pure cases surrounding the papilla of Vater, jaundice, anemia, and cachexia slowly increase in severity, without any gastro -intestinal symptoms, and pain is usually absent. Chills may at times occur and cholangitis may be a complication. Jaundice may vary in intensity or may be intermittent. When the tumor involves the common bile-duct and head of the pancreas jaundice is progressive and continuous. Ulceration may temporarily open a passage for the bile. Gastric symptoms ma>' occur in addition. The tumor can be palpated deep down in the right hypochondriac region near the middle line. At times it cannot be discovered. Carcinoma of the duodenum is a disease of late middle or advanced life, most often in males. The second part of the duodenum is most frequently involved, and next in frequency the first part. 566 DISEASES OF THE STOMACH AND INTESTINES Carcinoma of the small intestine (jejunum and ileum) is rare. The symptoms vary, depending on the position of the growth; the higher up, the more marked are the gastric s)Tiiptoms; the lower down, the more severe the intestinal symptoms. There may be anorexia and vomiting, or fair appetite and good stomach digestion, but obstinate constipation. In both conditions there are anemia and cachexia, pain, attacks of colic and constipation, which may alternate with a diarrhea. There may occasionally be hemorrhages from the bowel if the growth is low down. The clinical S3Tiiptoms of stenosis of the intestines may be present. The tumor is at times accessible to palpation, and is, as a rule, extremely movable. It may be so much displaced down- ward that it is difficult to draw an accurate conclusion. Local Symptoms of Carcinoma of the Large Intestine. — Cachexia and anemia are present. Pain is a frequent symptom; it may not be present at first, usually appears later in the disease, and becomes localized; in some cases, running an acute course, no pain appears until the symptoms of acute obstruction begin. Pain is usually localized ; it may appear near or at the region of the growth, or occasionally directly opposite, in the abdomen. The pain may not be severe, but may be more a sense of dis- comfort. There may be neuralgia of the sciatic or anterior crural nerves. Later pain usually becomes localized, and is increased on pressure, even if the tumor cannot be palpated. It may be due to local peritonitis near the tumor. Attacks of colic often occur, local or diffuse. The pains may be quite severe, are accompanied with constipation, and arereHeved by diarrhea or bv the passage of flatus. These attacks of colic are frequently caused by the commencing obstruction, and show gradually progressive steno- sis. Peristaltic and tetanic movements of the intestines are often associated. Complete obstruction may suddenly develop, or there may be a gradually progressive stenosis with its symptoms. Constipation is one of the marked symptoms; in some cases it may be the first, and becomes gradually progressive. Ten to twenty or even eighty-eight days have passed, according to various observers, before the bowels moved spontaneously or by artificial means. These were, of course, extreme cases. The majority of patients have symptoms of commencing or complete obstruction after coprostasis has lasted a week or ten days. This has been my experience in consultation practice. Recently I saw a case for the first time on the fourth day of coprostasis when acute symptoms were present. Loss of appetite, tension, fulness in the abdomen, and pain accompany the constipation. Spontaneous diarrhea may relieve the condition. If this does not occur, or relief is not afforded artificially, gradual occlusion will take place with its typic symptoms. In some patients diarrheal movements may occur for several weeks due to the catarrhal condition of the bowel. NEOPLASMS OF THE INTESTINES 567 Stools. — In some cases of carcinoma the stools may be normal and simply hard in character when constipation is present. In others they may be in small balls like sheep's dung, flattened, or ribbon shaped. Mucus shows the presence of catarrh of the mucous membrane. The presence of pus in the stools is of importance, but only appears when the growth ulcerates; hence its absence does not prove there is no tumor. Microscopic examination for pus is indicated. Pus in some cases may be derived from an abscess-cavity opening into the intestines. The same remarks hold true of blood, the amount found is usually small, and violent hemorrhages are rare. The appearance of pus and blood in the stool in a patient with symptoms of stenosis of the bowel favors the diagnosis of malig- nancy. Occult blood should be tested for if none is visible. If there is gangrenous disintegration of the tumor, the odor is very characteristic, and occasionally small bits of new growth may be found in the stool. Tumor. — The presence of palpable tumor strengthens the diagno- sis. It may be no larger than a nut, or the size of a child's head, and be soHd and hard like cartilage. If there is much infiltration, it may give the sensation of a solid and thick cord. These tumors are generally moderately tender on pressure, in some cases quite so; occasionally they are not tender at all. Their great mobility is char- acteristic. On palpation they are easily moved about, especially in the sigmoid and transverse colon ; fecal accumulation readily displaces the tumor and it may become adherent in an abnormal position. Occa- sionally peristaltic movements may cause it to appear and disappear during palpation. Respiratory mobility of the tumor also may occur if it be in the transverse colon, or if it be adherent to the liver, spleen, or stomach. Large amounts of fecal material may accumulate above the growth, and we must clear this material out by irrigation and laxa- tives, so as to determine the extent of the tumor. A pure fecal tumor may lead to narrowing and occlusion. These last tumors are more doughy, less firm, and quite frequently multiple. Differential Diagnosis, — We must remember that old, agglu- tinated masses from recurrent appendicitis may simulate cecal tumor. The history is an aid. Moreover, tumor-like tuberculosis of the cecum may simulate malignant growth. In these cases there may be pulmonary tuberculosis,^ a previous history of diarrhea, or the presence of tubercle bacilli* in the stools. Some cases cannot be differentiated. The tuberculin test aids diagnosis. Leube called to our attention that chronic inflammation of the sigmoid may occur and be mistaken for carcinoma. Undoubtedly these cases are so-called peridiverticulitis, with chronic thickening, and often stenosis of the sigmoid simulating carcinoma. These 568 DISEASES OF THE STOMACH AND INTESTINES patients are general!}^ over sixty years of age, fat and flabby, or they have been fat previous to emaciation. There is often a history of acute left-sided inflammation and generally of prolonged constipa- tion. One must remember the possibility of this condition. Blood and pus, as a rule, are absent from the stools in these patients. Often it is impossible to differentiate these conditions, even after resection, except by the microscope. Cachexia and anemia are always present in cancer. Primary Carcinoma of the Appendix. — This is rare; most of the cases give svmptoms of relapsing appendicitis or appendicitis; 53 per cent, are under thirty years, and 24 per cent, under twenty. This condition has only been detected after operation on the appen- dix. The carcinoma is spheroidal celled. Carcinoma of the Rectvun. — This is the most frequent type of cancer, is more readily diagnosed, and more amenable to treatment if early operation is performed. Many of the tumors are within reach of the finger. The symptoms resemble those of carcinoma of the colon, though there are certain signs peculiar to this condition. Rectal examination should always be made. Pain is more pronounced in rectal carcinoma, both local and radiating to the sacrum, back, bladder, genitals, and to the sciatic nerve ; there is often a desire to urinate. The pain is usually worse during defecation if the growth is low down, and it may even be agonizing in character, so much so that the patients try to retain the bowel contents as long as possible. Marked tenesmus is present, and if ulceration, mucus, blood, and pus are evacuated. Constipation is usually present. The higher up in the rectum, the more the symptoms resemble those of cancer of the sigmoid. Diarrhea may at times supervene; occasionally after sloughing of the tumor, paralysis of the sphincter occurs. Leube was the first to call attention to the fact that hemorrhoids frequently developed with carcinoma of the rectum, and that, too, at an early stage. Piles occurring suddenly, and not developing slowly or existing for many years, are suggestive. Rectal examination is most important, and the finger will usually give the necessary information. One can feel a mass lying directly beneath the mucous membrane or adherent to it. The surface may feel uneven and hard or there may be occasionally a cauliflower or mushroom growth, or a constriction, through which the finger cannot readily pass. If it be barely possible to feel the growth, it is similar in sensation to the cervix uteri. Blood, pus, or sanious material may be found on the finger if the growth is ulcerating. Vaginal examination in women must be made to differentiate the source of the tumor. The genito-urinary organs in the male should also be examined. Simple cicatricial stricture is usually smooth and not ulcerated, NEOPLASMS OF THE INTESTINES 569 while a carcinomatous stricture is usually nodular and frequently ulcerated. It is preferable for accurate diagnosis to excise a portion under cocain for microscopic examination. If the stricture cannot be reached by the finger, Kelly's speculum is of value. Never insert the hand into the rectum. Metastatic growths in other organs are quite frequent from small growths of the rectum; thus, with carcinoma of the liver, a small primary carcinoma of the rectum may be found, even if no symptoms are present. The bladder and vagina may be involved and fistulous openings occur. Periproctitis (abscess) and fistulae are rare. The peritoneum is rarely involved unless the carcinoma is high up. Course. — The termination is death if not operated on. This may occur by occlusion of the intestines and from peritonitis. It is hardly possible to give a prognosis as to duration. In cancer of the duodenum the general nutrition suffers early, or the case may be very acute and the duration of life is short. In many cases the course varies from six months to two years, while in rectal cancer it may last for three to even four years. Rarely cases come to a standstill and last some years. In some cases coma (carcinomatosum) appears quite early, probably due to auto-intoxication from intestinal decomposition or from the toxins of cancer. Ewald isolated a body from the urine belonging to the group of diamins in such a case. Thrombosis may develop and embolus of the lungs occur, with death resulting. Death may occur from exhaustion. Diagnosis. — Presence of a tumor by abdominal palpation or rectal examination, accompanied by cachexia floss of weight marked) and anemia, with marked constipation and increasing symptoms of stenosis of the bowel; or cachexia, intestinal disturbances, with no detectable tumor, but with symptoms of progressive stenosis in an elderly person, are suggestive of cancer. Examination of a tumor fragment, if it can be secured in the stool or from the rectum, is conclusive. Prognosis. — This is fatal, unless early and complete removal. Treatment. — Complete and early removal of the growth is indicated. An early diagnosis is important. If abdominal cancer is suspected, exploratory laparotomy and complete resection with end-to-end or lateral anastomosis are indicated. If resection is impossible, entero-enterostomy or enterocolostomy for drainage to relieve symptoms. If the tumor is low down in the colon, sigmoid, or rectum and inoperable, then colostomy to relieve the symptoms and prevent irritation of the surface of the cancer. In the rectum, resection, preferably Kraske's operation, is indicated if radical operation is possible. 570 DISEASES OF THE STOMACH AND INTESTINES Palliative curetment and the thermocautery may be employed in some cases. Colostomy under cocain can be performed in the aged and feeble. Trypsin treatment, described under Gastric Cancer, is pistifiable in inoperable cases, or in those in which a palliative operation has been performed. Coley's treatment by erysipelas toxins may be tried, but I would not recommend "it. It is more successful with sarcoma. Diet. — Soluble foods with little residue, such as milk, broth, bouillon, sanatogen, somatose, cream, butter, rice-gruel, sour milks, matzoon, kumyss, bacillac, etc., are indicated. Irrigation of the intestines, enemata, and injections wdth olive oil, and internally, castor oil, magnesium sulphate, rhubarb, cascara, etc., to keep movements soft; warm applications to the abdomen; morphin, codein, and belladonna are indicated for pain. These last can be given by suppository. Strength should be supported by tonics, iron, arsenic, etc., and pain relieved. Treat complications. SARCOMA AND LYMPHOSARCOMA OF THE INTESTINES • Sarcoma of the intestines is rather an infrequent disease, much less frequent than carcinoma. In the course of twelve 5-ears, 1882-93, in the Vienna General Hospital, out of 274 autopsies on sarcoma, only 3 were sarcoma of the intestines, the ileum, cecum, and rectum. In 61 cases of lymphosarcoma, 9 belonged to the intestines, i in the duodenum, 3 in the jejunum, 3 in the ileum, and 2 in the cecum. Of Tibmann's cases, 15 were of the duodenum, 18 of the jejunum and ileum, 14 of the ileum, and 3 of the entire small intestine. Sarcoma occurs as frequently in the small as in the large intestine, and lymphosarcoma preponderates in the small bowel, Of Krueger's 37 cases, 16 were of the small bowel alone and 16 of the rectum; the ileocecal region comes next. Sarcomata usually attain a large size, even as large as a child's head, and spread over a large part of the intestines. Anatomy. — -Sarcomata usually originate in the submucosa, the musculature is attacked early, and the serosa is rarely involved. Small round-celled sarcoma is most frequent; occasionally spindle celled. In the rectum they are often melanotic. Lymphosarcomata start from the lymphatic apparatus, the solitary and agminate lymph-follicles. These' occur chiefly in the small intestine. Sarcomata of the intestines show a rapid progress and metastases are found early. They do not produce stricture of the bowel, but a dilatation, and develop in a longitudinal direction along the intestines. The bowel mav be enormously dilated. Rectal sarcoma, however, may produce obstruction. Age. — Sarcoma is frequent in young persons; most frequent NEOPLASMS OF THE INTESTINES 57I from twenty to forty years of age ; from four to seventy years cases are reported, and one congenital case in an infant three days old. Symptoms. — The clinical symptoms differ from carcinoma. The general health becomes impaired early. The patients emaciate rapidly and become anemic. There is a peculiar want of proportion between the rapid impairment of the physical condition and the absence of local symptoms. They become rapidly weak and debili- tated (cachexia). There are, as a rule, an absence of abdominal pain and no symptoms of stenosis. Intestinal s3Tnptoms are slight — occasionally constipation, alternating with diarrhea. Exceptionally, stenotic symptoms appear, due to kinking or peritonitic incarceration, rarely ileus. Stenosis occurs in rectal carcinoma. The tumor appears early, grows rapidly, and can easily be made out. Duration. — ^The majority of cases die within nine months from general cachexia; only i case recorded lived twenty-one months. Prognosis. — This t^^pe of tumor proves fatal, and even early operation seems of no value on account of the metastases. Treatment. — Injection of Coley's fluid, the mixed toxins of ery- sipelas and Bacillus prodigiosus, is indicated, as in inoperable sar- coma in the other regions. One must remember that marked reac- tion follows the injection in some cases, and some patients cannot undergo the treatment. I have seen the latter occur, and also in another case temporary improvement. The patient should receive as liberal a diet as possible, and iron, arsenic, and cod-liver oil should be administered. As a rule no stenosis is present, but if in evidence, operative procedure is indicated. Removal has failed on account of metastases. BENIGN TUMORS OF THE INTESTINES (NEOPLASMS) Benignant neoplasms of the intestines are relatively rare, and their clinical significance is generally slight. They occasionally produce severe symptoms. These tumors may be attached to the bowel wall by a broad base or by a thin pedicle or stem, and are then termed polypi. The last type is usually of small size, that of a cherry, but rarely as large as a pear, and occur most frequently in the rectum. The following forms of benign tumor are found : Adenoma, fibroma, lipoma, papilloma, myoma, fibromyoma, angioma, and chylangioma. Adenomata are most frequently met with. They arise from the glands of Lieberkiihn and in the duodenum from Brunner's glands; are acinous in structure, and may be attached to the bowel by a broad base or by a pedicle. As a rule they are small, the size of a pea, rarely the size of a pear. They are red and have a tendency to bleed; usually they are soft and the surface is smooth, though occa- sionally of a cauliflower appearance. They occur most frequently in the rectum, are usually polypoid, though occasionally annular and 572 DISEASES OF THE STOMACH AND INTESTINES flat. They are most common in children from four to seven years, though occasionahy in adults. More than half the cases that occur are in males between sixteen and thirty years of age. Sometimes there is extensive involvement of the intestines, a condition known as polyposis intestinalis adenomatosa; in i case several thousand were present. Polypi are never limited to the small intestine. Carcinomatous degeneration of the polypi may occur. Fibroma, Lipoma, Papilloma. — These neoplasms derived from the connective tissues, especially from the submucosa, are very rare. They are, as a rule, lipomatous in structure, and often originate from the appendices epiploicae. They frequently project into the peri- toneal cavity and may twist their pedicle and become detached. They may have a broad base or pedicle, are of various shapes, and may grow to the size of an apple. The^/ occur most frequently in >the colon and rectum, less frequently in the jejunum, and rarely in the ileum. Myoma, Fibromyoma. — These are very rare and usually orig- inate from the outer muscular coat of the intestines, chiefly from the longitudinal coat. There are two forms: Spheric nodules, which grow toward the mucous lining and sometimes become pedun- culated, the mucous membrane lying loose in front; or they may have a broad thick base, forming a circumscribed thickening, the mucous membrane being adherent. Rarely the myoma will grow toward the peritoneal cavity. Angiomata. — These are exceedingly rare, and may occur as a telangiectatic mass, or as a flat vascular tumor involving more or less of the bowel wall. Cystic chylangiomata occur in the small intestine. Sjrmptoms. — In many cases there are no S3Tiiptoms at all, and the condition is discovered accidentally post mortem. Sometimes they give rise to intestinal hemorrhage. When this occurs in a person in good health, who has never given any history of previous intestinal trouble, the possibihty of an intestinal tumor should be thought of. This is especially true in children. Diarrhea with blood and mucus have been reported in cases of polyposis intestinalis adenomatosa. On account of their small size it is nearly impossible to discover them by palpation. Symptoms may rarely be produced by narrowing or occlusion of the bowel by the intestinal tumor, or from an intussusception caused by the tumor. When tumors are situated in the rectum disturb- ances are most likely to occur, such as hemorrhage, passage of mucus, tenesmus, and difflcult defecation. Sometimes the mass may be felt by the examining finger, and it may even protrude from the anus and give rise to severe pain. It may occasionally be torn off and passed with the stools, when the symptoms may disappear. Course. — They may remain latent or give symptoms for some years and then be passed per rectum. NEOPLASMS OF THE INTESTINES 573 Treatment. — Intestinal hemorrhage should be treated in the manner already described under Typhoid. The blood will often be bright in color if the hemorrhage is from the colon or rectum ; injec- tion of very hot or cold water with 5j (4.0) of alum or tannic acid, gr. 30 (2.0), locally, or Tremoliere's solution, by mouth and rectum; ice-bag to the abdomen; morphin, gr. I (0.016), and ernutin, lUv (0.296), by hypodermic, are indicated. If the tumors are accessible in the rectum, they should be removed by galvanocautery or by operation. GAS CYSTS OF THE INTESTINES (Synonym. — Pneumatosis Cystoides Intestinorum Hominis.) Cysts containing air, in the intestines of pigs, were probabh' first described by Mayer,^ of Bonn. This condition was also indepen- dently described by John Hunter. These intestinal gas cysts have been found quite frequently in apparently otherwise healthy pigs and occasionally in sheep. The theory has been held that bacteria are the cause, or that they are the result of mechanical and physical conditions ; for example, that gas may escape through some abrasion into the tissues. Bang^ first reported this condition in the human being, and Finney the first case in America. Finney and Welch^ believe the cyst to be a distinct variety of tumor, the cells of which have the faculty of secreting gas. In prac- tically every case so far the gaseous cyst has been associated with disease of some portion of the intestinal canal, producing an obstruc- tion to the lumen of the bowel. Cysts may be single or multiple and in the small and large intestines. Pathology. — There is a dense fibrous tissue framework contain- ing round and spindle cells, and there are clefts arid spaces whose walls contain large giant cells with many nuclei. Air spaces are found about these cells, and there is an endothelial lining to these spaces. The blood-supply is rich and hemorrhages may occur in the tissues. Air in the cyst resembles atmospheric air. The tumor is 'more pronounced in the subserous tissue, though it has been observed in all the layers of the walls. Clinically, there is no definite picture. Crepitation on palpation has been noted. Pain and constipation could be chieliy attributed to other factors. Diagnosis is usually made during operation for some other trouble or at autopsy. Treatment. — If symptoms of obstruction, operation is indicated. After operation for other conditions, they generally diminish in size or disappear. 1 Jour. d. prakt. Heilk., 1825. 2 Nord. med. Ark., 1876, viii, No. 18. 3 Jour. Am. Med. Assoc, October 17* 1908. CHAPTER XXVIII HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE HEMORRHOIDS (Synonyms. — Phlebectasia Hemorrhoidalis; Piles.) Hemorrhoids consist of diffuse or circumscribed varicose dilata- tions of the hemorrhoidal veins, lying either in the subcutaneous tissue of the anus external to the sphincter (external hemorrhoids) or in the submucous tissue of the lower portion of the rectum (inter- nal hemorrhoids). The hemorrhoidal' veins surround the lower portion of the rectum and there form the hemorrhoidal plexus. The majority of these veins enter into the inferior or external inferior hemorrhoidal veins, and from there into the common pudic and iliac veins; others pass into the median inferior hemorrhoidal veins and so into the internal iliac vein and the inferior vena cava. A small number of the veins enter the superior hemorrhoidal veins, thence into the inferior mesenteric veins and the portal system. In portal obstruction blood from the hemorrhoidal plexus can pass into the vena cava; while back pressure on the vena cava inferior, as of cardiac origin, may affect the hemorrhoidal system. All hemorrhoidal veins are devoid of valves. Anatomy. — External hemorrhoids are visible to the naked eye, lie below the sphincter ani, and are often arranged in groups around the anal orifice. They appear as bluish- red, tortuous vessels encircling the opening; or there may be isolated varicose protrusions, from the size of a pea to a walnut. They may be round, flat, or irregular in shape and their size sometimes changes in the same patient, often being smaller after defecation. Internal hemorrhoids often can only be discovered by digital examination or by use of the proctoscope, as they lie above the sphincter. In aggravated cases the patient by bearing down may cause them to protrude. They usually appear as soft nodules of bluish hue, with thin walls. The diffuse or circumscribed nodular forms may be present, and the last constitute a true varix. External and internal hemorrhoids may occur together. Piles may occur singly or in pairs, or be multiple and form a ring about the anal opening, both external and internal to the sphincter, and even a third higher ring has been described. In exceptional cases dilated veins are found high up the rectum even into the sigmoid flexure. 574 hemorrhoids; prolapse of rectum; fissure 575 Hemorrhoids are generally believed to be simple venous ectasias and are considered genuine varices, though some maintain them to be true angiomata. * Secondary changes probably account for the various conditions found. The dilated blood-vessels, venous varices, near a group of hemorrhoids may become inflamed, adhere and coalesce, and the walls of the vessels atrophy, so that tumors of some size, resembling cavernous multilocular tumors (angiomata), may develop. The external covering of the varix may become hard, thick, and resistant, through inflammatory processes. In other cases the walls may become thin and eventually rupture, or the blood coagulate within the pile and form a thrombus. Phleboliths occur in old cases. A blood-cyst is occasionally formed. Marked connective-tissue increase may take place in some of the external hemorrhoids; they may present the appearance of skin tabs, or skin externally and mucous membrane internally, which may become edematous and inflamed. They may give rise to warty growths. The mucous membrane of the rectum near the hemorrhoids is hyperemic, and, with internal hemorrhoids, in a condition of catarrhal inflammation. Fissure or prolapse of the rectum may be associated with piles. Allingham has subdivided internal hemorrhoids into three varieties : 1. Capillary piles, resembling nevi, consisting of hypertrophic capillary vessels and spongy connective tissue with thin mucous "membrane. They easily bleed. 2. Arterial piles, sessile or pedunculated tumors, ghstening or villous, slippery, hard, and vascular. 3. Venous piles, in which the veins predominate. Tumors are large and bluish or livid in color. Internal piles may be pushed down during defecation. A pedicle may be formed to the tumor and the mass ma}'^ slip out of the rectum. After defecation they may spontaneously return into the bowel, or can be replaced. If large they may become incar- cerated and even gangrenous and slough off. Hemorrhage is a common occurrence. Inflammatory processes may complicate internal piles, such as ulcers, proctitis, and periproctitis. With the latter abscess may result, which may form fistula?, external, internal, or complete. Etiology. — Hemorrhoids are frequently met with in practice and the condition is much more common than supposed, as many patients so afflicted never consult the physician. It is rare in children. The statement is often made that piles occur more frequently in men than in women. Undoubtedly more male cases are found in our 576 DISEASES OP THE STOMACH AND INTESTINES records. Habitual constipation, pelvic congestion, and sedentary life favor markedly the production of hemorrhoids, and these con- ditions we find most frequent in women. Males will at once consult the physician if there is difficulty in the anal region. Women are, as a rule, extremely sensitive and usually treat their piles by home remedies until conditions are such as to necessitate advice from the physician. It has been my experience that most of my women patients never refer to ' ' hemorrhoids ' ' unless specifically questioned. Actually I believe women are the more frequently afflicted. Age. — Piles occur most frequently between thirty and fifty years of age. The modern consensus of opinion is that hemorrhoids are a local disease and not due to any diathesis or faulty state of the general circulation. There are certain peculiarities in the rectal plexus of veins favoring the production of piles which are as follows : The walls of the hemorrhoidal veins are thin and contain few muscular fibers, and hence their contractile force is less than that of the veins in the lower limbs. There are no valves in the rectal veins, so that blood can be readily forced back into them. Muscular contraction aids the onward propulsion of the blood in other regions. In the rectum fecal masses compress the blood-vessels, the sphinc- teric contractions compress the vessels, and contraction of the ab- dominal muscles during defecation interfere with the return of blood. Thev are dependent blood-vessels, and with the unfavorable factors mentioned it is not surprising that hemorrhoids are frequent. Some of the hemorrhoidal veins enter the portal system, in which there is a low degree of pressure and in which the circulation is readily retarded. Stasis of this system may be a contributory factor in the production of hemorrhoids, as in cirrhosis of the liver; as may also diseases of the heart and lungs leading to engorgement of the venous system. All conditions which tend to produce interference with the return circulation of blood from the hemorrhoidal vessels, or produce or predispose to hyperemia, influence the production of hemorrhoids. Among such are: chronic constipation; sedentary habits, as in clerks, students, shoemakers, seamstresses, sitting on soft cushions, excessive horseback riding, etc. ; enlarged uterus, as from disease or pregnancy; prostatic affections, tumors of the bladder or growths in the pelvis. Hemorrhoids may develop suddenly in cases of carcinomatous stricture of the rectum and early in the course of the disease. Habitual constipation favors the production of piles. Hemor- rhoids also may be the primary condition, and on account of the pain of defecation the patient avoids having a movement as long as possi- ble. Excessive venery is given as causing congestion in these regions. Abuse of alcohol, spiced food, fatty food, excessive quantities of food and drink are believed by some to favor the plethoric habit and hemorrhoids; prolapse; of rectum; fissure 577 produce fulness of the portal circulation, with resulting piles. Gour- mands of this type are often of sedentary habit and are frequently disposed to constipation — a more likely cause. Von Recklinghausen has shown that piles are by no means common in plethoric individuals, but more in those of lean habit, of poor muscular development, with defective metabolism, who lead a sedentary life, and who are anemic, with poor circulation. Catarrh of the rectum is given as a cause, but it is not always easy to determine whether the catarrh or piles were primary. Drastic purgatives are said to produce hemorrhoids, but they are used for the constipation, which may be the chief factor, Cases do occur in which it seems probable that the excessive use of purges has produced hemorrhoids with prolapse. Among the Orientals, who lead a sedentary life, hemorrhoids seem quite common. Hereditary anatomic peculiarities have been suggested as a cause, since piles are often found in several successive generations. Symptoms. — External Hemorrhoids. — ^These are chiefly of local character. The patient may have a sensation of fulness, clogging, or pulsation in the lower rectum. At times there may be a feeling of obstruction at the time of bowel movement. Constipation usually precedes the attack. There is itching of the anus and perineum. The anus may be tender and swollen, and if the buttocks are drawn apart external piles, single or in clumps, round and bluish in color, distended with blood, are present. Stains of blood are often found on the toilet paper. The exacerbation may quiet down under rational methods. They may become swollen and edematous, painful, and even ulcerate and suppurate, with the production of a fistula. Tenesmus may be present, and the external pile may be drawn up into the sphincteric circumference and become pinched and stran- gulated. Under such conditions there are severe pain, throbbing, a desire for defecation with straining, and the patient cannot sit or walk about. Fever, anorexia, and severe constipation accompany the local manifestations. Hemorrhage is not as marked with external piles. Internal Hemorrhoids. — With internal hemorrhoids hemorrhage is often a prominent symptom. Frequently internal piles can only be detected by digital examination or by inspection through a speculum. They may prolapse and even become strangulated. In such event the pile becomes swollen, turns deep blue, there is agonizing pain, marked tenesmus, occasionally vomiting, constipa- tion, meteorism, fainting, prostration, and fever. Gangrene and sepsis may occur if the strangulation is not relieved. With mild types of internal hemorrhoids the only symptom may be an occasional hemorrhage. One must remember that hemor- rhoidal veins may be very high up and only be visible with a procto- scope. 37 578 DISEASES OF THE STOMACH AND INTESTINES Usually, subjective symptoms are present, such as itching, burn- ing, pressure and weight in the anus, and the sensation of a foreign body, with tenesmus. There may be feelings of pressure and even pain in the sacral and lumbar regions. Occasionally soreness over the lower part of the abdomen, pressure in the rectum, bladder, uterus, and vagina; pains radiating to the thighs may be present. Sometimes these symptoms precede a hemorrhage, after which temporary relief occurs. As a rule, the bowels are irregular and constipated. Hemorrhages may be frequent, so as to cause marked secondary anemia. Bleeding may be severe and bright red blood gush from the rectum nearly pure, or it may be dark brown mixed with fecal mat- ter. In such an event it lies on the surface of the feces and is not intimately mixed with it. Small quantities of blood are frequently passed with hard stools. Hemorrhages sometimes occur on no special provocation, or after a horseback or bicycle ride, etc. Gummy acrid mucus may be discharged from the hemorrhoids due to catarrh of the rectum, and may cause excoriations. In some the hemorrhage may last for several days and temporary relief may occur. It has been stated that bleeding from hemorrhoids may take the place of menstruation (vicarious). Dyspnea, palpitation, angina, hiccough, giddiness, despondency, and hypochondria, often attributed to piles, I believe, with Riegel, are merely associated with the constipation present. Proctitis, fissure, and occasionally abscesses or fistulae may develop. Disturbances of adjacent organs, such as strangury, hemorrhage from the bladder or vagina, or catarrh of the latter may occasionally occur. Diagnosis is made by inspection and digital examination; occa- sionally the proctoscope is necessary. The appearance of hemor- rhoids has been described. Condylomata encircle the anus and are often present on the scrotum. There are a history of syphilis and manifestations of lues. Skin tags are whitish looking, do not change their size, and do not bleed when punctured. Piles differ in the last regard. Internal hemorrhoids are reddish blue and bleed when punctured ; polypi do not do so. The latter occur most frequently in children. Carcinoma presents a hard consistency, stenotic s\TTiptoms, and cachexia. A small section placed under the microscope will settle the diagnosis. Piles may occur suddenly in association with cancer. Prognosis. — Piles are frequently a chronic affection and may exist throughout Ufe. In cases occurring during pregnancy, restitu- tion to normal is possible. This is true of the milder types if the cause is corrected. They may markedly diminish in size and then hemorrhoids; prolapse of rectum; fissure 579 an exacerbation take place. They rarely endanger life unless stran- gulation with gangrene or a large abscess or dangerous hemorrhage occur. Treatment. — Excesses of all kinds in food, drink, and venery should be avoided. The patient should lead an out-of-door life, take proper exercise, and have a daily soft evacuation of the bowels. All conditions causing venous engorgement of the rectum should be avoided, such as constant standing or sitting, horseback and bicycle riding. The patient should not sit on warm soft cushions, but on cane-seats or those covered with leather or horse-hair. ' Diet. — The diet should be mixed in character and in part consist of a considerable variety of green vegetables and raw ripe and cooked fruits, to regulate the bowels. It should suit the individual, and a stout full-blooded person must be somewhat limited in his diet. The patient should not take three large meals at long inter\^als, but preferably smaller and more frequent feedings. Alcoholic beverages, strong coffee, strong tea, highly seasoned dishes, cheese, coarse brown bread, peas, corn, and baked or lima beans are best avoided. String beans, spinach, asparagus, and green salads aid bowel action. Potatoes, rice, beets, and cauliflower may be allowed in small quantity. Raw fruits, such as apples, pears, prunes, grapes, oranges, and stewed fruits, such as prunes, baked apples, etc., are of value. vSoups of various kinds are allow^ed. Hot breads, richly spiced foods, and rich desserts should be avoided. Matzoon, kumyss, bacillac, lactone-milk, and buttermilk often have an excellent effect on the bowels. They can be taken as the extra meals midway between the usual m.eals. A few crackers or zwieback with plenty of butter can be given. Some recommend water only between meals and interdict much of that. Unquestion- ably a certain amount of fluid with the food is an aid to digestion and bowel action. I have seen severe cases of constipation result from the elimination of all fluids at meals. At least oviij (250 cc.) of fluid in the form of broth, soup, cocoa, or water should be taken at each meal. On rising, administration of a glass of water often aids bowel action, and between meals an equal amount should be given, or matzoon or kumyss substituted. Outdoor exercise, such as walking, is of service. It should not be carried to the point of fatigue and is contra-indicated during acute inflammation of the piles or if hemorrhage or unpleasant svmptoms result. Massage, gymnastics, and Swedish movements are of value. Bowels. — Constipation should receive appropriate treatment. Powerful cathartics should be avoided. The dietary methods men- tioned should be carried out. The patient should go to stool daily at a definite hour. I have found the administration of olive oil, 580 DISEASES OF THE STOMACH AND INTESTINES I to 2 tablespoonfuls (15.0-30.0) t. i. d. before meals, an aid to bowel action. The injection of oj to ij (30.0-60.0) of olive oil into the rectum with a small soft-rubber ear syringe just before having or attempting to have a movement is a valuable procedure. It renders the passage easier and less painful. Aloes should be avoided in hemorrhoid cases. Among our simple remedies are compound liquorice powder, oj (4-0); fiuidextract of cascara or aromatic fluidextract, oj (4-0); extract of cascara, gr. i to 5 (0.06-0.3); purgin (phenolphthalein) , gr. 1 2^ to 5 (0.1-0.3) ; tincture of rhubarb, 3j (4-0), or extract of rhei, gr. 4 (0.25). Other remedies are described in the chapter on Consti- pation. Carlsbad, Kissengen, and Saratoga waters are of service, especially at the springs. A good prescription is the following: I^. Ext. cascara gr. xv (i.o) Ext. belladonnse 1 .......,, tX ^ . . y aa Ejr. Ill (0.2). — M. Ext. nucis vomicae J a j \ / Make 12 pills. Sig. — One to two at bedtime. Hygiene oj the Anus. — After defecation, cleansing with a moist sponge or wet cotton is less irritating than paper. External piles should be protected with a small piece of cotton moistened with sweet oil or covered on the anal side with vaselin. iifiifii'iriririiniriiiiimi Fig. 213. — Kemp's tube (cooler) for hemorrhoids or prostate. Fig. 214. — Kemp's ice tube for hemorrhoids. boric acid, or zinc ointment. Cold sitz-baths and cold ablutions to the rectum are valuable. An external douche with cold water is excellent, thus: A fountain syringe is filled with cold water at about 60° F. and several ounces of witch-hazel added, or a hot douche at 1 10° to 115° F. can be substituted. The rectal tip is placed close to the anus, which is then thoroughh* douched. This is especially applicable for external piles, and lessens congestion even when they are internal. For external inflamed piles stronger medicated local applications can be employed than with internal piles, where greater absorption occurs. External Hemorrhoids. — With inflamed piles absolute rest in bed hemorrhoids; prolapse of rectum; fissure 581 or on a couch should be enjoined. A small ice-bag or gauze wrung out in cold solution of witch-hazel and water, equal parts, or of lead-and-opium wash, are excellent applications. Some prefer the application of warmth; cold is usually more efficacious. For the apphcation of cold to relieve congestion, both to external and internal hemorrhoids, the simple instruments in Figs. 213 and 214 are of value. The ice tubes for hemorrhoids are made in a nest containing several sizes, in appearance like a very small test-tube with a broad flange, to prevent slipping into the bowel. The tube is filled with powdered ice, corked, well lubricated, and inserted into the anus. They are of glass or metal, the latter the safer. The prostatic cooler is of small caliber— a simple closed tube with a large entering and small return attachment. The fountain syringe is attached to the large branch and a soft outflow tube to the smaller. Very cold (preferably) or hot water can be employed. The soft- Fig- 215. — Kemp's soft-rubber rectal bag, used as a cooler for hemorrhoids. rubber rectal bag (Fig. 215) is made on similar principles, but is more bulky.^ They were reported some years ago." In addition, one can attach a small catheter to the tip of the fountain syringe and, inserting the soft tube about i^ inches, thus douche the internal hemorrhoids. The current should be slow, the patient evacuating the fluid around the catheter every minute or so. Hot or cold normal saline solution with witch-hazel, 5 I (30.0) to the pint (500 cc), can be employed. The old Boden- ,hamer recurrent tip or the flexible or hard-rubber recurrent tubes (Kemp) can be used, introducing them only about 2 inches; but with inflamed piles they are apt to cause more pain than the small soft catheter. I have found the following prescriptions, recommended bv Samuel Gant, of value for the relief of pain and inflammation in external hemorrhoids: I^. Liq. plumbi subacet 5iv 13 Tinct. opii 5iiss 10 Ac], dcstil q. s. .'iv 125 Sig. — Apply cold, on gauze. -M. 1 A small rubber condom, with two catheters tied in, one for the entering and the other for the outflow current, can be substituted for this bag. 2 Manual on Enteroclysis, Hypodermoclysis, and Infusion, 1900. 582 DISEASES OF THE STOMACH AND INTESTINES or I^. Ung. stramonii 3iss Ung. belladonnEe Siiss Ung. acidi tannici oss I^. Morph. sulph g^- "J. Cocainae hydrochlor §^.-. -^^j Vaselin oij I^. Cocainse hydrochlor gr- v Ext. bellad. ] > Ext. opii I -- --•• Ext. aconite { * ^^^'^ Ext. stramonii J Glycerin 5 ss Sig. — Apply on cotton, externally. 15 60 -M. 195 78 .— M. 325 -M. This last prescription I prefer to use first at about one-third or one- half strength. It should be employed only for the temporary relief of severe pain and should be left on only for a short period, about fifteen minutes. Cold or, at times, hot injections, and opium and belladonna sup- positories are excellent for tenesmus. For internal hemorrhoids, when prolapsed, inflamed, and diffi- cult of reduction, it is advisable to apply cold, such as ice-water to which witch-hazel has been added, ice, or lead-and-opium lotion (cold) , for a brief period to lessen edema and inflammation. Local application of adrenalin (i : 1000) to an irreducible pile lessens congestion and aids reduction. One of the following ointments is excellent as a sedative: I^. Morph. sulph gr. viij Hydrarg. chlor. mit gr- xij Vaselin o j • 3° I^. Ext. opii .5ss 2 Cocainae hydrochlor gr. x Mentholi ^:'^^^ ^ Ung. zinci oxidi o j 30 52 78 .— M. (Gant.) -M. The prolapsed hemorrhoid should be well lubricated before the physician endeavors to push it up with the finger. Occasionally an anesthetic may have to be administered. There are the dangers of strangulation with gangrene and sepsis from an unreduced hemor- rhoid. For ulcerated hemorrhoids the following are useful : I^. Bismuth, subnit oij 8 Hydrarg. chlor. mit .Bij 2 IVlorph. sulph gr. iij Glycerin 5 ij 8 Vaselin 5 j 3" Sig. — Apply with pile syringe (Allingham). I^. Cocainae mur gr- xij Todoformi 5j 4 Ext. opii 5 ss 2 Vaselin 5 j 30 Sig. — Apply with pile syringe (Mathews). 6 195 -M. -M. hemorrhoids; prolapse of rectum; fissure 583 For hemorrhage the following are of service ; Rectal injections of ice- water, oviij (250 cc), alone or with tannic acid, gr. 5 (0.3), dis- solved therein, or alum, 5j (4.0), or witch-hazel, equal parts; local application of ice-bags or the ice tube. Several ounces of Tremoliere's solution — gelatin (5 per cent.) with chlorid of calcium (2 per cent.) — can be injected into the rectum. It was originally used as a local styptic. If the bleeding is from external piles, styptics can be applied in ointment form ; if from internal hemorrhoids, the ointment can be in- serted with the finger or applicator, or as a suppository. Among such useful remedies are unguentum acidi tannici and unguentum gallse : I^. Unguentum acidi tannici oiv 16 Unguentum stramon. \ - - ^ ■ : _y^ Unguentum belladonnse j •' "^ j" Ft. ung. T^. Suprarenal ext gr. v [3 01. theob gr. xxx 2]. — M. Ft. suppos. No. i. I^. Adrenalin chlorid (i: 1000) • TTLx (.592) 01. theob q. s.— M. One suppository. Py. Ichthyol, I - ^ ^, I Acidi tannici j o o Ext. belladonnse ) - - ^ 1^^^ Ext. stramon. J o j Ext. hamamelis gr. x 6 01. theob q. s. L— M. Ft. one suppository. (J. P. Tuttle.) An ointment or suppository containing chrysarobin has been ad- vised for the treatment of hemorrhage from piles : P^ Chrysarobin gr. xv i Ext. belladonnse gr. v 3 Iodoform gr. x 6 Petrolati 5ss 15 . — M. Ft. unguentum. I^. Chrysarobin gr. ij 13 Acidi tannici gr. iij I94 Iodoform! gr. ij 13 01. theob gr. xxx 2|.— M. Ft. one suppository. In many cases of hemorrhage the simpler remedies are sufficient. Rarely it may be necessary to tampon the rectum. This can be per- formed by slipping in a piece of cheesecloth like the finger of a glove, in effect, a bag, with the outside well lubricated. This is packed with cotton tampons or strips of gauze, and the distended bag drawn down against the sphincter. It can be done in emergenc>- without an anesthetic. If these measures fail, it may be necessary to ligate the bleeding artery or, if this be ipipossible, then the entire hemor- rhoid. 584 DISEASES OF THE STOMACH AND INTESTINES Radical Treatment. — Dilatation of the Sphincters. — By means of this the spasm of the sphincter is stopped, the pressure on the blood- vessels is relieved, and the bowels act more easily. It will frequently be of benefit in the early stages of hemorrhoids, and I have seen it relieve severe symptoms in advanced cases, especially if fissure is associated. The author has noted cases in which several years after dilatation the patient has claimed to be in comfort, with no recurrence. As a palliative the procedure is justifiable, especially if fissure is present. Gradual dilatation by the use of specula of increasing size or of dilators can be carried out. The procedure takes several weeks and is necessarily very painful. If this method is carried out, air dilatation with Roberts' dilator (Fig. 216), made on the principle of Barnes' cervical dilator bag, is the most satisfactory. The hard-rubber dilators cause more pain. Fig. 216. — Roberts' dilator. Rapid and complete dilatation under anesthesia is the best method when safe for the patient. With the aid of a skilled anesthetist it can be satisfactorily performed under nitrous oxid. Other anesthetics can be employed. The thumbs must be inserted into the rectum and the sphincter dilated gradually, both laterally and anteroposteriorly. All spasm must be overcome and the sphincter thoroughly relaxed. Violence must not be employed. An opium suppository, gr. i (0.065), with belladonna, gr. ^ (0.02), should be inserted and the bowels kept closed for about forty-eight hours. Carbolic Acid Injection. — This method has been recommended in order to produce shrinking of the piles and so avoid radical opera- tion-. It should not be performed if the hemorrhoids are inflamed. The following solutions for injection have been recommended : I^. Acid, carbolic. (Calvert's) oij |8 Acid, salicylic oss 2 Sod. bibor 5 j 4 Glycerin (sterile) q. s. o j 130. — M. (J. P. Tuttle.) HEMORRHOIDS, PROLAPSE OF RECTUM; FISSURE 585 The solution should be syrupy and clear ; if white, it is imperfect. The average injection into a hemorrhoid is TTLv (0.296). Not more than TTLx (0.592) should be injected into two to three hemorrhoids. After the injection a suppository of — I^. Opii (pulv.) gr. j Ext. laelladonnse S^- 7 lodoformi 8^- ij Ol. theob q. s. 065 022 13 .— M. Carbolic acid and glycerin, equal parts; or carbolic, i ; glycerin, 3; water (distilled), 3, have been employed. Inject 3 to 5 drops with a hypodermic syringe into the center of the pile. Care must be taken that none of the solution drops from the needle and cauterizes the mucous membrane. An enema is first given, the piles cleansed and dried, and then anointed with iodoform ointment after injection with carbolic. A few drops of a i per cent, cocain solution may be first used subcutaneously to deaden the pain. It is preferable to inject one hemorrhoid at a time. Considerable pain at times follows. The possible dangers are ulcer, abscess, and fistulse. There is some danger of sepsis and cases have been reported. Cauterization with Fuming Nitric Acid. — The surrounding parts are covered with a thick layer of vaselin except the pile that is to be treated. This is painted with the nitric acid by means of a small stick or glass rod. Care must be taken that the acid touches no other spot. The pile turns a grayish-green color as a result. Iodoform ointment or vaselin is appHed and the hemorrhoid pushed back into the rectuni. Allingham advises carbolic acid as a substitute for the nitric acid. There is an element of danger from sepsis in this method. Ligature of hemorrhoids under anesthesia without removal and then allowing them to slough off has been employed. The method is not to be recommended for obvious reasons. Crushing. — ^The hem.orrhoid is crushed longitudinally by means of a special instrument, the projecting portion cut off, and pressure kept up for about a minute. This technic is not advised. Clamp and Cautery. — Each pile is seized with a volsellum forceps and drawn well down. The clamp is applied to embrace its base. The portion above the clamp is cut off with scissors, and the cautery iron, heated to a dull red, is applied to the stump until the vessels are well seared. Either the thermocautery or galvanocautery can be employed. Excellent results have been secured by this opera- tion. Ligature and Extirpation ( Allingham' s Operation). — Incision is performed at the base of each pile through the mucosa, and the pedicle dissected out. This is ligatured and the pile cut ofif with scissors. Some operators remove every alternate hemorrhoid, the rest usually shrinking as a result of operation. Others incise the 586 DISEASES OF THE STOMACH AND INTESTINES mucous membrane above the base of the pedicle and force it back hke a cuff. After hgature and removal of the pile, the cuff of mucosa is drawn down and a single stitch taken. This last method is to be recommended. Extirpation and Suture {Whitehead's Operation). — The m^ucous membrane containing the hemorrhoids is dissected out, the incision frequentlv encircling the anus. The piles are removed, and the mucosa, being loosened up, is drawn down and attached by sutures to the skin at the anal margin. Stricture or incontinence of feces are sequels which may follow this operation. Subsequent treatment by bougies is necessary if stricturing be feared or if it occur. In these operations anesthesia is necessary, and dilatation of the sphincter previous to removal of the hemorrhoids. It is usually customary to close the bowels for twenty-four to forty-eight hours after operation by means of opium suppositories, though Graser opens the bowels at once. Gant's Water Infiltration Method. — ^This method, devised by Sam- uel Gant, is of special value in cases where an anesthetic is contra- indicated or when the patient objects to its employment. With a large hvpodermic sterile water is injected about the base of each hemorrhoid in the submucosa, producing thorough infiltration. An incision is then made around the base of the pile, the pedicle dissected out, the latter Hgatured, and the pile cut off with scissors. Careful preliminary dilatation of the sphincter is carried out. Having seen this operation performed by its originator and also the ultimate results, I can recommend it as excellent. Complications of Hemorrhoids. — Prolapse of the Rectum. — Etiology. — Rectal prolapse is a fairly frequent complication of hemor- rhoids, though it may occur alone. It may involve the mucous mem- brane alone or all the coats of the rectum (procidentia recti). Among other causes of prolapse are polypi, vegetations, tumors; conditions tending to weaken the sphincters, such as ulceration or operative incisions, spinal paralysis, or traumatism; conditions producing muscular spasm, such as worms, dysentery, phimosis, cystitis, cal- culus, enlarged prostate, or stricture of the urethra. In some cases wdth hemorrhoids, the prolapse may only be partial as regards the circumference of the rectum, while in others it involves the entire circumference and there is a scarlet or livid mass projecting from the anus. An internal prolapse of the rectum may occur, in which the upper part descends through the lower part, but does not appear outside the anus. It is probably due to relaxation of the ligaments of the rectum. It corresponds rather to an intussuscep- tion. Weakness and paralysis of the sphincters are predisposing factors. Prolapse of the rectum is frequent in debilitated children, espe- ciallv if there is intestinal catarrh with a tendency to frequent stools accompanied by straining. Rectal prolapse occurs in elderly people, hemorrhoids; prolapse of rectum; fissure 587 also in cases of severe constipation, and as a result of frequent pregnancies. Symptoms. — With moderate prolapse, during the act of defeca- tion, a protrusion of the rectum from i to 2 inches long appears outside the anus. It is red or bluish red in color and puckered in appearance, covered with some mucus. The swelling is continuous, with the skin on one side and with the mucous membrane on the other, and is arranged in folds which radiate from the central aperture toward the circumference. In advanced cases the mass resembles a tumor with a star-like opening at its center, and the color is a paler red or bluish. With children the mass generally protrudes only when at stool ; while with adults it comes down more readily or often remains constantly down. At first it is spontaneously reducible, later, easily replaced by slight pressure, and finally it may become very difficult or nearly impossible of reduction. It often becomes inflamed or ulcerated, and in old cases in- continence of feces may occur. At first there is no or little pain, but after a time it may become quite severe. There is a tendency for the prolapse to increase in size. If in- flammation occur, there will be fever and constitutional disturbances. As a rule, there is no marked bleeding from the prolapse itself, but more of an oozing. Hemorrhage from associated hemorrhoids mav occur. Diagnosis. — This is made from the appearances described. If operation is contemplated, it is important to differentiate between prolapse of the mucosa alone or of the' rectum. In the latter event the peritoneum may be involved and the intestines be found in the prolapsed portion. Prolapse of the mucosa is not as firm and thick to the feel, the folds of the mucous membrane radiate from the orifice to the circum- ference, and the opening is circular and patulous. With prolapse of the entire wall the tumor is more conic, the " walls are thick and firm, the orifice is slit-like. When the mass is pressed between the fingers gurghng of gas in a contained loop of gut may sometimes be heard and resonance obtained on percussion. In some cases where there is much inflammatory thickening it is difficult to differentiate. In following out treatment this possible danger should be recognized and due precaution be exercised. Internal prolapse is more difficult to recognize. Digital examina- tion of the rectum is necessary. First keep the finger close to the anterior wall until it passes into a cul-de-sac. Withdraw it slightly and examine the center of the mass until an orifice is found into which the finger or a bougie can be passed for some inches into the rectum. It may be necessary for the patient to bear down during ex- amination. 588 DISEASES OF THE STOMACH AND INTESTINES Treatment. — Predisposing factors should be eliminated, hemor- rhoids, polypi, etc., removed. Cleanliness after defecation should be observed. The prolapse should be replaced with the patient preferably in the knee-elbow position. The mass should be thor- oughly lubricated with vaselin and gently pressed into the rectum. If a considerable portion is down, a large flexible bougie can be cau- tiouslv passed into the bowel, pushing before it the upper part of the descended gut, and pressure (taxis) should be employed evenly on the other surrounding portions with the fingers. When the prolapse occurs frequently, a rectal supporter should be worn, such as a soft-rubber ball attached to the anus by means of a belt and T-bandage. A supporter can be improvised by em- ploying a small roll of gauze covered with oiled silk and attaching it to a home-made T-bandage. With children palliative treatment is more successful. The cause of the difficulty should be investigated and removed if possible, such as a polypus. The general health should be built up, mild laxatives should be administered, and the diet regulated to secure easy bowel action if there is constipation. If diarrhea is a factor, it should receive treatment. The child should be instructed not to strain at stool, and in many cases it is wise to have him defecate in the knee-elbow posture over a vessel to prevent prolapse as much as possible, or in the vSims posture, even at the expense of soiling the bedding or clothing, which can be easily changed. If prolapse occurs, it should be w^ashed with cold water or weak boric acid solution or an astringent alum solution, 5j (4.0) alum to oviij (250 cc.) water, smeared with vaselin, and gently returned into the anus. After this the patient should remain in the recumbent position for about half an hour, preferably lying on the abdomen. Radical measures must frequently be adopted. Cauterization of the prolapsed portion with fuming nitric acid or acid nitrate of mercury, as suggested by Allingham, or (preferably) with the thermo- cautery under anesthesia, has benefited or even cured cases. After cauterization the prolapsed part should be lubricated and returned into the anus. Strictures are occasionally produced by this pro- cedure. Other methods have proved successful, such as excision of elliptic portions of the mucous membrane with subsequent suture ; extirpa- tion of the prolapsed portion ; revision or narrowing of the caliber of the rectum; suspension of the prolapsed rectum by attaching its mesentery to the abdominal wall ; or suspension of the lower end of the sigmoid flexure. Fissure of the Anus. — This condition quite frequently occurs with hemorrhoids. The fissure consists of an oblong tear of the mucous membrane of the anus, which gives rise to pain and spasmodic con- traction of the sphincters. Some fissures are slight abrasions or they may be fairly large and deep. The edges may appear healthy, or be hemorrhoids; prolapse oe rectum; fissure 589 inflamed or indurated. Those of longer duration present the ap- pearance of an ulcer. In fact, they are classified as irritable ulcer. Anal fissure is usually caused by an injury or tearing of the mucosa at the edge of the anus. Excessive straining or the passage of dry hard scybalae are factors. It is more common among women. The fissure may occur in any location, though most frequently at the posterior portion of the anus. It generally lies parallel and close to the external sphincter, though it may be higher up near the internal sphincter or above it. Symptoms. — Severe pain in the rectum during defecation and at times tenesmus, persisting for a time thereafter, are present. The pain may be very severe in character, so that the patient dreads to have a stool, and increased constipation results. A small fissure over the external sphincter usually causes greater disturbance than a larger one higher up. There may be reflex irritation of the bladder and a discharge of pus and blood from the rectum. From the pain and suffering the nervous system may become affected. Diagnosis. — This is made from the symptoms and by local exam- ination. The patient should lie on the left side and be told to bear down. On opening the anus with the finger and thumb, a fissure (crack) or small club-shaped ulcer can frequently be seen. It may be red and inflamed or, if more chronic, of a gray color wdth indurated edges. The pain may be so severe that before local examination it may be necessary to introduce a suppository of cocain, gr. \ (0.016). Rarely an anesthetic may be required. For a fissure higher up, examination with the speculum may be necessary. Treatment. — Hemorrhoids or polypi, if present,, should be re- moved. The dilatation of the sphincter performed during this opera- tion and removal of the cause of the fissure will usually cure the case. An incision through the base of the ulcer can be made at the same operation as a precaution. Recent fissures are at times cured without operation. The patient should be in the recumbent position, hot lead-and -opium lotion can be applied externally to the anus if much pain, as heat relieves pain and spasm. The following ointment and suppository are of value for the same purpose : I^. Ext. conii oij 8l Olei ricini oiij 12 Ung. lanol q. s. oij 60I. — M. Ft. unguentum. IJ. Ext. belladonnae gr- i '02 Ext. opii gr. ^ |o3 01. theob gr. XV i|. — M. One suppository. 590 DISEASES OF THE STOMACH AND INTESTINES Locally, the fissure can be touched with silver nitrate solution (I have used the pure silver nitrate stick twice a week), varying in strength from gr. lo to 30 (0.6-2.0) to the ounce (30.0) of water every two to three days ; on the alternating days a 5 per cent, cocain solution can be carefully applied, only a few drops; or the follow- ing ointment can be alternated with the silver application, or sub- stituted for a time: or I^. Ichthyol gr. xxx 2 Lanolin 5ij 8 Petrolati q. s. 5 j 30 Ft. unguentum. I^. Hydrarg. chlo. mit gr. xv i Pulv. opii ) Kxt. belladonnae / ^^ f'"^ Petrolati oss 15 Ft. unguentum. -M. 3 .— M. Gradual dilatation of the sphincter without anesthesia, as de- scribed under Hemorrhoids, especially with Roberts' dilator, is some- times employed, but this procedure is painful. Dilatation of the sphincter under anesthesia is often found cura- tive of obstinate cases. Nitrous oxid is a valuable anesthetic for this purpose. Some recommend infiltration of the fissure with a hypodermic of I per cent, cocain, and a free incision through its base to the sphincters. An incision of the fissure under anesthesia, combined with sphincter dilatation, may be required. Proctitis. — If proctitis is present with hemorrhoids, it must re- ceive appropriate treatment, as described under the section on that subject. CHAPTER XXIX APPENDICITIS (Svnonvms. — Inflammation of the Vermiform Appendix; Perityphlitis; Appen- dicular Inflammation; Scolecoiditis.) Inflammatory conditions involving the right ihac region have been called by a variety of names: Iliac phlegmon; typhHtis (in- flammation of the cecum) ; perityphlitis (inflammation of the cover- ing of the cecum); and paratyphlitis (inflammation of the retro- peritoneal tissue behind the cecum). Though typhHtis was considered to be the cause of most of the inflammations in the right iliac fossa, modern investigation has demonstrated that appendicitis is the chief factor. Some go so far as to state that even stercoral typhlitis (an inflam- mation due to fecal accumulation) does not exist. This is an error, as G. A. McWilliams,! though admitting it to be rare, shows that an acute or chronic primary typhHtis may occur independently of ap- pendicitis, dysentery, tuberculosis, actinomycosis, or cancer; and that it may be either idiopathic in origin or due to coprostasis. Autopsy reports and findings at operations have confirmed this opinion. Cecal disease may go on to ulceration and perforation, with the formation of perityphlitic abscess or general peritonitis, while the appendix remains normal. Howard Kelly has reported 14 cases presenting primary lesions in the cecum, the appendix being normal. Over 90 per cent, of inflammations are due to the appendix ; the rest to the cecum. The symptoms of typhHtis are usually indistinguishable from those of appendicitis and the indications for operation are the same. The literature on appendicitis is enormous, and I shall only mention the names of a few of those specially identified with the operative technic and investigation of appendicitis, namely: Reginald Fitz, Richardson, Sands, McBurney, Bryant, BuH, Weir, Fowler, Hartley, Dawbarn, R. T. Morris, Wyeth, Blake, Brewer, Hotchkiss, Deaver, and Howard Kelly. Position of the Appendix.— It takes its origin generally from the posterior and median surface of the cecum, corresponding to McBurney's point (i^ inches from the anterosuperior spine of the ileum) , on a line drawn from the spine to the umbilicus. The average length is from 3 to 5 inches, but it may vary markedly. The statistics as to its direction are quite variable. It may point downward and 1 Annals of vSurgery, June, 1907. 591 592 DISEASES OF THE STOMACH AND INTESTINES inward, downward behind the cecum, or upward, upward and inward, transversely inward, or outward. In many cases the appendix is quite long, and the position and length thus explain the variable locations of adhesions or abscess. It may, therefore, come in contact with the male bladder or rectum, with the uterus or right tube and ovary, or even the left tube, or with the small intestine, or it may pass up as high as the liver or right kidney, even to the left rectus, and close to the spleen. It has been found behind the peritoneum with no peritoneal covering. Bryant has reported it outside the peritoneal cavity in 3 cases. It has been found quite frequently in hernial sacs, and on several occasions in the scrotum. It quite fre- quently hangs free in the abdominal cavity. Peculiarities of the Appendix. — The lumen of the canal is extremely narrow; the organ is bottle shaped, the narrowest part being near the entrance into the cecum. Gerlach's valve, a redupli- cation of the mucous membrane of the appendix near its origin from the cecum, makes the entrance of material more difficult, and also its exit. The circular muscular fibers are somewhat scanty. These factors tend to produce stagnation and predispose to infection. There are many lymph-follicles (adenoid tissue) in the appendix, which usually persist up to the age of about thirty and then begin to retrograde, so that infection is easy, as in the tonsils. In many cases the appendix, is completely surrounded with peritoneum, in some it is only partially covered, and the uncovered portion is in direct contact with the retroperitoneal connective tissue, which readily accounts for the so-called perityphlitic abscess. The appendix has a mesen- tery of its own, as a rule, the meso-appendix, but it is not constantly present. It rarely reaches up to the tip, but usually only one-half to two-thirds of the distance. It is believed to have some influence on the shape of the appendix, as when it is relatively short the latter may be bent. Crile,^ in an analysis of 1000 cases of appendicitis, found that in a large percentage there was a short meso-appendix, causing fixation of the proximal part and leaving the distal end free, which tended to cause the appendix to fold on itself and interfered with the circulation (an anatomic angulation). The blood-supply of the appendix is quite scanty. The ves- sels (the appendicular and a few cecal branches) Fowler believes to be functionally nearly end arteries, the most abundant being from the vessels (the appendicular) in the meso-appendix, so that the vascular supply of the tip of the organ is poor. In females, Clado^ holds that there is a third source of blood- supply from a vessel passing through the appendiculo-ovarian liga- ment (a fold of peritoneum passing from the meso-appendix to the broad ligament), and this possibly explains why appendicitis is less common in women, on account of the superior vascular supply. 1 Ohio State Medical Journal, June, 1907. 2 Compt. Rend. Soc. Biol., 1897, vol. iv, p. 133. APPENDICITIS 593 Fowler holds that the blood-vessels may be primarily affected. Misplacement and malformation of the appendix may also have an influence. The peculiar anatomic conformation of the appendix may predispose to infection. Etiology. — The chief cause of appendicitis is bacterial invasion, the most common of which present is the Bacterium coli commune. As a rule, the infection is a mixed one, streptococci being frequently associated. The proteus vulgaris has been present. The Diplococcus pneumoniae, staphylococci, the anaerobes, and the influenza bacillus have been found. These are the most fre- quent varieties and are found both in the appendix, appendical abscess, and in the general peritoneum (fluid of the), if peritonitis is present. In isolated cases, appendicitis is believed by some to be a local expre^ssion of a general infection, as associated with scarla- tina, measles, rotheln, small-pox, chicken-pox, parotitis, influenza, and acute articular rheumatism. It has accompanied suppurative tonsillitis. Typhoid, dysentery, and, more rarely, tuberculosis may be causes. Actinomycosis has also been demonstrated to have produced it. Traumatism^ or injury from lifting have been given as causes, but probably, if appendicitis occurs as a sequel, the organ was previously diseased or damaged, or the symptoms might be due to a circum- scribed traumatic peritonitis. Constipation as a factor in the production of appendicitis is a question of dispute. Fitz and Fowler believed that in the majority of patients the bowels acted regularly previous to the attack, and Riegel holds that constipation and diarrhea have no bearing on the subject. Though unquestionably many patients suffering from con- stipation never suffer from appendicitis, there is one .type of case in which it may be a factor, namely, patients in whom there is a tend- ency to fecal accumulation in the caput coli and lower ileum, with resulting appendix symptoms, probably from circulatory interference, pressure, blocking of the appendix opening, and catarrh secondary to a slight catarrh of the cecum. I have seen several such cases in which there were the typic symptoms, which rapidly subsided after thorough bowel irrigation, ice-bag, and later cathartics and sub- sequent treatment of the constipation, with no subsequent attacks during eight or ten years' observation. To this same class belong the rare type of typhlitis due to stercoral ulcer to which McWilliams refers. Dietetic indiscretions, in so far as they are productive of intestinal putrefaction or fermentation with increased bacterial activity, might be a factor in producing an acute attack in an appendix already damaged. Intestinal catarrh, involving the caput coli, in my own experience has been the direct cause of the catarrhal type of appendi- citis. ^ Deaver, New York Medical Journal, June 15, 1907. 38 594 DISEASES OF THE STOMACH AND INTESTINES Entozoa, such as the trichocephalus dispar, oxyuris vermicularis, ascaris lumbricoides, tapeworm, and bilharzia, have been factors in the production of appendicitis. Movable kidney, through pressure on the mesenteric vein, has been given as a frequent cause by Ede- bohls. This condition is associated with splanchnoptosis, and the circulatory changes from malposition of the viscera are more probably factors. These conditions occur most frequently with women, yet appendicitis is less frequent in the female. Foreign bodies entering the appendix, such as grape seeds, cherry stones, pits, pins, buttons, gall-stones , etc., are rare causes of appendi- citis. Fecal concretions are found frequently and have been mistaken for foreign bodies. Probably normally soft fecal matter enters and is expelled from the appendix. The fecal concretions are generally hard in character from absorption of water and are thickened by mucus. C. B. Lockwood has demonstrated that in many cases they consist of an inspissated mass of bacteria. It is easy to understand how such concretions, if of large size, can exert pressure and even be productive of ulceration, especially if there be any abnormal condition in the appendix. They have been found in one-third to nearly one-half of the cases. Small concretions might remain in an appendix without harm. They generally lie near the end (tip). Right tubo-ovarian inflammation may be a factor in the produc- tion of appendicitis. i4g^.— Appendicitis seems most frequent between ten and thirty years, Fitz stating that 50 per cent, occur before the twentieth year, and Einhorn 60 per cent, between sixteen and thirty years. It has been reported as early as the seventh week, but rarely before the third year. Sex. — Men suffer from appendicitis much more frequently than women (from 2 to 3 or more to i). Varieties. — I will describe both the pathologic and clinical types of appendicitis. From a pathologic standpoint, the following seems the best classi- fication : 1. Acute catarrhal appendicitis, in which the mucous membrane is involved, being swollen and edematous, the submucosa injected with excessive secretion of mucus or mucopus. This type is mild, and the appendix drains into the cecum with perfect recovery (endo-appendicitis, Fowler). 2. Acute Diffuse Appendicitis. — ^There is inflammation of the mucosa and thickening of the entire organ, which is rigid, tense, and infiltrated. By some it is classified as catarrhal, but this is incorrect. The peritoneal surface is hyperemic. There may be erosions or small ulcers and a fecal concretion. There may be mucus or muco- purulent material in the lumen, or in some cases it may be narrowed or obliterated. - APPENDICITIS 595 This type sometimes hangs free in the abdomen, but more gener- ally is adherent to the adjacent peritoneal structures, and is character- ized by the surgeons clinically as acute nonsuppurative appendicitis. It may resolve without operation. On the other hand, this pathologic type may be productive of abscess or perforation, when it would be placed under a different class by the surgeons. 3. Purulent or Suppurative Appendicitis. — This is a more advanced stage than the former. There is a definite pus-sac formed by the appendix. This type may also perforate and cause local abscess or general peritonitis. 4. Gangrenous Appendicitis. — This is characterized by necrosis, local or general. The tip is most frequently involved or the entire organ. 5. Chronic Appendicitis. — This may follow the acute, or the process may be slow and gradual from its incipiency. In some cases the changes have been found to be very slight, merely the evidence of a chronic catarrh of the mucosa, probably an extension from a chronic catarrh of the cecum. At times stenosis is present. On the other hand, the organ has been found firm, slightly en- larged and thickened, the mucosa thickened, and the lumen narrowed. In some cases there may be a stenosis, with formation of a cyst. In others there are concretions or erosions, or partial obliteration of the lumen; or the appendix may become converted into a cord-like structure, embedded in a mass of thick peritoneal adhesions. 6. Obliterative Appendicitis-. — A gradual involution process occurs in many individuals. The tube is thickened, the peritoneal surface smooth; the distal portion of the lumen may be entirely obliterated, and the organ becomes sclerotic and shrunken. Ribbert found these changes in more than 50 per cent, of subjects over sixty years of age. Normal involution seems to present no symptoms. From a clinical standpoint the physician will find several types of acute and chronic appendicitis, readily deduced from the pathologic classification. 1. Acute Simple Catarrhal Appendicitis (Endo-appendicitis). — A catarrh of the mucosa of the appendix. This is of mild type and is often secondary to a colitis or to fecal impaction in the cecum. Unless there is occlusion, the inflammatory products usually drain out (non-suppurative type, with complete cure). There may be recur- rent attacks. 2. Acute Non-suppurative Appendicitis (Sometimes Incorrectly Characterized as Acute Catarrhal). — ^The description is that of the Acute Diffuse Appendicitis, the entire organ being involved. There is fibrinous exudation agglutinating the appendix to neigh- boring structures, and the meso-appendix is thickened and inflamed. There may be kinking or torsion of the organ, stricturing, or even obliteration, and fecal concretion may be left within it. 596 DISEASES OF THE STOMACH AXD INTESTINES These cases often escape operation and may not have a recur- rence, but there is great habihty of the latter. 3. Chronic Appendicitis. — This may follow the acute, or the proc- ess be slow and gradual from the start. The chronic catarrhal cases ma}' exhibit but little change, or the appendix may be thickened, the mucosa thick and hyperemic, and its lumen narrowed, obliter- ated, or strictured. A fecal concretion may remain within it. It may present adhesions. It may follow an acute attack or be chronic from the onset. These three types are characterized by absence of perforation, gangrene, or abscess formation; though type 2 may progress to type 4, with resulting abscess or perforation. 4. Acute Suppurative Appendicitis {Formation of Abscess). — Of this W'C have two clinical types, the pathologic purulent appendici- tis (the appendix distended wdth pus) , on the verge of perforation, or an inflamed appendix enclosed in an abscess-cavity containing a varying amount of foul pus. The walls of the cavity are formed by adjacent peritoneal surfaces, coils of intestines, cecum, and omen- tum bound together by adhesions. The appendix lying in the abscess-cavity is congested and swollen, and may or may not be perforated or present areas of gangrene. It may be adjacent to the cecum or intestines or reach into the pelvis to the bladder or tubes and ovaries. Perforation, when present, is generally near the free end of the appendix. 5. Gangrenotis Appendicitis. — The appendix is congested, swollen, thick, and red, with gangrenous areas of greenish-black color and usually already perforated. It is marked by the absence of pro- tective peritoneal adhesions. There may be a fatal septic peritonitis before perforation of the appendix. Patches of fresh fibrin may be present with serous or bloody turbid serum in the peritoneal cavity or adhesions with pus. The condition is an acute gangrene due to thrombosis and oc- clusion of the blood-vessels. If the case is more chronic, some plas- tic peritonitis may be present. A purulent appendix, an acute diffuse appendicitis, or a concre- tion may ulcerate through, so that any of these types — including the gangrenous — may be classified as perforative appendicitis. 6. Harmful Involution of the Appendix (Morris). — The vermiform appendix normally undergoes an involution process with replace- ment of the lymphoid, mucous, and submucous coat by connective tissue. R. T. Morris^ notes that the ner\'e-filaments persist longer than other structures, and contraction of the connective tissue in some cases irritates these nerA'e-filaments, so that irritation of the ganglia of the bowel (Auerbach's and Meissner's plexuses) ensues and 1 Medical Record, April 6, 1907. APPENDICITIS 597 causes disturbances in the nearby intestines. This condition he characterizes as "fibroid degeneration of the appendix."^ The appendix is at no time the seat of acute or chronic infection, and the condition is characterized by intestinal dyspepsia and other definite symptoms which will be described later. The involution may be symmetric or nodular (Figs. 217-219), and occurs most markedly toward the distal extremity. Symptoms of Acute Appendicitis. — The symptoms of acute ap- pendicitis are modified by the character of the lesion, whether it is a simple catarrh, an appendicitis with the production of adhesions, a pus cavity, or of the acute gangrenous type. In general the cardinal symptoms of acute appendicitis are as follows : Fig. 217. — Symmetric involution of appendix (Morris). Fig. 218. — Nodular involution of ap- pendix (Morris). 1. Sudden pain in the abdomen in the right iliac region, or at times epigastric or umbilical, which soon or gradtially localizes in the right iHac fossa. Pains are continuous, increasing, or only exacerba- tions of pain. 2. Tenderness or pain on pressure in the right iliac region at McBurney's point. Often an area of resistance due to tumor or to muscular rigidity. 3. Fever of moderate or severe type. 4. Gastro-intestinal disturbances may be present, such as nausea or vomiting, and frequently constipation. 1 American Journal of Surgery, October, 190Q. 598 DISEASES OF THE STOMACH AND INTESTINES 5. In the septic gangrenous type I have, in a fairly large percentage of cases, observed a toxemic type of diarrhea^ with general abdominal pains at times, as the initial symptom, before localization of the appendix pain. This is evidently of septicemic character and has not to my knowledge heretofore been referred to as a symptom. 6. In some cases the thighs and knees are flexed. Pain. — The pain may be sudden and A^iolent, or at times inter- mittent and cramp-like, or even of a gnawing character or a dull ache. Fig. 219. — Transverse section of the appendix, showing replacement of the inner coats by connective tissue (Morris). Sudden and violent pain in the initial stage does not by any means mean perforation, unless other symptoms are associated. In about one-half the cases the pain begins in the right iUac fossa ; it may commence in the epigastrium, around the iimbihcus, or even be diffuse, but gradually becomes localized within twelve to twenty- four or thirty-six hours, and usually sooner. At times the pain is of a coUcky type (the so-called appendicular 1 Rudolph Schmidt assumes that the changes from normal in the intestinal flora of the feces, which occurs in appendicitis, may explain diarrhea in the early development of this disease; or possibly acute enteritis from dietary in- discretion may be the cause (Pain, by Rudolph Schmidt). The type of diar- rhea wnth gangrenous appendix seems to the author peculiarly septic and is relieved by appendectomy. APPENDICITIS 599 colic, supposed by some to be due to constriction of the appendix in forcing out mucus through a lumen nearly occluded). Pain is increased on moving. It is often relieved by flexing the knees and thighs, especially the right thigh, and so relaxing the abdomen. This position is at times assumed by the patient. Palpation of the Appendix. — Though some surgeons believe this to be an important procedure to render the diagnosis certain, Treves and lyockwood are very skeptical regarding the possibility of mapping out this organ. In the chronic cases palpation is of value, and the posi- tion and condition of the appendix can often be determined thereby. In acute appendicitis the methods of forcible palpation recom- mended often necessitate the use of considerable pressure, and I believe the procedure highly dangerous. In the initial stages of acute appendicitis it is often impossible to at first determine the Fig. 220. — A, McBurney's point, and B, R. T. Morris' point (lumbar ganglia) in appendicitis. character of the attack, and traumatism in some cases can precipitate a rupture. In the acute cases gentle palpation^ only should be used. Muscular Rigidity. — There is usually rigidity of the right rectus muscle of varying intensity. Tenderness on Pressure. — This occurs at McBurney's point and is of varying intensity, also at Morris' point, and Blumberg describes a new symptom. There are two points of great diagnostic value in appendicitis: tenderness at McBurney's point and at Morris' point (over the right lumbar ganglia). McBurney's Point. — If a line be drawn from the anterior superior 1 Percussion, according to Rudolph Schmidt, will often demarcate the area of pain better than will palpation. 6oO DISEASES OF THE STOMACH AND INTESTINES spine of the right ileum to the umbiHcus, a point i J inches from the spine along this is known as McBurney's point; and deep-seated tenderness on pressure over this point is diagnostic of appendical inflammation when taken in consideration with other symptoms (Fig. 220). Deep pressure also often causes reflex epigastric pain. Mere superficial tenderness means irritation of the sensory nerves of the abdominal wall due to hysteria, etc. Munro's point is slightly further out, where the same line crosses the outer border of the rectus. Morris' Point. — "Take another point on this same line, but i^ inches from the navel, ^ which lies over the right lumbar gangUa of the svm pathetic system, and we have another point of diagnostic value when tenderness on pressure is located in this region. " I . In the early stages of an acute infective process of the ap- pendix, the right lumbar ganglia are not tender. (The left lumbar ganglia may be described for diagnostic purposes as lying ih inches to the left of the navel.) Under these circumstances the point here described is of secondary importance, while McBurney's point is of prime consequence. "2. A. When an acute inflammatory process of the appendix has subsided, leaving a mucous inclusion or scar tissue, there may be no tenderness on pressure at McBurney's point, but there is ten- derness at the point here described and no tenderness at the point of the left lumbar ganglia. "5. When the appendix is undergoing an involution proc- ess, with replacement of its lymphoid coats by connective tissue, digestive disturbances and various local neuralgias may be due to irritation of nerv'e-filaments entrapped in the new^ connective tissue. There may be no tenderness at McBurney's point, but there is persistent tenderness at the point here described. There is no tenderness at the point of the left lumbar ganglia." The above condition constitutes fibroid degeneration of the appendix. "C. When the appendix is congested without the presence of infection, as in many cases of loose kidney, there may be little or no tenderness at the point here described. There is no tenderness at the point of the left lumbar ganglia." The author wishes to state, as before, that this type of appen- dical congestion he believes not due to loose kidney, but dependent on the enteroptosis. "In irritations of pelvic origin, both right and left lumbar ganglia are tender. Take, for illustration, a case in which the appendix and the right Fallopian tube are bound together by adhesions. We are to decide whether certain symptoms proceed from the appendix or from the Fallopian tube. If the symptoms proceed from the ap- 1 Surgical Section, New York Academy of Medicine, Dec. 5, 1907. The author here quotes Morris' deductions. APPENDICITIS 6oi pendix, the point here described is tender alone. If the symptoms proceed from the Fallopian tube, both right and left limibar ganglia are tender together. "To recapitulate: A patient comes in with the appendix in the form of a question mark. Right lumbar ganglia tender alone — appendix trouble. Right and left lumbar ganglia tender together —pelvic trouble. Neither right nor left lumbar ganglia tender — trouble somewhere cephalad from pelvis and appendix." Blumberg^ describes a sign pointing to peritoneal irritation or inflammation, which he considers will be found of assistance in the diagnosis of all peritoneal conditions, and especially of appendicitis. It consists in the fact that in palpating the abdomen in the neigh- borhood of an area of inflamed peritoneum, not only is the down- ward pressure painful, but if the examining hand is suddenly re- moved, the abrupt recoil of the abdominal wall also gives rise to pain. He has found that during an acute attack of appendicitis with peritoneal involvement patients invariably state that the pain caused by the sudden removal of the hand is greater than that caused by the pressure, w^hile if the inflammatory process is subsiding, the two painful sensations first become equal in intensity, and finally the pressure pain is greater than the other. He further believes that the sign is especially valuable in determining whether or not operation is indicated in early cases, since its presence indicates that the peritoneum has already begun to take part in the inflamma- tion. Its sudden appearance is, therefore, a danger signal, while its gradual diminution in intensity points to a subsidence of the peritoneal reaction. The advantage of the method is that it does not require an absolute estimation of the degree of pain caused by the palpation, which is often difficult to obtain, but demands simply a comparison of the intensity of the two painful stimuli which most patients are able to determine accurately. S. /. Meltzer's Method.— Meltzev extends the right knee, at the same time flexing the right thigh, while making pressure over McBurney's point. This projects the psoas muscle against the appendix and causes deep-seated tenderness in the appendix to be more readily appreciated. H. Illoway^ holds that forced flexion and especially forced ex- tension of the right thigh will cause pain in the appendix if inflam- mation is present. In many cases, especially in the acute catarrhal conditions or m the most virulent gangrenous type, no induration or swelling can be appreciated on palpation. As I have stated, forcible palpation in the endeavor to appreciate the appendix should be avoided. Percussion. — In cases with adhesions, exudation without pus, or of abscess, a boggy or, rarely, fluctuating mass can be appreciated in 1 Miinchener med. Wochenschr., June ii, 1907. 2 Archives of Diagnosis, July, 1908. 6o2 DisKASES OF the; stomach and intestines the right iHac fossa, and percussion will give a dull area in the region of the cecum. Fecal accumulation as a result of constipation must be differentiated by the methods I have already indicated. At times great irritability of the bladder is associated with this condition, and the urine may be scanty and contain indican and albumin, and even acute nephritis may be present. Rectal and vaginal examination may sometimes aid in localizing the condition if the appendix or abscess lie in the pelvis. Inspection may occasionally show protrusion on the right side or the distention of general peritonitis. If tumor is present, it may be variable in size, more frequently in the right iliac fossa. Its position, however, depends on that of the appendix, as described on page 603. Temperature. — An initial chill is rare. In the acute cases fever, even though slight, is present in the early stages. It may be only 99.5° Fo or keep low, or even rise to 101° or 102° F., or to a con- siderable height. Sometimes with circumscribed abscess there may for a time be only moderate temperature, and some cases of the virulent type will suddenly perforate, though the temperature be not high. In both of these, physical examination, the blood-count, and general symp- toms will aid the diagnosis. In general, a rise of temperature is significant of an active proc- ess, even though the temperature increase may be slight in degree and gradual in character. A sUght increase in rapidity of the pulse is also suggestive of an acute process, and at times this is noticeably much out of proportion to the temperature, especially the rapid pulse in gangrene or sudden perforation. Gastro-intestinal Symptoms. — Loss of appetite and coated tongue are present. Emaciation may occur in cases of long dura- tion. In the severer cases vomiting is quite common. It may be one of the first symptoms occurring with the pain, and then cease, or it may continue for several days. On the other hand, it may come on later in the attack and denote an exacerbation of the inflammation. It consists of the stomach contents, mucus, and bile; and in some cases it may be feculent. Associated with it there is at times hiccough. Black vomit ("vomito negro appendiculaire ") is the result of toxemia, producing hemorrhagic necrosis of the mucosa of the stomach and hemateme,sis. A few cases have also been reported of intestinal hemorrhage associated with jaundice and albuminuria. These conditions are all evidences of a fatal sepsis. Acute ectasia or acute gastro-intestinal dilatation may also occur a s complications. Bowels. — In some cases the bowels are regular until the attack, when constipation ensues. In others there may be a previous his- tory of constipation. Diarrhea of a toxemic type may be one of APPENDICITIS ' 603 the initial symptoms in acute gangrenous appendicitis. It is probably of septicemic character. I have noted it in several such cases. In- testinal paresis may occur as a complication. Tumefaction or Abscess. — In cases of acute appendicitis in which adhesions are present, a tumor due to adhesions and exudation, or an actual abscess, the position of the mass is dependent upon the position of the appendix primarily and then upon the direction of the extension of the inflammation or burrowing of the pus. It may pass down into the pelvis and produce bladder and rectal symptoms, or those pointing to the tubes and ovary (right) , and be palpable through the rectum and vagina. It may point below Poupart's ligament or simulate a psoas abscess. It may pass around in front of the cecum and superficial edema be noted in this region, or it may pass poste- riorly to the cecum and cause pain in the flank or back, with swell- ing, and produce perinephritic abscess or lumbar abscess. It may pass inward to the left and produce obstruction through pressure or bands. It may pass upward and produce subphrenic abscess and even perforate the diaphragm, pleura, and lungs. It may develop in a hernial sac. At times the tumor appears at the lower border of the liver, when the tip of the appendix lies in this region. The condition must then be differentiated between retroverted appendical abscess and gall- bladder or renal inflammation, such as infarction. Brewer has shown that tenderness at the costovertebral angle is diag- nostic of the latter ; the urine analysis is also important, and especially differential analysis after catheterization of both ureters. The his- tory will usually point to appendicular inflammation or disease of the gall-bladder, but operative procedure will alone settle some cases. The value of Head's zones of cutaneous hyperalgesia as an aid to differential diagnosis will be referred to under that section. The elements in the diagnosis of abscess formation are the grad- ual increase of the local tumor and the aggravation of the general symptoms. The abscess may perforate and cause a general peri- tonitis or the inflammation may extend to the peritoneum without perforation, so that there may be a slower process with various sac- culated collections of pus. The abscess may rupture through the skin or empty into the cecum, colon, small intestine, bladder, rectum, or pelvis of the kidney. Fukninating Type of Acute Appendicitis. — This is the most dangerous and fatal of all. This type of appendicitis can be sub- divided into two clinical varieties. Both, are characterized by the rapidity of the pathologic changes in the appendix and by the ab- sence of protective peritoneal adhesions, so that general peritoneal infection occurs quite rapidly. In the first class the pain in the region of the appendix and some of the subjective and objective symptoms are acute and quite marked, but not all of them. 604 DISEASES OE THE STOMACH AND INTESTINES In the second class, and by far the most dangerous because fre- quently undiagnosed until the general infection has occurred, the patient complains of no marked subjective symptoms; in fact, may say he is quite comfortable, and the objective symptoms are not marked. There are peculiarities in the pulse, temperature, and especially in the blood changes which tell the story. Acute gangrene of the appendix, with or without perforation, is the pathologic condition generally found on operation; though I have also seen an acute diffuse or purulent inflammation of the appendix, either with perforation or without it, produce the condi- tion. In some cases perforation was apparently due to ulceration from a fecal concretion which was found in the cavity. Perforation undoubtedly is present in many cases, but I agree with Riegel that acute virulent infection of the peritoneum, commencing in the region of the appendix, will produce the same clinical symptoms. In the first class of cases the patient may have given a history of previous attacks or have had some indefinite abdominal symptoms for several days, or may be attacked without warning, as in the mid- dle of the night, with severe pain in the abdomen. It may not at first be referred to the appendical region, may be epigastric or umbil- ical pain, but gradually localizes there. There is no tumor, the muscles are rigid, the appendix tender. The abdomen rapidly dis- tends. The patient is anxious and looks sick. The temperature at first may not be elevated much. The pulse is rapid and out of proportion to the temperature. General symptoms of peritonitis rapidly ensue. In others the pulse may be slow at first and a low temperature with local signs of appendicitis, but acute history, nausea, vomiting, and marked constipation. The pulse later becomes more rapid, high temperature, distention, coated tongue, and general tenderness. In others the first symptoms are of collapse, with subnormal temperature, rapid pulse, cold and clammy skin, respiration increased in frequency, followed by symptoms of general peritonitis. In the second class of cases the condition may be very deceptive. The patient, in perfect health, may suddenly complain of general abdominal pains. I have seen a number with diarrhea of toxic character as the initial symptom. The patient may impute the symptoms to dietary indiscretions. The tenderness may be diffuse or equal on both sides, and gradually it localizes in the appendix region. Even so, the tenderness at McBurn.ey's point may not be very acute, and the rigidity of the right rectus not very marked or very slight. The patient may state that he feels quite comfortable. The temperature may be moderate (ioo° F.) and the pulse loo. The temperature tends to gradually creep up, the pidse to increase in rapidity out of proportion to the temperature increase, which last may be slight, and the character of the pulse changes; the patient looks more sick, but still complains of no special symptoms except slight pain or exacerbations of it in the right side, and still feels comfortable. APPENDICITIS 6o.S The blood examination shows in many cases moderate leuko- cytosis (14,000 to 16,000), but marked increase in the polynuclears (88 to 92 per cent.)- Hyperinosis is present. The patient presents as yet no symptoms of general peritonitis, but nevertheless the sepsis is marked in these cases, and unless immediate operation is performed will have a virulent type of septic peritonitis. A patient of mine recently operated on by Hartley presented the mild type of symptoms just described: Diarrhea at 4 p. M.; no ap- pendical pain or tenderness; localized appendical pain at midnight, when the surgeon was at once called in. Differential blood-count at 8 A. M. and i p. m., showing a gradual increase in polynuclears and low leukocytosis (15,000 to 16,000). The patient was quite com- fortable; no distention; slight pain over appendix, but the tempera- ture and pulse slowly creeping up. At 5 P.M. operation at the New York Hospital ; acute gangrene of ap- pendix and commencing peritonitis; ultimate recovery. The examination of the blood is thus imperative when possible. The Blood in Acute Appendi- citis. — Hyperinosis (increased fibrin in the blood) has been demonstrated by E. E. Smith and Bartlett^ to be more marked in direct proportion to the involvement of the serous surface, and hence, depending on its degree, is suggestive of proportional peritonitic infection. One of the most important factors in the determination as to operative procedure in appendicitis and as to the relative severity of the case is the differential leukocyte count. Charles Langdon Gibson has especially pointed out that it is the disproportion between the percentage of poly- nuclear cells and the total leukocytosis that is important. The chart (Fig. 221) assumes that 10,000 leukocytes per cubic millimeter is the upper limit of ordinary normal leukocytosis, and that 75 is the normal percentage of polynuclears. Gibson further assumed that in inflammations which are well resisted the poly- nuclear cells are increased approximately by i per cent, for every 1000 leukocytes above the normal 10,000 per cubic millimeter. Then in the chart the horizontal line will indicate a leukocyte count of 1 1 ,000 with 76 per cent, of polynuclears, whereas the rising line repre- sents a leukocytosis of 1 1 ,000, but with 86 per cent, of polynuclears. I Blood Reactions of Inflammation, Med. Record, Feb. 8. 1908. Fig. 221. — C. L. Gibson's differen- tial chart for leukocytosis. 6o6 DISEASES OF THE STOMACH AND INTESTINES If the line connecting the total leukocytes and the percentage of polynuclears runs fairly horizontal, it indicates a lesion that, whether severe or not, is well borne and, therefore, of good prognosis. If the line runs upward from the leukocyte to the polynuclear side, it indicates a rather severe lesion and less resistance. Fatal cases all have a rising line. A falling line {e. g., leukocytosis of 30,000 with 80 per cent, of polynuclears) means a mild lesion; in appendicitis it would probably indicate an abscess well shut off, with little febrile or constitutional disturbance. Gibson's conclusions are as follows : The differential blood-count and its relation to the total leukoc\i:osis is the most valuable diagnos- tic and prognostic aid in acute surgical diseases that is furnished by any of the methods of blood examination. It is of chief value in indicating fairly consistently the existence of suppuration or gangrene, as evidenced by an increase of the poly- nuclear cells disproportionately high as compared to the total leu- kocytosis. E. B. Smith^ shows that it is an indicator of the activity of the process and not invariably of gangrene; but if the absolute leuko- cytosis is low (below 15,000), with high polynuclears, it is probably gangrene. Gibson further holds that the greater the disproportion the surer are the findings, and in extreme disproportions the method has proved itself practically infallible. As the relative disproportion between the leukocytosis and the percentage of the polynuclear cells is of so much more value than the findings based on a leukocyte count alone, this latter method should be abandoned in favor of the newer and more reliable procedure. The negative findings, showing no relative increase or even an actual decrease of the proportion of the polynuclears cells, while of less value, show with rare exceptions the absence of the severer forms of inflammation. In its practical applications the method is of more frequent value in the interpretation of the severity of the lesions of appendicitis and their sequelae. Though N. E. Ditman, in a paper read before the Obstetrical Section of the Academy, November, 1906, criticizes the differential count as of doubtful value, Sondern- shows that in cases quoted the pus was encapsulated in such a way that no toxic absorption occurred, and also demonstrates that polynuclear increase may occur in other than suppurative conditions. It is a well-known fact that such encapsulated abscesses may occur without marked constitutional symptoms, but physical signs determine their presence. 1 Blood Reactions of Inflammation, Medical Record, Feb. 8, 1908. 2 New York Medical Journal, June 26, 1907. APPENDICITIS 607 In this type the processes are less active, and this is probably the chief cause- I have seen a very low leukocytosis with a general fatal peritonitis, the system evidently being overwhelmed by the poison. The physical signs, with increased polynuclears and hyperinosis, aid our diagnosis in exceptional cases. A low leukocytosis with high polynuclear count also shows poor resisting power to the infection. To recapitulate : We may have numerous types of acute appendi- citis, which clinically are as follows : 1. Simple catarrhal appendicitis with mild symptoms, lasting a few days to a week or ten days; often secondary to colitis, intes- tinal disturbances, or fecal impaction in the caput coli; blood changes are moderate and the attack soon subsides under medical treatment combined with the ice-bag. It may never recur. 2. Acute appendicitis (diffuse), symptoms more severe; may be adhesions or slight exudation; temperature higher; more marked tenderness; tumor often palpable, but may disappear. It may become chronic or recurrent. 3. Acute appendicitis, with abscess, chills, tumor, etc., present- Abscess may perforate. 4. Fulminating type, perforation or gangrene. Remote Effects of Acute Appendicitis. — They are as follows: Hemorrhage from perforation of a blood-vessel; suppurative pyle- phlebitis; thrombosis of the iliac or femoral veins; pulmonary em- bolism ; strangulation of the bowel ; subsequent symptoms may occur due to incomplete removal or subsequent adhesions. Hartley has noted intestinal paresis in mild cases, with s3nTiptoms of ileus re- sulting; also infection of the mesenteric glands, subsiding in some cases after appendectomy, and in others causing subsequent in- flammation. Chronic Appendicitis. — ^This may follow an ordinary acute attack or be chronic from its incipiency- The latter often is secondary to chronic intestinal catarrh. The patient has frequently a continuous feeling of discomfort in the ap- pendical region; slight tenderness on pressure; generally intestinal and frequently nervous disturbances associated, also constipation or gastric disturbances. SUght tenderness or discomfort on pressure at McBurney's point- This may disappear for periods- At times no tenderness can be elicited at McBurney's point, but is noted at Morris' point. There may be exacerbations of acute attacks. Indiscretions in diet often cause exacerbations of the symptoms- In some of these cases there is simply a chronic catarrhal condition, but more frequently angulation with adhesions. This is the type where palpation by Edebohl's method is safe and of value, and where at times the enlarged appendix can be appre- ciated. 6o8 DISEASES OF THE STOMACH AXD IXTESTIXES The patient lies on his back^ with the thighs flexed, and the ex- aminer, placing three or four fingers of the right hand, palm side downward, draws them over the abdomen from the umbilicus to the anterior superior spine of the ileum, exerting considerable pressure. The appendix can be recognized as a firm cord. Morris reinforces this hand with the three fingers of the left hand. In the chronic cases there is generally no temperature unless subacute or acute exacerbations occur. Harmful Involution of the Appendix. — Symptoms of harmful involution of the appendix (Morris) : I. Symptoms of auto-intoxication with attacks of headache, ner- vousness, poor appetite, etc. 2. Intestinal dyspepsia. 3. Discom- fort in the appendical region. 4. An appendix feeling hard and narrow on palpation. 5. Hyperesthesia of the right lumbar plexus. There is persistent distention of the cecum and ascending colon, with gas and a sensation of discomfort in the appendical region. The patient has a tendency to press upon the abdomen at that point or to lean against a table. The sensation may pass away for a few hours or days, but tends to recur and last for years. On palpation the involution appendix feels narrow and hard. There is no history of acute or chronic appendicitis. The type gen- erallv occurs in those over twenty-five or thirty years of age. Diagnosis and Differential Diagnosis. — Abdominal pain, be- coming localized in the right iliac fossa; tenderness at McBurney's point ; rigidity of the right rectus ; temperature ; rapid pulse ; gastro- intestinal disturbances; in some cases the presence of tumefaction and in others the subsequent development of peritonitis— are all diagnostic of appendicitis. In addition there are the differential leukoc^-te count and hyperi- nosis, which are an aid to diagnosis. Renal colic with calculus impacted in the right ureter may simulate appendicitis, but there is the history of acute pain in the kidney, burning sensation of the urine, and drawing up of the right testicle, with sand, gravel, or blood, etc., in the urine. With Dietls' crisis there is the movable kidney, the history of the attack, and the kidney is swollen and sensitive. In intestinal colic the pain is relieved after passage of flatus. In biliary coUc the pain radiates to the back and up to the right shoulder, usually with a previous history of gall-stones, etc. In perforation of the gall-bladder or duodenum the contents gravi- tate toward the appendix ; and this possibility must always be consid- ered in apparently acute perforative appendicitis. In these cases the sudden acute pain occurs in the epigastrium and right hypochondrium. In women the differential diagnosis between a low appendix and salpangitis is sometimes difficult, as they frequently are associated. 1 It has been at times recommended to examine with the patient standing erect or bending slightly forward, but the dorsal posture is preferable. APPENDICITIS 609 With pneumonia, especially central near the right base, and with diaphragmatic pleurisy there is, occasionally in the early stages, pain transferred to the right iliac fossa and mistaken for appendicitis. The physical examination of the lungs and pulmonary symptoms should be carefully obser\^ed.^ This possibility must be considered. In typhoid fever there may be pain in the right iliac fossa and appendicitis is often a complication. In simple typhoid there is no leukocytosis, but leukopenia. In typhoid with appendicitis, in addition to the right iliac pain and tenderness, the presence of leukocytosis, increased polynuclears, and hyperinosis make the diagnosis of appendicitis. As an aid to differential diagnosis in affections of the viscera, the determination of Head's zones (cutaneous hyperalgesia) is of value. This is especially true, I believe, in the differentiation of appendicitis from the conditions to which I have just referred. Head found that in many visceral affections, if the sensitiveness of the skin was tested by running a pin point over the cutaneous sur- face, there could be shown to exist areas over w^hich there w^as a more or less hypersensitiveness to pain. These areas w^ere constant and distinct, could be mapped out on the surface of the skin, and, when present, were almost an infallible sign of an affection of the organ to which they corresponded. The skin tenderness was super- ficial and extended over definite areas which never overlapped one another. Each area or zone of hyperalgesia had a "maximum re- gion" which often corresponded to the seat of pain. These areas were sensitive to heat and cold, but not to simple touch. The areas corresponded to segments of the spinal cord, not to the distribution of peripheral nerves or spinal nerve-roots. The zones v/ere named according to the segments of the cord : cer\4cal, i to 7 ; dorsal, i to 12; lumbar, i to 5; sacral, i to 4. They were broader in front at the median line, narrowed at the side of the body, and again broaden out near the spinal column. The zones, as a rule, never extend bevond the median line in front or behind. Head gives the following zones for the abdominal viscera : Stomach, sixth, seventh, eighth, and ninth dorsal. Cardiac end, sixth and seventh dorsal, right. Pyloric end, eighth and ninth dorsal, left. Liver, eighth, ninth, and tenth dorsal, right. Gall-bladder, eighth and ninth dorsal, right. Intestines, ninth, tenth, eleventh, and twelfth dorsal. Colon, ninth, tenth, and eleventh dorsal. Cecum and appendix vermiformis, tenth and eleventh dorsal, right- Kidney, tenth dorsal, sometimes eleventh dorsal. 1 Determination of Head's zones is of value; the zone for the lungs is from first to the ninth dorsal segment, chiefly the third, fourth, and fifth, which give hyperalgesia over the thorax. With appendicitis hyperalgesia is below the um- bilicus (page 614). 39 6lO DISEASES OF THE STOMACH AND INTESTINES Ureter, eleventh and twelfth dorsal, first lumbar. Bladder (first?), second, third, and fourth sacral. Uterus, tenth, eleventh, and twelfth dorsal, first lumbar. Appendages, eleventh and twelfth dorsal, first lumbar. Head first tested sensitiveness to pain by pinching up folds of skin and later by stroking the skin with the point of a sharp pin. Elsberg^ and Neuhof suggest the following method of examination : "A sharp pin is held between the thumb and index-finger of the right hand, the nail of the index-finger resting on the patient's skin. The pin is then made to traverse slowly the surface of the skin, care being taken that the nail of the index-finger presses equally along the area examined. The patient is instructed to say ' now ' as soon as the pin stroke becomes painful. " In examining the skin of the abdomen f or hyperalgesic areas, the pin traverses the abdomen from side to side and from above down- ward ; the points at which the patient complains of pain are marked. In this manner it is possible to map out areas on the skin, and when such an area has been found, the pin is made to approach it from all sides, so that its form and position can be determined. Care must be taken that the pressure of the pin point remains constantly the same, especially as the pin passes over the groin and slips off the costal border or over the crest of the ileum. "After the zone has been thus mapped out on the skin the pro- cedure is repeated a second time, and now it is a good plan for the operator to control both patient and himself by keeping both the patient's and his own eyes away from the pin. "The hyperalgesia is sometimes so marked that the patient will shrink or cry out as soon as the border of the zone is reached. In very young children the examination is useless, but older children will give correct answers. " If the examination is carried out in the manner above described it will be possible in a large number of patients with visceral affec- tions to map out areas of hyperalgesia extending from the median line in front to the spines behind. The ' maximum ' areas can often be mapped out lying within the boundaries of the zones ; sometimes onlv the ' maxima ' are present. Sometimes several ' maxima ' are found in one zone." The zones appear early in the course of visceral affections, and frequently persist throughout. They have been reported as appear- ing very early; for example, in the commencement of acute appendi- citis while the pain was still in the epigastric region and there was no local tenderness at McBurney's point, the zone for the appendix was discovered. Shortly after the typic symptoms appeared. One must remember the following (Elsberg) : I. The characteristic zone may appear after palpation of the dis- eased organ. 1 American Journal of the Medical Sciences, Nov., 1908. APPENDICITIS 6ll 2. The hyperalgesia zone will not appear on examination until fifteen to thirty minutes have elapsed after removal of the ice-bag or hot-water bag, if such have been applied. 3. The disappearance of the zone, as a rule, follows relief of the lesion of the affected viscus. 4. The zones may disappear temporarily after repeated examina- tions in close succession. Later they reappear. 5. The disappearance of the zone, together with persisting or in- creasing symptoms, is probably a sign of ill omen. 6. The zones are not invariably present. While the absence of a characteristic zone in a suspected affection of an abdominal organ does not mean that there may not be disease of that organ, the pres- ence of the zone means that there is an undoubted lesion. From this one must not conclude that the viscus which gives the zone is the one which causes all the symptoms, for we may get a zone from an organ which is secondarily affected. 7. The presence of areas of skin hyperalgesia corresponding to several viscera may mean a combined lesion of several adjoining vis- cera, although it may occasionally mean disease of the spinal cord itself. 8. The presence of a Head zone alone must not be the only fac- tor in arriving at a diagnosis, but it must be used in conjunction with other signs and symptoms. When one is in doubt as to which of several viscera is the seat of the lesion, the presence of the charac- teristic zone has been an aid ; for example, in differential diagnosis between appendicitis (with retroverted appendix) and kidney and gall-bladder disease, or between appendicitis and salpingitis. It seems preferable to adopt Elsberg's method and speak of the zones by the names of the viscera to which they belong. The position of his zones vary a trifle from Head's, and are as follows: Thus, the stomach zone corresponds to the seventh, eighth, and ninth segments of Head (according to Head, sixth, seventh, eighth, and ninth) ; the gall-bladder zone, to the eighth and ninth segments on the right side (same as Head's diagrams) ; the appendix zone, to the tenth and eleventh segments of Head on the right side. It will be found, in the description of the zones, that the Umit of the posterior portions is not absolute. Thus, in describing the gastric zone, that it extends from the sixth to the tenth vertebrae approximately. The zones, except the gastric zone, stop sharply at the posterior median line, but their upper and lower margins are more variable. The zone appears on that side of the body on which the affected organ has its nervous connections, the side on which the organ is normally situated. If an organ belongs on the left side, the hyper- algesic zone will be found on that side, even if the organ, through disease or mobility, lies on the other side of the body. Those areas are called " objective zones " when the patient suf- fers actual pain as the stroking pin enters them. All less painful 6l2 DISEASES OF THE STOMACH AND INTESTINES zones will be called "subjective zones." By an "anterior zone" we mean an anterior maximal area; by a "posterior zone," a posterior maximal area. The Stomach. — The complete gastric zone was found to be un- common. It extended as a broad belt all around the body. At times only a portion of it showed on examination. In the median line in front it extends from the xiphoid almost to the navel ; it then passes upward and backward on both sides to- ward the spine, where it extends from the sixth to the tenth verte- Gall Bladder Cecum and Appendix Ovary and Tube ^] Stomach (Left Half) Kidney Ureter Fig. 222, a. — Head's zones. The general location and outline of the zones of cutaneous hyperalgesia for some of the abdominal viscera. Anterior view. The maxima are deeply shaded. Only the left half of the gastric zone is given. The ureteral zone consists of a series of maxima (diagrammatic) (Elsberg and Neuhof). bra (approximately). Incomplete zones are more frequent, either an anterior portion extending to the right or to the left, or on both sides of the anterior median line. In Fig. 222, a and h, the various zones are depicted on the ante- rior and posterior surfaces of the body. The Duodenum. — The duodenal zone lies between the gall-blad- ber and the appendix zones. It lies almost completely to the right, but occasionally extends slightly to the left of the anterior median line. Anteriorly it is broad ; its upper Hmit is about on a APPENDICITIS 613 horizontal line midway between the umbilicus and the ensiform car- tilage; its lower border is a little below the umbilicus. It extends backward and slightly upward, and narrows; at the anterior axillary Hne it is very narrow^ (about i J inches) ; it then becomes broader, and is lost about the midscapular line. It corresponded roughlv to the ninth dorsal zone of Head. With a perforating duodenal ulcer, intestinal contents gravitate to the appendical region. If the ulcer was occult, differential diag- nosis from appendicitis may be difficult. Presence of the typic zone may prove of assistance. 10th Dorsal Spine Isi Sacral Fig. 222, b. — Head's zones. The general location and outline of the posterior parts of the zones (diagrammatic) (Elsberg and Xeuhof). Gall-bladder and Liver. — This zone is present in acute affections of the gall-bladder more often than in any other acute intra-abdomi- nal affection. In these cases the Head zone has often been a val- uable diagnostic aid. In many cases an enlarged, tender, and palpable gall-bladder makes the diagnosis easy, but the recognition of the disease is often difficult or impossible in stout patients with- out jaundice, with marked abdominal distention and rigidity. These patients may refer their pain to the right lower abdomen, and may have their tenderness in this region. Acute intestinal obstruction, acute pancreatitis, or acute appendicitis are diagnoses often made. 6l4 DISEASES OF THE STOMACH AND INTESTINES In some patients the presence of a zone of hyperalgesia has been the only localizing sign. The gall-bladder zone lies in the right half of the abdomen, above the level of the umbilicus. The complete zone starts exactly at the median line in front, extending from some distance below the xiphoid to a short distance above the navel. Tracing it backward, it slants obliquely upward and becomes narrow, passing partly over and partly below the costal arch. It is narrowest at the midaxillary line, where it is about 2 inches wide. Posteriorly it becomes broader, and at the spines it is about as wide as in front. In some cases more or less of the anterior portion only has been present (maximal area). Kidney and Ureter. — -The kidney zone is wide at the posterior median line, where it begins, and gradually narrows anteriorly. Its greatest breadth is at the spinal column. It narrows to make a tri- angular area, with a rounded apex, situated a little to that side of the anterior median line on which the zone lies. It never quite reaches the anterior median line. Each zone is strictly limited to its half of the body. There is no difference in contour between the right and left kidney zones. The kidney zones are complicated b)^ the additional ureteral zones that are present in certain cases. The ureteral zone springs, so to speak, from the lower margin of the kidney zone at the anterior axillary line. In an average adult it is about 3 inches wide at its beginning. It narrows in its down- ward course, and passing obliquely downward and forward, it termiv nates on its side of the penis and scrotum in the male ; the labia in the female. After the first narrowing it widens again well below the umbilical level. In the male, it can be ascertained that the zone spreads fan shape to the anterior median line over the pubic area and its half of the scrotal and penile skin. There are anterior and posterior kidney maximal areas. The ureteral zone seems to be made up of a series of maxima. The kidney and ureteral zone is most often present, as in the other intra-abdominal affections, in the presence of pain and tenderness. In the differential diagnosis of septic infarction of the kidney, pyelonephritis, etc., from retroverted appendix (appendicitis), deter- mination of the kidney zone is of value, taken in connection with Brewer's sign, urinary analysis, etc. (author). Vermiform Appendix. — The zone begins at the median line in front, sometimes a little to its left, from a point a short distance below the umbilicus to one equally distant from the symphysis pubis. It narrows toward the anterior axillary line to a width of about 2 inches (average adult). From this line it widens and spreads to the posterior median line from the eleventh dorsal to the second lumbar spines (approximately). At the anterior median line there is often a tongue-like downward extension of the zone (Fig. 222, a and b). There is an anterior maximal area which is APPENDICITIS 615 sometimes present alone. It may be that the "appendix" zone is really an "appendix and cecum" zone, because the cecum is so fre- quently involved in appendicitis. Sometimes, when an ice-bag has been employed over the appendix region, only the posterior half of the zone is present. Diagnosis has been aided in a considerable number of the patients by the presence of the zone, especially in that large class of acute cases in which the abdomen is rigid and there is no palpable mass. The zone has been of the greatest value in helping to differentiate between diseases of the appendix and those of the gall-bladder or right uterine adnexa. The absence of a zone is of no significance. If a patient com- plains of symptoms which resemble appendicitis, and a zone is not present in the right lower abdomen, it is well to look elsewhere for hyperalgesia. Thus in cases of beginning pneumonia that had con- siderable pain, tenderness, and rigidity in the right iliac region, the presence of hyperalgesia over the thorax first lead to careful exami- nation of the lungs. •Intestines. — Head gives the zone as corresponding to the ninth, tenth, eleventh, and twelfth dorsal segments of the spine. Elsberg does not find these uniform. He shows, however, uniform zones in ileocecal tuberculosis and in perforation of the ileum. Ileocecal Tuberculosis. — ^There is a large area of hyperalgesia occupying the whole right lower abdomen down to Poupart's liga- ment, often extending a little to the left of the median line, and posteriorly becoming lost about the posterior axillary line. Perforation of the Ileum. — The zone resembles that of ileocecal tuberculosis, but extends more to the left of the median line. Uterus and Adnexa. — Head describes differences between the zones for the uterus, the ovary, and the tube. Elsberg differs some- what: The zone for the right adnexa lies on the right half of the median line; that of the left adnexa on the left half; the zone for the uterus is a combination of the two. There is no dift'erence be- tween the zones for the right and left adnexa. Beginning some distance above Poupart's ligament, the upper margin of the zone runs parallel to it, and pursues this obliquely upward course to the spine of the second lumbar vertebra (approximately). The lower margin is a long, tongue-like process that extends half-way down the thigh on its inner aspect. The lower margin, as it passes a short distance below the anterior superior spine of the ileum, ap- proaches the upper, the average breadth of the zone here being 3 inches. The lower border then passes horizontally backward over the buttock to reach the posterior median line partly over the sacrum. Sometimes the upper half of this zone is better developed, sometimes the lower; these may be considered maxima. Diagnosis in the diseases of the uterus has not been aided by the presence of a zone. Elsberg states that in about half of the 6l6 DISEASES OF THE STOMACH AND INTESTINES cases of dysmenorrhea and of endometritis with pain, the zone was present. Some of the cases of retroflexion, retroversion, anteflex- ion, and prolapse showed the zone. It was present in the 5 cases of uterine polyp that he observed (all of them had pain). It was not present in tumors of the uterus, except in a few cases. In diseases of the tubes and ovaries, especially those of the right side, the zones have been of diagnostic value. I can substantiate these observations of Elsberg and Neuhof, and believe that the tests^ for Head's zones are a valuable aid in differential diagnosis, especially in appendicitis. Prognosis. — There is always an element of uncertainty in every case of appendicitis, and it is well to be guarded in every acute case when expressing an opinion; for an apparently simple case may suddenly show dangerous or even fatal symptoms. It is a well- know^n fact that in the simple catarrhal cases there may never be but one attack, perfect recovery resulting. Many cases of exudation or abscess, especially of the old cases of so-called perityphlitis, have recovered without operation. Sahli has collected 7213 cases; of these, 473 were operated on, 6740 were not. Of the latter, 591 (8.8 per cent.) died; 6194 (91.2 per cent.) re- covered; recurrences took place in 4593 cases; of these 3653 recovered without a second recurrence. Nothnagel claims that 80 per cent, of cases of circumscribed appendicitis recover under medical treatment. The fact that a patient has recovered under medical treatment from one or two attacks during a period of several years is no guarantee that a fatal issue may not ultimately occur. If a simple catarrhal attack occurs, with moderate symptoms and no marked changes in the blood, the prognosis for immediate recovery is certainly favor- able. If no attacks occur during several years, the chances of sub- sequent attacks are lessened. In all statistics of a second attack and subsequent apparent cure, the history should be investigated for some years. In many cases, when recurrence has taken place, we find chronic appendicitis and practically invalidism as a result. If in acute cases there are marked blood changes with high poly- nuclear count, the danger is imminent. Treatment. — The medical treatment can be summed up very briefly. Absolute rest in bed in the dorsal position. The bowel and urine evacuation should occur with the patient confined to bed. The physician, having made his diagnosis of acute appendicitis, to the exclusion, of course, of general peritonitis, should pursue the following course: All food and even water at first should be pro- hibited by mouth. No cathartic should at this time be given. Thirst can be relieved by rinsing the mouth with cold water, by small rectal injections of oij to iij (60.0-90.0) of hot normal salt 1 American Journal of the Medical Sciences, Nov., 1908. APPENDICITIS 617 solution at 105° to 108° F., or by proctoclysis. If there is much distention, or if nausea or vomiting, lavage should be carefully performed. In these methods I agree with Ochsner. In the fol- lowing I differ. If the lavage does not markedly relieve the distention (if such be present), I would then advise the physician to person- ally gently wash the bowel with tube and funnel, after the method of lavage. Only about a quart of normal saline in all at 110° F., need be employed, allowing a few ounces to flow in and then siphon- ing it out. This practically mechanically carries off the gas and has little influence in producing active peristaltic action. A similar technic is employed in acute distention of typhoid fever with active hemorrhage. He should carefully note the patient's temperature, the rapidity and character of the pulse, and the ratio of pulse to temperature. When feasible, I advocate blood examination in every case, though, of course, it is in some cases impossible. The physician should return to his case in two to three hours for the purpose of further examination. The ice-bag should be applied to the painful area at the first visit. The pain in almost every case can be controlled by the use of an ice-bag of light weight and a small amount of ice therein, so arranged, supported by a circle of gauze, that only the sensitive area is touched by it. A thin layer or two of gauze can be placed between the bag and the skin, so no damage can be done b}' the cold, which should be continuously applied. The bag can also be suspended from a barrel hoop to take off the weight, but the former method is the simplest. In emergency I have used bits of ice tied up in dress shields or in pieces of rubber tissue as a substitute for the bag. On the following visit or the one thereafter (all of which visits should be made within a total period of nine to ten hours) some definite determination as to the proper course to follow at that spe- cific time can be made. Lavage may again be indicated to relieve distention, or even the special intestinal washing as previously de- scribed. Frequentlv, however, under abstention from food and drink and the application of ice, the tA'mpanites will be markedly re- lieved and physical examination be comparatively easy. If there is a history of long constipation, and on examination a large fecal accumu- lation can be determined in the cecum, I resort to radical treatment. Fecal accumulation with gaseous distention is an actual danger, from causing pressure on the inflamed appendix. I always resort in such cases to enema or, preferably, gentle intestinal irrigation once or twice a day every dav with normal saline solution, with two tubes or a recurrent tube, using 2 to 3 or 4 quarts at each lavage, only \ pint at a time, at 110° to 115° F., emptying the large intestine mechanically. I have frequently seen the acute symptoms rapidly subside with the above method. These cases are not so very rare. At the end of forty-eight hours, with symptoms defervescing, a dose of calomel or a saline is then indicated. If there is vomiting, 6l8 DISEASES OF THE STOMACH AND INTESTINES oxalate of cerium or bismuth, and heat to epigastrium; for excess- ive vomiting, lavage. The type with fecal impaction is the only class of cases in which such radical methods are resorted to. If in other acute cases in the course of the first ten hours the temperature does not rise markedly, and especially if the pulse does not increase in frequency, but rather diminishes, and its character improves, with improvement in the other symptoms, delay, with careful watching of the patient, is allowable. The attack then may gradually entirely subside with no subsequent recurrence or a fresh attack take place after an in- terval. In the case of a first attack comparatively mild, I would not advise operation subsequent to the attack unless the patient contemplated a journey beyond the reach of a surgeon. Interval operation is always preferable. The indications for surgical inter- vention are given on page 619. Diet. — ^As to diet, I am not quite as radical as Ochsner in all cases. For two days in the acute attack, no matter what the type, I allow nothing by mouth, neither food nor water.^ The mouth is rinsed and hot salines given by enema or by proctoclysis. After two days I allow small quantities of hot water by mouth, and if the tem- perature is 100° F. or over, no food by mouth, but nutritive enemata. As soon as the temperature falls to 100° F. or below, food is given by mouth, in small quantities at first. The general diet should then be fluid for some days; no gaseous fluid should be given. Milk well diluted with lime-water or equal parts with barley-water, oatmeal- water, rice-water, gruels, etc., are excellent. Personally, I believe the latter methods preferable to milk, as causing less tympanites; as the symptoms subside, eggs beaten up with milk, bouillon, chicken broth, and later soft-boiled eggs and milk-toast are added. I agree with Ochsner that lavage is valuable for the distention or for vomiting. If the tympanites, however, is not relieved by the lavage, I believe the funnel method of gentle irrigation of the bowel to be perfectly safe. If fecal accumulation occur later during the attack, a soapsuds enema is indicated. A cathartic should not be given by mouth during the early acute stage until the temperature falls to below 100° F. or until the local symptoms defervesce. Fecal impaction is the exception. Catarrhal colitis should receive treatment as soon as the acute stage of appendicitis has subsided. Opium has long been a much-vaunted remedy, on the theory of quieting peristalsis and allowing adhesions to form ; also for relieving pain; and given preferably as laudanum, or by suppository. I am absolutely opposed to its use. The character of the pulse and respiration are changed thereby; muscular rigidity will relax; and I have seen the symptoms of perforation, both of the appendix and gall-bladder, entirely masked by its employment. Tympanites, dis- 1 This checks peristalsis, as Ochsner claims, and furthermore places the patient »in the best condition for operation should such suddenly become necessary. APPENDICITIS 619 tention, and intestinal paresis are more apt to occur as a result of its use. The application of heat I am opposed to. The ice-bag continuously applied possesses all advantages and no disadvantages; and I only advise the use of a single small dose of morphin by hypodermic, and find it but seldom necessary, if the ice does not control the pain. Frequent examinations of the blood as regards differential leukocytosis and hyperinosis should be made in every case when possible, at first at least twice daily, and thereafter once a day. If the differential count is not marked and does not increase, but rather diminishes, and the symptoms gradually defervesce, do not operate during the acute attack. The indications for operation are as follows: i. If the patient shows the symptoms of acute peritonitis when first seen or suddenly develops them — general muscular rigidity, tender abdomen, tym- panites, etc. — operate immediately. 2. If there be found on examination an area of resistance in the right iliac fossa, and this increases with more marked symptoms after six to twelve hours' observation, whether chills be present or not, operation is indicated. An aspirating needle should never be employed for purposes of diagnosis. The blood-count is of value as an aid to prognosis and diagnosis, if the physician has the technical skill or can have it done. 3. In a large abscess, in complicated cases, or when temperature is steadily rising, operate. 4. If the course of the disease is protracted and the symptoms point to abscess or an active and progressive process, operate. 5. In acute fulminating cases. In this type, with apparently mild local symptoms, but especially a gradual increase of pulse and a moderate increase of temperature, there should be immediate operation. The blood examination is important, if possible. 6. A frequent pulse, increasing in rapidity, not corresponding to the more gradual rise of temperature, indicates operation. In all cases when the differential blood-count is marked and increasing, operate. 7. If the patient have a mild attack and subsequently develop a second attack (of less severe type than the first), delay may occur; but if a third attack occur, then an interval operation. If the second attack be more severe than the first, then interval operation. 8. In chronic appendicitis, with symptoms persistent and in- validism, or if recurrent acute exacerbations, operate. 9. In harmful involution of the appendix, operate. In effect, the best judgment is, operate if possible during interval; and do not operate if one or two mild catarrhal attacks. The method of operation depends on the location and type of appendicitis. CHAPTER XXX DIVERTICULITIS— PERIDIVERTICULITIS {Synonyms. — Sigmoiditis ; Perisigmoiditis. ) History. — During the past fifty years specimens of false diver- ticula of the descending colon and sigmoid, both with and without concretions, have been reported by pathologists, who have demon- strated their relationship to general or local peritonitis. Only recently has attention been especially focused on inflammation in the left iliac fossa, and the terms "sigmoiditis" and 'perisigmoidi- tis" been employed. Fig. 223. — Diverticulitis. Sigmoid laid open longitudinally. A diverticulum containing a sloughing ulcer is seen at the lower right hand; another is sectioned near the label needle (W. J. Mayo). There is confusion as to the definition of sigmoiditis, many using it in the sense of a catarrh of the sigmoid ; while others define it as an inflammatory condition, involving to a greater or less degree this entire portion of the gut (the musculature included). In other words, it is not a catarrh of the mucous membrane. It was so defined as a diffuse inflammation by PateP and will be so employed in this volume. Eisendrath" has recently contributed to this subject. Diverticulitis'^ and peridiverticuhtis, as when productive of disturbance they occur chiefly in the sigmoid, have been used inter 1 Revue de Chirurgie, Oct. and Dec, 1907; Lyon Med., Oct. 2, 1905. 2 Specific inflammations, such as dysentery, tuberculosis, and syphilis, are excluded (author). ^Sigmoid Diverticulitis, Archives of Diagnosis, Oct., 1909. 620 DIVERTICULITIS — PERIDIVERTICULITIS 621 changeably with sigmoiditis; and perisigmoiditis bears the same relationship as does perityphHtis to typhUtis. Fig. 224. — Diverticulitis. Section through ulcerated diverticulum shown in Fig. 223 (W. J. Mayo). Mayo first employed the term sigmoiditis, but the condition was first described by Joseph M. Mathews. J. P. Tuttle ^ has recently Fig. 225. — Diverticulitis. Enlarged view of sectioned diverticulum shown in Fig. 223. Note rnuscularis in wall, occluded lumen, and inflamed suhmucosa (W. J. Mayo). contribitted an excellent monograph. Though inflamed diverticula of the sigmoid undoubtedly cause the maximum of all cases of sig- 1 American Journal of Surgery, A])ril, 1909. 622 DISEASES OF THE STOMACH AND INTESTINES moiditis and perisigmoiditis, having about the same relation to left iliac abdominal suppuration as the appendix has to similar condi- 1^^, ^ ,^m^w\ i yjj^y^j^^^kj^ i ^^^afllB^ Iw ^^^Hb^-' ' i V >,« f^^ j^KBr^^ ' 1 k, tm^-^'"" : C; 19^Kf ^tJBT; 'SK/ A V^mBF '^ tHWBKW m ,P^nu^ "w^l^^Ml 1 &L '""^j^^^Hfet^'C ^ JnBfflk 1 Up Fig. 226.— Peridiverticulitis. Sigmoid divided longitudinally. Note defect- ive musculature and the diverticula. Inflammatory mass dissected away near label needle (W. J. Mayo). tions in the right iliac fossa, yet other causes of perisigmoiditis are given, such as ulcerations extending through the wall of the gut; Fig. 227. — Peridiverticulitis. Enlarged view of two diverticula and one point of defective musculature seen in Fig. 226 (W. J. Mayo). traumatism or puncture by foreign bodies; diverticula, in association with which Byron Robinson and Tuttle^ believe that traumatism ^ American Journal of Surgery, April, 1909 (J. P. Tuttle). DIVERTICULITIS — PERIDIVERTICULITIS 623 from the iliac and psoas muscles play a part; lumbricoid worms and wisps of hay entering the appendices epiploicae. Secondary perisigmoiditis is also believed to occur from inflammation by exten- sion from other abdominal or pelvic organs. Wm. J. Mayo^ draws a sharp distinction between diverticulitis and peridiverticulitis (Figs. 223-228). With diverticulitis there is a primary lesion in the mucosa, often of ulcerative type, and a tendency to perforation into the peritoneal cavity, wdth resulting acute peritonitis. It has no tendency to produce reduction of the lumen of the bowel. With peridiverticulitis there is a leakage of toxins and bacteria into the subserosa and tissues surrounding the diverticulum, with resulting inflammation and thickening of the gut, so that its lumen may be markedly reduced and symptoms of obstruction occur. Perforative peritonitis rarely occurs in this type, as so much repara- Fig. 228.— Peridiverticulitis. Sketch of diverticulum with inflammatory deposit in subserosa; 11 diam. (W. J. Mayo, Wilson, and Giffin). tive inflammation goes on. Local intraperitoneal abscess or acute or chronic obstruction may result. Lejars,^ Bittorf,^ and Rosenheim* classify sigmoiditis and peri- sigmoiditis clinically. Gordinier and Sampson^ hold that these con- ditions are more frequent than we suppose. Diverticula of the Intestines. — Diverticula are formed by a. bulging or protrusion of the intestinal wall, and are divided into the congenital and the acquired. In the congenital forms the wall of the diverticulum is formed by the whole intestinal wall; and these have been called "true" diver- 1 vSurgery, Gynecology, and Obstetrics, July, 1907. 2 Semaine Medicale, June 27, 1904, p. 26. 3 Miinchener med. Wochenschr., 1904, p. 147. ^ Zeitschr. fiir Klin. Med., 1904, Band, liv, p. 475. 5 Jour. Am. Med. Assoc, 1906, vol. i, p. 1686. 624 DISEASES OE THE STOMACH AND INTESTINES ticula. It was formerly thought that all acqtKfred diverticula were of the "false" type, consisting of protrusions of the mucosa through spaces in the muscular coat, so that their wall comprised mucosa and serosa. It has been demonstrated that acquired diverticula may be of the "true" type, and are caused most frequently by traction from tumors or adherent organs. False diverticula are the result of excessive pressure within the intestines combined with a congenital weakness of the bowels. The chief congenital diver- ticulum of importance is Meckel's. Meckel s diverticiihim, due to the persistence or incomplete obliteration of the omphalomesenteric duct, usually rises from the 229. — Hodenpyl's specimen of multiple acquired diverticula of the colon (sigmoid flexure) (Brewer). ileum ^ to I meter above the ileocecal valve, from the convex margin of the intestines opposite the mesenteric attachment, and varies in length from 3 to 10 cm., though rarely longer. Congenital diverticula have been found in the small and large intestines. Acquired diverticula occur both in the small and large intestines, and have even been recorded in the appendix by EdeP and JNIertius.^ They are generally more frequent in the large intestine, especially in the lower part of the descending colon and sigmoid flexure, the 1 Virchow's Archiv., Bd. cxxxviii. 2 Mitheilung ans der Grenzgebiet fiir Med. und Chur., Bd. ix. DIVERTICULITIS — ^PERIDIVERTICULITIS 625 latter providing the most examples, as in Fig. 228, reported by G. Brewer.^ Here they are usually multiple. Autopsies in death from other causes have been reported where diverticula were found, but no symptoms had ever occurred. As many as 400 diverticula in one case have been noted by Hausemann. One case of diverticulitis of the small intestine which gave symptoms has been recorded by Gordinier and Sampson.- With diverticula of the appendix, appendicitis has been simulated, but it is clinically unimportant to separate the conditions, as opera- tion is indicated in any event. Diverticula are most frequent in the sigmoid flexure. Quite a number give important symptoms. E. Beer^ has described the clinical symptoms of diverticulitis and Telling^ has collected 105 cases, giving a thorough exposition of the subject. Sudsuki^ found diverticula present 15 times in 40 autopsies, so that the condition is probably more frequent than has been sup- posed, and has often been overlooked, even in post mortem. Brewer^ has reported a case of acute diverticulitis of the sigmoid, with operation before rupture. Occurrence. — Acquired diverticula are much more common in the large intestine, more so in the descending colon, and especially so in the sigmoid flexure. They are usually multiple and may arise from any part of the surface. They are frequently seen in two rows at the sides of the gut, or close to the mesenteric attachment, more rarely on the convexity. Chlumsky claims that he finds by experiment that rupture in the living bowel upon distention occurs more frequently opposite the mesentery. The general opinion is that the mesenteric side is less resistant. Probably the most common occurrence of these diver- ticula is in the appendices epiploicae. In many cases they are con- fined to them, and present a double row of symmetrically placed hollowed-out pockets. In other cases none are so situated, and fre- quently some enter the appendices and some lie outside of them. The presence of the diverticula in these appendices may account for some of the tenderness found in many portions of the gut. The special favoring of the epiploicge is accounted for by the fact that the point of their attachment to the gid is a place of least resistance. In a majority of cases the affected appendages have been or are filled with a large amount of fat. Bland vSutton'' has stated and illustrated by diagrams that this fat is directly continuous with the subserous fat. If there is the 1 Am. Jour, of Med. Sci., Oct., 1907. 2 Jour. Am. Med. Assoc, 1906, vol. i, p. i6-mptoms 1 Peristaltic unrest (intestinal) is not always present, especially in the earlier stages of the disease; and at times, late in the condition, the bowel may become fatigued and paretic from overdistention. Often, however, the peristaltic move- ments will aid in locating the position of the obstruction. 2 The stomach contents are neutral or alkaline, due to regurgitation of ]ian- creatic juice and bile, and duodenal digestion takes place witliin the stomach. With stenosis alaove the papilla, gastric contents, as in benign ])yl()ric stenosis, are acid. Riegel states another sign of duodenal stenosis is, that when the stomach has been emi)lied the night l^efore, twelve hours later as nuich as 3 liters (quarts) can be frequently aspirated. The reaction and contents differ from that of gastrosuccorrhea. 66o DISEASES OF THE STOMACH AND INTESTINES for a considerable period if the stenosis be in the lower ileum or in the colon. The symptoms, however, are always more severe in chronic intussusception or chronic types of strangulation than in ordinary cicatricial stenosis. X-Rays.^ — The administration of bismuth by mouth and inspec- tion the following day with the fluoroscope or by photography may demonstrate the location of the stenosis. If it be apparently in the large intestine a few days later, it has been suggested that a high injection of bismuth and olive oil be given, and the examination be repeated as a check test. These procedures are not to be recom- mended in acute cases. Inspection of the Abdomen. — When the stenosis is high up in the small intestine there is apt to be distention of the epigastric region, and when in the low^er part of the small intestine or in the large intestine, then there is considerable abdominal distention. The active peristaltic contraction of the intestines is marked, the coils (stiffened) rising and falling, and often performing winding or vermicular motions. These movements are associated with col- icky pains and with gurgling and rolHng noises. Sausage-shaped ridges may appear with depressions in their vicinity, and in a few seconds the ridges disappear in one part and appear in another, the coils never remaining visible in one place for any length of time. They appear hard and stiff to the hand and then suddenly become elastic. The contractions in the small intestine are usually smaller than in the large intestine. Meteorism in the milder cases is not marked, as the gas can pass the obstruction. Later it may become quite marked, and, as in acute obstruction, may be local or general in character. If the obstruction is in the lower colon or rectum, it will be most pronounced at first in the course of the colon, on the sides of the abdomen, and in the epigastrium. If in the lower ileum, the distention is more pronounced in the umbilical and hypogastric regions, and the lumbar regions are re- laxed (undistended) . Later there may be more general distention and the barrel- shaped abdomen. Local manifestations of meteorism are described under Acute Obstruction. One of the important types is chronic intussusception, which may develop after an acute attack has subsided or may occur as such from its incipiency. It takes place most frequently in the ileocecal form. Some of the latter cases may continue for months or even years. The pain is paroxysmal, but may entirely intermit. There may be attacks of pain daily, or every few days or weeks. As the disease advances the intervals grow shorter. Vomiting is not marked. Often diarrrhea is present or constipation alternating with diarrhea. Blood may be passed and tenesmus is at times INTESTINAL OBSTRUCTION — ACUTE AND CHRONIC 66l present. Palpation shows the presence of a tumor in about 50 per cent, of the cases, or a tumor can be felt in the rectum. Local meteorism may be present. Occasionall}^ the invaginated part may slough off and perfect recovery ensue or, again, ultimate stenosis may follow. Death may occur through perforation. Chronic Obstruction through Fecal Accimiulation. — This is more common in females and usually in our older patients. The history is of habitual constipation. At times large amounts of fecal matter are voided by enema. Scybalffi are frequently present. There are digestive disturbances, flatulence, loss of appetite, eruc- tation, fetid breath, headache, dizziness, and symptoms of auto- intoxication; there may be oppression in breathing from distention, an unhealthy appearance of the skin, and a foul tongue. There may be pains in the thighs, legs, and genitals due to pressure on the lumbar or sacral nerves. The patient may be very neurasthenic. Distention and gurgling may occur. There are colicky pains, but usually they are not severe. If untreated, the condition may become worse, the constipation increase, and all the symptoms of chronic or even of acute obstruc- tion develop, as already described under Fecal Obstruction. The vomiting may even become feculent. Palpation shows the presence of a tumor frequently in the colon, especially in the cecum, sigmoid, or other flexures. It may be hard and uneven, and will often "pit" on pressure. It is not painful on pressure, as a rule. Rectal examination generally shows the pres- ence of scybalae. I have treated a case in which apparently nearly the entire abdomen was occupied by the fecal tumor. Operation for "tumor" had been advised. As a result of 80 bowel movements in one week the tumor disappeared. The patient had had no bowel action for three weeks. Enemata, and especially recurrent rectal irrigation, and later, catharsis will reduce the size of the tumor. I have seen cases in which acute flexions or angulations of the sigmoid and colon have been factors in the production of this condition. They are well described by J. P. Tuttle.^ Rectal Stricture. — There are the symptoms of progressive con- stipation at times with alternating diarrhea, with mucus and pus in the stools, colicky pains, tympanites, tenesmus, and loss of appe- tite. There may be hemorrhoids and rectal prolapse. Digital ex- amination, exploration with a rectal bougie or the proctoscope, will demonstrate the constriction. With stricture the pressure on the examining finger remains con- stant and is not like sphincteric spasm, which soon relaxes. Many of the strictures are within the finger reach, within 4 to 6 centimeters up the bowel; if not within reach but suspected, a Wales rectal bougie 1 New York Medical Journal, etc., March 14, 1908. Gant has also demon- strated that prolapse of the sigmoid flexure is a cause, and relief has been secured by suspension of the sigmoid. 662 DISEASES OF THE STOMACH AND INTESTINES or soft tube can be employed for the examination. The degree of stricturing can be determined by using tubes or bougies of varying sizes. It is preferable to pass the speculum up to the point of stric- ture, so as to examine its nature thoroughly. It is often advisable to remove a small section under cocain for microscopic examination. With malignant stricture there are cachexia, loss of weight, metas- tases, and the symptoms described under Carcinoma. Complications. — Above the stenosis on account of the ulceration we may have circumscribed peritonitis and abscess or perforation with general peritonitis. The abscess may rupture into other viscera or perforate the abdominal wall. The chronic condition may. suddenly become acute, and severe collapse occur with death, or thrombosis of some of the veins, or pyemic processes, or the patient may die of inanition. Diagnosis. — The gradually increasing constipation; colic at- tacks with frequent stoppage of the bowels, alternating at times with diarrhea and the temporary relief of symptoms; visible peristaltic movements with tetanic rigidity of the intestines; at first local meteorism and, later, the tendency to the barrel-shaped abdomen; the presence of gastro-intestinal disturbances of varying degree and, frequently, loss of weight are suggestive of the obstruction. Rectal examination is always of importance. If the constipation is of long standing, in an elderly person or invalid, and there is no cachexia, the tumor movable and doughy on pressure, scybalae being passed, and at times accumulation felt in the rectum, fecal tumor is evident. These occur chiefly in the caput coli, sigmoid, colon flexures, or rectum. With carcinoma there is marked cachexia^ and the tumor is hard and solid, occurs mostly in the caput coli, sigmoid, and rectum, and more frequently in persons over forty-five. There is slight or moderate leukocytosis, and also anemia. Tuberculous tumor of the cecum and peridiverticulitis (chronic) of the sigmoid must be held in consideration as causes. With chronic intussusception the mass is usually of sausage shape, and shows the peculiarity that it sometimes feels hard and sometimes soft on palpation; there are mucus and blood in the stool. External tumors can generally be appreciated. Vaginal examina- tion should be made. If there have been attacks of peritonitis, bands and adhesions would be suspected. A previous history of diarrhea, dysentery, syphilis, or tubercular difficulty would suggest ulcerative stenosis. Stricture of the small intestine is most frequently due to adhe- sions or tubercular ulcer. In the large intestine stercoral, syphilitic, or dysenteric ulcers are to be considered, chiefly carcinoma or pelvic 1 In the scirrhous type of carcinomatous stricture, cachexia may be scarcely noticeable for a considerable period. The progressive constipation and age of the patient are significant. INTESTINAL OBSTRUCTION — ACUTE AND CHRONIC 663 inflammation, perityphlitic adhesions, and, more rarely, tuberculosis of the cecum and chronic peridiverticulitis. Course and Prognosis. — This depends on the etiology and severity of the obstruction. With non-malignant stricture of the bowel of moderate type, or in the fecal obstruction cases, not pro- gressive, the patient by proper regulation of diet may live many years. With malignancy the prognosis is fatal unless relieved by early operation; chronic intussusception occasionally clears up, but the prognosis, as a rule, is bad. In progressive cases the symptoms rapidly become worse and life is shortened, with death from final acute obstruction. Unless radical operation is performed, complica- tions such as peritonitis, pyemic processes, etc., hasten the final result. Treatment. — If chronic obstruction suddenly or gradually devel- ops into acute obstruction, the same indications for treatment exist as in the latter condition. In the chronic cases the proper regulation of diet, omitting those things which will mechanically fill up the intestines and a careful regulation of the bowels, are most important. Substances that give a large residue of fecal matter, which are irritating and extremely constipating, should be excluded. Matzoon, kumyss, buttermilk, bacillac, lactone-buttermilk, and kefir milk are excellent. Milk agrees well, as a rule, with most cases and is readily digested, while others it constipates and is undigested. Raw eggs can be beaten up in milk, and soft-boiled eggs, broths, soups, and gruels administered. Sanatogen (flavored) and somatose are of value, administered in the broths or milk. If the stenotic symptoms are progressive 6r fairly marked, liquid or soft diet alone should be given. In milder cases scraped beef, tender meat (well divided), butter, a small amount of well-toasted bread, and moderate in quantity, rice, sago, and mashed potatoes in small amount are admissible. The patient should eat a small quantity frequently and should take sufficient food to preserve his nutrition. \'ery hot and cold drinks should be avoided. Irritating food, such as mustard, spices, pepper, vinegar, fruits in bulk, and green vegetables in large amounts, should be forbidden. Substances giving a large residue of fecal matter should also be cut off. Spinach I have found of service to aid bowel action. Fats, such as cream and butter, are useful. Fresh fruit juices are valuable, and the administration of a glass of water on rising is of service. Bowels. — The bowels must be moved every day. Injections of soapsuds enemata of medium size, not over i quart (liter), with the hips elevated ; Kussmaul's method of oil injection, Oj (500 cc.) or more, being retained over night ; or the addition of olive oil to the enema, mild cathartics, such as cascara, rhubarb, syrup of figs. 664 DISEASES OF THE STOMACH AND INTESTINES phenolphthalein, and occasionally sulphate of magnesia or Apenta water, are of service. Under Chronic Constipation numerous rem- edies are described. Enteroclysis (recurrent) is valuable in all cases. ]Massage, vibratory massage, and electricity are of ser\dce only in cases due to fecal accumulation. If diarrhea is present, unless the patient is weakened thereby, it should not be checked. In the latter event mild preparations, such as bismuth subnitrate, chalk mixture, or chalk and catechu, are preferable to opiates. If there are small diarrheal movements, evi- dently a diarrhea associated with constipation, then a dose of castor oil or a saline cathartic is indicated. For Colic Attack and Peristaltic Movements. — Hot applications to the abdomen are indicated and a recurrent irrigation of normal saline solution at 115° to 120° F. is of value, to be given for ten to twenty minutes. The latter removes gas and clears the bowels. Enema ta also can be administered. Tincture of belladonna, TTLx (0.59), once or twice, is of use to allay spasm, or by suppository, extract of belladonna, gr. ^ to |- (0.016-0.024). Opium I avoid if possible, and then only i to | gr. (0.008-0.016) of morphin or codein by hypodermic. It should be g ven only to allay severe pain. For vomiting and distention lavage is indicated. Cerium oxalate with bismuth and soda will check vomiting, also TTLj (0.059) doses of Fowler's solution of arsenic every hour for four doses. Cocain, which has been suggested, is a dangerous and pernicious drug. I have seen complete collapse after its use in as small doses asyu gr- (0.006). Lavage is of special value in temporarily allaying symptoms if the stenosis is in the small intestine. If chronic fecal impaction, our first efforts should always be directed from below. Hardened scybalse should be removed from the rectum by the finger, oil injections, and, later, by soapsuds enemata and recurrent rectal irrigations. Olive oil can be given by mouth. Later, cathartics, massage, electricity, and vibratory massage are of servdce. Electric enteroclysis I have found useful in obstinate cases of fecal impaction. Tincture of belladonna, TTLx fo.59) three or four times a day, and strychnin, gr. ^-^ (0.002) t. i. d., are of value. Eserin sulph., gr. TTo to-^ (0.00065-0.00108), may be required. Mild cases of rectal stricture, providing they are not malignant, can be benefited by dilatation for ten to fifteen minutes evers* two to three days with different sized bougies. Operation on the stricture may be necessay in some cases. Thiosinamin can first be INTESTINAL OBSTRUCTION — ACUTE AND CHRONIC 665 tried, injected into the bowel or by hypodermic. Dose, gr. h to ih (0.033-0.1); or by hypodermic, gr. i (0.065), in 15 per cent, alcohol solution or lo per cent, glycerinated solution. Operation. — ^Nlost types of chronic intestinal obstruction grow worse, except those due to fecal impaction. In mild types of rectal stricture local dilatation may be palliative and keep the patient com- fortable. Malignant growths must be extirpated as soon as possible. Stric- tures must be treated according to their location — in the rectum, by division and dilatation or by resection. In other regions, entero- plastv, splitting the gut parallel to its axis, at the same time dividing the stricture and uniting the incision transversely, has been success- ful. Complete excision may be necessary, with or without employ- ing Murphy's button to unite the ends. Anastomosis of the bowel above to that portion lying below the stricture may be required. In stricture of the colon in cases quite prostrated a simple colotomy above the point of stenosis is indicated. Adhesions should be severed and tumors compressing the bowel removed. If the chronic obstruction be due to any of the causes which may also produce acute obstruction, appropriate surgical measures are indicated. Early operation is preferable in most cases of chronic obstruction. In acute obstruction engrafted on chronic stenosis, there should be immediate resort to surgery. CHAPTER XXXII NERVOUS DISEASES OF THE INTESTINES Under this heading are included those conditions due to pen^er- sion of the innervation of the intestines independent of anatomic lesions of the intestinal wall or of distant organs. In manv cases the neurotic manifestations in the intestines are an independent manifestation of some general neurosis, such as of neurasthenia, hysteria, or hypochondriasis. Some few cases result purely from functional perversion of the intestinal ners^es. Intestinal neuroses may be divided into motor, sensory, and secretory. They often exist in combination. Psychic influences, such as fear, fright, worry, and anxiety, may be causes, as may reflexes from some diseased organs, such as the stomach or genito-urinary tract. The nerve-centers influencing peristalsis, iMeissner's and Auer- bach's plexuses, have been described in the chapter on Physiology of Digestion, Part I, under Nervous Control of Peristalsis, page 41. Secretion seems to be dependent to a great extent upon the gan- glionic plexus. Moreau^ ligated an intestinal coil and severed all the ner\^es passing to it. In a few hours it was filled with fluid, showing amylolytic qualities and containing albumin. After ingestion of food into the stomach, secretion takes place in the lower part of the intestines before the arrival of the chyme. This was demonstrated by Quincke and Demant. Vasomotor filaments exist in the intestines as stimulation of the splanchnic causes contraction, and its section causes dilatation of the intestinal blood-vessels. They are also concerned with absorption. Sensory filaments exist in the intestines, since stimuli of greater intensity than normal, such as the ingestion of beans or cabbage, may give rise to sensations of pain or pressure. Kast and ]\Ieltzer- have demonstrated experimentally that the sensation of pain exists in the intestines, and that laparotomy, under cocain, causes anesthesia of the intestines through the cocain being carried b}^ the blood. MOTOR NEUROSES OF THE INTESTINES Peristaltic Unrest (Tormina Intestinorum) . — This condition con- sists in marked rotary or rolling movements of the intestines, so that they frequently become visible. It is usually seen in patients with hysteria or hypochondriasis. Occasionally it is an independent affec- tion. It is almost exclusively seen in the small intestine. 1 Centralbl. fiir die Med. Wissensch, 186, No. 14. 2 Medical Record, Dec. 29, 1906. 666 NERVOUS DISEASES OF THE INTESTINES 667 Peristaltic restlessness, which accompanies complete or incom- plete occlusion of the intestines, is not included herein. There is not the peculiar stiffening of the intestinal coils, as is present with steno- sis, and other symptoms of that condition are absent. Occasionally the condition occurs in persons presenting no other nervous symp- toms, as after the ingestion of highly spiced or indigestible foods, after the excessive use of tobacco, mental excitement, or too much brain work. Clinically, there are rolling, gurgling, squelching noises in the abdomen of varying intensity. They can often be heard at some distance and are a source of mortification to the patient. Pain, as a rule, is not present. The movements of the intestines may occasionally become visible and palpable. Eructations sometimes occur when peristaltic unrest of the stomach is associated. Attacks occur at irregular intervals and may take place during menstruation. Diagnosis. — Stenosis of the bowel must be excluded. The ner- vous type of peristaltic restlessness of the intestines is readily recog- nized. Prognosis is favorable. Treatment. — ^This should be directed toward the tone of the nervous system. Heat externally applied and the drinking of hot water during the attack are of value. Spicy and indigestible food should be excluded. Priessnitz compresses should be applied to the abdomen at night. The bromids, valerian, and asafetida are useful. Arsenic alone or combined with iron should be employed in anemia. If there is any disturbance of the bowels (diarrhea or constipation) it should be properly regulated. Rarely a small dose of opiate, alone or combined with belladonna, is required. If the attacks occur at night, chloral hydrate, gr. 15 (i.o), or veronal, gr. 'j^ (0.5), sul- phonal or trional, gr. 10 (0.6), may be necessary. Electricity and massage have been recommended. Change of climate is beneficial. Nervous Diarrhea. — The exaggerated peristaltic movements occur not only in the small but also in the large intestine. They may be limited to the colon in some cases. There is an increased transu- dation of fluid due to nervous influences. The reader should refer to a description of this condition under Diarrhea (page 474). Spastic constipation, due to local enterospasm and also spasm of the sphincter, sometimes occurs in neuropathic, hypochondriac, or hysteric subjects. These conditions are described under Constipa- tion (page 461). Paralysis of the Intestines.— Paralysis resulting from a me- chanical obstacle to the passage of the intestinal contents has been described. Primary paralysis of the intestines without any organic obstacle will itself cause symptoms of obstruction. The reader is further referred to dynamic ileus (page 651). There are several forms of this condition : i . An intestinal coil may become paralyzed after forced reposition of a hernia or after 668 DISEASES OF THE STOMACH AND INTESTINES incarceration; it may be due to direct traumatism, to abdominal operation, or to inflammation or ulcerative processes of the intes- tines. 2. It may result from reflex irritation of the inhibitory nerves of the muscular coats of the intestines, especially where there is injury or inflammation which does not necessarily involve the bowel. Toxemia may be a factor. Contusion of the testicles, abdominal abscess, anesthesia, uremia, etc., are causes. 3. Neuroses, melancholia, hypochondria, or affections of the ner- vous system, such as meningitis, brain tumors, tabes, myelitis, etc., are also causes. Atony of the intestines, leading to coprostasis, has been suggested as a cause of intestinal paralysis. It would seem that the symptoms are produced by occlusion. Intestinal atony is really a subparetic condition, and the nervous type is described under Chronic Constipation (page 460). Meteorism in hysteria is probably due to sudden paresis of the muscular coat of the bowel. (See Meteorism, pages 451 and 452.) Treatment. — Removal of fecal impaction by the fingers if pres- ent, enemata of soapsuds containing olive oil, oviij (250 cc), and glycerin, 5ij (8.0), electric enteroclysis, enteroclysis, enemata, mas- sage, and electricity are useful. With fecal impaction, mercury, o 10 to 20 (300.0-600.0), given through a stomach -ttibe, is of value. It might otherwise enter the larynx. Various cathartics, such as castor oil, oj to ij (32.0-64.0), olive oil, oiv (128.0); physostigmin sulphate, gr. yU to go (0.0006-.001), may be employed. Lavage, followed by the administration of the cathartic through the stomach- tube, is useful. For further treatment, the methods pursued in dynamic ileus should be consulted (page 654). Paralysis of the Sphincters. — It occurs as one of the symptoms of rectal affections. Tenesmus may lead to exhaustion. Ulceration and infiltration of the rectum at times involve the sphincters, inter- fering with their function or destroying it. Improper methods of operations on the rectum may cause paral- ysis. Accumulation of feces may impair the tone of the muscles. Diseases of the brain and spinal cord may cause paralysis of the sphincters. // may be a pure neurosis. Some patients are not able to keep the rectum tightly closed and a small amount of discharge continually escapes. In others involuntary movements occur after excitement, exertion, or during urination, there being only a partial paresis. With complete paralysis, flatus and feces escape involuntarily, even when resting. With paralysis resulting from proctitis, hemorrhoids, stricture, etc., there is a continuous dripping of mucous secretion which irri- tates the skin. Diagnosis. — The anus appears patulous and several fingers can be introduced into the rectum without resistance. To diagnose purely NERVOUS DISEASES OF THE INTESTINES 669 nervous paralysis, anatomic lesions must he excluded by means of examination with specidum. Prognosis. — This depends upon the cause — in the pure neuroses it is favorable. Treatment. — Thorough evacuation of the bowels, preferably by enemata twice daily, is important. The addition of alum, oj (4.0) to Oj (500 cc.) of water by enema, is useful. If due to nervous con- ditions, electricity and massage, especially local vibrations, as sug- gested by J. P. Tuttle, are beneficial. Tonics, such as iron and arsenic, are useful. Strychnin, gr. gV to -g-V (0.001-0.0015), by hy- podermic into the anal folds has been recommended by Rosenheim. General improvement of the nervous system and at times change of scene are indicated. Occasionally difficulty in urination and straining may cause paresis of the sphincter. Catheterization will improve this condition. In the cases in which the nervous condition is not responsible, but some anatomic lesion, appropriate treatment is indicated. SENSORY NEUROSIS OF THE INTESTINES I agree with Riegel that true colic is not a sensory neurosis. On page 453 I have called attention to the fact that the pain of colic is produced by tetanic contractions of the intestinal muscles, and that it is a secondary symptom. Hyperesthesia of the Intestines. — Under normal conditions digestion is carried on without producing any sensation whatever. In cases of neurasthenia, hysteria, and hypochondriasis the patient may be conscious of abnormal sensations in the intestines after the ingestion of food. They may occasionally appear, after violent emotion or shock. These sensations consist in a feeling of fulness, stabbing, burning, tearing, and as if the ingesta were moving about in the abdomen. Occasionally delusions may develop. In some there is local hyperesthesia, especially in the rectum. There is a feeling of tenesmus or fulness, as if some foreign material were impacted there- in, though the rectum is normal and contains no fecal matter. In others pressure and weakness occur in this region, or there is burning, tickhng, itching, stabbing, or a cutting feeling, at times combined with voluptuous sensations. Anesthesia of the Rectum. — In these patients the desire for defecation is absent. In pronounced cases movement may occur without being felt. Such conditions are met with only in patients with spinal and brain trouble, or in the old and decrepit. Paralysis of the sphincters may occasionally accompany this condition. Treatment. — This must be directed toward the improvement of the nervous condition. Change of climate and hydrotherapy are valuable. Highly spiced food, alcohol, and red meats should be for- bidden. 670 DISEASES OF THE STOMACH AND INTESTINES Abnormal sensations in the rectum may be improved by cold rec- tal douches, sitz-baths, the cold prostatic cooler, such as I advocated in the treatment of hemorrhoids, and by rectal galvanization. With rectal anesthesia cleansing enemata are useful. It mav be necessary to wear a rectal obturator (Fig. 232) to prevent soiling. Nervous Enteralgia (Neuralgia Mesenterica). — Aside from en- teralgia due to irritating factors, it may result from a perverted state of the sensory intestinal nerves. This condition is not due to spasm of the intestinal muscles, like colic, but to a neuralgic affection of the bowels. It appears as a primary affection and is found in patients troubled with hysteria, neurasthenia, or spinal difficulty. It may occasionally be reflex, from abnormal conditions of the kidneys, bladder, uterus, ovaries, and liver. It may occur as a neuralgic con- dition even after the removal of some primary cause in the intestines. The first symptom is pain, which usually begins in the umbilical region, mild at first, but gradually increasing in intensity. It may Fig. 232.— Rectal obturator. radiate in various directions. Pressure over the abdomen and the passage of flatus usually relieve the pain.^ The bowels may be nearly normal or constipated. Appetite and digestion may be good. Pal- pitation, dyspnea, strangury, etc., may occur. Neuralgic attacks can occur in lead-poisoning without the true spasm. Hemmeter has reported 3 cases of gouty neuralgia of the intestines. Romberg holds that the abnormal crisis of tabes dorsahs is due to nervous enteralgia. Examination of the symptoms demon- strates that true colic is present. The Romiberg symptom, Argvll- Robertson pupil, and absence of patellar reflexes are diagnostic. Hypogastric Neuralgia (Romberg). — In some cases of tabes there is a purely local form of neuralgia, Hmited to the rectum. The attacks are characterized by violent tenesmus, paroxvsms of pain, a feeling as if a red-hot iron were inserted in the rectum, and occasion- ally diarrhea. This condition is also frequently found in diabetes and in women having uterine trouble, piles, or who are neurasthenic. ^ The pain may be of a cutting or stabbing type, and may even produce shock or syncope. NERVOUS DISEASES OF THE INTESTINES 67 1 The picture presented by nervous enteralgia, on the other hand, as Riegel remarks, may occupy an intermediate position between peritonitis and cohc (pseudoperitonitis). Violent attacks of pain occur in the abdomen at short intervals. Associated with this is frequently pronounced collapse, with great abdominal tenderness on light pressure. Vomiting, which is usually present in peritonitis, is always absent in these cases. The skin of the abdomen is generally hyperalgesic. The functions of the intestines and stomach between attacks are undisturbed, and the patients feel perfectly well. Treatment. — This should be directed toward improvement of the hysteria and neurasthenia. Change of climate, hydrotherapy, mas- sage, electricity, and moral treatment are of service. Arsenic is val- uable. The bowels should be kept regular and a simple diet advised. With neuralgia hypogastrica, if there is local disturbance, this should be treated. Warm sitz-baths and hot enemata are useful. Occasionally an opium-and-belladonna suppository may be required. Tabes should receive treatment. SECRETORY NEUROSES OF THE INTESTINES Though secretion in the intestines immediately follows the entrance of food into the stomach, thus demonstrating the pres- ence of secretory nerves in the intestines, we still have little knowl- edge of the subject. Nervous diarrhea, which has been described on page 474 as a motor neurosis, is often accompanied by an increased flow of intes- tinal juice. Increased intestinal secretion is found in membranous enteritis, though I do not consider this disease a pure neurosis of secretion. INTESTINAL NEURASTHENIA Combinations of the intestinal neuroses frequently occur. Rosen- heim designates such cases as intestinal neurasthenia. The appetite is good and the symptoms usually appear when intestinal digestion takes place — about two to three hours after meals. There are pressure, tension, and griping in the abdomen. Occa- sionally there is nausea, and at times an evacuation of the bowels occurs accompanied with painful sensations in the abdomen and anus. Palpitation occurs at times; sometimes flashes of heat or cold. Generally the patient feels worse when resting in the recumbent position than when walking about. The symptoms usually disap- pear in a couple of hours to return later after a meal. Constipa- tion usually is present. The cjuality of the food docs not excri nuy influence on the symp- toms. Borborvgmi and diarrhea occasionally are present, and the latter in the middle of the night or in the early morning. Indigesti- ble foods are often well borne, while at other times small meals con- sisting of light food cause severe symptoms. Gastric neurasthenia is 672 DISEASES OF THE STOMACH AND INTESTINES sometimes associated. This condition is found among the hysteric and neurasthenic. Diagnosis. — Anatomic lesions causing these symptoms, intestinal dyspepsia, and enteroptosis must be excluded. Treatment. — The general nervous condition must be toned up; iron, arsenic, strychnin, and the bromids are indicated, and ample feeding is required. Indigestible substances should be avoided, also red meats, to lessen the nervous irritability. The sour milks, such as bacillac, etc., are of value. MUCOUS COLIC (MEMBRANOUS ENTERITIS) Among the best -known synonyms for mucous colic are mucous colitis, membranous colitis, membranous or pseudomembranous en- teritis, and tubular diarrhea. In all, there are about twenty-five names for this condition. History, — Although no distinct accounts of this disease occur in the writings of the ancients, yet there may be detected some of its peculiar features in the description of certain pathologic conditions grouped under diarrhea, dysentery, etc. J. Mason Good, in 1825, was the first to classify the disease, calling it tubular diarrhea. Wood- ward descibed it in the ' ' Medical and Surgical History of the War of the Rebellion." Siredy contributed a valuable paper in 1869. Da- Costa, in 1 87 1, described the nervous elements of the disease, stating that the condition is not a true inflammation. Leyden's work, in 1882, gave further stimulus to investigation, especially regarding the character of the dejecta. Nothnagel suggested the name "mucous colic," in order to show that a true enteritis need not exist. Mucous colic is, therefore, an entity, and may be defined as a "condition characterized by the excessive production of mucus in the colon, by attacks of painful spasms of varying degrees of severity and fre- quency, accompanied or followed by the expulsion of mucus in gelatinous masses, or in the form of tubular casts, or in tape-like pieces or strings, and, furthermore, characterized by anomalies of the gastro-intestinal functions and by various nervous symptoms." Age and Sex. — It is a comparatively rare affection, occurring most frequently in women from twent)^ to forty, frequently in middle life. A few cases occur late in life and rarely in children. Boas reports one in early infancy. About 75 to 85 per cent, occur in women. Etiology. — Space will allow me to mention only a few of the chief investigators. Among the various theories regarding the etiology, we may mention the following: 1. Neurasthenia is the prime factor — mucous colic is a secretory neurosis. Among the advocates of this view are notably DaCosta, Siredy, and W. Mendelson, of New York City. 2. The anatomic origin. Kwald lays stress on ptosis of the colon; Boas, on atony; Glenard, on splanchnoptosis. 3. Partly nervous and partly anatomic origin. Mathieu considers NERVOUS DISEASES OF THE INTESTINES 673 it a hypersecretion of mucus in patients of a neuro-arthritic type, who suffer from enteroptosis, intestinal sand being present. Hemmeter believes that often there is some connection with arthritis. Von Noorden lays stress on long-continued constipation in nervous sub- jects. Einhorn places it among the neuroses, but finds that it is associated in many cases with Glenard's disease (with gastroptosis and enteroptosis), and that achylia gastrica is present in many patients. 4. Tumors, adhesions, enlarged prostate, and various other fac- tors are given. J. P. Tuttle believes mucous colic due to organic causes. Roger traces the cause to the liver, believing there is an an- ticoagulant in healthy bile, and when its production is interfered with by visceral ptosis, abnormal accumulation of mucus begins. Nepper^ also imputes the condition to disturbance of the biliary functions. Pathology. — Necropsies are rare unless death results from some intercurrent disease. Autopsies in the cases of O. Rothmann, Osier (Edwards), and Weigert demonstrate that no inflammatory condi- tion existed in the colon. There was simply hypersecretion of mu- cus. The consensus of opinion is that no inflammation exists. On the other hand, M. Rothmann reports i case and Hemmeter 2 cases in which, in addition, some catarrhal inflammation was present. Nothnagel explains this unquestionably b}^ the fact that there are two classes of cases, one in which there is the pure "mucous colic," with hypersecretion of mucus; and the second class, in which the mucous colic is engrafted on a catarrhal colitis. I have noted, in my own experience, that the catarrhal colitis may be of such a mild type that attention may readily be diverted from it on account of the predominance of the symptoms of the mucous colic. The mucus may be passed in the form of long, thin bands, ribbon- like or in the shape of a tapeworm ; they may be tubular or form a cast of the intestines; in some cases these are of considerable length, several feet; the mucus may be in jelly-like masses or even in shreds, occasionally streaked with blood. This discharge should be carefully differentiated from fascia, tendons, the membranes of oranges, etc. After first treating with subHmated alcohol and then staining with Ehrlich's triacid solution, a green color occurs with mucus, of which this discharge consists; with fibrin it turns red. The color of the membranes in mucous colic is ordinarily grayish, though they may be translucent or even transparent. IMicroscopically, the membrane consists of a structureless matrix, with columnar epithelium scat- tered therein ; its chief constituent is mucus. Symptoms. — These patients are markedly neurasthenic and morbidly self-conscious; in appearance they are usually emaciated, with a history generally of considerable loss of weight. There has been obstinate constipation of long duration, with an occasional in- 1 Mucomembranous Colitis, its Causes and Mechanism, New York Medical Journal, May 23, 1908. 43 674 DISEASES OF THE STOMACH AND INTESTINES termittent diarrhea. Palpitation, dizziness, disturbances of the genito-urinary system, hysteric symptoms, anemia, headache, and gastric disturbances of various types are present. On palpation of the abdomen sensitive points will often be de- tected. Patients give a history of a sudden attack of acute abdom- inal pain like severe colic, and the abdomen ma}^ become swollen and tense. At this time the nervous symptoms become extremely aggra- vated. Finally, the passage of the mucous masses described occurs spontaneously, with great straining or with artificial aid. These attacks occur with varying frequency and severity. Between the attacks the nervous conditions of the patient may be slightly improved. This is the type of uncomplicated (pure) mu- cous colic. Nothnagel describes a second type of enteritis membranacea which is engrafted on a colitis. He notes two classes of cases : (a) That in which the severe cramp- like attacks are absent; the patient passes mucus continuously, with occasional tube- casts — a cystic colitis(Abercrombie's case), as shown at autopsy. This is not a true mucous colic. (b) A class in which mucous colic is engrafted on a chronic catarrhal colitis — the latter due in this case to adhesions from recurrent appendicitis. There were small amounts of mucus passed at fre- quent intervals with occasional attacks of mucous coUc. Operation relieved both conditions at first, but the mucous colic later returned. I have had such a patient under treat- ment; the appendix had been removed and adhesions broken up. The patient improved for a time, but later relapsed. I found enteroptosis associated with gastro- ptosis. I applied Rose's belt and instituted treatment. Improve- ment immediately followed, with ultimate cure. Researches. — For some years the author has carried on investi- gations in gastroptosis and enteroptosis at the Manhattan State Hospital, as well as other institutions, and also into the etiology of mucous colic,* and he is thoroughly convinced that enteroptosis is a factor in mucous colic. In Fig. 233 is illustrated ptosis of the colon, narrowed at one point and sacculated above this. Gastroptosis is associated with it. 1 American Medicine, vol. ix, No. 9, pp. 349-354, March 4, 1905. Fig. 233. — Mucous colic: Presence of gastroptosis (G) even of a mild degree, as demonstrable by gastrodi- aphany shows enteroptosis (E) is present also; enter- optosis with sacculation and narrowing at ST; passive congestion and mucus accu- mulation occurs in enlarged (sacculated) portion of colon; mucous colic attacks occur as result. NERVOUS DISEASES OF THE INTESTINES 675 This misplacement of the colon undoubtedly favors circulatory and, hence, secretory changes in the sacculated portion of the colon. Fecal accumulation is also favored, a further cause of irritation. Absorption, with resulting auto-intoxication and nervous disturb- ances following the same, can thus readily result. Naturally, a patient of nervous temperament, and there are undoubtedly many such, may be more markedly affected, but I do not believe that neurasthenia per se will cause that peculiar entity known as mucous colic any more than it will cause gonorrhea. There must be other factors. We know that mucous colic occurs in Glenard's disease, that Bwald believes that ptosis, and Boas that atony, of the colon are important factors, and Einhorn finds a large percentage of patients with mucous colic that have enteroptosis associated with gastropto- sis and achylia gastrica. I believe that mucous colic has as its chief etiologic factor ptosis of the colon with associated gastroptosis. I have had under observation a patient with typic attacks of mucous colic which began one month after confinement. She had enteroptosis and gastroptosis (Landau's disease) due to insufficient support of the abdomen after the birth of her child. She was not neurasthenic, and was only nervous at the time of her attack. A specimen of the mucus passed by this patient was about 12 inches long, flat, and tape-like, and gave the typic reaction to the mucin test; no fibrin was present. To my knowledge, this is the first case of mucous colic that has been reported without the usual accom- paniment of neurasthenia,^ and it substantiates my views. In addition, in 9 cases of mucous colic which I have carefully examined since I began these special investigations, I have found in every case varying degrees of gastroptosis with its associated enteroptosis. In 4 cases there was hyperacidity; 2 cases, anacidity; 3 cases, achylia gastrica. Since the publication of the above article the author has investigated many more cases, all of which substantiated this view. In the newborn and in young children, in whom several cases of mucous colic have been reported, neurasthenia surely cannot be claimed as a cause of the condition. As before stated, visceral ptosis may be present and the patient be in perfect health; but some con- tributory factor, local irritation, anemia, or intercurrent disease may destroy the equiUbrium, and gastro-intestinal disturbances, constipa- tion, etc., may result, and finally, mucous colic. On the other hand, gastro-intestinal ptosis may be brought about by loss of weight or other factors mentioned under Etiology of Gastroptosis, and mucous colic finally result. Enteroptosis is not invariably productive of mucous colic, any more than is typhoid always complicated by hem- orrhage or perforation. Enteroptosis with associated gastroptosis with gastro-intestinal 1 Medical News, Aug. 6, 1904; American Medicine, March 4, 1905. 676 DISEASES OP THE STOMACH AND INTESTINES disturbances I consider factors in the production of mucous colic, and the neurasthenia the result of auto-intoxication. In effect, it may be considered as one of the manifestations of Glenard' s disease. Other con- tributory factors, such as rectal irritation, associated colitis, etc., will be referred to under Treatment. In a paper entitled "A Consideration of the Etiology of Mucous Colitis," by John A. Lichty,^ there are reported 2 1 cases of mucous colitis ; ptosis of the viscera was demonstrated in 16 cases; the other patients were seen before the author's attention had been directed to splanchnoptosis. He states that it is a well-known fact that not infrequently during the examination of a patient a con- dition of ptosis is found without any symptoms referring to it. In such cases there has been established what may be called a condition of perfect compensation, and physiologic function has not been dis- turbed. When, however, this compensation is lost or disturbed, the symptom-complex of mucous colitis appears. He notes a lithemic condition in several patients — notably one having had several attacks of acute articular rheumatism. The gastric secretion was studied in 8 patients — in 4 it was hyperacid; in 2, normal; in i, hypo-acid, and in i achylic. Prognosis. — These cases require tact and patience, and most of them are of long duration. With perseverance, I believe them to be curable. Treatment. — This may be summarized as follows: During the attack, rest in bed; the application of heat to the abdomen by flaxseed poultices, turpentine stupes, or hot pepper poultices — oj (4.0) red pepper to Oj (500 cc.) of boiling water — a flannel being Avrung out therein, covered with oiled silk, and applied to the abdo- men. Dry heat, by means of a hot-water bag, salt-bag, or light tinplate (pie plate), heated in the oven and covered with flannel, may be employed. Spice poultices are of service. Moist heat, however, seems best. The greatest relief to the cramps and bearing-down pains is afforded by enteroclysis by recurrent irrigation with normal saline solution at 110° to 120° F., oil of peppermint, Tllv to xv (0.296- 0.888) to the quart (liter), may be added. Several gallons should be employed once or twice in twenty-four hours, and no fluid should be left in the bowel after irrigation, lest further cramps ensue. High enemata of warm olive oil — i pint to i quart (500 cc. to i liter) — are also of service, as they aid in relieving spasm just as does the internal administration of olive oil in spasm or stenosis of the pylorus. Hot saline rectal injections containing oij to iv (60.0-125.0) of milk of asafetida may be employed. Diet.— Fluid diet, milk, broths, soups, etc., should be enjoined during an acute attack. Medication. — Tincture of belladonna in doses of TTLx (0.592 cc.) every three or four hours, and pushing even to physiologic symp- 1 American Medicine, Aug. 6, 1902. NERVOUS DISEASES OF THE INTESTINES 677 toms, has given me the best results in the treatment of spasm. Occasionally it may be necessary to employ codein in .016 to 0.03 gm. (i~i gr.) doses, or even morphin, 0.008 to 0.016 gm. {^l gr.), in con- ditions of extreme pain. If the acute attack is rather prolonged, the internal administration of valerianates or of asafetida, and the addi- tion of milk of asafetida to the enema may prove to be of value. Between attacks I apply proper abdominal support. For this purpose a silk elastic abdominal supporter, the Van Valzah-Hayes support, Gallant's or La Grecque corset, or Rose 's adhesive plaster belt can be used. Rose's belt has the advantage of simplicity and it cannot slip or become displaced. My great object is to " put on fat " in all cases, and as ptosis of the colon and of the stomach are great factors in the disease, the increase of intra-abdominal tension should be secured by this means. The belt is an aid in the relief of the functional disorders of the stomach incident to the gastroptosis. If the patient objects to the plaster, then the silk abdominal supporter may be employed. In exceptional cases it may be necessary to resort to the rest cure, associated with hydrotherapy and electrotherapeutics. Under such conditions we may increase the weight by following out Russell's method, such as he first instituted at the Post-Graduate Hospital in the treatment of tuberculosis. It was advocated by me in cases of gastroptosis. Re- garding the constipation, the Kiissmaul-Fleiner method of injecting into the rectum nightly or every other night warm olive oil, to be retained all night, is of great value. At the beginning one may em- ploy a few ounces, increasing it to i pint (500 cc.) or even i quart (liter). The patient should be taught regular habits in attempting bowel movement. A glass of hot or cold water administered an hour before breakfast is valuable as an adjunct. Fluidextract of cascara sagrada or the compound cascara tablets have been found serA'iceable, and in some cases sodium phosphate administered in the morning is of value. Other remedies, as suggested under Chronic Constipation, can be employed. A thorough bowel action should be secured daily. Massage of the bowel may be emplo}'^ed, massage with a cannon- ball, or vibratory massage. Sensitive areas must be avoided. These methods can be used while Rose 's belt is -z'n situ. Enteroclysis several times a week with normal saline solution is useful, since it promotes intestinal peristalsis, prevents the accunui- lation of mucus, and lessens the chances of spasmodic attacks. With obstinate constipation electric saline enteroclysis is of value. In addi- tion I sometimes employ baths, abdominal compresses, and electricity. The carbonic acid bath (Nauheim) is of value in improving the circulation. For the nervous conditions the same bath (Triton salts) has proved of service. Achilles Rose has devised a simple method for administering the dry gas bath without the patient being obliged to disrobe (I'ig. 234). The tank is filled with gas and the patient sits therein. The height 678 DISEASES OF THE STOMACH AND INTESTINES to which the gas rises is estimated by means of a burning candle, which goes out when the gas reaches that point. I have secured at least one brihiant result in the treatment of mucous coUc by inflation of the colon with CO2 gas, as advocated b}- Dr. Rose. The method seems in some cases to improve the local cir- culatory conditions in the colon, just as it affects the peripheral circulation when the bath is given. I believe it worthy of trial as an adjunct to the other treatment. It merely requires a bottle with a large mouth. A glass tube passes through the cork. To this tube is attached a piece of rubber Fig. 234 — Rom. - i1i\ tubing with a rectal tip. From oss to j (2.0-4.0) each of bicarbonate of soda and tartaric acid are placed in the bottle, w^hich is then filled two-thirds with water. The COo gas is thus generated, and the bottle being elevated slightly above the rectum the gas is allowed to flow in until slight distention is observed. This procedure can be carried out every other day. Rose's CO2 bottle is illustrated in this volume. I have referred to certain mixed cases in w^hich there was a catarrhal colitis with a mucous colic later engrafted upon it. Among such we can classify those that may apparently be caused by excess- ive bicycling or horseback riding, enlarged prostate, uterine fibroids, adhesions from appendicitis, etc. In some of these conditions a NERVOUS DISEASES OF THE INTESTINES 679 local congestion of the rectum or sigmoid can be detected, and careful investigation will demonstrate that the attack first starts as a simple proctitis or colitis. Constipation has been previously present. Subse- quent auto-intoxication, nervous symptoms, and mucous colic result. I believe that careful examination will reveal that these patients have had an existing ptosis of stomach and colon, quiescent, with no result- ing symptoms, but as a result of irritation causing favorable con- ditions, mucous colic develops. The correction of such sources of irritation is undoubtedly rational, and will thus readily explain the improvement which at all times occurs after operative procedure, as in the chronic appendicitis case with colitis and mucous colic pre- viously described. The existence of the "mixed cases" will un- doubtedly "clear up" the hitherto apparently diverse opinions as regards the etiology of this disease. In such cases, with a coexisting catarrhal colitis, irrigation with nitrate of silver, 1.3 to 2 gm. (20-30 gr.) to 2 quarts of water, and followed by saline solution, or with resorcin, .65 to 1.3 gm. (10-20 gr.) in 2 quarts, or with Hsterin, borolyptol, glycothymohn, 4 to 8 gm. (1-2 dr.) to 2 quarts, or with gomenol, 4 gm. (i dr.) in the same quan- tity of water, may prove to be of service. I have often found entero- clysis with demulcents, such as weak flaxseed tea, or 185 to 250 cc. (6 to 8 oz.) of a saturated solution 01 gum-arabic added to 2 quarts (liters) of warm water, of value. In pure mucous coUc I employ only normal saline solution or the demulcents for removal of the mucus, since the condition is due to hypersecretion and not to inflammation. I should avoid silver irri- gations in such cases, since I have already referred to the fact that irrigations of silver, tannin, alum, etc., can produce an artificial hypersecretion. Small doses of olive oil or of castor oil, in capsules, seem of value for constipation, and improve the tone of the mucous membrane of the intestines, providing they do not increase the patient's dyspeptic symptoms. Extract of nux vomica, gr \ (0.016), or strychnin, gr. Vo (coo 108) t. i. d., is of ser\dce in increasing the tone of the gastro-intestinal tract and the general muscular system. Resorcin, 5 gr. (0.3), or sodium benzoate, 5 to 10 gr. (0.3-0.6), or bismuth salicylate, 5 to 10 gr. (0.3-0.6), should be given if there is much gastro-intestmal fermentation. The use of the following, suggested by W. H. Thomson in the mixed cases for the treatment of catarrh, gives good results: I^. Silver nitrate 0-32 gm-jgr- ^') Resin of turpentine 8.0 gm. (oij) Potash solution 4-° gm. (oj) Pulverized licorice, q. s. to make pills soft. — ]\I. Divide into 60 pills. Sig.— Three pills t. i. d. Copper sulphate, 0.016 (-} gr.) t. i. d., may be substituted later; Fowler's solution of arsenic in .06 cc. (TTlj) dose t. i. d. has also been found useful in these mixed cases. 68o DISEASES OF THE STOMACH AND INTESTINES General Treatment. — Exercise and outdoor life, as golf, etc., to strengthen the abdominal muscles, are important. During winter weather fencing is useful. The general nervous system must be toned up and anemia should be corrected. Iron tropon is easy to assimilate. An excellent combination is a fresh Blaud's pill (iron), .32 gm. (5 gr.), made soft with honey; in each pill is incorporated tTLij (0.118) Fowler's solution of arsenic, and extract of nux vomica 0.008 gm. (I gr.), or 0.00108 gm. (-g'o gr.) of strychnin. The gly- cerophosphates or phosphorus compounds are of value for the ner- vous conditions. Hydrotherapy, massage, and electrotherapy may be used. Diet. — As before noted, fluid diet, milk, kumyss, bacillac, lac- tone-buttermilk, broths, gruels, etc., with the addition of somatose or liquid peptonoids, should be used during the attacks. Between attacks. Von Noorden advocates a very coarse diet (bread containing plenty of chaff, vegetables rich in cellulose, fruits with skins, etc.), to form ballast for the bowel. He claims excellent results. It is my custom to determine the condition of the stomach. Like Einhorn, I have found cases of achylia gastrica in mucous colic, but more cases of hyperchlorhydria and a few of hypochlorhydria. These special conditions should be treated in each individual case and appropriate diet instituted. Stomachics and dilute hydrochloric acid should be given when there is deficiency of HCl, and alkalis if there is hyper- acidity (see Hyperchlorhydria, Achylia Gastrica, etc.). We should, however, give our patient abundant nutrition. Cod-liver oil and fats, such as Russell's emulsion, cream, etc., are of value when they can be assimilated. The addition of healthy fat, with increase in weight, means the cure of our patient. Surgery. — Some writers, notably Hale White, have recommended a right inguinal colotomy to give rest to the colon in certain intract- able cases. This would not relieve the ptosis, however. In severe cases one might resort to shortening the suspensory ligaments of the stomach and colon. Gastropexy and colopexy might be performed, but to my mind it is always objectionable to suture a viscus to the abdominal wall. If there is hepatoptosis, Elliot 's operation for sup- port of the liver might be instituted at the same time. These pro- cedures will aid in the support of the floating kidney if such be present. Nephropexy, I believe, is rarely indicated when it is a part of general ptosis, unless there be some evidence of nephritis or interference with its functions. Some recommend a "revision" (tightening) of the ab- dominal muscles (recti) by means of suturing, so as to relieve the muscular relaxation. This last procedure, as advocated by R. T. Morris, I consider preferable. I believe that resort to surgery is rarely required except in the most obstinate cases, and only after at least two years' continuous medical treatment, with failure to secure cure or comparative comfort for the patient. CHAPTER XXXIII INTESTINAL PARASITES Most of the animal parasites that occur in mankind inhabit the in- testinal canal. There are about fifty varieties, but all do not produce morbid conditions. Some cause a pathologic state locally in the intestines or by their toxins in the blood. There are no absolutely characteristic symptoms produced by these parasites, but they are detected by discovering either them or, in the case of worms, their ova in the stools. Gastro-intestinal disturbances, with or without anemia and with nervous symptoms, may result from their presence. There are two chief groups — the protozoa and the vermes. Protozoa AMEB^ In addition to the dysenteric amebae which have been described, amebse differing sHghtly in certain characteristics from the dysen- teric variety have been reported. They are said to give rise to no symptoms or at times to slight diarrhea. Musgrave is skeptical as regards the existence of non-pathogenic amebae. SPOROZOA Coccidia are occasionally found in the stools. These are egg shaped, provided with a thin shell, are about 0.02 mm. long, con- taining in the interior a large number of nuclei, usually arranged in groups. They do not seem to have a pathologic bearing. INTERNAL PSOROSPERMIASIS Psorosperms have been found in the liver, spleen, kidneys, and ileum, producing a disease similar to that in rabbits. One patient, notablv referred to by Osler,^ was thought to be suffering from typhoid fever. The patient had diarrhea and enlarged liver and spleen. Masses resembling tubercles in the liver, spleen, and ileum were found to con- tain coccidia. INFUSORIA Cercomonas intestinalis is pear shaped, has a distinct nucleus, and eight flagellar The head tapers obliquely and has a depression 1 Practice of Medicine, 1906. 681 682 DISEASES OF THE STOMACH AND INTESTINES (Fig. 235). It is believed that this organism is Hable to prolong existing catarrhal affection of the intestines. Trichomonas intestinalis is distinguished from the former by its greater size and the row of fine cilia on its periphery (Fig. 236). In fresh dejecta it shows active movements. Zunker^ reports it in mushy dejecta of yellowish-brown color and putrid odor. Fig. 235. — Cercomonas intestinalis: A, Larger, B, smaller, variety (Davaine). Balantidimn (Paramcecium) Coli. — The body is oval shaped, measuring from 0.07 to o.i mm. in length, by 0.05 to 0.07 mm. in breadth (Fig. 237). The anterior end is slightly truncated, with a short peristome, generally funnel shaped, and opens externally near the anterior pole. When feeding it opens out and broadens, so one Fig. 236. — Trichomonas intestinalis (after Zunker). can see it is a mouth which leads to a gullet and not a simple furrow. The left border has long cilia, while the rest of the mouth is desti- tute of them. The surface of the cortical layer is surrounded by a cuticle covered with cilia. The interior structure consists of granu- lar substance. It contains a nucleus and contractile vacuoles. Fat and starch granules and, occasionally, red and white corpuscles may be found within the gran- ular substance. The posterior end is rounded and contains the anus. Particles may be obser\^ed to pass from it. The parasite can change its shape and possesses both forward and rotary motion. Reproduction occurs by division, budding, and con- jugation. The balantidium is a parasite of the colon and cecum of the hog. Human infection probably occurs most frequently through the infusorium entering its host in the encapsulated state. When hog feces are , dried and broken up, the encysted forms are scattered about and come in contact with the food or drinking-water. The parasite has been found in the city of London in the drinking-water. The disease f re- 1 Deutsche Zeitschr. f. Praktish. Medicin, 1878, No. i. Fig. 237.- lantidium (Malmsten) INTESTINAL PARASITES 683 quently occurs after the preparation of sausage or the ingestion of uncooked sausage-meat. Malmsten first described the disease in 1857. <^ 0f <*• Fig. 238. — Balantidium coli: Parasite more highly magnified, showing flagella (Strong). Musgrave has written on the subject, and for the most complete description the reader should refer to R. P. Strong's^ article, "The Fig. 239. — Balantidium coli: A parasite passing through the walls of a gland of Lieberkiihn, rupturing the basement membrane. The parasite shows the striation referred to in the text (Strong). Clinical and Pathologic Significance of Balantidium Coli." He tabu- lates 117 cases. 1 Bureau of Government Laboratories, Manila, No. 26, Dec, 1904. 684 DISEASES OF THE STOMACH AND INTESTINES The balantidia frequently exist alone, though sometimes other parasites, such as Bothriocephalus latus, Ascaris lumbricoides, Tri- chocephalus dispar, etc., may be associated. Harlow Brooks ^ found balantidia the cause of an epidemic of diarrhea among the orang-outangs in the New York Zoological Park. The lesions found in human beings seem to be an ulcerative colitis (Figs. 238-240), with the infection in the large intestine. In some cases there were swelling of the lymphatics of the mesentery and mesocolic glands and chronic adhesive peritonitis. Pulmonary, car- diac, renal, and cerebral complications may occur. Symptoms. — The presence of Balantidia coli in the stools is usu- ally associated with diarrhea ; the feces are liquid, often contain mucus, sometimes undigested food, and frequently blood. Diarrhea is per- Fig. 240. — Balantidium coli. The early lesions of the mucosa, consisting of desquamation of epithelial cells of the glands, round-celled infiltration, etc. About a dozen parasites may be counted in this field (Strong). sistent until treatment is directed against the parasite. Colic is fre- quent, nausea and vomiting may occur. The abdomen may be swollen. It is often painful on pressure along the colon, and on palpation the latter may feel thickened. Tenesmus is common. In chronic cases there are weakness, exhaustion, and emaciation; more or less anemia and edema of the feet and ankles. In the fresh stools the balantidia move about rapidly, but die in from one-half hour to two hours after the dejecta have been passed. Only 2 cases are reported in children; 25 per cent, of cases give the history of association with or caring for pigs or having eaten or prepared fresh sausage. Eosinophilia is present locally in the intestines and also in the 1 New York University Bulletin nf Medical Sciences, Jan., 1902. INTESTINAL PARASITES 685 blood. The temperature may be subnormal or at times of consider- able height. The disease has been found in Germany, Sweden, Russia, France, the United States, and the Philippines. Balantidia probably occur more frequently than we suppose. The mortahty was 30 per cent., but depended somewhat on the presence of other diseases which were associated in many of the fatal cases reported. In 33 per cent, there were cures, and improvement in the other cases. Treatment. — The following solutions for topical irrigations or enemata have been suggested : Ems' salt, by water enemata, gx. 15 (i.o) are added to 1500 cc. (ij quarts) of water, followed by quinin enemata, i quart (Hter) of 1 : 750 or 1 : 500 strength. Others suggest calomel, gr. 2 (o.i)t. i. d. for two days only, or naphthalin, gr. 5 (0.3) t. i. d., daily by mouth, with tannic acid, 3j (4.0) to Oj (500 cc.) of water, by injection, every day. Acetic acid enemata — acetic acid, gr. 50 (3.3) to 2 quarts (liters) of water at 37° C. — once or twice a day, with tannic acid, gr. 5 (0.3) t. i. d., by mouth, proved useful in some cases. Another combination is salicylic acid, gr. 15 (i.o), and sodium sulphate, oss (16.0), morning and night, by mouth, with enemata twice a day of salicylic acid (i : 1000), or salol, by mouth, gr. 5 (0.3), four or five times a day, with salicylic acid (i : 1000), or boracic acid enemata 5j (4.0) to the quart (liter) of water, are suggested. Sodium bicarbonate (2 per cent.) enemata, followed by a salicylic acid (i :2ooo to i : 1000) enema, with salol, gr. 5 (0.3), and tannalbin, gr. 5 to 10 (0.3-0.6), by mouth, each several times a day, have given good results. Thymol (i : 2500), acetozone (i : 1000), quinin bisulphate (i : 500), administered by enema or irrigation, as in dysentery, with the use of salol and tannin preparations by mouth, are valuable. One might also administer small quantities of acetozone (1:1 000) by mouth. Vermes Cestodes (Tapeworms) ; Hydatid Disease. — The adult para- sites live in the small intestine of man; the larv^al forms, in the mus- cles and other organs. The most important varieties of tapeworms found in human beings are the Taenia solium. Taenia mediocanellata, and the Bothrio- cephalus latus. The symptoms produced by these varieties of tapeworms are about identical, except in the case of the bothriocephalus, which at times gives special symptoms. The parasites are found at all ages, are not uncommon in children, and occasionally are found in sucklings. They may cause no disturb- 686 DISEASES OF THE STOMACH AND INTESTINES ance, and one may only learn of their presence by noting segments of the tenia in the dejecta. In other cases there may be general as well as intestinal disturb- ances. There ma}' be pressure in the pit of the stomach, abdominal pains, ravenous appetite (bulimia), nausea, at times loss of appetite, occa- sionally vomiting. Diarrhea is sometimes present or there may be constipation. In women and nervous patients we may see mental depression and even hypochondria. There may be dizziness, headache, fainting spells, chorea, convulsions, and even epileptic attacks. Some patients may emaciate, feel weak, and suffer from palpitation. The bothriocephalus may cause a severe and even fatal anemia (pernicious), with poikilocytosis and nucleated red blood-corpuscles; and with it there may be edema of the feet and eyelids and hemor- rhages from the mucous membranes. The metabolic products of this worm probably have a hemolytic action. The diagnosis can only be made by discovery of the segments of the parasites or their eggs in the stools. General Description of the Tapeworm. — It has a scolex or head, which may live for years even when detached from the rest of the body, an oblong neck, and detachable segments (proglottides). These last vary in size and shape and possess the power of motion. The worm is flat and devoid of mouth or intestines. It grows by alternate genera- tion through germination of a pear-shaped primary host (head), and remains united to the latter for a time as a colony of band-like shape. Each segment forms a sexually active individual. The proglottides gradually increase in size as they become more distant from the head, and then diminish again toward the extremity. The tapeworm is an hermaphrodite. On its head are four sucking disks, by which it attaches itself to the mucosa of the intestines. By means of pores it derives its nourishment from the chyme. The older proglottides contain many fructified eggs. These are emptied at intervals into the intestinal canal and appear in the dejecta. The ovum contains an embryo, which requires for its development an intermediary host. After reaching the stomach the envelope is dis- solved by the gastric juice. The embryo is set free and finds its way by the lymphatics or blood-vessels to some place (usually the muscles) where it settles. It here surrounds itself with a sac, which may later be surrounded by a calcareous deposit. In this condition it is called a cysticercus or measle. When the measle reaches the stomach of a new host it opens, and its scolex enters into the small intestine, where it develops into a full-grown tapeworm. Tcznia Solium. — Armed tapeworm or pork tapeworm. This is not common to North America, but more frequent in Europe and Asia. When mature it is from 6 to 12 feet (2-4 meters) or more long. The INTESTINAI. PARASITES 687 head is smaller than the head of a pin, spheric, and provided with four sucking disks, in the middle of which is the rostellum and a double row of hooklets, from twenty-four to twenty-six in number, and hence is called the armed tapeworm (Fig. 241). The neck is narrow and thread-like, nearly i inch long. The body is divided into segments, which possess both male and female genera- tive organs, and at about the four hundred and fiftieth they become mature and contain ripe ova. The segments are about i cm. in Fig. 241 . — Head of Taenia solium, ros- tellum with hooks; suckers (Mosler and Peiper). Fig. 242. — Mature segments of Tsenia solium; proglottides; uterus and branches (Mosler and Peiper). length and from 7 to 8 mm. wide. The worm attains its full growth in about three to three and a half months, about which time the seg- ments are continuously shed and appear in the stool. The uterus forms a straight median tube in each segment, giving off five to seven branches on each side. The branches are undivided at first, but finally ramify as a tuft (Fig. 242). Fig. 243. — Eggs of Taenia solium, 'showing thick shell (Mosler and Peiper). The eggs are rounded and provided with a thick shell (Fig. 243). Rarely the cysticerci (measles) are found in man, as in the mus- cles, brain, eye, and skin. In the muscular system they cause pain, numbness, weakness, and symptoms a little like peripheral neuritis. In the ventricles of the brain irritative symptoms may result. In one case diabetic symp- toms were reported. They can be recognized in the eye. Taenia 688 DISEASES OF THE STOMACH AND INTESTINES solium was formerly believed to exist alone, but several have been found together. T(Bma saginata, or Mediocanellata, the unarmed or beef tapeworm. This is the most common form seen in America as well as abroad. It is longer, thicker, and wider than the Tsenia solium. It may Fig. 246.- — Bothriocephalus latus: a, a, Head; b, neck (Blanchard). Fig. 244. — Scolex of Tsenia saginata (Hosier and Peiper). Fig. 245. — Segments of Taenia sag- inata (Mosler and Peiper). Fig. 247. — Bothriocephalus latus (Eichhorst). attain a length of 15 to 20 feet (approximately 4§ to 6 meters) or more. The head measures over 2 mm. in breadth, has four large suck- ing disks, but no hooklets and no rostellum (Fig. 244). It is square shaped. INTESTINAL PARASITES 689 The ripe segments are from 17 to 18 mm. in length and from 8 to 10 mm. in breadth. The uterus consists of a median stem, with from about twenty to thirty-five lateral branches (Fig. 245). The ova are larger and the shell thicker, and possibly slightly more elliptic, but the two forms are difficult to distinguish by their ova. The measles (cysticerci) occur in beef and are smaller than those of the Taenia solium. Human beings acquire this worm by the consumption of raw beef. Bothrwccphalus Latus (Taenia Lata, or Pig Head). — This is found in certain districts bordering on the Baltic Sea, in Holland, Switzer- land, and Japan. A few cases have occurred in the United States, believed generally to have been imported. The parasite is large and long, measuring 25 to 30 feet or, more approximately, 7^ to 9 meters. The head is elongated, almond shaped, being about 2 mm. long and I mm. broad ; it has two grooves, probably suckers, on its flat surface (Fig. 246). It has no booklets. The neck is narrow and short, about 2 cm. in length, and passes at once into the body segment. The body is thin and flat (Fig. 247). The full-grown proglottides are nearly square and show the sexual organs in the center. The uterus presents as a median dark line, with four to six lateral branches, looking like a star or rosette. The eggs are oval, round, wdth a thin membrane and a lid (Fig. 248). They measure 0.07 mm. p^^ 2lI-Eggs of Bothriocephalus long and 0.04 mm. in width. The latus (Mosler and Peiper). larvae develop in the peritoneum and muscles of pike especially, and of fish such as the turbot, perch, and trout. Infection occurs through eating insufficiently cooked fish. Taenia lata occur in the small intestine of men and rarely in dogs. A severe and even fatal form of anemia may result from this worm. There are a few rare forms of tapeworms occasionally found in human beings. TcBnia nana (Hymenolepsis nana) occurs chiefly in Italy, occa- sionally in Egypt. It is the smallest tapeworm found in man, measuring 10 to 15 mm. long, and may have nearly two hundred segments. The head has four sucking disks, a rostellum, and about twenty-four booklets in a single row. Proglottides are short and broad. It is found more frequently in children, and occurs in large numbers in the small intestine. Nervous disturbances, fainting spells, and even epileptiform at- tacks are produced thereby. The Davainea Madagascariensis (Taenia Madagascariensis) is a rare form of this worm. 44 690 DISEASKS OF THE STOMACH AND INTESTINES Tcenia cucumerina (Elliptica, or Dipylidium Caninum). — This is small, of cucumber shape, occurs frequently in the intestines of the dog, and has been found in small children. The larvae develop in the lice and flees of the dog. The worm is 10 to 40 cm. long and about 3 mm. wide. Tcenia Flavopunctata (Hymenolepsis Diminuta). — This has been met with in about 12 cases. The worm is 2 to 6 cm. long and about 3 mm. wide. Its head is small, club shaped, and provided with sucking disks. It is common in rats. The larvae develop in Lepi- doptera and in beetles. Bothriocephalus Cordatus. — This tapeworm resembles the Bothrio- cephalus latus, except that it is shorter and the head merges into the proglottides without an intervening neck. It occurs in the intestines of men and dogs in Greenland. Other types of tapeworms occur, but they are excessively rare and not found in Europe or America. Echinococci are the larvae of the Taenia echinococcus of the dog. The latter is a tiny cestode 4 or 5 mm. long, consisting of three or four segments, of which the terminal one alone is mature. The head is small, provided with four sucking disks, and a rostellum with a double row of hooklets. As a result of the ingestion of these parasites, cysts develop in various parts of the human organism, as in the liver, muscles, etc. These cysts contain scolices, the head of the taenia presenting four sucking disks and a circle of hooklets. Cysts have been passed per rectum. The disease is common to Iceland, not uncommon in Europe, but rare in this country. The reader is referred to Echinococcus Disease in any work pn Practice of Medicine. Treatment of Tapeworms. — To escape infection avoid raw, medium-done meats, pork, and fish. One should not trust to meat in- spection alone. Thorough cooking of the meat is the only guaran- tee of extinction of the cysticerci. All worms or fragments removed should be destroyed by burning, and if one handles the proglottides or ova, the hands should immediately be disinfected; also the stools. For about two days before administering a vermifuge the patient should be kept on a scanty diet, consisting of broths, soups or milk, with a few crackers. The night before, no food ; and in the morn- ing a cup of tea or coffee, followed in about an hour by the vermi- fuge. Calomel, gr. 5 (0.3), castor oil, oss to j (15.0-30.0), or a saline cathartic should be given daily for a couple of days previously. Male fern is considered quite efficient. Extract of filix mas, ethereal, 3iss to iiss (6.0-10.0), mixed with simple syrup; follow in a couple of hours by a saline cathartic or castor oil. The following have also been suggested : Oleoresin aspidii (male INTESTlNAIv PARASITES 69 1 fern), ossto j (2.0-4.0), in capsules, coated with keratin; a few hours later castor oil, oj (30.0). Filicic acid (filmaron), an amorphous principle from root of male fern, insoluble in water. It should not be administered in fatty oils or alcohol, as they dissolve it and it is toxic. Give in capsules, gr. viiss to XV (0.5-1.0); follow by a saline purgative (not castor oil). Pomegranate root is efficient, given as an infusion of the hark; 3 ounces are macerated in 10 ounces of water and then reduced to one- half by evaporation. The entire quantity is taken in divided doses within an hour or more. It is effective, though sometimes producing colic. The active principle of the root, peUetierin, gr. ivto viiss (0.25-0.5), in sweetened water, to which tannin, gr. v (0.3), can be added, may be given as a substitute. These remedies are followed in a couple of hours by a purge. PeUetierin tannate can be secured and given in the same dose. Pumpkin seeds (Semina cucurbitae), 3 or 4 ounces (90.0-125.0), should be bruised and macerated for twelve to fourteen hours ; then mixed with a little grape-sugar, diluted with milk, Oj (500 cc), and take in two doses about half an hour a part ; then follow in two hours by castor oil. Turpentine, Oleum terebinthinae (spirits of turpentine), oj (30.0), in honey or with sugar, follow with a glass or two of milk; and two hours later a cathartic. I have found pine-needle oil (Gardner's), oj to ij (4.0-8.0), also efficacious. ' Cusso (kousso), cusso pulv., oss (16.0); mel depuratum (honey), oss (16.0). Or cusso can be mixed with sugar, water, or lemonade, and taken in divided doses within an hour. Though cusso is cathartic, it is preferable to follow in two hours with a dose of castor oil. Kamala, pulv. kamala, oj to ij (4.0-8.0), suspended in syrup or in wine. This preparation is purgative and may cause griping, nausea, and vomiting. The dose should be distributed over an hour. Castor oil may be given later. Cocoanut has been recommended as a vermifuge ; the milk and albumin of an entire nut should be taken within an hour. Naphthalin, in capsules, gr. 10 to 30 (0.6-2.0), in divided doses,- within a few hours. Salol, gr. 45 (3.0), in capsules, in divided doses, has been recom- . mended. A combination of these remedies is often effective. Thus: take oss (16.0) of an infusion of pomegranate seeds; pumpkin seeds, oj (30.0); pulv. ergot, oj (4-0), and boiling water 10 ounces (300 cc. approximately). Make an emulsion of male fern — oj (4.0) ethereal extract with acacia powder. Mix the emulsion and infusion and 692 DISEASES OF THE STOMACH AND INTESTINES take fasting at 9 a. m. Follow a couple of hours later with castor oil or a saline cathartic. Osier recommends the addition of croton oil, TTlij (0.118), to the above, but I think this rather too active treatment. Male fern, pumpkin seed, pomegranate, and turpentine are the best remedies. About two hours after the vermifuge a cathartic, such as citrate of magnesia, 3j to ij (4.0-8.0), or magnesium sulphate, larger doses, or some other saline cathartic, or castor oil, o j to ij (30.0-60.0), should be given. The head of the tapeworm should be looked for, as the parasite will regrow if this is not removed. In some cases this is difficult to find. Children require proportionately smaller doses, according to their age. Care must be exercised with patients who are debili- tated, recently convalescent from typhoid, or have severe intestinal disorders. It may be necessary to postpone treatment. Trematodes (Fluke Worms) ; Distomiasis. — Flukes are found in the lungs, liver, small intestine, and in the blood; in the latter case affecting chiefly the urinary system and the rectum. Fig. 249. — Distoma hepaticum, with male and female sexual apparatus; X 2^ (Leuckart). The trematodes are soHd worms of leaf or tongue shape. They possess a clinging apparatus in the form of oral and ventral sucking cups, which vary in number. Sometimes they also have hook or clasp- like projections. The intestinal canal is without an anus and is split like a fork. They are generally hermaphroditic. Flukes are found in China, Japan, India, Egypt, Arabia, and Persia, and imported cases have been found in Canada and the United States. They have been found in the cat, dog, and hog in this country. Five species of liver fluke are known to occur in man. The Distoma conjunctum, the Indian liver fluke, usually described, the Distoma lanceatum (lancet fluke) , and the Distoma sinensis are the most fre- quent, occurring in the liver, the last being most important. The Fasciola hepatica, common to ruminants, and the Opisthor- chis (Distoma) felineus, occurring in Prussia and Siberia, and found in cats in Nebraska, are the other varieties. In general, we may say the liver fluke is of leaf shape. It ma}' vary in length from 10 to 20 mm. by 2 to 5 to 10 mm. broad. The cephaUc end projects like a beak and has a small cup-like sucker, in which lies the mouth. Behind this, on the ventral surface, is a second INTESTlNAIv PARASITES 693 cup, and between the two is a special orifice. The uterus appears as a convoluted bag behind the posterior sucker. On each side of the body are the ovisacs and the branched testicular canals (Fig. 249). The eggs are oval, 25 to 30/^- long by 15 to 17/-^ broad, of brown color, with a sharply defined operculum (lid) (Fig. 250). The Distoma lanceolatum, another variety of liver fluke, has a lancet shape and the head is not especially marked off from the body (Fig. 251). The eggs are rather small, 0.04 mm. long (Fig. 252). Young children suffer more fre- quently from liver fluke; sometimes whole families or villages are attacked. There is an irregular diarrhea ; there may or may not be blood. The liver en- larges. There is often pain and an in- termittent jaundice, but not much fever of Distoma hepaticuni and Distoma lanceo- latum, moderately magnified (Heller). Anasarca and ascites come on later. The ova of the parasite are found in the stool. Fig. 251. — Distoma lanceolatum with its inner organs; X 10 (Leuckarfj. Intestinal Distomiasis. — In India the Distoma fasciolopsis has been found in a number of cases in the small intestine, with diarrheal symptoms. Fig. 252. — Egg of Distoma lanceolatum shortly after the formation of a shell; X 400 (Leuckart). Hemic Distomiasis; Distoma Hcematobium; Bilharziasis; Schis- tosoma HcBmatobium; Bilharzia Hcvmatobia. — Endemic hematuria, 694 DISEASES OF THE STOMACH AND INTESTINES particularly in Egypt, had been known for many years, when in 1851 Bilharz discovered the parasite of the disease. The blood fluke pre- vails in South Africa (the Transvaal) ; in North Africa, especially in Egypt; in Arabia, Persia, and the west coast of India. It is preva- lent in Japan. It has been observed in Porto Rico and in the Philip- pines. The disease is rare in the United States, only 7 cases having been reported. In addition, 7 cases occurred among the Boers, who were on exhibition in this country after the African War. The first case of rectal infection reported in the United States was in a German, who evidently contracted the disease in Brazil and who was treated at the German Hospital. He suffered from mixed infection — Strongyloides intestinaHs, Trichocephalus, and Schis- tosoma hffimatobium, reported by I/. Blumgart,^ of New York. The Schistosoma has separate sexes and carries the female in a gynecophorous canal. The male is from 12 to 14 mm. long. Its body has ciliated warts on the integument, but otherwise is smooth, and in the posterior portion is rolled up into a tube, which serves for the reception of the female (Fig. 253). There is a sucker at the anterior end and a second one posterior to Fig. 253. — Male and female of Bilharzia hsematobia (Loos). Fig. 254. — Eggs of Distomum haema- tobium (Bilharzia hsematobia), length, 0.12 mm.; breadth, 0.05mm.: o, Egg with lateral spine; b, egg with terminal spine; X 150 (after Bilharz). it on the ventral surface. The female is from 16 to 18 mm. long and nearly cyHndric. The eggs have a terminal or lateral spine (Fig. 254). The trematode is most abundant in the blood of the portal system, while the ova lodge in the capillaries, especially of the bladder, urin- ary organs, rectum, and lungs. In the stools of the case reported, the spine was placed laterally on the ova. Infection is now considered to take place in two ways — either by the gastro-intestinal tract, through infected food or water, or through the skin by bathing in infected streams. 1 Medical Record, April 6, 1907. INTESTINAL PARASITES 695 The parasite reaches the portal system, where it develops. The males, bearing the females, creep to various parts, particularly the bladder and rectum. The eggs are laid in the tissues, but wander like other sharp foreign bodies, and escape with the urine and feces. The eggs in the tissues cause irritation, fibroid changes, and papillomata in the bladder and rectum. Hematuria and bladder irritation, chronic cystitis, tenesmus, mucus and blood in the stools, ulcerative proctitis, calculi in the kidney and bladder, peri-urethral abscess and perineal fistula, vaginitis, inflammation of the ureters and seminal vesicles, may all occur. Bilharzial colitis has been reported. Anemia is present and eosinophilia is quite marked. In 1904 there was described a new blood fluke. Schistosoma Cattoi, or Japanicum, found in Japan. It lives chiefly in the vessels of the ahmentary canal and ulcerative lesions are found therein. The ova appear in the feces. Katsurada has studied numerous cases. This condition is known in Japan as the "Katayama disease," from the name of a town in which it is quite prevalent. Catto described certain bodies he found in a Chinaman in 1904, and the new fluke is sometimes called by his name. Paul G. Woolley^ has reported a case occurring in the Philippines, and has given an excellent description of the disease. The worms are characterized by the absence of ciliated warts on the integument, which are a feature of the Schistosoma hcBmatohium. The worm averages 10.43 mm.- long. The eggs are smaller, brown in color, have blunter ends, and no spine. Katsurada gives the most definite reports of the disease "Kata- yama," according to Woolley: " Defective physical development is the rule in the affected children. Diarrhea is usually the first symptom to be noted, while anemia and ascites generally follow later; the most striking feature is the shape assumed by the trunk. The hypogastric region seems to shrink, while the epigastric enlarges, a transverse furrow forming directly above the umbilicus, so that the general appearance of the abdominal region is that of an inverted gourd. Dilatation of the epigastric region and of the lower part of the thorax were noted even in patients whose liver and spleen were not much enlarged. The commonest symptoms are an initial increase in the size of the liver, followed by a decrease, a secondary enlargement of the spleen, a mucosanguineous diarrhea, severe attacks of ascites, and progressive anemia." Katsurada found the ova of the parasite under discussion, and also those of Tricho- cephalus dispar, Uncinaria, and Ascaris lumbricoides in the stools of his patients. The rectum and appendix were the parts chiefly affected, but the ova were found in the subperitoneal layer, the submucosa,and mucosa, especially in necrotic areas, from the cecum to the anus. Adult trematodes were found in the blood-vessels. 1 Philippine Journal of Science, Jan., 1906, vol. i, No. i. 696 DISEASES OF THE STOMACH AND INTESTINES In Woolley's case there were also amebge and the ova of the unci- naria ; but in the fibroid tissue of the submucosa of the large intestine there were many ova of the Schistosoma Japanicum surrounded by round-cell infiltration (Fig. 255). A type of cirrhosis was pro- duced in the liver. Splenomegaly, ascites, dysentery (specific), and possibly Jacksonian epilepsy may be produced by these trematodes, according to Woolley. The disease is probably water-borne, originating in rice-fields or irrigated gardens, from human fertilizer. Infection may occur through the skin or by the gastro-intestinal canal. Treatment. — The extract of the male fern is recommended for dis- tomiasis and the treatment as of tapeworm. Nothing has been found for the treatment of the parasite in the blood. The author would Fig. 255. — Schistosoma Japanicum. Ova in mucosa and submucosa of large intestine. Shows atrophic and infiltrated condition of mucosa. Hematoxylin (Woolley). suggest the trial of Urotropin, gr. 10 (0.6), and sodium benzoate, gr. 10 (0.6), three or four times a day. The latter lessens the irritation of the urotropin, as demonstrated by William H. Thomson. The inflammation of the bladder, colon, and rectum should be treated as indicated by irrigation, etc. Solutions, as described under Proctitis and Colitis, can be employed for the. latter complications. Neniatodes (Round Worms). — Round worms have a slender, cylindric, at times a filiform body, with neither segments nor append- ages. The integument is thick and elastic. The mouth is at one extremity and furnished with either soft or horn-like lips. The ali- mentary canal extends through the entire body and terminates in an opening on the ventral side near the posterior extremity. The sexual organs and their orifices are on the ventral surface. The female INTESTINAL PARASITES 697 aperture is at the middle of the body, while in the male the sexual orifice is near the anus. The males are usually smaller than the females. Ascaris Lumbricoides (Round or Spool Worm). — This is one of the common parasites observed in man. It is cylindric in shape, pointed at both ends, and of a yellowish-brown or slightly reddish color. It varies from 4 to 12 inches (10-30 cm.) in length, the female being as large as 12 inches {30 cm.), while the male is only one-half or two-thirds the length, 8 inches (20 cm.), and frequently much smaller. The posterior extremity of the male is bent in the shape of a hook and furnished with two spicules or chitinous processes (Fig. 256). The mouth has three muscular lips provided with very fine teeth. Fig. 257. — Eggs of Ascaris lum- bricoides, double shell; albuminous envelope, magnified (Hosier and Peiper). Fig. 256. — Ascaris lumbricoides: a, Body; b, head; c, eggs (after v. Jaksch). Fig. 258. — Unfertilized egg of As- caris lumbricoides; X500 (Logan). The worm is transversely striated and has four longitudinal bands. The sexual opening of the female is anterior to the middle of the body. The eggs when ripe have a double shell, and around this is an albuminous envelope, irregular in shape, studded with excrescences (Fig. 257). The long diameter of the ovum is about 0.075 "^"i- ^"d 0.058 mm. in width. Atypic (unfertilized) eggs have been described by O. T. Logan^ of China. When taken from the uterus it has not the typic thick shell, but is granular, elliptic, and enclosed in a deli- cate membrane (F'ig. 258). 1 New York Medical Journal, Dec. 21, 1907. 698 DISEASES OF THE STOMACH AND INTESTINES In the feces, the yelk is not finely granular, but coarsely globular; the albuminous coat is less voluminous and projects from the shell like blunt saw teeth. The unfertilized egg^ is longer and narrower than the fertilized egg and markedly elliptic, with a tendency to flat- ten at one or both ends. It is occasionally oval, but never round. An irritating, odoriferous substance is formed by the round worm. Huber^ states that it may occasion urticaria in those predisposed to this symptom. Peiper suggests that the nervous symptoms, some- times resembling meningitis, may be due to this poison ; and Chauf- fard and Marie report fever, intestinal symptoms, diarrhea of inter- mittent character and foul breath, so-called typholumbricosis, in connection with these worms. The fever may continue for a month or more. The parasitic life history is direct, by ingestion of the ova, with no intermediate host. The parasite occupies the upper part of the small intestine. Usually not more than one or two are present, but they may occur in enormous numbers. Infection usually takes place by eggs in the soil near dwelUngs, in the drinking-water, and especially in raw foods, such as salads and fruits. These worms occur more frequently in children from three to twelve years of age and in the poorer class. They are not so frequent in adults. Females seem more frequently infected. Migration. — The worms may crawl into the stomach, whence they may be ejected by vomiting; or they may pass through the esophagus and enter the phar5^nx, whence they may be withdrawn. The \'\'orm has entered the larynx and has produced fatal asphyxia, or into the trachea and lungs and caused gangrene. They have passed through the Eustachian tube and appeared at the external meatus. They have been found in the bile-ducts, the gall-bladder, and even in the Uver, where they produced fatal abscess. They have entered hernial sacs, perforated intestinal ulcer, and some claim even the healthy bowel wall has been perforated by them. Appendicitis has been attributed to the ascaris ; and obstruction of the bowel is said to have been produced by a large mass of ascarides. Symptoms. — They may produce no symptoms. In children, irri- tability, restlessness, picking at the nose, grinding the teeth, twitch- ings or convulsions, have been attributed to them. Anorexia, nausea, irregular bowel action, meteorism, irregular pulse, and black rings around the eyes may also occur. In rare instances progressive anemia has been observed. Itching of the nose may be present. The worms probably produce local hyperemia of the intestinal walls. Diagnosis. — ^This is made by the detection of the worm or of its ova in the stools. Treatment. — The stools should be disinfected by carbolic (5 per 1 New York Medical Journal, Aug. 19, 1905 (Wellman); Reference Hand- book Medical Sciences, p. 502. 2 Twentieth Century Practice of Medicine, vol. viii, p. 583. INTESTINAL PAR.\SITES 699 cent.) or bichlorid (i : 1000) solution to destroy the ova. The hands should be disinfected and all food protected against infection. It is preferable to administer a simple saline for a couple of days and keep the patient on a light diet before administering the anthel- mintic. Santonin is the best remedy. It can be given mixed with sugar in doses of gr. | to | (0.022-0.032) for a child, and gr. 2 to 3 (0.13- 0.194) for an adult, followed by calomel or a saline purge. It can be administered in divided doses; thus, santonin, gr. i (0.06), three or four times a day, followed by a purge; or santonin, gr. 3J (0.2), with castor oil, oij (60.0) ; give i teaspoonful for a small child; I dessertspoonful for a larger child; i tablespoonful for an adult, two or three times daily (Einhom). Santonin, gr. ^ (0.022) ; hydrargyrum choridum mite, gr. i to 2 (0.065-0.13). Give one powder t. i. d. Yellow vision (xanthopsia) occasionally follows the use of santonin. Chenopodium (powdered seeds), in doses of gr. xv to xxx (i.o- 2.0), or oleum chenopodii, IfVLij to x (0.118-0.592), followed by a cathartic, have been employed. Thymol, gr. viiss to xxx (0.5-2.0), given in capsules in divided doses and followed by a saline cathartic, has been recommended. Fig. 259. — Oxyuris vermicularis: Female, enlarged (Hosier and Peiper). Enteroclysis with water, to which a few drops of benzine are added, has been suggested; but I scarcely see the benefit, as the habitat of the worms is in the small intestine. Ascaris Mystax. — ^This is a round worm resembling the ascaris lumbricoides, but smaller and thinner. It is found chiefly in cats and rarely in man. No special symptoms result. Oxyuris Vermicularis (Thread-worm; Pin- worm; Seat- worm ; Awl-tail ; Maggot-worm). — This parasite occupies the rectum and colon. It is white and filiform. The male measures about 4 mm. (| inch) in length and the female about 10 mm. (f inch) (Fig. 259). It has three small nob-like lips. The female has two uteri, passing backward and forward from the end of the vagina. The opening of the latter is situated above the middle of the body. The eggs are 0.05 mm. long and about 0.02 mm. wide, with granular contents and white shell (Fig. 260). Huber and others claim that they are generally deposited outside the body, so that feces rarely contain them; while Osier holds that they are usually found in the feces in large numbers. These worms occur at any age, though most commonly in children. The worms are found in the feces, at the anus, or in the vagina. 700 DISEASES OF THE STOMACH AND INTESTINES Infection takes place through drinking-water or through salads, radishes, fruits, etc., the ova being dried upon them, or through the unwashed hands of the host. The eggs of the oxyuris reach the stomach, when the shell opens and the embryo migrates into the small intestine. After fructification the females pass along the canal to the cecum, where they remain I, Female; 2, males; 3, ovum, magnified. Fig. 260. — Oxyuris vermicularis, natural size (Vierordt). until the eggs are ripe, and then pass on downward, chiefly to the sig- moid and rectum. The oxyuris may traverse the intestinal wall and have been found in the peritoneal cavity, where they may form ver- minous tubercles in Douglas' fossa or perirectal abscesses. Symptoms. — ^The oxyuris produce great irritation and itching around the anus, particularly at night. The pruritis ani is pro- Fig. 261. — Segmentation and development of embryo of Oxyuris vermicularis (Heller). nounced. The patient becomes nervous and irritable, sleep is dis- turbed. There mav be anorexia, nausea, dizziness, palpitation, pollutions in the male, occasionally diarrhea, and at times anemia. Sometimes the parasites enter the vagina and cause irritation or n^^mphomania. Diagnosis. — The worms are easily detected in the feces and are INTESTINAL PARASITES 7OI readily diagnosed by their appearance and location through inspec- tion of the anus. Treatment. — Cleanliness of the hands of the infected person and disinfection of stool, clothes, and bedclothes are important. Sleeping with an infected case should be forbidden. Raw fruits should be cleaned and peeled, salads, etc., thoroughly washed. One should not eat out of the same vessels as the patient. Santonin, administered by the same method as for ascaris, is an excellent remedy. Local treatment by enemata of water, i quart (liter) containing TTLv to x (0.296-0.592) of benzine, or vinegar oiss to ij (45.0-60.0), or thymol (i : 2500) by enema, or fiuidextract of quassia, TTlx to xxx (0.292-1.704) to the quart; or soak a quassia cup in water for half an hour and inject quassia water, Oj (500 cc). An enema of spirits (oil) of turpentine, 5j (4.0) to Oj (500 cc.) of water, is of value. These injections should be given with hips elevated and retained for a short period. Cold injections of strong salt water are of ser- vice in children. Carbolic acid I believe unsafe. Injections of lime- water are of use. Black wash — calomel, oj (4-0); lime-water, Oj (500 cc.) — locally, externally; lead-and-opium lotion, unguentum belladonna, vaselin, or I^. Unguent, belladonnse oij (8.0) Tr. aconite radix 3ss (2.0) Zinc oxid gr. xv (i .0) Unguent, aq. rosse q. s. o j (30.0). — M. Sig. — Ft. ung. External use to anus. Cocain, gr. ss (0.32), can be added to this. These preparations lessen itching. The saline enemata, given frequently, are of use. Ankylostoma (Anchylostoma) Duodenale ; Uncinariasis ; Hookworm Disease ; Miner's Anemia ; Egyptian Chlorosis ; Dochmius Duodenalis or Strongylus Duodenalis.— In 1843 Dubini first described this parasite in man. Griesinger, in 1854, demonstrated it as the cause of Egyptian chlorosis. Subsequently it was described in the tunnel workers of St. Gothard, and it is now recognized as an important cause of tropical anemia and of the anemia of miners, brick workers, and tunnel workers. Incidence. — This parasite is widely spread in tropical and sub- tropical countries, and is one of the most fatal of parasitic diseases. In Porto Rico, in 1903, 5736 deaths out of a total of 23,433 were from anemia due to uncinariasis, as shown by the Anemia Commission in the report issued by Ashford King and Igaravidez. Stiles has dem- onstrated that the disease is endemic in many places, and is the cause of the common anemia in the Southern States. Bass^ has reported a large number of cases in the country popu- 1 Journal American Medical Association, July 21, 1906. 702 DISEASES OF THE STOMACH AND INTESTINES lation of Mississippi. Uncinariasis has been found among the miners in Pennsylvania. It is not uncommon in the PhiHppines. The disease is prevalent among the miners of Germany and Austro-Hungary and Fig. 262. — Ankylostomum duodenale: o, Male (natural size); b, female (natural size) ; c, male (enlarged) ; d, female (enlarged) ; e, head; /, eggs (after v. Jaksch). also in Westphalia. The anemia of the Cornish miners has been shown to be due to hookworm. In Egypt the disease is very prevalent. Fig. 263. — Posterior extremity of female Uncinaria Americana, viewed ven- trolaterally, showing anal opening expanded: o, a, Anal papillae, showing small chitinous tips (A. J. Smith). Parasite. — The worm is a strongyle, closely allied to the scleros- toma, which causes verminous aneurysms and colic in the horse, and to the gapeworm of fowls. There are two forms — the Anchjdostoma duodenale and the Uncinaria Americana — described by Stiles. They have the same general characteristics, there being certain differences in the arrangement of the teeth, etc. INTESTINAL PARASITES 703 The worm is cylindric in shape, about 0.5 to i mm. thick. The males are from 7 to 11 mm. in length, the females 10 to 18 mm. The American worm is the longer. The worm is yellowish or grayish white in color, with translucent edges. The head is curved toward the dorsal surface and the mouth is provided with a heavy armature of hook-like teeth, with which they pierce the mucosa. There is a strong muscular esophagus. The male has a prominent caudal expansion or bursa (Fig. 262). In the female the caudal end is pointed and armed with an awl-like prong (Fig. 263). The eggs are oval, 64 to 76/^ long by 36/^- wide (Fig. 264) in the American form. They are laid in segmentation. The development is direct, without an intermediate host. The European eggs are smaller. The embryo lives in the water or moist ground and passes through the rhabditiform stage. Larvae may live for months in the mud and water of the mines. They may be taken into the body by drinking-water, with the dirt from the hands of the miners and tunnel workers, or in the soil eaten by the earth feeders, the geophagi. They may be carried in the dust and con- taminate green vegetables and fruit. Uncinarial Dermatitis. — Ashford and King^ refer to the fact that in Porto Rico infections through the mouth are rare, and that fully 96 per cent, of the patients have suffered from ground-itch ("Mazam- orra"), due to invasion of the skin^ by these larvae. The well shod were never affected.. Various stages of dermatitis occur, and even obsti- nate ulcers of the leg, in the lower third especially. These were called "tropical" or "syphilitic" by the ignorant. Loos demonstrated that embryo worms enter the skin and are carried by the veins to the right side of the heart and lungs, and then pass up through the trachea into the pharynx and are swallowed. Ashford further believes that skin infections can take place without manifest dermatitis from experiments on animals. Skin infection is probably very frequent. Infection is mope common in summer than winter, in part prob- ably due to the fact that greater protection is afforded the lower limbs during the cold or rainy season. 1 Uncinariasis, Journal American Medical Association, Au.s^. 10, 1907. 2 The skin eruption known as " bunches," occurring in the Cornish miners is probably due to the entrance of these worms (Haldane). Fig. 264. — Four eggs of the New World hook-worm {Unci- naria Americana), in the one-, two-, and four-cell stages. The egg showing three cells is a lateral view of a four-cell stage. These eggs are found in the feces of patients, and give a positive di- agnosis of infection. Greatly en- larged (after Stiles). 704 DISEASES OF THE STOMACH AND INTESTINES Immunity. — Some whites, and especially the negro race and Asi- atics, enjoy considerable immunity to this disease. One may find a large number of ova in the stools, and yet there may be few or no symptoms. Usually the greater the infection, the more acute the onset and course of the disease. The adult worm lives in the small intestine; more are found in the jejunum; many in the duodenum; and rarely in the ileum or colon. Symptoms. — In the early stage there may be gastro-intestinal symptoms, such as pains in the epigastrium (gastralgia), tenderness in the right h5^pochondrium, nausea, occasionally vomiting, consti- pation, rarely diarrhea. Pain in the sternum and chest, slight breath- lessness on exertion, and palpitation. A temperature of 37.5° to 38.5 ° C. (99.5 "-103.5 F.) is not uncommon. The patient feels unable to work; graduallv anemia becomes manifest, the fever disappears, hemoglobin steadily diminishes. Headache, vertigo, tinnitus aurium, hemic murmurs, weakening of the pulse, and dyspnea follow. The pains in the sternum become quite severe, debilit}' and mental hebetude increase; patellar reflexes are diminished or even lost. Impotence or amenorrhea may be present. In this advanced condition the skin is of a dirty muddy hue, at times waxy white. In the Southern States it is known as the "Flor- ida complexion." The eyes are dull, heavy, lack lustre, and have a blank stare.. Children are interfered with in their growth and become stunted and ill developed. The circulatory system becomes more profoundly affected; the heart, at first slightly hypertrophied, now becomes dilated and broken compensation ensues. There are edema of the feet and legs, pufhness of the face and a general anasarca, with pericardial, pleural, and peritoneal effusions. The patient is bed- ridden and gradually passes away in a semisomnolent condition. Acute cardiac dilatation, cerebral effusion, or violent diarrhea may be terminal events. Osier holds that the liver and spleen become enlarged, but this does not correspond to the findings of Ashford and King. The hemo- globin may fall below 30 per cent, and sometimes even to 8 per cent., and some of these latter have recovered under appropriate treatment. Morbid Anatomy. — Autopsies (Ashford and King). — Muscles are often brownish gray, friable, and atrophied. Skin and subcutaneous tissue pale and sodden with fluid. Serous effusion generally present in the pleurae and pericardium, sometimes in the cerebral ventricles. Ascites marked. Lungs. — Edema and passive congestion. Liver. — Never normal; once was increased in size; never dimin- ished; fatty degeneration often present; connective-tissue increase is not a feature. Kidneys. — Chronic parenchymatous or chronic diffuse nephritis. As a rule, there was little connective-tissue increase. INTESTINAL PARASITES 705 Stomach. — Uncinariae are occasionally found in the stomach, even adherent to its walls. Chronic gastritis is common. Intestines. — ^The jejunum contained most of the uncinariae, some unattached and others attached to the mucosa. The balance were mostly found in the first part of the duodenum, a few in the ileum, and none in the colon. The intestinal lesion is confined to the mucosa, there being a tiny superficial erosion about 0.5 mm. (3^0 inch) in diameter, and not a deep ulcer. They are usually not red and are difficult to find, except with a hand lens. The duodenum and especially the jejunum are the seat of a chronic intestinal catarrh. The dejecta are often of brownish color. Microscopically, eggs of the parasites and at times Charcot- Leyden 's crystals are found in the stools. Spleen. — This is frequently found reduced in size, soft, and has a wrinkled capsule. There was a paucity of lymphoid elements. Hemolymph Glands. — In the region of the abdominal aorta, espe- cially near the bifurcation, enlarged glands of dull reddish hue were noted. There was no surrounding trace of imflammation. Micro- scopic examination showed they were hemolymph glands of the type described as splenolymph. Bone-marrow. — Changes such as occur in pernicious anemia ; also eosinophilous cells. Anemia. — Blood. — The findings vary from a diminution of hemoglobin and red cells to those of pernicious anemia. The hemo- globin is usually relatively lower in uncinariasis; as low as 15 to 20 per cent, in severe cases is not uncommon, 8 per cent, having been registered. Polychromatophilia, and in severe cases poikilocytosis, with macrocytes and microcytes, occur. Normoblasts and megaloblasts were not uncommon, but the latter were in the minority. Ery- throcytes averaged 2,406,416 per cubic millimeter, the lowest 754,000; average hemoglobin slightly over 40 per cent. Osier reports marked leukocytosis in his cases. Some observers hold that leukoc}i:osis is generally due to complications; while Ash- ford and King find no constant leukocytosis, but that it is present at times in acute cases, while in chronic cases there is apt to be leuko- penia. There seemed to be a tendency of the leukoc}i:es to degen- erate. Eosinophilia is of importance. Boycott and Haldane hold it iS present in 94 per cent, of cases, and at times it is quite high. Ashford and King call especial attention to the fact that in the most serious cases it is liable to be absent, and that it is chiefly of prognostic im- portance. Very chronic cases of severe type, poor resisting power, and lack of blood regeneration, they state, rarely show eosinophilia, or only to a sHght degree; that a rise of eosinophilia is of good prognostic significance; that a fall, with lack of improvement in the 45 7o6 DISEASEIS OF THE STOMACH AND INTESTINES symptoms, is not a good omen. They hold that good resistance to the toxin of uncinarise is expressed by eosinophilia. Diagnosis. — By the finding of the eggs and parasites in the stool. It is well to examine the stools after a dose of thymol, followed by a saHne cathartic. Stiles suggests placing a small bit of feces on a white blotting paper when a microscopic examination cannot be made. In about an hour there is a blood-red or reddish-brown stain suggest- ive of blood. The worms to the naked eye are about J inch long, of the diameter of a pin, with one end sharply recurved. Eosinophilia is suggestive. The microscopic examination of the stool will settle the diagnosis. Prognosis. — ^This is good if the condition is detected early, but is bad in the advanced cases. Prophylaxis. — In camps or mines, proper sanitary regulations, such as the correct location of the latrines, etc., are important. In regions where this infection is endemic, new miners should be in- spected, and infected cases should be pronounced free from the dis- ease before being allowed to resume work. The feet and legs should be protected from the soil (should not be bare) and the hands prop- erly scrubbed before eating. The stools of infected patients should be disinfected with bichlorid of mercury (i:iooo) or carbolic acid (1:20) solution. Raw fruits and vegetables, such as apples, lettuce, etc., should be properly cleaned, and should preferably be avoided if there are many cases of ankylostomiasis. ' Treatment. — ^Filix mas, thymol, and betanaphtol are the best drugs. The ethereal extract of filix mas, same dosage as for tape- worms, and then the solid extract were tried in Porto Rico, but they seemed to be of no value. Ashford beheves that possibly the prepa- ration deteriorates in warm climates. Thymol proved to he the best remedy. The day previous the patient abstains from soHd food and at night is given 25.0 gm. sodium sul- phate or any good saline cathartic ; the next morning, if free bowel action, on an average about gr. 30 (2.0) of thymol should be given, and an equal dose two hours later, followed in a couple of hours by another saline cathartic. This procedure should be kept up once a week, until no ova are found. Smaller, occasionally even larger, or more frequent doses may be required. It is generally advised that oily cathartics, such as castor oil and also alcohol, should not be taken directly after the thymol. Dizziness or slight collapse may follow the use of thymol. Ashford mentions cases who have taken alcohol for these conditions with no deleterious effect. Betanaphtol, gr. xv (i.o), and two hours later the same dosage, administered like thymol, have been employed. It is somewhat irritating to the kidneys; is an excellent anthelmintic, but not quite as safe as thymol nor as efficacious. INTESTINAIv PARASITES 707 Ashford and King hold that hemoglobin increased more rapidly under the use of iron, but that the return to normal came about as surely without it, after the use of thymol. They used Blaud 's pills in obstinate cases. Iron and arsenic I believe valuable accessories. I^. Blaud's pill (iron) (made fresh) gr. v (0.3) Sod. arsen gi". -^V (0.0013). — M. One pill. Sig.— One t. i. d. Peptomangan (Gude), oj to iij (4.0-12.0), or Blaud's iron pill, gr. V to X (0.3-0.6), or iron tropon can be used, combined with Fow- ler's solution of arsenic, TTLv (0.274) t. i. d.; or atoxyl, gr. ^ (0.02), by hypo- dermic every other day. A subsequent high enema of thymol, I quart (liter), 1 12500, might be of value in aiding their destruction after the worms have passed into the large intes- tine. Strongyloides Intestinalis. — Under this name we now include the small nematode worms found in the feces and formerly described as Anguillata sterco- ralis, Anguillata intestinalis, and Rhab- donema intestinale. The parasite occurs abundantly in the stools of the endemic diarrhea of hot countries, and has been described by the French in the diarrhea of Cochin-China. It has been found in Manila by Strong. W. S. Thayer reported 3 cases from Osier's clinic. It has occurred in Italy. Blumgart^ reports their larvae in a case and refers to reports of 5 additional cases, and to the fact that Southern physicians refer to other cases, so that the disease is probably more widespread than is supposed. The worms are said to occupy all parts of the intestines, and have even been found in the biliary and pancreatic ducts. The female is from i to 2.20 mm. long and 0.04 to 0.03 mm. wide; the male is about a fifth smaller (Fig. 265). The mouth has three dis- tinct lips, continuous with a triangular esophagus, which after narrow- ing dilates again into a second ovoid enlargement, which is followed by intestines. The intestinal tract is bordered by fine granulations. Eggs are elliptic, with a thin, clear yellow shell, with granular contents about 0.00675 by 0.0375 mm. They hatch quickly, so are Fig. 265. — Strongyloides intestinalis and stercoralis: i, Larva (Anguillula intesti- nalis) ; 2, male Anguillula ster- coralis; 3, female Anguillula stercoralis (after Perroncito), 1 Medical Record, Ajiril 6, 1907, 7o8 DISEASES OF THE STOMACH AND INTESTINES rare in the stools. They occur chiefly in the duodenum and jejunum, but have been found in the stomach and other parts of the intestines. Symptoms. — They are usually more of chronic diarrhea than -of dysentery. There are at first mild dyspeptic symptoms, eructations, anorexia, and a diarrhea of moderate intensity, with soft and pasty stools, three or four a day, often in the early morning hours. The attacks are sometimes dysenteric, with mucus and blood; in other cases they are more choleraic, the dejecta consisting of liquid yellow material ; while vomiting, cyanosis, and collapse may occur. Emaciation and prostration may be present. Anemia is, as a rule, not very severe. Intercurrent dysentery is not uncommon, also headache, vertigo, tinnitus aurium, and prostration. Treatment. — Rest and liquid diet. Male fern, ethereal extract, 12 to 30 gm., divided in three doses during the morning and repeated daily, have been used by the Italians. Thymol has been quite successful. Large quantities of olive oil have seemed to give good results in some cases. Trichocephalus Dispar (Whip- worm). — This parasite is found in the cecum and large intestine of man. It measures from 4 to 5 cm. Fig. 266. — Trichocephalus dispar: o, Fe- male; b, male (natural size) (Heller). Fig. 267. — Egg of Trichocepha- lus dispar, moderately enlarged (Heller). long, the male being smaller than the female. It is readily recognized by the peculiar differences between the anterior and posterior por- tions. The anterior forms three-fifths of the body, is thin and hair- like; the tail end of the female is more conic and thicker, terminating in a blunt extremity; while that of the male is rolled like a spring (Fig. 266). The ovum is lemon shaped, dark brown, 0.05 mm. in length, and provided with button-like projections (Fig. 267). The number of worms is variable, as many as a thousand having been counted ; often only ten to twenty are found. In parts of Europe they are very common, but not so in the United States. Profound anemia with diarrhea have occurred from them. Many worms may be present without producing symptoms ; occasionally diarrhea and nervous symptoms occur. Diagnosis. — This can be made from the peculiar ova. Living worms are rare in the stool. INTESTINAI. PARASITES 709 Treatment. — Thymol, as previously described. Extract of male fern may be employed. High enemata of warm water, i quart (liter), containing 5 to 10 drops of benzin, may be of service. Trichina Spiralis (Trichiniasis). — The trichina in its adult condition lives in the small intestine. The embryos pass from the intestines and reach the voluntary muscles, where they become encapsulated larvae. Muscle Trichince. — Tiedemann, in 1822, described the ovoid cysts in human muscle. Owen named the parasite. Leidy, in 1845, described it in the p g. In i860 Zenker discovered in a girl both the intestinal and muscle forms, and established their connection with the specific symptoms. Incidence. — Man is infected by eating the raw or not completely cooked flesh of trichinous hogs, which contain encapsulated trichinae. The capsules are digested in the stomach and the trichinae set free. They pass into the small intestine, and about the third day become Fig. 268. -Trichina spiralis (greatly enlarged): a, Female; 6, male; c, embryo (after Heller). sexually mature. On the sixth or seventh day the embryos are fully developed. The young produced by each trichina (female) have been estimated at several hundred. The female worm penetrates the intes- tinal wall and the embryos are probably discharged directly into the lymph-spaces, and thence into the venous system, whence they reach the muscles; and in about two weeks they develop into the full- grown muscle form. A myositis is produced and they may become encapsulated. The trichinae may live therein for many years. Cal- cification may occur about them. One must remember that in the hog the capsule does not readily become calcified, so that the para- sites are not as readily visible as in man. Moreover, an apparently healthy looking animal may be suffering from trichiniasis. The intestinal tricliince are visible to the naked eye — white glistening worms 3 to 4 mm. long; and the male half this size, with two little projections from the hind end. The caudal extremity is thicker than the head (1-ig. 268). 7IO DISEASES OF THE STOMACH AND INTESTINES The muscle trichina is o.6 to i mm. long and coiled in the cap- sule. It has a pointed head and rounded tail (Fig. 269). Symptoms. — As a rule, a few days after eating the infected flesh gastro-intestinal disturbances occur, such as pain in the abdomen, anorexia, vomiting, and at times diarrhea. The attack may resemble cholera nostras or even typhoid fever. Invasion symptoms usually occur between the seventh and tenth days or, occasionally, not until the end of two weeks. There may be fever, intermittent or remit- tent, even to 102° to 104° F. Chills are not common. Pain occurs in the muscles on pressure and movement, also swell- ing of the muscles. There may be difficulty in chewing and swallow- ing. Dyspnea may be present from involvement of the intercostal muscles and diaphragm. Edema, especially about the eyes, is an important symptom. Sweating, itching, and urticaria occur. The general nutrition is disturbed and the patient becomes anemic and emaciated. In cases with severe infection, there may be dehrium, tremor, and dry tongue, suggestive of typhoid fever. Bronchitis, pleurisy, pneumonia, poly- uria, or albuminuria may occur. lyCukocytosis, especially marked eosin- ophilia, is diagnostic. Eosinophilia, edema of the eyelids, dyspnea, swelling, and tension of the muscles are at once suggestive. The presence of trichinae in the stools and muscles is conclusive. The muscle can be incised under cocain injection and the cyst examined. The disease has proved fatal in a number of cases. Prognosis. — This depends on the intensity of -the infection. Mild cases may recover in two weeks. The mortality has ranged as high as 30 per cent. Early diarrhea is favorable to evacuate infected pork. Prophylaxis.— Fork, such as ham, sausage, etc., should always be thoroughly cooked before eating. Proper inspection of hogs is important. Treatment.— ImmedieLte lavage, if infected pork is suspected and the case is seen early. Evacuation of the bowel by calomel, gr. x (0.6), or a saline cathartic. Thymol, santonin, male fern, kamala, and turpentine, have all been recommended as vermifuges in the early stage. Glycerin in large doses internally is said to be destructive of the worm. Later, the treatment is symptomatic and the strength is to be supported. Urotropin, in gr. x (0.6) doses four times a day, I believe of possible value during the early stages. It is preferable to combine it with equal doses of sodium benzoate. Fig. 269. — Fresh muscle tri- chinae (Mosler and Peiper) . INDEX Abdomen, anatomic landmarks of, 47 auscultation of, 55 blood-vessels of, 49 examination of, 47 inspection of, 49 mensuration of, 51 palpation of, 50 reinforced, 50 percussion of, 52 sources of error, 54 perforation into, in intestinal cancer, 564 protrusion of, intestinal disease and, 395 regions of, 48 topographic anatomy of, 48, 55 Abdominal arteriosclerosis, 455 belt, Kilmer's, 175-179 Rose's, 170-175 Rose water's, 175 cavity, sounds in, 55 muscles, functions of, 343, 344 pressure, increase of, in treatment of gastroptosis, 356 relaxation, 34. See also Gastrop- tosis. viscera, mechanical methods of sup- porting, 170 Abscess formation in appendicitis, 596, 603 symptoms, 597 in diverticulitis, 631, 632 of liver in amebic dysentery, 509 in bacillary dysentery, 524 of stomach, 188. See also Gastritis, phlegmonous. subphrenic, terminations of, 220 Absolute hepatic dulness, upper limit of, 59 Absorption in hyperchlorhydria, 283 Absorptive function of stomach, deter- mination, 121 Acetic acid in gastric contents, 103 Acholic feces, 414 Achroodextrin, test for, 106 Achylia gastrica, 203 absorption in, 207 carcinoma and, differentiation, 117 chronic gastritis and, differentia- tion, 195 conditions caused by, 207 course of, 207 diagnosis, 206, 207 diet in, 139, 208 etiology, 203, 204 gastralgia and, differentiation, 367 gastric analysis in, 206 cancer and, differentiation, 207, 259 ulcer and, 214 history, 203 intestinal irrigation in, 210 morbid anatomy, 204 motor function in, 207 prognosis of, 207 putrefaction in, treatment, 210 symptoms, 204 temporary, 203, 204 treatment, 208 Acid gastritis, 190, 194 hyperchlorhydria and, differentia- tion, 285 treatment, 195 salts, Topfer's test for, 99, 100 Acne rosacea, stomach functions in, 391 simplex, stomach functions in, 391 Acute febrile diseases, stomach func- tions in, 387 Adenocarcinoma of stomach, 242 Adenoma of intestines, 571 Adenomyoma of intestines, 560 Adhesion symptom, Gersuny's, of fecal tumor, 463 Adhesive belt, Rose's, 170-175 711 712 INDEX Adhesive strapping in intestinal dis- eases, 440 to support viscera, 170 Adler's test for blood in gastric con- tents and stool, 114 Adnexa, uterine. Head's zone for, 615 Aerophagy, 451 Agar-agar in constipation, 470 Air, inflation of intestines with, 406 of stomach with, 78 swallowing, 451 Akoria, 362 Albumin, absorption of, 39 in feces, 411, 412 in food, replacing of, 135 Albuminates, absorption of, 39 Albumoses, absorption of, 39 Alcohol as food, 136 Aldehyd, test for, 102 Alimentary glycosuria, 40 Alimentation, time required for, 423 Alkaline-saline waters in chronic gastri- tis, 199 Alkalis for removing mucus in chronic gastritis, 196 Allingham's operation for hemor- rhoids, 585 Allotriophagia, 362 Almond oil subcutaneously, 138 Aloes in constipation, 470 Aloin test for blood, Klunge's, 115 Amebae, 681 dysenterise, 503, 504 encysted, 505 isolation of, 503, 504 in gastric contents, 117 Amebic dysentery, 503. See also Dysentery, amebic. Amebiosis, intestinal, 503, 511. See also Dysentery, amebic. Ampulla of rectum, 32 Amylaceous dyspepsia, treatment, 445 Amyloid intestinal ulcers, 547 symptoms, 551 treatment, 553 Amylopsin, 37 test for, 1 1 3 Anacidity, diet in, 139 Anadenia ventriculi, 191, 203. See also Achylia gastrica. Anatomy of intestines, 22 of large intestine, 29 Anatomy of small intestine, 26 of stomach, 17 Anchylostoma duodenale, 701. See also Uncinariasis. Anemia, grave, in gastric cancer, per- nicious anemia and, differentia- tion, 255 in gastric ulcer, treatment, 230 in uncinarial dermatitis, 705 miners', 701. See also Uncinariasis. pernicious, auto-intoxication in, 448 grave anemia in gastric cancer and, differentiation, 255 stomach functions in, 389 treatment of constipation in, 471 Anesthesia of rectum, 669 Aneurysm of celiac axis, cancer of pylorus and, differentiation, 25S stomach functions in, 390 Angina abdominis, angina pectoris and, differentiation, 455 Angioma of intestines, 572 Anguillata intestinalis, 707 stercoralis, 707 Angustatio ventriculi, 340 Animal and vegetable foods, difference, 127 parasites, intestinal, 681 Ankylostoma duodenale, 701. See also Uncinariasis. Anorexia in gastric cancer, 245 nervosa, 362 transitory, 362 Antidotes for poisoning, 187 Antiperistalsis, intermittent, 41 physiologic, 41 Antiperistaltic restlessness of stomach, 371 Antiseptics in acute amebic dysentery, 517 Antrum cardiacum, 340 Anuria in intestinal obstruction, 635 Anus, 31 fissure of, 588 hygiene of, in hemorrhoids, 580 inspection of, 396 Apepsinia, T04 Aperient waters in constipation, 471 Appendices epiploicse of large intestine, 29 Appendicitis, 591 acute, 594, 595, 596 INDEX 713 Appendicitis, acute, abscess in, 603 adhesions in, 603 blood in, 605 count in, 605-607 Blumberg's sign in, 601 bowels in, 602 colic in, 598 treatment, 617 constipation in, 602 diarrhea in, 598, 602 diet in, 618 etiology, 593 fecal accumulation in, 617 fibrin increase in, 605 fulminating type, 603 gastro-intestinal symptoms, 602 hyperinosis in, 605 Illoway's test in, 601 intestinal symptoms in, 602 lavage in, 617, 618 leukocytosis in, 605 McBurney's point in, 599 Meltzer's method of palpation in, 601 Morris' point in, 599, 600 Munro's point in, 600 muscular rigidity in, 599 operation in, indications, 619 pain in, 598 treatment, 617 palpation of appendix in, 599 percussion in, 599, 601 polynuclear count in, 605, 606 prognosis, 616 pulse in, 602 rectal examination in, 602 remote effects, 607 stomach symptoms, 602 symptoms, 597, 602 temperature in, 602 tenderness in, 599 treatment, 616 medical, 616 operative, 619 tumefaction in, 603 tumor in, 602 tympanites in, treatment, 617, 618 types of, 594, 595, 596, 603, 607 vaginal examination in, 602 age and, 594 bacteria as cause, 593 Blumberg's sign in, 601 Appendicitis, catarrhal, acute, 594 simple, 595 symptoms, 597 symptoms, 597 chronic, 595, 596 diet in, 618 Edebohls' palpation in, 607, 608 etiology, 607 prognosis, 616 treatment, 616 clinical classification, 595 constipation as cause, 593 diagnosis, 60S diet in, 618 differential diagnosis, 608 diffuse, acute, 594 symptoms, 597 Edebohls' palpation in, 607, 608 endo-, 594, 595 symptoms, 597 etiology, 593 foreign bodies as cause, 594 gangrenous, 595, 596 symptoms, 597 Head's zones in diagnosis, 609 Illoway's test in, 601 McBurney's point in, 599 Meltzer's method of palpation in, 601 Morris' point in, 599, 600 Munro's point in, 600 non-suppurative, acute, 595 symptoms, 597 obliterative, 595 operation for, indications, 619 opium in, 618 pathologic classification, 594 perforative, 596 symptoms, 597 prognosis, 616 purulent, 595, 596 symptoms, 597 sex and, 594 suppurative, 595 acute, 596 symptoms, 597 treatment, 616 urine in, 602 varieties, 594 with abscess formation, 596 symptoms, 597 Appendicostomy in chronic amebic dysentery, 520 714 INDEX Appendicular colic, 598 treatment, 617 inflammation, 591. See also Ap- pendicitis. Appendix vermifojmis, 30 blood-supply of, 592 cancer of, primary, 568 diverticula of, 625 fibroid degeneration of, 597 harmful involutions of, auto- intoxication in, 608 s5miptoms, 608 Head's zones in affections of, 609, 614 inflammation of, 591. See also Appendicitis. palpation of, 599 . passing transversely to left iliac fossa, 633 peculiarities of, 592 position of, 591 Appetite, perversion of, 361 Areolar coat of stomach, 19 Armed tapeworm, 686 Arnold's test for lactic acid, 10 1 Arsenic in gastric cancer, 267 Arsenic-poisoning, intestinal obstruc- tion and, differentiation, 652 Arterial hemorrhoids, 575 Arteries, mesenteric, embolism of, 554. See also Emholisin. inferior, occlusion of, 557 superior, occlusion of, 555 thrombosis of, 554. See also Thrombosis. of cectun, 32 of colon, 32 of rectum, 32 of small intestine, 24 of stomach, 21 Arteriosclerosis, auto -intoxication in, 446 stomach functions in, 391 visceral, 455 Arthritis deformans, auto-intoxication in, 448 intestinal putrefaction and, 44S stomach functions in, 391 Artificial feeding in intestinal diseases, 444 Ascaris lumbricoides, 697 breath in, 698 Ascaris lumbricoides, diagnosis, 698 migration of, 698 symptoms, 698 treatment, 698 mystax, 699 Ascending colon, 31 palpation of, 398 Asiatic pills, 230 Aspirating bulb, 93 tube, 91 Aspiration of gastric contents, 91 Boas' bulb for, 92 . method, 92 bulb for, 92, 93 Ewald-Boas expression method, 93 Kemp's method, 94 Politzer bulb for, 92 position of patient and operator, 91 steps of, 93-95 tube for, 91 testing gastric secretion ^vithout, 108 Asthma, dyspeptic, 385 auto-intoxication in, 385 Atonia gastrica, 341. See also Garfro/)- tosis. Atonic constipation, 460 treatment, 469 Atonica gastrica, 71, 303, 304, 372 Atony complicating hyperchlorhydria, 284 of intestines, 458. See also Consti- pation. of stomach, 71, 303, 372 acute, 303 treatment, 304 chronic, 304, 305 auto-rntoxication in, 322, 323 constipation in, treatment, 306 electricity in, 306 medication in, 305 prognosis, 305 Rose's belt in, 305 symptoms, 304 treatment, 305 vibratory massage in, 305 definition, 321 etiology, 304 gastric analysis in, 305 physical examination, 304 spray douche in, 158 INDEX 715 Atony of stomach, third degree, 341. See also Gastroptosis. Atrophic gastritis, 191, 194, 203. See also Achylia gastrica. Atrophy of mucosa in chronic enteritis, 488 of stomach, 191, 194, 203. See also Achylia gastrica. Auerbach's plexus, 25 Auscultation, 52, 54 of abdomen, 55 of esophagus, 46 of intestines, 403, 404 of liver, 59 of stomach, 74 scratch method, 76 Auto-intoxication, acute ectasy of stomach from, 311 cyanotic, 450 hydrogen sulphid, 449 in acute dilatation of stomach, 308, 309 gastritis, 181 intestinal catarrh, 478, 482 in arteriosclerosis, 446 in arthritis deformans, 448 in atonic dilatation of stomach, chronic, 322, 323 in botulism, 449 in chronic enteritis, 490 gastritis, 193 obstruction through fecal accumu- lation, 661 in combined saccharobutyric and indolic putrefaction, 447 in constipation, 462, 464 in convulsions, 311, 338 in cutaneous eruptions, 391 in diarrhea, 473 in dyspeptic asthma, 385 in eczema, 391 in enterogenic cyanosis, 450 in epilepsy, 311, 322, 338 in eruptions of skin, 391 in fever, 323 in furunculosis, 391 in gastric tetany, 311, 336, 337 in gastroptosis, 345 in hepatic irritation, 446 in indicanuria, 445, 446 in intestinal dyspepsia, 444 in involution of appendix, 608 Auto-intoxication in melancholia, 323, 446 in migraine, 3 1 1 in mucous colic, 676, 679 in muscle fatigue, 448 in nephritis, transient, 446 in neurasthenia, 323, 446 in paresis, 323 in pernicious anemia, 448 in pruritus, 341 in pseudo-angina, 312 in putrefaction, 445, 446, 447 in strophulus infantum, 391 in syncope, 323 in tachycardia, 312 in temperature, 323 in transient heart block, 446 in urticaria, 391 Automassage in constipation, 467 Awl-tail worm, 699. See also Oxyuris vermicularis. Bacillary dysentery, 503, 520. See also Dysentery, bacillary. Bacilluria in typhoid fever, 533 treatment, 541 Bacillus aerogenes capsulatus, con- stipation and, 464 in feces, 420 intestinal putrefaction and, 447 bificus, 38 botulinus, poisoning from, 449 coli, 38 in feces, 420 odor of feces and, 39 dysenterise, 521 Flexner-Harris type, 521 groups of, 521 Hiss-Russell type, 521 isolation of, 522 Shiga type, 521 types of, 521 various strains of, 521 lactic acid, 38, 420 lactis aerogenes, 38 in feces, 420 typhosus, 528 conveyance of, 528, 529 distribution in body, 529 outside body, 529 vitality of, 529 Bacteria in feces, 419 7i6 INDEX Bacteria of intestine, 38 Bacterium coli commune, appendicitis and, 593 Bainbridge's modification of Beard's trypsin treatment of gastric cancer, 269 Balantidium coli, 682 diarrhea from, 684 Balloon man, 456 Barrel-shaped abdomen in acute ob- struction, 647 in chronic intestinal obstruction, 658, 660 Bassler's stomach electrode, 163 Baths, 170 in typhoid fever, 537 Bath-tub, Chambers' portable, 538 Bead test for intestinal motor func- tions, 420 Beard's treatment of gastric cancer, 268, 269 Beck's treatment of gastric cancer, 275 Bed, elevation of foot of, in gastropto- sis, 357 Beef tapeworm, 688 Beef -juice, 136 Beef -tea, 136 Belching, 375 Belts, supporting, 170-179 Benzidin blood test for gastric con- tents, 114 test paper, 1 14 Beverages, chemic composition of, 132 Bile, function of, 36 in empty stomach, 113 in gastric contents, 113 in vomit, 112 Bile-pigment, enteritis and, 484 in feces, 413, 416 sublimate test for, 425 Bilharzia hsematobia, 693 Bilharziasis, 693 treatment, 696 Biliary acids in feces, 413 calculi in feces, 416 colic, hyperchlorhydria and, differ- entiation, 285 Bismuth subnitrate internally for in- testinal examination, 405 treatment of chronic gastric erosions, 238 Bisulphate of quinin as fluorescent medium in gastrodiaphany, 85 Biuret reaction with pepton, 103 Black wash for oxyuris vermicularis, 701 Bladder in typhoid fever, 530 perforation into, in rectal cancer, 564 Blood, aloin test for, 115 benzidin test for, 114 fluke, 693 treatment, 696 in appendicitis, 605 in feces, 410, 413, 419 in intestinal cancer, 567 ulcer, 552 test for, 1 14 in gastric cancer, 247 contents, tests for, 113 in typhoid fever, 533 in uncinarial dermatitis, 705 in vomit, 112, 211 irritants transmitted in, diarrhea from, 474 treatment, 476 Klunge's aloin test for, 115 occult, 114 tests for, 114 of pig, heterologous, in gastric cancer, 274 tests for, 113— 115 vomiting of, 112, 211 Weber's modification of van Deen's test for, 115 Blood-vessels of abdomen, inspection of, 49 of intestines, diseases of, 554 of stomach, 19, 20 Blumberg's sign in appendicitis, 601 Boas' aspirating bulb, 92 method of aspirating gastric con- tents, 92 of diagnosing catarrh of large in- testine, 483 of eliciting splash in intestines, 400 nutritive rectal enema, 137 test breakfast, 90 for free hydrochloric acid, 97 for lactic acid, 102 meal for motor power, 122 Boas and Ewald's method of express- ing gastric contents, 93 test breakfast, 90 INDEX 717 Boas and Moerner's test for free hydro- chloric acid, 106 Boas-Oppler baciUi in gastric cancer, 254, 255 in gastric contents, 117, 119 Boldireff's oil test meal to secure tryp- sin, 420 Bone-marrow in typhoid fever, 530 in uncinarial dermatitis, 705 Bones in typhoid fever, 533 Borborygmi, 404 Bothriocephalus cordatus, 690 latus, 689 s)rmptoms, 686 Botulism, 449 auto-intoxication in, 449 Bougie, esophageal, divisible, 250 rectal, 401 Bouillon, 136 Brand treatment of typhoid fever, 537 Brandt's method of kidney massage, 357 Bread, 636 Breakfast dietary, 128 Brewer's point, 68 Broths, meat, 136 pastry, and solid food with milk diet, 133 Brunner's glands, 27 Bulb-compression method of spraying stomach, 157 Bulimia, 360 Bunches, 703 Burns, cutaneous, intestinal ulcers from, 546 symptoms, 551 treatment, 553 Butter, 136 meat, pastry, and soups with milk diet, 134 Buttermilk, 136 Cachexia, diverticula and, 627 in gastric cancer, 246 Calculi, biliary, in feces, 416 fecal, in feces, 416 intestinal, in feces, 416 pancreatic, in feces, 416 renal, gastralgia and, differentiation, 368 Calomel in acute enteritis, 484, 485 in constipation, 471 Calorie, 124 large, 124 small, 124 table, Chittenden's, 126 value of food, 1 24 calculating, 132 Cancer atrophicans, 243 fragments in feces, 410 of appendix, primary, 568 of body of stomach, 251 of cardia, 249 diagnosis, 249—251 dysphagia in, 249 esophageal examination in, 250 physical examination, 249 stricture of esophagus in, 250 of duodenum, 565 of gall-bladder, gastric cancer and, differentiation, 259 of ileum, 566 of intestines, 551, 559 age and, 559 blood in feces in, 567 carcinoma of liver from, 560 colic in, 566 constipation in, 566 course, 569 diagnosis, 569 diarrhea in, 563, 566 diet in, 570 differential diagnosis, 567 etiology, 559 exploratory laparotomy in, 569 feces in, 563, 567 from diverticulitis, 632 mimicry of, in diverticulitis, 630 mobility of tumor, 563 morbid anatomy, 560 operations for, 569 pain in, 566 perforation in, 564 into abdomen, 564 into bladder, 564 into stomach, 564 into uterus, 564 into vagina, 564 peritonitis from, 562, 564 physical signs, 563 prognosis, 569 pus in feces, 567 secondary changes, 561 sex and, 559 7i8 INDEX Cancer of intestines, situation of, 560 symptoms, 551, 562 due to position, 565 local, 566 treatment, 553, 569 trypsin treatment, 570 tumor in, 567 of jejuntun, 566 of liver from intestinal cancer, 560 of pylorus, 251 aneurysm of celiac axis and, differ- entiation, 258 partial gastrectomy for, 263 of rectum, 568 hemorrhoids and, 568 perforation into bladder in, 564 into vagina in, 564 treatment, 569 of stomach, 240 achylia gastrica and, differentia- tion, 117, 207, 259 age and, 240 anorexia in, 245 apparent tumors and, differentia- tion, 255 arsenic in, 267 atrophicans, 243 Beck's treatment, 275 blood in, 247 Boas-Oppler bacilli in, 254, 255 bowels in, 275 cachexia in, 246 cancer vaccine in, 274 carcinoma of gall-bladder and, differentiation, 259 chronic gastritis and, differentia- tion, 195 Coley's fluid in, 274 colloid, 242 coma in, 249 condurango in, 267 constipation in, 249 treatment, 275 cylindric-celled, 242 diagnosis, 251, 254 differential, 255 exploratory laparotomy in, 261 laboratory, 251 diarrhea in, treatment, 275 diet in, 138, 265 drugs for, 266 duration, 260 Cancer of stomach, ectasia in, treat- ment, 274 edema in, 249 emaciation in, 246 engrafted on ulcer, 257 enlarged lymph-glands and, differ- entiation, 260 erysipelas toxin in, 274 etiology, 240 eventration treatment of, 274 expiration fixation of tumor in, 248 fibrolysin in, 267 fibrous, 242 fluorescein in treatment, 265 frequency, 240 gastralgia and, differentiation, 367 gastrectomy for, partial, 263 gastric analysis in, 251 ulcer and, differentiation, 221, 222 gastritis and, differentiation, 259 gastro-enterostomy for, 264 gastrostomy for, 264 grave anemia in, pernicious anemia and, differentiation, 255 hematemesis in, 246 treatment, 274 heredity and, 240 heterologous blood of pig in, 274 hydrochloric acid in, 252 hyperchlorhydria in, 252, 253 inflation in, 248 inspection in, 247 lactic acid in, 253 laparotomy in, exploratory, 261 location, 244 loss of weight in, 246 medical treatment, 265 medullary, 242 mesenteric growths and, differen- tiation, 260 metastases in, 244, 249 methylene-blue in, 268 morbid anatomy, 242 multiple neuritis in, 249 nervous dyspepsia and, differentia- tion, 383 gastralgia and, differentiation, 259 pain in, 245 treatment, 274 palliative operation, 264 INDEX 719 Cancer of stomach, palpation in, 247 parasitic origin, 241 percussion in, 247 perforation in, 244, 249 peritoneal growths and, differen- tiation, 260 prognosis, 260 pus in, 254 race and, 240 radical operation in, 263 radium for, 265 resection in, 263 respiratory motility in, 248 Rontgen rays in diagnosis, 255 in treatment, 265 scirrhus, 242 sclerosis and, differentiation, 255 secondary changes in mucous membrane, 243 sex and, 240 shape of organ in, 244 sodium iodid in, 266 stenosis and, differentiation, 259 of cardia in, treatment, 275 stomachics in, 267 surgical treatment, 261 symptoms, 245 due to location, 249 syphilis and, differentiation, 255 syphilitic cirrhosis of liver and, differentiation, 256 stenosis of pylorus and, differ- entiation, 256 temperature in, 249 test breakfast in, 252 tetany in, 249 thiosinamin in, 267 thrombosis in, 249 thymus in treatment, 273 transillumination in, 248 treatment, 261 medical, 265 surgical, 261 trypsin, 253, 268, 269 Tremoliere's solution in," 274 trypsin treatment, 253, 268, 269 tumor in, 247 types of growth, 243 ulcer and, differentiation, 259 urine in, 249 varieties, 242 vomiting in, 246 Cancer of stomach, vomiting in, treat- ment, 274 vomitus in, 252 vaccine, 274 Cane-sugar, absorption of, 40 Canine hunger, 360 Cannon-ball massage in constipation, 467 with handle, 467 with screw cap, 467 Capillary hemorrhoids, 575 Caput coli, 29. vSee also Cecum. medusae, 49 Carbohydrates, absorption of, 40 digestibility of, 136 in feces, 412 fermentation test for, 425 liquid, with milk diet, 133 Carbolic acid injection for hemorrhoids, 584 Carbon dioxid, test for, no Carbonated bath, 170 Carbonic acid bath in mucous colic, 677 gas for tenesmus in amebic dysen- tery, 519 generator, Rose's, 406, 407 inflation of intestines with, 406 of stomach with, 77 Carcinoma. See Cancer. Carcinomatosum, 569 Cardia, cancer of, 249. See also Cancer of cardia. insufficiency of, 375 spasm of, 373. See also Spasm of cardia. stenosis of, in cancer, treatment, 275 Cardiac glands of stomach, 20 orifice of stomach, 17 Cardialgia, 365. See also Gastralgia. Cardioptosis, 353 Cardiospasmus, 373. See also Spasm of cardia. Carlsbad salts, Wolff's, 199, 290 Cascara sagrada in constipation, 469 Casein lest for pepsin, 104 Castor oil in constipation, 471 Catarrh, drunkard's, 190 intestinal, 478. See also Euteritis. of stomach, 180. See also Gastritis. Catarrhus atrophicans, 203. See also Achylia gastrica. intestinalis, 478. See also Enteritis. 720 INDEX Cauterization of hemorrhoids with fuming nitric acid, 585 Cecostomy, Gant's modification, 520 in chronic amebic dysentery, 520 Cecum, 29 arteries of, 32 inflammation of, 591 lymphatics of, 32 nerves of, 32 palpation of, 398 veins of, 32 Celiac axis, aneurysm of, cancer of pylorus and, difl'erentiation, 258 Cercomonas intestinalis, 681 Cereals, chemic composition of, 131 Cerebral disease, gastralgia from, 366 Cestodes, 685 description, 686 treatment, 690 Chambers' portable bath-tub, 538 Charcot-Iycyden crystals in feces, 418 Chemic composition of foods, 130 Chenopodium for ascaris lumbricoides, 699 Chewing the cud, 376 Chittenden's calorie table, 126 Chlorosis, Egyptian, 701. , See also Uncinariasis. stomach functions in, 389 Cholelithiasis, gastric ulcer and, differ- entiation, 221 Cholera nostras, 478. See also Enter- itis, acute. table, Lee's, 430 Cholesterin in feces, 416 Chronic febrile diseases, stomach func- tions in, 388 Chvostek's symptom in gastric tetany, 337 Chylangioma of intestines, 572 Chyme within stomach, determination, III Chymosinogen, 105 Circulatory organs in typhoid fever, 531 Circumpapillary cancer of duodenum, 565 Circumscribing gastrodiaphane, 83, 84 Cirrhosis of liver, gastric ulcer and, differentiation, 223 syphilitic, gastric cancer and, differentiation, 256 of stomach, syphilitic, 393 Cirrhosis ventriculi, 191, 192, 204 Clapotage, 400 Coccidia, 681 Cocoanut for tapeworm, 691 Coffee, 136 Cold, 168 diarrhea from, 475 Coley's fluid in gastric cancer, 274 Colic, 669 fecal, 463 intestinal, 453. See also Enteralgia. mucous, 672 abdominal support in, 677 age and, 672 auto-intoxication in, 676, 679 carbonic acid bath in, 677 catarrh in, treatment, 679 cramps in, treatment, 676 diet in, 676, 680 enteroclysis in, 676, 677 enteroptosis and, 674 etiology, 672, 674 exercise in, 680 fattening in, 677 history, 672 hydrotherapy in, 677 in newborn, 675 in young, 675 irrigation in, 676, 679 medication in, 676 mixed, treatment, 678 operation in, 680 other diseases and, 674 pathology, 673 prognosis, 676 pure, 674 removal of mucus, 679 researches, 674 secondary to colitis, 674 ^ sex and, 672 surgical treatment, 680 symptoms, 673 theories of, 672 tonics in, 679 treatment, 676 Colitis, acute catarrhal, diagnosis, 483 chronic, 487. See also Enteritis, chronic. in typhoid fever, treatment, 541 ulcerative, 550 symptoms, 551 treatment, 553 INDEX 721 Colloid carcinoma of stomach, 243 Colocynth in constipation, 471 Colon, arteries of, 32 ascending, 31 auscultatory percussion of, 402 cancer of, perforation into stomach in, 564 descending, 31 dilatation of, 456 congenital primary, 456 diseases of, Tiirck's gyromele in, 164 hypertrophy of, with congenital dilatation, 456 inflation of, with water, 408 location of, by Rontgen rays, 405 lymphatics of, 32 nerves of, 32 palpation of, 398 position of, inflation in determining, 407 transverse, 31 position of, 19 tuberculosis of, 549 ulcers of, 549, 550 upper, catarrh of, diagnosis, 483 veins of, 32 Colonic massage bags, 439 nebulizer, 439, 440 Colon-tube, 430 for high enema, 429 Color tests for free hydrochloric acid, 97 Columns of Morgagni, 33 Coma in gastric cancer, 249 Combined hydrochloric acid, Topfer's test for, 99 Compress, Priessnitz's, 168 Compression of intestines, 636 mechanism, 639 Concretions in feces, 415, 416 Condom as cooler in hemorrhoids, 581 Condurango in gastric cancer, 267 Condyloma in hemorrhoids, 578 Congo paper, preparation of, 107 tests for free hydrochloric acid, 106, 107 Connective-tissue fibers in feces, 410 Constipating foods, 443 Constipatio alvi, 458. See also Consti- pation. Constipation, 458 agar-agar in, 470 aloes in, 470 46 Constipation, aperient waters in, 47 1 appendicitis and, 593 atonic, 460 needle douche in, 439 treatment, 469 auto-intoxication in, 462 automassage in, 467 bacillus aerogenes capsulatus and, 464 calomel in, 471 cannon-ball massage in, 467 cascara sagrada in, 469 castor oil in, 471 classification, 458 colocynth in, 471 definition, 458 diagnosis, 464 diarrhea with, 474 treatment, 476 diet in, 465 diverticula and, 627 electric irrigation in, recurrent, 468 massage in, hot-and-cold, 467 electricity in, 468 enemata in, 468 enteroclysis in, 468 etiology, 458 fecal colic in, 463 treatment, 471 fever in, 464 tumors in, 463 treatment, 471 food laxatives in, 465, 466 from motor disturbances, 459 glycerin iniections in, 469 gymnastics in, 467 hemorrhoids and, 576 hydrotherapy in, 468 hygienic treatment, 465 in acute gastric ectasy, 314 treatment, 319 in anemics, treatment, 471 in appendicitis, 602 in atonic ectasy of stomach, treat- ment, 334 in auto-intoxication, 462, 464 in chronic enteritis, 490 diet in, 495 treatment, 496 gastric atony, treatment, 306 gastritis, treatment, 201 obstruction, 659 722 INDEX Constipation in gastric cancer, 249 treatment, 275 in gastroptosis, treatment, 358 in hemorrhoids, treatment, 579 in hyperchlorhydria, 291 in intestinal cancer, 566 in typhoid fever, 539 injections in, 468 jalap in, 471 laxatives in, 469 licorice powder in, 470 massage in, 466 medication in, 469 nervous symptoms, 463 olive oil in, 466, 470 orthopedics in, 469 physical treatment, 466 podophyllin in, 470 prescriptions for, 470 prognosis, 465 prophylaxis, 465 regulin in, 470 rhubarb in, 470 Rose's belt in, 469 spastic, 460 treatment, 469 symptoms, 461 nervous, 463 . syrup of figs in, 470 tamarinds in, 470 termination, 462 training of patient, 465 treatment, 465 vertigo in, 463 vibratory massage in, 467 Constitutional diseases, intestinal ulcers in, 550 symptoms, 551 treatment, 553 Convulsions, acute ectasy of stomach from, 311 auto-intoxication in, 311, 338 in ectasy of stomach, 338 Coproliths in feces, 416 Coprostasis in acute gastric ectasy, 314 Corsets for abdominal support, 179 in gastroptosis, 355 Costovertebral angle, tenderness at, 68 Counterirritation, 1 70 Covered hepatic dulness, 59 Crescentic fold of vermiform appendix, 31 Croton oil for tapeworm, 692 Cruveilhier's disease, 212. See also Ulcer of stomach. Crypts of Lieberkiihn in acute enteritis, 480 Crystals in feces, 418 Cul-de-sac of stomach, greater, 17 Curvatures of stomach, 18 Cusso for tape-worm, 691 Cutaneous burns, intestinal ulcers from, 546 symptoms, 551 treatment, 553 eruptions, auto-intoxication in, 391 Cyanosis during passing of stomach- tube, 144 enterogenic, 450 auto-intoxication in, 450 Cyclic vomiting in children, 378 Cylindric rectal bougie, 401 Cylindric-celled cancer of stomach, 242 Cynorexia, 360 Cysts in amebic dysentery, 509 of intestines, gas, 573 Dairy products, chemic composition of, 131 Davainea Madagascariensis, 689 Davidson's syringe to inflate intestines with air, 407 Dawbarn's method of lavage, 150 Debove's meat powder, 137, 209 Deglutible electrode, Einhorn's, 162 Deglutition sounds, 81 Dehio's method of determining posi- tion of stomach, 78, 89 Demulcents in toxic gastritis, 187 Denayer's peptone preparation, 133 Dermatitis, uncinarial, 703. See also Uncin arial dermatitis. Descending colon, 31 palpation of, 398 Desmoid test for gastric secretion, Sahh's, 108 Dextrin, test for, 106 Diabetes, stomach functions in, 390 Diaphragmatic hernia, 638, 639 Diarrhea, 472 acute, 478. See also Enfcritis, acute. auto-intoxication in, 473 cathartica, 473 treatment, 476 INDEX 723 Diarrhea, classification, 473 definition, 472 dyspeptica, 473 treatment, 476 entozoica, 474 treatment, 476 etiology, 472 from balantidium coli, 684 from cold, 475 from foods, 473 from gastric disturbances, 473 from intestinal parasites, 474, 476 from irritants transmitted in blood, 474 treatment, 476 from irritation of bowel contents, 473 from laxatives, treatment, 476 from parasites, 474, 476 from wet, 475 gastrica, 473 treatment, 476 in appendicitis, 598, 602 in cancer of intestines, 563, 566 in chronic enteritis, 490, 491 diet in, 495 obstruction, 659 in gastric cancer, treatment, 275 in intestinal ulcer, 552 in typhoid fever, 539 nervosa, 474, 667 treatment, 476 opiates in, 477 stercoralis, 474 treatment, 476 treatment, 475 vicarious, 475 with constipation, 474 treatment, 476 Diastase in feces, 415 Diazo-reaction in typhoid fever, 533 Diet, 124 in achylia gastrica, 139, 208 in acute amebic dysentery, 516 enteritis, 486 gastric ectasy, 318 gastritis, 138 in anacidity, 1 39 in appendicitis, 618 in atonic ectasy of stomach, 329 in bacillary dysentery, 527 in cancer of stomach, 138, 265 in chronic amebic dysentery, 519 Diet in chronic enteritis, 495 gastric atony, 305 erosions, 238 gastritis, 139, 197 intestinal obstruction, 663 in constipation, 465 in disease, 138 in ectasia, 139 in gastric ulcer, 226 in gastroptosis, 139, 356 in gastrosuccorrhea continua chron- ica, 300 periodica, 296 in health, 124 in hemorrhoids, 579 in hyperacidity, 139 in hyperchlorhydria, 286 in hypersecretion, 139 in intestinal cancer, 570 diseases, 442 indicanuria, 446 ulcers, 554 in motor disturbances, 139 in mucous colic, 676, 680 in nervous dyspepsia, 139, 383 in pyloric stenosis, 138 in simple acute gastritis, 184 in stenotic ectasy of stomach, 335 in stricture of stomach, 138 in subacidity, 139 in typhoid fever, 535 in ulcer of stomach, 138 Russell's, in gastroptosis, 356 scale, Leube's, 135 test, to determine intestinal func- tions, 421 to increase abdominal pressure in gastroptosis, 356 Dietaries, 128 breakfast, 128 dinner, 128 lunch, 1 28 milk, with carbohydrates in mushes and soups, 133 with liquid carbohydrates, 133 with pastry, butter, meat, and soups, 134 with solid foods, pastry, and broths, 133 non-irritating, 134 standard, 125 von Noorden's, 132-134 724 INDEX Dietl's crisis in gastroptosis, treatment, 358 in nephroptosis, 345, 352 Dieulafoy's iilcer of stomach, 235 Digestibility of food, 134 Leube's scale, 135 Penzoldt's scale, 135 Digestion, ferments of, 34 function of intestines in, 34 of stomach in, 34 gastric, 35 intestinal, 36 physiology of, 34 starch, 105. See also Starch diges- tion. Dilatation complicating hyperchlor- hydria, 284 of colon, 456 congenital primary, 456 of intestines in typhoid fever, pos- tural treatment, 539 of sphincters for hemorrhoids, 584 of stomach, 306. See also Ectasy of stotnach. Dilator, Roberts', 584 Dinner dietary, 128 Diphtheria toxin, gastric ulcer from, 213 Diphtheritic dysentery, 501, 503, 523 See also Dysentery, diphtheritic. gastritis, 181 Dipping, 51 Dipylidium caninum, 690 Dislocation of stomach, 341 Distoma hsmatobium, 693 hepaticum, 692 lanceolatum, 693 Distomiasis, 692 hemic, 693 treatment, 696 intestinal, 693 treatment, 696 Diverticula of appendix, 625 of intestines, 623 absence of fat and, 627 acquired, 623, 624 frequency, 625 age and, 627 anatomy, 626 aperture of, 626 cachexia and, 627 congenital, 623, 624 Diverticula of intestines, connective tissue around vessels and, 628 constipation and, 627 contents, 626 etiology, 626-629 false, 624 flatulence as cause, 627 foreign bodies in, 632 inflammation of, 627. See also Diverticulitis. Meckel's, 24, 624 strangulation by, 637 muscular deficiency of gut wall and, 629 obesity and, 627 occurrence, 625 perforation of, 631 pressure from within bowel and, 627 pulsion, 627 relation of, to points of entry of vessels through gut walls, 627 secondary pathologic processes in, 629 sex and, 627 sigmoid flexure and, 627 size, 626 of vessels and, 628 structure of intestinal wall and, 627 true, 623, 624 Diverticulitis, 620 abscess in, 631, 632 acute, 630 diagnosis, 634 symptoms, 632 treatment, 634 adhesive, 630, 631 as part of general peritonitis, 630 catarrhal acute, 630 chronic, 630 diagnosis, 634 symptoms, 632 treatment, 634 classification, 630 clinical aspects, 632 diagnosis, 634 Eisendrath's classification, 630 enterovesical fistulous, 630 etiology, 626-629 fistulse in, submucous, 631 vesicocolic, 633 IMDEX 725 Diverticulitis, foreign bodies and, 632 gangrenous, acute, 630 history, 620 hyperplastic, chronic, 630 intestinal obstruction in, 633 left-sided tumor in, 632 mesenteritis in, 632 metastatic suppuration in, 632 mimicry of carcinoma in, 630 pathology, 629 perforation in, 631, 632 of hernial sac, 632 perforative, acute, 630 peridiverticulitis and, distinction, 621, 623 peritonitis from, local chronic, 632 in, perforative, 631, 633 stenosing, chronic, 630 stenosis and obstruction in, 630 carcinoma and, differentiation, 631 submucous fistulse in, 631 symptoms, 632 Telling's classification, 630 treatment, 634 tumor formation in, 630, 632 types, 630 Divisible esophageal bougie, 250 Dochmius duodenalis, 701. See also Uncinariasis. Double-current irrigation of intestines, 432 lavage tubes, 153 needle douche for sigmoid, 439 rectal irrigators, 432 stomach douche, Gross', 156 Douche, fan, 170 needle, intestinal, 439 Scotch, 170 stomach, 155. See also Stomach douche. Douglas' pouch, 32 Dripping sounds of stomach, 81 Drop method of injecting saline solu- tion into rectum, 437. See also Proctoclysis. Drunkard's catarrh, 190 Dry heat, 169 Dulness, hepatic, 59 limits of, 59 splenic, 63 Dunham's thread test of gastric con- tents, 109 Duodenal bucket for obtaining in- testinal juice, 420 juice in fasting stomach, 113 ulcer, 543. See also Ulcer, duod- enal. Duodenitis, acute, 482 Duodenum, anatomic relations, 23 anatomy, 22 arterial supply of, 24 ascending portion, 23 cancer of, 565 descending part, 22 divisions of, 22 Head's zones for, 612 nerves of, 24 superior horizontal part, 22 transverse part of, 23 Dynamic ileus, 645 Dysentery, 501 amebic, 503 abscess of liver in, 509 acid mixtures in, 516 acute, 510, 512 antiseptics in, 517 diet in, 516 enemata in, 518 germicides in, 517 internal medication in, 516 irrigation in, 517 local treatment, 517 medication in, 515, 516 rectal injections in, 517 stools in, 512 treatment, 515, 516 internal, 516 local, 517 blood in, 513 chronic, 510, 513 appendicostomy in, 520 atrophic enteritis in, 508 cecostomy in, 520 Gant's modification, 520 diet in, 519 fluorescein in, 519 medication in, 519 Rontgen rays in, 519 treatment, 519 medical, 519 surgical, 520 circulatory system in, 513 classic ulcers in, 506 classification, 510 726 INDEX Dysentery, amebic, cyst formation in, 509 definition, 503 diagnosis, 514 geographic distribution, 503 Harris type, 505 healing process in, 507 hemorrhage in, treatment, 519, 520 history, 503 hypertrophy with mucoid degener- ation and cyst formation in, 509 in aged, 513 in children, 513 intestines in, 505 latent infection, 511 lesions in, location of, 505, 508 liver abscess in, 509 masked type, 511 microscopic pathology, 509 mild cases, 511 moderately severe cases, 512 mucoid degeneration in, 509 omentum in, 507 pains in,' 512, 514 pathology, 505 pre-ulceration stage, 505 prognosis, 515 prophylaxis, 515 Rogers' small red dots in, 505 severe cases, 512 source of infection, 503 subacute, 512 symptoms, 510 tenesmus in, 512, 514 carbonic acid gas for, 519 treatment, 515 types of, 505 ulceration in, 505 undermined ulcers in, 506 bacillary, 503, 520 abscess of liver in, 524 acute, treatment, 526 bacillus dysenteriae as cause, 521 chronic, treatment, 526 clinical types, 523 complications, 524 definition, 520 diet in, 527 enemata in, 526 etiology, 520 in infants, 523 Dysentery, bacillary, internal treat- ment, 524 irrigation in, 526 liver abscess in, 524 local treatment, 526 medication in, 524 morbid anatomy, 522 prognosis, 524 prophylaxis, 524 serum therapy in, 527 symptoms, 522 tenesmus in, treatment, 525 toxemia in, 522 treatment, 524 classification, 503 definition, 501 diphtheritic, 501, 503, 523 etiology, 501 geographic distribution, 502 historic note, 501 in war, 502 predisposing factors, 502 sanitation and, 502 Dyspepsia, amylaceous, treatment, 445 chronic, 189. See also Gastritis, chronic. fatty, treatment, 445 fermentative, diagnosis, 426 gastric, acute, 180. See also Gastri- tis, simple acute. intestinal, 444 auto-intoxication in, 444 chronic enteritis and, differentia- tion, 491 nervous, 381 course, 382 diagnosis, 382 diet in, 139, 383 differential diagnosis, 382 etiology, 381 gastric cancer and, differentiation, 383 juice in, 381 ulcer and, differentiation, 383 gastritis and, differentiation, 383 symptoms, 38 2 treatment, 383 pretubercular, 388 Dyspeptic asthma, 385 auto-intoxication in, 385 diarrhea, 473, 476 Dysphagia in cancer of cardia, 249 INDEX 727 ECHINOCOCCI, 690 Ectasia. See Ectasy. Ectasy, diet in, 139 gastrosuccorrhea continua chronica and, differentiation, 298 of stomach, acute, 306 age and, 310 anatomic types, 307 auto-intoxication in, 308, 309 cardiac symptoms with, 312 clinical types, 310 constipation in, 313, 314 treatment, 319 coprostasis in, 314 diagnosis, 71, 317 diet in, 318 duodenum in, 317 duration of attack, 316 etiology, 309 from auto-intoxication, 311 from convulsions, 311 in epilepsy, 310, 311 in infectious diseases, 312 in migraine, 310, 311 in pneumonia, 313 in tetany, 31 1 in typhoid fever, 312 lavage in, 318 mechanism of, 307 microscopic examination, 317 morbid anatomy, 316 nutritive enemata in, 318 of nervous origin, 311 onset, 315 operations for, 319 pain in, 315 percussion in, 316 peristalsis in, 316 physical signs, 315 postnarcotic vomiting in, 317 postural treatment, 319 prognosis, 316 prophylaxis, 318 pseudo-angina pectoris with, 312 pulse in, 309 rectal irrigation in, 318, 319 respiration in, 309 sex and, 310 splashing sounds in, 316 stenotic, 71 succussion sounds in, 316 Ectasy of stomach, acute, supervening on chronic ectasy, 314 surgical treatment, 319 symptoms, 309, 314 tachycardia with, 311, 312 tenderness in, 3 1 5 theories of, 307 treatment, 318 vomitus in, 315 atonic, 71, 321, 322 adhesive plaster belt in, 331, 332 chronic, auto-intoxication in, 322, 323 constipation in, treatment, 334 course, 324 diagnosis, 326 diet in, 329 differential diagnosis, 328 electricity in, 333 etiology, 322 fermentation in, treatment, 334 gastric analysis in, 324, 329 tetany in, treatment, 335 gastrosuccorrhea in, treatment, 334 hydrotherapy in, 331 in epilepsy, 322, 323 in insane, 323 in melancholies, 322 lavage in, 332 local treatment, 332 massage in, 333 mechanical support, 331 medication in, 333 nervous conditions and, 323 operations in, 335 Rose's adhesive plaster belt in, 331, 332 stomach douche in, ^t,t, spray in, 333 surgical treatment, 335 symptoms, 323 tetany in, 336 thirst in, 331 treatment, 329 local, 332 surgical, 335 chronic, 320 acute ectasy supervening on, 314 auscultatory percussion in, 327 complications, 336 728 INDEX Ectasy of stomach, chronic, convul- sions in, 338 definition, 320 diagnosis, 71, 326 differential diagnosis, 321, 328 epilepsy in, 338 Ewald's test breakfast in, 327 gastrodiaphany in, 327 gastroptosis and, differentia- tion, 320, 326 inflation in, 327 inspection in, 327 kidney in, diagnosis, 326 Leube's test meal in, 328 motor functions in, 327 palpation in, 327 percussion in, 327 Rontgen rays in, 327 scratch method in, 327 test breakfast in, 327 meal in, 327, 328 tetany in, 336. See also Tetany in ectasy of stomach. transillumination in, 327 treatment, 329 definition, 321 diagnosis, 71, 316, 317 in gastric cancer, treatment, 274 in typhoid fever, postural treat- ment, 539 obstructive, 322, 325. See also Ectasy of stomach, stenotic. stenotic, 71, 322, 325 benign, 326 diagnosis, 326 diet in, 335 differential diagnosis, 328 etiology, 325 gastric analysis in, 326, 329 gastrosuccorrhea in, treatment, 336 lavage in, 335 malignant, 326 treatment, 336 operations for, 336 pathology, 325 special type, 326 surgical treatment, 336 symptoms, 325 tetany in, treatment, 336 thirst in, treatment, 336 treatment, 335 Ectasy of stomach, stenotic, treatment, surgical, 336 vomiting in, 335 Eczema, auto-intoxication in, 391 stomach functions in, 391 Edebohls' palpation in appendicitis, 607, 608 Edema in gastric cancer, 249 Edinger and Spallanzani's test of un- aspirated gastric contents, 108 Egg-albumen diet in gastric ulcer, 229 Egyptian chlorosis, 701. See also Uncinariasis. Ehrlich's diazo-reaction in typhoid fever, 533 Einhorn's bead test for intestinal motor functions, 420 benzidin test paper, 1 14 deglutible electrode, 162 divisible esophageal bougie, 250 duodenal bucket for obtaining in- testinal juice, 420 esophagoscope, 82 gastric spray, 158, 159 gastrodiaphane, 83 gastrograph for testing motor power, 123 instrument for spraying stomach with powders, 159, 160 meat powder, 209 methods of localizing gastric ulcers, 223 radiodiaphane, 88 radium receptacle for treatment of gastric cancer, 266 stomach bucket, 109 douche instrument, 156 stool sieve, 415 technic of intestinal transillumina- tion, 404 test for intestinal juice, 113 treatment of gastric ulcer, 228 Eisendrath's classification of diver- ticulitis, 630 Elastic belts, silk, 179 Electric irrigation in constipation, Kemp's, 468 roller massage, hot-and-cold, in constipation, 467 Electricity in atonic ectasy of stomach, 333 in chronic gastric atony, 306 INDEX 729 Electricity in chronic gastritis, 197 in constipation, 468 in gastroptosis, 357 in hyperchlorhydria, 291 in intestinal diseases, 440 in stomach diseases, 161 indications, 164 intragastric method, 161 percutaneous method, 161 intrarectal, 441 static, 164 Electrodes, Bassler's, 163 deglutible, Einhorn's, 162 Lockwood's, i6t, 162 Electro-enteroclysis, electric attach- ment for, 431 Elsberg's division of Head's zones, 611 Elsberg and Neuhof's method of diag- nosis by Head's zones, 610 Emaciation in gastric cancer, 246 Enabolic intestinal ulcers, 547 symptoms, 551 treatment, 553 Embolism of inferior mesenteric artery, 557 of mesenteric arteries, 554 clinical symptoms, 556 diagnosis, 557 etiology, 555 prognosis, 557 treatment, 558 veins, 554 treatment, 558 of superior mesenteric artery, 555 Ems' salt for balantidia, 685 Endo-appendicitis, 594, 595 symptoms, 597 Enemata, 428, 429 high, with colon-tube, 429 in acute amebic dysentery, 518 in bacillary dysentery, 526 in constipation, 468 nutritive, in acute gastric ectasy, 318 in gastric ulcer, 227, 228 rectal, 137 saline, 137 uses, 428 value of, 436 Enteralgia, 453 clinical value, 454 diagnosis, 454 etiology, 453 Enteralgia, gastralgia and, differentia- tion, 368 in cancer, 566 nervous, 670 prognosis, 454 symptoms, 454 treatment, 454 Enteritis, 478 acute, 478 age and, 478 auto-intoxication in, 478, 482 bile-pigment and, 484 calomel in, 484, 485 diagnosis of, to localize lesion, 482, 483 diet in, 486 duration, 484 enteroclysis in, 485, 486 etiology, 478 feces in, 480, 481 examination of, to localize le- sion, 483 fever in, 482 hydrotherapy in, 486 idiopathic, 478 irrigations in, 486 laxatives in, 484 localization, 482 medication in, 484, 485 microscopic anatomy, 480 morbid anatomy, 479 opiates in, 485, 486 physical signs, 481 localization, 482 prescriptions in, 485 primary, 478 prognosis, 484 prophylaxis, 484 secondary, 479 symptoms, 480 subjective, 481 treatment, 484 urine, 482 chronic, 487 atrophic, in amebic dysentery, 508 atrophy of mucosa in, 48S auto-intoxication in, 490 bowel movements in, 490, 491 catarrhal, 490 chronic catarrhal colitis in, 490 constipation in, 490 diet in, 495 730 INDEX Enteritis, chronic, constipation in, treatment, 496 course, 493 diarrhea in, 490, 491 diet in, 495 differential diagnosis, 493 enemata in, 497 etiology, 487 feces in, 489 hydrotherapy in, 494, 496 hygienic treatment, 494 ^ hypertrophy in, 488 idiopathic, 487 intestinal dyspepsia and, differ- entiation, 491 local treatment, 497 massage in, 495 medication in, 496 morbid anatomy, 487 mucus in feces in, 487, 490, 491 nervous factor in, 49 1 peristalsis in, 490, 491 physical signs, 490 primary, 487 prognosis, 494 rectal examination in, 487, 493 sago grains in, 489 secondary, 487 surgical treatment, 498 symptoms, 489 treatment, 494 ulceration in, 489 urinary findings in, 495 follicularis seu nodularis, 480 membranacea, 491 membranous, 672. See also Colic, tnucous. mucus in feces as sign, 410, 411 of large intestine, diagnosis, 483 of small intestine, diagnosis, 483, 484 of upper colon, diagnosis, 483 phlegmonous, 500 purulent, 500 Enteroclysis, 429 * double-current, 432 in acute enteritis, 486 in ascaris lumbricoides, 699 in constipation, 468 in mucous colic, 676, 677 position for, 432-435 value of, 436 •without bed-pan, 434 Enterocolitis, chronic, 487. See also Enteritis, chronic. Enterofaradization, 163, 164 Enterogastroptosis, 348, 349 Enterogenic cyanosis, 450 auto-intoxication in, 450 Enterokinase, 38 Enteroliths, differential diagnosis, 651 in feces, 416 occlusion from, 645 treatment, 655 Enteroptosis, 341, 349, 456 mucous colic and, 674 Epilepsy, acute ectasy of stomach in, 310, 311 atonic ectasy of stomach in, 322, 323 auto-intoxication, 311, 322, 338 in ectasy of stomach, 338 Epithelial cells in gastric contents, 119 Epithelioma of stomach, 242 Epithelium in feces, 419 Erb's sign in gastric tetany, 337 Erepsin, 38 Erosions of stomach, 236 acute, 236 chronic, 237 bismuth treatment, 238 diet in, 238 emaciation in, 238 etiology, 237 gastric analysis in, 238 nitrate of silver treatment, 238 pains in, 238 prognosis, 238 suprarenal extract in, 239 symptoms, 237 treatment, 238 weakness in, 238 hemorrhagic, 236 Eructatio nervosa, 375 Eructation, 375 Eruptions, cutaneous, auto-intoxica- tion in, 391 from foods, 364, 391 Erysipelas toxin in gastric cancer, 274 Erythema from foods, 364 stomach functions in, 391 Erythrodextrin, test for, 106 Esculin as fluorescent medium in gas- trodiaphany, 85 Esophageal bougie, divisible, 250 orifice of stomach, 17 INDEX 731 Esophagoscope, 46 Einhorn's, 82 Esophagoscopy, 82 Esophagus, auscultation of, 46 examination of, 46 in cancer of cardia, 250 instrumental, 46 obstruction of, 47 palpation of, 46 stricture of, 47 in cancer of cardia, 250 Etat mamelonne in chronic catarrhal gastritis, 191 Eventration treatment of gastric can- cer, 275 Ewald's aspirating tube, 91 nutritive rectal enema, 137 test meal, 90 Ewald and Boas' method of expressing gastric contents, 93 test breakfast, 90 and Siever's test for motor power, 122 Ewald-Rosenheim stomach douche- tube, 156 Examination, physical, general meth- ods, 45 Examining rectal speculum, 398 Exercise in intestinal diseases, 439 Expiration fixation of tumor in gastric cancer, 248 Exposed hepatic dulness, upper limit of, 59 Expression of gastric contents, Ewald- Boas method, 93 Kemp's method, 94 Exulceratio simplex, 235 Faber and Penzoldt's test of absorp- tive function of stomach, 121 False diverticula, 624 Fan douche, 170 Faradism to intestines, 163, 164 to stomach, 163, 164 Fasting stomach, bile in, 113 contents of, 112 duodenal juice in, 113 intestinal juice in, 113 pancreatic juice in, 113 Fat, absorption of, 40 in feces, 412, 417 milk, Gartner's, 136 Fat, subcutaneous injection of, 137 Fatty acids in gastric contents, 102 dyspepsia, treatment, 445 Febrile diseases, acute, stomach func- tions in, 387 chronic, stomach functions in, 388 Fecal colic, 463 treatment, 471 fever, 464 tumors, 463 treatment, 471 Feces, accumulation of, in appendici- tis, 617 obstruction by, 661 auto-intoxication in, 661 differential diagnosis, 651 treatment, 653 acholic, 414 administration of special substance to mark, 421 albumin in, 411, 412 bacillus aerogenes capsulatus in, 420 coli in, 420 lactis aerogenes in, 420 bacteria in, 419 bacteriologic examination of, from test diet, 424 bile-pigment in, 413, 416 sublimate test for, 425 biliary acids in, 413 calculi in, 416 blood in, 410, 413, 419 test for, 1 14 in intestinal cancer, 567 ulcers, 552 calculi in, 416 cancer fragments in, 410 carbohydrates in, 412 fermentation test for, 425 Charcot-Leyden crystals in, 418 chemic examination of, 411 from test diet, 425 cholesterin in, 416 collection of, 422 colorless, 414 concretions in, 415, 416 connective-tissue fibers, 410 coproliths in, 416 crystals in, 418 diastase in, 415 enteroliths in, 416 epithelium in, 419 732 INDEX Feces, examination of, 409 bacteriologic, from test diet, 424 chemic, 411 from test diet, 425 from test diet, 423-428 results, 427 macroscopic, 409 after test diet, 423 microscopic, 409, 416 after test diet, 424 to localize enteritis, 483 fat in, 412, 417 fatty, 414 fermentation test for, 425 ferments in, 415 food remnants in, 409 foreign bodies in, 415, 416 frogs' spawn bodies in, 410 gall-stones in, 416 general view of, 417 in acute amebic dysentery, 512 enteritis, 480, 481 in chronic enteritis, 489 in intestinal cancer, 563, 567 ulcer, 552. indol in, tests for, 426 macroscopic examination of, 409 after test diet, 423 marking of, by administration of special substance, 421 meat -fibers in, 418 micro-organisms in, 419 microscopic examination of, 416 after test diet, 424 mucin in, 410 test for, 411 mucus in, 410, 419 in chronic enteritis, 487, 490, 491 in intestinal ulcer, 553 odor of, 409 colon bacilli and, 39 pancreatic calculi in, 416 parasites in, 411 peptone in, 412 polypi fragments in, 410 propeptone in, 412 proteid in fermentation test for, 425 pus in, 410, 419 in intestinal cancer, 567 ulcer, 552 putrefactive products in, tests for, 426 Feces, quantity of, 39, 409 reaction of, 39, 411 from test diet, 425 red blood corpuscles in, 419 sago grains in, 410 sand in, 416 sieve for, Einhorn's, 415 skatol in, tests for, 426 starch in, 410 examination for, 412 sugar in, 412 test-diet, bacteriologic examination, 424 characteristics of, 423 chemic examination of, 425 examination of, results, 427 macroscopic examination, 423 microscopic examination, 424 reaction of, 425 tissue shreds in, in intestinal ulcers, 553 transportation of, 422 trypsin in, 415 tubercle bacilli in, in intestinal tuber- culosis, 553 tumor fragments in, 410, 419 urobilin in, 413 vomiting of, in intussusception, 644 worms in, 415 Feeding to spare stomach, 136 Fermentation, gastric development of, 118 in stomach, gas, no test for feces, 425 tube, Strasburger's, 426 Ferments in feces, 415 milk-curdling, cells secreting, 20 of digestion, 34 of gastric juice, 35 of intestine, organized, 38 of saliva, 34 Fever, auto-intoxication in, 323 Fibrin increase in appendicitis, 605 Fibrolysin in gastric cancer, 267 Fibroma of intestines, 572 of stomach, 275 Fibrous carcinoma of stomach, 242 Fibromyoma of intestines, 572 Figs, syrup of, in constipation, 470 Filicic acid for tapeworms, 691 Filmaron for tapeworms, 691 Finger-breadth, 48 INDEX 733 Fish, chemic composition of, 130 Fissure of anus, 588 Fistulae in diverticulitis, vesicocolic, 633 submucous, in diverticulitis, 631 Flatulence, diverticula and, 627 Flatus in proctoclysis, 43S Fleischer's test for urobilin in feces, 414 Flicking percussion, 52, 53 Floating kidney. See Nephroptosis. liver, 352 spleen, 64 Flexner-Harris type of bacillus dysen- terise, 521 Fluke worms, 692 blood, 693 liver, 692 Fluorescein and resorcin as medium in gastrodiaphany, 85 in chronic amebic dysentery, 519 in treatment of gastric cancer, 265 Fluorescent media in gastrodiaphany, 85 Food, albumin in, replacing of, 135 animal, 127 and vegetable, difference, 127 caloric value of, 126, 127, 128 calculating, 124, 132 chemic composition of, 130 constipating, 443 digestibility of, 134 Leube's scale, 135 Penzoldt's scale, 135 gelatinous, 136 in hot weather, 1 30 laxative, 442 remnants in feces, 409 requirement, 124, 125 solid, pastry, and broths with milk diet, 133 vegetable, 127 Foreign bodies, diverticulitis and, 632 in feces, 415, 416 in stomach, 277 Rontgen rays for detecting, 87 Fore-stomach, 340 Free hydrochloric acid, 96. See also Hydrochloric acid, free. Friedlieb's lavage apparatus, 146, 148 modified, 149 Frogs' spawn bodies in feces, 410 Fruits, chemic composition of, 132 food value of, 1 29 Fuld's test for pepsin, 104 Fuming nitric acid for cauterizing hem- orrhoids, 585 Functional diseases of stomach, 279 Functions of stomach, examination of, 90 Fundus glands, 17, 20 Fungi in gastric contents, 120 Funnel for lavage, 140, 144 method of lavage, 140 Furunculosis, auto-intoxication in, 391 GaIvActose, absorption of, 40 Gallant corset, 354, 355 supporting, 179 Gall-bladder adhesions, spider, gastric ulcer and, differentiation, 223 anatomic relations of, 57 cancer of, gastric cancer and, differ- entiation, 259 distended, differentiation from mov- able right kidney, 70 Head's zone for, 613 in typhoid fever, 530 inspection of, 57 palpation of, 58 percussion of, 59 physical examination of, 57 Gall-stones, gastralgia and, differentia- tion, 368 in feces, 416 intestinal obstruction Isy, 644 differential diagnosis, 650 treatment, 655 Galvanization in gastrosuccorrhea con- ,tinua chronica, 302 to stomach, 163, 164 Game, chemic composition of, 130 Gant's examining rectal speculum, 398 hinged rectal speculum, 399 modified cecostomy in amebic dysen- tery, 520 water infiltration method for hemor- rhoids, 586 Gartner's fat milk, 136 Gas cysts of intestines, 573 fermentation in stomach, no significance, 110, in in intestines, abnormal, 45 1 . See also Tympanites. Gastralgia, 365 734 INDEX Gastralgia, achylia gastrica and, differ- entiation, 367 as neurosis, 366 chronic gastritis and, differentiation, 367 differential diagnosis, 367 duration, 367 enteralgia and, differentiation, 368 etiology, 366 forms of, 366 from cerebral disease, 366 from foods, 366 from myelitis, 366 from spinal disease, 366 from tabes, 366 gall-stones and, differentiation, 368 gastric cancer and, differentiation, 367 hyperchlorhydria and, differentia- tion, 367 hypersecretion and, differentiation, 367 intercostal neuralgia and, differen- tiation, 368 intestinal colic and, differentiation, 368 myalgia and, differentiation, 368 nervous, gastric cancer and, differ- entiation, 259 ulcer and, differentiation, 221, 222 hyperchlorhydria and, differentia- tion, 285 originating in stomach, 366 perigastritis and, differentiation, 368 prognosis, 367 pyloric stenosis and, differentiation, 367 reflex causes, 366 renal calculi and, differentiation, 368 rheumatism and, differentiation, 368 sex in, 366 symptoms, 366 treatment, 368 ulcer of stomach and, differentiation, 367 Gastralgokenosis, 369 Gastrectasy, 320. See also Ecfasy of stomach, chronic. Gastrectomy, partial, for pyloric cancer, 263 Gastric catarrh. See Gastritis. Gastric contents, abnormal constitu- ents, 113 acetic acid in, 103 achroodextrin in, 106 acid salts in, 99, 100 amebae in, 117 amylopsin in, 113 aspiration of, 91. See also Aspi- ration of gastric contents. bile in, 113 blood in, 113. See also Blood. Boas-Oppler bacillus in, 117, 119 carbon dioxid in, no chymosinogen in, 105 dextrin in, 106 Dunham's thread test, 109 Edinger and Spallanzani's test, without aspiration, 108 Einhorn's stomach -bucket test, 109 epithelial cells in, 119 erythrodextrin in, 106 examination of, 95 chemic, 95 macroscopic, 96 microscopic, 116, 117 tests, 96 expression of, 93 fasting, 112 fatty acids in, 102 fermentation in, no fungi in, 120 gases in, no gastric mucosa in, 119 Gunzburg's test of, without aspi- ration, 108 hydrochloric acid in, 96. See also Hydrochloric acid. in achylia gastrica, 206 in atonic ectasy, 324, 329 in chronic gastric atony, 305 erosions, 238 gastritis, 193 intestinal obstruction, 659 in duodenal ulcer, 545 in gastric cancer, 251 in gastroptosis, 348 in gastrosuccorrhea continua chronica, 298 periodica, 294 in hyperchlorhydria, 282 in stenotic ectasy, 326, 329 INDEX 735 Gastric contents in ulcer of stomach, 218 infusoria in, 117 intestinal juice in, 113 lactic acid in, 100. See also Lactic acid. maltose in, 106 megastoma entericum in, 117 micro-organisms in, 118 mould in, 118, 120 mucus in, 113, 116 o'idium albicans in, 1 20 penicillium glaucum in, 120 pepsin in, 103. See also Pepsin. peptone in, 103 propeptone in, 103 pus in, 115 quantity of, 95 motor function and, 95 reaction, 97 rennet in, 105. See also Rennet. saccharin in, 106 Sahli's desmoid test for, 108 sarcinae in, 117, 119 Spallanzani and Edinger's test, without aspiration, 108 starch digestion and, 106. See also Starch digestion. granules in, 118 steapsin in, 113 . succinic acid in, 121 sugar in, 106 thread test, Dunham's, 109 total acidity, Topfer's method for, 99 trichomonas hominis in, 117 trypsin in, 113 tumor particles in, 119 volatile acids in, 102 yeast-cells in, 118, 119 dyspepsia, acute, 180. See also Gastritis, simple acute. fermentation, development, 118 juice, 35 continuous secretion of, 291. See also Gastrosuccorrhea. hydrochloric acid in, 35, 96. See also Hydrochloric acid. in nervous dyspepsia, 381 normal, 96 pepsin in, 35 testing of, 95, 108, 116. See also Gastric contents. Gastric mucosa in gastric contents, 119 stamper method of localizing ulcer, 223 Gastritis, acid, 190, 194 hyperchlorhydria and, differentia- tion, 285 treatment, 195 acute, 180 auto-intoxication in, 181 diet in, 138 atrophic, 191, 194, 203. See also Achylia gastrica. catarrhal, chronic, 190, 191 chronic, 189 absorption in, 194 achylia gastrica and, differentia- tion, 195 alkaline-saline waters in, 199 auto-intoxication in, 193 belching in, treatment, 201 cancer and, differentiation, 195, 259 Carlsbad salts in, 199 catarrhal, 190, 191 classification, 190 constipation in, treatment, 201 course, 194 diagnosis, 193 differential, 194 diet in, 139, 197 electricity in, 197 etiology, 189 gas in, treatment, 201 gastralgia and, differentiation, 367 gastric contents in, 193 hydrotherapy in, 197 hygienic treatment, 196 inspection in, 193 intestinal fermentation in, treat- ment, 201 lavage in, ig6 massage in, 197 medication in, 200 microscopic examination in, 194 mineral waters in, 199 morbid anatomy, 191 motor function in, 194 nausea in, treatment, 201 nervous dyspepsia and, differen- tiation, 383 symptoms, treatment, 201 736 INDEX Gastritis, chronic, neuroses and, dif- ferentiation, 195 palpation in, 193 percussion in, 193 physical examination, 193 prognosis, 195 prophylaxis, 195 removal of mucus in, 196 saline waters in, 199 smoking in, 199 splashing sound in, 193 stomachics in, 200 symptoms, 192 test-breakfast in, 193 treatment, 195 dietetic, 197 electric, 197 hydro therapeutic, 197 hygienic, 196 local, 196 medical, 200 of belching, 201 of constipation, 201 of gas, 201 of intestinal fermentation, 201 of nausea, 201 of vomiting, 201 ulcer and, differentiation, 194 urine in, 193 vibratory massage in, 197 vomiting in, treatment, 201 diphtheric, 181 hyperpeptica, 190 hypersthenic, 190 membranous, 181 mucous, 194 phlegmonosa, 188 phlegmonous, 188 blood examination in, 189 circumscribed type, 188, 189 diagnosis, 189 diffuse type, 188 duration, 189 morbid anatomy, 188 symptoms, 188 treatment, 189 polyposa, 190 simple acute, 180 diagnosis, 182 diet in, 184 duration, 182 etiology, 180 Gastritis, simple acute, heat in, treat- ment, 183 microscopic anatomy, 181 morbid anatomy, 181 nausea in, treatment, 183, 184 physical examination, 182 predisposition, 180 prognosis, 182 prophylaxis, 182 symptoms, 181 treatment, 182 of mild cases, 183 of severe cases, 184 urine in, 182 vomiting in, treatment, 183, 184 toxic, 185 after-treatment, 188 anatomy, 185 antidotes, 187 demulcents, 187 diagnosis, 186 etiology, 185 prognosis, 186 symptoms, 185 treatment, 186 Gastrodiaphane, 83 circumscribing, 83, 84 Einhorn's, 83 Gastrodiaphany, 83 conclusions regarding, 89 fluorescent media in, 85 radium, 188 technic, 86 Gastrodynia, 365. See also Gastral- gia. Gastro-enteroptosis, 348, 349 Gastro-enterostomy for gastric cancer, 264 Gastrofaradization, 163, 164 Gastrogalvanization, 163, 164 Gastrograph for testing motor power, 123 Gastroptosia, 341. See also Gastrop- tosis. Gastroptosis, 71, 341 abdominal support in, 354 age and, 346 anatomic considerations, 342 auto-intoxication in, 345 chronic ectasy and, differentiation, 320, 326 complicating hyperchlorhydria, 284 INDEX 737 Gastroptosis, complications, treatment, 358 constipation in, treatment, 358 corsets in, 355 crescentic, 349, 350 definition, 341 degrees of, 348 diagnosis, 71, 73, 353 kidney in, 342 diet in, 139 to increase abdominal pressure, 356 Dietl's crisis in, treatment, 358 electricity in, 357 elevation of foot of bed in, 357 etiology, 345 exercise in, 356 gastric analysis in, 348 gastrodiaphany in, 348 Glenard's belt test in, 353 gymnastics in, 356 hydrotherapy in, 358 increase of abdominal pressure in, treatment, 356 inflation in, 348 inspection in, 347 massage in, 356 medication in, 357 motor functions in, 348 nephropexy in, 346 operations for, 358 palpation in, 347 percussion in, 348 physical examination, 347 prognosis, 353 prophylaxis, 353 Russell's diet treatment, 356 scratch pitch in, 77 sex and, 346 splashing sounds in, 347 surgical treatment, 358 symptoms, 346 treatment, 353, 354 surgical, 358 Gastroscopy, 83 Gastrospasmus, 365. See also Gas- tralgia. Gastrostomy for cancer, 264 Gastrosuccorrhea, 291 continua chronica, 296 alkali treatment, 301 diagnosis, 296, 298 47 Gastrosuccorrhea continua chronica, diet in, 300 differential diagnosis, 298 ectasy and, differentiation, 298 etiology, 297 frequency, 297 galvanization in, 302 gastric analysis in, 298 ulcer and, differentiation, 298 lavage in, 301 medication in, 300 pain in, treatment, 300 prognosis, 299 prophylaxis, 299 stomach spray in, 301 symptoms, 297 tetany and, differentiation, 299 treatment, 299 periodica, 292 diagnosis, 294 diet in, 296 etiology, 293 gastric contents in, 294 history, 292 hydrotherapy in, 295 lavage in, 295 nausea in, treatment, 295 pain in, treatment, 295 prognosis, 294 prophylaxis, 294 symptoms, 293 thirst in, treatment, 295 treatment, 294 vomiting in, treatment, 295 vomitus in, 293 diagnosis, 291, 292 diet in, 139 examination of fasting stomach in, 112 gastralgia and, differentiation, 367 hyperchlorhydria and, diflferentia- tion, 285 in atonic atony, treatment, 334 in stenotic ectasy, treatment, 336 intermittent form, 292. See also Gastrosuccorrhea continua periodica. Gastroxynsis, 291. See also Gastro- succorrhea. Gavage, 153 Gelatin in intestinal diseases, 443 in typhoid fever, 536 treatment of gastric ulcer, 231, 232 738 INDBX Gelatinous foods, 136 Germain See's test meal, 90 Germicides in acute amebic dysentery, 517 Gersuny's adhesion symptom of fecal tumor, 463 Gibson's differential chart for leuko- cytosis, 605 Girdle ulcer, 549 Glands of stomach, 20 Glass rectal irrigator, 431 Glenard's belt test in ptosis, 353 disease, 341 Glucose, absorption of, 40 Glycerin injections in constipation, 469 to intensify fluorescence in gastro- diaphany, 85 Glycosuria, alimentary, 40 Gonorrhea of intestines, 551 symptoms, 551 treatment, 553 Gout, stomach functions in, 391 Greater cul-de-sac of stomach, 17 curvature of stomach, 18 omentum, 19 Gross' double-current stomach douche, 156 test for pepsin, 104 Ground itch, 703 Gtinzburg's test for free hydrochloric acid, 97 of unaspirated gastric contents, 108 Gurgling sounds in intestines, 404 of stomach, 21 Gymnastics in constipation, 467 in intestinal diseases, 439 Gyromele, 439 Tiirck's, 164 HabituaIv constipation, 458. See also Constipation. Haggard, 137 Hammer percussion, 52, 53 Hand-breadth, 48 Haustra coli of large intestine, 29 Harris' type of amebic dysentery, 505 Harris-Flexner type of bacillus dysen- teria?, 521 Head's zones, Elsberg's division of, 611 Elsberg and Neuhof's method of diagnosing by, 610 Head's zones in affections of appen- dix, 609, 614 of duodenum, 612 of gall-bladder, 613 of intestines, 615 of kidney, 614 of liver, 613 of lungs, 609 of stomach, 612 of ureter, 614 of uterine adnexa, 615 of uterus, 6 1 5 of viscera, 609 in ileocecal tuberculosis, 615 in perforation of ileum, 615 in visceral affections, 609 precautions, 610, 611 objective, 611 subjective, 612 Heart block, transient, auto-intoxica- tion in, 446 lesions, stomach functions in, 389 ptosis of, 353 Heart-burn, 375 Heat in simple acute gastritis, 183 in treatment of simple acute gastritis, 183 unit, 124 Heat-retaining proctoclysis bottle, 437 Heichelheim's test for motor power 123 Hematemesis. See Hemorrhage. Hematuria, endemic, 693 ^ Hemic distomiasis, 693 Hemmeter-Moritz test for motor power, 123 Hemolymph glands in uncinarial der- matitis, 705 Hemorrhage in amebic dysentery, treatment, 519, 520 in duodenal ulcers, 545 in gastric cancer, 246 treatment, 274 ulcer, 217 treatment, 224 operative, 235 in hemorrhoids, 577, 578 treatment, 583 in intestinal ulcer, 552 in typhoid fever, death from, 530 treatment, 539 intestinal, 542 INDEX 739 Hemorrhage, intestinal, treatment, 553 of stomach, 211 Hemorrhagic erosions of stomach, 236 Hemorrhoidal plexus, 574 Hemorrhoids, 574 age and, 576 Allingham's operation for, 585 anatomy, 574 arterial, 575 bowels in, 579 capillary, 575 carbolic acid injections for, 584 cathartics in, 579 cauterization of, with fuming nitric acid, 585 clamp and cautery treatment, 585 complications, 586 condom as cooler in, 581 condyloma in, 578 constipation and, 576 treatment, 579 crushing of, 585 definition, 574 diagnosis, 577, 578 diet in, 579 dilatation of sphincters for, 584 etiology, 575 exercise in, 579 external, 574 anatomy, 574 diagnosis, 578 diet in, 579 etiology, 575 inflammation in, relief of, 581, 582 pain in, treatment, 581, 582 prognosis, 578 symptoms, 577 treatment, 579, 580 local, 580, 581 extirpation of, 585 with suture, 586 fissure in ano in, 588 frequency, 576 Gant's water infiltration method, 586 hemorrhage in, 577, 578 treatment, 5H3 hygiene in, 579 of anus in, 580 ice tubes for, 580, 58 1 infiltration treatment, Gant's, 586 internal, 574 anatomy, 574 Hemorrhoids, internal, diagnosis, 578 diet in, 579 etiology, 575 prognosis, 578 symptoms, 577 treatment, 579, 581 local, 582 varieties, 575 Kemp's ice tube for, 580 soft-rubber rectal bag in, 581 tube for, 580 ligature of, 585 with extirpation, 585 ointments for, 582, 583 operations for, 584 proctitis with, 590 prognosis, 578 prolapse of rectum in, 586 prolapsed, treatment, 582 rectal cancer and, 568 secondary changes, 575 sex and, 576 suppositories in, 583 symptoms, 577 tamponing rectum for hemorrhage, 583 tenesmus in, 577 treatment, 579 radical, 584 ulcerated, treatment, 582 venous, 575 water infiltration treatment, 586 Whitehead's operation, 586 Hepatic flexure of ascending colon, 31 irritation, auto-intoxication in, 446 Hernia, diaphragmatic, 638, 639 from strangulation, internal, 636 mechanism, 639 internal, strangulation from, 638 perforation of sac, in diverticulitis, 632 Hershell's test of absorptive function of stomach, 121 Heryng and Reichmann's gastrodia- phane, 83 Heterologous blood of ])ig in gastric cancer, 274 High-frequency current, 164 Hinged rectal speculum, 399 Hirschsprung's disease, 456 Hiss-Russell tyi)e of bacillus dysen- teriae, 521 740 INDEX History of patient, 42 Hoffmann's sign in gastric tetany, 337 Hoist and Schlesinger's test for blood in gastric contents, 114 Honigmann's determination of hydro- chloric acid deficit, 107 Hookworm disease, 701. See also Uncinariasis. Hot and cold alternate stomach douche, 157 applications, dry, 169 moist, 169 weather, food in, 130 Hot-water bag, 169 Hour-glass stomach, 340 Houston's valves, 33 Hunger, canine, 360 Hydatid disease, 685 treatment, 690 Hydrochloric acid, cells secreting, 20 combined, 96 Topfer's test for, 99 deficit, determination, 107 free, 96 Boas' test for, 97 Boas and Moerner's test for, 106 color tests for, 97 Congo paper tests for, 106, 107 Giinzburg's test for, 97 in gastric ulcer, 227 Mintz's test for, 106 Moerner and Boas' test for, 106 phloroglucin-vanillin test for, 97 quantitative test for, 97, 98, 99 resorcin-sugar test for, 97 Riegel's test for, 107 tests for, 97 Topfer's quantitative test for, 97, 98, 99 tropaolin-00 test for, 106 in gastric cancer, 252 Hydrogen-sulphid auto-intoxication, 449 Hydrotherapy in acute enteritis, 486 in atonic ectasy of stomach, 331 in chronic enteritis, 494, 496 gastritis, 197 in constipation, 468 in gastroptosis, 358 in gastrosuccorrhea continua period- ica, 295 in hyperchlorhydria, 286 Hydrotherapy in intestinal diseases, 440 in mucous colic, 677 local, 168 Hydrothionemia, 450 Hymenolepsis diminuta, 690 nana, 689 Hypanakinesis ventriculi, 372 Hyperaciditas hydrochlorica, 279. See also Hyperchlorhydria. Hyperacidity, 279. See also Hyper- chlorhydria. Hyperalgesia, cutaneous. See also Head's zones. Hyperanakinesis ventriculi, 369, 373 Hyperchlorhydria, 279 absorption in, 283 acid gastritis and, differentiation, 285 alkali treatment, 289 atony with, 284 biliary colic and, differentiation, 285 bowels in, care of, 291 complications, 284 constipation in, treatment, 291 course, 283 diagnosis, 284 diet in, 139, 286 differential diagnosis, 285 dilatation complicating, 284 electricity in, 291 etiology, 280 frequency, 280 gastralgia and, differentiation, 367 gastric analysis in, 282 ulcer and, 214, 218 differentiation, 216, 221, 222, 285 gastroptosis complicating, 284 gastrosuccorrhea and, differentiation, 285 hydrotherapy in, 286 hypersecretion and, differentiation, 285 in gastric cancer, 252, 253 magnesia in, 289 medication in, 289 motor function in, 283 movable kidney complicating, 284 nervous gastralgia and, differentia- tion, 285 pain in, treatment, 290 pathology, 284 prognosis, 283 INDEX 741 Hyperchlorhydria, proteid treatment, 286 removal of causes, 285 soda in, 289, 290 symptoms, 281 treatment, 285 Vichy water in, 289 Wolff's Carlsbad salts in, 290 Hyperesthesia of intestines, 669 of stomach, 364 Hyperinosis in appendicitis, 605 Hyperkinesis, 369 Hypermotility of stomach, 369 Hyperorexia, 360 Hyperpepsinia, 104 Hyperplasia in typhoid fever, 529 Hypersecretion, 291. See also Gastro- succorrhea. Hypersthenic gastritis, 190 Hypertrophy of colon with congenital dilatation, 456 of mucosa in chronic enteritis, 488 with mucoid degeneration and cyst formation in amebic dysentery, 509 Hypodermoclysis, 439 in iliolumbar region, 540 Hypogastric neuralgia, 670 Hypopepsinia, 104 Ice tubes for hemorrhoids, 580, 581 Idiopathic nervous vomiting, 379 Ileaca-ileocolic intussusception, 642 Ileocecal intussusception, 642 tuberculosis. Head's zone in, 615 Ileocolic intussusception, 642 Ileum, anatomy, 23 arterial supply of, 24 cancer of, 566 perforation of, Head's zone in, 615 tuberculosis of, 549 Ileus, 635. See also Intestines, ob- struction of. Iliac phlegmon, 591 Illoway's estimation of pepsin, 103 test in appendicitis, 601 Incontinence of pylorus, 371 Indicanuria, auto-intoxication in, 445, 446 causes, 37, 39 in acute intestinal obstruction, 635 intestinal, 445 Indicanuria, intestinal, diet in, 446 medication in, 447 Rosenbach's test for, 446 test for, 446 treatment, 446 Indol in feces, tests for, 426 Indolic putrefaction, auto-intoxication in, 445, 446 combined with saccharobutyric, 447 auto-intoxication in, 447 Infarction of bowel, 554. See also Embolism and Throm,bosis. Infectious diseases, ectasy of stomach with, 312 intestinal ulcers in, 550 symptoms, 551 treatment, 553 Inferior mesenteric artery, occlusion of, 557 Infiltration treatment of hemorrhoids, 586 Inflation of colon with water, 408 of intestines, uses, 407 with air, 406 with carbonic acid gas, 406 of stomach, conclusions regarding, 89 with air, 78 with carbonic acid gas, 77 with water, 78 Influenza, stomach functions in, 391 Infrapapillary cancer of duodenum, 565 Infusion, rectal, 439 Infusoria, 681 in gastric contents, 117 Ingesta, examination of, 95 Insane, atonic ectasy of stomach in, 323 Inspection, general, 45 of abdomen, 49 of abdominal blood-vessels, 49 of anus, 396 of esophagus, 46 of gall-bladder, 57 of kidneys, 66 of liver, 57 of neck, 46 of oral cavity, 45 of pharynx, 46 of rectum, 396 of sjjleen, 62 of stomach, 72 conclusions regarding, 88 742 INDEX Inspection of tongue, 45 of tonsils, 46 of uvula, 46 Insufficiency, motor, 304 definition, 321 of first degree, 304. See also Atony of stomach, chronic. of second degree, 320. See also Ectasy of stoinach, chronic. of cardia, 375 of kidneys in typhoid fever, treat- ment, 541 of pylorus, 371 Intercostal neuralgia, gastralgia and, differentiation, 368 Intermittent hypersecretion, 292. See also Gastrosuccorrhea contintia period- ica. Internal anal sphincter, 32 Interrogation of patient, 42 Intestinal colic, 453. See also Enter- algia. contents, irritation from, diarrhea due to, 473 dyspepsia, 444 indicanuria.' See also Indicanuria, intestinal, 445 irrigation in achylia gastrica, 210 juice, 38 aspiration of, 420 in fasting stomach, 113 in gastric contents, 113 obtaining of, 420 mechanical procedures, 428 neurasthenia, 671 obstruction, 635. See also Intes- tines, obstruction of. pain, 453. See also Enteralgia. putrefaction, arthritis deformans and, 448 in achylia gastrica, treatment, 210 indolic type, combined with sac- charobutyric, 447 saccharobutyric type, 447 combined with indolic, 447 sand, 456 false, 457 Intestines, absorption in, 39 adenoma of, 571 adenomyoma of, 560 anatomy of, 22 angioma of, 572 Intestines, anomalies in form of, 456 in position of, 456 bacteria of, 38 bismuth subnitrate in examination of, 405 blood-vessels of, diseases of, 554 cancer of, 551, 559. See also Cancer of intestines. symptoms, 551 treatment, 553 catarrh of, 478. See also Enteritis. chylangioma of, 572 compression of, 636 mechanism, 639 digestion in, 36 diseases of, 394 alimentary rest in, 442 artificial feeding in, 444 auscultation in, 404 auscultatory percussion in, 403 diet in, 442 electricity in, 440 exercise in, 439 gelatin as food in, 443 gurgling sounds in, 404 gymnastics in, 439 hydrotherapy in, 440 interrogation of patients in, 394 mechanical supports in, 440 milk in, 442, 443 percussion in, 402 splashing sounds in, 400 succussion in, 400 distomiasis of, 693 diverticula of, 623. See also Diver- ticula of intestines. examination of, 394 physical, 395 faradism to, 163, 164 ferments of, organized, 38 fibroma of, 572 fibromyoma of, 572 functions of, motor, bead test for, 420 test diet for, 421 testing, 420 gas cysts of, 573 gonorrhea of, 551 symptoms, 551 treatment, 553 Head's zone for, 615 hemorrhage of, 542 treatment, 553 INDEX 743 Intestines, hyperesthesia of, 669 in amebic dysentery, 505 in appendicitis, 602 in typhoid fever, 529 in uncinarial dermatitis, 705 inflation of, uses, 407 with air, 406 with carbonic acid gas, 406 inspection in disease of, 395 intussusception of, 641. See also Intussusception. irrigation of, 428. See also Irriga- tion of intestines. large, absorption in, 40 acute obstruction of, diagnosis, 649 anatomy of, 29 appendices epiploicse of, 29 bands of, 29 coats of, 33 descent of, 349. See also Enter- optosis. divisions of, 29 external pouches of, 29 function of, in digestion, 34 haustra coli of, 29 histology of, 33 length of, 22 mucous coat of, 33 submucous coat of, 33 teniae of, 29 lavage of, for diagnosis, 408 lipoma of, 572 lymphosarcoma of, 570 malignant growths of, 559 massage of, 165, 439. See also Massage. mechanical support of, 170 indications, 170 motor function of, 40 movements of, Rontgen rays in in- vestigating, 406 myiasis of, 551 treatment, 553 myoma of, 572 neoplasms of, 559 benign, 571 malignant, 559 nervous diseases of, 666 neuroses of, motor, 666 secretory, 671 sensory, 669 obstruction of, 635 Intestines, obstruction of, acute, 635 anuria in, 635 arsenic-poisoning and, differen- tiation, 652 auscultation in, 649 by fecal accumulation, differen- tial diagnosis, 651 by foreign bodies, differential diagnosis, 651 collapse in, 647 course, 652 definition, 635 diagnosis, 635, 647 differential diagnosis, 635, 636, 652 between forms of, 650 occlusion of small and large intestine, 649 due to chronic obstruction, 646 etiology, 636 indicanuria in, 635 inspection in, 648 intra-abdominal pressure in, 636 lead-poisoning and, differentia- tion, 652 medical treatment, 653 of large intestine, 649 of small intestine, 649 operation in, 655 pain in, 646, 647, 648 palpation in, 648 pathology, 646 percussion in, 648 peristalsis in, 647 peritonitis and, differentiation, 652 physical signs of, 648 prognosis, 653 surgical treatment, 655 symptoms, 646 treatment, 653 inedical, 653 surgical, 655 tympanites in, 647 types, 635 vomiting in, 647 bowels in, treatment, 663 by adhesions, 637 by l)ands, 637 by compression, 636 by enteroliths, 645 744 INDEX Intestines, obstruction of, by fecal masses, 645 chronic, 661 by foreign bodies, 644, 645 differential diagnosis, 651 treatment, 655 by herniaform strangulation, 636 by internal hernia, 638 by intussusception, 641. See also Intussusception. by paresis, 645 by rectal stricture, 66 1 treatment, 664 by strangulation of Meckel's di- verticulum, 637 through apertures, 637 slits, 637 by volvulus, 639 carcinomatous, diverticular steno- sis and, differentiation, 631 chronic, 657 anatomy, 657 barrel-shaped abdomen in, 660 by fecal accumulation, 661 colic in, treatment, 664 complications, 662 constipation in, 659 course, 663 diagnosis, 662 diarrhea in, 659 diet in, 663 etiology, 657 gastric analyses in, 659 inspection in, 660 location of, 658, 659 operation in, 665 peristaltic unrest in, 659 treatment, 664 prognosis, 663 Rontgen rays in, 660 surgical treatment, 665 symptoms, 658 treatment, 663 tjnmpanites in, 660 vomiting in, 659 treatment, 664 dynamic, 645 differential diagnosis, 651 treatment, 654 in diverticulitis, 633 with stenosis in diverticulitis, 630 obturation of, 644 Intestines, obturation of, differential diagnosis, 650 treatment, 655 oscillating movements of, 40 papilloma of, 572 parasites of, 681 diarrhea from, 474, 476 paresis of, 645, 666 differential diagnosis, 651 treatment, 654 peristalsis in, 40 physical examination of, 395 polypi of, 571 Rontgen rays in examination, 405 rotary movements of, 40 sarcoma of, 570 serous coat of, 33 small, acute obstruction of, diagnosis, 649 anatomy of, microscopic, 26 arterial supply of, 24 Brunner's glands in, 27 catarrh of, diagnosis, 483, 484 coats of, 25 fermentation in, 38 function of, in digestion, 34 length of, 22 Lieberkuhn's glands of, 27 lymphatics of, 24 mucous coat of, 25 muscular coat of, 25 nerves of, 24 peritoneal coat of, 25 Peyer's patches in, 28 serous coat of, 25 structure of, 25 submucous coat of, 25 veins of, 24 villi of, 26 volvulus of, 640 solitary follicles of, 27 splashing sounds of, differentiation from stomach splash, 81 stenosis of, chronic, 657. See also Intestines, obstruction of, chronic. strangulation of. See Strangula- tion. strapping, to support, 170 structure of wall of, diverticula and, 627 syphilis of, 551 symptoms, 551 INDEX 745 Intestines, syphilis of, treatment, 553 transillumination, 404 tuberculosis of, 548, 549 symptoms, 551 treatment, 553 tubercle bacilli in feces in, 553 tumors of, benign, 571 malignant, 559 tympanites of, 451. See also Tym- panites. ulcers of, 543. See also Ulcers of intestines. Intra-abdominal pressure, mainte- nance of, 344 Intragastric method of applying elec- tricity in stomach diseases, 161 Intrarectal electricity, 441 Intussusception, 641 age and, 643 bowels in, 644 chronic, 660 course, 652 diagnosis, 644 differential diagnosis, 650 duration, 644 etiology, 642, 643 fecal vomiting in, 644 frequency, 643 ileaca-ileocolic, 642 ileocecal, 642 ileocolic, 642 mechanism of, 642 pain in, 643 prognosis, 644, 653 symptoms, 643 treatment, 655 tumor in, 644 vomiting in, 643, 644 Intussusceptum, 641 Intussuscipiens, 641 Inunctions, nutritive, 138 Invagination, 641. See also Intussus- ception. Involutions of appendix vermiformis, harmful, auto-intoxication in, 608 symptoms, 608 lodin-potassium solution, Lugol's, 106 lodipin test for motor power, 123 Iodoform reaction for aldehyd, 102 Irrigation in acute amebic dysentery, 517 Irrigation in acute enteritis, 486 in bacUlary dysentery, 526 in mucous colic, 676, 679 in typhoid fever, 536, 537 of intestines, 428 by patient, 436 double-current, 432 in achylia gastrica, 210 position of patient, 434 rotation method, 434 solutions for, 435 uses, 428 value of, 436 with single tube, 430 of prostate by patient, 436 of stomach, 140. See also Lavage. rectal, in acute gastric ectasy, 318, 319 recurrent electric, in constipation, 468 Irrigators, rectal, 431 double-current, 432 Irritants transmitted in blood, diarrhea from, 474 treatment, 476 Irritation of intestinal contents, diar- rhea from, 473 Ischochymia, 320. See also Ectasy 0} stomach, chronic. Itch, ground, 703 Jacoby-Solms test for pepsin, 104 Jalap in constipation, 471 Jejunum, anatomy, 23 arterial supply of, 24 cancer of, 566 tuberculosis of, 549 Juvenile vomiting, 379 Kamala for tapeworm, 691 Katayama disease, 695 Kelly's rectal specula, 396 proctoscope, 397 Kelsey's rectal speculum, 398 Kemmerich's peptone preparation, 133 Kemp's circumscribing gastrodiaphane, 83, 84 continuous steam coil, 169 dietary in typhoid fever, 536 double-current irrigation tube, 432 flexible recurrent rectal irrigator, 431 glass rectal irrigator, 431 746 IND^X Kemp's ice tube for hemorrhoids, 580 intrarectal instrument, 441 metal rectal irrigator, 431 method for expressing gastric con- tents, 94 of using trypsin in treating cancer, 269 nutritive rectal enema, 137 recurrent electric irrigation in con- stipation, 468 soft -rubber rectal bag, 581 stomach-whistle, 79 strapping method, 170, 171 test meal, 91 for motor power, 122 treatment of gastric ulcer, 231 tube cooler for hemorrhoids, 580 for prostate, 580 Kerkring's valvulae conniventes, 25 Kidneys, anatomic relations of, 64 diseases of, stomach functions in, 390 effect of salt on, 130 floating, 67, 344. See also Nephrop- tosis. Head's zone for, 614 in diagnosis of chronic ectasy, 326 of gastroptosis, 342 in typhoid fever, 530 in uncinarial dermatitis, 704 inspection of, 66 massage of, 357 mobility of, 67 movable, 67, 344. See also Nephrop- tosis. palpation of, 66 new method, 68 old method, 66-68 percussion of, 69 position for, 69 physical examination of, 66 surface relations of, 65 posterior, 65 topography of, 64 Kilmer's abdominal belt, 175 Kjeldahl digestion flask for testing feces for putrefactive products, 426 Klemperer's oil test for motor power, 123 test meal, 90 KJunge's aloin test for blood, 115 Knapp's director for aiding passage of lavage tube, 152, 153 Knapp's method of inspecting liver, 57 test for succinic acid, 121 Koch's peptone preparation, 133 Kousso for tapeworms, 691 Kymograph, 123 La Grecque corset, 179, 355 Lacing liver, 352 Lactic acid, Arnold's test for, 10 1 bacillus, 420 Boas' test for, 102 Boas-Oppler bacUli in generation of, 119 estimation of, 102 in cancer of stomach, 253 significance of, 102 Strauss mixing funnel for, loi tests for, 100 Uffelmann's test for, 100 modified, loi Laparotomy, exploratory, in gastric cancer, 261 in intestinal cancer, 569 in gastric ulcer, 235 in pyloric stenosis, 262 Large calorie, 124 intestine, 22. See also Intestine, large. Lavage, 140 accessories for, 142 by single operator, 144 contra-indications for, 155 cyanosis from passing of tube in, 144 dangers of, 141 Dawbarn's method, 150 double-current tubes for, 153 duration of, 144 emergency, 146 emptying funnel in, 145 for office practice, 142 Friedlieb's apparatus for, 146, 148 modified, 149 funnel, 140, 144 method, 140 in acute ectasy, 3 1 8 in appendicitis, 617, 618 in atonic ectasy of stomach, 332 in chronic gastritis, 196 in gastric ulcer, 234 in gastrosuccorrhea continua chron- ica, 301 periodica, 295 INDEX 747 Lavage in nervous cases, 147 in simple acute gastritis, 184 in stenotic ectasy of stomach, 335 in toxic gastritis, 1S6 indications for, 153 interruption of flow during, 146 Knapp's director as aid in, 152, 153 Leube-Rosenthal method, 150 mouth-gag in, 152 occlusion of stomach-tube during, 146 of bowel for diagnosis, 408 passing of tube, 143 position of operator, 143 of patient, 142 slipping of tube into stomach in, 141 stomach-tube for, caliber of, 142 cleansing, 142 removal, 145, 146 selection, 141 technic, 142 testing of tube before, 141 through nostril, 153 with glass Y or J, 150 with patient on back, 152 Laxative foods, 442 Laxatives in constipation, 469 Lead-poisoning, intestinal obstruction and, differentiation, 652 Lee's cholera table, 430 Legs, flexion of, in abdominal palpa- tion, 50 Lenhartz's treatment of gastric ulcer, 228 Lesser curvature of stomach, 18 omentum, 19 Leube's diet scale of foods according to digestibility, 135 meat pancreas as nutritive rectal enema, 137 sound method for determining posi- tion of stomach, 79 test meal foi" rnotor power of stom- ach, 122 Leube-Rosenthal meat solution, 136 method of lavage, 150 Leube-Ziemssen rest cure in gastric ulcer. 228 Leukocytosis, Gibson's differential chart for, 605 in appendicitis, 605 Leukopenia in typhoid fever, 533 Levulose, absorption of, 40 Licorice powder in constipation, 470 Lieberkiihn's glands, 27 crypts in acute enteritis, 480 Ligature of hemorrhoids, 585 Linea alba, 47 Lineae semilunares, 47 Lipoma of intestines, 572 of stomach, 275 Liver abscess in amebic dysentery, 509 in bacillary dysentery, 524 anatomy of, 55 carcinoma of, from intestinal cancer, 560 cirrhosis of gastric ulcer and, differ- entiation, 223 syphilitic, gastric cancer and, differentiation, 256 delimitation of, 55 diseases, stomach functions in, 390 displacement of, 60 dulness, 59 floating, 352 fluke worm, 692 Head's zones for, 613 in typhoid fever, 530, 533 in uncinarial dermatitis, 704 inspection of, 57 lacing, 352 movable, 352 palpation of, 58 percussion of, 59 auscultatory, 59 physical examination of, 57 spilling of, 58 syphilitic stenosis of, gastric cancer and, differentiation, 256 tumor of, percussion of, 60 Lockwood's gastrodiaphane, 83 intragastric electrode, 161, 162 Locomotor ataxia, gastric crises of, gas- tric ulcer and, 223 Ludwig's kymograph, 123 Lugol's solution of iodin-potassium, 166 Lunch dietary, 128 Lungs, Head's zones in affections of, 609 in uncinarial dermatitis, 704 Lymphatics of cecum, 32 of colon, 32 of rectum, 32 of small intestine, 24 748 INDEX Lymphatics of stomach, 21, 262 enlarged, gastric cancer and, differentiation, 260 Lymphosarcoma of intestines, 570 Maggot- WORM, 699. See also Ox)uris "vermicularis . Magnesia in hyperchlorhydria, 2 89 Malacia, 361, 362 Malaria, stomach functions in, 391 Male fern for tapeworms, 690 Malignant growths of intestines, 559 Maltose, absorption of, 40 test for, 106 Massage, 165 bags, colonic, 439 electric roller, hot-and-cold, in con- stipation, 467 in atonic ectasy of stomach, 333 in chronic enteritis, 495 gastritis, 197 in constipation, 466 in gastroptosis, 356 in nephroptosis, 357 indications for, 165 intestinal, 439 roller, 167 tapping in, 165 vibratory, 165 in chronic gastric atony, 305 Matthieu and Remond's determination of chyme, 1 1 1 Mayo's partial gastrectomy for cancer, 263 Mazamorra, 703 McBm^ney's point in appendicitis, 599 Meals, regularity of, 136 Meat broth, 136 chemic composition of, 130 fibers in feces, 418 pancreas, Leube's, as nutritive rectal enema, 137 pastry, butter, and soup with milk diet, 134 poisoning from bacillus botulinus, 449 powders, 209 Debove's, 137 Mechanical procedures, intestinal, 428 Meckel's diverticulum, 24, 624 strangulation by, 637 Medullary carcinoma of stomach, 242 Megalogastria, 320, 340 Megastoma entericum in gastric con- tents, 117 Meissner's plexus, 25 Melancholia, auto-intoxication in, 323, 446 Melancholies, atonic ectasy of stomach in, 322 Meltzer's method of palpation in ap- pendicitis, 601 Membranous gastritis, 181 Merycism, 376 Mesenteric arteries, embolism of, 554. See also Emholism. thrombosis of, 554. See also Thrombosis. artery, inferior, occlusion of, 557 superior, occlusion of, 555 glands in typhoid fever, 530 traction, chronic, 349 veins, embolism of, 554. See also Embolis'in. thrombosis of, 554. See also Thronibosis. Mesenteritis in diverticulitis, 632 Mesentery, growths of, gastric cancer and, differentiation, 260 Meso-appendix, 31 Mesorectum, 32 Metabolism, proteid, 125, 126 Metal rectal irrigator, 431 Meteorism, 451. See also Tympan- ites. Methylene-blue in gastric cancer, 268 Mett's test for pepsin, 105 Microgastria, 340 Micro-organisms in feces, 419 in gastric contents, 118 Microscopic examination of gastric contents, 116, 117 Migraine, acute ectasy of stomach in, 310. 311 auto-intoxication in, 311 Milk as diet in intestinal diseases, 442, 443 chemic composition of, 131 diet in gastric ulcer, 226 with carbohydrates and fat in mushes and soups, 133 with liquid carbohydrates, 133 with meat, pastry, butter, and soup, 134 INDEX 749 Milk diet with solid food, pastry, and broths, 133 digestibility of, 135 dilution of, 135 fat, Gartner's, 136 in typhoid fever, 537 Milk-curdling ferments, cells secreting, 20 Milk-sugar, absorption of, 40 Mineral waters in chronic gastritis, 199 Miner's anemia, 701. See also Un- cinariasis. Mintz's test for free hydrochloric acid, 106 Miserere, 635. See also Intestines, obstruction of, acute. Moerner and Boas' test for free hydro- chloric acid, 106 Moist hot applications, 169 Morgagni, columns of, 33 Moritz-Hemmeter test for motor power, 123 Morris' point in appendicitis, 599, 600 Motor functions of stomach, 122. See also Stomach, functions of, motor. insufficiency of first degree, 304. See also Atony of stomach, chronic. of second degree, 320. See also Ectasy of stoinach, chronic. neuroses of intestines, 666 of stomach, 369 Mould in gastric contents, 118, 120 Mouth-gag in lavage, 152 Movable kidney, 67, 344. See also Nephroptosis. liver, 352 Mucin in feces, 410 test for, 41 1 Mucoid degeneration in amebic dysen- tery, 509 Mucous coat of large. intestine, 33 of small intestine, 25 of stomach, 20 colic, 672. See also Colic, tnu^ous. gastritis, 194 glands of stomach, 20 Mucus in feces, 410, 419 in chronic enteritis, 487, 490, 491 in intestinal ulcer, 553 in gastric contents, 113, 116 in vomit, 112 Mucus, microscopic appearance, 116 separate particles, examination, 412 Multiple neuritis in gastric cancer, 249 Munro's point in appendicitis. 600 Murphy's drop method of injecting saline solution in rectum, 437. See also Proctoclysis. Muscle fatigue, auto-intoxication in, 448 Muscular coat of small intestine, 25 of stomach, 19 Mushes and soups with milk diet, 133 Mustard poultice, 170 Myalgia, gastralgia and, differentia- tion, 368 Myasthenia ventriculi, 304 Myelitis, gastralgia from, 366 Myiasis, intestinal, 551 symptoms, 551 treatment, 553 Myoma of intestines, 572 of stomach, 275 Naphthalin for tapeworm, 691 Nauheim baths in typhoid fever, 537 Nausea due to abnormal sensation, 364 Nebulizer, colonic, 439, 440 Neck, inspection of, 46 Necrosis in typhoid fever, 530 Needle douche, intestinal, 439 Nematodes, 696 Neoplasms of intestines, 559 benign, 571 malignant, 559 Nephritis, stomach functions in, 390 transient, auto-intoxication in, 446 Nephropexy in gastroptosis, 346 Nephroptosis, 344, 350 complicating hyperchlorhydria, 284 degrees of, 351 diagnosis of chronic ectasy and, 326 Dietl's crisis in, 345, 352 hyperchlorhydria complicating, 2S4 massage in, 357 right, distended gall-bladder and, differentiation, 70 Nerves of cecum, 32 of colon, 32 of rectum, 33 of small intestine, 24 of stomach, 22 Nervous affections of stomach, 359 750 INDEX Nervous anorexia, 362 belching, 375 cases, lavage in, 147 diarrhea, 474, 667 treatment, 476 diseases of intestines, 666 dyspepsia, 381. See also Dyspepsia, nervous. enteralgia, 670 gastralgia, gastric cancer and, differ- entiation, 259 system in typhoid fever, 531, 541 tympanites, 451 vomiting, 377 idiopathic, 379 Neuhof and Elsberg's method of diag- nosis by Head's zones, 610 Neuralgia, hypogastric, 670 intercostal, gastralgia and, differ- entiation, 368 mesenterica, 670 of stomach, 365. See also Gastral- gia. Neurasthenia, auto-intoxication in, 323, 446 gastrica, 38r. See also Dyspepsia, nervous. intestinal, 67 Neuritis in typhoid fever, 533 multiple, in gastric cancer, 249 Neurosis of intestines, motor, 666 secretory, 671 sensory, 669 of stomach, chronic gastritis and, differentiation, 195 gastralgia as, 366 motor, 369 secretory, 380 sensory, 360, 364 Nitrate of silver treatment of chronic gastric erosions, 238 Nitric acid, fuming, for cauterizing hemorrhoids, 585 Non-irritating diet, abundant, 134 Normal saline solution enema, 137 injection into intestines, 429 Nutrition, principles of, 1 24 Nuts, chemic composition of, 132 food value of, 129 Obesity, diverticula and, 627 Objective Head zones, 61 1 Obstipatio alvi, 458. See also Consti- pation. Obstruction, 635. See also Intestines, obstruction of. Obturation of intestines, 644 differential diagnosis, 650 treatment, 655 Obturator, rectal, 670 Occult blood, 114 tests for, 114 Oidium albicans in gastric contents, 120 Oil test for motor power, Klemperer's, 123 meal to secure trypsin, 420 Olive oil in constipation, 466, 470 •Omentum, greater, 19 lesser, 19 protective function of, in amebic dys- entery, 507 Opiates in acute enteritis, 485, 486 in diarrhea, 477 Opium in appendicitis, 618 Oral cavity, inspection of, 45 Organized ferments of intestine, 38 Orthopedic methods, 170 in constipation, 469 Oscillating movements of intestines, 40 Osseous system in typhoid fever, 533 Overfeeding, 125 Oxyuris vermicularis, 699 diagnosis, 700 symptoms, 700 treatment, 701 Packs, 170 Palpation of abdomen, 50 reinforced, 50 of cecum, 398 of colon, 398 of esophagus, 46 of gall-bladder, 58 of kidneys, 66 new method, 68 old method, 66-68 of liver, 58 of rectum, 401 by sounds, 401 of spleen, 62 of stomach, 73 conclusions regarding, 88 Pancreas, anatomic relations, 60 INDEX 751 Pancreas, meat, Leube's, as nutritive rectal enema, 137 physical examination of, 61 topography of, 60 tumor of, 61 Pancreatic calculi in feces, 416 disease, steatorrhea and, 414 juice, function of, 37 in fasting stomach, 113 Papilloma of intestines, 572 Paramoecium coli, 682 diarrhea from, 684 Parasecretion, 291. See also Gastro- succorrhea. Parasites in feces, 411 in vomit, 112 intestinal, 681 diarrhea from, 474, 476 Parasitic origin of cancer, 241 Paratyphlitis, 591 Paratyphoid bacillus, 534 Paresis, auto-intoxication in, 323 of intestines, 645, 667 difTerential diagnosis, 651 treatment, 654 of sphincters, 668 Parorexia, 361 Passio iliaca, 635. See also Intestines, obstruction of, acute. Pastry, broths, and solid food with milk diet, 133 meat, butter, and soups with milk diet, 134 Patient, examination of, 45 preparation, 48 technic, 48 history of, 42 interrogation of, 42 in intestinal diseases, 394 preparation of, for examination, 48 Pelletierin for tapeworm, 691 Pemphigus of mouth, stomach func- tions in, 392 Penicillium glaucum in gastric con- tents, 119 Penzoldt's scale of digestibility, 135 Penzoldt and Faber's test of absorptive function of stomach, 121 Pepper poultice, 1 70 Pepsin, 103 casein test for, 104 cells secreting, 20 Pepsin, Fuld's test for, 104 Gross' test for, 104 Illoway's estimation, 103 in gastric juice, 35 Jacoby-Solms test for, 104 Mett's test for, 105 ricin test for, 104 Solms-Jacoby test for, 104 tests for, 103 Pepsinia, normal, 104 Peptic ulcer, 212. See also Ulcer of stomach. Peptone, absorption of, 39 biuret reaction with, 103 in feces, 412 in gastric contents, 103 preparations, 133 Percussion, auscultatory, 52, 54 flicking, 52, 53 hammer, 52, 53 of abdomen, 52 sources of error, 54 of gall-bladder, 59 of intestines, 402 of kidney, 69 position for, 69 of liver, 59 auscultatory, 59 of spleen, 63 of stomach, 74 auscultatory, 74 scratch method, 76 conclusions regarding, 88 scratch method, 52, 54 simple, 52 Percutaneous method of applying elec- tricity in stomach diseases, 161 Perforating gastric ulcer, 212, 219. See also Ulcer of stomach. Perforation in gastric cancer, 244, 249 Peridiverticulitis, 620. vSee also Diver- ticulitis. Perigastritis, gastralgia and, differen- tiation, 36S Periodic vomiting, 378 Perisigmoiditis, 620. See also Diver- ticulitis. Peristalsis, diagnostic value, 49 influence of foods on, 442, 443 intestinal, 40 centers of, 41 nervous control of, 41 752 INDEX Peristalsis of stomach, 72, 122 reversed, 41 Peristaltic unrest, gastric, 72, 370 in chronic obstruction, 659 treatment, 664 intestinal, 666 Peritoneal coat of small intestine, 25 of stomach, 19 Peritoneum, growths of, gastric cancer and, differentiation, 260 Peritonitis, acute, intestinal obstruc- tion and, differentiation, 652 from cancer, 562, 564 in typhoid fever, 540 local chronic, diverticulitis and, 632 perforative, in diverticulitis, 631, 633 Perityphlitis, 591. See also Appendi- citis. Pernicious anemia, auto-intoxication in, 448 grave anemia in gastric cancer and, differentiation, 255 Pertussis, vomiting in, Kilmer's belt for, 175-179 Peyer's patches, 28 in typhoid' fever, 529 Phantom tumor, 55, 451 Pharynx, inspection of, 46 Phlebectasia hemorrhoidalis, 574. See also Hemorrhoids. Phlegmon, iliac, 591 Phlegmonous enteritis, 500 gastritis, 188. See also Gastritis, phlegmonous. Phloroglucin-vanillin test for free hy- drochloric acid, 97 Phthalic anhydrid and resorcin as fluorescent medium in gastrodiaph- any, 85 Phthisis, stomach functions in, 388 ventriculi, 191, 203, 204. See also Achyiia gastrica. Physical examination, general meth- ods, 45 of gall-bladder, 57 of intestines, 395 of kidneys, 66 of liver, 57 of pancreas, 61 of spleen, 62 of stomach, 71 preparation of patient, 72 Physiology of digestion, 34 Pica, 362 Pig head tapeworm, 689 Pig's blood, heterologous, in gastric cancer, 274 Piles, 574. See also Hemorrhoids. Pine-needle oil for tapeworms, 691 Pin-worm, 699. See also Oxyuris vermicularis. Pneumatic proctoscope, Tuttle's, 397, 399 Pneumatosis, 380 cystoides intestinorum hominis, 573 Pneumograph, 123 Pneumonia, acute gastric ectasy in, 313 stomach functions in, 387 Podophyllin in constipation, 470 Poisons, antidotes for, 187 Politzer bulb for aspiration, 92 Polyphagia, 362 Polypi fragments in feces, 410 of intestines, 571 Polypoid excrescences of stomach, 275 Polyposis intestinalis adenomatosa, 572 Pomegranate root for tapeworm, 691 Pork tapeworm, 686 Portable bath-tub. Chambers', 538 Portal vein, thrombosis of, 555, 557 Posttyphoid pyemia, 534 septicemia, 534 Pouch of Douglas, 32 Poultices, 169 mustard, 170 pepper, 170 Powder-blower, stomach, 159 Einhorn's, 159, 160 indications, 161 Presecretin, 37 Pretubercular dyspepsia, 388 Priessnitz's compress, 168 Procidentia recti, 586 Proctitis, 498 classification, 498 diagnosis; 483 digital examination in, 499 etiology, 498 pathology, 498 symptoms, 499 treatment, 499 with hemorrhoids, 590 Proctoclysis, 437 bottle, heat-retaining, 437 INDEX 753 Proctoclysis, flatus in, 438 length of tube for, 438 number of drops per minute, 438 speed of, 438, 439 temperature of water in, 438 vacuum bottle for, 437 value of, 437 Proctoscope, Kelly's, 397 pneumatic, 397, 399 Proctoscopy, 396 Proctosigmoidoscope, pneumatic, 399 Proctospasmus, 461 treatment, 472 Prolapse of rectum, 586. vSee also Rectum, prolapse of. of stomach. See Gastroptosis. Propeptone in feces, 412 in gastric contents, 103 Prostate, cooler for, 581 Kemp's tube for, 580 self-irrigation of, 436 Proteids, absorption of, 39 diet, 125, 126 in feces, fermentation test for, 425 metabolism, 125, 126 requirement, 126, 127 Protozoa, 681 Pruritus, auto-intoxication in, 341 Pseudo-angina, auto-intoxication in, 312 pectoris with acute ectasy of stom- ach, 312 Psoriasis, stomach functions in, 391 Psorospermiasis, internal, 681 Ptyalin, 34 Pulmonary tuberculosis, stomach func- tions in, 388 Pumpkin seeds for tapeworm, 691 Purulent enteritis, 500 Pus in feces, 410, 419 in intestinal cancer, 567 ulcer, 552 in gastric contents, 1 1 5 Putrefaction, arthritis deformans and, 44S indolic, auto-intoxication in, 445, 446 combined with saccharobutyric, 447 saccharobutyric, 447 combined with indolic, 447 auto-intoxication in, 447 4s Pyemia, posttyphoid, 534 Pylorospasmus, 372 Pylorus, 17 cancer of, 251 partial gastrectomy for, 263 glands of, 20 incontinence of, 371 insufficiency of, 371 narrowing of, congenital, 340 resection of, for cancer, 263 spasm of, 372 stenosis of, 326, 328, 329 diet in, 138 laparotomy in, 262 syphilitic, 393 valve of, 17 Pyrosis, 375 QuiNiN bisulphate as fluorescent me- dium in gastrodiaphany, 85 Radiodiaphane, 88 Radiodiaphany, 88 Radium in treatment of gastric cancer, 265 photographs of stomach, 88 receptacle, Einhorn's, 266 transillumination of stomach, 88 Rectal alimentation, 137 bag, soft -rubber, Kemp's, 581 bougie, soft, 401 enemata, 137 examination, digital, 51 feeding in gastric ulcer, 227, 2 28 infusion, 439 injections in acute amebic dysentery, 517 irrigation in acute amebic dysentery, 517 gastric ectasy, 318, 319 in bacillary dysentery, 526 in typhoid fever, 536, 537 irrigators, 431 double-current, 432 obturator, 670 specula, 396-399 Recti muscle, thickening of, diagnosis, 277 Rectum, 31 ampulla of, 32 anesthesia of, 669 arteries of, 32 754 INDBX Rectum, cancer of, 568 perforation into bladder in, 564 into uterus in, 564 into vagina in, 564 treatment, 569 coats of, 33 examination of, digital, 51 in appendicitis, 602 in chronic enteritis, 487, 493 inspection of, 396 lymphatics of, 32 nerves of, 33 palpation of, 401 by sounds, 401 prolapse of, 586 diagnosis, 587 etiology, 586 internal, 587 operation for, 588 symptoms, 587 treatment, 588 stricture of, 661 treatment, 664 tamponing of, in hemorrhoids, 583 temperature in, 438 tuberculosis of, 549 veins of, 32 Red blood corpuscles in feces, 419 Reflex vomiting, 379 Regulin in constipation, 470 Regiu-gitation, 375, 376 of bile, permanent, examination of fasting stomach in, 112 Reichmann's disease, 291. See also Castrosuccorrhea ■ rod, 76 Reichmann and Heryng's gastrodia- phane, 83 Remond and Matthieu's estimation of chyme, iii Renal calculi, gastralgia and, differ- entiation, 368 Rennet, absent, 105 deficient, 105 normal, 105 tests for, 105 zymogen, 105 Rennin, 35 Resorcin and fluorescein as medium in gastrodiaphany, 85 and phthalic anhydria as medium in gastrodiaphany, 85 Resorcin-sugar test for free hydro- chloric acid, 97 Respiratory organs in typhoid fever, 530 Rest cure in gastric ulcer, 228 of intestines in disease, 442 Rhabdonema intestinale, 707 Rheumatism, gastralgia and, differen- tiation, 368 Rhubarb in constipation, 470 Ricin test for pepsin, 104 Riegel's test dinner, 90 for free hydrochloric acid, 107 Ringing sounds of stomach, 81 Roberts' sphincter dilator, 584 Rogers' small red dots in amebic dysen- tery, 505 Rontgen rays for detecting foreign body in stomach, 87 in chronic amebic dysentery, 519 intestinal obstruction, 660 in diagnosis of gastric cancer, 255 in examination of intestines, 405 in investigating intestinal move- ments, 406 in treatment of gastric cancer, 265 physiologic investigations with, 406 to locate colon, 405 Rontgenography of stomach, 87 Rose's apparatus for inflating bowel, 79 belt, 171, 172 in atony of stomach, 305 in constipation, 469 in intestinal diseases, 440 carbonic acid gas generator, 406, 407 dry carbonic acid gas bath in mucous colic, 678 strapping method to support viscera, 170 Rosenbach's test for indicanuria, 446 Rosenheim-Ewald stomach douche tube, 156 Rosenthal -Leube meat solution, 136 method of lavage, 150 Rosewater's adhesive belt, 175 Rotary movements of intestines, 40 Rotation of intestinal irrigation, 434 Round duodenal ulcer, 543 worms, 696 Rubber rectal bag, Kemp's, 581 Rubs, 170 INDEX 755 Rumination, 375, 370 Runeberg's colon-tube for inflating in- testines, 407 Russell's diet treatment of gastroptosis, 356 Russell-Hiss type of bacillus dysen- teriae, 521 Saccharin, test for, 106 Saccharobutyric putrefaction, 447 combined with indolic type, 447 auto-intoxication in, 447 Sago grains in chronic enteritis, 489 in feces, 410 Sahli's desmoid test for gastric juice, 108 Saline rectal enema, 137 solution, injection of, into intestines, 429 waters in chronic gastritis, 199 Saliva, ferments of, 34 Salol for tapeworm, 691 test for motor power, 122 Salt, effect of, on kidneys, 130 Sand in feces, 416 intestinal, 456 false, 457 Sanitation, dysentery and, 502 Santonin for ascaris lumbricoides, 699 Sarcinse in gastric contents, 117, 119 Sarcoma of intestines, 570 of stomach, 275 Schistosoma Cattoi, 695 haematobium, 693 Japanicum, 695 Schlesinger and Hoist's test for blood in gastric contents, 114 Schmidt's treatment of gastric ulcer, 231 Schmidt-Strasburger diets to deter- mine intestinal functions, 421 fermentation test for feces, 425 Scirrhous carcinoma of stomach, 242 Sclerosis of stomach, cancer and, differ- entiation, 255 ventriculi, 191, 192, 204 Scolecoiditis, 591. See also Appendi- citis. Scotch douche, 170 Scratch method of auscultatory per- cussion of stomach, 76 of percussion, 52, 54 Seasoning of foods, peristalsis and, 443 Seat-worm, 699. See also Oxyuris vermicular is. Secretin, 37 Secretory function of stomach, ex- amination, 90 neuroses of intestines, 671 of stomach, 380 Semina cucurbitse for tapeworm, 691 Senator's treatment of gastric ulcer, 231 Sensory neuroses of intestines, 669 of stomach, 360, 364 Septicemia, posttyphoid, 534 Serous coat of large intestine, 33 of small intestine, 25 of stomach, 19 Serumtherapy in bacillary dysentery, 527 in typhoid fever, 538 Shiga serum in dysentery, 527 type of bacillus dysenteriae, 521 Siever and Ewald's test for motor power, 122 Sigmoid, double-current needle douche for, 439 flexure, 31 diver ticiila and, 627 palpation of, 398 volvulus, 639 speculum, Kelly's, 397 Sigmoiditis, 620. See Diverticulitis. Sigmoidoscope, 398, 399 Sigmoidoscopy, 396 Silk elastic belt, 179 Silver nitrate treatment of chronic gastric erosions, 238 Simple percussion, 52 Sims' rectal speculum, 397 Single-tube irrigation of intestines, 430 Sitophobia, 364 Siturgy, 363 Sizzling sounds of stomach, 82 Skatol in feces, tests for, 426 Skin burns, intestinal ulcers from, 546 symptoms, 551 treatment, 553 diseases, stomach functions in, 391 eruptions, auto-intoxication in, 391 vSmall calorie, 1 24 intestine, 22. See also Intestine, small. 756 INDEX Smoking in chronic gastritis, 199 Soda bicarbonate and tartaric acid to determine position of stomach, 79 in hyperchlorhydria, 289, 290 Sodium iodid in gastric cancer, 266 Soft rectal bougie, 401 Solitary follicles of small intestine, 27 Solms-Jacoby test for pepsin, 104 Sounds, esophageal, use of, 46, 47 for palpating rectum, 401 Soups and mushes with milk diet, 133 chemic composition of, 132 meat, pastry, and butter with milk diet, 134 Sour milks in typhoid fever, 537 Spallanzani and Edinger's test of un- aspirated gastric contents, 108 Sparing stomach, feeding and, 136 Spasm of cardia, 373 diagnosis, 374 etiology, 373 prognosis, 374 symptoms, 373 treatment, 374 of pylorus, 372 of sphincter ani, 461 treatment, 472 of stomach, 365. See also Gastral- gia. Spastic constipation, 460 treatment, 469 Specula, rectal, 396-399 Sphincter ani, internal, 32 spasm of, 461 treatment, 472 dilatation of, for hemorrhoids, 5S4 paralysis of, 668 Spider gall-bladder adhesions, gastric ulcer and, differentiation, 223 Spilling, 51 liver, 58 spleen, 62 Spinal disease, gastralgia from, 366 Splanchnoptosis, 341. See also Gas- troptosis. Splashing sounds in intestinal diseases, 400 of intestines, differentiation from stomach splash, 81 of stomach, 80 and intestines, differentiation, 81 conclusions regarding, 89 Spleen, anatomic relations of, 61 dulness of, 63 floating, 64 in typhoid fever, 530 in uncinarial dermatitis, 705 inspection of, 62 palpation of, 62 percussion of, 63 physical examination of, 62 spUling, 62 topography of, 61 Splenic flexure of transverse colon, 31 Sponging in typhoid fever, 537 Spool worm, 697. See also Ascaris lumbricoides. Sporozoa, 681 Spray, gastric, 158. See also Stomach spray. Staining bacteria in feces, 425 Stamper method of localizing gastric ulcer, 223 Starch digestion, examination of, 105 intermediary stages, 106 Lugol's solution for determining, 106 tests for, 106 granules in gastric contents, 118 in feces, 410 examination for, 412 Starvation treatment in gastric ulcer, 228 Static electricity, 164 Steam coil, continuous, 169 Steapsin, 37 test for, 113 Steatorrhea, 414 pancreatic disease and, 414 Steele's diet to test intestinal functions, 422 Stenosis, diverticular, carcinomatous stenosis and, differentiation, 631 of cardia in cancer, treatment, 275 of intestines, 657. See also In- testines, obstruction of. of liver, syphilitic, gastric cancer and, differentiation, 256 of pylorus, diet in, 1 38 gastralgia and, differentiation, 367 laparotomy in, 262 syphilitic, 393 of stomach, gastric cancer and, differentiation, 259 IXDEX 757 Stenosis with obstruction in diverticu- litis, 630 Stenotic dilatation of stomach, 71 Stercoral diarrhea, 474, 476 Stomach, abscess of, 1S8. See also Gastritis, plilegmo/ious. adenocarcinoma of, 242 anatomy of, 17, 18, 71 antiperistaltic restlessness of, 371 areolar coat of, 19 arteries of, 2 1 atony of, 303, 372. See also Atony of stomach. atrophy of, 203. See also Achylia gastrica. blood-vessels of, 19, 20 bucket, E inborn' s, 109 cancer of, 240. See also Cancer of stomach. capacity of, 19, 320 carcinoma of, 240. See also Cancer of stomach. cardiac glands of, 20 orifice of, 17 catarrh of, 180. See also Gastritis. chyme within, determination, 1 1 1 coats of, 1 9 contents, 91. See also Gastric con- tents. cul-de-sac of, greater, 17 curvatures of, 18 deglutition sounds in, 81 digestion in, 35 dilatation of, 306. See also Ectasy of stomach. dimensions of, 19 diseases, 71 diet in, 138 electricity in, 161. See also Elec- tricity in stomach diseases. functional, 279 high-frequency current in, 164 static electricity in, 164 Tiirck's gyromele in, 164 dislocation of, 341 douche, 155 alternate hot and cold, 157 bulb-compression method, 157 double-current, 156 Einhorn's instrument for, 156 Gross' double-current, 156 in atony, 158, 333 Stomach douche, medication by, 156 technic, 156, 157 temperature of fluid, 1 58 time for, 156 Y-method, 157 dripping sounds of, 81 ectasy of, 306. See also Ectasy of stomach. electrodes, 161-163 epithelioma of, 242 erosions of, 236. See also Erosions of stomach. esophageal orifice of, 1 7 faradism to, 163, 164 fasting, bile in, 113 contents of, 112 duodenal juice in, 113 intestinal juice in, 113 pancreatic juice in, 113 fermentation in, gas, no fibroma of, 275 fore-, 340 foreign bodies in, 277 Rontgen rays for, 87 form of anomalies in, 340 functional diseases of, 279 functions of, absorptive determina- tion, 121 examination of, 90 in acne rosacea, 391 simplex, 391 in acute febrile diseases, 387 in anemia, 389 in aneurj-sm, 390 in arteriosclerosis, 391 in arthritis deformans, 391 in chlorosis, 389 in chronic febrile diseases, 38S in digestion, 34 in diseases of other organs, 387 in eczema, 391 in erythema, 391 in febrile diseases, 387, 38S in gout, 391 in heart lesions, 389 in influenza, 391 in kidney diseases, 390 in liver diseases, 390 in malaria, 391 in nephritis, 390 in pemphigus of mouth, 392 in phthisis, 388 758 INDEX Stomach, functions of, in pneumonia, 387 in psoriasis, 391 in pulmonary tuberculosis, 388 in skin diseases, 391 in typhoid fever, 387 in urticaria, 391 motor, 122 disturbances of, 303 diet in, 139 in hyperchlorliydria, 283 quantity of ingesta and, 95 test breakfast for, 122 meal for, 122 tests for, 122 fundus of, 1 7 glands of, 20 galvanism to, 163, 164 gas fermentation in, 1 10 glands of, 20 greater curvature of, 18 gurgling sounds of, 81 Head's zones for, 612 hemorrhage of, 211 hour-glass, 340 hyperesthesia of, 364 hypermotility of, 369 in appendicitis, 602 in uncinarial dermatitis, 705 inflammation of, suppurative, 188. See also Gastritis, phlegmonous. inflation of, conclusions regarding, 89 with air, 78 with carbonic acid gas, 77 with water, 78 inspection of, 72 conclusions regarding, 88 irrigation of, 140. See also Lavage. lavage of, 140. See also Lavage. lesser curvature of, 18 lipoma of, 275 local treatment of, 140 lower border of, locating, 326, 327 lymphatics of, 21, 262 massage of, 165. See also Massage. mechanical support of, 170 indications, 170 medullary carcinoma of, 242 motor function of, 35 disturbances of, 303 neuroses of, 369 mucous coat of, 20 Stomach, mucous glands of, 20 muscular coat of, 19 myoma of, 275 nerves of, 22 nervous affections of, 359 neuralgia of, 365. See also Gastral- gia. neuroses of, chronic gastritis and, differentiation, 195 motor, 369 secretory, 380 sensory, 360, 364 palpation of, 73 conclusions regarding, 88 percussion of, 74 auscultatory, 74 scratch method, 76 conclusions regarding, 88 perforation into, in colonic cancer, 564 peristalsis of, 72 peristaltic unrest of, 72, 370 peritoneal coat of, 19 physical examination of, 71 preparation of patient, 72 polypoid excrescences of, 275 position of , 1 7, 7 1 anomalies in, 340 determining, 77-80 Dehio's method, 78, 79 powder-blower, 159 Einhorn's, 159, 160 indications, 161 prolapse of. See Gastroptosis. pyloric glands of, 20 radium photographs of, 88 ringing sounds of, 81 Rontgenography for, 87 Rose's strapping method to support, 170-175 sarcoma of, 275 sclerosis of, cancer and, differentia- tion, 255 secretion of, disturbances of diet in, 139 secretory function of, examination, 90 neuroses of, 380 sensations within, 363 sensory neuroses of, 360, 364 serous coat of, 19 sizzling sounds of, 82 INDEX 759 Stomach, spasm of, 365. See also Gasiralgia. splashing sounds of, So conclusions regarding, 89 differentiation from intestinal splash, Si spray, 158 Einhorn's tube for, 158 in atonic ectasy, 333 in gastrosuccorrhea continua chronica, 301 indications for, 159 technic, 159 stenosis of, gastric cancer and, differ- entiation, 259 strapping to support, 1 70 stricture of, diet in, 138 structure of, 19 submucous coat of, 19, 20 succussion sounds of, 81 supermotility of, 369 syphilis of, 392 tapotement of, 165 tongue as mirror of, 45 transillumination of, 83. See also Gastrodiapiiany. Traube's space of, 19 tumors of, 240, 275 apparent, 277 cancer and, differentiation, 255 determination of, 76 syphilitic, 393 ulcer of, 212. See also Ulcer of stomach. unrest of, peristaltic, 370 veins of, 2 1 vertical, 349, 350 volume of, 18 weak, predisposition to, 180 Stomach-tube, cyanosis during passing of, 144 for douche, 1 56 for examination of esophagus, 250 for lavage, cleansing, 142 double-current, 153 Knapp's director as aid in passing, 152, 153 one-piece, 141 passing of, 143 selection of, 141 size of, 142 slipping of, into stomach, 141 Stomach-tube for lavage, testing of, 141 two-piece, 141 occlusion of, during lavage, 146 passage of, 47 removal of, 145, 146 Stomach-whistle, Kemp's, 79 to determine position of stomach, 79 Stools. See Feces. Storm's abdominal support, 179 Strangulation by adhesions, 636, 637 by bands, 636, 637 by hernia, internal, 636, 638 by Meckel's diverticulum, 637 course, 652 diagnosis, 635 herniaform, internal, 636, 638 mechanism, 639 through apertures, 637 slits, 637 Strapping, adhesive, in intestinal dis- eases, 440 to support viscera, 170 with narrow strips, 175 Strasburger's fermentation tube, 426 Strasburger-Schmidt diets to test in- testinal functions, 421 fermentation test for feces, 425 Strauss funnel method for lactic acid, lOI mixing funnel, 10 1 Stricture of colon, inflation with water in, 408 of esophagus, 47 in cancer of cardia, 250 of rectum, 661 treatment, 664 of stomach, diet in, 138 Strongyloides intestinalis, 707 Strongylus duodenalis, 701. See also Uncinariasis. Strophulus infantum, auto-intoxica- tion in, 391 Subacidity, diet in, 139 Subjective Head zones, 612 Sublimate test for bile-pigment in feces, 425 Submucous coat of large intestine, 33 of small intestine, 25 of stomach, 19, 20 Subphrenic abscess, termination, 220 Succinic acid, Knapp's test for, 121 760 INDEX Succus entericus, 38 gastricus, 35 Succussion in intestinal diseases, 400 sounds of stomach, 81 Sugar, chemic composition of, 132 in feces, 412 tests for, 106 Sugar-bouillon tubes, 425 Summer, food in, 130 Superacidity, 279. See also Hyper- chlorhydria. Superficial ulceration of stomach, 235 Superior mesenteric artery, occlusion of, 555 Supermotility of stomach, 369 Suprapapillary cancer of duodenum, 565 Suprarenal extract in treatment of gastric erosions, 239 Syncope, auto-intoxication in, 323 of intestines, 551 symptoms, 551 treatment, 553 of stomach, 392 cancer and, differentiation, 255 Syphilitic cirrhosis of stomach, 393 gastric ulcer, 393 pyloric stenosis, 393 tumor of stomach, 393 Syrup of figs in constipation, 470 Tabes, gastralgia from, 366 Tachycardia, auto-intoxication in, 312 with acute ectasy of stomach, 311, 312 Taenia cucumerina, 690 elliptica, 690 flavopunctata, 690 lata, 689 Madagascariensis, 689 mediocanellata, 688 nana, 689 saginata, 688 solium, 686 Tamarinds in constipation, 470 Tapeworms, 685 armed, 686 beef, 688 description, 686 pig head, 689 pork, 686 treatment, 690 Tapeworms, unarmed, 688 Tapotement of stomach, 165 Tapping of stomach in massage, 165 Tartaric acid and soda bicarbonate to determine position of stomach, 79 Tea, 136 in test meal, 91 Teeth, care of, 136 Telling's classification of diverticulitis, 630 Temperature, high, auto-intoxication in, 323 Tenesmus in amebic dysentery, 512, 514 carbonic acid gas for, 519 in bacillary dysentery, treatment, 525 in hemorrhoids, 577 Test breakfast. Boas', 90 Ewald and Boas', 90 for motor power, 122 in gastric cancer, 252 diet, Schmidt-Strasburger, 421 Steele's, 422 to determine intestinal functions, 421 dinner, Riegel's, 90 meal, 90 Boas', 90 for motor power, 122 Ewald' s, 90 Ewald and Boas', 90 for motor power, 122 Germain See's, 90 Kemp's, 91 motor power, 122 Klemperer's, 90 Leube's, for motor power, 122 oil, to secure trypsin, 420 Riegel's, 90 special, 91 tea in, 91 Tetany, acute ectasy of stomach in, 311 gastric, auto-intoxication in, 311, 336, 337 gastrosuccorrhea continua chronica and, differentiation, 299 in atonic ectasy of stomach, 331 treatment, 335 in ectasy of stomach, 336 Chvostek's symptom, 337 diagnosis, 337 INDEX 761 Tetany in ectasy of stomach, Erb's sign in, 337 etiology, 336 frequency, 338 Hoffmann's sign in, 337 pathology, 336 prognosis, 338 symptoms, 337 treatment, 338 Trousseau's symptom, 337 in gastric cancer, 249 in stenotic ectasy of stomach, treat- ment, 336 Thiosinamin in gastric cancer, 267 Thirst in gastric ulcer, treatment, 225 in gastrosuccorrhea continua period- ica, treatment, 295 Thread impregnation test for localiz- ing gastric ulcer, 223 test of gastric contents, Dunham's, 109 Thread-worm, 699. See also Oxyuris vermicularis . Thrombosis in gastric cancer, 249 of inferior mesenteric artery, 557 of mesenteric arteries, 554 clinical symptoms, 556 diagnosis, 557 etiology, 555 prognosis, 557 treatment, 558 veins, 554, 557 etiology, 555 treatment, 558 of portal vein, 555, 557 superior mesenteric artery, 555 Thrombotic intestinal ulcers, 547 symptoms, 551 treatment, 553 Thymol in ascaris lumbricoides, 699 in uncinarial dermatitis, 706 Thynms in treatment of gastric cancer, 273 Tissue shreds in feces in intestinal ul- cers, 553 Tongue as mirror of stomach condition, 45 inspection of, 45 Tonsils, inspection of, 46 Topfer's method for total acidity, 99 quantitative test for free hydro- chloric acid, 97, 98, 99 Topfer's test for acid salts, 99, 100 for combined hydrochloric acid, 99 Tormina intestinorum, 666. See also Peristaltic unrest. ventriculi nervosa, 370 Total acidity, Topfer's method for, 99 Toxic gastritis, 185. See also Go5/nVij, toxic. ulcers of intestines, 550 Transillumination in gastric cancer, 248 of intestines, 404 of stomach, 83. See also Gasirodi' apliany. Transverse colon, 31 palpation of, 398 position of, 19 Traube's space, 19 Trousseau's symptom of gastric tetany, 337 Trematodes, 692 blood, 693 liver, 692 Tremoliere's solution in gastric cancer, 274 in hemorrhage of amebic dysen- tery, 519, 520 Trichina spiralis, 709 in muscle, 708 intestinal, 709 Trichiniasis, 709 Trichocephalus dispar, 708 Trichomonas hominis ' in gastric con- tents, 117 intestinalis, 682 Tropaolin-00 test for free hydrochloric acid, 106 True diverticula, 623, 624 Trypsin, 37 in feces, 415 oil test meal to secure, 420 test for, 1 13, 420 treatment of gastric cancer, 253, 268, 269 of intestinal cancer, 570 T-tube lavage, 150 Tubercle bacilli in feces, in intestinal tuberculosis, 553 Tuberculosis, ileocecal, Head's zone in, 615 of colon, 549 of ileum, 549 762 INDEX Tuberculosis of intestines, 548, 549 symptoms, 551 treatment, 553 tubercle bacilli in feces in, 553 of jejunum, 549 of rectum, 549 pulmonary, stomach functions in, 388 Tumefaction in appendicitis, 603 Tumor fragments in feces, 419 of liver, percussion of, 60 of pancreas, 61 of stomach, 240, 275 apparent, 277 determination of, 76 gastric cancer and, differentiation, 255 syphilitic, 393 particles in gastric contents, 119 phantom, 55 Tiirck's double-current needle douche for sigmoid, 439 gyromele, 164 nebulizer, 439, 440 Turpentine for tapeworm, 691 Tuttle's pneumatic proctoscope, 397, 399 Tympanites, 451 etiology, 451 hystericus, 451 in acute intestinal obstruction, 647 in appendicitis, treatment, 616, 617, 618 in chronic intestinal obstruction, 660 in typhoid fever, 312, 532, 533 treatment, 538 in volvulus, 640 nervous, 451 prognosis, 452 symptoms, 452 treatment, 452 Typhlitis, 591 Typhoid bacillus, 528. See also Bacil- lus typhosus. fever, 528 acute ectasy of stomach in, 312 age and, 528 bacilluria in, 533 treatment, 541 bacillus typhosus as cause, 528 baths in, 537 bladder in, 530 Typhoid fever, blood in, 533 bone-marrow in, 530 bones in, 533 bowels in, 537 Brand treatment, 537 chronic distribution, 535 circulatory organs in, 531 colitis in, treatment, 541 constipation in, 539 convalescence, 541 diagnosis, 534 diarrhea in, 539 diazo-reaction in, 533 diet in, 535 digestive functions, 535 dilatation of intestine in, postural treatment, 539 of stomach in, postural treat- ment, 539 distribution, chronic, 535 Ehrlich's diazo-reaction in, 533 etiology, 528 gall-bladder in, 530 gelatin in, 536 healing of intestines in, 530 heart stimulants in, 540 hemorrhage in, death from, 530 treatment, 539 history, 528 hyperplasia in, 529 immunity from, 528 intestines in, 529 kidneys in, 530 leukopenia in, 533 liver in, 530, 533 medication in, 537 mesenteric glands in, 530 milk in, 537 morbid anatomy, 529 Nauheim baths in, 537 necrosis in, 530 nervous system in, 531 treatment, 541 neuritis in, 533 onset, 532 osseous system in, 533 perforation in, 530, 533, 540 peritonitis in, 540 Peyer's patches in, 529 . prevalence, 528 prognosis, 534 prophylaxis, 534 INDEX 763 Typhoid fever, pulse in, 532 pyemia after, 534 rectal irrigations in, 536, 537 renal insuflficiency in, treatment, 541 respiratory organs in, 530 season and, 528 septicemia after, 534 serumtherapy in, 538 sex and, 528 sleeplessness in, treatment, 541 sour milks in, 537 spleen in, 530 sponging in, 537 stomach functions in, 387 symptoms, 531 temperature in, 531 treatment, 535 tympanites in, 312, 532, 533 treatment, 538 ulceration in, 530 voluntary muscles in, 531 Widal's reaction in, 534 Typholumbricosis, 698 UFFELMann's test for lactic acid, 100 modified, 10 1 Ulcer, duodenal, gastric ulcer and, differentiation, 223 perforating, 543 round, 543 simple, 543 age and, 543 clinical aspects, 544 complications, 544 course, 545 diagnosis, 545 etiology, 543 gastric analysis in, 545 ulcer and, differentiation, 223, 545 hemorrhage in, 545 pathology, 543 prognosis, 546 sex and, 543 site of, 543 surgical treatment, 546 symptoms, 544, 551 treatment, 546, 553 vomitus in, 545 of colon, 549, 550 of intestines, 543 Ulcer of intestines, amyloid, 547 symptoms, 551 treatment, 553 blood in feces in, 552 cancerous, 551 symptoms, 551 treatment, 553 catarrhal, 550 decubital, 550 symptoms, 551 treatment, 553 diarrhea in, 552 diet in, 554 embolic, 547 symptoms, 551 treatment, 553 feces in, 552 fever in, 553 follicular, 550 from cutaneous burns, 546 symptoms, 551 treatment, 553 girdle, 549 gonorrheal, 551 symptoms, 551 treatment, 553 hemorrhage in, 552 in acute infectious diseases, 550 in chronic enteritis, 489 in constitutional diseases, 550 symptoms, 551 treatment, 553 in infectious diseases, symptoms, 551 treatment, 553 mucus in feces in, 553 nutrition in, 553 pain in, 553 perforation in, 553 prognosis, 553 pus in feces in, 552 stercoral, 550 S5anptoms, 551 treatment, 553 symptoms, 551 syphilitic, 551 symptoms, 551 treatment, 553 thrombotic, 547 symptoms, 551 treatment, 553 tissue shreds in feces in, 553 764 INDEX Ulcer of intestines, toxic, 550 symptoms, 551 treatment, 553 treatment, 553 tubercular bacilli in feces in, 553 primary, 548 secondary, 549 symptoms, 551 treatment, 553 of stomach, 212 achylia gastrica and, 214 age in etiology, 213 anemia in etiology, 2 1 3 treatment, 230 cancer engrafted on, 257 chlorosis in etiology, 213 cholelithiasis and, differentiation, 221 chronic gastritis and, differentia- tion, 194 cicatrization in, 215 cirrhosis of liver and, differentia- tion, 223 collapse in, 225 complications, 218 course, 223 diagnosis, 220—223 differential, 221, 222 diet in, 138, 226 Dieulafoy's, 235 duodenal ulcer and, differentia- tion, 223, 545 egg-albumen diet in, 229 Einhorn's treatment, 228 etiology, 212 experimental, 213 extent of, 215 free hydrochloric acid in, 227 frequency, 212 from diphtheria toxin, 213 gastralgia and, differentiation, 367 gastric carcinoma and, differentia- tion, 221, 222, 259 contents in, 218 crises of locomotor ataxia and, 223 stamper method of localizing, 223 gastrosuccorrhea continua chron- ica and, differentiation, 298 gelatin treatment, 231, 232 geographic distribution, 212 Ulcer of stomach, hematemesis in, 217 treatment, 224 operative, 235 hyperchlorhydria and, 214, 218 differentiation, 221, 285 Kemp's treatment, 231 laparotomy in, 235 latent cases, 216 lavage in, 234 Lenhartz's treatment, 228 Leube-Ziemssen rest cure in, 228 location, 215, 223 microscopic appearance, 215 milk diet in, 226 morbid anatomy, 214 motor function in, 218 nervous dyspepsia and, differentia- tion, 383 gastralgia and, differentiation, 221, 222 number, 215 nutritive enemata in, 227, 228 occupation in etiology, 2 1 3 operative treatment, 235 pain in, 217, 218 treatment, 234 perforation in, 219 treatment, 234, 235 physical signs, 219 with little air present, 220 with much air present, 220 prognosis, 224 progress, 215 progressive necrosis in, 215 rest cure in, 226, 228 Schmidt's treatment, 231 Senator's treatment, 231 sex in etiology, 212 simulating hyperchlorhydria, 216 spider gall-bladder adhesions and, differentiation, 223 starvation treatment in, 228 stools in, 218 surgical treatment, 235 sjmiptoms, 216 syphilitic, 393 terminations, 220 theories of, 213 thirst in, treatment, 225 thread impregnation test for local- izing, 223 traumatism in etiology, 213 INDEX 76: Ulcer of stomach, treatment, 224 general principles, 226 of collapse, 225 of hemorrhage, 224 of pain in, 234 of perforation, 234, 235 of thirst, 225 of vomiting, 234 operative, 235 tuberculous, 389 typical case, 216 urine in, 218 vomiting in, treatment, 234 Weinland's theory, 213 peptic, 212. See also Ulcer of stom- ach. undermined, in amebic dysentery, 506 Ulcus duodeni pepticum, 543. See also Ulcer, duodenal, simple. ventriculi, 212. See also Ulcer of stotnach. Umbilicus, position of, 47 Unarmed tapeworm, 688 Uncinaria Americana, 702, 703 Uncinarial dermatitis, 703 anemia in, 705 blood in, 705 bone-marrow in, 705 diagnosis, 706 hemolymph glands in, 705 immunity, 704 intestines in, 705 kidneys in, 704 liver in, 704 lungs in, 704 morbid anatomy, 704 prognosis, 706 prophylaxis, 706 spleen in, 705 stomach in, 705 symptoms, 704 treatment, 706 Uncinariasis, 701 incidence, 701 parasite of, 702 Ureter, Head's zone for, 614 Urine, elimination of decomposition products in, 39 Urobilin in feces, 413 Urticaria, auto-intoxication in, 391 from foods, 364 Urticaria, stomach functions in, 391 Uterine adnexa. Head's zone for, 615 Uterus, Head's zone for, 615 perforation into, in rectal cancer, 564 Uvula, inspection of, 46 Vaccine, cancer, 274 Vacuum bottle for proctoclysis, 437 Vagina, perforation into, in rectal cancer, 564 Vaginal examination, digital, 51 in appendicitis, 602 Valvulse conniventes of Kerkring, 25 Van Deen's test for occult blood, Weber's modification, 115 Vedee vibrator, 165, 166 Vegetable and animal foods, difference, 127 Vegetables, chemic composition of, 131 Veins, mesenteric, embolism of, 554. See also Em,holism. thrombosis of, 554. See also Thrombosis. of cecum, 32 of colon, 32 of rectum, 32 of small intestine, 24 of stomach, 21 Venous hemorrhoids, 575 Ventriculi, cirrhosis, 191, 192, 204 phthisis, 191, 192, 203, 204. See also Achy Ha gastrica. sclerosis, 191, 192, 204 Vermes, 685 Vermiform appendix. See Appendix vermiformis. Vertical stomach, 349, 350 Vertigo in constipation, 463 Vibrators, 165, 166 Vibratory massage, 165 in atonic ectasy of stomach, 333 in chronic gastric atony, 305 gastritis, 197 in constipation, 467 Vichy water in hyi)erchl()rliydria, 289 Villi of small intestine, 26 Viscera, mechanical support of, 170 Visceral arteriosclerosis, 455 Visceroptosis, 341. See also Gastrop- tosis. Volatile acids in gastric contents, 102 766 INDEX Voluntary muscles in typhoid fever, 531 Volvulus, 639 age and, 640 anatomy, 641 course, 641, 652 definition, 639 differential diagnosis, 650 etiology, 640 frequency, 640 mechanics, 639 of sigmoid flexure, 639 of small intestine, 640 pain in, 640 prognosis, 653 sex and, 640 symptoms, 640 treatment, 653 tjmipanites in, 640 vomiting in, 640 Vomit, bile in, 112 blood in, 112 examination of, 1 1 1 food in. III mucus in, 112 parasites in, 112 Vomiting, cyclic, in children, 378 in acute intestinal obstruction, 647 in chronic intestinal obstruction, 659 treatment, 664 in gastric cancer, 246 treatment, 274 ulcer, treatment, 234 in intussusception, 643, 644 in pertussis, Kilmer's belt in, I75-I79 juvenile, 379 nervous, 377 idiopathic, 379 of blood, 211 Vomiting, periodic, 378 reflex, 379 significance of, 1 1 1 , 112 Von Leyden's periodic vomiting, 378 Von Noorden's determination of hy- drochloric acid deficit, 107 diet lists, 132, 133, 134 AVar, dysentery in, 502 Water infiltration method for hemor- rhoids, Gant's, 586 inflation of colon with, 408 of stomach with, 78 Weak stomach, predisposition to, 180 Weber's modification of Van Deen's test for occult blood, 115 Weinland's theory of gastric ulcer, 213 Wet, diarrhea from, 475 Whip-worm, 708 Whitehead's operation for hemor- rhoids, 586 Widal's reaction in typhoid fever, 534 Wines as food, 1 36 Wolff's artificial Carlsbad salts, 290 formula for Carlsbad salts, 199 W^orms, 685 fluke-, 692 in feces, 415 round-, 696 X-RAYS. 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D., Professor of Surgery at the New York Post-Graduate Medical School and Hospital ; and Prof. Dr. Victor Schmieden, Assistant to Prof. Bier, University of Berlin, Germany. Octavo of 280 pages, with original illustrations. Cloth, ;^3.oo net RECENTLY ISSUED— NEW (2d) EDITION— FOR THE PRACTITIONER For the practitioner this work has a particular value, because it gives special attention to the hyperemic treatment of those conditions with which he comes in daily contact. Yet the needs of the surgeon and the specialist have not, by any means, been neglected. The work is not a translation, but an entirely original book, by Dr. Willy Meyer, who has practised the treatment for the past fifteen years, and Prof. Schmieden, Professor Bier's assistant at Berlin University. In the first part the three methods of inducing hyperemia are described; in the second, are taken up the details of apphcation. New York State Journal of Medicine " We commend this work to all those who are interested in the treatment of infections, either acute or chronic, for it is the only authoritative treatise we have in the English language." Campbell's Surg^ical Anatomy A Text=Book of Surgical Anatomy. By William Francis Camp- bell, M. D., Professor of Anatomy, Long Island College Hospital. Octavo of 675 pages, with 319 original illustrations. Cloth, ;^5.0o net; Half Morocco, $6.50 net. WITH 319 PRACTICAL ILLUSTRATIONS The first aim in the preparation of this original work was to emphasize the practical. It is in the fullest sense an applied anatomy — an anatomy that will be of inestimable value to the surgeon because only those facts are discussed and only those structures and regions emphasized that have a peculiar interest to him. Dr. Campbell has treated his subject in a very systematic way. The magnificent original illustrations will be found extremely practical. Boston Medical and Surgical Journal " The author has an excellent command of his subject, and treats it with the freedom and the conviction of the experienced anatomist. He is also an admirable clinician." SURGER V AND ANA TOM\ Schultze and Stewart's Topog(raphic Anatomy Atlas and Text=Book of Topographic and Applied Anatomy. By Prof. Dr. O. Schultze, of Wurzburg. Edited, with additions, by George D. Stewart, M.D., Professor of Anatomy and Clinical Sur- gery, University and Bellevue Hospital Medical College, N. Y. Large quarto of 189 pages, with 25 colored figures on 22 colored lithographic plates, and 89 text-cuts, 60 in colors. Cloth, ^5.50 net. WITH BEAUTIFUL COLORED PLATES It was Professor Schultze' s special aim, in preparing this work, to produce a Text-Book and Atlas, not for the anatomist alone, but more particularly for the general practitioner. The value of the knowledge of topographic anatomy in bed- side diagnosis is emphasized throughout the book. The many colored lithographic plates are exceptionally excellent. Arthur Dean Bevan. M. D., Professor of Stirgery in Rush Medical College, Chicago. " I regard Schultze and Stewart's Topographic and Applied Anatomy as a very admirable work, for students especially, and I find the plates and the text excellent." Sobotta and McMurrich*s Human Anatomy Atlas and Text-Book of Human Anatomy. In Three Volumes. By J. Sobotta, M.D., of Wurzburg. Edited, with additions, by J. Playfair McMurrich, a. M., Ph. D., Professor of Anatomy, University of Toronto, Canada. Three large quartos, each containing about 250 pages of text and over 300 illustrations, mostly in colors. Per volume : Cloth, ^6.00 net ; Half Morocco, ^7.50 net. VOLUME III NOW READY— COMPLETING THE WORK The oreat advantage of this over other similar works lies in the large number of mao-nificent lithographic plates which it contains, without question the best that have ever been produced in this field. They are accurate and beautiful reproduc- tions of the various anatomic parts represented. Edweo'd Martin, M.D., Professor of Clinical Surger/, University of Pennsylvania. "This is a piece of bookmaking which is truly admirable, with plates and text so well chosen and so clear that the work is most useful to the practising surgeon." lo SAUNDERS' BOOKS ON Eisendrath's Surgical Diag'nosis A Text=Book of Surgical Diagnosis. By Daniel N. Eisendrath, M.D., Professor of Surgery in the College of Physicians and Surgeons, Chicago. Octavo of 885 pages, with 574 entirely new and original text-illustrations and some colored plates. Cloth, $6.50 net; Half Morocco, 38.00 net. JUST ISSUED— THE NEW (2d) EDITION Of first importance in exerj surgical condition is a correct diagnosis, for upon this depends the treatment to be pursued ; and the two — diagnosis and treatment — constitute the most practical part of practical surger}-. Dr. Eisendrath takes up each disease and injury amenable to surgical treatment, and sets forth the means of correct diagnosis in a systematic and comprehensive way. Definite directions as to methods of examination are presented clearly and concisely, providing for all contingencies that might arise in any given case. Each illustration indi- cates precisely how to diagnose the condition considered. Surgery, Gynecology, and Obstetrics "The book is one which is well adapted to the ttses of the practising surgeon who desires intormation concisel)' and accurately given. . . . Nothing of diagnostic importance is omitted, yet the author does not run into endless detail." E^isendrath's Clinical Anatomy A Text=Book of Clinical Anatomy. By Daniel N. Eisendrath, A.B., M.D., Professor of Surgery in the College of Physicians and Surgeons, Chicago. Octavo of 535 pages, illustrated. Cloth, ^5.00 net; Half Morocco, ;$6.50 net. THE NEW (2d) EDITION This new anatomv discusses the subject from the clinical standpoint. A por- tion of each chapter 'is devoted to the examination of the living through palpation and marking of surface outlines of landmarks, vessels, nerves, thoracic and abdominal viscera. The illustrations are from new and original drawings and photographs. This edition has been carefully revised. Medical Record, New York " \ special recommendation for the figures is that they are mostly original and were made for the purpose in view. The sections of joints and trunks are those of formalmized cadavers and are unimpeachable in accuracy." SURGERY AND ANATOMY ii Moynihan*s Abdominal Operations Abdominal Operations. By B. G. A. Moynihan, M. S. (Lond.), F.R.C.S., Senior Assistant Surgeon, Leeds General Infirmary, England. Octavo, beautifully illustrated. Cloth, ^7.00 net ; Half Morocco, ^8.50 net. THE NEW (2d) EDITION TWO LARGE EDITIONS IN ONE YEAR It has been said of Mr. Moynihan that in describing details of operations he is at his best. The appearance of this, his latest work, therefore, will be widely welcomed by the medical profession, giving, as it does, in most clear and exact language, not only the actual modus operatidt of the various abdominal operations, but also the preliminary technic of preparation and sterilization. Complications and sequela; and after-treatment are presented in the same clear, clean-cut manner as the operations themselves. The beautiful illustrations have been especially drawn. Edward Martin, M. D. Professor of Clinical Su7'gery, University of Pennsylvania " It is a wonderfully good book. He has achieved complete success in illustrating, both by words and pictures, the best technic of the abdominal operations now commonly performed." Moynihan on Gall-stones Qall=stones and Tlieir Surgical Treatment. By B. G. A. Moyni- han, M.S. (Lond.), F.R.C.S., Senior Assistant Surgeon, Leeds General Infirmary, England. Octavo of 458 pages, fully illustrated. Cloth, $ 5.00 net; Half Morocco, $6.50 net. THE NEW (2d) EDITION Mr. Moynihan, in revising his book, has made many additions to the text, so as to include the most recent advances. Especial attention has been given to a detailed description of the early symptoms in cholelithiasis, enabling a diagnosis to be made in the stage in which surgical treatment can be most safely adopted. Every phrase of gall-stone disease is dealt with, and is illustrated by a large number of clinical records. The account of the operative treatment of all the forms and complications of gall-stone disease is full and accurate. A number of the illustrations are in color. Britiah Medical JoumzJ " He expresses his views with admirable clearness, and he supports them by a large num- ber of clinical examples, which will be much prized by those who know the difficult problems and tasks which gall-stone surgery not infrequently presents." 12 SAUNDERS' BOOKS ON Gould's Operations on the Intestines and Stomach The Technic of Operations upon the Intestines and Stomach. By Alfred H. Gould, M. D., of Boston. Large octavo, with 190 original illustrations, some in colors. Cloth, $5.00 net ; Half Morocco, |6.5Ciiet. WITH 190 ORIGINAL ILLUSTRATIONS Dr. Gould' s new work is the result of exhaustive experimentation, the technic of the operations described being simpHfied as far as possible by experiments on animals, thus leading to the development of many new features. The text is pur- posely concise, the technic being presented very clearly by the numerous practical illustrations, all made from actual operations done either upon the animal or the human being. As the success of gastro-intestinal surgery depends upon an accur- ate knowledge of the elementary steps, a thorough account of repair is included. New York State Journal of Medicine " The illustrations are so good that one scarcely needs the text to elucidate the steps of the operations described. The work represents the best surgical knowledge and skill." DaCosta*s Modern Surgery Modern Surgery — General and Operative. By John Chalmers DaCosta, M. D., Professor of Surgery and of Clinical Surgery in the Jefferson Medical College, Philadelphia. Octavo of 1283 pages, with 872 illustrations. Cloth, ^5.50 net; Half Morocco, $7.00 net. THE NEW (5th) EDITION For this new fifth edition the work has been entirely rewritten and reset. One hundred and fifty new illustrations have been added ; and the work has been en- larged by the addition of two hundred pages. To keep the book of a size to handle conveniently, a thinner but high-grade paper has been used. DaCosta's Surgery in this edition will more than maintain the reputation already won. Boston Medical and Surgical Journal " We commend the book, as we have previously commended it, to surgeons and to students as the most satisfactory one-volume contemporaneous treastise on surgery published in this country." SURGER Y AND ANA TOMY ^ 3 Preiswerk and Warren's Dentistry Atlas and Epitome of Dentistry. By Pkof. G. Preiswerk, of Basil. Ed- ited, with additions, by George W. Warren, D.D.S., Professor of Operative Dentistry, Pennsylvania College of Dental Surgery, Philadelphia. With 44 lithographic plates, 152 text-cuts, and 343 pages of text. Cloth, #3.50 net hi Saunders Atlas Series. " Nowhere in dental literature have we ever seen illustrations which can begin to compare with the exquisite colored plates produced in this volume." — Dental Review. Griffith's Hand-Book of Surgery A Manual of Surgery. By Frederic R. Griffith, M. D., Surgeon to the Bellevue Dispensary, New York City. i2mo of 579 pages, with 417 illus- trations. Flexible leather, $2.00 net. " Well adapted to the needs of the student and to the busy practitioner for a hasty review of important points in surgery." — American Medicine. Keen's Addresses and Other Papers Addresses and Other Papers. Delivered by William W. Keen, M. D., LL.D., F. R. C. S. (Hon.), Professor of the Principles of Surgery and of Clin- ical Surgery, Jefferson Medical College, Philadelphia. Octavo volume of 441 pages, illustrated. Cloth, ,$3.75 net. Keen on the Surgery of TypKoid The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen. M.D., LL.D., F.R.C.S. (Hon.), Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia, etc. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. " Every surgical incident which can occur during or after typhoid fever is amply discussed and fully illustrated by cases. . . . The book will be useful both to the surgeon and physician." — 'J he Practitioner, London. Lewis' Anatomy and Physiology for Nurses Just Ready— New (2d) Edition Anatomy and Physiology for Nurses. By LeRoy Lewis, M. D., Surgeon to and Lecturer on Anatomy and Physiology for Nurses at the Lewis Hospital, Lay City, Michigan. i2mo, 375 pages, with 150 illustrations. Cloth, ;> 1.75 net. A demand for such a work as this, treating the subjects from the nitrse's point of view, has long existed. Dr. Lewis has based the plan and scope of this work on tlie methods em- ployed by him in teaching these branches, making the te.xt unusually simple and clear. " It Is not in any sense rudimentary, but comprehensive in its treatment of the subjects in hand." — Nurses Journal of the Pacific Coast. McClellan*s Art Anatomy Anatomy in Its Relation to Art. By George McClellan, M. D., Professor of Anatomy, Pennsylvania Academy of the Fine Arts. Quarto volume, 9 by 12^ inches, with 338 original drawings and photographs, and 260 pages of text. Dark blue vellum, #10.00 net ; Half Russia, $12.50 net. 14 SAUNDERS' BOOKS ON Haynes* Anatomy A Manual of Anatomy. By Irving S. Haynes, M.D., Professor of Prac- tical Anatomy, Cornell University Medical College. Octavo, 680 pages, with 42 diagrams and 134 full-page half-tones. Cloth, I2.50 net. American Pocket Dictionary ""ISS^eSh The American Pocket Medical Dictionary. Edited by W. A. Newman Borland, A.M.,M.D., Assistant Obstetrician, Hospital of the University of Pennsylvania, etc. 598 pages. Full leather, limp, with gold edges, $1.00 net; with patent thumb index, I1.25 net. Grant on Face, Mouth, and Jaws A Text=Book of the Surgical Principles and Surgical Diseases of the Face, Mouth, and Jaws. For Dental Students. By H. Horace Grant, A.M., M.D., Professor of Surgery and of Clinical Surgery, Hospital College of Medicine. Octavo of 231 pages, with 68 illustrations. Cloth, I2.50 net. Fowler's Surgery in Two Volumes A Treatise on Surgery. By George R. Fowler, M. D., Emeritus Pro- fessor of Surgery, New York Polyclinic. Two imperial octavos of 725 pages each, with 888 original text-illustrations and 4 colored plates. Per set : Cloth, ^15.00 net ; Half Morocco, $18.00 net. International Text- Book of Surgery second Edition The International Text=Book of Surgery. In two volumes. By Ameri- can and British authors. Edited by J. Collins Warren, M. D., LL. D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Medical School ; and A. Pearce Gould, M. S., F. R. C. S., of London, England. Vol. I. : General and Operative Surgery. Royal octavo, 975 pages, 461 illustrations, 9 full- page colored plates. Vol. II. : Special or Regional Surgery. Royal octavo, 1 122 pages, 499 illustrations, and 8 full-page colored plates. Per volume : Cloth, $5.00 net ; Half Morocco, $6. 50 net. American Text-Book of Surgery Fourth Edition American Text=Book of Surgery. Edited by W. W. Keen, M. D., LL. D., Hon. F. R. C. S., Eng. and Edin., and J. William White, M. D., Ph. D. Octavo, 1363 pages, 551 text-cuts and 39 colored and half-tone plates. Cloth, 1^7.00 net ; Half Morocco, ^8.50 net. Robson and Cammidge on the Pancreas The Pancreas : Its Surgery and Pathology. By A. W. Mayo Robson, F. R. C. S., of London, England ; and P. J. Cammidge, F. R. C. S., of London, England. Octavo of 546 pages, illustrated. Cloth, $5.00 net ; Half Morocco, $6.50 net. SURGERY AND ANA TO Ml. 15 American Illustrated Dictionary The New (si^fE^'duion The American Illustrated Medical Dictionary. With tables of Arteries, Muscles, Nerves, Veins, etc. ; of Bacilli, Bacteria, etc. ; Eponymic Tables of Diseases, Operations, Stains, Tests, etc. By W. A. Newman Borland, M.D. Large octavo, 876 pages. Flexible leather, ^4.50 net; with thumb index, ^5.00 net. Howard A. Kelly, M.D., Prof cssor of Gynecology , Johns Hopkins University, Baltimore. "Dr. Borland's dictionary is admirable. It is so well gotten up and of such con- venient size. No errors have been found in my use of it." Golebiewski and Bailey's Accident Diseases Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, M.D. Consulting Neurologist to St. Luke's Hospital, New York City. With 71 colored figures on 40 plates, 143 text-cuts, and 549 pages of text. Cloth, ^4.00 net. In Saunders' Hand-Atlas Series. Helferich and Bloodgood on Fractures Atlas and Epitome of Traumatic Fractures and Dislocations By Prof. Dr. H. Helferich, of Greifswald, Prussia. Edited, with ad- ditions, by Joseph C. Bloodgood, M. D., Associate in Surgery, Johns Hopkins University, Baltimore. 216 colored figures on 64 lithographic plates, 190 text-cuts, and 353pages of text. Cloth, $3.00 net. In Saun- ders' Atlas Series. Sultan and Coley on Abdominal Hernias Atlas and Epitome of Abdominal Hernias. By Pr. Dr. G. Sul- tan, of Gottingen. Edited, with additions, by Wm. B. Coley, M. D., Clinical Lecturer and Instructor in Surgery, Columbia University, New York. 119 illustrations, 36 in colors, and 277 pages of text. Cloth, ^3.00 net. In Saunders' Hand-Atlas Series. Warren's Surgical Pathology ISn Surgical Pathology and Therapeutics. By J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard Medical School. Octavo, 873 pages; 136 illustrations, 33 in colors. Cloth, ^5.00 net; Half Morocco, I6.50 net. Zuckerkandl and DaCosta*s Surgery Ed^^^ Atlas and Epitome of Operative Surgery. By Dr. O. Zucker- KANDL, of Vienna. Edited, with additions, by J. Chalmers DaCosta, M. D., Professor of Surgery and Clinical Surgery, Jefferson Medical Col- lege, Phila. 40 colored plates, 278 text-cuts, and 410 pages of text. Cloth, ^3.50 net. In Saunders' Atlas Series. l6 SURGER V AND ANA TOMY Moore's Orthopedic Surgery A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo of 356 pages, handsomely illustrated. Cloth, $2.50 net. "Ju^ '^ j°'^ '^ eminently practical. It is a sate guide in the understanding and treatment ot orthopedic cases. Should be owned by every surgec-a and practitioner."— ^«>za/j o/^M^^^yy. Fowler's Operating Room New (2d) Edition The Operating Room and the Patient. By Russell S. Fowler, M. D., Surgeon to the German Hospital, Brooklyn, New York. Octavo of 284 pages, illustrated. Cloth, $2.00 net. Dr. Fowler has written his book for surgeons, nurses assisting at an operation, internes, and all others whose duties bring them into the operating room. It contains explicit directions for the preparation of material, instruments needed, position of patient, etc., all beautifully illustrated. Nancrede's Principles of Surgery New (2d) Edition Lectures on the Principles of Surgery. By Chas. B. Nancrede, M.D., LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Octavo, 407 pages, illustrated. Cloth, $2. 50 net. " We can strongly recommend this book to all students and those who would see something of the scientific foundation upon which the art of surgery is huWV— Quarterly Medical Journal, Sheffield, England. Nancrede's Essentials of Anatomy, seventh Edition Essentials of Anatomy, including the Anatomy of the Viscera. By Chas. B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Crown octavo, 388 pages ; 180 cuts. With an Appendix containing over 60 illustrations of the osteology of the body. Based on G7-ay s Anatomy. Cloth, $1.00 net. ht Saunders Question Comp ends. " The questions have been wisely selected, and the answers accurately and concisely given." — University Medical Magazine. Martin's Essentials of Surgery. ^^^Xvifed"""" Essentials of Surgery. Containing also Venereal Diseases, Surgical Land- marks, Minor and Operative Surgery, and a complete description, with illus- trations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Professor of Chnical Surgery, University of Pennsylvania, etc. Cro^vn octavo, 338 pages, illustrated. With an Appendix on Antiseptic Sur- gery, etc. Cloth, $1.00 net. In Saunders' Questmt Compends. '■ Written to assist the student, it will be of undoubted value to the practitioner, containing as it does the essence of surgical work." — Boston Medical and Surgical Journal. Martin's Essentials of Minor Surgery, Band« aging, and Venereal Diseases. ^^^'"Edit'kjn^*^^** Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A.M., M.D., Professor of Clinical Surgery, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, ^i.oo net. In Saunders'' Question Competids. "The best condensation of the subjects of which it treats yet placed before the profession."— The Medical News, Philadelphia. Kr^2_ \\<^y^ \ KC so\ K^z