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DISEASES 
 
 /^^^/£^^^ 
 
 THE INTESTINES 
 
 A TEXT-BOOK FOE PKACTITIOXEES AO 
 ' STITDEXTS OF MEDICINE 
 
 MiVX EINHOPvX, M.D. 
 
 PBOFESSOE OF MEDICINE AT THE NEW YOEK PO^ST-GKAPCATE MEDICAL 
 SCHOOL AND HOSPITAL, AND VISITING PHYSICIAN AT 
 
 THE GERMAN HOSPITAL. NEW YORK 
 
 Secont), IReviset) BMtion 
 
 NEW YORK 
 WILLIAM WOOD AXD COMPANY 
 
 MDCCCCIV 
 
Copyright, 1904, 
 BY WILLIAM WOOD AND COMPANY 
 
TO 
 
 MY ESTEEIVIED FRIEND AND TEACHER 
 
 ERNST VON LEYDEN, M.D. 
 
 PKOPESSOR OF MEDICINE IN THE UNIVERSITY OF BERLIN 
 THIS BOOK 
 
 IS RESPECTFULLY DEDICATED 
 
PREFACE TO THE SECOND EDITION. 
 
 It affords me iniicli gratification to see that my work on 
 ^' Disease;^ of the Intestines " has found favor with the medi- 
 cal profession. The entire issue being exhausted, a new 
 edition of this book is herewith published. Very few 
 additions have been made to the original text, as the prog- 
 ress in this branch of medicine within the last four years 
 has been but scanty. I trust the present edition will meet 
 with the same friendly reception as the first. 
 
 Max Eixhoex. 
 
 New Yokk, February lOth, 1904. 
 
 PREFACE TO THE FIRST EDITION. 
 
 This treatise is a continuation of ray work on " Diseases 
 of the Stomach," the two together comprising the principal 
 disorders of the digestive tract. In discussing the subject 
 of the intestinal affections an effort has been made to follow 
 the same lines laid down in my book on the stomach. The 
 practical points regarding diagnosis and treatment are al- 
 ways placed in the foreground. 
 
 Although our knowledge of diseases of the intestines has 
 not made such rax3id progress as that of morbid conditions 
 
VI PREFACE. 
 
 of the stomacli, mucli lias likewise been achieved in this 
 field. Surgery has made many successful advances. The 
 elucidation of the intimate relation existing between func- 
 tional disturbances of the stomach and of the intestines 
 also marks an important step forward, especially as to 
 therapy. 
 
 While there are many excellent works on intestinal dis- 
 eases by German authors, the more recent English literature 
 contains no monographs on this important subject. The 
 medical encyclopedias, it is true, contain very instructive 
 contributions on this topic, and among these Ewald's treat- 
 ise on diseases of the intestines in the "Twentieth Century 
 Practice of Medicine " is a most valuable acquisition. 
 
 The j)resent volume, it is hoped, will to a certain extent 
 fill the void in American literature of a monograph on the 
 affections of this portion of the digestive tract. The writer 
 desires to express his indebtedness toNothnagel, Eosenheim, 
 Boas, Fleischer, Ewald, Pick, Fowler, Treves, and Ailing- 
 ham, whose works have been frequently consulted. He 
 trusts that this book will prove of practical utility to the 
 practitioner, and if it will aid him in more successfully 
 treating this class of cases, the author's effort will be more 
 than recompensed. Max Einhorn. 
 
 New York, April, 1900. 
 
COJ^TENTS. 
 
 CHAPTER I. 
 
 / Anatomy and Physiology. 
 
 PASB 
 
 Anatomy, 1 
 
 The Intestinal Canal (Intestinum), 1 
 
 The Duodenum, 1 
 
 The Small Intestine, 4 
 
 Structure of the Small Intestine, 6 
 
 The Large Intestine or Large Bowel (Intestinum Crassum), . 11 
 
 Histology of the Large Bowel, . . . . , .17 
 
 Physiology, 18 
 
 1. The Secretory Function or the Chemical Processes in the 
 
 Intestines, 18 
 
 2. Absorption 24 
 
 3. Motion, 38 
 
 CHAPTER II. 
 
 Methods of Examination and Tbeatment. 
 
 Exammation, 33 
 
 Interrogation, 33 
 
 Inspection, 34 
 
 Proctoscopy, - . 87 
 
 Palpation, 40 
 
 Percussion, 44 
 
 Auscultation, 45 
 
 Inflation of the Intestine with Carbonic Acid Gas or Air, . 45 
 
 Injection of Water per Anum, 48 
 
 Lavage of the Bowel, 48 
 
 Examination of the Faeces, 49 
 
 Treatment, 77 
 
 Diet, 77 
 
 Mechanical Procedures, ...,..,. 81 
 
 Injections, 81 
 
 Massage and Gymnastic Exercises, 83 
 
vni CONTENTS. . 
 
 PAGE 
 
 Mechanical Procedures : 
 
 Hydrotherapy, . 83 
 
 Electricity, 84 
 
 CHAPTER III. 
 Acute and Chronic Intestinal Catabkh. 
 
 Acute Intestinal Catarrh, 86 
 
 Synonyms, 86 
 
 Definition, . , . 86 
 
 Etiology, 86 
 
 ' Morbid Anatomy, 88 
 
 Symptomatology, 89 
 
 General Subjective Symptoms, 90 
 
 Objective Symptoms, 91 
 
 Fever, 92 
 
 Localization of the Catarrhal Process, . . . . .92 
 
 Duration, 93 
 
 Diagnosis, 94 
 
 Prognosis, 94 
 
 Treatment, 94 
 
 Chronic Intestinal Catarrh, 97 
 
 Synonyms, .......... 97 
 
 Definition, 97 
 
 Etiology, c ..... 97 
 
 Morbid Anatomy, ......... 98 
 
 Symptomatology, 101 
 
 Objective Symptoms, 102 
 
 Course, ........... 106 
 
 Diagnosis, . 106 
 
 Prognosis, 107 
 
 Treatment, 108 
 
 Hydro therapeutic Measures, 109 
 
 Mineral Waters, 110 
 
 Medicaments, 110 
 
 CHAPTER IV. 
 Dysenteby. 
 
 Dysentery, . . . .' 113 
 
 Synonyms, . . . . , 113 
 
 Definition, 113 
 
 Etiology, 113 
 
 Morbid Anatomy, ,118 
 
CONTENTS. 
 
 IX 
 
 Dysentery : 
 
 Symptomatology of Acute Dysentery, 
 
 Symptomatology of Chronic Dysentery, 
 
 Course, .... 
 
 Complications, . 
 
 Diagnosis, 
 
 Prognosis, 
 
 Treatment of Acute Dysentery, 
 
 Treatment of Chronic Dysentery, 
 
 / 
 
 CHAPTER V. 
 
 Ulceks of the Intestines. 
 
 1. Duodenal Ulcer, . 
 
 Synonyms, 
 
 Definition, 
 
 Etiology, . 
 
 Morbid Anatomy, 
 
 Situation of the Tlcer 
 
 Symptomatology, 
 
 Course, 
 
 Diagnosis, 
 
 Prognosis, . 
 
 Treatment, 
 
 2. Embolic and Thrombotic Ulcers, 
 
 Pathological Changes, 
 
 Sjanptoms, 
 
 Diagnosis, 
 
 Prognosis, 
 
 Treatment, 
 
 3. Amyloid Ulcers, . 
 
 Diagnosis, 
 
 4. Tuberculous Ulcers, 
 
 5. Syphilitic Ulcers, 
 
 6. Toxic Ulcers, 
 
 Sjanptomatology, 
 Diagnosis, 
 Prognosis, 
 Treatment, 
 
 CHAPTER VI. 
 
 Neoplasms op the Intestine. 
 
 PAGE 
 . 128 
 
 . 126 
 . 127 
 . 127 
 . 128 
 . 129 
 , 129 
 , 131 
 
 133 
 133 
 133 
 133 
 134 
 135 
 136 
 138 
 138 
 139 
 139 
 140 
 140 
 141 
 143 
 144 
 144 
 145 
 146 
 146 
 149 
 15a 
 151 
 153 
 153 
 153 
 
 Malignant Growths, 
 Cancer, 
 
 156 
 
 156 
 
X CONTENTS. 
 
 PAGE 
 
 Cancer .- 
 
 Definition, , loG 
 
 Etiology, 15(5 
 
 Location 157 
 
 Morbid Anatomy, . 158 
 
 Symptomatology, 160 
 
 Course, 169 
 
 Diagnosis, 169 
 
 Prognosis, 170 
 
 Treatment, 170 
 
 Sarcoma and Lympho-Sarcoma, 172 
 
 Benign Tumors of the Intestine, 173 
 
 CHAPTER VII. 
 
 HEMORBHOrDS. 
 
 Hemorrhoids, 175 
 
 Synonyms, . . . . - 175 
 
 Definition, 175 
 
 Etiology 175 
 
 Morbid Anatomy, . . . 177 
 
 Symptomatology, . 180 
 
 Diagnosis, 185 
 
 Prognosis, 186 
 
 Treatment, 186 
 
 Radical, 191 
 
 Complications, 195 
 
 Prolapse of the Rectum, 195 
 
 Fissure of the Anus, 199 
 
 CHAPTER Vin. 
 
 Appendicitis. 
 
 Appendicitis, 302 
 
 Synonyms, 202 
 
 Definition, 202 
 
 General Remarks, 202 
 
 Etiology, 203 
 
 Morbid Anatomy, 208 
 
 Symptomatology, 212 
 
 Course, 214 
 
 Diagnosis, . . . . . . . . , . 220 
 
 Differential Diagnosis, 221 
 
 Prognosis, 222 
 
CONTENTS. xl 
 
 PAGE 
 
 Appendicitis: 
 
 Treatment, • 224 
 
 Medical 224 
 
 Surgical, 227 
 
 CHAPTER IX. 
 
 Intestiis'al Obstruction. 
 
 Introductory Remarks, 232 
 
 Acute Intestinal Obstruction, 233 
 
 Synonyms, 233 
 
 Definition, . 233 
 
 Etiology, 233 
 
 Compression of the Intestine, 233 
 
 Strangulation by Adhesions, 234 
 
 Strangulation by Meckel's Diverticulum, . . . 236 
 
 Volvulus, 238 
 
 Obturations, 239 
 
 Intussusception, 240 
 
 Pathological Changes, 242 
 
 Symptomatology 244 
 
 Objective Signs, 251 
 
 Course, 253 
 
 Diagnosis, 255 
 
 Prognosis, 204 
 
 Treatment, 264 
 
 Medical, 264 
 
 Surgical, 272 
 
 Chronic Intestinal Obstruction, 272 
 
 Etiology, 272 
 
 Symptomatology, 275 
 
 Complications, 282 
 
 Course and Prognosis, 283 
 
 Diagnosis, 283 
 
 Treatment, 284 
 
 Operative Intervention, 286 
 
 CHAPTER X. 
 
 Nervous Affections of the Intestines. 
 
 General Remarks, 288 
 
 Motor Neuroses of the Intestines, 290 
 
 Diarrhoea, 290 
 
 Etiology and Symptomatology, 290 
 
 Diagnosis, 295 
 
xu CONTENTS. 
 
 Diarrhoea : 
 
 Prognosis, . 295 
 
 Treatment, . , 295 
 
 Constipation, 297 
 
 Synonyms, ... .o .... 297 
 
 Definition, . 297 
 
 General Remarks, 297 
 
 Etiology, 298 
 
 Symptomatology, 303 
 
 Diagnosis, 308 
 
 Prognosis 310 
 
 Treatment, 310 
 
 Moral, 311 
 
 Dietetic, 311 
 
 Mechanical, . 312 
 
 CHAPTER XI. 
 
 Nervous Affections op the Intestines. 
 
 Motor Neuroses (Continued), 320 
 
 Paralysis of the Intestines, 320 
 
 Diagnosis, 321 
 
 Treatment, 321 
 
 Proctospasmus, or Spasm of the Rectum, 322 
 
 Diagnosis, . . ' 323 
 
 Treatment, 323 
 
 Paresis and Paralysis of the Sphincters of the Anus, . . 323 
 
 Diagnosis, 324 
 
 Prognosis, 324 
 
 Treatment, 324 
 
 Peristaltic Restlessness of the Intestines, 325 
 
 Definition, . 325 
 
 Etiology and Symptomatology, 325 
 
 Diagnosis, 326 
 
 Prognosis, . . . • 326 
 
 Treatment, 326 
 
 Meteorism, 327 
 
 Etiology, 327 
 
 Symptomatology, , . . . . . • . 328 
 
 Diagnosis, 329 
 
 Prognosis, 329 
 
 Treatment, 329 
 
 Sensory Neuroses of the Intestines, » . . . - .331 
 
 Enteralgia, 332 
 
CONTENTS. xiu 
 
 PACK 
 
 Enteralgia : 
 
 Synonyms, 332 
 
 Definition, 333 
 
 Etiology 333 
 
 Symptomatology, 333 
 
 Diagnosis, 335 
 
 Prognosis, 336 
 
 Treatment, 336 
 
 Hypogastric Neuralgia, 338 
 
 Treatment, 338 
 
 Hypersesthesia, Parsestliesia, and Anaesthesia of the Intestine, 339 
 
 T4-eatment, . ■ 340 
 
 Secretory Neuroses of the Intestines, 341 
 
 Membranous Enteritis, . . . . . . . . 341 
 
 Synouj'ms, 841 
 
 Definition, 341 
 
 History, 341 
 
 Etiology, 345 
 
 Symptomatology, 347 
 
 Diagnosis, 349 
 
 Treatment, .350 
 
 Intestinal Neurasthenia. . . ' . 358 
 
 Diagnosis, 354 
 
 Treatment, 354 
 
 CHAPTER Xn. 
 
 INTESTINAL PaEASITES. 
 
 General Remarks, . . ' 355 
 
 Protozoa, . , 3,55 
 
 Amoebse, 355 
 
 Sporozoa. 356 
 
 Infusoria, 356 
 
 Vermes, . 357 
 
 Cestodes (Tape Wonns), 357 
 
 General Remarks, 357 
 
 Ttenia Solium, 360 
 
 Taenia Saginata or Mediocanellata, ..... 361 
 Bothriocephalus Latus, Taenia Lata, or Pig Head, . . 363 
 
 Taenia Nana. 364 
 
 Taenia Cucumerina, 364 
 
 Taenia Flavopunctata or Taenia Diminuta, . . . 365 
 
 Treatment, 365 
 
 Trematodes (Fluke Worms) 368 
 
XIV CONTENTS. 
 
 PAGE 
 
 Ti'ematodes (Fluke Worms) : 
 
 Distoma Hepaticum or Liver Fluke, . . . . ,308 
 
 Distoma Lanceolatum 869 
 
 Distoma Haematoljium or Bilharzia Haematobia, , . 370 
 
 Nematodes (Round Worms), 371 
 
 Ascaris Lumbricoides (Common Spool or Round Worm), . 371 
 
 Diagnosis 873 
 
 Symptoms . 373 
 
 Prophylaxis, 874 
 
 Treatment . . . . . 374 
 
 Ascaris Mystax, 375 
 
 Oxyuris Vei-micularis, Awltail, Seat or Pin Worm, Maggot 
 
 or Thread Worm, 375 
 
 Symptoms, 376 
 
 Diagnosis, 377 
 
 Prophylaxis, . 377 
 
 Treatment, 377 
 
 Anchylostoma Duodenale, Dochmius Duodenalis, or Stron- 
 
 gylus Duodenalis, 378 
 
 Symptoms, 380 
 
 Course, 381 
 
 Diagnosis, 381 
 
 Treatment, 382 
 
 Anguillula Stercoralis, . 382 
 
 Anguillula Intestinalis, 382 
 
 Trichocephalus Dispar, Whip Worm, .... 388 
 
 Symptoms, . 383 
 
 Diagnosis, 383 
 
 Trichina Spiralis 385 
 
 Prophylaxis, 386 
 
 Treatment, . 386 
 
DISEASES OF THE INTESTINES. 
 
 CHAPTER I. 
 
 ANATOMY AND PHYSIOLOGY. 
 
 ANATOMY. 
 
 The Intestinal Caned (Intestinum). 
 
 The intestinal canal may be divided into two parts, the 
 small intestine and tlie large intestine (Fig. 1). The small 
 intestine (intestinum tenue) is about seven to eight metres 
 long, the first portion being called the duodenum, the sec- 
 ond the jejunum, and the third the ileum. With the ex- 
 ception of the duodenum the small intestine lies for the 
 most part inside the more fixed portion of the large intes- 
 tine and is connected to the posterior abdominal wall by 
 the mesentery. This broad membrane extends from above 
 downward and from left to right, from the end of the duo- 
 denum above to the ileocgecal valve below, enclosing the 
 jejunum and ileum along the whole of their extent. 
 
 The Duodenum. 
 
 The duodenum, so called on account of its length (being 
 
 about twelve inches long), is, unlike the other parts of the 
 
 small intestine, very definite in position and extent. It is 
 
 that part which is not suspended by the mesentery. It is, 
 
 further, the most fixed as well as the widest part of the 
 
 small intestine, measuring one and one-half to two inches 
 1 
 
^ DISEASES OF THE INTESTINES. 
 
 in diameter. It lias a curved shape, somewhat resembling 
 that of a horseshoe. It surrounds the pancreas and is 
 divided into four parts : 
 
 1. The superior horizontal portion (j)ars horizontalis 
 superior) begins at the pylorus, lying at the level of the 
 first lumbar vertebra, and runs slightly upvi^ard and back- 
 ward toward the right until it reaches the right side of the 
 vertebral column. It ends at the neck of the gall bladder, 
 and is the most movable of the four portions. It is cov- 
 ered by the two layers of the x)eritoneum which are contin- 
 ued from the stomach, and by these it is completely sur- 
 rounded. Above it lie the liver (quadrate lobe) and the 
 gall bladder, below it is the pancreas, and behind it are the 
 common bile duct and hepatic vessels. 
 
 2. The descending j^ortion of the duodenum, beginning at 
 the neck of the gall bladder, is about twice as long as the 
 first portion, and runs almost vertically to the second or 
 third lumbar vertebra. It lies to the right of the lumbar 
 vertebrae, and touches the right kidney. In front of it and 
 crossing it almost at a right angle, runs the transverse 
 colon. It is more fixed than the first portion. On its left 
 side is the pancreas, and the common bile duct a little 
 more posteriorly. Into this part of the bowel, and at its 
 inner and back part, but four inches from the pylorus, the 
 common bile duct and pancreatic duct enter. The portion 
 at which these ducts enter, occasionally forms a small sinus 
 (diverticulum or ampulla Vateri). 
 
 3. The third part or the transverse portion is the longest, 
 measuring about five inches. It extends from the base of 
 the second or third lumbar vertebra on the right side 
 obliquely across the spine to the upper part of the left side, 
 ascending a little on its way. In front of it is found the 
 lower layer of the transverse mesocolon. The superior 
 
ANATOMY. 
 
 mesenteric vessels cross this part of the duodenum, running 
 between it and the pancreas in order to reach the mesentery. 
 This portion is in relation with the i^ancreas and superior 
 
 22 
 
 Fig. 1.— The Intestine, as Seen from the Front, after Removing tbe Omentum (Testut). 
 1, Abdominal wall ; 2, wall of the thorax ; 3, oesophagus ; 3', cardia : 4, stomach ; 4', 
 pylorus ; 5, duodenum ; 6, pancreas ; 7, liver ; 8, gall bladder ; 9, gastrohepatic hga- 
 ment ; 10, right kidney and its suprarenal capsule ; 11, small intestine ; 12, terminal 
 portion of the ileum ; 13, CEecum ; 13', its appendix ; 14, ascending colon : 15, transverse 
 colon ; 16, descending colon ; 17, ileopelvlc colon ; 18, bladder ; 19. parietal peritoneum ; 
 20, spleen ; 21, diaphragm ; 22, thoracic aorta. 
 
 mesenteric artery above, with the vena cava, aorta, and 
 crura of the diaphragm behind. It is the most fixed por- 
 tion of the duodenum. 
 
4 DISEASES OF THE INTESTINES. 
 
 4. The fourth part of the duodenum or second ascending 
 portion ascends vertically at the left side of the spine. It 
 is aboat one inch long and forms the end of the duodenum. 
 It is firmly fixed in its place by the musculus suspensorius 
 duodeni, the latter being the name of the fibrous band, 
 containing some plain muscular fibres which descend to the 
 vertical part of the duodenum from the left crus of the 
 diaphragm and the tissues about the coeliac axis. It ter- 
 minates at this point in the jejunum, forming the flexura 
 duodenojejunalis at a place situated to the left of the sec- 
 ond lumbar vertebra. 
 
 The Small Intestine. 
 
 The small intestine which forms the continuation of the 
 duodenum is composed of the jejunum and ileum. There 
 is really no marked structural difference between the two, 
 and it is therefore hardly possible to determine where one 
 ends and the other begins. As a rule, the upper two-fifths 
 are designated as the jejunum and the lower three-fifths as 
 the ileum. The jejuno-ileum fills the greater part of the 
 abdomen. It occupies the umbilical, hypogastric, iliac, 
 and lumbar regions, and is more or less encircled by the 
 large intestine. The coils formed by the jejunum and 
 ileum are very movable and completely invested by the 
 peritoneum. They are supported and attached to the pos- 
 terior parietes by the mesenterj^ The latter extends from 
 the end of the duodenum to the ileocsecal junction. The 
 point at which the mesentery is attached above is on a level 
 with the lower border of the pancreas and just' to the left 
 of the vertebral bodies. From this point of insertion the 
 mesentery follows an oblique line running downward and 
 to the right, crossing the great vessels and ending in the 
 iliac fossa. The length of the mesentery from the spine 
 
ANATOMY. 5 
 
 to the intestines varies in different parts of the canal, its 
 average being eight to nine inches. It soon attains its full 
 length, and within one inch of the end of the duodenum is 
 already six inches long. The small intestine hangs on 
 the mesentery in the form of coils, and the folds which the 
 mesentery forms may be compared to those of a fan. 
 
 The small intestine including the duodenum has an aver- 
 age length of about twenty feet. The calibre of the small 
 intestine is larger at its upper end and gradually dimin- 
 ishes in size until its entrance into the large boweL Thus 
 at the beginning the jejunum has a circumferential calibre of 
 17.5 cm., the ileum at its beginning of 11.5 cm., and at its 
 end 9.5 cm. The ileum passes perpendicularly into the as- 
 cending part of the colon just above the csecum, its mucosa 
 forming a double valve, the valvula Bauhini. The jejuno- 
 ileum is the most movable part of the intestinal tract. 
 "WTierever a free space is left it occupies it. It is therefore 
 most often met with in hernias. During gravidity or when 
 a tumor ur ascites exists in the abdomen the small intes- 
 tine moves up higher and thus escapes compression. 
 
 The small intestine receives its blood supply from the 
 abdominal aorta. Tlie arteria gastroduodenalis, a branch 
 of the arteria hepatica, sujjplies the upper part of the duo- 
 denum ; the lower part of the duodenum and the jejunum 
 and ileum are supplied by the arteria mesenterica superior. 
 The latter vessel branches off into a fine net of numerous 
 small vessels which run through the intestinal wall. The 
 end ramifications penetrate the submucosa and here again 
 form a net. From the latter the finest ramifications pene- 
 trate the mucosa and form a capillary system of the villi 
 and glands. The venous blood flows partly into the vena 
 gastrica superior, partly into the vena mesenterica superior, 
 and empties itself into the vena porta. The lymphatics 
 
b DISEASES OF THE INTESTINES. 
 
 form a continuous series which is divided into two sets, 
 that of the mucous membrane and that of the muscular 
 coat. The lymjjh vessels of both sets form a copious 
 plexus. They run between the two folds of the mesentery 
 and end in the mesenteric lacteals. They are provided 
 with valves which prevent the current from flowing back- 
 ward, the direction of which is into the truncus lymphati- 
 cus intestinalis and finally into the thoracic duct. 
 
 The nerves of the small intestine originate j)rincipally 
 from the plexus mesentericus superior or the sympathetic. 
 The duodenum is supplied by the plexus hepaticus, a 
 branch of the plexus coeliacus. The abdominal part of the 
 vagus, namely, the plexus gastricus, anterior and posterior, 
 also supplies the small intestine with nerves. The nerves, 
 which are mostly non-medullary, enter the intestinal wall 
 in connection with the branches of the arteria mesenterica 
 superior and form a subserous net. They then penetrate 
 the long muscular fibres and form between these and the 
 circular muscular fibres ramifications which consist of nu- 
 merous groups of multipolar cells (plexus mesentericus 
 seu Auerbachii) ; fine branches of nerves arising here sup- 
 ply the muscularis. Others penetrate the circularis, reach 
 the submucosa, and form the submucous nerve plexus, 
 containing small groups of ganglion cells (Meissner's nerve 
 plexus) ; fine ramifications also supply the muscularis mu- 
 cosae, the muscles of the villi, and end in the remaining 
 part of the mucosa. 
 
 Structure of the Small Intestine. 
 
 The small intestine is composed of four principal coats : 
 the serous, muscular, submucous, and mucous (Fig. 2). 
 The serous coat is formed by the visceral layer of the peri- 
 toneum. The muscular coat consists of an internal circular 
 
ANATOMY. 7 
 
 and an external longitudinal layer (Fig. 3). The former 
 is usually considerably thicker than the latter. They both 
 
 Fig. 2.— Longitiidinal Cross-section through the Wall of the Small Intestine (Ileum). 
 Solitary lymph nodules (nodulus lymphaticus solitarius). Intestinal glands (Lieber- 
 kuehni) (Tuldt). n. The mucous layer; h. the muscularis mucoste ; c, the submucous 
 layer ; d, the muscular layer ; e. the subserosa ; /, the serous layer ; (/, intestinal villi ; 
 ?i, intestinal glands (Lieberkuehn) ; i, blood-vessels ; /c, a solitary lymph nodule ; Z, its 
 centre. 
 
 consist of bundles of unstriped muscular tissue supported 
 by connective fibres. The submucous coat consists of con- 
 nective tissue in which numerous blood-vessels and lym- 
 
 h- 
 
 a--- 
 
 FlG. 3.— Longitudinal Cross-section through the Wall of the Duodenum. Brunner's 
 glands (glandulte duodenales) (Toldt). a. The mucous layer ; b, the muscularis muco- 
 sae ; c, the submucous layer ; d, the circular muscular layer ; e, the longitudinal mus- 
 cular layer; /, intestinal villi ; g, intestinal glands (Lieberkuehn) ; h, Bninner's duo- 
 denum glands ; i, serous layer. 
 
 phatics ramify. The mucous membrane is the most im- 
 portant coat with regard to the function of digestion. It 
 
8 
 
 DISEASES OF THE INTESTINES. 
 
 consists of a very tliiu muscular layer (muscularis mucosae) 
 containiEg circular and longitudinal fibres, the tunica 
 propria of tlie mucosa, a tissue made up principally 
 
 of reticular connective 
 tissue with numerous 
 leucocytes, glands, and 
 the epithelial covering. 
 The mucous membrane 
 of the small intestine is 
 of a grayish-red color 
 and has a velvety ap- 
 pearance. It possesses 
 certain large folds of 
 valvular flaps ( valvules 
 conniventes Kerkringi) 
 (Fig. 4). These are 
 permanent crescentic 
 folds of mucous mem- 
 brane set transversely 
 to the long axis of the 
 intestine. Each one ex- 
 tends from one-half to two-thirds of the distance of the 
 lumen. The largest are more than two inches long and 
 about one-third of an inch wide. They begin somewhat 
 below the pylorus, are very large just below the entrance 
 of the bile duct, remain conspicuous until the middle of 
 the jejunum is reached, then become smaller and gradually 
 disappear at the lower part of the ileum. They serve to 
 increase the surface of the mucous membrane. 
 
 The microscopical anatomy of the mucous membrane 
 reveals the following : The entire inner surface of the small 
 intestine is composed of villi, certain papilliform processes, 
 .and glands ; an epithelial layer containing columnar epi- 
 
 FiG. 4.— Jejunum Partly Opened (Toldt). a, 
 Serosa ; b, mucosa ; c, circular folds of Ker- 
 kring. 
 
ANATOMY. 
 
 thelial cells with a striated border, and some goblet cells 
 cover tlie entire surface. The villi are formed principally 
 by elevations of the tunica propria of the mucous mem- 
 brane (Fig. 5). They are about 0.5 to 0.7 mm. in height 
 and about 0.1 to 0.2 mm. wide and number almost ten mil- 
 lions. Each villus possesses a centrally located space for 
 chyle which is covered with endothelial cells and connected 
 with the lymphatics of the intestinal mucosa. Each villus 
 contains a perfect arrangement of blood-vessels and muscu- 
 lar fibres ^hich originate in the muscularis mucosae. When 
 filling up with blood each villus expands, while under the 
 contraction of its muscle it shrinks. Thus it is enabled to 
 perform the function of suction and pumping. The villi 
 form the main organ for 
 the absorption in the 
 small intestine. 
 
 Around the villi lie 
 their glands. E i r s t , 
 there are tubular glands 
 (of Lieberkiihn), and, 
 secondly, acinous glands 
 of Brunner. The former 
 are similar in structure 
 to the tubular glands in 
 the stomach. They cover 
 almost the entire surface 
 
 of the whole small and large intestine. Each glandular 
 tubule is about 0.3 to 0.4 mm. long and opens without 
 forming any ramifications. They number over forty mil- 
 lions and form the principal organ of intestinal secretion. 
 Brunner's glands are confined to the duodenum. They 
 are most abundant at the commencement of this portion 
 of the intestine, diminishing gradually as the duodenum 
 
 Fig. 5.— Mucous Membrane of the Ileum with 
 a Solitary Lymph Nodule (Toldt). a, In- 
 testinal glands (Lieberkuehn) ; 7j, intestinal 
 villi ; c, a solitary lymph nodule. 
 
10 
 
 DISEASES OP THE INTESTINES. 
 
 advances. They are situated beneath the mucous mem- 
 brane and embedded in the submucous tissue. Each 
 gland is a branched and convoluted tube lined with col- 
 umnar exjithelium. In structure they are very similar to 
 the pyloric glands of the stomach, but are more branched 
 and convoluted, and their ducts are longer. The duct of 
 
 each gland passes through 
 the muscularis mucosae 
 and opens on the surface 
 of the mucous membrane. 
 Solitary follicles or 
 glands are found scat- 
 tered throughout the mu- 
 cous membrane of the 
 small intestine. They 
 are most numerous in the 
 lower part of the ileum. 
 Each one has a diameter 
 of from 3 to 6 mm. The 
 structure of the solitary 
 follicle is similar to that 
 of the lymph nodes and 
 consists of a dense reti- 
 form tissue packed with 
 lymph corpuscles and 
 permeated by fine capillaries. There are no ducts. The 
 interspaces of the retiform tissue are continuous with lar- 
 ger lymph spaces at the base of the gland, by which they 
 communicate with the lacteal system. The base of the 
 nodules is in the submucous tissue. It penetrates the 
 muscularis mucosae and enters the mucous membrane form- 
 ing a slight projection of its epithelial layer. The solitary 
 follicles are the breeding place of the lymph cells. They 
 
 Fig. 6.— Ileum Partly Opened (Toldt). 
 Solitary lymph nodules; b, serosa; 
 mucosa. 
 
ANATOMY. 
 
 11 
 
 are met with in two conditions, namely, eitlier scattered 
 singly, in whieli case they are termed glandulge solitarise 
 (Fig. 6), or aggregated in groups varying from one to three 
 
 Fig. 7.— Peyer's Patch (Noduli Lymphatici Aggregati) in the Ileum (Toldt). a, Peyer's 
 patch ; h, solitary lymph nodules. 
 
 inches in length and about one-half inch in width. The 
 surface of the solitary follicles is free from villi. Chiefly 
 of an oval form, their long axis is parallel with that of the 
 intestine. In this state they are called glandulae agminatge 
 or Peyer's patches or plaques (Fig. 7). They are almost 
 always placed opposite the attachment of the mesentery. 
 Peyer's patches number about twenty to twenty-eight. In 
 some cases they are already found in the jejunum, but 
 they are most prevalent in the ileum. 
 
 The Large Intestine or Large Bowel (Intestinum Crassum). 
 
 The large intestine extends from the termination of the 
 ileum to the anus. It is about five to six feet in length. 
 Its calibre decreases from beginning to end except at the 
 ampulla of the rectum where it is larger. It measures 
 28.5 cm. in circumference at the junction of colon and cse- 
 
12 
 
 DISEASES OF THE INTESTINES. 
 
 cum, 20.5 cm. at the end of the ascending portion, 14.5 cm. 
 in the descending portion. The large intestine is divided 
 into the caecum, colon, and rectum. With the exception 
 
 of the rectum 
 it possesses 
 three tsenise, 
 these being 
 groups of non- 
 striated muscu- 
 lar fibres run- 
 ning lengthwise 
 with the lumen 
 of the intestine. 
 Between the 
 taeniae the walls 
 are somewhat 
 sacculated. The 
 circular muscu- 
 lar fibres are 
 also accumulat- 
 ed in spots, 
 leaving s h o r t 
 intervals be- 
 tween each 
 other, thus 
 forming c o n - 
 strictions and 
 expansions (haustra coli) across the intestine (Fig. 8). 
 The large bowel is further characterized by aijpendices 
 epiploicae, external pouches, formed by the peritoneal cov- 
 ering containing fat. The caecum is the head of the colon 
 or that part of the large bowel situated below the mouth of 
 the ileum (Fig. 9). It lies in the right iliac fossa and is 
 
 Tig. 8. — Tbe Large Bowel Partly Opened along the Mesen- 
 tery (Toldt) . a. Free tsenia ; b, tsenla mesocolica ; c, 
 appendices eplplolcEe ; c?, the mucosa ; e, the semilunar 
 folds of the colon ; /, the mesocolon. 
 
ANATOMY. 
 
 13 
 
 completely covered by tlie peritoneum. In the filled con- 
 dition it touches the anterior abdominal wall. Starting 
 from the inner and back portion of the caecum lies the pro- 
 cessus vermiformis or appendix, forming a narrow, some- 
 what bent, blind-ending tube. The appendix is movable 
 and has its own 
 mesentery (mes- 
 enteriolum). 
 Its length varies 
 between 2 and 20 
 
 cm. and its 
 width between 
 0.5 and 1 cm. 
 The appendix 
 opens into the 
 C8Bcum (ostium 
 processus vermi- 
 formis), occa- 
 sionally form- 
 ing a crescentic 
 fold (v a 1 V u 1 a 
 processus v e r - 
 miformis). In 
 man it consti- 
 tutes an entirely 
 functionless or- 
 gan which occa- 
 sionally gives 
 rise to manifold 
 
 ailments. The appendix has no fixed position. J. D. 
 Bryant' found it most often "inward," then "behind the 
 caecum," "downward and inward," "into the true pelvis." 
 ' J. D. Bryant : Annals of Surgery, February, 1893, p. 164. 
 
 Fig. 9.— Section of the Caecum and Ileum, showing the En- 
 trance of the Latter into the Cseeum (Toldt). a, The 
 semilunar folds of the colon ; b, c, the ileocaecal valves (b, 
 the upper, and c. the lower one) ; d, the end portion of 
 the ileum ; e, the posterior ileocsecal valve ; /, the appen- 
 dicular valve ; y, the appendix. 
 
14 DISEASES OF THE INTESTINES. 
 
 Without distinct demarcation the caecum merges into the 
 ascending colon. It passes vertically above the crest of 
 the ileum and runs along the posterior abdominal muscles 
 and the lower part of the right kidney. At this point just 
 in front of the kidney and immediately beneath the liver 
 the colon bends tovrard the left of the flexura coli dextra. 
 The ascending colon is posteriorly adherent through con- 
 nective tissue with the parts just mentioned, while the 
 peritoneum covers only its anterior and partly also its lat- 
 eral surfaces. In close proximity to its median wall lies 
 the ascending part of the duodenum. Beginning at the 
 flexura coli dextra the colon runs across the abdominal 
 cavity from right to left (transverse colon), forming the 
 longest segment of the large intestine. It passes from the 
 hepatic flexure in the right hypochondrium transversely 
 and slightly upward from right to left along the anterior 
 abdominal wall to the splenic flexure in the left hypochon- 
 drium. This part of the colon is the most movable. It 
 has a very long mesentery, called the transverse meso- 
 colon. The usual position of the transverse colon corre- 
 sponds to a line separating the umbilical and epigastric 
 regions. It is in relation by its upper surface with the 
 lower part of the liver and gall bladder, the greater curva- 
 ture of the stomach and the lower end of the spleen ; by 
 its under surface with the small intestine; by its anterior 
 surface with the great omentum and abdominal wall; by 
 its posterior surface with the transverse mesocolon ; on the 
 right side with the second part of the duodenum, and on 
 the left besides the latter with some convolutions of the 
 small intestine. 
 
 The transverse colon does not form a straight line con- 
 necting the right and left flexures, but is about twice as 
 long as this line and therefore forms several curves. In 
 
ANATOMY, 15 
 
 the left hypochondrium especially, there is an S-shaped 
 coil. The latter fills out the free space in the left hypo- 
 chondrium which is left by the stomach in its various 
 states of fulness. Beginning at the flexura coli sinistra 
 the descending colon runs downward in front of the left 
 kidney and the quadratus lumborum and iliac muscles un- 
 til it reaches the left iliac fossa. The descending colon 
 runs just in the opposite direction to the ascending colon, 
 and like this is only partly covered by the peritoneum. 
 The descending colon passes into the sigmoid colon or 
 flexure (S Eomanum), commencing above the iliac crest 
 and ending below in the rectum at the brim of the true 
 pelvis opposite the left sacro-iliac articulation. It is gen- 
 erally described as an S-shaped curve having an upper 
 €olic rim turned toward Poupart's ligament and the lower 
 rectal rim, hanging down into the true pelvis. It has a 
 complete peritoneal covering or mesentery. This part of 
 the bowel is verj^ movable, and its calibre is the narrowest 
 of that of the large bowel. The sigmoid flexure continues 
 into the rectum, forming the terminal portion of the intes- 
 tinal tube. It runs, coming from the left, in front of the 
 OS sacrum down to the bottom of the small pelvis. Only 
 the upper half of the rectum is invested completely with 
 peritoneum (mesorectum) and is attached to the sacral ver- 
 tebra. The lower half passes between the organs occupj-- 
 ing the pelvic floor, being adherent to them by connective 
 tissue. It now runs posteriorly along the os coccyx and 
 terminates in the anus. This part has an incomplete peri- 
 toneal covering (plica Douglasii) lying anteriorly and turn- 
 ing backward in order to ascend either over the vagina or 
 the bladder (excavatio recto-uterina, excavatio rectovesica- 
 lis). Below this point the rectum has very little mobility 
 as it is covered all around by connective tissue. The en- 
 
16 DISEASES OF THE INTESTINES. 
 
 tire rectum is about 18 to 22 cm. long. Its calibre varies. 
 It is widest at tlie apex of tlie prostate, forming the am- 
 pulla of the rectum. 
 
 The longitudinal muscular fibres of the rectum are not 
 arranged in tsenige as in the colon, but pass all around the 
 lumen. The circular muscular fibres become more dense 
 from above downward and increase to such a degree at the 
 anal opening that they here form a thick ring (musculus 
 sphincter ani internus). A short distance above this mus- 
 cle there is also an accumulation of circular muscular fibres 
 (musculus sphincter ani tertius). At the anus the walls of 
 the rectum are connected with striated muscular fibres 
 (sphincter ani externus and levator ani), which are both 
 of importance in the act of defecation. 
 
 The colon is supplied by the three arterise colicse, 
 branches of the arteria mesenterica superior and arteria 
 meseuterica inferior. The arteria colica sinistra origi- 
 nates from the arteria mesenterica inferior, while the ar- 
 teria colica media and superior are tributaries of the arteria 
 mesenterica superior. The veins accompany the artery and 
 empty partly into the vena mesenterica superior, partly 
 into the vena mesenterica inferior. The lymphatics of the 
 .colon are numerous and lie below the glands and all 
 through the submucosa. The plexus mesentericus supe- 
 rior, a branch of the plexus coeliacus, provides the nervous 
 supply of the caecum, ascending colon, and the right half 
 of the transverse colon. The plexus mesentericus inferior, 
 a branch of the plexus aorticus abdominalis, supplies the 
 left half of the transverse colon, the descending colon, and 
 the sigmoid flexure. 
 
 The rectum is supplied by the arterise hsemorrhoidales 
 superior, media, and inferiores, branches of the arteria 
 mesenterica inferior and arteria pudenda communis. The 
 
ANATOMY. 17 
 
 venous blood of the rectum is carried to the venae hsemor- 
 rhoidales principally into the vena niesenterica inferior, 
 thus emptying into the vena portarum, partly, however, 
 into the vena iliaca interna. In this way there is a sepa- 
 rate communication (outside of the portal circulation) with 
 the remaining vessels of the abdomen. The lymphatics of 
 the rectum form a wide net, running partly to the glands 
 lying behind the rectum, partly to the plexus lumbalis 
 sinister. The nerves supplying the rectum originate from 
 the sympathetic, being branches of the plexus mesenteri- 
 cus inferioi% the plexus sacralis (nervi hsemorrhoidales in- 
 ferior and medii), and the plexus hypogastricus superior. 
 
 Histology of the Large Bowel. 
 
 The large bowel consists, like the small bowel, of four 
 coats: the serosa, muscularis, submucosa, and mucosa. 
 The structure of these four coats corresponds to that of 
 the small intestine, except that the longitudinal muscular 
 fibres are arranged in three groups (tsenise) running along 
 the wall, as mentioned above. The mucosa of the large 
 bowel diifers from that of the small intestine in that there 
 is an absence of the folds of Kerkring and of the villi. 
 Lieberkiilm's glands are here somewhat longer and some- 
 times curved. 
 
 The mucous membrane of the rectum is thicker, more 
 red, and succulent than that of the colon. There are nu- 
 merous folds. One conspicuous fold is found 6 to 7 cm. 
 above the anus (plica transversalis recti). In the neigh- 
 borhood of the anus the folds take a longitudinal direc- 
 tion, and are called columns Morgagnii sen recti. The 
 lower region of the rectum contains the epithelial cells of 
 the rectum, pavement-like epithelium, forming a gradual 
 
18 DISEASES OF THE INTESTINES. 
 
 transition from the mucous membrane of the digestive 
 tract to that of the external skin. The upper portion of 
 the rectum corresponds exactly to that of the colon. 
 
 PHYSIOLOGY. 
 
 The intestines are entrusted with the important office of 
 digesting the food which has not been acted upon by the 
 stomach, of absorbing it, and finally of eliminating the 
 undigested remnants. In order to fulfil this object they 
 have three functions, the secretory, absorbent, and motor. 
 All these functions are supervised by ganglionic cells and 
 nerves, the latter also transmitting sensory impressions. 
 
 1. The Secretory Function or the Chemical Processes in the 
 
 Intestines. 
 
 As is well known, the intestinal secretion consists, first, 
 of the bile; secondly, the pancreatic juice; and thirdly, the 
 intestinal juice proper (succus entericus). The composi- 
 tion of each of these and their properties may be found in 
 the text-books on physiology, and also briefly in my book 
 on "The Diseases of the Stomach." It will not be amiss, 
 however, to describe here more fully their joint action in 
 the intestinal canal. 
 
 The effect of each of the digestive juices is influenced by 
 that of the others. For this reason the chemical processes 
 in the intestines are quite complicated. The carbohy- 
 drates, whose conversion into maltose by the ptyalin has 
 been checked in the stomach by the free hydrochloric acid, 
 are now, after reaching the intestines, further changed by 
 the diastase of the pancreatic secretion into maltose, which 
 is further converted into glucose. Cane sugar is likewise 
 converted into grape sugar, while milk sugar, according to 
 
PHYSIOLOGY. 19 
 
 Voit and Lusk/ remains unchanged. The finer parts of 
 the cellulose also undergo some changes, but their ulti- 
 mate products are not known. It is certain, however, that 
 under the influence of micro-organisms they partly undergo 
 fermentation, giving rise to the formation of marsh gas, 
 acetic acid, and butyric acid. 
 
 The pancreatic juice forms the principal factor of all the 
 digestive processes in the intestinal canal. Besides its ac- 
 tion upon the carbohj'drates through its diastatic ferment, 
 it acts upon fats by means of the steapsin and upon al- 
 buminates by means of the trypsin ferment. According 
 to Nencki ^ and Eachford, ^ the fat-splitting action of the 
 pancreas is greatly increased by the presence of bile. The 
 splitting of the fats into fatty acids and glycerin is of 
 greatest importance for absorption. The fatty acids com- 
 bine with the alkalies of the intestinal and pancreatic 
 juices and form soaps which are either absorbed as such 
 or promote the absorption of fats. There is no doubt 
 that the greater amount of fats taken in with the nourish- 
 ment is absorbed as a fine emulsion in the formation of 
 which the soaps take part. These processes of fat emulsi- 
 fication, by the action either of the pancreatic juice or of 
 soaps, take place only in alkaline media. If the intestinal 
 contents are acid, emulsification does not occur, or does so 
 only at those places at which the fat comes in contact with 
 an alkaline secretion covering the mucous membrane. Ac- 
 cording to Claude Bernard* and Dastre," the action of bile 
 greatly increases the emulsifying property of the pancre- 
 
 ' Lusk : Zeitschr. f. Biologie, Bd. 28, p. 275. 
 ^ Nencki : Arch. f. experiraentelle Path. u. Pharm., Bd. 20. 
 ^ Rachford : Journal of Pliysiology, vol. 12. 
 
 ■* Claude Bernard : "Lemons de physiologle experimentale, " 2d edi- 
 tion, 1865. 
 
 ^ Dastre : Arch, de Physiologie, Tome 2, p. 315. 
 
20 DISEASES OF THE INTESTINES. 
 
 atic juice. While tlie bile exerts a deleterious influence 
 upon the action of pepsin in artificial solutions, its pres- 
 ence in the stomach does not seem to have any inhibitory 
 effect. The bile exerts an influence upon the digestion of 
 the albuminates in the intestines by precipitating the pep- 
 sin in the acid gastric contents. It thus destroys the ac- 
 tion of the pepsin. This precipitate, formed by the gas- 
 tric contents and the bile, is soon dissolved, partly through 
 the intervention of freslil,y secreted bile in abundance, 
 partl}^ through the sodium chloride which arises after the 
 neutralization of the gastric juice b}' the alkalies present. 
 The action of the bile upon the pancreatic digestion of al- 
 bumin is not deleterious, and may have a beneficial effect 
 in the presence of organic acids which, as a rule, exist in 
 the upper parts of the small intestine. 
 
 Aside from the chemical processes caused b}^ the enzymes 
 in the intestines there also exist fermentative and putre- 
 factive changes produced by micro-organisms. These are 
 but very slight in the upiDer part of the intestine and 
 increase in intensity toward the end of the small intestine 
 and in the greater part of the large bowel, while they again 
 decrease in the lower i:)art of the bowel and in the rectum. 
 According to Macfadyen, Nencki, and Sieber,' who have 
 repeatedly analyzed the intestinal contents of a man with 
 a fistula situated near the end of the ileum, only fermen- 
 tative processes take place within the small intestine. The 
 contents obtained in this case had a golden-yellow color 
 and showed an acid reaction, the acidity amounting to one 
 per mille. As a rule, they were odorless. The principal 
 elements of the acidity consisted of acetic, lactic, and 
 paralactic acids, volatile fatty acids, succinic acid, and 
 
 ' Macfadyen, M. Nencki und N. Sieber : Arch. f. experimentelle 
 Pathol, u. Pharm., Bd. 28, p. 311. 
 
PHYSIOLOGY. 21 
 
 biliary acids; albumin, peptone, mucin, dextrin, sugar, 
 and alcohol were i)resent; leucin and ty rosin, however, 
 were absent. Thus, according to these authors, fermenta- 
 tive processes in the small intestine result merely from 
 the action of microbes upon carbohydrates, which ac- 
 tion ultimately leads to the formation of ethyl alcohol 
 and the organic acids just mentioned. The latter pre- 
 vent the putrefaction of albuminates within the small in- 
 testii# and also partly check the decomposition of the 
 carbohydrates. 
 
 The putrefaction of the albuminates takes place in the 
 large intestine, the contents there having an alkaline reac- 
 tion. The decomposition of the albuminates by the putre- 
 factive processes caused by micro-organisms goes much 
 further than that by the pancreatic digestion. The pan- 
 creatic digestion of the albuminates gives rise to albumoses 
 and peptones, l^^sin, lysatinin, proteinchromogen, amido- 
 acids, and ammonia. In the putrefaction of the albumin- 
 ates at first the same products are formed, but the decom- 
 position advances still further and generates a host of new 
 products: indol, skatol, paracresol, phenol, phenyl-propi- 
 onic acid and phenyl-acetic acid, para-oxyphenyl-acetic 
 acid, hydroparacumaric acid, volatile fatty acids, carbon 
 dioxide, hydrogen, marsh gas, methyl mercaptan, and sul- 
 phuretted hydrogen. In the putrefaction of gluten neither 
 ty rosin nor indol is formed while glycocoll is developed. 
 Of the products of decomposition just named some are of 
 great importance, as they are eliminated by way of the urine 
 after their absorption from the intestinal wall. Some of 
 them, as for instance the oxj^-acids, appear unchanged in 
 the urine, others (like the phenols) after further oxidation, 
 and still others (like indol and skatol) after combination 
 with ethereal sulphuric acids. The presence of ethereal 
 
22 DISEASES OF THE INTESTINES. 
 
 sulphuric acids in the urine is thus to a certain extent an 
 indication of the amount of putrefaction going on in the 
 intestine. The putrefactive processes in the intestine relate 
 not only to the ingested food but also to the secretions 
 rich in albuminates. Thus Mtiller ' observed that Cetti 
 during his fasting period first showed a diminution of the 
 amount of indican in the urine which entirely disappeared 
 on the third day. The phenol elimination was also at first 
 diminished, but beginning from the fifth day of fasting it 
 commenced to increase, and on the eighth or ninth day 
 reached an amount which w^as three to seven times that of 
 a man under ordinary conditions. 
 
 The putrefactive processes within the intestines, how- 
 ever, do not reach that height which they attain outside 
 of the body. Thus, for instance, the fresh contents of the 
 large bowel do not present so fetid an odor as a pancreatic 
 infusion or decomposing albumin would reveal after long 
 standing. The putrefaction within the intestine is partly 
 checked by several factors : 
 
 1. Carbohydrates as such exert an inhibitory influence 
 upon putrefaction (Hirschler"); " the organic acids which 
 develop during their fermentation also partly check putre- 
 faction. Of other foods, milk and kumyss, according to 
 Schmitz," likewise lessen the processes of bacterial de- 
 composition, this effect being due to the presence of lactose 
 and also of lactic acid. 
 
 2. The bile exerts a decidedly anti-putrefactive action. 
 As shown by Liudberger ■* and Limbourg, ^ albumin to 
 which bile is added does not decompose so thoroughly as 
 
 J Mtiller: Berl. klin. Wochensclir., 1887, No. 24. 
 
 2 Hirschler : Zeitschr. f. physiol. Cbemie, Bd. 10, p. 306. 
 
 2 Schmitz : Zeitschr. f. physiol. Chemie, Bd. 17, p. 401. 
 
 •* Lindberger : Maly's Jahresber. , Bd. 14, p. 334. 
 
 ? Limbourg : Zeitschr. f. physiol. Chemie, Bd. 13. 
 
PHYSIOLOGY. 23 
 
 without it. Tlie biliary acids, moreover, inhibit putrefac- 
 tion through their acid elements. 
 
 3. Absorption. The rapid absorption of fluids from the 
 intestinal wall and the forward motion of the contents do 
 not permit the putrefactive processes to get the upper hand. 
 
 These fermentative and i)utrefactive processes taking 
 place within the intestines serve to augment the various 
 means at the disposal of the organism to utilize or to break 
 up into simpler components the more complex groups of 
 various food substances. In the normal state these putre- 
 factive processes are most probably checked before any 
 deleterious substances can be developed. 
 
 The intestinal contents on their long way from the duo-- 
 denum to the anus show the presence of different gases.' 
 These consist of traces of oxygen and a larger amount of 
 nitrogen ; the latter is derived either from swallowed air 
 which has come from the stomach, or from pure nitrogen 
 which has been diffused from the tissues through the in- 
 testinal walls. Carbonic-acid gas is present which has been 
 developed through neutralization of the acid gastric con- 
 tents by the pancreatic and intestinal juices, and also from 
 the butyric and lactic acid fermentation of the carbohy- 
 drates. Hydrogen is found in larger amounts after a milk 
 diet and onlj in small quantities after a pure meat diet. 
 Methyl mercaptan and sulphuretted hydrogen are present 
 in traces, and undoubtedly owe their origin to the albumin. 
 Marsh gas likewise results from the decomposition of 
 albumin, but it is also evolved from the fermentation of 
 carbohydrates, especially of cellulose. These different 
 gases are formed and absorbed all along the intestinal 
 walls, and most probably help to mix the contents and 
 thus facilitate absorption. If present in too large quanti- 
 ties, they are easily passed through the rectum ; occasion- 
 
24 DISEASES OF THE INTESTINES. 
 
 ally some of the gases contained in the upper part of the 
 small intestine may be eructated by way of the stomach 
 through the mouth. 
 
 In passing through the large bowel the intestinal con- 
 tents become thickened through the rapid absorption of 
 the fluids, and at last are eliminated as fecal matter. This 
 (fseces) comprises the remnants of the undigested material, 
 excretory products of the intestines, and a host of micro- 
 organisms. The quantity of fecal matter within twenty- 
 four hours varies greatly according to the mode of nourish- 
 ment. Thus after a mixed diet it amounts usually to from 
 120 to 150 gm. After a vegetable diet, however, the quan- 
 tity, according to Yoit,' reached 333 gm. The reaction of 
 the fseces is varied. Often it is found acid in their inner 
 parts, while the outer surface shows an alkaline reaction. 
 Their peculiar odor is principally due to Brieger's skatol, 
 but also to indol and other substances. Their color is 
 usually of a light or dark brown, according to the charac- 
 ter of the nourishment. 
 
 2. Absorption. 
 
 The object of digestion is to dissolve and partially 
 change the food substances into such combinations as can 
 be assimilated by the blood. Before assimilation can be 
 effected absorption must take place. The main place for 
 the absorption of nutritive material is the small intestine. 
 It will be best to describe the process of absorption of the 
 different food materials separateh^ 
 
 (a) The proteids are usually changed into albumoses 
 
 and peptones before their absorption. Albumen as such, 
 
 however, is also liable to be absorbed, although not so 
 
 quickly as when its change into peptone has been accom- 
 
 ' Voit: Zeitschr. f. physiol. Chemie, Bd. 13. 
 
PHYSIOLOGY. 25 
 
 plished. The absorption of albumoses and peptones takes 
 place through the intestinal wall by way of the capillaries 
 of the blood-vessels and not through the lacteals. Thus 
 Munk and Rosenstein ' observed in a patient with a lymph 
 fistula that after a meal rich in albuminous food the lymph 
 did not contain more proteids than before the meal. The 
 peptones and albumoses do not reach the blood current as 
 such, but are previously reconverted into albumin. This 
 fact has been clearly shown by the experiments of Ludwig 
 and Salvi/oli." These investigators tied a resected intesti- 
 nal coil at both ends and injected into its lumen a solution 
 of peptone, while the coil was kept alive with defibrinated 
 blood. Although the peptone entirely disappeared from 
 the intestinal coil, the blood did not contain even traces 
 of peptone. It therefore must have become changed into 
 another substance. This change of the peptones into al- 
 buminates before reaching the blood is of teleological im- 
 portance. For, as has been shown by Schmidt-Mtihlheim' 
 and others, peptone introduced into the circulating blood 
 is soon eliminated with the urine. Where the change of 
 the peptones into albuminates takes place and by what 
 mechanism are not as yet certain. Some seem to believe 
 that the epithelial cells of the intestinal walls perform this 
 office, others that the leucocytes are the means of its con- 
 version. 
 
 The absorption of the albuminates appears to be more 
 complete as regards animal than vegetable food. The 
 reason for this is that the cellulose surrounding the legu- 
 men partly renders its absorption more difficult. Again, 
 the peristalsis being greater after vegetable food, the intes- 
 
 • Munk and Rosenstein : Virchow's Arch., Bd. 123. 
 
 2 Ludwig and Salvioli : Du Bois-Reymond's Arch., 1880, Suppl. 
 
 3 Schmidt- Mtthlheim : Du Bois-Reymond's Arch., 1880. 
 
26 DISEASES OF THE INTESTINES. 
 
 tinal contents pass tlirough tlie canal quicker, and tlius 
 less of the albumen is utilized. And again, according to 
 Hammarsten, ' a part of tlie nitrogenous substances of the 
 plant proteids appears to be indigestible. 
 
 (6) The carbohydrates are absorbed principally as mono- 
 saccharides. Glucose, Isevulose, and galactose are absorbed 
 as such. Cane sugar and maltose are ordinarily changed 
 first into glucose and Isevulose. According to Yoit and 
 Lusk, sugar of milk is not converted, and is either partly 
 absorbed as such or else undergoes lactic-acid fermenta- 
 tion. The different kinds of sugar are absorbed through 
 the capillaries of the villi and thus reach the circulation. 
 They enter the liver through the vena porta and are here 
 retained in great part as glycogen. In case, however, a 
 large quantity of sugar is at once absorbed, it may occa- 
 sionally reach the lacteals and thus enter the blood current 
 outside of the liver. In such instances sugar appears in 
 the urine, a condition which is known as alimentary glyco- 
 suria. The introduction of larger quantities of sugar into 
 the intestinal tract occasionally gives rise to diarrhoea. 
 Carbohydrates, however, even in large amounts in the form 
 of starch, will be absorbed without difficulty and without 
 giving rise to any trouble. 
 
 (c) The fats. In the absorption of fats their emulsifi.ca- 
 tion seems to be of greatest importance. Although a small 
 part is absorbed in the form of soaps, the greatest quan- 
 tity of fat is taken up in the form of an emulsion. The 
 latter comprises not only neutral fats but also fatty acids. 
 These, however, undergo a change into neutral fats after 
 their absorption from the intestinal walls. It is generally 
 accepted that fats after their absorption from the intestinal 
 
 ' Olof Hammarsten : " Lehrbuch der physiologischen Chemie, " Wies- 
 baden, 1895, p. 293. 
 
PHYSIOLOGY. 27 
 
 wall directly reacli the lymphatics and thus enter the tho- 
 racic duct, whence they afterward find their way into the 
 blood current. In a girl with a lymph fistula Munk and 
 Rosenstein found that sixty per cent of the ingested fat 
 appeared in the lymph. After giving the patient erucic 
 acid (a fatty acid foreign to the organism) they could dis- 
 cover thirty -seven per cent of this particular substance in 
 the form of neutral fats. Thus it appears to be proven 
 that while the proteids and carbohydrates after their ab- 
 sorption directly reach the blood current, as mentioned 
 above, the fats are an exception and directly enter the lac- 
 teals. The ultimate way in which absorption takes place 
 is not as yet known. It must, however, be accepted that 
 the epithelial cells of the intestinal wall cause this process 
 by some specific action. The absorptive property of the 
 small intestine for fat is very great. According to Rub- 
 ner,' a man can absorb over 300 gm. of fat per day. Not 
 all kinds of fat, however, have the same coefficient of as- 
 similation. Thus fats with a low melting-point (olive oil, 
 goose fat, butter, etc.) are absorbed more quickly than 
 those with a high melting-point (mutton fat and stearin). 
 Moreover, free fats, like butter and lard, are assimilated 
 more quickly and thoroughly than bacon, in which the fat 
 is surrounded by connective tissue. 
 
 Besides the above-named three groups of food sub- 
 stances, water and different salts which are kept in solu- 
 tion are very quickly and thoroughly absorbed all along^ 
 the intestinal tract. Aside from the salts, other soluble 
 substances of the secretory juices are also absorbed. Thus 
 the urine contains traces of pepsin and also urobilin, 
 which shows that the biliary products must have been 
 absorbed and eliminated through the urine. According 
 ' Rubner : Zeitschr. f. Biologie, Bd. 15. 
 
28 DISEASES OF THE INTESTINES. 
 
 to Schiif,' the bile is absorbed from the small intestine 
 and reaches the liver with the blood current in order to be 
 eliminated again by this organ from the blood. 
 
 The pancreatic juice being the principal factor in the di- 
 gestion of the different kinds of food, it appears of interest 
 to ascertain how much of these foods will be absorbed after 
 the pancreas has been excluded from participation in the 
 act of digestion. Minkowski and Abelmann ^ experimented 
 on dogs by extirpating the pancreas, and found that forty- 
 four per cent of the proteids and from fifty -seven to seventy- 
 one per cent of carbohydrates (amylaceous food) were ab- 
 sorbed, while the fats remained totally unabsorbed . The fat 
 contained in milk, being emulsified, however, was absorbed 
 to the extent of from twenty-eight to fifty-three per cent. 
 
 While the main place at which the absorption occurs is 
 the small intestine, the large bowel is also able to serve in 
 this capacity. Thus aside from the absorption of fluids 
 and salts which normally takes place in this organ, albu- 
 minates and carbohydrates can be absorbed in consider- 
 able amounts, and fats in small quantities. This function 
 of the large bowel is of great practical importance, as it is 
 utilized in some conditions for nourishing purposes (rectal 
 alimentation). 
 
 5. Motion. 
 
 The motor function or peristalsis of the intestine has 
 for its objects the thorough mixture of the contents and 
 their propulsion through the entire canal until their final 
 exit through the anus. Nothnagel' and Braam-Houk- 
 
 1 Schiff : Pflliger's Arch., Bd. 3. 
 
 2 Abelmann : " Ueber die Ausnutzung der Nahrungsstoffe nach Pan- 
 kreasexstirpation. " Inaug. Dissert., Dorpat, 1890. 
 
 2 H. Nothnagel : " Beitriige zur Physlologie und Pathologic des 
 Darms, " Berlin, 1884. 
 
PHYSIOLOGY. 29 
 
 geest ' have studied the process of intestinal peristalsis in 
 animals. After laparotomy the latter were kept in a bath 
 of physiological salt-water solution of 38° C, and the mo- 
 tions of the intestines were investigated. 
 
 Three types of intestinal peristalsis were discerned: 1. 
 The ordinary peristaltic motion. The intestinal tract con- 
 tracts at a certain point and thereafter relaxes. The con- 
 traction is carried with moderate rapidity for a certain 
 length contiguously in the direction toward the anus and 
 the contents are xj^shed forward. 2. Oscillating motions. 
 An intestinal coil is here moved to and fro all along its 
 mesentery without am^ particular contraction at any point. 
 The contents are not propelled, but simply mixed up dur- 
 ing these motions. 3. Eotary motions. A filled intesti- 
 nal coil experiences a circular constriction which is rapidlj^ 
 carried over the intestine for the length of about 20 cm. 
 This is exactly the same process as described under 1, but 
 executed in a violent manner. 
 
 While the first two types of intestinal peristalsis are 
 purely physiological, the third tj-pe is partly pathological. 
 It is met with only when the contents are mixed with a 
 great deal of gas. Thus, after indiscretions in diet, we 
 often feel this kind of rapid motion going along with a 
 gurgling sound (tormina intestinorum) . This type is ob- 
 served only in the small intestine, but never in the large 
 bowel. 
 
 The small intestine manifests much quicker peristalsis 
 than the large bowel, the motions of which are very slow. 
 Here the haustra during the act of peristalsis contract and 
 then protrude in regular order. The small intestine while 
 empty does not show any motion whatever, but after the 
 entrance of chyme into the duodenum intestinal peristalsis 
 ' Braam-Houkgeest : Pfliiger's Arch., Bd. 7, p. 266. 
 
30 DISEASES OF THE INTESTINES. 
 
 begins. It is not, however, transmitted down to the Bau- 
 hinian valve without interruption, but stops as a rule at a 
 certain distance from its starting-point (about 20 cm.). 
 After an intermission of some duration it begins again. 
 Thus one or more intestinal segments may be in a state of 
 peristalsis while other parts of the intestine in between are 
 at rest. The time for the arrival of the first particles of 
 chyme from the duodenum into the csecum is about two 
 hours. But, of course, the intestinal peristalsis must con- 
 tinue until the stomach has expelled the last portions of 
 the chyme, that is to say, within about two hours after the 
 stomach has become empty the small intestine as a rule 
 will also be found free of contents. The forward motion 
 of the contents in the large bowel is a very slow one in- 
 deed. It takes as a rule from twenty to twenty -four hours 
 for the fecal matter to move from the csecum to the rec- 
 tum. 
 
 Antiperistalsis, or reversed motion of the large bowel 
 and the small intestine, beginning at the anus and extend- 
 ing upward, has never been seen by Nothnagel in physio- 
 logical conditions. 
 
 The process of peristalsis is controlled by nervous influ- 
 ences. Auerbach's and Meissner's plexus most probably 
 contain automatic nerve centres for this act. But there 
 are also other centrally located nervous agencies. Thus 
 after great mental excitement diarrhoea very often results, 
 showing that the intestinal peristalsis must have been 
 greatly increased through the influence of the brain. 
 There are also numerous nerves which supervise the motor 
 function of the entire intestinal tract. Pfliiger ' has shown 
 that the splanchnic nerve contains inhibitory fibres for the 
 
 1 Pfliiger : " Ueber das Hemmungs- und Nervensystem fiir die peri- 
 staltischen Bewegungen der Gedarme, " Berlin, 1857. 
 
PHYSIOLOGY. 31 
 
 intestinal peristalsis. According to Ehrmann,' accelerat- 
 ing and inhibitory fibres supervising intestinal peristalsis 
 are contained in the vagus as well as in the splachnicus, 
 but they have a varied function according to the way they 
 end, whether in the longitudinal or in the circular muscles. 
 The longitudinal muscles are stimulated by the splanchnic 
 and paralyzed by the vagus. The circular muscles, on the 
 other hand, are stimulated by the vagus and paralyzed by 
 the splanchnic. 
 
 Normally the chyme acts as a stimulus on the intestinal 
 canal and provokes peristalsis (through the influeiDce of the 
 nerves). Too cold drinks, indigestible food, organic acids 
 (present in too large amount) may often cause an increased 
 peristalsis and thus produce diarrhoea. Toxic substances 
 which are ingested or developed from unwholesome food 
 may have the same effect. 
 
 ' Ehrmann : Wiener med. Jahrbiicher, 1885. 
 
CHAPTER II. 
 
 METHODS OF EXAMINATION AND TKEATMENT. 
 
 EXAMINATION. 
 Interrogation. 
 
 The examination begins with a thorough interrogation 
 of the patient. Before starting with the narration of the 
 present ailment a general outline of previous sicknesses is 
 of value. Diseases which involve the intestinal canal, like 
 typhoid fever, dysentery, and the like, are of special impor- 
 tance, as they are liable to be etiological factors in the de- 
 velopment of consecutive ailments. The mode of living, 
 with regard to habits (drinking, smoking, etc. ), should also 
 be inquired into. 
 
 The patient is then asked to describe his present com- 
 plaint. He should state the time when the trouble began 
 and its nature. If the chief complaint refers to pains, it 
 is necessary to inquire as to their location and character. 
 Pains felt in the neighborhood of the navel usually origi- 
 nate in the small intestine ; those experienced in the right 
 iliac region often emanate from the appendix ; while those 
 in the left iliac region and in and about the rectum have 
 their starting-point in the sigmoid flexure and in the lower 
 portion of the rectum. Are the pains of long duration or 
 do they last only a very short while, a few seconds or min- 
 utes? The former variety is usually caused either by an 
 affection of the sensory nerves of the intestines or by some 
 organic lesion, like ulcers, etc. The latter variety, to which 
 
EXAMINATION. 33 
 
 the name colic is applied, is due to a strong spasmodic 
 contraction of a certain part of the bowel. Colicky pains 
 are often followed and relieved by the passing of flatus or 
 of fecal matter. Occasionally these pains also shift from 
 one place of the abdomen to another, and the route of their 
 travel is distinctly felt by the patient. 
 
 Abnormal sensations, a feeling of heat or cold may also 
 be experienced over a certain area of the abdomen. A fre- 
 quent or constant desire for an evacuation (tenesmus) is 
 encountered in dysentery and in many affections of the 
 rectum. It is also advisable to inquire whether the pains 
 and abnormal sensations appear at a certain period of the 
 day or at a certain time after meals (soon after eating or 
 three to four hours later), or whether they are experienced 
 at night or especially in the early morning hours, 
 
 The condition of the bowels should always be described 
 in detail. Do the bowels act regularly and is the evacua- 
 tion of sufficient quantity ? What is its consistency ? Is 
 the stool of sausage-shape and pliable, or is it hard or very 
 soft, mushy, watery ? What is its color? Is it dark brown 
 or light yellow or clay-colored or black? Is there an ad- 
 mixture of mucus or blood? If there is constipation, in- 
 quire whether the bowels move without any cathartics after 
 a period of constipation of a few days, and if not, whether 
 mild aperients are sufficient to cause an evacuation, or 
 whether a strong drastic remedy is necessary. Does the 
 constipation alternate with periods of normal movements 
 or with periods of diarrhoea? Are the periods of constipa- 
 tion, if cathartics are not resorted to, accompanied by any 
 marked symptoms (headaches, dizziness, anorexia, etc.) 
 or not? If there is diarrhoea, the patient should state how 
 many movements a day he has. Is he disturbed during 
 
 the night, or is the diarrhoea confined principally to the 
 3 
 
34 DISEASES OF THE INTESTINES. 
 
 morning hours? Does the diarrhoea alternate with periods 
 of constipation; does it disappear after a change of climate, 
 or is it aggravated by mental excitement? Is there a feel- 
 ing of exhaustion in connection with it? Is the abdomen 
 filled up with gas (meteorism) ? Does this phenomenon 
 Ijertain to a special part of the abdomen (the upper or 
 lower region, right or left side), or does it extend over the 
 entire abdomen? A feeling of tension in the abdomen 
 with frequent passing of wind, belching, and flatus, is com- 
 monly designated as flatulency. It is necessary to inquire 
 whether this symptom is present principally at a certain 
 time of the day or continuously. Absence of flatus is of 
 significance if it occurs in conjunction with obstinate con- 
 stipation, otherwise it is of no consequence. 
 
 In all intestinal disorders it is necessary to inquire as 
 to the state of the stomach. The latter organ being in 
 direct communication with the intestines, it will often be 
 subject to disturbances in intestinal affections. Com- 
 plaints of a bad taste and smell in the mouth are often 
 made, principally in constipation. Anorexia and nausea 
 are present in the most varied intestinal disorders. Vom- 
 iting frequently occurs in intestinal obstruction. 
 
 Inspection. 
 
 Inspection of the abdomen is best made in good daylight 
 with the patient in the recumbent posture, but should also 
 be completed by inspection in the standing position. The 
 condition of the skin of the abdomen is first examined. 
 Sometimes striae or scar-like lines running parallel to each 
 other over some part of the abdomen (especially the lower 
 part) , and presenting either a silvery hue or, if not old, a 
 rather reddish tinge, are observed ; these are always signs 
 of a very marked former distention of the abdominal pari- 
 
EXAMINATION. 35 
 
 etes. Thus they are fouud after frequent pregnancies, also 
 after the removal of rapidly developing- abdominal tumors, 
 or after tapjDing for ascites. These striae persist long after 
 the disappearance of the conditions which caused their 
 development. 
 
 Distention of the abdominal veins, giving them a bluish 
 hue, is observed whenever the return flow of the venous 
 blood of the lower extremities is retarded either by in- 
 creased intra-abdominal pressure (ascites, tumors of the 
 abdomen) or by thrombosis or compression of the iliac 
 vein or of the vena cava inferior. Cirrhosis of the liver 
 and compression of the portal vein often produce the same 
 result. In the latter condition there is an extensive forma- 
 tion of veins over the navel which is commonly called caput 
 Medusae. After observing the appearance of the skin, the 
 shape of the abdomen is then minutely considered. In 
 normal conditions, in grown people, the abdomen and the 
 chest are on the same level in the recumbent position. In 
 small children the abdomen as a rule is somewhat more 
 prominent than the thorax. In verj' old age the abdomen 
 appears somewhat sunken. The greatest degree of a re- 
 tracted or trough-shaped abdomen is found in stricture of 
 the oesophagus or cardia, in basilar meningitis, and in 
 lead poisoning. Long-continued inanition, no matter of 
 what origin, also causes this phenomenon. 
 
 Protrusion of the abdomen occurs either over a definite 
 area or over the entire surface. The abdomen may pre- 
 sent the shape of a round hemisphere or of a flattened one 
 if there is an accumulation of air and gas in the intestines 
 (intestinal meteorism). This occurs principally in atonic 
 conditions of the intestines and in hysteria. A uniform 
 protrusion of the abdomen or a general bloated condition 
 is present in general peritonitis, occasionally also in pro- 
 
36 DISEASES OF THE INTESTINES. 
 
 nounced atony of the intestines. In case of ascites, no 
 matter to what cause it is due (tumors, cirrhosis of the 
 liver, nephritis, etc.), the abdomen is also more or less 
 evenly protuberant above, while the lower parts bulge out 
 somewhat in the recumbent position. This is caused by 
 the accumulation of fluid in the lower portions of the ab- 
 dominal cavity. Change of posture alters the shape of the 
 abdomen. This applies to the early period of ascites, 
 during which the abdominal cavity is not yet filled to its 
 maximum ; later, when this is the case, the abdomen ap- 
 pears uniformly enlarged, and there is no bulging out of 
 any particular portion. Change of position then no longer 
 alters its shape. 
 
 Protrusion of a certain part of the abdomen is noticed 
 in many cases of neoplasm, sometimes in fecal concretions, 
 and occasionally in appendicular abscesses. In umbilical 
 hernia a small, more or less roundish protrusion is noticed 
 in the region of the navel. In diastasis of the rectus ab- 
 dominis muscles there appears in the middle line of the 
 abdomen a long protrusion of sausage shape consisting of 
 prolapsed intestine. Sometimes there is a pronounced 
 protrusion of this area owing to the escape of a large mass 
 of the bowel through the gap in the muscles. 
 
 In patients with thin abdominal walls very small sau- 
 sage-shaped prominences are occasionally visible which 
 quickly change their configuration, appearing now in one 
 place and now in another. This phenomenon is caused by 
 peristaltic contractions of the small intestine. As a rule, 
 they are not associated with pain and do not denote a mor- 
 bid condition. Sometimes similar peristaltic waves in the 
 small intestine appear periodically and annoy the patient. 
 Here they may be caused by nervous influences. Peri- 
 staltic contractions of the small intestine appearing in a 
 violent manner and caused by a stenosis or an obstruction 
 
 i 
 
EXAMINATION. 
 
 37 
 
 of tlie intestinal lumen are usually much more pronounced, 
 that is, the prominences are much higher and involve 
 larger areas of intestine, the waves moving with greater 
 rapidity and strength and being accompanied by intense 
 pain. Visible peristaltic contractions of the large bowel 
 
 Fig. 10.— Sims' Rectal Speculum. 
 
 Fig. 11. — Alllngham's Rectal Speculum. 
 
 are ordinarily met with only in cases of partial or total 
 intestinal obstruction. 
 
 Inspection of the anal region is best made when the pa- 
 tient lies on his side with his back toward the examiner. 
 The buttocks are held apart with the hands, and thus thor- 
 ough inspection of the anus is rendered possible. Piles, 
 fissures, fistulse may thus be discovered. 
 
 Proctoscopy. — In order to inspect the anus internally and 
 also the rectum it is necessary to introduce a speculum. 
 This method of inspecting the rectum is called proctoscopy. 
 Of the many specula devised for this purpose I would 
 mention those of Sims, AUingham, and Kelly as the most 
 practical (see Figs. 10, 11, 12). Kelly's speculum, which 
 consists of a hollow metallic tuba provided with an obtu- 
 rator, is best suited for this purpose. Before inserting the 
 
3S 
 
 DISEASES OF THE INTESTINES. 
 
 instrument it must be tliorouglily smeared with sweet oil 
 or vaseline. In cases in wliich the rectal region is inflamed 
 or ulcerated, it is necessary, in order to avoid too much 
 pain, to induce anaesthesia of these parts by painting them 
 with a ten-per-cent cocaine solution or by the introduction 
 
 of a suppository 
 of opium with 
 belladonna or of 
 cocaine. Re- 
 cently Tuttle ' 
 devised a new, 
 very practical 
 pneumatic proc- 
 toscope. It is 
 provided with a 
 lamp at the end 
 of the inspec- 
 tion tube and 
 also with an arrangement for inflation. Thus the rectum 
 can be filled with gas when the examination takes place, 
 and in this way a larger area of the canal becomes visible. 
 It is hardly necessary to say that endoscopy of the rectum 
 must not be performed until after a thorough evacuation of 
 the bowels. It is best to wash out the gut before examin- 
 ing with the speculum. When the speculum is in position 
 a portion of the rectal mucosa becomes visible when good 
 light is thrown into the endoscopic tube. The source of 
 light is immaterial, although it is best to have electric 
 light. Usually a small electric lamp with a reflecting mir- 
 ror fastened to the head of the examiner best serves the 
 purpose. The higher up the bowel has to be examined the 
 longer the speculum must be. After the full insertion of 
 
 'James P. Tuttle: "Diseases of the Anus, Rectum, and Pelvic 
 Colon," New York, 1902, p. 123. 
 
 Fig. 12.— Kelly's Rectal Speculum. 
 
EXAMINATION. 39 
 
 the instrument the highest portion of the bowel is first 
 examined, and while gradually drawing out the speculum 
 the entire area of the bowel through which it passes will 
 be brought into view. Small ulcers, atrophic and congested 
 conditions can thus be easih^ recognized and malignant 
 growths detected at an early period. 
 
 Transillumination. — Transillumination of the bowel was 
 first suggested by myself ' and later practised principally 
 by Heryng and Eeichmann." After a thorough cleansing 
 of the bowel by means of high irrigation about one quart 
 of water is injected and an electric illuminator (very similar 
 in construction to the gastrodiaphane) is inserted into the 
 rectum. The examination must be made in a dark room. 
 By gradually' pushing up the instrument successive portions 
 of the bowel may be transilluminated. This method, how- 
 ever, has not as yet proven to be of any practical value. 
 
 Roentgen Bays. — The examination of the colon by means 
 of Roentgen rays seems to be somewhat more promising. 
 A soft-rubber rectal tube through which a flexible wire 
 passes is introduced into the bowel as high up as jjossible 
 and the patient exposed to the Roentgen apparatus. The 
 wire within the tube becomes visible as a shadow, and thus 
 marks the course of the bowel in which it lies. Inasmuch 
 as it is hardly possible to insert an instrument higher up 
 than the sigmoid flexure, the following procedure for the 
 Roentgen examination appears to be of greater value : The 
 bowel is filled with two quarts of water in which 60 gm. (2 
 ounces) of subnitrate of bismuth are suspended hy means 
 of a starch solution. This mixture penetrates almost the 
 entire colon, and thus the position of the large bowel can 
 be determined by the Roentgen rays. 
 
 ' Max Einhorn ; " Die Gastrodiaphanie. " New-Yorker medicinische 
 Monatsschrift, November, 1889. 
 
 ^ Heryog und Reichmann : Therapeutische Monatshefte, 1893. 
 
40 DISEASES OF THE INTESTINES. 
 
 Palpation. 
 
 Palpation is the most important procedure available 
 among the methods of examination in abdominal diseases. 
 It is best performed in the recumbent position of the 
 patient, the head being slightly raised and the abdominal 
 muscles relaxed as much as possible. In order to effect 
 this the room must be of a comfortable temperature and 
 the hands of the examiner warm. If the patient is fidgety 
 and contracts his abdominal walls, it is necessar}^ to talk 
 to him and to draw his attention away from the exam- 
 ination. I have often noticed a great relaxation of the 
 muscles during an expiration following a deep inspira- 
 tion. Whenever, therefore, it is difficult to obtain relaxa- 
 tion of the abdomen I tell the patient to take a deep 
 inspiration and then make use of the following period of 
 expiration for palpation. If all these means fail to relax 
 the abdominal muscles, palpation may be tried in a warm 
 tub bath, as first recommended by Chlaj^owski, or under 
 chloroform narcosis. In cases of great diagnostic impor- 
 tance the latter method is certainly preferable. In palpat- 
 ing the abdomen it is advisable first to examine with the 
 entire palm of the hand, applying very little pressure, thus 
 determining the state and consistency of the abdomen. 
 The hand may thus be passed over the entire abdominal 
 surface from one place to another. This having been done, 
 palpation is then performed with a trifle more pressure, the 
 finger tips being used for this purpose. The latter j^rocedure 
 serves for exploring a more circumscribed area. Finally, 
 deep palpation is practised for which considerable pressure 
 may be required. 
 
 Palpation aids us in discovering the position of some of 
 the abdominal organs. With regard to the intestine the 
 
EXAMINATION. 41 
 
 following portions are often accessible to this method of ex- 
 amination : the caecum and part of the ascending colon, the 
 transverse colon, and the sigmoid flexure. In some in- 
 stances the descending colon above the sigmoid flexure can 
 also be palpated, especially if it is filled with hard scybala. 
 The jejunum and ileum filling most of the lower part of the 
 abdominal cavity (from the navel downward) cannot nor- 
 mally be separately outlined. 
 
 For the detection of tumors in the abdomen palpation is 
 of great service. By means of it we gain information with 
 regard to their size, shape, and consistency. An uneven 
 protuberant surface is characteristic of malignant growths, 
 while an even surface is more often found in benign neo- 
 plasms or in intussusception. A fecal tumor can be recog- 
 nized by indentations made by pressure with the fingers. 
 Sometimes after such pressure it is possible to notice for a 
 moment, when raising the finger, a slipping off of the in- 
 testinal wall from the fecal mass. This phenomenon, first 
 described by Gersuny ' under the name of " Klebesymptom, " 
 I have observed quite frequently and consider of practical 
 value. 
 
 Another important object of palpation is to ascertain 
 whether there is tenderness or pain on pressure. While 
 strong pressure exerted upon the intestine through the ab- 
 dominal wall even normally elicits an unpleasant sensation, 
 there is, however, no distinct pain connected with this act. 
 Tenderness on slight pressure is often present in inflam- 
 matory conditions of the bowels and also in ulcerative 
 processes. A circumscribed pain on pressure is present 
 in the appendicular region (McBurney's point) in appen- 
 dicitis, especially in the acute form. In chronic ai)peDdi- 
 citis the pain may be elicited only upon very strong press- 
 ' Gersuny : Wiener klinische Wochenschrift, 1896, No. 40. 
 
42 
 
 DISEASES OF THE INTESTINES. 
 
 FULL SIZE 
 
 G. TIEMANN & CO , N. Y. 
 
 Fig. 13.— Finger Cot. 
 
 lire. In ulcerations of the bowel there may be also one 
 or several circumscribed areas very painful to pressure. 
 In pains due to a purely nervous affection of the bowel 
 
 pressure may afford 
 relief. If a mere 
 touching of the ab- 
 domen elicits pain, 
 it is a sign either of 
 an extensive inflam- 
 matory process with- 
 in the bowel or of 
 peritonitis. 
 
 Palpation in the 
 form of tapping oc- 
 casionally produces a splashing sound (clapotage) over 
 some portions of the bowel. The splashing sound can be 
 elicited over the colon only when it is filled with liquid or 
 semi-liquid matter and gas. It can be discovered off and 
 on either in the caecum and in the portion of the bowel im- 
 mediately above it or in the sigmoid flexure. In the small 
 intestine clapotage can be obtained only in the dilated 
 portion of the gut above a stricture. Boas ' first suggested 
 the method of filling up the bowel with from 500 to 600 
 c.c. of water and then examining for the splashing sound 
 along the colon. When the patient has been thus pre- 
 pared, clapotage can be i^roduced in the sigmoid flex- 
 ure ; and by having the patient turn on his right side, it 
 can occasionally be produced in the transverse colon, and 
 finally in the csecal region. In cases of atony of the bowel 
 Boas was able to evoke the splashing sound even after 
 the injection of only 200 to 300 c.c. of water. Frieden- 
 
 ' Boas : " Diagnostik und Therapie der Magenkrankheiten, " Theil i., 
 1897, 4te Auflage, p. 105. 
 
EXAMINATION. 
 
 45 
 
 wald' lias also practised the same method with advan- 
 tage. Whenever the splashing sound can be produced in 
 the colon it serves the purpose of determining the situa- 
 tion of this organ. 
 
 The rectum is best palpated with the index finger well 
 oiled or smeared with vaseline or encased in a rubber cot 
 (Fig. 13) and anointed in the same 
 way. The condition of the anus and 
 the lower portion of the rectum can 
 be advantageously investigated with 
 the finger. The examination may be 
 made either in the recumbent posture 
 of the patient, in the side or knee- 
 elbow position, or in the standing po- 
 sition. In the latter instance it is 
 well to have the patient exert down- 
 ward pressure upon the rectum. 
 Hemorrhoids, polypi, and malignant 
 growths can thus be occasionally dis- 
 covered. In cases in which there is 
 a suspicion of malignant growths in- 
 volving portions of the colon not ac- 
 cessible either to palpation by the 
 finger or inspection with the procto- 
 scope, examination with the entire 
 hand in chloroform narcosis can be 
 tried as first practised by Simon. ^ 
 After dilating the anal sphincters, the 
 
 entire right hand and the arm are inserted into the bowel 
 through the anus, and thus the- higher portions of the 
 
 T'iG.14«. FIG. 15. Pig. 14b. 
 
 Figs. 14a and 146.— Cylin- 
 drical Bougies. 
 
 Fig. 15.— Olive-Point Bou- 
 gie. 
 
 1 J. Friedenwald : Medical News, 1894. 
 
 ^ Simon ■ Verbandlungen der deutsclien Gesellscli. f. Cliirurgie, 1871,^ 
 and Deutsche Klinik, 1872. 
 
44 DISEASES OF THE INTESTINES. 
 
 colon palpated with the fingers. This method can be rec- 
 ommended only in cases of extreme importance, as such 
 an examination is liable to produce unpleasant symptoms, 
 as, for instance, incontinence of the rectum, tearing of the 
 mucous membrane, etc. 
 
 Palpation of tlie rectum by meaDS of sounds is performed 
 whenever there is suspicion of a stricture involving por- 
 tions of the bowel not accessible to examination by the fin- 
 ger. For this purpose either bougies (see Figs. 14 and 
 15), or, still better, rectal tubes of various calibre may be 
 employed. Kuhn ' has recently recommended the use of 
 tubes provided with a metal spiral. He believes that 
 these penetrate the colon farther up without bending. 
 His statements have, however, not as yet been corroborated. 
 
 Percussion. 
 
 Percussion is of less importance than palpation. In 
 many instances it serves to confirm the results obtained 
 by the latter. In percussing the intestines it is best to 
 use the fingers. It should be done rather gently. Mild 
 percussion permits the discernment of slight differences 
 -of sound much better than strong percussion. As is well 
 known, percussion over empty intestinal coils or those 
 filled with gas or air gives a tympanitic sound which is 
 louder over the large than over the small bowel. Intestinal 
 coils filled with liquid or solid substances give dulness. 
 In meteorism of the intestines percussion will elicit a tym- 
 panitic sound of a deeper pitch than normally, and there 
 will be besides some areas of dulness over the abdomen. 
 The region of the liver and spleen will here show normal 
 •conditions with regard to the percussion sounds. Meteor- 
 ism of the abdomen as a result of perforation will manifest 
 ' Kuhn : Deutsche med. Wochenschr., 1897, Nos. 36 and 37. 
 
EXAMINATION. 45 
 
 an evenly diffused tympanitic sound all over tlie abdomi- 
 nal cavity. Usually the dulness over the region of the 
 liver and spleen will have disappeared. In ascites percus- 
 sion will reveal an area of dulness in the lower parts of the 
 abdomen, and there will be a change in the character of 
 the sound on altering the position of the patient. Tumors 
 of the intestine give dulness on percussion. Fecal accu- 
 mulations and appendicular abscesses will also manifest 
 dulness on percussion. 
 
 ' Auscultation. 
 
 Auscultation is not of great significance in diseases 
 of the intestine. Palpation of intestinal coils with the 
 application of moderate pressure may elicit either a gur- 
 gling noise or a friction sound. The latter was formerly 
 believed to be pathognomonic of typhoid fever. Of late, 
 however, it has been recognized that this sign is found in 
 many other conditions. At the time of active peristalsis 
 all kinds of gurgling sounds are heard within the intestine 
 (borborygmi), which, however, are not of much impor- 
 tance. In chronic stenosis of the intestine very loud noises 
 are at times heard, caused by the sudden passage of liquid 
 and gaseous contents through the stricture under great 
 pressure. In the latter affection splashing sounds can also 
 be easily produced over the enlarged bowel above the stric- 
 ture. Often a tympanitic sound of a metallic character can 
 be heard. 
 
 Inflation of the Intestine loitli Carbonic Acid Gas or Air. 
 
 Inflation of the intestine is one of the most important 
 diagnostic procedures. Yon Ziemssen,* who first intro- 
 duced this method of examination, injected successively 
 
 1 Von Ziemssen : Deutsches Arcliiv f. klinische Medicin, 1883, Bd.. 
 33, S. 235. 
 
46 DISEASES OF THE INTESTINES. 
 
 into the bowel two solutions, one containing tartaric acid, 
 the other bicarbonate of sodium in water. The carbonic 
 acid gas developing fills the large bowel, which can then 
 be recognized by the tympanitic percussion sound, or, in 
 rare instances, by inspection. Schnetter,' of New York, 
 suggested filling the bowel with carbonic acid gas by means 
 of a tube attached to an inverted siphon containing soda- 
 water, the valve of which is pressed. Here the carbonic 
 acid gas runs into tlie bowel without any admixture of 
 water. Rosenbach " made use of liquefied carbon dioxide 
 from a sparklet. Instead of the latter Kuneberg ' recom- 
 mended inflation of the intestine by means of air. This 
 is best done by a rectal tube to which a compressible air 
 suction bulb is attached. The advantage this method offers 
 consists in the possibility of regulating the amount of the 
 introduced air. In order to be able to measure the amount 
 of insufflated air, Damsch ^ has recommended the employ- 
 ment of a syringe of known capacity. An ordinarj^ bicycle 
 pump can be used for this purpose, the rectal tube being 
 attached to it. 
 
 Inflation of the bowel is of importance in detecting 
 a stenosis of this organ. Under ordinary conditions the 
 injected air evenly distends the entire colon, as can be 
 proven by inspection and percussion. In case there is a 
 stenosis in the large intestine the air will distend prin- 
 cipally that portion of the bowel below the stricture, while 
 that above will remain unchanged. It is thus possible to 
 recognize the seat of a constriction. The significance of this 
 diagnostic means, however, is confined merely to strictures 
 
 ' Schnetter : Deutsches Archiv f . klinisclie Medicin, 1884, Bd. 34, 
 S. 638. 
 '^O. Eosenbach: Berliner klinische Wochenschrift, 1889, No. 28. 
 ^Runeberg: Deutsches Archiv f. klinische Medicin, Bd. 34, S. 460. 
 * Damsch: Berliner klinische Wochenschrift, 1889, No. 75. 
 
EXAMINATION. ^ 47 
 
 of a liigh degree, while a beginning stenosis of the bowel 
 cannot be thus recognized, as the air will pass through it. 
 
 The position of the colon can be ascertained by this pro- 
 cedure. Normally the transverse colon is situated some- 
 what above the navel, while in cases of enteroptosis it may 
 be found about a hand's width above the symphysis. 
 
 Inflation of the colon is also of importance in the 
 differential diagnosis of abdominal tumors. As is well 
 known, tumors of the intestine will become more distinct 
 after iuflatipn of the bowel with air, while tumors of the 
 kidney, of retroperitoneal glands, and of the spine tend to 
 recede. According to Minkowski,' abdominal tumors after 
 filling the colon with air or water are usually slightly 
 shifted in the direction of the organ to which they be- 
 long. 
 
 Inflation of the bowel with air impregnated with ether 
 has been suggested by Dr. Sutton ^ as a means of recog- 
 nizing intestinal perforation. For this purpose he makes 
 use of a bottle filled with two drachms of ether. The bot- 
 tle is provided with a perforated rubber cork to which are 
 attached two rubber tubes provided with stopcocks. One 
 of these is then attached to a bicycle pump and the other 
 to an ordinary rectal tube. The air pumped into the bowel 
 must pass through the bottle containing ether and thus 
 takes up the ether vapors. In case of perforation of the 
 bowel, the ether quickly escapes through the opening into 
 the abdominal cavity and equally distends it; while, if 
 there is no perforation, the bowel, first the large and later 
 the small intestine, becomes filled with air and ether ; ulti- 
 mately the ether reaches the stomach and is usually er-uc- 
 
 ' Minkowski : Berliner klinische Wochenschrift, 1888, No. 31. 
 
 '^E. M. Sutton: "Diagnosis of In testioal Perforations by Means of 
 Ether Inflation per Rectum." Journal of the Am. Med. Assn., Decem- 
 ber 30th, 1899. 
 
48 DISEASES OF THE INTESTINES. 
 
 tated. Tiie ether can then be recognized bj' its charac- 
 teristic odor. It seems that this procedure is especially 
 useful in gunshot wounds of the abdomen. 
 
 Injection of Water 'per Anum. 
 
 This is done by means of a rectal tube and a fountain 
 syringe provided with a scale indicating the amount of 
 water used. In case of stricture, especially of the lower 
 portion of the colon, the quantity of water which can be 
 injected is not great, while ordinarily from three to five 
 quarts of water can be poured in. Inasmuch as even nor- 
 mally some people are not able to hold large amounts of 
 water in the bowels without experiencing considerable dis- 
 comfort, the quantity of fluid which can be injected with- 
 out pain is not of great diagnostic value. Filling up the 
 bowel with water can also be made use of for the determi- 
 nation of the position of the colon, as this organ will then 
 give a dull sound. For this purpose, however, the proced- 
 ure in question is not so good as the above-described method 
 of inflation with air. 
 
 Lavage of the Boiuel. 
 
 Lavage of the bowel in a similar manner as performed 
 in the stomach has been recommended by Boas ' for di- 
 agnostic purposes. It is best performed in the lateral 
 posture of the patient after an evacuation of the bowels. 
 The same apparatus as for gastric lavage may be used 
 here. The rectal tube, which represents the stomach tube 
 employed in gastric lavage, is attached to a long piece 
 of rubber tubing provided with a big funnel. The rectal 
 tube is inserted as high up in the bowel as possible and 
 then the water is poured in until the patient begins to 
 feel some discomfort. As soon as this is the case the fun- 
 ^ J. Boas: Deutsche Aerzte-ZeitTuig, 1895, Nos. 3 and 3. 
 
EXAMINATION. 49 
 
 nel is lowered and thus tlie water returns. The latter is 
 now subjected to a tliorougli examination. Normall}- the 
 returning water api:)ears prettj' clear or slightly turbid by 
 the admixture of small particles of mucus, epithelial cells, 
 and fecal matter. In catarrh of the large bowel a consid- 
 erable quantity of mucus is found. Ulcerative processes 
 accompanied by hemorrhages or by suppuration are often 
 recognized by the admixture of either pus or blood in the 
 wash-water. Occasionally exfoliated pieces of intestinal 
 mucosa are found in the wash-water, and a microscopical 
 examination of them may be of diagnostic importance. 
 
 Examiuatlon of the Fteces. 
 
 The examination of the faeces is of much service in dis- 
 eases of the intestine. The fseces represent the end pro- 
 duct of the digestive act, consisting of residue unsuitable 
 for further assimilation. It is evident that a thorough 
 knowledge of the dejecta will throw light upon the nature 
 of the activity of the intestines. 
 
 The normal faeces consist of changed and unchanged 
 remnants of food, bacteria, traces of digestive juices, epi- 
 thelial cells, and salts. The quantity of the fseces for 
 twenty-four hours varies greatly with the kind of food 
 taken. In a mixed diet it usually amounts to from four to 
 seven ounces. The color of the fseces is usually dark brown 
 owing to changed bile pigment, the bilirubin having be- 
 come changed in the intestine into urobilin. The diet has 
 great influence upon the color of the fseces. Meat pro- 
 duces a dark brown, milk a light yellow color, cacao a 
 more or less brownish-red, huckleberries and claret a dirty 
 black-brown color with a greenish hue. The salts of iron 
 and manganese give rise to a darker color than the usual 
 one, while bismuth produces a more or less blackish color. 
 According to Quincke, all these metals are reduced to 
 
60 DISEASES OF THE INTESTINES. 
 
 oxydule combinations which are responsible for these 
 colors/ while the former belief that these metals formed 
 sulphides is not correct. Calomel frequently produces a 
 greenish hue, while senna, santonin, gamboge, and rhubarb 
 give rise to an intensely yellow color. 
 
 The fseces are normally somewhat soft in consistency and 
 have a sausage shape. In abnormal conditions the con- 
 sistency may be changed in two directions. The dejecta 
 may be greatly hardened and appear in small balls, or in 
 the form of very thin cylinders. On the other hand, the 
 stools may be abnormally mushy or even liquid. The 
 hardened stools which occasionally show grooved impres- 
 sions from the taenia coli bear testimony to their long 
 sojourn in the intestine, thus being exsiccated from the 
 complete absorption of water. They are, however, by no 
 means characteristic of a stenosis of the intestine. Very 
 soft dejecta may be either water}-, as for instance in 
 cholera nostras or asiatica, or thej^ are mixed with mucus 
 which can be easily seen when pouring the dejecta into a 
 glass and inverting it, when the mucus as a rule adheres to 
 the surface of the vessel. 
 
 Odor. — The characteristic odor of the faeces is normally 
 caused by skatol and also to a less degree by indol. The 
 fecal odor maj^ be increased whenever the faeces have been 
 retained much longer than normally in the intestine. On 
 the other hand, faeces occasionallj^ present very little or no 
 odor when their sojourn in the intestine has been very 
 short. As a good instance of the latter variety the so- 
 called rice-water movements in cholera nostras and cholera 
 asiatica may be mentioned. Movements with a fetid odor 
 occur principally in malignant growths of the large bowel 
 accompanied by ulcerative processes. 
 
 Remnants of Food in the Faeces. — Undigested remnants of 
 
 ' Quincke: Munchner medizinische Woclienschrift, 1896, No. 36. 
 
EXAMINATION. 51 
 
 food, macroscopically visible, occur in the faeces. Nor- 
 mally, however, only small particles of vegetable sub- 
 stances, like potatoes, asparagus, spinach, peas, etc., are 
 found, while remnants of meat can never be discovered with 
 the naked eye. In case particles of meat are visible, it in- 
 dicates a severe lesion of the intestinal tract. If large 
 amounts of undigested food (even vegetable matter) are 
 present in the faeces, it is also an indication of an existing 
 severe lesion. Connective-tissue fibres appearing unal- 
 tered in the faeces, according to Schmidt, ' indicate a de- 
 ficiency of gastric digestion. 
 
 Abnormal admixtures frequently occur in the faeces, and 
 are occasionallj^ of great diagnostic importance. Thus, 
 blood may be found either in its fresh condition (red) or it 
 may be very dark but not coagulated. In both instances 
 the blood comes from the lower portions of the large bowel. 
 Sometimes the blood appears in a more changed and de- 
 composed form, giving the faeces the appearance of tar. In 
 this instance it originates from the higher portions of the 
 bowels or from the stomach. 
 
 An admixture of pus in the dejecta which can be macro- 
 scopically recognized occurs only in instances in which pus 
 exists in the lower portions of the large intestine. For if 
 there is pus present in the higher portions of the bowel, it 
 is usually changed before its exit in such a manner that 
 it cannot be detected unless the amount is very consider- 
 able. 
 
 Fragments of tumor (polypi or torn off j)articles of can- 
 cer) are occasionally found in the dejecta. A thorough 
 examination of these may be of great help in the diagnosis. 
 
 Mucus, although a normal constituent of the faeces, can- 
 not be discovered in large amounts under physiological 
 
 ' x\d. Schmidt: "Beitrage zur Diatotlierapie bei Magen- iind Darm- 
 krankheiten." Munch, med, Wocheuschr., 1902, Nos. Gaud 7. 
 
62 DISEASES OF THE INTESTINES. 
 
 conditions. Macroscopically visible mucus may exist in 
 the following forms : (1) It may surround the fecal matter 
 in the form of a glassy layer. This usually indicates a 
 diseased condition of the lower portion of the bowel. (2) 
 The mucus may appear in the form of membranes and may 
 be evacuated either alone or after a fecal evacuation. This 
 often occurs in membranous enteritis. (3) The mucus may 
 appear in a mushy movement having a yellowish coloration 
 and be well mixed with fgeces. If a glass rod is dipped 
 into such an evacuation the mucus adheres to it. (4) The 
 mucus exists in small particles visible with the naked eye 
 and floating in the watery dejecta. All these varieties of 
 mucus with the exception of (2) indicate the presence of a 
 catarrhal condition of the intestine. 
 
 Intestinal parasites also occur in the faeces, and their 
 discovery may elucidate the diagnosis. 
 
 Chemical Examination of the Fceces. — The reaction of the 
 faeces is normally neutral or slightly alkaline. Under a 
 diet rich in vegetables, however, it is slightly acid. In 
 cases in which there is an occlusion of the bile duct so that 
 it does not empty into the intestines the reaction is strongly 
 acid. The test for the reaction is best made by means of 
 litmus paper. The reaction at the surface of the fecal mat- 
 ter may be different from that in the interior. It is there- 
 fore best to test both. 
 
 The amount of acidity or alkalinity of the faeces can be 
 determined by mixing 10 to 20 c.c. of the fresh fecal matter 
 with about 100 c.c. of distilled water. A drop of a phenol- 
 phthalein solution is added and as much of a decinormal 
 solution of either sodium hj^lrate or sulphuric acid until 
 the red color appears, or if the alkalinitj^ has to be deter- 
 mined, disappears. The reaction of the faeces is, however, 
 not of much diagnostic value. 
 
EXAMINATION. 53 
 
 Tests for 31uciu. — According to Hoppe-Seyler, mucin 
 forms one of the principal constituents of the faeces. In 
 order to test for it the faeces are thoroughly mixed with 
 water and an equal volume of milk of lime, allowing the 
 mixture to stand for several hours. It is then filtered. 
 Acetic acid is now added to the filtrate. In the presence 
 of mucin a precipitate forms. In case particles of sus- 
 pected mucus are visible within the faeces, they can be 
 examined separately in the following manner : A small flake 
 of the mu^us is dissolved in a weak solution of potassium 
 or sodium hydrate, and acetic acid added; If the precipi- 
 tate remains undissolved after the addition of the acetic 
 acid in excess, it proves the presence of mucin. Inasmuch 
 as nucleoalbumin also gives the reaction just described, 
 the positive proof that the precipitate is due to mucin is 
 afforded by heating it in a diluted mineral acid to the boil- 
 ing-point. If mucin is present the heated solution will 
 contain a substance reducing copper oxide. Another very 
 useful test for the presence of mucin consists in staining 
 the flake of fecal matter resembling mucus with a weak 
 triacid solution (Ehrlich). The presence of mucus pro- 
 duces a green color, while if the flake consists of albumin, 
 a red color arises. This test, first described by Pariser,' 
 I have found of practical value. 
 
 Albumin. —In order to examine the faeces for albumin, 
 they are treated repeatedly with water slightly acidified 
 with acetic acid. The watery extract is filtered several 
 times and the filtrate examined for albumin according to 
 the methods used in examinations of the urine for this 
 substance. The addition of acetic acid and potassium ferro- 
 cyanide, however, is best suited for this purpose. Under 
 normal conditions there is no albumin present in the faeces. 
 ' Parlser : Deutsche medicinische Wochenschrift, 1893, No. 41. 
 
54 DISEASES OF THE INTESTINES. 
 
 Von Jakscli ' found it present in typlioid fever, in isolated 
 cases of acute enteritis, and in clilorosis. 
 
 Propeptone and Pep)tone. — After the test for albumin has 
 been made with negative result, the watery extract of the 
 faeces is treated with phosphotungstic acid, the precipi- 
 tate diluted with water and sodium hydrate and a small 
 amount of a weak solution of sulphate of copper added. 
 A purplish-red color (biuret test) shows the presence of 
 both propeptones and peptones. If it is desirable to ascer- 
 tain the presence of peptones separately it is necessary to 
 first precipitate the propeptone by the addition of a large 
 amount of ammonium sulphate. In normal dejecta Von 
 Jaksch never encountered peptone. Pathologically he 
 found it in typhoid fever, dj^sentery, tuberculous ulcer of 
 the intestine, and in perforation peritonitis. 
 
 Carbohydrates. ~ln order to test for the presence of car- 
 bohydrates, the fseces are subjected to distillation. The 
 residue is extracted with alcohol and ether; the extract is 
 then boiled with water, filtered, and again boiled with the 
 addition of dilute sulphuric acid. This solution is then 
 subjected to Trommer's or Nylander's test for the presence 
 of reducing substances. 
 
 In order to ascertain whether starch is present the 
 watery extract of the faeces is examined with Lugol's solu- 
 tion, the presence of starch producing a blue color. 
 
 If the dejecta be examined for the presence of sugar, then 
 a watery extract of the fecal matter can be directly tested 
 with the usual sugar reagents. Normally neither starch 
 nor its derivatives (sugar) are found. 
 
 Schmidt'' suggested testing the watery extract of the 
 fecal matter with regard to the amount of gas developing 
 
 1 Von Jaksch : " Klinische Diagnostik. " 
 
 2 Ad. Schmidt : Berliner klinische Wochenschrift, 1898, No. 41. 
 
lEXAMiNATION. 55 
 
 through fermentation. For this purpose Schmidt puts the 
 watery extract of the faeces into fermentation tubes (similar 
 to the fermentation saccharometer) and keeps them at blood 
 temperature. The greater the amount of gases developing^ 
 in the cylindrical part of the tube, the greater the evidence 
 of disturbances within the intestine. The greater propor- 
 tion of the gas consists of carbonic acid and is due to its 
 formation from the carbohydrates existing in the fecal 
 matter. In order to be able to judge more accurately from 
 this test, Schmidt examined his patients after a certain 
 diet which they had been taking for several days. It con- 
 sisted of 1,560 c.c. of milk, four eggs, three zwieback, one 
 plate of barley soup, one plate of flour soup, and one cup 
 of bouillon a day. While Schmidt asserts that whenever a^ 
 considerable amount of gas is found in the fermentation! 
 tube this indicates a real disturbance of the intestine, S. 
 Basch,' who has made a thorough study of Schmidt's 
 method in a considerable number of cases, is of the opinion 
 that on the one hand a considerable amount of gas may be 
 found in cases without any apparent intestinal lesion, and, 
 on the other hand, grave disturbances of the intestine may 
 show a total absence of gas. Inasmuch as Schmidt's fer- 
 mentation method is certainly complicated and its results 
 are not of great diagnostic value, I do not believe that it 
 will ever come into practical use. 
 
 Fat. — The presence of neutral fat and fatty acids is de- 
 termined in the following manner : The faeces are treated 
 with a considerable amount of ether ; the latter is separated 
 and evaporated in a water bath. The fat if present then 
 remains and is visible. In order to show the presence of 
 
 ' S. Basch : " Welche klinische Bedeutung bezeichnet die Schmidt'sche 
 Gahrungsprobe der Faeces?" Zeitsclirift f. klin. Med., Bd, 37, Heft 
 5 and 6. 
 
56 DISEASES OF THE INTESTINES. 
 
 soaps which do not dissolve in ether, another portion of 
 fecal matter is ilrst treated with acids which split up the 
 soaps and then extracted with ether. The quantitative de- 
 termination of the amount of fat and of its different com- 
 ponents is somewhat complicated and of not much service 
 clinically. Those interested in the subject may look up 
 Von Noorden's "Beitrage zur Lehre vom Stoffwechsel, " 
 Heft I., p. 109, Berlin, 1892. Normally fat is never per- 
 ceptible macroscopically in the faeces unless after the in- 
 gestion of very large quantities. It may then be visible in 
 small portions of pea size. Pathologically fat may exist 
 in very large quantities in the fecal matter and give it 
 a grayish silvery appearance, the so-called fatty stools. 
 This frequently occurs in diseases of the pancreas, and 
 also whenever the absorption by the lymphatics is greatly 
 disturbed. 
 
 Blood. — Fresh blood from the lower portion of the intes- 
 tine, and also from the higher portions of the bowel if pres- 
 ent in large amount, is easily recognized by its macroscopic 
 appearance. Often the microscope will reveal well-pre- 
 served red and white blood corpuscles. Sometimes, how- 
 ever, the blood is changed to such a degree that it is not 
 easily recognized. Here various tests are required in order 
 to prove its existence, the same procedures being used as 
 for the discovery of blood in the gastric contents. The 
 hsemin test which is chiefly used is made as follows: A 
 small particle especially suspected of containing blood is 
 dried and powdered and a portion of it put on a slide. A 
 trace of sodium chloride is now added and a drop of glacial 
 acetic acid poured over it and thoroughly mixed. A cover- 
 glass is now put over it, the specimen is slowly heated, and 
 after cooling examined with the microscope. The presence 
 of hsematin crystals shows that there was blood. 
 
EXAMIXATION. 57 
 
 Bile Pigmeni. — Under normal conditions no unchaaged 
 bile pigment is found in the fseces. In catarrhal conditions 
 of the small intestine it has been frequently detected. The 
 presence of bile i^igmeut is ascertained in the following 
 manner : A particle of highly colored fecal matter is brought 
 into contact with a drop of fuming nitric acid. The yellow 
 color usually i^asses through the various colors of the spec- 
 trum — red, violet to green. In some instances a green 
 discoloration appears at once. The test for biliary pigment 
 may also be made as follows: The faeces if liquid are 
 filtered through filter paper, and if not liquid a watery 
 mixture is made and filtered. When the filter paper is 
 dry a few drops of nitric acid are poured on it. The colors 
 just mentioned appear in the form of rings, if bile pigment 
 is x)resent. Still another test is as follows : A small quan- 
 tity of the fluid dejecta is treated with a concentrated 
 watery solution of sublimate. If the faeces contain biliary 
 pigments in considerable quantity, the entire mixture turns 
 green. If, however, the biliary pigment is adherent to cer- 
 tain small fecal particles then these alone turn green. 
 
 Biliary Acids. — Whenever biliary pigments appear in the 
 dejecta, biliary acids, as a rule, accompany them. The 
 presence of biliary acids is best revealed bj^ Pettenkofer's 
 test, and is made as follows: A small quantity of fecal 
 matter is thoroughly treated with alcohol, which is then 
 evaporated. To the residue a weak watery solution of bi- 
 carbonate of sodium is added, and to this mixture a small 
 quantity of cane sugar and a few drops of sulphuric acid. 
 W^hen biliary acids are present a characteristic red or pink 
 color arises. 
 
 Urobilin. — Normally the biliary pigment within the in- 
 testinal tract becomes changed into urobilin, which is the 
 principal factor of the characteristic brownish color of the 
 
58 DISEASES OF THE INTESTINES. 
 
 faeces. Tlie best test for the presence of urobilin is 
 Fleisclier's ' procedure which is as follows : A small quan- 
 tity of faeces is put into a test tube and a small amount of 
 alcohol with a few drops of hydrochloric or acetic acid 
 added; the mixture is then left undisturbed for a short 
 time. The presence of urobilin j^roduces a yellow or 
 brown color, the latter, if present in large amount. If 
 the alcohol is now poured out and a few drops of sodium 
 hydrate added, as well as a small quantity of a chloride-of- 
 zinc solution, there appears, according to the amount of 
 urobilin, a more or less greenish fluorescence in direct rays 
 of light, while in transmitted light the fluid appears pink 
 or yellowish-red. If the watery extract of faeces to which 
 some ammonia has been added is filtered and chloride of 
 zinc added, the presence of urobilin produces a pinkish-red 
 precipitate. If this precipitate is filtered under addition 
 of alcohol containing some ammonia there appears a more 
 or less greenish fluorescence (Schmidt's^ test). A small 
 piece of fecal matter is treated with a concentrated watery 
 solution of sublimate and thoroughly mixed with a glass 
 rod. The presence of urobilin gives rise either imme- 
 diately or a little later to a pinkish-red color, while biliver- 
 din, if present, produces a greenish color. 
 
 Normally urobilin is present in the faeces. Its absence 
 is observed only in pathological conditions. 
 
 Acholic Stool. — The acholic stool presents a grayish- 
 white, ashy gray, or clay color. It is usually of a soft salve- 
 like consistency. It occurs (1) in conditions in which 
 there is a total absence of bile in the intestine, and (2) 
 whenever the absorption of fat is greatly impaired. Until 
 very recently the grayish-white color has been generally 
 
 >R. Fleischer: "Krankheiten des Darms, "p. 1160, Wiesbaden, 1896. 
 5 A. Schmidt ; Verhandlungen des Congresses f . Innere Med. , 1895. 
 
EXAMINATION. 59' 
 
 ascribed to the absence of biliary pigments and their modi- 
 fications (urobilin), but Fleischer and Bunge ' have conclu- 
 sively shown that the whitish color may be observed in 
 faeces containing urobilin, the color being due to the pres- 
 ence of large amounts of fat. In the latter instance the 
 stool, after being treated with large amounts of ether, thus 
 separating the contained fat, assumes a brownish color. 
 This I can confirm also from my own experience. 
 
 Ferments. — In order to ascertain the existence of fer- 
 ments in the faeces a glj'-cerin extract of them may be mada 
 or the fecal matter may be directly mixed with water con- 
 taining a small proportion of thymol, and filtered. Th& 
 filtrate, or the glycerin extract, can now be directly tested 
 for the presence or absence of the different ferments, tryp- 
 sin and diastase. In order to test for trypsin the fecal 
 filtrate is made alkaline by the addition of bicarbonate of 
 sodium and a few flakes of fibrin are added. The solution 
 is kept at blood temperature for a few hours and then tested 
 with potassium hydrate and a weak solution of sulphate of 
 copper. If trypsin is present, a pinkish-red color will 
 arise in consequence of the peptone which has formed 
 (biuret test). In order to test for diastase, a few cubic 
 centimetres of the filtrate are mixed with about half the 
 amount of a starch solution and kept at blood temperature 
 for half an hour. The mixture is now subjected to Fehling's 
 or Trommer's test for the presence of sugar. Normally, as 
 a rule, these ferments are absent, but in pathological condi- 
 tions, especially in diarrhoea, they are frequently found. 
 
 Concretions. — The fseces occasionally contain concretions 
 which may be of diagnostic importance. In order to de- 
 tect them, especially if they are small, the faeces must be 
 
 * Bunge : " Lehrbuch der phys. u. patbol. Chemie, " Leipsic, 1887^ 
 p. 192. 
 
60 DISEASES OF THE INTESTINES. 
 
 thoroughly mixed with warm water and poured through a 
 large sieve. While the fecal matter is on the sieve some 
 more water is added and the mass constantly stirred with 
 a wooden stick. An}' concretions jjresent will thus be dis- 
 covered remaining on the surface of the sieve. 
 
 Recently Boas and I have each constructed special stool 
 sieves for the same purpose. Boas' ' apparatus consists 
 of two hemispheres, one fitting into the other, the lower of 
 which forms the sieve. In the upper hemisphere are two 
 openings, a larger one to admit water and a smaller one 
 through which a glass rod for stirring the faeces may be 
 introduced. Boas has enhanced the value of this appara- 
 tus by using it in the examination of the faeces not only 
 for gall stones, but also for undigested food remnants. 
 Boas expresses himself as follows : " The apparatus serves 
 the purpose of easily isolating substances that are indi- 
 gestible or that have escaped digestion by the stomach or 
 bowel, and of rendering them in this way more easily 
 accessible to a gross and microscopical examination. It 
 also serves the purpose of viewing in their whole extent 
 pathological admixtures to the stool, such as mucous con- 
 crements, and entozoa and of examining them in all di- 
 rections. The whole procedure lasts from ten to twenty 
 minutes." 
 
 Every phj'sician who has at heart the examination of 
 the bowel function will receive with interest this new ap- 
 paratus of Boas. The constant stirring of the faeces with a 
 glass rod seems to be somewhat tiresome. I " have, there- 
 fore, devised another apparatus which I have used for 
 
 'J. Boas: "Ein Sluhlsieb." Deutsche medicinische Wochenschrift, 
 1900, No. 36, p. 583. 
 
 '-^ M. Einhorn: "A New Stool Sieve." N. Y. Med. .Journal, August 
 24th, 1901, p. 378. 
 
EXAMINATION. 
 
 61 
 
 some time for the same purposes as Boas, and which 
 seems to me to have some advantages over Boas' stool 
 sieve. The apparatus (Fig. IG) is composed of three 
 parts: 1. A flour sieve (Fig. IG, B). 2. A cover (Fig. 
 16, A) provided with a large opening (Fig. 16, C). 3. A 
 tripod (Fig. 16, D). The flour sieve, which is the princi- 
 
 FIG. 16. 
 
 Fig. 17. 
 
 Fig. 16.— Br. Einhorn's Stool Sieve. A, Cover; J3, flour sieve; C, large opening ; D, 
 
 tripod ; E, liandle. 
 Fig. 17.— Dr. Einhorn's Stool Sieve; Section. F, Stirring apparatus ; G, hemispliere of 
 
 wire netting. 
 
 pal part of the apparatus and which may be used for the 
 examination of fasces without further additions, consists 
 of a cylindrical vessel the bottom of which is formed by a 
 hemisphere of fine wire gauze (Fig. 17, G) . In this cyl- 
 inder is an appliance for stirring (Fig. 17, F), consisting 
 of two circular wires placed at right angles and one 
 straight horizontal wire which, perforating the cjdinder, 
 ends outside of it in the handle (E). By turning this 
 handle the stirring apparatus is put in motion, and, 
 the wires running close over the wire sieve, the fseces 
 are constantly brought in contact with the latter. In_ 
 
■62 DISEASES OF THE INTESTINES. 
 
 the presence of water a constant washing and separa- 
 tion into fine particles of the brittle faeces takes place. 
 These finely separated substances flow off with the 
 water through the sieve, whereas coarser particles remain 
 behind. 
 
 Method of Examination. — The faeces to be examined 
 are put into the cylinder {B), the cover (^4) is put on, and 
 the apparatus is placed upon the tripod {D) . The appara- 
 tus being placed under a water faucet, the water is allowed 
 to run directly into the opening ((7) of the cover. At the 
 same time the handle {E) is constantly turned. The 
 whole process is usually terminated in from three to six 
 minutes. We now notice that the water runs off clear. 
 Wo then take off the cover and inspect the residue on the 
 wire gauze. In a normal stool the remnants are very 
 small, as I have determined by several examinations. They 
 consist of small pieces of cellulose, connective-tissue shreds, 
 and some fruit pits, the total quantity usually not exceed- 
 ing half a tablespoonful. In pathological cases the residue 
 is at times increased. With this method of examination 
 undigested substances and concrements are very easily 
 found. 
 
 Method of Ascertaining the Motor Function of the 
 Intestine. — By means of the stool sieve it is easy to dis- 
 cover any foreign, indigestible matter passing through the 
 alimentary tract. This can be utilized for the determina- 
 tion of the motor function of the digestive tract. The 
 test is made as follows : Patient is given from three to five 
 small porcelain pills in a capsule after breakfast. There- 
 after the fecal passages are examined separately on the 
 stool sieve and the time is noted when all the porcelain 
 globules have been recovered on the sieve. The longer the 
 time required for this purpose the slower the motor func- 
 
EXAMINATION. 60 
 
 tion of the intestine, and vice versa. Normally it takes 
 from twenty-four to forty-eight hours for the expulsion of 
 all the porcelain globules through the rectum. 
 
 The following different concretions may be met with in 
 the faeces: (1) Gallstones; (2) pancreatic calculi; (3) en- 
 teroliths; (4) coproliths; (5) foreign bodies. 
 
 Biliary calculi are easily recognized when they attain 
 considerable size. When they are very small, however, 
 their recognition is somewhat more difficult. The princi- 
 pal constituents of biliary calculi are cholesterin and bile 
 pigment in conjunction with lime. 
 
 The small concretions (sand) suspected to be of biliary 
 origin should be examined in the following way : About 
 2 gm. of the mass is well powdered and treated with 20 
 c.c. of ether, thoroughly mixed and filtered, the filtrate 
 evaporated and tested for the presence of cholesterin in the 
 following manner : (a) Part of the residue is dissolved in 
 hot alcohol and put aside on a porcelain dish for spontane- 
 ous evaporation. The precipitate is examined under the 
 microscope. Crystals of rhomboid shape with a ragged 
 edge are characteristic of cholesterin. {h) Another por- 
 tion of the residue is directly put on a slide, a drop of 
 concentrated sulphuric acid added, and covered with a 
 cover-glass. The cholesterin crystals assume a carmine 
 color at their margins. If now a drop of Lugol's solution 
 is added a violet color arises, (c) Another portion of the 
 residue is treated with hydrochloric acid and a trace of 
 chloride of iron and evaporated. If cholesterin is present 
 a blue color arises. The residue of the original ether mix- 
 ture is treated with diluted hydrochloric acid, heated, and 
 extracted with chloroform after it has cooled off. The 
 chloroform extract is now tested with Gmelin's reaction 
 
64 DISEASES OF THE INTESTINES. 
 
 (fuming nitric acid). The presence of bile pigment pro- 
 duces the well-known change of colors. 
 
 Pancreatic Calculi. — Pancreatic calculi usually have a 
 rough surface, are brittle, and may be faceted. They are 
 soluble in chloroform and produce on evaporation an aro- 
 matic odor (Minich'). Bile pigment and cholesteriu are 
 absent. 
 
 Enteroliths or calculi formed in the small intestine usu- 
 ally consist principally of inorganic salts (lime, magnesia). 
 They are light in color and ordinarily of small size. Thej^ 
 occasionally form after an extensive use of mineral medica- 
 ments (lime, magnesia, etc.). They hardly ever give rise 
 to intestinal obstruction. 
 
 Coproliths or fecal calculi are found in the large bowel, 
 principally in places in which there is a retardation in the 
 passage of the fseces. Thus they are encountered in the 
 CDecum, in the appendix, in sacculations of the colon, and 
 in the rectum. The coproliths are of stony hardness and 
 of sausage shape. They usually show on section concen- 
 tric rings. Occasionally they attain considerable size and 
 may give rise to obstruction of the bowel. 
 
 Foreign Bodies. — Foreign bodies which have been swal- 
 lowed vaaj pass through the entire intestinal tract and be 
 eliminated in the faeces. Thus pieces of bone, coins, mar- 
 bles, needles, and all kinds of foreign substances may be 
 found in the stools. In rare instances concretions of shellac 
 are discovered in the stools of patients who have drunk 
 furniture polish, the shellac forming concretions after the 
 absorption of the alcohol. Hair balls may be found in 
 patients who habitually bite off and swallow hair. 
 1 Minich : Berliner klin. Wochenscbrift, 1894, No. 8. 
 
EXAMINATION. 
 
 65 
 
 3Iicroscopical Examination. 
 
 The microscopical examination of the faeces is occasionally 
 of assistance in establisliing the diagnosis. With Ewald ' 
 I do not think it necessary to examine microscopically the 
 faeces of every patient presenting intestinal symptoms. In 
 
 Fig. 18.— Normal Faeces, showing a few Fat Crystals and Fat Globules ; Digested Muscle 
 and Epithelial Cells ; Micro-organisms. 
 
 cases, however, in which the diagnosis is not quite clear 
 and the symptoms point to an intestinal lesion, a micro- 
 scopical examination of the faeces should be made. 
 
 Diarrhoeal stools may be examined under the microscope 
 
 > C. A. Ewald: "Diseases of the Intestines." Twentieth Century 
 Practice of Medicine, vol. ix., p. 113. 
 5 
 
66 DISEASES OF THE INTESTINES. 
 
 without any further preparation. Solid fecal matter is 
 examined by taking a small particle of the faeces, putting it 
 on a slide, and mixing it thoroughly with a drop of physi- 
 ological salt solution. In order to avoid the unpleasant 
 odor, a small amount of a watery one-per-cent formalin 
 solution may be first added to the fecal matter. The micro- 
 
 PiG. 19.— Nonnal Faeces showing Detritus, Plant Cells, Digested Muscle Fibres, Bacteria. 
 
 scopic picture of the normal faeces varies greatly according 
 to the diet. In people living on a meat diet no vegetable 
 residue will be seen, while there will be no remnants of 
 meat in people subsisting on an exclusively vegetable diet. 
 In case of a mixed diet there will be remnants of both in 
 the stool. A mixed diet will reveal the following appear- 
 
EXAMINATION. 67 
 
 ances: There will be a large number of plant cells, the 
 remnants of various vegetables and fruits. They are usu- 
 ally of considerable size, present peculiar shapes, and can 
 be easily differentiated from animal cells (Figs. 18, 19, 20, 
 21) , The peels of pears and apples and of prunes com- 
 monly pass out in the stool entirely unchanged. Notwith- 
 
 FiG. 20.— Different Varieties of Vegetable Cells found in Normal Faeces. 
 
 standing the presence of these plant cells in the stools 
 starch, as a rule, is absent. Thus the microscopical speci- 
 men when stained with Lugol's solution will show no blue 
 color. If, however, starch appears in a stool in well-pre- 
 served granules, it is always pathological, indicating de- 
 ficient digestion. Minute fragments of meat are found 
 
68 DISEASES OF THE INTESTINES. 
 
 in small quantity in the stools. Althougli considerably 
 changed the muscles can be recognized as such, and the 
 transverse markings can often be noticed. Frequently they 
 present a yellowish tinge from biliary pigment. Connec- 
 tive-tissue fibres and also elastic fibres are occasionally met 
 
 Fig. 21.— Stool of an Hysterical Patient who Simulated Passing of Large Quantities of 
 Mucous Membranes In the Faeces. The membranes under the microscope showed the 
 structure of common tissue paper ; a few plant cells, epithelial cells, and fat crystals 
 were also present. 
 
 with, both being quite resistant to the action of the diges- 
 tive juices. The presence of numerous pieces of meat in 
 the stool is pathological. 
 
 Fat. — Microscopically fat can be detected in the faeces in 
 the form of colorless small globules which may exist in 
 
EXAMINATION. 69 
 
 large numbers after an excessive milk diet or in the shape 
 of small needle-shaped crystals, or again in the form of 
 sheaves. The small crystals of needle shape usually occur 
 singly, and consist mostly of fatty acids, while the sheaves 
 consist of fatty soaps. The fatty-acid crystals melt and 
 disappear when heated, while the soaps remain unchanged. 
 Ether likewise causes a disapjiearance of the fatty acids, 
 while the soaps remain unchanged. Rieder ' suggests the 
 use of the dye stuff Sudan II. (C.,,Hj„N,0) in a concentrated 
 alcoholic solution for the differentiation of the fats. This 
 dye stains plain fat bright red, while crystals of fatty acid 
 and of lime and magnesia soaps remain unchanged. While 
 normally these different forms of fat appear in very scanty 
 amounts in the faeces, they may be found considerably in- 
 creased under pathological conditions (affections of the 
 liver, pancreas, and acute enteritis). 
 
 Crystals. — Besides the crystals of fatty acids and their 
 soaps the following crystals are met with in the fEeces: 
 oxalate of lime appears in the well-known envelope form of 
 varying size, especially after a diet consisting principally 
 of vegetables. Calcium carbonate occasionally occurs in the 
 form of amorphous granules or dumbbell-shaped crystals. 
 Neutral phosphate of calcium and ammonio-magnesium 
 phosphate crystals are often present and can be readily rec- 
 ognized, the former occurring in more or less well-defined 
 wedge-shajjed crystals collected into rosettes, the latter pre- 
 senting the well-known coffin shape. They are soluble in 
 acetic acid. All the crystals just mentioned are found in 
 normal as well as in pathological fgeces, and have no diag- 
 nostic importance. Bismuth crystals: when bismuth is 
 internally administered it is usually found in the fseces in 
 
 1 Rieder : Deutsches Arcbiv fiir klin. Med., 1898, Bd. 59, Heft 3 and 
 4, p. 444. 
 
70 DISEASES OF THE INTESTINES. 
 
 rhomboid crystals of a dark-brown or almost black color 
 (Fig. 22). H8ematoidin crystals are occasionally encoun- 
 tered in severe catarrhal conditions of the intestines or 
 shortly after intestinal hemorrhages have taken place. 
 They occur in small amorphous particles of an orange or 
 
 Fig. 22.— Specimen of Stool of Mrs. W., living on Milk Diet and taking Bismuth and 
 Magnesia. Bismuth and magnesia crystals, some fat globules and detritus. No muscle 
 or plant cells. 
 
 ruby red color, or in crystals of the rhombic system. 
 Charcot-Leyden crystals of spermin phosphate, having 
 the shape of grains of oats, are occasionally met with in 
 the faeces and are of diagnostic importance. According to 
 Leichtenstern, ' these crystals are very frequently found in 
 ' Leichtenstern : Deutsche med. Wochenschrift, 1893, No. 35. 
 
EXAMINATION. 71 
 
 the faeces whenever intestinal parasites (helminthiasis) 
 exist. These crystals, however, occur also in other patho- 
 logical conditions as in typhoid fever, dysentery, tubercu- 
 losis of the lungs. In rare instances the Charcot-Leyden 
 crystals are absent in cases of helminthiasis. When they 
 
 FIG. 23.— Specimen of Stool of Mrs. V., with Clironic Intestinal Catarrh. Groups of epi- 
 thelial cells ; detritus ; a few muscle cells, partly digested ; plant cells ; bacteria ; yeast 
 cells. 
 
 occur, however, they are an indication that the stools 
 should be carefully watched for the presence of intestinal 
 worms. 
 
 Eleynents Derived from the Intestinal Wall. — Epithelial 
 cells and also goblet cells occur occasionally in the faeces, 
 but only in scantj' number (Fig. 23) . They are very sel- 
 
72 
 
 DISEASES OF THE INTESTINES. 
 
 dom unchanged with a distinctly visible nucleus ; usually 
 they appear in a metamorphosed condition without any 
 perceptible nucleus. Larger accumulations of epithelial 
 cells may bs found in desquamative catarrhal conditions 
 of the intestines. 
 
 Fig. 24.— stool of Patient L. , with Acute Dysentery. Pus cells in considerable number; 
 occasional epithelia ; mucus ; detritus. 
 
 Blood. — Blood in the faeces is occasionally easily recog- 
 nized under the microscope, both red and white blood cor- 
 puscles being present. This, however, is the fact only in 
 hemorrhages of the lower portion of the rectum. In hem- 
 orrhages originating in the upper portion of the large 
 bowel or in the small intestine, the blood cells are usually 
 
EXAMINATION. 
 
 73 
 
 already greatly changed and not to be recognized as sucli 
 microscopically. 
 
 Pus. — Pus corpuscles in tlie dejecta occur in ulcerative 
 processes of the intestines or whenever an abscess has 
 discharged its contents into the bowel. Besides these 
 two conditions, it is also met with in dysentery. The pus 
 
 Fig. 25. — Stool of Patient H., with Chronic Dysentery, during an Acute Exacerbation. 
 Highly magnlfled. Amoebie ; red and white blood cells ; crystals of fat and ammonio- 
 magnesium phosphate ; plant and muscles cells ; detritus. 
 
 .corpuscles are then distinctly visible under the microscope 
 (Figs. 24, 25, 26). [Forthebeautifulexecutionof the above 
 drawings I am indebted to Dr, C. A. Elsberg of this city.] 
 Mucus. — Mucus is frequenth^ seen in the dejecta under 
 the microscope. It is recognized by its thread-like ap- 
 
74 
 
 DISEASES OF THE INTESTINES. 
 
 pearance (Fig. 27). Occasionally it is also amorphous. 
 Thionin colors mucus reddish-violet, while it stains other 
 proteid substances blue. Mucus is often present in ca- 
 tarrhal conditions of the intestine and also in membranous 
 enteritis. 
 Pieces of Tumors.— In rare instances a small fragment of 
 
 Fig. 36.— From the Same Patient, a Few Days Later. Highly magnifled. Amoebae ; fat 
 in globules and crystals ; a few red and white blood corpuscles ; muscles cells ; detri- 
 tus; bacteria. 
 
 tumor may be found in the dejecta. Under the microscope 
 the structure of the mass will be seen and its character de- 
 termined. The result of such an examination may be of 
 great diagnostic importance. 
 
 Micro-organisms. — Numerous micro-organisms are found 
 
EXAMINATION. 
 
 75 
 
 in the faeces normally as well as pathologically. Their 
 number averages in daily evacuations fifty-three milliards. 
 Sometimes they may reach as high a figure as four hundred 
 milliards. Beginning with the stomach the number of 
 micro-organisms steadily increases all through the intesti- 
 nal tract down to the large bowel, where the maximum is 
 
 Fig. 27.— Specimen of the Stool of Mrs. J. B., Suffering from Intestinal Catarrh. Mucua 
 all over the field of vision ; a few plant cells and muscle cells, and an occasional fat 
 crystal. 
 
 reached. The micro-organisms appear to be intimately 
 
 connected with the physiological processes of digestion. 
 
 This is true notwithstanding the valuable investigations of 
 
 Nencki, Macfadyen, and Sieber,' and Thierf elder and Nut«- 
 
 •Nencki, Macfadyen, urni Sieber : Arcbiv f. experimentelle Patho- 
 logie u. Pharmakologie, Bd. 28, S. 301. 
 
76 DISEASES OF THE INTESTINES. 
 
 tal,' which have shown that normal digestion is possible 
 even without bacteria. PatJiologically various kinds of 
 bacteria play a very important part. Besides certain spe- 
 cies of pathogenic bacteria, the micro-organisms normally 
 sojourning in the intestine occasionally assume morbific 
 properties. 
 
 The different varieties of micro-organisms in the intes- 
 tinal tract have been thoroughly studied by Mannaberg,^ 
 who found fourteen different species of bacilli, nine species 
 of micrococci, and four species of schizomycetes. Of the 
 latter saccharomyces cerevisise are most frequently encoun- 
 tered in the fseces. They are found in groups forming 
 three or four buds, and assume a mahogany color when 
 treated with Lugol's solution. Of the bacteria and cocci 
 the following deserve special mention : 
 
 The bacterium coli commune, first described by Esche- 
 rich, " occurs in the form of thin or thick rods being about 
 0.4 ,'j. in length. Some show motile power. They are well 
 stained by the ordinary anilin dyes and decolorized by 
 Gram's solution. Their colonies growing upon gelatin re- 
 semble those of the bacillus of typhoid fever. 
 
 The bacterium lactis aerogenes (Escherich) greatly re- 
 sembles the bacterium coli commune. It is frequently 
 found in the stools of infants, and is now and then met with 
 in those of adults. It is found in thick rods frequently 
 lying in pairs. They are non-motile and have the property 
 of causing fermentation of milk, producing coagulation and 
 formation of gas within sixty hours. 
 
 ' Thierfelder u. Nuttal ; Zeitschrift f. pliys. Chemie, Bd. 21, S. 109, 
 u. Bd. 32, S. 62. 
 
 '^ Mannaberg : " Die Bacterien des Darms " — ^Nothnagel's Erkrankun- 
 gen des Darms, Wien, 1895. 
 
 3 Escherich : "Beitrage zur Kenntniss der Darmbacterien. " Miinch- 
 -ener mad. Wochenschr. , 1886, No. 1., 43-45. 
 
TREATMENT. 77 
 
 Bacillus pidrificus coll (Bienstock') forms slender rods 
 3 iJ. in length. This bacillus energetically decomposes 
 proteid substances in presence of air under the formation 
 of ammonia, amin bases, fatty acids, tyrosin, phenol, indol. 
 
 While all the above-mentioned micro-organisms give a 
 mahogany or brown color with solutions of iodine, there 
 are a few varieties which give a blue color with this sub- 
 stance. To the latter belongs the bacillus butyricus de- 
 scribed by Nothnagel.^ It is rod-shaped, 3 to 10 !j. long 
 and 1 fj- thick. It is often lemon-shaped. This bacillus 
 is anaerobic and produces fermentation of starch, sugar, 
 and cellulose, forming butyric acid and gas. The bacillus 
 butyricus is often found in pathological conditions of the 
 intestine, but occurs in small numbers also in normal faeces. 
 
 Of the pathogenic micro-organisms, cholera, typhoid, and 
 tubercle bacilli are found in the faeces. The cholera and 
 typhoid bacilli causing infectious diseases do not belong, 
 strictly speaking, to the micro-organisms producing dis- 
 eases of the intestine alone. The tubercle bacilli, occasion- 
 ally producing intestinal tuberculosis, are recognized in the 
 faeces by the same methods which are employed in th© 
 examination of the sputum. 
 
 TREATMENT. 
 
 Diet 
 
 The principles of diet are fully described in my book on 
 the stomach. Here I will add a few remarks referring to 
 the dietetic treatment of intestinal diseases. As in the 
 case of the stomach, acute intestinal disorders lasting a 
 
 'B. Bienstock : "Ueber die Bacterien der Faeces. " Zeitscbr. f. klin. 
 Med., Bd. 8, 1884. 
 
 °H. Notbnagel : "Die normal in dem ^lenscbendarm vorkommenden 
 niedersten (pflanzlicben) Organismen. " Zeitscbr. f. klin. Med., Bd. 3, 
 1881. 
 
78 DISEASES OF THE INTESTINES. 
 
 few days or weeks must be managed according to tlie prin- 
 ciple of rest. Very scanty and light foods (mostly liquid) 
 should be given. In chronic ailments of the intestines the 
 principle of rest may also be utilized occasionally for a 
 short time, while as a general rule we should bear in mind 
 the necessity of introducing sufficient quantities of food 
 and gradually accustoming the intestinal tract to the ordi- 
 nary foods. 
 
 In some instances it is i)ossible to exert a wholesome 
 influence upon the disturbances of the intestine by appro- 
 priate dietetic measures. This applies especially to dis- 
 orders accompanied by constipation or by diarrhoea. 
 
 I. Articles of diet ivMch increase the intestinal peristalsis 
 or " laxative foods " are the following : Most fruits, both 
 raw and cooked, and fruit juices increase the peristalsis 
 in consequence of the organic acids which they contain, as 
 apples, pears, plums, peaches, strawberries, gooseberries, 
 dates, and figs. Most salads and garden vegetables also 
 increase peristalsis, firstly, owing to the large amount of 
 water they contain, and secondly, owing to the consider- 
 able residue which is left undigested, as, for instance, 
 melons, cucumbers, tomatoes, pumpkins, all kinds of cab- 
 bage. By many of the latter foods the peristaltic action 
 of the intestine is also increased on account of the forma- 
 tion of acid and gaseous products. Fresh beer, cider, 
 bonny-clabber, and kumyss act in a similar manner. Cold 
 drinks of plain water or carbonated water act as mild ape- 
 rients in some instances. Here a reflex action upon in- 
 testinal peristalsis due to irritation must be assumed, for 
 often a movement of the bowels follows very soon (a quar- 
 ter of an hour to one hour) after drinking. 
 
 II. Articles of diet ivhich diminish the intestinal peri- 
 stalsis or "constipating foods'': (1) All substances con- 
 
TREATMENT. 79 
 
 taining a considerable portion of astringent agents, par- 
 ticularly tannic acid, as, for instance, dried bilberries, 
 French red wines (particularly San Rafael wines), tea, ca- 
 cao, the acorn preparations like acorn coffee, acorn cacao. 
 (2) Foods which have a mucilaginous character and thus 
 somewhat allay irritation also have a slightly constipating 
 effect : sago, tapioca, barley, rice. (3) Foods which leave 
 no residue whatever or very little residue, and thus exert 
 no irritation. To these belong egg water (prepared by dis- 
 solving the white of an egg in some water), scraped raw 
 meat, mutton broth. 
 
 Some foods manifest different action in different individ- 
 uals. Thus, for instance, milk is constipating in one i^er- 
 son and laxative in another, while in still others it has no 
 special effect upon intestinal peristalsis. 
 
 Most foods have no marked influence upon the intestinal 
 peristalsis. To these belong most kinds of meat and fish 
 not too highly seasoned, the various meat powders, and 
 most artificial foods like meat peptone and nutrose, eucasin, 
 somatose, sanose, eggs prepared in different ways, well- 
 baked bread, wheaten or rye bread, crackers, zwieback, 
 fats in small amounts, especially butter. The preparation 
 of the foods has an important bearing with regard to its 
 action upon the intestinal peristalsis. The finer the foods 
 are the less irritating they will act, and the coarser the 
 particles the greater the irritation they produce upon the 
 intestinal muscular layer. Highly seasoned foods also act 
 as a stimulant of the peristalsis. 
 
 In some severe conditions of the intestines the ordinary 
 way of ingestion of food must be avoided for a short period. 
 Here artificial feeding is employed. Artificial feeding can 
 be done in two different ways: rectal alimentation and 
 subcutaneous alimentation. 
 
80 DISEASES OF THE INTESTINES. i 
 
 1. Rectal Alimentation. — The rectum and the greater 
 part of the large bowel should be emptied if possible be- 
 fore injecting the feeding enema. The latter is best accom- 
 plished by using a fountain syringe and a soft-rubber tube 
 which is introduced for about five to seven inches into the 
 rectum. The quantity of the feeding enema may be be- 
 tween five and ten ounces. As feeding enemas the follow- 
 ing substances are used : (a) The different kinds of pep- 
 tones and propeptones in the market of which about two 
 to three ounces can be dissolved in six to eight ounces of 
 water. The different beef juices may also be dissolved in 
 water and injected in corresponding quantities. (6) The 
 milk and egg enemas. These are mostly used. Their 
 composition is as follows : Six to seven ounces of milk, 
 one or two raw eggs well beaten up, one teaspoonful of 
 powdered sugar, and the point of a knifeful of salt. The 
 addition of pancreatin (one tube of Fairchild pancreatin 
 to one enema) will facilitate assimilation, (c) Meat-pan- 
 creas enema. Leube ' employs enemas consisting of well- 
 chopped meat mixed with fresh pancreas. 
 
 Besides these food enemas injections of water into the 
 bowel are made in order to increase the amount of fluid in 
 the system. These injections of water for the purpose of ab- 
 sorption are of great importance. Usually saline solutions 
 are employed in quantities varying from one pint to one 
 quart. The nutritive enema should be given three or four 
 times in twenty-four hours, and the water enemas for ab- 
 sorption once or twice a day. 
 
 2. Subcutaneous Alimentation. — In diseases of the intes- 
 tine special conditions are met with in which neither the 
 ordinary way of feeding nor rectal alimentation is possible. 
 
 'Leube: Leyden's "Handbuch der Ernahrungstherapie, " Bd. i., p. 
 508, Leipsic, 1897. 
 
TREATMENT. 81 
 
 Here an attempt must be made to introduce nourishment 
 subcutaneonsly. Most food substances cannot be intro- 
 duced under the skin without inflicting more or less injury. 
 Two substances onl}- form an exception and are of practical 
 value : («) Olive oil. This can be injected subcutaneously 
 to the amount of one ounce twice or three times a day. It 
 is hardly necessary to say that the oil as well as the sj'ringe 
 used for this purpose should be thoroughly sterilized. A 
 large-sized Pravaz syringe is employed, and but little 
 pressure exerted while injecting. This precaution is neces- 
 sary in order to obviate any traumatism (tearing) of the tis- 
 sues. The best place for the injection is the thigh, {b) 
 AYater. A saline solution is subcutaneously injected in 
 amounts varying from one pint to a quart. This serves to 
 increase the amount of fluid in the sjstem. The injection 
 is made by means of the fountain syringe to the end of 
 which an aspirating needle is attached. The same pre- 
 cautions as above are necessary. The saline injection 
 may be emploj^ed twice or three times a day if necessary. 
 
 Jlechanical Procedures. 
 
 Injections. — Injections into the bowel in the form of clys- 
 ters were used for curative purposes even in old times. 
 The regular syringe with its stiff end may, if forcibly in- 
 serted, give rise to damage of the rectum. For this reason 
 nowadays a soft-rubber rectal tube is employed, to which 
 a fountain or Davidson syringe or any form of sj-ringe can 
 be attached. The tube being flexible cannot injure the in- 
 testinal walls. It can also be introduced higher up than 
 the ordinary hard-rubber end pieces of the fountain syringe. 
 Instead of the fountain syringe a funnel apparatus similar 
 *;o the one used in gastric lavage may be employed. For 
 
 Washing out the bowel Leube-Kosenthal's appliance for 
 6 
 
82 DISEASES OF THE INTESTINES. 
 
 wasliing out the stomacli can be used to advantage. For 
 irrigation of tlie bowel Kemp's hard-rubber rectal double- 
 current irrigator can be conveniently emi)loyed (Fig. 28). 
 
 These injections into the bowel are made for various 
 purposes : 
 
 1. To produce an evacuation. About a quart of luke- 
 warm water to which a teaspoonful of salt is added can 
 be employed, or a piece of soap dissolved in the same 
 
 G. TIEMANN & CO., N. Y. 
 
 Fig. 28.— Dr. R. C.Kemp's Rectal Irrigator (New Model). Outer tube of hard-rabber; 
 central tube of metal. Hard-rubber flange, protecting sphincter from transmission of 
 heat through the metal parts. 
 
 amount of water. As a rule, it is not advisable to intro- 
 duce larger quantities of water than these as they distend 
 the bowel too much. In greatly atonic conditions, how- 
 ever, in which a quart of water may be inefficient, an 
 injection of from two to three quarts will be required. In- 
 jections of oil (olive oil or sesame oil) in quantities varying 
 from half a pint to one pint have been recommended by 
 Fleiner.' According to this writer the oil should be in- 
 jected at blood temperature into the rectum when retiring 
 and be retained over night. While olive oil was used as a, 
 laxative injection long ago by Habershon' and others, we 
 owe its methodical use to Fleiner, to whom is also due the 
 credit for having promulgated the method. Small injec- 
 tions of glycerin (one or two drachms) in about an ounce 
 
 1 Fleiner: "Ueber die Beliandlung der Constipation." Berl. klia. 
 Wochenschr. , 1893, Nos. 3 and 4. 
 2 Habershon ; "Diseases of the Abdomen, " London, 1863. 
 
TREATMENT. 83 
 
 of water can also be advantageous!}' employed for produc- 
 ing an evacuation of the bowels. 
 
 2. Injections may be resorted to either to strengthen 
 the tonicity of the bowel, in which case plain very cold 
 water in amounts of from one to two quarts can be em- 
 ployed, or for medicinal purposes, i.e., for applying cer- 
 tain medicaments directly to the intestinal mucosa. The 
 drugs most frequently used for this purpose are nitrate of 
 silver, tannic acid, subnitrate of bismuth, as astringents; 
 thymol, hydrogen peroxide, boracic acid, essence of pep- 
 permint, as disinfectants. 
 
 31assage and Gymnastic Exercises. — Massage is frequently 
 employed in functional diseases of the intestine. Its field 
 of usefulness lies principally in neurotic and atonic condi- 
 tions. Massage should be applied by well-trained and 
 experienced persons. Abdominal massage requires great 
 care, as too rough manipulation is liable to do great harm. 
 Gymnastic exercises and sports are well adapted to stimu- 
 late and strengthen the muscles of the abdomen as well as 
 those of the intestine. Ewald particularly recommends 
 rowing in boats with sliding seats as an exercise which 
 gives definite results in chronic intestinal torpidity. Golf, 
 billiards, horseback riding, bicycle riding, walking may 
 also be included among the exercises contributing to a ton- 
 ing up of the system. 
 
 Hydrotherapy. — Moist applications in the form of either 
 Priessnitz's compresses or poultices are often of benefit. 
 Priessnitz's compresses are stimulating, while the warm 
 fomentations serve as a sedative. The latter are applied 
 to allay pain, the heat producing a temporary paralysis of 
 the superficial sensory nerves. Instead of either cold or 
 warm compresses a rubber bag filled with either cold or 
 hot water may be applied. When warm applications are 
 
84 
 
 DISEASES OF THE INTESTINES. 
 
 required they can also be used in tlie form of the Japanese 
 box. Sitz baths of various temperatures may be employed. 
 A shower bath, especially over the abdomen, of cold or 
 warm water or of alternating cold and warm water, is also 
 of benefit. Many of these procedures may be combined 
 
 with massage, and in this 
 way the curative action 
 is enhanced. 
 
 Electi iciiy . — The f ara- 
 dic, galvanic, or frank- 
 linic currents are em- 
 ployed. All these three 
 can be used percuta- 
 neously; the first two 
 also intrarectally. The 
 faradic current is mostly 
 applied in atonic condi- 
 tions of the bowel with 
 the object of stimulating 
 the motor function of the 
 intestines. The galvanic 
 current i s principally 
 employed in jDainful intestinal affections of neurotic char- 
 acter. The franklinic or static current ma}^ be advan- 
 tageously used in both conditions. For the intrarectal 
 application of the current I use an electrode which in prin- 
 ciple is very similar to that of Boudet ' and consists of a 
 perforated hard-rubber end piece in which is lodged a 
 metallic button connected by means of a wire with the bat- 
 tery. To the upper end of the hard-rubber piece is at- 
 tached a soft-rubber tube leading to an irrigator and pro- 
 
 ' Boudet : Cited after A. Mathieu : " Treatment of Diseases of the 
 Stomach and Intestines, " New York, 1894, p. 171. 
 
 FIG. 29.— Rectal Electrode. 
 
TREAT>IENT. 85 
 
 vided with a stoj^cock (see Fig. 29). Proceed as follows: 
 The irrigator is filled with water at blood temperature. 
 The hard-rubber piece, or the rectal electrode, is smeared 
 with vaseline and introduced into the rectum. Another 
 plate electrode is moistened and placed over the abdomen, 
 the stopcock partly opened, and the current applied. The 
 water running from the end piece of the electrode into the 
 bowel carries the electricity along with it. The electrical 
 application should last from five to ten minutes, the 
 amount of water used varies from ten to fifteen ounces. 
 The outflow of the water can be regulated by the stopcock 
 arrangement. I have applied both the faradic and gal- 
 vanic currents with this apparatus and found it very con- 
 venient. The faradic current may be applied as strong as 
 the patient can bear, while the galvanic current should be 
 used with the negative pole in the rectum, the intensity 
 of current ranging from eight to fifteen milliamperes. 
 
CHAPTER III. 
 
 ACUTE AND CHKONIC INTESTINAL CATAERH. 
 
 ACUTE INTESTINAL CATARRH. 
 
 Synonyms : Enteritis acuta ; Catarrhus intestinalis acu- 
 tns ; Acute diarrhoea ; Cholera nostras. 
 
 Definition. — An inflammatory affection of the intestines 
 characterized by a sudden development of pains and more 
 or less loose movements. 
 
 Etiology. — Acute intestinal catarrh is one of the most 
 frequent diseases. While it occurs more often in infants 
 and children it is found in persons of all ages. 
 
 The affection may attack the entire intestinal tract or 
 may be limited to a part of it. Thus we may have a duo- 
 denitis, jejunitis, ileitis, typhlitis, colitis, and proctitis 
 (inflammation of the rectum) . With regard to frequency 
 the colon is most often affected. According to Woodward, ' 
 an inflammation of the small intestine alone hardly ever 
 exists, a portion of the large bowel always being affected. 
 Intestinal catarrh is either primary (idiopathic) or second- 
 ary when occurring as a sequel of other diseases. Acute 
 enteritis may be due to a number of causes : 
 
 1. It may result from the ingestion of heavy indigestible 
 food, ice-cold drinks, and tainted meat or fish, unripe fruit, 
 stale or sour beer, bad water. 
 
 2. Good food and drink taken in unusually large quanti- 
 ties may also produce this condition. 
 
 1 Woodward : " The Medical and Surgical History of the War of the 
 Rebellion, " vol. i. , part 2. 
 
ACUTE INTESTINAL CATARRH. 87 
 
 3. A host of organic and inorganic substances may cliem- 
 ically irritate tlie intestinal mucosa and cause inflammatioDi 
 All the drastic remedies, like croton oil, colocynth, jalap^ 
 etc., belong to these organic irritating substances; of the 
 inorganic may be mentioned tartar emetic, arsenic, lead, 
 sulphate of copper, all the mercurial preparations, concen- 
 trated acids, and strong, caustic alkalies. 
 
 4. Enteritis may be caused by mechanical irritants. 
 Thus hardened scybala, biliary calculi, enteroliths, or 
 foreign bodies which have been swallowed, like large ker- 
 nels of fruit or coins, may evoke inflammation. The 
 catarrh accompanying intestinal worms may also be placed 
 in this group, 
 
 5. Intestinal catarrh is very often due to variations in 
 temperature or to catching cold. It seems that the dispo- 
 sition to this agent varies in different individuals. Thus 
 some people get an attack of diarrhoea if they sleep uncov- 
 ered during the summer and a drop in temperature occurs, 
 the colder atmosphere affecting the abdomen. Others, 
 again, are attacked with diarrhoea whenever they get their 
 feet wet. How the influence of cold acts in causing the 
 enteritis is difficult to say. Some writers believe that the 
 sudden change in the circulation of the blood caused by 
 the cold is the principal factor; others again explain it on 
 the ground of a more favorable development of micro- 
 organisms during the change of temperature. 
 
 6. Auto-intoxication. Poisonous substances may develop 
 in the intestinal tract and cause diarrhoea. The enteritis 
 following large burns of the skin belongs to this group. 
 Here the poisonous substance is probably formed at the 
 site of the burned skin and carried by the blood current 
 into the intestinal tract. 
 
 Secondary catarrh of the intestine occurs in almost all 
 
88 DISEASES OF THE INTESTINES. 
 
 acute infectious diseases in the same way as gastric catarrli. 
 It is further found accompanying heart, kidney, and liver 
 diseases, tuberculosis, diabetes, etc. Most .organic dis- 
 eases of the bowels are associated with intestinal catarrh, 
 as cancer of the intestines, volvulus, invagination, jjeri- 
 tonitis, thrombosis. In this class of cases, however, the 
 intestinal catarrh is of little importance compared with the 
 primary affection. 
 
 Morbid Anatomy. — The anatomical changes found in au- 
 topsies are not always very well marked, and there is cer- 
 tainly no exact relation between the intensity of the clinical 
 symptoms and the severitj^ of the pathological processes 
 discovered. The mucous membrane of the affected part 
 of the intestine appears reddened either over its entire ex- 
 tent or only in spots. This red color is more pronounced 
 around the follicles and patches, at the apex of the folds 
 and of the villi. If the j)rocess is intense, extravasations 
 of blood may be found. The mucous membrane appears 
 swollen, sometimes oedematous, often it is covered with 
 tenacious mucus. The villi and the solitarj- follicles are 
 succulent and appear as whitish, small prominences sur- 
 rounded by a red stratum (enteritis foUicularis sen nodu- 
 laris). If the process continues, these gray areas may 
 rupture, and thus give rise to ulcerative lesions (follicular 
 ulcers). Catarrhal ulcers also exist, however, caused by 
 the loss in some places of the protective epithelial covering 
 of the mucosa. Through extension of the inflammation in 
 width and depth irregular losses of substance with under- 
 mined edges are produced. Inflammatory irritation in the 
 neighborhood of these defects may give rise to polypoid 
 growths, especially when the process has run a protracted 
 course. 
 
 Microscopically the vessels of the mucosa and sub- 
 
ACUTE I2ITESTINAL CATARRH. 89 
 
 mucosa appear in a more or less congested state. Small 
 extravasations often exist between the glands of Lieber- 
 kuebn. Tlie spaces between the glands are frequently 
 widened and filled with an abundant accumulation of round 
 cells. The epithelium of the mucosa has mostly disap- 
 peared, especially in the large bowel. But according to 
 Nothnagel this may be a post-mortem phenomenon and not 
 always the result of inflammation. Desquamative processes 
 in the epithelial layer, however, occur during life caused 
 by the catarrhal affection, for the changed eroded epithelial 
 cells are found in the mucus voided with the stool. The 
 glands often appear altered with regard to their contour, 
 being wider at their fundus and much narrower at their 
 mouth, frequently presenting a flask shape. The sub- 
 mucous tissue is usually somewhat hyperplastic, otherwise 
 not much changed. The muscular and serous coats are 
 not affected. 
 
 Symjjtoiuatologi/. — Intestinal catarrh usually manifests 
 itself through a feeling of fulness in the lower i)art of the 
 abdomen, colicky pains appearing from time to time, and 
 diarrhoea. As a rule, no fever is present except in cases of 
 a severe type. The number of the stools and their quality 
 vary a great deal. In mild cases there may be only two or 
 three movements in twenty-four hours; in severer cases 
 fifteen to twenty diarrhoeal evacuations. The fii-st passage 
 as a rule still contains normal fecal matter in its first por- 
 tion, while the second part is of a mushy character. The 
 next movements are semi-fluid, and at last entirely liquid 
 dejecta may appear. The first stool still has a brown color 
 and the characteristic fecal odor, while the following evac- 
 uations present a slightly yellowish color or even a grayish 
 appearance, occasionally resembling rice-water. The latter 
 are sometimes devoid of fecal odor, have an acid reaction, 
 
90 DISEASES OF THE INTESTINES. '""" 
 
 and show a foamy surface. Mucus is almost always pres- 
 ent. Tlie fecal matter in its yellow parts contains, as a 
 rule, unchanged biliary substances which give a charac- 
 teristic Gmelin reaction. Microscopically undigested food 
 particles may be discovered in larger than normal amounts ;. 
 thus meat fibres and well-preserved granules of starch 
 may be observed. A host of micro-organisms, epithelial 
 cells, sometimes in contiguous groups, and mucus are 
 found. Yery seldom and only in severer cases small 
 amounts of pus and red blood corpuscles may be dis- 
 covered. Chemically peptones and sugar may be found in 
 the dejecta. 
 
 General Subjective Symptoms. — Aside from the diarrhoeal 
 movements and the unpleasant sensations consisting in a 
 feeling of pressure and fulness in the abdomen mentioned 
 above, there may in light cases be perfect euphoria ; usu- 
 ally a feeling of weakness exists which is especially marked 
 in the lower extremities. A feeling of dizziness and slight 
 nausea often also appear, esj)ecially shortly before and 
 during evacuations. Vomiting may also occur, as a rule, in 
 cases in which the stomach is likewise affected or when the 
 process of inflammation is of a severer type (cholera nos- 
 tras). Tenesmus is frequently present, if the process is 
 in the lower part of the colon, even if not especially pro- 
 nounced. This seems to be the result of the irritating 
 action of the dejecta upon the rectum. 
 
 The general symptoms above described are much more 
 pronounced in children and very old people. Here the 
 appearance of collapse (cold extremities, blue lips, and 
 apathy) is not very rare. Marshall Hall ' has described a 
 condition under the name of acute hydrocephaloid disease 
 
 1 Marshall Hall : " Diseases and Derangements of the Nervous Sys- 
 tem, "London, 1841. p. 153. 
 
ACUTE INTESTINAL CATARRH. 91 
 
 which occurs in weak children with acute enteritis. The 
 hydrocephaloicl apjjears in consequence of severe attacks of 
 gastro-enteritis with a temperature of 104°-106° F. There 
 is sudden collapse. ^Tiile the body is hot, the extremi- 
 ties become ice cold, the fontanelles sink in, the pulse, 
 becomes considerably accelerated, soft, and often irregular. 
 In this condition the little patient lies apathetic unless 
 suddenly disturbed with colicky pains when he utters a 
 cry. The pupils do not react alike and the conjunctival 
 reflex may be absent. Sometimes paralysis of the rectum 
 is present, which I have seen in one case. In this condi- 
 tion the patient often dies within a short time from paraly- 
 sis of the heart. 
 
 Objective Symptoms. — The physical examination of the 
 abdomen occasionally reveals on inspection a bloated con- 
 dition and some spots tender to pressure. As a rule, the 
 lower part of the abdomen, particularly the immediate 
 neighborhood of the navel, is slightly painful on palpation. 
 Occasionally there may be found a decided tenderness, 
 either in the right or in the left iliac region. Sometimes 
 this tenderness may be quite pronounced in a line running 
 across the abdomen between the margins of the false ribs 
 (transverse colon). Palpation often elicits gurgling sounds 
 caused by intestinal coils distended with gas and fluid con- 
 tents. This phenomenon is most frequently observed in 
 both iliac regions. 
 
 In patients with thin abdominal walls peristaltic move- 
 ments of the small intestine may be visible either sponta- 
 neously or after palpatory examination. 
 
 The urine is voided in small quantities, is concentrated, 
 and often shows Bosenbach's reaction (Burgundy red color 
 after boiling with nitric acid), and also contains indicaa 
 (this especially if the process involves the small intestine). 
 
92 DISEASES OF THE INTESTINES. 
 
 Casts and small amounts of albumin are sometimes found 
 in the urine, especially in severer cases (Fisclil '). 
 
 Fever. — In the greater number of instances there is no 
 rise of temperature during the course of this affection. In 
 some cases, however, fever is quite a prominent symptom, 
 and the disease may commence with violent chills and a 
 marked elevation of temperature (104°). The temperature 
 may either fall suddenly on the next day or after the lapse 
 of a few days, but it does not show that regular steady rise 
 which is characteristic of typhoid fever. Fever is espe- 
 cially met with in those cases of acute enteritis which are 
 caused most probably by infection (either pathogenic micro- 
 organisms or tainted food) . 
 
 Localization of the Catarrhal Process. — In order to find 
 out what part of the bowels is especially affected the fol- 
 lowing points are of value : 
 
 A duodenitis may be recognized if the above symptoms 
 are accompanied by icterus. Intestinal catarrh attended 
 with a constant painful sensation in the right epigastric 
 region, which, besides, is also tender to pressure, indicates 
 more or less a continuation of the catarrhal process from 
 the stomach to the duodenum. Pains appearing in the 
 same region after extensive burns of the skin also point to 
 a duodenal affection, even if there be no icterus. 
 
 Jejunitis alone or jejunitis and ileitis without any affec- 
 tion of the large bowel can be diagnosed only with diffi- 
 culty, for the principal symptom of enteritis (namely, that of 
 diarrhoea) is as a rule absent. Small amounts of mucus well 
 mixed with fecal matter, a considerable quantity of undi- 
 gested food particles, and epithelial cells tinged with yellow 
 bile pigment in the faeces, point to a catarrhal condition 
 of the small intestine. Indicanuria is also often present. 
 »Fischl: Prager Vierteljahresschr., 1878, Bd. 139, p. 27. 
 
ACUTE INTESTINAL CATARRH. 93 
 
 Acute colitis is characterized by painful sensations and 
 a greater tenderness on pressure over the entire colon. 
 The stools are diarrhoeal and contain large quantities of 
 mucus. The latter as well as the fecal matter may contain 
 undecomposed biliary pigment. Sigmoiditis, described by 
 Mayor' and later by Boas'^ and Mathews/ means an in- 
 flammatory i:)rocess involving the sigmoid flexure, and is 
 recognized by special tenderness on palpation of this por- 
 tion of the bowel, intense backache, and a frequent dis- 
 position to go to stool. 
 
 Proctitis, or inflammation of the rectum , is characterized 
 by severe tenesmus and colicky pains in the left iliac fossa. 
 The patients have a constant desire to go to the closet, but 
 at each time void only small quantities of fecal matter 
 under the greatest pains. The scybala are surrounded by 
 a layer of mucus which may be tinged with blood. Occa- 
 sionally the mucous membrane of the rectum prolapses 
 during defecation. It then appears intensely dark red and 
 is extremely painful to the touch. Even if not prolapsed, 
 a digital rectal examination is attended with much pain. 
 The mucous membrane of the rectum feels hot and the ex- 
 amining finger on removal sometimes shows traces of blood. 
 
 Duration. — The duration of acute enteritis varies consid- 
 erably. Mild cases improve in about two to five days, 
 while those of a severer type may last about two weeks. 
 After recovery from acute enteritis the intestinal tract 
 remains quite sensitive for a long time. If no attention is 
 paid to this condition and gross errors of diet are com- 
 mitted, relapses are liable to occur. Several relapses may 
 
 ' A. Mayor: Revue med. de la Suisse Romande, 1893, No. 4. 
 '^J. Boas: " Kranklieiten des Darms, " ii., p. 513. 
 3 Mathews : " Disease in the Sigmoid Flexure. " The American Med- 
 ical Quarterly, June, 1899. 
 
94 DISEASES OF THE INTESTINES. 
 
 also follow each other and ultimately cause a chronic en- 
 teritis. 
 
 Diagnosis. — As a rule the recognition of acute enteritis 
 is very easy. The characteristic diarrhoea, the admixture 
 of mucus in the dejecta, the fact that a dietetic error has 
 been committed, or that the abdomen (or other parts of the 
 body) has been exposed to cold, will all indicate the nature 
 of the affection. The localization of the process, whether 
 affecting more or less the entire intestinal tract or only 
 certain parts, is more difficult, and the important points of 
 differentiation have already been given above. Frequent 
 vomiting and very pronounced general symptoms (espe- 
 cially collapse) point to cholera nostras, which is the most 
 severe form of acute enteritis. If the diarrhoea is accom- 
 panied by high fever, urinary casts, and pains in the mus- 
 cles and joints, then the assumption of an acute enteritis 
 of an infectious type is justified. 
 
 Prognosis. — The prognosis of acute enteritis is, as a rule, 
 good, the disease tending to recovery in a very short time. 
 In children, however, and very old and weakened jjersons, 
 the course of the disease is sometimes not so favorable and 
 may lead to collapse and even to death. 
 
 Treatment. — In mild cases of acute enteritis no medicinal 
 treatment will be necessary. Abstinence from food for one 
 or two days, allowing the patient to take only weak tea, a 
 small quantity of bouillon, and some boiled water may suf- 
 fice to check the attack. Sometimes, however, especially 
 if the attack of enteritis has been caused by dietetic errors, 
 and fulness of the abdomen and frequent colicky pains in- 
 dicating that irritating substances are lodged within the 
 intestines are present, a good old-fashioned drastic is in 
 place. Thus castor oil — about one ounce — may be given 
 'or calomel 0.6 (gr. x.), the latter being preferable in cases 
 
ACUTE INTESTINAL CATARRH. 95 
 
 of a probably infectious nature. If there is no fever and the 
 symptoms are mild, then the patients may be up and about, 
 although it is always advisable for them to keep quiet more 
 or less. In cases of a severer type, and especially those with 
 fever, the patients should stay in bed until the symptoms 
 are entirely subdued. If the diarrhoea shows no signs of 
 abating after a day or two, or if the symptoms occur so 
 frequently as to be debilitating, then an opiate is in place. 
 Tincture of opium, seven drops every three hours, or co- 
 deine, 0.02 or 0.03 (gr. ^|) also every three hours, may 
 be given. Frequently the combination of an opiate with 
 subnitrate of bismuth and chalk or with tannigen may be 
 useful. Thus I often prescribe the following powders : 
 
 I^ Bism. subnitr 6.0 (3 iss. ) 
 
 Cret. pulv 3.0 (gr. xlv.) 
 
 Cod. phosph 0.1 (gr. iss.) 
 
 Elseosacch. menth. pip 5.0 (gr. Ixxv. ) 
 
 Misce f. pulv. Div. in p. geq. No. x. S. One powder three or 
 four times a day. 
 
 Or- 
 
 IJ Morpb. muriat 0.1 (gr. iss. ) 
 
 Tannigen, 
 
 Elseosacch. menth. pip aa 5.0 (gr. Ixxv.) 
 
 Misce f. p. Div. in p. seq. No. x. S. One powder three times 
 daily. 
 
 Calumba, cascarilla, catechu, kino, may also be employed, 
 twenty to thirty drops of the tinctures being given about 
 three times daily. Another useful remedy is dermatol, 
 which may be administered in doses of 0.5 gm. (gr. viii.) 
 three times daily. In cases in which the entire colon 
 or its lower part is affected, irrigation of the bowels with 
 astringent solutions is of great benefit. This may be done 
 with a solution containing nitrate of silver, 0.3 (gr, y,) 
 
96 DISEASES OF THE INTESTINES. 
 
 to 1,000 (one quart) water, or tannic acid, 2 to 5 gm. 
 (30 to 80 grains) to 1,000 water, or liquor ferri sesqui- 
 chlor. 2 : 1,000. It is best to inject these solutions after 
 a previous washing out of the bowel with plain water or 
 soon after a movement. The astringent solution should 
 be allowed to remain for about five to ten minutes, but in 
 case the patient is not able to retain it for even so short a 
 time, fifteen to twenty drops of tincture of opium may be 
 added to the injection. This, as a rule, lessens the irrita- 
 tion of the rectum and the patient is thus able to hold the 
 enema longer. The temperature of the water should be 
 tepid. All the above-mentioned astringent remedies have 
 also slight antiseptic qualities. In cases, however, in 
 which the fermentative processes within the bowels are 
 esi^ecially pronounced, the following stronger antifermen- 
 tative substances may be used for irrigation : salicylic acid, 
 2:1,000 water, or salicylate of sodium, 10.0 (3iiss.): 
 1,000; boracic acid, 5.0 : 1,000; creolin, 1.0 (gr. xv.) : 
 1,000. 
 
 If pains are present a warm poultice or a hot-water bag 
 over the abdomen is very beneficial. 
 
 Cold drinks should be forbidden. AVarm teas, fennel or 
 camomile, are useful; on the second or third day the pa- 
 tient can be nourished with soups or gruels (barley, rice, 
 oatmeal soup cooked with or without milk) ; water soup 
 (stale bread softened in hot water w4th the addition of a 
 little butter and salt) and hot spiced claret are then in 
 place. A little later toasted bread, crackers, soft-boiled 
 eggs may be added to the diet; still later, scraped meat, 
 lamb chops, tenderloin steak, bread and butter. As soon 
 as the diarrhoea has entirelj^ stopped we may allow mashed 
 or baked potatoes in addition to the other articles. For 
 quite a while after an attack of enteritis the patient has to 
 
CHRONIC INTESTINAL CATARRH. 9T 
 
 be careful with vegetables and especially fruits. The first 
 he may begin to take in small portions soon after an at- 
 tack, while the latter should be avoided for a somewhat 
 longer time. 
 
 In secondary enteritis the principal primary affection 
 must be considered first. Thus enteritis accompanying 
 malaria will be best remedied by quinine. Enteritis ac- 
 companying affections of the lung, heart, or liver must be 
 treated /after due attention has been given to the primary 
 affection. 
 
 CHRONIC INTESTINAL CATARRH. 
 
 Synonyms. — Enteritis chronica; Chronic catarrh of the 
 bowels. 
 
 Definition. — An affection characterized by a chronic 
 inflammation of the intestinal mucosa, giving rise to vari- 
 ous disturbances in the function of the bowels. 
 
 Etiology. — Chronic intestinal catarrh may arise either 
 from a severe acute enteritis which shows no tendency to a 
 cure, or (most often) from repeated attacks of acute enter- 
 itis following each other at short intervals before the bow- 
 els have had a chance to recover fully. This often occurs 
 in patients who do not pay sufficient attention to their 
 apparently slight trouble and disregard the dietetic rules 
 prescribed by the physician. The direct factors causing 
 chronic enteritis are the same as those of the acute condi- 
 tion. Like acute enteritis, chronic intestinal catarrh may 
 be divided into a primarj^ and a secondary form, the pri- 
 mary being idiopathic, while the secondary appears in 
 connection with affections predisposing to this condition. 
 Thus diseases of the lungs, especially tuberculosis, affec- 
 tions of the heart, liver, and kidneys, and diabetes are often 
 
 accompanied by chronic intestinal catarrh. Intestinal 
 
 7 
 
98 DISEASES OF THE INTESTINES. 
 
 parasites, round worms, tapeworms, etc., are quite often 
 the cause of a secondary chronic enteritis, due to the irri- 
 tation of the intestinal mucosa which they evoke. 
 
 Morbid Anatomy. — The anatomical changes in chronic 
 intestinal catarrh are similar to those of the acute condition 
 and are characterized by hypersemia, swelling, and in- 
 creased secretion of the mucous membrane. However, 
 instead of the bright red or intensely dark red color seen 
 in acute catarrh, the mucosa in the chronic form presents a 
 grayish brown-red tint. The blood-vessels are greatly dis- 
 tended, and often curved into a serpentine shape. In cases 
 of long duration the intestinal mucosa frequently appears 
 of a slate color intermingled with black pigment (changed 
 red blood pigment which has escaped from the blood-ves- 
 sels). These black dots are often found accumulated at 
 the tijjs of the villi and also in the immediate neighborhood 
 of the lymph follicles and of the glands of Lieberkuehn. 
 The surface of the mucosa is as a rule covered with a 
 viscid and transparent mucus. The epithelial cells are 
 cloudy, in a condition of fatt}' degeneration, and partly 
 desquamated. The interstitial tissue is infiltrated with 
 cellular elements. The glands themselves are of irregular 
 shape, sometimes elongated and tortuous, occasionally 
 much smaller than normally. In cases in which there is 
 an interstitial tissue proliferation, a constriction around 
 the neck of a gland arises. As a consequence there is 
 retention of the glandular secretion, and ultimately a cyst 
 .may develop. Hyperplastic processes around the inflamed 
 area very often lead to the formation of polypi. The latter 
 as a rule consist of muscular and fibrous tissues and con- 
 tain no glands. Exceptionally polypoid excrescences may 
 appear on the intestinal mucosa (especially in the colon), 
 which consist of a real proliferation of the intestinal mu- 
 
CHRONIC INTESTINAL CATARRH. 99 
 
 cosa containing glands. An excellent instance of this rare 
 occurrence lias been described bj Woodward. ' 
 
 In some of the most advanced cases, atrophy of the 
 mucosa may be present. As in the stomach, this process 
 may arise from two entirely different conditions. In the 
 one the process originates in the glandular tissue ; the lat- 
 ter becoming inflamed, the seat of fatty degeneration, and 
 ultimately atrophied. In the second group the process 
 leading^ to atrophy originates from an interstitial tissue 
 proliferation; the connective tissue becoming hypertro- 
 phied, compresses the glands, and, gaining the upper 
 hand, ultimately leads to their entire disappearance. 
 These atrophic processes, as a rule, do not extend over 
 the entire intestine, but more often involve certain parts. 
 Thus, the csecum and its immediate neighborhood have 
 often been found in this state, even in persons who ap- 
 parently during life had no intestinal afl'ection (Noth- 
 nagel). Large portions of the small and large intestines 
 or the entire intestinal tract are but rarely found atro- 
 phied, more often in children than in grown-up persons. 
 Ewald ^ mentions that he has observed this rare condition 
 in six autopsies in adults. They all had suffered during 
 life from pernicious anaemia and gastro-intestinal disturb- 
 ances. 
 
 Both the hyperplastic and atrophic processes, as a rule, 
 are not limited to the intestinal mucosa alone, but also in- 
 volve the neighboring structures (the submucosa and the 
 muscularis). Thus in the hyperplastic form the thickness 
 of the wall of the small intestine may be increased to six 
 times its normal size, while the large bowel may become 
 
 ' Woodward : L. c. 
 
 2 0. A. Ewald-. " Diseases of the Intestines. " Twentieth Century 
 Practice of Medicine, vol. ix., p. 127. 
 
100 DISEASES OF THE INTESTINES. 
 
 three times as thick as normally. In atrophy of the intes- 
 tine there is also a degeneration of the muscles. The gan-i 
 glionic cells of the Meissner and Auerbach plexus have been 
 found in a state of i&iiy degeneration, smaller and lessened 
 in number in the atrophic form ( Jiirgens ' and Sasaki ^) . 
 Whether these changes in the nervous tissue are the cause 
 or the result of this general intestinal atrophy is as yet not 
 known. 
 
 Several varieties of ulcerative processes exist complicat- 
 ing chronic intestinal catarrh. Some ulcerations arise in 
 consequence of superficial erosions of the mucosa, which 
 do not heal. The defect, once produced, gradually grows 
 deeper. Several superficial ulcers adjacent to each other 
 may grow larger and unite. Thus a considerable irregu- 
 lar ulceration develops. The ulcerative process increasing 
 in depth may lead to a secondary phlegmonous inflamma- 
 tion of the submucosa, and ultimately to perforation of the 
 intestinal walls. Another danger lies in the ulcerative 
 process involving a blood-vessel which may cause hemor- 
 rhage. If the perforation through the intestinal walls oc- 
 curs rapidly, fatal peritonitis results ; but if the perforative 
 process develops slowly, then agglutination takes place 
 and a localized peritonitis with or without the formation 
 of a fecal abscess follows. These eventualities are, how- 
 ever, rare. Generally the ulcerations either remain un- 
 changed (not progressing) for a long period of time or they 
 cicatrize. In the latter event strictures of the intestinal 
 lumen may occasionally develop. 
 
 Follicular enteritis is also occasionally the cause of the 
 formation of an ulcer. The lymph nodules swell up to pea 
 size, soften, and burst. A small ulcer thus arises. As a 
 
 'Jiirgens: Berl. klin. Wochensch., 1893, p. 357. 
 2 Sasaki : Virch. Arch., Bd. 96, p. 287. 
 
CHRONIC INTESTINAL CATARRH. 101 
 
 rule, healing takes place, the mucosa of the immediate neigh- 
 borhood extending over and gradually overlapping the de- 
 fect. Sometimes, however, the ulcerative area is covered 
 with a layer of mucus secreted by the goblet cells of the 
 neighboring glands. From time to time the accumulated 
 mucus is removed from the defect and appears in the dejecta 
 in form of particles resembling sago. Extensive ulcerations 
 are seldom met with in chronic enteritis. Most often they 
 occur in the enteritis accompanying pulmonary tubercu- 
 losis. 
 
 Symptomatology. — Chronic intestinal catarrh may occa- 
 sionally exist without giving rise to any subjective com- 
 plaints. As a rule, however, there is a feeling of discom- 
 fort and sometimes of slight pains in the abdomen. These 
 abnormal sensations may be especiallj^ marked some time 
 after the ingestion of food or shortly before the evacua- 
 tions. In some cases, again, these annoying sensations 
 appear early in the morning, about an hour or two before 
 rising. Borborygmi often occur; occasionally there is a 
 feeling of tension or of bloating in the abdomen, which 
 may be relieved by the passing of flatus. The latter symp- 
 tom may be so constant and annoying that the patient is 
 afraid to appear in society or may be hindered in his voca- 
 tion. An accumulation of gases in the intestine, especially 
 in the colon, may sometimes exert pressure upon the dia- 
 phragm and give rise to asthmatic complaints, palpitations 
 of the heart and angina pectoris, congestion of the head 
 and vertigo. Belching or passing of wind alleviates these 
 symptoms or entirely removes them. 
 
 Colicky pains sometimes appear and are of short dura- 
 tion. Severe pains, however, are almost always ab- 
 sent. 
 
 If the catarrh has lasted for some time, then symptoms 
 
102 DISEASES OF THE INTESTINES. 
 
 relating to tlie general state of health often appear. Thus 
 the patient may feel weak, show a disinclination to work, 
 be irritable and somewhat melancholic. Some patients 
 greatl}^ lose in flesh, and present an appearance of suffer- 
 ing, have cold extremities and a slow pulse. Headaches, 
 nausea, and anorexia are also often met with. 
 
 Whether these symptoms are due to auto-intoxication as 
 some, especially of the French writers, assume (Bouchard ') 
 is very difficult to state. It is, however, certain that this 
 theory does not apply to all cases of this kind. 
 
 Gastric symptoms (nausea, anorexia, etc.) are as a rule 
 met with only in cases in which the small intestine is 
 affected. If the catarrh is limited to the large bowel these 
 symptoms are usually absent. 
 
 Objective Symptoms. — In some cases the abdomen is 
 bloated, especially shortly after meals, and somewhat ten- 
 der to pressure. There may be tenderness all along the 
 colon; occasionally the ascending colon can be felt as a 
 sausage-like body containing hard masses, which change 
 their shape upon digital pressure, or this part of the colon 
 is filled with gas and liquids and a splashing sound can 
 then be easily evoked. Similar phenomena may be ob- 
 served also in the descending part of the colon (S Roma- 
 num) in the left iliac fossa. Tenderness along the colon 
 upon pressure is often found ; usually the pains are felt 
 just beneath the area where the pressure is exerted; some- 
 times, however, the pain appears in a more remote spot. 
 Thus, for instance, upon pressing upon the ascending co- 
 lon in the right iliac fossa, pain is felt across the abdomen 
 in a line lying horizontally at two fingers' width above 
 the navel (transverse colon). Intestinal peristalsis may be 
 observed in persons with thin abdominal walls, especially 
 ^Bouchard : "Le9onssur les Auto-intoxications," Paris, 1887. 
 
CHRONIC INTESTINAL CATARRH. 103 
 
 after a palpatory examination. All these signs, however, 
 are occasionally absent. 
 
 In the symptomatology of the chronic intestinal catarrh 
 the character and frequency of the stools are of greatest 
 importance. While in acute intestinal catarrh diarrhoea is 
 almost a constant characteristic symptom, there is much 
 variation in the frequency of the dejecta in the chronic 
 form. With regard to this point Nothnagel divides cases 
 of chronic intestinal catarrh into the four following groups : 
 
 1. Cases characterized by pronounced constipation. An 
 evacuation appears only once in two, three, or four days ; 
 sometimes only with the aid of cathartics. The fecal mat- 
 ter is usually hard. As a cause of the constipation, Noth- 
 nagel assumes a decreased activity of the automatic nervous 
 apparatus of the intestines, this being the result of the ca- 
 tarrhal process. 
 
 2. Cases in which constipation and diarrhoea constantly 
 alternate. For two or three days there may be a daily 
 evacuation of very hard dejecta. On the following day 
 there may be four to six very thin or mushy movements 
 mixed with mucus, accompanied by violent pains, and then 
 again constipation for a day or two, etc. Or there may be 
 quite normal evacuations (once daily) for a few days in 
 succession and then again four to seven diarrhoeal move- 
 ments in one day, and after this constipation. The prin- 
 cipal feature of these cases is the constipation, but the 
 excitability of the nervous apparatus being quite good, 
 the decomposed stagnant contents often cause increased 
 peristalsis and diarrhoea. Sometimes these alternating 
 periods of constipation and diarrhoea continue for a long 
 time. Thus the patient may be constipated for four or 
 five weeks, or even for a few months, and then again the 
 diarrhoea may set in, lasting several weeks or months. 
 
104 DISEASES OF THE INTESTINES. 
 
 3. In a very limited number of cases there is a daily 
 evacuation, which is usually not formed and mushy. 
 
 4. Cases in which there are for months several diarrhoeal 
 evacuations daily. The dejecta as a rule show the biliary 
 reaction, or they may contain yellow fragments of mucus, 
 yellow tinged epithelia, and round cells. In these cases 
 the catarrhal process affects not only the large bowel but 
 also the small intestine. The absorption suffers and there 
 are more abnormal products in the contents (acids), which 
 give rise to increased peristalsis in the small as well as 
 large bowel. 
 
 Besides these typical cases there are some in which the 
 nervous element plays a part in combination with the ca- 
 tarrhal process. Thus there are patients who are molested 
 with diarrhoeal movements only during the night or in the 
 early morning hours (morning diarrhoea of Delafield^), 
 while they feel well during the remainder of the day. 
 
 The quality of the dejecta in those cases in which there 
 is constipation is almost normal, with the only exception 
 that there is an admixture of mucus. Nothnagel considers 
 this point the most important in the recognition of a 
 catarrhal condition of the intestine. The mucus may be 
 absent in rare instances in which the scybala are small and 
 the layer of mucus within the intestine is very tough and 
 adherent, so that the fecal matter cannot carry it along in 
 its passage. 
 
 The quantity of mucus varies greath\ While in most 
 <3a8es only small particles of mucus are found, there are 
 some in which a considerable amount may be passed. 
 Large amounts of mucus without fecal matter are often 
 found in enteritis membranacea, less frequently in chronic 
 enteritis. 
 
 IF. Delafield : Medical Record, May 11th, 1895. 
 
CHRONIC INTESTINAL CATARRH. 105 
 
 In cases in which the dejecta are more or less thin, 
 mushy or watery, the fecal matter has a liglit color, brown- 
 ish-yellow or grayish-yellow, and may at times be very 
 poor in biliary matters. In these instances, undigested 
 food particles are easily found. Thus small particles of 
 meat or starchy food may be discovered. 
 
 The microscopical examination of the dejecta is often 
 very useful, for even in cases in which macroscopically 
 nothing/ abnormal can be discovered, the microscope may 
 reveal considerable amounts of undigested meat fibres, 
 starch granules, and fat globules. Such substances, if fre- 
 quently present, indicate that the catarrhal affection is 
 principally within the small intestine. The microscope 
 here further shows the presence of epithelial cells, some- 
 times of a yellow color and mostly in a shrivelled condi- 
 tion and embedded in mucus. 
 
 According to Rosenheim, ' chemical examinations of the 
 dejecta have no practical value in this affection. The reac- 
 tion with regard to litmus varies greatly and is dependent 
 upon the frequency of the stools and the quality of the in- 
 gested food. As a rule, however, an alkaline reaction is 
 found. 
 
 The degree of fermentative i)rocesses in the intestines 
 may be gauged by the intensity of the feeling of tension in 
 the abdomen, the frequency of flatus, and the condition of 
 the dejecta. The latter may present a very fetid odor and 
 a foamy surface. If the movements are diarrhoeal, a fer- 
 mentation tube may be filled with the liquid contents and 
 kept at blood temperature for a few hours ; the amount of 
 gas developed in the tube will indicate the degree of fer- 
 mentation. The character of the urine is also of impor- 
 
 ' Theodor Rosenheim : " Pathologie und Therapie der Krankheiten 
 des Darms, " Wien und Leipzig, 1893. 
 
106 DISEASES OF THE INTESTINES. 
 
 tance with regard to this point. In conditions in which 
 there is considerable fermentation and absorption of de- 
 composed products within the small intestine, it usually 
 gives a more or less strong indican reaction and also a 
 decided Rosenbach reaction (Burgundy red color after 
 boiling and the addition of nitric acid). 
 
 Chronic enteritis complicated with catarrhal ulcers mani- 
 fests itself by more frequent attacks of diarrhoea, admix- 
 ture of blood or pus in the dejecta, and pain. All these 
 symptoms are especially apt to be present if the lower 
 part of the intestinal tract is affected ; if the ulcer is in the 
 small intestine, diarrhoea is often absent, nor need there 
 be any signs of blood or pus in the dejecta. 
 
 Atrophic processes may also accompany the enteritis. 
 If these involve only a small part of the intestinal tract, no 
 symptoms whatever may result; if, however, larger parts 
 of the small intestine are affected, the absorption of food 
 is greatly impaired and then severe symptoms occur. 
 Diarrhoea without passage of mucus and accompanied by 
 a gradual but steady loss in weight is present, as are oc- 
 casional symptoms of pernicious anaemia. This condition 
 is found much oftcner in infancy than in later life. 
 
 Course. — As a rule chronic enteritis is a very tedious 
 affection. It may last many j'ears, even until the end of 
 life. The intensity of the symptoms varies a great deal, 
 and there may be periods of apparent perfect euphoria. 
 There always remains, however, a decided weakness of the 
 intestine, which is easily upset by slight errors in diet, 
 which in healthy persons would be harmless. 
 
 Diagnosis. — The diagnosis of chronic enteritis is made 
 if there are abnormal sensations within the abdomen, ac- 
 companied by irregularity of the bowels and the presence 
 of mucus in the stools. Habitual constipation can be ea- 
 
CHRONIC INTESTINAL CATARRH. lOT 
 
 silj differentiated from enteritis : (1) bj' tlie absence of mu- 
 cus ; (2) by the fact tliat it does not so easily nor so com- 
 pletely respond to mild cathartics. Malignant growths 
 are often accompanied by enteritis, and thus the symp- 
 toms of the latter often give rise to mistakes. A longer 
 period of observation, however, will aid in arriving at a 
 correct diagnosis. In case of a neoplasm symptoms of 
 cachexia will not fail to appear nor will the accompanying 
 enteritis ' be so readily alleviated as if it were the only 
 affection. In ulcer of the intestine pains predominate and 
 are a marked feature. Constipation and diarrhoea depend- 
 ent upon disease of the stomach will be recognized : (1) by 
 the absence of mucus in the stools ; and (2) by an examina- 
 tion of the gastric contents. They will readily yield to 
 treatment directed toward the gastric disorder. 
 
 With regard to the localization of the process, the fol- 
 lowing is of importance : Chronic inflammation confined 
 to the small intestine is usually accompanied by gastric 
 symptoms, constipation, and the presence of small parti- 
 cles of mucus in the stools, having a yellow tinge and being 
 well mixed with the dejecta. If the large bowel alone is 
 involved (colitis), there is constipation with the presence of 
 more or less mucus of a grayish color, either covering the 
 entire fecal mass or appearing here and there on its sur- 
 face. Occasionally, especially if the lower part of the 
 bowel is affected, the mucus appears at the end of the de- 
 fecation and is then voided without any admixture of fecal 
 matter. If the inflammatorj^ process involves both the 
 small and the large intestines, constant diarrhoea is a pre- 
 dominant feature. The mucus found in the dejecta has a 
 yellowish color; besides considerable quantities of undi- 
 gested food are discovered in the fecal matter. 
 
 Prognosis. — The prognosis of chronic enteritis depends. 
 
108 DISEASES OF THE INTESTINES. 
 
 upon the intensity of the symptoms, the duration of the 
 disease, and also greatl}^ upon the age and the constitution 
 of the patient. In infancy and in old age chronic catarrh 
 of the intestines must be considered a grave affection. 
 The same applies to persons with a weakened constitution 
 (tuberculosis, cardiac or other important lesions). A 
 chronic enteritis of intense type which has lasted a long 
 period of time is hardly ever cured perfectly. There may 
 l>e improvements in the condition of the patient, but re- 
 lapses are sure to follow soon. Cases of a mild nature, how- 
 ever, often end in recovery, especiallj^ under an appropriate 
 treatment. In old age a complete cure rarely takes place. 
 If atrophy of the intestines has developed, then the condi- 
 tion is very unfavorable, the patient succumbing after a 
 period of about twelve to eighteen months. 
 
 Treatment. — As in the treatment of chronic gastric ca- 
 tarrh, and perhaps in a still greater degree, hygienic and 
 dietetic measures here play the chief part. It will be at 
 first imjiortant to regulate the mode of living of the jjatient 
 ■ — not too much work, not too great business strain, plenty 
 of outdoor life and exercise, regularity of meals. Expo- 
 sure to cold should be carefully avoided. The patient 
 should dress warmly, especially the abdomen and feet (flan- 
 nel bandage around the abdomen), and should be particu- 
 larly careful not to get his feet wet. In rainy weather shoes 
 with thick soles or rubbers should be worn. With regard to 
 diet the following rules are of value : the meals should be 
 taken frequently- and in small portions. Indigestible sub- 
 stances should be avoided. Sufficient nourishment should 
 be given, and care taken that there is an increase rather 
 than a decrease in weight. In cases of diarrhoea the fol- 
 lowing should be forbidden : acid or sweet wines, all mine- 
 ral waters charged with carbonic-acid gas, lemonade, all 
 
CHRONIC INTESTINAL CATARRH. 109 
 
 kinds of fruits, salads, all kinds of cabbage including cauli- 
 flower, rye bread, and pastries. Give eggs (soft-boiled 
 or scrambled), light meats, especially sweetbread, calf's 
 brain, spring chicken, steak, lamb chops, oysters, lean fish, 
 white bread well baked or toasted, fresh butter, cream 
 soups, bouillon, rice, sago, macaroni, mashed or baked 
 potatoes, milk, cacao, tea. Kumyss, matzoon, ginger ale, 
 good claret or Tokay may also be allowed. As a rule noth- 
 ing should be taken in large portions, and the drinks should 
 be warm or cool (temperature of the room), but not cold. 
 Large amounts of liquids should be avoided. Patient with 
 very severe symptoms (frequent diarrhoea, intense pains, 
 great weakness) must be kept abed for a shoft time and 
 put on a rigorous diet at first, as in cases of acute ente- 
 ritis. Upon improvement of the condition the dietetic 
 rules described above should be followed. 
 
 In cases attended with constipation the diet may be more 
 liberal. Besides all the articles of food mentioned in the 
 diarrhoeal group, light fruits, as oranges, grapes, ripe 
 pears, and green vegetables, green peas, cauliflower may 
 be added. The ingestion of large amounts of starchy 
 foods, easily assimilated fats, butter, cream, and of fluids 
 is very beneficial. The more indigestible articles of food, 
 like bran breads (pumpernickel), sausages, lobster salad, 
 mayonnaise dressings, cabbage, cucumbers, etc., should 
 be avoided. Beer, ale, Rhine wine taken moderately are 
 permissible. 
 
 Hydrothei'apeuUc Measures. — In cases of diarrhoea warm 
 mineral baths or baths with the addition of pine needle 
 extract and mud and bran baths are favorable. Cold baths 
 should be avoided. A cold sponge bath, however, or a 
 cold shower on the back may be serviceable in chronic en- 
 teritis with nervous symptoms. A Priessnitz (wet pack) 
 
110 DISEASES OF THE INTESTINES. 
 
 over the abdomen may be advantageously "used over night. 
 Cold sitz baths and cold showers over the abdomen are 
 also often beneficial. 
 
 Mineral Waters. — According to Nothnagel chronic enteri- 
 tis is sometimes greatly improved, and even perfectly cured, 
 by a methodical course of drinking certain mineral waters. 
 Such a cure can best be carried out at the mineral springs 
 themselves. For here the patients not only take the waters 
 in the right way, but also observe the necessary rules of 
 diet and are besides kept free from their business cares. 
 Carlsbad is to be regarded as the best place in cases of 
 chronic enteritis in which the diarrhoea is a prominent fea- 
 ture; Vichy comes next. For cases of chronic enteritis 
 with constipation Marienbad seems to be very useful ; the 
 same applies to Saratoga (Hawthorn and Congress 
 Springs). For cases in which neither constipation nor 
 diarrhoea plays a prominent part Kissingen or Homburg 
 may be recommended. Chronic enteritis accompanied by 
 anaemia may be benefited at the watering-places of Fran- 
 zensbad and Elster. The Carlsbad water should be taken 
 in small quantities, about a wineglassful twice daily ; in 
 some cases even smaller amounts (25 to 50 gm.) three 
 to five times daily. In cases which have been benefited 
 by a drinking cure in Carlsbad, Nothnagel suggests having 
 these patients use at home the Carlsbad waters in a similar 
 manner as at this resort, four times a year for an entire 
 month. Nothnagel says : " The chronic condition requires 
 a chronic treatment." 
 
 Medicaments. — Strong cathartics should be avoided in 
 the treatment of the constipation. Here some articles of 
 diet which moderately increase the intestinal peristalsis 
 may be first tried— buttermilk, a glass of cold water, 
 stewed fruits, and the like. If these fail, small amounts 
 
CHRONIC INTESTINAL CATARRH. Ill 
 
 of rliubarb, fluid extract of cascara sagrada, podophyllin 
 may be used. Of greater value, Lowever, are rectal injec- 
 tions either of plain water or with the addition of some 
 soap or salt (a teaspoonful to a quart) or Carlsbad water. 
 Enemas of olive oil, as first recommended by Habershon 
 and latet by Kussmaul and Fleiner, may also be advan- 
 tageously used. The oil enemas should, however, be 
 given in small quantities (half a pint to a pint) and be re- 
 tained over night in the bowels. The frequent use of calo- 
 mel, castor oil, and jalap should be forbidden. 
 
 The diarrhoea is best treated either by large doses of 
 subnitrate of bismuth, salicj'late of bismuth, or bismutose 
 (1 to 2 gm., gr. XV. -XXX.) three times daily, or some of the 
 drugs containing tannic acid as their principal ingredient 
 (calumba, cascarilla, rhattania, catechu, kino, lig. campe- 
 chianum, fructus myrtili). Weber' recommends the fol- 
 lowing prescription : 
 
 IJ Extr. monesise, 
 
 Extr. calumbse aa 15.0 ( ^ ss.) 
 
 Extr. gent, et pulv. liq q.s. 
 
 Ut f. pil. cxx. S. Three times daily two to four pills. 
 
 I very frequently give fluid extract of condurango and 
 fluid extract of calumba of each twenty drops three times 
 daily. Dermatol (subgallate of bismuth) seems to be 
 quite beneficial in cases in which the formation of gas is 
 a predominant feature. It may be given in doses of half a 
 gram (gr. viii.) three times daily. For the same condition 
 salicylate of bismuth, benzonaphthol, and creosote in small 
 doses may be given. Tannigen and tannalbin may be used 
 in doses of 0.5 to 1 gm. (gr. viii.-xvi.) three times daily, 
 the first being preferable. Both substances seem to less- 
 en fermentation, and by their astringent qualities exert a 
 'L. Weber: New-Yorker medicinische Moaatsschrift, 1892. 
 
112 DISEASES OF THE INTESTINES 
 
 beneficial influence upon the healing-process. They may 
 therefore be given continuously for a long period of time. 
 
 Cases accompanied by pains will require an opiate (mor- 
 phine, or still better codeine), with or without the addition 
 of belladonna extract. In chronic proctitis suppositories 
 of opium and belladonna extract with cacao butter are indi- 
 cated. Small enemas of starch solution with an opiate are 
 also useful here. It is of course to be understood that the 
 administration of opiates will have to be limited to a short 
 period of time. 
 
CHAPTER IV. 
 
 DYSENTEEY. 
 
 Synonijms. — Enteritis crouposa et necrotica; Amoebic 
 dysenteiy. 
 
 Definition. — An infectious disease characterized by spe- 
 cific ulcerations of the large intestine, giving rise to fre- 
 quent bloody, mucous, or purulent dejections accompanied 
 by tenesmus and general symptoms. 
 
 Etiology. — Dysentery occurs under three different condi- 
 tions : (1) As a disease principally during the warm season 
 in temperate climates, appearing in local epidemics; (2) 
 endemic in hot climates ; (3) epidemic at certain times in 
 all latitudes, being quickly disseminated, and also sporadic. 
 While the endemic zone of dysentery is limited to places 
 lying south of the fortieth degree of latitude, epidemics of 
 the disease have occurred in almost every part of the 
 globe. Dysentery is one of the oldest diseases known. It 
 was observed by Hippocrates and well described by Are- 
 tseus and Celsus. Aretseus already recognized the ulcera- 
 tion of the intestines in dysentery. 
 
 Various causes have been adduced to explain the origin 
 of the disease, and meteorological influences have been held 
 responsible for its prevalence in local epidemics. The 
 endemic dysentery of the tropics was generally ascribed to 
 the combined action of heat and of the miasm of swamps. 
 Sudden exposure to cold, eating of bad and spoiled food, 
 and the use of stagnant or marshy water were all believed 
 
114 DISEASES OF THE INTESTINES. 
 
 to be factors in producing dysentery. It is only within 
 recent years that its infectious and also contagious char- 
 acter has been recognized. Sodre ' says : " A careful etio- 
 logical study shows that dysentery in whatever latitude it 
 be observed is always due to the action of the same exciting 
 cause, that it starts and is propagated always under the 
 influence of infection and contagion, and that it should be 
 included in the group of parasitic diseases." The exciting 
 cause of dysentery often lies in the soil, in circumscribed 
 foci of infection. These foci are represented by marshes 
 and bogs which receive the drainage fi'om dung heaps and 
 cesspools, or by a soil impregnated with human dejec- 
 tions. The contagious character of dysentery is best shown 
 by the following report of Dr. Beauchef.' This writer 
 states that the French ship Loreit, anchored on the west 
 coast of Africa, was in the best possible sanitary condition, 
 not one of the crew being ill. She was then ordered to 
 transport to Gorea the sailors of the sloop of war Eagle, 
 among whom were twenty -nine dysenteric patients. A few 
 days afterward, while on the high sea, dysentery spread 
 among the crew of the Loreit and ceased only after all the 
 patients had been landed at Gorea. 
 
 Among the causes which contribute to diffuse the dysen- 
 teric contagion and to produce the disease in an epidemic 
 form the following may be mentioned : Crowding together 
 of individuals, the vicissitudes of war, bodily privation, 
 chiefly hunger. These factors are frequently found asso- 
 ciated in times of war when epidemics of dysentery have 
 often appeared, causing great ravages. 
 
 Since bacteria have been found to play an important 
 
 ^ A. Sodre : "Dysentery, " Twentieth Century Practice of Medicine, 
 -vol. xvi., p. 241. 
 
 ' Beauchef : Cited after Sodre, loc. cit. 
 
DYSENTERY. 115 
 
 part in the etiology of infectious diseases, many investi- 
 gators have tried to discover tlie particular micro-organism 
 producing dysentery. Various bacilli and cocci have been 
 described and held responsible as etiological factors, but 
 their relative significance has not been determined. As 
 early as 1859, however, Lambl ^ called attention to the pres- 
 ence of amoebae in the intestinal contents. He found them 
 in the stools of a child suffering from dysentery. Loesch," 
 in 1875, observed amoebae in the dejecta of a patient suffer- 
 ing from chronic dysenter3\ He was the first to attribute 
 the disease to this micro-organism. He also succeeded 
 in experimentally producing a dysentery-like disease in 
 a dog to which he had administered rectal injections of 
 fecal matter containing amoebae. The observations of 
 Loesch have been confirmed by Koch,^ who, while investi- 
 gating dysentery in Egypt, found in post-mortem examina- 
 tions numerous amoebae in the intestine at the base of the 
 ulcers. The next important contribution on this subject 
 was made by Kartulis,* who, while practising in Alex- 
 andria, had an opportunity to observe several hundreds of 
 cases of dysentery. In more than five hundred post-mor- 
 tem examinations he found the amoebae constantly in the 
 faeces and on the surface of the ulcers, and in the abscesses 
 of the intestine as well as of the liver. In other affections 
 of the intestines Kartulis failed to detect the amoebae para- 
 sites. He also succeeded in cultivating them in infusions 
 of sterilized dry straw, and twice produced dysentery in 
 
 1 Lambl : " Beobachtungen und Studien aus dem Franz- Josef-Kinder- 
 Spital, " 1860. 
 
 ^ Loesch : "Massenhafte Entwickelung von Anioebeu im Dickdarm. " 
 Virch. Arch., Bd. Ixv. 
 
 3 Koch : Cited after Sodre, loc. cit. 
 
 ^Kartulis: "Zur Aetiologie der Dysenteric in Aegypten. " Virch. 
 Arch., Bd. 105, 1885. 
 
116 DISEASES OF THE INTESTINES. 
 
 cats by inoculation with these cultures. Kartulis, there- 
 fore, declared the amoebse to be the true etiological factor of 
 dj^sentery. 
 
 Very soon afterward observations of a similar character 
 were made both abroad and here. Thus Quincke and 
 Boos,' Hlava,"^ Massaiutin,' Nasse/ and others abroad, and 
 Osier, ^ Stengel,'' Musser," Eichberg,* Stockton,' Council- 
 man and Lafleur,'° and Harris " of this country have also 
 described cases of dysentery with the presence of the 
 amoebae parasites. 
 
 The theory of the amoebic origin of dysentery has been dis- 
 puted by some writers, for they have found this micro-or- 
 ganism in the fseces in other intestinal disorders and, in 
 some instances, even in the stools of healthy persons. Thus 
 Schuberg '' says : " The abundance of amoebae in dysentery 
 is the effect and not the cause of the disease, the ulcerative 
 lesions affording this habitual denizen of the intestines 
 more favorable conditions for its development." The con- 
 sensus of opinion, however, is that while harmless amoebae 
 may occur in the intestinal tract, there exists a pathogenic 
 variety of this organism which is specific for dysentery. 
 For this reason Councilman and Lafleur proposed the name 
 
 ^ Quincke und Roos : Berl. klin. Woclienschr., 1893. 
 
 2 Hlava : Centralbl. flir Bacteriologie, 1887. 
 
 ^ Massaiutin : Ibid. 
 
 ^Nasse: Deutsclie med. Wochensclir. , 1891. 
 
 5 Osier : Bulletin of the Johns Hopkins Hospital, 1890. 
 
 ^ Stengel : Medical News, November 15th, 1890. 
 
 ' Musser : University Med. Magazine, December, 1890. 
 
 8 Eichberg : Medical News, August 22d, 1891. 
 
 8 Stockton : International Clinics, 1894, i. 
 
 '" W. J. Councilman and H. A. Lafleur : " Amoebic Dysentery." Johns 
 Hopkins Hospital Eeports, vol. ii., Nos. 7-9, 1891, p. 395. 
 
 " K. F. Harris: "Amoebic Dysentery." American Journal of the 
 Medical Sciences, 1898, p. 384. 
 
 J2 Schuberg : Centralbl. fiir Bakteriologie, 1893. 
 
DYSENTERY. 117 
 
 of amoebae dysenterise for this special variety. The pres- 
 ence of the amoebfe in the contents of abscesses of the liver, 
 which are so often met with in dysentery according to 
 Sodre, constitutes a powerful argument in favor of the 
 amoebic etiology of the disease. 
 
 It is generally believed that the amoebfe enter the system 
 along with the food or drink. Sodre believes that they can 
 be taken in with the air. Certain waters, however, ap- 
 parenth- constitute the principal means of propagation of 
 these amoebae. Thus, Barthelemy ' relates that the troops 
 when operating on the shore of the Oueme, whose clear run- 
 ning water was filtered in Chamberland filters before being 
 used, were in good health and free from dysentery ; when, 
 however, the army moved away from the Oueme in the 
 direction of Abomey they were compelled to use unfiltered 
 swampy water. From that moment dysentery made its 
 appearance. Fitz and Gerry ' described a case of dysen- 
 tery with the presence of amoebae in the stools and found 
 the same micro-organisms in a cistern, the water of which 
 the patients constantly used. 
 
 The Bacillary Theory.— In 1897 K. Shiga/ of Tokio, 
 Japan, found a bacillus in the stools and intestinal walls 
 of dysenteric patients. This bacillus (which forms a 
 small, plump rod with rounded ends, resembling the colon 
 bacillus) was present in all the cases of dysentery exam- 
 ined by him, but was never found in healthy individuals 
 or those affected with other diseases. Furthermore, it 
 was plainly agglutinated by the serum of dysenteric pa- 
 tients, and has since been accepted as the producer of dj's- 
 
 ' Barthelemy : "Medical Report of the War of Dahomey." 
 2 Fitz and Gerry: Cited after Sodre, loc. cit. 
 
 ^ K. Shiga: "Bacillary Dj'sentery." Twentieth Century Practice of 
 Medicine, Supplement, p. 636. 
 
118 DISEASES OF THE INTESTINES. 
 
 entery. In 1900 Flexner found the same bacillus in dys- 
 enteric stools in Manila, and later in the United States. 
 Kruse discovered the same bacilli in dysenteric patients in 
 Germany. 
 
 According to Flexner and Strong, there exist two types 
 of dysentery— the bacillary and the amoebic. The first is 
 produced by the bacillus dysenterise and usually runs an 
 acute course. The second is chronic and shows the pres- 
 ence of no dysenteric bacilli, but the amcebse are found in 
 the dejections and in the submucous tissue of the dysen- 
 teric ulcers. This view is now generally accepted by most 
 writers. 
 
 Age does not seem to have any influence upon the disease. 
 Statistically a greater number of cases is found among 
 adults, as these are more exposed to the morbific causes. 
 Both sexes are equally predisposed to dysentery, and no 
 race enjoys immunity from it. One attack does not confer 
 immunity against others. Persons who suffer from want 
 of food or who live on food of bad quality are most liable 
 to contract the disease. Harris says: "Dysentery is a 
 disease pre-eminently of the poor, and is almost always 
 associated with filth, bad hygienic surroundings, and lack 
 of proper food." This statement, however, is somewhat 
 too categorical, and I fully agree with Sodre, who remarks 
 that dysentery is observed also in persons of the wealthier 
 class, who live on the best food and are surrounded with 
 every comfort. Nevertheless, it must be admitted that it 
 is most frequent among the poor, and chiefly among people 
 who live under bad hygienic conditions. 
 
 Morbid Anatomy. — In acute dysentery the large intestine 
 is almost always found in a thickened condition. This 
 thickening involves all the intestinal coats, but is most 
 marked in the submucosa. Sometimes the latter layer 
 
DYSENTERY. 119 
 
 {.lone is involved. The mucosa, when washed with water, 
 presents a bright red, at some places dark red color. The 
 folds of the mucosa are much more voluminous than nor- 
 mally, and thus present considerable prominences. Small 
 red nodules of various size are also seen scattered over the 
 mucous membrane. Besides these nodules more or less 
 numerous ulcers are found. These vary greatly in size 
 (from a pinhead to two inches long) and also in depth, 
 some b((ing superficial, others quite deep. The ulcers are 
 situated chiefly on the folds of the mucosa. Ordinarily 
 they are oblong and lie transversely to the long axis of 
 the bowel. Sometimes they are circular, sinuous, or ir- 
 regular. 
 
 Councilman and Lafleur have described on the surface ot 
 the mucosa sharply outlined projecting nodular thicken- 
 ings, in which are observed cavities filled with a gelatinous 
 mass communicating with the surface of the mucous mem- 
 brane by small openings, frequently not larger than the 
 head of a pin. These writers have also pointed out as 
 characteristic of the dysenteric ulcers their undermined 
 edges. The disease process in dysentery, according to 
 Councilman and Lafleur, is essentially one of advancing 
 infiltration and softening of the submucous and intermus- 
 cular tissue with subsequent necrosis of the overlying 
 tissue. The amoebse reach the submucosa without injur- 
 ing the mucous membrane. Here the essential changes 
 are first produced, and the mucous membrane is interfered 
 with later. The mucosa becomes cedematous and ruptures 
 after a while, forming an ulcer. 
 
 Harris described two anatomical forms of ulcers found in 
 dysentery. In the first form, which is encountered most 
 frequently and can be considered as the typical intestinal 
 lesion of the disease, changes in the submucosa may be 
 
120 DISEASES OF THE INTESTINES. 
 
 traced in advance of the surface ulceration for quite a dis- 
 tance, thus undermining the comjjaratively healthy mucosa 
 above. In the second form the ulcers increase in size by 
 gradual softening and breaking down at the surface, never 
 by necrosis and sloughing of the underlying tissue. Ul- 
 cers of the second category occasionally do not penetrate 
 deeper than half-way through the mucosa. Generally they 
 extend into the submucosa. They never contain amoebae. 
 According to Kartulis and Kruse, the first form is found 
 in amoebic, while the second is encountered in bacillary 
 dysentery. 
 
 The lesions described are usually found throughout the 
 entire large bowel, but as a rule they do not extend beyond 
 the ileocaecal valve. In a comparatively small number of 
 cases the small intestine is also involved, principally the 
 ileum. 
 
 In some instances gangrene of the intestine is found. 
 Many authors even describe a gangrenous form of dysen- 
 tery. Sodre, however, does not regard the gangrene as a 
 lesion brought on by the amoebae dysenterise, but by the 
 action of bacteria foreign to the dysenteric process. Ac- 
 cording to this author gangrene is a complication of dysen- 
 tery, but not a specific lesion. In this complicated form, 
 besides the ulcers described above, there exist others of a 
 gangrenous character. The gangrenous process may also 
 extend beyond the ulcers. On the brownish-red mucosa 
 gangrenous patches of a dark color and of various size are 
 seen. In this condition the mucosa may be detached over 
 a considerable area and eliminated with the dejections. 
 
 In chronic dysentery the intestine is pale with slate col- 
 ored spots. Its walls are thickened. The mucosa presents 
 a pale rosy or slate color. Ulcers in different stages of 
 development are encountered. Often the ulcers occur in 
 
DYSENTERY. 121 
 
 groups separated from each other by more or less extensive 
 healthy areas of intestine. Sometimes in certain portions 
 of the intestines the ulcers become confluent. Dysenteric 
 ulcers may be round, elliptical, or serpentine in form and 
 usually have thickened and callous edges . In the neighbor- 
 hood of the ulcers, there is no hypersemia or oedema, al- 
 though an increase of fibrous tissue is noted. Undermined 
 ulcers undergoing a process of repair are also found. The 
 mucosa glands are found dilated and filled with mucus. In 
 some places glandular cysts of considerable size are encoun- 
 tered, in others the glands have almost disappeared, and 
 only traces of them are left. The mucosa is thickened and 
 filled with round cells. The submucosa is likewise thick- 
 ened and in some places oedematous. Dense fibrous tissue 
 is found almost all over in this layer, predominating, how- 
 ever, at the location of the cicatrices and of ulcers in the 
 process of repair. 
 
 In both the chronic and the acute form of dysentery, but 
 principally in the latter, besides the lesion of the intes- 
 tines described above, the liver is frequently found dis- 
 eased. In dysentery complicated with gangrene this organ 
 is usually greatly increased in volume, tumefied, soft, and 
 friable. The cross-section presents a dark color inter- 
 spersed with yellowish spots. The latter are usually some- 
 what raised above the surface. On microscopical examina- 
 tion the hepatic cells show a large amount of fat; besides, 
 small round abscesses are found around the capillaries, 
 which are most probably due to emboli. 
 
 Aside from these very small pus collections of py?emic 
 origin, other abscesses are found which differ from these 
 by their size and the nature of their contents. They are 
 the so-called dysenteric abscesses of the liver, and are most 
 often encountered in acute dysentery without gangrene. 
 
122 DISEASES OF THE INTESTINES. 
 
 The dysenteric abscesses vary greatly in size from a few 
 lines to several inches. They are situated chiefly in the 
 right lobe of the liver near the surface. Often several are 
 found together. The contents of these abscesses vary 
 greatly. In the most recent, the abscess does not empty 
 itself on section. A small amount of glairy, semi-trans- 
 parent fluid exudes and leaves behind an irregular sponge- 
 like mass, the fluid being apparently held in the meshes. 
 In the older abscesses the contents are more fluid, the latter 
 having a greenish opaque color. In these are suspended 
 
 ,-rf- 
 
 ^;y 
 
 ^M 
 
 s^ 
 
 f/ 
 
 u-t 
 
 ';>. 
 
 Fig 30 — Amoebse from an Abbcess of the Liver. X 750. (Sodr^.) 
 
 some solid masses of tissue. In some instances the con- 
 tents are brownish or streaked with brownish-red from 
 admixture of blood. Microscopical examination of the con- 
 tents of the abscesses reveals the presence of a few pus. 
 cells, a large quantity of fatty granules, necrotic hepatic 
 cells, a few blood corpuscles, a great number of amcebse 
 (see Fig. 30), and sometimes micrococci and bacilli. Ac- 
 cording to Councilman and Lafleur, there is no definite 
 abscess-wall, the liver tissue passes gradually into the 
 abscess, and the contour of the edge is very irregular, 
 sometimes extending into the liver for a distance of several 
 nodules. The abscess may penetrate the capsule of the 
 liver and either open externally or it may burst into some 
 
DYSENTERY. 123 
 
 of the adjacent organs, as, for instance, the lungs, the 
 stomach, the intestines, or the peritoneal cavity. Most 
 often, however, it bursts into the lungs. 
 
 Symptomatology of Acute Dysentery. — The disease may 
 begin suddenly without any premonitory symptoms, or 
 after a few days of general malaise, loss of appetite, and 
 irregularity of the bowels, the patient is attacked with 
 abdominal colic and diarrhoea. These symptoms are 
 usually ac^companied by chills, vague pains through the 
 body, and fever. The stools, at first abundant and watery, 
 very soon become scanty, mucous, and usually contain 
 blood. Gastric disturbances are present in almost all 
 cases: anorexia, nausea, often vomiting. The principal 
 features of dysentery are the characteristic stools, the 
 abdominal pains, and tenesmus. 
 
 1. Stools. The evacuations increase in frequency, oc- 
 curring from twenty to twenty-seven times during the 
 twenty-four hours. The calls to stool are usually preceded 
 by rumbling and colicky pains, and are followed by strain- 
 ing and tenesmus. While during the first and perhaps the 
 second day of the disease the motions are copious, they 
 soon become scanty. The patient is then able to expel but 
 a small quantit^^, about a teaspoonful of mucus mixed with 
 blood, after painful efforts. Occasionally a few small 
 pieces of fecal matter are passed. The dejecta occasion- 
 ally change their character with regard to frequency aa 
 well as consistency. Intermissions and exacerbations of 
 the diarrhoea are sometimes observed in the course of the 
 disease. The mucus in the stools is almost always mixed 
 with blood. In some cases the dejecta are hemorrhagic, 
 that is, consist of almost pure blood, either red and fluid 
 or dark and coagulated. In dysentery complicated with 
 gangrene the stools are serous, of a dark reddish-brown 
 
124 DISEASES OF THE INTESTINES. 
 
 color, and contain, in addition to finely divided mem- 
 branous threads, large and thick masses of necrotic tissue 
 of a gray or black color. The gangrenous dejecta have an 
 intensely offensive odor. In many instances the stool con- 
 tains no bile. 
 
 Amoebse are almost always found in the dysenteric stools, 
 especially if the lesions are quite extensive. In examining 
 the faeces for amoebae it is well to use some precaution. 
 If jjossible the examination should be made immediately 
 after the dejecta have been passed. If this be impossible, 
 the stool should be preserved in a clean vessel and kept in 
 a warm place until the examination is made. The amoebae 
 are from 12 to 36 // in diameter, and when alive frequently 
 change their shape by contracting some part of their bodies 
 in order to move about. The body of these micro-organisms 
 consists of an outer clear homogeneous substance or ectosarc 
 and an inner highly refractive mass or endosarc. Within 
 the latter are usually found some bacteria, sometimes 
 changed red blood corpuscles, and a few quite large 
 vacuoles. The amoebae, when outside of the intestinal 
 tract, die very quickly, especially if they are kept in a cool 
 place. When dead, these organisms generally show a 
 round or almost round configuration. 
 
 In acute bacillary dysentery the bacillus dysenterise 
 (Shiga) is found in the fresh stools in almost pure culture 
 in the latter half of the first week of the disease. 
 
 (2) Abdominal pain. Abdominal pains exist with greater 
 or less severity in almost every case. The pains may be 
 experienced continuously, or principally before an evacu- 
 ation. Most often they are located in the umbilical region 
 and in the left iliac fossa, but sometimes they exist in the 
 right iliac fossa and may then almost simulate an attack of 
 appendicitis. The pains may be so severe that the patient 
 
DYSENTERY. 125 
 
 is forced to lie perfectly still for fear of increasing them. 
 Pressure exerted on the large intestine as a rule provokes 
 more or less intense pain. According to Dutrouleau, ' in 
 some very grave cases there is a total absence of colic 
 during the entire course of the disease. 
 
 (3) Tenesmus. Rectal tenesmus, consisting at first in 
 painful sensatioES of pressure and constriction and later in 
 an intense desire to go to stool, is encountered yeiy fre- 
 quently. In grave cases of dysentery the tenesmus may 
 exist almost uninterruptedly. Off and on the patient suc- 
 ceeds in expelling a small amount of fecal matter or slime or 
 merely gas, and then feels relieved for a short while. Very 
 soon, however, the pains in the anal region return with the 
 same severity. "\Mien the tenesmus is verj' severe it may 
 be accompanied by dysuria or strangury-. In this condi- 
 tion the patient presents a pitiable appearance. His 
 straining is frequently agonizing and occasionally accom- 
 panied by fainting. 
 
 Besides the three cardinal symptoms of dysentery just 
 described, other symptoms are often encountered. Fever 
 may be present, especially in the severer form of the dis- 
 ease. It may occur in the form of chills, when the disease 
 is first ushered in. As a rule, the fever is not very high 
 and shows an irregular course. Gastric sj^mptoms are 
 often present. They consist in intense anorexia, nausea, 
 vomiting, and pain in the epigastric region. The general 
 condition is more or less affected according to the severitj^ 
 of the disease. In grave cases prostration is marked, the 
 skin is dry, the features are altered, and the extremities 
 sometimes cold. The pulse is small and rapid. Some- 
 
 ' Dutrouleau : •' Traite des Maladies des Europeeus daus les pays 
 chauds," Paris, 1868. 
 
126 DISEASES OP THE INTESTINES. 
 
 iimes cerebral disorders, stupor, drowsiness, even delirium, 
 are encountered. 
 
 Dutrouleau and others divide cases of acute dysentery 
 into three groups: Cases of a mild character, those of 
 medium intensity, and those of a severe type. In the mild 
 form, there exist only local symptoms which are usually 
 not very intense. In the form of medium intensity, the 
 local symptoms are more accentuated and general symp- 
 toms are encountered. In the severe form, there are fever, 
 intense pain, very bloody stools, great prostration, and in- 
 tolerable tenesmus. 
 
 Symptomatology of Chronic Dysentery. — Chronic dysen- 
 tery develops either after several attacks of the acute form 
 or directly from the first acute attack, which after some 
 periods of improvement persists to a greater or less extent. 
 Cases of chronic dysentery are also divided into three 
 categories : 
 
 (1) The mild form. The general nutrition is not inter- 
 fered with. The patients usually complain of slight con- 
 stipation interrupted by light attacks of diarrhoea. Tenes- 
 mus is either entirely absent or present in a very slight 
 degree. Even during the attacks of diarrhoea the passages 
 are, as a rule, not bloody. 
 
 (2) Form of medium intensity. Here slight gastric symp- 
 toms are present, like anorexia, belching, etc. The gen- 
 eral condition is interfered with to a considerable extent. 
 There are almost always periods of intermission and exac- 
 erbation of the disease. The patient may have regular 
 movements or be slightly constipated, for a period varying 
 from a week to ten days, but soon diarrhoea api3ears and lasts 
 for four or five days. The stools are then watery, contain 
 mucus, and occasionally a little blood. Slight colicky 
 pains are present, as well as moderate tenesmus and a sen- 
 sation of heat or burning in the rectum. 
 
DYSENTERY. 127 
 
 (3) Tlie severe form. General nutrition is greatly im- 
 paired. The patient becomes emaciated, pronounced gas- 
 tric symptoms are present: anorexia, a bad taste in the 
 mouth, often nausea, occasiouallj' vomiting. As a rule, 
 there is persistent diarrhoea, and the dejecta present a mu- 
 cous or muco-sanguineous character. Colicky pains in the 
 abdomen and pronounced tenesmus are present. In some 
 cases, however, the diarrhoea alternates with short periods 
 of constipation lasting two or three days. The patient 
 usually feels very weak and is obliged to stay abed a great 
 deal of the time. 
 
 Course. — The course of acute dysentery is very indefinite. 
 Sometimes the disease terminates in recovery in eight to 
 fi.fteen days ; sometimes in one to three months ; sometimes 
 again death occurs a few days after the commencement of 
 the disease. Again, a case of dysentery may at first be mild, 
 but later assume a dangerous character, and even terminate 
 fatally. Intermissions and exacerbations are often encoun- 
 tered in this disease. When dysentery becomes chronic 
 its duration varies greatly, often depending upon the 
 severity of each particular case. Thus, it may last five to 
 six months or many years. Even in the chronic form 
 recovery is not entirely impossible. 
 
 Complications. — The course of the disease is occasionally 
 modified by various complications. Peritonitis often re- 
 sults from an extension of the ulcerative process from the 
 intestinal wall to the peritoneum. Perforation of the 
 intestine may occur in a similar way, and is observed 
 principally in gangrenous dysentery. Sudden death is 
 occasionally observed in such an event. In acute as well 
 as in chronic dysentery severe hemorrhages from the bowel 
 may take place. The loss of blood may be so great even 
 as to cause death. Thrombosis of the femoral artery as 
 well as of the venous sinuses of the brain has been observed 
 
128 DISEASES OF THE INTESTINES. 
 
 by Laveran ' as a complication of dysentery. A patient of 
 mine with acute dysentery, apparently on the road to im- 
 provement, suddenly one day developed a jjaralysis of the 
 upper and lower right extremities. He later lost con- 
 sciousness and died about forty-eight hours after the first 
 signs of paralysis. Here most probably thrombosis of 
 some brain vessels took place. 
 
 The most frequent complication of dysenterj^ is abscess 
 of the liver. In the majority of instances it is observed 
 in convalescence from acute dysentery or during the evolu- 
 tion of chronic dysentery. The symptoms of the forma- 
 tion of an abscess in the liver are : fever of an irregular 
 character, occasionally chills and pain in the hepatic region 
 which may radiate to the right shoulder. The physical 
 examination often reveals some enlargement of the liver. 
 In the event of a liver abscess opening into the lungs, 
 there is persistent cough and sometimes expectoration of a 
 reddish-brown fluid containing amoebae. Abscess of the 
 liver is more frequently encountered in tropical regions 
 than here. The course of such an abscess is very irregular. 
 Sometimes it progresses rapidly, at other times it shows 
 periods of intermissions and exacerbations. The large 
 abscesses of the liver, if not operated upon, usually termi- 
 nate in death. Rarely recovery may follow the opening of 
 the abscess into a neighboring organ. 
 
 Diagnosis. — The diagnosis of acute dysentery is usually 
 very easy. The symptoms above described, being ordi- 
 narily present, cannot fail to indicate the disease. The 
 most reliable evidence is afforded by the character of the 
 dejecta, the presence of mucus, an admixture of blood and 
 
 ' Laveran : " De la phlebite, de la thrombose et des paralysies comme 
 complications de la dysenteric." Archives de Medecine militaire, 
 1885. 
 
DYSENTERY. 129 
 
 pus corpuscles. Appendicitis is occasionally simulated by 
 dysentery if the pains involve principally tlie appendicular 
 region. Usually, however, it will be found that, besides 
 the tenderness over the appendix, there are also similar 
 areas of pain over other portions of the large bowel, espe- 
 cially in the left iliac fossa. Besides, the character of the 
 stool will help to reveal the true condition. Widal's reac- 
 tion is not of great value in the recognition of this disease, 
 for genersdly a positive agglutination reaction is not pres- 
 ent before the second or third week of the disease, and 
 sometimes it appears still later. 
 
 The diagnosis of chronic dysentery is usually somewhat 
 more difficult. Repeated examinations of the faeces will,, 
 as a rule, reveal the presence of amoebae at one time ot 
 another and thus aid in discovering the disease. Many 
 diseases of the rectum, as for instance j)roctitis, rectal 
 polypus, and cancer, often present symptoms similar to> 
 those of chronic dysentery. A careful local examination^ 
 however, will clear up the diagnosis without difficulty. 
 
 Prognosis. — Dysentery must always be considered a 
 quite serious disease. Even the mild form is at times 
 liable to assume a dangerous character. On the whole 
 dysentery must be regarded as a treacherous and insidi- 
 ous malady. In general it must be said that cases of 
 sporadic dysentery or of the epidemic form appearing in 
 the cold and temperate zones take a much milder course 
 and thus present a more favorable prognosis than does 
 the endemic dysentery of hot climates. These remarks 
 apply to both acute and chronic dysentery. 
 
 Treatment of Acute Dysentery.— The patient must be kept 
 abed and put on a diet consisting of liquid food (milk and 
 strained barley water, bouillon, bouillon with egg, egg 
 water, tea). Ipecacuanha has been found of great benefit 
 
130 DISEASES OF THE INTESTINES. 
 
 in tliis disease. It may be given, according to Sodre, in 
 t]ie following combination : 
 
 Powdered ipecacuanha 0.1 (gr. ij.) 
 
 Powdered opi um 0. 02 (gr. ^-) 
 
 Calomel 0.05 (gr. f ) 
 
 In capsules, one to be taken every two hours. 
 
 In case the evacuations contain very small quantities of 
 fecal matter, it is best to give a cathartic, as a large dose 
 of castor oil (one to two tablespoonfuls) or sodium or mag- 
 nesium sulphate one teaspoonful twice during the day. 
 The purgative, however, should be administered only on 
 the first or second day of the disease, and not be kept up 
 for a long time. In order to allay the pains, hot poultices 
 are applied over the abdomen and opium is administered. 
 Thus, Dover's powder may be given in three-grain doses 
 every two or three hours. This medicament may also be 
 combined with salol, subnitrate of bismuth, tannigen, 
 tannalbin, etc. The tenesmus, if severe, must be subdued 
 by suppositories containing opium and belladonna, and by 
 washing out the bowel with a quart of water containing a tea- 
 spoonful of essence of peppermint, which can be done once 
 or twice in twenty-four hours. Astringent solutions have 
 been recommended as injections for the large bowel. They 
 are not, however, of great benefit in acute dysentery. 
 
 Serum Therapy. — The serum is obtained, according to 
 Shiga, as follows : An agar culture of the bacillus dysen- 
 terise which has been maintained at the incubator tem- 
 perature for twenty-four hours is emulsified in normal 
 saline solution and heated at 60° C. for one-half an hour. 
 This mixture is then inoculated subcutaneously into horses 
 in the usual manner, beginning with small doses, which 
 are gradually increased in amount. The immunization 
 can be more easily produced if immune serum is added to 
 
DYSENTERY. 131 
 
 tlie emulsion of the dysenteric bacilli, because abscesses 
 which reduce the vitality of the animal are often produced 
 at the site of inoculation when bacilli alone are employed. 
 
 For the practical application of the serum, Shiga gives 
 the following rules : 
 
 1. In mild cases the serum is inoculated once in a dose 
 of from (i to 10 c.c. 
 
 3. In cases of medium severity the serum is twice inoc- 
 ulated in doses of 10 c.c. The interval is from six to ten 
 hours. 
 
 3. In severe cases the greatest quantities of serum are 
 inoculated (about 60 c.c). The daily dose does not, how- 
 ever, exceed 30 c.c. 
 
 By serum treatment the disease in its first stages is 
 quickly cured or markedly ameliorated. In advanced 
 stages the effects produced are about as follows : The 
 number of stools is markedly diminished, the tormina and 
 tenesmus decrease, the blood in the stools diminishes or 
 entirely disappears, the abdominal pains lessen, the fever 
 ceases, the appetite increases, and the general condition is 
 much improved. 
 
 Besides the points just mentioned, the condition of the 
 patient must be carefully watched and every complication 
 treated by itself. The high fever may necessitate the use 
 of an antipyretic ; the weak action of the heart analeptic 
 drugs, etc. As soon as the severe symptoms are allayed 
 and the patient is on the wa}" to recovery the diet can be 
 cautiously increased. 
 
 Treatment of Chronic Dysentery. — If the patient is living 
 in an endemic centre of dysentery, it is best to send him to 
 another climate. The hygienic surroundings of the patient 
 should be carefully selected. The food should be well pre- 
 pared. The patient should eat often, not too much at a 
 
132 DISEASES OF THE INTESTINES. 
 
 time, and sliould avoid all coarse and highly seasoned sub- 
 stances. Tannigen gr. viii. three times daily or benzo- 
 naphthol in the same dose, or subnitrate of bismuth gr. 
 XXX. t.i.d., can be advantageously given. Sometimes these 
 drugs are combined with codeine or opium. Here local 
 remedies play a prominent part. Loesch was the first to 
 recommend injections into the bowel of solution of quinine 
 (1 : 5,000) ; tannic acid, nitrate of silver, permanganate of 
 potassium have also been employed in clysters with good 
 results. Harris very recently recommended the use of hy- 
 drogen dioxide. The ordinary commercial hydrogen diox- 
 ide is diluted from four to eight times with water and the 
 solution injected. About a quart is injected twice daily for 
 about a week and then gradually decreased. Harris has 
 seen very good results from this mode of treatment. In 
 cases in which there is an exacerbation of the disorder, the 
 same mode of treatment may be required as in acute dys- 
 entery. 
 
CHAPTER V. 
 
 ULCEKS OF THE INTESTINES. 
 
 / 1. DUODENAL ULCER. 
 
 Synonyms. — Hound duodenal ulcer; Ulcus duodeni pep- 
 ticum (Leube). 
 
 Definition. — A defect in the mucous membrane of the 
 duodenum. 
 
 Etiology. — The etiology of duodenal ulcer corresponds 
 with that of gastric ulcer. It is undoubtedly caused, as in 
 the stomach, by the action of the acid gastric juice upon 
 the duodenal mucosa, the vitality and nutrition of which 
 have been previously impaired. Such conditions occur as 
 a result of circulatory derangements of various kinds. 
 Thus, affections of the lungs and heart or of the liver, an 
 atheromatous state of the duodenal artery may be the 
 positive factors in disturbing the circulation of the mucous 
 membrane. Burns of the skin are an etiological factor 
 which, while not operative in gastric ulcer, is of great im- 
 portance in duodenal ulcer. After extensive scaldings of 
 the skin, quite often one or several duodenal ulcers ap- 
 pear. According to Mayer ' these ulcers develop from seven 
 to fourteen days after the burn, yerj seldom much sooner. 
 The primary cause of these ulcers is not yet known. The 
 toxic theory which is the most plausible has been discussed 
 above. 
 
 Duodenal ulcer is much less frequent than gastric ulcer. 
 ' Mayer ; Annal. de la Soc. de Med. d' An vers, 1865. 
 
134 DISEASES OF THE INTESTINES. 
 
 Willigk ' found it twice in sixteen hundred autopsies. Ac- 
 cording to this writer, there are thirty-eight gastric ulcers 
 to one duodenal ulcer. According to Starke," however, 
 the ratio is twelve to one. Kraus " found that the fre- 
 quency of duodenal ulcers varies in different countries in 
 a similar manner as does gastric ulcer, the northwestern 
 part of Europe having the highest percentage, while it is 
 but rarely met with in the eastern part. In Kraus' expe- 
 rience duodenal ulcer most frequently occurs in persons 
 between thirty and sixty years of age. Next in frequency 
 comes the very early age (one to ten, and especially in- 
 fancy). This is another point of difference between gas- 
 tric and duodenal ulcers, for the former hardly ever occur 
 in children. With regard to the distribution of duodenal 
 ulcer among the sexes, Kraus found it much more preva- 
 lent among the male than among the female sex, the rela- 
 tion being ten to one. According to Lebert,' however, 
 the proportion is onlj' four to one. This again is another 
 X)oint of difference in the etiology of duodenal and gastric 
 ulcers, for the latter, as is well known, are much more fre- 
 quently encountered in women than in men (two to one). 
 
 Morbid Anatomy. — A duodenal ulcer resembles in most 
 particulars a gastric ulcer. It is a defect of the mucous 
 membrane having an oblong and oval contour and extend- 
 ing into the depth of the mucosa in form of a terrace or 
 funnel. The ulcer presents an irregular shape only in 
 those instances in which several ulcers have coalesced, thus 
 forming one large defect. The size of the ulcer varies 
 from that of a lentil up to that of a dollar. The margins 
 
 ' Willigk : Prager Vierteljahresschr., 1833. 
 
 2 Starke : Deutsche Klinik, 1870. 
 
 3 J. Kraus: "Das perforirende Geschwur des Duodenum," Berlin, 
 1865. 
 
 * Lebert : "Die Kranklieiten des Magens," 1878. 
 
DUODENAL ULCER. 135 
 
 are usually smooth and overlapping, tlie latter being espe- 
 cially tlie case in chronic affections. The base of the ulcer 
 is formed either bj^ thin layers of the remaining intestinal 
 wall, or, if perforation has taken place, by adhesions with 
 neighboring organs. 
 
 Situation of the Ulcer. — Ordinarily the ulcer is found in 
 the ascending or the upper horizontal part of the duodenum, 
 much more rarely in the descending part, and only excep- 
 tionally ih the lower horizontal section. As a rule it is 
 situated immediately behind the j)yloric fold, rarelj^ at 
 some distant point. If the ulcer is situated in the descend- 
 ing part of the duodenum, especially in the immediate 
 neighborhood of the diverticulum Yateri, it may cause 
 through cicatricial strictures important complications in- 
 volving the pancreatic and biliary outlets. 
 
 As a rule there is one duodenal ulcer, exceptionally there 
 are two or four. In the latter instance the ulcers may be 
 found in different stages of development : in the initial stage, 
 in that of commencing cicatrization, or fully cicatrized. The 
 cicatricial process may lead to manifold complications. A 
 stenosis of the duodenum just behind the pylorus or at 
 some distance may result, and create exactly the same dis- 
 turbances of the stomach as are found in cicatricial stenosis 
 of the pylorus itself. I had the opportunity of observing 
 two cases of this kind. In both the diagnosis of a benign 
 stricture of the pylorus had been made and the patients 
 subjected to operation. At the laparotomy the stricture 
 was found in the duodenum, in one case immediately behind 
 the pylorus and in the other at some distance therefrom. 
 
 Sometimes the ulcer progresses quickly and leads to per- 
 foration into the peritoneal cavity. Death from shock or 
 from diffuse peritonitis then occurs. If there is a slow 
 extension of the ulcer, it often gives rise to circumscribed 
 
136 DISEASES OF THE INTESTINES. 
 
 peritonitis, usually with adhesions to neighboring organs. 
 If the ulcer perforates after adhesions have been formed, 
 it usually leads to an encapsuled purulent peritonitis. The 
 ulcerative process may occasionally extend to contiguous 
 parts with the formation of ulcers in the liver, gall bladder, 
 or other neighboring organs. The development of a cancer 
 at the base of a duodenal ulcer has also been observed by 
 Eichhorst ^ and Ewald." 
 
 Symptomatology. — Occasionally there may be no symp- 
 toms whatever during life and the duodenal ulcer may not 
 be discovered until at the autopsy. Sometimes there are 
 no symptoms at first, then suddenly the disease manifests 
 itself by a severe and dangerous hemorrhage or by a fatal 
 perforation. In the majority of cases, however, there are 
 pronounced manifestations during the existence of a duo- 
 denal ulcer. Most frequently pains are present, usually 
 to the right of the linea alba, extending up to the right 
 parasternal line in the region below the liver. These pains 
 usually apiDear from half an hour to two or three hours 
 after meals ; as a rule they do not radiate to the back but 
 rather somewhat downward in the abdominal cavity . While 
 the pyloric region is often found slightly painful on press- 
 ure, there is no circumscribed area in the epigastrium 
 intensely painful on deep palpation as in ulcer of the 
 stomach. In rare instances the pains are felt by the patient 
 in the epigastric region, which may also show tenderness 
 on pressure. Dyspeptic symptoms, as for instance loss of 
 appetite, nausea, fulness in the epigastric region, are as a 
 "rule absent. Vomiting is likewise a rare occurrence in 
 simple duodenal ulcer, which has not gone on to a partial 
 stenosis of the intestinal lumen. 
 
 1 Eichhorst : Zeitschr. f . klin. Medicin, Bd. 14, p. 532. 
 « C. A. Ewald : Berl. klin. Wochenschr. , 1886. 
 
DUODENAL ULCER. 137 
 
 Hemorrhages as tlie consequence of an erosion of a more 
 or less large blood-vessel, through the progressing necrotic 
 process, occur in about thirty per cent of duodenal ulcers. 
 The blood is frequently voided with the stools (melsena) 
 which appear dark red or tarry. Occasionally, however, 
 there may be vomiting of blood (hsematemesis), in connec- 
 tion with the melsBua or without it. If the hemorrhage is 
 very great the patient maj-^ bleed to death. This, however, 
 is rare ; da a rule the patients recuperate from the loss of 
 blood in about the same time as they do from a gastric 
 hemorrhage. 
 
 Constipation is often present. The general condition of 
 the patient is usually good and there may be no loss in 
 flesh. 
 
 Perforation is quite a frequeDt event in duodenal ulcer. 
 The symptoms will differ according to whether perforation 
 has taken place before or after adhesions have been formed. 
 In the former instance perforation leads to a general peri- 
 tonitis, ending fatally in eighteen to thirty hours. Rarely 
 the course is more protracted when the inflammatory proc- 
 ess of the peritoneum has not assumed large dimensions 
 and has become quickly localized through the formation of 
 adhesions in the neighborhood. The perforation mani- 
 fests itself by a sudden appearance of intense pains in the 
 abdominal cavity, by the usual signs of a general collapse 
 (cold extremities, very quick pulse), and by a swelling of 
 the abdomen. The patient presents an expression of ex- 
 treme anguish and maintains a rigid attitude often with 
 the legs flexed, being afraid even to stir. The abdomen is 
 painful to the slightest touch. Nausea and constant sin- 
 gultus soon appear. Sometimes the patient is greatly 
 tormented with vomiting. A few hours later, in addition 
 to these symptoms, the area of liver dulness may be found 
 
138 DISEASES OF THE INTESTINES. 
 
 absent in consequence of the escaped gas which has accumu- 
 lated above its surface and has pressed it down. Dyspnoea 
 and coma ultimately set in and the patient succumbs. 
 
 If perforation has taken place after adhesions have been 
 formed, the same complications occur as in ulcer of the 
 stomach under similar conditions. The duodenal ulcer 
 often heals and there is a complete disappearance of all the 
 morbid symptoms. Sometimes the cicatrix leads to a stric- 
 ture of the duodenal lumen and then gives rise to ischo- 
 chymia. 
 
 Course. — The duodenal ulcer has, as a rule, a very pro- 
 tracted course. In some instances a perfect cure may be 
 established without any ill consequences. In the majority, 
 however, complications are common. Hemorrhages, ob- 
 struction of the duodenal lumen in consequence of the 
 stenosis and perforation are often observed. 
 
 Diagnosis. — The diagnosis of a duodenal ulcer can be 
 made with certainty' only in a very few instances. Most 
 often only a probable diagnosis will be possible. A duo- 
 denal ulcer can be diagnosed with certainty if the symp- 
 toms of ulceration follow within a short period after exten- 
 sive scalding of the skin has taken place. The sudden 
 development of icterus in a case presenting symptoms of 
 gastric ulcer speaks with a certain amount of probability 
 for a duodenal ulcer if gall stones can be excluded. The 
 points which indicate a probable location of the ulcer 
 within the duodenum are the following: 1. The pains 
 usually appear from half an hour to thfee hours after the 
 ingestion of food and are situated most often to the right 
 of the linea alba in the pyloric region. They never radiate 
 to the back. ■ 2. Repeated attacks of melaena, either not as- 
 sociated with hsematemesis or in which the latter was only 
 slight compared with the melaena. 3. Most of the patients 
 
DUODENAL ULCER. 139 
 
 are men presenting a liealthy appearance. 4. Perforation 
 is a frequent occurrence in duodenal ulcer, while it is very 
 rare in the course of gastric ulcer. If all these points are 
 found associated, then a probable diagnosis of duodenal 
 ulcer may be made, otherwise it is uncertain. 
 
 With regard to the differential diagnosis between ulcer 
 of the stomach and that of the duodenum, Leube ' stated 
 that in the latter the gastric contents show a normal degree 
 of acidity, while in gastric ulcer, as a rule, hyperchlorhy- 
 dria prevails. This point, however, is not of much value, 
 for on the one hand cases of gastric ulcer are found with 
 a lessened degree of secretion, and on the other hand 
 duodenal ulcer may be attended with hyperchlorhydria. 
 In the two cases of duodenal ulcers mentioned above whick 
 had been operated upon, the condition of the gastric juice in 
 one was normal, while the other showed intense hyperchlor- 
 hydria. The differential diagnosis between ulcer and can- 
 cer of the duodenum is the same as that between ulcer and 
 cancer of the stomach or pylorus. 
 
 Prognosis. — The prognosis of duodenal ulcer is almost 
 always quite serious, as complete recovery is very rare. 
 Relapses after apparent perfect recovery often occur. The 
 sequelae to which the cicatrizing process may give rise, 
 namely, obstruction of the duodenal lumen, must also be 
 taken into consideration, and the possibility of death from 
 perforation should never be forgotten. Another danger 
 lies in the formation of a cancerous growth on the base of 
 the ulcer. 
 
 Treatment. — On the whole the treatment must be con- 
 ducted on the same line as that of ulcer of the stomach. 
 
 'Leube: von Ziemssen's "Handbuch der speciellen Pathologic und 
 Therapie, " Bd. vii., Abth. 2. "Die Krankheiten des Magens und 
 Darms, " Leipzig, 1876. 
 
140 DISEASES OF THE INTESTINES. 
 
 In some cases the advisability of operative intervention 
 must be considered. Cases in which a duodenal ulcer can 
 be diagnosed with great probability and in which hemor- 
 rhages have recurred several times may perhaps be sub- 
 jected to a gastro-enterostomy during the period of com- 
 parative euphoria. For by this i^rocedure the duodenum 
 is relieved of a great deal of irritation caused by the pas- 
 sage of the chyme, and the ulcer is thus given a better 
 chance to heal. In two instances of duodenal ulcer with 
 periodically appearing large, almost fatal, hemorrhages, I 
 had a prophylactic gastro-enterostomy performed in the 
 interval, with perfect success. Cases in which the cicatrix 
 has led to a partial stenosis of the duodenal lumen should 
 certainly be operated upon, pyloroplasty or gastro-enter- 
 ostomy being selected. 
 
 2, EMBOLIC AND THROMBOTIC ULCERS. 
 
 This group of ulcers resembles the duodenal ulcer in that 
 disturbances of the circulation are the exciting causes. 
 These ulcers are of very rare occurrence. Embolic ulcers 
 were first described by Parenski.' They originate in con- 
 sequence of emboli which are carried into the fine branches 
 of the intestinal arteries, either from some abscess cavity 
 or from a focus of atheroma or endarteritis. 
 
 The pathological changes of the intestine after such an 
 occurrence are slight if a very small vessel, a capillary or 
 an arteriole, has been occluded. In case the embolus is of 
 an infectious nature, infiltration and formation of pus soon 
 develop, and the process may quickly penetrate down to 
 the serosa and infect the peritoneal cavity. It may also 
 rapidly reach the iiitestinal lumen and thus produce an 
 ■ulcer. In the infectious cases the fatal issue often ensues 
 ' Parenski : Wiener med. Jahrbiicher, 1876, Heft 3. 
 
EMBOLIC AND THROMBOTIC ULCERS. 141 
 
 so quickly that there is hardly time for a complete forma- 
 tion of the ulcer. In such instances only the initial stages 
 of the ulcerative process can be discovered. Fine nodulea 
 will be noticed in the intestinal wall originating from the 
 submucosa and consisting of accumulations of round cells 
 in the centre of which are very small blood-vessels. 
 
 The symptoms of these embolic ulcers are the same as. 
 those caused by other ulcerative processes of the intestines, 
 namely, severe pain which may be of a colicky nature, 
 tenderness on pressure over the abdomen, and diarrhoea 
 with more or less bloody admixture. If these symptoms 
 are present and embolic processes can be discovered in 
 other organs, then the diagnosis of embolic ulcer of the 
 intestine is probable. 
 
 The clinical symptoms and the anatomical changes re- 
 sulting from the obstruction of a very small blood-vessel of 
 the intestines are comparatively slight, compared to those 
 which rapidly appear if the embolus has entered the 
 arteria mesaraica superior. This affection is extremely 
 rare; only nineteen cases have been described in literature. 
 The emboli which have been found in the arteria mesaraica 
 superior itself or in its branches could be traced to the 
 left heart or to the aorta, which was the seat of excres- 
 cences due to endocarditis or atheroma. There is either 
 a total obstruction of the entire mesaraic artery or several 
 larger and numerous .smaller branches of this vessel are 
 occluded. The changes which frequently result after the 
 embolus has excluded the organ from circulation are hem- 
 orrhagic infarcts and necrosis with partial peritonitis. 
 According to Litten,' after an occlusion of the arteria 
 mesaraica superior or its branches, the intestine is deprived 
 
 ' Litten : " Ueber die Folgen des Verschlusses der Arteria mesaraica 
 superior." Yirchow's Arch., Bd. 63. 
 
142 DISEASES OF THE INTESTINES. 
 
 of all arterial blood, there being no vicarious blood current 
 from any anastomoses of these vessels. The arteria mesa- 
 raica superior, although it forms anatomical anastomoses, 
 acts functionally like a terminal artery. The reason of this 
 is that the anastomosing vessels are of a very small calibre 
 and pursue a very long course, and hence the mesenteric 
 arteries are not able sufficiently to supply with blood the 
 region deprived of its circulation. 
 
 The pathological changes which appear after the occlusion 
 of this artery consist of venous hypersemia, hemorrhagic 
 extravasations, oedema, and necrosis. In that part of the 
 mesentery and intestine which was supplied by this oc- 
 cluded vessel, the smaller arteries branching off from the 
 latter are contracted and empty, while the veins of the 
 serosa and mesenterj^ are overfilled with blood. The 
 mucous membrane appears dark red ; the entire intestinal 
 wall is oedematous and swollen; small hemorrhages exist 
 all over the mucous membrane and in the mesentery ; and 
 the intestinal canal contains extravasated blood either fresh 
 or tarry looking. If the process has lasted for some time, 
 necrotic changes soon appear and the mucosa presents a 
 dirty brownish-green appearance and may be wiped off 
 from the other layers like a slimy coating. The serous 
 layer may be the seat of inflammation not only over the 
 involved intestinal segment, but also over other still healthy 
 intestinal coils, the latter being agglutinated and covered 
 with a deposit of fibrin. In the peritoneal cavity there 
 may be a bloody fluid or a purulent exudation. 
 
 The clinical symptoms of an embolus of the superior 
 mesenteric artery have been best described by Gerhardt * 
 
 'Gerhardt: "Embolie der Arterise mesentericae. " Wurzburger med. 
 Zeitschr., 1863, Bd. iv. 
 
EMBOLIC AND THROMBOTIC ULCERS. ll''> 
 
 aud Kussmaul.' Tliey are not always alike, and two 
 groups of cases may easily be discerned. In the one, being 
 the larger, an intestinal hemorrhage is the feature most 
 marked, in the other the affection presents the picture of 
 intestinal occlusion with or without any signs of perito- 
 nitis. As a rule the disease sets in suddenly with violent 
 colicky pains involving the entire abdomen or some por- 
 tion of it, usually in the neighborhood of the navel. 
 Soon the pains grow diffused aud there is an extreme ten- 
 derness on pressure over the abdomen. Sometimes the 
 pain is accompanied by vomiting ; in rare instances, how- 
 ever, the pain may be entirelj^ absent. Such a case has 
 been mentioned by Nothnagel. Intestinal hemorrhage, 
 which is the chief symptom, soon occurs. As a rule sev- 
 eral bloody stools appear in succession, which have a dark, 
 almost black, brown or tarry appearance and occasionally 
 a very fetid odor. The blood of the hemorrhage, how- 
 ever, is not always necessarily voided per rectum, for it 
 may remain in the intestinal canal. The symptoms, how- 
 ever, which characterize a profuse intestinal hemorrhage 
 (falling of the body temperature and collapse) will never 
 be missing. In the second grouj) of cases there are merely 
 signs of an acute intestinal occlusion ; pains, constipation, 
 and peritonitis being the only symptoms. 
 
 The diagnosis of this affection can be made, according to 
 Kussmaul and Gerhardt, in cases in which the source of 
 the embolus can be determined. An intestinal hemorrhage 
 occurs (for which no primary lesion exists), colicky pains 
 of great violence and later a tympanitic swelling of the 
 abdomen and exudations make their appearance. The 
 diagnosis can be possibly made only if all the just men- 
 
 ' Kussmaul: " Zur Embolie der Arteriae meseutericte." Wiirzburgcr 
 mcd. Zeitschr., 1864, Bd. v. 
 
144 DISEASES OF THE INTESTINES. 
 
 tioned points exist. Otherwise, especially if the intestinal 
 liemorrhage is missing, the diagnosis ' cannot be made 
 during life. 
 
 The prognosis of this affection is very grave. As a rule 
 it ends fatally. It appears, however, according to Vir- 
 chow, that in rare instances a recovery is possible after 
 long illness, a collateral circulation having slowly devel- 
 oped. 
 
 With regard to treatment, there is no special indication 
 for this affection. The symptoms will have to be treated 
 as such. 
 
 Embolus of the inferior mesaraic artery is a very rare oc- 
 currence. Two cases have been described by Hegar ' and 
 Gerhardt. The prominent symptoms are violent colicky 
 pains, tenesmus, and bloody stools. The mucous mem- 
 brane of the small intestine remains normal, while that of 
 the colon, S romanum, and rectum becomes intensely red, 
 succulent, and contains effusions of blood here and there. 
 Severe anatomical lesions of the intestines, however, are 
 absent, for the circulation is quite quickly re-established 
 through anastomosis with the superior mesenteric artery 
 and with the rectal arteries of the hypogastric vessel. 
 
 Similar to the lesions of the embolic process of the 
 superior mesaraic artery are the consequences which result 
 from a thrombus ivitliin the mesenteric veins or the portal 
 vein. A few cases of this nature have recently been ob- 
 served by Pilliet,'^ Grawitz,' and Eisenlohr.* Tlie clin- 
 
 ' Hegar: "Embolie der Lungenarterie und der Arteria mesaraica in- 
 ferior." Virchow's Arch., Bd. 93. 
 
 ^Pilliet: "Thromboses des veines mesaraiques. " ProgrSs med., 
 1890, No. 25. 
 
 •^ Grawitz : " Ein Fall von Emholie der Arteria mesaraica superior. " 
 Virchow's Arch., Bd. 110. 
 
 "•Eisenlohr: "Zur Thrombose der Mesenterialvenen. " Jahrbucher 
 der Hamburger Staatskrankenanstalten, 1890. 
 
AMYLOID ULCERS. 145 
 
 ical picture of these cases is as follows : There appear sud- 
 denly violent colicky pains in the abdomen. The latter 
 swells up and grows intensely painful on i^ressure. Often 
 vomiting is present, occasionally haematemesis. There 
 may be constipation or very frequent diarrhoeal and bloody 
 movements. Accompanying these symptoms there is al- 
 ways collapse. The course is also a very rapid one, the 
 fatal end appearing after two or three days. This affection 
 is liable to occur in advanced pulmonary tuberculosis, in 
 highly marasmic conditions like the malarial cachexia, then 
 as a consequence of pressure of the portal vein, in cirrhosis 
 and cancer of the liver. All abdominal neoplasms may 
 likewise produce a thrombotic condition of the veins by 
 pressure. The same may happen in chronic peritonitis by 
 the formation of constricting cicatricial tissue. Similar 
 processes also arise whenever the intestine experiences 
 pressure or incarceration at a circumscribed spot. The 
 venous circulation becomes obstructed by the pressure, 
 while the arterial blood supi:)ly owing to its elastic walls 
 remains undisturbed. In consequence of the lacking out- 
 flow of the blood, hyper^emia appears, then follow hem- 
 orrhagic infarcts, and lastly necrosis. 
 
 As the symptoms and treatment of the following classes 
 of intestinal ulcers are identical, we shall discuss them 
 together later on, after having first given the etiological and 
 anatomical features of each separately. 
 
 3. AMYLOID ULCERS. 
 
 Amyloid processes within the intestine were first de- 
 scribed by Virchow' in 1855. The amyloid changes start 
 
 ' R. Virchow: "Ueber den Gang der amyloiden Degeneration," 
 Virchow'3 Arch., Bd. 8. 
 10 
 
146 DISEASES OF THE INTESTINES. 
 
 in the walls of the small blood-vessels (capillaries and the 
 finest arteries, occasional!}^ also the veins) . 
 
 At first the vessels of the mucosa alone are affected, but 
 afterward the process may extend through the submucosa 
 and even through the entire intestinal wall down to the 
 serous layer. The amyloid degeneration may also involve 
 the muscularis mucosae, or even the entire muscular layer 
 of the intestinal walls. The amyloid degeneration of the 
 blood-vessels makes them friable, thereby often leading to 
 necrotic processes with the formation of small ulcers. 
 
 Amyloid changes are found more often in the small intes- 
 tine than in the large bowel. The mucous membrane of 
 the affected part has a waxy and pale appearance. The 
 villi are missing here and there. 
 
 The diagnosis can be positively made by means of the 
 characteristic color tests. A solution of iodine poured over 
 the suspected area gives a brownish-red color which be- 
 comes violet or blue after the addition of sulphuric acid ; 
 a solution of methyl violet produces a bright pink color. 
 
 We have reason to suspect amyloid processes within the 
 intestine in conditions which are known to be often asso- 
 ciated with this process, as tuberculosis, syphilis, leukae- 
 mia. Especially is this true if amyloid degeneration is 
 detected in other organs (spleen and liver) as shown by 
 their enlargement, and besides there are signs of chronic 
 .diarrhoea and insufficient intestinal absorption. There are, 
 Jiowever, no positive means of establishing the diagnosis 
 of amyloid degeneration of the intestine during life. 
 
 4. TUBERCULOUS ULCERS. 
 
 Tuberculosis of the intestines is of very frequent occur- 
 rence. While it usually appears in phthisical patients, 
 there are also cases of an undoubted primary intestinal 
 
TUBERCULOUS ULCERS. 1^" 
 
 tuberculosis. Accordiug to Frericbs,' a tuberculous affec- 
 tion of tbe ileum is found in eigbty per cent of tbe cases 
 of chronic pulmonary phthisis. Bayle in 1810 was tbe first 
 to observe the occurrence and frequency of tuberculous ul- 
 cers of the intestine. The seat of these ulcers is princi- 
 pally in the ileum, especially in its lower portion. They 
 may extend from this point downward over the colon to the 
 rectum or upward over the entire ileum, jejunum, and even 
 the duodenum. 
 
 The development of the ulcer takes place in the following 
 way: In one of the solitary follicles a miliary tubercle 
 forms by extensive accumulation of cells, the latter swell 
 up; after a time a caseous degeneration appears in the 
 centre and the swollen follicle bursts; thus a small pea- 
 sized ulcer is formed. In the same way tuberculous proc- 
 esses may develop in the agminated follicles and also lead 
 to the formation of ulcers. But whereas Peyer's patches 
 are equally affected in their entirety in typhoid fever and 
 intestinal catarrh, in tuberculosis the infiltrations are con- 
 fijied only to several follicles of the group, while others be- 
 longing to the same patch remain intact. 
 
 The ulc3r enlarges either by spreading directly at the 
 periphery or by the coalition of several defects. As a rule 
 the extension of ulcers into the deeper layers i^roceeds in 
 a line transversely to the intestinal lumen corresponding 
 to the direction of the vessels supplying the bowels. Thus 
 in the small intestine the ulcer spreads in a line parallel 
 with the valvulae conniventes, and thus may form a circu- 
 lar defect over the entire lumen of the intestine, trans- 
 versely to its longitudinal axis (the so-called tuberculous 
 
 ^ E. Frerichs : "Beitrage zur Lehre von der Tuberculose, " Marburg, 
 1882. 
 
148 DISEASES OF THE INTESTINES. 
 
 girdle ulcer). Tliere exist, however, ulcers of an oblong 
 or entirely irregular shape. With regard to the depth of 
 the ulcer it usually penetrates to the muscularis and re- 
 mains at a standstill there. Small tuberculous foci, how- 
 ever, are often met within the latter, usually connected 
 with the lacteals. Sometimes a destruction of the mus- 
 cular layers is also present and the ulcer may advance 
 down to the serosa and may even perforate into the peri- 
 toneal cavity. 
 
 The fully developed large tuberculous ulcer has an irreg- 
 ular shape, and mostly a bright red margin, being partly 
 smooth, partly overlapping, sometimes undermined. Its 
 base is pultaceous, consisting partly of decomposed tissue, 
 partly of swollen remnants of the mucosa. Tuberculous in- 
 filtrations are noticeable here and there at the base as well 
 as at the margin. The surroundings of the ulcer often 
 show catarrhal changes. The serosa over it is usually in 
 a state of chronic inflammation, being reddened, thick- 
 ened, and surrounded with fibrinous exudations. Some- 
 times there are agglutinations with other intestinal coils, 
 the omentum, or other immediately adjacent organs. The 
 frequency of these peritonitic adhesions explains why per- 
 forations of tuberculous ulcers within the intestine are 
 comparatively so rare. 
 
 Tuberculous ulcers very rarely show a tendency to heal, 
 the process as a rule progressing steadily and leading to 
 the formation of new nodules in the neighborhood of the 
 margin. In very few instances, however, cicatrization of 
 the ulcers takes place. The latter, when occurring in ul- 
 cers of girdle shape, may produce a stenosis of the intes- 
 tinal lumen. 
 
 Tuberculous ulcers are very rarely primary, that is to 
 
TUBERCULOUS ULCERS. 149 
 
 say, developing in tlie intestines without a preyious tuber- 
 culous affection existing in other organs. In most instances 
 they are secondary and are met with in patients who are 
 in a more or less advanced stage of pulmonary tuberculosis. 
 The ultimate cause of tuberculous processes in the intes- 
 tine is Koch's tubercle bacillus. The latter may be car- 
 ried into the intestinal canal with the sputum which 
 phthisical patients swallow, or it may also, in rare in- 
 stances, be ingested directly with the food. Thus, meat 
 and milk of tuberculous cows may cause primary tubercu- 
 losis .of the intestine. This condition is specially fi'equent 
 in infants on account of their being fed with milk either 
 from phthisical nurses or tuberculous cows. 
 
 5. SYPHILITIC ULCERS. 
 
 SypMlitic ulcers of the intestines are quite rare. In the 
 small intestine they are mostly met with in the new-born. 
 Here the ulcers are found either singly or in great num- 
 bers over the entire small intestine. Thej- originate in the 
 lymphatic apparatus of the mucosa and submucosa, fii'st 
 forming gummata within the intestinal walls, which after- 
 ward undergo rupture. Syphilitic ulcers of the small in- 
 testine have also been observed in adult life (Klebs, ' Birch- 
 
 Hirschfekr). 
 
 Of greater clinical importance are the acquired syphi- 
 litic ulcers which often occur principally in the lower 
 part of the colon and the rectum, including the anus (most 
 frequently the lower part of the rectum a few centimetres 
 above the anus is affected). We may have primary ulcers 
 
 ' Klebs: "Handbuch der pathologischen Anatomie," Berlin, 1868. 
 * Birch-Hirschfeld : "Lehrbuch der pathologisclien Anatomie, " Leip- 
 zig, 1887. 
 
150 DISEASES OF THE INTESTINES. 
 
 of the rectum through direct infection after a preternatural 
 coitus. These are observed princijjally in men and are 
 located in the median line of the anus. They are character- 
 ized by a hard base, sharp margins, and bacon-like appear- 
 ance. We may also have secondary ulcers due to constitu- 
 tional syphilis. Condylomata and gummata may undergo 
 degenerative changes and form ulcers, which by their cica- 
 trization very often give rise to the development of stric- 
 tures of the rectum. The latter variety is much more fre- 
 quently found in women than in men. Among two hundred 
 and nineteen patients with constricting rectal ulcers 
 Poelchen ' found one hundred and ninety women. This 
 author, however, correctly remarks that not all these ulcers 
 resulting in stricture are due to syphilis. In a great many 
 instances their origin is attributable to a gonorrhoeal affec- 
 tion of the Bartholinian glands which ultimately through 
 infection leads to destructive processes within the rectum. 
 Some of these ulcers may also result from traumatic causes, 
 such as the frequent use of clj^sters or hard fecal matter 
 irritating the mucous membrane. 
 
 6. TOXIC ULCERS. 
 
 Under the term toxic ulcers of the intestine are under- 
 stood defects which develop in consequence of abnormal 
 (toxic) products contained in the blood. Thus intestinal 
 ulcers occur in severe forms of nephritis, especially when 
 they are complicated with ursemic symptoms. In leukaemia 
 and scurvy such ulcers are also met with. Intestinal ulcers 
 arising in cases of poisoning with mercury likewise belong 
 to this group. The ulcerative process in all these cases is 
 
 • Poelchen : " Zur Aetiologie der stricturirenden Mastdannge- 
 schwiire. " Virchow's Arch., Bd. 127. 
 
TOXIC ULCERS. 
 
 151 
 
 best explained as due to necrosis in consequence of the 
 altered condition of tlie blood. 
 
 Symptomatologij.—The symptoms which accompany ul- 
 cers of the intestines vary greatly. In the following we 
 shall enumerate all the symptoms which may be met with 
 in these conditions. 
 
 1. Diarrhoea. Frequent loose movements are often pres- 
 ent, especially if the ulcer is situated in the lower part 
 of the large bowel. Ulcerations of the small intestine, 
 csecum, and the upper end of the large bowel do not cause 
 diarrhoea, unless there is some other complicating affection 
 (a catarrhal condition of the bowels or an amyloid state). 
 But even if the ulcer is situated in the lower part of the 
 colon, diarrhoea may be absent in rare instances. 
 
 2. The occurrence of blood or 2^us in the dejecta. Blood 
 may be voided with the stools in consequence of a small 
 hemorrhage of the ulcerated intestine. If there is no gas- 
 tric ulcer, and other symptoms point toward intestinal ulcer,, 
 the presence of blood will help to make the diagnosis more 
 probable. But it is by no means a positive sign, for, oil 
 the one hand, an intestinal ulcer may exist without any 
 hemorrhages, and, on the other hand, intestinal hemor- 
 rhages may occur from other causes than ulcer. The 
 presence of pus in the stools seems to have much greater 
 importance. According to Nothnagel, real pus (numerous 
 round cells) in the faeces is one of the most valuable signs 
 of ulceration of the intestines. It is to be understood that 
 pus may also be present in ulcerative processes accom- 
 panying neoplasms of the intestines and in abscesses which 
 open into the intestine. The latter two conditions will 
 have to be excluded before we can infer the existence of an 
 intestinal ulcer from this symptom. The amount of pus 
 
152 DISEASES OF THE INTESTINES. 
 
 in true ulcerations of the intestines is, as a rule, very 
 small, and it is necessary to examine the dejecta quite 
 thoroughly in order to find it. While the presence of pus 
 is so important a symptom in intestinal ulcer, its absence 
 by no means speaks against it. For there may be no for- 
 mation of pus at the site of the ulcerative spot, or the pus 
 may be changed to such a degree that it is no longer recog- 
 nizable, especially if the ulcer is situated high up in the 
 intestine. 
 
 3. The existence of tubercle bacilli in the dejecta is of 
 great importance in cases in which pulmonary tubercu- 
 losis can be excluded, since they then show primary intes- 
 tinal tuberculosis. The absence of the tubercle bacilli 
 does not speak against the presence of ulcerative areas in 
 the intestines, nor does their presence positively indicate a 
 tuberculous affection of the intestine when pulmonary tuber- 
 culosis exists, for these microbes are then usually derived 
 from the sputa which have been swallowed and carried 
 down with the passages. 
 
 4. Pains. If pains exist in the abdomen in a more or 
 less circumscribed spot for a long period of time, and 
 if these pains are increased on pressure, they are prob- 
 ably due to an ulcer in the intestines. The absence 
 of this symptom, however, speaks in no way against an 
 ulcer, nor is its presence an absolute positive symptom for 
 ulcer. 
 
 The general state of the system need not be disturbed, 
 if the ulcers are only few in number and very small. If 
 their number, however, is great and their size extensive, 
 so that a large part of the intestinal tract is involved in the 
 ulcerative process, then nutritive disturbances will manifest 
 themselves and marked emaciation take place. 
 
INTESTINAL ULCERS. 153 
 
 Diagnosis. — As may be seen from the description of the 
 symptoms, the diagnosis of ulcer of the intestines is, as a 
 rule, quite difficult. Their existence may be suspected 
 whenever there is diarj^hoea of a severe nature and more or 
 less intense pain over a certain fixed region of the abdomen 
 extending over a great period of time. A positive diag- 
 nosis can be made only in the following instances : 
 
 1. If necrotic pieces of the intestinal mucosa or pus 
 appear in the stools (in the latter instance the perforation 
 of an abscess into the intestine has to be excluded) . 
 
 2. The more or less frequent appearance of small amounts 
 of blood quite changed in the stool, if ulcer of the stomach 
 or vicarious bleeding can be excluded. 
 
 3. Diarrhoea and the constant appearance of tubercle 
 bacilli in the stools, when pulmonary tuberculosis can be 
 excluded. This points to the presence of tuberculous proc- 
 esses (ulcers) in the intestine. 
 
 4. If the ulcers are situated in the lower part of the colon 
 or rectum and are accessible to a direct visual examination. 
 
 ±he nature of the ulcers (whether catarrhal, tuberculous, 
 syphilitic, or toxic) must be elucidated by a thorough 
 knowledge of the history of the case and the results of an 
 accurate examination of the patient. 
 
 Prognosis. — The prognosis of intestinal ulcers will de- 
 pend largely upon their number, size, and nature. A few 
 small catarrhal ulcers will heal quickly without any further 
 trouble. Amyloid ulcers hardly ever show a tendency to 
 heal. Tuberculous ulcerations occasionally are amenable 
 to treatment, still more so are the syphilitic ulcers. Very 
 extensive ulcerations, no matter of what nature, are very 
 dangerous to life. 
 
 Treatment. — In the treatment of intestinal ulcers the 
 
154 DISEASES OF THE INTESTINES. 
 
 etiological factors play tlie greatest part. Thus, in tu- 
 berculous ulcers general hygienic rules will have to be 
 observed. An out-of-door mode of living, and, if pos- 
 sible, in the mountains, should be recommended. Guai- 
 acol carbonate, creosote, ichthalbin are of value. In 
 syphilitic ulcers general anti-syphilitic treatment should 
 be instituted: inunctions with mercury, or injections of 
 sublimate or calomel, or the administration of large doses 
 of potassium iodide. In toxic ulcers (as those due to 
 uraemia and mercurial poisoning) the treatment must be 
 directed against the primary trouble. Besides the etio- 
 logical therapy, intestinal ulcers require specific and 
 symptomatic treatment. The treatment directed to the 
 healing of the ulcers is very successful if the latter are situ- 
 ated in the rectum or in the lower part of the colon, while 
 this object can hardly be attained if they exist high up in the 
 colon or in the small intestine. In the former instance the 
 ulcers, if accessible to view, may be directly treated by the- 
 application of a strong solution of nitrate of silver or pro- 
 targol. If not visible but situated in the colon, injections of 
 a 0.2 to 1 per cent, solution of nitrate of silver or of tannic 
 acid of the same strength into the bowels are of value. If 
 the ulcers are situated in the small intestine, large doses 
 of subnitrate of bismuth (1 to 2 gm. [gr. xv. to xxx.] three 
 times a day) may be tried. The symptoms which accom- 
 pany the ulcer and vary from time to time will have to be 
 treated as such. Diarrhoea, hemorrhage, and pain must 
 be combated with the customary remedies. 
 
 Most patients should be kept abed for some time. The 
 application of a hot-water bag or a wet pack over the 
 abdomen is very beneficial. 
 
 The diet should contain nourishing but easily digestible 
 
INTESTINAL ULCERS. 155' 
 
 and non-irritating food. Thus milk, kumyss, matzoon, 
 eggs beaten up in milk, soft-boiled eggs, farina, oat meal 
 cooked in milk, mutton broth, chicken souj^, scraped beef, 
 calf's brain, sweetbreads, cacao, tea, and toast may be 
 given. 
 
CHAPTER VI. 
 
 NEOPLASMS OF THE INTESTINES. 
 MALIGNANT GROWTHS. 
 
 Cancer. 
 
 Definition. — An epithelial neoplasm of the intestinal 
 walls. 
 
 Etiology. — The etiology of intestinal cancer, like that of 
 cancerous disease of other organs, is still unknown. The 
 traumatic theory (repeated irritation of one particular 
 area) appears quite plausible with reference to this organ. 
 As will be seen later, this malady occurs much more fre- 
 quently in those parts of the bowels in which the passage 
 of fecal matter is more apt to be retarded, and in conse- 
 quence to cause irritation. 
 
 With regard to sex, it is generally accepted that intes- 
 tinal cancer occurs somewhat oftener in men than in women. 
 With reference to age it is chiefly met with during the 
 period from forty to sixty-five years. Cancer of the intes- 
 tines is occasionally found also in young people, this hap- 
 pening much more commonly than cancer of the otomach 
 or of other organs. Nothnagel ' has observed cancer of the 
 caecum in a twelve-year-old boy, and Schoening * reports 
 two cases of rectal cancer in girls seventeen years old. 
 
 ' H. Nothnagel : " Die Erkrankungen des Darms und des Perito- 
 neum, " Wien, 1898. 
 * Schoening: Deutsche Zeitschr. f. Chirurgie, Bd. xxii., 1885. 
 
MALIGNANT GROWTHS. 157 
 
 According to Maydl, ' the total number of intestinal cancers 
 occurring from the first to the thirtieth year amounts to 
 one-seventh of the entire number of cases. 
 
 Location. — With regard to location the frequency of the 
 affection in the different portions of the bowel varies. The 
 frequency gradually increases the lower down the growth 
 is situated, beginning with the jejunum and ending with 
 the rectum. Among one hundred and sixty autopsies on 
 cases of cancer of the different organs, Maydl found in one 
 hundred cancerous disease of the bowels. In one hundred 
 and ten autopsies of patients suffering from intestinal 
 cancer, Bryant^ found the neoplasm located six times 
 within the small intestine, seven times in the csecal and ileo- 
 caecal regions, nineteen times in the transverse colon, includ- 
 ing the hepatic and splenic flexures, seventy-eight times in 
 the sigmoid flexure and rectum. Maydl gives the follow- 
 ing locations of the tumor in one hundred autopsies : Two 
 in the duodenum, four in the ileum (none in the jejunum), 
 forty-six in the large bowel (in the vermiform process, one; 
 caecum, nine; ascending colon, six; colon seventeen; sig- 
 moid flexure, thirteen), and forty-eight in the rectum, As- 
 regards cases observed during life, Maydl gives the follow- 
 ing figures : During twelve years there were in the Wiener 
 AUgemeines Krankenhaus 246,827 patients. Among these 
 there were 6,287 patients with cancer. Among the latter 
 there were 254 cases of cancer of the bowels, and in 224 of 
 these the neoplasm was in the rectum. This certainly shows 
 the great predilection of intestinal cancer for the rectum. 
 
 Intestinal cancers are almost always primary. It is 
 exceptional for cancer of the bowels to develop by way of 
 metastasis. It is obvious, however, that cancer in this, 
 
 ' Maydl: "IJeber den Darmkrebs," Wien, 1883. 
 
 ' Joseph D. Bryant : Annals of Surgery, February, 1893. 
 
158 DISEASES OF THE INTESTINES, 
 
 xegion may develop secondarily as a result of direct exten- 
 •sion of tlie cancerous process from a contiguous organ. 
 This often occurs in cancer of the stomach, gall bladder, 
 •or pancreas. Intestinal cancer often gives rise to metasta- 
 ses in other organs. According to Miiller,* these are more 
 frequently met with in cancer of the small intestine than 
 in that of the large bowel. The lymphatic glands are also 
 often secondarily affected. Those in the neighborhood of 
 the neoplasm show a greater tendency to become cancer- 
 ous than those farther off. 
 
 Morhid Anatomy. — All varieties of cancer are found in 
 the intestines. Most frequently, however, the cylindrical 
 •epithelial-celled carcinoma, having a glandular structure 
 (adeno-carcinoma), is encountered. The latter takes its 
 origin in the epithelial cells of the follicles of Lieberkuehn. 
 Colloid carcinoma is quite often found in the rectum, while 
 melano-carcinoma is here quite rare. Occasionally the 
 pavement-celled carcinoma (epithelioma cancroid) is met 
 with, especially in the lower part of the rectum, starting 
 principally from the anus. It often involves the perineum 
 and the vagina. 
 
 The neoplasm varies in consistency according as connec- 
 tive tissue or cells predominate. If the former is the prin- 
 cipal element, then the tumor presents a hard consistency 
 (as hard as cartilage) and is termed scirrhus. In case the 
 latter are more abundant, then it is less firm, occasionally 
 soft and succulent. The colloid cancer as a rule contains 
 a brownish, somewhat viscid fluid. The scirrhus shows a 
 greater tendency toward partial necrosis in its central part. 
 It often forms a carcinomatous ulcer. 
 
 The primary intestinal cancer frequently shows a ten- 
 
 ® Max Miiller : "Beitrage zur Kenntniss der Metastasenbildung ma- 
 Jigner Tumoren. " Inaugural-Dissertation, Bern, 1892. 
 
MALIGNANT GROWTHS. lo9 
 
 dency to extend iu a circular direction perpendicularly to 
 the lumen of tlie bowel. Stenosis of the intestinal canal 
 is very often the result of this circumstance. In case the 
 stricture is of marked degree, the intestine above the stric- 
 tured spot becomes greatly distended through stagnating 
 fecal matter and gas. The bowels working hard to over- 
 come the obstacle show thickened walls clue to hypertrophy 
 of the muscles. The irritating and stagnating contents in 
 the dilated part of the intestine give rise to catarrhal in- 
 flammation and also to ulcers. If the stenosis has become 
 still more pronounced, the dilatation of the intestine above 
 it may be so excessive that a rupture of its walls ultimately 
 occurs. Below the stricture the intestinal wall appears 
 thinner, and if the stricture is so narrow that no contents 
 pass downward, it appears empty and contracted. Occa- 
 sionally the neoplasm constricting the intestinal lumen 
 begins to break down and ulcerate, and this partly removes 
 the occlusion of the intestinal canal. This, however, does 
 not last long, for as a rule the cancer shows a tendency to 
 grow again and to fill up the defect. Thus the free lumen 
 of the bowel is very soon again occluded. 
 
 This partial necrotic process will also often cause more 
 or less hemorrhage through erosion of the smaller blood- 
 vessels. In case a larger artery or vein opens, a severe 
 hemorrhage with fatal issue may result. 
 
 Cancer of the bowels often involves, besides the mucosa 
 and submucosa, the muscularis and even the serosa. In 
 the latter event perforation occurs in rare instances before 
 adhesions have had time to form, and may result in fatal 
 general peritonitis. In most instances, however, adhe- 
 sions have formed around the involved area, and thus the 
 perforation causes merely a circumscribed peritonitis. 
 Even without the occurrence of perforation the cancer may 
 
160 DISEASES OF THE INTESTINES. 
 
 progress from the serous layer to the peritoneum and lead 
 to a carcinomatous peritonitis, which is often accompanied 
 by a hemorrhagic exudation. Another series of grave 
 complications is caused by the extension of the cancerous 
 process to a neighboring organ which has previously be- 
 come agglutinated to the bowel. The process of disinte- 
 gration in the cancerous growth then often establishes an ab- 
 normal communication between the bowel and other organs. 
 Thus fistulous openings may occur between colon and 
 stomach, between rectum and bladder, between rectum and 
 vagina, between rectum and uterus, between large and 
 small bowels, or a direct fistulous opening may form from 
 the bowel through the abdominal wall. 
 
 Symptomatology. — Cancer of the bowels develops quite 
 slowly and insidiously, and in most instances at the begin- 
 ning gives rise to hardly any symptoms at all. For this 
 reason it can never be detected at this time ; later, how- 
 ever, general and local s^-mptoms manifest themselves. 
 While the general sj^mptoms are common to all cancers of 
 the small and large bowels, the local symptoms will differ 
 according to the location of the tumor, and it will therefore 
 be necessary to consider the different portions of the intes- 
 tinal tract separately. 
 
 A. General Symptoms. — The general symptoms of cancer 
 of the bowels are those found in maliguant growths of other 
 organs. Of these anaemia and cachexia are the most impor- 
 tant. Usually both are present at the same time. Some- 
 times one is more pronounced than the other. In some in- 
 stances a general weakness, pallor, and emaciation are the 
 first indications of a severe affection. There may be as yet 
 no local symptoms whatever or a very slight degree of con- 
 stipation and scarcely noticeable sensation of discomfort in 
 the abdomen. Loss of appetite and slight dyspeptic symp- 
 
MALIGNANT GROWTHS. 161 
 
 toms are often encouutered. Fever is occasionally met with, 
 which is due to a suppurative process and absorption of 
 pyogenic matter into the blood. The neoplasm often gives 
 rise to disturbances in neighboring organs by constricting 
 or dragging upon them. Thus radiating pains from com- 
 pression of nerves may arise and in the same manner dis- 
 turbances of circulation. (Edema of the lower extremities 
 is often encountered, which after lasting for weeks and 
 months ^ay occasionally disappear shortly before death. 
 
 Symptoms of chronic intestinal obstruction are often pres- 
 ent. They develop either gradually, the constipation in- 
 creasing more and more, or they may apj)ear more abruptly. 
 The bowels, while formerly more or less regular, suddenly 
 cease to move, and even strong cathartics are of no avail. 
 
 The clinical features of cancerous obstruction of the 
 bowels are not different from stenosis of the intestine caused 
 by other processes, which are described in Chapter IX. 
 Such a sudden attack of obstruction of the bowel msiy ter- 
 minate fatally in a few days ; sometimes, however, after a 
 total occlusion of the bowels, life continues much longer. 
 Thus fecal retention of forty -four days' duration, without 
 even fecal vomiting, is mentioned by Heusgen,' and an- 
 ■other case of eighty-eight days' duration has been reported 
 by Cooper-Forster.'^ Diarrhoea is frequently present in 
 cancer of the bowels. This often serves partly to overcome 
 the beginning obstruction of the intestinal lumen. In some 
 cases diarrhoea alternates with constipation. In the latter 
 instance the stools often bear signs of having passed a 
 strictured spot. They may appear in the shape of a tape 
 or in the form of small, hard balls. These characteristics 
 of the evacuation are, however, by no means a positive 
 
 ' Heusgen : Deutsche med. Wochenschr. , 1877. 
 " Cooper- Forster : Medical Times and Gazette, September, 1867. 
 11 
 
162 DISEASES OF THE mTESTlNES. 
 
 proof of a real stricture, for they are also met witli in 
 merely neurotic conditions. The stools often contain an 
 admixture of mucus, blood, or i3us. In case the progress 
 of the necrosis of the neoplasm is pronounced, the stools 
 during that period have a very offensive, almost unbear- 
 able odor. In rare instances particles of tumor may be 
 discovered in the dejecta, which show under the micro- 
 scope the exact nature of the neoplasm. If these particles 
 are of a large size (cherry or walnut) ihej will be easily 
 discovered in the stools ; but if they are minute, a thor- 
 ough examination of the fecal matter will be necessarj^ in 
 order to find them. Washing out of the bowels will often 
 be helpful to discover such minute pieces of the growth, 
 in case the latter is situated in the colon. 
 
 While all of the above symptoms are of great value, they 
 are unimportant compared with the physical signs of a 
 tumor. Its presence in a doubtful case in most instances 
 helps to clear up the diagnosis. The tumor is often easily 
 palpable and bears the general characteristics of a cancer- 
 ous growth. It is hard and presents an uneven nodular 
 surface. Its size varies greatly, being often that of a wal- 
 nut and occasionally that of an apple or still larger. In 
 the latter instance the mere inspection of the abdomen may 
 already show the presence of the tumor. In autopsies the 
 neoplasm is frequently found much smaller than it ap- 
 peared to be during life. The cause of this is the hyper- 
 trophy which occurs in the walls of the bowel above the 
 tumor, together with the accumulation of fecal matter at 
 the same place. The tumor is usually situated in the 
 lower half of the abdomen, principally in the left iliac re- 
 gion, not only because this part of the intestine is so often 
 affected, but also because a neoplasm of other parts of the 
 bowels, if not fixed by adhesions, is as a rule dragged down 
 
jMaligxa^'t growths. 163 
 
 by its own weight into this region. Intestinal neoplasms 
 as a rule show a high degree of mobility. Often they can 
 be moved with the hand in all directions in the abdominal 
 cavity. The only exceptions to this rule are tumors of the 
 duodenum, the sigmoid flexure, and the csecum, which are 
 more or less fixed. 
 
 With regard to the detection of the tumor a thorough 
 palpation of the abdomen (if the abdominal walls are very 
 rigid, under ether or chloroform narcosis) is necessary. A 
 digital examination of the rectum, and, in women, of both 
 rectum and vagina, will in most instances be required. A 
 bimanual examination will also be found useful. In case 
 the afl'ected area in the rectum is not accessible to digital 
 examination, inspection of this organ and in some instances 
 a manual examination under anaesthesia with the whole 
 hand must be resorted to. 
 
 When the disease is fully developed, peritonitis (^either 
 circumscribed or general) often appears as a complication. 
 It may be simply caused by the inflammatory processes 
 accompanying the neoplasm or be of a real cancerous na- 
 ture. While at first it is impossible to differentiate these 
 two conditions, later on it is as a rule not diflicult to deter- 
 mine which of the two is present. The discovery of a 
 hemorrhagic exudation and of a few nodules under the 
 abdominal wall will indicate that a cancerous afl'ection of 
 the peritoneum is present. An acute perforation peritoni- 
 tis is much more rare and leads to shock and sudden death, 
 or in the presence of adhesions to grave complications in 
 consequence of fecal abscesses. If the perforation occurs 
 into adherent neighboring organs, new communications 
 may be formed between them and the intestine; they ag- 
 gravate the condition and are of great clinical importance. 
 The following communications are frequently met with : 
 
164 DISEASES OF THE INTESTINES. 
 
 1. Fistula between stomach and colon. The fistulous 
 opening may freely communicate witli both cavities or only 
 in one direction on account of the formation of a valve. 
 If the passage has the direction from the stomach into the 
 colon, symptoms of lientery develop, and undigested and 
 unchanged foods, as for instance pieces of meat, potatoes, 
 spinach, and the like, appear in more or less large quanti- 
 ties in the stools ; often diarrhoea manifests itself shortly 
 after a meal and examination of the evacuation shows 
 numerous particles of food from the last meal. Lavage 
 of the stomach performed in such a case will often show 
 that the liquid has escaped from the stomach in consider- 
 able quantity and may occasionally be voided by the rec- 
 tum. The admixture of some coloring matter to the water 
 used for lavage will facilitate the recognition of this condi- 
 tion. If the communication has a direction in the opj)o- 
 site way, namely, from the colon into the stomach, there 
 will be an api3earance of fecal matter in the latter. In 
 that event the gastric contents always contain decomposed 
 and fetid material, and vomiting of fecal matter is fre- 
 quently the result. Inflating the colon with air will often 
 cause a filling up of the stomach with this gas, and again 
 irrigation of the bowel with water (either clear or stained) 
 will be followed by its appearance in the stomach, which 
 may be easily discovered hy introducing a tube into this 
 organ and evacuating the gastric contents. If the fistulous 
 opening has a free communication in both directions, then 
 symptoms of lientery and fecal vomiting may be present 
 at the same time or they may appear alternately. 
 
 2. In case of a commimication between i^ectwn and blad- 
 der, small particles of fecal matter and gas appear in the 
 latter organ and may be voided through the urethra. They 
 give rise to a putrid cystitis. Occasionally urine may pass 
 
MALIGNANT GROWTHS. ItJo 
 
 from the bladder into the rectum and be discharged with 
 the stools. The recognitiou of the latter condition is, 
 however, more difficult, 
 
 3. Communications between the rectum and uterus or 
 vagina are also met with and give rise to the passage of 
 fecal matter through these organs. 
 
 4. A fistulous opening may exist between the bowel and 
 the abdominal locdl. This fistula may discharge externally 
 a putrid secretion having a fetid odor and containing par- 
 ticles of fecal matter or chyle, depending upon its location, 
 whether in the large or small intestine. 
 
 All these fistulous communications appear as a rule in 
 the last stages of the disease. They are, however, by no 
 means characteristic of cancer of the intestine, for they 
 may also, but very rarely, develop in consequence of other 
 ulcerative processes in the bowel (tubercles). Again they 
 may be a result of a cancerous growth in the stomach in- 
 volving secondarily the intestinal tract. 
 
 The urine does not show anything characteristic of can- 
 cer. However, it often contains large amounts of indican; 
 acetone and diacetic acid have also been occasionally met 
 with. 
 
 B. Symptoms Due to the Location of the Neoplasm. — (a) 
 Cancer of the duodenum. In the duodenum the neoplasm 
 almost always causes gastric symptoms similar in nature 
 to those of cancer of the pylorus. Thus anorexia, pains, 
 vomiting, and dilatation of the stomach will be the pre- 
 dominating features. If the tumor is situated near the 
 pylorus in the superior horizontal portion of the duode- 
 num it will be quite movable, and a differential diagnosis 
 between cancer of the pylorus and that of the beginning of 
 the duodenum will hardly ever be possible during life. In 
 case the neoplasm is situated in the descending part of the 
 
166 DISEASES OF THE INTESTINES. 
 
 duodenum, in the immediate neigliborhood of Vater's 
 papilla, icterus is often encountered. In sucli cases the 
 initial symptoms may be jaundice and sometimes chills. 
 The icterus may remain stationary or vary in intensity 
 from time to time according to the degree of the obstruc- 
 tion of the duct caused by the neoplasm. Ulceration of the 
 tumor may for a while open a passage for the bile and the 
 jaundice may then temporarily disappear. If the cancer 
 is located below Vater's papilla, especially in the inferior 
 horizontal part, the gastric contents will frequently show 
 the presence of a large amount of bile. In the latter two 
 instances the tumor, if accessible to palpation, is not mov- 
 able. On account of its deep situation it can frequently 
 not be discovered. 
 
 (h) Cancer of the small intestine. According to the re- 
 gion in which the neoplasm is situated, whether at the 
 beginning of the jejunum or in the lower x^arts of the 
 ileum, gastric or intestinal symptoms will predominate. 
 There may be anorexia and vomiting, or, on the other 
 hand, good appetite and apparently good stomach diges- 
 tion, but obstinate constipation. The tumor is often acces- 
 sible to palpation, and is as a rule very movable. 
 
 (c) Cancer of the large bowel. Pains are frequently en- 
 countered at a localized spot in the region of the large 
 bowel. They may exist before a tumor can be palpated 
 and may be felt either in its immediate neighborhood or 
 in almost exactlj^ opposite portions of the colon. Thus 
 cancer of the caecum may give rise to pain in the sigmoid 
 flexure, and vice versa. These pains are rarely severe ; as 
 a rule they consist merely in a sensation of discomfort or 
 in a feeling of tension. Besides these uncomfortable sen- 
 sations of a more or less permanent nature, there may be 
 more or less frequent attacks of colic. In the latter in- 
 
MALIGNANT GROWTHS. 167 
 
 stance tliere may be violent excruciating pains in tiie ab- 
 domen, which may be relieved after passing of flatus or 
 after a diarrhcBal movement. The attacks of colic are fre- 
 quently caused by the commencing obstruction of the in- 
 testine, and therefore become gradually aggravated in na- 
 ture. They may lead at last to a total obstruction and be 
 the immediate cause of death. Constipation is one of the 
 foremost/symptoms of a neoplasm of the large bowel. It 
 is encountered in the great majority of cases; in some in- 
 stances it forms the first symi)toms of the disease; at first 
 it may be slight in nature, but becomes steadily more ob- 
 stinate. Ten or twenty days may pass without a sponta- 
 neous evacuation, and even cathartics are very slow in their 
 action. The constipation as a rule is accompanied b}^ the 
 usual symptoms resulting from it, tension and fulness in 
 the abdomen, poor appetite, occasionally pains. The con- 
 stipation may at times disappear and give place to a pe- 
 riod of diarrhoea. In some instances diarrhoeal evacu- 
 ations may exist for many weeks, and they may be the 
 predominating feature of the disease. 
 
 (d) Cancer of the rectum. The symptoms met with in 
 cancer of the rectum resemble more or less those of a neo- 
 plasm of the upper portion of the large bowel. Here, how- 
 ever, the diagnosis can be made with greater ease and cer- 
 tainty. In most instances rectal cancer can be discovered 
 by a digital examination of the rectum. By means of the 
 latter we may discover a mass lying right beneath the mu- 
 cous membrane of the rectum, over which the mucosa can 
 be slightlj^ moved or not at all if it is adherent. The sur- 
 face may feel uneven and somewhat hard. Sometimes the 
 finger encounters a constriction through which it cannot 
 easily pass ; the tissues here present the same character- 
 istics as just described. Occasionally an ulcerated area 
 
168 DISEASES OF THE INTESTINES. 
 
 can be discovered on the surface of tlie neoplasm. In can- 
 cer of the rectum situated high up (not accessible to digital 
 examination), several clinicians have advised examination 
 with the whole hand passed through the rectum. This, 
 however, can be done only under chloroform narcosis and 
 is not free from danger. Such an examination may in rare 
 instances cause rupture of the intestinal wall as stated by 
 Yolkmann.' Inspection of the recium by means of Kellj^'s 
 speculum can be easily performed and aids us in discover- 
 ing a neoplasm situated quite high up in the rectum, even 
 if not accessible to digital examination. The latter instru- 
 ment may also be used in neoplasms of the lowest part of 
 the bowel, although its use here is not of much impor- 
 tance, as the palpating finger gives us enough certainty in 
 making the diagnosis. 
 
 Cancer of the rectum is as a rule accompanied by severer 
 pains than that of the large bowel. These as a rule are 
 local in character. They often radiate toward the caecum 
 and the lower lumbar region, toward the bladder and geni- 
 tal organs, and sometimes in the direction of the sciatic 
 nerves. In case the neofjlasm involves the anus, there is 
 an exacerbation of the pain at each evacuation. Tenesmus 
 is constantly present in the latter instance. If such a neo- 
 plasm of the lower j)art8 of the rectum becomes ulcerated, 
 the tortures of the afflicted person can hardly be described. 
 The patient as a rule is afraid of having an evacuation, and 
 tries to keep it back as long as possible. At last there is 
 a movement containing fecal matter, mucus, blood, and 
 sometimes pus, under most excruciating pains. 
 
 Leube has directed attention to the fact that hemor- 
 rhoids are frequently associated with the neoplasm of the 
 
 1 Volkmunn : " Ueber den Mastdarmkrebs. " Volkmann's Sammlung 
 klin. Vortraege, No. 131. 
 
MALIGNANT GROWTHS. 169 
 
 Tectum. This is of importance, as it sliows that tlie pres- 
 ence of liemorrlioids sliould not lead one to abstain from 
 digital rectal examination. If a patient has complained of 
 constipation for a short period (a few months) and hemor- 
 rhoids have developed during this time, the latter are 
 rather indicative of a more serious condition, and a digital 
 examination of the rectum should always be undertaken 
 under such circumstances. 
 
 Course. — An uncomplicated intestinal cancer may last 
 for years. Frequently, however, the time is much shorter. 
 Many complications are liable to occur — hemorrhages, per- 
 foration peritonitis, rupture of the intestines, ileus, auto- 
 intoxication, extension of the cancer to other organs, and 
 metastases. On account of these many possibilities the 
 life of the patient may be shortened, and it is hardly pos- 
 sible to foresee its duration. In some instances a condi- 
 tion of coma (coma carcinomatosum) appears quite early. 
 It is generally assumed that the latter is due to auto-intoxi- 
 cation, either by the products of decomposition of the in- 
 testinal contents or by the toxins of the cancer. Ewald in 
 such a case succeeded in isolating a body from the urine 
 belonging to the group of diamins. In cancer of the 
 duodenum the general nutrition suffers very early and ex- 
 tensively, and for this reason the duration of life is short. 
 In cancer of the rectum nutrition is well maintained for a 
 long period, and for this reason the duration of life in the 
 absence of complications is quite long (about four years). 
 In case anaemia of a high degree supervenes, a marasmic 
 thrombosis may develop and the patient may die in conse- 
 quence of an embolus of the lungs. If intestinal cancer is 
 unattended with complications, death often results in con- 
 sequence of general exhaustion. 
 
 Diagnosis. — The diagnosis of intestinal cancer can be 
 
170 DISEASES OF THE INTESTINES. 
 
 made with certainty in the following instances : 1. If by 
 abdominal or rectal palpation a tumor can be detected 
 which is situated in the small or large bowel, and accom- 
 panied by symptoms of cachexia and disturbances of defe- 
 cation. 2. The presence of a tumor as just described, and 
 the discovery of small particles of the neoplasm in the 
 evacuation giving microscopically the appearance of a can- 
 cerous growth. 3. Gradually increasing disturbances of 
 the bowel for a few months in a heretofore healthy person,, 
 accompanied by cachexia and symptoms of a beginning or 
 already developed stricture of the bowels and the presence 
 of a small particle of growth in the stools, giving as above 
 microscopically the picture of cancer. 
 
 If there is no tumor and if nothing cancerous is found 
 in the stools, the diagnosis can never be made with cer- 
 tainty. A probable diagnosis of intestinal cancer will 
 have to be made if cachexia is present, together with 
 symptoms of gradually developing intestinal disturbances, 
 indicating the beginning of an obstruction of the bowel, in 
 a middle-aged or elderly person who has been well up to a 
 few months before. 
 
 Prognosis. — The prognosis of intestinal cancer is always, 
 unfavorable. Unless an early operation and total ex- 
 cision of the growth is resorted to, a fatal issue is sure to 
 follow, although the exact duration of life can hardly be 
 predicted, the latter depending upon subsequent complica- 
 tions. 
 
 Treatment. — A cure is possible only by a total and thor- 
 ough removal of the growth. We must therefore alwaya 
 endeavor to make the diagnosis as early as possible and 
 advise an immediate operation whenever feasible. Cancer 
 of the rectum can be recognized quite early and resection 
 of the neoplasm is here followed by brilliant results. If 
 
MALIGNANT GROWTHS. 171 
 
 the tumor is located farther up in the large bowel or in 
 the small intestine, then the results of an operation are not 
 so promising, for here the recognition of the growth is pos- 
 sible only at an advanced period, and by that time often 
 adhesions with other organs and cancerous infection of the 
 glands have already taken place. Excision of the tumor 
 and resection of the intestine in the neighborhood of the 
 neoplasm with an end-to-end anastomosis should be prac- 
 tised whenever feasible. In case, however, total resection 
 is impossible, an entero-enterostomy or entero-colostomy, 
 or if the cancer is situated in the rectum, a colostomy (ar- 
 tificial anus) will be of benefit. These operations are pal- 
 liative in nature and prolong life, at the same time making 
 it more comfortable. They are intended to allay the symp- 
 toms of obstruction and to carry the fecal matter over a 
 new route, not passing through and thus not irritating the 
 cancerous area. In some instances of inoperable cancer of 
 the rectum curettage followed by the application of the 
 thermo-cautery is of benefit for a short period. 
 
 Aside from these surgical means the treatment should 
 be symptomatic. The diet should consist of foods con- 
 taining plenty of nourishment but very little indigestible 
 residue, thus forming only a small quantity of fecal mat- 
 ter. If there is stagnation of the intestinal contents, 
 cathartics will have to be given in order to liquefy the 
 fecal matter. This can be done by means of castor oil, 
 rhubarb, magnesium sulphate, and so on. If the neoplasm 
 is located in the large bowel, irrigations witli warm oil or 
 water are preferable. The pains should be allayed by 
 means of warm baths and cataplasms, but if these fail, 
 by narcotic remedies, such as morphine, opium, codeine, 
 or belladonna; suppositories being here most suitable. 
 Eventual complications should be treated as such. 
 
172 DISEASES OP THE INTESTINES. 
 
 Sarcoma and Lymplio-Sarcoma. 
 
 Sarcoma of the intestines is a much rarer affection than 
 cancer. According to Kunclrat, ' in the Wiener AUgemeine 
 Krankenhaus between the years 1882 to 1893 there were 
 2,125 autopsies on cases of cancer. Of this number 243 
 were cancers of the intestines. In the same period of time 
 there were 274 necropsies on patients with sarcoma, of 
 which 3 were located in the intestines. Among 61 lympho- 
 sarcomata 9 were in the intestines. E. Libman° has re- 
 cently published a number of i:)ersonal cases of sarcoma of 
 the small intestine. He is of the opinion that this affection 
 is not so rare as is generally believed. On the whole the 
 symptomatology of these malignant neoplasms coincides 
 with that of cancer of the intestines. There are, however, 
 a few points in which they differ from intestinal cancer. 
 While carcinoma is most frequently found in the lower 
 portions of the large bowel, sarcoma shows a greater predi- 
 lection for the small intestine and the upper portion of the 
 large bowel. Thus, according to Nothnagel, among 9 cases 
 of sarcoma of the intestines 1 was located in the duode- 
 num, 3 in the jejunum, 3 in the ileum, and 2 in the csecum. 
 
 Sarcoma of the intestines shows very rapid progress, 
 and metastases in other organs are very early found. The 
 duration of life is much shorter than in cancer, being in 
 most cases about but nine months. There is only one in- 
 stance mentioned in literature in which a patient lived one 
 and three-quarter years after the first appearance of symp- 
 toms. Symptoms of obstruction which are so frequently 
 
 ' Kundrat: Gerhardt's " Ilandbucb der Kinderkrankheiten," Bd. iv., 
 2te Abtheilung, Tubingen, 1880. 
 
 ^E. Libman: "Ueber Dlinndarmsarkome." Gienzgebiete der Medi- 
 ^in und Cliirurgie, Bd. vii., Heft 4 and 5, 19U1. 
 
BENIGN TUMORS. 173 
 
 found in cancer of tlie intestines are very rarely if ever met 
 with in sarcoma. Tlie tumor as a rule extends over a large 
 part of the intestines, but does not occlude the canal. 
 Cachexia and anaemia belong to the early symptoms, and 
 are much more pronounced than in cancer. The progno- 
 sis of this form of tumor of the intestines is absolutely 
 fatal. Even in cases in which an operation is performed 
 quite early, it is as a rule not of much benefit on account 
 of the numerous metastases which develop so early ; and 
 on this account Madelung ' even hesitates to advise surgi- 
 cal interference. 
 
 BENIGN TUMORS OF THE INTESTINES. 
 
 Of the benignant neoplasms the following forms are 
 occasionally met with in the intestines : adenoma, fibro- 
 ma, lipoma, myoma, angioma, and cyst. These growths 
 are termed polypi if they have a pedicle. Occasionally 
 they have a large base and form only a small prominence 
 over the surface. The polypi are usually of small size, 
 that of a cherry or plum ; rarely they are larger, i3ear-sized 
 or greater still. As a rule they are covered with normal 
 mucous membrane. Although they are found almost every- 
 where in the intestinal tract, they occur most frequently in 
 the rectum (according to Rosenheim in eighty per cent). 
 
 Among the benign tumors the adenomata are most fre- 
 quently met with. They arise from the mucosa, have a 
 typical acinous structure, and are attached to the mucous 
 membrane either by a broad base or by a pedicle. In the 
 latter instance they form polypoid excrescences which may 
 cover long distances of the intestinal canal, existing in large 
 numbers. Ewald refers to a specimen in his possession in 
 which the inner wall of the colon was covered from the 
 ' Madelung : Centralbl. f. Cliirurgie, 1892, No. 30. 
 
1<4: DISEASES OF THE INTESTINES. 
 
 •splenic curvature to the sigmoid flexure witli such numer- 
 ous polypi that they projected from the mucous membrane 
 like tassels from a ribbon. The whole specimen looked 
 somewhat like a gigantic bunch of grapes. The polypi are 
 most often met with in children from the fourth to the 
 seventh year, although they also occur in grown-up per- 
 sons. 
 
 With regard to symptoms the benign tumors located in 
 the upper parts of the intestinal tract cause hardly any 
 disturbances at all. Sometimes, however, especially if 
 they are present in larger numbers, they may give rise to 
 hemorrhages and catarrhal affections. On account of their 
 small size and soft consistency it is almost impossible to 
 discover them by paljpation through the abdominal wall. 
 In very rare instances they may give rise to serious symp- 
 toms by occluding the intestinal lumen or by causing in- 
 vagination. The benign tumors located in the rectum 
 more frequently give rise to disturbances. Thus tenesmus 
 and difficult defecation are often met with; hemorrhages 
 also occur frequently. Sometimes such a polypus, if situ- 
 ated near the anus, may protrude through this opening 
 during defecation and give rise to severe pains. Occasion- 
 ally a polypus is torn off from the intestinal wall and 
 passed with the stools. In such an event the symptoms, 
 if there have been any, suddenly disappear. 
 
 Whenever these tumors are situated in the lower rec- 
 tum they are accessible to direct examination and treat- 
 ment. The latter consists in removing them by galvano 
 cautery or by direct surgical measures. 
 
CHAPTER VII. 
 
 HEMOEEHOIDS. 
 
 Synonyms: Plilebectasia liemorrhoiclalis. Piles. 
 
 Definition. — Diffuse or circumscribed varicose dilata- 
 tions of the hemorrlioidal veins situated either in the sub- 
 cutaneous tissue of the external surface of the anus or in 
 -the submucous tissue of the lower portion of the rectum. 
 
 Etiology. — The affection under consideration is quite 
 frequently met with. It occurs more often in men than in 
 women and ver j rarely in children. While in olden times 
 it was believed that hemorrhoids were due to a faulty state 
 of the general circulation or dyscrasia, it is now generally ac- 
 cepted that they are the result of merely local disturbances. 
 The development of hemorrhoidal varices takes place in 
 the same manner as that of varices of other regions of the 
 body, principally by mechanical influences. The reason 
 V7hy these phlebectases are formed so often in the hemor- 
 Thoidal plexus is as follows : 1. The hemorrhoidal veins 
 occupy a low position of the body, no matter whether in 
 the standing or in the recumbent posture. 2. They are 
 often unduly compressed by the contraction of the muscles 
 situated in the lower end of the rectum and by fecal masses 
 accumulated here. The circulation is thus at certain times 
 obstructed or altogether arrested. 3. The hemorrhoidal 
 veins are not provided with valves, and thus blood which 
 has passed through them can be easily forced back. 4. 
 The rectal veins are the remotest branches of the portal 
 
176 DISEASES OF THE INTESTINES. 
 
 vein in whicli there is normally but a low degree of pres- 
 sure, and in which circulation is easily retarded by dis- 
 turbances of the liver. As all these factors exist even 
 under normal conditions it is readily conceivable that 
 phlebectases are found in the majority of people; usually, 
 however, they do not reach a marked development, and 
 for this reason do not give rise to complaints. 
 
 All conditions which tend to produce lasting hypersemia 
 of the lower portion of the rectum give rise to the develop- 
 ment of hemorrhoids. Too prolonged sedentary or stand- 
 ing occupations predispose to them. In this way hemor- 
 rhoids occur in clerks, students, some artisans, for instance, 
 shoemakers, tailors, and cavalrymen, seamstresses and 
 washwomen, etc. High livers and people who are used 
 to strongly seasoned or fatty foods also often suffer from 
 piles on account of the great fulness of the portal circula- 
 tion under these conditions. Habitual constipation also 
 favors their development. The use of strong cathartics 
 likff aloes, colocynth, gamboge, etc., irritates the large 
 bowel in a marked degree and often gives rise to hemor- 
 rhoids. Diseases of the uterus which lead to an enlarge- 
 ment of this organ and also pregnancy are predisposing 
 causes. In a similar way affections of the prostate and 
 tumors of the bladder as well as of other organs situated 
 in the small pelvis often produce hemorrhoids. All dis- 
 eases of the liver which are accompanied by a congestive 
 state of the portal circulation exert a direct influence upon 
 their formation. Diseases of the heart and lungs fre- 
 quently cause congestion of the inferior vena cava and 
 indirectly also of the rectal veins, thus predisposing to 
 the affection under consideration. 
 
 Hemorrhoids are most frequently developed between the 
 ages of thirty and fifty years. They are extremely rare 
 
HEMORRHOIDS. 177 
 
 in infants and children. With regard to frequency the 
 male sex seems to be more often afflicted than the female. 
 Some races show a special predisposition to this disease, 
 depending most probably upon their mode of living and 
 their diet. Whether heredity plays a part in the develop- 
 ment of hemorrhoids is yet unsettled. 
 
 Moi'hid Anatomy. — In some instances the hemorrhoidal 
 veins are evenly dilated and can be noticed as bluish-red 
 and tortuous vessels encircling the external anal opening. 
 At the same time there may be no special varicose swell- 
 ings; more frequently, however, besides the general con- 
 gested condition of the veins thare are isolated varicose 
 protrusions which may range in size from a pea to a wal- 
 nut. They vary greatly in shape: sometimes they are 
 round, sometimes flat, sometimes again irregular. Their 
 size greatly changes from time to time in the same person. 
 After defecation as a rule they grow smaller. Internal 
 hemorrhoids appear as soft nodules of a bluish hue and 
 have thin walls. They often develop to a considerable 
 size and make defecation difficult. As a rule, hemorrhoids 
 occur as multiple nodules, which may cover the mucous 
 membrane at different places, or they may encircle the 
 external surface of the anus, or be situated above the inter- 
 nal sphincter. Internal and external hemorrhoids may 
 also be present at the same time. Thus Cruveilhier ' de- 
 scribed a case in which there existed a wreath of external 
 hemorrhoids around the anal opening, another above the in- 
 ternal sphincter, and a third a few centimetres farther up. 
 
 External hemorrhoids are at first covered with normal 
 epidermis which can be moved over them. Later, how- 
 ever, through inflammatory processes the cutis becomes 
 adherent to the varicose nodule. At the same time the 
 
 ' Cruveilhier : "Traite d'anatomie pathologique generale, " 1849. 
 12 
 
178 DISEASES OF THE INTESTINES. 
 
 skin covering the nodule grows thinner through the steady 
 pressure to which it is subjected, and it may reach a point 
 when it breaks open after a forced defecation. The same 
 remarks also apply to internal hemorrhoids in which the 
 cutaneous covering of external hemorrhoids is represented 
 by the mucous membrane of the bowel. This also be- 
 comes adherent, thinned, and may ultimately mixture. 
 
 Internal piles are best divided, according to AUingham, ' 
 into the three following varieties : 
 
 1. Capillary Files. These present small, florid, rasp- 
 berry-looking tumors or rather vascular areas upon the 
 mucous membrane, having a granular spongy surface and 
 bleeding on the slightest touch; they are often situated 
 rather high in the bowel; in structure they consist almost 
 entirely of hypertrophic capillary vessels and spongy con- 
 nective tissue. They resemble arterial ngevi very closely, 
 indeed, in their microscopical structure, except that they 
 are covered externally by a very much thinner membrane 
 and consequently are readil}^ made to bleed. 
 
 2. Arterial Piles. These appear as tumors varying in 
 size, sessile or somewhat pedunculated, attaining sometimes 
 very considerable dimensions, glistening or slightly villous 
 on their surface, slippery to the touch, hard and vascular 
 with an artery often as large as the radial entering their 
 upper part. When they are villous on their surface, they 
 bleed very freely and for some reason or other have formed 
 and grown very rapidlj'. On dissecting one of these tumors 
 one will find that it consists of numerous arteries and 
 veins frequently anastomosing, tortuous, and sometimes 
 dilated into pouches, and of a stroma of cell growth and 
 connective tissue, the latter most abundant. 
 
 ' William AUingham and Herbert W. AUingham : " The Diagnosis 
 and Treatment of Diseases of the Rectum. " London, 1896, p. 113. 
 
HEMORRHOIDS. 1 • ^ 
 
 3. Venous Piles. In these the venous system predomi- 
 nates. The tumors are often very large and are sometimes 
 the size of a hen's egg. They are bluish or livid in color. 
 The surface may be smooth and shiny or pseudocutaneous. 
 
 External and internal piles often present themselves as 
 nodules situated closely to each other and sometimes coa- 
 lescing; thus larger tumors arise. In these hemorrhoidal 
 varices in);portant structural changes frequently take place. - 
 While at first soft, they may grow quite hard by the for- 
 mation of blood clots or by a process of calcification. In- 
 flammatory processes in the neighboring tissue have a 
 tendency to increase their size and to make them more 
 firm. 
 
 Internal piles are often pushed downward during the act 
 of defecation. In this manner the mucous membrane of 
 the base of the tumor is subjected to greater traction, and 
 thus ultimatelj^ a pedicle is formed. Such nodules pro- 
 vided with more or less long pedicles and situated near 
 the internal sphincter very frequently slip out from the 
 anus at each defecation. When, however, they are not 
 especially large, they spontaneously return into the rectum 
 after defecation is finished. If they are of considerable 
 size, it sometimes happens that thej^ become incarcerated 
 by the external sphincter, and if not carefully replaced, 
 inflammation may develop and give rise to intense pains. 
 Occasionally they may even become gangrenous and ulti- 
 mately drop off. In some instances hemorrhoids undergo 
 retrograde changes, become smaller, and even disappear 
 entirely. Flaps of skin hanging near the anus and pre- 
 senting a brownish color are often the remnants of pre- 
 vious piles. External jjiles sometimes give rise to the 
 formation of warts and their surface assumes an uneven 
 and wrinkled appearance. Internal hemorrhoids are often 
 
180 DISEASES OF THE INTESTINES. 
 
 complicated by inflammatory processes of tlie neighboring 
 tissues. Sucli processes give rise to tlie formation of ul- 
 cers, proctitis, and periproctitis. In the latter instance 
 an abscess may be formed, which may open either exter- 
 nally or internally, sometimes both ways. Thus a com- 
 plete rectal fistula originates. 
 
 In internal hemorrhoids the mucous membrane of the 
 rectum almost always exhibits the signs of a chronic ca- 
 tarrh. Its surface is swollen, succulent, and often covered 
 with a thick layer of mucus. Occasionally there may be 
 some pus. The proctitis accompanying piles may be either 
 the cause or the sequel of the latter ; sometimes, however, 
 both may be due to some other factor. 
 
 Symptomatology. — Most of the symptoms produced by 
 hemorrhoids are generally of a local character. They 
 greatly vary in the different varieties of piles. In the 
 early stage of external j)ile there occur off and on, espe- 
 cially after indiscretions in eating and drinking (princi- 
 pally effervescent wines or strong alcoholic beverages), 
 attacks caused by an increased congestion of the hemor- 
 rhoids. These attacks may be described as follows: A 
 sensation of fulness or clogging and slight pulsation in the 
 anus are felt by the patient. Moderate constipation exists, 
 compelling the patient to strain more than ordinarily. 
 Itching of the anal region and the perineum frequently 
 annoy the patient, especially soon after retiring, and may 
 keep him awake for quite some time. On awaking in the 
 morning the patient finds the anus tender and swollen, 
 and after a movement a few stains of blood are discov- 
 ered on the paper. Such an attack will, as a rule, pass off' 
 very quickly if the patient lives rationally and avoids the 
 predisposing causes ; if not, the atta,ck will quickly recur 
 with greater intensity and gradually assume a severer type. 
 
HEMORRHOIDS. 181 
 
 External piles may become swollen and cedematous, and 
 are tlien extremely painful to toiicli. Sometimes tliere 
 may be ulceration, or suppuration may take place and 
 small painful fistulse may form. Tlie venous tumors now 
 and tlien irritate tlie spliincter and levator ani muscles and 
 produce spasm of the latter. Tlie piles are then occasion- 
 ally drawn up into the anus and pinch.ed by the latter. 
 This causes a great deal of pain and keeps the patient 
 awake during the night. A feeling of throbbing and a 
 sensation as of a foreign body in the anus exist. A fre- 
 quent desire for defecation is thereby produced and the 
 patient, as a rule, is inclined to attempt to exj)el the for- 
 eign body by forcible straining, which of course only 
 aggravates the pain. Under these circumstances the 
 patient can hardly sit down nor can he walk about com- 
 fortabl}^ and on coughing and sneezing experiences great 
 suffering on account of the constriction of the involved 
 diseased parts. During a movement of the bowel and for 
 some hours afterward the pains are greatly increased. 
 The patient is unable to attend to his daily occupation. 
 General symptoms like fever, anorexia, dizziness, severe 
 constipation, may accompany the local manifestations. 
 
 Of the internal hemorrhoids, the capillary variety, being 
 small and only slightly elevated above the mucous surface, 
 gives rise to scarcely any trouble. As a rule, there is no 
 pain. Occasionally, however, ulceration takes place which 
 may cause considerable suffering. 
 
 Arterial and venous hemorrhoids give rise to many more 
 symptoms. In case the sphincter muscles are relaxed, the 
 hemorrhoids often protrude on the slightest exertion. 
 This also often occurs at stool. At first they spontane- 
 ously return within the sphincter after the bowels have 
 moved or whenever the exertion has ceased. Later in the 
 
182 DISEASES OP THE INTESTINES. 
 
 course of the disease, however, tlie patient is compelled to 
 return tliem with the finger. In still more advanced cases 
 they never remain long within the sphincter and pro- 
 trude very often whenever the least exertion is made. In 
 this manner the hemorrhoids cause much discomfort. 
 They also discharge a gummy acrid mucus which keeps 
 the parts constantly moist and leads to excoriations around 
 the anus, and also favors the development of cutaneous 
 excrescences. Patients with fully developed internal hem- 
 orrhoids experience a great deal of suffering during defe- 
 cation. They also feel quite uncomfortable for some time 
 afterward, occasionally to such a degree that they have to 
 lie down. When walking they are always conscious of the 
 fact that they have an anus. 
 
 In other instances in which the sphincter ani is strong 
 and tight, the piles in coming down become nipped and 
 their return is rendered difficult and painful. 
 
 The symptom from which the hemorrhoids originally 
 derived their name, namely, hemorrhage, is common to all 
 varieties of piles, although it is by no means constant. In 
 many instances it is absent, or it does not play any essen- 
 tial part, especially in external piles. In some patients a 
 more or less considerable hemorrhage takes place at cer- 
 tain intervals, appearing periodically, occasionally with 
 great regularity. A few premonitory signs, consisting in 
 painful sensations in the back and around the anus, con- 
 stipation, and other indefinite nervous symptoms usually 
 precede for a few days the beginning hemorrhage. The 
 blood as a rule then appears at first in small quantities 
 gradually increases in amount, and the hemorrhage stops 
 on the fifth or sixth day after its commencement. Physi- 
 cians in olden times — and some of the laity even nowadays 
 — looked upon the hemorrhage as an imj^ortant event, free- 
 
HEMORRHOIDS. 183 
 
 ing tlie system of vicious material. This is the reason why 
 formerly the hemorrhoidal bleeding was termed the golden 
 flow. Nowadays we do not attach any particular import- 
 ance to these hemorrhages. Their regularity or the perio- 
 dicity of their appearance is simply attributable to the 
 fact that the time necesary for the filling up of the nodules 
 until they rupture is usually of the same length. 
 
 In s6me instances there are transient hemorrhages, last- 
 ing a shorter or longer period. Ordinarily the patients feel 
 relieved after the bleeding ; occasionally they remain quite 
 well for a long time, sometimes for a year or two, until 
 there is suddenly a new hemorrhage. In the latter case 
 the hemorrhage is commonly caused by some unusual oc- 
 currence ; thus, a very copious meal, a long ride on horse- 
 back, or an excess in venery may bring it on. 
 
 In another class of patients there may be continuous 
 small hemorrhages. These occur more frequently in cases 
 of cajjillary hemorrhoids. The quantity of blood lost at 
 each action of the bowel is small, but being steady it be- 
 comes a serious strain upon the patient's constitution and 
 may give rise to sev^ere forms of anaemia and even per- 
 nicious anaemia. 
 
 The blood discharged from piles is either of a bright 
 red or a dark brown color, depending upon its origin from 
 arteries or veins. It is characteristic of hemorrhoidal 
 hemorrhages that the blood usually appears in a liquid, 
 non-coagulated state, covering the fecal matter, but not 
 mixed with it. If the hemorrhage is very copious, uncon- 
 sciousness may result combined with symptoms of pro- 
 found collapse. This, however, happens very rarely. Ac- 
 companying the local manifestations, especially if the latter 
 are of a high degree, there may be varied general symp- 
 toms. Thus dyspnoea, palpitations of the heart, angina 
 
184 DISEASES OF THE INTESTINES. 
 
 pectoris, irregular lieart action, hiccougli, headaches, gid- 
 diness, dizziness, buzzing in the ears, and cloudy vision 
 may be present. Often a despondent feeling and a condi- 
 tion resembling hypochondria is met with. Anorexia, 
 nausea, belching, and constipation also often occur. The 
 general symptoms are especially marked if incarceration 
 of internal piles within the sphincter has taken place. In 
 case the swelling of the hemorrhoids is so extensive that 
 a reposition cannot be quickly effected, there may be pres- 
 ent besides the local pains high fever and signs of col- 
 lapse. If the incarceration lasts a long period, the hem- 
 orrhoids may become gangrenous and either fall off, 
 accompanied by profuse hemorrhage, or, although rarely, 
 give rise to septic and peritonitic conditions. In most 
 instances after a falling off of the hemorrhoid a sponta- 
 neous cure takes x)lace. 
 
 Some cases of hemorrhoids are complicated with catarrh 
 of the "rectum (proctitis). In such instances the stools 
 reveal the presence of a considerable quantity of mucus, 
 occasionallj' even of i;)us. Sometimes the mucous or mu- 
 co-purulent fluid admixed with the feeces may be tinged 
 with blood. These cases are often accompanied by a 
 paretic condition of the sphincters, which allow the secre- 
 tion to dribble from the anus. This gives rise to excoria- 
 tions and inflammation of the anus and the neighboring 
 tissues. In the course of the proctitis prolonged tenesmus 
 may appear at times. If the inflammation extends into the 
 rectal cellular tissue, it may lead to the formation of ab- 
 scesses which may empty into or outside the bowel. This 
 is the most frequent way in which fistulse are produced. 
 
 Disturbances of the adjacent organs are also occasion- 
 ally met with in cases of piles. Thus ischuria, stranguria, 
 hemorrhages from the bladder, hemorrhages from the va- 
 
HEMORRHOIDS. 185 
 
 giua, and catarrlial conditions of the latter are encoun- 
 tered. 
 
 Diagnosis. — The diagnosis of hemorrhoids as a rule is 
 easy. External piles are found by inspection of the anus, 
 the patient lying on his side with the thighs drawn up. 
 The buttocks are pushed aside with the hands, and the 
 patient is instructed to strain in a similar manner as when 
 lla^ing a stool. Nodules of a reddish-bluish tinge will be 
 noticed in the immediate vicinity of the anus or partly 
 within it. It is characteristic of hemorrhoidal nodules 
 to increase in size during a period of constii^ation, and to 
 diminish after an efficient evacuation of the bowels. 
 
 Condylomata and small skin tags around the anus can be 
 easily differentiated from piles. Condylomata, as a rule, 
 encircle the anus and are present also on other parts of the 
 body, especially on the scrotum. Besides, there will be 
 a previous history of syphilis, and occasionally other lue- 
 tic manifestations. The cutaneous tags present more the 
 appearance of whitish-looking skin, never change in size, 
 and do not bleed when punctured, while hemorrhoids 
 bleed profusely on puncture. 
 
 The diagnosis of internal hemorrhoids can be made by a 
 digital examination or by this in connection with the in- 
 spection of the lower portion of the rectum by means of a 
 speculum. The characteristics of internal piles are similar 
 to those of external hemorrhoids. They can be easily 
 differentiated from xDolypi by means of puncture with the 
 needle. Polypi do not bleed when punctured. Besides, 
 polypi are usually found in children, while hemorrhoids 
 occur with greatest frequency in the advanced period of 
 life. 
 
 Carcinoma of the rectum will rarely give rise to mistakes, 
 the tumor usually presenting a much harder consistency 
 
186 DISEASES OF THE INTESTINES. 
 
 than hemorrlioids. As a rule, there will also be other 
 signs of a malignant trouble, cachexia, etc. It is needless 
 to say that cancer of the rectum may be combined with 
 hemorrhoids. As a matter of fact, it very often gives rise 
 to their development, and the discovery of piles which 
 have formed within a short period of time should indeed 
 rouse the suspicion of cancer of the rectum. 
 
 Prognosis. — The prognosis of external as well as internal 
 piles is as a rule favorable. They generally exist for a 
 long time, not infrequently throughout life. They hardly 
 ever endanger life, unless some grave complications (incar- 
 ceration of the hemorrhoids or gangrenous processes or 
 very profuse hemorrhages) supervene. Hemorrhoids are 
 liable to recede or even to disappear entirely, especially if 
 the factors producing them have been eliminated. 
 
 Treatment. — A rational mode of living is of the greatest 
 importance. Patients with hemorrhoids should have 
 plenty of outdoor exercise, should partake of food with 
 moderation, should avoid all excesses in baccho and in 
 venere, and should endeavor to have a daily evacuation of 
 the bowels. Any condition causing venous hypersemia of 
 the rectum must be removed. Thus vocations requiring 
 constant sitting, or constant standing, or horseback riding 
 should be entirely or partly given up. 
 
 With regard to diet the following general rules may be 
 given: Patients with hemorrhoids should avoid copious 
 meals. They should rather eat often and sparingly. Fish, 
 fresh, well-cooked vegetables, and ripe fruit should form a 
 considerable part of their diet. Alcoholic beverages, strong 
 coffee, and highly seasoned dishes should be avoided. The 
 different kinds of cheese, very coarse brown bread, cabbage, 
 peas, and beans are best eliminated from the diet. Salads, 
 potatoes, beets, spinach, asparagus, cauliflower, are, how- 
 
HEMORRHOIDS. 187 
 
 ever, rather of benefit if taken in small quantities, as these 
 articles make the intestinal contents more liquid. Stewed 
 fruits and also raw fruit, as for instance apples, pears, 
 prunes, oranges, grapes, are useful. As a beverage, plain 
 water, best taken between meals in the quantity of a pint, 
 is most beneficial. In some instances, especially in anae- 
 mic patients, buttermilk in the same quantity may be 
 taken iilstead of water. A small amount of light beer is 
 permissible in some cases. 
 
 With reference to hygiene or prophylactic measures it 
 is of importance for the patients to have plenty of outdoor 
 exercise, especially walking. The exercise, however, should 
 not be continued to over-fatigue. Gymnastic exercises at 
 home, sawing or chopping wood, and the like, and also 
 massage are best adapted for this purpose. The patients 
 should wash the affected part in the morning and evening 
 with cool water. They should sit on caned chairs, not on 
 upholstered ones, and should sleep on a mattress. 
 
 The patient should have a good evacuation of the bowels 
 daily. In case this does not occur, it will be of the great- 
 est importance to secure it by the different therapeutic 
 measures at our disposal (see Chapter X., on constipa- 
 tion). As a rule, however, powerful laxative and drastic 
 remedies should be avoided. The frequent use of injec- 
 tions had also best be omitted. The purgatives most 
 adapted for these patients are the saline ones, sulphur and 
 rhubarb drugs. Thus compound licorice powder, a tea- 
 spoonful in the evening, or sulph. depur., potas. bitartrat. 
 aa, also one teaspoonful in the evening. Ehubarb in the 
 form of tincture or in substance 0.5 to 1 gm., taken once 
 or twice daily, is also advantageous for a prolonged use. 
 The waters of Carlsbad, Kissingen, Marienbad, Tarasp, 
 Saratoga, will also be of benefit, especially if taken at the 
 
188 DISEASES OF THE INTESTINES. 
 
 watering-places themselves in connection with a prescribed 
 diet. If the hemorrhoids have already attained consider- 
 able size, local remedies will often be required. 
 
 Local Treatment. — The irritation or the rubbing of the 
 piles against each other or against the skin must be pre- 
 vented. For this purpose covering the piles with a small 
 piece of smooth and clean cotton is of benefit ; still better, 
 however, for this purpose is cotton moistened in olive oil 
 or covered with vaseline or a soft salve (Hebra's ointment 
 or ointments of zinc, lead, boracic acid) . If the piles are 
 inflamed, it is best to first paint them a few times with the 
 following solution: 
 
 I^Potas. iodidi 2.0(3ss.) 
 
 lodi puri 0.2 (gr. iiiss.) 
 
 Glycerin 40.0 ( 3 x. ) 
 
 before applying the ointment. After a movement the anus 
 ^nd the piles should be first washed with cool water and 
 then wiped off with soft cotton or linen. This must be 
 done very gently. Persons suffering with annoying tenes- 
 mus after defecation should accustom themselves to go to 
 stool before retiring. The recumbent position which the 
 patients are thus able to assume soon after the passage 
 affords them decided relief. 
 
 If there are pains in the rectum caused by a mere hyper- 
 sesthesia of the mucous membrane, an injection of one to 
 two teaspoonfuis of warm olive oil or of the same quantity 
 of warm water into the bowel will exert a favorable influ- 
 ence. If this fails, or in cases in which the pains are 
 caused by a superficial excoriation of the piles, it is best 
 to apply an ointment containing some narcotic after an 
 evacuation of the bowels, and sometimes even during the 
 intervals. The following salve, recommended by Kosen- 
 heim, is very appropriate : 
 
HEMORRHOIDS. 189 
 
 I^ Lanolin 20. ( 3 v. ) 
 
 Bism. subnitr 2.0 ( 3 ss.) 
 
 Extr. opii 0.3 (gr. v. ) 
 
 M. f. uugt. 
 
 In place of the ointment the piles may be painted witli a 
 solution containing equal parts of fluid extracts of opium 
 and belladonna, or with a two-per-cent cocaine solution. 
 Suppositories containing opium, belladonna, or cocaine 
 are also effectual. 
 
 Internal piles prolapsing through the anus should be 
 pushed back by the patient after anointing them with olive 
 oil or with vaseline. In case the re^josition is not easy, 
 painting of the piles with a two-per-cent cocaine solution 
 will after a while lessen the sensitiveness and thus make re- 
 position possible. In some obstinate cases the jjatient must 
 be narcotized in order to accomplish this. If the incarcerat- 
 ed piles have already become gangrenous, the pains usually 
 grow less. In order to arrest the necrotic process it is 
 advisable to dust the affected area with an antiseptic powder 
 (dermatol) and to cover it with dry gauze. The pile usu- 
 ally falls off spontaneously' and the wound heals of itself. 
 
 The inflammatory processes in piles require special 
 treatment in the stage of exacerbation (general antiphlo- 
 gistic remedies) . Thus rest in bed on the side, applica- 
 tion of cold in the form of an icebag or a Priessnitz poultice, 
 occasionally leeches in the neighborhood of the anns, not on 
 the piles themselves, are beneficial. Application of cold lead 
 water is also useful. In case there are signs pointing to 
 the formation of pus or the development of a septic process, 
 surgical intervention is imperative. An incision into the 
 hardened piles followed by thorough extirpation is essential. 
 Inasmuch as such an operation must be done under chloro- 
 form narcosis, the radical removal of the entire hemor- 
 rhoidal area is therefore best performed at the same time. 
 
190 DISEASES or THE INTESTINES. 
 
 Hemorrhoidal hemorrhages, if not extensive, and if occur- 
 ring at long intervals, will hardly require any therapeutic 
 measures. If, however, the quantity of blood is quite con- 
 siderable or if the hemorrhage is protracted, the following 
 means should be employed : An icebag should be applied 
 to the anus for several hours, or in case the hemorrhage 
 results from internal piles, a cylindrical piece of ice is 
 pushed up into the anus and replaced every half-hour. 
 The rectal refrigerator may likewise be used with benefit. 
 Tery cold injections are also useful. In cases with, very 
 frequent hemorrhages injections of water, to which an as- 
 tringent remedy has been added, are beneficial. Thus a 
 two-per-cent solution of tannic acid or of alum, or a 0.3- 
 per-cent solution of acetate of lead may be applied. Su- 
 prareDal gland applied locally in powdered form or used 
 in a salve vehicle or suppository — also adrenalin adminis- 
 tered in solution (1 : 10,000) — are of decided benefit. The 
 following ointment, first suggested by Kossobudskj,' may 
 also be applied in these cases : 
 
 I^ Chrysarobin 0.8 (gr. xilj.) 
 
 Iodoform 0. 3 (gr. v.) 
 
 Extr. bellad 0. 6 (gr. x.) 
 
 Vaselini 15.0 (§ ss.) 
 
 M. f. ungt. 
 
 This salve not only checks the hemorrhage, but has also 
 an excellent effect in reducing the size of the pile. In in- 
 ternal hemorrhoids the following suppository may be used 
 for the same purpose : 
 
 If Chrysarobin 0. 1 (gr. if) 
 
 Acidi tannici 0.1 (gr. if) 
 
 Iodoform 0. 2 (gr. iiif) 
 
 Extr, opii 0.02 (gr. i) 
 
 01. theobrom 2.0 (3 ss.) 
 
 M. f. Suppository. S. One suppository in the evening. 
 
 I Kf)ss()bu(lski: ('cntralhlatt fiir Chiniru-ic. ISSO. 
 
HEMORRHOIDS. 191 
 
 Badical Treatment. — 1. Dilatation of the Sphincters. Yer- 
 neuil ' was tlie iii'st to recommend dilatation of the sphinc- 
 ters as a cure for piles. This treatment is based upon the 
 idea that the spasm of the sphincter is thereby stopped, 
 that the bowels act more freelr and the pressure upon the 
 venous blood-vessels is relieved. The dilatation of the 
 sphincters may be accomplished gradually by introducing 
 specula into the rectum, taking a larger size each time, 
 which procedure occupies several weeks, or it may be done 
 in one sitting (the so-called forcible dilatation). In the 
 latter instance, however, chloroform narcosis is necessary. 
 Complete dilatation is effected, according to Allingham, in 
 the following way : The patient being fully under the influ- 
 ence of ether or chloroform, both thumbs must be inserted 
 into the rectum, which is to be dilated gradually, first in 
 the antero-posterior and afterward in the opposite direc- 
 tion. The amount of force used must be sufficient to over- 
 come the spasm thoroughly. This manipulation must be 
 continued until the sphincter muscles yield, as if reduced 
 to a really pulpy condition. Care must be taken to act 
 high enough up in the rectum so as to include the whole 
 of the sphincter. The result is that the state of contrac- 
 tion is abolished and no spasm can occur. In fact, for the 
 time being, as in any other stretched muscle, paralysis re- 
 sults. "With great gentleness the desired effect may be ac- 
 complished without tearing the mucous membrane. But 
 some extravasation is usually noted around the anus for a 
 few days. After this an opium suppository is kept in the 
 rectum and the patient is placed in bed in a recumbent 
 position. Dilatation of the sphincters may be recom- 
 mended in the early stage of hemorrhoids, especially in 
 cases combined with constipation ; further in hemorrhoids 
 > Verneuil : Gazette des bop., 1884, 1887. 
 
192 DISEASES OF THE INTESTINES. 
 
 during pregnancy or occurring in persons greatly debili- 
 tated by other grave diseases. 
 
 2. Carbolic-Acid Injections. Pooley, * Kelsey , ' Roux, ^ and 
 Lange * have recommended injections of carbolic acid into 
 the piles in order to produce shrinking. This method is per- 
 missible only if the hemorrhoids are not inflamed. Proceed 
 as follows: The piles are first thoroughly cleansed and 
 dried, then covered with iodoform salve. In order to 
 lessen the pains a few drops of a one-per-cent cocaine so- 
 lution may first be used subcutaneously. Then three to 
 five drops of either of the two following solutions are in- 
 jected into the centre of each pile: (1) Carbolic acidl, gly- 
 cerin 3; (2) Carbolic acid 1, glycerin 3, distilled water 3. 
 The injection is made with the common Pravaz syringe, 
 but care must be taken that none of the solution drips from 
 the needle, so as to avoid cauterizing the mucous mem- 
 brane. Several piles can be treated at the same sitting. 
 It is advisable, however, not to make the injections oftener 
 than about once a week. This procedure if carefully done 
 is not dangerous nor painful, and often effects shrinking 
 or even disappearance of quite considerable hemorrhoidal 
 nodules. 
 
 3. Cauterization loitli Fuming Nitric Acid. Houston," of 
 Dublin, was the first to recommend cauterization of piles 
 with fuming nitric acid. This may be done in the follow- 
 ing manner : After thorough cleansing and drying of the 
 anus and the surrounding parts, the entire area is covered 
 
 1 J. H. Pooley : "Injection of Carbolic Acid in Hemorrhoids." To- 
 ledo Med. and Surg. Journal, November, 1877. No. 11. 
 
 2 Charles B. Kelsey- : " The Treatment of Hemorrhoids. " Medical 
 Record, 1886, vol. ii.. p. 141. 
 
 ^ Roux : "Behandlung der Hamorrhoiden." Therap. Monatshefte, 
 1895, p. 124. 
 4 F. Lange : Centralblatt fllr Chirurgie, 1887, No. 25, Beilage, p. 70. 
 * Houston : Dublin Journal of Medicine, 1844. 
 
HEMORRHOIDS. 19^ 
 
 with a thick layer of vaseline excepting the pile which is 
 to be treated. The latter is then painted with nitric acid 
 by means of a small stick of wood or a glass rod. Special 
 care mnst be taken that the acid reaches no other spot. 
 After the nodule has assumed a grayish-green color it is 
 carefully dried, smeared with vaseline, and pushed back 
 into the rectum. This method is best adapted for smaller 
 nodules,/ especially if they have a wide base. Sometimes 
 a second cauterization is necessary, which may be done 
 after an interval of about five days or a week. Instead of 
 nitric acid other cauterizing substances may be used, and 
 Allingham has recommended concentrated carbolic acid as 
 especially efiicient for this purpose. 
 
 4. Ligature. Cooper * recommended the ligature of hem- 
 orrhoids in order to cut them off from the circulation and 
 thus destroy them. Salmon'^ has improved this method- 
 by making an incision before applying the ligature. Ac- 
 cording to this writer, the operation is performed in the 
 following manner : The patient is placed on the right side 
 on a hard couch and is completely anaesthetized. The- 
 sphincter muscles are then gently but completely dilated. 
 The hemorrhoids, one by one, are then drawn down with a 
 pronged hook fork; by means of sharp scissors the pile is 
 separated from its connections with the muscular and sub- 
 mucous tissues upon which it rests. The cut is best made 
 in the sulcus or white mark which is seen where the skin 
 meets the mucous membrane. This incision is made in a 
 direction parallel to the bowel and carried to such a dis- 
 tance that the pile is left connected by an isthmus of vessels 
 and mucous membrane only. A well-waxed, strong, thin, 
 aseptic silk ligature is now placed at the bottom of the deep 
 
 ' Cited from Allingham, loc. cit. 
 •' Ibid. 
 13 
 
194 DISEASES OF THE INTESTINES. 
 
 groove which has been made, and the ligature is tied right 
 at the neck of the tumor as tightly as possible. When all 
 the hemorrhoids have thus been ligated, they should be 
 returned within the sphincter. A small ijiece of absor- 
 bent cotton saturated with iodoform ointment is now 
 placed into the bowel and a pad of cotton applied over the 
 anus. 
 
 5. Crushing. Crushing of piles has been suggested by 
 Pollock and the method further improved by AUingham/ 
 who devised a very ingenious apparatus for this purpose, 
 namely, the "screw-crushing instrument." The operation 
 begins with the dilatation of the sphincters. The hemor- 
 rhoid is then drawn into the screw-crusher by means of a 
 hook, and this being intrusted to an assistant the bar is 
 pushed up and screwed home as tightly as possible. The 
 pile should be crushed longitudinally and not transversely. 
 The projecting portion of the pile is cut off with the knife 
 or scissors and the pressure kept up for about one minute. 
 According to AUingham crushing is a very satisfactory 
 method of removing internal piles. 
 
 6. Thermo-cautery (PaqueUn) and Galvano-cautery. Lan- 
 genbeck introduced the method of operating upon piles 
 by means of thermo-cautery. Each pile is seized with a 
 volsellum forceps and drawn well down. The clamp is 
 then applied so as to embrace its base. The portion above 
 the clamp is cut off with a pair of scissors and the cautery- 
 iron, heated to a dull red heat, is repeatedly applied to the 
 stump until all the vessels are well seared. 
 
 Instead of using the Paquelin, galvano-cautery may be 
 applied for the removal of hemorrhoids, the technique 
 being identical with the former. Bardeleben and also Ro- 
 senheim strongly recommend the latter method. 
 
 ' AUingham : "Diseases of the Rectum," 1896, p. 153. 
 
HEMORRHOIDS. 195 
 
 7. Extirpation of Hemorrhoids, followed by Suture. This 
 method was first introduced by von Esmarch* in Germany 
 and by Whitehead in England. It is not, however, exten- 
 sively used as it is quite complicated, besides giving rise to 
 many disagreeable complications. Thus Allingham has 
 noticed the following sequels of such an operation : 1. Anal 
 stricture. 2. Loss of sensation and control over the 
 anus. 3. Irritation of the mucous membrane due to fre- 
 quent discharges of mucus and at times accompanied by 
 bleeding. 
 
 xA.fter any of the above-named operations it was customary 
 to employ an astringent in order to prevent a movement 
 of the bowels for a few days. Contrary to this method E. 
 Graser " is of the opinion that such patients are better off 
 when having a free movement shortly after the operation. 
 He administers soon after its performance a small dose of 
 castor oil and instructs the patient to have an evacuation 
 while in a warm sitz bath. Cleansing of the anus is very 
 easily obtained in this manner. After an antiseptic wash- 
 ing a piece of cotton or linen, thickly smeared with an 
 ointment, is introduced into the rectum. This procedure 
 has usually to be performed once daily. According to 
 Graser, the patients if thus treated are almost without pain, 
 and are able to get up and be out of bed five or seven 
 days after the operation. For some time after its perform- 
 ance it is advisable to have the patient introduce bougies 
 of varying size into the rectum in order to prevent the for- 
 mation of a stricture. 
 
 Complications. — Prolajjse of the Rectum. Prolapse of the 
 rectum is a frequent complication of hemorrhoids, although 
 
 1 von Esmarch : "Die Krankbeiten des Mastdarms und Afters," 
 Stuttgart, 1887. 
 
 2 E. Graser : Penzoldt u. Stinzing, " Handbuch d. Tlierapie, " Bd. iv., 
 p. 634. 
 
196 DISEASES OF THE INTESTINES. 
 
 il may also occur alone. The prolapse may involve either 
 the mucous membrane alone or all the coats of the rectum. 
 In the latter instance this condition is also called proci- 
 dentia recti. Outside of the anus there is a protrusion of 
 the mucous membrane in its entire circumference. An 
 internal prolapse of the rectum may also occur, which con- 
 sists in the descent of the upper part of the rectum through 
 the lower part, but not appearing outside the anus. This 
 corresponds rather to an intussusception. A relaxation of 
 the ligaments which serve to keep the rectum in its place 
 is often the cause of this malady. Weakness and paralj'sis 
 of the sphincter ani muscles are also predisposing factors. 
 
 Prolapse of the rectum is frequently found in debilitated 
 children, especially if an intestinal catarrh is present, for 
 these little patients go to stool too often and usuall}' strain 
 too much and for too long a time. These conditions weaken 
 the muscular apparatus of the anus, and thus a prolapse of 
 the rectum easily arises. In elderly people, in patients 
 suffering from affections of the bladder or from severe 
 constipation and internal hemorrhoids, and in women 
 who have gone through many pregnancies in quick suc- 
 cession, prolapse of the rectum is also a frequent oc- 
 currence. 
 
 The symptoms are as follows : If the prolapse is only of 
 a moderate degree, there appears in the act of defecation a 
 protrusion of the rectum outside the anus, one or one and 
 a half inches in length, the mucosa looking quite red and 
 puckered. In the more advanced stage the bulged out 
 rectum resembles a large tumor with a star-like opening 
 at its centre, while the color is pale or bluish-red. In 
 children the mass generally protrudes only on going to 
 stool, but in adults it is constantly down or comes down 
 on the slightest exertion, and therefore may become ulcer- 
 
HEMORRHOIDS. l^T 
 
 ated or inflamed. In old cases of prolapse incontinence 
 of faeces is also frequently present. 
 
 The diagnosis of prolapse of the rectum is easily made 
 from the above-mentioned appearances. Internal prolapse 
 is net so easily diagnosed, as the mass never appears out- 
 side the anus. This condition can be recognized only by 
 means of a digital examination of the rectum. The finger 
 introduced into the bowel is first kept close to the anterior or 
 posterior vi^all, and is passed up until it meets with an ob- 
 struction (i.e., it has passed into the cul-de-sac). Then 
 the finger/ is slightly withdrawn and the centre of the gut 
 examined until an orifice is found into which the finger or 
 a bougie may be passed for some inches high up into the 
 rectum. If the intussusception is rather far up in the rec- 
 tum, the patient should bear down during the examination. 
 
 With regard to treatment it is of importance to eliminate 
 all the conditions which were predisposing factors for the 
 prolapse. Extreme cleanliness, especially after defecation, 
 should be observed. The reposition of the prolapse should 
 be performed in the most careful manner. It is best done 
 in the knee-elbow posture. If a considerable portion of 
 the bowel has come down, a large flexible bougie may be 
 passed into the bowel in such a manner as to carry before 
 it the upper part of the descended gut. General taxis 
 should at the same time be used, and in this way the mass 
 can generally be returned. In cases in which the prolapse 
 occurs quite frequently, even during a walk, a rectal sup- 
 porter, as suggested by von Esmarch., should be worn by 
 the patient. It consists of a soft-rubber ball attached to 
 the anus by means of a belt and a T bandage. 
 
 The palliative treatment which is especially successful in 
 children is as follows : All sources of irritation should be re- 
 moved and the general health strengthened. Straining at 
 
198 DISEASES OF THE INTESTIKES. 
 
 stool should be strongly forbidden and a mild laxative 
 remedy given. After a movement of the bowels the pro- 
 truded part should be well washed with cold water and 
 pushed back into the anus by gentle pressure. After this 
 procedure the patient should remain in a recumbent position 
 for half an hour or so, best lying on the abdomen. If these 
 means alone are not sufficient, the following more radical 
 measures will have to be adopted : Cauterization of the pro- 
 lapsed part with fuming nitric acid or with the thermo-cau- 
 tery under chloroform narcosis is often of great benefit. 
 Care should be taken while cauterizing not to touch the 
 verge of the anus or the skin. After this the prolapsed 
 part should be well oiled and returned. Instead of nitric 
 acid Allingham uses the acid nitrate of mercury. 
 
 These cauterizing methods have the disadvantage of often 
 producing strictures of the rectum. For this reason a num- 
 ber of surgical operations have been devised. Thus exci- 
 sion of triangular or elliptical portions of the mucous mem- 
 brane, bringing the edges together with sutures, has been 
 l^ractised. Extirpation of the entire prolapsed portion was 
 first advocated by Treves.' F. Lange," of New York, has 
 described a new operation, serving the purpose of reduc- 
 ing the calibre of the rectum and at the same time produc- 
 ing a narrow muscular ring. The patient is placed in the 
 genu-pectoral position, an incision is made from the lower 
 part of the sacrum down to the anus, until the posterior 
 wall of the rectum is reached; the coccyx is then removed. 
 The object in view is to narrow the gut as high as possible 
 and to lessen the impediments to the action of the levator 
 ani. The calibre of the rectum is lessened by introducing 
 buried etage sutures of iodoformed catgut, which do not 
 
 > Treves : Lancet, 1890, vol. 1. 
 
 *F. Lange : Annals of Surgery, vol. v., p. 497. 
 
HEMORRHOIDS. 199 
 
 perforate the entire thickness of the gut. The first rows 
 are inserted near the middle line and form a fold in the 
 posterior walls which protrudes into the bowel. In this 
 manner the more lateral portions of the gut are brought 
 into position without causing too much tension. Similar 
 sutures are applied to unite the cut surfaces of the levator 
 ani and sphincter externus, which had been previously dis- 
 sected in order to lay bare the posterior wall of the rectum. 
 The cavity thus formed is filled up with iodoform gauze 
 and the flaps of integument are united with sutures. 
 
 Another very efficient operation has been suggested by 
 AUingham and consists in making a small incision through 
 the anterior abdominal wall on the left side, just above the 
 outer third of Poupart's ligament, then introducing the 
 fingers into the abdomen, catching hold of the rectum and 
 pulling it up. After it has been drawn as high up as pos- 
 sible, silk threads are passed through the mesentery and 
 the latter is fastened to the abdominal wall. 
 
 Fissure of the Anus. Another affection which very fre- 
 quently occurs in connection with hemorrhoids is anal fis- 
 sure. The latter consists of an oblong tear of the mucosa 
 of the anus and gives rise to severe pain and spasmodic 
 contractions of. the sphincters. Fissures or ulcers of the 
 anus vary in depth and size. Some are mere abrasions of 
 the mucous membrane, others are quite large and deep so 
 that the muscular fibres are laid bare. The edges of the 
 fissure may be in a healthy state or they may be inflamed, 
 callous, and indurated. Fissure of the anus is usually 
 caused by an injury or tearing of the mucous membrane 
 at the verge of the anus. This may result either from ex- 
 cessive straining or from the passage of very dry hard 
 scybala. The affection is more often found in women than 
 in men. The posterior portion of the anus is the point of 
 
200 DISEASES OF THE INTESTINES. 
 
 predilection, althougli the fissure may occur at any other 
 place. It is usually situated parallel to the external sphinc- 
 ter, although in some instances it may lie higher up, par- 
 allel to the internal sphincter or even above it. 
 
 The symptoms consist in intense pains in the rectum on 
 defecation, sometimes persisting aftervv^ard.- The pains are 
 often of a very excruciating character. The size of the fis- 
 sure does not seem to be of so much importance with regard 
 to the severity of the pain as its position. A small crack 
 situated at the anal orifice over the external sphincter and 
 involving the shin causes much greater pain than a large 
 ulcer situated higher up in the rectum. There may also 
 be a discharge of blood and pus. 
 
 The diagnosis of anal fissure is made by the symptoms 
 just mentioned and by local examinations. The patient 
 lying on his left side should be told to bear down, and the 
 anus opened with forefinger and thumb as gently as pos- 
 sible. An elongated club-shaped ulcer will be seen within 
 the orifice. Its floor may be very red and inflamed, or if 
 the ulcer is of long standing, of a grayish color, with well- 
 defined and hard edges. Often the introduction of the fin- 
 ger into the anus is so painful that before making the ex- 
 amination a suppository containing one gyain of cocaine 
 has to be applied. Sometimes even this procedure is in- 
 sufficient, and then chloroform anaesthesia will be required. 
 For a fissure situated higher up above the internal sphinc- 
 ^;er examination with the speculum will have to be made. 
 
 Fissures of recent origin can often be cured without any 
 operation. Eest in the recumbent position should be 
 adopted as much as possible. Mild laxatives are to be 
 recommended, but no drastic remedies employed. If the 
 patient can manage to have a movement at night time be- 
 fore retiring, it will be of advantage. Locally the fissure 
 
HEMORRHOIDS. 201 
 
 should be touched off and ou with a ten-per-cent sohitiou 
 of cocaine or with a ten-per-cent sohition of nitrate of sil- 
 ver. Still better is the application of the following salve 
 recommended bj Allingham : 
 
 H Hydrarg. subchlor gr. iv. 
 
 Pulv. opii gr. ij. 
 
 Extr. bellad gr. ij. 
 
 Ung. sambuci 3 i. 
 
 M. f. ung. 
 
 If these palliative remedies are not sufficient, a free incision 
 through the fissure should be made. The cut should be 
 rather deep and should reach the sphincter muscles. 
 
CHAPTER VIII. 
 
 APPENDICITIS. 
 
 Synonyms: Scolecoiditis ; Perityphlitis; Paratyphlitis; 
 Appendicular inflammation. 
 
 Definition. — Inflammation of the appendix, characterized 
 by localized pains, commonly fever and digestive disturb- 
 ances. 
 
 General Remarhs. — The inflammatory lesions involving 
 the right iliac region were formerly designated as typhlitis 
 (inflammation of the csecum itself), perityphlitis (inflam- 
 mation of the peritoneal covering of the csecum), and para- 
 typhlitis (inflammation of the retro-peritoneal connective 
 tissue of the csecum) . GrisoUe ' was the first to maintain 
 that inflammation of the csecum could hardly give rise to 
 such grave lesions as are found in the right iliac fossa, for 
 even ulcerations of the csecum and colon do not, as a rule, 
 show any tendency to extend into the neighboring connec- 
 tive tissue. He ascribed the above conditions to an inflam- 
 mation of the appendix, which organ shows a tendency 
 to perforate and to lead to abscesses in the right iliac fossa 
 as verified by post-mortem examinations. The possibility 
 of a stercoral typhlitis (inflammation of the csecum as the 
 result of accumulated fecal matter) which was formerly 
 generally accepted, is now held by but very few writers, 
 
 1 Grisolle : " Tumeurs Phlegmoneuses des Fosses Iliaques. " Archives 
 de Medecine, 1839. 
 
APPENDICITIS. 203 
 
 as for instance, Lennander.' Salili/ Notlmagel/ Fow- 
 ler/ Sonnenburg/ and others deny its existence. Tlie 
 teachings of Grisolle found further support through the 
 brilliant investigations of Reginald Fitz® of Boston, 
 Sands,' McBurney,' Weir,=' Bull,'" and Fowler of New 
 York, were supplemented by the observations of Sonnen- 
 burg, Sahli, Eotter," Bous,'" Talamon," and others, and 
 are now generally accepted. 
 
 Etiology. — In former years much importance was at- 
 tributed to the occurrence of foreign bodies like cherry 
 stones', grape seeds, lemon and orange pits, date kernels, 
 fish bones, pins, etc., within the appendix as causative fac- 
 tors of the inflammatory suppurative process. According^ 
 to Fowler, the belief that the disease is frequently due to 
 the engaging of foreign bodies in the cavity of the organ is 
 based to a large extent upon purely speculative or imagi- 
 nary conditions or erroneous observations. In a very large 
 number of cases of this disease upon which he operatecl 
 Fowler found but in two instances any body other than 
 soft fecal masses which could be considered as being in. 
 
 ' Lennaader : "Ueber Appendicitis, " Wien, 1895. 
 
 2 Sahli : "Ueber das Wesen und die Bebandlung der Perityphliti- 
 den. " Correspondenzbl. f . Scbweizer Aerzte, Basel, 1893. 
 
 ^Notbnagel: "Krankbeiten des Darms, " Wien, 1898. 
 
 ^George E. Fowler: "A Treatise on Appendicitis, " Philadelphia,. 
 1894. 
 
 ^ Sonnenburg : "Pathologie und Tberapie der Perityphlitis, " Leip- 
 zig, 1895. 
 
 * Reginald Fitz : American Journal of the Medical Sciences, 1886 ;. 
 and New York Medical Journal, 1888. 
 
 ' Sands : New York Medical Journal, 1888, p. 197-205, 607. 
 
 '^ Charles McBurney : Annals of Surgery, 1891 ; Medical Record, 1893. 
 
 9 Robert F. Weir : Medical Record and Medical News, 1887-1892. 
 
 10 W. T. Bull : Medical Record, 1894. 
 
 " Rotter : "Ueber Perityphlitis, " Berlin, 1897. 
 
 1^ Roux : Revue de Medecine de la Suisse romande, 1890, 1891, 1892. 
 
 '^Talamon : " Appendicite et Perityphlite, " Paris, 1892. 
 
204 DISEASES OF THE INTESTINES. 
 
 -any sense foreign. Tlie fecal concretions within tlie ap- 
 pendix are now looked upon as of no importance whatever 
 with regard to the causation of the disease, as they are also 
 accidentally encountered in perfectly normal appendices. 
 The opinion generally prevails that the inflammation is 
 caused by micro-organisms which are conveyed to the in- 
 terior of the organ in the fecal matter. According to 
 Nothnagel, however, fecal concretions play a prominent 
 part in lesions leading to perforation of the appendix. 
 
 Movable kidney has been assumed to be a predisposing 
 factor in the development of appendicitis by Carl Beck ' 
 and Edebohls." The much greater frequency of movable 
 kidney in the female and the comparative infrequency of 
 appendicitis in the latter as compared with the male sex 
 «eems to speak somewhat against this view. 
 
 Actinomycosis, tuberculous and typhoid ulcers are pre- 
 disposing causes of the disease. Occlusion of the lumen of 
 the appendix, either partial or complete, is likewise a pre- 
 disposing factor. These occlusions may be the result of 
 former inflammatory lesions, but are most frequently due 
 io the retrograde changes which this organ is gradually 
 undergoing in the process of evolution. According to Rib- 
 bert^ and Zuckerkandl,* the appendix is found obliterated 
 in about twenty-five per cent of all living persons. Both 
 these writers ascribe this condition not to inflammatory 
 •diseases, but to the progress of evolution which takes place 
 in the appendix. This view is supported by the fact that 
 
 'Carl Beck: "Appendicitis." Volkmann's Sammlung klinischer 
 Vortrage, No. 221. Leipzig, 1898. 
 
 2 George M. Edebohls : Medical Record. 1898. 
 
 ^ Eibbert : " Beitrage zur normalen und pathologischen Anatomie 
 'des Wurmfortsatzes. " Virch. Arch., Bd. 132. 
 
 4E. Zuckerkandl : "Ueberdie Obliteration des Wurmfortsatzes beim 
 Menschen, " Wiesbaden, 1894. 
 
APPENDICITIS. 205 
 
 obliteration of tlie appendix is found witli gradually in- 
 creasing frequency in more advanced age. Thus Eibbert 
 found obliteration of tlie appendix in fifty per cent of per- 
 sons above sixty years of age. 
 
 Wh}' tlie appendix sliould be the seat of disease so very 
 much more frequently than other parts of the intestine is 
 a question which cannot be so easily answered. The fact 
 that the appendix is a rudimentary organ in which proc- 
 esses of evolution are even normally discoverable makes it 
 probable that it is imbued with less resistance against dis- 
 ease-producing agents. The comparatively narrow lumen 
 of the appendix and Gerlach's valve make the emptying of 
 this little canal a difficult matter. This, in connection with 
 the scantiness of circular muscular fibres in the walls of 
 the appendix explains the slowness with which substances 
 within the appendicular cavity are emptied into the intes- 
 tine. Stagnation of contents in this organ is certainly a 
 predisposing factor for disease. The abundance of ade- 
 noid tissue in the appendix has been believed by some 
 writers to be a predisposing cause of disease. Bacterial 
 infections here take place in a similar manner as in the 
 tonsils, and Sahli speaks by way of comparison of an an- 
 gina of the appendix. Fowler and Yan Cott ' believe that 
 the vascular arrangement of the appendix (scantiness of 
 blood supply, the main vessels being almost end arteries) 
 is responsible to a great extent for the frequency of dis- 
 ease in this organ. Some of the blood-vessels and nerves 
 are primarily affected, and the nutrition of the appendix 
 being thus disturbed, diseases of an infective character 
 easily take place. Another predisposing cause of appen- 
 dicitis is displacement and malformation of the appendix. 
 
 While all the above-mentioned factors may predispose 
 ' Van Cott-Fowler : "Treatise on Appendicitis." 
 
206 DISEASES OF THE INTESTINES. 
 
 the appendix to disease, tlie real cause of the latter must 
 be looked for in a bacterial invasion. Talamon was the 
 first to lay stress upon the importance of microbes in ap- 
 pendicitis. Nowadays all writers coincide with this view. 
 Thus Tavel/ Hodenpyl/ Fowler, Wilson,^ Barbacci,^ and 
 others ascribe a very important part to the bacillus coli 
 communis (Escherich), which is almost always encoun- 
 tered in lesions of the appendix, either in the exudate, pus, 
 or the walls of the appendix itself. Other micro-organ- 
 isms are, however, frequently found either in connection 
 with the bacterium coli commune or alone. Thus strepto- 
 coccus pyogenes, iDueumococcus, staphylococcus i)yogenes 
 aureus, bacterium lactis, bacillus pyocyaneus and pyogenes 
 foetidus, proteus vulgaris, and others have been encoun- 
 tered. In most cases probably a mixed infection (several 
 varieties of micro-organisms) takes place. The bacterium 
 coli commune, however, is most frequently found, as it has 
 a greater resisting-power and in the course of its growth 
 usually causes disappearance of the other micro-organ- 
 isms. 
 
 Sex and age seem to play an important part in regard to 
 the distribution of the disease. The male sex is much more 
 frequently affected than the female. Thus, 
 
 SoQoenburg reports 130 cases — 77 males, 53 females. 
 
 Rotter " 68 " — 44 " 24 
 
 Nothnagel " 180 " —105 " 25 " 
 
 Bamberger 5 " 73 " — 54 " 19 " 
 
 ' Tavel und Lanz : " Ueber die Aetiologie der Peritonitis. " Mitthei- 
 lungen aus Kliniken und Instituten der Schweiz, Basel, 1898. 
 
 2 Hodenpyl : " On the Etiology of Appendicitis. " New York Medi- 
 cal Journal, 1893. 
 
 3E. Wilson : Cited after Fowler. 
 
 * Barbacci : Lo sperimentale, 1898, fasc. 4. 
 
 ^ Bamberger : " Die Entzlindungen der rechten Fossa iliaca. " 
 Wiener med. Wochenschr., 1853. 
 
APPENDICITIS. 
 
 207 
 
 Volz ' reports 59 cases— 45 males, 14 females. 
 
 Matterstock* " 1,030 " —733 " 297 
 
 This preponderance of tlie male sex is already found in 
 early life. Thus Matterstock observed 72 cases of appen- 
 dicitis in early life (seven months to fifteen years), and 
 among this number were 51 male children and 21 girls. 
 The greater frequency of appendicitis in the male sex is 
 explained by Van Cott as due to the circumstance that the 
 appendix of the male has a less abundant blood supply 
 than that of the female ; for in the latter there is a col- 
 lateral circulation derived from the sexual ajjparatus. 
 
 With regard to age all writers agree that appendicitis is 
 most frequently encountered between the tenth and thir- 
 tieth years. It occurs less frequently in the first decade 
 of life and in the thirtieth to fortieth years, and is quite 
 rare in advanced age. The following table is submitted 
 with a view of showing the frequency of appendicitis in 
 the dilTerent decades of life as recorded by several eminent 
 writers : 
 
 Ages. 
 
 Fitz. 
 
 Matterstock. 
 
 jSTothnagel, 
 
 Total number 
 
 228 
 
 22 
 
 86 
 65 
 
 84 
 8 
 
 11 
 1 
 
 1 
 
 474 
 
 46 
 
 143 
 
 158 
 
 72 
 
 30 
 
 18 
 
 5 
 
 2 
 
 129 
 
 1 to 10 
 
 1 
 
 10 to 20 
 
 44 
 
 20 to 30 
 
 57 
 
 30 to 40 
 
 14 
 
 40 to 50 
 
 7 
 
 50 to 60 
 
 4 
 
 60 to 70 
 
 2 
 
 70 to 80 
 
 
 
 
 
 The frequency of appendicitis in relation to other dis- 
 eases can be studied from the report of the autopsies made 
 
 ' Ad. Volz : "Die dutch Kotbsteine bedingte Perforation des Wurra- 
 fortsatzes, etc., " Karlsruhe. 1846. 
 
 -Matterstock: "Perityphlitis." Gerhardt's Handbuch der Kinder- 
 krank., Tubingen, 1880. 
 
208 DISEASES OF THE INTESTINES. 
 
 in the pathological institute of the Wiener Allgemeine 
 Krankenhaus between 1870 and 1896. According to Noth- 
 nagel, the total number of autopsies was 44,940. Among 
 these the number of cases dying from appendicitis amounted 
 to 148. The percentage of appendicitis, therefore, was 
 0.32. With regard to sex there were 107 males (72.3 per 
 cent) and 41 females (27.7 per cent). The actual fre- 
 quency of appendicitis among the living, however, is much 
 greater than appears from these numbers, which relate 
 only to cases which have resulted fatally. 
 
 3Iorhid Anatomy. — The pathological anatomy of appen- 
 dicitis has been thoroughly studied recently, not only in 
 autopsies but principally in operative cases. In the latter 
 an insight is permitted into the changes which take place 
 early in the disease. Fowler distinguishes four stages of 
 anatomical lesions according to the spread of the morbid 
 process involving the different tissues of the appendix. In 
 the first stage (endo-appendicitis) more or less intense in- 
 flammation of the mucous and submucous layers takes 
 place. The second stage (parietal appendicitis) consists 
 in an inflammatory process involving the interstitial or 
 intermuscular structure of the body of the appendix. The 
 third stage (peri-appendicitis) means an inflammatory proc- 
 ess involving all the layers of the appendix, the peritoneum 
 included.' The fourth stage (para-appendicitis) consists in 
 lesions involving the appendix and the neighboring tissues. 
 This process is most often accompanied with suppurative 
 inflammations of the connective tissue adjacent to that por- 
 tion of the appendix which is not covered with perito- 
 neum. 
 
 According to Fowler, the above described stages are not 
 essentially different processes but furthel: developments of 
 one and the same lesion. 
 
APPENDICITIS. 209 
 
 Kieclel,' Notlinagel, and others distinguisli two different 
 types of appendicitis wliicli are of great clinical importance. 
 They are the following : 
 
 1. Catarrhal appendicitis (endo-appendicitts) . Here in the 
 acute form the mucosa of the appendix is swollen and red- 
 dened, the submucosa is engorged and filled with round 
 cells. The follicles are distinctly swollen. The appendix 
 appears swollen and more rigid, and its lumen is filled with 
 thick yellowish contents, mostl}^ mucus; sometimes the 
 latter may be mixed with fecal matter. Occasionally there 
 are fecal concretions. Often ecchymoses of the mucosa 
 occur, leading sometimes to superficial defects (erosions). 
 All these lesions may entirely disappear after the acute at- 
 tack is over, and thus a perfect cure may be established. 
 This, however, is i:)Ossible onlj' if there is no occlusion of 
 the lumen of the appendix and the inflammatory products 
 can be emptied into the caecum. 
 
 In the large majority of cases of catarrhal appendicitis 
 the cure is 3iot a perfect one and chronic appendicitis is 
 the result. In this stage the mucosa of the appendix 
 presents a slate-gray appearance. It is filled with accumu- 
 lations of round cells; at the same time proliferation of 
 connective tissue and occasionally blood pigment are found. 
 The submucosa and muscularis may show no changes 
 whatever, although as a rule they are hypertroj)hied. The 
 latter condition is probably due to stricture of the lumen 
 of the appendix and consecutive muscular (compensatory) 
 hypertrophy. The chronic form of appendicitis, owing to 
 suppurative processes of the mucous membrane, occasion- 
 ally leads to a total destruction of the mucosa, and an ob- 
 literation of the lumen of the appendix. This condition is 
 
 ' Riedel : " Ueber die Friihoperation bei Appendicitis purulenta seu 
 gangraenosa. " Berl. klin. Wochenschr. , 1899, Nos. 33 and 34. 
 14 
 
210 DISEASES OF THE INTESTINES. 
 
 very similar to obliteration of the lumen due to the involu- 
 tion processes wliicli have been mentioned above. The 
 appendix then forms a solid membranous band of uniform 
 thickness or with a few small protrusions. As a rule it is 
 found embedded in peritonitic adhesions. 
 
 Sometimes primary slight lesions of the apijendix lead 
 to complications, especially if a stricture is present. Thus 
 an accumulation of secretion within the occluded appen- 
 dicular cavity may take place and give rise to the forma- 
 tion of a cyst. Such cysts occur, varying in size from a 
 cherry to a fist. Guttmann ' observed a cyst of the appen- 
 dix fourteen centimetres (five and a half inches) long and 
 twenty-one centimetres (eight and a quarter inches) wide. 
 The contents of such a cyst are either of a watery mucous 
 character or gelatinous. 
 
 If ulceration takes place in the occluded appendicular 
 cavity, it may give rise to the formation of a small abscess 
 (py-appendix or empyema processus vermiformis). In 
 these cases the purulent process may penetrate the wall 
 of the appendix and lead to perforation. A timely opera- 
 tion in many instances prevents such an outcome. 
 
 2. The severe form of appendicitis {cqjpendicitis idcerosa 
 et gangrcenosa, appendicitis perforativa) . In this group 
 the bacterial infection is of a much more virulent nature 
 -than in the catarrhal form. The inflammation originating 
 in the mucosa of the appendix at once involves all its lay- 
 ers, including the serosa. Necrobiotic processes and for- 
 mation of pus take place quite early. The peritoneum is 
 also very soon involved, either in the immediate neighbor- 
 hood of the appendix or in its entirety. Ulcerations and 
 gangrenous processes may lead to the destruction of a 
 
 ^ P. Guttmann -. Verhandlungen des Vereins fur innere Medicin zu 
 Berlin, 1883-84, p. 301. 
 
APPENDICITIS. 211 
 
 part of the appeudix, thus causing perforation, or to a total 
 necrosis of the entire appendix. As a result of this proc- 
 ess the latter may be cast off from the csecum and be found 
 free in the iDeritoneal cavity or embedded in jdus. 
 
 The way in which the peritoneum is involved is quite 
 variable. There may be an adhesive type of peritonitis 
 leading to a matted and agglutinated condition of the ap- 
 pendix, or a circumscribed or diffuse peritonitis without 
 adhesions. The contents of the appendix may be emptied 
 into the abdominal cavity or hemmed in by adhesions. 
 The size, location, and direction of the abscess differ 
 greatly. The location and length of the appendix and the 
 portion perforated play an important part in this respect. 
 In the great majority of cases the abscess is at first intra- 
 peritoneal, but very soon extends toward the surface or 
 above or below Poupart's ligament. Again it may pene- 
 trate into the bladder, vagina, small intestine, or rectum. 
 In some instances it reaches the diaphragm and from 
 there perforates into the pleural cavity. 
 
 In some very grave cases there is no abscess but a dif- 
 fuse peritonitis. Here we often meet with a paretic con- 
 dition of the intestine, the latter being filled with gas ; the 
 serous layer is shiny and red, while there is an absence of 
 any exudation. In other cases a small quantity of a purely 
 serous or bloody serous exudation is found. The condi- 
 tion just described may be discovered either in operations 
 undertaken very early or at autopsies in cases which ter- 
 minate fatally at the beginning of the disease. In still an- 
 other group of cases which is a comparatively very small 
 one, the general peritonitis may assume a more protracted 
 and chronic form. In these cases mattings and adhesions 
 are formed over more or less large areas of the abdominal 
 cavity, and in these accumulations of jjus may be found. 
 
212 DISEASES OF THE INTESTINES. 
 
 Appendicitis due to tuberculosis is of comparatively rare 
 occurrence and shows a great tendency to tlie formation of 
 fistulse. Recently actinomycosis lias been found to be the 
 cause of some cases of appendicitis with the formation of 
 abscesses. In these cases the actinomycosis fungi can 
 easily be demonstrated. 
 
 Symptomatology . — In describing the symptomatology of 
 appendicitis it will again be best to differentiate the two 
 forms already mentioned above, namely, the catarrhal and 
 the severe form. 
 
 1. Catain'lial or endo-appendicitis. An attack of appendi- 
 citis is usually characterized by a sudden appearance of 
 pain in the abdominal cavity, which at first may be dif- 
 fused or in the region of the navel, but very soon is local- 
 ized in the right iliac region. A moderate rise of temper- 
 ature is very frequently present. Slight gastric symptoms, 
 nausea, and sometimes vomiting often occur, but are, as a 
 rule, only transient. The i)ains usually increase in inten- 
 sity, and the patient assumes a fixed position with the legs 
 flexed. Any change in the position or any movement of 
 the thighs increases the x)ain. Examination by palpation 
 shows extreme tenderness on pressure of the right iliac re- 
 gion, more especially at McBurney's j^oint, while the rest 
 of the abdomen can be examined by pressure without giv- 
 ing rise to the slightest pain. While the pains are gener- 
 ally continuous, they may show periods of exacerbation. 
 The latter, according to Nothnagel, are most probably due 
 to a spastic contraction of the muscles of the appendix. 
 
 The term " appendicular colic " has been given by Tala- 
 mon to the same condition. Talamon, however, assumed 
 that the colic is always due to an attempt of the appendix 
 to rid itself of a fecal concretion. Inasmuch as operations 
 for appendicitis have often been performed during the at- 
 
APPENDICITIS. 21? 
 
 tack of colic and no fecal concretions whatever found in 
 the appendix, and inasmuch as coproliths have been found 
 in cases in which no colic whatever existed, this theory 
 cannot be maintained. 
 
 In some cases there is an area of resistance in the right 
 iliac region. If the latter be due to an accumulation of 
 fecal matter in the csecum, the tumor can be slightly moved 
 and its shape changed by pressure. In a few of the cases 
 of catarrhal appendicitis the resistance is due to an inflam- 
 matory swollen (serous) condition of the apjiendix and of 
 the neighboring organs. In this instance the tumor is not 
 circumscribed but rather diffuse, immovable, and its shape 
 unaffected by pressure. 
 
 In comparatively few cases can the appendix be directly 
 palpated. It then appears as an elongated round body of 
 the size of the little finger, and is very painful on pressure. 
 The examination of the appendix itself, whenever this is 
 possible, is certainly of the utmost importance for diagno- 
 sis. Edebohls * deserves much credit for having cultivated 
 and perfected the method of examining the appendix by 
 palpation. According to Edebohls, this examination is best 
 done as follows : The patient lies upon his back with the 
 legs comfortably flexed. The physician standing at the 
 patient's right begins to search for the appendix by apply- 
 ing two, three, or four fingers of his right hand, palmar 
 surface downward, almost flatly upon the abdomen at or 
 near the umbilicus ; while now he draws the examining fin- 
 gers over the abdomen in a straight line from the umbili- 
 cus to the anterior superior spine of the right ilium, he 
 notes successively the character of the various structures 
 as they come beneath and escape from the fingers passing 
 over them. In doing this the pressure exerted must be 
 ' Edebohls : American Journal of the Medical Sciences, May, 1894. 
 
214 DISEASES OF THE INTESTINES. 
 
 strong enougli to recognize distinctly along the whole 
 route traversed by the examining fingers the resistant sur- 
 face of the posterior abdominal wall and of the pelvic brim. 
 Only in this way can we positively feel the normal or 
 slightly enlarged appendix. Pressure short of this must 
 necessarily fail. 
 
 E, T. Morris ' suggests for Edebohls' method of palpating 
 the use of three right-hand fingers to feel with and three 
 left-hand fingers placed upon these to press with. The 
 fingers that are to do the feeling are pressed by means of 
 the three others down to the border of the right rectus ab- 
 dominalis muscle at the level of the navel and slowly drawn 
 toward the examiner. I have found both these methods 
 very useful in detecting the position and size of the ap- 
 pendix. 
 
 The temperature is usually but slightly raised, some- 
 times even normal. The pulse likewise is either normal 
 or but moderately accelerated. 
 
 Constipation is often present, but seems to be rather the 
 result of the inflammatory condition of the appendix than 
 its cause, as was formerly believed. In a comparatively 
 small number of cases diarrhoea is present during the at- 
 tack of appendicitis. 
 
 Course. — An acute attack of catarrhal appendicitis may 
 last from two to three days to two to three weeks. After 
 this variable period of sickness the symptoms either en- 
 tirely disappear or persist in a slight degree. With regard 
 to the further development the following classes must be 
 distinguished: 1. There may be complete recovery without 
 any further trouble. 2. The patient may entirely recover 
 from the present attack, but have a return of the disease 
 after a variable period of time (from a few weeks, a few 
 
 ' R. T. Morris : "Lectures on Appendicitis," New York, 1899, p. 45. 
 
APPENDICITIS. 215 
 
 montlis to a year or two) — "recurrent appendicitis." 3. 
 The symptoms may not completely disappear but may 
 persist for many weeks and the patient may remain in a 
 lingering condition — "subacute or chronic appendicitis." 
 
 The first class of perfect recoveries is comparatively small. 
 In this group there is either an obliteration of the appen- 
 dix or the catarrhal process may have subsided completely 
 without having left behind any lesions. The second class 
 of recurrent appendicitis comprises the majority of the 
 cases. In these a chronic catarrhal condition of the mu- 
 cosa of the appendix may persist without manifesting 
 symptoms until a new invasion of micro-organisms gives 
 rise to an acute exacerbation of the process, or strictures 
 of the lumen of the appendix may have formed as a conse- 
 quence of the acute attack and thus become the cause of 
 renewed disturbances later on. In the third category the 
 catarrhal appendicitis has led to severe anatomical lesions. 
 There may be a considerable thickening of the appendix; 
 wall including the serosa. The appendicular lumen may 
 show ulcerations, strictures, or bends. There may also 
 be an accumulation of pus (py-appendix) . The second 
 and third varieties may exist without manifesting distinct 
 symptoms of the appendicular lesion, the patients com- 
 plaining merely of manifold digestive disturbances (appen- 
 dicitis larvata of Ewald ') . 
 
 2. The severe form of appendicitis {appendicitis suppura- 
 tiva or perforans). The disease usually begins quite sud- 
 denly in the midst of perfect health ; rarely it is preceded 
 by slight digestive disturbances. The patient is seized with, 
 violent pains in the abdomen. These are felt at first either 
 over the entire abdomen, in the epigastric region, or on 
 
 'C. A. Ewald: " Krankheiten des Darmes und Bauclifells," Beiliu, 
 1903, p. 226. 
 
216 DISEASES OF THE INTESTINES. 
 
 the left side of the abdomeri, but very soou they settle in 
 the right iliac region. The pains are of an intense charac- 
 ter, and occasionally are accompanied by paroxysms dur- 
 ing which they are almost unbearable. Any motion in- 
 creases the pain. The patient lies perfectly' motionless 
 and breathes superficially. The appearance is that of a 
 very sick person, the countenance manifests great suffer- 
 ing and anxiety. The temperature is usually considerably 
 increased and continues so during the first days of the dis- 
 ease. The pulse is accelerated. Occasionally it is of 
 small calibre, easily compressible, and at times irregular. 
 The latter phenomena are found principally in critical 
 conditions. A very frequent pulse and a comparatively 
 low degree of fever are also considered bad omens. There 
 is always complete anorexia and great thirst, the tongue 
 is dry and thickly coated, the bowels, as a rule, are con- 
 stipated. In rare instances there is diarrhoea. Accord- 
 ing to Nothnagel, vomiting is present in almost three- 
 quarters of the cases. It usually appears right at the 
 commencement of the disease and lasts only a short time. 
 In exceptional instances it persists for several days. The 
 vomited matter consists of gastric contents, mucus, and 
 bile. In very grave cases it exceptionally assumes a fecu- 
 lent character. The vomiting is occasionally accompanied 
 by hiccoughs. Both these phenomena are very annoying 
 and at the same time increase the pain through the mo- 
 tions evoked by them. 
 
 In many of the cases, soon after the commencement of 
 the disease a tumor begins to form in the right iliac re- 
 gion. At first a rigidity of the muscles in this region is 
 noted; later on a distinct resistance over an area of egg 
 size may be found. The tumor is either circumscribed 
 and sharply defined, or it is diffuse and connected with 
 the neighboring tissues. The skin over the tumor is as 
 
APPENDICITIS. 217 
 
 a rule easily movable, while the latter is immovable. The 
 tumor generally consists of a purulent exudation in and 
 around the appendix and congested portions of the intes- 
 tines, occasionally of the omentum, and of a purulent infil- 
 tration of the abdominal wall itself. In some instances 
 the size of the tumor is considerably increased by an ac- 
 cumulation of fecal matter in the caecum. The tumor may 
 be discovered by palpation and sometimes by percussion. 
 Fluctuation is present onh' in ver^' extensive abscesses. 
 Its absence does not signify the absence of pus. The re- 
 sistance as a rule increases either very slowly or quite 
 rapidly. In rare instances, namely in those in which the 
 abscess is surrounded by a firm capsule, it may remain 
 unchanged for a long time. The abscess occasionally in- 
 volves the muscles and even the skin lying above it. The 
 latter becomes infiltrated and oedematous, and in rare in- 
 stances the abscess may spontaneously open through the 
 skin. Occasionally the resistance disappears entirely when 
 the purulent exudation has descended into the deeper parts. 
 In such an event, by an examination through the rectum, 
 and in females through the vagina, the exudation may be 
 discovered filling Douglas' space. 
 
 In cases in which there is an extensive inflammation of 
 the peritoneum accompanied by a considerable quantity of 
 pus, severe pains in urination appear quite early, after two 
 or three days (Fleischer). On this account the patients are 
 often rather afraid to urinate. In the same cases there 
 may also be parsesthesia and anaesthesia in the limbs, or 
 obstinate erections of the penis, or a drawing up of the 
 right testicle. These symptoms all show that the accumu- 
 lation of pus presses upon the nerves of the sacral plexus. 
 
 The further course of the disease will largely depend 
 upon the way in which the newly formed pus around the 
 appendix acts. Often it leads to a perforation of the ap- 
 
218 DISEASES OF THE INTESTINES. 
 
 pendix. Sometimes the abscess forms adhesions and is' 
 eucapsuled. Sometimes, again, the abscess penetrates into^ 
 the peritoneal cavity and gives rise to diffuse septic or 
 fibrino-purulent peritonitis. 
 
 Perforation of the appendix which occurs quite fre- 
 quently in this class of cases is accompanied, according 
 to Sonnenburg, by the following symptoms: The disease 
 begins with febrile and marked symptoms; violent pains 
 in the abdomen appearing either suddenly or after a short 
 period of slight uneasiness and concentrating very quickly 
 in the right side; vomiting accompanied by diarrhoea and 
 in other cases by constipation ; small and frequent pulse ; 
 fever commencing with chills and quickly rising; pro- 
 nounced tympanites; general appearance extremely bad; 
 slight cyanosis and perspiration; a distinct area of resist- 
 ance over or around the affected spot. "WTiile all these 
 symptoms are certainly found in cases of perforation of 
 the appendix, they can by no means be absolutely relied 
 upon; for they may exist in the same manner without a 
 perforation taking place, and, on the other hand, the lat- 
 ter event may occur without any of the above-mentioned 
 symptoms being present. For these reasons Boas ' is re- 
 luctant to make the diagnosis of perforative appendicitis, 
 and contents himself with determining the presence of 
 purulent appendicitis. 
 
 Perforation peritonitis most often appears between the- 
 second and fourth days of the disease (Fitz). The danger 
 of a penetration of pus into the free peritoneal cavity less- 
 ens with the length of time the disease has lasted, on ac- 
 count of the formation of adhesions. On the other hand, 
 numerous other perilous events may take place. In some: 
 cases a few days after the commencement of the disease 
 
 1 J. Boas : " Diagnostik und Therapie der Darmkrankheiten, " Leip- 
 zig, 1899. 
 
APPENDICITIS. 219 
 
 there is a subsidence of the most important symptoms 
 (pains, fever, etc.), Avliile in others they persist with undi- 
 minished severity. Even in the first class, however, the 
 amelioration rarely persists, for pretty soon afterward the 
 pains reappear and the fever recurs, and in connection 
 with these symptoms the inflammation increases and the 
 pus augments. Periods of improvement and exacerbation 
 of the condition may alternate for quite a while until at 
 last either recovery or a fatal issue ensues. 
 
 A spontaneous cure or recovery without surgical inter- 
 vention inay occur in one of the following ways : 
 
 1. The abscess may become encapsulated, the pus losing 
 its virulence and becoming absorbed. In such an event the 
 tumor disappears and the patient is either definitely or ap- 
 parently' cured ; for dangers to life remain after such a cure 
 in consequence of the remnants of the abscess and of the 
 adhesions formed among the intestines. " The occurrence 
 of a sudden bursting of the abscess," using Ewald's words, 
 " hangs like the sword of Damocles over the head of the 
 patient as long as there is still pus present." In seemingly 
 perfect health a fatal peritonitis may thus occur in patients 
 who had previously suffered from an attack of appendicitis. 
 
 2. A cure may be established by the opening of the 
 abscess into adjacent hollow viscera. Thus the abscess 
 may open into the caecum, colon, small intestine, bladder, 
 vagina, or pelvis of the kidney. This favorable issue is, 
 however, rare. 
 
 3. The abscess may find its way externally by ruptur- 
 ing spontaneously through, the skin. Sometimes, however, 
 the pus burrows into other organs ; thus it may reach the 
 diaphragm (subphrenic abscess), and sometimes even force 
 its way through into the pleural cavity and perhaps the 
 lungs. But even from these places the pus may be evacu- 
 
220 DISEASES OF THE INTESTINES. 
 
 ated spontaneous!}-, principally through rhpture into a 
 bronchus and its expulsion during a coughing spell. 
 
 In a large number of cases peritonitis and septicaemia 
 terminate the life of the patient ; in others after recovery 
 there are frequently grave recurrences of the disease. 
 
 Diagnosis. — Catarrhal appendicitis can be diagnosed if 
 there is a sudden onset of pain in the right abdominal cav- 
 ity, principally in the region of the appendix, combined 
 usually with a slight rise of temperature and some light 
 gastric symptoms (nausea, anorexia, vomiting). The 
 grave form of the disease or purulent appendicitis shows 
 the same manifestations, only of a much severer type. 
 Besides there are always present signs of serious illness. 
 The patient is very pale and manifests an anxious ap- 
 pearance. Chills are frequently present and the tempera- 
 ture shows a certain irregularity in its course. There may 
 be a marked rise in temperature after it has been quite 
 low or almost normal for a time. 
 
 The presence of a tumor in the right iliac region is of 
 great importance in the diagnosis of appendicitis, although 
 this symptom is frequently absent. In order to recognize 
 the nature of the tumor with regard to its contents, espe- 
 cially whether pus is present or not, Sahli jQrst suggested 
 the use of an exploratory puncture. If pus can be aspi- 
 rated through the needle, then an abscess is positively 
 present. Although many physicians make use of this 
 method even nowadays, as for instance Ley den,' Noth- 
 nagel, Penzoldt,'^ Fleischer, Boas, and others, most of the 
 surgeons are decidedly opposed to this diagnostic measure 
 (Fowler, Treves,^ Sonnenburg, and others). In this coun- 
 
 'E. vonLeyden: Berl. klin. Wochenschr., 1889, No. 31. 
 
 '^Penzoldt: "Behandlung der Erkrankungen des Darras." Pen- 
 zoldt-Stintzing's "Handbucn der speciellen Therapie innerer Krank- 
 heiten, " Jena, 1896. 
 
 ^Treves: " On Peritonitis." British Medical Journal, 1894. 
 
APPENDICITIS. 221 
 
 try the consensus of opinion is against the use of explora- 
 tory puncture, for its employment adds a new element of 
 danger to the case, while its results, especially if negative, 
 are unreliable. 
 
 While appendicitis can usuallj^ be diagnosed without 
 difficulty, in some instances its recognition is quite diffi- 
 cult. In cases in which the appendix is abnormally situ- 
 ated, as for instance in the left iliac region or in the upper 
 part of the right abdominal cavitj^ the diagnosis of appen- 
 dicitis will hardly be possible. 
 
 Differential Diagnosis. — The following conditions may at 
 times be confounded with ajjpendicitis, namely, biliary, 
 renal, and intestinal colic. The following points will serva 
 as a guide in making a correct diagnosis. In biliary colic 
 the pains are referred by the iDatient to the right abdominal 
 cavit}^ radiating to the back and up to the shoulders. Pal- 
 pation shows a painful area situated immediately below the 
 right margin of the ribs ; occasionally jaundice is present. 
 In kidney colic (right side) the pain is felt by the patient. 
 in the right lumbar region, radiating toward the bladder. 
 There is generally a frequent desire for micturition and 
 slight burning in the urethra. The urine may show the 
 presence of mucus, sometimes of blood and pus cells. In 
 intestinal colic the pain may be referred to the right iliac 
 region, but, as a rule, it is relieved very soon after the 
 passage of .flatus. In contradistinction to these three con- 
 ditions the pain in appendicitis is referred to the right 
 iliac region, where it remains localized, does not disappear 
 upon passage of flatus, does not radiate to the shoulder 
 and but very rarely to the bladder, while there is also great 
 tenderness and pain upon pressure at McBurney's point. 
 No jaundice is present and the urine is normal. 
 
 In women the differential diagnosis between appendici^ 
 tis and a right-sided salpingitis is not always easily made. 
 
222 DISEASES OF THE INTESTINES. 
 
 A thorough examination through the vagina, however, will 
 in most instances enable us to decide as to the true condi- 
 tion. If the appendix is situated in the small pelvis and 
 has given rise to the formation of an abscess in this local- 
 ity the decision of the question whether the abscess is 
 due to appendicitis or to oophoritis is extremely difficult 
 and sometimes even impossible. T^^phoid fever in ex- 
 ceptional cases may simulate an appendicitis; the pres- 
 ence or absence of Widal's reaction will serve to differ- 
 entiate the former. 
 
 Prognosis. — Catarrhal appendicitis affords in most in- 
 stances a favorable prognosis as regaids to life. With ref- 
 erence to complete recovery, however, the outlook is by no 
 means bright, for the liability to recurrence of the disease 
 is very great. Inasmuch as an apparently mild form of 
 appendicitis may all of a sudden change its character and 
 assume alarming features, the prognosis should always be 
 made with a certain reserve, even in this class. 
 
 The purulent form of appendicitis must be regarded 
 as a very serious disease and gives quite an unfavorable 
 prognosis unless timely surgical intervention is adopted. 
 The intensity of the sj'mptoms in purulent appendicitis is 
 by no means a correct measure of the gravity of the dis- 
 ease. Experience shows that cases with violent symp- 
 toms, very high fever, and intense pains, etc. , occasionally 
 recover within a few days, the pus rupturing rato the intes- 
 tine, while apparently mild cases after a few days of sick- 
 ness suddenly develop symptoms of a general septic peri- 
 tonitis with a fatal issue. Diffuse peritonitis is liable to 
 occur between the second and fourth daj'S of sickness, but 
 even later the patient is subjected to numerous risks. 
 Grave complications may suddenly develop even in a pa- 
 tient who is apparently progressing nicely and already 
 convalescent. Thus purulent appendicitis may give rise 
 
APPENDICITIS. 223 
 
 to pyopneumothorax, empj'ema, or purulent pericarditis, 
 and these complications may result in a fatal issue. The 
 jjroguosis of jDerforatiug appendicitis is decidedly less fa- 
 vorable than that of a simple empyema of the appendix, 
 as in the former septicaemia is liable to occur. 
 
 After having described the numerous dangers present in 
 the severe form of appendicitis it is consoling to say that 
 spontaneous recoveries are, notwithstanding this, in the 
 majority. With regard to the frequency of spontaneous 
 recoveries Nothnagel gives the following statistics : Among 
 130 hospital patients he observed 85 complete recoveries, 
 4 deaths without operation, 30 partial recoveries, and 11 
 cures after operation. The large number of cases reported 
 by Sahli is also very important in this connection. This 
 author reports the results in 7,213 cases of appendicitis; 
 473 cases were operated upon, while 6,740 received onh^ 
 medical treatment. Among the latter 6,194 recovered (91.2 
 per cent) while 591 (8.8 per cent) died. Sahli further 
 states that of the 4,593 cases which had not been operated 
 upon and in which inquiries had been made with regard 
 to recurrence of appendicitis, 3,635 were cured without 
 &nj recurrence. 
 
 Nothnagel says that circumscribed appendicitis is cura- 
 ble in the large majority of cases, and that about eighty 
 per cent recover under simple medical treatment. Among 
 the rest there are still some that can be cured by means 
 of operative procedures. Careful watching of the pa- 
 tient and timely surgical intervention in proper cases 
 may reduce the number of deaths from appendicitis to 
 perhaps five per cent or three per cent. It is, however. 
 Impossible entirely to avoid fatal issues, even with the 
 greatest and strictest watchfulness. Aside from accidental 
 complications and from rare cases in which a correct diag- 
 nosis is hardly to be made, there remain instances in which 
 
224 DISEASES OF THE INTESTINES. 
 
 the peritoneum is diffusely affected quite early without 
 presenting any symptoms. These are the cases which 
 make the prognosis unfavorable and thej' form the great- 
 est contingent of deaths among patients with appendicitis. 
 The acute septic form with perforation of the appendix is 
 the most dangerous, while the progressive suppurative form 
 is comparatively favorable. 
 
 Treatment. — With reference to lyropTiylaxis the swallow- 
 ing of fruit pits, of very small bones, and coarse, indi- 
 gestible matter in the food was formerly strictly forbidden. 
 Nowadays, however, we know that the above-named sub- 
 stances play no part whatever in the etiology of appendi- 
 citis. Regulation of the bowels or, more practically^ speak- 
 ing, correcting constipation has been believed to be of 
 importance in preventing appendicitis. This maxim can 
 likewise not be maintained on the ground of recent re- 
 searches. Regularity of the bowels is in itself of impor- 
 tance, and hence it will be advisable to pay attention to 
 this factor. The only means we possess of preventing an 
 attack of appendicitis is the removal of the appendix. 
 While this suggestion is not generally practicable, for it 
 requires an operation which is not entirely without risk, 
 it may, however, be carried out in cases requiring a lap- 
 arotomy for other diseases, provided that this additional 
 operation does not demand too much time. 
 
 The medical treatment of appendicitis consists in abso- 
 lute rest of the entire body, especially of the intestinal 
 tract, and in appropriate diet. The patient must be kept 
 strictly abed from the commencement of the disease until 
 it is entirely over. He should not be permitted to leave 
 the bed for a moment. He must lie perfectly quiet ; even 
 turning from one side to the other should be avoided, or if 
 done, performed with the greatest care. In taking nour- 
 
APPENDICITIS. 225 
 
 ishment the head may be slightly raised; the urine should 
 be voided in a glass, and an evacuation of the bowels 
 should take place in a bed-pan. During this act the pa- 
 tient must be forbidden to strain or exert himself in any 
 way. The utensils needed must be handled by the nurse, 
 who must also attend to the cleansing of the patient. 
 
 The principle of rest must also be applied with reference 
 to diet. During the first few days of illness there should 
 be either total abstinence from food (only small quantities 
 of water being given now and then), or liquid food in small 
 portions. Thus strained barley water, or this with the 
 addition of a little milk, oatmeal water and rice water 
 given in the same way, chicken soup, very weak tea. In 
 the very severe forms of appendicitis, especially when per- 
 foration has taken place, or when symptoms of ileus and 
 fecal vomiting are present, absolute abstinence from food 
 and also drink is necessary. In accordance with Penzoldt, 
 Ewald, and Boas, rectal feeding appears to me to be con- 
 traindicated in these cases and the only way of supplying 
 the organism with nutritive material is a subcutaneous 
 injection of saline solutions, sugar solutions, and also per- 
 haps small subcutaneous injections of olive oil. 
 
 Small pieces of ice may from time to time be given to 
 the patient. He must, however, keej) the ice in his mouth 
 until it melts before swallowing. This often alleviates the 
 nausea and retching. The first two or three days of sick- 
 ness being over, the patient may be allowed to have milk, an 
 egg beaten up in bouillon or milk, in addition to the above- 
 named food. The diet should be kept up in this way until 
 the pains and fever have entirely disappeared. At this pe- 
 riod soft-boiled eggs, crackers, small portions of meat 
 (squab) or chopped beef may be given, and still later mashed 
 
 potatoes, bread and butter, and light vegetables added. 
 
 16 
 
226 DISEASES OF THE INTESTINES. 
 
 Medicaments. Tlie use of cathartics is mentioned here 
 onh^ in order to condemn it. Even injections into the 
 bowels should not be administered too frequently nor in 
 large quantities. A small enema of one-half to one pint of 
 water or one-half pint of olive oil may occasionally be given. 
 
 The remedy par excellence in the treatment of appendici- 
 tis is opium. Its use was originally recommended by Eng- 
 lish physicians (Graves, Stokes) and later by French clin- 
 icians (Petriquin, Grisolle) ; in Germany this remedy 
 found a fervent advocate in Yolz and in America in Alonzo 
 Clark. During the last decade the administration of opium 
 has met with great opposition especially on the part of many 
 surgeons. Their reasons against the use of this remedy are, 
 first, that opium masks the true picture of the disease, and 
 secondly, that it gives rise to paralysis of the intestines. 
 
 Some of the foremost clinicians, Nothnagel, Penzoldt, 
 Ewald, Sahli, Boas, and others, are even nowadays en- 
 thusiastic admirers of the opium treatment. The prin- 
 cipal element of importance of ojnum as a remedy is its 
 action in lessening or arresting the peristalsis of the in- 
 testine, and besides in alleviating pain. I myself have 
 always used and still use the opium treatment with great 
 satisfaction. It is of course understood that the opium 
 should be given only in sufficient amount to alla,y the pain, 
 while excessive doses should be avoided. As soon as the 
 active stage of the disease is passed, the opium must be 
 entirely discontinued. The best way of administering it 
 is that suggested by Sahli . Ten or fifteen drops of tinc- 
 ture of opium are at first given every hour until there is 
 a decided subsidence of the pain. Then five to six drops 
 are given every two or three hours until the pains disap- 
 pear completely. As soon as there is an exacerbation an- 
 other large dose is administered, but if the patient is entirely 
 
APPENDICITIS. 227 
 
 free from pain uo opium is given. If the administration 
 of the drug excites nausea or vomiting, it may be given in 
 tlie form of a suppository : 
 
 H Extr. opii 0. 05 
 
 01. theobrom 1.00 
 
 M. f. supp. One suppository every four hours until subsi- 
 dence of pain. 
 
 Or belladonna extract, 0.005-0.01 gm., may be added to 
 the opium in the same suppository. 
 
 Boas I'ecommends the administration of opium subcuta- 
 neously. (Extr. opii aquosi sterilis. 0.3 to 10.0 water; 1 
 Pravaz syringe [1 gm.] three times daily.) 
 
 In cases in which the pains are very intense and a quick 
 action is desired, morphine ni&j be administered subcuta- 
 neously in doses of gr. |- to ^. The action of this remedy 
 is, however, not so satisfactory as that of opium, as it has 
 but a very slight influence in diminishing the peristalsis. 
 When morphine is used, opium should be given in addition. 
 
 Poultices. The application of ice over the painful area 
 is often beneficial at the beginning of the disease, espe- 
 cially if the temperature is quite high and symptoms of 
 peritoneal irritation are present. If the i:)atientj however, 
 complains of great discomfort from the application of ice, 
 it must be discontinued. In the latter instance a cold 
 Priessnitz poultice may be tried. Cases not accompanied 
 by high fever often derive great relief from the application 
 of a hot- water bag or plain warm poultices. The latter 
 are especialh^ to be recommended in that form of appendi- 
 citis which is called appendicular colic of Talamon. 
 
 Surgical Treatment. — The question of operation in ap- 
 pendicitis is a very live one nowadays and is being every- 
 where discussed. The medical profession has not yet come 
 to a unanimous conclusion in regard to it. Surgical treat- 
 
228 DISEASES OF THE INTESTINES. 
 
 ment of appendicitis originated in this country, Dr. Regi- 
 nald Fitz of Boston having done the first operation for 
 this purpose, and it has been practised and perfected here 
 more than anywhere else. It is therefore quite natural 
 that we find many more advocates of surgical intervention in 
 America than abroad. As a general rule the majority of sur- 
 geons frequently recommend operative intervention, while 
 the larger number of physicians reserve the surgical treat- 
 meDt only for a small number of grave cases of aiDpendicitis. 
 
 Fowler, Morris, Beck, Deaver, Murphy, and others in 
 this country and Legueu ' in France urge surgical treat- 
 ment in every case of appendicitis. Legueu says: "Ap- 
 pendicitis belongs to surgery." . . . "There is no medi- 
 cal treatment of appendicitis." . . •. "Every appendicitis 
 must be operated early." C. Beck^ expresses himself 
 in the following manner: "No matter how mild the clini- 
 cal picture of appendicitis appears, even if it promises a 
 quick temporary recovery, the operation is always justi- 
 fied. Inasmuch as the gravit}^ of infection can never be esti- 
 mated at the beginning, it appears wiser to look upon every 
 case of appendicitis as serious. Of two evils one should 
 choose the lesser, and the lesser one here means opera- 
 tion. " In his article Beck makes the two following asser- 
 tions : "1. Appendicitis is a surgical disease and should be 
 treated surgically as soon as diagnosed. 2. So long as no 
 physician is able to estimate the gravity of the bacterial 
 infection at the commencement of the disease or to foresee 
 the course which the appendicitis will pursue, whether 
 mild or grave, the safest treatment consists in the early 
 removal of the appendix," 
 
 'Felix Legueu: "Traitmeut de I'Appendicite. " Suite de Mono- 
 graphies Cliniques, 1899, No. 80. 
 
 2 C. Beck : "Appendicitis. " Vollimann's Sammlung klinischer Voi- 
 trage, No. 221, Sept., 1898. 
 
APPENDICITIS. 229 
 
 Many surgeons, even in this conntr}", however, do not 
 take so radical a view as the above writers. Thus Willy 
 Meyer/ Charles McBurney, W. T. Bull, A. J. McCosh and 
 F. Hawkes," and others do not recommend the early opera- 
 tion in milder forms of appendicitis. McCosh and Hawkes 
 express themselves in the following manner with regard to 
 the necessity of operative interference : " When the presence 
 of pus is assured, the sooner operation is done the better. 
 Also there are cases which begin and continue for twenty- 
 four or forty-eight hours with such severity that a judicious 
 mind must conclude that operation is demanded. So in the 
 chronic and relapsing cases where the symptoms have con- 
 tinued for months with such severity and have recurred 
 so frequently as to subject the patient to a life of semi-in- 
 validism, no wise surgeon can counsel any other plan of 
 treatment than removal of the diseased appendix. Likewise 
 when the patient has suffered from three or more attacks 
 the offending organ should be removed, for other attacks 
 will in all probability follow. The same indication for 
 operation also exists in our opinion if a patient has suf- 
 fered from two attacks within a year or eVen two years." 
 ..." The view which we take is that operation is not 
 necessary in every case of appendicitis. We believe that 
 not infrequently patients recover, and recover permanently, 
 from one attack of appendicitis, and that in a certain num- 
 ber of cases, provided a careful watch is kept, operation is 
 not necessary. On the other hand, we acknowledge that 
 many cases which did not appear to be serious have been 
 allowed to die when they might have been saved by opera- 
 tion." 
 
 ' Willy Meyer : " When Shall we Operate for Appendicitis? " Medi- 
 cal Record, February 29. 1896. 
 
 ^ A. J. McCosh and F. Hawkes : " The Surgical Treatment for Appen- 
 dicitis." The American Journal of the Medical Sciences, May, 1897. 
 
230 DISEASES OF THE INTESTINES. 
 
 Willy Meyer, who was among the first to recommend 
 the removal of the appendix during the free interval, comes 
 to the following conclusions in his paper already men- 
 tioned: "1. In case of diffuse perforative appendicitis the 
 operation must always be done at once. 2. In cases of 
 acute appendicitis the patient always needs careful obser- 
 vation. If the ]3ulse goes above 116 and 120 and has a 
 tendency to stay there, the indication for an operation is 
 given. In cases of doubt the operation is better than 
 waiting. In cases of subacute attacks of appendicitis, also 
 after the first severe attack from which the patient recovers 
 without immediate operation, the appendix should be re- 
 moved. The appendix once inflamed has to be looked upon 
 as a diseased organ which is very apt to give repeated and 
 more serious, even fatal, trouble in the future." 
 
 Among the German surgeons Sonnenburg, and especially 
 Eiedel,' are advocates of early surgical intervention in the 
 grave forms of appendicitis. Riedel says : " As soon as the 
 temperature reaches 101°, the imlse 100, the immediate 
 removal of the appendix is indicated. ... A tumor which 
 has developed, accompanied by fever and an acceleration 
 of the pulse, is always an indication for immediate opera- 
 tion." R. Stein" aud Henry J. Wolf,' in papers read quite 
 recently before the German Medical Society of New York, 
 urged early surgical intervention in all the graver forms 
 of appendicitis. 
 
 With Penzoldt, Nothnagel, Ewald, Boas, and others I 
 would give the following indications for surgical interven- 
 tion in this disease : 
 
 1 Riedel : " Ueber die sog. Fruhoperation bei Appendicitis puru 
 lenta resp. gangraenosa. " Berliner klinische Wochenschrift, 1899, 
 33 und 34. 
 
 2R. Stein: Deutsche med. Wochenschr., 1899, p. 440. 
 
 ^H. J. Wolf: New Yorker raedicinische Monatsschrift, 1899. 
 
APPENDICITIS. 231 
 
 1. Diffuse peritonitis in consequence of jjerf oration of 
 the appendix demands immediate operation. As a rule tlie 
 following sj^mptoms will be found : Sunken and drawn fea- 
 tures, cyanosis, a small and very frequent pulse, an increase 
 of the jjainf ul area, often also a bloated condition of the 
 abdomen. 
 
 2. Whenever an appendicular abscess showing fluctua- 
 tion is present, an operation should be performed. 
 
 3. If the protracted course of the disease points to the 
 existence of an abscess, giving rise to slight septic symp- 
 toms, an ox^eration should be undertaken. 
 
 While in these three groups there can be no hesita- 
 tion in recommending the operation, in the following 
 groups the necessity of surgical intervention must be con- 
 sidered and decided in each individual case. 
 
 4. («) If the rational treatment does not produce any im- 
 provement in the course of three to five clays, the symptoms 
 persisting in undiminished severity or becoming even more 
 pronounced, an operation may be resorted to. (&) A sud- 
 den rise of temperature lasting over twenty-four hours, 
 after the first few days of sickness, is also an indication for 
 operation, (c) A very frequent pulse, not corresponding 
 to the degree of fever, is another symptom which justifies 
 the consideration of an operation, (c/) If the tumor con- 
 tinues to increase in size after the fifth day of sickness, an 
 operative treatment should be considered. 
 
 5. The removal of the appendix should be undertaken : 
 (a) In all cases of appendicitis in which after recovery the 
 pain in the right iliac region persists for a long time (sev- 
 eral months) ; (b) in recurrent appendicitis if the attacks 
 have been quite severe or if they have followed each other 
 at short intervals. 
 
CHAPTER IX. 
 
 INTESTINAL OBSTKUCTION. 
 
 " {Acute and Chronic. ) 
 
 Introductory Remarks. — By intestinal obstruction is un- 
 derstood a great variety of conditions which, although 
 unlike in character, have yet the common feature of me- 
 chanically causing an obstruction to the passage of con- 
 tents along the intestine. Leichtenstern ' distinguishes the 
 following three groups with regard to the causation of the 
 intestinal obstruction : 
 
 1, Occlusion due to pressure from without or com- 
 pression of the intestinal lumen in the full sense of the 
 word. To this group belong incarcerations of the intes- 
 tines in apertures, in slits, and in hernial openings; 
 strangulation by pseudo-ligaments, the vermiform proc- 
 ess, and diverticula ; compression by tumors, by the mes- 
 entery, or by displaced abdominal organs. Rotations of 
 the intestinal tube around its axis (torsions) and forma- 
 tion of knots also belong to this category. 
 
 2. Occlusion from within the intestinal lumen (obtura- 
 tion). The obturation may be produced either by gall 
 stones, enteroliths, foreign bodies, hai'dened fecal masses, 
 or by neoplasms of considerable size, especially polypi. 
 Intussusception (involution of one coil of the bowel into 
 another) also belongs to this class. 
 
 ' Leichtenstern : " Verengerungen, Verschliessungen und Lagever- 
 anderungen des Darms." Ziemssen's " Handbuch der speciellen Patho- 
 logie und Therapie, " Bd. vii.. Leipzig, 1878. 
 
ACUTE OBSTRUCTION. ' 23.S 
 
 3. Occlusions which originate from factors within the 
 intestinal wall and causing narrowing of the lumen either 
 directly or indirectly. Constriction may occur either in 
 circular form (strictures) or as a result of flexions. Ob- 
 structions developing after chronic peritonitis, distortions, 
 and angular bends of the intestine, cicatricial stenoses 
 as well as those produced by neoplasms, belong to this 
 class. 
 
 Notwithstanding the diversity and great multiplicity of 
 the anatomical factors causing stenoses and obstructions of 
 the intestines, the clinical picture and the consecutive le- 
 sions which they evoke greatly resemble each other. It 
 will therefore perhaps be practical to give first the clinical 
 picture of complete obstruction of the bowels (ileus) and 
 of stenosis of the intestine, and then to discuss the differ- 
 ent anatomical causes and also the differential diagnosis. 
 
 ACUTE INTESTINAL OBSTRUCTION. 
 
 Synonyms. — Ileus, miserere, passio iliaca. 
 
 Definition. — An acute stoppage of the passage of the in- 
 testinal contents. This may be caused either by a me- 
 chanical occlusion at a certain part of the intestinal canal 
 (mechanical ileus) or by an entire absence of motor power 
 in a portion of the bowel (dynamic or paralytic ileus) or 
 sometimes by both (mechano-dynamic ileus). 
 
 Etiology. — The etiology of ileus is quite complicated, 
 and it will be best to analyze separately the different factors 
 producing it. 
 
 Compression of the Intestines. Compression of the in- 
 testines can occur: (1) by strangulation through adhesions, 
 bends or pseudo-ligaments, by Meckel's diverticulum, by 
 normal structures abnormally attached, by slits and aper- 
 
234 DISEASES OF THE INTESTINES. 
 
 tures in the mesentery and omentum, and by incarcerations 
 into hernise; (2) bj^ torsions (volvulus); and (3) by tumors 
 from without. 
 
 The primary factor in producing isolated adhesions 
 (bands or pseudo-ligaments) is a preceding localized peri- 
 toniti^. In some cases these bands may have been con- 
 genital and due to intra-uterine peritonitis. The band 
 may have the form of a firm fibrous cord or it may be very 
 slender and may appear as a tough, rigid thread. Occa- 
 sionally it may be of comparatively large size. Seldom 
 the constricting ligament has the appearance of an actual 
 band, having a width of half an inch or more. 
 
 The strangulation of the intestine hy an isolated peritoneal 
 adhesion takes place in two ways : first, the intestine may 
 be strangulated under the band as beneath a shallow and 
 narrow arch; secondly, it may become snared and con- 
 stricted by a noose or knot formed by the false ligament 
 itself. Strangulation from bands occurs when these are com- 
 paratively short and tightly stretched over a firm surface. 
 The arch beneath which the implicated bowel passes is 
 usually large enough to admit one to three fingers. Stran- 
 gulation by a noose or knot requires the presence of a long 
 false ligament which must lie loose and free in the abdom- 
 inal cavity, being attached only at its two ends. The most 
 common way in which a coil of intestine becomes snared 
 is where a lax band forms a ring or spiral between its fixed 
 points. Through this ring a loop of the small intestine 
 slips ; the protrusion becoming larger the implicated coil 
 cannot free itself from the noose and is strangulated. 
 
 Strangulation by the formation of a knot is described by 
 Leichtenstern in the following manner : " There are several 
 kinds of this knotting. The most frequent is the follow- 
 ing : A long and loose ligament is fastened at one end to 
 
ACUTE OBSTRUCTION. 
 
 235 
 
 a loop of the small intestine, and hangs in the form of a 
 simple coil (Fig. 31); if the top of the intestinal loop 
 passes directly through the coil a simple knot is formed 
 about the piece of the intestine, as is shown in Fig. 32. 
 It is evident that the same result can be ])roduced by the 
 
 Fig. 32. 
 
 Fig. 34. FIG. 31. 
 
 Figs. 31-34.— Types of Constricting Peritonitic Bands. (After Leichtenstem and Treves.) 
 
 coil being drawn over the top of and around the intestinal 
 loop. Another and rarer form of knot is produced as fol- 
 lows: A long and perfectly loose false ligament forms a 
 simple coil between its points of attachment. If now one 
 leg of the so-called primary noose passes through it we 
 have a knot like that shown in Fig. 33, and if now the 
 
236 DISEASES OF THE INTESTINES. 
 
 intestinal loop passes directly through (Fig. 34), it be- 
 comes firmly caught and strangulated. A common char- 
 acteristic of all described knots is that when the strangu- 
 lated intestine is freed, the ligament can immediately be 
 drawn out straight." 
 
 Strangulation hy JleckeVs Diverticulum. Meckel's diver- 
 ticulum is due to the persistence or incomplete oblitera- 
 tion of the vitelline duct. Most commonly it exists as a 
 blind tube, given off from the ileum. Its length is about 
 three inches. As a rule, it is cylindrical in shape, with a 
 conical extremity. Occasionally it presents a globular 
 «hape and is then called "clubbed." Meckel's diverticle 
 is always single and is attached to the ileum one to three 
 feet above the ileo-csecal valve. As a rule, the end of the 
 diverticulum is free. In some instances it is attached to 
 the umbilicus or to the abdominal wall. Sometimes the 
 end attached to the abdominal jjarietes may give way and 
 form fresh adhesions with some points of the peritoneal 
 surface. The latter occurrence is of great importance with 
 reference to strangulation of the intestine, which frequently 
 takes place under these conditions. By means of the new 
 adhesion of the diverticulum a loop is formed -in which 
 some portion of the intestine is liable to engage. Another 
 possibility for strangulation by the diverticulum is afforded 
 when its end is free and club-shaped. The diverticulum 
 forms a ring into which its own free end projects. A loop 
 of the intestine entering the centre of this ring may push 
 the clubbed end of the process before it and so tie the 
 knot, thus leading to obstruction. Again the diverticulum 
 may surround the pedicle of an intestinal loop in such a 
 way as to encircle it with a single knot (see Figs. 35, 36, 37). 
 
 In a similar manner as Meckel's diverticulum some nor- 
 mal structures may act when they are abnormally attached. 
 
ACUTE OBSTRUCTION. 
 
 23T 
 
 Thus the vermiform appendix may become adherent to 
 some point of the neighboring peritoneum and so form an 
 
 arch under which 
 
 1 e l.^ • Fig. 35. Fig. 36. 
 
 a loop oi the m- 
 
 testine may b e 
 strangulated. 
 The Fallopian 
 tube may likewise 
 become adherent 
 to the ^adjacent 
 peritoneum situ- 
 ated in the iliac 
 fossa and thus 
 form an arch in- 
 to which a por- 
 tion of the intes- 
 tine may slip and 
 become incarcer- 
 ated. Other in- 
 ternal organs ab- 
 normally at- 
 tached mky form 
 similar traps for 
 intestinal stran- 
 gulation. 
 
 Of great clini- 
 cal importance is 
 the strangulation 
 
 of the intestine in slits and apertures of the mesentery or 
 omentum. These may be either congenital or of traumatic 
 origin. Similar to the action of slits in the production 
 of strangulation ftre also the various internal herniae (her- 
 nia duodeno-jejunalis, hernia retroperitonealis anterior. 
 
 Fig. 37. 
 
 Figs. 35-37.— Knotting of a Meckel's Diverticulum which 
 has a Button-like Swelling of its Extremity. (Treves.) 
 
238 DISEASES OF THE INTESTINES. 
 
 hernia intrasigmoida, hernia bursse omentalis, formed 
 by the foramen of Winslow, diaphragmatic hernia). 
 
 In all these cases the mechanism of the obstruction is as 
 follows : A coil of gut may be driven with sudden severe 
 force beneath the band or through an aperture and become 
 practically strangulated at once, as is often the case in 
 strangulated hernia. There being no natural force to drive 
 the coil out of its place of imprisonment, it remains firmly 
 gripped. In other cases the involved intestine may not be 
 strangulated at first, but the band pressing upon the mes- 
 enteric vessels produces a congestion in the implicated 
 coils, which become engorged and distended by an in- 
 creased accumulation of gas, and thus complete strangu- 
 lation is the result. In other cases, again, the final cause 
 of a strangulation is a twisting of the bowel. All the va- 
 rieties of intestinal strangulation just mentioned occur in 
 the small intestine, the lower portion of the ileum being 
 principally affected, less frequently its upper portion or 
 the jejunum. 
 
 The occlusion may in some cases be due to kinking of 
 the intestine through a band attached to the bowel and 
 dragging upon it. Adhesions may alscrobstruct the bowel, 
 compressing its lumen. This occurs when false mem- 
 branes are situated around the bowel and have undergone 
 shrinking. They then compress the intestine seriously 
 and narrow its lumen. The same process of shrinking 
 may also effect an obstruction of the bowel if it takes 
 place in the mesentery after inflammation. 
 
 Volvulus. By the term volvulus is understood an obstruc- 
 tion of the bowel by a twist about its mesentery, or its own 
 axis, or the intertwining of an intestinal coil within another. 
 Twisting of the bowel occurs most often in the sigmoid 
 flexure. The usual cause of this trouble is chronic consti- 
 
ACUTE OBSTRUCTION. 239 
 
 pation, for iu this condition the flexure fs more or less 
 constantly distended. Its walls become partly paralyzed 
 and hang down into the pelvis, like an inert heavy mass, 
 being filled with fecal matter. Traction is thereby exerted 
 upon the mesocolon and a loop is soon formed. A twist- 
 ing of the latter is brought about either by some displace- 
 ment of the bowel or hy a sudden change in the position 
 of the body. The ascending colon, csecum, and the small 
 intestine may also be affected in the same manner, al- 
 though less frequently. Intertwining of the intestine is 
 here more often met with. 
 
 Obturations of the Intestine. Intestinal occlusion often 
 takes place in consequence of obturation of the lumen of 
 the gut through foreign bodies lodging therein. Accumu- 
 lations of fecal matter may give rise to such an occurrence. 
 The hard fecal tumor is then situated either in the caecum 
 or in the colic or sigmoid flexures. In these cases chronic 
 constipation has existed for a long time. 
 
 Gall stones, although rarely, give rise to intestinal oc- 
 clusion. In order to do this they must be of considerable 
 size. " The puzzle as to how the camel could go through 
 the eye of the needle, i.e., how these enormous gall stones 
 could reach the bowel, has been solved, by the assumption 
 on fair evidence that an ulcerative process opens the way 
 from the gall bladder to the bowel, though doubtless very 
 large stones occasionally find their passage through the 
 ducts" (E. D. Ferguson'). 
 
 In a similar manner enteroliths may also cause obstruc- 
 tion of the bowel. This happens especially if an entero- 
 lith situated in an intestinal diverticulum has been dis- 
 lodged and found its waj^ into the canal of the gut. 
 
 ' E. D. Ferguson : Transactions of the New York State Medical 
 Association, 1898, p. 233. 
 
240 DISEASES OF THE INTESTINES. 
 
 Foreign bodies wliicli have been accidentally or inten- 
 tionally swallowed may under favorable conditions reach 
 some part of the bowel and here obstruct the lumen. This 
 will occur if the foreign body is of considerable size, or if 
 it is not smooth but provided with sharp points. The 
 latter catch in a fold of mucous membrane and prevent its 
 further passage. The most varied substances have thus 
 been found to be the cause of intestinal obstruction : mar- 
 bles, stones, coins, glass stoppers, corks, spoons, knives, 
 forks, keys, needles, pins, buttons, false teeth with the 
 plate. Kernels of fruit like cherries, prunes, etc., may 
 accumulate in the bowel and by means of fecal matter be 
 kept together, forming a large conglomeration, completely 
 obstructing the canal. 
 
 Recently Murphy's button has also been found in a few 
 instances to cause obstruction of the bowel. 
 
 Intestinal parasites (tapeworms, ascaris lumbricoides) , if 
 present in large numbers, may also form a mass obstruct- 
 ing the canal. This occurs especially after a vermifuge 
 has been administered and the dead parasites have re- 
 mained within the canal. 
 
 Similar to the action of foreign bodies are also tumors 
 (polypi, fibroma, myoma, etc.) connected by a pedicle 
 with the intestinal wall, filling up its lumen. 
 
 Intussusception. Intussusception or invagination means 
 the prolapse of one part of the intestine into the lumen of 
 an immediately adjoining part. An intussusception shows 
 in a vertical section six layers of intestine, three on either 
 side of the central canal, which are more or less parallel to 
 one another. The arrangement of the layers is such that 
 mucous membrane is in contact with mucous membrane, and 
 peritoneum with peritoneum. On transverse section the 
 invaginated mass shows three concentric rings of bowel. 
 
ACUTE OBSTRUCTION. 241 
 
 The external of tlie three layers is called the intussusci- 
 piens, the sheatli, or the receiviug layer. The innermost 
 cylinder is called the entering layer and the middle one the 
 returning layer. The latter two together form the intus- 
 snsceptum. The neck of the intiissusceptum is at its up- 
 per part where the returning layer joins the sheath. 
 
 In case the intussusception lasts for some time the se- 
 rous surfaces of the gut touching each other may become 
 glued together and ultimately adherent. This will prevent 
 the disengagement of the invaginated portion, while its fur- 
 ther passage into the other bowel will not be interfered 
 with. The mesentery always participates in the invagina- 
 tion and becomes more or less compressed and wedged in 
 by the sheath. The whole mass of a simple intussuscep- 
 tion may in its turn become iuvaginated and give five in- 
 stead of three coats, or even seven if the process is re- 
 peated, so that the upper edge of the intussuscipiens is 
 rolled over like a cuff. These double and triple intussus- 
 ceptions are comparatively rare. 
 
 With regard to the mechanism of intussusception Noth- 
 nagel's experiments on animals have proven of greatest 
 value. According to this writer intussusception may be 
 due either to a localized spastic contraction of a portion 
 of the bowel or to a total i)aralysis. The normal gut im- 
 mediately below the contracted part slips upward to a slight 
 extent over this strongly contracted and greatly narrowed 
 portion, and invagination is thus produced. Again if a 
 segment of the bowel is paralyzed, the gut lying immedi- 
 ately below it, on contraction will slip into the paralyzed 
 portion and thus an invagination may arise. 
 
 Intussusception may take place at any point within the 
 
 entire small and large intestines. Over fifty per cent of 
 
 the cases consist of the invagination of the ileum into the 
 16 
 
242 DISEASES OF THE INTESTINES. 
 
 colon. With regard to tlie remote cause of intussuscep- 
 tion Treves ' lias examined a number of reported cases and 
 found it in one hundred examples of intussusception dis- 
 tributed as follows : 
 
 1. No evident exciting cause 63 per cent. 
 
 2. Diarrhoea, dysentery, enteritis, marked irregularity of 
 
 the bowels 8 " 
 
 3. Polypi 5 " 
 
 4. Ingesta 5 " 
 
 5. Injuries and exposure to cold 5 " 
 
 6. Certain acute and chronic ailments which may or may 
 
 not have had a concern in the etiology, such as 
 typhoid fever, whooping-cough, measles, scarlet 
 fever, smallpox, cholera, and hernia ; with these 
 may be included pregnancy and labor 15 " 
 
 Total 100 " 
 
 This clinical form of intussusception must not be con- 
 founded with agonal intussusceptlou, which, as the term 
 indicates, occurs shortly before death and is purely of 
 anatomical importance. The agonal form of intussuscep- 
 tion is sometimes found multiple and is met with fre- 
 quently at autopsies of children who have died from affec- 
 tions of the brain. 
 
 Pathological Changes. — The lesions which are encountered 
 in acute ileus, no matter what be its origin, are the follow- 
 ing: The intestinal coils above the occluded part of the 
 bowels present a quite different appearance from those 
 below. The former are distended, filled with gas and ill- 
 smelling feculent contents; and this ectatic condition is 
 the more pronounced the nearer they are situated to the 
 occluded part. If the occlusion lies in the jejunum or 
 ileum, the distention will involve the entire upper portion 
 of the small intestine and also the stomach. If, however, 
 the stoppage is situated within the colon, the dilatation 
 * Treves : "Intestinal Obstruction," p. 211. 
 
ACUTE OBSTRrCTIOK 243 
 
 will at first occupy that portion of tlie colon situated be- 
 tween tlie ileocEecal valve and , tlie obtruded spot, wbile 
 the small intestine may remain unchanged, the ileocsecal 
 valve acting in its usual way and thus i^reventing an over- 
 ilow of the contents of the colon into the small intestine. 
 Under such circumstances the dilated portion of the colon 
 may attain considerable size, resembling almost the stom- 
 ach. After the condition has lasted a few days, however, 
 the ileocaecal valve ceases to functionate and now the con- 
 tents of ijhe colon overflow the small intestine and the 
 stomach and these organs become also overfilled and dis- 
 tended. The portion of the intestine situated below the 
 occlusion is empty and contracted. 
 
 The intestinal coils above the occluded spot are usuallj'^ 
 engaged in very active peristaltic movements, which repre- 
 sent an attemj)L of nature to overcome the obstacle. After 
 these peristaltic motions have lasted a few days, a paralytic 
 state of the intestines supervenes. 
 
 The intestinal mucosa situated near the occlusion is 
 subjected to great mechanical and chemical irritations 
 due to the constant i)resence of considerable amounts of 
 decomposed material, and thus grows intensely inflamed. 
 Often ulcers develop which may penetrate the wall of 
 the bowel and cause fatal peritonitis. In rare instances 
 after such a perforation, adhesion to neighboring intes- 
 tinal coils may occur and give rise to fecal abscesses 
 and abnormal communications between different intestinal 
 segments. By means of a similar process an opening may 
 be established between the intestine and the abdominal 
 walls in such a manner that the fecal matter finds an exit 
 here (anus prseternaturalis). 
 
 Localized or general peritonitis is thus often present in 
 cases of intestinal obstruction. Serous, bloody, or puru- 
 
244 DISEASES OF THE INTESTINES. 
 
 lent exudation is frequently found in the abdominal cav- 
 ity. The anatomical lesions are most pronounced in the 
 immediate vicinity of the occluded intestine. This is due 
 not only to the stoppage of the intestinal contents but also 
 to interference with the circulation of the gut produced by 
 the same factors which have caused the obstruction. Nu- 
 merous large and small mesenteric veins become com- 
 pressed, thus causing congestion and hemorrhages. The 
 intestinal walls appear infiltrated with blood, showing ec- 
 chymoses at various places, and may even apj^ear dark 
 red. In the neighborhood of the occlusion the intestine 
 may be covered with black curdled blood in the form of 
 a membrane. Its walls become brittle and gangrenous. 
 
 Symptomatology . — The symptoms of acute intestinal ob- 
 struction appear either suddenly or after slight disturb- 
 ances have existed for a few days, as for instance diar- 
 rhoea, constipation, feeling of uneasiness. In some 
 instances the history of an exciting cause is given. Thus 
 a severe blow on the abdomen, violent bodily exertion, a 
 cold, a too copious meal, or a strong laxative. 
 
 The patients are first seized with violent abdominal 
 pains, sometimes of a crampy character. The pain may 
 be felt at first at a certain definite spot within the abdo- 
 men, while later it becomes more diffuse. In other in- 
 stances the patient is unable to localize the pains dis- 
 tinctly. Occasionally the area around the navel is given 
 as the seat of the pains, while in other cases they are re- 
 ferred to the entire abdomen. The pain usually exists un- 
 interruptedly, though it may show exacerbations from time 
 to time. Soon after the occurrence of these colicky pains 
 eructations of gas and then vomiting appear. At the be- 
 ginning gastric contents are ejected, later bile, and finally 
 offensive feculent material is brought up. The latter usu- 
 
ACUTE OBSTRUCTION. 245 
 
 ally has a yellowish-brown color, is liquidj and contains 
 only very fine, small, solid particles suspended in the fluid. 
 At this period the eructated gases have a fetid odor and 
 hiccough almost constantly distresses the patient. After 
 the act of vomiting the patient may feel somewhat relieved 
 for a short while, but soon there is a return of the severe 
 symptoms. 
 
 Almost simultaneously with vomiting, meteorism of the 
 abdomen ensues. The i)assage from the rectum is entirely 
 stopped and there is no evacuation either of fecal matter 
 or of flatus. The meteorism may involve either a certain 
 region of the abdomen or the entire canity. The tympani- 
 tes gradually increases and a feeling of tension becomes 
 more and more x^ronounced. The diaphragm is soon 
 pushed upward by intestinal coils filled with gas in such 
 a manner that the liver dulness may be absent from the 
 entire right thoracic cavity. Dyspnoea supervenes; the 
 breathing becomes accelerated and superficial, assuming 
 the thoracic type. The pulse is small and frequent. The 
 extremities are cold, the skin is covered with perspiration, 
 the face is pale, bearing the expression of utmost anguish, 
 the eyes are sunken, dryness of the throat and extreme 
 thirst exist, and the patient is barely able to use his voice. 
 These extremely painful and tormenting symptoms persist 
 and the patient succumbs— unless there is a change in the 
 course of the disease — remaining conscious until the end. 
 
 After having given a general description of the clinical 
 picture of ileus it will not be amiss to discuss each symp- 
 tom separately. 
 
 1. Pains. Pain, the most constant and conspicuous 
 symptom of intestinal obstruction, depends upon several 
 conditions. It is usually due, first, to the injury inflicted 
 on the peritoneum and the intestinal walls in consequence 
 
246 DISEASES OF THE INTESTINES. 
 
 of the strangulation; secondly, especially at a somewhat 
 later period, to the tumultuous and increased irregular 
 peristaltic movement of the intestines. These movements 
 above the site of obstruction are of a very intense charac- 
 ter and produce " colic " as well as exacerbations of the 
 pains which occur at certain intervals. The intensity of 
 the pain depends upon the degree of excitability of the 
 individual, upon the state of the sensorium, upon the ex- 
 tent of the intestine and peritoneum involved, and upon 
 the severity of the occluding lesion and the rajDidity of its 
 occurrence. Later on the pain is iniinenced by the dis- 
 tention of the gut and by the presence or absence of peri- 
 tonitis. 
 
 At the commencement of the disease the pain is fre- 
 quently not aggravated and sometimes relieved by press- 
 ure. Later, however, the pain is considerably increased 
 by even slight pressure, the cause of this being the pres- 
 ence of peritonitis. 
 
 According to Treves,^ the pain is constant, although 
 liable to periodical exacerbations in cases of complete ob- 
 struction. In cases in which the obstruction is but par- 
 tial the pain is distinctly intermittent, and the patient 
 experiences intervals between attacks of pains during which 
 he is free from suffering. The pain as a rule grows more 
 intense with the progress of the disease. There may be, 
 however, a diminution in the severity of the pain for a short 
 period before a fatal issue, caused by a collapse, paralysis 
 of the intestine, rupture or perforation of the bowel, or by 
 a diminished activity of the sensorium, 
 
 Treves has pointed out that no matter in what part of the 
 small intestine the obstruction is situated, the pain arising 
 therefrom is usually referred to the region of the umbilicus. 
 'F. Treves: "Intestinal Obstruction," Philadelphia, 1884. 
 
ACUTE OBSTRUCTION. 247 
 
 If the obstruction is localized in tlie large bowel, tlien the 
 pain may be exi)erienced, especially at the beginning of 
 the disease, at the seat of the lesion; later, however, the 
 pain may assume a more diffused character or may be felt 
 at other regions of the abdomen. This is the reason why 
 only the initial i)ain is of some diagnostic significance with 
 regard to the seat of the lesion. 
 
 2. Vomiting. Vomiting is almost always present. At 
 the beginning of the disease it is of reflex origin due to 
 the irritation of the peritoneum ; later on it must be as- 
 cribed principally to the irregular, strong, peristaltic con- 
 tractions of the intestines. The appearance of fecal vom- 
 iting was believed by the old writers to be a sign that the 
 obstruction was situated in the large bowel. Nowadays, 
 however, it is generally known that this symptom is often 
 present in cases in which the obstruction is situated in the 
 ileum or even in the jejunum. The reason of absence of 
 putrefactive jDrocesses in the intestinal contents normally is 
 the rapidity with which they are moved farther on along 
 the canal until they reach the large bowel. In obstruction, 
 however, the peristaltic contractions are much slower and 
 thus putrefactive processes develop even in the small bowel. 
 
 In order to explain the mechanism of stercoraceous vom- 
 iting a reversed peristaltic or antiperistaltic motion of the 
 intestines was formerly assumed. Of late, however, the 
 mechanism of fecal vomiting as expounded by Haguenot ' 
 as early as 1713, is now generally accepted. According to 
 this author, stercoraceous vomiting takes place in the fol- 
 lowing manner : Above the occluded intestine there is an 
 accumulation of more or less liquid intestinal contents in. 
 
 ^ Haguenot : " Memoire sur les Mouvernents des Intestins dans la. 
 Passion Iliaque. " Histoire de TAcademie Royale des Scieoces, Paris, 
 1713. 
 
248 DISEASES OP THE INTESTINES. 
 
 considerable quantity; the bowels being distended with 
 large amounts of gas are under constant pressure, which 
 is increased after each inspiration and especially after 
 energetic contraction of the abdominal muscles, occur- 
 ring for instance during the act of vomiting. Under the 
 influence of pressure the stagnant liquid contents are re- 
 gurgitated from above the occluded spot into places in 
 which there is less resistance and thus reach the duo- 
 denum and the stomach. Here they irritate the mucous 
 membrane and cause vomiting. 
 
 This theory is perfectly in accord with the circumstance 
 that in stercoraceous vomiting mostly liquid or sometimes 
 semi-liquid contents are evacuated, but never solid fecal 
 matter ; for even in obstruction of the colon the fluid will be 
 moved farther upward while solid particles will remain in 
 the lower portion of the bowel. Vomiting of formed fecal 
 matter is a very rare occurrence, and must be ascribed to an 
 existing fistulous opening between the colon and stomach. 
 
 3. Constipation. Constipation almost always exists and 
 is very obstinate. After injections, very rarely spontane- 
 ously, there may be a slight movement of the bowel con- 
 sisting of the fecal matter lodged below the occluded spot. 
 In some rare instances a catarrhal condition may exist 
 in the segment of the bowel below the obstruction, and 
 the patient then may rather have diarrhoea combined with 
 tenesmus. Of greater significance than the absence of 
 stools is the inability to pass wind through the anus. The 
 passage of flatus is a sure sign that the permeability of the 
 intestine has been re-established. 
 
 4. 3Ieteorism. Meteorism is the result of increased for- 
 mation of gas developing in consequence of putrefactive 
 processes as well as of diminished absorption. According 
 to Zuntz, the absorption of intestinal gases into the blood 
 
ACUTE OBSTRUCTION. 249 
 
 takes place only wlien the circulation is in good working 
 order. Meteorism tlius indirectly points to a disturbed 
 circulation wliicli is often found in cases of incarcerations. 
 If meteorism is absent the absorption of gases must be 
 assumed to take place as rapidly as their formation. Me- 
 teorism may be at first present at a certain circumscribed 
 spot of the abdomen and later become more diffuse. If 
 the place at which it first appears can be distinctly defined, 
 this is of diagnostic importance with regard to the location 
 of the occlusion. 
 
 If the occlusion is in the large bowel the portion situated 
 between it and the ileocsecal valve will become considera- 
 bly distended with gas. Thus a protrusion of the right 
 side of the abdomen will be noticed when the obstruction 
 is at the right flexure. If the obstacle is situated in the 
 rectum there is at first a protrusion of the left side of the 
 abdomen and later the tympanites will involve the portion 
 of the abdomen situated above the navel (course of the 
 transverse colon) . In some instances, however, obstruction 
 of the rectum may be acompanied by more or less general 
 meteorism. This is especially the case after the disease 
 has lasted some time ; for then, as a rule, the resistance of 
 the ileocsecal valve is overcome by the gas pressure and 
 it remains more or less patent in such a way that the gases 
 easily penetrate the small intestine. 
 
 In occlusions affecting the duodenum or the upper part 
 of the jejunum the meteorism as a rule involves the upper 
 half of the abdomeu, and remains confined to this area. 
 After vomiting there is usually a perceptible decrease of 
 the protrusion for a short while. 
 
 If the meteorism has lasted for some time and is in- 
 tense, the abdomen assumes a barrel shape. This is espe- 
 cially found in cases in which the distended intestinal coils 
 
250 DISEASES OF THE INTESTINES. 
 
 are already paralyzed. The accumulation of gas can now 
 go on without encountering much resistance -and thus do 
 great harm. The diaphragm is then pushed upward. The 
 lungs as well as the heart become compressed. Stomach, 
 liver, and bladder are compressed by the intestinal coils 
 filled with gas lying upon them. In a similar manner the 
 large veins (vena cava, vena portse, etc.) are subjected to 
 the same disturbance. Thus the function of many impor- 
 tant vital organs is interfered with and impaired to such a de- 
 gree, if this condition persists, tliat a fatal issue may occur. 
 
 5. Collapse. The diverse symptoms of shock which ap- 
 pear in a marked degree in cases of ileus must be ascribed 
 to the sudden damage inflicted upon the peritoneum and 
 intestinal wall by the strangulating agent. The mechani- 
 cal irritation involves first the splanchnic nerves, and 
 through them the circulatory apparatus. As a conse- 
 quence there are a lowering of the temperature of the sur- 
 face, cold sweats, lividity of the extremities, anaemia of the 
 brain, and a small and rapid pulse. The degree of the 
 collapse d.epends upon the disposition of the patient, upon 
 the suddenness of the strangulation, and upon the amount 
 of peritoneum or of intestine involved in the lesion. 
 
 The gravest amount of shock is met with in cases in which 
 a considerable segment of the intestine is suddenly strangu- 
 lated and an injury thus abruptly inflicted upon an exten- 
 sive nerve area. As a rule, the shock met with in cases of 
 obstruction of the small intestine is much more pronounced 
 than in cases in which the obstruction is situated in the 
 large bowel. The reason for this is the greater supply of 
 nerves and the greater activity of the small intestine as 
 compared with the large bowel. The nerves of the small 
 intestine are also more directly associated with the great 
 sympathetic ganglia of the abdomen. 
 
ACUTE OBSTRUCTION. 251 
 
 6. The Decrease of the Amount of Fluid in the Blood. 
 In intimate connection with tlie disturbance of tlie nerves 
 and circulator}^ functions just described is the decrease in 
 the amount of fluid in the blood. This is due to increased 
 secretion in the intestine with absence of absorption, to 
 vomiting, and to increased perspiration. As a consequence 
 there exist dryness of the tongue and a tormenting thirst ; 
 the urine is also passed only in small quantities, and in 
 some instances there may even be anuria. 
 
 Certain symptoms which occur but rarely and also be- 
 long more or less to this group are cramps, tetanus, coma, 
 delirium, fever. Whether these symptoms are due to 
 auto-intoxication or to other factors (especially the dry con- 
 dition of the blood) is as yet not settled. 
 
 Objective Signs. — Inspection reveals either a symmetri- 
 cal fulness of the abdomen (sometimes barrel shaped) or a 
 protrusion of certain parts. Thus, as mentioned above, 
 the upper part of the abdomen is protruded when the oc- 
 clusion involves the duodenum or the ui^per part of the 
 jejunum. The right iliac region is intensely tympanitic 
 if the occlusion involves the hepatic flexure, while the left 
 iliac region is the seat of the protrusion if the occlusion 
 involves some portion of the descending colon. After the 
 disease has existed for some days there is as a rule a gen- 
 eral marked swelling of the abdomen. 
 
 Palpation reveals in some cases a circumscribed area 
 which is painful on pressure and thus serves to localize 
 the seat of the disease. This is especially the case very 
 soon after the onset of the symptoms. In the larger num- 
 ber of cases, however, there is a special tenderness either 
 in the region of the navel alone or over the entire abdomen. 
 In comparatively few cases will palpation reveal a tumor 
 situated deeply within the abdomen and in direct connec- 
 
252 DISEASES OP THE INTESTINES. 
 
 tion with tlie site of obstruction. This occurs especially 
 iu intussusception, strangulation, in occlusions due to com- 
 pression by tumors, and in fecal impaction. After a thor- 
 ough palpation of the abdomen a digital examination of 
 the rectum and also of the vagina should be performed. 
 It is hardly necessary to add that a thorough examination 
 should be made of any existing hernia which may be the 
 seat of incarceration. 
 
 By means of auscultation either from a distance or in 
 the immediate neighborhood of the abdomen we are often 
 enabled to judge about the state of the intestinal peristal- 
 sis ; for when the latter takes place in a violent manner 
 splashing and gurgling noises are always audible. 
 
 Percussion is usually of great importance. In general 
 meteorism it permits us to judge of the position of the dia- 
 phragm and liver. If percussion shows a change in char- 
 acter over a certain region of the abdomen during a period 
 of a few minutes, it follows that the condition of an intes- 
 tinal coil lying beneath has undergone some change in its 
 state of fulness, and thus indicates that the bowel is still 
 in active peristalsis. Auscultation and percussion may be 
 used conjointly and serve the same purpose. In case no 
 change whatever is noted on percussion for a very long 
 period of time, there is a suspicion that paralysis of the 
 bowels exists. The liver dulness will be found either 
 partly or entirely absent in almost all cases of perforation, 
 but in some rare instances even without perforation. In 
 the latter event we must assume that intestinal coils filled 
 with gas are lying above the liver. I have observed such 
 a case with recovery during the last year. Sometimes per- 
 cussion may help to discover existing exudation, dulness 
 being found in the lower part of the abdomen. 
 
 Examination of the vomited matter will show the pres- 
 
ACUTE OBSTRUCTION. 253 
 
 euce or absence of fecal elements. The urine is scanty^ 
 very concentrated, often contains albumin, and almost al- 
 ways shows an increase of indicau and i^lienol. Eosen- 
 bacli's reaction is almost always j)resent. 
 
 Course.— The course of an acute obstruction will depend 
 first upon its location, and secondly upon its nature. Tlie 
 higher up in the intestine the obstruction is situated the 
 more rapid as a rule is the course of the disease. Volvu- 
 lus and strangulation of the intestine are generally accom- 
 panied /by a more violent course than is obturation by for- 
 eign bodies. The duration of the disease is not alv/ays 
 the same. In some instances the patient dies very soon, 
 a few hours or a day or two after the commencement of 
 tlie obstruction, of shock and paralysis of the heart. In 
 other instances the disease lasts several days or even a 
 week. In intussusception the duration of the disease is 
 longer, several weeks, showing periods of exacerbations 
 and remissions. 
 
 If the patient recovers from the collapse and there 
 is a spontaneous re-establishment of the patency of the in- 
 testinal lumen {i.e., the obstruction is relieved, which may 
 happen in cases of invagination, torsion, and obturation 
 by foreign bodies), there is at first as a rule a passage 
 of flatus, which may be followed by a fecal movement of 
 offensive odor. In case of invagination there is often some 
 blood in the evacuation. All the symptoms which have 
 previously existed begin to abate, the fecal vomiting ceases, 
 the meteorism becomes less, and the patient gradually re- 
 covers from his severe illness. In cases in which the intes- 
 tinal obstruction has led to considerable anatomical changes 
 within the lumen of the bowel (ulcers, gangrenous proc- 
 esses, adhesions), after a period of comparative euphoria, 
 symptoms of chronic intestinal obstruction may develop. 
 
254 DISEASES OF THE INTESTINES, 
 
 111 the greater number of cases of acute intestinal ob- 
 struction the latter persists, and the patient, if not oper- 
 ated upon, generally dies of diffuse peritonitis, with or 
 without perforation of the intestine. Even without per- 
 foration, peritonitis may readily develop in consequence of 
 the paralytic state of the intestine; for, according to Bon- 
 necken, ' bacteria can easily penetrate the intestinal wall as 
 soon as the latter is in a paralyzed condition and thus give 
 rise to inflammation of the i^eritoneum. 
 
 Circumscribed peritonitis around the occluded part need 
 not give distinct symptoms. General j)eritonitis, however, 
 always enhances the alarming symptoms already existing. 
 Thus the meteorism increases; the dyspnoea, hiccough, 
 and vomiting become more violent, the pains unendur- 
 able ; the heart begins to give out and pronounced collapse 
 appears. Generally there is a rise of temperature and 
 frequentl}^ a fluid exudation within the abdomen is dis- 
 coverable. If perforation of the intestine has taken place, 
 the symptoms just described aijjjear still earlier and with 
 more violence. The abdomen becomes more or less 
 Tounded and the diaphragm is pushed upward in the high- 
 est degree. The liver dulness disappears and the pains be- 
 come excruciating. The shock may be so great that the 
 patient becomes unconscious and remains so until death 
 brings relief. 
 
 Complications appearing during the disease may also be 
 the cause of death. Thus deglutition pneumonia (Schluck- 
 pneumonie) which occasionally occurs by aspiration into 
 the lungs of gastric and intestinal contents during the act 
 of vomiting, or septicsemia in consequence of intestinal per- 
 foration, may develop with embolic processes in the lungs, 
 liver, and other organs. In exceptional cases there occurs 
 ' Bonnecken : Virchow's Archiv, Bd. 120. 
 
ACUTE OBSTRUCTION. 255 
 
 an adliesion of the occluded intestiual coils to the anterior 
 abdominal wall, and after the gangrenous destruction of 
 the latter as well as of parts of the gut, an anus praeter- 
 naturalis develops, or a fistulous oiDening between two por- 
 tions of the intestines, or again a fistula of the intestine 
 into the bladder, uterus, vagina, or stomach. 
 
 Diagnosis. — The diagnosis must deal with the following 
 three x^oints : A. Recognition of the intestinal obstruction. 
 B. Its seat. C. Its etiological factor. 
 
 A. Becognition of the Intestinal Obstruction. The recog- 
 nition of an acute intestinal obstruction is not difficult if 
 the sjmptonis described above are i)resent in a marked 
 degree. Thus total absence of passage of fecal matter and 
 flatus combined with symptoms of collapse, meteorism, 
 pains, and fecal vomiting will permit a positive diagnosis 
 of intestinal obstruction. In manj- instances, however, only 
 a few of the symptoms mentioned are present, and then 
 the diagnosis is quite difficult. The symptom of the great- 
 est diagnostic value is fecal vomiting, although even this 
 alone does not always warrant the diagnosis of obstruction, 
 for it also occurs in intestinal paralysis. The latter con- 
 dition must be especially borne in mind in cases in which 
 there has been a history either of contusion of the ab- 
 domen or of a reposition of incarcerated hernia shortly 
 before the appearance of the disease. The fecal vomiting 
 of hysterics can also be easily recognized, as there are 
 always symptoms jDresent which indicate the true condi- 
 tion. 
 
 The greatest difficulty in diagnosis lies in the differenti- 
 ation betAveen intestinal obstruction and diffuse peritonitis, 
 especialh' if the latter accompanies appendicitis. All the 
 symptoms characteristic of intestinal obstruction may oc- 
 cur also in i^eritonitis. A thorough consideration of all 
 
256 DISEASES OP THE INTESTINES. 
 
 the symptoms and their differentiation in these two dis- 
 eases will, however, permit a decision. 
 
 The following points will serve as a guide in this connec- 
 tion : In acute peritonitis there is a rise of temperature at 
 the beginning of the disease, while in intestinal obstruction 
 there is at first no fever or even a subnormal temperature. 
 There are exceptions, however, and a general peritonitis of 
 a grave nature may run its course without any fever but 
 with symptoms of collapse. The pains on pressure over the 
 abdomen are much more intense in peritonitis ; in intesti- 
 nal occlusion the spontaneous pain may occasionally even 
 be relieved by pressure. Fecal vomiting is of compara- 
 tively rare occurrence in peritonitis, and if present it usu- 
 ally appears later than in intestinal obstruction. The me- 
 teorism is diffuse in peritonitis right from the start. It 
 thus causes a general distention of the abdominal parietes. 
 In obstruction the accumulation of gas is at first less pro- 
 nounced, circumscribed, and increases gradually. In i^eri- 
 tonitis the abdomen becomes tense from the first, while in 
 obstruction, at the commencement at least, it is as a rule 
 soft. The existence of an exudation speaks in favor of 
 general peritonitis. In peritonitis accompanying appen- 
 dicitis there will be besides the above symptoms the phe- 
 nomena characteristic of the latter disease. In some in- 
 stances, however, the differentiation between peritonitis 
 and obstruction will hardly be possible and mistakes are 
 liable to occur. 
 
 Acute intestinal obstruction is occasionally simulated by 
 poisoning with arsenic and also by a very severe attack of 
 cholera. In the former condition there will be a history 
 of poisoning, and in the latter the presence of cholera ba- 
 cilli in the dejecta will clear up the diagnosis. In rare 
 instances a severe attack of biliary colic or of renal colic 
 
ACUTE OBSTRUCTION. 257 
 
 may in some respects resemble intestinal obstruction. A 
 tliorongli examination, however, will always reveal the true 
 condition. In biliary colic as a rule there is swellicg of 
 the liver and sometimes jaundice; in renal colic the pains 
 radiate from the kidney to the bladder, there is a burning 
 sensation during urination, and the urine often contains 
 mucus and occasionally a few pus corpuscles or blood cells. 
 Intestinal colic resulting from chronic lead poisoning occa- 
 sionally simulates true obstruction of the bowels. The 
 anamnesis, however, will show that we have to deal with 
 lead poisoning. Besides, in these cases there is, as a rule, 
 a more or less sunken condition of the abdomen. Simple 
 intestinal colic (of nervous origin) will hardly ever give rise 
 to mistakes in the diagnosis, as the clinical picture is less 
 severe and the disease quickly subsides. 
 
 B. Location of the Ohsf ruction. The location of the seat 
 of the obstruction is not merely of theoretical value, but of 
 great practical importance, for this decides the question 
 as to where abdominal incision should be made in cases of 
 operation. It will be useful to discuss first at what point 
 of the abdomen the obstruction is situated, and secondly, 
 what particular portion of the bowel it involves. 
 
 1. The point at which the patient first experiences pain 
 is significant in case he is able to locate it definitely. In 
 many instances, however, the pain is not experienced in 
 one circumscribed spot, and is often located diffusely in 
 the neighborhood of the navel. The presence of a tensely 
 tympanitic intestinal coil, which does not change its con- 
 figuration and thus makes the abdominal wall protrude 
 asymmetrically, is of great importance; for, according to 
 Von Wahl, such a coil is often found above the occluded 
 segment of intestine. Strong peristaltic contractions run- 
 ning in the same direction over a certain region of the ab- 
 17 
 
258 DISEASES OF THE INTESTINES. 
 
 domen, especially if they return periodically and always 
 in the same area, will serve to locate the place at which 
 the obstruction is situated. For these peristaltic waves 
 pass along the intestine down to the seat of the obstruc- 
 tion, which they are unable to overcome. 
 
 Palpation of the abdomen occasionally reveals the pres- 
 ence of a sausage-like tumor. This occurs especially in 
 cases of intussusception. If such a tumor is present, the 
 location of the obstruction is certainly easy. A thorough 
 examination of all hernial openings will occasionally re- 
 veal an incarceration of the intestine and also show the 
 site of the lesion. If there is no hernia the examination 
 must be continued through the vagina and through the rec- 
 tum. The exploration through the vagina will show whether 
 the pelvic organs are normal, and if not, whether a tumor 
 originating from the genital organs is compressing the in- 
 testines. Digital examination of the rectum will enable us 
 to discover a stricture, an intussusception, or a tumor of 
 the lower portion of the bowel. In some cases a thorough 
 examination of the entire rectum and the descending colon 
 may be undertaken with the whole hand under chloroform 
 narcosis, according to the method of Simon. In cases of 
 intussusception involving the sigmoid flexure and rectum, 
 the anus often remains open (paralysis of the sphincters) 
 and there appears an involuntary evacuation of a muco- 
 bloody fluid from time to time, 
 
 2. Determination of the Portion of the Intestinal Tract in 
 ivhich the Obstruction is Situated. Small Intestine. If the 
 obstruction is situated in the small intestine all the symp- 
 toms (pains, vomiting, collapse) are, as a rule, much more 
 intense and appear sooner than in obstruction of the large 
 bowel. Soon after the commencement of the disease, there 
 is copious vomiting which may become fecal after a short 
 
ACUTE OBSTRUCTION. 259 
 
 period. The meteorism at the begiuning is localized in the 
 upper part of the abdomen, while the lower part remains 
 unchanged. Pronounced visible peristaltic waves in the 
 small intestine also point to an occlusion situated within 
 the latter. 
 
 Jaffe ' was the first to show that obstruction of the small 
 intestine gives rise to pronounced indicanuria. As early 
 as the second or third day of the obstruction, indican can 
 be found in the urine in large quantities. In obstruction 
 of the lar'ge bowel there is as a rule no indicanuria, and if 
 it appears it does so only later in the disease, on the sixth 
 or seventh day. The higher up in the intestinal tract the 
 obstruction is situated, the sooner and the more frequently 
 anuria may appear. Injections of water into the bowel 
 may secure a fecal evacuation. The colon can also be 
 filled with a large amount of water or gas. 
 
 If the obstruction is situated within the duodenum or in 
 the upper part of the jejunum, it can often be easily recog- 
 nized. Obstruction of the duodenum above Vater's papilla 
 will manifest the same symptoms as acute dilatation of the 
 stomach in consequence of a stricture. There will be ischo- 
 chymia and continuous vomiting of chyme. An obstruc- 
 tion situated within the duodenum below Vater's papilla 
 will give rise to vomiting of large quantities of pure bile. 
 The vomited matter may contain acids from admixture of 
 gastric juice. It is never fecal in character. The gastric 
 region is protuberant but sinks in after a spell of vomiting. 
 
 If the obstruction is situated within the beginning of the 
 jejunum the vomiting assumes at first a greenish hue (de- 
 composed bile) which may be followed by the vomiting of 
 pure unchanged yellow bile. Occasionally the vomited 
 matter assumes a fecal character. Obstructions situated 
 ' JafiEe : Centralbl. f. die med. Wissenschaften, 1872. 
 
2(30 DISEASES OF THE INTESTINES. 
 
 within tlie duodenum or at the beginning of the jejunum, 
 as a rule, are unaccompanied with indicanuria. 
 
 Ohstnwtion of the Large Bowel. The symptoms here 
 are usually less violent and appear a little later than in 
 the obstruction of the small intestine. Fecal vomiting 
 often appears long after the establishment of the occlusion, 
 and it may even be absent if the obstacle is situated at the 
 beginning of the descending colon or lower down. The 
 meteorism is in most instances limited to the lower parts 
 of the abdomen and also to the lumbar regions. In occlu- 
 sion of the descending colon it may be noticeable that at 
 first there is a protrusion in the left iliac region, afterward 
 a protrusion of the transverse colon, and ultimately the as- 
 cending colon will also become tympanitic. As mentioned 
 above, indicanuria will be absent during the first five or six 
 days of illness. 
 
 With regard to the determination of the occlusion within 
 the lower parts of the colon, Brinton's ' method, already in 
 use over fifty years ago, is very valuable. It consists in 
 filling up the bowel with water through the rectum. If 
 not more than half a quart can be injected, the obstruction 
 must be situated in the upper part of the rectum. If one 
 to two quarts can be injected, the obstruction must be situ- 
 ated above the sigmoid flexure, in the descending colon, 
 or still higher. In case obstruction is situated in the as- 
 cending colon four quarts or still more can be injected and 
 retained in the bowel. Insufflation of air or carbonic acid 
 gas into the rectum will also occasionally show the seat of 
 the obstruction, if the latter is situated in the descending 
 or the transverse colon, as there will be a filling up with 
 gas of the free portion of the bowel up to the obstructed 
 point. When the obstruction is located beyond the trans- 
 ' Brinton : " On Intestinal Obstruction, " London, 1867. 
 
ACUTE OBSTRUCTION. 261 
 
 verse colon, however, it will not permit of distinct recog- 
 nition by this method. 
 
 C. Recognition of the Different Forms of Acute Obstruction. 
 If the diagnosis of acute obstruction of the bowel is not 
 always easy, the recognition of the special anatomical 
 lesion underlying it is still more difficult. In many in- 
 stances an exact anatomical diagnosis will not be possible 
 and we will have to be satisfied with a probable conjecture. 
 In some cases, however, the exact determination of the 
 etiologic9,l factor underlying the obstruction will be possi- 
 ble. The following groujjs of acute obstruction of the 
 bowels can be clinically differentiated : 
 
 1. Acute Incarceration of the bowels in hernias (also in- 
 ternal hernias, in slits of the omentum, mesentery, or di- 
 verticula), in strangulation by bands or twists of the bowel, 
 is most frequent between the ages of twenty and forty. 
 It occurs more often in males than in females. There is 
 often a previous history of peritonitis, of hernia, or of acci- 
 dents (contusions). The onset of the disease is sudden. 
 The pains are severe. Vomiting is present from the start, 
 becoming stercoraceous later on. Collapse is marked. 
 Tenesmus is absent. Physical examination of the abdo- 
 men gives, as a rule, negative results. 
 
 2. Volvulus most often involves the sigmoid flexure and 
 can then be easily recognized. Volvulus of the small in- 
 testine, which occurs very rarely, cannot be differentiated 
 clinically from incarceration. The rotation of the bowel 
 around its axis is either complete (360°) or incomplete 
 (half rotation, 180°). In the first instance there is total 
 occlusion, while in the latter the intestinal lumen is at first 
 partially pervious. Volvulus is more common in males 
 than in females in the i)roi)ortiou of four to one, ard occurs 
 principally late in life, usually between forty aud sixty. 
 
262 DISEASES OF THE INTESTINES. 
 
 Tliere is usually an antecedent historj^ of chronic constipa- 
 tion. The onset of the disease is sudden. The pain ordi- 
 narily is intermittent. Yomiting may be absent at first and 
 later on occurs intermittently. Constipation is almost ab- 
 solute and grows worse after the use of aperients. There 
 is pronounced meteorism. The sigmoid flexure can oc- 
 casionally be felt as a tumor. Only moderate amounts of 
 water can be injected into the rectum. 
 
 3. Intussusception occurs very frequently in early child- 
 hood. The onset is sudden, the pains appear early, are 
 colicky in character and come in paroxysms. There are 
 marked tenesmus and bloody evacuations. The collapse 
 is not pronounced. The invaginated coil may be acces- 
 sible to palpation and then appears in the form of a tumor 
 of egg-size or somewhat larger, this occurring in about 
 fifty per cent of the cases. Meteorism develops in con- 
 junction with peritonitis. 
 
 4. Obturation of the Intestine by Gall Stones, Enteroliths, 
 or Foreign Bodies. Obstruction by gall stones occurs chiefly 
 in women and is more frequent at an advanced age. A pre- 
 vious history of gall stones or a preceding attack of jaun- 
 dice, pains in the region of the liver, and swelling of this 
 organ are points which aid in the diagnosis. Obstruction 
 by gall stones usually occurs in the small intestine; the 
 symptoms, as a rule, are less severe than in other forms 
 of ileus. The collapse is not pronounced or may be en- 
 tirely absent. Flatus may occasionally be passed, copious 
 vomiting of bile may be present. If the gall stone is situ- 
 ated in the lower portion of the ileum the vomiting may 
 later become stercoraceous. Occasionally the stones can 
 be palpated through the abdomen and felt as a hard mass. 
 Meteorism is generally not highly developed. In some 
 instances there is diarrhoea with admixture of blood, the 
 
ACUTE OBSTRUCTION. 263 
 
 latter being due to abrasions of the intestinal mucosa pro- 
 duced by friction of rough gall stones. 
 
 The recognition of an enterolith as the cause of obstruc- 
 tion is very difficult and possible only when small frag- 
 ments of a fecal calculus have previously been found in the 
 dejecta. The seat of obstruction is as a rule then in the 
 large bowel, the latter being the place where enteroliths 
 develop. 
 
 Obstruction by foreign bodies will be recognized by the 
 previous history; often also, especially if they are of a 
 metallic nature, by a Eoentgen picture. An accumulation 
 of cherry pits or plum stones may also cause an obstruc- 
 tion and will likewise be recognized by the previous 
 history and by the presence of some of them in the de- 
 jecta. 
 
 Hardened fecal matter will very rarely give the picture 
 of obstruction. This will occur only in very weakened in- 
 dividuals and in persons with spinal trouble. In these 
 cases the rectum and colon will be found filled with greatly 
 hardened scybala. If a stricture or a tumor exists within 
 the intestine and narrows its lumen, an accumulation of 
 fecal matter above the stricture gives rise to acute ob- 
 struction. 
 
 5. Dynamic Ileus. Obstruction due to paralysis of a 
 segment of the bowel can be recognized only with great 
 difficulty. Often there has been a preceding laparotomy 
 or some operation on the genital organs in the female or 
 a history of a replaced hernia. 
 
 With regard to the recognition of the different forms of 
 intestinal obstruction the following table, which gives the 
 frequency of the principal symptoms in the various forms 
 of obstruction, may be of assistance. 
 
 Among two hundred and ninety-five cases of acute ob- 
 
264 
 
 DISEASES OF THE INTESTINES. 
 
 struction of tlie bowels collected in literature and minutely 
 examined by E. Fitz ' of Boston, the symptoms were as 
 follows with regard to the different groups of obstruction : 
 
 Pain 
 
 Nausea and vomiting 
 
 Fecal vomiting 
 
 Tympanites 
 
 Tumor 
 
 Visible coils 
 
 Strangu- 
 
 Intussus- 
 
 
 Gall 
 
 lation. 
 
 ception. 
 
 
 Stones. 
 
 Per Cent. 
 
 Per Cent. 
 
 Per Cent. 
 
 Per Cent. 
 
 83 
 
 70 
 
 60 
 
 83 
 
 69 
 
 75 
 
 37 
 
 74 
 
 47 
 
 13 
 
 15 
 
 61 
 
 56 
 
 33 
 
 55 
 
 56 
 
 10 
 
 69 
 
 
 13 
 
 11 
 
 
 7 
 
 
 Stricture 
 or Tumor. 
 Per Cent. 
 
 60 
 80 
 33 
 66 
 
 27 
 20 
 
 Prognosis. — The prognosis of acute obstruction of the 
 bowel is very serious. According to Curschmann/ only 
 thirty to thirty-five patients out of one hundred recover 
 from this disease. As a rule ileus caused by coprostasis 
 or by obturation with gall stones and foreign bodies gives 
 the best prognosis. Then come volvulus and intussuscep- 
 tion, while incarceration gives the worst prognosis. If in 
 the course of ileus deglutition pneumonia or diffuse peri- 
 tonitis or perforation of the bowel develops, then the case 
 is well-nigh hopeless. Operative intervention, especially 
 in cases in which the seat of the intestinal occlusion is 
 known, improves the prognosis considerably, but only if 
 it is resorted to early. Later, when the complications just 
 mentioned arise, not much can be expected from an opera- 
 tion. 
 
 ; Treatment. 
 
 ! 
 
 A. Medical Treatment. — Absolute rest is of the great- 
 est importance. The patient should be kept in bed and 
 told to avoid any abrupt motions. He should not be 
 
 ' R. Fitz : " Transactions of the Congress of Physicians and Sur- 
 geons," vol. i., 1888. 
 
 * Curschmann : "Die Behandlung des Ileus." Congress fur innere 
 Medicin, Wiesbaden, 1889. 
 
ACUTE OBSTRUCTION. 265 
 
 allowed to go to the water-closet, but should use a bed- 
 pan. With Treves, Graser, ' and others I am for absolute 
 rest of the stomach and intestines, i.e., no food whatever 
 should be given to i)atients suffering from acute obstruc- 
 tion of the bowels. 
 
 If there is great thirst a teaspoonful of hot water or Yery 
 weak tea ma\^ be given every half-hour or hour or a small 
 piece of ice may be held in the mouth until it melts, but 
 the water should not be swallowed. Neither should any 
 stimulants like wine, champagne, or whiskey be given by 
 the mouth. In obstruction of the small intestine small 
 quantities of a saline solution (about seven to twelve ounces) 
 may be injected into the bowel several times during the 
 day. If the sickness lasts several days, nutritive enemas 
 consisting of milk and egg or of a peptone solution may 
 be given in the same way. If, however, the patient is not 
 able to retain the enema, considerable quantities of saline 
 solution must be injected either subcutaneously or intra- 
 venously. 
 
 AH writers agree that no cathartic remedies whatever 
 should be used, as they increase the peristalsis and there- 
 by may cause great harm. A cathartic should be per- 
 mitted only in cases in which the obstruction is positively 
 due either to gall stones or hardened fecal masses or in 
 dynamic ileus. It is, however, of benefit to evacuate the 
 lower parts of the bowel by means of an enema. This 
 cleans out the rectum, diminishes the feeling of tension to 
 & slight extent, and prepares the bowel for the nutrient 
 enemas. 
 
 TJie administration of opium plays a principal part. It 
 
 'Graser: "Behandlung der Darmverengerung und des Darmver- 
 schlusses." Penzoldt-Stintzing's "Handbuch der speciellen Therapie 
 , innerer Krankheiten, " Jena, 1896. 
 
266 DISEASES OF THE INTESTINES. 
 
 is indicated not only as a means of allaying pain but for 
 its soothing action upon tlie intestinal peristalsis. The 
 arrest of the latter may have a direct curative effect, since 
 it may promote a return of the partly incarcerated or in- 
 vaginated or slightly twisted coil to its normal position. 
 
 In order to secure a prompt action of the drug it is best 
 to first give a hypodermic injection of morphine, one-sixth 
 to one-fourth of a grain. A short time afterward a sup- 
 pository of two-thirds of a grain of opium is administered 
 and repeated every three or four hours until the pains are 
 kept in abeyance. In cases in which the vomiting is not 
 so marked, opium ma^^ be given in the form of the tincture 
 fifteen to twenty drops every tliree to four hours. It is 
 hardly necessary to say that the opiates should not be used 
 too lavishl3^ Only so much should be administered as is 
 absolutely necessary for relieving the pain and quieting 
 the violent peristalsis of the intestine. Given in this way, 
 opium not only acts as a sedative but also as a stimulant 
 on the heart. Patients in deep collapse very soon after an 
 injection of morphine become warm, show a better pulse 
 and a more normal temperature. The only disadvantage 
 of opium is that it slightly masks the true picture of the 
 disease. It is therefore best whenever possible first to 
 make an exact diagnosis by thorough examination of the 
 abdominal viscera by palpation, auscultation, etc., before 
 administering it. 
 
 If the symptoms of the disease persist after the admin- 
 istration of opium, especially if the tension of the abdomen 
 is not relieved and no flatus is passed, it is well to dis- 
 continue the remedy for a certain period of time. This 
 will enable the physician to judge the situation critically. 
 
 As a further sedative agent applications of poultices can 
 be considered. A hot-water bag, a hot plate wrapped up 
 
ACUTE OBSTRUCTION. 267 
 
 in flannel, or a Japanese warm box, wet packs (Priessnitz) 
 are useful. If there are signs of peritoneal inflammation, 
 applications of ice or of very cold poultices are prefer- 
 able. 
 
 Lavage of the stomach was first recommended in tliia 
 disease by Kussmaul and Calm.' This procedure is of 
 benefit if the obstruction is situated high up in the small 
 intestine. It empties the stomach, relieves the vomiting, 
 and also decreases the abdominal tension. There is no 
 doubt that this therapeutic measure is sometimes crowned 
 with success in appropriate cases. As a striking instance 
 of the efiicacy of this mode of treatment the following case 
 may be reported : 
 
 E. K., thirty-five years old, had always been well, when 
 he suddenly became critically ill with violent abdominal 
 pains and constant vomiting. For three days there was 
 no evacuation of the bowels nor was the patient able to 
 pass any flatus. On examination I found his abdomen 
 considerably distended and tense. The stomach could be 
 mapped out and was considerably dilated, the greater cur- 
 vature extending a hand's width below the navel. On pal- 
 pation there was considerable tenderness all over the 
 abdomen. The pulse was quite frequent (110) and weak, 
 temperature 96.5° in the mouth, the extremities were cold. 
 The face showed an expression of great suffering. There 
 were almost continuous hiccough and now and then vomit- 
 ing of a watery, turbid, somewhat brownish-looking liquid 
 with fecal odor. On introducing the tube over a quart of 
 liquid of the same character was obtained. The stomach 
 was then washed out with several quarts of w^ater until the 
 fluid returned quite clear. The patient felt somewhat re- 
 lieved. The vomiting stopped and on the foUowiDg day 
 there was a spontaneous evacuation of the bowels. The 
 patient was now able to pass flatus, the distention sub- 
 
 ' Kussmaul-Cahn : "Heilung von Ileus durch Magenausspiilung. "' 
 Berl. klin. Wochenschr., 1884, Nos. 43 and 43. 
 
268 DISEASES OF THE INTESTINES. 
 
 sided, and lie gradually recuperated. For the sake of com- 
 pleteness I would add that besides washing out the stomach, 
 the treatment consisted in the administration of opium 
 suppositories. 
 
 Lavage of the Bowel. Injections of large amounts of 
 water into the bowel under considerable pressure are also 
 occasionally of benefit, especially in cases of intussuscep- 
 tion of the colon or when a foreign body or hardened fecal 
 matter is the cause of the obstruction within the large 
 bowel. According to Treves, it is desirable to use this 
 procedure after anaesthetizing the patient. A considerable 
 quantity of water (varying according to the age of the pa- 
 tient from half a pint to three quarts) is introduced into 
 the bowel by means of an ordinary fountain syringe. The 
 :fluid is allowed to remain in the colon for at least ten min- 
 utes. While injecting the water it is best to have the pa- 
 tient in such a position that his head is lowered and his 
 pelvis is raised. While the irrigation of the bowels is 
 going on the physician should hold his hand upon the 
 patient's abdomen and in this way notice any change which 
 may occur. 
 
 In intussusception when the tumor can be felt the 
 latter will in some instances suddenly disappear, giving 
 way to the pressure of the water. Too great force, 
 however, should never be used, as this may bring on rup- 
 ture of the bowels. Instead of water, injections of warm 
 olive oil, which were first recommended by Kussmaul and 
 Fleiner, may be used in the same way. Dr. Klubbe ' has 
 related three cases of cure by means of this method. 
 
 Inflation of the Boivel loith Air or Certain Gases in 
 Gases of Invagination. Trastour ^ recommended inflation 
 
 ' Klubbe : British Medical Journal, November 6th, 1897. 
 " Trastour : Bulletin General de Therapie, 1874, p. 107. 
 
ACUTE OBSTRUCTION. 269 
 
 of the bowel with air by means of a common bellows, to 
 which an India-rubber nozzle and rectal tube had been 
 attached. The forcible filling up of the bowel with air is 
 capable of producing the same effect as the injection of 
 water and may free the invaginated portion. Von Ziems- 
 sen ' has recommended the use of carbonic-acid gas, while 
 Senn " suggested hydrogen gas. Carbonic-acid gas is best 
 used in the form of "sparklets," as suggested by Dr. A. 
 Rose " of New York. Care must be taken not to fill up the 
 bowel too quickly and too forcibly. 
 
 Massage. Massage has been recommended by several 
 writers. Its use, however, is not entirely harmless. It 
 can be of benefit only in cases of obstruction by gall stones 
 and fecal matter, but even in these cases extreme care in 
 its use is necessary. 
 
 Electricity. Electricity has especially been recom- 
 mended by Boudet. Among seventy cases of ileus Boudet ■* 
 had fifty-three recoveries by this method. The faradic or 
 galvanic current may be used. In the application of the 
 faradic current one metal electrode of cone shape is in- 
 serted into the rectum while another large plate electrode 
 is kept over the abdomen for about ten to twenty minutes. 
 In using the galvanic current it is necessary to have a. 
 special rectal electrode, which is constructed in such a way 
 that water running through it forms the conductor, so as 
 to avoid burning the mucosa. The other electrode is placed 
 over the abdomen. The negative pole should be inside. 
 The strength of the current should vary from ten to fifteen 
 milliamperes. The duration of the treatment should be 
 twenty to twenty-five minutes. 
 
 * Von Ziemssen ; Archiv flir klinische Medizin, Bd. 33, Heft 3 and 4. 
 'Nic. Senn: "Intestinal Surgery, " Chicago. 1889, p. 244. 
 
 ' A. Rose : New York Med. .lournal, 1900, i. , p. 47. 
 
 * Boudet ; ProgrSs Medical, February 7th and 14th, 1885. 
 
270 DISEASES OF THE INTESTINES. 
 
 Electricity will be of special value in obstruction due 
 to hardened fecal matter or in the paralytic form of ileus, 
 while in incarceration it is rather contraindicated. 
 
 Puncture. Puncture of the distended bowel has recently 
 been recommended anew by Curschmann/ von Ziemssen, 
 and others. According to Curschmann, puncture of the 
 intestine is performed in the following way : A long aspi- 
 rator needle of thin calibre (like that of a Pravaz syringe) 
 provided with a stopcock is thrust into the abdomen over 
 a prominent coil of the intestine, A piece of rubber tub- 
 ing is then connected with the outer end of the needle ; 
 the free end of the latter is inserted into a bottle filled with 
 water, which is turned upside down in a basin likewise 
 filled with water. The stopcock of the aspirating needle 
 is now opened and the gas escaping from the intestinal 
 coil appears in bubbles rising to the upper part of the 
 bottle, displacing the water. There is no doubt that con- 
 siderable temporary relief can be afforded by this mode of 
 procedure, as it lessens the feeling of tension. Occasion- 
 ally it may also have a direct curative result. Thus 
 Curschmann reports three cures by this method. Punc- 
 ture, however, is not entirely free from danger. In cases 
 in which the intestine is already partly paralyzed, the 
 opening after the withdrawal of the needle may not entirely 
 close and intestinal gases and contents may continue to 
 ooze out and cause peritonitis. 
 
 Most surgeons of note are against this jjrocedure, as it 
 
 lacks precision and is not free from danger. Thus Treves, * 
 
 Kocher, ' and Graser * are all opposed to its employment. 
 
 ' Curschmann -. Deutsche med. Wochenschrift, 1887, No. 21. 
 2 Treves: "Intestinal Obstruction, " New York, 1899, p. 471. 
 2 Kocher: " Mittheilungen aus den Grenzgebieten der Medizin," 
 1898. Bd. 4, p. 3. 
 * Graser; Penzoldt-Stinzing's "Handbuch, " Bd. 4, p. 563. 
 
ACUTE OBSTRUCTION. 271 
 
 Sad experiences with puncture have been reported bv 
 Frentzel, ' Fiirbringer,' Hoffmann, Korte,' and Graser. 
 The latter observed the appearance of fecal matter and 
 consecutive peritonitis from such an opening. He con- 
 siders puncture permissible only if the patient absolutely 
 refuses an operation. 
 
 Mercury {Mercurius Vivus) . The internal administration 
 of pure mercury in tablespoonful doses was highly es- 
 teemed as a remedy for ileus by the old physicians. When 
 all resources had been exhausted without success, mercury 
 was given as an ultimum refugium. Even nowadays many 
 physicians are convinced of its efficacy. The use of mer- 
 cury in incarceration, strangulation of the bowel by twists 
 or bands, intussusception, is not permissible, as it does 
 real harm. In ileus in consequence of coprostasis or in 
 dynamic ileus, mercury may be employed if all other rem- 
 edies have proven futile. Its effect consists in the pene- 
 tration of the mercury into the accumulated fecal matter, 
 thus softening it. 
 
 All the enumerated internal methods of treatment must 
 be applied, first, in cases in which the obstruction is due 
 either to gall stones or to foreign bodies or fecal accumu- 
 lation or volvulus of the sigmoid flexure ; secondly, in cases 
 in which the exact diagnosis as to the kind of obstruction 
 is not settled, and which are not of a very severe type. In 
 all other varieties of intestinal obstruction and even in the 
 types just mentioned, after the failure of the medicinal 
 measures at hand, an operation should be resorted to. 
 
 'Frentzel: Deutsche Zeitschr. f. Chirurgie, Bd. 33. 
 
 * Fiirbringer : Verhandl. des 8ten Congresses f. innere Medicin, 1889. 
 
 " K5rte : Ibidem. 
 
272 DISEASES OF THE INTESTINES. 
 
 B. Surgical Treairaent. 
 
 Treves, the greatest authority on intestinal obstruction, 
 says : " Tliere is one measure for the treatment of acute 
 intestinal obstruction, and that is by means of laparotomy. 
 The operation should be performed at the earliest possible 
 moment, as soon indeed as the diagnosis is reasonably 
 clear. In case of acute abdominal trouble in which the 
 diagnosis is not clear, the better and safer course is to 
 operate." This view is now generally accepted by physi- 
 cians as well as surgeons. 
 
 As mentioned above, obturation, ileus, and volvulus of 
 the sigmoid flexure are the only groups of intestinal ob- 
 struction in which medical treatment plays a prominent 
 jjart. The importance of an early operation has been 
 shown by Naunyn, who found that among two hundred 
 and eighty -eight cases of ileus operated upon, the results 
 were the more favorable the earlier recourse was had 
 to sui'gical intervention. In those cases in which the 
 operation was performed during the first two days of 
 sickness recovery took place in seventy-five per cent. 
 During the third day and still later there were only 
 thirty -five to forty per cent of recoveries. 
 
 A similar view is expressed by Gibson, ' who dealt par- 
 ticularly with acute intussusception. Among one hundred 
 and forty-nine cases of this affection he found an average 
 mortality of fifty -three per cent. The first and second days 
 showed mortality inferior to the general mortality, while 
 the four succeeding days showed a steadily increasing mor- 
 tality, in each instance greater than the average. With, 
 regard to treatment by inflation of the bowels by enemata 
 
 ' C. L. Gibson : "Mortality and Treatment of Acute Intussusception, 
 ■with Table of 239 Cases. " Medical Record, July 17th, 1897. 
 
ACUTE OBSTRUCTION. 273 
 
 of fluids (or air) Gibsou sajs : " It is probably not an ex- 
 aggeration to say that if all cases of intussusception were 
 treated on tlie onset, or say within forty -eight hours, by 
 abdominal section, without any previous attempt at re- 
 duction, the mortality, while still considerable, would in all 
 probability be very much less than the present figures." 
 Gibson believes that injections should be tried only on 
 the first or at the latest on the second day. 
 
 In the discussion on intestinal obstruction which took 
 place at ]bhe New York State Medical Association,' all the 
 speakers (Parker Syms, E. D. Ferguson, George D. Stew- 
 art, J. W. Gouley, J. D. Kushmore, LeKoy J. Brooks, 
 John F. Erdmann, Fred. H. Wiggin, and H. O. Marcy) 
 were in favor of surgical treatment and for early interven- 
 tion. J. D. Rushmore says:' "I have no hesitation in 
 affirming that in competent hands operation for intestinal 
 obstruction would not have a mortality above twenty- per 
 cent. In my personal experience, including over one hun- 
 dred and ten operations, the mortality has been nearly forty 
 per cent. In the last thirty cases there have been six 
 deaths." Wiggin' considers that operations performed 
 within the first forty -eight hours will give a mortality of 
 22.2 per cent. 
 
 Inasmuch as the question of operation has to be dealt 
 with in each case of intestinal obstruction, it is advisable 
 to have the opinion and advice of an expert surgeon right 
 at the start of the disease. The physician and surgeon 
 should act together, the first watching the symptoms 
 carefully and making the diagnosis, the second prepared 
 to resort to surgical intervention as soon as it is demanded. 
 
 ' Transactions of the New York State Medical Association, 1898. 
 2 J. D. Rushmore ; Ibidem. 
 
 sp H. Wiggin; Da Costa's "Modern Surgery," p. 644. 
 18 
 
274 DISEASES OF THE INTESTINES. 
 
 In this way the number of recoveries will be greater in the 
 future than it has been in the past. 
 
 The operation consists in making an abdominal incision, 
 finding the seat of the lesion, and removing the obstacle if 
 possible. If not, an enterostomj^ is performed in the most 
 distended coil of intestine which is then attached to the 
 abdominal wall. The fecal matter and the gases thus find 
 an outlet through this opening. Enterostomy is also re- 
 quired in all cases in which the portions of the intestine 
 are already found gangrenous. Treves says that this oper- 
 ation (enterostomy) could be avoided in acute intestinal 
 obstruction if the abdomen were opened at the very earliest 
 possible moment. Every hour delayed adds to the grav- 
 it}^ of the case. " The earlier the operation the less the 
 need for enterostomy. Laparotomy should be performed 
 at an early enough period to render an opening into the 
 bowel unnecessary." 
 
 CHRONIC INTESTINAL OBSTRUCTION. 
 
 Etiology. — Chronic intestinal obstruction may be caused 
 by the same factors which produce acute ileus if they do 
 not occlude the entire lumen of the bowel but leave part of 
 the canal open. Besides, obstruction of the intestine is 
 frequently occasioned by strictures resulting from preced- 
 ing ulcers or from new growths. The latter, benign as 
 well as malignant, are liable to give rise to occlusion even 
 if they do not occupy the entire circumference of the bowel, 
 by simply obtruding part of the canal at the site of their 
 greatest development. Strictures caused by ulcers much 
 more frequently involve the large than the small intestine. 
 According to Treves, they are found six times as often in 
 the large bowel as in the small one. 
 
 While formerly dysentery was believed to be the cause of a 
 
CHRONIC OBSTRUCTION. 2/o 
 
 large number of these intestinal strictures, Woodward ' has 
 shown that this view is not supported by facts. Among 
 the many autopsies on patients with chronic dysentery 
 which the latter had an opportunity to observe, there was 
 not one case of dysenteric stricture of the intestiue. 
 Nothnagel agrees with Woodward. On the other hand, 
 tuberculous ulcers of the intestine which were regarded 
 as only rare causes of intestinal stricture have recently been 
 found to produce strictures quite frequently. Koenig ' laid 
 stress upon the frequency' of constricting tuberculosis of 
 the intestines. The latter may exist even if tuberculosis 
 in other organs is absent. Ulcers of typhoid fever very 
 rarely if ever cause strictures, and this also applies to the 
 small follicular ulcers. Syphilitic ulcers on the contrary 
 produce strictures quite often. All kinds of strictures are 
 met with most frequently in the lower portion of the colon, 
 principally in the rectum. Sometimes they lie just above 
 the anal region and can then be very easily discovered. 
 
 Symptomatology. — The symptoms and the course of the 
 disease vary considerably, and greatly depend upon the 
 cause of the obstruction. Thus, clinically, the benign 
 growths must be differentiated from the malignant ones 
 (in which the obstruction is caused by cancer). The pic- 
 ture which the intestinal obstruction as such produces 
 will, however, be pretty much the same, A stenosis which 
 is not very much pronounced may give rise to no symp- 
 toms whatever. It is therefore quite evident that the dis- 
 ease may exist for some length of time before manifesting 
 its presence. 
 
 In typical cases of chronic intestinal obstruction the 
 onset is slow and insidious. The patient at first notices 
 
 ' Woodward : Loc. cit. 
 
 2 Koenig : Deutsche Zeitschrift fiir Chirurgie, 1891, 
 
276 DISEASES OF THE INTESTINES. 
 
 slight digestive disturbances, some discomfort in the 
 abdomen which gradually changes into real pain, and 
 slight constipation. The latter as a rule quickly becomes 
 worse. Mild aperients which a short while before were 
 efficient refuse to act, and the patient is obliged to resort to 
 stronger cathartics ; at times even these will fail to work. 
 Frequently constipation suddenly alternates with an attack 
 of severe diarrhoea, which may last several days and be 
 followed by another period of obstinate constipation. In 
 some instances the color and form of the fecal matter will 
 be an indication of the seat of the stenosis. It is gener- 
 ally believed that pipestem-like or ta.pe-like motions indi- 
 cate a stricture in the colon. According to Treves/ how- 
 ever, this sign is of very little value, as in the great 
 majority of cases the sphincter muscle is the originator 
 of these peculiar shapes. Diarrhoea may also occasionally 
 occur. It is sometimes quite obstinate, especially if the 
 stenosis is situated in the large bowel. An admixture of 
 blood or jDUS in the dejecta is occasionally met with and is 
 due to ulcerative processes taking place at the seat of the 
 stricture or immediately above it. 
 
 Vomiting is not a very marked feature at first, but later 
 on occurs more frequently. When the obstruction, how- 
 ever, becomes complete, vomiting is a prominent symp- 
 tom and may assume a stercoraceous character. 
 
 The situation of the obstruction has much influence upon 
 the clinical picture of the disease. If the stenosis is situ- 
 ated in the duodenum above Yater's papilla, the symptoms 
 will resemble those of stricture of the pylorus. Ischochy- 
 mia, vomiting, nausea will be the prominent features. A 
 stenosis of the duodenum below Vater's papilla, although 
 presenting symptoms similar to those of stricture of the 
 ' Treves ; Loc. cit. , p. 395. 
 
CHROXIC OBSTRUCTION. !'< < 
 
 pylorus, will be recognized by the more or less constant pres- 
 ence of large amounts of bile in the stomach. The farther 
 down in the small intestine the obstruction is situated, the 
 less pronounced are the gastric symptoms and the more 
 marked the intestinal manifestations (less vomiting or 
 nausea, more constipation, colicky pains). If the stenosis 
 is situated in the lower portion of the ileum or in the colon 
 no gastric symptoms are as a rule present. The aj)petite 
 is good, there is no nausea, and the principal features are 
 obstinate constipation, sometimes alternating with diar- 
 rhoea and frequent attacks of colicky pains. 
 
 Condition of the Abdomen. The abdomen may present a 
 normal appearance when the stenosis is situated in the 
 upper portion of the small intestine, although in some of 
 these cases there may be a protrusion of the upper part 
 of the abdomen. If the site of obstruction is in the lower 
 portion of the small intestine or in the large bowel, then 
 some distention of the abdomen is usually noticeable, espe- 
 cially after the disease has advanced considerably. Above 
 the obstruction there is always distention and hypertro- 
 phy of the bowel. The latter is a manifestation of the 
 attempt which nature makes in order to overcome the diffi- 
 culty. The intestines above the stenosis act with greater 
 force in order to propel the contents through the narrow 
 passage. 
 
 The contraction of the bowel above the affected area 
 often assumes a tetanic type and is then painful. Such 
 violent tetanic contractions are often visible through the 
 abdominal wall, and by propelling large amounts of liquids 
 and gases through the narrowed lumen, give rise to gur- 
 gling and bubbling sounds audible at a distance. Treves 
 thus describes the picture which this violent peristalsis 
 manifests : " The surface of the abdomen becomes uneven, 
 
278 DISEASES OF THE INTESTINES. 
 
 a rounded elevation apxjears in one place and depressions 
 appear in another. They x^^'od^ce an aspect comparable 
 to that of a relief map of a hilly country. Slowly the 
 hill-like elevation sinks and vanishes and out of the 
 shallow valley appear fresh eminences which rise up and 
 move along beneath the skin. The movements are slow 
 and attended by colicky pains, and by more or less of 
 rumbling and gurgling sounds." . . . "The same coil 
 appears again and again and can often be quite definitely 
 recognized. Although as a rule the contracting coils of 
 the small intestine are of considerably smaller size than 
 those of the large bowel, occasionally even the small intes- 
 tine may assume such dimensions that it cannot be differ- 
 entiated from the large bowel." 
 
 Meteorism is often present. If the obstruction is situ- 
 ated in the lower portion of the colon or in the rectum, the 
 meteorism is at first restricted to the large bowel, the dis- 
 tention then being pronounced along the course of the colon 
 at both sides of the abdominal wall and in the epigastric 
 region. The lower part of the abdomen and also the re- 
 gion of the navel may be free from meteorism. If the 
 stricture is situated in the lower portion of the ileum or 
 caecum, the lumbar regions of the abdomen are quite lax, 
 while the distention is more or less pronounced in the me- 
 sogastric and hypogastric regions. 
 
 After having described the symptoms of chronic intesti- 
 nal obstruction in a general way it will be useful to point 
 out separately the characteristics of some special forms 
 which occur more or less frequently. 
 
 Chronic intussusception may develop either after an acute 
 attack or begin slowly and insidiously without at first giv- 
 ing rise to any marked symptoms. It is most frequently 
 found in the ileo-ceecal portion. Pain occurs during the 
 
CHRONIC OBSTRUCTION. 279 
 
 progress of the disease and is usually of a paroxysmal 
 character. Attacks of pain may appear several times a 
 day or once in twenty-four hours. Occasionally days and 
 even weeks elapse between the paroxysms. As a rule the 
 intervals between the attacks grow shorter as the disease 
 advances. In some cases there is almost continuous suffer- 
 ing with occasional exacerbations. Vomiting seldom oc- 
 curs and is certainly not a marked feature. A tendency to 
 diarrhoea very often exists. The bowels may be normal or 
 constipgited for a while and then become loose, or there 
 may be persistent diarrhoea. Blood is very often passed 
 with the stools and tenesmus is occasionally present. 
 
 On examination of the abdomen by palpation a tumor is 
 found in almost half of the cases. The nature of the tumor 
 corresponds to that found in acute intussusception de- 
 scribed above. Occasionally a tumor can be felt in the rec- 
 tum when the intussusception involves the lower portion of 
 the large bowel. In rare instances the invaginated portion 
 is separated from the bowel by necrotic processes, and may 
 then appear in the movement. While this event may in 
 rare instances lead to perfect recovery (the other portions 
 of the bowel growing together and the lumen thus being 
 restored), in the greater majority it causes death through 
 perforation, rupture of the intestinal walls, and general 
 peritonitis. 
 
 Chronic Obstruction Due to Fecal Accumulation. This 
 variety of intestinal obstruction is more common in fe- 
 males than in males and is usually met with in more ad- 
 vanced age and in patients suffering from hysteria and 
 brain troubles. As a rule, the patients have already long 
 before been subject to habitual constipation ; usuallj^ many 
 days elapse without an evacuation of the bowels. From 
 time to time enormous quantities of fecal matter are passed 
 
280 DISEASES OF THE INTESTINES. 
 
 by artificial means. Later on the symx)toms of constipa- 
 tion grow more intense. Tlie abdomen becomes distended 
 and it is much more difficult to secure an evacuation even 
 by artificial means. As a rule the patient is tormented by 
 eructations and flatulence. His appetite is poor ; he has 
 a bad taste in his mouth and frequently his breath has an 
 unpleasant odor. Headache, vertigo, and a general tired 
 feeling are often encountered. 
 
 These symptoms, as well as the marked unhealthy ap- 
 pearance of the skin, are most probably due to intestinal 
 auto-intoxication. Certain chromogens, the products of 
 decomposition, are absorbed from the bowel and give rise 
 to this peculiar discoloration of the skin. The conjunctivae 
 also are often yellow. A further symptom due most prob- 
 ably to the same process of auto-intoxication is the rise of 
 temperature which is often present. If the distention of 
 the abdomen is very marked, a feeling of oppression in the 
 chest and palpitations of the heart are experienced. 
 
 Fecal accumulation sometimes causes pressure upon the 
 lumbar or sacral nerves and gives rise to discomfort in 
 the genital organs or to pain in the thigh radiating down 
 the entire leg. Distended coils may be visible through 
 the abdomen and there may be much rumbling and gur- 
 gling heard after constipation has lasted a long period. 
 This symptom is, however, not so marked here as in cases 
 of stricture of the intestine. Vomiting may occur and even 
 become stercoraceous. Slight colicky pains are felt over 
 the abdomen, but as a rule they are not intense. 
 
 The symptoms having advanced to an extreme degree, re- 
 lief may ensue either spontaneously or after resort to differ- 
 ent procedures which serve to evacuate the bowels. Occa- 
 sionally, however, an evacuation of the bowel cannot be 
 obtained and the patient develops all the symptoms of an 
 
CHRONIC OBSTRUCTION. 281 
 
 unyielding obstruction which may be fatal. Often there 
 are attacks of obstruction following each other at certain 
 intervals. The narrowed lumen of the bowel most prob- 
 ably becomes entirely occluded or blocked by a piece of 
 hard fecal matter, which completelj^ fills it and cannot 
 move in either direction. Sometimes the abrui)t stoppage 
 may be due to some bending or kinking of the distended 
 bowel. 
 
 In almost all cases of obstruction by fecal masses 
 a tumol" can be palpated usually in some portion of the 
 colon. The tumor is caused by the fecal accumulation. 
 The caecum, the hepatic and the sigmoid flexures are the 
 places where the tumor is most often encountered. Such 
 a fecal tumor feels hard and uneven; sometimes it has a 
 globular shape. As a rule it is not painful on pressure. 
 Sometimes it is possible to change the shape of the 
 tumor by pressure. This is the best proof of its fecal 
 character. Sometimes, however, pressure does not give 
 rise to any change in the configuration of the mass if 
 the fecal matter is very hard. The best sign of its fecal 
 nature is the change in form after repeated irrigations of 
 the bowel. In some rare instances the fecal accumulation 
 occupies the greater part of the abdominal cavity and gives 
 the impression of one immense tumor of very hard consist- 
 ency-. I have seen two such cases in patients suffering 
 from grave melancholia. Here also after repeated irriga- 
 tions of the bowel and administration of cathartics the tu- 
 mor gradually becomes smaller and ultimately disappears. 
 
 Stricture of the Rectum. — In this condition as a rule there 
 are at first merely symptoms of constipation ; later on these 
 become more obstinate, requiring stronger cathartics. The 
 patient now begins to complain of congestion of the head, 
 anorexia, nausea, cold feet, and sometimes of disagreeable 
 
282 DISEASES OF THE INTESTINES. 
 
 sensations in liis limbs ; still later there is diarrhoea which 
 may persist as such or alternate with constipation. Off 
 and on muco-purulent material appears with the dejecta. 
 A burning sensation is often felt in the rectum, and tenes- 
 mus is freqiiently present. Hemorrhoids and prolapse of 
 the rectum often accompany the stricture. 
 
 Digital examination of the rectum often reveals a ste- 
 nosed area in its lower part. The finger is either not able 
 to pass any farther than a few centimetres (five to six) 
 above the anus or it meets with a resistance which it can 
 overcome. Contrary to spasm of the rectum which yields 
 completely after the finger has succeeded in passing the 
 constriction, in stricture of the rectum the pressure of the 
 narrowed lumen exerted upon the finger remains constantly 
 the same. 
 
 Most of the strictures are situated about five to six centi- 
 metres above the anus, seldom higher up. In the latter in- 
 stance the examination must be made with a bougie or with 
 a rubber tube which is not too soft. In order to determine 
 the exact nature of the stricture it is always best to make 
 a visual examination of the rectum by means of a specu- 
 lum. 
 
 Complications. — No matter to what cause the intestinal 
 obstruction is due, in the protracted course of the disease 
 several complications are liable to occur, although here 
 less often than in acute obstruction. Above the stenosed 
 area ulcerations of the bowel may take place and perfora- 
 tion may occur, giving rise to general peritonitis. Occa- 
 sionally circumscribed peritonitis may ensue in a similar 
 manner and lead to an abscess surrounded by adhesions. 
 Such an abscess may rupture through the abdominal wall 
 and under favorable conditions (if communicating with 
 the intestinal lumen) form a fecal fistula. In many in- 
 
CHRONIC OBSTRUCTION. 
 
 283 
 
 stances the patients gradually waste away and die in con- 
 sequence of tlirombosis of the crural vein and decubitus. 
 
 Course and Prognosis. — The 
 duration of chronic intestinal 
 obstruction depends largely 
 upon the nature of the partic- 
 ular affection and upon the 
 degree of the obstruction. If 
 there are no complications and 
 the patients lead a perfectly ra- 
 tional life (with regard to diet 
 and treatment) the condition 
 may last a number of years. In 
 other cases the symptoms of 
 intestinal obstruction rapidly 
 progress and life is then of 
 short duration unless something 
 radical is done. 
 
 Diagnosis. — The diagnosis of 
 chronic intestinal obstruction is 
 warranted by the presence of 
 gradually increasing symptoms 
 of constipation, and attacks of 
 intestinal colic with a temporary 
 stoppage of the bowels follow- 
 ing each other at not too great 
 intervals. The acute attack of 
 obstruction in these cases of 
 chronic intestinal stenosis is as a rule much milder than 
 in acute occlusion of the bowel not due to a chronic con- 
 dition. In the chronic form there is either no collapse at 
 aU or it is but slightly marked. Increased intestinal peri- 
 stalsis is often encountered in the chronic form, especially 
 
 Fig. 38.— Patient M. with Clironic- 
 Intestinal Stenosis (Stricture of 
 Descending Colon), Showing the 
 Barrel-shaped Abdomen. 
 
284 DISEASES OF THE INTESTINES. 
 
 during an attack of obstruction, while in tlie acute form 
 this is quite rare and, if present, less pronounced. The 
 barrel-shape of the abdomen is often present in chronic 
 intestinal stenosis and is of diagnostic value (Fig. 38). 
 The different forms of intestinal obstruction can be rec- 
 ognized by their varied symptoms which have already 
 been described above. 
 
 Treatment. — The treatment comprises the management 
 of the disease during the intervals and during the attacks. 
 During the intervals the following rules are of importance : 
 The diet should exclude all substances which give large 
 residue of fecal matter or which are of an irritating charac- 
 ter. Thus green vegetables, salads, fruits, vinegar, mus- 
 tard, pepper, must be strictly forbidden. Milk and milk 
 soups, eggs, tender meats without too much fat and with- 
 out tendons, butter, toasted bread or j)lain white bread 
 well baked, farina, rice and sago, well cooked, are permis- 
 sible. The patients should eat frequently and not too 
 much at a time. Cold drinks should be avoided. Atten- 
 tion must be paid to the patient's taking a sufficient quan- 
 tity of food. 
 
 The bowels must be kept in working order. It is abso- 
 lutely necessary to secure one evacuation daily. Massage, 
 electricity, and the usual mild cathartics (like magnesia 
 sulphate, rhubarb, cascara sagrada, syrup of figs) may be 
 used. Injections of water or oil into the bowel are also 
 of benefit. When diarrhoea is present it should not be 
 checked unless the patient is greatly debilitated. Even 
 then only mild astringent remedies are permissible. Often 
 even during periods of diarrhoea, when not very large evac- 
 uations take place, a mild cathartic (like castor oil or . 
 Carlsbad salts) must be employed in order to assure a 
 thorough cleansing of the bowel. 
 
CHRONIC OBSTRUCTION. l'^.") 
 
 During tlie attack of intestinal colic warm fomentations 
 over the abdomen should be applied. If these be insuffi- 
 cient, the narcotic remedies are in place. Opium alone or 
 opium with belladonna may be given either by the mouth 
 or in suppositories. Here also it is necessary to produce 
 a sufficient evacuation of the bowel, which is best done by 
 rectal injections. If there are great distention of the abdo- 
 men and vomiting, gastric lavage is beneficial. Cocaine 
 in doses of one-third to one-half grain, or menthol one 
 grain three times daily, will allay the vomiting. If there 
 is a real attack of acute obstruction this must be treated 
 in the same manner as primary acute intestinal obstruc- 
 tion, described above. 
 
 If the stenosis involves the upper portion of the small 
 intestine, lavage will play an important part in allaying 
 the symptoms temporarily. Chronic fecal impaction re- 
 quires the application of massage and also of electricity, 
 as described in the chapter on constipation. Sometimes 
 the hardened scybala will have to be removed from the 
 rectum by artificial means. For this purpose the sphincter 
 is first dilated and the fecal masses are removed with the 
 fingers or with a spoon-shaped instrument. If there is a 
 blocking of the passage higher up in the colon, strong 
 cathartics (croton oil) may be administered. Metallic 
 mercury has also been advantageously used in these in- 
 stances. 
 
 Strictures of the rectum, excepting those of a cancerous 
 nature, can first be treated by dilating them gradually with 
 bougies of various size. The rectal bougie of Crede best 
 answers this purpose. It is advisable to leave the bougie 
 within the stricture for at least fifteen minutes and to 
 insert it once every two to three days. If the stricture is 
 of a very high degree this method of treatment may be, 
 
286 DISEASES OF THE INTESTINES. 
 
 inefficient, and then surgical measures will have to be un- 
 dertaken. 
 
 Operative Intervention.— K\\ types of chronic intestinal 
 obstruction, with the exclusion of those caused by fecal 
 accumulation and strictures of the rectum, gradually grow 
 worse. The above-described modes of treatment are on\j 
 of a palliative nature. For this reason it must be consid- 
 ered as a decided advance that surgical means have been 
 found fully to remove the obstacle and restore the patient 
 to complete health. The procedures which are resorted 
 to are various and depend upon the anatomical lesion un- 
 derlying the obstruction. 
 
 Malignant growths must be extirpated as early as pos- 
 sible and an end-to-end anastomosis of the bowel estab- 
 lished. A circular stricture of the bowel (of benign type) 
 can be removed by enteroplasty in a similar way as pylo- 
 roplasty, namely, by splitting the gut parallel to its axis 
 or vertically to the stricture and uniting the edges of the 
 incision transversely. Pean ' has successfully performed 
 such operations. Several simple strictures of the bowel 
 can be treated in the same way, if they are not too close 
 together. If the stricture is of a tubular form or if it is 
 of too high a degree, excision of the involved part followed 
 by exact coaptation of the divided ends by sutures is best 
 done. This operation is greatly facilitated by Murphy's 
 button, which makes it possible to unite the two ends of 
 the severed bowel rapidly without losing too much time 
 in the suturing. 
 
 In cases in which the stricture cannot be excised nor 
 
 otherwise remedied, or in any other form of obstruction of 
 
 the bowel which cannot be removed, the bowel just above 
 
 the stricture is united to the bowel below it and a short 
 
 ' Pean ; Bulletin de I'Academie de Medecine, 1890, p. 856. 
 
CHRONIC OBSTRUCTION. 287 
 
 circuit thus establislied. This is likewise best accom- 
 plislied by Murx^liy's button or by McGraw's elastic 
 ligature. 
 
 In some strictures of the colon in patients who are already 
 quite prostrated, a complete operation of excision or even 
 of the formation of a new circuit cannot be performed with- 
 out too great risk of life. Here colotomy is indicated, 
 being later supplemented by a more radical procedure 
 when the patient is stronger and in better condition. 
 
 Adhesions should be severed and tumors compressing 
 the bowel treated by radical removal. Surgical treatment 
 of the intestinal stenosis, affording as it does radical re- 
 lief, should be resorted to in every case as soon as the 
 diagnosis is positive. The onlj^ excuse for subjecting the 
 patients to non-operative measures as long as they get along 
 in comparative comfort, is the high mortality which surgi- 
 cal intervention still furnishes. According to Treves,' the 
 mortality fluctuates between twelve and twenty per cent. 
 It is to be hoped, however, that owing to our advanced 
 knowledge of this subject the diagnosis of intestinal ste- 
 nosis will be made quite earlj^, and that the patients by 
 being operated upon at an early period will show a smaller 
 percentage of mortality. 
 
 1 Loc. cit., p. 560. 
 
CHAPTER X. 
 
 NEEVOUS AFFECTIONS OF THE INTESTINES. 
 
 General Remarks. — The intestinal tract is rich in gangli- 
 onic cells and nerves. The plexus mesentericus Auerbach 
 and the plexus entericus Meissner accompan}^ it through 
 its entire length. The vagus and the splanchnic nerves 
 surround the intestinal canal with numerous branches and 
 form ramifications with the ganglionic plexus. Although 
 a thorough knowledge of the exact action of these different 
 nerve groups has not yet been acquired, still we are certain 
 that they govern the secretory, absorptive, and motor 
 functions of the intestinal canal. 
 
 Secretion seems to be dependent a great deal upon the 
 ganglionic plexus, as can be learned from Moreau's ' ex- 
 periment. This investigator ligated an intestinal coil and 
 severed all the nerves belonging to it. In a few hours the 
 coil, thus treated, was found filled with a fluid showing 
 amylolytic qualities and containing small quantities of 
 albumin. In order to prove the secretory influence of 
 nerves upon the intestines Fleischer'' justly refers to 
 the fact demonstrated by Quincke, Demant, and Mass- 
 loff , ^ that in man as well as in animals after ingestion of 
 food into the stomach, secretion takes place in the lower 
 part of the intestine, long before the arrival of the chyme. 
 
 ' Moreau : Centralbl. f. die med. Wissensch., 1868, No. 14. 
 ^ R. Fleischer: "Krankheiten des Darms," Wiesbaden, 1896. 
 ^ Massloff : " Untersuchungen aus dem physiologischen Institut zu 
 Heidelberg, " Bd. ii. 
 
iNERVOUS AFFECTIONS OF THE INTESTINES. 289 
 
 This also sliows that the nerves of the intestinal tract are 
 influenced by reflex action from the nerves of the stomach. 
 
 Vasomotor nerve filaments have also been proven to 
 exist in the intestines. Thus stimulation of the splanch- 
 nic nerve causes a contraction, while its section is followed 
 by dilatation of the intestinal blood-vessels. These vaso- 
 motor nerve filaments are undoubtedly also much con- 
 cerned with absorption. 
 
 The motor function of the nerves and their influence upon 
 peristalsis have been studied in an exhaustive manner by 
 Nothnagel, Brahm-Houkgeest, and others, and have been 
 described in the chapter on physiology (page 28). 
 
 Although under normal conditions we scarcely perceive 
 any sensations within the intestinal tract, we are neverthe- 
 less certain that sensory filaments exist in the nervous ap- 
 paratus of the intestines. This is revealed by the fact that 
 the action of some stimuli of greater intensity than normal 
 ui)on the intestinal wall, gives rise to sensations of pain^ 
 and pressure. Thus, a person not accustomed to a coarse 
 diet, after ingestion of a large quantity of cabbage and 
 beans, for instance, may suffer after six to eight hours 
 from pains in the lower part of the abdomen caused bj^ the 
 undue irritation of the small intestine. In pathological 
 conditions the sensory character of the intestinal nerves 
 is evinced very frequently. In fact this is one of the im- 
 portant points which we have to consider in almost any 
 affection of the intestinal canal. 
 
 The neuroses of the intestine may be classified into : 1, 
 motor neuroses; 2, sensory neuroses; and 3, secretory 
 neuroses. Very often these different neuroses exist in 
 combination. Thus, a motor neurosis may exhibit fea- 
 tures belonging to secretory or sensory derangements. 
 
 The designation of the neurosis, however, should depend 
 19 
 
290 DISEASES OF THE INTESTINES. 
 
 "upon the type most prevalent. All affections of the intes- 
 tines in which no anatomical lesion can be discovered are 
 classified as neuroses or functional diseases of the intes- 
 tines. 
 
 Intestinal neuroses may be primary, i.e., the affection 
 emanates from the intestinal tract, or they may be second- 
 ary, occurring in connection with nervous manifestations 
 in other organs. Etiologically we know that psychical 
 influences, mostly of a depressing nature, as fear, fright, 
 worry and anxiety, are often the causative factors of intes- 
 tinal neuroses. Neurasthenia and hysteria as well as a 
 general neurotic tendency are also liable to produce ner- 
 vous affections of the intestinal tract. In some instances 
 the latter conditions are due to a reflex action originating 
 from some other diseased organ (stomach, the genito-uri- 
 nary tract, uterus, etc.). 
 
 MOTOR NEUROSES OF THE INTESTINES. 
 ,, Diarrhoea. 
 
 Etiology and Symptomatology. — Diarrhoea, meaning too 
 frequent and usually too watery movements of the bowels, 
 is always due to increased intestinal peristalsis. Diar- 
 rhoea may be the result of various morbid conditions of the 
 intestines, but here we shall describe the form of diarrhoea 
 which exists without any apparent anatomical lesions. 
 
 Diarrhoea may be classed under three groups: 1. Ner- 
 vous diarrhoea (Trousseau).' 2. Dyspeptic diarrhoea. 3. 
 Stercoral diarrhoea. 
 
 1. Nervous Diarrhoea. Although all the three groups of 
 diarrhoea are primarily produced by increased peristaltic 
 action of the bowels which is in turn caused by exagger- 
 ' Trousseau : "Clinique de I'Hotel Dieu, " Bd. ii. 
 
DIARRHCEA. ' 2Q1 
 
 ated action of the nervous apparatus, this group is desig- 
 nated as nervous diarrhoea on account of the predominance 
 of the nervous element. Trousseau was the first to de- 
 scribe nervous diarrhoea. It originates either through 
 undue stimulation of the accelerating jjeristaltic nerves or 
 through some nervous influences which cause a serous 
 transudation into the intestinal canal. Frequently both 
 factors are probably implicated. 
 
 In many cases the stimulus may emanate from the centre 
 and readli the intestinal ganglia through the vagus, the sym- 
 pathetic, or the splanchnic. In some cases, however, the 
 stimulus affects the ganglionic cells of the intestinal wall 
 directly. As characteristic instances of nervous diarrhoea 
 we would mention those cases in which there are several 
 watery evacuations after a strong emotion, thus after fright 
 or fear. Here the stimulus arises in the brain centres 
 supervising intestinal motions. While in these instances 
 we have to deal with an acute transitory condition, nervous 
 diarrhoea can also appear in a chronic form (Nothnagel, 
 Peyer ') . There are persons who are attacked with diar- 
 rhoea as soon as they are in a place where a toilet-room is 
 inaccessible. They may then be seized with abdominal 
 pains, tenesmus, and diarrhoea. In other persons, again, 
 the mere sight of a water-closet evokes an intense desire 
 for an evacuation. 
 
 Occasionally the diarrhoea is preceded by several other 
 nervous symptoms, as for instance vertigo, giddiness, con- 
 gestion of the head, a sensation of heat all through the 
 body, fright, shortness of breath, or palpitation of the 
 heart. All these symptoms as a rule raj^idly disai)pear 
 after a satisfactory movement. 
 
 ' A. Peyer : " Die nervosen Affectionen des Darmes bei der Neurasthe- 
 nic des mannlichen Geschlechts. " Wiener Klinik, 1893, Heft 1. 
 
292 DISEASES OF THE INTESTINES. 
 
 This form of diarrhoea is found in persons suffering 
 from neurasthenia or hysteria, in debilitated persons, or 
 in perfectly healthy people after a more or less pronounced 
 shock to the nervous system. Moreover it is met with 
 accompanying affections of the spine. Thus Charcot de- 
 scribed attacks of diarrhoea appearing periodically in tabes 
 dorsalis (intestinal crises). Lastly, nervous diarrhoea may 
 exist as a reflex condition in consequence of abnormal proc- 
 esses in the neighboring organs (the genito-urinary tract, 
 uterus, etc.). 
 
 As an instance of nervous diarrhoea the following case 
 may be described: 
 
 N. S., thirty years old, physician, was always perfectly 
 well. After a year of hard study and a great deal of care 
 and anxiety he had begun to suffer from frequent loose 
 evacuations during the last six months. As a rule the 
 patient had one or two passages a few minutes after each 
 meal. Preceding the evacuation rumbling noises were 
 heard in the lower part of the abdomen, while a slight 
 feeling of discomfort was experienced. The movements 
 were softer and more watery than usual, but did not con- 
 tain anything abnormal (no mucus, no undigested food). 
 The patient felt perfectly well in every respect, had a good 
 appetite, slept well, and had not lost weight. Exami- 
 nation of the gastric contents showed the stomach to be 
 perfectly normal. The patient was given no medicines and 
 was instructed to respond to nature's call in the morning 
 and to try to suppress the evacuations after meals when- 
 ever possible. For the first few days he succeeded in hav- 
 ing no movement after some of the meals, and gradually 
 after a few weeks was perfectly free from the desire to 
 evacuate the bowels after eating. 
 
 The following case is reported by Fischel : ' 
 
 A lady, twenty -three years old, complained of a feeling 
 ' F. Fischel: Prager med. Wochenschr. , 1891. 
 
DIARRHOEA. 293 
 
 of oppression, cardiac palpitation, and severe attacks of 
 diarrhoea, wliicli appeared periodically independent of the 
 quality of the food. The passages were watery and of a 
 strong alkaline reaction, smelled bad, and contained 
 triple phosphate and considerable amounts of intestinal 
 epithelial cells. The examination revealed a retroflexion 
 of the uterus. After insertion of a pessary the diarrhoea 
 ceased. 
 
 The diarrhoea appearing after exposure to cold and wet 
 weather is most probably caused by a reflex emanating^^ 
 from the nerves of the skin and producing hypersemia of 
 the intestines. The latter gives rise to transudation into 
 the lumen of the bowel and also to increased peristalsis. 
 This form of diarrhoea disappears very quickly (in twelve 
 to twenty -four hours) and does not produce any anatomi- 
 cal changes of the intestinal walls. 
 
 Another group of diarrhoeas takes its origin from an irri- 
 tation of the intestinal nerves through some abnormal sub- 
 stances contained in the blood. The cathartic action of 
 some remedies subcutaneously injected is the best proof 
 of this possibility. The diarrhoea occurring in cases of 
 septicaemia, of nephritis (with or without ursemic symp- 
 toms), and also diabetes is best explained by the theory 
 of irritating products circulating in the blood. The diar- 
 rhoea accompanying typhoid fever and dysentery in the 
 first stage before there has been time for the formation of 
 ulcers, is caused by the circulating in the blood of toxic 
 elements produced by the pathogenic micro-organisms. 
 
 2. Dyspeptic Diarrhoea. Under dyspeptic diarrhoea may 
 be comprised (a) the diarrhoea which appears after certain 
 articles of food; (6) diarrhoea accompanying abnormal 
 conditions of the gastric contents. 
 
 (a) Certain foods may cause mushy or watery evacua- 
 tions, as, for instance, fresh fruit, cucumbers, cabbage, and 
 
294 DISEASES OF THE INTESTINES. 
 
 beets. Tlie liability to diarrhoea from these foods, how- 
 ever, greatlj' varies in different persons. In some people 
 milk produces diarrhoea, while in others it is rather con- 
 stipating. 
 
 (6) Pronounced conditions of subacidity of the gastric 
 contents and still oftener achylia gastrica are associated 
 with diarrhoea. Here probably the chyme on account of 
 its not having undergone any considerable changes in the 
 stomach exerts mechanically too great a stimulus on the 
 intestinal wall and thus causes the increased peristalsis. 
 Hyperchlorhydria, although rarely, is also found associ- 
 ated with diarrhoea. Here the chyme containing too much 
 acid most probably produces the increased peristalsis. 
 
 3, Stercoral Diarrhoea. Stercoral diarrhoea means a diar- 
 rhoea arising in consequence of too great a stimulus from 
 fecal matter. 
 
 Etiology and Symptomatology. — If healthy persons for 
 some cause or other become constipated for a certain pe- 
 riod of time, the constipation may be followed by diar- 
 rhoea. The latter is generally produced by the formation 
 of certain gases which chemically or mechanically exert a 
 stronger stimulus upon the intestinal peristalsis. Occa- 
 sionally hard scybala, as such, irritate the mucous mem- 
 brane of the bowel too much and cause increased secretion 
 and peristalsis. In stercoral diarrhoea the evacuations are 
 as a rule at first formed and solid, later mushy and watery. 
 Off and on these watery passages contain several small 
 scybala as hard as a stone. Shortly before the appearance 
 of diarrhoea the abdomen is often quite bloated and borbo- 
 rygmi are heard in the intestines. The patients very fre- 
 quently complain of intense headaches. The passage of 
 bad smelling flatus affords only temporary relief, while a 
 good movement removes almost all the symptoms. Slight 
 
DIARRHCEA. 295 
 
 gastric symptoms may accompany tliis condition. A ra-. 
 tional diet effectually arrests the diarrhoea, but after an- 
 other period of constipation it may reapfjear, and if this 
 happens very frequently, intestinal catarrh may be the 
 result. 
 
 Diagnosis. — The diagnosis of nervous diarrhoea can be 
 made, if anatomical lesions of the intestines can be ex- 
 cluded and if the passages do not contain a considerable 
 amount of mucus. The special type of the diarrhoea may 
 be determined either by the symptoms (nei*vous diarrhoea 
 proper, stercoral diarrhoea) or by an examination of the 
 gastric contents (dyspeptic diarrhoea) . 
 
 Prognosis. — Most cases of nervous diarrhoea give a favor- 
 able prognosis. In some instances the diarrhoea, origi- 
 nally of a nervous origin, assumes a chronic course aud 
 ultimately produces an enteritis. 
 
 Treatment. — The treatment will vary according to the 
 type of the diarrhoea. In nervous diarrhoea proper the 
 general condition of the patient must be strengthened and 
 the remedies will have to be directed toward this end. 
 Arsenic and iron will often prove efficient. In some cases 
 the administration of bromides for a few weeks will be of 
 great benefit. 
 
 In nervous diarrhoea dependent on a reflex action emanat- 
 ing from some other diseased organ, the treatment must 
 be directed toward the primary affection. 
 
 In all cases of nervous diarrhoea, persistent training of the 
 intestines in the normal direction must be urged by the 
 physician. The patient should be instructed after having 
 had his first movement in the morning to refrain from any 
 other evacuations of the bowels during this day, answering 
 nature's call only when absolutely necessary. In quite a 
 number of instances the patient at first continues to have 
 
'296 DISEASES OF THE INTESTINES. 
 
 the desire for an evacuation quite often, but succeeds in 
 controlling it. Later on the desire for defecation appears 
 less often and at last a normal state is reached. 
 
 In dyspeptic diarrhoea the treatment should be directed 
 toward the improvement of the abnormal condition of the 
 stomach. Thus diarrhoea due to hyperchlorhydria can be 
 successfully checked by bicarbonate of sodium taken in half- 
 teasfjoonful or teaspoonful doses two hours after meals. 
 The diarrhoea resulting from achylia gastrica can be rem- 
 edied by a diet rich in vegetable foods, prepared in such 
 a manner that they are easily broken up into minute par- 
 ticles. Stomachics, intragastric faradization, and gener- 
 ally the treatment of achylia gastrica will also control the 
 diarrhoea. 
 
 In stercoral diarrhoea an efficient cathartic is the best 
 means of checking the diarrhoea. Diarrhoea having its 
 cause in a faulty' composition of the blood should be rem- 
 edied by improving the constitutional condition. If this 
 is impossible the treatment must be symptomatic. 
 
 In this connection it may be advisable to describe the 
 means we have at our command symptomatically to treat 
 diarrhoea, no matter of what nature it may be. The first 
 place must be given to opium, a remedy which has stood 
 the test of ages and is still the most reliable. It efficiently 
 decreases the abnormal jjeristalsis and probably also di- 
 minishes the intestinal secretion. Morphine and the other 
 derivatives of opium act in a similar manner, but opium as 
 such seems to be preferable in diarrhoeal conditions. Be- 
 sides opium there is hardly another remedy efficient to 
 check increased intestinal peristalsis, although there are 
 several others which may arrest the diarrhoea. Among 
 these may be mentioned nitrate of silver, subnitrate and 
 salicylate of bismuth, and all the remedies containing tan- 
 
CONSTIPATION. 297 
 
 nic acid. Another important means in treating diarrlioeal 
 conditions is heat. A hot-water bag or warm linseed poul- 
 tice applied over the abdomen and warm drinks have a 
 favorable influence upon the diarrhoea. 
 
 Coyistipation. 
 
 Synonyms. — Habitual constipation, atony of the bowel, 
 constipatio, constipatio alvi, obstipatio. 
 
 Definition. — By constipation is understood a diminution 
 in the frequency of evacuations of the bowels. 
 
 General BemarJcs. — Healthy persons have as a rule one 
 evacuation of the bowels daily. Under normal conditions 
 a movement occurs almost always at about the same time 
 of the day. The cause of this periodicity lies most prob- 
 ably in nervous influences. As mentioned above in the 
 chapter on physiology, the contents of the small intestine 
 are propelled with comparative rapidity. In the large in- 
 testine, however, the prochoresis is very slow. The upper 
 rectum and the sigmoid flexure form a reservoir for the 
 storage of the fecal matter. Once in twenty-four hours 
 through certain nervous influences the faeces are carried 
 lower down into the ampulla of the rectum and there is 
 then experienced the desire for defecation. This is accom- 
 plished voluntarily by relaxing the sphincter ani and by 
 exercising a moderate pressure with the abdominal walls 
 after more or less deep inspirations. No pain is connected 
 with this act and a rather pleasant sensation is felt after 
 its accomplishment. 
 
 Even physiologically there is a great variability in the 
 number of movements. Some persons have normally two 
 or three movements a day all their lifetime, while others 
 have only one evacuation every other day or even every 
 three days. In both instances there may be no abnormal 
 
298 DISEASES OF THE INTESTINES. 
 
 sensations whatever and we are thus forced to consider 
 them as physiological. Constipation, therefore, should 
 signify a condition in which a person has less frequent 
 movements than he has been accustomed to. 
 
 In rare instances, however, the number of evacuations 
 remains the same, but their quantity diminishes. Thus a 
 stagnation of fecal matter in the bowels occurs (copros- 
 tasis). This condition is also usually comprised under 
 the head of constipation. The quantity of the daily 
 evacuation of the bowel varies greatly, depending princi- 
 pally upon the diet. A vegetable diet gives voluminous 
 stools, while one consisting mainly of meats produces only 
 a small quantity of fecal matter. The average quantity 
 of fecal matter for twenty-four hours is about 250 c.c. 
 While a marked divergence from the above-mentioned fig- 
 ure must be recognized as pathological, a small decrease 
 of evacuated fecal matter cannot be easily discovered, the 
 more so since, according to Woodward, a considerable 
 quantity of the fecal matter is made up of micro-organ- 
 isms whose number is apt to vary greatly, even under 
 normal conditions. 
 
 Constipation may be due to organic lesions of the bowel 
 (stenosis of the intestine or catarrhal conditions), or may 
 exist without apparent anatomical changes in the intestinal 
 tract, and thus be functional in nature. The latter class 
 alone is dealt with here^ Inasmuch as in the great major- 
 ity of these cases of constipation a disturbance in the ner- 
 vous apparatus of the intestine may be presumed to exist, 
 we discuss constipation in this chapter on intestinal neu- 
 roses. 
 
 Etiology. — Habitual constipation may be divided into 
 three groups: 1. Constipation due to retarded intestinal 
 peristalsis (atony of the bowel). 2. Constipation due to 
 
CONSTIPATION. 299 
 
 a spasmodic contraction of a certain portion of intestine 
 (enterospasmus, spastic constipation). 3. Constipation 
 depending upon abnormal conditions of other organs. 
 
 With regard to the etiology of the first group, namely, 
 constipation due to atony of the bowels, which comprises 
 by far the greater majority of cases, the following may be 
 said : In most instances the constipation is brought on by 
 a repeated neglect of nature's calls. Thus, young girls 
 while in school suppress the desire for defecation out of 
 bashfulness, which gives rise at first to irregularity of the 
 bowels and later on to constipation. The mental state is 
 also responsible to a great extent for the causation of this 
 trouble. 
 
 It is not among the working class that constipation is- 
 most frequently found, but among the wealthier classes. 
 This shows that the mode of living has much to do with 
 this affection. If we would go a little more into detail 
 and try to analyze cases of chronic constipation, we would 
 learn that the patient had perliaj)s at first a great deal of 
 worry or of mental strain. At that time his bowels first 
 became sluggish and after a while the affection became 
 more developed. The patient experienced more and more 
 difficulty, began to take drugs, and after a short time was 
 not able to have a movement without medicine. 
 
 Often we find that after an acute gastric catarrh there 
 was at first a little diarrhoea, which after a few days 
 changed into constipation. After a short time this would 
 have disappeared of itself, if the patient in his haste to have 
 a movement had not resorted to cathartics, thus upsetting 
 again the normal state of the intestinal tract, in conse- 
 quence of which chronic constipation developed. Yer^^ 
 frequently the patient has some trouble, perhaps a head- 
 ache, and thinks the stomach is disordered, and begins. 
 
300 DISEASES OF THE INTESTINES. 
 
 to live on a one-sided diet, avoids vegetables, butter, fat 
 — all substances which excite the peristaltic action of the 
 bowels — and then constipation arises and assumes a chronic 
 form. 
 
 In a limited number of cases the retarded intestinal 
 peristalsis is due to a real muscular weakness of the 
 bowel, the intestinal muscularis being much thinner 
 than normally. Nothnagel observed some cases in which 
 at the autopsy the muscularis of the large bowel measured 
 in thickness 0.12 to 0.25 mm., while normally it ought 
 io be 0.5 to 1 mm. In these cases the muscular devel- 
 opment of the entire body was poor. It will therefore be 
 easily seen that such rare conditions cannot be recognized 
 during life. 
 
 In former years the opinion prevailed that chronic consti- 
 pation gives rise to the developement of numerous nervous 
 affections (neurasthenia, hypochondriasis, hysteria, and 
 even epilepsy and paranoia). Dunin ' was the first to show 
 that in reality quite the reverse is true, namely, that con- 
 stipation is the result of many nervous conditions and not 
 their origin, for a treatment directed against the existing 
 neurosis in many instances removes the constipation with- 
 out the administration of cathartics. Dunin, however, 
 goes too far in ascribing all cases of habitual constipation 
 to a neurosis. There are certainly cases of chronic consti- 
 pation in which no nervous derangement whatever can be 
 •discovered. 
 
 Formerly the cause of constipation was presumed to lie 
 in abnormal conditions of the bowels. Thus, peritonitic 
 adhesions of the intestines and congenital malposition of 
 the bowel have been held responsible for chronic consti- 
 
 ' Dunin r " Ueber habituelle Stuhlverstopfung, deren Ursachen und 
 BehandluDg. " Berliner Klinik, 1891, Heft 34. 
 
CONSTIPATION. 
 
 301 
 
 pation. But aside from tlie fact that these two factora 
 are so rarely found iu comparison witli the large num- 
 ber of cases of constipation, Leichtensteru ' proved that 
 an abnormal position of the bowels need not cause con- 
 stipation as long as the intestinal lumen is not obstructed. 
 
 Spasmodic contraction of the bowels or enterospasmus 
 is produced by increased peristaltic action confined to one 
 portion of the bowels. A j^ermanent contraction of a por- 
 tion of the intestine exists which may affect both the circu- 
 latory and the longitudinal muscles. This spastic state 
 may be of variable duration and may involve intestinal 
 segments of different lengths. The contracted portion of 
 the bowel is almost completely occluded, thus creating 
 an obstacle to the onward passage of the intestinal con- 
 tents. 
 
 The enterospasm may involve the entire small intes- 
 tine. The abdomen then appears contracted in the form 
 of a trough. This condition is met with in spinal menin- 
 gitis and in other morbid processes involving the pons 
 and the medulla oblongata. Moreover, the same affection 
 occurs in chronic lead poisoning. 
 
 Much more frequent than the diffused enterospasm is. 
 the localized or circumscribed contraction of the bowel 
 which usually affects a certain portion of the large intes- 
 tine. Here the abdomen does not show any abnormal 
 appearance on inspection. This condition is frequently 
 met with in nervous people, neurasthenics, hysterical per- 
 sons, and also in those debilitated by long ailments. Con- 
 stipation of an obstinate nature, lasting for several days, 
 followed by a painful evacuation of small balls (like th& 
 
 ^ Leichtenstern : " Verengerungen, Verscbliessungen und Lageveran- 
 deruDgen des Darms." von Ziemssen's "Handbuch der speciellen Pa- 
 thologie und Therapie, " Bd. vii., 2te Halfte. Leipzig, 1878. 
 
o02 DISEASES OF THE INTESTINES. 
 
 feces of goats) or leadpencil-sbaped fecal matter are the 
 predominant symptoms. Pains in the umbilical region or 
 on the left side of the lower abdomen of a constricting 
 nature and relieved after a very small passage, are also 
 characteristic of this affection. 
 
 Constipation Depending upon Diseases of Other Organs. 
 Numerous diseases of the stomach give rise to constipa- 
 tion. Foremost among these are hyperchlorhydria, ulcer 
 and cancer of the stomach, ischochymia, atonic and catar- 
 rhal conditions of the stomach, and finally achylia gastrica 
 — the last three, however, show a smaller percentage of 
 this complication. In this group of cases constipation is 
 attributable either to the abnormal qualities of the chyme 
 passing through the digestive canal or to the retarded gas- 
 tric prochoresis or to some retarding reflex act originating 
 in the stomach. 
 
 Tumors of the intestinal canal or of neighboring organs 
 compressing the bowel, strictures within the intestines, and 
 peritonitic adhesions are also often associated with consti- 
 pation. These conditions, moreover, frequently lead to a 
 far more serious condition, namely, to acute or chronic 
 ileus. Catarrhal inflammation of the small intestine alone 
 is also ordinarily accompanied by constipation. Ulcers 
 of the small intestine are sometimes attended by constipa- 
 tion. Ulcers of the large bowel are ordinarily accompa- 
 nied b}^ diarrhoea, excepting dysenteric ulcers, which often 
 produce constipation. Fissure of the anus and an increased 
 contraction of the sphincter of the anus are often causes of 
 constipation. 
 
 In many diseases of the brain, spinal cord, and the 
 nerves (cerebro-spinal meningitis, brain tumors, hemor- 
 rhages of the brain, chronic hydrocephalus, myelitis, 
 tabes, neuroses and psychoses) constipation is present. 
 
CONSTIPATION. 303 
 
 It is due here either to a disturbance of the nervous appa- 
 ratus communicating with the centre for defecation, or to 
 a diminished sensibility of the intestinal nerves so that 
 stronger stimuli are required than under normal condi- 
 tions. 
 
 Diseases of the lungs, heart, liver, and kidney increase 
 the liability to constipation, first, by the hyperemia of 
 the intestinal mucosa, and, secondly, by the congestion 
 in the portal circulation, which both retard the peristalsis* 
 Diabetes mellitus often gives rise to constipation, first, 
 by the polyuria which drains the organism of water and 
 thus leads to an exsiccated condition of the fecal matter, 
 and, secondly, by the diet, which consists principally of 
 meat and of a very restricted quantity of starchy food. 
 Diarrhoea, however, is not rarely met with in this disease. 
 
 Anaemia and chlorosis are also often attended by consti- 
 pation. The latter is due to an atonic condition of the 
 bowels, which is one of the symptoms of the general mus- 
 cular atony dependent upon the impoverishment of the 
 blood. 
 
 Most febrile diseases are also usually accompanied by 
 constipation. Lack of exercise and an increased elimina- 
 tion of the fluids of the body caused by the greater activity 
 of the lungs and the sudoriparous apparatus are the prin- 
 cipal factors. Constipation encountered in people living 
 in high altitudes must be ascribed, according to Euedi,' 
 to the same causes. The restricted diet, consisting chiefly 
 of milk, also contributes to a lessened activity of the intes- 
 tinal peristalsis. 
 
 Symptomatology. — In many cases constipation does not 
 induce any subjective symptoms whatever. Ordinarily, 
 
 ' Carl Ruedi : " On Indications and Contraindications of High Alti- 
 tude in Phthisis. " The Climatologist, July, 1892. 
 
304 DISEASES OF THE INTESTINES. 
 
 however, continued constipation gives rise to sensations' 
 of slight pressure, fulness and tension in the abdomen ^ 
 and borborjgmi may at times molest the patient. Occa- 
 sionally intense colicky pains are experienced. These are 
 due to an increased effort of the intestines to rid them- 
 selves of the accumulated fecal matter by violent contrac- 
 tions. The abdomen is often symmetrically distended, 
 rarely asymmetrically, namely, in partial atony of the 
 bowels. 
 
 In patients with thin abdominal walls, a more or less 
 filled state of some portions of the intestine, especially 
 of the colon, may be perceived by inspection and pal- 
 pation. The appetite is often diminished and in some 
 instances complete anorexia exists. Other gastric symp- 
 toms — belching, nausea, pyrosis, feeling of pressure after 
 meals, and bad taste in the mouth — may be present. That 
 all these symj^toms are due to the constipation and not to 
 a separate lesion in the stomach, is proven by the fact that 
 they all disappear as soon as efficient evacuation of the 
 bowels has taken place. 
 
 Besides these gastric symptoms the following derange- 
 ments may be present : congestion of the head, dizziness, 
 headaches, sleeplessness, a despondent feeling, palpitation 
 of the heart, tachycardia, irregularity of the pulse. The 
 latter symptoms have been considered by many writers to 
 be due to auto-intoxication from the intestinal tra^t. Ac- 
 cording to the experiments of Bouchard,' however, this 
 does not seem to be true, for this investigator has shown 
 that intoxication within the intestinal tract takes place 
 when there is a retention of fluid fecal matter, but not 
 when the faeces are solid, for in this condition no absorp- 
 tion of the fecal matter takes place. 
 
 ' Bouchard : Loc. cit 
 
CONSTIPATION. .'>05 
 
 Constipation which has lasted for a long time, as a rule, 
 terminates by a spontaneous evacuation of ordinarily very 
 hard masses of fecal matter. The latter often appears in 
 the form of balls which may be covered with a thin layer 
 of mucus. In some instances the constipation terminates 
 in an attack of diarrhoea. In these cases the diarrhoea has 
 been caused by an acute hypersemia and inflammation of 
 the intestinal mucosa due to the hardened fecal matter, the 
 latter becoming liquefied through increased intestinal per- 
 istalsis and secretion. In other instances no spontaneous 
 evacuation takes place and it becomes necessary to make 
 use of diflferent cathartic remedies in order to i)roduce a 
 movement of the bowels. 
 
 Retention of fecal matter may cause not only a slight 
 transient catarrhal condition of the bowels as just referred 
 to, but may, although rarely, effect more pronounced an- 
 atomical lesions, as formation of ulcers (stercoral ulcers), 
 local peritonitis, and even perforation of the gut with fatal 
 issue. 
 
 One of the serious symptoms which may result from 
 continued constipation is fecal colic. The latter begins 
 with sudden violent pain of a colicky nature in the ab- 
 domen. In weakened persons fainting spells may occur. 
 The abdomen is usually greatly bloated and tender on 
 pressure. Passing of wind (flatus) gives temporary relief, 
 but the pains soon reappear and subside only after an 
 efficient evacuation. Fecal colic is mostly observed in 
 cases of obstinate constipation, although it may occur in 
 patients with daily evacuations of the bowels, but in these 
 insufficient fecal passages must be presupposed. In fact, 
 hardened balls of fecal matter can be discovered in such 
 cases on palpation of the abdomen. 
 
 These conditions are not always of a mild character. 
 20 
 
306 DISEASES OF THE INTESTINES. 
 
 As a rule cathartic remedies are efficient. In some cases, 
 however, the latter produce energetic intestinal peristalsis 
 and violent pains, but fail to secure a copious movement. 
 Under these circumstances the patient may after a while 
 sink into a state of collapse and be seized with a paroxysm 
 of vomiting. The clinical picture now resembles very 
 closely that of ileus. High rectal irrigations or injections 
 of oil into the bowel ordinarily yet produce the desired 
 effect and the patient quickly recuperates. In rare cases, 
 however, especially in very old and cachectic persons, these 
 means also remain fruitless. Total paralysis of the intes- 
 tine now takes place and the patients are then in a most 
 critical condition. 
 
 A frequent complication of constipation is the formation 
 of fecal tumors. They are found most frequently in the 
 caecum, rectum, and at the colic flexures. These masses 
 may cause a dislocation of the colon ; thus, such a tumor 
 may be felt just above the symphysis and may belong to 
 the transverse colon which has been dragged down to that 
 region. Fecal tumors are as a rule easily recognizable. 
 They are not of a very firm consistency^, have a rosary-like 
 configuration, are movable, and undergo a change in shape 
 upon pressure. They may be of large size. Thus Levi ' 
 found the rectal pouch of a patient suffering for nine years 
 with constipation filled with a fecal mass weighing four 
 pounds. Still larger fecal concretions have been found 
 by Lemazurier.^ These large masses necessarily dilate 
 the colon. 
 
 Habershon described cases in which the dilated colon 
 measured twelve to fifteen inches in circumference, and 
 :jtated that some of the normal sacculations of the colon 
 
 ' Levi : Gazette med. , 1839. 
 
 ' ijevi : uazeite mea. , looy. 
 
 - Lemazurier : Arch. gen. de med., vol. 
 
 1. 
 
CONSTIPATIO:?^. 307 
 
 may become distended to such a degree that they appear 
 as true diverticula. In the latter fecal accumulations may 
 occur which remain undisturbed by the further passage of 
 the intestinal contents. These stagnant fecal masses often 
 produce inflammatory processes which may lead to a de- 
 struction of the intestinal coats down to the peritoneum^ 
 The colon occasionally is distended not only in width 
 but also in length. The latter circumstance explains the 
 abnormal position of the bowel often present iu these 
 cases. 
 
 Among the local symptoms which constipation produces 
 hemorrhoids play an important part. They are treated 
 in a special chapter. 
 
 A host of nervous symptoms may develop in consequence 
 of constipation in people who are apparently not nervously 
 inclined. Thus constipation lasting several days may 
 produce slight cerebral symptoms, namely, a sensation of 
 pressure, weight and dulness in the head, sometimes 
 headaches and vertigo. The dependence of these symp- 
 toms upon constipation is proved by the fact that after a 
 full evacuation of the bowels they all suddenly disappear, 
 but again return after another period of constipation, "We 
 have as yet no positive explanation of the causation of 
 these symptoms. Some authors assume them to be of a 
 reflex origin. 
 
 Leube ' described several cases of intestinal vertigo in 
 which the dizzinevss was due to pressure existing in the lower 
 end of the bowels, the vertigo appearing only in consequence 
 of irritation of the intestinal walls by fecal matter or a large 
 amount of gas, or by the examining finger. Leube concluded 
 that pressure upon the hemorrhoidal plexuses of the sym- 
 
 ' Leube: "Ueber Darmschwindel. " Deutsclies Arch. f. klin. Medi- 
 cin. Bd. 36, 1885. 
 
308 DISEASES OF THE INTESTINES. 
 
 pathetic nerve produces tlie sensation of vertigo in are- 
 flex way. 
 
 Senator' tried to explain the above symptoms as due 
 to the absorption of poisonous gases within the intestine, 
 such as sulphuretted hj^drogeu, and Nothnagel assumed 
 that ptomains may be absorbed and thus cause an auto- 
 intoxication. But neither theory seems to hold good; for 
 sulphuretted hydrogen gas exists in too small quantities 
 to produce any marked symptoms, and the fecal ptomains 
 can scarcely be absorbed from dried-up fecal matter. 
 
 As mentioned above, real brain diseases, hypochondria 
 and melancholia, are never due to constipation as such. 
 There is, however, hardly any doubt that in nervously 
 inclined individuals obstinate constipation may be a con- 
 tributing factor in the further development of some psy- 
 choses, especially melancholia. 
 
 Fecal fever, which has played a great part in the works 
 of old writers, appears to be due in most instances not to 
 an accumulation of fecal matter but rather to some com- 
 plicating condition, an inflammatory process, a stercoral 
 ulcer, a local peritonitis, etc. In infants and children, 
 however, who much more readily develoj) fever, the latter 
 may be due to accumulation of fecal matter alone. Some 
 of the English writers have referred to chlorosis as due to 
 habitual constipation, and Clark has treated chlorosis, with 
 cathartics. But this view has not been generally accepted 
 and the dependence of chlorosis upon constipation is far 
 from being proved. 
 
 Diagnosis. — The recognition of constipation is not diffi- 
 cult, except in those cases in which there is a daily evacu- 
 ation of the bowels but not a complete one, so that fecal 
 
 ' Senator : " Hydrothionaemie und Selbstinfection durch abnorme 
 Verdauungsvorgange. " Berl. klin. Wochenschr. , 1868, No. 34. 
 
CONSTIPATION. 
 
 809 
 
 matter is more and more accumulated in tlie intestine. 
 Frequently hard fecal masses of rosary sliax^e will be dis- 
 covered on palpation of the abdomen in the region of the 
 colon. Most often the sigmoid flexure and the caput coii 
 are the favored sites of this phenomenon. The detection 
 of these fecal masses shows the existence of an insufficient 
 evacuation of stools, in other words, constipation. 
 
 The diagnosis of pure constipation (habitual constipa- 
 tion) can be made, if organic lesions of the bowels (stric- 
 ture, tumor, and also intestinal catarrh) can be excluded. 
 This diagnosis having been made, it is of importance to 
 find out to which group the constipation belongs, whether 
 it be due to an abnormal gastric condition, or disease of 
 some other organ, or to a neurotic affection of the bowel 
 itself (atonic and spastic constipation). 
 
 Constipation due to anomalies of the function of the 
 stomach can be ascertained only after a thorough analysis 
 of the gastric contents and after resort to treatment directed 
 toward the improvement of the gastric condition. Con- 
 stipation due to disease of other organs (heart, lungs, 
 kidneys, liver, etc.) may be assumed to exist when an 
 examination discloses their presence. Constipation due 
 to atony of the bowels is often revealed by a slightly 
 bloated condition of the abdomen with evacuations of hard 
 fecal matter, often balls, sometimes covered with a thin 
 layer of mucus. While there may be a feeling of despond- 
 ency, dizziness, and somnolence, real severe pains are 
 rare. Constipation due to a spasmodic contraction of the 
 bowel is attended with a general feeling of uneasiness and 
 pains in the abdomen, occasionally accompanied by fainting 
 fits. The fecal matter is not so hard, although it is evac- 
 uated only after severe straining of the abdominal walls, 
 and is voided in narrow tapelike pieces. The abdomen 
 
310 DISEASES OF THE INTESTINES. 
 
 is often rather sunken and contracted. Intestinal coils can 
 frequently be palpated. 
 
 Prognosis. — The prognosis of constipation is favorable in 
 the large majority of cases, especially with regard to life. 
 It must, however, be admitted that after having lasted a 
 long time constipation may give rise to severe, sometimes 
 irreparable anatomical lesions of the intestine, as for in- 
 stance atrophy, peritonitic adhesions, malpositions of the 
 bowel, even perforation with consequent peritonitis and 
 death. The latter instances, however, are very rare, if we 
 take into consideration the large number of persons suffer- 
 ing with constipation who reach an advanced age, and they 
 will most probably become still less frequent if the patients 
 do not neglect this condition and consult a physician at an 
 early period. 
 
 Treatment. — Cases of constipation due to dyspeptic con- 
 ditions must be treated by first ameliorating the gastric 
 disorder. Cases of constipation secondary to diseases of 
 other organs must be managed by first applying remedies 
 toward the improvement of the original trouble. If these 
 alone are insufficient, they must be managed like typical 
 cases of habitual constipation. 
 
 With regard to the prophylaxis of constipation, we 
 should avoid administering cathartics in slight transient 
 disturbances of digestion and rather let nature take its own 
 course. Never put a patient on a one-sided diet for too 
 long a time; the exclusion of vegetables, fruits, and starchy 
 foods in general, from the diet is frequently the cause of 
 marked constipation. A hygienic mode of living, regular 
 habits, less business strain and worry, and more outdoor 
 life and exercise are of the greatest importance in the pre- 
 vention of constipation. 
 
 Generally no purgatives whatever, or as few as possible, 
 
CONSTIPATION. 311 
 
 sliould be used. Tlie chief measures in curing constipa- 
 tion are the following : 
 
 1. The Moral Treatment.— li is of utmost importance to 
 allay the patient's anxiety to have a movement. He should 
 be told to pay as little attention as possible to the condi- 
 tion of his bowels. Absence of a movement for a few days 
 will cause no harm whatever. Avoidance of purgatives and 
 keeping the mind of the patient free from worry over the 
 condition of his bowels is occasionally sufficient to produce 
 spontaneous movements. 
 
 Training the patient to have an evacuation at a certain 
 time every day is also of great importance. The patient 
 should be taught to go to the watercloset every morning at 
 the same time and should try to have a passage. In doing 
 this he should not exert himself too hard and should spend 
 only three to five minutes for this purpose. In case the 
 attempt be unsuccessful, he should wait until the follow- 
 ing morning, unless there is a strong desire to go to stool.. 
 Trousseau was the first to advocate this mode of treatment^ 
 and the importance of this maxim has since been geD-^ 
 erally accepted. My own experience coincides with that of 
 others, and I cannot lay too much stress upon this ap- 
 parently unimportant piece of advice. Even when using 
 other measures in combating constipation we must not 
 lose sight of the influence in " training " the patient. 
 
 2. Dietetic Measures. — The dietetic measures have for 
 their object the ingestion of foods which increase the intes- 
 tinal peristalsis and the avoidance of substances which are 
 of a more or less constipating nature. Advocate the drink- 
 ing of plain cold water, especially in the fasting condition, 
 the use of buttermilk, cider, grapes, oranges, and other 
 fruits, raw or cooked (apples, prunes, pears, peaches), 
 lemonade, honey; salmon, sardines, herring, plenty of 
 
312 DISEASES OF THE INTESTINES. 
 
 vegetables, spinach, green peas, cauliflower, cabbage, green 
 salads, rye bread, butter. Avoid strong tea, claret, huckle- 
 berries, cacao and chocolate. 
 
 Some substances have a constipating effect upon one 
 person and a purgative effect upon another, as for instance 
 milk. In treating the patient we must acquaint ourselves 
 with his peculiarities in this respect. In prescribing a 
 diet for patients with constipation we should allow them 
 the usual foods with a predominance of those just enum- 
 erated. It is needless to say that some of the articles 
 mentioned will not be permissible in every case. Thus a 
 patient with a very delicate stomach should certainly be 
 told not to take cabbage and cider, etc. 
 
 In some instances in which too much vegetable food has 
 been taken and a constipation has develojjed in consequence 
 of the intestine being overburdened with too much ballast, 
 food articles containing much cellulose will have to be re- 
 stricted. As a rule, however, a mixed diet with a prepon- 
 derance of vegetable food is adapted for most cases. 
 
 3. Mechanical Measures. — The mechanical measures 
 serve to strengthen the bowel and in this way promote a 
 better action, or they directly effect a stronger intestinal 
 peristalsis. The mechanical measures comprise massage, 
 exercise, electricity, hydrotherapy, and lastly injections 
 into the bowel. 
 
 (a) Massage. The general principles of massage have 
 been described above (page 80). Its action consists prin- 
 cipally in producing more efficient peristalsis of the large 
 bowel. It should therefore never be used in conditions in 
 which spasmodic contractions of the bowel may be assumed 
 to exist. Its most useful field lies in cases of atony of the 
 bowel. 
 . Massage should be applied at first either by the physi- 
 
CONSTIPATION. 313 
 
 cian himself or under liis strict supervision. It should 
 never be applied with much force and it should never 
 cause pain. According to Illoway, ' the duration of massage 
 treatment should be from five to fifteen minutes for a 
 grown person and from three to five minutes for children. 
 The massage should be employed every other day with 
 great regularity for a period of about six weeks at least, 
 nioway suggests that the massage sittings may be per- 
 formed less frequently as soon as there is a decided 
 improvement in the condition of the bowels. It is, how- 
 ever, never advisable to stop the massage treatment sud- 
 denly, but it should rather be kept up for a long period 
 of time, although later at longer intervals. Massage is 
 best applied early in the morning in the fasting condition 
 of the patient. During its employment no other remedy for 
 constipation should be administered unless the latter has 
 lasted several days and gives rise to various symptoms. 
 
 Auto-massage may also be of benefit. This may be 
 carried out by the patient himself, kneading his abdo- 
 men principall}' over the course of the large bowel with 
 his right hand or by means of some instrument adapted 
 for this purpose. Sahli was the first to recommend the 
 use of a cannon-ball, weighing about three to five pounds. 
 These balls may be wrapped in flannel and rolled over the 
 abdomen for about five to ten minutes. This procedure is 
 best performed early in the morning in bed in the fasting 
 condition of the patient. The ball is best rolled over the 
 abdomen in a spiral direction, principally along the course 
 of the colon. But the other parts of the abdomen should 
 also be subjected to this procedure. The flannel covering 
 the baU may be left off if desired. Dr. A. Eose,' of New 
 
 1 Illoway : " Constipation in Adults and Children, " New York, 1897. 
 * A. Eose : New Yorker medizinische Monatsschrift, January, 1893. 
 
314 DISEASES OF THE INTESTINES. 
 
 York, lias practised tliis method quite extensively and 
 warmly recommends its use. Dr. Arthur Kahn/ also of 
 New York, has invented an apparatus for auto-massage 
 which may also be used for this purpose. Kosenheim'^ 
 suggests using auto-massage in the following manner : The 
 patient in an upright posture makes short palpating strokes 
 with the fingers of his right hand inclined somewhat in- 
 wardly over his abdomen for several minutes. In this 
 procedure also the course of the colon is especially to be 
 considered. 
 
 (h) Gymnastic exercises. Exercises which bring into 
 play especially the muscles of the abdomen are of great 
 benefit. Exercises on the horizontal bar, horseback rid- 
 ing, mountain climbing, skating, rowing, bicycle riding, 
 are all beneficial, provided these sports are not kept up 
 for too long a time, and do not cause a superabundant 
 loss of water by extensive perspiration. 
 
 Indoor gymnastic exercises may also be used. Bend- 
 ing of the body, rotations of the trunk, especially in a 
 siting posture, quickly drawing up the knees toward the 
 thorax in the recumbent position, also alternate squatting 
 and rising are of special benefit. The passive, so-called 
 Swedish movements may also be employed either in a 
 Zander Institute or manually by a nurse. Massage and 
 these exercises are best applied in conjunction. 
 
 (c) Electricity. Percutaneous electrization (principally 
 faradization) of the abdomen has been recommended by 
 some writers as a cure for constipation, Recently direct 
 electrization of the intestine, applying one electrode to the 
 rectum and the other over the abdominal wall, has been 
 
 ' A. Kahn : Centralblatt fiir Chirurgie und orthopadische Mechanik,. 
 Berlin. 1889, Bd. v., p. 4. 
 
 2 Th. Rosenheim : "Krankheiten des Darms, " 1893, p. 513. 
 
CONSTIPATION. 315 
 
 used. Boudet's rectal electrode is best adapted for this 
 purpose, especially when galvanization is employed. The 
 insertion of one electrode in the stomach and the other in 
 the rectum, as suggested by Kussmaul and Leubuscher,' 
 has not come into use to any extent. 
 
 Electricity seems to act favorably on the intestinal peri- 
 stalsis and it is especially indicated in the treatment of 
 constipation in conjunction with massage, particularly in 
 atony of the bowel. Doumer^ has very recently recom- 
 mended/the use of static electricit3\ He applies localized 
 franklinization in the form of sparks or "souffles elec- 
 triques " for about five to twelve minutes in the iliac fossse, 
 principally the left. By the employment of this method 
 of treatment every other day for a period of two to three 
 weeks Doumer reports having cured the most obstinate 
 cases of chronic constipation. 
 
 {d) Hydrotherapeutic means. Hydrotherapeutic meas- 
 ures may be applied either alone or in conjunction with 
 the above-named mechanical means. HackeF gives the 
 following rules : In constipation due to atony of the bowels 
 use a jet of water of about the thickness of the small finger 
 with the force of two atmospheres, first over the epigas- 
 trium. The hose of the mobile douche is then placed over 
 the region of the colon. Charcot's douche is best adapted 
 for this purpose, as it allows a sudden change of tempera- 
 ture. When using the latter apparatus the temperature 
 can be readily changed to any degree desired during ita 
 application. The alternations in temperature should be 
 considerable, often from 102° F. to 120° F. Thus both 
 mechanical and thermic effects come into play. After 
 
 1 Leubuscher : Centralbl. f. klin. Medicin, 1887, No. 25. 
 
 2E. Doumer et Musin : Annalesd'Electro-Biologie, 1898, p. 722. 
 
 3 Jeannot Hackel : Deutsche med. Wocbenscbrift, Jan. 5, 1899. 
 
316 DISEASES OF THE INTESTINES. 
 
 using the douclie over tlie abdomen, it is applied over the 
 chest and back, throwing a fan-shaped jet, the temperature 
 being kept constant. 
 
 In constipation due to spastic contractions of the bowels 
 Hackel applies water under a pressure of two and a half 
 kilograms, letting it flow in the form of a fine spray. It 
 falls like a fine rain on the abdomen. The temperature of 
 the water should not be lower than 95" F. and not higher 
 than 102° F. and should not be changed. The duration of 
 the douche is from two to two and a half minutes. The hose 
 is directed along the course of the colon while the water 
 constantly runs over the epigastrium. Ninety-six such 
 circuits over the intestines may be made. Afterward the 
 lower extremities, chest and back, are douched. The skin 
 . of the abdomen must not be subjected to vigorous friction 
 after the douche ; the extremities, however, should be well 
 rubbed. After the douche the patient should lie in bed 
 for about five to ten minutes, being warmly covered, and 
 then may walk for about a quarter of an hour. 
 
 Cold sitz baths (12° C.) for about five minutes are also of 
 benefit, as well as a Priessnitz compress or Neptune's gir- 
 dle over the abdomen over night. 
 
 4. Injections. — Injections into the bowels of water alone 
 or of water with the addition of soap, vinegar, common 
 table salt, or castor-oil are often used with advantage. 
 The amount of fluid required for a purging effect varies in 
 different persons. As a rule a pint to a quart or one and 
 a half quarts are necessary. These water injections should 
 be made daily at the same hour for a period of three to 
 four weeks, and then every other day also for the same 
 length of time. 
 
 Recently Klemperer ' has recommended the use of small 
 ^ Klemperer : " Therapie der Gegenwart, " 1899, p. 48. 
 
CONSTIPATION. 317 
 
 water injections into the bowel at bed-time. Half a 
 pint of water is injected and the patient is told to re- 
 tain the fluid. The latter is very soon absorbed by the 
 intestine and the patient has an evacuation on the fol- 
 lowing morning. Klemperer cured cases of constipation 
 by giving these small water injections for about three 
 weeks every day, and then every other day for the follow- 
 ing two or three weeks. 
 
 Injections of sweet oil into the rectum, which have been 
 recommended by Xussmaul and Fleiner, are best adapted 
 for the treatment of obstinate cases of constipation, espe- 
 cially if due to spasmodic contraction of the bowel. The 
 injections should be made in the following way : Take 
 about one pint of good olive oil and heat it to the tem- 
 perature of the body. Then take a fountain syringe pro- 
 vided with a soft-rubber rectal tube, and inject the oil into 
 the rectum. The patient takes the injection while in bed, 
 and it is advisable to have him retain the oil as long as 
 he can. I usually order it to be taken in the evening, so 
 that the patient may fall asleep at once and retain it over 
 night. The following day the oil is passed and an evacua- 
 tion follows. If the patient is treated for two to three 
 weeks with oil, the spasmodic condition will subside. The 
 oil injections should then be given every other night for 
 a period of two weeks, thereafter twice a week for some 
 time, then once a week for several months. 
 
 Injections of glycerin, which were first recommended 
 by Anacker,' are also beneficial. Two to four grams of 
 glycerin are dissolved in about three to four ounces of 
 water and injected into the rectum. An evacuation of 
 the bowels results in a very short time, ten to twenty 
 
 'Anacker: "DasPurgativOidtmann. " Deutsche med. Wocheaschr.,. 
 1887, p. 833. 
 
318 DISEASES OF THE INTESTINES. 
 
 minutes. Tlie glycerin maj also be given in the form 
 of a suppository, acting the same way. While this mode 
 of treatment is very convenient to produce an evacuation 
 of the bowels, it should not be resorted to daily, as the 
 bowel is thereby greatly irritated. 
 
 Similar in its action but less harmful is Flatau's ' method 
 of applying boric acid directly to the rectum. Boric-acid 
 powder, about one to three grams, may be inserted into 
 the rectum with the finger or blown into it by means of a 
 powder-blower through the anus. A movement of the bow- 
 els occurs half an hour to three hours later. 
 
 5. Purging Medicaments.— In many instances of habitual 
 constipation the use of drugs must be resorted to. As a 
 general rule we should administer as mild cathartic rem- 
 edies as possible, and instead of increasing the dose we 
 should rather try to reduce it gradually, and ultimately 
 relieve the . constipation without the help of cathar- 
 iics. 
 
 The various preparations of rhubarb are very serviceable. 
 Tinum rhei and tinctura rhei aromatica or dulcis may be 
 given in doses of from half a teaspoon to one teaspoonful. 
 Khubarb may also be given as a powder in conjunction 
 with calcined magnesia and bicarbonate of soda, as for in- 
 stance : 
 
 I^ Pulv. rad. rhei, 
 
 Magnes. ustse, 
 
 Sod. bicarb aa 20.0 (3 v.) 
 
 M. f. pulv. D. ad scatulam. S. One-lialf teaspoonful two or three 
 times a day. 
 
 Pulvis glycyrrhizse compositus is also a very suitable prep- 
 «,ration. It can be given in teaspoonful doses at night or 
 in the morning. It has the following composition : 
 'Flatau: Berl. klin. Wochenschr. , 1891, p. 231. 
 
COXSTIPATION. 319 
 
 IJ Fol. sennge, 
 
 Rad. glycyrrbizse aa 10.0 (3iis9,) 
 
 Fruct. fceniculi, 
 
 Sulph. depur aa o.O ( 3 ii) 
 
 Sacch. alb 30.0 ( I i.) 
 
 Aloes is anotlier very efficient and popular remedy. It 
 effects a movement of tlie bowels in about eight to twelve 
 hours after its ingestion and does not cause any griping. 
 I often give the following prescription : 
 
 I^ Aloes 1.0 (gr. xv.) 
 
 Extr. belladonnse, 
 
 Extr. strychn aa 0. 3 (gr. v. ) 
 
 Extr. et pulv. glycyrrhlzse q. s. 
 
 Ut f. pil. No. XX. S. One pill twice daily. 
 
 Of the newer remedies podophyllin and cascara sagrada 
 are very valuable. Podophyllin is given in doses of one- 
 sixth to one-third of a grain twice a day. I use the fol- 
 lowing prescription : 
 
 ^ Podophyllin 0.3 (gr. v. ) 
 
 Extr. physostigmatis, 
 
 Extr. nuc. vomic aa 0.5 (gr. viiss.) 
 
 M. f . cum extr. et pulv. glycyrrhizte q. s. pil. No. xxx. S. One pill 
 twice daily. 
 
 Cascara sagrada may be given in the form of fluid extract, 
 fifteen to twenty-five drops twice daily, or cascara sagrada 
 '\vith maltine, one teaspoonful once or twice daily. 
 
 Syrup of figs, one teaspoonful at night time, or tama- 
 Tind, also one teaspoonful, is often of value. 
 
 Jalap and colocynth belong to the stronger drastic rem- 
 edies, and hardly ever find a place in the treatment of the 
 cases under consideration. Hunyadi Janos water, Fried- 
 richshaller, Homburger or Eakoczy waters, Apenta, Eu- 
 biuat and the like are also sometimes of benefit. They 
 should, however, not be used for a long period of time in 
 cases of anaemia and neurasthenia. 
 
CHAPTER XI. 
 
 NEEVOUS AFFECTIONS OF THE INTESTINES, 
 
 MOTOR l^iEVROSBS.- {Continued.) 
 Paralysis of the Intestines. 
 
 Paktial parah'sis of the intestines may occur and give 
 rise to symptoms resembling a complete occlusion of tlie 
 intestinal lumen. Paralysis arising in consequence of a 
 mechanical obstacle to the passage of the intestinal con- 
 tents has been described above. Here we shall deal with 
 primary paralysis of the intestine without any organic ob- 
 stacle. In this condition the peristaltic motion of this 
 organ is absent. The passage of fecal matter is thereby- 
 interrupted and symptoms of obstruction result. 
 
 Hem'ot ' distinguishes three forms of intestinal paraly- 
 sis: 
 
 1. Direct paralysis of a portion of the intestine caused 
 by alterations of its walls. Thus an intestinal coil may 
 become paralyzed after repeated forced reposition of a 
 hernia or after it has been incarcerated in the hernial 
 pouch for a long time. The paralysis may also occur as a 
 consequence of a direct trauma or after extensive abdomi- 
 nal operations, and finally after various chronic inflamma- 
 tory and ulcerative processes of the intestine (enteritis, 
 tuberculosis, dysentery). 
 
 2. The paralysis is caused indirectly in consequence of 
 
 ' Henrot : "Des Pseudo-etranglements, " Paris, 1865. 
 
INTESTINAL PARALYSIS. 321 
 
 a reflex nervous action. Thus contusion of the testicles, 
 inflammation of a hydrocele, abscesses of the abdomen may 
 inhibit the abdominal nerve centre in such a way that the 
 peristalsis ceases, although this is of very rare occurrence. 
 
 3. The intestinal paralysis maj' result from general neu- 
 roses (hj'steria), from psychoses (melancholia, hypochon- 
 dria), or from affections of the central nervous system 
 (meningitis, brain tumors, tabes dorsalis, myelitis, etc.). 
 
 Besides these three grouj^s, which are all of a more or 
 less acute character, Eosenlieim also mentions paralysis of 
 the intestines as a consequence of coi)rostasis due to atony 
 of this organ, which condition is less acute and more pro- 
 tracted. The patient, as a rule, has suffered from consti- 
 pation for a long time. Evacuation of the bowels has been 
 artificially produced only after the appearance of many 
 annoying symptoms. At last the usual remedies refuse to 
 work and the patient now becomes a chronic sufferer. 
 Dyspepsia, intense meteorism, and palpitations of the 
 heart are present. The ingestion of food grows smaller 
 every day and the patient becomes weaker. This condition 
 may last for weeks and months, and if no radical remedies 
 are resorted to, the patient may ultimately be seized with 
 fecal vomiting and die of the intestinal paralysis. 
 
 According to Rosenheim, a sudden attack of serious in- 
 testinal obstruction in a patient suffering from chronic 
 constipation is, as a rule, not caused by paralysis of the 
 intestine, but rather by an occlusion of the intestinal lu- 
 men through hardened fecal matter. 
 
 The diagnosis of intestinal paralysis can be made if all 
 the other numerous factors causing ileus can be excluded 
 and one of the above-mentioned etiological points can be 
 discovered. 
 
 The treatment of these cases consists in the applica- 
 21 
 
322 DISEASES OF THE INTESTINES. 
 
 tion of electricity (recto-abdominal galvanization), mas- 
 sage, and purgative high rectal injections. Cases in 
 which the paralysis is caused by chronic constipation must 
 be treated by high injections of either ice water two hun- 
 dred to five hundred grams, or water with the addition of 
 two hundred to five hundred grams of oil. These injec- 
 tions should be applied twice or three times a day for sev- 
 eral days in succession until a satisfactory result has been 
 obtained. Massage and electricity can be used in addition 
 to these injections. Internal purgatives, even croton oil, 
 are not efficacious in this class of cases. The use of mer- 
 cury, however, in doses of three hundred to eight hundred 
 grams is here of great value. In cases in which the lower 
 part of the colon is the seat of the i^aralysis, the stagnant 
 fecal matter must be removed with the hand before the 
 rectal injection is resorted to. 
 
 Proctospasmus, or Spasm of the Rectum. 
 
 This condition consists in attacks of painful contraction 
 of the sphincters of the rectum and is in most instances 
 a secondary affection. It is mostly found in inflammatory 
 and ulcerative processes of the rectum and colon, in fissure 
 of the anus, and also in inflammatory diseases of neighbor- 
 ing organs, bladder, prostate, uterus. 
 
 Spasm of the rectum may, however, occur also indepen- 
 dently as a primary nervous affection. As such it is prin- 
 cipally met with in individuals with a nervous taint, and 
 in diseases of the spinal cord. The attacks of proctospas- 
 mus differ in intensity and also in duration. Sometimes 
 they last only a short while, a few minutes, sometimes sev- 
 eral hours or even days. In the milder form defecation is 
 accompanied by intense pains and takes place only after 
 great effort. In the severer forms there is a strong desire 
 
PARALYSIS OF THE SPHINCTERS. 323 
 
 for defecation, but notwithstanding the most intense pains 
 and great straining there is no movement of the bowels. 
 If these attacks last several hours thej greatly weaken the 
 patient and render him very despondent. The anus is very 
 sensitive to touch, and a digital examination of the rectum 
 during the spasm is hardly ever possible. A thorough 
 examination of the rectum can be made only during anaes- 
 thesia. In instances of very severe proctospasmus a tran- 
 sient paresis or paralysis of the sphincter muscles may 
 result. 
 
 The diagnosis of proctospasmus is easy, as the symp- 
 toms are very distinct. The diagnosis of the primary ner- 
 vous form will be made if organic diseases of the rectum 
 and of the neighboring organs can be excluded. 
 
 The treatment must be directed principally toward the 
 primary affection. In cases of nervous proctospasmus the 
 treatment should be symj)tomatic and consist in the use 
 of narcotic remedies. In severe forms of this malady hy- 
 podermic injections of morphine must be resorted to. In 
 some instances a forcible divulsion of the sphincter under 
 chloroform narcosis may become necessary. 
 
 Paresis and Paralysis of the Sphincters of the Arms. 
 
 Paralysis of the anal sphincters occurs frequently in con- 
 sequence of long-lasting affections of the rectum. Some- 
 times over-exertion of these muscles (tenesmus) ultimately 
 leads to exhaustion. Occasionally ulcerations and infiltra- 
 tions of the rectum involve also the sphincters or entirely 
 destroy them, thus annulling their functions. The tonicity 
 of the sphincter muscles may be impaired in persons who 
 have suffered for a long time from an accumulation of 
 fecal matter in the lower portions of the bowel. The mus- 
 cular apparatus being over-irritated for a long time becomes 
 
324 DISEASES OF THE INTESTINES. 
 
 weakened and. exliausted. Diseases of the brain and spi- 
 nal cord, leading to inhibition of the will power, may like- 
 wise cause paralysis of the sphincters. 
 
 Atony, paresis, and paralysis form different degreea 
 of this affection. Some patients are not able to keep the 
 rectum tightly closed, and a small amount of secretion con- 
 tinually penetrates through the anus. After defecation 
 they have the sensation of not having finished the act. 
 Sometimes there may be an involuntary movement of the 
 bowels in consequence of the loss of the contractile power. 
 This, however, occurs only after strong excitement, intense 
 bodily exertion, during urination, and rarely in walking. 
 
 In case the paralysis of the sphincters is complete, flatua 
 and fecal matter will escape involuntarilj^ even in a state o£ 
 rest. In paralysis resulting from proctitis, hemorrhoids, 
 stricture, etc., there is a continuous dripping of a muco- 
 sanguinary secretion which greatly irritates the skin sur- 
 rounding the anus. 
 
 Diagnosis. — Paralysis of the anal sphincter can be recog- 
 nized very easily. The anus appears patulous and the 
 anal folds have disappeared. Two and even three fingers- 
 may be introduced into the rectum without encountering 
 any resistance. In making the diagnosis of a purely ner- 
 vous paralysis anatomical lesions must first be excluded. 
 This is done by means of a thorough examination of the 
 rectum with a speculum. 
 
 Prognosis.— Paralysis resulting from anatomical lesiona 
 of the rectum gives an unfavorable prognosis. In the purely 
 neurotic form, however, the prognosis is much better. 
 
 Treatment. — It is of great importance to secure a thor- 
 ough evacuation of the bowels, which is best done by rec- 
 tal injections of water twice daily. Paralysis due to fecal 
 impaction as such, can be entirely remedied by the just 
 
PERISTALTIC RESTLESSNESS. 325 
 
 mentioned measures alone. Thus Wallace ' reports a cure 
 iu a case of a nine-year-old boy wlio was troubled for 
 three years with incontinency of ftieces, which dropped out 
 whenever he walked. The patient was treated with water 
 enemas to which castor oil had been added, and later on 
 Avith injections of water with the addition of alum. After 
 a month's treatment he entirely recovered. 
 
 In paralysis due to affections of the central nervous sys- 
 tem electricity and massage may be of benefit. Hypoder- 
 mic injections of strychnine (0.001 to 0.0015 pro dose) 
 into the anal folds have been recommended by Rosen- 
 heim. Cases in which the paresis of the sphincter is due 
 io a difficulty in urination and a continuous straining in 
 order to void the bladder, will be improved by artificially 
 emptying the bladder by means of a catheter for a con- 
 siderable length of time. 
 
 Peristaltic Restlessness of the Intestines. 
 
 Definition. — Increased peristaltic motions of the intes- 
 tines in such a way that they become visible through the 
 abdominal walls. 
 
 Etiology and Symptomatology. — While in the normal 
 state intestinal x)eristalsis is accomplished without being 
 visible or making itself felt, in pathological conditions 
 increased peristalsis may exist which can be easily per- 
 •ceived through the abdominal walls and which is usually 
 accompanied by distinct noises (borborygmi). Increased 
 intestinal peristalsis may accompany any complete or in- 
 complete occlusion of the intestinal lumen or it may be 
 caused by purely neurotic influences. Here only the lat- 
 ter form is dealt with, as the former condition is discussed 
 in connection with the organic lesions causing it. 
 » Wallace : St. BartLol. Hosp. Report, 1888. 
 
326 DISEASES OF THE INTESTINES. 
 
 Usually peristaltic restlessness of the intestines occurs in 
 the form of attacks, lasting several hours in succession and 
 reappearing after more or less long periods of time. In 
 some instances the patients complain of various movements 
 and noises within the abdomen due to the increased intes- 
 tinal peristalsis, while pain is absent. In other instances 
 the above sensations are now and then interspersed with 
 severe colicky pains. The majority of cases of peristaltic 
 restlessness of the intestines is accompanied rather by con- 
 stipation, seldom there are either normal evacuations or 
 diarrhoea. In some instances the exaggerated peristaltic 
 motions continue even after intestinal digestion has been 
 completed, and are accompanied by painful sensations. 
 Peristaltic restlessness of the intestines is occasionally as- 
 sociated with peristaltic restlessness of the stomach. 
 
 Peristaltic restlessness of the intestines is principally 
 met with in nervous persons, in the hysterical and hypo- 
 chondriacal. Occasionally, however, it occurs in persons 
 who do not present any other nervous symptoms. In 
 women this condition ma}^ exist during the monthly periods 
 or pregnancy. In some persons it appears after the inges- 
 tion of highly spiced or indigestible foods, after the exces- 
 sive use of tobacco, after great psychical excitement or too 
 much brain work. In other cases, however, none of these 
 etiological factors can be discovered. 
 
 Diagnosis. — The diagnosis of peristaltic restlessness of 
 the intestines is made whenever pronounced intestinal mo- 
 tions are visible through the abdomen. The nervous char- 
 acter of this condition is recognized, first, after exclusion 
 of organic affections of the intestines ; secondly, by its pe- 
 riodic appearance. 
 
 The prognosis is favorable. 
 
 Treatment. — In the first place it is of importance to in- 
 
METEORISM. 32T 
 
 vigorate the entire organism and especially improve the 
 condition of the nervous system. With regard to diet 
 sufficient quantities of food should be given, but too spicy 
 and indigestible nourishment should be excluded. In 
 cases accompanied by some abnormality of the bowels 
 their function should be regulated. The bromides, valer- 
 ian, and asafetida are of decided value. Drinking of warm 
 water or tea and hot applications are useful during the 
 attack. Arsenic alone or in combination with iron is of 
 benefit in cases combined with anaemia. If the condition 
 assumes a violent character and is accompanied by severe 
 pains, a small dose of an opiate, alone or in combination 
 with belladonna, is appropriate. If the intestinal restless- 
 ness appears at night time and prevents the patient from 
 sleeping, chloral hydrate, sulphonal, or trional may be ad- 
 ministered. Electricity and massage of the abdomen have 
 been variously recommended, but neither of the two ap- 
 pears to me to be of great value in this condition. Change 
 of climate and surroundings is often of benefit. 
 
 Meteor ism. 
 
 Meteorism, tympanites, or flatulency signifies a condi- 
 tion in which there is an excessive accumulation of gas 
 in the intestinal tract. 
 
 If not caused by an organic obstruction in the bowel this 
 condition is due to an abnormal state of the intestinal mo- 
 tion and absorption. Owing to the first factor we describe 
 this anomaly under motor neuroses. 
 
 Etiology. — The causes of the excessive accumulation of 
 gas are : 1, an increased ingestion of gases themselves or 
 of substances which easily form them ; and 2, a diminu- 
 tion or impairment of their elimination from the intes- 
 tines. The increased introduction of gases may consist in 
 
328 DISEASES OP THE INTESTINES. 
 
 swallowing of air or in drinking beverages liiglily charged 
 witli carbonic-acid gas. In both instances the gases prin- 
 cipally accumulate in the stomach, although a portion of 
 them reaches the intestines. 
 
 Increased formation of gas within the intestine is the 
 consequence: 1, of various processes of fermentation and 
 disintegration of carbohydrates and fats, hydrogen and 
 carbon dioxide being the principal gases ; 2, of the decom- 
 position of proteids which produce besides the gases just 
 mentioned sulphuretted hydrogen, carburetted hydrogen, 
 and methyl mercaptan. The increased formation of gas is 
 mostly due to an increased ingestion of easily fermenting 
 food. 
 
 A diminished elimination of the gases may be due : 1, 
 to an inhibition of the passage of the flatus ; and 2, to re- 
 tarded absorption. The passage of flatus is inhibited either 
 by an intestinal obstruction or occlusion, or by a paresis 
 or paralysis of the intestinal muscles. The latter condi- 
 tion is found in peritonitis and in grave infectious diseases, 
 after shock, in severe ansemia, in spinal affections, and 
 also in general neuroses. Most cases of meteorism, which 
 quickly appears and just as quickh* leaves the patient, are 
 due to paresis of the intestinal walls and are usually asso- 
 ciated with a large number of other nervous symptoms. 
 
 Symptomatology . — A certain degree of tension about the 
 abdomen, more or less pronounced, is almost always expe- 
 rienced by the patient. In some instances the abdomen 
 protrudes in balloon-shape, the region of the navel being 
 principalh' involved. This picture is mostly met with in 
 X)atients with relaxed abdominal walls. In cases in which 
 the latter are tense the accumulation of gases may push 
 the diaphragm upward. Sometimes the lungs and heart 
 are forced upward and severe dyspnoea develops, which 
 
METEORISM. ."-J-'J 
 
 in rare Instances may be followed by asphyxia, collapse, 
 und even death. There is a constant feeling of press- 
 ure and a desire to pass wind, while colicky pains are 
 also occasionally'' met with. As a rule no flatus can be 
 passed or very inconsiderable amounts at long intervals. 
 
 Differing from the form of meteorism just described are 
 those cases in which there is a slight tension over the abdo- 
 men and wind is passed from the anus almost constantly 
 ior a long time with much noise. It is highly improbable 
 that they gases emitted in this variety of cases are really 
 produced in the intestinal tract for the following reasons : 
 1, there is no considerable change in the size of the abdo- 
 men after a repeated passage of considerable amounts of 
 gas from the anus ; 2, the absence of relief felt by the pa- 
 tient after the passage of flatus; and 3, the almost odorless 
 character of these gases. Rosenheim compares these cases 
 wdth those of nervous eructation from the stomach. While 
 in the latter the air is constantly swallowed by the patient 
 and belched up again, in the intestinal variety Rosenheim 
 assumes that the air is constantly pumped into the rectum 
 in order to be again emitted as flatus. 
 
 The diagnosis of meteorism is made whenever an exces- 
 sive amount of gas is discovered in the intestines. 
 
 The prognosis will depend upon the cause which creates 
 the tympanites. If it be due to organic lesions of the 
 intestines (occlusion of the lumen) the prognosis is very 
 grave, while meteorism dae to a purely nervous disturb- 
 ance gives a favorable outlook. 
 
 Treatment. — In instituting a curative plan for this afi^ec- 
 tion it will be necessary to elucidate the etiological factor 
 of the meteorism. If the latter is caused by an obstruc- 
 tion of the bowel, this primary' affection will have to be 
 treated as such. In most instances of meteorism of neu- 
 
330 DISEASES OF THE INTESTINES. 
 
 rotic origin the following points are of importance : Drinks 
 and foods containing or forming a large amount of gas 
 should be prohibited; thus all carbonated waters, beer, 
 champagne, and cider should be avoided. Fresh fruits, all 
 kinds of cabbage, leguminous foods, potatoes, coarse rye 
 bread, sweetened cake, rich gravies should be carefully ab- 
 stained from. These rules apply not only when the mete- 
 orism is fully developed but in patients with a disposition 
 to flatulency. 
 
 Formerly numerous intestinal antiseptics were given 
 with the object of lessening the fermentative processes 
 in the bowels. Recently, however, the general view pre- 
 vails that they are of no benefit whatever. Benzonaphthol, 
 salol, and salicylate of sodium are still regarded as the most 
 efficient in this respect and may be tried in suitable cases. 
 They can perhaps be advantageously administered in 
 Sahli's' glutoid capsules in order to prevent their ab- 
 sorption in the stomach. Calcined magnesia, lime water, 
 charcoal, testa prseparata, and subnitrate of bismuth are 
 given with the intention of absorbing the gas, although 
 their actual effect in this respect can naturally be only 
 very limited. 
 
 The following drugs are believed to have a beneficial 
 influence in diminishing the gas, especially in mild forms 
 of flatulency : poppy-seed, peppermint, spearmint, thyme, 
 cinnamon, cloves, nutmeg, anise, fennel. These are best 
 given in infusions. It has not as yet been scientifically 
 proven whether the reaction following their administra- 
 tion is due to a slight increase of the intestinal peristalsis. 
 Brunton and Cash'' are of the opinion that the carmin- 
 atives, such as asafetida and oil of cloves, have a distinct 
 
 ' Sahli : Deutsche med. Wocbenschr. , 1897, No. 1. 
 
 « Brunton and Cash : St. Barthol. Hosp. Report, 1887. 
 
METEORISM. 381 
 
 effect upon the absorption of several gases (carbonic-acid 
 gas and sulphuretted hydrogen). 
 
 The removal of the gas per vias naturales through the 
 anus is the most eflficient therapeutic measure. This can 
 be done through cathartic remedies whenever there is no 
 contraindication against their use. Large cleansing ene- 
 mas of water, with the addition of a teaspoonful of essence 
 of peppermint or oil of turjjentine emulsified with an egg^ 
 to a quart, are of benefit. 
 
 When there are no anatomical lesions, massage of the 
 abdomen and faradization may be of advantage. This 
 also applies to friction of the abdomen with a. cloth dipped 
 in some alcoholic solutions of aromatics or ethereal oils^ 
 (linimentum saponis, oleum carvi, cajuputi, terebinthinse, 
 etc.). The introduction of a tube into the rectum maybe 
 helpful in favoring the escape of gas from the lower parts 
 of the colon. In desperate cases in which the meteorism 
 has reached such dimensions as to endanger life, punc- 
 ture of the intestine through the abdomen with the trocar 
 has to be resorted to. The meteorism of hysterical per- 
 sons often requires no treatment, as it usually disappears- 
 of itself. Sometimes, however, it is very obstinate to all 
 therapeutic measures. 
 
 SENSORY NEUROSES OF THE INTESTINES. 
 
 While normally no sensations originate in the intestinal 
 canal which become perceptible even during digestion, in 
 pathological conditions this organ may be the seat of the 
 most painful feelings. The latter originate in the fibres of 
 the sympathetic nerve. Most of the sensory neuroses of 
 the intestine consist in an increased excitability of the sen- 
 sory filaments of these nerves. There are, however, a few 
 
S32 DISEASES OF THE INTESTINES. 
 
 conditions in wliicli a lessened sensibility exists. The 
 latter relates principally to tlie sensory nerves of the rec- 
 tum. Normally the entrance of fecal matter into the rec- 
 -tum mechanically irritates these nerves and creates a desire 
 ior an evacuation, while a lessened irritability of the rectal 
 nerves may fail to produce the above sensation. 
 
 Enterdlgia. 
 
 Synonyms. — Intestinal colic. Neuralgia mesenterica. 
 
 Definition. — Pains in the intestines. 
 
 Etiology. — Enteralgia is present in most organic lesions 
 •of the intestines. Enteralgia of purely neurotic origin, 
 Tiowever, which is considered in this chapter, occurs inde- 
 pendently of any anatomical lesions of the intestinal walls. 
 
 Sometimes abnormally strong stimuli may be evolved 
 within the intestinal canal, producing painful sensations. 
 These stimuli may be of a mechanical, chemical, or ther- 
 mal character. Thus, a conglomeration of intestinal 
 worms, foreign bodies, gall stones, or enteroliths may pro- 
 duce intense colic. Sometimes hardened fecal masses 
 press upon the sensory nerves. The intestinal lumen 
 loeing temporarily occluded by these masses, gases collect 
 ^bove this space and increase the tension within the intes- 
 tinal canal, thus giving rise to intense pain (wind colic, 
 colica flatulans, which is quite often seen in children). 
 Sometimes the ingestion of very coarse foods, indigestible 
 substances, tainted foods, too cold beverages, highly fer- 
 mented drinks cause enteralgia. In the gouty diathesis it 
 may precede a gouty attack or replace it. Similar to these 
 conditions in which the enteralgia takes its origin from 
 toxic substances contained in the blood and irritating the 
 intestinal nerves, is also the intestinal colic met with in 
 ■chronic intoxication from lead or copper. 
 
ENTERALGIA. 333^^ 
 
 Aside from these forms of enteralgia due to a certain 
 discoverable irritating factor, it may also result from a= 
 perverted state of the sensory intestinal nerves themselves. 
 The latter group is principally found in patients affected 
 with hj'steria, or spinal troubles, although it may also ba 
 of a reflex nature due to abnormal conditions of neighbor- 
 ing organs, kidneys, bladder, uterus, ovaries, and liver. 
 
 Symptomatology. — The symptomatology of enteralgia. 
 presents quite a varied picture, in many instances depend- 
 ing upon the cause of the enteralgia. If the neuralgiar 
 mesenterica is due to an error in diet, it usually begins 
 with gastric disturbances, belching, nausea, vomiting, and 
 anorexia. In cases in which an accumulation of fecal mat- 
 ter produces the enteralgia, obstinate constipation and flat- 
 ulence, occasionally alternating with diarrhoea, precede the 
 attack. In chronic lead poisoning there are present a 
 bluish line around the gums near the teeth, retarded pulse, 
 and oliguria. 
 
 The principal symptom of neuralgia mesenterica is pain 
 wdthin the intestine. It seldom appears suddenly and with 
 great violence. As a rule, the pains are at first of light, 
 character and gradually increase in intensit3^ They are 
 of a cutting, throbbing, or pinching nature, and are ex- 
 perienced usuall}^ in one and the same abdominal area, 
 most often in the region of the navel. Starting from this 
 spot they radiate toward the back, the loins, the thighs, 
 and the testicles. In some cases the pain wanders from 
 one area to another and may be felt at different times in 
 the most varied regions of the abdomen. In the latter 
 instances the pains are accompanied by a visible peristaltic 
 restlessness of the intestine, often producing gurgling 
 noises. 
 
 In mild cases the pain is quite endurable, and often lasts 
 
334 DISEASES OF THE INTESTINES. 
 
 but a short while. In severer forms of enteralgia, how- 
 ■ever, tlie pains may be of extreme violence, and in weak 
 patients may produce syncope, while in the more robust 
 they may give rise to attacks of panting and crying. The 
 iace grows pale and assumes an expression of intense suf- 
 fering. The forehead is covered with cold perspiration 
 ^nd the extremities are cold. The entire picture resem- 
 bles very much that of shock. 
 
 Pressure in many instances slightly alleviates the pain, 
 «,nd for this reason the patients often press their hand or 
 «ome other hard substance against their abdomen. For 
 the same reason they are often found lying on their abdo- 
 men, pressing the latter against the mattress. In cases, 
 however, in which the intestinal tract is filled with gas 
 and the abdomen therefore in a tense condition, even very 
 «light pressure increases the pains. Under these circum- 
 stances a suspicion of peritonitis often arises. Ultimately 
 the pains gradually decrease, and disappear much quicker 
 if the accumulated fecal masses and gases have been evacu- 
 ated spontaneously or by means of injections. The attack 
 is then over. 
 
 Spastic contractions of the intestine are often encoun- 
 tered, especially when the pains are of intense character. 
 If these contractions involve a large part of the intestine, 
 as is often the case in lead colic, the abdomen appears 
 trough-shaped. The abdominal walls are quite tense and 
 often very rigid. In case the spasms are limited to iso- 
 lated intestinal coils, the abdomen is not drawn in and at 
 some places where there are intestinal coils overfilled with 
 fecal matter and gas, may asymmetrically protrude. In 
 stercoral and wind colic the abdomen usually is tympanitic. 
 
 Constipation is almost always present. Frequently 
 there is also a retention of the intestinal gases. If the lat- 
 
ENTERALGIA. 335 
 
 ter are passed in considerable quantity, the pains often 
 subside for a sliort wliile, or, in some instances, especially 
 in the so-called wind colic, entirely disappear. 
 
 The intensity and the duration of the attack are subject to 
 great variations. It may last from a few hours to several 
 days. The pains are sometimes but very slight, and again 
 of such violence that even large doses of opium are hardly 
 effective. 
 
 Aside from the above-mentioned symptoms there exist 
 quite often shortness of breath, palpitations of the heart, a 
 sensation of oppression, tenesmus, strangury, hiccough, 
 vomiting, seldom pollutions and priapism. Occasionally 
 cramps of the calves and even general convulsions are ob- 
 served. In cases of hysteria hypersesthesia of the abdomi- 
 nal walls is encountered. 
 
 Diagnosis. — Enteralgia is easily recognized when it pre- 
 sents the above-described characteristic picture. Its neu- 
 rotic nature, however, will be inferred from the following 
 features: It appears in attacks, and subsides suddenly. 
 There are almost always other nervous symptoms present. 
 In enteralgia due to anatomical lesions of the intestine the 
 pain is, as a rule, increased by pressure upon the abdomi- 
 nal walls. Another distinguishing mark for the latter is 
 that it is more often accompanied by diarrhoea, and that 
 the dejecta contain pathological admixtures (blood, mucus, 
 rarely pus). 
 
 With regard to the differential diagnosis the following 
 conditions which are accompanied by abdominal pains will 
 have to be excluded : Rheumatic affections of the abdomi- 
 nal muscles, lumbar abdominal neuralgia, hyper£esthesia 
 of the abdominal walls, peritonitis, biliary and renal colic. 
 
 Rheumatism of the abdominal muscles is characterized 
 by the following features : The pain is situated over the 
 
336 DISEASES OF THE INTESTINES. 
 
 suxjerficial area and not within tlie abdominal cavity. It 
 often changes its seat. It is of longer duration than enter- 
 algia and does not show any distinct exacerbations nor 
 diffusion. Pressure increases the pain, while rest in a re- 
 cumbent position eases it. Anti-rheumatic remedies (salol, 
 sodium salicylate, salipyrin) subdue it. 
 
 In lumbar abdominal neuralgia the pain is localized on 
 the surface and limited to one intercostal space which is 
 very painful to i:)ressure. The pains often radiate to the 
 back, the hypogastrium, and the genital organs. Anti- 
 neuralgic remedies (antipyrin, antifebrin, phenacetin) are 
 often efficient. 
 
 Hypergesthesia of the abdominal wall is, as a rule, met 
 with in hysteria and neurasthenia. The pains are local- 
 ized in the superficial layer. The slightest touch of the 
 skin of the abdomen increases the pain. The faradic cur- 
 rent often quickly removes it. 
 
 In peritonitis there is almost always fever, and the pain 
 is increased on pressure. Meteorism is here much more 
 frequently encountered than in intestinal colic. Frequently 
 dulness in the lower part of the abdomen (exudation) is 
 observed. 
 
 Biliary and renal colic are recognized by the situation 
 of the pain which often corresponds to the location of the 
 affected organ. Besides, other symptoms are usually pres- 
 ent which are characteristic of the latter (icterus, strangury). 
 
 Prognosis. — The prognosis of intestinal colic is almost 
 always good with regard to life, for the attack usually ends 
 in recovery. Exceptional cases of death have, however, 
 been observed by Oppolzer' and Wertheimer.'^ 
 
 Treatment. — The treatment consists, first, in measures 
 
 'Oppolzer: Wiener med. Woclienschr., 1867. 
 
 * Wertheimer : Deutsches Arch. f. klin. Medicin, 1866, Bd. 1. 
 
ENTERALGIA. osi 
 
 directed toward the removal of the cause, and secondly, 
 toward the relief of the pain. In most cases of intestinal 
 colic a thorough evacuation of the bowels is of benefit. 
 For this purpose injections of a considerable quantity of 
 water (one to two quarts) or of olive oil (one-half to one 
 pint) are very serviceable. Mild cathartic remedies, cas- 
 tor-oil, calomel, and the like, maj^ also be administered. 
 In cases in which worms have been found a vermifuge must 
 be given with the cathartic. If meteorism is quite pro- 
 nounced passage of the abdomen may be tried. If the 
 colic is due to an error in diet, the latter must be strictly 
 regulated. If due to a general cold, hot beverages (tea, 
 infusions of camomile and of peppermint), hot poultices 
 over the abdomen are of value. 
 
 In nervous enteralgia occurring in patients suffering from 
 hysteria and neurasthenia the treatment should be directed 
 toward the improvement of the latter conditions. Climate, 
 electricity, massage, and hydrotherapy play a predominant 
 part here. 
 
 The following symptomatic measures which serve to 
 subdue the pains are of great importance : If the colicky 
 pains are quite severe, the administration of an efficient 
 dose of an opiate is indicated. Tincture of opium may be 
 given in doses of fifteen or tAventy drops, or opium ex- 
 tract, O.OB to 0.05; or morphine, 0.01 to 0.015, may be in- 
 jected subcutaneously. Even in cases in which the colic 
 is due to a retention of fecal matter, the narcotics just 
 mentioned are indicated, for they relieve the spastic con- 
 tractions of the intestines. 
 
 During a severe attack of intestinal colic the diet should 
 consist principally of liquids, small quantities of milk and 
 broth being given at frequent intervals (about every two 
 hours) . If the attacks recur quite often, the application 
 
338 DISEASES OF THE INTESTINES. 
 
 of the galvanic current (one electrode within the rectum, 
 negative pole, the other over the abdomen) is sometimes 
 of benefit. 
 
 Hypogastric Neuralgia. 
 (Neuralgia hypogastrica, Romberg/) 
 
 Enteralgia limited to the lower portion of the large 
 bowel is termed hypogastric neuralgia. In this condition 
 there exist disagreeable, sometimes painful sensations in 
 the lower region of the abdomen and in the lower parts of 
 the back, accompanied by a violent feeling of pressure in 
 the rectum and sometimes also in the bladder. In female 
 patients the same sensation may also extend to the uterus 
 and vagina. Sometimes the patient also complains of 
 painful sensations in the perineum and the thighs. Per- 
 sons suffering from hemorrhoids and women afflicted with 
 nervous and uterine troubles are principallj- liable to suffer 
 from this condition. This form of neuralgia is also fre- 
 quently found in diabetic patients. Sometimes the pa- 
 tients have the sensation as if a foreign body were in the 
 rectum. 
 
 The ireatment resembles very much that of intestinal 
 colic. The original trouble predisposing to hypogastric 
 neuralgia should always be first treated. If congested 
 piles are present, application of leeches about the anus 
 and warm sitz baths must be recommended. If the pains 
 are violent, suppositories of opium alone or with bella- 
 donna should be used. The diet should be a bland one 
 and the bowels should be carefully regulated. 
 
 1 Romberg : " Lehrbuch der Nervenkrankheiten, " Berlin. 
 
HYPERESTHESIA. •339 
 
 Hypercesthesia, Parcesthesia, and Ancesthesia of the 
 Intestine. 
 
 While in the normal state no disagreeable sensations are 
 manifested during the act of intestinal digestion and defe- 
 cation, in some cases of neurasthenia or hysteria we meet 
 with exceptions to this rule. Thus, even without apparent 
 anatomical lesions of the intestine, there may be a sensa- 
 tion of pressure, fulness, of pinching, of heat or cold in the 
 lower region of the abdomen a few hours after the inges- 
 tion of food. The same sensations may also occasionally 
 appear without the patient having eaten anything, after 
 bodily exertion and excitements, especially after sexual 
 intercourse. 
 
 The rectum and the anus are particularly liable to be 
 the seat of abnormal sensations. Physiologically a feel- 
 ing of fulness is experienced in the rectum when the fecal 
 mass has accumulated in this locality. In case of neuras- 
 thenia a sensation of fulness with an inclination to go to 
 stool may appear, even when the rectum is entirely empty. 
 Sometimes a feeling of pressure or weakness in the anal 
 region may be present; sometimes the patient ma}^ be 
 tormented by a constant burning or itching in the same 
 region. The act of defecation may be accompanied by 
 erections, sometimes by a feeling of uneasiness; quite 
 often a feeling of extreme fatigue after defecation is ex- 
 perienced. 
 
 Ancesthesia of the rectum is observed in the same class of 
 patients. The sensation of fulness in the rectum, which 
 causes the desire for defecation, is then absent ; there is, 
 therefore, never a desire for evacuation. In very pronounced 
 cases of rectal anaesthesia it may occur that even the pas- 
 sage of fecal matter through the anus is not felt. Such a 
 
340 
 
 DISEASES OF THE INTESTINES. 
 
 liigli degree of ansesthesia, however, is met with only in pa- 
 tients with, spinal and brain troubles and in very old and 
 decrepit individuals. Paralysis of the sphincters, which 
 has been described above, may occasionally accompany 
 the anaesthesia of the rectum and thus aggravate the latter. 
 In such instances involuntary evacuations of the bowels 
 take place without the patient's knowledge. He becomes 
 aware of this fact only after his clothes have been soiled 
 and by the fecal odor. 
 
 In the treatment of these abnormal sensations within the 
 intestines attention must be directed toward the improve- 
 
 FiG. 39.— Rectal Obturator. 
 
 ment of the general condition, thus raising the nervous 
 tone of the organism. Hydrotherapeufcic measures and 
 climatic influences are of the greatest importance. While 
 dietetic measures as such are without much influence upon 
 the nervous disturbances which api^ear during the intesti- 
 nal digestion, spicy food and alcoholic beverages should, 
 notwithstanding, be forbidden and an essentially vege- 
 tarian 'regimen recommended. The abnormal sensations 
 within the rectum and anus may be improved by cooling 
 rectal douches, by sitz baths, and also b}' rectal galvani- 
 zation. 
 
 In cases of anaesthesia of the rectum a cleansing enema 
 in the morning will remove the fecal matter and thus be 
 beneficial during the day. Patients suffering from the 
 
MEMBRANOUS ENTERITIS. -'^l 
 
 severer forms of antestliesia should wear a rectal obturator 
 lield iu place by means of a T-bandage during tlie day 
 (Fig. 39). 
 
 SECRETORY NEUROSES OF THE INTESTINES. 
 
 Altliough there is no doubt that secretory nerves exist in 
 the intestines — for it has been shown that the entrance of 
 food into the stomach is immediately followed by secre- 
 tion not only in the small intestine but also in distant 
 parts of the large bowel — still we are yet very far from the 
 [knowledge of their exact location. Nervous diarrhoea, 
 which has been described under the motor neuroses, is 
 often accompanied also hj an increased flow of intestinal 
 juice. Conditions in which there is a lessened secretion 
 of intestinal juice are not yet positively known. It may 
 he that they exist in cases of constipation, being perhaps 
 the cause of the latter in some instances. While, however, 
 in the disturbances just mentioned the increase or decrease 
 of intestinal secretion is a mere hypothesis, one affection 
 of the intestines exists in which increased secretion is posi- 
 tively found. This is the so-called membranous enteritis. 
 
 Membranous Enteritis. 
 
 Synoni/ms. — Mucous Colic; Tubular Diarrhoea; Mem- 
 Taranous Diarrhoea. 
 
 Definition. — By membranous enteritis is understood an 
 affection in which more or less large pieces of mucus (usu- 
 ally ribbon-like) are passed periodically with the fteces. 
 
 History. — This affection seems to have been familiar to 
 the medical world for several centuries. Paulus ^gineta,' 
 in speaking of the passage of the imier membrane of the 
 
 ' Paulus ui^gineta : Cited from Da Costa, American Journal of the 
 Medical Sciences, 1871, p. 321. 
 
342 DISEASES OF THE INTESTINES. 
 
 intestine, lias certainly dealt witli cases of membranous 
 enteritis, and erred only in the explanation of these 
 masses. 
 
 Senuertius and Morgagni ' recognized these membranes 
 as mucus, which had been inspissated and moulded in the 
 intestine. 
 
 Mason Good '^ was the first to describe this affection un- 
 der the name of " tubular diarrhoea, " which name has also 
 been accepted by Woodward. ^ The latter author adds that 
 in case the membranes in a given instance have no tubu- 
 lar form, the expression " membranous diarrhoea " is suit- 
 able. 
 
 F. Siredey * contributed a very valuable paper in 1869 
 in reference to the knowledge of this affection. He de- 
 scribed one case of mucous discharge in a man and six 
 cases in women, and arrived at the conclusion that in some 
 instances these mucous discharges occur in patients whose 
 intestinal tract does not reveal any organic lesion whatever. 
 For this reason Siredey regards this affection as an in- 
 testinal neurosis, occurring principally in hypochondriacs 
 and hysterics. 
 
 Whitehead ^ describes this affection under the name of 
 "mucous disease," cites the entire old literature, and gives 
 detailed rules with regard to treatment and diet. He 
 says : " Exercise, short of fatigue, should be taken daily. 
 
 ' Sennertius and Morgagni : Cited from J. G. Woodward, " The 
 Medical and Surgical History of the "War of the Rebellion, " 1879, part 
 11., vol. 1., p. 363. 
 
 2 Mason Good: "The Study of Medicine," cl. 1, ord. 1, species 7, 
 vol. i., Philadelphia. 1835, p. 162. 
 
 ^ Woodward : Loc. cit. 
 
 ^ Siredey, F. : " Note pour servir a I'etude des concretions muqueuses 
 membraniformes de I'intestin. " Union med., Nos. 7-9, 1869. 
 
 5 Whitehead, W. : "Mucous Disease." British Medical Journal, 
 February 11, 1871, p. 140. 
 
MEMBRANOUS ENTERITIS. -'^^ 
 
 The diet is perhaps the point of all others where the great- 
 est mistake is made. An idea, strongly felt by the patient, 
 that a great amount of strengthening food is required, 
 leads to the further exhavistion of an already enfeebled 
 digestion. Impress upon the patients the fact that it is 
 the quantity absorbed which means strength, and not the 
 bulk swallowed, and it is possible to check the error they 
 are so anxious to commit. Certain articles of diet should 
 be strictly interdicted, the chief of which are the follow- 
 ing : Liquid food, excepting milk, aggravates in the major- 
 ity of cases every symptom; sugar is invariably hurtful; 
 tea, coffee, and alcohol — Burgundy being the only wine 
 from which I have ever derived benefit — vegetables, and 
 fruit also prove injurious. " 
 
 Cruveilhier ' and Laboulbene '^ discuss this ailment under 
 the term "pseudo-membranous enteritis," 
 
 One of the best papers upon this disease was written by 
 Da Costa," who called it "membranous enteritis." This 
 author gave a full description of this affection, recognized 
 its nervous character, furnished several detailed cases, and 
 put particular stress upon dietetic treatment. Da Costa 
 permits eggs, milk, bread, and solid food, which is better 
 borne than liquids; tea, coffee, and alcoholic stimulants 
 are to be permitted only in very small quantities. As re- 
 gards vegetables, we must observe whether they pass un- 
 changed in the stools. Fresh meat juice is serviceable; 
 from an exclusive milk diet, even faithfully carried out, he 
 has seen no good. Furthermore, Da Costa recommends 
 that great attention be paid to the action of the skin, and 
 
 ' Cruveilhier: Anat. path, gen., t. ii. 
 
 ^ Laboulbfene : "Recherches sur les affections pseudomembraneuses, " 
 1861. 
 
 3 J, M. Da Costa: "Membranous Enteritis." American Journal of 
 the Medical Sciences, 1871, p. 331. 
 
344 DISEASES OF THE INTESTINES. 
 
 believes baths followed by systematic friction to be very 
 useful. Daily moderate exercise is advocated, particularly 
 in cool weather, and if possible an occasional trip to the 
 mountains and living out of doors in the bracing mountain 
 air. Everything that can be done to invigorate the diges- 
 tive and nervous systems forms the essential part of the 
 therapeutics. 
 
 A few years later there appeared an article by Edwards,* 
 wdio coincided with Da Costa's views in most points, 
 being, however, much stricter with regard to diet. He 
 says: "Easily digested or even predigested food should 
 be supplied, and care should be taken that undigested 
 particles of food are not irritating the intestinal canal." 
 
 Ley den, ^ in 1882, directed attention to membranous en- 
 teritis in Germany, where also very soon appeared ex- 
 liaustive j)ublicatious on this subject. Nothnagel' sug- 
 gested the name "colica mucosa," in order to show that 
 s> true enteritis need not exist in these cases and that the 
 disease really is a mucous colic. Eothmann * was the first 
 to publish a case of membranous enteritis — complicated 
 with cancer of the skull — in which an autopsy was made. 
 Bj- means of Weigert's stain, or rather by Ehrlich-Hoy- 
 er's thionin (a specific stain for mucus), double-stained 
 specimens could be obtained, which showed the presence 
 of large quantities of mucus on the surface of the large 
 bowel in the glandular tubules. 
 
 ' Edwards : American Journal of the Medical Sciences, April, 1888, 
 p. 329. 
 
 * E. Leyden : Verhandl. d. Vereins f. innere Medicin in Berlin, 
 Deutsche med. ■Wochenschr., 1882, Nos. 16 and 17. 
 
 3 Nothnagel : " Colica mucosa. " Beitrage zur Physiologic und 
 Pathologie des Darms, " 16tes Capitel, 1884. 
 
 ^ Max Rothmann : " Ueber Enteritis membranacea. " Deutsche med. 
 Wochenschr., 1893, p. 999. 
 
MEMBRANOUS ENTERITIS. 345 
 
 Ewald/ Boas/ Kittagawa,' Pariser/ and otliers have 
 added further contributions. 
 
 Ewald laid stress on a ptosis of the colon, Boas on atony 
 of this organ as important factors in this affection. 
 
 Utiology. — Most authors agree that membranous enteritis 
 is quite a rare affection ; it occurs much more frequently 
 in women than in men (children being only exceptionally 
 affected). 
 
 That the nervous element (hysteria, neurasthenia) plays 
 a great role in the origin of this trouble, no one can doubt, 
 -and W. Mendelson ^ is right when he asserts that neuras- 
 iheuia is not absent in any of his cases. Mendelson goes 
 too far, however, when he says : " I believe that the reverse 
 of the proposition may also as confidently be affirmed — 
 namely, that if neurasthenic patients be closely questioned, 
 very few will be found who have not had at some time re- 
 peated characteristic passages of stringy mucus, associated 
 with abdominal pains." Membranous enteritis is found 
 in nervous individuals (possibly the affection as such adds 
 much to their neurasthenia) ; but only a small fraction of the 
 great mass of neurasthenics is afflicted with this ailment. 
 
 With regard to the frequency of membranous enteritis, 
 1 examined my private patients of the year 1897 relative 
 io its presence, and take the following data from my day- 
 book. The total number of patients was 1,315 — 772 men, 
 543 women. Twenty of these patients suffered from mem- 
 
 ' C. A. Ewald: "Membranous or Mucous Enteritis." Twentieth 
 ■Century Practice of Medicine, vol. ix. , p. 265. 
 
 2.1. Boas: Deutsche med. Wochenscbr. , 1893, No. 41. 
 
 2 O. Kittagawa : " Beitrage zur Kenntniss der Enteritis membrana- 
 cea." Zeitschr. f. klin. Medicin, 1891. 
 
 ^Pariser: Deutsche med. Wochenschr., 1893, No. 41. 
 
 * Walter Mendelson : " Mucous Colitis a Functional Neurosis. " 
 Medical Record, January 30, 1897. 
 
346 DISEASES OF THE INTESTINES. 
 
 branous enteritis — two men and eighteen women. The 
 frequency of membranous enteritis among sufferers from 
 digestive disorders expressed in percentages is, in men, 
 0.25 per cent; and in women, 3.31 per cent. Among these 
 twenty patients, twelve had enteroptosis in a pronounced 
 degree. Ewald has already pointed out that a prolapse 
 of the colon is frequently found in patients with mem- 
 branous enteritis. My own observations fully confirm this 
 statement, for with the prolapse of the stomacli descent of 
 the colon naturallj' must be presupposed. It ajjpears that 
 enteroptosis certainly creates a fruitful soil for the devel- 
 opment of membranous enteritis, although it does not di- 
 rectly cause it. Enteroptosis is, as is well known, very 
 frequent, while membranous enteritis is rare in compari- 
 son with the former. There must, therefore, be still other 
 factors which are of importance in the causation of mem- 
 branous enteritis. 
 
 With reference to gastric secretion and the motor func- 
 tion of the stomach in this disease, I ' have made examina- 
 tions on twelve cases and found the following two points 
 most conspicuous : 
 
 1. The motor function (prochoresis) of the stomach — 
 judged from the amount of contents found one hour after 
 the test breakfast — was increased in eight cases and nor- 
 mal in the four remaining. 
 
 2. Five cases presented a typical achylia gastrica. 
 
 Considering the comparative infrequency of achylia gas- 
 trica, which hardly amounts to two or three per cent of the 
 digestive disorders, this large proportion of achylia in pa- 
 tients with membranous enteritis — namelj', five in twelve — 
 is certainly noteworthy. 
 
 1 Max Einborn : " Membranous Enteritis. " Medical Record, January 
 28, 1899. 
 
MEMBRANOUS ENTERITIS. 847 
 
 Three cases of membranous enteritis with normal acid- 
 ity revealed, besides the increased prochoresis, still another 
 feature in common with achylia — namely, the extraordi- 
 narily small amount of fluid surrounding the scarcely 
 changed particles of roll, one hour after the test breakfast. 
 Although this symptom may occasionally be met with in 
 other cases than achylia, it is nevertheless, as a whole, 
 characteristic of this affection. Therefore we are justified 
 in making the following statement : In many cases of mem- 
 branous enteritis typical achjdia is present, in some it is 
 lacking, but even then some features characteristic to achy- 
 lia are encountered. In membranous enteritis achylia thus 
 plays a great part. Whether one condition causes the 
 other, or one and the same factor (nervous influences) cre- 
 ates both, is difficult to say. The latter, however, is more 
 plausible. 
 
 Symptomatology. — The disease is characterized by at- 
 tacks of rather violent colicky pains in the abdomen, which 
 are followed by the x^assage of mucous masses with the 
 stools. The mucus may be voided either alone, without 
 any admixture of fecal matter, or it forms a considerable 
 part of the evacuation. Usually the attack is preceded by 
 a period of obstinate constipation, and often followed by 
 diarrhoea lasting a few days, and sometimes accompanied 
 by tenesmus. Gastric symptoms — as loss of api^etite, fre- 
 quent belching, now and again a burning sensation at the 
 pit of the stomach — are generally quite pronounced during 
 the attack. Yomiting may occasionally appear, while fever 
 is, as a rule, absent. The attack lasts three to seven days, 
 and then the pains subside, the diarrhoea ceases, and eu- 
 phoria reappears. More or less constipation, however, 
 and some other dyspeptic as well as nervous symptoms 
 persist. These free intervals last various periods of time 
 
348 DISEASES OF THE INTESTINES. 
 
 (four weeks to five or six montlis). In rare instances the 
 niucous discliarges may be present continuously. 
 
 "With reference to the mucous masses, they present a 
 grayish-white appearance, seldom yellowish, and have 
 either a ribbon-like or membranous form; at times the 
 pieces are several feet long ; ordinarily, however, they are 
 considerably smaller. Complete moulds of the intestinal 
 lumen have been observed by several authors, and Leyden 
 not unjustly has compared this process with that of croup 
 of the larynx. As already stated by Cornil,' the false 
 membranes consist of mucus, mixed with dried-up epithe- 
 lial ovoid cells, which arise from a mucous metamorphosis 
 of the cylindrical cells or the leucocytes. Nothnagel 
 and others have proven the mucous nature of these dis- 
 charges. 
 
 As suggested by Pariser, the mucous nature of these 
 masses can be demonstrated by treating them, first, with 
 sublimate alcohol, and then staining them with Ehrlich's 
 triacid solution. A green color appears, which indicates 
 mucus (fibrin treated in the same manner assumes a red 
 color). Judging from my experience it is unnecessary to 
 dip these membranes first into sublimate alcohol, as the 
 same result will follow when they are put directly into the 
 weak triacid solution. Microscopically this substance re- 
 veals a somewhat fibrillary nature, and contains many 
 shrivelled cells, so called by Nothnagel. Micro-organisms 
 are found admixed, although they do not seem to play any 
 important part in this affection. In two of my cases mi- 
 croscopically single-celled corpuscles were found in these 
 masses, having a distinct nucleus and a tail-like process. 
 The accompanying drawing shows these corpuscles (Fig. 
 40). These are most probably metamorphosed goblet cells. 
 'Cornil: Cited from Siredey. See above. 
 
MEMBRANOUS ENTERITIS. 
 
 349 
 
 Diagnosis. — The diagnosis of membranous enteritis is, 
 as a whole, simple when the above-mentioned character- 
 istic symptoms, including the mucous discharges, are pres- 
 ent. It is, however, necessary to be careful not to mis- 
 take for mucus other substances admixed in the fgeces^ 
 
 Fig. 40.— Microscopical Picture of Mucous Masses Found in the Evacuation of Mrs. L., 
 Showing Numerous Cells Having a Nucleus and a Tail-like Process. 
 
 which occasionally resemble shreds of mucous membrane^ 
 • — as, for instance, the fibre of an orange, tendons, pieces- 
 of tapeworm. A microscopical examination will guard 
 against all such errors. 
 
 This affection will hardly be confounded with real intes- 
 tinal catarrh, as it presents an entirely different picture 
 and only occasionally may have an abundant secretion of 
 mucus in common with mucous colic. There are, however,. 
 
350 DISEASES OF THE INTESTINES. 
 
 cases of chronic intestinal catarrli which are complicated 
 with membranous enteritis — that is, having typical attacks 
 of mucous colic. The following case presents an instance 
 of this kind : 
 
 Miss L. N , twenty-eight years old, had diarrhoea 
 
 eleven years ago for quite a while, which disappeared after 
 two or three months. The patient was then well until 
 four years ago, when she again began to be troubled with 
 diarrhoea. Soon periods of obstinate constipation ap- 
 X)eared, which alternated with diarrhoea. The patient re- 
 ports having occasionally observed mucus in the passages ; 
 at times (about every five or six weeks) there appear 
 abdominal pains for about one or two hours, followed by 
 an evacuation of pure mucus, the quantity being one to two 
 tablespoonfuls. The aj)petite was always good. Now and 
 again there was belching. The patient lost about twenty- 
 five pounds in weight. Sleep is undisturbed, only at times 
 restless for a few days. Her strength greatly failed. Pal- 
 pation of the abdomen reveals spots sensitive to pres- 
 sure in the entire course of the colon. The examination 
 of the fseces in the free interval shows small quantities of 
 mucus well mixed with the fecal matter. The mucous 
 masses voided after an attack of pains are free from fecal 
 matter, appearing grayish-white and staining green when 
 treated with Ehrlich's triacid solution. 
 
 Treatment. — Diet plaj's the principal part in the treat- 
 ment of membranous enteritis. While the older writers 
 laid stress on scantj^ light food, it is now generally ac- 
 cei)ted that abundant nutrition is of the greatest value. 
 That a fluid diet is unsuitable, the older authors have al- 
 ready been cognizant of (Da Costa, Whitehead, Siredey), 
 and this axiom holds good in its entirety even to-day. 
 
 Recently von Noorden ' advised a very coarse diet, being 
 
 ' C. von Noorden : " Ueber die Behandlung der Colica mucosa. " 
 Zeitschr. f. practiscbe Aerzte, 1898, No. 1. 
 
MEMBRANOUS ENTERITIS. ool 
 
 guided by tlie idea that the intestinal tract should be exer- 
 cised and strengthened by increased work. He recom- 
 mends per day half a pound of bread containing plenty of 
 chaff, leguminous vegetables, garden vegetables rich in 
 cellulose, fruits with small pits and coarse skin, as cur- 
 rants, gooseberries, grapes — these being foods rich in un- 
 digestible material, thus forming much ballast for the 
 bowel. Among fifteen patients subjected to this treatment 
 by von Noorden, seven were permanently cured, seven im- 
 proved, aijd one was unchanged. 
 
 This method has certainly much in its favor ; it may be 
 better, however, not to institute this diet abruptly, as sug- 
 gested by von Noorden, but rather gradually. 
 
 I, for my part, for some jears past have seen to it that 
 my patients partook of an abundant and nutritious diet, 
 without, however, advising substances that were too coarse. 
 As a whole, I recommend ample food and try to keep the 
 patients on a mixed diet containing plenty of vegetables. 
 In patients who have lived on a strict diet (as for instance 
 milk diet or beef and hot water), I arrange the change 
 gradually. The principle here is the same as stated by 
 von Noorden, only not carried to such an extreme. It ap- 
 pears sufficient if the intestines of the patient with mem- 
 branous enteritis are trained to master the foods customary 
 in healthy persons, and the accomplishment of this object 
 is all that is required. If we subsequently see that the 
 organism amply fulfils its work, a few less digestible foods 
 may then be added. It is not necessary to recommend 
 these immediately from the start, nor are they important 
 for the cure. 
 
 With regard to therapeusis, two phases will have to be 
 considered — the treatment during the attack and the treat- 
 ment during the interval. In severe attacks, rest in bed, 
 
362 DISEASES OF THE INTESTINES. 
 
 warm poultices over tlie abdomen, a cleansing enema (of 
 ordinary warm water with the addition of some common, 
 table salt or essence of peppermint — one teaspoonful to a 
 quart), and afterward the administration of codeine or 
 opium, with or without belladonna, are of value. As long 
 as the pains last it is necessary to give light food (small 
 quantities frequently) . In mild attacks a stay abed may 
 not be requisite, nor the administration of an analgesic 
 remedy, and the diet may be the same as during the in- 
 terval. 
 
 In the interval free from pains the treatment consists in 
 a methodical application of olive-oil enemas, as suggested 
 by Kussmaul and Fleiner. ' These enemas are injected into 
 the bowel at night, at blood temperature, the quantity being 
 two hundred and fifty to five hundred cubic centimetres. 
 The patient is then instructed to try and retain the oil in 
 the bowel during the night. The patients seldom assert- 
 that they are disturbed in their sleep by these injections 
 and have to answer nature's call. In such an instance the 
 quantity of oil may be reduced to one hundred and fifty or 
 one hundred cubic centimetres. The oil should be injected 
 every night for three weeks; then every other night for 
 three weeks, and twice weekly for four weeks ; finally, once 
 weekly for five or six months. Besides, patients must 
 accustom themselves to a regular morning evacuation, by 
 promptly visiting the closet every day at the same hour in 
 the morning. 
 
 Next to abundant nourishment the methodical oil cure 
 is of the greatest importance in the treatment of this 
 affection, and the results achieved are, according to my 
 experience, very satisfactory. The administration of oil 
 injections in membranous enteritis is mentioned here and 
 ' Fleiner . Berliner klin. Wochenschr. , 1893, No. 3. 
 
INTESTINAL NEURASTHENIA. 353 
 
 there in recent literature, especially by Ewalcl, but its 
 value must be placed mucli liiglier than heretofore. The 
 oil has not only a favorable influence upon the constipa- 
 tion which is always present in this malady, but at the 
 same time also effects a diminution or a disappearance of 
 the mucous discharges. How the oil brings this about is 
 difficult to say. The favorable efl^ect may perhaps be ex- 
 l^lained by the circumstance that by means of the oil the 
 intestine is not left in an empty condition during the 
 night, and thereby a spasmodic contraction is avoidedy 
 which must be regarded as one of the principal factors in 
 the formation of mucus. 
 
 It is evident, according to my statement with regard to 
 the etiology, that enteroptosis and anomalies of the gas- 
 tric functions (principally achjdia) exist in a large number 
 of these cases. It will, therefore, be necessary to bear 
 these points in mind and to treat the cases accordingly. 
 The neurotic symptoms present in these cases should not 
 be neglected in the general plan of treatment. We shall 
 have to pay attention to a regular hygienic mode of living 
 and ample physical exercise. In suitable cases occasional 
 hydrotherapeutic measures will be of value. The tonic 
 remedies, like iron, arsenic, etc., will also prove beneficial. 
 
 Intestinal Keur asthenia. 
 
 The various intestinal neuroses have been separately 
 described. In practice combinations of different neuroses 
 frequently occur. Following Rosenheim we designate such 
 cases as intestinal neurasthenia. The appetite as a rule 
 is good and the symptoms usually appear during the pe- 
 riod when intestinal digestion takes place. The symptoms 
 generally develop one to three hours after meals and consist 
 
 in a feeling of pressure, tension, and sometimes of griping 
 23 
 
354 DISEASES OF THE INTESTINES. 
 
 in the abdomen. Occasionally there may be a sensation 
 of nausea, at times an evacuation of the bowels accompa- 
 nied with painful sensations in the abdomen and in the 
 anus. Sometimes palpitation of the heart occurs, some- 
 times again a sensation of flashes of heat or of cold extend- 
 fng upward. As a rule, the patients feel worse when rest- 
 ing, especially in the recumbent position, than when 
 walking about. After a j)eriod of one or two hours the 
 symptoms usually disappear, to return again later on after 
 a meal. 
 
 Constipation is as a rule associated with this condition. 
 The quality of the food does not seem to exert much 
 influence upon the symptoms, although the latter are 
 more marked after heavier meals. In a few instances, es- 
 pecially when the pains play a predominant part and bor- 
 borygmi occur, diarrhoea is encountered. In these cases 
 the diarrhoea appears in the middle of the night or toward 
 early morning, and disturbs the patient's sleep. It is 
 of diagnostic importance that the pains do not in any way 
 depend upon the quality of the food. Indigestible foods, 
 even taken in considerable quantity, are occasionally well 
 borne, while at other times a small meal, consisting of the 
 lightest food, causes severe symptoms. Intestinal neuras- 
 thenia is sometimes associated with gastric neurasthenia 
 and completes the picture of the other. 
 
 In making the diagnosis of intestinal neurasthenia ana- 
 tomical lesions of the intestines must first be excluded. 
 
 The treatment consists in hygienic measures which serve 
 to tone up the system, in ample feeding, and in the admin- 
 istration of the bromides, occasionally in conjunction with 
 iron and arsenic. With regard to diet all foods are al- 
 lowed excepting indigestible substances, and a preponder- 
 ance of vegetable food is to be recommended. 
 
CHAPTER XII. 
 
 INTESTINAL PAEASITES. 
 
 General Bemarks. — Most of the animal parasites found 
 in man inhabit the intestinal canal. Leuckart ' estimates 
 the number of varieties at about fifty. Not all parasites, 
 however, produce morbid conditions. Comparatively few 
 of them evoke a pathological state, either in the intestine 
 by their direct presence, or in the blood by the formation 
 of toxic products which are absorbed and reach the circu- 
 lation. The intestinal parasites are detected by repeat- 
 edly examining the stools. They may be seen or their 
 presence may be assumed from the discovery of their ova 
 (the latter referring to the helminths). There are no char- 
 acteristic symptoms which would be encountered only in 
 morbid conditions due to animal parasites. The diagno- 
 sis, therefore, must be made by directly discovering them 
 or their eggs in the dejecta. It will always be wise to look 
 for worms in cases in which gastric and intestinal symp- 
 toms of a functional character exist, accompanied or not 
 by antemia and certain neuropathic affections. The intes- 
 tinal parasites are divided into two large groups: (1) Pro- 
 tozoa. (2) Yermes. 
 
 I. PROTOZOA. 
 
 Amcehce. 
 
 Besides dysenteric amoebae which have been described 
 above, a similar variety is occasionally encountered giving 
 'Leuckart : "Die menscbliclieu Parasiten, " Leipzig, 1886, Bd. ii. 
 
356 DISEASES OF THE INTESTINES. 
 
 rise to no symptoms whateTer or sometimes to sliglit at- 
 tacks of diarrhoea. 
 
 Sporozoa. 
 
 Among tlie sporozoa coccidia are occasionally found in 
 the stools. This organism is egg-shaped, provided with 
 a thin shell, 0.02 mm. long, and contains in its interior a 
 large number of nuclei usually arranged in groups. The 
 coccidia do not seem to have any pathological bearing. 
 
 Infusoria. 
 
 To these belong cercomonas intestinalis, trichomonas 
 intestinalis, and paramsecium coli. All of them are found 
 principally in conditions in which diarrhoea is the fore- 
 most symptom. 
 
 The cercomonas intestinalis is pear-sliaped, has a distinct 
 nucleus and eight flagellse. The head portion of the body 
 tapers obliquely and presents a depression (Fig. 41). It 
 is not believed to have a direct pathogenic significance. 
 
 V 
 
 Fig. 41.— Cercomonas Intestinalis (Da- Fig. 42.— Trichomonas Intestinalis (Zun- 
 vaine). ker). 
 
 It is assumed, however, that this micro-organism is liable 
 to prolong pre-existing catarrhal affections of the intestine. 
 
 Trichomonas intestinalis presents the same features as 
 the cercomonas and can be distinguished from the latter by 
 its somewhat greater size and the row of fine cilia upon the 
 periphery of its body (Fig. 42). In fresh dejecta this mi- 
 cro-organism moves around very actively. Zunker ' found 
 
 ^ZuDker: Deutsche Zeitschr. f. praktische Medicin, 1878, No. 1. 
 
TAPE WORMS. 
 
 35T 
 
 it principally in mushy dejecta having a brownish-yellow 
 color and a somewhat putrid odor. 
 
 Faramcecium (or balantidium) coli is egg-shaped, 0.1 mm. 
 long and covered with fine cilia, the latter being densely 
 grouped about the mouth, while but few of them surround 
 the anus. In the interior of this or- 
 ganism are found a nucleus and two 
 contractible vesicles, besides fat drop- 
 lets, starchy particles, etc. (Fig. 43). 
 The balantidium coli was first de- 
 scribed by Malmsten ' in 1857. In 
 the fresh stools the balantidium moves 
 about very rapidly, but it dies as early 
 as one-half an hour to two hours after 
 the dejecta have been passed. Like 
 the cercomonas, the paramsecium coli 
 is believed to keep up conditions of 
 diarrhoea. 
 
 The treatment directed against these 
 infusoria consists in intestinal irriga- 
 tion with watery solutions of tannic acid, boracic acid, 
 thymol, or quinine. 
 
 II. VERMES. 
 Cestodes (Tape Worms). 
 
 General Remarks. — In describing the disorders caused 
 by tapeworms it is best to include the taenia solium, taenia 
 mediocanellata, and bothriocephalus latus. 
 
 The symptoms produced by these three different entozoa 
 are almost identical. In some instances the tapeworm is 
 domiciled in the intestine for a long period of time with- 
 out manifesting any symptoms. The host may enjoy per- 
 ' Malmsten: Virchow's Archiv, Bel. xii. 
 
 Fig. 43. — Balantidium 
 Coli (Claus). a, Mouth ; 
 b, nucleus ; c, a granule 
 of starch which has 
 been ingested ; d, a for- 
 eign body in the process 
 of being expelled. 
 Highly magnified. 
 
o58 DISEASES OF THE INTESTINES. 
 
 feet health and only after noticing segments of taenia in the 
 dejecta does he become conscious of his uninvited guest. 
 In other instances the worm produces intestinal as well as 
 general disturbances. A feeling of pressure at the pit of 
 the stomach and pains at different points of the abdomen 
 may be present. Bulimia is frequently encountered. 
 Anorexia and anorexia alternating with bulimia are also 
 occasionally observed. Nausea, even vomiting, may be 
 present, especially in the morning. The bowels are usu- 
 ally constipated. In a few instances, however, there is 
 persistent diarrhoea. 
 
 Besides these gastro-intestinal symptoms there may be 
 present various disturbances of the nervous system or of 
 the blood; dizziness, headache, fainting spells, convul- 
 sions, epilepsy, various forms of j)ar?esthesia of the ex- 
 tremities. Some patients, again, look very bad and be- 
 come emaciated, notwithstanding that they take sufficient 
 quantities of food. The anaemic condition is occasionally 
 very marked. The patient feels extremely weak, suffers 
 from palpitation of the heart, is hardly able to walk, and 
 is subject to fainting spells. In this serious form of anae- 
 mia oedema of the feet and eyelids may exist as well as 
 hemorrhages from the mucous membranes. The micro- 
 scopical examination of the blood in these instances reveals 
 poikilocytosis and also nucleated red blood corpuscles, 
 thus demonstrating the existence of a progressive per- 
 nicious anaemia. The grave condition just described has 
 been observed only in the presence of bothriocephalus 
 latus but not of the other varieties of tapeworms. 
 
 The proof that the symptoms described are produced 
 by the tapeworm is found in the circumstance that they 
 disappear entirely after the removal of the parasite. 
 
 None of the above symptoms, however, permits the diag- 
 
TAPE WORMS. 359 
 
 nosis of tapeworm, for tliey are found also when it is not 
 present. The diagnosis can be made only by the discov- 
 ery of either segments of the i)arasite or their eggs in the 
 stools. 
 
 The tapeworm has a head or scolex, which may remain 
 alive for years, — even when separated from the other part 
 of the body, — an oblong neck and detachable segments 
 (proglottides). The latter vary in size and in configura- 
 tion the farther away from the head they are situated. 
 They possess the power of moving. The tapeworm is a 
 flat worm devoid of mouth or intestine. It grows by alter- 
 nate generation through the germination of a pear-shaped 
 primary host (head) and remains united with the latter for 
 a considerable time as a long band-shaped colony. Each 
 member of the colony forms a sexually active individual. 
 The proglottides increase in size the more distant they are 
 from the head. The tapeworm is an hermaphrodite. It is 
 provided on its head with four sucking discs, by means of 
 which it is enabled to attach itself to the intestinal mu- 
 cosa. It derives its nourishment by means of pores from 
 the intestinal chyme. The older proglottides contain a 
 large number of fructified eggs. The latter are off and on 
 emptied into the intestinal canal and then appear in the 
 dejecta. 
 
 The ovum contains an embryo which requires for its de- 
 velopment an intermediary host. After reaching the stom- 
 ach of the intermediary host the envelope of the ovum is 
 dissolved by the gastric juice. The embryo is now set 
 free and finds its way either by the lymphatics or by the 
 blood-vessels to some place (usually the muscles) where it 
 settles. Here it surrounds itself with a sac, which later 
 on may become surrounded with a calcareous deposit. In 
 this condition the embryo is called cysticercus or measle. 
 
360 
 
 DISEASES OF THE INTESTINES. 
 
 When the measle again reaches the stomach of a new host 
 it then opens and its scolex advances into the small in- 
 testine, where it develops into a full-grown taenia. 
 
 Tcenia Solium. — Taenia solium, or the armed tapeworm, 
 when fully developed, is from two to three metres long. 
 Its head is of pinhead size and spherical in shape. It has 
 four cuplike suckers, in the middle of which is situated the 
 rostellum, the latter being surrounded with a large number 
 of hooks (Fig. 44). These are arranged in two rows and 
 number from twenty-four to twenty-six. Succeeding the 
 head is a filiform neck, almost an inch long. Commencing 
 
 at a certain distance from 
 the head the body is di- 
 vided into segments. 
 The mature proglottides 
 
 IFiG. 44.— Head of Taenia Solium with Pro- 
 truding Rostellum. Magnified 50 diameters. 
 (Ziegler.) 
 
 Fig. 45.— Half Developed and Fully 
 Matured Segments. Natural size. 
 (Leuckart.) 
 
 are 1 to 1.5 cm. long and 6 mm. wide. The genital open- 
 ing is situated at the side near the posterior border of the 
 segment (Fig. 45). The uterus forms a straight median 
 tube, giving off at right angles five to seven branches on 
 
T^NIA SAGINATA. 361 
 
 ■eacli side. These branches are undivided at first, but to- 
 ward the periphery ramify in the form of a tuft (Fig. 46) . 
 The eggs are round and provided with a thick shelL 
 
 Tgenia solium inhabits the small intestine of human 
 beings. The further developjnent of the embryo into 
 
 A 
 Fig. 46.— Taenia Solium. Showing two proglottides. A, A^ pores. (Huber.) 
 
 measles occurs in the intermediary host, the pig, in which 
 condition they reach the human system and are trans- 
 formed into mature tsenias. Earely the measles (cysto- 
 cercus cellulosse) are found in men, in which instance they 
 occur in various organs, brain, eye, skin, etc. The grav- 
 ity of the disease which they produce depends upon the 
 importance of the organ they involve. 
 
 Tc&nia Saginata or Mediocanellata. — This tapeworm is 
 the one most frequently observed in America as well as 
 abroad. The taenia saginata is much longer, thicker, and 
 wider than taenia solium. The head is 2.5 mm. large, has 
 four large sucking-discs but no rostellum, and is often 
 pigmented (Fig. 47) . The length of the worm is 4 to 5 
 metres, the proglottides are unusually thick, the widest 
 being in the middle. The mature segments occasionally 
 attain a length of 2.5 cm. The uterus lies in the middle 
 of the segment and gives off numerous branches on both 
 sides (about twenty on each side (Fig. 48). The genital 
 opening is situated on the side below the middle. The 
 
362 
 
 DISEASES OF THE INTESTINES. 
 
 eggs liave an elliptical shape, a brownisli color, and a con- 
 tour exhibiting radiating streaks. 
 
 The taenia saginata inhabits the small intestine of man. 
 Its measles occur in beef, as has been demonstrated by 
 
 Huber ' and Leuckart. These measles are usually smaller 
 
 than those of taenia solium. Human beings acquire this 
 
 'Huber: "Twentieth Century Practice of Medicine," vol. viii., p. 
 570. 
 
BOTHRIOCEPHALUS LATUS. 363 
 
 tfenia by tlie consumption of raw beef. The measles have 
 not as yet been found in man. 
 
 Both7'iocepJudiis Latus, Tcenla Lata or Pig Head. — This 
 tapeworm is the longest. It measures from five to eight 
 metres. The head is elongated, of almond shape, being 
 about 2.5 mm. in length (Fig. 49). It has two lengthy 
 big grooves on its flat surface (Fig. oOj . The neck is nar- 
 row, about 2 cm, long. The body is thin and flat like 
 a ribbon, excejiting the central part of the segments which 
 
 Fig. 48.— The Uteras and its Branches in a Segment of TEenia Saginata. Enlarged 3^ 
 diameters. CHuber.) 
 
 project somewhat outward. The genital openings are on 
 the flat surface in the middle, the female very close to the 
 male. The uterus has a special opening and four to six 
 visible uterine convolutions on each side, which look al- 
 most like a rosette. The eggs are oval, round, with a thin 
 membrane and a lid (Fig. 51). They measure 0.07 mm. 
 in length and 0.04 in width. 
 
 The measle of bothriocephalus latus occurs principally^ 
 in fish, especially in pike, turbot, perch, and trout. 
 
 The taenia lata lives in the small intestine of man, but 
 is also, though rarely, found in dogs. In the northeast- 
 ern part of Europe, Holland, Switzerland, and Japan this 
 tapeworm is very prevalent. In America it occurs but in- 
 
364 
 
 DISEASES OF THE INTESTINES. 
 
 frequently. As stated above, among the symptoms pro- 
 duced by botliriocephalus anaemia is often observed. 
 
 Aside from tlie three tape- 
 worms just described there exist 
 a few more varieties which are 
 only rarely met in human 
 beings. They are : 
 
 (1) Tcenia Nana. — This is the 
 smallest tapeworm found in 
 man. It measures 10 to 15 mm. 
 in length and may have one hun- 
 dred and ninety segments. The 
 head has four sucking - discs, 
 a rostellum, twenty - four to 
 twenty-eight hooklets in a sin- 
 gle row. The proglottides are 
 short and broad; the genital 
 openings are on one side. 
 This tapeworm has been ob- 
 served principally in Egypt and 
 Italy in children. It usually 
 occurs in large numbers in the 
 small intestine, from forty to 
 even five thousand. The symp- 
 toms produced by this tapeworm 
 are mostly nervous disturbances, 
 fainting spells, occasionally 
 even epilepsy. 
 
 (2) Tee n i a Cucumerina. — 
 This small cucumber-shaped 
 tapeworm occurs frequently in 
 
 the intestine of the dog, but has also been found, although 
 rarely, in small children. The tapeworm is 10 to 40 cm. 
 
 Fig. 49. — Bothriocephalus Latus. 
 Natural size. (Leuckart.) 
 
TAPE WORMS. 
 
 )65 
 
 long and about 3 mm. wide. The measle of this taenia 
 inhabits the flea. 
 
 (3) Tcenia F lav o- Punctata or Tcenia Diminuta. — This 
 parasite is 2 to 6 cm. long and 3.5 mm. wide. Its head 
 is very small, club-shaped, and provided with sucking- 
 discs. The measle infests the caterpillar and cocoon of 
 
 FIG. 50. Fig. 51. 
 
 Fig. 50.— Head of Botbriocephalus Latus. Magnified. (Heller.) 
 Fig. 51.— Eggs ol Botbriocephalus. (Krabbe.) 
 
 asopia famialis and in the coleoptera axispinosa. This 
 tapeworm has been observed in man only a few times. 
 
 (4) Bothriocephalus Cordatus. — This tapeworm resembles 
 in all particulars the bothriocephalus latus except that it 
 is much shorter and that the head merges into the proglot- 
 tides directly without an intermediary neck. It occurs in 
 the intestine of men and dogs in Greenland. 
 
 The list of the tapeworms enumerated above is not com- 
 plete, for there exist the taenia madagascariensis, bothrio- 
 cephalus liguloides, and others, but as these do not occur 
 in Europe or America a description of them does not ap- 
 pear to be of practical interest. 
 
 Treatment. — Prophylaxis. In order to escape infection 
 with tapeworm it is necessary to abstain from raw or me- 
 dium done meats, including fish. The sanitary inspection. 
 
366 DISEASES OF THE INTESTINES. 
 
 of the meat is no absolute guarantee that it is free of 
 measles. Thorough boiling or broiling of the meat de- 
 stroys the cysticerci and thus the danger is avoided. In 
 order to diminish the spread of tapeworm it is advisable 
 to free the patient of the worms and thoroughly to destroy 
 them as soon as possible after thej^ have left the intestine. 
 Whoever examines the proglottides or the ova should care- 
 fully wash and disinfect his hands immediately afterward 
 in order to avoid auto-infection. 
 
 The direct treatment of the tapeworm consists in meas- 
 ures to expel it from the intestinal canal. This is accom- 
 plished by emptying the bowels previously and giving a 
 vermifuge afterward. The treatment is carried out in the 
 following way : For about two days before giving the ver- 
 mifuge the patient is kept on a scanty diet, consisting cf 
 some milk, meat and broth, very little bread or none at 
 all. A laxative (calomel eight to ten grains or castor oil 
 one tablespoonful) is given once a day. On the evening 
 preceding the administration of the vermifuge the patient 
 should have no supper or should take only salt herrings 
 with onions. On the following morning a cup of coffee or 
 tea is given. Half an hour to one hour later the vermifuge 
 is administered. Among the drugs for the removal of the 
 tapeworms the following are the most efficient : 
 
 Male-fern extract is given in doses of 6 to 10 gm. ( 3 iss.- 
 iiss.), as for instance: 
 
 I^ Extr. fllicis mar. gether 8.0 ( 3 ij.) 
 
 Syr. simpl 40.0 ( 1 ii) 
 
 S. To be taken in ten minutes. 
 
 The dose of male-fern should never be very high and 
 should not exceed 10 gm. ( 3 iiss.), as symptoms of intoxi- 
 cation have frequently been observed. 
 
 Pomegranate root is also an efficient remedy, espe- 
 
TAPE WORMS. 367 
 
 cially if it is fresli. It may be given in an infusion of the 
 bark, three ounces of which are macerated in ten ounces of 
 water and then reduced to one-half by evaporation. The 
 entire quantity is then taken within half an hour. 
 
 Pelletierine, the active principle of pomegranate root, 
 may also be used in doses of five to eight grains. 
 
 Flores koosso, about 20 to 30 gm. ( 3 v. to 3 i. ) of the 
 blossoms are thoroughly mixed in sugar water or lemon- 
 ade and should be taken within one-half or one hour, or — 
 
 IJ Flores koosso, 
 
 Mellis despumati aa 3 v. (20 gm.) 
 
 Fiat electuarium. S. To be taken in two portions. 
 
 Kamala may also be employed in doses of 10 gm. 
 ( 3 iiss.) mixed in aqua foeniculi or in wine and taken in 
 the same way. 
 
 Turpentine 30 to 60 gm. ( 3 i.-ii.) may be given in cap- 
 sules. After this medicament one or two glassfuls of milk 
 should be taken. 
 
 Pumpkin seeds (semina cucurbitae) may be administered 
 in doses of 120 gm. ( 3iv.), thoroughly mixed with the 
 same amount of grape sugar. 
 
 Cocoanut has also been recommended for this purpose. 
 The milk and albumin of an entire nut should be consumed 
 within one hour. 
 
 Naphthalin in doses of 0.6 to 2.0 gm. (gr. x.-xxx.) may 
 be given in capsules. 
 
 Salol 3 gm. (gr. xlv.) in capsules may also be advanta- 
 geously employed. 
 
 One or two hours after the administration of the vermi- 
 fuge a cathartic should be given, usually about two table- 
 spoonfuls of castor oil, or citrate of magnesia one to two 
 teaspoonfuls. The resulting evacuation must be thor- 
 
368 
 
 DISEASES OF THE INTESTINES.. 
 
 oughly examined and tlie tapeworm looked for, especially 
 its head. 
 
 Children require a correspondingly smaller dose of the 
 above remedies, according to their age. Patients who are 
 debilitated, or have intestinal disorders or organic lesions 
 of the digestive tract, should not be subjected to this treat- 
 ment, nor should it be employed shortly after typhoid 
 fever or other grave diseases. In these conditions it is: 
 necessary to postpone the treatment until a more oppor- 
 tune time. 
 
 Trematodes (Fluke Worms). 
 
 The trematodes are solid worms of a tongue or leaf 
 shape. They possess a clinging apparatus in the form of 
 
 Fig. 53.— Distoma Hepaticum, with Male and Female Sexual Apparatus. 0^euckart.> 
 Magnified 33^ diameters. 
 
 oral and ventral sucking-cups varying in number. Some- 
 times they are also provided with hook or clasp like pro- 
 jections for this purpose. The intestinal canal is without 
 any anus and is split like a fork nearly throughout its 
 extent. The fluke worms are mostly hermaphroditic. To 
 these belong : 
 
 Distoma Hepaticum or Liver Fluke. — This parasite has 
 a leaf shape, is 22 mm. long and 12 mm. wide. The ceph- 
 alic end projects like a beak and bears a small cuplike 
 
DISTOMA LANCEOLATUM. 369 
 
 sucker, in which the mouth is located. Close behind this 
 on the ventral surface is a second suction cup and between 
 the two lies the sexual orifice. The uterus consists of a 
 
 Fig. 53.— Eggs of Distoma Hepaticum. (Leuckart.) Magnified 300 diameters 
 
 convoluted bulb-shaped bag situated behind the posterior 
 sucker. On each side of the hodj lie the ovisacs and be- 
 tween them the much branched testicular canals (see Fig. 
 52). The eggs are oval, 0.13 mm. long and 0.08 mm. 
 wide. They have a brownish color and are provided with 
 a lid (Fig. 53). 
 
 The liver fluke is rare in man, though frequently found 
 in ruminating animals. It inhabits the biliary ducts and 
 is occasionally found in the intestine and in the inferior 
 vena cava. The symptoms which it produces are varied: 
 jaundice, enlargement of the liver, diarrhoea, hemorrhages. 
 
 Fig. 54.— Distoma Lanceolatum with its Inner Organs. (Leuckart.) Magnified 10 
 
 diameters. 
 
 Most probably the liver fluke reaches the intestinal canal 
 
 by means of impure water or vegetables. 
 
 Distoma lanceolatum is 8 to 9 mm. long and 2 to 2.5 mm. 
 
 wide. It has a lancet shape and the head portion is not 
 
 specially marked off from the body (Fig. 54). The eggs 
 24 
 
870 
 
 DISEASES OP THE INTESTINES. 
 
 are considerably smaller tlian those of distoma hepaticum, 
 being only 0.04 mm. long (Fig. 55). Witb regard to its 
 occurrence and symptoms it resembles tbe liver fluke. 
 
 Distoma hcematobium or Bilharzia hcematobia is fre- 
 quently found in hot climates, especially in Egypt. In 
 
 Fig. 55.— Egg of Distoma Lanceolatum Shortly After the Formation of a Shell. CLeuck- 
 art.) MagnlQed 400 diameters. 
 
 the United States and in Europe it is very rarely found. 
 This parasite has separate sexes. The male is from 12 
 to 14 mm. long. Its body is smooth, but in its posterior 
 portion rolled up into a tube, which serves for the recep- 
 tion of the female (canalis gynsecophorus) (Figs. 56 and 
 57). The female is from 16 to 19 mm. long and almost 
 
 Fig. 56. 
 
 FIG. 57. 
 
 Fig. 56.— Distoma Haematobium. (Leuckart.) Male and female, the latter in the ca- 
 nalis gyn^cophorus of the former. Magnified 10 diameters. 
 Fig. 57.— Eggs of Distoma Hgematobium. (Leuckart.) a. Egg with terminal spine; b, 
 egg with lateral spine. Magnified 150 diameters. 
 
 cylindrical. The sexual opening lies in both sexes close 
 behind the ventral sucker. The distoma haematobium 
 
ROUND WORMS. 371 
 
 finds its way into the intestinal canal of man and then 
 readies the portal circulation, where it develops. In the 
 intestinal canal it has been encountered verj- rarely, in 
 which case ulcerations of the intestinal mucosa were pres- 
 ent. It frequently causes hsematuria and great cachexia, 
 terminating fatally in some instances. 
 
 As regards treatment, the removal of these fluke worms 
 must be undertaken in identically the same manner as that 
 of the tapeworms described above. 
 / 
 
 Nematodes {Round Worms). 
 
 The round worms which occur as parasites have a slen- 
 der, cylindrical, sometimes filiform body, with neither 
 segments nor appendages. The integument is thick and 
 elastic. The oral opening is at one extremity and provided 
 with either soft or hornlike lips. The alimentary canal 
 extends throughout the entire body cavity, terminating in 
 an opening upon the ventral side at a short distance from 
 the posterior extremity. The sexual organs and their ori- 
 fices lie on the ventral surface. The female aperture is 
 located at about the middle of the body ; in the male the 
 sexual orifice is situated close to the anus. The males 
 are usually much smaller than the females. 
 
 Ascaris Lumbricoides (Common Spool or Bound Worm). — 
 This worm is one of the most frequently observed para- 
 sites in man. The round worm has a light brown or red- 
 dish color and a cylindrical shape. The male is 20 cm. 
 and the female 30 cm. long. The posterior extremity of 
 the male is bent in the form of a hook and provided with 
 two spicules or chitinous processes. The mouth is sur- 
 rounded by three muscular lips provided with very fine 
 teeth. The sexual opening of the female lies anterior to 
 the middle of the body (Fig. 58). The eggs when ripe 
 
372 
 
 DISEASES OF THE INTESTINES. 
 
 Fig. 58.— Ascaris Lumbricoldes. (Perls.) 
 A, Female ; B, male. (Natural size.) 
 At a is the female sexual orifice ; c, 
 the two spicules of the male ; b, head 
 
 , extremity (magnified) of the worm, 
 with the three lips. 
 
 have a double shell and 
 around this is an albumi- 
 nous envelope which is ir- 
 regularly shaped, and 
 studded with excrescences 
 (Fig. 59). The long di- 
 ameter of the egg is about 
 0.05 mm. 
 
 The round worm pos- 
 sesses a strong odoriferous 
 principle which is very 
 perceptible even after the 
 worm has been carefully 
 washed. According t o 
 Huber, ' this substance 
 may occasion urticaria in 
 persons predisposed to this 
 eruption. It is not im- 
 probable that certain of 
 the symptoms of ascariasis 
 are due to the action of 
 the same element. 
 
 The principal habitat of 
 ascaris lumbricoides is the 
 small intestine of man. It 
 develops here often in large 
 numbers, fifty to one hun- 
 dred and more occurring 
 together. The mode of 
 transmission, according to 
 
 ' Huber : " Twentieth Century 
 Practice of Medicine, " vol. viii, 
 p. 583. 
 
ASCARIS LUMBRICOIDES. 
 
 '673 
 
 Leuckart, Grassi,' and Lutz/ is by ingestioQ of the eggs of 
 the ascaris, there being no intermediate host. The full 
 development of the round worm from the egg to its period 
 of sexual maturity requires ten to twelve weeks. Infection 
 usually takes place by eggs existing in the soil near dwell- 
 ing-places, in the drinking-water, and 
 also in some foods, principally salads 
 and fruits. Ascaris lumbricoides is 
 most frequently found in children three 
 to twelve' years old, the poorer classes 
 showing a larger percentage than the 
 well-to-do. In grown persons the worm 
 is not so frequent. The female sex is 
 more frequently infected than the 
 male. 
 
 The diagnosis of ascariasis is made 
 by the detection of the worm in the fecal matter, or of its 
 eggs, which are easily recognized. 
 
 Sijmptoms. — Ascariasis may exist without giving rise to 
 any symptoms whatever. Occasionally, however, there are 
 various disturbances : anorexia, nausea, irregularity of the 
 bowel, meteorism, an irregular pulse; in children black 
 rings around the eyes, much nervousness, even convul- 
 sions. In rare instances progressive anaemia has been ob- 
 served (Leichtenstern). Anatomically hyperaemia of the 
 intestinal wall has been frequentlj^ found, erosions are rare. 
 Itching of the nose is often present in ascariasis and may 
 be due to the odoriferous principle. 
 
 The round-worm is liable to wander and may then give 
 rise to severe complications. In several instances it has 
 
 Fig. 59.— Egg of As- 
 caris Lumbricoides 
 (Leuckart) with Shell 
 and Albuminous En- 
 V e 1 o p e . Magnified 
 300 diameters. 
 
 ^ Grassi: Centralbi. f. Bacteriologie unci Parasiteukunde, 1887. 
 ^ Adolf Lutz : " Klinisches ilber Parasiten des Meuschen und der 
 Hausthieie." Centralbi. f. Bacteriologie, 1889. 
 
374 DISEASES OF THE INTESTINES. 
 
 been found in tlie bile duct, in the gall bladder, and even 
 in the liver, producing abscesses and even a fatal issue. 
 The worm occasionally migrates into the stomach and pro- 
 duces pain and often vomiting. In the latter act it is often 
 expelled from the mouth. Occasionally it ascends the 
 oesophagus and enters the larynx, causing asphyxia, and, 
 in rare instances, even death. It has also been found in 
 hernial sacs and in the peritoneal cavity, but it is gen- 
 erally believed that it cannot penetrate through the 
 healthy intestinal wall. Obstruction of the bowels by a 
 conglomeration of ascarides has also been thought pos- 
 sible; its real occurrence, however, is denied by Leichten- 
 stern.' 
 
 Prophylaxis requires total destruction of all the eggs of 
 the ascaris passed with the fecal matter of the patient. 
 The grounds near dwellings should be kept perfectly clean 
 and the hands should be frequently washed. All foods 
 should be protected against a possible infection. 
 
 Treatment. — The treatment consists in freeing the pa- 
 tient from the worms. This is done in a similar manner 
 as in the case of tapeworms. The intestinal tract is kept 
 partially empty for a day or two before the administration of 
 the anthelmintic. The most efficient remedy for this pur- 
 pose is santonin, which is given in a dose of 0.02 to 0.06 
 gm. (gr. ^i.) twice or four times a day. Then a purgative 
 remedy is given. Some combine the santonin with the 
 purgative and give them together. Thus santonin 0.2 (gr. 
 iiiss.), castor oil 60 gm. ( 3 ii.), twice or three times daily 
 one teaspoonful for small children, a dessertspoonful for 
 larger children, and one tablespoonful for grown people. 
 
 ' Leichtenstern : " Verengerungen, Verschliessungen und Lageveran- 
 derungen des Darms." von Ziemssen's Handbuch der spec. Path, und 
 Therapie, Bd. vii., Abth. 2. 
 
OXYURIS VERMICULARIS. 375 
 
 The santonin may also be given in combination with cal- 
 omel; thus — 
 
 ^ Calomel :•-.. 0.05 to 0. 1 (gr. i.-ij.) 
 
 Santonin 0.02 (gr. i) 
 
 T. d. No. Ix. S. One powder three times daily. 
 
 riores ciuse, the plant from which santonin is obtained, 
 may also be administered in doses of 0.5 to 2 gm. as 
 powders or as an electuary, with the addition of jalap, 0.1 
 to 0.2 gm. I 
 
 Chenopodium or wormseed is also a popular remedy, 
 the powdered seeds being given in doses of 1 to 2 gm, 
 (gr. XV. -XXX.), or the volatile oil in five to ten drop doses. 
 Thymol has also been recommended in doses of 0.5 to 
 2 gm. (gr. vii.-xxx. ) in twenty -four hours. It lasiy be given 
 in gelatin capsules. Irrigation of the bowels with water 
 to which three to five drops of benzene have been added 
 has likewise been suggested, but does not appear as bene- 
 ficial as santonin. 
 
 Ascaris Mystax. — A round- worm resembling ascaris lum- 
 bricoides but much smaller and somewhat thinner. This 
 parasite frequently occurs in animals, principally in cats, 
 but has been discovered very rarely in man. No symp- 
 toms whatever have been observed. 
 
 Oxyuris Vermicidaris, AivUail, Seat or Pin Worm, Mag- 
 got or Thread Worm. — This parasite is white and filiform, 
 4 to 12 mm. long and 0.2 to 0.6 mm. thick (Fig. 60). The 
 males are much smaller than the females. The oxyuris 
 has three small knoblike lips. The female possesses 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 0.02 
 wide. The contents are granular and the shell appears 
 white. 
 
376 
 
 DISEASES OF THE INTESTINES. 
 
 Infection takes place when the eggs of oxyuris reach tht 
 stomach. Here the shell opens and the embryo migrates 
 
 into the small intestine 
 (Fig. 61). After fructi- 
 fication has taken place 
 the females usually begin 
 to wander along the in- 
 testinal canal. In the 
 csecum they generally 
 make quite a long sojourn 
 until the eggs are almost 
 ripe. Then they again 
 begin to pass down- 
 ward. According t o 
 Leichtenstern, Lutz, and 
 Huber, the females do not 
 pass their eggs within 
 the intestinal canal. As 
 a rule they first leave the 
 For this reason the fecal 
 
 Fig. 60.— Oxyuris Vemiicularis : a, natural 
 size ; b, head ; c, tail, magnified ; d, head 
 greatly magnified. 
 
 bowel and then deposit the eggs. 
 
 matter usuallj^ does not contain any eggs. 
 
 The symptoms which are most frequently observed con- 
 sist in pronounced pruritus ani due to the irritation pro- 
 duced by the passing of the parasites out from the rectum. 
 Frequently" the itching annoys the patient as soon as he 
 retires. Various nervous symptoms are occasionally ob- 
 served: anorexia, nausea, dizziness, palpitation of the 
 heart, pollutions and spermatorrhoea in the male ; besides 
 diarrhoea occasionally occurs. Pronounced anaemia is en- 
 countered, although rarely. In rare instances the para- 
 sites reach the vagina and cause irritation there. Nymph- 
 omania has then been observed. 
 
 Infection probably occurs through direct conveyance of 
 
OXYURIS VERMICULARIS. Oi i 
 
 the eggs by the unwashed hands of the host. It is also 
 possible that ova dried by the sun exist on fruit, radishes, 
 or salads, in which state they may be carried into the 
 stomach. 
 
 The diagnosis of the thread worm is made by inspection 
 of the anal region and by the finding of the oxyuris. 
 
 With regard to prophylaxis extreme cleanliness is of the 
 greatest importance. Fruits should be thoroughly cleaned 
 and then peeled before the}' are eaten. The eating uten- 
 sils of a person infected with oxyuris should never be used 
 by another, unless they have been thoroughly disinfected. 
 The same applies to the clothes. Sleeping with an infected 
 person should be forbidden, and even touching his hands 
 
 Fig. 61.— Development of Oxyuris Vermicnlaris. (Heller.) a-e. Segmentation of the 
 yolk ; /, ovum containing tadpole-shaped embryo, seen from the side ; g, abdominal 
 ■\iew" of the same ; ??, ovum with worm-shaped embryo ; i, embryo escaping from the 
 shell ; iu free embryo capable of motion. 
 
 requires immediate washing, as otherwise infection may 
 take place. 
 
 Treatment. — Santonin is the principal remedy for com- 
 bating oxyuriasis. It is given in the same way as de- 
 
378 DISEASES OF THE INTESTINES. 
 
 scribed in the treatment of ascaris liimbricoides. Here, 
 however, irrigations of the bowel with water and the addi- 
 tion of a few drops of benzene or thymol or vinegar (three 
 to four tablespoonsful to a quart), or of sapo medicatus in 
 a one-half to one-per-cent solution may be advantageously 
 used. The anal region should be thoroughly cleansed. 
 If the pruritus ani is quite intense, application to the anal 
 region and rectum of unguentum hydrarg. cinerei or the 
 use of a suppository of ung. hydrarg. cinerei 1 gm., in 
 cacao butter 2 gm. will afford relief. 
 
 AncJiylostoma Duodenale. Dochmius Duodenalis, Unci- 
 naria Duodenalis, or Strongylus Duodenalis. — This impor- 
 tant parasite was first described by Dubini ' in 1838. 
 Bilharz ^ and Griesinger ^ recognized this parasite as the 
 cause of the Egyptian chlorosis. Some time afterward 
 the anchylostoma was observed in severe cases of anaemia 
 among workmen in tunnels and brickmakers. 
 
 The anchylostoma duodenale is cylindrical in shape, 0.5 
 to 1 mm. thick and 6 to 18 mm. long. It is yellowish or 
 grayish-white in color, with translucent edges. The male 
 is much shorter than the female. The cephalic end is 
 curved toward the dorsal surface and is provided with an 
 oral capsule at the margin of which there are six hooklike 
 teeth. Further within the capsule there are three sharp 
 chitinous processes (Figs. 62 and 63). The male is more 
 slender and transparent than the female. Its head end is 
 bent backward. The tail end appears somewhat swollen, 
 containing the bursa copulatrix, and is much more curved 
 than the head. In the female the caudal end is pointed 
 and armed with an awl-like prong; the genital opening; 
 
 ' Angelo Dubini: Gaz. med. Lombard., 1843. 
 
 '^Bilharz: Wiener med. Wochenschr. , 1856. 
 
 2 Griesinger : Arch, f . pbysiolog. Heilkunde, 1854 
 
ANCHYLO STOMA DUODENALE. 
 
 379' 
 
 Fig. 63.— Cephalic End of Anchylostoma Duo- 
 denale. (Schultlieiss.) a, Mouth-capsule ; 
 b, teeth of ventral border ; c, teeth of dorsal 
 border; cl, buccal cavity: e, skin-sac on. 
 ventral side of head ; /, muscular layer ; g, 
 dorsal groove ; /;, oesophagus. 
 
 Fig. 64.— Eggs of Anchylostoma Duodenale. 
 (Perroncito and Schultheiss.) a, b, c, d. 
 Different stages of cleavage ; e, /, eggs with 
 embryos. Magnified 200 diameters. 
 
 Fig. 63.— Male of Anchylostoma Duodenale. (Schultheiss.) a. Head with mouth-cap- 
 sule ; b, oesophagus ; c, intestine ; d, anal glands ; e, cervical glands ; /, skin ; g, 
 muscular layer ; ?!, porus excretorius ; i, triple bursa ; 7c, ribs of the bursa ; Z, testicu- 
 lar canal ; wi, vesicula seminalis ; 11, ductus ejaculatorius ; 0, groove of latter ; p, 
 penis ; g, sheath of penis. Magnified 20 diameters. 
 
S80 DISEASES OF THE INTESTINES. 
 
 lies behind the centre of the body. The eggs are oval, 
 0.06 mm. in length and 0.03 mm. in width (Fig. 64). 
 
 The habitat of the anchylostoma is the duodenum, the 
 jejunum, and the upper part of the ileum. Here the worm 
 attaches itself to the intestinal mucosa and feeds by suck- 
 ing the blood of his host. According to Leichtenstern, ' 
 active migration of the worm begins at the time of the first 
 copulation in the fifth week. Young worms change their 
 place quite frequently and hence give rise to repeated hem- 
 orrhages. Colic, and acute ansemia are encountered at an 
 earl}^ period after infection. 
 
 Under favorable conditions the eggs develop outside of 
 the body into rhabditis-like larvae, becoming enclosed in 
 a protecting envelope or encysted. In this stage the larvae 
 may be carried along with the dust and contaminate fruit 
 and water. On reaching the small intestine they develop 
 into mature worms. This parasite is always encountered 
 in great numbers if present in the intestines. Leichten- 
 stern never found them in a smaller number than one 
 hundred, but sometimes their total reached three thou- 
 sand. 
 
 The symptoms produced by anchylostoma consist of gas- 
 tralgia, nausea, occasionally vomiting, constipation, rarely 
 diarrhoea, and severe anaemia, the latter becoming progres- 
 sively worse. The patient with anchylostoma does not 
 greatly emaciate, but becomes pale, extremely weak, and 
 suffers from dizziness and shortness of breath after the 
 slightest exertion. His extremities are cold, slight hemor- 
 rhages occur frequently, and oedema of the ankles devel- 
 ops. A systolic murmur may be heard at the apex of the 
 heart, the pulse is accelerated, and fever may be present 
 
 ' Leiclitenstern : Centralbl. f . kliQ. Medicin, 1885, and Deutsche med. 
 Wochenschr., 1885, 1886, 1887. 
 
ANCHYLOSTOMA DUODENALE. 381 
 
 toward evening. An inclination to eat eartli (geopliagia)' 
 Is not rarely observed. 
 
 The dejecta are of a brownish color, although admixture 
 of blood cannot be recognized macroscopically. Micro- 
 scopically Charcot-Leyden's crystals, as well as the eggs 
 of the parasites, are often found in the stools. The urine 
 rarely contains albumin, but frequently indican. The con- 
 dition of the blood resembles that found in pernicious 
 anaemia : enormous decrease of the red blood corpuscles, 
 poikilocytosis, nucleated red blood corpuscles, and a slight 
 increase of the leukocytes, especially of the eosinophile 
 cells. 
 
 Anatomically the mucosa of the small intestine is found 
 greatl}^ congested and ecchymoses are visible here and 
 there. Peyer's patches and the solitary follicles are often 
 swollen. The heart is found hypertrophied and dilated, 
 the liver and spleen may be diminished in size, normal, or 
 in an amyloid condition. The same can be said of the 
 kidneys. There is no doubt that the principal deleterious 
 action of the anchylostoma consists in the profuse loss of 
 blood caused by the parasites. Whether some toxic sub- 
 stances generated by them participate in producing the 
 grave symptoms is questionable. 
 
 The course of the disease is protracted and its severity 
 depends greatly upon the number of parasites present. If 
 the latter is great, the disease may progress quickly and 
 the patient succumb with the symptoms of general dropsy, 
 dyspnoea, and heart failure or pulmonary oedema. If the 
 number of the parasites is small, the patient may live 
 many years and ultimately recover entirely. Recovery is 
 also possible by successful expulsion of the parasites from 
 the intestinal tract. 
 
 The diagnosis of anchylostomiasis is made by the pres- 
 
382 
 
 DISEASES OF THE INTESTINES. 
 
 ence of tlie symptoms of anaemia in conjunction with the 
 •discovery of the anchylostoma eggs in the dejecta. 
 
 With regard to prophylaxis the 
 above given rules for the prevention of 
 the round- and thread-worms are also 
 applicable here. Extreme cleanliness 
 of the body and of the food is of 
 greatest importance. 
 
 The treatment consists in the ad- 
 ministration of extract of male-fern, 
 which should be employed in the 
 same manner as described above for 
 the tapeworm disease. 
 
 Angidlhda Stercoralis. — This nema- 
 tode is 0.8 to 1.2 mm. long, the male 
 shorter than the female (Fig. 65). 
 The male is indigenous in Cochin 
 China and Italy. In the latter coun- 
 try it often occurs simultaneously with 
 anchylostoma. If the worms exist in 
 large numbers they may produce patho- 
 logical conditions. According to Golgi 
 and Monti, ' the anguillula stercoralis 
 penetrates into Lieberkuehn's crypts 
 and there deposits its eggs and young. 
 Angidllida intestinalis, which is 2.25 
 mm. long, belongs to the same variety 
 as anguillula stercoralis and is found 
 under the same conditions. Only the female of this worm 
 is known. The eggs develop in the intestinal canal and 
 exhibit only the first stages of segmentation at the time 
 -of their passage with the faeces. 
 
 ' Golgi e Monti : Arch, per le science med. , 1886, No. 3. 
 
 Fig. 6.5.— Female of An- 
 guillula Stercoralis, 
 with Eggs and Embryos. 
 (Perroncito.) Magni- 
 fled 85 diameters. 
 
TRICHOCEPHALUS DISPAR. 383 
 
 Tricliocephalus Dispar. TT^np-Worm. — This parasite is 
 quite common, but comparatively harmless. Its habitat 
 is the csecum and the neighboring section of the intestine. 
 It lives upon blood which it abstracts from the intestinal 
 mucosa. This parasite is 4-5 cm. long, the male being 
 smaller than the female. The head end, which is about 
 three-fifths of the entire length, is drawn out into a fine 
 thread; the tail end is not so thin, being up to 1 mm. in 
 thickness (Fig. 66). The male has a spiral body from the 
 end of which the sijicule projects. The body of the fe- 
 male is straight and terminates in a blunt extremity. The 
 
 Tig. 66.— Trichocephalus Dispar. (Heller.) a. Fig. 67.— Ova. of Trlchocephalus 
 Female . h, male. Natural size. Dispar in Process of Develop- 
 
 ment. CHuber.) 
 
 ova are almost lemon-shaped, dark brown in color, 0.05 
 mm. in diameter (Fig. 67). The number of eggs in a sin- 
 gle female was estimated by Leuckart at 58,000. They are 
 hatched out very slowly. 
 
 Leuckart asserts that the dispersion of the eggs and con- 
 sequent spread of infection may readily occur through 
 wind, rain, or dust, and that the eggs may be ingested with 
 fruit and salads. The number of these worms found in 
 one patient is usually small, from six to twenty. 
 
 The symptoms are but very slight, occasionally diarrhoea 
 exists, sometimes there are some reflex nervous conditions. 
 
 The diagnosis can usually be easily made from the shape 
 of the ova. The passage of the living worms in the stools 
 occurs but rarely. 
 
384 
 
 DISEASES OF THE INTESTINES. 
 
 Plate I.— Trichina Spiralis (Hubert. 
 
TRICHINA SPIRALIS. 385 
 
 With regard to treatment Lutz recommencls the admin- 
 istration of thymol; Mosler' and Peiper' employ rectal 
 irrigation of water, to which a few drops of benzene have 
 been added. Extract of male-fern may also be used inter- 
 nally. 
 
 Trichina Spiralis. — The trichina spiralis was discovered 
 by Paget, ' but its pathological importance was first recog- 
 nized by Zenker.* This parasite is observed in two forms, 
 the trichina of the intestine and the trichina of the muscles 
 (see Plate I.). 
 
 The trichina reaches the stomach through the ingestion 
 of pork containing encapsulated trichinae. In the stomach 
 the capsule opens about three to four hours after the inges- 
 
 ' Mosler: "Darminfusion." Real-Encyclopadie der gesammten Heil- 
 kunde, Bd. v. 
 
 '^ Peiper: "Helminthen." Real-Encyclopadie der gesammten Heil- 
 kunde, Bd. ix. 
 
 2 Paget, cited after Huljer : " Twentieth Century Practice of Medi- 
 cine, " vol. viii., p. 608. 
 
 ■* Zenker: Deutsches Arch, flir klin. Medicin, i., 1866. 
 
 Explanation of Plate I. 
 
 Fig. 1.— Muscle Trichina Enclosed In a Fully Developed Cyst. X 240. Cy, cyst; Bg, 
 connective-tissue envelope ; Fk, fat globules. 
 
 Fig. 2.— The Same Removed from the Cyst. X 400. Oe, (Esophagus ; Zfe, cell 
 bodies ; i/, side lines ; Oi\ ovary ; Ch.D, chyle duct. 
 
 Fig. 3.— Part of the Ovary, x 600. Is readily distinguished from the testicle'by the 
 varying size of the germ ceUs. 
 
 Fig. 4.— Male Intestinal Trichina. X 100. T, Testicle ; d ej, ejaculatory duct ; Zk, 
 cell bodies. 
 
 Fig. 5.— Female Intestinal Trichina. X 90. Ov, ovary ; E, embryos ; Oe, genital 
 opening from which the embryos escape. 
 
 Fig. 6.— Free Embryo. X 400. 0, mouth ; A, anus. 
 
 Fig. 7.— Embryo About Three Days After Having Entered the Muscle Fibre. MF, 
 normal muscle fibre. 
 
 Fig. 8.— Muscle Trichina, About Six Days Old, in the Greatly Swollen Sarcolemma 
 Sheath Traversed by Capillary Vessels, Cap. 
 
 Fig. 9.— Muscle Trichina, Four Weeks Old, Enclosed in a Capsule, Cy A, within the 
 sarcolemma sheath, Sk; Bk, connective-tissue capsule in process of active growth; fc, 
 nuclei ; MF. contents of the sarcolemma sheath at each pole of the capsule. 
 
 Fig. 10.— Muscle Trichina with Calcifled Capsule. 2^, Fat globules. 
 
 25 
 
386 DISEASES OF THE INTESTINES. 
 
 tion of tlie meat and tlie embryos rapidly develop. At the 
 end of thirty to iortj hours fructification of the young par- 
 asites takes place. 
 
 The intestinal trichinae are visible with the naked eye, 
 the females being 3 to 4 mm. long and the males half this 
 size. The caudal extremity is thicker than the head end. 
 Five days after fecundation the females give birth to living 
 young ones. The young brood wanders directly from the 
 intestine of the host into his muscles. Here they further 
 develop. In this condition they give rise to a febrile dis- 
 ease accompanied by severe muscular symptoms which 
 may lead to death. Sometimes the trichinse become en- 
 capsulated. The symptoms vary according to the number 
 of worms which have been ingested. Gastro-intestinal dis- 
 turbances usually appear on the second or third day after 
 the ingestion of the contaminated meat. Vomiting, diar- 
 rhoea, colic often ai3pear. 
 
 The disease known as tricliinosis, which depends upon 
 the further development of the young embryos in the mus- 
 cles of the host, is not within the scope of this book, and 
 we refer to this parasite only as far as its occurrence in 
 the intestines is concerned. With regard to prophylaxis 
 pork should never be eaten raw. The treatment after the 
 ingestion of trichinous meat consists in the employment of 
 lavage of the stomach, if the physician is called early enough 
 after the meal. In addition a vermifuge and cathartic rem- 
 ed}^ should be given immediately. 
 
INDEX. 
 
 Abelmanx, 22 
 
 Absorption as u function of the 
 
 bowel, 24 
 Acholic stool, 58 
 Adenoma of the intestines, 173 
 ^gineta, Paulus, 341 
 Albumin in the f*ces, 53 
 Albuminates, putrefaction of, in 
 
 the large intestine. 21 
 Alimentation, rectal, 80 
 
 subcutaneous, 80 
 Allingham, 37, 178, 191, 194 
 Allingham's rectal speculum, 37 
 Amoeba, 355 
 Amoebic dysenterj-, 113 
 Amj'loid ulcers, 145 
 Anacker, 317 
 
 Anaesthesia of the intestine, 339 
 of the rectum, 339 
 treatment, 340 
 Anatomy of the intestine, 1 
 Anchylostoma duodenale, 378 
 course, 381 
 diagnosis, 381 
 prophylaxis, 382 
 symptoms, 380 
 treatment, 382 
 Angioma of the intestines, 173 
 Anguillula intestinalis, 382 
 
 stercoralis, 382 
 Autiperistalsis of the intestine, 30 
 Anus, anatomy of the, 16 
 
 fissure of the, 199 
 Appendicitis. 202 
 catarrlial. 208 
 definition, 203 
 
 Appendicitis, diagnosis, 220 
 
 differential diagnosis, 221 
 
 etiology, 203 
 
 general remarks, 202 
 
 indications for operation, 231 
 
 larvata of Ewald, 215 
 
 morbid anatomy, 208 
 
 perforativa, 210 
 
 prognosis, 222 
 
 severe form, 210 
 
 symptomatology, 212 
 
 synonyms, 202 
 
 treatment, 224 
 
 ulcerosa et gangreenosa, 210 
 Appendicular inflammation, 203 
 Appendix vermiformis, 13 
 Aretosus, 113 
 Ascariasis, diagnosis, 373 
 
 pi'ophj'laxis, 374 
 
 s^'mptoms, 373 
 
 treatment, 374 
 Ascaris lumbricoides, 371 
 
 mystax, 375 
 Atony of the bowel, 297 
 Auscultation, 45 
 Awl-tail, 375 
 
 Balaxtidiuii coli, 357 
 Bamberger, 206 
 Barbacci, 206 
 Barthelemy, 117 
 Basch, 55 
 Bauhin's valve, 13 
 Bayle. 147 
 Beauchef, 114 
 Beck, Carl, 204, 228 
 
388 
 
 INDEX. 
 
 Benign tumors of the intestines, 
 
 173 
 Bernard, Claude, 19 
 Bienstock, 77 
 
 Bile pigment in the faeces, 57 
 Bilbarz, 378 
 
 Bilharzia hasmatobia, 370 
 Biliary acids in the faeces, 57 
 Birch-Hirschfeld, 149 
 Blood in the faeces, 56 
 Boas, J., 42, 48, 93, 218, 220, 225, 
 
 226, 227, 230, 345 
 Bonnecken, 254 
 Borborygmi, 45 
 Bothriocephalus cordatus, 365 
 
 latus, 363 
 Bouchard, 102, 304 
 Boudet, 84, 260, 315 
 Bougies, rectal, 43 
 Bowel, atony of the, 297 
 Brahm-Houkgeest, 28, 289 
 Brinton, 260 
 Brooks, LeEoy J., 273 
 Brunner's glands, 9 
 Brunton, 830 
 Bryant, J. D., 13, 157 
 Bull, W. T., 203, 229 
 Bunge, 59 
 
 Ca;cum, anatomy of the, 12 
 Cahn, 267 
 
 Cancer of the duodenum, S3'mp- 
 toms, 165 
 of the intestine, 150 
 course, 169 
 definition, 156 
 diagnosis, 169 
 etiology, 156 
 location, 157 
 morbid anatomy, 158 
 prognosis, 170 
 symptomatology, 160 
 treatment, 170 
 of the large bowel, symptoms, 
 166 
 
 Cancer of the rectum, symptoms, 
 167 
 
 of the small intestines, symp- 
 toms, 166 
 Carbohydrates in the faeces, 54 
 Carbolic acid injections in hemor- 
 rhoids, 292 
 Cash, 330 
 Catarrh, acme intestinal, 86 
 
 chronic, of the bowels, 97 
 Cauterization in hemoi'rhoids, 292 
 Celsus, 113 
 
 Cercomonas intestinalis, 356 
 Cestodes, 357 
 Charcot, 292 
 Chlapowski, 40 
 Cholera nostras, 86 
 Clapotage, 42 
 Clark, Alonzo, 226, 308 
 Colic, intestinal, 332 
 
 mucous, 341 
 Colitis, acute, 93 
 Colon, anatomy of the, 11 
 
 ascending, 14 
 
 descending, 15 
 
 transverse, 14 
 Compression of the intestine, 233 
 Concretions in the faeces, 59 
 Constipation. 297 
 
 definition, 297 
 
 dependent upon other dis- 
 eases, 302 
 
 diagnosis, 308 
 
 etiology, 298 
 
 habitual, 297 
 
 prognosis, 310 
 
 prophylaxis, 310 
 
 symptomatology, 303 
 
 S3'nonyms, 297 
 
 treatment, 310 
 dietetic, 311 
 mechanical, 313 
 moral, 311 
 Cooper, 293 
 Cooper-Foi'ster, 161 
 
INDEX. 
 
 ;j8'j 
 
 Oornil, 348 
 
 Councilman, 116, 119, 133 
 Crede, 385 
 
 Crushing in Uie treatment of hem- 
 orrhoids, 194 
 Cruveilhier, 177, 343 
 Curschmann, 364, 370 
 Cj'sts of the intestines, 173 
 
 Da Costa, 343, 344, 350 
 Daniscli, 46 
 Dastre, 19 
 Deavei', 338 
 Demant, 2^88 
 Delafield, F., 104 
 Diarrhoea, 390 
 
 acute, 86 
 
 diagnosis, 395 
 
 dyspeptic, 393 
 
 etiology, 390, 394 
 
 membranous, 341 
 
 morning, 104 
 
 nervous, 390 
 
 prognosis, 395 
 
 stercoral, 394 
 
 symptomatology, 890, 394 
 
 treatment, 395 
 
 tubular, 341 
 Diet, 77 
 Dilatation of the sphincters in the 
 
 treatment of hemorrhoids, 191 
 Distoma haematobium, 370 
 
 hepaticum, 368 
 
 lauceolatum, 369 
 Dochmius duodenalis, 378 
 Douglas' fold, 15 
 Doumer, 315 
 Dubini, 378 
 Dunin, 300 
 Duodenal ulcer, 133 
 course, 138 
 definition, 133 
 diagnosis, 138 
 etiologJ^ 133 
 morbid anatomy, 134 
 
 Duodenal ulcer, prognosis, 139 
 symptomatology, 136 
 synonyms, 133 
 treatment, 139 
 Duodenitis, acute, 93 
 Duodenum, anatomy of the, 1 
 Dutrouleau, 185 
 Dynamic ileus, 363 
 Dysentery, 113 
 
 amosbic, 113 
 
 bacillary theory of, 117 
 
 complications, 137 
 
 course, 137 
 
 definition, 113 
 
 diagnosis, 139 
 
 etiologj', 113 
 
 morbid anatomy, 118 
 
 prognosis, 189 
 
 serumtherapy of, 130 
 
 symptomatology, 183 
 
 synonyms, 113 
 
 treatment, 139 
 Dyspeptic diarrhoea, 393 
 
 Edebohls, 304, 313, 314 
 Edwards, 344 
 Ehrlich, 344, 348 
 Ehrmann, 31 
 Eichberg, 116 
 Eichhorst, 136 
 Eisenlohr, 144 
 
 Electricity in intestinal obstruc- 
 tion, 869 
 in the treatment of constipa- 
 tion, 314 
 in the treatment of disease, 84 
 Elsberg, C. A., 73 
 Embolic ulcers, 140 
 Embolus of the arteria mesaraica 
 superior, 141 
 of the inferior mesaraic artery, 
 144 
 Endo-appendicitis, 309 
 Enemata in the treatment of con- 
 stipation, 316 
 
390 
 
 INDEX. 
 
 Enteralgia, 332 
 
 definition, 333 
 
 diagnosis, 335 
 
 etiology, 332 
 
 prognosis, 336 
 
 symptomatology, 333 
 
 synonyms, 332 
 
 treatment, 336 
 Enteritis, acute, 86 
 
 chronic, 97 
 
 crouposa, 113 
 
 membranous, 341 
 
 necrotica, 113 
 Enterospasmus, 301 
 Erdmanu, John F., 273 
 Escherich, 76, 206 
 Esmarch, 195 
 Ewald, C. A., 65, 99, 136, 215, 225, 
 
 226, 230, 345, 346 
 Examination, methods of, 32 
 Extirpation of hemorrhoids, 195 
 
 F^CES, abnormal admixtures in 
 
 the, 51 
 albumin in the, 53 
 bile pigment in the, 57 
 biliary acids in the, 57 
 blood in the, 56 
 carbohydrates in the, 54 
 chemical examination of the, 
 
 52 
 concretions in the, 59 
 examination of the, 49 
 fat in the, 55 
 ferments in the, 59 
 fragments of tumor in the, 51 
 micro-organisms in the, 74 
 microscopical examination of 
 
 the, 65 
 mucin in the, 53 
 odor, 50 
 
 peptone in the, 54 
 propeptone in the, 54 
 pus in the, 51 
 reaction of the, 52 
 
 Faeces, remnants of food in the, 51 
 Fat in the faeces, 55 
 Fecal accumulation as a cause of 
 chronic obstruction, 276 
 
 fever, 308 
 
 tumors complicating consti- 
 pation, 306 
 Ferguson, E. D., 239, 273 
 Fermentation test, Schmidt's, 55- 
 Ferments in the faeces, 59 
 
 of the pancreas, 19 
 Fever, fecal, 308 
 Fibroma of the intestines, 173 
 Finger cot, 42 
 Fischel, 292 
 Fischl, 92 
 
 Fissure of the anus, 199 
 Fitz, Reginald, 117, 203, 228, 264- 
 Flatau, 318 
 Flatulency, 327 
 Fleiner, 82, 268, 317, 352 
 Fleischer, 59, 220, 288 
 Flexner, 118 
 Fluke worms, 368 
 Foreign bodies, obturation by, 240^ 
 Fowler, 203, 205, 206, 208, 320^ 
 
 228 
 Fi'entzel, 271 
 Frerichs, 147 
 Friedenwald, J., 43 
 Furbringer, 271 
 
 Gall stones, obturation by, 239 
 
 Galvano-cautery in the treatment, 
 of hemorrhoids, 194 
 
 Gerhard t, 142 
 
 Gerry, 117 
 
 Gersuny, 41 
 
 Gibson, C. L., 272 
 
 Glycerin injections in the treat- 
 ment of constipation, 317 
 
 Golgi, 382 
 
 Good, Mason, 342 
 
 Gpuley, J. W., 273 
 
 Graser, 195, 265, 270, 271 
 
INDEX. 
 
 391 
 
 Grasse, 373 
 
 Graves, 226 
 
 Giawitz, 144 
 
 Griesinger, 378 
 
 Grisolle, 202, 203, 226 
 
 Guttmann, P., 210 
 
 Gymnastic exercises iu the treat- 
 ment of constipation, 314 
 exercises in the treatment of 
 disease, 83 
 
 Habershon, 82, 306 
 Habitual constipation, 297 
 Hackel, 3l'5 
 Hagueuot, 247 
 Plall, Marshall, 90 
 Hamrnarsten, 26 
 Harris, 116, 118, 119, 132 
 Haustra coli, 12 
 Hawkes, F., 229 
 Hegai', 144 
 Hemorrhoids, 175 
 
 complications, 195 
 
 definition, 175 
 
 diagnosis, 185 
 
 etiology, 175 
 
 morbid anatomy, 177 
 
 prognosis, 186 
 
 symptomatology, 180 
 
 synonyms, 175 
 
 treatment, 186 
 radical, 191 
 Henrot, 320 
 Hcryug, 39 
 Heusgen, 161 
 Hi pjDO crates, 113 
 Hirschler, 22 
 Hlava, 116 
 Hodenpyl, 206 
 Hoffmann, 271 
 Houston, 192 
 Hoyer, 344 
 Huber, 362, 372, 376 
 Hydrocephaloid, acute, 90 
 Hydrotherapy, 83 
 
 Hydrotherapy in the treatment of 
 
 constipation, 315 
 Hypersesthesia of the intestine, 339 
 Hypogastric neuralgia, 338 
 treatment, 338 
 
 Ileo-cecal valve, 13 
 Ileum, anatomy of the, 4 
 Ileus, 233 
 
 dynamic, 263 
 Illoway, 313 
 Incarceration, acute, 261 
 Inflation of the bowel with air in 
 intestinal obstruction, 268 
 of the intestine, 45 
 Infusoria, 356 
 Injection of water per anum for 
 
 examination, 48 
 Injections as a method of treat- 
 ment, 81 
 iu the treatment of constipa- 
 tion, 316 
 Inspection, 34 
 Interrogation, 32 
 Intestinal catarrh, acute, 86 
 definition, 86 
 diagnosis, 94 
 duration, 93 
 etiology, 86 
 localization, 92 
 morbid anatomy, 88 
 prognosis, 94 
 symptomatology, 89 
 synonyms, 86 
 treatment, 94 
 catarrh, chronic, 97 
 course, 106 
 definition, 97 
 diagnosis, 106 
 etiology, 97 
 morbid anatomy, 98 
 symptomatology, 101 
 synonyms, 97 
 treatment, 108 
 colic, 332 
 
392 
 
 INDEX. 
 
 Intestinal neurasthenia, 353 
 
 diagnosis, 354 
 
 treatment, 354 
 obstruction, 232 
 
 acute, 232 
 
 course, 253 
 
 definition, 233 
 
 diagnosis, 255 
 
 etiology, 233 
 
 location of the obstruc- 
 tion, 257 
 
 objective signs, 251 
 
 pathological changes, 242 
 
 recognition, 255 
 
 recognition of the differ- 
 ent forms, 261 
 
 symptomatology, 244 
 
 synonyms, 233 
 
 treatment, 264 
 
 treatment, medical, 264 
 
 treatment, surgical, 272 
 obstruction, chronic, 274 
 
 complications, 282 
 
 course, 283 
 
 diagnosis, 283 
 
 etiology, 274 
 
 prognosis, 283 
 
 symptomatology, 275 
 
 treatment, 284 
 
 treatment, surgical, 286 
 parasites, 355 
 vertigo, 307 
 Intestine, anatomy of the, 1 
 anfEsthesia of the, 339 
 compression of the, 233 
 hyperaesthesia of the, 339 
 obturation of the, 239, 262 
 parsesthesia of the, 339 
 strangulation of the, 234 
 Intestines, motor neuroses of the, 
 290 
 neoplasms of the, 156 
 nervous affections of the, 288 
 
 classification, 289 
 paralysis of the, 320 
 
 Intestines, paralysis of the, diag- 
 nosis, 321 
 treatment, 321 
 peristaltic restlessness of the, 
 
 325 
 secretory neuroses of the, 341 
 sensory neuroses of the, 332 
 ulcers of the, 133 
 Intussusception, 240, 262 
 
 agonal, 242 
 Irrigator, Kemp's rectal, 82 
 
 Jaffe, 259 
 V. Jaksch, 54 
 Jejunitis, acute, 92 
 Jejunum, anatomy of the, 4 
 Jlirgens, 100 
 
 Kahn, Arthur, 814 
 Kartulis, 115, 116 
 Kelly, 37 
 
 Kelly's rectal speculum, 38 
 Kelsey, 192 
 
 Kemp's rectal irrigator, 82 
 Kerkring's valves, 8 
 Kittagawa, 345 
 Klebs, 149 
 Klemperer, 316, 317 
 Klubbe, 268 
 Koch, 115 
 Kocher, 270 
 Koenig, 275 
 Korte,' 271 
 Kossobudskj, 190 
 Kraus, 134 
 Kruse, 118 
 Kuhn, 44 
 Kundrat, 177 
 
 Kussmaul, 143, 267, 268, 315, 317, 
 352 
 
 Laboulbene, 343 
 Lafleur, 116, 119, 122 
 Lambl, 115 
 Lange, F., 192, 198 
 
INDEX. 
 
 393 
 
 Langenbeck. 194 
 
 Large bowel, physiology of the, 
 18 
 structure of the, 17 
 
 intestine, anatomy of the, 11 
 Lavage of the bowel, 48 
 
 in intestinal obstruction, 
 268 
 
 of the stomach in intestinal 
 obstruction, 267 
 Laveran, 128 
 Legueu, F., 228 
 Leichtenstern, 70, 232, 234, 301, 
 
 373, 374, 376, 380 
 Lemazurier, 306 
 Lenauder, 203 
 Leube, 80, 139, 307 
 Leubuscher, 315 
 Leuckart, 363, 373, 383 
 Levi, 306 
 
 V. Leyden, 220. 344, 348 
 Libman, 172 
 Lieberkiilm's glands, 9 
 Ligature in hemorrhoids, 193 
 Limboiirg, 22 
 Liudberger, 22 
 Lipoma of the intestines, 173 
 Litten, 141 
 Liver fluke, 368 
 Loesch, 113 
 Ludwig, 25 
 Lusk, 19, 26 
 Lutz, 373, 376, 385 
 Lympho-sarcoma of the intestines, 
 172 
 
 Macfadten, 20, 75 
 Madelung, 173 
 Malmsten, 357 
 Marcy, H. O., 273 
 Matterstock, 207 
 Maggot-woi-m, 375 
 Mannaberg, 76 
 
 Massage in intestinal obstruction, 
 269 
 
 Massage in the treatment of con- 
 stipation, 312 
 of disease, 83 
 Massaiutin, 116 
 Massloff, 288 
 Mathews, 93 
 Mayer, 138 
 Mayor, A., 93 
 McBurney, 41, 203, 229 
 McCosh. A. J., 229 
 Meckel's diverticulum, strangula- 
 tion by, 236 
 Membranous diarrhoea, 341 
 enteritis, 341 
 
 definition, 841 
 diagnosis, 349 
 etiologj", 345 
 history, 341 
 symptomatology, 347 
 synonyms, 341 
 treatment, 350 
 Mendelson, Walter, 345 
 Mercury, metallic, in intestinal 
 
 obstruction, 271 
 Meteorism, 327 
 diagnosis, 329 
 etiology, 327 
 prognosis, 329 
 symptomatology, 828 
 treatment, 329 
 Meydl, 157 
 
 Meyer, Willy, 229, 230 
 Micro - organisms in the faeces, 
 
 74 
 Miller, 22 
 Minich, 64 
 
 Minkowski, 28, 47 ■ 
 Miserere, 233 
 Monti, 382 
 Moreau, 286 
 Morgagni, 342 
 Morris, R. T., 214, 228 
 Mosler, 385 
 
 jMotion of the intestine, 28 
 Motor function of the intestine, 
 
394 
 
 INDEX. 
 
 Einhovn's method of ascertain- 
 ing, 62 
 
 Mucin in the fa-ces, 53 
 
 Mucous colic, 341 
 
 Miiller, Max, 158 
 
 Munk, 25, 27 
 
 Murphy, 228, 286 
 
 Murphy's button, obturation by, 
 240 
 
 Musser, 116 
 
 Myoma of the intestines, 173 
 
 Nasse, 116 
 Nematodes, 371 
 Nencld, 19, 20, 75 
 Neoplasms of the intestines, 156 
 Nervous affections of the intes- 
 tines, 288 
 diarrhoea, 292 
 Neuralgia, hypogastric, 338 
 
 mesenterica, 332 
 Neurasthenia, intestinal, 853 
 Neuroses of the intestines, motor, 
 290 
 secretory, 341 
 sensory, 331 
 V. Noorden, C, 56, 350, 351 
 Nothnagel, 28, 30, 77, 156, 172, 
 203, 208, 220, 223, 226, 230, 241, 
 275, 289, 291, 300, 308, 344, 348 
 Nuttal, 75 
 
 Obstipatio, 297 
 Obstruction, intestinal, 232 
 Obturation of the intestine, 239, 
 
 262 
 Oil injections in the treatment of 
 
 constipation, 317 
 Opium in intestinal obstruction, 
 
 265 
 Oppolzer, 336 
 Osier, 116 
 
 Oxyuris vermicularis, 375 
 diagnosis, 377 
 prophylaxis, 377 
 
 Oxyuris vermicularis, symptoma- 
 tology, 376 
 treatment, 377 
 
 Paget, 385 
 
 Palpation, 40 
 
 Pancreatic juice, digestive power 
 
 of, 19 
 Parsesthesia of the intestine, 239 
 Paralysis of the intestines, 320 
 of the sphincters of the anus, 
 323 
 
 diagnosis, 324 
 
 prognosis, 324 
 
 treatment, 324 
 Paramecium coli, 357 
 Parasites, intestinal, 355 
 Paratyphlitis, 202 
 Parenski, 140 
 Paresis of the sphincters of the 
 
 anus, 323 
 Pariser, 53, 345, 348 
 Passio iliaca, 233 
 Pean, 286 
 Peiper, 385 
 
 Penzoldt, 220, 225, 226, 230 
 Peptone in the ffeces, 54 
 Percussion, 44 
 
 Peristalsis of the intestine, 28 
 Peristaltic restlessness of the in- 
 testines, 325 
 
 definition, 325 
 
 diagnosis, 326 
 
 etiology, 325 
 
 symptomatology, 325 
 
 treatment, 326 
 Perityphlitis, 202 
 Petriquin, 226 
 Pettenkofer, 57 
 Peyer, 291 
 Peyer's patches, 11 
 Pflliger, 30 
 
 Phlebectasia hemorrhoidalis, 175 
 Pighead, 363 
 Piles, 175 
 
INDEX. 
 
 395 
 
 Piles, arterial, 178 
 capillary, 178 
 venous, 179 
 Pilliet, 144 
 Piu-worm, 375 
 Plica Doiiglasii, 15 
 Poelcheu, 150 
 
 Polypi of the intestines, 173 
 Pooley, 192 
 Proctitis, 93 
 Proctoscope, Tattle's pneumatic, 
 
 38 
 Proctoscopy, 37 
 Proctospas^mus, 323 
 diagnosis, 323 
 treatment, 323 
 Prolapse of the rectum, 195 
 Propeptone in the fseces, 54 
 Protozoa, 355 
 Puncture of the bowel in intestinal 
 
 obstruction, 270 
 Purgatives in the treatment of 
 
 constipation, 318 
 Putrefaction of albuniinates in the 
 
 large intestine, 21 
 
 Quincke, 50, 116, 288 
 
 RACnFOKD, 19 
 
 Rectal alimentation, 80 
 
 bougies, 43 
 
 electrode, 84 
 
 specula, 37 
 Rectum, anaesthesia of the, 339 
 
 anatomy of the, 15 
 
 prolapse of the, 195 
 Reichmann, 39 
 Ribbert, 204 
 Riedel, 208, 230 
 Rieder, 69 
 Roentgen rays in examination of 
 
 the bowel, 39 
 Romberg, 338 
 Rose, A., 269, 313 
 Rosenbach, 46,. 253 
 
 Rosenheim, 105, 173, 314, 331, 825, 
 
 329, 353 
 Rosenstein, 25, 27 
 Ross, 116 
 Rothmann, 344 
 Rotter, 203 
 Round-worms, 371 
 Roux, 192, 203 
 Rubner, 27 
 Ruedi, 303 
 Ruueberg, 46 
 Rushmore, J. D., 273 
 
 Sahli, 203, 223, 226, 313, 330 
 Salmon, 193 
 Salvioli, 25 
 Sands, 203 
 
 Sarcoma of the intestines, 173 
 Sasaki, 100 
 Schiff, 38 
 
 Schmidt, 51, 54, 58 
 Schmidt's fermentation test, 55 
 Schmidt-Miihlheim, 25 
 Schmitz, 22 
 Schnetter, 46 
 Schoeuing, 156 
 Sclmberg, 116 
 Scolecoiditis, 202 
 Seat-M'orm, 375 
 
 Secretory function of the intes- 
 tines, 18 
 neuroses of the intestines, 341 
 Senator, 308 
 Senn, 269 
 Sennertius, 336 
 Shiga, 117, 130 
 Sieber, 20, 75 
 
 Sigmoid flexure of the colon, 15 
 Simon, 43 
 Sims, 37 
 
 Sims' rectal speculum, 37 
 Siredey, F., 342, 350 
 Small intestine, anatomy of the, 4 
 
 structure of the, 6 
 Sodre, 114, 120, 130 
 
396 
 
 INDEX. 
 
 Solitaiy follicles of tlie intestines, 
 
 10 
 Sonuenburg, 203, 220, 230 
 Spasm of the rectum, 322 
 Spasmodic contraction of the 
 
 bowel, 301 
 Specula, rectal, 37 
 Spool-worm, 371 
 Sporozoa, 356 
 
 romauum, 15 
 Starke, 134 
 Stein, R., 230 
 Stengel, 116 
 Stercoral diarrhoea, 294 
 Stewart, 273 
 ■Stockton, 116 
 Stokes, 226 
 Stool, acholic, 58 
 sieve, Boas', 60 
 Eiuhorn's, 61 
 Strangulation of the intestine, 
 
 234 
 Stricture of the rectum as a cause 
 
 of chronic obstruction, 281 
 Strong, 118 
 
 Strongylus duodenalis, 378 
 Subcutaneous alimentation, 80 
 Sutton. E. M., 47 
 Syms, Parker, 273 
 Syphilitic ulcers, 149 
 
 T^NiA cucumerina, 364 
 
 diminuta, 365 
 
 fiavopunctata, 365 
 
 lata, 363 
 
 mediocanellata, 361 
 
 nana, 364 
 
 saginata, 361 
 
 solium, 360 
 Tsenias of the large Intestine, 13 
 Talamon, 203 
 Tapeworms, 357 
 
 prophylaxis, 365 
 
 treatment, 365 
 Tavel, 206 
 
 Thermocautery in the treatment of 
 
 hemorrhoids, 194 
 Thierfelder, 75 
 Thread- worm, 375 
 Thrombotic ulcers, 140 
 Thrombus of the mesenteric veins, 
 
 144 
 Toxic ulcers, 150 
 Transillumination of the bowel, 39 
 Trastour, 2 
 
 Treatment, methods of, 77 
 Trematodes, 362, 368 
 
 treatment, 371 
 Treves, 198, 220, 242, 246, 265, 368, 
 
 370, 273, 274, 376, 377, 387 
 Trichina spiralis, 385 
 
 sjnnptoms, 386 
 Trichinosis, 386 
 
 prophylaxis, 386 
 treatment, 386 
 Trichocephalus dispar, 383 
 
 diagnosis, 383 
 
 sj'mptoms, 383 
 
 treatment. 385 
 Trichomonas intestinalis, 356 
 Trousseau, 390 
 Tuberculous ulcers, 146 
 Tubular diarrhoea, 341 
 Tuttle, 38 
 Tympanites, 337 
 
 Ui.CER, duodenal, 133 
 Ulcers, amyloid, 145 
 
 embolic, 140 
 
 of the intestines, 133 
 
 syphilitic, 149 
 
 thrombotic, 140 
 
 toxic, 150 
 
 tuberculous, 151 
 Urobilin in the faeces, 57 
 
 Valve, ileo-cascal, 13 
 
 of Bauhin, 13 
 Valvulse conniventes Kerkringi, 8 
 Van Cott, 305, 307 
 
INDEX. 
 
 397 
 
 Vermes, 357 
 Vermiform appendix, 13 
 Verneuil, 191 
 Vertigo, intestinal, 307 
 Virchow, 145 
 Voit, 19, 24, 26 
 Vollcmanu, 168 
 Volvulus, 238, 261 
 Volz, 207, 226 
 
 Wertlieimer, 336 
 
 Whip-worm, 383 
 
 Whitehead, 195, 342, 350 
 
 Wiggin, Fred. H., 273 
 
 Willigk, 134 
 
 Wilson, 206 
 
 Wolf, H. J., 230 
 
 Woodward, 86, 99, 275, 298, 34^ 
 
 Worms, intestinal, 357 
 
 Wallace, 325 
 Weber, L., Ill 
 Weigert, 344 
 Weir, 203' 
 
 Zenker, 385 
 Ziemssen, 45, 269, 270 
 Zuckerkandl, 204 
 Z anker, 356 
 
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