Presented by Mrs. Frank C. Peirsol COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA DISEASES OF THE Stomach, Intestines, AND Pancreas BY ROBERT COLEMAN KEMP, M. D. Professor of Gastro-intestinal Diseases at the Fordham University Medical School; Gastro-enterologist at the Fordham University Clinic; Consulting Physician and Gastro-enterologist to the Manhattan State Hospital; Late Junior Physician to the Roosevelt Hospital; Late Gastro-enterologist to the New York Red Cross Hospital, St. Bartholomew's Clinic, and West Side Ger- man Dispensary; Member American Medical Association; Fellow New York Academy of Medicine; Member Amer- ican Therapeutic Society, Medical Association of the Greater City of New York, etc. THIRD EDITION, REVISED. WITH 438 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1917 Copyright, 1910, by W. B. Saunders Company. Reprinted July, 1910, September, 1910, and June, 1911. Revised, reset, reprinted, and recopyrighted August, 1912. Reprinted March, 1913. Revised, reset, reprinted, and recopyrighted February, 1917. Copyright, 1917, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF B. SAUNDERS COMMA PHILADELPHIA TO HUltam Vf. ufyomurm, tfL I., OIJ)., CONSULTING PHYSICIAN TO THE ROOSEVELT AND RED CROSS HOSPITALS AND LATE PRESIDENT OF THE NEW YORK ACADEMY OF MEDICINE, THIS VOLUME IS INSCRIBED AS A TRIBUTE TO HIS HIGH PROFESSIONAL ATTAIN- MENTS AND IN REMEMBRANCE OF HIS MANY ACTS OF KINDNESS, BY THE AUTHOR VQ> PREFACE TO THE THIRD EDITION IN view of the great value of the #-rays as an aid to diagnosis in the gastro-intestinal tract, a special section has been devoted in this new edi- tion to the radiography of gastric ulcer, gastric cancer, duodenal ulcer and gall-bladder disease and in addition there are a large number of radio- graphs of other conditions. Many of these are from cases of the author, for whom some excellent radiography has been performed by Dr. Sinclair Tousey. I feel that I must express my indebtedness to Dr. Lewis Gregory Cole for his description of the motility of the normal stomach and of the duodenal cap. There is a chapter on Lane's kinks, Jackson's membrane, duodenal dilatation and ileo-cecal valve incompetency. Although Lane's investigations are of great value, and in some cases, release of these kinks by severance, or separation of the adhesions, may be of benefit, the writer at the present time is conservative and hardly feels the radical operation of resection of the large intestine as advocated by Lane to be a justifiable procedure except under rare conditions. The Mayos, with their large surgical experience, report only twenty cases of resection of the cecum, ascending and part of the transverse colon, apparently for stasis of such severe type that there was nearly obstipation, in which adhesions were a marked factor. In view of the promiscuous and improper use of the term auto-intoxi- cation, I have inserted a brief section on " Subinfection" and "Protein Absorption," and have enlarged my work on chronic intestinal putre- faction. Herter held that the Bacillus aerogenes capsulatus, by produc- ing excessive intestinal putrefaction, was a factor in the production of pernicious anemia. Streptococci (of oral origin sometimes) are found in connection with the above in some cases, and experimentally a severe grade of anemia with spinal degeneration in the columns of Goll has been produced in dogs, by repeated injections of colon bacilli of low virulence. Therefore intestinal putrefaction, or the same plus infection (streptococci) from the mouth, or subinfection may all produce pernicious, or a severe type of anemia. Incidentally acute articular inflammation, resembling rheumatism, may be found with colon bacillus infection (colon bacillus in the urine). These facts all illustrate that infection may arise from without or may have its origin from almost any part of the gastro-intes- tinal tract, from the mouth to the anus. Since many physicians have neither the time nor the opportunity to devote to a clinical course in gastro-enterology, and next in value for the purpose of instruction, is the employment of photography, I have taken extensive advantage of the latter method. Many of the illustrations are from photographs of patients at the Manhattan State Hospital taken by Mr. Hill, the official photographer, for whose services I am indebted to Dr. Wm. Mabon, the medical director. Some of the illustrations have been made by my artist, Mr. Thomas Nast, Jr., from models. 6 PREFACE As visceral displacements have assumed an important position, their symptoms, diagnosis and treatment, notably by mechanical methods, are particularly described. The writer is indebted to Dr. E. E. Smith for a brief but practical de- scription of the tests of the intestinal functions. It has been my endeavor to clearly set forth the indications for surgical procedure and to demonstrate the futility of medical treatment in surgical conditions such as in benign stenosis of the pylorus, and the necessity of early exploration for the purpose of diagnosis in suspected carcinoma of the stomach. The #-rays will aid in determination of a surgical condition, but often in the early stages will not determine whether it is benign or malignant. The writer holds that chronic gastric ulcer should be considered as a precancerous condition and be treated by radical procedure (resection). Typhoid fever is again included in this volume, on account of its in- testinal complications and for the purpose of differential diagnosis. In the chapter on this subject, the writer particularly discusses the question of diet and in his belief the excessively high calorie values which have been advocated. There is a special chapter devoted to "Diverticulitis." Pure gastro-intestinal neuroses I believe to be extremely rare. Some of these conditions are explainable as due to disturbance of the vegetative nervous system, vagotonia and sympathetico-tonia, to which I have given considerable space; particular attention is moreover directed to reflex gastro-intestinal disturbances emanating from disease of the gall-bladder, appendix and other organs. There are other important additions to this volume notably on hypochlorhydria and on the treatment of obesity. ROBERT COLEMAN KEMP. NEW YORK CITY, February, 1917. PREFACE IN view of the excellent works on diseases of the stomach and intestines that have been placed before the medical profession, the publication of a new book on these subjects might almost seem to be superfluous. From a great accumulation of material, it is often difficult for the general practitioner to select simple and practical methods, and it is the endeavor that this volume should render service in this special direction. Many physicians have neither time nor opportunity to devote to a practical clinical course, and next in value to this for the pur- pose of instruction is the employment of photography to demon- strate the methods of diagnosis and treatment. Of this I have endeavored to take advantage. Many of the illustrations are from photographs of patients at the Manhattan State Hospital, taken by Mr. Hill, the official photographer, for whose services I am indebted to the courtesy of Dr. Wm. Mabon, the Medical Superintendent. Some of the illustrations have been made by my artist from models. As visceral displacements have recently assumed an important position, their symptoms, diagnosis, and treatment, notably by me- chanical methods, are specially described. Typhoid fever is included in this volume on account of its intestinal complications and for the purpose of differential diagnosis. A chapter is devoted to DiverticuUtis , which has become an important subject. The endeavor has been made to indicate as clearly as possible the conditions which call for surgical procedure. ROBERT COLEMAN KEMP. NEW YORK CITY. CONTENTS PART I CHAPTER I PAGE ANATOMY OF THE STOMACH AND INTESTINES 17 Anatomy of the Stomach 17 Anatomy of the Intestines 22 Histology of the Large Intestine 32 CHAPTER II PHYSIOLOGY OF DIGESTION 33 , The Gastric Juice 33 Intestinal Digestion 38 CHAPTER III INTERROGATION OF THE PATIENT (HISTORY) 46 CHAPTER IV GENERAL METHODS OF PHYSICAL EXAMINATION 49 General Inspection 49 Topographic Anatomy '. 74 Physical Examination of the Liver and Gall-bladder 75 PART II DISEASES OF THE STOMACH CHAPTER V METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 89 Rontgen Rays (x-Rays) in the Diagnosis of Diseases of the Esoph- agus and Stomach 113 Radium Transillumination of the Stomach 134 Radium Photographs of the Stomach 135 Conclusions 135 CHAPTER VI EXAMINATION OF THE FUNCTIONS OF THE STOMACH 136 Test Meals 136 Method of Aspiration of the Gastric Contents 139 Examination of the Ingesta 143 Abnormal Constituents of the Stomach Contents 158 Microscopic Examination of the Gastric Contents 163 Determination of the Absorptive Function of the Stomach 168 9 IO CONTENTS CHAPTER VII DIET 172 Diet in Health 172 Diet in Disease 192 CHAPTER VIII LOCAL TREATMENT OF THE STOMACH 196 Lavage 196 Stomach Powder-blower 214 Electricity 216 CHAPTER IX MASSAGE, VIBRATORY MASSAGE, HYDROTHERAPY, COUNTERIRRITATION, ORTHOPEDIC APPLIANCES 221 Massage 221 Vibratory Massage 22 1 Local Hydrotherapy ' 224 Counterirritation 225 Orthopedic Methods 225 CHAPTER X CATARRH OF THE STOMACH 236 Acute and Chronic Gastritis 236 Acute Gastritis 236 Simple Acute Gastritis 236 Toxic Gastritis 243 Phlegmonous Gastritis 246 Chronic Gastritis 248 Acid Gastritis 248 CHAPTER XI ACHYLIA GASTRICA, ACHLORHYDRIA H^MORRHAGICA GASTRICA 262 Achylia Gastrica 262 Achlorhydria Hagtnorrhagica Gastrica 269 CHAPTER XII HEMATEMESIS, ULCER OF THE STOMACH, EXULCERATIO SIMPLEX, ACUTE AND CHRONIC EROSIONS, PERIGASTRITIS, PERIGASTRIC ADHESIONS . . 276 Gastric Hemorrhage 276 Ulcer of the Stomach 277 Exulceratio Simplex (Dieulafoy) or Superficial Ulceration of the Stomach , 314 Gastric Erosions 315 Acute Erosions (Hemorrhagic Erosions) 315 Chronic Erosions , 315 Perigastritis and Perigastric Adhesions . 318 CHAPTER XIII CANCER OF THE STOMACH (CARCINOMA VENTRICULI), OTHER TUMORS OF THE STOMACH, APPARENT TUMORS OF THE STOMACH, FOREIGN BODIES IN THE STOMACH 320 Cancer of the Stomach (Carcinoma Ventriculi) 320 Other Tumors of the Stomach 363 Apparent Tumors of the Stomach 366 Foreign Bodies in the Stomach 367 CONTENTS 1 1 CHAPTER XIV FUNCTIONAL DISEASES OF THE STOMACH 370 Hyperacidity (Hyperchlorhydria) 370 Hypochlorhydria and Achlorhydria ' 383 Gastrosuccorrhea (Continuous Secretion of Gastric Juice) 386 Gastrosuccorrhea (Continua Periodica) 387 Gastrosuccorrhea (Continua Chronica) 391 Alimentary Hypersecretion 396 DISTURBANCES OF THE MOTOR FUNCTION OF THE STOMACH, ACUTE ATONY, CHRONIC ATONY, ACUTE DILATATION OF THE STOMACH, CHRONIC DILATATION OF THE STOMACH 398 Atony of the Stomach Diminished Peristole 398 Acute Atony of the Stomach Acute Diminished Peristole 398 Chronic Atony of the Stomach Chronic Diminished Peristole. . 399 Acute Dilatation of the Stomach Acute Diminished Peristole with Dilatation 401 Chronic Dilatation of the Stomach Diminished Peristole with Chronic Dilatation 414 Atonic Dilatation of the Stomach Diminished Peristole with Gas- tric Dilatation 416 Obstructive Type (Stenotic) of Ectasia 419 Diagnosis 422 Treatment 425 Treatment of Stenotic Dilatation (Benign Stenosis) 431 Treatment of Malignant Stenosis 433 Complications of Chronic Ectasy 433 Gastric Tetany 433 Convulsions, Epilepsy 435 CHAPTER XVI ANOMALIES IN THE POSITION AND FORM OF THE STOMACH, HOUR-GLASS STOMACH, DISLOCATIONS, GASTROPTOSIS 437 Hour-glass Stomach 437 Dislocation of the Stomach 439 Diaphragmatic Hernia, Eventration of the Diaphragm Volvulus of Stomach 439 Gastroptosis, Enteroptosis, Gtenard's Disease 442 CHAPTER XVII NERVOUS AFFECTIONS OF THE STOMACH 469 Sensory Neuroses of the Stomach 470 Bulimia .' 470 Parorexia (Perversion of Appetite) 472 Polyphagia 472 Akoria 472 Nervous Anorexia (Anorexia Nervosa) 472 Sensations Within the Stomach 473 Abnormal Sensations 474 Hyperesthesia of the Stomach : 474 I 2 CONTENTS NERVOUS AFFECTIONS OF THE STOMACH: Sensory Neuroses of Stomach Gastralgia 475 Gastralgokenosis (Boas) 479 Motor Neuroses of the Stomach 479 Hypermotility of the Stomach 479 Peristaltic Restlessness of the Stomach (Kussmaul) 480 Antiperistaltic Restlessness of the Stomach 48 1 Incontinence of the Pylorus 48 1 Spasm of the Pylorus (Pylorospasmus) 482 Atony of the Stomach 485 Hypanakinesis Ventriculi (Einhorn) 485 Hyperanakinesis Ventriculi (Einhorn) 485 Spasm of the Cardia (Cardiospasmus) 485 Insufficiency of the Cardia 487 Singultus Gastricus Nervosus 488 Pyrosis (Heart-burn) 489 Regurgitation 489 Rumination 490 Nervous Vomiting (Vomitus Nervosa) 490 Periodic Vomiting (Von Leyden) 491 Cyclic Vomiting in Children 492 Juvenile Vomiting 494 Reflex Vomiting 494 Idiopathic Nervous Vomiting 494 Pneumatosis 495 Secretory Neuroses 495 Nervous Dyspepsia (Leube) 496 CHAPTER XVIII DYSPEPTIC ASTHMA 499 CHAPTER XIX THE STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 501 Functions of the Stomach in Acute Febrile Diseases 501 Chronic Febrile Conditions 502 Condition of the Stomach in Pulmonary Tuberculosis 502 Pellagra 503 Chlorosis and Anemia 503 Heart Lesions 504 Diseases of the Liver 504 Aneurysm 504 Diseases of the Kidneys 504 Diabetes 505 Arthritis Deformans 505 Gout 505 Malaria 505 Diseases of the Eye 506 Diseases of the Skin 506 Tuberculosis of the Stomach 507 Syphilis of the Stomach 508 Gastric Ulcer (Syphilitic) 509 Syphilitic Tumor of the Stomach 509 Syphilitic Pyloric Stenosis 509 Syphilitic Cirrhosis of the Stomach 511 Gastric Crises of Tabes 512 CONTENTS 13 PART III DISEASES OF THE INTESTINES CHAPTER XX METHODS OF EXAMINATION OF THE INTESTINES; EXAMINATION OF THE FECES; MECHANICAL PROCEDURES 515 Physical Examination of. the Intestines 516 Inspection of the Rectum Proctoscopy and Sigmoidoscopy 517 Transillumination of the Intestines 528 Inflation of the Intestines with Carbonic Acid Gas or Air 529 Lavage of the Bowel for Diagnosis 532 Examination of the Feces 532 Testing the Intestinal Functions 543 Mechanical Procedures 552 CHAPTER XXI DIET, INTESTINAL DYSPEPSIA, CHRONIC INTESTINAL PUTREFACTION (INDOLIC TYPE), INDICANURIA, SACCHAROBUTYRIC PUTREFACTION, SUBINFEC- TION, PROTEIN ABSORPTION, BOTULISM, HYDROGEN SULPHID AUTO- INTOXICATION, ENTEROGENIC CYANOSIS, METEORISM, ENTERALGIA, VISCERAL ARTERIOSCLEROSIS, SENILE DYSPEPSIA, ANOMALIES, IN- TESTINAL SAND 568 Diet 568 Intestinal Dyspepsia 570 Subinfection, Protein Absorption, and Chronic Intestinal Putrefaction 571 Indicanuria 574 Saccharobutyric Type of Intestinal Putrefaction 578 Acidosis (Acetonuria) 580 Botulism 582 Hydrogen Sulphid Auto-intoxication 583 Enterogenic Cyanosis 583 Meteorism; Tympanites " , 584 Intestinal Pain (Intestinal Colic, Enteralgia) 587 Visceral Arteriosclerosis 588 Senile Dyspepsia 590 Anomalies in the Position and Form of the Intestines; Enteroptosis . 592 Intestinal Sand 593 CHAPTER XXII INFECTIONS BY THE BACILLUS COLI 594 CHAPTER XXIII CONSTIPATION AND DIARRHEA 609 Constipation 609 Diarrhea 624 Diarrhea Due to Irritation of the Bowel Contents 625 Diarrhea Due to Irritants Transmitted in the Blood 626 Diarrhea Nervosa (Nervous Diarrhea) 626 Diarrhea from Exposure to Cold and Wet 627 Treatment of Diarrhea 627 CHAPTER XXIV CHRONIC INTESTINAL STASIS 630 Chronic Dilatation of the Duodenum 634 Movable Cecum 639 Incompetency of the Ileocecal Valve 640 14 . CONTENTS CHAPTER XXV INTESTINAL CATARRH, ENTERITIS, COLITIS, CATARRHAL SIGMOIDITIS, PROCTITIS, PHLEGMONOUS ENTERITIS. 643 Acute and Chronic Intestinal Catarrh 643 Acute Intestinal Catarrh 643 Chronic Intestinal Catarrh (Chronic Colitis) 652 Proctitis 663 Phlegmonous (Purulent) Enteritis 665 CHAPTER XXVI DYSENTERY 666 Diphtheritic Dysentery 666 Predisposing Causes and Climatic Location 667 Amebic Dysentery 668 Bacillary Dysentery 692 CHAPTER XXVII TYPHOID FEVER, PARATYPHOID FEVER, BRILL'S DISEASE 700 Typhoid Fever 700 Paratyphoid Fever 718 Mild Endemic Typhus, or Brill's disease 1 .... 720 CHAPTER XXVIII INTESTINAL HEMORRHAGE, INTESTINAL ULCERS, DUODENAL ULCER, DISEASES OF THE BLOOD-VESSELS (EMBOLISM AND THROMBOSIS) 724 Intestinal Hemorrhage 724 Ulcers of the Intestines 724 Duodenal Ulcers 724 Simple Duodenal Ulcer 725 Intestinal Ulcers from Cutaneous Burns 754 Embolic and Thrombotic Ulcers 754 Secondary Tubercular Ulcers of the Intestines (Tuberculosis) . . . 757 Catarrhal and Follicular Ulcers 758 Ulcerative Colitis 758 Stercoral or Decubital Ulcers 758 Ulcers in Acute Infectious Diseases 759 Ulcers in Constitutional Diseases 759 Toxic Ulcers ' i 759 Syphilitic, Gonorrheal, and Cancerous Ulcers 759 Intestinal Myiasis .' 760 General Symptoms of Intestinal Ulceration 760 Treatment 762 Diseases of the Blood-vessels; Embolism and Thrombosis of the Mesenteric Arteries and Veins (Infarction of the Bowel) 763 CHAPTER XXIX NEOPLASMS OF THE INTESTINES 767 Malignant Growths 767 Carcinoma of the Intestines 767 Sarcoma and Lymphosarcoma of the Intestines 778 Benign Tumors of the Intestines 779 Gas Cysts of the Intestines 781 CHAPTER XXX HEMORRHOIDS, PROLAPSE OF RECTUM, FISSURE, ABSCESS OF THE RECTUM, PRURITUS ANI, FISTULA IN ANO '. 782 Hemorrhoids 782 CONTENTS 15 Abscess of the Rectum 797 Pruritus Ani 799 Fistula in Ano 799 CHAPTER XXXI APPENDICITIS 801 CHAPTER XXXII % DlVERTICULITIS, PERIDIVERTICULITIS, DISEASES OF MECKEL*S DlVERTICU- LUM 839 Meckel's Diverticulum and Its Diseases 856 CHAPTER XXXIII INTESTINAL OBSTRUCTION, ACUTE AND CHRONIC 859 Acute Intestinal Obstruction 859 Chronic Intestinal Obstruction 883 CHAPTER XXXIV VAGOTONIA, SYMPATHETICOTONIA, VISCERAL CRISES IN THE ERYTHEMA GROUP, UMBILICAL DYSPEPSIA 892 Vagotonia and Sympatheticotonia. Their Relation to Gastro- intestinal Symptoms 892 Visceral Crises in the Erythema Group 896 Umbilical Dyspepsia 899 CHAPTER XXXV NERVOUS DISEASES OF THE INTESTINES 900 Motor Neuroses of the Intestines 900 Sensory Neuroses of the Intestines 903 Secretory Neuroses of the Intestines 905 Intestinal Neurasthenia 905 Mucous Colic (Membranous Enteritis) 905 CHAPTER XXXVI OBESITY 915 CHAPTER XXXVII INTESTINAL PARASITES 920 Protozoa 920 Amebse 920 Sporozoa 920 Intestinal Psorospermiasis 920 Infusoria 920 Vermes 924 PART IV DISEASES OF THE PANCREAS CHAPTER XXXVIII THE PANCREAS AND ITS ANOMALIES SURGICAL RELATIONS 955 Anatomic Anomalies of the Pancreas 959 Surgical Relations 9 6x CHAPTER XXXIX HISTOLOGY OF THE PANCREAS PHYSIOLOGY 964 Physiology of the Pancreas 969 1 6 CONTENTS CHAPTER XL METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 972 Testing the Functions of the Pancreas 972 Examination of the Duodenal Contents 976 The Fats in the Feces 980 The Use of Pancreatic Enzymes as an Aid to Diagnosis; Pancreatic Infantilism 983 Carbohydrates in the Stool. Pancreatic Diastatic Ferments 985 General Character of the Stool 986 Changes in the Urine in Pancreatic Disease 987 The Blood in Diseases of the Pancreas 99 1 CHAPTER XLI GENERAL SYMPTOMS AND DIAGNOSIS OF PANCREATIC DISEASE 993 Physical Signs 994 Symptoms 996 CHAPTER XLI I INJURIES OF THE PANCREAS; CLASSIFICATION OF ACUTE AND CHRONIC INFLAMMATION OF THE PANCREAS; CATARRH OF THE PANCREAS.. . . 1001 Injuries of the Pancreas 1001 Classification of Acute and Chronic Inflammation of the Pancreas. . . 1 002 Functional Disturbances of the Pancreas 1005 Pancreatic Achylia 1005 Catarrh of the Pancreas 1005 CHAPTER XLIII ACUTE PANCREATITIS; CHRONIC PANCREATITIS 1008 Acute Pancreatitis 1008 Acute Hemorrhagic Pancreatitis 1008 Gangrenous Pancreatitis 1012 Symptoms of Acute Pancreatitis (Hemorrhagic and Gangrenous) 1013 Suppurative Pancreatitis 1015 Chronic Pancreatitis 1018 CHAPTER XLIV FAT NECROSIS; TUBERCULOSIS; SYPHILIS; PANCREATIC CALCULI 1029 Fat Necrosis 1029 Tuberculosis 1 030 Syphilis 103 1 Pancreatic Calculi 1031 CHAPTER XLV CYSTS OF THE PANCREAS; NEOPLASMS 1035 Cysts 1035 Neoplasms IO 44 Carcinoma : I( H4 Sarcoma : . . . 1048 Adenoma 1 049 CHAPTER XLVI DEGENERATIVE CHANGES OF THE PANCREAS; THE PANCREAS AND DIABETES; HEMOCHROMATOSIS 1050 Degenerative Changes of the Pancreas 1050 The Pancreas and Diabetes 1051 Hemochromatosis 1053 INDEX 1055 DISEASES OP THE STOMACH, INTESTINES, AND PANCREAS PART I CHAPTER I ANATOMY OF THE STOMACH AND INTESTINES ANATOMY OF THE STOMACH A BRIEF description will be given of the anatomy of the stomach, but for a complete exposition of the subject the reader is referred to any standard anatomy. The stomach lies in the epigastric and left hypochondriac regions, about five-sixths of it to the left of the median line. The larger end, the fundus, fits into the concave left vault of the diaphragm. Modern investigation by means 'of the #-rays has demonstrated that the stomach does not lie transversely across the abdomen, as was formerly described. The fundus is nearly vertical, and the pyloric portion nearly transverse that is, of course, with the patient in the standing posture. The position may be described as J shaped, that is, a reversed L (Fig. i). It may be well compared to a gourd. The cardiac orifice (C), the junction of the esophagus and stomach (the esophageal orifice), is fixed and lies behind or a little to the left of the sternal junction of the left seventh cartilage (seventh rib), or about i% inches from the edge of the sternum, in the left parasternal line, on a level with the spinous process of the ninth dorsal vertebra. The cardia is situated 4^ inches from the anterior surface of the abdomen. The point of communication with the small intestine is called the pylorus (P), and shows a furrow on the outer surface and within a protruding fold (the valve of the pylorus). The pylorus (P) lies between the right sternal and parasternal lines, slightly below the tip of the ensiform process, and corresponds to the spinous process of the twelfth dorsal vertebra. It descends slightly when the stomach is distended and moves somewhat to the right. A line (+), drawn in the axis of the esophagus through the stomach to its lower border, cuts off about one-fourth of the organ to the left. This portion is called the greater cul-de-sac or fundus (F). The fundus (F) rises as high as the lower border of the left fifth rib 2 17 i8 DISEASES OF THE STOMACH AND INTESTINES in the mammillary line, slightly above and behind the apex of the heart, and from i to 2 inches higher than the cardia. It is in contact with the diaphragm above, and to the left with the spleen and left kidney. The lesser curvature (L) lies to the left of the vertebral column, passes downward and parallel with it, and then crosses it to the upper border of the pylorus. The greater curvature (G) forms the fundus and lower border of the stomach and extends to the lower border of the pylorus. The lower border, when the organ is distended, lies about two to three fingers' breadth (i>-2 to 2J4 inches"; above the umbilicus. lug. i. The stomach: C, Cardia; F, fundus; P, pylorus; L, lesser curvature; G, greater curvature (modified from W. J. Mayo). The volume of the stomach varies according to its contents. Dehio has shown that the healthy stomach when empty is contracted and hidden away in the left cavity of the diaphragm, and it is the colon that we then demonstrate by percussion. The pancreas and splenic vessels lie behind the stomach. The an- terior surface is overlapped above by the liver, the left lung, and the seventh, eighth, and ninth ribs. Below it is in relation with the abdominal wall. ANATOMY OF THE STOMACH AND INTESTINES The pyloric end, the lesser curvature, and the cardia lie behind and beneath the quadrate and left lobes of the liver. Traube's space is the area in which the stomach lies in direct contact with the ribs, and is bounded above by the liver and left lung, externally by the spleen, and the inner border is formed by the free costal margin. Both here and in the epigastric region pure gastric tympany can be elicited. When the stomach is distended, the lesser curvature is directed ob- liquely backward toward the spine, the posterior wall looking some- what downward and the anterior wall slightly upward. The transverse colon, if distended, may overlap the greater curvature, and the latter tends to fall away from the abdom- inal wall when the patient is in the dorsal position. The trans- verse colon lies ordinarily below the greater curvature. With moderate distention, the average length from fundus to pylorus is 10 to 12 inches; from the lesser to greater curvature, 4 to 5 inches; from the anterior to the posterior wall, about 3 to 3^2 inches. The average capacity is vari- able. It may contain even as much as 2 quarts. A plane drawn transversely through the base of the lesser curvature will lie parallel with the plane of the diaphragm. The lesser omentum extends from the lesser curvature to the liver above, and the great omen- tum is suspended from the greater curvature, protecting the viscera. The blood-vessels enter the upper and lower borders, and thus divide the surface into two equal parts. They mark the greater and lesser curvatures. Structure of the Stomach. The stomach consists of four coats: serous or peritoneal, muscular, submucous or areolar, and mucous. The peritoneal coat forms a thin, transparent, elastic membrane, and closely covers the organ, except along the curvatures, where it is more loosely attached for the passage of the blood-vessels. The muscular coat consists of three sets of fibers (Fig. 2), disposed in layers the outer or longitudinal, middle or circular, and inner or oblique. The last is a continuation of the circular fibers of the esopha- gus and the fibers descend obliquely from the cardia upon the anterior and posterior surface, and, spreading out like a fan, terminate at the greater curvature. Fig. 2. Vertical section of the stomach: i, Mucosa; 2, submucosa; 3, 4, muscularis; 5, serosa. 2O DISEASES OF THE STOMACH AND INTESTINES The submucous coat consists of areolar tissue, connecting the mucous and muscular coats. The blood-vessels subdivide therein. The mucous membrane is soft, smooth, somewhat pulpy, and of pink color, thickest in the pyloric region and thinnest at the fundus. It constitutes the glandular layer of the organ. It is covered by columnar epithelial cells, which extend for a variable distance into the mouths of the glands. There are about five million glands in the stomach, tubular in form, and perpendicular to the surface. They are surrounded by fibrous tissue and lymphoid cells and by a thin muscle layer (muscularis mucosae). The glands are composed of a mouth, neck, body, and base, and several tubules, from two to even four or five, may end in one mouth. On microscopic examination, the dots appearing on the surface of the mucosa are the openings of the glands. There are three varieties of glands in the stomach: Cardiac or fundus glands; pyloric glands; mucous glands. Cardiac or fundus glands are the most numerous. They fill the greater part of the stomach, and are characterized by the shortness of their mouths and the length of the glands. They contain two varieties of cells. Cells bordering on the lumen of the tube, which are small, granular, and polyhedral or columnar, the chief or principal cells, and which stain only to a slight extent with anilin dyes. The other cells, parietal or oxyntic, lie between the principal cells and the membrana propria (Fig. 3). They are most numerous in the necks of the glands, larger than the chief cells, are oval or ajigular, and finely granular in structure. They have strong affinity for anilin dyes. Pyloric Glands. These are characterized by the greater length of their mouths, which are lined by cylindric epithelium. They are found only in the region of the pylorus. The body or secretory portion of the gland is represented by a single layer of short and finely granular columnar cells, resembling the chief cells of the fundus glands. There are also a few isolated cells (Nussbaum) which resemble, in structure and in their behavior to anilin dyes, the parietal cells of the fundus glands (Fig. 4). Besides these specific glands, a number of mucous glands are found near the pylorus. The hydrochloric acid is secreted by the parietal cells: pepsin and the milk-curdling ferment by the principal cells of the fundus and pyloric glands. Some consider the mucus to be also a product of the cylindric goblet-cells lining the stomach and the wider portions of the glandular ducts. The ferments do not exist as such in the cells, but as zymogens, which are transformed into ferments through the activity of the free hydrochloric acid. Blood-vessels, Lymphatics, and Nerves of the Stomach. The arteries of the stomach are derived from branches of the celiac axis, the gastric and pyloric branches of the hepatic artery supplying the upper curvature, and forming the superior ventricular arch, and the right gastro-epiploic from the hepatic, and the left gastro-epiploic and vasa brevia from the splenic, forming the inferior ventricular arch. They reach the stomach between the folds of peritoneum and ramify ANATOMY OF THE STOMACH AND INTESTINES 21 between the muscular coats, giving off a number of capillaries and divid- ing into small vessels in the submucosa, and finally enter the mucous membrane and pass between the tubuli, where they form a plexus of fine capillaries both on the walls of the tubules and around the mouths of the glands. The veins arise from this capillary network and pass nearly straight through the mucous membrane between the glands. They pierce the muscularis mucosae and form a plexus in the submucosa, and finally form the coronary and pyloric veins emptying into' the portal vein, the right gastro-epiploic vein emptying into the superior mesenteric vein, and the left gastro-epiploic vein emptying into the splenic vein. h'li Fig. 3. Cardiac gland: a, Parietal cells; b, principal cells. Fig. 4. Pyloric gland: a, Mouth; b, neck; c, fundus. The lymphatics extend directly to the surface of the mucosa. They form a dense network of lacunar spaces between and among the gland tubuli, which they inclose, as well as the blood-vessels, with sinus-like dilatations. The lymph is collected near the surface of the mucous membrane into vessels which form loops and possess dilated extremities. They are less superficial than the capillaries, though the lacunar spaces extend as far as the basement membrane of the surface. The lymphatic glands extend along the lesser curvature to the cardia, while they are present on the greater curvature from the pylorus to only about one- fourth to one-third of the distance. This fact is of important consideration 22 DISEASES OF THE STOMACH AND INTESTINES in gastrectomy for carcinoma, as the lesser curvature must, therefore, be entirely removed. Nerves. The left vagus supplies the anterior surface of the stomach. The right vagus supplies the posterior surface with only one-third of its fibers, the remainder passing to the other viscera. Branches of the sympathetic nerves pass from the celiac plexus and anastomose with the vagi. These nerves, with numerous ganglia, form a network in the submucosa. i ANATOMY OF THE INTESTINES The intestinal canal is divided into two parts: the small intestine and the large intestine; the former about 7.6 meters (25 feet) long, and the latter 1.5 to 1.8 meters (5 to 6 feet) long. The small intestine is subdivided into three portions the duodenum, jejunum, and ileum and lies, excepting the duodenum, to the inner side of the large intestine, and is connected to the posterior abdominal wall by the mesentery, which last incloses the jejunum and ileum throughout. The Duodenum. The duodenum, which is about 10 to 12 inches (25.5-30.5 cm.) long, is not suspended by the mesentery, and is the most fixed and widest part of the small intestine, having a diameter of i% to 2 inches (3.81-5.08 cm.). It is curved like a horseshoe, surrounds the pancreas, and is divided into four parts (Fig. 5). The superior horizontal part of the duodenum is about 2 inches (5.08 cm.) long, begins at the pylorus at the level of the first lumbar vertebra, and passes slightly upward and to the right of the gall-bladder. It is the most movable portion, is surrounded by the peritoneum, and sus- pended chiefly by ligaments from the hilus of the liver and neck of the gall-bladder. The quadrate lobe and neck of the gall-bladder lie above it; below it is the pancreas, and behind it the 'common bile-duct and hepatic vessels. The descending portion of the duodenum, about 3 inches (7.5 cm.) long, commences at the neck of the gall-bladder and runs vertically to the third or fourth lumbar vertebra on the right side, and touches the right kidney. The transverse colon passes in front of it; on the left side *is the pancreas, and the common bile-duct lies a little posterior. At its inner and back part, about 4 inches from the pylorus, the common bile- duct and pancreatic duct enter it and form the diverticulum or ampulla of Vater, and the duct of Santorini enters it a short distance above. The third or transverse portion of the duodenum, about 5 inches (12.5 cm.) long, extends from the right side of the body of the third or fourth lumbar vertebra across the spine, and slightly ascends to the left side of the spine. The superior mesenteric vessels cross it, as does the mesentery. The lower layer of transverse mesocolon lies in front. The pancreas and superior mesenteric artery lie above, and the aorta, vena ca-va, and crura of the diaphragm behind it. It is the most fixed portion of the duodenum. The fourth or ascending portion of the duodenum, about i to 2 inches ANATOMY OF THE STOMACH AND INTESTINES 23 (2.54-5.08 cm.) long, ascends vertically along the left side of the spine, from the third or fourth lumbar vertebra to the side of the second or first lumbar vertebra. It is firmly fixed by the suspensory muscle of the duodenum (muscle of Treitz), which descends from the left crus of the diaphragm. Anteriorly are the transverse colon and transverse meso- colon (lower layer). It terminates in the jejunum (usually opposite the second lumbar vertebra) and forms the duodenojejunal flexure. Jejunum and Ileum. They form the continuation of the duodenum. It is hard to determine where the one ends and the other begins. The jejunum occupies the upper two-fifths of the remaining small intestines, Fig. 5. Stomach and duodenum, liver and intestines removed, and showing anatomic relations of the duodenum (after Testut). or about 9 feet 7 inches (2.9 meters); the ileum, the lower three-fifths, or about 14 feet 5 inches (4.3 meters), and ends at the ileocecal junction. Their position is not fixed, but the jejunum is more apt to occupy the left side of the abdominal cavity, with the loops more transverse; while the ileum is usually found on the right side and in the pelvis, with the loops more vertical. The coils of the jejunum and ileum are very movable and are com- pletely invested by peritoneum. They are supported and attached to the posterior parietes by the mesentery, which is attached above to the left of the vertebrae on a level with the lower border of the pancreas. 24 DISEASES OF THE STOMACH AND INTESTINES The mesentery runs downward and to the right and presents the form of a fan, the intestines hanging on it in the form of coils. The diameter of the jejunum is about i^ inches (3.81 cm.), and this gradually diminishes in size to the ileum; and in this, in turn, the diameter decreases until its entrance into the large intestine. The ileum passes nearly perpendicularly into the ascending colon, its mucosa forming a double valve (valvula Bauhini). ' The jejunum and ileum are the most movable parts of the intestinal tract. They are often met with in hernias, and if pregnancy, a tumor, or ascites are present, the intestines move up and escape compression. Occasionally Meckel's diverticulum (the remains of the vitelline duct), a process 2 or 3 inches long, is given off from the ileum, on an average of i to 2 feet above the ileocecal junction. It is of importance in reference to intestinal obstruction. Arterial Supply of Small Intestine. The duodenum is supplied by the pyloric branch of the hepatic, by the superior pancreaticoduodenal branch of the gastroduodenal branch of the hepatic, and by the inferior pancreaticoduodenal branch of the superior mesenteric, and the jejunum and ileum by the superior mesenteric artery. They branch into small vessels which run through the intestinal wall, ramify in the submucosa, and form the capillary system of the villi and glands. Veins.. The venous blood flows partly into the superior gastric vein and partly into the superior mesenteric vein, and empties into the vena porta. Lymphatics. The lymphatics are divided into those of the mucous membrane and muscular coat, and form plexuses. They run between the folds of the mesentery and end in the mesenteric lacteals, and so on into the intestinal lymphatic trunk and thoracic duct. They are provided with valves to prevent a backward flow. Nerves. The duodenum is supplied by the hepatic plexus, a branch of the celiac plexus, with branches of the right vagus. The superior mesenteric plexus, formed by nerves from the celiac plexus, the semilunar ganglia, and right vagus, supply the jejunum and ileum. The nerves enter the intestinal wall with the blood-vessels and form a subserous net. They then. penetrate the longitudinal muscular fibers and form between these and the circular muscular fibers ramifications consisting of numerous groups of multipolar cells (Auerbach's plexus), from which fine branches supply the muscular tissue. Other branches penetrate the circular muscular layer to the submucosa, where they form the submucous nerve plexus (Meissner's plexus), and branches supply the muscularis mucosae, the muscles of the villi, and end in the mucosa. Structure of the Small Intestine. The small intestine is composed of four coats: serous or peritoneal, muscular, submucous, and mucous (Fig. 6). The serous coat is formed by the visceral layer of the peritoneum. The muscular coat consists of an internal circular layer and an external longitudinal layer, the former being considerably the thicker. They consist of bundles of unstriped muscular tissue supported by ANATOMY OF THE STOMACH AND INTESTINES 2 5 connective-tissue fibers. The submucosa consists of connective tissue in which blood-vessels, lymphatics, and nerves ramify. Fig. 6. Longitudinal cross-section through the wall of the small intestine: i, Mucous layer; 2, muscularis mucosas; 3, submucous layer; 4, muscular layer; 5, sub- serosa; 6, serous layer; 7, intestinal villi; 8, intestinal glands (Lieberkiihn); 9, blood- vessels; 10, solitary lymph nodule; n, center of same. The mucous membrane comprises a thin muscular layer (muscularis mucosae), containing circular and longitudinal fibers and the tunica propria of the mucous membrane, which is made up principally of reticular connective tissue, with leukocytes, glands, villi, and an epithelial covering. muscular coat subseroiis . adipose tissue mesentery x circular folds (+ intestinal villi) Fig. 7. A portion of the jejunum showing the circular folds or valvulae conniventes of Kerkring (Sobotta). The mucosa is of a grayish-red color, appears velvety, and forms crescentic folds, set transversely to the long axis of the intestine (valvulae conniventes of Kerkring, Fig. 7). Each valve extends from one-half to 26 DISEASES OF THE STOMACH AND INTESTINES two-thirds of the circumference of the gut, and they may be 2 inches long and y$ inch wide. They begin a short distance below the pylorus, at the middle of the jejunum commence to diminish in size, and gradually disappear at the lower part of the ileum. They serve to increase the absorptive surface of the mucous membrane. Microscopic Anatomy of the Small Intestine. The inner surface of the small intestine is composed of villi and glands, the surface being covered by a layer of columnar epithelial cells, with striated borders and some goblet-cells. The villi are formed chiefly by ele- vations of the tunica propria of the mu- cous membrane. The"y are from 0.5 to 0.7 mm. in height and about o.i to 0.2 mm. in width, and number about ten millions (Fig. 8). Each villus has a central space for chyle, which cavity is covered with en- dothelial cells and connects with the lymphatics of the mucosa. The villus has blood-vessels and muscular fibers which are derived from the mus- cularis mucosae. It expands when filling up with blood, and when the muscle contracts it shrinks. The villi thus have an action of suction and pumping, and also form the chief organs for absorption in the small intestine. Around the villi Fig. 8. Mucous membrane of ileum: a, Intestinal glands (Lieber- kiihn); b, intestinal villi; c, solitary lymph nodule (follicle). Fig. 9. Longitudinal cross-section through wall of duodenum: i, Mucous layer; 2, muscularis mucosae; 3, submucous layer; 4, circular muscular layer; 5, longitudinal muscular layer; 6, intestinal villi; 7, intestinal glands (Lieberkiihn) ; 8, JJrunner's duo- denal glands; 9, serous layer. are numerous glands; the tubular glands of Lieberkiihn and the acinous glands of Brunner. The latter are confined to the duodenum. The glands of Lieberktihn resemble in structure the tubular glands of the stomach, and cover almost the entire surface of the small and ANATOMY OF THE STOMACH AND INTESTINES 27 large intestine. Each tubule is from 0.3 to 0.4 mm. long, and opens with- out ramifications. They form the chief organ of intestinal secretion and number over forty millions. B runner's glands are found only in the duodenum and are most abun- dant at its commencement, diminishing in number lower down. They lie beneath the mucosa, being embedded in the submucosa. They re- semble the pyloric glands of the stomach, but are more branched and convoluted, and their ducts are longer. They are lined with columnar epithelium. The duct of the gland passes through the muscularis mucosje and opens on the surface of the mucosa (Fig. 9). Solitary follicles (or glands) are scattered throughout the mucous membrane of the small intestine and are most numerous in the lower ileum. They have a diameter of 2 to 6 mm. (Fig. 10). mesentery x circular folds solitary lymphatic nodules Fig. 10. A portion of the ileum showing solitary lymphatic nodes (Sobotta). The follicles consist of a dense retiform tissue packed with lymph- corpuscles and permeated by capillaries. They have no ducts. The spaces in this tissue are continuous with lymph-spaces at the base of the gland and the base of the follicle is in the submucous tissue. The gland enters the mucous membrane, causing a slight projection of its epithelial layer. Lymph-cells develop in these follicles. , There are no villi on their surface. These follicles are scattered singly through the intestine as solitary glands, or collected into groups, known as Peyer's patches or plaques, or as the agminate glands. These last may be from i to 3 inches long and % inch wide, usually oval, with the long axis parallel with that of the 28 -DISEASES OF THE STOMACH AND INTESTINES intestine. They lie generally opposite the attachment of the mesentery, are twenty to thirty in number, and are found chiefly in the ileum, though a few are present in the jejunum (Fig. n). circular folds aggregated lymphatic nodules mesentery x (Fever's patch) Fig. ii. A portion of the ileum, cut open along the line of attachment of the mesentery, showing Peyer's patch and solitary lymphatic nodes (a) (Sobotta"). Fig. 12. Partial section of colon: i, Free tenia; 2, tenia mesocolica; 3, appendices epiploicae; 4, mucosa; 5, semilunar folds; 6, mesocolon. Anatomy of the Large Intestine. The large intestine, which is about 5 to 6 feet (1.5-1.8 meters) long, extends from the termination of the ileum to the anus, and is divided into the cecum (or caput coli), the colon, ANATOMY OF THE STOMACH AND INTESTINES 2Q and the rectum. Its caliber is largest at the cecum, and this gradually decreases until it reaches the ampulla of the rectum, when it again increases in size. The large intestine, excepting the rectum, is characterized by three longitudinal unstriated muscular bands or teniae (Fig. 12), with saccula- tion of the walls between these bands and by the appendices epiploicse, or external pouches formed by the peritoneal covering and containing fat. The circular muscular fibers also accumulate in bands with intervals between them, thus forming expansions or semilunar folds across the colon (haustra coli) (Fig. 13). The cecum (caput coli) is that part of the colon lying below the ileocecal valve '(Fig. 14). It is about 3 inches (7.5 cm.) broad and 2> inches (6.3 cm.) long, and lies in the right iliac fossa above the outer half of Poupart's ligament, being completely covered by peritoneum. When filled, it is situated close to the abdominal wall. The vermiform appendix, semilunar folds lumen omental band " free band Fig. 13. A segment of the colon (Sobotta); haustra coli. a small blind tube, hollow nearly to the tip, is given off generally from the posterior and inner portion of the caput coli, about ^{e inch (1.7 cm.) below the ileocecal valve. Its average length is 3% inches (9.2 cm.). It may be much shorter or longer. The diameter is about Y inch (6 mm.) at the base and 2{ 6 inch (5 mm.) at its apex. It may be slightly larger at the middle. It is usually guarded by a valve (crescentic fold) where it enters the cecum. It has a meso-appendix (mesentery) only extending about two-thirds its length. The position of the appendix is not fixed and it may point in various directions. The colon is depicted in Fig. 32. The ascending colon, about 8 inches (20 cm.) in length, extends verti- cally upward from the cecum to the inferior surface of the right lobe of the liver to the right of the gall-bladder, at which point it bends to the left (hepatic flexure). It passes along the posterior abdominal muscles and lower part of the right kidney, and is in relation to the abdominal wall in front. It is bound posteriorly by connective tissue to the muscles, and is only covered by peritoneum anteriorly and laterally. 3O DISEASES OF THE STOMACH AND INTESTINES The transverse colon, with an average length of 20 inches (51 cm.), extends from the hepatic flexure beneath the liver transversely across the abdominal wall, with a slightly downward and forward convexity at its center, to the spleen in the left hypochondrium (splenic flexure). It has a long mesentery, transverse mesocolon, connecting it with the posterior abdominal wall, and is the most movable part of the large intestine. It usually corresponds to a line separating the umbilical and epigastric regions. Formerly it was believed that the normal transverse colon lay just above the umbilicus, but it has been demonstrated by the x-rays that a moderate degree of sagging is most frequent and that in most cases it lies below the umbilicus. This occurs frequently without any disturb- free band ascending colon ant. frenulum of valve post, frenulum of valve. upper lip of valve. semllunar folds'- lower Up of valve vermiform process Fig. 14. The cavity of the cecum (Sobotta). ances and with no ptosis of the stomach. The liver, gall-bladder, greater curvature of the stomach, and lower end of the spleen lie above it; the small intestine lies below; the descending duodenum and small intestine behind; the great omentum and abdominal wall in front. At the splenic flexure below the lower end of the spleen, the colon turns downward (descending colon). This is about 8^ inches (21.5 cm.) long, and extends from the splenic flexure vertically through the left hypochondriac and lumbar regions to the sigmoid flexure. It is covered anteriorly and laterally by the peritoneum, and passes down in front of the left kidney and quadratus lumborum and iliac muscles, to the left iliac fossa into the sigmoid flexure. ANATOMY OF THE STOMACH AND INTESTINES 31 The sigmoid flexure of the colon (S. romanum) is an S-shaped curve, about 13 inches (31 cm.) long, beginning at the iliac crest and ending at the brim of the true pelvis opposite the left sacro-iliac articulation. The upper, or colic, limb tends down, inward, and forward toward Pou- part's ligament, while the lower, or rectal, limb hangs down into the true pelvis, where it joins the rectum. The sigmoid flexure has a complete peritoneal covering, or mesentery, is very movable, and is the narrowest portion of the large intestine. The rectum, which is about 8 to 9 inches (20-23 cm.) long, passes from the left sacro-iliac junction obliquely to the middle of the sacrum and follows it down to the bottom of the pelvis to about i inch (2.5 cm.) below the tip of the coccyx, where it passes downward and backward to end in the anus. It is divided into three portions. Only the first part, 3^ inches (9 cm.), of the rectum is -completely invested with peritoneum (mesorectum), and it is attached to the sacral vertebrae. The second part is partially invested with peritoneum (pouch of Douglas), which lies anteriorly and ascends over the bladder or vagina. The third part has no peritoneal investment. The lower half of the rectum passes between the organs occupying the pelvic floor and is adherent to them by connective tissue. The rectum is surrounded by connective tissue below the pouch of Douglas. It is widest at the point opposite the prostate, there forming the ampulla of the rectum. The outer longitudinal muscular fibers of the rectum are not arranged in teniae, as in the colon, but are present in all parts of its circumference. The inner circular layer of muscle-fibers increases in density from above downward and forms a thick ring at the anal opening (the internal sphincter). The walls of the rectum are connected at the anus with the spincter ani and levator ani muscles, which are of importance in defecation. Arterial Supply of the Cecum and Colon. They are the ileocolic, colica dextra, and colica media from the superior mesenteric artery; the colica sinistra and sigmoid from the inferior mesenteric artery. Veins of the Cecum and Colon.- These are the superior and inferior mesenteric, emptying into the portal system. Lymphatics of the Cecum and Colon. Those of the sigmoid colon empty into the lumbar glands; those of the rest of the colon into the mesenteric glands. Nerves of the Cecum and Colon. The cecum, ascending colon, and right half of the transverse colon are supplied by the superior mesenteric plexus, a branch of the celiac plexus. The rest of the colon, including the sigmoid flexure, is supplied by the inferior mesenteric plexus, a branch of the aortic plexus. Arterial Supply of the Rectum. They are the superior hemorrhoidal (of the inferior mesenteric); the middle hemorrhoidal (of the internal iliac); the inferior hemorrhoidal (of the internal pudic); branches from the sacromedia (of the abdominal aorta); branches from the sciatic (of the internal iliac) ; in the female, branches from the vaginal. Veins of the Rectum. They are chiefly from the superior hemor- rhoidal, passing to the inferior mesenteric and to the portal system; part 32 DISEASES OF THE STOMACH AND INTESTINES of the other hemorrhoidal veins empty into the internal iliac veins, and so enter the general venous system. Anastomosis thus occurs in the rectum between the portal and the general venous system, and there is a communication also with the other abdominal veins. Lymphatics of the Rectum. They empty into the sacral and lumbar glands from the rectum; from the anus, into the inguinal glands. Nerves of the Rectum. The cerebrospinal nerves come from the sacral plexus; the sympathetic nerves from the inferior mesenteric and superior hypogastric plexus. HISTOLOGY OF THE LARGE INTESTINE The large intestine (colon), like the small intestine, consists of four coats; serous, muscular, submucous, and mucous. The longitudinal muscular fibers of the large intestine, however, are arranged in three bands (teniae) running along the wall, as already described. The serosa and submucosa resemble those of the small intestine in structure. The mucosa of the large intestine differs from that of the small intestine in that the villi and circular folds of Kerkring (valvulae conniventes) are absent. The glands of Lieberkiihn are somewhat longer and at times curved. The mucous membrane of the rectum is thicker, redder, and more generously supplied with blood-vessels than that of the colon. When the rectum is empty, the mucous membrane of the upper part is thrown into a multitude of superficial transverse velvety folds. From two to seven folds (Houston's valves) are made more prominent by dis- tention (Gant). Just above the anus are a number of longitudinal folds (columns of Morgagni), extending for y$ to % inch (8.46-15.23 mm.). The mucous membrane of the rectum consists of columnar epithelium, except at the lowest portion, a narrow layer of stratified pavement-like epithelium, transitional between skin and rectal mucosa. The upper part of the rectum resembles the colon. CHAPTER II PHYSIOLOGY OF DIGESTION THE stomach and intestines form an important part of the digestive tract, and in order to understand their functions it will be necessary to review briefly the process of digestion. This term includes those processes which convert the food into such condition that it becomes fit to enter the circulation and afford nutrition to the human organism. These changes are brought about by means of certain ferments contained in the saliva, gastric juice, bile, pancreatic juice and intestinal juice, which are a part of the human organism at birth. There are certain fermentative and putrefactive processes which take place in the gastro-intestinal canal, the result of bacterial invasion, which play an important part in the physiology and pathology of this tract. The first ferment (ptyalin) with which the food comes in contact by the act of chewing, is found in the saliva. The latter is alkaline in reaction, of low specific gravity (1.002 to 1.0009), and contains water, ptyalin, mucus, epithelia, albumin, and salts. The ptyalin, which converts starch into maltose, or sugar, begins its action on the food already in the mouth, but the principal work is done during the first period of digestion within the stomach. The food passes into the fundus and accumulates there to form a mass, and it is not until twenty to thirty minutes later that the first movements of the stomach begin to appear. Under normal conditions during this early stage of gastric digestion the free hydrochloric acid is becoming combined acid, and the action of the ptyalin continues; but if the free hydrochloric' acid be excessively secreted, further digestion of the starch is interfered with; this physiologic fact has a bearing on the treatment of hyperchlorhydria. We must remember that thorough mastication of the food, which promotes salivary secretion, and the care of the teeth have an important bearing on digestion. It has been demonstrated that acid fermentation in the mouth interferes with the action of the saliva, and that cleansing the mouths of nursing infants will diminish fermentative processes in the gastro-intestinal tract. Hemmeter has apparently recently demonstrated on dogs that the salivary glands secrete a chemical substance (a hormone) during mastica- tion which passes into the blood and starts up the secretion of the gastric juice. After extirpation of the glands, HC1 and rennin were much reduced. Intravenous injection of salivary gland extracts partially restored gastric secretion. THE GASTRIC JUICE Hydrochloric acid was discovered in the gastric juice by Prout in 1824; and Beaumont, in 1833, by his experiments on St. Martin with his 3 33 34 DISEASES OF THE STOMACH AND INTESTINES gastric fistula, greatly advanced our knowledge. Schwam, in 1836, discovered the pepsin ferment; and Bedder and Schmidt, in 1854, showed that the acid of the gastric juice is hydrochloric acid. The gastric juice is a clear, colorless fluid, of an acid reaction and a specific gravity of 1.002 to 1.003. It contains water, salts, inorganic matter, proteins, hydrochloric acid, pepsin, rennet, and recently a fat- splitting ferment has been discovered (lipase). There is also a peri- staltic hormone. The quantity of this secretion in twenty-four hours is estimated to be about 3 pints. The degree of acidity varies from o.i to 0.2 per cent. Pepsin and rennet when first secreted are inactive bodies, known as pepsinogen and rennet-zymogen, but on coming into contact with the hydrochloric acid become converted into active pepsin and rennet. Vari- ous theories have been advanced to explain the production of the gastric juice, how an inorganic acid comes to be secreted by the blood which is of alkaline reaction. We are so far forced to accept the view that the secre- tion of the gastric juice must be due to the specific action of the cells. Through the combined action of hydrochloric acid and pepsin, it con- verts the albuminates into propeptones and peptones, which are more soluble. The rennet ferment curdles the milk. A small percentage of emulsified fat, as in milk, is split into fatty acids by lipase, a fat splitting ferment of the stomach. The gastric juice has the property of converting cane-sugar into grape- sugar, and gelatin into a soluble peptone which does not coagulate. Some of the substances contained in the liquefied chyme are absorbed through the stomach-wall, such as peptone, sugar, salts, and possibly propeptone. Meltzer has demonstrated that only a small quantity of water is absorbed in the stomach. The residue of the gastric contents passes into the small intestine, where further digestive processes occur through the action of the other ferments and the principal absorption takes place. Bacteria in the Mouth and Gastric Juice. Formerly the acid of the stomach was looked upon as destructive to bacteria. The mouth contains many bacteria and the importance of pyorrhea alveolaris, naso-pharyn- geal and tonsillar infections to gastro-intestinal disturbances, rheumatic and other conditions is now coming to be realized. Many varieties of bacteria are ingested into the stomach and are not destroyed by the gas- tric juice. Smithies from the microscopic examination of the gastric contents of 2406 patients with gastro-intestinal disturbances of various types, showed that irrespective of the degree of acidity of the gastric con- tents that bacteria were present in 87 per cent. The different varieties were cocci and diplococci, bacilli short and long, often of the colon b. type, streptococci and staphylococci and leptothrix buccalis. In the saliva cul- ture in fifty-four cases, streptococci and staphylococci were present in over 80 per cent. The pus-producing organisms have their proliferation retarded by the gastric juice but the bacilli (particularly the colon b.) and the leptothrix grow well in the stomach. Bacteria furthermore live in the small intestine or pass through it, or enter the blood-stream through the mucosa. . PHYSIOLOGY OF DIGESTION 35 I. Secretion of the Gastric Juice. Pawlow 1 has discovered many new facts relating to the physiology of gastric secretion. Among these are the following: The amount of gastric juice secreted is proportionate to the quantity of food ingested; the secretion is acid, and the more rapidly it appears, the greater is the quantity of acids produced. The gastric juice appearing after a bread diet shows the most marked digestive activity; following this is the gastric juice after a meat diet, and the least digestive activity is found after a milk diet. Moreover, every variety of food stimulates a definite quantity of secretion. Quantity of Secretion. The average quantity of juice secreted every hour is one and a half times less after a bread diet than after a milk or meat diet, the digestion consuming a longer period of time. A latent period occurs between the ingestion of food and the appearance of the secretion, lasting from four and a half to ten minutes. Nervous influences play an important role in the secretion of the gastric juice as is demonstrated by the fact that after feeding a dog in whom an esophagotomy has been performed (sham feeding), a certain quantity of gastric juice will appear in the gastric fistula within a few minutes. The sensations of taste, smell, sight, and the presence of food within the mouth reflexly stimulate the secretory nerves in the vagus. Sham feeding has no longer any influence on the secretion of gastric juice if the vagus has been severed, demonstrat- ing that this is the secretory nerve of the gastric glands. As already men- tioned, the sight of food will cause secretion of the gastric juice (appetite juice), since the appetite is a strong stimulant to the secretory nerves. Hertz and Sterling, however, in studying the psychic gastric juice in a gastrostomy patient, 2 found that in this case there was not the intimate correlation in the simultaneous presence of appetite and a flow of gastric juice, nor did mastication of sapid substances cause the flow of an "appe- tite juice." They refused, however, to generalize from this single sub- ject. Pawlow, moreover, found that further secretion of the gastric juice is due to certain substances contained in the foods, known as secretogogues (which stimulate further secretion). Pure mechanical stimulation is not the cause. Meat juice and beef extracts are marked stimulants to the flow of gastric juice, while milk is less so, and water is a weak stimulant. Pawlow further claims that the ash of meat, sodium chlorid, hydrochloric acid, and soda do not stimulate the secretion, and that egg-albumen and pure peptone have no effect. Starch, cane-sugar, and grape-sugar have no influence, while starch paste and meat extract together markedly in- crease this secretion. Fats have no influence on the secretion of gastric juice, and when introduced with other food diminish this secretion. Edkins 3 claims that the secretogogues, whether they are preformed in the food, or formed from it in the process of digestion, act upon the pyloric mucous membrane and form gastrin (or gastric secretin), which is absorbed into the blood and then carried to the gastric glands to stimulate their activity. Starling shows that this is similar in action to the secretin in producing pancreatic secretion. He designates these internal secretions as "hormones." 1 The Digestive Glands. 2 Deutsche med. Woch., Aug. 4, 1910. 3 Journal of Physiology, 1906, xxxiv, p. 133. 36 DISEASES OF THE STOMACH AND INTESTINES 2. The Motor Function of the Stomach and Cap (Duodenal). The motor function of the stomach is of importance in the process of digestion, as by its active and passive movements physical changes are brought about in the ingesta. The movements transmitted by the diaphragm and abdominal muscles assist the action. The food is brought more closely in contact with the stomach- wall and becomes more liquefied. The pylorus opens and closes at intervals, and allows the entrance of the chyme into the small intestine, at an interval of about twenty seconds, according to Cannon, depending on the acidity of the chyme and the consistency of the food. About two to three hours after a small meal, and six to seven hours after a large meal, the stomach is empty. Cannon 1 has studied the movements of the stomach by the axrays, by administering food mixed with bismuth, and by observation with a fluoroscope. He found that the contractions start in the middle of the stomach and pass toward the pylorus at regular intervals. The pyloric end of the stomach lengthens out and the peristaltic waves increase during advanced digestion. At intervals the pylorus relaxes and the contraction squeezes part of the chyme into the duodenum. He 2 found that carbohydrates pass out the soonest after ingestion and require only about one-half the time that proteins do for gastric digestion. If the protein is given first, the passage of the carbohydrate will be delayed. Fat when taken alone remains for a considerable time in the stomach, and if combined with other food, the exit of the latter is delayed. It is believed that chemic stimuli, such as hydrochloric acid, control the opening and closing of the pylorus. With achylia gastrica, however, the motor func- tion of the stomach, in spite of the absence of hydrochloric acid, is fre- quently normal. The consistency of the chyme, to which Cannon refers, and possibly some new formed chemical constituents, may be responsible for the regularity of the pyloric reflex in this case. Bassler 3 has made some rather interesting observations with the x-ray in this regard. Griitzner and Cannon 4 have demonstrated, moreover, that the waves in the fundus are very slight and do not affect the contents in that portion of the stomach for a considerable period of time, so that the food lying there does not immediately mix with the acid gastric juice. This is an important fact in connection with the salivary digestion of the starches, so that ptyalin digestion may in some cases continue for an hour, before it is inhibited by the acid gastric juice. The swallowed food arranges itself in co.nsecutive layers in the stomach. Physiologic observations apparently show that nature provides against the danger of diluting the gastric contents during digestion by the drinking of fluids during the meal; since O. Cohnheim observes that even in a stomach containing considerable food, the ingestion of a large quantity of fluid causes a separation of the food from the lesser curvature, along which the fluid passes rapidly into the duodenum. F. Hoffmeister, Schuetz, Rieder, Brunner, and Groedel 5 describe three phases in the motor mechanism of the stomach. 1 American Journal of Physiology, 1898. 2 Ibid., 1904. 3 Diseases of the Stomach and Upper Alimentary Tract. 4 Archiv f. die gesammte Physiologic, p. 106^ 463. e Archiv fiir exper. Pathologic, xx. PHYSIOLOGY OF DIGESTION 37 Motility of the Stomach and Duodenal Cap. They divided the move- ments into those occurring in the fundus, a sphincter antri pylori pro- ducing temporary occlusion and division of the stomach into two parts, the antrum pylori (accessory stomach and fundal portion). Both peristal- tic and antiperistaltic movements of the antrum were described. The sphincter antri is now believed to be merely the point of maximum con- traction. L. G. Cole interprets a "single peristaltic contraction of the stomach" or more correctly an "individual peristaltic contraction" as the formation and progression of a peristaltic contraction from its origin in the fundus to the pylorus, it should not be confused with the formation and duration of an individual antrum or gastric cycle. The individual contraction passing from the fundus to the pylorus usually does not exceed ten seconds, while the single gastric cycle takes from two to three seconds. The individual contraction is divided into as many gastric cycles as there are peristaltic contractions. Holzknecht de- scribes a one-cycle type as the normal, having the marked contraction known as the sphincter antri which periodically cuts off the antrum pylori from the body of the stomach. Cole shows five types: the one-cycle, one-and-a-half-cycle, two-cycle, three- and four-cycle type (the latter the most common), and a group where more than four cycles occur for the progress of the contraction (choreic type). Corresponding contractions occur in the lesser and greater curvatures, except in the one-and-a-half- cycle type in which there is a second small contracture in the lesser curva- ture without corresponding contraction in the greater. With each gastric cycle there is a systole and diastole. The gastric cycle is governed, but not entirely controlled by the vagus through the same nervous impulses which govern respiration, or indirectly by respiration itself. Cannon believes the opening of the pylorus to be governed by the degree of gastric acidity, stage of digestion and nature of the duodenal contents. Cole imputes further movements to contraction of the cap (the ascending duodenum) giving a broad propulsive peristalsis and probably dependent upon changes in reaction of the contents of the descending duodenum. If atony of the stomach be present, motor insufficiency and stasis result, and the latter favors fermentation and putrefaction. It has been demonstrated that the presence of hydrochloric acid in considerable quantities does not prevent these conditions if stasis be present. Shape of the Cap (Duodenal). The cap is usually triangular in shape with the base parallel to and at the pyloric ring. At times, however, it may be square or like a parallelogram. Shape of the Stomach. There are variations in the shape of the stomach and yet all the functions, as well as its position may be normal. The most frequent types of stomach are the cow-horn, text-book, drain-trap (water- trap) and fish-hook. The fish-hook and drain-trap frequently occur with gastroptosis and the possibility of these peculiar shapes being an accessory in producing gastroptosis through weight of the food in the trap or hook portion might suggest itself. Though the infant stomach directly after birth was formerly believed to be vertical and that it later assumed the adult position, it has been recently demonstrated that there is no definite normal type of stomach in the infant. Pisek 1 and LeWald in their radio- 1 American Journal Diseases of Children, Oct., 1913, vol. 6. 38 DISEASES OF THE STOMACH AND INTESTINES graphs distinguish the (i) ovoid or Scotch bag-pipe shape; (2) the tobacco-pouch or retort shape; and the (3) pear-shaped stomach. The stomach was larger than the ordinary conception, and infant stomachs were characterized by their rapid motility the food quickly escaping through the pylorus. INTESTINAL DIGESTION Under normal conditions, when the chyme enters the duodenum its reaction is acid. It is here subjected to the influence of the bile, pancreatic juice, and intestinal secretions, all of which, in their action, have a more or less close interdependence upon each other. Bile. The bile in the intestine precipitates the pepsin from the chyme. This, however, is soon dissolved. Others hold that albuminoids are precipitated from the chyme, together with the pepsin, and are then more readily absorbed. It does not have a deleterious effect on the pancreatic digestion. Bile contains a weak amylolytic ferment. The bile is one of the chief factors in gradually altering the reaction of the chyme to neutral or alkaline, and it strongly supplements the action of the pancreatic juice in emulsifying fats, aiding their absorption and its absence or diminution lessens this function. Roger 1 and Chabanier hold it enhances the starch splitting of the pancreatic juice, activates the lactase of the intestinal secretion, and exerts a tractor influence by drawing forth certain ferments contained in the cells of the intestinal epithelium particularly invertin. It aids in the digestion of proteins which last tend to form in an acid medium cer- tain insoluble compounds with the bile. The precipitates thus formed redissolve in an excess of bile. Pawlow believes that it may augment slightly the effects of the other pancreatic ferments. One of its chief functions is undoubtedly excretory, and through it many of the useless products of metabolism are eliminated. When ab- sorbed into the system it acts as a poison and produces a definite toxemia. The bile is a clear, tenacious mucoid fluid with an alkaline reaction, consisting of water, bile-acid salts (glycocholic and taurocholic acid), pigments (bilirubin and biliverdin), mucin, cholesterin, lecithin, soaps, fats, etc.; about 500 to 600 c.c. are excreted in twenty-four hours. Wm. H. Porter 2 believes that the precipitation of the pepsin from the chyme through the action of the bile is necessary for the action of the pancreatic ferments, and the enterokinase of the intestinal juice, as the pepsin, as long as it remains active, inhibits their action. Some consider that it has antifermentative and antiputrefactive powers, and that it helps to maintain the nutrition of the epithelial cells. Lindenberger has shown experimentally that a small amount of bile com-, bined with 0.05 per cent, of lactic acid prevents putrefaction in an infusion of pancreas, while lactic acid alone has no effect. Von Noorden holds that bile has no antiseptic action. 1 Universal Medical Record, April, 1913. 2 Indicanuria a Danger Signal, Postgraduate, 1907. PHYSIOLOGY OF DIGESTION 39 Roger shows that it checks putrefaction. 1 It favors 2 propagation of the colon bacillus and inhibits growths of the anaerobic agents of putre- faction. It exercises an antitoxic function by neutralizing certain poisons arising from intestinal putrefaction. Mucin is coagulated by a ferment (mucinase) contained in the intestinal cells. Bile inhibits this action so that mucus contained in the upper part of the intestine is in a liquid state. When mucus coagulates, it occurs in the lower part of the intestine where there is the least amount of bile. He attributes pseudomembranous enteritis (mucous colic) partly to biliary insufficiency the other factors being an excess of mucus and mucinase, administering ox gall for treat- ment of such. Clinically, we at times see cases of indicanuria with the presence of bile in the urine and with light-colored stools in whom there is no perma- nent disappearance of indican, though there is a temporary improvement after the use of calomel, etc., until the biliary excretion into the intestine is restored to normal. The internal use of the bile-salts, which can be given as inspissated bile, seems to be of some value. Bile stimulates the functions of the liver and possesses slightly purgative qualities by increasing peristalsis. The liver has special functions. Many of the substances taken up by the digestive process are stored there until used in the system, namely, some of the peptones and sugar in the form of glycogen. It excludes some poisonous matters from the circulation. Thus it is the chief organ for the removal of indol and poison, such as curare or of various autotoxins. Urea is also formed in the liver. Pancreatic Juice. The pancreatic juice is the principal factor of diges- tion in the intestinal canal. It is clear, colorless, alkaline, sticky and odorless, quite albuminous, containing water, solids, proteins, and inor- ganic matter. The most important constituents are the three ferments: Amylopsin, an amylolytic enzyme, which converts starch into dextrin and maltose, and still further into glucose. Cane-sugar is converted into grape-sugar, while milk-sugar is unchanged. Some of the cellulose ferments form marsh-gas and various acids. The activity of pancreatic diastase is increased by very small quantities of acids (Chittenden). Steapsin, a lipolytic ferment. This acts upon fats by splitting them into fatty acids and glycerin; and this action is increased by the bile. The fatty acids combine with the alkalis in the intestines to form soaps, which aid in the emulsifying of fats, and thus promote their absorption. The emulsification occurs in an alkaline medium, or in contact with the alkaline secretion of the mucous membrane. Trypsin, a proteolytic ferment, changes the proteins into alburnoses and peptones. There is probably a rennet-zymogen also. The trypsin ferment acts in a neutral or alkaline medium, though slight degrees of acidity seem to favor it. Indol is a product of intestinal putrefaction, and not from the action of the pancreatic ferment, as was formerly supposed. The same is true of hypoxanthin. Some hold there 1 Med. Record, June 14, 1913. 2 La Presse Medicale, Oct. 2, 1912. 4O DISEASES OF THE STOMACH AND INTESTINES is a lab ferment and a ferment "nuclease." (See Section on the Pan- creas.) There is an internal secretion of the pancreas influencing the metabolism of sugar. The secretion of the pancreatic juice is not reflex, but is due to direct excitation* of the cells of the pancreas by secretin (Starling). This is formed from " prosecretin " in the mucous membrane of the duodenum and jejunum and reaches the pancreas by the blood-stream. The passage of the hydrochloric acid in the chyme over these portions of the small intestine stimulates the production of secretin or, rather, splits it off from the prosecretin, which is present in the mucous membrane. Some of the French physiologists claim that the secretin also stimulates the production of prosecretin and the functional activity of the liver and jejunum (the succus entericus). Probably the spleen produces a similar hormone which stimulates the digestive glands and has a part in the activation of trypsinogen. Secretin is said also to influence (increase) the motility of the bowel. The intestinal juice (succus entericus) consists of water, albumin, mucin, and salts. It seems to neutralize the acids formed by the fermen- tation of the carbohydrates, and the presence of mucin shows it to be of service in aiding peristalsis. Pawlow's experiments demonstrate that it augments the activity of the pancreatic, ferments, especially of trypsin. The fat-splitting and amylolytic pancreatic ferments are augmented by the succus entericus from all parts of the small intestine, while that from the duodenum aug- ments chiefly the proteolytic ferment. Ptyalin and several enzymes have been found in the intestinal juice. The intestinal juice contains three enzymes acting on the carbo- hydrates: Maltose, which acts on maltose; invertin, which acts on cane-sugar; and lactose, which acts on milk-sugar. Pawlow found enterokinase, a ferment of other ferments, which is believed to be necessary to excite intestinal ferments into activity. It probably acts chiefly in converting trypsinogen into trypsin. Erepsin, another ferment, is also present, which transforms hemi- albumose into other bodies, completing the work of the pepsin and trypsin. Organized Ferments. There exist in the intestines fermentative and putrefactive changes produced by microorganisms. 1 At birth the gastro- intestinal tract is sterile, but rapidly, by the ingestion of food and through the air and by the anus, bacteria of various types enter this tract. Herter 2 has estimated their number at one hundred and twenty-six billions for the daily human excreta. Many of them are no longer living. He considers the chief function of the obligate bacteria (Bacillus lactis aerogenes, Bacillus coli, and Bacillus bifidus) to be their capacity for checking the development of other types of organisms capable of doing injury, though they themselves under certain conditions may produce much harm. Many other varieties are described. Some observers believe that 1 Proceedings American Medico-Psych. Association, April 21, 1905. Some Ob- servations on the Relations of the Gastro-intestinal Tract to Nervous and Mental Diseases (Kemp). 2 Bacterial Infections of the Digestive Tract. PHYSIOLOGY OF DIGESTION 41 there is a so-called normal fermentative process which aids in the digestion of cellulose, though Bergman claims there are enzymes (intracellular) which decompose it. The fermentative processes in the small intestine caused by the action of bacteria on the carbohydrates (Bacillus lactis aerogenes) leads to the formation of ethyl alcohol and various organic acids, such as lactic, acetic, paralactic, succinic, biliary acids and albumin, peptone, mucin, sugar, etc. These organic acids are believed to prevent putrefaction within the intestines, to partly check the decomposition of the carbohydrates, and to aid in producing intestinal peristalsis, which render putrefaction less likely. The lactic acid in koumyss, matzoon, bacillac and lactone butter- milk, and even in plain milk (to a slighter degree), is believed to lessen putrefaction. In the lower jejunum and ileum the reaction is acid. When the intestinal contents pass into the colon the reaction becomes alkaline, fermentation stops, putrefaction begins, and the fecal odor appears. The colon bacilli are marked factors in this process. The decomposition of the albuminates caused by bacteria goes much further than that produced by pancreatic digestion. Albumoses, peptones, lysin, ammonia, amido-acids, etc., are produced in both cases, but with putrefaction the process goes further and we have new products formed, such as indol, skatol, paracresol, phenol, various acids and gases, such as sulphuretted hydrogen, marsh-gas, carbon dioxid, etc. Some of these products of decomposition are eliminated unchanged in the urine, such as the oxyacids, others, like the phenols, after further oxidation; others, like indol and skatol, after combination with ethereal sulphuric acids. For example, indol forms an indoxyl-potassium sulphate or indican, and is so eliminated in the urine; and thus may be an indica- tion of the amount of putrefaction occurring in the intestines. The causes of indicanuria are various, such as excessive protein diet, catarrh of the small intestine causing alterations in the mucosa and in- creased intestinal putrefaction therefrom, typhoid, cholera, a pus-cavity, constipation, alimentary putrefaction, decrease of normal digestive fluids, intestinal obstruction, and peritonitis. Certain drugs, such as salol, salophen, and creosote, will give nearly similar 'reaction, while urotropin will cause its disappearance. These possible conditions must all be considered. As the intestinal contents pass through the large intestine they be- come thickened through the absorption of fluids and are at last eliminated as feces. These comprise the remains of undigested material, excretory material from the intestines, and many microorganisms. The quantity of feces depends upon the character of the food, being greater after a vegetable diet. The average amount after a mixed diet is about 100 to 150 gm. The reaction of the feces is ordinarily alkaline, though occasionally variable. The odor is chiefly due to skatol, and the color is a light or dark brown. Absorption from the Intestines. Absorption chiefly occurs in the small intestine. 42 DISEASES OF THE STOMACH AND INTESTINES In the stomach the greater part of the protein is dissolved and much of it is converted into albumoses and peptones. In the intestine the dissolved products as well as the remaining un- dissolved residues are attacked by the trypsin and are thereby split up into amino-acids. Erepsin, a ferment from the intestinal wall prevents the absorption of albumoses and peptones by converting those that es- cape the action of trypsin, into amino-acids. The amino-acids as fast as they are formed are absorbed and transported by the blood and lymph to all parts of the body. Each tissue rebuilds itself from the amino- acids. Those that are not needed are converted into urea and carbona- ceous remainders. The latter are converted into carbohydrates or oxidized for the production of heat and energy. The liver and par- ticularly the muscles form the urea. Vaughan 1 believes that the amino-acids are synthetized into specific proteins peculiar to the sp*ecies. The blood and lymph carry in solution both proteins and protein-split substances (amino-acids). Each kind of cells of the various organs must split the proteins and amino-acids in such a way as to serve the need of that particular structure, such as the liver cells, pancreatic cells, etc. The agencies which accomplish the work are known as ferments and there are as many specific ferments as there are kinds of cells. Sometimes small amounts of undigested or imperfectly digested pro- teins are absorbed through the intestinal wall. Foreign proteins entering the body must be digested by ferments supplied by the blood and tissues. This is known as "parenteral digestion" in contradistinction to "enteral digestion" occurring in the alimentary canal. With parenteral digestion poison from the protein molecule is set free in the blood and tissues, and gives rise to symptoms. Idiosyncrasy to certain foods may result in unchanged proteid absorption or from partially proteolized derivatives and toxic symptoms result in effect anaphylaxis and sensitization occur. Albuminates from animal food are more completely converted than those from vegetable food, on account of the indigestibility of the cellulose and the increased peristalsis caused by the latter. Absorption of the Carbohydrates. These are chiefly absorbed as monosaccharids through the capillaries of the villi, enter the liver through the portal vein, and are retained as glycogen for use in the animal economy. If sugar is absorbed in excess, it may enter the general circulation and be excreted by the kidneys, so-called alimentary glycosuria. It may also cause diarrhea. Carbohydrates, as starch, are absorbed without difficulty. Glucose, levulose, and galactose are absorbed as such, while cane- sugar and maltose are first changed to these products. Milk-sugar is unchanged and absorbed as such, or undergoes lactic-acid fermentation. Absorption of Fats. The process of fat digestion results in the pro- duction of fatty acids and glycerol, soaps also being formed if the condi- tions under which the alkali is contributed in the intestines are favorable. These various products pass through the alimentary wall in emulsion and are resynthesized into true fat at the seat of their absorption. They 1 Parenteral Protein Digestion, Journal A. M. A., Aug. i, 1914. PHYSIOLOGY OF DIGESTION 43 enter the lacteals probably through the action of the epithelial cells of the intestinal wall and reach the thoracic duct. Mineral oil and petroleum are not absorbed even when introduced in the finest emulsion. The intestine rejects the paraffin and takes up the fat and excludes undesirable wool fats. The tissue fats maintain a characteristic similarity of composition in spite of variations in the texture and make up of blood fat. Bloor 1 has demonstrated evidences of various changes in the fats during absorption which make it probable that the intestines are able to radically modify their composition, the tendency being toward the production of a fat more nearly like the typical body fat of the animal than the fat ingested. The absorptive power for fat in the small intestine is considerable, probably over 300 grams per day. Olive oil and butter (fats with a low melting-point) are absorbed more quickly than mutton fat, for instance (fat with a high melting-point), and a free fat, such as butter, is taken up more quickly than bacon, which contains considerable connective tissue. Water, salts, some of the secretory juices, and bile are readily absorbed. Disease or removal of the pancreas stops the absorption of fats, except of milk, of which part is absorbed in emulsified form. Absorption in the Large Intestine. Water, fluids, and salts are well absorbed, in fact, markedly absorbed, as is noted by the change in the character of the intestinal contents. Albumin and carbohydrates are absorbed in considerable amount and fats in small quantities. Advantage is taken of this fact for the employment of nutritive enemata. Intestinal Peristalsis (Motor Function). The contents are thoroughly mixed by the movement of the intestines, and the residuum left after digestion is expelled through the anus. There are four types described: First. Cannon has shown in animals that the small intestine is much more actively engaged in the segregation or segmentation of food than in its mere propulsion. Actually, however, propulsion is rapid. One type of motility is given over to the segmentation of food in short blocks in the small intestine, thus giving sufficient time for thorough diges- tion as well as absorption. During this process the mucous membrane, with its large absorbing valvulae conniventes, is thrust into the food mass, thus exposing its maximum surface to absorption. Second. The second movement is peristaltic, and the intestines con- tract at a certain point and then relax, and continue this in successive segments or blocks progressively toward the anus, pushing the contents forward (ordinary peristaltic movements). Third. Oscillating movements, by which the coil is moved to and fro along the mesentery, with no particular contraction. The contents are mixed up by these movements and not propelled forward. Fourth. Rotary movements, by which a coil contracts in a circular direction rapidly along the intestines for 15 or 20 cm. in a violent manner. The last is usually pathologic and occurs when there is considerable x Fat Absorption, Jour. Biol. Chem., 1914, xvi, 517. 44 DISEASES OF THE STOMACH AND INTESTINES gas, after indiscretions in diet, or with stenosis. It is observed only in the small intestine. In the duodenum (descending and transverse), the chyme is propelled in finger-like masses (Holzknecht). The masses appear flocculent in the jejunum and have a coagulated appearance in the ileum. Propulsion is most rapid in the jejunum. Peristaltic action is much more rapid in the small intestine than in the large. After ingestion of a small meal the stomach becomes empty in about two hours, the small intestine in the same length of time; but in the large intestine it takes at least twenty hours before the contents are expelled. Nothnagel has never seen a physiologic antiperistalsis (reversed peri- stalsis) beginning from the anal direction upward toward the stomach, though some describe an intermittent antiperistalsis occurring in the ascending colon. It is said that strong injections of salt water into the colon will produce this effect. Movements of Proximal Colon. W. B. Cannon, Amer. Jour. Physiol., vol. vi, p. 253, has demonstrated by the Rontgen rays that antiperistaltic movements or anastalsis, a movement of waves backward toward the cecum, occur normally in the cecum, ascending and transverse colon of cats thoroughly churning and mixing the food, and bringing it in more perfect contact with the absorbing surface of the colon. Motor Functions of Large Intestines. Rieder 1 has brought evidence on the basis of his x-ray studies that anastalsis occurs in the human colon. Though it appears in the main along the cecum, ascending and proximal transverse colon, it might appear in any part of the large intestine. Haustral Churning. Schwarz 2 demonstrates from his #-ray studies on man that haustral changes occur constantly. Rieder describes these oscillations of the haustra as "pendulum movements." Whether the predominant movements of the proximal colon are ex- tensive contractions shifting the mass of contents rhythmically forward and backward, or gentle compressions of the contents of the sacculi, the effect produced is a thorough mixing and overturning of the material in this region and the exposure of the semifluid mass to the absorbing mucosa. The first part of the large intestine should be therefore regarded as a place in which digestion and absorption still continue. Movements of the Distal Colon. The distal colon may be regarded as beginning in man near the middle of the transverse portion and contains normally, firm and formed masses of waste material. The characteristic activity of the intestinal wall is the onward moving wave or diastalsis. Two modes of advancing the contents have been observed. Holzknecht records by means of the fluorescent screen that the contents of one sec- tion of the colon is moved onward into an empty distal section by a sudden push, lasting a few seconds. The haustral segmentation disappeared just before the advancement began, but at once reappeared when the material settled in its new position. This suggested that the function of ^ortschr. a. d. Geb. d. Rontgenstrahlem, 1912, xviii, 119. 2 Munch. med. Woch., 1911, Iviii, 1489. PHYSIOLOGY OF DIGESTION 45 the haustra, as in the proximal colon, was to increase intestinal absorption and not to propel the feces. The second method is reported by Fisch- land and Forges. 1 They saw a small piece, the size of a thumb, separated from the mass in the transverse colon, and pushed to and around the splenic flexure and thus down the descending colon. Several masses then followed the first, each new one starting as the previous one came to a stop. Thus small or large accumulations are transmitted toward the rectum. The interval between taking the meal and the excretion of the resi- due may vary between nine and thirty-two hours, the period depending on the time of eating and hour of defecation. The latter may occur at 5 P. M. nine hours after breakfast or if a failure at this time, the contents would likely be retained for twenty-four hours longer. Nervous Control of Peristalsis. Auerbach's and Meissner's plexuses are probably the automatic centers for peristalsis, but there are central agencies. For example, fright or excitement may cause diarrhea. The splanchnic nerve contains inhibitory fibers for the control of intestinal peristalsis. Ehrmann claims that the longitudinal muscles are stimulated by the splanchnics and inhibited by the vagus, and the circular muscles stimulated by -the vagus and inhibited by the splanchnics. The chyme acts as the normal stimulus to peristalsis through the nerves. Toxic material that has been ingested or developed in the in- testinal canal, indigestible food, organic acids from excessive fermenta- tion, and too hot or too cold drinks, may overstimulate the peristaltic action and be the cause of diarrhea. 1 Munch, med. Woch., 1911, Iviii, 2064. CHAPTER III INTERROGATION OF THE PATIENT (HISTORY) IN every case suffering from symptoms pointing to the gastro-intestinal tract, before the physical examination is undertaken the patient should be carefully interrogated as to his general history and the past and present symptoms. I shall briefly indicate the form of taking and preserving the history of such cases: Date Diagnosis No. of patient Name Nativity Age .- . Occupation Sex. Cause of death of parents Family and Personal History Tuberculosis: Rheumatism- Syphilis: Malaria: Diphtheria: Influenza: Scarlatina : Nephritis : Measles: Heart disease: Typhoid: Disease of liver: Gout: Cancer: Habits Tea cups: Sexual excess: Coffee cups: Mastication: Tobacco: Character of food: Alcohol: Past History of Present Complaint Began: Duration: Onset Sudden: Gradual: Probable cause: Symptoms Progressed: Same in character: Changed in character: Loss of flesh Present: Increasing: Absent: Bowels Constipation: Mucus: Diarrhea: Blood: Alternating: Odor: Regular: 46 INTERROGATION OF THE PATIENT 47 Headache Character: Location: Time of: Vertigo Nervousness: Drowsiness: Sleeplessness: Appetite- Good: Anorexia (loss): Time: Parorexia (perversion) : Thirst: Taste Normal: Bitter: Time: Deglutition: Dysphagia With solids: With liquids: Abnormal sensations Bloating: Fulness: Time: Belching Quantity: Time of: On full stomach: Regurgitation Water-brash: Sour: Time: Rumination: Pyrosis (heart-burn) Time: Duration: Pains Location : Cardialgia: Gastralgia: Character: Time of appearance: Duration: Affected by position: Affected by food or drink: Local tenderness Position : Nausea Time: Affected by food: Present Condition and History Bulimia (canine hunger): Polyphagia: Akoria: Sour: Sticky: Pressure: Weight: On empty stomach: Odor: Circumscribed Diffuse: Radiating: Sudden: Gradual : Relieved by pressure: Increased by pressure: Rigidity 48 DISEASES OF THE STOMACH AND INTESTINES Vomiting Time: Blood and its character: Frequency: Bile: Quantity: Mucus: Character of: Easy: Odor: Difficult: Taste: Relief of pain by: Stools Regular: Time of appearance: Constipation: Undigested food: Diarrhea: Mucus: Alternating constipation Blood: and diarrhea: General character: Number of movements: Bile: Tenesmus: General health and strength Loss of weight: Symptoms Referable to Circulatory System. Symptoms Referable to Nervous System Chief Complaint After the physical examination has been made, the results should be incorporated with the history, as should also the data secured from examination of the gastric contents, urine and stool. General Physical Examination Comprises Forehead and Face: Neck as to thyroid and glands: Tongue: Uvula: Tonsils: Pharynx: Teeth: Esophagus, if history points to the same: Eyes as to difficulty in reading or headache therefrom; exophthalmos. Nose as to nasal discharge and patency. Ears as to deafness. Heart: Blood pressure: Lungs: Liver: Stomach Position: Tenderness: Normal: Motor function: Dilated: Tympanites: Gastroptosis: Gastric analysis: Tumor Spleen: Kidneys Position: Urine: Intestines Position: Tympanites: Tender points: Borborygmi: Thickening: Rectum Local examination: Examination of stool, including microscopy and fermentation test. Nervous system: Weight of patient: Examination of genital organs: CHAPTER IV GENERAL METHODS OF PHYSICAL EXAMINATION As patients who complain of digestive disturbances may suffer from disease of other organs which may be the cause of the symptoms, a thor- ough physical examination should be made in every case. This should literally be carried out from the top of the head to the soles of the feet; in view of the numerous conditions which may have in association symp- toms pointing to the gastro-intestinal tract. It should include the scalp, forehead, eyes, face, nose, mouth, ears, neck, thorax, abdomen, genito- urinary organs, rectum, the gait, patellar reflexes, etc. There should be a careful examination of the heart and lungs. On examination of the chest, it should be noted as to whether the patient has the long narrow chest of a gastroptotic, whether there are beaded ribs, a floating tenth rib and whether there are dorsal pain and tenderness to the left of the spine near the eighth to tenth ribs suggestive of gastric ulcer or to the right suggestive of gall-bladder disturbance. The character and rapidity of the pulse, blood pressure, and respiration should be noted, and a specimen of urine requested for analysis and stool for general ex- amination. In all acutely commencing processes pointing to the digestive tract, the temperature should be taken. Gastric analysis and stool examination are important. GENERAL INSPECTION The general appearance of the patient may afford valuable informa- tion. With cancer there is often the sallow and emaciated appearance (cachexia) with anemia; with gastric neurosis the patient may often appear rosy and well nourished; while with ulcer there is frequently marked anemia and the face may have the appearance of suffering. Protrusion of the eyeballs, with inability of complete closure of the lids, taken in connection with tachycardia, are suggestive of Graves' disease, even though no thyroid enlargement be present. Von Graefe's sign and tremor of the lids should all be tested for. Determination of the Argyll-Robert- son pupil would be of diagnostic value. The skin should be inspected for eruptions and the exanthemata. Oral Cavity. This should be carefully inspected. Defective and carious teeth or inflammation, pyorrhea alveolaris, or abscess of the gums may give rise to gastric disorders. Disease of the posterior nares or middle ear, with resulting discharges passing into the pharynx, may be factors. The tongue was formerly regarded as a mirror of the stomach, but it can hardly be so considered, as there are some gastric affections in which the appearance of the tongue is normal; while in smokers, for example, 4 49 50 DISEASES OF THE STOMACH AND INTESTINES the tongue may be coated and yet no gastro-intestinal disturbance be present. A thick gray or grayish-yellow, moist, coated tongue showing indentations is suggestive of chronic gastritis; while with ulcer it may be dry and red, with a white median stripe, or smooth and moist or slightly furred. The condition of the mouth, smoking, drinking, and the teeth, have a decided bearing on its appearance. This is also true in reference to the odor of the breath. I hardly deem the tongue diagnostic in diseases of the gastro-intestinal tract, except in association with other symptoms. With the typhoid state, we have the narrow tongue, with the deep median fissure, thickly furred, the tip and edges being red and denuded, or the dry, brown fissured, and tremulous tongue; while with scarlet fever and in some other acute specific infections there is the so-called strawberry or raspberry tongue, with bright red projecting papillae. Fig. 15. Kemp's improved flexible esophageal bougie with inch markings; stylet; perforated olives. The uvula is sometimes elongated and^ may cause reflex digestive disturbances. In the pharynx and tonsils there may be inflammatory conditions of an acute or chronic type which influence the case. Inspection of the neck is important. Enlarged thyroid with tachy- cardia is diagnostic of Graves' disease, and a swelling to the left of the larynx, which increases in size after the ingestion of food, is suggestive of a diverticulum of the esophagus. Enlargement of the cervical glands refer- able to syphilis, tuberculosis, leukemia, inflamed teeth, or head lice, etc., would influence the diagnosis. Examination of the Esophagus and Esophageal Diseases. The cardinal symptom of esophageal disease is dysphagia, with or without regurgitation. The object of examination is to determine whether a stricture or a diverticulum is present. Palpation of the esophagus is possible in the neck, usually on the left side behind the trachea. A tumor found here may be a diverticulum GENERAL METHODS OF PHYSICAL EXAMINATION 51 distended with food or fluid. It is sometimes possible to empty it by the exertion of pressure. After the administration of considerable water, on rising a splashing sound can often be determined by grasping the larynx and shaking the patient's neck. Respiration and swallowing should be avoided during the test. A brawny swelling, in some cases with subcutaneous emphysema, may result from perforation or rupture of the esophagus, with inflamma- tion, which proceeds to suppuration. An abscess in this locality may be due to caries of the vertebrae. Auscultation of the esophagus is often of service. Place the stetho- scope posteriorly to the left of the spine, at the level of the sixth dorsal vertebra or at the tip of the ensiform and at a signal let the patient swallow a mouthful of water. At the instant of swallowing the deglutitory sound is heard, followed in six or seven seconds by the esophageal bruit, which resembles the sound one hears when swallowing saliva. Three to five seconds later there is a second sound, caused by the fluid entering the stomach or by regurgitation of air. If the first sound is delayed longer than seven seconds, or replaced by a splashing or gurgling noise, or if the second sound is delayed longer than five to twelve seconds, partial stenosis may be suspected. If both sounds are absent, there is probably nearly complete or complete stenosis. Gurgling sounds lasting several minutes and heard along the left side of the spine are probably due to contractions in a diverticulum, or in the dilated portion of the canal above a stricture. Instrumental examination of the esophagus is made by flexible stom- ach-tubes of various sizes the safest method or by flexible solid bougies or sounds. There is an excellent flexible bougie with small spiral wire tube stem covered with rubber (Lerche). Olives of various size can be attached. Einhorn's divisible bougie is a good instrument, though the whalebone handle is slightly stiff. It should not be employed by a novice. Callmann's and Schreiber's sounds are advocated by Willy Meyer. With Schreiber's instrument the deflated bulb is passed into the stomach and is then inflated with water. It i^ then slowly pulled upward. It moves readily in a normal esophagus, but slight narrowing or a diseased area arrest its passage. Schreiber claims 80 to 90 per cent, cases of stenosis to be malignant. The writer invariably examines the pharynx and postlingual region with the finger, before attempting to pass a stiJJ instrument, as he has found on several occasions adenoids or a pro- jecting cervical vertebra (from curvature) to interfere with its passage. I have recently devised an improved flexible esophageal bougie 1 with which early stenosis can be more readily detected through increased delicacy of touch with a flexible instrument (see Fig. 15). It is per- fectly safe and can be passed with the head in the natural position (i.e., without extension). There are three stylets of varying stiffness which can be inserted after the instrument has entered the esophagus. The stem is small, only n French, and has markings at inch intervals. There are several olives of different sizes. These are perforated so that they can 1 Improved Flexible Esophageal Bougie, Medical Record, Feb. 12, 1916. DISEASES OF THE STOMACH AND INTESTINES be threaded on a silk guide. This instrument is simple, safe and practical and can be used with children. Before the passage of an esophageal instrument, preliminary spray- ing of the pharynx with 4 per cent, cocaine or 5 per cent, eucain may be required. The administration half an hour previously of tincture belladonna, gtts. 10, or Hoo~3^o atropine is advisable if there is much spasm. Olive oil, 5n-5ss, ingested just before introduction of the instrument aids its passage. A practical method of differential diagnosis between stenosis and diverticulum of the esophagus has been devised by H. S. Plummer 1 and successfully employed by C. H. Mayo. The patient is directed at bed- Fig. 16. Sound pocketed in a di- verticulum. Esophageal probe bulb threaded on a swallowed thread passed into diverticulum (Plummer). Fig. 17. Traction on the thread lifting the sound out of the diverticu- lum. Probe bulb elevated by tighten- ing the thread, showing depth of sac (Plummer). time to swallow 3 yards of buttonhole silk twist with the assistance of drinking water, and the next morning to swallow three more yards of the continuous thread; if there is an opening through the stricture or diverticulum, the thread will be washed into the stomach, and from there into the bowel, a sufficient distance to stand traction without being readily withdrawn. A whalebone stem with several sizes of olive tips is employed for the examination. There is an opening at the side of each tip, the channel emerging at its apex. The thread which is employed as a guide passes through the tip of the olive and out at its side. The 1 Trans. Sect. Surgery, Amer. Med. Assoc., Sixty-first Session, St. Louis, June, 1910; also Jour. Amer. Med. Assoc., February 25, 1911. GENERAL METHODS OF PHYSICAL EXAMINATION 53 instrument is passed down the esophagus on the thread, which is held loosely until an obstruction is encountered. If this is due to a stricture, the tip will not change Us level when the thread is tightened; but if there is a diverticulum, the probe will be elevated to the level of the opening into the lower esophagus (Figs. 16 and 17). This proves at once the existence of a pocket and also its depth, by the amount of elevation of the probe on tightening the thread. By means of the thread as a guide it is possible to pass through apparently nearly impermeable strictures with a small olive and gradually to dilate them. Only sufficient force to detect an obstruction and readily to pass through it with olive bougies of smaller size is permissible with an unguided sound. With the silk thread as a guide, sufficient force may be used short of carrying the thread out of its course and through the esophageal wall. If sufficient ob- Fig. 1 8. Various forms of esophageal sounds (Plummer). Fig. 19. Piano-wire guide and carrier (Plummer). struction is present to make it possible that the thread might be carried out of its course, a piano wire (Fig. 19) should then be passed on the thread, and then the olive passed on the wire. This renders, in some cases, the sound more easily introduced. When passing the olive over the wire, tension on the thread should be maintained to avoid any possi- bility of the tip of the wire injuring the esophagus or stomach wall. In Fig. 19 and Fig. 18, d are shown the distal portion of the piano wire guide and carrier for working the wire through a tortuous cicatricial stenosis on a thread. Various sizes of piano wire may be used and its flexibility may be varied by the amount of wire exposed. In the treatment of cicatricial stenosis, the wire guide is not often necessary after the first dilatation, and the thread may be dispensed 54 DISEASES OF THE STOMACH AND INTESTINES with as soon as the smaller sizes of spindles will readily pass. Plummer recommends further dilatation with a sound (Fig. 18, a, b), consisting of a series of superimposed spindles (olives), the smallest one being at the bottom and gradually increasing in size. Lerche 1 has devised a flexible wire shaft esophageal sound, covered with rubber, on the ends of which olives of various sizes can be screwed. They are perforated so that the sounds can be threaded on a guide. The writer's instrument is shown in Fig. 15. A stomach-tube with a perforated metal tip can be employed over a thread as a director, the tube being stiffened with a whalebone staff, in order to obtain the contents of a diverticulum, or, as in Fig. 20, a case of diffuse dilatation of the esophagus, to enter the stomach. By this method it is possible to feed the patient while grad- ually dilating the stenosis, and thus avoid in some cases a preliminary gastrostomy. In endeavoring to calibrate a stricture in the lower 3 inches of the esophagus, or to dilate the same by means of a sound, one must remember the following anatomic features: the thoracic portion of the esophagus lies nearly in the median line, but deviates to the left as it passes forward to the opening in the diaphragm. In passing an olive through the lower 3 inches of a normal esophagus the staff impinges on the left anterior wall and the olive is directed to the cardia by the left posterior wall. This last portion presents an increasing degree of obstruction as it approaches a hori- zontal plane in cases of diffuse dilatation. The degree of obstruction encountered depends also on the stiffness of the staff, the size of the olive, and the tone of the wall of the esopha- gus. A stiff staff (Fig. 21, A) would have a tendency to injure or penetrate the wall, while a flexible staff, B, would curve in conformation to the shape of the esophagus and would ap- proach the opening at an angle with this portion of the esophagus and no harm result. In some cases, however, of diffuse dilatation of the esophagus from cardiospasm an unguided sound cannot be passed with safety, but a 15 mm. olive will readily and safely pass, when guided by the thread. The flexible sound or a small stomach-tube is more readily passed and with greater safety in the case of a carcinomatous cardia (Fig. 22). Benign Stricture. A benign stricture may be dilated every day, or every other day, or according to indication. The use of olive dilators or soft tubes, when possible, is preferable. Soft-rubber bags of various design, introduced empty and then inflated, have been advocated. Metal dilators which can be expanded by a screw thread and wheel, modeled 1 Jour. Amer. Med. Assoc., July 29, 1911. Fig. 20. Metal-tipped stomach-tube guided by a thread (Plummer). GENERAL METHODS OF PHYSICAL EXAMINATION 55 somewhat after urethral dilators, have been devised, and Lerche 1 recom- mends an esophageal dilator, which is used through the esophagoscope under guidance of the eye, somewhat like the Kollman dilator. Malignant Stricture. The history and age of the patient (40-60 years), absence of the Wassermann reaction, and cachexia, will usually determine malignancy. A palpable tumor may sometimes be felt if the stenosis is above the sternum and also enlarged glands are present. In such event the author deprecates the attempted passage of an instru- ment through a cancerous stenosis. In the use of the sound one must remember that it is 6 inches from the incisors to the commencement of the esophagus at the cricoid cartilage; Fig. 21. Diagram of diffuse esoph- ageal dilatation, showing danger from stiff staff (A), together with use of flexible staff (B) (Plummer). Fig. 22. Passing a sound through a carcinomatous cardia (Plummer). 9 inches to the crossing of the left bronchus, and 16 inches to the cardiac orifice of the stomach. There is normally some constriction of the esophagus at these three points. Obstruction to the passage of the tube may be due to esophageal spasm, but by waiting this will usually subside. I have found that in some of these cases a large tube can be passed more readily than a small one. I have treated neurasthenics suffering from a temporary form of spasmodic stricture. The passage of a large tube daily for the purpose of overcoming the spasm, antispasmodics such as belladonna and the bromides, and treatment of the neurasthenia have relieved this condi- tion. If the tube passes readily on one occasion and refuses to pass on 'Jour. Amer, Med. Assoc., July 29, 1911. 56 DISEASES OF THE STOMACH AND INTESTINES another, it has probably slipped into a diverticulum, or the latter has filled up and by pressure prevented the passage of the instrument. If the obstruction is permanent, one must decide whether it is due to stricture (narrowing) or external pressure, such as from aneurysm, tumor, or enlarged glands. Syphilis, cancer, tubercular, peptic, and rarely typhoid ulcers, and contraction following burns from acids or alkalis are the principal causes of stricture. Congenital stricture is rare and is usually found in the upper part of the gullet. If stricture be present, the locality, caliber, and permeability must be determined. Locality. Pass the tube or olive to the strictured point, nip it close to the incisor teeth, and measure the distance from here to the entering Fig. 23. Diverticulum of esophagus, from skiagraph (Plummet). tip of the tube or olive after withdrawal. My instrument has inch markings which facilitate this. Caliber. Sounds or olives of varying diameters will determine the caliber by finding one which will pass the obstruction. By the esophageal bruit and the use of a somewhat rigid sound one can tell whether or not the obstruction is permeable. Occasionally small portions of new growth may be found in the open- ings of a fenestrated tube. Blood shows ulceration or erosion. Contraindications. The tube should never be passed if there is aneurysm of the thoracic aorta or recent vomiting of blood. X-ray Examination. From a pfactical standpoint, stenosis of the esophagus can be readily diagnosed by the various methods of sound- ing, and a diverticulum by the symptoms already described, and by Plummer's thread method as a guide, to which the writer has already re- GENERAL METHODS OF PHYSICAL EXAMINATION 57 f erred. Radiography, however, is advised. Rontgenography will disclose thoracic masses obstructing the esophagus by outward pressure and occasionally an esophageal tumor. An impacted foreign body can also be thus determined. Other methods for the determination, particularly of early esophageal stenoses, have been suggested. Bassler, for example, first passes a collapsed bag on the end of a small tube into the stomach. He then inflates the bag and withdraws it up to the cardiac orifice, thus plugging the latter. Barium or bismuth is then ingested, and fluoros- copy, or preferably a radiograph, will demonstrate an irregularity in the esophagus (a commencing stricture). The bag is then deflated and removed. Others 1 have the patient swallow a small, long, finger-shaped bag of gold beater's skin or animal membrane closed except at point of exit from the mouth. This is then filled with barium or bismuth Fig. 24. Diverticulum of esophagus, from skiagraph (Plummer). and the esophagus radiographed. Subsequently the patient is placed in Trendelenburg position and the contents of the bag evacuated when the latter is also removed. The position, shape, size, and relations of diver- ticula and dilatation are also shown when filled with barium mixture. Diverticula are thus demonstrated in Figs. 23 and 24. Large dilatations occurring in the upper third of the esophagus above organic strictures usually have a tail-like portion of bismuth extending down from the bottom of the sac, thus distinguishing them from diver- ticula. When the tail is absent, and there is doubt, Plummer's thread guide method will differentiate the two conditions. With diffuse dilatation of the esophagus, following spasmodic and infrequently organic stricture, at the cardia, the shadow is large and irregularly spindle shaped. Under the section entitled "Diffuse Dilata- tion of the Esophagus without Anatomic Stenosis," other etiological 1 W. H. Stewart, "Advanced Rontgen Technic in the Diagnosis of Esophageal Lesions," "American Journal of Rontgenology," October, 1914. 58 DISEASES OF THE STOMACH AND INTESTINES factors besides cardiospasm are shown to produce this condition. JVIore- over cardiospasm may occur without causing diffuse dilatation of the esophagus or even dilatation at all. With cardiospasm, the lower extremity of the shadow is cone-shaped and its apex corresponds to the hiatus esophagi (Fig. 25). With organic stricture, with diffuse dilatation, the outline is irregular and terminates above the hiatus. In most cases the dilatation extends to the upper Fig. 25. Diffuse dilatation of the esophagus in case of cardiospasm (Plummer). border of the manubrium and is constricted at the root of the lung. Dila- tation occurring above organic strictures are, as a rule, of limited extent and irregular in outline in their lower portion. Mucilage of acacia is recommended as a valuable vehicle for the bismuth mixture and zoolak for barium. Other methods of differentiating a dilatation of the esophagus and a diverticulum have been described, 1 but those to which the author has referred are the most practical. 1 Kelen, New York Med. Jour., Feb. 23, 1907. GENERA!, METHODS OF PHYSICAL EXAMINATION rg The writer briefly suggests the following methods of treatment: For benign stricture or cardiospasm with dilatation of the esophagus, soft-rubber inflating bags and mechanical dilators, opening their jaws by manipulating a screw thread from above, have been advocated. The use of various sized olive dilators, combined, when necessary, with the thread guide, as devised by Plummer, seems most practical. Soft dilators which can be distended with air or water (Plummer's) to which a manometer is attached, to measure the pressure are of ser- vice, particularly for the purpose of diluting spasmodic stenosis. When the patient begins to have pain, then the pressure of the dilating fluid should be diminished. In persistent spasmodic strictures, gastrostomy, with rest to the esophagus and feeding through the fistula temparorily, will often effect a cure. Dilatation of the spasmodic stricture is carried out after op- eration, and the gastrostomy opening is closed later. At times internal section of the stricture can be made by manipulation through an esophagoscope, but this is rather dangerous; or, on occasions, a preliminary gastrostomy, with the subsequent thread-cutting method of Abbe, may be employed. Willy Meyer 1 reports a successful case of im- permeable cardiospasm treated by thoracotomy and esophagoplication. Syphilitic cases require appropriate treatment "6o6,"orneosalvarsan, etc. Thiosinamin (0.06 to 0.12) has been recommended hypodermically every two to three days as an aid to the treatment of benign strictures. Liquid diet is indicated and lavage of the diverticulum or dilated esophagus during medical treatment. In the case of malignant stricture, radical operation may occasionally be possible if the stenosis is high up and there is no great involvement. Preliminary gastrostomy is indicated in such an event. Torek re- ports successful resection of one case through the thorax. Gastrostomy is indicated for the purpose of prolonging life in all malignant cases. For the cure of diverticula operative procedure is usually required. Foreign Bodies in the Esophagus. Foreign bodies may be classified as inorganic and organic. The former are subdivided into smooth, round bodies such as coins, beads, pebbles, etc., and into irregular, sharp bodies such as nails, pins and glass. Organic substances consist of vegetable substances which swell in the presence of fluids such as beans, those which do not swell, and also animal bodies. Symptoms. There are primary symptoms resulting from the im- pacture of a foreign body in the esophagus. There is first a voluntary effort at expulsion, and with failure of this, a temporary spasm of the glottis, resulting in some cases in severe inspiratory dyspnea, cyanosis, slow heart action and collapse. The initial paroxysm of suffocation varies in severity and may even result in death. These symptoms are due to irritation of the superior laryngeal nerve. The initial symp- toms may entirely subside to be ultimately followed by secondary symp- toms due to the obstruction below, or the initial symptoms may be very slight. Impaction most frequently occurs at the beginning of the 1 Jour. Amer. Med. Assoc., May 20, 1911. 60 DISEASES OF THE STOMACH AND INTESTINES esophagus opposite the sixth cervical intervertebral cartilage, behind the cricoid; second in the thoracic part opposite the fourth dorsal vertebra, where the left bronchus crosses, and third at its termination where it passes through the diaphragm. There may be only moderate spasm followed with slight difficulty in swallowing. However, pain, dysphagia, regurgitation, nausea, vomiting, singultus, cough, hoarseness and hemor- rhage are symptoms common to impaction in any part of the esophagus. The foreign body may remain impacted, causing only partial obstruc- tion, for a long period. Secondary symptoms such as acute esophagitis, peri-esophagitis, ulcer, perforation, hemorrhage, death from erosion or perforation of the aorta, pneumothorax, etc., may result. Diagnosis. The body should be located by the #-rays. When they are not available the esophagoscope is of service. Treatment. The object may be removed by forceps, special coin catcher, etc., preferably with the aid of direct vision through the esopha- goscope. Occasionally if it is round and smooth it can be pushed into the stomach. Acute Esophagitis. Mechanical, chemical, or thermal irritation (too hot liquids) are the chief causes. It may also accompany acute infectious diseases or result from extension from adjacent tissues. Types. It may be catarrhal, follicular, ulcerative, phlegmonous, or necrotic. Symptoms. With corrosive poisons, inspection of the throat and pharynx often makes the case clear, and there may be vomiting of necrotic mucosa streaked with blood. Pain, dysphagia, and thirst are present in most cases, with expectoration of mucus in the milder types. Pain is increased on swallowing dry or hard food or very hot or cold fluids. Instrumentation is painful ; occasionally perforation may take place in the phlegmonous or necrotic types. Treatment. Antidotes and emollients are indicated in the cases due to poisoning, and also immediate lavage. Olive oil with bismuth in sus- pension is of value, and hot or cold external applications. Small bits of ice dissolved in the mouth may furnish temporary relief. Rectal feeding may be temporarily indicated. Rarely a hypodermic of morphin or codein may be required. The occasional use of a 2 per cent, cocain or eucain spray may render swallowing less painful. Chronic Esophagitis. This type of esophagitis occurs most frequently in alcoholics or is secondary to cardiac or pulmonary disease of long stand- ing. It may follow an acute esophagitis or be secondary to an inflam- matory condition occurring with carcinoma of the esophagus, dilatation, or a diverticulum. Thrush may also extend into the esophagus. Pathology. There are grayish streaks of degenerated epithelium on the summit of the longitudinal folds and an increase of mucus. The mucosa may be dusky red or bluish and have a granular appearance, with local areas of desquamation or ulceration. Symptoms. There may be uneasiness or difficulty in swallowing and a feeling of distress behind the sternum, which persists after irritating food or drink. The symptoms may be masked by those of the primary disease. Treatment. The main indication is removal or treatment of the cause. GENERAL METHODS OF PHYSICAL EXAMINATION 6 1 Alcohol, spiced foods, acids, and hot fluids are to be avoided. Demulcents and soft food are indicated. Occasionally, local application of a weak solution (i per cent, of silver nitrate or tannin) may be of value. Bismuth subnitrate, 30 grains (0.2), suspended in i to 2 ounces of olive oil, three times a day, particularly before food is given, is useful when there are erosions. Ulcers of the Esophagus. Etiology. Severe burns from the ingestion of acids or alkalis, syphilis, typhoid, cancer, and tuberculosis may pro- duce local ulceration of the esophagus. Decubital ulcers may occur in emaciated persons who have suffered from wasting disease. They usually are found at a level with the cricoid cartilage, resulting from pressure, probably of the esophagus, between the larynx and vertebrae when in the dorsal position. Pressure ulcers may result from circulatory interference of growths encroaching on the esophagus. Uremic ulcers occasionally occur and peptic ulcers are probably the most common. The latter possibly result in part from regurgitation of the gastric juice. The peptic ulcer of the esophagus resembles that of the stomach. In some cases it lies just above the orifice of the cardia, while in others it begins in the stomach and extends through the cardia into the esophagus. Symptoms. In some cases esophageal ulcer is latent during life, while in others there are no symptoms until perforation takes place. Dysphagia and hemorrhage may occur. If the ulcer lie well up in the esophagus, there may be local pain on swallowing at the site of the ulceration; while with the peptic type the pain lies behind the sternum or at the level of the ensi- form. It may radiate to the back. The pain usually occurs on swallow- ing or immediately afterward, and is thus earlier than with gastric ulcer. Diagnosis. During active hemorrhage no instrumentation should be employed. About ten days later, the gentle passage of soft stomach- tubes of various size may enable one to determine the sensitive area of the ulcer. Olives of various sizes with a flexible stem may be cautiously em- ployed for the same purpose. In some cases one may examine carefully with the esophagoscope without the mandrin, with the light turned on, as in the case of removal of foreign bodies. Einhorn recommends locating the ulcerated area by the thread method. The patient swallows about 2 feet of No. 15 braided surgeon's silk, the end being tied about the patient's ear. This is left in situ for two to three hours and then withdrawn. Blood will stain the thread where it passes over the ulcerated surface, and its distance from the mouth can thus be located. This method for esophageal ulcer is much more accurate than when employed for gastric ulcer, for obvious reasons. It is worthy of trial in the former, but the writer does not believe it of value for the diagnosis of duodenal or gastric ulcer. Perforation of the Esophagus. Intense thoracic pain, dyspnea, and collapse are the salient symptoms. Pneumothorax or hydropneu- mothorax may follow. If perforation occur high up in the neck, local inflammation may result. Perforation may also take place into the mediastinum. If perforation occurs below the diaphragm, subphrenic abscess or peritonitis may follow. 62 DISEASES OF THE STOMACH AND INTESTINES Treatment of Ulcer. For hemorrhage, morphin, % to y grain (0.008- 0.016), should be given by hypodermic injection. Adrenalin chlorid (i: 1000), 5 to 10 drops in y% to i ounce of water, is to be administered by mouth for the local styptic effect. Gelatin solution or Tremoliere's solution, as described under Gastric Ulcer, should also be given. A piece of cracked ice may be swallowed and an ice-bag applied externally. Rectal feeding should be employed for a few days, and subsequently liquid diet for several weeks. The patient should remain in bed. Bis- muth subnitrate in 3o-grain (0.2) doses should be begun on the second or third day in i ounce of water by mouth, four times daily. Tincture of belladonna, 10 drops, four times a day, in i dram (4.0) of water can be given for the spasmodic pain. If the ulceration be syphilitic, as shown by the Wassermann reaction, "606," neosalvarsan, or appropriate antiluetic treatment should be instituted. Tubercular ulcer may receive local treatment through the esophagoscope and at times ulcers of other types. A bougie should occasionally be cautiously passed to prevent stenosis. If symptoms of the last occur, treatment should in any event be at once begun. If recurrent hemorrhages occur or stenosis becomes progressive, a gastrostomy is indicated. The stricture should be ultimately divided. If perforation occurs, operation is indicated. Its character depends on the location of the perforation. Gastrostomy is also indicated in connection with the emergency opera- tion, in order to give rest to the esophagus and thus enable one to feed the patient. Syphilitic Paralysis of the Esophagus. R. Saundby 1 reports a case of syphilitic paralysis of the esophagus. The patient had difficulty in swal- lowing, with regurgitation of fluids. There was no obstruction to the passage of a sound. For eight days it was necessary to feed him by a tube. Under antisyphilitic treatment he made a rapid recovery. Stricture of the Esophagus. The method of determination of stricture of the esophagus, malignant, benign, and that due to cardiospasm of persistent type, with resulting fusiform dilatation of the esophagus, has previously been described. Lerche 2 describes three cases of membran- ous stricture of unknown origin. Diffuse Dilatation of the Esophagus without Anatomic Stenosis (Cardiospasm). Diffuse dilatation of the esophagus without anatomic stenosis, occurs with cardiospasm, but as it is also due to other causes Plummer 3 justly holds that a change in nomenclature would be advisable. Some term this condition an idiopathic dilatation. Etiology. The following have been considered factors in the produc- tion of this condition: primary cardiospasm; primary atony of the muscula- ture of the esophagus; simultaneous development of paralysis of the cir- cular muscles of the esophagus through degeneration of the vagi with cardiospasm; congenital; primary esophagitis; kinking of the hiatus esophagi, gross lesions of the esophagus or stomach; congenital or acquired asthenia, and vagotonia. 1 Brit. Med. Jour., Jan. 31, 1914. 2 Journal A. M. A., April, 10, 1913. 3 Journal A. M. A., Aug. 15, 1908, and June 29, 1912. GENERAL METHODS OF PHYSICAL EXAMINATION 63 Cardiospasm may occur with sight dilatation of the esophagus above the point of spasm or with no dilatation at all. The writer has referred to cardiospasm as seen occasionally in neurasthenics. Symptoms. These patients complain of distress or difficulty in swal- lowing, choking, dragging under the sternum and discomfort or pain in the epigastrium. Regurgitation, often described by the patient as vomiting, frequently occurs early in the disease and within a few minutes to an hour, the food is partly or completely expelled. In some cases food taken at a previous meal is regurgitated. The third stage is characterized by irregular regurgitation, with the discharge of food while lying down, with the patient being occasionally wakened by food in the mouth or nose. There are loss of flesh and strength; aspiration and tests show that the food in these extreme cases comes from the esophagus. In mild cases we may secure the food both from above the stenotic area and from the stomach and compare them analytically. Sounds,- bougies and the z-rays confirm the diagnosis. The esophagoscope is sometimes indicated for exploration. I rarely find it necessary. Treatment. Plummer's hydrostatic dilator under pressure of 675 mm. of Hg. as an average, has benefited many cases. The degree of pain has been considered a measure for the dilatation and when such is complained of, dilatation should be stopped. Operation may at times be required such as that of Mikulicz. Temporary gastrostomy to rest the esophagus, may be indicated, and Willy Meyer reports a successful thoracotomy and esophagoplication. Atropine gr. Koo-^o t.i.d., bro- mides, valerian and tonics are particularly indicated when vagotonia is the cause. Liquid diet of high caloric valu with cream butter, etc., is indicated, also esophageal lavage. Carcinoma of the Esophagus. Cancer may occur in any part of the esophagus, with resulting stenosis and infiltration of the neighboring structures. In the English-speaking countries, statistics show that cancer of the esophagus is only slightly less frequent than carcinoma of the stomach. The disease is most frequent in the male and usually occurs between the ages of forty and sixty years. The squamous-celled epithelioma is the most common, or the adeno- carcinoma. Occasionally the growth is of the soft, fungating, cauliflower type. Stenosis results, with dilatation of the esophagus above the point of stricture. Symptoms. In a patient over forty years of age, in whom there is no history or any cause that might produce a cicatricial stricture of benign type, where dysphagia (difficulty in swallowing food) gradually develops, when stenosis is determined by examination and the patient is rapidly losing weight and strength, carcinoma is properly the diagnosis. Regur- gitation of food is present, and the higher the obstruction, the sooner it occurs. The food regurgitated or aspirated is alkaline and contains no gastric secretion. Blood (visible or occult) and also pus are present later when ulceration has occurred. One of the recurrent laryngeal nerves may become involved and there may be dyspnea and a hoarse voice. If the sympathetic system is affected, there may be contraction of the pupil on 64 DISEASES OF THE STOMACH AND INTESTINES that side, with ptosis and sluggish reaction to light. There is a feeling of pressure and sometimes severe pains are present near the seat of the growth or radiating into the shoulders and back. Cachexia and marked anemia develop. Occult blood may be found in the feces. The cervical and supraclavicular glands are often palpable later in the Course of the disease. The growth, with enlarged glands, if it be in the neck above the level of the sternum, is palpable quite early. The growth usually extends into the surrounding tissues, involving eventually the blood-vessels, nerves, pleura, lungs, diaphragm, peri- cardium, mediastinum, and glands. The method of examination for all types of stenosis has already been described. Syphilis should be excluded by the Wassermann and Noguchi tests. Early Diagnosis. When a patient complains of difficulty in swallow- ing arousing in the physician's mind the suspicion of a commencing stenosis of the esophagus, local examination should be immediate. With a normal esophagus, the impression to the fingers guarding the sound is that of a smooth elastic surface while with a change in the tissue or a slight narrowing from benign or malignant cause, an uneven surface is felt. The author's flexible esophageal bougie is particularly adapted for detecting such. Radiography should be employed in every case. Bassler's 1 method by plugging the cardia and injecting bismuth and then radiographing, and the use of goldbeater's skin and animal mem- brane bags have been previously described. Esophagoscopy has also been employed to detect a commencing growth, and a section of the latter has been removed for examination. There is the possible danger of inflammation and perforation. Exploratory thoracotomy has also been suggested. Treatment. Gastrostomy is indicated and later complete excision of the growth, if such be possible. Gastrostomy in any event allows feeding the patient through the fistula and thus prolongs life. Franz Torek has performed intrathoracic resection successfully in one patient and there has been one other successful case. Three years and two months have elapsed and Torek informs me the patient is still in perfect health. Willy Meyer 2 describes various methods of extrathoracic and intrathoracic esophagoplasty in connection with resection of the thoracic portion of the esophagus. If consent cannot be obtained for operation, lavage of the esophagus above the stricture, liquid diet, cocain (2 per cent, spray), or eucain (3 per cent, spray) before eating, and hypodermics of morphin, > to y grain (0.008-0.016), to relieve pain, are indicated. The ingestion of olive oil, % to i ounce before each feeding, aids the passage of food through the stricture, just as it is of value in pyloric stenosis for the same purpose. Local treatment with radium and cautious dilatation may be tried. The writer considers the condition usually fatal and palliative operation (gastrostomy) only justifiable in advanced cases. In early cases there 1 Journal A. M. A., April 26, 1913. 2 Journal A. M. A., Jan. 10, 1914; also Transactions Surgical Section, A. M. A., June, 1913; Surgery, Gynecology and Obstetrics, Dec., 1912. GENERAL METHODS OF PHYSICAL EXAMINATION 65 appears to be some hope of success by a more radical procedure. Torek's result is certainly brilliant. I refer my readers for operative treatment to Torek's article in the Annals of Surgery, April, 1915. Benign Growths of the Esophagus. These are rare and usually of small size, such as fibroma, papilloma, myoma, fibromyoma, and lipoma. They may be single or multiple, pedunculated or sessile. The symptoms are those of a mild stenosis. The esophagoscope will determine their presence and in some cases they can be removed through it by a snare. Examination of the Abdomen. The special methods of physical ex- amination of the stomach and intestines are described in the parts of this volume devoted to these subjects. It seems advisable to refer to the general methods of examination of the abdomen and the other viscera. Anatomic Landmarks. The ensiform appendix and down-curved arches of the ribs constitute the upper bony landmarks. The iliac crests, Fig. 26. Topographic areas of the abdomen. anterior superior spines of the ilia, and the symphysis pubis in the median line are the lateral and lower boundaries. The linea alba lies between the recti muscles in the median line, runs from the ensiform appendix to the pubic symphysis, and is visible as a groove above the umbilicus. The umbilicus is somewhat variable in its position, though usually lying about 2 inches above the bispinal line drawn transversely between the anterior superior spines of the ilia or about the level of the crests of the ilia. The recti muscles lie on each side of the linea alba and are bounded externally by the lineae semilunares, which run with an outward curve from the lowest part of the seventh rib to the pubic spines. These lines lie on each side about 3 inches from the umbilicus. Topographic Areas. In order to describe the situation of organs or 5 00 DISEASES OF THE STOMACH AND INTESTINES lesions, the surface of the abdomen is divided into regions, of which the method depicted in Fig. 26 is in general use. There are nine regions divided off by four lines, two horizontal and two vertical. The horizontal lines are the infracostal or subcostal, drawn transversely at the level of the inferior borders of the tenth ribs, and the bispinal line, connecting the anterior-superior spines of the ilia. The vertical lines pass through the center of Poupart's ligament on each side and are downward prolongations of the mammillary lines of the thorax. The boundary lines between the epigastric and hypochondriac regions correspond with the costal margins, and the iliac regions correspond to the so-called inguinal regions. A second method of dividing the abdomen is by a vertical and trans- verse line through the umbilicus, forming four quadrants. In reference to the various landmarks, one often measures distances by the finger-breadth. The average finger-breadth is % inch; two, ij inches; etc. A hand-breadth averages 3^ to 4 inches. Preparation of the Patient and Technic. The patient should pref- erably lie in bed in the dorsal position, quite flat, with the head on a single thin pillow. The same posture should be assumed if the examination be made on the office table. The bedclothing should be drawn well down, except the sheet, under cover of which the nightdress or undershirt should be drawn up to the lower sternum, and the sheet then folded down to a short distance above the pubes. The sheet may not be required in the office, though generally preferable. The patient should lie as symmetrically as possible, with the pubic spines at the same level and a good light secured. It is of value to make an observation also in the sitting or standing position, as prolapse of the abdominal walls or viscera can thus be more clearly seen. Inspection. Inspection should be from the front, sides, and back. It is of great importance. With excessive abdominal distention the skin is smooth, shining, and stretched. Copper-colored, scaly, somewhat circular spots are significant of secondary syphilis; and whitish streaks, or striae, of long-continued distention, such as from pregnancy or ascites. Typhoid eruption or exanthemata may in some cases be in evidence. Glandular enlargements in the groin or old scars are suggestive of venereal infection. Inguinal, umbilical, or femoral hernia may be observed. Inspection of the blood-vessels often affords valuable information. Enlarged veins radiating from the umbilicus (the caput medusas) are significant of portal obstruction, cirrhosis, or tumor of the liver. General enlargement of the abdominal veins may be present in similar conditions, or from pressure on the venae cavae by thoracic or abdominal tumors. Distended veins lying over the liver in the right lower thorax are also suggestive. If a dilated lateral vein is present running up the right midaxillary line, it should be emptied by massage, and the method of its refilling carefully observed. If the portal vein, or the inferior vena cava, is obstructed, the direction is upward; but if the superior vena cava is pressed upon, the direction is downward. GENERAL METHODS OF PHYSICAL EXAMINATION 67 Distention of the veins in the pubic region alone shows some probable obstruction below the liver. Enlarged epigastric arteries are diagnostic of obstruction of the aorta or iliacs. An umbilicus that protrudes is suggestive of hernia, ascites, pregnancy, or some form of abdominal distention. Absence of respiratory abdominal movements, with accentuation of thoracic respiration, is significant of peritonitis. Peristaltic unrest (visible peristalsis) is usually diagnostic of stenosis of the pylorus or intestines or of intestinal obstruction. It may rarely occur normally in thin persons. Stomach Stiffening of Cohnheim. On stroking the epigastrium, the stomach-walls are seen to stiffen and peristaltic waves appear. These indicate some obstructive lesion of the pylorus. Peristalsis. One can at times infer the site of the obstruction by the location and character of the peristalsis. The waves run in the stomach from left to right and in the transverse colon from right to left. If the obstruction is near the ileocecal valve, the swollen and moving coils of the intestine lie one above the other in the central part of the abdomen (ladder pattern). If the constriction is lower down in the large intestine, the distention is chiefly visible in the course of the colon (in the cir- cumference of the abdomen). A recurring protuberance at one point, disappearing with a loud ^dBH***^ ^. .V, sound, is probably near the point of stenosis. Finally peristalsis may dissappear and we may have Fig. 27. Abdominal palpation, the barrel-shaped abdomen of chronic obstruction. Protrusion from a tumor can at times be observed. Method, of Abdominal Palpation. The right hand should be warmed and laid flat upon the surface of the abdomen, the physician sitting to the right of the patient (Fig. 27). Palpation should be at first with somewhat circular pressing move- ments, sliding the skin over the parts beneath, and passing from one portion of the abdomen to another. One should not poke suddenly with the finger-tips. Gradually deeper localized palpation may be made with the finger-pulps to determine the presence of tender spots, or the shape, size, and mobility of existing masses or swellings. 68 DISEASES OF THE STOMACH AND INTESTINES The facial appearance of the patient rather than the verbal expression tells whether true pain is present. Tenderness suggests inflammation or ulceration. McBurney's point should always be explored for appendicitis, and also Morris' point and the left lumbar ganglia, Meltzer's method for determination of appendicitis should be used and the Blumberg sign for peritonitis should be applied over the appendix, gall-bladder, etc. The head zones for the appendix, gall-bladder and stomach should be tested for. In chronic cases of appendicitis, the Rovsing- Chase, Meltzer's, or Bastedo's method could be tried. They are all described in the chapter on appendicitis. Robson's point for pancreatitis, Murphy's point over the gall-bladder, Brewer's point of tenderness, at the costo-vertebral angles over the kidneys, Moynihan's point over the duodenum and the epigastric and left dorsal tenderness of gastric ulcer should all be tested for. Right dorsal tenderness, slightly lower than the left dorsal for gastric ulcer, occurs at times with gall-bladder in- flammation (Boas point). If firm pressure elicits tenderness, it is apt to be real and deep seated, rather than a surface lesion or hyper- esthesia. If hysteria is suspected, the pa- tient's attention can be diverted by pressing on a different part of the surface with one hand, while the other hand explores the original seat of pain complained of. Absence of true tenderness . is thus frequently revealed. If the abdominal muscles are con- tracted, the knees and thighs should be flexed and a pillow placed be- neath the head and shoulders to secure relaxation. The flexion of the lower limbs I believe preferable in every case. Deep and rapid respira- tions at the end of expiration relax the muscles momentarily and render examination more easy. This method aids in differentiation, whether the mass felt is due to contrac- tion of the belly of a muscle, such as of the rectus, and whether a tumor is movable with respiration. Howard Kelly recommends vibratory move- ments with the fingers while palpating. In some cases reinforced palpation, the left hand exerting pressure over the right, as in Fig. 28, is of value, especially in examination of the deeper organs. During examination forced respiration should be taken, and at each expiration the abdominal wall should be pressed upon firmly, maintaining during inspiration the ground which has been gained. This method is of special service in determining a chronic enlarged appendix. If there is fluid in the peritoneal cavity and one desires to palpate Fig. 28. Reinforced palpation. GENERAL METHODS OF PHYSICAL EXAMINATION 69 an organ which is obscured by its presence, sudden deep pressure with the finger-tips ("dipping") will displace the fluid. In some cases a general anesthetic may be necessary for a thorough examination. All the regions of the abdomen should be explored, the umbilical, the inguinal, and femoral regions being examined for hernia. Bimanual Method. When the lateral regions are examined, both hands should be employed, one being slipped under the body so as to make forward pressure between the last rib and iliac crest, thus pushing forward the structure against the examining hand in front. At times it may be of service to examine in the knee-chest position, or with the patient standing and leaning forward, supporting himself with the hands by a table or chair. If he is very fat, it is often useful to have him turn partly on the side, thus "spilling" the intestines and fatty abdominal walls away from the region under investigation. Digital rectal and "vaginal examination are advised in all cases, especially when the lesion is suspected in the lower third of the abdomen. There is a method of abdominal examination used abroad which I have not seen recommended in our text-books. This is the practice of making abdominal, or bimanual, vaginal examination of the patient while in a very hot bath. In many instances the abdominal relaxation thus obtained nearly equals that while under an anesthetic, with the additional advantage that the patient can help the examiner by volun- tary movements, such as deep inspiration, holding the breath, etc. The examination can be made in an ordinary bath-tub in water as hot as the patient can bear. If it is necessary to have the patient higher in the tub, a long sheet can be let down over the tub into the water and fastened about the ends of the tub by knotting the corners under the rolling edge, or by passing clothesline beneath the tub. The patient is thus suspended in a hammock. Movable Kidney suggests gastroptosis. The Recti Muscles. Diastasis of the recti muscles suggests gastroptosis. Rigidity of one or both of the recti muscles is of great diagnostic im- portance, being significant of peritoneal irritation, local peritonitis (if one muscle be involved), or general peritonitis if both recti and all the abdominal muscles are affected. Occasionally a rigid rectus is found on the side of a pneumonia or diaphragmatic pleurisy. The upper segments 1 of one or both recti may be rigid in abscess of the liver, or in subphrenic abscess, or of the right rectus in acute cholecystitis ; the right rectus, especially the lower segment, in appendicitis; and the lower left rectus in diverticulitis, or in left-sided pelvic inflammation. Boston's Method of Double Palpation. Boston 2 recommends a special technic in palpation which I have sometimes found of service. He em- ploys the index-fingers of his two hands and compares the degree of tension over various portions of the abdominal surface. In normal sub- jects, in the dorsal position with the thighs flexed, there is a slight increase 1 The upper right rectus may be rigid in duodenal ulcer, and the upper left rectus in gastric ulcer, or phlegmonous gastritis. 2 N. Y. Med. Jour., Nov. i, 1913. 70 DISEASES OF THE STOMACH AND INTESTINES in tension below the right margin of the ribs (hepatic tension). This area when compared with the same region in the left upper abdominal quad- rant offers slightly more resistance to the palpating finger. Comparing the two sides of the abdomen up to 2 inches above the level of the umbilicus, there is the same degree of resistance offered to the two palpating fingers. No difference in the degree of resistance on the two sides of the abdomen below the umbilicus can be appreciated during health. Begin on each side immediately above Poupart's ligament, ascending in lines drawn through its center to the costal border. The two halves of the abdomen should be compared at equal levels as one ascends. The entire abdomen should be palpated ascending on each side from the inferior abdominal re- gion with the index-finger simultaneously and at the same level to the costal margin, following lines approximately 2 inches to the right and the same distance to the left of the original lines first mentioned. One can elicit slight localized increase in tension even over commencing lesions, such as enlargement of the liver, spleen, kidney, uterus, cystic and ovarian growths, fecal impaction, early carcinoma, etc. Prolapse of a viscus causes lessened resistance to the finger when palpating over its normal position and increased tension over its abnormal position. Local- ized inflammation is accompanied by undue tension over that area, as in acute appendicitis, pyosalpinx, gastric cancer and any condition ac- companied by local peritonitis. As posture may alter the degree of tension, this method should be carried out also with the patient on the right and left side and also standing. Mensuration of the circumference of the abdomen at the level of the umbilicus and of the length of its anterior wall from the ensiform to the symphysis, are of use in noting the increase in ascites or the growth of a large tumor. An uneven protuberant surface is characteristic of a malignant growth; an even surface is more often found with benignant neoplasms or intussusception. A fecal tumor can usually be indented, and as the finger is raised the intestinal wall slips from the mass. (Gersuny's symptom). Percussion of the Abdomen. With the exception of pulmonary reso- nance, which we note in defining the upper limits of the stomach and liver, and splenic and hepatic dulness, the normal abdomen is tympanitic. From the presence of food in the stomach or fecal accumulation in the intestines there are variations, with resulting dulness or even flatness. The percussion note over the cecum, the sigmoid flexure and lower part of the descending colon is quite frequently dull, owing to the tendency to fecal accumulation in these regions. In general, we may say that the pitch of the resonant note varies with the size of the air space and the degree of tension of the containing cavity; the smaller the air space and the greater the tension, the higher is the pitch. Hence, the empty stomach and colon would afford a lower pitched note than the small intestine. The presence of food and liquid in the stomach modifies the results of percussion, as do also feces in the large intestine. For example, with an empty stomach we have tympanites; and then quite frequently a change in note over the transverse colon to dulness or even flatness; or GENERAL METHODS OF PHYSICAL EXAMINATION 71 with the partially full stomach and empty intestine, tympanites, above, then' dulness or flatness over the contents and intestinal tympanites below. It is well, therefore, to have the large intestine cleared out by enema before examination. Practically we find in many cases stomach tympanites with change in note over the colon due to some contents. Fig. 29. Simple percussion. Among the best methods of percussion are simple percussion with the finger or hammer, flicking percussion, auscultatory percussion, and the "scratch method" of auscultation. - In simple percussion, the middle finger of the left hand should be laid flat on the abdomen (the pleximeter) and the middle finger of the right hand, bent at right angles, should be employed as the plexor, as Fig. 30. Percussion hammer. depicted in Fig. 29. The other fingers and thumb should be folded into the palm of the hand. In Fig. 30 is shown the method with the percussion hammer and the correct position. The finger is preferable as a pleximeter, as the rubber instruments interfere with the sounds. Light percussion ("piano percussion") was first suggested by John B. Murphy to determine the seat of the primary focus of a general peri- 72 DISEASES OF THE STOMACH AND INTESTINES tonitis. H. Neuhof 1 advocates the employment of deep percussion in subacute and subsiding intraperitoneal infections as an aid to localizing the lesion. A fair amount of percussion force may be required, the pleximeter finger being pressed in deeply. If this gives doubtful results then tap vigorously the abdominal wall with the crooked middle finger of the right hand. The presence of percussion tenderness by these methods locates the trouble. This is of particular value in stout patients who are difficult to palpate. "Flicking percussion" is useful in detecting slight degrees of dulness. The forefinger or middle finger of the left hand should be placed nail downward on the surface; the middle finger of the right hand is well flexed, so that the nail is pressed against the palmar surface of the thumb. It is then suddenly allowed to escape, so as to strike sharply against the palmar surface of the finger lying on the abdomen (Fig. 31). Auscultatory percussion is probably of greatest value in outlining contiguous air-containing viscera. Fig. 31. Flicking method of percussion. The stethoscope is placed over the organ and the normal note secured by percussion close to the instrument. Then percussion is carried out, beginning at some distance, from above, below, and laterally, and the change of note observed. This method and the "scratch" method will be described later in outlining the position of the stomach and intestines. If the percussion note of a deep-seated mass is to be elicited, the pleximeter finger must be pressed slowly and firmly down in order to push aside or compress air-coils of intestine which would mask the note. If dulness is present where it should not exist, it should be ascertained whether it disappears or shifts with changes in the position of the patient, i.e., whether it is fluid. If the distention is due to ascites (fluid), the center of the abdomen is flattened and the lateral and dependent portions bulge outward, pro- viding the fluid is not excessive. If it is very great, the abdomen is 1 Medical Review of Reviews, June, 1912. Fig. 32- Relations of the viscera. Anterior view: L, L, Lungs; A, heart; B, liver; C, stomach; oc, gall-bladder; D, colon; E, small intestine. GENERAL METHODS OF PHYSICAL EXAMINATION 73 arched and prominent, the umbilicus is bulging or stretched, and the shape is not changed when the posture is altered. On percussion, the flanks are dull and the center of the abdomen tympanitic, as the intestines float to the highest point. Unless the quantity of fluid is excessive the line of dulness changes its position, as the patient is turned on the side, the fluid gravitating to the lowest point and being replaced by the tympanitic intestine. The upper flank, previously dull, is now tympanitic. If a small amount of fluid is sus- pected, percussion of the umbilical region in the knee-chest position will give dulness when it was tympanitic in the dorsal position. Fluctuation may be elicited if there is considerable fluid. The ulnar edge of a nurse's or assistant's hand should be pressed firmly on the linea alba, to cut off muscular vibrations. One hand of the examiner is placed upon one lateral abdominal wall, while he should tap sharply with the fingers on the opposite side. If fluid is present, a transmitted wave at times visible will be felt by the palpating hand. With tumors, enlargement of the abdomen is not symmetric. Per- cussion does not show the uniform resonance of gas nor the lateral dulness and central tympanites of fluid, and palpation demonstrates the solidity of the mass. With gas, the abdomen is arched and tense, universally tympanitic, and fluctuation cannot be obtained. Sources of Error. The segments of the recti muscles when contracted may simulate a small tumor. By insinuating the tips of the fingers under the edge of the apparent tumor and having the patient raise the head and shoulders, the muscle is felt to contract and thicken. A localized contraction of the abdominal muscles or a persistent gaseous distention of a portion of the intestines ("phantom" tumor) may be deceptive. These occur, as a rule, in hysteric women and are dull or tympanitic, depending on the above conditions. They disappear during rapid forced respiration or under anesthesia. Fitz believes that some "phantom" tumors are congenital or acquired dilatation of the colon. Auscultation of the Abdomen. Sounds in the Abdominal Cavity. In the healthy intestines there are always bubbling or gurgling sounds heard on auscultation. The entire absence of sound is significant of intestinal paresis. With mechanic obstruction the sounds are usually increased in in- tensity and number. With intestinal paresis, usually due to peritonitis, the heart and respiratory sounds may be audible over the entire abdomen. This is not true in tympanites due to other causes. Crepitation or friction sounds are at times heard in peritonitis, as in perihepatitis in the right hypochondrium, or in the left hypochondrium with perisplenitis. The venous hum or aneurysmal bruit of abdominal aortic aneurysm can be appreciated, or occasionally a venous hum over the liver from pressure on the vena cava. If pregnancy is present, there are the fetal 74 DISEASES OF THE STOMACH AND INTESTINES heart sounds. The sounds over the stomach are of little diagnostic value, except the duration of the swallowing sound. TOPOGRAPHIC ANATOMY The position and relations of the stomach and intestines have been described, but for the purpose of physical diagnosis we must briefly refer to the normal relations of the other abdominal viscera. In Fig. 32 are depicted diagrammatically the relations of the organs on the anterior surface of the body, and in Fig. 33 the relations on the posterior surface. Fig. 34. Delimitation of the normal liver (diagrammatic) : G, Gall-bladder. The Liver. The general shape is that of a wedge with its base in the right hypochondrium, the upper surface lying in relation to the vault of the diaphragm, an.d its lower surface with the stomach, duodenum, gall- bladder, transverse colon, and small intestine; its anterior, lateral, and posterior portions are in relation with the abdominal parietes and lower right ribs. Delimitation of the Normal Liver. Mark a point i (Fig. 34) at the lower border of the fifth rib, between the left parasternal and mammillary lines, or about 2 to 2% inches from the left edge of the sternum. Point 2 lies in the fourth right intercostal space in the mammillary line. From 2 to i draw a connecting line, slightly convex upward on the right half and concave on the left, curving down at the lowest point to the base of the ensiform appendix. From 2 draw a line nearly horizontally to the right and posteriorly, which should cut the midaxillary line in the seventh space and the scapular GENERAL METHODS OF PHYSICAL EXAMINATION 75 line in the ninth space, to the midspinal line. This line, front, side, and back, corresponds to the upper border of the liver. To delimit the lower border, mark point 4 in the median line (linea alba) about a hand-breadth (3^ to 4 inches) below the base of the ensiform process of the sternum. Mark point 3 at the lower edge of the ninth right costal cartilage, and another point 5 at the edge of the left costal arch on a level with the lower border of the sixth rib. A line should then be drawn from 3 to 4 upward and to the patient's left. At 4 is indicated the notch between the liver lobes. From 4 a slightly curved line to i, passing through 5, should next be drawn. The line from 3 to i indicates the lower an- terior border of the organ. From point 3 draw a line back- ward and to the patient's right, cut- ting the tenth intercostal space in the midaxillary line, from which point it joins the spine at a level of the elev- enth rib (Fig. 35). This line demarks the lower border of the liver laterally and posteriorly, and is a continuation of the anterior-inferior border. This illustration shows diagram- matically the relations of the lower borders of the lung, pleura, and liver in the midaxillary line. The left lobe lies to the left of the linea alba and extends nearly to the nipple, the notch lying in the midline. In the right mammillary line the liver extends from just below the level of the nipple to the costal margin. The horizontal shadings in Fig. 34 show the portion of liver overlapped by lung, and the vertical shadings, that overlapped by the heart. The gall-bladder, which is pear shaped, lies just internal to the ninth right costal cartilage. Fig. 35. Lower border of liver (mid- axillary line). PHYSICAL EXAMINATION OF THE LIVER AND GALL-BLADDER Inspection. -The method advocated by M. Knapp I have found most practical. The patient stands with the abdomen uncovered facing a good light, the examiner slightly to the patient's right, so as not to interfere with the exposure to light. The lower edge of the enlarged liver shows on the abdomen as a linear transverse shadow, moving up and down with respiration and being especially prominent at the close of expiration, when there is a sudden check to the movement. Pulsation 76 DISEASES OF THE STOMACH AND INTESTINES can occasionally be observed. Extreme enlargement may cause fulness in the right hypochondrium. An enlarged gall-bladder can be appreciated in the same manner. Inspection may also be made with the patient in the dorsal position, the examiner stooping so as to bring the eyes on a level with the abdomen. Palpation. The head and shoulders should be slightly raised and the knees and thighs flexed, the patient being in the dorsal position. The examiner, sitting on the right side of the patient, should lay the right hand flat on the abdomen below the right costal arch, the fingers pointing upward and obliquely inward just to the right of the right rectus. Depress the fingers and feel for the resistance edge of the liver. The patient should be directed to take deep respirations, and by pressing in- ward and upward with the fingers the edge of the organ can be felt to move up and down. As the liver may be enlarged, palpation for its lower edge must be begun from the level of the umbilicus upward. It is often necessary Fig. 36. "Spilling" the liver. to feel for the notch of the gall-bladder or round ligament to determine whether it is the edge of the liver which is felt on palpation. One should note whether the edge is sharp or thick, or smooth or irregular. In some cases with thick abdominal walls the liver may be "spilled" against the latter by turning the patient on the right side, as in Fig. 36, thus render- ing palpation more easy. The hand in this case may be in the reversed position. The surface of the liver should be palpated, the left lobe in the epi- gastrium and the portion projecting below the ribs, if it be enlarged. One should observe whether it is rough, smooth, nodular, or whether large tumor-like masses are present; also whether it is hard or soft and fluctuating; or if there is a thrill (hydatid), or friction during respiration, or pulsation. If the abdomen is distended the "dipping" method of palpation may be necessary. The empty gall-bladder is not palpable. If distended it feels like a smooth pear-shaped tumor, moves with respiration, and is movable laterally, unless there are adhesions. GENERAL METHODS OF PHYSICAL EXAMINATION 77 If malignant growth is present, the gall-bladder is irregular and nodular. If there are many gall-stones, Hutchinson describes the feel as of a "bag of nuts." Percussion of Liver and Gall-bladder. For anterior and lateral percussion the patient should lie down; for percussion posteriorly he should be sitting or standing, or if very ill, lying on the belly. The upper part of the right lobe is overlapped by the lung, and of the left lobe, a small area is covered by the left lung and heart. Percussion over the covered part gives impaired pulmonary resonance, or modified dulness (deep, relative, or covered hepatic dulness). The part in contact with the parietes gives absolute dulness (superficial or exposed dulness). It is necessary to delimit the entire area. Percuss downward, first in the mammillary line, beginning at the second intercostal space; then in the midaxillary line from the fourth interspace, and in the scapular line from the angle of the scapula. Percussion should then be made from below upward, in the midline from the umbilicus and from lateral and posterior points below the ribs. Covered Hepatic Dulness. Strong percussion should be employed, commencing above in the areas noted, and watching for the change from pure pulmonary resonance to impaired resonance, which denotes the presence of the liver. Impaired resonance is found normally in the fourth space in the mammillary line; in the seventh space in the midaxil- lary line; and in the ninth space in the scapular line. Upper Limit of Exposed (Absolute) Hepatic Dulness. Gentle per- cussion should then be employed and normally absolute liver dulness appears in the mammillary line at the sixth rib; midaxillary line at the eighth rib ; and in the scapular line at the tenth rib. Lower Limit of Hepatic Dulness. Gentle percussion along the lines previously indicated from below upward will differentiate between tym- panites and hepatic dulness. The lower limit normally is in the median line anteriorly a hand-breadth (3^ to 4 inches) below the ensiform; in the mammillary line, the tenth space. In the scapular line, it joins the dulness of the right kidney. The vertical width of liver dulness is normally in the mammillary line 4 inches; in the midaxillary, 6 inches; in the scapular, 3 inches. Percussion of the Gall-bladder. This is only possible when it is dis- tended or enlarged, in which event there is an area of dulness projecting downward and inward from the lower border of the liver and continuous with the dulness of the latter. In some cases the transverse colon may pass over the neck of the distended gall-bladder and separate its dulness from that of the liver by a tympanitic area. This is important to re- member. Auscultatory Percussion of the Liver. The stethoscope should be placed over the middle of the area of the liver anteriorly, laterally, and posteriorly, and percussion be carried out on the lines already described. As a rule, simple percussion is sufficient; but the auscultatory method is of special value to determine whether a tumor is connected with the liver or not. DISEASES OF THE STOMACH AND INTESTINES Fig. 37- Tumor of liver. Thus, in Fig. 37 the stethoscope is placed over point 5. The note over the tumor T resembles more closely in intensity and quality the percussion note over the liver at C than it does over the point A. 1. Chaujffard' 's l Method of Percussion for Hydatid Cyst of the Liver. Place the left hand under the right side of the thorax of the recumbent patient and percuss with the right hand, with short strokes, the anterior wall of the thorax as well as the epigastrium. Transmission of waves or vibrations to the left hand through the thorax indicates cystic disease. 2. Suprahepatic Ballottement. The left hand is placed on the anterior aspect of thorax at the level of the second and third intercostal spaces, while the right hand hooks around the lower margin of the liver and the attempt is made to drive it upward by a series of sharp pulls. At each pull a slight impulse is transmitted up to the left hand, when there is cystic disease. 3. Transthoracic Hydatid Fremitus. This is elicited when the patient is erect. The left hand is placed across the back below the lower angle of the left scapula and per- ceives, in hydatid disease, light undulatory vibrations, when the fifth or sixth rib is percussed anteriorly with the right index- finger. General enlargement of the liver may be due to passive congestion, usually from valvular disease of the heart, amyloid disease, cancer, fatty infiltration, hypertrophic cirrhosis, leukemia, abscess, gumma, or, rarely, Weil's disease. Circumscribed enlargement of the liver, i.e., of the left lobe, is usually due to abscess, hydatid cyst, gumma, or cancer. Downward displacement of the liver is caused by various intra- thoracic lesions, such as emphysema, effusions, etc., by subphrenic abscess, or as a part of a general ptosis of the viscera. In downward displace- ment the upper surface, especially of the left lobe, is readily accessible to palpation and presents a rounded surface. A prolapsed liver does not move as freely with respiration, on account of its separation from the diaphragm. The consistence of the liver is somewhat diagnostic. It is abnormally hard, dense, and resistant in cirrhosis, carcinoma, amyloid disease, or syphilis. A fluctuating swelling at the lower border may be a distended gall- bladder, abscess, or hydatid cyst. The surface is smooth in fatty infiltration or degeneration, in passive congestion, and in amyloid disease; it is rough in tubercular peritonitis and granular to the feel in cirrhosis. 1 Lejars, Presse Medicale, April 25, 1914. GENERAL METHODS OF PHYSICAL EXAMINATION 79 Hard nodules, varying in size, are suggestive of cancer; smooth, elevated prominences occur with gummata. A smooth projection may be due to abscess or cyst. Topography of the Pancreas. The pancreas (Fig. 38) lies about 3 inches above the umbilicus, midway between the navel and the ensiform appendix, corresponding to the level of the first lumbar vertebra. It is about 6 inches long and lies deep in the epigastrium, transversely across the spine, with its head resting in the curve of the duodenum and its tail extending to the spleen. The stomach covers it in front. It is rarely accessible to direct examination. The head of the organ lies in close relation to the inferior vena cava, portal vein, and common bile-duct, which are posterior. A cancer or growth of the head of the pancreas may press upon these blood-vessels and cause edema and ascites, or upon Fig. 38. The pancreas. the bile-duct and produce presistent jaundice with dilatation of the gall-bladder. Pain, fatty diarrhea, ascites, glycosuria, and jaundice may result from pancreatic disease. The diseases in which these conditions are present are acute hemor- rhagic or suppurative pancreatitis, chronic pancreatitis, and tumor either carcinomatous or cystic. Under Diseases of the Pancreas the author refers his readers for a complete description of the subject. Physical Examination. Normally the pancreas cannot be palpated unless the patient is extremely emaciated. An important physical sign of pancreatic disease is the presence of a tumor in the median portion of the epigastrium, midway between the navel and the ensiform process. It is deep seated and often nothing 80 DISEASES OF THE STOMACH AND INTESTINES more than a sense of resistance can be appreciated by the palpating hand. Tenderness at Robson's point also is diagnostic of pancreatic disease. Topography of the Spleen. The spleen is oval, flattened in shape, and lies in the left hypochondriac region, measuring on an average 5 by 3 inches. It reaches from a point i% inches from the midspinal line posteriorly nearly to the midaxillary line, lying along the ninth, tenth, and eleventh ribs, the long axis being parallel with the ribs and running obliquely forward and downward, as in Fig. 41. The lower two-thirds of its outer surface lie against the lateral ab- dominal wall, and the upper third is overlapped by the diaphragm, which separates it from the lower border of the left lung. The diaphragm lies above and the left kidney posteriorly, and it is in contact elsewhere with the stomach, pancreas, colon, and small intestine. The anterior border is sharp and indented by two to four notches. Fig. 39. Examination of the spleen. " Spilling " the spleen. Physical Examination of the Spleen. Inspection. If the spleen is greatly enlarged, it may be visible as a protuberance extending from the left hypochondrium downward and inward, moving with respiration. Palpation. With the patient in the dorsal position and the knees and thighs flexed, the examiner on the right side of the bed should lay the right hand flat on the abdomen and with the finger-tips exert pressure, pushing obliquely upward under the left costal margin at the tenth cartilage. The edge of the enlarged spleen can, as a rule, then be felt. If it is not palpable, then request the patient to take deep breaths, when the sharp edge of the organ, which is smooth and usually notched, moving with respiration, will be felt riding over the finger-tips and directed downward and inward. The left hand may be placed posteriorly between the ends of the tenth and eleventh ribs and firm pressure be made, so as to tilt the organ forward and thus make palpation more easy. Normally the spleen cannot be felt. If the organ is enlarged a depression or space, into which the finger- tips can be sunk, can be detected at the posterior border of the enlarged spleen between it and the erector spinae. GENERAL METHODS OF PHYSICAL EXAMINATION 8l An excellent method of palpation of the spleen is shown in Fig. 39. By turning the patient on the right side, combined with posterior pressure, palpation is rendered easier. It is often necessary to differentiate between tumor of the left kidney or spleen. The spleen is oval, moves with respiration, is notched, has a sharp edge, a gap is present between it and the lumbar muscles, and it has no tympanitic resonance over it. The kidney is reniform in shape and rounded, has no sharp edge or notch, and is overlaid by tympanitic resonance (Fig. 40). Percussion of the Spleen. The patient may be recumbent, partially turned to the right, midway between the dorsal and right lateral position, Fig. 40. S, Tumor of spleen; K, tumor of kidney. Kidney tumor overlaid by tym- panitic colon. with the left arm extended over the head; or the examination may be made in the sitting posture. Percussion should be light, except over the posterior portion near the kidney. It should be carried out along the lines A, B, C, D in Fig. 41. Anterior percussion at the costal margin along the tenth rib, along A until the tympanites of the stomach is replaced by dulness, usually at the midaxillary line. From above percuss along B, commencing at the level of the angle of the scapula midway between the posterior axillary and scapular lines, passing vertically downward until pulmonary resonance is impaired, generally at the ninth rib. Percuss from below upward along line C, commencing below the border of the ribs, in or slightly posterior to the posterior axillary line, and passing upward until tympanites become dull, usually at the eleventh rib. 6 82 DISEASES OF THE STOMACH AND .INTESTINES Posteriorly percuss strongly from midspinal line at level of the tenth rib and along the latter. Splenic dulness should commence i^ inches from the median spinal line. It is difficult to determine. The area of splenic dulness is oval, 2 to 2> inches by 3 to 3^ inches. Dulness of over 3^ inches, on vertical percussion, shows enlargement. Pleuritic effusion, consolidation at the left base of the lung, and fecal accumulation in the splenic flexure, may obscure percussion of the spleen. Palpation is the most important method and the most accurate. Acute enlargement of the spleen occurs with infectious diseases, MIDAX1LLARY LINE Fig. 41. Lines for percussion of spleen. such as typhoid, malaria, etc., and, in septic processes; chronic enlarge- ment, with leukemia, malaria, cirrhosis of the liver, amyloid disease, pernicious anemia, etc. The organ may be displaced downward by intrathoracic pressure. Abscess, carcinoma, or hydatids may cause an unequal enlargement. Liver and spleen may be enlarged together in passive congestion, cirrhosis of the liver, leukemia, and in amyloid disease. A floating spleen may occur as a result of congenital laxity of its ligaments or to overstretching from the increased size or weight. It may be part of visceroptosis, usually in women. It is recognized by its mobility, shape, sharp edge, and notches. GENERAL METHODS OF PHYSICAL EXAMINATION 83 Topography of the Kidneys. The two kidneys lie against the posterior abdominal wall, one on each side of the spinal column, in beds of fat and connective tissue. They are of reniform shape. The upper end of the right kidney is in contact with the liver, and the left kidney with the spleen. They are retroperitoneal, the ascending and descending colon respectively lying in relation in front. The right kidney lies about y% inch lower than the left. Each organ is about 4 inches long, 2 to 2% inches in breadth, and i inch thick. Surface Relations of the Kidneys. Draw a horizontal line through the upper margin of the umbilicus; prolong the mammillary lines on each side downward until they intersect this horizontal line. The points of intersection lie about 3 inches on each side of the median line. Fig. 42. Anterior surface of kidneys. From the intersections measure upward i inch on the right and i% inches on the left mammillary line, and draw on each side a short horizontal line. The lower ends of the kidneys lie at these levels (Fig. 42). One can measure 3 inches on each side along the horizontal line and then upward, without drawing the mammillary line. The kidneys extend upward and inward about 4 inches, one-third to the outer side and two- thirds to the inner side of the vertical lines. Posterior Surface Relations of the Kidneys. Draw a horizontal line across the back at the level of the tip of the spine of the eleventh dorsal vertebra; a second line at a level of the tip of the spine of the third lumbar vertebra. On each side draw a vertical line from the upper to the lower horizontal lines, i inch from the median line of the spine, and second vertical lines 2^ inches away from the first vertical lines. Within these outer parallelograms lie the kidneys (Fig. 43). The lower ends of these organs lie from i to i> inches above the iliac crests, the right } 2 ' inch lower than the left. About a third of the 8 4 DISEASES OF THE STOMACH AND INTESTINES upper ends are covered by the eleventh and twelfth ribs ; the liver overlaps the right kidney and the spleen the left. Physical Examination of the Kidneys. Inspection is seldom of service; palpation is most valuable; percussion is often uncertain. Inspection. A large tumor of the kidneys may be visible in the anterior lumbar regions, extending into the umbilical region, with outward bulging of the ribs on the affected side, such as in the case of sarcoma, hydronephrosis, or cyst. A perinephritic abscess may become visible as a swelling in the posterior lumbar region. Palpation. This is most important. There are several methods described, of which the two following are the most practical: Fig. 43. Posterior surface relations of kidneys: A, Lower border of lungs; B, level of spine of eleventh dorsal vertebra; C, lower border of liver; D, level of spine of third lumbar vertebra; , colon. Method i. The patient lies in the dorsal position, with the knees and thighs flexed, and the head is slightly raised to secure perfect re- laxation. If the right kidney is to be examined, the left hand is slipped under the back, so that it rests on the two lower ribs and the lumbar space below them. The right hand is laid flat on the abdomen in front, resting below the costal margin to the outer side of the rectus, as in Fig. 44. The patient should take deep and slow respirations, and during expiration firm pressure should be made with the fingers in front against posterior counterpressure, so that the kidney may be grasped between the hands. If the kidney is normal in position and size, the extreme lower edge GENERAL METHODS OF PHYSICAL EXAMINATION 85 can be felt if the abdominal walls are not too thick. If the lower quad- rant of the organ can be clearly palpated, it may be considered a movable kidney (of the first degree). Various classifications of mobility have been given, some consider- ing the organ when palpable in half its extent, mobility of second degree; entirely palpable, mobility of third degree; and when descending into the abdominal cavity, mobility of fourth degree. Others consider it movable if the entire length be accessible, especially if it can slip down as far as the horizontal umbilical line; and if it can be displaced below this or across the abdomen, as a floating kidney. I believe that any kidney which can be palpated to one-fourth of its extent should be considered movable, and the subdivision into various degrees of mobility to be excellent. A movable kidney from strain or traumatism is comparatively rare. Occasionally we find a congenital Fig. 44. Palpation of kidney (older method). floating kidney with no visceroptosis. As a rule, I believe that in about 95 per cent, of cases of movable kidney the condition is merely part of a ptosis of the abdominal organs, and it may be considered to be practi- cally pathognomonic of this condition. The right kidney is most frequently movable, though both may be so. If the kidney is not found at its normal site, it should be searched for in the abdomen. In examination of the left kidney, the position of the hands is reversed. Method 2. This js, from personal experience, the most practical method of palpation, and the varying degrees of mobility can be detected with greater ease than by the method already described. For examination of the right kidney, the patient sits up in bed, and the left hand of the examiner grasps the right flank, the thumb resting under the costal margin, the fingers posteriorly. The patient breathes deeply, or coughs, or bears down, and the kidney can be felt to slip 86 DISEASES OF THE STOMACH AND INTESTINES down between the thumb and fingers, like "a pea in a pod," or the lower margin or part of the kidney may be felt (Fig. 45). Fig. 45. Palpation of kidney. Step i. If the organ slips beyond the thumb and fingers or is not found in its normal position, then the left hand grasps the flank more firmly and up- Fig. 46. Palpation of kidney. Step 2. Patient in semi-oblique posture. ward palpation is made with the right hand, as in Fig. 46 the patient gradually assuming the semi-oblique, and finally, the dorsal position, the final step, as shown in Fig. 47. GENERAL METHODS OF PHYSICAL EXAMINATION 87 A similar method with the patient standing was employed by Goelet, but the technic described seems preferable. For palpation of the left kidney, the position of the hands is reversed, the right hand grasping the loin and the left hand anteriorly. Tumors, hydronephrosis, and cysts of the kidney may be detected by palpation of the abdomen, as already described. Brewer's Point. Tenderness at the costovertebral angle is diagnostic of an acute inflammatory condition of the kidney, such as infarctions, etc., and aids in differentiation between this condition, appendix adherent to the liver, and acute cholecystitis. A small area of tenderness may be found overlying the lowest two or three ribs 1 when that at Brewer's point is absent. Percussion of the Kidney. The lower and part of the outer border of the kidney may at times be determined by percussion, comparing the dulness with the tympanitic note of the colon which lies anteriorly. As a rule, the thickness of the muscles, peritoneal fat, or fecal accumulation renders the results uncertain. Inflation of the colon with air or carbonic Fig. 47. Palpation of kidney. Step 3 (final). Patient in dorsal position. acid gas may aid in outlining renal dulness on percussion by comparison with the tympanitic area. A clear tympanitic note will be given if the kidney is absent (prolapsed) on that side. Position for Percussion. The patient may lie on the abdomen, with one or two pillows placed underneath, to arch the back; or on the side, midway between the lateral and prone position, the physician sitting facing the patient's back and percussing the uppermost kidney. One should commence percussion in the middle of the area in which the kidney lies (Fig. 43), using heavy strokes, and percuss outward until the kidney dulness is replaced by tympanites; also percuss downward in the same way. Increased dulness shows enlarged kidney. Lerche 2 holds that, with the percussion hammer and ivory plate (plexor-pleximeter) , and using a drop stroke (not tapping), better results are secured. To Differentiate a Movable Right Kidney from the Distended Gall- bladder. The kidney is movable in all directions, can be carried down- ward, does not move with respiration. Tympanites is found between 1 Med. Rec., July 15, IQII. 2 Ibid., Feb. 4, IQII. 88 DISEASES OF THE STOMACH AND INTESTINES it and the costal margin; the shape is reniform, and it may be pushed back into its normal position. The distended gall-bladder moves with respiration, and can only be moved laterally; if pushed away from the abdominal wall, it tends to resume its original position, and there is no tympanites as a rule between it and the liver dulness. Occasionally the colon overlaps its neck. The chief causes of enlarged kidney are pyonephrosis, perinephritic abscess, hydronephrosis, cysts, carcinoma, and sarcoma. An enlarged kidney tends to develop toward the front; an abscess, posteriorly, between the last rib and the iliac crest. With enlarged kidney, the colon overlays in front of the tumor. With splenic tumor, this does not occur (Fig. 40) as a rule. If in doubt, inflate the descending colon with air through a colon-tube or catheter. PART II DISEASES OF THE STOMACH CHAPTER V METHODS OF PHYSICAL EXAMINATION OF THE STOMACH General Considerations. For an intelligent understanding of the subject, it is necessary briefly to define those conditions which constitute an abnormality in the position of the stomach and to differentiate between them. The greater curvature of the normally distended stomach lies about two to three fingers-breadth (i^i-2% inches) aboye the umbilicus. The normal position of the organ has been indicated in Chapter I. It must be remembered that some possess an abnormally large stomach, and that it can be considered to be dilated only if there are symptoms associated which point to this organ. If there is atony of the stomach, with motor insufficiency, the patient having gastric symptoms, while the lower border of the stomach is defined at the level of the umbilicus or below it, the lesser curvature maintain- ing its relations to the diaphragm, we may consider the organ to be dilated. This constitutes the atonic type of dilatation, which is ex- tremely common. Many of this class suffer from autointoxication with nervous sequelae, and are found in great numbers in our asylums and among our nervous cases. Attention may be diverted from the gastric symptoms and they may even be slight. As a result of pyioric spasm, or benign or malignant stricture of the pylorus, or any obstruction in the pyioric region interfering with the egress of the gastric contents, we have the so-called stenotic type of dilatation of the stomach. In these cases the lesser curvature retains its relation to the diaphragm, while the lower border extends to the umbilicus or below it, and gastric symptoms are present to a marked degree and of a special type. With gastroptosis (prolapse of the stomach), the suspensory ligaments of the stomach are relaxed and the entire organ sinks, the lesser curvature as well as the greater. In aggravated cases the lesser curvature looks inward to the right, and. the greater curvature outward to the left. The pylorus may often lie below the level of the umbilicus. With this condi- tion, movable kidney especially of the right organ is present, and may practically be considered pathognomonic, in my opinion, as only in about 5 per cent, or less of cases is mobility due to strain or injury. The con- genital floating kidney, without ptosis of other viscera, is exceedingly rare. 89 90 DISEASES OF THE STOMACH AND INTESTINES There may be various degrees of gastroptosis, a loop-shape, or even a vertical stomach, similar to that of the fetal period, which are pictured in the chapter on Gastroptosis. The change in position of the lesser curvature is, therefore, diagnostic of gastroptosis, and not the position of the lower border of the stomach. The presence of movable kidney is also diagnostic. It seems advisable to describe the methods of physical examination generally employed, and at the end of the chapter briefly to summarize those which are of most practical value. Preparation of the Patient. On the day or night previous to examina- tion the bowels should, if possible, be thoroughly emptied by a cathartic. If there is much tympanites, it should be relieved by a hot enema of about i liter (i quart) of normal saline solution or soapsuds and water; or, if the condition is marked, then by enteroclysis at 110 to i2oF. with the re- current tube (Kemp's) or two catheters. This carries off the gas in a satisfactory manner. The patient should be examined in the dorsal, semi-oblique, and standing positions. Inspection. Examination in the dorsal position should first be made. A recognizable bulging, distinct from the epigastrium, especially if it occur in the umbilical or hypogastric region, may be due to a dilated stomach; the epigastrium, under these conditions, is usually hollow and depressed. Inspection is often of assistance in thin patients, especially after artificial distention of the stomach with carbonic acid gas. Peristaltic movements of the dilated stomach are at times observed. Kiissmaul has noted very active peristaltic movements in the dilated stomach (peristaltic unrest), the waves passing from the linea alba below the umbilicus in an upward direction and to the right to the lower margin of the liver. This is found present in cases in which stenosis of the pylorus exists. We can facilitate inspection by placing the patient upon a raised table, the head toward the window, the shades being arranged so that the light enters on a plane only slightly above that of the patient, and is directed from the head toward the feet. The examiner, standing toward the foot of the table and bending from side to side, can at times make out shadows cast by the inequalities of the abdomen. The shadows move with respiration. By this method the size, shape, and position of the stomach can often be made out. Knapp places the patient in the same position, but stands at the side or at the shoulders, and brings his eyes down to the level of the abdomen and observes the respiratory waves passing over its surface. After some experience one can detect delicate transverse lines or waves passing upward and downward with respiration. These lines correspond to the curvatures of the stomach. More recently he places the patient facing a good light, and, stand- ing slightly to the side, observes the movements of the transverse lines. I have seen good results from this method, especially for detemination of the lower border of the stomach. The following signs I have found quite reliable: With the patient METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 9 1 in the recumbent position, a marked concavity between the costal arches extending from the ensiform process to or below the umbilicus, with a vertical median sulcus, wider above than below, the abdomen being flattened in the central part and bulging in the lateral regions is signifi- cant of gastroptosis. In the erect position the epigastrium becomes stll more depressed, while the umbilical and especially the pubic regions bulge outward. Tumors of the stomach may sometimes be observed, causing slight projection or protuberance on the abdominal wall. Palpation of the Stomach. Inspection should be supplemented by palpation. Palpation should be performed gently, and the hands of the operator should be warm. The patient should be in the dorsal position, with the legs flexed, to relax the abdominal muscles. He should breathe naturally and keep the mouth open to aid relaxation. The physician should be seated on the right side of the bed and palpate with the right hand, which should be flat or slightly bent upon the abdomen, with the ulnar side down. One can stroke from above downward, and with practice it is possible, in some cases, to feel the stomach-wall and appreciate the position of the greater curvature, as the stomach gives a more uniform elastic sensation than do the intestinal walls. Some commence palpation from below and work upward, dipping in the ulnar edge of the hand rather deeply. By these means it is at times possible to determine the position of the greater curvature. By palpation we can discover if nephroptosis is present. Diastasis of the recti muscles and floating tenth rib can also be determined. These conditions are significant of gastroptosis. Under inspection I have noted the signs that are significant of gastroptosis. If we find a "movable kidney," this renders our diagnosis conclusive. By gentle palpation one can frequently discover a tumor, its position, size, consistency, and mobility. Occasionally, more pressure is necessary, and the palpating hand may be reinforced by the other hand, after the method described. (See Fig. 28.) Sensitive or tender points can be located by palpation; for example, the circumscribed tenderness of an ulcer, or the diffuse tenderness of the gastric region in acute inflammation. Boas has devised an algesimeter for indicating the degree of pain. T. Kilmer has also an instrument for the same purpose. Considerable care should be exercised in palpation in cases of sus- pected ulcer, and I prefer the hand for this purpose. Percussion of the Stomach. The accurate determination of the position and size of the stomach is often difficult by simple percussion. The sound varies, according to whether the organ is empty or filled with air, food, and water. The position of the patient, whether lying down, semi-oblique, or standing, modifies the findings. In order to obtain results, the stomach should contain some air. Dehio has demonstrated, both on living subjects and on the cadaver, that if the stomach is empty, the tympanitic sound which we produce on percussion is due to the colon and not to the stomach, since the latter is contracted into the left concavity of the diaphragm and 92 DISEASES OF THE STOMACH AXD INTESTINES is not in contact with the anterior thoracic wall. Hence the time at which the examination is made is important. Moreover, the lower curvature tends to fall away from the abdominal wall. The patient should first be examined in the dorsal position with the knees flexed. This method determines with fair accuracy the upper right and upper left portions. The percussion hammer is sometimes an aid. The ab- solute determination of the lower border by percussion is more difficult. It is rendered easier if the bowels have been thoroughly emptied, since the colon is then less likely to ride over the greater curvature. The per- cussion sound over the colon is lighter and does not equal that over the stomach. The stomach sound is of greater intensity and clearness and of higher pitch. This, of course, refers to conditions when air is present as the factor. Food or fecal contents alter the result, which is further modi- fied by percussion in the semi-oblique and standing positions. As a rule, there are some contents in the transverse colon, so that we have the tympanites of the stomach merging into dulness or flatness. With gastroptosis, determination of the position of the organ by simple percussion is often difficult. The presence of a tumor can frequently be determined by percussion. Dorsal Gastric Nucleus of Resonance. William Ewart, in his com- munication in the Proceedings of the Royal Society of Medicine, July, 1910,. has contributed a new method of post-gastric percussion, and has described a hitherto unrecognized " dorsal gastric nucleus of reso- nance." This consists of a circular area, from 2 to 2> inches in diameter, situated immediately below the inferior angle of the left scapula. Over this area the percussion-note is one of increased resonance and of a tym- panitic quality. This is the result of the deep-seated resonance of the stomach, the constancy of its position and its circular shape being deter- mined by sound refraction, the liver acting as a lens for the resonant waves. The clinical value of this sign is concerned chiefly with the diagnosis of the various forms of dilatation of the stomach. The loss of perfectly circular outline is the first step toward the disappearance of the gastric nucleus, which may be the starting-point of progressive encroachment outward of an enlarging area of dorsal gastric resonance. This is the dorsal or backward type of upward dilatation of the stomach which was first definitely described by Ewart, who believes this to be the cause of one of the most severe and dangerous forms of heart distress of mechanical gastric origin. Auscultatory Percussion. With this method we employ the stetho- scope. The chest-piece may be placed above the seventh rib in the left mammillary line, or between the tip of the ensiform process and the left costal margin; or in the same vertical line, but slightly below these points. First percuss near the stethoscope to fix the characteristic sound. The tympanites of the stomach is transmitted generally through the liver and lung. The percussion should be begun well distant from the possible location of the stomach, and should be performed in the vertical direction, downward, upward, and also laterally. One should begin nearly at the symphysis and percuss in vertical lines upward (Fig. 48). METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 93 The patient should be in the usual position, as described, and should hold the stethoscope for the operator against the abdomen. A sound of Fig. 48. Vertical lines of auscultatory percussion. Circles show positions of stethoscope. greater intensity and clearness and of higher pitch denotes the border of the stomach. The greater bulk of the organ, when dilated or in a condition of ptosis, lies to the left of the median line. We must remember Fig. 49. Auscultatory percussion of tumor of stomach wall. that some cases of marked dilatation extend a great distance to the right of the abdomen. This method is of value in determination of a tumor of the stomach. 94 DISEASES OF THE STOMACH AND INTESTINES Place the stethoscope at O, Fig. 49, and percuss toward the tumor from all directions. The sound heard over the tumor (C) differs in char- acter from that heard over the stomach at D. If the growth involves the stomach wall, C resembles D much more nearly than A (percussion of liver) and B (percussion of intestines) resembles D (stomach percussion). Differential Diagnosis. If a tumor lies at Z>, near the margin of the liver (Fig. 50), tumor of the liver is excluded as follows: place stethoscope at S, over liver. Percussion note over D resembles note over G more than it resembles that over F. Then to exclude intestines, shift stethoscope to K, over stomach. Percussion over D resembles that over M more closely than that over G resembles that over M. The tumor is, therefore, of the stomach. Fig. 50. Differential diagnosis. Reichmann's Rod. This consists of a short ivory rod, with circular grooves and intervening projections, like the handle of an ivory knitting- needle. The rod is pushed firmly down over the stomach at a right angle to its surface (in a vertical line to the abdomen), and is gently stroked with the finger. The stethoscope is applied over the organ and the "pitch" carefully observed. When the rod passes beyond the limits of the stomach, a change in "pitch" occurs. Scratch Method of Auscultatory Percussion. This method I have found satisfactory in many cases. The stethoscope is placed on the abdomen below the left border of the ribs, and with the index-finger of the right hand the abdominal wall is scratched gently by the examiner so as to secure the "normal pitch" over the stomach. The abdomen is then scratched lightly from above downward and also from below upward, commencing below the umbilicus, and the change in "pitch" is readily observed when the lower border of the stomach is reached. If gastroptosis is believed to exist, the stethoscope is placed more to the left, and the "scratch pitch" noted from left to right. The method METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 95 is shown in Fig. 51. It is of special value in determining the lower border of the stomach. Flicking. This method was described and illustrated in the previous chapter. Inflation of the Stomach with Carbonic Acid Gas. Carbonic acid gas inflation is employed to render the stomach visible to inspection; to aid the determination of the position of the lesser curvature, as well as the greater, and so enable a differential diagnosis between dilatation and gastroptosis. The method is to administer, first, one glass of water in which about i dram of tartaric acid is dissolved, and, after this, one glass of water Fig. 51. "Scratch method" of auscultatory percussion. containing from i to i^ drams of soda bicarbonate. If small quantities are employed, the stomach will not become visible and palpable. There are certain objections to this procedure. At times there is considerable escape of gas through the cardiac orifice or pylorus and the small intestine may be distended. This is a possible source of error. There may be sudden hyperdistention of the stomach, with resulting pres- sure on the heart and lungs, and unpleasant or even dangerous symptoms result in the aged or in a patient suffering from cardiac or pulmonary disease. In the chapter on Acute Dilatation of the Stomach the effects of sudden distention of the stomach on the heart and circulation are described by Thomas Satterthwaite and the author. When there has been a recent hemorrhage from ulcer or cancer, or signs of peritonitis, the use of this method is contraindicated. Several fatal accidents have occurred. It sometimes irritates the mucous mem- g6 DISEASES OF THE STOMACH AND INTESTINES brane. One could employ a stomach-tube and Dr. Rose's carbonic acid gas generating-bottle as a substitute. Carbonic acid gas inflation is valuable in those who are in fair physical condition. In the determination of the position of a tumor, whether it lies on the anterior or posterior surface of the stomach, inflation with carbonic acid gas is of service. A posterior tumor will disappear under inflation. This is fully described under Cancer of the Stomach. Inflation of the Stomach with Air. This consists in introducing a soft stomach-tube and slowly pumping air into the stomach with a double- bulb or a Davidson syringe. The tube should be introduced with the patient sitting up in bed, and he should then gently recline on the back and inflation should be carried out. It possesses the advantage that the amount of air pumped into the stomach can definitely be regulated. Fill a vessel with i liter (i quart) of water, invert it over a pail of water, and note how many compressions of the bulb displace the given quantity of fluid. One can thus estimate the quantity of air pumped in at each compression. The first few squeezes of the bulb should be given rapidly, so as to cause spasmodic closure of the pylorus. The same indications and contraindications exist as for the use of carbonic acid gas. There is the advantage of being able to regulate more definitely the degree of inflation. Some patients, however, object to the passage of the tube. If there are discomfort or unpleasant symptoms from either method of inflation, the condition should be immediately relieved by the passage of the stomach-tube. Furbringer suggests that when we inflate with air the tube should be introduced only to the middle of the esophagus, and air should then be pumped in. He claims that this procedure prevents retching. Inflation of the Stomach with Water. To Dehio we must give the credit of determining the position of the stomach by water inflation. He percusses over the patient's stomach, preferably with the organ empty and the patient in the erect position. He then administers a glass of water (8 ounces), not too cold, and percusses the area of the dulness. He follows this with a second, third, and fourth glass of water, percussing each time, and notes the position and extent of the dulness. The patient is then directed to lie on his back, and tympanites will appear where dul- ness previously existed. This conclusively demonstrates that the area corresponded to the stomach. If there is pronounced dilatation or ptosis, a single glass of water will often cause dulness to appear below the navel or in the inguinal region. The results may be obscured in patients with much adipose tissue or if there is fecal accumulation in the colon. In this last event, it should be cleared out by injection. I have also found the following method of value, es- pecially if there be some gastric contents: first, place the patient in the semi-oblique position and percuss the stomach; then administer two or even three glasses of water. We secure stomach tympanites above, then a band of stomach dulness, and intestinal tympanites below. It is easier to differentiate between dulness and tympanites than between two types of tympanites. There are numerous complicated methods by means of inflatable bags, METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 97 manometers, etc., for determining the position of the stomach which are scarcely of practical value. Leube introduces a stiff sound and determines the position of its lower end through the abdominal walls. This method does not seem to be safe. Others differentiate between the stomach and the colon by inflating the colon with air or carbonic acid, employing the same methods as in the stomach, only using twice the quantity of soda bicarbonate and tartaric acid. Rose's apparatus would prove of value to inflate the bowel. To further differentiate, water was given by the stomach. Some first empty the bowel thoroughly and then inflate the intestine with water. It is often difficult for the patient to hold the enema. There are two other methods for determining the lower margin of the stomach: First, the administration of small quantities of soda bi- carbonate and tartaric acid, with the patient in the standing position. In some cases one can approximately map out the lower border of the stomach by listening to the "sizzling sounds" with the stethoscope. Second, the use of the stomach-whistle (Fig. 52). This consists of a rectal tube of small caliber, with a whistle in the end. To the other extremity is attached an ordinary stomach aspirating bulb without valves. The Fig. 52. Kemp's stomach-whistle. tube is inserted into the stomach, the finger placed over the open end of the bulb, and a single bulbful of air is forced into and aspirated out of the stomach by rapid and short intermittent contractions. This entirely eliminates the possible chance of distending the stomach with air, and the organ remains practically empty. A stethoscope is placed over the abdomen and the point of greatest intensity of sound is marked by a cross with a colored pencil. The tube is pushed in and out and the various points of sound are marked the lowest is in the lower border of the stomach. The ear can be applied in place of the stethoscope. Transillumination of the organ was then performed and the lower margins absolutely corresponded. The method of administering water and then blowing air into the stomach through a tube, and producing "bubbling sounds," only gives the level of the fluid, and not accurately the lower margin of the stomach. The whistle will not differentiate between dilatation and gastroptosis. This experiment with the stomach-whistle demonstrated that in the standing position the stomach, when empty, descends to the full length of its suspensory ligaments, and its lower border is at a constant level or within about i inch of the same, whether the organ be full or empty. The stomach- whistle was described as early as 1892 by Spivak, of Denver, for the 7 9 8 DISEASES OF THE STOMACH AND INTESTINES purpose of measuring the esophagus, and S. J. Meltzer previously experi- mented with an instrument devised on the same principle. The writer does not recommend the whistle, but merely recounts its use as a matter of interest. Splashing Sounds. The splashing sounds of the stomach are pro- duced when water and air in the organ are agitated together, when either the whole body or the stomach alone is shaken. They are best demon- strated by rapidly tapping with the index- and middle fingers of the right hand over the stomach several times in succession without removing the fingers, as in striking chords on the piano. The patient should be in the dorsal position, with the lower limbs flexed. The sounds resemble those produced by shaking a rubber bag con- taining air and water. They can be elicited in many people in ordinary good health shortly after meals, but if found at an abnormal time or in an abnormal position, , are of diagnostic value. If present an hour after a test-breakfast, the patient suffering from gas- tric symptoms and the position of the stomach being normal, they are significant of simple atony. This is true if they be found several hours after an ordinary meal or on an empty stomach. If the splash is present in an abnor- mal position at the level or below the umbilicus, it shows the lower border of the stomach lies abnormally low, and that either dilatation or gastroptosis is present. The presence of movable kidney demon- strates it is a ptosis. The upper border may be determined to be in an abnormal position by inflation or gastrodiaphany, as a further test. The splashing sound determines the position of the lower border of the stomach with greater accuracy than percussion. Some patients hold the abdomen rigid, so that it does not appear on examination, but it can be produced artificially for examination purposes. The following is a simple method to differentiate between stomach and intestinal splash: In Fig. 53, if the splash be found at A, mark same on the abdominal wall; then give several glasses of water or, preferably, Vichy. If the splash at A be intensified, it is stomach splash. If, on the other hand, the splash appear at B, this is the true stomach splash and A is the in- testinal splash. If no splash is present on examination, it can be created artificially by giving several glasses of water or small quantities of soda bicarb, and tartaric acid in a glass of water or, preferably, Vichy. Sometimes three or four glasses of water are required; the patient takes several deep breaths, the splash being determined during expiration. I find the determination of the lower border of the stomach most accurate by means of the splashing sound. Fig- S3- Splashing sound. Differential diag- nosis between stomach and intestinal splash. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 99 Deglutition Sounds. These were first described by Kronicker and Meltzer. 1 When drinking, a sound is heard simultaneously with the act of deglutition, which is termed the first deglutition sound. A second sound is noted about seven seconds later. Both sounds can be heard by plac- ing the ear or stethoscope at the ensiform process. As a rule, only the second sound is heard. If the first sound is heard, the second may be present or absent. The presence of these sounds assists in forming judg- ment as to the permeability of the cardiac orifice. If they are absent, the ingested liquid has remained in the esophagus, and hence a tight stricture is present. If the second sound is markedly delayed, there is probably partial obstruction. Other Sounds have been Described. Dripping sounds, arising from the passage of fluid along the gastric wall, are suggested as a means of mapping out the stomach. The method is inaccurate. The succussion sound, obtained by shaking the body of the patient, is not as accurate a method as by tapping. Gurgling sounds occur from the contraction of the empty stomach about air or gas. Sounds are heard in the stomach due to movements imparted to the organ through the respiration, and also ringing sounds, imparted from the heart in gastric dilatation. 2 These sounds are of no diagnostic value. Occasionally sizzling sounds are heard on auscultation, which are produced by fermentation of the gastric contents. They resemble the sounds produced after the administration of soda bicarbonate and tartaric acid, with the re- sulting generation of carbonic acid gas. Esophagoscopy. Mikulicz, Rosenheim, Kelling, von Hacker, 3 Ein- horn, 4 and many others have advocated this method. Fig. 54. Einhorn's esophagoscope. In the earlier instruments the source of illumination was outside the esophageal tube. The instrument with the lamp at the end of the tube near the point to be inspected, such as devised by Einhorn, is more practical. 1 Centralbl. f. die med. Wissensch., 1883, No. i. 2 Laker, Wiener med. Presse, 1889, Nos. 43 and 44. 3 Beitrage zur klinischen Chir., Bd. 20, 1898, pp. 141, 275; Ibid., Bd. 29, 1901, p. 128. 4 New York Med. Jour., Dec. n, 1897. IOO DISEASES OF THE STOMACH AND INTESTINES In Fig. 54 is depicted his instrument, which is readily understood. The obturator is inserted and held in place by the plug d and the wires connected with the battery. After introduction, the plug is removed, the obturator withdrawn, and the current turned on. Fig- 55- Misleading schema of direct bronchoscopy. Same position improper in esophagoscopy (Chevalier Jackson). Technic. The pharynx should be sprayed with cocain (4 per cent.) or eucain (5 per cent). The patient sits on a chair with a straight back. The instrument with obturator inserted is immersed in warm water, and inserted like a pen along the roof of the mouth to the posterior wall of the pharynx, the head being thrown backward on the shoulders, but not in Fig. 56. Schema showing correct position of patient and of the instrument in relation to the air-passages. The instrument should touch the upper teeth very gently, if at all. This is also the proper position for esophagoscopy (Chevalier Jackson). too forced extension. The tube should be lubricated with olive oil or white vaseline if difficult to pass. The tube is then pushed down in a vertical line into the esophagus without the exertion of any force. By this method it is unnecessary to press down on the tongue, and thus gagging is avoided. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 101 The lips of the patient should not be pressed upon by the instru- ment. The obturator is removed, the light turned on, and the eye of the operator applied to the opening. r FIG. 57. Correct position of the cervical spine for esophagoscopy and bronchoscopy. Radiograph by Dr. George C. Johnston (Chevalier Jackson). Fig. 58. -Curved position of the cervical spine in the Roser position, rendering esophagoscopy and bronchoscopy difficult or impossible. The devious course of the pharynx, larynx, and trachea are plainly visible. Radiograph by Dr. George C. Johnston (Chevalier Jackson). For complete inspection of the esophagus, the instrument is gradually withdrawn. 102 DISEASES OF THE STOMACH AND INTESTINES This esophagoscope is made in several lengths and in two sizes. Lewisohn has devised a rectangular telescopic esophagoscope, which can be introduced in the normal position of the head. It possesses the disadvantage of being complicated, gives indirect vision, is more difficult to keep free from mucus and instrumentation through it is practically impossible. It is of chief value for inspection. Chevalier Jackson 1 has devised an improved esophagoscope which contains an auxiliary tube for drainage and suction of the secretions. For esophagoscopy frequently the upright position can be employed, though in some cases the dorsal position is preferable. Fig. 55 is the incorrect position. In Fig. 56 Jackson shows the correct position of the head when bronchoscopy is performed in the upright position. The posture is the same in esophagoscopy. In Figs. 57 and 58 are shown the correct and incorrect positions for esophagoscopy in the dorsal position. In the dorsal recumbent position, the head should be squarely ex- tended on the occipito-atlantal joint, not on the cervical spine. If the head is held in the position of Roser, the cervical vertebrae are curved, Fig. 59. Fig. 60. Fig. 59. Schema showing relation of the cricoid cartilage (the circle) to the pos- terior hypopharyngeal wall, in the dorsally recumbent patient, observer looking down the esophagus. The pyriform sinuses are at the position marked X Fig. 60. Thimble gag or bite block for bronchoscopy and esophagoscopy (Jackson). and the esophagoscope abuts almost vertically on the convexity and can- not be introduced within the introitus esophagi, according to Jackson (Fig. 58). The assistant is placed on the right side of the patient's head, on a stool of appropriate length, as though on a side saddle, his right leg beneath him in the kneeling position, his left foot supported on a stool 26 inches lower than the top of the table. His right forearm is passed beneath the patient's neck, supporting it; his right hand holds the mouth- gag, drawing it strongly at, or in front of, the bregma, bending it back- ward and exerting a certain degree of upward pressure. The mouth-gag is inserted on the left side. The patient should have the tops of the shoulders clear of the table by from 4 to 6 inches. If an attempt is made to pass the esophagoscope in the middle line, it encounters the cricoid cartilage. It should be inserted into the pyriform sinus (Fig. 59), preferably the right one, and thence into the esophagus. A bite block, preferably Boyce's (Fig. 60), should be used in preference to a mouth-gag the so-called thimble gag. Jackson's armamentarium for esophagoscopy consists of the following instruments: 1 Jour. Amer. Med. Assoc., Sept. 25, 1909. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH i esophagoscope (10 mm. by 53 cm.) for adults. i esophagoscope (7 mm. by 45 cm.) for children. i adult's slide speculum. i child's slide speculum. i aspirator for the esophagoscope, to remove secretions. i specimen forceps, long and short (Fig. 61). 103 Fig. 61. Specimen forceps tip to fit universal handle. The side jaw will bite into a flat lateral wall. The cross forms the bottom of a basket to hold the tissue removed. i foreign body forceps. 3 Coolidge sponge-holders. In esophagoscopy for foreign bodies, the tube should be introduced without the mandrin, and every part be explored during its introduction. This avoids the danger of overriding the foreign body. The safest cur- o Fig. 62. Brunning's modification of Killian's esophagoscope (Plummer). rent for the light is a double dry battery, two sets of four cells each, in case one fails. Each set should have two binding posts and a rheostat. Ingalls holds that rheostats devised for adapting commercial circuits to tube work are dangerous when attached to a tube which makes a moist contact with tissues close to the course of the vagi. It is preferable, when 104 DISEASES OF THE STOMACH AND INTESTINES possible, to determine the position of a foreign body in the esophagus by a radiograph before attempted removal through the esophagoscope. Both lateral and anteroposterior radiographs should be taken, as the foreign body may show in one and not in the other. Plummer 1 recommends Brunning's modification of Killian's esophago- scope (Fig. 62), as it has a tip well adapted for easily passing the cricoid. Occasionally, a guide may be necessary, after the methods already described under Stenosis of the Esophagus. Lerche 2 has devised an ingenious instrument for closing an open safety-pin impacted in the esophagus, and removing the same through the esophagoscope (Fig. 63). Indications. Esophagoscopy is of chief value as an aid for the removal of foreign bodies. It may be employed for inspection of suspected ulcera- tipn and for topical application through the esophagoscope or to remove through it a small section of a tumor. In suspected cancer it should be used with caution. Fig. 63. Instrument devised for closing open safety-pin and directing it through gastroscope (Lerche). Contraindications. Aneurysm or recent hemorrhage. Gastroscopy. This method of examination of the gastric mucosa was inaugurated by Mikulicz in i88i. 3 The general principle of the instrument is based on the cystoscope. Rosenheim has devised a new instrument, and Chevalier Jackson has carried on numerous investigations with gastroscopy. The latter has conclusively demonstrated that general anesthesia should be given for such an examination. Chevalier Jackson's method with gastroscopy is described under his dorsal method of introduction of the esophagoscope. The instruments are identical, except that the gastroscope is longer, as in Fig. 64. Einhorn 4 has recently devised a gastroscope in which the lamp serves as an obturator. It can be pushed aside at the time of inspection. 1 Jour. Amer. Med. Assoc., Feb. 25, 1911. 2 Ibid., March 4, IQII. 3 Wiener med. Presse, 1881, No. 45. 4 Med. Record, June u, 1910. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 105 London reports a gastroscope with a special lens system giving a large horizon. Sussmann's flexible instrument seems the safest. I must confess that in cases of suspected cancer or ulcer I would not submit a patient to the certain degree of risk from the introduction of an instrument of the present type in an attempt to make a diagnosis. The clinical symptoms and the use of the #-rays are more satisfactory as well as safe. In milder cases of gastric disturbances I can see no advantage, except for the purpose of scientific study. It would seem that a large number of normal organs, as well as mild types of gastric disease, should first be investigated as a basis for comparison, and that the instrument should be improved upon before the method can be generally recommended. The gastroscope, however, is a valuable adjunct for the attempted removal of foreign bodies from the stomach, such as a tack, a pin, etc. Fig. 64. Chevalier Jackson's gastroscope. Inflating Gastroscope and Duodenoscope. These instruments 1 were developed with the assistance of my associate, Albert Vander Veer, Jr., for the purpose of inspection of the stomach and duodenum through the gastric incision, after laparotomy for a gastric or intestinal lesion, or through the gastric incision for gastro-enterostomy. It has been impressed upon me that the surgeon is often largely de- pendent upon his sense of touch for the determination of the location of the existing lesion or lesions. 2 For example, the induration of an ulcer is distinguished by this means. One may at times fail to detect an in- durated ulcer on the posterior surface of the stomach by the method of palpation, while a nonindurated ulcer usually will not be detected at all. 3 In one patient suffering from severe gastric disturbances, hyperchlor- hydria with vomiting, the surgeon and I agreed that the gall-bladder was responsible. At operation, it was found to be infected and was removed. The stomach was carefully examined by external inspection and palpa- tion, with negative results. The outcome of the operation was a tem- porary improvement. Subsequently the patient suffered from the symptoms of gastric ulcer, which ultimately was shown to be present. After several such experiences, it occurred to me that a practical method of internal inspection of the stomach at the time of abdominal section 1 N. Y. Medical Journal, Feb. 7, 1914. 2 Cancer of the Stomach (Smithies and Ochsner). 3 Deaver substantiates this statement and recommends opening the stomach for the purpose of accurate diagnosis. New York Medical Journal. July 3, 1915. 106 DISEASES OF THE STOMACH AND INTESTINES would be of value; especially as incision into the stomach is performed either for gastro-enterostomy or for partial gastrectomy, and the exploring instrument should be passed through that incision, or through one in another part of the organ, if necessary. During the course of our experimental investigations my associate, Dr. Vander Veer, and myself discovered a particularly important fact, that an ulcer of considerable size may be present in the stomach, so covered by the folds of the mucosa that it cannot be seen through the gastroscope, unless the organ is inflated. In fact in cases with small superficial ulcer, the #-rays may only show hypermotility. On the other hand, there may be several ulcers and only one be determined by the radiograph. You will doubtless remember that in superficial ulceration of the stomach, described by Dieulafoy, it has been demonstrated that even on autopsy, it has proved difficult to detect the ulceration, as it may be con- cealed in some of the folds of the mucous membrane. Fig. 65. Inflating gastroscope and duodenoscope. This would further suggest the value of the' inflating gastroscope, to locate a hemorrhagic lesion requiring suture. Our instrument is based on the principle of Tuttle's inflating procto- scope. The light carrier, however, must lie inside the tube, so as not to interfere with the spherical clamp. There are six projecting rims each, He inch in diameter, which completely encircle the tube, one at the entering tip and each in succession an inch apart. They prevent the circular clamp from slipping down. The rim acts as a plug or washer, so that when the edges of the incision are drawn up above it and the circular clamp is applied, no air can escape. The circular clamp extends into a beak further to prevent leakage (Fig 65). By means of the rims at various intervals, one can insert the tube to different distances and thus explore the entire stomach from the fundus to the gastric side of the pyloric ring. The spherical clamp is covered with rubber, to prevent injury to the musculature of the stomach. The eyepiece fits snugly and has a short side tube for attachment of the inflating bulb, preferably that employed for the Tycos sphygmoman- METHODS Of PHYSICAL EXAMINATION OF THE STOMACH 107 ometer, since the small side valve enables one to allow the escape of mod- erate amounts of air, if the inflation is excessive. Fig. 66. Inflation with the pneumatic gastroscope (Manhattan State Hospital). Fig. 67. Semi-oblique posture for pneumatic gastroscopy (Manhattan State Hospital). The length of the instrument is 6 inches, and the diameter nearly an inch. 108 DISEASES OF THE STOMACH AND INTESTINES There is an introducer which is subsequently removed and the eye- piece and light placed in position, also a detachable handle. We found by experiment that elevation of the shoulders and chest, so as to remove the pressure of the distended stomach on the diaphragm and lungs, is indicated, when considerable distention is necessary for exploration. The inflating duodenoscope is 12 inches long; of a diameter of % inch; the first projecting rim lies 3^ inches from the tip; each succeeding rim is separated by an inch. It is introduced by direct vision, preferably through an initial small opening in the stomach, the duodenum being first explored. The opening then can be enlarged for the introduction of the gastroscope. The inflating tube in this small instrument is directly attached by a branch to the main tube, thus giving more space for the eyepiece. The duodenoscope cannot be employed when there is marked pyloric stenosis, and its field of usefulness is therefore limited. We are familiar with the principle of the operating cystoscope. This is simplified in our instruments. Eyepieces are made in which there is a small short tube, through which thin forceps, or a curette which fits snugly can be passed and the necessary procedures carried out while the organs are inflated. This special eyepiece is usually unnecessary. Sterilization of the Instrument. Various methods were experimented with. We found as follows: Five minutes in 80 per cent, alcohol. Sterilization complete. Dipped in a mixture of 3 parts of 95 per cent, alcohol and i part pure carbolic acid, wiped with sterile gauze or 95 per cent, alcohol. Sterilization complete. These were found to be the best methods. The light carrier should only be wiped with 80 per cent, alcohol, or preferably with the alcohol-carbolic solution and then dried with sterile gauze. The clamp forceps and introducer can be boiled; the eyepiece wiped in one of these solutions. The conducting wires inflating bulb and battery (Wappler portable six-cell is convenient) should be covered with sterile towels. The gastroscope and duodenoscope can be suspended in alcohol (80 per cent.) for four or five minutes, or preferably for one minute in alcohol-carbolic solution. No fluid should be allowed to enter the con- taining sheath of the light carrier. The instrument can then be wiped with sterile water, dried with sterile gauze and wrapped up in it. A series of experiments were carried out in the Physiological and Anatomical departments of the Fordham University Medical School on live dogs and on the cadaver. As a result of our experiments the direct pneumatic gastroscope may aid in determining: Character and position of an ulcer. Number of ulcers or erosions, and hence the degree of resection of the stomach required. Position of a foreign body facilitating its rapid removal. Study of the pylorus. Point of endogastric hemorrhage. Its rapid ligature is thus possible. Removal of a polypus. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH A scraping of an ulcerated surface may be secured and a study made of the bacterial types found in gastric or duodenal ulcers, and hence aid in determination of the etiology. A small section could also be obtained for examination. This is not usually recommended, as chronic ulcers of the stomach should be excised. Some years ago Rovsing employed an adaptation of a specially large Nitze cystoscope combined with inflation, for examination of the stomach and duodenum. Gallant has also used a cystoscope. We know of no practical direct vision instrument such as the present one heretofore reported. Gastrodiaphany or Transillumination of the Stomach. Casenave, in 1845, nrs t applied the method of transillumination to living tissues. In 1867 Milliot succeeded in transilluminating the stomachs of animals and experimented with the stomachs of cadavers, but to Max Einhorn, of New York, the credit is due of being the first to demonstrate transillu- mination of the stomach on the living subject and the practical value of gastrodiaphany. His instrument, which he denominates a gastrodiaphane consists of a soft-rubber stomach-tube, at one end of which is fastened an Edison lamp. Conducting wires run through the tube to the battery, and there is a current interrupter at some distance from the tube. The lamp is inclosed in a glass bulb, to act as a reflector and prevent the ac- tion of heat on the stomach. He has the patient drink only one or two glasses of water, so as not to distend the stomach, inserts the light, and ex- amines the case in a dark room, either in the sitting or in the recumbent position. Heryng and Reichmann employ a modified tube, with a wate.r-cooler about the lamp. Kuttner and Jacobson, under Ewald's direction, performed a great number of experiments. These experimenters, together with Meltzing, are the chief foreign investigators with gastrodiaphany. Manges, Stockton, and many others have employed it. Among various gastrodiaphanes are those of Hem- meter, Lincoln, Solis-Cohen, Koplik, and Lockwood. To Lockwood we must credit a decided advance in the type of instrument a fine, wire- bound cable (rubber insulated) and a small light, no larger than a 5-grain capsule. The cut of my instrument, the " circumscribing gastrodia- phane," will sufficiently explain the Lockwood instrument, after which it is modeled, with certain additions. The Circumscribing Gastrodiaphane. A series of observations with transillumination of the stomach suggested an improvement on the gas- trodiaphanes in use. Manipulation of the tube after the electric light has entered the stomach frequently causes gagging and, at times, vomit- ing, interfering thus with the accuracy of the method. The cables of all the instruments were found unsatisfactory in cases of gastroptosis of great degree when we endeavored to explore carefully the pyloric end of the greatly dilated stomach. It was impossible to guide the light in a definite direction; it would sometimes pass to the right, sometimes to the left, and often it was necessary to draw it in and out a number of times for a distance of several inches. The instrument I devised to overcome these drawbacks has a cable no DISEASES OF THE STOMACH AND INTESTINES about 6 inches longer than the Lockwood gastrodiaphane, and is of about the same caliber (Fig. 68). The cable is more flexible for the space of ^ inch at about the same distance from the light in effect, a joint at this point. At the base of the light is attached an extremely thin accessory cable, covered with rubber. This runs parallel with the main cable and increases the diameter only a very slight degree. After introduction of the instrument the main cable is held firmly, and the accessory cable drawn upon. By turning the cable at the same time, the instrument can be guided in the desired direction. By manipulation of the accessory cable the main cable can be so bent that the light will explore the entire wall of the stomach anteriorly, and can be made to pass up to the pylorus and along the borders of the ribs. The lesser curvature is thus explored. Care should be taken that the cables are parallel when passed into the stomach, and the accessory cable should be relaxed before withdrawal. The main cable, except at the joint near the light, is stiff er than the Lock- Fig. 68. Kemp's gastrodiaphane (circumscribing). wood light. Eight dry cells are employed with a rheostat. Wappler manufactures a small pocket battery with six cells which I have found excellent. An extra lamp should be carried. Water was the medium formerly employed. A great advance in the technic of gastrodiaphany is the employ- ment of fluorescent media. 1 There are three such media found to be of value: Bisulphate of quinin, 10 grains (0.6), in a pint of water. The addi- tion of 5 minims (0.3) of dilute phosphoric acid intensifies its action. The same amount of dilute sulphuric acid may be substituted. The reaction of the quinin solution is acid and the fluorescence a very pale violet. Increased acidity intensifies its action and fluorescence disappears if the solution is rendered alkaline. Esculin. This is derived from the ^sculus hippocastanum (horse- chestnut), indigenous to Europe; i5-grain doses have been used in malaria. 1 New York Med. Jour.: Philadelphia Med. Jour., Feb. 13, 1904; New York Med. Jour., August 6, 1904. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH One can employ small doses, % to y~ grain (0.008-0.032), in a pint of alkaline solution, which gives a blue fluorescence. This preparation is difficult to secure and is expensive. Fluorescein (phthalic anhydrid, 5 parts), a naphthalin product, and resorcin (7 parts), heated to 2ooC. (392 F.). It is a reddish powder, faintly soluble in water, with a neutral action, and gives thus no fluores- cence; soluble in alcohol and in alkaline media, it gives a green fluorescence like liquid opal. It has been employed to detect ulcers of the cornea. It can be secured from Merck & Co., and is extremely cheap. The addition of glycerin intensifies the fluorescence, and the hy- drochloric acid of the stomach must first be neutralized. The patient should first be given a glass of water (8 oz. 250 c.c.) in which 15 grains l) Fig. 69. Gastrodiaphany: A, Normal stomach; B, dilated stomach; C, D, E. F, varying degrees of gastroptosis (Rose and Kemp). (i) of bicarbonate of soda have been dissolved. A second glass of water (8 oz. 250 c.c.) is then administered, in which are dissolved the same amount of sodium bicarbonate, i dram (4) of glycerin, and % grain to several grains (a small amount on a knife tip) of fluorescein; i or 2 ounces of lime-water may be substituted for. the sodium bicarbonate. If we increase the fluorescein much in strength, fluorescence diminishes and colorization begins. By means of fluorescent media I have found it possible to illuminate the stomachs of fat or muscular subjects that were formerly unsatisfactory, and to examine for tumors and for the location of the stomach with greater accuracy. The brilliancy of the illumination is markedly increased. 112 DISEASES OF THE STOMACH AND INTESTINES Examination of the urine of patients who have taken fluorescein shows no deleterious effects no albumin, no sugar, no casts. The fluorescein acts in an alkaline medium, and free acid destroys fluorescence, yet on catheterization of these patients, greenish fluorescent urine is obtained one hour after the administration of fluorescein solution, and this condition persists for about four hours. The acidity of the urine is not due to the presence of free acid. With fluorescein solution we have an additional means of testing the permeability of the kidneys. The technic of gastrodiaphany is as follows: The patient's stomach should be empty. He is given a glass (8 oz. 250 c.c.) of the alkaline solution, and then a second glass (8 oz. 250 c.c.) of the fluorescein solu- tion. I frequently give an extra half or even two additional glasses of water, especially in the suspected cases of dilatation or ptosis or in stout subjects. In the latter, gastrodiaphany is not as satisfac- tory, but by pressing on the abdominal wall, the outlines can be secured. A dark room gives the most satisfactory re- sults. It can be devised by pinning blankets across the windows. The patient can also be examined in a light room by covering him from neck to feet with a dark blanket or black gown, and the examiner looking through an opening therein. The gastrodiaphane is introduced by gas- light or candlelight, the patient sitting oppo- site in a chair, with the abdomen exposed. The electric current is turned on and the room darkened. The patient should then stand up, as this position is preferable. It is my custom to mark out the anatomic regions on the abdo- men of each case with blue pencil, and then draw the outlines of the stomach during transillumination. With gastroptosis, the lesser curvature can be determined. In some cases the stomach will be bottle-neck above, with the base below; or somewhat pear shaped, the narrow part showing above, as the light dis- appears beneath the ribs. With a dilated stomach the transverse diameter of transillumination is nearly the same throughout; as we withdraw the light it begins to narrow just below the tip of the ensiform. If we illu- minate in the dorsal position, the light hardly shows at all; it becomes clearer as the patient gradually sits erect, and is most marked in the standing position. This substantiates the view of Meltzing, who states that in the dorsal position only a portion of the stomach is in contact with the abdominal wall, and it demonstrates the necessity of the standing position for accurate illumination. In Fig. 69 are shown a normal stomach, the dilated organ, and several degrees of gastroptosis. There is no question but that ptosis of the stomach exists from a very slight to an extreme degree. Tumors or thick- enings of the anterior wall of the stomach, or of the lesser or greater cur- Fig. 70. Cancer of greater curvature. Gas- trodiaphany. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 113 vature, or anterior surface of the pylorus, appear as a dark area projecting into or surrounded by a light zone (Fig. 70). By the circumscribing gastrodiaphane the entire contour of the stomach is determined. The older instruments show only the lower segment clearly. RONTGEN RAY (X-RAYS) IN THE DIAGNOSIS OF DISEASES OF THE ESOPHAGUS AND STOMACH Unquestionably the discovery of the #-rays constitutes one of the greatest advances in medicine in recent times, and their application to diagnosis in gastro-intestinal diseases has proved of great value. The Esophagus. By means of the x-rays the scientific study of the motor functions of the esophagus has been rendered possible. One can readily make a diagnosis of stenosis of the esophagus or of a diver- ticulum by the methods already described. The #-rays after the ingestion of bismuth or barium are of value as an adjunct. One can thus readily determine the contour and relations of a diverticulum to the esophagus (Figs. 23, 24, and 25), a fusiform dilatation, a stricture, abnormalities due to adhesions, fistulae alternations of outline, and pressure of aneurysm or tumor. The author advocates the use of #-rays when possible, though generally one can make the diagnosis without their use. The position of a foreign body can usually be determined by direct inspection through the esophagoscope, and can be at the same time removed. A preliminary rb'ntgenograph is preferable when possible. The Stomach. From a scientific standpoint, the study of the stomach with the o;-rays has proved of great service. It has been demonstrated that the fundus is vertical and the pyloric portion is transverse, and that the viscus does not lie transversely across the abdomen, as was formerly supposed. Cannon has also made an interesting study of the motility of the stomach by means of the #-rays, and also of the relative rapidity of the exit of the carbohydrates, proteins, and fats from this organ. From a practical standpoint Rontgenography is of great value for the detection of a foreign body lodged within the stomach and for demonstrat- ing its location. The possibility of its removal through the gastroscope, or the location of an incision for its removal, often depends upon the information secured by this means. The author's new gastroscope, when laparotomy is required, simplifies its removal. The Rontgeno-cinemetographic method has enabled us to make a scientific study of the digestive tract to determine the normal changes in the contour of the stomach and intestines, the types of peristaltic waves, motility, etc. There has been a tendency to make a positive diagnosis from the a-ray findings alone, disregarding the clinical symptoms. The writer notes that recently, uncertainty is often expressed as to the differ- ential diagnosis between gastric ulcer and early cancer as determined from the radiographs alone, and chronic ulcer is considered a pre- cancerous stage, which view I believe is correct. The diagnosis should be made from the history, clinical symptoms, and physical examination plus the #-rays. These will determine whether or not the case is surgical. I 8 114 DISEASES OF THE STOMACH AND INTESTINES believe that in most cases the large number of serial pictures 40, to 80, are unnecessary. Even the brief exposures to a powerful tube, might in some cases be the equivalent to a longer exposure to a weaker tube and do harm, and the method is tiresome, and expensive for the patient. Surgical operation and pathological examination settle the diagnosis. A picture taken immediately after the ingestion of the bismuth meal; one every fifteen minutes for the first hour and. in some cases, four to six pictures in all at six-second intervals are required. At the end of one, two and six hours radiographs are taken of the stomach and intestines. Then a bismuth or barium enema with radiograph standing; then five minutes in the knee-chest position followed by a radiograph in the Tren- delenburg position. These last procedures suggested by Wm. P. Healy are of great value, particularly in cases of enteroptosis when a mass of intestines may lie in the pelvis. It will determine whether the intestines are freely movable or are bound down by adhesions not showing in the radiograph. Tousey recently radiographs in an oblique position lying on the belly, head downward. The stomach should be radiographed both in the dorsal and standing positions and at times on the right side particularly in stout patients to obtain a better picture of the duodenal cap (ascending duodenum). Fluorscopic examination is recommended by many alone or combined with palpation in addition to radiography. It would seem to endanger some risk to the patient and operator in spite of the precautions observed, the personal equation, with possibility of error is more likely and the method less accurate than photography. Marked success has also been claimed for stereo-radiography. It is not within the province of this article to describe the technic of the #-ray examination, but it seems more practical and for the benefit of the reader, that as a clinician the writer should endeavor to interpret the most important radiographs of the gastro-intestinal tract. 1 The Duodenal Cap. The normal cap (ascending duodenum) is in the x-ray picture usually triangular in shape the base lying at the pyloric ring and parallel with it. Compare the normal cap (Fig. 71 A) with that deformed by ulcer (B). It, however, may be drawn down like the modern basket hat over the pyloric end, or the position may differ slightly depending on the type of stomach. The cap may also be somewhat squarer in shape or in the form of a parallelogram. Under normal conditions there are no irregularities in its contour except occasionally a slight indentation from the adjoining duodenum. With dilated stomach from obstruction at the pars pylorica, there is a disappearance of a portion of this last, including the cap. With atonic dilatation, there is no disturbance in the contour of the stomach and the pylorus is relaxed. Gastric Ulcer. Radiological Findings. i. Bismuth retention six hours after the meal shows mechanical interference with the exit of the gastric contents due to tumor, cicatricial contracture of the pylorus from ulcer, or ulcer adhesions, or gall-bladder adhesions. Such retention also oc- curs with atonic dilatation of the stomach, but the outline of the organ is 1 Unless otherwise noted, the radiography of all cases in this volume is the work of Sinclair Tousey on private patients of the author. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH normal in this condition, while it is irregular at some point from ulcer con- traction, tumor or adhesions. Pylorospasm associated with hyperchlorhy- dria, secondary to chronic appendicitis, gall-bladder infection or intra-ab- dominal adhesions, such as occur with Lane's kink, may cause bismuth retention. Cole holds spasm of the cap to be responsible and that he can determine it by the #-rays. Correction of the hyperacidity (which the writer believes is often reflex from the other conditions and the spasm secondary) by belladonna, antacids, etc., will at times temporarily re- lieve the spasm. The preliminary use of these before radiography usually eliminates it, Chronic appendicitis is not particularly difficult to diagnose, especially if one examines Morris' point as well as McBurney's. It can often be determined by the former when not by the latter. Further radiographs of the intestines and the clinical history afford us the required diagnosis. Chyme passing through lumen of pyloric Clinical diagnosis: Ulcer of the cap. sphincter into reservoir cap. A, Pilleus Rontgenologic diagnosis : Ulcer of the cap. ventriculi (cap). B, Pyloric sphincter. C, Surgical findings : Ulcer of the cap. Case i Lumen (normal) (L. G. Cole). (Brewer,and Cole). Fig. 71. Compare normal cap (ascending duodenum) with deformed cap from ulcer. In Fig. 72 is depicted a case of the author's. The patient, aged 58, had gastric disturbance for many years becoming worse two years previously, and had lost 25 pounds in the course of a few months. He has vomited once or twice daily of late. The gastric analysis was typical neither of benign nor malignant stenoses total acidity 60 + , no occult blood in stomach-contents or stool. The writer believed the case to be benign stenosis due to ulcer, no tumor palpable. The radiograph shows marked retention of gastric contents, with disappearance of the pylorus and cap. It did not differentiate between simple adhesions, with or without ulcer, and carcinoma. Operation disclosed perforated gastric and duodenal ulcers well walled in with a mass of adhesions nearly obliterating the pylorus and cap and adherent to the pancreas. 2. In some cases, when the ulcer lies upon the lesser curvature, it may cause contraction of the upper border of the stomach, thus bringing the cardia and pylorus closer together, the latter being displaced (drawn) n6 DISEASES OF THE STOMACH AND INTESTINES upward and to the left," so-called "snail form." Ulcer at the pylorus, on the greater curvature, like cancer, may produce the "undershot stomach" with pyloric stenosis. 3. Penetrating ulcer of the stomach shows a patch branching out from the bismuth or barium meal, or at times isolated from it. In the latter event there may be a gas bubble at the summit of the patch. 4. Bismuth or Barium Patch on Shallow Ulcer. In Fig. 73 a case of the writers at the upper end of the radiograph is a black patch marked +. -S.TOU8EY Fig. 72. Perforating gastric and . duodenal ulcers (posterior). Adhesions sur- rounding pylorus and cap. Pancreas attached by adhesions. Ulcers were walled off by adhesion. Condition was evidently chronic. Bismuth retention marked at end of six hours. Stomach dilated and ptosed. This represents a bismuth deposit on a shallow ulcer surface, six hours after the bismuth meal. By comparison with radiographs taken directly after the meal this patch was demonstrated to lie near the cardiac orifice probably posteriorly. This patient suffered from hyperacidity, hyper- secretion and chronic gall-bladder infection of mild type. Abdominal section demonstrated infected gall-bladder which was removed. The operator palpated the stomach and duodenum with particular care and examined them as usual, as far as possible. No ulcer could be determined. For a few months there was marked improvement but attacks of METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 1 17 hypersecretion, headache and vomiting, still occurred later. Five months after operation the condition was nearly as bad as before. The ulcer was determined by the .r-rays subsequent to operation. Unquestionably bismuth deposit will not occur on some ulcers and when there is little or no cicatricial contraction, no deformity may be appreciable so that hypermotility may alone show in the radiographs accompanied sometimes by pyloric spasm and retention. Hypersecretion can best be determined by Reichmann's method. On the other hand a bismuth patch does not always necessarily mean Fig- 73- Bismuth deposit on a shallow ulcer (at -f-) surface, six hours after bis- muth meal. Infected gall-bladder removed. Palpation at operation could determine no ulcer. Hyperacidity and hypersecretion present. Ulcer demonstrated by radio- graph subsequent to operation. ulcer. In a case of gastroptosis with a history of gastric disturbance formerly marked and more lately less severe, there was a bismuth patch of fair size near the fundus. There were no clinical evidences of ulcer. Evidently the patch was due to contractions from an old healed ulcer, or from adhesions, with resulting bismuth deposit in the irregularities. Motility was disturbed in that area. Clinical conditions must therefore be also considered in arriving at our diagnosis. 5. Deformity of the contour of the stomach without pyloric stenosis may occur, such as a saddle-back ulcer of the lesser curvature. n8 DISEASES OF THE STOMACH AND INTESTINES 6. A small puckered area with distortion of the rugae is suggestive of gastric ulcer, particularly if the region fails to contract with the rest of the organ and when this area coincides with tenderness on palpation. 7. Distortion or displacement of the stomach or cap by adhesions is suggestive of gastric or duodenal ulcer. In most cases the pyloric sphincter and cap are involved. The sphincter is not clear cut and is wider on one surface appearing wedge-shaped or on both surfaces with an annular appearance (Cole). The cap may be contracted, asym- metrical, displaced or even absent. Peristaltic contractions are clean- cut in the normal portion of the stomach but are irregular or cease at the point of adhesions. The stomach may be bound to an adjacent viscus and radiographs taken in the dorsal, standing and Trendelenberg posture may aid in the determination of that viscus, to which there are adhesions. \Jr (I%^>1 ^*\f There is usually a deep incisura "^ ' on the opposite, non-adherent portion of the stomach. It may occur opposite to or slightly to the cardiac side and represents com- pensatory hypermotility of the organ or it may be due to spasm S" ^\ ^^ "N \ ( Carman )- 1 Diffuse spasm of the A^ ^^^--*' J I p ars pyl or i ca or pylorus alone with retention of contents may also occur. Adhesions to the gall- bladder or liver generally result in the stomach being held up more horizontally. With gall-bladder infection and adhesions there- from, the cap is often angulated and drawn more to the right, so that the lumen is more horizontal than vertical. It is not always possible in the writer's opinion to differentiate between adhesions from gall-bladder infection, or adhesions from ulcer. The radiograph shows that the condition requires surgical procedure. 8. Hour-glass contraction occurs at times as a sequel to gastric ulcer as in Fig. 74. A spastic hour-glass contraction is at times seen with ulcer of the lesser curvature particularly if it is adherent to the under- surface of the liver. The incisura (indentation) occurs on the . greater curvature only. It may be found on some plates and not in others, and may disappear in the dorsal position. Spasm of the pars pylorica or entire stomach may be due to extrinsic causes such as disease of the ap- pendix, gall-bladder, pancreas, etc. It can be generally excluded by belladonna gtts. 10-20 t.i.d. several days before examination. Duodenal Ulcer. Radiological Findings. There is" considerable dis- pute among our radiologists as to which should be considered the major and minor radiological signs of this condition. Cole of New York, places most confidence in changes in contour of the cap as the most im- J Journal A. M. A. (Carman) April, 22, 1916. Fig. 74. Hour-glass contraction of stomach secondary to ulcer. Local pain. Seven years previously blood in the stool. Pain aggravated by food. Previous history of ulcer (MacFarlane in N. Y. State Jour, of Med.). METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 1 19 portant feature, while Carman of Rochester, Minn., believes that with ulcers chiefly limited to the mucosa, or not extending deeply and with slight visible scar production but no marked contraction or deformity, that: i. gastric hyperstalsis is the chief radiological symptom, and that deformity of the cap may not necessarily occur. Undoubtedly with superficial ulceration of the duodenum no changes may occur in the cap to cause marked distortion, though I believe some bismuth or barium retention or slight irregularity would be found in most cases. Carman's contention that stenotic lesions on the gastric side of the pylorus are rarely accompanied by gastric hyperperistalsis is not well founded, especially in some cases of stenotic dilatation of the stomach. The phenomenon of peristaltic unrest hyperstaltic action of the stomach with waves visible through the abdomen is a clinical entity. Radiographs at this time might show exaggerated peristaltic action on the part of the stomach in endeavoring to overcome the pyloric obstruction. More- over, this type of stomach pathologically gives evidence of a hypertrophy of the musculature at the pyloric end of the stomach, an endeavor to compensate for the obstruction' and an evidence of exaggerated muscular activity. Most frequently of course there is retention without hyper- peristalsis as the radiographs are generally taken during the quiescent period. With pylorospasm associated with hyperacidity, during the active spasm we may have hyperperistalsis. Furthermore, uncured pyloro- spasm may result in hypertrophic pyloric stenosis. Finally, in the event of the inability to overcome the obstruction (organic or spasmodic) reversed peristalsis (antiperistalsis) occurs and -vomiting follows. We place i. gastric hyperperistalsis 1 as one of the radiological signs of duodenal ulcer contributory to our diagnosis, when present, though it may also occur with gastric ulcer, or erosions. 2. Retention of bismuth in the stomach after six hours occurs in some cases with hyperstalsis (gastric). 3. Irregularities or deformity of the cap (ascending duodenum) or of the sphincter pylori produced by the induration surrounding the crater of an ulcer or resulting from it. These signs so ably described by Cole 2 are of extreme importance. The indurated ulcer may project into the lumen of the cap (Fig. 75) and cause a displacement of barium or a dent, or entirely distort the lumen, or half the cap may be involved. In some cases one sees only a pocket filled with barium, or a barium pocket lying in a distorted cap. Sometimes the deformity lies along side the sphincter pylori and may involve it. In other cases, the cicatricial contraction may practically obliterate the cap and it is doubtful whether one can differentiate this as due to induration or adhesions. In addition to the deformity of the cap adhesions may pass to the gastric side of the sphincter and distort the pyloric end of the stomach giving the aspect much like the snail form of stomach as in gastric ulcer. About 90 per cent, of duodenal (post-pyloric) ulcers lie in the cap 1 Journal A. M. A., May, 8, 1914. 2 Lancet, May 2, 1914. I2O DISEASES OF THE STOMACH AND INTESTINES (ascending duodenum) though other times they occur lower in that viscus. 4. Lagging or retention of bismuth or barium in the duodenum, or a dilated cap, or an accumulation of bismuth or barium filling part of the duodenum may be due to ulcer, or ulcer contraction adhesions from ulcer, or other adhesions such as from the gall-bladder. 5. A diverticulum in the cap from perforating ulcer is a major sign described by Carman who also refers to minor signs such as Fig- 75- Fish-hook stomach. Marked peristalsis at pyloric end (hyperperistalsis) cap small and slightly irregular (c). Hyperchlorhydria. Four months history. No hemorrhage. No occult blood on several examinations. Point of tenderness corre- sponds to cap. Improved for a time under treatment, then relapsed. Operation advised but refused. Diagnosis. Duodenal ulcer. 6. Gastric hypermotility with early opening of the pylorus and rapid emptying of the stomach when no stenosis is present. 7. Gastric hypertonus. 8. Spasms of the stomach such as hour-glass, or slow traveling in- cisura. The writer finds deformity of the cap and hyperstalsis with a six-hour residue, the most reliable radiological data. In some cases there may be lagging of bismuth in the cap, or a large accumulation therein and more rarely a diverticulum. Deformity of, the cap is the most frequent sign METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 121 elicited. Constriction of the duodenum by adhesions or a mesenteric band may simulate duodenal ulcer. Simulation of symptoms of duodenal ulcer caused by rolling up and thickening of part of the mesentery, constricting the duodenum and passing to the transverse colon near the hepatic flexure. This patient had been ill twenty months with stomach trouble, belches gas suffers from nausea no vomiting. Has attacks of pain in the stomach which are relieved by food. These occur two to three hours after meals. Bowels costive. ' Fig. 76. Fish-hook stomach. Hyperperistalsis particularly in pyloric region. Cap enlarged, + , with bismuth lagging in same. Believed to be due to duodenal ulcer near end of ascending duodenum (apex of cap). Patient has local pain and tenderness corresponding to this point. Operation shows no ulcer, no ulcer scar, but thickened mesenteric band exercising traction at junction of ascending and descending duodenum. It does not surround the gut. Bismuth eventually deposited above traction point. On one occasion he found blood in his mouth which he believed was belched or regurgitated from the stomach. Slight tenderness was present on pressure in the epigastrium a little to the right of the median line. Gastric analysis showed hyperacidity and no occult blood. No occult blood in the stool. Diagnosis " Hyperchlor- hydria" with probable ulcer of the duodenum. Finally several months later, pain and tenderness persisting, the patient consented to an .v-ray examination. The results appear in Figs. 76 and 77. There was hyper- 122 DISEASES OF THE STOMACH AND INTESTINES motility particularly marked at the pyloric end yet the cap was unduly large and showed lagging of bismuth. Six hours later the stomach was empty but there was a bismuth deposit at +, corresponding to the ascending duodenum (cap). There was deformity of the transverse colon and hepatic flexure, the latter with part of the transverse being abnormally distended and evidently involved by some and causing partial stenosis below. The descending colon was narrow probably congenitally so. Fig. 77. Stomach empty in six hours, but bismuth deposit in ascending duo- denum at +. Hepatic flexure enlarged and distorted also dilated. Believed to be drawn up by adhesions, or due to adhesions at angulation below. Operation shows thickened rolled up mesenteric band adherent to duodenum above and upper surface of hepatic flexure below. Traction exerted on duodenum causes lagging bismuth. Weight of hepatic flexure suspended from narrow thickened section of mesentery causes dilatation. Small descending colon probably congenital. The patient was referred to Dr. Wm. P. Healy with the diagnosis duodenal ulcer with adhesions. Operation demonstrated absolutely no evidence of ulcvr or cicatncial contraction from the same and no adhesions. A narrow section of the mesentery extending from the hepatic flexure to the duodenum (at the juncture of the ascending and descending portion) was rolled up on edge and thickened into a band not circumscribing but by the drag, causing narrowing of and traction on the cap. This ac- counted for local pain and tenderness and hypermotility of the stomach. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 123 Though the traction was sufficient to produce delayed bismuth deposit in the cap at the end of six hours, yet it did not cause retention (gastric) at this period. The mesenteric thickening passed to the junction of the hepatic flexure and transverse colon but did not surround the gut. Par- ticularly in the standing position there would be a painful drag on the duodenum, while the colon contents would weight down the flexure and pull downward on the suspending band. The cause of this condition could not be determined unless possibly there were mechanical factors. The patient was a day laborer and in spite of this very costive. The hyperacidity was probably reflex. The thickened mesenteric band was divided with subsequent excellent results. Hour-glass stomach can be determined by means of the tf-rays (Fig. 78). The diagnosis can be made by the methods described under that subject, but it is advisable to confirm the same by Rontgenography when possible. Fig. 78. Hour-glass stomach. Rontgenography has been recommended for the purpose of locating the position of the stomach. The method is expensive for the patient, and the diagnosis can be made by the usual methods of physical examination. Even though I have determined the diagnosis to be gastroptosis by the ordinary methods, I usually advise radiography of the stomach and intestines. The patient is thus convinced of the correctness of the diagnosis and is more amenable to treatment. Adhesions if present can also be discovered. For thoroughness, pictures should be taken in the dorsal and standing position. One notes in some cases a mass in the pelvis, in which it is not always possible to determine adhesions. Wm. P. Healy suggests placing the patient for five minutes in the knee-chest position, then turning case over into the Trendelenberg posture and securing an additional radiograph. The gut will drop back out of the pelvis and adhesions or stenosis will be thus readily determined. Radiography both confirms the diagnosis to the satisfaction of the patient and aids in the prognosis. If the gut is bound down by adhesions, operative procedure is indicated in cases with 124 DISEASES OF THE STOMACH AND INTESTINES obstinate constipation of severe type, though with slight adhesions I do not advise operation. Marked angulations are thus also demonstrated. Fig. 79. Gastroptosis (water-trap with dilatation. Radiograph by Tousey). Fig. 80. Retention one hour later (Ra- diograph by Tousey). In Fig. 79 is shown a case of gastroptosis. This patient suffered from hypochlorhydria and attacks of vomiting. Rose's belt and sub- sequently Lane's belt, forced the stomach up sufficiently so it emptied itself Fig. 81. Shows marked enteroptosis (prolapse of large intestine. Radiograph by Tousey). Six-hour residue in stomach. (Same case.) Fig. 82. Shows adhesions and sharp an- gulation of the transverse colon way down in the left side (Radiograph by Tousey). (Same case.) quite well and vomiting ceased. Patient refused operation for ad- hesions. He has gained weight and only has occasional attacks. The types of gastroptotic stomachs will be illustrated under Glenard's Diseases. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 12 The Diagnosis of Carcinoma. Holzknecht, Jonas, Pfahler, and Cole particularly advocate the value of the .r-rays for the early diagnosis of carcinoma of the stomach. Pfahler, 1 makes the following interesting statement: "Based upon a rather large experience in the Rontgen diagnosis of carcinoma of the stomach, it is my opinion that we have in this method the most positive means yet devised for the recognition of carcinoma in any stage of the disease. It stands next to an exploratory operation." This last is significant. The value of the method of diagnosis depends on the fact that carcinoma of the stomach modifies the outline, position, or lumen of the organ, or interferes with the peristaltic waves, the motility of any part, or obstructs the passage of food. The earliest evidence will be some interference with the peristaltic waves. Most of our radiologists do not now differentiate between indurated ulcer and early gastric cancer, in which they are wise, for the radiograph Fig. 83. Carcinoma of pylorus. Stomach is dilated, mostly vertical, reaching to false pelvis. Some evidence of peristalsis in walls of vertical part. The hori- zontal part extends to the middle line, and ends with a peculiar serrated border (ragged edge) (characteristic for carcinoma). of ulcer and cancer near the pylorus may be quite similar. Syphilitic conditions must also be excluded. The Wassermann test should be made in doubtful cases. Holzknecht holds that in a patient with achylia, when bismuth residue is found in the stomach six hours after the meal, when the head of the bismuth column has reached the splenic flexure and the second bismuth meal shows a normal stomach shadow, the diag- nosis of early carcinoma can be made. This means a hypermotility of the stomach with retention of bismuth and yet a normal contour of the stomach after the second meal. With hypermotility and yet retention in the stomach there is a change in contour at the pyloric opening or in the cap, i.e., some obstructive condition even though it may be slight in the radiograph, so Holzknecht's claim seems erroneous. The radiographic findings of carcinoma depend on the position, type and form of the growth. 1 Med. Rec., March 25, 1911; N. Y. Med. Jour., May 6, 1911; Jour. Amer. Med. Assoc., June 17, 1911. 126 DISEASES OF THE STOMACH AND INTESTINES i. Filling Defects. A large rounded mass may project into the stom- ach and prevent the bismuth from filling this portion. If the body or fundus of the stomach are the part involved, obstruction of the pylorus ' Fig. 84. Gastroptosis. Hyperperistalsis. Patient, Mrs. X, standing. Fig. 85. Hyperperistalsis. Patient, Mrs. X, lying down. naturally does not occur. Absence of the rugae of the stomach in the involved area Cole believes an important sign of malignancy. 2. Nodular growths infiltrating the stomach walls show "finger- print" indentations. MINUTES AFTER BISMUTH MM Fig. 86. Hyperperistalsis. Irregularity Fig. 87. Bismuth retention in duodenal near pyloric orifice. Cap well filled. Mrs. X. cap. Mrs. X. 3. With an extensive destructive process an area may be obliterated and the edge of the uninvolved area appear serrated (ragged) Fig. 83. 4. An annular growth may give a funnel appearance. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 127 5. If the pylorus is obstructed, only a thin distorted line of bismuth may be seen in this region, or there may be disappearance of the pyloric orifice with evidences of adhesions, or a worm eaten line of involvement; dilatation and stasis occur. 6. With scirrhous cancer the stomach may be held up high in position, with disturbance of motility of the lesser curvature. 7. Involvement of the pars media of the stomach does not cause dila- tation. Sometimes the stomach empties itself very rapidly in these Fig. 88. Normal umbilicus lies at the level of a line drawn transversely through the highest points of the iliac crests. Fixed points should be taken as the basis of comparison, as the umbilicus varies in position, in fat or flabby subjects particularly between the standing and dorsal postures. With the line noted taken as the standard, the umbilicus and transverse colon are seen to be slightly lower than normal. The arm of the trans- verse colon at -f- is sharply angulated and held up apparently by adhesions. Stomach empty in 6 hours. Mrs. X. cases, as it does also in early cases of ulcer (carcinomatous) near the pylorus without interference (contraction) to the exit of contents. 8. The size and contour of the deformity is constant. Case for Exploration. In Figs. 84-89 an interesting case is de- picted. The history is as follows: Female, aged 57, first visit November 6, 1914. Stomach trouble since previous February, 1914. Nausea nearly 128 DISEASES OF THE STOMACH AND INTESTINES continuous vomited once, feels weaker daily, very costive, soreness in stomach most of the time, pain regularly half an hour after meals relieved some by food. Residuum only few cubic centimeters. Total acid 6 + free HC1O lactic acid O, etc. Stomach apparently emptied very rapidly no occult blood; believed at first to be achylia gastrica. Fig. 89. Same patient after 5 minutes in Knee-chest position then turned over and radiographed in Trendelenburg position this combined method known as Wm. P. Healy's. Note the umbilicus has dropped toward the patjent's thorax and to the left. Taking the constant line between the iliac crests (superior) as the level of normal umbilicus. We find in Fig. 88 the transverse colon lay i\$ inches below the line while in Fig. 89 it lies 3 inches above this line, or 4),$ inches change in posture. This demon- strates no adhesions bending the gut in the pelvis, but the same narrowing due to probable adhesion is shown at + in Fig. 89. Mrs. X. Stool. Soaps and some fat globules (slight excess) few red cells from hemorrhoids. Physical Examination. Slight epigastric tenderness. Lower border stomach reaches umbilicus. Blood. Hemoglobin 70 per cent., red cells slightly over three million, a quite marked secondary anemia. Though this case presented gastric findings of achylia gastrica, she was quite weak, secondary anemia quite marked and six to eight weeks' feeding only keeps the weight the same. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 129 Radiographs, Figs. 84-86, show hypermotility but stomach empty in six hours in one picture some irregularity in the pyloric end of stomach and cap; in two pictures lagging of bismuth and excess of same in cap and apparently adhesions to transverse colon. The case the writer believes warrants exploratory laparotomy. Adhesions from the transverse colon to the duodenum might produce such deformity simulating duodenal ulcer; or an ulcer near the pyloric ring becoming malignant might be responsi- ble. No operation. Patient subsequently died of carcinoma of stomach. 1 Fluoroscopy is a most valuable feature of the method. There is con- siderable danger in fluoroscopy to the operator and also to the patient, unless in the hands of an expert. The writer would recommend the phy- sician to avail himself of the method if he can secure the services of such. There are many who can take an excellent Rontgenograph, but no great Fig. 90. Dilated duodenal cap. Shows passage of bismuth at end of two hours. Diagnosis gall-bladder adhesions from stones, operation refused. number at present writing qualified by experience to correctly interpret the fluoroscopic appearances diagnostic of early cancer. Radiography is therefore the most practical. In many cases, the examination by the ic-ray cannot be carried out particularly in country districts and a trip to a distant city is financially impossible. In suspicious cases exploratory laparotomy is indicated. I would give this advice to the country surgeon. Radiography of Perigastric Adhesions the Gall-bladder and Gall- stones. Cole has demonstrated the effects of adhesions on the peristaltic waves of the stomach cinematographically. The lesser curvature is usually involved. Pfahler shows that the normal position of the stomach and duodenum is modified by adhesions to the gall-bladder in other words, that these organs are pulled upward and to the right. With chronic cholelithiasis and cholecystitis, the swelling of the liver and gall- bladder brings them nearer the stomach and duodenum, and the peri- cystitis leads to adhesions. When the swelling is reduced, the adhesions lr The writer at the time of the radiographs stated he believed carcinomatous de- generation of an ulcer was commencing and suggested exploration. 9 130 DISEASES OF THE STOMACH AND INTESTINES Fig. 91. Stomach, gastroptosis. Gall-bladder adhesions, cap obliterated. Only small amount of bismuth meal retained, rest vomited. Apparent finger print on upper surface but angle quite acute. Small projection at inner edge of inner print. No incisura opposite showing motor phase. In view of history of case (inflammation of gall-bladder with removal) and high position of transverse colon on right side, evi- dently due to adhesion, distortion of stomach believed to be due to inflammatory band of adhesions. Cap moreover was obliterated. This diagnosis proved to be correct on operation by Wm. P. Healy. A band ran from stump of gall-bladder to the cap, with adhesions at angulation or lesser curvature. The stomach was not held upward and transverse as is usual, but was misplaced in the standing position. This caused the patient severe pain, relieved by dorsal posture. ^ Fig. 92. Intestines. Gall-bladder adhesions. Transverse colon on right side midway between hepatic flexure and umbilicus drawn up in high position +. This from history of case believed to be due from adhesions following removal of gall-bladder. Note the caput coli, ascending colon, and hepatic flexure are low down (enteroptosis) while the transverse colon is held abnormally high by adhesions. The patient presented the characteristics of an enteroptosis, diastasis of recti muscles, etc. The transverse colon as noted was found at operation, held up at + by adhesions from the stump of the excised gall-bladder. There was a thin Jackson's membrane on ascending colon of which no evidence was given by #-rays. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 131 Fig. 93. A. Stomach in normal position, but the liver and gall-bladder swollen and thereby approaching more closely the Stomach and duodenum, and more easily permitting the formation of adhesions to these organs. B. Liver and gall-bladder returned to their normal position, the stomach and duodenum drawn upward and to the right by adhesions (Pfahler). Fig. 94. -At + a large bismuth deposit in the duodenum showing it dilated; probably obstruction from adhesions from gall-bladder. No stones visible in radiograph. Indirect method. Diagnosis: Gall-stones, adhesions and chronic pan- creatitis. Demonstrated correct at operation by John Erdmann. 132 DISEASES OF THE STOMACH AND INTESTINES pull the stomach upward and to the right (Fig. 93). In such cases the clinical symptoms appear most marked during digestion, when the motor unctions of the organs are at their height, especially when the emptying of the stomach and gall-bladder has been interfered with. Adhesions from gastric and duodenal ulcer to the gall-bladder or liver may also hold the stomach up more horizontally see adhesions "under radio- graphic findings of gastric ulcer." Moreover from gall-bladder adhesions the duodenal cap is often angulated and drawn more to the right so that its lumen is more horizontal than vertical. The determination of adhesions show- Fig. 95. At + adhesions near hepatic flexure believed to come from gall-bladder. Same case as Fig. 94. Gall-stones and adhesions demonstrated at operation by John Erdmann. ing deformity of the cap or pylorus, or change in position of the stomach are often our only positive radiographic evidences of gall-stones, or chole- cystitis. This is known as the indirect method. It is estimated that only in 30 to 50 per cent, of cases can gall-stones be directly determined by the #-rays (Fig. 97). Cholesterin stones (Cole), on the other hand, cast a negative shadow, 1 a ring-like shadow in the bile. In Figs. 91 and 92 is demonstrated an interesting case. The patient, female, had the gall- bladder removed for infection. There were many adhesions at that time. She suffered from severe hyperacidity, local tenderness in the epigastrium, 1 American Journal of Roentgenology, February, 1913. METHODS OF PHYSICAL EXAMINATION OF THE STOMACH 133 regurgitation of sour fluid and marked nervous symptoms. She vomited occasionally. Adhesions were present as demonstrated in the radiographs. The following case is instructive: male, aged 57, two years previously had 163 gall-stones removed from gall-bladder which was temporarily drained, but left in situ. Subsequently epigastric pains, looseness of the bowels, sometimes movements of putty color, tenderness in the epigas- trium, no jaundice, no gall-stone attacks. Examination showed marked tenderness at Robson's point with some sensitiveness in the epigastrium. The gall-bladder was slightly sensitive and there was discomfort on pressure at McBurney's and Morris' point. Fig. 96. Patient with jaundice believed due to duodenitis. Dark stripe in the shadow of the liver + + + may indicate inspissated bile. Gastric analysis free HC1 O ; comb. HC1 12 + ; trace lactic, total acidity i7 + . Urine intermittent glycosuria no bile occassionally indican. Stoo 1 showed excess of unabsorbed fats excess of soap, and partly undigested meat, #-rays showed dilated duodenum believed to be due to gall-bladder adhesions also adhesions near hepatic flexure of colon (see Figs. 94 and 95). The writer's diagnosis was: gall-stones, cholecystitis, chronic pancreatitis, adhesions to duodenum and colon probably ap- pendical infection. He believed the achylia reflex operation by John 134 DISEASES OF THE STOMACH AND INTESTINES Erdmann confirmed these findings. In Fig. 96 is illustrated the findings possible with inspissated bile. The patient was treated for inspissated bile and duodenitis with recovery. For preparation for the #-rays, it is best two nights before examina- tion to give a good cathartic with a saline cathartic the following morning, and an enema that night and generally early in the morning on the day of examination. The day before examination no solid food of any description and no milk should be taken. Food should consist only of strained soups and broths. The patient should appear for examination with an empty stomach or take a cup of broth. To eliminate spasm of the pars pylorica or cap, tinct. belladonna gtts. 10 t.i.d. or atropine gr. J^ t.i.d. should be given several days before 1 and on the morning of examination. If there is hyperacidity an alkali should also be administered. Bismuth Fig. 97. Pressure on terminal wave and cap by four gall-stones. Anterior view. Proven by surgery. Direct Method. (L. G. Cole). subnitrate has been generally abandoned on account of the possibility of a toxic effect, methemoglobinemia having been reported as a result. Bismuth subcarbonate, i ounce in a glass of kefir, fermillac, or koumiss, is excellent for #-ray work or preferably barium sulphate in zoolak. Bismuth^ oxychlorid may be substituted or barium sulphate. Cole and Einhorn 2 have advocated radiograms of the digestive tract by in- flation with air, but the author does not believe the method as satisfactory as by the older technic. The determination of gastric atony by a study of the peristaltic waves (i.e., their absence) is interesting scientifically, but simple methods only are necessary for the purpose of diagnosis. RADIUM TRANSILLUMINATION OF THE STOMACH This method was first suggested by Einhorn 8 with his radiodiaphane, a rubber-covered glass capsule containing 0.05 gm. bromid of radium 1 Some advise as much as gtts. 20 belladonna tinct. t.i.d. 2 New York Med. Jour., Oct. 8, 1910. 3 Med. Rec., July 30, 1904. 135 (Curie, 1,000,000 strength (an inflating bulb, and using Kahlbaum's fluroscope. The transillumination is very faint, and the method im- practical. RADIUM PHOTOGRAPHS OF THE STOMACH The same may be said of this procedure devised by Einhorn. 1 The length of exposure to radium is never less than an hour which is decidedly objectionable, as severe burns are possible from radium. The following methods I have found from experience to be most practical for general use. Inspection. By this method the peculiar shape of the abdomen, suggestive of gastroptosis, can at once be determined. Palpation. If movable kidney be present, it is pathognomonic of gastroptosis, especially if the lower border of the stomach lies abnorm- ally low. Sensitive areas can be also determined, and often the presence of a tumor. Percussion. The scratch method of auscultatory percussion is serviceable in mapping out the stomach, as is also auscultatory percussion. Splashing Sound. If not present, it can be artificially produced, and i? most valuable in determining the lower border of the stomach. Dehio's Method. Additional water can be given, if desired, and by percussion, the observations determined by the splashing sound can be substantiated for accuracy. Gastrodiaphany. This can be employed to differentiate in very slight degrees of gastroptosis between ptosis and dilatation, and is of value in accurately mapping out the stomach before surgical operation. It is useful for these purposes when radiography cannot be performed, as at times in country practice, and convinces the patient of the presence of ptosis or dilatation. By it one can at times determine the presence of a tumor at an early stage, if on the anterior surface of the stomach. Inflation. This method, especially by distention with carbonic acid gas, is an aid in mapping out the stomach and in determining the position of the upper as well as of the lower border. X-Rays. Are confirmatory of stenosis or diverticulum of the esoph- agus or of the presence of a foreign body. They will also determine the latter in the stomach and the presence of hour-glass stomach. They assist in the determination of perigastric adhesions, carcinoma, an ulcer, dilatation of the stomach with stenosis, gastroptosis, intestinal misplace- ment, angulations, patency of the ileo-cecal valve, adhesions, stenosis, degree of intestinal stasis and in some cases the position of the appendix. 1 Archives of Physiological Therapy, Sept., 1905. CHAPTER VI EXAMINATION OF THE FUNCTIONS OF THE STOMACH SECRETION, motility, sensation and absorption constitute the functions of the stomach. The determination of the secretory and motor functions is of impor- tance for accurate diagnosis. Examination of the function of absorption, as will be demonstrated later, is usually unnecessary. The Function of Sensation. As a rule, under normal conditions we do not recognize that we have a stomach, unless for example after the inges- tion of very cold, or hot material, such as ice cream, very hot coffee, etc., on an empty stomach. Even so, the gastric sensation is evanescent. On the other hand with a pathological condition of the organ, subjective sensations such as cramps, pain, burning, etc., may be present; or even a combined subjective and objective manifestation of sensation such as tenderness; which last may be objective through the manifestation of protective muscular rigidity on palpation over an ulcer for example. The function of sensation may therefore be of considerable assistance to our diagnosis. Examination of the Gastric Secretion (Secretory Function). The gastric secretion may occur under the influence of the pleasant odor or agreeable appearance of the food before ingestion (psychic secretion), particularly if the subject has been fasting. It chiefly occurs as soon as food enters the stomach, and continues until the chyme has passed into the intestines. The secretion is diminished toward the last. Examination at various periods after taking food will give different results, and it is necessary to examine the gastric contents at a definite time during the height of digestion. It is desirable that a definite test- meal should be administered. TEST-MEALS Riegel's Test-dinner. Riegel's test-dinner is the oldest advocated. This consists of a plate of meat broth (about 400 c.c.) ; a beafsteak weigh- ing from 150 to 200 gm. (5-7 ounces); 50 gm. (i% ounces) of mashed potatoes; and a roll (35 gm.). The average time one should aspirate the stomach-contents is about four hours after this meal. Ewald's Test-meal. This consists of about 6 ounces (175 gm.) of finely chopped meat; stale bread, 35 gm., and butter, to be taken three hours before withdrawal of the stomach-contents. 136 EXAMINATION OF THE FUNCTIONS OF THE STOMACH 137 This is practical as regards quantity, as by some the test-meal of Riegel is considered large in amount. Test-meal of Germain See. The patient is given 3 to 5 ounces (100- 150 gm.) of white bread; 2 to 3 ounces (60-80 gm.) of finely chopped meat, and a large glass (300 c.c.) of water, and the contents examined two hours later. Klemperer's Test-meal. This consists of i pint (500 c.c.) of milk and 2 rolls (70 gm.), given on an empty stomach. Examination two hours later. Test-breakfast of Ewald and Boas. This is given in the morning in the fasting condition, not even water to the allowed, and consists of i to 2 rolls (35-70 gm.) and i cup (300-400 c.c.) of tea or water. Examina- tion one hour later. The writer prefers two slices of bread (60 gm.} and an average of 350 c.c. water. Tea is of unstable strength, is irritating to some patients and colors the gastric contents. The average slice from the loaf weighes about 30 gm. If the patient is of small physique, lesser quantities may be used. When hypermotility is present little or no contents may be secured an hour after the breakfast, in which event a new test-breakfast must be administered the following morning and part of the contents asperated 30 minutes later and the balance 40 to 45 minutes after the meal. I generally advise a full dinner the night before at which spinach, boiled rice and six raisins without seeds are taken. Often when marked disturbance of motility is present, spinach, etc., will be found in the aspirated contents. Fractional Study of Gastric Digestion by Intermittent Aspiration. Rehfuss, Bergheim and Hawk have made a fractional study 1 of gastric digestion but the writer sees no advantage in their method. As a scientific study the fractional method is of value; for practical use, the simple method in vogue is sufficient. Dry Test-meal. Boas has suggested a dry test-breakfast, consisting of a roll without water, as giving a more accurate index of gastric secre- tion. In cases of disordered motility the dry method is possibly more accurate, but from a practical standpoint there is no advantage in the method. Chace 2 reports a recent series. Some prefer it in differentiat- ing between hyperacidity and hypersecretion. Boas' Test-breakfast. One ounce of rolled oats boiled in i pint of water, with salt to taste. Boas advocates this, as it contains no lactic acid, and believes it should be employed when an accurate test for this acid is desired. Two shredded wheat biscuits with water (300 c.c.) or a pint bowl of granose have been recommended as a convenient substitute. Sahli, Jaworski, Friedman, Roberts and others have suggested modi- fications. They possess no advantages. The test-meals that are in chief use are the Riegel test-dinner and Ewald-Boas test-breakfast. The latter is easily procured and can be 'Journal A. M. A., Sept. 12, 1914. 2 Jour. Amer. Med. Assoc., July i, 191 1. 138 DISEASES OF THE STOMACH AND INTESTINES administered during office hours which is the most accurate method. It is easy to recognize therein remnants of food from the previous day. The test-dinner gives better results as regards the investigation of the microscopic appearances and the study of the motor functions. The test-breakfast in many cases will be sufficient, particularly by the special method described by the author. It is often of service to administer a special test-dinner at 7 P. M. and the test-breakfast in the office at 7.30 to 8.00 A.M. It will be described under Testing the Motor Functions. I agree with Fleiner that tea is to some an irritant. In addition, it is not of stable strength, and water is preferable. The average slice of bread from the loaf weighs 30 gm. I employ usually two slices (60 gm.) of bread and 300 to 350 c.c. of water, the latter by preference. One must allow for a patient of small physique and poor nutrition, for in such cases he cannot or will not take this quantity. The diagnosis in most cases should not be made from a single examination of the gastric contents. Practically the specialist is often obliged to make a diagnosis from one examination the gastric contents, stool, of urine, physical examination and the radiographs. E. L. Eggleston 1 reports some interesting variations of the gastric juice after similar test-breakfasts in the same patient. One should make several tests and take a general average. In some patients it would be probably preferable to employ the test-dinner as well as test-breakfast. The gastric secretion appetite juice is undoubtedly greater after a dinner of a character agreeable to the patient than following an unat- tractive meal, consisting of bread and water. All these factors must be considered. Precautions before the Test Meal. Internal medication should be stopped for at least two days before the test-breakfast is administered, so as not to influence the result. This is particularly true if acids or alkalis are being administered. If the patient is very nervous it is preferable not to inform her ahead that the stomach tube is to be passed, as the increased nervousness might influence the secretion. Contradict'ons to Aspiration. These are recent gastric, intestinal, renal, bladder or pulmonary hemorrhage, angina pectoris, high blood pressure in elderly persons, thoracic aneurism, active bronchitis with difficult breathing, severe asthma and thoracic aneurism. At least two weeks should elapse after hemorrhage before aspiration is attempted. I once precipitated a severe angina attack, fortunately not fatal, when attempting to pass the stomach tube. I also had an unpleasant experi- ence in a case of endocarditis. With poisoning, however, all risks should be disregarded and lavage should be performed. When aspiration is contraindicated the diagnosis should be made by testing the digestive functions by the Schmidt- Strassburger diet and then examining the stool by the history of the case and by physical examination. There are no contraindications to radiography, except recent hemorrhage or an acute condition. 1 Observations on the Variability of the Gastric Juice, New York Med. Jour., Oct. 29, 1910. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 139 METHOD OF ASPIRATION OF THE GASTRIC CONTENTS The selection of the proper type of tube is important. It should be of soft rubber, of a caliber of 30 to 32 French, 1 to allo wfree exit of contents; Fig. 98. Aspirating tube. Fig. 99. Ewald's tube. Fig. 100. Correct position for passage of aspirating tube. have an opening at the tip, and one or even two lateral openings, as in Fig. 98 or the Ewald tube (Fig. 99). 1 It may be necessary to employ a tube of caliber 26 to 28 French in a patient of small physique and a still smaller tube for a child. 140 DISEASES OF THE STOMACH AND INTESTINES Fig. 101. Boas' aspirating bulb. r * Fig. 102. Aspirating bulb. J Fig. 103. Filling the bulb. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 141 Position of Patient and Operator. The patient sits upright on a chair and is protected by a sheet or towel. False teeth should be re- moved. The operator stands in the position as depicted in Fig. 100, and passes the tube along the roof of the patient's mouth. The advantages of this method are described under Lavage, The tube should be moistened in warm water and introduced about 20 inches until resistance is felt, when it should be slightly withdrawn. In the event of gastroptosis or dilatation the distance would be greater. A Politzer bulb can be employed for aspiration. Fig. 104. Second step of aspiration. Boas' Method. The Boas aspirator (Fig. 101), which consists of a rubber bulb having two soft-rubber ends and provided with a clamp, is attached to the stomach-tube by a piece of glass tubing. The clamp is fixed, the bulb compressed and then released, and thus filled up; the clamp is opened, and the contents, by compression of the bulb, forced into a bottle, glass, or some other receptacle. This is a simple method of as- piration. Other devices with a vacuum bottle, mouth suction, forcing air through a double tube, etc., have been suggested, but they are more complicated and unnecessary. Ewald-Boas Expression Method. This consists in having the patient exert pressure upon the stomach by means of his abdominal 142 DISEASES OF THE STOMACH AND INTESTINES muscles. He should first inspire deeply, and then compress the abdominal walls in the same manner as during defecation. The pressure expels the gastric contents through the tube into a receptacle. This method is considerably employed, and when successful, is unquestionably excellent. In cases of marked atony, both of the stomach and abdominal walls, in excessive dilatation, and at times from plugging of the stomach-tube, the expression method is a failure. Author's Method. It is my custom to attach to the stomach-tube a bulb without valves, such as is depicted in Fig. 102. The patient is then Fig. 105. Final step of aspiration. directed to express the contents. If the tube becomes stopped, the thumb is placed over the open end, the bulb squeezed, and the obstruction im- mediately relieved. This obviates blowing through or removing the tube. If expression fails, then immediate aspiration is resorted to. The tube is pinched near the teeth, the bulb squeezed, and the thumb placed over the open end. The stomach-tube is then released, and the vacuum in the tube allowed to fill with gastric contents, as in Fig. 103. When the bulb is filled, the stomach-tube is again pinched, the thumb removed from the bulb, and the contents gradually expressed into the receiving vessel, as in Fig. 104. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 143 The final step is depicted in Fig. 105. This process is repeated until the gastric contents are removed. EXAMINATION OF THE INGESTA Before chemic examination of the ingesta is begun, the quantity aspirated should be carefully measured. After the Ewald-Boas test- breakfast one may expect to secure on an average 50 to 75 c.c. of contents, and if 100 c.c. or more be present, this would show motor insufficiency. A large quantity of gastric contents (350 to 400 c.c.) four hours after the test-dinner would determine it likewise, as described under Examination of Motor Functions. The quantity of the residue, therefore, has a chief bearing on the motor function, though in hypersecretion abnormal quan- tities are found. Reichmann's test should be made when this is suspected. Macroscopic inspection gives considerable information. After the test-breakfast, in some cases large undigested pieces of bread are brought up; in others, remnants of bread that are nearly digested or only slightly digested; and in others, a fine fluid mushy mass. These findings are at once 'suggestive. With Riegel's test-meal the differences are more pronounced; the mass may be fine, uniform, and mushy, containing no coarse elements; or there may be coarse undigested meat-fibers. Mucus, blood (unless occult), and bile are readily visible. Red mold may be mistaken for blood and green mold for bile. The microscope will determine the presence of mold. In some cases the gastric contents, when placed in a glass vessel, forms three layers: at the bottom fine starchy material; next, cloudy fluid; and on top a foamy layer, which latter is evidence of gaseous fermentation. Chemic Examination. The aspirated gastric contents may be filtered through filter-paper. If this is not at hand, several layers of cheese-cloth or gauze can be employed, a simple and convenient method. From a practical point of view, the most important feature to de- termine is the content of hydrochloric acid during the height of digestion. If free hydrochloric acid be present, it is then necessary to find out whether the secretion is normal, increased, or deficient. If it is deficient in amount or absent, the digestive power of the stomach is deficient. When free hydrochloric acid is present, the determination of pepsin is unnecessary; in fact, it is often present, even if free hydrochloric acid is absent. In such event, if the gastric contents are acidified with suf- ficient hydrochloric acid and digestion of albumin then occurs, this is evidence of sufficient pepsin formation. In cases complicated by the absence of free hydrochloric acid the examination for pepsin and rennet should be carried out. For a complete chemic analysis the following tests should be performed: 1. Reaction. 2. Total acidity. 3. Free hydrochloric acid. 4. Combined hydrochloric acid. 5. Total hydrochloric acid. 144 DISEASES OF THE STOMACH AND INTESTINES 6. Lactic acid. 7. Propepton. 8. Pepton. 9. Pepsin. 10. Rennet. 11. Dextrin. 12. Erythrodextrin. 13. Achroodextrin. Before describing the tests it is well to remember the findings of the normal gastric juice after the test-breakfast for a basis of comparison. Normal gastric juice is of acid reaction; total acidity, 40 to 60 (0.15- 0.21); free hydrochloric acid, 25 to 50 (0.1-0.2 per cent, approximately) propepton, small amount; pepton more; pepsin and rennet present; sugar and achroodextrin present; erythrodextrin present in small amount or absent; dextrin absent. Some patients may have free hydrochloric acid within the above normal limits, and yet suffer from the symptoms of hyperchlorhydria, while others may have free hydrochloric acid as high as 100+ and present no symptoms at all. Individual peculiarities must be considered. Reaction. This is determined by means of blue and red litmus- paper. If the filtrate is acid, it turns the blue paper red; and if alkaline, the red turns to blue; neutral gastric contents cause no change. Test for Free Hydrochloric Acid. Numerous coloring-matters when exposed to the action of weak solutions of hydrochloric acid undergo changes, and have been employed as tests for its presence. Those that are of greatest practical value I will describe shortly. There has been considerable dispute as to the respective superi- ority of these tests. Though organic acids, when present in considerable quantities, may give these color changes, yet they are not as sensitive to organic acids as to mineral acids. I agree with Riegel that this danger is practically negligible. As a precaution one may employ one of the following qualitative check tests, which react only to free mineral acids and not to the organic acids. In addition, the test for lactic acid should be performed. The Phloroglucin-vanillin Test (Giinzburg's). This reagent consists of 2 grams of phloroglucin and i gram of vanillin dissolved in 30 grams of absolute alcohol. An equal number of drops, i or 2 each, of this and the gastric juice are placed on a porcelain dish and mixed with a glass rod. The dish is then held over an alcohol lamp and the fluid allowed to evapo- rate slowly. A cherry-red color appears, as in Fig. 106, if free hydro- chloric acid be present. If there are only traces, then there is a rose tint at the margin. If hydrochloric acid is absent, the color varies from yellow to brown. This test responds to free hydrochloric acid and not to organic acids. The solution is unstable, and should be preserved in a dark glass bottle. It is advisable to make a fresh solution frequently. The Resorcin-sugar Test (Boas). Five grams of resorcin and 3 grams of cane-sugar are dissolved in 100 c.c. of alcohol. Equal drops of m 1 Fig. 107.- Resorcin test. Color reaction. Fig. 106- Phloroglucin-vanillin test. Color reaction. A. B. c. 5 c.c.Gas trie Juice Sc.c.GastricJuice 5 c.c.Gastric Juice - PHENOLPHTHALEIN. ALIZARIN. At^ of the total quantity), the number of centimeters of the sodium hydroxid necessary to produce the end-reaction must be multiplied by 20. Thus if 3 c.c. sodium hydroxid produced the end-reaction in 5 c.c. of the filtrate, the total acidity would be 3 X 20, or 60+ . Multiply this figure of acidity by 0.00365, and we have the percentage of total hydrochloric acid, or 60 X 0.00365 =0.219 per cent. Free Hydrochloric Acid. Commence titration of beaker C, to which the dimethyl-amido-azobenzol solution has been added, and continue titration until the solution becomes a pale lemon yellow, as in Fig. no. As saturation with the decinormal sodium hydroxid solution was computed on the basis of 100 c.c. of gastric contents, and only 5 c.c. or ^o were tested, the number of cubic centimeters of sodium hydroxid solution required to produce the end-reaction must be multiplied by 20. Thus, if 2 c.c. of this alkaline solution will produce this result, we must multiply it by 20, and we say the free hydrochloric acid is 40+. To compute free hydrochloric acid in percentage, multiply 40 X 0.00365 = 0.146 per cent. Combined Hydrochloric Acid. Commence titration of beaker B, to which the sodium-alizarin-sulphonate has been added, and continue the process until the end-reaction, the violet color, as in Fig. in, occurs. As only 5 c.c. of gastric contents are employed, and again the compu- tation is based on 100 c.c., the number of cubic centimeters of decinormal sodium hydroxid employed must be multiplied by 20. If, for example, 2.2 c.c. were required, 2.2 X 20 = 44 + acidity. Topfer has shown that alizarin is sensitive for all the elements compris- ing acidity, except for the combined hydrochloric acid. The acidity 44, therefore, secured by this reaction must be subtracted from 60, the total acidity; and this gives 16 acidity as the combined hydrochloric acid. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 147 In percentage 16 X 0.00365 = 0.06 per cent, combined hydrochloric acid. The total acidity, free and combined hydrochloric acid, are important to examine for as a matter of routine. As fractions of a centimeter must often be computed, I give an example in tabulated form: Beaker A, 5 c.c. gastric contents; for total acidity, 3.2 c.c. decinormal sodium hydroxid gives end-reaction. Beaker B, 5 c.c. gastric contents; for alizarin test, 2.4 c.c. decinormal sodium hydroxid gives end-reaction. Beaker C, 5 c.c. gastric contents; for free hydrochloric acid, 1.5 c.c. decinormal sodium hydroxid gives end-reaction. 1. Total Acidity. Beaker A. 5 c.c. X 20 = 100 c.c. 3.2 c.c. X 20 = 64 c.c. 64 X 0.00365 = 0.23 per cent. 2. Free Hydrochloric Acid. Beaker C. 1.5 c.c. X 20 = 30 c.c. 30 X 0.00365 =0.11 per cent. 3. Combined Hydrochloric Acid = A B. B = alizarin reaction. A = 64 2.4 X 20 = 48. B = 48 A - B = 1 6 = combined HC1. 16 X 0.00365 = 0.06 per cent. 4. Total Hydrochloric Acid, Free and Combined. o.n per cent, -f- 0.06 per cent. =0.17 per cent. 5. Acid Salts = B C (Organic Acids Absent). B = 48 C = 30 B - C = 18 B - C = 18 18 X 0.00365 = 0.07 per cent. If 10 c.c. of gastric juice be employed in the tests, then the number of cubic centimeters of sodium hydroxid required to produce the end-reaction must be multiplied by 10. If 2 c.c. of gastric juice is used, the multiple is 50, and so on. Author's Method. Simple Technic for Topfers Method. In place of the buret or pipet for titration, the writer employs a small measuring glass of 10 c.c. capacity marked each cubic centimeter up to ten. With slight practice, one can easily estimate within % c.c. sufficiently near for diagnostic purposes. One can employ a centrifuge glass marked in cubic centimeters and J-f c.c.s. an excellent method. The gastric fil- trate 5 c.c. each is placed in three small test-tubes, Topfers reagents added to each as usual and titration is carried with the decinormal sodium hydrate from the small measuring glass drop by drop. This enables the consultant to carry his reagents in small compass and make chemical tests on the spot. When there is a scanty amount of gastric filtrate, after determination of the free hydrochloric acid, add to the same solution, i to 2 drops of the phenolphthalein solution; no change of color is produced. Then titrate 148 DISEASES OF THE STOMACH AND INTESTINES with decinormal sodium hydrate until the red end-reaction is reached. The sum of the free HC1 already determined plus the amount of sodium hydrate required to produce the end-reaction, will give the total acidity. The further tests are as follows: Lactic Acid. Ujfelmann's Test. This reagent is the one most fre- quently employed and is sufficiently accurate, if necessary precautions are observed. It should be freshly prepared before each test. It can be prepared as follows: 10 c.c. of a 4 per cent, carbolic acid solution is mixed with 20 c.c. of distilled water, and to this is added i drop of sesqui- chlorid of iron. A watery solution of carbolic acid (2 per cent.), to which is added i drop of liquor ferri sesquichlorid, is another method of preparation. These solutions have an amethyst-blue color. A simple method employed by the writer is to place a few drops (4 or 5) of carbolic acid in a test-tube and fill about two-thirds with water. If the carbolic is not in perfect solution, decant a little, and add sufficient water to secure such. Then add a few drops of liquor ferri sesquichlorid, or tincture iron chlorid sufficient to give a clear amethyst color when shaken. As about 5 per cent, is the maximum solubility of carbolic, the above method about corresponds to the per cent, methods described above. Other methods of preparation are recommended by Riegel: 20 c.c. of distilled water, 10 c.c. of a 4 per cent, carbolic acid solution, and o.i c.c. of neutral 10 per cent, iron chlorid solution; or, dilute the officinal iron chlorid solution with distilled water until the solution is about colorless, and then add a 2 to 4 per cent, solution of carbolic until the amethyst-blue color appears. A very dilute iron chlorid solution will also give the reaction, but the blue color acts as a contrast. The lactic acid reaction has been described as a canary-yellow or, more often, a canary-green color (Fig. 112). Fatty acids produce an ash-gray and inorganic acids decolorize the blue solution. As at times the phosphates may be present in the gastric contents and they give the same reaction, a modification has been recommended, which is practical for general use. Modified UJjelmann. Take 5 c.c. of the filtrate plus 10 c.c. of ether, and shake in a test-tube for a few minutes; then allow it to stand until the ethereal solution has separated from the watery solution. Pour the ethereal part into another test-tube and place it in a glass of hot water to evaporate. Add i c.c. of distilled water to the remaining drops, and test for lactic acid with the Uffelmann solution. If the canary color occurs, lactic acid is positively shown. A larger quantity of the filtrate can be employed with two or three times the quantity of ether. Fleiner does not evaporate the ether, but adds Uffelmann's solution directly to it. The solution will appear yellow at the bottom of the tube if lactic acid be present. Strauss employs a mixing funnel with two markings, one at 5 c.c. and the second at 25 c.c. (Fig. 114). Fill to 5 c.c. with the stomach filtrate. Pour on ether (Squibbs') up to 25 c.c. and shake the mixture well. Open the lower stop-cock Pis. Fig. 113. Fig. 112. rffelmann's test. Fiij. 113. Congo red test. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 149 and allow the fluid to run off until it reaches 5 c.c., and then pour in distilled water to 25 c.c. To this mixture add 2 drops of iron chlorid solution (i :g distilled water), and shake the whole. Investigations by Strauss show that if one promillimeter of lactic acid be present, an intense green color occurs; if less lactic acid, the color is light green. Arnold 1 suggests a new test: 1. A solution of gentian violet (0.2 c.c. saturated alcoholic solu- tion in 500 c.c. distilled water), and 2. Tinctura ferri perchloridi, 5 c.c. (U. S. P.), diluted with distilled water (20 c.c.). A drop of the iron solution gives a blue color with i c.c. of the gentian violet, which changes to yellowish green when gastric contents which contain lactic acid are added. Other methods have been suggested, notably that of Boas, which is rather complicated. It is based on the oxidation of lactic acid into acetaldehyd and formic acid. The presence of aldehyd is demonstrated by the iodoform reaction with alkaline iodin solution or of al- dehyd of mercury with Nessler's reagent. Boas' Method. Take 10 to 20 c.c. of the gastric fil- trate and evaporate it into a syrupy consistency over the water-bath. If free hydrochloric acid is present, an excess of barium carbonate is added. A few drops of phosphoric acid are then mixed in, and the carbonic acid is expelled by boiling. The fluid is then cooled and extracted two or three times with 50 c.c. of ether. After half an hour pour off the clear ethereal layer. The ether is now evaporated, and the residue washed in a flask with 45 c.c. of water, well shaken and filtered. Concentrated sulphuric acid, 5 c.c. (sp. gr. 1.89), and a pinch of manganese dioxid are added to the filtrate. The mixture is then distilled over a small flame, and the vapor conducted into a narrow cylinder containing 5 to 10 c.c. of an alkaline iodin solution. This consists of equal parts of a decinormal iodin solution and the Fig. I M/~ _, Strauss mixing standard potassium hydroxid solution. The vapor may f uim el. be conducted into the same quantity of Nessler's re- agent. If lactic acid is present, it gives rise to the iodoform reaction (clouding and odor of iodoform) with the iodin mixture. If Nessler's reagent is used, yellowish-red aldehyd of mercury appears. This procedure is further elaborated for the quantitative estimation of lactic acid, but it is extremely complicated and clinically unnecessary. We may say that when a test-breakfast or test-dinner is taken under proper conditions, only traces of lactic acid are introduced, and finding it in appreciable quantities in the gastric contents is of pathologic significance, 1 Jour. Amer. Med. Assoc., 1898, vol. viii, p. 21. 150 DISEASES OF THE STOMACH AND INTESTINES showing subacidity and stagnation. It is not pathognomonic of cancer, but these conditions frequently exist in such cases. Quantitative Estimation of Lactic Acid. The acidity of the filtrate is first determined; 10 c.c. of the nitrate are shaken up with ether in excess. The ether is then separated and the degree of acidity computed therein. Subtract this figure from the total acidity and multiply by 0.09, which gives the percentage. Volatile acids must be first tested for and eliminated by boiling. This method is only approximate. Volatile Acids. Fatty or volatile acids are recognized by boiling a few cubic centimeters of the filtrate in a test-tube. A strip of moistened blue litmus-paper is held over the escaping vapors. The paper will turn red if they are present. Their quantitative determination is hardly necessary. Acetic Acid. In large quantities, acetic acid can be detected by its characteristic odor. For the detection of small quantities, Einhorn neutralizes the watery residue of the ethereal extract of the gastric filtrate with carbonate of soda, and then adds neutral chlorid of iron solution, when a red color is developed. Propeptone. Add to the gastric filtrate of, say, 5 c.c., an equal quantity of a saturated solution of sodium chlorid. Propeptone, if present, is precipitated. If none is formed, then add i or 2 drops of acetic acid, and precipitation will occur if propeptone is present. On heating, the solution clears up, but again becomes turbid on cooling. Peptone. Preferably, after filtering out the propeptone, take 2 c.c. of the gastric filtrate and make strongly alkaline by adding sodium hydroxid solution and then add a few drops of a weak i per cent, copper solution. Peptone gives a purple or violet-red color (biuret reaction). Pepsin. A thin disk of the white of a hard-boiled egg, weight of about i gram (i cm. in diameter and i mm. thick), is placed in a test- tube containing 5 c.c. of the gastric filtrate and kept at blood temperature. The tube can be placed in water at blood temperature in a Thermos bottle. If free hydrochloric acid is not present in the filtrate, add 2 drops of dilute hydrochloric acid. The presence of pepsin will cause dis- appearance of the albumin in from two to six hours. The methods for the quantitative determination of pepsin that have been recognized as practical for clinical purposes are those of Ham- mefschlag and Mett. Henry Illoway 1 has devised a simple method for determining the relative quantity of pepsin, which seems to the author of value: 10 cgm., exact weight, egg-albumen (white of hen's egg) is coagulated in the following manner: The egg is placed in a small pot of cold water, which is then covered with a lid and put on to boil. It is allowed to cook for ten minutes after the water has begun to boil in all, heating twenty minutes from the time it has been put on. The egg is then taken out and allowed to cool, either by setting it in a saucer or by putting it in cold water. 1 Amer. Jour. Med. Sci., Aug., 1909. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 151 To imitate the usual way, food is, or should be, ingested, the segment of albumin is divided into 2 parts. Observation has shown, as it has long been known clinically, that thus subdivided the gastric juice can act upon it more quickly. The action being from all sides, it is more effective when we have eight sides for a given quantity than where we have only four. The coagulated albumin is put into 10 c.c. of the gastric nitrate (from stomach-contents extracted one hour after an Ewald-Boas test- breakfast), and this is then placed in the thermostat, which is kept at 3 8C. The time in which the 10 cgm. are digested, entirely, partially, or not at all, will give us a correct idea as to the status of the pepsin secretion in the case under examination. Illoway, by experiments, shows that normal digestion of the albumin requires from five to five and one-half hours. He classifies as follows: Hyperpepsinia. Digestion requiring only from three to four hours, not in any pathologic sense necessarily, but only, to indicate a secretion of pepsin greater than usual, which may, however, be the normal for that case. Normal Pepsinia. Digestion requiring from five to five and one-half hours. Hypopepsinia. Digestion requiring more than the usual time. The degree indicated by the number of hours required beyond the standard of time. Apepsinia. No digestion at all. Jacoby-Solms Method to Determine Pepsin. Ricin Test. 1 Dissolve i gram of ricin in 100 c.c. of a 5 per cent, solution of sodium chlorid and filter. Mix 2 c.c. of this filtrate with 0.5 c.c. decinormal HC1 solution; i c.c. of diluted stomach-contents is added, and allowed to remain at blood temperature for three hours. Ferments clear up the ricin deposit. The quantity of pepsin is determined from the amount of dilution in which the stomach-contents will cause the ricin deposit to disappear. Solms designates the amount of gastric juice which is sufficient to clear up the 2 c.c. of a 2 per cent, ricin solution in three hours, kept at the blood temperature, as one pepsin unit. The normal stomach-contents contain about 100 pepsin units to the cubic centimeter. Witte 2 has modified the above methods. Fuld employs a solution of edestin instead of ricin. 3 An ordinary Thermos bottle partially filled with water at a tempera- ture of about iooF. can be employed in place of a thermostat, test-tubes containing the solutions being tightly corked and placed therein. Ein- horn 4 employs a Thermos bottle with metal framework to hold the 1 "Ueber eine neue Methode der quantitative Pepsinbestimmung und ihre klinsche Verwendung," Zeitschr. f. klin. Med., Bd. 64, Heft i und 2. 2 Berlin, klin. Wochenschr., 1908, p. 643. 3 "Pepsinbestimmung vermittelst Edestins," Munch, med. Wochenschr., 1907, No. 27, Vereinsbeilage. 4 Einhorn, "A Simplification of the Jacoby-Solms Ricin Method for Pepsin Deter- mination," Med. Record, Aug. 29, 1908. 152 DISEASES OF THE STOMACH AND INTESTINES tubes. These last are graduated in millimeters, so as to dispense with measuring glasses. Casein Test. Gross 1 mixes a i : 1000 solution of casein containing 16 c.c. of a 25 per cent. HC1 to the liter with the filtrate or its dilutions., and leaves it for a quarter of an hour in the thermostat. He then adds a few drops of the concentrated solution of sodium acetate, which results in a precipitate if the casein has not been digested; otherwise the solution remains clear. W. C. Rose, 2 has devised a test to be employed as a substitute for the "ricin test," employing a globulin preparation derived from the ordinary garden pea (Pisum sativum). Metfs Method. This consists in sucking fresh egg-albumen into capillary tubes of i or 2 mm. diameter, coagulating the albumin by boiling, and then cutting off portions 3 to 5 cm. long of the filled tube and adding these pieces to the gastric contents. This should be kept at body temperature for ten hours in the incubator. At the end of this period each end of the tube will show a lack of solid albumin, owing to digestion, while some will remain in the central portion. Both the empty portions and the portion that is full are measured, and the activity of the pepsin digestion is thus determined. The relative amount of pepsin varies according to the square of the length of the empty portion of the tube, the figures of the latter being expressed in millimeters; thus, 3 mm. of digestion equals 9 parts of pepsin; 2 mm., 4 parts of pepsin, etc. Rennet. Add 5 drops of the filtered gastric contents, preferably neutralized with decinormal sodium hydroxid solution, to 10 c.c. of fresh neutral milk in a test-tube. Place this in a glass of warm water at a temperature of about iooF., or in a thermostat. A Thermos bottle containing warm water is extremely convenient. Normal Rennet. In about five to fifteen minutes coagulation will occur if the rennet be normal. If the same quantity of filtrate (5 drops) be added to 20 c.c. of milk, Illoway finds, under normal conditions, coagulation will occur within fifteen to thirty minutes. He suggests a simple quantitative method. Deficient Rennet. Add i c.c. of gastric filtrate to 10 c.c. and 20 c.c. of milk if the smaller quantity of filtrate (5 drops) gives no result. If reaction occurs within the same period, rennet is deficient. More marked deficiency when no result is obtained with i c.c. of gastric filtrate, but is obtained within the half-hour with 5 c.c. of filtrate. Absence of Rennet. When no reaction is obtained within half an hour with 5 c.c. of gastric juice and 10 c.c. of filtrate, no reaction will occur. It has been demonstrated by Illoway's experiments that rennet may be present in nearly normal amount, even if pepsin is markedly deficient; it may be present even if pepsin is absent. Rennet is usually the last one of the elements active in the process of gastric digestion to disappear. 1 "Die Wirksamkeit des Pepsins und eine einfache Methode zu ihrer Bestimmung," Berlin, klin. Wochenschr., 1908, No. 13, p. 643. 2 Arch, of Internal Medicine, May, 1910, vol. 5, pp. 459-465. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 153 Rennet Zymogen (Chymosinogen). Add to the same specimen of milk 3 to 5 drops of a i per cent, solution of calcium chlorid and place in an incubator. Coagulation shows the presence of the enzyme; other- wise it is absent. Examination of Starch Digested. The salivary ferment continues its action on starch in the stomach while the amount of hydrochloric acid is not too great. It is estimated that as soon as the total hydro- chloric acid reaches 0.12, the action ceases. If the secretion of hydro- chloric acid is abnormally great, starch digestion is soon stopped, and there is either no digestion of starch or the end-products are not formed. The reverse is the case in subacidity. To determine the intermediary stages, a dilute iodin-potassium solu- tion (Lugol's) is employed. It consists of iodin, o.i; potassium iodid, 0.2; aqua destillata, 200.0. A few drops of the filtered gastric juice are placed on a porcelain dish, and to it is added a drop or two of Lugol's solution. The reactions are as follows: Dextrin turns the fluid blue; erythrodextrin, a red purple; achro- 6 dextrin discolors slightly the yellow tincture of the Lugol; maltose does not change the color. For sugar or maltose, Fehling's or Trommer's test must be employed. In normal cases, sugar and achroodextrin are present; erythrodextrin absent or present in small amount; dextrin absent. If a blue or blue-violet color appear, saccharification is deficient. Other Methods for Determining Free Hydrochloric Acid. It seems advisable to describe a few additional practical methods of determining free hydrochloric acid: 1. Tropaolin oo (Merck's) in a concentrated watery solution is recom- mended by Riegel. Knapp employs a supersaturated alcoholic solution of the same. To 5 c.c. of the filtered chyme add 2 drops of the tropaolin solution. Free hydrochloric acid turns it a cherry-red. Titrate with decinormal sodium hydroxid until it becomes amber the end-reaction. As 5 c.c. is Yw of 100, on which the calculation is based, and if it takes 3 c.c. of the alkali to produce the end-reaction, free hydrochloric acid therefore = 20 X 3 = 60. Multiply 60 X 0.00365 to secure percentage. 2. Mintz's Method. For example, to 10 c.c. of the gastric filtrate, decinormal sodium hydroxid is gradually added, until i drop of the mix- ture no longer responds to the Giinzburg reaction (phloroglucin-vanillin test). A platinum loop should be employed as a drop carrier. The amount of the sodium hydroxid solution in this case should be multiplied by 10 to give free hydrochloric acid. For example, if the reaction no longer appears after the addition of 3 c.c. sodium hydroxid, free hydrochloric acid = 30; percentage = 30 X 0.00365, or 0.109 per cent. 3. Boas and Moerner. -They estimate the free hydrochloric acid by Congo paper, or by a i per cent, watery solution of Congo red, which turns blue in the presence of this acid (see reaction, Fig. 113). 154 DISEASES OF THE STOMACH AND INTESTINES Take 5 c.c. of the filtrate and add 3 or 4 drops of the Congo red solu- tion. More is unnecessary, though Boas adds 5 c.c. of it. On the other hand, Congo paper can be moistened in the filtrate. A blue reaction results in each case. Decinormal sodium hydroxid is then added to the mixture, or the paper is placed in a porcelain dish and the alkali added. Titration is continued until the blue begins to turn red. The estimation is performed in the same way as before. 4. RiegeVs Method. Congo paper is employed in his test. Take 10 c.c. of the gastric filtrate. The Congo paper is dipped in the filtrate, giving the blue reaction of free hydrochloric acid. It is then placed on a saucer. Decinormal sodium hydroxid is allowed to drop slowly from the buret into the filtrate, and a drop of the mixture is removed from time to time with the platinum loop and applied to the Congo paper. As the change in color becomes indistinct, this is controlled by dropping distilled water on the same piece of paper. The alkali is dropped on the paper until it begins to turn a violet red. The number of cubic centimeters of decinormal sodium hydroxid necessary to secure the end-reaction, say, 3 c.c., is multiplied by 10, giving free hydrochloric acid as 30. This is necessary, as the original figure is computed for TOO c.c. of contents, and only 10 c.c. were employed. To complete the analysis and estimate the total acidity, 2 drops of phenolphthalein solution are added to the same filtrate, and titration with the sodium hydroxid is continued until the color of the solution turns red (the end-reaction). The total acidity is indicated by the total quantity of decinormal sodium hydroxid used from the beginning of the first titration. For ex- ample, if in both titrations 6 c.c. of sodium hydroxid have been employed, the total acidity is 60, as 10 c.c. of filtrate were examined. Various modifications have been employed for these tests, which serve only to confuse the reader. Those described are the most practical. Small booklets of Congo paper can be secured from Merck. It may be prepared by saturating filter-paper with a watery solution. It is of a reddish-pink color. The qualitative examination for free hydrochloric acid can be made with this paper by dipping it into the filtered or unfiltered gastric contents. If free hydrochloric acid is present, it will turn blue. Determination of Hydrochloric Acid Deficit. Honigmann 1 and von Noorden 2 determine the degree of hydrochloric acid insufficiency by adding a decinormal hydrochloric acid solution to the stomach-con- tents until free hydrochloric acid can be detected by Congo paper or Giinzburg's test. Ten c.c. of the filtrate are placed in a beaker and the decinormal hydrochloric acid solution allowed to flow into it gradually, the solution being well mixed. The test being continued until after repeatedly dipping the Congo paper into it, the paper shows a bluish tinge. The more hydrochloric acid required to secure the reaction, the less the amount of combined acid in the filtrate. 1 Berlin, klin. Wochenschr., 1893, Nos. 15 and 16. 2 Ibid., No. 19. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 155 Or, about 25 drops of Giinzburg's solution can be added to the nitrate, and then titration with the dilute acid follows until a red mirror appears on a porcelain dish as a couple of drops of this mixture are evaporated over an alcohol-lamp. We know, however, that the average amount of combined hydro- chloric acid is 25, or o.i per cent., under normal conditions, and Tb'pfer's method of testing will give the required data. The amount of peptone and propeptone qualitatively are an indi- cation. When there is no biuret reaction, there will be no combined hydrochloric acid. Other Methods of Testing the Gastric Secretion. There are several ingenious methods for testing the gastric secretion in order to obviate the unpleasant procedure of aspiration, or because some patients absolutely refuse the tube, or there is danger incurred from its passage, such as in cases of aneurysm, angina, severe endocarditis, or after a recent hemor- rhage from the stomach or lungs, or in the very debilitated. Sahli's Desmoid Test. 1 This consists in placing methylene-blue or iodoform in a small rubber bag and tying it tightly with thin raw catgut. The bag is swallowed after a large meal, and the urine is ex- amined for methylene-blue, or the saliva for iodin. Methylene-blue colors the urine green or greenish blue. The iodin is tested for in the saliva by starch-paper and fuming nitric acid, giving a bluish or violet color. It is based on the fact that raw connective tissue, including catgut, is, according to Schmidt, 2 digested only by the gastric juice and not by the pancreas. The reaction occurs in healthy persons usually six to eight hours after swallowing the bag. If it takes place later, or not at all, the secretory function is insufficient. An early reaction shows hyperacidity, according to Kaliski. Einhorn, 3 in some cases of achylia gastrica and cancer, has demon- strated that catgut is also digested in the bowel, and considers that the method is unsuitable. Giinzburg's Method.* This is based on the same principle as Sahli's. The patient swallows 0.2 gm. potassium iodid, inclosed in a small rubber bag, which is tied with fibrin threads. After the fibrin is digested, the potassium iodid is set free and ab- sorbed. The test of the saliva is made with starch-paper and fuming nitric acid, giving a violet or bluish color. This necessitates frequent examinations of the saliva, and the bag may escape and the fibrin be digested in the intestine. The objections are the same as to Sahli's test. Spallanzani's 5 sponge test, Dunham's 6 thread test, Rehfuss's" capsule 1 Correspondenzblatt fur Schweizer Aerzte, 1905, Xos. 8 and 9. - Deutsch. med. Wochenschr., 1899, No. 49. 3 Jour. Amer. Med. Assoc., May 12, 1906. 4 Deutsch. med. Wochenschr., 1889, No. 4. 6 Deutsch. Arch. f. klin. Med., vol. xxviii, 1881. 6 New York University Bulletin of the Medical Sciences, vol. i, No. 4, p. 178, Oct., 1901. 7 Journal A. M. A., July n, 1914. 156 DISEASES OF THE STOMACH AND INTESTINES test and Einhorn's 1 stomach bucket are of no practical value and not to be recommended. Gas Fermentation. The presence of free hydrochloric acid does not prevent the development of gas. It may occur in a soil that is non-acid, together with lactic acid fermentation. Stagnation is the chief factor favoring fermentation. Various gases may be formed, but from a practical point of view the determination of their occurrence, quantity, and the time necessary for their development are sufficient. The unfiltered gastric contents should fill a tube such as is employed for the determination of sugar in the urine (the Fiebig tube). It should be placed in an incubator at 37C. (98.6 F.), or if this is not at hand, in a uniform warm place. One can employ a test-tube, as suggested by Moritz, closed by a rubber cork through which is passed a bent glass tube. The test-tube is filled with gastric contents and then closed with the cork, thus forcing some of them into the curved tube and preventing the entrance of air. The apparatus is inverted in a beaker. As at times the sugar may already be destroyed by fermentation, it is well to prepare a control tube of gastric contents to which a small quantity of powdered dextrose has been added, or it may be added at once. If no development of gas is noted after twenty-four hours, the tube should be allowed to stand for three or four days. Carbon dioxid may be identified by allowing a small amount of KOH to flow through a pipet to the bottom of the gas column. The carbonic acid is absorbed by it and the fluid moves up to take the place of the absorbed gas. The expressed test-meal, or test-breakfast, or vomitus can be employed. If fermentation is excessive, one can assume motor insufficiency, though this should be tested for by measuring the aspirated contents. If rapid fermentation occurs within a few hours, pyloric stenosis should be suspected, as this produces the most severe degree of motor insufficiency If the stomach contains a large amount of lactic acid and no free hydrochloric acid, carcinoma of the pylorus is probably the cause of this stenosis. Gaseous fermentation is usually more intense in cases of motor in- sufficiency in which free hydrochloric acid is present. It can occur, however, in any form of stomach disease in which there is a disturb- ance of gastric secretion. Lactic acid fermentation only occurs markedly in subacid conditions. Alcohol, various hydrocarbons, and sulphureted hydrogen have been found as products of fermentation. Boas finds H2S chiefly in benign ectasia. The determination of the quantity of chyme within the stomach is described under Testing the Motility of the Stomach. Examination of the Vomit. The same methods that are employed in examination after the test-meal apply to investigation of the vomitus. The information, however, is not as positive, as the admixture of bile, saliva, etc., obscures the result. Important information is secured, but the physician should inspect the vomitus in person. If the vomiting consists chiefly of food, it should be learned when 1 Medical Record, July, 1890. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 157 the last meal was taken and of what it consisted. If coarse morsels are found six or seven hours after a meal, the conclusions are naturally different than if they were found directly after eating; and by this means we can often determine the digestive and motor powers of the patient. If food is vomited that was ingested the day before, marked motor insufficiency is present. With gastric ulcer, vomiting often occurs at the height of digestion. In some nervous diseases it usually takes place immediately after eating. With ectasia, vomiting occurs late in digestion and often in great quantity. In dilatation with hypersecretion the fluid is abundant, and there are fine remnants of amylaceous material; while with carcinoma of the pylorus undigested morsels of meat are present. In the former case free hydrochloric acid is present, and Congo paper will turn blue; in the latter case, no color change occurs. The presence of blood is important, and its appearance depends on the presence or absence of hydrochloric acid, on the rapidity with which it is poured forth, and on the length of time it has remained in the stomach. It may, therefore, appear chocolate brown, like coffee- grounds, or as fresh blood. Mucus is also readily discovered. Pus is rarely found, unless from perforation in phlegmonous gastritis, or from some neighboring focus into the stomach, or unless it has been swallowed. Microscopic pus occurs with ulcer ation. During violent vomiting bile is frequently in evidence, or when vomiting occurs on an empty stomach. It may occur with pyloric stenosis, when the opening is kept slightly patent. With persistent vomiting of bile one would suspect some obstruction of the duodenum, such as carcinoma, torsion, gall-stones, etc. Parasites, such as ascarides or the oxyuris vermicularis, are occa- sionally found in the vomit, and very rarely a piece of gastric tumor. Examination of the Contents of the Fasting Stomach. It may be necessary to investigate the contents of the fasting stomach, especially when disturbance of the motor function is present or when hypersecretion is suspected. Under normal conditions one might expect to find from 5 to even 15 c.c. of gastric contents in the normal stomach. Anything over 20 c.c. to 30 c.c. is considered pathologic, when there are gastric symptoms. The examination should be made in all cases, where one suspects an abnormal quantity of gastric contents will be found in the morning after fasting; also in all cases of suspected ectasia or atony of the stomach. The best method is to wash the stomach thoroughly the night before, both in the sitting and reclining posture, and then administer a test- supper. The contents are aspirated, measured, and examined the following morning before breakfast. The chief purpose is to test the motor function of the organ, especially to determine whether motor insufficiency of a high degree is present. Reichmann's Method. When hypersecretion is suspected, the pro- cedure is slightly different. The stomach is thoroughly washed at about 10 p. M. and care taken that all the water is removed. No food or drink 158 DISEASES OF THE STOMACH AND INTESTINES is allowed thereafter, and in the morning before breakfast the contents are aspirated and examined. A quantity over 20 c.c. to 30 c.c. found re- peatedly I would consider pathologic (hypersecretion), when there are symptoms. When there is permanent regurgitation of bile into the stomach, Riegel has shown that this method of examination is important. If bile and pancreatic juice enter the stomach, digestive processes are arrested. Bile, pancreatic, and probably intestinal juice are occasionally found in the empty stomach (duodenal juice, Boas). This material is grass green or yellowish, containing bile constituents, and converts starch into maltose and dextrose, proteins into peptones, and splits fats. If it is aspirated occasionally, it is probably not significant; but if there is constant regurgitation, it is suggestive of obstruction in the duodenum. When there is obstruction to the flow of the intestinal contents, or a communication between the stomach and intestine, intestinal contents are found in the stomach. ABNORMAL CONSTITUENTS OF THE STOMACH-CONTENTS Abnormal products which are of importance for our diagnosis are quite frequently found in the gastric contents. They may contain mucus, blood, bile, intestinal juice, and pus. Mucus when present in considerable quantity is easily recognized. It generally occupies the upper part of the fluid, appearing in swollen, glassy lumps or in flakes and shreds. It is also intimately mixed with the food. It can be readily lifted with a glass rod. If in small amount, a few drops of dilute acetic acid are added, it will be revealed by the characteristic precipitate. Bile and Intestinal Juice. Small quantities of bile and intestinal juice may occasionally be met with normally. In the paragraph on "Examination of the Contents of the Stomach after Fasting" I referred to the presence of bile and intestinal juice, and that their frequent oc- currence is due either to relaxation of the pylorus or stenosis of the duodenum below the mouth of the bile-duct. Pure bile is golden yellow, but green if mixed with gastric juice. I believe that too often the diag- nosis is made by simple inspection. Mold may produce a greenish color, and I have found it on several occasions. For accuracy, the tests should be made Gmelin's for bile-pigment, and Pettenkofer's for bile-acids. Einhorn suggests the following tests for the intestinal juice, which is recognized by its ferments, trypsin, amylopsin, and steapsin: Trypsin. Mix the filtrate with i per cent, solution of sodium carbonate until the reaction is decidedly alkaline; add a flake of fibrin and keep in a warm place for several hours. Trypsin will dissolve the fibrin. Amylopsin. Starch is changed into maltose. Steapsin. Add i drop of blue litmus tincture and a few cubic cen- timeters of the neutralized filtrate to a small portion of milk and keep it at blood temperature. Steapsin changes the blue color, and the milk becomes slightly reddish from decomposition of the fat into fatty acids. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 159 Blood. Blood in large quantities is easily recognized, as is fresh blood, even if in small amounts. Fresh blood mixed with gastric contents presents a reddish appear- ance, while old blood is brownish or of a coffee-ground color. It may even appear blackish. When the blood cannot be detected microscopically and gastric hemorrhage is suspected, occult blood must be examined for. It is advisable to make the same examination of the stool. i. Benzidin Blood Test for Gastric Contents and Stool. This is a test devised by O. and R. Adler. 1 They first applied it to test the feces. Schlesinger and Hoist 2 advise boiling the gastric filtrate and testing in the same manner as for feces. Gastric Contents. Solution i. Knifepointful of benzidin (Merck's) is added to 2 c.c. of glacial acetic acid and allowed to stand and dissolve. Solution 2. Ten to 12 drops of the benzidin solution are added to 2% or 3 c.c. of a 3 per cent, peroxid of hydrogen solution. Three or 4 drops of the gastric filtrate, which has been boiled for about half a minute, are added to Solution 2. In the presence of blood, a green or blue color results in from a few seconds to a minute. Stool. The stool should also be examined. A small piece of feces about the size of a pea is mixed with 2 c.c. of water and boiled in a test- tube closed with cotton for half a minute; 3 or 4 drops of the boiled fecal solution are added to Solution 2. A green or blue color results if blood be present. For making this test Paul Cohnheim has devised a slight modifica- tion. Place a little benzidin (Merck) in a dry test-tube and shake it with about % c.c. of glacial acetic acid; add 2 c.c. of HgC^ and then care- fuHy place on its surface a little of the fluid which is to be examined. The last should be previously boiled. A green-tinted ring results. The intensity of the green or bluish ring affords one conclusions as to the quality of the occult blood. Benzidin Test Paper. Einhorn 3 has devised a benzidin testing paper as follows: Take a saturated solution of benzidin and glacial acetic acid; moisten filter-paper therein and dry it. Both in preparing the paper and making the test avoid contact with the fingers, as a drop of perspiration causes the reaction. When handling the paper, employ ivory-tipped forceps or protect the hand by a towel. Method. Gastric Contents. A piece of benzidin paper is first im- mersed in the gastric filtrate, and then a few drops of hydrogen peroxid are added. The paper is then placed on a piece of white porcelain and examined for the development of a blue color. If blood is present, a blue or green color occurs in a few seconds to a minute. Einhorn shows that if we wait longer periods, other substances may cause the reaction, also in time the paper moistened with peroxid will become blue. Feces. In testing for occult feces with the paper, a small piece the size of a pea is rubbed up with 2 c.c. of water, the benzidin paper im- 1 Zeitschr. fur physiol. Chemie, Bd. 41, Heft i and 2, p. 59. 2 Deutsch. med. Wochenschr., igo6, No. 36, p. 1444. 3 "A New Blood Test," Med. Record, June 8, 1907. l6o DISEASES OF THE STOMACH AND INTESTINES mersed therein, a drop of hydrogen peroxid added, and the blue color then examined for. The benzidin paper Einhorn recommends as a preliminary, and if there is immediately a strong reaction or none at all, he regards the result as reliable. If at the end of a minute only a trace of reaction occurs, then the aloin-ether extract method may be employed as a check. In the fecal examination, ether extract of feces, as employed in the aloin test, makes the benzidin test more reliable. In examination of the gastric contents no meat products or iron prepa- rations should be taken for at least twenty-four hours before the test, and in testing the stool the same rule must be observed; but, preferably, for a longer period if possible at least two or three days as a precautionary measure. It has been demonstrated that prunes give the typical reaction and that rice, milk, and potatoes react to it. 2. Phenolphthalein Test for Occult Gastro-intestinal Hemorrhage. The reagent 1 is made as follows: Dissolve i gm. of phenolphthalein and 25 gm. of potassium hydroxid in 100 c.c. of water, and reducing with 10 gm. of pulverized zinc. The resulting red fluid is stirred or shaken over a small flame until it is entirely decolored, the phenolphthalein being reduced to phenolphthalin. The solution is then filtered, when it is ready for use. It keeps indefinitely. A small amount of the stool, about 5 c.c. is rubbed up in water until it forms a thin fluid. Into this a little glacial acetic acid is stirred to acidify, ether is then added in equal volume, and the containing glass is slowly moved to and fro until the contents are well mixed. The ethereal solution is then decanted into another reagent glass and 20 drops of the phenolphthalin reagent are added. This last is shaken, and then 3 or 4 drops of hydrogen dioxid are added. In the presence of blood the phenolphthalin is oxidized into phenolphthalein, and as it is in alkaline medium, the fluid turns pink. -With considerable blood the pink tint persists for some time; with little blood, it soon fades. With much blood, the reaction is pronounced, even without the hydrogen dioxid. To test the stomach-contents, a few drops of glacial acetic acid are added to a few cubic centimeters of gastric filtrate and the same methods followed. 3. Weber's 2 Modification of Van Deen's Test for Occult Blood. Dilute the stomach-contents or, preferably, the filtrate thereof, with one- third volume of glacial acetic acid, and extract with about 10 c.c. of ether. A few cubic centimeters of this acid ether extract are mixed with 10 drops of tincture of guaiac and 20 to 30 drops of ozonized oil of turpentine (old turpentine exposed to air). If blood is present, the mixture turns a blue or blue violet; if absent, it turns a reddish brown with a green tinge. The reaction is more distinct if a little water is added and the blue pigment extracted with chloroform. Many authors insist that the tincture of guaiac should be freshly prepared on each occasion. Soper 3 demonstrates that this is unnecessary. He reduces the guaiac resin in a mortar to a fine powder, slowly adding 1 Boas believes this method the best. Deutsche med. Wochenschr., Berlin, Jan. 12, 1911, vol. xxxvii, No. 2. 2 Berl. klin. Wochenschr., 1893, No. 19. 3 Jour. Amer. Med. Assoc., Jan. 28, 1911. EXAMINATION OF THE FUNCTIONS OF THE STOMACH l6l 95 per cent, alcohol, leaving a residuum of guaiac in the mortar to insure a strong tincture. This is filtered and kept in a glass-stoppered bottle as a stock preparation. Dilute a portion of this stock tincture with 95 per cent, alcohol (tincture, i part; alcohol, 5 parts), and keep in a smaller glass-stoppered bottle for daily use. The Stool. The test for occult blood is as follows: Treat 5 c.c. of feces with 20 c.c. of ether; the latter is then poured off; 2 c.c. of glacial acetic acid are added to the feces and thoroughly stirred. This mixture is again treated with about 10 c.c. of ether and allowed to separate. To 2 c.c. of the etherized extract add 2 or 3 drops of a fresh tincture of guaiac. Then add 20 to 30 drops of ozonized oil of turpentine, or pure hydrogen dioxid, and shake well. If blood be present, there appears a blue or blue-violet color. Meat and iron preparations should be avoided for from twenty-four to seventy-two hours before these tests. 4. Kliinge's Aloin Test. Feces. In this test freshly prepared aloin is employed. Dissolve as much aloin as can be placed on the tip of a Fig. 115. Teichmann's hemin crystals (Jakob). knife-blade in 10 c.c. of 70 per cent, alcohol; add 2 c.c. of the aloin solu- tion to 2 c.c. of the ethereal extract of feces, prepared as above, and then the oil of turpentine or dioxid of hydrogen as described. A cherry-red color appears in the fluid if blood be present. Gastric Contents. Ethereal extract of the filtrate is prepared as in Weber's test. The rest of the test is the same as the aloin test of feces. Einhorn at times employs aloin paper prepared with filter-paper saturated with a solution of aloin in 70 per cent, alcohol, the paper being then dried for future use. Iron Test. This is useful if the patient is not taking iron. Place a small amount of unfiltered gastric contents in a porcelain dish. Add to it a pinch of potassium chlorid and a few drops of concentrated hydrochloric acid. Mix these thoroughly. Then heat over a small alcohol flame until a dry residue is secured. Add to this a few drops of a weak solution of l62 DISEASES OF THE STOMACH AND INTESTINES potassium ferrocyanid. If blood is present, a Prussian blue color results. I prefer the benzidin or Weber's lest. The spectroscopic test Heller's, Schonbein's, Korcznski's, the hemin test, etc. have been suggested, but the ones described are the most practical. Hemin Crystals. Hematin combines with one molecule of hydro- chloric acid to form hemin. This last substance crystallizes in brown plates or columns, and when produced by the addition of glacial acetic acid, may be of considerable size. Star or rosette-shaped crystals may also be present. The formation of hemin may occur from mere traces of blood. Negative results are not conclusive. The test is as follows: Evaporate a small sample of gastric nitrate on a watch-crystal over a small alcohol flame. Scratch the residue free, and mix with it a grain or two of finely powdered salt. Transfer this to a microscopic slide, and add a drop or two of glacial acetic acid. Fig. 116. Crystals of hydriodic hematin ester (Gross). Gently heat the slide for a minute or two until bubbles begin to form, then cool it off and examine under the microscope with a one-sixth or one-seventh objective. The crystals will be seen as in Fig. 115. Gross 1 employs Stozyzowski's modification of the above (Teich- mann's) 2 method. He recommends it particularly in the determina- tion of blood in suspected duodenal ulcer, first obtaining the duodenal contents by his aspirator. He notes small apparent blood points in the contents, and placing one of these on a slide, drying it slightly, then covers it with a cover-glass. At the margin he places i or 2 drops of the following mixture: alcohol, water, glacial acetic acid, of each, i c.c., and 3 drops of hydriodic acid (undecomposed, if possible, and of a specific gravity of 1.5). The specimen surrounded by this solution is boiled for about ten seconds over a small spirit lamp. The loss sustained by evaporation should be constantly replaced. Objective 7, ocular 3, 1 New York Med. Record, April 22, 1911. 2 Therap. Monatsh., Sept., 1902. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 163 should be employed in the microscope. If the specimen is blood, there will be rhomboid prismatic crystals of a black color (hydriodic hematin ester), as in Fig. 116. Pus is seldom found in the gastric contents, and is recognized readily under the microscope. Excluding ingested pus and phlegmonous gastritis, pus shows ulceration of the gastric mucosa. MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS The relative value of the microscopic examination of the gastric contents after the test-meal, of the vomitus, and of the fasting stomach- contents, as compared with gastric analysis, is still a matter of dispute. Some of the ardent advocates of the microscope go so far as to claim that their method is alone necessary. Undoubtedly, in many cases the clinical symptoms, gastric analysis, the test of the motor function, and macroscopic inspection of the contents afford sufficient information for Fig. 117. Fasting gastric juice containing mucus, snail forms, epithelial cells, and amorphous material. diagnosis. I do not wish, however, to depreciate the value of the micro- scope, as in some cases it is of fundamental importance. Gastric Secretion. When fasting, the gastric secretion shows normally under the microscope epithelial cells, cell nuclei, some mucus, amorphous material, and microorganisms. Jaworski 1 describes spiral or snail-like bodies in cases of hyperchlorhydria, but Boas believes they are quite com- mon and that they are developed from the mucus *by the action of the gastric juice (Fig. 117). Einhorn has found them in patients with normal secretion. Mucus. Mucus from the bronchi and lungs is characterized by the presence of alveolar cells and myelin drops; while the occurrence of a great many columnar epithelial cells is evidence of its origin from the gastric mucous membrane while squamous epithelia show it is from the pharynx or mouth. In doubtful cases the microscope will thus determine the source of the 1 Miinch. rned. Wochenschr., 1887, No. 30. 164 DISEASES OF THE STOMACH AND INTESTINES mucus, either by examination of the fasting contents, or after a test-meal. The clinical symptoms and macroscopic appearance of the contents, as described under Chronic Gastritis, will, however, generally give sufficient information. Paul Cohnheim holds that the presence of free nuclei of leukocytes Fig. 118. a, Nuclei of leukocytes; b, spiral bodies; c, nuclei of epithelial cells; d, striated mucus. and epithelial cells is a positive evidence of hydrochloric acid and pepsin (Fig. 118). I believe that gastric analysis is much preferable for such deter- mination. Importance has been attached to the presence of two varieties of infusoria, the Trichomonas hominis and Megastoma entericum, notably Fig. 119. a, Pus cells; b, trichomonas; c, megastoma; d, pavement epithelium. by Cohnheim (Fig. 119). He believes that their presence is pathognomonic of carcinoma, not affecting the motility of the stomach. Amebae are often associated with them. The development of these infusoria requires the absence of hydro- chloric acid, an alkaline medium, and the existence of deep folds in the EXAMINATION OF THE FUNCTIONS OF THE STOMACH 165 mucosa. Previous to aspiration, the stomach-tube and receptacle should be warmed. To differentiate between cancer and achylia gastrica in the suspected cases with emaciation, gastric distress, and achylia, special examination for these infusoria is advocated by Cohnheim. The presence of pus, especially if associated with blood in the non-fetid gastric contents, he also believes aids in the early diagnosis before the tumor is palpable. Microscopic pus in the gastric contents shows ulceration, but not nec- essarily malignant in type. Phlegmonous gastritis and the ingestion of pus from above must be excluded. Sarcinae and the Boas-Oppler bacillus can be examined for, both in the fasting stomach and after the test-meal. The same is true as regards epithelial cells and pieces of the gastric mucosa. I will refer to them shortly. Gastric Contents. The microscopic examination of the gastric contents after the test-breakfast or dinner shows, under normal con- Fig. 120. Benign ectasia. Yeast-cells and sarcinae are prominent: a, Muscle- fiber; b, plant-cells; c, sarcinae; d, starch granules; e, degenerated sarcinae;/, yeast-cells; g, fat crystals. ditions, a few starch granules, many of which no longer appear in spiral form. The muscular fibers do not show their diagonal stripes; globules of fat, plant-cells, and microorganisms are present in small numbers. Many unchanged starch granules are found in hyperchlorhydria and hypersecretion, and the muscle-fibers are well digested; while with hypochlorhydria (deficient secretion) unchanged muscle-fibers are present. The granules of starch are brought out clearly by the addition of i drop of tincture of iodin, giving a blue reaction. The microscopic findings are here confirmatory of macroscopic inspection. The varieties of microorganisms have been thoroughly studied by DeBary, 1 Nencki, 2 Boas, 3 and others. It has been demonstrated that they may be present even in hyperchlorhydria, showing that the hydro- chloric acid does not always prevent fermentation. 1 Archiv f. exper. Path, und Therap., Bd. 20, p. 243. 2 Archiv f. exper. Path., Bd. 28. 3 Deutsch. med. Wochenschr., 1892. 1 66 DISEASES OF THE STOMACH AND INTESTINES J. Kaufmann 1 has described a case of hyperchlorhydria in which the motor function of the stomach was not markedly disturbed, but which showed fermentative processes. He isolated eight varieties of microorganisms in a specimen of the gastric contents. Boas has also described the development of sulphureted hydrogen in a case of hyperchlorhydria. In general, we may say that fermentation develops in cases when the motility of the stomach is reduced. Minkowski 2 has shown that if free hydrochloric acid be abundant, yeast and thread fungi may be found; while if it is absent, numerous mold organisms are present. This last corresponds to the findings of A. Rose and myself. Yeast. A few isolated yeast-cells are found in the normal stomach. In ectasia or atony of marked degree the yeast-cells are numerous, arranged in colonies, and are in active process of germination (Fig. 120). b Fig. 121. a, Boas-Oppler bacilli; b, leptothrix; c, potato-cell; d, yeast-cells. Sarcinae. These occur usually in cubes or bales, and are only patho- logic if present in large numbers, as in benign ectasia or atony (Fig. 120) in the presence of hydrochloric acid. They are rare in ectasia from cancer, and, if present, occur usually in cancer developed on an ulcer. Their presence in large numbers is an aid to diagnosis. Boas-Oppler Bacilli. They are unusually long, non-motile bacteria, and are characterized by their large size and end-to-end arrangement (Fig. 121). They must be differentiated from the Leptothrix buccalis by Gram's solution, with which they stain brown, the leptothrix, blue. Kaufmann's 3 investigations prove the Boas-Oppler bacillus has the power of generating lactic acid from different sugars. Stagnation with lactic acid fermentation is not specific of pyloric carcinoma, but depends on the absence of hydro- chloric acid and the presence of stagnation. These conditions exist in stenotic gastritis. 1 Berlin, klin. Wochenschr., 1895, ^- 6. 2 See Naunyn, Mittheilungen aus der medicin. Klinik zu Konigsberg, Leipsic, 1888. 3 Weiner klin. Wochenschr., 1895, No. 8. EXAMINATION OF THE FUNCTIONS OF THE STOMACH 167 These bacilli have been found occasionally in stomach-contents that contain free hydrochloric acid (Rosenheim). Kaufmann has demon- strated them in 19 out of 20 cases of carcinoma. The presence of these bacilli, with pronounced lactic acid fermenta- tion and taken in connection with the clinical symptoms, is very significant. Epithelial Cells, Particles of Tumor, and Fragments of Gastric Mucosa. Single cells cannot be diagnosed as cancer-cells, but cell-nests must be found. These are rarely discoverable. Occasionally, after aspiration of the fasting stomach or test-meal, or after lavage, or in the vomitus, small particles of tissue may be found, which on staining may reveal the nature of a tumor. Hemmeter recommends in suspected cases, first, thorough lavage and rectal feeding for a day; then passing the tube, moving it about actively, and subsequent aspiration of the fasting stomach. This is to be followed by lavage. All tissue fargments are to be examined. Einhorn finds, especially after lavage, or at times after aspiration, small pieces of mucous membrane which he stains and examines. Some point to erosions, others to other affections. The fragment may be normal mucosa, or there may be proliferation of the connective tissue, or of the glands, or atrophy (partial or complete), or vacuolization. These conditions are illustrated in their appropriate chapters. A positive judgment cannot be given from this examination, as only a small area may be actually involved and no changes observed in the gastric secretion. On the other hand, a bit of normal mucosa may be aspirated from a diseased organ. Mold. Mold in the stomach has been little referred to in literature as a pathologic condition except by Talma, A. Rose, Naunyn, Einhorn, 1 and Knapp. 2 In an article on "Dilatation of the Stomach" 3 I have already referred to it. Einhorn has found it in the wash-water of the empty stomach as blackish-gray or brownish-green flakes of varying number; while Knapp describes it as coloring the chyme a yellowish green or dark red, and states that it has been mistaken respectively for bile or blood from its macro- scopic appearance. He emphasizes the necessity for appropriate tests for bile and blood, and not the diagnosis from appearances. I can sub- stantiate this in one case at least, in which the reddish-brown material proved to be mold. The mold flocculi consist of clusters of spores and mycelia, sometimes mixed with mucus and epithelial cells. Crystals are also found, which Knapp considers to be segments of mold filaments. The mold generally found has been identified by E. K. Dunham as the Penicillium glaucum, though Knapp reports in addition the Oiidium albicans and the aspergillus groups. These fungi probably adhere quite closely to the mucosa and may involve considerable areas (Fig. 122). Mold fungi, Streptothrix Foersteri, 4 a rare condition have been re- covered from the gastric contents by Stanley. 1 Medical Record, June 6, 1900. 2 Organacidia Gastrica, Sept. 6, 1902. 3 Medical News, Aug. 16, 1904. 4 Journal A. M. A., July n, 1914. i68 DISEASES OF THE STOMACH AND INTESTINES Einhorn reports mold formation in hyperchlorhydria, in some cases attended with hypersecretion, and also in gastralgia with normal or re- duced gastric secretion. Knapp holds that the presence of organic acids in the stomach has a decided bearing, and that succinic acid and mold go hand in hand, the presence of the former being conclusive. His test for succinic acid is as follows: Extract i c.c. of filtered chyme with 4 c.c. of ether, and float this extract on a solution of ferric chlorid (i drop of a 10 per cent, ferric chlorid to 2 c.c. of distilled water) in a narrow test-tube. At the line of junction is a dark mahogany-red ring. He further describes symptoms in many respects resembling severe hyperchlorhydria, with spasm of the pylorus, and believes the condition influenced by saccharine material in the chyme. In the experience of A. Rose and the author, diminished motUity of the stomach is a marked factor in favoring the growth of mold. I have found Fig. 122. Green mold follicle, mycelia, spores, and crystals. it ID cases of atonic ectasia, producing many of the symptoms of chronic gastritis, and again in benign stenosis with hypersecretion. The subject requires still further investigation. Treatment of Mold. Rose finds the administration of i minim (0.059 c.c.) doses of beechwood creosote or carbonate of creosote 5 grains (0.3) t. i. d. of value, and lavage is, of course, indicated, preferably with warm water i liter followed by lavage with nitrate of silver i : 2000, or spraying the stomach with the latter, as suggested by Einhorn. The general treatment should be according to the other conditions present. DETERMINATION OF THE ABSORPTIVE FUNCTION OF THE STOMACH The absorptive function of the stomach is usually tested by the method of Penzoldt and Faber, as follows: 0.2 of potassium iodid is administered in a gelatin capsule, and the saliva or urine examined every minute or two with starch-paper and fuming nitric acid. The strip of paper is EXAMINATION OF THE FUNCTIONS OF THE STOMACH 169 moistened with saliva or urine and then touched with a drop cf the acid. A violet or blue color is the reaction. It takes six and one-half to fifteen minutes before the reaction appears in normal conditions. In pathologic cases it is retarded. The test should be made on an empty stomach, as with the full organ it is retarded. It is self-evident that the gastric digestion of proteins and hence their absorption is delayed in cases of subacidity or anacidity, while these conditions are not so important for the digestion of carbo- hydrates. In some cases the absorption of iodid is normal, though we know protein digestion is interfered with, so that I do not consider the test in every case reliable. Hershell gives a capsule containing 2 decigrams of powdered rhubarb. Under normal conditions the urine gives a red color with liquor potassae. They are, however, the best tests so far known. Motor Functions of the Stomach. By this we mean the peristaltic action of the stomach which expels its contents into the intestine. The impairment of the motor power is fully as, and in many cases more, impor- tant than damage to the secretory functions. Under normal conditions after the Ewald test breakfast, about 50-75 c.c. of gastric are aspirated. The quantity of chyme found within the stomach an hour after the break- fast is an index of the motor function of the organ. If 100 c.c. or more is aspirated at this time, or varying quantities in 2 hours, motor insufficiency is considered to be present; the greater the residue, the greater the motor insufficiency. With the aspirating bulb employed by the author, particu- larly if aspiration be performed not only with the patient sitting up, but also lying on the right side, so that all the gastric contents will gravitate into the pars pylorica, quite complete emptying of the stomach can be secured. This method is quite practical for determination of the motor function and is sufficient in many cases. Lesser degrees of motor insufficiency may be found 100 c.c. of contents or slightly more one hour after the test breakfast which may account for some of the symptoms, and yet the radiograph 6 hours after barium ingestion, shows the stomach to be empty. The radiologist may therefore state the motor functions are normal in such a case and be in error. I often administer a test supper or dinner the night before, adding to it spinach, boiled rice and six raisins without seeds. When motor insufficiency is marked, the spinach particularly may appear in the aspirated contents the following morning. To determine that the stomach is empty, air can be forced into the organ by covering the free end of the bulb and squeezing the latter. If no bubbling is heard the stomach may be considered empty. There should be no contents two hours after the test breakfast. An excellent method of testing the motor power is by the test-meal. Leube's is the oldest method. He administered a plate of soup, a beef- steak, and a roll. If the stomach was found empty seven hours later and nothing could be washed out, it indicated that its motor power is suffi- ciently active. If the food remains in the stomach longer, the motor power is reduced. The greater the residue (often 350-400 c.c.), the greater the motor insufficiency. We must remember that in pyloric stenosis the motor power may be 170 DISEASES OF THE STOMACH AND INTESTINES really increased in endeavoring to overcome the obstacle, but that food remains in the stomach for an abnormal length of time; strictly speaking, it is a relative motor insufficiency. If five hours after a test-meal a small amount of chyme is aspirated, the motor power is good. If large quantities are found six hours after the meal, the motor function is absolutely (or if stenosis, relatively) decreased. Greater degrees of insufficiency may be present. For example, lavage is performed and a test-supper admin- istered, say, at 12 p. M. and the contents aspirated seven or eight hours later. In one case there may be a small quantity of food remaining, and in another case a large amount; while in another, none. As noted, chopped spinach, a few raisins, or a piece of fig are a good addition to the test, as they are readily recognized. Boiled rice can be added. The presence of food ingested at a previous meal shows marked motor insufficiency. Boas recommends cold meat with rolls and butter and a large cup of tea. It may be more convenient to follow the same procedure, but give the meal at lunch-time. I sometimes, as a variation, administer a test-supper after previous lavage and aspirate in the morning to test the motor func- tion, following immediately with the test-breakfast to examine the secre- tory function, and for lesser degrees of motor insufficiency. With marked dilatation from pyloric stenosis, it is at times difficult to completely empty the organ. The following method is at times employed. Mathieu-Remond Method. Mathieuand Remond suggest the follow- ing method of determining the total quantity for motor insufficiency. After removal of the contents a funnel is attached to the tube and 200 c.c. of water poured into the stomach. The funnel is moved up and down several times, and the patient shakes the abdomen so that complete mixture of the water and contents occurs. They are then removed by a combination of siphonage and expression. The quantity of liquid originally contained in the stomach is equal to the number of cubic centimeters of water poured into the stomach multi- plied by the degree of acidity of the second portion removed, divided by the figure resulting by deducting the degree of acidity of the second por- tion from that of the first plus the portion previously withdrawn. Salol Test (Ewald and Siever's Method}. Salol is not decomposed in the stomach, but in the alkaline medium of the intestine. Here it is split up, and the salicylic acid is absorbed and eliminated in the urine as sali- cyluric acid. The latter is recognized by testing the urine with neutral ferric chlorid solution, which gives a violet color with this acid. The patient takes salol 15 grains (i.o) in two gelatin capsules half an hour after a light meal. The bladder is first emptied. Thereafter he urinates every half-hour for about two hours, and the different specimens of urine are tested with the iron solution. Under normal conditions the reaction appears in from thirty to seventy-five minutes. With retarded motility it takes two hours or more. Ewald treats the urine with ether and examines the ethereal residue; while Einhorn moistens a piece of filter-paper with the urine and touches the middle of it with the iron solution. Huber suggests to determine the time required for the complete dis- EXAMINATION OF THE FUNCTIONS OF THE STOMACH 171 appearance of the reaction in the urine. The longer the time required for the salol to be absorbed and entirely eliminated through the urine, the longer it has remained within the stomach. He found that normally the excretion of the salicyluric acid after salol was administered lasted twenty- four hours; in patients with diminished motor function it lasted forty-eight hours or more. lodipin Test. lodipin is decomposed in the intestine. Heichelheim gives 1.6 gm. iodipin in gelatin capsules at breakfast. The saliva is then examined every fifteen minutes for iodin by starch-paper and fuming nitric acid. In normal cases the reaction appears within an hour. Klemperer's Oil Test. Oil is not absorbed in the stomach. After washing the stomach, 100 c.c. of pure olive oil are poured into the empty organ. Two hours later the stomach is thoroughly aspirated. The difference between the original quantity of oil and that withdrawn indicates the condition of the motor function. Normally at this time only 20 to 40 c.c. of oil should be aspirated. Einhorn's Gastrograph. Einhorn has invented a deglutible ball, arranged with an electric circuit, so that the movements which mix and break up the food can be registered. Hemmeter-Moritz Method. This method has been independently employed by Hemmeter and Moritz. A thin, deglutible bag is attached to an esophageal tube. The bag is then blown up and connected with a tambour on the Ludwig kymograph, which registers all the movements with a pen. A pneumograph is tied about the chest to record the respiratory movements as a basis of com- parison. The muscular contractions of the stomach are demonstrated on the record as independent of the respiration. These instruments are of interest scientifically, but their practical value has not been demonstrated. CHAPTER VII DIET THE study of nutrition, both in health and disease, is important, but it will only be possible to enunciate the general principles. There are three groups of food stuffs Proteins, carbohydrates, and fats procured from the animal and vegetable kingdoms, which in com- bination furnish the most suitable form of nourishment. Climatic conditions and environment have an influence on the requirements for nutrition. In extremely cold climates the Eskimos have lived for many generations on nearly an exclusively nitrogenous diet, with the addition of a large amount of fat, which produces the greatest number of heat units. In hot regions many of the races live principally on a non- nitrogenous diet. We also know that vegetarians live and thrive on carbohydrates. A mixed diet is the most suitable form of nourishment. DIET IN HEALTH Voit has emphasized the fact that the smallest amount of protein, with non-nitrogenous food added, that will keep the body in continual vigor is the ideal diet. He holds that a healthy adult of average weight should ingest 100 gm. of albumin, 50 gm. of fat, and 450 gm. of carbo- hydrate in twenty-four hours; others place the requirement for protein as considerably higher. A small proportion of the food serves the purpose of reconstructing the tissue waste, while the major part is used for generat- ing the heat required for the maintenance of life. It is, therefore, custom- ary to speak of the necessary amount of heat units during the twenty- four hours instead of the quantity of food. A calorie (or heat unit) may be denned as the amount of heat re- quired to raise i gram of water iC. This is a small calorie. A large calorie is the amount necessary to raise i kilogram of water iC. Hence a large calorie equals 1000 small calories. i gm. carbohydrate yields 4.1 large calories, i gm. fat " 9.3 " i gm. protein " 4.1 " In order to calculate the calorie value of any kind of food, the number of grams of albumin that are contained in it are multiplied by 4.1; the grams of carbohydrate by 4.1; the grams of fat by 9.3. These are added together and give the total calorie value of the food. For example: 172 DIET 173 100 gm. albumin X 4.1 = 410 calories. 50 " fat X 9-3 = 465 " 450 " carbohydrate X 4.1 = 1845 " 2J2O total calories. The calorie value of vegetable protein is slightly less than that of animal protein; 50 gm. of fat about equal 113 gm. of starch in calorie value. Riegel holds that a human being at rest, demands about 35 calories per kilogram of his body weight, and a person performing light work about 40 calories per kilo. From this estimate, the calorie value of the food of an individual weighing 50 kilos is from 1750 to 2000 calories. The weight of the patient must, therefore, be known in order to select the correct amount of nourishment. Rubner states that different articles of food can replace each other according to their calorie value, and that it is immaterial in what form the calories are introduced into the organism. This may be taken advan- tage of temporarily in certain pathologic conditions when it is necessary to limit some special variety of food, such as the carbohydrates. On the other hand, a certain amount of protein is necessary for the organism, while unquestionable damage can be done by excess in this direction. The amount of heat produced during digestion and assimilation depends upon the digestibility of food, that is upon the amount of energy needed to bring about its digestion. Easily digested foods causes little expendi- ture of energy for digestion, 'while food difficult of digestion calls for more energy. Chapin 1 illustrates that physiological food value and calorie value are not identical. For example, two foods when burned in calorimeter may yield 1000 calories each, yet the digestion of one food may call for the expenditure of 100 calories, while 700 calories of energy are used in the digestion of the other food, hence they would have a net value respect- ively of 900 and 300 calories. Some foods have no nutritive value, because the energy required for their digestion is greater than the energy they contain. The carbohydrates and fats are primarily suppliers of energy and secondarily of heat. Babcock has recently shown that they also supply water to the cells in a manner that controls cell nutrition and growth, so-called metabolic water. Its function is to cause growth and a flow of nutriment from the blood to the cells. The fats are of particular value in this regard especially milk fat and egg yolk. Overemphasis should not, therefore, be placed on the calorie value of foods, but their digestibility, suitability to the individual case and their capacity to produce improvement or in the case of an infant, proper development and growth, must be considered. The results of scientific study are opposed to the prevailing dietary standards, especially in regard to protein foods. It is true that no other form of food can take the place of proteins, for a certain quantity is needed each day to replace the loss of tissue material broken down, and our choice of the varied articles of diet should be regulated by the amount of pro- 1 The Double Function of Fats and Carbohydrates in Nutrition, N. Y. Med. Jour., Feb. 8, 1913. 174 DISEASES OF THE STOMACH AND INTESTINES tein they contain. It is not necessary, however, that they should exceed the other foods in amount, or approach them in quantity. Russel H. Chittenden 1 has clearly demonstrated by his scientific researches that the recommended dietary standards are excessive in quantity, 2 especially in regard to proteins. They do not undergo com- plete oxidation in the body like non-nitrogenous foods, but there is left behind a residue of non-combustible matter, crystalline nitrogenous pro- ducts, which ultimately, if occurring in excess of the requirements of the body, prove injurious to the gastro-intestinal tract, liver, kidneys, and the circulatory and nervous system. The fats and carbohydrates are easily eliminated, becoming carbonic acid gas and water. Potential energy, however, can be fully as advanta- geously met by the non-nitrogenous foods, carbohydrates, and fats. On the other hand overfeeding with a tendency to obesity, is an evil, as the fat acts as a mechanic obstacle to the activity of the body and interferes with the movements of the heart and other organs; and, in addition, fatty degeneration may occur. It is interesting to note that the body cells require a certain amount of mineral ash in the food, in order to perform their functions. A dog, for example, fed abundantly on all varieties of food from which the ash had been extracted died in thirty days. Though the author has been criticized for his approval of Chittenden's low protein diet in health, he must confess that, from personal experience and prolonged investigation, he must continue to advocate Chittenden's methods. Unquestionably a considerable percentage of temporary dis- turbances, or permanent damage to the gastro-intestinal tract, the liver, kidneys, and in the arterial and nervous systems can be imputed to exces- sive protein diet, from the intestinal putrefaction resulting therefrom. Rheumatic affections, gravel, and rheumatoid arthritis, the writer believes, are influenced by the same factor. Mastication, Fletcher ism. Unquestionably thorough mastication and, insalivation of our food which necessitate slow eating, are of value. Fletcher claims that by his method, there is an early occurrence of satiety on the ingestion of small amounts of food, and hence excess is avoided. He cites 722 chews to masticate % ounce of onion in one case. This would destroy the appetite both of operator and spectator. Most reformers are extremists, but the writer must credit Fletcher with having done some good. It is clear that a man of 170 pounds weight has more protein tissue to nourish than one of 130 pounds, and consequently what will suffice for the latter will not for the former. Dietary standards are merely approximate and depend on the physical work to be performed, the body weight, sex, age, climate, etc. There is doubtless a specific coefficient of nutrition characteristic of the individual. Chittenden demonstrated on professional men, soldiers, and athletes that they could perform their duties with greater vigor, and their strength as measured by tests was increased under diminished protein diet; in 1 Nutrition of Man. 2 Physiologic Economy in Nutrition. DIET 175 fact, with about one-half the amount as compared with the standards suggested. CHITTEXDEN'S TABLE Fuel value. 1 60 gm. of protein are contained in Calories H lb. fresh lean beef (loin) 308 9 hens' eggs 720 % lb. sweetbread 660 94 lb. fresh liver 432 J6 lb. lean smoked bacon 1820 34 lb. halibut steak 423 H lb. salt codfish (boneless) 245 2\i Ibs. oysters, solid 506 } lb. American pale cheese 1027 4 Ibs. (2 quarts) of whole milk 1300 56 lb. uncooked oatmeal I 5SQ ij-i Ibs. shredded wheat 2125 i lb. uncooked macaroni 1665 iH Ibs. white wheat bread 1520 i'/i Ibs. crackers 2381 i% Ibs. flaked rice 2807 % lb. dried beans 963 i % Ibs. baked beans 1 1 25 Vt lb. dried peas 827 iM2 Ibs. potato-chips 5728 % lb. almonds 2020 % lb. pine-nuts, pignolias 1138 i% Ibs. peanuts 3584 10 Ibs. bananas (edible portion) 4600 10 Ibs. grapes 4500 11 Ibs. lettuce 990 15 Ibs. prunes 5550 33 Ibs. apples 957 The standards of 100 gm. of protein or more mean the excretion of excessive nitrogen through the urine. Chittenden 2 found by experiment that the average need of protein food by adults is fully met by a daily metabolism equal to an exchange of 0.12 gm. of nitrogen per kilogram of body weight. This means a catabolism of % gm. of protein matter daily per kilogram. The intake of protein food must be somewhat in excess of protein catabolism, since not all of the protein is available, and this is a variable amount, depending on the proportion of animal and vegetable foods with their different degrees of digestibility and availability. The required intake of protein Chittenden places at 0.85 gm. per kilogram of body weight, giving a maximum for safety. Hence, for a man weighing 70 kilos (154 Ibs.) there would be required daily 59.5 gm. (say, 60 gm.) of protein food to meet the needs of the body. This is about one-half the Voit standard, and far below that of many other so-called diets. As the specialist is so often consulted as to the proper diet to maintain the health of the body, I quote Chittenden at some length, being a firm believer in his principles. The daily protein requirement of 60 gm. can be obtained from K pound of uncooked lean meat, of which loin steak is the type. Lamb, x Fuel value of the quantity needed to furnish 60 gm. of protein. 2 Physiologic Economy in Nutrition; Nutrition of Man. 176 DISEASES OF THE STOMACH AND INTESTINES veal, poultry, or lean flesh of any variety, of equivalent weight, will approximately furnish the same amount of protein. Fish, such as halibut steak, and liver require % pound, and of sweet- breads % pound is necessary. Of salt codfish > pound is equivalent to the same weight of fresh beef, while of lean smoked bacon % pound is necessary. Three hen's eggs furnish one-third the amount of protein required in twenty-four hours. Dried peas and beans, almonds, and pine-nuts are as rich in proteins as the above-mentioned animal foods, and essentially the same weight is called for to provide the daily requirement of protein. The same is true of cheese, the composition of J pound being equivalent to the same amount of protein, but of much higher caloric value than the equivalent weight of fresh beef. There are some differences in digestibility which tend to lower slightly the availability of the vegetable products, also of the cheese, which neces- sitates a slight increase in the amount of these foods to equal the protein value of the equivalent weight of lean beef. Certain foods are poor in proteins, such as fruits, bananas, grapes, prunes, apples, etc., lettuce, and, to a less degree, potatoes. These are all palatable, but add little to the proteins, even when given in large amount. The radical difference between the animal foods and those of veg- etable origin, is, that the fuel value necessary to furnish the 60 gm. of protein is small in the former, as compared with that of the vegetables; % pound of lean beef, with its 60 gm. of protein, has, for example, a fuel value of only 308 calories, while % pound of almonds has one of 2020 calories; % pound of cheese has one of 1027 calories; } of i per cent, sodium carbonate solution, though hypertonic, can be given with safety, though some advise a 2.25 per cent. I prefer administration by hypodermoclysis. Inunctions with preparations of oil or lanolin may at times be of service. Gavage, or forced feeding through the stomach-tube, is referred to under Lavage through the nasal route. DIET IN DISEASE General principles will be enumerated. In acute diseases of the stomach^ as in acute gastritis, the indication is to spare the organ as much as possible. In some cases no food is admin- istered by mouth for several days and rectal feeding is employed. If food is administered, it should be given in small quantities at first and in liquid form weak broths, bouillon, barley-water, a small quantity of 1 Arch. Int. Med., vii, 694, 1911. DIET 193 water. They should be neither excessively hot nor cold. Peptonized milk, milk and lime-water, white of raw egg beaten up; later, toasted bread, soft-boiled eggs, etc., and a gradual return to full diet. Ulcer of the Stomach. In this condition both mechanic and chemic irritation of the stomach should be avoided. Albumin solutions and finely divided protein material are indicated, such as milk, beef-juice, somatose, and tropon. Einhorn allows barley-, oatmeal-, or rice-water in the early treatment. Raw eggs beaten up aid in binding the free acid. Dextrose and butter aid nutrition and lessen acidity. Starch in any great quantity is not well borne on account of the acidity. Leube avoids all stomach feeding for several days after the hemorrhage, employing nutritive enema; while Lenhartz feeds immediately, binds the free acid, and endeavors to rapidly improve nutrition. Gelatin solutions are of value in these cases. Chronic Diseases of the Stomach. In the chronic diseases it is extremely important to see that sufficient quantity of food is taken and to improve the nutrition of the patient, as frequently subnutrition is present. Carcinoma. In malignant disease of the stomach or its orifices little can be accomplished by diet alone. The patient should receive frequent meals in small quantities, liquid or pultaceous in form. This is advisable, even if the cancer is so situated as not to interfere much with the motor function. I have seen cases improve temporarily in nutrition. Radical or palliative operation is indicated. Benign Stricture. Stricture of the cardia can at times be dilated with bougies; operation may be required; with pyloric stricture perfect recovery often follows operation. With benign pyloric stenosis, hyperacidity, at times with hypersecretion, and ectasia are present. The indications in these cases are to administer liquid or mushy foods, chiefly of albuminous type. There are relative motor insufficiency and increased secretion. Starchy food in quantity is not, therefore, well borne. The gastric secretion, motility, and sensibility of the stomach must be studied in every case. When there are disturbances of the motor Junction, food should be given so prepared that it will be most easily evacuated from the stomach, as in liquid or pultaceous form. Among the disturbances of gastric secretion we have hyperacidity and hypersecretion (an increase in the secretory function) ; and subacidity and anacidity, an impairment of secretion. Motor disturbances may complicate any of these conditions, and sensory disturbances are most frequent in the first class. In the hyperacid forms, a diet should be selected which stimulates hydrochloric acid secretion as little as possible and at the same time combines with it. Abundant albuminous diet should be administered, with hyperacidity, in coarse form if the motor function is intact, otherwise in liquid or mushy form. With hypersecretion, smaller and more frequent meals are indicated, and fluids should be limited. Carbohydrates in any quantity are not well borne, though their digestion is better with hyper- is 194 DISEASES OF THE STOMACH AND INTESTINES acidity than with hypersecretion. 'Solutions of dextrose are readily absorbed and lessen the secretion of hydrochloric acid. The diet of ulcer has been previously referred to. Fats are quite well borne, and in the form of olive oil lessen the hydro- chloric acid secretion. In cases of subacidity as in chronic gastritis, meat must be diminished and carbohydrate material increased. Nutrition must be improved. Koumiss, matzoon, milk, and raw eggs must be taken with crackers and butter between meals. As an example of anacidity we have achylia gastrica. This may be a temporary functional disturbance or a permanent condition with organic changes. Chemic action has ceased and vegetable food (in which starch granules possess an albuminous coat) as well as animal food pass from the stomach unchanged and irritate the intestines. A rich carbohydrate diet is indicated, but it must be well pulverized. With ectasia and gastroptosis small and frequent meals are indicated, the character depending on the gastric secretion. With severer forms of motor insufficiency liquids and mushes are required. In nervous dyspepsia one must gradually increase the quantity of food. The administration of frequent small meals, koumiss, matzoon, etc., be- tween the chief meals is of value. The rest cure is often serviceable. One must individualize in every patient, and with the aid of the general principles described it will be possible to formulate a diet to suit the case. Methods of Feeding Before and After Gastro-enterostomy. This subject is of such importance that the author feels that he should offer some brief suggestions. . For a period of twenty-four to forty-eight hours before gastro-enteros- tomy the patient should be placed on a sterile liquid diet broths, bouillon, milk, and water, all thoroughly sterile. The nares and pharynx should be sprayed with hydrogen peroxid, 20 per cent, solution, before and after each feeding. Acetozone, 5 grains daily, may be given in the sterile drinking-water in divided doses. The writer further advocates in addition to the usual examination of the urine, that a special examination be made for acetone and diacetic acid, and if such be present, oatmeal gruel (strained) be given for several days previous to operation, and about 2 drams (8.0) soda bicarbonate be administered daily. Subsequent to operation, 3 drams (12.0) soda bicarbonate should be given daily in the nutritive ene- mata, thereby lessening the chance of vomiting due to acidosis. If chloro- form is to be administered, preliminary alkaline treatment is useful even if no acetone be present before operation. Lavage should be performed about an hour before operation with acetozone solution i : 1000, the stom- ach being thoroughly washed and the contents well aspirated, so as to have an empty organ. If this procedure is not carried out, particularly if there is pyloric stenosis, there may be considerable fluid in the stomach, even though the patient has not been fed for twelve to eighteen hours previous to operation. In view of the frequency of colon bacillus infection, the writer advocates examination of the urine for gram negative bacilli both before and after operation. If they are in evidence, cultures should be taken and treatment at once begun. See chapter on "Infections by the DIET 195 Colon Bacillus." If indicanuria is marked, hexamethylenamine tablets gr. v t.i.d. and lactic acid bacilli in liquid form should also be given preparatory to operation. Postoperative Feeding. The lips should be moistened with wet cloths after operation and protocylsis or small enemata (4 ounces normal saline solution) be given for thirst. Four to six hours after operation nutritive enemata should be begun, and these may be given four or five in number during the twenty-four hours and so continued for a week after operation. Six hours after gastro-enterostomy and immediately after other operations i -dram (4.0) doses of hot water may be given by mouth at first at hour intervals and then increased gradually in quantity. At the end of twenty-four to forty-eight hours i-dram (4.0) doses of strained barley-water gruel or strained rice gruel may be given every hour, gradually increasing to larger quantities at greater intervals. On the third or fourth day peptonized milk in small quantities, well diluted with lime-water, and on the fifth to seventh days two to four raw eggs well beaten should be added. Thereafter soft diet until the end of two weeks. Strained gruels the writer believes preferable at first to milk. The patients upon whom this operation is performed are usually in poor physical condition and proper methods of early feeding are indicated. CHAPTER VIII LOCAL TREATMENT OF THE STOMACH LAVAGE SINCE the year 1867, when Kussmaul employed lavage in a scientific manner with his stomach-pump in the treatment of disease of the stomach, there has been a gradual improvement in the type of instrument. The hard tube and the use of the stylet for introduction have passed into disuse, and the modern method is based upon the principle of siphonage with the soft-rubber tube. Funnel Method. The one that is in most common use for washing the stomach is by means of the funnel. The latter may be of hard rubber, glass or a flexible rubber funnel, attached to a piece of soft-rubber tubing about a yard long, the latter being joined to the upper end of the stomach-tube by a small connecting glass or hard-rubber tube (Fig. 124). Fig. 124. Funnel and tube for lavage. The glass funnel is more readily broken and the soft-rubber funnel not as easily managed by a novice, so that for general use the hard-rubber funnel is preferable. One of medium size, holding about 250 c.c., is most convenient. The glass connecting tube, in one case to my knowledge, came near being the source of considerable danger to the patient. During the lavage he suddenly grasped the glass tube and managed to splinter off a portion of it, fortunately at the same time partially pulling out the stomach-tube. The accident was immediately noted and the tube entirely withdrawn. Fragments of glass were found in the tube. There is always the possibility of a similar accident to the glass funnel, and the use of a rubber instrument and metal or rubber attachment would seem to be preferable. Dangers. There is one possible danger, namely, the stomach-tube may separate from the attachment to the funnel tube and slip down into the 196 LOCAL TREATMENT OF THE STOMACH 1 97 stomach. Leube 1 reports such a case. On the ninth day after swallowing the tube after an attack of coughing the tube passed up into the esophagus and pharynx and was withdrawn therefrom. The connection between the stomach-tube and funnel-tube had become loosened and the water from the latter forced the tube into the mouth. Moreover, every tomach-tube should be tested before using to be sure that it is not cracked or weakened by some defect. Friedenwald 2 reports such an accident resulting from the use of a defective tube, with the result that two fragments were subsequently removed by gastrotomy. At the Manhattan State Hospital, Ward's Island, among our nervous and insane patients, a long, continuous, single-piece stomach-tube (3^ to 4^ feet in length), with a rubber funnel at the end, is employed. This obviates all possible danger of swallowing the tube, which would be the most likely accident with this class of patients. For ambulance work such a tube is decidedly to be recommended. Under ordinary conditions, with the two-piece tube, the patient or an assistant can hold the stomach-tube tightly at the point of junction with the connecting- joint, or the operator can hold it firmly at the lips of the patient when he elevates the funnel. Selection of the Stomach-tube. The selection of the stomach-tube may seem to be an unimportant matter, but from a varied experience there is undoubtedly a decided advantage in the choice of an instrument. The tube should be of value both for aspiration of the stomach-contents and for lavage. Some prefer the tube closed at the end and with two lateral openings, claiming that there is less danger of traumatism from the smooth rounded end and less chance of aspirating the mucous membrane into the openings of the tube. Fig. 125. Best tube for lavage. In actual practice, one has to exercise more pressure with this type of tube in order to force it to take the curvature of the stomach and lie parallel with the same, if thorough aspiration or lavage is to be performed. This tube is, moreover, not so readily cleansed. The tube open at the end and with a large lateral opening is preferable ; a tube with two lateral openings is the best, though not absolutely essential (Fig. 125). It is much easier to thoroughly aspirate the stomach or perform lavage with tubes of this description. The pressure is so minimized by these large openings that in my own experience I have never seen damage result to the mucous membrane. For practical purposes a tube of from 28 to 30 (French) is thoroughly efficient. I have seen physicians in their general practice employ tubes of very large caliber, irrespective of the size or age of the patient. This is 1 Deutsch. Arch. f. klin. Med., vol. xxxiii, p. 6. 2 American Medicine, August 2, 1902. 198 DISEASES OF THE STOMACH AND INTESTINES about as sensible as using a large sound in every case, irrespective of the caliber or conditions of the urethra. The tube of medium caliber that I have indicated will pass comfortably through any average or even small adult esophagus, unless stricture be present. The best tubes are marked at about 18 inches from the distal end (it is 1 6 inches from the teeth to the stomach), and by this means we know when the instrument has reached that organ. The tube should be inserted a little further until checked by the lower border of the stomach, and then withdrawn slightly until no resistance is felt by the operator. With Fig. 126. Correct method of passing the stomach-tube. ectasia or gastroptosis it may be necessary to pass it a considerable distance. If the tube is not marked it is easy to estimate the correct distance and make a scratch-mark on the tube with a pencil, or insert it until checked by the lower border of stomach, as just described. A pitcher; pail, or large basin, towels, and rubber sheets are required. Special irrigating stands can be secured, but are unnecessary and expensive for the young physician. The correct method of lavage in office practice, without an assistant, is first described. False teeth should be removed. The patient should sit upright in a straight back chair, with a rubber LOCAL TREATMENT OF THE STOMACH 199 sheet or towels about the neck thus protecting the front of the body. His confidence should be gained. He should be told that the procedure is slightly disagreeable, but absolutely safe. He should be admonished that he is to breathe deeply and steadily all the time, as this will prevent the gagging and sensation of choking; and he should be directed, while the lavage is actually in process, to follow out this method. The stomach-tube should be lubricated by dipping it in warm water. Vaselin, cold cream, or olive oil may be used, but they are disagreeable and unnecessary. The irrigating fluid should be pleasantly warm to the hand. This is sufficient index to the temperature, though for absolute accuracy a thermometer may be employed; and about 100 to ioiF. is correct. Plain water or, preferably, normal saline solution, i dram (4.0) of salt to i pint (500 c.c.) of water, is employed in the average case for the purpose of cleansing the stomach. Special solu- tions will be appropriately indicated in their places. The patient should bend the head slightly forward and open the mouth, but not protrude the tongue. In rare cases a 2 per cent, cocain or 5 per cent, eucain spray may be required if the pharynx is irritable. Freezing the stomach-tube is also serviceable. This consists in placing the tube for a brief period in ice or ice-cold water, so that it is extremely cold when it enters the pharynx, hav- ing an anesthetic effect. The physician should never insert his ringer into the mouth to depress Fig. 127. Course of tube. the tongue or act as a guide to the tube, as it renders the operation more difficult, and will only cause gagging or vomiting. Most of our text-books advise that the operator stand in front of the patient and pass the tube along the base of the tongue. The most practical method is the one shown in Fig. 126. The physician stands on the right side and a little back of the patient and passes the left arm about the neck, the fingers supporting the tube at the lips, the little finger resting on the chin. This method prevents the patient from throwing his head back and struggling, and gives the operator perfect control. The stomach-tube should be passed into the mouth with the right hand, it being held about 2 inches from the lips, and being supported by the left hand against the roof of the mouth. It should then be rapidly forced in with the right hand, the index-finger and thumb of the left hand continuously aiding its introduction. The tube follows the arch of the mouth, and glides down the posterior' 2OO DISEASES OF THE STOMACH AND INTESTINES wall of the pharynx (Fig. 127). Interference from the tongue is thus avoided. When its progress is checked, the patient should be told to swallow, and it will enter the esophagus. It should now be rapidly fed into the mouth until the marked ring has been reached, and then more slowly to the bottom of the stomach. If the tube is checked during introduction, it is probably due to a spasm of the esophagus, and the act of swallowing or a deep inspiration will free it. There is practially no danger of its entrance into the larynx. Fig. 128. Lavage by single operator: Position one. Sometimes the patient may become cyanotic, and a beginner may fear that this has happened; but this is due to the fact that the breath is held, and deep and regular breathing will immediately relieve the condition. Occasionally the tube may slip out of the esophagus and coil in the mouth, but that is easily detected. Patients accustomed to lavage can often introduce the tube themselves. I prefer a funnel 1 of a capacity of 250 c.c. or about 8 ounces, and allow 1 If the funnel is of smaller capacity, more funnelfuls should be used; total 250 to 500 c.c. (8 ounces to i pint). LOCAL TREATMENT OF THE STOMACH 2OI two funnelfuls to run into the stomach (in all about i pint) and to run out again at once. It is a bad practice to overdistend the stomach, just as it is the bladder. At times I employ one funnelful. Lavage is continued until the water is perfectly clear. The patient may move the body about so as to bring the water in more thorough contact with the stomach wall, or may lie down, as suggested by Fleiner, rotating to the right side and then to the left; but this is rarely necessary except in cases of marked dilatation with insufficiency. Fig. 1 29. Lavage by single operator: Position two. Lavage by a Single Operator. During lavage the patient steadies the stomach-tube, holding it to the lips with one hand. He should be instructed not to bite the tube. The operator holds the funnel in the left hand and pours the water into it from a pitcher in the right hand, then elevates the funnel to about the level of the patient's forehead (Fig. 128). As soon as it is empty, he pours in the second funnelful. Then before the latter is empty he quickly lowers it to below the level of the patient's stomach, and allows the fluid to siphon out into a pail or bowl placed on the floor to the right of the patient (Fig. 129). The rim of the funnel should be held upward. It should be allowed to fill before emptying it, as in this way it can be estimated whether the 2O2 DISEASES OF THE STOMACH AND INTESTINES amount of fluid that flows out equals that which was poured in. In empty- ing the funnel it should only be slightly tipped, so that the column of water is still visible in the bottom. This prevents the entrance of air and also the aspiration of the mucous membrane into the openings of the tube. When the washing is completed, the funnel should be rapidly raised and the stomach-tube withdrawn in this position. The small column of water remaining in the tube flows back into the stomach and prevents the Fig. 130. Lavage by two nurses: Step one. possibility of the accident just noted. The tube should not be pinched during the withdrawal, as mucous membrane might be aspirated in. If the water stops flowing during lavage, one should observe if the patient has not inadvertently withdrawn the tube slightly, and in this event, it should be pushed back. On the other hand, the tube may be bent and the flow stopped by reason of its being forced too far into the stomach. If so, withdrawing it slightly will correct the trouble. Pieces of food may occlude the tube by stopping up the stomach LOCAL TREATMENT OF THE STOMACH 203 openings. By pouring more water into the funnel the instrument will usually be cleared out. By forcing air through the stomach-tube or by suction this can be accomplished if the above method fails. Thus, a rub- ber bulb with metal attachments is inserted between the stomach-tube and the funnel-tube, in place of the tube joining them. Close the end leading to the funnel and compress the bulb. This will force air through the stomach-tube; or first compress the bulb, then close the distal end con- necting with the funnel by making an angle or compressing the soft tube of the latter, then let the rubber bulb expand again. The last method Fig. 131. Lavage by two nurses: Step two. described is that originated by Friedlieb. The stiff rubber bulb made by Tiemann, with metal attachments, is a better instrument than Friedlieb 's, which has glass attachments. On rare occasions it may be necessary to remove the tube, clean it, and reintroduce it. In emergency in country practice one can employ an ordinary tin kitchen funnel and a piece of small red or even white rubber tubing. A fountain syringe with the long soft-rubber tubing has been used in poison cases. A stomach-tube can be improvised out of a long colon tube. 204 DISEASES OF THE STOMACH AND INTESTINES The lateral opening can be cut with a pair of sharp scissors, and the rough edges of the "window burned over an alcohol lamp, wiping them quickly with a wet cloth, thus making a smooth velvet eye. If the opening of the improvised tube is rough, it can be trimmed down and smoothed by the above method. It is best to lubricate all such emergency tubes with olive oil or vaselin, as they are less smooth and more difficult of introduction. With an intelligent patient who will cooperate with the physician the method described is excellent. . In nervous cases, when possible, it is easier to have an assistant or for two nurses to perform lavage, as in Figs. 130 and 131. The technic is the same as to passage of the tube, etc. One nurse steadies the tube at the patient's mouth and carries on the manipulation with the funnel, the other pouring the fluid. Fig. 132. Friedlieb's apparatus for lavage. If the patient resist, nurse No. i both holds the tube and prevents interference by the patient's hands, while nurse No. 2 manages the funnel and pours the fluid. Friedlieb's apparatus is demonstrated in Fig. 132. In Figs. 133 and 134 we have two nurses performing lavage with a funnel, the modified Friedlieb bulb connecting the stomach-tube and funnel- tube. This is a favorite method of mine. It is best to close the bulb on the side joining the stomach-tube by pinching the latter with the fingers, then squeeze out the air and pour the fluid into the funnel, allowing the bulb to fill with water. This prevents aspirating air into the stomach. Lavage is then performed in the usual way. The advantage is that we have the bulb in position to employ air- pressure or suction if the stomach-tube becomes occluded. Intermittent squeezing of the bulb also aids expulsion of the fluid. LOCAL TREATMENT OF THE STOMACH 205 The modified bulb made by Tiemann has metal connections (instead of glass) and is stiff er and better than Friedlieb's. Irrigation of the Stomach by Means of a Glass Y or T. This method has generally been known as Leube-Rosenthal's, but R. H. M. Dawbarn has taught this plan for many years. It is useful for office work. A large glass irrigator, about 2 quarts' capacity, is hung at a level slightly above the patient's head. This should be marked in 250 to 2000 c.c. or in ounces or pints. This irrigator is connected with a long soft- Fig. 133. Nurses performing lavage with modified Friedlieb bulb: Step one. rubber tube by means of a Y- or T-shaped glass or, preferably, hard-rubber or metal tube; one branch with the stomach-tube and the other with a carry-off tube which passes down into a pail or basin. The irrigator tube should be closed with a damp. This is kept closed until after the introduction of the stomach-tube and commencement of lavage. A second clamp on the outflow tube is unnecessary, as all manipulation can be thereafter conducted by the operator, by alternately opening and closing the inflow and outflow tubes with the fingers. The stomach-tube is introduced in the way described. The outflow 2O6 DISEASES OF THE STOMACH AND INTESTINES is pinched as in Fig. 135, and the clamp on the inflow tube opened. Only 500 c.c. of fluid or about i pint, is allowed to flow into the stomach. I do not approve of employing the larger quantities, as recommended by some authors. While the fluid is still entering, the outflow tube is suddenly released and part of the current is diverted, thus starting the siphon action. The inflow tube is then pinched, as in Fig. 136, and the stomach rapidly empties itself. The outflow is then pinched and the inflow released, and so on. The patient may shake his abdomen, so as to wash all parts more thoroughly. Fig. 134. Nurses performing lavage with modified Friedlieb bulb: Step two. This procedure must be continued until the wash-water returns clear. There are cases among the insane or when the patient is unconscious when the methods described cannot be used. It may be necessary to employ a mouth-gag, forcibly distend the jaws, and force in the stomach-tube. Under such conditions numerous assist- ants may be required. The operation may be performed with the patient lying on the back, being properly restrained. The tube should be passed along the roof of the mouth, and the patient should lie on a sufficiently high level, so that the LOCAL TREATMENT OF THE STOMACH 207 funnel can be carried below the level of the body in order to secure the siphon effect. If no mouth-gag can be secured, the handle of a spoon, protected with gauze or a handkerchief, can be inserted between the teeth, turned, and the jaws forced apart, or some such instrument improvised. The director devised by Mark Knapp (Fig. 137) would be of value in such cases. Being all metal, it can.be left in situ during lavage, and acts as a gag. Fig. 135. Stomach irrigation by the T-rnethod : First step. The simplest method in such cases is to introduce the tube through the nostril. The technic of lavage by this method is shown in Figs. 138 and 139. The tube is passed along the floor of the nostril, just as is the guide for posterior nasal tamponade. It is fed directly through the nostril for about 20 inches, and no difficulty, as a rule, is experienced, as it passes down the posterior wall of the pharynx and so on into the esophagus and stomach. The nares should be examined, and that nostril selected which is of 208 DISEASES OF THE STOMACH AND INTESTINES larger dimensions. This is important, as there are irequently deflections of the septum. At the Manhattan State Hospital a stomach-tube of fair size (about 27, French) is employed. I frequently use this tube in my office lavage per orem. It is rarely necessary to employ the very small tubes so frequently recommended. For thorough lavage a fair caliber is preferable. Gavage. Gavage is a different proposition and the small tubes are to be preferred. Gavage or forced feeding is employed chiefly among the insane who Fig. 136. T-method: Second step. refuse food, the tube being introduced as in lavage, the nasal route being preferable. It may be necessary to employ this method of feeding in children who have been intubated and also in feeding the unconscious. In some cases, of course, the mouth route may be preferable. Hemmeter and others have employed double-current tubes for lavage, but I can see no advantage. Indications for Lavage. i. In All Cases oj Poisoning. Some authors advise against it in cases from acids or alkalis, for fear of causing perfora- tion; but there is greater danger of the latter by leaving the poison, since LOCAL TREATMENT OF THE STOMACH 2OQ thorough emesis cannot be secured, especially if the patient be uncon- scious; there is the increased danger of subsequent damage to the intestinal canal below and often to the other organs, such as the liver and kidneys, or cardiac or respiratory poisoning might result. 2. In acute and uncontrollable vomiting from any cause, as from acute gastritis, the value of lavage was first definitely shown by our specialists in pediatrics. Bilious vomiting is included. 3. In chronic gastritis, with excessive production of mucus. 4. In dilatation of the stomach (atonic type), where there are marked fermentation and motor insufficiency. 5. In dilatation of the stomach (stenotic type), with fermentation, motor insufficiency, gastritis, vomiting, etc. 6. In acute dilatation of the stomach from all causes. Fig. 137. Knapp's director. 7. In vomiting due to vicious circle, after gastro-enterostomy. 8. At the end of anesthesia, to prevent postoperative vomiting, or to treat the same, if it has occurred, before anesthesia and also to prepare for gastro-enterostomy so as to have a clean stomach for the surgeon. 9. In postoperative intestinal paresis (correctly, gastro-intestinal paresis) lavage should be employed together with enteroclysis. 10. In acute tympanitis of typhoid fever, lavage is of great value to aid reduction of the same; especially when hemorrhage is occurring and enteroclysis is contraindicated, see Typhoid Fever. 11. In intestinal obstruction, especially in intussusception. Frequent lavage has so relieved abdominal distention above the point of obstruction that the condition has been spontaneously reduced. It also checks the vomiting in this condition. 12. Occasionally lavage with iced water has proved successful in 14 2IO uncontrollable hemorrhage from gastric ulcer. It should be used as a last resort and with great caution. Fig. 138. Lavage through the nostril: First step. Fig. 139. Lavage through the nostril : Second step. 13. It is also of service in estimating the degree of motor insufficiency by washing out the residue after aspiration following the test-meal. 14. In gastric tetany. 15. In the convulsions of young children which immediately follow LOCAL TREATMENT OF THE STOMACH 211 the ingestion of improper food. Epileptiform convulsions occasionally occur in adults from overfeeding and lavage is indicated. 1 6. In vomiting of peritonitis. Contraindications to Lavage. i. Aneurysm of the aorta. 2. Gastric hemorrhage, as a general rule, except as in No. 12 above. 3. Marked heart lesions, when danger might be incurred, such as in angina, etc. 4. Last months of pregnancy. 5. Special conditions where it might damage the patient or be dangerous. In cases of poisoning lavage would take precedence over all other risks. 6. Recent rectal, vesical, or renal hemorrhage. 7. Recent hemoptysis. 8. Extreme prostration from any cause. 9. High arterial tension with respiratory disturbance. Stomach Douche. This method was first described by Malbranc, and the measure was first employed by Kussmaul. It consists in sprink- ling the stomach with water under pressure. Ewald and Rosenheim 1 have devised the most practical stomach-tubes for this purpose. Fig. 140. Tube for stomach douche. The instrument, as in Fig. 140, has numerous small lateral openings and a slightly larger hole at the end. This last is so that the water can run off more rapidly in emptying the stomach, and any mucus or food products can more readily escape. If the hole is too large, the bulk of the fluid will pass through this and no diffuse irrigation of the mucous mem- brane be accomplished. Some tubes have only a number of small holes at the end. The tube is introduced in the manner already described, and the funnel method is employed. This is held quite high above the patient, so that the water is under considerable pressure and numerous small streams are forced out of the tube. . Rosenheim recommends it on an empty stomach before breakfast, or, if this is impractical, three or four hours after the first meal. It is ap- plicable to mild motor insufficiency. He 2 advises its use in mild cases of chronic catarrh and in irritation of the sensory and secretory apparatus. Salt added to the irrigation fluid increases the hydrochloric acid pro- duction, nitrate of silver (in i : 1000 strength) or argyrol or protargol >iooo reduce the secretion of gastric juice. Other observers have agreed 1 Therapeut. Monatssch., August, 1892. 2 Berlin. Klinik, 1894, No. 71. 212 DISEASES OF THE STOMACH AND INTESTINES with these findings, and Riegel advocates the use of the silver nitrate. Fleiner 1 recommends the douche for stimulating the appetite. Thus, infusions of hops, quassia, condurango, or cinchona bark are valuable. Boric acid, salicylic acid, sodium salicylate, thymol, gomenol, creolin, lysol, etc., may be empolyed in average strength (i : 1000) if antiseptic treatment is indicated. If medicated douches are employed, the stomach should first be washed with plain water; then the medicated fluid applied for one to three minutes and then siphoned out; the stomach should be rewashed with plain water if toxic materials have been used. Gross has devised a double-current gastric douche, which is scarcely practical, and Einhorn an instrument with a ball-valve and hard-rubber tip. The following simple addition to the Ewald-Rosenheim tube gives Fig. 141. The bulb- compression method of spraying the stomach. Fig. 142. The Y-method of spraying the stomach. satisfactory results. Employ a fountain syringe instead of a funnel and also a compression bulb (Fig. 141). The stomach douche is passed in the usual way, and the bulb (aspirat- ing) joins it to the fountain syringe, which contains the irrigating fluid at a temperature of iooF. Clip X is previously closed. The tube is pinched tightly at A , and the clip then opened. By squeezing the bulb B, all air is driven out through the fountain syringe C. The bulb is then released and fills with fluid. This prevents air from entering the stomach. The finger releases the tube at A and the fluid begins to flow into the stomach ; and by intermittent pressure of bulb (B) the spraying effect can be intensified at the will of the operator. When the douching is completed, the bulb is detached from the fountain syringe and with pressure of the 1 Saraml. klin. Vortrage, New Series, No. 103. LOCAL TREATMENT OF THE STOMACH 213 same the thumb over the end slight aspiration is commenced and the contents will then siphon out. In Fig. 142 is illustrated the Y-method of spraying the stomach. The technic is the same as the similar procedure in lavage. In Fig. 143 the use of the alternate hot and cold douche, with the pres- sure bulb, is depicted. The addition of the bulb enables one to employ the spray without distending the stomach with air, and to reach much further than with simple hydrostatic pressure. When stronger medicaments are employed, CLIP BULB 'Ml BUCKET Fig. 143. The alternate douche. the rapid emptying of the stomach within one to two minutes and im- mediate lavage eliminate all danger, especially in view of the fact that by the compression method of spraying much less fluid is required, as com- pared with the older procedures. The temperature of the fluid should be about iooF. When stimulat- ing effects are required, it could be 105 to ii5F. if cold, at 75 to 8oF. when used with the alternate douche. In atony, with or without commencing dilatation, the douche method, employing in all not over Y 2 pint to i> pints, is at times of service to stimulate the organ. With this exception, I rarely use it. 214 DISEASES OF THE STOMACH AND INTESTINES Gastric Spray. This consists of an ordinary spray apparatus with a double bulb, to which is attached a soft Nelaton tube 70 cm. long; within this is a fine central flexible tube, which connects the inner capillary tube with the nozzle (Fig. 144). Einhorn, 1 who devised the tube, recommends it highly, as thereby one employs a small amount of fluid to secure results; and hence there is less danger when toxic or irritating substances are used. The spray should be employed when the patient has fasted or after a previous lavage. The bottle is filled with the required amount of the antiseptic solution, the tube dipped in warm water, and introduced in the usual manner. The patient should hold the tube at the lips and the operator steady the bottle and compress the bulb. The spraying should be begun when the tube has entered to the mark (about 16 inches). It can be forced further in. Einhorn advocates it to disinfect the mucous membrane of the stomach; Fig. 144. Einhorn's gastric spray. for the application of astringents; and to relieve pain in gastralgia, as from ulcer, cicatrix, or cancer. It is recommended in erosions of the stomach; in chronic gastritis, with marked production of mucus; in hypersecretion and hyperacidity, and in gastralgia. Riegel holds that the necessary insufflation of air distends the stomach, and on this account it is objectionable. I have found the weak spray, i : 5000 nitrate of silver or argyrol or protargol i : 2500, of value in gastralgia and in the treatment of erosions. STOMACH POWDER-BLOWER A dry method for spraying the stomach with insoluble substances (powders) has been devised by Einhorn. 2 His instrument consists of a flexible rubber tube about 28 inches long (Fig. 145), the distal end of which connects with an air suction-bulb. 1 New York Medical Journal, Sept. 17, 1892. 2 New York Medical Journal, April i, 1899. LOCAL TREATMENT OF THE STOMACH 215 - Fig. 145 i, The stomach powder-blower: a, the tubing part; b, connection with the bulb; c, hard-rubber end with screw thread for capsule; 2, the capsule-shaped powder receptacles (natural size); 3, the small spoon for putting the powder into the capsule. Fig. 146. New model powder-blower. 2l6 DISEASES OF THE STOMACH AND INTESTINES The extremity of the tube is attached to a hard-rubber piece c, which is hollow and has lateral openings. It is provided with a screw thread. To this is attached a capsule with numerous side holes. Capsules of several sizes are furnished. A capsule is filled with powder and screwed on to the tip piece. A small spoon is employed to fill the capsule. It is well to lubricate the latter with a thin layer of vaselin to prevent entrance of moisture. The tube is then dropped into warm water and inserted into the stomach in the usual manner. The bulb is quickly compressed several times and the air drives out the powder, opening up the vaselin layer over the holes. It has been recommended for ulcer of the stomach, employing bismuth subnitrate; in gastralgia, orthoform; and in erosions, protargol or supra- renal powder. I would not care to advocate the passage of the instrument in ulcer, but in tlie other conditions it is at times of service. Recently Einhorn has modified this instrument (Fig. 146). There is a double bulb with a. stop-cock. This is last closed. Bulb a is compressed several times, thus overdistending bulb b, which is without valves. The stop-cock is opened and a single blast of air distributes the powder: about 15 gr. (i.o) is the capacity of the capsule. ELECTRICITY From clinical experience it is found that the electric current exercises an influence on the secretory and motor functions of the stomach and also on its sensibility. Physiologic experiments and clinical experience do not always agree. Meltzer, experimenting on animals, passed strong induced currents through the fundus of the organ and noted no contraction of the pylorus. The influence of the anesthetic or of morphin or similar drugs would in- fluence the experiment. Pepper demonstrated on a very thin patient that percutaneous electricity produced no peristaltic movements in the stomach. It is believed that it is through contraction of the abdominal muscles that this procedure influences the musculature of the stomach. The two methods for the application of the galvanic and faradic current are the percutaneous and the intra ventricular. The latter seems preferable from a therapeutic standpoint, but the former is easier and is more readily sub- mitted to by the patient. Percutaneous Method. Von Ziemssen employs two large plate- electrodes, one anteriorly between the pylorus and fundus, and the other from the fundus to spinal column, with a separating space of only 2 cm. The electrodes should be moistened, and sufficient current employed to cause strong contraction of the ' abdominal muscles. If smaller sponges are used, they can be moved about in these regions. The seance should last ten to fifteen minutes, and be carried out at first every other day, depending upon indications, which are the same as for the intragastric method. Intragastric Method. Kussmaul first suggested the internal applica- tion of electricity, and was the first to introduce the sound with a copper LOCAL TREATMENT OF THE STOMACH 217 wire and olive point into the stomach. Bardet improved upon this, and employed an electrode which did not touch the stomach wall, the circuit being established by filling the organ with water. Numerous intragastric electrodes have been devised, of which the most practical are Einhorn's, Lockwood's, and Bassler's. Lockwood's Electrode. This consists of a very small cable of con- ducting wire covered with rubber. The intragastric tip is olive pointed Fig. 147. Lockwood's intragastric electrode. and protected from the gastric mucous membrane by a rubber fenestrated capsule (Fig. 147). The instrument in appearance is much like his gastro- diaphane. It is easy of introduction and of such small caliber that it does not incommode the patient. A glass or two of water is administered on the empty stomach, and the instrument is passed along the roof of the mouth, like the stomach-tube, about 18 inches or, preferably, until the resistance of the stomach wall is encountered. It is then slightly withdrawn. The outer end of the instrument is furnished with a key Fig. 148. The deglutible stomach electrode. which is inserted into the negative pole of the battery. The sponge which is connected to tne positive pole is applied over the stomach. Einhorn's Deglutible Electrode. The intragastric tip is similar in construction to Lockwood's. The conducting wire is much more flexible than Lockwood's and is covered with thin rubber. It is not introduced by the operator, but swallowed by the patient, being similar in principle to the stomach bucket (Fig. 148), The key is connected to the cord of the negative pole of the battery. 2l8 DISEASES OF THE STOMACH AND INTESTINES The patient drinks about a glass of water. The deglutible electrode is placed on the root of the tongue, and the patient is directed to swallow more water, which carries the instrument into the stomach. A mark can be placed on the cord, about 20 inches from the electrode, to determine that it has reached the bottom of the stomach. The sponge is attached to the positive pole. If there is resistance to the withdrawal of the instrument, the patient should swallow to relieve the spasm. Bassler's Gastric Electrode. This instrument is practically a combina- tion of Figs. 147 and 148. It has the usual capsule with a cord-like conducting wire and also an introducer (Fig. 149). The latter is withdrawn after the introduction of the electrode. After the application is completed the electrode is removed by the flexible conducting cord. I have found Lockwood's electrode easy to introduce and unobjec- tionable to the patient. All are good instruments. Fig. 149. Bassler's gastric electrode. Gastrofaradization. Duration ten to twelve minutes. The intra- gastric electrode is attached to either pole with this current. A plate electrode connected with one pole is placed in the epigastric region for four or five minutes, and later a sponge. The electrode is then moved from left to right several times in the gastric region; and later, if marked constipation, from the caput coli to the sigmoid along the colon, and also over the umbilical region. The application over the stomach occupies about two minutes. The electrode is then placed to the left of the seventh dorsal vertebra for one to two minutes, and then returned to the front for the balance of the time. The current should be strong enough to cause contraction of the muscles, btit not produce pain. Appli- cation of the sponge to the intestines, occupies several minutes, in addition to the ten minutes over the stomach. Gastrogalvanization. Duration, eight to ten minutes. Contractions occur only at the make and break of the galvanic current. The strongest is the make with the negative, and the next the break with the positive. A small sponge electrode is placed on the epigastrium. The intragastric electrode is connected with the positive pole for the sedative effect with a constant current. It also contracts and hence decreases secretion. The LOCAL TREATMENT OF THE STOMACH 2IQ strength of the current should average 15 to 25 milliamperes. The full strength is not used at first. The application is two minutes to the epi- gastrium. It is then moved about over the gastric region for three to four minutes; then for one to two minutes in the dorsal region as described, and the balance of the period in the gastric region. There has been some dispute as to the effects of these currents and the indications for their use. In general we may say that direct faradization increases the gastric secretion, while galvanization decreases it. Faradization affects the musculature and galvanization the sensory field. The claims regarding increase in absorptive power from the use of electricity seem hardly to be substantiated, as it was so small as to be within normal limits. Therapeutics. The percutaneous method has proved of service in nervous anorexia and in motor insufficiency. The intragastric method is preferable when possible. It renders some patients more nervous, and in such should be avoided. Among the indications for gastrofaradization are: Atonic ectasia, atony, relaxation of the cardia and pylorus, and diminished secretion. For gastrogalvanization they are: Gastralgias, especially of nervous type, nervous anorexia, and hyperacidity. Faradization, however, has proved of benefit in gastric neuroses. Fig. 150. Tiirck's latest gyromele. Triphase Method. Hershell 1 recommends the polyphase or triphase method in which two electrodes are placed on the back and one on the abdomen or intragastrically. Static Electricity. This has been recommended especially in the atonic types of ectasia, claim being made that it causes contraction of the organ. In neuroses it is sometimes of service. Tousey 2 states that the motor functions are favorably influenced by the static indirect current. High-frequency Current. This method is scarcely applicable by the general practitioner, but I believe it of some benefit in gastric neuroses, in atony, and for hyperchlorhydria. On the other hand, others claim it will increase HC1 if deficient. Tousey recommends it further in chronic colitis, fissure, rectal ulcer and in incontinence of the sphincter. Occasionally it has proved of value in hemorrhoids. 1 Archives of the Roentgen Rays, 1906, 1907, vol. xxi, p. 221. 2 Medical Electricity and Roentgen Rays, p. 400. 220 DISEASES OF THE STOMACH AND INTESTINES Tiirck's 6-yromele. Tiirck has introduced this instrument for the local treatment of the stomach and colon. It consists of a cable with a sponge attachment, which can be made to revolve within an outer stomach- tube. There is an arrangement so that medicated fluids can flow into the stomach or colon through the outer tube, and also an attachment for a battery pole. He advocates its use for catarrhal gastritis to cleanse the mucous membrane. It can also be employed alone for internal massage of the stomach or combined with electricity. It is depicted in Fig. 150. The author questions its utility. CHAPTER IX MASSAGE VIBRATORY MASSAGE HYDROTHERAPY COUNTERIRRITATION ORTHOPEDIC APPLIANCES MASSAGE MASSAGE of the stomach is indicated in atony or in the atonic form of dilatation and temporarily to aid in the removal of gas. The intestines should also be manipulated in these conditions. It is of value in stimu- lating the abdominal muscles in gastroptosis. I will briefly refer to a few simple methods. If massage is performed on the absolutely empty stomach, it is con- tracted and cannot be palpated. It is preferable to perform it two or three hours after a meal. This aids in emptying the stomach. Earlier manipulation might cause vomiting. Contraindications are ulcer, recent hemorrhage, and acute inflam- mation. The patient should be in the dorsal position; lower limbs flexed. The left hand of the operator is placed on the right hypochondrium to exert counterpressure against the pyloric end. With the thumb and fingers extended, the right hand performs stroking motions from left to right over the stomach. Then the stomach is kneaded. These procedures should alternate. This technic should be carried out daily for five to ten minutes. With dilatation or ptosis of the stomach the direction of the stroking must be adapted to the position of the organ in each case. Tapping (tapotement) or rapid vibratory movements with the fingers can be employed. It is often well to rotate the patient to the right side during massage, so as to aid in emptying the atonic stomach. VIBRATORY MASSAGE Various vibrators, especially electric, many of which are quite expen- sive, have been devised for this purpose. Of late, vibrators can be pur- chased at a reasonable figure which can be attached to the street current 1 in the patient's residence. The method is very convenient when the facilities exist. There is an instrument run by carbonic acid gas pressure, which necessitates carrying a large tank. There is a small portable vibrator, the Vedee, manipulated by hand (Fig. 151), which is cheap, simple of manipulation, and efficacious. The strength of the vibration is regulated by changing the position of the rotating disk. The instru- ment can be employed, with the addition of electricity, by attaching a sponge arranged for battery connection and employing the other pole with a sponge over the abdomen. Electric vibratory massage can thus 1 The Eureka vibrator is convenient, having many excellent attachments 221 222 DISEASES OF THE STOMACH AND INTESTINES be given over the stomach and intestines (Fig. 152). In addition, one battery pole can be attached to the vibrator and the other to the intra- gastric electrode for treatment of atony of the stomach. Fig. 151. Vedee vibrator (new model). Fig. 152. Combined electricity and vibratory massage. There are other small hand vibrators now manufactured and also small vibrators which can be run by a portable storage battery. VIBRATORY MASSAGE 223 Fig. 153. Massage roller with demonstration of alternating hot and cold electric massage: a, Screw cap; b, filling tube; c, funnel for filling; d, attachment for battery pole. (Author's Instrument.) Fig. 154. Combined application of electricity and roller massage with heat. 224 Vibratory massage should be given from left to right over the stomach for about three minutes, then two minutes to the left of the seventh dorsal vertebra, and three minutes more over the stomach. This should be performed daily. It is generally advisable to vibrate the intestines, following the course of the colon, especially over the sigmoid, and also over the small intestines. This last can be done before breakfast to stimulate the bowels. Two or three hours later the stomach should be vibrated. The patient's, family can be taught to use this instrument. Bassler has recently devised an excellent vibrator, requiring the street current. For city practice a good electric vibrator is preferable. Massage Roller. Various instruments have been devised, but the following is simple. It consists of a revolving cylinder, which can be filled with hot or cold water, and which is furnished with a battery at- tachment. Heat or cold, or with an instrument attached to each battery pole, alternating heat and cold, combined with electricity, can be applied (Fig. 153). This method can be employed for abdominal massage in some cases of chronic constipation. I have found the method next depicted of some value in stimulating atonic conditions of the gastro-intestinal tract (Fig. 154). LOCAL HYDROTHERAPY Cold. For hemorrhage or acute inflammation, the ice-bag is prefer- able to the Leiter coil. At times it relieves ulcer pain more than does heat. Priessnitz's Compress. A towel folded several times is dipped in cold or warm water, then wrung out, and placed over the stomach. Oiled silk or gutta-percha is placed over it, and a flannel binder applied to keep it in place. A temperature of 50 to 75F. or warmer if desired can be employed. This method is of value in nearly all painful diseases of the stomach. The compress can be changed two or three times a day. Some patients do better with the cold, others with the warm compress. Hot Applications. Moist Heat. For cardialgia, ulcer, vomiting, etc., hot moist applications are of value, Poultices can be made of linseed, flaxseed, or br.an, boiled in water, or of hot bread and milk. I have seen, hot meal or hot mashed potatoes used in country practice. The poultice is wrapped in gauze or cheese-cloth and applied as hot as the patient can bear it. Fresh hot poultices are continually applied. There is an apparatus which can be boiled in water, wrapped in a cloth, and then applied over the cataplasm. It will keep it constantly hot. A felt sponge dipped in boiling water, wrung out, and covered with oiled silk can be employed. Dry Heat. The hot-water bag, hot cloths, a light tin pie-plate, heated in the oven and covered with flannel, the Japanese hot box containing burning punk, are all useful. A continuous hot-water coil has been devised, to be connected with a faucet. In the illustration (Fig. 155) is shown a continuous steam coil 1 of my 1 Enteroclysis, Hypodermoclysis, and Infusion, 1900. ORTHOPEDIC METHODS 225 own. The steam passes through a metal coil plate and is recondensed. Only a small quantity of water is necessary in the boiler. The tempera- ture can be regulated by the coverings of the plate and by the stop-cocks on the Y-branch at the top of the boiler, thus allowing less steam to enter the coil. The coil can be placed over a moist poultice to preserve its heat. In general, moist compresses are preferable. The Douche. The fan-douche and the Scotch douche, played over the stomach region, alternating cold 55F. and warm 95F. for about three minutes, may have a tonic effect. Packs, rubs, baths, and the carbonated bath are at times employed for the general tonic effect. Fig. 155. Continuous steam coil for the application of heat. COUNTERIRRITATION Mustard and flour poultice (equal parts), or black or red pepper, i dram (4.0) to the pint (500 c.c.) of boiling water, flannel to be wet therein, wrung out, and applied with an oiled silk cover or a turpentine stupe, prepared by the same method; also spice poultices are of service. The clay poultice (cataplasma kaolini) sold also as antiphlogistine is useful at times. ORTHOPEDIC METHODS Mechanical support of the stomach and intestines is of great service. Many nervous symptoms referred to the gastro-intestinal tract can be imputed to ptosis of the viscera and relaxation of the abdominal walls. In simple atony of this tract the proper support frequently aids the bowel action. 15 226 DISEASES OF THE STOMACH AND INTESTINES The indications for mechanical support are as follows: Ptosis of any or all of the viscera from any cause; atony of the stomach ; atonic dilatation of the stomach; stenotic ectasia as a temporary measure; Fig. 156. Pattern for cutting the Rose plaster abdominal binder: Dotted lines for section. Fig. 157. Pattern for cutting the Rose plaster abdominal binder: Plaster after section. atony of the intestines; pains from intraabdominal adhesions dragging on the viscera; hernia of the abdominal wall; after laparotomy as a tem- porary support; postpartum to prevent ptosis (Landau's disease), and Fig. 158. Rose's belt (under plaster): Step one. Fig. 159. Rose's belt: Step two, left wing. also to enable the patient to sit up in bed earlier and so drain the uterus. This last was suggested by me to Douglas H. Stewart, who has reported successful results. Cases of constipation in which atony is a factor. ORTHOPEDIC METHODS 227 Fig. i6p. Rose's belt: Complete. Fig. 161. Dorsal view: Under plaster with overlapping ends (Rose and Kemp). 228 DISEASES OF THE STOMACH AND INTESTINES Pelvic disturbances which are associated with splanchnoptosis and result from general prolapse. Mucous colic in which ptosis is a factor. Pendu- lous abdomen, vomiting of pertussis (T. W. Kilmer), sea-sickness, and nervous vomiting. There are four methods: The use of adhesive plaster, the most scien- tific; elastic bandages, special corsets, and the Lane model supporting pad with springs. To A. Rose we must credit the best method of adhesive strapping. The author first suggested the use of zinc oxid on moleskin plaster, from experiments finding it most suitable, and this was adopted by the origi- Fig. 162. Dorsal view: Plaster dressing complete (Rose and Kemp). nator of the method. For a full description I would refer to our work on this subject. 1 The method is as follows: Adhesive plaster, zinc oxid on soft mole- skin (Johnson and Johnson), preferably 7 inches wide, though 6 inches can be employed. A yard in length will suffice in most cases. The circumference of each patient should be measured, and the plaster should be long enough to encircle the waist. Rose has recently recommended a German white rubber plaster (Leukoplast) spread on moleskin or canvas. I can see no advantage. The plaster is folded over so that the free ends 1 Rose and Kemp, Atonia Gastrica. ORTHOPEDIC METHODS 22Q are in line and a curved line drawn in pencil from the lower margin of the point where it folds to the free margin, to about i inch below the upper border. The plaster is cut along this line, giving three pieces; or Fig. 163. Application of narrow strips of adhesive plaster: First step. Fig. 164. Application of plaster: Sec- ond step. the plaster is stretched out and the dotted lines marked, as in Fig. 156, and cut along these lines, giving three pieces, / and the two lateral pieces, II, III, as in Fig. 157. Fig. 165. Application completed. 7 is applied to the abdomen, and the lateral pieces, //, ///, overlap in front and are applied to the under plaster. These serve to draw up the abdomen. 230 DISEASES OF THE STOMACH AND INTESTINES To avoid irritation of the umbilicus, I cut a V out of the upper border of the under plaster or invert a small portion of it. The sharp angle below should be cut off to avoid interference with the pubic hair. The curved portion of the lateral wings should look upward and somewhat inward and adhere to the lower ribs. The sharp angles of the lateral wings at the symphysis may also be cut off to avoid the hair. Hair, if present on the abdomen, is shaved and the surface cleaned with ether or chloroform. The plaster is applied with the patient in the dorsal position, with hips well elevated and preferably in the Trendelenburg position. Of late the writer has augmented the upward pressure of the belt by Fig. 166. Front view: Step one. Fig. 168. Front view. Belt complete. Figs. 166-168. Rosewater adhesive plaster belt (Rose and Kemp). an oblique strip 2 inches wide from the median line in front to the spine behind on each side. These strips should overlap slightly over the abdomen. They are held firmly in front by two short transverse strips which also cause additional pressure. To secure additional upward lift, a two-inch strip of plaster is applied from just inside the crest of the right ilium in a downward direction toward the midsymphysis (adherent to the other plaster) and then exerting an upward pull, it is gradually curved upward to a similar level inside the left iliac crest. Extra cross strips are applied to hold it firmly. In the illustrations (Figs. 158 160) are shown the three stages of application of the belt, the under plaster, one wing applied, and the ORTHOPEDIC METHODS 231 Fig. 169. Kilmer's belt stockinet band: Step one. VI ./ Fig. 1 70. Kilmer's belt (complete) : Elastic webbing, front. 232 DISEASES OF THE STOMACH AND INTESTINES complete contrivance. In Figs. 161 and 162 are shown the rear view during application. The plaster should remain on for four to six weeks, depending on the season of the year, irritation (which is rare), or its loosening. It should then be removed, a full bath given, talcum dusted on, and twenty-four hours later a new belt applied. Oil of wintergreen, applied to adhesive plaster, aids its easy and pain- less removal. One can also apply to the plaster a 10 per cent. 1 winter- green oil ointment. Fig. 171. Kilmer's belt (complete): Elastic webbing, rear. One patient sent me by Wm. H. Thomson, a severe case of splanchno- ptosis, wore the belt fourteen months, gained 40 pounds in weight, and was completely cured. The device gives brilliant results. The method of support by a pad for the special organ is unscientific. Only on occasions, when the material for Rose's belt was not at hand, have I applied a method with narrow strips of plaster, as depicted in Figs. 163-165. They overlap at the linea alba in front and at the spine behind. As the final procedure, two transverse strips are applied in front. 1 Beardsley, Jour. Amer. Med. Assoc., Jan. 28, 1911. ORTHOPEDIC METHODS 233 I T~~\ Fig. 172. Improved belt (front). 1 Fig. 173. Improved belt (rear). 234 DISEASES OF THE STOMACH AND INTESTINES Rosewater Adhesive Belt. A strip of zinc oxid plaster of sufficient length and 2 to 3 inches wide is fastened to the abdomen just above the pubes. This is drawn upon upward and fastened above to the lower end of the sternum. Diagonal strips crossing the lower end of the vertical strip, overlapping behind at the spine, are then applied (Figs. 166 and 167). A horizontal strip is fastened to one hip and stretched across the pubes Fig. 174. Teufel's abdominal supporter. to the other hip, overlapping the ends of the other plaster and acting as an additional girdle (Fig. 168). Plaster strapping affords continuous support during treatment which other methods do not. Numerous modifications, with and without eyelet holes for lacing, have been devised, but those described are the most practical. Fig. 175. Abdominal supporter. Fig. 176. Abdominal supporter. Kilmer's Abdominal Belt. An ingenious belt was devised some years ago by T. W. Kilmer for the relief of vomiting in pertussis. The original belt consisted of a stockinet band applied as in Fig. 169. Around this was wound a strip of silk elastic webbing, which could be pinned or sewed on, as in Figs. 170 and 171. The apparatus extends from just above the hips and symphysis well up on the thorax. The relief of vomiting and cough is quite remarkable in pertussis. ORTHOPEDIC METHODS 235 Recently, Kilmer reports a simplified belt made of linen, with strips of elastic webbing inserted on either side. It laces up the back (Figs. 172 and 173). The belt should measure slightly less (2 to 3 inches) than the circum- ference at the navel. The degree of constriction should be determined in every case. This belt is valuable for the prevention of seasickness, for nervous vomiting, and as an abdominal support. The cost is slight. 177. Lane's abdominal supporter (Curtis Spring Pad). Silk Elastic Belts. Various types of silk elastic belts are employed as pictured in Figs. 174-176. Storm's abdominal supporter is also excellent. Sir Arbuthnott Lane's abdominal supporter (the Curtis spring pad), a broad leather pad which exerts upward pressure from the symphysis to the umbilicus is depicted in Figs. 177 and 178. It is held in position by springs similar to those employed in a truss extending on each side to Fig. 178. Lane's abdominal supporter in position. the spine. He employs it in cases of enteroptosis with kinks and intes- tinal stasis treated medically. Special Corsets. A valuable support of this type is that of E. Gal- lant, which is depicted under Gastroptosis. The La Grecque surgical corset is also useful, and is illustrated in the same chapter. The latter is frequently employed by the writer. 1 Archives of Pediatrics, February, 1907. CHAPTER X CATARRH OF THE STOMACH ACUTE AND CHRONIC GASTRITIS Acute Gastritis ACUTE gastritis may be defined as an acute inflammation of the gastric mucous membrane with resulting disturbances of digestion. It is of different degrees of severity, being limited to the superficial layer of the mucous membrane, or it may extend to the glandular parenchyma or involve the interstitial tissues. It is subdivided into simple acute gastritis, toxic gastritis, and phleg- monous gastritis. Simple Acute Gastritis (Synonyms. Acute Gastric Catarrh; Acute Gastric Dyspepsia.) Etiology. Simple .acute gastric catarrh is one of the most frequent diseases met with by physicians. It occurs in all classes of society and at all ages. It may be primary or secondary to another disease. One of its frequent causes is some irritant, mechanic, chemic, or thermal; thus, errors in diet, or too large a quantity of food that has been im- perfectly masticated or rapidly bolted; too hot or too cold food or drink; too highly spiced or fermented foods; rancid butter; unripe or spoiled fruit; spoiled food or drink, or overindulgence in alcohol. Fermentation or putrefaction are most apt to occur in food during the summer, and these factors probably account for the epidemics occurring at that season, though infection has been suggested. Such cases generally occur as gastro-enteritis. Bacterial infection of food may be a cause, as the colon bacillus in milk, or meat, or sausage poisoning. Primary mycosis of the stomach, the favus fungus; schizomycetes ; parasites, as the larvae of flies (myiasis); ascarides, oxyuris and taenia, by entering the stomach, and abdominal burns are rare causes. Acute catarrhal or suppurative conditions of the nose and throat may produce acute gastritis from the ingestion of discharges. Pyorrhea alveolaris and poor teeth may be factors. I have recently seen one such case, and the patient, suffering from acute gastritis, cured by treatment of the source. Some persons have a predisposition to a "weak stomach," and this condition seems almost to be hereditary. Others have been trained to such a simple diet, as the children of dyspeptics, that the stomach cannot perform its normal amount of work and readily becomes irritated. In old persons, invalids, or anemic women the organ is readily affected. Acute gastritis may be secondary to the acute infectious diseases, such as measles, typhoid, variola, pneumonia, etc., or as a sequel of acute nephritis. I have seen an attack follow prolonged anesthesia. 236 CATARRH OP THE STOMACH 237 A diphtheritic or membranous gastritis has been met with in diph- theria, anthrax, or as a secondary process in typhoid, typhus, pneumonia, etc. It cannot be diagnosed unless the membranes are vomited. Diffuse acute gastritis is reported to have occurred with syphilis. Morbid Anatomy. Acute gastritis is characterized by an acute in- flammation of the superficial layers of the mucosa, with an increased secretion of mucus and a desquamation of the epithelial cells. The mucous membrane is reddened and swollen, less gastric juice is secreted, and mucus covers the surface. The swelling is diffuse or in circumscribed areas. There are sometimes slight hemorrhages and small erosions or sacculations of the mucous membrane. The sub- mucosa may be edematous. The pyloric end is more frequently affected. Fig. 179. Acute gastritis: Round-celled infiltration in the interglandular struc- ture. Dark clumps represent hemorrhagic areas. (From Bassler's Diseases of the Stomach and Upper Alimentary Tract." Copyright, 1910, by F. A. Davis Company.) Gastric secretion is weakly acid, neutral, or even alkaline and diminished in quantity. Beaumont, from his observations on St. Martin, has given an excellent description. Microscopic. The superficial epithelial layer is partially loosened or in a condition of cloudy swelling. The parietal and principal cells can- not be distinguished apart; they are granular and in a condition of cloudy swelling and fatty degeneration, and are shrunken. The capillaries are dilated and round cells are found in the interglandular tissue, between the epithelial cells and on the surface (Fig. 179). Karyokinesis may be present. Bacteria are commonly found present, of which the most frequent types are the Bacillus lactis aerogenes, Bacillus coli communis, proteus vulgaris, o'idium albicans, and streptococci. 238 DISEASES OF THE STOMACH AND INTESTINES Symptoms. These vary according to the severity of the attack. There are loss of appetite, discomfort, fulness or pressure in the region of the stomach, belching of gas which may taste sour, and occasional nausea. In some cases there are no rise of temperature and no vomit- ing, and the symptoms pass off in a day or two; the bowels are costive or diarrhea is present. In more severe cases there are pains in the gastric region, headache, nausea, vomiting (prolonged and excessive), first of food, then chiefly of mucus, at times streaked with blood, and frequently bilious vomiting. There may be considerable prostration. Often there is an acid taste in the mouth. There is generally a temperature, sometimes rising to 102 to io4F., and at times chills, and the tongue is usually coated and swollen. The pulse is frequently rapid and feeble. In the cases due to ingestion of spoiled food, etc., auto-intoxication undoubtedly results and aggravates the symptoms. Vomiting usually follows the introduction of the irritant, but is some- times delayed for some hours, and food is found that was ingested twelve or fifteen hours before, a condition of acute motor insufficiency. Consti- pation or diarrhea is present. The early vomitus often has a disagree- able odor and contains food remnants. The reaction is slightly acid and free hydrochloric acid is often absent. Lactic and other organic acids are at times present. Occasionally a duodenitis with jaundice is associated. Herpes labialis is quite frequent. Physical Examination. The region of the stomach is usually distended and sensitive, and may be tender on pressure. Urine is scanty, dark in color, of high specific gravity, urates are marked, and occasionally indican and albumin are present. Duration. This is usually short, from two to three days, though at times prolonged to a week. Diagnosis. Some of the infectious diseases, notably scarlatina, begin like the febrile form of acute gastritis, and one should always be on the watch for such an occurrence. In rare cases the symptoms are intensely severe, headache and even delirium being so marked as to have been mistaken for meningitis. In the latter case, Kernig's sign can be elicited and lumbar puncture is an aid to diagnosis. In biliary colic, with acute vomiting, the pain -radiates to the right side or right shoulder, and pain over the gall-bladder is present. In cholecystitis, with or without calculi, with little or no pain and no jaundice, but vomiting, the diagnosis is more difficult. The previous history, tenderness over the gall-bladder, and the presence of leukocytosis, especially the increase in the polynuclears, are significant. Hyperchlor- hydria is frequently associated. The presence of Head's gall-bladder zone of cutaneous algesia aids diagnosis. With peritonitis, we have muscular rigidity, leukocytosis, increased polynuclears, marked abdominal tenderness, and distention. With nervous gastralgia, the material vomited is usually very acid (hyperchlorhydria), no mucus, and there is the nervous history. Gastrosuccorkea has been occasionally diagnosed incorrectly as bilious CATARRH OF THE STOMACH 239 vomiting. Hypersecretion occurs most frequently at night; the vomitus is very acid, a high content of HC1. With bilious vomiting (gastro- enteritis) the vomitus is weakly acid, neutral or even alkaline and contains bile. Reichmann's test may furthermore be employed to dif- ferentiate. Wash out the stomach on retiring -withhold all food and drink. On aspiration of stomach twelve hours later 50 to 125 c.c. of acid gastric contents are obtained diagnostic of hypersecretion. With typhoid fever, we have the gradual rise of temperature, increas- ing daily, the splenic enlargement, frequently the eruption, often bron- chitis, Ehrlich's diazo and the Widal reactions; while with acute gastritis the rise of temperature is sudden and the fall equally sudden, and there are the absence of splenic enlargement and other symptoms. When jaundice is associated with acute gastritis, the duodenum has evidently become involved. The gastric crises of locomotor ataxia have been mistaken for acute gastritis, but the absence of knee-jerks, the Rom- berg symptom, and Argyll-Robertson pupil are diagnostic of tabes. Prognosis. This is favorable, except in very old people, infants and invalids. Treatment. Prophylaxis. In patients subject to attacks of acute gastritis, excess in eating, rich food, lobster, food and drink that are too hot or cold, or any articles for which they have an idiosyncrasy should be forbidden. Candy and cake should not be allowed. Unripe and dirty fruit should be avoided. With infants, care should be taken as to the storage of milk and its preparation. If the acute gastritis be due to ingestion of improper food, there are two principles to follow: Clear out the gastro-intestinal tract and give rest to the stomach. If there are other factors, the first consideration does not apply. In all cases rest in bed should be enjoined. In the mild cases, with nausea but no vomiting, castor oil, i to iH ounces (32.0-48.0); or, if there is doubt of this being retained, then calomel, 2 to 5 grains (0.125-0.3), or blue mass, 5 grains (0.3), followed in twelve hours by a saline, such as a wineglass of Apenta, or citrate of magnesia (wineglass), or magnesium sulphate, i to 2 drams (4.0- 8.0), should be administered. Laxol, a preparation of castor oil without the disagreeable taste (practically castor oil 5 i with oil of cinnamon gtts. 5~x), is often well borne in the same dosage as castor oil. If much nausea, calomel, Ho grain (0.006), with sodium bicarbonate, H grain (0.0325), every hour for eight or ten doses is useful, followed by a saline cathartic. Other combinations are given shortly. Children should receive proportionately small doses of cathartics. For eructation of acid fluid (pyrosis), bismuth subnitrate, 3 grains (0.2), with sodium bicarbonate, 3 grains (0.2), every hour or two; or magnesia usta, Y* ounce (16.0), with sodium bicarbonate, % ounce (16.0), dose as much as covers the point of a knife, every three hours. For nausea or vomiting, oxalate of cerium, i grain (0.065), every hour for several doses, or bismuth subnitrate, 2 to 4 grains (0.125-0.25), alone, or with sodium bicarbonate, same dose; or gelatin (i per cent, solution, dose i dram (4.0), every hour, given cold; or milk, 8 ounces (250.0 c.c.), with oxalate cerium, 10 grains (0.6) and sodium bicarbonate, 240 DISEASES OF THE STOMACH AND INTESTINES 10 grains (0.6), packed in ice; dose, i dram (4.0) every hour; or Fowler's solution of arsenic, i minim (0.06), every hour for four doses, are of value. This last is very efficacious. Teaspoonful doses of very hot water or, occasionally, a piece of cracked ice, or white of raw egg beaten up and given cold in i-dram doses (4.0), every half-hour to an hour, are useful. Cocain, carbolic acid, or creosote I strongly deprecate. Heat should be applied to the abdomen. Application of Heat. A hot-water bag, one-third full to avoid weight; a Japanese hot box, a light hot salt-bag, a thin tin pie-plate heated in the oven and covered with flannel; or moist heat by means of a flaxseed poultice, hot mashed potato, or bread poultice in country practice; mus- tard and flour poultice (equal parts) ; or black or red pepper poultice i dram (4.0) to i pint (500 c.c.) of boiling water and wring out flannel in the same and apply, covering with oiled silk. If the discomfort is marked, then give warm salt water, > to i dram (2.0-4.0) of salt. to 8 ounces (250 c.c.) of water, and tickle the fauces to promote vomiting, or perform lavage. Small doses of hot water may be given to relieve thirst and food should be avoided for twenty-four hours. If small quantities of nourishment be given, I have found i ounce (32.0) doses every hour of a 5 per cent, gelatin solution (in a glass packed in ice) of special value, or small quantities of milk and lime-water (equal parts), or peptonized milk or koumiss or albumen water, or egg white, beaten up cold. In severer cases, the stomach should be emptied, preferably by lavage, i to 2 ounces (32.0-64.0) of Phillips' milk of magnesia to 2 quarts (liters) of warm water being excellent for this purpose. Plain warm water or normal salt solution may be employed. I frequently administer calomel, 3 to 5 grains (0.2-0.3), and sodium bicarbonate, 5 grains (0.3), in a little water, through the stomach-tube after lavage before withdrawal of the tube. This is generally retained, with resulting thorough clearing of the bowels. Saline solution should not be employed for lavage if calomel is thus given. Later an enema of a saturated solution 2 to 3 ounces (64.0-96.0) of magnesium sulphate, or a recurrent enteroclysis with normal saline solution at noF. should be administered (several quarts liters), or a soapsuds enema, i quart (liter), containing olive oil, 6 ounces (200 c.c.), may be substituted. Even if the calomel be omitted, it is of great im- portance to move the bowels. If the case is not due to ingestion of irritating food, then bismuth subnitrate, oxalate of cerium, a few doses of Ho grain (0.006) of calomel every hour, sodium bicarbonate, etc., may be tried for a brief period; and if these fail, lavage should be performed. Gelatin solution or white of egg often are of value in such cases. If jaundice is associated due to a complicating duodenitis, as soon as vomiting is relieved by lavage treatment for this condition should be instituted and remedies should be given to liquefy the bile. Those em- ployed for cholecystitis or cholelithiasis are of service. Generally the writer begins with soda bicarbonate 5 SS m vichy twice or three times CATARRH OF THE STOMACH 241 daily. The salicylates are of service such as sodium salicylate gr. 3-5 t.i.d. in capsules. The best form to administer them are as probilin pills. The formula is as follows : 1$. Acid salicylic gm. 2 Natr olein gm. 8 Natr stear gm. 4 No. i Phenolphthalein gm. i Camph. menth gm. 3 J Ft. pill. No. TOO. Three to four pills are given morning and night. Some administer them with a pint of hot water but the writer prefers to give them directly after meals or two to three pills t.i.d.; oleic acidTfl.. v t.i.d. in soft gelatin capsules is also of service. If infection of the gall-bladder complicate, hexamethylenamin gr. v to gr. x t.i.d. is a valuable adjunct, given with an equal amount of sodium benzoate. This is also a good prophylactic against infection and I usually give it. Apply heat to epigastrium and give saline irrigations cool 80 or 9oF. or hot at ii5F., of the bowel. No. 2 fy Bile-salts (Fairchild) gr. i i This may be Succinate of soda gr. 5 I substituted Phenolphthalein gr. J^ J for No. i . One capsule t.i.d. and at bedtime can be substituted or else succinate of soda gr. v t.i.d. The following is also excellent: 5i No. 3 J$. Sodium glycocholate 5i Sodium salicylate grs. 75 Pancreatin grs. 150 Sodium bicarbonate grs. 150 M., Dir. in capsule No. 90. Sig. Two to three capsules t.i.d. after meals. Phosphate of soda or sprudel salts (powder) 5i~5ii> may be alter- nated once every day or apenta or some other saline cathartic water. For several weeks, once a week give blue mass gr. 3~v. The insertion of the duodenal tube and lavage of the small intestine with a quart of normal saline solution in which 5 s s-5i of sodium bicar- bonate has been dissolved may be of benefit in obstinate cases of jaundice (obstructive) due to catarrhal duodenitis. The alkali helps dissolve the mucus. This procedure may be carried out every other day, or less frequently. The solution is allowed to flow slowly into the duodenum and is not siphoned out but should wash through the intestine. The temperature of the solution should be 101 to 103 F. Enteroclysis (recurrent) with normal saline solution or high enemata i quart at a temperature of 115 to i2oF. should be given daily. Some do better with cold enemata at 70 to 8oF. but if there is renal disturb- ance, heat is preferable. Diet. This should consist of milk and vichy, mixed, zoolak, koumyss, lactone buttermilk, rice gruel and barley gruel, until marked improvement occurs, when toast, chicken broth, oyster broth, boiled rice, crackers, toast baked in the oven, raw and soft boiled eggs may be added, with a 16 242 DISEASES OF THE STOMACH AND INTESTINES gradual return to full diet. The disappearance of bile from the urine shows that the obstruction to the exit of bile has ceased. The conjunctivae and skin take longer to clear up that is, for the coloring matter to absorb. The urine should frequently therefore be carefully examined as to the presence of bile. With bilious vomiting, lavage should be employed at once, as there is practically reversed peristalsis with an open pylorus, and the con- tinuous accumulation of bile in the inflamed stomach keeps up the vomit- ing. Enteroclysis should be used after lavage (within one hour) to promote normal peristalsis. It may be necessary to wash the stomach several times, but it is the best method to check vomiting. In the severe cases, due to ingestion of improper food, it is my opinion that calomel should be given directly after lavage, even though some of it be vomijted, as auto-intoxication is a factor, in which event plain water should be used for lavage. In addition to the milk of magnesia, if tne vomitus is very foul, I add 10 grains (0.6) resorcin to the fluid for lavage and wash with the patient both in the erect and lying-down position. I do not care for apomorphin, Ho grain (0.006), ipecac, or tartar emetic to empty the stomach. ; If there is considerable prostration, enemata of hot normal salt solu- tion (ii5-i2oF.) and strychnin by hypodermic % Q to Ko grain (0.00108-0.002) may be necessary, or even 5 grains (0.3) camphor in 20 minims almond oil by hypodermic. In rare cases, when there has been much vomiting and the patient is exhausted, codein, ^ to ^ grain (0.008-0.016), by hypodermic, or the same amount of morphin may be used. I sometimes employ a single dose after lavage to quiet the patient. A suppository i grain (0.064) opium, or y grain (0.016) morphin with % grain (0.021) extract bella- donna may be substituted. Diet. Entire abstinence from food during the first twenty-four hours or longer is preferable; nutritive enemata may be given and injections (rectal) of hot saline solution to relieve thirst. For the latter, i-dram (4.0) doses of hot water by mouth, or of a cold i to 2 per cent, gelatin solution are preferable to cracked ice. The gelatin seems to have an excellent effect. Proctoclysis is also excellent for the same purpose. Later, small doses of cold gelatin (5 per cent, solution) or milk and lime-water (equal parts) can be given, or milk, 8 ounces (250 c.c.), with sodium bicarbonate, 10 grains (0.6), and cerium oxalate, 10 grains (0.6), in y?,- to i-ounce (16.0-32.0) doses, given cold, every two or three hours. White of egg beaten up and given cold; barley-water alone or with milk (equal parts); rice gruel, very thin, made from rice flour (Park and Tilford) with milk may be added. Later, add eggs (soft boiled), scraped raw beef, pigeon (boiled), calves' brains, zwieback, broths, soups, bouillon, boiled chicken, and gradually increase to full diet. If after the acute attack has subsided the patient suffer from a feeling CATARRH OF THE STOMACH 243 of pressure and discomfort, dilute hydrochloric acid may be given to aid digestion. !$. Acid, hydrochlor. dilut : Siiss (10.0); Aq. destil q. s. ad. 5ij (60.0). Sig. 3j to ij (4.0-8.0), in water, t.i.d. The same, combined with small doses of tincture of nux vomica, 5 minims (0.3) in each dose, or with compound tincture of cinchona, 10 minims (0.6) in each dose, may be given. These remedies should be administered one-half hour after meals or the same time before. Oxyntin capsules with nux vomica, one to two capsules t.i.d., a. c. or p. c., are an excellent substitute. TOXIC GASTRITIS Etiology. This most intense form of inflammation of the stomach is caused by the swallowing of concentrated mineral acids or strong alkalis, or by poisons, such as phosphorus or arsenic. Among such acids are nitric, sulphuric, hydrochloric, oxalic, and carbolic; the caustic alkalis; as caustic potash, caustic soda, soap lees, and strong ammonia; alcohol, phosphorus, arsenic, potassium cyanid, corrosive sublimate, and potas- sium chlorate. The effects are more severe on the empty stomach. Croton oil may also produce this condition. Anatomy. The acids and alkalis destroy the parts they come in contact with, causing various degrees of sloughing of the mucous mem- brane. They may penetrate the submucosa or the entire stomach wall and produce perforative peritonitis. Alcohol, phosphorus, or arsenic cause an acute inflammation of severe type, the mucous membrane becoming swollen and superficially necrotic, with hemorrhagic spots in the submucosa, and there is fatty degeneration of the epithelia of the glandular tubuli. Symptoms. There is intense pain in the gastric region, Violent and burning in character, and increased on pressure; and frequently pain in the pharynx and esophagus (along the sternum). There are salivation, diffi- culty in swallowing, and usually vomiting, constant and repeated, which fails to relieve the pain. This is generally immediate, though not always so. There may be food remnants in the vomit, mucus, streaks of blood, and even shreds of mucous membrane. The abdomen is tender, at times distended, though occasionally contracted. Symptoms of collapse often appear, the face is pale and anxious, the skin pale and extremely cold, pulse rapid and feeble, respiration rapid and shallow. There are restless- ness and sometimes convulsions. Albumin and blood often are present in the urine and petechiae under the skin. The writer has recently seen a fatal case of bichlorid poison- ing with marked hemorrhagic tendency, subcutaneous, intestinal, and gastric. Peritonitis, shock, or respiratory or cardiac failure may cause the fatal issue. Some cases are more protracted. There may be jaundice or hema- turia, or intestinal ulceration, or degeneration of the liver or kidneys. 244 DISEASES OF THE STOMACH AND INTESTINES Phosphorus poisoning may produce hemorrhagic jaundice and symptoms simulating acute yellow atrophy of the liver. Stricture of the esophagus, pylorus, or cardiac orifice of the stomach may result from the damaged mucous membrane, with corresponding symptoms, such as dilatation of the stomach, etc. In rare cases atrophy of the mucous membrane (achylia gastrica) follows, or hour-glass stomach, or perigastric adhesions. Diagnosis is usually easy. The sudden appearance of violent gastric symptoms in a perfectly healthy subject should excite suspicion. Inspection of the lips, mouth, and tongue will show the effect of corro- sive poison, if such have been taken, and examination of the vomitus and odor of the breath may afford information. Inspection, if possible, of the receptacle from which the substance was taken, and examination of the latter, if any remain, are important. The patient often gives a clear history. Prognosis. It is best to give a guarded prognosis even in apparently favorable cases. Treatment. There are certain cardinal rules to follow in the treat- ment of toxic gastritis: first, administer fluid to dilute the poison, and at the same time give an antidote; empty the stomach as rapidly as possible, preferably by lavage; administer demulcents; stimulate the patient and give a cathartic to clear the poison from the bowels. 1 Though some advise against lavage in poisoning from acids and alkalis for fear of perforating the stomach, there is far greater danger of perfora- tion by leaving the poison in the organ, with the additional risk of cardiac or respiratory failure, or subsequent damage to the intestines or other viscera. Lavage by siphonage of the stomach is indicated in all cases of poison- ing. Warm water at about ioiF. should be employed, and the organ washed until thoroughly clean. Any bland fluid, such as tea, coffee, soup, water, or milk, can be used in an emergency to dilute the poison and wash the stomach. A gastric siphon can be improvised from a fountain syringe by re- moving the tip and clip and rounding the edges of the extremity; or from a kitchen funnel and rubber tube of small caliber. If lavage be impossible, then give a pint of lukewarm water with 2 drams (8.0) of mustard dissolved therein, or warm salt water, and tickle the fauces with the finger or a feather. I have used a small rubber tube or large hat feather in emergency, pushing them into the esophagus and working them up and down to promote emesis. Apomorphin, Ho grain (0.006), by hypodermic; zinc sulphate, 30 grains (2.0), in 4 ounces (30.0) of water; copper sulphate, 5 grains (0.3), providing these latter were not the poisons ingested; or syrup of ipecac, i to 3 drams (4.0-12.0), can be employed. Among useful demulcents are whites of raw eggs, milk, olive oil, barley- water, flour boiled with water, and gum-arabic water. Fats and oils should be avoided in phosphorus-poisoning. The subsequent treatment is of acute gastritis, enteritis, and of special symptoms. 1 Strychnine or camphor oil by hypodermic may be required. CATARRH OF THE STOMACH 245 Antidotes. For Acid Poisoning. Alkalis, such as calcined magnesia; powdered chalk in water; sodium carbonate (washing soda), dilute; potassium carbonate; sodium or magnesium sulphate, J^ ounce (16.0), in water; Carlsbad salts; soapsuds in water. Soda bicarbonate, i ounce (16.0), or, if nothing else is at hand, plaster scraped from the wall, dissolved in water, 8 ounces (250 c.c.), can be employed. For Carbolic Acid. Alcohol (95 per cent.), i to 3 ounces (32.0-96.0); raw whiskey or brandy, or liquor with a large percentage of alcohol. The alkalis can be used subsequently or alone if alcohol or liquors are not obtainable. For Caustic A Ikalis. Dilute acids, such as dilute vinegar or lemon juice; tartar or citric acid. For Tartar Emetic and Antimony and Its Compounds. Tannic acid or strong tea. For Arsenic and Its Compounds. Tincture of perchlorid of iron, i> ounces (48.0) in a wineglass of water, add ^ ounce (16.0) sodium carbonate (washing soda) in half-tumbler of water, mix, and administer. This renders insoluble about 5 grains (0.3) of arsenic. Repeat dose, or give dialyzed iron, tablespoonful doses. For Copper Salts. Potassium ferrocyanid, i dram (4.0) to 4 ounces (125 c.c.) of water, forms insoluble copper cyanid. For lodin, lodids, and lodoform. Starch solution in cold water; sodium bicarbonate; lead acetate, 2 drams (8.0) in 4 ounces (125 c.c.) of water. For Lead and Its Salts. Magnesium or sodium sulphate, i ounce or more, or dilute sulphuric acid, 30 minims (2.0), in water. For Mercury and Its Salts (Corrosive Sublimate, etc.). White of raw egg; milk; form albuminate. . For Silver Nitrate. Salt solution, teaspoon of salt in water, 4 ounces (125.0). For Zinc Salts. Sodium or potassium carbonate; tannic acid; tea; white of egg; milk. For Phosphorus (Rat Paste, Matches). Copper sulphate, 3 to 5 grains (0.2-0.3), m 4 ounces (125 c.c.) of water, a number of doses; forms in- soluble phosphid of copper and acts as an emetic; old French turpentine. Avoid oils, fats, milk, and yolks of eggs. Avoid American or German turpentine. For Alcohol. Ammonium carbonate, 3 grains (0.2), in water. The stomach should receive rest after immediate treatment. Pain may be relieved by local heat, or codein or morphin, % to y grain (0.008- o.o 1 6), hypodermically. Large doses of bismuth subnitrate may be given if the bowels continue irritable. Retention, or suppression of urine must be watched for. For the former catheterize; in the latter case, entero- clysis, with hot normal salt solution at 115 to i2oF. Hypodermoclysis and proctoclysis are also useful. Stenosis of the esophagus may be dilated if possible; if stenosis of the pylorus, appropriate treatment as for gastric dilatation temporarily, and then subsequent operation. If atrophy of the gastric mucosa result, the treatment is for achylia gastrica. For perfora- 246 DISEASES OF THE STOMACH AND INTESTINES tive peritonitis operation is indicated. For uremic poisoning from bi- chloride, section of the kidney capsules has been advised. PHLEGMONOUS GASTRITIS (Synonyms. Suppurative Inflammation of the Stomach; Gastritis Phlegmonosa; Abscess of the Stomach.) This is a rare disease and usually runs an acute course, though oc- casionally subacute. The process begins in the submucosa and some- times extends to the muscular coat, and at times to the mucous or serous coats. It is more frequent in men. It is primary or idiopathic, due to some microorganism, especially the streptococcus, probably entering Fig. 1 80. Phlegmonous gastritis: i, Gastric mucosa infiltrated with pus-cells in the interglandular tissue; 2, submucosa thickened and infiltrated;. 3, purulent col- lection oozing out on section; 4, fat tissue. (From Bassler's "Diseases of the Stomach and Upper Alimentary Tract." Copyright, 1910, by F. A. Davis Company.) through some solution of continuity in the mucous membrane, such as a gastric ulcer or the erosions of achlorhydria hemorrhagica gastrica. Pyorrhea alveolaris or the colon bacillus may be responsible in some cases. It may be secondary (metastatic), due to pyemia, puerperal infection, or the exanthemata. Errors in diet, alcoholic excess, trauma, etc., have been given as causes, but probably only are contributory by depressing the system. Trauma- tism might cause damage to the mucosa and render infection more easy. Schnarwyler 1 has tabulated 83 cases, Robinson 2 reports 8 additional cases and Baird 3 has contributed more recently on this subject. f. Verdaurgetev Bull., 1906, xii. 2 Journ. A. M. A., Dec. 26, 1909, p. 2143. 3 Amer. Jour. Med. Sci., Nov., 1911, p. 6488. CATARRH OF THE STOMACH 247 Age. Cases have been reported from ten years of age to eighty-five. It is probably most frequent in early adult and middle life. There are two forms met with: a diffuse purulent infiltration and a circumscribed abscess. Morbid Anatomy. In the diffuse type a large area of the submucosa is frequently involved. It is thickened, infiltrated with pus, and multiple small abscesses are often present (Fig. 180). The pyloric end is more frequently attacked. The muscular wall is often involved or the pus* may burrow through to the peritoneum. The mucosa is usually also affected and is swollen, and there is granular degeneration of the gland cells. Perforation of the mucosa may occur. In the abscess type there is generally a single circumscribed abscess of variable size, starting in the submucosa and involving the muscular layer. The mucosa and serosa are often involved. It may terminate favorably by perforating into the stomach (a rare event) or perforate into the peritoneal cavity. Symptoms. The patient may have for a brief period a few dyspeptic symptoms, such as loss of appetite, thirst, and some burning in the stomach, but these are usually absent. The attack is generally of an acute fulminating type: Severe pain or burning in the gastric region, a rapid rise of temperature to 103 to io5F., with slight intermissions; frequently chills; often vomiting of mucus, bile, and food remnants, but no pus, unless the abscess breaks into the stomach, which is a rare event. The area over the stomach is very sensitive to pressure and there is some tympanites. There is constipation or, more usually, diarrhea. The pulse is rapid and feeble, occasionally there is jaundice. The patient presents all the aspects of a severe infection, with delirium and coma preceding death. The blood examination shows leukocytosis with increase in the polynuclears. There is muscular rigidity, in the upper quadrant of the abdomen, of the recti muscles, due to peritoneal irritation, even before perforation occurs. This is a valuable sign. With general peritonitis we have the usual symptoms pain, distention, general tenderness on pressure, etc. With a circumscribed abscess the tenderness is more localized, the symptoms not so severe, and the duration longer. Percussion and palpation may locate the process if localized. Duration. Three or four days, rarely one to two weeks. Diagnosis. The temperature, chills, fulminating character, leuko- cytosis, and early recognition of muscular rigidity all point to an acute suppurative process. Abscess of the liver and subphrenic abscess are not of such acute type. Acute cholecystitis and acute pancreatitis are more apt to be confounded with abscess of the stomach. With acute pancreatitis the temperature at first may be low, tym- panites is earlier and more marked, and there are circumscribed tender- ness in the course of the pancreas 1 and tender spots throughout the ab- domen (Fitz). Hemorrhages from the mucous membranes and subcu- taneously occur and there is jaundice. Constipation is usual; also the tenderness at Kobwin's point is present. 248 DISEASES OF THE STOMACH AND INTESTINES symptoms may resemble intestinal obstruction. Abscess of the pancreas is slower in its course and there is a longer history. Acute cholecystitis is a much more frequent condition than phleg- monous gastritis. The gall-bladder can at times be palpated, is tender, and we have the previous history. Treatment. Laparotomy is advised, both to settle the diagnosis and afford relief if possible. Should this not be consented to, then the ice- bag, rectal feeding, enteroclysis to relieve tympanites, protoclysis for sep- sis and thirst, and opiates are indicated. 1 Bovee 2 reports a case with operation and recovery. CHRONIC GASTRITIS (Synonyms. Chronic Gastric Catarrh; Chronic Dyspepsia.) Definition. A chronic inflammation of the mucous membrane of the stomach, with the production of mucus and changes in the gastric juice, causing disturbances in the act of digestion. Etiology. This disease is more frequent in men than in women. It may follow the acute type, especially after recurrences of this condition. The same irritating agents that cause acute gastritis can produce the chronic type when acting for a long period of time; notably, fast eating with imperfect mastication, overloading the stomach, indigestible food, highly spiced dishes, cold drinks in excess, overrich food, excessive use of tea or coffee, and overindulgence in alcohol (the so-called " drunkards' catarrh"); excessive use of tobacco, especially in tobacco-chewers and those who indulge in dry smoking (chewing the cigar-butt), an unhealthy condition of the mouth or teeth, and swallowing the products of decom- position. Habitual use of drugs may be a cause. Discharges from the nose or ear through the Eustachian tube, which are then swallowed, have been factors in several cases that I have ob- served. Thrush may cause mold in the stomach. Chronic gastritis may be secondary to the acute infectious diseases, such as typhoid fever. It is frequently associated with cancer of the stomach and is often present in the atonic type of dilatation of the stomach. It may be secondary to cirrhosis of the liver, pulmonary or cardiac disease, and chronic nephritis and syphilis. Among constitutional causes are gout, diabetes, leukemia, and severe anemia. Classification. Chronic catarrhal gastritis may be classified as follows : 1. Acid gastritis (gastritis hyperpeptica, hypersthenic gastritis), or acid catarrh of the stomach, first described by Boas. This is considered on the borderline and to be the initial stage of chronic gastritis. There is an increase in the hydrochloric acid to a variable degree, at times only slight, and Boas believes this occasionally occurs in the early stages of chronic gastritis. There is also the presence of mucus. 2. Chronic catarrhal gastritis, under which is described mucous gas- tritis (Ewald), which is merely a severe type with great secretion of mucus. 1 Strychnine and camphor by hypodermic may be' required as stimulants. - Amer. Jour. Med. Sci., May, 1908. CATARRH OF THE STOMACH 249 We must remember that occasionally from a long-continued chronic gastritis, other conditions may arise. (a) There may be a great thickening of the mucosa (hyperplasia), so as to produce thick folds, the so-called etat mamelonne, and this, combined with swelling of the mucosa, causes benign stenosis of the py- lorus; or sometimes wart-like excrescences (gastritis polyposa) develop, which, if situated at the pylorus, can produce partial obstruction a benign stenosis, with dilatation of the stomach; or a proliferation of interstitial tissue occurs and muscular hypertrophy, with resulting hypertrophic stenosis of the pylorus. Chronic gastritis may, therefore, produce and have associated with it benign pyloric stenosis and dilatation of the stomach. (6) On the other hand, a degeneration or atrophy of the muscular fibers due to hyperplasia of the connective tissues may cause atony, and atonic dilatation of the stomach may result, and these conditions will improve with the improvement of the gastritis. They only occur in the more advanced cases. In the patients whom we are called upon to treat, the stomach is usually of normal size, non- atonic, and with normal or slightly diminished motor functions. 3. Atrophic gastritis (Anadenia ventriculi, Ewald), an atrophy of the mucous lining of the stomach, can result from chronic gastritis. Of these, there are two forms: (a) Phthisis ventriculi, a thinning of the coats of the organ, which may remain of normal size or be increased in size. (6) Cirrhosis, or sclerosis ventriculi, an enormous thickening of the muscular coat and a great reduction in the volume of the stomach. Atrophic gastritis is described under Achylia gastrica. Morbid Anatomy of Chronic Catarrhal Gastritis. The mucous mem- brane is yellowish-gray or slate-gray in color, and in secondary catarrhal conditions produced by congestion may, in some parts, be intensely red. It is swollen, thickened, and covered with a closely adherent tenacious mucus, which is usually cloudy and gray in color, due to various cells, epithelia, and leukocytes, and occasionally it is tinged with blood. En- larged veins, patches of ecchymosis, and small hemorrhagic erosions may be present. The mucosa in some instances forms papillary projections (etat mamelonne). The pyloric portion is usually involved, though the inflammation may extend over the entire mucosa. The submucosa and muscular coats are at times hypertrophied or atrophied. Microscopically the following conditions appear: The glands are enlarged, sacculated, and dilated in cyst-like forms, the tubuli in many places being atypic and branching like the fingers of a glove; the gland- cells are cloudy, granular, and in a condition of fatty degeneration, and the principal and parietal cells cannot be differentiated. Abundant small cell infiltration presses the glands apart, being especially marked toward the surface of the mucosa. Extensions of connective tissue may be seen passing from the mucosa between the glands. The mouths of the glands are at times filled with mucus which projects against the lumen. Mucoid transformation of the cells of the tubuli is a striking feature and 250 DISEASES OF THE STOMACH AND INTESTINES may extend to the fundus of the glands and cells. Mucoid degeneration may replace the principal and parietal cells. The mucus fills part of these cells, or may crowd the protoplasm and nucleus against the base, or rupture the cell-membrane and escape into the duct of the gland. The pyloric region is usually thus affected. After a long period the inflammatory process may lead to a total destruction of the glandular layer, or atrophy of the mucous membrane of the stomach Anadenia ventriculi (Ewald). Of this there are two forms, as heretofore noted: (a) Phthisis ventriculi, atrophy of the stomach, or Anadenia ventriculi is a thinning of the coat of the stomach, with a retention of, or usually an increase in the size of the organ (dilatation). There are fatty de- generation and destruction of the glands, the process progressing from the surface of the stomach inwardly. In the early stage no glands are found, but glandular cysts are present near the submucosa. Later these disappear and the mucous membrane consists chiefly of round cells. The submucosa is changed and the muscular layer is thinner. (b) In cirrhosis, or sclerosis ventriculi, the stomach coats are thickened and there is a great reduction in the volume of the organ; in some cases it is no larger than a pear and the walls may be 2 to 3 cm. in thickness, the greatest increase being in the submucosa, where the process starts. The inflammatory process causes the formation of fibrous tissue, which progresses from the submucosa to the surface, spreading around the glands, constricting them, and finally replaces them with fibrous tissue. The hypertrophy extends to the muscular layer. This condition may cqexist in the cecum and colon and so be difficult to distinguish from diffuse carcinoma. Proliferative peritonitis with periphepatitis and ascites are at times associated. Atrophy of the gastric mucosa is described under Achylia gastrica. Symptoms of Chronic Gastritis. These develop slowly; the appetite diminishes or is irregular or easily satiated. There is a feeling of fulness or pressure in the gastric region after eating. Occasionally heartburn or cardialgia in the epigastrium or precordial region or behind the sternum occurs, generally at the height of digestion; while with hyperchlorhydria it is present late or on an empty stomach. Discomfort or pain on pressure over the stomach is present. Belching of gas is the most frequent symptom and it is usually odorless; water-brash (pyrosis), a bitter or a tasteless t fluid, may be brought up into the mouth (regurgitation) ; the stomach and intestines are often markedly distended with gas. Nausea is frequently present and occasionally vomiting. When the latter occurs, it is frequent in the morning, when the stomach is empty, and consists chiefly of slimy mucus, and sometimes of partly digested food of the previous day with mucus. It may take place after breakfast. There is a sour, bad, or salty taste in the mouth. The patient in some cases complains of palpitation and shortness of breath (dyspeptic asthma or, more correctly, dyspnea). The pulse is small and sometimes slow. There are fulness in the head, insomnia, lack of energy, and dis- taste for work. Dizziness may be present. Sensation of fear, depres- sion, melancholia, or hypochondriasis occur in some patients. The CATARRH OF THE STOMACH 251 tongue is usually covered with a thick gray moist fur, though not always so, and it cannot be said to be characteristic. The margins are at times indented. Odor of the breath is present when there is disease of the mouth or teeth or atony of the stomach with fermentation. Headache is quite common and a desire to yawn. There is at times the so-called stomach- cough, doubtless due to pharyngeal irritation. The patient's appearance may be quite good and he may preserve his weight. In severe cases he looks quite badly, and shows black rings under his eyes, has cold hands and feet, and chills easily. Some even lose considerable weight and become thin and emaciated. In the severe types with nervous symptoms, intestinal fermentation or putrefaction are often present and auto-intoxication is undoubtedly a factor. The bowels are, as a rule, constipated; though occasionally diarrhea or diarrhea alternating with constipation are present. Occasionally there may be an associated duodentis with jaundice. Physical Examination. Inspection. The gastric region appears bloated. Percussion. Tympanites is present, but the stomach is usually in the normal position. Palpation. The gastric region is in some sensitive to pressure; ten- derness is rather diffuse. No real pain or sense of resistance. Splashing sound can be produced if liquid and gas are present. It is only abnormal if found at a time when the stomach should be empty. It would then show atony. If found in an abnormal position (low), it is an evidence of dilatation or ptosis. With movable kidney ptosis can be diagnosed. Urine is scanty; contains phosphatic and urate deposits. Indican may be present. Specific gravity is increased. Diagnosis. The presence of gastric mucus in the stomach contents is the chief diagnostic point in chronic gastritis, so that examination of the vomitus or, preferably, of the gastric contents after a test-breakfast is imperative. The diagnosis should not be made from clinical symptoms alone. Gastric Contents. One hour after Ewald's test-breakfast or the one I employ 2 slices (60 grams) of bread without butter and 350-400 c.c. of water the contents of the stomach are withdrawn. The following are the conditions found present: Total acidity is diminished; free hydrochloric acid is markedly les- sened or is small in amount or absent; pepsin and rennet are present, but diminished; erythrodextrin present in small quantities; a chroodextrin and sugar abundant; quantity of gastric contents frequently normal (under loo c.c.) or may be slightly more (100 to 150 c.c.), which last would show some motor insufficiency. The pieces of roll are not as fine as normally, but larger and coarser. Mucus is usually intimately mixed with the food remnants and is adherent to the morsels of food. The stomach-contents are thick, tough, and sticky, and difficult to filter. A glass rod dipped into them and lifted up will draw up strings of mucus with it. Acetic acid added to the filtrate produces turbidity. 2$2 DISEASES OF THE STOMACH AND INTESTINES Mucus that has been swallowed is never mixed -with the food remnants, but floats as isolated balls on the surface. Mucus in some cases is in large amount, while there may be very little in others. In the latter event, lavage of the empty stomach will determine its presence, in shreds or flakes. In the fasting condition there are often only a few cubic centimeters of turbid liquid in the stomach, consisting chiefly of mucus of an alkaline, neutral, or slightly acid reaction. If no contents can be thus secured, lavage again will show the mucus. The vomitus shows the same characteristics already described, but the examination by the test-breakfast is more accurate. Microscopically. Mucus, round cells, and epithelial cells are found to be present. In doubtful cases the microscope may differentiate the types of mucus. If squamous epithelia be mixed with it, it probably comes from the mouth or pharynx; if pigmented alveolar epithelia, probably from the air-passages. Columnar epithelia mixed with mucus show it is gastric. With acid gastritis we find the total acidity and free hydrochloric acid slightly increased and the presence of mucus. I had recently a case in which the total acidity averaged 90+ and free hydrochloric acid 70+, with a large amount of mucus. The so-called cases of mucous gastritis merely contain an excessive amount of mucus, with little or no hydrochloric acid. With atrophic gastritis there is absence of hydrochloric acid, absence of pepsin, and absence of rennet, as described under Achylia gastrica. If dilatation be present, we have the physical signs of such. Einhorn finds small shreds of the mucosa present in the wash-water of some cases of chronic gastritis, due, as he believes, to erosions. Motor function may be normal or slightly diminished, so that the ingesta escape before fermentation can occur. This is the usual course in the ordinary type of case. In some cases with hypertrophy the motor function may^ be increased. If atony or dilatation is present, there are motor insufficiency and fermentation. In those with excessive mucus production, the action of the saliva and gastric juice is interfered with, and, though the motor function is good, the ingesta passes into the intestines with little change, and intestinal fermentation or putrefaction results. Absorption. This depends on the severity of the case; in milder cases, with the iodid of potassium test, it seems, normal; in severe cases it is interfered with. Course. The duration of chronic gastritis is long, often extending over many years. Marked improvement may take place, but relapses are apt to occur from indiscretions. Milder cases can be permanently cured. Differential Diagnosis. Chronic Gastritis. No severe pain; no cir- cumscribed spot painful to pressure; no hematemesis; no cachexia; no marked emaciation, except in severe cases of long duration; free HC1 diminished or absent; gastric mucus present; slow course. CATARRH OF THE STOMACH 253 Ulcer of the Stomach. Hydrochlorhydria present, but not invariably so; severe pain in the epigastrium, with intervals free from pain when the stomach is empty; local tenderness which is circumscribed; dorsal pain, hematemesis, or occult blood in the stool or gastric contents; microscopic pus; no mucus; patient has appearance of suffering; no true cachexia. X-ray findings of such. Cancer. Age, usually over forty-five; rapid course; free HC1 usually markedly diminished or absent; lactic acid present; mucus sometimes present; pain generally continuous, but not as acute as in ulcer; Boas- Oppler bacillus; cachexia; tumor on physical examination; small amount of blood or occult blood present in gastric contents; microscopic pus; blood or occult blood in the stool; hematemesis much less than ulcer; foul odor to vomitus at times present. X-ray findings of such. Achylia Castrica. Slow course; scarcely any gastric juice; acidity very low (2+ to 4+); absence of HC1; absence of pepsin; absence of rennet; usually no mucus; no lactic acid. In the early stage (transi- tional) Riegel holds that mucus may at times be present. Achlorhydria Haemorrhagica Gastrica. This is frequently a reflex from a diseased appendix or gall-bladder. Large numbers of bacteria, most frequently streptococci or colon bacilli, are present in the gastric contents. Free hydrochloric acid is absent. Occult blood from erosions is present in the gastric contents. The amount recovered after the test-breakfast is usually less than that ingested, and the bread is in a coarse state of division, practically as when swallowed, and thin mucus is incorporated with it. The contents when aspirated vary from a yellow tinge to a light orange. Total acidity is 6+ to 8+. Pain occurs in about one-third the cases directly after food, but may be present at other times. Vomiting of a sour taste occurs in about half the cases and nausea is frequent. These patients generally have periods of depression alternating with nervous excitement. Constipation is usual. Pylorospasm usually is present which, together with the erosions, often accounts for the pain. The condition is in most cases a reflex disturbance of gastric secretion (absence of hydrochloric acid) with a secondary invasion of the stomach by microorganisms and ultimately erosions of the mucosa. It has also been found secondary to infectious diseases and other conditions, and cure of the primary disease has usually resulted in the cure of the gastric lesion. Gastric Neuroses. Symptoms not uniform; character of food makes little difference; indigestible food may be well borne and digestible food may cause symptoms; no gastric mucus; HC1 may be diminished or in some cases normal or increased, and the gastric findings often vary at different times in the same patient. Subjective symptoms are sometimes similar to chronic gastritis, but they disappear and reappear abruptly. Prognosis. Some cases can be cured ; many improved. Relapses may occur. The affection is frequently a tedious one. Treatment. This may be divided into: (i) Prophylaxis. (2) Hygiene. (3) Local treatment of the stomach. (4) Diet. (5) Mineral springs. (6) Medication. Acid Gastritis. The borderline cases, acid gastritis, should receive the 254 DISEASES OF THE STOMACH AND INTESTINES treatment of hyperchlorhydria; also occasional lavage to remove mucus, say, twice a week, is advisable. In a recent case I have employed it daily, using several ounces of milk of magnesia (Phillips) to the quart of water. Extract of belladonna, H grain or tinct. belladonna 10 gtts. (0.022), t.i.d. before meals, and magnesia usta and soda bicarbonate, da, 10 grains (0.6), combined with resorcin resub., 5 grains (0.3), in water, or the magnesia and soda 5ss doses, or soda bicarb. 5ss t.i.d. alone, an hour after meals are excellent. Milk of magnesia, i to 2 drams (4.0-8.0), is also of value. 1. Prophylaxis, Unquestionably, repeated attacks of mild so-called acute dyspepsia (acute gastritis) may ultimately lead to the development of chronic gastritis. The causes of both conditions are practically the same. The patient, therefore, should masticate thoroughly, avoid bolt- ing the food, overindulgence in alcohol, tobacco, very hot or very cold food and drink, indigestible food, etc. He should rest for fifteen to thirty minutes after meals before returning to business. The mouth and teeth should be kept in good condition ; and if there are aural or nasal discharges escaping into the mouth, or tonsillar or pharyngeal inflammation, treat- ment should be instituted. Cardiac disease should be treated with cardiac stimulants, especially if there is failing compensation; and diseases of the liver and kidney should receive appropriate diet and treatment, so as to lessen the chances of secondary gastritis. 2. Hygiene. Slow eating, with subsequent rest; exercise, preferably in the open air, driving, golf, rowing, walking, and horseback all of which should be carried out in a leisurely manner and not overdone, so as to exhaust the patient, are useful. Moderate gymnastic exercises five or ten minutes daily, as with an exerciser, with open windows, are of value. Avoid badly ventilated rooms and sleep with the windows open. Cold salt-water sponging morning and night, followed by friction with a rough towel, is of service. If the patient is excessively nervous, change of climate may be necessary. 3. Local Treatment. The removal of the mucus is of importance. This can be done by two methods: By administering alkaline remedies that will dissolve the mucus and by lavage. In mild cases lavage is not always necessary, and the use of alkalis is of service. They should be administered about an hour before breakfast and, if necessary, also before luncheon and dinner. For example, in 6 to 8 ounces (200 to 250 c.c.) of hot water, soda bicarbonate, 30 grains to i dram (2.0-4.0), or lime-water, K ounce (16.0), or milk of magnesia (Phillips), i to 2 drams (4.0 to 8.0). Magnesia usta, 30 grains to i dram (2.0 to 4.0), is of use, alone or combined with equal quantities of soda bicarbonate. Penzoldt has demonstrated that mucus will adhere to bismuth. The late A. Rose suggested a tablet consisting of 10 grains (0.6) magnesia CATARRH OF THE STOMACH 255 usta and 10 grains (0.6) bismuth subnitrate, to be chewed with a full glass of water one hour before meals; or two tablets, if required. The magnesia usta, milk of magnesia, or soda bicarbonate are especially useful. Lavage. When the mucous secretion is more marked, lavage should be substituted; or if a mild case does not improve by the above method. This should be employed on the empty stomach before breakfast, so as to aid subsequent digestion. An alkali should preferably be added to the fluid to dissolve the mucus. The stomach should be washed with the patient both sitting and lying down and turning on the sides, to remove all mucus possible, and washed until the outflow is clear. The following are excellent: Milk of magnesia (Phillips), i to 2 ounces (30.0 to 60.0) to the quart (liter); or lime-water the same quantity; or soda bicarbonate, i to 2 drams (4.0 to 8.0); or magnesia usta, i to 4 drams (4.0 to 8.0) -all to the quart (liter). Normal saline solution i dram (4.0) salt to water i pint (50x3 c.c.) or boric acid, i dram (4.0) to the quart (liter), may be employed. I use normal saline solution combined, preferably, with milk of mag- nesia or magnesia usta. Fleiner mixes 2 parts sodium chlorid and i part soda bicarbonate and employs i dram (4.0) to 2 to 3 quarts (liters) of water. Frequency of Lavage. Once a day before breakfast is often sufficient; in some cases it may be necessary to repeat it before supper. If there is dilatation with fermentation, resorcin (resub.), 10 to 20 grains (o.o to 1.3), or the same quantity of salicylic acid or sodium salicylate; or gomenol, 15 drops to % dram (i.o to 2.0); or potassium permanganate, 5 grains (0.3); or listerin, glycothymolin, or borolyptol, i dram (4.0) all to the quart (liter), can be employed. In such event, I wash with the alkali in the morning to remove mucus, and with the antifermentative at night. In some cases, lavage with nitrate of silver (i : 5000 to i : 2000) or protargol or argyrol (i : 2000) is of value, used every two or three days, preceded by warm water lavage, to first remove mucus. No saline should be used in the silver nitrate solution. Saline solution may subsequently be used if the silver cause pain or irritation. Pepper, in place of this, advocates an aqueous solution of silver nitrate; dose, % to y grain (0.008-0.016) internally, three times a day for a short period. This should be kept in a dark bottle. Electricity. Unless atony with lessened motor function of the stomach, or severe subjective symptoms, with little mucus are present, electricity is of no practical value. When there is little mucus, it may aid to stimulate gastric secre- tion. In such event the intragastric method is preferable to the per- cutaneous. Removal of the mucus is of the first importance. Electricity, however, is of service applied to the abdomen to increase intestinal peristalsis. Massage. Vibratory Massage. The same holds true of these methods. They are also of value over the intestines to promote peristalsis. 256 DISEASES OF THE STOMACH AND INTESTINES Hydr other apy. In sensitive cases hot water compresses applied to the stomach are useful. 4. Diet. This is an important feature, and its character depends on the severity of the symptoms. It is always preferable to give four or five light meals than three full meals a day. In severe cases give food in liquid and semiliquid form (mushes), such as milk or matzoon with Vichy, kumiss, bacillac, lactone-buttermilk, barley, oatmeal, or rice soups prepared with milk; or chicken soup or bouillon, with raw egg beaten up; somatose, plasmon, or tropon can be added to the soups. Later, soft-boiled eggs, mashed potatoes, rice gruel, scraped raw or broiled beef, toast baked in the oven, stale bread (white), butter, cocoa, weak tea, barley gruel, oatmeal gruel, hominy and other cereals and purees. The diet should be mixed, the albumin somewhat reduced; the car- bohydrates should be given in suitable form, avoiding those that contain too much cellulose. Peas should be passed through a sieve to remove the skins. Fats, such as butter and cream, are especially necessary, when there is loss of nutrition. In the latter case I feed by the "scales," endeavoring to put on weight, improve assimilation, and at the same time ameliorate symptoms. The mere estimate of requisite calories and feeding by this method alone is of no value, as each patient is a rule to himself. For example: In severe cases, give at first liquids and mushes. 8.00 A. M. Milk, one glass, with 2 ounces (about 125 c.c.) of lime- water, or peptonized milk, 8 ounces (about 250 c.c.). 10.30 A. M. Matzoon and Vichy equal parts, in all 6 to 8 ounces (200-250 c.c.). 1.30 P. M. Oatmeal soup or chicken soup, with an egg beaten in, 8 ounces (250 c.c.). 4.00 P. M. Same as at 10.30 A. M. 6.30 P. M. Same as at 8.00 A. M. 9.30 P. M. Milk and Vichy equal parts, in all 8 ounces (250 c.c.). Additions can gradually be made to this diet. Milk, however, does not agree with some, and soups and broths must be substituted. The following diet is useful in many cases for a week or two, but must be modified to suit the individual: Calories 8.00 A. M. i cup cocoa or tea, about two-thirds milk, approximately. 100 1 lump of sugar 40 2 soft-boiled eggs 165 2 ounces zwieback, or toast, or stale white bread (2 slices). 150 M ounce butter 115 10.30 A. M. 8 ounces (250 c.c.) koumiss, matzoon, or milk. 168 2 ounces crackers or somatose biscuit 150 ft ounce butter 115 i.oo P. M. 2 ounces of steak, chicken, or chop 70 3 ounces of mashed potatoes or rice 130 2 ounces white bread (stale), or toast, or zwieback 150 i cup tea, about two-thirds milk, approximately 100 Vt ounce butter 115 CATARRH OF THE STOMACH 257 Calories 4.00 A. M. 7 ounces (250 c.c.) milk, mixed with i ounce top-cream. . 210 1 ounce crackers 100 H ounce butter 100 6.30 P. M. 8 ounces (250 c.c.) hominy, rice, or cereal boiled in milk. 450 2 scrambled or poached eggs 165 2 slices bread (average about 2 ounces) 150 K 1 ounce butter 115 2858 The above is for about three weeks, and the diet of each patient should later correspond, as nearly as possible, to the usual mode of living. There are things which it is necessary to forbid, such as fried food; meat with tough fibers or that is too old or too fresh, pork, sausages; lobster, salmon; chicken salad; mayonnaise; cucumbers, fresh tomatoes, pickles, corn, radishes, raw celery, cabbage; hot breads, brown and Graham bread; also fresh bread and all alcoholic beverages, which last I believe do special harm to the inflamed mucous membrane. Foods which disagree should be interdicted. Sugar should be taken in small quantity and avoided by some. Soda-water and candy are forbidden; also hot and cold drinks, and ice-cream. Veal, as a rule, in this country is interdicted, as it is often tough. Salt is of value, as it aids the production of HC1. Beef, mutton, lamb, chicken, potatoes, hominy, rice, oatmeal, spinach, lettuce, asparagus, eggs, etc., are all admissible. Water should be taken in small amounts during the meal. Smoking. Excessive smoking should be stopped. It is chiefly the tobacco juice from chewing the cigar, carried by the saliva, that damages the mucous membrane of the stomach; chewing tobacco should be forbidden. // a cigar-holder or cigarette-holder be employed, I can see no objection to two cigars or four cigarettes a day; otherwise it should be interdicted. If there is nasopharyngeal catarrh, smoking should be stopped. 5. Mineral Waters. These dissolve the gastric mucus, hasten the emptying of the stomach, and often stimulate the mucosa. On account of the rest and regular life and diet the springs are often preferable, though the waters may be taken at home. The most useful are the saline and the saline-alkaline waters. (a) Saline Springs. These contain chiefly sodium chlorid and varying quantities of carbonic acid gas, and stimulate the secretion of hydrochloric acid. The most notable are Kissengen, Homburg, Wies- baden, Soden and Saratoga (Congress Spring). Dose, glass of mineral water on arising. (6) Alkaline-saline Springs. These contain sulphate of soda, sodium bicarbonate, sodium chlorid, and carbonic acid gas. The Carlsbad Springs are the most famous. Marienbad and Saratoga (Hawthorne Spring) belong to this group, also Glauber's Salt Springs and Glauber's salts. One can employ the imported Carlsbad salts or Glauber's salts and 17 258 DISEASES OF THE STOMACH AND INTESTINES by adding sodium bicarbonate to Glauber's salts imitate imported waters more closely. Wolff's formula for artificial Carlsbad salts: fy Sulphate of soda 30.0 Sulphate of potassium 5.0 Sodium chlorid 30 . o Carbonate of soda 25 .o Biborate of soda 10 . o. M. Sig. i to i dram (2.0-4.0) in warm water before breakfast. The Alkaline-Saline springs are of value for the solution of large quantities of mucus and for constipation. Care should be taken not to purge the patient excessively, and nervous cases do not take them especially well. 6. Medication. The methods described will often be sufficient, but medication is of service as an accessory. Leube was the first to recommend the use of dilute hydrochloric acid to supplement this deficiency of the gastric juice. Ewald advised the use of large amounts, 40 to 60 drops, taken in divided doses three times a day after meals. For example: The entire dose in a glass of water and commenc- ing one-half hour after meals, a third of this being taken every fifteen minutes. I prefer a smaller dose, from 15 to 20 drops, in a small glass of water three times a day one-half hour after meals, and taken in three divided doses, as advised by Ewald. This is impossible to pursue with some patients, as they will not devote the time; so in such an event a single dose can be administered, commencing at 5 drops and gradually increasing to 15 drops. The following is an excellent prescription: Tfc. Tinct. nucis vomicae 12.0 (3i'j) Acid, hydrochlor. dilut. \ Comp. tinct. cinchona / aa l6 ' (3ss); Aq. destil q. s. ad. 125.0 (5iv). M. Sig. i to 2 drams (4.0-8.0) t.i.d. in water one-half hour after food. A convenient method of administering hydrochloric acid is in the form of oxyntin. This can be given in 5-grain (0.3) capsules. Ten grains of oxyntin represents 5 minims of dilute hydrochloric acid. There is also a preparation of oxyntin with nux vomica. A 5-grain (0.3) capsule of this preparation contains 5 minims of the tincture of hux vomica. One to two of these capsules can be given half an hour to an hour after meals. Oxyntin is a powdered form of HC1 and is convenient. Pepsin is present in considerable quantity in chronic gastritis, so it is hardly indicated; though some add 7^ to 15 grains (0.5-1) in com- bination. Papayotin, papain or papoid, or pancreatin, 15 to 22^ grains (1.0-1.5), with sodium bicarbonate, have been suggested; also the diastase combinations, wines of pepsin, etc. The use of artificial digestants would tend to weaken the gastric functions, and are not indicated. CATARRH OF THE STOMACH 259 The bitter medicaments such as stomachics, to stimulate the secretory function and appetite, are often employed, and Riegel believes the hydrochloric acid acts in this way. They should be used fifteen minutes before meals in i to 2 ounces of water. There has been considerable dispute as to the effect of bitter tonics on gastric secretion. Pawlow notes in dogs that the bitters cause increased salivary flow, but have no effect on the gastric glands even when introduced into the stomach. Others claim the bitters depress gastric secretion. Cushny believes their chief value is due to their mental impression as they are an aid to psycho- therapy. Hemmeter has demonstrated the presence of a hormone in the saliva of dogs which stimulates gastric secretion and it would seem that remedies stimulating the salivary secretion would thus at least in- directly effect gastric secretion. Clinically the stomachics seem useful. Among such remedies are tincture aurantii amara; tincture amara (bitter tincture, Squibb's); tincture calumba; fluidextract calumba; tincture cardamomi; tincture hydrastis; tincture gentian compositum; fluidextract hydrastis; fluidextract condurango; fluidextract quassia. The average dose for this purpose of any of these remedies would be from 15 to 20 drops; quassia, in 5 to 10 drops; and tincture nux vomica, if given as a stomachic, in 5 to 10 drops. They may be given alone or in combination, with smaller individual doses. The alkaloidal form of administering stomachics is often of value. Thus: Condurangin (Abbott's), % 7 grain (o.ooi). Quassin (Abbott's), > 7 to H2 grain (0.01-0.005). Condurangin (Merck's), Ho to y grain (0.0065-0.016). Quassin (Merck's), ^2 to y$ grain (0.002-0.02). Hydrastin (Merck's), y to K grain (0.016-0.032). Strychnin arsenici, Koo grain (0.00065), and quassin, >f grain (0.0065), are a good combination. Orexin, y% to i grain (0.032-0.065), can be given in bouillon for the same purpose. In the gastritis of phthisis, carbonate of creosote or guaiacol carbonate, 5 grains (0.3) each t.i.d. after meals, are of value. For Nausea and Vomiting. Cerium oxalate, i grain (0.065), alone or combined with soda bicarbonate or bismuth subnitrate, 2 grains (0.13), or any of the methods described under Acute Gastritis. Lavage may be necessary. For Jaundice. If jaundice is present with chronic gastritis this is an evidence that duodenitis is associated. The treatment would be the same as for the jaundice from complicating duodenitis with acute gastritis, and is described under that heading. For Belching. Milk of magnesia, K to i dram (2.0-4.0), or magnesia usta, 10 grains (0.6). For Gastric and Intestinal Fermentation. Resorcin resublimed, iK drams (6.0); aqua menthae piperitae, q. s. 4 ounces (125.0). Dose, 2 drams (8.0) t.i.d. after food in water, or ichthoform or ichthalbin, 5 grains (0.32) each, or sodium benzoate, 10 grains (0.6) t.i.d., etc. 260 DISEASES OF THE STOMACH AND INTESTINES The following prescriptions are also excellent, and are recommended by William H. Thomson: 1$. Resorcinolis .............. . ............... ... 3j (12.0); Tr. nucis vomicae ............................ 5iv (16.0); Syrup zingiberis .................. , . . ........ Jij (125.0); Aq. menth. piperit ............ . ....... q. s. ad. Oss (250.0). M. Sig. Two teaspoons in water, half an hour after meals. fy Potassii bichromatis .............. ... ........ gr. iss (0.096); Bismuthi subcarb ............................ 5 iss (6.0); Ext. gentianae ........................ q. s. ad. M. Div. in pillulae, xxx. Sig. One-half an hour before meals. For nervous symptoms associated -with intestinal putrefaction I would refer to the chapter on the latter subject. Iron and arsenic can also be added to the treatment, such as a Blaud's gr. v. pill containing gr. J^ sod. arum. For Constipation. Patients under treatment with the Carlsbad waters require no treatment for constipation; otherwise attention must be paid to this condition. The patient should have a movement every day, go to the closet at a definite hour, and endeavor to secure bowel action. This can be' assisted by a 2-ounce injection of olive oil, or by a glycerin or gluten suppository, or 2 drams to > ounce (8.0-16.0) glycerin in i ounce (30.0) of water, by means of a small rectal syringe. Green vegetables, such as spinach, asparagus, lettuce, green peas, etc., are of service. Stewed fruits, such as prunes, apples, or pears, are often effectual. Some cases do well with food containing much cellulose and with rye bread, but many cannot take them. A glass of cold or hot water on rising is of value. If mild cathartics are necessary, cascara (fluidextract), >| to i dram (2.0-4.0), or the aromatic fluidextract; or extract cascara, i to 2 grains (0.065-0.13); or regulin, i to 2 drams (4.0-8.0) at meals; or compound rhubarb pills all at night. Russian mineral oil 5ss A. M. and p. M. is often of value; or one of the American mineral oils as a substitute. The following prescriptions are of service: I}. Aloin ................................. .... gr. (0.0x6); Podophyllin ................................ gr. J^ (o.on); Atropin. sulph. \ Strychnin ) ......................... aa r " Hoo (0.00065); Cascara ext ................................ gr. y (o . 016). M. In one pill. ]$. Ext. aloes Ext. nucis vomicae \ ..................... aa gr. % (o. 008). M. Ext. belladonnas J In one pill. !$. Podophyllin ................................ gr. % (o.on); Ext. n Ext. ph In one pill. Ext. nucis vomicae \ Ext. physostig. / ................ ia & * (o-oi6).-M. CATARRH OF THE STOMACH 261 ty. Aloin gr. V* (0.016); Strychnin gr. H (0.00108); Ext. belladonnas gr. H (0.008). M. In one pill. Other remedies are described under Constipation. Olive-oil injections 5viii-oi to be retained at night; an occasional enema of soapsuds, not over i quart (liter); massage or vibratory mas- sage or electricity to the intestines are useful. CHAPTER XI ACHYLIA GASTRICA ACHLORHYDRIA HEMORRHAGICA GASTRICA ACHYLIA GASTRICA (Synonyms. Atrophy of the Stomach; Atrophy of the Gastric Mucosa; Anadenia Ventriculi; Phthisis Ventriculi; Atrophic Gastritis; Catarrhus Atrophicans.) Definition. Achylia gastrica (the term first suggested by Einhorn) may be defined as a functional perversion of the stomach, characterized by the absence of the gastric secretion (of hydrochloric acid, pepsin, and rennet). Introduction. In many cases, atrophy of the mucosa is the cause, and the condition is permanent. Einhorn, however, has reported a case in which there was eventually some return of secretion, so that portions of the mucosa could have not been much altered; and a case of achylia in a vegetarian, apparently an atrophy from disuse. Achylia gastrica may result from organic changes in the stomach, or may be a pure neurosis, or a temporary disturbance of function, so I prefer to place it in a special chapter. The loss of function may be temporary from nervous disturbances, and A. Rose 1 and the author 2 have observed achylia occurring in gastroptosis, with a return of secretion following the cure of ptosis, the latter ap- parently being a factor, though causing disturbances of the circulation. Temporary achylia is present occasionally with mucous colic. History. Atrophy of the gastric mucosa was first described in connec- tion with pernicious anemia by S. Fenwick, 3 and later by Lewy 4 , Ewald, 5 Osier, 6 Kinnicutt, 7 Nothnagel, Boas, and others. It was believed to be the cause of pernicious anemia and productive of the fatal result Herter has demonstrated the influence of intestinal putrefaction, chiefly through the gas bacillus (Bacillus aerogenes capsulatus), in the production of pernicious anemia, and favorable results produced by intestinal irrigation and lactic acid fermented milk diet. Stockton has called to our attention that achylia does not occur in the early stages of pernicious anemia, but only when it becomes severe. In view of these facts, achylia seems to be a secondary and not a primary cause. Numerous non-fatal cases of achylia have been reported by Ewald, 8 1 Atonia Gastrica, Rose and Kemp. a Observations on Dilatation of the Stomach and Gastroptosis, Medical News, August 6, 1904. Mucous Colic, American Medicine, March 4, 1905. 'Lancet, July, 1877. 4 Berlin, klin. Wochenschr., 1887. No. 4. 6 Ibid., 1886, No. 32. 6 Amer. Jour. Med. Sci., vol. xci, 1886, p. 498. 7 Ibid., 1887, p. 419- 8 Berliner klin. Wochenschr., 1892, Nos. 20 and 27. 262 ACHYLIA GASTRICA 263 Boas, Einhorn, 1 Jaworski, Jones, and Martius, and the latter has written a work on the subject. Etiology. Severe chronic catarrhal gastritis, or toxic gastritis, may produce permanent destruction of the glands; atrophy from disuse, as in vegetarians; achylia, associated with cirrhosis of the liver (syphilis); or with carcinoma of the stomach, or, rarely, with carcinoma of other organs, occasionally with diabetes mellitus; achylia with pernicious anemia and rarely with gastric ulcer and achlorhydria hemorrhagica gastrica. Organic changes are present in most of these cases. Achylia may occur as a temporary functional disturbance in nervous conditions, neurasthenia, gastroptosis, achlorhydria, hemorrhagica, gastrica, and mucous colic. Achylia may also be secondary to a general infection, such as typhoid fever, grippe, pellagra, 2 etc. Age. It is quite common in the middle and later years of life, but has occurred in a number of young persons, especially in the transitory type. Morbid Anatomy. When the achylia is of nervous origin, or associated with gastroptosis or mucous colic, there are no organic changes in the mucosa, and the condition is a temporary functional disturbance of secre- tion. Rose and myself believe the achylia in mucous colic due to the gastroptosis and not to the nervous condition. Einhorn has shown that in cases where a portion of the mucous mem- brane has been aspirated, showing the organic changes of achylia, there has been some return of secretory function under treatment, so that this is no evidence of permanent destruction of secretory power in all the gastric glands. Of the organic changes, there are the two types described under the terminal stage of chronic gastritis: 1. Phthisis venticuli round-celled infiltration and fatty degeneration, with thinning of the stomach wall; round cells taking the place of the glands; and the stomach is normal in size or may be dilated (Fig. 181). 2. Cirrhosis, or sclerosis ventriculi, a fibrous inflammation, starting in the submucosa, fibrous tissue takes the place of the glands, and the stomach is contracted and the walls thickened. Symptoms. One can scarcely say that there are symptoms character- istic of achylia gastrica; it is the examination of the gastric contents which will alone determine the true diagnosis. In describing the symptoms, it seems best to classify achylia under certain groups, some of which we may dismiss briefly: 1. Gastroptosis (splanchnoptosis), with its symptoms; gastric disturb- ances; achylia is present in some cases. 2. Mucous colic, with its symptoms; occasional presence of achylia. 3. Patients with no symptoms and enjoying good health. Einhorn calls attention to this class, one of which had the habit of rumination, and achy- lia was found present, of forty years' duration. Patient had no other symptom. Clinically this class cannot be considered. 4. Cases with gastric symptoms of varying severity, associated with intestinal disturbances. These are the most common type. 1 New York Med. Presse, Sept., 1888. 2 Stockton, Amer. Jour. Med. Sci., Aug., 1909. DISEASES OF THE STOMACH AND INTESTINES There are loss of appetite, a feeling of fulness or pressure in the epigas- tric or gastric regions, and in some cases severe paroxysms of pain, usually soon after eating and persisting for some time; vomiting may occur soon after the ingestion of food; belching of gas; headache and occasionally vertigo; usually constipation, sometimes diarrhea. Some cases may remain fairly well nourished. In others there may be considerable loss of weight, which extends over a period of several years, and nervous symptoms may be present. In cases in which nutrition is preserved, the intestines perform the digestive functions of the gastro-intestinal tract. : ..- ./' : -- . . Fig. 181. Achylia gastrica: i, Mucosa; 2, submucosa; 3 and 4, muscularis; s,serosa; section shows round-celled infiltration of mucosa and absence of glands. Einhorn describes cases whose symptoms resemble hyperchlorhydria, with pains one to two hours after eating, which are relieved by food and drink, especially the latter, which prevents irritation of the mucosa by the coarse particles. This has been given as an explanation for the pain. 5. Cases with marked intestinal disturbances, especially diarrhea, or occasionally diarrhea alternating with constipation; quite frequently there may be no gastric symptoms or slight belching or a feeling of pressure. Some of the cases lose considerable weight and strength and feel weak. I have recently treated a case suffering from these symptoms who was, in addition, markedly nervous. At the end of four months' treatment ACHYLIA GASTRIC A 265 gastric secretion returned and all symptoms disappeared, there being 15 pounds increase in weight a case of nervous achy Ha. Some cases of this type may present symptoms (subjective) of diabetes, according to Einhorn. 6. Cases with severe anemia (described by Riegel) with diarrhea. Examination of the blood shows secondary anemia, and of the stomach, achylia gastrica. Diarrhea favors the production of anemia and the latter improves under treatment. These cases must not be confounded with pernicious anemia. The blood examination easily differentiates. 7. Achylia developing during acute febrile conditions, such as influenza (Ewald) typhoid, etc. Riegel believes it probably preexisted, and that the intestines, which formerly performed the digestive functions, are thus disturbed and achylia symptoms first appear in consequence. 8. Patients suffering from nervous conditions, or neurasthenia, or gastric neuroses; achylia a temporary perversion. My case under the diarrheal class belonged to this type. 9. Pernicious anemia with achylia, in which the blood-findings are typic; megalocytes and nucleated red blood-corpuscles (normoblasts and megaloblasts), etc. Diagnosis. The diagnostic feature of achylia is the gastric analysis one hour after Ewald's test-breakfast. The characteristics are as follows: Total acidity is 2+ to 4+ , or even neutral; HC1 = O; pepsin = O; rennet = O (rennet zymogen may be present); propetone = O; peptone = 0; lactic acid = O; or faint trace; erythroodextrin = O; sugar = +; gastric contents have no odor, no evidence of fermentation; quantity of liquid is very small, aside from that soaked into the particles of bread (this is quite characteristic) ; bread particles are not minutely minced, but rather coarse; absence of mucus. Schmidt and Riegel believe mucus to be present in some cases in the early stage of achylia, developed from chronic gastritis, while there are some glands remaining in mucoid degeneration, and that the presence of mucus does not signify that the case is not one of achylia. Some cases of old chronic gastritis certainly seem on the borderline. The small amount of fluid in achylia is explained by the fact that the liquid chyme rapidly leaves the stomach, leaving the solid particles, and that practically no secretion takes place in the stomach. Motor function is often normal or even increased. It is diminished where there is degeneration with dilatation of the stomach. Absorption. Though this has apparently seemed normal by the iodid of potash test, in some cases it is evident that this test is often fallacious, in view of the fact of the general loss of nutrition in some patients. I agree with Riegel that from the pathologic condition present, absorp- tion must be diminished. Course and Prognosis. In nervous achylia, secretion may be resumed in a few months under proper treatment, and in gastroptosis and mucous colic the condition is dependent on the treatment of these diseases. In some patients the condition perhaps exists for years, with the patient in good health; while in others the subjective symptoms may be 266 DISEASES OF THE STOMACH AND INTESTINES removed or cured, while the objective symptom (the analysis) persists. Others run a long and protracted course. With pernicious anemia and carcinoma the prognosis of achylia depends on the primary disease. Diagnosis. Repeated analyses of the gastric contents are necessary to arrive at the diagnosis. Achylia Gastrica. Gastric contents: Little fluid, no mucus, low acid reac- tion (2+ to 4+), no HC1, no pepsin, no rennet, no lactic acid, coarse particles, no blood. Stool: No blood. Tongue: Often clean. Pain: At times. Motor power: Normal usually. Course: Slow. Loss of weight: Gradual. Cachexia: None, or slow emaciation. Tumor: None. Achlorhydria Haemorrhagica Gastrica. There are numerous bacteria and occult blood in the gastric contents, yellow tinge, total acidity 6+ to 8+ biuret reaction -f- rennet+; mucus+ secondary to other diseases or surgical conditions. Some advocate the Wolff- Junghans test as a means of differentiating carcinoma from achylia gastrica. The possibility of achylia gastrica being the cause of various types of gastro-intestinal disturbances, of chiefly intestinal derangement or irregu- larities, or of severe anemia must be considered. Its association with pernicious anemia, gastric neuroses, various nervous symptoms, gas- troptosis, and mucous colic must be remembered. These facts further emphasize the importance of gastric analysis. Treatment. This depends on the cause. Rose's belt, if achylia is due to gastroptosis or mucous colic, is necessary. If associated with nervous affections, these conditions should receive treatment. Such patients should have their nutrition improved, and be placed on the diet shortly to be laid down. As in these cases achylia is a functional disturb- ance, the secretion should be stimulated by Strychnin, Ho to ^ grain (0.00108.0.0021), t.i.d. before meals, or condurango (fluidextract), 15 to 20 minims (0.88-1.18), or tincture nux vomica, 5 to 10 minims (0.29-0.59), with the addition of hydrochloric acid, thus: Cancer of the Stomach. Gastric contents: Mucus, acidity higher, lactic acid, free HC1 may be present, though usually absent, contents more fluid, and odor and food less coarse, blood or occult blood present. Boas-Oopler bacilli. Blood, or occult blood. Coated. Constant. Diminished. Rapid. Rapid. Rapid and peculiar type. Present later. Chronic Gastritis. There is much mucus in the gastric contents and pepsin and rennet are present; HC1 is diminished or absent. Higher acidity. ACHYLIA GASTRICA 267 R. Tinct. nucis vomicae 1 .-..../ x Acid, hydrochlor. dilut. / 5a 3 " J (l2 * o); Comp. tinct. cinchona 5> J (3-)> Pure pepsin 3 iss (6.0); Aq. destil q. s. ad. 5 iv (125 . o). M. Sig. Two drams in water t.i.d. before meals (preferably). Pancreatin, 5 to 10 grains (0.3-0.6), with soda bicarbonate, 15 grains (i.o), holadin or pancreon, 5 grains (0.5), given three times a day, are useful to aid intestinal digestion, or taka-diastase, 5 grains (0.33), can be given after meals in cases with diarrhea to aid digestion of starch food. Cellasin tablets, 5 grains (0.3), t.i.d., are also useful. In the general treatment of achylia gastrica endeavor: (i) To stimulate gastric secretion. (2) To aid intestinal digestion as noted above. (3) To arrange the diet so that the food is easily digested. To stimulate gastric secretion employ stomachics, such as nux vomica, condurango, etc., fifteen minutes before meals, as just described. The occasional use of lavage twice a week is of service in some cases. Litten advises the use of a 2 per cent, dilute hydrochloric acid solution for this purpose. Van Noorden has employed hepptin (the natural gastric juice of the pig) with success in some cases, in tablespoon doses, three times a day. It can be given after meals in water, seltzer, or tea. If administered in milk, it will coagulate the same if it is warm, but it can be taken by this method. Oxyntin (a hydrochloric acid preparation in powder form) can be given in capsules, 5 grains (0.3), each alone or with nux vomica. Dose, one to two capsules three times daily before meals. They can be secured already prepared. Intragastric faradization (preferably) twice a week or percutaneous faradization may be valuable. I would not advise this in the purely nervous cases. If the symptoms simulate hyperchlorhydria, the use of water, 8 ounces (250 c.c.), or crackers and milk one to two hours after meals, as suggested by Einhorn, lessens the irritation. Diet. This is very important. Food should be prepared so as to pass readily from the stomach, and should be finely divided and thoroughly masticated. Meat should be given in small quantity, finely chopped, scraped (rare or broiled), chicken, pigeon, raw scraped beef, calves' brain, steak, fish, and game. Starchy foods are excellent and should be thoroughly prepared; mem- branes covering any such should be removed. Starch is rapidly converted into sugar. Mushes and liquids are preferable. Pea and bean soup (strained), purees, barley, oatmeal, rice, sago, and potato soups. Mushes from rice, potato, tapioca, oats, flour, etc,; puddings. Soft-boiled eggs; yolks of eggs in soups; raw eggs beaten with water or milk; koumiss; matzoon; ba- cillac; bread; crackers; milk, plenty of cream up to half a pint, and butter up to ^-y^ pound daily are indicated. Some of course cannot digest this amount. Somatose, tropon, and meat powder; Valentine's or Liebig's beef-juice; Armour's extract of beef can be added. 268 DISEASES OF THE STOMACH AND INTESTINES Cocoa possesses^ considerable nutritive power. Tea and coffee well diluted with milk can be given. My personal view is that alcoholic bever- ages are objectionable, though some allow them in moderation. The second indication in the feeding is to employ it at frequent inter- vals, about every three hours, in small quantities, but so that the sum total shall be considerable. The object should be rather to overfeed and to increase the patient's weight by selecting those foods which best agree in each case. In diarrheal cases, constipating food, such as potatoes and rice, should be selected. Feed by the "scales" to increase body weight is my rule in cases where loss of weight has occurred. For the preparation of meat powder, either of the following methods is excellent: (1) Debove's Method. Roast finely chopped lean beef on a tin-plate until desiccated, then powder in a mortar. (2) Einhorn's Method. Dry finely chopped meat three to six hours on a stove; then pound in a mortar and grind twice in a coffee-mill. Butter, milk, cream, eggs (soft boiled or raw), potatoes, rice, peas, and beans (strained through a colander) , cocoa, chocolate, and a small amount of beef, chicken, or game, and crackers or stale bread always seem to agree. I have often given four to eight eggs a day, several soft-boiled and the rest raw in milk. For example: Calories 8 A. M. Oatmeal with cream, 150 gm 400 Cocoa with milk, 200 gm 135 Soft-boiled eggs (2) . . . 160 Toast (2 slices) 160 Butter, 20 gm 163 ii A. M. 6 ounces (200 c.c.) milk with raw egg 240 Crackers, 2 oz. (60 gm.) 150 Butter, 20 gm 163 2 P. M. Soup, bean or pea, 100 gm. (with i egg and 10 gm. of cane-sugar) ' 122 Rare meat scraped, 100 gm 215 Mashed potatoes, 50 gm 63 Spinach, 50 gm 30 Bread, 2 slices (60 gm.) 135 Butter, 20 gm 163 Tea and milk (2 lumps of sugar) 60 5.30 to 6 P. M. Soft-boiled egg (i) 80 Rice, 50 gm.; milk, 200 gm 302 Bread (i slice) 67 Butter, 20 gm 81 Tea and milk 60 9 to 9.30 P. M. 6 ounces (200 c.c.) milk or koumiss 128 Zwieback, 50 gm 1 29 Butter, 20 gm 1 63 Total calories . 3269 It may be necessary to modify this diet and give less, especially at firsc. In cases of severe anemia, rest in bed; arsenic in large doses, begin- ning with Fowler's solution, 5 minims (0.296), t.i.d. and increasing to 10 to 15 minims (0.59-0.88) t.i.d.; or by hypodermic in sterile water in the form of atoxyl, % to % grain (0.022-0.044), every other day or ACHLORHYDRIA H^MORRHAGICA GASTRICA 269 cacodylate of soda and, in addition, iron tropon, or any other good iron preparation. Intestinal irrigation is of value in these cases when putrefactive processes are present in the intestines, for example, with i to 2 ounces (30.0-60.0) peroxid of hydrogen or acetozone 15 grains (i.o) to the quart (liter) of water. Enteroclysis is especially advocated in pernicious anemia cases. Matzoon, koumiss, buttermilk, bacillac, lactone buttermilk are suitable as a diet, and lactic acid bacilli tablets or preferably liquid lactic acid bacilli in tubes internally for the intestinal putrefaction present in this disease. I have found hexamethylenamin 5 to 10 grains (0.3-0.6), alone or preferably combined with equal quantities of benzoate of soda, is of great service as a remedy for intestinal putrefaction. Resorcin and the other remedies suggested for this purpose under Chronic Gastritis and in the paragraph on Indicanuria are of value. The bismuth preparations, notably bismuth subcarbonate or sub- nitrate, 10 to 30 grains (0.6-2.0) t.i.d., can be given if diarrhea is present, and in this type boiled milk, potatoes (mashed), and rice are serviceable. If there is atonic dilatation of the stomach, lavage and the treatment for this condition must be carried out and Rose's belt applied. ACHLORHYDRIA HJEMORRHAGICA GASTRICA Definition. Achlorhydria haemorrhagica gastrica is characterized by the absence of hydrochloric acid in the gastric secretion, usually the result of reflex disturbance from disease of some other organ, or from some other primary disease, and by the presence of gastric erosions, with occult blood, mucus, and a large number of organisms, most frequently strep- tococci, colon bacilli, or diplococci, in the gastric contents. Introduction. This condition has been extensively investigated by the Mayos of Rochester in a large series of cases. In seven instances a reflex achylia gastrica (absence of all the secretions) was present. The disease is somewhat difficult to classify, though it appears usually to be the result of a reflex disturbance of gastric secretion, with a secondary in- fection of the mucosa. From the presence of mucus in the gastric con- tents it might be allied to a chronic gastritis of an infected type following a reflex disturbance of gastric secretion. J. T. Pilcher 1 reports 271 cases from a large mass of material, or ap- proximately one in every fifteen stomachs examined after the Ewald test-meal. As a further demonstration that achlorhydria haemorrhagica gastrica is a reflex disturbance, it proved interesting to note the disap- pearance of all gastric symptoms after removal of the primary irritant, such as the appendix, gall-stones, etc. Etiology. In 156 out of 271 cases of achlorhydria haemorrhagica gastrica reported, the onset of the gastric symptoms seemed to bear an immediate relation to other diseases; to infectious diseases in 38 cases; to circulatory disturbances in 12; to postoperative development in 14; 1 Pathological Laboratories of St. Mary's Hospital, Rochester, Minn., and Jour. Amer. Med. Assoc., Nov. IQ, 1010. 270 DISEASES OF THE STOMACH AND INTESTINES and to derangement of the ductless glands in 24 cases. In 100 cases an operation was performed while achlorhydria haemorrhagica gastrica was present. The appendix was involved in 36 cases; the gall-bladder, in 32; the gall-bladder and pancreas, in 16, and in the stomach there were 1 6 cases in which there was some additional lesion. There were 12 cases in which the appendix and gall-bladder were together diseased. Reflex nervous phenomena are doubtless primarily responsible for the inhibition of the production of hydrochloric acid in these cases, for it is a well-known fact that irritation in distant organs may produce an extraordinary degree of gastric disturbance. Morbid Anatomy. In 64 cases the stomach and pylorus were ap- parently normal. In 24, pylorospasm was demonstrated on the operating Fig. 182. Gross appearance of posterior wall of stomach, showing non-contiguous erosions or superficial ulcerations in fundus (J. T. Pilcher). table. It accompanied appendicitis in 18 cases and gall-bladder involve- ment in 6. In 4 cases previous gastro-enterostomies were cut off, as they seemed not to be required. In several cases other lesions of the stomach were also present. In 2 cases, ulcer; in i, pyloric insufficiency; in 3 the pylorus was much thickened; there was i congenital stenosis of the pylorus and i hour-glass contraction. Microscopic Examination. In 3 cases specimens of the gastric mucosa were secured for examination. There were non-contiguous erosions or ulcerations extending down to the muscular coat and a submucous infil- tration of round cells (Fig. 182). In many places there was a marked engorgement of the capillaries due to the inflammatory reaction. There were masses of yellowish blood pigment lying irregularly over the epithe- lium which are not found in the normal organ. It was believed that they ACHLORHYDRIA H^MORRHAGICA GASTRICA 271 were probably due to precipitation of the ferruginous element contained in the blood-serum which had exuded from the eroded and inflamed areas. Bacteriology. These cases are characterized by the presence of a large number of pathogenic organisms in the stomach, particularly strepto- cocci and colon bacilli. Their presence in great numbers is believed to be due to the lowered acidity of the gastric juice (absence of hydrochloric acid). The examination of 350 specimens from 150 stomachs showed the following results: Streptococci in 127 cases, colon bacilli alone in 8, streptococci and colon bacilli in 64, diplococci (marked) in 84, lactic acid bacilli in 42. Staphylococci, the proteus, and leptothrix were always present. In several cases the cells of the mucosa possessed phagocytic properties. Degenerated leukocytes were almost always present, sufficient to be designated as pus in 48 cases. The bacteria were actively growing. Streptococci are apparently the most important factors, since they Oc- curred in larger numbers in those cases in which pus was present. Prob- Fig. 183. Photomicrograph through defect in mucosa in Fig. 182, showing de- struction of epithelium and round-cell infiltration of submucosa (J. T. Pilcher). ably the active irritation accounts for the presence of the erosions, and the latter are responsible for the pain. The yellow color in the gastric con- tents and the occult blood reaction must be due to the oozing of serum and blood from the erosions. Gastric Analysis. The results of analysis of the gastric contents are quite characteristic. The Ewald test-breakfast with water (not tea) is administered, and an hour later the contents are withdrawn. The amount recovered is usually less than that ingested. The bread is in a coarse state of division, practically as it has been swallowed. There is no viscosity, but the bread is frequently incorporated in thin mucus. The color of the contents is quite characteristic varying from a yellow tinge, just off the white, to a light orange. Occasionally there is a slight rancid odor. The nitrate is clear and may have a yellow tinge. Remnants 272 DISEASES OF THE STOMACH AND INTESTINES of former meals are seldom found, and if present are due to a continuous pylorospasm. The biuret reaction is usually present and also milk coagu- lation, showing there is no true "achylia." In seven cases, however, "achylia" was present. Free hydrochloric acid is absent and combined acids are practically negative, though traces have been found. Lactic acid is present in about 15 per cent, of cases. The Strauss method of determining lactic acid the investigators deem preferable, as by that of Uffelmann the reaction is usually obtained. Blood. The reaction for occult blood is always present. Pilcher employs the modified guaiac test, but the benzidin test is satisfactory also. Symptoms. The symptoms are somewhat inconstant and capricious, but these features are suggestive of the diagnosis when considered with the other facts. In the majority of cases there is oppression or distress in the epigastrium, amounting usually to a sensation of pain. This is generally of a burning, gnawing character, and occurs in about one-third of the cases immediately after the ingestion of food, and acids increase the pain. Sometimes the pain comes on much later or even before meals. It is usually increased by taking food, though it may be temporarily re- lieved thereby. Vomiting, particularly, relieves the pain, as do also alkalis and lavage. There is considerable belching, and sour, bitter, acrid, eructations occur, probably due to the formation of organic acids. In about half the cases vomiting of the ingesta occurs immediately after meals, and the vomitus has a sour, bitter taste. Nausea is quite frequent, and hematemesis has occurred in a few cases. Constipation is the rule, but it may alternate with periods of diarrhea of from one to four weeks' duration. In some cases the bowel movements may occur directly after eating. The appetite is usually impaired, though vagaries are noted, and these patients discriminate as to the quantity and quality of their food, usually first discarding meats and fats. There is generally a loss of weight of from 15 to 25 pounds. These patients generally present a perverted mental attitude, having periods of depression alternating with nervous excitement. This mental condition is probably due more to worry over their disturbed digestion or to the fear of cancer than to a neurosis. The patient suffers from malaise, is easily fatigued, .is unable to work, has occasional headaches, and at times insomnia. Diagnosis. The diagnosis of achlorhydria haemorrhagica gastrica is usually not particularly difficult, as it generally results as a reflex from primary disease in some other organ. The determination of gall-bladder disease, appendicitis, pancreatic disease, or some other primary disease is at once suggestive, as are the restoration of hydrochloric acid and the disappearance of occult blood after operation for a surgical condition extraneous to the stomach, or after the cure of some other medical con- dition. The absence of hydrochloric acid, presence of occult blood mucus, and the large number of organisms, streptococci, colon bacilli, etc., in the gastric contents, and the other peculiarities of these contents as already described as pathognomonic. Gastric Ulcer. Free hydrochloric acid, in the acute cases in excess, is ACHLORHYDRIA H^EMORRHAGICA GASTRICA 273 usually present. Examination of the gastric contents shows no mucus and the large number of various types of bacteria. Bacteria, however, are present. The gastric contents do not present the peculiar appearance of achlorhydria, and in the latter the total acidity is very low, 6+ to 8+, and free HC1 is absent. At times, however, one meets with cases of gastric ulcer with an absence of hydrochloric acid, and the possibility that an erosion of achlorhydria haemorrhagica gastrica may become an ulcer must be considered. Under Gastric Ulcer, the writer refers to the view that gastric ulcer does not result from an erosion. In the case of achlorhydria haemorrhagica, however, there are erosions plus an infection with various organisms, notably colon bacilli. The experiments of Tiirck show that by feeding dogs with pure cultures of colon bacilli one may produce gastric ulcer. Hence, it is possible that an erosion of achlorhydria haemorrhagica gastrica may develop into an ulcer. In fact, Mayo refers to two cases of gastric ulcer associated with this condition. The type of gastric ulcer with absence of hydrochloric acid would in some cases seem to be the probable result, such as Connors' case, under Gastric Ulcer. Carcinoma of the Stomach. The age of the patient, rapidly progres- sive emaciation, and anemia associated with the gastric symptoms are suggestive. There is more usually absence of free hydrochloric acid (though in some cases in the early stage it may be present to even considerable amount). Lactic acid and Boas-Oppler bacilli are present. They may be absent in the early stage if HC1 is present. The gastric contents do not present the peculiar appearance of achlorhydria haemorrhagica gastrica,. though blood or occult blood is present. The total acidity in cancer is usually higher. There are not the numerous varieties of bacteria in excess. There is usually disturbance of the motor functions of the stomach in cancer. With achlorhydria haemorrhagica there is some primary cause. Carcinoma may, however, develop from achlorhydria haemorrhagica gastrica from an erosion. X-rays show gastric deformity with cancer. Chronic Erosions. There are the characteristic pieces of mucosa found in the wash-water. Usually chronic gastritis is present, though occasionally hyperchlorhydria. The peculiar yellow appearance of the gastric contents is absent, and there are no excessive numbers of various bacteria. The condition is not a reflex from some other primary disease. Chronic Gastritis. This condition may be differentiated from achlor- hydria hasmorrhagica gastrica, though the latter might be considered an infective gastric catarrh resulting from reflex achlorhydria with infection. With chronic gastritis there is not the peculiar yellow appearance of the contents from serum exudation, the acidity is usually somewhat higher, and combined hydrochloric acid is generally present. There are not the excessive numbers of bacteria, and occult blood is usually absent and not always present as it is in achlorhydria haemorrhagica. Chronic gastritis is not a reflex from another primary disease. 1 Prognosis. In the cases reported, 172 have been traced as to the ultimate results. Sixty-one have entirely recovered, 38 have an occasional complaint, 23 feel comparatively well, 9 were moderately improved, in 26 there was no improvement, 4 became worse, and n died. Among 1 More mucus present with chronic gastritis. 18 274 DISEASES OF THE STOMACH AND INTESTINES those who died, the chief primary factor were pancreatitis, nephritis, myocarditis, and pernicious anemia. One case developed carcinoma of the stomach, and two histories suggested the same condition, but were not positively confirmed. The best results secured were in those operated on for the primary cause. One must remember, therefore, the possibility of gastric ulcer or carcinoma developing from an erosion of achlorhydria haemorrhagica gastrica. The somewhat rare condition, phlegmonous gastritis, the author believes may occasionally result from this infected type of achlor- hydria. The cure of the latter may, therefore, be prophylactic against more serious conditions. Treatment. The primary factor upon which the reflex achlorhydria depends should be determined and receive appropriate treatment. The most favorable results have been secured when this has proved to be a surgical condition amenable to cure, such as appendicitis, gall-stones, etc. Complete restoration of the hydrochloric acid, disappearance of the occult blood from the gastric contents, and cure of the gastric symptoms have resulted. If the primary cause be a medical condition, it should also receive treatment. The secondary condition, achlorhydria haemorrhagica gastrica, should be properly cared for. Diet. The diet is important, milk with lime-water or peptonized, koumiss, bacillac, fermillac, lactone buttermilk, gruels, broths, and raw eggs beaten up with milk are indicated during the first few weeks. Soma- tose, plasmon, or tropon can be added to the gruels or milk. It is pref- erable at first to give four or five small feedings daily. Later, soft-boiled eggs, mashed pa to toes, thickened gruels, rice well boiled and passed through a colander, scraped raw beef, stale toasted bread, etc., may be added. Fats, such as plenty of butter and cream, are necessary to increase the weight. Later there may be a gradual return to full diet of a simple type. Care should be exercised for some time. Acids cause pain from the erosions. Pickles, spices, alcohol, and all irritating material should be avoided. Smoking should be interdicted. Lobster, cucumbers, corn, sausage, hot breads, and all indigestible food should be avoided until complete recovery. Medication. Alkalis combined with bismuth give the best result. They dissolve or remove the mucus and the bismuth coats the erosions. One can combine soda bicarbonate, 15 grains to H dram (1.0-2.0), with equal doses of bismuth subnitrate, given stirred up in a half glass of water t.i.d. before meals. The addition of olive oil given J to i ounce before the other two meals helps nutrition, coats the erosions, and aids bowel action. Tonics are indicated, such as iron, tropon, or any good prep- aration particularly with arsenic in combination. In view of the fre- quent presence of colon bacilli in the stomach, particularly when the achlor- hydria is secondary to appendicitis or gall-bladder disease, treatment for colon bacillus infection, the writer believes, is indicated. The urine should be examined also for these bacilli. The writer advocates the administra- tion of hexamethylenamin, 30 grains to i dram (2.0-4.0) daily, in lo-grain doses, combined with sodium benzoate, equal quantities, for achlorhydria ACHLORHYDRIA H^EMORRHAGICA GASTRICA 275 haemorrhagica gastrica. Vomiting is relieved by oxalate of cerium, etc. Lavage affords most rapid relief. Lavage. Lavage affords great relief to the pain and clears off the mucus. Mild antiseptics should be added on account of the bacterial infection. Acetozone, i : 1000 in normal salt solution, once daily is useful, and if there is much pus it could be employed more frequently, say twice a day. In some cases substituting lavage twice a week with silver nitrate solution, i : 5000 to i : 2000, followed by washing with normal saline solution, or protargol or argyrol i : 2500-1 : 1500; on the other days use acetozone. Tincture of belladonna in id-drop doses several times daily, in some cases pushed to physiologic symptoms, is of value to relieve the pain from the erosions and also for pylorospasm. In addition, one can employ for the pain hot fomentations or dry heat over the epigastrium. Orthoform hydrochlorid or anesthesin 5 to yH grains (0.3-0.5) t.i.d. can be given for pain. Lavage also affords relief. Cocain should never be used. Opiates should be avoided unless all other means fail, and should only be given under the immediate direction of the physician, first, codein, % to H grain (0.008-0.032), or, as a last resort, morphin, H to H grain (0.008-0.016), by hypodermic. Constipation or diarrhea should receive appropriate treatment. CHAPTER XII HEMATEMESIS ULCER OF THE STOMACH EXULCERATIO SIMPLEX ACUTE AND CHRONIC EROSIONS PERI- GASTRITIS AND PERIGASTRIC ADHESIONS GASTRIC HEMORRHAGE VOMITING of blood cannot be considered to be a proof of gastric "hemorrhage, as it may come from the esophagus, nose, or mouth, or be coughed up and swallowed. On the other hand, gastric hemorrhage may occur, and the blood only appear in the stools. The causes of gastric hemorrhage may be classified as follows: 1. Trauma over the stomach; injuries to the mucous membrane from foreign bodies, as bones or needles; damage from the stomach-tube, mineral acids, or caustic alkalis. 2. Thrombosis or embolism of the vessels; aneurysm; varicosities; atheroma of a vessel, or fatty degeneration. 3. Venous stasis due to cirrhosis of the liver; tumors of the liver; pylephlebitis; compression of the vena cava. In case of cirrhosis the hemorrhage is from the mucous membrane or from esophageal varices. 4. Lesions of the heart or lungs, causing stasis in the vena cava. 5. Constitutional diseases, as leukemia; pseudoleukemia; pernicious anemia; hemophilia; scurvy; purpura; melena (morbus maculosus neonatorum). 6. Menstrual type, when amenorrhea is present. 7. Lesions of the central nervous system (brain or spinal cord). 8. Hysteria. 9. Ulcer of the stomach and carcinoma. 10. Acute infectious diseases, as yellow fever, scarlet fever, measles, small-pox, pneumonia, etc. n. Weil's disease (epidemic jaundice); malignant jaundice (acute yellow atrophy) ; diseases of the pancreas, acute and chronic. 12. Band's disease with enlarged spleen, anemia, ascites, cirrhosis of the liver, gastro-intestinal hemorrhage, etc. 13. Phosphorus-poisoning. 14. Acute jaundice with hemorrhage, following operation. 15. Erosions postoperative hematemesis due to these; the French describe them after appendicitis as vomito-negro-appendiculaire. 16. Exulceratio simplex (Dieulafoy), or superficial ulceration of the stomach. 17. Achlorhydria haemorrhagica gastrica; hematemesis from the erosions has occasionally been reported. It is, however, rare. 276 ULCER OF THE STOMACH 277 18. Arteriosclerosis with high tension, gastric hemorrhage which may take the place of cerebral hemorrhage. As it is the general' tendency to impute cases of gastric hemorrhage chiefly to ulcer or cancer, it seemed desirable to classify all causes. Symptoms. The chief symptoms are hematemesis and melena. Acute anemia develops if much blood is lost; the patient feels dizzy and weak and faints easily. The sight is blurred, pulse rapid and feeble, and extremities cold; rarely convulsions and death follow. Nausea and vomit- ing occur. The blood may be dark in color or coffee ground in appearance, or light if in a large amount. An evanescent rise of temperature may occur after the hemorrhage. At times the symptoms may take place with no hematemesis and nothing definite visible in the stool, when Weber's or the benzidin test may be necessary to determine the presence of occult blood. Prognosis. The prognosis is rarely fatal from the hemorrhage itself, but depends on the primary disease. Treatment. A hypodermic of morphin, y grain (0.016), and locally the ice-bag; extract ergot, K dram (2.0) in solution by hypodermic, or ernutin, 5 minims (0.3) by hypodermic, and in addition gelatin 10 per cent, solution, or Tremoliere's solution gelatin, 5 per cent, with calcium chlorid, 2 per cent. These gelatin preparations should be given from 2 drams to i ounce (8.0-30.0) every half hour to an hour by mouth. Tannic acid, 15 grains (0.33), or lactate or chlorid calcium, 15 grains (i.o), should be given in solution (water 6 ounces or 200 c.c.) by rectum; Tannic acid, 5 grains, may be given by mouth in capsule. Lactate of strontium or magnesium, 15 to 30 grains (1.0-2.0) in 2 ounces (60 c.c.) of water, can also be administered by hypodermic. Adrenalin chlorid (i : 1000); 5 to 10 drops (0.291-0.582 c.c.), by mouth or hypodermic is recommended, but it at times too rapidly increases pulse tension, especially if given hypodermically. By mouth, sterile horse serum, 30-80 c.c. daily, or human blood serum, 20 c.c., by hypodermic are of value. Hypodermoclysis or the rectal injection of normal saline at i20F. are useful. Proctoclysis is of value. Ice-water lavage in rare instances may be necessary, to which add adrenalin 10 drops, lactate calcium 3 SS and 3i of 10 per cent, gelatin. Stimulants, such as strychnin, J^ grain (0.00108), or camphorated oil, 7^ grains (0.5), camphor in 20 minims (1.3) of sterile almond oil, by hypodermic, may be required. ULCER OF THE STOMACH (Synonyms. Ulcus Ventriculi (Simplex); Peptic Ulcer; Ulcus Ventricuti Rotundum; Perforating Gastric Ulcer; Cruveilhier's Disease) Ulcer of the stomach is characterized by a destruction of the mucous membrane of the stomach varying in degree, exhibiting no tendency to heal, and in typic cases attended with gastric symptoms associated with pain, vomiting, and hematemesis. It was first described by Cruveilhier in 1829. Etiology. Postmortem and Geographic Distribution. Brinton found evidences of gastric ulcer in 5 per cent, of persons dying from all causes, 278 DISEASES OF THE STOMACH AND INTESTINES and most frequently in London and on the Continent. Others claim that gastric ulcer is found in at least 10 per cent, of cases. Gerhardt notes its frequent occurrence in Thuringia, and Von Sohlern its rarity in Russia, the Rhine region, and in the Bavarian Alps, believing this to be due to the vegetarian diet (rich in potassium salts) in these countries. This theory lacks scientific confirmation. Sex. Gastric ulcer occurs more frequently in women than in men. Welch places it at 60 per cent, in women and 40 per cent, in men, while Brinton believes it twice as frequent in women. Frequency. The Mayos and Moynihan hold that duodenal ulcer is more frequent than gastric ulcer. Personally I have found gastric ulcer a trifle in excess of duodenal. Observers probably vary slightly. Age. Cases have been reported in children under ten years. It occurs most frequently between twenty and forty years in females, and in males quite often between forty and fifty. Ewald places the highest mortality between forty and sixty. It may occur in old people. Occupation. Cooks, tailors, shoemakers, metal workers, and porcelain makers are most liable to this disease, but it seems a matter merely of coincidence. It was believed that swallowing of overhot food by cooks, the ingestion of metal and glass particles by the metal and glass workers and the cramped position with pressure occupied by tailors and shoe- makers were causes. Etiology of Gastric Ulcer. Many theories have been advanced as to the cause of gastric ulcer, and C. F. Martin 1 describes, in an article on gastric and duodenal ulcers, some thirty-six causes. If one investigate the writings of various authors, this list can be considerably increased. Traumatism. Simple trauma probably cannot produce gastric ulcer unless other conditions are associated. Blows, falls, and the swallowing of foreign bodies, such as knives by jugglers, etc., have produced severe damage to the mucosa of the stomach and marked hemorrhage, without the ultimate production of ulcer. Grifiini and Vassale have resected or burned out portions of the mucosa of the stomachs of animals and perfect healing has taken place, with no ulceration. Traumatism may be a factor, as is shown in the following case of mine: Girl, aged twenty-two, with no gastric symptoms, was thrown from a trolley car, striking on the epigastric region. Pain and tenderness were present at this point and gastric symp- toms developed. There was no visible hemorrhage, but pain and symp- toms continued for six weeks, apparently of hyperchlorhydria, but local tenderness persisted at the point of injury. The patient then had a sudden gastric hemorrhage of severe type and the ultimate course was of ulcer of the stomach. Cure resulted in eight months, the case being observed for several years subsequently, with no recurrence. This girl wa& anemic before the accident and probably hyperchlorhydria was present, though no symptoms were complained of. A hematoma was, I believe, produced in the stomach wall, interfering with its nutrition, and the other conditions favored ulcer development. The patient also had a hematoma of the thigh from the same accident. Traumatism under such conditions may be a factor. 1 Osier's Modern Medicine, v, p. 175. ULCER OF THE STOMACH 279 Anemia and chlorosis may predispose to ulcer, and Riegel and Charles Stockton have shown that hyperchlorhydria frequently accompanies these conditions, and that it has an influence in the prevention of the cure of ulcer or even in its production. Experiments on animals have been per- formed for the purpose of studying the etiology of ulcer. Quincke and Daettwyler made animals anemic by venesection and produced lesions in the gastric mucosa. Section of the spinal cord, with the introduction of one-half of i per cent, hydrochloric acid solution in the stomach of a dog, has produced ulceration (Koch and Ewald). It has occurred after injury to the anterior corpora quadrigemina. Hypodermic injections of pyrodin with the production of anemia with and without bilateral section of the vagus nerve has been practised on dogs by Crescinome 1 and Anglesio, with resulting gastric ulcers. The vagus resection aggravated the lesions. Halliburton 2 states that just as poisons from without stimulate the cells to produce antitoxins, so harmful substances produced within the body are provided with antisubstances capable of neutralizing their effects. For this reason the blood does not clot within the blood-vessels, and Wein- land recently has shown that there is formed in the gastric mucosa an antibody, an antipepsin, which opposes the digestive action of the acid gastric juice. If the antibody is deficient in a certain area, this umpro- tected region is readily injured by the gastric juice. The same writer holds that the intestinal epithelium forms an antitrypsin. The principle just referred to has been lately put into practical use. E. C. Hort 3 maintains that gastric ulcer is not a disease sui generis, but merely a local expression of a general dyscrasia caused by the presence in the blood of cytolitics for the gastric epithelium; he attempts by this treatment to reestablish a condition of immunity of the gastric mucosa to the action of gastrolytic toxins and enzymes, which first cause and then render per- manent the ulcers. He employs fresh normal horse serum, given by mouth. The method and dosage are described later. Rosenow has produced gastric ulcer by the injection of diphtheria antitoxin. Botton 4 has produced gastric ulcer in animals by injecting the macerated gastric mucosa of other animals and of animals of other species. Epinephrin, liquor formaldehyd, nicotin, silver nitrate, etc., by injection into the walls of the stomach and injection of bacteria into the gastric artery have produced gastric ulcer, and the association of mouth and tonsillar infections with ulcer of the stomach has been noted. Rosenow 5 has demonstrated experimentally that ulcer of the stomach has followed intravenous injection of organisms isolated from rheumatism especially after passage through animals. One strain originally a pneumococcus isolated from the blood in pneumonia after being passed through twenty rabbits had been transformed into a hemolytic streptococcus. The neurotrophic theory has been held by some. Stockton believes that nerve perturbation analogous to herpes may be a factor; and de la 1 Riforma Medica, Nov. 21, 1914. 2 The Lancet (London), Dec. 21, 1907; Ibid., Feb. 15, 1908; Brit. Med. Jour., Oct. 10, 1909; Ibid., Jan. 5, 1910, p. 75. 3 Kirkes' Physiology, aoth Ed., p. 488. * The Lancet, 1908, i, pp. i33~ I 333- 6 Journal A. M. A., April 19, 1913, and Nov. 29, 1913. 280 DISEASES OF THE STOMACH AND INTESTINES Verdora produced ulcer and hyperchlorhydria by injecting alcohol into the splanchnic and celiac plexus of a dog. Section of the vagi below the diaphragm has caused ulceration of the gastric mucosa. These experi- ments suggest that the nervous system may be a factor. Kaufmann believes that lack of gastric mucus (amyxorrhcea gastrica) has a relation to hyperacidity and gastric ulcer. Silberman introduced substances into the blood producing hemolysis (hemoglobinemia) with resulting anemia, and found that defects of the mucosa healed tardily. Tiirck has produced gastric ulcer by feeding dogs with pure cultures of the bacterium coli commune. R. T. Morris holds that gastric ulcer may result secondarily from gall-bladder or from appendical infection with the colon bacillus, or that toxins may cause vascular disturbances in the terminal arteries with ulcer as a result. Pilcher believes it may develop from an infected erosion from achlorhydria haemorrhagica gastrica. The Mayos have called to our attention the close association between gall-bladder infection, appendicitis and gastric ulcer. The writer has had several patients in whom gastric ulcers were ap- parently secondary to an infected appendix or gall-bladder. Friedman and Hamburger 1 have experimentally produced chronic gastric ulcer in ani- mals, by partially obstructing the pylorus by surrounding it with a silk ligature and acute ulcers were first produced by injecting silver nitrate into the submucosa. The ulcers in some cases changed into the chronic type. Rosenow, 2 after further experimentation, has produced gastric ulcers by streptococci injections secured from gastric ulcers and believes there is a special strain of bacteria, and Carlson has observed in dogs in whom experimental parathyroid tetany had been produced, in 75 per cent, of cases showed ulcers in the duodenum and pylorus. Intravenous injec- tion of staphylococci, pneumococci, B. coli, etc., have produced acute gastric ulcers. Vagotonia with spastic contraction of the musculature of the stomach resulting in erosions, in combination with hyperacidity is believed by some to be a factor. It is known that burns of the abdomen may produce gastric ulcer, though usually the duodenum is affected. Pavy held the theory of diminished alkalinity of the blood, but this can hardly be accepted. Erosions have been considered by some, notably Bassler, to be the cause of ulcers, but Langerhans opposed this from his experience in autopsies, and Einhorn claims that gastric erosions are a clinical entity and that ulcer does not result. The Mayos report two cases substantiating Pilcher's view. We know that autodigestion of the gastric mucosa occurs after death. The effect, therefore, of circulatory disturb- ances of the blood-vessels of the stomach in the development of ulceration is important. Virchow first suggested that ulceration may result from the plugging of a nutrient artery to part of the mucosa by a thrombus or embolus, and that the infarction is destroyed by the gastric juice. Panum supported this view by producing infarcts and ulcers of the stomach in a dog by in- jecting an emulsion of wax into the femoral artery. Occlusion of the por- tal vein or of some of the large veins of the stomach may cause gastric ulcer. 1 Journal A. M. A., Aug. i, 1914. 2 Rosenow, "Elective Localization of Streptococci," Journal A. M. A., Nov. 13, 1915. ULCER OF THE STOMACH 28 1 Injection of chromate of lead into the gastric and splenic arteries (Cohnheim) has produced ulcer. Talma, by increasing the tension of the gastric wall by ligating the orifices of the stomach, has brought about ulceration. Artificial anemia by faradization of the stomach has caused ulcer. Local interference with the circulation, with resulting necrosis, associated with hyperchlorhydria and changes in the blood and deficiency 1 of antibodies are probably the most frequent causes. Hyperchlorhydria is present in about 95 per cent, of the acute cases, but occasionally there is subacidity or achylia gastrica, as reported by Einhorn and others. Moreover, Spriggs 2 has demonstrated that the total acid content may be increased by hypersecretion, by interference with the motility of the stomach due to pyloric spasm, for example, and by the production of organic acids. This statement as to hyperchlorhydria in gastric ulcer refers, of course, chiefly to the acute cases, especially in the younger subjects. On the other hand, the reports from Mayo's cases show that of 75 per cent, of the cases that come to the operating-table, chiefly chronic cases, many of the patients do not show the high degree of acidity as is commonly supposed. Thus, in 250 cases of gastric or duodenal ulcer. 3 Free HC1 Below normal Normal Above normal Absent 23 cases. 102 cases. 112 cases. . 13 cases. I have recently seen a case with very low acidity (Connors' case). Frequent gastric analysis showed free HC1 trace or absent; lactic acid present; microscopic pus and occult blood. Multiple ulcers (non-malgi- nant) were found by John Connors at operation. Probably gastric ulcer is not always produced by the same factors, and several of the theories described may apply. Hyperchlorhydria undoubtedly has a bearing on many cases, and frequently anemia, or chlorosis, with local interference with the gastric circulation. Colon bacilli, or infection from the appendix or gall-bladder are responsible in some cases. It is now deemed advisable to inspect the gall-bladder and appendix (generally removing the latter), when operating on gastric or duodenal ulcer. Morbid Anatomy. The peptic ulcer is found in the regions exposed to the gastric juice, in the stomach, lowest part of the esophagus, and upper duodenum. It is round or oval, occasionally oblong; is funnel shaped, the upper part being the larger; is of variable depth, its floor being formed by the submucosa, muscular tissue, serosa, or by adjacent adherent organs. The acute ulcer is usually small, punched out, with clean cut edges and a smooth floor, with no thickening of the peritoneal coat; occasionally the floor may be covered with a thick green or brown mucus (Fig. 184). The chronic ulcer is of larger size, with callous margins, and the border may be sinuous. It is often markedly indurated, so if situated at the pylorus it may feel like a tumor on palpation. Embolism or endarteritis of the artery supplying the ulcerated region has been found, or a small aneurysm on the floor of the ulcer. Microscopically. The ducts of the glands are cut off toward the base, 1 Bacterial infection is probably a factor. 2 Brit. Med. Jour., May 21, 1910. 3 New York Med Jour., Sept. 4, 1909, Graham and Guthrie. 282 DISEASES OF THE STOMACH AND INTESTINES being eaten away or digested up to where the tissue offers sufficient resist- ant power to the gastric juice. Healing occurs by proliferation of the connective and glandular tissue near the margin of the gland. As the connective tissue contracts the pro- liferation of the glands is stopped. If the stomach wall is adherent to an adjacent organ and the ulcer perforates, the neighboring tissue may grow into the hole and unite with the connective tissue growing from within. Muscle-fibers do not regenerate. This is true of the large deep ulcers. The mucosa and muscularis roll in and ahdere to the adjacent organ. There is further proliferation of tissue casued by irritation of the gastric juice, and the latter may cause erosion of vessels. Fig. 184. Gastric ulcer, acute: i, Glandular layer; 2, submucosa; 3, muscular layer; 4, peritoneum. (From Bassler's "Diseases of the Stomach and Upper Ali- mentary Tract." Copyright, 1910, by F. A. Davis Company.) The rest of the mucous membrane of the stomach, as a rule, remains normal. Extent of the Ulcer. It may vary from the size of a pea to a diameter of 5 or 6 inches; the average being from a 5-cent piece to a 25-cent piece. Peabody reports one measuring 19 by 10 cm. Location. It is commonly situated on the posterior wall of the pyloric end of the stomach, at or near the lesser curvature. Welch states that out of 793 cases, 288 were in the lesser curvature, 95 at the pylorus, 96 on the anterior wall, 50 at the cardia, 29 at the fundus, and 27 on the greater curvature. Other statistics are given. Number. In about 80 per cent, of cases i ulcer is found; in a trifle over one-half the remainder, 2 ulcers; in the balance, 3 to 5 ulcers; Osier ULCER OF THE STOMACH 283 reports 34 ulcers in i case, and Lange i in which he could not count them. Progress of the Ulcer. i. Cicatrization may occur, with formation of a connective-tissue scar, which tends to depress and contract. Depend- ing on its location, it may cause stricture of the pylorus, esophagus, or an hour-glass stomach. In other situations it may produce no trouble. 2. Progressive necrosis may take place and there may result: (a) Erosion of a blood-vessel with severe or occasionally fatal hemor- rhage from perforation of a large vessel, such as the gastric, hepatic, or splenic artery, portal vein, etc. (b) Adhesions to neighboring organs or various perforations. The stomach may become adherent to the liver, gall-bladder, spleen, pancreas, or intestines, and there may be perforation into these organs. If the ulcer is on the anterior surface, then direct perforation and general peritonitis may follow. There is sometimes a circumscribed peritonitis when adhesions form with other organs, and a local abscess, which may later perforate into the peritoneal cavity. The ulcer may perforate into the lesser peritoneal cavity and cause subphrenic abscess; the diaphragm may be perforated and a communica- tion formed with the pleura, lungs, pericardium, and even with the left ventricle; or, rarely, an emphysema of the subperitoneal tissue occurs, which may pass into the posterior mediastinum; or adhesions may form and a perforation of the anterior abdominal wall take place; or general emphysema of the subcutaneous tissues may rarely result. In cases with adhesions to adjacent organs, with or without abscess, localized growing tumors, hard in consistency, may be formed, and Ger- hardt notes the possibility of mistaking these for carcinoma, but the his- tory and gastric analysis determine the diagnosis. Symptoms. Some cases present typic symptoms, in which event the diagnosis is easy; others suffer apparently from a simple hyperchlorhydria for a long period of time, with no special symptoms pointing to ulcer; while in others the condition is latent. In the latent cases the patient is sometimes apparently perfectly well, when there will suddenly develop hematemesis or symptoms of perf orative peritonitis. Others may not vomit, but suddenly turn faint and weak, become pale with a feeble pulse, presenting the symptoms of internal hemor- rhage. Examination of the stool for occult (concealed) hemorrhage by Weber's, the aloin, or the benzidin test is a valuable aid. Cases Simulating Hyperchlorhydria. Kaufmann, 1 of New York, has suggested that in cases of hyperchlorhydria not yielding to treatment and in whom the pain is of a gnawing or tearing character the suspicion of ulcer is -justified. This is undoubtedly true, and repeated examina- tions of the gastric contents and stool for blood or occult blood are indi- cated. Pus in the gastric contents is significant. This is determined by the microscope. Typical Case. As a rule, the symptoms of gastric ulcer develop slowly, and are as follows: at first a feeling of fulness and pressure aftev eating; 1 New York Med. Jour, and Philadelphia Med. Jour., March n, 1905. 284 DISEASES OF THE STOMACH AND INTESTINES gradually increasing to pain in the epigastrium, which may become so severe that the patient is afraid to eat. Nausea, regurgitation, or vomit- ing may occur early. Pain occurs generally a few minutes after eating, though sometimes one- half to one hour later, and persisting during digestion. If there is hyper- acidity, milk or the white of eggs (raw) or soda bicarbonate may tempo- rarily relieve the pain. Liquid nourishment causes the least disturbance. Coarse substances, hot ingesta, and large quantities of food increase it. It is of a burning or gnawing character. Epigastric pain is increased on pressure and the sensitive point is usually circumscribed. A few weeks later dorsal pain begins, gnawing in character, lying to the left of the spine, between the eighth and tenth vertebrae, alternating with the epigastric pain; at times there is sensitiveness on pressure in this region. The epigastric pain is not continuous, as in cancer, but there are periods of relief. Later, vomiting may occur, one to two hours after meals, of very acid, watery material, mixed with food; emesis generally relieves the pain; occasionally there is vomiting late at night or early in the morning if gastrosuccorrhea (hypersecretion) is associated with ulcer. Appetite is variable; at times the patient desires food, but fears to eat on account of pain; constipation is generally marked; amenorrhea is fre- quent in women; anemia marked in many cases. These symptoms continue, then hemorrhage suddenly occurs, and is visibly present in one-third to one-half the cases, and in a very large per- centage when occult hemorrhage is included, as it should be. W. L. Rod- man, 1 holds that hemorrhage is a marked symptom in at least 50 per cent, of all cases, and if the gastric contents and stools were carefully examined macroscopically, microscopically, and for occult blood from day to day, the probabilities are that blood would be found in nearly every case. With this last the author cordially agrees. 1. Hemorrhage may be occult, no vomiting of blood, the patient turning pale and faint and in a cold sweat, and on the next day there are tarry stools, or occult blood is found in the stool by Weber's or the benzidin test. Progressive anemia may be caused by small repeated hemorrhages. 2. The patient may experience a sense of fulness after a meal and be- come nauseated and restless; then hematemesis occurs in large amount, of fluid blood, bright red, or of liver color, brown, or coffee grounds, mixed with food. Patient may feel faint, extremities cold, temperature subnormal, be- come collapsed, and, rarely, even die from hemorrhage. Convulsions and unconsciousness may precede death. Death from internal hemorrhage can occur without vomiting. Blood is generally passed by the stools (melena), black and tarry in color, and may be found in cases with no vomiting or in latent cases. Convulsions from cerebral anemia, or hemiplegia from thrombosis, or amaurosis (possibly permanent) have occurred. A temporary rise of temperature may follow the collapse. Persistent temperature shows com- plications. The vomitus in acute cases usually shows hyperchlorhydria 1 Jour. Amer. Med. Assoc., Sept. 15, 1906, vol. xlvii, pp. 842-845. ULCER OF THE STOMACH 285 and no mucus. With chronic ulcer hyperchlorhydria may not be present. Tongue is clean and red, rarely coated. Often there are remissions and exacerbations of the symptoms, and they may be protracted; from no apparent cause a relapse may occur. With an unhealed ulcer, complications or perforation may occur at any time. In others, ulcer symptoms may disappear, but those of gastric dilatation, adhesions, etc., may follow. In the long cases, from pain and self-starvation, marked emaciation takes place, the suffering shows in the patient's face, but there is not the sallow appearance of cancer. Tetanic attacks complicating chronic ulcer have been reported by Kaufmann. 1 Pain. The epigastric pain usually occurs about the center of this region, in the median line, just below the tip of the ensiform. Occasionally it is more to the right or left, and lies in a circular area of i to 2 inches in diameter. Throbbing and pulsation may be felt in the epigastrium. Pain is usually increased on pressure, rearly lessened. It is injurious to fre- quently manipulate the painful area or subject it to marked pressure. Singer 2 calls particular attention to an early sign, which consists of dis- comfort or pain radiating from the epigastrium toward the costal arches, and thence along the intercostal nerve-roots to the spine. The regularity of the appearance of this pain or sense of discomfort, especially in connection with eating, is characteristic even when there is scarcely any dyspeptic disturbance. Testing with the algesimeter is not advisable. Dorsal pain comes later. In place of vomiting, some patients regurgitate acid chyme, with pyro- sis, or suffer from nausea. Motor Function. In uncomplicated cases of gastric ulcer this is in- creased. If pyloric stenosis or adhesions complicate, then this function is interfered with (is diminished) and retention of contents occurs. Examination of the Stomach Contents. If the diagnosis of ulcer has been positively determined, it is preferable not to pass the tube. If there is no recent hematemesis, or if vomiting is excessive, it is well to give the test-meal and examine, in addition, for occult blood. For example, in order to combine the test both for motor function and chemic analysis, the night before a meal of meat, potatoes, rice, a few dried raisins, and some chopped spinach can be given. On the following morning the Ewald test-breakfast can be administered and the contents withdrawn an hour later. The presence of raisins, rice, and spinach withdrawn at this time give valuable data. The Mayos 3 wash out the stomach and examine the washings for food remnants. Moreover, while the stomach-tube is still in situ, the organ is artificially distended with air by means of attach- ing a Davidson's syringe, and it is then carefully palpated for tumors or ridges. It is deflated before removal of the tube. If hemorrhage is recent, the writer does not advise this method of inflation. Lavage after the contents are removed is of service, as it checks emesis, and thus renders a hemorrhage less liable to recur. If the patient states there has been a hemorrhage, but the diagnosis is 1 Amer. Jour. Med. Sci., April, 1904. 2 Medizin klinik, Berlin, Dec. 18, 1910, vi, No. 51. 3 New York Med. Jour., Sept. 4, 1909 (Graham and Guthrie). 286 DISEASES OF THE STOMACH AND INTESTINES in doubt, the tube should not be passed earlier than ten days to two weeks after the history of hematemesis. The stool can be examined at once for occult blood. If vomiting occurs, the vomitus may be examined by preference, but the quantity and quality of the food and time of ingestion would influence the analytic findings and might lead to error. Immediate examination of the vomitus and stool for occult blood is important. In about 95 per cent, of acute uncomplicated cases of ulcer, hyper- chlorhydria is present; the total acidity is high, from 90+ to 150+, and free hydrochloric acid. 50+ to 60+ or even 90+, and there is no mucus. Comparing 1000 cases of ulcers of the stomach and duodenum operated on at the Mayos 1 clinic from Jan. i, 1907, to Dec. 31, 1912, there was an average total acidity in these cases of over 63, more than five-sixths of which was free. In a similar number of cases of carcinoma of the stomach there was an average total acidity of 31, of which one-third was free, the more advanced the case the lower the acidity and the less the free acid. This shows the necessity of early diagnosis and operation before the typic gastric contents are found. In fact, it has been demonstrated that a differential diagnosis between a chronic gastric ulcer and commencing malignancy cannot be determined even by the z-rays and only by pathologic exami- nation, so that chronic ulcer should be considered as a pre cancerous stage and should be treated by radical operation as for cancer. The writer finds that quite a number of his cases of chronic ulcer do not show high acidity. These are chiefly the chronic cases. Blood. The gastric contents should be examined for occult blood. There are cases of subacidity, or even of achylia gastrica, with ulcer. The Absence of Hyperchlorhydria Does Not Exclude the Presence of Ulcer. In all doubtful cases gastric analysis and examination for occult blood and pus in the stomach contents and for blood in the stool should be carried out. In all cases we must think of the possibility of development of car- cinoma on the base of a chronic ulcer, but in such event a recent exacerba- tion of symptoms which were previously less marked, loss of weight, weak- ness, and increasing anemia are apt to occur. Cachexia and appreciation of tumor on palpation occur later and frequently when too late for radical operation. Urine. The quantity is reduced when there is much vomiting and food is diminished. There are no characteristic changes. Complications. Perforation and general peritonitis; circumscribed peritonitis; sacculated abscess; adhesions with other viscera, with or with- out perforation of them; pyloric stenosis; stenosis of the cardia; perigas- tritis with adhesions; subphrenic abscess; perforation of the diaphragm, pleura, lungs, pericardium, or heart; hour-glass contraction of the stom- ach; external fistulous opening; anemia of severe type; mediastinal emphy- sema, and subcutaneous emphysema may occur. Stenosis of the pylorus, due to stricture or hypertrophy from spasm, produces dilatation of the stomach and its symptoms; stenosis of the cardia causes dysphagia and regurgitation of food. 1 Journal A. M. A., Aug. 23, 1913. ULCER OF THE STOMACH 287 Perforation. This occurs in ulcers on the anterior stomach wall, or from perforation of a circumscribed abscess, with resulting general peri- tonitis. The symptoms are sudden pain, at times with a tearing sensa- tion, shock, muscular rigidity, distention of the abdomen; and tenderness on pressure, disappearance of liver dulness, cold sweat, rapid and feeble pulse, followed by a rise of temperature, singultus; frequently vomiting, anxious and sunken face (facies Hippocratica), usually coma, then death. Leukocytosis , especially increase in the polynudears, is present. Blood may be vomited and appear in the stool. It is interesting to observe that in some patients, particularly when the leakage is light, the shock may be transient or even slight. Nausea and vomiting are of value as symptoms. During the first few hours the pulse may be only moderately increased and but little increase in the temperature but the respirations become more rapid due to abdominal muscular rigidity. Directly after the perforation rigidity is most marked in the upper abdomen but later becomes general. Tenderness directly after perforation is marked over the site of perforation but later becomes general. If perforation occurs at the pylorus just as with duodenal ulcer the peritonitis may spread into the right iliac fossa and simulate perforated appendicitis. Pelvic and rectal tenderness assist in determining the general peritonitis. In the later stages with the general peritonitis we have the symptoms noted above. In perforation', with circumscribed abscess formation, the symptoms are less intense and are localized. Perforation of the stomach occurs usually after a full meal, or following coughing, sneezing, or local mechanic violence. If adhesions form with other organs, these may be perforated. Frequency of Perforation. Brinton gives the frequency of perforation as i in eight cases. Others place it at 6 to 7 per cent. In women, Brinton places one-half the perforations at the age of four- teen to thirty, the average being twenty-seven; while in men they are distributed up to fifty, the average age being forty-two. The chances of perforation of an ulcer on the anterior stomach wall are 5 to i in its favor, on account of its mobility, which prevents adhesion formation, but ulcers are much less frequent in this location. Subphrenic abscess (pyopneumothorax subphrenicus, when gas is pres- ent) may occur. Etiology. The chief causes are as follows: Posterior perforating ulcer of the stomach (the most frequent cause); traumatism of the liver; abscess of the liver; retro verted appendix, and perforation of a duodenal ulcer. The boundaries of the abscess-cavity are: above, the diaphragm; below, the stomach and liver; to the left, the spleen; to the right, the suspensory ligaments of the liver. The liver is pushed down and the diaphragm up- ward. Symptoms. These are abrupt when due to perforation of gastric ulcer and are as follows: severe pain; vomiting of bilious or bloody material; embarrassment of respiration; subsequently chills, fever, tenderness on pressure, and emaciation. Leukocytosis and increased polynuclears occur during the suppurative period. 288 DISEASES OF THE STOMACH AND INTESTINES Physical signs depend on the quantity of air in the cavity and upon the presence or absence of a complicating pleurisy. Physical Signs (with Little Air Present). Dulness or flatness in the lower part of the thorax, but cough and expectoration are absent; signs of pressure in the pleural cavity are absent or slight, the thorax not being much dilated, and there being scarcely any obliteration of the intercostal spaces; the lungs are intact and distensible, and on deep inspiration there is vesicular breathing. Physical Signs (with Much Air Present). The lower part of the thorax protrudes and respiratory movements diminish; the heart is sometimes pushed upward and slightly to the right; the liver extends well down into the abdomen, occasionally as far as the umbilicus; the liver dulness in the back and lower part of the lung is replaced by a tympanitic zone; on aus- cultation the respiratory sounds are absent in this zone, and there are suc- cussion sounds of a metallic pitch. When pleurisy complicates subphrenic abscess from uleer, there are the signs of pleurisy. Senator gives the following diagnostic points: Violent pain in the epigastric and hypochondriac region; pain in the back on sitting up; pain on belching; patients prefer dorsal position when abscess complicates; while with pleurisy alone, they lie on the diseased side; edema of the lower lateral and posterior thoracic walls. Pfuhl suggests a diagnostic point between subphrenic abscess and pyo- pneumothorax. With subphrenic abscess, if an aspirating needle be inserted and a manometer be attached, the pressure is greater on inspiration and less on expiration. With pyopneumothorax the pressure conditions are reversed. Exploratory puncture is the accurate method of diagnosis, pus and food particles being aspirated. X-rays. These show signs of a high diaphragm on the right side in the rontgenograph. Lee reports cases of subdiaphragmatic inflammation without abscess, notably one case of colon bacillus infection. Terminations of Subphrenic Abscess. Perforation of the diaphragm and pleura; perforation of the lung, with expectoration of pus; or of the pericardium; or of the left ventricle; or of the colon; rarely perforation into the general peritoneum; or perforation of the skin, with resulting fistula. Successful operations have been performed for subdiaphragmatic ab- scess, notably by Carl Beck. 1 Tuberculosis may occur in association with ulcer. Some authors describe so-called atypic forms of ulcer, taking the most prominent symptom as a basis, such as: Gastralgic; catarrhal or vomiting; dyspeptic or latent; hemorrhagic; cachectic or perforative. Diagnosis. This is easy in the typic form characterized by hematem- esis, the epigastric pain circumscribed and present during the digestive process, the dorsal pain, local tenderness, and vomiting. This constitutes the acute type of ulcer. Cohnheim holds that real pain referred to the stomach is usually due 1 Medical Record, Feb. 5, 1896. ULCER OF THE STOMACH 289 to an organic lesion somewhere, and almost never to a neurosis. There are two methods of determining whether the pain is of gastric origin or not, and which may assist us in our diagnosis of gastric ulcer: First, gastric sedatives during the occurrence of the pain are given on an empty stomach, such as orthoform or anesthesin, 5 grains (0.3); or cocain, > grain; or chloroform-water, i to 2 drams (4.0-8.0). If the pain is controlled directly, it is gastric (usually ulcer). The second method was devised by Bonnin- ger. 1 After washing out the stomach and examining the washings for blood-cells, etc., he introduces through the tube 200 c.c. of a decinormal solution of hydrochloric acid (concentrated HC1, 3.6 c.c.; water, 1000 c.c.). If a gastric ulcer is present, this acid solution will probably cause immedi- ate pain. If the pain is due to other causes, the test will be negative. This method is also used to show the progress and result of treatment. 1 he test with orthoform or anesthesin may be tried. In the less severe and non-typic cases (i.e., without hematemesis) one frequently finds hyperchlorhydria, the presence of occult blood in the vomitus or stool, and pus on microscopic examination, either after the test- meal or on aspirating the empty stomach. With cases belonging to the acute type I have never failed to find occult blood, pus, or the combina- tion, though sometimes several examinations may be necessary. The Mayos report blood as found in only about 33 per cent, of their gastric and duodenal ulcer cases. It will be noted that a large percentage of their operative cases were those in which food remnants (motor disturbances) were present. Cases with motor disturbances pointing to stenosis or spasm of the pylorus as the cause are, in the majority of instances, due to ulcer (benign or malignant) at the pylorus, and the condition is frequently chronic. In these cases one may at times find pus in the gastric contents and occult blood more rarely, but the condition is surgical in any event. On the other hand, with chronic ulcer involving the body or curvatures of the stomach, and not lying within the pylorus, microscopic pus is usually found according to my experience. Occult blood is sometimes present. Pus or pus and blood in the gastric contents, when not ingested, or when there is no abscess of the stomach, show ulcer ation. This was demonstrated in Connors' case already referred to. It is chiefly in the chronic cases that acidity is reduced. One must then determine whether the ulcer is benign or malignant by careful investigation into the history and observations as to rapid loss of weight, etc. As already noted this differentiation is often impossible and such cases should be treated as cancer. X-ray Diagnosis. The Rontgen rays are one of the most valuable methods as an aid. to diagnosis. In acute ulcer, with hemorrhage and the typic symptoms, the #-rays are unnecessary for diagnostic purpose, in fact, immediate resort to bed and active treatment are indicated. Sub- sequently even after apparent cure, their employment is a wise procedure, as one can determine thereby whether or not deformity is produced by the healing process or motor disturbances, such as might indicate that ulti- mate excision of the scar area would be preferable. For the aid in diag- nosis of chronic gastric ulcer, the #-rays are invaluable. Fluoroscopy and radiography are both employed. The writer feels that in the former 1 Amer. Jour. Med. Sci., June, 1908. 2QO DISEASES OF THE STOMACH AND INTESTINES erroneous interpretation on the part of the operator is a possibility, while the radiographs are more accurate. Under the section o>rays in Gastro- intestinal Diseases the radiographic findings of gastric ulcer are fully de- scribed. Among them were the bismuth residue in the stomach six hours after the meal, which in connection with obliteration or deformity at the pylorus may show a contracting ulcer producing stenosis. A small erosion or ulcer near the pylorus may produce spasm of the pylorus and some bismuth retention. The writer believes that with these cases peristaltic unrest and often hypersecretion occur in addition to hyperacidity. On the other hand he has seen pyloric spasm and increased peristalsis occur with high degrees of acidity the patient complaining of local tenderness as with ulcer. Correction of the hyperchlorhydria with the use of large doses of belladonna or atropin have corrected the condition. One also frequently determines a chronic appendicitis with secondary gastric symp- toms, sometimes those of gastric ulcer. The #-rays beyond spasm of the cap or pyloric spasm with hyperperistalsis may show nothing. Associated reflex hyperacidity may be a factor. Removal of the appendix and treat- ment of the local conditions frequently cures the case. Appendectomy, however, is necessary. On some occasions, however, the writer observes that the tenderness etc., still persists and cure does not result, in which event some small superficial ulcer or erosion, undoubtedly present, persist. Among other radiological findings in gastric ulcer are displacement of the pylorus upward and to the left "snail form," undershot appearance of the stomach, hour-glass contraction, any distortion or displacement of the stomach by adhesions, distortion (projection) on one curvature with a deep incisura on the opposite curvature, a small puckered area with dis- torted rugae with disturbance in motility, the niche, or a bismuth patch retained in the stomach, or an ulcer crater with bubble of air showing per- forated ulcer (the accessory cavity described by Carman). Incidentally some of the distortions cannot be differentiated from those due to gall- bladder infection with adhesions, or malignancy, except by taking into consideration the physical examination and clinical symptoms. The bis- muth patch method is based on the principle that a bismuth deposit occurs on the ulcerated surface and remains there for a period, even though the rest of the organ is clear. Adler 1 determines the motility of the stomach. He administers i J drams of bismuth subcarbonate in half a glass of water on an empty stomach. The picture is taken four to six hours later. This allows ample time for all bismuth to disappear from the stomach or duo- denum, so that there alone remains that which is deposited in the crater of an ulcer. After this first x-ray examination, i ounce of bismuth sub- carbonate is given in a glass of water, and a second picture taken immedi- ately. The bismuth spreads rapidly over the gastric mucous membrane. This last can be facilitated by having the patient turn from side to side several times. By this second examination the shadow of the entire stomach is shown, so that the shadow obtained on the first plate can be localized with reference to its relation to the stomach. 1 Jour. Amer. Med. Assoc., Nov. 12, 1910. ULCER OF THE STOMACH Cholelithiasis Over forty mostly; rare under twenty-five. Mostly in women. Paroxysms of pain independent of eating often late and in the right hypochondrium. Pain is shorter and sometimes terminates suddenly. It may continue even after stomach has been emptied by lavage or vomiting. Pain over gall- bladder, which at times is en- larged to percussion and pain- ful. Alkalis and albuminous food do not relieve pain. Deaver 1 states that in many cases the only symptom dur- ing a long period of time may be a sense of tightness or L) 2 s rt t/3 O IT ^ rtt j 1 gall-stone case 5 or soreness o V O. >, B a j "" a J*c O 43 rt *J O C "o $ >W 3 75 *j tn SJ-ag,!" 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C/3 >-< o. 2 a . i> bb a *l s 5 3 _C [n 'g i II 3-2 "O w i ^H ^ "C *J "n "^ ~ 60 *} y * **" T3 <*H ^ '_2 **^ t3 1 ^ m -2 _ J| .S i- u 2 "3 ,_, 38 T3 '^ "0 4^^ " 3 w e "?. EJ O -j . 0*| ^5'g ^ ^ rt W .S u o - Q -3 fc 5 M W 4 i > o K^ > C e a! a -ll * ^ 3 -3*3 4> - h S s IS o |1 o 2 S ' G ~ la 4> g M^.S fj CO *** y 1 e.s2- 4) in - 2 ^> cS 4) 3 . - -^ B. 41 CJ g c I! t{ o g=3 a c a o rt S 85 o rt m g s5 B o 00 CJ .n o rt & ^ > fc 55 S <0 ^ CO | b-g .S3Jgijj g uT A 4J .2 S c *>i K 6 kn 4) 4> a >* c3 , . tt^ *T-i ^ T3 _C 9 Cancer No waterbrash; pyrosis pre Once or twice a day, or e^ day or so, and not after < meal; quantity large. Vomiting of blood, general! small quantities; color usu of coffee grounds. May 01 at frequent intervals. Is o decomposed and fetid in o melena. Occult blood at f 51 " ,j S S, a -S3 i ^ d 2s rt S g C * > u o m figi -'l tj > ^ 4) . U Jj - S^o -ss y"E C tj 3 c C ^ O, 8-S JT " "s 9 - 1 i3 ^ "O IS . "" O.S eS C ^ X rt O. eS Z3 .2 in tn^ ' ) rf UJ 3 RJ a PH PH S Rare; in last stages. Sallow and yellow; skin < peculiar and marked cad ia; rapid loss of weight. Leukocytosis is moderate; sinophilia. Occult blood, often present. Sometimes affects the p though often not. a 5 ... h 1 1 ll 'C . ea 4) Si 3< O gs "5 T5 y 3 -^ ^ a; p 4) 2 H U a 4) cd u g C U p 8 C ' " -- <" e 4) C 1 cij O O II >~ " & I 8 u 5 Present at times; waterbrash with pyrosis. Soon after meals, during diges- tion. Vomiting of often large amount; red or coffee ground; blood in stool (melena) ; often repeated same day or next day, and then none for some time. Occult blood usually present. Present at some period in gas- tric contents. None; unless thickened ulcer at pylorus, which then is smooth. Increased, as a rule. HCI in- creased usually. Lactic acid absent. Chronic cases no in- crease. May take place early. Often fresh; may be anemic after losses of blood; face anx- ious and suffering in old cases. Some loss of weight in old cases, but more gradual. Occult blood often present. Makes a difference as to ulcer pain. c ,/ u 1 2 1 c "o 5 tb S X 8*8 V 5 e I* be - 4J l_ Cfl 4? y *"* M o a gO, _; g> e s in 8 %'Z 3 4> O 4> ' > E 33 V PH H C/2 W O 3 --0 u) jq U 2Q4 DISEASES OF THE STOMACH AND INTESTINES Invaluable as the #-rays are as an aid to diagnosis, the latter should not be made from them alone, but the clinical symptoms should be consid- ered as otherwise incorrect interpretation will occur. Other conditions have been mistaken for gastric ulcer. With Gastric crises of locomotor ataxia, we have absence of patellar reflexes. Romberg symptom and the Argyll-Robertson pupil are diagnostic. The Wasser- mann test should be made in doubtful cases and the #-rays employed. Duodenal Ulcer. This is at times impossible to differentiate, if the ulcer extends through the pylorus. There is a history of long duration (chronicity), periodicity and the symptoms occur in attacks. Pus absent in gastric contents. It occurs most frequently in males; is often latent; melena is frequent; pain and tenderness are often a little more to the right than in gastric ulcer; no local dorsal pain spot; hematemesis not as fre- quent; pain after the ingestion of food is later than in gastric ulcer. Hun- ger pain, occurring two hours or more after the meal, is relieved by food. Occult blood is most frequent in the stool and there is symptomatic (often not true) hyperacidity. (Under Differential Diagnosis of Duodenal Ulcer further data are given. 1 ) Spider Gall-bladder Adhesions. Robert T. Morris has demonstrated that gastric hemorrhage occurs at times with this condition. The stom- ach is dilated, and the diagnosis has been made of stenosis of the pylorus with ulcer. There is a previous history of gall-bladder disease in these cases. The possibility of this condition must be considered. Cirrhosis of the Liver. Severe gastric hemorrhage may occur, but examination of the liver, the history, and other symptoms will differentiate. Chronic Tuberculous Diaphragmatic Pleurisy with Symptoms Re- sembling Gastric Ulcer. Male 2 reports a series of cases giving the symp- toms-complex pain, vomiting and gas of gastric ulcer. Adhesions be- tween the diaphragm and pleura and pain referred along the course of the intercostal nerves to their termination over the abdomen were re- sponsible. Radiographs demonstrated retraction of the diaphragm, calcified lymph-nodes and other evidences of pulmonary disease. Some of these patients had no cough, no temperature and no expectoration. This possibility must be remembered. Location of the Ulcer. Occasionally one can make a probable diag- nosis as to the position of the ulcer; if relief is afforded when standing, the ulcer is probably on the lesser curvature; if pain is intense on standing, it is on the greater curvature; if less severe pain when lying on left side, the ulcer is probably at the pylorus, etc. The position which affords most comfort to the patient is the one -which permits the ulcer to remain above the gastric contents. Einhorn 3 has described two methods for recognizing and localizing gastric ulcers: the so-called "thread impregnation test," in which the patient swallows the duodenal bucket with thread attachment, which is removed ten to twelve hours later. Blood discoloration on the string 1 "Roentgen Diagnosis of Gastric Ulcer," Mayo Clinic, vol. vi, 1914. 2 Journal A. M. A., Feb. 28, 1914. 3 Med. Rec., April 3, 1909; Internal. Jour, of Surg., November, 1909; and Med. Rec., March 18, 1911. ULCER OF THE STOMACH 295 shows the presence of ulcer, and the distance of this spot from the teeth, its location. Sufficient blood to discolor the thread would generally respond to the test for occult blood in the gastric contents. The method presupposes that the string will pass over the ulcerated surface which it may not do at all, or may abrade the surface through irritation at the pylorus or at the time of removal. His second method, by the "gastric stamper," consists in the introduction of a collapsed balloon into the stomach, which is then distended, and secures an impression of blood from the ulcer. It is then deflated and removed. Both methods are uncertain, and pressure from inflation, I believe, dangerous. The use of the gastro- scope to locate the ulcer is a risky procedure. The #-rays are of great value in locating the ulcer in most cases, but not invariably as previously noted, thus when there is a superficial ulcer or erosion without deformity. Hyperperistalsis, however, would be suggestive. The presence of blood or occult blood in the gastric contents, vomitus, or stool, the determina- tion of pus in the gastric contents together with the methods of diagnosis previously described, are often sufficient for diagnosis. Course. Gastric ulcer occasionally runs a rapid course, with death from perforation or hemorrhage. Stowell 1 states that 18 per cent, last a year or less; 46.5 per cent., from one to six years. A case of thirty years' duration has been reported. There are often intermissions of improvement and exacerbations; or the patient may become a chronic invalid. The subsequent development of cancer is the worst danger. Prognosis. Excepting the fulminating cases, the more recent the ulcer, the more favorable the prognosis as to cure. The mortality has been estimated at from 8 to 10 per cent.; some place it up to 20 per cent. In private practice Musser believes the mortality of ulcers treated medically to be 3.1 per cent., while in hospital cases it was 12.4 per cent. The position of the ulcer modifies the prog- nosis: if on the anterior wall, perforation is more apt to occur; if the pylorus is involved, stenosis and dilatation of the stomach result; if hypersecretion be associated, the results are less favorable. Stowell's statistics are as follows: Death from hemorrhage, 3 to 4 per cent.; from exhaustion, 5 per cent.; from fatal perforation, 6.5 to 13 per cent. Pulmonary tuberculosis was the terminal event in 20 per cent. (Debove and Remond) out of 100 cases investigated. Greenough and Joslin, in the Massachusetts General Hospital, found that while 82 per cent, cases of ulcer were discharged as cured or re- lieved, only 40 per cent, remained well. Leube's marvelous statistics of medical cure, 90 per cent., are based on a very brief period and are of no value. Three years should elapse. The statistics of 500 cases at the London hospital show that 50 per cent, were uncured by medical means, and of those discharged as cured, one-half relapsed. Parker Syms 2 believes that the mortality of cases treated medically will reach beyond 50 per cent., since though the majority do not die from the immediate effects of the ulcer, yet the anemia and 1 Med. Rec., July 8, 1905. 2 Some Surgical Aspects of Gastric Ulcer, N. Y. Med. Jour., July 16, 1910. 296 DISEASES OF THE STOMACH AND INTESTINES starvation so reduce their vital forces that they become a ready prey to intercurrent diseases. Chronic ulcer is responsible for about 70 per cent, of cancer of the stomach. Eliminating the dangers of death from hemor- rhage or perforation, the author believes the acute type of nicer the most favorable for cure, while the chronic cases, as a rule, belong to the province of the surgeon. Lockwood 1 holds that the mortality for gastro-enteros- tomy for ulcer is 2 to 3 per cent, in the hands of a skilled surgeon, and 6 to 8 per cent, by the average surgeon; while in more complicated operations the mortality was 10 to 15 per cent. The writer believes that about 80 to 90 per cent, of chronic cases are cured by surgical intervention. Treatment. For Hemorrhage (Hematemesis). Absolute rest in the dorsal position; immediate injection of morphin sulphate, % to % grain (0.008-0.016), and the application of a light ice-bag over the stomach, if necessary suspended from a barrel hoop to avoid weight. In emer- gency I have tied bits of ice in a sheet of rubber tissue or in dress shields. One to two teaspoonfuls of a 5 to 10 per cent, solution of gelatin (cold), depending on the severity of the case, should be given by mouth every half-hour for ten to twelve hours, even if vomiting. This is an excellent hemostatic, and also takes up the free acid. The frequent administration of small quantities is preferable to larger amounts given every two or three hours. Gelatin, 3 ounces (100 c.c.) of a 2 per cent, solution by hypodermic with a large syringe, given between the lowest rib and crest of the ilium, is of value. Ernutin (Burroughs, Wellcome & Co.), 5 to 10 minims (0.33-0.66), by hypodermic, or, fy Ext. ergot gr. xv (i.o); Glycerini ] _ . , -. Aq. destil./- aa OJ(4 ' 0) - by a large syringe subcutaneously have proved useful adjuncts; or fluid- extract of ergot or hydrastis, i to 2 drams (4.0-8.0), in 2 ounces of water by rectum. Chlorid or iron and acetate of lead are objectionable. Emetine hydrochloride gr. J by hypodermic has been recommended. Tannic acid gr. v t.i.d. in soft capsule has been employed. Tremoliere has recently advocated a solution as a local styptic con- sisting of a 5 per cent, gelatin solution containing 2 per cent, chlorid of calcium. In a severe case I should not hesitate to give at once by mouth i to 2 ounces of a 10 per cent, gelatin solution containing 5 to 10 grains (0.3-0.6) of chlorid or, preferably, lactate of calcium. The drug is dissolved in a little water and added to the gelatin solution while still warm, and then rapidly cooled off on ice. The plain gelatin solution should be administered in every case. Lactate, or chlorid of calcium, 10 to 15 grains (0.66-1.0), in 4 ounces (125 c.c.) of warm water can be given by enema as an adjuvant. Lactate of strontium, or lactate of magnesium, 15 to 30 grains (i.o- 2.0), in 2 to 3 ounces (125 to 200 c.c.) of sterile water, are recommended 1 The Prognosis and End Results of Treatment of Gastric Ulcer, Jour. Amer. Med Assoc., April, 1911. ULCER OF THE STOMACH 297 by hypodermoclysis, by Maas, to increase the coagulability of the blood, and would be valuable in gastric hemorrhage. Calcium chlorid should never be so given, as it causes local coagulation necrosis, and the lactate of calcium never stronger than i : 20 by hypodermic, and even so there is danger. Adrenalin chlorid (1:1000), 5 to 15 minims (0.66-1.0), has been recommended by hypodermic for internal hemorrhage, but the pulse tension is markedly increased thereby, and I have seen secondary hemor- rhage result. Five drops may be given by the mouth in 2 drams (8.0) of water for the local styptic effect if other remedies are insufficient. Bismuth subnitrate, Yi dram (2.0) in i ounce of water, is at times of service. Ewald recommends cautious lavage with ice-water after cocainiz- ing the pharynx (2 per cent, solution of cocain is sufficiently strong by spray), in cases in which death seemed imminent from continuous hemorrhage. I have never found the procedure necessary,, though I have treated severe cases. If it is employed, the addition of 4 ounces (125 c.c.) of a 5 per cent, gelatin solution, 15 grains (i.o) lactate of cal- cium, and 10 minims (0.66) adrenalin to the water for lavage would be of advantage. J. Kaufmann 1 recommends gentle gastric lavage, the quantity of water at a washing about 300 c.c. The patient should lie down during the lavage, and the tube should be inserted just far enough to secure siphonage. If the hemorrhage has ceased, he does not wash the stomach, but only if the bleeding is continuing. He believes there is no danger of perforation unless the operator should overdistend the stomach by large quantities of water. He advocates the serum treatment of hemor- rhage, and large doses of crystalline bismuth subnitrate to aid in the coagulation of the blood. Kaufmann further argues that the removal of the masses of clotted and disintegrated blood, which may cause gas formation and gastric distention, would lessen the chance of subsequent recurrence of the hemorrhage. Wiel advises lavage with hot water at 42C., but I doubt its ad- visability. W. L. Rodman advocates lavage with hot water at 120 to i3oF. When all methods fail, and the hemorrhage continues or soon recurs, opening the stomach and direct suture of the bleeding ulcer has been advised. The author holds that a temperature of 130 is too high; 120 is the maximum. The administration of sterile horse-serum, as described by Hort shortly, might be of value. The hypodermic use of normal human blood- serum in cases of hemophilia neonatorum has been successfully employed by Welch. 2 It may be used for severe hematemesis in doses of 20 c.c or more. Serum sickness, which might occur from the use of animal serum by this method, is thus avoided. For Thirst. The cold gelatin given for hemorrhage helps relieve thirst. A small piece of gauze dipped in cold water and held in the mouth, frequent washing of the latter; an occasional pellet of ice and 1 Amer. Jour. Med. Sci., June, 1910. 2 Ibid. 2Q8 DISEASES OF THE STOMACH AND INTESTINES enemata of normal saline solution at io5F., 4 to 5 ounces (125 to 200 c.c.), if no relief by other methods, and given every three hours. Proctoclysis, the administration of saline solution per rectum by the drop method, is also useful. Hypodermoclysis is of value employing 5vi-5viii. Collapse. Caution must be employed not to overstimulate the heart, lest the coagulum be forced out and hemorrhage recur. Only collapse that is fairly marked a pulse 120 or over should be treated, as depression of the pulse favors clotting. Among the valuable methods are: External application of heat to the limbs by hot- water bags; rectal injections of i pint (500 c.c.) to i quart (liter) of hot normal salt solution at 115 to i2oF. every two to three hours; proctoclysis may also be employed. Hypodermoclysis with normal saline solution, 6 ounces to i pint (375 to 500 c.c.), given at io5F., through a large needle attached to a fountain syringe, preferably between the iliac crest and twelfth rib, is valuable, and does not stimulate too rapidly. In emergency I saved one patient by employing an ordinary hypo- dermic needle and elevating the fountain syringe 6 to 8 feet to obtain forcible flow. In this event a higher temperature (n8F.) should be employed, as the fluid cools in passing through the small needle. In one case apparently in extremis, having no time to perform infusion and also no assistance procurable, being in the mountains, I needled a large superficial vein with a hypodermic needle 1 and infused by this method, elevating the fountain syringe about 6 feet. The patient re- covered. Infusion with i liter of normal saline solution at 1 2OF. in severe cases is indicated. Direct infusion of blood from donor to patient is often impractical, and the simple method is the best. Direct infusion from donor to patient may be employed in some cases. A careful selection of the donor must be made. Strychnin, % to ^ grain (0.00108-0.0021), every three or four hours by hypodermic, or pulverized camphor, 5 grains (0.3), in sterile almond oil, 20 minims (1.184 c.c.). Large doses of camphor (20 grains) may be necessary. A single dose by hypodermic, and repeated in three or four hours, is often required. Bandaging the extremities and elevation of the foot of the bed are of service. Whiskey or brandy, i to 2 ounces (30.0-60.0), may be added to the enema. Author's Method. Chief dependence should be placed on morphin, the ice-bag, gelatin, and lactate of calcium and bismuth subnitrate internally. Ernutin is useful and the serums may be employed if nec- essary, particularly human serum by hypodermic. The rational methods for the cure of acute or chronic gastric ulcer differ widely, the chief exponents being Leube-Ziemssen and Lenhartz. General Principles. There are certain general principles to which I must first refer. 1 Manual on Enteroclysis, Hypodermoclysis, and Infusion (Kemp). ULCER OF THE STOMACH 299 Absolute rest in bed for a period of two to four weeks, even though the hemorrhage may not have taken place recently, gives the best results. The longest period is preferable. Cruveilhier first recommended milk in gastric ulcer as an ideal food. Pure milk coagulates rapidly with some patients and does not agree. Boiled milk does not form large curds and leaves the stomach more rapidly. Lime-water and milk of magnesia lessen milk coagulability. Lenhartz believes that the general nutrition should be improved as rapidly as possible to hasten the healing of the ulcer, and that sufficient milk to secure this result requires so large a quantity that it would over- distend the stomach. Though given in divided doses, he states that 2 to 3 quarts per diem are excessive, and limits the total quantity of milk to i liter, adding other materials to increase the calorie value. Riegel demonstrated the capacity of egg-albumen to bind free hydro- chloric acid, and also the use of sugar solutions to lessen acid secretion, such as pure dextrose or even ordinary dextrose. These possess high calorie value. Soluble dry peptonoids, i ounce (30.0), have a calorie value of 120.4. They dissolve in milk or water. Milk powder, 100 grams; Gartner's fat milk; casein nutrose, 30 to 60 grams and somatose, 4 to 6 drams (16.0-24.0) and tropon are at times of service as adjuncts. Among other foods are meat jelly, prepared by boiling chicken or beef with calves' feet (Fleming); Leube-Rosenthal's meat solution; flour soup boiled with milk, and barley-water or rice-water to dilute the milk. Protection of the gastric mucosa and lessening hyperchlorhydria by the use of olive oil H to i ounce (16.0-32.0) t.i.d. before meals, is of service. Glycerin in 5i doses also useful and the mineral oils par- ticularly as a carrier for bismuth have been suggested. Kaufmann 1 has demonstrated that the normal gastric mucus exercises a protective influence and is absent in ulcer, and that silver nitrate both aids the healing of ulcer and stimulates mucous secretion. Tiirck substantiates this by showing the increase of mycogen cells during the process of healing. Large doses of bismuth act as a protective layer to the ulcer and prevent irritation. Neutralization of the free hydrochloric acid is important. Among the most valuable alkalis are magnesia usta, milk of magnesia (Phillips), and soda bicarbonate. Magnesia preparations are also of use for the constipation. If their action becomes excessive, bismuth can be combined. At times I employ soda bicarbonate in combination with magnesia. Bicarbonate of soda alone is apt to produce too much carbonic acid gas and distend the stomach. In cases without dilatation, Carlsbad water or their salts are of service, as they lessen gastric secretion and empty the bowels. They form a permanent feature in Leube's cure. Belladonna is valuable to lessen acidity, to relieve pain and spasm therefrom and also if there is hypersecretion, ^ grain (0.022) of the extract or 10 minims (0.6) of the tincture three times a day. Atropin gr. Koo-Ho t.i.d. may be substituted. 1 Amer. Jour. Med. Sci., February, 1908. 3OO DISEASES OF THE STOMACH AND INTESTINES Iron and arsenic are imperative to improve the condition of the blood. Alcoholic drinks, coffee and tobacco, heavy salads, hot breads, acids, pastry, etc., should be excluded during the course of treatment. If nutritive enemata are given for twenty-four hours following Leube's method, plain milk should never be employed, but should always be peptonized. This feature is often overlooked. An enema of saline solution should be administered an hour or more before the nutritive enema, in order to cleanse the bowel. This cleansing enema may be required twice daily to relieve irritation. The following is of service: Peptonized milk, 4 ounces (125 c.c.); raw egg, or whites of 2 eggs beaten up, with salt, 15 grains (i.oo); water, q. s. 8 ounces (250 c.c.). An iso- tonic solution of dextrose is less irritating than glucose, and has con- siderable calorie value. One can add 10 per cent, dextrose or 25 c.c. to each 8-ounce enema. A 10 to 15 per cent, solution of peptone may be substituted or boiled starch may be added. Ewald advises 2 tablespoons flour boiled with 150 c.c. water or milk to which add 2 eggs (raw) and 50 to 100 c.c. of a 15 to 20 solution of glucose with a knife point of salt. Boas employs 250 c.c. milk (which the author states should be pep- tonized), yolks of 2 eggs (raw), i tablespoon Kraftmehl, i tablespoon red wine, a penknife point of salt and 5 drops tinct. opii. If irritation is marked an occasional small dose of opium in the enema may be required. It is not advisable in every enema. It may be necessary to use a smaller enema, only 4 ounces (125 c.c.). Somatose, 2 drams (8.0), or dry peptonoids, i dram (4.0), or liquid peptonoids, i ounce (32.0) may be added. Four nutritive enemata should be given during the day of sixteen hours. Metzger has shown that wine in the enema increases gastric secretion. Having enunciated the general principles of treatment, I will describe the chief methods employed and the procedures with which I have been most successful in my own experience. Riegel confines himself exclusively to rectal feeding for six Or eight days at the commencement of treatment following hematemesis, giving only a few pieces of ice by mouth, and then follows with a mild, non- irritating diet and the use of Carlsbad water or salts; while others confine the feeding to the rectum for two or three weeks. Good results have been reported, but, as the patient is suffering from subnutrition, these methods can be improved upon. Leube-Zwmssen Rest Cure. This is substantially as follows: The patient is kept in bed for two or three weeks, not being allowed to rise for any purpose, either for defecation or urination; rectal feeding for three days if hematemesis has just occurred; hot poultices (flaxseed) over the stomach by day and warm Priessnitz compresses at night. Then after the first three days the subsequent diet for ten days should consist chiefly of milk, boiled milk, or milk with barley-water, strained barley, oatmeal- or rice-water, tea, and a little bouillon or meat extract. Un- sweetened biscuits may be added. On the fourth day, for example, the patient receives 2^ pints of milk, 6 ounces of rusks (softened), and some meat extract. For the next ten days (second period) boiled calves' TJLCER OF THE STOMACH 30! brain, boiled thymus, rice, and sago in milk, gruels and mushes, raw and soft-boiled eggs. This is followed by a little scraped rare or raw beef. Scraped raw ham and mashed potato for a week or so are added, and, finally, broiled chicken, venison, partridge, macaroni, white bread, roast beef, pike, and shad, etc.; coarse bread, skin, tendons, fruits, alcohol, and acids should be avoided. Carlsbad water, a glass, or i to 2 drams (4.0-8.0) Carlsbad salts in 8 ounces (250 c.c.) of water should be taken half an hour before break- fast. This can be begun after the first week or ten days. Ewald 1 uses nutrient enemas for three days after a hemorrhage, and then gives milk, butter, and eggs, and gradually increases the diet. He adds a labferment to the milk alone, or mixed with flour soup; later sayo and tapioca. At the third week raw scraped ham and breast of fowl with rolls or zwieback softened in cocoa. He objects to Lenhartz's method, but practically employs a mixed method with not as satisfactory results. Einhorn 2 employs nutritive enemata for a day or so after hema- temesis, and then milk as the basis of his diet for the first two weeks; for the first week giving 5 ounces (150 c.c.) every hour, adding barley- water and bouillon; and gradually increasing the quantities of milk, but giving it at longer periods, adding eggs, crackers, etc.; at the end of ten days gradually increasing the diet. Recently he employs raw eggs and milk from the first day. Duodenal Feeding. Einhorn now advocates duodenal feeding in order to rest the stomach, the duodenal tube employed being the same as that described under Diagnosis of Pancreatic Diseases "Direct Method of Securing Pancreatic Secretion." It is now advised to swallow the per- forated capsule and tube on retiring at night, attaching the outer end of the tube to the ear by a string. Einhorn recommends feeding from 7 A. M. to 9 p. M. every two hours. He employs as a formula, i glass of milk, i raw egg beaten in and a tablespoon of sugar of milk. At the start 100 c.c. of this mixture is injected through the tube by a syringe and this is gradually increased to 280 to 300 c.c., until about 2800 calories are given daily. The mixture should be gradually heated and then strained and should be given at the body temperature entering the duodenum slowly. This method the writer believes is not to be advised since the soft rubber tube is irritating to the ulcer, tends to irritate the pylorus by its continuous presence during a period of ten to twelve days, irritates the pharynx and by its presence in the stomach tends to increase secretion and motility. Flatulence and distress are often produced. The end- results 3 secured do not justify the method. Lenhartz's Method. Lenhartz 4 believes that many cases of gastric ulcer do not definitely improve, or but very slowly, under the method of entrenched milk feeding; that the high acidity is not measurably lessened; 1 Centr. f. d. ges. Therap., Sept., 1906; also Deutsch. med. Woch., 1908, xxiv, 361. 2 N. Y. Med. Jour., Nov. 20, 1909. 3 The writer has had no success with this method, but only disturbance of the patient, while marked weight increase, etc., results from Lenhartz's method. 4 International Congress at Wiesbaden, 1901; Therap. Gaz., Xov. 16, 1906; Mitt. a. d. Hamb. Staatsk., 1906, vi, 345. 302 DISEASES OF THE STOMACH AND INTESTINES The at least and that if patients are in a poor physical condition consequent upon one or more hemorrhages, often, indeed, in collapse, the "starvation treatment" the ice and nutrient enemata and insuffi- cient milk feeding following not only maintain the patient in his anemic state, but may even drag him into serious inanition, and such an undermined constitution hardly favors the speedy healing of an ulcer. Frequent nutrient enemata excite the gastro-intesti- nal tract into peristaltic activity and may thus induce renewed bleeding; besides, very little nu- triment is, after all, obtainable. Should more milk be given by mouth, merely enough to pre- serve the body weight 3 liters for an adult it would overfill the stomach and stretch its walls, thus preventing a contraction of the ulcer and again offering the dan- ger of renewed bleeding. He ad- vises another dietary treatment, one that will especially combat the hyperchlorhydria and rein- force the enfeebled and anemic state of the patient. The concentrated egg-albumen diet was tried. In case after case the effect proved so gratifying that this method became the rou- tine treatment. The sour regur- gitation subsides, the vomiting 1 immediately ceases, the pain and distress after eating, within a few hours to a few days, disappear, and finally an increase in the body weight is manifest as early as the first week. Besides, the improve- ment is comparatively rapid, so that the patient can be dismissed _as cured within a briefer time than formerly. following is the tabulated regimen: "Absolute rest in bed for four weeks. All mental excitement to be avoided. An ice-bag 2" 00 O O to o o O 10 O O *O tO O o 4-> (t 8 J3 M 00 O O 10 O 2 8"* 2. 10 -. 8- a *o c natemesis . OO O O >o O M en O y O O OO o o ^ C* * M M S 3 <2 V ter last bei 00 00 3-8 i <" , IH *, r~- M 4-> O M 9) a R oj - 00 8 00 8O O O 00 00 s +> " R 3 O O 10 g a \o o o ro O O O O O <5 "5 J - ir> O O M o O O f- 3 g M * 8 1 o o o o ^ V d IH - ,00 00 O O PI > M o first to the se -half are coo to V 60 -3 2 T3 O EG e ^bfl 5, ^MO ^N O rC o o t-i rt "s_ ULCER OF THE STOMACH 303 is placed upon the stomach and kept there almost continually for two weeks. This prevents gaseous distention and promotes contraction of the stomach-walls, thus tending to obviate hemorrhage, and eases the pain when present. On the first day, even when a hematemesis has occurred, the patient receives between 6-9 ounces (200 and 300 c.c.) of iced milk given in spoonfuls, and from two to four beaten raw eggs within the first twenty-four hours. At the same time bismuth subnitrate is given twice or thrice a day, 30 grains (2 grams) per dose, and continued for ten days. The eggs are beaten up entire (with a little sugar), and the cup containing them is placed in a dish filled with ice, so that they remain cold. This food at once 'binds' the supersecreted acid, and, therefore, mitigates the pain rapidly and causes the vomiting, often quite trouble- some, to cease. The fat which is present in the egg yolk also inhibits the secretion of hydrochloric acid. The portion of milk is increased daily per 3 ounces (100 c.c.), and at the same time one additional egg is given, so that at the end of the first week the patient is receiving 25 ounces (800 c.c.) of milk and from six to eight eggs. Both these foods are now continued in the same amount pro die for another week. No more than i liter of milk a day is allowed at any time. Besides milk and eggs, some raw chopped meat is given from the fourth to the eighth day, usually on the sixth, 9 drams (35 grams) pro die, in small divided doses (stirred up with the eggs or given alone); the day after 18 drams (70 grams), and later possibly more if well digested. The patient is now able to take some rice, well cooked, and a few zwieback (softened). In the third week quite a mixed diet is tolerated, the meat being given now well cooked or lightly broiled." All heavy foods are interdicted, as well as vegetables with husks, etc., and those tending to produce flatulence. The patient is given strict orders to masticate his food thoroughly. The table gives the daily quantities. The bowels are not moved, both in order to avoid any peristaltic irri- tation and to permit the reabsorption of blood that may have passed into the intestine. One need pay absolutely no attention to constipation in the first week, even in many cases to the end of the second. After the second week the bowels are moved with small glycerin injections or warm water, and after the third week this is done daily if a movement does not occur spontaneously. After this one tries to control the bowels by means of the food and by getting the patient to go to stool regularly. For the anemia iron is given in the form of a soft preparation of Blaud's pills: fy Ferri sulphas 10.0 gm.; Magnesia usta 1.75 gm.; Glycerinum gtt. xxx (3.6 gm.). M. Divide in pilulae Ix; 2 pills to be taken two or three times a day. The pills are given as early as the sixth, eighth, or tenth day of treat- ment, according to need, administering them first in a macerated condition. In severe cases arsenic is also given in the form of "Asiatic pills," each containing o.oooi gm. of arsenous acid. The dose is gradually in- creased, 3 for three days, 4 for four days, up to 7 for seven days, then de- creasing again, 6 for six* days, etc. After the tenth day and to the sixth week bismuth compositum is substituted for the subnitrate and given 304 DISEASES OF THE STOMACH AND INTESTINES three times a day before meals. The patient is usually allowed up on the twenty-eighth day and is dismissed in the sixth to the tenth week. Len- hartz reports only 8 per cent, of recurrent hemorrhages after this method of treatment as compared with 20 per cent, after the older methods. No unfavorable results were produced. Samuel Lambert, 1 of New York, and E. I. Spriggs, 2 of London, have reported favorable results. Senator's Method. Senator has modified Lenhartz's treatment, and employs a nourishing diet, non-irritating, which tends to check hemor- rhage. It consists chiefly at first of gelatin, fat, and sugar. At first a 10 per cent, sweetened gelatin solution is given in tablespoonful doses every fifteen minutes to two hours. Small amounts of fresh butter and cream are allowed, the butter given in small frozen balls and the cream beaten up with sugar to form whipped cream, or it is iced. He gives daily 15 to 20 grams of gelatin, J- pint of cream, and 30 grams of butter. The daily allowance is from 900 to 1000 calories, and may be begun immediately after a hemorrhage. Olive oil may be given instead of butter. Gelatin is later replaced by calves'-foot jelly, milk and eggs, etc. He occasionally adds rectal feeding, though little of late. Gradual additions are made to the diet. Sippy 3 , with gastric or duodenal ulcer, feeds every hour 5iii of a- mixture of equal parts milk and cream from 7 A. M. to 7 P. M.; after two to three days soft eggs and well-cooked cereals; or example, in addition to cream and milk, 3 soft eggs, 9 ounces cereal, each day of twelve hours. Cream soups and vegetable purees occasionally are substituted. Later he adds jellies, custards, creams, marmalades, etc. The object should be a gain of two to three pounds weekly. The same observer keeps the gastric contents neutral all the time. In cases, particularly with retention of gastric contents, as much as grs. 100 soda bicarb, have been given every hour be- tween feedings 7 A. M. to 7 P. M. and 3 doses ^ hour apart after 8 p. M. Neu- tralize all free HC1 during the night. Magnes. usta is also used, but should not be pushed to diarrhea. In cases without retention of gastric contents gr. xaa magnes. usta et soda bicarb, are alternated every hour with bismuth subcarb. grs. x + soda bicarb, grs. 20-30 midway between feedings. Schmidt* believes in the Lenhartz principle of feeding, but does not increase the diet as rapidly. He gives the stomach rest a few days, like Leube, and then increases the diet more rapidly by giving gelatin, eggs, butter, cream, sugar, and rice; but chopped meat and ham with caution. E. Weiss, of Paris, has demonstrated the value of the injection of fresh animal serum in the treatment of hemophilia and purpura, and Wm. Hanna Thomson has employed with success the injection of 15 c.c. of rabbit's serum hypodermically every day in a case of subcutaneous ex- travasation of blood and of hematuria. Hort 6 claims success in arresting 1 Trans. Assoc. Amer. Phys. 2 British Med. Jour., Apr. 3, 1909; Med. Chir. Trans., 1907, xc, 783; Proc. Roy. Soc. Med., 1909, ii, iii; Therap. Sect, 81; and British Med. Jour., May 21, 1910. 3 Journal A. M. A., May 15, 1915. 4 Deutsch. med. Woch., Jan. 18, 1906. 5 N. Y. Med. Jour., June n, 1910. 6 Brit. Med. Jour., Jan. 5, 1910, p. 75; ibid., Oct. 10, 1909. ULCER OF THE STOMACH 305 O 00 O O Tf 10 O HI O N-l o o o y o IN 00 .^ "5 is O 00 O O CO >O O HI O 'o O IN O >/-. s O CO O o M n CN O 00 O O O- CO O O CO O '0 O O O 'O M O >o O O vo N O M O o o o o -t O O O O O O o 'o 1 c ^* rt " C 306 DISEASES OF THE STOMACH AND INTESTINES severe hematemesis by administering normal horse-serum by mouth, and also excellent results in the treatment of gastric ulcer without hemor- rhage, with the subsidence of pain and -vomiting. He begins with 10 to 15 c.c. of sterile horse-serum, daily increasing it until no less than 30 c.c. are taken each day. The serum is administered by mouth in milk or in half an ounce to an ounce of water, and never on an empty stomach. If the pain is severe or there is hemorrhage, from 60 to 80 c.c. may be given in twenty-four hours. The treatment should continue for six weeks or longer, and preferably for some weeks after apparent cure. This same treatment is employed for duodenal ulcer. Hort employs serum treat- ment for chlorosis and externally locally for ulcers of the leg. Hort's dietetic treatment follows the lines of Lenhartz. Levison 1 reports the local styptic effect of horse-serum in hemorrhage following operation on the gall-bladder and bladder. My own method depends upon whether I first treat the patient during the period of hemorrhage or later. If the hemorrhage is taking place or has just occurred, i to 2 drams (4.0-8.0), of a 5 to i o per cent, solution of sweetened gelatin is given cold every half hour for ten to twelve hours, even if there be vomiting. During the remaining period of the first twenty-four hours the gelatin is con- tinued, > to i ounce (16.0-32.0), every two to three hours while the pa- tient is awake, and in addition the whites of two raw eggs are beaten up and placed in a cup on ice and given in divided doses. An ice-bag is kept on for at least two weeks if hemorrhage has just occurred. The addition of horse-serum according to Hort's method the writer believes justifiable, or the use of human blood-serum by hypodermic. Gelatin treatment is continued for a week. Scraped beef and ham are omitted for the first two weeks and cream substituted, to obtain the calorie values. A little sugar can be beaten up with the cream. The day following the hemorrhage milk is begun, 6 ounces (200 c.c.) cold, in spoonful doses, 100 grams (10 per cent, gelatin solution) cold, in divided doses % ounce (16.0) every three hours, and one raw egg beaten up and given in divided doses. These are placed in cups which are packed in ice. The milk is increased 100 c.c. daily up to 1000 c.c., and no more; eggs are increased daily one egg up to eight a day. With the exceptions noted, the rest of the diet is after Lenhartz for the two weeks. Purees and various cereals are then added. I give no scraped beef until the commencement of the third week after hemorrhage, and then increase the diet after Leube's method. If no recent hemorrhage, I start the diet after the method correspond- ing to the third day in the table on page 305. An ice-bag is kept on for two weeks if there is hemorrhage or one has occurred within a week or ten days. The patient should increase in weight 2 to 3 pounds per week during the four weeks rest cure. Bismuth subnitrate, K-I dram (2.0 to 4.0), is given in 2 ounces (60.0) water t.i.d. before feedings, commencing on the day after hemorrhage. i 1 Journal A. M. A., Mar. 8, 1913. ULCER OF THE STOMACH 307 At times I combine magnesia usta, 15 grains (i.o), or sodium bicarbonate, 15 grains (i.o), with the bismuth. Pain. This may be caused by the hyperacid condition of the gastric contents irritating the ulcer or frequently by gastric spasm. Tincture belladonna, 10 gtts. (0.66) in a teaspoonful of water should be given t.i.d. for pain and spasm. It also lessens gastric secretion and motility, and is a valuable adjunct to the treatment. At times a fourth dose may be indicated. It further lessens the tendency to vomiting and hemorrhage by diminution of the motility and of hypersecretion. Stockton 1 has employed hypodermic injection of i c.c. adrenalin solution (1:1000) successfully in several cases of gastric and pyloric spasm. Orthoform or anesthesin, of which the dose is 5 grains (0.3) is also recommended for the pain of ulcer. They are of some value, but as excessive acidity and increased motility have the most influence in these ulcer cases in aggra- vating the pain, belladonna seems of most value. Extract of belladonna, H grain (0.22), or atropin, Koo~Ko grain (0.0006), may be substituted for the tincture of belladonna. Rarely a hypodermic of K to K grain (0.016-0.032) of codein or morphin, % to y grain (0.008-0.016), may be necessary for the acute pain. Bowels. I prefer to move the bowels gently by a small soapsuds enema containing 2 ounces (60.0) of olive oil on the third day after hemor- rhage, and thereafter every other day. If no hemorrhage has occurred recently, then a daily movement should be secured. Milk of magnesia, i to 2 drams (4.0-8.0) in 4 ounces (125.0) water, given on rising, or small doses of Sprudel salts, i dram (4.0) in a glass of hot water, are of service. On the seventh day after hemorrhage, or immediately if there has been no hemorrhage, iron and arsenic should be given: fy Blaud's iron pill gr. v (0.3) (made fresh); Sod. arsen gr. ^ (0.0013). Pill made soft with honey and crumbled when taking, one pill t.i.d. after eating. The arsenic can be gradually increased to gr. ^5 (0.0026) sod. arsen. t.i.d. The bismuth treatment should be continued, or one can substitute the nitrate of silver treatment. It is advisable to keep this up for several months as a precaution, and then continue the diet and alkaline treatment for hyperchlorhydria for a considerable period. At the end of three weeks the patient may be allowed to sit up for a short time daily; and at the end of four weeks to begin to go outdoors for a short time. In favorable cases it is advisable not to resume work under six weeks after bed treatment. Some of the cases either will not remain in bed or cannot, for financial reasons, particularly if there is no hematemesis. In such event, we are obliged to employ careful but liberal feeding; the use of Carlsbad salts, iron and arsenic tonics, and either the subnitrate of bismuth treatment with an alkali in addition, or nitrate of silver. The following prescriptions are of service: 1 N. Y. State Journal of Medicine, October, 1913. 308 DISEASES OF THE STOMACH AND INTESTINES fy Bismuth subnitrate 3 iv-J S 2.0 to 4.0 (3ss-j). Stirred in 4 ounces (125 c.c.) of water, given t.i.d. half an hour before meals. This is preferable to pouring the bismuth suspension through a stomach- tube. As olive oil protects the surface and lessens the secretion, I some- times employ the bismuth suspended in i to 2 ounces (30.0-60.0) of olive oil instead of water. Alkalis should also be used. Mineral oil has been advocated as a carrier for the bismuth. fy Magnesia usta 2.0 (gr. xxx), or Milk of magnesia 4.0 to 8.0 ( 3 j-ij)* In 3 or 4 ounces (100-125 c.c.) of water alone, or combined with equal quantities of soda bicarbonate. R. Soda bicarb. 1 ,, . > aa 10.0 (Suss); Magnesia usta / Milk-sugar 2.0 (5ss). Dose, 2.0 (3ss) in water t.i.d. an hour after eating. Nitrate of silver can be employed in place of the bismuth, to be given on an empty stomach t.i.d. half an hour before meals, as advocated by Boas and Kaufmann: 1$. Argenti nitratis 0.2 (gr. iij); Aq. destil 180.0 (5 vj). Keep in dark bottle. Tablespoonful in wineglass of water t.i.d. half an hour before eating. Occasionally lavage of the stomach with 1:5000 to 1:3000 silver nitrate or protargol or argyrol i : 2500 has been advocated once or twice a week, if there has not been a hemorrhage for some weeks. The internal administration of silver nitrate is usually preferable. It should be given for two to three weeks, then discontinued and the bismuth substituted. The alkali can be given in addition t.i.d. an hour after meals. The meals should, preferably, be frequent and in smaller quantities, as in hyperchlorhydria. Stenosis with Dilatation. In cases complicated by stenosis and ectasia surgery is always indicated. Temporarily lavage, particularly at night so the stomach will be empty, is necessary for the fermentation, and olive oil, i to 2 ounces (30.0-60.0) t.i.d. before the chief meals, to aid the passage of food. The application of Rose's belt, and the patient lying on the right side for half an hour after eating, both temporarily aid in emptying the stomach. Resorcin in 5-grain (0.3) doses t.i.d. is also of value for the fermenta- tion. Wm. H. Thomson 1 advocates the use of resorcin and also potas- sium bichromate in gastric ulcer. His formulae are found on page 260 under treatment of Chronic Catarrh of the Stomach. The writer prefers the omission of the nux and ginger in the ulcer cases. Hemorrhage is rare in this type, the ulcer being dormant and the chief symptoms due to stenosis. Surgery, resection of the ulcer with gastro- enterostomy especially, is advocated in these cases. If there is tetany, the same procedure is advisable. 1 N. Y. Med. Jour., June n, 1910. ULCER OF THE STOMACH 309 Hyper secretion. This should be treated by lavage about 10 A. M., following the same by atrbpine Hoo~Mo an d an alkali. Vomiting. In cases described by Lenhartz, this is relieved by neutral- izing the acid, and this is the best treatment. Rarely, rectal feeding may be required for a few days. Bismuth subnitrate, 2 grains (0.13), and oxalate of cerium, i grain (0.065), should be given, or i-drop doses of Fowler's solution of arsenic, four in all, an hour apart. If the vomiting continue, a single cautious lavage is a safer procedure than the risk of recurrent hemorrhage from the strain of emesis. Tincture of belladonna, 10 gtts. (0.66), or atropin, Koo-^so grain (0.0060), are also of service for the vomiting. Pain from Adhesions. Rose's belt will at times aid in alleviating the pain due to the dragging of adhesions, by the support afforded to the viscera. Bacterial vaccines have been employed to treat the ulcer. On account of Tiirck's experiments in producing gastric ulcer in dogs by the ingestion of colon bacilli, a weekly dose of bacterial vaccines, 40,000,000 each, has been advocated by Aaron for the treatment of gastric ulcer. X-rays. Bassler 1 advocates the employment of the #-rays for the healing of gastric ulcer, but I am skeptical of their value on the internal organs for such purpose. In cutaneous affections they are undoubtedly of value. Their prolonged use is also dangerous. Perforation. Temporarily, rectal feeding, a hypodermic of morphin, the ice-bag, and cautious lavage after cocainizing the pharynx, as sug- gested by Ewald, are indicated. Immediate recourse should be had to laparotjmy. Surgery. The following are the indications for operation: Perfora- tion with commencing peritonitis; local peritonitis, .with or without abscess; subphrenic abscess; perigastric adhesions; ectasia due to stenosis from ulcer or spasm from its irritation; gastric tetany with ulcer. In recurring acute hemorrhages the Mayos advise opening the stomach, locating the bleeding point, suturing it firmly with catgut on the inner (mucous) side, and protecting the region by mattress sutures (musculo- peritoneal). Gastrojejunostomy they have not found reliable. In six cases ->ne case of death from hemorrhage followed gastrojeju- nostomy five cases treated by primary operation on the bleeding point, with or without excision of the ulcer, recovered. 2 Rovsing, in cases of severe hemorrhage, employs direct diaphanoscopy and gastroscopy (the light introduced through a minute incision in the stomach- wall). The writer's new inflating gastroscope is a more practical instrument for this purpose. After locating the source of hemorrhage, it is obliterated by running a suture about the bleeding surface. Kraft 3 reports five cases. In cases of ulcer, with one or more recurrent hemorrhages, after systematic medical treatment for six months by the methods I have de- scribed, if the patient is uncured, I advocate resort to surgery. An ulcer 1 Diseases of the Stomach and Upper Alimentary Tract, Med. Times, Sept., 1909. 2 Jour. Amer. Med. Assoc., Sept. 22, 1906. 3 Archiv fur Klinische Chir., Berlin, xciii, No. 3, pp. 557-789. Last indexed, Nov. 19, p. 1850. L. Kraft, Zur Behandlung der lebensgafahrlichen Magenblutungen. 310 DISEASES OF THE STOMACH AND INTESTINES uncured by six months medical procedure, I believe to be of chronic type and that surgical procedure is indicated. I am aware that some surgeons are loath to operate on such cases unless there is pyloric stenosis, and claim that in such event the gastric contents will not pass through the new opening, but through the pylorus. Canon and Blake have demonstrated this experimentally on animals. On the other hand, when a large anas- tomotic opening is made, this has been shown to be of practical value, at least for a time, especially by the posterior no-loop method. It has been demonstrated that the pancreatic juice and bile entering the stomach aid in neutralizing the hyperacidity, and this is of service. Wm. Mayo states that in chronic ulcer, where there is no mechanic obstruction, the result has not been as favorable. Unfortunately, we do find cases of multiple ulcers with hemorrhages from various areas and with an open and soft pylorus, such as Munro 1 reports, in which the results of surgery are not favorable; but in any event the lessening of hyperacidity through gastro-enterostomy is of value.- Excision of the ulcer is indicated when possible. With a patent pylorus, however, the anastomosis will at times close. In Figs. 185, 186, and 187, an interesting case is demonstrated. This patient was operated on for ulcer of the body of (he stomach, by gastro-enterostomy, the pylorus being patent at time of operation presumably. The wound became infected and broke open. He came to me suffering from epi- gastric burning two hours after meals and for me to examine the hernia which had developed at the site of the old incision. There was hyper- acidity but no blood. There was no vomiting. Radiographs show (Fig. 185) stomach slightly distended (hardly dilated) with deep incisura at +. Fig. 1 86; marked bismuth retention six hours later irregular streaks of bismuth passing upward no vomiting no symptoms of stenosis stomach normal position. Adhesions believed responsible for disturbance of motility, at + an incisura believed to correspond probably to stoma of gastro-enterostomy. No bismuth escape noted. In Fig. 187 is also a radiograph six hours after bismuth by mouth, but after bismuth enema. The stomach is forced up slightly higher. The same bismuth retention and incisura are noted. Operation by Wm. P. Healy demonstrated marked adhesions between anterior surface of the stomach and the abdominal wall, liver and spleen thus accounting for disturbance of motility and bismuth retention. No pyloric stenosis perfectly patent, evidences of an old ulcer in the body of the stomach now healed. A band occupied the position of a former gastro-enterostomy opening. The stomach and intestine were separated by the operator. Only the finest probe could be passed through this band into the stomach. Adhesions were separated and the hernia closed. With chronic ulcer at the pylorus, pylorectomy and gastro-enteros- tomy give the best results. The writer now believes that in the case of chronic gastric ulcer or ulcers (extra-pyloric) which it may be advisable to excise, that, in addition to the gastro-enterostomy, infolding the stomach on the gastric side of the pylorus should be performed, thus closing the pyloric orifice. The gastric contents must then of necessity pass through the 1 Annals of Surg., June, 1907. ULCER OF THE STOMACH Fig. 185. -Case of epigastric hernia. Old history of ulcer with gastro-enterostomy. Slight distention of stomach. Incisura at + Indentations above at pyloric end somewhat irregular, believed to be due to adhesions. No vomiting, no symptoms of pyloric stenosis. The incisura is stoma, no longer patent. FIG. 186. FIG. 187. Fig. 186. Same case as Fig. 185 six hours after bismuth meal, before enema. Marked retention of bismuth, irregular contour above. Incisura at + believed to be site of old gastro-enterostomy opening, but no bismuth passes out, no vomiting. Stasis shown at operation to be due to adhesions, pylorus patent, ulcer of body of stomach heated. Stoma of gastro-enterostomy opening, no longer patent for food, reduced to pin-head opening. Fig. 187. Same case as Fig. 185 six hours after bismuth meal and after bismuth enema. Stomach pushed up slightly, normal position. Bismuth retention marked below, streaked above. No vomiting. Retention believed to be due to adhesions interfering with mobility and that pylorus is patent. Incisura at + believed to represent old stoma of gastro-enterostomy with no bismuth escape. Proved correct at operation. 312 DISEASES OF THE STOMACH AND INTESTINES gastro-enterostomy opening. The same method would be useful in some cases of pyloric spasm. A. Berg 1 ingeniously employs an occluding purse-string ligature just proximal to the antrum. Among other methods advocated are unilateral pyloric exclusion, blocking the pylorus by means of winding a strip from the sheath of the rectus abdominis about it; while Charles Mayo uses a strip of tissue from the gastro-hepatic or greater omentum leaving it attached at its gastric end. Peck 2 states that he has collected a number of rontgenographic ob- servations, some of them four years after gastro-enterostomy, which show the openings of the latter still functionating through the pylorus was patent in these cases. He does not believe one can draw deductions from animal experimentation in this regard. Kuttner, 3 in the study of noo cases of gastro-enterostomy by late rontgenoscopy, states that the func- tioning of the stoma was excellent except in a few cases. He believes it functionates even with an open pylorus. Hartmann 4 holds the same view reporting animal experiments and rontgenoscopies. He states, however, that it remains open when the stoma is at the pyloric antrum. In view of the practical demonstration in Figs. 185-187, it would seem to the writer that pyloric closure would be preferable. Excision of the ulcer in chronic cases, I now believe the safest procedure. This is especially true in view of the frequent occurrence of cancer engrafted on gastric ulcer. Prophylaxis of gastric cancer can be aided by ulcer ex- cision, as Wilson and MacCarty have shown that 71 per cent, of cancers had their origin in chronic gastric ulcer (Mayo). 5 Coffey 6 excised the entire lesser curvature in a case of ulcer with success. W. L. Rodman further advocates pylorectomy in chronic gastric ulcer to prevent later cancerous implantation on the base of the ulcer. Moreover, the danger of hemorrhage, adhesions, etc., are thus eliminated. In cases of pyloric obstruction (stenosis) from ulcer with dilatation of the stomach, I always advocate surgical procedure, finding that though there may be temporary improvement, at times quite marked under medical treatment, in every case there is subsequent relapse. Gastrojejunal and Jejunal Ulcers. One must remember the pos- sibility that after gastrojejunostomy for gastric ulcer a secondary ulcer occasionally occurs in the intestinal loop or at the gastrojejunal junction. A unique case of this type is reported by J. F. Percy, in the Journal of the American Medical Association, April 9, 1910, a recurrent ulcer per- forating at the gastro-intestinal (anterior gastrojejunostomy) anas- tomoses. An omental adhesion prevented peritonitis. A posterior operation was then performed. Percy believes that infection from chronic cholecystitis is a factor in these cases. Dunham, in the November 10, 1910, issue of the same journal, gives some interesting statistics on gastro- enterostomy. 1 Journal A. M. A., p. 883, Mar. 22, 1913. 2 Journal A. M. A., Aug. 12, 1915. 3 Arch. f. klin. chir., 1914, cv, 789. 4 Annals Surgery, 1914, lix, 835. 6 Jour. Amer. Med. Assoc., May 14, 1910, p. 1609. 6 Ibid., Sept. 10, 1910 (Wilson and Willis); Jan. 28, 1911. ULCER OF THE STOMACH William J. Mayo 1 calls attention to the development of gastrojejunal ulcer at the site of anastomosis and attributes the ulcer in some cases to irritation by a silk suture which may remain hanging in the wound, advising therefore very fine silk sutures. Pressure ulcer from impaction of a Murphy button, retention of infected suture material and infected hematoma have been reported as causes. Jejunal Ulcers. A single ulcer is the rule generally occurring near the anastomosis. Etiology. Hyperacidity has been considered the cause in most cases and in others hypersecretion. Among other causes are contraction of the jejunum below the anastomosis with stagnation above it, traumatism at the time of operation, disturbance of circulatory conditions due to abnormal position of the loop, and infective origin. Symptoms. The first symptom may be perforation. In other cases after temporary relief by operation, epigastric pain will recur, generally two to four hours after meals and not relieved by food; the pain is often lower, usually to the left of the midline and below the umbilicus occa- sionally soda bicarbonate is of benefit. Gastric analysis usually shows hyperacidity but not always, and occult blood is present, and is usually also found in the stools. Tenderness may be present. Hemorrhage may occur with black tarry stools. Many of the old symptoms of gastric ulcer recur. Perforation may occur into the peritoneal cavity through the abdominal wall or into the colon. Radiology. Carman and Balfour 2 note the following radiological find- ings under normal conditions following gastroenterostomy. 1. The opaque meal passes freely through the stoma. This is the rule, subject to occasional exceptions, even after the lapse of years. 2. No retention is present in the stomach from the six-hour meal. 3. The duodenum is not dilated. 4. The stomach is usually small. 5. Peristalsis is not overactive. RONTGEN FINDINGS IN ELEVEN CASES OF GASTKO-JEJUNAL ULCER Rontgen-ray findings Case number 50276 83614 81306 76684 98939 12869 69645 96667 "5553 101624 131378 Deformity about stoma. . Exaggerated peristalsis. . Large stomach + + + + + + + + + + + + Mod. + Aver. Mod. + + + + + + + + + + + + + Mod. Gastro-enterostomy not freely patent Retention from six-hour meal Lessened mobility of stomach + + Dilatation of duodenum . Spasticity of stomach + + Irregularity of jejunum. . + + + + + 'Boston Med. and Surg. Jour., Jan. 29, 1914. 2 Journal A. M. A., July 17, 1915. 314 DISEASES OF THE STOMACH AND INTESTINES 6. The gastric contour in the vicinity of the stoma is not usually deformed, save for a slight dimpling at that point occasionally. 7. The efferent limb of the jejunum is neither narrowed nor markedly irregular in outline. 8. Extensive adhesions about the stoma simply as a result of opera- tion are uncommon, and the stomach is at least moderately mobile. 9. The stomach is not deformed (unless by the original lesion or its resection) and has no tendency to hour-glass form or spasticity. Noteworthy is the fact that of the eleven patients examined ten showed abnormalities not customarily seen in the gastro-enterostomized stomach. Prognosis. This is grave. Treatment. Ulcer cure may be tried for a brief period, but surgical procedure should preferably be instituted. EXULCERATIO SIMPLEX (DIEXJLAFOY) OR SUPERFICIAL ULCERA- TION OF THE STOMACH Small ulcerations of the mucous membrane of the stomach, so minute that they appear to be little more than erosions, have been observed, from which fatal hemorrhage has taken place. The usual symptoms of ulcer have been absent and no vomiting occurred prior to the hemorrhage. On the other hand, symptoms of hyperacidity may be present. Dieulafoy was the first to minutely describe this affection. Anatomy. There is a superficial round or elliptic loss of substance, involving merely the mucous membrane and the muscularis mucosae and some blood-vessels. It does not penetrate further into the coats of the organ. The defect may be from pinhead size to a quarter of a dollar in dimension; the margins are not indurated, and it may be difficult to detect even on autopsy, being concealed in some of the folds of the mucous membrane. The stomach is healthy throughout. There may be a slightly reddened zone about the area and it may be in any location. Etiology is unknown. It may be the beginning of an ordinary ulcer, or possibly a toxic element is responsible. Age. Chiefly in persons from twenty-five to thirty. Symptoms. The patient may be in perfect health, when he suddenly vomits H liter (o.i) to i quart (liter) of blood, accompanied by melena. The hemorrhage may prove fatal. The symptoms are those of any hemor- rhage: dizziness, cold extremities, collapse, and the patient may become rapidly moribund. Occasionally the patient may recover and suffer from recurrences. On the other hand, Dieulafoy holds that a case repre- senting severe symptoms of hyperacidity, but showing actual subacidity, should always suggest exulceratio simplex ventriculi. Diagnosis. Ordinary cases of gastric ulcer suffer from gastric symp- toms, while these cases may not. From latent ulcer of the stomach it cannot be differentiated. With chronic erosions there are no hemorrhages. With achlorhydria haemorrhagica gastrica, the gastric findings are typic and the condition is secondary to other disease. GASTRIC EROSIONS 315 Treatment. This is the same as in hematemesis from ulcer, morphin, y grain (0.016); ice-bag over stomach; 10 per cent, gelatin solution every half hour, 2 drams (8.0) by mouth; lactate of calcium, 10 grains (0.66), by mouth and by rectum; ergot, injections of human blood-serum by hypo- dermic or horse-serum by mouth, hypodermoclysis (2 per cent, gelatin), also of saline solution, etc. Dieulafoy recommends operative procedure, suturing the bleeding point if medical remedies fail or if the hemorrhages are recurrent. The author's inflating gastroscope would be of value to locate the erosion. GASTRIC EROSIONS These are subdivided into acute erosions and chronic erosions. Acute Erosions (Hemorrhagic Erosions) These are small (2 to 4 mm.) abrasions of the mucosa of the stomach, in character usually multiple, and extend partly or through the layer. In the early stages there are hemorrhages into the substance of the mucosa which appear as purplish brown or blackish spots, later becoming digested, showing small eroded areas. Often they are difficult to find at post- mortem, lying between the folds of the mucosa. There is hemorrhage (hematemesis) with this type with its symptoms preceded at times by pain. Etiology. They occur in the newborn; in the cachexia of children; in chronic heart and arterial diseases; cirrhosis of the liver; in acute in- fections with the pneumococcus (Dieulafoy), and with septic organisms also in postoperative cases, such as after appendicitis operation (vomito- negro-appendiculaire). Retrograde embolism resulting from detached thrombi from veins ligated in the omentum or mesentery has been con- sidered a cause of erosions and they are found associated with the throb- bing aorta in a considerable number of neurotic women. Muscular contraction with pylorospasm associated with hyperacidity secondary to gall-bladder or appendical infection have been considered causes; though the toxic element from these infected organs would seem to the writer the more likely cause. Such contractions and formation of erosions have been considered a result of vagotonia. Treatment is that of hematemesis and also of the cause. Chronic Erosions (Erosions of the Stomach) An erosion is a small superficial exfoliation of the gastric mucous membrane. Erosions of the stomach have been quite frequently found at autopsy, and the subject has been discussed by Virchow, Ewald, Gerhart, and others. The latter found nothing characteristic. Riegel notes the frequency with which small fragments of mucous membrane are washed out of the stomach, and believes it due to the tearing from this procedure. He denies its significance as a special pathologic process, but believes that at times an examination of the fragments will demonstrate the general condition of the mucous membrane. There is even to-day some dispute as to whether the erosions of the 316 DISEASES OF THE STOMACH AND INTESTINES stomach can be described as a separate clinical entity, in view of the fact that in the majority of cases there is a chronic gastritis, and only on lavage the bits of mucous membrane are secured, some believing it to be due to manipulation with the tube. We must credit Einhorn 1 with first describing erosions of the stomach as a clinical entity. Pariser, 2 Quintard, 3 Mintz, 4 and others have re- ported cases. Undoubtedly, not in every case in which bits of mucous membrane are washed out of the fasting stomach have we chronic erosions. I have noted in several cases of chronic gastritis in which unquestionably lavage was performed in an unscientific manner by the physician in attendance the appearance of these small fragments, and yet the patient never subsequently suffered from the salient symptoms described. Traumatism was the evident cause. Erosions may occur in acute cases. I was recently called to attend a patient with acute gastritis, having severe and persistent vomiting streaked with blood, and though I washed the stomach with greatest care, in two washings several pieces of gastric mucous membrane were found, evidently exfoliation from the acute process and violent vomiting. The case made a rapid recovery with no further symptoms. Unrecognized cases of chronic erosions occur, but those recognized intravitam by the clinical symptoms are, so far reported, comparatively few. Etiology. Chronic catarrhal gastritis is the chief factor, though Einhorn reports erosions associated with hyperchlorhydria, and I have seen them once with acid gastritis, and once with achylia. Symptoms. The diagnostic symptoms described by Einhorn are: Pain, emaciation, weakness and lassitude, and the finding in the wash-water after lavage of one or more small pieces of gastric mucous membrane. There is usually decrease in acidity and free hydrochloric acid and considerable mucus (chronic gastritis). Pains. These are not intense and occur directly after meals, ir- respective of the character of the food. They last one or two hours and are never severe. There are usually intervals free from pain, though rarely the pains are constant. Emaciation. The patients lose weight at first; the face becomes rather thin. They have not the cachexia of cancer nor the appearance of suffering as in ulcer. Weakness. The patient feels weak and unable to work, and likes keeping quiet, most markedly so for a period after meals. Loss of appe- tite is present in some cases. Pathology. If the stomach is washed out in the fasting condition, one or more small pieces of gastric mucous membrane are found in the wash-water. They appear normal under the microscope, but are in- filtrated with red blood-cells. This lesion is constantly found after lavage. 1 N. Y. Med. Rec., June 23, 1894; also Jour. Am. Med. Assoc., May 20, 1894. 2 Berlin, klin. Wochenschr., 1900, No. 43. 3 Arch. f. Verdauungskrankheiten, 1901. 4 Zeitschr. f. klin. Med., Bd. 46, 1902. GASTRIC EROSIONS 317 Blood is rarely present, though occasionally the wash-water is slightly streaked with it. Einhorn believes the "erosions" resulting from the peeling off of the mucous membrane are responsible for the pain and tenderness, and that it has not yet been determined whether the exfoliation recurs at the same place after healing, or in new regions of the stomach. N. W. Jones 1 describes hemorrhagic erosions and autopsy findings in chronic erosions (Einhorn's disease). Considerable blood was found in the intestines, and blood had previously been found in the stools. The cause of death is not given. The case is apparently one of acute hemorrhagic erosions, recurrent type, or possibly more the aspects of achlorhydria haemorrhagica gastrica, and not of chronic erosions at all. Gastric Analysis, The hydrochloric acid secretion is, as a rule, de- creased and also the total acidity. Considerable mucus is usually found. Rarely , hyperchlorhydria is present, and in one case I found acid gastritis. In washing the fasting stomach, one to four pieces of mucous mem- brane (0.3 to 0.4 cm.) are found. They are blood-red, and under the microscope and the gastric glands and red corpuscles are visible. Prognosis. The disease is usually of long duration, with at times intervals of improvement. Treatment. The diet depends on the gastric findings. The treat- ment is the same as for chronic gastritis, acid gastritis, or for hyper- chlorhydria, depending on the case. Hydrotherapy and out-of-door exercise are of service. If deficient hydrochloric acid, nux vomica, compound tincture of cinchona, and condurango are indicated; if hyperacidity, the alkalis, such as magnesia usta or sodium bicarbonate. There are three methods of local treatment: 1. Bismuth Treatment. Lavage every other day with milk of magnesia to dissolve the mucus, and t.i.d. 15 to 30 grains (1.0-2.0) of bismuth subnitrate before meals. 2. Nitrate of Silver Treatment. This is superior in many cases. It may be administered internally, y grain (0.016) in solution t.i.d. three hours after eating; lavage with an alkali every two or three days de- pending on the mucus; or lavage every other day with i : 2000 to i : 1000 silver nitrate, preceding it by lavage with warm water. Argyrol or protargol i : 2000 can be substituted. Einhorn recommends intragastric galvanization on one day, with nitrate of silver spray preceded by lavage on the following day, and so alternating. He first washes the stomach with warm water, which is all removed, and then sprays the stomach with his instrument, employing 10 c.c. of a o.i to 0.2 per cent, solution of nitrate of silver solution, employing most of it and moving the tube about. The bottle should be opened before removal of the spray. 3. The extract of the suprarenal gland (Armour & Co.) has been recommended by Einhorn. He employs it in his powder-blower and 1 Jour. Amer. Med. Assoc., Oct. 14, 1911. 318 DISEASES OF THE STOMACH AND INTESTINES applies it every other day to the stomach, 3 grains (0.194) at a time, instead of the silver nitrate spray. Good reports are given of this method. PERIGASTRITIS AND PERIGASTRIC ADHESIONS Localized perigastritis with the formation of adhesions to other organs may result from various causes, among which are the follow- ing: gastric ulcer; recurrent attacks of acute gastritis by extension or by infection from within; infections from the gall-bladder, liver, appendix, spleen, duodenum, or transverse colon; cancer or ulcer of adjacent organs; and tubercular peritonitis. Adhesions are more fre- quently due to gastric ulcer and are not at all uncommon in cases in which cicatrization has taken place, in which event the pylorus and lesser curvature are most frequently involved. In at least 7 to 8 per cent, of cases of gastric ulcer such adhesions occur. They may also take place to the parietal peritoneum. Infection of the gall-bladder is a quite frequent cause of gastric adhesions, particularly of the spider web variety, which may produce pyloric stenosis with dilatation of the stomach, and at times even gastric hemorrhage from the congestion caused by cir- culatory interference, so that the diagnosis of stenosing gastric ulcer has been made. R. T. Morris particularly refers to this type. The stomach, liver, and gall-bladder may be bound together by adhesions originating from either gastric ulcer or gall-bladder infection. When the adhesions result, for example, from gastric ulcer, there is at first a localized peritonitis (perigastritis) with increased pain, tenderness, at times vomiting, and a moderate temperature in the cases of more acute type. The location of the pain and tenderness depends on the site of the perigastritis. In the subacute cases there may be few clinical symptoms, possibly an in- crease in gastralgia, with some interference in the motility of the stomach, increased pain when the stomach is distended with food, some loss of flesh and strength, etc. If ulcer be the cause, the gastric findings do not alter. Disturbances of gastric secretion, however, frequently occur with gall-bladder disease (infection) with accompanying adhesions. J. A. Lichty 1 has experimentally demonstrated on dogs disturbances of the gastric functions produced by gall-bladder infection. If the adhesions affect the pylorus, stenotic dilatation of the stomach may result with its accompanying symptoms. Gastroptosis may also occur from adhesions forming on the lower border of the stomach and dragging down the organ. Adhesions to the intestines may produce acute or chronic intestinal ob- struction and distention of the gall-bladder from interference with the common duct. If adhesions involve the pancreas affecting the duct, disturbance of the pancreatic functions may result. A local abscess may occasionally occur which may require surgical intervention. In some cases one can palpate a thickened mass due to the perigastritis. If the perigastritis and adhesions occur at the cardia, partial sten- osis may result, with regurgitation of food, etc., the symptoms of sten- osis of the esophagus. 1 Amer. Jour. Med. Sci., Jan., 1911. PERIGASTRITIS AND PERIGASTRIC ADHESIONS 319 A frequent symptom observed is that when adhesions are present in the stomach, exclusive of the cardia, as above noted, after disten- tion of the stomach with food or gas, considerable pain often follows from dragging on the adhesions. Diagnosis. The previous history of gastric ulcer or some other intra-abdominal lesion is of great assistance in the diagnosis. Local tenderness and pain, increased pain after distention of the stomach with food, the symptoms of pyloric stenosis with dilatation of the stomach (when such conditions are present) are of service. Sometimes a thickened mass can be palpated. The -rays are a valuable aid, showing local disturbance in the motility of the stomach, a change of contour, and in some cases an abnormal position of the organ. The reader is referred to the X-ray Diagnosis of Stomach and Gall-bladder Disease, where, for example, the abnormal position of the pylorus when adherent to the gall-bladder is well illustrated. Treatment. Perigastric adhesions in most cases require opera- tive interference. If a localized abscess is present with the perigastri- tis, it should be opened and drained. Mild types of adhesions may go for years without operation, but there is invariably considerable dis- comfort, and frequently disturbances of the gastric secretion ultimately result, as well as disturbances of motility of the organ. The nervous strain on the patient is marked and invalidism results. The author advocates operation by preference even on these cases. Adhesions producing pyloric stenosis require operative procedure. . CHAPTER XIII CANCER OF THE STOMACH (CARCINOMA VENTRICULI) OTHER TUMORS OF THE STOMACH APPARENT TUMORS OF THE STOMACH FOREIGN BODIES IN THE STOMACH CANCER OF THE STOMACH (CARCINOMA VENTRICULI) Frequency. In an analysis of 30,000 cases of cancer, W. H. Welch, of the Johns Hopkins Hospital, finds the stomach involved in 21.4 per cent., standing next in frequency to uterine cancer. Osier states that there were 150 cases of carcinoma ventriculi in 8464 patients admitted to the hospital wards. Haberlin gives 41 per cent, from 1877 to 1886 in his statistics, while Brinton places it at about 25 per cent. Virchow stated that the stomach was the site of primary carcinoma in 34.9 per cent, of all cases, while d'Espine places it at 45 per cent. William J. Mayo 1 holds that nearly one-third of all cancers occur in the stomach. The Census Bureau reports out of a total of 140,088 deaths from cancer, the stomach and liver combined were 36.4 per cent., and the female genitals 14.7 per cent. In a study of 2268 autopsies at the Philadelphia General Hospital, 2 the total number of cases of primary cancer were 121. Of these, 45 were of the stomach; 32 were in males, 13 in females. There were 13 cases of uterine cancer. Kiittner 3 comments on the prevalence of cancer in southeastern Germany. Haberlin demonstrated that gastric cancer is on the increase in Switzerland, and Joseph D. Bryant shows the same in the United States. Its frequency seems to vary in different countries, Griesinger having never observed it in Egypt. Coley 4 shows the general increase of cancer. Age. Welch finds that three-fourths of his cases occured between the ages of forty and seventy. Smithies 5 reports 16 cases of gastric cancer, 9 females and 7 males under thirty-one years of age, the youngest only eighteen years old and the general average 28.7 years. The duration of previous gastric trouble was four months in the shortest and fifteen years in the longest, the average time being 4.2 years. In no case was there achylia, the average free HC1 being 26. He found cases showing the longest free HC1 were in association with large cancerous ulcers, a significant fact. Osier analyzes 150 cases as follows: Between twenty and thirty years, 6 cases; from thirty to forty, 17; forty to fifty, 38; fifty to sixty, 49; sixty to seventy, 36; seventy to eighty, 4. 1 Journal A. M. A., Aug. 23, 1913. 2 Cancer of the Stomach, A Statistical Study (J. A. McGlinn), Amer. Jour. Surg., Dec., 1 909. 3 Therapie der Gegenwart, Berlin, Jan., 1911, No. i. 4 Surgery, Gynecology, and Obstetrics, June, 1910, pp. 591-597. 5 Sixty-fifth Annual Meeting A. M. A., June 22, 1914, in Journal A. M. A., Nov. 22, 1914. 320 3 2I Fifty-eight per cent, occurred between forty and sixty, the youngest case was twenty-two. Welch's statistics show the majority of cases between forty and sixty. The maximum liability to cancer of the stom- ach is, therefore, between the ages of forty and sixty. Two cases of congenital carcinoma have been reported and also several cases under the age of thirty, as just referred to. Sex, Welch finds cancer of the stomach slightly more frequent among men, 1233 men to 981 women; and Osier, in 150 cases, 126 males and 24 females. Statistics vary somewhat regarding percentages, but it seems to preponderate in males. Race. -Among 150 cases at the Johns Hopkins Hospital, there were 131 among the whites and 19 among the blacks. The ratio of colored patients to white, however, in our hospitals is small. Heredity. Since several members of one family have been afflicted with cancer, many are inclined to believe heredity plays a part. Delafield 1 and Prudden hold that, "while the influence of heredity is difficult to estimate, there are a few well authenticated cases of the remarkable prevalence of malignant tumors in families within a few generations." The statistics of Williams showed that in 235 cases of carcinoma of the uterus or breast, 9 per cent, gave a history of carcinoma in the father or mother, while in nearly 20 per cent, there was evidence of carcinoma in the family; though such statistics are suggestive and indicate that an hereditary predisposition to the development of tumor may exist, this does not account for the immediate excitement of the growth of tumors, and is, as Menestrier has urged, but one of the examples of hereditary disposition which is observed in many forms of disease, such as infections, cerebral apoplexy, etc. Williams cites the fact that the father, brother, and two sisters of Napoleon died of cancer of the stomach, to which he himself succumbed. William S. Bainbridge, 2 who has extensively investigated the ques- tion, believes that the hereditary acquirement of cancer requires much more study before definite conclusions can be formulated, and in this I agree. Etiology .. Traumatism has been given as a frequent cause of cancer of the stomach, but Osier reports only one case in his series. Prob- ably attention is drawn to this part by reason of the injury, and the tumor is thus recognized more early. Coley 3 has, however, recently reported a number of cases in his own experience, and in that of foreign observers, in which traumatism would seem to act as a direct causative agent, both of carcinoma and sarcoma. John B. Deaver 4 refers to the influence of trauma, citing as an example skin carcinoma caused by continued exposure to the .r-ray. Cider, sour wines, mental worry, and nervous strain have been suggested as predisposing causes, but they have no influence. As the muscular fibers of the cardia and pylorus, undergo frequent expansion and contraction, and are subject to more work than other 1 Handbook of Pathologic Anatomy and Histology. 2 Boston Med. and Surg. Jour., June 27, 1907. 3 Annals of Surg., April and May, 1911. 4 Amer. Jour, of Surg., Aug., 1911. 322 DISEASES OF THE STOMACH AND INTESTINES portions of the stomach, Brinton believes the necessarily increased nutrition of these parts may favor glandular proliferation and be pro- ductive of a neoplasm. Some consider chronic inflammatory disease of the mucous mem- brane of the stomach to be a predisposing factor in the production of carcinoma, notably the polypoid form of chronic gastritis (Menes trier). As a rule, carcinoma develops without a previous history of long-stand- ing gastric disturbance, and I agree with Ewald and Einhorn in believing these conditions have no influence. The gastritis found with cancer is a secondary condition. The de- velopment of cancer on an ulcer scar has been clinically demonstrated by Hauser. Haberlin places about 7 per cent, of cases as occurring in this manner, while Moynihan gives 60 per cent. Of the tissue removed from the stomach and duodenum in the Mayo clinic since 1905 approximately 60 per cent, of the specimens showing cancer, gave more or less pathological evidence of the precedence of ulcer in the same area. Smithies 1 states that out of 566 cases operated and demonstrated as cancer 0.65 per cent. gave early clinical evidences of chronic gastric ulcer. Wilson 2 published a paper in December, 1914, reporting on 445 gastric carcinomas examined in the Mayo clinic in which he states that in all probability very few cases of gastric cancer exist which have not originated at the site of a previous ulcerative lesion of the mucosa. Wilson and McDowell also report on the relationship between gastric ulcer and cancer. MacCarty and Broders 3 show the enormous incidence of cases showing the characteristics of simple ulcer plus the presence of carcinoma (microscopic) and that the differential diagnosis can only be made by the microscope. It is now held that about 71 per cent. 4 of cases develop from ulcer. McCarthy 5 demon- strates that even radiography plus the history and clinical symptoms will not differentiate between a chronic gastric ulcer and early malignancy. He shows by pathological examination, that cases believed to be non- malignant were determined to be undergoing malignant degeneration. This further emphasizes the necessity of radical operation in all cases of chronic gastric ulcer. When one remembers that in about 5 per cent, of persons dying from all causes Brinton finds evidences of gastric ulcer, it can be readily under- stood how carcinoma can develop on an ulcer scar with no apparent previous gastric symptoms. The author's view is that 70 per cent, develop on a previous ulcer in spite of the fact that Fenwick reports only 3 per cent, of cases with previous ulcer history, and Osier 2.6 per cent. These last statistics do not militate against the theory of development of carcinoma on the base of an occult ulcer with no symptoms. Bloodgood, 6 in a series of 182 cases from the Pathological Laboratory of the Johns Hopkins Hospital, notes duration of disease (symptoms) in 67 cases, ex- 1 Journal A. M. A., Nov. 15, 1913. 2 Wilson and McDowell, Amer. Jour. Med. Sci., Dec., 1914; also Mayo clinic, vol. vi, 1914. 3 Arch. Int. Med., Feb., 1914, p. 208. 4 Wilson and MacCarty, Amer. Jour. Med. Sci., Dec., 1909. 6 Amer. Jour. Med. Sci,. April 15, 1915. Jour. A. M. A., June 18, 1915. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 323 tending over a period of two to six years, or more. This suggests to the author a previous ulcer. The author has had impressed upon him by two practical experiences, the danger of non-radical operation in chronic gastric ulcer, both in private patients. In the first case, a woman aged forty-five with chronic gastric ulcer near the pyloric ring, though I advised resection of the stomach, the operator, through error of judgment, would only consent to a gastro-enterostomy. There was marked improvement, in fact for one and one-half years an apparent cure. Gastric symptoms then recurred and two years after the first operation, the patient was reoperated for cancer which had developed at the site of the old ulcer, and died directly after operation. The second patient, a woman of fifty-seven was anemic, had lost some weight; achlorhydria was present, but no Boas-Oppler bacilli. The radio- graphs showed hypermotility of the stomach, but no deformity was visible. I believed a superficial ulcer or erosion to be present, insufficient as yet to cause deformity. Having radical views I advised exploration. She preferred medical treatment. It seemed absolutely impossible to improve her nutrition, there only being a few pounds gain under forced feeding. Her pain would disappear, and then recur. About six months later radio- graphs were again taken, showing hypermotility of the stomach with slight deformity near the pylorus, in my belief a chronic ulcer with prob- ably commencing cancerous degeneration. Operation was once more ad- vised. The patient then drifted into other hands, but I learned that she died about six months later from gastric cancer. In securing the history from patients with gastric cancer, there is a tendency to center the attention on the existing symptoms, or on those that have been marked for a recent period. Usually, however, with per- sistent questioning one can secure a history of some previous gastric dis- turbance frequently dating back a considerable period. In a series of 20 cases of cancer, the writer finds that 75 per cent, of cases gave a his- tory of previous gastric disturbances before their present illness, while five of these cases gave an undoubted ulcer history. These figures are of course small as compared with hospital records, but they are suggestive. Some hold that cancer originates from embryonic rests, or prenatal wrongly placed tissue elements, which at some time take on a morbid action and develop into cancer, others that local injury or irritation may be the dominant factor in determining the activity of these misplaced cells. Duncan Bulkley 1 notes the rarity of cancer in vegetarian people such as in Japan, China, etc., and its frequency among the meat eating races, believing this may have some bearing in activating the process. Ross 2 holds there is a failure in the potash element in patients who are subject to cancer, while Lane believes that the left breast for example be- comes indurated as a result of autointoxication (intestinal toxemia) and cancer may result. Cancer of intestines, etc., may also occur. Regarding the parasitic origin of cancer and its infectious nature 1 Med. Rec., Oct. 24, 1914. 2 Cancer, the Problem of Its Genesis and Treatment, London, 1912. 324 DISEASES OF THE STOMACH AND INTESTINES there is much dispute. Scheurlein believed he had discovered a bacillus, but later researches demonstrated his error. Gaylord, Park, and Adami hold to the parasitic theory, and Gaylord states that in all the organs, including the blood taken from cases dying of cancer, certain organisms (parasites) are found. He has inoculated guinea-pigs and dogs with peritoneal fluid from a human abdominal tumor and produced adenocarcinoma in the lung and liver. Coley has secured, in a few cases, good results in the treatment of cases chiefly of sarcomata and of a few cases of carcinoma by the injection of his serum, and I have personally seen a favorable result in one case of kidney sarcoma. Psorosperms have been found in cancer cells, but it has not yet been proved whether they are real psorosperms or dried-up and changed cells. Beard's recent theory and his suggestion of the use of trypsin in the treatment of cancer has been proved of no value. We must confess so far the origin of cancer has not yet been determined, though I believe it will eventually be demonstrated to be due to some bacillus or parasite in spite of many views to the contrary. Morbid Anatomy. Waldeyer demonstrated that cancer of the stomach originated from the glandular structure of the mucous mem- brane, being an atypic proliferation of the epithelium of the glands. Beginning in the mucosa, it infiltrates the submucosa, the muscular coat, and extends to the serosa. Early in the development of the disease the lymphatic glands become enlarged, particularly those of the lesser curva- ture. Metastatic growths may take place. The cancerous growth, especially of a certain type, may slough and form irregular ulcers. Varieties. The most common varieties of cancer are the cylindric- celled adenocarcinoma (or epithelioma) and the encephaloid or medullary carcinoma; next in frequency is the scirrhus, and least frequent, the colloid cancer. 1. Adenocarcinoma (Cylindric-celled) or Epithelioma. This type forms soft tumors, of firmer consistency than the medullary type, and sloughing more slowly. Microscopically, the section shows elongated tubular spaces filled with columnar epithelium, and the intervening stroma is abundant. Gradually the tubular spaces develop into cell-nests. There is frequently infiltration of the connective tissue with white blood- corpuscles. Cystic degeneration is quite common. Metastases and hemorrhage may occur. 2. Medullary Carcinoma. This occurs in soft, spongy, fungating masses, which involve all the coats of the stomach and usually ulcerate early. It is large and often flat, projecting above the mucous membrane, and may form villous-like projections, or a cauliflower-like outgrowth. It is soft and grayish or yellowish white and contains many blood-vessels and cells. Microscopically, it shows scanty stroma, enclosing alveoli containing irregular polyhedral and cylindric cells. It is often blackish in color, due to hemorrhage (melanotic), and has a tendency to ulcerate. Metastases are frequent. 3. Scirrhous (Fibrous) Carcinoma. This is characterized by great hardness, due to abundance of stroma and the limited amount of alveolar structure. The large amount of connective tissue makes the tumor very CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 325 firm and compact. It cuts almost like cartilage, and on section has a yellow or grayish-white appearance. There is little tendency to ulcerate, except at a late stage superficially, and secondary metastases are not common. It is seen quite frequently at the pylorus, there being a diffuse thickening and hardening of the wall and then a contraction, being a common cause of stenosis. The tumor may be diffuse, involving all parts of the stomach, when it may be difficult to recognize it microscopically from cirrhosis ventriculi. It has occurred in the stomach secondary to ovarian cancer, and as a part of a diffuse carcinomatosis, with involve- ment of the small and large intestines. It may be combined with the medullary form. 4. Colloid Carcinoma. This type of cancer is peculiar, from the fact that it invades widely all the coats of the stomach. It spreads with great frequency to the neighboring parts, and at times causes secondary growths of the same nature in other organs. The appearance on section is distinctive, showing large alveoli filled with translucent gelatinous colloid material. This is often present, even to the naked eye. On scraping, no cancer juice exudes, but gelatinous fragments. Various transitional forms, from one variety to another, are often found. Rarely a carcinoma consisting of squamous epithelium may extend from the esophagus into the cardia. Brinton, in analyzing 180 cases of cancer, finds the scirrhus type to be most common (72 per cent.), the medullary next in frequency, though other observers, notably Osier, consider the epithelioma to be most frequent. Cancer of the stomach is usually primary, though secondary growths have been reported. Cancer may also extend from the liver, pancreas, and intestines. Types of Growth. Medullary and colloid cancers involve large areas of mucous membrane, growing little above the surface, being somewhat flattened, with occasional rough nodular masses. Blood extravasations and adhesions to neighboring organs are of frequent occurrence. The scirrhus variety extends usually only over a small portion of the mucosa, and may develop extensively in thickness, growing in depth and height. The latter type, however, occasionally infiltrates the entire stomach, causing a contraction of the organ (cancer atrophicans). Secondary Changes in the Mucous Membrane of the Stomach. Hammerschlag has investigated the gastric mucosa in cases of carcinoma by examining fresh pieces of mucous membrane removed in cases of resection of the pylorus at the time of gastro-enterostomy, examining also the section of the stomach. When the hydrochloric acid secretion was intact, there were no changes in the mucous membrane. When it was absent and lactic acid present, changes occurred, and there were found destruction of the rennet glands in certain areas and small-celled infiltration and formation of connective tissue in the gastric mucosa, also mucoid changes or cystic degeneration; in effect, a secondary atrophic gastritis. Eosinophile cells are present. Hypertrophy of the muscular fibers and connective tissue has been ob- 326 DISEASES OF THE STOMACH AND INTESTINES served. Ewald has also noted that the entire mucosa may show the lesions of chronic gastritis. It is interesting to learn that Fenwick has demonstrated that atrophic gastritis may occur with carcinoma of the breast and uterus. Wilson and MacCarty, however, in an extensive study of 230 stomachs resected by William Mayo for carcinoma of the stomach, in the majority of which free hydrochloric acid was absent, found that in none of them was there a general atrophy of the mucous membrane. There was present, almost without exception, a marked proliferation of the mucous membrane at the margin of the ulcer, but usually an accompanying round-cell infiltration of the submucosa of a greater or less degree. Location of the Cancer. The development of the cancer may take place in various regions of the stomach, at the pylorus, or cardia, or within the organ, causing variation in the symptoms according to location, and in each case necessitating a special plan of treatment. Welch's analysis of 1300 cases is as follows: Pyloric region, 791; lesser curvature, 148; cardia, 104; posterior wall, 68; the whole or greater part of the stomach, 61; multiple tumors, 45; greater curvature, 34; anterior wall, 38; fundus, 19. In Brinton's cases, 60 per cent, were found at the pylorus. The latter is evidently the point of selection. Wm. J. Mayo believes 70 per cent, involve the pyloric region, and that 60 per cent, originate in the pylorus or within 3 inches of it. Changes in the Shape of the Stomach. If the cancer is situated at the cardia, the stomach is usually retracted and small in size, while the esophagus above the stricture is dilated. If the tumor constricts the pylorus, the stomach will be dilated. Gastroptosis of varying degree may be present by reason of the weight of the tumor dragging down the pylorus, and it may even lie down in the pelvis. Adhesions may distort the shape of the organ, and Riegel reports an hour-glass contraction of the stomach, resulting from cancer. Perforation. Perforations into other viscera, through the skin, or into the general peritoneal cavity are rare. The aorta has been perfor- ated. Subphrenic abscess has been produced. Perforation, however, seldom occurs. Cancerous Metastases. In an analysis of 1574 cases by Welch, metastases occurred in the lymphatic glands in 551; in the liver, 475; in the peritoneum, omentum, and intestines, 357; in the pancreas, 122; in the pleura and lung, 98; in the spleen, 26; in the brain and meninges, 6; in other parts, 92. Some interesting material has been furnished by Eisner 1 regarding cancerous metastases of the nervous system from cancer of the stomach or intestines. He describes peripheral invasion with symptoms of multiple neuritis. Klippel 2 reports five cases of this type. Schlesinger 3 gives statistics as to spinal invasion. Eisner reports three cases, in one of which spinal symptoms preceded the gastric symptoms, and in another case the spinal symptoms were so severe that they masked the presence of the 1 N. Y. Med. Jour., Jan. 21, 1911. 2 These, Paris, 1889. 3 Beitrage zur Klinik des Riickenmarks und Wirheltumoren, Jena, 1889. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 327 primary stomach growth. The bodies of the vertebrae were first involved. These spinal cases are characterized by "agonizing pain." Pinatelle and Cavaillon 1 describe two cases of gastric cancer with secondary deposits in the cranial bones and meninges, and Holden 2 reports a case of invasion of the optic nerve secondary to gastric carcinoma. The abdominal lymph-glands are usually affected, but the cervical and inguinal glands are sometimes attacked. Secondary growths may occur at the navel, or in the skin in the im- mediate vicinity. Infection occurs either by the blood-vessels or lymph- channels. Direct invasion by continuity may take place. The medullary and colloid types of carcinoma are often associated with metastases. Sometimes numerous small cancerous deposits occur in the pleura. The microscope will differentiate them from tuberculosis, though they have occurred together. Rarely, metastases are found in the eyes, as noted above. Symptoms. There are general symptoms and special symptoms, depending on the location of the growth. General Symptoms. Usually a patient of middle age, fifty to sixty years, up to a short time previous a few months or so being in perfect health and having had no gastric symptoms, will begin to complain of slight dyspeptic disturbance, loss of appetite, and fulness, pressure, and discomfort after eating. The author believes that this statement must be modified, in view of the fact that a careful history will usually elicit some previous gastric disturbance or exacerbation, though at times slight at first, or a previous so-called dyspepsia. Moynihan's and Rodman's views are noted below. Undoubtedly a history of former gastric ulcer, in some cases years before, can often be obtained. Kuttner 3 reports that 30 per cent, of his cancer patients had suffered for years from stomach trouble. Belch- ing occurs, also more or less loss of sleep and loss of strength the symptoms looking much like a mild gastritis. The tongue is usually thickly coated. The symptoms gradually become more marked. Rarely the attack be- gins more acutely. The feeling of discomfort gradually merges into pain. This is generally not of the severe spasmodic type of ulcer, but is con- tinuous in character, there not being the intermissions of freedom as in ulcer. It may remit somewhat. The pain is at times increased by the food, but is often intense at a later period after eating than in ulcer. With the belching there is at first regurgitation of food, later vomiting, usually not after every meal, but once or twice a day. This is a prominent symptom when the growth causes a stenosis of the pylorus. I have had a patient with carcinoma of the greater curvature and body of the stomach, an inoperable case who has never vomited at all, the motor function being fairly good. Later, hematemesis occurs, generally several times in succession, and the vomitus is of coffee-ground appearance and not large in quantity. The tumor usually becomes palpable at this time, though often earlier. The patient has, meanwhile, been steadily losing weight, and this loss 1 Progres Medical, April 14, 1906. 2 Arch, of Ophthalmol., 1902, xxi, pp. 427-432. 3 Therapie der Gegenwart, Berlin, Jan., 1911, p. 411, No. i. 328 DISEASES OF THE STOMACH AND INTESTINES becomes more and more marked and anemia and cachexia are prominent. He becomes more weak and prostrated and finally dies of inanition or of complications. These constitute the symptoms of a straightforward case. Unfortunately cases of apparently simple chronic ulcer of the stomach with the symptoms, gastric analyses, and radiological findings of ulcer have proved to be incipient carcinoma. In this connection Smithies 1 makes the following interesting statement: "The early diagnosis of gastric cancer is a microscopic one, it is possible from histologic study of freshly removed tissue; such tissue is seen least developed in those patients whose gastric history has been that of chronic recurring peptic ulcer and in whom to eye and hand such ulcer appears at laparotomy." From the study of 921 cases of gastric cancer he groups the following classes of cases: 1. Gastric cancer coming to laparotomy for clinically benign ulcer and in whom cancer was diagnosed microscopically. 2. Gastric cancer clinically developing in patients with years of ante- cedent dyspepsia of the "peptic ulcer type" in whom malignancy subse- quently appeared. 3. Gastric cancer in those who previous to the onset of this disease had enjoyed perfect gastric health. 4. Gastric cancer in patients in whom malignancy followed periods of gastric disturbance of no clinical type. 5. Gastric cancer in individuals who presented few clinical evidences of a malignant process primary in the stomach wall. 6. Gastric cancer secondary to an extragastric malignant process. Bleeding, constant nausea, distention, diarrhea, persistent pain, loss of appetite, weight and strength, and vomiting may usher in the malignant stage. Various types of symptoms may therefore occur and yet the case be malignant. The author of this volume has long held that chronic gastric ulcer should be considered a precancerous condition and should receive the surgical treatment of cancer. Rodman 2 reports that within a year he has seen 5 cases in which it was practically certain that carcinoma of the stomach was preceded by a long- standing ulcer, in one instance for twenty-seven years, in another, nearly twenty years. Moynihan 3 states that in his last 22 cases of carcinoma of the stomach operated upon, 16 patients gave a previous history of gastric ulcer. In 2 cases a history of chronic indigestion, extending for over 'twenty-five years, was given. Hence, in 72.1 per cent, there had been a gastric ulcer years before. The shortest interval between the attack of gastric ulcer and the onset of the symptoms leading to operation was three years, the longest interval twenty-six years, while 2 patients gave a history of less than three months. In the same' article Moynihan reports 17 additional cases of carcinoma upon which he operated, out of which 8 gave a previous history of gastric ulcer. These records show that a careful anamnesis will usually elicit previous gastric disturbances. 1 Cancer of the Stomach (Smithies and Ochsner), W. B. Saunders Co., 1916. 2 Jour. Amer. Med. Assoc., Jan. 18, 1908, pp. 165-169. 1 Brit. Med. Jour., Feb. 17, 1906, p. 370. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 329 The general symptoms are modified by the position of the growth. A brief analysis of the symptoms is advisable. Anorexia, or loss of appetite, occurs in about 85 per cent, of the cases, and it seems, as a rule, to be progressive. There is at times a special aversion to meat. Riegel believes that in the early stages, while the motor power remains undisturbed, the appetite remains good. This would seem as if toxemia were a factor. Boas reports fair or increased appetite in some cases, believing loss of appetite to be due to lack of care of the mouth and tongue. The toxemic theory of loss of appetite seems most logical. Pain. Pain is the most constant symptom, Osier reporting it in 130 out of 150 cases; Brinton finds it in 92 per cent, of his patients, and others report a higher percentage. It usually begins at an early date, generally in the epigastrium, but may be referred to the hypochondriac regions, the sternum, or sometimes extends to the shoulders or back. It may be lanci- nating, or of a dull, gnawing, or burning character. There may be ten- derness on pressure in the epigastrium. The pain does not occur in paroxysms and is not relieved by vomiting, as in ulcer. It is continuous and never entirely disappears, though it may remit. As a rule, it is less intense than with ulcer. It is not relieved at the end of gastric digestion. In some cases it may occur more markedly after eating, though it is not especially influenced thereby. In other cases there may be more of a painful dull feeling, and it is not circumscribed as in ulcer. Sometimes over the region of the tumor the pain is most intense, as is the tenderness. Head believes there are areas of skin tenderness between the nipple and umbilicus in front and the fifth to the twelfth dorsal vertebrae behind. Exacerbations of pain are caused by ulceration of the growths, or by formation of adhesions. Moreover, Erlanger 1 describes cases in which attacks of pain diag- nosed in some cases as intercostal neuralgia were the first or the principal sign of gastric cancer. The pain radiated to the shoulder in one case. One must think of the possibility that neuralgic pains may be due to the cancerous involvement of the regions innervated by the intercostal, lumbar, or sacral nerves. Vomiting. It may come on early, but more usually later. Osier reports it in 128 cases out of 150; and Brinton in 87 per cent. At first it occurs at rather long intervals, but later may be present several times a day. It is more frequent when the Pylorus is involved, and may come on some hours after the ingestion of food, or at times on rising, when there may be mucus or undigested food in the vomitus. It may be offensive in odor or contain changed blood, microorganisms (Boas-Oppler bacilli), and isolated yeast-cells; but rarely sarcinae, which are most common in benign stenosis. Vomiting can occur, even if the orifices are not in- volved; if the cardia is affected, then regurgitation is characteristic. Extensive involvement of the anterior or posterior wall or fundus may be present without vomiting. Hemorrhage occurred in 36 of Osier's cases out of 150; while Brinton places it at 42 per cent. Riegel believes these percentages too low, 1 Archiv fur Verdauungs-Krankheiten, Berlin, 82. 330 DISEASES OF THE STOMACH AND INTESTINES as hemorrhage may be occult, or often not examined for in the vomitus or stool. The blood is occasionally ejected in sufficient quantity to be visible. It is more frequently mixed with gastric juice, food, and mucus, and presents a blackish, brownish, or coffee-ground appearance; is rarely bright red, Osier finding it in three cases. The quantity is much less than with ulcer, though frequent small hemorrhages may occur. Blood in the stool (melena) may accompany it, though this is rarer than in ulcer. A fatal hemorrhage seldom occurs. Loss of Weight and Cachexia. Progressive emaciation, especially if the disease is running a rapid course or has existed for some time, is a consistent feature. In the early stages we may occasionally see patients who appear fairly healthy or have little loss of weight, or at times temporary improvement may occur under treatment. Unfor- tunately, this is evanescent, and progressive emaciation takes place. In the later stages this is marked, as are the sallow skin and peculiar ashy and cachectic appearance, with loss of strength proportionate to the loss of weight. The Blood. Anemia is always present, and usually marked and progressive; when pyloric stenosis occurs with dilatation and insuffi- cient water absorption, on account of the concentration of the blood the number of red cells may not be greatly reduced. The average count in 59 of Osier's cases was 3,712,186 per cubic millimeter. Average of the hemoglobin was 44.9 per cent. Schneyer 1 has shown that normal digestive leukocytosis is absent in gastric cancer, and that the number of leukocytes during digestion and fasting is the same. Osier claims that only 54 per cent, gave positive reaction. Leukocytosis is present in gastric carcinoma, usually of mild de- gree, and rarely above 12,000 to 15,000. Eosinophilia is usually pres- ent and suggestive. We find some cases without apparent tumor in which the blood count is so low as to be suggestive of pernicious anemia, but the absence of megaloblasts and the presence of leukocytosis speak for cancer. Tumor. In connection with the symptoms, the presence of a tumor in the gastric region is a reliable diagnostic point. In the early stage it often cannot be determined. If large and superficial, it is readily detected. In Osier's 150 cases, tumor was detectable in 115. The methods of its determination are as follows: i. Inspection. Position should be dorsal and the knees flexed to relax the abdomen. In some cases a protrusion can be seen in the gastric region below the ensiform, or at the margin of the ribs. If there is dilata- tion, the lower curvature of the stomach may appear as an arched line below the umbilicus, moving up and down during respiration. Peris- taltic movements are present with stenosis. With gastroptosis, the lesser curvature may be seen at times and the tumor situated thereon moving during respiration. If the tumor is at the pylorus, it may draw the stomach downward and the protrusion may be seen low down in the abdomen, or even at the pelvic brim. Pulsation from the aorta may be 1 Berliner klin. Wochenschr., 1894, No. 41. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 331 transmitted to the tumor. Intrinsic movements in the hypertrophied muscularis may cause the tumor to appear and disappear. A subcu- taneous umbilical nodule can at times be observed. Inspection with the patient standing, as suggested by Knapp, should be carried out in any case, as the tumor can at times be thus more readily appreciated. Frequently, simple inspection gives no information. 2. Percussion. There is dulness on percussion, or a. dull tympanitic note over the tumor, which can be differentiated from the surrounding tympanites. Auscultatory percussion for its determination is described and illustrated in Chapter V. Smithies 1 describes a new percussion sign when the cancer involves the fundus or anterior wall of the body of the stomach. " When the patient is in the dorsal position, percussion of Traube's space is not uncommonly dull, instead of normally tympanitic. Examination of the same area at the end of deep inspiration, or upon the patient lying on the right side, or standing, sometimes results in the disappearance of the dull tones upon percussion of Traube's space and the appearance of characteristic tym- pany. This sign was observed in 18 out of 24 cases of carcinoma involv- ing the superior portion of the stomach where an epigastric tumor could not be palpated." 3. Palpation. This is usually quite reliable. It determines the position and size of the growth, whether hard and nodular or smooth, its respiratory motility, and whether it is painful. It is difficult to recognize a tumor on the posterior stomach-wall unless it is thin and the stomach empty. On the lesser curvature, with the stomach in the normal position, it can only be felt on forced inspiration. 4. Respiratory Motility. Tumors of the curvatures show greater respiratory motility than those of the pylorus. When the latter is adherent to the liver, it follows the excursion of the diaphragm. Tumors are smaller to the palpating finger than they are found to be on operation. 5. Inflation. This is of value in aiding inspection and also in deter- mining whether the growth is connected with the stomach, if it be ad- herent, and in some cases, the position of the tumor in the organ. Air can be employed for the purpose, or, more easily, carbonic acid gas, by the method already described. If the tumor lies in close contact with the liver and moves away from it during inflation, the diagnosis of tumor of the stomach is evident, and the liver and gall-bladder are excluded. If this does not occur, there may be adhesions, or involvement of both organs. If the tumor changes its position during inflation, there are probably no marked adhesions with the neighboring organs, an important fact in reference to operative procedure. A tumor of the pylorus generally moves to the right and downward on inflation; and if held in this position by the hand will not ascend during expiration expiratory fixation (Minkowski). If adherent to the liver, it will move upward. Tumors of the posterior wall and lesser curvature that are palpable 1 Cancer of the Stomach, Smithies and Ochsner, 1916. 332 DISEASES OF THE STOMACH AND INTESTINES before inflation are frequently no longer so thereafter. With gastroptosis, however, the tumor would be palpable, but lie higher up. A tumor of the greater curvature descends when the stomach is in- flated and occupies the lowest border of the area of inflation; it is freely movable on respiration. The position of the tumor should be marked on the abdominal wall before inflation for a basis of comparison. Inflation of the colon some- times aids in the location of the growth. 6. Transillumination of the Stomach. This method is of value for the early recognition of a tumor, but only if it lies on the anterior surface, on the curvatures, or at the pylorus. With the circumscribing gastro-diaphane the lesser curva- ture can be explored. The method with fluores- cent media is preferable. The tumor being opaque, appears as a dark spot projecting into, or within, the transilluminated area; on top, when the lesser curvature is involved; below, if the greater curvature; to the right, if the pylorus (Fig. 188). Temperature. This is not a regular symptom, but often appears in the later stages. It oc- curred in 74 of .Osier's 150 cases. It is of an in- termittent type and rarely runs over ioiF. Chills have occasionally been associated. Fever is prob- Fig 188. -Composite a bi v d ue to some inflammatory process, or to from three patients show- \ ing dark areas in trans- illuminated stomach, pro- pylorus. toxic absorption from the growth. Constipation occurs in the majority of cases duced by carcinomata of and is o b st inate and marked; occasionally there the curvatures and .. . . .. . . . J is diarrhea, due to food decomposition or to scybalae, causing irritation of the intestinal canal, or as a terminal symptom due to sloughing of the cancer. Coma 1 similar to diabetic coma may occur, and is believed to be due to acid intoxication. Thrombosis of the femoral vein is an occasional symptom. Osier reports general thrombosis of the superficial veins in one case. Edema. Swelling of the ankles frequently occurs toward the close, ascites and general anasarca sometimes are present, and the latter may appear early. Metastases have already been described. A small nodule appearing at or near the umbilicus, and though rather rare, may aid in the dagnosis. Multiple neuritis is an occasional complication. Perforation is rare. Tetany is a rare complication, but has occurred with malignant stenosis of the pylorus with ectasia. Urine. Excessive nitrogen excretion has been found in some cases, but it is not constant. Salkowski 2 and Kojo have worked out a method 1 In the terminal stage of cancer, the patient becomes bed ridden, there may be metastasis of the lungs or hypostatic congestion occurs, with rapid respiration, rapid and feeble pulse, irregular temperature, being in a dormant or semi-comatose condi- tion, with resulting coma and death. 2 Berliner klin. Wochenschr., Dec. 12, xlvii, No. 50. CANCER OF THE STOMACH (CARCINOMA VENTRICULI) 333 for determination of the nitrogen precipitated by salts of the heavy metals in relation to the total nitrogen output. The average in the urine of 10 healthy persons was 1.22 per cent., while in 10 cancer patients it averaged 3.03 per cent., the maximum being 4.62 per cent. The minimum 2.15 per cent., was never reached in healthy urine. These facts are suggestive, but further investigation must be made to see if these findings are pathognomonic of malignant disease. Diminution of the chlorids is quite frequent, while indicanuria is common. Glycosuria, acetonuria, and peptonuria have been described. Peptonuria indicates absorption from an ulcerated area. Nephritis is often present, but would be expected in advanced age. Special Symptoms Produced by the Location of the Growth. (a) Cancer of the Cardia. One of the first and an important symptom is dysphagia. The patient finds that there is some impediment to the entrance of solid food into the stomach and assists it by drinking water. The condition gradually grows worse. Later, it is impossible to take solid food at all, as it sticks in the esophagus, causing much discomfort, and is finally regurgitated, often with considerable straining or retching. Finally, most of the fluid even is returned. There are often severe pains behind the end of the sternum and burning sensations. Mucus is some- times ejected with the food, and occasionally blood. The cervical lymph-glands are often enlarged. Bronchitis or bronchopneumonia are frequent terminal events. Physical Examination. The stomach is of normal size or, in some cases, contracted; the swallowing sound is occasionally absent or heard in fifteen to twenty seconds instead of in the normal period of seven, though this is not invariably true. Examination of the esophagus, preferably with soft stomach-tubes of different sizes, should be made. The position of the stricture can be noted by marking on the tube at the teeth when resistance to its passage is first encountered, and measuring the distance from the mark to the tip of the tube. Smaller tubes are then employed, until one of sufficiently small caliber is secured to enter the stomach. In this way the degree of stenosis can be determined. Much force should never be used. In some cases it may be necessary to employ a stiff er tube of silkworm, or bougies of varying sizes. The author's flexible esophageal bougie is a safe instrument. The soft stomach-tube, with openings at the tip and side, is of value for safety; by pinching the tube before withdrawal, blood, either fresh or decomposed, of foul odor or mixed with mucus, may be found within it, which, in conjunction with the other symptoms, is suggestive of malig- nancy. Occasionally a small tumor fragment may be removed, which should be submitted to microscopic examination. With malignant stricture of the esophagus, dilatation above the point of stenosis and retention of food are associated. It also occurs in benign stricture from syphilis or from traumatism from burns by acids or alkalis, or with con- genital stenosis of the esophagus, a rare condition. After the ingestion of suspended bismuth subcarbonate, examina- tion with the #-rays and the fluoroscopc will aid in determining the 334 DISEASES OF THE STOMACH AND INTESTINES site of the stricture. This is of special value when it is not desirable to use the bougie. A rontgenograph should be taken. The complete methods of examination are described under Examination of the Esoph- agus and Esophageal Diseases, under which section is depicted the Writer's flexible bougie. Aspiration of the esophagus above the seat of stricture after a small test-meal, and then the passage of a smaller tube and aspiration of the stomach contents, and a differential examination of the contents are not necessary for diagnosis, though they have been recommended. The food removed from the esophagus would present the appear- ance as when swallowed, and there would be no hydrochloric acid; while in the stomach the particles would be finer, the reaction acid, and free hydrochloric acid might or might not be present. This is also true of the ferments. It has been demonstrated by Moore and Friedenwald 1 that, in cancer of other organs than the stomach, there may be diminution or absence of free hydrochloric acid in the gastric contents, and this occurs at times in cancer of the cardia. The presence of stricture and dysphagia, the age of the patient, and the general symptoms are diagnostic. With diver ticula of the esophagus, which usually occur at the junction of the pharynx and gullet, there is generally a swelling in the neck, which can be diminished by pressure (the contents ex- pressed), and symptoms of cancer are absent. (See also Examination of Esophagus). Spasm of the esophagus usually occurs in nervous patients, and the tube when passed is temporarily arrested. Larger tubes often pass more readily than the small ones. There are no symptoms of malignancy. With persistent cardiospasm, fusiform dilatation of the esophagus may result. This has been referred to and the rontgeno- graph depicted. (b) Cancer of the Pylorus. The chief subjective symptoms are pain, a full, feeling in the stomach and other dyspeptic symptoms, and later frequent attacks of vomiting. Just before emesis there are often severe exacerbations of pain, due to the contractions of the stomach and the effort to expel the contents through the pylorus (peristaltic unrest). The vomitus is generally large in amount (i to 2 liters) and may consist of food taken the day before. Motor insufficiency is marked, the contents on aspiration being found to consist of more or less de- composed food, when the fasting stomach is examined. The particles of food are often quite large and obstruct the openings of the tube, and are difficult to remove by lavage. Cancer of the stomach occurs most fre- quently at, or near the pylorus, producing as noted, food remnants in the stomach; as more than 50 per cent, of cases of gastric cancer have food remnants according to Mayo, the sign is very important as showing mechanical obstruction. Physical Examination. Peristaltic unrest is a frequent symptom in more advanced obstruction. Dilatation of the stomach is present, as determined by the methods of examination described. Gastroptosis may be present. Frequently a tumor can be detected lying in the epi- 1 N. Y. Med. Jour., Aug. 24, 1907. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 335 gastrium to the right of the median line or, if ptosis is present, at a lower level. (c) Cancer of the Body of the Stomach. Pain, anorexia, and other symptoms are manifested. Vomiting occurs in some, but in many cases is absent. The vomitus contains food and occasionally coffee- grounds, the food is more finely divided. The tumor frequently lies to the left of the median line; but if on the upper curvature or posterior surface of the stomach, is not always detectable. There is motor insufficiency of a slight or moderate degree due to infiltration of the muscular tissue by the growth, and occasionally, if the tumor be large and on the greater curvature, a slight dilatation. On the other hand, in the transition cases from ulcer to cancer, there may be only an exacerbation of ulcer symptoms with increasing anemia, loss of strength, etc., with no tumor. Fig. 189. Gastric contents in carcinoma. Dark ground illumination X 460; a, Leukocyte; b, Boas-Oppler bacilli; c, squamous epithelium; d, yeast; e, mucous membrane fragment with carcinomatous cells as rarely found in wash- water; /, bacilli; g, wheat starch grain; h, sarcinse (very rare); i, fat-droplet; j, cocci. Laboratory Diagnosis. In conjunction with the clinical symptoms, analysis of the gastric contents and microscopic examination aid in de- termining the diagnosis of cancer of the stomach in well-established cases, while in the early cases it frequently will not do so. Gastric Contents. Golding Bird, in 1842, first refers to the diminu- tion or absence of hydrochloric acid in gastric cancer, but Von der Velden, in 1879, first studied the question in a scientific manner. For accuracy the vomitus should be examined; analysis of the gastric contents and microscopic examination, after the test-breakfast, should be made and the stomach washed out. If small fragments of mucosa are found, these should be examined. Vomitus. Macroscopically, undigested meat-fibers and coarse food DISEASES OF THE STOMACH AND INTESTINES particles are found; the quantity is variable, depending upon the motor functions. Coffee-ground material is present in many cases and often a foul odor in advanced cases. Microscopically, undigested muscle-fibers, remnants of vegetable material, starch granules, fat-droplets, numerous fungi; sarcince, are rare; yeast-cells are found in stagnating contents, though usually as isolated specimens; and blood and Boas-Oppler bacilli (Fig. 189). Boas and Strauss report pus 1 in some cases. Palier 2 holds that staphylococci are present in the gastric contents of cancer. Occult blood should be tested for by Weber's or the benzidin or aloin test, if none appear microscopically. Examination of the Test-breakfast. Ewald's or Boas' test-breakfast should be given, and one hour later the contents aspirated and ex- amined. Repeated analyses should be made. Residuum of over 100 c.c. at the end of an hour and particularly if there are larger quantities with food remnants from a preceding meal, even if there is as yet no vomiting, shows inter- ference with emptying of the stomach and is a suspicious circumstance taken in connection with the other symptoms and the gastric findings. i. Hydrochloric Acid. Out of 94 of Osier's cases of gastric cancer, in 84 free hydrochloric acid was absent; and in 40 cases, Boas found it absent in 35; while Graham and Guthrie found in 150 cases of cancer of the stomach in the Mayos clinic that free hydrochloric acid was absent in only 80 cases. In the first stages of gastric carcinoma, however, free HC1 is dimin- ished, not absent. A progressive diminution in the percentage of free HC1 during the course of a month or more, as determined by frequent examinations, when taken in consideration with the other symptoms, is corroborative of cancer. Einhorn reports 6 cases of gastric cancer in which free hydrochloric acid was present in normal or excessive quantity. Smithies finds that practically i out of every 3 cases of gastric cancer with food retention has free HC1 above, an average of twenty-six in the fasting stomach contents (retention). In gastric cancer, engrafted on gastric ulcer, free HC1 (or hyper- chlorhydria) has been noted in the earlier stages, often with progressive diminution accompanying the increased development of the cancer. I have seen hyperchlorhydria persist in quite an advanced stage, notably in a case at the Red Cross Hospital. The patient, aged sixty-eight, suf- fered with the symptoms of gastric ulcer for a year, falling off in weight from 240 to 200 pounds. There was then a slight gain. Later, he lost 1 Pus may be found in benign ulceration, as in Connors' case, as well as in malignant ulcer. 2 N. Y. Med. Record, Nov. 19, 1904. Fig. 190. Carcinoma of stomach, anterior wall in- volving greater curvature; slight reduction of motor function. Tumor evident by palpation, percussion, and gastro-diaphany. His- tory of ulcer with carci- noma engrafted. Hyper- chlorhydria present. 337 steadily, and when admitted to the hospital weighed 149 pounds, was ex- tremely weak and cachectic, with a tumor on the anterior surface of the stomach, involving the greater curvature, and with the clinical symptoms of carcinoma, except the gastric findings, which were hyperacid, with a total acidity of 90+, free hydrochloric acid 70+. The position of the growth is shown in Fig. 190. There was only slight disturbance of motor function and no vomiting. Anemia, leukocytosis, and eosinophilia were present. This case was deemed inoperable and was under trypsin treat- ment some years ago, when some advocated its trial. The patient gained 20 pounds in weight under treatment and proper diet, and was able to go out daily. From his ultimate experience with trypsin, the writer was obliged to con- clude that the diet and treatment of the hyperacidity were the main factors. His strength markedly improved, as well as his appearance. The growth did not dis- appear. The patient returned to work and at the end of several months con- tracted pneumonia and died. We know that free hydrochloric acid is markedly diminished, or even absent, in severe catarrhal gastritis, and is absent in achylia gastrica. Moreover, hypo- chlorhydria (diminished acidity) or even absence of free hydrochloric acid per se are not always of diagnostic significance of cancer. Kelling 1 gives the findings in 4937 stomach cases, and in these, exclud- ing ulcer, every seventh man and fifth woman had no free hydrochloric acid. This condition was frequently associated with disease of other organs. No free HC1 was found in 30 per cent, of 254 cases of gall-stones, and in from 30 to 40 per cent, of diabetes, gout, renal calculus, and tuberculosis. Diagnosis was only possible after the test-breakfast. The absence of HC1 is not patJiognomonic of cancer, but taken in conjunction with the clinical symptoms is confirmatory. 2. Lactic Acid. It has been known for some years that organic acids were increased in cancer of the stomach and lactic acid was present; but to Boas must be given the credit of attaching diagnostic signifi- cance to it, and who first described exact quantitative and qualitative methods. He washes the stomach and gives a plate of barley soup, which con- tains no lactic acid, and an .hour later aspirates the contents. Lactic acid should be examined for by Uffelmann's test or by Boas' method. Ewald's test-breakfast will often suffice for practical purposes. In most cases lactic acid is present in considerable quantity, though occasionally it is absent when free hydrochloric acid is in evidence. In non-malignant stenosis with dilatation it has been found, so it can- not be said to be absolutely pathognomonic. The absence of free hydro- 1 Archiv fur Verdauungskrankheiten, Oct., 1909. Fig. 19 1. Boas-Oppler bacillus from near top of fluid from wash- ing in case of gastric cancer. Ob- servation at Pennsylvania Hos- pital (Boston). 338 DISEASES OF THE STOMACH AND INTETSINES chloric acid and the presence of lactic acid are confirmatory, in conjunction with other symptoms. Boas-Oppler Bacilli. Boas-Oppler bacilli are found. These are rods of considerable length, frequently joined at their ends, and form long angulated threads, stainable by methylene-blue or other anilin dyes (Fig. 191). They must be distinguished from the Leptothrix buccalis (found in the mouth). A drop or two of Gram's solution should be added to the specimen. The Boas-Oppler stains brown with the iodin. the lepto- thrix, blue. Gram's solution consists of iodin, i part; potassium iodid, 2 parts; water, 300 parts. The Boas-Oppler bacillus is found in about 80 per cent, of cases of carcinoma of the stomach; also rarely in non-malignant stenosis with dilatation of the organ. Smithies demonstrated this in 93 per cent, out of 140 cases of gastric cancer. With absence of HC1, an alkaline medium, and absence of stagna- tion, Paul Cohnheim also holds that the Trichomonas hominis, Megas- toma entericum, with associated amebae, pus, and blood, are found in carcinoma of the stomach, not affecting its motility. Pus. The detection of pus in the gastric contents by microscopic examination is of diagnostic value. Blood. The presence of blood, or occult blood, is also important before the tumor is palpable. Blood in some form was found in 73 per cent, of 1000 cases in the Mayo Clinic. Rectal examination in all suspected cases of carcinoma of the stomach should be made for Blumer's shelf. This consists of a sharp shelf-like process lying just above the prostate, felt on digital examination in males; also a process in the female about the cervico-corporeal portion of the uterus in Douglas cul-de-sac. This shelf is due to a secondary deposit or metastasis. When it is present, operation is futile. John Erdmann calls this to our attention particularly in an instructive article on Gastric carcinoma. 1 Diagnosis. Specific Tests for Cancer. Glycyltryptopkan and Trypto- phan Tests for Carcinoma of the Stomach. This test, devised by Neubauer 2 and Fisher 3 , in December, 1909, depends on the fact that the digestion of proteins proceeds further in a carcinomatous stomach than in a normal one. This is due to the presence of an enzyme from the carcinoma, which exhibits strong proteolytic powers, and which, like trypsin, is capable of converting proteins as well as simple peptids into amino-acids. Pepsin can only digest proteins to albumoses and peptones. These investigators have utilized these facts, and use an amino-acid, tryptophan, which in peptid combination, as glycyltryptophan, cannot be digested by pepsin and does not give a color reaction with bromin, but when the tryptophan is split by tryptic ferments (carcinoma) a reddish-violet color or reddish- pink results, when bromin vapor is added. It has been demonstrated that solutions of glycyltryptophan added directly to cultures of bacteria grown from saliva are readily split with 1 Med. Record, July 3, 1915. -' Bull. Johns Hopkins Hosp., 1911, xxii, 150. 3 Deutsch. Arch, fiir Klin. Med., xcvii, 449, 1909. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 339 liberation of free tryptophan. Free tryptophan is also met with in salivas when there are dirty or infected oral cavities. Smithies 1 holds that while the agent in saliva causing the cleavage of glycyl tryptophan has some characteristics of an enzyme, it seems that a considerable factor in such cleavage power is the action of normal, or pathologic oral micro- organisms, or products of their growth. These factors would therefore render the test uncertain. Weinstein holds that glycyltryptophan is unnecessary and tests the gastric nitrate directly for tryptophan. Blood, bile, swallowed saliva, bacteria, free hydrochloric acid, peptid splitting bacteria, and regurgitated duodenal contents are regarded by some as interfering with the tests, while others claim there is interference by some of these and not by others. Smithies 2 shows that in proved cases of cancer of the stomach more than one-third gave positive glycyltryptophan, and one-thirteenth tryptophan reactions but in all these cases the' diagnosis was possible without these tests. The glycyltryptophan reaction occurred more frequently in cancer, but in many cases other than cancer it also occurred. Friedman 3 has tested this reaction and, though finding it positive in many cases, does not look upon it as pathognomonic of cancer. He be- lieves the tryptophan test to be worthless. Though the author described these tests at length in his previous edi- tion and advocated their employment, he now feels that they are unreliable and are of no assistance in the early diagnosis of cancer. Improvements may occur which may later cause him to alter his opinion. For the early diagnosis of cancer, or in the transition stage, the develop- ment of carcinoma from gastric ulcer with hyperchlorhydria or even a moderate amount of HC1 being present one must depend on the presence of occult blood, pus (microscopic), and if no tumor is palpable, upon pro- gressive anemia, loss of weight, and progressive weakness, and the #-rays. In the early stage of carcinoma, when no history of previous gastric ulcer can be secured and when there are merely progressive anemia, loss of weight, weakness, loss of appetite, and gastric symptoms with considerable free HCl still present, in a patient of middle age such symptoms are suggest- ive of malignancy. It is in this class, as well as in the suspected transition cases, when frequently no tumor is palpable, the ar-rays demonstrating changes in the contour or lumen, disturbance of peristaltic waves or motil- ity that the author believes exploratory laparotomy for the purpose of diagno- sis is indicated with the addition of such operative procedure as is required. The writer believes that not until the medical profession can be educated to this view point will we secure tJie early operation for and cure of carcinoma of the stomach. On discovery of a chronic ulcer at operation, radical pro- cedures, and not gastro-enterostomy alone, should be carried out. Antitryptic Reaction of the Blood in Cancer. Brieger and Trebing 4 have announced that they have determined a new characteristic of the blood in cancer namely, a marked increase in the power of the blood- x Arch. of Int. Med., Dec., \, No. 6, 1912. 2 Arch, of Int. Med., Oct. 15, 1912. Also Cancer of the Stomach, Smithies and Ochsner, 1916. 3 Archiv of Diag., New York, April, 1911; also N. Y. Med. Journal, Aug. 17, 1912. 4 Berl. klin. Woch., 1908, p. 1041. 34O DISEASES OF THE STOMACH AND INTESTINES serum to inhibit the proteolytic activity of solutions of trypsin. Fuld and Gross 1 employ a solution of casein as a medium of digestion, thus differing in technic, while Feldstein and Weil 2 employ the viscosity method. All observers agree that the great majority of cases of cancer give evidence of increased antitryptic value in the serum. This condition, however, has been frequently found in the acute infections, such as pneumonia, typhoid fever, sepsis, and polyarticular rheumatism; in chronic infections, notably, tuberculosis; in diabetes and severe anemias; and in Graves' disease almost constantly. The reaction occurs with the inauguration of artificial feed- ing in infants and with the onset of labor and persists through the puer- perium. 3 The increase in the antitryptic index cannot, therefore, be called a specific symptom, but, on the other hand, the absence of the anti- tryptic reaction in the blood may be taken generally as arguing against the existence of cancer. 4 A positive reaction, excluding the conditions noted, argues the probability of cancer. 5 The writer doubts its practical value. Hemolysis as a Diagnostic Method in Cancer. By recent researches they have attempted to demonstrate that there exists in the blood-serum of patients affected with cancer a certain substance or substances which are capable of causing destruction of the red blood-cells of patients not cancerous. Kelling first commented on this occurrence, and Crile ap- parently sets store by the method. Weil has experimented with it, and Smithies 6 has recently reported on the subject. It will be noted that the reaction occurs with tuberculosis, anemia, syphilis, and occasionally with normal subjects. The author does not believe it furnishes accurate information. Weil believes the method not diagnostic, but a positive re- action may be cautiously considered as an auxiliary to the diagnosis. 7 A Skin Reaction in Cancer. Based on the same hemolytic action of the serum of cancerous patients, Elsberg 8 and Neuhof conceived the idea of bringing the red cells into immediate contact with the serum of the cancerous patient in vivo. A suspension of crushed erythrocytes in saline solution was injected under the skin of both normal and cancerous patients. About five hours after the injection a reaction appeared, consisting of an oval, irregular reddish area from 2 to 5 cm. long, and from i to 3 cm. wide, at times surrounded by a white areola. This increased in intensity for two to three hours, and persisted for six to twelve hours. In 432 individu- als, 684 injections were given. In 89.9 per cent, of the cases in which reaction occurred, there was a positive diagnosis of cancer, and in 94.3 per cent, of cases with no reaction it was possible to exclude malignant disease. Lisser and Bloomfield 9 hold that a positive skin reaction is strongly presumptive of cancer. It is a question whether this reaction would not occur with other conditions. 1 Deutsch. Arch. f. klin. Med., 1908, p. 319. 2 Proc. Soc. Exp. Biol. and Med., Feb., 1910. 3 Becker, Munch, med. Woch., 1909, p. 1363. 4 Weil, The Antitryptic Activity of Human Blood-serum, Amer. Jour. Med. Sci.. May, 1910. 6 Jour. Amer. Med. Assoc., Oct. 29, 1910. 6 Med. Rec., Nov. 17, 1909. 7 Jour. Amer. Med. Assoc., Oct. 29, 1910. 8 Med. Rec., Oct. 15, 1910. 9 Bulletin Johns Hopkins Hospital, Dec., xxiii, No. 262, 1912. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 341 Grafe and Rohmer 1 claim there are hemolytic substances in the stomachs of cancer patients. This never occurs in the healthy subject except in the presence of trypsin, when the test is of no value. A negative test excludes malignancy, a positive test shows an ulcerating surface, cancer, or ulcer. Salomen's Test. The method consists in washing out the stomach in the evening, and then on the following morning the introduction of 400 c.c. of normal salt solution. This is aspirated out after a short stay in the stomach and tested for the presence of albumin and for the proportion of nitrogen. Marked turbidity with Esbach's reagent (picric acid) or the presence of more than 30 milligrams of nitrogen indicates the presence of carcinoma. It cannot be considered of value in the writer's estimation. Woljf-Junghans Test for Soluble Albumen. Smithies 2 summarizes his experience with this method in 747 cases where there was achylia or asso- ciation with conditions conf usable with malignancy. In 78.4 per cent, the diagnosis was checked by operation. He found the test positive or sus- picious in 80 per cent, of the series of gastric cancer of which there were 215 cases proved by operation. The test is therefore apparently of value. Silica Metabolism. Rohden in 1902, announced that the pancreas is a reservoir for silicic acid in the organism and four years earlier Kail made a study of silica metabolism in cancerous subjects and found an amount of silica in the pancreas double the normal content, while that excreted by the urine was correspondingly lessened. Kahle and Rossle 3 show that the opposite relationship is found in tuberculosis. The de- termination of silica content in the urine might possibly be of service in the diagnosis of internal cancer. Urinary Methylene-blue Reaction with Cancer. Fuhs 4 claims that methylene-blue is decolorized by the urine of patients suffering from cancer. Three to five drops to Loffler's methylene-blue is added to a test-tube of the patient's urine, or sufficient to give it a decided blue color. The urine is shaken and allowed to stand for twelve to twenty-four hours at the room- temperature. A control fresh specimen of normal urine is similarly prepared. The blue color of the urine of the patient disappears at the end of twenty-four hours, except the color of the upper layer in contact with the air. The normal urine retains its blue color. The urines of pregnancy, rheumatism, nephritis, meningitis, etc., particularly of preg- nancy, decolorize, but in most cases the test is negative in subsequent examinations as the condition of the disease improves, while with malig- nant disease the change is constant. Verbrycke, 5 after a series of tests, holds the method of no value. There are many other tests advocated for the determination of cancer, but the author believes possibilities lie particularly in Van Slyke's modi- fication of the Abderhalden test. Lowy 6 has reported on the Abderhalden test and has recently investi- 1 Deutsch. Arch, fiir klin. Med., xciv; also Med. Rec., Aug. 19, 1911. 2 Cancer of the Stomach (Smithies and Ochsner), 1916. W. B. Saunders Co. 8 Munch med. Woch., Apr. 7, 1914. 4 Jour. Amer. Med. Assoc., June 24, 1911. 6 Med. Rec., Oct. 28, 1911. 8 Postgraduate, 1914, xxix, p. 914. 342 DISEASES OF THE STOMACH AND INTESTINES gated the Van Slyke method of amino-nitrogen estimation as applied to the Abderhalden test. He 1 reports the application of Van Slyke's amino- nitrogen determination for the diagnosis of cancer in 42 cases of cancer at the N. Y. Post Graduate School, of which 14 were of the stomach, 2 of the pylorus, 3 of the colon, 4 of the esophagus and the balance of the breast and uterus. There were 83.3 positive and 16.7 negative in the series. In nonmalignant cases examined, out of 44, positive 15 per cent., negative 85 per cent. Other Tests. Boas-Oppler Bacilli in the Stool. Neusser and R. Schmidt hold that Boas-Oppler bacilli are more easily found in the stool than in the gastric contents and aid early diagnosis of cancer. Gram-negative stools exclude cancer of the stomach; Gram-positive stools, uniform-sized Gram-positive bacilli (Boas-Oppler bacilli), show cancer. 2 I believe the Bacillus aerogenes capsulatus are found, and their deductions probably erroneous. Anaphylaxis 3 from injection of cancerous gastric juice into animals; the increase of amino-nitrogen in the gastric contents Wolffs dissolved albumin test, and marked urine pepsin have been suggested as tests for cancer. Some suggest gastroscopy as an aid to diagnosis. Suss- man of Berlin has invented a flexible gastroscope which can be made stiff after insertion. It is the safest instrument so far devised, though somewhat complicated. Gastroscopy affords us, however, insufficient information. Again in a patient of forty to sixty or more years of age, suffering from recent gastric disturbances of six months' or a year's duration, or less, with a previous history of good health or of former gastric ulcer, there being con- tinuous pain, frequently epigastric rigidity,* rapid loss of weight and strength, anorexia with or without vomiting, motor insufficiency moderate, or great with marked ectasia or even with fair motility, with free HC1 present in considerable quantity, diminished or absent; lactic acid present or absent; Boas-Oppler bacilli present or absent; whether or not there be tumor detectable, or whether or not coffee-grounds are present in the vomitus, such symptoms should be considered diagnostic of carcinoma of the stomach. As already noted, the presence of pus and occult blood are important when found. Exploratory laparotomy is at least indicated. This rule is given particularly for the benefit of the country practitioner who may not have the facilities of the #-rays. If radiography is possible, the changes in the contour, lumen, peristalsis and motility of the stomach render the diagnosis more positive. The Mayos now frequently send a patient to the operating-room with a diagnosis of cancer on an old ulcer, based on the history of a chronic ulcer with recent exacerbation, accompanied by loss of weight, weakness, and anemia associated with the radiological findings noted. They do not wait for cachexia, tumor, and the text-book test-meal. Rontgen Rays. The #-rays aid undoubtedly in the early diagnosis of gastric carcinoma, or at least demonstrate a surgical condition to be 1 Journal A. M. A., May 8, 1915; also Journal A. M. A., Sept. n, 1915 (Levin- Van Slyke.) 2 P. K. Brown, Jour. Amer. Med. Assoc., Nov. 6, 1909, p. 1525. 3 Med. Rec., Aug. 19, 1911. 4 Anders, N. Y. Med. Jour., Nov. 21, 1908. CANCER OF THE STOMACH (CARCINOMA VENTRICULl) 343 present. They are of paramount importance. The new growth makes itself evident by a change in the contour of the stomach- wall; by dis- turbance of the peristaltic waves at certain points; at times by rigidity and contraction of the stomach- wall; by adhesions which prevent the free motility of the stomach when the abdominal walls are contracted, or when PRONE IMMEDIATELY AFTER BARIUM MEAL QQ1 ounce (8.0-16.0), every one to two hours for twelve hours are useful; also hypodermics of ernutin, 5 minims (0.296 c.c.), or ergot fluidextract, and the methods described for hemorrhage under Gastric Ulcer. Tremoliere's Solution. Gelatin (5 per cent, solution) with calcium chlorid (2 per cent.) therein. Dose, ^ to i ounce (30.0-60.0) by mouth, repeated every four hours, is of value. There are usually not the indica- tions to relieve hyperchlorhydria as in ulcer, so rectal feeding may be instituted for twenty-four hours. The ice-bag should be kept on for several days. Gelatin thereafter (3 per cent, solution) should be used for a week in divided doses up to 12 ounces (375 c.c.) in twenty-four hours. White of egg is of value on the following day, and then fluid diet, and a gradual return to the usual feeding. Lactate calcium, 10 grains (0.6), is preferable to calcium chlorid. It can be given t.i.d. Pain. The application of heat by the hot-water bag or hot poultices is indicated. Boas recommends 3 to 5 drops of chloroform on ice to be given occasionally. Chloral hydrate, 3 to 5 grains (0.2-0.3) in water, has been recommended by Ewald, but if the patient be very weak it is a danger- ous remedy. Lavage will often relieve acute attacks, especially if stenosis with dilatation are present. Orthoform or, preferably, orthoform hydrochlorid, which is more soluble in water, can be given t.i.d., 5 to 7^ grains (0.3-0.5). The same dose of anesthesin is at times of service. Tincture belladonna, 10 minims (0.66) t.i.d., or extract belladonna, K 1 Trans, of New Hampshire Med. Soc., May 12 and 13, 1910. OTHER TUMORS OF THE STOMACH 363 grain (0.022) t.i.d., are valuable. Heat, belladonna, lavage, and ortho- form or anesthesin should first be tried. If they fail, it may be necessary to employ codein, preferably, Y% to y 2 grain (0.008-0.032) by mouth, or Y grain (0.016) by hypodermic; or, as a last resort, morphin, % to y grain (0.008-0.016). In terminal cases the opiates are indicated. Bowels. For constipation, enemata of soap and water, with or without olive oil, bowel irrigation, injection of olive oil (8 ounces to i pint (250 500 c.c.) at night, to be retained, rhubarb pills, the cascara preparations, aloin and belladonna compound pills, purgen or phenolax tablets, regulin, Russian or one of the American mineral oils and compound licorice powder, are all of service. For diarrhea, the bismuth preparations, subnitrate of bismuth, i.o to 2.0 (15 grains to ^ dram), several times a day; or bismuth salicylate, 5 to 10 grains (0.32-0.64), three or four times a day; or subgallate of bismuth, the same dose; or subcarbonate bismuth, i.o (15 grains), three or four times a day, are of value. Chalk mixture or compound tincture catechu or kino, in H-dram (2.0) doses, may be combined; or at times tincture opii, 10 minims (0.892), or tincture opii camphorata, 15 to 30 minims (0.888-1.7776 c.c.), may be required in addition. Stenosis of the Cardia. This may require cautious dilatation, prefer- ably with soft tubes, if possible. Palliative gastrostomy is preferably recommended. In conclusion, I desire to refer to an interesting communication by the late Carl Beck. 1 In several cases of intra-abdominal cancer, one, notably of the pylorus, incision was made over the growth, and the latter stitched to the skin, making it practically cutaneous. The #-rays were then ap- plied, with the apparent disappearance of the growth in several cases. In some, the wounds were allowed to granulate, and in others the stomach was reduced after separation of adhesions. In some of the cases the report was certainly favorable. It would seem that in cases of cancer of the stomach in which extirpation is impossible, gastro-enterostomy combined with Beck's treatment, just described, and forced feeding to improve the resisting power of the patient, might give the best results. OTHER TUMORS OF THE STOMACH Multiple Polypi of the Stomach Undergoing Malignant Changes. An interesting case 2 of this type has been reported associated with multiple subcutaneous telangio-endothelioma, multiple lymphangio-endothelioma of the intestines, general vascular sclerosis, and cirrhosis of the liver. Vomiting, dropsy, and ascites were prominent symptoms. Other tumors of the stomach (excepting carcinoma) are comparatively rare. Sarcomata, lipomatoma, fibromata, and myomata have been found, and also polypoid excrescences due to proliferation of the glands. Sarcoma is the most common of these varieties, and may be primary or secondary. 1 On External Rontgen Treatment of Internal Structures (Eventration Treatment, New York Med. Jour., March 27, 1909). - Bull, of Johns Hopkins Hospital, July, 1910. 364 DISEASES OF THE STOMACH AND INTESTINES Primary myosarcoma and fibrosarcoma are generally in the form of circumscribed nodules in the stomach-wall, while lymphosarcoma is flatter and infiltrates. The tumors vary in size and form, and are situated generally on the greater curvature. Metastases are frequent. Harlow Brooks believes the growth usually appears at the lesser curva- ture of the stomach, though it may occur in other regions. It may be multiple. Primary lymphosarcoma appears most frequently between twenty and thirty-five years of age, while the other types occur more frequently in older subjects. It has occurred at the age of three and a half years. The cases are about equally divided as to sex. Corner 1 and Fairbank report 58 cases. Symptoms of Sarcoma of the Stomach. These appear somewhat insidiously, in some cases gradual emaciation being first noted; the stomach symptoms are practically the same as in carcinoma: loss of appetite, sour belching, a feeling of pressure and fulness, disagreeable taste, pain, vomit- ing, and, finally, coffee-grounds in the vomitus. Dilatation of the stomach, if pyloric involvement, and tetany have been observed in this type of case. Some of the cases run a rapid course, with marked anemia, with an absence of hematemesis and no gastric dilatation, though the tumor grows rapidly in size. Gastric Analysis. Absence of free hydrochloric acid; presence of lactic acid; Boas-Oppler bacilli are frequently present. In effect, we may say the gastric findings and symptoms are similar to carcinoma. The methods of physical examination are the same as in carcinoma of the stomach. Average duration is from one to one and a half years. Schlesinger and Kundrat have shown that certain factors may be utilized for the purpose of differential diagnosis. Metastases of the skin are more frequent with sarcoma, and excision, with examination of a cutaneous nodule, when such is present, will afford positive information. Metastases in the intestines occur more frequently with lymphosarcoma, and these do not produce stricture, but dilatation; while carcinoma causes stenosis of the gut. The lymph-glands are more swollen in sarcoma. The spleen is also swollen in sarcoma, not so in carcinoma. The tongue follicles are at times swollen and tumefied and infiltration of the tongue may occur; there is a symmetric arrangement of the ridges, nodules, and papillae. Treatment. Early surgical operation, if possible, the indication being the same as in carcinoma. Lavage is indicated if dilatation be present. Coley's fluid (erysipelas toxin and bacillus prodigiosus) has proved of value, especially in some cases of sarcoma, and should be tried in inoperable cases. Severe reaction and renal disturbance may follow its use, so it should be employed with caution. 1 Practitioner, 1904, Ixxii, 810. OTHER TUMORS OF THE STOMACH 365 Hematemesis should be treated as when it occurs in carcinoma as should other complications. The diet should be the same as in carcinoma, and the use of stomachics oxyntin with nux vomica, etc. Arsenic (Fowler's solution), beginning at 5 minims (0.296) and gradu- ally increasing to 15 minims (0.888), t.i.d., can be tried in lymphosarcoma. Benign Tumors. Benign tumors of the stomach are a rarity and prac- tically impossible to differentiate in many cases. Polypi are the most common, though fibroma, lipoma, myoma and rarely chondroma or osteoma have occurred. Angiomas and cysts are occasionally found, but the latter occur most frequently as result of degenerative changes in a myoma. Lymphomas occur with leukemia. About 84 cases of myoma were collected up to 1912 and Farr 1 reports an interesting case charac- terized by tarry stools and hematemesis. No tumor could be palpated and the clinical diagnosis of gastric ulcer was made. Myomas furthermore tend to undergo sarcomatous degeneration. Myomas may be internal when they are usually of small size and may produce no marked symptoms unless involving the pylorus, when stenotic symptoms would ensue. There may be some epigastric pain when involving the body of the stom- ach and disturbance of appetite. If ulcerative then hematemesis and melena occur suggestive of ulcer. Sometimes emesis without blood soon after eating occurs. With external myoma (i.e., of the body-wall) the mass sometimes grows to considerable size. The cachexia and gastric findings of malignancy would be absent in benign tumors. When producing benign pyloric stenosis, a tumor (thickening) is pal- pable in some cases, but the symptoms would be of benign stenosis, with dilatation of the stomach, cachexia absent, and usually hyperacid gastric contents. Occasionally a small tumor has been noted lying on the greater curva- ture, due to enlargement of a lymph-gland secondary to an inflamed ulcer. Polyposis Gastrica (Polyadenoma). This condition is quite rare. Ebstein reported 22 cases of gastric polyps and Menetrier made a thorough study of the subject. A number have reported single polyps of the stom- ach, but multiple polyps are quite rare. Etiology. Chronic gastritis is an important factor (the hypertrophic type) though they may develop independently. The condition occurs with advancing years and atheroma of the vessels is always present and hence changes occur in the mucosa resulting from disturbance of the nutrition. Age. Two cases are reported respectively thirty-four and thirty-six years, while most of them are older over fifty years. It seems more frequent in males. Pathology. Macroscopically the polyps are small pediculated, in size from a lentil to a pea, gray or reddish in color, and soft in consistency. They are generally covered with mucus and are pigmented. Menetrier describes a type in which hypertrophy and hyperplasia involve chiefly the excretory part of the tubular glands in which lobulation is more apparent and cysts are more common. When the deeper portion is involved the 1 N. Y. Med. Jour., June 28, 1913. 366 DISEASES OF THE STOMACH AND INTESTINES polyps are more uniform in appearance and the tabulation is less pro- nounced. The mucosa between the polyps usually shows the character- istics of a chronic gastritis. Microscopically there is a central stalk of connective tissue which contains the blood-vessels and lymphatics. Next comes the muscularis mucosae and over this excessive growth of mucosa with elongated, dilated and tortuous glands some of which form cysts filled with mucus. Menetrier describes a more rare condition which occasionally occurs, known as polyadendme en Nappe, in which the hypertrophic mucosa develops in large plagues over the stomach and not as polyps. Location. The single polyps generally occur near the pylorus, while the multiple ones are widely distributed, but chiefly at the pyloric end. Symptoms. Sometimes there may be none especially if the fundus alone is affected. If there is a polypi near the pylorus causing obstruction, we may have nausea, vomiting, gastric dilatation and other symptoms of pyloric stenosis. In other situations there may be belching, discomfort, nausea, and at times vomiting. The gastric analysis may show marked hypochlorhydria with some mucus, there may be achylia. Red cells (microscopic) may be present in marked cases with leukocytes or occult blood or even visible blood. Hematemesis and melena may occur. In several cases a small polyp has been found in the wash water or partly digested in the stool. Diagnosis. This is difficult except in cases with hypochlorhydria with excessive mucus suggestive of progressive chronic gastritis or achylia which in connection with gastric hemorrhage would be indicative of the probability of a polypoid condition. The Radiograph shows irregularity in the contour of the stomach. Treatment. Operation with enucleation of the growth or partial resec- tion would be successful in case of a single or a few polypi. Exploration would be indicated in any event. APPARENT TUMORS OF THE STOMACH Einhorn 1 has described cases of apparent tumors of the abdomen which have been mistaken for tumors of the stomach, notably, prolapse of the left lobe of the liver, exposure of the aorta (abdominal) from gastroptosis, thickening of the abdominal muscles (recti), and adhesions of the lesser curvature. Enteroptosis of a considerable degree is usually associated with the first two conditions and the history is a long one. Pulsation of the aorta may be mistaken for aneurysm. Cirrhosis of left lobe of liver may simulate cancer of the stomach on palpation. The gastric analysis and other symptoms will differentiate these conditions. With gastropto- sis the pancreas has been palpated and mistaken for gastric tumors. In some cases a transient tumor in the region of the stomach, dependent evidently on spasm, as from ulcer, has been noted. Schnitzler 2 observed such a case. Thickening of the recti is diagnosed as follows: The thighs and knees 1 Med. Rec., Nov. 24, 1900. 2 Centralb. f. Chir., Sept. 3, 1898. FOREIGN BODIES IN THE STOMACH 367 are well flexed, and the head and shoulders elevated, so as to produce marked relaxation of the abdominal muscles. It will then be possible to slip the finger-tips beneath the edges of the relaxed and thickened rectus muscle. With adhesions, pain on distention of the stomach, motor dis- turbances, etc., are present. (See Perigastritis.) FOREIGN BODIES IN THE STOMACH These may be swallowed accidentally or purposely, or may be gradu- ally deposited in the stomach. Fig. 201. A human hardware store. A collection of foreign bodies found at necropsy in the stomach of an insane patient (Vandivert and Mills). Among such articles are pins, needles, scarf-pins, knives, spoons, forks, artificial teeth, glass, hooks, pens, buttons, balls of hair, bits of iron, nails, lead, wood, and even the stomach-tube. Lunatics, idiots, and young chil- dren frequently swallow foreign bodies, as do trick knife-swallowers. Cases have been reported of patients who have worked with an alcoholic solution of shellac, and who had swallowed small quantities daily, with 368 DISEASES OF THE STOMACH AND INTESTINES the ultimate formation of stones in the stomach. Sarcinae ventriculi have also accumulated in large numbers and formed a tumor. An interesting case of the ingestion of foreign bodies by a lunatic is reported by Vandivert and Mills 1 from State Hospital No. 2, St. Joseph, Missouri. This patient died apparently of nephritis and there was no suspicion of gastric trouble until autopsy. The mass of foreign material lay on the sacculated portion, leaving a narrow channel along the lesser curvature for the passage of food. There was an atrophy of the mucous membrane, much formation of connective tissue, erosions, and the points of some of the foreign bodies had penetrated the stomach- walls, but adher- ing omentum prevented leakage. There were some small walled-in abscesses. The appetite remained good until two weeks before death, and no symptoms pointed to the stomach. In all, 1446 objects were found in the stomach. As a matter of interest the list is given, also a photograph (Fig. 201) of the material found in the organ. LIST Nails ao-penny 5 i6-penny 21 lo-penny , 24 8-penny 80 5-penny 113 3-penny 210 Total 453 453 Screws 2% inches 4 i% inches n i^ inches 5 i inch 9 % inch 6 % inch _7 Total 42 42 Bolts % X i inch 3 % X i% inches i ^6 X 2^ inches i % X 2 inches i JKe X i inch 3 Total 9 9 Miscellaneous Teaspoon handles 5 Nail-file, 3)^ inches i Pieces of steel, 2% inches 3 Thimbles 5 Salt-shaker tops 3 Taps for %-inch bolts 10 Buttons 63 1 Jour. Amer. Med. Assoc., Jan. 21, 1911. FOREIGN BODIES IN THE STOMACH 369 Safety-pins 105 Hairpins 115 Carpet-tacks 52 Common pins 136 Large white-headed pins, 2 J^j X /^ inches 16 Needles 37 Broken coat-rack hooks, 2 X M inches 7 String beads, small, 4 feet long i Larger beads, loose 70 Small stones and pieces of glass 85 Prune seeds 7 Pieces of metal, combined weight 3 ounces 54 Hooks and eyes 19 Grape, and other small seeds 148 Total 942 942 Making a combined total of 1446 Weight 21,268 gm. There may be local disturbances of severe type and vomiting, or if damage be done to the mucous membrane, then hemorrhage. On the other hand, there may be no disturbances at all, and the foreign body, especially if of small size and smooth, may be evacuated from the bowels. The history of the case will generally give us information. If the tumor be of sufficient size and very movable, it can be at times appreciated by palpation. The x-rays will give information as to its presence and location. Treatment. The use of an emetic is objectionable, as a rule, unless the foreign body is extremely small and smooth. Personally, I never employ it. Mayou has recommended the use of an electromagnet in- serted in a stomach-tube, there being sufficient space at the end of the tube to draw in a small metallic object which can be located by the #-rays. Under usual conditions, the administration of constipating food, pota- toes, rice, and the soft part of bread, and keeping the bowels costive for several days, so as to form a protective mass about the foreign body, is the best method of treatment. It is an error to immediately administer a cathartic, as damage is done to the intestinal canal if there be any sharp edges to the object. Complications, such as perforation or inflammatory adhesions, are liable to occur if it be of any size. Intestinal obstruction may even result. If the body is of large size or serious symptoms ensue, early gastrotomy is indicated. The author's inflating gastroscope inserted through the gastric incision is a valuable aid through which to remove the foreign body. Occasionally a small foreign body may be located by the gastroscope and removed through it by long forceps. 24 CHAPTER XIV FUNCTIONAL DISEASES OF THE STOMACH UNDER functional diseases of the stomach we may classify those affec- tions in which either the secretory or motor functions of the stomach are at fault. Anatomic lesions are present in some cases and are absent in others. The principal symptoms are due to the disorders of secretion or mo- tility. Among these we classify hyperacidity (hyperchlorhydria), hyper- secretion (gastrosuccorrhea), atony of the stomach, dilatation of the stomach, and achylia gastrica. Many cases of hyperacidity and of hypersecretion are pure secretory neuroses, or they may be reflex or due to vagotonia; atony may also result from nervous disorders, but there are other causes for these conditions. When there is dilatation due to stenosis of the pylorus, as from malig- nant tumor, the symptoms are due to the cancer and also to the relative motor insufficiency. It is difficult, therefore, to place any special disease of the stomach under a pure classification, owing to the diverse etiology. With achylia gastrica we have the loss of secretory functions of the stom- ach, and it may be classified under functional diseases. It is produced either by nervous influences or by anatomic changes in the gastric mucous membrane. As in many cases organic changes are present, I judged it advisable to devote to it a separate chapter. HYPERACIDITY (HYPERCHLORHYDRIA) (Synonyms. Hyperaciditas Hydrochlorica; Superacidity) The term "hyperchlorhydria" should be used to designate an increased secretion of gastric juice or, more correctly, of hydrochloric acid, during the period of digestion; that is, an overproduction of this acid. Under normal conditions the free hydrochloric acid fluctuates in the stomach within certain limits, thus: Free HC1 averages between 25+ and 50+, or about o.i to 0.2 per cent., and the total acidity is from 40+ to 65+, or 0.146 to 0.237 per cent. We speak of hyperchlorhydria when not only the total acidity is higher than normal, but when the excess of free HC1 is above normal. It is not sufficient to merely test for the total acidity, as it may be 1 increased by organic acids. The free HC1 should be determined quantitatively. We might place a total acidity of 70+, of which the greater part con- sists of free hydrochloric acid, on the dividing line. A patient with such a degree of acidity and complaining of clinical symptoms may be consid- ered a case of hyperchlorhydria. A total acidity of 100 to 120, with free HC1, 80+ to 90+, is quite 1 In the mild types of hyperchlorhydria, however, the free HC1 may be within normal limits, but the addition of the combined HC1 brings the total HC1 above normal 'limits for such and the patients have symptoms. 370 FUNCTIONAL DISEASES OF THE STOMACH 371 common, and much greater degrees of hyperchlorhydria have been observed. We must remember that individual idiosyncrasies exist as to the sus- ceptibility to free HC1. We occasionally find patients with a total acidity of ioo+, the greater part of which is free HC1, who have no subjective disturbances whatever and never suffer any discomfort. In this regard an unusual case is reported by Verbrycke, 1 a patient of Morgan, with free hydrochloric acid 154+, or 0.56 per cent., and a total acidity of 204+, or 0.74 per cent., with only slight pains after meals. One must also re- member that there may be a small amount of gastric juice with high acidity, or a larger amount with lower percentage, but high total content of hydrochloric acid. Moreover, bacteria may be present when there is considerable hydrochloric acid, their presence then indicating diminished motility. On the other hand, I have at present a patient under treatment with a total acidity of 6o-f- and free HC1 40+, who has all the symptoms of hyperchlorhydria. Frequency. It was formerly thought that in most diseases of the stomach the gastric secretion was deficient, but it has been demonstrated that the gastric juice is increased in about one-half the cases. One does not see so many cases of hyperchlorhydria in hospital prac- tice, except in connection with gastric ulcer, since the symptoms rarely become so severe as to require hospital treatment. As a concomitant of chlorosis it is frequently found. The gastric analysis in these cases is often neglected. Moreover, the general practitioner rarely examines the gastric contents in cases which present the symptoms of hyperacidity. It is, therefore, difficult to secure statistics as to its frequency. Einhorn reports a trifle more than one-half his patients, to be sufferers from hyperchlorhydria. Records of my private patients show that about 50 per cent, come to me for treatment for this condition. Etiology. No age is exempt. It is met with in adults and quite fre- quently in young people. In some cases it is a neurosis. Nervous excite- ment, violent emotions, sorrow, worry, and severe mental labor may be direct causes. Neurasthenics and melancholies often suffer from it. Vagotonia is a cause in some cases. It is a frequent concomitant of gastroptosis. In this condition the hyperchlorhydria is not the result of the nervous condi- tion alone, but in part due to the ptosis, with resulting circulatory changes. Its relief by Rose's belt is the proof, as reported in a series of cases at the Manhattan State Hospital. 2 It occurs with mucous colic, in which case I believe gastroptosis is a factor. Chlorosis is a frequent cause. Irritation of the mucous membrane of the stomach may be a direct factor, as from bolting the food, large quantities of cold or hot drinks, alcoholic excess, pickles, rich condiments, and insufficient mastication. Special articles of food or drink are often productive of it, such as very 1 N. Y. Med. Jour., July 16, 1910. 2 Rose and Kemp, Atonia Gastrica. 372 DISEASES OF THE STOMACH AND INTESTINES strong coffee. Deeks 1 and Stone 2 hold that excessive sugar and starch diet producing butyric acid fermentation are factors in causing hyper- acidity, hypersecretion, and ulcer. Excessive smoking and chewing of tobacco are also factors. Chronic appendicitis, cholelithiasis, cholecystitis and nephrolithiasis are causes. Spasm of the pylorus may accompany these conditions. Hyperchlorhydria is a frequent accompaniment of gastric ulcer. This is particularly true of the acute ulcer. It may accompany duodenal ulcer, and is found with benign stenosis and dilatation of the stomach, and with gastrosuccorrhea. It is more frequent among the wealthy class, such as bankers, brokers, and professional men, though it occurs among the poor. There seems to be no special predilection for either sex. Kaufmann 3 calls to our attention that hyperacidity may in some in- stances precede the gall-bladder trouble and holds that the constant irrita- tion of the duodenum by the very acid stomach contents may cause a spasm of the opening of the common duct with resulting retention and inflammation thus causing infectious cholangitis or gall-stones. Arpad Gerster 4 refers to this probability. Symptoms. They rarely appear suddenly, but usually develop gradu- ally. They always come on after eating and never on an empty stomach, after the time for digestion has elapsed. At first the patient complains of a disagreeable sensation or any uneasy feeling, about one to three hours after a meal. It may be a feeling of pressure or fulness, or of heat, or of tingling. This increases into a feeling of distress in the epigastric region, or a burning sensation after each meal. In the mild cases there is no actual pain. In severe cases pain may be marked, with acid belching and heart- burn, and the patients suffer severely and in some cases appear almost in a state of collapse. The burning may be felt in the esophagus or along the back, and is due to the eructation of the acid contents. Violent head- ache often accompanies it. Some claim they can feel spasmodic move- ments in the stomach. This is due to contraction (spasm), of the pylorus and an increased peristaltic action of the organ endeavoring to overcome the obstacle. Mild attacks of pain last for a brief period of time, while the more severe attacks persist for several hours. Vomiting occurs occasionally during the height of the cardialgic at- tacks. The vomitus is very acid and burning, and after its occurrence relief, as a rule, results. In some cases the pain appears after eating certain articles of food, and patients seem to have idiosyncrasies, such as to coffee, etc. The attacks are not always directly dependent on the degree of the digestibility of the food, and at times they can eat indigestible material without discomfort; whereas at other times digestible articles of diet will cause pain. Prob- ably the nervous element plays a part in these cases, causing undue irrita- tion of the nerves of secretion. 1 N. Y. Med. Jour., Nov. 30, 1912. 2 Journal A. M. A., (Stone), Jan. 29, 1916. 3 Amer. Med., Nov., 1903, vi; also Journal A. M. A., July 26, 1913. 4 Surgery, Gyn. and Obstet, Nov., 1912. FUNCTIONAL DISEASES OF THE STOMACH 373 Some suffer more disturbance after a small meal, while after a large meal they have no distress. This is readily explained by the fact that the larger amount of food combines with a greater portion of the free HC1 secreted. Patients when the symptoms first appear can ease their pain by taking nourishment, especially if rich in albumin, as the whites of eggs and milk or meat. It also disappears after the administration of an alkali, such as milk of magnesia (Phillips), Vichy, or soda bicarbonate. Persons living chiefly on a starch diet suffer more intense pain than those who live largely on meat and eggs; hence, the character of the food has frequently a relation to the pain. Appetite. In most cases the appetite is very good, and in some is greatly increased. Others are readily satiated, but the desire for food soon comes on again. Thirst is at times increased during the active attack, but in many cases is normal. If hyperchlorhydria is complicated by dilatation of the stom- ach, thirst is present. Bowels. Constipation is, as a rule, present, though constipation and diarrhea may alternate. Headache. Severe headache often occurs, or even attacks of dizziness, generally during the occurrence of gastric pain. Nutrition. These patients generally do not lose in weight nor present the aspect of being very sick. They are rarely particularly well nourished and are often of nervous temperament or anemic. This is not invariable, as one has at times to treat stout, well-nourished men, high livers, and inveterate smokers and drinkers, who suffer from this complaint. Rarely, under improper diet, loss of weight may occur. Nervous Symptoms. Some patients are depressed, nervous, suffer from insomnia, and are neurasthenic. Migraine occurs in others. Urine. Acidity of the urine may be reduced during the course of digestion. There are no characteristic features. Physical Examination of the Stomach. During intervals between at- tacks there may be nothing in evidence. Percussion. At the time of the attack the stomach may be distended. Palpation. In mild cases there will be no tenderness. The greater part of the gastric region will be found to be tender on pressure or even painful in severer cases. The tenderness covers a large area, generally over the greater part of the stomach ; often in the region of the pylorus this tenderness is accentuated. Splashing Sound. This can be produced after meals or after the inges- tion of water, but is not present in the fasting condition. Examination of the Stomach Contents. This is the decisive test. If the stomach is aspirated in the fasting condition, it is found to be empty, or only a few cubic centimeters of juice can be secured. One hour after Ewald's test-breakfast or three to four hours after the Leube-Riegel test-dinner the stomach contents show an extremely acid reaction, often two to three times higher than normal (from 100+ to 150+)- It is not sufficient to determine the total acidity, but the value of the 374 DISEASES OF THE STOMACH AND INTESTINES free hydrochloric acid is the important feature. Only in hyperchlorhydria is it increased, and in this condition the free HC1 causes the high degree of acidity; and Topfer's test (dimethyl-amido-azobenzol) shows that the free hydrochloric acid constitutes the chief content, and is often within 10+ to 15+ of the total acidity. Mintz's method is also excellent. The digestive power is very good; a small disk of egg-albumen will be digested in a short time, sometimes within one-half to one hour. Three to four hours after the test-dinner meat will be found to be perfectly digested, while starchy substances will be at times unchanged or little altered. Starch or erythrodextrin will be found, Lugol's solution giving a blue or dark red reaction. If, however, a small amount of starchy food be given with a large amount of albuminous material, while the HC1 is enter- ing into combination and before free hydrochloric acid appears, the normal reduction changes in the starch may occur. With large quantities of amylaceous material the brief period before the appearance of hyperchlor- hydria will not allow a complete conversion of all the starch, and this tends to remain in the stomach an abnormally long time and to produce fermentation. A. L. Benedict 1 describes an effervescent test for gastric acidity. He administers 30 to 50 c.c. of a strongly saturated solution of sodium bi- carbonate, to be taken at a single gulp, and, preferably, by means of a stethoscope, determines, by the degree of effervescence, the degree of acidity. This method is only relative. Boardman Reed has experi- mented with the method. The writer does not, however, recommend it. Absorption from the stomach is not disturbed; potassium iodid appears, if anything, more rapidly in the saliva. Motor Function. This is not impaired, but is often rather increased. Two hours after the test-breakfast or six to seven hours after the test- dinner the organ is found to be empty or nearly so. Salol appears as salicyluric acid in the urine an hour after its ingestion when tested for with ferric chlorid solution. We must- remember that hyperchlorhydria untreated, with fermentation resulting from improper diet (excessive starch), may in some cases produce atony and resulting insufficiency. Hypersecretion, which may accompany hyperchlorhydria, is another factor. Course. It may be rapid, coming on suddenly and lasting a short time, or chronic, for months to years. It often varies in the early stages and may be intermittent in its character. The attack may last for days, weeks, or even months, and then there be a free interval for a considerable period of time. It can recur without any apparent cause, or result from some mental shock or worry, or from some dietary indiscretion. Gradu- ally the hyperchlorhydria becomes more frequent and at last the condition becomes permanent. , In rare cases the attacks appear to come on later than usual, and vomiting of an acid mass of undigested food may occur, showing the con- tents were retained an abnormally long time. This is undoubtedly due to spasmodic closure of the pylorus from irritation by the acid contents. 1 N. Y. Med. Jour., May n, 1911. FUNCTIONAL DISEASES OF THE STOMACH 375 Atony and even atonic dilatation may develop from this type, and hypersecretion (gastrosuccorrhea) may result in some cases. Prognosis. The prognosis is, as a rule, good. Many patients can be completely cured. In some very old or severe cases there is a tendency to relapses. The disease is not dangerous to life. Those in whom the nervous element plays a part often do not readily respond to treatment and are a source of discouragement to the physician. Relapses, in spite of the greatest care and for no apparent reason, are not infrequent. If atony, dilatation of the stomach or hypersecretion complicate the hyperchlorhydria, the prognosis as to cure is not as favorable. Pathology. As the cases are not fatal, it is hence unknown. In one case, dying of intercurrent disease, a few erosions were found. It is evi- dently a disorder of the secretory function. Diagnosis. The diagnosis of hyperchlorhydria can be made from the examination of the gastric contents: 1. An hour after Ewald's test-breakfast the acidity is found increased, due to the increased quantity of free hydrochloric acid. 2. In the fasting condition the stomach is found empty or nearly so. (This excludes gastrosuccorrhea.) Furthermore, the patient suffers from certain subjective symptoms: 1. Discomfort or, more generally, a pain which comes on from one to three hours after a meal. This is directly dependent upon the ingestion of food. It is not a continuous pain and there are intervals of relief. The character of the food and the quantity usually have a bearing. Starchy food readily produces it, and a light meal more than a full meal. The latter, when rich in albumin, often causes no disturbance. The pain may be "a dead dull pain, with a gnawing sensation," or may be of a burn- ing character. The administration of an alkali, such as Vichy or sodium bicarbonate, relieves the pain by neutralizing the acid; or milk, raw eggs, or a meat sandwich, by binding the free acid, produces the same result. 2. In others there is more the -feeling of a heat or burning in the stom- ach or the feeling of a sour stomach. 3. Appetite and thirst are generally normal. 4. No cachexia. 5. Marked constipation is the rule. . 6. Some cases are quite nervous or even neurasthenic. Complications. It is often necessary to determine whether atony, dilatation of the stomach, or gastroptosis are associated with the hyper- chlorhydria. Simple Atony. Presence of the splashing sound and too c.c. or more of gastric contents aspirated one hour or more after Ewald's test-breakfast; or the splash with the presence of food in the stomach six or seven hours after the test-meal; the lower border is in normal position as determined by the splash and by percussion. Dilatation. Splash at the umbilicus, or below it, shows descent of lower border. Percussion alone or with inflation, or gastrodiapbany substan- tiate this finding; there is no descent of the upper border. Kidneys are normal in position. 376 DISEASES OF THE STOMACH AND INTESTINES Gastroptosis. Splash at the umbilicus or below it shows descent of lower border. Movable kidney is diagnostic if found in addition. There is diastasis of the recti muscles; inflation or gastrodiaphany shows descent of the upper border of the stomach as well as the lower, but are scarcely necessary. The #-rays are unnecessary for diagnosis, but determine the degree with exactness, the presence or absence of complication and convince the patient. Differential Diagnosis. Acid Gastritis. Hyperacidity is present plus abundant stomach mucus. Hyper secretion (Gastrosuceorrhea). The stomach in the fasting condi- tion contains 75 to 100 c.c. or more of very acid gastric juice. The per- sistent appearance over 20 c.c. to 30 c.c. of gastric juice in the fasting stomach is considered pathognomonic by many. Severe attacks of pain and vomiting generally occur during the night or early morning. Biliary Colic. Pains are later (four to five hours after meals) or inde- pendent of meals. The pains of hyperchlorhydria are dependent on the meals. Pains of biliary colic are not dependent on the food, are not re- lieved by alkalis, and they extend over the right epigastrium and hypo- chondrium, and frequently to the right shoulder or right axillary region. A patient with biliary colic or even after the attack has no appetite and cannot eat. The appetite is good in hyperchlorhydria. The gall-bladder is painful on pressure and at times swollen. Icterus may be present. Gall-stones at times are found in the stool. Leukocy- tosis is present in biliary colic if inflammation is associated. Sometimes the differential diagnosis is difficult. Gastric analysis may be necessary to determine it, though occasionally both conditions occur together. The presence of Head's gall-bladder zone may aid diagnosis. Ulcer of the Stomach. Epigastric pain is intense, appears shortly after the ingestion of food ; local tenderness on pressure and pain increased there- by. Pain disappears at the end of digestion. Dorsal pain occurs later, and vomiting in many cases soon after meals. Hematemesis occurs or occult blood is found in the gastric contents or stool. Occult blood may occur with gall-bladder disease in the gastric contents of achlorhydria hsemorrhagica gastrica, a disease of peculiar characteristics already described, and not particularly difficult of diag- nosis. Ulcer is more frequent in women. The discovery of occidt blood is often the determining factor in our diagnosis as is the presence of micro- scopic pus in the gastric contents. 1 Nervous Gastralgia. More frequent in women from eighteen to thirty years. Pain appears without regularity, and is in no way dependent upon the meals, or character of food. Is relieved by pressure. Intervals of perfect health; nervous temperament always present. Gastric analyses often vary in the same case. Treatment. The treatment comprises, first, the removal of the causes of hyperchlorhydria; and second, the cure of the condition itself. Removal of the Causes. Interdict tobacco smoking and chewing. If a cigar or cigarette holder is employed, smoking once or twice a day I 1 X-rays may be required to determine gastric ulcer. FUNCTIONAL DISEASES OF THE STOMACH 377 believe may be harmless, as it prevents swallowing saliva impregnated with tobacco juice, the chief source of irritation in my opinion. Alcohol in every form, including wines and beers, should be prohibited. All kinds of acids, such as acetic, tartaric, or citric, should be forbidden; and all foods prepared with them, such as with vinegar or lemon-juice; and all acid or acidulated drinks. Avoid excess of salt. Condiments, such as pepper, ginger, horseradish, etc., pickles, mustard, paprika, nuts, acid fruits, grapefruit, and radishes, should be prohibited. Avoid all extremes of heat and cold in food and drink. Thorough mastication of the food should be enjoined. Nervous conditions, when present, should be treated. Hygienic regulations are important. Overwork and mental anxiety are factors in the production of hyper- chlorhydria. Brokers, professional, and business men must be relieved temporarily from overwork and worry by being sent into the country, where various open-air amusements, such as golf, horseback riding, driv- ing, walking, etc., can be indulged in. If the patient have a taste for fishing or shooting, such diversions are excellent. I have seen a few weeks in camp work wonders. Those indulging in a continuous round of social festivities should be compelled to lead a quiet life. On the other hand, there are many people of wealth with no occupa- tion whatever who become entirely self-centered and nervous therefrom, and for such a class of persons occupation is of great value. Hydrotherapy, such as sponge-baths, douches, etc.; also a moderate indulgence in calisthenics (ten minutes morning and night). For the cure of the hyperchlorhydria there are practically two methods used, alone or in combination: We may bind the excess of free hydrochloric acid by the administra- tion of large quantities of proteins, or we may neutralize the excessive acid by the administration of an alkali. Clinical observation has demonstrated that those articles of food which are capable of binding large quantities of HC1 are borne the best. The burning feeling of distress or pain is relieved by the administration of albuminous food. Carbohydrates, if given in any quantity, cause distress. The diet is, therefore, of greatest importance. Diet in Hyperchlorhydria. As noted under Prophylaxis, all articles which are liable to overstimulate the secretory glands of the stomach should be forbidden. Among such are acids, all spices, as pepper and mustard, pickles, horseradish, olives, acid fruits, beers, and wines. Salt should be diminished. The food should be rich in albumin, such as chops, steak, roast beef, mutton, game, eggs, milk, oysters, and fish. Bread and butter can be taken, the former in moderation. Green vegetables, such as spinach, asparagus, lettuce, peas and string beans, potatoes, rice, and other cereals, should be given in small quantity. They should be taken in combination with large amounts of albuminous food. The writer finds that some cases of hyperchlorhydria complain that milk does not agree. The addition of 378 DISEASES OF THE STOMACH AND INTESTINES a small dose of sodium citrate to each glass of milk will often obviate this difficulty. Alcohol in all forms, including beers and wines, I believe should be avoided, also coffee; though some allow a small amount of beer and very weak coffee. Fleiner has demonstrated that egg-albumen binds more free hydrochloric acid than any other food. Among other articles especially suitable for this purpose he recommends boiled veal, beef, mutton, raw ham, Leube-Rosenthal's beef solution, boiled ham, boiled pork, Swiss cheese, Roquefort, pumpernickel, milk, and cocoa. In my own experience I have found gelatin 1 an excellent remedy, employing i or 2, or even 3 ounces of a 5 to 10 per cent, gelatin solution, flavored with a pinch of sugar or a little vanilla, and given midway be- tween meals. The value of egg-albumen and cocoa is marked. Starchy foods that have been well dextrinized, such as zwieback and toast, subse- quently dried in the oven, are more readily digested. Strauss has shown that if carbohydrates are introduced in the form of sugars in solution they do not markedly increase HC1 secretion. He gives 200 to 300 c.c. of a 20 per cent, dextrose solution during the day. Considerable water should be taken during meals, or Appollinaris and seltzer, if no atony is present. A. Schmidt uses a mixed diet and advises that all foods should be well cooked and carefully minced. He recom- mends that the stomach should come to rest at least once in twenty-four hours and gives a large quantity of food in the morning, but small amounts at night. In the forenoon, two to three meals at two-hour intervals so there is little appetite for lunch; thereafter no food until 7 p. M. and then only porridge. He allows no sparkling waters and diminishes fluid, re- stricting it to hours when the stomach is not filled with food. He gives the meals rather dry except at breakfast and the evening soup and has the patients drink a short time before lunch or in the afternoon. If the condition is severe the patients have to remain in bed several weeks. Hot compresses are applied twice daily for two hours. Fats, such as butter and cream, are of value. Since the carbohydrates are restricted and additional calories must be secured, Strauss, Ewald, and others advise their use. Furthermore, fats lessen the acidity, also possibly the irritable tendency of the mucous membrane. Cream has been thus recommended. For some years I have been accustomed to administer olive oil once or even three times daily before meals in obstinate cases of hyperchlorhydria, using from % to i ounce (15.0-30.0), suspended in water. This has lessened the hyperacidity. In the same way, glycerin, % to 2 drams (2.0- 8.0), mixed in water, may be used. Illoway 2 employed it in one case. Almond oil is also of value. If we attempt to treat hyperchlorhydria by diet alone, we should give three additional feedings at a time after the regular three meals, such as would bind the excessive hydrochloric acid and prevent the symptoms. The extra feedings may consist of koumiss, matzoon and Vichy, bacillac, bouillon, a sandwich, milk, raw eggs (especially the whites) and milk, with 1 Calves' foot and chicken jellies are excellent. 2 N. Y. Med. Jour., .May 25, June i, 15, and 29, 1901. FUNCTIONAL DISEASES OF THE STOMACH 379 crackers or bread and butter. One can select a diet from the tables with a sufficient number of calories. For practical purposes an improvement in nutrition i.e., some increase in weight should be secured, even though slight, in addition to the amelio- ration of symptoms. This refers only to those of thin habit, not to the well nourished. The use of the scales, weighing at stated intervals, is of radical importance. Assimilation differs in individual cases, and though on paper, the calories may be correct, a loss of -weight shows a radical error in the treatment. The following is a sample dietary, such as is usually recommended for a patient of good physique and quite active. The con- tent of protein is very high as compared with Chittenden's scale, which I advocate in health. It is frequently advisable to diminish the quantity of meat and substitute milk, matzoon, koumiss, or bacillac. Lactone- buttermilk is also excellent. Gelatin solutions bind the free hydrochloric acid in a satisfactory manner. Depending on the normal weight, height, and occupation, the diet must be formulated in every case: Calories 7.30 A. M. 250 c.c. milk, cocoa, 2 eggs, 3 zwieback, and butter (20 grams) 690 10.30 A. M. 200 c.c. milk, with i raw egg, or matzoon and Vichy 125 c.c., or koumiss 250 c.c., or milk 250 c.c., or bouillon with i raw egg (approximately) 240 Bread 2 slices, or cracker 2 oz. (gm. 60) 160 Butter gm., 20, water, or Appollinaris, or Vichy 250 c.c., occasionally weak tea 163 1.30 P. M. Chops, steak, beef, or mutton, 100 gm. (about) 200 Mashed potatoes, 30 gm 37 Spinach, 30 gm 12 Bread (i slice), 30 gm 81 Butter, 10 gm 80 4.30 P. M. Same as at 10 . 30 A. M 563 7.00 P. M. Soup (barley), 200 c.c 100 Meat, broiled 100 gm 200 Spinach or peas, 50 gm 30 Potatoes mashed with milk, 50 gm 80 Weak tea, 100 c.c. (three-fourths milk) 64 Toast (i slice) 75 Butter, 10 gm 81 10.00 P. M. Milk and Vichy, aa 100 c.c 64 Total calories 2920 Various modifications may be made. Coffee I interdict. All fried food should be forbidden, as should hot breads, fresh bread, hot biscuits, acid fruits, acids, highly spiced food, pastry, and rich desserts. The food should not be excessively hot or cold. The patient should eat slowly, masticate thoroughly, and rest after eating for at least twenty minutes to one-half hour. Illoway and Bouveret advocate only three meals a day, with a sandwich at bedtime in some cases. They believe the stomach should have an interval of rest so as to become perfectly emptied. Practically, Illoway's only medication is one-half glass of French Vichy, given at 10 to n A. M., at 4 to 5 P. M., and at night, if the sandwich is omitted. 380 DISEASES OF THE STOMACH AND INTESTINES They believe that unless the stomach have some rest, atony or atonic dilatation may result? On the other hand, some patients can only eat a small amount of food at a time, have the desire to eat at frequent intervals, and feel better if they do so. Repeated feedings are difficult to follow out in some cases, so conditions vary. My method is to give the three regular meals a day with diminished carbohydrates, with the alkalis an hour to an hour and a half or even two hours later. If it is necessary to improve nutrition, additional feedings are given, a glass of koumiss, or milk and raw egg, or matzoon and Vichy, or i to 2 ounces of 10 per cent, gelatin solution (sweetened) between meals or if pain comes on after the administration of the alkali. These foods can be alternated. Medication. Among the alkalis that are of value are Vichy, imported or siphon, bicarbonate of soda, milk of magnesia (Phillips), magnesia usta, magnesia ammoniophosphorica, and biborate of soda (Jaworski). A little sugar of milk can be added to the soda or magnesia prepara- tions to make them more agreeable. If the hyperchlorhydria is compli- cated by atony, then bicarbonate of soda (which generates considerable carbonic acid gas) would be objectionable. The following rule should be carried out as regards the administration of the alkalis: "Give them in ample time to anticipate the appearance of symptoms by a considerable margin." They should be administered t.i.d. after meals, depending upon the time of appearance of symptoms. Repeat the dose if the symptoms begin later, unless albuminous food is given as a substitute. The magnesia preparations have the tendency to move the bowels and hence are of special value. If the result is too active, combine the mag- nesia with varying porportions of soda bicarbonate, or give the latter alone, or give bismuth subnitrate with the magnesia. Magnesia usta will neutralize about four times more acid than soda bicarbonate. The dosages are as follows, given from one to two hours after meals t.i.d.: Vichy 175 to 250 c.c. (J-S-i glassful). Vichy M to i glassful plus sod. bicarb. W to i teaspoonful (2.0-4.0). Allow this to become flat (effervescence to disappear). Sod. bicarb W to i (2.0-4.0) teaspoonful in one-third glassful of water. ty Magnesia usta j * , . i i (..... ........ dcV _) 3o Sod. bicar. j Dose, H to i teaspoonful (2.0-4.0) in water t.i.d. A little sugar of milk or i minim of oil of peppermint may be added to flavor. If the bowels move too freely, diminish magnesia, then give: fy Magnesia usta 5ss (16.0); Sod. bicarb q. s. gij (64.0). M. Dose, W to i teaspoonful (2.0-4.0) in water. If necessary, bismuth subnitrate, 2 drams to M ounce (8.0-16.0), may be added to the above combination. FUNCTIONAL DISEASES OF THE STOMACH 381 If. Sod. bicarb 5j (32.0); Magnesia usta 5ss (16.0); Magnesia ammon. phos 5ss (16.0). M. Dose, l /2 to i (2.0-4.0) teaspoonful in water. 1^. Magnesia usta. . -. 5ss (16.0); Pulv. rhub gm. xv (i.o); Soda bicarb 5ss (16.0); Sugar of milk 5ss (16.0). M. Dose, Vi teaspoonful (2.0) in water if costive, or, Milk of magnesia (Phillips) 5j toiv (4.0-16.0), in water t.i.d. This last I have found to be an excellent preparation, especially where constipation is marked. It is one of the most serviceable remedies for hyperchlorhydria. Adolf Schmidt: 1 1$. Magnes. oxid 3ss; Ext. bellad gr. ^; Sod. sulph 5ss; One dose t.i.d. p. c. particularly if costiye. Powdered charcoal, kaolin and aluminum silicate have been suggested as an acid binder by mechanical absorption. Winternitz employs magnesium peroxid 5ss t.i.d. having observed that small quantities of hydrogen peroxid diminish pronouncedly the acid- ity of the gastric contents. Peroxid of hydrogen was recommended by Petri in large amounts, 300 c.c. of a o. 5 solution on an empty stomach, but was found to produce nausea. Giving it in almond water lessens this objection. It should be given in smaller dosage and only for long periods as its prolonged use is apt to cause catarrh. Sod. biborate gr. x to xv (0.6-1.0), in water (Jaworski), has been recommended. The use of Carlsbad water or a glass of the imported Carlsbad salts, i to 2 drams (4.0-8.0) in warm water on rising, lessens acidity and helps the bowels. Wolff's artificial Carlsbad mixture consists of: 1$. Sod. sulph 30.0; Sulph. potass 5.0; Sod. chlorid 30.0; Sod. carb 7S-; Sod. biborate 10.0. M. He adds sod. biborate on account of Jaworski's recommendation. Dose, W dram (2.0) in one-half glassful of warm water two hours before meals. In some cases I give olive oil, % to i ounce (15.0-30.0) or more, or glycerin, % to 2 drams (2.0-8.0), in a little water before meals, to lessen gastric irritability; bismuth subnitrate, 15 grains to % dram (1.0-2.0), given with the olive oil, is often useful. 1 Journal A. M. A., Feb. 17, 1914. 382 DISEASES OF THE STOMACH AND INTESTINES If the pain is severe, the administration of belladonna before secretion commences, in order to lessen the gastric juice, is of value. At the time of pain it is too late. It is serviceable also in marked or obstinate cases to lessen Hcl, thus before meals: 1$. Tinct. belladonna 3iss (6.0); Aq. destil q. s. 5 ij (60.0). M. Dose, ^ to i teaspoonful (2.0-4.0), or larger dose of tinct. belladonna, up to 10 drops, may be given, t.i.d. 15 minutes to half hour be- fore meals. or Ext. belladonna gr. 5-6 to H (00.1-0.02). or Atropin gr. Moo (0.0006) or Ho (0.0012) Illoway suggests: fy Tinct. aconite root 6 drops; Tinct. belladonna 25 drops; Aq. destil q. s. 5j (30.0). M. Dose, i teaspoonful (4.0) on rising and a second dose in half an hour. No more. If the pain is extremely severe and not relieved by an alkali or bella- donna, hyoscyamin hydrobromate gr. ^ 00 t.i.d. before meals should be tried. A small dose of codein, % to y grain (0.008-0.016), may be re- quired. This may even be given by hypodermic with excellent results. Morphin in same dosage is rarely necessary and should only be given by the physician. The application of heat to the epigastrium by moist compresses, hot- water bag, or poultice is of service. If the patient is very restless and disturbed, one of the bromids strontium bromid, sodium bromid, or ammonium bromid may be given in 10- to i5-grain (0.06-1.0) doses for a brief period, t.i.d. In obstinate cases, silver nitrate, ^ to y grain (0.008-0.016) t.i.d., or in solution, has been recommended to relieve gastric secretion, or occa- sionally a douche or spray with silver nitrate (i : 2000) followed by lavage with water or argyrol or protargol i :25oo by lavage. If the douche is used, lavage is unnecessary unless there is a complicating atonic dilatation. If one sees the patient during a severe attack of pain, aromatic spirits of ammonia, y^ to i dram (2.0-4.0), diluted well with water; lime-water, i to 2 ounces (30.0-60.0), mistura cretae, K to i ounce (15.0730.0), or bi- carbonate of soda or the magnesia preparations can be given at once, with belladonna 10 drops, or atropine Hoo~^so- Sometimes sodium bicarbonate distends the stomach and causes more pain. Emesis is often a relief, and at times, when other treatment fails, lavage may be used as a temporary method. Electricity has been recommended, especially by Einhorn, for the treat- ment of hyperacidity. Internal galvanization has been suggested for the relief of pain. It seems to be impractical. In cases when constipation is obstinate or when atony is present, it might be of service, either the intragastric or, preferably, the percutaneous method of faradization. FUNCTIONAL DISEASES OF THE STOMACH 383 Bowels. Massage, vibratory massage, and rectal injections of olive oil are of service, as well as out-of-door exercise, horseback riding, etc. Remedies such as cascara, aloes, phenolax, purgen, regulin, the mineral oils, olive oil, etc., may be at times temporarily necessary. If there are atony, dilatation, or ulcer, these conditions must be treated. Rose's belt is indicated for atony or atonic ectasia. To briefly recapitulate. I have found the following of value: Carlsbad salts on rising, though not always required. Milk of magnesia (Phillips) or magnesia usta, alone or with soda bicar- bonate, or Vichy and soda bicarbonate, one to two hours after meals; midway between the chief meals a little milk and raw eggs, koumiss, mat- zoon, and Vichy, or i to 2 ounces (30.0-60.0) of gelatin solution (5 to 10 per cent.). In some cases olive oil before meals t.i.d. with belladonna extract gr. y or tincture 5-10 drops, preferably. The proper diet must be followed. HYPOCHLORHYDRIA AND ACHLORHYDRIA These functional disturbances of the stomach may be associated with organic disease of this organ, may be a reflex from some other disease, may occur with a constitutional disease such as syphilis or arteriosclerosis, may be associated with nervous disease, or result from a general depression of the entire system such as due to overwork or from sympatheticotonia or rarely may be a neurosis. Achlorhydria (absence of hydrochloric acid) is a progressive stage of hypochlorhydria. Unfortunately there is a tend- ency among some of our gastrologists to confuse achylia gastrica and achlorhydria. With the former the acidity is low, 4+ to 6+, HC1 is absent, as are also pepsin and rennet. With achlorhydria HC1 is absent, the ferments are present and total acidity is higher, and also mucus is present only if there is catarrh in addition. Under normal conditions free hydrochloric acid averages 25+ to 50+. With free hydrochloric acid on an average 20+ or less we may consider it a hypochlorhydria if gastric symptoms are present. Etiology. Hypochlorhydria, or achlorhydria have been found in association with the following: gastric cancer, gastric ulcer, achlorhydria haemorrhagica gastrica, chronic gastritis, gastroptosis, visceral arterio- sclerosis, syphilis or the gastric crises of locomotor ataxia, chronic erosions, atonic dilatation of the stomach, acute gastritis or reflex from disease of some other organ such as from gall-bladder disease, chronic appendicitis, chronic pancreatitis, or with cancer of the breast or uterus without in- volvement of the stomach. Sympatheticotonia may be a factor. Neu- rasthenics or patients of nervous type may suffer from these conditions and those who have overworked, or have been undergoing severe mental strain may have these derangements. Rarely hypochlorhydria or achlor- hydria may be a neurosis. In 4937 cases with stomach disturbances, Kelling 1 found, excluding ulcer, every seventh man and fifth woman had no free HC1. No free HC1 1 Archiv fur Verdamingskr., Oct., 1909. 384 DISEASES OF THE STOMACH AND INTESTINES was found in 30 per cent, of gall-stones, and in 30-40 per cent, of diabetes, gout, renal calculus and tuberculosis. The author cites a few cases of various types. CASE i. Stomach in normal position. Patient a priest of nervous tem- perament, aged fifty-two, has been very active mentally with sedentary life. Is obese. For a few months pain half an hour after meals, gas and eructation. Achlorhydria. Improved rapidly under diet, exercise, hydrochloric acid, triple valerian pills, etc. CASE 2. Stomach in normal position. Priest, aged forty-seven. Sister had urticaria. No history of asthma. Has had gastric trouble for some years. Some time ago hydrochloric acid was found to be deficient by another physician. His first visit to the writer was on Jan. 13, 1915. He had marked urticaria with which he had been continuously afflicted for two months, and had suffered considerably there- from. He had three attacks of angioneurotic edema within six weeks, affecting the left side of the face and lower lip, the last attack, Jan. n, 1915, two days before his visit to me. With his first attack there was hoarseness, evidently edema of the glottis. He traced one of these attacks apparently following eating of a large steak. The urticaria at the time became worse. His gastric analysis showed total acidity 16+, free HC1 8+, comb. HC1 8+; hypochlorhydria. Urine showed a trace of indican and trace of ace- tone. With deficient protein digestion, and the history, the case was evidently one of protein absorption with anaphylaxis, resulting in urticaria and angioneurotic edema. Treatment was begun with elimination of red meat and cutting down proteids, oxyntin (powdered HC1) with nux, hexamethylenamine, gr. v, t.i.d. and phosphate soda 3i A- M. ' Jan. 16, 1915, urticaria had disappeared entirely, later, Feb. 19, 1915, a mild attack recurred. At the present time, though the achlorhydria still persists (May 25, 1916), the patient is in excellent condition and has no further attacks of urticaria or angioneurotic edema. Diet is rigid. CASE 3. Infantilism. Chronic intestinal putrefaction, hypochlorhy- dria, convulsions. Patient sent in consultation by Dr. Denis of Jersey City. Boy, aged four and one-half, artificially fed, has convulsions off and on since eight months of age, and of late every month or two had convulsive seizures. His weight when the author first examined him, Jan. 2, 1912, was only 22 pounds, the child was fairly bright but physically undevel- oped, with a pot belly. He also had attacks of vomiting. The lower border of the stomach reached the umbilicus (dilatation). Gastric analysis. Total acidity 30+; free HC1 o; comb. HC1 20+; lactic and inorganic acids. Since there was sufficient HC1 to give 20+ comb., though no free HC1, it should be considered hypochlorhydria, and not achlorhydria. Indican and oxalates were in very large amount, urea 3.09. The stool showed large numbers of gram-positive organisms such as are described by the late Christian Herter in his brochure on infantilism. There was marked secondary anemia. By Jan. 6 all reports secured. Jan. 2, 1912, the diet advised was well-boiled rice, arrow-root gruel, FUNCTIONAL DISEASES OF THE STOMACH 385 cream of wheat, Huntley and Palmer breakfast biscuit, milk sugar, avoiding malted milk, Mellen's food and potatoes; Cox's gelatin 5i daily in jelly form, chicken jelly, rice flour gruel, milk, spinach, beef, chicken or mutton broth, beef juice from i pound of rump. No meat. Total milk 1 8 ounces daily, the diet advocated by the late Dr. Alerter. Huntley and Palmer, 6 biscuits daily. Gelatin 5i daily. Beef, chicken or mutton broth 5 vi daily. Rice 5i daily. Beef -juice from i pound rump daily. The feedings were arranged as follows: [Milk 5vi with gelatin (jelly), one Huntley and Palmer 7 .OO A. M. ,. ., I biscuit. 9 . 30 A. M. Milk 5 vi with gelatin, Huntley and Palmers, two. Beef juice, 5ss~5i. Spinach, 5 SS - i . 30 P. M. Rice, 5ss. Huntley and Palmer, one 4.30 P. M. Variety of broth 5vi with gelatin. Rice 5ss. 6 . 30 P. M. Milk 5 vi with gelatin. Huntley and Palmers, two. Medication. 1 aka-diastase gr. 3 to 5 t.i.d., mixed with food, lacto- bacillin tablet one t.i.d., iron tropon one t.i.d., lactate calcium gr. i to 2 t.i.d. Acetozone enema Mooo i pint to iH pints (high) daily. Feb. 24, 1912. 37 pounds, gain 15 pounds in seven weeks, no convul- sions. Dec. 2, 1912. Weight 48 pounds, only one convulsion since previous to Jan. 6, 1912, due to stopping out a day or two. Jan. 6, 1913. Weight 52 pounds, normal stool, still some excess of indican, but much less than one year ago, oxalates normal, urea now low and chlorides high. Subsequently by June, 1913, the patient's weight increased to 58 pounds as reported to me. He later had an attack of diphtheria and lost some weight, having subsequently had two convulsions, but no others followed for a year. On May 18, 1916, the boy reported to me. He has had no convulsions for two years. His mother states that he is now extremely active and for a year has acted like a normal boy. He is very small, weight only 53 pounds, less than in 1913. He is bright in his studies. The pot belly has disappeared and the stomach is in normal position. The diet has now been amplified into a greater variety, but still with avoidance of red meat and excess in proteids. CASE 4. Male, aged fifty-eight. 163 gall-stones removed two years previously. In July, 1914, abdominal distress loose stools of putty color no nausea, tongue coated, belching. Physical Examination. Tenderness at Robson's point, some soreness in epigastrium, sensitive at Morris and McBurney's points, gall-bladder slightly sensitive, secondary anemia. 25 386 DISEASES OF THE STOMACH AND INTESTINES Radiograph shows dilated duodenum from adhesions. Gastric analyses. Total acidity 17+ ; free HC1 o; comb. HC1 12, trace, lactic acid. Urine. Indican, faint trace, no bile. Stool, excess of unabsorbed free fats, partly digested meat and excess of soaps. Diagnosis. By the writer, gall-stones, cholecystitis, chronic pancreati- tis, chronic appendicitis, adhesions, with hypochlorhydria (or achlorhydria 1 as to free acid). All were confirmed at operation by John Erdmann, who removed the appendix and an infected gall-bladder containing calculi. The chronic pancreatitis and adhesions were present. The latter were separated. The hypochlorhydria was evidently reflex. Subsequent to operation, the diarrhea and putty stools disappeared and the patient has greatly improved, having gained some weight. In general with hypochlorhydria we have the following symptoms: These may be gastric, with belching, pain, discomfort after food, suggestive of chronic gastritis, or they may be nervous chiefly with intestinal toxemia. Treatment. The diet would be much the same as with chronic gas- tritis, less meat and more carbohydrates. Hydrochloric acid, or in the form of oxyntin would be indicated, also strychnin or nux vomica, and the treatment of indicanuria if present, nerve tonics should be given in the nervous, or neurasthenic cases. Gastroptosis should be corrected if in evidence. If the condition is reflex, or associated with organic disease of the stomach, the cause must receive treatment. If sympatheticotonia is a factor, it should be treated. GASTROSUCCORRHEA (CONTINUOUS SECRETION OF GASTRIC JUICE) (Synonyms. Hypersecretion; Parasecretion; Excessive Flow of Gastric Juice; Reich - mann's Disease; Gastroxynsis Rossbach) Gastrosuccorrhea is a perversion of function in which the glands of the stomach secrete large quantities of gastric juice even when the stomach is empty, and hence when there is no irritation from ingested food. The diagnosis rests on the removal from the stomach in the fasting condition of a considerable quantity of gastric juice, with the addition of symptoms which present a characteristic picture. To Reichmann the credit is due of having first called attention to this perversion of function. Gastrosuccorrhea may be classified in two types: 1. Gastrosuccorrhea continua periodica or the intermittent form of hypersecretion; the attacks occur at irregular intervals. 2. Gastrosuccorrhea continua chronica or chronic hypersecretion. Though some believe that hypersecretion is a purely secretory neurosis, other factors can also produce it. Unquestionably, nervous conditions, such as mental excitement or mental overexertion, may be the direct cause in some cases; hence, gastrosuccorrhea may be a pure neurosis. On the other hand, direct irritation of the mucous membrane can be the cause; in fact, the same factors that produce hyperchlorhydria, such as rapid eating, indigestible food, spices and condiments, abuse of alcohol, bolting the food, excessively hot or cold food or drink, etc. 1 Noting the HC1 o, Erdmann feared the possibility of malignancy of the pancreas. The author has observed, however, that with marked chronic pancreatitis HC1 is much diminished, or absent, while with an incipient case, as reported under chronic pan- creatitis there may even be hyperchlorhydria. FUNCTIONAL DISEASES OF THE STOMACH 387 Hyperchlorhydria of long standing, especially if neglected, may be a factor in the ultimate production of continuous secretion. In some of the gastric crises of locomotor ataxia, gastrosuccorrhea is at times observed. Hypersecretion is also at times an accompaniment of dilatation of the stomach, either of the atonic type or, more frequently, in the form due to stenosis of the pylorus. It also may occur with ulcer of the stomach or duodenum. It can even accompany acute dilatation of the stomach, especially in that form engrafted on a chronic stenotic dilatation, to which I refer under Acute Ectasy. It at times is caused by vagotonia. Tetany may be rarely associated. In many cases of hypersecretion disturbances of the motor functions of the stomach are present in addition. GASTROSUCCORRHEA (CONTINUA PERIODICA) (Synonyms. Intermittent Secretion of Gastric Juice; Intermittent Hypersecretion; Gastroxynsis; Periodic Continuous Flow of Gastric Juice) This type of hypersecretion is characterized by an acute attack of continuous secretion of gastric juice associated with severe pains in the stomach, usually spasmodic in character, and by vomiting of acid fluid, the attacks generally occurring in the night or early morning and at irregu- lar intervals; hence it is known as intermittent or periodic. Probably this condition is more frequent among nervous cases than we generally suppose. I have been able to absolutely determine in several cases of supposed intermittent attacks of acute gastritis, or so-called acute bilious attacks, that this condition of intermittent hypersecretion was present. History. Reichmann 1 was the first to describe this perversion of function, and Rossbach, 2 under the nomenclature gastroxynsis, described what is generally considered the same disease. Sahli, Riegel, and many others have written on it. Etiology. In some cases it is a neurosis, or the result of mental over- excitement or of overexertion; irritation of the gastric mucous membrane, as from cold water, or smoking spices, etc., may precipitate an attack. It is associated with the gastric crises of locomotor ataxia in some patients, or with organic affections of the peripheral or central nervous system, with gastric or duodenal ulcer, or with the stenotic form of ectasia or with acute dilatation of the stomach. These are not pure cases, but have the additional symptoms incident to the disease. Symptoms. These usually begin during the night. The patient, who is generally apparently perfectly well, suddenly begins to feel discomfort in the gastric region, which is rapidly followed by pain of severe type and generally spasmodic in character. There are nausea, a feeling of faint- ness, and the patient is obliged to assume the recumbent position. He grows pale, the extremities become cold, and the abdomen at times is sunken and the pulse rapid and feeble. The nausea becomes worse and 1 Berl. klin. Wochenschr., 1882, No. 40. 2 Deutsch. Arch. f. klin. Med., 1883, Bd. 35. 3 88 worse and soon a violent attack of vomiting of a large amount of acid fluid takes place. There is temporary relief, but the symptoms begin again, and after a short period the patient again vomits up a large quantity of fluid, far out of proportion to the amount previously ingested. During the attack the appetite is lost and there is extreme thirst. Severe headache and constipation generally accompany these attacks. The attacks generally occur in the middle of the night or early in the morning, and awaken the patient by the pain, if he be sleeping. During the attack the stomach is tender on pressure and there is a good deal of heart-burn and acid belching, the urine is scanty, alkaline, and of high specific gravity. Character of the Vomitus. The fluid is watery and very acid. It may be clear or somewhat tinged with bile (yellowish green). There may be particles of food in the first vomit, if motor insufficiency is associated with the condition, but in many cases there is simply the clear gastric juice alone or mixed with bile. If this fluid be examined it will be found to contain free hydrochloric acid in considerable quantity, rennet, and pepsin. The desire to vomit frequently persists, and generally several attacks of vomiting succeed each other. Even though the patient abstain from all fluid, in a few hours or less he will again vomit a large quantity of gastric juice. Rarely the vomitus may contain traces of blood, which does not necessarily mean an ulcer. This condition may last for several hours or for several days, when gradually the vomiting stops, the nausea and pain subside, and the patient begins to desire food. Gradually the appetite returns, the food is retained, in a few days he begins to feel nearly well, and in a brief time is apparently in perfect health. The patient may continue in good health for weeks, months, or a year, and then have a recurrence. The intermissions of good health, on the other hand, may become shorter until, finally, the intermittent gastro- succorrhea becomes chronic. In many cases during the intermissions, if the gastric contents are analyzed, they will be found to be perfectly normal. On the other hand, some cases may suffer from mild symptoms of hyperchlorhydria, and such a condition will be found to exist on examination. Diagnosis. This can be made by the characteristic symptoms begin- ning during the night, the vomiting of pure gastric juice occurring when no ingesta are present in the stomach. Analysis shows that it possesses all the properties of the gastric juice with an excess of free hydrochloric acid. If no food is given and the stomach be aspirated before the second attack of vomiting occurs, at the time of appearance of pain and nausea, or if the second vomitus be analyzed, and in either event be found to con- sist of a considerable quantity of pure gastric juice, the diagnosis is conclusive. The attacks are intermittent. All cases should be examined as to motor functions and dilatation, since attacks of gastrosuccorrhea occur with these conditions. One should also exclude organic disease, such as ulcer and the gastric crisis of loco- FUNCTIONAL DISEASES OF THE STOMACH 389 motor ataxia. In the latter case we have loss of patellar reflexes, the Argyll-Robertson pupil, and the Rhomberg symptom and the Wasser- mann reaction which should be tested for in suspicious cases. Prognosis. In pure cases of gastrosuccorrhea continua periodica the prognosis may be fairly good. It is often possible to lessen the severity of the attacks or in some cases even to effect a cure. Treatment. Prophylaxis. We must first endeavor to find the cause of these attacks, and by correcting it, prevent their occurrence. In the interval between attacks the stomach contents should be examined after a test-breakfast or meal, and we should determine whether or not hyper- chlorhydria exists, or gastric or duodenal ulcer. The motor functions of the stomach should also be carefully tested, and any motor insufficiency if present should receive treatment. If there be excesses in smoking or drinking, tobacco and alcohol should be cut off. If there are errors in diet, they should be corrected. If mental overexer- tion or nervous excitement is a cause, such conditions should be corrected. If the patient is neurasthenic, he should receive careful treatment. Hy- gienic method of living, exercise out of doors, horseback riding, golf, etc., are serviceable. Treatment of the Attack. During the early stage, when the pain and nausea first begin, binding the free acid with the whites of several raw eggs beaten up in water or in milk, or the use of i or 2 ounces (30.0-60.0) of 10 per cent, gelatin, or neutralizing the acid by the administration of an alkali, such as % to i dram (2.0-4.0) sodium bicarbonate in water, 4 ounces (125.0), or Vichy; or milk of magnesia, Y^ ounce (16.0), or mag- nesia usta, H to i dram (2.0-4.0), will at times mitigate the symptoms. Einhorn recommends a large dose of bromid at the appearance of the first symptoms, and claims that it will often cut the attack short or lessen its severity. About 15 to 30 grains (1.0-2.0) of sodium bromid should be given, preferably in Vichy (an alkali). The patient should be kept recumbent, with the application of moist heat or dry heat (wet hot flannel compress or hot-water bag) applied to the gastric region. He will generally vomit in spite of treatment. The best method, I believe, is to perform lavage early, not waiting until vomiting occurs, if the pain and nausea are not relieved by adminis- tration of the albuminous food or alkalis. Wash the stomach thoroughly with an alkaline solution i to 2 quarts (liters) of warm water in which 2 to 3 ounces (30.0-45.0) of milk of mag- nesia (Phillips) have been dissolved or ^ ounce (16.0) of sodium bicar- bonate or % ounce (16.0) of magnesia usta. Before withdrawing the tube after lavage, pour through it into the stomach 2 drams (8.0) of milk of magnesia dissolved in 2 ounces (30.0) of water, to which is added 10 drops (0.6) tincture of belladonna or Koo~Ho of atropine to check further secretion. Sodium bicarbonate, i dram (4.0), may be substituted for the magnesia. If the pain is very severe it may be necessary to give one or several hypodermics of morphin, ^ to % grain (0.008-0.016), preferably com- bined with atropin, ^ 00 grain (0.00065), which last is of value to lessen hypersecretion. Codein may be employed. 39 DISEASES OF THE STOMACH AND INTESTINES To the use of cocain for nausea and vomiting I am opposed. It gives but temporary relief, is a marked cardiac depressant, many patients have an idiosyncrasy to even a sma.ll amount, and there is danger of the cocain habit. It may be necessary to repeat lavage several times. The belladonna or atropin should be pushed to physiologic limits, with dilatation of the pupils and dryness of the throat, if one expects to have any effect in check- ing the hypersecretion. Some recommend washing the stomach with i : 2000 silver nitrate solution, and following it with plain warm water; argyrol or protargol (1-2000) can be substituted. Some patients will not consent to lavage, and m these cases we can simply give internally several large, doses of the alkalis with belladonna every two to three hours, whether they vomit or not. If there is great thirst, a glass of hot water in which sodium bicarbonate, i dram (4.0), has been dissolved is of service, if taken in small amounts (teaspoonful doses). It often relieves the nausea and the alkali is of value; or a small piece of cracked ice or an occasional teaspoonful of cool water can be also employed. The raw white of eggs beaten up, placed in a cup and packed around with ice, or the 5 to 10 per cent, gelatin, two teaspoonfuls given every half-hour or so, both relieves thirst and binds the acid; or Milk gviij (250 c.c.); ] Pack ^ Oxalate of cerium gr. x (0.6); 1 dissolved > . . c ,. , . \ v t \ ! 4.1. m ice - Sodium bicarbonate gr. xv to 5 ss (1.0-2.0) j therein. J Give i teaspoonful (4.0) every half hour, or so as to relieve thirst and bind the acid, and check nausea and vomiting. In some cases rectal enemata of hot normal salt solution at ii5F., i pint (500 c.c.), relieve thirst and stimulate the pulse. It may be neces- sary to employ smaller quantities of saline solution or to use proctoclysis. It is best for the patient not to drink too much the first day of the attack, except the remedies noted, as an excessive amount of fluid favors vomiting. No food should be given except as above advised. On the next day small quantities of milk diluted with lime-water or matzoon and Vichy or albumin-water can be given, % to i ounce (16.0-32.0), every hour, and the gelatin can be kept up. The quantity of nourishment may then gradually be increased, and, finally, soft-boiled eggs, scraped raw meat, and a subsequent diet such as is used in hyperchlorhydria. The bowels should be moved early in the attack by a soapsuds enema, i quart (liter), to which 8 ounces (250 c.c.) olive oil have been added, or by enteroclysis. To recapitulate. In the treatment of the acute attack I follow out the following method: Heat to the abdomen, the administration at once of an alkali by mouth; the bowels are moved by enema, and the stomach, after a brief period of rest, washed with an alkali, preferably with milk of magnesia; 2 drams (8.0) of milk of magnesia diluted with water, 2 ounces (125 c.c.), with tincture of belladonna, 10 drops (0.6) or atropin (Hoo~ , being poured into the stomach through the tube before removal. FUNCTIONAL DISEASES OF THE STOMACH 391 A hypodermic of morphin is then given, the room darkened, and the patient kept perfectly quiet. This treatment is repeated if necessary. If the patient will not consent to lavage, then alkalis, gelatin, and whites of raw eggs with belladonna or atropin should be administered. GASTROSUCCORRHEA (CONTINUA CHRONICA) (Synonyms. Chronic Gastrosuccorrhea; Chronic Hypersecretion; Chronic Parasecre- tion; Chronic Continuous Secretion of Gastric Juice; Reichmann's Disease) Chronic continuous secretion of the gastric juice is a perversion of function which is characterized by the secretion of an excessive quantity of gastric juice, not only after the ingestion of food, but also when the stomach is empty. The chief diagnostic point is the secretion of large quantities of gastric juice in the fasting stomach. Reichmann, 1 in 1882, was the first to de- scribe this condition. We must make a distinction between the pure cases of chronic gastro- succorrhea and those in which dilatation (atonic) of the stomach or dila- tation from stenosis, especially with ulcer, exist, and with which hyper- secretion is an associated symptom. After fasting, small quantities of gastric juice, as much as 5 to 10 c.c. or 15 to 30 c.c., on one or two occasions have been aspirated. Thus the possibility of a normal small secretion may exist. If, however, we find 20 to 30 c.c. or more of gastric juice constantly in the stomach of a patient who has been fasting for some time with the clinical symptoms described, the finding we would consider to be pathologic and to be an evidence of continuous hypersecretion. Rehfuss has reported a number of cases of aspiration of the fasting stomach with 75 to too c.c. gastric juice and yet no hypersecretion. He therefore states that more than this quantity should constitute hyper- secretion and believes former methods of aspiration, as compared with his fractional method, are faulty. These subjects of Rehfuss gave no symptoms. The fractional method (long continued presence of the tube) may in itself excite more secretion. Moreover we see patients with a free HC1 (hyperchlorhydria) giving no symptoms. If the fasting juice be over 20-30 c.c. plus the symptoms, hypersecretion may be fairly diagnosed. Frequency. Cases of pure gastrosuccorrhea chronica without any associated organic lesions of the stomach I believe, with Einhorn, to be quite a rare disease, while those found in association with ectasia are not uncommon. Undoubtedly the latter class have been confused with the pure cases. Chronic hypersecretion is more rare than the periodic type. Etiology. Chronic hypersecretion occurs more frequently in men than women, and in youth and middle life. Severe mental strain or worry seem to be factors, also the neurotic condition, and vagotonia. The periodic type may develop into the chronic; persistent hyper- chlorhydria or its causes, such as indigestible or irritating food or condi- 1 Berlin, klin. Wochenschr., 1882, No. 40. 392 DISEASES OF THE STOMACH AND INTESTINES ments, the abuse of alcohol or tobacco, or excessive hot or cold food and drinks, may be factors. Dilatation of the stomach, ulcer of the stomach or duodenum, or tetany may have chronic gastrosuccorrhea associated with them. One must also remember that chronic hypersecretion may be reflexly produced by disease of some other organ, the appendix, gall-bladder, pan- creas, tuberculosis, or a new growth of the cecum, and that severe inflam- mation of the stomach, Fen wick 1 believes, may follow, and that even gas- tric ulcer or ulcer of the duodenum may on the other hand result. This same hypersecretion may give rise to spasm of the pylorus, causing pain and intermittent obstruction. Fenwick even goes so far as to state that the character of the inflammation of the appendix is indicated by the gas- tric secretion; an active irritation being indicated by hypersecretion, while torsion, thickening, cystic dilatation or adhesion are followed after a time by a type of chronic gastritis characterized by flatulence, nausea, anorexia, excess of mucus, and absence of free hydrochloric acid. This last corre- sponds nearly to the achlorhydria gastrica haemorrhagica described by Pilcher 2 in Mayo's clinic. Symptoms. In most of the cases the patients state that the gastric symptoms began gradually, a feeling of pressure, fulness, and sour eructa- tion commencing a couple of hours after the ingestion of food, resembling the symptoms of hyperchlorhydria. Then pain occurs several hours after meals or shortly before the ensuing meal ; it is most frequent on the empty stomach, just before the next meal is due. It may be spasmodic in char- acter; nausea and then vomiting follows. The vomiting may increase in frequency, and, finally, occur several times a day after breakfast and sup- per. In some cases the attacks take place during the night between 12 and 2 o'clock, the patient being awakened by burning and pain in the epi- gastrium, acid eructations, and, finally, vomiting of very acid fluid takes place; after vomiting the pain is relieved. The night vomitus is generally a clear fluid. Albuminous food, egg or milk, will often relieve the pain. The day vomitus is very acid (quite liquid), but some food is mixed with it; is often of a grass-green color. The appetite is generally good and often increased. Sometimes the patient develops excessive hunger; loss of appetite is rather rare. Thirst is increased, the bowels are constipated, the urine diminished and less acid than normal. There may be some loss of weight, but ho marked emaciation. The contrast between the physical condition of the pure type of chronic hypersecretion and that in which dilatation of the stomach accompanies it will be described under Differential Diagnosis. Palpation. The stomach is more or less sensitive to pressure. Diagnosis. The diagnosis of gastrosuccorrhea continua chronica can only be made by examination of the stomach in the fasting condition. To exclude error, the method suggested by Reichmann is the best. 1 The Clinical Significance of Gastric Hypersecretion and Its Connection with Latent Disease of the Appendix, Proc. Royal Soc. Med., April, 1910, Surg. Sect., p. 177. 1 Jour. Amer. Med. Assoc., Nov. 19, 1910, p. 1790. FUNCTIONAL DISEASES OF THE STOMACH 393 The stomach should be thoroughly washed out with warm water, preferably at night, all food and drink should be withheld for ten to twelve hours, and then aspiration of the stomach contents should be performed. Anywhere from 50 to 125 c.c. of gastric contents are thus obtained. This secretion exhibits all the properties of the gastric juice. It contains no particles of food. The fluid is usually watery and clear in color or it may be yellowish green from admixture with bile. There is an increased degree of acidity, the values for free hydrochloric acid being, as a rule, pretty high. There are no starchy products contained therein. There are no evidences of fermentation and no organic acids present. Under the micro- scope no sarcinae are found. An hour after Ewald's test-breakfast more liquid than usual is present and the acidity is quite high (75 to 125), higher than when the fasting contents are aspirated. A thin disk of egg-albumen will be digested at blood temperature in an hour or so. LugoPs solution gives a blue or violet reaction, showing the starch is unchanged or slightly so. Three to four hours after Riegel's test-dinner hardly any meat fibers are found, whereas considerable starchy material is present. The acid content is high and the residue considerable. We must remember that the above description is a case of pure chronic gastrosuccorrhea in which there is no motor insufficiency. These cases I believe to be quite rare. Differential Diagnosis. Many of our writers do not properly dis- tinguish between cases of pure chronic hypersecretion and those in which dilatation of the stomach is a complication. The examination of the stom- ach as regards its size, position, and motor functions should always be carried out, and this will aid us. Ulcer of the stomach may be complicated by hypersecretion, and in a few rare cases gastric tetany is associated with it. Occasionally no symp- toms pointing to a previous ulcer can be obtained, though there may have been a previous history of hyperchlorhydria, and at subsequent operation the stenosis will be found to be due to an ulcer not entirely healed. In ectasy from pyloric benign stenosis with hypersecretion we have ex- cessive vomiting of a large quantity of greenish-yellow fluid, pain, cramp- like attacks, peristaltic unrest, excessive thirst, skin over the abdomen dry and wrinkled, loss of weight which is often very great, and occasion- ally some tinge of blood in the vomitus. The patient presents almost a cachectic appearance, and there is in some patients the sense of resistance, or even a feeling of thickening at the pylorus. The vomitus or contents aspirated after a test-meal will separate into three layers: an upper layer of foam, middle layer yellow or yellowish green, and a lower layer of sediment. Meat is digested, the sediment consists of starchy material. Acidity is markedly increased and content of hydrochloric acid is high. Pepsin digestion is rapid. Starchy materials yeast-cells, and sarcinae are found under the microscope. Examination further shows marked dilatation of the stomach, with great relative motor insufficiency. Hyperchlorhydria with atonic dilatation must also be differentiated. The pain and vomiting occurring in some cases present some of the symptoms of hypersecretion. 394 DISEASES OF THE STOMACH AND INTESTINES For example, in one case a test-meal given at night shows A. M. on aspiration 500 c.c. of contents; separating into three layers, fermentation being present, stomach one finger below umbilicus. Reichmann's method was then employed, i.e., the stomach was thoroughly washed out and noth- ing given for twelve hours. Morning aspiration showed the organ to be empty, no secretion, hence the diagnosis was clear. In many cases of marked stagnation of the stomach-contents with dilatation, continuous secretion may be simulated. The method of test- ing the empty stomach will determine the diagnosis. If there have been hematemesis, melena, circumscribed tenderness, or dorsal tenderness, ulcer will be suspected. Frequent examinations for occult blood in the stomach contents and stool are of service. The ar- rays should be employed for diagnosis when stenosis or ulcer are suspected. Tetany may complicate hypersecretion with dilatation. The symp- toms are characteristic. Prognosis. In the cases of pure chronic hypersecretion the prognosis is fairly good. Most patients improve under treatment, but quite fre- quently there are relapses. Sometimes the condition persists for years. Hypersecretion per se is never fatal. When complications such as dila- tation of the stomach are present, the serious features are dependent on them. Treatment. Prophylaxis. The patient should not overwork, should be relieved of all mental overexertion, and lead a rational out-of-door life, with proper attention to exercise and hygiene. Nervous conditions when present should be treated. The patient should avoid bolting his food, should not eat any irritating substances, such as mustard, pepper, spices, alcohol, and very hot and very cold food and drink; in fact, he should avoid everything that will overstimulate the secretion of gastric juice. Avoid smoking. Albuminous food is digested well, and starchy food, badly; hence the latter should be reduced in quantity. Diet. This is practically the same as in hyperchlorhydria, except that very large quantities of fluid should be avoided. If the appetite and physical condition are good, it is just as well to give but three meals a day, so as to give the stomach a rest and not tend to keep up gastric secretion. In this event the excessive acidity can be neu- tralized between feedings by alkalis. Doses, J^ to i dram (2.0-4.0) of magnesia usta, milk of magnesia, or soda bicarbonate should be given, as in hyperchlorhydria, in water one to two hours after meals, and the hyper- secretion and the pain relieved by tincture of belladonna, 10 drops (0.6), or atropin, gr. Koo-Mo t.i.d. On the other hand, some patients, as in hyperchlorhydria, readily feel satiated, and yet desire food frequently. They may also be losing some weight, especially in the cases complicated with dilatation; small meals, which are readily expelled from the stomach (i.e., in soluble form or mushes), must be given, and yet the nutrition must be kept up, which last necessitates frequent feeding. FUNCTIONAL DISEASES OF THE STOMACH 395 The diet, for example, when given in small frequent meals would be as in hyperchlorhydria, but less fluid: 7.30 A. M. Milk or cocoa, 250 c.c. (8 ounces), 2 zwieback or toast and egg (i). 10.00 A. M. Beef sandwich or ham sandwich. 1.30 P. M. Soup, 250 c.c. (8 ounces), with raw egg, steak (100 grams), potatoes (50 grams). 4.00 P. M. Same as 10 A. M. 7.00 P. M. 2 eggs or meat (too grains), 2 slices toast, butter (20 grams). If there is dilatation, more soluble food should be given (see Dilatation of the Stomach). Starches should be given thoroughly cooked, or pre- digested and in small amounts, and preferably in soups and mushes; potatoes should be mashed and alcohol avoided; also avoid cabbage, turnips, spices, pickles, mustard, etc. Medicaments. To lessen hyper secretion. Tincture belladonna in doses of 10 drops (0.6) or more, t.i.d. before meals, up to physiologic effects, or extract belladonna, % to ^ grain (0.01-0.02), will lessen secretion and subsequent hypersecretion. Atropin, Moo to y$Q grain (0.0006-0.0014) t.i.d., by mouth or hypodermic, is also of value; the pain and the spasm of the pylorus and the hypersecretion are lessened by these remedies. One can administer a large dose of belladonna after lavage before withdrawing the tube. Bismuth subnitrate, 30 grains (2.0), in 2 ounces (60.0) water, t.i.d. half an hour before meals, or olive oil, i ounce (30.0) t.i.d. before meals, or the latter containing 30 grains (2.0) of bismuth, lessen secretion. Large doses of morphin, as have been recommended, I believe to be a pernicious method for obvious reasons. For Attacks of Pain. Alkalis, such as milk of magnesia (Philips), K ounce (15.0) in 2 ounces (60.0) of water, or magnesia usta, i dram (4.0), or soda bicarbonate alone, i dram (4.0), or combined with the above, are of service. Albumin-water (white of raw egg) or gelatin, 5 to 10 per cent, solution, i ounce (30.0), are useful. Heat should be applied ex- ternally. Lavage, preferably with an alkaline solution, with i ounce (30.0) milk of magnesia in i quart (liter) of warm water, or with soda bicarbonate, H ounce (15.0), or magnesia usta, % ounce (15.0) in the same amount of water, is the best method. A small quantity may be left in the stomach and belladonna, 10 drops (0.6), or atropin, gr. ^ , with an additional dose of the alkali poured in before removing the tube. In some cases it may be necessary to administer a hypodermic of codein, H to H grain (0.0016-0.032), or morphin, % to y grain (0.008-0.016). They should only be given by a nurse or physician. Alkalis. If there be no ectasy, a course at Carlsbad is of service, or artificial Carlsbad salts or the imported salts, or alkaline mineral waters, such as Vichy, can be taken at meals or just before meals. This lessens hyperacidity and thus aids digestion. To prevent subsequent attacks of pain an alkali should be given at the height of digestion, about two to two and a half hours after food; magnesia usta or milk of magnesia, \i to 2 drams (2.0-8.0), alone or com- 396 DISEASES OF THE STOMACH AND INTESTINES bined with soda bicarbonate or, ammonia magnesia phosphate, as described under Hyperchlorhydria, are useful. Lavage. Reichmann and Riegel were the first to recommend lavage for the treatment of this condition. Reichmann and Einhorn perform lavage in the morning with the stomach fasting, while Riegel washes it out six or seven hours after the heavy meal. My method is entirely de- pendent on the time of appearance of the symptoms. If the attack comes on at midnight or early in the morning, it seems most logical to perform thorough lavage at bedtime with an alkaline solution, leaving some of it in the organ, and also pouring into it a large dose of belladonna, 10 to 15 drops (0.6-1.0) or > atropin. If the attacks come on after breakfast or the noon meal, then the early morning lavage on the empty stomach seems best. I often recom- mend pouring Carlsbad salts directly through the tube before withdrawal. With severe pain it may be necessary to perform lavage again during the exacerbation. If there be dilatation and marked retention of food, lavage six hours after the full noon meal is necessary, then followed by a light supper; an alkali and belladonna or atropin should be given at bedtime. In some obstinate cases Reichmann recommends lavage with i : 1000 to i : 2000 silver nitrate solution. It is safest to wash the stomach with about 500 c.c. of this solution, 150 c.c. at a time, and then wash out the stomach with warm water. Argyrol or protargol 1-2000 may be employed. Normal salt solution may be substituted if there is much irritation. Some also recommend the internal administration of % to ^ grain (0.011-0.016) of silver nitrate in pure form or in solution t.i.d. and at bedtime. Stomach Spray. Einhorn claims excellent results from spraying the stomach with his gastric spray with nitrate of silver i : 2000 to i : 1000 after a previous washing with warm water. Direct Galvanization. The same author reports good results from in- ternal galvanization of the stomach, employing it and the gastric spray on alternate days. Riegel finds no benefit from intragastric galvanization unless atony is present, and in this I agree. If the condition of chronic hypersecretion be complicated by dilatation, this condition must be treated. Rose's belt is of value for atonic ectasia. If there is pyloric stenosis, gastro-enterostomy is indicated. Lavage with an alkali, belladonna or atropin in large doses, the alka- line treatment, diet, and in some cases spraying or lavage with nitrate of silver, i =4000 or argyrol or protargol i 12500 several times a week, are the chief requirements. ALIMENTARY HYPERSECRETION This rare condition, believed by some to be a neurosis, is characterized by an excessive quantity of gastric juice secreted within the stomach dur- ing digestion. This hypersecretion ceases when the contents have escaped from the organ, so that the fasting stomach is empty. This is unlike the other types of hypersecretion in which gastric secretion is secured from the stomach when empty of food. FUNCTIONAL DISEASES OF THE STOMACH 397 Etiology. Claims are made that alimentary hypersecretion occurs with atony and gastroptosis. The media between the residuum found in these cases is due to disturbance of motility. There are various theories advanced for this condition, a primary neurosis or irritant from undigested starch, but I am inclined to believe that these cases are complicated by some small gastric erosion, undetectable by the #-rays, which act as an irritant only at the time of food ingestion. On aspiration of the test meal one finds the liquid contents three or four times in excess over the solid and with the Boas dry meal an excess of liquid. The gastric findings are frequently hyperacid but not always so. Symptoms. In the writer's experience these patients have many symp- toms like gastric ulcer, particularly pain and heart-burn, and are troubled with constipation. They are often nervous or neurotic. I have not ob- served the great loss of weight as noted by Boas and others. The writer has held these cases to be practically small erosions with disturbances of secretion which may if untreated result in gastric ulcer. Treatment. The diet depends on whether hyperacidity or hypoacidity is present and is followed out on these lines: The treatment is the medical treatment of gastric ulcer atropin or belladonna are of value to lessen secretion and the alkalis are of service. Even if acidity is not marked, it is sufficient to cause irritation. Lavage several times a week with silver nitrate 1 24000 or protargol or argyrol 1 12500 is of value. CHAPTER XV DISTURBANCES OF THE MOTOR FUNCTION OF THE STOMACH ACUTE ATONY CHRONIC ATONY ACUTE DILATATION OF THE STOMACH CHRONIC DILATATION OF THE STOMACH ATONY OF THE STOMACH DIMINISHED PERISTOLE ATONY of the stomach (or diminished peristole) may be defined as a relaxation and weakening of the muscular wall of the organ, so that it cannot empty itself in the normal time, and thus motor insufficiency results. It is a perversion of motor function. With simple atony, the stomach is of normal size, but motor insufficiency exists. When the organ is enlarged, we speak of ectasy or dilatation, which is combined with motor insufficiency. There are two types of atony of the stomach : First, acute atony; second, chronic atony. Acute Atony of the Stomach Acute Diminished Peristole Acute atony of the stomach may occur as a preliminary to acute dilatation of the stomach, just as may chronic atony to chronic atonic dilatation. Acute atony does not necessarily result in acute dilatation. Many of the causes which produce acute dilatation are the factors with acute atony, but the stomach has not become dilated. The early recognition of the condition is, therefore, important. The motor insuffi- ciency which occurs with it may also lead to error in diagnosis. The con- dition takes place most frequently after overloading the stomach, bolting the food, or indigestible food, or alcohol. It may complicate acute gas- tritis, with belching, fulness or discomfort in the stomach, some distention, constipation, and delayed vomiting; in fact, merely discomfort for a con- siderable period of time and then the vomiting of food taken some hours before. The splashing sound is present. The stomach becomes distended, tympanitic, and often sensitive to pressure. A sudden attack of retention of chyme for an abnormal length of time is the salient symptom. In one case, because of motor insufficiency following a single dietary indiscretion, a diagnosis of ectasy with motor insufficiency was made. Examination demonstrated normal functions, the attack evidently being an acute atony (acute motor insufficiency) of temporary duration. During typhoid or the infectious diseases, gastric disturbances with belching, discomfort, sudden distention of the stomach, constipation, or diarrhea, with delayed vomiting, the vomitus consisting of milk (curdled) or other food taken some hours previously, are significant of this condition. 398 ATONY OF THE STOMACH 399 There may be evidences in the stool of nourishment taken forty-eight hours before. Treatment. The immediate emptying of the gastro-intestinal tract is the indication. Lavage should be performed at once. A good cathartic, calomel, 3 to 5 grains (0.2-0.3), or blue mass, 5 grains (0.3), followed by a saline cathartic, should be given. Castor oil, i to 2 ounces (30.0-60.0), is also excellent. Enemata, and especially rectal irrigation, are of value to produce intestinal peristalsis. Acute atony may progress rapidly to acute dilatation or develop more slowly for ten to twelve hours, and then, if untreated, result in acute ectasy. Its early recognition is, therefore, important. CHRONIC ATONY OF THE STOMACH CHRONIC DIMINISHED PERISTOLE (Synonyms. Motor Insufficiency; Gastric Insufficiency; Motor Insufficiency of the First Degree; Myasthenia Ventriculi; Atonia Gastrica 1 ) Chronic atony of the stomach, if untreated, may result in the atonic type of dilatation of the stomach. Its correction is, therefore, of great importance. We use the term "chronic" in distinction from the acute, evanescent form. In the pure cases no dilatation is present. Etiology. Atony of the stomach may complicate many digestive dis- orders, such as chronic gastritis, hyperchlorhydria, neurasthenia gastrica, and diseases of the heart and lungs, as tuberculosis. It occurs in nervous and hysteric subjects and may exist as a primary neurosis. It may occur as a result of biliary colic or the crisis of tabes. Symptoms. If atony occurs as a complication of some other affection of the stomach, its symptoms will be overshadowed by the primary dis- ease. The characteristic symptoms of atony are: a feeling of fulness after meals, slight distention, belching of gas, diminution of appetite, headache, and constipation. The resulting motor insufficiency is productive of fermentation and gas production. Physical Examination. There is generally some distention of the stomach with gas. The splashing sound is easily produced over the greater part of the stomach an hour or two after the test-breakfast, or four or five hours after a full meal. If the splash extend to the umbilicus or below it, this is evidence that dilatation is associated. If movable kidney is associated, gastroptosis is present. These are not pure cases. An hour after Ewald's test-breakfast aspiration of the stomach con- tents will remove 100 c.c. or more of gastric contents; an excellent test taken in connection with the symptoms. Six hours after Leube's test-dinner, aspiration and lavage show con- siderable chyme, 150 to 200 c.c. The fasting stomach in the morning is found empty. Boas states that on filling the stomach with water, the greater curva- ture will descend as water is added. This is not reliable. The lower 1 Rose has called to our attention that atonia gastrica is an improper term, really meaning abdominal relaxation. It is so applied in our work " Atonia Gastrica " to define splanchnoptosis. 4OO DISEASES OF THE STOMACH AND INTESTINES border will descend after a moderate amount of water, if the stomach is dilated. Prognosis. This is good if proper treatment is instituted. Treatment. If hyperchlorhydria or chronic gastritis is present, each should receive appropriate treatment; as should tuberculosis, endocarditis, nervous conditions, etc. In all cases of chronic atony of the stomach, Rose's plaster belt is indi- cated. Atony of the intestines is frequently associated, and the use of mechanic support lends tone to the general musculature of the abdomen, keeps the stomach well supported, and prevents atonic dilatation of the organ. Vibratory massage or massage over the entire gastro-intestinal tract is of value. It stimulates the muscles and lessens the tendency to consti- pation. Outdoor exercise, walking, golf, and horseback riding are indi- cated. In some cases douching the abdomen is of service; in this event one must employ a silk elastic abdominal support, or Lane's leather pad, which can be readily removed. I have secured the best results with Rose's belt. The patient should not overwork, either mentally or physi- cally, and should eat slowly and masticate the food thoroughly; the teeth should be kept in good condition. An excessive quantity of fluid should not be taken in all, including water, soups, tea, etc., not over ij liters a day. It is best to give numerous divided meals of rather moderate size, four or even five daily, so as not to overburden the stomach with three large meals, and allow it to thoroughly empty itself. This can be aided by lying on the right side for 15 minutes or more after each meal. The diet may include bread (fresh and hot breads are interdicted) and butter, eggs in various forms, cereals, milk, soup, chicken, steak, chops, game, squab, fish, oysters, and green vegetables, which are specially valuable for the constipation; cocoa, weak tea, occasionally weak coffee, with milk and sugar. The diet must be modified if hyperchlorhydria or chronic gastritis is present, or to suit the special idiosyncrasies of the pa- tient. Alcohol should be interdicted. An occasional cigar smoked with a holder or two or three pipes daily are allowable unless there is catarrh of nasopharynx or stomach. Medicaments. Strychnin or nux vomica is of great service to tone up the muscular system. They may be given alone, or 1$. Tr. nucis vomicae TIRX (0.59 c.c.); \ n . Comp. tinct. cinchona TIRXV (0.888 c.c.). M. j Sig. Give in a wineglassful of water t.i.d. half an hour before meals. Some prefer it at the same time after meals. or, if the patient is anemic, it may be combined with iron and arsenic, thus: 1$. Strych. sulph gr. Ho (0.0021) ; Sod. arsen gr. Ho (0.0013); Blaud's iron pill gr. v (0.3). M. One pill; administer t.i.d. after meals. Strychnin sulphate, ^ to ^ grain (0.00108-0.021), is excellent, or ACUTE DILATATION OF THE STOMACH 401 tincture nux vomicae in combination with fluidextract of condurango, or compound tincture of cinchona, thus: R. Tinct. nucis vomicae, r . , \ aa 125 c.c. (about gij). M. Fluidext. condurango j Dose, 20 drops in water, t.i.d. before meals. If hyperchlorhydria is present, I omit strychnin; though Musser advo- cates nux in the neurotic type. Strychnine may be given if belladonna is added. Other iron preparations such as: Iron tropon 5j to ij (4.0-8.0), t.i.d. can be given. Electricity. This is of service applied by the external method or, in some cases, by intragastric faradization. Static electricity or the high-frequency current may be useful in nerv- ous cases. Lavage is not indicated. Massage or vibratory massage is especially useful. For Constipation. The green vegetables, brown, rye, and Graham bread, and raw or stewed fruits are serviceable. A glass of water should be taken on rising. The patient should accustom himself to go to stool at a definite hour, and on the closet may gently massage the stomach and bowels to aid action. A small gluten or glycerin suppository, or the injection of i ounce (30.0) of olive oil, or 4 to 6 ounces (125-185 c.c.) of warm water have a good effect in exciting peristalsis; or a soapsuds enema, but never of larger size than i quart (liter). Olive oil injection, i pint to i quart (500 c.c. to i liter), at bedtime, to be retained, is useful. It may be necessary to employ medication, such as extract of cascara, i to 4 grains (0.065-0.26), at bedtime, or fluidextract of cascara, i to 2 drams (4.0-8.0), or pills, such as the lapactic, aloin, belladonna, podophyl- lin, phenolax, purgen tablets, regulin, the mineral oils, etc. ACUTE DILATATION OF THE STOMACH ACUTE DIMINISHED PERISTOLE WITH DILATATION Acute dilatation of the stomach may be defined as acute atony of the stomach, with resulting acute motor insufficiency, gradually merging into a paralytic condition, and accompanied by a distention of the organ to beyond its normal physiologic limits. Its lower border extends to the umbilicus, or usually to below this point, and the stomach may even occupy the entire abdominal cavity. Brunton, Fagge, Boas, Hemmeter, notably Campbell Thomson, 1 and Lewis A. Conner, 2 have written on this subject. The fatal, or most severe cases have been reported, but the condition occurs quite frequently. I have already referred to numerous types. 3 Personal investigation demon- strates that five anatomic types of acute ectasy exist : 1 Brochure. 2 Amer. Jour. Med. Sci., March, 1907. 3 Med. News, Aug. 6, 1904. 26 402 DISEASES OF THE STOMACH AND INTESTINES 1. Acute dilatation of the stomach alone. 2. Acute ectasy, which supervenes on an existing chronic dilatation (due to stenosis of the pylorus). Thomson also reports one case. 3. Acute dilatation of the stomach and duodenum, the most fatal type. 4. Acute dilatation of the stomach engrafted on chronic atonic dila- tation. 5. Acute dilatation of the stomach and intestines, a mixed type, so- called acute tympanites. This last is quite common, especially in the acute infectious diseases, such as typhoid fever and pneumonia. For a complete description of the theories of its mechanism and of th subject, I refer my readers to the "American Journal of Surgery," Novem- ber-December, 1908. Weston and the author found that the fibrous at- tachment of the transverse duodenum to the diaphragm (muscle of Treitz) and the pressure of the dilated stomach on the transverse duodenum were chief factors in the production of the gastroduodenal type of dilatation. Mesenteric traction was chiefly produced by the downward pressure of the stomach on the intestines, which last exercised a countertraction against the muscle of Treitz. The collapsed intestines were the result of pressure. Mechanism of the Production of Acute Dilatation of the Stomach. The nature of the condition as stated is undoubtedly an acute atony, with acute motor insufficiency, finally merging into a paralytic condition. Many factors in the production of acute dilatation have been described, namely: 1. Section of jthe vagi -by Carion and Hallion producing acute dilatation of the stomach, thus demonstrating that an injury or inflam- mation of these nerves may be a cause, as in cerebral injury, or pneumonia at the base. 2. Injury to the dorsal spine by stimulation of the inhibitory nerves. 3. Direct action of the agent on the musculature or its terminal nerve- filaments; among such may be chloroform or other anesthetics, toxemia from fermentation, etc. 4. Traumatism. 5. Spasmodic stenosis of the pylorus, due to fermentation or hyper- acidity. 6. Acute gastrorrhea (Morris); or possibly acute gastrosuccorrhea (Kemp). 7. Kelling's and Conner's experiments on spasmodic closure of the cardia, and the demonstration of kinks in various parts of the duodenum, or of spasm of the pylorus. 8. Rotation of the pylorus. 9. Kelling's and Braun's experiments, demonstrating that acute dila- tation of the stomach is a paralytic condition by producing it with animals under deep narcosis. 10. Rotation at junction of cardia and esophagus. 11. Toxemia from infection, as from the toxins of typhoid, pneumonia, etc.; or auto-intoxication from improper diet, causing gastro-intestinal dilatation during the course of these diseases. Dietary indiscretions are the causes of acute ectasy of the milder types which I shall shortly describe. ACUTE DILATATION OF THE STOMACH 403 12. Obstruction of the transverse duodenum is one of the frequent causes so far found in the fatal cases, producing acute gastroduodenal dilatation, the most dangerous type. There are a number of causes given for this condition, notably: (a) Mesenteric obstruction of the duodenum from mesenteric traction. Out of 69 fatal cases, 19, or 27.5 per cent., Conner states were caused by this, and probably 33 to 50 per cent, is nearer the figure, according to his view.' Albrecht first called attention to its condition, performing numer- ous experiments. (b) Pressure from the distended stomach on the transverse duodenum, producing complete obstruction, is most frequently the cause in my belief. (c) The firm fibrous band (muscle of Treitz) attaching the transverse duodenum to the crus of the diaphragm, a factor hereafter noted and demon- strated by Dr. Weston and myself, is also an important factor. Regarding mesenteric traction, Con- ner further believed that the conditions essential for this were the dorsal position, an empty intestine, and a mesentery of such length that the intestine can slip into the pelvis and yet hang free. He holds that fasting, purges, and enemas after operation have a possible bearing. The author notes that acute dilatation of the stomach, however, does not occur more frequently with enteroptosis as might be expected if that theory were correct. 13. Obstruction of the pylorus from a gall-stone which had ulcerated into the intestine and thence into the stomach has been reported by Babcock. 1 Accessory factors are suggested, such as a lax abdominal wall, pressure from weight of hepatized lungs (in pneumonia), coughing and laughing paroxysms, lordosis, or an abnormal position of the duodenum. It gen- erally crosses the third lumbar vertebra; the fourth is the most prominent, and more pressure would be exercised at this point. Clotted blood behind the transverse duodenum was a cause in one case. On the other hand, some believe the stomach dilatation is the primary factor, and the mesenteric constriction is produced secondarily by the stomach forcing down the intestines. T. Satterthwaite and the author studied the effects of acute gastric distention on the pulse and respiration by artificially distending the stom- achs of patients with carbonic acid gas and taking the blood-pressure before, during, and after the experiment. In Fig. 202 is illustrated the result in one of our cases. 202. Experiment: Acute dila- tation by CO 2 distention. 1 N. Y. Med. Jour., June 7, 1913. 404 DISEASES OF THE STOMACH AND INTESTINES Physician Position dorsal. Pulse Pressure Respiration Pulse Before distention 72 135 18 Slightly irritable (to- bacco). After distention 86 120 24 Irregular in force; some intermission in the beats. Pain under the sternum and over the abdomen, sensation of suffoca- tion and of flushing of the face, nausea, and discomfort accompany the acute distention. The stomach extends to one finger-breadth below the umbilicus; in all a distention of 3^ fingers' breadth. Aspiration of the contents relieved the symptoms. These facts em- phasize the danger of overdistention of the stomach with carbonic acid gas for testing the position of the organ in patients with cardiac or pul- monary disease, or in old age, also the danger of acute ectasy as a compli- cation. Moreover, the true dimensions of th'e stomach may not be obtained by the method of carbonic acid gas distention. In this connection, the author feels that he must briefly refer to an article 1 entitled "The Non-entity of Acute Dilatation of the Stomach," to which some physicians have referred. As a sample the writer states, "But as has been already intimated, nothing short of crushing and stretch- ing of the musculature should cause acute dilatation, and such causes do not exist." Such productions, when taken seriously by the profession, I feel do positive harm. The author invites the writer of this article or any skeptic, to test on himself the experiment with tartaric acid and bicarbonate of soda. Ingest separately about 3 drams (12.0) each of soda bicarbonate and tartaric acid in 8 ounces (250 c.c.) of water and observe the results. A physician or nurse should be at hand with a stomach-tube. Etiology of Acute Ectasy. It may be primary or secondary. The causes are as follows: Indigestible food; infectious diseases, such as ty- phoid, pneumonia, acute tuberculosis, and scarlatina; during convalescence from long-continued disease, as chronic tuberculosis, hip-disease, pneu- monia, typhoid, sarcoma, and anemia; injury to the head or spine; trau- matism to the abdomen; postoperative, in which manipulation of the viscera, shock, uremia, sepsis, and the anesthetic are factors; one case after gastro-enterostomy reported by the author; retroperitoneal abscess; disease and deformity of the spine, lordosis, etc.; application of plaster jacket in spinal deformity; paroxysm of laughing supposedly (true cause undiscovered). Toxemia or auto-intoxication are, therefore, factors in many cases. Age. It may occur from infancy to old age. Three-fourths of the cases are developed during adolescence or early adult life (ten to forty years). Sex. Is about equally divided. Clinically, we may classify acute dilatation of the stomach into cases presenting various clinical types, in this sense atypic, and into the typic cases, which are usually described. The mild atypic cases will be first described. 1 Med. Rec., Nov. 5, 1910. ACUTE DILATATION OF THE STOMACH 405 Clinical Types of Acute Ectasy. I shall briefly refer to these cases (milder types) which have already been fully reported by me. 1 One of my eminent confreres referred to the types now to be described as probably aeorophagy, which, mildly speaking, seems untenable. - /Vonrta/ "Position ,/fcute Dilatation Fig. 203. Acute dilatation of the stomach during epileptic attack. i. Cases of Acute Dilatation of the Stomach with Symptoms Pointing to the Nervous System. Convulsions in Infants and Young Children. Auto- intoxication is the cause. I have seen a case in an infant two years of age Fig. 204. Acute dilatation of the stomach in migraine, August 29, 1902. Borders of stomach: i, August 16; 2, August 29, in the morning; 3, August 29, in the evening; 4, August 30, in the morning; 5, August 30, in the evening; 6, August 31, in the morning. in which the stomach extended 2 inches below the umbilicus. Vomiting of bread and curds occurred, with immediate cessation of convulsions 2 and return of the stomach to normal position. Repeated attacks may lead to chronic ectasy or epilepsy. 1 Amer. Jour, of Surg., Nov.-Dec., 1908. 2 No aerophagy in this case. 406 DISEASES OF THE STOMACH AND INTESTINES Epilepsy. Mangelsdorf 1 has demonstrated acute ectasy during the convulsive seizure and the gradual return to normal position (Fig. 203). Migraine. The same author rioted similar conditions during attacks of migraine (Fig. 204), and reports 500 cases in epilepsy and migraine. Lauder Brunton 2 noted transitory dilatation in sick headache. Tetany. Broadbent 3 describes a case of acute ectasy with tetany, which ended in recovery. Fig. 205. Acute dilatation of stomach with tachycardia. Chorea. Acute ectasy has been reported as a terminal event in chorea. 4 3. Acute Ectasy Producing Acute Cardiac Symptoms. Tachycardia. Girl, aged twenty-one, with chronic endocarditis, excellent compensation, no gastric disturbances. Tachycardia, 210 beats per minute, followed dietary indiscretion. Acute ectasy was found as in Fig. 205. Emesis oc- curred, the stomach contracted to normal size, and the tachycardia ceased. The patient suffered from several attacks, but has had no further trouble since she has exercised care in diet. Pseudo-angina Pectoris. Female, aged sixty-five, suffered from attacks of pseudo-angina, following dietary indiscretions, at times consciousness 1 Rose and Kemp, Atonia Gastrica. 2 Allbutt's System of Medicine, vol. iii, p. 392. 3 Practitioner, 1908. 4 Lancet, April 19, 1890. ACUTE DILATATION OF THE STOMACH 407 was lost. A number of attacks occurred and in every instance acute ectasy was present, as in Fig. 206. Emesis relieved both the dilatation and the attack. Ultimate cure resulted from proper diet. 4. Acute Ectasy Complicating Infectious Diseases, Notably Typhoid and Pneumonia. The tympanites of typhoid is frequently not purely intes- tinal. Acute gastro-intestinal dilatation is by no means rare; in fact, I have found it quite frequent. Systemic infection or improper diet cause this condition. Acute gastroduodenal dilatation has been reported. In the milder types of acute gastro-intestinal dilatation there is often no vomiting. There are cardiorespiratory symptoms which might suggest pulmonary involvement. Examination shows acute distention. Postural treatment, 1 by elevation of the head of the bed, enteroclysis, and lavage, Fig. 206. Acute dilatation of the stomach with symptoms of pseudo-angina pectoris. will relieve the symptoms. The same mixed type of distention may occur with pain and shock and simulate perforatioa After relief of the disten- tion, examination shows absence of muscular rigidity (no peritonitis). In the acute distention of typhoid, with intestinal hemorrhage, lavage will relieve gastric distention and diminish intra-abdominal tension. I have never seen it recommended. Pneumonia.'- We may have the gastroduodenal type of acute ectasy, of which several cases are reported. The mixed type is quite common and constitutes a serious danger. Undoubtedly, sudden heart-failure has been precipitated by this condition. The etiology and treatment are the same as in typhoid fever. There is greater danger to the heart from the pressure than from the passage of the stomach-tube. 1 See Treatment of Typhoid Fever. 408 DISEASES OF THE STOMACH AND INTESTINES 5. Acute Ectasy with Coprostasis the Prominent Symptom. Male, aged fifty-five, following indiscretions in diet, complained chiefly of coprostasis, with occasional vomiting. Constipation had been present eight days when I saw the case. Fecal impaction was present in the sigmoid and caput coli. Frequent lavage, enteroclysis, and cathartics relieved the condition. In Fig. 207 is depicted the stomach before and after relief. 6. Acute Dilatation Supervening on Chronic Ectasy. Female, aged forty-five, suffered from chronic ectasy due to pyloric stenosis from ulcer. Fig. 207. Acute dilatation of the stomach, with constipation (ten days' duration) a prominent symptom. Following a dietary indiscretion, acute ectasy resulted with gastrosuc- corrhea, pain, vomiting, peristaltic waves, constipation, and collapse. In Fig. 208 is shown the acute ectasy, with return to the position of chronic ectasy after lavage. Subsequently gastro-enterostomy was per- formed with a gain of 100 pounds in the patient's weight. Symptoms of the Severe Cases. This type may occur after opera- tion (post-operative dilatation). The symptoms are characteristic, and are as follows: Sudden abdominal distention, pain, tenderness, excessive vomiting, ACUTE DILATATION OF THE STOMACH 409 constipation, thirst, scanty urine, and collapse. It has been mistaken for intestinal obstruction, or for peritonitis. Onset. This is nearly always sudden. The patient may be well, or follow operation, or suffer from some illness taking its usual course, when he suddenly complains of great distention, discomfort, or severe pain in the abdomen. This is rapidly followed by vomiting, which is the most constant symptom, begins early, and generally persists throughout the. attack. Rarely there may be an intermission due to temporary cessation of secretion, or cessation of vomiting may be a terminal event, the abdominal muscles and diaphragm being no longer able to expel the Fig. 208. Acute dilatation of the stomach engrafted on chronic dilatation. contents. Cessation of vomiting is, therefore, not always a favorable symptom. The vomiting is profuse, in large amounts, and comes up in gulps without straining. In the early stage it may consist of the gastric con- tents, of food in various degrees of fermentation; later, it becomes thinner and watery, and generally of a greenish hue. It is often described as bilious. It may be brownish, grayish, or even inky black; occasionally there may be a trace of blood. Often in the postoperative cases acute distention, pain, and greenish vomiting are the first symptoms. The vomitus may be sour or foul or even (rarely) feculent in odor. 410 DISEASES OF THE STOMACK AND INTESTINES Character of the Vomitus. Various constituents, such as bile, diastase ferment, hydrochloric acid, lactic acid, and traces of blood, visible or occult, have been found. Pain is present in the majority of cases, usually in the epigastric and umbilical regions. In the gastro-intestinal mixed cases at the commence- ment it is more general and acute from sudden distention, being suggestive of peritonitis. Sudden perforation may even be suspected. Later there is a feeling of distention, not so acute, with accompanying cardiorespiratory symptoms. It differs from the continuous pain of acute obstruction. Tenderness occurs in some cases. Muscular rigidity is absent. The urine becomes scanty and nearly suppressed during the last twenty-four hours. Anuria is diagnostic of obstruction high up in the intestinal tract, and does not occur with obstruction of the large intestine. It has been mistaken for uremia. The temperature is usually normal or subnormal, unless the patient has preceding fever. Thirst is marked. Hiccough may occur as a terminal symptom, as may also de- lirium. General muscular cramps occurred in one case; and Broadbent reports a case of tetaiiy. Physical Signs. In the gastric or the gas- troduodenal type there is distention of the abdomen, but the swelling is not uniform; it chiefly fills the left half and lower part of the abdomen, and the right hypochondrium ap- pears to be flattened. There is often swelling in the epigastrium. The following is of service: Draw a line from the tip of the ensiform to the junction of the middle and outer third of Poupart's liga- ment (Fig. 209). The distention usually lies to the left and below this oblique line. Occa- sionally it appears more below the navel and sometimes there is general distention, particularly in gastro-intestinal dilatation. Splashing sounds (succussion) and the sense of fluctuation are an aid in some cases. They are not always present in the early period, when there is chiefly gas in the organ. They occur below the level of the umbilicus. Percussion will show the resonance increased, but will be interfered with when there is much fluid. It is important when the splash is absent. Peristaltic waves of contraction occur very seldom. They are found only before complete paresis takes place, or in the acute cases engrafted on the stenotic type of chronic dilatation. The general symptoms are those of collapse, a rapid and small pulse, frequent respiration, a clammy skin, and subnormal temperature. Duration of the Attacks. The duration of the attack depends on its severity and type of case. In my case of tachycardia it lasted less than an hour. In the mixed cases it depends on the treatment accorded by the physician. Among the severe cases, one case of Conner's died v/ithin three hours Fig. 209. Line drawn from ensiform to Poupart's ligament. ACUTE DILATATION OF THE STOMACH 411 after the onset of the pain, which, with distention, was the first symptom. There was no vomiting. Several cases died within twenty-four hours, and sixteen days was the longest duration. The average was about five days. Some cases recur, or several weeks may elapse, before the dilatation entirely disappears. Prognosis. In the severe cases it has been extremely bad, being a most formidable condition. There is a 72 per cent, death-rate recorded. In reality many cases occur, and with our present knowledge with proper treatment, the mortality should be comparatively small. Morbid Anatomy. The postmortem appearance of the stomach is quite characteristic, being cylindric and bent into a horseshoe or V shape. The cardiac portion is the longer (Fig. 210). The walls of the stomach are distended and thinned. A large amount of elasticity is retained, as shown by the shrinking that takes place after the distending force is removed. 1 The stomach may occupy the entire ab- domen or even reach into the pelvis. It has been mistaken on operation for cyst of the pancreas. Its color may be purplish-red, gray, or bluish- white. Microscopic Examination. This has been made in a few cases. There was thinning of the musculature and no definite microscopic changes were noted, though in some there were small hemor- rhages. Duodenum. In a large number of cases over 50 per cent. (Conner) a part or the whole of the duodenum shared in the dilatation; in many the distention stopping where the mesen- tery crossed. Kinks have also been found in the duodenum. The coils of the intestines are flattened and col- lapsed in the pelvis. Diagnosis. One should always think of the possibility that tachy- cardia, convulsions, epilepsy, migraine, anginoid symptoms, increased cardiac and respiratory rapidity, and even tetany may occur with acute ectasy. Sudden gastro-intestinal dilatation is quite frequent in typhoid and pneumonia. Often vomiting is absent at first in the milder cases, and the chief symptom pointing to the abdomen is distention. At times there may be acute pain in typhoid, simulating perforation, but muscular ri- gidity is absent. Cardio-respiratory symptoms may occur. Examination in every case should be made by percussion, the splashing sound, and espe- cially by lavage, if there is any doubt. Intestinal irrigation (recurrent) will often relieve distention when present, and aid in diagnosis. Fig. 210. Postmortem appearance of acute dilatation of the stomach. 1 McKvitt, N. Y. State Jour, of Med., July, igo6. 412 DISEASES OF THE STOMACH AND INTESTINES Postnarcotic vomiting may become gradually persistent, and this should be looked on with suspicion. Pain, tenderness, distention, continuous vomiting of bilious appear- ance are suggestive, especially with collapse, rapid and feeble pulse, urinary suppression, and obstinate constipation. In the severe cases there may be occasionally no vomiting and no pain, but only acute distention and some diarrhea. The use of the stomach- tube and determining the position of the stomach before and after its em- ployment are of value in all cases. If, after lavage, the distention disappears and there is no distention of the intestines, or only slight tympanites in the colon, the acute dilatation is of the stomach, or of the gastroduodenal type. If intestinal distention persists, the dilatation is of the mixed type. If all the tympanites is relieved by enteroclysis, subsequent examina- tion will determine the stomach not to be dilated. The presence of pancreatic juice, absence of fecal vomiting, and pres- ence of bile show the gastroduodenal type. This is especially true if the abdominal posture affords relief. Bile, however, may be present, with acute gastric distention alone. True stercoral vomiting shows obstruction lower down, and muscular rigidity is a symptom of peritonitis. Treatment. Prophylaxis. Rapidity in operating, the minimum amount of manipulation of the viscera, a minimum quantity of anes- thesia, and care in feeding after operation are important. Distention following operation should receive immediate treatment by lavage and enteroclysis. These methods will prevent subsequent acute dilatation of the stomach and should be advocated in all cases. Open the bowels early after operation. The abolition of milk-diet in typhoid fever, pneumonia, and acute infectious diseases is advisable, with the substitution of broths, strained soups of various kinds, as barley, rice, and gruels. If the patient has had an attack, then the conditions of the gastric secretion should be investi- gated, irregularities corrected, and proper diet instituted. In every case of acute ectasy the stomach should be immediately evacuated by lavage. It is an error to wait until the symptoms appear marked, or until the patient vomits, before lavage is instituted. The stomach may redistend in the severe cases. Lavage immediately on the appearance of distention. It is advisable to repeat lavage within two hours or at times in three hours, and thereafter every four to six hours, during the first twenty-four hours, depending on the physical signs and symptoms. It may be -neces- sary to perform it more frequently. At times it must be carried out for some days. It is safer to err on the side of frequency. Bassler has devised a method for continuous drainage of the stomach. He passes a small stomach-tube through one nostril into the stomach. It is fastened to the wings of the nostrils with adhesive strapping. To the stomach-tube, by means of a small glass joint, a long tube with lavage funnel is attached. The funnel lies at a level below the bed. By this method a siphon action is exerted to continuously drain -the stomach of ACUTE DILATATION OF THE STOMACH 413 gas and fluid, and the tube is always in situ for lavage. The writer finds that the small nasal feeding tube attached by means of a large medicine dropper to a larger tube and funnel is often more comfortable and yet practical. Lavage can be given also through this tube. Some patients, however, object to this method or it may cause irritation so it cannot be retained. No food or drink should be given by mouth. For severe thirst, saline enemata, proctoclysis, or even hypodermoclysis may be administered. They are also efficient in the collapse, and saline or mediate infusion may be required. Rectal feeding must be kept up for several days until symptoms disappear. If there is intestinal distention, continuous recurrent rectal irrigation with normal saline solution at i2oF. is of value. It is advisable to pro- mote peristalsis as soon as possible. Unless hemorrhage, peritonitis, or appendicitis complicate (as might occur in typhoid) , or there be a suspicion of a true intestinal obstruction, after washing the stomach with plain water, in which milk of magnesia, 2 ounces (60.0), has been dissolved, I give calomel, 3 to 5 grains (0.2-0.3), i n water % ounce (15.0), directly through the stomach- tube before removal; and a saline cathartic by the same method four to six hours later. In some cases I have given by preference a high enema of 4 ounces (125 c.c.) of a saturated solution of magnesium sulphate two hours after lavage. This may be preferable, lest the patient vomit the saline cathartic. Tincture of belladonna is useful. It lessens the secretion, relaxes pyloric spasm, and has an excellent effect on the atony. It should be given in 5- to lo-gtt. (0.296-0.592) doses on the tongue, with strychnin, Ho to ^o grain (0.00108-0.00212), every four to six hours by hypodermic injection. The latter stimulates the musculature, the heart, and respira- tion. Atropin, >foo grain (0.00065) to ^ grain (0.00130) may be substituted hypodermically for belladonna. Physostigmin sulphate (eserin), ^f 00 grain (0.00065), has been recom- mended to promote evacuation of the bowel. I have recently employed % grain (0.0013) every two hours for three doses with success. It is well to arrange to give strychnin, ^ 00 to % grain (0.00065-0.00108), to guard the eserin. Pituitary extract (Vaporole Burroughs, Wellcome & Co.), i c.c. by hypodermic, is of value both to promote muscular contrac- tion of the gastro-intestinal tract, to stimulate action of the bowels and also to improve the pulse. Elaterin, gr. Ko is a l so f service to move the bowels by hypodermic. Hormonal 1 (peristaltic hormone) has been suggested, by intra-muscular or, preferably, by intravenous injection, for the paretic condition of the intestines. Average dose, 20 c.c., with normal saline solution at i2oF. Rectal electric recurrent irrigations of the bowels are efficacious for obstinate constipation. The writer has a recurrent irrigator with battery attachment. The second most important therapeutic measure is postural treatment. The position of the patient depends on the anatomic type of the dilatation. 1 Medizin Klinik, 1910, No. n. 414 DISEASES OF THE STOMACH AND INTESTINES 1. The semi-oblique or nearly sitting position, the head of the bed is blocked up as in the illustration under Typhoid Fever. The patient lies on an inclined plane. This is of value in the acute gastro-intestinal (or mixed) type, with general abdominal distension, so frequent in typhoid or pneumonia, where the cardiac and respiratory symptoms are pronounced from abdominal pressure. By elevation of the head of the bed in one severe case of typhoid the tympanitic area in the thorax lowered 4 inches, and the pulse and respiration dropped 20 points each. A fatal issue may result from pressure-effects on the heart and lungs with this type. Frequent lavage and enteroclysis should be instituted in these cases, and later milk-free diet, substituting soups and broths. This position would be incorrect in the gastroduodenal type of dilata- tion. 2. Elevation of the foot of the bed to relieve pressure on the duodenum. The objectionable feature is the danger from pressure on heart and lungs if the stomach should begin to redilate. 3. In the acute gastroduodenal type the lateral position, on the right or left side, has relieved the symptoms. The patient recovered. 4. The abdominal position (patient lying on the belly] is the best method to treat the acute gastroduodenal type, or for acute dilatation of the stomach alone. That this position affords relief seems to me to show quite conclusively that the gastroduodenal type of obstruction is caused chiefly by the stomach pressure on the transverse duodenum. Baumler kept the patient fifteen minutes in the knee-chest position in each two hours; the balance of the time on the belly. Operations. These have not generally proved successful. Among those performed or suggested were: The stomach opened and evacuated, and gastro-enterostomy. Gas- tric fistula might be tried. A kink at the duodenojejunal junction was relieved in one case, and the patient recovered. Recovery has also been reported after one case of gastro-enterostomy. Frequent lavage, combined with postural treatment, enteroclysis, and securing bowel action as soon as possible are indicated. Food and drink should.be interdicted. Relieve thirst by enemata of saline solution and by proctoclysis, and hypodermoclysis in extreme cases. CHRONIC DILATATION OF THE STOMACH DIMINISHED PERISTOLE WITH CHRONIC DILATATION (Synonyms. Ectasy; Ectasia Ventriculi; Gastrectasy; Ischochymia Einhorn; Motor Insufficiency of the Second Degree Boas) The term "dilatation of the stomach" is employed for descriptive purposes, but in view of the existence of an acute type of dilatation of the organ, chronic dilatation of the stomach would seem a preferable nomenclature. Definition. How may dilatation of the stomach be defined? Is it to be measured by the capacity of the stomach alone or by the increased CHRONIC DILATATION OF THE STOMACH 415 capacity plus the alteration of its functions? The latter is correct. The capacity of the normal stomach is extremely variable. Ziemssen has shown that a stomach may be normal and only contain 8 ounces (250 c.c.), whereas another stomach, also normal, may possess a capacity of 2 quarts (liters). The large stomach ("megalogastria"), at times found during a physical examination, produces no symptoms. This may be congenital, or acquired by large eaters or by those who live on a vegetable diet. Such cases, however, can readily develop atony. As long, however, as the func- tions of the stomach are normal, we cannot regard the conditions met with as pathologic, and hence cannot consider that dilatation exists. As already described, the lower border of the normal stomach when distended with food or liquid lies from i^ to 2 fingers' breadth above the level of the umbilicus. Examination of normal subjects, complaining of no symptoms, will frequently show that the stomachs are abnormally large, or in an abnormal position. Such cannot be considered pathologic. If it descends to nearly the level of the umbilicus, to its level or below it, and symptoms ac- company it, we must consider the organ dilated. One must not commit the error of mistaking gastroptosis for dilatation. With gastroptosis the upper border of the stomach descends as well as the lower border, and there are movable kidney and enteroptosis. There are varying degrees of gastroptosis. The prolapsed stomach may, in ad- dition, be dilated. With dilatation, the upper border of the stomach does not descend, but maintains its relation to the diaphragm, and the stomach is dilated chiefly in the direction to which Fig. 211. DUatation of the stomach, the greatest force is applied, downward and laterally. The muscular fibers first elongate in the vertical direction and the distance between the lesser and the greater curvature is in- creased. Dilatation may also ensue in the transverse and anteropos- terior dimensions, and the pylorus may be. a little further to the right and in a slightly lower plane, but the lesser curvature maintains its re- lation to the diaphragm, and this is the differential point between dila- tation and gastroptosis (Fig. 211). There is confusion as to the terms "atony," "ectasy," and "motor insufficiency," as they are often used interchangeably by different authors. Atony of the stomach may be defined, as already stated, as a loss of tone or contractile power of the muscles of the stomach, so that the organ does not contract about its contents, with a resulting motor insufficiency 416 DISEASES OF THE STOMACH AND INTESTINES (inability to expel its contents within the normal limit of time). This con- dition has not progressed to dilatation. Ectasy may be denned as dilatation, an enlargement of the stomach permanent in character, combined with motor insufficiency. With the atonic type of ectasia, there is motor insufficiency. Relative Motor Insufficiency. When there is dilatation of the stomach due to obstruction at the pylorus, the motor power of the stomach is not sufficient to expel the stomach-contents within normal time limits. This is spoken of as insufficiency. This should be considered a relative insufficiency, as in this type the musculature of the stomach is hypertrophied, especially at the pyloric end, and the contractile power is often increased, but not sufficiently to expel the contents past the obstruction within the normal time. In the dilated stomach without pyloric obstruction we have the true atony of the musculature, with varying degree of motor insufficiency. Some claim that stenosis exists in all cases of dilatation of the stomach, but it is easy to demonstrate that there are two distinct types of chronic dilatation of the stomach differing in symptoms and pathologic findings: (i) The atonic type of chronic dilatation of the stomach. (2) The stenotic (obstructive) type of chronic dilatation of the stomach. Radio- graphs also clearly demonstrate the difference between these conditions. Differential Diagnosis. Atonic Type. In the atonic type there may be few or no symptoms pointing directly to the stomach, the patient frequently suffering from nervous symptoms due to auto-iijtoxication and from intestinal disturbances. I have seen many such cases at the Man- hattan State Hospital continue a year, or even four or five years, without vomiting. There are no peristaltic waves and cramp-like pains such as occur in the stenotic type followed by vomiting; though some may have dyspeptic symptoms and rarely an attack of vomiting. The postmortem shows the stomach often enormously dilated, with thin walls and no evi- dence of pyloric stenosis. Stenotic Type. In the stenotic (obstructive) type of dilatation dys- peptic symptoms are marked, there are peristaltic waves and cramp-like pains preceding vomiting of large quantities of gastric contents, thirst, etc. In the benign type of long duration the patient often suffers markedly in nutrition, but the cachexia and other symptoms of malignancy are absent and the disease runs a long course. The postmortem shows considerable hypertrophy of the musculature at the pyloric end of the stomach, and elsewhere thinning and dilatation of the muscular wall with evidence of stenosis at the pylorus, or constriction from some external factor. ATONIC DILATATION OF THE STOMACH. DIMINISHED PERISTOLE WITH GASTRIC DILATATION * Etiology. As causes, we may have a primary reduction or loss of muscle power, or impairment of it from overwork, for example, from the ingestion of too much material. It directly follows chronic atony of the stomach, which is the preliminary stage, and hence there are similar CHRONIC DILATATION OF THE STOMACH 417 etiologic factors, such as wasting disease, tuberculosis, chronic gastritis, heart disease, etc. Among other causes are bolting the food, frequent overloading the stomach, excessive drinking of large quantities of fluid, especially of those containing much gas; it may rarely be congenital; it is quite fre- quently associated with rickets, in which case gastroptosis is quite often also present. It sometimes follows repeated attacks of acute atony or acute dilatation. Nothnagel traces back some cases of chronic dilatation to improper meth- ods of feeding during early life. Atonic ectasy we frequently find among the insane. I have found an enormous number of patients at the Manhattan State Hospital suffering from this condition, and quite a number of the women with gastroptosis, and frequently dilatation associated with it. Examinations of many hundreds of cases during the last five years show that very few stomachs were in the normal position, or possessed normal functions. Many of these cases have never vomited, and in very many no special symptoms directed. attention to the stomach. Unquestionably the habit of bolting the food common to such patients is a frequent cause of ectasy. Among the acute melancholies, in whom some ultimate cures resulted, auto-intoxication, in some cases the result of ectasy with fermenta- tion or putrefaction, was the primary factor in the production of the nervous symptoms. In the epileptic ward one case suffering from dila- tation (atonic) with gastroptosis, and absence of free hydrochloric acid, had suffered from numerous epileptic convulsions both day and night, averaging 140 seizures per month. Under simple diet, initial lavage, and later diet and medication directed to the gastro-intestinal tract alone, she had no convulsions for two years and a half, with the exception of one week, some fourteen months after treatment was begun, during which period she was taken off diet and medication while in the general hospital ward with an acute nephritis. Bromids were only given two months at the commencement in small dosage to break the convulsive habit. At the end of three years the patient was discharged. There were no convul- sions, and her mental condition was apparently excellent. 'I have also another case of epilepsy with atonic ectasia and hypochlorhydria, who has gone over two years without a seizure under gastro-intestinal treat- ment alone. Even in the incurable insane this atonic type of dilatation has a direct bearing on some of the symptoms. In a series of 13 paretics, examined for the late Dr. Dent at the Manhattan State Hospital, 1 I found n cases of atonic dilatation of the stomach and 2 cases of gastroptosis, and in all secretory derangements of the functions of the stomach; n of these cases had at some time of the day a temperature of 99.5^. and upward, in one io2.5F. Under treatment directed to the gastro-intestinal tract the temperature was lowered in all n (in some to normal), the convul- sions, which were present in 5 cases, were diminished in frequency, and in one patient suffering from attacks of syncope, cessation of attacks followed treatment. 1 Proceedings of the American Psychological Association, Sixty-first Annual Meet- ing, April, 1905; also the Medical News, July 8, 1905. 27 41 8 DISEASES OF THE STOMACH AND INTESTINES The atonic type of ectasy is quite common in many nervous cases, and is undoubtedly, in some, the cause of the auto-intoxication, and the nervous condition is secondary. Atonic ectasy may, therefore, be in many cases the cause of various conditions. On the other hand, ectasia resulting from insufficient mastication and bolting of food among many of the nervous and insane may be a factor in the production of a vicious circle. Beer drinkers and diabetics suffer from this type of dilatation. Professional men, bankers, and brokers, from their irregular habits and rapid eating, are quite liable to this form. The musculature of the pylorus, as we know, is much thicker than other parts of the stomach- wall, and the latter naturally gives way and distends more readily. This does not constitute, however, a stenosis at the pylorus. Ultimately, however, the pylorus itself relaxes in these atonic cases, which undoubtedly accounts for the usual absence of vomiting in these patients. This type of ectasy is extremely common. Symptoms are at times not particularly referred to the stomach at all, and often point to the nervous system, or cause an exacerbation of a pre- existing nervous condition. The patient is often neurasthenic or melan- cholic, with the symptoms associated with these conditions. Intestinal toxemia (auto-intoxication) is often present. I have seen the lower border of the stomach in atonic ectasy reach nearly to the symphysis. The following symptoms are generally associated: Constipation usually marked, rarely diarrhea, coated tongue, fre- quently headache, and at times dyspeptic disturbances, such as belching and pressure after eating, though often these symptoms are absent The symptoms may be those of chronic gastritis. In a few cases of extreme dilatation there may be occasional vomit- ing of large quantities of fluid. There are no spasmodic pains, no per- istaltic waves, and no marked vomiting, as in the stenotic type. In atonic ectasia with chronic gastritis, the gastric symptoms of the latter may be present, in addition to the other symptoms already noted. Occasionally there is mold in the stomach. More rarely there may be hyperchlorhydria with atonic ectasy. I have found a number of such cases among the epileptics, there being no vomiting, or at times it may occur, but at times usually with no peristaltic unrest. They suffer from the symptoms of hyperchlorhydria, motor insufficiency is present, there may be spasmodic pains and occasionally vomiting of considerable severity, the vomitus being very acid. These cases, as already noted, have been mistaken for gastrosuccorrhea. After lavage, and later by aspiration of the contents of the empty stomach, one readily demonstrates that hypersecretion is not present. The symptoms in this type are due to the extreme hyper- chlorhydria and to spasm of the pylorus resulting. Excellent results are secured by lavage and by the treatment of the hyperchlorhydria. Most of the so-called cures of stenotic ectasia belong, I believe, to this class. The mild types belong to the atonic class, though they might be considered border-line cases. In the cases in which cure results without operation, organic changes at the pylorus, I believe, must necessarily have been slight, while the severe cases with ultimately peristaltic unrest and pro- gressive symptoms should be classed under stenosis. These last cases CHRONIC DILATATION OF THE STOMACH 419 which do not rapidly respond to treatment of the hyperchlorhydria, should be referred to the surgeon. Treatment of pyloric spasm by Einhorn's pyloric dilator the writer believes useless. Gastric Contents. The gastric findings are variable; fermentation is quite frequently present and hypochlorhydria, or nearly complete ab- sence of free HC1; chronic gastritis, occasionally hyperacidity; mold has been found, and in cases with gastroptosis and dilatation at Ward's Island I have even noted achylia. The usual manifestations are toxemic in character, with intestinal fermentation or putrefaction and indicanuria. Course. The milder cases of atonic dilatation are quite amenable to treatment and can be cured. The severe cases do not run so favorable a course, and I have seen such among the nervous and insane where the dilatation extended nearly to the symphysis. I believe that in this type, drainage by gastro-enterostomy with closure of the pyloric ring is indicated, since lavage and diet are only palliative. In some gastroplication may prove successful. In the cases of ectasia due to benign stenosis there is at times, under treatment, a temporary improvement. The stomach, from an increased hypertrophy of the muscles and a subsidence of the hyperemia at the pylorus, may secure a certain amount of compensation and empty its contents fairly well for a time, but usually the symptoms return, and, finally, resection of the pylorus, or gastro-enterostomy- become imperative in order to save the life of the patient. I have known these cases to drag along twelve to fifteen years without operation. They become chronic invalids. Only by operative procedure can a cure of the case be accomplished. If the stenosis is malignant, then the course depends on the extent of the disease. Even in those cases where removal cannot be undertaken, gastro-enterostomy will relieve the symptoms. Obstructive Type (Stenotic) of Ectasia The stenosis causing this type of dilatation of the stomach may be in the gastric tissue at the pylorus, or near the pylorus in the duodenum, or it may be external to the stomach intrinsic and extrinsic causes. The factor causing constriction may be benign or malignant in character, which would modify the clinical symptoms. Etiology. (i) Congenital stenosis of the pylorus (hypertrophic stenosis). (2) Acquired stenosis, such as from ulcer, cicatrices following burns from acids or alkalis; from severe gastritis, causing hypertrophy at the pylorus; repeated spasmodic closure of the pylorus due to hyperacidity (spastic stenosis due to inflammation or irritation); benign tumors; pedunculated polypi; adhesions at the pylorus; external tumors; pressure from large gall-stones (in the gall-bladder); perigastric adhesions; spider- web adhesions (Morris) from the gall-bladder; stenotic hypertrophic gastritis (Boas), a fibrous disease of the pylorus (linitis plastica); sclerosis in the pyloric end of stomach (Ottinger); pressure from external tumor; malignant disease of the pylorus. (3) Stenosis of the duodenum from ulcers, cicatrices, carcinoma, external compressions, adhesions, kinks, or diverticula. 420 DISEASES OF THE STOMACH AND INTESTINES It is the modern consensus of opinion that bile may regurgitate into the stomach even if the stenosis is present at the pylorus, as the cicatricial tissue holds it open in many cases; so its presence or absence does not always aid us as to locating whether the stenosis be pylori c or duodenal. Continuous regurgitation of bile and pancreatic juice, however, is sug- gestive of obstruction of the duodenum below the common duct. Movable kidney I do not believe has any relation to ectasy, but when associated with so-called dilatation, it can be demonstrated that the latter is really a gastroptosis. Pathology. In the stenotic type, the musculature at the pyloric end of the stomach is much thickened; the fundus is much thinner than normal. The pathologic findings at the pylorus vary according to the cause of the stenosis. The intestines are pushed downward and the liver slightly upward when marked ectasy is present. Symptoms. The symptoms of dilatation of the stomach due to pyloric stenosis are quite characteristic, but are modified if the condition is can- cerous, or in the special type described by R. T. Morris, spider adhesions with hemorrhage. Congenital Stenosis of the Pylorus. The symptoms of congenital stenosis of the pylorus are rather acute in their progressive severity. They usually come on directly after the birth of the infant or in the second or third week, depending on the degree of stenosis. The condition is most readily confounded with a rapidly progressing marasmus. There are present: wasting, the infant rapidly losing weight, projectile vomiting, visible gastric peristaltic waves, non-fecal and no curdled bowel movements, with, in some cases, a palpable tumor mass in the region of the pylorus. Pro- jectile vomiting occurring early and apparently without cause in an otherwise healthy appearing breast-fed infant, when it can be proved that the mother's milk is without fault, should always excite suspicion of this condition. There is marked constipation and the lower abdomen is generally empty and passively retracted, while the upper abdomen is bulging and tense. In cases in which it is impossible to detect the pyloric thickening, even when a whiff of chloroform is administered, and the bowel movements are at times fecal and contain occasional curds, and there is no rapid loss of weight and strength, in spite of the projectile vomiting and peristaltic waves, one may probably assume the condition is due to pylorospasm. These cases, I must say, are difficult to diagnose, and may go on to a slow recovery unrecognized, being considered cases of difficult feeding. As an aid to diagnosis, one may say that, if the infant's weight and strength remain practically the same during medical treatment i.e., lavage twice daily, the temporary use of the nutritive enema, and later careful mouth-feedingthen the assumption that the chief factor in the condition is due to pylorospasm, either spastic or intermittent, would be correct though Emmet Holt believes there is some fibrous thickening even in these cases, Hyperchlorhydria is believed to be a factor in some cases. Richter 1 calls to our attention that the radiograph, as a diagnostic measure should be limited to determining the rate of emptying the stomach and not to the patency of the pylorus. One should not exclude a diagnosis 1 Journal, A. M. A., Jan. 31, 1914. CHRONIC DILATATION OF THE STOMACH 421 of hypertrophic stenosis on the basis of the fact that there is some passage of bismuth from the organ. He cites two subsequently fatal cases in which this error of interpretation occurred. Treatment. Dilatation of the pylorus has been suggested by Einhorn. The writer does not find it practical, and in the attempt on a young infant one encounters insuperable difficulties. It is important to determine the degree of pyloric obstruction by measuring the amount of gastric retention. It is best to give for the motility test, food that does not coagulate such as boiled milk twice diluted with barley water or barley gruel. Aspirate three hours later and measure the quantity and if nearly as much is obtained as previously ingested or if no food has been given during the night and in the morning 4 to 5 ounces are secured by aspiration, obstruction is evident. If there is, however, a progressive loss of weight and strength, operation should not be delayed. Personally, I am very skeptical regarding the ultimate curability of congenital pyloric stenosis by medical means, and believe the so-called cures to be simply cases of pylorospasm which have recovered. I have no faith in attributing dila- tation of the stomach in adults to a congenital stenosis, believing that a careful investigation will show some other cause for the condition. Acquired Stenosis of the Pylorus. The usual symptoms of acquired stenosis are thirst, dryness of the throat, dry skin, oppression, feeling of cramp-like pains of considerable severity, generally associated with peristaltic restlessness of the stomach, eructation of odorous gas, vomiting of considerable chyme, often containing remnants of food taken the meal or even the day before. This may occur from once to several times a day. The bowels are extremely constipated. Emaciation may become very marked and the loss of fat on the abdomen so great that the skin is in dry wrinkled folds. The urine becomes markedly diminished in advanced cases; its reaction is frequently alkaline. Intestinal fermentation and putrefaction with indicanuria are often present. Bradycardia and dyspnea (cardiac asthma) at times occur, as do also stupor, headache, and so-called gastric vertigo. Tetany or epileptiform attacks may complicate the condition. The benign type of stenotic dilatation is characterized by rather a long course, with often considerable temporary improvement under treatment, with a tendency to relapse. In my experience the cases of benign stenosis characterized by attacks of gastrosuccorrhea are more frequently associated with ulcer at the pylorus. In the malignant type we have the marked cachexia and rapid loss of weight within a few months, the age of patient usually over forty or forty- five, and the character of the vomitus to be noted later. Secondary anemia is present and tends to progress. There is often moderate leuko- cytosis. Tumor is palpable later. Special Type. In an interesting type, to which Robert T. Morris has called attention, there may be vomiting of considerable blood, pain, etc., suggestive of an active ulcer. Gall-bladder spider adhesions to the pylorus have been found to be the factor. The symptoms are probably explain- 422 DISEASES OF THE STOMACH AND INTESTINES able by circulatory interference. The history of previous gall-bladder disease should be examined into. Examination of the Gastric Contents in Malignant Pyloric Stenosis. Coffee-ground vomit, or the presence of occult blood; free HC1 markedly diminished or absent, lactic acid present; few or no sarcince and the Boas- Oppler bacilli present, in connection with the clinical symptoms, are diagnostic of malignant stenosis. Meat is undigested. Free HC1 may be present even in considerable amount, especially in the early stages, or when the carcinoma is engrafted on an ulcer. Gastric Contents in Benign Stenosis. With benign stenosis we have: the gastric contents separating into three layers, the upper being gaseous; HC1 is marked (hyperacidity); yeast and sarcince are abundant; undigested starch is present. Mold may be found and occasionally bile or sulphuretted hydrogen. I agree with Einhorn that bile can enter the stomach in some cases of stenosis of the pylorus, the thickened tissue allowing a slight patency. Diagnosis Ectasy means dilatation of the stomach combined with motor insufficiency. We must, therefore, first determine the position of the organ. Fre- quent errors have been made in differentiating dilatation and gastroptosis. The position of the upper border of the stomach is the chief point. There is a simpler method which is dependent on whether or not a movable kidney be present. The movable kidney is almost invariably part of a general ptosis of the viscera (splanchnoptosis), and movable kidney from traumatism is extremely rare. If we find a movable kidney with a stomach whose lower border is in an abnormal position (too low down), the diagnosis is gastroptosis. If no movable kidney is present and the greater curvature is low down, plus motor insufficiency and symptoms, the condition is one of dilatation. An extremely simple method of locating the lower border of the stomach is by the splashing sound (succussion). This has been fully described, and also the creation of the splash for diagnosis. Dehio's method can be used as a check. We may employ in addition: 1. Inspection, which will in some cases show the outline of the dis- tended stomach, especially after distention with carbonic acid gas. Active peristalsis is also at times evident on inspection and when present is diagnostic of pyloric obstruction. 2. Palpation. By this means the peristaltic movements may at times be felt, as can also the cushion-like resistance of the distended stomach. Occasionally a small oval tumor can be determined in benign stenosis, though generally it is not appreciable. With carcinoma of the pylorus the hard resistant mass can often be appreciated. 3. Percussion and' auscultatory percussion, especially before and after the addition of water, as already described, are useful. The "scratch method " is of service. CHRONIC DILATATION OF THE STOMACH 423 Age Duration. Course. Tumor. Pain. Peristaltic rest- lessness. Vomiting. Cachexia. Symptoms. TABLE OF DIFFERENTIAL DIAGNOSIS Atonic dilatation Stcnotic dilatation All ages A. Benign stenosis of B. Malignant stenosis of pylorus, all ages pylorus, over 40 generall\ Blood. Gastrosuc- corrhea. Long unless re- cently acquired. Long, often. None. Absent. Xone. Most frequently absent. Present more in hyper- acid cases. None, but some loss of weight. Often toxemic from intestinal putre faction, referred to ner- vous system and not spe- cially referred to stomach; at times gastric, such as of chronic gastritis. None in vomitus. Rare. Quite long, two years, generally considerably more. Generally intervals of quiescence or improvement if treated. Occasional (small and smooth). Spasmodic attacks. Present, marked when advanced. Frequent. Short, few months to one year or one year and a half. Progressive. Present; later palp- able. Always present and exacerbations. Present and at times marked. Fairly frequent. Xone, but great Present, emaciation. Marked gastric. Marked, gastric and general None except in gall- bladder adhesion More frequent with ulcer. Atonic dilatation GASTRIC CONTENTS Benign stenosis Coffee-grounds in vomit or occult blood: occult blood in stool or coffee color blood. Generally absent, though occasional. ' Malignant stenosi Total acidity. Lessened; more Increased. Generally diminished. rarely increased. Free hydro- Often hypochlor- Generally increased, Usually absent. chloric acid. hydria; more hyperchlorhydria. rarely hyper- chlorhydria. Lactic acid. At times present. Absent. Present, usually marked. Fermentation. Often marked. At times marked. At times, depending on location of growth. Odor. Often present. Unpleasant. Fetid at times. Boas-Oppler ba- Occasional. Rare. Usually present. cilli. Mucus. At times, if gas- At times, if gastritis. In some cases. tritis. Sarcinae. Present often. Present markedly. Usually absent. Yeast. Marked at times. Often present. Pronounced yeast fer- mentation rare. 424 DISEASES OF THE STOMACH AND INTESTINES 4. Inflation. The stomach may be inflated with air or carbonic acid gas. The outlines can thus be more readily determined and the position of the upper curvature mapped out. Inflation with air or water renders a tumor, if present, more evident to percussion and palpation if it lie on the anterior wall. It disappears if posterior. 5. Transillumination. This method, especially with the circum- scribing gastrodiaphane and fluorescein, readily determines the outline of the stomach and differentiates between dilatation and gastroptosis in disputed cases. It is often unnecessary. The use of mensuration by means of stiff sounds is deprecated. X-rays. The x-rays are of particular value in cases of stenotic dila- tation of the stomach, determining changes in the contour of the organ, distortions, etc., suggesting ulcer, carcinoma or other causes. The residue of bismuth six hours after the meal also gives an index as to motility though the writer believes the test-meal is more accurate as regards to qualitative motility tests. For example, minor degrees of motor insufficiency will show after the test breakfast or test meal, while the stomach in the radiograph, at the end of six hours after the barium meal, may be empty. The radiologist may state motility is good, on the basis of the six-hour radiograph, while actually some lesser degree of motor insufficiency may exist. This fact is of special importance, as otherwise we might fail to properly treat a case of minor degree of atonic dilatation of the stomach. I have seen such occur. The atonic cases of gastric dilatation when determined by the x-ray, show a contour perfectly even (no distortion) and there is evidence of some immediate escape of bismuth, with an open pylorus (i.e., compensatory relaxation), though there may be some retention at the end of six hours in the more marked cases. The x-rays are not absolutely necessary for diagnosis of the atonic type of dilatation, though a wise precaution to avoid possible error. Motor Functions. The determination of the motor functions is most important, as motor insufficiency is a salient feature. There are different degrees of this motor insufficiency, and this is best determined by the test-breakfast or test-meal as noted above. Test-breakfast. Ewald's test-breakfast. Aspirate the contents one hour later. 1. Normal position of the stomach, with a residuum aspirated of 100 c.c. or over, and symptoms, show atony of the stomach. 2. Descent of the lower border of the stomach; 100 to 150 to 200 c.c. residuum or more, with symptoms, and with kidneys in normal position show dilatation of the stomach. 3. If movable kidney, gastroptosis is present. Six or seven hours after Leube's test-meal the healthy stomach should be found empty. If undigested food is found (300 to 600 c.c. or more), insufficiency is present and the degree of insufficiency is indicated by the amount of residuum. It is always preferable to wash the stomach before the test-meal, so as to get rid of the old residuum and make an accurate test. If consider- able residuum be found at the end of seven hours, a further test should be made. Wash the stomach and directly thereafter give at 10 p. M. a CHRONIC DILATATION OF THE STOMACH 425 light supper a little soup, a slice of bread, a slice of beef, and a little chopped spinach with a small amount of boiled rice and a dozen raisins without seeds. Aspirate and measure residuum and wash the stomach twelve hours later before breakfast, noting if additional material in wash water. In some cases there will be a marked residuum after seven hours, but none after twelve hours; in others there will also be considerable after twelve hours, showing different degrees of insufficiency. The stomach should be washed, as well as aspirated, to remove all the contents. Also aspirate the empty stomach to test for hypersecretion. The salol and olive oil tests are not as reliable. Treatment The treatment of chronic dilatation of the stomach varies consider- ably, depending on whether it be due to atony or to benign or malignant stenosis. Cases due to stenosis whether benign or malignant are surgical. Atonic Dilatation. This is by far the most frequent type of dilatation which we are called upon to treat, especially among bankers, brokers, and professional men, who habitually overeat, bolt their food, or are heavy drinkers. Associated with or having a direct bearing on this condition, we may find hypochlorhydria, hyperchlorhydria, or, at times, chronic gastritis. Some of these cases are, in their incipiency, of rather mild type, and prophylaxis, as regards avoiding rapidity of eating and eliminating indigestible food and overeating, is of value. If the patient is run down or anemic, iron and tonic treatment are indicated. Diet. Though some have recommended a so-called dry diet in dilatation of the stomach, it is a well-known fact that liquids are first evacuated from the stomach, then mushy food, and finally solid food, and this scientific knowledge should be our guide in feeding such cases. Water and food soluble in water leave the stomach soonest of all. Large quantities of fluid should not be given at a time lest they over- distend the flaccid stomach, but if they are administered in smaller quantities at frequent intervals, a considerable amount can be employed. It has been demonstrated that alcohol, sugar, and dextrin cause a secretion of water in the stomach. Milk has been usually recommended as the standard diet in this con- dition as possessing highly nutritive properties, and the statement has been made that it does not stay in the stomach much longer than plain water. Penzoldt has demonstrated that water, cocoa, meat broth, soft- boiled eggs, and boiled milk (100 to 200 gm.) leave the healthy stomach within one to two hours, cooking altering the curd formation. Raw milk takes a considerably longer period, and curds have been found frequently in the normal stomach two or three hours after ingestion. Experiments have been conducted on my service at the Manhattan State Hospital in cases of dilatation of the stomach, and the periods for the raw milk to remain in the stomach were investigated. After three hours large masses of curd were aspirated. If the milk were diluted one-half with water, the residuum found at a certain period was just one-half as much as when pure raw milk was used, 426 DISEASES OF THE STOMACH AND INTESTINES which formed curds. The higher the dilution, the greater the quantity passed from the dilated stomach within a definite time. Another objec- tion is that i liter of milk only represents about 640 calories, and too large ah amount would be required if sufficient nutrition is to be obtained from milk alone. Strained soups and strained gruels are evacuated more rapidly. If milk be given, it should, preferably, be combined with some strained gruel or the latter made with milk, so that the nutritive value may be increased. In the severer type of cases the diet suggested by Seibert in typhoid appeals strongly to the author. It possesses considerable nutritive value, namely : Strained rice, 8 ounces (250 c.c.), barley or oatmeal soup containing the extract of % pound of meat and the yolk of a fresh egg. This can be spiced slightly to improve the flavor, except in hyperacid cases. It can be given five or six times daily. Strained pea soup, lentil, tomato, or potato soup can be used in addition. Rice flour is excellent in the form of a thin gruel, and can be made with milk which has been thoroughly boiled. The object should be to give frequent (jive or six smaller] meals, so as not to overburden the stomach, and yet secure a sufficient amount of nutrition to improve the patient's physical condition. Cream, 2 ounces (60.0) in 4 ounces (125 c.c.) of water, possesses considerable nutritive value. I have given as much as half a pint daily. Crackers heated thoroughly and well buttered can be rubbed up in the broth. Fat in the form of cream and butter up to y to >2 pound daily should be administered. In the milder cases, scraped beef, rare beef, soft-boiled eggs thickened with a small amount of mashed potatoes, and rice strained through a colander, with plenty of butter, can be given, with a little asparagus and spinach. Other vegetables are more difficult to expel from the stomach. Matzoon, koumiss, bacillac, 1 kefir, and milk prepared with lactone tablets (lactone-buttermilk) are of special value in cases suffering from auto- intoxication, having nervous symptoms and indicanuria (intestinal putre- faction). The matzoon can be diluted with one-third water or Vichy that has been allowed to become flat. This last avoids gaseous distention of the atonic stomach. It is also preferable to allow some of the gas to pass off from the koumiss. About i quart of one of these preparations can be used daily additional water or Vichy one-third in volume being then added. These sour milk preparations, especially with the slight dilution, pass readily from the stomach. They do not curdle like plain milk. The yolks of several raw eggs, stale bread or crackers with plenty of butter and cream, strained vegetable soups, and rice gruel, can be added. Meat preparations should be avoided in these cases. In cases with deficiency of hydrochloric acid, the meats are not well digested and should be given in smaller quantities; rice, barley, and tapioca (strained) or in purees, and mashed potatoes are of service, and 1 Fermillac also is of value. CHRONIC DILATATION OF THE STOMACH 427 in larger amounts. I have often found raw eggs beaten up in water or milk of great service, employing at times six to eight daily. The milk can be completely or partially peptonized to lessen curd formation. With the precaution noted, milk may be employed in the cases with not too marked motor insufficiency. It is a simple matter to test whether it leaves the stomach readily or not. If thirst is marked, rectal enemata of hot normal saline solution are indicated, and in very severe cases the stomach may be given a rest and nutritive enemata be given for a few days. Proctoclysis is of value for the thirst, or hypodermoclysis in severe cases. Fig. 212. Fig. 213. Fig. 212. Dilatation of the stomach. Transillumination with fluorescein before application of Rose's belt (Case i) (Ward's Island Gastro-intestinal Clinic, Manhattan State Hospital). Fig. 213. Dilatation of the stomach, same patient (Case i). Transillumination with fluorescein after application of Rose's belt. By accurate measurement the stom- ach has been elevated and the lower border is 4 inches higher than it was before the belt was applied. The lower border now lies above the umbilicus (Ward's Island Gastro-intestinal Clinic, Manhattan State Hospital). Tropon, and somatose are useful adjuncts, given in divided doses in the broths. If anemia is present, iron tropon can be added, i dram (4.0), three times a day or any good iron preparation, particularly com- bined with arsenic. Always peptonize the milk if given by enema. After eating, the patient should lie down for from one-half an hour to an hour, preferably on the right side, so the stomach can empty itself more readily. Mechanic Support. One of the most important methods of treatment is the use of proper support to the organ, and the ideal method is by 428 DISEASES OF THE STOMACH AND INTESTINES Rose's adhesive plaster belt, a description of which has been given. It increases infra-abdominal pressure and the stomach is pushed upward, acting in effect like gastro plication. Transillumination was employed in one case (Fig. 212), the belt applied, and transillumination again carried out (Fig. 213). The illustration (Fig. 213) shows the result, the lower border of the stomach being elevated 4 inches. Though Pancoast, Sailer, and Worden 1 claim that the x-ray has determined that no form of belt, binder, or corset elevates the stomach to the smallest extent, in the experiments described after illumination of the stomach without support, the patient was then placed in the Trendelenburg position, and Rose's belt applied. It was clearly demonstrated the elevation had then occurred. The same excellent result can be demonstrated by radiography before and after Rose's belt is applied. Some of the properly made corsets will also elevate the stomach as is demonstrated by radiographs in this volume. This belt should be worn four or five weeks and a new one then applied. It aids in the evacuation of the stomach contents. Silk abdominal belts may be substituted, but the support is not continuous and the adhesive strapping is superior. From the positive results secured by the writer, he can only assume that if adhesive strapping was employed, the technic was not correct in Pancoast's cases. Undoubtedly many of the belts and corsets are useless. General Hydrotherapy. External douches the fan douche and also the Scotch douche applied to the region of the stomach and changing the temperature of the water have been serviceable in some cases. Cold compresses and cold sponging are at times useful. An adjustable silk belt is worn in such events. Local Treatment of the Stomach. (i) Lavage. In some of the milder atonic cases proper diet, mechanical support, and appropriate medication may suffice without or with occasional lavage. In the more severe cases lavage is indicated, and the time of its performance and frequency de- pend upon the degree of dilatation and the amount of residuum found after the test-meal (degree of motor insufficiency). If there is not immediate improvement if lavage is omitted, it must be added to the treatment. If a large amount of residuum is present after a test-meal or test- breakfast, or there are nervous symptoms, or in the morning before breakfast a residuum is present, lavage should be carried out. As to the proper hour for lavage, I believe Riegel holds sound views, and my own experience agrees with his; if the residuum is 200 to 500 c.c. or more before supper, it is best to wash the stomach then and follow with a light meal; if this is not done, the organ will contain fermenting food during the night which will increase the atony. If food is present before breakfast a second lavage is then indicated. The washing should be performed with the patient both sitting and lying down, turning on each side particularly on the right, so as to remove all the irritating material. The stomach should be washed until the return is clear. 1 Trans. Coll. Phys., Philadelphia, 1906, series 3, xxviii, 151-196. CHRONIC DILATATION OF THE STOMACH 429 Daily lavage is generally necessary at first. As the tone of the stomach improves, the residuum found will decrease and washing may be per- formed less often. The first part of the washing may be done with plain warm water, though normal saline solution is preferable. I have found milk of magnesia (Phillips), 2 ounces (60.0) to i quart (liter) of water, excellent for the preliminary lavage. It is well to employ antifermentatives in the final treatment, such as Acid salicylic i : 1000 Sodium salicylate i : 1000 Sodium benzoate r : 1000 Listerin 'I Glycothymolin |- 3j (4-0) to i quart (liter). Borolyptol J Resorcin or 1 gr. 15 to 30 (1.0-2.0) to i Boric acid / quart (liter). (2) Electricity. The intragastric faradic current (preferably) can be employed if there be no objection on the part of the patient, using Lock- wood's instrument. In many cases the percutaneous method is advisable. Static electricity is claimed to be of value, and in some cases to reduce the size of the atonic dilated stomach. Massage or vibratory massage is of service to tone the musculature and aid in emptying the stomach. (3) The stomach douche has been recommended in the milder forms to stimulate the organ. The fluid should be at a temperature of 95 to 85F. (gradually reduced). If hydrochloric acid is diminished, normal salt solution may be em- ployed; if HC1 is increased, then use silver nitrate i : 3000 to i : 2000, or protargol or argyrol i : 2000. Bitter remedies, such as quassia (fluidextract), 15 minims to ^ dram (0.888-1.77 c.c.), or a cup of quassia- water (quassia cup filled with water and allowed to set for half an hour); or hops (fluidextract lupulin), 15 minims to > dram (0.888-1.77 c.c.), or fluidextract of condurango, > to i dram (1.77-3.54 c.c.) to a liter of water, have been recommended for lavage as a stimulant, but I see no special value in their use. The stomach spray has also been suggested in place of the stomach douche, but it possesses the disadvantage of injecting considerable air. Medicines. If there is deficiency of hydrochloric acid, the stomachics and hydrochloric acid should be administered, such as are employed in chronic gastritis. The following prescription is often valuable: 1^. Tinct. nucis vomicae , , Acid hydrochloric, dilute / ' Comp. tinct. cinchona 16.0 (5ss); Aq. destil q. s. ad. 125.0 (5iv)- M. Sig. One to two teaspoonfuls in a wineglassful of water t.i.d. half an hour before meals. Oxyntin with nux vomica, one to two capsules t.i.d., before or after meals, is useful. If there is hyperacidity, magnesia usta, 15 grains to > dram (i.o- 2.0) or more, in water t.i.d. an hour after meals. Or milk of magnesia (Phillips), i to 2 drams (4.0-8.0), in water. These are excellent remedies. 430 DISEASES OF THE STOMACH AND INTESTINES If bicarbonate of soda be employed, it is better to combine it with magnesia usta, equal parts, as it readily generates carbonic acid gas. In the atonic type of dilatation I have always been inclined to employ nux vomica or its alkaloid as a stimulant to the musculature of the stomach, even though hyperacidity be present, which is rare; in the latter event combining belladonna with the nux, as a pill, before meals: fy Ext. nucis vomicae \ ., , ,,. , , T? * u 11 j r It gr. H (0.016). M. Ext. belladonna J or 1^. Strychnin gr. 54o (0.00108); Atropin. gr Moo (0.00064). M. If nux vomica is incorporated in the stomachic mixture, it should not be repeated. If the tincture of nux vomica is employed, it can be gradually increased to large dose ^ dram (2.0) t.i.d. For fermentation and intestinal putrefaction the following remedies are of service, given three times a day half an hour to an hour after meals: Salicylate of soda, benzoate of soda, ichthoform, ichthalbin, bismuth salicylate, salol, resorcin, benzonaphthol, bismuth phenolate, or bismuth sulphocarbolate, all in doses of 5 grains (0.3) each. Hexa- methyl-enamin 5 grains (0.3), given in combination with sodium benzoate, 5 grains (0.3), in water t.i.d. after meals, is also useful. I have found resorcin an excellent remedy, alone or combined with bismuth subnitrate. If mold is present the creosote preparations are preferable, such as beech wood creosote, i minim (0.059 c.c.), or carbonate of creosote (creosotal), 5 grains (0.3), three times a day after meals. For constipation the olive oil injections at night, to be retained, 4 ounces to i pint (125-500 c.c.) or more; massage, electricity, the establish- ment of a regular hour for stool, the administration of a glass of water on rising, and, if required, the use of the cascara preparations or the aloin and belladonna pill, regulin, or one of the phenolphthalein preparations, such as phenolax or purgen, at night. Russian mineral oil 5 ss A. M. and P. M. or American mineral oil, vaselin 5i~5ii t.i.d. or albolene, 3ss A. M. and p. M. or olive oil 5ii~5 ss ~5i t.i.d. are excellent. The saline cathartics are objectionable. Gastrosuccorrhea is rare in the atonic type of dilatation. In the event of its presence, lavage with nitrate of silver (i : 2000) twice a week, and belladonna tincture, 10 minims (0.592 c.c.) t.i.d., or extract of belladonna, y$ grain (0.022) t.i.d. or atropine gr. Hoo~^oo t.i.d. are indicated. For further treatment, the chapter on this subject should be consulted. For gastric tetany, which may occur in the atonic type of ectasy, but which is a rare condition, lavage is of service, but gastro-enterostomy is indicated. Moynihan has operated on 14 cases of gastric tetany, with cures in all. Surgery. In atonic ectasy, when no improvement occurs under treat- ment or when the dilatation is of great degree and the patient's condition seems to be getting worse, operation is indicated preferably drainage of the stomach by gastro-enterostomy. CHRONIC DILATATION OF THE STOMACH 431 Gastroplication infolding the wall of the stomach and sewing it in pleats has also been successfully reported. Coffey has sutured the greater omentum to the abdominal wall and thus supported the stomach in a hammock. He reports two favorable results. TREATMENT OF STENOTIC DILATATION (BENIGN STENOSIS) The author wishes to preface this section with the statement that he considers all cases of pyloric stenosis to belong to the surgeon. He does not consider them curable except by radical operation. Moreover carcinoma may form on the cicatrix. The medical treatment is only palliative; though some cases may live many years, especially the milder types, but always be under the care of a physician for a considerable period during each year. In addition, some cases when untreated may become so re- duced as to be unfit for operation. Medical treatment, lavage, often twice daily, accompanied by proper methods of feeding by mouth, to- gether with nutritive enemata, may so improve the physical condition of these patients that they can in a short time undergo operation. This was particularly demonstrated in a case of carcinomatous stenosis in which the methods of feeding are described under Carcinoma of the Stomach. Treatment of Congenital Stenosis of the Pylorus. This is surgical gastro-enterostomy as early as the positive diagnosis can be made. In the cases with hyperacidity which are more intermittent in character, and which, under medical treatment, retain their weight and strength the condition may be believed to be due to pylorospasmus. The #-rays are of value in determining the character of the stenosis. If the condition is spasmodic correction of acidity before the second radiograph and previous to the #-rays the administration of belladonna 3 to 5 drops will diminish spasm and the previous large amount of retained bismuth may not appear. The medical treatment consists of lavage twice daily with a warm weak solution of soda bicarbonate, i to 2 drams (4.0-8.0) to the pint 500 c.c.), proper feeding by mouth, nutritive enemata, and small doses of strontium bromid, 3 to 5 grains (0.2-0.3), by" mouth or rectum. Correct hyperchlorhydria if present. This method can be tried for a short time in any event, and if the symptoms continue and the loss of weight and strength are progressive, one may assume the case to be due to stenosis, in which event operation is indicated gastro-enterostomy. Incision through the indurated tissue down to the mucosa has been employed. This method is rapid and produces little shock. Einhorn 1 advocates the use of an infantile pyloric dilating catheter, but the writer does not advise his method. Medical Treatment of Acquired Stenosis of the Pylorus. This is only justifiable when the patient refuses surgery or to prepare for operation. In early stenosis of the pylorus due to syphilis, I have seen a few cases relieved apparently by antisyphilitic treatment without surgery. On the other hand, cases with marked symptoms of stenosis in my experience have always ultimately required gastroenterostomy in addition to the treatment for lues. In the cases of acquired stenosis where there is a mechanical obstruction to the exit of the gastric contents, the muscular 1 Med. Rec., June 10, 1911. 432 DISEASES OF THE STOMACH AND INTESTINES action is increased during the earlier stages and hypertrophy of the pyloric end of the stomach is present; later the fundus and body become distended and thinner. Gentle massage from left to right, or vibratory massage by the same method, the patient lying on the right side and the manipulations being performed an hour or two after meals, may aid in emptying of the stomach. Electricity is of slight or no value. I have seen no permanent benefit from these methods in the obstructive type of dilatation. Olive oil, 2 to 4 ounces (60.0-125.0 c.c.), administered three or four times a day before meals will aid the passage of the food through the ste nosed region, and Rose's adhesive plaster belt is also of service to elevate the stomach, and render its emptying more easy. The diet must be liquid in the worst cases and mushes may be em- ployed in the less severe types. Raw eggs, six to eight a day, plenty of fat, such as butter and cream, somatose, and tropon, are all of service. The general method of feeding with small frequent meals is the same as in atonic ectasy. Improvement in weight must be secured. Solid food is objectionable. "The sour milks, such as bacillac, lactone- buttermilk, kefir, matzoon, and koumiss, administered after the manner described in Atonic Ectasy, are of value." The patient should lie on the right side for about half an hour after each feeding in order to facilitate the exit of the food from the stomach. Lavage is always necessary, and for the attacks of spasmodic pain is the most rapid method to secure relief. As hyperacidity is present, alkalis are indicated to correct this condition, as in hyperchlorhydria. The writer has referred to a case of carcinoma of the stomach upon whom the surgeons would not operate on account of his weakened physical condition. This patient was prepared for subsequent operation by the above methods. Tincture of belladonna in large doses, 10 to 15 drops t.i.d. or atropin g r - Hoo~Ho> will often relieve spasm and pain, as will also the application of heat. Vomiting. For vomiting lavage is indicated, followed for several days by rectal feeding, and then commencing with a small amount of liquid nourishment. Rectal injections of normal saline solution, 8 ounces to i pint (250- 500 c.c.), may be indicated to relieve thirst and collapse. Proctoclysis is of service. Thiosinamin, 5 grains (0.3) t.i.d. by mouth, or 3-grain (0.2) doses in 15 per cent, alcoholic or 10 per cent, glycerinated solution by hypodermic, have been reported to be of service in fibrous contractures of the pylorus. Fibrolysin (thiosinamin and sodium salicylate, Merck), each ampoule containing 0.2 gram thiosinamin, can be given daily or every other day, for a month or two, in cases refusing operation. The writer has not been successful with this method, though it should be tried in cases refusing operation. Gastrosuccorrhea may occur in cases when there is an ulcer with stenosis at the pylorus and, rarely, hemorrhages. Temporary treatment as for hemorrhage of gastric ulcer is indicated, and then surgical procedure. The treatment for gastrosuccorrhea, is described in the chapter on that subject. COMPLICATIONS OF CHRONIC ECTASY 433 Gastric tetany may be a complication for which lavage is indicated temporarily, and then operation (gastro-enterostomy). I have seen cases of ectasy from benign stenosis lose 75 pounds in weight and regain 50 to 60 pounds under treatment, and ultimately relapse and come to operation. I have treated many patients of this type, so-called brilliant cures by specialists, the ultimate results being the same. They, even at the best, tend to become chronic invalids and always require treatment. The best physician for these cases is the surgeon. If the cause of the stenosis lies external to the pylorus, bands, ad- hesions, etc., can be separated. If it is intrinsic, resection of the pylorus, pyloroplasty, or gastroduodenoplasty can be performed in suitable cases, or drainage by gastro-enterostomy. The latter is usually the operation of selection. Divulsion I do not approve. I have seen a patient gain 100 pounds in weight in eight weeks after gastro-enterostomy, and, from being a confirmed invalid, restored to perfect health. Einhorn 1 advocates the use of his dilating catheter or pyloric dilator with diaphane to stretch the stenosed pylorus. The writer knows the method to be uncertain, and the results not permanent. Valuable time is thus lost. Surgery is always indicated for stenosis. Malignant Stenosis In these cases early radical operation is indicated, as described under Cancer of the Stomach; otherwise, palliative gastro-enterostomy or gas- trostomy if stenosis at the cardia. If operative procedure be refused, then diet, lavage, and the treatment laid down under Carcinoma Ventriculi. COMPLICATIONS OF CHRONIC ECTASY Gastric Tetany Tetany is characterized by peculiar bilateral tonic spasm of the extremities, either paroxysmal or continued. Pathology. In all cases there is dilatation of the stomach of a high degree, due generally to stenosis of the pylorus or the duodenum; fre- quently the result of an ulcer; rarely from carcinoma. Gastrosuccorrhea has been associated with it in. some cases. Tetany has also been reported with acute ectasy and in atonic ectasia. Etiology. There are three theories as to its cause: (1) Kussmaul and, later, Fleiner believed its symptoms are due to the great loss of fluid in the system, the thickening of the blood, and the consequent drying of the tissues. (2) Friederick Miiller and Germain See consider it to be the result of some reflex action, as Miiller brought on an attack by tapping the epi- gastric region. Riegel has observed it on passing the stomach- tube; and it has also occurred in cases of intestinal worms. (3) The third theory explains it on the ground of auto-intoxication, since fermentation and putrefaction are present in the stomach. This last is probably correct, as the cases have been benefited by lavage and cured by stomach drainage (gastro-enterostomy). 1 Med. Rec., Oct. 9, 1909; Ibid., June 10, 1911, and N. Y. Med. Jour., May n, 1912. 28 434 DISEASES OF THE STOMACH AND INTESTINES Amato reports a case of gastric tetany with death. He has intro- duced fermenting materials into the stomachs of animals and produced dyspnea, myosis, muscular contraction, and trismus. The liver and pancreas (postmortem) showed lesions, such as are usually found with poisonings and intoxications. Symptoms. There are tonic and clonic bilateral spasms, which ap- pear suddenly and are generally confined to the extremities, the flexor muscles being chiefly affected. The fingers are bent at the metacarpo- phalangeal joint, extended at the terminal joints, being pressed close together, and the thumb is contracted into the palm of the hand. The wrists are flexed, the elbows bent, and frequently the arms are folded over the chest. The knees are bent, the feet extended, and the toes adducted. In severe cases there may be trismus, and the angles of the mouth are drawn up. There is sometimes edema of the hands and feet. The spasms are usually paroxysmal and last for a variable time. The eyes may be turned up. In the acute attack there may be a rise of temperature and elevation of the pulse. In some cases there may be involvement of the muscles of the back and of the thorax, with dyspnea and cyanosis. The attacks may be acute, from a few minutes to several hours, but there may be some stiffness and contraction lasting several weeks. Diagnosis. There are certain diagnostic features: (1) "Trousseau's Symptom" As long as the attack is not over, the paroxysms may be produced by compressing the affected parts, either in the direction of their principal nerve-trunk or over their blood-vessels, so as to impede the venous or arterial circulation. (2) "Chvostek's Symptom." There is an increase in the mechanical excitability of the motor nerves. A slight tap over the facial nerve will throw the muscles to which it is Distributed into active contraction. (3) "Erb's Sign." The electric irritability of the motor nerves, to the galvanic current especially, is increased. (4) "Hoffmann's Sign." Heightened excitability of the sensory nerves. The slightest pressure may cause paresthesia in the region of distribution. The prognosis of tetany is extremely bad. Frequency. Moynihan believes it to be not so very rare, and reports 14 cases in which gastro-enterostomy was performed, with a cure in each case; though some claim only 30 to 40 cases are reported. Tetany-like attacks with epileptiform attacks are more frequent, and will be referred to under Epilepsy. Treatment. Bromids, and even chloroform inhalation, during the acute attack are of value. Lavage is beneficial. The chief indication is drainage of the stomach by gastro-enterostomy. REFERENCES Smith, Med. Rec., 1900, Iviii, 910. Dujardin-Beaumetz, L'Union Medicale, 1884, Nos. 15 and 18. Strong, Boston Med. and Surg. Jour., 1902, cxlvii, 561, 597. Simpson, Pract., 1900, Ixv., 283. Kussmaul, Deutsch. Archiv f. klin. Med., 1869, Bd. 6. CONVULSIONS EPILEPSY 435 Moynihaji, Pract., 1903, Ixx, 354. Bouveret, Rev. de Med., 1892, p. 48. Ewald, Berl. klin. Wochens., 1894, No. 2. Fleiner, Arch. f. Verdauungskrankheiten, Bd. i, Heft 3. Einhorn, Diseases of the Stomach. Amato, La Riforma Med., Feb. 4, 1903. E. Neumann, Deutsch. Klinik, 1861. Boas, loc. cit., 107, and others. CONVULSIONS EPILEPSY Epileptic seizures occur both in cases of chronic ectasy and in other affections of the stomach. I have had a case under observation at the Manhattan State Hospital who suffered from repeated attacks of epilepsy, 140 seizures a month. There was dilatation of the stomach, with ptosis and hypochlorhydria. For the last three years, while having occasional lavage, dietetic treatment with medication directed to the stomach, no bromids, she has had no attacks, except for the period of a week, over two years ago, when the treatment was omitted. The mental condition cleared up, and the patient was recently discharged. At the same institution there is another patient with atonic ectasia and hypochlor- hydria, who had frequent epileptic attacks and who has had no seizures for over two years, as a result of treatment directed to the gastro-intestinal tract. I have reported a case of hyperchlorhydria, 1 with epileptic seizures, apparently cured by appropriate treatment; and cases of dementia paralytica with chronic ectasy, in which the convulsions were diminished under treatment and the high temperatures returned to normal. I have also seen tetany-like convulsions in a case of dementia praecox, with gastrop- tosis and marked ectasy, improve after treatment of the stomach. Salt- free diet, the avoidance of meat, open air, and treatment appropriate to the gastric findings in each case are indicated. In conclusion, I cannot recommend too highly the sour-milk diet in the treatment of these cases. Matzoon, koumiss, kefir, fermillac, or the lactone-buttermilk can be employed after the manner indicated under Atonic Ectasy. I have found Wm. H. Thomson's formula for the preparation of matzoon of great value in these cases. It is as follows: "i. Place half a cake of yeast in i pint (500 c.c.) of fresh milk in a pitcher covered with a towel in a warm place for twelve hours; then 11 2. Add to this i quart (liter) of milk and keep in a warm place for twelve hours; then "3. Take i pint (500 c.c.) of No. 2, add to it i quart (liter) of milk, and keep in a warm place for twelve hours; then "4. Take i pint (500 c.c.) of No. 3, add to it i quart (liter) of milk, and keep in a warm place for twelve hours. "This makes \y 2 quarts (1500 c.c.) of matzoon, the entire process occupying forty-eight hours. "One quart (liter) of this can be administered in divided doses daily, 1 Observations on the Relation of the Gastro-intestinal Tract to Nervous and Mental Diseases, reported April 17-21, 1905, American Medicopsychological Associa- tion, and in their proceedings. 436 DISEASES OF THE STOMACH AND INTESTINES breaking in it stale bread or crackers, and eating it with a spoon. The remaining pint (500 c.c.), with the addition of i quart (liter) of milk at the end of twelve hours, will furnish i>^ quarts (1500 c.c.) of matzoon. Fresh matzoon can be made daily from the former pint (500 c.c.) of mother matzoon for about two weeks, when the process must be started over again. If larger quantities are to be used, i quart (liter) of No. 2 can be used with 2 quarts (liters) of milk, and so on." This method has been extensively employed by Thomson and the author in feeding our epileptics. One can also use 4 to 6 ounces (125- 185 c.c.) of the ordinary bottled matzoon to i quart (liter) of milk, which will produce matzoon if kept twelve hours in a warm place. From this daily matzoon can be made from each previous supply for about a week, when a fresh bottle must be employed. CHAPTER XVI ANOMALIES IN THE POSITION AND FORM OF THE STOMACH HOUR-GLASS STOMACH DISLO- CATIONS GASTROPTO SIS ANOMALIES of form are frequently congenital. Fore-stomach is a dilatation of the lower end of the esophagus immediately above the diaphragm. Antrum cardiacum is a sacculated diverticulum of the esophagus situated below the diaphragm. In some cases no symtoms occur; in others food becomes lodged and causes serious results. Megalo- gastria is a congenital or acquired large stomach with normal functions. Microgastria is an abnormally small stomach with normal functions. Angustatio ventriculi is an extremely small stomach due to stricture of the cardia or esophagus or to cirrhosis ventriculi. Congenital Narrowing of the Pylorus. This condition is due to hyper- trophy of the circular muscles of the pylorus It may be of so severe a type that ingestion of food may be impossible and the infant die within a few days after birth. In milder cases chronic ectasy may result according to some. HOUR-GLASS STOMACH This condition may be congenital, but is more frequently acquired. The stomach has a peculiar sacculated outline, and is divided into two parts the cardiac and pyloric (Fig. 214). In some cases the cardiac sac is larger, in others, the pyloric. Hour-glass contraction may occur as con- genital, acquired or organic, spastic (or hy- pertonic) and hypotonic. The congenital form is extremely rare. Etiology of the Acquired or Organic Type. Cicatrized tissue contraction following an ulcer; less frequently perigastric (peritonitic), adhesions, gastritis from corrosive poisons, and carcinoma are causes. Slight forms may produce no characteristic symptoms. In ad- vanced cases the division may be recognized. By the ingestion of bismuth and the use of the fluoroscope with the #-rays this condition can be demonstrated. It is advised to secure a rontgenograph when possible. Symptoms. There may be the previous history of ulcer, perigastritis, corrosive poisons or cancer, followed by symptoms of stenosis of the cardia or pylorus. 437 Fig. 214.' Hour-glass stomach. DISEASES OF THE STOMACH AND INTESTINES The following diagnostic points are of value: With lavage, part of the fluid is lost (Wblfler's first sign); if the stomach is washed clean, a sudden reappearance of the stomach contents takes place often cloudy in character, "paradoxical dilatation" (Wolfler's second sign) which suggests the passage of contents from the pyloric pouch into the cardiac pouch. When the stomach has been apparently emptied, a splashing sound may be elicited by palpation of the pyloric segment; after distending the stomach, a change in the position of the distention tumor may be seen in some cases. Gushing, bubbling, or siz- zling sounds are heard on dilatation with carbonic acid gas at a point distinct from the pylorus. With inflation with gas, the upper pouch Fig. 215. Hour-glass stomach. Female aged forty-three. Operation by Dr. Walton Martin showed the presence of a band of omentum adherent to the liver, near the site of a former operation. (Bastedo and Le Wald.) will first distend, and then subside with more general dilatation. In some cases, when both parts are dilated, two tumors with a notch or sulcus between are apparent to sight and touch. On both sides of the furrow there will be a loud tympanitic sound which cannot be elicited in the middle. Stockton finds that if the first part of the stomach is aspirated, after manipulation, it is sometimes possible to force from the second into the first portion a gastric juice of different quality. Radiography. In the majority of cases the stomach is divided into two pouches, generally 3 or 4 inches from the pylorus. Occasionally a tripartite stomach is found. It may assume various irregular shapes, DISLOCATION OF THE STOMACH 439 sometimes appearing like a saddle bag. In corrosive poison cases there may also be deformity at the pylorus or in the duodenum. The neck usually does not emerge from the most dependent portion of the upper sac, but from a point higher up. In Fig. 215 is demonstrated a radiograph of an hour-glass stomach. Spastic Hour-glass Stomach. With pyloric stenosis when there is increased (hypertonic) peristalsis, a contraction may be seen separating the pyloric end from the rest of the stomach. Though it may have an hour-glass appearance; the neck comes from the most dependent portion, the construction rings are equal and the hour-glass appearance does not appear in all the radiographs thus differing from the organic type. In other cases, with ulcer of the lesser curvature, a deep incisura is seen in the greater curvature. This is liable to indicate hepatic adhesion and the incisura is spastic and often disappears when the patient lies down. Thus spastic contracture sometimes occurs when there are no adhesions. Sometimes the greater curvature may be drawn up by adhesions and the radiograph appear to be hour-glass on standing but this disappears when the #-ray is employed in the Trendelenburg position. Hypotonic Hour-glass Stomach. Hertz describes a ptosed and atonic- ally dilated stomach which sags so extremely that in the radiograph the lower segment contains bismuth the walls meet above this obliterating the lumen and some bismuth accumulates above. This gives an apparent hour-glass stomach which disappears when the patient lies down or if the shoulders are depressed (moderate Trendelen- burg). Operative procedure is the only method of cure. DISLOCATION OF THE STOMACH The fundus may be dislocated upward. Among the causes are: Absorption of a pleuritic exudate on the left side; after contraction of the lung or any process which is accompanied by upward dislocation of the diaphragm; excessive distention of the abdominal cavity, forcing the diaphragm upward, such as from pregnancy, ascites, tumors, and rneteorism and diaphragmatic hernia. The cardiac end of the esophagus may become bent. Lateral dis- location is rare, and may be caused by tumors of the spleen, distended colic flexure, or lateral pressure from an enlarged liver. As a rule, the latter forces the stomach downward. Downward dislocation (gastroptosis) is the common form. DIAPHRAGMATIC HERNIA. EVENTRATION OF THE DIAPHRAGM. VOLVULUS OF THE STOMACH Diaphragmatic Hernia. With this condition, the stomach and colon are most frequently involved though diaphragmatic hernia of nearly all the viscera may occur. In the majority of cases there is more or less torsion of the stomach in the vertical or longitudinal axis, in addition to its upward displacement, and the colon may lie above it. 44O DISEASES OF THE STOMACH AND INTESTINES This type of hernia may be congenital through some defect of develop- ment; or acquired in which event the hernia takes place through one of the normal openings in the diaphragm, chiefly through the esophageal opening and there is a true hernial sac. Finally, there may be traumatic hernia due to laceration of the diaphragm from wounds by knife or bullet, crushing, or severe blows or falls. If a portion of the stomach form the hernia, or torsion of the organ is marked, strangulation and gangrene may occur, or the esophagus, pylorus or duodenum may be occluded. Symptoms In congenital cases they may appear soon after birth, there being cyanosis, dyspnea, cardiac misplacement to the right, inter- ference with left lung expansion and rapid death. Occasionally there are milder cases, or the symptoms develop later in life. In these there are digestive disturbances, attacks of pain and vomiting of yellow fluid, later of blood, increased tympany in the anterior axillary line, at times jaundice, distention in the upper left quadrant of the abdomen. Relief may follow vomiting, or sudden death may follow from gas pressure o'n the heart, or peritonitis may result. In the acquired cases, symptoms of less severe type may occur as noted above or there may be sudden strangulation with its symptoms, hemate- mesis, etc., or in some cases obstruction of the esophagus with distention and no vomiting. In the traumatic cases, the symptoms follow the injury, or may occur later, such as dyspnea, thoracic and epigastric pain, cyanosis, shallow breathing; vomiting or attempts to vomit if torsion of the esophagus, with distention and marked thirst. In the chronic types there are attacks of recurrent vomiting and pain after meals the latter worse in the erect posture. Subsequently if strangulation occur there may be hematemesis, or inability to swallow if the esophagus is obstructed, collapse, and per- forative peritonitis. Diagnosis, The physical signs are distention of the chest on the af- fected side, restriction in pulmonary expansion, intestinal peristaltic move- ments communicated to the thorax (in some cases) ; epigastrium retracted or distended depending on the degree of hernia, and rigidity of the upper abdominal wall. There may be a tympanitic note at the base of the lung, or a dull area due to the spleen, omentum or fluid contents of the stomach. Artificial distention of the stomach and colon increase the tympanites. Gurgling sounds are present over the stomach, respiratory sounds are no longer distinct. Compression of the lung occurs above the hernia and the heart is usually displaced to the right. Radiographs. If the colon forms part of the hernia, bismuth or barium enema will demonstrate its presence above the line of the diaphragm. The bismuth meal will show a curved shadow line with the concavity down- ward, i.e., the upper wall of the stomach. Below this is usually an air bubble which in turn lies above the diaphragm level. With diaphrag- matic hernia there is a mottled appearance of lung tissue visible through the gas lying in the stomach, which does not occur with eventration of the stomach (Giffin). Paradoxical Expiratory Displacement. On forced inspiration the dia- phragm descends normally on the right side, but on the left side it ascends. GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 441 On forced expiration the reverse occurs, and the shadow line on the left side is found high up. Differential Diagnosis. With eventration of the stomach, the mottled appearance of lung tissue is not visible in the radiograph through the gas in the stomach, as it is with diaphragmatic hernia. The shadow lines in the radiograph or by fluoroscopy may give information. With two curved shadow lines, if after artificial distention of the stomach, the lower one move upward against the upper, then the lower is stomach and the upper diaphragm. If the upper Hne was stomach, then it would move up higher after distention. However, a single shadow line may represent both stomach and diaphragm, but distention will cause the pyloric end of the stomach to unfold. Recurrent attacks of pain and vomiting after injury to the lower thorax point to hernia. With pneumothorax we have the physical signs, and fre- quently signs in the other lung; there are fewer gastric symptoms. Radio- graphs show an unbroken line of the diaphragm and no bismuth or barium deposit above it. With subphrenic abscess, there is a previous history of gastric or duo- denal ulcer; leukocytosis and increased polynuclears are present. The .T-rays show the stomach below the diaphragm. Prognosis. This is grave in all cases, though operation after early diagnosis, has proved successful. Treatment. For acute distention with cyanosis, lavage affords tem- porary relief providing the esophagus is patent. Surgical procedure is indicated. Eventration of the Diaphragm. This consists in a thinning and weakening of the diaphragm usually on the left side, so that it bulges upward and forms a sac into which the stomach or other viscera may enter. The condition is often congenital and lack of development of the left lung is associated. It may be acquired by atrophy or degeneration of the muscle of the diaphragm, or as a result of paralysis of the phrenic nerve. Radiograph. This shows a high line of the diaphragm unbroken and overlying the bismuth area in the stomach. Symptoms. These are not characteristic and the "physical signs re- semble those of hernia (diaphragmatic) which are described under that section. Treatment. Only symptomatic treatment can be employed. Volvulus of the Stomach. This consists of an abnormal rotation of the stomach on one or more of its axes, resulting in the occlusion of one or both of its orifices (the pylorus most frequently). The volvulus may be partial or complete. While the cardia is still patent vomiting occurs and lavage affords relief. Later cardiac occlusion occurs and the tube can no longer be passed. Axial rotation is usually from below forward and upward, the anterior form, and less frequently from below backward and upward, the pos- terior form. Rotation about the vertical axis is less frequent and then more generally from right to left. The degree of rotation varies; mild cases with pain, distention and vomiting may spontaneously recover. The 442 DISEASES OF THE STOMACH AND INTESTINES rotation is usually 180 degrees or more producing strangulation, the stomach becoming greatly distended. Etiology. Among the causes are diaphragmatic hernia, tumors, hour- glass stomach, adhesions, trauma produced by displacement of liver or spleen, a blow or a fall ; gastroptosis has been given as a cause but I doubt it. Some so-called idiopathic (non-explainable) cases are reported. Symptoms. There are the previous symptoms of hour-glass stomach, adhesions, or diaphragmatic hernia in some cases. In others there is sudden intense and continuous pain in the epigastrium or lower left thoracic region ("douleur thoracique" as described by Faure) with severe pressure over the heart as if the thorax would break; vomiting, often hematemesis; later the vomiting stops and distention increases and it is impossible to pass a stomach-tube, due to torsion of the esophagus. There is an effort to vomit but no ability to do so. Localized rigidity of ab- dominal muscles appears early and spreads. Death occurs from collapse or peritonitis. Differential Diagnosis. With diaphragmatic hernia, there are the usual signs, with heart displaced to the right. With intestinal obstruction vomiting persists while with volvulus it stops and the stomach-tube is blocked. This last also differentiates it from acute dilatation of the stomach where the tube is readily passed and affords relief. With acute pancreatitis we have epigastric peritonitis, tenderness at Robson's and other points, subnormal temperature, general hemorrhagic tendency, jaundice, the history, etc. Prognosis is bad as a rule. Treatment. Early lavage when possible may aid in spontaneous re- duction. Surgery is otherwise indicated. GASTROPTOSIS ENTEROPTOSIS GLENARD'S DISEASE (Synonyms. Gastroptosis Rose; Visceroptosis; Splanchnoptosis; Abdominal Relaxa- tion or Atonia Gastrica Rose; Atony of the Third Degree) Definition. Gastroptosis may be denned as a prolapse or downward displacement of the stomach, right kidney or both kidneys, and other organs of the abdominal cavity, which may be associated with disturbances of the gastro-intestinal tract and pelvic organs, together with various nervous symptoms. Ptosis of the heart may also occur. Nephroptosis is a stigma of gastroptosis. Introduction. I here use the term "gastroptosis" with the usual definition (ptosis of the stomach), though Rose has shown it correctly means descent of the belly (spalnchnoptosis). The reader must remember that gastroptosis is a quite frequent condition, and that it may be acci- dentally discovered in some cases which have no symptoms whatever. On the other hand, there are various degrees of ptosis of the stomach, in some of which the symptoms are rather mild in character, while in others there may be the symptoms-complex of Glenard's disease. It is not the position of the lower border of the stomach which con- stitutes a ptosis, but that of the upper border; with the relaxation of the suspensory ligaments of the stomach the lesser curvature sinks as well as GASTROPTOSIS ENTEROPTOSIS GLENARD'S DISEASE 443 the greater, and we may have varying degrees of ptosis, from moderate obliquity of the upper border, to a vertical stomach; while on the other hand, the entire organ may sink and give the crescentic form of gastro- ptosis. The determination of the lower border alone is not diagnostic, since it may merely be evidence of a dilated stomach. Hundreds or even thousands of cases of nephroptosis have been reported as having dilated stomachs, the dilatation being imputed to pressure of the kidney on the duodenum, and no investigation has been made of the position of the lesser curvature. From my own experience, I do not hesitate to say that movable kidney (nephroptosis), with the lower border of the stomach lower than normal, is diagnostic of gastroptosis. Dilatation of the stomach is often associated with gastroptosis, but kidney pressure on the duodenum, in my opinion, has no bearing as to its production. This combination has been found in cases at the Manhattan State Hospital. Furthermore, treatment for gastroptosis will generally cure this condition. Ptosis of the stomach in some of these cases may be of extremely mild type. Anatomic Considerations. It is necessary to briefly allude to certain anatomic features. The liver, as we -know, is suspended from the dia- phragm by ligaments derived from the peritoneum. The cardiac end of the stomach is held quite fixedly in position by the esophagus, and there is a peritoneal attachment to the diaphragm at this point, the gastro- phrenic ligament. In this location the stomach lies in close relation to the diaphragm, while the lesser curvature is suspended from the liver by the lesser omentum (gastrohepatic). The spleen lies in close relation to the diaphragm, being attached thereto by ligaments (processes of the peri- toneum), and to the stomach by the gastrosplenic omentum. It is thus readily understood how compression of the lower part of the thorax or effusions above the diaphragm may mechanically force down the latter and produce ptosis of organs so closely associated. The descent of the intestines is a natural accompaniment. A tumor of the pylorus may cause ptosis of the stomach, and prolapse of the transverse colon and of the other viscera follow. On the other hand, a severe type of dilatation of the stomach may be followed by ptosis of the organ and then general visceroptosis. These primary types of gastroptosis are not so very frequent. The transverse mesocolon surrounds the transverse colon and con- nects it with the back of the abdomen at the spine. The transverse colon is attached to the abdominal surface of the eleventh rib on each side by a fold of peritoneum. As the colon passes across the abdomen it sags somewhat, presenting a slightly concave surface superiorly. Glenard, whom we must justly credit as the first to describe splanchnoptosis as a pathologic entity, believes enteroptosis (ptosis of the transverse colon) to be the starting-point. He thinks the transverse colon is fastened to the pyloric end of the stomach by a band (ligament), and that the hepatic flexure first sags, followed by the transverse colon, causing thus a sharp flexion at the attachment of the ligament, and a hindrance to the progress of the intestinal contents, with resulting accumulation in the ascending and transverse colon. From the point of stenosis the transverse colon 444 DISEASES OF THE STOMACH AND INTESTINES passes downward diagonally across the abdomen as a hard cord-like mass (corde colique transverse). The sagging of the transverse colon exercises traction on the pylorus and omentum, thus causing descent of the stomach and liver. The descent of the hepatic flexure, he believes, causes traction on the parietal peritoneum and encourages ptosis of the right kidney. The gastro- intestinal tract, he noted, was suspended in the form of loops, six in number, by means of ligaments; and he believed in the possibility of too great a bend at such an acute angle, that it might cause a partial obstruc- tion to the passage of the contents. This might occur at the gastroduo- denal, the duodenojejunal, transverse colon, or sigmoidorectal curves. The gastroduodenal and transverse colon ligaments Glenard holds to be the weakest, and if they give way, with resulting ptosis of the in- testine, increased traction and angulation is produced at the next fixation point, causing an enterostenosis. Glenard found the transverse colon displaced and stenosed in numerous autopsies, and was the first to realize that many cases of so-called nervous dyspepsia were dependent upon these abnormalities. Riegel has demonstrated that the hepatic flexure is not dislocated downward in the majority of cases, and Glenard's explanation I hardly believe tenable, as there are other very important factors which have a bearing. A tumor, however, of the transverse colon or adhesions may produce primary enteroptosis. We must remember there is one type of case, a congenital constitutional defect, the patient with long narrow thorax, who suffers from splanchno- ptosis. Keene finds in autopsies on babies evidences in favor of the congenital origin of enteroptosis. In many of these there was a redundant colon. A potential enteroptosis is, therefore, present, which is latent. Later, through some cause, weakening of the abdominal musculature or diminu- tion of intra-abdominal pressure, sagging of the intestine occurs and symptoms develop. The writer believes there are quite a number of these congenital cases. The round-shouldered, hollow-backed position, Reynolds 1 holds, results in the formation of pot-belly and leads to the production of splanchnoptosis. Undoubtedly, spinal curvature or rickets may be factors. The major number of cases of gastroptosis, however, are acquired from various causes; and in my opinion the development of the prolapse of the various organs generally occurs synchronously, the stomach, right kidney, and transverse colon most frequently prolapsing together; while in other cases the left kidney or the rest of the viscera may descend in addition. These following are the prominent factors which have a marked bearing in preserving the proper position of the viscera: 1. The abdominal muscles. 2. The maintenance of normal intra-abdominal pressure. i. Abdominal Muscles. In an interesting article, the late A. Rose 2 1 Jour. Amer. Med. Assoc., Dec. 3, 1910. 2 Surgery, Gynecology, and Obstetrics, November, 1906, Physiology and Pathology of the Abdominal Muscles. GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 445 calls attention to the fact that in addition to the usual functions described in the text-books, in assisting expulsion of the fetus, bowel action, urina- tion, and vomiting, the abdominal muscles aid in the preservation of the physiologic position of the abdominal organs. The crosswise arrange- ment of the external and internal oblique and transversalis muscles- supported by the recti effect a narrowing of the abdominal cavity and prevent visceral ptosis. Groddeck, of Baden-Baden, has, moreover, described the mechanical influence of healthy muscle, by the alternate contraction and expansion, in assisting the circulation of the blood and lymph, and an atonic condi- tion of the abdominal musculature would certainly interfere with the maintenance of the normal relations between the extra- and intra- abdominal circulation. Moreover, clinically, simple inspection will differentiate between normal conditions and the typic "pot-belly" of the gastroptosis patient. Acute or wasting disease may also cause changes in the muscles. 2. Infra-abdominal Pressure, Normal abdominal muscles also main- tain the normal intra-abdominal pressure necessary to preserve the posi- tion of the viscera. Walkow 1 has made a very exhaustive study of this question and has demonstrated, for example, on the cadaver, with the upper part of the trunk elevated (the reversed Trendelenburg position), that after abdominal section, mobility of varying degrees of the kidney is found, which did not previously exist. Sturmdorf has found similar results after laparotomy on the living. Clinically, changes in the intra-abdominal pressure, the result of child- birth or tapping for ascites, have resulted in the production of splanchno- ptosis, the thinned and distended musculature of the abdomen also being a factor. Rapid loss of weight from emaciation and absorption of omental fat is another example. Nephroptosis. Movable kidney, in probably 95 per cent, of cases in my own experience, is one of the stigmata of gastroptosis. The congenital type, with long mesonephron, or those cases due to traumatism, are com- paratively few in number. The right kidney has a longer pedicle and lies lower on account of the liver. Stiirmdorf refers to certain skeletal deformities as influencing the shape of the bony receptacle for the kidneys, and which in some cases predisposes to prolapse; but gastroptosis is associated with these same conditions. It has been claimed that there is a nephrocolic ligament connecting the kidneys to the ascending and descending colon, and that traction of the colon may influence its descent. Reversed peristaltic action occurring intermittently in the ascending colon, which does not take place in the descending, is believed to have an influence, arid the peritoneum over the left kidney is said to be thicker. The fact that the tail of the pancreas lies in front of the left kidney seems to me to have some bearing on the ques- tion. Absorption of the fatty capsule is probably another factor. 1 Med. Rec., Jan. 13, 1906. 446 DISEASES OF THE STOMACH AND INTESTINES The peculiar position of the right kidney and lessening of intra-ab- dominal pressure seem to be the chief causes of its more frequent descent. With gastroptosis we have also a relaxation of the gastro-intestinal musculature and of all the peritoneal ligaments. Changes in the position of the stomach and in its secretory and, at times, in its motor functions account for the gastric disturbances. The secretory function one might expect to be influenced by circulatory disturbances following displacement of the organ. Associated are changes in the position of the duodenum productive of stasis, and which readily account for gall-bladder symptoms simulating stone, so often attributed to nephroptosis. Similar disturbances in the intestine, constipation, diarrhea, mucous colic, or chronic appendicitis can thus be accounted for. There is a relaxation of the broad ligaments and with it ovarian and uterine descent, and even descent of the pelvic floor, with dysmenorrhea and various symptoms of the pelvic organs. I do not agree with Edebohls' theory of compression of the superior mesenteric vein by the kidney as a cause of congestion of the appendix. Occasionally, Dietl's crisis from torsion of the kidney pedicle and, rarely, nephritis or hydronephrosis occur. More rarely the kidney may become adherent to the gall-bladder or appendix. In addition, circula- tory disturbances and marked neurasthenia, the latter due chiefly, I believe, to auto-intoxication, are present; and from the severe type of splanchnoptosis we have the symptoms-complex of Glenard's disease all of which the "kidney experts" attribute to nephroptosis. Etiology. We must remember that the vertical stomach is the fetal position of the organ. Some hold that every infant is born with it in this position and that after a few weeks or months, through the weight of the food and the action of the diaphragm, the position of the stomach becomes normal. Recently radiographs of the stomach, of very young infants and children, apparently show that the position and shape of the infant stom- ach is not always constant, though the normal organ lies in its entirety- above the umbilicus. Occasionally, it may remain vertical, but I believe this is true more especially in those suffering from the congenital consti- tutional defect, to which I shall refer. The causes of gastroptosis may be divided into congenital and acquired : i. Congenital constitutional defect, the long narrow thorax, with the diaphragm and liver pushed down. In these, splanchnoptosis is a con- stitutional defect. Stiller's floating tenth rib is usually present. Butler, 1 from more recent investigations, holds that the floating tenth rib is rare in adults; though fully 50 per cent, of all children have a movable tenth rib, though it is rarely unattached. Mobility of this rib is not a stigma of enteroptosis in children. Butler holds that the ptoses are usually first noted at the period of puberty. The enteroptotic habit of the adult finds its counterpart in the child, with frail habit, lack of fat, slender muscles and lack of vigorous bodily development. The prolapse of the organs does not usually occur in children under twelve years of age. With constitu- tional inferiority vagotonia is believed by Eppinger and Hess to be present. 2. Other skeletal deformities, spinal curvature, rickets, kyphosis and kypho- 1 Enteroptosis in Children, Jour. Amer. Med. Assoc., Dec. 31, 1910. GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 447 scoliosis are contributory. Lordosis, Lerch 1 believes an important factor, and that the large overdistended thymus occurs with enteroptotics and has a bearing on circulatory and nervous disturbances. 3. Intrathoracic pressure on the diaphragm from effusions, tumor, etc. 4. Tumors of the liver. 5. Leukemic enlargements of the spleen. 6. Tumor of the pylorus or adhesions (gastric). 7. Tumor of the colon or adhesions. 8. Chronic dilatation of the stomach. 9. Compression of the thorax by tight lacing, poor corsets, tight waist-bands, etc. 10. Relaxation of the abdominal muscles and diminution of intra-abdominal pressure. This may result from rapid emaciation in acute diseases, with degeneration of the muscular tissue; or the same condition in longer chronic wasting diseases, or from loss of weight and muscular tone from any cause. Landau's disease, splanchnoptosis folio-wing confinement, is fairly fre- quent. Emptying of the uterus produces a sudden diminution in intra- abdominal tension, and the tendency of the viscera is to fill the vacuum previously occupied by the uterus. The abdominal walls are lax and thin from uterine pressure. The accoucheur is often to blame for not properly supporting the relaxed abdomen. Tapping of ascites, with removal of all the fluid, may produce a similar condition; or removal of large tumors. One occasionally finds gastroptosis in women who have become obese, especially after several parturitions, the abdomens are pendulous and the musculature soft and flabby. The treat- ment of these cases differs considerably from that from the other causes. Sex. Meynert found in 50 girls, aged twelve, 50 per cent, gastroptosis, and about 80 per cent, females in his gynecologic clinic to 5 per cent, males among adults. From the study of various statistics it can be estimated that from about 20 to 25 per cent, of women complaining of digestive disturbances are affected with movable kidney and enteroptosis. Unquestionably the percentage of gastroptosis among all women, including those who complain of no symptoms, will average at least 15 per cent, in our city population. The advocates of nephropexy find nephroptosis, disregarding the other ptoses, in 20 to 33 per cent, of all women, a satisfactory surgical viewpoint. The improvement following promiscuous nephropexy in gastro-intes- tinal and other symptoms can be often imputed to the post-operative rest in bed and to the increase in fat by proper feeding. The ratio of males complaining of digestive disturbances, with entero- ptosis and nephroptosis, is about 2 to 3 per cent. The ratio in women is 8 or 10 to one male. Glenard finds a lower ratio, 70 women to 30 men in 100 cases. Age. -The most frequent age is from eighteen to forty, though between fifty to sixty the condition appears most marked. Symptoms. Gastroptosis may exist without the production of any symptoms; while on the other hand, it may be present with those of a mild character, or may finally present the aggravated type of Glenard. The following symptoms, in part or whole, may be present: Some cases complain chiefly of nervous, cardiac, gastro-intestinal or pelvic disturb- ance, or of special organs, such as the kidney or liver. 1 N. Y. Med. Jour., Dec. 19, 1914. 448 DISEASES OF THE STOMACH AND INTESTINES There are usually anemia, a feeling of weakness, dizziness or faintness and fatigue on slight exertion and backache. The appetite in some cases is poor, while in others quite good. Some patients have the symptoms-complex of hyperchlorhydria, while others complain of belching and discomfort immediately after eating. There are usually marked and obstinate constipation, rarely diarrhea; at times intestinal catarrh or mucous colic. Flatulence is present. They have headache, are frequently nervous and hysteric, and at times neuras- thenic and are irritable or mentally depressed. There is often a feeling of weight or bearing down in the abdomen, which is relieved by proper sup- port. Menstrual disorders are frequently present, dysmenorrhea quite often. At times the pain and discomfort are focused in the kidneys, especially the right; and in addition they may have attacks of Dietl's crisis. Pains in the region of the liver and gall-bladder occur in some, and there may be attacks of pain resembling gall-stones and occasional jaun- dice, or rheumatic, or neuralgic pains, or pains in the coccyx, breast or heart region. There mav be irritability of the bladder, with frequent Fig. 216. Abdominal projection; lead-tape outline between anterior superior spines; curved line, when standing; flat line, when lying on back (from Gallant). inclination to urinate, and pains or tenderness in the ovaries and appen- dical region. Various sensitive points are often found in other regions of the abdomen. Paresthesia or hyperesthesia may occur as may areas of anesthesia. There are sensory or vaso-motor disturbances in others. Palpitation is frequently present and occasionally attacks of tachycardia may occur. Slight cases of gastroptosis may even give symptoms pointing to the entire gastro-intestinal tract. For example, Miss H. V. EL, age twenty-eight, referred to me by Dr. Wm. Posey of Philadelphia, com- plained chiefly of poor appetite, coated tongue and diarrheal attacks (three to four movements daily), followed by constipation. Systolic pressure 140, high for that age, and evidences of intestinal putrefaction in the stool and urine. There was slight motor insufficiency of the stomach, but no residuum showed in the radiograph six hours after the barium meal. The gastric analysis was within normal limits, but on the border of excess for the individual: Total acid 60+ ; free Hcl 34+; comb. Hcl 22 + ; acid salts 4+; no occult blood. X-rays, slight gastroptosis; no retention of barium meal at six hours; ptosis of the hepatic flexure of the colon, with sharp angulation, no adhesions. Heart and lungs were normal. Immediate relief was afforded to the .bowel condition, by Rose's belt and subsequently by correct corsets, evidently by elimination of the angulation. I imputed more to this than to the simple medication ordered. The increase in pressure was attributed to the indicanuria (in- GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 449 testinal putrefaction), so red meats were abolished. Iron tonic was administered for the anemia, etc. Physical Examination. Inspection. These patients are usually thin and slender; the abdominal walls are generally flaccid. The angle formed by the ensiform and lower margins of the thorax is sharp (very acute) in the congenital cases, with a long narrow thorax. The form of the patient is angular and the muscles are thin. There is a concavity be- tween the costal arches in the epigastrium from the ensiform to the umbilicus; and in some a vertical median sulcus between the recti muscles wider above than below. In the dorsal position the abdomen may be flattened below and bulge laterally; and when the patient is erect the epigastrium becomes more depressed; while the hypogastric regions from the umbilicus to the sym- physis and the pubic region markedly bulge forward and outward (pot- belly). Fig. 216 shows this clearly. Palpation. Diastasis (separation of the recti muscles) can be readily appreciated. Stiller's floating tenth rib is present in some cases (the congenital). Marked pulsation of the abdominal aorta is often met with as it is uncovered by the stomach. Movable kidney of varying degrees can be readily appreciated, and this, taken in connection with the splashing sound found below the normal position of the lower border of the stomach, is pathognomic of gastroptosis. The corde oblique transverse is generally found to be the pancreas, which may also prolapse. Splashing Sound. This is the best method to determine the lower border of the stomach and has been thoroughly described. If no splash can be originally detected, create it artificially by giving water, or, if required, add a little Vichy, or tartaric acid and sodium bi- carbonate. Inflation of the stomach with air or CO 2 will settle doubtful cases, as the upper border is then to be seen on inspection, and percussion is an aid. Gastrodiaphany is an accurate method, but usually unnecessary. Percussion. There is at times dulness or flatness in the epigastrium when the stomach is markedly depressed, the liver descending in such cases. It is difficult to differentiate by simple percussion unless CO2 dis- tention has also been employed. The scratch method is of assistance. Gastric Secretion. Examination of the Gastric Contents. Ewald's test- breakfast should be employed and gastric analysis made in every case. Hyperchlorhydria, hypochlorhydria, achlorhydria, or, more rarely, achylia gastrica (functional) may be present. Rarely the secretion is normal, and then usually in the cases found accidentally, presenting no symptoms. I agree with George R. Lockwood to this extent, that in many cases no evidences of fermentation can be found on test, and the gas also may be odorless. In hysteric women some of the air is swallowed. On the other hand, in some patients with associated marked dilatation (the latter probably being primary), such as I have seen among the nervous and insane at the Manhattan State Hospital, marked fermentation has been found. The treatment is modified by the gastric findings. It is evident, in some cases, that the secretory conditions are influenced by the misplace- 29 450 DISEASES OF THE STOMACH AND INTESTINES ment, since Graham-Rogers, at the Ward's Island Clinic, found that in four out of seven cases (six of hyperchlorhydria and one of hypochlor- hydria) improvement followed the use of Rose's belt 1 alone, without medication or special diet. Motor Functions. Motor insufficiency 2 is undoubtedly present in some cases. This is particularly true in the water-trap or fish-hook type of gastroptosis. On the other hand, many cases exist with few or any gastric symptoms, and though there is relaxation of the musculature of the stomach, compensation takes place probably by relaxation of the py- Fig. 217. Slight gastroptosis. Fig. 218. Gastroptosis. loric ring, so that the contents of the stomach enter the intestine within the normal limit of time. Per contra on some occasions, or from some cause, this compensation may fail and then symptoms develop. Motor functions appear only slightly diminished in other cases, or even normal, as just explained. This is the probable explanation for those cases which have existed for years without symptoms and in whom they suddenly develop. Stomach and Small Intestine. Gastroptosis may occur in various forms and degrees, semi-oblique of different degrees, looped, or, more rarely, crescentic, and even the vertical stomach (Figs. 217-221). In some cases we may have primary dilatation and then ptosis. These illustrations represent gastrodiaphany of various cases. Radiographs will be given shortly. 1 Rose and Kemp, Atonia Gastrica, p. 124. 2 Ibid., p. 79. GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 451 Mainert and Holzknecht 1 point out that gastroptosis is always ac- companied by lengthening of the stomach. Bonninger holds that the Fig. 219. Vertical stomach. Fig. 220. Vertical stomach (extreme). lengthening can be demonstrated by the #-rays and is brought about by a longitudinal growth of the body. As far as I can determine, from physical examination, post-mortem, Fig. 221. Crescentic form of gastroptosis. and operative cases, especially in the marked semi-oblique or particularly in the vertical stomach, there seems to be a straightening of the pyloric curve and some dilatation of the pyloric end and of the duodenum, probably with 1 Med. Press and Circular, Feb. 23, 1910. 452 DISEASES OF THE STOMACH AND 'INTESTINES relaxation of the pylorus. The supports of the duodenum are relaxed and it crosses the spine at a lower level. I believe there is some relaxation with descent of the pancreas, and also relaxation of the mesentery and descent of the rest of the small intestine. I pvn m sro c H HOURS AFTER BIMOTR iEH FIG. 222. FIG. 223. Fig. 222. Gastroptosis. Stomach very low + S. FIG. 223. Residuum six hours later with indentations in organ from adhesions. Enteroptosis marked. Agglutinated mass of intestine in pelvis. Bismuth enema not 'yet given. FIG. 224. Enteroptosis marked with adhesions at S, a six-hour residuum in stomach. FIG. 225. Agglutinated mass of in- testine in pelvis. Same case as Fig. 224. The duodenal distention in some cases is to be expected from gravita- tion of the stomach contents, and as there is relaxation of the mesentery I believe the so-called "chronic mesenteric traction" with dilatation of GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 453 the duodenum as a result, producing symptoms does not occur very frequently. Gastroptosis should favor acute dilatation of the stomach, on the mesenteric traction theory, but I have never seen such a condition asso- ciated with acute ectasy. The questions of the relative motility of the different types of ptosed stomachs with duodenal distention (dilatation) with enteroptosis and gas- troptosis and the motility of the small and large intestines are all of great interest in this connection. One may have various shaped normal stom- Fig. 226. Vertical stomach. Slight descent. Slightly cow-horn. Found empty in six hours. Moderate" enteroptosis found with this case. achs the text-book, fish-hook, water-trap and cow-horn as described by Cole. I believe that the fish-hook and water-trap type of stomach are more likely, from their conformation, to become atonic and retain their contents and proportionally more readily prolapse. The degree of duo- denal prolapse occurring with enteroptosis has undoubtedly a bearing. Fortunately nature is usually an excellent compensator and though the stomach may in some cases empty rapidly and somewhat distend the duodenum (one explanation of this condition), yet rapid peristalsis of the small intestine and the presence of liquid contents overcome the obstacle. One must remember two characteristics of the small intestines, first, rapid motility and second that quite marked stenosis of the small intestine, more 454 DISEASES OF THE STOMACH AND INTESTINES in proportion than can occur in the large intestine, is necessary before the liquid contents are interfered with in their passage. With the fish-hook and water-trap type of stomach the writer has noted in gastroptosis cases, the most marked bismuth retention after six hours. He has seen patients with vomiting, pain suggestive of ulcer, etc., rapidly improve and the symp- toms gradually disappear after proper abdominal support particularly Rose's belt has been supplied and correct treatment instituted. The severe types of drain-trap stomach the stomach with long pyloric arm, described by Satterlee and LeWald do occur and may very rarely re- quire suspension operation, but the writer's experience teaches him that Fig. 227. Gastroptosis. Deep incisura showing active motility (cow-horn). empty in six hours. Found operation is usually unnecessary. It is remarkable to what extent the small intestines may prolapse and yet the peristalsis be excellent, in which connection radiograph (Fig. 230) is worthy of notice. Stasis seems to occur most frequently in the colon, where normal peristalsis is slow and where angulations will most readily interfere with the passage of solid feces. This does not correspond to Lane's theories. Unquestion- ably kinks and adhesions may interfere with the passage of contents in the small intestine, but they must be fairly severe to produce interfer- ence with fluid contents. In radiographs 222-230 are depicted an in- teresting series. In Fig. 231 is a severe case of gastroptosis of drain- GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 455 trap type. The writer during a lengthy experience has treated many cases of this worst type of gastroptosis (water-trap) with vomiting and retention both marked and has secured excellent results never as yet having to resort to surgical procedure (suspension). In a few cases with adhesions, these have been freed, but no suspensory operation was performed. Large Intestine. Enteroptosis. The degree of enteroptosis varies and there seem to be almost numberless types with many varieties of angula- tions. Descent of the transverse colon is most common (Fig. 232); it can be demonstrated by inflation with air or water, or with bismuth and Fig. 228. Fish-hook stomach. Vertical gastroptosis. at the end of six hours. Some retention was shown .v-rays, and they help in differentiating between cases of redundant sig- moid, transverse colon of exaggerated length, and displaced and angulated flexures which may on rare occasions require special operation. Movable cecum occurs quite frequently with enteroptosis and presents at times symptoms suggestive of chronic appendicitis. Undoubtedly there may also be relaxation, with changes in the position of the sigmoid (see Fig. 233) or even of the descending colon. I have seen a case of this type recently. Nephroptosis. It seems important to further discuss this condition, though I have already described many of its features. Movable kidney from traumatism or straining, and the congenital floating kidney with a 456 DISEASES OF THE STOMACH AND INTESTINES long mesonephron, constitute, I believe, a comparatively small percentage of all cases in my own opinion, about 5 per cent.; while Meynert places them at 10 per cent. The balance are concomitants of enteroptosis (gastroptosis). It is most common on the right side. Einhorn, as well as many other authors, recognize movable kidney as an essential symptom of enteroptosis. Nephroptosis occurs at least six or seven times more frequently in women than in men. Nephroptosis exists in about 15 per cent, of all women examined, as- sociated with gastroptosis; but in many cases no symptoms are present. Fig. 229. Water-trap stomach. Gastroptosis with some dilatation. No worse judgment can be shown than to tell a patient that she has a movable kidney. Edebohls finds it in 20 per cent, of his cases, disregarding associated ptoses, and some even place it at 33 per cent. The normal kidney is slightly movable during respiratory movements. The most accurate method of kidney palpation I have already described. Glenard classifies four degrees of movable kidney: First Degree. The lower pole of the kidney is palpable on deep inspira- tion and slips back on expiration. It cannot be arrested. Second Degree. The body of the kidney can be palpated and arrested, but not the upper border. GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 457 Third Degree. The superior border of the kidney can be palpated. Fourth Degree. The entire kidney is palpable and it may be found in various regions of the abdomen, near the gall-bladder or as low as the ap- pendical region. I have already referred to the various symptoms attributed to movable kidney, such as dilatation of the stomach due to pressure on the duodenum; jaundice; gall-stone symptoms or stasis with the production of stone; Fig. 230. (Same case as 229.) Six hours after bismuth meal. Residuum in stomach. Note that the small intestines have rapidly emptied, showing excellent motility. Note furthermore the bismuth has passed rapidly into the large intestine as far as the splenic flexure. The entire colon is markedly ptosed. Constipation marked. This patient suffered chiefly from nervous symptoms, headaches, mental depression, poor memory. Hyperacidity moderate. Evidently stasis not present in small intestines. gastro-intestinal and pelvic disturbances; chronic appendicitis as a result of congestion from compression of the superior mesenteric vein against the pancreas and spine (in 20 per cent, of cases, according to Edebohls). All these symptoms are referable to splanchnoptosis. Goelet believes that in 75 per cent, of nephroptosis of the third degree, or beyond, there is a pyelonephritis or interstitial nephritis. In 20 cases of nephroptosis of the third degree or more (with entero- ptosis) at the Manhattan State Hospital, I requested LeRoy Broun to examine the gynecologic conditions, and in no case could' any connection be found between the prolapsed kidney and the genital organs. The late 458 DISEASES OF THE STOMACH AND INTESTINES Ferd C. Valentine 1 and Terry M. Townsend, as a check, made special examinations of the genito-urinary tract and urine, but found no evidence of nephritis or pyelonephritis in these 20 cases. Such examinations should not be made immediately after palpation, as Menge demonstrated that albuminuria appeared directly thereafter. Schreiber 2 showed this in 39 out of 42 cases examined within ten to fifteen minutes after palpation, and that it sometimes lasted hours. Renal epithelium, red and white cells, but no casts were found. He believes it DNFMATOGR0H UMBILICUS PRONE IMMEDIATELY AFTER BARIUM WEAL 3006 B SINCLAIR TOUSEY MD FIG. 231. Gastroptosis (drain- trap type) with tubular ascending duodenum at +. Type with motor insufficiency and vomiting. Treated by Rose's belt, diet and medication; forced feeding. No operation. Author's case of severe type. will furnish a method of differential diagnosis, as if, on palpation of a doubt- ful mass, this condition occurs, it will prove to be kidney. Of course, nephritis or pyelonephritis may occur in some cases; and after differential ureteral catheterization, if both kidneys are prolapsed, nephropexy is indicated in the diseased prolapsed organ. Hydronephrosis, or adhesion of the kidney to the appendix or gall- bladder, may also occur occasionally. In some cases more marked or severe symptoms may be attributed to the movable kidney: 1 Kemp, Amer. Jour, of Urology, Jan., 1906 2 Zeitschrift fur klin. Med., vol. Iv, No. 3. GASTROPTOSIS ENTEROPTOSIS GLENARD S DISEASE 459 (1) There may be a weight or special feeling of traction on that side, increased on standing or walking, and lessened in the recumbent posture. (2) The kidney may be increased in size, tender on pressure, and there may be pain and tenderness in the lumbar region, frequent urination, and burning headache. (3) Dietl's crisis, probably due to torsion of the pedicle, will produce severe abdominal pain, chills, nausea, vomiting, fever, and even collapse. The urine may be high colored and blood be present. Abdominal support should first be tried systematically in these conditions before operation is advocated. Floating Liver (Movable Liver). Osier claims that on a considerable number of cases there is a mistaken diagnosis. One anomaly is the tilting forward of the organ, so that the anteroposterior axis becomes vertical Fig. 232. Enteroptosis. and not horizontal, and a considerable part of the surface of the right lobe is in contact with the abdominal wall. In one type of lacing liver, the anterior part of the right lobe is greatly prolonged, a shallow transverse groove separating it from the rest of the organ. A slight grade of mobility (floating liver) is found in enteroptosis, but the cases reported are comparatively few. In some cases the upper surface may lie below the costal margin. G. E. Graham has collected 70 cases. The condition is rare in men. In some cases of enteroptosis with hepatoptosis, the symptoms may be fairly marked in the liver, there being pains in the hepatic region radi- ating toward the back and at times of a tearing character. There may be some local tenderness and attacks similar to hepatic colic, though usually no jaundice. Einhorn 1 described several groups of cases, dyspeptic asthma among 1 Med. Rec., Sept. 16, 1804. 460 DISEASES OF THE STOMACH AND INTESTINES them, but from my own point of view this condition seems to be a part and parcel of the general syndrome "enteroptosis," with marked local symp- toms, such as pain or colic, in some cases. In extreme cases the liver may drop down so that the upper surface is below the costal margin. Gall-bladder. In cases of marked gastroptosis, gall-bladder symp- toms simulating biliary colic at times occur. With the descent of the stomach and associated torsion, or descent of the duodenum, there is probably interference witfy the passage of the bile. It is interesting to note that after proper abdominal support of the prolapsed organs, the Fig. 233. Ptosis of sigmoid flexure. symptoms of gall-stone colic will disappear. E. Gallant reports a number of cases. Cardioptosis. In my own experience, ptosis of the heart is present only in marked cases of splanchnoptosis, especially where there is skeletal deformity. Einhorn finds it associated with floating liver. The latter is more frequently a concomitant of skeletal deformity, I believe, and hence the two conditions are associated. Movable Spleen. Movable spleen may occur from below the rib even into the pelvis. There may be dragging pains in the side, torsion of the pedicle, swelling of the organ, with pain and fever associated. Diagnosis. Curiously enough, the majority of writers pay chief at- tention to nephroptosis, refer to the stomach as dilated (a result of kidney GASTROPTOSIS ENTEROPTOSIS GLENARD'S DISEASE 461 pressure), and do not differentiate between gastroptosis and dilatation of the stomach. It is the position of the upper border which determines ptosis, but the following symptoms will usually settle the diagnosis. The peculiar conformation of the abdomen heretofore described, the separa- tion of the recti, movable kidney, and the determination that the lower border of the stomach is abnormally low, are sufficiently diagnostic of gastroptosis. Inflation or gastrodiaphany may be used in disputed cases to settle the question. The #-rays are also of great value for this purpose. Glenard's "Belt Test." If one stand behind the patient and, en- circling him with the arms, lift up and support the lower protuberant ab- domen, and this gives relief, it suggests enteroptosis. X-rays. The diagnosis of gastroptosis can be made without the use of the #-rays. I prefer their employment as one secures an excellent idea as to existing conditions, can diagnose angulations and adhesions if present, and can give an exact prognosis. The patient is convinced as to the cor- rectness of the diagnosis and the necessity of following the treatment. Radiographs of the stomach directly after the bismuth meal and six hours later; also after a bismuth enema with the patient standing should be taken. Healy's method should then be employed, i.e., the patient placed five minutes in the knee-chest position, then turned over and radio- graphed in the Trendelenburg posture or Tousey's modification, the belly Trendelenburg. This determines the mobility of the intestines and the degree and location of adhesions if present. Prognosis. The cases of congenital type with funnel thorax or other skeletal deformities are the most unfavorable to treat; but even in these much can be done. The acquired type presents a favorable prognosis as to absolute cure, though some tend to relapse if continuous care, as to regulation of mode of life, exercise, and diet, is not kept up. I have seen a number of cures, as has every other observer. Treatment. Prophylaxis. Much can be done to prevent the acquired type of gastroptosis. Improperly made corsets compress the thorax or waist. Tight lacing and the use of tight bands around the waist are productive of ptosis. These should be avoided. In my opinion, most of the Landau (postpartum) cases of splanch- noptosis are absolutely preventable, the fault frequently being due to the physician in attendance, the patient's abdomen not being properly sup- ported, and she also being allowed to leave the bed too soon. There is a marked thinning and weakening of the abdominal wall during pregnancy, and after delivery immediate attention should be given to its support. For several years Douglas H. Stewart, of New York, has been employ- ing as a routine postpartum method of support (at my suggestion) Rose's plaster strapping, reinforcing it with lateral soft-rubber strips (an idea of his own;. He states that it supports the organs perfectly, prevents abdominal relaxation, and enables the patient to sit up in bed earlier, with resulting improved drainage of the uterus, and to be about at an earlier period. Bassler 1 treats of the necessity of abdominal support after confinement, 1 Prophylactic Measures Against the Development of Landau Cases of Visce- roptosis, Therapeutic Gazette, Sept. 15, 1907. 462 and describes methods of strengthening the abdominal muscles and the value of forced feeding. Treatment of Existing Gastroptosis (Splanchnoptosis). There are three chief principles involved: (1) The support and strengthening of the abdominal muscles, which also increase infra-abdominal pressure. (2) The increase of intra-abdominal pressure, by reducing the volume of the abdominal cavity through accumulation of fat, and thus lifting up the stomach. (3) Correction of the gastro-intestinal disturbances and the toning up of the nervous system. (i) Abdominal Support. The selection of a proper apparatus for mechanical support to the abdominal muscles, which at the same time will increase intra-abdominal tension, is the first indication. I have employed, by preference for some time past, adhesive plaster strapping in the form of the belt devised first by Achilles Rose. I have already referred to the superiority of moleskin, first suggested in this coun- try by me after numerous experiments. The Z. O. type should be used by the method already described. The support afforded is continuous, Fig. 234. The proper way of adjusting the corset (after Gallant). should never be kept on over three to five weeks, and on signs of loosening, a new belt should be applied; the patient, between belts, taking a full bath and employing talcum powder over the surface during the twelve to twenty-four hours' intermission. My longest case wore the belt four- teen months, winter and summer, it being reapplied every four to six weeks, with a gain of 44 pounds and perfect cure. Some of the other types of adhesive strapping belts may be employed if the wide plaster necessary for Rose's belt cannot be procured. Pressure is exerted by the belt, from the symphysis to the umbilicus in front, the intestines are forced up, and hence the stomach; and the increased pressure aids in holding back the kidneys. Next in value to adhesive plaster is the Gallant corset, which also exercises upward pressure and support below, and is loose above. The method of its application is shown in Fig. 234. The La Grecque corset (Van Orden's), recently devised, is an excellent appliance. It well supports the spine and pelvis, is made in a single piece behind, and is subdivided in front, as in Fig. 235, A. In Fig. 235 > B, is shown the corset after application. It should be applied in the dorsal GASTROPTOSIS ENTEROPTOSIS GLENARD's DISEASE 463 position, like the Gallant corset. The pressure is exerted like Rose's belt, from the symphysis to the umbilicus, and it is loose about the thorax and upper abdomen. Of late I use the adhesive strapping for several months and then follow it with the Van Orden corset. The indications are the same as for Rose's plaster. In Figs. 236 and 237 is demonstrated by x-rays the stomach and colon before and after the application of the corset. The raise was only slight i inch in this case. If the patient will not consent to these methods, the silk abdominal bandages,, as previously illustrated, are useful. In male cases Rose's belt and, later, the silk belt are indicated. Lane's leather abdominal sup- port is excellent. A B Fig. 235. La Grecque corset: A, Lower segment of corset; B, corset after adjustment. Supports formed with pads for special organs are unscientific. Kilmer's belt, drawn snug below and lax above, or the Van Valzah- Hayes belt can be employed. Exercise. Massage. Gymnastics. There are marked inconsistencies in many of the recommendations as to active exercises, flexion, and ex- tension of the body by elevation of the legs, gymnastics, etc., to strengthen the abdominal muscles. There is no better way to take off abdominal fat and to reduce omental fat than by these means; and in the cases with marked weight reduction it is impossible to put on fat if excessive exercises are employed. 1 In moderation and properly directed, they are of service later when the weight has been increased. Driving or moderate walks in some cases are useful. 1 In the cases of ptosis due to excessive fat production, with relaxed muscles, active exercise combined with abdominal support are indicated. 464 DISEASES OF THE STOMACH AND INTESTINES Massage. On the other hand, gentle abdominal massage and often general massage of mild type, taken several times a week, will improve the muscular tone. The use of light cannon-ball massage of the abdomen, taken five minutes once or twice a day, or mild vibratory massage, at home in bed, with a good vibrator, I have found of service. In the severe type of case, absolute rest in bed for three to six weeks with the Rose's belt applied, forced feeding, and mild massage, etc., give the best results; and if the patient is very much prostrated I omit massage at first. 2. Increase of Abdominal Pressure through Diet by Fat Accumulation. Diet. There are certain general principles we must follow: M Fig. 236. Without corset. (Courtesy of Van Orden Co.) If there is hyperchlorhydria, plenty of albuminous foods and fats (the calories being made up by butter and cream), should be given. Diminish starchy foods, order frequent feedings, avoid acids, spices, and alcohol. Often alkalis are required. If hypochlorhydria or achylia, little meat and abundance of carbohy- drates and fats, with dilute hydrochloric acid, stomachics, etc. Not more than 8 ounces (250 c.c.) of fluid should be taken at a time and thorough mastication of the food should be enjoined. If the case is not confined to bed, a rest of fifteen to thirty minutes after each meal, if possible, is advisable. The patient should take the three chief meals daily at 8.00 A. M., ) i.oo P. M., J- with intermediate feedings at 6.30 P. M., J 10.30 A. M., 3.30 P. M., and often at 9.30 P. M. GASTROPTOSIS ENTEROPTOSIS GLENARD'S DISEASE 465 John Russell's method, as employed in tuberculosis, is of value in some cases. The foods especially of use to increase weight and which can be employed for the interval feedings are: Milk, raw eggs, i ounce (30 c.c.) cream in 8 ounces (250 c.c.) milk, koumiss, matzoon, bacillac, lactone-buttermilk and crackers or bread with plenty of butter. I have given butter up to, half-pound and cream 3viii daily in addition to the other food. Raw eggs can be given, beaten up in milk. It is well to start with one or two daily, and increase gradually to six or eight per day. They possess considerable value. One could give, for example, at the intermediate feedings: 10.30 A. M. Milk, 5 v iij ( 2 5 c - c -), with 2 raw eggs. 3.30 P. M. Koumiss, 5viij ( 2 5 c.c.). 9.30 P. M. Same as at 3.30 P. M., or milk with cream, and vary the methods. Fig. 237. With corset. (Courtesy of Van Orden Co.) Two soft-boiled eggs can be given for breakfast. Green vegetables and raw or cooked fruits should be given for constipa- tion, depending on the gastric conditions. Strict attention to the bowels is imperative. I have seen the stomach elevated 3 or 4 inches by the increase of fat. 1 Electricity. In the ambulant cases, the use of static electricity will prove of service with some patients to improve the general muscular tone, or it may be employed after the rest cure has been completed. The ex- ternal application of galvanic or faradic electricity I have used with good results in some cases, but I never remove the belt. Intragastric faradization has been recommended to improve the atony of the stomach, and galvanization for the pain. I have had patients x On the other hand, fat reduction is indicated in the rare cases of adipose with gastroptosis. The method is described under "Obesity." 3 466 DISEASES OF THE STOMACH AND INTESTINES bitterly complain of the intragastric method; one case notably had beer, treated thus systematically, with increasing nervous symptoms being pro- duced and marked nausea, stating she was worse after each treatment. The simple method of external application seems to me advisable in those cases. Massage of the Kidney. Several methods have been recommended for treatment of the painful movable kidney. The operator, sitting on the side of the kidney to be massaged, places the left hand (if it is the right kidney) on the lumbar region, so that the organ rests on the finger, the thumb being supported by the ribs. With the finger-tips of the right hand he pushes on the kidney from in front and gently kneads it. Brandt places the patient in the lithotomy position, and, having re- placed the kidney, places both hands in front under the margin of the ribs, and makes vibratory movements backward and upward, allowing the finger-tips to slip around to the back. The patient aids in securing this position by lifting his buttocks. As palpation alone -will cause albuminuria, I do not approve of these methods, but merely refer to them. It is sufficient to replace the kidney. Elevation of the Foot of the Bed. This method may be employed in those cases taking the rest cure who do not wear an abdominal support continuously. Elevation of the buttocks may be substituted. They are unnecessary when Rose's belt is employed. Iron and arsenic are indicated in all cases, such as Iron tropon, 3j (4-o), t.i.d.; or Fowler's solution of arsenic, TTliij to v (0.177-0.296 c.c.), t.i.d., or any good combination of iron and arsenic. An excellent pill is Blaud's iron, 5 grains (0.3), in which sodium arsenate, Ho to > grain (0.00108-0.0021), has been incorporated. If no hyperchlorhydria is present, strychnin, % to ^ grain (0.00108- 0.0021), can be included. Hyperacidity should be treated with the alkalis. Hypo-acidity with nux, strychnin, hydrochloric acid, and stomachics. Bromid, 10 grains (0.6), or veronal, 5 to 7^ grains (0.33-0.5), sulfonal, 10 grains (0.6), or trional, 10 grains (0.6), are valuable for sleeplessness, given an hour before retiring. Midonal, 5 grains (0.3), is useful. Eydrotherapy. The Scotch douche, one to two minutes over the ab- domen, in convalescent cases has rendered service. The patients with much adipose, with relaxed abdominal muscles and gastroptosis require different treatment; a silk supporting belt for the abdomen, weight reduction by diet and active exercise, and par- ticularly strengthening of the abdominal muscles by flexion and exten- sion movements of . the abdomen. One sees the type occasionally to which I refer under Etiology. The Priessnitz compress aids to relieve pain. A glass of cold water, Vichy or Carlsbad, on rising helps the bowel action. DieWs Crisis. Apply heat to the kidney; employ fluid diet; elevate the food of the bed; replace the kidney. GASTROPTOSIS ENTEROPTOSIS GLENARD S DISEASE 467 Codein, y to ^ grain (0.016-0.022), or morphin, y% to y grain (0.008- 0.016), may be required, by hypodermic. Constipation. Olive oil enemata; cascara; compound rhubarb, purgen, and regulin, 1 if required, are excellent. Russian mineral oil or American mineral oil, 5 ss A. M. and p. M. is my favorite remedy. Complications, such as mucous colic or catarrhal colitis, must be ap- propriately treated. Surgery. In splanchnoptosis, if all medical treatment after a year conscientiously applied prove a failure, suture of the recti (abdominis) and thus tightening of the abdomen, as advocated by Robert T. Morris and by Charles Codman, 2 is the most scientific procedure. c w Fig. 238. Beyea's operation; suture of the gastrohepatic omentum to secure elevation of the stomach in gastroptosis. The first layer of sutures completed, the second and third being introduced (Moynihan). If there are nephritis, pyelonephritis, or intermittent hydronephrosis confined to the prolapsed kidney, then nephropexy is indicated. After repeated attacks of Dietl's crisis, when medical measures afford no relief, nephropexy may be advised. Hydronephrosis or pyelonephritis may be of such a character as to require nephrectomy. Operations on individual organs except, as noted below, I am opposed to unless there be marked gastric dilatation with the ptosis, and a year's treatment affords no relief. Occasionally a redundant sigmoid may require sigmoidopexy, or it may be necessary to hitch up an angulated colon or a ptosed cecum. Shortening of the lesser omentum (plication), and thus elevating the 1 See under Constipation for other remedies. 2 Med. Rec., Oct. 19, 1907. 468 DISEASES OF THE STOMACH AND INTESTINES stomach, as devised by Beyea 1 is depicted in Fig. 238. When these sutures are drawn and tied, the stomach is elevated into its normal position. Gastroplication, shortening of the lesser omentum, attaching the lesser curve of the stomach to the abdominal wall, suture of the transverse colon to the abdominal wall, sewing the greater omentum to the abdominal wall, have all been recommended. Gastro-enterostomy may be indicated in gastroptosis with ectasia and marked fermentation which does not respond to medical treatment. The spleen has been stitched up, or removed if inflamed. Duodena -enter ostomy has been advocated by Byron Robinson, but I see no indication for it. Elliot 2 recommends anchoring the liver In hepatoptosis. In rare cases, gastroplication, with shortening of the lesser omentum ; or the latter, with gastro-enterostomy, might be necessary. Author's Experience with Surgery. In many of these cases of Gle- nard's disease, veils or adhesions are present. As a rule I do not advocate operation upon these, unless persistent constipation (intestinal stasis of an obstinate character) continues and medical treatment with the use of forced feeding and proper mechanical support fails to afford relief after a reasonable trial of six months. In such event, separation of adhesions or veils, I have had performed in several cases. Quite frequently tender- ness at McBurney's point is in evidence, a slight appendical catarrh secondary to the enteroptosis, particularly when mobility and misplace- ment of the cecum, with resulting intestinal stasis, are present. I have seen a number of these cases relieved by Rose's belt and the usual treat- ment for gastroptosis all the symptoms disappearing. On the other hand, if medical treatment affords no relief, after several months trial, I have had appendectomy performed and simple anchoring of the cecum, with excellent results, the usual mechanical support and treatment of the enteroptosis being then carried out to a successful issue. On one occa- sion, a case of enteroptosis, with persistent catarrhal colitis, and marked prolapse of the sigmoid, as medical treatment afforded no results; the sigmoid was suspended by my advice with cure of the colitis. General treatment for the enteroptosis was continued after operation. On several occasions I have had bands passing to the ileum (producing the ileal kink) cut by the surgeon, when the constipation could not be relieved. On one occasion, the stomach was gastroplicated and suspended with bad results (a fatality). Special correction of complications, as herein men- tioned may occasionally require some surgery and that rarely. For example these few experiences occurred among a large number of cases of gastroptosis not less than 500 in number. Suspension of the stomach or colon (transverse) should rarely be required. I have yet to see a case of enteroptosis that required the dangerous resection operation, in my opinion. 1 Jour. Amer. Med. Assoc., March 5, 1910. 2 Med. News, Nov. 12, 1904. CHAPTER XVII NERVOUS AFFECTIONS OF THE STOMACH GASTRIC neuroses may be defined as functional disturbances of the stomach without any discoverable anatomic basis, there being no organic lesion of the organ. Etiology. These cases have either inherited a nervous constitution, or, through indiscretions, have brought about a condition of nervous prostration. Sometimes the gastric disturbances have apparently a reflex origin, depending on disturbances in remote parts of the body, as in the sexual organs, appendix, eyes, etc., and these factors must always be searched for. For example, as a reflex from appendicitis, we may have hyperchlor- hydria with or without hypersecretion, pylorospasmus, hypochlorhydria, excessive vomiting, achlorhydria hasmorrhagica gastrica (symptoms of chronic gastritis accompanied by hemorrhage apparently from erosions), and apparently symptoms of gastric ulcer. Graham 1 and Guthrie cured 89 out of 115 patients with gastric symptoms by appendectomy, and se- cured improvement in 20 others. They are divided into sensory, motor, and secretory neuroses, and may appear separately or in combination. They occur most frequently in women from puberty to menopause, and quite frequently at these special periods. In men they appear most often during middle life and most frequently in the higher classes. There is probably a predisposition to the condition. Worry, extreme mental exertion, excesses, and excitement may be predisposing factors. Organic lesions of the stomach must be excluded. Classification. Neurosis of the stomach may present the appearance of some primary disease, or may be one of the symptoms of hysteria or neurasthenia, or may be a reflex symptom due to disease of some other organ. In cases of this last description, though there is no organic change in the stomach and the disturbance in this organ is purely reflex, there is an ana- tomic cause elsewhere. They should, strictly speaking, be differentiated from the pure gastric neuroses, since treatment of a distant diseased organ may cure an apparently pure gastric neurosis. This emphasizes the neces- sity of thorough examination. Vagotonia, or sympatheticotonia, or the mixed condition may be. responsible for cases previously believed to be gastric neuroses. See the section on these conditions. Pure gastric neurosis I believe rare. Peculiarities. Generally the nervous system shows more or less devia- tion from normal conditions. Leube and Boas have probably best de- scribed the condition. There are headache, mental depression, lack of energy; at times fear, palpitation, dyspnea, and sweating. On the other 1 Jour. Amer. Med. Assoc., March 19, 1910, p. 960. 469 47O DISEASES OF THE STOMACH AND INTESTINES hand,, there may be excitement and sensitiveness. There are an increase or diminution of reflexes, local hyperesthesia, paresthesia, or anesthesia. Polyuria may or may not be present. Some patients remain in compara- tively good condition, while others emaciate. The digestive disturbances are usually independent of the quantity and character of the food, and are not always connected with the act of diges- tion. Errors in diet are often not followed by an exacerbation of the symptoms, and sometimes they occur when the simplest food has been taken. The gastric secretion and motor functions are often variable. We may find hyperchlorhydria at one time and normal secretion at another, or, conversely, normal conditions may alternate with hypo-acidity or anacid- ity. At times the motor functions may be normal, at others, diminished. TJie condition of the bowels also varies; there may be constipation al- ternating with diarrhea; or the bowels may be regular and a sudden diar- rhea appear. Climate and surroundings may influence the condition. SENSORY NEUROSES OF THE STOMACH There may be abnormal sensations more or less general in character external to the stomach, such as regarding hunger, appetite, or abnormal sensations within the stomach itself. Among the abnormal sensations of appetite are bulimia (or canine hunger) ; parorexia (perversion of appetite) ; polyphagia (excessive eating) ; akoria (absence of satiation); anorexia (loss of appetite). Bulimia Bulimia, hyperorexia, or canine hunger (cynorexia) denotes a marked increase of the sensation of hunger which may occur in attacks, either as an independent neurosis or as. a secondary affection, the result of some other disease. The attacks are paroxysmal. The hunger center is be- lieved to be located in the medulla. This center is probably irritated when a certain degree of impoverishment of the blood takes place. On the other hand, if the latter is marked, the sensation of hunger may not be produced or may even be suppressed. The stomach is also concerned in its production, and the amount of food contained therein has an influ- ence. For example, with hyperacidity and increased motor function, hunger is present. In a case of mine suffering from stenosis of the pylorus and dilatation of the stomach, while before operation anorexia was marked, the patient is now continuously hungry. Reflexly, the hunger center is often disturbed; this loss of appetite may occur after fright, or on the appearance of food that is greasy and badly served, whereas with food daintily prepared and of pleasant odor, the appetite is increased. The olfactories have also undoubtedly an influence on the digestion. 1 For example, it requires about 2000 cubic feet of air to pass daily through the lungs to furnish sufficient oxygen to maintain digestion. As the greater 1 Niles, Jour. Amer. Med. Assoc., Oct. 16, 1909, vol. liii, pp. 1274-1278. part of the air passes over the olfactory region, the contact of odorous substances may exert a marked influence. Moreover, appetizing odors may stimulate the salivary glands and the flow of the gastric juice; while repulsive smells may lessen the appetite, inhibit the secretion of the gastric juice, and lessen the motility of the stomach and the salivary gland secre- tion. The time at which hunger appears depends on the time the person is accustomed to eat. Pathologically the sensation of hunger may also be stimulated or inhibited in various ways. Etiology. Bulimia may be a primary affection or may be secondary to ulcer of the stomach, hyperchlorhydria, hypersecretion, epilepsy, hys- teria, neurasthenia, tumor of the brain, tapeworm, intestinal diseases, rarely to diseases of the pancreas or to diabetes mellitus. Occurrence. It is more frequent in women than in men, and most frequent from eighteen years of age to menopause. Symptoms. The patient may be in perfect health, when suddenly a feeling of intense hunger comes on which is extremely persistent and calls for food. There is frequently a gnawing in the stomach and a feeling of fear and anxiety. Unless the hunger is relieved, headache, trembling, and even fainting spells may occur. The attack may take place immedi- ately after a large meal, or come on in the night. In some cases small amounts of food will relieve the conditions; in others, enormous quantities are necessary. One patient recorded ate 23 eggs in forty-five minutes and drank i> quarts of milk and i quart of wine. Character of Attacks. They may be severe or very slight. In some cases they occur every few hours; in others they last a few days, or they may exist chronically and last for years. The periodic form is generally more intense. Hypermotility is found in some cases. Prognosis. In the secondary form it depends on the primary disease, though sometimes bulimia persists. The more frequent and violent the attacks, the worse the prognosis. Ordinarily it is difficult to give an absolute prognosis. Gastritis, atony, or dilatation of the stomach may result in some cases. Treatment. If bulimia is secondary, the primary disease should be treated, such as hyperchlorhydria, tapeworm, diabetes, or neurasthenic or hysteric symptoms. For the bulimia we should give frequent light meals every two hours. The bromid of sodium, potassium, ammonium, or strontium may be given in 2o-grain to ^-dram (1.3-2.0) doses two or three times daily; for example: 1^. Sod. bromid ^iiss (10.0); Aq. menth. piperit t q. s. 5iv (125 c.c.). M. Sig. Two teaspoonfuls in water t.i.d. after meals. Codein, opium, and cocain I strongly deprecate, though recommended by some. There is great danger of acquiring the habit. Tincture belladonna, 10 minims (0.59 c.c.) t.i.d., is a good substitute. Arsenic (Fowler's solution), 5 minims (0.296 c.c.), or sodium arsenate, Ho to > 5 grain (0.0013-0.0026), or arsenous acid, >f o grain (0.00065) t.i.d., are useful. 472 DISEASES OF THE STOMACH AND INTESTINES Iron can be given, also strychnin, y &Q grain (0.00108), for the nerves. Change of climate is of value. Food should be carried by those suffer- ing from abnormal hunger for immediate use. Parorexia (Perversion of Appetite) Sometimes the appetite is manifested for special, or peculiar kinds of food. There are three types: (1) Malacia, a desire for spiced foods, such as for mustard, vinegar, green fruits, etc. (2) Pica, a desire for substances that are not foods, such as earth, chalk, ashes, sand, insects, etc. (3) Allotriophagia, a craving for disgusting and harmful substances, such as fecal matter, pins, etc. Malacia is met with in disturbances of the stomach and neurasthenia, while the other types occur chiefly in idiots, lunatics, or with severe hysteria. The treatment is of the disease which is the cause of the perversion. Polyphagia Polyphagia is the demand for large quantities of food before satiation occurs. The cases do not feel hungry until the food is digested. It may occur as a primary condition in neurotics, or secondary to diseases of the gall-bladder, spleen, diabetes, or brain tumor. The attacks may be of shoit duration or as a chronic trouble. One case could eat 100 pounds of meat in twenty-four hours. Disease, if present, should be treated, neurotic conditions should be corrected. The general treatment is the same as of bulimia. Akoria Akoria is absence of satiety. Patients with akoria never feel satiated, and never know when to stop eating. It is at times combined with poly- phagia. It is met with among the neurasthenic and hysteric. Bromids are of service and the general treatment of the nervous condition. Nervous Anorexia (Anorexia Nervosa) Anorexia is diminution or loss of appetite, with absence of the hunger sense, so that even aversion to food may be present. It occurs in most of the organic, as well as in the functional disorders of the stomach, but the nervous type appears as a primary affection. It has been attributed to a depressed condition of the hunger center or to hyperesthesia of the mucous membrane of the stomach. Etiology. Psychic shock, some mental depression, worry, a disagree- able odor, or some nauseating sight may cause transitory anorexia in a healthy person. It may, however, be more persistent in hysteria, neurasthenia, and the NERVOUS AFFECTIONS OF THE STOMACH 473 psychoses; morphin and excessive smoking may produce it. It is more frequent in women and may result from anemia or chlorosis. Symptoms. There is at first loss of appetite, and the patient begins to eat less. These cases may first have an aversion to meat, and later to bread and butter, vegetables and all solid food, and may finally live only on fluids, sometimes on very small quantities. They often vomit at the sight or smell of food, and may, in severe cases, emaciate markedly. They will refuse to increase their nourishment (" siturgy "). The pulse becomes slow and the temperature subnormal; they become pale, cyanotic, and the eyes sunken. Such cases may even terminate fatally. This condition may be mistaken for organic disease or for phthisis, and a careful physical examination and gastric analysis should be made. Treatment. -The patient should be impressed with the idea that he must take his food in sufficient quantity and eat everything put before him. He should not be questioned as to his desires. Frequent small meals with koumiss, matzoon, bacillac, fermillac, lactone-butter-milk, butter, milk, and cream should be given to improve nutrition. Raw eggs are of service. The sour milk products are of value, as auto-intoxication is an im- portant feature in these neurasthenics. Stomachics, such as tincture of nux vomica, 10 minims (0.59 c.c.) t.i.d., and fluidextract of condurango, 20 minims (1.184 c.c.), are of service. Fluidextract of Peruvian bark, i dram (4.0) t.i.d., is excellent. R. Tr. nucis vomicae, ) _ ... , \ A ., , , ,, ' ,., > aa oij (8.0); Acid, hydrochlor. dil. } Comp. tinct. cinchona 5ss (16.0); Aq. destil q. s. 3i v (125.0). M. Sig. 3j to ij (4.0-8.0) t.i.d. in water before meals. Basic orexin, ^ to ^ grain (0.02-0.03) t.i.d., may prove of service. Morphin and tobacco, if they are factors, should be cut off. Sanatorium treatment and rest cure are important in severe cases, especially by the Weir-Mitchell method. Isolation from the family, strict supervision by the physician, massage, and electricity are valuable. Forced feeding (gavage) or nutritive enemata may be required. After a while the patient will be convinced she can digest food. Small quanti- ties are given at first, and then they are increased. In milder cases change of climate is useful. Strychnin, y^ to ^ grain (0.001-0.002), Blaud's iron pills, or iron tropon are of service. Arsenic may be added, Fowler's solution, 5 minims (0.29), sodium arsenate, y &Q to ^ grain (0.001-0.002), glycerophosphates of soda, or Chapoteaut's glycerophosphate of lime. These remedies should be given t.i.d. Sensations within the Stomach Under normal conditions we do not recognize that we have a stomach, and there are no sensations after the ingestion of food. The stomach is not devoid of sensation even normally, as excessive quantities of hot or 474 DISEASES OF THE STOMACH AND INTESTINES cold material are noted by internal sensations, such as after the ingestion of a large quantity of ice-cream on an empty stomach. Gastric sensation, however, may be increased to a pathologic degree and be a source of great discomfort. We must remember that certain persons are peculiarly constituted and have idiosyncrasies to particular foods. Idiosyncrasies. For example, shell-fish, such as lobsters, crabs, and oysters, strawberries, bananas, onions, etc., will produce skin eruptions such as urticaria or erythema, and gastric symptoms such as pain, belch- ing, pressure, and even nausea or vomiting. Talma and Einhorn have described cases having a peculiar idiosyncrasy to hydrochloric acid. I have seen several cases where the patient suffered from the symptoms of hyperchlorhydria, and yet the free hydrochloric acid found was well within normal limits. The administration of alkalis relieved the symptoms. The gastric nerves were evidently peculiarly sensitive to acid in these cases. If patients have an idiosyncrasy to special food, it must be avoided. Abnormal Sensations (Sensory Neuroses of the Stomach) The nervous and hysteric at times complain of sensations of heat, cold, or of some foreign body, such as the feeling of worms, etc., within the stomach. These symptoms are not dependent on the food or upon the gastric secretion. There may be in some a feeling of constriction, cramp, or "pulsation" within the stomach. The latter is probably due in many cases to hyperesthesia and the transmission of the aortic pulsation. Nausea. There may be a nervous type of nausea in such patients, either during the fasting condition or after meals, the treatment for which should be directed to the neurasthenia. Nausea may also be reflex, as from an affection of the genital organs, or in organic disease of the stomach. Einhorn recommends intragastric galvanization. The indication, however, is to treat the hysteria or neurasthenia. Hyperesthesia of the Stomach This consists in an increased sensibility of the nerves of the stomach, so that the mucous membrane is abnormally sensitive even after ordinary food is taken. It differs only in degree from gastralgia. It may be sec- ondary to organic affections, associated with secretory disturbances, or it occurs as a primary neurosis. Etiology. It is present especially in the higher classes. Mental over- exertion, excitement, alcohol, and veneral excesses, which weaken the constitution, are factors. It is associated with hysteric, or nervous symp- toms. Though anemia is given as a cause, hyperchlorhydria with hyper- esthesia occur with this condition, and this type is, therefore, not a pure sensory neurosis. Symptoms. There is a sensation of fulness, weight, or pressure after meals, which may become real pain, and, finally, vomiting may occur. Sometimes considerable emaciation is present, as the patient fears to eat NERVOUS AFFECTIONS OF THE STOMACH 475 (sitophobia). Hyperesthesia occurs after excess of food or, in some, in cases of fasting. Persistent hiccough may occur with this condition. Physical Signs. The epigastrium and region of the stomach are sensi- tive to pressure throughout, but there is no specially sensitive area as in ulcer. Certain articles of food, such as sugar, fat, starch, or coffee, may pro- duce the condition. The secretory and motor functions are normal in the purely nervous cases. Diagnosis. This is based on the absence of organic disease of the stomach, the absence of hyperchlorhydria, or of other secretory disturb- ances, and the absence of motor disturbances. With hyperchlorhydria and gastritis the gastric analysis and other symptoms will give us the requi- site differential points. With ulcer, hyperacidity is the rule, and the de- gree of pain is dependent considerably on the character of the food, which is not generally so in hyperesthesia; the other symptoms also differ. With erosions small bits of mucous membrane are washed out and there are secretory changes. Prognosis depends on the result of the treatment of the nervous con- dition. Treatment. In many of these cases, as when anemia is present, secretory disturbances are associated with the sensory neurosis, as hyper- chlorhydria, so that the pure sensory condition is often complicated. Iron and arsenic are necessary in such cases and, in fact, have an excellent effect. Iron tropon, or any good iron preparation combined with Fowler's solution, 5 minims (0.296 c.c.) t.i.d., is excellent. The Blaud pill gr. v, combined with sod. arsen. gr. % Q and strych. sulp. gr. >6o is good. The patient should be kept in bed in severe cases and warmth applied to the stomach, dry heat, or Priessnitz compresses. Fluid diet in rather small quantity should first be given. Milk and lime-water, broths, chicken soup, white of egg, later entire raw eggs beaten in water, calves'- foot jelly, scraped meat, zwieback softened in milk, butter, and, gradually, solid food should be administered. Tincture of belladonna, 5 to 10 minims (0.296-0.592) t.i.d., is ex- cellent for the pain. The use of opium and its derivatives and cocain are to be deprecated. Rarely an occasional dose of codein may be required. In some cases silver nitrate, ^ to % grain (0.008-0.016), in aqueous solution t.i.d. before meals is of service. External galvanization to the stomach is of value. Bromids in some cases are serviceable. Baths and change of scene may be enjoined. Treatment by "sugges- tion" should be used by the physician. Gastralgia (Sytwnyms. Gastrodynia, Spasm of the Stomach (Gastrospasmus) ; Cardialgia, Neuralgia of the Stomach) Gastralgia may be defined as the occurrence of violent attacks of pain in the stomach, paroxysmal in character and alternating with free inter- vals. 476 DISEASES OF THE STOMACH AND INTESTINES Etiology. We may have a number of forms of gastralgia originat- ing from various conditions, and these must be referred to in order to differentiate them from the purely nervous type. Gastralgia Originating in the Stomach. (a) Connected with organic affections, such as ulcer, cancer, stenosis of the pylorus, or gastritis, hyperacidity, hypersecretion, hypoacidity, peritonitic adhesions, or with perigastrids. (b) Special varieties of food, as rich spices, or of drink, as strong coffee, or ice cream, etc., may produce it in people not accustomed to these substances. Spinal disease, as tabes, may cause gastric crises, or, more rarely, cere- bral disease or various types of myelitis. Absence of patellar reflex, Argyll-Robertson pupil, and Rhomberg symptom are diagnostic of tabes. Wassermann test should also be made. Gastralgia as a Neurosis. This occurs with neurasthenia or hysteria. It may appear before the nervous symptoms are in evidence. Reflex Causes. Gastralgia of this type occurs most frequently in women. It takes place reflexly from disturbances in the female or in the male genital organs. Gastralgia may occur at the time of menstrua- tion or in place of it. Disease of the liver, spleen, bladder, pancreas, and ptosis of abdominal organs may be reflex causes. Other Causes. Malarial infection may be a cause of gastralgia. The latter may be associated with the usual symptoms of malaria or it may be substituted for the malarial cycle, appearing every day, alternate day, or third day at the same hour, as do other neuralgias. Gouty infection, mercurial or lead-poisoning, or excessive smok- ing may produce it. Exophthalmic goiter, anemia, or chlorosis with malnutrition may be a cause, although the attacks in many of these cases are the result of the associated hyperchlorhydria. Sex. It occurs most frequently in women and girls from fifteen to forty, and decreases in frequency with age. Symptoms. The attacks usually appear suddenly and occur in paroxysms, though they may be preceded by nausea, with belching and distention, headache, or dizziness. There is a sudden extreme pain in the epigastric region of a boring, tearing, burning, and constricting character. It may radiate over the abdomen or to the back and shoulders. The attacks may occur independently of eating and whether the stomach is empty or full, or at any hour (in the nervous cases). The face is pale and distorted with the pain, by which the patient is frequently doubled up, as with colic, and there is inability to lie straight, and often clammy sweating. Strong pressure on the abdomen frequently relieves the pain, though it may be sensitive to lighter pressure. The gastric region is usually sunken. There are often hiccough and belching, with nausea and collapse. The pulse is generally rapid and feeble, though in some cases slow. Duration. Gastralgic attacks may last from a few minutes to an hour or longer. There may be several attacks in a day, every few days, or at intervals of weeks or months. NERVOUS AFFECTIONS OF THE STOMACH 477 The pain disappears suddenly and may be followed by hunger or even bulimia. In mild cases the patient may not be greatly affected and may be able to work immediately, while in the severe cases there is often prostration for several days. Prognosis is favorable as far as life, and depends on the removal of the primary cause. Differential Diagnosis. The sudden onset, violent spasmodic pain in the stomach, general in character and lessened by pressure, nausea, vomiting, and headache that these symptoms are independent of eating and frequently occur after mental overexertion or emotional shock and are associated with nervous hysteric symptoms all point to the nervous type. We must exclude the secondary form by gastric analysis, and by the determination that no organic disease exists. A careful physical examination is necessary, thereby eliminating other conditions that may cause pain in the gastric region. Ulcer of the Stomach. The pain at the height of digestion depends on the quantity and quality of food; disappears when the stomach is empty; intervals free from pain; hyperchlorhydria often present; cir- cumscribed spot in the epigastrium painful on pressure and increased by it; left dorsal pain present, hematemesis present in some cases, or occult blood and pus in gastric contents or stool. If these characteristic symptoms are absent it may be necessary to try one of the ulcer cures; which, if it fails, would rather point toward nervous gastralgia. The #-rays would determine the presence of ulcer in doubtful cases. Cancer of the Stomach. Pains not as severe, but more continuous, never free from pain; absence of hydrochloric acid most frequent; lactic acid and Boas-Oppler bacilli present; cachexia; loss of weight; age of patient usually forty to sixty years; tumor often present. Chronic Gastritis. -Intense pains are absent; are continuous and more a sense of discomfort after the ingestion of food; no paroxysms; mucus in gastric contents; hypochlorhydria. Stenosis of the Pylorus. Attacks of pain (gastralgia), associated with peristaltic unrest and vomiting. Dilatation of the stomach is present; usually hyperacid contents if benign stenosis; and lactic acid present with absence of free HC1 and Boas-Oppler bacilli if malignant. Functional Disorders. Hyperchlorhydria and hyper secretion; pains disappear after albuminous food or alkalis. Gastric analysis, hyper- acidity, and if hypersecretion, excessive quantity of secretion in the empty stomach, of high acidity, afford information. Achylia Gastrica. Pains disappear when stomach is empty. Gastric analysis shows low acidity, 2+ or 4+; free HC1 absent; rennet = o; pepsin = o. Tabes. Gastralgic attacks may be very severe. Absence of patellar reflexes, the Argyll-Robertson pupil and the Rhomberg symptom are diag- nostic. Wassermann reaction should be tested for and is diagnostic in doubtful cases. Rheumatism and Myalgia. Myalgia is muscular pain which may be due to exertion. In both conditions when occurring in the abdominal 478 DISEASES OF THE STOMACH AND INTESTINES muscles the pain is not paroxysmal; corresponds to the course of the muscles, and is relieved by abdominal relaxation; we have a rheumatic history or that of overexertion. Intercostal Neuralgia. Pain is superficial and can be traced along the intercostal nerves, which are sensitive at numerous points on pressure. Renal Calculi. Pain in the kidney (dorsal region) radiates to the ureter and bladder; testicle drawn up in the male; urine is acid and shows albumin, casts, and blood. Sand often present. Kidney is fre- quently tender on pressure. Gall-stones. Pain over liver and gall-bladder; deep pressure increases the pain; rise of temperature; pain passes to right and often up into the right shoulder. Head's gall-bladder zone often present. Leukocytosis frequently present. Right dorsal tenderness at Boas point at times. Jaundice occurs at times and gall-stones in the stool are conclusive though often not found. // the motor or secretory functions of the stomach are normal, the attack of pain especially if it is in the right hypochondrium and the patient has no nervous symptoms is probably due to gall-stones. With gastralgia there are no pain and no fever. It is sometimes difficult to differentiate between the other conditions. Perigastritis. A high position of the stomach, with the left lobe of the liver drawn down and covering that organ, is suggestive of peri- gastritis when pains come on regularly several hours after meals (Kauf- mann). 1 The #-rays are of great value in determining abnormal positions or shape of the stomach resulting from adhesions. Intestinal Colic (Enter algia). Pain changes its position in the ab- dominal cavity. Passage of flatus relieves pain. Bowels are irregular. Treatment. In secondary gastralgia it is necessary to treat the pri- mary cause. If it is due to tobacco, it should be cut off. Malaria should be treated with quinin or Warburg; and anemia, with iron and arsenic and the rest cure. Correct a gouty tendency, if present; or treat tabes, if this be found. Sexual disorders, ulcer, gall-bladder disease, or cancer should receive appropriate treatment. If hysteria or neurasthenia are present, tonics, isolation, the rest cure, massage, and hydrotherapy are of value. The galvanic current, the anode over the stomach, or intraventricular galvanization, with the cathode over the spinal column, is of service when repeated attacks of primary gastralgia occur. For the active condition, if moderately severe, hot applications (dry or moist heat) and hot drinks are useful. Tincture of belladonna, 10 to 15 minims (0^592-0.088), to relieve the spasm. Tincture of valerian, 20 minims to ^ dram (1.184-2.0), in comp. tinct. of lavender and water, or Hoffmann's anodyne, >- 2 dram (2.0), may be given in water with sugar. Chloroform spirits, 2 to 3 drops in water at a dose, can be administered. The bromids are also valuable. 1 Amer. Med., vol. vi, No. 20, pp. 792, 794, Nov. 14, 1903. NERVOUS AFFECTIONS OF THE STOMACH 479 If there is retention of food during the attack, then lavage with warm water or saline solution will relieve some cases. If the pain is unbearable, codein, y 2 grain (0.032), by hypodermic, or morphin, K grain (0.016), with atropin, Koo grain (0.00065), car * be administered. Suppositories of morphin, ^ grain (0.016), and extract of bella- donna, y grain (0.016), or opium, i grain (0.065), an d extract of bella- donna, y grain (0.016), every two to three hours for several doses, are useful. Opiates should be used with caution even by the physician lest habit result. Gastralgokenosis (Boas 1 ) This is characterized by pain in the stomach when it becomes empty, and is relieved by food. It may be periodic or permanent. Frequent meals and nerve sedatives are required. MOTOR NEUROSES OF THE STOMACH Under normal conditions, the cardia remains closed after the process of digestion has begun, while the pylorus opens at intervals to allow a certain amount of escape of chyme. The muscular movements of the stomach mix the ingesta with the gastric juice and aid in its disintegration by churning movements. Later they propel it into the intestine. These motor functions may be irritated (exaggerated) or depressed (diminished). Hypermotility of the Stomach (Synonyms. Supermotility; Hyperkinesis; Hyperanakinesis Ventriculi Einhorn) In this condition the stomach propels the ingesta into the intes- tines more rapidly than normally. Etiology. -Hypermotility may be secondary to achylia gastrica or hyperchlorhydria or diseases complicated thereby, or the condition may exist as a primary neurosis. It may occur as a radiological sign of duo- denal ulcer and at times with gastric ulcer or early gastric cancer near the pylorus, but not producing stenosis. In some cases achylia and hyperchlorhydria exist as a secretory neurosis, and with this there is the motor neurosis, hypermotility. Supermotility may exist as a motor neurosis alone (primary neurosis) or be due to some nervous influence or associated with nervous con- ditions, and is analogous to increased intestinal peristalsis from nervous influence. It occurs with vagotonia. In pyloric obstruction there is often actual increased motor power in the early stages, but the resistance to the exit is so increased that the final result is relative motor insufficiency. Diagnosis. Aspiration of the stomach contents will demonstrate the condition. For example, one may find the stomach, empty thirty- five to forty-five minutes after the test-breakfast, or only a minute quan- tity can be removed. Radiography should then be done so as to determine if there rs any organic cause for the condition. 1 Krank. des Magen, II, Feb. 418, Auflage, S. 260, Leipzig, 1901. 480 DISEASES OF THE STOMACH AND INTESTINES Einhorn suggests the employment of the gastrograph, noting an increase of the "makes" and "breaks," but this method is complicated. Careful analysis of the gastric contents should be made to test the secretory functions, and an early aspiration would be necessary. Hypermotility in itself does not produce any special gastric symptoms. Treatment. In the secondary cases hypermotility will be relieved by treating' the cause. Peristaltic Restlessness of the Stomach (Kussmaul) (Synonyms. Peristaltic Unrest; Tormina Ventriculi Nervosa) This is really an exaggerated hypermotility in which the peristaltic action is unusually great, and is appreciated by the patient as a dis- agreeable sensation. It may become visible through the walls of the abdomen, and waves of contraction can be seen running from left to right along the stomach. This condition usually occurs when there is ob- struction at the pylorus or duodenum, with dilatation of the stomach, and is produced by the effort of the organ to overcome the obstruction. Kussmaul first described two cases of peristaltic unrest which were pure neuroses of motility. The movements began early in the empty stomach and became more violent after eating. Gastroptosis was present. Emotional shock and abuse from sexual excesses were the causes. Mechanical forms must be excluded. In these, it occurs only when the stomach is full. In the nervous cases movements take place both when the stomach is full and empty. If the patient is well nourished and the stomach is in normal position, it may be difficult or impossible to see the movements, but the patient will complain of the contractions and wave-like movements, and borborygmi and gurgling may be heard. Nausea, vomiting, and cramp-like pains may occur, especially in the obstructive type. Physical examination and gastric analysis will determine whether the peristaltic restlessness is primary (a neurosis) or secondary, and the #-rays whether there is organic obstruction. Course and prognosis depend upon the cause and the nervous condition in primary cases. Cases may be continuous, when they may cause loss of sleep, or may be intermittent. Treatment. This must be directed against the primary cause, such as stenosis of the pylorus, etc. If it is a pure gastric neurosis, resulting from mental overexertion, grief, sexual excess, or nervous or hysteric conditions, we must remove these factors. Iron, arsenic, and the glycerophosphates are indicated. Treat vagotonia if present. Hydrotherapy, diet, and "change of scene are valuable. The diet should be regulated, all irritants to the stomach should be avoided. The food should be digestible, non-irritating, and in moderate quantities at a time, especially at night. Locally, heat or cold to the stomach; galvanic electricity, percutaneous or intragastric. This last is of no value in stenotic cases, but does harm. NERVOUS AFFECTIONS OF THE STOMACH 481 Lavage is indicated if there are stenosis and dilatation as a tem- porary measure with operation for permanent cure. Antiperistaltic Restlessness of the Stomach In rare cases the peristaltic action is reversed, the waves running from right to left. These cases are generally of neurotic origin. Intestinal waves are of small caliber and move in different direc- tions in various regions, while gastric waves are of large size and move in the gastric region. These waves may extend to the intestines and colored enema ta have been voided from the mouth (Osier). Treatment should be directed to the neurosis. Incontinence of the Pylorus (Synonym. Insufficiency of the Pylorus) This condition was first described by de Sere and Ebstein. It may be caused by some growth in the pylorus, keeping the opening patent, or by stenosis or other organic changes, or when the pylorus is relaxed (atonic), due to some nervous derangement, hysteria, or myelitis. Relaxed pylorus, I believe, to be frequently associated with atonic ectasy, and that this feature accounts for the absence of pain and vomiting. It is also present in some cases of gastroptosis. The relaxation in these cases is probably compensatory. I do not believe it to be a true incontinence, but merely atony with weakening of the pyloric musculature, with no re gurgitation. Ebstein has shown that if we attempt to inflate the stomach with air. or CO 2 , it will rapidly pass into the intestine and distend it, and gastric tympany is absent. A diagnostic feature of true incontinence is the regurgitation of the intestinal contents into the stomach. On aspiration or lavage in the fasting condition, intestinal juice and often a considerable quantity of bile will be found. It is sometimes present on aspiration of the test-breakfast or test-meal. Very little chyme is present in these cases, but regurgitation is in evidence. There are no distinctive clinical symptoms in most cases; though Knapp 1 reports diarrhea alone or alternating with constipation, as some- times associated, and also toxemic symptoms, as does Ebstein; and Einhorn refers to two cases in which there was associated cardiac relaxation, with belching as the chief symptom. My prolonged investigations among the nervous and insane lead me to absolutely disagree with Knapp that achylia (functional or organic) and insufficiency of the pylorus are com- pounded. That author believes there is no functional achylia, and with this I .entirely disagree. Treatment. Occasional lavage; strychnin, J4 grain (0.00146), and belladonna extract, % grain (o.on) t.i.d., with intragastric faradization (every other day). Massage and douches are serviceable. 1 Phila. Med. Jour., May 24, 1902. 482 DISEASES OF THE STOMACH AND INTESTINES Duodenal Regurgitation Due to Fatty Foods Bassler 1 has drawn attention to regurgitation of the duodenal contents into the stomach in some cases as a result of the ingestion of fatty foods and oils with the consequent production of gastric symptoms. Fat foods, such as milk, fresh cream, butter, eggs and the native oils were responsi- ble for this condition. The middle aged were chiefly affected and the physical examination of the stomach and abdomen was apparently nega- tive in these patients. Symptoms. Acute gastric pain radiating to the back, occurring in paroxysms persisting from several minutes to several hours and sometimes for several days, were present. Incapacity from the pain sometimes resulted, and when it suddenly disappeared, the patient was apparently as well as ever. Occasionally nausea was present, but no vomiting. Considerable anxiety and distress are produced during the period of pain. Gastric Analysis. There is a large residuum after the Ewald meal. Part of this consists of duodenal contents, the aspirated material being deeply bile-stained and containing considerable floating fat, fatty acids, pancreatic juice, hydrochloric acid in large amount and mucus, the latter perhaps explained by stomach irritation. The empty stomach, aspirated in the morning shows an accumulation of the duodenal contents fat and fatty acids and small amounts of hydrochloric acid, as much as 73 c.c. being aspirated in one patient. During the paroxysm the stomach invariably contains these constit- uents and even so to a less degree when the pain has disappeared or when the patient has been on a fat free diet for several days. It is known that the administration of a considerable quantity of olive oil will produce duodenal regurgitation in many cases and thus enable one to secure the pancreatic juice for analysis. This is the probable explana- tion of the effect of the fats on these patients. Bassler explains the pain as due to the collection of the regurgitated material in the stomach causing formation of the fatty acids from the oils and fats and these together with the bile producing irritation of the stomach. Treatment. These cases rapidly recover when a fat-free diet, white of eggs, skimmed milk carbohydrates, green vegetables, salads, boiled meats, etc., are administered. The author has had no-experience with this condition. Spasm of the Pylorus (Pylorospasmus) Spasm of the pylorus means a spasmodic contraction of the pyloric ring, the pyloric canal or of both. It is usually a secondary occurrence, associated with hyperchlorhydria, hypersecretion, ulcer of the pylorus or of the duodenum, or in its immediate neighborhood; and in the latter case must be considered a reflex. It may result from irritation of the stomach by indigestible diet, by food that is too hot or cold, or by strong spices, etc. It is rare with carcinoma with abundant lactic acid. Bentijac 2 described a case who drank a glass of kerosene by mistake, 1 Bassler: Diseases of the Stomach and Upper Alimentary Tract. 2 These de Paris, 1888. NERVOUS AFFECTIONS OF THE STOMACH 483 and who later developed all the symptoms of stenosis of the pylorus and dilatation. Operation showed the pylorus normal, but spasmodically contracted. Vomiting ceased after operation. Pylorospasm may be secondary to gall-stones, gall-bladder disease, to chronic or protective appendicitis, to kinks according to Lane, or to chronic pancreatitis or cancer of the pancreas, in which events a careful investigation of the history of the patient and the physical examination will prove of service. As a pure neurosis, spasm of the pylorus is a rare affection, and is much rarer than cardiospasm. All possible causes of spasm of the pylorus must first be excluded. Numerous other factors are given as producing reflex spasm of the pylorus, such as non-bacterial toxic disturbances 1 resulting from gout, diabetes and nephritis; bacterial infections, infectious fevers such as tuberculosis and acute endocarditis; tumors, abscesses, hemorrhages, embolism and emotional states of the brain; ocular disturbances, conditions in the pharynx, larynx and also in the lungs, such as whooping cough and tuberculosis; aneurysm, goiter, hepatitis, hepatic colic, nephritis, pyelitis, renal colic, floating kidney; pregnancy, uterine displacement or inflammation, stenosis of the cervix; intestinal parasites, hernia, chronic intestinal obstruction from adhesions, bands, etc., inflammation of the bladder or prostate, acute infections of the peritoneum, etc. Though all these factors must be considered, the author finds that organic lesions of the stomach or duodenum are fre- quently responsible; while on the other hand many cases of pyloric spasm are reflex from disease of the gall-bladder or appendix. Hyper- chlorhydria of marked degree is also the cause in a certain number of cases. There are no specific symptoms of pure pyloric spasm without organic lesion at the pylorus, though some claim to have discovered such. Secretory and motor disturbances of the stomach are associated even with the pure spasmodic cases. The history, careful physical examina- tion, study of the gastro-intestinal functions, and radiographs are the requisites for a successful diagnosis. Repeated spasm of the pylorus, in conjunction with hyperacidity or hypersecretion, is undoubtedly at times the cause of gastric dilatation; and in some cases benign stenosis may result from hypertrophy at the pylorus caused by the repeated spasm. Pylorospasm with gastric tetany has been reported by Pitfield. 2 Pyloric spasm may occur in vagotonia. Symptoms. Pain, increased peristalsis of the stomach, and often vomiting are present. It may be induced by the patient. The pain may radiate from the middle of the epigastrium. There may be local tender- ness, and at times the pylorus may be felt to contract under the examining fingers. There are discomfort and eructation of gas or sour and acrid fluid. Retention and stagnation of food may occur and ultimately dilata- tion of the stomach. Pure nervous spasm of the pylorus is difficult to diagnose. All perversions of secretion and all mechanical obstacles must be excluded 'Haynes: Pyloric Spasm, Amer. Jour. Surgery, Dec., 1915. 2 N. Y. Med. Jour., May 31, 1913. 484 DISEASES OF THE STOMACH AND INTESTINES as noted. Nervous spasm (pyloric) is most likely to be associated with the hysteric or neurasthenic condition, or vagotonia. The writer has seen a number of cases of pyloric spasm in which hyper- chlorhydria was unquestionably the chief factor. This has been present in a number of nervous patients, especially in anemic women, and the possibility of ulcer has been suggested. Cure followed the treatment of the hyperchlorhydria. In the pure neurosis cases the gastric analysis may vary on different occasions. X-Rays. Fluoroscopy, and more particularly radiography, are impor- tant for the purpose of diagnosis and differentiation between pyloric spasm from a local organic cause, or as a reflex from some distant organ. De- formity of the stomach from ulcer, or of the duodenum from ulcer or adhesions, gall-stones, or gall-bladder adhesions (from stones or cholecys- titis), intestinal adhesions, or angulations, chronic appendicitis (if appendix is patent) can all be recognized or excluded. A reflex spasm is usually unstable and may not appear on second examination. To exclude spasm tinct. belladona 10 to even 20 drops, up to physiological effects, or large doses of atropia are usually given t.i.d. before the second examination. Personally I arrive at my conclusion by one examination, eliminating spasm by the previous use of belladonna and examine for various organic conditions plus pyloric deformity (contraction.) Treatment. Belladonna is of value to relax spasm and lessen secretion; the tincture, 10 minims (0.592) t.i.d., or extract, 34 grain (0.016) three or four times a day, or atropin, gr. Hoo~/1so t.i.d. Olive oil (i to 2 ounces) before meals lessens spasm. The nervous system must be toned up and bromids may be of service. Vagotonia or sympatheticotonia must receive treatment. In the secondary cases, secretory perversions and other causes of the condition must receive appropriate treatment. Lavage is necessary if there is dilatation. Einhorn 1 has described and recommended for treatment of pyloric spasm a dilating inflatable catheter, and recently a small gauze balloon (pyloric dilator), to which is attached a long thin soft-rubber tube with 2 a stop-cock and syringe at its distal end.^ A diaphane 3 is attached to the latest instrument, the light demonstrating when it has passed the pylorus. More recently he has devised a double-balloon dilator. 4 This method the writer has determined to be unreliable, in fact, no cure can be effected thereby in his belief, and suggestion that benign stenosis of the pylorus can be cured by this treatment is a serious menace to the safety of the patient by reason of the delay. Organic stenosis of the pylorus is always a surgical condition. So-called medical cures of ectasy due to stenosis of the pylorus invariably relapse until surgical measures are undertaken. Surgery. Appendectomy is indicated if appendicitis is the cause, or operation on the stomach, duodenum or gall-bladder if such is at fault. Exploratory laparotomy may be necessary to determine the cause of the 1 Med. Rec., Oct. 9, 1909; 111. Med. Jour., June, 1910; Med. Rec., June 10, 1911; Ibid, June 10, 1911. 2 Med. Rec., Jan. 21, 1911. 8 Med. Rec., June 10, 1911. 4 N. Y. Med. Jour., May n, 1912. NERVOUS AFFECTIONS OF THE STOMACH 485 pylorospasm, and one may find that pyloroplasty, pylorectomy, or gastro- enterostomy, with closure of the pylorus may be indicated. Other sur- gical causes should be treated. Atony of the Stomach This is a condition in which the muscular action of the stomach is retarded and weakened, and moderate motor insufficiency results. It may be acute or chronic and secondary to other conditions, or as a primary neurosis. It has been already fully described. Hypanakinesis Ventriculi (Einhorn) This is defined as a condition in which the mechanical function of the stomach is greatly reduced. There are no breaks, or few, in the gastro- graph,an instrument to determine the churning movements of the stomach. It seems a minor degree of atony, and is of no special clinical significance. Hyperanakinesis Ventriculi (Einhorn) This is an excessive mechanical action of the stomach. It seems to correspond to hypermotility. Excessively active churning movements occur in this condition (Einhorn). It seems difficult to separate it from hypermotility. Spasm of the Cardia (Cardiospasmus) Spasm of the cardia consists in a spasmodic contraction of the muscles of the cardia, with the production of pain and difficulty in swallowing (dysphagia). Etiology. It may be produced by the passage of the stomach-tube or after rapid eating, by very hot or cold drinks, and by coarse or hard food. It may be secondary to other diseases (organic disease), reflex from local irritation, or as a primary neurosis, associated with nervous condi- tions or result from vagotonia. . Among other causes are ulcer or carcinoma of the cardia. Hyperacidity may occasionally cause it, though pyloric spasm is more frequent with this affection. Diverticula, or inflammation of the esophagus, are causes. It may occur in tetanus. It is quite frequent in hysteric or neuras- thenic individuals, especially in air swallowers (aerophagia), in whom spasm of the pylorus may also occur with resulting distention of the stomach ("pneumatosis"). Violent psychic shocks may also produce it, so the condition may be a primary neurosis. Fermentative processes in the stomach, with the production of gas, may be a cause; but organic disease is usually associated. Primary spasm of the cardia cannot produce gastric distention unless spasm of the pylorus is also present. Symptoms. As a pure neurosis the attack usually begins suddenly. The patient may be in perfect health, when an acute pain begins in the region of the cardia radiating toward the chest or back. It occurs gener- 486 DISEASES OF THE STOMACH AND INTESTINES ally during the ingestion of food, and there is a feeling as if some of it were arrested. There is at times some interference with breathing. Slight dyspnea is present and the respiratory movements are more forcible. There may be regurgitation and the patient feels better thereafter. There are gagging and often vomiting. The attack can be acute and last only a short time, or the condition may become chronic. The dysphagia in these cases, as a rule, increases; and though for a time the patient, by taking a deep inspiration and com- pressing the thorax while holding his breath, can force down the food, the deglutition of solid food becomes more and more difficult, and finally, only liquids can be taken. Emaciation may become quite marked, and after several years atonic dilatation of the esophagus may result similar in character to atonic gastric dilatation from pyloric spasm. Dilatation of the esophagus may also be produced by benign or malignant stenosis at the cardia; or by paralysis of the dilator nerves of the cardia, from paralysis of the esophagus, or by loss of reflex relaxation of the cardia (Einhorn). Diagnosis. In acute cases the existence of pain and dysphagia, the delay or absence of the swallowing sound, and the spasmodic resistance at the cardia on insertion of the stomach-tube, which can be overcome by pressure, together with the presence of neurasthenia or hysteria, settle the diagnosis. In the chronic type the history of the case, the fact that often the resistance to the large tube is less than to the small one in nervous cases, all aid the diagnosis. Dilatation of the esophagus may finally result. In true stenosis (organic stricture) the small sounds are more readily passed. The method of determining esophageal stricture has been described. If blood appears with the sound, ulceration is at once suggested. Cachexia is suggestive of malignancy, and aspiration of the gastric contents will settle the question. Dilatation of the esophagus occurring as a result of cardiospasm can be further determined as follows: A slice of bread can be dissolved in 200 c.c. of water to form a soft mass, and administered, the patient being instructed to employ forcing movements, so that it will enter the stomach. An hour later 200 c.c. of water may be given, no forcing movements to be employed. In about three to five minutes an aspirating tube can be passed to the cardia, a'nd if dilatation and spasm exist the water just ingested can be removed, and will be in the same condition as taken. The tube should then be forced on into the stomach and the true gastric contents removed. These are tested. The administration of barium or bismuth with the employ- ment of the x-rays is also of value for the purpose of diagnosis of dilata- tion of the esophagus. Plummer's method for determination of stenosis of the esophagus is described under that subject. Prognosis is good in the acute cases, but as regards complete cure in chronic cases it is not so good, though there is no danger to life, as a rule, except in cases with marked dilatation of the esophagus. Treatment. If the spasm occurs while eating and drinking, they should be performed slowly. The food should be well masticated or should be, preferably, soft in character; and excessively hot or cold food, NERVOUS AFFECTIONS OF THE STOMACH 487 rich, spiced food, etc., should be avoided. Nutritive enemata to rest the esophagus may temporarily be required. General tonics should be given. The employment of sounds, left in place for some time, is of value. Tincture of belladonna, 10 minims (0.592) or atropine, gr. ^ 00 to ^ > should be given t.i.d. to relieve spasm. Anesthesin, 5 grains (0.3) t.i.d., relieves pain. The bromids are of service; thus, sodium bromid, 15 to 30 grains (1.0-2.0) t.i.d. Opium or chloral should be administered with caution, or not at all. In the chronic cases soft or liquid food should be given. The patient should bear down to force the food thoroughly by the obstruction. Olive oil, i to 4 drams t.i.d. before food, is of value. The stomach-tube should be introduced at least once a day to relax the cardia; if there is emaciation, food can be administered through the tube; if the esophagus is dilated, it can be emptied and washed out. Dilatation of the cardia may be neces- sary. There are numerous inflatable bags and metal dilators (Einhorn's, 1 for example) devised for this purpose. For severe cases the writer prefers Plummer's method with olives, or a stomach-tube with the thread guide, as already described. He also has an inflatable rubber dilator, which can be guided by the same method. Rectal feeding must be enjoined for a time in severe cases. As improvement occurs the diet can be increased. Surgery. In some cases gastrostomy with temporary feeding through the opening may be required. Insufficiency of the Cardia Under this we may classify eructation, singultus, pyrosis, re gurgitation, and rumination. Eructation (Belching). Eructation may be defined as the expulsion of gas from the stomach through the mouth. The condition may be secondary to various affections of the stomach and intestines, or may be a primary neurosis. Normal healthy subjects may eructate after drinking carbonated water, or those who eat rapidly without proper mastication, and thus swallow considerable air. Secondary Cases. Belching may be associated with acute or chronic gastritis, hyperacidity, carcinoma of the stomach or with fermentative processes in the stomach. The clinical symptoms, gastric analysis, and fermentation test will render a positive diagnosis. In fermentative processes the gas is often malodorous. Primary Cases. Nervous Belching (Eructatio Nervosa) and Aerophagy. We have cases in which belching occurs at short intervals, which is independent of the character of the food and usually of nervous origin. It is noisy, as a rule, and may persist for a considerable period or occur in paroxysms. The gas consists of atmospheric air which has been swallowed (aero- phagia) or aspirated into the stomach. Aerophagy is sometimes found 1 Amer. Jour. Med. Sci., Oct., 1910. 488 DISEASES OF THE STOMACH AND INTESTINES as an accompaniment of various gastro-intestinal diseases and believing the discomfort due to gas and in endeavoring to eructate by swallowing, the patients actually force air into the esophagus and swallow it, actually becoming aerophagics without knowing it. It may also result from gum- chewing or from swallowing mucus from a retro-pharyngeal catarrh. Osier claims that the stomach acts as an elastic sac, and can aspirate the air without the effort at swallowing, and that it tends to fill after expulsion. Some of the air probably comes from the esophagus and has been swallowed just previous to the act of belching. Bouveret considers it due to spasm of the pharynx. Etiology. This nervous type of eructation is observed in hysteric women and chiefly in neurasthenics, or after excitement, shock, or mental worry. It frequently occurs in children, often in several of a family. Symptoms. The belching may last for a long period, only occur during the day, and may be extremely annoying. Some patients may not readily relieve themselves by belching, and the air thus swallowed may be retained, causing a balloon stomach. The distention may even become so great as to produce acute dilatation. Regurgitation may occur with the belching and they complain of digestive disturbances. The air may escape into the small intestines and distend them or pass into the colon. When marked distention of the stomach occurs, there may be dyspnea, tachycardia, arrhythmias or cyanosis all of which are relieved by passage of the stomach-tube. Diagnosis. Absence of fermentation, as shown by the test, the history of nervousness or of shock, and the gastric analysis showing normal secre- tion, render the diagnosis conclusive in the nervous cases. Treatment. The mouth should be kept open when belching, to pre- vent further air swallowing. Massage, hydrotherapy, iron, arsenic, bromides and belladonna, change of climate, the faradic current (extra- ventricular or intragastric), hydrotherapy and suggestion to the patient are of service. In cases in which aerophagy complicates other gastric conditions, acids, or alkalis as required or lavage if there is chronic gastritis, are indi- cated. When there is acute distention from aerophagy with no relief by belching, the stomach-tube is indicated. Singultus Gastricus Nervosus Singultus or hiccough may last for a few minutes, several hours, or even for some days. It may cease and then recur. Hiccough has even resulted in a fatal issue, the patient dying of exhaustion. Etiology. Among the various causes are diseases of the viscera, such as gastritis, hyperchlorhydria, atony of the stomach, acute or chronic ectasy, carcinoma of the stomach, catarrh of the intestines, intestinal obstruction, peritonitis, appendicitis, intestinal paresis, pancreatitis, dis- eases of the liver, typhoid fever, pulmonary disease, alcoholism, anesthesia, diabetes, gout, nephritis; diseases of the nervous system, such as epilepsy, meningitis, brain tumor, etc. It is often one of the terminal symptoms as death approaches. It may frequently occur with hysteria. NERVOUS AFFECTIONS OF THE STOMACH 489 As a pure neurosis it is an extremely rare condition, though I agree with Bassler 1 that it may occur, though associated with hyperesthesia of the stomach or with gastralgia. It must be diagnosed by the process of ex- clusion and I believe most of the so-called cases of singultus gastricus nervosus are really a symptom of the hysterical condition. Treatment. The gastric functions must be examined in all cases and functional disturbances corrected. Iron, arsenic, sodium bromid, strychnin, and, at times, belladonna are indicated. The general nervous condition of the patient must be treated and the physical condition improved. During a severe attack, inhalation of amyl nitrite will at times be beneficial. Pyrosis (Heart-burn) This consists in the ejection of chyme from the stomach into the esopha- gus, with which is associated a burning sensation in the epigastrium. Etiology. As a symptom it most frequently occurs with hyperchlor- hydria, also with chronic gastritis, and has been found with achylia and other gastric conditions. It may occur as a neurosis, especially among the hysteric or neuras- thenic, with normal gastric contents, and is of mixed type, both motor and sensory. General tonics and electricity are of value in the nervous cases. If hyperacidity, chronic gastritis, achylia, or other gastric disturbances are present, they should receive appropriate treatment as being the primary cause of the pyrosis. Sodium citrate acts as an alkali and is of value in many cases of pyrosis. Regurgitation Regurgitation denotes the condition in which, after eating, some of the food ingested, liquid or liquid and solid, rises from the stomach, enters the mouth, and is ejected. Occasionally, small fragments are swallowed again. The act is usually involuntary, though it can be produced by some at will. Early regurgi- tation tastes of the food, later it is acid. The patients can suppress it at will, and in this way it differs from regurgitation due to cardiac stenosis or diverticula. The passage of the esophageal sound or olive, and chemic analysis also give aid in diagnosis. In some cases, if regurgitation is marked, con- siderable emaciation may result. Organic disease, such as stricture of the esophagus, must be excluded; also gastritis. Etiology. Patients of nervous or hysteric type develop this condition; and mental worry and nervous strain may be the cause. Prognosis is good. Treatment. The patient should eat slowly and masticate his food. Treatment by "suggestion" is good; also forbid the patient to spit out his food, and tell him to swallow it again. 1 N. Y. Med. Jour., Aug. 13, 1910. 4QO DISEASES OF THE STOMACH AND INTESTINES Massage, faradization (intragastric and extragastric) ; strychnin, ^ grain (0.0016) t.i.d., and the treatment of the nervous condition are indicated. Rumination (Synonym. Merycism, "Chewing the cud") In this condition the food is returned from the stomach, without nau- sea, into the mouth, some time after meals, where it is chewed and swal- lowed again. Etiology. It occurs more frequently in men than in women ; and most of the cases reported belong to the higher classes, especially among pro- fessional men. Many of the lower class would not deem the condition abnormal, and women would conceal it, so it may be said to belong to all classes. It occurs among hysteric persons, neurasthenics, epileptics, and idiots. Possibly heredity and, undoubtedly, imitation in many cases are fac- tors. Occasionally there may be a pathologic condition of the stomach, with regurgitation, and rumination follows. Several cases have been reported of imitation among children. Shock, trauma, rapid eating, and emotional disturbances in nervous persons are at times accessory factors. Gastric Findings. In some cases hyperacidity has been found, and rumination diminished after this was corrected. Diminished acidity has been found by Boas, and improvement fol- lowed after hydrochloric acid was administered. On the other hand, achylia gastrica has been present in such cases and also normal secretion. The motor functions are nomaly in most cases. Prognosis. The habit may be corrected in part, but may persist for years, with no impairment of health. In some patients the attacks are periodic. Treatment. Any secretory anomaly that exists must be corrected. The treatment should be by mental impression (psychic) on the part of the physician. The patient should be taught that he can readily suppress the condition. Small bits of ice after meals, lavage, and gavage have been suggested. The bromids may be of service. The nervousness should be corrected by iron, strychnin, and arsenic. G. Variot 1 reports a case in which after failure of dieting and other remedies he secured improvement by the use of sodium citrate, 5 i to 5 iss given daily in divided doses in water before meals. The use of one glass of water to which the juice of half a lemon and a 3 i of sodium bicarbonate was added, exercised a sedative action in another case. Nervous Vomiting (Vomitus Nervosa) Vomiting is a complex process. There is a contraction of the ab- dominal muscles and fixation of the diaphragm, with a contraction of the stomach, accompanied by closure of the pylorus and opening of the cardia; 1 Bulletin et Memoires de la Societe medicule des Hopitaux de Paris, May i, 1913. NERVOUS AFFECTIONS OF THE STOMACH 49! reversed peristalsis of the esophagus and closure of the larynx and posterior nares occur, with resulting expulsion of the stomach-contents through the mouth. The vomiting center lies in the medulla near the vagus center. Vomiting may be due to some organic disease of the stomach or as a result of irritation due to the ingestion of food of abnormal character. Certain intoxications, as from uremia, cholemia, opium, morphin, tobacco, ether, or chloroform, may produce vomiting. Nervous vomiting is characterized by the absence of these conditions just mentioned, and may be either cerebral or spinal in origin, or due to reflex disturbance, overexertion, emotional shock, anger, fright, or neurasthenia. Among the cerebral causes are organic disease of the brain and its meningesj concussion, and tumors. Spinal forms, such as tabes, or occasionally paresis, multiple sclerosis, and subacute myelitis. Reflex causes, such as from the pharynx, larynx, palate, liver, peri- toneum, kidneys, genitals, etc. Juvenile vomiting and the periodic or cyclic vomiting (Leyden), also the cyclic vomiting of children (infants) are included. Characteristics of Nervous Vomiting. Stiller calls attention to the following peculiarities: This type of vomiting seems to be independent of the character and quality of the food, and occurs generally without any premonitory symptoms. Sometimes digestible foods are vomited, while indigestible material is well borne. There seems at times to be power of selection to vomit cer- tain nutriment, and the patients suffer from no inanition. Vomiting may also occur from the empty stomach, and the condition is associated with various nervous symptoms. Boas has noted that the motor and secretory functions are normal, though Bouveret and Einhorn have observed a diminution or absence of secretory function in some cases. Treatment. Tonics. Correct disturbance of secretory functions. Mental impression on the part of the physician is important. Change of scene is at times of value. Rosenhaubt recommends anesthesin t.i.d, ten minutes before meals given in a 2 to 3 per cent, strength in a given mixture, of which the dose is one teaspoon. PERIODIC VOMITING (VON LEYDEN) There are several peculiarities connected with this type of vomiting. As a rule, no cause can be discovered, and the attack appears when the patient is in perfect health. The attacks occur at intervals of equal duration. After the attack the patient is immediately restored to health, and remains well until the next one occurs. They resemble somewhat the gastric crises of tabes, and are similar in suddenness of occurrence to violent attacks of migraine. They seem to be influenced by emotional disturbances. They begin with slight nausea and with a chilly feeling and headache, followed by vomiting of the gas- tric contents, and, later, bile and mucus streaked with blood. Lerche 1 1 Med. Rec., April 30, 1910. 492 DISEASES OF THE STOMACH ANT> INTESTINES reports a case in which the patient vomited from a few tablespoons to a cupful of blood during each attack. The vomiting is very persistent, and all food or even small quantities of water are ejected. In some cases there is severe pain. The patient becomes greatly prostrated, the abdomen sunken, and the face pale. The attack may last from a day to a week or longer. Suddenly the nausea and vomiting cease, the appetite returns, and the patient is rapidly re- stored to health. Gastric Juice. This has been found to be normal in most cases, though Einhorn reports a case of achylia gastrica. On the other hand, with gastrosuccorrhea, the content of hydrochloric acid is high, a valuable aid to differential diagnosis. Treatment. Rest, ice pellets, morphin, y grain (0.016), by hypo- dermic, and belladonna tincture, 10 minims (0.59), are useful. Cocain I deprecate. Tincture of hyoscyamus, 30 drops (2 c.c.), and hot applica- tions during attacks. Oxalate of cerium in grain doses is of value. Be- tween attacks, tonics, change of climate, and hydrotherapy. Avoid opiates as far as possible. Cyclic, Recurrent, or Periodic Vomiting in Children This is probably due to faulty metabolism (auto-intoxication) ; occurs generally in those from two to four years of age, of a nervous type and rheumatic diathesis (the rheumatic complex). Etiology. Kerley * shows that these children belong to the class known as "the rheumatic complex" suffering frequently in addition to cyclic vomiting from habit spasm, chorea, recurrent spasmodic croup and spas- modic bronchitis. They have growing pains and are subject to rhinitis, tonsillitis, acute rheumatism and endocarditis. The fats and sugar have a deleterious effect. These cases represent defective oxidation with the liver probably at fault. Habitual constipation may precipitate an attack, or fright or fatigue. When elimination is better and open-air exercise is possible as in late spring, summer and early fall, there are fewer attacks. Griffith 2 holds that cyclic vomiting may give symptoms very similar to appendicitis, the absence of signs of local inflammation being the chief differential point. Russell 3 reports a case of cyclic vomiting which autopsy apparently showed was due to recurrent spasm in an hypertrophied and somewhat stenosed pylorus. . Comby 4 believes that cyclic vomiting is generally due to chronic appendicitis and that cures have followed in many cases as a result of appendectomy. Symptoms. There are rarely premonitory symptoms such as loss of ap- petite, foul breath or a yellow tint; temperature is but seldom over ioo.5F. though it may not occur. It may even be subnormal; anorexia, nausea, 1 Practice of Pediatrics. 1 Amer. Jour. Med. Sci., cxx, p. 553. 3 Brit. Jour, of Children's Diseases, Feb., 1910. 4 Archiv f. Kinderheilkunde, vol. 1, 1909, p. 33. NERVOUS AFFECTIONS OF THE STOMACH 493 languor, followed by persistent and violent vomiting of food, mucus streaked with blood occasionally and at times bile. Prostration is marked ; the gastric contents very acid; occasionally large amounts of blood are vomited. The child becomes pale, eyes sunken, and loss of weight marked. Acetone, diacetic acid, and oxybutyric acid are present in the urine, and so it is believed it is a form of acid intoxication; others consider the acidosis a result of the condition; uric acid in the urine is diminished. Breath has odor of acetone. The attack may last a few hours but usually three to five days. It is a lithemic manifestation. The attacks are periodic and rapid recovery from each ensues. The attack resembles migraine in the adult. Antecedents are a neurotic and gouty family history. Carbohydrates in excess some be- lieve have a bearing on its production, but fats and sugar are thought to be responsible. Fatigue, excitement, or tonsillitis bring it on. Prognosis. Good. Diagnosis. Attacks are not precipitated by indigestible food but by fats and sugar; the disease is self-limited, and the child rapidly returns to the normal state. The attacks are repeated. Treatment. Calomel to abort it; food and drink should be stopped; enemata and enteroclysis are advisable. Hypodermoclysis or procto- clysis for thirst and fluid loss may be necessary in severe cases and rectal feeding is indicated. For Acute Attack. Alkaline Treatment. Sodium bicarbonate, 15- to 30-grain (1.0-2.0) doses, may be given t.i.d. by mouth, or double dose by rectum even to 5ii every six to eight hours in 5vi-5viii water if neces- sary for the acidosis. Small amounts of strained oatmeal gruel or white of egg may be given at this time. Heat should be applied over the abdomen and perfect quiet enjoined. Small doses of cerium oxalate, gr. Y^-y^ three or four times a day can be given. Medication and Diet between Attacks. Kerley advises the following medication and general diet, which I believe excellent. For a child three to ten years, 9 to 10 drops oil wintergreen or salicylate of soda, or aspirin total 9 to 12 grs. per diem after meals, in divided doses (f.e.,3to4grs. at a dose) for five days out of fifteen. During the other ten days gr. 10 soda bicarbonate twice daily after meals and so on for months. Aspirin is excellent if the salicylates disagree. The child should have regular meals and rest a short period thereafter. The bowels must be kept regular by means of green vegetables and fruit, avoiding enemata. These children should not take fat, or sugar, or cane sugar, nor cow's milk fat. Cream and raw fruit, especially highly acid fruit are excluded. Red meat is given sparingly (only occasionally). Yolks of eggs are prohibited. Sugar is absolutely excluded and deserts and stewed fruits are flavored with saccharin. Poultry, fish and egg whites are allowed. Skimmed milk or buttermilk may be given A. M. and P. M. Among the cereals allowed are cornmeal, oatmeal, hominy, rice, farina and cream of wheat served with a little butter and salt or skimmed milk. The child may take occasionally a baked potato, also carrots, squash, cauliflower, turnip, asparagus tips, 494 DISEASES OF THE STOMACH AND INTESTINES purees of peas or beans, custard made with whites of eggs, saccharin and skimmed milk flavored with vanilla, cornstarch, junket, or rice pudding. 1$. Sodii bicarb 3"; Fl. ext. cascara aromatic, Syrup rhei aa 5"- Sig. One-half to one teaspoon after each meal for constipation. Juvenile Vomiting Overwork at school is often the cause. Cardialgia and vomiting occur. There may be headache, slow pulse, pallor, dilatation of pupils, etc. Treatment. Tonics, proper diet, removal from school. Reflex Vomiting Nervous vomiting is frequently reflex in character from disease of almost any organ. Among the causes are disease of the pharynx, elon- gated uvula, diseases of the abdominal organs, as hydronephrosis, movable kidney, kidney colic, ptosis of the liver or spleen, peritonitis, appendicitis, hernia, cerebral disease and disease of the sexual organs. These condi- tions should receive appropriate treatment. The vomiting of pregnancy belongs to this type. Belladonna tincture, 10 minims (0.59), t.i.d.; cerium oxalate, 2 grains (0.13), t.i.d.; Fowler's solution of arsenic, several doses i drop each; bromids, 15 grains (i.o); codein, *4 grain (0.016); or chloral, 3 grains (0.194), t.i.d. 1$. Menthol gr. x (o. 6); Syrup 59 (60 . o) ; Aq. destil q. s. 3i y (125.0). M. Sig. Two teaspoonfuls t.i.d. The use of cocain I deprecate. Lavage is temporarily of service. Abortion may occasionally be required in pregnancy cases. Change of scene may be necessary. Idiopathic Nervous Vomiting . In some hysteric or neurasthenic persons (adults) vomiting will occur after meals without any apparent cause, more frequently in women and without showing the periodic type. Usually part of the meal is vomited. It may continue for a long period. Nutrition is frequently not disturbed. The vomiting may occur so quickly during the act of ingestion of food that it seems as if it did not enter the stomach, but was rejected by the esoph- agus. Other patients seem normal in this regard. Occasionally hysteric subjects may vomit blood. In all cases the gastric secretion must be studied, so as to exclude hyperchlorhydria, hypersecretion, etc., and to observe whether vomiting complicates some other disease or is a reflex affection. NERVOUS AFFECTIONS OF THE STOMACH 495 Treatment. Suggestion by the physician, the regulation of the mode of life, tonics, such as arsenic and iron, bromids; change of climate; gavage for about two weeks; lavage, with i : 1000 nitrate of silver, has proved of value. Faradization, extra-abdominal or intragastric, has been of benefit. Pneumatosis Spasm of the cardia, combined with pyloric spasm, may produce pneumatosis (distention of the stomach with air), with a resulting sensa- tion of tension and at times dyspeptic asthma. Hysteric or neurasthenic symptoms are associated. Aerophagia (air swallowing) is probably the cause, and to the section on such the reader should also refer. The upper part of the abdomen is markedly distended and tympanitic, and there is interference with res- piration. As a rule, there is no belching. Diagnosis. Organic affections of the stomach must be excluded, in which the gas has a foul odor and the contents ferment. Treatment. Tonics and bromids are indicated. Aspiration of the stomach in the acute attack, so as to give exit to the air, is the best method. It may be necessary to repeat it. Extract physostigmatis, % grain (0.008), or eserin, >{ o grain (0.00065) or morphin, y grain (0.016), or tincture of belladonna, 10 minims (0.59), or extract of belladonna, y grain (0.016), may be required. A little pep- permint water or spirits of chloroform aid the belching of gas. SECRETORY NEUROSES The secretory function of the stomach is undoubtedly under the direct control of the nervous system. For example, in a hungry dog with a fistula the sight of meat will produce gastric secretion, and in the case of a man with impermeable esophagus, but with a gastric fistula, mastication produced gastric secretion. The vagus has been demonstrated to be the secretory nerve. The stomach itself, however, possesses some secretory power since after section of the pneumogastric and sympathetic nerves, secretion will occur after the application of an irritant. Hyperchlorhydria, gastrosuccorrhea (hypersecretion), and achylia gastrica may all be functional disorders of secretion, and have been de- scribed in special chapters. Subacidity (hyposecretion, hypochylia gastrica, hypochlorhydria) may be of nervous origin, and must be differentiated from cases occurring with organic disease of the stomach, especially gastric catarrh. Hydrochloric acid, strychnin, massage, and electricity are of service in these last cases. In the subacid cases sudden changes in the gastric findings (secretory) are in favor of a neurosis. Disorders of secretion may accompany other diseases, such as tabes or spinal lesions. 496 DISEASES OP THE STOMACH AND INTESTINES NERVOUS DYSPEPSIA (LEDBE) (Synonym. Neurasthenia Gastrica) Leube originally described nervous dyspepsia as a disorder of the stomach, characterized by a variety of distressing subjective symptoms during the act of digestion, but in which it was normal as regards time and chemism. In effect, he originally considered "nervous dyspepsia" as a neurosis of sensibility. He has more recently extended his definition to other forms. Strictly speaking, nervous dyspepsia is a combined gastric neurosis in which the sensory disturbances (subjective symptoms) are the most prominent. It may be combined with secretory and, at times, even with motor disturbances. Gastric Juice. The findings in the gastric juice are not characteristic. It may be frequently normal; it may occasionally be hyperacid, more frequently diminished acidity, or at times there may be variations in the same subject. In long persistent cases atony may be present. Some authors refer to the presence of enteroptosis or membranous colitis with neurasthenia gastrica. In this connection it is evident that fre- quently the diagnosis of "nervous dyspepsia" is made, when, in reality, gastroptosis (enteroptosis) is the basis of the difficulty. With the ptosis of the viscera we have sensory, secretory, and frequently motor dis- turbances of the stomach, associated with nervous symptoms, but the correction of the ptosis will cure the condition. In pure nervous dyspepsia all organic lesions of the stomach must be excluded, and also ptosis of the viscera. The stomach must occupy the normal position. Etiology. Neurasthenia gastrica may occasionally appear as an independent neurosis, but more usually with nervous symptoms, hysteria, or neurasthenia. Grip, pulmonary disease, anemia, chlorosis, malaria, or debilitating conditions predispose to it, as do also reflex irritation from the sexual organs, excessive venery, abuse of alcohol, or tobacco. Age and Sex. This disease occurs more fequently in men than in women, especially among brokers and those subject to worry and mental strain, and usually at the prime of life, between thirty and fifty, though it may be present at other periods. Symptoms. The patient generally complains of a feeling of fulness or pressure after eating, or even of slight pain or belching, loss or irregularity of appetite, a sleepy feeling, or even weakness or dizziness. The tongue is usually clean. There is marked mental depression, and the patients are nervous and anxious. One peculiarity is that the quantity and quality of the food seems to make little difference in their symptoms. At times indigestible food can be taken without discomfort, while at other times digestible food may produce the symptoms. Occasionally the pain and discomfort are present when the stomach is empty. There is often nausea and occasion- ally vomiting. Thirst is variable. There is usually tension or fulness of the intestines due to accumulation of gas, which is passed later per rec- tum. The bowels, as a rule, are constipated, with occasionally an alter- NERVOUS AFFECTIONS OF THE STOMACH 497 nating diarrhea. The movements may appear in narrow cylindroids or small balls in some cases. In addition to the feelings of depression, insomnia, palpitation, head- ache, and lassitude may be present; also, vertigo, impotence, or emissions. The surroundings and general mood of the patient have a marked in- fluence on the symptoms. The cases are often extremely disagreeable in their "home life." Circumscribed points, sensitive to pressure, have been described as diagnostic; one below the ensiform and the others near the navel, especially to the left, but Ewald has demonstrated "nervous dyspepsia" in which no such points could be found. Course. The course of the disease is slow and the symptoms vary; sometimes one symptom being prominent; at another time, another. The mood of the patient has a marked influence, and in good company he may forget his trouble. They generally do not suffer much in nutrition, but in cases with insomnia they at times lose considerable weight. Diagnosis. The presence of general nervous symptoms, especially of those pointing to the stomach, without the presence of organic disease of the organ;' the fact that the gastric secretion is often found to be normal, though at times hypochlorhydria and more rarely a mild hyperchlor- hydria, and that we frequently obtain variable gastric analyses in the same patient; that there is lack of proportion between the gastric findings and the condition of the digestive organs, as compared with the severe com- plaints voiced by the patient; that the character of the food, whether digestible or indigestible, seems to make no difference as regards increasing or ameliorating the symptoms, and, finally, that change of scene or the mental condition of the patient has a decided influence on the condition all these facts point to neurasthenia gastrica. The writer believes pure nervous dyspepsia to be rare, and that it is often thus incorrectly diagnosed. Differential Diagnosis. The chief differences are as follows: Neurasthenia Gastrica. Character of the food makes no difference as to symptoms. There are sudden changes in the patient's condition : well for a few days, and then marked symptoms; nervous symptoms marked. Gastric secretion often normal, and frequently variable in the same patient at different times. Chronic Gastritis. Aggravated by errors in diet; symptoms constant; mucus in the gastric contents; reduction in hydrochloric acid is marked as a rule. Ulcer of the Stomach. Painful area in the epigastrium, tender on pressure; dorsal pain; hematemesis or occult blood, melena, and pain is increased markedly after ingestion of food. The character of the food influences the pain markedly, even in the more obscure cases. Pain remits or disappears. Hyperacidity in some, but not in all. Cancer. Age of patient 40-60 yrs.; tumor, cachexia; quality and quan- tity of the food may not markedly influence the pain; gastric analysis usually showing absence of free HC1, lactic acid, and Boas-Oppler bacilli present; pain continuous; progressive emaciation. Treatment. If there are any sexual disorders which reflexly might affect the nervous condition, these should be treated; sexual excesses or overindulgence in alcohol or tobacco should be checked. Brokers and 32 498 DISEASES OF THE STOMACH AND INTESTINES professional men who have mentally overexerted themselves or are tired with the worry of business cares, lead an irregular life, or who are engaged too actively in social pursuits, if possible, should have a change of scene. Horseback riding, walking, golf, yachting, fishing, shooting, camp life for a few weeks, a pleasure trip, all give excellent results. A short ocean trip south or abroad is of service. For those who cannot afford these methods, the lightening of business and professional cares is important. Hydrotherapy, massage, electricity, especially by the faradic current, combined with out-of-door life and proper exercise, mild gymnastics, so as not to tire the patient, are of value. The mental impression created by the physician is important. Static electricity is at times of service. General faradization, the bare feet on one electrode, and the other being passed over the body, is useful (Rockwell). The diet should be abundant, the patient avoiding highly seasoned food, alcohol, strong coffee, and excessive smoking. Stomachics should be given if hydrochloric acid is deficient, such as nux vomica, compound tincture of cinchona, dilute hydrochloric acid, etc. If hyperchlorhydria, then the alkalis should be administered. The patient should secure the proper amount of sleep. Forced feeding and the Weir-Mitchell rest cure are necessary in severe cases. Milk, cream, butter and raw eggs are of value in reduced nutrition. Malbranc's gastric douche has been recommended in some cases, and Einhorn suggests the use of his gastric spray. Personally I do not employ such local measures. The general tone of the patient should be built up by iron, such as iron pills, iron tropon, arsenic, and strychnin. Small doses of nux vomica, combined with compound tincture of cinchona, are excellent to improve the appetite: 1^. Tr. nucis vomicae 5iij (12.0); Comp. tinct. cinchona 5ss (16.0); Aq. destil q. s. giv (125.0). M. Sig. i to 2 teaspoonfuls t.i.d. in water before meals. Basic orexin, 3 grains (2 decigrams) t.i.d., has also been recommended by Einhorn for this purpose. Sodium or ammonium bromid, 5 to 10 grains (0.3-0.6) two or three times a day, lessens the nervousness. The bowels should be properly regulated by the diet and by cascara, aloin pills, phenolax, regulin, mineral oils, olive oil, etc. Iron springs, such as Franzensbad, or salines, as Kissengen or Weisbaden, are of service. The carbonated bath (Nauheim, Triton) I have found^-given every other day at home for a course of 12 baths at a temperature of 95 to 98F. to be of service in toning up the circulation and general nervous condi- tion. CHAPTER XVIII DYSPEPTIC ASTHMA THIS type of asthma, due to digestive disturbances, was first described by Henoch, 1 later by Silberman, 2 Oppler, 3 Boas, 4 Murdoch, 5 Einhorn, 6 and others. The symptoms first reported by Henoch were of an acute type, and, according to his belief, were the result of reflex action starting from the stomach. It is noteworthy that the most severe symptom disappeared when the patient vomited. In his cases the breathing was rapid and shallow, pulse rapid and feeble, and at times so rapid that it could not be counted, extremities cool, the temperature subnormal, and there were even symp- toms of collapse. In all cases there was acute dyspepsia due to some error in diet. The region of the stomach was usually distended and painful. The greatest number of cases were observed in children. Numerous explanations have been given for this condition, and a variety of experiments have been performed. Henoch believes it to be due to reflex action, starting from the stomach and causing a vasomotor spasm; while Einhorn suggests reflex irritation of the vagus fibers. In view of the fact that the majority of cases occur after dietetic error, Riegel's suggestion of auto-intoxication as a factor seems to have a decided bearing on the subject. On the other hand, under Acute Dilatation of the Stomach I referred to certain peculiar clinical types, in one of which many of the symptoms resembled angina pectoris, there being dyspnea and rapid and feeble heart action, and in some attacks loss of consciousness. These attacks followed indiscretion in diet. In view of this fact and also that Henoch describes distention of the stomach as present in most cases, and dietary indiscretion as a cause, it would seem to me that in this type at least acute gastric dilatation from auto-intoxication is a factor. Einhorn describes acute cases following excesses in eating, drinking or smoking, excitement, or from no discoverable cause. Even these facts do not mitigate against the theory of distention. The second group which he classifies are more of a chronic type, appear- ing after meals, or after overexertion, or without apparent cause, or those appearing several hours after meals spontaneously, or after exertion. In some of these cases a small amount of food would check the attack. The last type would seem to suggest reflex irritation from hyperchlor- hydria, for example, which when relieved would stop the asthma. 1 Berlin, klin. Wochens., 1876, No. 181. 2 Ibid., 1882, No. 23. 3 Allgem. Mecl. Central. Zeit., 1890, No. 71, p. 849. 4 Arch. f. Verdauungskrank., Bd. n, 1896, p. 444. 8 N. Y. Med. Jour., Jan. 12, 1901. 8 Jour. Amer. Med. Assoc., Feb. i, 1902. 499 500 DISEASES OF THE STOMACH AND INTESTINES Some of the last group present, in some cases, symptoms suggestive of pseudo-angina pectoris. Secretory Functions. Achylia gastrica has been found in some patients and hyperchlorhydria in others. Treatment of these conditions caused subsequent disappearance of the attacks of asthma. With achylia the coarse particles of food, Einhorn believes, might cause reflex irritation of the vagus. Asthma dyspepticum may also occur with chronic gastritis. On the other hand, these attacks have occurred in patients in whom the gastric secretion was normal; and Boas believes that hyperesthesia of the stomach with reflex irritation is the cause. Again, in my case of acute dilatation with some of the attacks similar to angina, the gastric secretion was normal; but dietary indiscretion pro- duced gastric distention and the attack noted. It was immediately relieved by vomiting. Floating liver was noted by Einhorn in five cases, and this together with abdominal ptosis of other organs; and he believes that the prolapsed liver, by dragging down the diaphragm, may be a cause of this type of asthma. In my own opinion, ptoses of the viscera have an influence on the secretory conditions in the gastro-intestinal tract, and only to this degree predispose to dyspeptic asthma. Probably these various factors to which I have referred may have a bearing in different cases. Treatment. Disorders of the gastric secretion must be appropriately corrected, and ptosis of the viscera supported by Rose's adhesive belt. Excesses in the use of alcohol and tobacco must be corrected, mental worry and strain be avoided, and the mode of life must be regulated. All indigestible food must be avoided and diet suitable to each case must be instituted. By this means many cases will be relieved and often cured. In acute cases with distention of the stomach, lavage is indicated, also calomel, 5 grains (0.3), followed by a saline cathartic. Catharsis is also indicated in cases following excesses in eating or drinking. CHAPTER XIX THE STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS UNQUESTIONABLY there are few diseases, either constitutional or local, which are not attended to a greater or lesser degree by some disturbance of the digestive organs. These are dependent on the general disturbance of the organism and are appropriately discussed under the symptoms of each disease. In the present chapter I shall only briefly refer to those diseases in which disturbances of the gastric functions are particularly conspicuous. FUNCTIONS OF THE STOMACH IN ACUTE FEBRILE DISEASES Numerous investigations have been carried out both on animals and men, in some of which at least accurate quantitative gastric analyses were performed. Riegel concludes that we are probably justified in stating that in acute febrile infectious diseases the production of hydrochloric acid was more frequently reduced than normal, and the secretion of pepsin is, as a rule, unchanged. Probably the fever is responsible and the condi- tion is temporary. Von Noorden 1 showed that hydrochloric acid reaction can be obtained in fever cases if pepper and salt are administered with the food. Some interesting researches have been carried out in numerous cases of typhoid and pneumonia. During the high temperature of these dis- eases there was a marked diminution, and in some cases an absence of hydrochloric acid. During defervescence an increase of the secretion was noted. During high temperatures pure milk was found in the stomach in a curdled condition several hours after the normal time for evacuation, and in one case, on autopsy, the stomach was found filled with the curdled milk of previous feedings, thus demonstrating a diminution of the motor function. Water alone was then administered at this period. During lower temperatures the administration of foods freely soluble in water, such as broths and gruels, were found to be best. There were less fermentation and distention under this method of feeding and the stomach more readily emptied itself. In my own experience 2 I can confirm the fact that during the high temperature of typhoid the free hydrochloric acid diminished, often mark- edly, and the motor function is not as active. It has also been found that biliary secretion is disturbed during high fever. Stolmkow noted dis- turbances in the pancreatic secretion during high temperature. These facts demonstrate that the excessively high calorie food values advocated by some in typhoid fever are unscientific. 1 Lehrbuch der Pathologic des Stoffwechsels, 1893. 2 Amer. Med., May, 1909. 5O2 DISEASES OF THE STOMACH AND INTESTINES CHRONIC FEBRILE CONDITIONS Observers vary considerably in their findings in the gastric secretion in these cases, some noting no changes whatever. In my own experience the temperature, as a rule, caused disturbance in the secretory function of the stomach, lessening the HC1 production. The type of disease, the physical condition, the personal equation of the patient, and, most im- portant, the time at which the analysis is made, all have a bearing. I shall refer to the work of Hildebrandt on this subject, under Tuberculosis. The power of absorption seems to be impaired in fever (Sticker). 1 CONDITION OF THE STOMACH IN PULMONARY TUBERCULOSIS Phthisis quite frequently begins with dietetic disturbances, such as heart-burn, belching, pressure, nausea, loss of appetite, constipation alter- nating with diarrhea, and even vomiting, with the lung symptoms so slight as to be at first overlooked. It has been called pretubercular dys- pepsia. In the later stages we may have the dyspeptic symptoms quite marked. Hildebrandt 2 found the following results: The cases in which free hydrochloric acid was present usually had no fever, while those in whom it was absent suffered from continuous fever. When it was absent at one part of the day, it was when the temperature was high; and when present at another part, it was when the temperature was low. The temperature, therefore, exercised an influence. These findings were in advanced cases. Klemperer 3 studied 10 cases in the initial stage, three in the advanced, and one in the moderate. In the beginning the secretory power of the stomach was usually in- creased, often normal, and rarely reduced. In the terminal stages, always greatly reduced. Motor reduction slight in the initial stages, reduced in later stages. Brieger 4 analyzed 64 cases: 31 advanced, with continuous fever; 37 moderate, with more or less fever; 6 incipient cases, with no fever. Gas- tric secretion normal in 16 per cent, of advanced cases, and in the others insufficiency of varying degrees; in 9. 6 per cent, absence of free hydrochloric acid. In moderate cases, 33^ per cent, normal, and in all others perver- sion; and in 6.6 per cent, normal secretion absent. In the initial cases, normal secretion and perversion were equally divided. Einhorn 5 has shown in analyses of 15 cases that the appetite does not seem to correspond, as would be expected, to the gastric findings; and also that frequently the subjective symptoms do not harmonize with the objective findings. Treatment.^-The main indication is to improve the resisting power of the patient against the primary disease. Forced feeding, especially by Russell's method, rest in bed, and fresh 1 Deutsch. med. Wochens., 1889, No. 15. 2 Berlin, klin. Wochens., 1885. Ibid., 1889, No. 2. 4 Deutsch. med. Wochens., 1889, No. 14. 6 Loc. cit. STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 503 air, with milk and vegetable juices, I believe the best treatment for the tuberculosis when the patient is unable or not compelled to work. I have seen a gain of 15 to 25 pounds in each case by his methods at Ward's Island in 12 cases in eight weeks. The heart and kidneys must functionate properly for success with his method. I have also employed a diet such as I use in gastroptosis to improve the nutrition, though the presence of temperature would modify the power of assimilation. I know of some excellent results in the treat- ment by Russell 2 of his ambulant cases with a diet based upon his theory of "lime starvation," though I can express no opinion as to the correct- ness of his view. Functional disturbances of the stomach should be treated. Tuberculous ulcer of the stomach is occasionally met with in connection with tuberculosis of the other organs ; the primary condition is rare. PELLAGRA The changes in the gastro-intestinal vary in degree, being most marked in the acute forms. In the acute form (typhus pellagrosus) there is a chronic gastro- enteritis with the formation of ulcers and swelling of the mesenteric glands. In acute cases true gastritis has been found and atrophy of the muscular coat of the stomach (achylia) has been noted. The gastro-intestinal symptoms 3 are the earliest, most persistent and dangerous; they may begin with sore mouth, nausea, gastralgia (pyrosis), distention and belching. CHLOROSIS AND ANEMIA Among the gastric symptoms in these conditions are found gastralgia, anorexia, hyperesthesia of the stomach, hyperchlorhydria, and chronic atony. These symptoms appear more frequently after eating, than on an empty stomach, and occur, as a rule, in attacks at irregular intervals. There are often perversions of appetite. The atony, if neglected, may progress to chronic atonic ectasia. In chlorosis (primary anemia) the hydrochloric acid secretion is, as a rule, increased. In anemia (secondary), on the other hand, depending on the causative disease we may find variable results; hydrochloric acid decreased, normal, or (more rarely) increased. The relation between achylia gastrica and pernicious anemia has already been described. The relation of intestinal putrefaction to this disease is described later. Many of the derangements belong to the neuroses and are dependent on the condition of the blood. The administration of iron is chiefly indi- cated, with the additional correction of the functional disturbance, if such be present. 1 Medical Record, June 17, 1916. 2 Medical Record, March 22, 1913. * Roberts, Pellagra, p. 107. 504 DISEASES OF THE STOMACH AND INTESTINES HEART LESIONS In general we may say that while compensation is present, in many cases the stomach functions are normal or nearly so; with imperfect or failing compensation, with resulting stasis and hyperemia in the gastric mucous membrane, I have noted diminution in the amount of free hydro- chloric acid with accompanying digestive disturbances, belching, epi- gastric distention with a feeling of pressure, anorexia, and at times nausea and even vomiting, with sick headache. These conditions improved after treatment was directed to the circulation. In severe cases free HC1 may be absent. In one case with poor compensation and frequent gastric attacks, a course of treatment at Nauheim produced excellent results. Symptoms simulating heart lesions may be produced by gastric dis- orders, thus: Ulcer, chronic ectasy, and chronic gastritis may produce bradycardia or arrhythmia; or tachycardia may occur with chronic gastritis, in nervous gastric disorders, or with atony. Tachycardia with acute dilatation of the stomach, especially with existing heart lesions, the author has described in the chapter on Acute Ectasy. DISEASES OF THE LIVER Diseases of the liver are generally accompanied by gastric symptoms; with cirrhosis and the resulting circulatory disturbances of the viscera, the gastric secretion (free hydrochloric acid) is more frequently diminished. The findings in other liver disturbances are not constant. Hematemesis may occur with cirrhosis, acute yellow atrophy, etc. ANEURYSM In a case of aneurysm of the celiac axis, referred to under Cancer, free hydrochloric acid was absent, lacid acid present, and the stomach dilated. Circulatory disturbances were responsible for the gastric findings and pressure, for the dilatation of the stomach. DISEASES OF THE KIDNEYS Gastric disturbances are frequent in nephritis, and nausea and vomit- ing may be the first symptoms. In fact, Osier has reported death with these symptoms, and nephritis may be unsuspected until autopsy. The excretion of urea through the gastric mucous membrane, or cerebral irrita- tion from the poison are responsible for the vomiting. Variable conditions of the gastric secretion have been reported by various observers. Biernaki 1 has studied 25 cases of nephritis, both acute and interstitial, and found in general, the gastric secretion was diminished, and also that the quantity of free hydrochloric acid was reduced in proportion to the extent of the edema, the excretion of albumin, and the reduction in the quantity of urine excreted. Pepsin was reduced and the motor function was increased. Free hydrochloric acid was present in the mild cases in large or small quantities. 1 Berlin, klin. Wochens., 1891, Nos. 25 and 26. STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 505 Einhorn has observed achylia gastrica in a case of renal calculus, which disappeared after operation, and A. A. Jones 1 has found achylia gastrica among patients with kidney disturbances. DIABETES The digestion is sometimes good in diabetic patients, so that frequently the functions of the stomach are never examined. Variable results, however, have been secured. Atrophy of the gastric mucosa has been found in a few cases. The motor power was good. The gastric motility is quite frequently markedly increased, so that it may be necessary to aspirate a test-breakfast within less than half an hour after its ingestion. Rosenstein 2 reports normal secretion in four cases and abnormal in six, while Cans 3 found six normal and four negative. Gilbride 4 finds that the secretion of pepsin is frequently reduced and sometimes absent; also that a high percentage of hydrochloric acid does not indicate a good pepsin digestion. Hydrochloric acid was absent in three of the seven cases reported. Chronic gastritis has been associated in some cases. The findings are not constant, and both normal and abnormal conditions of the secretion have been observed. Hydrochloric acid may be absent for a long time and then reappear. As most diabetics have arteriosclerosis, it is probable that the latter accounts for some of the changes in gastric functions in certain cases. ARTHRITIS DEFORMANS In one easel found hyperchlorhydria marked; and Einhorn reports one case of achylia. The relation of intestinal putrefaction to arthritis deformans is described later under that topic. GOUT In two cases Einhorn reports achylia, and in several mild cases hyperchlorhydria. Grip. Gastric disturbances are reported by Kaufmann in grip. MALARIA Gastralgia may occur as a substitute for the malarial paroxysms and has already been described, or vomiting may be present, associated with malarial symptoms. There are no characteristic features of the gastric secretion, but in the latter cases free hydrochloric acid may be diminished. Arteriosclerosis. General arteriosclerosis may affect the gastric vessels and produce disturbances. Harlow Brooks refers to arteriosclerosis oc- curring chiefly in the abdominal vessels. The possibility of this latter condition should be considered (see Visceral Arteriosclerosis). 1 N. Y. Med. Jour., Jan. 19, 1895. 2 Berlin, klin. Wochens., 1890, No. 15. 3 IX Congress f. innere Medicin, 1890, Wiesbaden. *Jour. Amer. Med. Assoc., Feb. 18, 1911. 506 DISEASES OF THE STOMACH AND INTESTINES DISEASES OF THE EYE Reflex disturbances of the stomach, loss of appetite, irritability such as nausea and vomiting, dizziness and dyspeptic symptoms regardless of the nature of the food may result from eye strain. Headache may be present. Eye strain due to errors of refraction, disturbances of accom- modation or of motility, iritis or glaucoma are examples of factors pro- ducing reflex gastric disturbances. DISEASES OF THE EAR, NOSE AND THROAT Acute conditions of these organs are responsible for gastric disturbances, while chronic discharge will also directly affect the stomach. These facts simply emphasize the necessity of a complete physical examination. DISEASES OF THE SKIN Eczema. Various systemic conditions probably have a bearing, and in some few cases correction of the digestive disturbances seem to have an influence in improving the condition. In one case I found hyperchlor- hydria, and in another deficient hydrochloric acid. Hyde 1 believes that gout, dyspepsia, constipation, and scrofula have a decided influence. James C. Johnston 2 reports on the toxic effects in the skin resulting from disorders of digestion and metabolism. He finds hyperchlorhydria most frequent, and intestinal fermentation with constipation and indi- canuria as accompaniments. Among the cases cited are loss of hair in acneif orm dermatitis with hyperacidity and gastro-intestinal crises. There were subsequent attacks of colitis. In some of the attacks no errors of diet were apparent and Johnston believes them to be anaphylactic through protein absorption. With urticaria, eczema, dermatitis herpetiformis, prurigo, psoriasiform scaling of scalp, purpura, pompholyx, scaling derma- tosis, and herpes facialis change occurred in nitrogen partition. There were most often a decrease of urea and a corresponding increase in the rest nitrogen fractions. Detoxicated thyroid to promote urea synthesis, hydrotherapy and reduction of nitrogen intake were valuable accessories in the treatment. Such susceptibility may be an hereditary transmission. Johnston reports cases of angioneuro tic edema, chronic urticaria and ulcera- tive stomatitis presenting the aspects of anaphylaxis, one showing an inherited tendency, but the urticaria case, the appearance of resulting anaphylaxis from absorption of certain definite proteins from the digestive tract. Adrenalin and atropin proved of value in urticaria as in the anaphylaxis of animals. Acne Simplex and Acne Rosacea. These are associated at times with gastric disturbances. Einhorn reports two cases of acne rosacea in whom chronic continuous gastrosuccorrhea was found. The correction of the latter benefited the skin affection. 1 Twentieth Century Practice, vol. v. 2 Journal of Cutaneous Diseases, Including Syphilis, March, 1912. STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 507 Psoriasis. The treatment of gastric disorders in this affection does not seem to benefit the lesion, according to Einhorn. Urticaria and Erythema. Some persons have an idiosyncrasy to lob- sters, crabs, strawberries, etc., and develop therefrom poisonous substances which produce these eruptions, associated at times with acute gastric symptoms. These conditions were formerly considered due to auto- intoxication. Combe (" Intestinal Auto-intoxication ") believes that acne, the seborrheic eczemas, urticaria, pruritus, strophulus infantum, and furunculosis to be chiefly due to intestinal auto-intoxication. He advises fresh brewer's yeast, i dram (4.0) t.i.d. before meals, for these conditions. Duncan Bulkley holds that cutaneous lesions are in some cases produced through cutaneous elimination of toxic substances. As noted above these conditions are held by others to be the result of protein absorption with anaphylaxis. This explanation is reasonable though intestinal toxemia might play a part in some cases. Protein absorption would not explain the case of strawberries in the author's opinion. The author holds that the entire gastrq-intestinal tract should receive attention. Thorough catharsis should be carried out. These foods should thereafter be avoided. Pemphigus of the Mouth. Einhorn has noted three cases in which there was hyperchlorhydria or neurasthenia gastrica, and in two cases improvement resulted from treating the gastric symptoms. In general, we may say that considerable investigation is still neces- sary to definitely determine the relations of gastric disturbances to skin diseases. TUBERCULOSIS OF THE STOMACH History. Tuberculosis of the stomach is a comparatively rare condi- tion. Arloing in 1903 collected 147 cases and Ricard and Chevrier in 1905 discussed 107 cases. Winternitz in 1908, refers to seven cases of primary and 47 cases of secondary tuberculosis of the stomach reported up to 1901, and nine or more secondary cases since that date. From these diverse statements, it seems difficult to decide on the authenticity of some of the reported cases. A. G. Ellis, in the New York Medical Journal, March 12, 1910, reports two cases. In the first patient, the condition was secondary to an extensive pulmonary tuberculosis. There were numerous gastric ulcers and a number of tubercles in the gastric mucosa. In the second patient, there were several ulcers, a number of tubercles, and a cyst containing tubercle bacilli. There was a chronic tuberculous peritoni- tis with adhesions. These cases were found at autopsy; as are most cases of tuberculous gastric ulcer. Tuberculous ulcers of the pylorus, with nar- rowing of the orifice, have been reported, and Ricard and Chevrier de- scribe a sclerosing type of pyloric tuberculosis. Anatomic Types of Gastric Tuberculosis. There may be a single ulcer or multiple ulcers. Diffuse miliary tuberculosis of the organ may be present and more rarely solitary tubercles. Tumor-like masses, usually at the pylorus, have been described. They may simulate carcinoma. Tuberculous cicatricial pyloric stenosis may occur. 508 DISEASES OF THE STOMACH AND INTESTINES Diagnosis. The determination of pulmonary tuberculosis, or a tuber- cular focus elsewhere is of value, as gastric tuberculosis is most frequently a secondary condition. Syphilis must be excluded by the Wassermann and Noguchi tests. A persistent afternoon elevation of temperature is suggestive. The tuberculin test should be made for diagnostic purposes. Symptoms. There are no specific symptoms of gastric tuberculosis. The tubercular ulcer is chronic, is not as apt to bleed as the simple ulcer, and the pain is liable to be severe in character. Treatment. Pulmonary tuberculosis or any other tubercular primary lesion should receive appropriate treatment. Carbonate of creosote or guaiacol carbonate, 5 grains (0.3) three or four times a day, are indicated for tubercular gastric ulcer; thiocol, 10 grains (0.6) t.i.d. is excellent. Also the bismuth preparations and proper feeding. Iron, arsenic, and the fats should be employed. Tuberculin may be employed cautiously by injection. Surgery. If a localized tubercular process, ulcer, or tubercular mass can be diagnosed, excision is indicated. SYPHILIS OF THE STOMACH Gastric symptoms quite frequently occur in the secondary and tertiary stages of syphilis. In the secondary stage they may often be attributed to fever (the constitutional condition) though at times a gastric syphilitic lesion may be responsible; while in the tertiary stage there are anatomic changes in the stomach itself. Fen wick 1 believes that syphilis may affect the stomach in three ways: By the formation of gummata, by producing er.darteritis, and by a chronic inflammation of the mucous membrane. The symptoms arising subside under antisyphilitic treatment. Flexner 2 holds that syphilitic gastric ulcer is not rare, while Dieulafoy 3 notes various lesions, such as hemorrhagic erosions, ecchymoses, gummata, infiltration of the submucosa and circumscribed gummatous ulceration, and cicatrices of the latter. Hour-glass 4 stomach may result. Pain, emaciation, vomiting, hematemesis, and melena occur in some cases. Riegel 5 reports 12 cases in which they complained of gas, nausea, dis- tress after eating, and gastralgia, which responded promptly to antisyphi- litic remedies. Death has resulted from perforation of a broken-down gumma. All doubtful cases should be examined for signs of previous syphilitic infection, for active syphilitic manifestation and also as to the history. Wassermann 's or Noguchi's test should be made. If this is not feasible then the diagnosis must be made by the usual methods of physical ex- amination for syphilis and should be tested by specific treatment. Of course, many patients may have digestive disturbances without any con- nection with the old luetic condition. 1 London Lancet, Sept. 20, 1901. 2 Amer. Jour. Med. Sci., Oct., 1898. 3 Gaz. Heb. de Med., 1902. 4 Cronin, Interstate Med. Jour., Sept., 1914. ' Diseases of the Stomach. STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 509 Hemmeter 1 has described syphilis of the stomach. Einhorn 2 gives the following classification and describes cases: (1) Gastric ulcer of syphilitic origin. (2) Syphilitic tumor of the stomach. (3) Syphilitic stenosis of the pylorus. To this I shall add & fourth type: (4) Syphilitic cirrhosis of the stomach. Smithies describes in addition: 3 (5) Chronic gastritis. (6) Perigastritis. His article on "Syphilis of the Stomach" is well worth studying. He reports 26 cases. (i) Gastric Ulcer (Syphilitic) A number of cases have been reported in which the usual treatment for ulcer failed, and which made complete recovery under specific treatment. (2) Syphilitic Tumor of the Stomach This condition is excessively rare. Einhorn has reported two cases, and refers to the fact that they may run their course like carcinoma. I re- ferred to a case in this volume under Differential Diagnosis in Carcinoma of the Stomach. In this patient the gastric analysis showed absence of hydrochloric acid and lactic acid abundant. The patient had lost 77 pounds in eight months and was vomiting continuously. The stomach was dilated to below the umbilicus, and though he had been on specific treatment for a time before I saw him, the pyloric' obstruction was so marked that drainage of the stomach was necessary to preserve life. Palpation gave a sense of resistance at pylorus. A rapid laparotomy at the Red Cross Hospital disclosed a gummatous tumor at the posterior wall of the pylorus, nearly blocking it. Gastro- enterostomy was performed and specific treatment pushed. There was no more vomiting and the case steadily improved. Niles 4 also recently reports a case of gastric syphilis with findings suggestive of carcinoma. (3) Syphilitic Pyloric Stenosis Einhorn reports a case of pyloric stenosis cured by antisyphilitic treat- ment. In most of these cases, however, gastro-enterostomy is required in addition to the antiluetic treatment. The following case of syphilis with gastric ulcer and pyloric stenosis is instructive. Infection dated posi- tively from June, 1915. Wassermann 4+, on August i, 1915. Patient, male, aged thirty-six. Gastric disturbances for several months previous to my first examination which was April 15, 1916. A month previous to this, early in March, 1916, patient began to have attacks of severe pain in the stomach, crampy in character, and vomiting spells, which afforded 1 Diseases of the Stomach, p. 556, 1897. 2 Ibid., p. 534, 1906. 3 Smithies, Journal A. M. A., Aug. 14, 1915. 4 Niles, Ibid., Feb. 19, 1916. 510 DISEASES OF THE STOMACH AND INTESTINES relief. A specialist in venereal disease had injected salvarsan three times and in addition 22 mercurial injections from early August, 1915, to early March, 1916. At this last, when vomiting first started all specific treat- ment was stopped, gastric disturbance being imputed to the mercury. No examination of the stomach was made. The patient grew steadily worse. The specialist certainly made a fatal error in stopping treatment. By the middle of April patient had lost 12 pounds in weight and had cramp attacks with vomiting several times daily often of material taken hours before. The prepuce was swollen, slight eruption about head of penis, inguinal glands enlarged. After the test breakfast, the stomach (lower border) apparently slightly distended, to 4 about reach the upper edge of the umbilicus. It was interesting to note, however, that though the radio- graph showed marked retention at the end of six hours; the stomach was not apparently dilated. The fibrous formation and blocking of the pylorus, therefore, must have been extremely rapid, after cessation of the specific treatment; aspiration one hour after Ewald's test breakfast yielded a residuum of 350 c.c. and y% glass of spinach ingested fourteen hours before. The gastric findings were of benign stenosis total acidity 85+; free HC1 55+; comb. HC1 25+; acid salts 5+; no occult blood no occult blood in the stool. Fig. 239 is the radiograph of the six-hour retention. On account of the rapidly developed symptoms and marked stenosis, I advised immediate gastro-enterostomy in addition to mercurial injec- tions. The surgeon, Wm. P. Healy, to whom I referred him, concurred in this view. The patient at first refused operation mercurial injections were pushed appropriate treatment for the hyperacidity belladonna and alkalis, olive oil, forced liquid feeding, raw eggs, cream, butter, etc.; the Rose belt applied and the patient directed to lie on the right side after each feeding. He insisted continuing at business so that lavage, which should have been consistently followed, could not be carried out. The first week, in spite of the omission, he gained 4 pounds and was delighted. / still advised operation. The next ten days he lost 8 pounds and was then immediately operated on by Dr. McGrath in Dr. Healy's absence. The result of the gastro-enterostomy has been a gain in weight of 1 5 pounds in three weeks and disappearance of all symptoms. Mercury, of course, should be continued persistently and also further salvarsan or neo- salvarsan injection. It is interesting to note that this patient undoubtedly acquired his stenosis from a syphilitic ulcer, during the second stage of syphilis, and the gastric findings were of benign stenosis. On the other hand, my case of pyloric stenosis (syphilitic), due to gumma, showed findings much like gastric cancer; which would be expected from the tertiary stage with fibrosis similar to fibrosis (cirrhosis) of the liver pancreas, etc. X-rays in Gastric Syphilis. Though some radiologists claim they can diagnose gastric syphilis from the radiologic findings alone, in cases of syphilitic pyloric stenosis, I believe it utterly impossible. The history, physical examination and serological tests must all be considered. On the other hand, if the stomach is diminished in size and of dumb-bell appearance due to deformity caused by infiltration involving the middle or pyloric half of the stomach, the pylorus being held open, so that the STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 511 stomach empties or begins to empty rapidly, with a slight retention in the cardiac end, syphilis can be diagnosed according to some of our radiolo- gists. In other cases of similar deformity there is more marked reten- tion on account of involvement of the pylorus or marked stenosis of part of the infiltrated body. Personally I should not exclude the possibility of cancer unless after serological tests. Operative procedure on syphilitic pyloric stenosis I do not believe requires more than gastro-enterostomy with subsequent antiluetic Fig. 239. Marked six-hour retention. Frequent vomiting and peristaltic move- ments. Syphilitic stenosis of the pylorus, secondary to syphilitic ulcer. Hard fibrous mass felt at pyloric opening nearly completely blocking same. Wassermann 4+. Syphilis one year's duration. Gastro-enterostomy by Dr. John J. McGrath (author's case). treatment. One does not see cancer engrafted on syphilitic cirrhosis of the liver, or on chronic syphilitic pancreatitis though Lane believes the latter to occur as a result of his Kinks, while secondary lesions respond to active luetic treatment. (4) Syphilitic Cirrhosis of the Stomach This case has also been referred to under Cancer. The stomach was small, hard, and contracted, and on palpation felt like a cirrhotic carcinoma, 512 DISEASES OF THE STOMACH AND INTESTINES involving the entire stomach. The patient was an elderly man, had lost considerable weight, and was suffering from gastric symptoms. Examination demonstrated cirrhosis of the liver and evidences of old syphilis. Deficient HC1, or achylia, occurs in this type. These facts show that the syphilitic history, or evidences of the same, should be investigated carefully in gastric affections. Treatment should be for syphilis. The author believes that mercury should be combined with the iodid treatment in these cases. For example, mercury salicylate in albolene (10 per cent, strength). Inject of this by hypodermic 10 minims every third or fourth day. In addition, preferably, potassium iodid, 30 grains to i dram (2.0-4.0), should be given daily in divided doses at meals. Twice the quantity may be administered by a gradual increase. It may be necessary to substitute sodium iodid. The injection of "606" or preferably neosalvarsan may be employed followed by mixed treatment. Appropriate remedies may be given in addition for special symptoms, or secretory or motor disturbances. GASTRIC CRISES OF TABES In the preataxic stage Starr found gastric crises as the first symptom 1 8 times out of 450 cases. They may occur early in the course of the dis- ease alone or with laryngeal, nephric, rectal and other crises. In the incipient stage the so-called lightening pains are frequent; they some- times are not so severe, but are merely a sensation of soreness, or burning, leaving an area of tenderness. They are most common in the legs and about the trunk and follow usually the dorsal root areas, and occur at irregular intervals. There are paresthesia, with numbness of the feet, tingling, at times a sense of constriction about the body. There may be the Argyll-Robertson pupil which occurs in the preataxic stage, or ptosis or paralysis of the external muscles of the eye which often may be transient. This paralytic condition, developing painlessly in adults, is believed by some to be almost of as important diagnostic import as the Argyll-Robert- son pupils. Optic atrophy may occasionally occur early. Some patients complain of difficulty in emptying the bladder. An early and important symptom years before the development of ataxia is the gradual decrease and finally loss of knee and ankle jerks one before the other, or first in one leg. Though gastric crises may be the first subjective symptom noted by the patient and reported to the physician, if a thorough history is secured and a proper examination is made, there is little excuse of failure to diagnose the gastric crises within a brief period at least. It may of course be neces- sary to make the Wassermann or Noguchi tests. A preexisting vagotonia, Eppinger believes, has a predisposing effect upon the occurrence of crises. Symptoms. Suddenness of attack is one of the characteristics of this condition. The patient is seized with a violent pain in the epigastrium radiating through the abdomen, back and limbs. At times it is of a girdle character. Sometimes the pain begins with less severity and gradu- ally increases in intensity. There may be cutaneous hyperesthesia in the STOMACH FUNCTIONS IN DISEASES OF OTHER ORGANS 513 epigastrium pressure causing severe pain and areas of anesthesia may be found. The pain may last eight to twelve hours, or even to two weeks or more, but is not continuous and the paroxysms may be of short duration. Vomiting accompanies the onset of the pain both before and after meals. It consists first of stomach contents, then of a glairy mucus secretion at times tinged with bile and occasionally with blood. The latter may even be considerable in quantity. Hypersecretion may accompany the attack and large quantities, as much as 2 liters, may be vomited. As soon as the stomach is empty the effort of vomiting is more severe and the straining is added to the severity of the pain. The patients apparently suffer agony in many cases. The strength becomes rapidly reduced, there is profuse sweating, the extremities are cold, pulse small and rapid; respira- tion increased and there is intense thirst. There are frequently intestinal disturbances such as gaseous distention, flatus, and continuous diarrhea, the stools containing mucus and bile. The patient becomes extremely exhausted. Intestinal, rectal, laryngeal and other crises may coexist. Rarely death has occurred as a result of collapse or from exhaustion from the diarrhea. The attack generally terminates abruptly and the patient soon eats food with relish, the digestion being excellent, though in some recovery takes longer. Physical Examination of the Abdomen. The epigastrium is retracted and painful to pressure. Areas of hyperesthesia are found and occasion- ally areas of anesthesia. Succussion sound is usually absent. Occasion- ally there are eructation and hiccoughs. Distention is not frequent. Gastric Analysis. There may be variations in the stomach of the same individual and no finding can be considered pathognomonic. Some cases have hyperacidity, others hyperacidity with hypersecretion, or hypo- acidity, or anacidity, or hematemesis, or conditions may vary during the crises. Course and Duration. Crises may occur six months apart, or within a few months or within a few days of each other. The crises increase as the disease advances as a rule. Duration may vary from twenty-four to forty-eight hours, or may be prolonged several weeks. Differential Diagnosis. One must differentiate these crises from hepatic colic, nephritic colic, Dietl's crises, lead colic, attacks of hypersecretion and hysterical crises. The heavy blue line on the gums, neuritis, wrist drop and excessive granular basophilic degeneration, suggest lead colic and the hysterical crises are less violent. The symptoms of the other con- ditions have been already thoroughly described. Treatment. Acute Attack. Abolition of food as at first indicated and the remedies employed in acute gastritis for vomiting. One or two doses of antipyrin, gr. xv, or acetanilid guarded with caffein, gr. i, can be tried for the pain. Morphin, gr. y, by hypodermic or codein, gr. >, by hypo may be required. They should be used by phy- sician or nurse only. Hyoscyamin, gr. Koo> r hyoscin, gr. Koo, can be tried or cannabis indica or the bromids. If there is hyperacidity or hypersecretion or spasm, alkalis can be given and also belladonna. Lumbar puncture has relieved the acute attack. Foerster has recom- 33 514 DISEASES OF THE STOMACH AND INTESTINES mended rhizotomy, i.e., resection of the posterior spinal nerve roots from the twelfth to the fifth dorsal. High pressure sometimes occurs between attacks and for this the nitrites or aconite tincture, gtts. 8 (35 per cent.), t.i.d. is advised. After the attack, syphilis should receive treatment. Salvarsan or neosalvarsan should be infused intravenously or injected into the spinal canal and this should be followed by mixed treatment. PART III DISEASES OF THE INTESTINES CHAPTER XX METHODS OF EXAMINATION OF THE INTESTINES; EXAMINA- TION OF THE FECES; MECHANICAL PROCEDURES Special Interrogation. We presuppose that the method of interroga- tion of the patient, as described in Part I, has been carried out. Disease of the stomach may produce secondary intestinal symptoms, and hence the condition of this organ must be inquired into, and in most cases the func- tions examined. Inquire, furthermore, whether abdominal pains are present, and also their position. In the right iliac fossa they suggest appendicitis or catarrh of the cecum; in the left iliac fossa, disturbances of the descending colon or sigmoid. With rectal pain, inflammation in that region is probable, while pains near the navel usually originate in the small intestine. Pains of short duration and sharp in character are generally due to colic, and are fol- lowed and relieved by the passage of flatus or feces. They often shift from one region to another. Pains of long duration are usually from some organic lesion, such as ulcer or from some affection of the sensory nerves. Abnormal sensations, such as feelings of heat or cold, may be experi- enced over different regions of the abdomen. Tenesmus is present in dysentery and in many rectal affections. The time of the pain, whether immediately after meals or later, or during the night or in the early morning, is important. The stool should be investigated whether constipation, diarrhea, or alternating conditions exist, the number of movements, time of appear- ance, odor, color, and characteristics, as to whether mucus, blood, bile, pus, or undigested food are present. Do climatic changes or mental excitement influence the bowel action, or are headache, dizziness, or exhaustion associated with the movements? Is there distention of the abdomen with gas, localized or general? When does it appear? Is rumbling (are borborygmi) present? Do belching of wind or passage of gas from the bowel occur, and does this give relief? Total absence of flatus is important. Occurring with obstinate con- stipation, it would then suggest obstruction. Continuous vomiting associated with intestinal symptoms suggests obstruction. With acute symptoms, the temperature should be taken immediately. 515 516 DISEASES OF THE STOMACH AND INTESTINES PHYSICAL EXAMINATION OF THE INTESTINES The reader is referred to Chapter IV for general methods. Inspection. The retracted or trough-shaped abdomen occurs in stricture of the esophagus or cardia, basilar meningitis, lead-poisoning, and with long-continued inanition. The peculiar contour of enteroptosis has been described the concave epigastrium, sulcus between the recti above the umbilicus, and the pot-belly below. On distention of the normal colon with gas (CO2), the ascending and descending portions are seen as elongated swellings in the lateral regions, and the transverse colon at or just above the umbilicus. Protrusion of the abdomen may be over a definite area, or over the entire surface. It may assume the shape of a rounded hemisphere, or oval, slightly flattened, especially in atonic conditions of the intestines and in hysteria. Marked uniform distention with tense abdominal walls, absence of respiratory abdominal movements, and increased thoracic respiration are present in peritonitis. There may be a general bloating with atony, but there is not the marked tension of the abdominal walls, and the other symptoms are absent. Withascites, the abdomen is evenly protuberant above, with the center somewhat flattened, while the lateral and dependent parts bulge somewhat in the recumbent position; change of posture alters the shape of the ab- domen. This applies to the milder types. With marked distention, as with meteorism, the enlargement is uni- form. There is no bulging in any special location, except that the anterior portion is more prominent and change of position has no effect. Palpa- tion aids under these conditions. There may be protrusion of the abdomen in cases of neoplasm, in fecal accumulation, and occasionally in abscess, as of the appendix, from diver- ticulitis, or other intra-abdominal suppuration. Hernial protrusions at the umbilicus or in the inguinal regions, may be observed. In patients with thin abdominal walls, small sausage-shaped protru- sions are occasionally visible, which change their shape and position. This is due to peristalsis of the small intestine, occurs with no pain, and denotes no morbid condition. Similar waves may appear periodically and annoy the patient when caused by nervous influences. There are sometimes violent contractions (peristaltic unrest) of the small intestine visible, caused by stenosis or obstruction. If it is near the ileocecal valve, the swollen and moving coils of intestine lie one above the other in the central part of the abdomen (ladder pattern). Intense pain accompanies these movements. Marked distention may be visible in the course of the colon (in the circumference of the abdomen), and if associated with visible peristaltic contractions of the large intestine, passing along it from right to left, it is diagnostic of partial or total obstruction of the large bowel. In some cases a recurring protuberance is noted, disappearing with a loud sound. This is probably near the point of stenosis. INSPECTION OF RECTUM PROCTOSCOPY AND SIGMOIDOSCOPY 517 INSPECTION OF THE RECTUM PROCTOSCOPY AND SIGMOIDOSCOPY The anus can be inspected by having the patient lie on his side with thighs and knees flexed, and his back toward the examiner. The buttocks should be held apart with the hands. The patient may be instructed to bear down as if to defecate. This is often an aid to the examination. Hemorrhoids, condylomata, skin eruptions, rectal prolapse, occasionally Fig. 240. Kelly's short rectal speculum. polypi which may extrude, abscess (periprocititis) occasionally thread worms, rarely intussusception, fissures, and fistulae may be discovered. For inspection of the rectum the introduction of a speculum (procto- scope) is necessary. Palpation of the rectum (described later) should be carried out, before the introduction of the proctoscope. Fig. 241. Kelly's standard rectal speculum. Proctoscopy. Various instruments have been devised, notably those of Howard Kelly, Roberts, Sims, Kelsey, Gant, and J. P. Tuttle (Figs. 240-248). Roberts' 1 glass speculum may be of value for the examination of a patient with an irritable anus. The instrument does not distort the parts and can be readily introduced. There is a lateral opening for the purpose 1 Jour. Amer. Med. Assoc., Jan. 8, 1910. DISEASES OF THE STOMACH AND INTESTINES of making an application or employing a probe. There is a mirror so arranged that it can be pushed in, withdrawn, or rotated, and so give a view of the entire wall at a varying depth. It is necessary to use reflected light from a head-mirror or an electric head-light (Fig. 242). Fig. 242. Roberts' glass anal speculum. The bowels should preferably be thoroughly evacuated by enema before the examination. If the region is sensitive, a few drops of a 2 to 5 per cent, cocain solution can be injected inside and along the sphincters with a narrow-pointed rubber syringe. A suppository containing opium, Fig. 243. Kelly's proctoscope (^ actual size). i grain (0.065), with extract of belladonna, y$ grain (0.022), or cocain, Y% grain (0.008), can be substituted. Tuttle's pneumatic proctoscope is a valuable instrument. There is an electric lamp at the end of the inspection tube and an arrangement for Fig. 244. Kelly's sigmoid speculum. inflation of the rectum, so that it can be distended with air at the time of examination With other specula, a head-mirror with electric-light attachment is most convenient, though an ordinary light can be arranged. The patient lies on the side, with thighs and knees flexed, with back toward examiner, or the legs can be elevated on a crutch, or in some cases the knee-chest INSPECTION OF RECTUM PROCTOSCOPY AND SIGMOIDOSCOPY 519 position can be assumed. The external sphincter as well as the speculum should be lubricated with sweet oil or vaselin, to render introduction more easy. Sigmoidoscopy. A long speculum (sigmoidoscope) may be required for examination ot the sigmoid (Figs. 250 and 251). Among the best sigmoidoscopes are those of Kelly, Tuttle, and H. Strauss; Beer 1 reports Fig. 245. Sims' rectal speculum. a modification of the latter. My own preference is the pneumatic sig- moidoscope of Tuttle or Strauss. Strauss' instrument possesses the advantage that if the lamp becomes dirty, it can be removed and cleaned without taking out the entire instrument, and also has a pneumatic inflator, as has Tuttle's sigmoidoscope. Tuttle introduces the instrument in the Sims posture, while Strauss advocates the knee-chest position as in Fig. 246. Kelsey's speculum. Fig. 249. Sigmoidoscopy should be performed by direct vision. The instrument should be warmed and thoroughly lubricated. It should be introduced with the obturator for about 4 inches along the sacral curve, keeping the end of the instrument toward the sacrum. The obturator should then be removed and the light turned on. The inflating instru- ment is best, as by slight puffs of air with the bellows, the folds of the bowel are pushed aside. The operator should look for the lumen of the bowel and 1 N. Y. Med. Rec., Feb. n, 1911. 520 DISEASES OF THE STOMACH AND INTESTINES gently follow it. The bowel passes back along the sacral curve and then turns sharply forward over the prominence of the sacrum and at this point the tip of the instrument must be carried forward. At the recto-sigmoidal juncture, there is a fold of mucosa somewhat like Houston's valves which may catch the tip of .the instrument. Usually the sigmoid passes to the left after the recto-sigmoid junction, though this is not invariable. Fig. 247. Gant's examining speculum. One must avoid entering the cul-de-sac of the rectum which extends up and behind this junction. Force should never be used. The procedure is somewhat more difficult in women particularly with enteroptosis. If the rectum is very sensitive a weak cocain injection gr. y in water 5iv may be given as preliminary. Occasionally anesthesia may be required. In Fig. 252, 1 arrow No. i shows the direction of the apparatus at the Fig. 248. Gant's hinged speculum. beginning of the entry; arrow No. 2, the position at the view of the ampulla recti, and arrow No. 3, the direction at the time of entering the flexure of the colon (sigmoid). The presence of blood, or blood and pus in the stools, or progressive constipation are indications for examination of the rectum and sigmoid. One should, of course, exclude ulcerations of any portion of 1 S. Kelen, Pester Medizinische-chirurgische Presse, April 17, 1904. INSPECTION OF RECTUM PROCTOSCOPY AND SIGMOIDOSCOPY 521 the small intestine. When rectal examination (proctoscopy) fails to afford the desired information, sigmoidoscopy is indicated. One should, of course, acquire all possible information by abdominal palpation and other methods. Fig. 249. Sigmoidoscopic examination of the colon with the patient in the genupectoral position. Palpation. The technic of simple and reinforced palpation has been described in Chapter IV. The cecum, parts of the ascending and descending colon, the transverse B Fig. 250. A, Tuttle's pneumatic proctosigmoidoscope. Two lengths rectal 4 inches, sigmoid 10 inches with window attachment to make instrument air-tight for bowel inflation; B, Tuttle's sigmoidoscope with Mercier curve. colon, and the sigmoid flexure are often accessible to palpation, but not as readily so in obese or in muscular subjects. Fecal accumulation, tumors, thickening of the gut, or purulent collections connected with the intestine can often thus be recognized. 522 DISEASES OF THE STOMACH AND INTESTINES An uneven protuberant surface is characteristic of malignant growth, while an even surface is more often found in benignant neoplasm or intus- susception. Volvulus occurs usually in the sigmoid. A fecal accumula- tion will, as a rule, "pit" on pressure (give a doughy ieel). Hard scybalae Fig. 251. Strauss' sigmoidoscope. occasionally feel like marbles under the fingers, but can be moved or slightly indented. Sometimes when raising the fingers from palpating, there may be a crepitating or sticky sensation, or the intestinal wall can be felt to slip off from the fecal mass. This symptom was first described by Gersuny. 1 Fig. 252. Sigmoidoscopy (knee-chest posture, Strauss) : Arrow i shows the direction of the apparatus at the beginning of entry; arrow 2, the position at the view of the ampulla recti; arrow 3 shows the manner of entering the flexure. Gurgling occurs in typhoid on palpation in the right iliac fossa, but is not diagnostic. Tenderness or pain on pressure can be readily determined by palpation, and are suggestive of inflammatory processes or ulceration. There may 1 Wiener klin. Wochens., 1891, No. 4. INSPECTION OF RECTUM PROCTOSCOPY AND SIGMOIDOSCOPY 523 be the general tenderness of acute intestinal inflammation or the acute pain and tenderness of peritonitis, either localized or general. Circumscribed pain on pressure may be present at McBurney's point (i% to 2 inches to the inner side of the anterosuperior spine of the right ileum) on a line drawn from this process to the umbilicus. Morris' point and the lumbar ganglia (referred to under Appendicitis), Robson's point, Murphy's point (gall bladder), tenderness at the costo- vertebral angles, and the tender points for duodenal and gastric ulcer should be tested for. With ulceration of the bowels, there may be circumscribed areas very sensitive to pressure ; with hysteric manifestations there are often sensitive spots complained of in the abdomen, as, for example, in mucous colic. By palpating simultaneously two distinct points, the supposed painful area and another region, with the different hands, and at the same time distracting the patient's attention by conversation, one often finds an absence of true tenderness at the supposed seat of pain. Muscular rigidity shows peritonitic involvement. It may be localized, as of the right rectus in the region of the appendix or gall-bladder, or over the left rectus, as in diverticulitis or phlegmonous gastritis, or in abscess of the left lobe of the liver. General rigidity shows general peritonitis. Splashing Sound (Clapotage, Succussion). If the intestines contain liquid material and gas, tapping over them with the fingers will at times produce the splashing sound. The method of differentiation between stomach and intestinal splash has been described under "Splash of the Stomach" in Chapter V. In the small intestine clapotage can usually only be obtained in the dilated portion of the gut above a stricture. It is not uncommon in the large intestine, and can be most determined in the sigmoid flexure, caput coli, and the transverse colon. In case of atony of the bowel it is quite frequently present, also in the relaxed abdomen of enteroptosis, and often in patients with hysteric manifestations. Boas 1 first suggested injecting into the bowel i pint (500 c.c.) or more of water and then examining for the splash along the colon. It should be given with hips elevated. The splash will first be secured in the sigmoid, and by turning the patient on the right side it can at times be produced in the transverse colon and in the cecal region. It is possible to administer an enema of moderate size and cause it to gravitate to the caput coli, by the method of rotation described under Enteroclysis. By the splash one can determine whether an injection given for dysentery has passed through the entire colon to the cecum. In atony of the bowel, Boas produced the splash, even after the injec- tion of only 6 to 10 ounces (200-300 c.c.) of water. The position of the colon can be determined by the splashing sound when it is present; it can be produced artificially by the injection of water into the bowel, and be thus employed for locating position of the intestines. A little Vichy, 4 ounces (125 c.c.), can be added to the injection to increase the amount of gas. 1 Diagnostik und Therapie der Magenkrankheiten, 1897. 5 2 4 DISEASES OF THE STOMACH AND INTESTINES Palpation of the Rectum. This procedure, the author believes, should be carried out, before inspection with the proctoscope. The rectum is preferably palpated with the index-finger. Soap should be placed under the edge of the nail to prevent fecal material lodging therein, and the finger lubricated with vaselin or olive oil. It is well to grease the external sphincter, as it renders entrance of the finger easier. It is more cleanly to encase the finger with a thin rubber cot, or to employ a rubber glove, well lubricated. The patient lies on the side, with knees flexed and the back to the examiner, or he may be in the knee-chest position, or stand with the waist flexed leaning forward over a chair and bearing down as if to defecate. Hemorrhoids, polypi, low-seated stricture, tender points or a pit-like feel suggestive of ulcer or fissure, malignant growths, rectal prolapse, abscess, fecal obstruction, foreign bodies, and intussusception are often within reach of the examining finger. The prostate and seminal vesicles, or uterus with the tubes and ovaries should be palpated during the examination. A gum-boil like feel is suggestive of a submucous fistula and cord-like infiltra- tion, of fistulous tracks. The sacrum, coccyx and the condition of the Fig. 253. A, Soft rectal bougie; B, cylindric bougie. sphincter should be examined. If the difficulty is located beyond reach of the palpating finger, inspection with the proctoscope or sigmoidoscope will give the required information. Simon's method of dilating the sphinc- ter under anesthesia and passing the hand and arm into the bowel, for the purpose of palpation, is a most dangerous procedure. Vaginal Examination. The author recommends that in every case the female pelvic organs should be also examined. Irritation, or inflammation of the pelvic organs may have a reflex effect in producing irritation of the rectum and vice versa. Traumatism or inflammation of the one are liable to extend to the other directly or through their lymphatic connections. An overweighted uterus may sag down on the rectum and produce hemor- rhoids. Many other examples can be given. Pelvic and sacral pains, reflex pains, and irregularity of functions, in fact, very similar symptoms, may occur from either rectal or pelvic disease. The primary cause should be carefully investigated, and hence the a/lditional value of a vaginal examination. INSPECTION OF RECTUM PROCTOSCOPV AXD SIGMOIDOSCOPY 525 Palpation of the Rectum by Sounds, This is indicated when there is suspicion of stricture in the bowel not accessible to the fingers. Soft rectal tubes of various caliber may be employed. When the obstruction stops the passage of the tube, a mark is made at the external sphinc- ter, so that the distance of the stricture up the bowel can be estimated. Smaller tubes are then employed until one can pass the obstruction. Its caliber is thus estimated. The ordinary soft flexible rectal or colon-tube is the safest for diagnostic purposes in the hands of the general practitioner. In Fig. 253, A and B, are shown an olive-pointed flexible and a cylindric bougie. The latter is somewhat stiff and can be softened in hot or boiling water before use. This last is also employed for dilatation of the stricture. Fig. 254. Auscultatory percussion of the colon. Kuhn's metal spiral tube is of no advantage. Care should be exercised if stiff tubes are employed. Percussion should be gentle. Over empty intestinal coils, or those containing gas or air, a tympanitic sound results, which is louder over the lacge than over the small bowel. As there may be considerable dis- tention of the small intestine, it is sometimes difficult to delimit the large intestine by simple percussion. If the colon is emptied by enema, and then distended artificially with air or carbonic acid gas, the procedure is much easier. Intestinal coils which are filled with liquid or solid material give dul- ness on percussion. With meteorism there is tympanites of a deeper pitch than normal, and sometimes there is a metallic sound with auscul- 526 DISEASES OF THE STOMACH AND INTESTINES tatory percussion. The meteorism may be localized or general. If local, in connection with visible peristalsis, intestinal stenosis is at once suggested. With local meteorism there will be dull areas elsewhere; with general meteorism the entire abdomen is symmetrically distended, the anterior portion being most protruded, and there is the diffused tym- panitic note of the peculiar type noted, and dulness over the region of the liver and spleen may disappear. With ascites, percussion shows dulness in the lower lateral regions of the abdomen and tympanites in the middle. The sounds change on altering the position of the patient (turning him on his side). The intestines ride up on the fluid, and the upper flank, previously dull when in the dorsal position, is now tympanitic. Fecal accumulation, tumors, and abscesses give dulness on percussion. Auscultatory Percussion, This is the best method of determining the position of the colon. If the small intestine is excessively distended, it is difficult to differentiate the per- cussion sounds. It may be neces- sary to empty the colon by enema or irrigation and then inflate with air or CO 2 . Place the stethoscope at the circle (Fig. 254) over the cecum; begin percussion midway between the umbilicus and sym- physis, and percuss to the right, to the left, and upward, in the di- rection of the arrows, until in each direction the greater intensely al- tered quality and heightened pitch show that the inner border of the colon has been reached. These points can be marked on the ab- domen with a pencil. Then per- cuss in the epigastric region (mid- way between the ensiform and um- bilicus) downward, and from the lateral lumbar regions inward. The changes in pitch, quality, etc., should be marked, and thus the outer limits of the transverse ascending and descending portions of the colon are determined. The scratch method of auscultatory percussion may be carried out in the same lines. Stengel claims that by auscultatory percussion it is possible to de- termine that a tumor found to lie in the course of the intestine originates in the wall of the colon. In Fig. 255, C represents the tumor; the circle O, the stethoscope placed over the colon near the tumor; B, percussion note over small intestine; A, percussion over normal large intestine near the stethoscope. First percuss directly over the tumor, then toward it from every direction. The note over tumor, C, if it is connected with the colon, Fig. 255. Differential percussion. INSPECTION OF RECTUM PROCTOSCOPY AND SIGMOIDOSCOPY 527 resembles the percussion note at A (colon) more closely than does per- cussion note at B (small intestine) resemble note at A (colon). Auscultatory Inflation of the Colon. Musser's 1 Method. The bowels are well emptied by a cathartic and subsequent enema. A thick, rather stiff tube is inserted well into the rectum. It should be sufficiently long to project 20 to 24 inches outside the rectum so that it be can be brought outside the blanket covering the patient without exposure of the latter. An air bulb is attached to the distal end. With the patient in the dorsal position and the abdomen uncovered, the stethoscope is placed on the lowest part of the abdomen. The bulb is squeezed and the stethoscope moved upward an inch or so. This procedure is continued along the course of the descending colon until the transverse colon is reached, when the character of the inflation sound is changed. While it was formerly a muffled distant sound, it now becomes clearer and louder with a rather metallic tone, while the passage of the air can be distinctly heard. The same procedure is repeated in every direction and the first change of tone is marked on the skin with a dermographic pencil. In this way the entire outline of the colon is marked off on the abdomen. This patient then stands and the outline in this position is made. Usually there is a change in the inflation tone over the sigmoid flexure, the descending and transverse colon. The tone is not always clear in the region of the hepatic flexure and the ascending colon, but becomes usually very distinct over the cecum. Abnormal variations are readily appreciated, such as redundant sigmoid, ptosed colon, dilated and movable cecum, etc. Partial obstruction Musser states may be diagnosed by this method through the subjective sensations of the patient. Normal patients suffer moderate distress from distention, which is relieved by removing the bulb and allow- ing the escape of air. If there is mechanical obstruction, the air is not promptly passed, but is retained for some time, and there are sharp, colicky, cramp-like pains in the region of suspected obstruction due to increased peristalsis from retained air. The pain is not relieved until most of the air is passed. Auscultation. This is not of great significance in intestinal diseases. Palpation may elicit a gurgling noise in the right iliac fossa, formerly thought to be pathognomonic of typhoid, but it is found in many other conditions. Gurgling sounds (borborygmi) are at times heard. They may be due to fermentative processes or occur in neuroses, and are not specially significant. The entire absence of intestinal sounds may be significant of in- testinal paresis. If the latter is due to peritonitis, cardiac and respiratory sounds may be audible over the entire abdomen. Friction sounds from perisplenitis or perihepatitis may rarely be auscultated. With chronic stenosis very loud noises are at times heard, caused by the sudden passage of fluid and gas through the stricture under pressure. Splashing sounds are at times distinguishable in the enlarged bowel above the stricture. 1 N. Y. Med. Jour., June 27, 1914. 528 DISEASES OF THE STOMACH AND INTESTINES TRANSILLUMINATION OF THE INTESTINES This method was first suggested by Einhorn, 1 and further practised by Heryng and Reichmann. 2 Einhorn's technic is as follows: A high enema or irrigation of the bowel is first given. A quart of water is later injected per rectum, and the illuminator, very similar to the gastrodiaphane, is inserted and gradu- ally pushed up the intestine. The examination must be made in a dark room. Experiments were carried out by the author with specially devised illuminators at the Manhattan State Hospital. As the average adult rectum is 8 inches long, the sigmoid flexure 17^ inches, and allowance must be made for the sphincters, it requires an instrument at least 30 inches in length to pass through the sigmoid into the descending colon. The '3o-inch instruments, with which I experi- mented, on almost every occasion caught and coiled back, and rarely did I succeed in securing transillumination of the lowest part of the sigmoid, and even then the light was so faint that it was entirely unsatisfactory. Inflation of the bowel with water, with fluorescein solution, and' with air were all tried before passage of the light, as were various positions of the patient. The experiments demonstrated practically the impossibility of passing a flexible instrument or tube through the sigmoid. The sigmoid is quite movable, and Howard Kelly has shown that the colon-tube readily pushes it up. My experiments demonstrated visually the impossibility of passing the long colon-tube through the sigmoid flexure, and showed that trans- illumination of the sigmoid has not been sufficiently certain to prove of practical value. RontgenRays (X-rays). For examination of the intestines the x-rays are of value for the following conditions: The determination of the presence of a foreign body in the intestinal tract, accurately locating its position, and hence the site for operation. Einhorn 3 has recommended the internal administration of bismuth subnitrate in watery solution to locate the constriction in acute intestinal obstruction with the aid of the #-rays. The delay necessitated would be dangerous. For locating the seat of chronic intestinal occlusion the method is of service. An ounce (30.0) of bismuth subnitrate or bismuth subcarbonate or barium sulphate preferably, can be administered in 12 ounces (375 c.c.) of milk or water or zoolak by preference and about twenty-four hours later examination should be made with the #-rays. With the fluoroscope or by a radiograph one would see a distended area of intestine filled with bismuth, a region below with apparently no bismuth or a trace (the point of stenosis), and below this a small amount of bismuth that had passed through the stricture. If the stricture is apparently in the large intestine, a check test can be made as suggested by Einhorn. 4 1 N. Y. Med. Montasschr., Nov., 1889. 2 Therapeutische Montashefte, 1892. 3 N. Y. Med. Jour., May 18, 1907. Ibid. TRANSILLUMINATION OF THE INTESTINES 529 A few days later, when the bowel is free from bismuth, an injection per rectum is given of i pint (500 c.c.) of water containing 30 grams (about i ounce) of bismuth subcarbonate or barium sulphate. If the stenosis is in the large intestine it will be located by the Rontgen picture, there being the area apparently free from bismuth (the stricture) and the collections above and below the stricture. Location of the Colon by the X-rays. Two quarts (liters) of water,. in which 60 grams (about 2 ounces) of subnitrate of bismuth or bismuth subcarbonate or barium sulphate suspended by means of a little starch solution, are injected per rectum, with the hips elevated or in the knee- chest posture. The position of the colon can be immediately determined by the Rontgen ray. One could administer the barium by mouth and examine at the end of twenty-four hours, but the enema method is preferable. Misplacements of the colon, enteroptosis, and angulations of the sigmoid can thus be determined. It has been claimed that a soft tube, in which lies a flexible wire, can be introduced per rectum, and the course of the colon determined by the *-rays, the wire showing a shadow. It is practically impossible to insert the tube beyond the sigmoid, so the method is not accurate. The x-ray pictures shown of the long colon-tube supposedly in the descending colon are usually in the ampulla of the rectum. H. W. Soper 1 has demon- strated, by means of the #-rays, that it is impossible to pass the colon- tube into the sigmoid, excep.t in the case of Hirschsprung's disease (congenital idiopathic dilatation and hypertrophy of the colon). As a general method for locating the position of the colon the Rontgen rays are expensive and often unnecessary as they frequently give no more information than by inflation. In obscure cases, or when angula- tions, stricture, adhesions causing stricture, etc., are suspected, they are of value. The appendix when patent, can be determined. Physiologic Investigations with Rontgen Rays. Cannon's 2 investigations have already been described. He holds that some of the material after enema may be forced back into the small intestine, and that this may occur with a high nutrient enema. Some investigators disagree with Cannon. Griitzner has shown that starch granules, lycopodium, powdered carbon, etc., in physiologic salt solution, injected into the bowel under favorable circumstances, will find their way upward into the stomach. By means of the #-rays Hemmeter observed that the upward move- ment of these particles goes on simultaneously with the downward move- ment of the feces, i.e., there is upward marginal current. He considers the epithelia and muscularis mucosa as instrumental, and that it is not true antiperistalsis. INFLATION OF THE INTESTINES WITH CARBONIC ACID GAS OR AIR Von Ziemssen 3 first employed inflation of the colon for diagnostic purposes by injecting in succession into the bowel solutions of tartaric 1 Jour. Amer. Med. Assoc., Aug. 7, 1909. . 2 Amer. Jour, of Physiol., vol. vi, p. 253. 3 Deutsch. Archiv f. klin. Medizin, 1883, Bd. 38, S. 325. 34 530 DISEASES OF THE STOMACH AND INTESTINES acid and sodium bicarbonate, with the resulting development of carbonic acid gas. The bowel could then be recognized by the marked tympanitic sounds on percussion or, more rarely, by inspection. Preferably, the gut should be previously emptied by enema. Inject into the bowel i dram (4.0) of tartaric acid, which has been dissolved in 6 to 8 ounces (200-250 c.c.) of water, and follow it by the injection of the same quantity of soda bicarbonate in same amount of water. Preferably the hips should be elevated. . Schnetter suggested attaching a flexible tube with rectal tip to the nozzle of an inverted soda-water siphon and driving out the CO* by pressing the valve. The gas has also been injected by obtaining it from the liquefied gas in a sparklet and conducting the CO 2 from a bottle into the rectum. One of the simplest methods to inflate the bowel with carbonic acid gas is by Rose's gas bottle. This consists of a moderate-sized bottle with perforated cork, through which passes a glass tube. To this is attached a soft-rubber tube and rectal tip (Fig. 256). Fig. 256. Rose's carbonic acid gas generator. The bottle is half-filled with water and i dram (4.0) each of tartaric acid and soda bicarbonate added, and the cork tightly inserted. The accumulating gas is conducted off by the tube into the rectum. Inspection and percussion will determine the extent of distention. Runeberg 1 recommended inflation of the intestines by air by means of a colon-tube, to which a compressible air-bulb is attached. It is possible by this means to measure and regulate the quantity of air employed for inflation. An ordinary Davidson's syringe can be used to pump in the air, and its capacity can be determined as follows: Take a measuring glass of i pint (500 c.c.) to i quart (liter) or a glass vessel of unknown capacity and measure its capacity when filled to the brim. Invert the filled vessel in a pail of water, so that the entire column of water is sustained in the inverted vessel. Then slip the colon-tube under water, so that its tip enters the inverted glass. Observe how many 1 Deutsch. Archiv f. klin. Med., Bd. 34, S. 460. TRANSILLUMINATIOX OF THE INTESTINES 53! compressions of the bulb are required to replace the water column with air, that is, to drive out all the water from the inverted vessel. If, for example, it contained i pint (500 c.c.) of water and it required sixteen squeezes of the bulb to replace this by air, then each squeeze of the bulb replaces i ounce of water by the air equivalent. Uses of Inflation. It is of service to detect stenosis of the large intestine. Under normal conditions the injected air distends the colon evenly. If there is stenosis, the air will distend chiefly that part of the bowel below the stricture, while above it remains unchanged. This is true in marked strictures, but in those of mild type the air will pass through. Even in some such cases there will be less distention above than below the strictured point. The position of the colon can be determined by air inflation. Nor- mally it passes with a slight downward curve across the abdomen with lower edge about touching the upper margin of the umbilicus, or it may even lie just below or above the latter. Enteroptosis is demonstrated by this method, and the transverse colon may descend to a hand's breadth above the symphysis. It may as- sume a V shape. Angulations of the sigmoid may at times be determined by this means. For the diagnosis of the location of abdominal tumors, inflation of the intestine is often of service. After inflation of the colon with air, tumors of the viscera become more distinct; while tumors of the kidney, retroperitoneal glands, spine, etc., tend to disappear. Minkowski 1 holds that after filling the colon with air or water ab- dominal tumors are shifted in the direction of the organ to which they belong. Sutton 2 suggests inflating the bowel with air impregnated with ether for the diagnosis of intestinal perforation. He employs a bottle provided with a perforated rubber cork to which are attached two rubber tubes with stop-cocks. To one of these tubes is attached a bicycle pump or a Davidson's syringe; to the other, an ordinary colon-tube, by means of a short glass connecting tube. Two drams of ether are placed in the bottle. The air pumped into the bowel passes through the bottle and thus takes up the vapor of ether. With the stop-cocks the pressure of ether and air can be regulated. If perforation of the bowel is present, the ether escapes through the opening into the abdominal cavity and distends it equally in all directions. If there is no perforation, first the large intestine and later the small in- testine become filled with air and ether, and, finally, ether vapor may be eructated and readily recognized. This method is useful in gunshot wounds of the abdomen. Inflation of the Colon with Water. This can be performed with a graduated irrigating jar and a rectal tube. With a fountain syringe of known capacity it is easy to estimate the quantity injected. In stricture of the colon, especially in the lower portion, the quantity of water which can be injected is not great. Normally the colon will 1 Berlin, klin. Wochens., 1888, No. 31. 8 Jour. Amer. Med. Asso., Dec. 30, 1899. 532 DISEASES OF THE STOMACH AND INTESTINES contain from 3 to 4 quarts, or occasionally 5, without dangerous disten- tion. The injection should be given with hips elevated. Many people are unable to hold any quantity of water in the bowels without pain, discomfort, and rapid evacuation of the fluid. Determination of the position of the colon by inflating it with water is, therefore, often difficult. The air inflation is preferable for the above reasons. LAVAGE OF THE BOWEL FOR DIAGNOSIS Boas 1 first recommended this procedure to be carried out in a manner similar to lavage of the stomach. The bowels should be previously evacuated. The patient should lie on the side with the knees and thighs flexed. The colon-tube is attached by a short piece of metal or glass tubing to a long tube, provided with a funnel. The rectal tube is lubri- cated and inserted high up to its full length, and about i pint (500 c.c.) to i quart (liter) gradually poured in through the funnel held i or 2 feet above the patient, until some discomfort is expressed. The funnel is then lowered below the anus and the contents siphoned off. They are then submitted to a thorough examination. Normally the contents are fairly clear or slightly stained with fecal matter, and contain a little mucus and a few epithelial cells. With intestinal catarrh a large amount of mucus is present. Blood or pus may be found, showing hemorrhages, or a suppurative process, such as an ulcer or abscess. Exfoliated portions of the mucous membrane may occasionally be found or, rarely, tumor fragments. Microscopic examination of such material is of diagnostic importance. Intestinal worms are occasionally discovered. Lavage of the bowel is also employed for the removal of dysenteric discharges and mucus, and for the purpose of examination for amebge. EXAMINATION OF THE FECES The Stool. General Considerations. The normal stool consists of changed and unchanged remnants of food, bacteria (estimated at about 126,000,000,000 daily), epithelial cells, salts, and traces of the digestive juices. The normal daily quantity under a mixed diet averages 100 to even 200 grams (3^ to 7 ounces). It may be increased by a vegetable diet. There is usually one movement daily of dark brown color, though diet and medicine have an influence. Milk gives a light yellow; claret and huckleberries, a brownish black; salts of iron and magnesia, a blackish brown; bismuth, black. Blue is given by iodids (long continued); green by calomel; yellow, by santonin, senna, and rhubarb; violet, by salol and betanaphtol. The feces are slightly soft and of sausage shape. Ab- normally they may appear in small balls, cylinders or tape-like, or as hard scybalas (dry in character,) or they may be mushy or liquid. They may be very watery, as in choleraic conditions, or fluid and mixed with mucus. 1 Deutsch. Aertze-Zeitung, 1895, Nos. 2 and 3. EXAMINATION OF THE FECES 533 Odor. This is normally caused by skatol and slightly by indol. It is increased when the f eces have been retained an abnormal time. After a short sojourn in the intestines, as with rice-water movements, there is often no odor. The character of the food may affect the odor. Very fetid movements occur with ulcerative processes, or with malignant growths. Macroscopic Findings. Remnants of Food in the Feces. Undigested remnants of food can often be seen in the stool. Normally they consist of only small particles of vegetable material, such as potato, asparagus, spinach, and peas; while remnants of meat cannot be seen. Providing abnormal quantities of food have not been ingested, it is often possible to draw definite conclusions as to the state of intestinal digestion, from the excess of one form of non-digested material over another. The presence of large quantities of undigested starch indicates a catarrhal con- dition of the small intestine, and, indeed, more than traces of this material should be regarded with suspicion. If particles of meat are visible, this indicates a lesion of the intestinal tract. Connective-tissue fibers appearing unaltered in the feces indicate deficient gastric digestion, according to Schmidt, and the presence of nuclei, under the microscope, disturbance of the trypsin function of the pancreas. Blood. Blood may be visible in the feces, either fresh (red) or dark in color and uncoagulated, which shows its origin from the lower part of the large bowel. It may appear changed, giving the feces the appear- ance of tar, then originating from the small intestine, or even from the stomach. Blood shows the presence of an ulceration or of an ulcerating cavity communicating with the gut. Pus. Visible pus in the dejecta only occurs when pus exists in large quantities in the lower part of the large intestine. It shows ulceration or an abscess communicating with the gut. Pus in small quantity or from higher up the intestine can only be determined by the microscope. Fragments of tumor (polypi or cancer) may rarely be found in the dejecta. Microscopic examination will give important information. Mucus. Mucin can always be detected in normal feces by chemic examination. The amount of mucus in the feces in health is so small and so intimately mixed as to be only recognized by chemic tests. Mucus in the stool, either macroscopic or microscopic, indicates some deviation from the normal physiologic condition. It does not invariably show an anatomic lesion. We may, for example, have a few flakes of mucus or an extremely thin layer adherent to scybalae, due to irritation of the mucosa from a fecal accumulation or impaction, or mucus, which is contained normally in the higher portions of the small intestine, may occasionally appear in the stool as a result of increased peristalsis. Under other circumstances the presence of mucus is pathologic. Macroscopically, mucus may exist as follows: (1) An abundant coating in the form of a glassy layer may cover fecal masses. It may be gray or cloudy from epithelial or round cells. This usually indicates catarrh of the lower portion of the bowel. (2) It may be intimately mixed with the feces in mushy movements, and may adhere to a glass rod if this is dipped in the stool. 534 DISEASES OF THE STOMACH AND INTESTINES (3) It may float on top of watery movements. (4) It may be passed almost pure in large amount. Material resembling frog's spawn or sago grains may occur in the feces. They were formerly considered due to follicular ulceration, but are now believed to be of vegetable origin. Kitagawa holds that some of them are pure mucus, but that they are not pathologic. Yellow or yellowish-brown granules occur in the stool, from the size of a pinhead to a poppy seed, resembling butter in consistency. Some of these have been considered bile-stained mucus, while other fragments are believed to be albuminous, or vegetable material, or yellow calcium salts. Boas and Schmidt believe these yellow granules to be albuminous matters stained with bile-pigment. The presence of any one of the previously described types of mucus indicates intestinal catarrh. Mucus without feces, or surrounding the feces, shows the colon is inflamed. When mucus is mixed with the feces the upper colon or small intestine is inflamed. Mucus in the food residue shows catarrh of the small intestine. There are two exceptions to the rule that visible mucus indicates catarrh. (1) In mucous colic (membranous enteritis) pure mucus due to hyper- secretion is evacuated in the form of a cast membrane or in long tape-like formation. (2) In intestinal dyspepsia with acid fermentation the patient has a jejunal diarrhea, with gelatinous, tenacious, semifluid stools. Mucus is present. Epithelial or round cells, which are abundant in catarrhal mucus, are absent from the mucus in dyspepsia of the small intestine. The stools are also green, acid, and give a bile-pigment reaction. Intestinal parasites may be visible in the feces. Chemic Examination of the Feces. Reaction is normally neutral or slightly alkaline. Marked acidity results from occlusion of the bile-duct. Rich vegetable diet causes slight acidity. The simplest method to test the reaction is by litmus-paper (red and blue). Normal stools react slightly differently with different indicators. With phenolphthalein they react slightly acid, while to litmus they would be neutral. If the phenolphthalein test is employed, take feces 5.0 c.c., rub up in a mortar, and add 30.0 c.c. distilled water, after the modified Schmidt diet. Place 2 c.c. of this in a test-tube, add 2 drops of i per cent, alcoholic solution of phenolphthalein. With this quantity titration with decinormal sodium hydrate never exceeds 1.5 c.c. to secure end-re- action. Above this the stool should be considered acid, and if less than i c.c. it may be considered alkaline (Kaplan 1 ). For general use the litmus test is sufficient. Test for Mucin. Mucin is normally present in the feces. Mix feces with water and an equal quantity of milk of lime and let the mixture stand for several hours. Then filter, add acetic acid to filtrate, and mucin precipitates if present. 1 N. Y. Med. Jour., Dec. 7, 1907. EXAMINATION OF THE FECES 535 To Examine Separate Particles of Suspected Mucus. Dissolve a flake of material in a weak solution of potassium or sodium hydroxid and add acetic acid. If the precipitate is undissolved after adding the acid in excess, mucin is present. Heat the precipitate to the boiling-point in a dilute mineral acid; if mucin is present the heated solution will reduce copper oxid. This last test excludes nucleo-albumin, which otherwise gives a similar reaction (Einhorn). Stain a flake of apparent mucus with a weak triacid solution (Ehrlich), mucus produces a green color; albumin, red. This test is of value in determining the presence of mucus in mem- branous specimens from mucous colic. The tests otherwise are rarely required. Albumin. Treat the feces with water slightly acidified with acetic acid. Filter the watery extract and employ boiling test as for albumin in the urine. Normally, no albumin is present, but it has been found in typhoid, occasionally in acute enteritis, and in chlorosis. Propeptone and Peptone. After the test for albumin has proved nega- tive, the watery extract of the feces is treated with phosphotungstic acid, the precipitate is diluted with water and sodium hydrate,, and a small amount of a weak solution of sulphate of copper added. A purple red (biuret reaction) shows the presence of both propeptones and peptones. To determine the presence of peptones separately, first precipitate the propeptones by ammonium sulphate in large amount. Pathologically, peptone is found in typhoid, dysentery, tuberculous ulcer of the intestine, and in perforative peritonitis. Normally it is not present. Carbohydrates. The feces are first subjected to distillation. The residue is extracted with alcohol and ether; the extract boiled with water, filtered, and again boiled, with the addition of dilute sulphuric acid. Trommer's or Nylander's test is then employed. Examination far Starch. The watery extract of feces is examined with Lugol's solution, the presence of starch producing a blue color. For Sugar. A watery extract of feces can be directly tested by Fehling's method. Normally, neither starch nor sugar are found. Gas Fermentation. Schmidt's method will be described later. Fat. The feces are treated with considerable ether, and the latter is separated and evaporated in a water-bath. The neutral fat, if present, remains visible. To show the presence of soaps which do not dissolve in ether, another portion of fecal matter is first treated with acids which split up the soaps, and then extracted with ether; quantitative determination is complicated. Normally, fat is never present macroscopically in the stools unless after ingestion of very large quantities. It may then be visible in very small portions, the size of a pea. Pathologically, fat may exist in large quantities in the fecal matter and give the grayish-silver fatty stools, especially in disease of the pancreas and whenever lymphatic absorption is disturbed. Blood. Fresh blood can often be recognized macroscopically. The tests for occult (concealed) blood are of importance. The best methods 536 DISEASES OF THE STOMACH AND INTESTINES are the benzidin test (the latest); Weber's modification of the guaiac test; and the aloin test. These are fully described under Tests for Occult Blood in the Stomach-contents and Stools in Part II of this volume. Neither meat nor iron preparations should be ingested for two or three days previous to the tests. The hemin test has been employed. A small particle of fecal material is dried, powdered, and placed on a slide. A trace of sodium chlorid is added and a drop of glacial acetic acid poured on and thoroughly mixed. A cover-glass is placed over the specimen and the slide slowly heated. After cooling, a microscopic examination is made. In the presence of blood, hematin crystals are found (Fig. 257). These are reddish pink and rhomboid in shape. Bile-pigment. Normally, no unchanged bile- pigment is found in the feces. In catarrh of the small intestine it has been detected. The presence >. q ^ - of bile-pigment is determined as follows: A par- \ \ ^ " ticle of the colored fecal matter is brought into * ^^^^ r*r\r\tr\rt \a\t\\ a rlrrr rf fiimincr nitric Ckf\r\' Tlii=> contact with a drop of fuming nitric acid*. The 2S7 Hematin yellow color passes through the various colors of the crystals. spectrum, red, violet, to green ; in some cases green appears at once; or liquid feces can be filtered through filter-paper or a watery mixture can be made and then filtered. The paper is then dried and a drop or two of the fuming nitric acid poured on it. The colors will appear in rings if bile is present; or: A small quantity of the feces is treated with a concentrated watery solution of corrosive sublimate. Biliary pigments will turn the mixture green, or green appears in that portion where pigments are present. Biliary Acids. These usually accompany biliary pigments. They are revealed by Pettenkofer's test: A small quantity of feces is treated with alcohol and then the latter is evaporated. To the residue a weak watery solution of bicarbonate of soda is added, and to this mixture a small amount of cane-sugar and a few drops of sulphuric acid. Red or pink occurs when biliary acids are present. Urobilin. Normally, the biliary pigment in the intestinal tract be- comes changed to stercobilin, which gives the brown color to the feces. A small piece of fecal matter is treated with a concentrated watery solution of corrosive sublimate and thoroughly mixed with a glass rod. Urobilin (stercobilin ) gives rise to a pinkish-red color; bilirubin, to a green color. Urobilin is normally present and is absent in pathologic conditions, while bilirubin is present in the latter. Fleischer's Test. Place a small quantity of feces in a test-tube with a small amount of alcohol to which has been added a few drops of hydro- chloric or acetic acid. After a short time urobilin produces a yellow or brown color. If the alcohol is then poured off and a few drops of sodium hydroxid with a small quantity of zinc chlorid are added, there appears a green fluorescence in direct rays of light, and in transmitted light, pink or yellowish red, greater or less in proportion. Acholic and Colorless Stools. The acholic stool presents a grayish white, ash-gray, or clay color due to absence of bile-pigment. The de- EXAMINATION OF THE FECES 537 jecta are of penetrating odor, buttery consistency, and on chemic and microscopic examination are found to contain much fat. The latter is present as needle-shaped crystals, or in sheaves of crystals, or, less generally, in fat-droplets. This type of stool occurs in conditions such as occlusion of the bile-duct, when there is an exclusion of bile from the intestine. Stools can be entirely devoid of color or of a grayish-white color re- sembling true acholic stools, though there is no jaundice or occlusion of the bile-ducts. These stools are less putrid in odor and more acid. They contain enormous amounts of fat, like the true acoholic stool, and urobilin has been demonstrated in them. Such movements occur in conditions when the absorption of fat is impaired, as in tuberculosis of the intestines and peritoneum. At other times abnormal quantities of fat are not present, and the lack of color is imputed to the presence of a colorless decomposition product of bilirubin, the leuko-urobilin of Mencki. The conclusion that a stool contains an excessive amount of fat be- cause it is apparently acholic, is not justifiable unless a microscopic ex- amination is made. An apparently acholic stool may also be due to excessive fat ingestion and urobilin be present. Fatty Stools (Steatorrhea). This term is applied to all cases in which isolated masses of fat are present in the feces and can be recognized with the naked eye. It appears in whitish or grayish lumps, or it may cling around the feces or be adherent to the vessel. Ingestion of excessive fat even under normal conditions may produce an evacuation of superfluous fat. If the mucosa of the small intestine and the lymphatic system (mesenteric glands) lose their powers of ab- sorption, fat must appear in the stools, as in tuberculosis of the small intestine, chronic tubercular peritonitis, intestinal catarrh, etc. In occlusion of bile from the intestines with acholic stools, the fat is revealed microscopically and by chemic analysis, but fatty stools are not then spoken of in the clinical sense. Steatorrhea is not per se diagnostic of pancreatic disease. In the absence of icterus and of demonstrable intestinal disease, fatty stool is probably due to pancreatic disease. Disturbed digestion of fat is diagnostic of pancreatic disease. Muller shows that qualitative changes in the fat (lipolysis) is much slighter, only 39.8 per cent, in pancreatic disease, where it is 84 per cent, in healthy subjects, or even in those with icterus, if the pancreatic juice has free access. Ferments. A glycerin extract can be made of the feces, or the fecal matter may be mixed with water containing a small proportion of thymol and filtered. To test for trypsin, the filtration extract is made alkaline by the ad- dition of soda bicarbonate and a few flakes of fibrin added. The solutions are kept at a blood temperature for a few hours and then tested with potassium hydroxid and a weak solution of copper sulphate. If trypsin is present, there will be a pinkish-red reaction (biuret) in consequence of peptone. For Diastase. A few cubic centimeters of the filtrate are mixed with about one-half the amount of a starch solution and kept at a blood tern- 538 DISEASES OF THE STOMACH AND INTESTINES perature for about thirty minutes. The mixture is then subjected to Fehling's or Trommer's test. Normally, these ferments are absent, 1 but in pathologic conditions, especially in diarrhea, they are frequently found. Wynhausen 2 describes a new test for the pancreatic activity. (See Testing the Pancreatic Functions.) Fig. 258. Einhorn's stool sieve. Concretions, Foreign Bodies, Worms. To examine for such material the feces should be thoroughly mixed with water and poured through a sieve. This can be improvised a circular wire rim can be fitted to a water-closet seat, and attached to the wire a network bag made of two thicknesses of cheese-cloth, practically a dip-net. The patient defecates in the net, and water can then be poured through several times until only the more solid parts remain. Boas has constructed a stool sieve, and Einhorn's, as in Fig. 258, is readily understood. Water is poured through and there is a stirring apparatus. Concretions. Among such are gall-stones, pancreatic calculi, entero- liths, and coproliths. Biliary calculi are readily recognized when of any size. The principal constituents are cholesterin, bile-pigment, and lime. Tests for small biliary concretions (sand) are as follows: first, powder 30 grains (2.0) of the mass and treat with ether, 5 drams (20 c.c.), mix and filter, evaporate, and test for cholesterin. Dissolve part of residue in hot alcohol and allow it to evaporate. Microscopic examination of the precipitate shows rhomboid crystals with ragged edge (cholesterin); second, another part of the residue is placed on a slide, a drop of concen- trated sulphuric acid added and covered with a cover-glass, the cholesterin crystals become carmine at their edges, add i drop of Lugol's solution and a violet color arises; finally, a portion of the residue is treated with hydro- 1 Goldschmidt (Deut. med. Wochens., 1909, No. 12, xxv, 522) and Gross (Ibid., 1909, No. 16, xxv, 706), using the latter's method for detecting trypsin, have discovered it in the feces of all normal persons examined. This, if confirmed, will prove a great advance. 2 Berl. klin. Wochens., July 26, 1909; also Med. Rec., Sept. n, 1909. EXAMINATION OF THE FECES 539 chloric acid, a trace of iron chlorid, and then evaporated. If cholesterin is present, a blue color occurs. The residue of the original ether mixture is treated with dilute hydro- chloric acid mixture, heated, and extracted with chloroform after cooling. The chloroform extract is tested with Gmelin's reaction (fuming nitric acid). Bile-pigment produces the rainbow play of colors. Pancreatic Calculi. These usually have a rough surface, are brittle, and may be faceted. They are soluble in chloroform, and on evapora- tion produce an aromatic odor. 1 Bile-pigment and cholesterin are usually absent. (See Pancreatic Lithiasis.) Enteroliths. Calculi formed in the small intestine consist of inorganic salts (lime and magnesia). They are light in color and usually of small size. They form occasionally after the extensive use of lime and magnesia. Rarely they cause obstruction. Coproliths (fecal calculi) are found in the large bowel, chiefly where there is retardation to the passage of feces, as in the cecum, appendix, sacculi of the colon, sigmoid, and rectum. They are of stony hardness and sausage shape and show concentric rings on section. They may attain considerable size and even cause intestinal obstruction. Foreign Bodies. Bodies which have been swallowed may pass through the entire bowel and be passed in the feces, such as bones, coins, marbles, oyster shell fragments, needles, etc. Concretions of shellac have been found in the stools of patients who have drunk furniture polish. Hair- balls may be found. Microscopic Examination. The microscopic examination of the feces is often of great assistance to diagnosis. For examination for amebae the stool should be kept warm. A thermos bottle is useful for this purpose. To diminish the disagreeable odor of a watery stool, place it in a conic glass and cover it with a layer of ether. If it is mushy or firm, it can be spread on a plate and covered with a layer of spirits of turpen- tine, or a 5 per cent, solution of carbolic acid or thymol, or 4 per cent, formalin. Diarrheal stools may be examined without further preparation. With solid fecal matter, a small piece of feces may be placed on a slide and mixed with a drop or two of normal salt solution. If there is odor, a i per cent, formalin solution may be added. The findings depend on the diet. With meat diet, no vegetable residue is found, and vice versa. With a mixed diet, in a normal stool, there will be plant cells, the remnants of various vegetables and fruits, no starch granules, meat-fibers changed beyond recognition, or with slight stria- tion (Fig. 259). More commonly they appear as oval yellow translucent masses with a high degree of refractibility. The presence of numerous meat-fibers striated and with nuclei is pathologic, showing deficient pancreatic digestion (tryptic). They may appear as spirals (Fig. 260). Fat. Fat appears microscopically as colorless small globules or as needle-shaped crystals (fatty acids) or in sheaves (soaps). The fatty acids disappear when heated or when ether is added; soaps remain un- changed. Sudan dye-stuff, in concentrated alcoholic solution, stains plain 1 Minch, Berl. klin. Wochens., 1898, No. 8. 540 DISEASES OF THE STOMACH AND INTESTINES fat bright red, while crystals of fatty acid and the soaps remain unchanged. In pathologic conditions these forms of fat are markedly increased, as in affections of the liver, pancreas, and intestines. Normally, they are scanty. Fig. 250. General view of the feces: a, Epithelial cells and leukocytes; b, stone- cells; c, cuticular formations; d, crystals of ammoniomagnesium phosphate; e, fat- crystals; /, yeast-fungi; g, Amoeba coli; h, Trichomonas intestinalis; i, Cercomonas intestinalis; m, ovum of ascaris; n, ovum of oxyuris; o, ovum of trichocephalus; p, ovum of ankylostomum; q, ovum of bothriocephalus; r, ovum of Taenia saginata; s, ovum of Taenia sodium (Jakob). Crystals. Oxalate of lime, calcium carbonate, neutral phosphate of calcium, and ammonium magnesium phosphate are found in normal as well as. pathologic feces and have no diagnostic importance. Bis- muth, if administered, occurs as dark brown or nearly black rhomboid Fig. 260. a, Spirals of undigested meat-fibers in stool; b, pieces of bronchi. (Butler). crystals. Hematoidin appears in rhombic crystals of orange or red color, shortly after intestinal hemorrhage. Charcot-Leyden crystals (Fig. 261) are fine colorless, pointed octahedra. These when present excite the suspicion of helminthiasis (intestinal parasites), and their EXAMINATION OF THE FECES 541 persistence after removal of the tenia shows the head has probably not been removed. They occur occasionally in normal stools and in typhoid, dysentery, and phthisis. Epithelium. Epithelial cells when present in large numbers always indicate an inflammatory condition of some part of the intestinal tract. Cylindric epithelial cells are found in abundance in inflammation of the intestinal mucosa (Fig. 262). They cause the cloudy appearance of the mucus. If bile-stained specimens of epithelia are met with, the small intestine is involved. Degenerative forms without nuclei are mostly seen, though well-preserved cylindric or goblet-cells are often found. Red blood cells are rarely observed unless hemorrhage is from the colon or rectum, as in dysentery. Hemorrhage higher up gives a brownish- red color to the feces, and hematoidin rhombic crystals in some cases, and the blood cells cannot be recognized microscopically. Fig. 261. Charcot-Leyden crystals (after Riegel). Pus occurs in the dejecta in ulcerative processes when an abscess communicates with the bowel, or in dysentery, or in any form of intestinal ulcer. It presents the usual characteristics. Often it can only be deter- mined by the microscope. Mucus when bile-stained indicates disease of the small intestine; and if colorless, catarrh of the large intestine or lower part of small in- testine is present. Mucus also occurs with mucous colic, in which condition no catarrh exists. Mucus is thread-like in appearance, though occasionally amorphous (Fig. 263). Hyaline particles of vegetable residue must not be mistaken for mucus. lodin stains it blue. Thionin colors it reddish violet and other proteins blue. Mucus has no definite structure. Tumor. Fragments of tumor may rarely be found in the feces and its character determined by the microscope. 542 DISEASES OF THE STOMACH AND INTESTINES Microorganisms. A large portion of the stool is constituted by bacteria, as already mentioned. Among the most important are the Bacillus coli, Bacillus lactis aerogenes, Bacillus bifidus, Bacillus aerogenes capsulatus (gas-forming), and Bacillus putrificus. The Bacillus coli is of importance in reference to the indolic type, and the Bacillus aerogenes capsulatus, to the saccharobutyric type of intestinal putrefaction. The Bacillus-lactis aerogenes causes fermentation of milk and the production of lactic acid. The lactic-acid-producing bacilli are held to be antagonistic to put- refactive changes. For a description the reader is referred to any work on Bacteriology. Typhoid, tubercle, dysenteric, and the cholera bacilli are the chief pathogenic microorganisms found in the feces which are of interest to us. Fig. 262. Chronic intestinal catarrh: Groups of epithelial cells, detritus, some muscle cells partly digested, bacteria, plant cells, and yeast cells. Fig. 263. Intestinal catarrh: Con- siderable mucus, some plant cells, mus- cle cells, and fat crystals. Preparation of Feces for Examination for Parasitic Ova. Mix a small amount of the feces, a portion y inch in diameter, with 10 to 15 c.c. of equal parts of 25 per cent, antiformin and ether and shake thor- oughly. When the feces are hard, they may first be warmed with the antiformin and the ether subsequently added. After shaking, filter the mixture through gauze and centrifugalize the filtrate. Four layers are thus obtained. The upper consists of the ether holding in solution, the neutral fats and fatty acids. The next layer is a ring made up of coarse vegetable fibers, etc. The third layer is the antiformin containing soaps, soluble mucus and coloring matter, and the lower layer consists of the remaining sediment of the feces. It may contain cellulose, epithelia, salts, elastic fibers and muscle fibers. It is in this material that the para- sitic ova may be found. The sediment is transferred to a glass slide and searched in the usual way. The ova will be found to be a little or not at all influenced by the reagent; 50 per cent, antiformin is slightly de- structive toward the ova. TESTING THE INTESTINAL FUNCTIONS 543 TESTING THE INTESTINAL FUNCTIONS (E. E. Smith, M. D.) Boas has obtained intestinal juice by passing the stomach-tube into the empty organ and massaging the region of the liver, thus forcing the juice into the stomach. Hemmeter and Kuhn have passed the tube directly. These procedures are uncertain and possess no advantages. Einhorn 1 has devised a new method of obtaining the intestinal juice by means of a duodenal bucket. The quantity secured (and it is not always obtained) is infinitesimally small; there is the possibility of an admixture of gastric juice and saliva during withdrawal, and the procedure requires three to five hours or even longer. It does not admit of the thorough technic as secured by Schmidt's test-diet. Einhorn has recently suggested passing a soft tube along the duodenal bucket cord (on the principle of Gouley's tunnel sound along the filiform bougie), and then aspirating the intestinal contents with a bulb. Einhorn's bead test 2 the author does not believe to be sufficiently accurate. Testing the motor function with foreign bodies (beads) is not a proper criterion; the food material attached to each bead is too infinitesimally small in amount to test the digestive capacity for an average diet; it may work loose from the beads, in which event it could not be recovered and wrong deductions might result. There is a slight element of risk from fish-bone escaping from the bead and damaging the mucosa. Additional methods of securing the secretion of the pancreas, such as by means of the duodenal tube, etc., are described under Diseases of the Pancreas. The author believes the stomach functions should be tested separately, and one should not depend on the connective-tissue test for the stomach test also, as suggested by Schmidt. Boldyreff's oil test-meal, the tests of Mett, Volhard, and Gross, and the duodenal pumps of Gross and Einhorn are described under Diseases of the Pancreas. Tests of the Intestinal Functions. The determination of the func- tional activity of the stomach is made with relative ease, compared to the similar examination of the intestines. Correspondingly, methods for such determination have long been applied to the former organ, while they have recently found application to* the latter; and even- now the diagnostic determination of intestinal function by exact methods is only in its infancy. The problems presented are essentially these: (a) Is intestinal secretion, including pancreatic and biliary secretions, normal in quality and quantity? (b) Is intestinal absorption normal? (c) Is the intestinal motor activity normal? If not, in what respect is each of these processes abnormal? The investigation of these problems is made by the use of a test- diet. While in the case of the stomach, the diet is relatively simple and the digestive mixture withdrawn for examination within a few J N. Y. Med. Jour., June 20, 1908. 2 Med. Rec., Feb. 10, 1906; Ibid.. Oct. 26, 1907; Jour. Amer. Mod. Assoc , Feb. 2, 1907; Therapeutic Gaz., Jan. 15, 1908. 544 DISEASES OF THE STOMACH AND INTESTINES hours, in the case of the intestines, only inferences as to the intestinal contents may be reached, and then indirectly from the conditions affect- ing the bowel contents after they have been ejected, perhaps in one or several days. The feces corresponding to the test-diet may be indicated by a material administered for the purpose, usually soot in capsules, No. oo hard gelatin capsules filled with soot accomplishing this purpose; or carmin may be used, 5 grains (0.3 gram) in a capsule. Either of these is administered at the beginning of the first meal of the test-diet. The subsequent appearance of black or red stool indicates that the intestinal contents corresponding ,to the special diet are being ejected. The administration of a special substance to mark the stools is, in a majority of instances, not absolutely necessary, the diet being of a nature that gives rise to a stool sufficiently distinctive for recognition. Until the observer is familiar with the examination, it is advisable to employ one of the substances mentioned. The test-diet to be employed is selected to meet the requirement that it shall present a sufficient quantity of all classes of food stu/s to test the digestive capacity, that the digestive processes shall not be unduly anticipated in the preparation of the food, and that normally very little food residue shall be present in the ejected bowel contents. Naturally, the stomach plays its usual part, so that the test is not limited to the intestinal tract proper, but applies to alimentation as a whole. The test-diet made use of is a modification of the original Schmidt- Strassburger diets. Instead of three diets, as were originally employed in connection with the fermentation test of these observers, one diet is now advocated which presents the conditions essential for the meat test. This diet, as recently described by Schmidt, is as follows: In the Morning. 0.5 liter milk, or, if milk does not agree, 0.5 liter cocoa (prepared from 20 gm. cocoa powder, 10 gm. sugar, 400 gm. water, and 100 gm. milk), to this add 50 gm. zwieback. In the Forenoon. 0.5 liter oatmeal gruel made from 40 gm. oatmeal, 10 gm. butter, 100 gm. milk, 300 gm. water, i egg (strained). At Noon. 125 gm. chopped beef (raw weight), broiled rare with 20 gm. of butter, so that the interior will remain raw; to this add 250 gm. potato broth (made of 190 gm . mashed potatoes, 100 gm. milk, and 10 gm. butter). In the Afternoon. As in the morning. In the Evening. As in the forenoon. This diet consists of: 1.5 liters milk, 100 gm. zwieback, 2 eggs, 50 gm. butter. 152 gm. beef, 190 gm. potatoes, and gruel of 80 gm. oatmeal. It contains about: 102 gm. albumin, in gm. fat, 191 gm. carbohydrates, or a total of 2234 calories (raw calories). The test is generally given for three days, sometimes longer; at any rate until a stool is obtained, which comes with certainty from this diet. Steele advocates an arrangement of the diet to conform to American dietary habits, which still maintains the essential features of the above. It consists of: TESTING THE INTESTINAL FUNCTIONS 545 2?i pints milk, 3 ounces well-dried toast, 2 eggs, iYi ounces butter, Y\ pound tender rare steak, 6 ounces mashed boiled white potato, and gruel made from 2K> ounces ordinary oatmeal, V ounce sugar. This may be given somewhat as follows: Breakfast. 2 eggs, one-third of the amount of toast and butter, 2 glasses of milk, oatmeal, and sugar. Dinner. The steak and potato, one-third of the amount of toast and butter, rW glasses of milk. Supper. 2 glasses of milk, remainder of toast and butter. For the collection of the stools, where they are not to be transported for any considerable distance, an ordinary tin basin of 24-ounce capacity serves well for a receptacle, as suggested by Prof. L. B. Mendel. This may be supplied with a cover, consisting of a cake tin of appropriate size; or where, this is not readily provided, a small pie tin may be used. This outfit is inexpensive (8 cents), adequate, and where a considerable number are to be kept, may be advantageously stacked. Moreover, where the stools are to be weighed and dried for exact quantitative analysis, this may be directly done in the weighed basins, thus avoiding the transfer of the specimens. If the feces are to be transported for any considerable distance, a pint glass jar (with patent air-tight top) serves admirably for the collec- tion. The specimen may be hermetically sealed. If transported in ordinary wide-mouthed bottles, the stoppers should be tied on, as gas formation is quite likely to produce sufficient pressure to force out any stopper not securely fastened. The characteristics of the test-diet stool, aside from the coloration given by the special marking substance administered, are the light brown color and uniform consistency. It usually appears at the second or third defecation after the beginning of the test-diet. The period of time required for the passage of food through the entire alimentary tract is of importance and is readily observed. Normally it takes about twenty-four hours. It is not necessarily, though it is commonly, related to the frequency of defecation. In some cases the stool appears with regularity and is fairly copious, yet the patient suffers from fecal accumulation a latent constipation. The period of passage may suggest the seat of the intestinal disturbance in diarrhea, since it is only decidedly increased when the cause is high up. Strauss has shown that chronic colitis may be accompanied by several watery movements a day with a normal period of passage. The examination of the collected stool should be made while the feces are perfectly fresh. Macroscopic Examination. This is the most important part of the procedure. Experience with this part of the investigation may enable the observer to at once recognize some defect in alimentation. Note the consistence, color, and odor. Inspect the surface of the formed stool for morbid products, notably for pus, blood, and mucus, which are to be removed for microscopic and bacteriologic examination. Bits of tissue from some diseased area may also be sought for, but their occurrence is so unusual that it is exceptional when they are found. 35 546 DISEASES OF THE STOMACH AND INTESTINES The mass of feces is then well mixed, for which procedure a wooden or tin-plate spoon is useful; and a piece the size of a walnut transferred to a mortar, in which it is thoroughly but not forcibly ground with dis- tilled water added gradually until the whole is of a uniform fluid consist- ency and no small masses of fecal matter remain. The fluid feces is then examined in thin layers, conveniently in a Petri or similar larger dish, against a black background, with the naked eye or low-power magnifying glass, for all elements that may be differentiated. In normal digestion only a few brown points, smaller than pin-heads will appear, these consisting of chaffy remains of oatmeal .gruel and remains of cocoa, if this latter has been taken. Under pathologic conditions, there may be present: 1. Mucus, which appears usually as larger or smaller, soft, glossy, translucent flakes, often bile stained; infrequently, when from the large intestine, white or brown, with a gummy or almost leathery hardness. 2. Pus, blood, parasites, stones, and other foreign bodies. 3. Connective tissue and tendons, distinguished by their whitish- yellow color, thread-like appearance, and solid consistence. 4. Muscular tissue, chiefly in very small, brown colored rods, like splinters of wood. 5. Potato, appearing like boiled tapioca grains, readily confused with flakes of mucus. The distinction is made with the microscope. 6. Large crystals of ammoniomagnesium phosphate, which grate when the specimen is ground. Microscopic Examination. This serves chiefly to complete the gross inspection. In addition to the preparations of material selected during the macroscopic examination, three slide preparations are made. The first consists merely of a drop of the liquefied stool under the cover-glass. The second, a drop of the liquefied stool mixed with a drop of acetic acid, heated to the beginning of boiling and covered with a cover-glass. The third consists of a drop of the liquefied stool mixed with potassium iodid solution of iodin and covered with a cover-glass. Inspection of the first slide preparation by the aid of the microscope, using a high, dry lens, reveals finely divided material consisting of bacteria and mostly unrecognizable detritus, in which are imbedded: (a) Isolated fragments of muscle-fibers, usually bile stained, partially digested, but occasionally with the transverse sl.riations recognizable. (b) Larger or smaller yellow crystals of the alkali earth salts of the fatty acids. (c) Colorless soaps. (d) Isolated potato cells, without distinguishable contents. (e) Particles of oatmeal and cocoa shells, where the latter is taken instead of milk. The second slide gives a general idea of the fat present in the stool. While hot, the fatty acids, liberated in the acetic acid, appear as drops; on cooling, these congeal to small needle-like crystals. In the third preparation potato remains have a violet color, while isolated fungous spores (Clostridium butyricum) may appear blue. The pathologic findings which the slide may present, in addition to those enumerated under the macroscopic examination, are: TESTING THE INTESTINAL FUNCTIONS 547 Slide I. Muscle fragments in greater number and better state of preservation, par- ticularly with retained nuclei; drops of neutral fat; needles of fatty acids and soaps; many groups of potato cells. Slide II. Massive fatty acid drops and crystals. Slide III. Blue starch grains, free or in the potato cells; oatmeal cells; any considerable number of blue-staining fungous spores or thread-like bacteria. Bacteriologic Examination. The recognition of the tubercle typhoid, Shiga, or cholera bacillus calls for technic which will be found described in special treatises. The selection of material to be examined for tubercle bacilli is best made from the surface of formed stools, since in soft move- ments morbid products from the diseased area will be so mixed with the feces as to easily escape detection. For amebse, a saline cathartic such as magnesium sulphate should be given and the warm liquid stool examined. The stool to which several ounces of normal saline at ioiF. is added may be kept warm in a Thermos bottle for transportation to the laboratory. Mention has already been made of the detection of bacteria and fungi which are colored blue by iodin (granulose reaction). Procedures that yield information of considerable value in the less specific forms of intestinal infection have recently been advocated by Herter. Of first importance is the preparation of smears of the mixed stools on microscopic slides, stained by the Gram method. The relative number of Gram-positive bacteria, as also their character, is of diagnostic value, since they are relatively few in health and in meat-free diet, while they are increased in some diseased conditions and when notable quantities of meat are eaten. Not only is it of value to note the actual increase, but the potential. The latter is determined by the observation of the relative number of Gram-positive bacteria in the residues in the sugar- bouillon tubes (see below), a predominance of Gram-positive bacteria indicating a pathologic tendency of the fecal flora. Among the various bacteria that may be observed it is well to have in mind that B. coli are Gram-negative, usually small bacilli that may even appear almost like diplococci; that B. bifidus are Gram-positive bacilli usually some of which appear forked; that the pyogenic cocci are in general Gram-positive; and that Gram-negative cocci are ordinarily to be regarded as saprophytic. The sugar-bouillon tubes just mentioned are ordinary fermentation tubes, containing i per cent, lactose-bouillon, i per cent, glucose-bouillon, and i per cent, saccharose-bouillon respectively. Normally, little fermentation occurs when the tubes have been in- cubated at 37C. for tv/enty to twenty-two hours. Active gas pro- duction, so that it accumulates to the extent of more than one-third of the tube capacity, is most frequently due to the predominance of a bacillus identical with or allied to the Gram-positive Bacillus aerogenes capsulatus, the growth of which replaces the Bacillus coli communis, the normal in- testinal inhabitant. For more exact quantitative bacteriological examination, the following procedures may be employed: One gram of the representative fecal matter is accurately weighed out with an analytical balance of precision, in a sterile small glass crystallizing 548 DISEASES OF THE STOMACH AND INTESTINES dish. This material is then tritrated with successive small portions of sterile water by the aid of a sterile glass rod with rounded end, transferring each portion of the suspension to a small weighed Erlenmeyer flask containing glass beads, continuing the procedure till after five or six such transfers the entire sample has been transferred and the suspension in the flask has been accurately brought to 20 grams. The suspension is further pro- moted by rotating the flask for ten minutes or longer as necessary, to allow the beads to completely subdivide the suspended particles. This is: Suspension A, of which each c.c. contains 50 mgr. of feces. Suspension B is prepared by diluting 10 c.c. of A to 100 c.c., each c.c. containing 5 mgr. Suspension C is prepared by similarly diluting 10 c.c. of B, each c.c. containing 0.5 mgr. Suspension D is prepared by similarly diluting 10 c.c. of C, eachc.c. containing 0.05 mgr. Suspension E is prepared by diluting i c.c. of C to 100 c.c., each c.c. containing 0.005 mgr. 1. Total number of bacteria. Winterberg Method. A one to ten dilution with weak carbol-fuchsin (Ziehl's, diluted i : 10) is made of sus- pension B in a white blood-counting pipette and transferred to a Thoma- Zeiss chamber in which the count is made. The average number per small square multiplied by 8 is the number of million bacteria per milligram of fresh feces. 2. Number of living bacteria cultivable in lactose-litmus-agar at 37C. growth in air and in hydrogen. For the aerobic bacteria, }4. c.c. of sus- pension E corresponding to 0.0025 mgr. feces is employed for each plate. The number of colonies multiplied by 0.4 is the number of thousand per milligram of fresh feces. For the anaerobic bacteria, i c.c. of suspension E, corresponding to 0.005 m g- feces is employed for each plate. The number of colonies multiplied by 0.2 is the number of thousand per milligram of feces. 3. The number of living bacteria cultivable in lactose-litmus-gelatin at 2oC., growth in air and in hydrogen. For the aerobic bacteria, ^ c.c. of suspension E, corresponding to 0.0025 mgr. feces, is employed for each plate. The number of colonies multiplied by 0.4 is the number of thousand bacteria per milligram of fresh feces. For the anaerobic, i c.c. of suspension E, corresponding to 0.005 m &- feces is employed for each plate. The number of colonies multiplied by 0.2 is the number of thousand per milligram of feces. In each case the differentiation into liquefiers and non-liquefiers is made during the count. 4. The number of living spore forms. For the aerobic spore forms, i c.c. of suspension C, corresponding to 0.5 mgr. is heated for ten to fifteen minutes at 8oC. and then plated in lactose-litmus-agar and grown at 37C. The number of colonies multiplied by 2 is the number of aerobic spores per milligram of feces. For the anaerobic spore forms, i c.c. of suspension D, corresponding to 0.05 mg. is heated as above, plated in lactose-litmus-agar and grown in hydrogen at 37C. The number of colonies multiplied by 20 is the number of anaerobic spores per milligram of feces. 5. The relative number of Gram-negative and positive. Films are prepared from one of the suspensions, usually B, air-dried, fixed, stained with aniline-gentian-violet for one and one-fourth minutes, washed with Lugol's solution and covered with same for one minute, decolorized with TESTING THE INTESTINAL FUNCTIONS 549 95 per cent, alcohol for thirty minutes, washed with distilled water, stained with i per cent. Bismark brown one and three-fourths minutes, washed, dried and if desired mounted in balsam. The count is made by the aid of an eye piece marked off in squares. 6. The relative number of cocci, bacilli and spirillae, etc., in the original fecal material. This is determined by an independent differential count of the film prepared under 5. 7. Quantity of gas production. Fermentation is conducted in i per cent, glucose bouillon, inoculated with two loops of sus- pension A, and kept at 37C. for forty-eight hours. Gas V c formation is measured as usual in the closed limb of the tube. 8. The relative number of cocci, bacilli and spirillae, etc., developed during fermentation. This is determined from the count of a film prepared from the sediment of the fermentation tube and stained, as described under 5. Chemic Examination. The chemic reaction is best determined by smearing one side only of moistened red and blue litmus-paper with the diluted (see Macroscopic Examination) fecal matter. After some time the reaction is noted on the opposite side. It is usually amphoteric, feebly acid, or alkaline. Excretion of Bile. The sublimate test for unchanged bile-pigment is performed by adding some of the diluted fecal matter to a considerable excess of strong solution of bichlorid of mercury, allowing the mixture to stand over night. The normal feces are colored red; more in- tensely, the fresher and less decomposed the excrement. Herter points out that this red coloration may be patho- logically increased in excessive saccharobutyric putrefac- tion. This excessively strong reaction is probably due to the reduction of the bilirubin to hydrobilirubin through the Bacillus aerogenes capsulatus. In the presence of bilirubin, a green coloration is produced. This, even to the extent of microscopically small particles, is patho- logic. A negative sublimate test suggests suppression of bile. This last is of value, as it indicates that an acholic stool is bile free and that the color- less stool is due to complete occlusion of bile from the intestines. An in- complete test with fresh stools shows abnormal processes of decomposition. Functions of the Liver. The best method of testing the functions of the liver depends on the power of the normal liver to metabolize 100 grams of levulose when given all at once in solution, as in weak coffee, on an empty stomach. Normally, no trace of this should appear in the urine by Fehl- ing's test. The urine should be first examined six hours after its ingestion. The fermentation test of Schmidt and Strassburger for fermentable carbohydrate or putrescible protein is performed in the Strassburger fermentation tube (Fig. 264). A 5-gram portion of the well-mixed, undiluted, fresh excrement, or proportionally more of the thinner material, is well mixed with sterile Fig. 264. Strass- burger's tube. 550 DISEASES OF THE STOMACH AND INTESTINES water; the chemic reaction noted; and then the mixture is introduced into the lower vessel of the apparatus. The bottle is entirely filled with water and stoppered, with exclusion of air. The adjacent upper tube is filled or nearly filled with water, while the distal tube remains empty. The apparatus is incubated at 37C. for twenty-four hours. The extent of gas formation is indicated by the amount of water dis- placed by the gas from b' and which accumulates in the distal tube c 1 '. Normally, there is practically no gas formation, and the chemic reaction of the fecal mixture remains about unchanged. Gas production to such an extent as to introduce an amount of water into the distal tube equal to one-third its capacity is pathologic. If coincidently with the gas pro- duction the chemic reaction has developed a decidedly increased acidity, the gas production is due to carbohydrate fermentation; if alkalinity, albuminous putrefaction has occurred. When the proximal tube is opened it gives off a butyric acid odor in the former case and a putrefactive odor in the latter. The color of fermenting feces is generally brighter; of putrefying feces, darker. The test is more especially applicable to the test-diet stools. If the condition approximates the normal, a further test should be carried out for accuracy. In such event, the patient is placed on a diet which differs only from the first in the absence of meat and potato. If there is still a positive result,. the diagnosis of "fermentative dyspepsia" is justifiable. Putrefactive Products. Tests for indol and skatol may be applied to the distillate, using 10 gm. of the feces mixed with 120 c.c. of water, and the whole made alkaline, a bit of paraffin added to prevent frothing, and the first 50 c.c. collected. A suitable apparatus for conducting the process consists of a 5oo-c.c. capacity long-neck Kjeldahl digestion flask connected with a Liebig con- denser. Distillation with steam is sometimes advantageous; 10 c.c. of the distillate is rendered slightly alkaline with sodium or potassium hydroxid and an excess of a fresh solution of betanaphthoquinone-sodium- monosulphonate added. The substance, in the course of a few minutes, reacts almost completely with the indol present, but not with the skatol; .with the resulting formation of a bluish precipitate with much indol, and a mere coloration of the solution with little. If more than a trace is pres- ent, the reaction is conducted with the remaining 40 c.c. of the distillate, the indol naphthaquinone compound removed from the whole by filtra- tion, and from the portion remaining in solution by distillation, after acidifying. The distillate containing the skatol, if necessary, freed from indol as described, is tested by the use of a well-marked excess of dimethyl- amido-benzaldehyd (Ehrlich's aldehyd), being boiled with a 5 per cent, solution in.io per cent, sulphuric acid. Dilute hydrochloric acid is added to the point of the production of the maximum color intensity and the mixture rapidly cooled. The presence of skatol is indicated by the blue coloration. The color may with advantage be extracted with chloroform. If the process described is to be conducted quantitatively, 25 grams TESTING THE INTESTINAL FUNCTIONS 551 of feces should be employed^ and distillation continued till the distillate is free from substances reacting with the above reagents, the color shaken out with known volumes of chloroform, and the depth of color compared by the aid of the Duboscq colorimeter, with a similar chloroform extract obtained by starting with solutions of known strength of indol and skatol respectively. REFERENCES Herter, C. A., Bacterial Infections of the Digestive Tract, 1907. Herter, C. A., and Foster, M. Louise, Jour of Biol. Chem., i. p. 257; ii, p. 267. Schmidt, A., translated by C. D. Aaron, The Test-diet in Intestinal Diseases, vol. Ixxvii, 1906. Steele, J. Dutton, Medical News, 1905, p. 1158, vol. Ixxvii. Results. In interpretation of results, we have to consider both the occurrence of pathologic admixtures and an increase of the constit- uents from the test-diet. A thin coating of mucus is normally collected by the hardened fecal matter. Otherwise the appearance of this product indicates catarrh of the mucosa, the mucus containing many cellular elements. An exception is the overproduction of mucus in colica mucosa, with cellular elements less abundant and with the striking consistence. Pus, blood, masses of epithelia from the mucosa, and similar elements carry the pathologic significance of these products, and require investiga- tion and interpretation, as when found elsewhere. Considering an increase of the constituents of the test-diet, a dis- tinct connective-tissue increase indicates , deficient gastric 1 digestion. An excessive quantity of meat-fibers points to deficient protein digestion in the small intestine. The albumin fermentation (putrefactive) test further indicates increased protein in stools, frequently derived from pathologic secretions, probably associated with an abnormal putrefactive flora. The bacteriologic examination, especially as to fermenting and Gram-positive bacteria, is of value along these lines. Also test for pu- trefactive products, if increased activity in this direction quarts (liters). Milder medicated solutions can be employed in this way. The low enema is of more value for low impaction, or to relieve local irritation in the rectum or adjacent organs (prostate, bladder, tubes, ovaries). 3. Irrigation with a Single Tube. There are four modifications of this method: (a) A colon-tube is inserted into the bowel, a funnel attached, and by raising and lowering the funnel the bowel is washed out. 1 Enteroclysis, Hypodermoclysis, and Infusion, Kemp; Hydrotherapy, S. Baruch; Enteroclysis, Reference Handbook of the Medical Sciences, 1900 and 1915. MECHANICAL PROCEDURES 555 (6) A fountain syringe can be attached to the colon-tube, and when sufficient fluid has flowed in from the fountain syringe, the connection is detached and the fluid flows out through the colon-tube. (c) The patient can void the fluid around the colon-tube or catheter Fig. 266. Colon-tube. during irrigation. This is the method usually employed with infants. Elmer Lee carried out this technic at the cholera stations (Fig. 267). An irrigating jar may be substituted for the rubber bag. (d) A glass Y or T tube 1 is attached to the colon-tube, as in lavage of the stomach; one branch is connected with the fountain syringe, the Fig. 267. Lee's cholera table. other is to a soft carry-off tube. By alternately pinching the soft-rubber outflow and inflow tubes, the bowel can be irrigated. 4. Double-current Irrigation with Two Tubes or a Recurrent Tube. 1 Enteroclysis, Hypodermoclysis, and Infusion, Kemp; published by J. T. Dougherty, 1900. 556 DISEASES OF THE STOMACH AND INTESTINES Advantages. The quantity of the fluid is under the control of the operator, since it can be regulated by manipulation of the outflow and inflow tubes. The labor is placed upon the operator and not upon the patient, and there is no straining to overcome the resistance of the sphincter. The straining of self-evacuation is avoided, and mere mechanical cleansing of the bowel is employed. The temperature of the fluid entering the bowel can be kept constant. Fig. 268. Kemp's flexible recurrent rectal irrigator. Tympanites is relieved best by this method, the return flow carries off the gas by suction. With the enema the gas frequently collects in the intestines behind the injection and it is often impossible to exert sufficient force to expel it with the enema. Two catheters or two small rectal tubes passed through a perineal pad can be improvised for this purpose. The illustrations of the author's tubes are shown (Figs. 268-272). They are readily understood. J. P. Tuttle's, Hemmeter's, and various recurrent rectal tubes are described Fig. 269. Kemp's glass rectal irrigator (recurrent). Cork opening above for cleansing. by the author in his manual "Enteroclysis." The hard-rubber tube with metal center is the best. All metal tubes are good for hospital work. The flexible tube is excellent for sensitive cases, or for young children. To the middle tube of the irrigator is attached the tube of the fountain syringe; to the curved tube the outflow soft-rubber tubing is fastened. This last must be pinched, as it is the larger, in order that fluid may pass up the bowel. By alternately pinching the inflow and outflow the quantity of fluid may be regulated. MECHANICAL PROCEDURES 557 The height 1 of the douche bag should be 3 to 5 feet above the patient. Precautions before insertion of the tube: The rectum should always be examined digitally before a hard instrument is introduced, (i) Allow the irrigating fluid to flow from the tube, so as to force out all air and then check the flow. (2) As the tip of the instrument passes through the sphincter into the bowel, it is well to start the flow, so as to force the Fig. 270. Kemp's rectal All metal tube. irrigator. Fig. 271. Electric attachment for electro- enteroclysis. Hard-rubber tube with metal center. mucosa away from the irrigator and fenestrae. Also the entrance of the tube is not interfered with by the resistance of the mucous membrane. Insertion of the instrument: The tube should be well lubricated and inserted with a gentle rotary movement, the tip directed slightly back toward the sacrum and not forced in; this is especially the case with the hard tubes. Forcing the tube in might injure the mucosa. Do not Fig. 272. Kemp's tube (ready for cleansing). Hard rubber with metal Three sizes. center. press the tip of the tube against the wall of the bowel or direct the current against it, as either is irritating. (3) If the flow ceases, rotate the tube slightly or withdraw it slightly while rotating and push it back. If the return tube seems plugged, attach the fountain syringe to it for an instant, and force the current in the opposite direction. 1 Modern Methods of Intestinal Irrigation, The Medical Brief, Dec., 1910; also Manual on Enteroclysis. 558 DISEASES OF THE STOMACH AND INTESTINES The best method to clear the outflow tube is as follows: A small soft or hard.-rubber, or glass rectal syringe (enema) which contains from y pints to i quart (750-1000 c.c.) of fluid are allowed to run into the bowel. Fig. 274. Enteroclysis (double current). Patient in Sims' position. The shoulders are then elevated to above the level of the hips, the patient being still on the right side. This is to make the fluid gravitate into the caput coli. The shoulders are then depressed to below the hip level, the patient on the right side; he is then gradually rotated to the dorsal position and then to the left side, and as a final step the shoulders are elevated, etc. In other words, the process is reversed. The return tube is then released and the fluid is allowed to escape. Douglas H. Stewart of New York has devised an ingenious and con- 560 DISEASES OF THE STOMACH AND INTESTINES venient method. For continuous irrigation, he partly fills a wash-boiler with normal salt solution at the desired temperature, and this is kept hot by the addition of fresh hot saline solution; he hangs a gallon fountain syringe about 6 or 7 feet above the patient. He employs a hand-pump to force the solution from the wash-boiler through a connecting tube to the fountain syringe above. This simplifies the entire procedure and one does not have to disturb the bag in order to refill it. In addition, the outflow tube of the irrigator is left open, as there is sufficient force on Fig. 275. Enteroclysis (double current) without the bed-pan. account of the height of the bag to carry the fluid well up the intestines Distention is carefully watched for and the entering current shut off in such event. The author has had this method employed on himself with excellent results. I employ most frequently the dorsal position without the bed-pan. Temperature of the solution depends upon the conditions of its em- ployment, an average of 101 to io5F. in intestinal catarrh; at noF. in typhoid for an additional eliminative effect, and for shock and uremia at 115 to i2oF. In the latter conditions continuous enteroclysis may MECHANICAL PROCEDURES 561 be kept up for one-half to one hour, about >^ to i pint of hot saline solution being kept in the bowel continuously. Solutions Employed. Flaxseed tea (2 drams 8.0 of flaxseed to i quart liter of water, boiled twenty to thirty minutes and strained). Temperature, 101 to iO3F. This should be rather thin and oily in order to flow easily from a fountain syringe. Dilute it with boiled water if too thick. Normal saline solution with oil of peppermint, 5 to 15 minims (0.296-0.88 c.c.), or oil of cinnamon, 5 to 15 minims (0.296-0.88), Fig. 276. Enteroclysis (double current). Patient in semi-oblique position, as in pulmonary edema, etc., when dorsal position is impossible. to i pint (500 c.c.). Listerin, borolyptol, glycothymolin, borax, boric acid, bicarbonate of soda, tannic acid, tannin, and alum have been em- ployed at a strength of i dram (4.0) to i quart (liter), and gomenol, 15 to 20 minims (0.88-0.00) to i quart (liter). Gum arabic solution, and slippery-elm solution are also excellent for irritation. Acetozone or alphazone i-iooo; peroxid hydrogen 5ii to the liter; protargol or argyrol 1-2500 to i-iooo; quinine i-iooo to 1-500 are useful in appropriate cases. 36 562 DISEASES OF THE STOMACH AND INTESTINES Solutions of nitrate of silver, 15 grains to y% dram (1.0-2.0) to the quart (liter), have been used in chronic dysentery. Permanganate of potash, 2 to 5 grains to i quart of water, is valuable, when there is foul odor or much fermentation. Douglas H. Stewart recommends the Fig. 277. Enteroclysis (double current). Self-irrigation of the prostate per rectum following when there are foul odor, fermentation, putrefaction, and excessive bacteria: Chlorinated lime 2 teaspoons; Commercial acetic acid i tablespoon. Dissolve in i quart of water. Then add 9 quarts of plain sterile water. Salt is incompatible with acetic acid. Requisite portion of the 10 quarts is used for irrigation. The solution eliminates chlorin and yet does not seem to irritate. If salt solution is desirable, omit the acetic acid and substitute 2 teaspoonfuls of commercial sulphuric acid thus: Commercial sulphuric acid 5U(8-o); Chlorinated lime 3 j (4-); Normal salt solution 10 quarts (liters). Delafield has used bichlorid of mercury (i : 10,000), 2 quarts (liters). for septic membranous colitis complicating typhoid fever, with a re- current tube, with success. Special solutions are described appropriately, MECHANICAL PROCEDURES Normal saline solution, i dram (4.0) of salt to i pint (500 c.c.) of water, has a wide field of usefulness. Enemata and enteroclysis are of value in dysentery, intestinal hemor- rhage, 1 intestinal catarrh, typhoid, intestinal colic, tympanites, intestinal toxemias, apoplexy, intestinal dyspepsia, diarrhea, thirst, constipation, impaction, intestinal paresis, and jaundice. They are extremely useful in shock, oliguria, uremia, sepsis, renal colic, and in inflammatory conditions of the genito-urinary organs of both sexes. The high enema is at times of value to reduce intussusception. Irrigation may also be cautiously employed with cool saline solution at 90 to 5oF. to aid in the reduc- tion of temperature. There is an element of danger in the prolonged use of very cold water for this purpose, shock or urinary suppression being possible in asthenic cases. Proctoclysis. In conclusion, I wish to refer to proctoclysis, the injection of normal saline solution into the rectum by the drop method, as first suggested by Dr. John B. Murphy of Chicago. This procedure is of special value in sepsis, and is of use as an adjunct to other treatment in postoperative shock, intestinal paresis, hemorrhage, to prevent post-operative thirst or to treat it, also for uremia. In my experience the employment of continuous (recurrent) irrigation, with a temperature of the saline solution at i2oF., is more efficacious in shock, intestinal paresis and uremia, fol- lowed by proctoclysis as an adjunct. Rectal feeding can also be administered by the drop method (procto- clysis) and also calcium lactate for hemorrhage, when it cannot be retained by mouth. One of the difficulties which the physician must endeavor to overcome in the administration of saline solution by the rectum or by infusion is the mainte- nance of a constant temperature of the solution. El- brecht's apparatus necessitates a special heating chamber in addition to the containing reservoir, with the employment of an electric heater, an alcohol lamp, or a Bunsen burner. The method, though scientific, seems complicated and is quite expensive. There are many other devices. One can use a fountain syringe of hot saline solution in which is placed a hot electrc-light bulb, hot towels being wrapped around the conducting tube. I have for some time employed the vacuum bottle 2 with a specially devised attachment, which has proved efficacious in preserving the saline solution at a constant temperature. It is readily understood. The original instrument has been improved by placing the flatus tube high up. It is readily understood from the illustration (Fig. 278). The writer 1 This refers to hemorrhage in the large intestine, where an extremely hot or cold astringent enema is of service. 2 New York Med. Jour, and Philadelphia Med. Jour., Aug. 14, 1909. H Fig. 278. Proc- toclysis bottle (heat- retaining). 564 DISEASES OF THE STOMACH AND INTESTINES was the originator of the vacuum bottle method of protoclysis. All the other instruments were reported later than his own. Through the screw cap (B), which closes the bottle (^4), passes a small hard-rubber conducting tube, to which is attached the outflow tube OF). Parallel with this is the filiform tube (C), which allows the entrance of a fine column of air, so as to render the flow possible. This last tube passes through the solution to within about % inch from the bottom of the bottle. As the instrument is employed inverted, it would correspond to the same distance from the top of the bottle. This filiform tube is of hard rubber externally where exposed to the air as a non-conductor of heat. The part lying within the bottle is purposely made of metal, so that it is rapidly heated by the surrounding solution, and the entering air is thus, in turn, heated markedly. A series of experiments have demonstrated that there is only a loss of i to 2F. in the temperature of the solution in the bottle during the administration of proctoclysis (the drop method) lasting half an hour, a negligible amount. The screw compression valve (D) is applied close to the bottle attachment, so as to avoid as much as possible the solution cooling in the soft outflow tube. At () is a stopcock with branch tube to allow escape of gas from rectum a flatus tube. This outflow tube (F) is joined to the catheter (H) by a short piece of glass tubing (G), for the purpose of observing whether the flow is constant. The catheter for rectal injection passes through a self -retaining rectal tip (/), and the former can be inserted to any length desired. The conducting tube F is especially thick, as in Elbrecht's apparatus. An asbestos tube surrounds the conducting tube from its junction at the bottle to the catheter. This lessens dissipation of heat and ob- viates the use of hot towels. The asbestos wrapping can be occasionally slipped off the glass connecting joint, so as to observe the flow. The vacuum bottle is filled in the usual manner and the special cap with at- tachment screwed on. The bottle is then inverted and suspended in a cord sling, as in the illustration. A small amount of fluid will escape from the bottle by the filiform air tube until the solution reaches the level of the tube, which now lies near the top of the bottle. The bottle is then suspended about 6 inches above the rectum or higher if desired, and the flow tested for the proper speed before inserting the rectal tip and catheter. Formerly if flatus occurred, one lowered the reservoir for a brief period to below the level of the abdomen, so the gas may escape into the bottle. At times, however, it was necessary to remove the tube for a short period. The writer formerly inserted a T-tube between the reservoir and rectal catheter to allow escape of gas. A short piece of rubber tubing was at- tached to the branch and immediately clamped. On occurrence of flatus, the lateral clamp is removed and the gas allowed to escape. It is then reclamped. This obviates removal of the tube. These procedures are no longer necessary with the newer instrument. As already stated, there is practically no loss of heat in the container, all of it occurring during the passage of the drops through the outflow tube; the slower the speed, the greater the loss. At the start the speed is always more rapid, and, though gauged to, MECHANICAL PROCEDURES 565 say, 15 drops per minute, may, in the course of two minutes, drop to 5. A test of two to three minutes should, therefore, be made before inserting the catheter, so as to insure a constant flow at the desired rate. The fol- lowing table will be found of service; with Temperature of water Length of tube Number of drops Temperature in in bottle (inches) per minute rectum igoF. 30 60 H5F. i6oF. 30 20 or less iooF. i5oF. 30 401050 iooF. 138 to i4OF. 30 150 to 200 105 to noF. If the injection is given at a greater speed than 200 drops per minute, the solution in the bottle should not be over i2oF., as there is practically no loss of temperature. Sixty drops to the minute is the speed usually employed. This method by enema or recurrent enteroclysis would be of great value in shock. It could then be followed by proctoclysis as an adjunct. Hypodermoclysis. There is a loss of 10 to 2oF. during the injection, depending upon the size of the hypodermic needle. Infusion. Dawbarn advocates a temperature of 115 to i2OF., preferably the latter; time, ten minutes to the liter (quart). With the small vacuum bottle, containing about i quart (liter), a glass V tube can be inserted between the conducting tube and the Fig. 279. Turck's double-current needle douche for the sigmoid. rubber tube for attachment to the infusion canula. By this means it is possible to tell when the bottle is empty and thus prevent the! entrance of air. A clamp can be applied close to the V tube on the canula side and the bottle refilled, the V tube being refilled before the conducting tube is reattached, and the latter being done while the solution is flowing. A larger bottle can be secured for infusion, but the smaller one can be employed with these precautions. The temperature of the saline solution does not practically change during the infusion, and should be at 115 to i2oF. in the reservoir. Needle Douche; Nebulizer; Colonic Massage Bags; Gyromele. These instruments 1 have been devised by F. B. Tiirck. The colon needle douche (Fig. 279) I believe of some value for local treatment by the alternate hot and cold spray in the atonic type of constipation. The nebulizer (Fig. 280) is recommended by its inventor for spraying oils of cloves or cinnamon into the colon for their antiseptic, analgesic, and vasomotor effect. He recommends distensible bags for massage of the atonic sigmoid and rectum, which I do not advocate. The gyromele, already described, Turck recommends in the rectum and sigmoid for cleansing the mucosa and producing vibratory movements. 1 Journal A. M. A., May, 1895. 566 DISEASES OF THE STOMACH AND INTESTINES I question the possibility of its entering into the sigmoid flexure except on rare occasions. Massage, Gymnastics, and Exercise. The general methods of massage have been described. The course of the colon should be followed. The cannon-ball and vibratory massage are of service. The portable Vedee vibrator is a useful instrument for the general practitioner. It is illustrated in Part II of this volume. The modern electric vibrators are preferable. Gymnastic exercises and out-of-door sports are valuable for strengthening the abdominal and intestinal musculature, especially in intestinal atony with constipation. Rowing with a sliding seat, golf, horseback-riding, bicycling, and walking are useful. Fig. 280. Tiirck's nebulizer. Mechanical Support. Adhesive strapping (Rose's belt), abdominal supporters, etc., are indicated in enteroptosis, in atonic conditions of the intestines, or of the musculature of the abdominal wall, in hernial pro- trusions, etc. Hydrotherapy. The Priessnitz compress, poultices, and the appli- cation of heat or cold locally are useful for pain. Sitz-baths 1 and abdominal douches are employed as already described. Electricity. Galvanic, faradic, and static electricity may be employed percutaneously. The faradic, chiefly in atonic conditions; the galvanic, in painful neurotic affections. Static electricity can be used for both purposes. About ten to fifteen minutes is the average period of treatment. When externally applied the current should follow the course of the colon and then be given over the small intestine. Electric vibration may be used. Violet rays, the high-frequency current, etc., have been advocated for various conditions. The application of heat and light (electric-light bath) to the abdomen in painful conditions due to a gouty or rheumatic 1 The artificial Nauheim bath (Triton Salts) is useful in intestinal atony, or mucous colic with sensitive abdominal points, and with poor circulation. MECHANICAL PROCEDURES 567 tendency, or in enteroptosis, or mucous colic, its application to the sensi- tive areas may prove of service. Intrarectal Electricity. Boudet's electrode presents the disadvantage that sometimes frequent evacuations necessitate withdrawal of the electrode. The author's instrument (Fig. 271) depicted under "Enteroclysis" consists of a recurrent irrigator, external tube, hard rubber internal tube metal, with an attachment for a battery pole; a sponge attached to the other pole is placed over the abdomen. Continuous enteroclysis is given with hot normal saline solution, the water carrying the current. The treatment should be given for five to thirty minutes, depending on the indications. It is excellent for simple atonic constipation and for intestinal paresis. The faradic current is preferable, as strong as the patient can bear. The galvanic may be employed, with negative pole in the rectum, with a current of 10 to 15 milHamperes. CHAPTER XXI DIET; ; INTESTINAL DYSPEPSIA; CHRONIC INTESTINAL PU1 FACTION (INDOLIC TYPE); INDICANURIA; SACCHA BUTYRIC PUTREFACTION; SUBINFECTION ; PROTEIN SORPTION; BOTULISM; HYDROGEN SULPHID AT YTVTrH/^V VT/-1 A rrVTX^IkT . T^WTnVT^T 1 * XX f~* T^TKTT^t /"ITF A TVTXN riVrt - T*f*T" &UKK11U1N J J5U1UU.&JYL; lXJJKULrJllN OU.b.flJ INTOXICATION; ENTEROGENIC CYANOSIS; ISM; ENTERALGIA; VISCERAL ARTERIOSC SENILE DYSPEPSIA; ANOMALIES; INTESTINAL TNTTS1* THE general principles of diet were described in Diseases of the Stomach. I will briefly mention a few rules which should be applied. Acute intestinal disorders must be managed on the principle of rest. Light food (chiefly liquid) should be given, such as broths, barley-water, gruels, koumiss, matzoon, bacillac fermillac, lactone-buttermilk, and in some cases milk, but diluted with barley-water or lime-water. It has been demonstrated that in the acute intestinal catarrh of infants and children, undiluted (or at times even diluted) milk will frequently pass undigested and intensify the inflammatory process, so that reliance is placed for a time on barley-water and similar preparations. Seibert has shown conclusively that milk is not the ideal food for typhoid fever. In chronic intestinal disease, for a brief period, rest may be given to the intestines by means of a fluid diet, but feeding should soon be increased, the general nutrition improved, and the intestinal tract gradually accus- tomed to a regular diet, if such be possible. Milk, cream, raw eggs, car- bohydrates, and fats (butter) are of value to improve nutrition. In these chronic cases especially, and also in intestinal dyspepsia, all or some special digestive function may be disturbed, such as for proteins, fats, or carbohydrates. The presence of indicanuria, the test-diet with stool examination, the fermentation test, together with the clinical symp- toms, will determine the type of disturbance of the intestinal digestive function. The findings would modify the diet. Dietetic measures are of special value in reference to disturbances accompanied by constipation or diarrhea. i. Laxative foods are articles which increase intestinal peristalsis. Among such are fruit juices and raw and cooked fruits, such as apples, pears, plums, peaches, strawberries, gooseberries, dates, and figs. Salads, garden vegetables, due to water contained and indigestible residue, such as melons, cucumbers, spinach, tomatoes, pumpkins, and cabbage; cider; bonny-clabber, koumiss, matzoon, and bacillac, fermillac through formation of acid products and gas, increase peristalsis. Some of the fruits and vegetables mentioned have a similar effect. Brown bread and oatmeal 568 DIET 569 tend to move the bowels, also water or carbonated waters. Sugar has a laxative effect. Considerable fat, in the form of cream, butter, or olive oil, aids bowel action. 2. Constipating Foods. Among such are substances containing astringent agents, especially tannic acid, such as tea, dried bilberries, French red wines, cocoa, the acorn preparations, such as acorn coffee, acorn cocoa; mucilaginous foods, such as sago, tapioca, rice, and barley; also foods which leave little residue and exert no irritation, such as albu- min-water (white of egg dissolved in water), scraped raw beef, mutton broth, etc. Pathologically, excess of carbohydrates may be a cause of diarrhea, as may excess of proteins. Milk is constipating in one person, laxative in another, and has no special effect on others. Boiled milk is usually constipating. Dietetics have changed markedly during the last few years. In chronic colitis with diarrhea the chief diet was formerly scraped meat. Modern methods allow a much greater variety, and the employment of mashed potatoes and boiled rice lessen peristalsis and are often of con- siderable value. Certain foods, when taken under ordinary conditions, have no marked influence in increasing peristalsis; among these are meats, fish, meat powders, artificial foods, such as peptone, nutrose, somatose, plain or flavored; eggs, well-baked bread (wheat), crackers, zwieback, and butter or fat in small amount. Marked seasoning of foods increases peristalsis. The finer the particles of food, the less the irritation; the coarser they are, the greater stimula- tion they produce on the intestines. Gelatin. I have referred to the value of gelatin in ulcer of the stomach and in hyperchlorhydria. Gelatin does not built up new tissue, no matter how much is ingested, though it may diminish tissue waste (Voit). 1 It cannot be reconverted into a protein. Kirshmann 1 shows that gelatin spares protein in metabolism. The ingestion of 7.5 per cent, of the total heat requirement of the organism in the form of gelatin spares 23 per cent, of the body's protein, while 60 per cent, gelatin reduces it 35 per cent. One gram of gelatin furnishes 4.1 calories. About 50 grams of gelatin represents this require- ment in a person weighing 154 pounds. The small amount of gelatin has nearly as much effect as larger quantities. Its value in typhoid is, there- fore, evident to lessen nitrogen excretion. Kaufmann 3 shows that when the lacking tryosin, cy stein, and trypto- phan are mixed with gelatin in the proportion in which they occur in true protein, and are given to a dog or man, nitrogen equilibrium may be established. Gelatin does not yield indol, and can be employed in the form of jellies as a nitrogenous substance to replace proteins in cases of indicanuria (Herter). 4 1 Hermann's Handbuch, Stoffwechsel, 1881, p. 396. 2 Zeitschrift fur Biologic, 1900, Bd. xl, p. 54. 3 Pfltiger's Archiv, 1905, Bd. clx., p. 440. 4 Bacterial Infections of the Digestive Tract, p. 267. 570 DISEASES OF THE STOMACH AND INTESTINES In severe inflammation of the intestines artificial feeding may be necessary, by rectum or subcutaneously. Rectal alimentation has been described under Diet, in Part II. Sterile olive oil, i to 2 ounces (30.0-60.0), may be injected subcu- taneously two or three times a day between the crest of the ileum and lower border of the ribs (preferably). Sterile almond oil in doses of i to 2 drams (4.0-8.0) may be substituted. I do not advocate, however, the subcutaneous method. Normal saline solution, i pint (500 c.c.) to i quart (liter), may be slowly injected in the same region in case of collapse or hemorrhage. INTESTINAL DYSPEPSIA With intestinal catarrh, or biliary or pancreatic obstruction, there is perversion of intestinal digestion. These conditions will not be considered here. Digestive processes in the intestine may become abnormal when the intestinal contents are no longer normal. This may occur even with intact mucosa and with sufficient bile and pancreatic juice. Indigestible food, or excess in some special types of food, may lead to fermentative or putrefactive processes in which bacteria take part, and may produce dyspeptic symptoms. Indicanuria or saccharobutyric putrefaction occur from these conditions. There may be functional disturbances of pancreatic digestion for the proteins, carbohydrates, and fats, or any one or two of these functions may be disturbed. Riegel describes cases with marked fermentation of the carbohydrates. There is a jejunal diarrhea of gelatinous semifluid character, often quite green, with bile-pigment reaction and acidity. There is mucus in these movements, but no formed elements, such as epithelial and round cells, which occur in catarrhal conditions. Catarrh may ultimately result. Herter 1 shows that there is an intestinal indigestion in children of marantic type, in which there is intolerance to carbohydrates, and light- colored and gray or fatty stools occur. Indican and phenol are found in large amount in the urine. A great number of Gram-positive bacilli of the Bacillus bifidus type occur in these cases. Schmidt and Strassburger describe "intestinal fermentation" as dyspepsia in which the stools are light yellow, foamy, with the odor of butyric acid. Fatigue, discomfort, loose stools, or even diarrhea may occur. Abdominal pains, distention, and some tenderness may be present. These cases correspond to saccharobutyric putrefaction (Herter) , 2 Dyspeptic symptoms may be due to the decomposition of proteins. 3 Various symptoms, as stated, may be present with intestinal dyspepsia, such as distention, pain, borborygmi, passage of flatus, feeling of dis- comfort in the abdomen. Diarrhea or irregularity of the bowels is present ; loss of appetite, eructations, nausea, and even vomiting may occur. The 1 Ibid., p. 285. 2 Bacterial Infections of the Digestive Tract, pp. 294, 300. 3 Ibid., pp. 280, 306. SUBINFECTION; PROTEIN ABSORPTION 571 best metho4 of determining the intestinal functions is by the Schmidt- Strassburger test-diet, with examination of the stool. Treatment. That variety of food must be limited for which the par- ticular disturbance exists. Liquid or semiliquid diet may be necessary. Indicanuria and saccharobutyric putrefaction must be appropriately treated. Lactic acid has been recommended in the form of fermented milks such as koumiss, matzoon, bacillac, fermillac, kefir, or lactone-buttermilk; chicken, jellies, gruels, etc., can be given later. Calomel, Ho grain (0.0016) four times a day, is suggested by Van Valzah 1 for fermentation; or resorcin, 5 grains (0.3) t.i.d., is excellent. Taka-diastase, 5 grains (0.3) t.i.d., is valuable in amylaceous dys- pepsia; or pancreon, 5 grains (0.3) t.i.d., in disturbances of fat and pro- tein digestion, 2 and pancreatin, same dosage. Cellasin, 5 to 10 grains (0.3-0.6), given t.i.d. an hour after meals, in combination with bicar- bonate of soda, 10 grains (0.6), has of late proved valuable in amylaceous and fatty dyspepsia. Holadin, an extract of the entire pancreas gland, represents all the constituents of the gland, both of the digestive and internal secretions. This may be given in a 3-grain (0.3) capsule. One would begin with one capsule immediately before or two hours after each meal, and increase to two capsules t.i.d. The writer usuaUy adds a tablet of secretin or, preferably, prosecretin, i grain t.i.d., to the above to stimulate pan- creatic secretion. As the bile salts intensify the action of the pancreas, one may at times substitute capsules containing holadin and bile-salts (holadin, 2% grains; bile-salts, ^ grain in each capsule). One of these is given t.i.d. about three hours after meals. Enterokinase in 3-grain (0.2) doses may also be given. This product (Fairchild's) is still in the experimental stage. A ferment of the duodenum, it activates the tryp- sinogen. The writer usually first tries holadin with prosecretin and, lately, the addition of enterokinase. Ad. Schmidt, 3 Gross 4 and others have recommended insufflation of the small intestine through the duodenal tube for intestinal fermentation. The writer believes it might be worthy of trial in obstinate cases. In conclusion, I would advise that in the milder cases the special food stuff which causes dyspepsia should be limited in quantity, but not entirely cut off. Eggs, soft boiled or raw, vegetables in mashed forms, bread or crackers, stale and well broken up, are of service, butter or cream according to indication. Later the diet is increased. SUBINFECTION; PROTEIN ABSORPTION; AND CHRONIC INTESTINAL PUTREFACTION There has been an unfortunate tendency to attribute many human ills to the well-worn term " auto-intoxication." Self -poisoning properly speaking is due to substances arising within the organism, to products of metabolism, or derivatives of disintegrated or disorganized cells. Adami 1 Med. News, Jan. 17, 1903. 2 True Intestinal Dyspepsia (Einhorn), Amer. Jour, of Med. Sciences, November, 1907; also Med. Record, September 4, 1909. 3 Zentralblatt f. innere Medicin, 1912, No. I. 4 Med. Record, Nov. 30, 1912. 572 DISEASES OF THE STOMACH AND INTESTINES justly holds that products which arise in the alimentary tract by the action of invading organisms (from without) are not auto-intoxicants; for example, with botulism the Bacillus botulinus has been isolated from raw ham and the Germans assert that Bacillus paratyphosus is a habitat of beef and that the fever is produced by toxins generated by these bacilli in ingested beef. In some cases, apparently originating from the intestinal tract in primary pernicious anemia and secondary anemia, where there are pronounced indications of excessive saccharobutyric intestinal putrefaction such as described by Herter, and in which the intestinal condition was believed to be the chief cause, streptococci some- times of oral origin have also been found; so that these conditions were due to a combination of intestinal putrefaction and infection from without (streptococci). Adami holds that many cases of improperly called auto-intoxication originate not necessarily through the lower bowel but are due to the carriage of bacteria through the mucosa at any point from the mouth to the anus and the leukocytes may act either as carriers or destroyers, of these organisms. When there is an inflammation in the alimentary tract, there is an increased passage of leukocytes from the inflamed area, and increased carriage of bacteria into the blood. An active inflammation may result in some other regions, or the condition which Adami terms "subinfection." In this last, the bacteria become destroyed and liberate toxins which poison the cells in their vicinity. Certain cells may die as a result and be replaced by fibrous tissue. Adami argues that the veils of intestinal stasis described by Lane, result more from subinfection and low forms of infection than from chronic intoxication. Experimentally, repeated infection of colon bacilli during anesthesia on animals may produce con- nective-tissue formation (cirrhosis) of the liver. Moreover a high grade of anemia, closely resembling pernicious anemia, has been produced in dogs by repeated injections of cultures of colon bacilli of low virulence and changes consisting of diffuse degeneration in the columns of Goll, resembling those found in cases of pernicious anemia also occur. This is another illustration of Adami's theory of subinfection. We thus may have an apparently pernicious anemia, result from chronic excessive intestinal putrefaction the B. aerogenes capsulatus as a factor (Herter), or from chronic excessive intestinal putrefaction plus strepto- coccus infection (oral in some cases), or from subinfection. Moreover cases are reported of apparently acute articular rheumatism in whom colon bacilluria was marked, and cure resulted from the use of autogenous vaccines, or from large doses of hexamethylenamin, an illus- tration of direct bacterial infection. The writer on the other hand has had excellent results in a case of rheumatoid arthritis following the use of sour milks, lactic acid bacilli and intestinal irrigation, as to disappear- ance of pain, and diminution of swelling and more ready ability to move the joints. There was no cure, however. A number of observers have noted improvement after intestinal irrigation. A second source of error, is the disregard of the fact that certain con- ditions may arise which may be due not to auto-intoxication (so-called) CHRONIC INTESTINAL PUTREFACTION 573 but to protein absorption, from an idiosyncrasy which may particularly occur with certain foods in certain patients. The Protein Poison (Protein Absorption). Vaughan and Wheeler in 1903, found that the cellular substance of the colon bacillus 1 con- tains a highly active poison and that a closely related or similar poison could be obtained from other pathogenic and non-pathogenic bacteria and from vegetable and animal proteins. It is not found in gelatin. The symptoms induced by this poison in guinea-pigs are first, peripheral irritation such an urticarial rash; second stage, partial paralysis with rapid and shallow breathing, and the third or convulsive stage which begins as isolated clonic movements and finally becomes general, involv- ing all the muscles of the body; with fatal doses there is a progressive fall of temperature. Small doses administered subcutaneously in animals produce fever and various types of fever may be simulated by varying the size of the dose and the intervals of administration. When proteins are acted on by the digestive juices, the product be- comes poisonous at the peptone stage and, if it were so absorbed into the circulation, it would be highly injurious, but with normal digestion, the peptone is broken up into harmless amino-acids. If proteins, how- ever, enter the blood without being properly changed by the action of the digestive juices, then they must be digested in the blood and tissues (parenteral digestion) and during the process the protein poison is set free and exerts its deleterious effects on the body. It is suspected by some that the protein has an influence in the production of the summer diarrheas of infancy, and studies of the protein poison and protein sensitization have demonstrated how the protein element of bacteria influence the nature and progress of the infectious diseases. Special idiosyncrasies to certain foods may be explained on the above-mentioned grounds, as for example urticaria, presenting the aspect of anaphylaxis from absorp- tion of protein. In certain conditions at least protein absorption with parenteral digestion is a cause. Johnson has referred to its causal rela- tionship to urticaria and other skin lesions. An acute exacerbation of chronic nephritis resulting from dietetic indiscretion may be the result of protein poison in my belief, and L. F. Bishop holds that arteriosclerosis may result from certain idiosyncrasies of the protein absorption. Under the section on hypochlorhydria the author recounts an interest- ing case of urticaria with angioneurotic edema attacks which he believes due to protein absorption. Finally, in its production we will take up the consideration of chronic intestinal putrefaction which may be subdivided into (i) the indolic type, characterized by the production of indicanuria; (2) the saccharobutyric type, in the simple cases of which indol is usually absent; (3) combined saccharobutyric and indolic type, associated with excessive production of indol. CHRONIC INTESTINAL PUTREFACTION Chronic intestinal putrefaction is in itself a serious enough condition and may be responsible not only for nervous symptoms, but the writer 1 Journal A. M. A., Nov. 15, 1913. 574 DISEASES OF THE STOMACH AND INTESTINES believes that the toxemia therefrom may directly affect the kidneys, and be productive of nephritis. From his personal observations, it may produce high arterial tension and ultimately arteriosclerosis with cardiac lesions. L. F. Bishop has written at length on this subject. He further believes protein absorption may be a factor. I. Indolic Type (Indicanuria). Indicanuria designates the presence of indican in the urine, as demonstrated by reactions, with the formation of indigo, on using Jaffe's, Obermeyer's, or similar tests. Indol is absorbed from the intestines and forms in the liver indoxyl potassium sulphate, or indican, an ethereal sulphate which is eliminated in the urine. Etiology. There are various causes of indicanuria: excessive protein diet, catarrh of the small intestine causing alterations in the mucosa and increased intestinal putrefaction, typhoid, cholera, etc., constipation, alimentary putrefaction, partial or complete obstruction of the common bile-duct, decrease of normal digestive fluids, intestinal obstruction, peritonitis, fetid bronchitis, tuberculosis with pus cavity, gangrene, etc. Certain drugs, such as salol, salophen, and creosote, give reactions which must not be mistaken for it, while hexamethylenamin causes its disappearance. Baar, after a series of tests holds that non-constipated cases show indi- canuria more frequently than do the constipated and believes that consti- pation has no bearing, with which last the author does not agree. It is a factor in some cases, but not in all. Baar imputes indicanuria to onlv some anatomic lesion of the intestinal tract. The writer agrees so far that an inflammatory lesion may be a factor. In cases where the patients have increased in fat from sedentary pursuits, even in former athletes, persistent indicanuria will occur during the winter months, when little exercise is taken. I have observed this in patients who have normal bowel movements daily. This condition per- sists, or recurs in spite of rigid diet and treatment, but disappears in summer with active exercise. Sedentary life with fat accumulation and insufficient exercise (with no constipation) may therefore produce in- dicanuria as a result of disturbed metabolism. One frequently sees patients complaining of some difficulty other than constipation, when on close questioning, one finds normal bowel action occurs every other day or every third day or more. With some ap- parently healthy persons this is a normal condition. They may have no disturbing results from this habit, no headache, no nervous symptoms and no indicanuria. Evidently they do not absorb indol. There are individual peculiarities. Yet with some, constipation is a marked factor in producing indicanuria. Intestinal indicanuria is an evidence of intestinal putrefaction. Ex- cessive quantity of protein, especially of meat, may be a cause. Any condition favoring stagnation in the intestines helps produce this condition. Imperfect action of a cathartic can produce indicanuria. In children little indican appears. Many adults show indican and suffer from no symptoms, but this is true of constipation. Finally, persons 1 Med. Soc. Greater X. Y., Mar. 16, 1914. CHRONIC INTESTINAL PUTREFACTION 575 with indicanuria show clinical evidences of intestinal disorder and some- times symptoms of auto-intoxication, frequently affecting the nervous system. Neurasthenic and even melancholic symptoms may be dependent on this form of auto-intoxication. Headache, migraine, myasthenia, epileptiform seizures, early fatigue, cyclic vomiting, or progressive muscular atrophy may also be dependent on this condition (Herter). Intestinal putrefaction may directly affect the liver and kidneys. I have a patient with marked indicanuria with bile in the urine, albumin casts, cylindroids, and diminished urea. Treatment of the intestinal putrefaction cleared up this condition. This corroborates the view of W. H. Porter 1 that excessive intestinal putrefaction may cause disturbance of the hepatic cells. There was no jaundice in this patient. I further believe that cirrhosis of the liver may result from chronic intestinal putrefaction just as may arteriosclerosis. From personal experience, therefore, the author finds that marked in- dicanuria (intestinal putrefaction) may be directly productive of an acute nephritis, or produce an acute exacerbation in a case of chronic nephritis. This has been the experience of Wm. H. Thomson in a number of cases which he has reported. Under such conditions, I would advocate adher- ence to the most rigid form of diet for the indicanuria, chiefly the sour milks. After a practical disappearance of the indicanuria, with clearing of the acute condition, one should regulate the protein diet in the cases of chronic nephritis according to this amount of nitrogen excreted in the urine. Give the patient what he can take care of and no more. The colon bacilli, through their activity in the decomposition of proteins, are chiefly responsible for the production of indol. The Bacillus aerogenes capsulatus and the Bacillus putrificus, when present, favor the putrefactive action of the colon bacilli on the proteins. 2 Indicanuria, I believe, further influ- ences the production of arteriosclerosis. I will briefly recount an inter- esting case. The writer was called in consultation to a patient suffering from persistent vomiting which apparently could not be relieved. On physical examination, evidences of arteriosclerosis and excessively high pulse tension were found. Blood-pressure was taken at once and found to be 250. Under the hypodermic administration of nitroglycerin, > grain every two hours, the vomiting rapidly ceased and the pressure fell. 3 Sodium nitrite was subsequently added to the treatment. The urinary analysis at this time showed a very slight chronic nephritis. The most interesting feature of the case was that the patient had during the course of the preceding two years several such attacks. Numerous examinations of the urine had been made by competent pathologists, and, excepting the excessive indicanuria, no evidences of nephritis had been found; but the high tension and arteriosclerosis were always present. Numerous eminent consultants had examined the patient, and all agreed that the indicanuria had an influence on the arteriosclerosis. The author believes the slight nephritis found, when he saw the case, to be undoubtedly of recent development, and that the indicanuria had a direct bearing on the production of the arteriosclerosis. There were no evidences of syphilis in a The Post-graduate, Oct., 1902. 2 Herter, Bacterial Infections of the Digestive Tracts 3 Tinct. aconite gtts. 8 (35 per cent, tincture) also given t.i.d. 576 DISEASES OF THE STOMACH AND INTESTINES this patient and the Wassermann test was negative. The treatment of this condition would be the treatment of indicanuria plus the reduction of blood-pressure by the use of the nitrites and tincture of aconite (35 per cent, old Pharmacopoeia), 5 to 10 drops t.i.d., as recommended by Wm. H. Thomson, with the subsequent addition of the iodid of soda or of potash. In severe cases of high pressure the writer gives in addition J glonoin three or four times daily. Occasionally one sees high pressure cases in which large doses of the 35 per cent, aconite, 10 drops four times daily even with the addition of nitroglycerin, gr. 3^0 f ur times daily will not cause lessening of high tension. Tincture veratrum viride, 10 to 15 drops t.i.d. given in addition to the above remedies is often effect- ive. Recently I saw in consultation a case of apoplexy with a systolic pressure of 240 in whom all these remedies failed to reduce pressure. Venesection was indicated, but refused. The author then administered amyl nitrate by the drop method of inhalation, i dram in half an hour with resulting fall of pressure of 40 points. This was followed immediately by aconite, etc., and the pressure gradually fell to 160 where it was held without difficulty. Metchnikoff believes that his experiments have now established beyond question that small doses of paracresol and indol, acting on the organism over a longer or shorter period, are capable of inducing chronic lesions of the nature of sclerosis. Such lesions are the ones that are most frequently encountered in senility. He has demon- strated, he states, that the phenols and indol found in the urine and stool are not the excreta of our tissues, but are the products of the permanent microbian flora. It is not unreasonable to suppose that the digestive tract can constantly harbor an injurious flora, the source of chronic poison- ing leading to arteriosclerosis. The colon bacillus and Bacillus perfringens produce poisons which are absorbed by the intestinal walls and are capable of inducing serious lesions in arteries, kidneys, liver, and other organs. His observations are described in the Annales de 1'Institut Pasteur, Paris, October, 1910, xxiv, No. 10, pp. 753-831. Taylor 1 recently reports transient heart-block due to indicanuria. Polyneuritis with vaga tonic symptoms and vagotonia have been imputed to intestinal putrefaction by von Noorden. 2 The following test for indican is reliable: Place in a test-tube equal quantities (10 c.c. of each) of urine and chemically pure concentrated hydrochloric acid. To this mixture add 3 drops of % per cent, solution of potassium permanganate. Then add a small portion of chloroform, i or 2 more drops of the permanganate solution, and a few drops more of chloroform, or a total of 75 drops (5 c.c.) of chloroform, and shake vigor- ously for a few seconds. Indigo-blue is deposited in presence of this indicator. Bile should be tested for, even if there are no evidences of jaundice. W. H. Porter's scale (Plate I) is a basis of comparison in the absence of the bile test. Rosenbach's test, which consists in boiling the urine with nitric acid, gives a Burgundy red if putrefaction is present. This may occur when no indican is found. It is due to substances of a like class. 1 Jour. Amer. Med. Assoc., April 18, 1908 2 Journal A. M. A., Jan. n, 1913. 3 o o ?iH a d5l P*; 5r-<= Ira o< 3 V m v^. T -/I I CHRONIC INTESTINAL PUTREFACTION 577 Treatment. Diet. Matzoon, koumiss, lactone-buttermilk, bacillac; fermillac, later, stale crackers with butter, boiled rice, grape-nuts and jellies (gelatin) are to be added. Herter shows that clinically the carbohydrates have an influence, and the substitution of a quickly digested carbo- hydrate, like rice which has been well cooked and forced through a colander or large quantities of bread or sugar, will lessen the excretion of indican. Taka-diatase or cellasin can also be given to aid their digestion. Medication. Blue mass, 5 grains (0.3); calomel, 5 grains (0.3), once a week, and a saline cathartic for a short period daily. Hexamethylenamin, 5 to 10 grains (0.3), with benzoate of soda, 10 grains (0.6), t.i.d., has cleared up many cases, albumin casts, bile, and indican disappearing within a short time. This shows the improvement was not due to the mere interference with indican reaction. Lactic acid bacilli tablets or preferably the liquid form of lactic acid bacilli are useful. Fairchild's and those advocated by Metchnikoff have given me good results. Aspirin, salicylate of soda, and salol, 5 to 10 grains (0.3-0.6), are of service. The following have sometimes proved of value. 1$. Sulphocarbolate of soda 5iv; Permanganate potass gr. xlviij; Beta-naphthol gr. xlviij. M. Div. in capsules No. xlviii. Shellac cover. Sig. One three times a day, after meals and at bedtime, or, 1^. Sod. glycocholate 3i; Sod. salicy gr. Ixxv; Pancreatin gr. cl; Sod. bicarb gr. cl. M. Div. in capsules No. xc. Sig. Two to three capsules t.i.d., a.c. or two hours p.c. Enteroclysis is valuable, especially the injection of i pint to i quart (500-1000 c.c.) of a i : 1000 acetozone solution, with the patient in the knee-chest posture. This should be retained for a short time. This procedure can be carried out every day or few days. Gastric disturbances should be investigated and corrected. George A. Tuttle has shown that potassium iodid, especially in cases with arteriosclerosis, will lessen indican. Basham's tincture has been of benefit in some. Some have advocated acetozone solu- tion (i :iooo), i pint (500 c.c.), in divided doses daily by mouth. Bassler 1 recommends rectal instillations of autogenous bacteria and strains of the colon bacillus in chronic intestinal putrefaction, but the writer does not advise the method. Rectal and duodenal inflation with oxygen has been advocated by Gross. 2 The writer is dubious of its value. The author recommends hexamethylenamin treatment combined with lactic acid bacilli, liquid form, and sour milks, with enteroclysis in obstinate cases. 1 Med. Record, Sept. 24, 1910. 2 Med. Record, Nov. 30, 1912. 37 578 DISEASES OF THE STOMACH AND INTESTINES 2. Saccharobutyric Type of Intestinal Putrefaction. This type of decomposition is produced chiefly by the Bacillus aerogenes capsulatus, 1 Gram-positive. Bacillus putrificus or Gram-positive diplococci may at times be associated. The Bacillus aerogenes under anaerobic conditions can attack car- bohydrates and proteins. Butyric acid is often formed in considerable amount, carbon dioxid, hydrogen, ammonia, and often propionic, caproic, or valeric acids. The odor of the movements is often intense and char- acteristic of butyric or caproic acid. Excessive gas is liberated. The seat of this process is chiefly in the large intestine and lower ileum. When proteins are attacked there is less gas liberated. With ex- cessive gas production the feces have a low specific gravity and float on water. There are small bubbles in the contents and the feces are a light color. Patients who suffer from this condition do not tolerate well either carbohydrates or acids, flatulence and diarrhea occurring after use of cereals, starchy food, and especially sugar. The mucous membranes of the digestive tract are easily irritated, and there may be epithelial desquamation in the mouth. Howard 2 has described instances of superficial necrosis of the mucous membrane of the stomach and intestines, associated with an abundant presence of the Bacillus aerogenes capsulatus. These necrotic areas most often lie beneath the folds of the valvulae conniventes and may occur with gas cysts. It does not seem likely that these bacilli are responsible for severe acute inflammatory lesions of the intestines, but more probably for the subacute enteritis that is so often present in cases that show large numbers of the bacilli in the stools. There are, moreover, many instances of acute diarrhea associated with free Bacillus aerogenes capsulatus multiplication and with severe primary anemia, and in children capsulatus infection may lead to the develop- ment of extreme anemia with general edema. The Bacillus aerogenes capsulatus is an active hemolysing agent 3 and many instances of "pri- mary" pernicious anemia and of secondary anemia show pronounced indications of excessive saccharobutyric putrefaction (infection with the Bacillus aerogenes capsulatus), and probably this infection has a causal relation to the anemia. Streptococci (sometimes of oral origin) are at times found in some of these anemias in addition to the Bacillus aerogenes capsulatus, and the anemia may be due to the combination. In the simple cases indol is generally absent. 3. Combined Saccharobutyric and Indolic Type. The Bacillus aerogenes capsulatus is also able to break down proteins into a suit- able form for the use of other putrefactive bacteria, among which are the indol-forming organisms. This last form, associated with the excessive production of indol, is the most severe type, and these cases are subject to auto-intoxica- tion, depressive mental conditions, and diminution in muscular power (muscle fatigue), according to Herter. 1 Herter, Bacterial Infections of the Digestive Tract. 2 Contributions to the Science of Medicine, dedicated by his pupils to Wm. Henry Welch on the asth anniversary of his doctorate, Baltimore, 1900, p. 461. 3 On Bacterial Processes in the Intestinal Tract in Some Cases of Advanced Anemia, etc. (Herter), Jour, of Biological Chemistry, vol. II, Nos. i and 2, Aug., 1906. CHRONIC INTESTINAL PUTREFACTION 579 In the severe types the anaerobic organisms, especially the Bacillus aerogenes capsulatus, produce hemolytic substances which are believed to have a bearing on the production of pernicious anemia. The results of intestinal irrigation in such cases have been favor- ably reported by Hollis 1 and Ditman, 2 as in Fig. 281, with marked im- provement in the hemoglobin and red cells. Arthritis deformans 3 has recently been imputed to putrefactive changes in the intestinal canal. In one case excellent results were secured by the author by enteroclysis and fermented milks, no medication; the swelling in the joints rapidly subsiding. Nov. December January February March globm Red Blood C.ll. 23 SO 3 e IB 2O a 1O 18 2O 1 7 13 SI 1 7 13 Very Strong Strong Modtr.ti 100* 9,000,000 4,900,000 4,000,000 3,900,000 3,000.000 2,900,000 2,000,000 1,900,000 1,000,000 900,000 90% / /^ X 80% 1 / 70% / / /s X 60% / / / S0% N t / / / 40% \ -A J | / / i / 30% ~ A ? 7 A X^ V / / 30% \ ; \ \ \ Xv J w%. \ \ 0% Hemoglobin 1 ?ed B ood Cells_o_^^_o. Indi CHAXT i. Fig. 281. Chart of pernicious anemia demonstrating value of enteroclysis. Treatment. Careful mastication of the food, cleanliness of the mouth, and correction of gastric disturbances are necessary. Sugars should be omitted, starchy food cut down, and meat diminished or eliminated if the mixed type with indican is present. Taka-diastase, 5 grains (0.03) t.i.d., aids starch digestion. Pan- creatin preparations may be tried. Holadin, 3 grains (0.2), with presecretin, i grain, and enterokinase, 3 grains (0.2) t.i.d., may be substituted. Pancreon, 5 grains (0.3) t.i.d., is useful. The fermented 1 Herter, Bacterial Infections of the Digestive Tract. 2 Med. Record, Feb. 2, 1907. 3 A Preliminary Report on the Relation of Albuminous Putrefaction in the Intestines to Arthritis Deformans, by Andrews and Hoke, American Journal of Orthopedic Surgery, July, 1907; also Cornwall, Med. Record, April i, 1911. 580 DISEASES OF THE STOMACH AND INTESTINES milks are of special value. Lactic acid bacilli tablets and particularly the liquid form are useful. Enteroclysis, or high enemata, with saline solution, acetozone (i : 1000) or hydrogen peroxid (i : 1000), are of service. The latter are of special value. Ichthoform, formidin, ichthalbin, aspirin, salol, salicylate of soda, 5 grains (0.33) t.i.d., are useful, or urotropin, 1 5 grains (0.3), with benzoate of soda, 10 grains (0.6) t.i.d. This last combination, with the addition of the high enema of acetozone, i quart (liter), strength i : 1000, 1 have found of great value. Permanganate of potash, up to i grain (0.06) t.i.d., may be of service. Herter suggests the possible value of dioxid of manganese. Surgery may be indicated in extreme cases. If dilatation of the stomach, not responding to medical treatment, is the cause, then gastro-enterostomy is indicated. With failure of medical treatment and progressive anemia and mental disturbances, Herter suggests ap- pendicostomy followed by enteroclysis. I am opposed to shortening or short circuiting the large intestine for this condition. In extreme cases Gant's cecostomy, with irrigation of colon and ileum, might be of service. ACIDOSIS (ACETONURIA) Since acidosis involves the problems of metabolism and is considered a toxemia, a brief reference to the subject is included for convenience under Intestinal Auto-intoxication. The healthy performance of the functions of the tissues depends on certain chemical processes taking place in solutions of a certain composition, the chemical reaction of which is faintly alkaline. Any disturbance in metabolism which tends to reverse the condition, that is, to diminish the alkalinity of the juices, may set up a condition of acidosis. This disturbance does not necessarily lead to an actual reduction of the alkalinity of these fluids; the blood, for example, since considerable quantities of acid may be produced in the body by abnormal metabolic processes, and yet lead to no appreciable alteration in the reaction of the tissues or the blood, being neutralized by the alkalis hi the body fluids and cells and by ammonia produced from the hydrolysis of proteins, which would, in the absence of the call for an alkali, have been converted into urea and excreted in that form. If the amount of acid ingested or produced in the body is so great that it cannot be neutralized or disposed of by oxidation, then the reaction of the blood can no longer remain unaltered, there will be a reduction of its alkalinity, and there is danger of the condition passing from the milder one of acidosis to one of acid intoxication. Acidosis is characterized by excretion in the urine of an excess of acid radicles, acetone alone hi the milder cases, and diacetic acid in addition in the more severe types, and these two, with .B-oxybutyric acid as well, or .B-oxybutyric, as the chief in the most severe cases. There is sometimes the characteristic sweet odor on the breath from the acetone, particularly in diabetes or with acid intoxication. The simplest test for determination of acidosis is the discovery of one or more in these acid radicles acetone alone or the others in addi- tion in the urine. The amount of ammonia in the urine is also a valuable 1 Hexamethylenamin, grs. v-x t.i.d., may be substituted. ACIDOSIS (ACETONURIA) 581 indication of the degree of acid poisoning, and the odor of acetone on the breath. The determination of the Co 2 tension of the blood plasma by Van Slyke's method, will afford information in suspected cases before acetone appears. The reduction of the alkalinity in the blood further shows there is danger of acidosis passing into acid intoxication. In severe cases of acidosis the reaction of the urine to an alkali serves as a test as to the comparative severity of the process. A large amount of bicarbonate of soda may be taken without producing neutrality or alkalinity of the urine in severe cases. Fridderucia 1 determines the degree of acidosis in diabetics by means of measurement of the carbon dioxid pressure in the expired air; with an increased ammonia excretion there is an abnormally low carbon dioxid pressure. As acidosis may exist for a long time without any symptoms, in some cases for a considerable period, and in others with none, except that the patient may be subject to digestive disturbances, and since this mild type of acidosis may at any time become severe and even result in danger- ous acid intoxication, the urine should always be examined for acetone as a matter of routine. This is particularly true in early pregnancy and in all patients about to be operated upon. The presence of even a small amount of acetone previous to operation would contraindicate chloroform, and also indicate preparation of the patient by the administration of soda bicarbonate previous to operation. Other anesthetics such as ether and nitrous oxid may produce acetonuria as well as chloroform. In fact, the writer believes the administration of an alkali (soda bicarbonate) several days before operation is an excellent procedure. James Ewing 2 divides cases of acidosis into two main groups: one without fatty degeneration of the liver, as represented by diabetic acidosis, and one with fatty degeneration, represented by the toxemia of preg- nancy, delayed chloroform-poisoning, Eck's fistula, cyclic vomiting in children, and poisoning by hematoxic immune serum. Acetone bodies are found in the urine in a large number of other clinical conditions, in gastro-intestinal diseases, diseases of the liver gastro-intestinal diseases accompanied by inanition, starvation, in some cases acute yellow atrophy, phosphorus-poisoning, chronic renal disease. Sellards 3 has made an important clinical study of acidosis and of its occurrence in chronic renal disease. Acidosis of high degree occurs in renal disease particularly in the uremia of acute and chronic diffuse nephritis and it often appears many months before the development of uremia. The acidosis is probably the result of a defective function of the kidney and would be an indirect expression of renal retention. Some of the clinical symptoms of uremia are partially relieved by the injection of bicarbonate of soda. Park 4 reports cases of ileocolitis with acidosis and marked respiratory disturbances, and Singer 5 a case of severe auto-intoxication with acetonuria, extreme bradycardia, and convulsions. 1 Zeitschrift fur Klinische Medizin, vol. Ixxx, Xos. i and 2. 2 Acidosis and Associated Conditions, Arch. Int. Med., 1908, ii, 330. 3 Johns Hopkins Hosp. Bull., May, 1914. 4 Jour. Amer. Med. Assoc., Sept. 17, 1910. 5 N. Y. Med. Jour., June 26, 1909. 582 DISEASES OF THE STOMACH AND INTESTINES Deprivation of the carbohydrates and dependence on protein and fats results in the development of acetone bodies from the latter. The ingestion of carbohydrates is followed by lessened acetonuria, and advantage has even been taken of this in the acidosis of diabetes by giving temporarily an oatmeal diet to relieve the acetonuria and lessen the chance of a subsequent diabetic coma. Disturbance of the liver functions, with interference with metabolism as a result, have, therefore, an influence in many cases as noted by Ewing. In view of the occurrence of acetonuria with intestinal auto-intoxication and ileo- colitis, etc., and the probable damage to the liver cells by the toxins, further interference with metabolism with acetonuria resulting, would readily suggest itself. Postoperative vomiting from acidosis may be a decided menace to the patient. The writer has- recently treated two severe cases of Virgil P. Gibney, following the administration of ether. It occurs most frequently after chloroform, but also after ethyl chlorid and nitrous oxid. These cases were both girls, aged eight and nine years, with a previous history of weak stomachs and possibly cyclic vomiting. In one the vomiting was so persistent that nutritive enemata and saline injections combined with 180 grains of soda bicarbonate were given daily for a week. There was acute congestion of the kidneys, with large hemor- rhages of visible blood on two occasions. Albumin and casts were present, but the specific gravity was low, due to the large injections of saline solu- tion by rectum, and quite marked diuresis resulted. The writer reported in the Summer Symposium on Acidosis in 1916, American Medicine, a child of eight years, suffering from acidosis, intestinal putrefaction and angioneurotic edema of the larynx and ascending colon. The latter simulated appendicitis. In all cases before operation, a careful examination of the urine to determine whether acetone bodies are present should be made. Preparatory treatment of cases with acetone in the urine by administration of soda bicarbonate is indicated, and the administration of oatmeal with glucose or lactose for several days is of value. Sufficient sodium bicarbonate or sodium citrate should be given to render the urine neutral or alkaline for several days before operation if possible. It has been the author's object to merely briefly call attention to this interesting problem of acidosis, and to suggest in future a careful examination of the urine for the acetone bodies in all cases. BOTULISM This is a variety of meat-poisoning due to the Bacillus botulinus, isolated by Van Ermengen from raw ham. The symptoms resembled those of so-called sausage-poisoning. This same type of poisoning has occurred from eating beans that were imperfectly canned. These were probably infected through the manure of pigs. Meat may be extensively infected with the Bacillus botulinus, and contain a large quantity of the toxins, without showing the signs of decomposition. The filtered toxins may produce the effects. Incubation. The symptoms seldom appear before twelve to twenty- four hours after ingestion of the infected meat. They are: First, dis- ENTEROGENIC CYANOSIS 583 turbances of the external muscles of the eyeball, such as ptosis, abducens paralysis, disturbances of associated movements with nystagmus; second, disturbances of the internal muscles of the eyes, such as enlargement and rigidity of the pupils; third, there are swelling or paralysis of the tongue, pharyngeal and laryngeal paralyses, and disturbances of the heart and respiration; fourth, there may be weakness or paralysis of motion. Changes in sensibility and consciousness usually do not ac- company these disturbances. Fever has frequently been absent and there has even been absence of disturbances of the stomach and intestines. This condition is not so rare abroad and occurs in this country. Treatment. Evacuation of the gastro-intestinal tract. Treatment of symptoms. Herter recommends Kempner's antitoxin when procurable. HYDROGEN SULPHID AUTO -INTOXICATION In health the formation of hydrogen sulphid seems probably limited to the large intestine and a small adjacent portion of the small intestine. Under pathologic conditions, it is formed in other parts of the digestive tract. In chronic ectasia, hydrogen sulphid is at times liberated when putrefactive changes take place. Herter believes the eructation generally occurs from this viscus, so that no symptoms result. He holds that the stagnating stomach contents probably go on to the formation of cystin, and that the Bacillus lactis aerogenes, Bacillus coli, and other bacteria produce hydrogen sulphid therefrom. Senator 1 reports a case of auto- intoxication from hydrogen sulphid (hydro thionemia). After an error in diet, the patient became ill with gastro-enteric catarrh. On the third day vomiting accompanied with the odor of hydrogen sulphid occurred. The patient became dizzy and went into collapse, without loss of con- sciousness. The eructation of gas continued, and the first urine gave the reaction of hydrogen sulphid. The case recovered. Betz 2 and Stefanio and Emminghaus 3 describe cases. Headache, dizziness, delirium, mental depression, drowsiness, stupor, and collapse were prominent symptoms. Treatment. Catarrh of the gastro-intestinal tract, ectasia, and in- testinal putrefaction must receive appropriate treatment as required. ENTEROGENIC CYANOSIS This peculiar type of auto-intoxication was first described by Stokvis. 4 The patient, aged fifty-eight, suffered from severe enteritis with pro- nounced cyanosis of the skin and visible mucous membranes, together with a swelling of the terminal phalanges. Spectroscopic examination of the skin and mucous membranes showed a band corresponding to the absorption spectrum of methemoglobin. It was believed that poison substances were formed in the intestines which transformed part of the hemoglobin into methemoglobin. Talma 5 reported three cases. Van der 1 Berlin. klin.Wochenschr., v, p. 254, 1868. 2 Memorabilien, Ix, p. 145, 1864. 3 Berlin, klin. Wochenschr., Ix, pp. 447, 491, 1872. 4 Festsch. f. v. Leyden, 1, p. 597, 1902. 6 Tijdschrift voor Geneesk., li, p. 721, 1902. 584 DISEASES OF THE STOMACH AND INTESTINES Bergh 1 reported two cases, one of which was evidently due to sulphemo- globin (from hydrogen sulphid) in the blood, and in the other the blood contained nitrites. Van der Bergh also reports a case in a child nine years of age, who suffered from marked digestive disturbances with diarrhea. Anuria was marked. Child was very cyanotic and the ends of the fingers were clubbed; abdominal distention marked. Urine contained no albumin, no sugar, but a little indol. No cardiac affection present. Several cases of sulphemoglobinemia 2 have been associated with obstinate constipation, the relief of which has been followed by improve- ment. Technic of Clinical Spectroscopic Blood Examination. Several cubic centimeters of blood are obtained, preferably from a vein. Examination can be made by drawing a few drops from the ear or finger. The blood should be drawn directly into about twice its volume of distilled water. This lakes the blood and gives a watery solution of the blood pigment. The solution is then filtered several times through a single filter-paper to remove the corpuscles and fibrin. A few drops of this solution are placed in a test-tube or, preferably, in a glass dish or bottle with parallel sides, and examined with the spectroscope by transmitted light. To the speci- men distilled water is added drop by drop until the dilution is obtained which allows a good transmission of the red light only. If a black band is seen in the red, the blood contains either methemoglobin or sulphemoglobin. If the band persists on the addition of a few drops of ammonium sulphid, the pigment is sulphemoglobin; if it vanishes, it is methemoglobin. The addition of a reducing agent, as hydrazene or phenylhydrazene, may intensify a sulphemoglobin band which was too faint to be seen otherwise. Methemoglobin results from drug poisoning, such as from large quantities of bismuth subnitrate, or from auto-intoxication from ab- sorption of nitrites from the intestines in chronic diarrhea; while sul- phemoglobin results from auto-intoxication associated with chronic constipation, the result of hyperformation or hyperabsorption of HUS, or of the presence of an abnormal reducing agent in the blood, acting with a small trace of H 2 S. Treatment. This should be directed to the intestinal tract. Proteins should be reduced; sour milks given; purgatives; enteroclysis and the general treatment of intestinal putrefaction by intestinal antiseptics are indicated. METEORISM (TYMPANITES) This is defined as an accumulation of gas in the intestines. Flatu- lence is used to indicate a great formation of gases that are removed by eructations and flatus. Part of the gas thus accumulated is expelled and part is absorbed, and thus the volume of gas in the intestines is regulated. Etiology. The causes of tympanites are as follows: i. An increased introduction (ingestion) of gas. 1 Deutsch. Archiv f. klin. Med., xciii, p. 86, 1905; also Berlin, klin. Wochenschr., No. i, p. 7, 1906. 2 Clarke, N. Y. Med. Record, Dec. 3, 1910. METEORISM (TYMPANITES) 585 2. The development of excessive gas within the intestines. 3. A diminution or impairment of the eliminative power of the in- testines for gases. 1 . The increased introduction of gases may be due to the excessive drinking of aerated beverages or the swallowing of air. Aerophagy (air swallowing) usually occurs in hysteric women, and may result from shock or emotional disturbance. It is generally in- voluntary, due to spasm of the pharynx. The symptoms are distention after food, loss of appetite, frequent noisy eructations, often insomnia or sleeplessness, constipation. Frequently mucous colic or gastroptosis (enteroptosis) coexist. Rapid deglutition movements precede the eructations. The mucous colic or enteroptosis should be treated; the hysteria com- bated; pharyngeal spasm checked by keeping the mouth widely open, applying cocain (i per cent.) locally, blisters externally, belladonna, bromids, or valerian internally; hypnotic suggestion in some cases; strychnin to stimulate the muscular tone of stomach; food should be concentrated. 2. Formation of Abnormal Quantity of Gas in the Intestines. This may be due to fermentation of the carbohydrates or to putrefaction of the proteins. An excessive amount of fermentable or putrefactive material or food which cannot be assimilated, are factors. Catarrhal conditions influence the activity of the ferment and putrefactive organisms. 3. Diminished Elimination of Gases from the Intestines. This is due to mechanical obstruction or to a reduction or inhibition (paralysis) of the muscular power of the intestinal wall. Among the causes are stenosis, intestinal obstruction, paresis of the intestines in the infectious diseases, such as typhoid fever, pneumonia, cerebrospinal meningitis, peritonitis, etc. In pathologic conditions, where there is circulatory disturbance in the intestinal walls, as in peritonitis, etc., absorption of gases must be interfered with. It is difficult to estimate to what degree this is a factor. Nervous Meteor ism. This is most common in the hysteric, and usually occurs as a diffuse distention of the abdomen (tympanites hystericus), but also as a circumscribed swelling (phantom tumor). Various factors have been suggested, such as swallowed air; in- sufficiency of the pylorus, allowing passage of air from the stomach to the bowels; or continuous contraction of the diaphragm (Talma). With narcosis, the abdomen becomes flaccid, while with returning consciousness meteorism recurs, and air cannot be detected entering or leaving the tract, hence Talma denies that there is any increase of gas in the intestines. Some attribute, the condition to acute general paresis, of sudden onset, passing off rapidly, analogous to other hysteric paralyses. Symptoms. The shape of the abdomen is usually altered, a feeling of tension is almost always experienced. With general meteorism the abdomen is distended quite symmetrically, while with partial distention the affected parts stand out in marked relief. With local distention, the coexistence of visible peristalsis, as with stenosis, sinplifies the diagnosis. The degree of distention generally 586 DISEASES OF THE STOMACH AND INTESTINES corresponds to the amount of gas present; but the weaker the muscles and the more reduced their tone, the greater is distention. An example of this is marked tympanites in peritonitis. When the abdominal muscles are tense, sometimes the diaphragm, heart, and lungs are forced upward, and severe dyspnea results, which occasionally may be followed by a fatal issue. In severe cases, there is a constant feeling of pressure and a desire to pass wind, while colicky pains are sometimes present. As a rule, no flatus is passed, or in inconsiderable amounts at long intervals. Palpation shows the abdominal walls are very tense. They present an air-cushion resistance. The percussion note is abnormally low and loud, the tympanitic ring is usually lost. With auscultatory percussion a metallic sound is elicited. The liver dulness may be reduced and finally disappear. There are some cases of meteorism, in which the wind is passed almost constantly from the anus with considerable noise. Rosen- heim believes, as these gases are odorless, that the air is pumped into the rectum and emitted again as flatus. Prognosis. If occlusion of the intestines is present, the outlook is serious. Ordinary cases are favorable. Treatment. This should be directed toward removal of the cause responsible for meteorism, such as peritonitis, typhoid, stenosis, etc. Drinks and foods known to produce flatulence must be prohibited. Avoid carbonated waters, beer, champagne, cider, excessive carbohydrates, rich pastry, etc. Intestinal fermentation or intestinal putrefaction, if they cause the meteorism, must be treated after the methods already described. Among the intestinal antiseptics are ichthalbin, ichthoform, formidin, salol, salicylate of soda, benzonaphtol, urotropin, 1 and sodium benzoate, average dose of each, 5 grains (0.3) t.i.d. after meals. They may be given in shellacked capsules. Bismuth salicylate and bismuth subni- trate, 5 to 10 grains (0.3-0.6) t.i.d., are of service. Calcined magnesia, lime-water, and charcoal are suggested to absorb the gas. In mild forms of flatulency various carminatives have been employed, such as caraway seed, peppermint, mint, thyme, cinnamon, cloves, anise seed, nutmeg, sassafras, and fennel. These are best given as infusions. Asafetida and the oil of cloves are believed by Brunton to aid absorption of CO 2 and H 2 S. Cathartics and laxatives may be necessary when there is no peritonitis or obstruction. Physostigmin salicylate, Hoo to ^ grain (0.0006-0.001), has been recommended in severe cases. Massage, abdominal douches, electricity, and electric enteroclysis are of service in cases where there are no anatomic lesions. Friction of the abdomen with spiritous, aromatic, or ethereal substances, such as cam- phorated oil, turpentine, oil of cajeput, etc., are serviceable. The introduction of a colon-tube may aid the escape of gas. Water enemata of soapsuds, containing spirits of menth. piperit., i dram (4.0), or oil of turpentine, i dram (4.0), are useful. 1 Hexamethylenamin, grs. v-x t.i.d., may be substituted. INTESTINAL PAIN (INTESTINAL COLIC; ENTERALGLA.) 587 Puncturing the intestines with a trocar is a dangerous procedure. Meteorism in the hysteric occasionally disappears without treatment. Attention should be paid to the nervous condition. Valerian and asafetida are useful by mouth or enema in such cases. Pill asafet., one t.i.d.; emulsion (milk) asafet., r to 2 ounces (30.0- 60.0), by enema. Zinc valer., 2 grains (0.125), or ammon. valer., 5 grains (0.3), t.i.d. Tinct. valer. and tinct. lavend. co., aa 2 ounces (60.0). Dose, i dram (4.0) of the mixture in water t.i.d. after food. Iron, arsenic, and strychnin are of tonic value in the nervous cases. Massage, friction, and a tight abdominal band are useful. INTESTINAL PAIN (INTESTINAL COLIC ; ENTERALGIA) Intestinal pain can be distinguished as follows: 1. Pain originating from inflammation of the intestinal wall or of its peritoneal coat. 2. Pain of colic. 3. Nervous enteralgia, described under Neuroses. Colic is the painful stimulation of the intestinal nerves which is produced by severe tonic contractions of the intestines. G. F. Shiels 1 holds that the pain is produced in the peritoneal coat. Kast and Meltzer have demonstrated by a series of experiments that the intestines are sensitive to pain. Etiology. Organic lesions of the intestines, excess in or improper articles of food, cold drinks, substances causing marked gas formations, fecal accumulation, intestinal worms, foreign bodies, gall-stones, entero- liths, tainted foods, large quantities of mucus, as in mucous colic, exposure to cold, gout, occasionally ulcers, internal strangulation of the bowels, stenosis, purgatives, lead- and copper-poisoning may produce colic. Symptoms. The pain of colic is peculiar pinching, boring, or occasionally of a tearing character it occurs in paroxysms which may last a few seconds or be prolonged several hours. It usually appears suddenly and disappears as rapidly. Its intensity may be so severe that fainting and collapse occur. If colic begins from error in diet, there may be gastric disturbances, belching, nausea, and vomiting. Obstinate constipation and flatulence may be present, or if the cause be from improper food, diarrhea. The pain frequently starts at the umbilicus and remains localized or radiates in other directions. The face of the patient shows his suffering. Pressure over the abdomen relieves the pain in some, while in others it increases it. There may be straining sensations in the bladder and rectum and occa- sionally borborygmi can be heard. Persistaltic movements can be seen in thin patients. If accumulated fecal masses and gas are evacuated spontaneously or by injections, the attack rapidly subsides. Spastic contractions of the intestines may be encountered. If they involve a large part of the bowels, as in lead-colic, the abdomen appears trough shaped. In stercoral and wind-colic, it is usually tympanitic. 1 Amer. Jour, of Surgery, April, 1908. 588 DISEASES OF THE STOMACH AND INTESTINES Diagnosis. In enteralgia due to anatomic lesions of the intestines, the pain is increased by pressure. There is frequently diarrhea and the stools contain blood, mucus, and, rarely, pus. With rheumatism of the abdominal muscles, the pain is superficial and not within the abdominal cavity. It often changes its location. Pressure increases the pain, while rest and antirheumatic medicines diminish it. With lead colic we have the history, blue line on the gums, peripheral neuritis, steppage gait, paralysis of various muscles, wrist drop, saturnine arthralgias and in the blood, excessive granular basophilic degeneration. With peritonitis there are fever, tenderness on pressure, muscular rigidity, meteorism, absence of abdominal respiration, increase of poly- nuclears, and leukocytosis. Hyperesthesia of the abdominal wall usually occurs in hysteria and neurasthenia. The pains are superficial, lying chiefly in the skin. The faradic current often removes the pain. Biliary and renal colic are recognized by the location of the pain and characteristic symptoms. Neuralgic pains are superficial and radiate. Prognosis. These cases end in recovery, with rare exceptions. Treatment. For the relief of pain, morphin by hypodermic % to y grain (0.008-0.016), or codein, the same or even a double dose, or tincture of opium, 10 minims (0.59 c.c.), heat to the abdomen, and hot saline enema or enteroclysis at ii5-i2oF. Squibb's mixture is useful. Later, the bowels should be throughly evacuated by an enema, the simple soapsuds, enema, i quart (liter), or which may contain J^ pint (250 c.c.) of olive oil and i dram (4.0), of spirits of turpentine. A cathartic, castor oil, i^ 2 ounces (45.0), or calomel, 5 grains (0.3), followed by a saline cathartic, should be given. The cause of the colic should be corrected, as should any errors in diet. Fluid diet should be employed. Tincture of belladonna, 5 to 10 minims (0.3-0.6), the writer finds of value for the spasm. For lead colic, as prophylactic, among all lead workers, the hands should be thoroughly cleansed before eating, no food should be taken on the factory premises. Sulphuric acid lemonade has been suggested. Potas- sium iodid gr. v-x t.i.d. is of value and magnesium sulphate when costive. Hot baths and electricty to the paralyzed muscles are serviceable. VISCERAL ARTERIOSCLEROSIS Harlow Brooks 1 calls to our attention that the presence of diminished visceral function, with occasional and otherwise unaccountable elevations of the blood-pressure, should, particularly in connection with possible etiologic factors, lead to a suspicion of some localized, if not general, area of arterial disease. When associated with pain of peculiar anginal character, location in some special organ may be within the range of possibility. I feel quite certain that careful observation of cases of obscure abdominal pain, paroxysmal in character and associated with elevation of the blood- 1 Amer. Jour. Med. Sci. VISCERAL ARTERIOSCLEROSIS 589 pressure, will eventually make it possible to diagnose these generally unrecognized types of arterial disease while in a stage when something may still be done for their alleviation or for the prevention of their further progress. Etiology. Alcohol, nephritis, syphilis, old age, tuberculosis, tobacco excesses, and toxemia are the chief causes. Intestinal toxemia is respon- sible for a considerable number in my opinion. Some of these patients give a history of nervousness, gastric catarrh, and pain; vomiting and even hematemesis may occur. Meteorism and constipation are not uncommon. The epigastrium may be distended and tender. Anginoid attacks may occur with rapid, slow or irregular pulse, with salivation and sweating. Pain over the pancreas and intestinal functional disturbances have been noted. When such symptoms occur in a patient with well-marked arteriosclerosis, and are relieved by iodids and nitrates, one is justified in diagnosing abdominal arteriosclerosis. The determination of increased blood-pressure by means of the sphygmo- manometer aids the diagnosis of the milder types of such cases. This method should always be employed. Under Indicanuria the writer re- ports an interesting case. Perutz 1 shows we must differentiate between angina pectoris and angina abdominis due to arteriosclerosis: I have recently seen several cases who have complained of pain in the epigastrium, belching, constipation, and headache. The gastric analysis showed deficient hydrochloric acid secretion and the pulse the characteristics of arteriosclerosis. Treatment afforded no relief until the nitrites were administered. "Gilbride 2 reports a number of cases with symptoms of pain in the epigastric or umbilical regions, rarely in the lower abdomen. This is increased by exertion and in some cases during diges- tion. Weakness, loss of weight, abdominal distention, and belching are present. Bowels are constipated, or there is constipation alternating with diarrhea, or occasionally normal movements. There may be vertigo or disturbances of vision. The gastric analysis showed in most cases defi- ciency of hydrochloric acid; in one it was nearly absent and in one normal. Stomach motility normal or increased. Lactic acid and Boas-Oppler bacilli were absent. Cancer has been suspected. The radial pulse and blood-pressure may show arteriosclerosis. In some cases there are no evidences of this, but there are two symptoms significant of abdominal arteriosclerosis tenderness of the abdominal aorta with epigastric pulsation. Some patients may have attacks of angina pectoris with pain referred to the epigastrium. The age of the patient is usually over forty." Ortner 3 has contributed to the subject, demonstrating the disturbances of the motor, secretory, and absorptive functions of the intestines due to arterio- sclerosis; and Akin 4 has reported several cases. Nitrites afford the most relief, with the addition of potassium or sodium iodid. Tincture aconite 1 Munch. Med. Wochenschr., May 28 and June 4, 1907. 2 Gastro-intestinal Disturbances Due to Arteriosclerosis, Jour. Amer. Med. Assoc., March 20, 1909. 3 Volkmann, Samml. klin. Vortr., No. 347. 4 Jour. Amer. Med. Assoc., June 5, 1909. 5QO DISEASES OF THE STOMACH AND INTESTINES (35 P er cent, old pharmacopcea) 5 to 10 drops t.i.d., aid in lowering excessive high tension. SENILE DYSPEPSIA The dyspepsia of old age has been investigated by Fen wick, 1 who shows that in every 100 cases of chronic dyspepsia in persons over sixty- five years of age, 66 are secondary to organic diseases of some important organs of the body, while 34 owe their symptoms to a progressive de- generation of the secretory structures of the stomach and intestines. Disease of the kidneys, heart, lungs, liver, or a gouty condition all have a bearing in a large percentage of cases on the gastro-intestinal disturbances of the aged, and in a certain number, gastric hypersecretion of long dura- tion from an old gastric or duodenal ulcer may be a factor. Chronic appendicits or fibroid degeneration of the appendix may also result in gastro-intestinal disturbances. In about one-third of the cases, no organic change can be located in any particular organ. There is, however, an impairment of the secretory functions of the digestive tract, the general assimilative powers decline, the body assimilates less organic matter, and destroys less in- organic material with a resulting waste of tissue in many cases. In others disturbances of metabolism occur, which result in obesity and in the derangement of the eliminative functions. In such there is associated frequently fatty degeneration of the organs. Even though there be no marked evidences of general arteriosclerosis, the author believes these disturbances of the gastro-intestinal functions in the aged to be in most cases a manifestation of visceral arterioslcerosis, varying from a mild to a severe type, with resulting damage to the glands presiding over the functions of digestion. Undoubtedly, the condition of the mouth, deficiency or absence of teeth, decayed roots, with associated putrefaction in the mouth, all have an influence. Insufficient mastication also has a bearing on the subject. Gastric Analysis. Examination of the .gastric contents after the test-breakfast shows a diminution of free hydrochloric acid (hypo- chlorhydria), and sometimes even achylia gastrica. Intestinal Functions. The functions of the intestinal digestion should be tested. Intestinal fermentation or intestinal putrefaction are present. Symptoms. Belching of gas and flatulence occur. Constipation is usually present, though in some it alternates with a diarrhea. Many cases suffer from loss of appetite and from insufficient nutrition and there is loss of weight as a result. Other patients are of a different type and are obese. They suffer from belching of gas and flatulence. Their appetite is good, in fact, cannot be satisfied, but elimination is imperfect. The stomach is atonic, but pyloric insufficiency is often present. There is atonic constipation, but it frequently alternates with lienteric diarrhea. 1 London Lancet, Nov. 6, 1909. SENILE DYSPEPSIA 59! The first class of patients, the asthenic type, Niles 1 classifies as hyper- koric dyspepsia, in whom there is early satiety for food, loss of appetite, or even sitophobia. As a result scarcely sufficient food is ingested to properly support life. The second class, the obese or sthenic type, he characterizes as akoric dyspepsia, since they are never satiated. One also meets among the aged cases with very marked symptoms such as described under Visceral Arteriosclerosis. Diagnosis. The diagnosis can be made by exclusion of other fac- tors, taken in association with the age of the patient. The determination of increased blood-pressure by means of the sphygmomanometer is also of value. It should always be employed. Treatment. The mouth should be cleansed with boric acid, glyco- thymolin, listerin, borolyptol, or some mild antiseptic several times daily. Old roots and decayed teeth should be extracted and artificial teeth should be worn, so that the patient can masticate properly. Active catharsis should be avoided; simple remedies, such as purgen, cascara, phenolax, regulin, and small enemata of olive oil, 2 are indicated. Dilute hydrochloric acid with nux vomica should be given for the subacidity. A convenient preparation is oxyntin with nux vomica in capsules, 5 to 10 grains (0.3- 0.5) t.i.d., before or after meals. Taka-diastase, 5 grains (0.3) t.i.d., is valuable to aid starch digestion, and holadin, 5 to 10 grains (0.3-0.5) t.i.d., or some other pancreatic preparation for intestinal dyspepsia. Other remedies are noted under the section on that subject. The nitrites, nitroglycerin, ^ O o to J grain t.i.d., or more frequently, should be administered for the arterial condition or tinct. aconite (35 per cent.), 5 to 8 drops t.i.d., and the iodids may be added, sodium iodid, 5 grains (0.3) t.i.d., preferably, as it causes less disturbance of the stomach. Exercise. Those cases characterized by malnutrition should take a minimum amount, but be in the fresh air as much as possible, while activity is indicated for the obese within the limits of fatigue. Diet. Food should be prepared in the most digestible form. It is preferable to administer four or five small meals daily to three large ones. In the asthenic cases with malnutrition, food of a high calorie value, such as fats and starches carefully prepared, are indicated, while patients of obese type should receive a minimum of these. In these cases, the frequent small meals relieve best the sensation of hunger. The above rules are only general. As the condition is one of deficient hydrochloric acid secretion, the diet can be much the same as for achylia gastrica. In the earlier stage of treatment, peptonized milk may be given for a brief period. Matzoon, koumiss, lactone-buttermilk, bacillac, fermillac, eggs, and barley and rice gruel. Excessive fluids, however, tend to produce too much gas in some patients. Small quantities of thicker gruels and soups, such as pea, strained bean, potato, barley, rice, and sago often agree. Fenwick holds that barley, oatmeal, and rice must be given with caution. Much depends, however, 1 Amer. Jour. Med. Sci., Jan., 1911. 2 Olive oil by mouth, or Russian, or American mineral oil are of service. 592 DISEASES OF THE STOMACH AND INTESTINES on the cooking of the cereal, which must be thorough, and it should be passed through a colander so to ensure removal of the membranous coverings. As the patient improves, meat should be given in small quantities and finely minced, such as fish, chicken, game, calves' brains, sweet-bread, calves' feet, rare or raw scraped beef, and pigeon. Fats, such as butter or cream, must be tried on the sthenic cases suffering from malnutrition. They sometimes agree and at times not. The diet must be necessarily modified by the conditions found in the functions of the intestine, which as noted should be determined. Red meat should be avoided when there is intestinal putrefaction of a marked character or when high blood pressure and the condition should receive treatment. Toast baked in the oven to dry it out and zwieback are preferable to bread. Crackers are admissible, green vegetables and oranges may be tried. If plain milk disagree and peptonized milk be disagreeable, a little lime-water or citrate of soda may be added to the milk. Tropon, or somatose may be added to the milk or gruels. ANOMALIES IN THE POSITION AND FORM OF THE INTESTINES; ENTEROPTOSIS Various anomalies in the position and form of the intestines occur, in some cases congenital and in others acquired, of which Koch and Curshman have made a study. They may be congenital in some cases, acquired through coprostasis, the weight of a tumor, or the formation of adhesions, in the majority of cases the colon being affected. Various angulations of the sigmoid, espe- cially due to adhesions, are described by the late J. P. Tuttle. Inflation with air and the use of bismuth injections with the re-ray aid diagnosis. Dilatation of the Colon. There are three varieties of dilated colon usually described : First, the Makro-colic, an elongation of the colon with no deviation from its normal circumference; second, megalocolic (large colon) with uniform increase in its internal diameter and a relative thick- ening of its walls; third, ecta-colic (dilated colon), a congenital form, an extensive dilatation of the colon with or without hypertrophy and dilata- tion of the adjacent section of the intestine. The prognosis of the first type is fairly good under medical treatment, while in the last two, it is not so. Hirschsprung's disease, or congenital primary dilatation and hyper- trophy of the colon, is found at birth. Dyspeptic symptoms, obstinate constipation, and colicky pains with great distention are present. By insertion of a finger or catheter into the rectum a movement will occur with relief of the distention. A large percentage of cases of Hirschsprung's disease die in early childhood. This is one condition in which the writer believes that if there is no improvement under medical treatment by enteroclysis, electricity, etc., after a short period of time, better results are secured by removing the dilated colon, or by laparotomy with separa- tion of adhesions if such cause the dilatation. Idiopathic dilatation of the colon is a rare event, and enteroptosis, the most common displacement, is described under Gastroptosis. INTESTINAL SAND 593 Idiopathic dilatation of the colon, in which there is no mechanical obstruction to the feces, may be congenital,. develop early or later after birth, or be acquired in adult life. Nervous derangement, habitual con- stipation, rickets, or chronic colitis may be factors. The colon and espe- cially the sigmoid are greatly distended, so that the protrusion of the ab- domen may justify the term "balloon man." Ulceration may occur in the distended gut. Constipation or irregularity of the bowels, gaseous distention, intestinal putrefaction, shortness of breath, palpitation, edema of the legs from pressure on the vena cava occur. Treatment. Enteroclysis, ox-gall enemata or simple enemata which should be small so not to overdistend, resorcin, gr. v t.i.d. and salol, gr. v t.i.d. to diminish gas, strychnin, gr. %o~Mo t.i.d. to improve bowel tone, or occasionally physostigmine salicylate, gr. ^ 00 once or twice daily, electricity and massage if there are no ulcers, regulation of the bowels, and treatment of indicanuria are indicated. The diet should be laxative. Iron and cod-liver oil are of value. Abdominal support is of service. Operative procedure may be required, such as colon resection, with junction of the ileum to the sigmoid. INTESTINAL SAND This material is gritty, contains organic matter, inorganic salts, espe- cially calcium phosphate and carbonate, but no cholesterin, which distin- guishes it from biliary sand. It has been considered by others as a manifestation of the arthritic diathesis. It is usually associated with mucous colic or possibly constipa- tion. It occurs generally in women between thirty and forty years of age. The associated condition must be treated. Sodium bicarbonate 5 SS t.i.d. and bismuth salicylate gr. x t.i.d. have been recommended. False intestinal sand, such as the residue of vegetable food, especially from pears, must not be mistaken for true sand. Symptoms are absent. CHAPTER XXII INFECTIONS BY THE BACILLUS COLI INVASION of the kidneys by the colon bacillus is not a particularly uncommon occurrence. As the author 1 has diagnosed this condition as a serious complication in a number of cases of typhoid fever, and as he has furthermore observed the invasion of other organs by the colon bacil- lus, it seems proper, in view of its source, that this infection should be described in this volume. The colon bacillus has, furthermore, a definite relation to certain infections in the gastro-intestinal tract. For example, it has been found as a factor in acute appendicitis and also in the fluids of acute peritonitis. It has been responsible for inflammation of the pan- creas, for gall-bladder inflammation, and colon bacilli have been found as the nucleus of gall-stones and pancreatic calculi. Furthermore, Fen ton B. Tiirck has fed colon bacilli to dogs and has experimentally produced gastric ulcer in these animals. Injections of the B. coli have also produced gastric ulcer. Reference has been made to Herter's investigations into intestinal putrefaction as to the influence of the Bacillus aerogenes capsulatus in the production of pernicious anemia. The possibility that this last condi- tion may at times be the result of colon bacilli infection is suggested by A. Charlton 2 in his researches at McGill University, in an article entitled "On the Anemia Produced by Repeated Injections of Cultures of a Colon Bacillus of Low Virulence." Striking results followed intravenous injections the experiments being carried on for many weeks. They were as follows: Advanced anemia occurred, in some respects strikingly like the conditions found in pernicious anemia, namely, a great diminution in the number of red cells, marked poikilocytosis, the appear- ance of pear-shaped cells, crescents, macrocytes, microcytes, and, lastly, nucleated red cells. On suspension of the injections for some weeks, even when the fall of erythrocytes was from 550,000 to only 1,500,000, spon- taneous recovery took place. When injection of the bacilli was resumed, the injurious results were more marked than before. But in addition to the effects on the blood, strikingly progressive changes were produced in the spinal cord, consisting / of diffuse degeneration in the columns of Goll, and in the anterolateral columns of the cord, closely resembling the conditions occurring in the spinal cord in some cases of pernicious anemia; extreme emaciation oc- curred the animals dying apparently from pure asthenia, though they fed well and suffered from no gastro-intestinal disturbances. Wm. H. Thomson 3 compares this condition to progressive anemia with emaciation and nervous weakness, grouped under the vague term neurasthenia. 1 Boston Med. and Surg. Jour., Nov. 30, IQII. 2 Jour, of Med. Research, vol. viii, No. 2, Nov., 1002. 8 Med. Rec., May 28, 1910. INFECTIONS BY THE BACILLUS COLI 595 H. G. Harris 1 of New York has reported an interesting case of infantile paralysis in which colon bacilli were found in large numbers in the urine. The patient recovered under the use of urotropin. In view of the changes produced in the spinal cord experimentally by the injection of colon bacilli into the circulation, the clinical case cited is of interest. Method of Infection by the Colon Bacillus. Some suggest that the origin of colon bacilluria is due generally to the introduction of these organ- isms from without (ascending infection). Thus, catheterization is given as a cause. Box holds that he has found this condition more frequently among girls than boys, and explains it by -the short urethra in the former, which more readily allows entrance of the bacilli. He states there is no more common cause of enuresis among children than the presence of this bacillus. While doubtless these organisms may enter the bladder through the urethra instead of descending from the infected kidneys, it is difficult to account for the persistent enormous multiplication of these bacilli in the urine, when, unlike all urines decomposed by other bacteria, in c,olon bacillus cases it remains strongly acid and not alkaline, and gives off no ammoniacal odor. Of course, in all cases of organs infected other than those' of the urinary tract, the bacilli must come through the blood, and it is the author's belief that in most cases the bacilluria results from auto- infection from the intestinal tract in some cases the bacilli causing an active process in the kidneys while in others a few bacilli are eliminated through these organs without clinical symptoms for a considerable period. As a rule, there is some ulcerative 2 process in the intestinal canal, or in some cases probably a mere solution of continuity. Chronic constipation alone may suffice to allow the occurrence of chronic infection from the colon. The possibility of entrance through the tonsils has been suggested. In fact, two such cases have been reported. Infection by contiguity may also occur, as by rupture of an abscess, and infection through the lymphatic system may also be possible. Hematogenous infection i.e., through the blood is the most common method. Types of Infection Produced by the Colon Bacillus. Among the types of infection produced by the colon bacillus are acute, subacute, and chronic nephritis, pyelitis, pyelonephritis, pyonephrosis (50 out of 60 cases of Lenhartz due to colon bacillus), septic infarcts of the kidney, cystitis, enuresis, septic endocarditis, otitis, meningitis, infantile paralysis, pros- tatitis, seminal vesiculitis and urethritis. Berstein 3 also reports a case of brain abscess due to the bacillus coli. Daugherty 4 reports a number of cases of infection of the middle ear, one of which was complicated by brain abscess, all of which were produced by colon bacillus infection. Cases of aggravated constipation which exhibit typhoidal symptoms are occasion- ally met with, in which isolation from the urine and blood of the Bacillus coli communis, or positive and exclusive agglutination of the patient's serum against most strains of this organism, prove these cases to be a gen- eral infection with the colon bacillus. An epidemic of this type has been 1 N. Y. Med. Jour., April i, 1911. 2 W. H. Thomson, Acute, Subacute, and Chronic Infection of the Kidneys and of Other Organs by the Bacillus Coli, Med. Rec., May 28, 1910. 8 Med. Rec., Feb. 7, 1914. 4 N. Y. Med. Jour., Dec. 12, 1914. 596 DISEASES OF THE STOMACH AND INTESTINES reported in Bavaria. 1 Phlegmonous enteritis (colon infection) is recorded. Apparent rheumatic articular attacks have been reported due to colon bacillus infection and have been cured by autogenous vaccines. The writer knows of one case apparently secondary to cholecystitis, where the colon bacilli were found on blood culture and the case cured by vaccines. Attacks of intermittent fever, the fever coinciding with the appearance of colon bacilli in the urine, and the intermission, with their disappearance have been reported. Recently I have treated such a case. Intra-abdom- inal exudates and tumors, believed to be tubercular or cancerous, have been demonstrated to be pure colon bacilli infections. Cases simulating per- nicious anemia may be due to this infection, and choroiditis has also been reported as due to the same cause. Gastric ulcer and achlorhydria haemor- rhagica gastrica secondary to a primary appendicitis infected by the colon bacillus are also possibilities. The author reports in this article a case of a private patient at the New York Hospital, who was under his care, who suffered from general infection with the colon bacillus. This patient had a double pyelitis, cystitis, double pneumonia, purulent bronchitis, two attacks of acute colitis, and myocarditis, all in succession, and ultimately recovered. Colon bacilli were present in the urine and sputum in enor- mous numbers. In acute pancreatic disease and acute cholecystitis this type of infection must be considered, and in cases of acute postoperative general hemorrhagic attacks in patients with gall-stones and pancreatitis. The writer has treated a case of chronic pancreatitis due to colon bacilli infection. Subdiaphragmatic abscess and wound infection by colon bacilli may also occur. Three cases of onynychia due to colon bacillus are reported. Reference has previously been made to the fact that colon bacilli are found as a nucleus of gall-stones and pancreatic calculi, and to Harris' case of apparent infantile paralysis with colon bacilli in the urine, cured by the administration of hexamethylenamin. Experiments have also demon- strated the possibility that colon bacilli may be factors in the production of cirrhosis of the liver. Reaction of the Urine in Colon Bacillus Infection. The urine reaction is acid in colon bacillus infection. Some claim it is at times alkaline, but the writer has not found this so, unless after the administration of large quantities of water or of alkalis. Symptoms of Colon Bacillus Infections. On account of the diversity of these infections, it seems best to the author to illustrate them by various cases. Acute infection of the kidneys will be first described. An inter- esting case is reported by Wm. H. Thomson 2 in consultation with Robert Abbe: "On the fifth day after operation for pelvic tumor, the patient com- plained of cramps and pain in the abdomen extending to the rectum. These were accompanied by nausea and frequent vomiting, followed by a rise of temperature to 104.3^. The patient then became drowsy and apathetic, with muscular twitchings in the face and upper extremities. The wound was healthy and healed by first intention. These symptoms 1 De Haan and De Gouge: Laboratte Weldobrecken Mederlingen, Bavaria, 1902. 1 Med. Rec., May 28, 1910. INFECTIONS BY THE BACILLUS COLI 597 cleared up. On the twenty-second day after the operation the patient had slight chills lasting twenty minutes, rise of temperature to 103. 5F., with the development of the symptoms described above. In addition the pulse became rapid, small, and irregular. The chills, sudden onset, early cere- bral symptoms, which may pass into coma or delirium, but no convulsions, rapid rise of temperature, and some vomiting, Thomson believes pathog- nomonic of involvement of the kidneys by some septic organism, of which the colon bacillus is the most common. The following day the urine be- came loaded with pus, blood, and casts, and colon bacilli were found in large numbers in the urine. "On account of the vomiting, hexamethylenamin and sodium benzoate, each 10 grains, were administered by rectum every three hours. As the patient also had oliguria (16 to 26 ounces daily), enteroclysis with Kemp's tube was ordered A. M. and P. M., 2 gallons of normal saline solution at 1 1 5F. ; the urine increased up to from 60 to 1 1 2 ounces in twenty-four hours. During the course of a week the pus and blood cleared up. The urine continued acid with a specific gravity averaging 1008, but it still showed a diffused white cloud. This is characteristic and is caused by immense numbers of colon bacilli in suspension. The cerebral symptoms and vomiting ceased within twenty-four hours after initial treatment, and the temperature fell to 9QF., and thence to normal. The bacilluria still persisted until on the twentieth day she developed symptoms of subacute appendicitis. Abbe operated under local anesthesia, and removed a dis- eased appendix with several hemorrhagic points in its lumen and a large ulcer in its base at the junction with the cecum. The bacilli subsequently disappeared from the urine. Though the treatment alleviated the severe symptoms, the focus of infection was present until removed." Chas. R. Box, of St. Thomas Hospital, London, in an article in the Lancet 1 observes that in many cases where the kidneys are involved in typhoid fever, scarlet fever, measles, and diphtheria, the organism found in the urine is the colon bacillus. In view of this fact, the colon bacillus should be examined for in all cases. In any event, even if not found, it would seem to the author that the large doses of hexamethylenamin and sodium benzonate are the best disinfectants for the kidneys. Wm. H. Thomson 2 reports an interesting case of A. Seibert, of New York, during the course of scarlatina. Dr. Seibert found the girl, age eleven, in the sixth week of her illness, suffering from universal edema, most marked in the face, some ascites, pulse 48, intermitting every third beat. She was semiconscious, with total blindness, which had persisted for five days, nausea, and incessant vomiting, which had lasted for ten days, necessitating rectal feeding. Two severe uremic convulsions had occurred on the previous day. Only 4 or 5 ounces of urine had been passed in the previous twenty-four hours, and this contained but a moderate amount of albumin. Hexamethylenamin, 5 grains dissolved in i ounce of cold water, with 15 drops of dilute hydrochloric acid, was administered and retained. The same dose of hexamethylenamin was continued every 9 l Jan. ii, 1908. 2 Med. Rec., March 21, 1908; May 28, 1910. 598 DISEASES OF THE STOMACH AND INTESTINES three hours. The headache first disappeared, marked diuresis set in, so that no ounces of urine were passed in the next twenty-four hours, and all the edema disappeared within forty-eight hours. The amaurosis diminished in two days and, finally, disappeared in a week, after which she made an uninterrupted recovery. A second illustrative case is that of a physician who had been treated for chronic ulcerative colitis and who had had a rectal ulcer excised. Shortly after this he became delirious, with moderate temperature. This condition lasted four weeks. The urine was examined daily by an expert, who reported blood, albumin, and many casts laboratory diagnosis, acute parenchymatous nephritis. Thomson, on being called in consulta- tion, finding that the patient had no edema, that the pulse was soft, and the delirium prolonged and active, which were not common in parenchy- matous nephritis also being cognizant of the history of intestinal ulcera- tion diagnosed infection of the kidneys with the colon bacillus, and re- quested examination of urine for the same. Meanwhile his usual treat- ment, hexamethylenamin and sodium benzoate, each 10 grains every three hours, was ordered. It was first given by rectum. The laboratory report showed colon bacilli in abundance. Two days later the blood, albumin, and casts disappeared, and six months later the physician re- ported sixteen hours professional work a day. Typhoid Fever. Acute invasion of the kidneys by the bacillus coli is not uncommon, and is at times a fatal complication of typhoid fever, especially in the later stages of extensive ulceration. Sudden severe rigors occurring late in the disease, increased albuminuria and casts, often with diminished urine, and at times with commencing delirium, are all signifi- cant of colon bacillus infection. The urine should at once be examined for the bacilli, and the usual treatment, hexamethylenamin 40 to 80 grains daily, and sodium benzoate, an equal amount, instituted. The author has had numerous such cases during the past few years. Pyelitis. Acute invasion of the kidneys may be productive of a simple pyelitis, usually bilateral, attacking first one and, after subsidence of the acute symptoms, then the other organ. There is then a subsidence of symptoms, but recurrences take place usually in one kidney, and these continue until final cure. There is a sudden rise of temperature, 103 to io5F., often preceded by a chill; first one, and later, frequently the other kidney, becomes tender on pres- sure. There is pain in the lumbar region, urine is highly acid, contains pus, occasionally blood, and is loaded with colon bacilli. The pyelo- nephritis of pregnancy, particularly postpartum, is quite frequently the result of colon bacillus infection. L. C. Dudgeon, 1 in his Erasmus Wilson lecture on Acute and Chronic Infections of the Urinary Tract, also de- scribes such cases. He reports that such attacks sometimes occur with appendicitis. Finding such cases prone to relapse, he recommends treat- ment with vaccines. As a matter of routine, the author believes that in all cases of pyelitis one should examine the urine for colon bacilli. The dose of hexamethylenamin usually given is too small, as will be described under Treatment. If appendicitis is present, as in some of Dudgeon's 1 The Lancet, Feb. 29, 1908. INFECTIONS BY THE BACILLUS COLI 599 cases, it should be removed, as it is the source of infection under such conditions. Acute Unilateral Septic Infarcts of the Kidney. George E. Brewer 1 reports several cases in which the lesions were confined to one kidney. This condition may be due to pure cultures of the staphylococcus pyogenes aureus, virulent forms of streptococci, and in one case the organism was the Bacillus coli. Other authors mention the latter as a frequent cause of this condition. The symptoms, which are sudden in their onset, are chills, a temperature rising rapidly to 103 to 105?., to even io6F., tenderness over the kidney, especially at the costovertebral angle (Brewer's point); pus, albumin, casts, and, at times, blood are present in the urine, and colon bacilli when such are the cause of the infection. The cause of unilateral infarctions can be readily explained by the probable occurrence of preceding lesions in this organ according to the principle illustrated by S. J. Meltzer who, on producing minute lesions with long needles in the liver, kidneys, and other organs of rabbits, and then injecting a virulent culture in the vein of the ear, produced abscesses only at the seat of these traumatisms. Infarctions occasionally occur in both kidneys, so that differential urethral catheterization will absolutely determine the correctness of the diagnosis as to whether one or both are involved. Chronic Interstitial Nephritis. Wm. H. Thomson holds that this con- dition may be primarily caused by slow infection of the kidneys by the Bacillus coli. Sudden terminations of cases of chronic instertitial nephritis, characterized by oliguria or suppression of urine, are nearly always preceded by acute indigestion in some form, and Thomson always dreads an attack of so-called cholera morbus in an elderly patient, and at once examines the urine. These cases are frequently attributed to an acute exacerbation of the chronic kidney disease, whereas numbers of such cases have been saved by immediate resort to hexamethylenamin and sodium benzoate, admin- istered by rectum when the patients were comatose. He holds that it is suggestive how soon in the course of chronic interstitial nephritis symptoms of increased kidney affection develop after errors of diet. The author, under Indicanuria, has called attention to the acute kidney disturb- ance produced by intestinal putrefaction, and also noted the value of hexamethylerfamin and sodium benzoate for the treatment of this condition. Cholecystitis. Inflammation of the gall-bladder is frequently pro- duced by the colon bacillus, which may reach it, as it does probably most frequently through the gall-duct, or, at times, through the blood-stream or lymphatics. At the Johns Hopkins Hospital the gall-bladders of animals were infected with the colon bacillus, and subsequently cured, or inflammation prevented by the administration of hexamethylenamin. It would seem wise to examine the urine for colon bacilli in all cases, and in any event to administer hexamethylenamin to disinfect the gall-bladder, in all infections of that viscus. 1 Surgery, Gynecology, and Obstetrics, vol. ii, No. 5. 600 DISEASES OF THE STOMACH AND INTESTINES H. Batty Shaw 1 gives the histories of seven cases of his own of colon bacilli infection, in which he states that clinically such patients may be supposed to be sufferers from malaria, tuberculosis, mucous colitis, recur- rent cystitis, dyspepsia, acute suppression of urine, typhoid fever, or pernicious anemia. He recommends that every case of chronic febrile affection of obscure origin should have the urine examined for the Bacillus coli. The author has recently treated a case of chronic pancreatitis with marked steatorrhea and colon bacilluria. In view of an old history of intestinal ulcer, the possible influence of colon bacillus infection in the production of chronic pancreatitis is suggested. Choroiditis. Robert T. Morris 2 reports the case of a patient referred to him by John S. Kirchendall, of Ithaca, who suffered from choroiditis, which threatened to end in blindness. Morris found that for years the patient had suffered from intestinal troubles due to fibroid degeneration of the appendix, and on its removal the patient recovered, both from the intestinal dyspepsia and also from the choroiditis. Stockton, of Buffalo, has for years asserted that the colon bacillus was the cause of many cases of choroiditis. The author has seen a case of choroiditis suffering from gastro-intestinal disturbances, in whom marked colon bacilluria was found. This was treated by large doses of hexamethylenamin, grs. 60 daily, given in divided doses with apparent improvement in the ocular symptoms. Pelvic Exudate and Intra-abdominal Tumors Due to Colon Bacillus Infection. F. Charlton Briscoe, 3 Physician to Kings College Hospital, London, relates several instances of the matting together of the pelvic viscera by an exudate, showing caseous changes, which led to a mistaken clinical diagnosis of tubercular nature, but which proved, on microscopic examination, to be caused by the Bacillus coli. In each case colon bacilli were found abundantly in the urine. Case i. This patient was a woman with rectal ulcer and chronic hemorrhoids, who gradually lost weight, with daily fever and constant pain in the right flank. These were evidences of an intra-abdominal mass. On laparotomy, the pelvic organs were found matted together, the uterus, posterior wall of the bladder, and a coil of the small intestine being bound together. Under treatment by vaccines, she fully recovered. Case 2. This patiet suffered from intra-abdominal tumor, with temperature. The condition was thought to be tubercular. On laparot- omy, a large mass of caseous material was found attached to the small intestine, great omentum, left ovary, and tube. This was thought to be surely tuberculous, but no tubercle bacilli were found. There was a structureless material from which pure cultures of colon bacilli were obtained. Case 3. In an Italian woman, age fifty-two, there was a large tumor which was suspected to be malignant. On laparotomy, it was found to be attached to the wall of the bladder and extended from the pelvis to the umbilicus. It was of dark red color and covered with peritoneum. 1 Clinical Jour., Feb. 12, 1908. 2 N. Y. Med. Jour., Jan. i, 1910. 3 The Lancet, Oct. 30, 1909. INFECTIONS BY THE BACILLUS COLI 6oi There were many large blood-vessels passing over its surface. On the supposition that it was malignant and inoperable, it was let alone. For three days after the temperature rose daily to io3F., and on the fourth day she passed a considerable quantity of pus and large flakes of lymph in the urine. The tumor was found to have disappeared, but from time to time it re-formed and emptied itself, eventually disappearing entirely. From the urine a pure culture of Bacillus coli was obtained. Briscoe further refers to an interesting number of cases who have attacks of intermittent fever, the temperature coinciding with the ap- pearance of colon bacilli in the urine, and the intermissions, with their disappearance. He advises that the urine be examined for colon bacillus in all cases of ferbile attacks of obscure origin. He also notes how frequently ulcers in the rectum occur previous to invasion of the kidneys and other organs. He, together with other authors, comments on the pale color of the urine, the milky haze, acid reaction and high specific gravity, to- gether with the chronic persistence of the colon bacilli, when they once appear in the urine. He also notes that the urine never decomposes with an ammoniacal odor. The urine is always acid. Briscoe makes the urine alkaline, gives frequent mercurial purges, and administers autogenous vaccination, the initial dose being 50,000,000 of the dead organisms every seven to eight days, with effective results. Wound Infection with the Colon Bacillus. The writer has seen a number of cases of wound infection with the colon bacillus, notably several cases after operation for appendicitis. E. A. Babler 1 reports a case fol- lowing gunshot wound of the liver and colon, and an interesting case of subphrenic abscess with destruction of part of the diaphragm and marked necrosis of the tissues and skin. The condition is depicted in Fig. 282. Septic onychia due to the colon bacillus has been reported by Houston. 2 All the patients were cured by autogenous vaccines. Finally, the author reports a case of general infection with colon bacilli, in which the organisms were found both in the urine and in the sputum. This patient ultimately recovered. The case was of such severity and suffered from so many complications that it is described at length. H. G., broker, aged forty-four, operated on at the New York hospital by Frank Hartley, for right inguinal hernia. The subsequent complica- tions were as follows, all due to infection with the colon bacillus: Double pyelitis, cystitis, double pneumonia, purulent bronchitis, two attacks of acute colitis, and a myocarditis. On March i, 1910, the patient entered the New York hospital. Pre- vious to admission heart, lungs, and urine were found to be normal. These findings were confirmed at the hospital before operation. His weight was 165 pounds, height 5 feet n> inches, was in perfect physical condition, smokes a pipe several times a day, and for two years has not indulged in alcohol except an occasional Scotch-with-soda when dining out. Urine has been normal for two years before operation. Previous to this time a few casts and a trace of albumin were found for a brief period of several weeks. Alcohol was shut off and diet instituted, and urine 1 Jour. Amer. Med. Assoc., Oct. 29, 1910. 2 Lancet, May 23, 1914. 602 DISEASES OF THE STOMACH AND INTESTINES rapidly returned to normal, in which condition it remained. The patient, though very active as to exercise, has always had a tendency to constipa- tion. He. has secured bowel action by olive oil internally and other simple remedies. March 2d. Operation for a rather small reducible hernia. Catherterization was required the afternoon of the day of operation. On the following day there was some irritation of the bladder, which was washed out once, and on the day after this, a pain in left kidney first began. Urine showed pus diagnosis, left pyelitis no examination for colon bacilli was made at this time. Hexamethylenamin, 10 grains t.i.d., was given, and an ice-bag was applied to kidney. The tenderness disappeared within three or four days, and then an attack began in the right kidney, but of not so great severity. The pain in the right kidney rapidly dis- appeared, but pus persisted in the urine and also a slight temperature. Fig. 282. Subphrenic abscess (colon bacillus infection) (Babler). On Friday, March nth, the patient complained of pains on the right side of the chest, and on March i2th (Saturday) Hartley found a slight dry pleurisy, increasing up to March i3th. On March i4th the writer was requested to examine the patient, and on that date found a small pneu- monic area at the right base. The operating surgeon thereupon requested me to take charge of the case. March i6th there was a sudden attack of heart failure, accompanied by a fall in temperature. The patient was nearly pulseless in spite of heroic stimulation and oxygen. Hartley and S. Lambert (the consultants) believed he would die at any moment. Digitalone, 15 drops, and sodium caffein salicylate, 2 grains, were admin- istered every four hours; also strychnin sulphate, ^ g ram > every four hours one given at 2, 6, 10, etc., the other at 4, 8, 12, etc. so that stimulants were administered every two hours. In addition, the writer had given hourly a hypodermic, 5 grains of camphor in olive oil, for sixteen hours, in all, 80 grains during this period. INFECTIONS BY THE BACILLUS COLI 603 The patient's chest was kept thoroughly oiled to prevent blistering, and boiling hot stupes were applied every three minutes over the heart and thorax continuously for seven and one-half hours; then an intermission of one-half hour, then renewal for four hours continuously, and so on. In all, during the twenty-four hours, hot stupes were applied for twenty hours. As there was some distention, the head of the bed was blocked up to prevent pressure (gas) on the thorax, and the stupes were carried down over the abdomen. The writer believes the application of continuous extreme heat and the camphor injections were the chief factors in saving the life of the patient in the acute heart failure attack. He was given 40 to 50 grains of camphor daily for some days by hypodermic, in addition to the other stimulants noted. For several days no food was administered, only hot water. On March igth some increase in temperature occurred, showing further involvement of the lung at the right base; the temperature at no time was very high, and after two to three days gradually defervesced. At midnight, March 24th, the patient was suddenly taken with an extremely severe chill, lasting about half an hour; the respirations rapidly increased, and when the writer saw him at i A. M., March 25th, they averaged 65 to 70 per minute, the heart action was rapid, and the patient was suffering for lack of oxygen. Continuous hot stupes, oxygen, camphor and strychnin, in about an hour gradually relieved the condition, the respirations gradually diminishing in frequency. The temperature shot up to io4F., then dropped to normal, and then gradually rose to 101 to ioi.5F. Hartley and S. Lambert saw the case at once, and suspecting the possibility of complicating empyema, Hartley put in aspirating needles in several locations, with negative results. As there was no apparent cause for this condition, and as the pyelitis was still in evidence, hexamethylenamin 30 grains a day, had been resumed after the acute stage of pneumonia had passed. The writer having had a number of cases of colon bacillus infection with the same type of chill and temperature noted in this case, requested an examination of the urine for this organism, and on suspicion, increased the hexamethylenamin to 10 grains every three hours, adding sodium benzoate, an equal amount, for the next twelve hours. In the morning a large number of Gram-negative bacilli were reported under the microscope. The hexamethylenamin, 10 grains, and sodium benzoate, 10 grains, were continued every three hours, both day and night, a total of 80 grains each per day, and later pure cultures of colon bacilli were reported in the urine. The temperature gradually defervesced to about 9Q.5F., where it remained. Resolution of the right lung was very slow, there was little expectoration, but abundant colon bacilli were found in the sputum. The following events then occurred: In early May a sharp, attack of acute colitis, no blood or occult blood could be found; intestinal irrigations with acetozone (i : 1000) were given; lactic acid bacilli tablets begun and kept up thereafter. Early in May a second pneumonia at the left base developed, very slight with mild symptoms; temperature slight and with no cardiac dis- 604 DISEASES OF THE STOMACH AND INTESTINES turbance; it was slow to resolve; undoubtedly the saturation of the patient with hexamethylenamin was contributory to its mildness. Colon bacilli were again found in the sputum. Blood-culture Taken at this Time and Found Sterile. In the middle of May a sudden attack of acute purulent bronchitis occurred. So thick was the pus that pulmonary abscess was feared. Culture showed enorm- ous numbers of colon bacilli and some streptococci. As there was still some expectoration from the pneumonia, the author believes the bron- chitis was thus directly produced. Beyond the initial few hours there was no especial discomfort except from the cough. Autogenous vaccines were then begun 1,000,000,000 to i c.c. One minim was first ad- ministered by hypodermic, and this continued daily for several days and then gradually increased by >-minim doses up to the maximum, 5 minims. The bronchitis improved, but there was no disappearance of the bacilli from the urine, though the vaccines were given daily by advice of the pathologist. At the end of May, however, the general condition of the patient had so improved, and the temperature being generally normal the greater part of the day with only a slight evening rise, that he was removed to his home. At the end of three weeks the administration of vaccines caused a marked reaction, so they were stopped. In June an exacerbation of pyelitis occurred and a second attack of acute colitis, a very suggestive coincidence. Again the stool was examined for pus and occult blood, as ulcer was suspected by the writer, but the results were negative. The author is, however, fully convinced that the colon bacillus infection was autogenous from the gut. A thorough in- vestigation was made at the time of the catheterization, and no flaw in the technic could be detected. The subsequent history of the case proved the theory auto-infective process to be correct. In June autogenous vaccines were again administered, 200,000,000, and about a week later 300,000,000. Considerable reaction followed these injections, which rather alarmed the patient. They were discontinued and reliance placed on the hexamethylenamin and sodium benzoate. In early June the patient went to Williamstown, at this time there being only a slight evening temperature, 99 to 99.5^., bacilluria persist- ing, with few pus cells. There was still a slight evidence of unresolved pneumonia at the left base, but no cough. The patient suffered some shortness of breath on exertion, and the heart action was somewhat rapid, a myocarditis of mild degree, due chiefly to the toxemia in the author's opinion. In early July the writer joined the patient, and twice each week the urine was sent to New York and examined for colon bacilli. On August 27th the colon bacilli disappeared, there being only a few pus cells found thereafter. The urine remained free from colon bacilli until October. On the first of this month the patient returned to the Stock Exchange and, against advice, persisted in a full day's work. On about the fourth day, he had slight chilly feelings, slight rise of tempera- ture, and a reappearance of the colon bacilli in the urine, though not in great numbers. These gradually diminished under dosage of hexamethylenamin, 50 to INFECTIONS BY THE BACILLUS COLI 605 60 grains daily, and there was slight evening temperature only every day or two, to 99 to 99.5^. William H. Thomson, on examining the case, agreed with the writer that further physical rest was necessary. He also held that the infection undoubtedly arose from the intestinal tract through some undiscoverable lesion in the intestinal canal. The patient was sent to Europe to a warm climate, where he remained until May i, 1911. He continued hexamethy- lenamin about 40 grains daily, until the disappearance of the colon bacilli; thereafter hexamethylenamin 15 grains daily, until his return. The patient, December 24, 1910, wrote me that his temperature re- mains normal, and only a few colon bacilli persist in the urine. In January, 1911, the colon bacilli entirely disappeared from the urine. The subse- quent course of this case is of considerable interest. From January, 1911, to July, of the same year, no colon bacilli were found in the urine. In May the patient returned to the Stock Exchange. In July, 1911, an attack of acute tonsillitis occurred, with immediate reappearance of colon bacilli in the urine. The writer was absent from the city, and the physician in attendance did not examine the throat discharge. It would have proved interesting to note whether an exterior reinfection could have occurred through the tonsils. From January to May i, 1911, the patient had continued hexamethylenamin, 15 grains daily in divided doses, as a prophylactic, and thereafter took occasional doses up to the time of re- currence. The writer advised a return to 60 grains of hexamethylenamin a day at this time. The patient rapidly recovered from the tonsillitis, felt well, and in about a week resumed business, but the bacilluria was still present. About October 16, 1911, an occasional colon bacillus was found in the urine, though the patient was apparently well. Hexamethyl- enamin, 15 grains daily, was still continued. The case is particularly interesting from the fact of recovery from apparently what was believed to be a fatal infection and from the tendency to recurrence. The tendency to chronicity of this infection is undoubtedly difficult to combat. The patient before October ist had regained his loss of weight, which was 35 pounds. Hexamethylenamin, 80 grains, with sodium benzoate, 80 grains, were given daily from March 25th to June ist, 1910. From June ist to July gth, he averaged 60 grains daily. Up to May ist no irritation re- sulted from the treatment. Sudden changes in the urinary reaction then occurred, and there was considerable difficulty in controlling the irrita- tion. It would be extremely acid at one time and very alkaline later, both conditions causing irritation. The writer finally secured the best results keeping the urine slightly acid, and stopping the benzoate when a sudden excessive irritation with acidity occurred, and then giving an alkali (citrate of potash) with the hexamethylenamin. On the other hand, when the urine was alkaline with irritation from too much alkali, sodium benzoate was given with the hexamethylenamin and the potash stopped. The urine was carefully watched for the presence of casts and cylindroids, but no evidence of renal irritation from the hexamethylenamin could at any time be discovered. From July ;th to August yth, hexamethylena- min, 50 to 60 grains, was administered daily. From August yth to October 4th, 1910, hexamethylenamin was re- 606 DISEASES OF THE STOMACH AND INTESTINES duced to 40, 30, and, finally, 20 grains daily, the latter as a prophylactic as the colon bacilli disappeared for a few weeks. In spite of this the colon bacilli reappeared later in October. The subsequent course of this patient is interesting as he is still in June, 1916, a chronic colon bacillus carrier. From January, 1912, to January, 1913, the colon bacilli in the urine varied for a few thousand per cubic centimeter to as many as 100,000. There were no symptoms, and only occasionally a temperature of 99F. The patient continued his hexamethylenamin 40 to 60 grains daily, excepting during courses of autogenous vaccines up to 1,000,000,000 each with no curative results during this period. Vaccinations alternating with hexamethylenamin were carried out during 1914, the vaccines being pushed to 1,800,000,000 on one occasion with vomiting, diarrhea, and acute urinary suppression for twenty-four hours (anaphylaxis) relieved by hypodermoclysis, enteroclysis at i2oF., etc. subsequently dependence was placed on the hexamethylenamin. It has been impossible to determine in this patient whether the source of infection lies in the small intestine, large intestine or rectum. He has been a chronic colon bacillus carrier for six years; practically since his return from Europe, May, 1911, he has attended to business regularly and has rarely had even a slight temperature. On the occasion of his large dose of vaccines there was an exacerbation in the number of colon bacilli in the urine following dietetic indiscretions and intestinal disturb- ance, in addition to the evident anaphylaxis. Excepting during the periods of vaccination for four years the dosage of hexamethylenamin averaged 40 to 60 grains daily, usually 50 and at no time did renal disturbance result from the drug. For the past two years he has taken at times from 1 5 to 30 to 40 grains hexamethylenamin daily, varying the dosage. There have been considerable intervals with no medication but careful diet. He feels perfectly well, has no temperature and attends to business regularly. With even acute nephritis from colon bacillus infection, large doses even 80 grains of hexamethylenamin can be given daily, with clearing up of the renal congestion. On the other hand large doses of this drug may be given for other conditions and cause renal congestion which immediately disappears on cessation of the remedy, particularly if cream of tartar lemonade is also administered. It was interesting to note that the 30 grains daily of the drug given for the initial pyelitis did not prevent the nearly fatal colon bacillus pneu- monia, and that the large doses (80 grains daily) did undoubtedly pre- vent severe symptoms in the subsequent second pneumonia and purulent bronchitis. The autogenous vaccination evidently was of some value to relieve the symptoms of the bronchitis, but the disappearance of the bacilli only occurred following the persistent use of hexamethylenamin. Hugh Cabot 1 has shown that the use of the vaccines is followed by im- provement in the clinical symptoms in one-half the cases, but that they have but little effect on the bacteriuria. 1 Amer. Assoc.- of Genito- Urinary Surgeons, Eighth Congress of American Physicians and Surgeons, 1910. INFECTIONS BY THE BACILLUS COLI 607 There was considerable reaction toward the end of the first period of autogenous vaccination, and marked after the second. The patient, however, is a chronic carrier apparently immune to symptoms. Finally, the author wishes to call to the reader's attention that, in addition to the marked indicanuria in intestinal obstruction, colon bacilli infection may also occur. The possibility that gastric hemorrhage as a complication of acute appendicitis, may be the result of colon infection carried to the stomach producing an erosion, is worthy of investigation, especially in view of Turck's experiments. Diagnosis. Urine should be examined for Gram-negative bacilli (colon bacilli), and then cultures should be grown; the sugar fermentation test is also of value; wound infection should be cultured, and also the discharge from tumors or infected wounds. Urine Reaction. With colon bacillus infection and tubercle infection the urine is always acid. This is an aid to diagnosis. Other types of pus in the urine, with pyelitis or cystitis, give an alkaline reaction to the urine. Treatment of Infection by the Colon Bacillus. Several methods have been suggested; first, the use of alkalies, the latter being pushed so that the urine becomes strongly alkaline, the claim being made that the colon bacilli do not propagate in an alkaline medium. Alkalinity of the blood is also increased. The writer has not been successful with this method. The employment of hexamethylenamin in large doses in association with increased acidification of the blood and urine (it being claimed that hexamethylenamin gives off formalin best under these conditions) is now advocated. Hinman 1 has demonstrated that hexamethylenamin in dosage less than 45 grains daily has no antiseptic value and to produce formaldehyd conversion in antiseptic amounts, the urinary acidity should be greater than 2 c.c. of decinormal sodium hydrate for 10 c.c. of urine. Acid sodium phosphate (Merck's) gr. 30 every three hours three to four doses daily has been advised, it being claimed, as noted, that the increased acidity renders the formaldehyd more active. The sodium phosphate should be given about one and a half hours before the hexa- methylenamin. The writer was not as successful with this as with the sodium benzoate in most of his cases. Sodium benzoate gr. x with an equal dose of hexamethylenamin has given the best results in my experience. The employment of autogenous vaccines, or irrigation of the pelvis of the kidney have also been advised. Koll 2 and others recommend irrigation of the pelvis of the kidney with 2 per cent, liquor aluminium acetate in colon bacillus pyelitis. In ascend- ing infection it might be of value, but in case of hematogenous infection with continued reinfection from the blood, I consider it useless. Silver nitrate i : 20,000 to i : 10,000; or mercuric oxycyanid i : 10,000 to i : 5,000 have also been advocated for pelvic irrigation. 1 Journal A. M. A., Nov. i, 1913. 2 Amer. Jour. Urology, Nov., 1911. 608 DISEASES OF THE STOMACH AND INTESTINES The writer recommends (i) hexamethylenamin and sodium benzoate, each 10 grains, every three hours by mouth; by rectum, if there is vomiting or coma. After prolonged use, if excessive acidity with irritation occur, omit the benzoate and give, with the hexamethylenamin, potassium citrate; thus quickly regulate the urine so as to lessen acidity but not suffi- cient to make it continuously neutral or alkaline. Thomson has shown that the sodium benzoate augments the effects of the hexamethylenamin. As the condition improves the hexamethylenamin and sodium benzoate may be gradually reduced. (2) Autogenous vaccination, especially if the infection is chronic or does not respond to treatment, or there is additional infection elsewhere, 50,000,000 increasing to 300,000,000 to 500,000,000 gradually, first given every two or three days; larger doses at longer intervals, four to seven days. I have more recently used up to i ,000,000,000 to i ,800,000,000 without cure. Some advise 200,000,000, increasing to 1,000,000,000. (3) Lactic acid bacilli in liquid form should be given t.i.d. Fair- child's lactobacillin or any reliable preparation. (4) High enemata i : 1000 acetozone, i quart every day, and later every other day are of value. (5) Sour-milk diet: bacillac, fermillac, matzoon, lactone-buttermilk, and koumiss; later, cereals, particularly rice grape nuts, etc., avoid red meats. (6) Bowels should be opened at once by calomel or blue mass, followed by a saline cathartic and then regulated carefully daily. Calomel or blue mass once a week. Russian mineral oil, 1 olive oil by mouth, agar-agar (regulin), purgen and cascara are an aid. (7) Antibacillus coli serum, 2 25 c.c. in divided doses in three days' time, has been recommended. (8) Surgical procedure when indicated, i.e., for example if a chronic infection of the appendix, or rectal ulcers or hemorrhoids (ulcerated) are deemed responsible. 1 American mineral oil gss, A. M. and P. M. may be substituted. 2 Rawls, Med. Rec., Oct. 7, 1911. CHAPTER XXIII CONSTIPATION AND DIARRHEA CONSTIPATION (Synonyms. Obstipatio Alvi; Constipatio Alvi; Atony of the Bowel; Habitual Constipation) HEALTHY persons usually have one bowel movement daily, generally about the same hour. Some normally have two actions a day, while others empty the bowels every other or every second day, and yet are in perfect health. Constipation is denned as a condition in which the feces are not passed sufficiently often. Another form is that in which defecation occurs daily, but the movements are insufficient in quantity. A stagnation of fecal matter may thus occur. The quantity of feces is somewhat variable, from 100 to 150 grams, the average, even up to 250 grams, being greater after a vegetable diet and less after meats. Considerable of the evacuation is made up of microorganisms, of which Herter 1 has estimated the daily number as 126,000,000,000, which explains the fact that patients who eat little may pass considerable material. Constipation may be acute or chronic. The acute type is due to complete obstruction of the intestinal tract, or to dynamic ileus (intestinal paresis). The chronic type is extremely common. Henry Illoway and Samuel Gant have written excellent works on this subject. My classification is slightly modified from their books. Etiology. All possible factors must be carefully investigated and corrected. 1. Diseases of the stomach, such as hyperchlorhydria, ulcer, cancer, dilatation, simple atony, catarrhal conditions, and achylia gastrica, may cause constipation. 2. Obstruction of the bowel by tumors of the intestine or tumors press- ing on the bowel from some adjacent organ; by stricture within the intestine; by external stricture, as by peritonitic adhesions; by chronic intussusception. Lane describes a type of chronic obstruction with dilatation of the small intestine, including the duodenum, due- to partial obstruction of the termination of the ileum by a mesentery, or band developed in the mesentery, by an anchored appendix or by pressure of the ileum on the pelvic brim. Mayo 2 also refers to cases of chronic intestinal stasis due to kinks and adhesions of the terminal ileum (the Lane kink) frequently associated with chronic appendicitis. 1 Bacterial Infections of the Digestive Tract. 2 Surgery, Gynecology, and Obstetrics, March, 191 1. 39 609 6 10 DISEASES OF THE STOMACH AND INTESTINES 3. Catarrh of the small intestine alone; in some cases catarrh of the large intestine: mucous colic; atrophy after catarrh; ulcers of the small intestine are occasionally attended by constipation; dysenteric ulcers at times produce constipation, though ulcers of the large intestine usually cause diarrhea. 4. Voluntary abstention from stool on account of the pain it produces, by reason of disease of the rectum, such as from piles, fissures, or ulcer. Increased contraction of the sphincter ani (irritability), at times with resulting hypertrophy, also occurs from irritation and interferes with bowel action. Hypertrophied levatores ani muscles which may be felt as thick rigid bands about 2 inches above the anus may clamp the rectum and interfere with bowel movements. 5. Obstruction to the entrance of bile into the intestine or deficiency of bile. 6. Diseases of the heart, lungs, liver, and kidneys. Intestinal hyperemia and congestion of the portal system are factors in these cases in retarding peristalsis, as in cirrhosis of the liver. 7. Disease of the pancreas. 8. Diabetes, anemia, and chlorosis. 9. In many diseases of the brain, spinal cord, and of the nervous system constipation is present. Among such are chronic insanity, diphtheritic paralysis, tabes, brain tumors, cerebrospinal meningitis, hemorrhage of the brain, chronic hydrocephalus, myelitis, neuroses, and psychoses. 10. Acute febrile conditions are usually accompanied by constipation, as pneumonia, etc. This generally excludes those with special intestinal lesions. We must remember that constipation occurs in some cases of typhoid, and even of dysentery. 11. Chronic constipation from foreign bodies. They may be lodged in the bowel or beneath the mucosa and either obstruct the rectum or cause sphincteric contraction. 12. Malformations, such as abnormally developed or dilated colon; undue size or length of the sigmoid flexure; diverticula of the large intest- ine; a diaphragm partially closing the large intestine. 13. Defective development or essential primary atrophy of the colon. 14. Enter opto sis; angulations of the sigmoid flexure due to adhesions; prolapse of sigmoid into rectum from long mesentery in effect, slight intussusception; cecum mobile (movable cecum). 15. Atrophy of the intestinal musculature following catarrh or fatty degeneration, as in consumption or in alcoholics. 16. Hypertrophy of Houston's 1 valves, or hypertrophied O'Bierne's sphincter, which is located at the rectosigmoidal juncture, may be causes. Coccygeal deviation with projection inward of the bone may be a factor. 17. Loss of power in the abdominal muscles may be a factor in some cases, as in the emaciated, with multiparous women with diastasis of the recti, etc. 1 8. Distention of the duodenum secondary to compression or obstruc- tion of the third part of the duodenum by reason of a strain exerted on it 1 Gant, N. Y. ,Med. Jour., April 15, 1911. CONSTIPATION AND DIARRHEA 6ll by the mesentery of the small intestine or by the pull on it by the jejunum. Some of these cases have associated a duodenal ulcer, and Lane 1 describes a case in which there was torsion at the duodeno-jejunal junction, the patient being a sufferer from chronic intestinal stasis, a stenosis of the pylorus being suspected. 19. Chronic constipation from impaired physiologic function. This type is due to disturbance of the motor function of the intestines, and is strictly classified under motor neuroses, under which we have: (a) Constipation due to retarded intestinal peristalsis (atony or relaxation of the bowel). (b) Spastic constipation, perverted action, or enterospasm. The constipation is due to a spasmodic contraction of a portion of the intestine. (c) Spasm of the sphincter is included under this type. Constipation Due to Disturbances of the Motor Function. Habitual constipation due to impairment of the physiologic function (i.e., caused by motor disturbances) constitutes an important class of cases. It should be strictly classified under motor neuroses. There are the two types mentioned above: the atonic and the spastic forms of constipation. Atonic Constipation. Constipation due to atony (literally, relaxation) of the bowels constitutes the majority of cases. Predisposing Causes. The character and quantity of food and the amount of physical exercise influence bowel evacuation. Boas has laid stress upon the importance of the type of nourishment and its influence in the production of constipation (alimentary constipation). Albuminous diet consisting of meat and eggs leaves little residue, and eventually tends to constipate; while with vegetable diet there is more residue and the fermentation products excite peristalsis. A patient may diet by avoiding vegetables, butter, and fat, and thus constipation result which may become chronic. Repeated neglect of the call of nature is a frequent cause, such as in the case of young girls and children while at school, or among women at social gatherings, etc. Interruption of the habit of regularity, as on a railroad journey, or an attack of diarrhea with subsequent constipation, or of acute fever, may lead to habitual constipation. The same is true of mental condi- tions, such as depressing emotions. Prolonged exercise, such as long marches, has produced chronic constipation. Constipation is more frequently found among the wealthy than among the working class. The mode of living, sedentary life, etc., have a bear- ing. Worry and mental strain have an influence, and it occurs among neurasthenics and hypochondriacs. Habitual constipation is found in those engaged in active exercise and who are of strong constitution. In such persons the cause of this perversion of motor function is unknown, but it seems inherent to the patients that the bowels respond slowly to stimuli. In some cases there seems to be hereditary or congenital diminution of intestinal peristalsis (constipation). 1 Surgery, Gynecology, and Obstetrics, March, 1911. 6l2 DISEASES OF THE STOMACH AND INTESTINES Riegel observed cases in which at autopsy the musculature of the large intestine was abnormally thin and was probably congenital. In some of these cases the skeletal muscles were strong. Nothnagel described similar cases in which the general muscular development was poor. These rare conditions cannot be recognized intra mtam. Enteroptosis is given as a cause of chronic constipation on account of the intestinal angulation which occurs. This is true in some cases. The general atony 1 with enteroptosis is the chief factor. The musculature of the stomach, intestines, and also the abdominal muscles are relaxed, which have a bearing on the production of constipation. The abuse of cathartics, and repeated distention of the bowel from large enemata, may produce constipation. Spastic Constipation. Spasmodic constipation of the bowels, or enterospasm, is produced by a perversion of the motor function of the intestines, taking the form of a spasmodic contraction of a portion of the intestines, which may involve both the circular and longitudinal muscles. This spastic condition may be of variable duration and involve dif- ferent segments of the intestines. Fleiner holds that the contracted portion retains its contents, while others believe that it is nearly occluded by the spasm, thus creating an obstacle to the passage of the intestinal contents. Diffuse enterospasm involving the small intestine occurs in spinal meningitis, in diseases of the pons and medulla, and in chronic lead- poisoning. In these cases the abdomen is retracted like a trough. Local or circumscribed enterospasm is more frequent, and it gener- ally affects a portion of the large intestine. The abdomen shows no abnormality on inspection. Spastic constipation is more frequently met with in nervous persons, neurasthenics, the hysteric, and in those debilitated by long-continued disease. It may be one of the symptoms of vagotonia. The constipa- tion is quite obstinate, lasting for several days. The evacuation is somewhat painful and consists of small balls (goat feces), or pencil-shaped fecal material. There are spasmodic pains in the left lower abdomen or in the umbilical region which are relieved by the passages. Spasm of the Sphincter (Proctospasmus). This condition really be- longs to spastic constipation. There is painful spasmodic contraction of the sphincter. I have seen cases, however, in which pain was not marked, but spasm occurred when defecation was attempted; in effect, spasmodic stricture was present. Such cases may be a direct factor in the production of constipation. Many cases of sphincteric spasm are secondary to fissure or ulcer of the rectum, or are reflex when there are inflammatory conditions in the neighboring organs, such as the uterus, bladder, etc. Some cases occur as a primary nervous affection and are chiefly met with in those with a nervous taint or disease of the spinal cord. Rectal examination is often extremely painful. In some cases there is simply reflex spasm on examination, and the sphincter is found to be extremely tight and evidently hypertrophied from frequent contraction. 1 Rose and Kemp, Atonia Gastrica. CONSTIPATION AND DIARRHEA 613 It is important to consider the possibility of the last type in connection with chronic constipation. Symptoms. In many cases, constipation causes no subjective symp- toms. Some have a stool every second or third day or even once a week. There is a classical case who had an annual movement. Never- theless, chronic constipation should not be made light of. Constipation may be accompanied by one or more daily stools and even by diarrhea. In spite of a daily movement, there is a gradual accumulation of fecal material, and great relief is afforded by a cathartic. With fecal impaction there may be some escape of material around or through the mass, or the irritation causes some diarrhea at times. Boas describes a so-called "fragmentary constipation," in which condition there is a conscious feeling of feces accumulated in the rectum, but only occasional fragments escape with efforts. There may be a daily movement, but hard masses of foul odor, are evacuated. Some patients on the appearance of constipation immediately suffer from subjective symptoms, which may become at times quite severe. Among milder symptoms are sensations of fulness, tension, and discomfort in the abdomen; at times they are referred to the stomach; loss of appetite, occasionally belching, nausea, pyrosis, and a disagreeable taste in the mouth. Coated tongue and headache are often present. Colicky pains and distention may occur. Intestinal Sapremia. In cases of marked constipation severe symp- toms may occur, such as headache, apathy, a dry furred tongue, anorexia, prostration, abdominal pain, sustained elevation of temperature, palpable spleen, and even an eruption, so that typhoid may be suspected. The eruption is profuse and blotchy, macular and erythematous, and not likely to be mistaken for typhoid, roseola, or Brill's disease. Physical examina- tion will determine fecal accumulation. These symptoms disappear after thorough evacuation of the bowels. In cases of doubt, such as intestinal sapremia of a duration which is not definitely obtainable, it may be advisable to make the laboratory tests to differentiate from typhoid fever. On inspection and palpation considerable fecal accumulation can be found in the intestines, especially in the colon. Some patients suffer from severe headache, dizziness, sleeplessness, despondency, palpitation, tachycardia, or irregular pulse. Such symptoms I believe due to auto- intoxication from the intestinal tract. Motor insufficiency) as in consti- pation, favors stagnation and putrefactive changes. Duprey 1 reports extreme cases in which the patients become uncon- scious, but recovered after free bowel evacuation. One death also occurred. In most of my patients suffering from chronic constipation, with the symptoms just described, especially with nervous manifestations, marked indicanuria was present. Herter 2 states that most children and many adults may fail to develop 1 The Lancet, 1902, p. 1832. 2 Bacterial Infections of the Digestive Tract, p. 263. 6 14 DISEASES OF THE STOMACH AND INTESTINES indicanuria with constipation, yet there are others in whom it is marked, and that a satisfactory explanation is not possible. In my report of 13 cases of dementia paralytica before the American Medicopsychologic Association 1 marked constipation was noted in all the cases, and all suffered with considerable temperature. Rectal irriga- tion lowered the temperature in three cases, and under general treatment for the gastro-intestinal tract it was lowered in eight more. Convulsions diminished in five cases. The bowels were freely opened. Bouchard's theory, that no intoxication from the intestinal tract can take place when the feces are solid, I believe untenable. Dunin has shown that constipation may be the result of nervous conditions. There are many in which no nervous factor can be discovered, and others in whom constipation and intestinal auto-intoxication are factors in the production of nervous symptoms. Termination. The bowels may act spontaneously, hard masses of fecal matter being passed, covered with a thin layer of mucus. Feces are often passed in small balls, or in rod shape. With the atonic type of constipation relief is usually felt after defecation, while with the spastic type movement is accomplished with great effort, and there is a feeling as if there were still material in the rectum. In some cases the constipation terminates in an attack of diarrhea, due to hyperemia and the secretion of fluid from irritation of the mucosa by the hardened feces. In others, purgatives or enemata may be required, or removal of scybalae from the rectum by the fingers. Slight catarrh may occur or, rarely, stercoral ulcers, local peritonitis, or even perforation and general peritonitis. Constipation has been a factor in the production of typhlitis, diverticulitis, catarrh of the cecum with secondary catarrhal appendicitis, volvulus, and subacute or acute intestinal obstruction. Fecal Colic. When large masses of fecal matter accumulate colic may occur. The patient is seized with violent colicky pains which may cause a fainting spell. The abdomen is distended and tender. Passage of flatus brings temporary relief. Th& symptoms do not disappear until thorough evacuation of the fecal accumulation takes place. Fecal colic may occur, with daily evacuation of the bowels. The detection of fecal accumulation by palpation is of chief importance. In obstinate cases of constipation cathartics may fail to produce movements and the patient go into marked collapse and vomit profusely, with symptoms resembling intestinal obstruction. Rectal irrigations or oil injections may relieve the condition. Rarely, in the insane, old, or weak, total paralysis of the colon may take place and the patient die with the symptoms of obstruction. In cases of fecal accumulation, it is always safer to employ injections and irrigations before resorting to active catharsis. Fecal Tumors. They occur most frequently in the cecum, sigmoid flexure, rectum, and hepatic and splenic flexures. They may cause dis- location of the transverse colon, and the mass be felt a short distance above 1 Proceedings of the Sixty-first Annual Meeting, April, 1903. Some observations on the Relations of the Gastro-intestinal Tract to Nervous and Mental Diseases. CONSTIPATION AND DIARRHEA 615 the symphysis. In most cases the tumor is not of very firm consistency, is movable, and pits on pressure. On the other hand, it may be nodular, hard, or angular. In some cases the bowels may move every day, there evidently being a free central passage. Gersuny's Adhesion Symptom. If the abdominal wall over the tumoj is gradually depressed with the finger-tips, the pressure gradually dimin- ished and the fingers slowly withdrawn, one can feel the mucous coat of the intestines loosening itself from the feces forming the tumor (i.e., the wall of the bowel separates from the tumor when palpating pressure is relaxed). If under intestinal irrigations, etc., the tumor diminishes in size, it is evidently fecal. Anesthesia may rarely be required for examination. Some of these fecal tumors have developed into large size over 4 pounds or more and after the colon is dilated, stercoral ulcers, local or general peritonitis, or intestinal obstruction from kinking, compression, torsion, or internal occlusion may result. Hemorrhoids are a complication. They are described in a special section. I have referred to various nervous symptoms that are dependent on constipation. Leube describes intestinal vertigo, which he believes reflex and due to pressure on the hemorrhoidal plexuses of the sympathetic, since the palpating finger in the rectum also produced it. Senator imputed dizziness and vertigo to absorption of poisonous gases, such as sulphuretted hydrogen; while Nothnagel assumes that nervous symptoms are due to absorption of ptomains, thus causing auto- intoxication. Auto-intoxication I believe to be the correct explanation. In persons of a neuropathic disposition auto-intoxication (intestinal toxemia) from chronic constipation is undoubtedly a contributory factor in the produc- tion of nervous disease, especially melancholia. It is also evidenced by indicanuria. Fecal Fever. This is generally due to some complication, such as inflammation, local peritonitis, or stercoral ulcer. With infants and young children fever may be caused by fecal accumulation. I have referred to the cases of dementia paralytica with temperature, with disappearance of the latter after bowel action. Clark holds that chlorosis is the result of toxins absorbed from copro- stasis. Hyperchlorhydria is generally present and this would have an influence on the bowels. Though diarrhea with marked multiplication of the Bacillus aerogenes capsulatus often occurs in common with severe primary anemia, and in some instances the cases present the blood-picture and clinical character- istics of pernicious anemia, yet Herter shows that advanced infection with the gas bacillus can occur 1 without any diarrhea, in iscct, with obstinate constipation. Stasis is favorable to putrefaction. The possibility, there- fore, of stasis (constipation) favoring in some cases the development of poisons having a hemolytic action on the blood should be considered. 1 Bacterial Infections of the Digestive Tract, p. 207. 6l6 DISEASES OF THE STOMACH AND INTESTINES Diagnosis. The irregularity of the movements and their character, occurring in small balls, pencil shape, or in small fragments, and ab- dominal palpation, disclosing fecal masses, are diagnostic. One must remember that daily incomplete evacuations may occur. Fecal masses are found most frequently in the caput coli, sigmoid, and the rectum. It is always well to examine the latter. All possible causes of constipation must be considered. If it is suspected to be due to anomalies of the functions of the stomach, gastric analysis must be performed and treatment directed toward the gastric condition. Diseases of the heart, lung, liver, and kidneys must be treated if present. Rectal examination may disclose hypertrophy of Houston's valves; in such event, their division by the application of Gant's valve clamps is indicated. Hemorrhoids must be removed, also polypi if present, or tumors. If adhesions are a cause, they must be severed or released from the gut. Hernia if a factor must be operated upon. Prolapse of the sigmoid may be determined by inspection with the sigmoidoscope. 1 Gant's suspensory operation is then indicated. Splanch- noptosis if present must be treated and Rose's belt applied. Intestinal stasis due to Lane's kinks, adhesions, angulations, dilated duodenum, mov- able cecum and patent ileocecal valve will be described in a special chapter. If none of these causes can be determined, the constipation must be purely functional (habitual), either of the atonic or spastic type. With atony of the bowels there are slight bloating, evacuation of hard fecal matter, often in balls covered with a thin layer of mucus, at times dizziness and nervous symptoms. Severe pains are rare. With enterospasm there are uneasiness and pain at the time of evacua- tion or just preceding it, and at times spells of faintness. The fecal matter is not so hard and is evacuated after considerable straining in narrow, tape-like or pencil-shaped pieces. There is no feeling of complete relief after evacuation, but as if more were present. The abdomen may at times be sunken and retracted and the intestinal coils can sometimes be palpated. Prognosis. This is favorable in the majority of cases as regards life, though occasionally incurable lesions, such as diverticulitis, ulceration, or even peritonitis and death may result. These complications are comparatively rare. The prognosis as to cure depends on the cause of the constipation. In the functional cases of habitual constipation cures result, but many cases require more or less care for the balance of their lives. Treatment. General Methods. The cause of the constipation should be diagnosed and treated. This has been referred to under diagnosis. Having excluded all causes but the atonic or spastic types, they should receive treatment as follows: Persons who for years have habitually had a movement every second or third day and are in good health should be let alone. Prophylaxis. Never place a patient on a restricted diet for too long a period, excluding vegetables, fruits, starchy foods, and fats which would dispose to constipation. Abuse of cathartics should be avoided. 1 The #-rays will also determine prolapse of the sigmoid or other portions of the large intestine. CONSTIPATION AND DIARRHEA 617 A hygienic method of living, proper out-of-door life and exercise, diminution of strain and worry are necessary. As few purgatives as possible should be employed. Training of the Patient. One should allay the patient's anxiety. He should be told not to worry if the bowels fail to act for a day or two. Meanwhile, rational methods should be undertaken by the physician to produce the desired result. Trousseau first advocated teaching regularity. The patient should be taught to endeavor to have an evacuation at a regular time every day, preferably half an hour after breakfast. He should go to the closet and try to have a passage, but should not exert himself for over five minutes. It is an excellent procedure to aid the return to the habit, by insertion of a small gluten or glycerin suppository or, pref- erably, the injection of i to 2 ounces (30.0-60.0) of olive oil with a soft- rubber hand syringe. This is better than waiting twenty-four hours, as the desire is often thus stimulated. Regular habits could thus often be cultivated and the small injection then stopped. Diet. The main object is the ingestion of foods which increase intestinal peristalsis and the avoidance of constipating material. A glass of cold water, or, in some cases, of hot water, should be taken on rising. Water should be taken on the fasting stomach and a moderate amount 8 to 10 ounces (250-310 c.c.) at least of fluid at meals. Total abstinence from liquid at meals tends to constipate. The following are of value, buttermilk, cider, sour milks, fermented milk, such as lactone- milk, koumiss, matzoon, bacillac, f ermillac, carbonated waters ; raw fruits, such as grapes, oranges, grape-fruit, apples, figs, prunes, cranberries, pears, peaches, plums, mandarins, gooseberries, currents, strawberries, rasp- berries, blackberries; cooked fruits, jams, treacle, honey, lemonade; vege- tables rich in cellulose, cabbage, cucumbers, spinach, green peas, Brussels sprouts, cauliflower, green salads, turnip tops, Spanish onions, carrots, asparagus; syrup, sugar; salmon, sardines, herring; rye bread, 1 Graham bread, pumper-nickel; fatty and highly seasoned foods, plenty of butter, cream, and fat cheese. Excess of potatoes or rice constipate. Oatmeal is often of value. Milk is constipating with some and purgative with others. Whortleberries are constipating. Red wines, tea, chocolate, and cocoa should be avoided. Beer and champagne are recommended by some. Chicken and red meats are given in moderation. We may say the diet should be mixed, with a preponderance of vege- table food. Some patients, of course, have idiosyncrasies to certain foods, and one would not give a patient, with a delicate stomach, cabbage, cider, and brown bread. If the intestines are already overburdened with too much ballast and excess of cellulose has been given, such articles must be restricted. The internal administration of olive oil, i to 2 ounces (30.0-60.0) or more, has often an excellent effect; to be given once or thrice daily. If fermentative or putrefactive processes are present, they must receive attention. In very obese patients, one would not give excessively fattening food. Often a few prunes with the morning glass of water and fruit for breakfast 1 Whole wheat bread and bran biscuits are of value. 6l8 DISEASES OF THE STOMACH AND INTESTINES are serviceable. The administration of a raw apple thoroughly masti- cated at 9 P. M. and an hour later a large glass of Vichy, I have often found valuable, a morning movement resulting. As a sample diet one may give as follows: Breakfast. Oatmeal with cream or porridge with syrup, fat bacon, rye bread with plenty of butter, marmalade or honey, coffee with cream, water 8 ounces (250 c.c.) grape-fruit or oranges. Grape nuts, which are twice baked and contain whole wheat, are a cheap cereal and are of some value to aid bowel action. Lunch. Fish, potatoes (very little), green vegetables, salad with plenty of oil, stewed apples or figs, wholemeal bread, butter, fruit, water, or lemonade. Dinner. Tomato or some vegetable soup, meat, spinach, string-beans, asparagus, salad with oil, dry toast or biscuit with plenty of butter, apple charlotte, stewed pears or prunes, cheese, uncooked fruits, water or lemonade. Whole wheat biscuit which contain phytin (a laxative); bran biscuit Fig. 283. Cannon-ball with screw cap. Fig. 284. Cannon-ball with handle. (well dried), the bran having a mechanical effect, and the whole wheat ingredients containing phytin, are an excellent addition to the dietary. Physical Methods. These are useful to strengthen the bowel and promote better action or to directly stimulate peristalsis. Massage. This is of use in the atonic cases, but not as much so in spastic constipation. It should, preferably, be administered by an expert and the treatment carried out for many months. Abdominal massage should be carried out in the course of the colon by short tapping motions (vibratory), or by kneading and rubbing. It is preferable to massage from the caput coli to the sigmoid. The small intestine should also be manipulated as well as the abdominal muscles. Illoway, 1 recommends massage for five to fifteen minutes in adults and three to five minutes for children, at least every other day, for a period of six weeks, and then, if there is improvement, at longer intervals, 1 Constipation in Adults and Children. CONSTIPATION AND DIARRHEA 6lQ but for a long period of time. It should be given preferably early in the morning in the fasting condition. Automassage. The patient sitting upright with the right hand should stroke the abdomen from the caput coli to the hepatic flexure, and then along the transverse colon. With the left hand he can then massage down the descending colon. Circular stroking movements should then be made over the median abdominal region. I often have the patient follow this out while endeavoring to have the morning defecation. Seances should last about five to ten minutes. Cannon-ball Massage. A 3- to 5-pound cannon-ball rolled over the abdomen in the course of the colon and small intestine spirally is of value. The patient can employ this in the dorsal position. The hollow wooden cannon-ball with a screw-cap, arranged so that shot can be placed therein*, and thus different weights employed with the same ball, is an excellent instrument (Fig. 283). It is arranged with a handle and frame so that it can be more easily manipulated (Fig. 284). One should begin with a weight of 2 pounds and increase it gradually to 5 pounds. Vibratory Massage. This is of great value. Special vibration should be given over the sigmoid flexure. The Vedee vibrator can be used alone or with electricity, or the Eureka or any good electric vibrator can be attached to the street current. Seances should last about ten to fifteen minutes in the course of the colon and over the small intestine. Hot and Cold Massage Electric Roller. This instrument has been described and can be employed for the atonic cases. Gymnastic Exercises. Exercises which bring the abdominal muscles into play are of value, such as gymnastics on the horizontal bar, horse- back riding, hill climbing, skating, rowing, bicycling, golf, tennis, boxing, fencing. Overexertion and too abundant sweating should be avoided. Flexion and extension of the body and lateral rotation while in the sitting posture; bending downward and then upward in the standing position with the knees held stiff; attempting to touch the floor about 25 to 50 times morning and night; lying on the back and raising the legs one after another with the knee stiff and the thigh at right angles to the body, Swedish movements and treatment by the Zander methods are all of value. Electricity. Percutaneous electricity, especially faradization over the abdomen, is useful as an adjunct. The intrarectal method (one electrode in the rectum and the other over the abdomen) is recommended, especially galvanization. The author's method with recurrent electric irrigation is practical. With a glass Y attachment and two fountain syringes, alternate hot and cold electric douches can be employed for the atonic condition. I have used both the faradic and galvanic current. In obstinate cases of high im- paction I have found hot normal saline douches at i2oF. with the faradic current most efficacious, duration fifteen to thirty minutes. Kussmaul has suggested one electrode in the stomach and the other in the rectum. Electricity is indicated in the atonic cases. Static electricity is also 620 DISEASES OF THE STOMACH AND INTESTINES recommended. Doumer 1 has employed it in the form of sparks, especially in the left iliac fossa. Hydrotherapy. Frictions, cold douches, the alternating cold and warm fan douches, Scotch douches, short cold sitz-baths (five minutes at i2C.), the wet binder (Neptune's girdle) applied over night, and the Priessnitz compress are all recommended. Hydrotherapy must needs be conducted at a sanatorium. For practical purposes the sitz-bath and wet abdominal compress suffice the general practitioner. Injections; Enteroclysis. Recurrent enteroclysis with hot normal saline solution at 110 to i2oF. for fifteen minutes three times a week, alone or combined with electricity (rectal method) or with the alternating cold douche at 6oF., may prove of service in the very obstinate cases. Enteroclysis with flaxseed tea has also proved valuable. The soapsuds and water enema alone i pint to i^ quarts (500- 1500 c.c.) or with live oil, 8 ounces. (250 c.c.), or castor oil, i to 2 ounces (30.0-60.0), included, or normal salt solution alone, may be required, depending on the conditions. A high enema of olive oil, 8 ounces (250 c.c.), combined with glycerin, 4 ounces (125 c.c.), is often useful. Alum Si-jii to the pint of hot water, a quart enema is efficacious in some obstinate cases. Often a small enema of normal saline or soapsuds and water of i pint (500 c.c.), if given with the patient in the knee-chest position is more efficacious than the larger injections. The water injections may be employed at the same hour daily for a considerable time. The large injections, as recommended by some, overdistend the already atonic intestines. The Sims' position is excellent for the injection. Klemperer 2 recommends the injection into the bowel of small quantities of water at bedtime only y% pint (250 c.c.) and the patient is told to retain the fluid. It is soon absorbed and evacuation occurs the follow- ing morning. These injections are given every night for three weeks, and then every other night. Kussmaul and Fleiner employ an injection of sweet oil into the rectum at bedtime, which is to be retained. I believe it advisable to start with a small quantity, only 4 to 6 ounces (125.0-200.0), heated to the tempera- ture of the body and slowly injected through a colon-tube from a fountain syringe. The patient should retain the oil as long as possible (over night if he can). Gradually increase the quantity to 8 ounces to i pint (250- 500 c.c.), and in obstinate cases nearly to i quart (liter). As a rule, evacuation follows the next morning. I give the injection every night for a week, then every other night for several weeks, then twice a week, and, finally, once a week. The treatment should cover several months. This method is recommended especially for the spastic type of constipation, but I have found it of value in other cases. Aromatic liquid albolene a refined Russian petroleum is also useful but is more expensive. Olive oil, i to 2 ounces (30.0-60.0), by mouth once to three times a 1 Annales d'Electro-Biologie, 1898, p. 722. 2 Therapie der Gegenwart, 1899, p. 48. CONSTIPATION AND DIARRHEA 621 day is a valuable adjunct. Cottonseed oil can be substituted by enema for olive oil, it is much cheaper. Glycerin Injections. Glycerin, i to 2 drams (4.0-8.0), dissolved in 3 ounces (95.0) of water and injected into the rectum is of service in some cases, or given as a suppository. It is sometimes irritating. Flatau 1 inserts or insufflates into the rectum 15 to 45 grains (1.0-3.0) of boric acid powder. Bowel action results one-half to three hours later. Orthopedics. I have found Rose's belt of value in chronic atonic constipation, even if no ptosis is present. It lends strength to the abdominal muscles and so aids evacuation. Medication. In many cases of constipation mild laxatives must be employed, sometimes only temporarily. More powerful cathartics are often required. In constipation of the spastic form due to vagotonia and in the atonic type with fecal impaction, belladonna is of great value. It should be given preferably as atropin gr. Koo to gr. %o t.i.d., or tinct. belladonna gtts. x-xv t.i.d. The writer finds olive oil from 5i to ss, floated on a little water, and taken in association with a pinch of salt, three times daily after meals an excellent adjunct. This seems to eliminate the taste of sweet oil, to which some object; Russian mineral oil one tablespoon (5ss) A. M. and p. M. is of service. Aromatic liquid albolene, a highly refined Russian petroleum, American mineral oil, or even white vaselin can be substituted in doses of 5* to 5 SS t.i.d. The author generally starts the treatment with laxatives, training the patient as to regular habits, exercise, auto-massage, agar-agar at meals Russian oil A. M. and p. M., or olive oil after meals in addition. Occa- sionally the tincture of belladonna may be used in large doses, 10 to 15 minims (0.592-0.888 c.c.), and pushed three or four times a day, so that physiologic symptoms are apparent. In constipation due to atony, strychnin, %o to ^ grain (0.00108-0.0021) t.i.d., or tincture of nux vomica in 5- to jo-drop doses are of value, even if no laxatives are given. They are often combined with a laxative. Among the milder laxatives are fluidextract of cascara sagrada and the aromatic fluidextract of cascara, of which the dose is i to 2 drams (4.0-8.0); extract of cascara, i to 5 grains (0.065-0.0324); laxophen, a solution of phenolphthalein, i to 4 drams (4.0-16.0); phenolphthalein (purgen), 2 i to 5 grains (0.065-0.324) to 15 grains (i.o); phenolax (i to 3 wafers); phenolphthalein may be given in capsules i to 5 grains each at bed -time or even t.i.d.; purgatin, 15 to 30 grains (1.0-2.0), which last is contraindicated in renal disease. Ad. Schmidt 3 claims that the internal administration of agar-agar, cutting up the straws into small fragments and administering as much as 25.0 grams a day, aids in softening the feces and also evacuation. He adds to it 25 per cent, of an aqueous extract of cascara sagrada. Schmidt recommends this combination, which is dispensed as "Regulin," as being of value in chronic constipation. Dose, i teaspoonful (4.0) to a table- 1 Berlin, klin. Wochenschr., 1891, p. 231. 2 Purgen tablets (Bayer), each tablet contains ij.<> grains (o.i) of phenolphthalein; each phenolax wafer contains i gr. of the same. 8 Miinchener med. Wochenschr., No. 41, 1903. 622 DISEASES OF THE STOMACH AND INTESTINES spoonful (16.0) or more, mixed with stewed apples or mashed potatoes. It can be secured as tablets. Agar-agar may be employed alone. The writer believes regulin to be of considerable value. It can be given t.i.d. if required. One to three or four tablespoons of wheat bran in a glass of cold water once or twice after meals is at times of service. Syrup of tamarinds, i dram (4.0), or a sauce of tamarinds; syrup of figs, i to 2 drams (4.0-8.0); compound licorice powder, i to 4 drams (4.0-16.0). This last gripes some patients. Olive oil by mouth, i to 2 ounces (30.0-60.0), several times a day is valuable. Aloes does not lose its effect even when employed for a long time, and painless defecation results. It may be used alone or in combination. If hemorrhoids are present I do not advise it. Rhubarb is an excellent drug. Pilula aloes, dose, i to 2 pills at night. Tincture rhei aromatici, } to i dram (2.0-4.0). Tincture rhei, i to 2 drams (4.0-8.0). The following are of value: 1$. Tinct. nucis vomicae 5iss 6 Fl. ext. cascara 5ss 16 Pulv. ipecac gr. iv 26 Pulv. rhei gr. xv i Sod. bicarb 3 iss 6 Aq. menth. piperit q. s. 5iv 125 M. Sig. Shake. One or two teaspoonfuls (4.0-8.0) three times a day in water after meals as a mild laxative. IV Pulv. rhei 1 Magnes. usta } aa 3iv (16.0). M. Sod. bicarb. J Sig. One-half teaspoonful (2.0) three times a day after meals. fy Pulv. aloes gr. xx 1 13 Ext. balladonna Ext. nucis vomicae | " ' . . . aa gr. v | 3 .-M. Ft. pil. No. xx. Sig. One to two pills at night. Podophyllin combinations are quite useful. IV Podophyllin Ext. physostigmatis | , aa gr. v [3. M. Ext. nucis vomicae J Ft. pil. No. xxx. Sig. One pill at night and in the morning if required. R. Pil. colocynthi comp. ] } aa gr. j (0.065). Pil. rhei comp. Ext. hyoscyam gr. ss (0.032). M. One pill. Sig. One pill before dinner. I*. Aloin gr. H (0.013) Strychnin sulph gr. }/Q (0.00108) Ext. belladonna gr. J (0.008) Pulv. ipecac gr. ^g (0.004). M. One pill. Sig. One to two pills at bedtime. CONSTIPATION AND DIARRHEA 623 1$. Resinae podophyllin gr. ^ (o.on) Pil. rhei comp gr. iiss (0.162) Ext. hyoscyam gr. ^ (0.032). M. One pill. Sig. One to two pills at night. If. Ext. colocynth comp gr. j (0.065) Ext. jalap gr. % (0.032) Resin podophyllin gr. Y (0.016) Leptandra gr. % (0.32) Ext. hyoscyami 1 aa gr. H (0.016) Ext. taraxaci j Ol. menth. pepmt q. s. M. One pill. Sig. One to two pills at bedtime. .aa gr. Ho If. Aloes Resin of jalap Resin of scammony Turpeth root Extract of belladonna Extract of hyoscyamus Almond soap q. s. M. Ft. pil. No. i. Sig. One to two pills on retiring. An excellent combination of saline laxatives is If. Sodium sulphate 3j Magnesium sulphate 3 j- M. Sig. Dissolve in a half glass of lukewarm water, add a quarter of a glass of seltzer water, and drink at once. Compound jalap powder, 30 grains (2.0), with calomel, 5 grains (0.6), is a good combination. Jalap and colocynth belong to the stronger remedies, and I only em- ploy them temporarily to empty the bowels. The same is true of castor oil and calomel. Hunyadi, Friederickshall, the Homburg Waters, Carlsbad salts, Pluto, Apenta, Rubinat, Congress, etc., may be necessary for a brief period, but should not be used for any length of time. In anemic patients with constipation the following pills are of service: If. Pill (Blaud's iron) gr. v. (0.324) Aloin gr. 3^o (0.032). M. One pill. Sig. One to two pills three times a day after meals, or If. Blaud's iron pill gr. x (0.6) Pulv. capsici. gr. Y (0.016) Aloini. Strychnin sulph. \ aa gr. }^0 (0.0022). M. Acid, arseniosi J One pill. Sig. One pill three times a day after meals. Fecal Colic, Fecal Tumor. It is an error to at once administer large doses of cathartics, and in some cases positive harm may result. The rectum should first be examined, and all material found therein removed 624 DISEASES OF THE STOMACH AND INTESTINES by the finger and then by enemata. High injections of soapsuds and water, in all, 1500 c.c., containing olive oil 8 ounces to i pint (250-500 c.c.), should be given, in some cases in the knee-chest posture, in order to soften and remove accumulation. Frequent injections and irrigations should be given to start movement for the first twenty-four to forty-eight hours. Ox-gall, i to 3 drams (4.0-12.0), with glycerin, 2 to 4 ounces (60.0-125.0), added to the enema, are of value. Olive oil, 2 to 6 ounces (60.0-200 c.c.), can be given by mouth, if neces- sary, t.i.d. to soften the dejecta. Later, castor oil, laxol (a tasteless castor oil), calomel, or compound jalap by mouth, and saline cathartics, or eserin gr. Koo-Mo- Frequent irrigations, in some cases with electricity, can be added to the treatment. Large doses of tincture of belladonna and strychnin may later be of service. In some cases it takes several weeks for an old accumulation to be completely removed. With marked impaction in- jection of olive oil i pint, or Russian oil 1 through the duodenal tube may be of value. Vomiting is then avoided and large amounts can be given. Spasm of the Sphincter. This should always be examined for, especially in cases of spastic constipation. Gradual dilatation, or, preferably, rapid dilatation under an anesthetic, are curative. Local disease should be treated. DIARRHEA Clinically, diarrhea may be defined as abnormal rapidity of intestinal peristalsis, accompanied by frequent evacuations of , the bowel contents, which are too liquid, or are watery in character. Some patients normally pass solid dejecta several times a day, but this is not diarrhea; yet a single solid movement may possess pathologic significance. Diarrheal stools are caused by the excess of water in the feces, and may be due to the liquid contents of the small intestine being so rapidly hurried into the colon that little absorption is able to occur in the small intestine. Free transudation of water from the blood-vessels or the glands may be a factor. Rapid peristalsis in both the small and large intestines, or in the latter alone, is another cause. At times increased peristalsis is the only factor, and there are no chemic or physical changes in the bowel contents and no structural changes in the wall of the gut. Increased peristalsis usually involves the large intestine as well as the small. Pathologic increase of intestinal peristalsis may be produced in numer- ous ways. In the majority of cases it is caused by intestinal diseases in which anatomic changes are present, as in intestinal catarrh, ulcers, typhoid, etc. It may be present without any apparent anatomic lesions, as a result of irritants in the contents of the bowel; or when the contents are normal, but the irritability of the nerves of the intestinal wall is in- creased; or when the muscular coats of the intestines are stimulated by an irritant circulating in the blood, or affecting the central nervous system. 'Russian oil, or American mineral oil, 5i-3iii, can be given through the duodenal tube, as noted above. CONSTIPATION AND DIARRHEA 625 Frequently there are several factors. The appearance of the evacua- tion, both macroscopic and microscopic, in diarrhea vary according to the etiology of the disease and the anatomic changes in the gut, when such are present. In every diarrhea it is important to know whether it is produced by abnormal transudation or exudation, with increased peristalsis of the large intestine; or whether, in addition, the peristalsis of the small intestine is increased. In the last event large quantities of unchanged digestive fluids and undigested food remnants are evacuated, and nutrition is markedly impaired. Bile-pigment reaction in the feces shows involvement of the small intestine. We may classify two forms of diarrhea: First, with intestinal lesions; second, diarrhea without lesions. The first group is described in the appropriate sections. The second group, with no intestinal lesions, is classified as follows: 1. Diarrhea due to irritation from the bowel contents. Diarrhea dyspeptica, Diarrhea gastrica, Diarrhea stercoralis, and Diarrhea entozoica are subdivisions. 2. Diarrhea due to irritants transmitted in the blood, such as the uremic type. 3. Diarrhea nervosa (nervous diarrhea), due to irritation of the nervous system. 4. Diarrhea Catharlica. This type belongs in a class by itself. It is thus referred to by Nothnagel, and merely mentioned in passing. Colo- cynth and aloin in excess may also produce the condition. The majority of purgatives stimulate the peristaltic action of the entire intestinal tract. The peristaltic action of the large intestine is chiefly affected, as by the aromatic laxative drugs. The movements in this case are thin and liquid, since increased peristalsis interferes with the absorption of the ingesta and intestinal secretions. With the alkaline laxative salts the action is not only to increase peri- stalsis, but they withdraw the water from the blood and stimulate the intestinal secretions. The prolonged use of drastic purgatives or excess- ively large doses produce an acute catarrh of the intestines. Diarrhea Due to Irritation of the Bowel Contents Diarrhea Dyspeptica. Certain articles of diet may produce diarrheal evacuations, such as fresh fruit, cucumbers, pickles, cabbage, turnips, beets, etc. Patients vary as to susceptibility. Milk produces diarrhea in some, while others it constipates. Excess of food or too great ingestion of water or beer with the food may prevent gastric digestion. The ingesta entering the intestines unchanged may cause diarrhea. Intestinal fermentation or putrefaction, spoiled food, and auto-in- toxication may produce diarrhea. With the last the diarrhea is due to more than the mere local irritation. In neglected or severe cases of pure dyspeptic diarrhea, long-continued irritation may give rise to true catarrh. Diarrhea Gastrica. Einhorn and Oppler first called attention to diarrhea resulting from disturbances of the stomach functions. 40 626 DISEASES OF THE STOMACH AND INTESTINES Hypochlorhydria and achylia gastrica are the most frequent causes of this type of diarrhea; more rarely hyperchlorhydria or motor insuf- ficiency. With hypochlorhydria or achylia, diarrhea with intestinal symptoms, such as flatulence, borborygmi, and colicky pains, may pre- dominate. The stools are often quite undigested. These cases, if prolonged, may develop intestinal catarrh. Diarrhea Stercoralis. Diarrhea with constipation. If constipation occurs in a person whose bowels usually are regular, diarrhea may follow the attack of constipation. The diarrhea is accompanied by colicky pains, bloating, and by the development of more or less offensive gases, such as sulphuretted hydrogen, etc. It is believed that the diarrhea is caused by the development of these gases in the intestinal contents, as a result of stagnation of the fecal matter. Hardened fecal matter may irritate the mucosa and produce secretion and peristalsis. With stercoral diarrhea, the passages are at first formed, then mushy, and finally liquid. Scybalae may be found in the dejecta. The passage of flatus affords temporary relief. Thorough evacuation of the bowels relieves all the symptoms. Neglected cases may cause intestinal catarrh. Diarrhea Entozoica. Intestinal parasites, the tapeworm, for ex- ample, may in some cases cause persistent diarrhea. Like other types of diarrhea, there are probably at first no changes in the mucosa, but long- continued irritation will produce catarrh. Diarrhea Due to Irritants Transmitted in the Blood Diarrhea due to the hypodermic injection of certain drugs belongs to this class. The diarrheas of septicemia, nephritis, diabetes, cholera, malaria, etc., are explainable by this theory. Diarrhea Nervosa (Nervous Diarrhea) This type depends on nervous disturbances, without any morbid changes in the walls of the intestines. Trousseau first described nervous diarrhea. No impairment of digestive functions is present. It originates either from excessive stimulation of the nerves governing peristalsis (the motor function) or from the transudation of serous material into the intestinal canal (secretory function), produced by nervous influences. In some cases probably both factors are concerned. The stimulus may arise from the nerve-centers and be transmitted through the fibers of the vagus, sympathetic, or splanchnic nerves to the intestinal ganglia. As an example of nervous diarrhea, numerous watery evacuations may occur as the result of some emotion, such as fright or shock, in which cases the stimulus arises in the brain centers. These are more especially acute transitory attacks. Nothnagel and Peyer 1 report instances of chronic nervous diarrhea: thus, some persons will be attacked with gurgling, abdominal pain, tenes- 1 Wiener Klinik, 1893, Heft i. CONSTIPATION AND DIARRHEA 627 mus, and diarrhea as soon as they find they can secure no access to a water-closet; while with others the sight of the toilet produces diarrhea. Some patients may have attacks at definite hours, without any relation to surrounding conditions. In others, nervous symptoms precede the diarrhea, such as vertigo, stupor, giddiness, congestion of the head, reddening of the face, hot flushes over the body, fear, oppression, palpitation, rapid breathing, etc. These symptoms often disappear after a few diarrhea! movements. The number of stools varies; these may be from two to four, or even to fifteen, consisting of thin liquid contents, with mucus rarely present. At times the first movement is solid, the next mushy, and the subsequent movements liquid. Occasionally peristaltic unrest, borborygmi, and severe tenesmus may accompany the movements. This form of diarrhea is found as a symptom in hysteria or neurasthenia, in the nervous and debilitated, and even in healthy persons after a nervous shock. With Graves' disease and migraine this type may occasionally occur. Charcot 1 describes attacks with tabes (intestinal crisis). Peyer speaks of a reflex form of nervous diarrhea found in consequence of abnormal processes in the genito-urinary tract; for example, in uterine catarrh, emissions, spermatorrhea, and sexual excess. Fischl cites a case of diarrhea which persisted for several years and resisted all treatment. Replacement of a reflexed uterus cured the case. Vicarious diarrhea in pregnant women of the neuropathic type has been described by Condio. The diarrhea takes the place of vomiting. Nervous diarrhea has also been attributed to excessive smoking. Diarrhea from Exposure to Cold and Wet This occurs after a sudden or severe chill from exposure to cold, or wetting of the surface of the body, especially the feet or abdomen. Probably it is due to reflex irritation, transmitted from the cutaneous nerves. Accelerated peristalsis of the intestines occurs, whether due to reflex stimulation or secondary to hyperemia, it is uncertain. This type of diarrhea is usually transitory. At times it may assume the character of true intestinal catarrh. Treatment of Diarrhea The method of treatment depends on the cause. In the cases with anatomic lesions in the intestines, regulation of the diet and medication appropriate to each special type should be carried out. These methods are described under their special sections, such as under Intestinal Catarrh, Dysentery, etc. With diarrhea due to a laxative, heat to the abdomen and opium are indicated. Pilulae opii, i grain (0.065), three or four times a day, or one of the other opium preparations, or, 1 Prager med. Wochenschr., 1891. 628 DISEASES OF THE STOMACH AND INTESTINES fc. Tinct. opii Bismuth subnit ............. ................ 3" Mist, cretae ............................ q. s. 5 i Sig. Shake. Two teaspoonfuls (8.0) four times a day. 10 12 i2 5 . M. With dyspeptic and stercoral diarrheas thorough removal of the sources of irritation are indicated, such as the use of calomel or blue mass, 5 grains (0.3), castor oil or laxol, ij^ ounces (45.0), or a saline cathartic, such as magnesium sulphate, ^ to i ounce (15-30 grams), or Sprudel salts, apenta, etc. Intestinal irrigation is indicated in these types. For intestinal parasites an appropriate remedy and a cathartic should be administered. For Diarrhea Gastrica. Treatment should be given for the existing condition in the stomach; for hypochlorhydria, stomachics, dilute hydrochloric acid, intragastric faradization, etc. For achylia gastrica, chiefly vegetable food, finely divided, and the methods employed for this condition. For hyperchlorhydria, a rare cause, diet and the alkalis, etc., are indicated. For Diarrhea Due to Irritants Transmitted in the Blood.-^-The cause should receive treatment, thus, nephritis, malaria, etc. The general condition should be improved. Heat locally to the abdomen, liquid diet, rest in bed, the bismuth and astringent preparations, stfch as bismuth subnitrate, 30 grains (3.0) t.i.d., bismuth salicylate, 10 grains (0.6) t.i.d., or bismuth subgallate, 10 grains (0.6) four times a day; or tannalbin, tannigen, or tannopin, or tanocol, 10 grains (0.6) each, three or four times a day. Opium preparations may be required, but they should be used with caution. Nervous Diarrhea. If this depends on reflex action, such as from uterine disturbance, etc., the primary affection must be treated. In other cases, the general -condition of the patient must be built up. Neurasthenic and hysteric conditions must receive special treatment. Constipating food may be administered. Iron preparations, such as iron tropon, i to 2 drams (4.0-8.0), t.i.d.; or Fowler's solution of arsenic, 5 minims (0.296 c.c.), or smaller doses t.i.d.; or sodium arsenate, J^o to Y^ grain (0.0013-0.0026), are of value as tonics. fy Blaud's iron pill gr. v (0.6) Sodium arsenate gr. Jo (0.0013). M. One pill. Make 30 such pills soft with honey and silver coat. Sig. One three times a day after meals. The bromids of sodium, ammonium, or potassium, or Dromid of strontium, given for a few weeks, 15 to 30 grains (1.0-2.0) t.i.d., lessen irritability. The glycerophosphates are useful. Bismuth subnitrate or salicylate, in dosage already given, silver nitrate, % to y grain (0.008-0.016) t.i.d., and the astringents noted above are useful. Heat should be applied. Opium and its derivatives are generally recommended for this, as well as other types of diarrhea, and are preferable to morphin. The general tendency to at once prescribe opiates in all diarrheas, is CONSTIPATION AND DIARRHEA 629 to be deplored, especially in the nervous type, as the habit is readily gained. If other remedies fail, they may be used with caution. The following (Wm. H. Thomson) is a useful combination for such purposes. The dosage is small : ]}. Pulv. opii \ Silver nitrate / ...... aa gr. v (0.3) Resin of turpentine 5ij (8.0) Liquor potass 3j v4-o) Pulv. licorice q. s. to make pills soft. M. Divide in pil. No. Ix. Sig. Two or three pills three times a day. H. Tinct opii camphor \ Bismuth submt. Mist, cretae q. s. 5* v (125 c.c.). M. Shake. Sig. Two teaspoonfuls in water every two or three hours. Ifc. Tinct. opii 5iij (12.0) Tinct. catechu comp . 5ss (16.0) Aq. destil q. s. ad. fiiv (125 c.c.). M. Shake. Sig. Two teaspoonfuls in water every three hours. Opium pills or other combinations can be employed. For nervous diarrhea the intestines should be trained in the normal direction. Suggestion by the physician is of value. The patient should be instructed that after his morning evacuation he should refrain from other movements except when absolutely necessary. Often he can thus control the desire. CHAPTER XXIV CHRONIC INTESTINAL STASIS (Lane's Kinks. Dilatation of the Duodenum. Jackson's Membrane. Movable Cecum. Incompetent Ileocecal Valve. Angulations and Adhesions. Dilated Sigmoid) Chronic intestinal stasis is our old friend " chronic constipation" with a new name, of which the causes are manifold. Lane and his followers consider mechanical conditions, special kinks (angulations) as the chief factors in the production of intestinal stasis and that certain evolutionary membranes developing on the peritoneum reflected from the large and particidarly from the small intestines, have a decided influence in the pro- duction of kinks and resulting stasis. It is interesting to note that Glenard many years ago called to our attention that kinks or angulations, of the transverse colon particularly, result from enteroptosis, and interference with passage of the intestinal contents ensues. He furthermore specifically refers to similar angulations which may occur with splanchnoptosis, at the gastroduodenal, duodeno- jejunal and sigmoido-rectal curves all interfering with the passage of con- tents by enterostenosis and he was the first to realize that many cases of so-called nervous dyspepsia were dependent on these abnormalities. These features are referred to under " Glenard's Disease." Lane describes numerous kinks, some of which correspond to the above. He defines 1 chronic intestinal stasis as "a delay in the passage of the contents of the intestinal canal, of sufficient length as to result in the production in the small intestine especially, of an excess of toxic material, and in the absorp- tion into the circulation of a greater quantity of poisonous products than the organs which convert and excrete them, are able to deal with. In consequence there exist in the circulation materials which produce degen- erative changes in every single tissue of the body and lower its resisting power to invasion by deleterious organisms." Lane refers later to the symptoms occurring from the "auto-intoxication" of chronic intestinal stasis. This term, "auto-intoxication," is a misnomer, as direct bacterial infection, subinfection, or chronic intestinal putrefaction might respect- ively be responsible for the various symptoms. In the above definition of Lane, particular stress is placed on the stasis in the small intestines and resulting absorption of toxic material. The contents of the small intestines are liquid and marked narrowing, or angulation, is necessary to interfere with their passage. Moreover the motility of the small intestine is rapid, which makes stasis from an angu- lation still less easy to occur. Reversely in the large intestine, motility is slow, the contents are solid, and stasis from an angulation or adhesions easily results. Study of the radiographs of Glenard's disease confirms 1 Brit. Med. Jour., Nov. i, 1913. 630 CHRONIC INTESTINAL STASIS 63! this view. The motility of the stomach is often excellent, though depend- ent somewhat on the degree of the descent of the duodenum and the type (shape) of the stomach. On the other hand, in spite of the marked enteroptosis of the small intestines, their motility is usually found to be excellent. Nature is a wonderful " compensator." When stasis occurs, it is usually found in the large intestine, where the angulations have a marked influence in retarding the movements. Of course there are ex- ceptions and we know enteroptosis is present with Lane's kinks. About one- third of my gastro-intestinal cases have splanchnoptosis, yet I find few iliac, or gastroduodenal, or duodeno-jejunal kinks. Many, however, have angulations of the colon and some of them adhesions, with stasis. I advise operation on rare occasions, as medical treatment usually results favorably. Moreover, some individuals normally have bowel action every second or third day and yet no symptoms result, while other adipose in- dividuals taking no exercise, yet with daily bowel action may suffer from indicanuria with nervous symptoms, resulting from faulty metabolism and improper diet. Etiology. Lane holds that an unsuitable diet in infancy, and the habitual assumption of the erect position result in delay of fecal material in the large intestine. Consequently new membranes, or folds, or "re- sistances to downward displacement," are formed by the " chrystallization of lines of force upon the surface of the peritoneum along which strain is specially exerted." Others believe these membranes or folds are congenital (of fetal devel- opment); or that they are more likely to result from infection from bac- teria, or their toxins, emanating from the intestinal canal. Lane's kinks and membranes are as follows: the "first and last kink," the first to form and the lowest in the bowel, is a membrane fixing the large bowel on the left side to the pelvic brim. It may attach itself to the left ovary rendering it cystic and producing a tumor. The stenosed region in the intestine may become the seat of cancer. Evolutionary membranes are developed on the surface of the peritoneum which is reflected from the cecum, ascending and descending colon. They are exaggerated at the splenic and hepatic flexures. Membranes also develop between the trans- verse prolapsed colon and the adjacent ascending and descending colon. There are angulations (or kinks) in the locations described. The appendix may be anchored by an acquired membrane passing upward and outward from the cecum and thus become kinked or obstructed and "appendicitis" result from inflammation. Obstruction in any part of the intestine may result in inflammation or cancer. Kinking of the sigmoid loop from evolu- tionary bands may also occur. Accumulation of material in a large pro- lapsed cecum may cause delay in evacuation of the ileum and accumula- tion in the small intestines. As a result of traction, a thickening (developmental membrane) forms on the undersurface of the mesentery partially obstructing the lumen of the ileum. This "ileal kink" upon which great stress is placed by Lane, develops about 2 inches from the termination of the ileum. Fixation of the appendix to the undersurface of the iliac mesentery by acquired adhesions (evolutionary according to Lane) may further kink or obstruct 632 DISEASES OF THE STOMACH AND INTESTINES the ileum. (See Fig. 285.) Accumulation of material in the small intes- tine drags upon the duodeno-jejunal junction and forms a kink at that point, where also an evolutionary membrane develops (Fig. 286). Conse- quently the duodenum becomes elongated and dilated. Spasmodic con- tractions of the pylorus result in the endeavor to prevent regurgitation of duodenal contents. Chrystallization of a membrane occurs at the pyloric opening (according to Lane) with further increase of gastric dila- tation. Stasis in the small intestines and stomach results in infection by organisms and chemical changes. As a result, we have engorgement of the mucosa of the ascending duodenum, with ulcer and even perforation; or similar conditions at the pylorus or lesser curvature of the stomach, with resulting ulceration, perforation, or cancer; pancreatic infection with ultimate degeneration or even cancer; infection of the ducts of the liver or gall-bladder with resulting gall-stones, cholecystitis, or cancer; acute and chronic diseases of the liver and spasm of the cardiac orifice of the esophagus. The writer by no means subscribes to many of these claims of Lane and Gordan 1 (the latter's radiologist). For example, "a duodenal ulcer only occurs in the distended duodenum of intestinal stasis " (Jordan). Under one radiograph, "There was malignant disease of the pancreas, the final stage of long-continued chronic pancreatitis." An adjacent interstitial pancreatitis occurs with pancreatic cancer. It is "new pathology" to consider cancer of the pancreas a final stage of chronic pancreatitis. Among the symptoms of chronic intestinal stasis from auto-intoxication the following are described by Lane: loss of fat, wasting of the voluntary and involuntary muscles, subnormal temperature, extremities bloodless, with loss of sensation, appearing to be a stage of Raynaud's disease, blue hands and blue skin ("microbic cyanosis"). Degenerative changes in the skin with alteration in texture and color with pigmentation and offen- sive odor to the perspiration may occur. The mental condition may be one of apathy, misery or stupidity, melancholia, or apparently imbecility and these patients are liable to commit suicide. Parenthetically, the author, during fourteen years service as gastro- enterologist to the Manhattan State Hospital for the Insane, an institution of 4600 beds has never seen or heard of a case of suicide from this cause. Among other symptoms described are sleeplessness, neuralgias, neuritis and epileptiform tic, headache, loss of control of the temper making the patient difficult to live with and leading to misery and crime (a more frequent cause of the latter than imagined) ; rheumatic pains in the mus- cles, joints and skin; wasting of the thyroid, so that it cannot be felt and elevation or lowering of the blood-pressure. The breasts show definite degenerative changes which are most marked in the upper and outer zone, especially in the left breast, from which cancer readily develops. The several organs prolapse and alter in shape because of loss of fat and wasting muscle fiber, for example acquired mobility of the kidneys and uterine prolapse. Incidentally Lane describes downward displacement (enterop- tosis) and his medical treatment is that of this condition. Shortness of breath, produced by asthmatic attacks or gastro-intestinal distention, 1 International Journal of Surgery, April, 1914. CHRONIC INTESTINAL STASIS 633 occurs. Among the cardiac changes are dilatation of the left heart and aorta with degeneration of its coats and atheromatous changes in the small vessels as well. Degenerative and inflammatory changes occur in the kidneys. The hair loses its color and tends to fall out, more so in the case of dark hair while "red heads" suffer little. Hair grows excessively where it is usually absent or inconspicuous, such as about the nipple, and along the middle of the back, 1 on the cheeks, chin, upper lip and forearms. The author presumes this last statement refers to women chiefly, and that some of "our freaks" would be explained on the "kink theory." Infection of the pancreas may occur with resulting chronic induration, inflammation and cancer, or diabetes. The liver and gall-bladder are infected, gall- stones, cholecystitis and cancer may result or acute or chronic liver dis- ease. Diseases of the eye which are degenerative in origin may be pro- duced. Lane refers to indirect changes, or those that result from the lowered resisting power of the tissues to the exclusion of organisms produced by auto-intoxication. How long since, has auto-intoxication produced organisms? (Author.) Among these changes are pyorrhea alveolaris, tuberculous infection when not produced by direct inoculation, rheumatoid arthritis and infec- tion of the genito-urinary tract either directly or indirectly through the blood-stream by organisms other than tubercle producing nephritis, cystitis, pyelitis endometritis, salpingitis, etc. This last type seems to the writer suspiciously like colon bacillus infection. In addition, there may be changes in the thyroid gland, such as ade- noma, general enlargement or Graves' disease; Still's disease (polyarthritis affecting children and marked by enlargement of the lymph-nodes) ; pus- tular infections of the skin; varieties of mucous and ulcerative colitis pro- duced by infection of organisms, and ulcerative endocarditis. The dentists treat many cases of pyorrhea and when related to gastro-intes- tinal disturbances it is usually considered primary. Pus-producing organ- isms occur with it and recently some cases of amebic infection have been reported. We have, of course, colon bacillus infection with endocarditis, but there are other causes. Treatment. Lane advocates liquid paraffin before meals and a leather spring abdominal support which holds up the prolapsed viscera. He avoids butchers' meat. In other words, his medical treatment is that of enteroptosis to which I refer my readers, with appropriate diet and treat- ment of chronic intestinal putrefaction. Paraffin or Russian mineral oil may not prove sufficient to improve the constipation in which event further medical treatment must be instituted. If the medical measures fail to relieve, the iliac kink being demonstrated by the .T-ray, removal of an appendix anchored to the mesentery of the ileum may relieve the kink, or if a membrane is the cause, dividing this band may relieve the condition. The author is prepared to agree with Lane as far as appendectomy, or section of the band is concerned, though in the latter event adhesions may reform necessitating a second operation. Lane holds that if the band is not limited in breadth and not very tense, that it is better to short-circuit by dividing the ileum and attaching it to the pelvic colon, but removes 1 Brit. Med. Jour., Nov. i, 1913. (534 DISEASES OF THE STOMACH AND INTESTINES the large bowel in addition if it is loose and pendulous. At the Guy's Hospital, London, from May, 1909 to October, 1913, there were performed 54 short-circuits and 52 removals of the colon for various conditions, such as intestinal stasis, rheumatoid arthritis, tuberculous joints, Graves' dis- ease, cancer, trigeminal neuralgia, etc., with a mortality of 7.5 per cent. It would seem to the writer that the physical condition of several of these patients would contraindicate such radical operations, though even, so the death rate was low with a skilled operator such as Lane. Lane 1 reports, for example, 17 cases, in about 15 of which cure is stated to have been secured, with marked improvement in two. Twenty-six various opera- tions were performed on these 17 patients. Wm. Seaman Bainbridge 2 reports favorably on Lane's operations. Morison 3 has employed chiefly ileo-colotomy in most cases, but also colectomy particularly in the treatment of obstinate tuberculous lesions especially of the bones and glands in cases of evident stasis and also in rheumatoid arthritis. Out of 18 tuberculous cases, five died, subsequently. Three healed after operation and three improved. The rheumatoid arthri- tic cases improved but later relapsed. Drummond 4 by his radiographs showed that after the ileo-colostomy, there were regurgitation of the bis- muth into the short-circuited colon, complete evacuation of the colon was delayed and the last portion of the ileum above the anastomosis tends to become dilated and form a fecal reservoir. Wm. J. Mayo, in about 20 cases of exaggerated ceco-colic stasis with nervous symptoms and in whom constipation amounting to obstipation was present, due to bands, kinks and adhesions, removed 10 inches of the terminal ileum, the appendix, cecum, ascending colon, hepatic flexure of the colon, but to no extent that part containing the omentum, since severe adhesions often follow removal of the latter. Constipation was relieved in 87 per cent. Mayo concludes as follows: The number of persons whose condition in our opinion would warrant the risk, however, is comparatively small, and I cannot but deplore the widespread adoption by the medical profession of surgical measures for this or allied conditions which is in the experimental stage with little evidence to show that the supposed cures are permanent." The writer feels that he must at present hold conservative views and does not advocate the radical procedures of Lane except in rare instances of progressive obstipation, or of cancer. CHRONIC DILATATION OF THE DUODENUM In view of the importance attributed by Lane to chronic dilatation of the duodenum, due to the duodeno-jejunal kink resulting from stasis of the ileum, it seems advisable to describe this subject at this point. I have already referred to the fact that the motility of the duodenum is rapid. Moreover, the gastric contents macerated and partially prepared for diges- tion are expelled intermittently into the duodenum in small quantities, so that considerable angulation or stenosis of the duodenum must occur 1 Brit. Med. Jour., Nov. i, 1913. 2 Med. Rec., Sept. 27, 1913 and Woman's Med. Jour., Jan., 1914. 3 International Journal of Surgery, April, 1914. 4 International Journal of Surgery, April, 1914. CHRONIC INTESTINAL STASIS 635 before symptoms result. Even though the x-rays may actually show some dilatation, there may still be sufficient motility to empty the duodenum without the production of symptoms that could be imputed to the dilata- tion. This last is demonstrated among the classes of cases described. First. Chronic duodenal dilatation occurs with some cases of gas- troptosis, distention occurring on account of its prolapse and the muscular action of a stomach of good motility, rapidly distending the dependent duodenum (i.e., gravity plays a part). There is, however, sufficient motility for the latter to empty itself without the production of symptoms that could be imputed to the dilated duodenum. This condition has been noted during the general x-ray examination for splanchnoptosis. It is possible in extreme cases, to have nausea and vomiting as a result of reten- tion in the duodenum, though sometimes a marked water-trap, or fish- hook stomach may be a factor. Rarely these patients complain of pains simulating ulcer. Usually proper mechanical support to the abdomen, with treatment for enteroptosis affords relief even in the marked cases though temporary rest in bed occasionally may be required. Operation is a rare necessity. During an experience of many years, I have had numerous cases with vomiting, relieved by Rose's belt and proper treat- ment I have never as yet had to resort to operation in this type. Occa- sionally these patients through the drag of the ptosed duodenum causing torsion of the duct have attacks of jaundice, or other attacks simulating gall-stones, cured by proper corsets or mechanical support and treatment of the enteroptosis. Second. Under the x-ray section, I have referred to dilatation of the duodenum from adhesions extending from the transverse colon to the duodenum, with symptoms simulating duodenal ulcer. Operations dem- onstrated that no ulcer was present and separation of the adhesions relieved the symptoms. Third. I further reported a case of chronic pancreatitis with marked diarrhea and symptoms suggestive of gall-stones. There was retention in the duodenum due to obstruction from adhesions. There were no symptoms referable to the dilated duodenum. Moreover, recently the writer has examined a patient in whom the x-rays showed dilatation of the duodenum with marked deformity resulting from adhesions following cholecystectomy which extended also to the transverse colon. Dragging pains and local tenderness were marked so much so that the patient was continuously endeavoring to use opiates in order to obtain relief. Fourth. Dilatation of the duodenum with symptoms simulating duo- denal ulcer or gall-bladder disease have been reported by Harris as due to abnormal folds of the anterior mesogastrium (embryonic). No ulcers were found on operation. Fifth. Duodenal dilatation due to duodeno-jejunal angulation, pro- duced by the drag weight of the dilated ileum caused by the iliac kink according to Lane, was described in the previous article; duodenal ulcer disease of the gall-bladder, pancreas, etc., were attributed to this condition. Sixth. Bloodgood holds that a prolapsed dilated cecum with a short mesentery to the ileum may produce a kink and subsequently dilated duodenum. 636 DISEASES OF THE STOMACH AND INTESTINES Seventh. In competent ileocecal valve according to Kellogg and Case produces iliac distention, a drag at the duodeno-jejunal junction and dilated duodenum. Determination of Chronic Duodenal Dilatation. The x-rays are the most accurate method. The duodenum is seen to be dilated, or in milder cases there will be retention of bismuth or barium. When marked adhe- sions are present, there may be considerable irregularity in the contour. With the fluoroscope, writhing movements may be observed, a hyper- peristalsis of the duodenum endeavoring to force the contents past the stenosis. Wm. Van Valzah Hayes employs an excellent method of determining duodenal dilatation by physical examination. Hayes' Methods (Percussion with Pressure). The first part of the duodenum is percussed in the ordinary way as it lies close to the abdominal wall. As the second and third parts lie deep in the abdomen, deep pres- sure should be exerted by the finger (pleximeter) so to bring it fairly close to the intestinal wall. By this method of percussion with pressure, the distended duodenum can usually be mapped out. Corded Colon. Frequently the left iliac colon is felt as a rope-like body directly beneath the abdominal wall, apparently due to spasm above the sigmoid which occurs with stasis. Pressure Paradox. The examiner should then exert pressure upward and backward with the palm of the hand placed just below the umbilicus and this position should be maintained for ten to twenty seconds. The gas from the duodenum can at times be felt or heard passing into the jejunum as the angulation at the duodeno-jejunal junction is thus relieved. Percussion with pressure is now repeated over the duodenum and as a rule the tympanites has disappeared. Occasionally deep breathing and further gentle pressure may be necessary. Incompetence of the iliocecal valve may be associated with intesti- nal stasis with Lane's kink (ileal). It is best demonstrated by the ff-rays. Hayes suggests a useful method of determining this condition by palpation. Palpation Method of Determining Incompetent Ileocecal Valve. If gas is not present in the cecum, then distend it artificially with air or CO per rectum. Pressure is then made with the left hand near the middle of the ascending colon. Palpation with the right hand shows the lower por- tion of the ascending colon and cecum quite tense. The tension remains constant when gentle pressure is employed, provided the ileocecal valve is competent. If incompetent, the bowel (cecum) gradually collapses and gas and fluid are often felt to pass through the valve. Percussion now shows the absence of tympanitis over the cecum. At times the gas may be passed back and forth between the ileum and cecum. Treatment. As enteroptosis is the factor in most cases, mechanical support and its appropriate treatment are indicated. Intestinal putre- faction and constipation should be corrected when present. When ad- hesions are a factor, pressure should be relieved by operation. Medical treatment is indicated for incompetency of the ileocecal valve and fre- quently the treatment of enteroptosis will alleviate Lane's kinks, though CHRONIC INTESTINAL STASIS separation of adhesions (the membrane) may be necessary, advocate the more radical operations. 637 I do not JACKSON'S MEMBRANE PERICOLITIS There has been considerable confusion in regard to the differentiation of Jackson's membrane and true pericolitis. Jackson's membrane belongs, in the writer's opinion, to the congenital class and is non-inflammatory. The proof of its developmental origin is found in the study of the fetus and new-born infant. Clemen 1 in 36 still-born infants found in four in- stances veil-like membranes extending from the parietes over the hepatic flexure and ascending colon, fusing with the peritoneum of the colon near its mesenteric border. He believes twisting of the cecum and colon in their descent may be responsible for drawing attached peritoneum over the colon. I Fig. 285. A, Jackson's membrane. B, Multiple Lane's bands. C, Lane's kink. D, Appendix caught in bands. E, Thickened part of mesentery forming a strong band (W. S. Bainbridge). Jackson holds that it occurs in association with abnormal mobility of the proximal colon and is due to a failure of fusion of the ascending mesocolon with the posterior parietal peritoneum. Jackson's Membrane. Jackson describes this structure as follows: ''From a point just at the hepatic flexure to 3 inches above the caput coli there spreads from the parietal margin over the external lateral margin to the internal longitudinal muscle band, a thin vascular veil, in which long straight unbranching blood-vessels course, most of which are parallel with each other and take a slightly spiral direction over the colon from the upper peritoneal attachment to the inner lower portion of the gut ending just above the caput. The appendix is not implicated in any way. Coursing with the blood-vessels are numbers of shining narrow bands of connective tissue, which gradually broaden as they go and end in a slight journal A. M. A.. July, 26, 1914. 6 3 8 DISEASES OF THE STOMACH AND INTESTINES fan-shaped attachment at various points on the anterior and inner surfaces of the colon. At these points of attachment the gut is held in rigid plica- tion. At the beginning of the hepatic flexure the drawn membrane par- ticularly angulates the contained colon." In some cases the folds may extend further down the inner margin of the upper part of the ascending colon extending to the descending arm of the transverse colon. Symptoms. 1 The writer has had cases operated on for other conditions where radiographs had been taken and where neither they, nor the symp- toms pointed to the presence of Jackson's membrane, and yet when it was found present at operation, it was not disturbed. On the other hand, one may have evidences of stasis in the cecum and ascending colon with Fig. 286. A, Kinking at pyloric outlet. B, Duodenojejunal kink. C, Dilated stomach. E, Bands to gall-bladder. F, Retractors holding up liver (W. S. Bainbridge). intestinal disturbances, indicanuria and nervous symptoms. Severe con- stipation may ensue and there may be pain over the region of the cecum and ascending colon, slightly increased on pressure and intensified four to five hours after meals. From fecal irritation, mucus may be present in the stools. X-rays. In mild cases there may be no evidence, or merely stasis in the cecum and ascending colon of varying degree. At times an angulation at the hepatic flexure, or evidences of narrowing from adhesions, or angu- lation, with frequently displacement of the cecum. In some there is a "double-barrel gun" appearance of the ascending colon and descending arm of the transverse colon occurring during the administration of the bismuth enema, seen fluoroscopically. As the colon distends the veil between the ascending colon and arm of the transverse draws them to- gether. The best method to determine this condition is to first radiograph the patient standing, after the barium enema. Then follow Healy's method 1 Journal A. M. A., Aug. 30, 1913. CHRONIC INTESTINAL STASIS 639 (knee-chest) position for five minutes and radiograph in the Trendelenburg or belly Trendelenburg (Tousey). If there is a Jackson membrane the double-barrel gun appearance persists in the Trendelenburg radiograph. Pericolitic membranes or adhesions likewise are clearly demonstrated. When there are no adhesions or veils, etc., the transverse colon slips well above the umbilicus in the Trendelenburg posture and swings freely at the flexures. Adhesions bind the colon at some point. Treatment. Various measures are advocated. Some immobilize the cecum when it is misplaced or movable; others, the ascending colon. Division of the veil (membrane) is indicated if symptoms occur. Pericolic Membranes. Many of these membranes resemble that of Jackson, but they are apt to be thicker in portions and frequently involve the appendix. This type is believed to be due to infection through the intestinal wall by bacteria, or their toxins. The same type of membrane may occur in the neighborhood of non-perforating gastric and duodenal ulcers. There is probably partly a proliferation and partly a floating up of delicate layers of peritoneum by a temporary serous exudate, with the ultimate formation of lymph-spaces and new blood-vessels, with the forma- tion of connective tissue. The blood-vessels run in parallel lines. The writer has seen such cases in association with chronic appendicitis. The symptoms usually are more active than in many cases of Jackson's membrane, as there seems a greater tendency to interfere with motility by contraction of the bands. The radiological findings show stasis and often a stenotic point or evidences of angulation, or a long double-barrel appearance of the colon in some cases. Treatment. Division or separation of the membrane is indicated. MOVABLE CECUM Movable cecum has been considered by some as an anomaly of devel- opment (congenital) as it has been found associated with Jackson's mem- brane. The author finds that the cecum is prolapsed and is usually atonic and dilated and believes it occurs chiefly in association with enter- optosis. Incompetent ileocecal valve is believed at times to be dependent on this condition and it is also thought to have a bearing in the production of the ileal kink. Fishel denies that mobile cecum and constipation pro- duce the symptoms, since some of the patients suffer from diarrhea, but holds that chronic catarrhal typhlitis is the cause, producing motor insufficiency and atony, with retention of contents, fermentation, etc. J. A. Blake Attributes the symptoms to the atonic condition and dilatation which account for the fact that fixation does not cure many cases. Un- questionably, the misplaced cecum predisposes to colitis, and even to appendicitis, in view of its tendency to produce kinks in the appendix. Symptoms. Among the symptoms of movable cecum are pain in the cecal region (right lower quadrant of the abdomen), spontaneous and colicky, or only felt on palpation and also intermittent, the attacks being rather ill-defined, or there may be gurgling in that region and evidences 1 Med. Rec., April 4, 1914. 640 DISEASES OF THE STOMACH AND INTESTINES of distention of the cecum (a tumor-like air cushion painful on deep palpa- tion, marked by tympany and the splashing sound. The balloon-like cecum may be felt or at times seen. Colitis may develop, severe consti- pation or diarrhea alternating with constipation occur. There are fre- quently nervous symptoms resulting from chronic intestinal putrefaction. These cases may be mistaken for appendicitis, a normal appendix being found at operation, or the symptoms may occur after appendectomy, much to the discomfort of the patient. Diagnosis. The #-rays furnish the most accurate method of diagnosis. The cecum will be found prolapsed and often tipped over (oblique). By inflating the rectum with air or COa one can also by percussion and pal- pation determine this condition. Treatment. Medical treatment should first be instituted. A proper supporting belt, or Rose's adhesive plaster belt for the enteroptosis and diet and treatment for this condition should be carried out, in addition to appropriate remedies for the intestinal putrefaction and constipation. Some advocate fixation of the cecum, but Blake advises plication of the cecum and ascending colon. He suggests removal of the cecum, ascend- ing and part of the transverse colon with ileo-sigmoidostomy in severe cases that have resisted all methods of treatment. R. T. Morris' opera- tion is also excellent. On several occasions, when appendectomy has been performed for chronic appendicitis, the operator has performed fixation of the cecum in cases of mine with marked movable cecum and enteroptosis. INCOMPETENCY OF THE ILEOCECAL VALVE Functions of the Ileocecal Valve. The ileocecal valve retains the mate- rial in the small intestine until the digestive work is complete and the digested portion has been absorbed. In small successive amounts, it allows the passage of undigested food residues, water, etc., into the large intestine and further prevents the reflux of material from the colon into the ileum. Under normal conditions one would expect a competent ileocecal valve, though the writer has observed several cases in which incompetency of the valve was demonstrated during examinations for other conditions, when he could impute no symptoms whatever to the valvular insufficiency. The radiologists have made a study of this condition for some years past, and Kellogg 1 and Case 2 consider it of grave pathologic import. Etiology. Among the causes, Kraus considers stretching or breaking of the hebenula (muscular longitudinal band maintaining the partial normal intussusception of the ileum forming the valves) by reason of over- distention of the cecum and colon from constipation or gas accumulation. Distortion of the folds by cicatricial contraction or inflammation, tuber- cular disease, colitis, atrophy of tissue of valves from inflammation, typhlitis, appendicitis with adhesions, movable cecum with atonic dilata- tion of the cecum, and Lane's ileal kink, though Kellogg believes ileocecal incompetency is the cause of the kink. Temporary incompetency may 1 Med. Rec., June 21, 1913; Surgery, Gyn. and Obstet., Nov., 1913. 2 Journal A. M. A., Oct. 3, 1914; Med. Rec., Mem., 7, 1914. CHRONIC INTESTINAL STASIS 641 result from overdistention by accumulation of gas or liquid contents or of an excessively large enema (Cannon, Case). Case has observed that the presence of a foreign body, a string in transit, has produced it. Symptoms. Some claim that pain, faintness and nausea followed by distention may occur at the time of commencement of ileocecal incompe- tency. Hayes, under chronic "dilatation of the duodenum," describes a method of determining such incompetency. Among symptoms attributed to incompetency of the ileocecal valve are: Irritation and diarrhea due to passage of a large amount of undigested material from the small intestine, occur in a small per cent, of cases. Overdistention of the colon, stasis, putrefactive processes, colitis, peri- colitis or appendicitis result. Development of tuberculosis and cancer may ensue. The cecal contents are forced back into the small intestine and the accumulation in the small intestines acts as a drag upon the root of the mesentery, producing obstruction at the junction of the duodenum and jejunum and so causes duodenal and gastric stasis. Then as a result of bacteria and toxins in the dilated duodenum, we have gastritis, duodenitis, gastric and duodenal ulcer, cholelecystitis, cholangitis, gall-stones, pan- creatitis, adhesions about the pylorus and duodenum with chronic pain in the pyloric region, and various digestive disturbances. It aggravates a Lane's kink if present. Gas regurgitates into the small intestines causing distention, and it may oscillate back and forth between the small and large intestine. Constipation with stagnation and feces resembling that of sheep occurs. The returned feces give a putty-like feel on palpation. There is marked intestinal intoxication with all its symptoms sallow skin, nervous symptoms or neurasthenia, arteriosclerosis, cardio-vascular and renal disease, neuritis, insomnia, rheumatism, etc., practically all the symptoms that have been imputed by Lane to his kinks. I have seen cases with no clinical symptoms resulting. The condition is readily determined by the #-rays by the use of bismuth, or barium enema. - Treatment. This comprises diet and active regulation of the bowels. Chronic intestinal putrefaction, colitis, etc., should receive appropriate treatment. With development of special organisms in the stool, autogen- ous vaccines are indicated. Abdominal support is required if there is enteroptosis, and surgical procedure for appendicitis, or any other surgical condition. Kellogg suggests revision of the valves by a special technic, in the event of laparotomy for some other purpose. I do not advocate it. Angulations, Adhesions, Dilated Sigmoid. Various angulations may occur in the colon, particularly as a result of enteroptosis. Adhesions may be associated. Obstinate constipation and chronic intestinal putrefaction with its symptoms occur, plus the symptoms of splachnoptosis when such is present. The #-rays will determine these conditions after the method described under determination of Jackson's membrane. Ap- propriate medical 1 treatment is indicated, though at times separation of adhesions may be required and rarely enteroenterostomy. With a di- 1 Rose's plaster belt and treatment of enteroptosis should be employed when such is present. 41 642 DISEASES OF THE STOMACH AND INTESTINES lated and redundant sigmoid, pain, discomfort, distention, obstinate con- stipation and at times colitis occur. In the event of failure of medical treatment, operation may be required. One occasionally sees cases of prolapse of the sigmoid with slight intussus- ception into the rectum in association with enteroptosis. The writer treated one such case suffering from obstinate colitis without success. Subsequently Gant suspended the sigmoid with resulting cure. CHAPTER XXV INTESTINAL CATARRH; ENTERITIS; COLITIS; CATAKRHAL SIGMOIDITIS; PROCTITIS; PHLEGMONOUS ENTERITIS ACUTE AND CHRONIC INTESTINAL CATARRH (Synonyms. Enteritis; Catarrhus Intestinalis) INTESTINAL catarrh is one of the commonest conditions with which we have to deal, and is of importance, since in acute cases in the young or aged, it may seriously endanger the life of the patient ; while the chronic cases are often obstinate and difficult to cure, and may impair the general health. It occurs in two types, the acute and chronic, and these in turn may be primary or secondary to some other disease. ACUTE INTESTINAL CATARRH (Synonyms. Enteritis Acuta; Catarrhus Intestinalis Acutus; Cholera Nostras; Acute Diarrhea) Acute intestinal catarrh is defined as an acute inflammation of the intestines, characterized by pains or considerable severity and accom- panied by diarrheal movements containing an admixture of mucus. The disease may attack a portion of the bowel and we may have a duodenitis, jejunitis, ileitis, colitis, sigmoiditis, and proctitis. In many cases the entire intestinal tract is involved. Appendicitis is described in a separate chapter. Though Woodward 1 held that the small intestine may not be involved alone, yet it unquestionably occurs. In many cases acute catarrh of the colon, on the other hand, gives the prominent symptoms, though there is frequently involvement of the ileum. The inflammation may also be confined to the large intestine. Etiology. Age. It may occur at all ages, and is frequently found in in- fants and children. Acute intestinal catarrh may be primary (idiopathic), or secondary to some other disease. Primary acute catarrh is due to the following causes: i. An exces- sive quantity of food, so that a considerable portion remains undigested and acts as a source of irritation; heavy and indigestible food; extremely cold drinks, or an idiosyncrasy to certain foods. In others, who are suffering from slight intestinal disturbances, some articles of diet which otherwise would produce no difficulty may lead to the development of catarrh. Unripe fruit, tainted meat, milk or fish, or vegetables that are overripe or spoiled. Auto-intoxication with diarrhea may result from ingestion of such material , and catarrh is frequently produced, if the source of irritation is not immediately removed. 1 Medical and Surgical History of the War of the Rebellion. 643 644 DISEASES OF THE STOMACH AND INTESTINES 2. Chemic irritants, both organic and inorganic substances, such as colocynth, croton oil, jalap, senna, podophyllin, spices, pepper, copaiba, mustard, garlic, cantharides, mercury, arsenic, lead, copper, tartar emetic, phosphorus, antimony, alcohol, chloroform, ether, and some of the alkaloids, such as colchicin, veratrin, acids, and alkalis. With concen- trated irritants the mucosa may be permanently damaged. Catarrh is caused when smaller quantities are ingested. 3. Mechanical irritants, such as hardened scybalae, enteroliths, biliary calculi, foreign bodies, such as seeds, fruit-pits, coins, etc. 4. Exposure to cold or high temperature, especially in children and infants, or sudden variation in temperature, wetting the feet, are predis- posing causes; these conditions probably favor the development of micro- organisms and the production of circulatory changes. 5. Chemic irritants from the blood, such as in catarrhal nephritis, catarrh from mercurial inunction, or from abdominal burns. Elimina- tion of the poisons through the bile and from the blood during intestinal secretion is the probable cause of the catarrh. Acute intestinal catarrh may be secondary: 1. To general infection, as in typhoid, dysentery, cholera, sepsis, influenza, pneumonia, scarlatina, measles, malaria, rheumatism, or other infectious diseases. ~ In dysentery and typhoid the ulcerations are in part responsible. 2. Direct action of microorganisms, as in infantile catarrhs due to the activity of numerous types, such as proteus vulgaris and streptococci, Bacillus enteritidis sporogenes, 1 colon bacillus, also Bacillus dysenteriae; and myiasis (larvae of flies). 3. Extension of the inflammatory process from adjacent parts, as in peritonitis, invagination, hernia, tubercular or cancerous ulceration, and thrombosis. 4. Diseases of the liver, heart, and lungs due to stasis and engorgement. 5. In the cachexia of cancer, profound anemia, diabetes, Addison's and Bright's disease, intestinal catarrh may be a terminal event. Morbid Anatomy. The entire gastro-intestinal tract may be involved, or only portions of the intestines are affected. These differences depend on the extent of the catarrhal process and upon the cause and intensity of the inflammation. The anatomic changes are not always commensurate with the severity of the symptoms. The mucous membrane of the intestines is reddened uniformly or in spots, from light red to dark purple in color, especially marked around the follicle's and plaques, on the summit of the valvulae conniventes and of the villi. If the inflammatory process is intense, extravasations of blood occur. The mucous membrane is swollen and edematous, and is often covered with tenacious glassy mucus, stained by bile or blood and more or less opaque. Desquamated epithelial cells and occasionally a few pus-cells are seen in the mucus under the microscope; layers of epi- thelium may desquamate and form gray shreds. Fecal contents are 1 This was believed to be possibly an impure culture of the Bacillus aerogenes capsulatus, though it may be a distinct organism (Herter, Bacterial Infections of the Digestive Tract). ACUTE 1NTKST1XAL CATARRH 645 usually liquid. The villi and solitary follicles are swollen and appear as whitish nodules surrounded by a red injected area (enteritis follicularis seu nodularis). If the process continues, these nodules may rupture and give rise to follicular ulcers. Catarrhal ulcers are produced by loss of the epithelial covering and extension of the inflammation. Irritation in the neighbor- hood of these ulcers may, in protracted cases, give rise to polypoid growths. Microscopically, there are congestion and distention of the blood-vessels of the mucosa and submucosa and small extravasations are at times seen between the glands of Lieberkuhn. The spaces between the glands are frequently widened and contain abundant masses of round cells. They are also present in the superficial or deeper layers of the submucosa. The swelling of the solitary follicles is due to proliferation of their cells and to round-cell infiltration. This is also true of Peyers patches when they are involved, which is rare to any extent. The epithelium of the mucosa is detached, especially in the large intestine, but this is believed to be chiefly a postmortem change. The epithelium is undoubtedly involved in the catarrhal process, as degenerated epithelial cells are found in the mucus with the stool. The cells of the glands may be cloudy and swollen. Crypts of Lieberkuhn. The glands are enlarged or the fundus is wider than normal, the opening is narrow, so that the crypt becomes bottle shaped. They may be detached from their base and raised, or protrude into the intestines, or even desquamate. The submucosa is hyperemic. The muscular and serous coats are unaffected. Symptoms. They depend on the etiology, the location of the catarrh, and its severity, so that considerable variation occurs. The general symptoms of an ordinary primary attack are as follows: It usually begins with a feeling of fulness in the lower part of the ab- domen, with attacks of colicky pains and diarrhea. Nausea and vomiting may be associated with these symptoms at the incipiency of the attack. In the mild cases there may be no temperature, or it may be moderate; while in the severe types there may be a chill with rise of temperature to 103 to io4F. In severe cases of ileocolitis in young children, as a result of intestinal intoxication, symptoms resembling meningitis may occur. They may suffer from somnolence, convulsions, trismus, etc. Lumbar puncture will show there are no cellular elements or microbes. In some cases there may be tympanites. There are gurgling sounds (borborygmi) and the abdomen is tender on pressure, at times over special regions markedly so. Loss of appetite occurs. The number of stools depends upon the severity of the case. There may be only two or three movements in twenty-four hours, or as many as fifteen to twenty evacuations. The first one or two movements usually contain fecal matter and are somewhat mushy in character. They rapidly become semifluid, and finally thin and liquid. Feces and scybala* may be found later. The more the colon is involved, the greater is the diarrhea. Diarrhea does not always occur if the small intestine alone is the seat of inflammation. The early stools are frequently of a dark brown 646 DISEASES OF THE STOMACH AND INTESTINES color, sometimes of offensive odor, the latter condition being especially noticeable if dietetic errors are the cause. The amount of material passed, exceeds the quantity of food ingested, due to the digestive secretions and catarrhal secretion, all of which are rapidly evacuated. When the stools consist of watery discharge and mucus there is often little or no odor. They are slightly acid in reaction and foam-like in appearance. The stools may be light yellow in color, grayish, or even greenish in young children, or colorless, resembling rice-water. These differences in color are dependent upon the location of the catarrh. In the yellow fecal material Gmelin's reaction for bile-pigment can often be obtained, and this is also found in the green movements, demonstrating involve- ment of the small intestine. The colorless stools most frequently occur in the specific choleraic types. With duodenitis alone, or associated with gastritis, when there is con- siderable duodenal catarrh and interference with the escape of bile, there may be jaundice, the presence of bile, and indican in the urine, at times albumin and casts, and the whitish stools found with jaundice. Mucus is contained in the stools. It may float on top of the dejec- tions in shreds of various sizes and be of glassy appearance, or be stained in various colors, or mixed with the bowel contents and form a jelly-like mass; it may coat the feces or be mixed with it in small amounts; or the movement may consist chiefly of mucus. In some cases the mucus may only be determined by the microscope. The localization of the seat of the catarrh is shown by the character- istics of the mucus, to be described later. Microscopically, there are epithelial cells, numerous microorganisms, mucus, occasionally a little pus and blood, and undigested food particles in the stool. Blood is found only in severe cases where there is marked congestion or ulceration, and pus when ulceration is present. Chemically, peptones and sugar may be present in the dejecta. Macroscopically, food remnants may be seen with the naked eye for several days, especially if dietetic indiscretion be a factor. Subjective Symptoms. In the milder cases, except for the colicky pains, diarrhea, and the feeling of pressure and fulness, the patients may not feel very badly. In more severe cases they may feel chilly, feverish, dizzy, and weak, at times nauseated, and in some cases they may vomit. Tenesmus may be present if the lower part of the colon or rectum are affected. Gas may be expelled. Borborygmi may be audible. With children and elderly persons the symptoms are often pronounced. Col- lapse may occur. With infants the hydrencephaloid condition may occur, temperature io4F. or more, sunken fontanels, rapid pulse, cold extremities, collapse, etc. General Physical Signs. The abdomen may be bloated, but when gas is expelled the distention lessens or disappears. Splashing sounds can often be elicited. Over the abdomen usually there is tenderness on palpation, especially in the region of the navel, and frequently in the right or left iliac regions, or along the course of the transverse colon; gurgling sounds can often be heard on palpation. In thin subjects, peristaltic ACUTE INTESTINAL CATARRH 647 movements of the small intestine may be visible either before or after palpation. If there is much gas, there is a tympanitic note on percussion; it may be dull in character if much fluid be present. Large accumulations of gas are not frequent. Fever. There may be no temperature or only moderate fever. In severe types the temperature may be quite high (102 to io4F.). In some cases there are chills associated with the fever, but the temperature has a tendency to fall after a few days and does not show the characteristic steady increase of typhoid fever. With tainted food or bacterial infection, fever is especially apt to occur. Such cases run an acute course with severe clinical symptoms. Undoubtedly auto-intoxication is a prominent factor in their production. With gastroduodenitis, jaundice is present, and often vomiting. Urine may become scanty and concentrated, especially in severe cases where there are frequent movements, and there may be found cylindroids, albumin in small amounts, and hyaline casts. Indican is often present, especially if the small intestine is involved, and bile, if jaundice. Rosenbach's reaction (Burgundy red), on boiling urine with nitric acid, is also found. This also shows intestinal putrefaction. Acetone has been found. Localization of Acute Catarrh. Involvement of the small intestine alone is more uncommon, and is usually associated with gastritis. I believe in acute cases the involvement of the small intestine is a more frequent occurrence than some suppose; though the intensity of the inflammation may be greater in one portion of it, and in addition in some cases there may be an especially severe inflammation in the colon. Some believe the large intestine alone is most frequently involved. This is more so in chronic cases. In the rectum local involvement is quite frequent. Acute catarrh of the caput coli, due to fecal accumulation, at times occurs, and this must be differentiated from appendicitis. The fecal tumor can be generally discovered by the doughy feel on palpation. The acute symptoms subside rapidly under intestinal irrigation and catharsis. This refers to a simple catarrh and not to a true typhlitis which in- volves the muscular tissue. Acute catarrh may occur in the sigmoid and should be classified as catarrhal sigmoiditis. In sigmoiditis or perisig- moiditis the musculature is also involved. The cases described by Mayor and Leube are evidently of this type. Diverticulitis belongs to this last class. The nomenclature should be very specific. Localized Physical Signs. An acute duodenitis is usually associated with acute gastritis, and we have jaundice with local tenderness on pressure in the right portion of the epigastric region. Inflammation of the duodenum with local tenderness may occur after cutaneous burns. Tenderness on pressure (pain), confined to the middle of the abdomen and not laterally, shows the affection to be probably confined to the other portions of the small intestine; but when the small intestine alone is involved, as diarrhea is usually absent, the diagnosis is difficult. The 648 DISEASES OF THE STOMACH AND INTESTINES presence of a considerable number of undigested food particles and epithelial cells tinged with yellow bile-pigment in the feces; microscopic mucus mixed with the stool, with rarely a small amount of visible mucus, are a valuable aid to the diagnosis. Indican is usually present in the urine. Acute Colitis. With acute colitis 1 the pain and tenderness are most marked along the course of the colon, over the cecum, transverse or de- scending colon, sigmoid flexure, or over all together. The stools are diarrheal and contain considerable mucus. Proctitis is characterized by tenesmus and colicky pains in the left iliac fossa. There is a constant desire to defecate. The scybalae or stools are surrounded with mucus, sometimes tinged with blood, and the mucous membrane may prolapse during defecation and is red and tender. Rectal digital examination is accompanied by much pain, and the examining finger shows, at times, traces of blood. The most important method of diagnosis to localize the process is by examination of the feces, noting the character of the mucus. Macroscopic examination is often sufficient. When pure mucus is passed without any fecal admixture, catarrh of the rectum, sigmoid, or of the descending colon is indicated. If small masses of fecal matter or solid balls are passed covered with a layer of mucus, the same condition is indicated. If there is catarrh of the entire large intestine up to the cecum, even if the movements are thin, shreds of mucus are intimately mixed with the fecal matter, and can be recognized by the naked eye. The close admixture of fecal material and mucus distinguish it from catarrh of the lower colon. In catarrh of the upper colon alone or of the small intestine, or small intestine and upper colon alone, usually no mucus can be seen with the naked eye, and hyaline microscopic lumps of mucus are found intimately mixed with the stools. Small amounts mixed in the feces are at times visible. Diagnosis. If a colon-tube be introduced high into the rectum, and lavage be carried out intermittently with warm water through a funnel, by the same method as lavage of the stomach, the recovered fluid will contain visible mucus, and demonstrate that catarrh of the large intestine is present. This method was suggested by Boas. The presence of yellow mucous granules in the movements has been considered diagnostic of inflammation in the small intestine, though Schmidt and Boas believe them to be structureless remains of muscle substance, casein, or egg-albumen, colored with bile-pigment. Bile-pigment. If the bile-pigment reaction can be obtained in the stool or in some of its constituents, this indicates an inflammation of the small intestine, and the more marked the reaction, the higher up the involvement. It may be found in the mucus, and this may be stained a dark orange, green, or greenish yellow. Cylindric epithelium, round cells, or rarely fat (droplets) may be stained yellow. 1 More properly, acute catarrhal colitis, to distinguish it from dysenteric and other types. ACUTE INTESTINAL CATARRH 649 An acid reaction of the stool also shows involvement of the small intestine. Boas has subjected a filtrate of the feces to the digestion test with a small piece of albumin, and, when the result is positive, justly concludes that the condition originates in the small intestine. Duration. Mild cases may rapidly recover in three to five days, while severe cases often continue for several weeks. The intestines remain susceptible to irritation for a considerable time, and errors in diet may cause a recurrence of the attack. The condition may become chronic. Constipation may follow the acute attack, and this should carefully be treated, lest habitual constipation develop. The acute attack may never be entirely recovered from, but gradually develop into a chronic catarrh. Prognosis. These cases frequently recover within a short time, but in children or very old and enfeebled persons, the disease may occasionally prove fatal. The prognosis as to cure depends upon the etiology of the disease; thus, if due to chemic irritants, the condition may become chronic. Treatment. Prophylaxis. Particular articles of food or drink known to produce attacks of acute intestinal catarrh should always be avoided. Some are affected by ice-cream and ice-cold drinks, and these should be forbidden. Exposure to cold or wet should be avoided. Rest in bed should be enjoined. When tainted food has been ingested, or indigestible, or an excessive amount of food, even though there is diarrhea, a laxative should be given immediately to thoroughly empty the bowel. Calomel, 5 to 10 grains (0.3-0.6), followed by a saline cathartic, preferably within six hours for .rapid effect, or castor oil or laxol, i to 2 ounces (30.0-60.0), should be given to an adult. Castor oil may be administered in coffee, sarsaparilla, ginger ale, or with orange or lemon juice. For infants and young children calomel, ^ to i grain (0.32-0.65), in divided doses, or i to i>2 drams (4.0-6.0) of castor oil, or, preferably, laxol. If an acid chemic irritant has been taken, then an alkali should be given, and vice versa. Antidotes should be administered in the case of chemic poison. It is preferable also to administer a cathartic, so as to remove the poison from the intestinal canal. Enteroclysis with normal saline solution at 110 to H5F. is indicated in all these cases, employing i gallon (4 liters) by the recurrent method, so as to thoroughly cleanse the large intestine. Calomel is useful when there are flatulence and indicanuria. I prefer a fairly large initial dose in these cases, and to repeat it within a few days, to the method of daily small doses. There is some danger of salivation from frequent small doses. Colonic irrigation once or twice a day is of great importance. These methods, combined with salol or beta-naphthol-bismuth (orphol), 5 grains (0.3), three or four times a day, with the other bismuth preparations, or with hexamethylenamin, 5 grains (0.3), and sodium ben- zoate, 10 grains (0.6), t.i.d., are generally sufficient. Dilute hydrochloric acid in lo-minim (0.59) doses t.i.d. is an ex- cellent adjunct, providing there be no nausea or vomiting; oxyntin cap- 650 DISEASES OF THE STOMACH AND INTESTINES sules with mix vomica may be substituted. Resorcin, 5 grains (0.3) t.i.d., may be employed for intestinal fermentation. One of the best remedies for diarrhea is bismuth. Bismuth subnitrate, 20 to 30 to 40 grains (1.3-2.0-2.6), given four or five times a day, is of service. It may be combined with saccharated pepsin as a vehicle in mild cases in smaller doses; thus: Bismuth subnitrate, saccharated pepsin, equal parts, ^ to J^ tea- spoonful every two or three to four hours during the twenty-four hours. Bismuth subcarbonate, 15 to 30 grains (1.0-2.0), four times a day. Bismuth subgallate, 5 grains (0.3), three or four times daily with the bismuth subnitrate, is excellent. Bismuth salicylate, 5 grains (0.3), four times a day is a good anti- fermentative; or ichthoform, 5 grains (0.3) t.i.d., in combination with bismuth subnitrate. Ichthalbin, 5 grains (0.3) t.i.d., is useful. Tannalbin, tannigen, or tannopin, 5 to 10 grains (0.3-0.6), can be used in combination with bismuth. fy Bismuth, subnit 5ss (16.0) Mist, cretae q. s. 5iv (125.0). M. Sig. Shake. One to two teaspoonf uls in water every two orthree hours. The same prescription, with 10 to 15 drops (0.6-1.0) of tincture opii camphor, in each dram dose, is useful if the diarrhea continues excessive. The following represent single doses of remedies which can be taken every three or four hours in persistent diarrhea: !$. Tinct. opii TTlx (0.59) Tinct. kino - m i o\ ~ , , } aa TUXX (1.18) Comp. tmct. catechu J Aqua destil q. s. 3ij (8.0). M. !$. Tinct. opii Hlx (0.59) Mist, cretae 3 J (4-0) Comp. tinct. catechu q. s. 3ij (8.0). M. !$. Bismuth, subnit gr. x (0.6) Tinct. opii deodor Tfl,x (0.59) Aq. cinnamomi q. s. 3 J (4-o)- M. I prefer, however, to avoid opiates as much as possible in my treatment. Cotoin, i to 2 grains (0.06-0.1); tincture coto, 15 minims (0.888), or paracotoin, in double dose as compared to the cotoin, have been suggested for diarrhea. Codein, ^ to y grain (0.008-0.016), or, rarely, morphin may be required. Patient should be kept in bed. Heat. Dry or moist heat, or Priessnitz compress, hot-water bag, flaxseed, or milk or potato poultice, hot pieplate, hot salt-bag, compress of hot water, pepper poultice, weak mustard and flour poultice should be applied. If there are symptoms of collapse, warmth, hot drinks, camphor hypodermics, camphor gr. v in Tltx sterile almond oil, and strychnin gr. Ko> are indicated 1 . Hypodermoclysis may be required. Enteroclysis is useful to rid the bowel of irritating material, and for treatment of the acute catarrh when located in the colon. It may be given by enema or, preferably, with the recurrent tube. About i to i^ 1 The cardiac stimulants can be given alone or together, every 4 to 6 hours. ACUTE INTESTINAL CATARRH 651 quarts (1000-1500 c.c.) should be used by enema, hips elevated, injecting with a long tube. When there is marked fermentation Acetozone i : 2000 to i : 1000; Alphazone i : 2000 to i : 1000; Peroxid of hydrogen 5 j (3-o) to 2 quart^ (liters), or Salicylic acid (i : 1000) 2 quarts (liters) ; Boric acid 5 j U-o) to 2 quarts (liters) ; Permanganate of potash 1 : 3000. Irrigate with 2 or 3 quarts (liters) with a recurrent tube once a day. Soothing irrigations are flaxseed tea, gum-arabic solution in water at noF., slippery-elm water, or normal saline solution. Occasionally astringent irrigations may be necessary. First wash the bowel with warm water, then inject tannic acid, 30 grains (2.0) to i liter (quart), and 15 drops (0.888) of laudanum, and hold a while. Weak nitrate of silver, 5 grains (0.3) to i quart (liter), has also been recommended, but is better in chronic cases. Protargol or argy- rol i : 3000 has also been employed but is also preferable for chronic cases. Gastritis, jaundice, and malaria should be treated, if present, or any disease to which the intestinal catarrh is secondary. In referring to the cases of duodenitis with jaundice, the author wishes to impress on his readers the value of hexamethylenamin and sodium benzoate. These should be given in doses, 10 grains each, dissolved in water, by rectum, if acute gastritis is present, and in 5 grains (0.3) each, 1 when this has subsided. These remedies have an excellent effect on the severe indicanuria which I usually found present, and the hexamethylen- amin disinfects the biliary tract, and I believe prevents cholecystitis and other biliary infections. The writer always uses these methods. High enemata or irrigation with hot normal salt solution are of value. Occasionally cold enemata may be used. The sour milks are, moreover, of great value. If acute gastritis accompanies the acute duodenitis, the former con- dition must receive particular attention, since remedies directed to the obstructive jaundice (duodenal) would not be retained. External heat should be kept on continuously, occasionally a mustard poultice, and soda bicarbonate given at first in small doses, 5 grains (0.3), to liquefy the bile. When the acute gastric condition has subsided, the soda bicarbonate can be increased to 15 grains (i.o), or more t.i.d., and later, salicylate of soda, 5 grains (0.3) in capsules, can be substituted t.i.d. for the soda. The following prescriptions aid intestinal digestion, and the sodium suc- cinate has an excellent effect on the biliary tract. They represent a single dose in capsule: I). Holadin gr. iij (0.198); Succinate of soda gr. v (0.3) ; Bile salts (Fairchild) gr. ss (0.033). M. fy' Holadin gr. ij (0.132) ; Bile salts gr. ss (0.033); Phenolphthalein gr. j (0.066). M. 1 They are then given by mouth. 652 DISEASES OF THE STOMACH AND INTESTINES fy. Bile salts gr. j (0.066); Succinate of soda gr. v (0.3) ; Phenolphthalein gr. ss (0.033). M. Sig. One capsule before meals or at bedtime. Olive oil, > to i ounce (30.0-60.0) t.i.d., is of value when it can be retained. Oleic acid, 5 minims (0.3) in capsule, can be substituted. Diet. Cold drinks should be avoided. Warm teas, such as chamomile, fennel, anise seed, or plain tea and gruels (barley or rice), with or without milk, very dilute milk with lime- water, etc., should be given. Milk is often indigestible and gruels are preferable. Later, bouillon, water soup (bread softened in hot water with butter and salt), yolk of egg or white, or entire egg (raw or soft boiled), stale bread, boiled water, etc. Avoid carbonated waters. Vichy and milk may be given if the gas is allowed to pass off before drinking. As soon as the diarrhea is over, soft-boiled eggs, calves' brains, scraped beef, mashed potatoes, cocoa, weak coffee", chicken, chops, steak, stale bread and butter, potatoes mashed or baked can be given. Fruit, green vegetables, hot breads, fat, and acids should be avoided for a considerable period. CHRONIC CATARRH OF THE INTESTINES; CHRONIC COLITIS (Synonyms. Enteritis Chronica; Chronic Enterocolitis) This disease is characterized by a chronic inflammation of the mucous membrane of the intestines, which gives rise to various functional dis- turbances of the bowels. Any portion may be affected. Etiology. Chronic intestinal catarrh may arise from an acute enteritis which shows no tendency to recovery, or more frequently from repeated attacks of acute catarrh which follow each other at short intervals before complete recovery occurs. Patients frequently pay no attention to an apparently mild attack and disregard the rules of diet prescribed. As a result, the condition becomes chronic. In other cases, however, chronic catarrh may have an insidious onset from the beginning. Fecal accumulation, notably scybalae, may be a cause of a subacute or chronic catarrh. Pressure of tumors narrowing the canal, as pressure from fibroids of the uterus or adhesions, may be factors. The direct causes of chronic enteritis are the same as in the acute type, and chronic catarrh may be either primary (idiopathic) or secondary to other affections. For the complete etiology the reader should refer to the causes of acute intestinal catarrh. Chronic catarrh may be secondary to diseases of the lungs, especially tuberculosis, and also diseases of the liver, heart, kidneys, and diabetes. Intestinal parasites, tapeworms, round- worms, seat- worms, etc., may be causes by producing irritation. I recently attended a case of splanchnop- tosis, in which there was marked prolapse of the sigmoid flexure with a tendency to fecal accumulation therein. The patient never had an acute enteritis, but for five years has had discomfort in this region, and in- variably every few days the passage of strings of mucus and scybalae. CHRONIC CATARRH OF THK 1XTKSTIXES 653 There were no symptoms of mucous colic. The case was one of chronic catarrh of the sigmoid. The symptoms disappeared under treatment for visceroptosis. The possibility of chronic localized catarrh from viscero- ptosis, associated with fecal accumulation, is worthy of consideration. Chronic appendicitis is suggested as a cause by G. R. Lockwood, and the cure of chronic colitis has followed appendectomy. The rectum should always be examined. Pressure on the rectum from a uterine fibroid I have seen produce partial stenosis with coprostasis above, and resulting intestinal catarrh. Ulcer, fissure, or hemorrhoids may cause not only local manifestations, but catarrh higher up. I have seen a case with chief symptoms pointing to the descending colon and sigmoid, in which an ulcer high in the rectum was the cause. Morbid Anatomy. The anatomic changes in chronic enteritis are similar to those in acute cases, being characterized by hyperemia, swelling of the mucous membrane, and increased secretion of mucus. The color of the mucosa varies from a dark venous red to a pale grayish-red tint; in some cases it may even be gray or slate colored from extravasation of pigment between the glands and at the tips of the villi. The last cases are those of long duration. The surface of the mucous membrane is covered with a transparent viscid mucus and the epithelial cells are cloudy, in a condition of fatty degeneration, and partly desquamated. In the majority of cases of chronic catarrh the accumulations of round cells (which are characteristic of the acute type) are not seen, but there is connective-tissue proliferation in the chronic form. Exceptions. In some of the early cases of chronic enteritis the micro- scopic picture may be much the same as in the acute process; and in other mild cases the only abnormality determined is the accumulation of pigment between the glands, or in the muscularis mucosse and a slight widening of the interstices. As a result of chronic enteritis, hypertrophy, or atrophy of the intestinal mucosa may develop. Hypertrophy of the Intestinal Mucosa. The glands of the mucosa are elongated, tortuous, irregular in shape, and may form diverticula. Their orifices may become occluded through connective-tissue proliferation and there will be a retention of secretion and the formation of cysts (enteritis chronica cystica). Connective-tissue proliferation leads to the formation of polypi (enteritis polyposa), which are more rare, and are usually found in the large intestine. In many cases the walls of the intestines may become thickened throughout, including the muscular coat, to the extent of several times its normal thickness. Woodward reports a few cases of proliferation of the intestinal mucosa with its glands. ^ Atrophy of the Intestinal Mucosa. The clinical entity of atrophy of the intestines has been in considerable dispute, and undoubtedly a pseudo- atrophy due to postmortem change occurs. Riegel, Ewald, and Einhorn believe there is a true intestinal atrophy. In view of the existence of an atrophy of the gastric mucosa resulting from a chronic gastritis and from its occurrence in pernicious anemia, I 654 DISEASES OF THE STOMACH AND INTESTINES am convinced that an atrophy of the intestinal mucosa may occur in ad- vanced cases of chronic intestinal catarrh. The condition I believe to be rare. Such atrophy may originate in the glandular tissue in the glands of Lieberkiihn. There may be an infiltration of round cells, a fatty de- generation, a disintegration, and desquamation or atrophy. On the other hand, it may result from a connective-tissue proliferation compressing the glands. Musgrave believes an atrophic condition of the intestines may follow the chronic catarrh occurring with amebic dysentery. The villi degenerate with the atrophy of the glands, shrink, and become small. No ulceration of the solitary or agminate follicles occurs, and it is a question whether atrophy to any extent ever takes place in them. There is a degeneration of the muscular coat and some thinning of it. Jiirgens 1 has described a fatty degeneration of Meissner's and Auer- bach's plexus and of the muscular tissue, as a special type of intestinal atrophy ; Sasaki records two similar cases dying with the clinical symptoms of pernicious anemia. These conditions probably are related to intestinal atrophy. Atrophy of the mucosa occurs more frequently in the colon, especially in the cecum, ascending colon, or ileum near the valve. Large portions of the intestines are rarely found atrophied, but the process generally involves certain parts. Ulcerated Processes. As in acute enteritis, we may have ulcerative processes in chronic catarrh of the intestines. Superficial erosions of the mucosa may become deeper with the production of ulcers. Rarely they increase sufficiently in depth, and result in erosion of a blood-vessel with hemorrhage, or cause a local peritonitis with or without abscess, or even a perforative peritonitis. Generally the ulcers remain unchanged for a considerable time, or cicatrize; occasionally stricture of the intestines may result. The follicles may occasionally swell up and burst, producing small follicular ulcers. Frequently healing takes place. Extensive ulcerations are seldom met with in chronic enteritis, unless accompanying a tubercular process. The " sago grains " or frog spawn in the feces, formerly believed pathog- nomonic of follicular ulceration, are shown to be of vegetable origin. Kitagawa finds that some of these grains are mucous in character, but this in itself militates against ulceration, as ulcers do not discharge mucus, but pus. The presence of mucus merely indicates catarrh. Symptoms. The chief diagnostic symptoms of chronic intestinal catarrh is the abnormal character of the feces. It seems advisable to first describe the subjective and objective symptoms which occur in many cases. Some patients complain of no subjective symptoms whatever. The majority of cases complain of a feeling of discomfort or occasionally of slight pains in the abdomen. These symptoms are apt to be most marked after eating, usually several hours; or frequently just before or even after defecation. At times these sensations may disturb the patient an hour or two before rising. There is a feeling of tension or bloating of the abdomen which may 1 Berlin, klin. Wochenschr., 1892, p. 357. CHRONIC CATARRH OF THE INTESTINES 655 be relieved by the passage of flatus, and this tendency gives rise to con- siderable annoyance. Flatulence may become so severe as to cause shortness of breath, an asthmatic attack, palpitation, angina pectoris, or cerebral congestion and vertigo, all of which symptoms are alleviated by belching of gas. Flatulence is much more characteristic of chronic enteritis than of the acute type. Borborygmi are often present. Severe pains are usually absent, though slight colicky pains of rather brief character may be present. These are often relieved by bowel movement or by the expulsion of flatus. In some cases the general health is not impaired, while in other cases it is undermined. General nutrition may become impaired, especially if the small intestine is also involved. In the latter case gastric symptoms, such as anorexia and nausea, and occasionally vomiting, may be met with. The patient may feel weak, disinclined to work, be irritable, depressed, and even hypochondriac or melancholic. There may be loss of weight, anemia, slow pulse, cold extremities, and attacks of severe headache. The nervous symptoms are due in part to depression from an evidently chronic and persistent disease, and in a large degree to auto-intoxication. Physical Signs. The abdomen may appear distended, especially a couple of hours after eating, with some tenderness on pressure. In chronic enteritis the colon seems to be more usually affected. Chronic Catarrhal Colitis. There may be chronic catarrhal colitis, with tenderness over the caput coli and ascending colon, with the sensa- tion of a hard mass which yields to the examining finger on pressure (fecal accumulation), or this part may be tympanitic and give the splashing sound from gas and liquid. The same may be true over the descending colon, sigmoid flexure, or transverse colon. There is often tenderness on pressure along the entire colon. Pain is felt directly under the point of pressure, or occasionally at a different point further along the colon, due to the passage of gas, which has been forced along by local pressure. In thin persons peristaltic movements of the intestines are occasionally observed, especially after palpation. In some cases there are no special objective symptoms. The diagnostic symptom in chronic intestinal catarrh is the abnormal character of the stool the presence of mucus. The movements are irregular and the consistence of the stool is variable, but the mucus is diagnostic. Diarrhea is not a constant symptom. Types of Movements. There are five types of movements which occur in chronic enteritis : 1. In one set of cases there is marked constipation, and a solid move- ment occurs only once every two or three days and at times only after a cathartic. The feces are usually hard. It is probably due to a diminished activity of the automatic nervous mechanism of the intestines produced by the catarrh (Nothnagel). 2. In others, constipation and diarrhea alternate; there may be hard movements for several days and these succeeded by five or six thin or mushy movements, mixed with mucus, and accompanied by severe colicky pains. These, in turn, will be followed by constipation, and so 656 DISEASES OF THE STOMACH AND INTESTINES on. In some instances the evacuations will be fairly normal for several days and then diarrheal movements will occur, and after this constipa- tion. Constipation is the chief feature in these cases. The reflex irri- tability of the nervous apparatus, however, is quite good, and decomposi- tion of the stagnating bowel contents eventually causes increased peristalsis with diarrhea. The periods of constipation or diarrhea, on the other hand, may con- tinue for a long time; thus, constipation for several weeks or months, and then diarrhea for weeks or months. Probably in the latter class there is an acute exacerbation of the catarrh. 3. Rare cases occur in which there is a daily evacuation of unformed and mushy feces. 4. Cases in which for months the patients pass several diarrheal stools each day. The small intestine is involved as well as the large bowel, as there is a bile-pigment reaction, as a rule, or there are yellow frag- ments of mucus, or epithelial and round cells tinged with bile. The food, on account of the catarrhal process, is not completely digested in the small intestine, and abnormal products, such as acids, etc., are produced, so that the undigested food and fermenting material give rise to increased peristalsis. 5. In addition, there are some in which the nervous element is a factor combined with the catarrh, and movements occur during the night or early in the morning. F. Delafield 1 describes this type. Diagnosis. The presence of mucus in the feces is characteristic. The type of mucus in mucous colic (Enteritis membranacea), which occurs in large amount, and the symptoms render the differential diagnosis com- paratively easy. In other cases the presence of mucus demonstrates a true catarrh. In habitual constipation there may be a thin shellac-like covering of mucus over the scybalae, and this appearance is not found in chronic enteritis. With chronic catarrh with constipation, the quality of the dejecta may be nearly normal, except there is an admixture of mucus. In rare cases the mucus may be absent, or it may be very tough and adhere to the intestinal wall, or the scybalae may be too small to scrape if off. However, on most occasions, mucus will be present, and if there is doubt, washing of the bowel by means of the tube and funnel will eventually bring it away. Besides the presence of mucus in mucous colic, in some cases of intestinal dyspepsia there is mucus in the stools. Intestinal Dyspepsia. Chronic Enteritis. Pure mucus alone. Stools gelatinous. Mucus with epithelial and round cells Mucus microscopic and seldom visible. (diagnostic) . Green stools with acid reaction; bile-pigment gives pronounced reaction. No fecal odor. Alkaline stools. Fecal odor. The quantity of mucus varies greatly; in most cases there may be only a small or moderate amount. The various combinations of mucus with the stool and the localization 1 Med. Rec., May n, 1905. CHRONIC CATARRH OF THE INTESTINES 657 of the catarrhal process have been described under Acute Enteritis, to which I refer my readers. We may have therefore: (i) Chronic catarrhal enteritis (alone), rare; (2) chronic catarrhal enterocolitis; (3) chronic catarrh of various portions or of the entire colon or of the rectum; thus, chronic catarrh of the caput coli, of the ascending, transverse, or descending colon; or chronic catarrhal sigmoiditis, or proctitis. The colon is most frequently involved. When the movements are watery and thin, the fecal matter is a light brownish yellow or grayish yellow, and may contain little biliary matter. Undigested meat or starch particles can often be seen in these cases. Microscopically. Though nothing may be discovered macroscopically, we may find with the microscope undigested meat-fibers, starch granules and fat droplets, also mucus and round and epithelial cells, at times yellow and shrivelled up. They indicate catarrh of the small intestine. Blood is never present unless due to ulcer, or hemorrhoids. Pus is rarely found and only as isolated cells. Dejecta resembling pus diluted with water (Blenorrhcea intestinalis) shows diphtheritic inflammation when pus is seen in large amount under the microscope. Large masses of epithelial cells in various degrees of degeneration are present in chronic catarrh. They are responsible for the cloudiness in the mucous secretion. The character of the food and of the stool, and whether there is con- stipation or diarrhea, determine the consistence and reaction of the feces and the .degree of fermentation. As a rule, alkaline reaction is present. The presence of fermentation and putrefaction can be de- termined by the abdominal tension, flatus, and character of the stool, which may be fetid and present a foamy surface. Fecal material may be placed in a fermentation tube and kept at blood temperature for several hours, and the degree of fermentation or putrefaction will be shown by the quantity of gas in the tube. The method is described under Testing the Intestinal Functions. The presence of putrefaction will be shown by indican in the urine, and the Rosenbach reaction (Burgundy red) on the addition of nitric acid and boiling. A chronic catarrhal enteritis complicated with ulcers will show marked diarrhea with pus and blood in the stool. If the ulcers occur in the small intestine alone and there is -no diarrhea, pus and blood often will not be present, but there will be more severe pain, more marked tenderness on pressure, and the clinical symptoms will be more severe. Occult blood should be tested for. The diagnosis of the atrophic type of chronic enteritis is extremely difficult. Some question its possibility. There will be a previous history of intestinal catarrh of long standing. Later there will be diarrhea, no mucus, with gradual loss of weight, and at times symptoms of pernicious anemia. Tuberculosis must be excluded. This condition is more frequent in the young. Course. The course of chronic intestinal catarrh is usually very tedious. It may last for many years. There may be periods of perfect health, but there is a tendency to relapses from any slight indiscretion. 42 658 DISEASES OF THE STOMACH AND INTESTINES Differential Diagnosis. The method of localization of the catarrh, as previously stated, is the same as in acute enteritis. Irregular bowel action, with the presence of mucus in the stools of the character described, -associated with abdominal symptoms of discomfort, suggest chronic catarrh. The discharge of mucous colic is characteristic, as are also the symptoms. In the mucus which is occasionally found with intestinal dyspepsia there is an absence of epithelial and round cells, and the stools are green and acid, as I have already stated. In habitual constipation there is an absence of mucus in the move- ments. With marked fecal impaction I have frequently seen a small amount of mucus in the feces due to temporary irritation. After re- moval of the impaction and subsequent care of the bowels there is no further appearance of mucus. Impaction, if neglected or occurring in frequent attacks, may be a cause of local intestinal catarrh, and, as heretofore noted, occasionally of stercoral ulcers. With malignant disease of the intestines, enteritis is often associated, but the cachexia is marked and other symptoms of the neoplasm are present. With intestinal ulcers there are marked pains, local tenderness, and pus and blood in the stool. With enteroptosis we may have a pro- lapse of the sigmoid, fecal accumulation, and chronic catarrhal sig- moiditis. In every case of chronic intestinal catarrh, enteroptosis should be examined for. Rectal examination should be made in every case of chronic intestinal catarrh, as the focus occasionally starts from the rectum and progresses up the bowel as, for example, from an ulcer. On account of its importance I shall devote later a brief section to Proctitis. A uterine fibroid may block the bowel, acting as a ball-valve, and, from fecal accumulation above this point, a marked catarrh of the mucous membrane may result. Chronic appendicitis may result from a chronic intestinal catarrh, while in some cases a chronic appendicitis may act as a focus of irritation for a localized chronic catarrh in the cecum. Removal of the appendix is curative in the last type. In certain diseases of the stomach there may be constipation or diarrhea, but the absence of mucus in the stools and examination of the gastric contents will settle the question. In chronic enteritis of the small intestine alone there are usually gastric symptoms, constipation, yellow tinged mucus in the stools, generally microscopic and well mixed with the feces, and the biliary salts reaction. With chronic catarrhal colitis there is usually more constipation 1 and more or less mucus of a grayish tinge, either covering, or on the surface of the feces or in small strings. Pure mucus may at times be voided at the end of defecation if the lower bowel is affected. Palpation is of value in locating the position of the chronic colitis, as the affected area is apt to be sensitive to pressure. Chronic diarrhea is prominent in cases in which both the small and large intestines are involved, and the mucus may be yellow in color and considerable undigested food is often present. Prognosis. This depends on the severity of the symptoms, the duration of the disease, and the physical condition of the patient, diarrhea, or alternating constipation and diarrhea may occur, however. CHRONIC CATARRH OF THE INTESTINES 659 In the very young, very old, or those weakened by some other disease, such as endocarditis or tuberculosis, severe types of chronic catarrh may be accessory in producing a fatal result. As a rule, the prognosis as to life is favorable, but in tne severer cases of long standing it is not so favorable as to perfect cure. The cases have a tendency to relapse, especially after indiscretions, though they may continue for a considerable time with comparative comfort. The milder cases of not long standing may recover under appropriate treatment. Treatment. The cause of the chronic catarrh should be carefully sought out and corrected. If, for example, endocarditis with resulting circulatory disturbances (which are a predisposing factor) be present, this should receive treatment. The Nauheim bath, even though taken at home by means of the Triton salts, would be of value in such cases. If enteroptosis is present, such as in the case I have described, where there was marked prolapse of the sigmoid, fecal accumulation, and local chronic catarrh, treatment by abdominal support (Rose's belt) and in- creasing the nutrition by the methods described under Gastroptosis would be indicated, in addition to the general treatment for chronic catarrh. I have seen one obstinate, case cured by S. Gant by drawing up and suturing the sigmoid to the abdominal muscles. Angulations of the sigmoid should be corrected. If worms are present, they should be removed. These remarks will sufficiently illustrate the necessity for investigation of the cause of the catarrh. Hygienic and dietetic measures are of great importance. The patient should regulate his life carefully, not overwork nor be under too great business strain, eat slowly and at regular hours, and live in the open air as much as possible. In the constipated cases consider- able exercise is of value. When the diarrhea is marked the patient should keep quiet during its active stage, and in some cases remain in bed until it has passed. Nervous disturbances should be avoided. The patient should exercise care not to wet the feet or undergo exposure to cold, and should be properly protected in rainy weather. A flannel band about the abdomen is of value. Change of scene and climate are often serviceable. Diet. The patient should eat at regular hours, slowly, and masticate thoroughly. It is preferable to give small meals more frequently than three large meals, and sufficient nourishment should be administered so that there is an increase in weight. Fried foods, hot breads, rich pastries, desserts, and indigestible sub- stances should be avoided. Though some allow the very moderate use of light wines, and occasionally beer or ale, in constipated cases, and the use of claret in diarrhea, in my own experience, I find that patients with catarrhal conditions of the gastro-intestinal tract do much better by eliminating alcoholic beverages altogether. The character of the diet is dependent upon whether diarrhea or constipation is present. In diarrheal cases, if the type be severe, milk and lime-water equal parts, or boiled milk, or milk and barley-water, or rice-water in combina- 660 DISEASES OF THE STOMACH AND INTESTINES tion, often are efficacious, though some patients have an idiosyncrasy to milk. Rest in bed for a brief period may be necessary. Koumiss, matzoon, bacillac, fermillac or lactone-buttermilk are often useful in such cases, though with some these preparations are objection- able, increasing the diarrhea, also raw eggs beaten in milk, may be of value. In milder cases of diarrhea the diet may be more liberal. Carbonated waters, lemonade, fruits, salads, acids, cabbage, cauliflower, rye bread, brown bread, ice-cream, pastries, oatmeal, green vegetables, corn and beans, turnips, carrots, beets, radishes, celery, and lobster should be avoided. Mashed and baked potatoes, rice, sago, macaroni, bread well baked and toasted, with a moderate amount of butter, cream, soups, bouillon, soft-boiled or scrambled eggs, sweet-breads, calves' brains, chicken, lamb chops, lean fish, cocoa, tea and milk, or matzoon (with some) can be given. The drinks should not be too hot or too colds, and an excess of liquid should be avoided. In constipated cases the diet must be more liberal. In addition to the food mentioned above, fruits, such as oranges, ripe pears, grapes, green vegetables, such as spinach, peas, lettuce, cauliflower, plenty of butter, cream, and fluids are of service, whole wheat crackers are useful. Cabbage, cucumbers, brown bread, sausages, lobster, and mayonnaise dressing, should be avoided in these cases also. Bran biscuits are of value. The urine findings should modify the diet if indicanuria, less meat or none for a time; if intestinal fermentation, less vegetables; if nephritis, an appropriate diet. Massage. In cases characterized by chronic constipation, gentle massage over the course of the colon or the use of a light cannon-ball is indicated. No pressure should be exerted on the ball, but it should be rolled along the colon for five minutes morning and night. Light vibratory massage is of value under similar conditions. Hydrotherapy. Warm salt baths at 98 to iooF., or Nauheim baths (artificial), eight to ten minutes every other day for two or three weeks, or pine-needle baths, bran baths, or mud baths may be of some service in some diarrheal cases. Cold baths should be avoided in diarrhea. A Priessnitz wet pack over the abdomen is of value when applied on retiring. Cold showers and cold sponges are of service in nervous cases. Cold sitz-baths and cold douches over the abdomen are of use in constipated cases, but should be preferably carried out at some sanatorium. I have rarely found the latter methods necessary, but use the artificial Nauheim, pine-needle, or bran- baths, also the cold compress to a considerable extent. Mineral Waters. A methodic course of drinking certain alkaline or saline mineral waters has proved beneficial in many cases. When taken at the springs, the patient is obliged to follow a rational method of life and diet and is free from worry, and thus receives additional benefit. Carlsbad is especially valuable when there is a tendency to diarrhea, and Vichy is next. 66 1 In cases of marked constipation, Marienbad is of service, and also the Hawthorne and Congress Springs at Saratoga. Virginia Hot Springs are also to be recommended. Where neither diarrhea nor constipation are prominent, Kissengen or Homberg; with constipation and anemia, Franzensbad and Elster. Carlsbad water should be taken in small quantities, a wineglassful twice a day, or small amounts of the imported salts, 30 to 60 grains (2.0 to 4.0), three to five times a day. It is preferable to begin with small doses. Some do badly with this method. If the diarrhea increases so that the patient begins to lose weight, the treatment should be dis- continued at once. Medication. The method of internal medication depends upon whether constipation or diarrhea is the existing condition. As a prelimi- nary it is always wise to begin treatment with a thorough cleansing of the intestines by a single dose of castor oil, i^ ounces (45.0), or a good dose of Carlsbad salts or magnesium sulphate. If there be marked fecal accumulation, it is better first to employ enteroclysis or enemata, to remove the impaction, and then follow with the single cathartic. In constipated cases, fruits, buttermilk, cold water (glass) on rising, stewed fruits, and a regular hour for attempted stool are all rational. An enema, olive oil, 4 ounces (125.0), increasing to i pint (500 c.c.) or more, given slowly by a long tube on retiring, and to be retained, is an excellent procedure. It may be necessary to employ soapsuds enema (never over i quart) or normal salt solution. Russian or American mineral oil at night may be required. Rhubarb pills, fluidextract of cascara in i-dram (4.0) doses, or the same quantity of aromatic fluid- extract of cascara, regulin, or podophyllin pills are of service. Carlsbad water has been given by enema. Small doses of castor oil or olive oil combined with salol are of considerable value in all cases. Thus: Salol, $-grain (0.3) tablet; with it give castor oil, 10 minims (0.59), in a soft gelatin capsule coated with shellac, four times a day; or olive oil can be substituted. The gelatin capsules containing salol and castor oil can be secured already prepared. In the constipated cases larger doses of olive oil by mouth, i to 4 ounces (30.0-125.0) t.i.d., are of service. The oil preparations seem to have an excellent effect on the mucous membrane. Lead and zinc preparations I do not employ. Nitrate of silver is sometimes of service. It can be given in aqueous solution, each i dram containing % to Y grain (0.011-0.016), being kept in a dark bottle, or the same dosage in an enteric coating. The following pill, % grain (0.008), of silver nitrate is excellent: fy Argenti nitratis gr. v (0.3) Resin turpentine "1 . _ . , ,. Liq. potass. ' ' aa 3j (4 ' o) Pulv. licorice q. s. M. Div. in pil. No. xl. Sig. One pill t.i.d. 662 DISEASES OF THE STOMACH AND INTESTINES Bismuth salicylate, 5 to 10 grains (0.30.6) t.i.d., is of some value, but a movement should be secured every day if it is given in the constipated cases. The bismuth and tannin preparations are of special value in the diarrheal cases, the dosage being dependent on their severity. The movements should be reduced to one or, at the most, two a day. Opiates I always avoid, if possible. Bismuth subnitrate, 10 to 20 grains (0.6-1.3) three or four times a day or more, alone or combined with chalk mixture. Bismuth salicylate, 5 to 10 grains (0.3-0.6) t.i.d., combined with sub- nitrate bismuth; or bismuth subcarbonate, 10 to 20 grains (0.6-1.3) t.i.d.; or bismuth subgallate, 5 to 10 grains (0.3-0.6) t.i.d. Tannigen, tannalbin, or tannopin, 5 to 15 grains (0.3-1.0) t.i.d, Beta-naphthol-bismuth, 5 grains (0.3) three or four times a day, if there is fermentation. For some of the combinations with kino, catechu, etc., I refer to treatment of Acute Enteritis. Belladonna can be used for pains, but codein and morphin rarely should be employed. Local Treatment. This is of great importance, especially when the large intestine is involved, which is usual. This method may be em- ployed by an enema of i pint (500 c.c.) to i or even 2 quarts (liters) of the solution, preferably employing several quarts (liters), with the re- current tube or two tubes. If possible I use my own rectal irrigator of hard rubber, or, if the rectum is sensitive, the soft-rubber tube or two catheters. Normal saline solution i dram (4.0) salt to i pint (500 c.c.) water at 105 to noF. is excellent if there is much pain. Oil of peppermint (10 drops) can be added to this. Flaxseed tea at the same temperature is useful. Slippery elm solution and gum-arabic solution are excellent soothing applications. Listerin, glycothymolin, borolyptol, and boric acid, i to 2 drams (4.0-8.0) to the quart, are of service. Tannin, gr. 10 to 20 (0.6-1.3) to the quart (liter); zinc sulphocarbolate, 10 to 15 grains (0.6-1.0); or borax, i dram (4.0) to the quart, are good astringents; salicylic acid, 15 grains (i.o) to the quart (liter); irrigation once a day or every other day is of value. I often employ flaxseed tea or gum-arabic one day, and one of the mild antiseptics or astringents the following day. In obstinate cases, nitrate of silver solution, 10 to 20 grains (0.6- 1.3) to a quart (liter), given once or twice a week, is a valuable adjunct. If the patient complains of pain, a subsequent injection of normal saline solution is of service. The bowels should be thoroughly emptied, preferably an enema given an hour or two before local treatment. Protargol or argyrol (1:1000 or 1:1500) is of service in place of the silver nitrate. Rectal inflation with oxygen has been advocated by Gross 1 particularly when fermentation and putrefaction are associated with the catarrh. 1 Med. Rec., Nov. 30, 1912. PROCTITIS 663 Surgery. In cases with evident ulceration, if no benefit results from medical treatment conscientiously applied for a year, I would advocate appendicostomy or cecostomy with subsequent intestinal irrigations. In catarrh without ulcers, I do not believe operation is indicated. PROCTITIS The rectum is very liable to bacterial infection, both from within and without, through the anal opening, so that ulcerations and periproctitis may occur. I will briefly refer to this disease, merely to serve as an index to the practitioner. Etiology. As this condition is often a part of chronic enteritis, the etiologic factors may be identical. Local conditions may also produce it; thus, traumatism, as by a syringe-tip; sodomy; impacted feces; worms; foreign bodies introduced through the rectum or lodged there during their passage from above, such as fish-bones, pins, etc., hemorrhoids, polypi; prolapse, intussusception; tumors; pressure from other organs; displace- ment of the uterus; stone in the bladder; inflammation of adjacent organs, such as uterus, tubes, prostate, or seminal vesicles. Sitting on cold stones or wet seats may be a cause. Idiosyncrasies to certain foods seem to be a factor. Proctitis is classified as follows: 1. Acute simple catarrhal proctitis. 2. Chronic proctitis: Atrophic form; hypertrophic form. 3. Specific forms: Gonorrheal, dysenteric, diphtheritic, erysipelatous, and syphilitic proctitis. Pathology. With simple catarrh there is no pus, except possibly a minute amount. With ulceration there are pus and blood. The acute and chronic types of intestinal catarrh have already been described. It is preferable to examine pus (if such is present) for gonor- rhea, especially if there be a gonorrheal vaginitis, and it may even pass by extension from Bartholin's glands. Erysipelas may extend from without. Pseudomembranes occur with the diphtheritic type. Amebae, or the bacilli dysenteriae, are found with the dysenteric type. We may have the primary chancre of syphilis in the rectum, in which case relaxation of the sphincter will also be noted, or there may be secondary ulceration and catarrh. The test for Wasser- mann's or Noguchi's reaction should be made if syphilis is suspected. Actinomycosis may rarely occur. Primary rectal infection from the larvae of flies (myiasis) has been re- ported by Nicholson. 1 The patients all suffered from hemorrhoids with rectal prolapse and exposure of the rectal mucosa to fly infection thus resulted. Protection of the prolapsed mucosa prevented subsequent infection. Symptoms. They have been described. They are: Marked strain- ing and tenesmus; passage of mucus with the stool, or mucus alone with pus and blood if ulceration is present; frequent micturition; throbbing heat and weight in the rectum. Constipation at first, later diarrhea; heavy 1 Jour. Amer. Med. Assoc., May 21, 1910. 664 DISEASES OF THE STOMACH AND INTESTINES and aching pain in the rectum and down the limbs; often pruritus and prolapse of the rectal mucous membrane or hemorrhoids; temperature in the acute cases; coated tongue; abscesses of the rectum may develop. The chronic cases present less severe symptoms, and no temperature. Thus, there may be pain referred to the rectum, or a feeling of weight and pressure within the pelvis or over the sacrum. There may be reflex pain down the left leg, simulating sciatica, dysmenorrhea, dysuria with no discoverable lesions in the geni to-urinary tract, swelling of the left leg, anemia, and loss of weight. In young children there are often picking the nose, scratching the anus, straining and protrusion at stool, as symptoms. Mucus, pus, or blood may be found in the feces. Digital examination is painful on account of spasm, and the rectum will be found to be very sensitive and hot to the feel. If the inflammation extend deeper into the tissues, it will feel hard and rigid. By speculum examination it will be seen to be a deep red, with hemor- rhages and erosions. Often the condition is so painful that it is not ad- visable to use a speculum at first. The chronic cases run a less severe course. Complications : Periproctitis or ischiorectal abscess may occur. Treatment. Recurrent rectal irrigation with hot normal saline solu- tion at noF., or in other cases with cold saline solution at 50 to 7oF., with the patient in the Sims posture for fifteen minutes' duration, is of value, once or twice a day, to relieve inflammation. Flaxseed-tea irriga- tion is also useful, or the other antiseptics described under Chronic Enteritis. Injection of hydrastis, i to 2 per cent., or aqueous fluidextract of krameria (J. P. Tuttle), 5 to 20 per cent., several quarts, are of service in some cases. Carbolic acid solutions should never be employed. In the acute conditions I do not care to employ nitrate of silver at first, though later i : 2000 every day or two is of value. Argyrol or protargol (i : 500 or i : 1000) is less irritating. Tuttle suggests the use of the following by injection to quiet irritation after local treatment. !$. Flaxseed tea 5 J (3-o); Opium gr. ss to j (0.32-0.065) ; Aqueous fl. ext. krameria itjjxxx (1.77). M. A suppository of opium and iodoform may be substituted. If there is marked purulent inflammation, then twice daily irrigate with : Peroxid of hydrogen 8 to 10 per cent., or i : 1000 acetozone or alpha- zone, or even i : 10,000 bichlorid of mercury once in twenty-four hours. The latter should be used by the recurrent method only. The bowel should be irrigated well with saline solution after each movement and medicated solutions used once or twice a day. Injections of starch and laudanum should only be used once or twice a day in severe cases to relieve irritability. After the acute stage has passed S. Gant recommends spraying the rectum with permanganate of potassium (i : 3000), or with zinc sulphate, copper sulphate, or nitrate of silver, i per cent. PHLEGMONOUS (PURULENT) ENTERITIS 665 In chronic cases irrigation with nitrate of silver (i : 2000 to i 14000) is of value, every two or three days, or with protargol or argyrol 1-1500 to i-iooo. I have seen an excellent result in a severe chronic case from the injec- tion of the aqueous fluidextract of krameria, suggested by J. P. Tuttle. His formula is as follows: Macerate i pound of bark of krameria in a long percolating tube twenty-four hours. After this a mixture of glycerin (20 per cent.) and water (80 per- cent.) is allowed to percolate through it. The percolate should be constantly stirred and refiltered through the bark a second time. The filtrate is then evaporated down to i pound, thus obtaining an aqueous fluidextract containing gram for gram all the therapeutic proper- ties of the bark. The preparation should be kept in a dark place and not exposed to air. A 10 to 20 per cent, solution of this can be used for irrigation, or a local application of it pure. The diet and internal medication should be the same as described under Chronic Enteritis. Syphilis, if present, should be treated by "606," neosalvarsan or mercury and the iodids. Warm sitz-baths aid in relieving pain. PHLEGMONOUS (PURULENT) ENTERITIS This disease, a purulent inflammation of the submucous tissue of the intestines, is rare as a primary process. It is probably due to streptococcic infection, the jejunum being most frequently involved. Several epidemics have been reported among children one at the Sheltering Arms in 1910 and another in 1913. The stools were very offensive and complications such as septic pneumonia, otitis and menin- gitis occurred. Bartley 1 reports six deaths out of 25 cases. This condition is evidently less fatal in children than in adults. Peritonitis is often present, but the purulent enteritis cannot usually be diagnosed as the cause, in my opinion until after operation. The writer has seen one case which was secondary to intestinal ulcers, where the bacteria (streptococci) appeared in great quantities in the stool. Autogenous vaccines and local irrigation (intestinal) were advised. Phlegmonous enteritis may be secondary to intestinal ulceration, to intussusception, or strangulated hernia. Maragliano has reported septic infection of the ileum probably by the colon bacillus, with hemorrhage, ulceration, and peritonitis. The large intestine may be involved and Dowd 2 reports such a case, with recovery after resection and enter o enter ostomy. The staphylococcus pyogenes aureus, Bacillus proteus, etc., may also be responsible for phlegmonous enteritis. Delafield and Prudden 3 refer to a fatal necrotic colitis septic in character as does Ziegler 4 and gangrenous enteritis with acute phlegmonous cholecystitis 5 has been reported. 1 N. Y. State Journal of Medicine, Dec., 1914. 2 N. Y. Surg. Soc., Mar. 27, 1912. 3 Handbook of Path. Anat. and Histol., gth Ed., p. 681. 4 Text-book of Spec. Pathol. Anatomy., loth Ed., p. 662. 6 Med. Rec., Dec. 13, 1913. CHAPTER XXVI DYSENTERY DYSENTERY is defined as an infectious disease characterized by specific ulcenations of the large intestine. In typic acute cases it gives rise to bloody mucus or mucopurulent dejections, accompanied by tenesmus and general symptoms. Dysentery was known to .the ancient world, being first described accurately by Hippocrates 430 B. c., and later by Celsus, Aretaeus, and Galen. In 1506 the first records of postmortem examinations of dysenteric subjects were published in the posthumous work of Antonio Benevieni. Following these came many writers, among whom I shall mention a few of the most prominent of recent years: Cruveilhier, Virchow, Wood- ward, Lambl, Loesch, Kartulis, Quincke, Roos, Musser, Osier, Stengel, Stockton, Harris, Councilman, Lafleur, Ogata, Shiga, Russell, Flexner, His, Barker, Duval, Bassett, Vedder, Musgrave, Strong, Craig, and Thomas. It has been demonstrated that the disease is due to infections of a specific type either to the amoeba dysenteriae, or to the Bacillus dysenteriae (Shiga) or one of its strains. The disease is transmitted in the same way as is typhoid fever. It sometimes assumes a diphtheritic type, in which case other bacteria are undoubtedly associated. In the ileocolitis.of infants, dysenteric bacilli of various strains have been discovered, and some of these cases, both clinically and pathologically , present the appearance of an acute catarrh. The so-called acute catarrhal dysentery, the sporadic form, I believe, is undoubtedly due to the Bacillus dysenteriae or one of its strains. DIPHTHERITIC DYSENTERY Diphtheritic dysentery (or, more strictly speaking, pseudodiphtheritic, as Klebs-Loffler bacillus is not present] has been shown in many cases to be due to the Bacillus dysenteriae. Undoubtedly mixed infections with other bacteria are found in this type. They may be found in combination with amebic dysentery, and, in addition, in some of the amebic liver abscesses numerous other bacteria are present, which demonstrate mixed infection from other sources. Secondary diphtheritic dysentery is a common terminal event in many acute and chronic diseases; and Vedder and Duval have demonstrated that the Bacillus dysenteriae is present in these cases. Diphtheritic dysentery in which the diplococcus pneumoniae has been isolated has been several times reported. In addition, mercurial poison- ing or uremia may have this lesion associated. It is evident, therefore, 666 DYSENTERY 667 that other bacteria, either present in, or entering the intestinal tract under favorable conditions, may produce this lesion. PREDISPOSING CAUSES AND CLIMATIC LOCATION Many causes were formerly given for the production of dysentery, but we may say that, they only predispose to infection, on account of weakening the organism, producing intestinal disturbances. In the case of overcrowding in asylums and camps, there is a tendency to unsanitary conditions. By inattention to the proper relation of the latrines to the water-supply, for example, there may result a severe epidemic. Dysentery is found in all parts of the world, but is endemic and often epidemic. It is most common in warm climates, such as the southern United States, Cuba, the Philippines, southern coast-line of Asia, Africa, Egypt, Mexico, Central and South America. It has been met with in cold climes, as in North Russia and Greenland; is sporadic in all parts of the United States and occasionally epidemic. Severe epidemics have occurred in the New England States. During the Civil War, Woodward collected 259,071 cases of acute dysentery and 28,451 of chronic dysentery in the Federal service. During the recent Spanish-American War the mortality from dysentery and typhoid was far in excess of that from battle; and in the African War the English troops suffered severely. In the Russo-Japanese War the deaths in the Japanese army from dysentery and typhoid were infini- tesimal in number, demonstrating that by intelligent care of the water- supply and proper sanitation epidemics of dysentery can be absolutely stamped out. Dampness, overcrowding, and imperfect ventilation vitiate the system, and so predispose to subsequent infection. With overcrowding and necessarily insufficient and improper attention to sanitary conditions, infection from the dejecta can readily occur, if a sporadic case develop. Heat and moisture predispose to intestinal disturbances, and readily cause changes in fresh fruits or canned material, if improperly cared for, which in turn produce diarrheal disturbances, and cause susceptibility to infection. Sudden alternations from heat to cold produce the same result. Errors in diet are predisposing causes. No race or age is exempt from dysentery, and a person going from his native to a warm climate with the sudden change in food and mode of life incident thereto is probably more susceptible. Dysentery is more fatal among the poor and ill-nourished than among the rich, though the latter are not exempt. It is probably more prevalent in epidemic and endemic form in small country towns, villages, and farms, where one so frequently sees the well in close proximity to the privy, a stagnant pool, or the family cow-yard. Dysentery may be endemic, the so-called tropical dysentery; epidemic or diphtheritic; and sporadic (the acute catarrhal dysentery). It is classified as follows: i. Amebic 'dysentery, in which there is at times a mixed infection (diphtheritic process). 668 DISEASES OF THE STOMACH AND INTESTINES 2. Bacillary dysentery (Shiga), or one of its strains, under which are included the sporadic type (acute catarrhal), which probably belongs to this classification, as a catarrhal type (ileocolitis) exists in infants. The diphtheritic type is included and also the secondary diphtheritic type, which may be a terminal event in acute and chronic disease, and in which Vedder and Duval have demonstrated the presence of the Bacillus dysenteriae. Undoubtedly other varieties of bacteria play a part in the diphtheritic type. AMEBIC DYSENTERY (Synonym. Intestinal Amebiosis) Definition. A colitis, latent, subacute, acute, or chronic, caused by the amoeba dysenteriae. There is a special liability to formation of abscess of the liver. Often these cases occur without the clinical symptoms of dysentery at all. I agree with Musgrave that the condition should be more correctly given the name of "intestinal amebiosis." The disease is widely prevalent in Egypt, India, the Philippines, West Indies, Southern States, and in tropical countries. It occurs fre- quently in the United States, and much more in many of our cities than is generally supposed. I have recently attended a case clearly infected in New York State, the patient having never been south. The late J. P. Tuttle has reported similar cases, as have H. S. Patterson, 1 Stockton, Graser, Braunan, Harvey, 2 and Carey. It is endemic, especially in warm climates, and often becomes epidemic. Sporadic cases occur in tem- perate climates. In Manila, Strong states that out of 1328 cases in the United States army, 561 were of the amebic type. At the Johns Hopkins Hospital, Osier reports most of the acute and chronic cases of dysentery were of the amebic variety; during the first fourteen years there were 119 cases admitted, 95 of which came from Maryland 108 males anc^n females. Source of Infection. Chiefly from contaminated water or green vegetables and fruit. Musgrave has found the ameba in ice-cream and water-ices. Allen 3 reports two cases of apparent contact infection in amebiosis, probably from the ingestion of dried encysted amebae. These occurred in a tenement, the mother nursing a case, and preparing all food for the family, with subsequent development in other children. Amoeba Dysenteriae. Lambl first described amebae in the stools in 1859, and in 1857 Loe'sch investigated the stools of a dysenteric patient and described the amebae. He injected the stools into the intestines of dogs and produced ulceration. Osier, Councilman, Lafleur, Dock, Quincke, Roos, Musgrave, Strong, and many others have carried on investigations. 1 Med. Rec., May 14, 1910. 2 N. Y. Med. Jour., Jan. 21, 1911. 3 Med. Rec., Jan, 8, 1910. DYSENTERY 669 To obtain a specimen for examination little flakes of mucus or pus should be selected, or the mucus may be secured by passing a soft catheter, or through a speculum. Preferably a saline cathartic should be admin- istered, as suggested by Musgrave, and the fluid portion of the stool examined while warm. The author in his previous remarks referred to the value of the thermos bottle to preserve a warm stool. The latter should be passed into a vessel previously warmed with hot water. A portion of the stool, particularly that part containing mucus, should be placed in the thermos bottle (or cheap vacuum bottle) and a few ounces (2 to 3) normal saline solution at ioiF. should be added to it. Swollen, altered epithelial Fig. 287. Amebae from a culture. Impression preparation. Borrel's stain (Woolley and Musgrave). cells must be distinguished from the amebae. The cells are round with granular protoplasm. Amoeba dysenteries is from 15 to 20 microns in diameter, and consists of a clear outer zone, or ectosarc, and a granular inner zone (endosarc), and contains a nucleus and one or two vacuoles (Fig. 287). The movements are similar to an ordinary ameba, consisting of a slight protrusion of the protoplasm. They vary somewhat and can be intensified by having the slide heated. They have a pale green appearance under the microscope. Red blood-corpuscles are at times contained in the ame- bae, and occasionally bacteria. Musgrave recommends Borrel's stain for the study of amebae in the tissues. 670 DISEASES OF THE STOMACH AND INTESTINES They may be in large numbers in the tissues. In the pus of a liver abscess amebae may be abundant. In the sputum from a pulmonary in- fection from an hepatic abscess they can be recognized. Quincke and Roos describe three varieties of amebae in the stools of healthy persons, and Strong two types, only one of which is pathogenic. Allen 1 holds that amebae are frequently found in the stools of pellagrins, and that they may be of a pathogenic or non-pathogenic variety ; amebiosis may complicate pellagra or the diagnosis may be confused. Exclusion of amebiosis is necessary. Musgrave and Clegg do not think it has been proved there are amebae non-pathogenic to man. They hold that all such are, or may become, pathogenic. Craig 2 believes the types can be differentiated and Schaudinn classifies two varieties. Amoeba dysenteriae can be grown in cultures from stools or intestinal ulcers, but not alone as a pure culture. A symbiotic organism is necessary for its development. It has been isolated as a pure culture, in combina- tion with a pure culture of another organism. Fivea, Celli, and Miller claim to have grown it pure, and that it multiplies by division. Resistant forms of the ameba have been described by Cunningham and Quincke. They are apparently analogous to the gamete forms of the malarial parasite. The "encysted amebae" seem, under certain conditions, to be neces- sary for the transmission of the disease from one person to another, and are regarded by Musgrave and Clegg as the most dangerous type. The free unprotected amebae, when swallowed, are apparently destroyed by the digestive juices, while in the encysted condition they pass through the stomach and upper intestine unharmed, and in the large intestine grow free and produce dysentery. 3 Cultures of amebae have withstood drying for fifteen months. Location of Lesions. The lesions are found in the large intestine, rarely in the lower end of the ileum; and abscess of the liver is a common accompaniment, being present in 22 per cent, of Osier's cases. Pathology of Amebic Dysentery. Intestines. Though writers refer to the classic undermined type of ulcer in amebic dysentery, three types of lesions are described, which may shade gradually into each other: 1. Pre-idceration. This stage is characterized by the presence of the "small red dots" of Rogers, varying from 0.2 to 0.5 mm. in diameter, and which are intensely congested (Fig. 288). They consist of capillary hem- orrhages into the intraglandular tissue. Erosion of the superficial layers of mucous membrane is usually associated. There is moderate injection of the mucous membrane and but little thickening of the submucosa. These lesions may be seen in any part of the affected gut, and chiefly in the acute cases. In view of the presence of this pre-ulcerative stage, Musgrave believes that sometime in the future we may recognize an amebic colitis without ulceration of the mucosa. 2. Ulceration (type of Harris) rarer than the classic type, and believed 1 N. Y. Med. Jour., Dec. 18, 1909. 2 Jour. Infec. Dis., June 4, 1908, v, 324. 3 Marshall, Jour. Amer. Med. Assoc., April 23, 1910. DYSENTERY 671 , Fig. 288. Intestinal amebiosis. Cecum. Shows all stages of ulceration. The smallest black points indicate the positions of pre-ulcerative lesions (Woolley and Musgrave). Fig. 289. Intestinal amebiosis. Rectum. Extensive ulceration and diphtheritis. Thick-walled gut (Woolley and Musgrave). 672 DISEASES OF THE STOMACH AND INTESTINES to be intermediate between the petechiae and "undermined" ulcer. They are probably the result of the superficial erosions, and are primarily con- fined to the mucous membrane, though they reach into the submucosa or to the circular muscle, but no deeper (Fig. 290). They spread laterally. The ulcer has a punched-out appearance and is round or oval, the edges thick and congested. Base is clean, gray and edematous. They often lie at the apex of the intestinal fold and tend to increase in the direction of the short axis of the bowel, and are found in all regions, but less often in the advanced or chronic cases. They are most common in the ileum. 3. Classic or Undermined Ulcers. In the early stage they appear as minute yellow or gray spots in the mucosa, at times at the centers of Fig. 290.' Early intestinal lesion. Shows superficial necrosis, glandular dis- tortion, and round-cell infiltration. Borrel's stain. Zeiss obj. A, A, oc. comp. 4 bellows at 30 cm. (Woolley and Musgrave). "Rogers' red dots," and are usually surrounded by a congested area. These spots are the mouths of passages leading to cavities in the sub- mucosa; the mouths and cavities are filled with necrotic material. As the ulcerative process extends, the cavity in the submucosa is enlarged, and though the necrobiosis eventually involves all the coats, the muscular layers and mucosa are affected less rapidly, and the latter may be markedly undermined. The ulcers may gradually coalesce on the sur- face, or quite frequently the cavities in the submucosa may communicate with each other by tunnels, while the mucous membrane shows a catarrhal condition. The submucosa becomes thickened and edematous, as do often the muscular layers and peritoneal coat (Fig. 291). The ulcers may be from the size of a pin-head to the palm of the hand. DYSENTERY In extensive ulceration the muscular layer may become necrosed or even perforated, and the base of the ulcer be formed by peritoneum or omentum. The omentum plays an important protective part, being frequently, early in the ulcerative stage, found adherent to the surface of the intestines. Localized suppuration is, therefore, common. Ulcers may perforate into the subperitoneal or retroperitoneal tissue. They are usually circum- scribed, though they may burrow (Fig. 292). Fig. 291. Colon. A moderately thick- Fig. 292. Colon. Thin-walled gut, ened gut with various types of ulcers (Wool- with shallow ulcers, some slightly un- ley and Musgrave). dermined, others punched out (Woolley and Musgrave). Healing Process. In the case of the small ulcers there may be complete repair, the epithelium from the mucous membrane lining the ulcer, except its base. In larger ulcers there may be considerable scar tissue, which may lead to contraction. J. Cantlie, 1 in the Journal of Tropical Medicine, suggests that amebic infection is probably much more common than is usually supposed. It is known that quite extensive infection can exist 1 Amer. Med., March, 1910. 43 674 DISEASES OF THE STOMACH AND INTESTINES without symptoms. He believes that some cases of stricture, or cancer of the sigmoid and rectum especially, may be postdysenteric conditions. According to Musgrave's observation, there is established in cases of long duration not systematically treated, a chronic catarrhal condition with subsequent atrophy (enteritis chronica atrophicans), a thinness of the bowel, absence of normal folds, atrophy of the mucosa, and increased length; and he places it in the classification of sprue or psilosis, believing untreated amebiosis to be one of the causes of this condition. There may be, on the other hand, in some cases localized hypertrophy with well- developed polypi. Location of the Lesions. Harris believes that in fully one-half the cases the lesions do not extend beyond the beginning of the transverse colon; Fig. 293. Amebae in a blood-vessel; X 500. Heidenhain iron hematoxylin (Woolley and Musgrave). while Rogers holds that they are more frequently limited to the cecum and ascending colon. The ileum just above the ileocecal valve is rarely involved, and generally by only a few ulcers (superficial) and a slight in- volvement may occur if diphtheritic inflammation complicates. The lower rectum is rarely involved. Strong and Musgrave, comparing 200 cases treated and untreated, find 159 cases involve the entire large bowel, excepting the lower rectum; 23, the cecum and ascending colon; 2, the transverse colon; the descending colon, sigmoid, and rectum, 9; unrecorded, 7; appendix ulcerated, 2 (amebic); appendix involved with large intestine, 14; ileum with large intestine, 7. The presence or absence of irrigation treatment makes a difference. DYSENTERY 675 In cases dying early from intermittent disease, ulceration in the cecum and ascending colon, n; in descending colon, sigmoid, and rectum, 8; in the entire bowel, 6. Microscopic, Mucous membrane between the ulcers is little changed. In the neighborhood of the lesions a tendency to hypertrophy with mucoid degeneration and cyst formation. In the early lesions, congestion with capillary hemorrhages and edema of the mucosa; increase of lymphoid cells in the interglandular tissue. Amebae from 4 to 35/4 long are present in the glands, interglandular tissues and blood-vessels, muscularis mucosa, and in the veins of the sub- mucosa (Fig. 293). In the more advanced condition there is necrobiosis (coagulation necrosis) in the ulcers, with lymphoid infiltration, congestion and throm- bosis, and very little polymorpholeukocytic invasion. The amebae secre- tion and thrombosis both tend to produce the necrobiosis. If there is marked polymorphonuclear infiltration, pathogenic bacteria are playing an active part in the process; noticeably then there is diph- theritic inflammation (Fig. 289) or gangrene. When amebae are found in exudates rich in bacteria, they show evidences of active phagocytosis. In some cases there are many bacteria, but they are probably non-patho- genic, as marke 1 leukocytosis was not present and no process could be seen to be attributed to them. "In effect, intestinal amebiosis may be said to be rather a subacute chronic inflammatory process, as was demonstrated by the character of the exudate and infiltration, by the early formation of granulation tissue, and by the absence of leukocytic infiltration, a notable absence of puru- lent inflammation. This applies to the cases not complicated by diph- theritic process or gangrene" (Musgrave). If the diphtheritic process is associated, some strain of the bacillary type is probably responsible; and if gangrene, some other bacteria (mixed infection). Lesions (Abscesses) of the Liver. There may be local necroses of the parenchyma scattered throughout this organ, due to probable chemic products of the amebae, and also abscesses. This is quite a common complication of amebic dysentery, and occurred in 27 out of Osier's 119 cases. In most cases the right lobe is involved either alone or with other portions. In 40 per cent, to 65 per cent, the abscess is solitary, particularly in the dome of the right lobe. In the majority of cases the abscesses lie rather close to the surface. Under ten years of age and over sixty, they are rare. They occur most frequently in young adult males. Abscess of the liver is infrequent among the natives such as the Filipinos and rare among the Chinese, though intestinal ame- biosis is prevalent. Amebic abscess is most apt to occur among the unacclimated. The portal venous system is the usual channel of transmission of the amebae to the liver, though occasionally they may follow directly con- tinuous tissue. Most of the so-called amebic liver abscesses are really local necroses and no pus at all. They may be single or multiple; when single, the right 676 DISEASES OF THE STOMACH AND INTESTINES lobe is most commonly affected on the convex surface near the attachment to the diaphragm, or on the concave surface near the bowel. Multiple abscesses (small and superficial), miliary, containing amebae, may be scattered throughout the liver substance. The hepatic abscess, though it often occurs within the first two to three months after the onset of the dysentery, in some cases may not appear for several years. Some cases are reported as occurring when no dysenteric symptoms had apparently been complained of by the patient. In the early stage the abscesses are a grayish-yellow color, sharply defined in shape, and contain a spongy necrotic material, with more or less glairy semitransparent fluid in the interstices. The larger abscesses have ragged necrotic walls and contain a viscid greenish-yellow or reddish- yellow purulent appearing material, mixed with blood and shreds of liver tissue. Old abscesses of a chronic type have a dense fibrous wall. The outer zone is hyperemic; the midzone shows proliferations of connective-tissue cells, compression and atrophy of the liver cells, and an inner necrotic zone. There is the same absence of true purulent inflammation as in the intestines, except where there is a secondary infection with pyogenic organisms. When the latter are present, we have purulent accumulations. The contents of the necrotic type of abscess show fatty and glandular detritus, necrotic hepatic cells, amebae, and occasionally Charcot-Leyden crystals. Amebae are also found in the abscess walls. Cultures are frequently sterile. Micrococci and bacilli may be found, notably the Staphylococcus aureus, Streptococcus pyogenes, Bacillus coli (with other organisms), Bacillus pyocyaneus, and Micrococcus lanceolatus, and rarely pneumo- cocci. Bacteria are more commonly associated with amebae in the multiple abscesses. The abscess most frequently points upward and ruptures into the right lung. In some cases an empyema may be produced or a pyopneumo- thorax. Perforation may occur in other directions, into the pericardium, peritoneum, stomach, intestines, portal or hepatic veins, inferior vena cava, kidney, psoas muscle, bladder, spleen, gall-bladder, retro-peritoneal tissue, or externally. If bacteria are associated 'with amebic abscesses, death may result from sepsis within a short time, while patients with a single simple amebic abscess may remain in fair health for several years. Symptoms and Diagnosis of Amebic Abscess of the Liver. Sometimes there are slight symptoms, even with large abscess, and even exploratory puncture may not avail. Exploratory puncture is the surest method at our command, with examination of the contents of the abscess for the amebae. Physical Signs. The liver usually shows some enlargement particularly if the right lobe is involved, and the enlargement is more usually upward. Fever remittent, intermittent or continuous is usually present. Septic temperature is due to mixed infection. Leukocytosis and increased poly- nuclears are present, though Musgrave believes they are given an undue importance, as the intestinal infection alone may be responsible for them. The pain of amebic abscess is rarely acute and is more of the nature of a DYSENTERY 677 general soreness over the liver and there is tenderness on pressure over its lower border, or over the gall-bladder. If the abscess is subdiaphragmatic; pain is usually increased by change of position, particularly on lying on the left side or on standing. Pain is not so frequently referred to the shoul- der. Local pains are most pronounced. Respiratory disturbances occur when abscesses rupture into the lung or pleura. Jaundice of a marked type is rare with solitary abscess and not very frequent with multiple ones. A slight subicteric tinge is quite common. Except with sepsis, there are no important stomach symptoms. There may be nausea and rarely vomiting. There is frequently an increase in the number of bowel move- ments during the development of liver abscess. Abscess in OtJier Locations. (i) Spleen. Amebic abscess of this organ may rarely occur. Rogers 1 reports such cases cured by aspiration and emetin injections. (2) Abscesses more generally result from perforation and may occur anywhere from the region of the cecum to the rectum. They may involve the appendix, perirenal tissue, psoas muscle, kidney and abdominal wall. Along the descending colon, they may be of the dissecting type and may cause it to slough away, or there may be small abscesses in the anterior surface of the colon. Ischio-rectal abscess may occur. Complicating Bacteria and Intestinal Parasites. Bacillus dysenteriae (Shiga) diphtheritic processes due to streptococci, etc., balantidium coli, strongyloides intestinalis, oxyuris, trichomonas, circomonas, megastoma entericum, tenia, trichiuris, ascaris and other parasites may occur with amebic dysentery. Symptoms. There has been a tendency to arbitrarily divide amebic dysentery into two clinical types, the acute and the chronic, and to create the impression that in acute and chronic dysentery we have necessarily diarrhea, or diarrhea alternating with constipation, the passage of blood and mucus, and the presence of tenesmus. Unquestionably, latent and masked infections, with intestinal amebiosis are by no means rare, and marked pathologic changes may be present without objective clinical symptoms. Councilman, Lafleur, Osier, Dock, Strong, and Musgrave have reported such cases. The latter notably refers to one case, treated six months for constipation, in whom autopsy showed perforation of a liver abscess as the cause of death, with associated lesions (amebic ulceration) of the cecum and ascending colon. The early recognition of these irregular types is of great importance, especially when amebic dysentery is endemic. Unquestionably, some of our old cases of apparently simple catarrhal colitis are of this type. In fact, I have had one experience with such a case, where amebae were found present, with ultimate recovery under appropriate treatment. Since many of the cases may present no clinical symptoms of amebic dysentery, I believe Musgrave's 2 classification, under "Intestinal Amebi- osis," to be the most scientific. i. Latent and masked infections with the amebae. 1 Brit. Med. Jour., Aug. 24, 1912. 2 Jour, of Amer. Med. Assoc., Sept. 16, 1905. 678 DISEASES OF THE STOMACH AND INTESTINES 2. Mild and moderately severe infections (subacute dysentery). 3. Severe infection, including gangrenous and diphtheritic types (acute dysentery). 4. Chronic dysentery. 5. Infection in children and in the aged. Latent Infection. In these cases, there is a pathologic amebic process in the intestines, without any diarrhea or any other symptoms that would indicate the infection. Musgrave has demonstrated that the symptoms pointing to dysentery may be absent for a long time, yet there are certain symptoms which sug- gest the condition. Dull, aching abdominal pains are present, which are attributed to catch- ing cold. They first appear and are most active during the night or early morning. Indigestion, headache, lassitude, coated tongue, and a foul breath are present. There are loss of appetite, some loss of weight, loss of color, and at times a yellow skin. Physical examination discloses on deep palpation tenderness along the colon, especially over the cecum and ascending colon. This last is a signifi- cant symptom; occasionally thickened intestines can be made out. If a hydragogue cathartic be administered, there will be present in the stool amebse, mucus, tissue elements, and often old blood. Musgrave has demonstrated by autopsy on his fatal latent cases, that the lesions are in the cecum and ascending colon. Any patient, therefore, living where amebic dysentery is endemic, suffering from the symptoms referred to, should be given a saline cathartic and the stool carefully searched for amebae. The possibility of amebic injection in chronic colitis with no diarrhea should be considered in New York. I have already referred to a patient infected in that State. On the other hand, some of the latent cases, if untreated, may later develop the symptoms of amebic dysentery. Under the same class of cases (latent) in regions where amebiosis is endemic, we may have patients in whom other symptoms, such as chronic constipation, gastric symptoms, or even appendicitis, may mask the in- testinal amebiosis. Musgrave has reported such cases. Mild and Moderately Severe Cases (Subacute Dysentery). Mild Cases. These frequently develop from the latent type, and often present the aspects of a diarrhea and not of dysentery. Abdominal pain, tenderness along the colon, headache, digestive disturbances, irritability, melan- cholic condition, anemia, and loss of weight are present. Amebae are found in the diarrheal movements. Some of these cases never show dysenteric movements, even without treatment. This type Musgrave believes often becomes chronic; while, on the other hand, chronic gastro-enteritis or "sprue" may be the ultimate outcome, giving their clinical pictures. The patient usually dies from intermittent disease or complications. Moderately Severe Cases (Subacute Dysentery). In these cases with the symptoms just described, there may be a diarrhea more marked in the morning, consisting of several semifluid stools, no mucus or blood, and passed without pain. This may intermit with constipation. Finally, the DYSENTERY 679 attack may increase in intensity, and mucus and blood will appear. In other cases they will occur from the onset. Usually the more acute the onset, the more rapidly the severe symptoms develop. Severe Cases (Acute Dysentery), These are the classical cases usually described. Diphtheritic and gangrenous processes, due to some secondary infection, are most common in this type. In the most serious cases, por- tions of the large intestine may be felt through the abdominal wall as very tender, greatly thickened sausage-shaped or rounded masses, showing that the entire thickness of the gut is involved. This class of cases is nearly always accompanied by -an extremely high leukocytosis from 30,000 to 50,000, though more moderate leukocytosis is at times present. The onset is usually quite sudden, whether primary, or following on a milder type. There are marked abdominal colic; diarrhea; tenesmus, which may be constant and very painful; straining, and then, finally, passages, chiefly of small quantities of mucus and blood. In some cases the dejecta are hemorrhagic, consisting of pure blood or dark and coagu- lated blood. Sloughs are passed in others, consisting of gray or blackish masses of necrotic tissue 6f very foul odor. The temperature, as a rule, is not high. The patient rapidly emaciates, and the heart becomes rapid and feeble. Death may occur in severe cases within a week from the onset. There may be gangrene of the intestine or a post-colic abscess form with resulting fatal termination. Hemorrhage (intestinal) or perforative peritonitis may take place. Many cases recover, but some become chronic. In others extensive ulceration may remain after sloughing and the diarrhea con- tinues, the patient rapidly emaciating, and finally dying exhausted within a couple of months. Emaciation is very marked in these patients. Cor- neal ulceration may occur. Stools. As many as twenty to thirty may be passed in twenty-four hours, colicky pains usually precede them, and they are followed by straining and severe tenesmus. Movements at first are copious, later scanty, and consist chiefly of mucus and blood. Intermissions and ex- acerbations of diarrhea occur, gangrenous dejecta, dark red brown and containing gray or black fragments of tissue (foul in odor), may be passed, or pure blood. Amebas are present in the stools. Abdominal Pains. These are quite severe, chiefly before evacuation, and sometimes they are continuous. They are frequently located in the umbilical region and left iliac fossa; at times in the right iliac fossa, and may simulate appendicitis. Pressure increases the pain. Tenesmus. This consists of pressure and constriction in the rectum and a desire to go to stool. It may be continuous and accompanied by dysuria or strangury. Other Symptoms. Fever may occur, generally of moderate type, and it may be accompanied by chills at the onset. Temperature is irregular. Anorexia, nausea, and vomiting may occur. There may be severe pros- tration, cold extremities, delirium, stupor, drowsiness, and cerebral dis- orders. Chronic Dysentery. This type of dysentery shows several forms. It may be rather mild, characterized chiefly by diarrhea, with no blood or 68o DISEASES OF THE STOMACH AND INTESTINES tenesmus, following on the mild type previously described. This may continue a number of years. Dysentery in more marked cases is subacute from the onset, or gradu- ally passes into the chronic stage. There are generally alternating periods of diarrhea and constipation covering several years. During the exacer- bations there are pain, passages of blood and mucus, tenesmus, and a slight rise of temperature. Many such cases do not feel especially ill between attacks and keep fairly well nourished. The appetite is often irregular in this type, and errors in diet are followed by exacerbations of the disease. The tongue is red, glazed, and beefy. In more severe cases emaciation may be extreme and the patient be confined to bed most of the time. There are loss of appetite and nausea; diarrhea is quite persistent, there being mucus or mucus and blood in the stools, with attacks of colic and tenesmus. There may be some periods of improvement. Infection in Children and in the Aged. Musgrave reports cases in children from the age of six months to ten years in the Philippines. Chil- dren seem to present a natural immunity, he believes, and when infection does occur, it seems of a mild type and readily yields to treatment. The symptoms resemble those of the mild type in adults. In the aged there also seems to be a natural immunity, but when the disease was established it ran a severe and rapid course. Liver abscess is infrequent in the very young and aged; Musgrave notes it is infrequent in the natives. The only certain method of diagnosis is by microscopic examination of the feces or discharges and finding the amebae. Other parasites are found at times associated with the amebae, such as the trichomomedae, ova of uncinariae, embryo strongyloides, tenia, oxyuris, etc. Circulatory System. The pulse may be of good quality at first; later, rapid and feeble. There are the changes of secondary anemia. Early, the blood is normal; later, the red cells are those of anemia. Still later, they may become irregular in size and shape and the count be reduced. Leukocytes. An increase in polynuclears and eosinophiles may occur. Hemoglobin decreases with the red cells. Spleen is usually not enlarged. Temperature may be absent, moderate, or intermittent. In cases that are complicated, especially if there is diphtheritic inflammation of the colon, it may become quite high. With liver abscess temperature is frequent, but not constant. If there is mixed infection in the liver, bac- teria with the amebae, the temperature may be intermittent or remittent and resemble malaria or endocarditis. Sometimes it may be subnormal. Nervous System. Neuritis and neuralgias may* be present. Pain. This varies in type and intensity. Tenesmus. More often it is an indication of secondary involvement or complications. It is never present in the latent forms, and is often absent or very slight in the moderately severe cases. In acute cases with diphtheritic process or secondary infection, as from Bacillus dysenteriae (Shiga), it may be severe. It is more likely absent when the lesions are in the cecum or upper colon. DYSENTERY 68 I Colicky pains frequently occur, and at times severe colic. The dull, aching abdominal pain is often prodromic and persists during the course of the disease, at times interfering with the patient's rest. The greatest intensity is usually along the colon, as demonstrated by palpation. Sometimes it is confined to the cecum. It may be complained of in the back. It is probably due to the ulcerative process in the bowel and -as demonstrated in the latent cases, as shown by postmortem is the only indication during life of serious lesions. These pains are often the worst at night. Burning pains ("heart-burn in the abdomen"), Musgrave states, may be general or local; when the disease is in the sigmoid or rectum these pains may be intense, and extend down the backs of the thighs to the calves, and old cases of sciatica may be started up. Musgrave holds that the beginning of sciatica, associated with such cases, is of sufficiently frequent occurrence to be suggestive. Appendicitis pains are at times simulated, but examination will show that the tenderness is located in the caput coli. The differential method by Morris' point would be of value in these cases, as described under Appendicitis. Neuralgia, myalgia, and arthralgia may be present. There is per- sistent dull headache in the back of the head and neck. The geni to-urinary, respiratory, and special senses are rarely involved, as is also true of the joints and osseous systems, though complications may occur. Complications of Amebic Dysentery. Malaria, beri-beri, tuberculosis, Bright's disease, pernicious anemia, leukemia, specific bacterial dysentery, chronic rheumatism and certain nervous affections may occur in associa- tion with amebic dysentery. Cancrum oris occasionally complicates, though it is more frequent with the bacillary or streptococci types. Stom- atitis and esophagitis occur more frequently as after-effects, though some- times earlier. There may be gastralgia, gastritis, achylia gastrica, hyper- chlorhydria, gastric ulcer, arteritis and reversed intestinal peristalsis, the latter from local treatment, renal complications, amebic infection of the urinary bladder, hemorrhoids, fissure, fistulae, dilatation of part of the colon, occasionally general dilatation of the large intestine, and cicatricial contraction from healed amebic ulcers. Perforation of intestinal ulcers occurs with untreated and fatal cases, but is rare when proper treatment has been instituted early. Intestinal hemorrhage of severe type is rare with amebic dysentery and is liable to be associated, when occurring, with liver abscess or with the diphtheritic type. Amebic Appendicitis. This condition has been reported by several writers. Etiology. Amebic appendicitis is nearly always an extension of the amebic process from the cecum, and has a marked relation to infection on, and above, the valve of Bauhini. It does not develop early in the disease and most often attacks a normal appendix. It occurs most frequently with severe dysenteric infection, such as when the amebic is complicated by the diphtheritic or gangrenous type (the mixed infections). Morbid Anatomy, The lesions in the appendix resemble those in the 682 DISEASES OF THE STOMACH AND INTESTINES bowel, but are small and more superficial. The ulcers are rarely along the meso-border, though they sometimes extend nearly around the mucosa. The appendix is usually patulous, with a large lumen, and concretions are the exception. There are moderate engorgement and injection of the blood-vessels, so that external evidences of inflammation are not very marked. Symptoms. The symptoms of amebic appendicitis resemble those of acute appendicitis, but are as a rule less severe, thus tenderness at Mc- Burney's point, but less rigidity of the abdominal muscles; the tumor mass is not so sharply circumscribed and the fever and general prostration are less marked. There are fulminating cases which cannot be distinguished from other types. The leukocyte count is not of a great value in amebic appendicitis, since leukocytosis occurs with intestinal amebiosis. Appen- dicitis (no n-amebic) may also complicate amebic dysentery. Differential Diagnosis. Severe Amebic Infection of Colon, or Cecum and Ascending Colon. The fever, leukocytosis, nausea, vomiting, abdominal tenderness, etc., would suggest appendicial involvement but the history, absence of rigidity of the abdominal muscles, the diffused area of tenderness, and the location and character of the thickened intestine usually furnish the diagnosis. Operation is useless in these cases, inter- fering with the treatment of the dysentery. Disease of the lower ileum cannot be accurately diagnosed. Gaseous distention and fecal accumula- tion in the cecum may cause local pain, and suggest appendicial inflamma- tion, but an active cathartic will relieve the condition. A localized peri- tonitis and adhesions about the cecum can usually be determined particu- larly when the bowel is empty. Pericecal amebic abscess may occur. Fecal impaction with distention of the cecum and neuralgic pains must be differentiated from appendicitis. Anatomic displacements and malformations such as enteroptosis, an unusually long mesentery, and flexures of the sigmoid and rectum, may interfere with bowel irrigation. Acute general peritonitis may follow perforation of an ulcer of the colon, of the appendix, or of a liver abscess, or without any perforation, but perforation of an ulcer is usually walled off by omentum, without producing a general peritonitis. Chronic localized adhesive peritonitis is one of the most frequent com- plications of amebic infection. It may be slight or extensive and gives rise to all the varieties of adhesions omental or between the viscera, or to the abdominal wall or diaphragm which may occur within the abdomen. The chief symptoms of these adhesions are abdominal pain, soreness and intestinal stasis in some cases. Strangulation of the small or large intes- tine, complete or partial, most frequently below the splenic flexure, may occur. Phlebitis, emboli, venous thrombosis and infarctions of the liver, spleen, intestines and kidneys have occurred. Chronic rheumatism, both articular and muscular, is frequently met with and seems to bear a definite relation to amebiosis. It is particularly apt to develop in cases of dysen- tery of long duration, while in other cases a pre-existing rheumatism is rendered much worse by recurrent dysentery. Nervous System. The nervous system shows disturbances apparently DYSENTERY 683 associated with amebic dysentery, thus some forms of neuritis and neurosis. Sciatica is particularly excited by amebic dysentery, also various chronic types of nervous disease and occasionally acute chorea may occur. Albuminuria is common in chronic amebic dysentery and organic changes may exist as a late complication or one of its after-effects. Among other occasional complications are fibroid degeneration of the heart, terminal pericarditis, purpura, gangrenous ulcers of the stomach, mastoid abscess, abscess of the brain (Kartulis), pseudoparalysis and gangrene of the foot. Diagnosis. In amebic dysentery there are so many clinical types that the diagnosis is by no means easy, and can only be made absolutely by microscopic examination of the feces. In regions where the disease is endemic and the microscope is not available, one can reasonably infer its presence by the most valuable symptom, to which I have already alluded, namely, "abdominal soreness, which is increased on pressure, and extends along the course of the colon, especially when there is maximum intensity over the cecum and ascending colon." If bowel movements are present, their odor and the appearance of blood are of chief diagnostic import. Indigestion, pain, nausea, and other symptoms are not as important. Often a thickened tender colon may be felt on palpation. These symptoms give the nearest approach to diagnosis without microscopic ex- amination of the feces. Loss of weight is a guide to the infection. Musgrave believes that the presence of amebae in the stools in tropical regions should be considered diagnostic for purposes of treatment. Amebiosis should be treated, even if other complications are present. Prognosis. The disease is generally milder in children and in the natives of the tropics. The course is shorter and the mortality higher among the aged. Previous good health is a favorable factor. The shorter the duration of the disease and the earlier the local treatment, the better is the prognosis. Early emetin treatment shortens it. The higher up the lesion, the greater the mortality and the less active the clinical symptoms of dysentery. Infections of the cecum are the most serious. Under proper treatment recovery is the rule in young and welf-nour- ished adults if the disease is not of long duration. The early diagnosis and treatment are the important features, as otherwise the apparently mild cases may assume a dangerous character. Tendency to relapse or chronicity are characteristics. Abscess of the liver is a serious complica- tion. After-effects. Constitutional disturbances, the result of wasting and of lowered resistance, may occur. Sprue is held by Musgrave to be a symptom-complex and not a distinct disease and to arise in a variety of wasting diseases, particularly in those attacking the gastro-intestinal tract. It is fairly common in the Philip- pines and believed to develop in those cases of amebiosis particularly complicated by disturbances of the stomach and small intestines. The 1 Miinch. Med. VVoch., Mar. 3, 1914. 684 DISEASES OF THE STOMACH AND INTESTINES walls of the intestines are enlarged, thinned, with an atrophied, cystic and often papilloid condition of the mucosa of the entire gastro-intestinal tract, and a relaxation and partial destruction of the muscular bands of the bowel, which leave it elongated, enlarged in diameter and without its natural folds, or rugae. Change of climate is the chief requisite for these cases. Leonard Rogers has cured two cases by the subcutaneous injection of emetin and the use of autogenous streptococci vaccines from the mouth. Chronic gastro-enteritis may also follow dysentery, and abdominal pain and sore- ness may persist for years, particularly if recurrences have taken place. They are due to chronic adhesive peritonitis and the symptoms vary with the character and location of the lesions. They may resemble a chronic appendicitis due to cecal adhesions. Pains in the region of the stomach, liver, spleen, ovaries and other locations occur. There may be general abdominal soreness, increased in the erect posture and relieved when lying down. The reverse, however, has been seen. These pains may continue for years or they may recur particularly after exposure to cold, or after violent exercise. Proper exercise, massage and belts, bandages, or corsets of correct type (particularly if there is splachnoptosis) may improve the symptoms. Mechanical support will often prevent the drag- ging down pains from adhesions, when the patient is erect. Various types of nervous disease, chronic rheumatism, disturbances of the genito- urinary system such as the kidneys and bladder, skin, etc., may also be among the after-effects. Treatment. Medical. The disease is contracted probably in the same way as typhoid fever, and the same prophylactic measures should be used. Infection through the drinking-water is undoubtedly the chief method. Musgrave holds that the best rule to observe in countries where the disease is endemic is to "take nothing into the gastro-intestinal tract which has not been sterilized." He has found the amebae in the drinking- water; on dishes washed in tap- water; in the soil from contamination; on the surface of uncooked vegetables, such as lettuce; on raw fruits; from hand contamination; and in ice-cream, water-ices, and milk. Prophylaxis, when the disease is endemic or during epidemics, is very important. Air drinking-water should be boiled, and dishes should be washed in boiled water, also the hands. Raw fruits and vegetables should first be placed on ice, and then have scalding water poured over them, which kills the amebae. Ice-cream and water-ices should not be taken. The vaginal douche and, especially, rectal enemata from tap-water should be avoided. The stools should be disinfected in carbolic acid (i : 20) or in bichlorid of mercury (i :iooo), and the same precautions taken with linen soaked in carbolic acid (i : 20) and boiled. Care of the hands and the prevention of fly infection (by screens) are necessary. We have already noted that mixed infection with the Bacillus dysen- teriae (Shiga) may be present. DYSENTERY 68 5 The acid of the stomach lessens the chance of infection, and acid mixtures may be given, such as dilute hydrochloric acid. In acute dysentery the patient should be put to bed and placed on a liquid diet: barley-water, rice-water, bouillon, broths, gruels, white of raw egg, tea, also peptonized milk diluted with lime-water (at least 25 per cent, or more), or peptonized and diluted, or equal parts of milk and barley-water. With some sour milks agree, as koumiss, etc. Turnip-top puree has been advocated as of value. Somatose and tropon are of service as adjuncts. Personally, I prefer milk-free diet and only the strained broths, gruels, etc., and 10 per cent, gelatin solution flavored with vanilla, 4 to 6 ounces (125-185 c.c.). Give nourishment in divided doses (2 quarts daily) and a large amount of acidu- lated water. If the temperature is over 103 F., only water is given until defervescence to that point. Later the diet can be increased (see author's diet in typhoid fever). Hot applications or poultices should be employed over the abdomen for the relief of pain or colic. Internal Medication. Musgrave and Osier both object to the use of bismuth preparations for the diarrhea, on the ground that they coat the ulcers and interfere with their local treatment. I believe this probably to be true as regards bismuth subnitrate or subcarbonate, which would be required in large doses. I have occasionally employed bismuth subgallate, 5 to 10 grains (0.3-0.6) t.i.d., in combination with other remedies, appar- ently with benefit. On the other hand, I have seen at times that, in spite of all treatment, too frequent movements continue either in the acute or chronic cases. In such event I have employed bismuth subnitrate, as much as go to 120 grains (6.0-8.0) in divided doses in twenty-four hours, with good results. This is preferable to the use of opiates, and I only employ it to avoid such. I have never had poisoning from large doses of bismuth subnitrate. It would seem a more likely occurrence in children. At the Ancon Hospital, Deeks and Shaw employ chiefly the subnitrate of bismuth treatment, i to i^ drams (4.0-6.0), by measurement, or 3 drams (12.0), by weight, stirred in a glass of water, every three hours until the patient improves, which may be from three to fifteen days. Normal saline, or plain water irrigation of the bowels are added. Rest in bed and an absolute milk-diet are enjoined. An occasional dose of morphin and atropin may be required to relieve tenesmus. They claim fewer fatalities by this method than by other courses of treatment. Finally, if improve- ment does not follow this treatment, and the acute symptoms are severe and toxic, they recommend surgical interference (appendicostomy or cecostomy), as advocated by Herrick. The latter suggests this treatment for the following conditions: First, appendicostomy in chronic cases; second, appendicostomy or, preferably, cecostomy in acute fulminating and toxic cases. By means of cecostomy, especially through the tempo- rary artificial anus, rest is given to the diseased bowel, and it also can be kept irrigated. For the literature, the reader is referred to the Medical Record, Nov. 13, 1909. The writer hardly advocates an artificial anus 686 DISEASES OF THE STOMACH AND INTESTINES in acute cases, and doubts the advisability of the bismuth treatment, except as previously noted. In the initial stage the patient should be given magnesium or sodium sulphate, i to 2 drams (4.0-8.0), one or two doses, so as to thoroughly cleanse the bowels. Calomel, 5 grains (0.3), may be given, or a single dose of castor oil, 1% ounces (45.0). In young persons these remedies should be administered in smaller doses. Ipecac Treatment. Some recommend 20 minims (1.18) of laudanum, followed in half an hour by 20 to 30 grains (1.3-2.0) of pulv. ipecac, after the saline treatment. Though given thus to prevent vomiting it is not always successful in this regard. Brem and Zeiler 1 report excellent results at the Colon Hospital in the treatment of intestinal amebiosis from the use of ipecac pills freshly coated with fused salol >f 6 inch thick. By this means the ipecac passes through the stomach unattacked by the gastric juice; vomiting is pre- vented and no opiate is necessary. Simon 2 has used a salol coating % inch thick, but many pills passed through the intestines undissolved. They found the best method usually was to begin with 60 to 80 grains at bedtime, 8 to 9 P. M., decrease the dose by 5 grains daily until a dose of 10 grains (in all) is reached, and then, as a rule, stop. Occasionally rapid cures may be effected by giving 40 grains t.i.d. These writers observed that milk curds or solid food delayed the passage of the pills until the salol coat was corroded, and vomiting ensued. They, therefore, direct that no solid food or milk should be given for at least six hours previous to the ipecac, and no liquids for three hours previous. No opiate is necessary. Have the patient lie on the right side to aid passage of pills from the stom- ach. The patient should remain in bed and the general diet should be liquid. Enemata of normal saline solution, quinin, thymol, and thymol and quinin combined, i : 500 to i : 1000 each, are useful. Dock 3 has reported excellent results from the ipecac treatment. Leonard Rogers 4 reports favorable results in Calcutta in the prevention of tropical abscess (amebic) of the liver by the treatment of the presup- purative stage with ipecac. He suggests the use of capsules of ipecac, keratin coated. A shellac coating can also be employed (author), while Sandwith advocates capsules of animal membrane. Anders 5 starts the treatment with calomel (several doses), and then administers magnesium sulphate, i dram (4.0) every third hour, until all hardened fecal masses are removed. Saline laxatives, however, should not be continued after the dysenteric have been converted into diarrheal dejecta. Anders ad- vocates also the use of ipecac administered by salol-covered pills in the earlier stages of the disease, not less than 30 grains (2.0) of ipecac on the first day, and diminishing the dose daily by 5 grains (0.3), so that by the sixth day only 5 grains (0.3) are administered, and for a week or ten days this nightly dose of 5 grains (0.3) should be continued. He adds to the 1 Amer. Jour. Med. Sci., Nov., 1910. 2 Jour. Amer. Med. Assoc., 1909, liii, 1526. 3 N. Y. Med. Jour., July 10, 1909; ibid., Dec. 4, 1909. 4 Therap. Gaz., June 15, 1909. 6 Jour. Amer. Med. Assoc., Feb. 12, 1910. DYSENTERY 687 treatment daily high enemata of quinin solution, i : 5000, gradually in- creasing the strength to i : 1000. In obstinate chronic cases appendicos- tomy with bowel irrigation is advocated. H. G. Beck 1 administers the ipecac suspended in mucilage of acacia or macerated in warm water through Einhorn's duodenal tube by means of a syringe. He claims to thus avoid vomiting. Burroughs and Wellcome have recently intro- duced a gr. v ipecac tabloid deprived of its emetic principles. Dose 4 to 6 tablets t.i.d. dissolved in water. A great improvement in therapeutics is the use of emetin. It has a specific action on the amoeba dysenteric. Leonard Rogers 2 reports that the amoeba dysenteriae is immediately killed by a i in 10,000 solution of emetin and after a few minutes was rendered inert and apparently killed by a weak solution of i in 100,000. He advocates the use of emetin by hypo- dermic. He secured excellent results in the most serious cases, following the use of emetin hydrobromid hypodermically. 3 He estimates gr. i of emetin an equivalent of 90 grains of ipecac. Improvement usually occurred in twenty-four to forty-eight hours, and in three to five days con- valescence apparently began. The preparation comes in ampoules or in ^ grain tablets. Usually gr. % can be given by hypodermic twice or three times the first day. Subsequently i> to 2 grains in divided doses, by hypo- dermic the second day, depending on the severity of the case and a grain by hypodermic on the third and fourth day. For a child of seven, y$ grain t.i.d. has been administered. The injection of emetin cured acute hepati- tis and aborted a commencing amebic abscess of the liver. Liver abscesses have been cured by aspiration and then injecting through the tube 2 ounces of sterile saline solution in which i^ grains of emetin were dissolved. Hy- podermics of emetin totaling % to i grain daily, were also administered. Success was also secured in amebic abscess of the spleen by similar treat- ment. Emetin treatment has also rapidly cured cases of chronic amebic dysentery. Burroughs and Wellcome and Parke Davis supply tablets and ampoules. Emetin hydrochlorid is somewhat more soluble than the hydrobromate. Rogers holds that emetin affects the amebic type of dysentery favorably, and not the bacillary and other types materially; and hence favorable results from its use diagnose the amebic type when pathologic examination is impossible. Though patients may be clinically cured of amebic dysentery the Entamceba histolytica may be found subsequently for two years or more without development of symptoms. They constitute a menace as "car- riers." Enteroclysis with silver nitrate, quinin or other remedies, such as acetozone, etc., would be of value, also emetin. Emetin has also been used successfully by mouth. It can be so administered, y$ grain t.i.d. in keratin-coated pills, or capsules shellaced. A standardized preparation of emetin, from a reliable source should be employed. Two fatal cases have been reported, one of acidosis and acute nephritis following its use. Persistent diarrhea may also result, after apparent cure of the dysentery. 1 Jour. A. M. A., Dec. 14, 1912. 2 Brit. Med. Jour., June, 22, 1912. 3 Ind. Med. Gazette, 1912, xlvii, 421, Aug. 24, 1912. 688 DISEASES OF THE STOMACH AND INTESTINES Occasionally, salol, 3 grains (0.194), with guaiacol carbonate, 3 grains (0.194), and i grain (0.065) f pulverized ipecac, given several (three or four) times a day, with small doses of Dover's powder, 2 to 3 grains (0.13-0.194), have proved of service according to some reports. Kho-sam (Brucea Sumatra or Brucea antidysenterica), in i-grain pills three or four times daily, has been suggested in place of ipecac by Lemoine 1 and Schnei- der. 2 Salvarsan and neosalvarsan have been advocated but I doubt their value. Chaparro amargosa in the form of fluidextract, 3i~3iii t.i.d. before meals, or as an infusion, 5 v i~viii t.i.d. before meals, and at bedtime and in addition rectal injections, 500 to 2000 c.c. of infusion, have been recom- mended by Nixon (Journal A. M. A., May 16, 1914). This remedy has been employed in Mexico for many years and is said to be destructive to the ameba. Strong has reported good results in some cases by giving internally acetozone (i 15000 or i 13000) in carbonated water, i to 2 liters (quarts) in twenty-four hours in divided doses. I have employed i liter (quart) of acetozone (i : 1000), given in divided doses by mouth during the day with good results. Just before administer- ing, each dose can be flavored with orange-juice to make it more palatable. Among valuable astringent remedies are: Salicylate of guaiacol (guaiacol-salol), 5 to 10 grains (0.3-0.6); tannal- bin, 10 grains (0.6) ; tannigen, 10 grains (0.6) ; or tannoguaiaform, tannopin, and tannocol, given in doses of 5 to 10 grains (0.3-0.6) three or four times a day. Hydrochloric acid with pepsin or alone, or nitromuriatic acid are of value being destructive to nonencysted amebae. Musgrave recommends hydrochloric acid to immunize chances of infection. Thus: R. Acidi hydrochlor. dil. \ -_...,, '. . , > aa 3"J (12.0); Comp. tinct. cinchona j Aq. destil q. s. iv (125.0). M. Sig. 3 j to ij (4.0-8.0) in water t.i.d. before food. Vomiting should be treated by the methods described under Acute Gastritis. Small doses of Dover's powder may be required for persistent diarrhea. Local Treatment. This is of extreme importance, not only in the acute, but also in the latent and chronic cases. Extensive researches were conducted by J. B. Thomas, reported in Bulletin 32, Bureau Government Laboratory, Manila, who. found the following solutions destructive to amebae or inhibiting their growth : Acetozone, i : 1000, most destructive to amebae, and alphozone, i : looo, nearly as much so. They destroy other bacteria as well. Protargol and argyrol, i :5oo, were excellent antiseptics. Sulphate of quinin, 1:500, preferable strength, or bisulph-quinin; nitrate silver, 1:2000, of service; thymol, 1:2500, readily destroys amebae, also per- manganate of potash, i : 2000, is useful. 1 Bull. Path. Exot., Paris, 1908, i, 72. Ibid. DYSENTERY 689 Hydrogen peroxid was recommended by Harris some years ago, and I have used it successfully for some time. Cold water (under a temperature of 45F.) has been highly advocated by the late J. P. Tuttle as destructive to the amebae, and also removing them from the bowel. He sometimes employed 5 to 10 per cent, hydro- gen peroxid in this injection, and placed the patients in the knee-chest position and had them retain the injection for a considerable time (one- half hour). A glass irrigator, attached to a colon-tube, with the opening preferably at the end, can be employed; if the ulcers extend low down into the rectum or there is extreme tenesmus, then an ordinary rectal tip. The foot of the bed should be elevated 12 to 18 inches and the patient placed in the Sims position, or the hips can be elevated on a pan. The patient's position should be changed, and he should be moved so the fluid will gravitate into the caput coli by movements described as "rotation method" under Enteroclysis. Musgrave recommends the injection of at least 2 to 3 liters up occa- sionally to 4 liters (quarts) in women, which should be retained five to fifteen minutes, preferably the latter. At the commencement, if there is much irritation, often a smaller quantity must be used. He recognizes the futility of attempting to pass the colon tube and now employs an ordinarily large-size male soft rubber catheter to which is attached an irrigating jar, preferably one of glass. Brandy 25 to 30 c.c. can be given by mouth before the injection. Enemas should not be given during digestion, as the reversed peristalsis set up by the injection may aggravate stomach symptoms. The knee-chest position is excellent in the latent or chronic cases, but I would not advise it in acute conditions. If there is much irritation, .one can precede the antiseptic injection one-half hour by a small enema of normal saline solution 2 ounces (60.0) containing y grain (0.016) of morphin or with tincture of bella- donna, 10 minims (0.592), alone or together. This should only be done once or twice in the first twenty-four hours and not repeated. Musgrave has suggested taking advantage of the action of reversed peristalsis by giving occasionally a preliminary enema of a 7 to 8 per cent, salt solution, about i pint (500 c.c.), containing y grain (0.016) of morphin, one-half hour before the antiseptic injection. Musgrave has found thymol very efficient and as it is difficult to dissolve it in water he recommends If. Thymol gm. 25. Alcohol (95 per cent.) Glycerin aa 250 c.c. M. Sig. Add 10 c.c. of above to each liter of water used in enema. This gives approximately a strength of i : 2000 quite an efficient solution as it is destructive to the amebae at i : 10,000 strength. He alternates at times with quinin i : 1000 to i :soo or with silver nitrate o.i to i per cent, in distilled water. The nitrate of silver is preferable I believe in chronic cases- He at times employs acetozone (i : 500x5 to i :30oo), combined with quinin (i :iooo to 1 1500), or gives the injections alternately, employing 44 690 DISEASES OF THE STOMACH AND INTESTINES one to five enemata every twenty-four hours, according to the severity of the case. Bisulphate of quinin is more soluble. Alphozone, same strength, or hydrogen peroxid (i : 10) can be substituted. We must remember that quinin affects some cases badly, causing gastric symptoms, vomiting, and headache. It must be omitted or weaker solutions given to such patients. Quinin is much more efficacious in the strong solutions (1:1000 to even 1:500). The usual solutions suggested are much too weak. One can take advantage at the same time of the cold injections, as suggested by Tuttle, unless the patient have an idiosyncrasy to cold, or renal complications are present. In such event a hot injection at i2oF. is of service. Author's Method. In conclusion the author now employs the hypo- dermic use of emetin gr. ^ t.i.d, and administers acetozone i : 1000, i quart daily in divided dose by mouth. The patient should also receive hydrochloric acid mixture. The local treatment is also important. The writer prefers the following local treatment. An excellent method is to alternate, giving an enema of acetozone (1:1000), and the next enema of quinin (1:1000 to 1:500), cold, at 45 to 4 oF. ^ If the quinin disagrees, then alternate the acetozone or alphozone with thymol (1:2500), or protargol or argyrol (1:500). The silver nitrate is at times found irritating in the acute cases. Permanganate of potash (1:2000) is also of service, or hydrogen peroxid, 4 ounces (125.0 c.c.) to i liter (quart). Emetin is a specific and the local treatment helps check the lesions and prevent liver abscess. For prevention of the latter emetin is of great value given by hypodermic. In the latent cases, the bowels should be opened freely with magnesium sulphate and daily injections of quinin and acetozone given. In cases of marked tenesmus, where the large or even small injections cannot be retained, recurrent irrigations with the antiseptic solutions, i or 2 gallons i pint (500 c.c.) being kept in the bowels, with marked elevation of the bed and the solution of one-half strength are of great service. Emetin should also be given in the latent cases. Local, or general peritonitis Require surgery. Chronic Dysentery. In the chronic cases the diet should be quite liberal, but indigestible and rich food should be avoided. Mashed potatoes, boiled rice, and constipating food are often indicated in the diarrheal cases, and the avoidance of fruits and green vegetables. Milk, eggs (raw), the sour milks, and fats are of value. Judgment must be used in each case as to what will agree, whether liquid, semisolid, solid food, or combinations. The iron preparations are often indicated. The tannic acid preparations, as suggested in the acute cases, should be employed. Occasionally large doses of bismuth subnitrate are necessary. Quinin and acetozone injections should always be employed; and nitrate of silver (1:3000 to 1:2000) or protargol, or argyrol i : 2500 are of value, used once or twice a week to heal the ulcers. Change of climate is useful. 1 Proctoclysis is of value for sepsis, or thirst. . DYSENTERY 691 Erne tin gr. ^ t.i.d. by hypodermic should be given as in the acute cases and also acetozone by mouth. In all cases of fever, sponging (alcohol) is the best method of treat- ment. I deprecate the use of antipyretics. If heart stimulants are required, small doses of strychnin, caffein, and spartein, or camphorated oil by hypodermic are indicated. I have, moreover, a suggestion which I believe may prove of value. Piffard and Tousey have demonstrated that Morton's claims regarding the production of internal fluorescence by the #-rays after the adminis- tration of small doses of fluorescein or quinin are fallacious. However, the use of y grain (0.016) to about grs. 2 fluorescein in 6 ounces (200 c.c.) of water, and placing the patient in the full electric-light bath for fifteen minutes or more, I believe, might prove of service in latent, chronic, or even in acute dysentery. There is great heat penetration from light bath, as has been demonstrated in rheumatic and other conditions, and neces- sarily a certain penetration of light rays. The heat, light, and fluorescence are destructive to amebae. The fluorescein solution should be given by high enema; soda bicarbonate, 15 grains, should be added before injection, and water q. s. i quart (liter). Musgrave reports to me the disappear- ance of filaria after the administration of fluorescein and the use of light. He has demonstrated that violet light, #-ray light, and fluorescence in- hibit amebic action. Carbonic Acid Gas for Tenesmus. Rose has shown that the injection of COa into the rectum will relieve tenesmus. It is worthy of use as an adjunct and can be given by his bottle. Intestinal hemorrhage from dysenteric ulcers should be treated by high injections of 10 per cent, gelatin or, preferably, Tremoliere's solution, or, rather, a modification: Tremoli&re. Gelatin, 5 per cent, solution, containing calcium chlorid, 2 per cent. Tremoliere (Modified}. Calcium lactate, 20 grains (1.3); gelatin (10 per cent.), 8 ounces (500 c.c.). Hot (i20F.) or cold (4OF.) astringent injections i dram (4.0) alum or tannic acid to i pint (500 c.c.) of water may be required. Avoid cold if there is shock. Morphin, % to K grain (0.008-0.016), by hypodermic at once, ernutin, 5 minims (0.296), hypodermically, or fluidextract of ergot, i dram (4.0), internally; ice-bag locally; calcium chlorid or lactate, 10 grains (0.6), by mouth every three hours, gelatin solution 1 (5 per cent.) may also be taken by mouth. Hypodermoclysis may be required if there is marked shock, or even infusion. Horse serum or human serum by hypodermic may be required in severe cases. Surgical Treatment. In cases of chronic dysentery of long duration which do not respond to medical treatment, or in such cases with repeated acute exacerbations, surgical procedure is indicated. This is true of either the amebic or bacillary type of dysentery. Appendicostomy. This operation was first suggested by Weir. It consists in suture of the appendix to the abdominal wall and skin, and 1 The gelatin solution should be given in 5 i doses every 3 hours. 692 . DISEASES OF THE STOMACH AND INTESTINES removal of its apex. Subsequent irrigations of the large intestine are carried out by means of a small tube or catheter, which is inserted through the lumen of the appendix. Cecostomy. An incision is made over the cecum and the latter brought into the abdominal wound. The cecum is incised and sutured to the abdominal wall. A catheter or drainage-tube is then inserted for the purpose of irrigation of the colon. Gibson has devised a valve operation, separating the abdominal muscles in a special manner, so as to prevent leakage and ultimately secure a more ready healing. Cecostomy is indicated when the appendix is diseased or in an abnormal position, so that appendicostomy is impossible. S. G. Gant's Modified Cecostomy. Gant 1 makes his incision over the cecum nearer the ileocecal junction. After opening the cecum and suturing it to the abdominal wall by means of a special director, he in- serts a drainage-tube or catheter through the ileocecal valve into the ileum. A second tube is inserted into the cecum. In cases where ulcera- tion of the ileum is present, it is thus possible to irrigate both ileum and colon. With amebic dysentery the ileum is rarely involved. Excellent results have been reported from these methods. Abscess of the Liver. These should be opened and drained. Rogers 2 states that in the presuppurative stage of amebic abscess of the liver there is an exacerbation of temperature, with usually, but some- times without, pain in the liver region, and leukocytosis is present. He recommends ipecac as a preventive of suppuration. With suppuration there is increased density of the liver shadow to the x-rays, local swelling, and edema with increasing leukocytosis. Rogers holds that 86 per cent, of these abscesses are sterile and are infected by other bacteria by the open operation. He recommends repeated aspirations of the abscess- cavity with the injection of quinin solution without drainage. If this method fails, add sterile siphon drainage. Ipecac is also given. As- piration, with the injection of gr. i emetine in 5ii saline solution into the abscess-cavity, together with the hypodermic administration of emetin gr. i daily, give the best results. BACILLARY DYSENTERY Definition. A form of colitis, frequently an ilecolitis, usually of an acute type; occurring sporadically and in severe epidemics; attacking children as well as adults, and characterized by pain, tenesmus, and the frequent passage of blood and mucus; the result of infection by a specific bacillus, of which there are various strains. Etiology. Owing to improvement in sanitary conditions, bacillary dysentery is less frequent. This is the type which has proved such a scourge, as epidemics in crowded asylums, institutions, and camps. It is one of the great camp diseases, and I have already referred to the fact that Woodward collected 259,071 acute cases during the Civil War. The disease prevails in the Philippines, Porto Rico, Cuba, and in South Africa. In Japan a fatal type has prevailed, especially in summer and 1 N. Y. Med. Jour., Aug. 15, 1908. 2 Philippine Jour, of Sci., July, 1910. DYSENTERY 693 autumn, having a mortality of over 25 per cent. In 1899 there were 125,489 cases with 26,709 deaths, collected by Eldridge. Most of the severe epidemics in the tropics are of the bacillary type, and the same form prevails in the temperate climates. Bacillus Dysenteric. In 1892 Ogata, during an epidemic of dysentery in Japan, isolated fine bacilli which, when introduced by the mouth or rectum, produced ulceration in the intestines of cats. In 1897, during a severe epidemic, Shiga isolated the Bacillus dysenteriae and described its special characteristics, demonstrating it to be the specific cause of the disease. Flexner and Barker found in the dysentery in the Philippines an identical organism, and Strong, Musgrave, and Craig have made a careful study of it. It has been found in acute dysentery in Porto Rico. Out of 1238 cases of dysentery in Manila, Strong and Musgrave report 71 of the bacillary type, 51 suspected bacillary, and 561 amebic. Kruse, in Germany, has isolated an identical bacillus. Vedder and Duval demonstrated that sporadic cases in adults in Philadelphia, and also epidemics in the Lancaster County Asylum, Pennsylvania, and in the Almshouse, New Haven, were due to the Bacillus dysenteriae. Duval and Bassett, during the summer of 1902 at Mount Wilson Sanitarium, first demonstrated that certain forms of summer diarrhea in infants were due to Bacillus dysenteriae, and under Flexner's direction at the Rockefeller Institute investigation into the cause of infantile diarrhea in New York, Boston, Philadelphia, and Baltimore, showed the Bacillus dysenteriae present in 63 per cent, out of 412 cases. Several strains of this bacillus have been found, and the Flexner- Harris type is the one most frequent in the United States. These strains have been determined by the relative agglutinative power of immune serum upon the bacilli isolated, and also by the action of the bacilli upon various sugars. Flexner formerly recognized three types: 1. "Shiga type" attacks glucose, without action on other sugars, including mannite and lactose. 2. " Flexner-Harris type" attacks glucose, mannite, and dextrin, not lactose. 3. "Bacillus" (His and Russell) attacks glucose and mannite. No action on dextrin and lactose. His now recognizes four groups based on fermentative characteristics, and Shiga has added a fifth, intermediate between the acid and non-acid bacilli. Grolier 1 states that no less than 123 different strains of dysentery have been isolated, differing from one another widely. In some cases clinically dysenteric, it may be impossible to isolate any of the forms because they are soon overgrown by the colon group. The lesions produced by the different strains are identical. The organism agglutinates with the blood-serum of cases with acute dysentery, as well as with the serum of immunized animals. The Flexner-Harris type agglutinates in dilutions of i : 1000 to i 11500. In two instances the organism has been isolated by Duval in the stools of healthy children. In dysenteric stools it is most readily isolated from 1 Deutsche medizin. Wochens., Oct. i, 1914. 694 DISEASES OF THE STOMACH AND INTESTINES the particles of mucus. The organism has not yet been isolated outside the human body, but the belief is that it is probably water-borne, and that the same prophylactic measures should be taken as in typhoid fever. Camp epidemics clearly originate in this way, and the care taken by the Japanese in regard to the latrines and water-supply practically eliminated the disease during their recent war. Bussow 1 describes a small epidemic of dysentery in a hospital ward due to the cook as a carrier. Flexner bacilli were recovered from the stools. The cook was suffering from diarrhea, but without general symptoms. Morbid Anatomy. In acute cases, when death has occurred during the first week, the mucous membrane of the large intestine is swollen, hyperemic, of a deep red color, and presents elevated coarse ridges and folds. There are ecchymotic patches scattered throughout the swollen mucosa; over the surface there is usually a superficial necrotic layer, which can be brushed off lightly with the finger. This may be in patches or over large areas. There is no ulceration, but only the superficial general necrosis of the mucosa. They are, in effect, superficial erosions which give it a worm-eaten appearance. This superficial necrotic layer is, in effect, a fine pseudomembrane. The solitary follicles are swollen and red, but their prominence is obscured in the involvement of the mucosa. In severe cases the entire coats of the colon may be stiff and thick, and the mucous membrane greatly increased in thickness, grayish-black in color, extensively necrotic, and in places gangrenous. The submucosa is often enormously thickened and edematous. The serous surface is often deeply injected, and the vessels of the mesentery, especially near the sigmoid and rectum, may be distended. The ileum for 10 to 15 cm. is quite frequently involved (which is rare in amebic dysentery), having a deeply hemorrhagic mucosa with super- ficial necrosis. Peyer's patches and the solitary glands may be moder- ately swollen. The specific bacilli and various cocci are abundant in the necrotic mucous membrane, and are said by Strong to be seen in all the coats. Streptococci and various other types may be present. In the subacute cases there is less thickening of the intestinal walls, there is less necrosis, the solitary follicles are more swollen, the mucosa less red, there are superficial erosions, and no ulcers. The disease, as suggested by the complications, is evidently characterized by a more or less acute general toxemia, starting from a localized process. The toxins of dysentery are probably excreted by the bile and also through the in- testinal mucosa, thus aiding in the damage to the intestines. Probably the toxins are responsible for cerebrospinal lesions (Herter). Symptoms. The incubation period is not more than forty-eight hours. The onset is usually sudden and characterized by fever, pain in the ab- domen, and frequent stools, first containing mucus, and later consisting chiefly of mucus and blood. The movements increase in frequency and are associated with tenesmus, which becomes very marked. The move- ments may occur as frequently as every half-hour, and there is much straining. The tongue is coated with a white fur and there is excessive 1 Miinchener medizinische Wochens., Dec. 27,1910. DYSENTERY 695 thirst; nausea and vomiting may occur. The abdomen is not distended, but there may be tenderness, especially over the colon. There are cramp-like pains in the abdomen. The spleen is not usually enlarged. The temperature rises to 103 or io4F. It may run an irregular course and rise or fall before death. The pulse increases in rapidity (100 to 120 or even to 150) and becomes rapid and feeble. Urine is decreased and may contain albumin. Liver is not enlarged and no liver abscess occurs; moderate leukocytosis may be present. In very acute cases the patient becomes seriously ill within forty-eight hours, the movements increase in frequency, the pain is of great intensity, severe headache occurs, and the patient becomes delirious and dies on the third or fourth day. Lobar pneumonia, bronchopneumonia, acute bronchitis, and fibrinopurulent pleurisy may complicate. In cases of moderate severity the symptoms abate, stools lessen in frequency, temperature falls, and within two or three weeks the patient is convalescent. In the subacute cases the attack may last many weeks or even months, and the patient have three to five bloody mucous stools in twenty-four hours, and become very emaciated. One of Strong's cases died on the sixty-fourth day. The Bacillus dysenteriae is found in the stools and agglutinates with blood-serum. Other Clinical Types. The description just given applies to the types of bacillary dysentery such as seen in Japan, the Philippines, and the tropics, and the features of that in adults in temperate climates differ in no essential, except in many cases the symptoms are less severe. Duval, as noted, has found one of the bacillary dysentery strains in sporadic cases in Philadelphia and elsewhere, and the probability is that . most cases of non-amebic dysentery belong to this type. The so-called acute catarrhal dysentery is unquestionably a sporadic form due to the Bacillus dysenteriae. This is the more probable when we consider that in ileocolitis (dysentery) in infants we find a catarrhal type. In infants there are four types of lesion found on autopsy (Holt): Follicular ulceration; catarrhal inflammation; catarrhal inflammation with superficial ulceration; membranous inflammation. This last differs from the membranous type in adults, in that there is little pseudomembrane and no deep sloughing. Holt has well described these varieties. Methods of serum diagnosis in the bacillary dysentery of infants are described by Lucas and Fitzgerald 1 at the laboratories of the Harvard Medical School. They advocate the conglutination reaction. His and Russell some years ago differentiated the Y bacillus as causative of dysentery in infants and young children. Two epidemics of this type occurred among children in Diisseldorf and Berlin in the summer and fall of 1912. Diphtheritic dysentery is a type of the bacillary form with great necrosis and infiltration of the mucosa. It is believed that other types of bacteria are also often associated in the process. The pure dysentery bacillus, unlike the typhoid bacillus, does not lead to bacillemia or bacil- 1 Jour. Amer. Med. Assoc., Feb. 5, 1910. 696 DISEASES OF THE STOMACH AND INTESTINES luria (Herter, Bacterial Infections of the Digestive Tract). In the diphtheritic type, a mixed infection in which streptococci undoubtedly are prominent, the condition is unquestionably, in my opinion, a general infection, as shown by the complications. The secondary diphtheritic dysentery is a common terminal event in many acute and chronic diseases. Vedder and Duval have demon- strated that the bacilli are present in these cases. Peritonitis is rare, either through extension or by perforation. When it occurs about the cecal region, perityphlitis results, or when low down, periproctitis. In 108 cases collected by Woodward, perforation occurred in n. Abscess of the liver is very rare. A few cases occurred in the Civil or South African War. In the tropics malaria and dysentery may coexist, and typhoid and dysentery coexisted quite frequently in the Civil War. In ordinary practice it is very rare. Complications. Acute bronchitis, pneumonia, bronchopneumonia, cancrum oris, pleurisy, gangrene of the lung, albuminuria, meningitis, paralysis, paraplegia, in many cases due to a neuritis, are not uncommon; thrombosis of the cerebral sinuses, embolism (cerebral), rheumatic pains and swollen joints (analogous to gonorrheal arthritis), pericarditis, endo- carditis, periproctitis, perityphlitis, and occasionally pyemic manifesta- tions, such as pylephlebitis or abscess of the spleen, may occur. Anemic edema may be present in protracted cases. Chronic B right's disease is an occasional sequel and intestinal stricture is rare. Persistent dyspepsia and irritability of the bowels may follow. Prognosis. In the very severe cases, the prognosis is bad, the patient often dying within one to two weeks. This is especially true in epidemics. In milder cases convalescence begins by the end of the second week. Chronic cases may run weeks or even months, the patient becoming very emaciated. They may die at the end of several months. Convalescence is slow in any but the mild cases. Treatment. Prophylaxis. The same precautions should be exercised as regards boiling drinking-water, avoiding green vegetables, cleanliness of the hands, destruction of flies disinfection of stools and linen, as are carried out in amebic dysentery and in typhoid fever. Medication. The bowels should be at once thoroughly cleared with castor oil, i to 2 ounces (30.0 60.0), or with magnesium sulphate or sodium sulphate, i to 2 drams (4.0-8.0). Buchanan has had excellent results by the sodium sulphate treatment; he gives i dram (4.0) sodium sulphate four to even eight times a day, for two to three days until blood and mucus have disappeared. He has treated 855 cases with nine deaths an excellent record. The old ipecac treatment is still in considerable repute in tropical countries. No food is taken for three hours, then 20 drops of laudanum are administered and one-half hour later 20 to 60 grains (1.3-4.0) of pul- verized ipecac. If this is vomited, the dose is repeated in a few hours. The salol-coated ipecac pill, as described under Amebic Dysentery, may be substituted, or emetin preferably by hypodermic. Rogers claims that emetin has no effect on the bacillary type and it may be used as a DYSENTERY 697 means of differential diagnosis, i.e., favorable results show the dysentery is amebic. In South Africa the saline treatment was often given combined later with the ipecac, and Washbourne reported good results. Ringer recommends small doses of bichlorid, Koo grain (0.00065), every two to three hours, and large doses of bismuth subnitrate have been used with success, at least }$ dram (2.0) and sometimes as much as i dram (4.0) every two hours daily for the first few days. . The following I have found the most rational method of internal medication. The bowels should first be thoroughly cleared by the administration of i% to 2 ounces (45.0 60.0) of castor oil in the adult, or by several doses of i to 2 drams (4.0-8.0) of magnesia sulphate or sodium sulphate; calomel, 5 grains (0.3), may precede this. A hot application should meanwhile be applied to the abdomen to relieve the pain, and if the latter be un- endurable and there is considerable collapse, a very small hypodermic of morphin may be given, sufficient to render it endurable and not large enough to interfere with peristalsis. Camphor gr. v-x in almond oil by hypo may also be required. It is preferable not to administer opiates until thorough cleansing of the bowels has been accomplished. In fact, it is m,y belief that opium is given too frequently and in too large doses, so that material accumulates in the bowel which had better be expelled. Bismuth subnitrate, which it is preferable, as a rule, not to use in the undermined ulcers of amebic dysentery, in this type is of great value. The dose should be large. After thorough clearing of the bowels, bismuth subnitrate alone, or combined with equal parts of saccharated pepsin should be given. At least 20 to 30 grains (1.3-2.0) of this mixture or even 20 grains (2.6) of bismuth subnitrate every two to three hours. Bismuth subcar- bonate, 10 to 15 grains (0.6-1.0), can be substituted. Bismuth subgallate, 5 to 10 grains (0.3-1.6) t.i.d., or bismuth salicylate, 10 grains (0.6) t.i.d., can be substituted in place of some of the usual doses of the other prepara- tions; thus, for example, bismuth subgallate and bismuth subnitrate could alternate. Bismuth subnitrate, 30 grains (2.0), mistura cretae, 2 drams (8.0), is an excellent combination in one dose, given every three or four hours. The tannin preparations, such as were suggested in amebic dysentery, can be given, three doses substituted for three of the bismuth in the course of twenty-four hours. Thus, if seven doses of bismuth were given in twenty-four hours, give three of tannin and four of bismuth. Tannalbin, 5 to 7> grains (0.3-0.5), or even 15 to 30 grains (1.0-2.0), can be given four or five times daily. It can be administered with grated chocolate or beaten up with an egg or with a little strained rice gruel. Tablets, 5 grains (0.3), can also be secured. If the pain is severe, small doses of opium may have to be given, with the precautions noted. The opiates are described under Diarrhea. Hexamethylen- amin I believe is of service, 5 to 10 grains (0.3-0.6), combined with equal quantities of sodium benzoate, given four to six times daily. It tends to lessen the toxemia and is of service in the cases of mixed infection. Tenesmus should be relieved first by thorough bowel irrigation, and after this, if it continue, by inflation with a small amount of CC>2 (Rose's 698 DISEASES OF THE STOMACH AND INTESTINES method), or by a small injection of starch- water and laudanum, 15 minims (0.888), with tincture of belladonna, 10 minims (0.59). Opium should never be given first, thus tying up the foul secretions. Strychnin, nitroglycerin, or camphorated oil by hypodermic may be required. Local treatment is of paramount importance. Zinc, sulpho- carbolate of zinc, and silver nitrate are preferable in the chronic cases. Hypodermoclysis, or even infusion, may be required in shock or severe sepsis or thirst. Proctoclysis is of use in the latter. Further Treatment of Tenesmus. A preliminary suppository of bella- donna extract, ^ grain (0.022), alone or, rarely, combined with % grain (0.008) cocain, or the injection of % grain (0.008) cocain in i ounce (30.0) water, may rarely be necessary. The best method is to insert a recur- rent tube and gently irrigate with normal saline solution at 110 to ii5F., or cold at 40 to 5oF., and then, forcing the tube in still further, con- tinue the antiseptic irrigation. I have found the recurrent method of irrigation with a double tube (preferably), or two tubes (soft catheters) of great value in dysentery, the patient's hips or foot of the bed being elevated. The patient is gradually accustomed to the fluid, and the quantity allowed to run in before permitting return, can slowly be increased, and there is not the endeavor to expel the solution. A single injection of any size can often not be given. On the other hand, i to i% liters (quarts) can be injected, by the method of Musgrave in amebic dysentery, in some cases. In the acute cases acetozone, alphozone, hydrogen peroxid, and per- manganate of potash are of especial value, in the same strength noted below as employed in amebic dysentery. Delafield has secured excellent results by the use of bichlorid of mercury (i : 10,000), using 2 quarts (liters), but cautiously, with my recurrent tube. I have had good results by this method, but it should never be given by ordinary enema. Acetozone (i : 1000), hydrogen peroxid 5ii to liter of water, alphozone (i : 1000), and permanganate of potash (i : 1000) are excellent. Mucol, i dram (4.0) to i quart (liter) or even stronger, has been em- ployed. This preparation contains the chlorid, borate, bicarbonate, and benzoate of soda, with zinc sulphocarbolate and essential oils. Several irrigations or enemata may be necessary daily, depending on the tenesmus, or character of the stool: one or two antiseptic, and the rest of normal saline solution, or flaxseed tea or gum-arabic. If mucus and blood increase, a cathartic is again indicated, and I believe it should be given every three days in any event. Carbolic acid should never be employed for irrigation. Chronic Dysentery. Bismuth is of value. Nitrate of silver injections are of service 10 to 30 grains (0.6-2.0) to i pint (500 c.c.) and inject 2 to 3 pints if possible; if there is irritation, follow it with an injection of normal saline solution. Protargol or argyrol (i : 500) are useful, and often preferable to silver nitrate. Normal saline or normal saline with oil of peppermint, 10 minims DYSENTERY 699 (0.59), can be used between the antiseptic injections, or an injection of flaxseed tea or gum-arabic solution. The latter are soothing. Diet. Acute Cases. Fluid diet, broths, gruels, barley- and rice-water, beef juice, egg-albumen, and milk well diluted. Somatose and tropon are of use. Personally I prefer milk-free diet. In the chronic cases, fruits and green vegetables should be avoided and constipating food given if there is diarrhea. The weight of the patient should be increased by administration of fats, cream, butter and raw-eggs. The general diet rules should be similar to those in amebic dysentery. Serum Therapy. Shiga immunized horses and produced a polyvalent serum from which he claims to have reduced the mortality of dysentery in Japan from 35 to 9 per cent. Flexner has prepared a serum, but Holt states results in children have proved disappointing. Complications should receive appropriate treatment. Treatment of Dysentery Bacilli Carriers. Mayer 1 states that at- tempts to dispossess these bacilli by internal medication have failed. He advises isolation until the germs disappear from the stools. This has been found to require from three to seven months. The author refers chiefly to cases in troops where sanitary measures are more available and where the danger of lighting up new epidemics is more marked. In addition to isolation, the stools require immediate disinfection. It has been found that if the period of isolation is too short, bacilli which have temporarily disappeared from the stools may reappear. Meanwhile treatment should be continued and the effort made to prevent the con- dition from becoming chronic. Hexamethylenamin and sodium benzoate (aa gr. x), four to six times daily, and high irrigations with acetozone (i : 1000) should be continued. 1 Munch, medizin. Wochens., Dec. 6, 1910. CHAPTER XXVII TYPHOID FEVER PARATYPHOID FEVER BRILL'S DISEASE A MERE outline of this disease will be given for the purpose of dif- ferential diagnosis. Typhoid may be denned as a general infection caused by the Bacillus typhosus, characterized anatomically by hyperplasia and ulceration of the intestinal lymph-follicles, swelling of the mesenteric glands and spleen, and by parenchymatous changes in the other organs, such as in the kidneys, liver, etc. Clinically the disease is marked by fever, rose-colored eruption, abdominal tenderness, tympanites, diarrhea, and splenic enlargement, but these symptoms are inconstant. History. Louis, in 1829, gave the name to the fever. Gerhard, in 1837, first clinically differentiated between typhoid and typhus. Etiology. General prevalence. It prevails in temperate climates. Imperfect sewage and contaminated water-supply favor the distribution of the bacilli; filth, overcrowding, and bad ventilation aid in lowering the resistance of the individual. Fingers, food, and flies spread the disease from the infected person. It is prevalent in England, Wales, India, parts of Germany, and in the United States, where it occupies about fourth place in the mortality list. It has been one of the great scourges of armies, more desctructive than powder and shot. The mortality in the South African and Spanish-American wars was greater from typhoid than from bullet wounds; among the American troops, about one-fifth of the soldiers in the national encampments had this disease. The former inefficiency of our sanitary methods was a blot upon our govern- ment. In great contrast to this were the remarkable results secured by the Japanese in the recent Russo-Japanese War, where, in comparison with our own records, typhoid and dysentery were practically negligible factors. Season. The disease is more prevalent in the autumn, though fre- quent cases occur during August. Sex. Both sexes are equally liable, but males are more frequently admitted to the hospitals. Age. Typhoid is a disease of youth and early adult life, the greatest susceptibility being between the ages of fifteen and thirty. Cases are rare over sixty. It is not infrequent in children. Infants are rarely attacked. Immunity. Not all exposed take the disease. One attack usually protects; two attacks have been described, and occasionally three. Bacillus Typhosus. The researches of Eberth, Koch, and others have shown that the disease is due to a special microorganism. It is a short, thick, flagellated, motile bacillus with rounded ends, in one of which, sometimes in both, there can be seen a glistening round body, probably an area of degenerate protoplasm. It grows readily on various nutritive 700 TYPHOID FEVER PARATYPHOID FEVER BRILL'S DISEASE JOl media and must be differentiated from the Bacillus coli. 1 The organism fulfils all the requirements of Koch's law. Cultures are killed in ten minutes by a temperature of 6oC. The direct rays of the sun destroy them in from four to ten hours' exposure. Bouillon cultures are destroyed by carbolic acid (i : 200) and by bichlorid (i : 2500) solution. Toxins have been isolated from the bacilli. Distribution in the Body. The typhoid bacilli may be demonstrated in the circulating blood, and have been found in the urine, stools, sweat, sputum, and in the rose-spots. They occur in the mesenteric glands, spleen, and gall-bladder, and have been found in almost all the organs, even in the muscles, uterus, and lungs. Cultures from the intestines show that few, and frequently none, can be cultivated from the rectum up to the cecum. Above this they are numerous. They have been found in the mucous membrane of the stomach, in the doudenal contents, 2 also in the esophagus, and on the tongue and tonsils, and have been isolated from endocardial vegetations, meningeal and pleural exudates, and from foci of suppuration in various parts of the body. They may be present in the stools of healthy people who have lived in close association with typhoid patients. Bacilli Outside the Body. They retain their vitality for weeks in water. This is further demonstrated from infection by ice, in which they exist for several months, and live for some days in butter from in- fected cream. They may live in the upper layers of the soil for months; in street dust for a month or more; on linen for two months; and on wood for a month. Modes of Conveyance. Aerial transmission is not probable. Fingers, food, and flies are the chief means. House infection is difficult to avoid unless finger contamination is carefully eliminated. Such epidemics have been reported at the Johns Hopkins Hospital. Epidemics have occurred from infection of water, milk, and food, such as celery and un- cooked vegetables which have grown in infected soil. Raw oysters are recorded as a cause of epidemics. Bedbugs and fleas may be carriers. Water infection is the most common cause. There is some evidence that the digestive tract is not the only portal of infection for typhoid fever, but that the bacilli may enter by way of the throat, notably by the tonsils (Herter). Morbid Anatomy. Intestines. A catarrhal condition exists throughout the large and small intestine. Specific changes occur in the lymphoid elements; chiefly in the lower end of the ileum. Four stages are described: i. Hyperplasia, involving Peyer's patches in the jejunum and ileum and, to a variable extent, those in the large intestine. They are swollen, grayish-white in color, and may project from 3 to 5 mm. The solitary glands may project to a variable extent. There is hyperemia of the follicles; later an increase and accumulation of the cells of the lymph-tissue, which may infiltrate the adjacent mucosa and muscularis; the blood-vessels are compressed, which give a white anemic appearance to the follicles. 1 Paratyphoid infection is referred to under Diagnosis. 2 Purjesz, Wiener Klinische Wocbens., Jan. i, 1914. 7O2 DISEASES OF THE STOMACH AND INTESTINES This process reaches its height from the eighth to the tenth day, and then undergoes either resolution or necrosis. 2. Necrosis. When the hyperplasia is marked, resolution is no longer possible. The blood-vessels become choked; there is a condition of anemia; then necrosis occurs and sloughs form, which must be separated and thrown off. This process is always more intense toward the ileocecal valve. The necrosis is variable, it may pass deep into the muscular coat, and even perforate the peritoneum. 3. Ulceration. Sloughing is effected from the edges inward, and results in the formation of an ulcer, the extent of which is directly propor- tionate to the amount of necrosis. The muscularis usually forms the floor of the ulcer. 4. Healing. The mucosa extends from the edge and a new growth of epithelium is formed, as are the glandular elements. The healed ulcer is depressed. Healing is never associated with stricture. Large Intestine, The cecum and colon are affected in about one-third of the cases, and the solitary glands are sometimes enlarged. Perforation. About one-third of the deaths, Scott's statistics state, are due to perforation. It occurred in 3.6 per cent, of all cases. The German statistics are much lower; in Munich only 5.7 per cent, of deaths are due to perforation. Among 1500 cases at the Johns Hopkins Hospital there were 43 of perforation; 20 were operated on, and 7 of these recovered. The site of the perforation is usually in the ileum, within 12 inches of the ileocecal valve. It may be from a pin-point to large size. Death from Hemorrhage. This occurred in 12 of 137 deaths in Osier's 1500 cases. He could not find the bleeding vessels. Mesenteric glands are hyperemic and swollen. Necrosis is common; abscesses may occur, causing peritonitis or hemorrhages. Spleen is enlarged, infarction is not infrequent. Rupture may occur. Bone-marrow. Some changes occur as in lymphoid tissue, and there may be foci of necrosis. Liver. Parenchymatous degeneration present. Liver abscess has been found, also acute yellow atrophy. Pylephlebitis may occur. Gall-bladder. Acute cholecystitis may be present. Kidneys. Cloudy swelling with granular degeneration is frequent; less commonly an acute nephritis; miliary abscesses or diphtheritic in- flammation of the pelvis may occur; also infection by colon bacilli. With colon bacilli infection, chills, rise of temperature, and acute renal symptoms occur. Bladder. Cystitis or diphtheritic inflammation may complicate. Orchitis, acute mastitis, and parotiditis are occasionally met with. Respiratory Organs. Ulcer of the larynx; edema of the glottis; diph- theritic inflammation; bronchitis; pneumonia; hypostasis, pleurisy; gangrene; abscess of the lung; hemorrhagic infarction and empyema may complicate. Osseous System. Periostitis, osteitis, etc., are referred to later. Circulatory Changes. Endocarditis, pericarditis, and myocarditis, endarteritis, arthritis of a peripheral vessel with thrombus formation may occur. Venous thrombosis is more frequent, especially of the left femoral. TYPHOID FEVER PARATYPHOID FEVER BRILL S DISEASE 703 Nervous Symptoms. Meningitis is rare; optic neuritis may occur; the cause of aphasia seen in children is not positively known. Paren- chyma tous changes may occur in the peripheral nerves. Voluntary Muscles. The muscular substance, especially of the recti, pectorals, and adductors of the thigh, may undergo granular degenera- tion or hyaline transformation. Rupture, hemorrhage, or abscess have been found. Reflexes. The superficial skin reflexes of the abdominal walls are fre- quently absent or markedly diminished in typhoid fever. The return of these lost reflexes is usually synchronous with other evidences of recovery. Symptoms. Incubation, eight to fourteen days, occasionally to twenty-three days, during which period there are lassitude and inapti- tude for work. Onset is rarely abrupt, with occasional chills. There 1HU ' ferl t f > t / m A. if 19 ir * ff~it 4 ,. u U- LI U .1- ll U . *. U . tl IfU 1W - ivr . m' . uf - 104 - ...lit-* 771 la - T/v|N? AwOTXf^AA ^ ' in . - -fj --t r [_ (\_[ IT 5-W-i tor TJ ] , x ! loo / V T w : , v _ y vA. .9 > __ y j i^" ! iSMSiUki !2 IM !. . ' r ,ou.i"*J<' 1t "Y' v .' , iilRiiiMMIMIll l tt A 19 H * Ti tfltpuiufffcti*!*'*'****' PCCiSffEEifr* * *4rr* **' TMll I'rlMJ t?' tr 1 jrl Fig. 294. Typhoid chart. may be cough (bronchitis), epistaxis, headache, anorexia,, diarrhea in many cases, but frequently early constipation, abdominal pain, and dis- tention; and in some cases there is pain in the right iliac fossa. At the onset the patient usually takes to his bed. During the first week there is in many cases a steady rise of tem- perature, the evening record rising a degree or more each day, and reach- ing 103 to io4F. (Fig. 294). Variations of temperature are common. It may rise suddenly to io4F. or may fall suddenly. It may be high A. M. and lower p. M. The pulse is rapid, 100 to no, full, but of low tension, and often dicrotic. The tongue is coated and white, the abdomen slightly dis- tended and tender. Unless there is high temperature, there is no delirium. The patient complains of headache and there may be mental confusion at night. The bowels are loose, or may be constipated. At the end of 704 DISEASES OF THE STOMACH AND INTESTINES the week the spleen becomes enlarged and the eruption appears in the form of rose-colored spots, seen first on the abdomen. They are raised, flattened papules, can be felt by the finger, and disappear on pressure. They come out in crops and may appear on the trunk or extremities. Desquamation may occur. In the second week the symptoms become aggravated; the fever re- mains high and the morning remissions are slight, the pulse is rapid and loses its dicrotism. There are mental torpor and dulness; the lips are dry and the tongue may become dry. Tympanites, tenderness, and diarrhea, if present, become aggravated. The stools are described as "pea-soup." Death may occur at the end of this week from hemorrhage or perforation, but generally later. In the third week the pulse ranges ffom no to 130. The temperature shows marked morning remissions and there is a gradual decline in the fever. Loss of flesh is more marked and weakness is pronounced. Diarrhea and meteorism may in some cases occur for the first time. Unfavorable symptoms are pulmonary complications, feebleness of the heart, delirium with muscular tremor, and acute tympanites. The tongue may become brown or brownish black and the lips and teeth be covered with sordes. Special dangers are perforation and hemorrhage. The fourth week convalescence begins. Temperature gradually be- comes normal; diarrhea stops; tongue cleans; the desire for food returns. In severe cases the fourth and fifth weeks present an aggravated picture of the third, the patient grows weaker, pulse more rapid and feeble, tongue dry, and abdomen distended. He lies in profound stupor with low muttering delirium and subsultus tendinum, and passes the feces and urine invol- untarily. Heart-failure and secondary complications are the chief dangers. In the fifth and sixth weeks, protracted cases show irregular fever, and convalescence may not set in until the fortieth day or longer. Dur- ing this period, recrudescence of temperature may occur from errors in diet, constipation, or excitement; or a relapse (re-infection) may take place. With relapse, there is a repetition of the ascent of the original fever. A rise in temperature from inflammatory complications usually has leuko- cytosis associated with it. Modes of Onset. As a rule, the onset is insidious. The following deviations may occur: Marked nervous symptoms, such as headache or cerebrospinal symptoms, with retraction of the head and convulsions; or mania; or stupor. Pulmonary symptoms, such as bronchitis, pneu- monia, or pleurisy. Intense gastro-intestinal symptoms, with pain and vomiting, suggestive of poisoning, or in some cases simulating appendicitis. Acute nephritis may be the first symptom. Ambulatory form, in which the patient keeps about and attempts to work. This runs a severe course and often a fatal issue results. Chills may occur at the onset and may be followed by sweats, and they are present with complications. Varia- tions from the typic temperature are common, the step-like ascent does not always occur, but the fever may rise suddenly. A sudden fall of temperature is suggestive of hemorrhage, before blood appears in the stools. Peliomata, maculae pale-blue or steel-gray spots are sometimes present, TYPHOID FEVER PARATYPHOID FEVER BRILL'S DISEASE 705 due to lice. Erythema may occur. Bed-sores are not uncommon and boils are a troublesome sequel. Blood. Leukopenia (hypoleukocytosis) is present; lymphocytes are relatively increased. Eosinophiles disappear or are markedly diminished. The reappearance or increase of eosinophilia is a good prognostic sign. Leukopenia and absence of eosinophiles aid diagnosis. Hemoglobin and red corpuscles are reduced. Severe meteorism is a danger-signal and predisposes to hemorrhage or perforation. Acute gastro-intestinal dilatation, or acute ectasia alone may occur. Acute distention may even simulate perforation; and it is only possible to differentiate, by relieving the distention by enteroclysis and lavage. Symptoms of Perforation. Sudden sharp pain, at times paroxysmal, often in the hypogastric region to the right of the median line sometimes lower down; tenderness, sudden distention, and muscular rigidity. This last is an important symptom. There are shock, fall of temperature, pallor, sweating, and the Hippocratic facies. The temperature then rises, pulse rapid and feeble, respiration increases. Vomiting is often present. Leukocytosis and especially increase in the polynuclears occur. Percus- sion may show a flat note in the flank, due to exudate. Obliteration of liver flatness may be caused by tympany. Abscess of the liver and cholecystitis may complicate. Gall-stones in many cases are probably associated with the presence of typhoid bacilli in the gall-bladder. Under Lesions, most of the complications are referred to. Loss of hair may take place. Local neuritis, as in the arms, legs, or toes (tender toes), may occur. Multiple neuritis is a complication of convalescence. Poliomyelitis r tetany, and hemiplegia have been reported. Typhoid psychoses may occur, also eye and ear complications, and retention of urine. Post- typhoid anemia may be severe. EhrlicWs Diazo-reaction. This test is not absolutely diagnostic, as it occurs in miliary tuberculosis, in malaria, and occasionally in other acute disease, associated with high fever. It is of accessory value taken with other data. Bacilluria occurs in about one-third of the cases. Acute appendicitis may complicate. Osseous System. Periostitis, 1 osteitis, caries, and necrosis are trouble- some sequelae of typhoid, as are arthritis and typhoid spine. Colitis, simple catarrhal or of a septic (diphtheritic) type, may complicate. Thrombosis of the Veins. The writer has recently seen a case of thrombosis of the left femoral vein which resulted in the ultimate necessity of amputation of the thigh. Post-typhoid septicemia and pyemia are not uncommon. Furuncles, abscesses, and infarcts in various regions may occur. With children, typhoid fever often runs a mild and irregular course. Diagnosis. The type of temperature, splenic enlargement, eruption, absence of leukocytosis (leukopenia), disappearance of the eosinophiles, together with Ehrlich's reaction, are the chief signs. Isolation of the typhoid bacilli from the blood, stools, and urine is diagnostic. ^The writer has seen several cases of periostitis involving the ribs and femur, within a few years. 45 706 DISEASES OF THE STOMACH AND INTESTINES Widal's reaction is of positive value when found. It is generally not in evidence until the seventh to tenth day, sometimes not until con- valescence, and occasionally not at all. Cabot claims over oo per cent, reactions before the eighth day. Fortunately, it is present in about 90 per.cent. of cases. Blood examination will differentiate between typhoid and malaria. Sasky 1 concludes that bacteremia is an almost constant occurrence in the first week of the disease and tends to disappear in the course of the following weeks. In the severe and moderately severe cases the typhoid bacilli may be isolated from the blood in the second, and even in the third weeks of the disease, while in the mild cases they are no longer to be found in the second week. Ulcerative endocarditis has been mistaken for typhoid, but the presence of the heart lesion and the streptococci in the blood are diagnostic. With acute miliary tuber- culosis the temperature is irregular or intermittent. Tubercle bacilli may be found in the fluid by lumbar puncture, and there is an absence of typhoid bacilli in the blood-culture. The tuberculin test (ocular) or by injection is of value. Respiration is more rapid and there is more cyanosis. Widal is negative, but leukocytosis is common. With typhoid we have the Widal reaction; there is leukopenia, splenic enlargement is present, and the typic eruption. Intestinal grip may for a few days simulate typhoid, as may intestinal toxemia. The subsequent course, absence of Widal reaction, etc., clear the diagnosis. The paratyphoid 2 bacilli A and B may produce symptoms like a mild typhoid fever, and paratyphoid B may be found in meat-poisoning, and have a causal relation to the typhoidal symptoms. The Bacillus enteri- tis (Gartner) may be found in meat-poisoning, and this bacillus, and also the Bacillus faecalis alcaligenes, Herter shows, may incite symptoms simulating mild typhoid fever. Recent studies, however, have shown that these bacilli differ from typhoid bacilli in their agglutination reactions. Hemorrhage is rare and never alarming. Widal is negative. Moreover, the serums of patients ill with meat-poisoning, regularly agglutinate known cultures of the causative organism, as does that of paratyphoid A. With Brill's disease, cultures from the blood, urine, and feces are negative as to typhoid bacillus, and Plotz organism is found with blood. Widal is negative. There is no. intestinal hemorrhage. Leukopenia is absent. Prognosis. Mortality. Death-rate is variable, depending on the sever- ity of the epidemic and when treatment has begun. Of recent years it has been from 5 to 20 per cent. Fat people stand typhoid badly. Meteorism, hemorrhage, high fever, and nervous symptoms give a bad prognosis. Prophylaxis. Care in drainage and water-supply are most important. These are the chief precautions to be taken in army camps. Vaccine therapy as a means of prophylaxis the writer also believes of great value. Undoubtedly this proved efficacious during the Boer War in the English army, being introduced by Wright. Russell 3 reports favorably on this method as a prophylactic in the U. S. Army, and refers to the work of Leischmann in the English army, and to the results secured in the German- 1 Zeitschrift fur Klinische Medizin., vol. Ixxx, Nos. i and 2, 1914. 2 Colon bacilli infection may simulate typhoid, but the colon b, are found in the urine and respond to the appropriate fermentation tests. 8 N. Y. State Jour, of Med., Dec., 1910. TYPHOID FEVER PARATYPHOID FEVER BRILL* S DISEASE 707 African campaign. Russell advocates three preventive injections at ten-day intervals the first injection of 500,000,000 dead bacteria, and the subsequent doses of 1,000,000,000 each. Antityphoid Vaccination. The result^ of antityphoid vaccination in the U. S. Army can be characterized only as marvellous. Russell reports in an army of 90,000 men in the year 1913* only three cases of typhoid with no fatalities. It should be obligatory in the militia, and among hospital nurses and internes who are exposed to typhoid in all public institutions and asylums at the first appearance of a typhoid case and it should be administered to one's patients as a prophylactic before summer vacation, or travelling, or when there is an epidemic of typhoid. In those weakened by disease it might do harm, and the writer believes it might activate an existing tubercular process. Alcohol should be avoided as should severe exercise during the periods of vaccination. Occasionally a more severe reaction occurs with headache, malaise, chills, fever, nausea, vomiting and diarrhea. In view of the difficulty of enforcing proper sanitary regulations in an ignorant community, the writer believes that antityphoid vaccination is as necessary as vaccination against smallpox. The Widal reaction should be tested for when possible 4 to 6 weeks later. Its appearance shows a successful vaccination. N. Y. Board of Health antityphoid vaccine, and U. S. Army vaccine are excellent. I advise all my patients to be immun- ized against typhoid. Immunity following antityphoid vaccination, it has been believed results for about two years; though more recently Gaither 2 reports the occurrence of five cases of typhoid from nine to twenty-one months subsequent to vaccination against the disease. Gay 1 has recently announced a new antityphoid vaccine from which he claims practically no reaction results and that it is more certain and confers a longer immunity. Antityphoid Vaccination in Childhood. Russell 3 reports antityphoid vaccination in cases of children. No case of typhoid occurred in those vaccinated. Revaccination should be performed more frequently in children. The dose is regulated according to the weight of the child; if one-third weight of adult then a one-third dose should be given, but it is preferable to give a little more vaccine in proportion, and if the child increases rapidly in weight it should be revaccinated. He believes the duration of immunity is about three years but two years as a safer esti- mate. Russell advocates antityphoid vaccination at least once in in- fancy, once in childhood, once in youth and once in adult life. I believe in it more frequently. Raw milk, raw oysters, and uncooked fruit and vegetables should be avoided during an epidemic. Raw oysters in New York should generally be avoided, unless the source of the supply is known. A number of epidemics have been traced to infected oysters and a recent epidemic has been attributed to this source (Brooks). 4 The urine, stools, and sputum 1 Jour. Amer. Med. Assoc., May 2, 1914. 2 Jour. Amer. Med. Assoc., Oct., 10, 1914. 3 N. Y. Jour, of Med., July, 1914. 4 Jour. Amer. Med. Assoc., May 6, 1916. 708 DISEASES OF THE STOMACH AND INTESTINES should be disinfected. The sputum can be collected in cloths and burned and bichlorid (i : 1000) or carbolic (i : 20) used to disinfect the other dis- charges. About twice the volume of the disinfectant should be mixed with the stools, and it should be left to stand for two hours before emptying. For disinfection of the bath-water, % pound of chlorid of lime will render an ordinary bath of 200 liters sterile in one-half hour (Babucke). The nurse should wear a rubber apron and should wash it frequently with carbolic or bichlorid. When giving baths, rubber gloves, or especially rubber finger-tips, should be worn, and the hands thoroughly disinfected later. The hands have been found to be the source of transfer of the disease in about 90 per cent, of the cases, 1 which proves the necessity of isolating these patients. All bedding and the patient's night-dress should be soaked two hours in i : 20 carbolic and then boiled. A special cup, dish, spoon, etc., should be used for the patient, and disinfected on each occasion after using. It is best to keep them in the room and transfer the food from another vessel to the special cup or dish; if in a ward, after each feeding, they should be placed in carbolic (i : 20). After recovery, the room should be disinfected. Osier shows that 1.81 per cent, of cases of typhoid at the Johns Hopkins have been of hospital origin. I have noted great carelessness in our hospitals as re- gards fly protection, seldom observing screening of the patient during the fly season. Typhoid cases should preferably be kept in a special ward to avoid the danger of infection of other patients through carelessness. Mabon demonstrated this some years ago at the Manhattan State Hospital. The method so often followed in some of our hospitals of treating typhoid in the general medical ward the writer believes most pernicious. Chronic Typhoid Distribution. Many cases are discharged from the hospitals while there are still typhoid bacilli in the urine and stools. Examinations of these discharges should be made. Hexamethylenamin 5 to 10 grains (0.3-0.6), with an equal amount of sodium benzoate t.i.d., is excellent to disinfect the urine. It is generally necessary to increase it to four or five doses daily. An interesting case of typhoid carrier of nearly seven years' duration, "Typhoid Mary," with five small epidemics to her credit, is reported by George A. Soper. 2 Rosenberger 3 gives a report on the literature of typhoid carriers. Treatment. General Management. The patient should be in a light, well-ventilated room, confined to bed. This should preferably be single, with a comfortable mattress, covered with a blanket, and a rubber cloth placed under the sheet. Nursing and diet are the essentials. Diet. There is a tendency among many practitioners to endeavor to increase the resisting power to typhoid by increased feeding, and who hold that for this purpose the patient should lose as little weight as possible. In some cases solid food has been administered; in others liquids with considerable dextrose and cream. W. Coleman 4 advocates milk, cream to a pint daily, bread and butter, 1 Jour. Royal Army Med. Corps, Jan., 1907. 2 Jour. Amer. Med. Assoc., June 15, 1907. 3 N. Y. Med. Jour., March 26, 1910. 4 Jour. Amer. Med. Assoc., Oct. 9, 1909. TYPHOID FEVER PARATYPHOID FEVER BRILL'S DISEASE 709 milk-sugar, and eggs, giving from 4000 to 5500 calories per day, and re- ports good results. The author disagrees with a method which places upon diseased organs twice the labor which they perform in health, with the dangers incident to excessive feeding. F. Meara 1 employs milk, cream, etc., in his diet, toasted bread, gruels, ice-cream, etc. He is more conservative as to forcing the quantities, but gives as much as the patient takes well, and diminishes the quantity if gastro-intestinal disturbances appear. C. W. Strong 2 gives a milk-free diet, boiled rice, 6 to 7 ounces at a time, being the basis of his feeding, together with eggs, gelatin, bread, butter, broths, with milk-sugar and a little cane-sugar, up to 3500 calories a day. He secures best results by omitting milk. // has been thoroughly demonstrated that no matter what the intake, the nitrogenous output in this disease is always markedly in excess. 3 Kocher has demonstrated that in fever there is an actual destruction of protein and that it is difficult or impossible to maintain protein equi- librium at certain periods of febrile disease even with a high calorie diet. Typhoid is an acute general infection, and in such conditions all the digestive functions are abnormal. The appearance of the tongue, the mouth and lips of a typhoid patient are certainly significant of disturbance of the salivary glands. There is change in the character of the bile. Stolmkow 4 noted disturbances in the pancreatic juice; and I recently referred to the diminution 5 of motor power and the lessening, or absence of hydrochloric acid during the high temperature of typhoid fever. The parenchymatous changes in the liver and kidneys interfere with elimination by these organs, and the associated intestinal catarrh causes further interference with the digestive functions. Du Bois 6 during his calorimetric observations in disease made the following interesting statement. "In disease on the other hand, the appetite is no index of the requirement, and the nutri- tion of the cells is at the mercy of the physician. Likewise the stomach and kidneys are at his mercy and he must regulate the diet so that it will nourish the cells without throwing too much work on damaged organs, or oxid&tive functions of the body." Hemorrhages, tympanites and relapses are the writer's experience with excessively high calorific feeding. Ex- cessive feeding, as now advocated by some 3500 to 5500 calories the writer holds prolongs the temperature, as much detritus will be found in the bowels, and after the emptying of the same, followed by proper milk- free diet, the temperature runs a lower course. Stuffing the patient is done at the expense of diminishing water, which the writer advocates in large amounts to eliminate the toxins. In spite of the disturbance of digestive secretions many patients can apparently assimulate 2000 to 2500 calories daily without distention and with apparent benefit. One must individualize, however, in every case. Fat does not constitute resistance 1 Amer. Jour. Med. Sci., Jan., 1911. 2 Amer. Med., Oct., 1910. 3 Finkler and Lichtenfeld, Central, fur die Allgemeine Gesundheitspflege* 1902. 4 Pfliiger, Archiv Physiologic. 6 Med. Rec., June 20, 1908, and Amer. Med., May, 1909. 6 Jour. Amer. Med. Assoc., Sept. 6, 1914. 7 1C DISEASES OF THE STOMACH AND INTESTINES and fat people generally do badly when infected with typhoid, yet it seems to be the tendency not simply to diminish loss of weight as much as possi- ble, but to increase the weight. The writer notes that in quite a number of cases of high caloric feeding, tissue loss occurred and the nitrogen out- put was in excess. Most of these observers seem to have entirely over- looked the value of gelatin in lessening nirogen excretion. Seibert, in 1889, noted that the temperature and tympanites were lessened when milk was withheld, the fever falling to 99 or iooF. on the ninth to twelfth days. Rectal irrigations he found of great value. He 1 gives rectal in- jections with 3 pints of warm normal saline solution, preferably several times a day (depending on the case), thus irrigating the bowel. During the first day of treatment, cold water only is given as food. From the second day on, > pint of strained rice, oatmeal or barley soup, containing the extract of K pound of meat and the yolk of a fresh egg, well spiced, are given every three hours, five times daily. From the fourth day on, strained pea, lentil, potato, and tomato soup with rice, were added to the menu. Two or three zwiebacks were given with the soup at the end of the first week. Orange-juice was given in water three times daily. Egg albumen was not given on account of the probability of forming toxins. Before each meal 15 to 25 drops of hydrochloric acid were administered in Yz ounce of water. No alcohol was given except to topers, and cam- phorated oil was employed by hypodermic, if stimulation was required. Cold baths were never employed, even in hyperpyrexia. Sponging was added if necessary. Opium was only used in bowel hemorrhage. Wm. N. Johnson 2 has secured excellent results in 65 cases of typhoid treated by the milk-free diet at the Germantown Hospital. There were an extremely low percentage of distention and hemorrhage and no perfora- tion. Of hemorrhage, 6 per cent., as compared with Coleman's 1 1 per cent, of hemorrhage in one series reported. With the excessively high calorie feeding, 3503 to 5500 calories, the writer has found more tympanites and a larger number of hemorrhages. Lesser 3 has treated all fevers above 102. 5F. with water alone, and below this point with broths, rice-, and barley-water, also employing enteroclysis. Good results were secured by these methods in typhoid fever during the Spanish-American War. The author's method is as follows: As gelatin lessens nitrogen excre- tion, and as it aids in preserving weight, and furthermore causes no putre- faction in the intestines, it is of some value as a food. The ingestion of 7.5 per cent, of the total heat requirement of the organism in the form of gelatin spares 23 per cent, of the body's protein. Thus, in a total of 2800 calories required by a man of 154 pounds (Chittenden), 210 calories in gelatin are necessary; i gram of gelatin contains 4.1 calories, so about 50 grams of gelatin are required, or i% ounces (50.0). The gelatin and cereal gruels approximate 2000 to 2500 calories, all that can be digested properly. Gelatin also lessens the tendency to hemorrhage. It should not be given if thrombosis occurs. 1 Med. Rec., June 20, 1908. 2 N. Y. Med. Jour., Feb. i, 1913. 3 Amer. Med., Oct., 1910. TYPHOID FEVER - PARATYPHOID FEVER - BRILI/S DISEASE 71! Approximately, i% ounces (50.0) of gelatin in 12 ounces (375 c.c.) of water, gives a 12 per cent, solution. This gelatin solution can be flavored with lemon, vanilla, or with sugar or saccharin and be given in divided doses. Strained rice, barley, oatmeal gruels, and chicken broths, the sum total not over i> to 2 quarts (liters), are also to be given in divided doses every three hours, the last feeding no later than 9 p. M. This makes in all about 2 to 2\i quarts (liters) of nourishment. The yolks of raw eggs, 3 to 4 daily, are beaten in with the broths, and gruels and butter are added. Of this last a trifle under > ounce represents 100 calories. Milk-sugar repre- sents about 1 20 calories to the ounce, and it may be added to each feeding with broth if it seems to agree. Feeding should begin about 6 A. M., and the last nourishment at 9 P. M. (six feedings in all) . One should give addi- tional doses of gelatin between the other feedings. Strained pea or strained potato soup may be given once daily in place of one of the gruels. For example the following table would give an average diet of 2000 to 2500 calories daily. It is noted below that the cereals average about five times higher in calorie value than does milk. A pat of butter may be added to the gruels occasionally sugar of milk disagrees. For thin barley gruel use i tablespoon Robinson's prepared barley to the pint of water, and double the quantity of flour for the thicker gruel. The same pro- portions may be used for the rice and oatmeal. Thinner the gruel, less the calories. The six gruel feedings furnish 548-60. 6.00 A.M. Barley gruel, sugar milk 3i ? yolk i egg, i pat butter, total 7.30 A. M. Gelatin solution 5iv (jelly). 9.00 A. M. Chicken broth or occasionally lamb broth 5viii-x. 10.30 A. M. Gelatin sol. 5" (jelly)- 12.00 M. Rice gruel, sugar milk 5i, yolk i egg, i pat butter, total 5viii-x. 1.30 P. M. Gelatin gii (jelly). 3.00 P. M. Barley gruel, sugar milk 5i> yolk i egg, i pat butter, total 5viii-x. 4.30 P. M. Gelatin 5" (jelly). 6.00 P. M. Strained pea soup 5viii-x. 7.30 P. M. Gelatin 5" (jelly). 9.00 P. M. Rice gruel, sugar milk 3i, yolk i egg, i pat of butter, total 5viii-x. Only water after 9 p. M. as the patient requires. One should administer about 2500 calories daily if there are no diges- tive disturbances and particularly no tympanites, and as low as 2000 in some cases or even less. One should individualize in each case. The gelatin is of great value for the reasons stated. The various foods are alternated for variety. The patient is not urged to eat. Whenever the temperature reaches 103 F. or more, nothing but water is administered until it falls to below 103 F., say 102.5. The juice of several oranges is given during the day. When the temperature falls to 99.5^., the gruels are thickened considerably and the yolks of raw eggs increased to 5 or 6 daily or even 8. When temperature becomes normal, soft-boiled eggs and soft diet, but no return to full diet until ten days have elapsed. At least i to ij quarts (liters) of water, to which dilute sulphuric acid, 20 minims (1.184 c.c.), is added, are to be drunk by the patient during the twenty-four hours if no distention is produced. The water can be saved for the night period when thirsty, 9 P. M. to 6 A. M. Dilute 712 DISEASES OF THE STOMACH AND INTESTINES nitromuriatic, or dilute hydrochloric acid may be substituted for the dilute sulphuric acid. For the advocates of milk, I would state that the sour milks, such as matzoon, bacillac, fermillac, koumiss, kefir, and lactone-butter-milk, are preferable to plain milk. Effervescence should be allowed to pass off from them before administering, and it is preferable to dilute some with lime-water or water. Matzoon and the thicker sour milks should be diluted one-half with plain water, or Vichy that has become fiat, to avoid distention. Milk, if administered, should be diluted one-half, preferably with barley-water or rice gruel. In 100 c.c. of milk are contained only 64 calories, or 640 calories per liter; 4 quarts (liters) of undiluted milk would not give more than 2800 calories required for a man weighing 154 pounds. The fallacy of pure milk-diet is thus demonstrated. Rice, barley, and oatmeal average about 350 calories per 100. If milk is given, its calorie value and digestibility are increased by these cereals. About T. l /i quarts (liters) of milk, or sour milks thus diluted, could be given in twenty-four hours. I do not advocate their use. Carbonated waters, while effervesc- ing, add to distention. Bowels. The bowels are freely opened by calomel, 5 grains (0.3), or castor oil, ij^ ounces (45.0), on the first day, and thereafter hot saline enemata, i> liters (1500 c.c.), at 110 to ii5F., or if gas, enteroclysis (recurrent), i gallon is given A. M. and p. M. as a routine. Hemorrhage, perforation, or appendicitis are the only contraindications. There is one exception to this rule: gentle bowel irrigation with a tube and funnel, with hot normal saline solution at i2oF. during hemorrhage, lessens tym- panites and helps contract the vessels. Performed by the physician, if guarded by a hypodermic of morphin, y grain (0.016), to prevent subse- quent peristalsis, I believe the procedure to be of value. Temperature. Sponging. With proper diet and irrigation of the bowels, tub-baths are rarely necessary. Cold sponging with alcohol and water, combined with friction when the temperature reaches 102. 5F. or over, generally suffice. Strong 1 has secured reduction of temperature and relief of nervous symptoms by continuous irrigation of the bowel with cold normal salt solution with the Kemp tube, in one case with ice-cold water for an hour or more, where baths failed. Cold irrigation should be avoided if there is marked nephritis or poor circulation. Baths. I am not opposed to the Brand method, as a scientific procedure for its additional effects on the pulse and on elimination. If the friction bath is given, it should be started at about ooF., never given below 7oF. Often the warm bath is preferable. I have used the Brand method frequently. Improvised Tub. One can improvise a bath-tub, in fact, build it about the patient, by rolling up heavy blankets, in the shape of bolsters, forming the shape of a bath-tub. A rubber horse-blanket, or heavy rubber sheet is then slipped under the patient and the edges brought over the rolled blank- ets. Water at the desired temperature is poured gently over the patient, friction being employed at the same time. The water is ultimately 1 Amer. Med., Oct., IQIO. TYPHOID FEVER PARATYPHOID FEVER BRILL'S DISEASE 713 mopped up with large sponges, and the patient dried in a blanket. The head can be flexed and lie on a pillow just beyond the edge of the tub, the shoulders lying within it. The feet can also extend beyond the improvised tub, being wrapped in blankets. This method allows one to use a short improvised tub in the patient's bed and avoids practically all manipula- tion and lifting. The Nauheim bath (Triton salts), advocated by William H. Thomson, especially if friction is combined, is superior to the Brand bath. In Fig. 295 is a portable tub, weight 5 pounds, excellent for private work. Strychnin, % to ^ grain (0.00108-0.0021), or Hoffmann's anodyne, i dram (4.0), may be required in the bath. The average duration of the bath should be twenty minutes, longer if no reduction of high temperature occurs. If the patient looks blue or shivers, he should be removed. Fig. 295. Chambers' portable bath-tub. Medicinal Treatment. Antipyretics should be avoided. Though Chantemesse has reported some results from serum-therapy, it is doubtful whether anything of value has yet been obtained, though interesting data have been reported on the injection of bacterial vaccines by Walters and Eaton. 1 Anders 2 believes vaccine therapy should receive a more extended trial, and advocates it as a prophylactic, during convalescence, to prevent relapses, to combat local infections from the typhoid bacillus, and for the removal of typhoid bacilli from the feces and urine. He questions its safety in the severe types. Recently some favorable results have been reported from the use of sensitized vaccines. 3 I have not, however, employed that method. Bismuth subnitrate or subcarbonate, in a dose of 15 to 20 grains (i.o- 1.3), combined with the same quantity of saccharated pepsin, I employ 1 Med. Rec., Jan. 16, 1909. 2 Jour. Amer. Med. Assoc., Dec. 10, 1910. 3 Jour. Amer. Med. Assoc., July 24, 1915. Gay (Sensitized Vaccines). DISEASES OF THE STOMACH AND INTESTINES every three hours, on an average of four doses a day. The bismuth helps control the ulcers. As hexamethylenamin causes disappearance of the bacilli from the urine, it would seem a logical remedy. Hexamethylen- amin, 5 to 10 grains (0.3-0.6), given preferably with equal quantities of sodium benzoate in water. It should be administered four times a day or oftener, from 40 to 60 grains daily. I have apparently seen some benefit in lessening the temperature and tympanites by this method. Acetozone (i : 1000), given in divided doses, about i to i> quarts (liters) per day, has been favorably reported in some cases; each dose is flavored with orange juice. Protoclysis. Riesman 1 suggests the value of proctoclysis in the severe cases, as it increases urinary flow and lessens nervous symptoms. As an aid to elimination of the toxins, the writer believes it may prove of Fig. 296. Postural treatment for acute dilatation of stomach and intestines in typhoid fever. value. It is also useful when perforation and sepsis occur subsequent to operation. Tympanites. Hot fomentations and turpentine stupes are employed. The ice-bag is best in many cases. A rectal tube may be inserted, or a soapsuds enema containing oil of turpentine, i dram (4.0), be given. Spirits of turpentine, 10 to 15 minims (0.592-1.184), can be given three or four times a day, or resin turpentine, 3 grains (0.194), four times a day, or oil of cinnamon, 3 to 5 minims (0.178-0.296), every two hours. Char- coal, 5 grains (0.3), bismuth subnitrate, 15 grains (i.o), beta-naphthol, 3 grains (0.194), or ichthalbin, ichthoform, or formidin, 5 grains (0.3), every three to four hours, may be substituted. Acute distention is re- lieved by enteroclysis. As acute dilatation of the stomach is often asso- ciated, lavage is also of value. This is especially true, in distention with active hemorrhage. 2 1 Jour. Amer. Med. Assoc., Jan. 29, 1910. 2 With general distention, lavage should be employed in addition to enteroclysis. TYPHOID FEVER PARATYPHOID FEVER BRILL 's DISEASE 715 A thorough bowel action should at once be secured if there is no hemor- rhage. Eserin, ^ grain (0.00108) by hypodermic, may be of value for this purpose. Several doses may be required at two-hour intervals, two or three in all, each guarded with strychnin, % Q grain. As I order magnesium sulphate or citrate, i dram (4.0) every second or third day, in addition to the rectal irrigation, tympanites is rare. In Fig. 296 is illustrated the correct position to relieve pressure from tympanites (gastro-intestinal distention) pulse and respiration lessened 20 points as a result, and the tympanitic area in the thorax diminished 4 inches. If the dilatation is of the stomach alone, or gastro-duodenal, then the right side or the belly position should be assumed. Diarrhea. The bismuth preparations, chalk, and occasionally a little opium (see chapter on Diarrhea), rnay be required, and the enemata should be stopped for twenty-four hours, if the movements are excessive. Constipation does not occur when the methods described are employed. Hemorrhage. Morphin, y grain (0.016), by hypodermic, is indicated, and the ice-bag should be immediately applied. Then lactate of calcium, 15 grains (i.o), is given with 2 to 4 drams (60.0125.0) of 5 to 10 per cent, gelatin solution; chlorid of calcium, 10 grains (0.6), may be substituted. Thereafter, lactate of calcium, 10 grains (0.6), with 2 ounces (60.0) of 10 per cent, gelatin every four hours. Ernutin, 5 minims (0.296), may be given by hypodermic. William H. Thomson recommends the following: 1^. Pulv. opii , > ArgentinitratisJ ' . .aa gr. v (0.3); Resin turpentine : 5ij (8.0) ; Liquor potassii 3 j (4-) ', Licorice pulv q. s. M. Divide into 60 pills. Sig. Two pills every four hours. They may be given for a few doses at two-hour intervals. Large doses of opium should be avoided, as they obscure symptoms. Adrenalin (i : 1000), 5 to 10 minims (0.296-0.592), has been advocated by hypodermic, but it may increase pulse-tension too markedly. The administration of human serum may be indicated in severe hemorrhage. Hypodermoclysis, preferably in the iliolumbar region, as in Fig. 297, with normal salt solution, may be required, or even saline or mediate infusion. At any time, on the appearance of blood in the stool or of suspected hemorrhage, stop enteroclysis and baths (if they are being given) at once. Perforation and Peritonitis. Early operation is indicated. Heart Stimulants. ^-Strychnin sulphate, ^ to ^o grain (0.00108- 0.0021), every three or four hours by hypodermic, or, ty Pulv. camphor gr. viiss (0.5), Sterile almond oil TTlxx (1.184). M. Sig. One dose every four to six hours by hypodermic may be required, especially if there are cardiac complications. Aromatic spirits of ammonia or Hoffmann's anodyne, in i-dram (4.0) doses, are useful in emergency. I have employed camphor gr. 40-60 daily in divided doses for a week. 716 DISEASES OF THE STOMACH AND INTESTINES Caffein citrate, i to 2 grains (0.0650.13) every three or four hours, is of service; or give carfein by hypodermic in the form of sodii salicylate of caffein, or sodium benzoate of caffein. Camphor in sterile almond oil gr. v camphor in TT|.xx almond oil by hypodermic given every hour or two if necessary, is of great value. For pneumonia complicating typhoid, 80 to 100 grains daily by hypodermic as first suggested by Seibert is useful. The writer prefers to subdivide into four hypodermics, daily as causing less local pain. Some advise alcohol, 8 to 12 ounces (250-375 c.c.), in divided doses, but, like Seibert, I have not found it necessary. Large doses of tincture of digitalis, or digitalone, 5 to 15 drops every four hours, may be added in the case of alcoholics. Careful stimulation with drugs, I believe, causes less strain on the kidneys. Fig. 297. 'Hypodermoclysis in the iliolumbar region. The former views as to the value of alcohol as a food, or its power to increase the capacity for work, seem, by scientific research, to be pretty thoroughly exploded. Its use in the arctic regions, where food of high calorie value is at a premium, has been found to be deleterious. In sud- den emergency, as a heart stimulant, it is of value ; but its prolonged use as a circulatory tonic has been shown to be harmful. Proper individual dosage is difficult to estimate, and the strain on the already damaged eliminating organs in typhoid fever is severe. Professor Frederick S. Lee, 1 in a series of experiments, finds that in small quantity ethyl alcohol does not appear to exert any action on frog's muscle; while in medium quantity it increases the rapidity of contraction and relaxation, and increases the working time, i.e., delays fatigue. In 1 The Action of Alcohol on Muscles, Amer. Jour, of Physiol., 1902, viii, p. 61. TYPHOID FEVER PARATYPHOID FEVER BRILL S DISEASE 717 large quantities it exerts an unfavorable action, the reverse of that caused by medium quantities of the drug, i.e., it hastens fatigue. The advocates of the use of alcohol in typhoid fever administer it in considerable quanti- ties. Moreover, the author wishes to call to the reader's attention that alcohol interferes with the oxidation process. For Nervous Symptoms. Warm or cool packs with ice-bag to the head, and at times bromids or opiates, are indicated. For Headache. Cold applications and the bromids are useful. For Sleeplessness. Sulphonal, trional, or veronal, 10 grains (0.6). Bacilluria. Hexamethylenamin and benzoate of soda, of each 10 grains (0.6), every three hours by mouth, or by enema if nausea, should be given in colon bacillus infection. Care should be taken to guard against bed-sores. Tender toes should be protected from the weight of the sheets, and hyperextension of the feet should be avoided. In some cases a water- or air-bed or an old sheepskin spread under the patient, as suggested by Thomson, may be required. For Renal Insufficiency. Cream of tartar lemonade: Cream of tartar, i dram (4.0); juice of 2 lemons; saccharin, i grain (0.063); water, i quart (liter). Drink in divided doses during the day. Recurrent enteroclysis with normal saline solution at 1 2oF. and proctoclysis are useful. Caff ein citrate, 5 grains (0.3), t.i.d., is of value, or an equivalent of a soluble preparation of caffein by hypodermic. Hypodermoclysis may be neces- ary. Recurrent enteroclysis several times daily at i2oF. is the best method. Colitis should receive treatment as described in that chapter. The late Francis Delafield 1 has secured results in membranous colitis by irrigation with 2 quarts (liters) of bichlorid of mercury (i : 10,000) with the recurrent tube. It should only be used with such. Complications should receive appropriate treatment. Convalescence. It is usually preferable to have a normal temperature for a week before commencing with solid food. Soft-boiled eggs, milk- toast, jellies, and a little scraped beef should be first tried. In some prolonged cases, with temperatures of 99 to iooF., cautious feeding may be attempted with the above materials. I have seen the temperature fall as a result. Bacilluria I believe a frequent cause of slight persistent temperature. This should receive treatment as already described. The patient should first sit up for a brief period about the tenth day of normal temperature. During convalescence the urine should be particularly examined for colon and typhoid bacilli, and hexamethylenamin, 10 grains, with an equal quantity of sodium benzoate, should be given three or four times daily. The urine should be free from typhoid bacilli before discharging the patient. Typhoid Carriers. Some of these are convalescents from the disease, while others have not had typhoid, but have been in contact with cases. These cases should be kept isolated and hexamethylenamin gr. 60 to 80 combined with equal quantities of sodium benzoate aa gr. x per dose, in twenty-four hours should be given until the urine is free from typhoid bacilli. The patient should be carefully examined subsequently to see 1 Enteroclysis, Hypodermoclysis, and Infusion (Kemp). 718 DISEASES OF THE STOMACH AND INTESTINES that there is no reappearance of the bacilli. In obstinate cases the use of autogenous vaccines up to 1,000,000,000 at an injection has proved success- ful. The importance of the typhoid carrier is shown by the fact that they are a potent source of infection to others. " Typhoid Mary " is a well- known classical case, 1 having again recently been responsible for an epidemic of typhoid at the Sloane Maternity Hospital. Park 2 holds that about 2 per cent, of all typhoid cases become carriers. The gall-bladder harbors the bacilli, which are excreted in the feces, though they may be found in the saliva and two cases have been reported of typhoid prostatitis and seminal vesiculitis. Leary 3 reports two cases of removal of the gall-bladder and entire cystic duct for the cure of typhoid carriers. This procedure would be justifiable, after failure of the vaccine and hexamethylenamin treatment. PARATYPHOID FEVER This is a term applied to a group of diseases which, in their clinical course, may somewhat resemble typhoid fever. Etiology. Paratyphoid fever is caused by the microorganisms known as Bacillus paratyphosus A and Bacillus paratyphosus B, which differ in their agglutination reactions, that is, the blood-serum of the patient agglutinates the cultures of the causative organism. The organisms are isolated from the blood, urine, or feces. They are intermediate between the Bacillus typhosus and the Bacillus coli. In the epidemics abroad, Bacillus paratyphoid B is recovered from much more frequently than the paratyphoid A, which seems more common in America. 4 Recently, how- ever, in Virginia, an epidemic from paratyphoid B, in all 35 cases, has been reported by Hoskins. 5 The Bacillus paratyphosus B also has an etiologic relationship to bacterial food (meat) poisoning, and the question has arisen whether there is a common infectious disease, assuming an acute form as meat-poisoning and a subacute form as paratyphoid fever. The Germans, in fact, assert that meat, particularly beef, is the habitat of the germ Bacillus paratyphoid B, and that the fever is produced by toxins generated by these bacilli in ingested beef. They describe one variety resembling ptomain-poisoning, occurring with prodromal symp- toms, such as bronchitis, nose-bleed, headache, malaise, and abdominal tenderness. There is at first a high temperature, which subsides after the administration of calomel. Subsequently, the temperature curve is. very little above normal, though tympanites, gurgling in the right iliac fossa, rose-spots, enlarged spleen, abdominal soreness, and increased pulse- rate are present. This variety lasts seven to eleven days. A second variety is characterized by a higher temperature and symp- toms simulating typhoid fever, and lasts eleven to fourteen days, and in several cases three weeks. Proescher 6 and Roddy have conducted some American Medicine, March, 1915. 2 Journal A. M. A., Sept. 19, 1908. 3 Jour. A. M. A., June 26, 1913. 4 H. Fox, Univ. Penna. Med. Bull., 1905, vol. xviii; and Proescher and Roody, Jour. Amer. Med. Assoc., Feb. 6, 1909. 6 Jour. Amer. Med. Assoc., March 19, 19 10. 6 Archiv of Int. Med., March, 1910. TYPHOID FEVER PARATYPHOID FEVER BRILL'S DISEASE 719 interesting investigations on the paratyphoid A and B bacilli. These types of paratyphoid bacilli can readily be differentiated from the Bacillus typhosus and the Bacillus coli. Mode of Infection. Ingestion of meat containing the germ of the Bacil- lus paratyphoid B is claimed as a cause of this type, while the usual meth- ods of conveyance are the same as of typhoid fever, such as the food, water, by the fomites, urine, fingers, and flies. Pathology. There are splenic enlargement and intestinal ulcerations, resembling those of dysentery rather than of typhoid fever. There are involvement of the solitary and agminated follicles and of the mesenteric glands. Incubation. The incubation is generally shorter than that of typhoid, though in Hoskins' cases it averaged in 50 per cent, nine to eleven days. The prodromal symptoms are languor, headache, torpor, and, in some cases, nose-bleed and muscular pains. There may be discomfort in the abdomen and constipation, though occasionally a diarrhea. The head- ache is often quite severe, and the prodromata are usually shorter and more sudden than with typhoid. There is bronchitis in some cases, com- ing on shortly, the headache is constant, and some chilliness is complained of in some cases, particularly in the extremities. The temperature fre- quently rises more rapidly than in typhoid, at times there 'being a high initial temperature, even to io4F. The morning remissions are more marked than in typhoid fever. Paul 1 reports, in fact, a series of cases in which there was a daily remission nearly to normal. The pulse is rapid, 1 20 or more, but there is usually no dicrotism. Delirium rarely occurs. Nausea is frequently present, but vomiting is not very frequent. Tym- panites is frequently present, though not as marked as in typhoid. There may be abdominal pains in the lower abdomen, though some cases are reported of severe gastric pain. Constipation is the rule, though diarrhea sometimes occurs. In Hoskins' cases the stools were at first normal, later, green tinted with yellow, and later, watery, with the peculiar tint noted. The urine is scanty and high-colored, with, at times, albumin and casts. Intestinal hemorrhage may sometimes occur, but it is not as severe as with typhoid, and is usually not recurrent. Perforation has not been reported. Bronchitis, as noted, is quite frequent. The tongue becomes thickly coated, particularly toward the center, and the edges may remain red and granular. The tongue is moist and does not dry and crack as with typhoid, and there are no sordes. The spleen is enlarged, but gener- ally not as markedly as with typhoid. In many cases there are severe pains in the muscles and nerves. The skin is at first dry, but later becomes moist. Rose-spots appear on the third or fourth day, and may be seen in successive crops over the abdomen, chest, and back. In Hoskins' cases there was dilatation of the pupils which persisted throughout the disease. In his cases also, day dreaming, illusions with no delirium, were reported in 25 per cent., and most of his patients were children. Some of the cases of paratyphoid infection, as already noted, are more of a ptomain type, a high initial rise of temperature with nausea and 1 N. Y. Med. Jour., Oct. 22, 1910. 72O DISEASES OF THE STOMACH AND INTESTINES vomiting, with a rapid subsidence of temperature after the administration of calomel. Course. The course of paratyphoid is more frequently rather short, the highest temperature being reached on the third or fourth day, remain- ing high for three or four days, and then abating by lysis. It may occa- sionally be prolonged, though usually it is much shorter than typhoid, and relapses are rather rare. Complications. Bronchitis often accompanies it. Neuritis, nephritis, and cardiac disease are not as liable as with enteric fever. Intestinal hemorrhage is quite rare and never alarming. Perforation has never occurred. Parotiditis, arthrititis, otitis, and osteomyelitis have been reported. Diagnosis. The onset of paratyphoid fever is more abrupt, the initial headache is more severe, the temperature rises more rapidly, the daily remissions are more marked, the tongue remains moist, there are no sordes, and intestinal hemorrhage is not frequent and is not apt to recur. Per- foration has never been reported. The Widal reaction is absent. The specific agglutination reactions occur to Bacillus paratyphoid A or B, and the causative microorganisms can be cultivated from the feces, urine, blood, and from the rose-spots. These all serve to differentiate from ty- phoid fever. With Brill's disease the cultures from the blood show bacilli-type exanthematici and not typhoid bacilli. Widal reaction is negative. The type of fever is peculiar. There is no intestinal hemorrhage and rapid convalescence occurs. Prognosis. Most patients recover, though a fatal result may occur. Treatment. This is essentially the same as for typhoid fever. The same precautions should be taken regarding safe-guarding the urine, feces, etc. Hexamethylenamin, 10 grains (0.6), with benzoate soda, 10 grains (0.6), should be given four or five times a day to disinfect the blood. Autog- enous vaccines may be employed, of the specific bacilli found in each case. MILD ENDEMIC TYPHUS, OR BRILL'S DISEASE Definition. This is an acute infectious disease, a mild endemic typhus, characterized by a short incubation period, a period of continuous fever, intense headache, apathy, and prostration, a profuse and extensive maculopapular eruption, the fever ceasing at the end of between one and two weeks, either by crisis or lysis. History. The attention of the medical profession was first called to this disease by Nathan E. Brill, 1 who demonstrated that it possessed peculiar characteristics which differentiated it from typhoid and para- typhoid fever. He has made a study of 255 cases. 2 Ziegel 3 reports three cases. Anderson 4 and Goldberger have experimentally demonstrated its identity with typhus fever. 1 N. Y. Med. Jour., Jan. 8 and 15, 1898; Amer. Jour. Med. Sci., April, 1910. 2 Amer. Jour. Med. Sci., Aug., 1911. 3 Med. Rec., June 25, 1910. * N. Y. Med. Jour., May n, 1912. TYPHOID FEVER PARATYPHOID FEVER BRILI/S DISEASE 721 Incubation. This varies from a sudden onset to fourteen days. Etiology. The disease is infectious, a mild endemic typhus. The bacillus typho-exanthematici discovered by H. Plotz is responsible. In Brill's 255 cases members of the same family or occupants of the same house were never attacked. W. Coleman, however, has observed four cases from the same family and household. M. Nicoll 1 reports four cases in one family, two of them young children. Brill, 2 however, reports a fatal case. Anderson estimates that in 1912, there were 72 cases in New York City, and cases were reported in Boston, Baltimore, Philadelphia, and Chicago. Males are more commonly affected than females, and it is more fre- , quent between twenty and forty years. The largest number of cases occur in summer. Method of Transmission. Head lice and body lice are the chief source. Symptoms. After a few days, marked by malaise, loss of appetite, nausea, and slight headache, the invasion is usually abrupt, ushered in with a chill or chilly sensations, followed by severe headache and a high fever. Occasionally there is vomiting, usually general pains, or pains in the back. The headache becomes intense and there is marked prostra- tion, with a rising temperature. The temperature curve reaches its height in two to three days, and, with but slight daily remissions, remains con- stant. The temperature is shown in Figs. 298 and 299. The eyes are dull and suffused and the face flushed. The patient is dull and prefers to be let alone. The tongue is coated and moist. On the fifth or. sixth day an eruption appears on the abdomen and back, and spreads rapidly to the chest and to the extremities. It is sometimes seen on the neck, palms, and soles in addition. The rash is profuse but discrete, and sometimes small patches are formed. It is maculopapular in character, dull red in color, slightly raised, and the spots usually have an oval indistinct outline. They fade somewhat under pressure, but do not disappear entirely. At times hemorrhagic spots are interspersed with the other lesions. The eruption fades rapidly at the time of defervescence, but its remains are seen for some days as brownish stains. The bowels are obstinately constipated. The spleen is frequently enlarged. Herpes labialis is sometimes present. Leukopenia is excep- tional; at times there are 9000 to 11,000 leukocytes, though often the absolute and differential leukocyte count is normal unless there are com- plications. About the twelfth to fourteenth day the fever and other symp- toms disappear and rapid convalescence follows. Complications. Bronchitis develops early in some cases. Broncho- pneumonia is rare, in which event marked leukocytosis occurs. Meningis- mus, rigidity of the neck, contracted pupils, and bilateral Kernig's sign are sometimes present. Phlebitis has been observed once and otitis media once. Diagnosis. The absence of the Widal reaction and negative blood, stool, and urine cultures as to typhoid, paratyphoid, colon bacilli 1 Amer. Jour. Med. Sci., Aug., 1911. 2 Journal A. M. A., Aug. 17, 1912. 3 N. Y. Med. Jour., Dec. n, 1915. 46 722 DISEASES OF THE STOMACH AND INTESTINES or intermediate infections, with presence of positive bacillus typhosus of Plotz, give the diagnosis. Leukopenia, which occurs in typhoid, is absent 1 a 4 P= ^p- N t m STaasT s I* * ^ in Brill's disease. The character of the onset, absence of intestinal hem- orrhage, type of fever, character of the eruption, and rapid convalescence TYPHOID FEVER PARATYPHOID FEVER BRILL.'s DISEASE 723 exclude typhoid fever. Its apparent non-communicability, the uniformity of its type, and usually the absence of fatal cases seem to exclude typhus fever, though now proven to be a mild form of such. The occasional meningismus which occurs suggests meningitis, but lumbar puncture shows its absence. Influenza can be excluded by the history and by the speedy recovery from Brill's disease. Prognosis. The total mortality of this mild endemic type in the U. S. is estimated at not over i per cent. Treatment. As a matter of precaution, the stools, urine, beds, bedding, etc., are disinfected, clothing steamed, and the same prophylactic measures taken as with typhoid fever. Hair should be shaved and para- siticides applied such as petrol, benzol, xylol, turpentine or paraffin oil. The last two or petrol or naphthalin especially destroy the " nits. " Spong- ing or friction baths should be employed to relieve temperature. Plenty of water should be given and the diet should be fluid, preferably strained broths and gruels. One may employ sour milks, such as matzoon with Vichy, koumiss, lactone-buttermilk, bacillac, etc., or equal parts of milk and lime-water. The bowels should be opened freely with calomel, 5 grains (0.3), and a daily movement should be secured. For headache, cold applications and the bromids are indicated. For the muscular pains the following is of value: fy Phenacetin gr. iij; Acetanilid .. gr. ij; Caffein citrate gr. Y. M. Sig. One capsule three or four times a day. Stimulation with strychnine and camphor as required. Immuniza- tion against typhus should be performed to protect those exposed to an epidemic or when the disease is prevalent. CHAPTER XXVIII INTESTINAL HEMORRHAGE; INTESTINAL ULCERS ; DUODENAL ULCER ; DISEASES OF THE BLOOD-VESSELS (EMOBLISM AND THROMBOSIS) INTESTINAL HEMORRHAGE IT would seem advisable to refer to the various causes of intestinal hemorrhage for the purpose of diagnosis. Among such are dysentery, typhoid, yellow fever, malarial poisoning, ulceration from various causes, cancer, scurvy, purpura, traumatism, volvulus, intussusception after re- duction of a strangulated hernia, excessive use of laxatives, hemorrhoids, injury (traumatism), venous hyperemia of the intestines due to diseases of the heart or lungs, stasis or obstruction of the portal system, such as cir- rhosis of the liver, injury from dried scybalae, ankylostoma, isolated venous varicosities, arterial aneurysms of the intestinal wall, aneurysms in adja- cent arteries, as of the hepatic, from which blood may enter the bile-pas- sages and be passed by the bowel. One case is reported resulting from punctures in the intestines made by a male round worm. A peculiar type of enterorrhagia occurs with no anatomic changes, but there is probably an alteration in the walls of the blood-vessels. Thus, intestinal hemorrhages have occurred in phthisis when there were no ulcers. Intestinal hemorrhages in pernicious anemia, leukemia, scurvy, morbus maculosus, septicemia, icterus, phosphorus-poisoning, intermittent fever, and erysipelas probably belong to this class. Amyloid degeneration may be complicated by intestinal hemorrhages. Some believe vicarious hem- orrhage may take the place of menstruation. There may be collapse, with all the symptoms of internal hemorrhage, and blood may or may not pass from the rectum. The blood may be bright red, brown, or like coffe-grounds. No visible blood may appear in the stools, and it may be detected only by tests for occult blood. Microscopic examination may show the presence of red blood-corpus- cles and hematin. Treatment. The immediate hemorrhage should be treated as de- scribed under Hemorrhage in Typhoid, and the cause should be deter- mined and treated. ULCERS OF THE INTESTINES Duodenal Ulcers In considering the subject of duodenal ulcers, it is necessary to briefly classify the various types which occur. They are as follows: i. Simple duodenal ulcer, or peptic ulcer of the duodenum, or chronic duodenal ulcer (Moynihan). 724 SIMPLE DUODENAL ULCER 725 2. Duodenal ulcer due to burns or scalds. 3. Duodenal ulcer due to the uremic condition. 4. Tuberculous ulcer of the duodenum. 5. Duodenal ulcer due to Melaena neonatorum and to purpura. 6. Embolic or thrombotic ulcer of the duodenum, as with appendicitis. 7. Amyloid ulcer of the duodenum. 8. Duodenal ulcers in infectious diseases, as in pneumonia (rare), typhoid, erysipelas, and varioloid. 9. Duodenal ulcers have been reported in isolated cases of acute pemphigus and pellagra. 10. Syphilitic gummatous ulcer at the pyloric ring, involving the stom- ach, or duodenum, or both. SIMPLE DUODENAL ULCER (Synonyms. Duodenal Ulcer; Ulcus Duodeni Pepticum Leube; Round or Perforating Ulcer; Chronic Duodenal Ulcer Moynihan) The earliest mention of duodenal ulcer occurs in the London Medico- Chirurgical Transactions of 1817, vol. viii, p. 232. The condition is characterized by a defect of the mucous membrane of the duodenum, usually tending to run a protracted course, though in some instances it may be acute. Mayo 1 believes, however, that acute ulcers are usually toxic. One may say. in general, that duodenal ulcer presents in many cases the appearance and characteristics of ulcer of the stomach, particularly when found on the posterior wall. When the ulcer is crater-like on the anterior wall of the duodenum, there is a localized mass over the site of the ulcer. Wm. Mayo 2 finds that in many cases no crater is found in the mucosa, but rather a dis- colored moth-eaten patch in whose center there is a dimple-like ulcer, and outside of this, induration. Etiology. The cause is generally believed to be the action of the acid gastric juice upon the mucous membrane of the duodenum, whose nutri- tion and vitality have previously been impaired as a result of circulatory derangement. Chlorosis seems to play no part in its production, Fried- man claiming that polycythemia or polyglobulia and eosinopenia occur with non-hemorrhagic duodenal ulcer. Codman 3 advances the theory that more or less obstruction is produced in some cases by the pressure of the superior mesenteric artery on the duo- denum, and as a result the secretions of the pancreas and liver may at times be thrown backward on the first part of the duodenum, which is unfitted to withstand the long-continued action of these secretions, since the mucosa is histologically and developmentally different from the rest of the duodenum, and is more closely allied to that of the stomach. The author believes that if pressure obstruction from the superior mesenteric artery were a factor, one would frequently find duodenal ulcer associated with splanchnoptosis, which, according to some, favors chronic 1 Boston Med. and Surg. Jour., April 6, 1911. 2 N. Y. Med. Jour., Apr. 18, 1914. 3 Ibid., Nov. 25, 1909. 726 DISEASES OF THE STOMACH AND INTESTINES mesenteric traction. The writer has seen no preponderance of duodenal ulcers in such cases. Wm. J. Mayo believes the acid chyme attacking the mucosa of the duodenum to be an important factor, and that when the chyme has been neutralized by the alkaline juices of the duodenum it ceases to produce irritation. He shows that, owing to anatomic formation, the alkaline juices reach a higher level in females than in males, and hence, the lesser number of ulcers of the duodenum in females. Recently he states that 1 the same causes that produce gastric ulcer, produce duodenal ulcer and further refers to Rosenow' theory of infection by a specific streptococcus. Mayo further believes a possible source of injury may be extremely hot and cold (drinks which pass rapidly into the duodenum. R. T. Morris 2 believes that toxic endarteritis, or toxic spasm of the terminal arteries in the duodenum, to be an explanation of the cause of duodenal ulcer in most cases. Cobweb adhesions, interfering with motility and leading to acid hypersecretion with local injury of the mucosa, he deems factors in other cases, or that colon bacilli in the terminal blood-vessels may produce an infarct. Wilkie believes that the "silent type" of duodenal ulcer occurs most frequently with cases suffering from arteriosclerosis and that some toxic or irritative factor within the abdomen, often associated with the appendix or colon, is found with most duodenal ulcers. The vascular deficiency may be due to arteriosclerosis, but probably, usually to spasm of the muscular coats of the duodenum, induced by local anemia conse- quent on a strain on the supraduodenal vessels, the spasm being favored by the increased vagotonus and the irritable condition of the autonomic nervous system. Lane's kink and simple vagotonia have been considered factors. There is a close association between infection of the gall-bladder or appen- dix or both, and gastric or duodenal ulcers, the latter conditions probably resulting in some cases from a septic infarct, or toxins from the former. Frequency. There are wide discrepancies in the opinions of various observers as to the frequency of duodenal ulcer. The writer is now refer- ring to the peptic type. Trier places it as i to 9 to the gastric as to fre- quency; while Andral gives i duodenal to 40 gastric ulcers; and Starke, i duodenal to 12 gastric. Moynihan believes duodenal ulcers to be quite common; and Wm. J. Mayo has demonstrated that many pyloric ulcers are found to have their origin in the duodenum, and in many cases it is impossible to differentiate between the two conditions. Wm. J. Mayo 3 in 1914 placed the incidence of duodenal ulcer as 73 per cent, and gastric ulcer 27 per cent. Codman believes duodenal ulcer to be more frequent than gastric ulcer, and to be even as common as acute appendicitis. Deaver 4 holds that duodenal ulcer outnumbers gastric ulcer in the pro- portion of 2 to i , and probably more. The writer believes that undoubtedly many cases have been diagnosed as gastric ulcer, which were duodenal ulcers lying close to the pyloric ring. Ulcer of the duodenum is more 1 Journal A. M. A., June 19, 1913. 8 Amer. Jour, of Surg., April, 1911. 3 Ibid. 4 N. Y. Med. Jour., March 18, 1911. SIMPLE DUODENAL ULCER 727 frequent than is generally supposed, but not quite as frequent as gastric ulcer, in the author's opinion. In making this statement the writer desires it to be understood by the reader that his diagnoses are not made from clinical symptoms alone but from confirmatory evidence by the #-rays. Women as a rule in his experience, usually are insistent that medical treatment should first be attempted and will devote time to the rest cure. Many cases will appar- ently result in cure and then drift away from the attending physician, so that ultimate results are unknown. Personally I always advise operation in chronic ulcer cases whether of the stomach or duodenum. Males as a rule prefer to secure a quick result and do not usually care to attempt an ulcer cure of six weeks in bed with no promise that operation may not later be required. I believe that will explain in part why the surgeons operate on so many more cases of duodenal than of gastric ulcer. Moynihan holds that chronic duodenal ulcer, as far as concerns the cases coming to the surgeon, is a more frequent disorder than is ulcer of the stomach. Age. It occurs most frequently between the ages of fifteen and sixty. It occurs in the various decennial periods as follows in Moynihan's l cases: Years i to 10 None 10 to 20 3 20 to 30 37 30 to 40 56 40 to 50 45 50 to 60 27 60 to 70 ii Age not stated 7 This table refers to the peptic type of duodenal ulcer. With melena neonatorum duodenal ulcer is not so uncommon in infants. The youngest was seventeen years of age and the oldest sixty-seven. These were the ages given at the time of operation and not at the com- mencement of the symptoms. Many of the patients who were over forty had had symptoms for some years. Case 163, age forty-nine, had had symptoms for forty years, or they dated from the age of nine (see page 412, Moynihan 2 ). The operative findings in this case appear to the writer as an ulcerative process originating in the gall-bladder and not in the duodenum. Some cases of duodenal ulcer have been reported by other writers in young children from one to ten years of age, and also a number of cases among the newborn. In the latter, melena neonatorum or thrombosis of the umbilical vein, with a deposit of the thrombus in a duodenal vessel, with a resulting infarct, are the factors. Hereditary syphilis, with local ulcer of the duodenum, has been reported. Kiittner 3 reports death in a child four years of age from duodenal ulcers. The postmortem showed duodenal ulcers, pseudomembranous colitis, and parenchymatous nephritis. These are not the true peptic duodenal ulcer and should not be thus classified. 1 Duodenal Ulcer, W. B. Saunders Co., 1912. 2 Duodenal Ulcer, 2d ed., W. B. Saunders Co., 1912. 8 Berlin, klin. Wochensch., Nov. 9, 1908. 728 DISEASES OF THE STOMACH AND INTESTINES Gastric ulcers occur in young children, but less frequently than the duodenal ulcers described. The average age of death in 127 fatal cases was thirty-eight years (Rolleston), but the Fenwicks show that in the acute cases, 68 per cent, proved fatal between fifteen and thirty years; and in chronic cases between thirty and thirty-five years. Sex. Mayo reports 61 per cent, of duodenal ulcers as occurring in males. In an analysis of 186 cases, Moynihan reports its occurrence in 137 males, or 73.6 per cent.; females 49, or 26.4 per cent.; Weir, 30 women in 176 cases; Collins, 52 women in 257 cases. The ratio is variously given as 5 men to i woman, to 3 men to i woman. The proportion of males affected by duodenal ulcer is considerably greater than that of females. Variety of Ulcer. Among Moynihan 's 137 male patients, there were 107 cases in which duodenal ulcer occurred alone, and 30 cases in which there were both gastric and duodenal ulcers. Of the 49 female patients, 32 had duodenal ulcer, and 17 had both duodenal and gastric ulcers. AM !*"' '"i^ i ^1 Fig. 300. Duodenal ulcer (Le Tulle). On the right, the pyloric sphincter; on the left, the duodenum, with its mucous membrane studded with inflammatory nodules, the glands of Briinner, the submucosa, and the muscular coat uniformly invaded by the inflammatory lesions; in the center, the ulcer cut out perpendicularly, invading the muscular coat and resting on the thickened peritoneum, cicatricial tissue with large open vessels and lymphatic glands chronically inflamed (Gaultier). Pathology. William Mayo classifies duodenal ulcers surgically as indurated and non-indurated. In the former case they have a callous margin. The base is formed usually of the intestinal muscle, with scar tissue. There may be adhesions to adjacent organs, particularly to the omentum. Moynihan finds the majority free from adhesions. He be- lieves that the peptic duodenal ulcer is usually chronic. Others classify duodenal ulcer as acute and chronic. Melchior 1 discusses chronic duodenal ulcers and reports an acute case of duodenal ulcer, the hemorrhage occurring two days after operation for sarcoma of the thigh. He quotes nine similar cases, and believes there is a diathesis which goes with a reduction in the vital resistance of the wall of the duodenum to the peptic action of the gastric juice. The writer, how- ever, thinks the occurrence following operation rather suggestive of an embolic ulcer of the duodenum and not of the true peptic ulcer. Characteristics of the Ulcer. The duodenal ulcer resembles the gastric ulcer in its clean, punched-out appearance. In its earliest stage the ulcer 1 Berl. klin. Wochens., Dec. 19, 1910. SIMPLE DUODENAL ULCER 729 is circular; later it may be oval or oblong. The crater of the ulcer is deep in proportion to its width (Fig. 300). Fig. 301. Duodenal ulcer. The usual position and size of the ulcer are well shown (Moynihan). In some cases there seems to . be steps leading down the side of the ulcer from the lumen of the gut to the base of the ulcer. This ridging or Fig. 302. Duodenal ulcer. Showing adhesions to the gall-bladder. The radiating scar is not infrequently seen (Moynihan). "terracing" is seen quite frequently. The walls of the ulcer are usually thick and indurated. The outer surface (peritoneal) is white and appears 730 DISEASES OF THE STOMACH AND INTESTINES like a cicatrix as a rule. At times it may be red, vascular, and mottled with blood-stained spots. In the older ulcers the base is pearly white and puckered in the center, which is depressed and hard. They feel hard and Fig. 303. Duodenal ulcer. Showing the puckering up of the scar, which leads to "pouching" (drawn during operation upon the case) (Moynihan). dense to the fingers, and look smaller from the mucous than from the serous aspect. In others the entire breadth of the anterior wall of the duodenum may be occupied by a dense, fibrous mass, which extends even to the pos- Fig. 304. Chronic ulceration of duodenum with formation of a pouch (Moynihan). terior surface. It may even have a keloid appearance. The ulcer may be star shaped, the center being drawn in. In some, "pouching of the gut" is produced, a piece of the duodenal wall being almost separated from the rest, so that a diverticulum is formed. SIMPLE DUODENAL ULCER 73! In the majority a healthy margin of the bowel lies between the ulcer and the pylorus, but the lesion may extend to, within, or through the pylorus. Mayo has shown that the gastric margin of the ulcer may be the start- ing-point of a carcinomatous growth. The occurrence of a malignant change in a simple duodenal ulcer is extremely rare, while it is quite fre- quent in gastric ulcer. In Fig. 301 is shown the usual position and size of a duodenal ulcer. In Fig. 302 we have an ulcer with adhesions, and in Figs. 303 and 304 a "pouching ulcer." Site of the Ulcer. In at least 95 per cent, of all cases the ulcer lies within the first portion of the duodenum ; that is, within i \$ inches of the pylorus. In Collins' cases, 262 in all, the ulcer was found in the first portion of the duodenum in 242 cases; in the second part, in 14; in the Fig. 305. The vein which shows the position of the pylorus ("pyloric vein") (Moynihan). third, in 3; and in the fourth, in 3. In the cases in which the ulcer is "tucked back/' adherent to the liver or posterior wall of the abdomen, in which event the pain comes on three or four hours after food instead of two hours, though the ulcer may apparently be situated in the second part of the duodenum, if the position of the pyloric vein be noted, it will be seen that the ulcer is within y z to % inch from the pylorus. This vein (Fig. 305) is an important landmark, and generally runs a little to the gastric side of the pylorus, and its recognition enables the operator to at once determine where the stomach ends and the duodenum begins. The vein runs upward from the greater curvature, is thick and short, and may often be met by a smaller vein descending from the lesser curvature. Usually there is no visible anastomosis. The ulcer is generally situated on the anterior wall of the duodenum, midway between the upper and lower border, about \i inch beyond the pylorus. This part of the duodenum 732 DISEASES OF THE STOMACH AND INTESTINES is apparently prone to attack, possibly because the chyme directly im- pinges there as it is expelled through the pylorus. Occasionally the ulcer is found on the upper or lower border and rarely on the posterior surface. One case of circular ulcer dividing the duodenum and opening into a local abscess is recorded by Meunier, 1 Fig. 306. Recurrences. The recurrence of attacks in duodenal ulcer may be due to the healing and breaking down of a single ulcer or to the development of new ulcers. The former is more frequent, as in only 10 to 20 per cent, of cases is more than one ulcer found. Occasionally a large ulcer may be due to the merging of one small ulcer into another and so on. A large mass of fibrous tissue may occasionally be found. There is usually one ulcer, from the size of a lentil to a dollar. Fig. 306. Circular ulcer of duodenum. Perforation into a localized abscess (Moynihan, after Meunier). Number of Ulcers. In about 10 to 20 per cent, of cases, as noted above, the ulcers are multiple. Occasionally, from two to four or more ulcer scars are seen on the anterior surface of the duodenum, together with a new active ulcer. Old ulcers and new ones are found side by side; and when two ulcers are present, they are generally almost touching. One may lie on the posterior wall, opposite the anterior ulcer. When the gut is empty, they seem to be in apposition; and Moynihan suggests the term of "kissing" or contact ulcers (Fig. 307). When several ulcers are present they are usually found in the first part of the duodenum. As many as nine ulcer scars have been seen within the space of 1^4 inches. Complications. Stenosis of the duodenum near the pylorus, or even at a greater distance, may occur, with resulting dilatation of the stomach 1 Bull. Soc. Anat., 1893, i, 488. SIMPLE DUODENAL ULCER 733 and the symptoms of benign stricture, the same as in the stenosis of gastric ulcer. The stricture of the duodenum may be thin and narrow, the bowel Fig. 307. A, Perforating ulcer on anterior surface of duodenum; B, "kissing ulcer" on posterior surface; C, pyloric ring; D, cut edge of lesser curvature of stomach. Note the position of the ulcers immediately outside the pylorus. The specimen was removed from a woman aged thirty, who died about two hours after admission to the Royal Victoria Hospital, Belfast, May, 1909. No operation was undertaken. From a photograph kindly given to Mr. B. G. A. Moynihan bv Dr. A. B. Mitchell, Belfast (Moynihan). appearing as if a string had been tied about it ("hour-glass"), or the stricture may be long, tortuous, and markedly indurated. In Figs. 308 and 309 we have illustrated the hour-glass condition. Fig. 308. Hour-glass stomach and duodenum (Moynihan). Jaundice, with marked inanition and distention of the gall-bladder and inflammatory conditions therein, may result from stenosis from ulcers which blocks the common bile-duct, so that pancreatic carcinoma is sus- 734 DISEASES OF THE STOMACH AND INTESTINES pected. Atrophy of the pancreas or chronic pancreatitis may take place from closure of the pancreatic duct. The type of hemorrhage is usually severe with the pancreatitis. Fatal hemorrhage may occasionally occur. In acute cases quite frequently perforation and general peritonitis result, with death from shock or peritonitis. If the process is slower, there may be a circumscribed peritonitis with abscess. There may be adhesions to the omentum and with other organs and ulcerations involving the liver, gall-bladder, pancreas, aorta, portal vein, or hepatic artery. Subphrenic abscess may result. Thrombosis of the portal vein has also resulted from the deep cicatrization of an ulcer. The blood-vessels of the duodenum have frequently been eroded, chiefly the gastroduodenal, the pancreaticoduodenal, and the right gastro-epiploic arteries. In one case the hepatic artery was eroded, and in a few cases there was an aneurysmal dilatation of the vessel at the point of rupture. Perforations of the aorta, portal vein, and superior mesenteric vein have been reported. Hepatic abscess may result from duodenal ulcer. Two cases of duodenocolic fistulae are recorded. Fig. 309. Double stenosis in the duodenum ("hour-glass duodenum") (Moynihan, after W. J. Mayo). Ulcus Carcinomatosum. Change from a simple ulcer of the duodenum to a malignant condition is extremely rare. W. J. Mayo 1 reports four cases. Perry and Shaw report five cases; Boxwell, 2 one case; Ewald, 3 one case; Eichhorst, 4 one case; and Arnold and S. Fenwick, each one case. Cancer developing on the edge of a duodenal ulcer which has involved the stomach at the pyloric ring is more frequent. Clinical Aspects. Occasionally the cicatrix of an old ulcer may be found at autopsy, though there have been no symptoms during life. Other patients may be apparently in perfect health, when suddenly a severe and dangerous intestinal hemorrhage takes place, or perforation of the intestine and resulting peritonitis. As in many cases the ttlcer is free from adhesions, there is great danger when perforation occurs. In some the omentum fortunately adheres. 1 Jour. Amer. Med. Assoc., 1908, ii, 558. 2 Lancet, 1907, ii, 1687. 3 Berl. klin. Wochens., 1886, No. 32, p. 527. 4 Zeitschr. f. klin. Med., 1888, xiv, 519. SIMPLE DUODENAL ULCER 735 Symptoms. In discussing the symptoms of duodenal ulcer, the author must take exception to the statement of Moynihan that either hyperchlor- hydria,or acid gastritis "is" duodenal ulcer. Acid gastritis is a definite clinical entity; while hyperchlorhydria, in many cases, is a functional dis- turbance and readily cured. The writer does believe, however, that a "persistent hyperchlorhydria," or persistent symptoms simulating such, are suggestive of either gastric, or duodenal ulcer. The determination of pus in the gastric contents alone, or with the presence of blood or occult blood, point to the stomach; while the absence of pus in the gastric con- tents, and the presence of blood or occult blood in the stool and sometimes in the stomach in addition, point to the duodenum. 1 In some cases both stomach and duodenum may be involved. Acute Duodenal Ulcer. The writer has seen a few cases of acute duo- denal ulcer of apparently brief duration. ' They occurred in males. There Fig. 310. Profile of ulcer: A, cap; B, everted edge of ulcer; C, crater of ulcer; D, everted edge of ulcer; E, fleck of bismuth in crater of ulcer (Lewis Gregory Cole*). were pain and tenderness in the epigastrium to the right of the linea alba, over the duodenum; vomiting was rare, melena and collapse were marked, and subsequent gastric analysis showed marked hyperchlorhydria; no pus, no occult blood. Severe secondary anemia was present after the hemorrhage. Recurrent hemorrhage may also occur in the gastric contents. As a rule, duodenal ulcer is characterized by its chronicity. Chronic Ulcer. The writer believes the anamnesis to be of exceptional importance, but that repeated and persistent tests for occult blood in the stool in suspected cases, even in the early stage, to be of diagnostic value, and also the use of the microscope, in that the latter will show the presence or absence of pus, and aid in differential diagnosis between gastric and duodenal ulcer. There are, however, certain symptoms which are char- acteristic of duodenal ulcer. Thus: A long history (chronicity); the periodicity of the symptoms, and their recurrence from time to time in 1 Radiography settles the diagnosis. 2 The diagnosis of post-pyloric (duodenal) ulcer. The Lancet, May 2, 1914. 736 DISEASES OF THE STOMACH AND INTESTINES "attacks;" and their complete abeyance in the intervals. The fact that persistent treatment fails to cure the patient is most suggestive. Occa- sionally even after persistent stool examination, occult blood may not be found. The rs-rays, however, will determine the presence of the ulcer. X-rays. In every event when possible, examination should be made with the x-rays which will demonstrate as a rule some deformity in the cap (ascending duodenum) or retention in the duodenum (see Fig. 310), or as Codman shows in cases without scar tissue, a hyper peristalsis of the stomach with subsequent bismuth retention in some cases. A full descrip- tion of the radiological findings is given in the section on "#-rays in gastro- intestinal disease." Spasm of the duodenum may occur as a reflex from a chronic appen- dicitis, or gall-bladder inflammation, and from other causes. This condi- tion has been described by Carman. I always advise examination at time of operation of the appendix and gall-bladder as well as of the duo- denum. The method of prevention of duodenal spasm is described in the section on #-rays (duodenal ulcer). History of Symptoms. The patient, moreover, frequently dates his complaint from an early period, with intermitting periods of comfort. As a rule, he is from twenty-five to forty-five years of age; males are more frequently affected. The early symptoms are a sense of weight, oppression, or distention in the epigastrium after meals. The discomfort appears usually two hours or a little more after food has been taken. There is comfort immediately after a meal; if pain or discomfort were present before, the meal relieves them for a time. Then, again, the pain is felt in two, three, four, or even six hours later. When it occurs three or four hours after food, Moynihan finds that the ulcer is " tucked back." And when the pain comes on earlier than two hours after food, either there are recent adhesions between the ulcer and the liver or abdominal wall, or pyloric stenosis is beginning to develop. Pain. Usually the pain comes on gradually and increases gradually in severity, being accompanied by a sense of fulness and distention ("a blown-up feeling"). There is later an eructation of fluid or gas, which affords relief. The interval between the taking of food and the onset of the pain is constant from day to day, providing the quantity and character of the food remain the same. With liquid food the pain comes earlier, as a rule; while with food that is solid and indigestible, the pain comes later; while with an ordinary meal (liquid and solid), the pain rarely appears in less than two hours. The author finds, however, that this is not invariably the case, as in a recent case examined, of seventeen years' duration, no solid food could be taken at all, liquids alone being ingested with comfort. Discomfort and pain appeared at the end of three hours, and this was temporarily relieved by milk feeding. "Hunger pain" has been suggested as descriptive of this symptom, since patients state that it appears when they are beginning to feel hungry. There have been several explanations offered as to the cause of hunger pain, and it would seem difficult to determine why bland liquid often causes an earlier ap- ^our. Amer. Med. Assoc., April 22, 1916. SIMPLE DUODENAL ULCER 737 pearance of pain. It has been clearly demonstrated by the x-rays that liquids pass out along the lesser curvature early and with great rapidity. The writer believes the earlier appearance of pain to be due to the earlier and more active pyloric contraction, with resulting movements of the irritable ulcer. Cannon has shown that the waves (motor) in the f undus are slight, and, unquestionably, for at least an hour a considerable por- tion of the solid food lies in this region, while it is further acted on by the ptyalin. The smaller quantities of solid food which pass from the stomach at this period are well diluted with liquid. Later, the undiluted chyme passes out in larger quantity, with increased pyloric movements, and also increased motility in the ulcerated region. Moynihan holds that probably the acid content is greater at that period, or possibly some other change has taken place in the chyme, which increases the irritating effects. Codman also calls attention to the primary symptoms of "hunger pain" and indigestion. The pain is, as a rule, noticed at first only after the heaviest meal of the day. For example, if dinner is taken between i and 2 p. M., the pain will appear regularly about 4 p. M. Frequently this is the only time when discomfort is felt; but later, or in subsequent attacks, the pain comes on at the usual interval after every meal; though tem- porarily, after the meal the pain is relieved, but only to return in time. The patient usually states that "food makes the pain better, and that the pain comes on when he begins to feel hungry." It is quite characteristic that the pain should awake the patient in the night, generally about 2 A. M. The patient soon realizes that food relieves the pain, and so has at hand a biscuit, or bread and butter, or milk, to be taken when it begins; and food is often kept beside the bed, to be taken early in the morning when awakened by the pain. Stockton 1 has demonstrated experimentally that the mechanical stimulus given by the food to the stomach excites a reflex flow of the alkaline duodenal secretion, which neutralizes the irritating hydrochloric acid present in the duodenum and J. T. Pilcher 2 makes the same claim. The appearance of the pain at definite intervals after taking food is consistent. A sensation of weight, or fulness, or dis- tention, in the epigastrium, often precedes or accompanies the pain. It may be of a boring, gnawing, or burning character, and it may be relieved by belching. The patient often endeavors to eructate gas in order to secure temporary relief. Slight regurgitation of food sometimes occurs. This may taste bitter or acid, and the throat may feel scalded, and the teeth like chalk. The salivary flow may be copious and cause consider- able annoyance. In some, swallowing the saliva may temporarily re- lieve the discomfort. The author has seen some cases in which the pain was not marked, but there was more a sensation of dull ache or local discomfort. For a long period, sometimes throughout the entire history, the pain may remain confined to the epigastrium. It may pass through to the back, or around the right side, and may radiate down into the abdominal cavity. In my own experience I have not seen it pass into the back, as in gastric ulcer, but it lies rather to the right of the linea alba. Pressure 1 N. Y. State Journal of Medicine, Oct., 1913. Med. Rec., July 26, 1-913. 47 738 DISEASES OF THE STOMACH AND INTESTINES at times gives relief, such as by hugging a pillow to the abdomen. In some cases the pain is cramp-like, a spasm is felt with exacerbations and remissions, as in colic. This is probably due to spasm of the pylorus. - Great epigastric distention occurs with it, with a feeling almost of bursting. The appetite remains good during the period of pain. The patient may eat less than he desires to, since he has learned by experience that excess or even satiation of the appetite may be followed by a more enduring pain. Fluid food, as previously noted, when taken alone, may cause the pain to come earlier and to last longer than after ordinary meals. For a while the patient may feel worse on the liquid diet; but persistence in the latter will bring relief after a time. Vomiting is infrequent and is rarely present until stenosis develops. Stenosis appears in the late period when the ulcer is healed or nearly so, or pyloric spasm may produce an evanescent stenosis. The symptoms of duodenal ulcer are periodic, they recur from time to time in "attacks" and they are in abeyance in the intervals. The "at- tack" may come on as a result of exposure to cold, wetting the feet, a hasty or indigestible meal, or worry or overwork. "Catching cold" is a frequent cause, the attacks being most prevalent in December, January, or February. The symptoms are nearly always absent in summer. The attack may follow another disease, such as influenza. The at- tacks may vary in length from two to three weeks to several months, and a few days rest in the country or at the seashore may cut them short. The onset and termination may be sudden. A chill may bring on the attack immediately and the symptoms may continue for months. At times they may cease abruptly. On the other hand, the pain may become a daily occurrence and retain its peculiar character. In the intervals between attacks there is complete immunity from pain, and food is taken with enjoyment, there is no discomfort, and there is a gain in weight. The recovery may apparently be complete. The patient or physician may believe the case to be one of acid dyspepsia or a neurosis. All these symptoms may be present for years without any physical signs. Though the anamnesis is extremely important, the writer does not agree with Moynihan's statement, that it is not necessary for an accurate diagnosis that any exmination of the patient should be made. Repeated and frequent examinations of the stool should be made for occult blood. The writer believes it can usually be discovered. Bleeding from hemor- rhoids should, of course, be excluded. The test-meal is also important. In many cases, especially in the stage when the ulcer is latent, or be- tween the presence of symptoms, nothing may be revealed by physical examination. There may be some epigastric tenderness in the middle line or to the right. During the period of pain, between two or three hours after a meal, there is usually some tenderness, which may rarely be marked. This may be in the middle line over an area of 2 or 3 inches. The pyloric region may in some be sensitive. Tenderness on pressure over a small circumscribed point is more frequent with gastric ulcer. SIMPLE DUODENAL ULCER 739 In some cases, however, of duodenal ulcer, there may be continuous pain and tenderness due to a local peritonitis. Rarely pain and tender- ness appear on the left side for which there is no explanation. When acute pain is present the right epigastric reflex may be strongly accentu- ated. Local tenderness is usually combined with local rigidity, and the upper part of the right rectus muscle may be contracted and tense. Hence, tenderness in the middle line and to the right, accentuation of the right epigastric reflex, and rigidity of the right upper rectus are the chief physical signs of duodenal ulcer; they may be absent. Vomiting is rare with duodenal ulcer, unless there is stenosis with dilatation of the stomach, and this condition occurs in the later stages. With reflex spasm of the pylorus, vomiting occasionally occurs, but it does not relieve the pain of duodenal ulcer as it does that of gastric ulcer. A regurgitation of acid chyme is, however, quite frequently present. When stenosis occurs, we have the physical signs of dilatation of the stomach, with peristaltic unrest, vomiting, motor insufficiency, etc. S. Kemp 1 believes that hypersecretion suggests either gastric or duodenal ulcer as a rule, and when it is excessive, it speaks strongly for duodenal ulcer; in fact, he believes it more frequent with the last. Pyloric spasm was quite frequent with duodenal ulcer, and gastric motor insufficiency he believed to be the rule. The author only finds hyper- secretion, and motor insufficiency in the advanced cases with stenosis. Examination of the Blood. Secondary anemia, often quite severe is found, after hemorrhage in acute cases of duodenal ulcer; and I have ob- served secondary anemia quite marked in chronic cases where there was evidence in the stool of repeated small hemorrhages. Friedman 2 reports polycythemia in cases of duodenal ulcer of non-hemorrhagic type, and holds that it is an important aid to the diagnosis, and claims the following differences in the blood picture of gastric ulcer and non-hemorrhagic duodenal ulcer. Gastric ulcer Duodenal ulcer Anemia Polycythemia (erythrocytosis) Eosinophilia Eosinopenia Bowels. Constipation is the rule, diarrhea rarely occurs. Gastric Contents. The test-breakfast should be given in all cases. The patients usually complain of an acid stomach (hyperacidity). In the writer's own experience, in the cases with acute symptoms, with melena or a clear history of hemorrhage, he has found hyperchlorhydria present. This corresponds with Boas' observations. On the other hand, the in- tractible cases of so-called "acid dyspepsia" of long standing which do not yield to remedies, and which are recurrent, Moynihan believes to be due to duodenal ulcer. In the type of chronic duodenal ulcer, the gastric juice often contains less free HC1 than normal, in spite of the symptoms of hyperchlorhydria. The Mayos report a number of cases of chronic duodenal ulcer with hyperacidity or on the border line between normal acidity and hyperacidity. On the other hand, the cases which have 1 Ungekrift for Laeyer, Copenhagen, Dec. 15, 1910, Ixxii, Nos. 49 and 50. 2 Med. Rec., May 16, 1914, and same Oct. 18, 1913. 740 DISEASES OF THE STOMACH AND INTESTINES progressed to stenosis of the pylorus, and dilatation of the stomach have hyperacidity as a rule; but in these the chief symptoms are re- ferable to the mechanical obstruction. Even the absence of free HC1 and the presence of lactic acid have been reported in cases of duodenal ulceration. As about 50 per cent, of one's private office cases suffer from true hyperchlorhydria (an excess of free HC1 above normal, in addition to excessive total acidity), the writer absolutely disagrees with Moynihan in his statement that the term hyperchlorhydria is a misnomer, is due to an organic condition, and is never functional, and that the presence of an excess of acid is most infrequent. Hyperchlorhydria results chiefly from dietary indiscretions, and also is associated with chlorosis, gastrop- tosis, and nervous conditions. There may be attacks with free intervals, just as in the case of duodenal ulcer; excepting in the pure nervous cases, or those reflex from the gall-bladder and appendix, the character of the food may influence the attacks. Simple hyperchlorhydria is, as a rule, amenable to treatment. Hyper- chlorhydria with gastric ulcer is present in the acute cases in the author's opinion, with a history of hematemesis and melena. In hyperacidity cases not amenable to treatment gastric ulcer is often also present. Hyperchlorhydria occurs in acute cases, of duodenal ulcer with melena. Symptomatic hyperacidity recurrent and intractable with less HCl than normal is suggestive of chronic duodenal ulcer. The presence of blood visible or occult, and pus in the gastric con- tents, are diagnostic of gastric ulcer. Of course, pus from the pharynx or from gastric abscess must be excluded. Preliminary antiseptic naso- pharyngeal sprays, a preliminary lavage, and sterile diet are valuable methods to exclude ingested pus. The determination of pus, therefore, diagnoses ulcer affecting the stomach either benign or malignant in type, or achlorhydria haemor- rhagica gastrica. In the latter condition other peculiarities of the gastric contents are present which are described under that subject. With achlorhydria hemorrhagica free HCl notably is absent, and microorganisms are in excess. On the other hand, melena is most frequent with duodenal ulcer and hematemesis is less frequent.. If the examination of .the gastric contents show an absence of pus, occult blood present or more usually absent, and occult blood 1 be found present in the stool, the case is one of duodenal ulcer. Acid gastritis is hyperchlorhydria with mucus, an early stage of chronic gastritis and an entity in itself. These .features show the importance of the test-meal. Gross has recently suggested aspirating the duodenal contents with his duodenal pump and examining for blood and occult blood. The method may possibly prove of service. Hemorrhage. This sign sometimes appears early, but is more fre- quently a late symptom. Visible hemorrhage Moynihan believes a sign of neglected opportunity. Various authors place the frequency of hemor- 1 Hemorrhoids and other causes must be excluded. SIMPLE DUODENAL ULCER 741 rhage as occurring in about one-third of all cases, while Moynihan notes it in 37.6 per cent. When hemorrhage occurs, it may manifest itself either, more rarely as hematemesis, vomiting of blood, or usually as melena (blood in the f eces) ; as a rule, the blood has a tar-like or coffee-ground appearance. Sometimes both occur, but melena is the most frequent, without hematemesis. Hemorrhage from duodenal ulcer is far more serious than bleeding from a gastric ulcer. There may be first an exacerbation of the indiges- tion and a feeling of distention. The patient may suddenly become faint and weak, the head feels light, and he becomes pale, the forehead covered with sweat, and he asks for air. There are all the signs of an internal hemorrhage. Tarry blood may be voided in the stool or brighter blood vomited. The patient may bleed to death without any visible blood. Death from hemorrhage may be nearly instantaneous, when such vessels as the aorta, the hepatic, superior pancreaticoduodenal right gastro-epiploic and pyloric arteries, or the portal or superior mesenteric veins are eroded. On the other hand, there may be progressive anemia and weak- ness with no particular symptoms, resulting from smaller repeated hemorrhages. Undoubtedly careful and repeated examination of the stools and gastric contents for occult blood by Weber's, the benzidin, or phenolphthalein tests, would demonstrate that ulcer is present in every suspected case. A number of examinations may be necessary, but the writer believes occult blood can ultimately usually be found in the stool. A meat-free diet for two days, administration of a coarse diet, and elimination of bleed- ing from hemorrhoids, are necessary precautions. Celery, radishes, etc. (coarse ballast), fret the ulcerated surface and tend to cause slight hemorrhage. Einhorn suggests the thread impregnation test, as described under the gastric ulcer. The writer believes, however, that if blood is present in sufficient quantity to discolor the thread, the occult blood test will invariably be present. The thread test is uncertain. Moynihan's statistics are as follows: 70 patients (37.6 per cent.) gave a history of bleeding. Of these 7 had hematemesis alone, 23 had melena alone, 30 had both hematemesis and melena. Out of 139 cases in which duodenal ulcer alone was found, hemor- rhage was noted in 49 cases (35.2 per cent.); 9 had hematemsis alone (6.4 per cent.); 18 had melena alone (13 per cent.); 22 had hematemesis and melena (15.8 per cent.). In 18 cases the hemorrhage was severe in all 9.2 per cent, suffered from dangerous bleeding. Jaundice. Jaundice is rare with duodenal ulcer. The development of icterus in a case presenting some of the symptoms of gastric ulcer, probably shows duodenal ulcer, if gall-stones can be excluded. The death-rate from hemorrhage is quite large and is variously estimated at from 13 to 33 per cent. Tetany. Three cases gave a history of tetany. Cardiospasm. In three cases cardiospasm was present. Dilatation of the Stomach. In a small number of cases the symptoms 742 DISEASES OF THE STOMACH AND INTESTINES of active ulceration are latent and the physician is first consulted for copious and repeated vomiting. The stomach is dilated there is per- istaltic unrest the symptoms are those of pyloric stenosis. The history may possibly differentiate between gastric and duodenal ulcer but the author believes this result can only be positively attained by operation, which he holds is invariably imperative in such cases. In this type the ulcer is usually nearly healed, and the cicatricial contraction is responsible for the stenosis. The #-rays aid the diagnosis. Perforation. Perforation is the most serious complication that can Fig. 311. Showing the disposition of the duodenal peritoneal coat, and explains the direction taken by duodenal contents in case of perforation (Gaultier). occur with duodenal ulcer. It may take place in acute or chronic ulcer, both in the young and old. Finney 1 reports a case in a child two months old, while Moynihan has seen it in a woman aged seventy-seven. Sudden perforation may occur with the acute duodenal ulcer, due to burns, septicemia, etc. Perforation may be acute, subacute, or chronic. In Moynihan' s series of 1 1 cases, acute perforation occurred in a chronic ulcer. In every case, there was evidence that the ulcer had long been present , but only recently was the ulcer the seat of a more active pathological 1 London Lancet, 1908, ii, 1748. SIMPLE DUODENAL ULCER 743 change, and there had been an exacerbation in the symptoms. Occasion- ally a perforation may occur without previous symptoms. Symptoms of Acute Perforation. There is a sudden onset of intolerable and agonizing pain. This is so severe, that sudden death may occur from it. The patient is prostrated, he is pale and faint, the expression anxious, and sweat appears on the brow. Respirations are short and quick. Deep inspiration causes a groan of agony and a spasm of pain. Replies to questions are given in snatches and expiration ends abruptly in a catch. Collapse may be complete in some cases, the author finds in his own ex- perience. In some, however, it may not be apparent. When the patient is seen jj& an hour or two after perforation, at which time the pulse may not be par- ticularly rapid, muscular rigidity is a marked symptom and the abdomen is at this time retracted. Distention comes later. The tenseness of the ab- dominal muscles is persistent. On over- coming the protective muscular rigidity, abdominal tenderness is present. There is an area of more marked tenderness and rigidity to the right of the median line above the umbilicus. Vomiting may occur at first, but it usually does not. The liver dulness is not yet impaired. Percussion of any part of the abdomen is resented by the patient. As a rule, the symptoms rapidly alter, as fluid escapes through the rup- ture into the peritoneal cavity, produc- ing the symptoms of acute peritonitis. The pulse-rate rises steadily, the quality becoming poorer. The abdo- men, preserving its rigidity, becomes fuller, until a uniform tight distention occurs. Tenderness, as a rule, be- comes more marked on the right side, and the right iliac fossa becomes the most tender and most distended region. Leukocytosis and increase of polynuclears are present. The temperature, which was previously normal or subnormal, begins to rise and may reach io2F. or more. Intestinal stasis is absolute from the first. Repeated enemata may bring a little gas, and feces in some cases. Interference with respiration persists and increases as the ab- domen distends. The face becomes livid, the face and hands cold and damp, and, finally, cyanosis develops. From the time of perforation to the death of the patient a period averaging from two to five days may elapse. The right side of the abdomen, as heretofore noted, is chiefly affected, so that the mistaken diagnosis of perforative appendicitis has been fre- Fig. 312. Schema, after Moyni- han, showing direction taken by duo- denal contents in perforation of the duodenum; how they arrive in the region of the cecum and simulate appendicitis. 744 DISEASES OF THE STOMACH AND INTESTINES quently made. The fluid escaping from the duodenum is prevented from passing to the left by the reflection of the great omentum from the duo- denum and the stomach. It flows down to the outer side of the colon to the right iliac fossa and brim of the pelvis and then overflows into the latter. If the ascending colon is bound down and has no mesentery, the fluid may rise alongside the colon, crossing a few inches below the hepatic flexure, and then flow to the appendix region, guided by the obliquity of the mesentery (Figs. 311 and 312). Differential Diagnosis between Acute Perforation of Duodenal Ulcer and other Conditions. Duodenal Ulcer. The previous history of the case is of great value; it occurs more frequently in men. Pains appear two hours or later after meals. At the time of perforation the pain is overwhelming in character. It is frequently to the right of the median line in the epigastrium, though it may be referred to the whole abdomen. Within one to two hours, however, the pain is always of greater severity on the right side, and tenderness and muscular rigidity are also excessive there. The rigidity is extreme. No conditions, except perforation of the duodenum or stomach, give rise to such extreme tension in the muscles. Rigidity also persists, and retraction of the abdomen continues until distention due to peritonitis develops. Rigidity does not lessen until profound toxemia ensues. Gastric Ulcer. Perforation. Pain appears earlier; frequently local tenderness, dorsal pain, and other symptoms precede the perforation, though not always so. With perforation of the stomach, the pain is usually to the left of the median line. After perforation, careful examina- tion will show an area which is more resistant and more tender, beneath which the ulcer lies, and hence, the site of the perforation. When the most tender area is in the left hypochondrium, the perforation is toward the cardia; if around the umbilicus, it is in the body of the stomach; and if to the right of the median line or in the right hypochondrium, then the perforation is probably in the pyloric end of the stomach or in the duodenum. Per for alive Appendicitis. The pain may be first referred to the epi- gastrium or to the entire abdomen, and then becomes localized in the right iliac fossa. There may be a dyspeptic history, but not the typical history of gastric dyspepsia, as with duodenal ulcer. There is generally a history of preceding pain in the appendical region, or of previous attacks, or of constipation, or colitis. In many cases an aperient has been taken previous to perforation. The muscular rigidity with appendicitis is not as intense as with duodenal perforation, nor are the pain and agony as intolerable. The diaphragm is not held as tight and the respirations are not as short and jerky. In both conditions there is tenderness in the right iliac fossa. Tender- ness and rigidity are always present in the right hypochondrium with duodenal perforation, and shortly after perforation of the duodenal ulcer, rigidity of the right rectus (upper part) and tenderness are most marked in this region. With appendicitis they are exceptionally there, and only when the appendix is retroverted and extends to the liver. Even then the tender- SIMPLE DUODENAL ULCER 745 ness is less marked. Rigidity of the lower portion of the right rectus is usual. Moreover, the test Head's zone for the appendix is of value in these cases, as it lies below the umbilicus. Rarely perforation of ulcer and perforative appendicitis may coexist. 1 At times, however, one sees a patient with general peritonites, with tenderness most marked in the right iliac fossa and believe the condition due to perforated appendix. The his- tory may be obscure. On operation appendix is found to be uninvolved. In such cases perforation of gall-bladder or duodenum may be the cause. Acute Pancreatitis. As a rule, there are no initial symptoms. Occurs more in males. Occasionally acute pancreatitis may be dependent on the impaction of a stone in the ampulla of Vater, in which event there may be the previous history of "gall-stones" or "gall-stone dyspepsia." The pain of acute pancreatitis is more in the epigastrium. Muscular rigidity, tenderness, and distention chiefly occur there "an epigastric peritonitis" and the enlarged and edematous pancreas may at times be felt on deep palpation. -Fitz describes scattered areas of abdominal tenderness lying probably over the areas of fat necrosis, and there is tenderness at Robson's point. The pulse is bad from the start, and it is always rapid and of poor quality. Its rate is at first disproportionate to the severity of the other symptoms. Temperature is normal or subnormal. Constipation is marked. Vomiting is frequent and obstinate. It consists of food, bile, and black altered blood. Blood is frequently passed from the intestines and from the other mucous membranes, and bleeding may be subcu- taneous. A deep lividity or cyanosis of the skin, chiefly of the face, occurs. Corpulent people are often attacked by acute pancreatitis, and it occurs with considerable frequency during the early months of pregnancy. Jaundice may occur. With acute pancreatitis, a general distention of the abdomen is rare, the right side of the abdomen is not specially involved, and the hurried, jerky respiration due to contraction of the diaphragm does not occur. Fat necrosis is present with acute pancreatitis. A case of fat necrosis with peritonitis resulting from perforation of a duodenal ulcer is reported by Richter 2 as a rare occurrence. The pancreas was found to be normal. Acute Perforation of the Gall-bladder. The local and general symptoms may simulate acute perforation of duodenal ulcer. A careful investigation into the previous history is the only means of diagnosis. A history of hepatic colic, with occasional attacks of jaundice, can usually be secured. It occurs usually in fat females of over 40 years. The previous paroxysms of pain occur generally regardless of eating and usually occur in the right hypochondrium, and pain may pass around or through the right shoulder blade. Gall-bladder may be sensitive to pressure, tender at Murphy's point, and the head zone is present or there may be rigidity of the right upper rectus. There may be tenderness at Boas point (posterior right side level of 10-12 dorsal vertebrae). With a previous acute inflammation there are leucocytosis, increased poly- 1 B. Carter, London Lancet, 1901, ii, 1195. - Quarterly Bulletin Northwestern University Medical School, Dec., 1910. 746 DISEASES OF THE STOMACH AND INTESTINES nuclears, temperature and at times chills. Jaundice occurs in only 20 per cent, of cases. Other cases may only have a sense of tightness or con- striction in the epigastric region, or a feeling of stiffness, or soreness in the right upper abdominal quadrant, while the appetite is capricious, there is flatulence independent of food, and discomfort on an empty stomach. Any of these premonitory symptoms may occur or perforation may occur suddenly without premonitory symptoms and may be diffi- cult to differentiate from perforation of duodenal ulcer. The onset of pain is acute. Some claim it is not as agonizing as with duodenal ulcer, though I have seen cases in which it was fully equal and in one apparently more so. Some hold it is more painful (sudden rupture of a sac under tension). Collapse, prostration with rapid pulse and respiration, sub- normal temperature are present at first; then local rigidity and tenderness in gall-bladder region. Vomiting and intestinal paresis- gradual general peritonitis with distention, tenderness and rigidity, most marked in right inguinal region, as contents gravitate there just as with duodenal ulcer perforation. Temperature rises with general peritonitis, leucocyto- sis, increased polynuclears. Facies Hippocratica follows, cyanosis and death. Acute Thoracic Disease. The mimicry of appendicitis is more usual than that of perforation of ulcer of the duodenum. During the onset of pneumonia, diaphragmatic pleurisy or acute bronchitis, the pain may be felt exclusively in the abdomen, the ab- dominal muscles may be tense and the surface tender. There are several features which are an aid to differential diagnosis: (1) The temperature in acute lesions of the thorax often ranges higher 103 to io4F. than it does in acute abdominal lesions (rarely above io2F.). (2) The respirations are more rapid 35 to 40 or more in pulmonary conditions. (3) There is a disproportion in the early stages in thoracic lesions, between the pulse and respiration. The pulse may not be much over ico, and the respirations 35 to 45. A more rapid pulse-rate, 120 or more, with a slower respiration, about 25, would be most frequent in an abdominal lesion. (4) In abdominal conditions there is persistent rigidity and deeper tenderness. With thoracic inflammation the tenderness is superficial, and deep pressure may even give relief, and during respiration, at the height of expiration, the abdominal muscles may be soft and the rigidity absent. The rigidity is less marked and less persistent and the area affected is limited. (5) With diaphragmatic pleurisy, the respiratory movements in the upper thorax are exaggerated, while they are slower below. (6) Head's zones of cutaneous hyperalgesia for the lungs lie over the thorax, while for the duodenum Head's zone lies just below the free border of the ribs, chiefly to the right of the median line, and for the appendix, it lies below the level of the umbilicus. Treatment of Acute Perforation of the Duodenal Ulcer. In brief, immediate operation is indicated; suture of perforation, drainage, usually SIMPLE DUODENAL ULCER 747 gastro-enterostomy. Subsequent to operation, proctoclysis in Fowler's position is most valuable. Resection of the ulcer may be required. Subacute Perforation of Duodenal Ulcer. In this case, though there is a sudden rupture of an ulcer, as in the acute perforation, there is a definite localization of the fluid escaping through the rent and in many instances a narrow circumscribed peritonitis. An empty stomach at the time of perforation would render the symp- toms less severe. A sudden movement or violent strain may be the cause of the rupture. A tag of omentum may plug the opening of the ulcer, or peritoneal irritation, as the ulcer deepens, may cause plastic lymph deposits on the base of the ulcer, so that there is a nearly impenetrable barrier at the moment of perforation. Moreover, the duodenum may become adherent at the base of the ulcer to the anterior abdominal wall, the liver or the pancreas. The symptoms are the same as in acute perforation, except that they are less intense. There is a previous history pointing to duodenal ulcer; in some cases there is increased pain for a few days previous to perforation, or the ab- domen is stiff and sore, and discomfort is felt on laughing or stretching. The pain of perforation is again sudden in its onset and severe in character, but not as intolerable as in acute perforation. Vomiting 1 and prostration may follow. The abdomen is everywhere tender; but there may be a particularly tender and resistant area, which on palpation may feel like a flat, hard mass inserted in the wall of the abdomen. Leuko- cytosis and increased polynuclears are present. The symptoms subside slowly, the character of the pulse improves, vomiting ceases and the abdomen, which was at first hard and retracted, may become soft, except at the one spot, or it may be slightly distended, with some free fluid. If no operation is undertaken, there may be several results, either a periduodenal abscess may form, or a secondary rupture into the general peritoneum may occur, or the adhesion of the ulcer to the abdominal wall, liver or pancreas may increase in firmness, the acute inflammation subside and the patient live for years. This last is more common. Differential Diagnosis of Subacute Perforation of the Duodenum. The chief difficulty is differentiating this condition from acute chole- cystitis. In both conditions there are pam, sudden in onset, which is severe and often colicky. There is no general invasion of the peritoneum, but a localized peritonitis with a tender resistant area. The best clue is the previous history of the case. The determination of Head's zone may be of service. Treatment. Since, in the early stages, a differential diagnosis between acute and subacute perforation cannot be made, in view of the uncertainty, immediate operation is indicated. Chronic Perforation of Duodenal Ulcer. In this type of perforation the intestinal coat is destroyed slowly by the ulcer, and by the time the serous coat is reached a protective barrier, often reinforced by omentum, is raised by newly formed lymph deposit and adhesions, so that the 1 There may be blood in the vomitus. 748 DISEASES OF THE STOMACH AND INTESTINES inflammatory process is circumscribed and perforation into the general peritoneal cavity does not occur, but a local peritonitis. The local cavity increases in size and the contents may become purulent, so that a periduodenal abscess results. In other cases, the perforation may occur suddenly, but be so minute in size or the duodenum be so empty that leakage is excessively small. In this event, the inflammation may become rapidly circumscribed by adhesions and again a periduodenal abscess result. Communication with the duodenum may then be shut off completely, or it may be closed in such a way as to reopen when the abscess has been opened. A duodenal fistula then results. The periduodenal abscess may perforate, or burrow in various direc- tions. Fistula may be present between the duodenum and the gall- bladder 1 or between the duodenum and colon 2 or hepatic abscess 3 may result; or a pancreatic 4 duodenal fistula. A few cases are also recorded of fistula between the stomach and duodenum; but in these cases it seems probable the primary ulcer was in the stomach. Subdiaphragmatic abscess may result from chronic perforation of duodenal ulcer. A periduodenal abscess may burrow to a great distance; thus it may pass into the retroperitoneal spaces and ascend along the greater vessels into the neck, or may point between the seventh and eighth ribs pos- teriorly, or at the tip of the right scapula. It has passed down along the ascending colon to the right iliac fossa and burst into the cecum or may lead to an abscess of the right iliac fossa and pelvis. It has burrowed beneath the right psoas sheath, causing flexion of hip and lordosis. It may penetrate the gall-bladder. Meunier 5 reports a case where an abscess cavity was found on the under surface of the liver. It was traversed by the duodenum, which was completely severed by a circular ulcer. The abscess which forms may reach the anterior abdominal wall and pef orate the same with resulting external duodenal fistula. 6 These cases ultimately die of inanition and sepsis unless definite surgical procedures are adopted. Treatment. Appropriate surgical measures are indicated for chronic perforation of a duodenal ulcer. Differential Diagnosis of Duodenal Ulcer. This matter is so important that it is deemed proper to recapitulate some former observations. Constriction of the Duodenum due to Abnormal Folds of the Anterior Mesogastrium. This condition is a constriction of the second portion of the duodenum due to the remains of a definite embryological structure. Six cases are reported by Harris. 7 There are disturbances of digestion, distress in the epigastric region usually two to three hours after eating. 1 London Lancet, 1850, i, 776; Schmidt's Johrbuch, cxxxix, 293. 2 Pathol. Soc. Trans., 1862, xiv, 173. 3 Munch, med. Wochens., 1887, i, 678. 4 Guy's Hosp. Museum, No. 757. 5 Bull. Soc. Anat., 1893, Ixviii, 487. 6 Archiv Gen. de Med., 1887, i, 414 et seq.; also Bull. Soc. Anat., 1870, xv, 439. T Journal A. M. A., April 18, 1914. SIMPLE DUODENAL ULCER 749 There are attacks of sharp pain in the right epigastric or hypochondriac region. Distress is described as a sensation of pressure in the stomach. Tenderness in the epigastrium is present to some degree. Nausea oc- casionally occurs, but seldom vomiting. Chronicity is characteristic, the trouble often dating from early life. Though there are more or less intermissions during the early history, the symptoms become practically continuous after they are well established. Hyperchlorhydria is always present. Thus it differs from chronic duodenal ulcer where with symp- toms of hyperacidity, hypochlorhydria is generally present. No occult blood in the stools. The attacks of pain in the right hypochondriac region with slight jaundice in two cases suggested gall-stones. There were ab- sence of marked intermissions with relapses such as occur with ulcer. The radiograph is of great diagnostic value. The head (first part of the duodenum) is long, large and dilated and often part of the second portion, with a fixed point at the right of the constriction. Congenital stenosis of the duodenum 1 in an adult has also been reported and also other varieties of duodenal stenosis. Stricture of the duodenum due to inflammatory adhesions, or cicatricial contraction may also occur and in some cases closely simulating duodenal ulcer. In one patient of the author's, the pain occurred at the usual time as with duodenal ulcer, there was epigastric tenderness, but the gastric analyses showed hyperchlorhydria, while with chronic duodenal ulcer, the symptoms are those of hyperchlorhydria, with frequently hypo- chlorhydria present. No occult blood was present in the stool at any time. The radiograph demonstrated a bismuth deposit in the duodenum and partial stenosis 2 of the transverse colon from adhesions. Operation by Wm. P. Healy showed a stenosing band about the transverse colon. It passed upward and slightly constricted the duodenum. Above this the bis- muth deposit occurred. There was no ulcer. Usually the duodenum is some- what dilated. In stenosis cases of marked type, the stomach is also dilated and the symptoms in that event, point more to benign pyloric stenosis. Duodenal Ulcer. This condition is more frequent in males; pain after food does not appear until two hours or more; the hunger pain is relieved by food; pain may be in the median line, though quite frequently it is to the right of it, and may radiate over the right costal margin to the breast or round to the back. Tenderness on pressure, when present, is always to the right of the median line. It is, as a rule, not as circumscribed as with gastric ulcer. Attacks are apt to be recurrent in the cold and wet seasons. Vomiting is rare, unless there is stenosis of the duodenum or pylorus. Helena more usually occurs without hematemesis; hemorrhage is more dangerous; perforation more frequent; latent type with sudden hemorrhages is more frequent; history is usually chronic, symptoms recur in attacks; patients complain of hyperacidity. Gastric findings, usually in chronic cases, show no excessive content of HC1, in fact, as a rule, it is less than normal. On the other hand, in the cases with brief history and acute hemorrhage, I have generally found hyperchlorhydria. These last are of easy diagnosis. In the more obscure cases repeated examina- tions of the stool for occult blood will usually show its presence. The 1 Terry and Kilgore, Journal A. M. A., June 3, 1916. 2 The deposit was present in the cap and in the descending duodenum. 750 DISEASES OF THE STOMACH AND INTESTINES gastric contents show no pus, and at times blood or occult blood is present. The presence of pus shows an ulcer ation in the pylorus or stomach. The determination of occult blood in the stool, in cases where there is no definite history of hemorrhage or visible evidences of the same, is of great im- portance. In an obscure case a positive diagnosis of duodenal ulcer was made chiefly on this point and was confirmed at operation by Herman Haubold. It served to exclude gall-bladder disease and a gastric neurosis. Radiographs were objected to by this patient, though not operation. The special Head zone aids differentiation of ulcer of the duodenum from disease of the gall-bladder and stomach. Gastric Ulcer. This is more frequent in women, is frequent with chlorosis; pain is earlier, within a short tune or less than an hour after food, rarely within one to two hours; pain in the median line or to the left and may radiate to the left margin, left breast, and even down the left arm; dorsal pain is present at a point between the scapula and spine; tenderness is more circumscribed and is in the median line and often to the left of the same; there is not the same dependence of the attacks on the climate or seasons; vomiting is more frequent; hematemesis more frequent; melena less so, but quite often present; hyperchlorhydria is present in the acute cases; diminished acidity or absence of HC1 may occur in the chronic ulcers. Pus (microscopic] always present in the gastric contents; occult blood or blood is found in the gastric contents. Pus is extremely important, as in a case of Connor's, the diagnosis was made from its presence alone, no occult blood being found. Occult blood in the stool is frequent. No mucus is present in the gastric contents. Bassler holds that 2 per cent, or more of gas in hyperchlorhydria is suspicious of ulcer. Duodenal ulcer has also been mistaken for chronic appendicitis, since the latter may cause hyperacidity with pylorospasm and symptoms pointing to the duodenum without ulcer being present. Lewisohn reports four cases believed to be chronic appendicitis in which duodenal ulcer 1 was apparently the lesion. Frankly if proper #-ray examination has previously been carried out and the duodenum is carefully explored, I can see no reason for such an error. Simple Hyperchlorhydria. This is a very frequent condition con- tent of HCl is always high and constitutes chief acidity total acidity is usually high though mild cases occur. No pus in gastric contents and no blood or occult blood. No occult blood is found in the stool. There is no special predilection for either sex. Dietary indiscretions, anemia, gas- troptosis, nervous conditions, etc., may be the cause. Cases may be persistent, but are amenable to relief by treatment. When hyperchlor- hydria occurs with other conditions, such as appendicitis, gall-bladder disease, and gastric or duodenal ulcer, the anamnesis and physical ex- amination for the first two conditions and the presence of gastric and in- testinal occult blood with the last two will aid diagnosis. With the ulcer- ated 2 conditions, gall-bladder disease and appendicitis, special Head zones are present. There is no mucus with simple hyperchlorhydria. 1 Medical Record, June 17, 1916. 1 The *-rays will exclude ulcer. SIMPLE DUODENAL ULCER 751 Acid Gastritis. There is hyperacidity plus mucus. 1 It is an initial stage of chronic gastritis. Achlorhydria Hcemorrhagica Gastrica. There are absence of free HCi, presence of mucus, many actively growing bacteria, pus, blood, or occult blood. The condition is reflex. Gall-bladder disease or appendicitis are a frequent cause and the condition is relieved by operation. Cholelithiasis. There are no definite attacks which occur at certain seasons (no periodicity); the pain is unendurable; is more severe than duodenal ulcer, except when there is perforation, which last has associated definite symptoms. Pain occurs within an hour after food. There are often a "catch in the breath," depression, nausea, and sweating. The pain begins suddenly, is abrupt in the onset and in its relief, as it may rapidly pass away; acidity or heartburn may be present. Food or an alkali does not relieve the pain and the idea of food is repugnant. Chills, sweats, a "feeling of gooseflesh," shivering, and sub- sequent heat are present. There may be a sensation of pain in the shoulder-blade, which is suggestive of gall-stone impaction in the cystic duct. The pain is cramp-like, passes through and around the right side to the shoulder-blade, and epigastric distention accompanies it. A feeling of stiffness or soreness remains for some hours. The gall-bladder is tender and Head's zone is present, also Boas point of tenderness. Ulceration of a Gall-stone into the Duodenum. The writer has seen a case suffering from an attack of acute pain to the right of the median line in the epigastric region, followed by several attacks of hematemesis and marked melena. One consultant believed it due to hemorrhage from an occult duodenal ulcer. The patient was a stout, elderly woman, with an apparent history of previous gall-stone attacks. The possibility of sub- acute pancreatitis with hemorrhage was suggested. Subsequently a gall- stone the size of an English walnut was removed from the intestines. It had ulcerated through from the gall-bladder, eroding a large vessel. The patient recovered. Chronic Pancreatitis, Simulating Gastric or Duodenal Ulcer, with Symp- toms of Pyloric Stenosis, Moderate Dilatation of Stomach. This condition is particularly interesting. The writer recently examined a case (female) for John Connors presenting the following symptoms: pain one to three hours after eating; tenderness in the epigastrium; occasional vomiting; history of apparent coffee grounds; complains of hyperacidity, but acidity and HCI within normal limits, three years' history; stomach dilated to umbilicus; no pus; no occult blood found in gastric contents; no occult blood in stool (two examinations). The writer found evidences of mechanical obstruction to the exit of gastric contents. In view of ab- sence of pus and occult blood in the same, believed obstruction to be on the duodenal side, and probably due to ulcer. Stool showed some dis- turbance of intestinal functions, but chronic pancreatitis was not sus- pected. Laparotomy showed no ulcer, but mechanical obstruction to the duodenum from an enlarged head of the pancreas; also a chronic pancrea- titis, no obstruction to the common bile-duct, and no gall-stones. The common bile-duct evidently lay outside the enlarged head of the pancreas. The gall-bladder was opened and drained. It contained no gall-stones, 1 These are demonstrated by gastric analysis. There is no gastric mucus with ulcer. 752 DISEASES OF THE STOMACH AND . INTESTINES but thick inspissated bile. This case is of particular interest. Whether subsequent to operation the enlarged head will subside or gastro-enter- ostomy will be necessary, it is too soon to determine. Patient is doing well. Banti's Disease. The anamnesis and the presence of the enlarged spleen are an important aid to diagnosis. One should also determine that cirrhosis of the liver particularly in syphilitics is not a factor in gastro-intestinal hemorrhage and that the patient is not a "bleeder." I have recently seen a most interesting case of persistent intestinal hemorrhage with indefinite gastro-intestinal symptoms of four years' duration, in which duodenal ulcer was believed to be the cause. Opera- tion by Meeker at the Red Cross Hospital showed a single male lumbricoid worm 1 1 inches long in the jejunum i foot below the duodenum. There were evidences of numerous perforations of the intestinal mucosa, with resulting hemorrhages. No eosinophilia was present, and no other worms or ova were found. The worm was coiled into a U and was very active. This is the first such case I believe recorded of a lumbricoid worm producing intestinal hemorrhage, though it has occurred with ankylostoma. Prognosis. The prognosis is, as a rule, quite serious, especially in the cases with frequent recurrent hemorrhage. Perforation requires immediate surgical procedure. Relapses may occur in the apparently cured cases, but I have seen perfect recovery follow proper treatment. Treatment. This is similar to ulcer of the stomach. Hemorrhage. For acute hemorrhage, apply an ice-bag to the epigastrium and give at once a hypodermic of morphin, y grain (0.016). Tremoliere's solution, calcium chlorid (2 per cent, solution) in gelatin (5 per cent, solution), i ounce (30.0) every two to three hours by mouth, is useful. Gelatin (5 to 10 per cent.), by mouth, i ounce (30.0), or a 2 per cent, solution subcutaneously may be employed; calcium chlorid or, preferably, calcium lactate, 10 grains (0.6) in 4 ounces (125.0) of water every three hours by mouth, or by enema if vomiting, or strontium or magnesium lactate by hypodermoclysis, 1 15 to 30 grains (1.02.0) in 4 ounces (125 c.c.) of sterile water, or ernutin, 5 minims (0.296) by hypo- dermic, are all useful. Emetin in gr. % doses has been advocated. Adrenalin (i : 1000), 5 minims (0.296) or more, has been recommended by mouth or by hypodermic. It may too markedly raise pulse tension. Normal horse-serum or human serum by mouth or the latter, preferably by hypodermic, 15 to 30 c.c., might prove of value. Spriggs 2 advocates the use of olive oil or almond oil, as suggested by Cohnheim and Walko. He gives y% to i ounce (30.0-60.0) t.i.d., in- creasing the dose to 2 ounces (120 c.c.) in some cases. Spriggs often starts the treatment by giving the olive oil alone by mouth every three hours, and nothing else except water for the thirst. This method is continued until the blood disappears from the stool. He then gives cream, and the foods of the Lenhartz diet are added, excluding rice. The oil is then reduced to i dram (4.0) before each meal. Author's Method. The author advocates the ice-bag, morphin by 1 The calcium salts may also be given for long periods by protoclysis. 2 Brit. Med. Jour., May 21, 1910. SIMPLE DUODENAL ULCER 753 hypodermic, lactate of calcium, 10 grains every three hours in 4 ounces (125.0) of water, and i ounce (30.0) of a 5 to 10 per cent, gelatin solution every three hours; ernutin, 5 minims (0.296) by hypodermic, is useful, and in severe cases the serum treatment by mouth or hypodermic. In a recent case with a tendency, to vomit, the lactate of calcium was first given by rectum. After two doses it was not retained. Lactate of calcium, 15 grains (i.o), was then dissolved in 6 ounces (185 c.c.) of water and dram doses of this given every half hour, with similar doses of 5 per cent, gelatin solution, i dram (4.0) each. The result was most successful. The lactate of calcium may also be given by proctoclysis 60 grains in one quart of water rate 60 drops to the minute. This is par- ticularly valuable if there is vomiting. Nourishment can be administered at the same time. Olive oil, i ounce (30.0), in which bismuth subnitrate, i dram (4.0), is suspended, may aid in coating the bleeding surface. With a persistent hemorrhage, surgical procedure may be indicated, and it is certainly called for in persistent recurrent hemorrhages. For collapse, rectal normal saline enemata at i2oF., a pint to a quart, proctoclysis, or hypodermoclysis are indicated. Rarely saline or mediate infusion may be required. In one case the writer needled a superficial vein and injected saline solution by this method. Camphorated oil, 5 grains (0.3) camphor in 20 drops of almond oil, repeated every hour for several doses, and strychnin sulphate, > to Ko grain every three hours, may be required. During the stage of collapse rectal feeding is indicated. White of egg and gelatin solution (cold) may be given by mouth. They take up free acid and the latter tends to check hemorrhage. Diet. Unless collapse be present, the author's modification of the Lenhartz method of diet the writer believes most efficacious, to be begun directly after hemorrhage, if it has occurred. This relieves best the hunger pain and takes up the free HC1. The patient should remain in bed and the general method of treatment followed as with gastric ulcer. Hyperchlorhydria if present should be treated, and it is advisable, even if the HC1 be less than normal but in fair amount, to administer an alkali, such as milk of magnesia, magnesia usta or soda bicarbonate, since the patient complains of acidity and evidently there is some irritant action from the acid. Iron and arsenic should be given for the anemia caused by hemorrhage. The bismuth treatment should be followed out, with which the silver nitrate may be alternated, as in gastric ulcer. The medical treatment should be tried for the first, or even second, attack. I have given one patient recently the benefit of the doubt. He had a duodenal ulcer with two hemorrhages a year apart. I advised medical treatment for the present with careful watching, and a resort to surgery if furthur hemorrhage ensued. An acute attack with marked hyper chlorhydria, as in the similar type of acute gastric ulcer, seems most amenable to medical treatment unless there be dangerous hemorrhage, or perforation. Surgery. With the above exception, when a series of attacks have occurred, surgical procedure is indicated, as in no other way can the 4 8 754 DISEASES OF THE STOMACH AND INTESTINES chronic ulcer be cured. The type of operation depends on the conditions found, and the methods are as follows: 1. Excision of the ulcer. Simple excision. Finney's operation. Excision should be practised when the ulcer is small and the gut is not narrowed by the operation. 2. Gastro-enterostomy. Infolding the ulcer, so as to narrow the lumen of the gw^and prevent the exit of food through the pylorus, should be carried out at the same time. If obstruction is already present from contraction of the ulcer, then infolding is unnecessary. 3. Resection of the duodenum with or without the pyloric portion of the stomach. 4. Resection and end-to-end anastomosis, the pylorus being left intact. Posterior gastrojejunostomy is the best operation. Anterior gastro- enterostomy, Roux's operation, or Moynihan's modification may be required. Stenosis with Motor Disturbances and Dilatation of the Stomach. Stenosis of the duodenum near the pylorus or at the pylorus, from con- traction and connective-tissue formation from an ulcer, produces dila- tation of the stomach with marked disturbance in motility, vomiting, peristaltic unrest, etc. All cases of organic stricture are surgical and gastro-enterostomy is indicated under such conditions. Acute and subacute perforation require immediate operation. With chronic perforation (periduodenal abscess), whether localized or whether it has burrowed, the abscess should be freely opened. These patients often remain with a duodenal fistula and die from inanition, unless further surgical procedure is undertaken. Gastro-enterostomy in such event is indicated and with it an infolding at the pylorus 1 or of the stomach in front of the pylorus, so that food is thus compelled to pass through the new opening and can no longer escape through the duodenal fistula. Adhesions and obstructive jaundice require operation. If the patient have recurrent large hemorrhages and be apparently bleeding to death, operation is at once indicated. Intestinal Ulcers from Cutaneous Burns Ulcers from extensive burns (cutaneous) generally occur in the upper transverse duodenum, seldom lower down. Rarely an ulcer may occur in the stomach or other part of the intestines. There may be a single ulcer or five or six of them. There is considerable loss of tissue in some cases, in others erosions, and at times inflammation of the mucous membrane. The shape of the ulcer is irregular and dentate or long and narrow. The course is very acute, the result generally fatal; hemorrhage or perforation occurring within one to two weeks after the burn or even within two to three days. The condition is probably due to septic embolism. Operate if there is perforation. In mild cases the treatment is that of duodenal ulcer. Intestinal hemorrhage and local tenderness are the salient symptoms. 1 Division at the pylorus and suture of the stomach and duodenum with gastro- enterostomy may be substituted. SIMPLE DUODENAL ULCER 755 Embolic and Thrombitic Ulcers Parenski 1 first described this condition. These ulcers originate from emboli, which are carried into the small branches of the mesenteric arteries from an endocarditis or atheromatous degeneration of the aorta, from an abscess focus or foci, or from thrombosis, as a result of endarteritis. They occur in the jejunum, ileum, colon, and also in the duodenum. If the embolus is aseptic, infarction with hemorrhagic infiltration occurs and necrosis results, with the pro- duction of an ulcer. The ulcers, as a rule, are small, circular, or irregular in outline. Occasionally the whole thickness of the intestines may be- come involved, so that peritonitis of a fibrinous or purulent type occurs, or at times perforation. These ulcers occur in the area of distribution of the occluded vessels. Infarction of the spleen and kid- neys may be present. If the emboli are septic, numerous small abscesses are seen in the submucosa, which may break down and form ulcers. These conditions may result from sepsis, acute appendicitis, etc. Hem- orrhage may occur as a result. In Fig. 313. A, Ulcer of duodenum secondary to appendicitis; B, primary diseased appendix. Fig. 313 is shown such a case, the duodenal ulcer resulting from acute appendicitis. Small nodules (miliary abscesses), consisting of round cells surrounding a blood-vessel, are at times found postmortem in fatal cases, not yet having broken down into ulcers. Colicky pains, tenderness, diarrhea with blood and pus, occurring in cases in whom embolic processes can be discsovered in other organs, or when a cause for emboli can be found, render the diagnosis of embolic ulcer probable. 1 Wiener med. Jahrbiicher, 1876, Heft. 3. 75 6 DISEASES OF THE BLOOD-VESSELS become extreme mucous, watery, and at last bloody or an intestinal hemorrhage may occur at the commencement, with dark-brown or tarry stools, which at times may have a fetid odor. The blood may not always be voided, but retained, and the patient may have the symptoms of hemorrhage collapse, cold extremities, rapid and feeble heart, and subnormal temperature. In the other type of cases the patient may have signs of acute in- testinal obstruction; a history of constipation for some days; distended and painful abdomen; vomiting, at times feculent; severe abdominal pains; collapse and peritonitis. The attack is clearly due to intestinal paralysis. Sprengel groups the cases according to their pathological causes: First, hemorrhagic infarct; second, anemic gangrene. Under the first group, one would expect: Bloody ejections per rectum or os; serohemor- rhagic exudate in the peritoneal cavity; thickening of the intestinal wall, due in part to hemorrhage; gradual paralysis of the intestine; late peri- tonitis, local or diffuse. Under the second group (anemic gangrene): Early paralysis of the intestinal walls from local necrosis, early obstruction (early distention of abdomen, following distention of afferent gut) ; early peritonitis, diffuse or local, depending also on the occurrence of early or late perforation; inflammatory exudate in the peritoneal cavity; all these symptoms can also be met with in acute invagination and in other forms of acute obstruction. Diagnosis. The following may be of service: An intestinal hemor- rhage from no apparent cause : colicky pains of great severity, tympanites and tenderness; evidences of effusion into the peritoneal cavity; the discovery of simultaneous embolism in other vessels or of an endocarditis. In many cases, however, the salient symptoms are not all present; and in the type simulating obstruction the true cause cannot be determined. Prognosis. This is generally fatal in occlusion of the superior mes- enteric artery. In rare instances recovery may be possible. Treatment will be described at the end of the chapter. Embolism and Thrombosis of the Inferior Mesenteric Artery. In 83 cases of Gerhardt, in only five instances was the inferior mesen- teric artery obstructed; in four cases by emboli and in one by thrombosis; and in two of these the superior mesenteric artery was also obstructed. This condition is rare. Symptoms. The chief symptoms are pain, tenesmus, and bloody stools. Gerhardt states that the blood is bright red and that in ob- struction of the superior vessel it is darker, but I believe it generally dark unless from lower sigmoid or rectum. The descending colon, sig- moid, and rectum, or parts of these are affected, the mucosa becoming red, succulent, and containing effusions of blood. The mucous membrane may be loose and detached in places and hemorrhagic. There are not the serious lesions, as a rule, as in occlusion of the superior mesenteric artery. The artery (inferior mesenteric) is not an end artery functionally, and the circulation is generally re-established. Rarely there may be infarction or gangrene with perforation. SIMPLE DUODENAL ULCER 757 may also be a cause. The meat of tuberculous cattle probably plays a lesser role, as it is generally thoroughly cooked. There is no reason why other raw food products may not be occasionally a source of infec- tion, especially if exposed to infection by flies or sources of contamination. In adults primary intestinal tuberculosis is rare (in the Munich Pathologic Institute i in 1000 cases). The lower ileum is usually first involved and then the rest of the small intestine and colon. Symptoms. The condition may begin with irregular diarrhea, slight fever, and colicky pains. Rarely, hemorrhage may be the first symp- tom. At first the symptoms may simulate a chronic catarrh. Until subsequent emaciation becomes marked or an involvement of the lungs occurs, the condition may not be suspected. The stools in every doubtful case should be examined for Koch's tubercle bacillus, which is diagnostic. The tuberculin test, by injection or by the ocular method, should be made. A deceptive condition is when the ulceration begins in the cecum, and there are symptoms suggestive of appendicitis, with tenderness in the right iliac fossa, constipation, or irregular diarrhea. Osier reports, in his primary cases of intestinal tuberculosis, occasional fatal hemorrhage or perforation, with the formation of pericecal abscess or perforative peri- tonitis, or, rarely, partial healing, with great thickening of the intestinal walls and narrowing of the canal (chronic hyperplastic tuberculosis). Secondary Tubercular Ulcers of the Intestines (Tuberculosis) These are very common in chronic pulmonary tuberculosis. Frerichs 1 found tuberculosis of the ileum in 80 per cent, of these cases. In 566 of 1000 Munich autopsies secondary tuberculosis was found in the ileum, cecum, or colon, and in all but three the lungs were in- volved. Swallowing tuberculous sputum is the cause. The lowest part of the ileum is the chief point of infection with ulcers. It often extends to the cecum, colon, or rectum, and upward to the jejunum or even duodenum. Tuberculous ulceration has even occurred in the stomach. At times tuberculous ulcers develop primarily in the colon. The development of the tuberculous ulcer is preceded by the formation of a miliary tubercle. It usually begins in the solitary or agminated follicles. Caseation and necrosis of the tubercle lead to ulcera- tion. In Peyer's patches only isolated follicles are at first involved, while in typhoid and intestinal catarrh they are uniformly affected. Ulcera- tion at first occurs in certain points of the plaque, but later it becomes entirely involved, and the ulcer, therefore, may be ovoid. This occurs in^the ileum. In the jejunum and colon they may be round, but usually lie transverse to the long axis. The chief characteristics of the tuberculous ulcer are as follows: It is irregular in shape, more rarely ovoid, and generally extends along the transverse axis (girdle ulcer) ; the. margin is a light red color; the edges and base are infiltrated and often caseous. The submucous and muscular coat are usually involved, and on the serosa are miliary tubercles or a 1 Beitrage zur Lehre von der Tuberculose, Marburg, 1882. 758 DISEASES OF THE STOMACH AND INTESTINES marked tubercular lymphangitis. The serosa is reddened and thick- ened, covered with layers of fibrin, and is often adherent to the mesentery, or other loops of the intestines. As compared with the great frequency and number of tuberculous ulcers, perforation is, therefore, not frequent. There may be stenosis from cicatrization of the ulcers and this may be multiple. They do not, as a rule, show much tendency to heal. Swelling and tuberculous infection of the mesenteric glands are often present. Secondary infection of the intestines from the peritoneum may produce tuberculous ulceration. The affection may be primarily in the peri- toneum, or extend from the Fallopian tubes or mesenteric glands. The intestinal coils may mat together, containing caseous, suppurating foci. There may be the peculiar localized form of tuberculous tumor from a chronic hyperplastic tuberculosis occurring in the ileocecal region, to which I have already referred. It may simulate a new growth and cause constriction of the lumen of the bowel. There may be a chronic hyperplastic tuberculosis of the intestines with thickening of the gut. There is no definite tumor to be felt, but the in- duration in the right iliac fossa, when it occurs there, is similar to a re- curring appendicitis. It may attack other parts of the intestines. Tuberculosis of the rectum may occur, with fistula in ano. Tubercle bacilli in the stools are diagnostic of these conditions when found; otherwise they are difficult of diagnosis unless by operation. The symptoms and treatment of tuberculous ulcer (tuberculosis) of the intestines will be described at the end of this chapter. Catarrhal and Follicular Ulcers These types of ulcer occur in the course of catarrhal inflammation of the intestinal mucous membrane, and are described in that chapter. Ulcerative Colitis This special form of ulceration of the colon was first described by Hale White, colitis occurring especially in institutions and insane asylums. Probably the greater percentage of these so-called cases of colitis', such as occur in institutions, are true dysentery. Vedder and Duval, 1 while working under Flexner, found that in- stitutional outbreaks were due to Bacillus dysenterise. Osier and the late J. P. Tuttle differ in this regard and classify it as non-dysenteric. The symptoms and treatment are of dysentery. Stercoral or Decubital Ulcers These ulcers are produced by the pressure of hardened and stagnating feces on the mucous membrane, resulting in necrosis and purulent in- flammation. They develop particularly in the cecum, flexure of the colon (hepatic and splenic), sigmoid flexure, and the rectum, where stasis is most apt to occur. Fecal concretion in the appendix is fairly common and may produce ulcer and appendicitis. They sometimes develop in chronic intestinal stenosis above the seat of stricture. 1 Journal Exp. Med., Feb. 5, 1902, vol. vi. SIMPLE DUODENAL ULCER 759 Ulcers in Acute Infectious Diseases Under this group are the specific ulcers of typhoid and dysentery; diphtheritic ulceration; ulcers of sepsis; rarely duodenal ulceration in erysipelas; in varioloid; ulcer of the duodenum in pneumonia, a rare oc- currence. In acute pemphigus and in pellagra isolated cases have been reported, also in purpura. Ulcers in Constitutional Diseases In acute leukemia, lymphatic tumors may occur in the intestines, especially in the ileum, and break down, with the production of ulcers. This is rare in the chronic type. Intestinal ulceration has occurred in scurvy and a few , ^ isolated cases are reported in gout. / -^ - Toxic Ulcers Intestinal ulcers occur in nephritis, with uremic symptoms associated with the intes- tinal catarrh. They lie chiefly in the large intestine. They may occur in the duodenum (Fig. 314). In poisoning with mercury they are also found, even when it is not administered by mouth or rectum, but by inunction. Changes in the blood have been held responsible for these conditions. With nephritis, the intestinal catarrh is probably a factor. It is believed by many that the mercury reaches the intestines by excretion in the bile, and produces direct inflamma- tion with resultant ulcer, in which decom- position or intestinal bacteria play a part, since we find in some cases a pseudodiph- Fig 3I4 ._ Uremic ulceration of theritic membrane. the duodenum (Gaultier). Syphilitic, Gonorrheal and Cancerous Ulcers Syphilitic ulceration of the intestines is rather rare. In the small intestine it may be found in a young infant with inherited syphilis. Ulcers originate in the lymphatics or in the mucosa or submucosa, from a gumma which gradually breaks down. A few cases of syphilitic ulcer of the small intestine in an adult have been reported by Klebs, Osier, and Birch- Hirschfield. These ulcers are rarely encountered in the large intestine, except in the rectum in its lowest part. Primary chancre of the rectum has been observed. If feasible, the test for the Wassermann reaction should be made to confirm the diagnosis. The physical examination and history of the case are important. 760 DISEASES OF THE STOMACH AND INTESTINES Condylomata and gummata may break down, and by cicatrization give rise to stricture of the rectum. Virchow notes that syphilitic ulcers are of slight depth and have a smooth base. They are more frequent among women than men. Polchen 1 found 190 cases of stricture among women out of 219 cases, but believes that many of these result from ulcerations caused by gonor- rheal infection, from abscess of the Bartholin glands, or from fecal pressure (decubital ulcer), or local traumatism from the syringe-tip. Ulcers from gonorrhea, traumatism, and hemorrhoids occur in the rectum and are referred to under Proctitis. Ulceration of intestinal carcinoma may occur, or metastatic nodules may break down and ulcerate. Intestinal Myiasis A case of fatal ulceration of the colon due to maggots has been reported. 2 General Symptoms of Intestinal Ulceration Our readers must take into consideration the special types of ulcer, their etiology, and the history of the case in making the diagnosis. In some cases this is quite difficult, as the symptoms are not constant. The salient diagnostic points of intestinal ulcer are as follows: 1. The appearance of pus in the stool. This is frequently in small quantity and in the form of minute grayish-white lumps, which appear under the microscope as closely aggregated masses of pus-cells, and are especially important. At times the pus is only microscopic. 2. Necrotic pieces of the intestinal mucosa, such as shreds of tissue from the intestinal wall, which must be differentiated from membranous or shred-like particles of food, occur in some cases. 3. The appearance more or less frequently of blood in the stool, unchanged and in large amount as pure blood, or changed, coffee-ground, or occult blood. In some cases blood is only shown under the microscope, or by hematin crystals, or by Weber's or the benzidin test. Gastric ulcer and vicarious hemorrhage such as from hemorrhoids, etc., must be excluded. 4. The constant appearance of tubercle bacilli in the stools in connec- tion with diarrhea and increasing emaciation are diagnostic of tuberculous ulceration; also the tuberculin reaction. 5. Persistent diarrhea (with local tenderness) and pain of a greater or lesser degree over a definite region of the abdomen, extending over a considerable period of time, associated with the presence of pus and blood in the dejecta. 6. Tenesmus, with pus and blood in the stool, suggests ulcer, probably in the rectum, and visual examination makes the diagnosis. The presence of mucus is not diagnostic of ulcer. Diarrhea. This is present in a large number of cases. It is de- pendent on the site of the lesions; ulcerations of the small intestine, cecum, or ascending colon probably do not produce diarrhea unless there is a 1 Virchow's Archiv., Bd. 127. 2 Schlessinger, Wiener klin. Wochens., January 9, 1901. SIMPLE DUODENAL ULCER 761 complicating catarrh, amyloid degeneration, or some special infection like typhoid fever. Even in the latter we have constipated cases. Ulcers of the lower colon and rectum usually produce diarrhea, but even here it may occasionally be absent. Blood. Pure blood may be passed in large amounts in simple duodenal ulcer, in ulceration from burns, and in typhoid. Large hemorrhages at times occur from dysenteric ulcers. The hemorrhages from catarrhal and tuberculous ulcers are, as a rule, not as large. The blood may be bright red or dark, or of coffee-ground color, or may be only determined microscopically as blood-corpuscles orhematin crystals, or by tests for occult blood. Intestinal ulcer may be present without hemorrhage, and other condi- tions may produce intestinal hemorrhage, such as liver cirrhosis, etc. Repeated examinations, however, will generally show occult blood. Pus is diagnostic of intestinal ulcer. It is also found in connection with ulceration accompanying neoplasms of the intestines, and in ab- scesses which open into the intestines. It is generally in small amounts. Occasionally no pus is found, as in the case of duodenal ulcer; or the ulcer may be single and high up, so that the pus will disappear. If small grayish-white specks are discovered in the stool, and under micro- scopic examination they are found to be pus, the diagnosis of ulcer is established. Pus is often only found by the microscope. Mucus found mixed with the intestinal contents is the result of asso- ciated intestinal catarrh. We can draw some conclusion from the relative amount of pus, blood, and mucus. Mucus is never diagnostic of ulcer. Pure pus is also found in a diphtheritic process of the bowel or from perforating abscess. Blood, pus, and mucus occur in dysentery and in carcinoma of the lower colon or rectum. Shreds of Tissue. They consist of mucous membrane and are differentiated from particles derived from food; they occur most fre- quently in dysenteric ulcer and not, as a rule, in the slower type, as in tuberculosis; or in the more rapid, as in typhoid. Tubercle Bacilli. Generally are diagnostic of tuberculous ulcer, in connection with the other symptoms. Rarely sputum may be swal- lowed and pass through without infection. Absence of bacilli does not always prove absence of tuberculous process. The injection of tuberculin or the ocular test (conjunctival) aid diagnosis in the doubtful cases. Pain. This is occasionally absent. If pain exists in a circumscribed spot for a long time and is increased on pressure, it is probably due to ulcer. It may at times be caused by local peritonitis. Ulcers of the rectum produce tenesmus, which is quite characteristic. Rectal examination should always be made. Fever is present in the tuberculous type, dysentery, etc., but not in all types of ulcer, being dependent on the etiologic cause. General Nutrition. This may not be disturbed by a few small ulcers, but marked ulceration, especially of the tuberculous type, leads to great emaciation, as the intestinal contents are rapidly propelled and also normal absorption is interfered with. 762 DISEASES OF THE STOMACH AND INTESTINES Perforation with general peritonitis, local peritonitis, or encapsulated abscess may occur. Stricture may result from ulcers; also pancreatitis. Prognosis. The prognosis depends on the etiology. Treatment Hemorrhage should be treated as when from duodenal ulcer. The primary cause should receive appropriate treatment; in uremic ulcers, the nephritis; in syphilitic ulcers, by hypodermics of bichlorid of mercury; mercurial inunction; protiodid, bichlorid, and iodid of potassium, or "606" or neosalvarsan. Heat or cold can be applied for the pain and rest in bed for the severe cases. In tuberculous ulceration, out-of-door life and change of climate are important. Beechwood creosote, 2 minims (0.118) t.i.d., guai- acol carbonate, carbonate of creosote, and creosal (tannosal) are useful. Average doses of these remedies are 10 grains (0.6) t.i.d. Diet is important; it should be non-irritating and chiefly liquid, such as milk, koumiss, matzoon, bacillac, kefir, fermillac, lactone-butter- milk, raw eggs beaten in milk; soft-boiled eggs, broths, barley and rice gruel, chicken soup, mushes, etc. Fats, such as butter, emulsion of mixed fats (Russell's), cream, etc., are of value. Some cases can take sweetbread, scraped beef, calves' brains, cocoa, tea or weak coffee, milk toast, rice, mashed or baked or boiled potato, etc. Somatose and malt-tropon can be given in broths or soups. Compound tincture of catechu, chalk mixture, opium, etc., are useful for severe diarrhea. The following are excellent : R. Camph. tinct. opii \ f f \ T.. _., ... r ai 5ss (16.0); Bismuth subnit. } Mist, cretae 5 ij (60.0) ; Aq. destil q. s. 5iv (ras.o). M. Sig. Shake. Dose, 5ij (8.0), every three hours. 1$. Tr. opii mx (0.59); Mist, cretae 5 j U-o) ; Comp. tinct. catechu q. s. 3ij (8.0). M. Sig. Dose, oij (8.0). Administer every three hours. Bismuth subnitrate, 15 to 30 grains (1.0-2.0), three or four times a day, or bismuth subcarbonate or bismuth salicylate, 10 to 15 grains (0.6-1.0), may be substituted. Avoid opiates as much as possible. Tannigen, bismuth, subgallate, tannalbin, and tannocol are useful in average doses of 10 to 15 grains (0.6-1.3) three or four times a day. High injections of silver nitrate, i 13000; thymol, i :2ooo; salicylic acid, i : 500; boric acid, i : 500; tannic acid, i : 1000; and protargol or argyrol, i : 1000, are of service in rectal and colonic ulcers. Carbolic acid should not be used, and bichlorid of mercury (i : 10,000) by recurrent irrigation only in typhoid in the diphtheritic form of colitis. Special local treatment is necessary for proctitis, as already described. DISEASES OF THE BLOOD-VESSELS 763 DISEASES OF THE BLOOD-VESSELS ; EMBOLISM AND THROMBOSIS OF THE MESENTERIC ARTERIES AND VEINS (INFARCTION OF THE BOWEL) Embolism and thrombosis of the mesenteric arteries are comparatively rare affections. When the mesenteric vessels are blocked by emboli or thrombi, infarction follows in the territory supplied by the vessel, which may continue on to gangrene or perforation and peritonitis. If only a few small vessels are occluded there may be few if any symptoms, and the circulation may be re-established. Welch 1 states that about 70 cases of embolism or thrombosis of the mesenteric arteries have been published, while Gallavardin 2 has collected 83 cases, of which 63 were of embolism. As the clinical symptoms of obstruction of the mesenteric arteries and veins can scarcely be differentiated during life, the symptoms being much the same, and since careful study of their etiology may aid in diagnosis, it is advisable to describe them together. Including both arterial and venous mesenteric obstruction, Jackson, Porter, and Quimby have studied about 30 cases in Boston, and have collected 214 cases in all. Etiology. Embolism and Thrombosis of the Mesenteric Arteries. In a majority of cases occlusion is due to embolism and rarely to thrombosis. The chief source of the emboli are traceable to endocarditis (valvular lesions) or atheroma of the aorta, or rarely from a pulmonary thrombosis or aneurysm of the aorta. Thrombosis. Local changes in the vessels, as endarteritis (described by Litten), syphilitic endarteritis, injury and pressure from calcareous glands, have been given as causes. Rolleston refers to periarteritis nodosa, a rare condition in man, with the production of multiple aneurysms which produces pain, colic, and diarrhea with ulceration. The superior mesenteric artery is more often affected. Verminous aneurysms cause infarctions in the horse. Etiology of Thrombosis of the Mesenteric Veins or the Portal Vein. Welch 3 has collected 32 cases, and has demonstrated that the superior mesenteric vein is more often affected than the inferior mesenteric. Among the causes are pressure on the portal vein, as in cirrhosis or cancer of the liver; neoplasms of the abdomen; chronic peritonitis, with forma- tion of constricting tissue; local pressure or incarceration of the intestines; suppurative inflammation of the portal system as a result of infection, as in appendicitis, intestinal ulcer, or dysentery. Traumatism may produce inflammation and thrombosis. May land 4 shows that it may occur after operation; from tuberculous peritonitis or diseased mesenteric glands. Hemorrhagic infarction of the intestines, as a rule, occurs with venous thrombosis, and the general symptoms are the same as due to arterial occlusion; hence, the comparative study of the etiology of these differ- ent conditions is important for diagnosis. We would note that in a few rare instances Welch and Rolleston have reported exceptional conditions; the former, that acute portal 1 Allbutt's System of Medicine, 1894, vol. ii; also vol. iv. 2 Gaz. des H6p., Paris, 1901, p. 929. 3 Allbutt's System of Med., vol. v. 4 Brit. Med. Jour., 1901, vol. ii. 764 DISEASES OF THE STOMACH AND INTESTINES obstruction has caused hemorrhagic infarction of the intestines, without thrombosis of the mesenteric vein; and the latter, thrombosis of both veins without infarction. 1 Elliot, Sprengel, and Berg have described cases, and H. Fisher 2 reports two cases that are of interest. Pathology of Occlusion to the Superior Mesenteric Artery. The changes resulting from occlusion of this vessel or its branches are hemor- rhagic infarcts and peritonitis. If only small branches are occluded, the results are embolic or thrombotic ulcers of the intestines, to which article I refer my readers. The transverse duodenum, ileum, jejunum, caput coli, ascending and transverse colon are supplied by this vessel and lesions of the intestines occur in that portion of the bowel supplied by the occluded branch or branches. It usually involves a continuous segment of the gut, quite frequently in the lower jejunum and ileum; but if smaller vessels or branches are occluded, there may be lesions scattered in several places over the bowel, with healthy segments between them. The superior mesenteric artery has such long and small branches that it acts functionally, like a terminal artery, so sufficient blood cannot be supplied to the intestines if it or one of its branches be occluded. Welch and Mall 3 have demonstrated experimentally that if a branch be occluded, the blood which produces the hemorrhagic infarction is derived from anastomosing arteries and not from regurgitation from the portal vessels, as was formerly supposed. The following are the clinical appearances in the intestines: Arteries, empty, except at obstruction. There are venous hyperemia; edema and necrosis; hemorrhages in the mucous membrane and mesentery. The mucosa is a dark red and finally becomes necrotic, of a brownish- green appearance. The intestinal canal contains extra vasated blood, either fresh or tarry looking. Necrosis of the intestines is present. The serous coat is inflamed, not only in the affected area but also over the healthy intestines, and the coils may become adherent and be covered with fibrin. There may be a blood-stained or purulent exudate in the peritoneal cavity. Occasionally gas may be present in the cavity, due to the Bacillus aerogenes capsulatus or to emphysema of the mucosa. Clinical Symptoms. Kussmaul and Gerhardt 4 first clearly described these some years ago. There are two types, the most frequent characterized by hemor- rhage from the intestines; the second, simulating intestinal obstruction, with or without peritonitis. Usually the onset is sudden, frequently with violent, colicky pains in the region of the umbilicus, which may gradually become diffuse, and at the same time, there is tenderness on pressure over the abdomen. We must remember that in some cases there is an absence of pain. Vomiting may accompany the pain. In some cases there may be blood in the vomitus. Diarrhea may begin shortly after the pain and 1 Rolleston, Trans. Path. Soc., vol. xlii. 2 Archiv of Diag., N. Y., Oct., 1909. s Johns Hopkins Hosp. Reports, vol. i. 4 Wurzburger med. Zeitschr., 1863 and 1864, Bd. iv. and v. DISEASES OF THE STOMACH AND INTESTINES 765 Intestinal ulceration occurring with multiple degenerative neuritis probably belongs to the class of thrombotic ulcers, there being degenera- tive changes (arteritis) influenced by the neuritis (trophic). Fracture of the spine has resulted in intestinal ulceration. Amyloid Ulcers This type of intestinal ulcer is rare, and would only be suspected when associated with amyloid degeneration of other organs, such as of the liver, spleen, in cases suffering from long-continued suppuration, cachexia, tuberculosis, syphilis, rickets, or leukemia. There would be diarrhea, symptoms of ulcer, and deficient absorption from the intestines. Amyloid ulcers may be found in any part of the intestinal tract, though more usually in the small intestine. They are generally multiple and may involve large areas. They are from the size of a pea to large girdle ulcers, nearly circumscribing the bowel. Leube believes the ulcers originate from circulatory disturbances due to amyloid degeneration of the walls of the small arteries. The vessels of the mucous membrane are first affected, but the process may involve the entire coat of the bowel. The ulcers have no tendency to heal. Other areas of intestines between the ulcers may be in a condition of amyloid degeneration. The mucous membrane is pale and waxy in appearance and some of the villi are missing. On postmortem a weak solution of iodin gives a mahogany-brown color, the test for amyloid degeneration. The addition of sulphuric acid turns it violet or blue. Tubercular Ulcers and Intestinal Tuberculosis Tuberculosis is a quite frequent cause of ulceration of the intestines. The infection may be: (i) Primary in the intestinal mucous membrane; (2) most commonly secondary to diseases of the lungs; and, rarely, (3) secondary to tubercular peritonitis. Primary intestinal tuberculosis occurs most frequently in children, and with it may be associated tuberculosis of the mesenteric glands or tubercular peritonitis. R. Koch believes that bovine tuberculosis differs from human tubercu- losis, and that infection from diseased milk or milk of tuberculous cattle hardly ever occurs, and it is unnecessary to take any precautions. Von Behring takes the opposite view. In the Charite Hospital in Berlin there were only 10 cases in ten years. In 3104 cases of tuberculosis in children, there were 16 of primary infection. There have been investigations recently reported which are suggestive that infection through the intestines is more common than we suppose; notably, Macfayden found tubercle bacilli in the mesenteric glands of 5 out of 20 children postmortem, with no tubercular lesions elsewhere; and Ravenel in 8 cases out of 25. Recent consensus of opinion holds that primary intestinal infection occurs through tuberculous milk. Milk from an infected nurse or mother 766 DISEASES OF THE STOMACH AND INTESTINES Thrombosis of the Mesenteric Veins or Portal Vein. This condition is extremely serious. Anatomic Findings. The arteries are distended (thus differing from the superior mesenteric artery obstruction); thrombotic processes are found in the mesenteric vein or its branches or in the portal vein. The intestines show similar conditions to obstruction of the arteries infarc-v tion, necrosis, hemorrhage, peritonitis, etc. Symptoms. The clinical picture may present the same type as in obstruction of the mesenteric arteries colicky pains, tenderness, blood, diarrheal movements, etc. Rarely there may be hematemesis, and occasionally constipation. The etiology, such as appendicitis, diseases of the liver causing pressure on the portal vein, abdominal neoplasms or constricting bands, producing pressure, etc., and the ex- clusion of the causes of embolism, may aid our diagnosis. Treatment. Temporarily employ an ice-bag to the abdomen; stimu- lants, such as strychnin or camphor oil, by hypodermic ; morphin, y grain (0.016), and ernutin, 5 minims (0.296), by hypodermic; gelatin solution, calcium chlorid, or lactate of calcium to check hemorrhage, as described in Dysentery. Immediate resort to laparotomy and resection of the diseased area is indicated, if possible. Cases of recovery after this procedure have been reported. Elliott resected 48 inches of intestines in one case with recovery. Proctoclysis is of value for the sepsis. CHAPTER XXIX NEOPLASMS OF THE INTESTINES MALIGNANT GROWTHS (Synonym. Neoplasmata Maligna Intestini) THOUGH many have claimed that intestinal cancer is a comparatively rare disease, recent statistics show that it has increased in frequency, and is more common than has been generally supposed. Among the malignant tumors met with in the intestines, carcinoma is by far the commonest. Sarcoma and lymphosarcoma are also found and will be described in a separate section. CARCINOMA OF THE INTESTINES Etiology. The cause of intestinal cancer, like that of cancer of other organs, is still unknown. There have been many theories ad- vanced, such as the embryonal origin, parasitic infection, the theory of irritation, etc. The traumatic theory (irritation as the cause), in so far that it might hasten the development of the condition, is afforded a certain amount of plausible support, in view of the fact that the disease occurs most frequently in those parts of the bowels in which the feces are retarded, and hence act as a source of irritation. The points of selection for the development of cancer are the same as those in which the so-called decubi- tal or stercoral ulcers most frequently develop, and we may assume they probably originate from the cicatricial tissue of these ulcers, in some cases at least, or on the base of other ulcers. Billroth has found a carcinoma in the scar of a dysenteric stricture, just as it occurs in the case of carcinoma engrafted on the scar of a stomach ulcer. It will probably eventually be shown to be due to some specific organism in my opinion. Sex. Carcinoma of the intestines appears to be somewhat more common in men than in women. Age. In general this lesion is most common between the fortieth and sixty-fifth year. Contrary to cancer developed in other regions, cancer of the in- testines has been encountered quite frequently before the fortieth year. It has been found even in children; several cases being reported at the ages of eleven to seventeen, and two cases in children of three years of age. Maydl, of Vienna, has calculated from records that one-sixth of all cases of intestinal carcinoma occur between thirty and forty years, and one-seventh before the thirtieth year. It is important to remember that early occurrence is fairly frequent. 767 768 DISEASES OF THE STOMACH AND INTESTINES Situation of the Carcinoma. Cancer of the bowel is rare in the small intestine, occurs quite frequently in the colon, and most commonly in the rectum. From 1882-93, from autopsies in the Vienna General Hospital, Riegel states 5 cases were in the duodenum; 6 in the ileum; none in the jejunum; i in the vermiform appendix; 14 in the cecum; 63 in the colon; 40 in the sigmoid, and 114 rectal cancers. At the same hospital, during twelve years, out of 254 cases of cancer of the intestines, Maydl found in the living that 224 were cancer of the rectum. Bryant, in no autopsies, found carcinoma of the small intestine 6 times; 7 times in the cecum and ileocecal region; 19 times in the transverse colon, including its flexures; 78 times in the sigmoid flexure and rectum. Leichtenstern's data show that 80 per cent, of all intestinal cancers occur in the rectum. Other statistics are given. They all show the preponderance of rectal cancer. Intestinal cancers are almost always primary, and secondary growth by metastasis is extremely rare. It may occur through direct extension by continuity, as a cancer of the pancreas may extend to the intestines. Primary carcinomata of the intestines often give rise to metastases in other organs. These are most frequently found in the lymph-glands, especially in the neighborhood of the neoplasm. Secondary metastases in the liver are quite frequent, no matter where the situation of the carcinoma. The peritoneum, omentum, mesentery, and lungs may be involved, and occasionally the kidneys. Hauser calls attention to certain peculiarities regarding the metastases in different forms of carcinoma of the large intestine. Colloid carcinoma chiefly involves the serous coat and metastases of internal organs are rare. Medullary tumors involve adjacent lymph-glands, while simple and scirrhous carcinomata, even when small, frequently cause carcinoma of the liver. Morbid Anatomy. Several varieties of carcinoma are found in the intestines, most often the cylindric epithelial-celled carcinoma (adeno- carcinoma), starting in the cylindric epithelium of the intestinal glands (follicles of Lieberkiihn). It occurs most frequently in the large intestine, as do medullary carcinoma and colloid cancer. More rarely the scirrhous carcinoma is found. The epitheliomatous chancroid occurs in the lower rectum at the anus, and it may involve the perineum and vagina. In the small intestine the primary proliferation starts from the glands of B runner; in cases developing from cicatrices, proliferation may start from glandular tubules which have grown deep down into the tissue. The growth varies in consistency, depending upon whether connective tissue or cells predominate; if the former, then the tumor presents a hard consistence (scirrhous) ; and if the latter, then it is less firm and occasion- ally soft and succulent. The colloid cancer contains a brown viscid fluid. The scirrhous shows a tendency to ulcerate. The cancer may form a hard annular induration, as in the colon, NEOPLASMS OF THE INTESTINES 769 or a circumscribed nodule or an ulcerating gangrenous, cauliflower growth as in the rectum. The nodule may develop into a single large tumor or several smaller masses; the softer tumors usually grow to larger size. At other times the mass may protrude into the intestines, like a polypus; or may infiltrate a large surface of the bowel, so that it becomes stiff and rigid. In the majority of intestinal carcinomata the surface is ulcerating. The annular form of the growth is most common, tending to involve the circumference of the bowel. It may develop from a small nodule or, more frequently, on the base of an old annular cicatrix, due to former ulceration. Stenosis of the canal is often the result; colloid cancer, however, rarely produces it. Secondary changes develop; the intestines become dilated through stagnating feces and gas, and the walls hypertrophied above the point of stenosis through overexertion to overcome the obstacle. Catarrhal inflammation and stercoral ulcers develop in the dilated portion of the gut and perforation may ultimately occur. Below the stricture the intestinal walls are thinner, and if the stenosis is narrow, the intestines may be empty and contracted. Stenosis of the bowel may be produced by a growth of the cancer into its lumen or by infiltration of the entire wall. Large masses of very hard scybalse often accumulate above the seat of obstruction and are difficult to distinguish from the carcinoma proper, so that on autopsy a small growth may be found which intra vitam was believed to be of large size. When stenosis of the bowel occurs, all the symptoms are present which are described under this condition. Narrowing of the bowel does not always take place. Sometimes the symptoms of stenosis may gradually disappear, being due to ulcera- tion of the neoplasm, so that the canal again becomes patent. As a rule, the tumor tends to grow and fill it up again. The necrotic process often causes more or 1 less hemorrhage, and in rare cases, if a large vessel is eroded, there may be a fatal issue. The canal may become patent by a direct connection becoming established, through ulceration and adhesions, between two loops of the intestines. The muscular and serous coats are frequently involved, and peritoneal adhesions develop which may unite the diseased intestines to other portions of the intestines, or to some adjacent organ, which may con- stitute a serious obstacle to the removal of the growth. Perforation may rarely occur before the formation of adhesions, with resulting general peritonitis, or there may be a circumscribed abscess formed within the adhesions. Marked displacement of the intestines may be caused by the formation of these adhesions. A carcinomatous peritonitis may be produced by extension from the serous layer of the intestines, accompanied by hemorrhagic exudation. Perforation into other organs which have become agglutinated to the bowel can occur; thus a fistulous opening forms between the colon and the stomach or bladder, or vagina or uterus, or between the large and small intestines, or from the bowel through the abdominal wall. 49 770 DISEASES OF THE STOMACH AND INTESTINES The omentum and mesentery may become infiltrated with cancerous masses. A band may be formed by the stiffened omentum, which may cause a knuckling or a twisted bowel. The mesentery may kink and twist the intestines. Symptoms. The symptoms vary, depending on the position of the neoplasm, the rapidity of its growth, and the character of the cancer. There may be symptoms at first of habitual constipation or of hemorrhoids, or of stenosis of the intestines, or of peritonitis, or icterus, or of cachexia of uncertain origin. It seems preferable to first review the general and then the local symptoms, depending upon the position of the tumor, as occurring with 1. Carcinoma of the duodenum. 2. Carcinoma of the small intestine (jejunum and ileum). 3. Carcinoma of the colon (cecum to sigmoid flexure). 4. Carcinoma of the rectum. General Symptoms. There are symptoms common to all cases of carcinoma, of which anemia and cachexia are the most important. As a rule they occur together, though one may develop before the other. In many patients weakness, pallor, and emaciation are the first signs noticed, and arouse the suspicion of a serious disease. There may be only slight local symptoms, moderate constipation, and a sense of weight or discomfort in the abdomen, with loss of appetite, coated tongue, and slight dyspeptic disturbances. There are loss of weight and a peculiar cachectic appearance. On the other hand, the local symptoms may be the more pronounced, or the local and general symptoms may occur together. Quite frequently, especially in those cases of carcinoma which run a rapid course, fever is present. I have seen a number of cases in which it is entirely absent. It probably depends upon an ulcerative condition in the growth and absorption of toxic products. The tumor may cause symptoms in adjacent organs by dragging upon them or constricting them. There may be radiating pains from compression of nerves and also dis- turbances of the circulation, such as edema of the lower extremities. Symptoms of chronic intestinal obstruction are frequently present, but not in all cases. The symptoms may develop gradually, the constipa- tion increasing, or there may be a sudden stoppage, with all the -signs of acute obstruction. The clinical symptoms of cancerous obstruction are similar to those from stenosis of the intestines caused by other processes, and are described in the chapter on that subject. When acute obstruction suddenly occurs during the course of. chronic stenosis a fatal result may ensue within a few days. Fecal retention has been reported in connection with malignant stenosis, lasting even over eighty days, 1 without the presence of fecal vomiting. Diarrhea is fairly frequent in carcinoma of the intestines. It is of assistance in clearing up the commencing obstruction, and in some cases alternates with constipation. In some patients the stools appear as small hard balls, cylindric, like a pencil, or flat and tape-like, as if they had passed a strictured point. 1 Copper-Foster, Med. Times and Gazette, Sept., 1867. NEOPLASMS OF THE INTESTINES 771 These are not always characteristic, as they may appear with nervous conditions. The stools frequently contain pus, blood, and mucus. The pus may be microscopic and the blood occult. The appearance of the first two (pus and blood) is significant. If the growth is ulcerating markedly, the stool has a most offensive odor. In this event particles of tumor may rarely be found in the dejecta, which show under the microscope the nature of the growth. They may be of fair size or very small, so that careful examination of the fecal matter may be necessary in order to find them. Irrigation of the bowel is of assistance if the neoplasm is situated in the large intestine. One of the most important factors in our diagnosis is the detection of the physical signs of a tumor. The growth is from the size of a walnut to that of a child's head. It is often easily palpable, hard, and usually has an uneven nodular surface. A marked peculiarity of this type of tumor is its great mobility under the palpating hand of the examining physician. Even in the cecum and ascending and descending colon the tumor is distinctly movable as a rule. The mass is usually situated in the lower half of the abdomen, most fre- quently in the lower left iliac region, as, unless there are marked adhesions, the intestines are dragged down there by their own weight. If the growth is in the cecum, the right iliac region is involved. I have already referred to the fact that on autopsy the tumor is frequently found to be smaller than it was apparent to palpation, this being due to the thickening of the gut above the stenosis and to the fecal accumulation. Abdominal pain is present, which will be described under Local Symp- toms, and the tumor is at times tender. In some cases simple abdominal palpation is not sufficient, and it may be necessary to examine the patient under an anesthetic. In every case digital examination of the rectum and, if necessary, the passing of a rectal bougie or introduction of a speculum should be employed. In women a vaginal examination should be also made. I strongly deprecate the inser- tion of the entire hand into the rectum under anesthesia, as has been some- times advised. The-# rays are of great value as an aid to diagnosis, the rontgenograph showing the point of stenosis caused by the growth. When the cancer is fully developed we may have peritonitis, either local or general, as a complication. If the peritonitis is of a cancerous nature, a hemorrhagic exudation and the presence of nodules under the abdominal wall will indicate this fact. Acute perf orative peritonitis will be indicated by the usual symptoms of this condition. On the other hand, we may have circumscribed adhesions with the presence of local fecal abscess. Perforation may occur into adjacent adherent organs which will present special symptoms. Among the chief communications are: i. Communication between the colon and stomach. There may be a valvular communication or it may be free. If the direction of the passage is from the stomach into the colon, symptoms of lientery develop un- digested food, such as rice, potatoes, meat, etc. , appear rapidly in the stools. 772 DISEASES OF THE STOMACH AND INTESTINES Diarrhea occurs shortly after the ingestion of food with evacuation of solid contents. If the valvular action is in the opposite direction, feculent vomiting takes place. If the fistulous opening is perfectly free, then lientery and fecal vomiting occur together or may alternate. This com- bination of symptoms is pathognomonic. Lavage, especially if the fluid be colored with methyl ene-blue or carmin, 3 grains (0.194), will demon- strate that the liquid rapidly escapes from the stomach, and is expelled from the bowel without being decolorized or discolored. If the rectum is inflated with air or CO 2 the stomach will be distended with gas, or after injection of i to 2 liters (quarts) of colored fluid into the bowel some can be secured from the stomach by aspiration. 2. Communication between the rectum and bladder. Fecal matter and gas escape into the bladder and are voided through the urethra. Severe septic cystitis results, or the urine may escape from the bladder and be discharged through the stools. A carmine solution injected into the rectum or bladder will demonstrate the condition, and will appear respectively in the urine or feces. 3. Communication between the rectum, uterus, and vagina are also met with, and give rise to the passage of fecal matter through these organs, and also to severe inflammation. Injection of weak carmin solution or methylene-blue into the rectum will demonstrate the communication. 4. Communication between the bowel and abdominal wall. There may be a feculent or fetid discharge, or even of particles of fecal matter, if the communication is with the lower small or large intestines. If the communication is high up, it may be chylous or biliary. This condition appears usually in the last stage of the disease. Injection of carmin red solution through the fistula will appear in the stool. Ulcerative processes (tubercular) may produce similar communication. The urine is not characteristic, shows indican, occasionally acetone and diacetic acid. Albumin is present, frequently casts. Secondary anemia occurs. Leukocytosis is moderate and eosinophiles are increased. Symptoms Due to Position of the Cancer. Cancer of the Duodenum. This is a rare condition. There are the anemia and cachexia and pain usually in the right hypochondriac region; this last occurs in the midepi- gastric region or upper part of abdomen. The tumor, when palpable, is usually found in the right hypochondriac region, near the middle line. If it is in the ascending part of the duodenum, there may be fair mobility; if in the descending or transverse parts, the tumor is only slightly movable. Nearly all the symptoms are referred to the stomach anorexia, pains, belching, vomiting, and dilatation of the stomach and if the mass is in the ascending part of the duodenum, it will hardly be possible to differen- tiate it from gastric tumor without operation. Blood may be mixed with the vomitus. Boas makes use of the terms suprapapillary, infrapapillary, and circum- papillary carcinoma, according to the position of the growth relative to the papilla of Vater. If the carcinoma is suprapapillary, we have stenosis of the upper part of the duodenum, and, as already noted, symptoms identical with pyloric stenosis, from which it can hardly be differentiated. NEOPLASMS OF THE INTESTINES 773 With infrapapillary carcinoma the gastric symptoms again pre- dominate, but there are stasis of bile and pancreatic juice, and regurgita- tion of these secretions into the stomach; bilious vomiting is frequent. The vomiting is intermittent and the symptoms those of obstruction. Trypsin should be tested for in the vomit by observing whether fibrin is digested in an alkaline solution. This would differentiate from a gastrobiliary fistula. Circumpapillary carcinoma. In the pure cases surrounding the papilla of Vater, jaundice, anemia, and cachexia slowly increase in severity, with- out any gastro-intestinal symptoms, and pain is usually absent. Some of Fig. 315-- -Cancer of the region of the papilla of Vater emanating from the common duct (after Letulle). these cases doubtless have their origin in the wall of the ductus communis choledochus as it passes through the wall of the duodenum as in Fig. 315. Chills may at times occur and cholangitis may be a complication. Jaundice may vary in intensity or may be intermittent. When the tumor involves the common bile-duct and head of the pancreas jaundice is pro- gressive and continuous. Ulceration may temporarily open a passage for the bile. Gastric symptoms may occur in addition. The tumor can be palpated deep down in the right hypochondriac region near the middle line. At times it cannot be discovered. Carcinoma of the duodenum is a disease of late middle or advanced life, occurring most often in males. The second part of the duodenum is most frequently involved, and next in frequency the first part. 774 DISEASES OF THE STOMACH AND INTESTINES Carcinoma of the small intestine (jejunum and ileum) is rare. The symptoms vary, depending on the position of the growth; the higher up, the more marked are the gastric symptoms; the lower down, the more severe the intestinal symptoms. There may be anorexia and vomiting, or fair appetite and good stomach digestion, but obstinate constipation. General Symptoms. In -both conditions there are anemia and cachexia, physical depression, indigestion characterized by rumbling belching and a sense of weight; pain, borborygmi attacks of colic and constipation which may alternate with a diarrhea. There is often a feeling of incomplete emptying of the bowels after a movement. There may be mucus, pus or blood in small amount in the stool. There may occasionally be larger hemorrhages from the bowel if the growth is low down. Loss of weight occurs. The clinical symptoms of stenosis of the intestines may be present. The tumor is at times accessible to palpation, and is, as a rule, extremely movable. It may be so much displaced downward that it is difficult to draw an accurate conclusion. Local Symptoms of Carcinoma of the Large Intestine. Cachexia and anemia are present. Pain is a frequent symptom; it may not be present at first, usually appears later in the disease, and becomes local- ized; in some cases, running an acute course, no pain appears until the symptoms of acute obstruction begin. Pain is usually localized; it may appear near or at the region of the growth, or occasionally directly opposite, in the abdomen. The pain may not be severe, but may be more a sense of discomfort. There may be neuralgia of the sciatic or anterior crural nerves. Later pain usually becomes localized, and is increased on pressure, even if the tumor cannot be palpated. It may be due to local peritonitis near the tumor. Attacks of colic often occur, local or diffuse. The pains may be quite severe, are accompanied with constipation, and are relieved by diarrhea or by the passage of flatus. These attacks of colic are frequently caused by the commencing obstruction, and show gradually progressive stenosis. Peristaltic and tetanic movements of the intestines are often associated. Complete obstruction may suddenly develop, or there may be a gradually progressive stenosis with its symptoms. Constipation is one of the marked symptoms; in some cases it may be first, and becomes gradually progressive. Ten to twenty or even eighty-eight days have passed, according to various observers, before the bowels moved spontaneously or by artificial means. These were, of course, extreme cases. The majority of patients have symptoms of commencing or complete obstruction after coprostasis has lasted a week or ten days. This has been my experience in consulta- tion practice. Recently I saw a case for the first time on the fourth day of coprostasis when acute symptoms were present. Loss of appetite, tension, fulness in the abdomen, and pain accompany the constipation. Spontaneous diarrhea may relieve the condition. If this does not occur, or relief is not afforded artificially, gradual occlusion will take place with its typic symptoms. NEOPLASMS OF THE INTESTINES 775 In some patients diarrheal movements may occur for several weeks, due to the catarrhal condition of the bowel or ulceration of the growth. Stools. In some cases of carcinoma the stools may be normal and simply hard in character when constipation is present. In others they may be in small balls like sheep's dung, flattened, or ribbon shaped. Mucus shows the presence of catarrh of the mucous membrane. The presence of pus in the stools is of importance, but only appears when the growth ulcerates; hence its absence does not prove there is no tumor. Microscopic examination for pus is indicated. Pus in some cases may be derived from an abscess cavity opening into the intestines. The same remarks hold true of blood, the amount found is usually small, and violent hemorrhages are rare; at times only occult blood can be determined. The appearance of pus and blood in the stool in a patient with symptoms of stenosis of the bowel favors the diagnosis of malignancy. Occult blood should be tested for if none is visible. If there is gangrenous disintegration of the tumor, the odor is very characteristic, and occasionally small bits of new growth may be found in the stool. Tumor. The presence of palpable tumor strengthens the diagnosis. It may be no larger than a nut, or the size of a child's head, and be solid and hard like cartilage. If there is much infiltration, it may give the sen- sation of a solid and thick cord. These tumors are generally moderately tender on pressure, in some cases quite so; occasionally they are not tender at all. Their great mobility is characteristic. On palpation they are easily moved about, especially in the sigmoid and transverse colon; fecal accumu- lation readily displaces the tumor and it may become adherent in an ab- normal position. Occasionally peristaltic movements may cause it to appear and disappear during palpation. Respiratory mobility of the tumor also may occur if it be in the transverse colon, or if it be adherent to the liver, spleen, or stomach. Large amounts of fecal material may accumulate above the growth, and we must clear this material out by irrigation and laxatives, so as to determine the extent of the tumor. The region of the liver must be ex- amined for metastases and the rectum palpated to see if the primary growth lies there. A pure fecal tumor may lead to narrowing and occlusion. These last tumors are more doughy, less firm, and quite frequently multiple. Differential Diagnosis. We must remember that old, agglutinated masses from recurrent appendicitis may simulate cecal tumor. The his- tory is an aid. Moreover, tumor-like tuberculosis of the cecum may simu- late malignant growth. In these cases there may be pulmonary tuberculo- sis, a previous history of diarrhea, or the presence of tubercle bacilli in the stools. Some cases cannot be differentiated. The tuberculin test aids diagnosis. Leube called to our attention that chronic inflammation of the sigmoid may occur and be mistaken for carcinoma. Undoubtedly these cases are 776 DISEASES OF THE STOMACH AND INTESTINES so-called peridiverticulitis, with chronic thickening, and often stenosis of the sigmoid simulating carcinoma. These patients are generally over sixty years of age, fat and flabby, or they have been fat previous to emacia- tion. There is often a history of acute left-sided inflammation and gen- erally of prolonged constipation. One must remember the possibility of this condition. Blood and pus, as a rule, are absent from the stools in these patients. Often it is impossible to differentiate these conditions, even after resection, except by the microscope. Cachexia and anemia are always present in cancer. Primary Carcinoma of the Appendix. This condition has been con- sidered rare, but it has been demonstrated to occur more frequently than was formerly supposed. (See Appendicitis.) Most of the cases give symptoms of relapsing appendicitis or appendicitis; 53 per cent, are under thirty years, and 24 per cent, under twenty. This condition has only been detected after operation on the appendix. The carcinoma is sphe- roidal celled. Carcinoma of the Rectum. This is the most frequent type of cancer, is more readily diagnosed, and more amenable to treatment if early opera- tion is performed. Many of the tumors are within reach of the finger. The symptoms resemble those of carcinoma of the colon, though there are certain signs peculiar to this condition. Rectal examination should always be made. Pain is more pronounced in rectal carcinoma, both local and radiating to the sacrum, back, bladder, genitals, and to the sciatic nerve; there is often a desire to urinate. The pain is usually worse during defecation if the growth is low down, and it may even be agonizing in character, so much so that the patients try to retain the bowel contents as long as possible. Marked tenesmus is present, and if ulceration, mucus, blood, and pus are evacuated. Constipation is usually present. The higher up in the rectum, the more the symptoms resemble those of cancer of the sigmoid. Tenesmus may be absent if the growth is high up. Diarrhea may at times supervene; occasionally, after sloughing of the tumor, paralysis of the sphincter occurs. Leube was the first to call attention to the fact that hemorrhoids fre- quently developed with carcinoma of the rectum, and that, too, at an early stage. Piles occurring suddenly, and not developing slowly or existing for many years, are suggestive. Rectal examination is most important, and the finger will usually give the necessary information. One can feel a mass lying directly beneath the mucous membrane or adherent to it. The surface may feel uneven and hard or there may be occasionally a cauliflower or mushroom growth, or a constriction, through which the finger cannot readily pass. If it be barely possible to feel the growth, it is similar in sensation to the cervix uteri. Blood, pus, or sanious material may be found on the finger if the growth is ulcerating. Vaginal examination in women must be made to differentiate the source of the tumor. The genito-urinary organs in the male should also be examined. NEOPLASMS OF THE INTESTINES 777 Simple cicatricial stricture is usually smooth and not ulcerated, while a carcinomatous stricture is usually nodular and frequently ulcerated. It is preferable for accurate diagnosis to excise a portion under cocain for microscopic examination. If the stricture cannot be reached by the finger, Kelly's speculum is of value. Never insert the hand into the rectum. Metastatic growths in other organs are quite frequent from small growths of the rectum; thus, with carcinoma of the liver, a small primary carcinoma of the rectum may be found, even if no symptoms are present. The bladder and vagina may be involved and fistulous openings occur. Periproctitis (abscess) and fistulae are rare. The peritoneum is rarely 'involved unless the carcinoma is high up. Course. The termination is death if not operated on. This may occur by occlusion of the intestines and from peritonitis. It is hardly possible to give a prognosis as to duration. In cancer of the duodenum the general nutrition suffers early, or the case may be very acute and the duration of life is short. In many cases the course varies from six months to two years, while in rectal cancer it may last for three to even four years. Rarely cases come to a standstill and last some years. In some cases coma (carcinomatosum) appears quite early, probably due to auto-intoxication from intestinal decomposition or from the toxins of cancer or the patient may become melancholic. Ewald isolated a body from the urine belonging to the group of diamins in such a case. Thrombosis may develop and embolus of the lungs occur, with death resulting. If obstructions do not occur, death may occur from exhaustion or these patients, becoming asthenic and bed-ridden, may develop hypo- static congestion of the lungs or cancerous infiltration of the same. With hypostasis there are irregular temperature, rapid and feeble pulse, in- creased rapidity of respiration and gradually listlessness 'or a dormant or somnolent condition, merging into semi-coma, coma and finally death. Preceding the latter there are usually fecal and urinary incontinence as terminal symptoms. Diagnosis. Presence of a tumor by abdominal palpation or rectal examination, accompanied by cachexia (loss of weight marked) and ane- mia, with marked constipation and increasing symptoms of stenosis of the bowel; or cachexia, intestinal disturbances, with no detectable tumor, but with symptoms of progressive stenosis in an elderly person, are suggestive of cancer. Examination of a tumor fragment, if it can be secured in the stool or from the rectum, is conclusive. Inflation per, rectum of the intestines with air or with water is of service. In many cases most of the enema will at once be returned. X-rays. The re-rays are of particular value in demonstrating a stenosis due to the growth. Bismuth or barium may be given by mouth and radiographs be taken 6, 8 and 24 hours later. There is an accumulation above the stricture and a narrow zone passing through it. A barium enema can be given and a second series of radiographs be taken. Prognosis. This is fatal, unless a radical operation is performed. Treatment. Complete and early removal of the growth is indicated. An early diagnosis is important. If abdominal cancer is suspected, ex- 778 DISEASES OF THE STOMACH AND INTESTINES ploratory laparotomy and complete resection of the growth, with end-to-end or lateral anastomosis, are indicated. If resection is impossible, entero-enterostomy or enterocolostomy for drainage to relieve symptoms is indicated. If the tumor is low down in the colon, sigmoid, or rectum and inop- erable, then colostomy to relieve the symptoms and prevent irritation of the surface of the cancer. In the rectum, resection, preferably Kraske's operation, is indicated if radical operation is possible. Palliative curetment and the thermocautery may be employed in some cases. Colostomy under cocain can be performed in the aged and feeble. Coley's treatment by erysipelas toxins may be tried, but I would not recommend it. It is more successful with sarcoma. Diet. Soluble foods with little residue, such as milk, broths, bouillon, tropon, somatose, cream, butter, rice-gruel, sour milks, matzoon koumiss, fermillac, bacillac, raw eggs, etc., are indicated. Irrigation of the intestines, enemata, and injections with olive oil, and internally, castor oil, magnesium sulphate, rhubarb, cascara, regulin, mineral oil, olive oil, etc., to keep movements soft; warm applications to the abdomen; morphin, codein, and belladonna are indicated for pain. These last can be given by suppository. Strength should be supported by tonics, iron, arsenic, etc., and pain relieved. Treat complications. Opiates should be employed only. when absolutely necessary. SARCOMA AND LYMPHOSARCOMA OF THE INTESTINES Sajrcoma of the intestines is rather an infrequent disease, much less frequent than carcinoma. In the course of twelve years, 1882-93, in the Vienna General Hospital, out of 274 autopsies on patients dying of sar- coma, only 3 were sarcoma of the intestines, the ileum, cecum, and rectum. In 6 1 cases of lymphosarcoma, 9 belonged to the intestines, i in the duo- denum, 3 in the jejunum, 3 in the ileum, and 2 in the cecum. Of Libman's cases, 15 were of the duodenum, 18 of the jejunum and ileum, 14 of the ileum, and 3 of the entire small intestine. Sarcoma occurs as frequently in the small as in the large intestine, and lymphosarcoma preponderates in the small bowel. Of Krueger's 37 cases, 16 were of the small bowel alone and 16 of the rectum; the ileocecal region comes next. Sarcomata generally attain a large size, even as large as a child's head and spread over a large part of the intestines. Anatomy. Sarcomata usually originate in the submucosa, the muscula- ture is attacked early, and the serosa is rarely involved. Small round- celled sarcoma is most frequent; occasionally spindle-celled. In the rec- tum they are often melanotic. Lymphosarcomata start from the lymphatic apparatus, the solitary and agminate lymph-follicles. These occur chiefly in the small intestine. Sarcomata of the intestines show a rapid progress and metastases are found early. They do not produce stricture of the bowel, but a dilatation, and develop in a longitudinal direction along the intestines. The bowel may be enormously dilated. Rectal sarcoma, however, may produce obstruction. NEOPLASMS OF THE INTESTINES 779 Age. Sarcoma is frequent in young persons; most frequent from twenty to forty years of age; from four to seventy years cases are reported, and one congenital case in an infant three days old. Symptoms. The clinical symptoms differ from carcinoma. The gen- eral health becomes impaired early. The patients emaciate rapidly and become anemic. There is peculiar want of proportion between the rapid impairment of the physical condition and the absence of local symptoms. They become rapidly weak and debilitated (cachexia). They are, as a rule, an absence of abdominal pain and no symptoms of stenosis. Intes- tinal symptoms are slight occasionally constipation, alternating with diarrhea. Exceptionally, stenotic symptoms appear, due to kinking or peritonitic incarceration, or, rarely, ileus. Stenosis occurs in rectal carcinoma. The tumor appears early, grows rapidly, and can easily be made out. Duration. The majority of cases die within nine months from general cachexia or pulmonary involvement, or from hypostatic congestion of the lungs; only one case recorded lived twenty-one months. Prognosis. This type of tumor proves fatal, and even early operation seems of no value on account of the metastases. Treatment. Injection of Coley's fluid, the mixed toxins of erysipelas and Bacillus prodigiosus, is indicated, as in inoperable sarcoma in the other regions. One must remember that marked reaction follows the injection in some cases, and some patients cannot undergo the treatment. I have seen the latter occur, and also in another case temporary improvement. The patient should receive as liberal a diet as possible, and iron, arsenic, and cod-liver oil should be administered. As a rule, no stenosis is present, but if in evidence, operative procedure is indicated. Removal has failed on account of the metastases. BENIGN TUMORS OF THE INTESTINES (NEOPLASMS) Benignant neoplasms of the intestines are relatively rare, and their clinical significance is generally slight. They occasionally produce severe symptoms. These tumors may be attached to the bowel wall by a broad base or by a thin pedicle or stem, and are then termed polypi. The last type is usually of small size, that of a cherry, but rarely as large as a pear, and occur most frequently in the rectum. The following forms of benign tumor are found: Adenoma, fibroma, lipoma, papilloma, myoma, fibromyoma, angioma, and chylangioma. Adenomata are most frequently met with. They arise from the glands of Lieberkiihn and in the duodenum from Brunner's glands; are acinous in structure, and may be attached to the bowel by a broad base or by a pedicle. As a rule they are small, the size of a pea; rarely, the size of a pear. They are red and have a tendency to bleed; usually they are soft and the surface is smooth, though occasionally of a cauliflower appearance. They occur most frequently in the rectum, are usually polypoid, though occasionally annular and flat. They are most common, in this location, in children of from four to seven years, though occasionally found in adults. More than half the cases that occur are in males between sixteen and 780 DISEASES OF THE STOMACH AND INTESTINES thirty years of age. Sometimes there is extensive involvement of the intestines, a condition known as polyposis intestinalis adenomatosa; in one case several thousand were present. Polypi are never limited to the small -intestine. Carcinomatous degeneration of the polypi may occur, Fibroma, Lipoma, Papilloma. These neoplasms derived from the connective tissues, especially from the submucosa, are very rare. They are, as a rule, lipomatous in structure, and often originate from the appen- dices epiploicae. They frequently project into the peritoneal cavity and may twist their pedicle and become detached. They may have a broad base or pedicle, are of various shapes, and may grow to the size of an apple. They occur most frequently in the colon and rectum, less frequently in the jejunum, and rarely in the ileum. Myoma, Fibromyoma. These are very rare, and usually originate from the outer muscular coat of the intestines, chiefly from the longitudinal coat. There are two forms: Spheric nodules, which grow toward the mucous lining and sometimes become pedunculated, the mucous mem- brane lying loose in front; or they may have a broad thick base, forming a circumscribed thickening, the mucous membrane being adherent. Rarely the myoma will grow toward the peritoneal cavity. Angiomata. These are exceedingly rare, and may occur as a telan- giectatic mass, or as a flat vascular tumor involving more or less of the bowel wall. Cystic chylangiomata occur in the small intestine. Symptoms. In many cases there are no symptoms at all, and the con- dition is discovered accidentally postmortem. Sometimes they give rise to intestinal hemorrhage. When this occurs in a person in good health, who has never given any history of previous intestinal trouble, the possibility of an intestinal tumor should be thought of. This is especially true in children. Diarrhea with blood and mucus have been reported in cases of poly- posis intestinalis adenomatosa. On account of their small size it is nearly impossible to discover them by palpation. Symptoms may rarely be produced by narrowing or occlusion of the bowel by the intestinal tumor, or from an intussusception caused by the tumor. When tumors are situated in the rectum disturbances are most likely to occur, such as hemorrhage, passage of mucus, tenesmus, and difficult defecation. Sometimes the mass may be felt by the examining finger, and it may even protrude from the anus and give rise to severe pain. It may occa- sionally be torn off and passed with the stools, when the symptoms may disappear. Course. They may remain latent or give symptoms for some years and then be passed per rectum. Treatment. Intestinal hemorrhage should be treated in the manner already described under Typhoid. The blood will often be bright in color if the hemorrhage is from the colon or rectum ; injection of very hot or cold water with i dram (4.0) of alum or tannic acid, 30 grains (2.0), locally, or Tremoliere's solution, by mouth and rectum; ice-bag to the abdomen; morphin, y grain (0.016), and ernutin, 5 minims (0.296), by hypodermic, are indicated. NEOPLASMS OF THE INTESTINES 781 If the tumors are accessible in the rectum, they should be removed by galvanocautery or by operation. Ligation and excision, after water infiltration of the pedicle, is an ex- cellent method. When the polypi are higher up, each may be exposed in turn by the aid of the proctoscope. A Gant valve clamp may be snapped on the pedicle of each and they may then be allowed to slough off. This last method is extremely simple and requires no anesthetic. When the growths are very numerous, large or ulcerated, and scattered throughout the colon or sigmoid flexure, cecostomy with irrigation of the bowel, or in some cases extirpation of the diseased portion may be necessary. GAS CYST OF THE INTESTINES (Synonym. Pneumatosis Cystoides Intestinorum Hominis) Cysts containing air, in the intestines of pigs, were probably first described by Mayer, 1 of Bonn. This condition was also independently described by John Hunter. These intestinal gas cysts have been found quite frequently in apparently otherwise healthy pigs and occasionally in sheep. The theory has been held that bacteria are the cause, or that they are the result of mechanical and physical conditions; for example, that gas may escape through some abrasion into the tissues. Others believe the process is analogous to a traumatic emphysema. Bang 2 first reported this condition in the human being, and Finney the first case in America. Finney and Welch 3 believe the cyst to be a distinct variety of tumor, the cells of which have the faculty of secreting gas. In practically every case so far, the gaseous cyst has been associated with disease of some por- tion of the gastro-intestinal canal, in some cases producing an obstruction to the lumen of the bowel. Turnure 4 has reported an interesting case with a careful investigation of the subject. Practically all the cases with autopsy show the presence of gastric or duodenal ulcers or of symptoms pointing to some chronic disease of the intestinal tract of long duration. Cysts may be single or multiple and occur in the small and large intestines. Pathology. There is a dense fibrous tissue framework containing round and spindle cells, and there are clefts and spaces whose walls contain large giant cells with many nuclei. Air spaces are found about these cells, and there is an endothelial lining to these spaces. The blood-supply is rich and hemorrhages may occur in the tissues. Air in the cyst resembles atmospheric air. The tumor is more pronounced in the subserous tissue, though it has been observed in all the layers of the walls. Clinically, there is no definite picture. Crepitation on palpation has been noted. Pain and constipation could be chiefly attributed to other factors. Diagnosis is usually made during operation for some other trouble or at autopsy. Treatment. If symptoms of obstruction, operation is indicated. After operation for other conditions, they generally diminish in size or disappear. 1 Jour. d. prakt. Heilk., 1825. 2 Nord. med. Ark., 1876, viii, No. 18. 3 Jour. Amer. Med. Assoc., October 17, 1908. 4 Annals of Surgery, June, 1913. CHAPTER XXX HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE; ABSCESS OF THE RECTUM; PRURITUS ANI; FISTULA IN ANO HEMORRHOIDS (Synonyms. Phlebectasia Hemorrhoidalis; Piles) HEMORRHOIDS consist of diffuse or circumscribed varicose dilatations of the hemorrhoidal veins, lying either in the subcutaneous tissue of the anus external to the sphincter (external hemorrhoids) or in the submucous tissue of the lower portion of the rectum (internal hemorrhoids). The hemorrhoidal veins surround the lower portion of the rectum and there form the hemorrhoidal plexus. The majority of these veins enter into the inferior or external inferior hemorrhoidal veins, and from there into the common pudic and iliac veins; others pass into the median inferior hemorrhoidal veins and so into the internal iliac vein and the inferior vena cava. A small number of the veins enter the superior hemorrhoidal veins, thence into the inferior mesenteric veins and the portal system. In portal obstruction blood from the hemorrhoidal plexus can pass into the vena cava; while back pressure on the vena cava inferior, when of cardiac origin, may affect the hemorrhoidal system. All hemorrhoidal veins are devoid of valves. Anatomy. External hemorrhoids are visible to the naked eye, lie below the sphincter ani, and are often arranged in groups around the anal orifice. They appear as bluish-red, tortuous vessels encircling the open- ing; or there may be isolated varicose protrusions, from the size of a pea to a walnut. They may be round, flat, or irregular in shape, and their size sometimes changes in the same patient, often being smaller after defecation. Internal hemorrhoids often can only be discovered by digital examina- tion or by use of the proctoscope, as they lie above the sphincter. In aggravated cases the patient by bearing down may cause them to protrude. They usually appear as soft nodules of bluish hue, with thin walls. The diffuse or circumscribed nodular forms may be present, and the last constitute a true varix. External and internal hemorrhoids may occur together. Piles may occur singly or in pairs, or be multiple and form a ring about the anal opening, both external and internal to the sphincter, and even a third higher ring has been described. In exceptional cases dilated veins are found high up the rectum, even into the sigmoid flexure. Hemorrhoids are generally believed to be simple venous ectasias and are considered genuine varices, though some maintain them to be true angiomata. Secondary changes probably account for the various conditions found. The dilated blood-vessels, venous varices, near a group of hemorrhoids 1782 HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 783 may become inflamed, adhere and coalesce, and the walls of the vessels atrophy, so that tumors of some size, resembling cavernous multilocular tumors (angiomata), may develop. The external covering of the varix may become hard, thick, and resist- ant, through inflammatory processes. In other cases the walls may be- come thin and eventually rupture, or the blood coagulate within the pile and form a thrombus. Phleboliths occur in old cases. A blood-cyst is occasionally formed. Marked connective-tissue increase may take place in some of the ex- ternal hemorrhoids; they may present the appearance of skin tabs, or skin externally and mucous membrane internally, which may become edema- tous and inflamed. They may give rise to warty growths. The mucous membrane of the rectum near the hemorrhoids is hy- peremic, and, with internal hemorrhoids, in a condition of catarrhal inflammation. Fissure or prolapse of the rectum may be associated with piles. Allingham has subdivided internal hemorrhoids into three varieties: 1. Capillary piles, resembling nevi, consisting of hypertrophic capillary vessels and spongy connective tissue with thin mucous membrane. They easily bleed. 2. Arterial piles, sessile or pedunculated tumors, glistening or villous, slippery, hard, and vascular. 3. Venous piles, in which the veins predominate. Tumors are large and bluish or livid in color. Internal piles may be pushed down during defecation. A pedicle may be formed to the tumor and the mass may slip out of the rectum. After defecation they may spontaneously return into the bowel, or can be re- placed. If large they may become incarcerated and even gangrenous and slough off. Hemorrhage is a common occurrence. Inflammatory processes may complicate internal piles, such as ulcers, proctitis, and periproctitis. With the latter abscess may result, which may form fistulae, external, internal, or complete. Etiology. Hemorrhoids are frequently met with in practice and the condition is much more common than supposed, as many patients so afflicted never consult the physician. It is rare in children. The statement is often made that piles occur more frequently in men than in women. Undoubtedly more male cases are found in our records. Habitual constipation, pelvic congestion, and sedentary life favor mark- edly the production of hemorrhoids, and these conditions we find most frequent in women. Males will at once consult the physician if there is difficulty in the anal region. Women are, as a rule, extremely sensitive, and usually treat their piles by home remedies until conditions are such as to necessitate advice from the physician. It has been my experience that most of my women patients never refer to "hemorrhoids" unless specific- ally questioned. Actually, I believe women are the more frequently afflicted. Age. Piles occur most frequently between thirty and fifty years of age. The modern consensus of opinion is that hemorrhoids are a local disease and not due to any diathesis or faulty state of the general circula- 784 DISEASES OF THE STOMACH AND INTESTINES tion. There are certain peculiarities in the rectal plexus of veins favoring the production of piles which are as follows: The walls of the hemorrhoidal veins are thin and contain few muscular fibers, and hence their contractile force is less than that of the veins in the lower limbs. 4 There are no valves in the rectal veins, so that blood can be readily forced back into them. Muscular contraction aids the onward propulsion of the blood in other regions. In the rectum fecal masses compress the blood-vessels, the sphincteric contractions compress the vessels, and contraction of the abdominal mus- cles during defecation interferes with the return of blood. They are de- pendent blood-vessels, and with the unfavorable factors mentioned it is not surprising that hemorrhoids are frequent. Some of the hemorrhoidal veins enter the portal system, in which there is a low degree of pressure and in which the circulation is readily retarded. Stasis of this system may be a contributory factor in the production of hemorrhoids, as in cirrhosis of the liver; as may also diseases of the heart and lungs leading to engorgement of the venous system. All conditions which tend to produce interference with the return cir- culation of blood from the hemorrhoidal vessels, or produce or predispose to hyperemia, influence the production of hemorrhoids. Among such are: chronic constipation; sedentary habits, as in clerks, students, shoemakers, seamstresses, sitting on soft cushions, excessive horseback riding, 1 etc.; enlarged uterus, as from disease or pregnancy; prostatic affections, tumors of the bladder, or growths in the pelvis. Hemorrhoids may develop suddenly in cases of carcinomatous stricture of the rectum and early in the course of the disease. Habitual constipation favors the production of piles. Hemorrhoids also may be the primary condition, and on account of the pain of defeca- tion the patient avoids having a movement as long as possible. Excessive venery is given as causing congestion in these regions. Abuse of alcohol, spiced food, fatty food, excessive quantities of food and drink are believed by some to favor the plethoric habit and produce fulness of the portal cir- culation, with resulting piles. Gourmands of this type are often of seden- tary habit and are frequently disposed to constipation a more likely cause. Von Recklinghausen has shown that piles are by no means com- mon in plethoric individuals, but more in those of lean habit, of poor mus- cular development, with defective metabolism, who lead a sedentary life, and who are anemic, with poor circulation. Catarrh of the rectum is given as a cause, but is not always easy to determine whether the catarrh or piles were primary. Drastic purgatives are said to produce hemor- rhoids, but they are used for the constipation, which may be the chief factor. Cases do occur in which it seems probable that the excessive use of purges has produced hemorrhoids with prolapse. Among the Orientals, who lead a sedentary life, hemorrhoids seem quite common. Hereditary anatomic peculiarities have been suggested as a cause, since piles are often found in several successive generations. Symptoms. External Hemorrhoids. These are chiefly of local char- 1 Bicycle riding in excess may be a factor. HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 785 acter. The patient may have a sensation of fulness, clogging, or pulsation in the lower rectum. At times there may be a feeling of obstruction at the time of bowel movement. Constipation usually precedes the attack. There is itching of the anus and perineum. The anus may be tender and swollen, and if the buttocks are drawn apart external piles, single or in clumps, round and bluish in color, distended with blood, are present. Stains of blood are often found on the toilet paper. The exacerbation may quiet down under rational methods. They may become swollen and edema- tous, painful, and even ulcerate and suppurate, with the production of a fistula. Tenesmus may be present, and the external pile may be drawn up into the sphincteric circumference and become pinched and strangulated. Under such conditions there are severe pain, throbbing, a desire for defeca- tion with straining, and the patient cannot sit or walk about. Fever, anorexia, and severe constipation accompany the local manifestations. Hemorrhage is not as marked with external piles. Internal Hemorrhoids. With internal hemorrhoids hemorrhage is often a prominent symptom. Frequently internal piles can only be detected by digital examination or by inspection through a speculum. They may prolapse and even become strangulated. In such event the pile becomes swollen, turns deep blue, there are agonizing pain, marked tenesmus, occa- sionally vomiting, constipation, meteorism, fainting, prostration, and fever. Gangrene and sepsis may occur if the strangulation is not relieved. With mild types of internal hemorrhoids the only symptoms may be an occasional hemorrhage. One must remember that hemorrhoidal veins may be very high up and only be visible with a proctoscope. Usually, subjective symptoms are present, such as itching, burning, pressure and weight in the anus, and the sensation of a foreign body, with tenesmus. There may be feelings of pressure and even pain in the sacral and lumbar regions. Occasionally soreness over the lower part of the abdomen, pressure in the rectum, bladder, uterus, and vagina; pains radi- ating to the thighs may be present. Sometimes these symptoms precede a hemorrhage, after which temporary relief occurs. As a rule, the bowels are irregular and constipated: Hemorrhages may be frequent, so as to cause marked secondary anemia. In one case notably the patient, a woman, from repeated hemorrhages suffered from air hunger, dizziness, faint spells, and even some loss of memory. The hemoglobin was reduced to 28, the red cells to 2,ooo,ooo,kthe patient nearly dying as a result. It was after nearly two months of most careful treatment before she could be operated upon; the result was excellent. Bleeding may be severe and bright red blood gush from the rectum nearly pure, or it may be dark brown mixed with fecal matter. In such an event it lies on the surface of the feces and is not intimately mixed with it. Small quantities of blood are frequently passed with hard stools. Hemorrhages sometimes occur on no special provocation, or after a horseback or bicycle ride, etc. Gummy acrid mucus may be discharged from the hemorrhoids due to catarrh of the rectum, and may cause excoriations. 786 DISEASES OF THE STOMACH AND INTESTINES In some the hemorrhage may last for several days and temporary relief may occur. It has been stated that bleeding from hemorrhoids may take the place of menstruation (vicarious). Dyspnea, palpitation, angina, hiccup, giddiness, despondency, and hypochondria, often attributed to piles, I believe, with Riegel, are merely associated with the constipation present, though giddiness and dyspnea may result from hemorrhage as in the case cited. Proctitis, fissure, and occasionally abscesses or fistulae may develop. Disturbances of adjacent organs, such as strangury, hemorrhage from the bladder or vagina, or catarrh of the latter may occasionally occur. Diagnosis is made by inspection and digital examination; occasionally the proctoscope is necessary. The appearance of hemorrhoids has been described. Condylomata encircle the anus and are often present on the scrotum. There are a history of syphilis and manifestations of lues. 1 Skin tags are whitish looking, do not change their size, and do not bleed when punctured. Piles differ in the last regard. Internal hemorrhoids are reddish blue and bleed when manipulated or punctured; polypi do not do so. The latter occur most frequently in children. Carcinoma presents a hard consistency, and produces stenotic symp- toms and cachexia. A small section placed under the microscope will settle the diagnosis. Piles may occur suddenly in association with cancer. Prognosis. Piles are frequently a chronic affection and may exist throughout life. In cases occurring during pregnancy, restitution to normal is possible. This is true of the milder types if the cause is cor- rected. They may markedly diminish in size and then an exacerbation take place. They rarely endanger life unless strangulation with gangrene or a large abscess or dangerous hemorrhage occur. Treatment. Excesses of all kinds in food, drink, and venery should be avoided. The patient should lead an out-of-door life, take proper exer- cise, and have a daily soft evacuation of the bowels. All conditions causing venous engorgement of the rectum should be avoided, such as constant standing or sitting, horseback and bicycle rid- ing. The patient should not sit on warm soft cushions, but on cane-seats or those covered with leather or horse-hair. Diet. The diet should be mixed in character and in part consist of a considerable variety of green vegetables and raw, ripe and cooked fruits, to regulate the bowels. It should suit the individual, and a stout full-blooded person must be somewhat limited in his diet. The patient should not take three large meals at long intervals, but preferably smaller and more frequent feedings. Alcoholic beverages, strong coffee, strong tea, highly seasoned dishes, cheese, coarse brown bread, peas, corn, and baked or lima beans are best avoided. String beans, spinach, asparagus, and green salads aid bowel action. Potatoes, rice, beets, and cauliflower may be allowed in small quantity. 1 The Wassermann or Noguchi reaction should be tested. HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 787 Raw fruits, such as apples, pears, prunes, grapes, oranges, and stewed fruits, such as prunes, baked apples, etc., are of value. Soups of various kinds are allowed. Hot breads, richly spiced foods, and rich desserts should be avoided. Matzoon, koumiss, bacillac, fermillac, lactone-milk, and buttermilk often have an excellent effect on the bowels. They can be taken as the extra meals midway between the usual meals. A few crackers or zwie- back with plenty of butter can be given. Some recommend water only between meals and interdict much of that. Unquestionably a certain amount of fluid with the food is an aid to digestion and bowel action. I have seen severe cases of constipation result from the elimination of all fluids at meals. At -least 8 ounces (250 c.c.) of fluid in the form of broth, soup, cocoa, or water should be taken at each meal. On rising, the administration of a glass of water often aids bowel action, and between meals an equal amount should be given, or matzoon or koumiss substituted. Outdoor exercise, such as walking, is of service. It should not be car- ried to the point of fatigue, and is contraindicated during acute inflam- mation of the piles or if hemorrhage or unpleasant symptoms result. Massage, gymnastics, and Swedish movements are of value. Bowels. Constipation should receive appropriate treatment. Power- ful cathartics should be avoided. The dietary methods mentioned should be carried out. The patient should go to stool daily at a definite hour. 1 have found the administration of olive oil, i to 2 tablespoonfuls (15.0- 30.0) t.i.d. before meals, an aid to bowel action. The injection of i to 2 ounces (30.0-60.0) of olive oil into the rectum with a small soft-rubber ear syringe just before having or attempting to have a movement is a valuable procedure. It also renders the passage easier and less painful. Aloes should be avoided in hemorrhoid cases. Among our simple remedies are compound liquorice powder, i dram (4.0); fluidextract of cascara or aromatic fluidextract, i dram (4.0); ex- tract of cascara, i to 5 grains (0.06-0.3); purgen (phenolphthalein), i>^ to 5 grains (0.1-0.3); tincture of rhubarb, i dram (4.0), or extract of rhei, 4 grains (0.25), mineral oil and regulin. Other remedies are described in the chapter on Constipation. Carlsbad, Kissengen, and Saratoga waters are of service, especially at the springs. A good prescription is the following: 3$. Ext. cascara gr. xv (i.o); Ext. belladonnae ) ... , \ ,, ~ . . . } aft gr. nj (0.2) . M. Ext. nucis vomicas j Make 1 2 pills. Sig. One to two at bedtime. Hygiene of the Anus. After defecation, cleansing with a moist sponge or wet cotton is less irritating than paper. External piles should be protected with a small piece of cotton moist- ened with sweet oil or covered on the anal side with vaselin, boric acid, or zinc ointment. Cold sitz-baths and cold ablutions to the rectum are 788 DISEASES OF THE STOMACH AND INTESTINES valuable. An external douche with cold water is excellent, thus: A foun- tain syringe is filled with cold water at about 6oF. and several ounces of witch-hazel added, or a hot douche at no to ii5F. can be substituted. The rectal tip is placed close to the anus, which is then thoroughly douched. This is especially applicable for external piles, and lessens congestion even when they are internal. For external inflamed piles stronger medicated local applications can be employed than with internal piles, where greater absorption occurs. External Hemorrhoids. With inflamed piles absolute rest in bed or on a couch should be enjoined. A small ice-bag or gauze wrung out in cold solution of witch-hazel and water, equal parts, or of lead-and-opium wash, are excellent applications. Some prefer the application of warmth; cold is usually more efficacious. For the application of cold to relieve congestion, both to external and internal hemorrhoids, the simple instruments in Figs. 316 and 317 are of value. The ice tubes for hemorrhoids are made in a nest containing several sizes, in appearance like a very small test-tube with a broad flange, to Fig. 316. Kemp's tube (cooler) for hemorrhoids or prostate Fig. 317. Kemp's ice tube for hemorrhoids. prevent slipping into the bowel. The tube is filled with powdered ice, corked, well lubricated, and inserted into the anus. They are made of glass or metal, the latter the safer. The prostatic cooler is of small caliber a simple closed tube with a large entering and small return attachment. The fountain syringe is attached to the large branch and a soft outflow tube to the smaller. Very cold (preferably) or hot water can be employed. The soft-rubber rectal bag (Fig. 318) is made on similar principles, but is more bulky. A small rubber condom, with two catheters tied in, one for the entering and the other for the outflow current, can be substituted for this bag. They were reported some years ago. 1 In addition, one can attach a small catheter to the tip of the fountain syringe and, inserting the soft tube about i% inches, thus douche the in- ternal hemorrhoids. The current should be slow, the patient evacuating the fluid around the catheter every minute or so. Hot or cold normal saline solution with witch-hazel, i ounce (30.0) to the pint (50x5 c.c.), can be employed. The old Bodenhamer recurrent tip or the flexible or hard- 1 Manual on Enteroclysis, Hypodermoclysis, and Infusion, 1900. HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 789 rubber recurrent tubes (Kemp) can be used, introducing them only about 2 inches; but with inflamed piles they are apt to cause more pain than the small soft catheter. I have employed a recurrent uterine irrigator for the same purpose. Fig. 318. Kemp's soft-rubber rectal bag, used as a cooler for hemorrhoids. I have found the following prescriptions, recommended by Samuel Gant, of value for the relief of pain and inflammation in external hemor- rhoids: fy Liq. plumbi subacet .......................... 3iv Tinct. opii .................................. 3iiss Aq. destil ............................... q. s. 3 iv Sig. Apply cold, on gauze. Ung. stramonii Ung. belladonna? Ung. acidi tannici or or Morph. sulph Cocainae hydrochlor Vaselin fy Cocainae hydrochlor Ext. bellad. Ext. opii Ext. aconite J Ext. stramonii Glycerin Sig. Apply on cotton, externally. aa 5iss Siiss 5ss gr. iij gr. xij 5 ij gr. v 3ij 3 ss 15 10 125 6 . M. . M. 78 . M. 325 . M. This last prescription I prefer to use first at about one-third or one-half strength. It should be employed for only the temporary relief of severe pain and should be left on only for a short period, about fifteen minutes. Cold or, at times, hot injections, and opium and belladonna supposi- tories are excellent for tenesmus. For internal hemorrhoids, when prolapsed, inflamed, and difficult of reduction, it is advisable to apply cold, such as ice-water to which witch- hazel has been added, ice, or lead-and-opium lotion (cold), for a brief period, to lessen edema and inflammation. Local application of adrenalin (i : 1000) to an irreducible pile lessens congestion and aids reduction. One of the following ointments is excellent as a sedative: Morph sulph gr. viij Hydrag. chlor. mit gr. xij Vaselin 5 J 52 78 . M. (Gant.) 790 DISEASES OF THE STOMACH AND INTESTINES Ext. opii 5ss Cocainae hydrochlor gr. x Mentholi gr. xx Ung. zinci oxidi 5 j 65 3 . M. The prolapsed hemorrhoid should be well lubricated before the physi- cian endeavors to push it up with the finger. Occasionally an anesthetic may -have to be administered. There are the dangers of strangulation with gangrene and sepsis, from an unreduced hemorrhoid. F.or ulcerated hemorrhoids the following are useful: R. Bismuth subnit 3U Hydrarg. chlor. mit 9ij Morph. sulph gr. iij Glycerin 3ij Vaselin 5 j 3 M. Sig. Apply with a pile syringe (Allingham). !$. Cocainae mur gr. xij lodoformi 3 j Ext. opii 3ss Vaselin 5 j Sig. Apply with a pile syringe (Mathews). . M. For hemorrhage the following are of service: Rectal injections of ice- water, 8 ounces (250 c.c.), alone or with tannic acid, 1 5 grains (i .o), dissolved therein, or alum, i dram (4.0), or witch-hazel, equal parts; local appli- cation of ice-bags, or the ice tube. Several ounces of Tremoliere's solution gelatin (5 per cent.) with chlorid of calcium (2 per cent.) can be injected into the rectum. It was originally used as a local styptic. If the bleeding is from external piles, styptics can be applied in oint- ment form; if from internal hemorrhoids, the ointment can be inserted with the finger or applicator, or as a suppository. Among such useful remedies are unguentum acidi tannici and unguen- tum gallae. 1^. Unguentum acidi tannici Unguentum stramon. \ Unguentum belladonnas / Ft. ung. . . M. 3 . M. R. Suprarenal ext gr. v Ol. theob gr. xxx Ft. suppos. No. i. R. Adrenalin chlorid (i : 1000) Ityx (0.592) Ol. theob q. s. M. One suppository. R. Ichthyol \ . .,.. . . f aa gr. v Acidi tannici J 3 Ext. belladonnae \ .. ,/ 022 Ext. stramon. / ' ' Ext. hamamelis gr. x J6 Ol. theob ..- q. s. j. M. Ft. one suppository. (J. P. Tuttle.) An ointment or suppository containing chrysarobin has been advised for the treatment of hemorrhage from piles: HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 791 3$. Chrysarobin gr. xv Ext. belladonnae gr. v lodof orm gr. x Petrolati 3ss Ft. unguentum. 1^. Chrysarobin gr. ij Acidi tannici gr. iij lodoformi gr. ij Ol. theob gr. xxx Ft. one suppository. 3 6 . M. 13 194 13 - In many cases of hemorrhage the simpler remedies are sufficient. Rarely it may be necessary to tampon the rectum. This can be performed by slipping in a piece of cheese-cloth like the finger of a glove, in effect a bag, with the outside well lubricated. This is packed with cotton tampons or strips of gauze, and the distended bag drawn down against the sphincter. It can be done in emergency without an anesthetic. If these measures fail, it may be necessary to ligate the bleeding artery or, if this be impossi- ble, then the entire hemorrhoid. Radical Treatment. Dilatation of the Sphincters. By means of this the spasm of the sphincter is stopped, the pressure on the blood-vessels Fig. 319. Robert's dilator. is relieved, and the bowels act more easily. It will frequently be of benefit in the early stages of hemorrhoids, and I have seen it relieve severe symp- toms in advanced cases, especially if fissure is associated. The author has noted cases in which several years after dilatation the patient has claimed to be in comfort, with no recurrence. As a palliative the procedure is justifiable, especially if fissure is present. Gradual dilatation by the use of specula of increasing size or of dilators can be carried out. The procedure takes several weeks and is necessarily very painful. If this method is carried out, air dilatation with Robert's dilator (Fig. 319), made on the principle of Barnes' cervical dilator bag, is the most satisfactory. The hard-rubber dilators cause more pain. Rapid and complete dilatation under anesthesia is the best method when safe for the patient. With the aid of a skilled anesthetist it can be satisfactorily performed under nitrous oxid. Other anesthetics can be employed. The thumbs must be inserted into the rectum and the sphinc- 7Q2 DISEASES OF THE STOMACH AND INTESTINES ter dilated gradually, both laterally and anteroposteriorly. All spasm must be overcome and the sphincter thoroughly relaxed. Violence must not be employed. Formerly an opium suppository, i grain (0.065), with belladonna, ^ grain (0.02), was inserted and the bowels kept closed for about forty-eight hours. It is now believed preferable not to use opium but as soon as possible to have the patient return to his regular diet to which fruit, mineral oil or mild cathartic may be added. It is best to insert into the rectum a drain tube for escape of gas for at least twenty-four to forty-eight hours after operation. Carbolic Acid Injection. This method has been recommended in order to produce shrinking of the piles and so avoid radical operation. It should not be performed if the hemorrhoids are inflamed. The following solutions for injection have been recommended: . Acid, carbolic. (Calvert's) -. 5ij Acid, salicylic 3 ss Sod. bibor 3i 8 2 4 30 M. Glycerin (sterile) q. s. 5 j (J. P. Tuttle.) The solution should be syrupy and clear; if white, it is imperfect. The average injection into a hemorrhoid is 5 minims (0.296). Not more than 10 minims (0.592) should be injected into two to three hemor- rhoids. After the injection insert a suppository of Opii (pulv.) . gr. j Ext. belladonnae gr. % lodoformi gr. ij 065 022 13 . M. Ol. theob q. s. Carbolic acid and glycerin, equal parts; or carbolic, i; glycerin, 3; water (distilled), 3, have been employed. Inject 3 to 5 drops with a hypodermic syringe into the center of the pile. Care must be taken that none of the solution drops from the needle and cauterizes the mucous membrane. An enema is first given, the piles cleansed and dried, and then anointed with iodoform ointment after injec- tion with carbolic. A few drops of a i per cent, cocain solution may be first used subcu- taneously to deaden the pain. It is preferable to inject one hemorrhoid at a time. Considerable pain at times follows. The possible dangers are ulcer, abscess, and fistulae. There is some danger of sepsis and cases have been reported. Cauterization with Fuming Nitric Acid. The surrounding parts are covered with a thick layer of vaselin, except the pile that is to be treated. This is painted with the nitric acid by means of a small stick or glass rod. Care must be taken that the acid touches no other spot. The pile turns a grayish-green color as a result. Iodoform ointment or vaselin is applied and the hemorrhoid . pushed back into the rectum. Allingham advises carbolic acid as a substitute for the nitric acid. There is an element of danger from sepsis, in this method. Ligature of hemorrhoids under anesthesia without removal and then allowing them to slough of has been employed. The method is not to be recommended for obvious reasons. HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 793 Crushing. The hemorrhoid is crushed longitudinally by means of a special instrument, the projecting portion cut off, and pressure kept up for about a minute. This technic is not advised. Clamp and Cautery. Each pile is seized with a volsellum forceps and drawn well down. The clamp is applied to embrace its base. The por- tion above the clamp is cut off with scissors, and the cautery iron, heated to a dull red, is applied to the stump until the vessels are well seared. Either the thermocautery or galvanocautery can be employed. Excellent results have been secured by this operation. Ligature and Extirpation (Allingham's Operation). Incision is 1 per- formed at the base of each pile through the mucosa, and the pedicle dis- sected out. This is ligatured and the pile cut off with scissors. Some operators remove every alternate hemorrhoid, the rest usually shrink- ing as a result of operation. Others incise the mucous membrane above the base of the pedicle and force it back like a cuff. After ligature and removal of the pile, the cuff of mucosa is drawn down and a single stitch taken. This last method is to be recommended. There is less danger of postoperative hemorrhage, and healing is more rapid. Extirpation and Suture (Whitehead's Operation). The mucous mem- brane containing the hemorrhoids is dissected out, the incision frequently encircling the anus. The piles are removed, and the mucosa, being loos- ened up, is drawn down and attached by sutures to the skin at the anal margin. Stricture or incontinence of feces are sequels which may follow this operation. Subsequent treatment by bougies is necessary if strictur- ing be feared, or if it occur. In these operations anesthesia is necessary, and dilatation of the sphinc- ter previous to removal of the hemorrhoids. Former operators closed the bowels for twenty-four to forty-eight hours after operation by means of opium suppositories, though Graser opens the bowels at once. It is now advised to return to. normal diet as soon as possible, adding fruit, green vegetables and mineral oil or some simple laxative if required. No opium is given. A drain tube is inserted for twenty-four hours for gas escape. Ten grains of muriate of quinine in water ij are injected through the rectal drain tube which is then clamped for about one hour. This method is claimed to prevent pain. It is repeated in six hours. The temperature of the fluid should be iooF. Cant's Water Infiltration Method. This method, devised by Samuel Gant, is of special value in cases where an anesthetic is contraindicated or when the patient objects to its employment. With a large hypodermic, sterile water is injected about the base of each hemorrhoid in the sub- mucosa, producing thorough infiltration. An incision is then made around the base of the pile, the pedicle dissected out, the latter ligated, and the pile cut off with scissors. Careful preliminary dilatation of the sphincter is carried out. Having seen this operation performed by its originator and also the ultimate results, I can recommend it as excellent in selected cases. Complications of Hemorrhoids. Prolapse of the Rectum. Etiology. Rectal prolapse is a fairly frequent complication of hemorrhoids, though 794 DISEASES OF THE STOMACH AND INTESTINES it may occur alone. It may involve the mucous membrane alone, or all the coats of the rectum (procidentia recti). Among other causes of pro- lapse are polypi, vegetations, tumors; conditions tending to weaken the sphincters, such as ulceration or operative incisions, spinal paralysis, or traumatism; conditions producing muscular spasm, such as worms, dysen- tery, phimosis, cystitis, calculus, enlarged prostate, or stricture of the urethra. In some cases with hemorrhoids, the prolapse may be only partial as regards the circumference of the rectum, while in others it involves the entire circumference and there is a scarlet or livid mass projecting from the anus. An internal prolapse of the rectum may occur, in which the upper part descends through the lower part, but does not appear outside the anus. It is probably due to relaxation of the ligaments of the rectum. It corresponds rather to an intussusception. Weakness and paralysis of the sphincters are predisposing factors. Prolapse of the rectum is frequent in debilitated children, especially if there is intestinal catarrh with a tendency to frequent stools accompanied by straining. Rectal prolapse occurs in elderly people, also in cases of severe constipation, and as a result of frequent pregnancies. Symptoms. With moderate prolapse, during the act of defecation, a protrusion of the rectum from i to 2 inches long appears outside the anus. It is red or bluish red in color and puckered in appearance, covered with some mucus. The swelling is continuous, with the skin on one side and with the mucous membrane on the other, and is arranged in folds which radiate from the central aperture toward the circumference. In advanced cases the mass resembles a tumor with a star-like opening at its center, and the color is a paler red or bluish. With children the mass generally protrudes only when at stool; while with adults it comes down more readily or often remains constantly down. At first it is spontan- eously reducible, later, easily replaced by slight pressure, and finally it may become very difficult or nearly impossible of reduction. It often become? inflamed or ulcerated, and in old cases incontinence of feces may occur. At first there is no or little pain, but after a time it may become quite severe. There is a tendency for the prolapse to increase in size. If inflamma- tion occur, there will be fever and constitutional disturbances. As a rule, there is no marked bleeding from the prolapse itself, but more of an oozing. Hemorrhage from associated hemorrhoids may occur. Diagnosis. This is made from the appearances described. If opera- tion is contemplated, it is important to differentiate between prolapse of the mucosa alone or of the rectum. In the latter event the peritoneum may be involved and the intestines be found in the prolapsed portion. Prolapse of the mucosa is not as firm and thick to the feel, the folds of the mucous membrane radiate from the orifice to the circumference, and the opening is circular and patulous. With prolapse of the entire wall the tumor is more conic, the walls are thick and firm, the orifice is slit-like. When the mass is pressed between HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 795 the fingers, gurgling of gas in a contained loop of gut may sometimes be heard and resonance be obtained on percussion. In some cases where there is much inflammatory thickening it is diffi- cult to differentiate. In following out treatment this possible danger should be recognized and due precaution be exercised. Internal prolapse is more difficult to recognize. Digital examination of the rectum is necessary. First keep the finger close to the anterior wall until it passes into a cul-de-sac. Withdraw it slightly and examine the center of the mass until an orifice is found into which the finger or a bougie can be passed for some inches into the rectum. It may be necessary for the patient to bear down during examina- tion. Treatment, Predisposing factors should be eliminated, hemorrhoids, polypi, etc., removed. Cleanliness after defecation should be observed. The prolapse should be replaced with the patient preferably in the knee- chest position. The mass should be thoroughly lubricated with vaselin and gently pressed into the rectum. If a Considerable portion is down, a large flexible bougie can be cautiously passed into the bowel, pushing be- fore it the upper part of the descended gut, and pressure (taxis) should be employed evenly on the other surrounding portions with the fingers. When the prolapse occurs frequently, a rectal supporter should be worn, such as a soft-rubber ball attached to the anus by means of a belt and T-bandage. A supporter can be improvised by employing a small roll of gauze covered with oiled silk and attaching it to a home-made T-bandage. With children palliative treatment is more successful. The cause of the difficulty should be investigated and removed if possible, such as a polypus. The general health should be built up, mild laxatives should be administered, and the diet regulated to secure easy bowel action if there is constipation. If diarrhea is a factor, it should receive treatment. The child should be instructed not to strain at stool, and in many cases it is wise to have him defecate in the knee-cJwst posture over a vessel to prevent prolapse as much as possible, or in the Sims posture, even at the expense of soiling the bedding or clothing, which can be easily changed. If prolapse occurs, it should be washed with cold water or weak boric acid solution or an astringent alum solution, i dram (4.0) alum to 8 ounces (250 c.c.) water, smeared with vaselin, and gently returned into the anus. A weak zinc sulphate solution can be substituted. After this the patient should remain in the recumbent position for about half an hotfr, preferably lying on the abdomen. Radical measures must frequently be adopted. Cauterization of the prolapsed portion with fuming nitric acid or acid nitrate of mercury, as suggested by Allingham, or (preferably) with the thermocautery under anesthesia, has benefited or even cured cases. After cauterization the prolapsed part should be lubricated and returned into the anus. Stric- tures are occasionally produced by this procedure. Other methods have proved successful, such as excision of elliptic por- tions of the mucous membrane with subsequent suture; extirpation of the prolapsed portion; revision or narrowing of the caliber of the rectum; sus- 796 DISEASES OF THE STOMACH AND INTESTINES pension of the prolapsed rectum by attaching its mesentery to the abdom- inal wall; or suspension of the lower end of the sigmoid flexure. In some cases Gant infiltrates the mucosa with water or a i per cent, eucain solution at a number of points until glassy white welts are formed. These are in turn seized, pulled down, ligated, and left to slough off. The rectum is shortened and narrowed as healing of the ulcerated areas takes place. Fissure of the Anus. This condition quite frequently occurs with hem- orrhoids. The fissure consists of an oblong tear of the mucous membrane of the anus, which gives rise to pain and spasmodic contraction of the sphincters. Some fissures are slight abrasions or they may be fairly large and deep. The edges may appear healthy or be inflamed or indurated. Those of longer duration present the appearance of an ulcer. In fact, they are classified as irritable ulcer. Anal fissure is usually caused by an injury or tearing of the mucosa at the edge of the anus. Excessive straining or the passage of dry hard scybalae are factors. It is more common among women. The fissure may occur in any location, though most frequently at the posterior portion of the anus. It generally lies parallel and close to the external sphincter, though it may be higher up near the internal sphincter or above it. Symptoms. Severe pain in the rectum during defecation and at times tenesmus, persisting for a time thereafter, are present. The pain may be very severe in character, so that the patient dreads to have a stool, and increased constipation results. A small fissure over the external sphincter usually causes greater dis- turbance than a larger one higher up. There may be reflex irritation of the bladder and a discharge of pus and blood from the rectum. From the pain and suffering the nervous system may become affected. Diagnosis. This is made from the symptoms and by local examination. The patient should lie on the left side and be told to bear down. On open- ing the anus with the finger and thumb, a fissure (crack) or small club- shaped ulcer can frequently be seen. It may be red and inflamed or, if more chronic, of a gray color with indurated edges. The pain may be so severe that before local examination it may be necessary to introduce a suppository of cocain, y grain (0.016). Rarely an anesthetic may be required. For a fissure higher up, examination with the speculum may be necessary. Treatment. Hemorrhoids or polypi, if present, should be removed. The dilatation of the sphincter performed during this operation and re- moval of the cause of the fissure usually will cure the case. An incision through the base of the ulcer can be made at the same operation as a precaution. Recent fissures are at times cured without operation. The patient should be in the recumbent position, hot lead-and-opium lotion can be applied externally to the anus if there is much pain, as heat relieves pain and spasm. The following ointment and suppository are of value for the same purpose : HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 797 fy Ext. conii 3ij g' Olei ricini 5iij 12 Ung. lanol q. s. 5 ij 60 . M. Ft. unguentum. 1$. Ext. belladonnas gr. % Ext. opii gr. \^ Ol. theob gr. xv One suppository. 3 . M. Locally, the fissure can be touched with silver nitrate solution (I have used the pure silver nitrate stick twice a week), varying in strength from 10 to 30 grains (0.6-2.0) to the ounce (30.0) of water every two to three days; on the alternating days a 5 per cent, cocain solution can be carefully applied, only a few drops; or the following ointments can be alternated with the silver application, or substituted for a time: fy Ichthyol. gr. xxx 2 Lanolin 3 ij 8 Petrolati q. s. 5j 3 Ft. unguentum. or 1$. Hydrag. chlor. mit gr. xv i Pulv. opii T-, . , , > aa. gr. v Ext. belladonnae } Petrolati 5ss 15 Ft. unguentum. . M. . M. Gradual dilatation of the sphincter without anesthesia, as described under Hemorrhoids, especially with Robert's dilator, is sometimes em- ployed, but this procedure is painful. Dilatation of the sphincter under anesthesia is often found curative of obstinate cases. Nitrous oxid is a valuable anesthetic for this purpose. Some recommend infiltration of the fissure with a hypodermic of i per cent, cocain, and a free incision through it;s base to the sphincters. Gant anesthetizes the tissues posterior to the rent by injecting them with sterile water or a 0.125 P er cent, eucain solution until they become white. He then severs the sphincter with scissors or a bistoury. An incision of the fissure under anesthesia, combined with sphincter dilatation, may be required. Proctitis. If proctitis is present with hemorrhoids, it must receive appropriate treatment, as described under the section on that subject. ABSCESS OF THE RECTUM Abscesses of the rectal region are superficial or deep-seated, and the latter are subdivided into the ischio-rectal and pelvic abscess. Superficial Abscess. It generally originates in one of the minute glands near the anal margin and may result from traumatism, from infec- tion such as from rectal or vaginal discharges, from horseback or bicycle riding and from suppuration from an inflamed external hemorrhoid, or follow carbolic injection into a hemorrhoid, may result from a gumma and rarely may be a local tubercular process. It is usually small and 798 DISEASES OF THE STOMACH AND INTESTINES frequently circumscribed. It may break spontaneously through the cutaneous or mucous surface at the anal margin, and heal without the formation of fistula. The best treatment for these cases is early incision 1 with subsequent packing of the cavity. Local anesthesia can usually be employed. Ischio-rectal Abscess. This type lies below the levator ani muscle between it and the skin, between the rectum and pelvic wall. It may gravitate or burrow toward or through the mucosa into the rectum, or upward into the perineum and even press upon the prostate and urethra causing retention of urine. Etiology. Among the causes are traumatism from without or within, such as kicks, falls, wound from the tip of an injection syringe, puncture of the rectum from fish bones or an ingested pin; a hemorrhoidal opera- tion or carbolic injection into hemorrhoids; ulceration of the rectum in connection with stricture, rectal ulcers, proctitis and purely a local tubercular process may be responsible. Symptoms. There are often chills, temperature, pain in the rectal region and if the process gravitates down toward or starts more super- ficially, the skin will be red and edematous, and there may be a brawny swelling near the anus, spreading a considerable distance over the buttock. Difficulty of urination and even retention may occur, if the abscess bur- rows toward the bladder. When the inflammatory process is deep-seated lying near the mucosa of the rectum, there may be no cutaneous redness or swelling, but severe pain in the rectum, particularly on defecation; rectal examination with the finger will detect a sensitive area, sometimes projecting into the lumen of the canal. It may feel boggy or even give the sensation of fluctuation. There are also throbbing, and heat or burn- ing in the rectum. The blood shows leukocytosis and increased poly- nuclears. The patient may feel quite ill and have gastro-intestinal dis- turbances with considerable temperature, or the inflammatory process may not be so acute and the case attend to business though suffering con- siderable pain and discomfort. Treatment. This is surgical consisting of a free incision from the skin surface with drainage and packing. All pockets should be opened up and sloughs removed. Pelvic Abscess. This type of abscess forms above the levator ani muscles, lying between them and the peritoneum above. It may burrow in many directions in the pelvis and become of great size; may discharge into the rectum or bladder, or point in the groin, loin, or thigh, and may cause retention of urine or even intestinal obstruction by pressure. Etiology. It may result from many of the same causes as the ischio- rectal abscess, such as damage of the gut by a rectal bougie, or injury by a syringe tip, from appendicitis, from disease of some neighboring organs such as inflammation of the prostate, extravasation of urine from rupture or ulceration of the urethra, from gonorrheal infection, tubo-ovarian or uterine infection or necrosis of some adjacent bone of the pelvis or spine. With bone disease the abscess may be of the cold (tubercular) variety. 1 Occasionally a small superficial abscess may be excised and an attempt be made to secure primary union by deep suture. HEMORRHOIDS; PROLAPSE OF RECTUM; FISSURE 799 Psoas abscess, abscess from hip disease, perinephritis and periproctitis may all cause pelvic abscess. Symptoms. In acute cases, the pelvic pain may be severe, also lumbar pain; defecation and urination may be painful and there may be acute symptoms, with rise of temperature, chills, etc. Diarrhea may occur and the patient sink into the so-called "typhoid state." The rectum may be found extremely tender to palpation. Pus may escape into the rectum or bladder. In the chronic type, the symptoms may not be acute but the patient suffers from pain and discomfort; there is a low grade of temperature with leukocytosis, etc., and the rectal and vaginal examination give us information. Treatment. This consists of surgical procedure free incision and drainage at all dependent points. PRURITUS ANI Irritation and itching about the anus is designated by this name. It often produces great discomfort. The irritation is usually worse when the patient is in a warm bed. Scratching aggravates the condition. There may be no morbid appearances; more usually the skin about the anal margin is red and thrown into deep folds which may appear to be drawn within the anus. On separating these folds the sulci may appear eczematous. The skin may feel harsh and rough in old cases. Etiology. This may be local or general, such as minute thread worms, pediculi, hemorrhoids, fissure, proctitis, or a gouty diathesis. Treatment. This should be of the cause. If gouty or rheumatic, treat these conditions; if pediculi or thread worms appropriate treatment is indicated. The same is true of proctitis or other causes. Locally lead and opium lotion, witch-hazel applications, weak carbolic ointment, weak mercurial or ichthyol ointment, resinol, etc. In extreme cases section of nerves supplying this locality has been suggested. FISTULA IN ANO Fistula of the rectum may result from ulceration or perforation of the rectal wall from within. Thus a circumscribed ulcer may perforate the mucosa, or rupture of an inflamed hemorrhoid may be responsible. It is usually the result of a previous abscess, the etiology being that of abscess as already described. Fistulae may be superficial or deep. They are divided into the complete, which open both on the skin and into the bowel; external, which open only on the skin; and internal, which open only within the bowel. Diagnosis. When there is an external opening injection through it of methylene blue solution gr. v to 5i or same amount of carmine solu- tion results if there is also an internal opening, in the escape of colored solution into the bowel. The external opening may be very small, a point with excess of moisture, at times of a slightly bluish appearance. Frequently the cavity which it drains fills up at times so we get an in- 8OO DISEASES OF THE STOMACH AND INTESTINES durated area. In many cases one can detect a whip cord hardness running toward or around the anus under the skin. Simple internal fistula is more difficult to determine. One may have a sensitive point on digital examina- tion which may be due to ulcer or fissure. Through the proctoscope with a fine probe one may determine the opening of the fistula in most cases. There is usually some discharge at this point, or sometimes a small ulcer which when gently probed will admit the probe to a fistulous opening. Even a small internal fistula may cause considerable pain of a burning character which may last several hours after defecation. Moreover, the small cavity which the fistula drains, often fills up so that one can feel an indurated area or a tract of whip-cord hardness beneath the mucosa. When probing the external fistula, whether complete or incomplete, gentleness should be eihployed. Treatment. The writer finds the preliminary injection of a methylene blue solution, gr. v to 5 i water, stains the fistulous tracts and enables one to follow them out with ease during operation. In some cases with ex- ternal fistula, a wide incision with curetment and packing or iodoform oil (10 per cent.) injection is satisfactory. With complete fistula incision should be made at the external opening and the tract should be opened up gradually into the rectum. The sphincter should be divided at right angles and the edges trimmed so ultimate healing is not interfered with ; Gant omits packing. When there is an internal fistula it seems preferable to cut down externally and make it in effect a complete fistula, also divid- ing the sphincter. Occasionally excision of a small fistula may be prac- ticed with deep suture of the fresh surfaces. CHAPTER XXXI APPENDICITIS (Synonyms. Inflammation of the Vermiform Appendix; Peri typhlitis; Appendicular Inflammation : Scolecoiditis) INFLAMMATORY conditions involving the right iliac region have been called by a variety of names; Iliac phlegmon; typhlitis (inflammation of the cecum); perityphlitis (inflammation of the covering of the cecum); and paratyphlitis (inflammation of the retroperitoneal tissue behind the cecum). Though typhlitis was considered to be the cause of most of the inflammations in the right iliac fossa, modern investigation has demon- strated that appendicitis is the chief factor. Some go so far as to state thet even stercoral typhlitis (an inflamma- tion due to fecal accumulation) does not exist. This is an error, as C. A. Me Williams, 1 though admitting it to be rare, shows that an acute or chronic primary typhlitis may occur independently of appendicitis, dysentery, tuberculosis, actinomycosis, or cancer; and that it may be either idiopathic in origin or due to coprostasis. Autopsy reports and findings at operations have confirmed this, "a typhlitis" with the formation of perityphlitic abscess or general peritonitis, while the appendix remains normal. Howard Kelly has reported 14 cases presenting primary lesions in the cecum, the appendix being normal. Over 90 per cent, of inflammations are due to the appendix; the rest to the cecum. The symptoms of typhlitis are usually indistinguishable from those of appendicitis and the indications for operation are the same. The literature on appendicitis is enormous, and I shall only mention the names of a few of those specially identified with the operative technic and investi- gation of appendicitis, namely: Reginald Fitz, Richardson, Sands, Mc- Burney, Bryant, Bull, Weir, Fowler, Hartley, Mayo, Dawbarn, R. T. Morris, Wyeth, Blake, Brewer, Hotchkiss, Deaver, and Howard Kelly. Position of the Appendix. It takes its origin generally from the pos- terior and median surface of the cecum, corresponding to McBurney's point (i> inches from the anterosuperior spine of the ileum), on a line drawn from the spine to the umbilicus. The average length is from 3 to 5 inches, but it may vary markedly. The statistics as to its direction are quite variable. It may point downward and inward, downward behind the cecum, or upward, upward and inward, transversely inward, or out- ward. In many cases the appendix is quite long, and the position and length thus explain the variable locations of adhesions or abscess. It may, therefore, come in contact with the male bladder or rectum, with the uterus or right tube and ovary, or even the left tube, or with the small intestine, or it may pass up as high as the liver or right kidney, even to the left rectus, and close to the spleen. It has been found behind the peritoneum with no peritoneal covering. Bryant has reported it outside the peritoneal J Ann. of Surg., June, 1907. Si 801 802 DISEASES OF THE STOMACH AND INTESTINES cavity in three cases. It has been found quite frequently in hernial sacs, and on several occasions in the scrotum. It often hangs free in the abdominal cavity. In a few instances intussusception of the appendix into the cecum has been reported, the appendix being apparently absent, yet the patient suffering from symptoms. These are described under Intussusception as Intussusception of the Appendix. Moreover, the appendix may be be- neath the serous covering of the cecum, so that it cannot be determined by palpation. An incision through the serosa will reveal it. This condi- tion undoubtedly accounts for the so-called congenital absence of the appendix. Peculiarities of the Appendix. The lumen of the canal is extremely narrow; the organ is bottle shaped, the narrowest part being near the en- trance into the cecum. Gerlach's valve, a reduplication of the mucous membrane of the appendix near its origin from the cecum, makes the entrance of material more difficult, and also its exit. The circular muscu- lar fibers are somewhat scanty. These factors tend to produce stagnation and predispose to infection. There are many lymph-follicles (adenoid tissue) in the appendix, which usually persist up to the age of about thirty and then begin to retro- grade, so that infection is easy, as in the tonsils. In many cases the ap- pendix is completely surrounded with peritoneum, in some it is only par- tially covered, and the uncovered portion is in direct contact with the retroperitoneal connective tissue, which readily accounts for the so-called perityphlitic abscess. The appendix has a mesentery of its own, as a rule, the meso-appendix, but it is not constantly present. It rarely reaches . up to the tip, but usually only one-half to two-thirds of the distance. It is believed to have some influence on the shape of the appendix, as when it is relatively short the latter may be bent. Crile, 1 in an analysis of 1000 cases of appendicitis, found that in a large percentage there was a short meso-appendix, causing fixation of the proximal part and leaving the distal end free, which tended to cause the appendix to fold on itself and interfered with the circulation (an anatomic angulation). The blood-supply of the appendix is quite scanty. The vessels (the appendicular and a few cecal branches) Fowler believes to be functionally nearly end arteries, the most abundant being from the vessels (the appen- dicular) in the meso-appendix, so that the vascular supply of the tip of the organ is poor. In females, Clado 2 holds that there is a third source of blood-supply from a vessel passing through the appendiculo-ovarian ligament (a fold of peritoneum passing from the meso-appendix to the broad ligament), and this possibly explains why appendicitis is less common in women, on account of the superior vascular supply. Fowler holds that the blood- vessels may be primarily affected. Misplacement and malformation of the appendix may also have an influence. The peculiar anatomic con- formation of the appendix may predispose to infection. Etiology. The chief cause of appendicitis is bacterial invasion, the most common of which present is the Bacterium coli commune. As a 1 Ohio State Med. Jour., June, 1907. *Compt. Rend. Soc. Biol., 1897, vol. iv, p. 133. APPENDICITIS 803 rule, the infection is a mixed one, streptococci being frequently associated. The dependence on tube cultures alone is somewhat inaccurate, since the Bacillus coli readily overgrows and destroys less vigorous organisms. Smears should be taken in addition. Careful plate cultures should be made at the time of operation and also cultures under anerobic conditions. The swab should always be brushed against the intestinal walls and not simply dipped in the exudate. In Kelly's 400 cases the Bacillus coli was present in 92 per cent. The proteus vulgaris has been present. The Diplococcus pneumoniae, staphylococci, the anaerobes, and the influenza bacillus have been found. These are the most frequent varie- ties, and are found both in the appendix, appendical abscess, and in the general peritoneum (fluid of the) if peritonitis is present. In isolated cases, appendicitis is believed by some to be a local expression of a general infec- tion, as associated with scarlatina, measles, rotheln, small-pox, chicken- pox, parotitis, influenza, and acute articular rheumatism. It has ac- companied suppurative tonsillitis. Typhoid, dysentery, and, more rarely, tuberculosis may be causes. Actinomycosis has also been demonstrated to have produced it. Traumatism 1 or injury from lifting have been given as causes, but probably, if appendicitis occurs as a sequel, the organ was previously dis- eased or damaged, or the symptoms might be due to a circumscribed traumatic peritonitis. Constipation as a factor in the production of appendicitis is a question of dispute. Fitz and Fowler believed that in the majority of patients the bowels acted regularly previous to the attack, and Riegel holds that constipation and diarrhea have no bearing on the subject. Though unquestionably many patients suffering from constipation never suffer from appendicitis, there is one type of case in which it may be a factor, namely, patients in whom there is a tendency to fecal accumulation in the caput coli and lower ileum, with resulting appendix symptoms, probably from circulatory interference, pressure, blocking of the appendix opening, and catarrh secondary to a slight catarrh of the cecum. I have seen sev- eral such cases in which there were the typic symptoms, which rapidly subsided after thorough bowel irrigation, ice-bag, and later cathartics, and subsequent treatment of the constipation, with no subsequent attacks during eight or ten years' observation. To this same class belong the rare type of typhlitis due to stercoral ulcer to which Me Williams refers. Dietetic indiscretions, in so far as they are productive of intestinal putrefaction or fermentation with increased bacterial activity, might be a factor in producing an acute attack in an appendix already damaged. Kelly and Deaver hold that disturbances of digestion have an important influence in determining an attack of acute appendicitis. Intestinal catarrh, involving the caput coli, in my own experience has been the direct cause of the catarrhal type of appendicitis. Entozoa, such as the Trichocephalus dispar, Oxyuris vermicularis, Ascaris lumbricoides, tapeworm, and bilharzia, have been factors in the production of appendicitis. An interesting case of perforation of the appendix by a round worm, 2 with appendical abscess resulting, has been 1 Deaver, N. Y. Med. Jour., June 15, 1907. 2 Jour. Amer. Med. Assoc., Sept. 25, 1909. 804 DISEASES OF THE STOMACH AND INTESTINES reported. Metchnikoff, in 1901, first emphasized the importance of in- testinal parasites as the exciting cause of appendicitis, and reported three cases in which the feces contained ova of the ascaris and trichocephalus. They all recovered without operation after a vermifuge. Cecil and B uckley report five cases of appendicitis produced by the Oxyuris vermicularis at a meeting of the New York Academy of Medicine, May 17, 1910. Movable kidney, through pressure on the mesenteric vein, has been given as a frequent cause by Edebohls. This condition is associated with splanch- noptosis, and the circulatory changes from malposition of the viscera 1 are more probably factors. They occur most frequently with women, yet appendicitis is less frequent in the female. Foreign bodies entering the appendix, such as grape-seeds, cherry-stones, pits, pins, buttons, hairs, shot, gall-stones, etc., are rare causes of appendicitis. Fecal concretions are found frequently and have been mistaken for foreign bodies. Probably normally soft fecal matter enters and is ex- pelled from the appendix. . The fecal concretions are generally hard in character from absorption of water and are thickened by mucus. C. B. Lockwood has demonstrated that in many cases they consist of an in- spissated mass of bacteria. It is easy to understand how such concretions, if of large size, can exert pressure and even be productive of ulceration, especially if there be any abnormal condition in the appendix. They have been found in one-third to nearly one-half of the cases. Small concretions might remain in an appendix without harm. They generally lie near the end (tip). Diverticula of the appendix may be the cause of appendicitis. Some interesting observations have been made by W. C. MacCarty 2 as to the relations of carcinoma to appendicitis. 1. In a series of 2000 specimens, 0.6 per cent., or about i in every 175 appendices removed at operation are malignant. 2. In a series of 5000 specimens, 0.44 per cent., or about i in every 225 appendices removed at operation are malignant. 3. In a series of 2000 specimens, 2.2 per cent., or about i in every 40 partially or completely obliterated appendices are malignant. 4. In a series of 5000 specimens, 1.6 per cent., or about i in every 53 partially or completely obliterated appendices are malignant. 5. Carcinoma of the appendix may occur as early as five years of age and as late as eighty years of age. 6. Of the carcinomata of the appendix found in this series, 77 per cent. were not capable of being diagnosed from the gross external appearance. Harte has only collected five cases of primary sarcoma of the appendix, and Powers 3 reports one case in a girl of seventeen years. Williams 4 believes intestinal lithiasis depending on the calcium soaps from fats in food, has some bearing on the incidence of appendicitis. 1 With enteroptosis, the appendix may be tender in some cases, and relief be afforded by proper mechanical support and forced feeding (curing the ptosisj; others require operation. 2 Jour. Amer. Med. Assoc., Aug. 6, 1910. 3 N. Y. Med. Jour., Jan. 7, 1911. 4 Brit. Med. Jour., Dec. 31, 1910. APPENDICITIS 805 Right tubo-ovarian inflammation may be a factor in the production of appendicitis. Age. Appendicitis seems most frequent between ten and thirty years, Fitz stating that 50 per cent, occur before the twentieth year, and Einhorn 60 per cent, between sixteen and thirty years. It has been reported as early as the seventh week, but rarely before the third year. 1 At the Pres- byterian Hospital, New York, 33.9 per cent, occurred before twenty years, and 68.9 per cent, before thirty years. Sex. Men suffer from appendicitis much more frequently than women (from 2 to 3 or more to i). Johnson states 4 to i; Deaver 64.2 per cent, in males. At the Presbyterian Hospital the percentage was nearly equal. 2 Varieties. I will describe both the pathologic and clinical types of appendicitis. From a pathologic standpoint, the following seems the best classifica- tion: 1. Acute catarrhal appendicitis, in which the mucous membrane is involved, being swollen and edematous, the submucosa is injected with excessive secretion of mucus or mucopus. This type is mild, and the appendix drains into the cecum with perfect recovery (endo-appendicitis, Fowler). 2. Acute Diffuse Appendicitis. There is inflammation of the mucosa and thickening of the entire organ, which is rigid, tense, and infiltrated. By some it is classified as catarrhal, but this is incorrect. The peritoneal surface is hyperemic. There may be erosions or small ulcers and a fecal concretion. There may be mucus or mucopurulent material in the lumen, or in some cases it may be narrowed or obliterated. This type sometimes hangs free in the abdomen, but more generally is adherent to the adjacent peritoneal structures, and is characterized by the surgeons clinically as acute non-suppurative appendicitis. It may resolve without operation. On the other hand, this pathologic type may be productive of abscess or perforation, when it would be placed under a different class by the surgeons. 3. Purulent or Suppurative Appendicitis. This is a more advanced stage than the former. There is a definite pus-sac formed by the appen- dix. This type may also perforate and cause local abscess or general peritonitis. 4. Gangrenous Appendicitis. This is characterized by necrosis, local or general. The tip is most frequently involved or the entire organ. 5. Chronic Appendicitis. This may follow the acute, or the process may be slow and gradual from its incipiency. In some cases the changes have been found to be very slight, merely the evidence of a chronic catarrh of the mucosa, probably an extension from a chronic catarrh of the cecum. At times stenosis is present. On the other hand, the organ has been found firm, slightly enlarged and thickened, the mucosa thickened, and the lumen narrowed. In some cases there may be a stenosis, with formation of a cyst. In others there 1 Appendicitis may apparently occur in several members of one family. Horace Baldwin reports to me three children operated for chronic appendicitis for example. 2 McWilliams, Analysis of 1417 Operations upon the Appendix, N. Y. State Jour, of Med., March, 1910. 806 DISEASES OF THE STOMACH AND INTESTINES are concretions or erosions, or partial obliteration of the lumen; or the appendix may become converted into a cord-like structure, embedded in a mass of thick peritoneal adhesions. 6. Obliterative Appendicitis. A gradual involution process occurs in many individuals. The tube is thickened, the peritoneal surface smooth; the distal portion of the lumen may be entirely obliterated, and the organ becomes sclerotic and shrunken. Ribbert found these changes in more than 50 per cent, of subjects over sixty years of age. Normal involution seems to present no symptoms. On the other hand, W. C. MacCarty, 1 from his observations at St. Mary's Hospital, Rochester, Minn., concludes as follows: 1. Of all appendices removed at operation 23.5 per cent, are partially or completely obliterated. 2. The shortest duration of the process of obliteration when it is con- tinuous is less than ten years. 3. The process may be complete at ten years of age. 4. Obliteration does not occur as a physiologic involutionary process, but is dependent on a definite inflammatory reaction. 5. There seemed to be a large percentage of appendices (52 per cent.), with partially or completely obliterated lumina, in association with in- flammatory conditions of the gall-bladder (cholecystitis and cholelithiasis). This partial obliteration of the lumen occurred more frequently in females, which may be possible evidence that this inflammatory process in the appendix causes disturbances in the bile passages directly or indirectly, and may have some relation to the fact that cholecystitis is more frequent in females than in males. MacCarty 2 and McGrath in a subsequent article show that total ob- literation of the appendix occurs on the average at 34.6 years, while that of the tip averages at 29.8 years of age. Carcinoma of the appendix oc- curred 22 times out of 5000 specimens, or in 0.44 per cent, of cases. In 17 cases diagnosis by the surgeon at time of operation was impossible and the carcinomatous condition was only, revealed by the microscope. On section there is an orange-colored area in the obliterated portion of the appendix. They hold that all obliterated appendices should be re- moved and sectioned. Moreover, they found that obliterated appendices may become acutely inflamed and carcinoma may appear at any age in an obliterated appendix. Diverticula of the appendix were found in 17 cases, and of these 56 per cent, occurred in acute appendicitis, and in women. They conclude that all obliterated appendices should be removed. From a clinical standpoint the physician will find several types of acute and chronic appendicitis, readily deduced from the pathologic classification. i. Acute Simple Catarrhal Appendicitis (Endo-appendicitis). A catarrh of the mucosa of the appendix. This is of mild type and is often secondary to a colitis or to fecal impaction in the cecum. Unless there is occlusion, the inflammatory products usually drain out (non-suppurative type, with complete cure). There may be recurrent attacks. 1 Jour. Amer. Med. Assoc., Aug. 6, 1910. 1 Surgery, Gynecoiogy, and Obstetrics, March. 1911. APPENDICITIS 807 2 . A cute Non-sup pur ative A ppendiciiis (Sometimes Incorrectly Character- ized as Acute Catarrhal). The description is that of the Acute Diffuse Appendicitis, the entire organ being involved. There is fibrinous exudation agglutinating the appendix to neigh- boring structures, and the meso-appendix is thickened and inflamed. There may be kinking or torsion of the organ, stricturing, or even oblit- eration, and a fecal concretion may be left within it. These cases often escape operation and may not have a recurrence, but there is great liability of the latter. On the other hand, ulceration with perforation may occur. 3. Chronic Appendicitis. This may follow the acute, or the process be slow and gradual from the start. The chronic catarrhal cases may exhibit but little change, or the appendix may be Fig. 320. Symmetric involution of ap- pendix (Morris). Fig. 321. Nodular involution of ap- pendix (Morris). thickened, the mucosa thick and hyperemic, and its lumen narrowed, obliterated, or strictured. A fecal concretion may remain within it. It may present adhesions. It may follow an acute attack or be chronic from the onset. These three types are characterized by absence of perforation, gangrene, or abscess formation; though type 2 may progress to type 4, with result- ing abscess or perforation. 4. Acute Sup pur ative Appendicitis (Formation of Abscess). Of this we have two clinical types, the pathologic purulent appendicitis (the appen- dix distended with pus), on the verge of perforation, or an inflamed appen- dix enclosed in an abscess-cavity containing a varying amount of foul pus. The walls of the cavity are formed by adjacent peritoneal surfaces, coils of intestines, cecum, and omentum bound together by adhesions. The appendix lying in the abscess-cavity is congested and swollen, 8o8 DISEASES OF THE STOMACH AND INTESTINES and may or may not be perforated or present areas of gangrene. It may be adjacent to the cecum or intestines or reach into the pelvis to the blad- der or tubes and ovaries. Perforation, when present, is generally near the free end of the appendix. 5. Gangrenous Appendicitis. The appendix is congested, swollen, thick, and red, with gangrenous areas of greenish-black color and usually already perforated. It is marked by the absence of protective peritoneal adhesions. There may be a fatal septic peritonitis before perforation of the appendix. Patches of fresh fibrin may be present with serous or bloody turbid serum in the peritoneal cavity or adhesions with pus. Fig. 322. Transverse section of the appendix, showing replacement of the inner coats by connective tissue (Morris). The condition is an acute gangrene due to thrombosis and occlusion of the blood-vessels. If the case is more chronic, some plastic peritonitis may be present. A purulent appendix, an acute diffuse appendicitis, or a concretion may ulcerate through, so that any of these types including the gangren- ous may be classified as perforative appendicitis. 6. Protective Appendicitis, or Harmful Involution of the Appendix (Morris). The vermiform appendix normally undergoes an involution process with replacement of -the lymphoid, mucous, and submucous coat by connective tissue. R. T. Morris 1 notes that the nerve-filaments per- 1 Med. Rec, April 6, 1907; ibid., Jan. 8, 1910. APPENDICITIS 809 sist longer than other structures, and contraction of the connective tissue in some cases irritates these nerve-filaments, so that irritation of the ganglia of the bowel (Auerbach's and Meissner's plexuses) ensues and causes disturbances in the nearby intestines. This condition he char- acterizes as "fibroid degeneration of the appendix." 1 The appendix is at no time the seat of acute or chronic infection, and the condition is characterized by intestinal dyspepsia and other definite symptoms which will be described later. The involution may be sym- metric or nodular (Figs. 320-322) and occurs most markedly toward the distal extremity. R. T. Morris 2 classifies four kinds of appendicitis. 1. Protective Appendicitis. An irritative lesion without infection. 2. Appendicitis with Intrinsic Infection. 3. Syncongestwe Appendicitis. An irritative lesion, due to serous infiltrates in the tissues of the appendix and occurring synchronously with similar congestion of neighboring tissues. For example, it may occur with obstruction of the lymph and blood circulation through certain diseases of vital organs and with loose right kidney. 4. Appendicitis with Extrinsic Infection. An infective lesion due to bacterial approach from other structures lying outside of the appendix, such as from inflammation of the uterine adnexa. A. V. Mosckowitz suggests a classification 3 which he has elaborated after a study of nearly 4000 cases at the Mt. Sinai Hospital. It embraces both the pathologic and clinical aspects. I. Catarrhal inflammations. (a) Acute catarrhal appendicitis. (b) Chronic catarrhal appendicitis. (c) Acute catarrhal appendicitis with abscess. (d) Appendicular abscess. II. Destructive inflammations. (a) Acute gangrenous appendicitis. (b) Acute gangrenous appendicitis with abscess. (c) Acute gangrenous perforative appendicitis. (d) Acute gangrenous perforative appendicitis with abscess. (e) Acute gangrenous or perforative appendicitis with gangrene of cecum. III. Retention cysts. (a) Hydrops of appendix (mucoid contents). (b) Empyema of appendix. (c) Empyema of gangrenous appendix. IV. In combination with blood infections. (a) Acute gangrenous or perforative appendicitis with thrombosis of mesentery. (b) Acute gangrenous or perforative appendicitis with portal pyle- phlebitis. 1 Amer. Jour, of Surg., October, 1909. 2 Protective Appendicitis, p. 97. Dawn of the Fourth Era in Surgery (R. T. Morris), W. B. Saunders Co., 1910. 3 Amer. Jour, of Surg., Sept., 1910. 8 10 DISEASES OF THE STOMACH AND INTESTINES V. In combination with peritonitis. (a) Dry or fibrinous peritonitis. (b) Serous peritonitis. (c) Seropurulent peritonitis. (d) Purulent peritonitis. (e) Appendicular abscess with purulent peritonitis. VI. Specific inflammations. (a) Tuberculosis. (b) Actinomycosis, etc. VII. New growths. (a) Carcinoma. (b) Sarcoma. (c) Fibroma. (d) Diverticula, etc. This table the writer believes of chief value as an index to the possible conditions that may be found at operation. Symptoms of Acute Appendicitis. The symptoms of acute appendi- citis are modified by the character of the lesion, whether it is a simple catarrh, an appendicitis with the production of adhesions, a pus-cavity, or of the acute gangrenous type. In general the cardinal symptoms of acute appendicitis are as follows: 1. Sudden pain in the abdomen in the right iliac region, or at times first epigastric or umbilical, which soon or gradually localizes in the right iliac fossa. Pains are continuous, increasing, or there are only exacerba- tions of pain. More rarely general abdominal pain is at first present. 2. Tenderness or pain on pressure in the right iliac region at Mc- Burney's point. Often there is an area of resistance due to tumor or to muscular rigidity. Localized rigidity is frequently our main guide in children. The symptoms are often misleading in infants. Deaver 1 re- ports 300 cases. Moreover, we must remember that in children the abdomens are small and their appendices are relatively long, so that sensitiveness at a distance from McBurney's point is more common than in adults. 3. Fever of moderate or severe type. 4. Gastro-intestinal disturbances may be present, such as nausea or vomiting, and frequently constipation. 5. In the septic gangrenous type I have, in a fairly large percentage of cases, observed a toxemic type of diarrhea with general abdominal pains at times, as the initial symptom, before localization of the appendix pain. This is evidently of septicemic character and has not, to my knowledge, heretofore been referred to as a symptom. Rudolph Schmidt 2 assumes that the changes from normal in the intes- tinal flora of the feces, which occurs in appendicitis, may explain diarrhea in the early development of this disease; or possibly acute enteritis from dietary indiscretion may be the cause. The type of diarrhea with gan- grenous appendix seems to the author peculiarly septic and is relieved by appendectomy. 1 Jour. Amer. Med. Assoc., Dec. 2, 1910. z Rudolph Schmidt, Pain. APPENDICITIS 8ll 6. In some cases the thighs and knees are flexed. 1 7. Irritability of the bladder, if the appendix extends down into the pelvis, may occur in some cases. Appendicitis in Infants and Children. Appendicitis is more common in the male sex and usually runs a rapid and severe course. In a more recent article Deaver 2 states that "all cases of abdominal trouble in chil- dren are appendicitis until proved otherwise." There should be a sys- tematic examination of all organs. Appendicitis in infants is difficult to diagnose, as the symptoms are often misleading. The younger the child, the more deeply the appendix lies in the pelvis. Urinary symptoms may predominate in these cases, for example, cloudy urine from edema of the bladder, tenesmus, and even retention. Pelvic abscess is common and hip-joint disease may be simulated. Rectal examination is of great im- portance as an aid to diagnosis, as an appendical abscess or enlarged appen- dix can frequently be determined by this method. Pain of Appendicitis. The pain may be sudden and violent, or at times intermittent and cramp-like, or even of a gnawing character or a dull ache. Sudden and violent pain in the initial stage does not by any means mean perforation, unless other symptoms are associated. In about one-half the cases the pain begins in the right iliac fossa; it may com- mence in the epigastrium, around the umbilicus, or even be diffuse, but gradually becomes localized within twelve to twenty-four or thirty-six hours, and usually sooner. At times the pain is of a colicky type (the so-called appendicular colic, supposed by some to be due to constriction of the appendix in forcing out mucus through a lumen nearly occluded). Pain is increased on moving. It is often relieved by flexing the knees and thighs, especially the right thigh, and so relaxing the abdomen. This position is at times 'assumed by the patient. Palpation of the A ppendix. Though some surgeons believe this to be an important procedure to "render the diagnosis certain, Treves and Lock- wood are very skeptical regarding the possibility of mapping out this organ. In the chronic cases palpation is of value, and the position and condition of the appendix can often be determined thereby. In acute appendicitis the methods of forcible palpation recommended often necessitate the use of considerable pressure, and I believe the pro- cedure highly dangerous. In the initial stages of acute appendicitis, it is often impossible to at first determine the character of the attack, and trau- matism in some cases can precipitate a rupture. In the acute cases gentle palpation only should be used. Percussion, according to Rudolph Schmidt, will often demarcate the area of pain bet- ter than will palpation. Muscular Rigidity. There is usually rigidity of the lower right rectus muscle of varying intensity. Tenderness on Pressure. This occurs at McBurney's point and is of varying intensity, also at Morris' point, and Blumberg describes a new symptom. There are two points of great diagnostic value in appendicitis: 1 The right thigh and knee are most frequently flexed. 2 Jour. Amer. Med. Asspc., Dec. 24, 1910. 8l2 DISEASES OF THE STOMACH 'AND INTESTINES tenderness at McBurney's point and at Morris' point (over the right lumbar ganglia). McBurney's Point. If a line be drawn from the anterosuperior spine of the right ileum to the umbilicus, a point ij inches from the spine along this is known as McBurney's point; and deep-seated tenderness on pres- sure over this point is diagnostic of appendical inflammation when taken in consideration with other symptoms (Fig. 323). Deep pressure also often causes reflex epigastric pain. Berthonier has recently pointed out that the examination in the left lateral position produces severe pain over McBurney's point in appendicitis, even in cases where this is not found with the patient in the dorsal position. Mere superficial tenderness means irritation of the sensory nerves of the abdominal wall due to hysteria, etc. Fig. 323. A, McBurney's point; B, R. T. Morris' point (lumbar ganglia) in appendicitis. Munro's point is slightly further out, where the same line crosses the outer border of the rectus. Lanz's Point. This observer draws a line between the two antero- superior iliac spines, and divides this line into three equal parts. He claims that the first point of division corresponds to the base of the ap- pendix and that McBurney's point is too high up. Morris' Point. 1 "Take another point on the line between the umbili- cus and anterosuperior spine of the ileum, but ij inches from the navel, which lies over the right lumbar ganglia of the sympathetic system, and we have another point of diagnostic value when tenderness on pressure is located in this region. "i. In the early stages of an acute infective process of the appendix, the right lumbar ganglia are not tender. (The left lumbar ganglia may be described for diagnostic purposes as lying \y% inches to the left of the 1 Surgical Section, New York Academy of Medicine, Dec.. 5, 1907. The author here quotes Morris' deductions. APPENDICITIS 813 navel.) Under these circumstances the point here described is of second- ary importance, while McBurney's point is of prime consequence. "2. A. When an acute inflammatory process of the appendix has sub- sided, leaving a mucous inclusion or scar tissue, there may be no tender- ness on pressure at McBurney's point, but there is tenderness at the point here described and no tenderness at the point of the left lumbar ganglia. "B. When the appendix is undergoing an involution process, with replacement of its lymphoid coats by connective tissue, digestive disturb- ances and various local neuralgias may be due to irritation of nerve-fila- ments entrapped in the new connective tissue. There may be no tender- ness at McBurney's point, but there is persistent tenderness at the point here described. There is no tenderness at the point of the left lumbar ganglia." The above condition constitutes fibroid degeneration of the appendix. "C. When the appendix is congested without the presence of infec- tion, as in many cases of loose kidney, there may be little or no tenderness at the point here described. There is no tenderness at the point of the left lumbar ganglia." The author wishes to state, as before, that this type of appendical congestion he believes is not due to loose kidney pressure, but is dependent on the enteroptosis. "In irritations of pelvic origin, both right and left lumbar ganglia are tender. Take, for illustration, a case in which the appendix and the right Fallopian tube are bound together by adhesions. We are to decide whether certain symptoms proceed from the appendix or from the Fal- lopian tube. If the symptoms proceed from the appendix, the point here described is tender alone. If the symptoms proceed from the Fallopian tube, both right and left lumbar ganglia are tender together. "To recapitulate: A patient comes in with the appendix in the form of a question mark. Right lumbar ganglia tender alone appendix trouble. Right and left lumbar ganglia tender together pelvic trouble. Neither right nor left lumbar ganglia tender trouble somewhere cephalad from pelvis and appendix." Superficial Reflexes of the Abdominal Wall. In appendicitis the skin reflexes of this region are frequently absent or markedly diminished. The return of the lost reflexes is usually synchronous with other evidences of recovery. Blumberg 1 describes a sign pointing to peritoneal irritation or inflam- mation, which he considers will be found of assistance in the diagnosis of all peritoneal conditions, and especially of appendicitis. It consists in the fact that on palpating the abdomen in the neighborhood of an area of inflamed peritoneum, not only is the downward pressure painful, but, if the examining hand is suddenly removed, the abrupt recoil of the abdominal wall also gives rise to pain. He has found that during an acute attack of appendicitis with peritoneal involvement, patients invariably state that the pain caused by the sudden removal of the hand is greater than that caused by the pressure, while if the inflammatory process is subsiding, the two painful sensations first become equal in intensity, and finally the pres- 1 Miinchener med. \Yochenschr., June ri, 1907. 814 DISEASES OF THE STOMACH AND INTESTINES sure pain is greater than the other. He further believes that the sign is especially valuable in determining whether or not operation is indicated in early cases, since its presence indicates that the peritoneum has already begun to take part in the inflammation. Its sudden appearance is, there- fore, a danger signal, while its gradual diminution in intensity points to a subsidence of the peritoneal reaction. The advantage of the method is that it does not require an absolute estimation of the degree of pain caused by the palpation, which is often difficult to obtain, but demands simply a comparison of the intensity of the two painful stimuli, which most patients are able to determine accurately. S. J. Meltzer's Method. Meltzer extends the right knee, at the same time flexing the right thigh, while making pressure over McBurney's point. This projects the psoas muscle against the appendix and causes deep-seated tenderness in the appendix to be more readily appreciated. H. Illoway 1 holds that forced flexion and especially forced extension of the right thigh will cause pain in the appendix if inflammation is present. Rovsing-Chase Method. The patient is preferably placed on a hard low bed or table. The knees should be flexed and two pillows placed under the head and shoulders, giving a dorsal semirecumbent position, and thus rendering the abdomen flaccid for a satisfactory abdominal compression. The examiner stands on the patient's left, facing the feet. The palmar surfaces of the ringers of the right hand are placed at the low- est part of the patient's left inguinal region, and the fingers of the left hand are used to reinforce the right. Deep pressure is then made back- ward along the descending colon, the fingers being slowly drawn upward, toward and under the left costal arch. By this procedure, the lower por- tion of the descending colon is compressed and its gaseous content forced into the transverse, and thence into the ascending colon. The pressure over the descending colon being maintained with the fingers of the left hand, the right hand is then removed and placed over the upper part of the descending colon, or, preferably, over the transverse colon, and the fingers are quickly and forcibly depressed. A gaseous compression wave will travel across the transverse and down the ascending colon, and on arriving at the cecum will produce distention, producing a typical sharp pain in the right iliac fossa, if inflammation of the cecum or appendix be present. This method is of chief value in testing for chronic appendicitis. Bastedo's Method for Testing for Chronic Appendicitis. A colon tube is passed n or 12 inches into the rectum and air is injected by means of a bulb; that of an atomizer may be employed. If as the colon distends, pain and tenderness on pressure by the finger point occur at McBurney's point, then chronic appendicitis is present. Most of the air should be allowed to escape before removal of the tube to avoid subsequent colicky pains. This method aids differentiation between appendicitis and right tubo-ovarian inflammation. In many cases, especially in the acute catarrhal conditions or in the most virulent gangrenous type, no induration or swelling can be appreciated on palpation. Under such conditions forcible palpation in the endeavor to appreciate the appendix should be avoided. 1 Archiv of Diagnosis, July, 1908. APPENDICITIS 815 Percussion. In cases with adhesions, exudation without pus, or of abscess, a boggy or, rarely, fluctuating mass can be appreciated in the right iliac fossa, and percussion will give a dull area in the region of the cecum. Fecal accumulation as a result of constipation must be differentiated by the methods I have already indicated. At times great irritability of the bladder is associated with this con- dition and the urine may be scanty and contain indican and albumin and casts, and even acute nephritis may be present. Rectal and vaginal examination often aid in localizing the condi- tion if the appendix or abscess lie in the pelvis. In single women one should employ rectal examination. These methods also aid differential diagnosis. Inspection may occasionally show protrusion on the right side or the distention of general peritonitis. If turner is present, it may be variable in size, and it lies more fre- quently in the right iliac fossa. Its position, however, depends on that of the appendix, as already described. Temperature. An initial chill is rare. In the acute cases fever, even though slight, is present in the early stages. It may be only 99.5^. or keep low, or even rise to 101 or io2F., or to a considerable height. Sometimes with circumscribed abscess there may be for a time only moderate temperature, and some cases of the virulent type will suddenly perforate, though the temperature be not high. In both of these the physical examination, the blood-count, and general symptoms will aid the diagnosis. In general, a rise of temperature is significant of an active process, even though the temperature increase may be slight in degree and gradual in character. A slight increase in rapidity of the pulse is also suggestive of an acute process, and at times this is noticeable much out of proportion to tlie temperature, especially the rapid pulse in gangrene or sudden perforation. Gastro-intestinal Symptoms. Loss of the appetite and coated tongue are present. Emaciation may occur in cases of long duration. In the severer cases vomiting is quite common. It may be one of the first symptoms occurring with the pain, and then cease, or it may continue for several days. On the other hand, it may come on later in the attack and denote an exacerbation of the inflammation. It consists of the stomach contents, mucus, and bile; and in some cases it may be feculent. Associated with it there is at times hiccup. Black vomit ("vomito negro appendiculaire ") is the result of toxemia, producing hemorrhagic necrosis of the mucosa of the stomach and hematemesis. A few cases have also been reported of intestinal hemorrhage asso- ciated with jaundice and albuminuria. These conditions are all evi- dences of a fatal sepsis. Acute ectasia or acute gastro-intestinal dilatation may also occur as complications. Bowels. In some cases the bowels are regular, until the attack, when constipation ensues. In others there may be a previous history of constipation. Diarrhea of a toxemic type may be one of the initial symptoms in acute gangrenous appendicitis. It is probably of septicemic 8i6 character. I have noted it in several such cases. Intestinal paresis may occur as a complication. Tumefaction or Abscess. In cases of acute appendicitis in which adhesions are present, a tumor due to adhesions and exudation, or an actual abscess, the position of the mass is dependent upon the position of the appendix primarily and then upon the direction of the extension of the inflammation or burrowing of the pus. It may pass down into the pelvis and produce bladder and rectal symptoms, or those pointing to the tubes and ovary (right), and be palpable through the rectum and vagina. It may point below Poupart's ligament or simulate a psoas abscess. It may pass around in front of the cecum and superficial edema be noted in this region, or posteriorly to the cecum and cause pain in the flank or back, with swelling, and produce perine- phritic abscess or lumbar abscess. It may pass inward to the left, even to the spleen, or produce obstruction through pressure or bands, or upward and produce subphrenic abscess (Fig. 324), and even perforate the diaphragm, pleura, and lungs. It may develop in a hernial sac. Retroperitoneal 1 rupture of the appendix has occurred with subsequent extravasa- tion of pus into the thigh resulting in gangrene. At times the tumor appears at the lower border of the liver, when the tip of the appendix lies in this region. The condition must then be differentiated be- tween retroverted appendical abscess and gall-bladder or renal inflammation, such as infarction. Brewer has shown that tenderness at the costovertebral angle is diagnostic of the latter; the urine analysis is also important, and especially differential analysis after catheterization of both ureters. Determi- nation of Head's zones may also aid in the diagnosis. The history will usually point to appendicular inflammation or disease of the gall-bladder, but operative procedure will alone settle some cases. The value of Head's zones of cutaneous hyperalgesia as an aid to differential diagnosis will be referred to under that section. The elements in the diagnosis of abscess formation are the grad- ual increase of the local tumor and the aggravation of the general symp- toms. The abscess may perforate and cause a general peritonitis or the inflammation may extend to the peritoneum without perforation, so Fig. 324. D, Diaphragm; L, liver; K, kidney; P, perito- neum; C, colon. The appendix lies behind the cecum and colon. The dotted area indicates the retroperitoneal spread of appen- dical inflammation to the cellular tissues around the kidney and the under surface of the liver (Cantlie). 1 Journal A. M. A., June 7, 1913. APPENDICITIS 817 that there may be a slower process with various sacculated collections of pus. The abscess may rupture through the skin or empty into the cecum, colon, small intestine, bladder, rectum, or pelvis of the kidney. Fulminating Type of Acute Appendicitis. This is the most dangerous and fatal of all. This type of appendicits can be subdivided into two clinical varieties. Both are characterized by the rapidity of the patho- logic changes in the appendix and by the absence of protective peritoneal adhesions, so that general peritoneal infection occurs quite rapidly. In the first class the pain in the region of the appendix and some of the subjective and objective symptoms are acute and quite marked but not all of them. In the second class, and by far the most dangerous because fre- quently undiagnosed until the general infection has occurred, the patient complains of no marked subjective symptoms; in fact, may say he is quite comfortable, and the objective symptoms are not marked. There are peculiarities in the pulse, temperature, and especially in the blood changes which tell the story. Acute gangrene of the appendix, with or without perforation, is the pathologic condition generally found in operation; though I have also seen an acute diffuse or purulent inflammation of the appendix, either with perforation or without it,- produce the condition. In some cases perforation was apparently due to ulceration from a fecal concretion which was found in the cavity. Perforation undoubtedly is present in many cases, but I agree with Riegel that acute virulent infection of the peritoneum, commencing in the region of the appendix, will produce the same clinical symptoms. In the first class of cases the patient may have given a history of previous attacks or have had some indefinite abdominal symptoms for several days, or may be attacked without warning, as in the mid- dle of the night, with severe pain in the abdomen. It may not at first be referred to the appendical region, may be epigastric or umbilical pain, but gradually localizes there. There is no tumor, the muscles are rigid, the appendix tender. The abdomen rapidly distends. The patient is anxious and looks sick. The temperature at first may not be elevated much. The pulse is rapid and out of proportion to the temperature. General symptoms of peritonitis rapidly ensue. In others the pulse may be slow at first and a low temperature with local signs of appendicitis, but acute history, nausea, vomiting, and marked constipation. The pulse later becomes more rapid, high temperature, distention, coated tongue, and general tenderness. In others the first symptoms are of collapse, with subnormal tem- perature, rapid pulse, cold and clammy skin, respiration increased in frequency, followed by symptoms of general peritonitis. In the second class of cases the condition may be very deceptive. The patient, in perfect health, may suddenly complain of general abdom- inal pains. I have seen a number with diarrhea of toxic character as the initial symptom. The patient may impute the symptoms to dietary indiscretions. The tenderness may be diffuse or equal on both sides, and 52 8l8 DISEASES OF THE STOMACH AND INTESTINES gradually it localizes in the appendix region. Even so, the tenderness at McBurnery's point may not be very acute, and the rigidity of the right rectus not very marked or very slight. The patient may state that he feels quite comfortable. The temperature may be moderate (iooF.) and the pulse 100. The temperature tends to gradually creep up, the pulse to increase in rapidity out of proportion to the temperature increase, which last may be slight, and the character of the pulse changes; the patient looks more sick, but still complains of no special symptoms except slight pain or exacer- bations of it in the right side, and still feels comfortable. The blood examination shows in many cases moderate leukocytosis (14,000 to 16,000), but marked increase in the polynuclears (88 to 9 2 per cent.). Hyperinosis is present. The patient presents as yet no symptoms of general peritonitis, but nevertheless the sepsis is marked in these cases, and unless immediate operation is performed will have a virulent type of septic peritonitis. A patient of mine operated on by the late Frank Hartley presented the mild type of symptoms just described; diarrhea at 4 P.M.; no appendical pain or tenderness; localized appendical pain at midnight, when the sur- geon was at once called in. Differential blood-count at 8 A. M. and i p. M., showing a gradual increase in polynuclears and low leukocytosis (15,000 to 16,000). The patient was quite comfortable; no distention; slight pain over appendix, but the temperature and pulse slowly creeping up. At 5 A. M. operation at the New York Hospital; acute gangrene of appendix and commencing peritonitis; ultimate recovery. The examination of the blood is thus imperative when possible. Brewer, 1 however, reports one case of acute gangrenous appendicitis in which the blood count was within the normal limit, a temperature of only gg.2F., and the only evidence of severe disease was a well-marked rigidity of the lower half of the right rectus muscle. One must also remember that in the course of tabes, acute appendicitis has occurred even with perforation, and with the formation and rupture of an abscess or with diffuse peri- tonitis, with little or no pain, and with very few local evidences of an inflammatory process. Connors 2 reports an interesting case. The patient had chills, irregular temperature, later vomiting and leukocytosis. There were no pain, tenderness, and muscular rigidity. Autopsy showed perforative appendicitis and diffuse peritonitis. There were found the spinal lesions of tabes dorsalis. The Blood in Acute Appendicitis. Hyperinosis (increased fibrin in the blood) has been demonstrated by E. E. Smith and Bartlett 3 to be more marked in direct proportion to the involvement of the serous surface, and hence, depending on Us degree, is suggestive of proportional peritonitic infection. One of the most important factors in the determination as to operative procedure in appendicitis and as to the relative severity of the case is the differential leukocyte count. Charles Langdon Gibson has especially pointed 1 Masked Appendicitis, N. Y. State Jour, of Med., March, 1910. 2 Jour. Amer. Med. Assoc., Oct. 22, 1910. 3 Blood Reactions of Inflammation. Med. Rec., Feb. 8, 1908. APPENDICITIS 819 out that it is the disproportion between the percentage of polynuclear cells and the total leukocytosis that is important. The chart (Fig. 325) assumes that 10,000 leukocytes per cubic milli- meter is the upper limit of ordinary normal leukocytosis, and that 75 is the normal percentage of polynuclears. Gibson further assumed that in inflammations which are well resisted the polynuclear cells are increased approximately by i per cent, for every 1000 leukocytes above the normal 10,000 per cubic millimeter. Thus in the chart the horizontal line will indicate a leukocyte count of 11,000 with 76 per cent, of polynuclears, whereas the rising line represents a leukocytosis of 11,000, but with 86 per cent, of polynuclears. If the line connecting the total leukocytes and the percentage of polynuclears runs fairly horizontal, it indicates a lesion that, whether severe or not, is well borne and, therefore, of good prognosis. If the line runs upward from the leuko- cyte to the polynuclear side, it indicates a rather severe lesion and less resistance. Fatal cases all have a rising line. A falling line (e,g., leukocytosis of 30,000 with 80 per cent, of polynuclears) means a mild lesion; in appendicitis it would probably indicate an abscess well shut off, with little febrile or constitutional disturbance. Gibson's conclusions are as follows: The differential blood-count and its relation to the total leukocytosis is the most valuable diagnostic and prognostic aid in acute sur- gical diseases that is furnished by any of the methods of blood examination. It is of chief value in indicating fairly consistently the existence of suppuration or gangrene, as evidenced by an increase of the polynuclear cells disproportionately high as compared to the total leukocytosis. The Gibson chart is to a certain extent schematic, as it is only applicable to a leucocyte count of about 25,000, since if it were 30,000 or over, there could only be a rise of 5 units in the polynuclears, and this would be 100 per cent., which never occurs. It would also suggest a good prognosis according to his unit system of rise and fall. One can apply Gibson's principles for the higher counts by the chart (Fig. 326), as suggested by Coons and Bratton. 1 Sondern substantially employs this same type of chart. E. E. Smith 2 shows that the differential blood-count is an indicator of the activity of the process and not invariably of gangrene; but if the absolute leukocytosis is low (below 15,000), with high polynuclears, it is probably gangrene. 1 Prognostic and Diagnostic Value of the Leukocytes and Differential Count in Acute Abdominal Infection, N. Y. Med. Jour., July 21, 1909. 2 Blood Reactions of Inflammation, Med. Rec., Feb. 8, 1908. TOTAL LEUCOCYTOSIS PERCENTAGEOF POLYNUCLEARS iS.ooo 3o,OOO 25,000 ^0,000 15.000 JNOMvMI (.10.000 5,000 100% 95* 90* 85 y 80* * 70* I ^ \T~ 1 Fig. 325. C. L. Gibson's differential chart for leukocy- tosis. 820 DISEASES OF THE STOMACH AND INTESTINES Gibson further holds that the greater the disproportion the surer are the findings, and in extreme disproportions the method has proved itself practically infallible. As the relative disproportion between the leukocytosis and the per- centage of the poynuclear cells is of so much more value than the findings SaL 85 5 V" cent. Fatal f the gallbladder. Leucocytes, 4,300; polynucle S3 per cent Fatal. c Puerpural sepsis. Leucocytes, cent. Fatal. polynuclear, 00.2 per cent. Recovery. . Appendicitis, local peritonitis, dear, 80.9 per cent Recovery. I. Appendicitis, spreading peritoniti cuclcar, g^.6 per cent. Recovery. :ucocytes, 40,000: polynu- Leucocyt", 49,000; poly. Fig. 326. Blood-count chart (Sondern). based on a leukocyte count alone, this latter method should be abandoned in favor of the newer and more reliable procedure. The negative findings, showing no relative increase or even an actual decrease of the proportion of the polynuclear cells, while of less value, show with rare exceptions the absence of the severer forms of inflammation. In its practical applications the method is of more frequent value APPENDICITIS 821 in the interpretation of the severity of the lesions of appendicitis and their sequelae. Though N. E. Ditman, in a paper read before the Obstetrical Section of the Academy, November, 1906, criticizes the differential count as of doubtful value, Sondern 1 shows that in cases quoted the pus was encap- sulated in such a way that no toxic absorption occurred, and also demon- strates that polynuclear increase may occur in other than suppurative conditions. It is a well-known fact that such encapsulated abscesses may occur without marked constitutional symptoms, but physical signs determine their presence. In this type the processes are less active, and this is probably the chief cause. I have seen a very low leukocytosis with a general fatal peritonitis, the system evidently being overwhelmed by the poison. The physical signs, with increased polynudears and hyperinosis, aid our diagnosis in all but exceptional cases. A low leukocytosis with high polynuclear count also shows poor resist- ing power to the infecion. To recapitulate: We may. have numerous types of acute appendi- citis, which clinically are as follows: 1. Simple catarrhal appendicits with mild symptoms, lasting a few days to a week or ten days; often secondary to colitis, intestinal dis- turbances, or fecal impaction in the caput coli; blood changes are moderate and the attack soon subsides under medica 1 treatment combined with the ice-bag. It may never recur. 2. Acute appendicits (diffuse), symptoms more severe; may be adhesions or slight exudation; temperature higher; more marked tender- ness; tumor often palpable, but may disappear. It may become chronic or recurrent, or occasionally perforate. 3. Acute appendicitis, with abscess, chills, tumor, etc., present. Abscess may perforate. 4. Fulminating type, perforation or gangrene. Remote Effects of Acute Appendicitis. They are as follows: Hemor- rhage from perforation of a blood-vessel; suppurative pylephlebitis; pyelitis; thrombosis of the iliac or femoral veins; pulmonary embolism; pericystitis; strangulation of the bowel; subsequent symptoms may occur due to incomplete removal or subsequent adhesions. Hartley has noted intestinal paresis in mild cases, with symptoms of ileus resulting; also infection of the mesenteric glands, subsiding in some cases after appendec- tomy, and in others causing subsequent inflammation. Acute dilatation of the stomach may occur. Cellulitis of the abdominal wall has occurred. Subphrenic abscess has followed acute appendicitis especially, the retro- verted appendix extending to the liver or from appendical abscess. Box, 2 Russel and Neuhof 3 report cases of non-suppurative subphrenic inflam- mation complicating appendical abscess. 1 N. Y. Med. Jour., June 26, 1907. 2 St. Thomas Hosp. Reports, vol. xxvi, 1891. 3 Surgery, Gynec. and Obst., March, 1912. 822 DISEASES OF THE STOMACH AND INTESTINES Postoperative stomach and intestinal hemorrhage after appendi- citis operations are described by Schwalbach, 1 who collected 30 cases. They are more frequent in children and in men. There are hemorrhages, erosions, and ulcerations in the stomach and intestines due to thrombosis in the circulatory system of the omentum and mesentery. The hemor- rhage is from erosions. These cases are septic and the prognosis is bad. They are described as the vomito-negro-appendiculaire. Chronic Appendicitis. This may follow an ordinary acute attack, or be chronic from its incipiency. The latter often is secondary to chronic intestinal catarrh. The patient has frequently a continuous feeling of discomfort in the appendical region; slight tenderness on pressure; generally intestinal and frequently nervous disturbances associated, also obstinate constipation and more rarely diarrhea or gastric disturbances even with headache, nausea, or vomiting. Some of the symptoms may simulate gastric or duodenal ulcer, or cholelithiasis or achlorhydria haemorrhagica gastrica may be secondary, or there may be persistent vomiting. There may be hyper- acidity or hypo-acidity of the stomach, or achlorhydria, or the findings may be normal. Renal disease, or renal calculus, or ureteral calculus may be simulated. In my own experience vomiting is not so prominent a symptom in chronic appendicits as with gastric ulcer, and when vomiting occurs it more frequently consists of food rather than sour liquid. Nausea is more characteristic. There may be pain or, more frequently, distress shortly after eating, which may continue for a time. The pain may be epigastric, but is more frequently indefinitely or plainly abdominal in chronic appendicitis. Pylorospasm may occur. Pressure over the appendix at McBurney's point or pressure at Morris' point may pro- duce reflex pain or discomfort in the epigastrium. Aaron 2 reports reflex pylorospasm seen by fluoroscopy in one case occurring as a result of pres- sure on the appendix. Orthoform or anesthesin relieves the pain of ulcer, but not that of chronic appendicitis. Slight tenderness, or discomfort on pressure at McBurney's point may be present. This may disappear for periods. At times no tenderness can be elicited on pressure at McBurney's point but there is a referred distress or pain in the epigas- trium, or in the percordial region. Discomfort or pain on pressure is found, however, at Morris' point. Examination of this point is frequently neglected. There may be exacerbations of acute attacks. Appendicitis Claudicans. Rochard 3 and Stern apply this term to cases of chronic appendicitis which presented two misleading symptoms, pain referred by the patient to the right hip and intermittent claudication coming on after fatigue. The pain was ascribed to neuritis of the crural or abdomino-genital nerves. They suffered from nausea, anorexia, flatulence and constipation with occasional diarrheal attacks, and tender- ness at McBurney's point, complaining chiefly of claudication and pain in the right lirnb. All recovered after appendectomy. Indiscretions in diet often cause exacerbations of the symptoms. 1 Deutsch. Zeit. fur Chir., Bd. 95, H. 1-5, p. 141. 2 Journal A. M. A., May 29, 1915. 3 Presse Medicale, Oct. n, 1913. APPENDICITIS 823 In some of these cases there is simply a chronic catarrhal condition, but more frequently angulation with adhesions. Serious conditions are at times found in the appendix in these chronic cases, and a brief reference to such is important. A patient, F. J. G., age thirty-five, financier, with a history of a mild appendical attack three years ago, presented the following symptoms: For a period of three weeks a feeling of general malaise, appetite capricious, pains in the neck and limbs, occasional belching, considerable intestinal gas; occasional discomfort and tenderness on pressure in the right iliac region. Patient at times awakened by gas-pressure; occasional chilly feelings. He came to the office for examination; temperature 99F.; slight tenderness on pressure over the appendix; somewhat higher and nearer median line than usual; leukocytosis 10,000; polynuclears normal. At end of nine days, on subsidence of symptoms, appendectomy by the late Frank Hartley. The base of the appendix and about 2 inches of the body .was firmly bound to the cecum, lying almost vertical. There was then an acute bend (right angle), and about i> inches pointed out free into the abdominal cavity toward the median line. The appendix lay high up. The tip was bulbous, contained two small concretions, and the e was a small superficial ulceration. With an acute attack, perforation and general peritonitis would have resulted. Blood Clotting Time. In connection with a case of chronic appendi- citis the writer had an interesting and suggestive experience. The patient was a young girl of sixteen. There was no history of ''bleeders" in the family, nor had the patient ever had such symptoms. She was operated on by Alfred S. Taylor at the New York Hospital. On separating appendical adhesions, marked oozing and at several points considerable bleeding occurred. The hemorrhage was stopped with some difficulty, it being necessary to sew with fine catgut at one point. After operation a Murphy drip containing 5* calcium lactate was begun. The blood was tested and blood-clotting time was found to be twelve minutes, markedly delayed. Lactate of calcium gr. 60 with gelatin were given daily and by the end of five days blood-clotting was normal. The cause of her condition could not be determined. The writer believes that it is in this type of case, with poor blood-clotting, that may produce "pulmonary embolism." The blood-clotting time should be tested before every operation. Chronic appendicitis is the type where palpation by Edebohl's method is safe and of value, and where at times the enlarged appendix can be appreciated. The patient lies on his back with the thighs flexed, and the examiner, placing three or four fingers of the right hand, palm side downward, draws them over the abdomen from the umbilicus to the anterosuperior spine of the ileum, exerting considerable pressure. The appendix can be recognized as a firm cord. Morris reinforces this hand with the three fingers of the left hand. Gentle palpation by the following method is often preferable (Morris): First seek the ascending colon as a land- mark. It is palpated by pressing the three fingers of the left hand gently beneath the right rectus muscle on a plane above the navel, and then 824 DISEASES OF THE STOMACH AND INTESTINES drawing the fingers away so that the colon slips out from beneath them. Second, follow this landmark down until the cecum is reached. Gently indent the abdominal wall with these fingers at the site of the appendix. With the other hand on the other __ side of the abdomen, press back and forth, so the cecum is carried back and forth beneath the fingers. If this fails, press the feeling fingers beneath the inner edge of the cecum, so the latter will be lifted over their tips and make lateral pressure on the opposite side as before. It has been at times recom- mended to examine with the pa- tient standing erect or bending slightly forward, but the dorsal posture is preferable. In the chronic cases there is L Fig. 327. An appendix which was quite normal in external appearance, but it felt harder than normal on pal- pation, and longitudinal section shows the inner coats to have been replaced by connective tissue, with total oblitera- tion of the lumen. The patient had suffered from occasional attacks of pain in the appendical region, and from in- testinal dyspepsia, both of which dis- appeared on removal of the appendix (Morris). Fig. 328. Two appendices in which all structures had practically been re- placed by connective tissue, but enough nerve-filaments had remained to cause persistent intestinal dyspepsia, for which the patients had received treat- ment by authorities without perma- nent result, until the appendices were removed. Both patients then became well (Morris). generally no temperature unless subacute or acute exacerbations occur. Protective Appendicitis or Harmful Involution of the Appendix. Symptoms of harmful involution of the appendix (Morris) : APPENDICITIS 825 i. Symptoms of auto-intoxication with attacks of headache, nervous- ness, poor appetite, etc. 2. Chronic intestinal dyspepsia. 3. Discomfort in the appendical region. 4. An appendix feeling hard and narrow on palpation. 5. Hyperesthesia of the right lumbar pleuxs (tenderness at Morris' point.) There are persistent distention of the cecum and ascending colon, with gas and a sensation of discomfort in the appendical region. In some cases there may be acute local pain and tenderness, but not enough to send the patient to bed. They are rather apt to stay up and about on account of their general irritability. In others there is merely a sensation of warmth in the appendical region, which fluctuates in intensity from day to day and may be sometimes absent. In Figs. 327, 328 are depicted three appendices which were removed for this condition. 1 The patient has a tendency to press upon the abdomen at that point or to lean against a table. The sensation may pass away for a few hours or days, but tends to recur and last for years. On palpation the involution appendix feels narrow and hard. There is no history of acute or chronic appendicitis. The type generally occurs in those over twenty-five or thirty years of age. Diagnosis. Acute Appendicitis. Abdominal pain, becoming localized in the right iliac fossa; tenderness at McBurney's point; rigidity of the right rectus; 2 temperature; rapid pulse; gastro-intestinal disturbances; in some cases the presence of tumefaction and in others the subsequent development of peritonitis are all diagnositc of acute appendicitis. In addition, there are the differential leukocyte count and hyperinosis, which are an aid to diagnosis in acute cases. Chronic Appendicitis. There is slight tenderness or feeling of dis- comfort at McBurney's point and at times under deep pressure the en- larged appendix can be felt beneath the fingers. Morris' point may also be tender. When there is no tenderness at McBurney's point, it may be found at Morris' point due to mucus inclusion or scar tissue after an acute attack. Fibroid degeneration of the appendix also gives tender- ness at Morris' point. Neglect to palpate the latter point, because McBurney's point is not tender, is the most frequent cause of failure to detect chronic appendical trouble. On the other hand some patients complain of gas- tric or intestinal disturbance and have never noted pain or tenderness in the appendical region, but palpation of McBurney's or Morris" 1 points will demonstrate a sensitive appendix. X-ray Diagnosis of Appendicitis. This is contraindicated in acute and subacute cases. Chronic cases of appendicitis the writer believes can be, as a ride, easily diagnosed without the use of the x-rays, but they have their uses in many cases. One must remember that the fibrous condition may be so marked that the entrance to the appendix may be shut off and no bismuth be able to enter the chronically inflamed appendix. In some cases with retroverted adherent appendix, it can at no time be detected. In normal cases with a tight valve, bismuth often may not enter. With a chronic appendicitis with interstitial inflammation, motility of the appendix would be disturbed and there would be a retention of bismuth 1 Protective Appendicitis, pp. 99-103. Dawn of the Fourth Era in Surgery (Morris). 2 The lower segment of the rectus is rigid, unless the appendix is retroverted, when the rigidity extends further upward. 826 DISEASES OF THE STOMACH AND INTESTINES in the appendix beyond normal length of time. The radiologists base their diagnosis chiefly on this feature and also on the evidences of dis- tortion, angulations and adhesions of the appendix. Many of them employ fluoroscopy as well as radiograph. The radiographs the writer believes the most valuable, as error of interpretation is less likely with the pictures. When the appendix is demonstrable by the radiograph, one can determine its size, position and evidence of angulation, adhesions or the presence of a concretion. First in importance are the physical examination and clinical symptoms. Six hours or more after administration of the barium or bismuth meal one can often determine the appendix. If the colon is entirely free from bismuth in two days, but bismuth retention still continues in the appendix, I should consider the motility of the appendix diminished and in connection with local tenderness, diagnose a chronic appendicitis. Evidences of angulation or adhesions with local tenderness would cause one to arrive at the same conclusion. Stasis of the caput coli and ascending colon frequently occur in con- nection with adhesions from chronic appendicitis. It may be present with Jackson's membrane. It is advisable also to radiograph after a barium or bismuth enema, which aids in the determination of Lane's kink with adhesions near the ileocecal valve and also of adhesions of the colon. The particular value of the #-rays in chronic appendicitis in my opinion, is not to determine the appendicular condition, but the question of adhesions about the cecum and ascending colon, in which event a longer incision would be required than the minute one usually employed. When there are gastric symptoms with chronic appendicitis suggestive of ulcer, additional radio- graphs of the stomach and duodenum are indicated. Spasm of the pylorus or cap may be demonstrated or even the radiographic appearances of ulcer. Differential Diagnosis. Renal colic with calculus impacted in the right ureter may simulate appendicitis, but there are the history of acute pain in the kidney, burning sensation of the urine, and drawing up of the right testicle, with sand, gravel, or blood, etc., in the urine. The re-ray may give information. Movable cecum has been mistaken for appendicitis. With movable cecum 1 there is local distention (tympanites) of the cecum, and the condition is usually associated with enteroptosis and its symp- toms. Symptoms are not acute. With Dietls' crisis there are the movable kidney, the history of the attack, and the kidney is swollen and sensitive. In intestinal colic the pain is relieved after passage of flatus. In biliary colic the pain radiates to the back and up to the right shoulder, usually with a previous history of gall-stones, etc. In perforation of the gall-bladder, or duodenum the contents gravitate toward the appendix; and this possibility must always be considered in apparently acute perforative appendicitis. In these cases the sud- den acute pain occurs in the epigastrium and right hypochondrium and there is the previous history pointing to duodenal ulcer, or to gall- bladder disease. Osier, in the Johns Hopkins Bulletin, July- August, 1904, in an article entitled "The Surgical Importance of the Visceral Crises 1 The tf-rays show the misplaced cecum. APPENDICITIS 827 in the Erythema Group," calls attention to the fact that abdominal pain in the erythema group occurs in angioneurotic edema; with simple urticaria; with Henoch's purpura; with erythema multiforme, and in other conditions in which skin lesions only occur late in the disease. Musser, in Amer. Med., March, 1904, reported cases. Osier describes purpura, various types of erythema, urticaria, and angioneurotic edema with visceral lesions in his Practice of Medicine. A. B. Johnson 1 reports cases of Henoch's purpura with initial abdominal symptoms, colic, pain, rigidity, vomiting, temperature, leukocytosis, etc., the cases closely mimicking acute appendicitis. In fact, until the eruption and joint lesions appeared, diagnosis was impossible. The writer in the Symposium on Acidosis in American Medicine, summer of 1916, reports a case of acidosis and indicanuria with angioneurotic edema of the cecum and ascending colon, simulating appendicitis. In women the differential diagnosis between an inflamed low appendix and salpingitis is sometimes difficult, as they frequently are associated. Tenderness of both lumbar ganglia, however, shows pelvic 2 trouble, and when the hypersensitiveness is greater on the right side, that the appendix and tubes are both diseased; with salpingitis, there is no tender- ness at McBurney's point with the patient on the left side. Malaria may occasionally give abdominal symptoms simulating appendicitis. Brickner 3 reports some interesting cases. With pneumonia, especially central near the right base, and with diaphragmatic pleurisy, there is occasionally in the early stages pain transferred to the right iliac fossa, and mistaken for appendicitis. This possibility must be considered. The physical examination of the lungs and pulmonary symptoms should be carefully observed. Determination of Head's zones is of value; the zone for the lungs is from the first to the ninth dorsal segment, chiefly the third, fourth, and fifth, which give hyperalgesia over the thorax. With appendicitis hyperalgesia is below the umbilicus. Hyperesthesia of the right lumbar ganglia is absent in pneumonia without involvement of the appendix. In other words, no hypersen- sitiveness of the right lumbar ganglia on deep pressure, then no appendi- citis. Look for inflammation elsewhere according to Morris. Myalgia. Rarely from exposure, there may be inflammation or myalgia of one of the abdominal muscles. If the right rectus is affected in lower quadrant, one might suspect appendicitis. There may even be a slight rise of temperature and mild leukocytosis. Lateral pressure on the rectus, for example, gives pain, and a sharp tap on the muscle (superficial pressure) over its tendinous attachment will cause more pain than deep pressure. There are often muscular rheumatic pains elsewhere. In addition the patient does not look ill. In typhoid fever there may be pain in the right iliac fossa and appen- dicitis is often a complication. In simple typhoid there is no leukocytosis, but leukopenia. 1 Conditions Simulating Appendicitis, N. Y. State Jour, of Med., March, 1910. 2 The New Point in Diagnosis Between Appendicitis and Tubal Disease (Morris), Amer. Jour, of Obstet., 1909, vol. Ix, No. 5. 3 Archives of Diagnosis, April, 1913. j 828 DISEASES OF THE STOMACH AND INTESTINES In typhoid with appendicitis, in addition to the right iliac pain and tenderness, the presence of leukocytosis, increased polynuclears, and hyperinosis make the diagnosis of appendicitis. Luckett 1 has reported a case of torsion of the greater omentum complicated by acute appendicitis, in which the diagnosis of acute appendicitis with probable abscess was apparently justified by the symptoms. This is an interesting possibility to remember. Seminal vesiculitis may simulate a chronic appendicitis and rectal examination aids in differentiation. As an aid to differential diagnosis in affections of the viscera, the determination of Head's zones (cutaneous hyperalgesia) is of value. This is especially true, I believe, in the differentiation of appendicitis from the conditions to which I have just referred. Head found that in many visceral affections, if the sensitiveness of the skin was tested by running a pin point over the cutaneous surface, there could be shown to exist areas over which there was a more or less hypersensitiveness to pain. These areas were constant and distinct, could be mapped out on the surface of the skin, and, when present, were almost an infallible sign of an affection of the organ to which they corresponded. The skin tenderness was superficial and extended over definite areas which never overlapped one another. Each area or zone of hyperalgesia had a "maximum region" which often corresponded to the seat of pain. These areas were sen- sitive to heat and cold, but not to simple touch. The areas corresponded to segments of the spinal cord, not to the dis- tribution of peripheral nerves or spinal nerve-roots. The zones were named according to the segments of the cord: cervical, i to 7; dorsal, i to 12; lumbar, i to 5; sacral, i to 4. They were broader in front at the median line, narrowed at the side of the body, and again broaden out near the spinal column. The zones, as a rule, never extend beyond the median line in front or behind. Head gives the following zones for the abdominal viscera. Stomach, sixth, seventh, eighth, and ninth dorsal. Cardiac end, sixth and seventh dorsal, right. Pyloric end, eighth and ninth dorsal, left. Liver, eight, ninth, and tenth dorsal, right. Gall-bladder, eighth and ninth dorsal, right. Intestines, ninth, tenth, eleventh, and twelfth dorsal. Colon, ninth, tenth, and eleventh dorsal. Cecum and appendix vermiformis, tenth and eleventh dorsal, right. Kidney, tenth dorsal, sometimes eleventh dorsal. Ureter, eleventh and twelfth dorsal, first lumbar. Bladder (first?), second, third, and fourth sacral. Uterus, tenth, eleventh, and twelfth dorsal, first lumbar. Appendages, eleventh and twelfth dorsal, first lumbar. Head first tested sensitiveness to pain by pinching up folds of skin and later by stroking the skin with the point of a sharp pin. Elsberg 2 and Neuhof suggest the following method of examination: "A sharp pin is held between the thumb and index-finger of the right hand, the nail of the index-finger resting on the patient's skin. 1 Jour. Amer. Med. Assoc., April 23, 1910. 2 Amer. Jour. Med. Sci., Nov., 1908. APPENDICITIS 829 The pin is then made to traverse slowly the surface of the skin, care being taken that the nail of the index-finger presses equally along the area examined. The patient is instructed to say 'now' as soon as the pin stroke becomes painful. "In examining the skin of the abdomen for hyperalgesic areas, the pin traverses the abdomen from side to side and from above down- ward; the points at which the patient complains of pain are marked. In this manner it is possible to map out areas on the skin, and when such an area has been found, the pin is made to approach it from all sides, so that its form and position can be determined. Care must be taken that the pressure of the pin point remains constantly the same, especially as the pin passes over the groin and slips off the costal border or over the crest of the ileum. "After the zone has been thus mapped out on the skin the proced- ure is repeated a second time, and now it is a good plan for the operator to control both patient and himself by keeping both the patient's and his own eyes away from the pin. "The hyperalgesia is sometimes so marked that the patient will shrink or cry out as soon as the border of the zone is reached. In very young children the examination is useless, but older children will give correct answers. "If the examination is carried out in the manner above described it will be possible, in a large number of patients with visceral affections, to map out areas of hyperalgesia extending from the median line in front to the spines behind. The 'maximum' areas can often be mapped out lying within the boundaries of the zones; sometimes only the 'maxima' are present. Sometimes several 'maxima' are found in one zone." The zones appear early in the course of visceral affections, and fre- quently persist throughout. They have been reported as appearing very early; for example, in the commencement of acute appendicitis, while the pain was still in the epigastric region and there was no local tenderness at McBurney's point, the zone for the appendix was discovered. Shortly after the typic symptoms appeared. One must remember the following (Elsberg) : 1. The characteristic zone may appear after palpation of the diseased organ. 2. The hyperalgesic zone will not appear on examination until fifteen to thirty minutes have elapsed after removal of the ice-bag or hot-water bag, if such have been applied. 3. The disappearance of the zone, as a rule, follows relief of the lesion of the affected viscus. 4. The zones may disappear temporarily after repeated examina- tions in close succession. Later they reappear. 5. The disappearance of the zone, together with persisting or in- creasing symptoms, is probably a sign of ill omen. 6. The zones are not invariably present. While the absence of a characteristic zone in a suspected affection of an abdominal organ does not mean that there may not be disease of that organ, the presence of the zone means that there is an undoubted lesion. From this one must not 830 DISEASES OF THE STOMACH AND INTESTINES conclude that the viscus which gives the zone is the one which causes all the symptoms, for we may get a zone from an organ which is secondarily affected. 7. The presence of areas of skin hyperalgesia corresponding to several viscera may mean a combined lesion of several adjoining viscera, although it may occasionally mean disease of the spinal cord itself. 8. The presence of a Head zone alone must not be the only factor in arriving at a diagnosis, but it must be used in conjunction with other signs and symptoms. When one is in doubt as to which of several viscera is the seat of the lesion, the presence of the characteristic zone has been an aid; for example, in differential diagnosis between appendicitis (with retroverted appendix) and kidney and gall-bladder disease, or between appendicitis and salpingitis. It seems preferable to adopt Elsberg's method and speak of the zones by the names of the viscera to which they belong. The position of his zones vary a trifle from Head's, and are as follows: Thus, the stomach zone corresponds to the seventh, eighth, and ninth segments of Head (according to Head, sixth, seventh, eighth, and ninth) ; the gall-bladder zone, to the eighth and ninth segments on the right side (same as Head's diagrams); the appendix zone, to the tenth and eleventh segments of Head on the right side. It will be found, in the description of the zones, that the limit of the posterior portions is not absolute. Thus, in describing the gastric zone, that it extends from the sixth to the tenth vertebrae approximately. The zones, except the gastric zone, stop sharply at the posterior median line, but their upper and lower margins are more variable. The zone appears on that side of the body on -which the affected organ has its nervous connections, the side on which the organ is normally situated. If an organ belongs on the left side, the hyperalgesic zone will be found on that side, even if the organ, through disease or mobility, lies on the other side of the body. Those areas are called "objective zones" when the patient suffers actual pain as the stroking pin enters them. All less painful zones will be called "subjective zones." By an "anterior zone" we mean an anterior maximal area; by a "posterior zone," a posterior maximal area. The Stomach. The complete gastric zone was found to be uncommon. It extended as a broad belt all around the body. At times only a portion of it showed on examination. In the median line in front it extends from the xiphoid almost to the navel; it then passes upward and backward on both sides toward the spine, where it extends from the sixth to the tenth vertebra (ap- proximately). Incomplete zones are more frequent, either an anterior portion extending to the right or to the left, or on both sides of the anterior median line. In Figs. 329 and 330 the various zones are depicted on the anterior and posterior surfaces of the body. The Duodenum. The duodenal zone lies between the gall-bladder and the appendix zones. It lies almost completely to the right, but occasionally extends slightly to the left of the anterior median line. APPENDICITIS Anteriorly it is broad; its upper limit is about on a horizontal line midway between the umbilicus and the ensiform cartilage; its lower border is a little below the umbilicus. It extends backward and slightly upward, and narrows; at the anterior axillary line it is very narrow (about n% inches); it then becomes broader, and is lost about the midscapular line. It corresponded roughly to the ninth dorsal zone of Head. With a perforating duodenal ulcer, intestinal contents gravitate to the appendical region. If the ulcer was occult, differential diagnosis from appendicitis may be difficult. Presence of the typic zone may prove of assistance. Gall-bladder and Liver. This zone is present in acute affections of the gall-bladder more often than in any other acute intra-abdominal Oall Bladder Y^ Cecum and Appendix Ovary and Tube = : = >el = :=:: = : = Stomach Fig. 329. Head's zones. The general location and outline of the zones of cutane- ous hyperalgesia for some of the abdominal viscera. Anterior view. The maxima are deeply shaded. Only the left half of the gastric zone is given. The ureteral zone consists of a series of maxima (diagrammatic) (Elsberg and Neuhof). affection. In these cases the Head zone has often been a valuable diag- nositc aid. In many cases an enlarged, tender, and palpable gall- bladder makes the diagnosis easy, but the recognition of the disease is often difficult or impossible in stout patients without jaundice, with marked abdominal distention and rigidity. These patients may refer their pain to the right lower abdomen, and may have their tenderness in this region. Acute intestinal obstruction, acute pancreatitis, or acute appendicitis are the diagnoses often made. In some patients the pre- sence of a zone of hyperalgesia has been the only localizing sign. 8 3 2 DISEASES OF THE STOMACH AND INTESTINES The gall-bladder zone lies in the right half of the abdomen, above the level of the umbilicus. The complete zone starts exactly at the median line in front, extending from some distance below the xiphoid to a short distance above the navel. Tracing it backward, it slants obliquely upward and becomes narrow, passing partly over and partly below the costal arch. It is narrowest at the midaxillary line, where it is about 2 inches wide. Posteriorly it becomes broader, and at the spines it is about as wide as in front. In some cases more or less of the anterior portion only has been present (maximal area). Kidney and Ureter. The kidney zone is wide at the posterior median line, where it begins, and gradually narrows anteriorly. Its greatest 10th Dorsal Spine 1st Sacral Fig. 330. Head's zones. The general location and outline of the posterior parts of the zones (diagrammatic) (Elsberg and Neuhof). breadth is at the spinal column. It narrows to make a triangular area, with a rounded apex, situated a little to that side of the anterior median line on which the zone lies. It never quite reaches the anterior median line. Each zone is strictly limited to its half of the body. There is no difference in contour between the right and left kidney zones. The kidney zones are complicated by the additional ureteral zones that are present in certain cases. The ureteral zone springs, so to speak, from the lower margin of the kidney zone at the anterior axillary line. In an average adult it is about 3 inches wide at its beginning. It narrows in its downward course, and passing obliquely downward and forward, it terminates on its side of the penis and scrotum in the male; the labia APPENDICITIS 833 in the female. After the first narrowing it widens again well below the umbilical level. In the male, it can be ascertained that the zone spreads fan shape to the anterior median line over the pubic area and its half of the scrotal and penile skin. There are anterior and posterior kidney maximal areas. The ureteral zone seems to be made up of a series of maxima. The kidney and ureteral zone is most often present, as in the other intra-abdominal affections, in the presence of pain and tenderness. In the differential diagnosis of septic infarction of. the kidney, pyelo- nephritis, etc., from retro verted appendix (appendicitis), determination of the kidney zone is of value, taken in connection with Brewer's point (tenderness at the costovertebral angle), urinary analysis, etc. (author). Vermiform Appendix. The zone begins at the median line in front, sometimes a little to its left, from a point a short distance below the umbilicus to one equally distant from the symphysis pubis. It narrows toward the anterior axillary line to a width of about 2 inches (average adult). From this line it widens and spreads to the posterior median line from the eleventh dorsal to the second lumbar spines (approximately). At the anterior median line there is often a tongue-like downward ex- tension of the zone (Fig. 329-330). There is an anterior maximal area which is sometimes present alone. It may be that the "appendix" zone is really an "appendix and cecum" zone, because the cecum is so frequently involved in appendicitis. Sometimes, when an ice-bag has been employed over the appendix region, only the posterior half of the zone is present. Diagnosis has been aided in a considerable number of the patients by the presence of the zone, especially in that large class of acute cases in which the abdomen is rigid and there is no palpable mass. The zone has been of the greatest value in helping to differentiate between diseases of the appendix and those of the gall-bladder or right uterine adnexa. The absence of a zone is of no significance. If a patient complains of symptoms which resemble appendicitis, and a zone is not present in the right lower abdomen, it is well to look elsewhere for hyperalgesia. Thus in cases of beginning pneumonia that had considerable pain, tender- ness, and rigidity in the right iliac region, the presence of hyperalgesia over the thorax first lead to careful examintion of the lungs. Intestines. Head gives the zone as corresponding to the ninth, tenth, eleventh, and twelfth dorsal segments of the spine. Elsberg does not find these uniform. He shows, however, uniform zones in ileocecal tuberculosis and in perforation of the ileum. Ileocecal Tuberculosis. There is a large area of hyperalgesia occupy- ing the whole right lower abdomen down to Poupart's ligament, often extending a little to the left of the median line, and posteriorly becoming lost about the posterior axillary line. Perforation of the Ileum. The zone resembles that of ileocecal tuber- culosis, but extends more to the left of the median line. Uterus and Adnexa. Head describes differences between the zones for the uterus, the ovary, and the tube. Elsberg differs somewhat: The zone for the right adnexa lies on the right half of the median line; that of the left adnexa on the left half; the zone for the uterus is a com- 53 834 DISEASES OF THE STOMACH AND INTESTINES bination of the two. There is no difference between the zones for the right and left adnexa. Beginning some distance above Poupart's liga- ment, the upper margin of the zone runs parallel to it, and pursues this obliquely upward course to the spine of the second lumbar vertebra (approximately). The lower margin is a long, tongue-like process that extends half-way down the thigh on its inner aspect. The lower margin, as it passes a short distance below the anterior-superior spine of the ileum, approaches the upper, the average breadth of the zone here being 3 inches. The lower border then passes horizontally backward over the buttock to reach the posterior median line partly over the sacrum. Sometimes the upper half of this zone is better developed, sometimes the lower; these may be considered maxima. Diagnosis in the diseases of the uterus has not been aided by the presence of a zone. Elsberg states that in about half of the cases of dysmenorrhea and of endometritis with pain, the zone was present. Some of the cases of retroflexion, retroversion, anteflexion, and prolapse showed the zone. It was present in the five cases of uterine polyp that he observed (all of them had pain). It was not present in tumors of the uterus, except in a few cases. In diseases of the tubes and ovaries, especially those of the right side, the zones have been of diagnostic value. I can substantiate these observations of Elsberg and Neuhof, and believe that the tests 1 for Head's zones are a valuable aid in differential diagnosis, especially in appendicitis. Prognosis. There is always an element of uncertainty in every case of appendicitis, and it is well to be guarded in every acute case when expressing an opinion; for an apparently simple case may suddenly show dangerous or even fatal symptoms. It is a well-known fact that in the simple catarrhal cases there may never be but one attack, perfect recovery resulting. Many cases of exudation or abscess, especially of the old cases of so-called perityphlitis, have recovered without operation. Sahli has collected 7213 cases; of these, 473 were operated on, 6740 were not. Of the latter, 591 (8.8. per cent.) died; 6194 (91.2 per cent.) recovered; recurrences took place in 4593 cases; of these 3653 recovered without a second recurrence. Nothnagel claims that 80 per cent, of cases of circumscribed appen- dicitis recover under medical treatment. The fact that a patient has recovered under medical treatment from one or two attacks during a period of several years is no guarantee that a fatal issue may not ultimately occur. If a simple catarrhal attack oc- curs, with moderate symptoms and no marked changes in the blood the prognosis for immediate recovery is certainly favorable. If no attacks occur during several years, the chances of subsequent attacks are lessened. In all statistics of a second attack and subsequent apparent cure, the history should be investigated for some years. In many cases, 1 Amer. Jour. Med. Sci., Nov., 1908. APPENDICITIS 835 when recurrence has taken place, we find chronic appendicitis and prac- tically invalidism as a result. If in acute cases there are marked blood changes with high poly- nuclear count the danger is imminent. Treatment. The medical treatment of acute appendicitis can be sum- med up very briefly. Absolute rest in bed in the dorsal position. The bowel and urine evacuation should occur with the patient confined to bed. The physician, having made his diagnosis of acute appendicitis, to the exclusion, of course, of general peritonitis, should pursue the following course: All food and even water at first should be prohibited by mouth. Sonnenburg recommends the castor-oil treatment of ap- pendicitis, but the writer believes it dangerous. No cathartic should at this time be given. Thirst can be relieved by rinsing the mouth with cold water, by small rectal injections of 2 to 3 ounces (60.090.0) of hot normal salt solution at 105 to io8F., or by proctoclysis. If there is much distention, or if nausea or vomiting, lavage should be carefully performed. In these methods I agree with Ochsner. In the following I differ. If the lavage does not markedly relieve the distention (if such be present), I would then advise the physician to personally gently wash the bowel with tube and funnel, after the method of lavage. Only about a quart of normal saline in all, at noF., need be employed, allowing a few ounces to flow in and then siphoning it out. This practically me- chanically carries off the gas and has little influence in producing active peristaltic action. A similar technic is employed in acute distention of typhoid fever with active hemorrhage. He should carefully note the patient's temperature, the rapidity and character of the pulse, and the ratio of pulse to temperature. When feasible, I advocate blood ex- amination in every case, though, of course, it is in some cases impossible. 1 The physician should return to his case in two or three hours for the purpose of further examination. The ice-bag should be applied to the painful area at the first visit. The pain in almost every case can be controlled by the use of an ice-bag of light weight and a small amount of ice therein, so arranged, supported by a circle of gauze, that only the sensitive area is touched by it. A thin layer or two of gauze can be placed between the bag and the skin, so no damage can be done by the cold, which should be continuously applied. The bag can also be suspended from a barrel hoop to take off the weight, but the former method is the simplest. In emergency I have used bits of ice tied up in dress shields or in pieces of rubber tissue as a substitute for the bag. On the third visit or the one thereafter (all of which visits should be made within a total period of six to eight hours) some definite determination as to the proper course to follow at that specific time can be made. Lavage may again be indicated to relieve distention, or even the special intestinal washing, as previously described. Fre- quently, however, under abstention from food and drink and the applica- tion of ice the tympanites will be markedly relieved and physical examina- tion be comparatively easy. If there is a history of long constipation, and 1 This last refers to country practice. 836 DISEASES OF THE STOMACH AND INTESTINES on examination a fecal accumulation can be determined in the cecum, I resort to radical treatment. Fecal accumulation with gaseous distention is an actual danger by causing pressure on the inflamed appendix. I always resort in such cases to enema or, preferably, gentle intestinal irrigation once or twice a day every day with normal saline solution, with two tubes or a recurrent tube, using 2 to 3 or 4 quarts at each lavage, only y% pint at a time, at 110 to ii5F., emptying the large intestine mechanically. I have fre- quently seen the acute symptoms rapidly subside with the above method. These cases are not so very rare. At the end of forty-eight hours, with symptoms defervescing, a dose of calomel, castor oil, or a saline cathartic is then indicated. If there is vomiting, oxalate of cerium or bismuth and heat to epigastrium; for excessive vomiting, lavage. The type with fecal impaction is the only class of cases in which such radical methods are resorted to. If in other acute cases in the course of the first eight hours the temperature does not rise markedly, and especially if the pulse does not increase in frequency, but rather diminishes, and its character improves, with improvement in the other symptoms, delay, with careful watching of the patient, is allowable. The attack then may gradually entirely subside with no subsequent recurrence, or a fresh attack may take place after an interval. In the case of a first attack, comparatively mild, I would not advise operation directly after the attack unless the patient contemplated a journey beyond the reach of a surgeon. Interval operation is always preferable. The indications for immediate surgical intervention are given later. Diet. As to diet, I am not quite as radical as Ochsner in all cases. For two days in the acute attack, no matter what the type, I allow nothing by mouth, neither food nor water. This checks peristalsis, as Ochsner claims, and furthermore places the patient in the best condition for operation should such suddenly become necessary. The mouth is rinsed and hot salines are given by enema or by proctoclysis. After two days I allow small quantites of hot water by mouth, and if the tem- perature is iooF. or over, no food by mouth, but nutritive enemata. As soon as the temperature falls to iooF. or below, food is given by mouth in small quantities at first. The general diet should then be fluid for some days; no gaseous fluid should be given. Milk well diluted with lime- water or equal parts with barley-water, oatmeal-water, rice-water, gruels, zoolak, fermillac, bacillac, etc., are excellent. Personally, I believe the gruels preferable to milk, as causing less tympanites; as the symptoms subside, eggs beaten up with milk, bouillon, chicken broth, and, later, soft-boiled eggs and milk-toast are added. I agree with Ochsner that lavage is valuable for the distention or for vomiting. If the tympanites, however, is not relieved by the lavage, I believe the funnel method of gentle irrigation of the bowel to be perfectly safe. If fecal accumulation occur later during the attack, a soapsuds enema is indicated. A cathartic should not be given by mouth during the early acute stage until the temperature falls to below iooF., or particularly until the local symptoms defervesce. Fecal impaction is APPENDICITIS 837 the exception. Catarrhal colitis should receive treatment as soon as the acute stage of appendicitis has subsided. Opium has long been a much-vaunted remedy, on the theory of quieting peristalsis and allowing adhesions to form; also for relieving pain; and given preferably as laudanum, or by suppository. / am absolutely opposed to its use. The character of the pulse and respiration are changed thereby; muscular rigidity will relax, and I have seen the symptoms of perforation, both of the appendix and gall-bladder, entirely masked by its employment. Tympanites, distention, and intestinal paresis are more apt to occur as a result of its use. The application of heat I am opposed to in acute cases. It is difficult to secure a continuous high degree of heat and a warm poultice is deleterious. The ice-bag continuously applied possesses all advantages and no disadvantages; and I only advise the use of a single small dose of morphin by hypodermic, and find it but seldom necessary, if the ice does not control the pain. Frequent examinations of the blood as regards differential leuko- cytosis and hyperinosis should be made in every case when possible, at first at least twice daily, and thereafter once a day. If the differential count is not marked and does not increase, but rather diminishes, and the symptoms gradually defervesce, do not operate during the acute attack. The indications for operation are as follows: i. If the patient shows the symptoms of acute peritonitis when first seen or suddenly develops them general muscular rigidity, tender abdomen, tympanites, etc. operate immediately. 2. If there be found on examination an area of resistance in the right iliac fossa, and this increases with more marked symptoms after six to eight hours' observation, whether chills be present or not, opera- tion is indicated. An aspirating needle should never be employed for purposes of diagnosis. The blood-count is of value as an aid to prognosis and diagnosis, if the physician has the technical skill or can have it done. 3. In a large abscess, in complicated cases, or when temperature is steadily rising, operate. 4. If the course of the disease is protracted and the symptoms point to abscess or an active and progressive process, operate. 5. In acute fulminating cases. In this type, with apparently mild local symptoms, but especially a gradual increase of pulse and a moderate increase of temperature, there should be immediate operation. The blood examination is important, if possible. 6. A frequent pulse increasing in rapidity, not corresponding to the more gradual rise of temperature, indicates immediate operation. In all cases when the differential blood-count is marked and increasing, operate at once. 7. If the patient have a mild attack and subsequently develop a second attack (of less severe type than the first), delay may occur; but if a third attack occur, then an interval operation. If the second attack be more severe than the first, then operate at once. 838 DISEASES OF THE STOMACH AND INTESTINES 8. In chronic appendicitis, with symptoms persistent and invalidism occurring as a result, or if recurrent acute exacerbations, operate. 9. In harmful involution of the appendix, operate. In effect, the best judgment is, operate within twelve to sixteen hours from the onset if improvement does not occur. The surgeon should operate during the intermediate stage with a spreading inflammatory process, if he unfortunately sees the patient for the first time during this period. A rapid operation with little manipu- lation is best at this time. In this I disagree with Ochsner, who does not operate at this stage. I continue the other part of his treatment, however. It is furthermore interesting to note that in C. McWilliams' analysis of 1411 operations upon the appendix at the Presbyterian Hospital, New York, one case died following operation for acute appendicitis during the first sixteen hours, and that of pericarditis. Mortality during first twenty-four hours was 5 per cent. Operations on third to sixth day, mortality was 12.7 per cent.; from the seventh to the tenth day, mortality was 20.2 per cent., and thereafter, 13.4 per cent. The method of operation depends on the location and type of appendicitis. CHAPTER XXXII DIVERTICULITIS PERIDIVERTICULITIS DISEASES OF MECKEL'S DIVERTICULUM (Synonyms. Sigmoiditis ; Perisigmoiditis) History. During the past fifty years specimens of false diverticula of the descending colon and sigmoid, both with and without concretions, have been reported by pathologists, who have demonstrated their rela- tionship to general or local peritonitis. Only recently has attention been especially focused on inflammation in the left iliac fossa, and the terms "sigmoiditis" and " perisigmoiditis " been employed. Fig. 331. Diverticulitis. Sigmoid laid open longitudinally. A diverticulum containing a sloughing ulcer is seen at the lower right hand; another is sectioned near the label needle (W. J. Mayo). There is confusion as to the definition of sigmoiditis, many using it in the sense of a catarrh of the sigmoid; while others define it as an inflam- matory condition, involving to a greater or less degree this entire portion of the gut (the musculature included). In other words, it is not a catarrh of the mucous membrane. It was so defined as a diffuse inflammation by Patel 1 and will be so employed in this volume. Specific inflammations, such as dysentery, tuberculosis, and syphilis, are excluded. Eisendrath has recently contributed to this subject. Diverticulitis 2 and peridiverticulitis, as when productive of disturbance 1 Revue de Chirurgie, Oct. and Dec., 1907; Lyon Med., Oct. 2, 2 Sigmoid Diverticulitis, Archiv. Diag., Oct., 1909. 839 1905. 840 DISEASES OF THE STOMACH AND INTESTINES they occur chiefly in the sigmoid, have been used interchangeably with sigmoiditis; and perisigmoiditis bears the same relationship as does perityphlitis to typhlitis. Fig. 332. Diverticulitis. Section through ulcerated diverticulum shown in Fig. 331 (W. J. Mayo). Mayo first employed the term sigmoiditis, but the condition was first described by Joseph M. Mathews. The late J. P. Tuttle 1 has contributed Fig. 333. Diverticulitis. Enlarged view of sectioned diverticulum shown in Fig. 331. Note muscularis in wall, occluded lumen, and inflamed submucosa (W. J. Mayo). an excellent monograph and John F. Erdmann 2 reports 16 cases of great interest. Though inflamed diverticula of the sigmoid undoubtedly cause 1 Amer. Jour. Surg., April, 1909. 2 N. Y. Med. Jour., Mar. 14, 1914, and Yale Med. Jour., February, 1912. DIVERTICULITIS PERIDIVERTICULITIS 841 the maximum of all cases of sigmoiditis and perisigmoiditis, having about the same relation to left iliac abdominal suppuration as the appendix has to similar conditions in the right iliac fossa, yet other causes of perisig- Fig- 334- Peridiverticulitis. Sigmoid divided longitudinally. Note defective musculature and the diverticula. Inflammatory mass dissected away near label needle (W. J. Mayo). moiditis are given, such as ulcerations extending through the wall of the gut; traumatism or puncture by foreign bodies; diverticula, in association Fig- 335- Peridiverticulitis. Enlarged view of two diverticula and one point of defective musculature seen in Fig. 334 (\V. J. Mayo). with which Byron Robinson and Tuttle 1 believe that traumatism from the iliac and psoas muscles play a part; lumbricoid worms and wisps of hay 1 Amer. Jour.^Surg., April, 1909. 842 DISEASES OF THE STOMACH AND INTESTINES entering the appendices epiploicae. Secondary perisigmoiditis is also believed to occur from inflammation by extension from other abdominal or pelvic organs. Wm. J. Mayo 1 draws a sharp distinction between diverticulitis and peridiverticulitis (Figs. 331-336). With diverticulitis there is a primary lesion in the mucosa, often of an ulcerative type, and a tendency to perforation into the peritoneal cavity, with resulting acute peritonitis. It has no tendency to produce reduction of the lumen of the bowel. With peridiverticulitis there is a leakage of toxins and bacteria into the subserosa and tissues surrounding the diverticulum, with resulting inflammation and thickening of the gut, so that its lumen may be markedly reduced and symptoms of obstruction occur. Perforative peritonitis rarely occurs in this type, as so much reparative inflammation goes on. Local intraperitoneal abscess or acute or chronic obstruction may result. ______ mg-. Fig. 336. Peridiverticulitis. Sketch of diverticulum with inflammatory deposit in subserosa (W. J. Mayo, Wilson, and Giffin). Lejars, 2 Bittorf, 3 and Rosenheim 4 classify sigmoiditis and perisig- moiditis clinically. Gordinier and Sampson 5 hold that these conditions are more frequent than we suppose. Diverticula of the Intestines. Diverticula are formed by a bulging or protrusion of the intestinal wall, and are divided into the congenital and the acquired. In the congenital forms the wall of the diverticulum is formed by the whole intestinal wall; and these have been called "true" diverticula. It was formerly thought that all acquired diverticula were of the "false" type, consisting of protrusions of the mucosa through spaces in the muscular coat, so that their wall comprised mucosa and serosa. It has been demonstrated that acquired diverticula may be of the "true" type, 1 Surgery, Gynecology, and Obstetrics, July, 1907. 2 Semaine Medicale, June 27, 1904, p. 26. 3 Munch, med. Wochenschr., 1904, p. 147. * Zeits. fur Klin. Med., 1904, Band, liv, p. 475. 6 Jour. Amer. Med. Assoc., 1906, vol. i, p. 1686. DIVERTICULITIS PERIDIVERTICULITIS 843 and are caused most frequently by traction from tumors or adherent organs. False diverticula are the result of excessive pressure within the intestines combined with a congential weakness of the bowels. The chief congential diverticulm of importance is MeckePs. Meckel's diverticulm, due to the persistence or incomplete obliteration of the omphalomesenteric duct, usually rises from the ileum y 2 to i meter above the ileocecal valve, from the convex margin of the intestines opposite the mesenteric attachment, and varies in length from 3 to 10 cm., though rarely longer. Congenital diverticula have been found in the small and large intes- tines. An accessory pancreas may be responsible for a diverticulm in the stomach or small intestines. Fig. 337. Hodenpyl's specimen of multiple acquired diverticula of the colon (sigmoid flexure) (Brewer). Acquired diverticula occur both in the small and large intestines, and have even been recorded in the appendix by Edel 1 and Mertius. 2 They are generally more frequent in the large intestine, especially in the lower part of the descending colon and sigmoid flexure, the latter pro- viding the most examples, as in Fig. 337, reported by G. Brewer. 3 Here they are usually multiple. Autopsies in death from other causes have been reported where diver- ticula were found, but no symptoms had ever occurred. As many as 400 diverticula in one case have been noted by Hausemann. 1 Virchow's Archiv, Bd. cxxxviii. 2 Mitheilung ans der Grenzgebiet fiir Med. und Chir., Bd. ix. 3 Amer. Jour. Med. Sci., Oct., 1907. 844 DISEASES OF THE STOMACH AND INTESTINES One case of diverticulitis of the small intestine which gave symptoms has been recorded by Gordinier and Sampson. 1 With diverticula of the appendix, appendicitis has been simulated, but it is clinically unimportant to separate the conditions, as operation is indicated in any event. Diverticula are most frequent in the sigmoid 1909 Fig. 338. Diverticula of sigmoid showing enteroliths in situ. The abundant fat has been dissected from off one-half of the bowel, showing the pouches which entered the appendices epiploicse. At a a single pouch has been dissected out and shows well how they are buried in fat and liable to pass unrecognized unless specially sought for; b, longitudinal muscular band; c, a concretion (W. H. Maxwell Telling). flexure. Quite a number give important symptoms. E. Beer 2 has de- scribed the clinical symptoms of diverticulitis, and Telling 3 has collected 105 cases, giving a thorough exposition of the subject (Figs. 338-342). Suduski 4 found diverticula present 1 5 times in 40 autopsies, so that the condition is probably more frequent than has been supposed, and has often been overlooked, even in postmortem. 1 Jour. Amer. Med. Assoc., 1906, vol. i, p. 1684. 2 Amer. Jour. Med. Sci., July, 1904. 3 Lancet, March 21 and 28, 1908. 4 Langenbeck's Archiv., Bd. Ixi, p. 708. DIVERTICULITIS PERIDIVERTICULITlS 845 Brewer 1 has reported a case of acute diverticulitis of the sigmoid, with operation before rupture. Occurrence. Acquired diverticula are much more common in the large intestine, more so in the descending colon, and especially so in the sigmoid flexure. They are usually multiple and may arise from any part of the surface. They are frequently seen in two rows at the sides of the gut, or close to the mesenteric attachment, more rarely on the convexity. Charles Mayo 2 reports two cases of diverticula of the rectum and one in the anal ring. A B Fig. 339. Diverticula of sigmoid. A, The fat has been dissected from off the outer aspect of the bowel. The pouches are for the most part into the appendices epiploicas. One of the sacs is laid open at a. B, Inner surface of the bowel from the same specimen. A concretion is seen at b presenting at the orifice of one of the diverticula. At c, the lipped orifice is well seen (W. H. Maxwell Telling). Chlumsky claims that he finds by experiment that rupture in the living bowel upon distention occurs more frequently opposite the mes- entery. The general opinion is that the mesenteric side is less resistant. Probably the most common occurrence of these diverticula is in the appendices epiploicae. In many cases they are confined to them, and pre- sent a double row of symmetrically placed hollowed-out pockets. In other cases none are so situated, and frequently some enter the appendices and some lie outside of them. The presence of the diverticula in these 1 Jour. Amer. Med. Assoc., Aug. 15, 1908. 2 Jour. A. M. A., July 27, 1912. 846 DISEASES OF THE STOMACH AND INTESTINES appendices may account for some of the tenderness found in many por- tions of the gut. The special favoring of the epiploicae is accounted for by the fact that the point of their attachment to the gut is a place of least resistance. In a majority of cases the affected appendages have been or are filled with a large amount of fat. Bland-Sutton 1 has stated and illustrated by diagrams that this fat is directly continuous with the subserous fat. If there is the slightest tendency to the formation of diver- ticula, it will readily be seen that the soft fatty tissue of the appen- dices epiploicae form a point of lowered resistance. Size. The diverticula vary in size from a millet-seed to a hazel- nut. Large size is seldom attained, as secondary changes occur leading to detachment, ulceration, abscess, or peritonitis. When small, they are semiglob- ular; as they increase in size, more oval or flask shaped; the aperture on the gut wall usually being smaller than the maximum diameter of the diverticulum, and almost constantly so when they enter the appendices epiploicae. This is an anatomic point of great importance in regard to the causation of inflammation. In those which do not enter the appendices the aperture may be relatively large. They are then generally true diverticula and Fig. 340. Diverticula of sigmoid. The fat has been partly dissected from off the outer surface of the gut, showing several pouches. At a is seen a larger one containing a calcareous concretion, with a thin fibrous pedicle in the proc- ess of separation to form a loose peri- toneal body. A similar concretion, the size of a bean, was free in the pelvis (W. H. Maxwell Telling). are formed from normal haustra (Sudsuki), 2 usually not extending much above the middle of the de- scending colon. They increase in number and size from above down- ward, and may be quite crowded to- gether in the sigmoid flexure. At the commencement of the rectum they generally stop abruptly. This is possibly due to the absence of appendices epiploicae in this situation; but the fact that the feces are not retained so long in this part of the bowel is also partly responsible. Schreiber 3 thinks that the stronger musculature of the rectum plays some part in preventing their formation. Mayo, as noted, reports 3 cases in this region. 1 Lancet, Oct. 24, 1903, p. 1148. 2 Langenbeck's Archiv, Band Ixi, p. 708. 3 Deutsch. Archiv fiir Klin. Med., 1902, p. 122. DIVERTICULITIS PERIDIVERTICULITIS 847 They are almost invariably filled with fecal material, generally con- cretions of some degree of firmness. This fact probably determines their subsequent clinical importance, and sharply distinguishes them from acquired diver ticida in the small intestine, which rarely contain fecal material. To this we can ascribe the immunity of the latter from secondary patho- logic processes and symptoms. Usually in the early stages all the coats of the bowel are represented, but in some the muscularis is absent. There has been controversy as to the presence or absence of muscular fibers in the diverticulum wall. Cruveilhier and Rokitansky originally regarded the diverticula as hernial protrusions of the mucous and serous coats, with absence of muscular tissue. The presence or absence of muscle was for many years the criterion for distinction between congenital and acquired diverticula. The microscopic findings in numerous cases show that acquired diverticula often have all the coats of the bowels represented. In the early stages of the formation it is almost the rule, although the muscular tissue undergoes atrophy as the sac enlarges. Etiology. One case of an acute catarrhal inflammation of a diver- ticulum of the sigmoid has been recorded in a child 1 seven years of age, while the great majority are in old or even aged subjects. More recently, J. A. Hartwell 2 and R. L. Cecil have reported a careful study of 18 cases of intestinal diverticula. They find that children and young adults are also subject to them and to the secondary changes occurring in them. They seem to be generally acquired. 1. Generally, advanced age of the patient. In 80 cases the average age was sixty years, but of those in whom diverticula caused symptoms in 47 cases, the age was fifty-five years. In 33 cases no symptoms were referred to their presence, but they were accidentally discovered, the age was sixty-seven. Fiedler 3 records the youngest case at twenty-two years. William J. Mayo places the majority at over fifty years. 2. Sex. In 81 cases 53 males, 28 females. 3. Obesity. Klebs, Mayo, and others have laid stress on this. Many have been fat; the presence of much fatty tissue in the gut walls and appendices epiploicae have been shown by Bland-Sutton to predispose to mucosal out-pushings. In 22 cases, 17 were stated to be more or less obese and to have much fatty tissue in the gut wall. 4. Cachexia and Absence of Fat. On the other hand, many sub- jects are noted as having been thin (Hausemann) 4 ; 5 of the 22 cases were stated to be of this type. Undoubtedly some had previously been obese, and from age or illness had lost much of their fatty tissue. This has not been definitely referred to. It will be readily understood that the fatty deposit would first weaken the gut wall; the subsequent loss of fat with possible concomitant weakening and wasting of the muscle-fibers would probably increase this tendency. 5. The Normal Structure of the Large Intestine. This readily lends itself to local yielding of its walls, as is suggested by the normal sacculi, 1 Ann. of Surg., vol. xlvii, by A. P. C. Ashhurst. 2 Amer. Jour. Med. Sci., Aug., 1910. 3 Denkschriit der Gesellschaft fur Natur. v. Heilknade, Dresden, 1868. 4 Virchow's Archiv, Band cxliv. DISEASES OF THE STOMACH AND INTESTINES which are often exaggerated in cases of constipation, sometimes in association with diverticula. 6. Physiologic Role of the Sigmoid Flexure. In this portion of the bowel is the longest retention of fecal material, and here consequently the pressure from within will be liable to be the greatest. 7. Pressure from Within the Bowel. This may be due to accumu- lation of feces or gas, or both. (a) Presence of Constipation. This stands in most frequent and im- portant causal relationship to this condition. In 22 cases in which the point is definitely mentioned, constipation, often severe and generally for a considerable period, was present in 17. In the remaining 5 its absence was particularly noted. Constipation in old people, whether obese or emaciated, is very common, while diverticula are comparatively rare; hence, other factors must be present. (6) Flatulence. This is usually associated with constipation, and acts in the same way by increasing internal pressure; so much stress has been laid on the factor of internal pressure that the term " pulsion divertiulca" has been applied to them. 8. The Relation of the Diverticula to the Points of Entry of the Vessels through the Gut Walls. This fact was first pointed out by Klebs 1 in the case of acquired diverticula in the small intestine, and has been confirmed by others (Hausemann and Fisher) with regard to the large intestine. Microscopically it is evident that the spots in the gut wall where it is pierced by the vessels are areas of weakened resistance to internal pressure, because the vessels are accompanied by a certain amount of lax con- nective tissue, through which an out-pushing of the mucous membrane can more easily take place. 9. Variations in the Size of the Vessels. Graser 2 was the first to investigate this point. In his case, the patient suffered from chronic heart disease, with venous back-pressure, leading to distention of the veins in the gut wall. This dilatation he regarded as further weakening the vessel spaces by pushing aside the muscular fibers. He examined microscopically the sigmoids of 28 patients who had suffered prior to death from mesenteric venous stagnation. In 10 of them he found definite evidence (mostly microscopic) of commencing out-pushings of the gut-wall; and in every case they occurred through these "vessel holes." The diverticula were most numerous in the sigmoid and practically ceased at the middle of the ascending colon. Mesenteric venous congestion may be due to chronic heart or lung disease, portal back-pressure, or intra-abdominal tumor, etc. "'He is inclined to ascribe a special importance to a distention which is not constant, but of frequent repetition, as recurs in the repeated failures of cardiac compensation and in frequent recoveries therefrom in patients with chronic heart disease." When the vessels are engorged the vessel holes are enlarged; when they are smaller these areas are thereby weakened, and there is a greater liability to hernia of the mucosa. 1 Pathologic Anatomy, 1869, p. 271. 2 Centralbl. fur Chirurg., 1898, etc. DIVERTICULITIS PERIDIVERTICULITIS 849 While in the small intestine the diverticula are practically always on the mesenteric side of the bowel where the vessels pierce the walls, in the larger bowel many of the diverticula occur on the side remote from the mesentery. Another explanation must be sought for. Therefore, Schrieber believed the congestion of the vessels was second- ary to the presence of feces in the diverticulum, rather than to the original cause of the formation of the latter. 10. The Connective Tissue Around the Vessels. Sudsuki 1 found in 40 cases not suffering from mesenteric venous stagnation which he ex- amined microscopically, diverticula present in 15 bodies; in 6 cases, true diverticula, that is, all the coats were therein. In 20 cases, where mesenteric congestion was present, he found diverticula in only 6; in 12 cases free from congestion, diverticula were found in 9. The subjects were all adults and nearly all men, middle aged or old. He suggests there is a congenital predisposition with regard to the amount and laxity of connective tissue surrounding the vessels at these spots; if there is much fatty deposit, this will act in the same way; and if there be subsequent wasting of such fatty tissues, further weakening takes place. Beer states that this theory fails to explain the non-mesenteric diver- ticula and those which have muscular layers in their walls. These vessel spaces have some influence, but they have some additional cause, and Beer finds this in the following: 11. Muscular Deficiency of the Gut Wall. Since diverticula occur in old people, in whom the muscular power of their intestines has been more or less exhausted (as evidenced by constipation) , and are in associa- tion with obesity (or obesity followed by cachexia), these fac.ts all point to a muscular deficiency. In this muscular weakness Beer thinks the cause of the false diverticula must be sought. Hartwell 2 believes that an inherent weakness existing in the mus- cularis of the intestines is probably an important factor in the etiology of diverticula, and in the small intestine this weakness appears to exist along the mesenteric attachment. He reports a number of cases of diverticulitis, and Bruce 3 describes a patient with perforation of a diver- ticulum, abscess, and adhesions with a secondary appendicitis. In Mayo's cases areas of muscular deficiency were noted opposite early diverticula, or even in areas yet free from out-pushing. Probably no one factor is sufficient. Out of 105 cases reported, 60 per cent, were attended with symptoms (Telling). Secondary Pathologic Processes in the Diverticula. The diver- ticula of themselves occasion no symptoms, but, as one would expect, readily undergo inflammatory changes therein. They tend in most cases to form fusiform pouches connecting with the lumen of the gut by a constricting neck, and these pouches are situated for the most part on that portion of the bowel the sigmoid flexure of which the normal 1 Langenbeck's Archiv, Band Ixi, p. 708. 2 Ann. Surg., Aug., 1910; Amer. Jour. Med. Sci., Aug., 1910, p. 174. 3 Ann. Surg., May, 1911. 54 850 DISEASES OF THE STOMACH AND INTESTINES anatomy and physiology favor most the retention of feces and the accumu- lation of gas. If a condition of constipation exists and the "force from within" is increased it is almost inevitable that they will from the first have fecal contents. On account of the narrow neck and deficient muscular fibers in the sac wall the contents rarely are expelled and concretions form. These probably cause the trouble. The first result would be a tendency to enlargement of the sac. Then the muscular layers atrophy, as do the glands; the muscle may be replaced by fibrous tissue. The increase in the size of the diverticulum with atrophic changes, in its walls, produces necessarily a dangerous thinning of the sac. In some cases there is little more than a peritoneal covering, with the contained feces visible through it. The irritation of the retained and hardened feces then leads to inflam- matory changes. These may be slight and only microscopic in the mucosa and submucosa, or may produce more serious acute or chronic lesions. The fecal matter is a nidus for bacteria; their products undoubtedly determine the nature of the inflammatory reaction which occurs. An ulceration may result from bacterial infection. Moreover, the con- cretion will tend to be forced through an inflamed or ulcerated area. These features explain the occurrence of local abscess or general peritonitis. The latter may be also the result of sudden trauma or strain, which may cause an increased pressure within the bowel. Definite types are produced by the following causes (Telling) 1 : 1. Thinning of the diverticulum wall. 2. Perforating action of the retained concretion. 3. The presence of micro-organisms and their toxins. 4. Inflammatory reaction of varying types and degree. With these data one can forecast the various cases which one might expect clinically; viz.: 1. Infection of the general peritoneal cavity from thinning of the sac walls without perforation. 2. Acute or gangrenous inflammation " diver ticulitis." 3. Chronic proliferative inflammation, with thickening of the gut wall and stenosis of the bowel "peridiverticulitis." 4. Formation of adhesions, especially to the (a) small intestine, (b) bladder. 5. Perforation of diverticula, giving rise to (a) general peritonitis, (6) local abscess, (c) submucous fistulae of the gut wall, (d") fistulous communication with other viscera, especially the bladder. 6. The lodgment of foreign bodies. 7. Chronic mesenteritis of the sigmoid loop. 8. Local chronic peritonitis. 9. Metastatic sup- puration. 10. Secondary development of carcinoma, n. Perfora- tion into a hernial sac. 12. Formation of loose bodies in the peritoneal cavity. Eisendarth gives a simple clinical classification: 1. Acute: (a) Acute catarrhal; (b) acute gangrenous, with or without local abscess; (c) acute perforative, with general peritonitis. 2. Chronic: (a) Chronic hyperplastic or stenosing (peridiverticu- 1 The Proctologist, March, 1911. DIVERTICULITIS PERIDIVERTICULITIS 851 litis); (b) enterovesical fistulous form; (c) chronic adhesive form, causing acute or chronic obstruction. The following classification, by Telling, of the pathologic processes which result, I believe the most scientific: 1. Infection of the general peritoneum as a result of thinning of the sac walls. Organisms make their way through the wall and cause peri- tonitis without perforation. Loomis 1 records one case. 2. Acute or Gangrenous Inflammation of the Diverticulum (Acute Diverticulitis). Symptoms. Pain, tenderness, and swelling in the left inguinal region are present. Local abscess or general peritonitis may result. Rigidity of the left rectus; fever; hyperinosis (increased fibrin in the blood); leukocytosis; increase in polynuclears are present. If there is general peritonitis, we have the additional symptoms. fl A> Fig. 341. Peridiverticulitis with great thickening of the gut wall, causing stenosis and simulating carcinoma, for which it was mistaken when resected at operation. The thickening due to fibrosis is seen at a (W. H. Maxwell Telling). 3. Chronic Inflammation. A chronic proliferative inflammation of the submucous and serous coats may occur. Thickening may be considerable. It may lead to (a) tumor formation, (b) stenosis with obstruction (c) mimicry of carcinoma. This last type of inflammation is most important, most frequent, and generally overlooked. Crasser 2 in 1898 first described a case. Moynihan recorded one as also did Abbe. 3 The mimicry of carcinoma is so perfect that not only is the diagnosis made during life, but also at the operation, and again confirmed erroneously at postmortem (Fig. 341). Differential diagnosis between carcinomatous stenosis and diverticular stenosis is as follows: With carcinoma, there are nearly invariably an involvement and ulcera- tion of the mucous membrane, with fungation of the growth into the lumen 1 N. Y. Med. Rec., 1870, vol. iv. - Centralbl. fur Chirurg., 1898. 3 Med. Rec., Aug. i, 1914. 852 DISEASES OF THE STOMACH AND INTESTINES of bowel. With diverticulitis it is the rule for the mucous membrane to be free from ulceration (unless a fistulous tract or abscess-cavity open into it from without inward) ; also the folds of the mucosa are strongly marked and crowded together, giving an unduly rugose appearance (Fig. 342). The orifices of the pouches may be visible, but are generally small and often concealed by these folds. One should examine the folds with a fine probe. There are usually absence of blood and pus in the stool in diverticulitis, but they are present in carcinoma. One must also remember that carcinoma of the sigmoid may originate from diverticulitis. Age of the patients is usually the same. Stenosis may cause acute or chronic obstruction (Mayo). Fig. 342. Sigmoid showing diverticula. Inner aspect of gut. Normal but rugose mucosa. The orifices show well-marked lipping and concretions protruding partially from some of the pouches (W. H. Maxwell Telling). 4. Formation of Adhesions. (a) Adhesions to the small intestine may produce acute or chronic obstruction, (b) Adhesions to the bladder are also noted. 5. Perforation of Diverticula. Results differ, according to (a) acute- ness of ulcerative process, () amount of chronic inflammatory thickening present, (c) presence of adhesions. These factors determine whether perforation leads to (a) general peritonitis, (b) local abscess formation, (c) fistulous communication with other viscera, notably the bladder. (a) General perforative peritonitis has occurred in 14 cases. C. A. McWilliams reported a case at the Surgical Society, October 30, 1907, DIVERTICULITIS PERIDIVERTICULITIS 853 upon which he operated at the Presbyterian Hospital for general peri- tonitis; the history of constipation was of only a week's duration. Male, aged forty-seven. The case was believed to be perforative appendicitis, not having been seen until general peritonitis was in evidence. Milky fluid under considerable tension was evacuated at operation. There was also fluid between the liver and diaphragm. Appendix, gall- bladder, stomach, and pancreas were examined, but no perforation was found. The patient's condition became such that further search was deemed inadvisable. Postmortem showed diverticula of large size commencing in the ascending colon. In the descending colon, 10 cm. below the splenic flexure, a perforation of a diverticulum was discovered. Culture from the peritoneum, etc., showed Bacillus coli. (b) Local Abscess Formation in 24 Cases. There may be several small abscesses shut off by thick adhesions or a single large abscess. The abscess may be intra- or extraperitoneal, and may lead in turn to communication with the external surface, with the bladder or the bowel. (c) Submucous Fistula. In some cases with much inflammatory thickening the ulceration of the inside of the sac leads to a small abscess. This happens in several focci in the thickened area. These abscesses tend to burrow through the thickened tissues and form submucous fistulous communications with each other. There may be a labyrinth of such tracts. They may re-enter the lumen of the sigmoid or communicate with a peritoneal abscess-cavity by one or several openings. This sup- purating process is often excessively chronic and gives rise to great thickening, adhesions, and tumor formation, with sequelae in the shape of intestinal obstruction or adhesions to and subsequent perforation of the bladder. 6. Lodgment of Foreign Bodies. Diverticula are liable to harbor foreign bodies, which may give rise to perforation, diverticulitis, or local abscess. Bland-Sutton reports several cases. 7. Chronic Mesenteritis. In some there is inflammatory thickening of or abscess formation in the sigmoid mesentery. It is believed by Ries 1 that retraction of the sigmoid loop is produced thereby and also adhesions, and hence twists, kinks, or volvulus. 8. Local Chronic Peritonitis. This is often found in the neighborhood of the sigmoid, causing thickening, opacity, or adhesion of the peritoneum, probably in some cases due to leakage of toxins through the thin wall of an overlooked diverticulum, though at times due to the pelvic organs. 9. Metastatic Suppuration. One case recorded, with abscesses of the liver from diverticular abscess (Whyte 2 ). 10. Development of Carcinoma. Secondary to diverticulitis. Carcinoma may result from chronic irritation and ulceration of diverticula due to retained feces (Hochenegg 3 ). 11. Perforation of a Hernial Sac. One case is recorded (Stierlin 4 ). 1 Ann. Surg., vol. xi, p. 523. 2 Scottish Med. and Surg., Jour. 1906. 3 Verhandlungen der Deutsche Gesellschaft fur Chirurg., Thirty-first Congress, 1902, p. 402. 4 Correspondenzbl. fur Schweitzer Aertze, 1902, vol. xxxii, p. 749. 854 DISEASES OF THE STOMACH AND INTESTINES Clinical Aspects. Patel, 1 in discussing inflammation of the sigmoid, classifies these conditions as acute non-suppurative sigmoiditis, suppura- tive perisigmoiditis, chronic perisigmoiditis, sigmoiditis, and sigmoiditis with general peritonitis. Inflammatory trouble, more or less acute in the left lower abdomen, has been described as left-sided appendicitis, sigmoiditis, perisigmoiditis, epiploicae appendicitis, diverticulitis, or peridiverticulitis. Clinically, the acute cases resemble appendicitis, except for the fact that the inflammation is on the left side. The symptoms are as follows: Pain; constipation; tenderness on pressure; muscular rigidity, espe- cially lower part of the left rectus, and later tumor; local tympanites is present. Tumor is not always present. Left-sided Tumor and Abscess Formation. In 63 cases tumor was felt in 20, and abscess formation occurred in 23. In some cases with considerable pus formation there may be but little pain and no pyrexia (Georgi). Tumor is elongated, sausage shaped, tender, and often ill defined. It may be movable or fixed, lying a little above Poupart's ligament (fre- quently parallel with it). Shortly after the occurrence of symptoms, this swelling may be made out; it may disappear rapidly or gradually, or may increase with signs of pus formation. Patel has shown that the tumor may be higher, lower, or posterior. The position depends on the location of the inflamed diverticulum. In a patient of middle age or older the diagnosis of diverticulitis would be probable. Telling 2 now classifies the diverticular inflammations in the following clinical groups: 1. Inflammatory trouble, more or less acute in the left lower region of the abdomen (so-called left-sided "appendicitis," sigmoiditis, peri- sigmoiditis, epiploic appendicitis; diverticulitis; peridiverticulitis; peri- colitis sinistra, etc.). 2. Perforative peritonitis. 3. Intestinal obstruction: Acute, usually due to involvement of the small intestine by an adhesion producing kinking or strangulation by a band. Chronic, a mimicry of carcinoma. 4. Vesicocolic fistula. 5. Inflammatory trouble in the right iliac fossa or its neighborhood. This last has been recently added and will shortly be referred to. Differential Diagnosis. Differential diagnosis must be made from appendicitis, with left-sided symptoms, pelvic inflammation, ovarian cyst with inflammation or strangulation, actinomycosis of the sigmoid, syphilitic or tuberculous pericolitis, sigmoid catarrh, and dysentery. Tuberculosis is too often accepted. An appendix passing transversely to the left iliac fossa can sometimes be determined by vaginal or rectal examination. Palpation at McBurney's point, examination at Morris 7 point, and, in addition, of the left lumbar ganglia, may give some informa- tion. The determination of the appendix Head zone may also be of assist- 1 Revue de Chir., Oct. 10, 1907, and Dec. 10, 1907. 2 The Proctblogist, March, 1911. DIVERTICULITIS- PERIDIVERTICULITIS 855 ance. An abnormal position of the cecum occasionally occurs. With tuberculosis, bacilli may be found in the stools, also pus and blood, but not always at first. The tuberculin reaction, ocular or by injection, aids diagnosis. Pus and blood appear in dysentery and syphilis, and the Ameba or Bacillus dysenteriae in the former and Wassermann's reaction in the latter. Mucus alone is present in catarrh. Actinomyces are found in the stool in actinomycosis. Vaginal examination helps diagnose pelvic conditions. Sigmoiditis. The writer classifies catarrh of the sigmoid as a colitis (acute or chronic) of catarrhal type, involving this portion of the colon or as "catarrhal sigmoiditis." True sigmoiditis Patel defines as a diffuse inflammation. In some cases there may be acute inflammatory changes not involving the entire wall of the bowel, which may yield to the external application of ice and enemata. In other cases the entire thickness of the bowel is involved, and there may be local signs with tumor formation, fever, etc. These last cases may be acute, subacute, or chronic. At times the inflammation may subside in any of these types. The writer believes a diverticulum or diverticula are responsible for these cases, and that they correspond to diverticulitis and peridiverticulitis. Intestinal Obstruction. When acute, this is probably due to secondary involvement of a coil of small intestine, and the diverticulitis frequently cannot be diagnosed except at operation. The same is true of chronic obstruction of the small intestine. Obstruc- tion, which is chronic, recurrent, or acute engrafted on chronic, when localized in the sigmoid region -is nearly always diagnosed as the result of carcinoma, when it occurs in an elderly person with a history of constipation. Advanced age, more recent constipation, cachexia, and blood in the stools favor cancer; while long-standing constipation, absence of blood in the stools after repeated examinations, and slight cachexia (or, rather, loss of weight), together with an evidence of pus formation, would favor peridiverticulitis. Entire absence of constipation may occur with either, and blood has been found in one diverticular case. Probably many of the so-called cases of cancer are really this condition. X-rays. With progressive stenosis the x-rays are of value in locating the position of the lesion. There is an accumulation of barium or bis- muth (administered per oram) above the stenosed region and by enema the narrowing and interference with passage of bismuth readily appear in the radiograph. Diverticula may also be demonstrated in the chronic cases, and may appear in the radiographs taken for diagnosing other lesions. The #-ray should never be employed in acute cases. Perforative Peritonitis. In these cases a routine examination of the sigmoid should be made. It some cases there may be a previous history of left-sided abdominal inflammation, but in others there is no such history. Vesicocolic Fistula. Probably many of these cases, supposedly due to cancer of the sigmoid, are the result of diverticulitis with adhesions and perforation of the bladder. Air and feces pass through the urethra. 856 DISEASES OF THE STOMACH AND INTESTINES Cripps found 45 cases of vesico-intestinal fistula out of 63 to be inflamma- tory, only 9 cancerous, and some of these doubtful. There seems to be a liability of postoperative peritonitis following an operation for diver ticulitis, probably from other thin-walled diverticula. Inflammatory Lesions on the Right Side of the Abdomen. Diverticula may sometimes occur throughout the colon and are found in the cecum. Taylor and Lakin 1 report perforation of a diverticulum, 5^ inches from the cecum. This possibility must always be considered; i.e., in some cases which may simulate an inflamed appendix, the cause may be a diverticulum. Diagnosis. To recapitulate: Diverticulitis occurs usually in persons over thirty-five years of age suffering from constipation and of obese habit. The site of pain about corresponds on the left side to that of appendicitis on the right. Muscular rigidity, especially of the left rectus, is present. There is tenderness on pressure in the left iliac fossa. Tumor may or may not be present. In suppurative cases there may be chills. Leukocytosis is present. The increase in the polynuclears and hyperinosis are of importance for diagnosis. The various types have been described; among the most common are acute peritonitis, resulting from perforation; local abscess, which may break into some viscus, as the bladder, or which must be opened ; acute or chronic obstruction, resulting from stenosis of the sigmoid from peri- diverticulitis; chronic tumors, simulating carcinoma; and milder cases, with local pain, tenderness, constipation; and a local tumor, which symptoms gradually subside under treatment. Treatment. The acute cases should receive the same treatment as acute appendicitis. In mild cases the bowel should be emptied by enema; liquid diet, preferably broths and gruels; ice-bag continuously applied; absolute rest in bed. Subsequent attention, after recovery, should be directed to the careful regulation of the bowels by diet and medication. Intestinal irrigation and high olive oil injections also are of value. Cases of chronic stenosis may be temporarily treated as such. Indications for operation are the same as in appendicitis. Acute obstruction, peritonitis, and abscess require immediate opera- tion. Chronic obstruction may require resection. Appropriate operative procedures are necessary for the complications described. MECKEL'S DIVERTICULUM AND ITS DISEASES The persistence of this organ in some form is found in i to 2 per cent, of all persons and more frequently in males. As a rule it gives rise to no symptoms. Disease of this organ is believed by some to occur most frequently in childhood, while others believe it to be most frequent in adult life, the average age being about twenty-one. Strangulation of the intestine by the diverticulum or its remains, is the most frequent lesion and is described under acute intestinal obstruction. The diver- ticulum may also become strangulated by the ileum. The diverticulum may persist and open at the umbilicus with resulting fecal fistulae. There 1 Lancet, Feb. 19, 1910, p. 495. DIVERTICULITIS PERIDIVERTICULITIS 857 may be two lateral openings and occasionally the intestine may protrude and become strangulated. The diverticulum may become obstructed at both ends and a cystic tumor form or concretions may be present and a communication be found between the intestine and bladder. Super- involution may occur, resulting in a narrowing of the intestine; the obliterating process in the diverticulum has passed into the intestine in such event. Rarely invagination of the diverticulum occurs, which is liable to be followed by an ileocecal intussusception. The average age of these cases is said to be about thirteen years, a contrast to the early age of other cases of intussusception. Complete obstruction may not follow a partial invagination but hemorrhage of slight or severe type ensue. Volvulus of the diverticulum may rarely occur though that of the ileum is usually associated with it, especially if the distal end of the process is attacked. Hernia of this process, both inguinal and femoral, more frequently the latter, has been reported. Inflammation of Meckel's Diverticulum. This condition has also been described as "diverticulitis" and it may be primary or secondary. In the latter, another lesion first develops, such as obstruction of the ileum by the diverticulum and then obstruction of the diverticulum, with subsequent inflammation, or the diverticulum may become stran- gulated in a hernial sac. Primary Diverticulitis. With primary diverticiditis there are acute, and chronic, or recurring cases. Etiology. The chief source is infection. Previous digestive dis- turbances or traumatism may be factors. Among other causes are foreign bodies, intestinal parasites and rarely typhoid ulcer. Age. It may occur at all ages about 33 per cent, in children and the balance from twenty to seventy years. Pathology. There are all grades of inflammation from simple catarrh to gangrene with a local or general peritonitis, resembling appendicitis. Perforation of a typhoid ulcer may occur without gangrene. Symptoms. These vary considerably. With subacute, chronic or recurring cases, there are gastric disturbances, constipation and recurring attacks of pain in the region to the right of the umbilicus or in the right iliac fossa. With acute cases or acute exacerbation of the chronic, acute appendicitis may be closely simulated except that the pain is usually higher and nearer the umbilicus. There are abdominal tenderness in this region, muscular rigidity and finally dulness on percussion, also nausea, vomiting, rise of temperature, leukocytosis and increase in the poly- nuclears. Constipation is a frequent symptom though diarrhea occurs fairly often. In the subacute or chronic cases intestinal hemorrhage may occur. Local or general peritonitis may result. Intestinal ob- struction may become complete from compression, inflammatory adhe- sions or kinking; constipation is liable to occur from kinking of the intestinal coils involved in a local peritonitis or from intestinal paresis. With secondary diverticulitis intestinal obstruction may first occur with diverticulitis later associated with a local or general peritonitis. Diagnosis. So far correct diagnosis has not been made but the con- dition has been attributed to appendicitis. Since the diverticuluro 858 DISEASES OF THE STOMACH AND INTESTINES may originate from the ileum from i to 3 feet above the ileocecal valve and the ileum is very movable, its position in the abdominal cavity is variable and its localization not fixed. The pain and tenderness, however, are not so often at McBurney's point, but generally higher and to the right of the umbilicus, or even above it, though occasionally in some dif- ferent region. There is an area of puffiness or firm resistance at the site of inflammation and an absence or only a slight degree of meteorism early in the attack. Blood is present in the stools and at times in the vomitus. Gastric disturbances, local attacks of pain constipation or diarrhea, rise of temperature, leukocytosis and increased polynuclears occur. There may be an earlier existence of an umbilical fistula or some malformation elsewhere in the body. Prognosis. Recovery in catarrhal cases has never been recognized as such during life, though postmortem, when dying from an intercurrent disease, it has been demonstrated that it has occurred. The prognosis is unfavorable 40 to 65 per cent, mortality in acute cases. Treatment. Immediate operation is indicated. If Meckel's diver- ticulum be found at any abdominal operation, it should be removed. CHAPTER XXXIII INTESTINAL OBSTRUCTION ACUTE AND CHRONIC INTESTINAL obstruction occurs in two types acute and chronic. Acute obstruction is, in turn, characterized by two anatomic types: 1. Acute intestinal obstruction with sudden complete occlusion of the intestinal lumen. 2. Acute intestinal obstruction engrafted suddenly on a chronic obstruction (chronic stenosis), due to a sudden blocking of the stenosed intestines from various causes, such as by a foreign body or a fecal accu- mulation above the stricture. ACUTE INTESTINAL OBSTRUCTION (Synonyms. Ileus; Miserere; Passio Iliaca) General Considerations. Acute intestinal obstruction may be defined as a sudden acute stoppage of the passage of the intestinal con- tents. This may be caused by mechanical occlusion of the intestinal canal (mechanical ileus), by a sudden loss of motor power in a portion or in all the bowel (dynamic or paralytic ileus), or by a combination of these conditions. Before discussing the matter further, as a means of assistance to diag- nosis, I wish to call a few very important facts to my reader's attention. As a rule, we may say that acute obstruction of the small intestine gives rise to more severe and violent symptoms than that of the large intestine. The nervous apparatus of the small intestine is in connection with most important plexuses, the solar and superior mesenteric, and the pain is more violent, the vomiting earlier and more marked, and the prostration and shock more rapid. Various explanations have been advanced for the marked toxemia occurring with strangulation of the small intestines. Draper has dem- onstrated that life is prolonged in animals in whom this condition has been artificially produced, by feeding with the intestinal cells of the small intestines, so that it would seem that their destruction by stran- gulation has apparently some influence in the production of the toxemic symptoms. The early appearance of indicanuria and of anuria are also significant of obstruction in the small intestine. Moreover, simple occlusion of the intestines does not lead to nearly as acute symptoms as when strangulation is present. In the latter condition interference with the circulation of the intestinal wall and of the mesentery and the irritation of the sensory nerves give rise to acute and violent symptoms, marked pain, vomiting, and shock. In this class of cases we have the acute internal hernias and strangulations, volvulus, 859 86o and the severe type of acute intussusception. Local meteorism is gen- erally present in the early stages of volvulus, internal herniaform strangu- lation and kinking of the bowels, and enables us at times to locate the character of the lesion. Often this distention rapidly becomes very extensive, as in volvulus, for example, a general distention ensues, so that determination of the condition is difficult. In the majority of cases of acute obstruction when we find present marked increased peristaltic movements of the bowel, with stiffening and rigidity of loops of intestines; they occur in acute cases engrafted on cases of chronic stenosis with hypertrophy of the bowel muscle above the stricture. We occasionally see this symptom in primary acute conditions, especially in acute intussusception. We must remember, moreover, that acute dilatation of the stom- ach, either alone or associated with intestinal paresis, quite frequently occurs after operation, and presents many of the symptoms of acute dynamic ileus. There is obstruction, in fact, in many cases due to pressure of the organ on the transverse duodenum or, as some believe, by mesenteric traction. The stomach may occupy the left half, or even the entire abdominal cavity. I have referred to this condition under Acute Dilatation of the Stomach. Practically we may say that in every case of acute obstruction, intra-abdominal tension is markedly increased, thus interfering with the physical examination. I place the following suggestions at the commencement of this chapter in order to emphasize them the more. They are of value as an aid to diagnosis in every case with acute symptoms. Immediate and thorough lavage, digital examination of the rec- tum, and if no evidences therein of obstruction or intussusception, pre- venting the entrance of an injection, then a careful recurrent rectal irrigation; vaginal examination and inspection of hernial openings should be the preliminaries in the examination of every case. Lavage and irrigation of the bowel immediately promote the comfort of the patient by lessening distention, render the physical examination easier, and the combined methods are thus an invaluable aid to diagnosis. It may be necessary to substitute a high enema for irrigation. ' Etiology of Acute Intestinal Obstruction. The various causes of acute intestinal obstruction, on account of their importance, will now be considered separately: The first classification that I shall describe is the so-called internal herniaform strangulation of the bowel (compression of the intestines), due to strangulation by (a) bands and adhesions, the result of a former peritonitis; (b) Meckel's diverticulum; (c) slits and apertures; (d} in- carceration into herniae; (e~) tumor pressure from without. Frequency. Fitz, in an analysis of 295 cases of acute obstruction, gives 34 per cent, of the cases as due to this type of strangulation (internal herniaform), excluding volvulus; 35 per cent, out of 1134 cases are reported by Leichtenstern. Out of 101 cases of strangulation Fitz shows that 63 were due to adhesions and bands, and 21 to vitelline remains. Strangulation of the intestines by adhesions and bands thus con- INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 86 1 stitutes the largest percentage of this class. In some cases they may be congenital. The band may be a firm fibrous cord, or may be tough and thin as a thread, occasionally it may be % inch wide. Strangulation from bands and adhesions may occur in four ways: 1. There may be a short tense band firmly attached at each end, beneath whose arch a knuckle of the intestines passes, the space may only be of a size to admit two or three fingers. 2. On the other hand, there may be a long lax band, attached at its ends and forming a ring or spiral 8, through which a loop of the small intestine may slip. 3. A loop of intestines filled with contents may lie over a tense band of adhesions and thus become strangulated; this is a rare occurrence, but has been described by Treves. 4. The intestines may suddenly become kinked and occluded by traction from an adhesive band, as if an ovarian cyst were tapped and the sudden contraction drew on an adhesion to the intestines. These bands and adhesions may occur between any of the viscera, the parietal peritoneum, omentum, and mesentery. Adhesions may surround the bowel and contract, narrowing its lumen, also a mesenteric contraction may be a cause. A coil may be caught between the pedicle of a tumor and the pelvic wall or may circumscribe a tumor pedicle. Strangulation by MeckeVs Diverticulum. -'Meckel's diverticulum is due to the incomplete obliteration of the vitelline duct, and forms a finger-like projection from the ileum, usually within 18 inches from the ileocecal valve. As a rule, it is about 3 inches long, though fre- quently longer, and cylindric in shape with a conic end, though the latter is occasionally "clubbed." The end may become attached to the abdominal wall near the navel, to the mesentery, or to some other point, and thus form a band or loop under which strangulation may occur. More often the diverticulum is free and may form a ring into which its end projects. A loop of the intestines may enter the ring and, especially if the tip is club shaped, may push it before it and tie a knot (Fig. 343). The vermiform appendix may become adherent to some point in the peritoneal cavity and from an arch under which a loop of the intestines may become strangulated. This may likewise occur with the Fallopian tube. Strangulation of the Bowel through Slits and Apertures. This type is less often met with, and is, in fact, quite rare. Slits and apertures in the mesentery and omentum may be congenital, but are more fre- quently traumatic. They generally occur in the mesentery near the lower part of the ileum. Fissures, holes, or rings are more frequently formed by peritoneal adhesions; more rarely strangulation may occur in a tear of the uterus or bladder. Strangulation from Internal Hernia. These are situated within the abdominal or thoracic cavity, or are subperitoneal or retroperitoneal, parallel to the abdominal wall without passing outward. In some of the so-called external herniae no swelling can be detected 862 DISEASES OF THE STOMACH AND INTESTINES externally. Moreover, hernia may develop in an accessory form between the muscles and fascia. Among internal herniae we may have those of the recessus duodeno- jejunalis, intersigmoid recess, retroperitoneal, anterior, retrocecal, fora- men of Winslow, and diaphragmatic (Figs. 344-346). Diaphragmatic hernia is most frequently met with of these forms and can occasionally be diagnosed. It has previously been described. It may be congenital or traumatic, as from wounds, contusions, or excessive vomiting. Fig. 343. Knotting of a Meckel's diverticulum which has a button-like swelling of its extremity (after Treves). In the true form, a hernial sac of peritoneum or pleura covers the viscera; in the false form (the more frequent) it does not. This type is found on the left side, the stomach being involved most frequently, the colon and small intestine less so. The stomach fundus passes into the thorax and apical rotation occurs. Physical Signs of Diaphragmatic Hernia. Pneumothorax, less motility of the side of thorax involved, bulging of the walls of the thorax, and metallic sounds are the chief symptoms. Dyspnea, distress or pain in the thorax, and difficulty in swallowing (dysphagia) may be present. Diaphragmatic hernia can be diagnosed by inflation of the stomach with INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 86 3 air or water, the use of the x-ray, or by gastrodiaphany. See section on this subject. Mechanism of Internal Herniaform Strangulation (Compression of the Intestines). The mechanism of the type of obstruction just described is as follows: A coil of gut is drawn beneath a band or through an aperture, and becomes at once strangulated, or con- gestion of the mesenteric vessel occurs, then gas and pus accumulate, and later strangulation occurs, or, in addition, a torsion of the bowel may take place- necrosis, gangrene, and perforation result. The lower part of the ileum is chiefly affected. Peritonitis may occur early, in twenty-four hours, or late, in one to two weeks. Various types of strangulation are shown in Figs. 347-354. Fig- 344- A rod in the ileo- o ~jf\ T i pendicular, or ilapeocecal, fossa Sex and Occurrence. In males 70 per [cantlie). cent., though some claim occurrence in the sexes is equal. Between twenty and forty years cases chiefly occur, though 40 per cent, are between fifteen and thirty years. In 90 per cent, the seat of the trouble is in the small intestine, usually the ileum; in 67 per cent, strangulation is in the right iliac fossa; in 83 per cent., in the lower abdomen (Osier). Clinical Symptoms. These are characterized by their sudden acute onset while the patient is in perfect health. Rarely injury, violent move- Fig. 345. The intersigmoid lossa exposed by holding upward the pelvic colon; the double dotted line indicates the ureter behind the peri- toneum (Cantlie). Fig. 346. A rod in the ileocolic fossa (Cantlie). rhent, or diarrhea may precede the attack, and are considered to be factors. Sudden severe pain first occurs, occasionally colicky, 'often severe throughout, though at the end it may lessen. The pain at times corresponds to the seat of the strangulation. Vomiting begins early and is persistent and soon becomes feculent; absolute constipation is present, no flatus is passed. There is early and rapid appearance of collapse, 864 DISEASES OF THE STOMACH AND INTESTINES Fig. 347. A band in the form of a loop attached to the intestine and mesen- tery (Cantlie). Fig. 348. The coil of intestine has slipped through the loop of Fig. 347, and caused strangu- lation by a complicated knot (Cantlie). Fig. 349. A coil of in- testine, in addition to being snared under a band, has undergone rotation on its mesenteric axis (Cantlie). Fig. 350. A knuckle of intestine snared over a band which is stretching from the intestine to the mesentery (Cantlie). Fig. 351. A knuckle of intestine snared by a band which has assumed the form of a simple loop (Cantlie). Fig. 352. A knuckle of intestine snared under a band which is stretch- ing from the intestine to the mesentery (Cantlie). Fig. 353. A coil of small intestine ad- herent to a caseating tuberculous mesen- teric gland (Cantlie). Fig. 354. A band attached to the small intestine and umbilicus ; causing an acute kink of the bowel (Cantlie). INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 86 5 urine is scanty, meteorism slight or absent, slight tenderness on pressure, no blood in bowel movements if such occur, nor is it discoverable by enema. Death occurs in two to four days. If peritonitis occurs, meteorism is marked and pain recurs and is severe. A circumscribed area of dulness or tumor is rare. The attack is of a fulminating character. Volvulus may be denned as an obstruction of the bowel caused by a rotation of the intestines about their axis, a rotation of the bowel about its mesentery, or an intertwining (rotation) or knotting of two intestinal loops with their mesenteries. It occurs most frequently in the sigmoid flexure. The ascending colon, cecum, and small intestine, especially the ileum, may sometimes be affected, and intertwining of the intestines is most often met with in this location. Mechanics. The Sigmoid Flexure. The sigmoid flexure must be large and its mesocolon long and narrow for the development of volvulus. The ends of the sigmoid are thus approximated, and it can readily rotate around the mesocolon as a pedicle Fig. 355- Illustrating the disposition of a loop of bowel which is predisposed to volvulus. The parietal attachment of the mesen- tery is considerably shorter than its intestinal attach- ment, and the coil is, as it were, suspended os from a pedicle (Cantlie). Fig- 35- Illustrating a volvulus in which the upper segment of intestine passes in front of the lower one (Cantlie). Fig. 357. Illustrating a volvulus in which the upper segment of intestine passes behind the lower one (Cantlie). (Fig. 355). This condition may be congenital or due to some chronic inflammation. Etiology. Chronic habitual constipation is the chief cause, as the weight of the fecal matter produces local displacement and distorts and elongates the mesentery. The rotation is usually the result of bodily exertion. On the other hand, one branch of the flexure, being overdistended, may drop down over the other. The branches may be rotated through 180 to 360 degrees, or even several complete rotations may occur. The distention of the sigmoid, the congestion and exudation of fluid and accumulation of gas in the loop, prevent restitution to the normal position. The accumulation of gas in the colon also prevents return to normal. Volvulus is illustrated in Figs. 356 and 357. Small Intestine. -The same conditions favor axial rotation of the small intestine. Inflammation of the mesentery is sometimes a cause, also gall-stones, by producing colic and spasm. 55 866 DISEASES OF THE STOMACH AND INTESTINES Accessory Causes. Leanness, the absence of fat in the mesentery, and hence lessened intra-abdominal pressure have been considered pre- disposing causes, also trauma, jumping and lifting, sudden diarrhea (peristalsis) in these constipated cases, or a large enema (according to some). Age. It is more common in older than in young objects, generally in those over forty years of age, though Fitz places it more frequently at thirty to forty years in his statistics. Frequency. Fitz finds 42 out of 295 cases of acute intestinal obstruction due to volvulus. Sex. According to Fitz it is more frequent in men 68 per cent. Some place the proportion much higher, as three or four men to one woman. Symptoms. This condition is characterized by its acuteness and rapid course. It is more rapid than any other form, except, possibly, internal strangulation of the intestines. Pain is sudden, violent, and never absent, and sometimes localized in the left lower quadrant; it may remit, but there is never a complete intermission. Vomiting is, as a rule, violent and profuse, continuous, and is an early symptom, though occasionally less frequent in sigmoid volvulus. Fecal vomiting is comparatively rare. Constipation, both for feces and flatus, occurs, as a rule, from the incipiency of the attack. Occa- sionally a history of violent exercise or of acute diarrhea may precede the attack. Tenesmus may be present in volvulus of the sigmoid, though not as frequent as in intussusception, and in rare instances there is the passage of a small amount of blood. Local meteorism is an important symptom, the left lower portion of the abdomen protrudes as a tense and elastic swelling, feeling like a rubber ball; visible peristaltic movements do not occur; percussion may be tympanitic, there may be metallic sounds, or rarely, dulness if there is much edema. In some cases there is an S-shaped protrusion of the abdomen, most prominent in the upper left and lower right quadrant. This is in the early stages. General meteorism develops most rapidly, next in rapidity to that of general peritonitis, but in the latter the abdomen is very tender; while in the former it is only slightly so. Within forty- eight hours the abdomen may be balloon shaped. This rapid meteorism is an aid to diagnosis. The symptoms are very acute and collapse is marked. In axial rota- tion of the small intestine at the onset there may not be absolute consti- pation; the local meteorism starts higher up and there is no tenesmus. In these cases, curiously enough, the symptoms are no more violent than in sigmoid volvulus. Anatomy. There is local meteorism, the walls of the distended loop are thickened, rigid, edematous, and dark red. The peritoneal coat is often torn, as is the muscularis. Hemorrhages are seen in the intestinal wall. Blood, gas, mucus, and feces lie in the loop. The mesentery is hyperemic and infiltrated. The twisted part of the intestines is attenu- ated and pale. Gangrene may occur at the line of demarcation. Other parts of the intestines are collapsed and pale unless general meteorism subsequently occurs. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 867 Course. The course of volvulus is always acute. The patients may occasionally die in twelve to twenty-four hours or in two to three days; the average course is a week. They die of collapse, exhaustion, peritonitis, or from paralysis of the heart due to compression from tympanites. Unless operation is performed, the cases, as a rule, are fatal, especially those with complete axial rotation. Some patients who, from the symptoms, seem to have suffered from partial rotation, the course being more chronic, have recovered. Intussusception; Invagination. It is in this condition that one seg- ment of the intestines slips into an adjacent segment, so that the latter forms a sheath for the former. The two portions make a cylindric tumor which varies in length from an inch to many feet. The condition is always a descending intussusception. The outer tube is called the sheath or intussuscipiens; the middle and inner tubes, the intussusceptum ; the innermost tube, the entering tube; the middle one, the returning tube Fig. 358. Intussusception. Fig. 359. An in- tussusception (Cant- lie). c-- Fig. 360. An intus- susception in longitudi- nal section: A, The en- tering layer; B, the re- turning layer; -C, the sheath (Cantlie). (Figs. 358-360). The upper part, where the middle tube bends over into the sheath, is called the neck; its lower part, where the inner tube bends over into the returning cylinder, is called the head. Mucous membrane is in contact with mucous membrane and peritoneum with peritoneum. Those depicted are the usual form, sometimes a double or triple invagina- tion may occur, or an incomplete lateral invagination, the reverse of a diverticulum. The mesentery participates in the invagination and becomes compressed and wedged in the sheath. The serous surfaces may become adherent, so that the invagination cannot be disengaged. There are various types of intussusception which may occur in every portion of the bowel. 1. The Ileocecal Form. In this type the ileocecal valve forms the apex of the intussusception, the ileum the internal cylinder, and the colon the sheath; this often forms a very long intussusception, so that the valve may even protrude at the anus. 2. The Ileocolic Form. The lowest part of the ileum forms the apex 868 DISEASES OF THE STOMACH AND INTESTINES and protrudes into the cecum. If the cylinders become adherent, then the ileocecal valve and cecum may become inverted. 3. Ileaca-ileocolic Form. There is first an ileac invagination which may force the intussuscepted part into the colon. There may also be intussusception of the ileum, jejunum and ileum, jejunum, duodenum and jejunum, duodenum, colon, colon and rectum, and, rarely, of the rectum. The ileocecal form seems to predominate, and is especially frequent in children. The ileocolic is also quite frequent, and these two types give the longest intusussceptions. In adults the ileac and ileocecal forms occur with about equal frequency and in the colon it is quite frequent. Intussuception of the vermiform appendix into the cecum has been reported, and also of the ileum into the open Meckel's diverticulum, when this is patent at the umbilicus, and also by the gut, grasping it, or by traction. The mesentery exerts traction on the intussusception and the bowel curves so that the concavity points toward the mesenteric attachment. This may cause a kinking, which further closes the intestinal lumen. Circulatory changes take place in the intussusception, edema, swelling, etc., and in severe cases strangulation and gangrene. The intussusception may slough off. Peritonitis is first noted on the second or third day; it may be local or become general. Mechanism of Intussusception. The probable reason of intussuscep- tion being so frequent in young children is that during the early months of the infant's life there is a rapidly increasing disproportion between the transverse diameters of the large and small intestines, the large intestine increasing very rapidly in diameter, so that the ileum can readily prolapse. For the production of invagination there is probably a local spasm of a portion of the intestines, and the normal gut below is pulled upward by its longitudinal fibers over the contracted piece of bowel, and the irrita- tion caused by the invaginated part then causes spasmodic contraction of the gut above, which carries the incarceration further downward. Numerous experiments have been carried out for a study of the mechanism. None of these seem to show that primary paralysis is a factor, but that the condition is rather of a spasmodic type. Paralysis of a limited part of the bowel may, I believe, be a factor in some cases. Frequency. Weiss finds that out of 321 cases, intussusception occurs: Per cent. Per cent. Per cent. Per cent. In the newborn and sucklings. Iliac, 24 Ileocecal, 42 Ileocolic, 10 Colic, 24 Childhood to puberty Iliac, 23 Ileocecal, 43 Ileocolic, 14 Colic, 26 Adult Hiac, 29. 5 Ileocecal, 34. 5 Ileocolic, 4.5 Colic, 27 Meckel's diverticulum (adult)... 4.5 177 in first year; 85, two to fourteen years; 59, later age. The agonal type of intussucseption occurs just before death, is of no importance, and is often multiple. Of Leichtenstern's cases, 131 out of 543 occurred in the first year, 80 of them at four to six months. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 869 Age. Most frequent in infancy and early childhood, up to the fifth year. Causes. Diarrhea, intestinal polypi, carcinoma and stricture, inges- tion of irritating food, contusion of the abdomen, shaking the body, and acute and chronic diseases have been given as factors. Benign tumors when present, such as accessory pancreas, fibroma, myoma, especially the polypoid form, are generally at the apex of the intussusception, and most frequently occur in the ileum. They may set up peristalsis, and constriction and invagination so result. It is rare with carcinoma or stenosis, and it may occur when the tumor is pedunculated. Often the cause is not discoverable. Symptoms. In the acute cases the attack is characterized by its sud- denness. There may be preliminary intestinal disturbances, such as diarrhea or colicky pains. Often they appear while the patient is quiet, asleep or nursing. I shall refer to the acute cases only in this chapter. The iliac and ileocecal forms are the most acute. The colic and rectal form are more gradual. Pain. There is first pain of a violent colicky character, at times aris- ing at a definite point. It may be very severe and overwhelm the patient, and in children may cause convulsions, or they may scream and groan. It is continuous at first, later may intermit, though at times it may be continuous throughout. In some cases the pain is in the right iliac region or occasionally at the umbilicus, and at times local tenderness is present. Spasms and contraction with rigidity of loops of intestines sometimes occur in acute cases, but more usually in the chronic. Vomiting is constant and early in children, is not constant in adults, and hence is a less impor- tant symptom in them. The vomiting depends on the position of the intussusception; the lower down it is, the less likely the vomiting at the outset; peritonitis brings it on. Feculent movements may occur at first; later, diarrhea with blood and mucus, and tenesmus if the invagination is low down. In some cases this is quite marked; hemorrhages from the bowels ensue, even if the invag- ination is high up. Fecal vomiting is rare. Vomitus usually contains gastric contents, mucus, and bile, and only occurs in one-fourth of the cases in adults. The higher up the invagination, the sooner it appears. Meteorism of a great degree is exceptionally present; sometimes the abdomen is even re- tracted. It is dependent on the degree of constriction. Tumor. A palpable tumor can at times be appreciated in about one- half the cases. It varies in size, may seem shorter to the touch than it really is, or it may impart the feel of a double swelling; it is usually of a cylindric or sausage shape, elongated, and curved. Its consistency may vary at different times and it can be slightly compressed. It may feel hard and then suddenly soft, or even vanish. The changes in consistency and resistance are due to the spasmodic contraction in the intestinal wall During contraction it may be tender. Situation. Most frequently the tumor is located in the region of the sigmoid; then at the anus or rectum, then at the cecum, descending trans- verse or ascending colon. 870 DISEASES OF THE STOMACH AND INTESTINES The position of the tumor may be permanent if there are any adhe- sions, or it may change if the intussusception increases. Prolapse of the swelling through the anus often occurs. Duration. Especially in children severe symptoms of collapse may take place within two to three days, and if vomiting persists, it may be feculent. About 80 per cent, of young subjects die; subacute cases run two to four weeks and spontaneous cures occur in this type. Death from collapse, gangrene, and peritonitis may occur during the first week in infants, or in two to three weeks in adults. Sepsis and phlebi- tis may be associated. Diagnosis. Acute commencement, vomiting constant in children, but not so in adults; at times tenesmus, the presence of bloody stools; then retention of f eces and flatus, distention of tlie abdomen usually slight; and last the appearance of a tumor are diag- nostic of intussusception. Intussusception of the Appendix. Moschowitz, 1 reports a case of intus- susception of the appendix (Fig. 361), and collects 24 additional cases. In the pure uncomplicated cases, with- out invagination of the ileum into the Fig. 361. Intussusception of the ap- . . pendix vermiformis (Cantlie). cecum, the history usually covers a considerable period from a few weeks to even several months. The oldest patient was forty-two years old, the youngest two, and the general average was five years of age. Symptoms. The pain is usually intense, cramp-like, and localized around the umbilicus. It occurs in paroxysms, during which period the patient suffers severely. The distinguishing feature of the pain is its remitting character. During the period of remission the patient may apparently feel perfectly well. Attacks of pain with remission alternate and there may be from one to two to many attacks a day. The duration of the disease varies from a few weeks to several months. There is rigidity of the abdominal muscles but examination with the patient in a hot bath or under an anesthetic enables one to determine a swelling about the size of an egg in the right iliac fossa. It differs from the sausage-shaped swelling of an ileocolic intussusception. The bowels may move spontaneously or with cathartics. Blood in gross or minute quantites (by chemical test) is present in the stool during the cramp-like attacks. The remissions and chronicity differentiate it from acute in- vagination involving the entire gut. Obturation of the intestines signifies the occlusion of the bowels by a foreign body situated therein; among such are gall-stones, entero- liths, foreign bodies which have been swallowed or, rarely, inserted into the rectum, lumbricoid worms, and masses of fecal matter. Gall-stones, in exceptional cases if very large, may cause an acute intestinal obstruction. They probably have ulcerated through into 1 N. Y". Med. Rec., Dec. 17, 1910. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 871 the bowel from the gall-bladder. They may become impacted in the duodenum, jejunum, or at the ileocecal valve. Cases of this last type are more frequent in women than in men. In many there is a previous history pointing to cholelithiasis. The symp- toms are pain, violent vomiting (generally bilious), which frequently becomes feculent, constipation, which is not always absolute, meteorism, often not pronounced, and collapse. In some cases a hard resistant swell- ing may be felt. In others there will be some flatus from the rectum. Milder symptoms of occlusion may occur, evidently when the lumen of the bowel is not completely shut off. The patient in this class of cases would suffer from attacks of colicky pain, vomiting, and constipation, but no collapse. These cases may also have perforative peritonitis, and often die on the fifth to tenth day unless operated on. At times the stone may move onward and escape, with recovery of the patient. Occasionally there will be some diarrhea with blood during the onward movement of the calculus, the result of traumatism to the mucosa. Enteroliths. An intestinal calculus rarely causes acute obstruction unless it has been dislodged from an intestinal diverticulum, and suddenly occludes the bowel. It generally produces the symptoms of chronic ob- struction or digestive disturbances and obstinate constipation. Calculi ordinarily consist of carbonates or phosphates with a foreign body as a nucleus; or as a result of the prolonged use of drugs, such as chalk, bismuth, magnesia or salol, or some indigestible material, such as oat-stones from oatmeal, etc., in which inorganic salts are deposited. They frequently develop in the large intestine. Foreign Bodies. These are accidentally or intentionally swallowed. This is especially apt to occur with children or with insane or hysteric persons. Occlusion has also been produced by the insertion of a foreign body into the rectum. Among such substances are knives, spoons, forks, keys, marbles, stones, false teeth, fruit stones, neckties, hair or beads, pins and needles; in fact, all varieties of objects. In some cases the symptoms may first be chronic, when suddenly acute occlusion will occur; in others it is acute from its incipiency. Murphy's button has caused occlusion, also a large mass of tapeworms or round worms. Pedunculated tumors of the intestinal wall, such as polypi, fibroma, and myoma, may produce it. Many of these objects can be readily recognized by means of the #-rays and the fluoroscope, or by a Rontgen picture. Fecal masses may completely occlude the intestines as a result of habit- ual constipation. The symptoms are usually subacute or chronic at first, and finally become acute from complete occlusion. Dynamic Ileus (Intestinal Paresis). Acute obstruction produced by paralysis of the bowels is called paralytic or dynamic ileus. Among the various causes are hydrocele, contusion or inflammation of the testicles, etc., which may cause a reflex paresis; paracentesis of ascites; trauma over the abdomen; after laparotomy from manipulation of the viscera or follow- ing removal of a large tumor, or after Cesarean section; other operations from the effect of the anesthetic; damage to the intestines, as from hernia after relief of the strangulation; local or general peritonitis; renal or biliary colic may cause reflex obstruction, possibly due to spasm or paresis; over- 872 DISEASES OF THE STOMACH AND INTESTINES distention of the intestines from gas or feces; various toxemias, as from typhoid or pneumonia or from any acute infection, also sepsis, as from appendicitis, and as a concomitant of shock or uremia. Congenital Causes. Congenital occlusion of the rectum or colon pro- duces acute obstruction. Acute Obstruction Engrafted on Chronic Obstruction. Chronic stenosis with chronic constipation may suddenly produce an acute obstruction. Pathology of Acute Obstruction. In acute obstruction the pathologic findings differ somewhat, according to the various types and factors. There has been an unfortunate tendency to confuse the findings in acute and chronic obstruction. If we have an acute condition engrafted on a chronic obstruction, we may then find above the point of obstruction dila- tation and hypertrophy of the intestines, catarrh, and ulcerations. In true acute occlusion the process is too rapid for these changes, but the following occur: the intestines below the occlusion are empty and con- tracted ; above it the intestines are markedly dilated and distended and the walls are thinner. If a loop is involved, the walls are thick and congested (but not hypertrophied). The coils above the obstruction are distended, filled with gas and ill-smelling contents. If the small intestine is occluded the distention will involve the gastrointestinal tract above the occlusion; if the large intestine is occluded the colon will be distended first; later regurgitation through the ileocecal valve occurs and universal distention. In a loop which is strangulated, there is local meteorism, and it may be markedly distended; there are congestion, edema, hemorrhage, a dark red color of the gut and gangrene, with general peritonitis and bloody fluid in the cavity; or a single perforation from ulceration or gangrene may occur (the distention ulcer with perforation " Dehnungsgeschwtir," de- scribed by Kocher); and rarely, if the case be prolonged, a local abscess or local peritonitis. General Symptoms of Acute Obstruction. As a rule these begin very acutely, though rarely there is a previous history of diarrhea or constipa- tion, improper food, a laxative, traumatism, or of violent exertion. There are at first violent abdominal pains, colicky in type, local or dif- fuse. The pain is continuous, though sometimes it may remit. Nausea, hiccough, and vomiting first of the gastric contents, later bilious, and, finally, feculent vomiting rapidly follow. Meteorism quickly appears; there are absolute constipation and no passage of flatus. Tympanites increases, a great increase of intra-abdominal pressure is present, and the muscles become tense and rigid and the entire abdomen tympanitic; res- piration is markedly interfered with, the breathing is rapid and shallow, pulse rapid and feeble, extremities cold, cold sweat, face pale, eyes sunken, and extreme thirst; total collapse and the patient rapidly succumbs. General peritonitis occurs. Only a brief analysis will be made of these symptoms, as they have been thoroughly described under the respective causes of acute obstruc- tion. Pain is the most constant symptom and it never remits completely. As a rule, it is more acute in obstruction of the small intestine; the initial pain is probably due to irritation of the intestines and peritoneum, later to spasmodic intestinal contraction, and finally to peritonitis. In the INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 873 last stage pain may cease as a result of the terminal fatal intestinal paresis. External pressure, as a rule, increases the pain. Active and visible peristaltic movements and tetanic stiffening of the bowel are exceptionally seen in acute occlusion, when the intestines were previously healthy and unobstructed; and if they are visible, are never as marked as in cases of acute obstruction supervening on a chronic stenosis of the intestine. This is an important point to remember. The visible peristaltic movements if present, in connection with the other symptoms are an aid to diagnosis. Vomiting is nearly always present. At first it is probably due to reflex irritation of the nervous system; later it has been ascribed to antiperistal- sis; or to mechanical causes, as explained by Haguenot, who states that fluid contents accumulate above the obstruction; and from gas pressure and contraction of the abdominal muscles the contents are forced into the areas of less resistance and thus reach the stomach, where they cause vomiting. Feculent vomiting often occurs when the obstruction is in the small intestine, due to putrefactive processes therein. Constipation is usually marked; though rarely there is diarrhea with blood, as in intussusception. Absence of flatus is quite significant. Meteor ism. This may first be circumscribed (local), there being tympanites and protrusion of the intestines for a short distance above the point of obstruction; thus, a protrusion of the right side would first be noted if an obstruction occurs at the hepatic flexure. Later the meteorism becomes general and the abdomen barrel shaped. Collapse. This is marked, especially so if there is strangulation, and it is more rapid if the small intestine is involved. Thirst and dryness of the tongue are present, being due to vomiting, sweating, and increased intestinal secretion, which diminish the fluidity of the blood. Coma, delirium, and fever rarely occur, unless a general peritonitis. Diagnosis of Acute Intestinal Obstruction. Having described the symptoms of acute obstruction, a careful study of the physical signs and the methods of physical examination are necessary to complete the diagnosis. Investigation of the type and degree of meteorism (tympanites), both by inspection and percussion, is of great importance. At this point I again desire to call to my reader's attention that acute dilatation of the stomach presents many symptoms of ileus and may obscure the diagnosis. The pain of acute ectasia is not as severe and continuous as with acute intestinal obstruction, in that it is immediately relieved by lavage. The stomach may occupy the entire abdominal cavity, though usually it fills the left half and lower part of the abdomen. The vomiting of acute ectasy is also peculiar, in that it is very profuse, incessant, and in large amount, and comes up in gulps without straining. It is usually watery and greenish in hue, though it may be brownish or black. If the stomach alone is involved, distention will disappear after lavage. Temperature is normal or subnormal. Vomiting is nonstercoral. Inspection. If there be occlusion of the jejunum or duodenum, unless 874 DISEASES OF THE STOMACH AND INTESTINES the stomach also be greatly dilated, the upper part of the abdomen is protruded slightly. Occlusion at the cecum or lower ileum gives the so-called "ladder' 1 pattern, the coils lying one above another either obliquely or transversely in the abdomen, and the distention is more central. In stenosis of the sigmoid flexure 1 the upper and lateral aspects of the abdomen are usually distended, and we have so-called flank meteorism. When the distention is limited to a section of the colon, flank meteorism may be unilateral ; thus the right iliac region is intensely tympanitic if the oc- clusion involves the hepatic flexure. If the small intestine alone be included, the distended loops are seen in the center and flank meteorism is absent. With volvulus the left lower portion of the abdomen protrudes; or an S-shaped protrusion of the abdomen, most prominent at the upper left and lower right quadrants, occurs. We must remember that local meteorism occurs only early, and later general tympanites ensues, so that we may not see the case early enough to avail ourselves of these data. Peristaltic waves, if present, aid to locate the obstruction. Palpation. In some cases palpation reveals a circumscribed area which is tender 2 on pressure, and may aid in localizing the obstruction. In others a tumor is palpable, especially with intussusception, occlusion by tumors, or fecal impaction. Palpation of the hernial openings is necessary. Digital examination of the rectum and vagina are most important. We may feel a stricture or intussusception in the rectum and bloody fluid may escape. I depre- cate the method of inserting the hand in the rectum. Percussion. Local meteorism gives a deep and loud note, which is not truly tympanitic, but often of a metallic ring, and helps locate the obstruc- tion. Exceptionally, dull percussion may be heard over the swelling, due to edema of the intestinal walls or to accumulation of fecal contents or blood admixture. - In normal subjects the percussion note in the upper lumbar region behind, is high, flat, and dull. It is loud and deep in stenosis of the large intestine. When the obstruction is in the sigmoid, the loud and deep note is found on both sides, and when in the splenic flexure or transverse colon, then only in the upper lumbar region of the right side. If there is general tympanites and no change of percussion is noted for a long time over any one region of the abdomen, there is probably intes- tinal paresis. General tympanites, with absence or diminution of liver does not always mean perforation of the bowel, though it frequently does so. One can often determine peritoneal exudation by percussion. Auscultation. Splashing and gurgling noises often demonstrate that peristalsis is marked. Succussion sounds and fluctuation on palpation are frequently found in the intestines above the point of stenosis. Ex- amination of the vomited matter will show whether fecal material is pres- ent. Urine is scanty and albuminous, and often shows indican and gives Rosenbach's reaction, especially in obstruction of the small intestine. 1 Ultimately complete distention with barrel-shaped abdomen may occur. 2 Muscular rigidity shows peritonitis. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 875 Suppression of urine occurs in this condition. The writer opposes the use of .r-rays for diagnosis in acute cases. Differential Diagnosis Between Obstruction of the Small and Large Intestine. Obstruction of Small Intestine Pain, vomiting, and collapse are more acute and appear early. Early feculent vomiting. Indicanuria early, on second or third day. Anuria early, early meteor ism, and often is high up. Absence of early indicanuria (excluding peritonitis and intes- tinal inflammation) tends to show obstruction is not in the small intestine. Vomiting in duodenal obstruction is rarely feculent, but is so if the obstruction is lower down. Obstruction of Large Intestine. If the disease is chronic or runs a long course, absence of indican shows lesion is present in the large intestine; its presence, however, tells nothing, as it may appear late. General symptoms are usually less violent, though they are violent in volvulus. Fecal vomiting occurs later. Meteroism is lower down in the early stage of acute obstruction. Tenesmus and blood in the stool suggest an obstruction low down. Brinton's method by the injection of water is sometimes of service. If not more than i quart can be injected, the obstruction is probably low down; if 2 quarts, it is probably above the sigmoid, and if 4 quarts, then in the commencement of the colon or higher up. Inflating the bowel with CO% by Rose's bottle or by air will fill the large intestine up to the obstruction. This method is of no service if there is very marked distention, and lavage should be first performed to reduce it. Differential Diagnosis between the Different Forms of Acute Obstruc- tion. This is often difficult. In some cases it is possible, but in others we can only conjecture the probable type. Acute strangulation in herniae, omental slits, or by bands constitutes about 34 per cent, of cases. This is more frequent in males between twenty and forty years. In 90 per cent, the small intestine is the seat of trouble, mostly in the ileum and lower abdomen or right iliac fossa. The symptoms are sudden and acute. There may have been a previous history of peritonitis, hernia, or injury. Pains are severe, vomiting begins early and soon becomes feculent, absolute constipation is present and no passage of flatus. Tenesmus absent. Collapse is early and marked. Urine is scanty and meteorism slight. Attack is of fulminating type. Physical examination often gives no definite data. Volvulus. This most frequently involves the sigmoid. History fre- quently of chronic constipation, is more common in males and in those over forty years of age, from forty to sixty, though Fitz's statistics show frequency from thirty to forty years of age. If volvulus is of the small intestine, it cannot be differentiated from incarceration. Pain is sudden and violent, it may remit, but never intermits. Vomiting is quite com- mon, but may be absent at first in volvulus of the sigmoid, and in the latter case fecal vomiting may not be present. It occurs in some cases, but is not as frequent as in internal strangulation; in fact, it is rather rare. Meteorism occurs early and is at first local in the lower left quadrant, or as an S-shaped protrusion. General meteorism rapidly occurs, and thus is an 876 DISEASES OF THE STOMACH AND INTESTINES aid to diagnosis. The sigmoid can occasionally be felt as a tumor. Con- stipation and absence of flatus are usually complete; occasionally there is a little blood in the stool and only a moderate amount of water can be injected into the rectum. Symptoms are acute and collapse is marked. Intussusception. Most frequently in infancy and early childhood. Onset is sudden. Pains appear early, are colicky in character; in children, may cause them to scream or have convulsions; pains are paroxysmal. Vomiting occurs early and constantly in children; a less important symptom in adults. Invaginated coil can be appreciated or a tumor in about one-half the cases. Occasionally the swelling may prolapse through the anus. Tenesmus and evacuation of blood occur, then constipation and reten- tion of flatus. Fecal vomiting rare, unless case is prolonged; collapse is Fig. 362.- Section of obstructed intestine after opening into lumen, showing worms (Whelan). early in children (in two to three days), but not as early as in strangulation; collapse is slower in adults. Obstruction by Gall-stones, Enteroliths, and Foreign Bodies. Occlusion from gall-stones occurs chiefly in older women. There is at times a prev- ious history of gall-stones, jaundice, and liver enlargement or tenderness, which aids our diagnosis. The obstruction usually occurs in the small intestine. The general symptoms are often not so severe as in other types, there being some flatus passed at times and in some cases slight diarrhea with blood. If obstruction of the ileum, feculent vomiting is more marked. Meteorism is not so marked and collapse not so great. Occasionally the stone can be palpated. Enteroliths. Their recognition is quite difficult unless small fragments have been voided. They develop most frequently in the large intestine. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 877 Symptoms of chronic obstruction or digestive disturbances and obstinate constipation are more frequent. Acute symptoms are more rare. Foreign Bodies. The previous history and use of the s-rays will de- termine these. Obstruction from accumulation of fruit pits will generally be suspected by reason of the appearance of some of them in the stool. Ascaris Lumbricoides. An interesting case, demonstrating that round worms may be the cause of intestinal obstruction in a young child, has been reported by Charles Whelan. 1 The patient, male, aged five and a half years, about April i, 1910, became peevish, restless, complained of loss of appetite and frequently of stomachache. The child became ob- stinately constipated. No worms were noted in the stools by the mother. On Aug. 2d, the child awoke about midnight crying with pain, and soon afterward began to vomit. This continued for two days, the abdomen becoming more and more distended. The vomiting increased in fre- quency and the pulse became extremely rapid, with evidences of shock. Several convulsions occurred, the child dying during a convulsive seizure. The autopsy showed an impacted mass obstructing the lower jejunum for about 6y 2 inches. The first 2 inches were completely occluded by a bunch of round worms, then there was a "kink" or constriction. Two worms lay side by side in the direction of the long axis of the bowel, passing through the constricted portion. The lower 2 inches of the jejunum were also completely occluded by the worms (Fig. 362). The condition was evidently an acute engrafted on a chronic obstruction. Fecal Accumulation. This rarely gives the picture of acute obstruc- tion unless a tumor or stricture of the intestine be present, when accumula- tion may suddenly cause complete occlusion. Rectal examination usually shows hardened scybalae, and palpation demonstrates a hardened mass in the colon (descending, sigmoid or cecum especially). If the mass be softer, it will impart a doughy feel on pressure. Dynamic Ileus. Acute gastroduodenal dilatation of the stomach pre- sents symptoms of intestinal obstruction, and commences with acute pain, undoubtedly due to stenosis of the duodenum by pressure. Under Diag- nosis of Acute Obstruction I have described the peculiar type of vomiting in acute ectasy and also the position of the stomach. The pain, disten- tion, and other symptoms are relieved by frequent lavage and by the adoption of the abdominal position (the patient lying on his belly). Obstruction of the bowel from a paralytic condition involves, as a rule, a considerable segment, or frequently the entire tract. After reduction of a hernia probably only a small segment is first involved, but I believe paralysis of a considerable segment, and in many cases of the entire bowel, finally results. The acute cramp-like pains, persistent and paroxysmal, are absent in this type of obstruction (really not a true obstruction at all) , which always occur in the early stages of other types of obstruction. When acute spasmodic pain is present and persistent, I always feel positive of a true obstruction. The vomiting, constipation, collapse, etc., may be similar to obstructive ileus. There may be sudden pain with the acute distention, so that perforation is suspected, but after lavage and enterocly- sis the pain disappears, and muscular rigidity is found to be absent. These 1 Jour. Amer. Med. Assoc., Oct. 22, 1910. 878 DISEASES OF THE STOMACH AND INTESTINES features exclude, first, "obstructive ileus," on account of disappearance of the pain; and second, "peritonitis." In the early stages of "dynamic ileus," distention, interference with the cardiorespiratory functions, and obstinate constipation precede the vomiting and severe symptoms as a rule. There is usually more of a sense of painful discomfort and oppres- sion, except in the cases of sudden acute distention. In the terminal stages of true obstruction, paresis of the bowel may occur, and then spasmodic pain disappears; in paresis of the bowel from peritonitis there is the general pain and tenderness from the peritonitis, but not the acute spasmodic pain peculiar to true obstruction. In true dynamic ileus, therefore, there is the absence of that acute persistent spasmodic pain of severe type which is present in all cases of true obstruction, and absence of muscular rigidity. Differential Diagnosis between Intestinal Obstruction and Other Diseases. Acute Peritonitis. Generally a history of local peritonitis, such as appendicitis with pain localizing in the right iliac fossa, and then sudden cessation of the cramp-like pains, followed by abdominal tender- ness, muscular rigidity, great distention, and frequently a rise of tem- perature. Leucocytosis and increase in polynuclears are present. Vomit- ing generally begins later and feculent vomiting still later, etc. In obstruction the character of pain is more severe and persistent, as a rule, and often in the umbilical region or in the left lower quadrant; temperature is subnormal at the start; abdominal tenderness is not as marked; feculent vomiting earlier; often local meteorism before general tympanites. General pains are colicky and persistent until peritonitis and paresis set in. The paralytic form of ileus may often occur with infectious diseases, or acute appendicitis with peritonitis (general), also after operation or inflammation in the pelvis or genito-urinary organs; and the knowledge of these facts aid our diagnosis. We must remember that in hysteric women all the symptoms of ileus, even to fecal vomiting, may occur without there being any obstruction. With biliary and renal colic there may be a reflex paralytic ileus, but the symptoms of these conditions aid the diagnosis. Lead- and arsenic-poisoning have sometimes been mistaken for ileus, but again we have the history and other symptoms, especially of enteritis. Simple intestinal colic soon subsides under treatment. Acute pancreatitis and enteritis give their symptoms. There is tenderness in the course of the pancreas if this is involved, a circumscribed epigastric swelling, and tender spots throughout the abdomen (Fitz) ; tenderness at Robson's point, history of gall-stones as a rule, jaundice, hematemesis, melena, and hemorrhages from all the mucus membranes, subnormal temperature, constipation, but in some cases it is difficult to differentiate acute pancreatitis from obstruction. The former presents the aspects of an epigastric peritonitis. Fat necrosis is found on operation. Course. The course of acute obstruction depends upon its cause and site. The higher up in the intestine, the more acute the course, as a rule. Volvulus and strangulation are very acute. The patient may die in collapse within a few hours, or the course may be prolonged to two or INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 879 three days or even a week. Intussusception, if unoperated, may last several weeks. If the patient survives the collapse, and the patency of the gut becomes reestablished (as in intussusception, foreign bodies, or volvulus), flatus is first passed and then later a fecal movement, and the symptoms gradually abate. The invaginated bowel has been known to slough off and be passed in the stool. From changes in the gut, due to ulcers, adhesions, etc., the patient may subsequently develop symptoms of chronic obstruction. If operation is not performed, the patient usually dies of acute shock or peritonitis. The latter may be due to perforation or to direct penetra- tion of the paralyzed wall of the gut by intestinal bacteria. It is further believed that toxemia from intestinal bacteria may be a cause of death. In some there may be a circumscribed peritonitis. With the diffuse peritonitis we have the symptoms already described. Embolic processes may develop in the liver, lungs, and other organs. There may be aspiration pneumonia, or exceptionally, local abscess, with perforation of the abdominal wall, or into another part of the intestines or into other viscera, as into the stomach, bladder, vagina, or uterus. Prognosis. The prognosis of acute obstruction is very serious. Some observers state that about one-third of all cases recover, however. Obstruction caused by coprostasis, gall-stones, or some foreign body give the best prognosis. Dynamic ileus with modern methods of treat- ment, I believe, is next in regard to favorable results, then intussusception, and the worst cases are volvulus and strangulation. The earlier the operation, the better the prognosis. The last types I believe fatal nearly invariably, unless early operation is carried out. Treatment. This may be divided into medical and surgical, and' the respective indications are extremely clear. I shall first briefly classify these, giving the treatment in tabulated form. Cases for Medical Treatment. i. Acute obstruction due to fecal ac- cumulation. Acute attacks are rare; they are, rather, subactite or acute engrafted on chronic: (a) Lavage is indicated to relieve tympanites, if present, or if vomiting. (V) Digital examination of the rectum and removal of scybalag with the fingers, and then frequent enemata of soapsuds, olive oil, glycerin, or 6 ounces (200 c.c.) of magnesium sulphate (saturated solution) in water, i pint (500 c.c.), followed by recurrent enteroclysis with normal saline solution at 110 to i2oF., using 2 to 3 gallons at a sitting, about K to i pint (250-500 c.c.) being kept in the bowel. For the first twenty- four to forty-eight hours the treatment consists in the simple mechanical emptying of the rectum and large intestine. The enemata should contain about i to 2 quarts (liters), in which is olive oil, i pint (500 c.c.), alone or with glycerin, 4 ounces (125 c.c.). It is well to give the enema with the patient in the knee-chest position, the buttocks elevated as high as possible. In two recent cases the writer found a high enema containing olive oil, 8 ounces (250 c.c.); glycerin,' 4 ounces (125 c.c.); castor oil, 2 ounces (60 c.c.); and several grains of ox-gall, given with a large hand syringe under considerable pressure, to be of great value. The soft rectal tube was inserted as high as possible. If vomiting or distention, no food at all until this ceases; thirst may be relieved by moistening the mouth, 880 DISEASES OF THE STOMACH AND INTESTINES sucking a piece of lemon or orange, and, if necessary, by hypodermoclysis, rectal saline enemata, or proctoclysis. Milk is objectionable, as it forms curds and helps fill the bowels. Brths and soups should be given until the accumulation has been removed. This only refers to after the subsidence of acute symptoms and after the bowels have acted. No food is given before this time. Strychnin by hypodermic, 3^ to y^ grain (0.00108 -0.0021) three or four times a day, can be given as a stimulant. It also helps tone up the bowel. Tincture of belladonna in large doses, admin- istered up to physiologic symptoms, 10 drops (0.59) three or four times a day, is of service, as soon as it can be retained. Later, olive oil, 2 to 4 ounces (60.0-125.0), can be given several times a day by mouth. On the second or third day, if matters are progressing favorably, give cathartics, calomel, castor oil, etc., by mouth. Massage and external electricity are of value in these cases after the acute symptoms have subsided. I have frequently employed electric enteroclysis. I have seen it take several weeks 1 to completely empty the bowel. 2. The second class of cases in which medical treatment is indicated is in dynamic ileus. The indications are: (a) Abolition of food. (b) Relief of thirst, as previously indicated. (c) Frequent lavage to relieve intra-abdominal tension and also vomiting. (d) Frequent enteroclysis (recurrent) with hot normal saline solu- tion at 115 to i2oF., several gallons being used, a small part being kept in the intestines (preferably). High enemata 2 with soapsuds, olive oil, and glycerin are also of service. (e) Electric enteroclysis. (/) Tincture of belladonna, 10 drops (0.59), given three or four times a day up to physiologic symptoms. Strychnin, ^ grain (0.002), every four hours. (g) Magnesium sulphate (saturated solution) by rectum, 4 ounces (125.0). Heat locally is of value, and in one case the continuous local application of the ice-bag stimulated the bowels to contract. I prefer the ice-bag in many cases, unless collapse is present. Cathartics by mouth immediately after lavage, especially calomel, 5 grains (0.3), crushed up in water and poured in through the stomach- tube at the end of the washing. Plain -water and no saline solution should be employed for lavage when calomel is administered. Physostigmin sulphate (eserin), ^ 00 to J^ grain (0.0006-0.001), every two to three hours for three doses. It should be arranged to give strychnin, ^ g ram > with each dose. Hormonal and pituitary extract are also suggested as described under treatment of acute dilatation of the stomach. Some recommend elaterin, >f grain. If all methods fail and the patient is rapidly losing ground, then simple enterostomy of the most distended loop, under cocain, as suggested by Elsberg in obstructive ileus, I believe, is indicated. This procedure allows the escape of gas and some contrac- tion of the intestines to take place. Magnesium sulphate solution should 1 When acute symptoms have subsided, olive oil or mineral oil through the duode- nal tube may be of value. See Enteroclysis. 2 Alum 5i to one to two quarts of water by enema is also useful. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 88 1 be injected through the opening, and the procedures already suggested should be continued. Drainage should be closed after twenty-four hours. In my own experience I have had good results from continuous and active medical treatment. The lavage followed by catharsis by mouth is of equal importance as the enteroclysis. Proctoclysis is not sufficiently active. Obstruction by Foreign Bodies. If the obstruction is by accumu- lation of fruit stones, an enterolith, or a gall-stone, and the case is seen on the first day of attack, lavage and the administration of 4 ounces (125 c.c.) of olive oil through the stomach-tube aids to lubricate its passage, followed by enteroclysis. No cathartic should be given by mouth. If the mass begins to come away and symptoms are relieved at once, then delay; otherwise, operate. If the case is seen later, with progressive symptoms, use lavage and enteroclysis to relieve distention and operate at once. Intussusception. With infants or young children the stomach should first be washed out to relieve abdominal tension. An anesthetic is then administered and the child placed in the Trendelenburg position, and an attempt at reduction may then be made by inflation. A bellows is attached to a catheter, and the air should be injected slowly, the but- tocks being held together. The best guide to the amount introduced is the tension of the abdominal walls; if tension is marked some air is allowed to escape. This procedure should not occupy over fifteen or twenty minutes. . A saline solution, milk and water, or thin gruel at a temperature of 100 to io5F., for the relaxing effect can be employed instead (as sug- gested by Holt). The fluid is suspended in a fountain syringe 4 or 5 feet above the patient's head, the tension of the abdomen being watched. Otherwise the procedure is the same. Reduction is indicated by a rumbling sound and by. the abdomen resuming its natural contour, with the disappearance of the tumor; in some cases a gush of feces follows. If these symptoms are absent, the abdomen is examined while the patient is still under chloroform, especially the right iliac fossa, for the continued presence of the tumor. It is better not to repeat the injection. If the tumor is present, or if vomiting continues and no gas or feces are expelled, or the pulse and temperature rise, immediate operation is indicated. This method of taxis should be tried on the young in an early stage (the first day) ; if later, operate. If, on the other hand, there is immediate improvement, small doses of opium are given for a few days to prevent re-invagination. Surgery. In all other cases of acute intestinal obstruction except those noted, early, preferably immediate, operation is indicated. A large percentage of fatalities imputed to operation are due to : dePay v on the part of the physician; thus, in strangulation, volvulus, intussus- ception, and obstruction from foreign bodies (except under the condition of the rapid passage of foreign bodies, as noted above), immediate opera- tion is indicated. The earlier the operation the better the prognosis. 56 882 DISEASES OF THE STOMACH AND INTESTINES In these cases cathartics should never be given, the bowel should not be massaged, nor electricity used. Puncture of the bowel through the abdominal wall to relieve gas is absolutely dangerous an invitation to peritonitis. Laxatives do positive harm. The attempted diagnosis of the seat of the acute obstruction by the administration of bismuth by mouth and the use of #-rays, which necessitate a delay of six hours or more, should never be undertaken. Bismuth or barium enema, followed by the #-rays is only of use in determining obstruction in the large intestine. // is of value in chronic cases, but not advisable in acute ones. Lavage (frequent) is of first importance; it lessens intra-abdominal tension and also the pain, makes diagnosis easier, and in some cases has actually proved curative as in intussusception. This last is explained by the fact that the gastro-intestinal distention is relieved above the point of obstruction, and occasionally the gut escapes from the constriction. If the patient is seen on the first day of the attack, lavage should be given at least twice, one or two hours apart, while preparing for operation; if later, then once before operation. Enteroclysis at 115 to i2oF. is of value to lessen the distention due to general paresis and improve the pulse; if the intussusception lies in the rectum, irrigation is contra-indicated. No fluid or ice by mouth, but the tongue can be moistened and small normal saline injections or proctoclysis be administered for thirst. These methods also relieve postoperative thirst. Heat or cold to abdomen. Hypodermoclysis and infusion if there is shock. Lavage often relieves the pain, but if this is very severe, morphin, y grain (0.016), by hypodermic, and repeat to lessen shock. Ail these methods are of use while preparing for immediate operation. The general medical methods of treatment by opium or morphin for three or four days and expectant treatment, with subsequent operative fatality, are to be deplored. Operate in acute peritonitis. Subsequent to operation, lavage, if vomiting, and nutritive enema ta; no food or water by mouth; later, a little hot water. Proctoclysis is of value for the sepsis. Open bowels by enema or enteroclysis in twenty-four to forty-eight hours, as intestinal paresis is usually present; earlier if the symptoms persist which are due to this condition. Rectal injection of 400 c.c. (12 ounces) of 7 to 8 per cent, salt solution in intussusception to produce reversed peristalsis has been suggested by Riegel. Experimentally it has proved efficacious, but practically I am dubious of its value, as most cases of intussusception are adherent or strangulated. In desperate cases enterostomy with drainage of the intestines, done under local anesthesia (cocain), is advisable. A few hours later (within twenty-four hours) radical operation with relief of the obstruction can be performed. Elsberg 1 holds that preliminary enterostomy, leaving the 1 The Value of Enterostomy and Conservative Operative Methods in the Surgical Treatment of Acute Intestinal Obstruction, Ann. Surg., May, 1908. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 883 prolonged search for the obstruction for a second operation, to be more frequently advisable. CHRONIC INTESTINAL OBSTRUCTION In this condition there is a stenosis or narrowing of the lumen of the intestines, but the obstruction is not acute and complete in the earlier stages, but comes on gradually. Etiology. It may be caused by the same factors which produce acute obstruction, if the entire lumen of the canal' is not occluded. One of the most frequent causes of chronic obstruction is stricture resulting from ulcers or new growths. The latter, even if they do not occupy the entire canal, may protrude at one point and partially occlude the intestines. They may be benign or malignant. In addition we have the peculiar tumor-like tuberculosis of the cecum, which causes a progressive stenosis, and chronic peridiverticulitis (sig- moiditis) may produce a narrowing of the lumen with symptoms. Both of the latter conditions often simulate carcinoma. Strictures resulting from ulcers involve the large intestines much more frequently than the small, probably in a ratio of 6 to i, according to Treves. Among the causes of stricture are tubercular, stercoral, syphilitic, typhoid, dysenteric, and duodenal ulceration. Woodward 1 has demonstrated that dysenteric ulcers rarely cause intestinal stricture, and Nothnagel agrees with him. Stercoral and tubercular ulcers are a quite frequent cause, as is also syphilitic ulceration. Typhoid ulcers are a rare cause. There are other rare factors reported, such as ulceration in a portion of the bowel that has been incarcerated, or stricture following the slough- ing off of invaginated intestines. A few cases of traumatism with damage to the intestines and subsequent stricture, or of a circumscribed peritonitis with adhesions, following trauma, and subsequent stenosis have been reported. Carcinoma of the pancreas, or chronic pancreatitis with en- largement of the head of the pancreas, enlargement of the retroperitoneal glands, and gall-stones may cause stricture. A stricture may be congenital. Rectal strictures are quite frequent, and much more so in women, as from syphilitic, tubercular, stercoral, and hemorrhoidal ulcers. Opera- tion for prolapse of rectum or for hemorrhoids, especially the Whitehead operation, traumatism from the syringe-tip, or the introduction of foreign bodies may produce stricture. Traumatism from the child's head during parturition may be a cause. Gonorrheal abscess of the Bartholin glands may lead to ulceration of the rectum and stricture ultimately results. Adhesions may be a frequent cause of chronic stenosis, sometimes of rather a mild type with persistent constipation of long duration as the chief symptom, but no actual obstruction. The Lane kink due to adhesions of the ileocecal junction, various angidations in extreme enterop- tosis not relieved by medical treatment and prolapse of the sigmoid may 1 Medical and Surgical History of the War of the Rebellion. 884 DISEASES OF THE STOMACH AND INTESTINES be causes. In a recent case of T. A. Gonzales, seen by the writer in con- sultation, a point of stenosis was found at the sigmoidorectal junction due to adhesions, but more marked and unsuspected adhesions were demon- strated by S. Tousey by a rontgenograph. The case was successfully operated on by Parker Sims, confirming the x-ray diagnosis. Anatomy of Chronic Stenosis of the Intestines. The intestines below the stenotic area are empty and contracted and the bowel normal. Above the point of stenosis the bowel is dilated, often to a great degree, and may form a sac-like pouch. The dilatation may involve only a short part of the bowel above the stenosis. In some cases there is considerable distention from gas and the ab- domen may assume the barrel shape. The degree of distention depends on the tightness of the stricture. There is stagnation of the intestinal contents above the stricture, which causes mechanical distention and may stimulate the peristaltic action. This material also acts as an irritant. When the musculature is stimulated to increased activity hypertrophy is thus produced. This accounts for the violent visible peristaltic movements in chronic obstruction. Patel claims that in stenosis from external pressure we have dilatation without hypertrophy, and that the latter only occurs if ulcers, which cause contraction through irritation, are present. This would explain the oc- currence of hypertrophy without stenosis in some cases of intestinal ulceration. Changes in the mucosa and submucosa are frequently present, a catarrhal condition and ulceration (stercoral). General peritonitis, local peritonitis, or local abscess may result. The intestines may become elongated above the stenosis. Location of Stenosis. The large intestine is the most common seat of the stricture. Syphilitic, dysenteric, and stercoral strictures are chiefly localized here, as are also those resulting from traumatism or from follicular ulceration. Tuberculous ulceration produces stricture most commonly in the small intestine, though tuberculous tumor is found in the cecum, and probably tuberculous ulcer is more frequent in the rectum than has been usually credited. Tuberculosis of the sigmoid also occurs. Malignant strictures are most frequent in the large intestine. If the ulcer producing the stricture lies parallel to the longitudinal axis of the bowel, stenosis is not as marked as when it is an annular ulcer (girdle ulcer). The stricture, as a rule, is short and the external aspect of the intestine looks as if a ribbon had been tied about it. The external surface of the gut is often covered with exudate, so that the bowel is thickened and there may be adhesions between the intestines and other loops or other viscera, which further constrict the intestines. The stricture consists of cicatricial tissues unless malignant. Folds of mucous membrane near the cicatrix or hypertrophic polypoid protrusion of mucous membrane may aid in closing the gut. If there are numerous stenoses, as from tubercular ulcers, there may be sacculated dilatation of the small intestine between the stenosed points. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 885 Symptoms. These depend upon the cause of the obstruction; malig- nant growth must be differentiated clinically from benign conditions. The symptoms generally come on gradually. In stenosis of the small intestine they may be latent for a considerable time, on account of the fluidity of the bowel contents, and then appear with rapidity. On the other hand, stenosis of the colon produces symptoms more rapidly on account of the solid contents. As a rule, constipation is one of the earliest symptoms, and this gradu- ally becomes worse. The patient complains of digestive disturbances and swelling of the abdomen, there are loss of appetite, and nausea. Stenotic feces in round balls, cylinder (pipe-stem) or tape-like movements, are suggestive, but not conclusive. This type of feces may occur in spastic constipation and, on the other hand, the feces may be normal in form with a stricture high up. Diarrhea at times alternates with constipation. The diarrheal movements may be extremely offensive and contain mucus, or even pus and blood; this last is especially true in malignant stenosis, where there are active ulcerations, or in intussusception. The diarrhea often relieves the patient. We must remember that chronic diarrhea is present in some cases when there is a marked catarrh above the stricture, and this will sometimes lead one astray. Severe pain of a colicky type occurs in all cases, and this may at times be excruciating; it may be localized near the seat of stricture, but in other cases be more diffuse, radiating even toward the thorax and producing a feeling of oppression and dyspnea. A symptom which occurs with the colic, which can be considered pathognomonic, is the visible peristaltic movement of the intes- tines, in which the loops can be seen to stiffen and relax alternately. The coils appear and disappear. Peristaltic unrest (intestinal) is not always present, especially in the earlier stages of the disease; and at times, late in the condition, the bowel may become fatigued and paretic from over- distention. Often, however, the peristaltic movements will aid in locating the position of the obstruction. Vomiting may not occur at first, but is later more frequent, and if finally the obstruction becomes complete, may be marked and even feculent. Gurgling, rolling sounds, and meteorism are present. Location of the Obstruction. This influences the character of the symptoms. If the stenosis is situated above Vater's papilla, the symp- toms are similar to those of stenosis of the pylorus. Marked dilatation of the stomach, nausea, and vomiting are prominent. R. T. Morris has demonstrated that in some cases of spider adhesions from the gall-bladder there may be severe hemorrhage and pain which may simulate gastric ulcer. There is usually a history of previous gall-bladder disease. If the obstruction lies below Vater's papilla, we again have gastric dilatation, but frequent bilious vomiting. The stomach contents are neutral or alkaline, due to regurgitation of pancreatic juice and bile, and duodenal digestion takes place within the stomach. With stenosis above the papilla, gastric contents, as in benign pyloric stenosis, are acid. Riegel states another sign of duodenal stenosis is, that when the stomach has been emptied the night before, twelve hours later as much as 3 liters (quarts) 886 DISEASES OF THE STOMACH AND INTESTINES can be frequently aspirated. The reaction and contents differ from that gastr osuccorrhea . The lower down the obstruction, the less pronounced the gastric symptoms, as a rule, and the more marked the constipation and colicky pains. There may even be an absence of gastric symptoms for a con- siderable period if the stenosis be in the lower ileum or in the colon. The symptoms, however, are always more severe in chronic intussusception or chronic types of strangulation than in ordinary cicatricial stenosis. X-rays. The administration of barium or bismuth by mouth and inspection six to twelve hours later with the fluroscope or, preferably, by radiography may demonstrate the location of the stenosis. If it be apparent in the large intestine a high injection of bismuth and olive oil or bismuth suspended in water or of barium is given, in addition, 6 to 12 hours later, and the examination is then made again. These procedures are not to be recommended in acute cases, though valuable in the chronic for diagnosis. In the less marked cases of stenosis as from adhesions of mild type radiography both in the standing and Trendelenburg positions after the barium enema should be carried out. Inspection of the Abdomen. When the stenosis is high up in the small intestine there is apt to be distention of the epigastric region, and when in the lower part of the small intestine or in the large intestine, then there is considerable abdominal distention. The active peristaltic contraction of the intestines is marked, the coils (stiffened) rising and falling, and often performing winding or vermicular motions. These movements are associated with colicky pains and with gurgling and rolling noises. Sausage-shaped ridges may appear with depressions in their vicinity, and in a few seconds the ridges disappear in one part and appear in another, the coils never remaining visible in one place for any length of time. They appear hard and stiff to the hand and then suddenly become elastic. The contractions in the small intestine are usually smaller than in the large intestine. Meteorism in the milder cases is not marked, as the gas can pass the obstruction. Later it may become quite marked, and, as in acute obstruction, may be local or general in character. If the obstruction is in the lower colon or rectum, it will be most pro- nounced at first in the course of the colon, on the sides of the abdomen, and in the epigastrium. If the obstruction is in the lower ileum, the distention is more pro- nounced in the umbilical and hypogastric regions and there may be the ladder-pattern of distention, and the lumbar regions are relaxed (undistended). Later there may be more general distention and the barrel-shaped abdomen. Local manifestations of meteorism are described under Acute Obstruction. One of the important types is chronic intussusception, which may develop after an acute attack has subsided or may occur as such from its INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 887 incipiency. It takes place most frequently in the ileocecal form. Some of the latter cases may continue for months or even years. The pain is paroxysmal, but may entirely intermit. There may be attacks of pain daily, or every few days or weeks. As the disease advances the intervals grow shorter. Vomiting is not marked. Often diarrhea is present, or constipation alternating with diarrhea. Blood may be passed and tenesmus is at times present. Palpation shows the presence of a tumor in about 50 per cent, of the cases, or a tumor can be felt in the rectum. Local meteorism may be present. Occasionally the invaginated part may slough off and perfect recovery ensue or, again, ultimate stenosis may follow. Death may occur through perforation. Chronic Obstruction through Fecal Accumulation. This is more common in females and usually in our older patients. The history is of habitual constipation. At times large amounts of fecal matter are voided by enema. Scybalae are frequently present. Rectal examination may show impaction. There are digestive disturbances, flatulence, loss of appetite, eructation, fetid breath, headache, dizziness and symptoms of auto-intoxication; there may be oppression in breathing from distention, an unhealthy appearance of the skin, and a foul tongue. There may be pains in the thighs, legs, and genitals due to pressure on the lumbar or sacral nerves. The patient may be very neurasthenic. Distention and gurgling may occur. There are colicky pains, but usually they are not severe. If untreated, the condition may become worse, the constipation increases, and all the symptoms of chronic or even of acute obstruction develop, as already described under Fecal Obstruction. The vomiting may even become feculent. Harris 1 however reports a case of fecal impaction in the ileum for fifty- three days with recovery. Palpation shows the presence of a tumor frequently in the colon, espe- cially in the cecum, sigmoid, or other flexures. It may be hard and uneven, and will often "pit" on pressure. It is not painful on pressure, as a rule. Rectal examination generally shows the presence of scybalse. I have treated a case in which apparently nearly the entire abdomen was occupied by the fecal tumor. Operation for " tumor" had been advised. As a result of 80 bowel movements in one week the tumor disappeared. The patient had had no bowel action for three weeks. Enemata, and especially recurrent rectal irrigation, and later, catharsis will reduce the size of the tumor. I have seen cases in which acute flexions or angulations of the sigmoid and colon have been factors in the production of this condition. They are well described by the late J. P. Tuttle. 2 Gant has also demonstrated that prolapse of the sigmoid flexure is a cause, and relief has been secured by suspension of the sigmoid. Rectal Stricture. There are the symptoms of progressive constipa- tion at times with alternating diarrhea, with mucus, and at times, pus with traces of blood in the stools, colicky pains, tympanites, tenesmus, and loss 1 Journal A. M. A., Mar., 8, 1913. 2 X. Y. Med. Jour., etc., Mar. 14, 1908. 888 DISEASES OF THE STOMACH AND INTESTINES of appetite. There may be hemorrhoids and rectal prolapse. Digital examination, exploration with a rectal bougie or the proctoscope, will demonstrate the constriction. With stricture the pressure on the examining finger remains constant and is not like sphincteric spasm, which soon relaxes. Many of the strictures are within the finger reach, within 4 to 6 cm. up the bowel; if not within reach but suspected, a Wales rectal bougie or soft tube can be employed for the examination. The degree .of stricturing can be determined by using tubes or bougies of varying sizes. It is preferable to pass the speculum up to the point of stricture, so as to examine its nature thoroughly. It is often advisable to remove a small section under cocain for microscopic examination. With malignant stricture there are cachexia, loss of weight, metastases, and the symptoms described under Carcinoma. Complications. Above the stenosis on account of the ulceration we may have circumscribed peritonitis and abscess or perforation with general peritonitis. The abscess may rupture into other viscera or perforate the abdominal wall. The chronic condition may suddenly become acute, and severe collapse occur with death, or thrombosis of some of the veins, or pyemic processes, or the patient may die of inanition or become bed-ridden and die of hypostatic congestion of the lungs. Diagnosis. The gradually increasing constipation; colic attacks with frequent stoppage of the bowels, alternating at times with diarrhea and the temporary relief of symptoms; visible peristaltic movements with tetanic rigidity of the intestines; at first local meteorism and, later, the tendency to the barrel-shaped abdomen; the presence of gastro-in- testinal disturbances of varying degree and, frequently, loss of weight are suggestive of the obstruction. Rectal examination is always of importance. If the constipation is of long standing, in an elderly person or invalid, and there is no cachexia, the tumor movable and doughy on pressure, scybalae being passed, and at times accumulation felt in the rectum, fecal tumor is evident. These occur chiefly in the caput coli, sigmoid, colon flexures, or rectum. With carcinoma there is marked cachexia and the tumor is hard and solid, occurs mostly in the caput coli, sigmoid, and most frequently in the rectum, and more frequently in persons over forty-five. There is slight or moderate leukocytosis, and also anemia. In the scirrhous type of carcinomatous stricture, cachexia may be scarcely noticeable for a con- siderable period. The progressive constipation and age of the patient are significant together with increasing anemia. Tuberculous tumor of the cecum and peridiverticulitis (chronic) of the sigmoid must be held in consideration as causes. With chronic intussusception the mass is usually of sausage shape, and shows the peculiarity that it sometimes feels hard and sometimes soft on palpation; there are mucus and blood in the stool. External tumors can generally be appreciated. Vaginal Examination should be made. If there have been attacks of peritonitis, bands and adhesions would be suspected. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC A previous history of diarrhea, dysentery, syphilis, or tubercular difficulty would suggest ulcerative stenosis. Stricture of the small intestine is most frequently due to adhesions or tubercular ulcer. In the large intestine stercoral, syphilitic, or dysenteric ulcers are to be considered, chiefly carcinoma or pelvic inflam- mation, perityphilitic adhesions, and, more rarely, tuberculosis of the cecum and chronic peridiverticulitis. Course and Prognosis. This depends on the etiology and severity of the obstruction. With non-malignant stricture of the bowel of moderate type, or in the fecal obstruction cases, not progressive, the patient by proper regulation of diet may live many years. With malignancy the prognosis is fatal unless relieved by early operation; chronic intussuscep- tion occasionally clears up, but the prognosis, as a rule, is bad. In pro- gressive cases the symptoms rapidly become worse and life is shortened, with death .from final acute obstruction. Unless radical operation is performed, complications such as peritonitis, pyemic processes, etc., hasten the final result. Treatment. If chronic obstruction suddenly or gradually develops into acute obstruction, the same indications for treatment exist as in the latter condition. In the chronic cases the proper regulation of diet, omitting those things which will mechanically fill up the intestines and a careful regulation of the bowels, are most important. Substances that give a large residue of fecal matter, which are irritating and extremely constipating, should be excluded. Matzoon, koumiss, buttermilk, bacillac, fermillac, lactone-buttermilk, and kefir milk are excellent. Milk agrees well, as a rule, with most cases and is readily digested, while others it constipates and is undigested. Raw eggs can be beaten up in milk, and soft-boiled eggs, broths, soups, and gruels administered. Tropon and somatose are of value, administered in the broths or milk. If the stenotic symptoms are progressive or fairly marked, liquid or soft diet alone should be given. In milder cases scraped beef, tender meat (well divided), butter, a small amount of well-toasted bread, and moderate in quantity, rice, sago, and mashed potatoes in small amount are admissible. The patient should eat a small quantity frequently and should take sufficient food to preserve his nutrition. Very hot and cold drinks should be avoided. Irritating food, such as mustard, spices, pepper, vinegar, fruits in bulk, and green vegetables in large amounts, should be forbidden. Substances giving a large residue of fecal matter should also be cut off. Spinach I have found of service to aid bowel action. Fats, such as cream and butter, are useful. Fresh fruit juices are valuable, and the administration of a glass of water on rising is of service. Bowels. The bowels must be moved every day. Injections of soap- suds enemata of medium size, not over i quart (liter), with the hips ele- vated; Kussmaul's method of oil injection, i pint (500 c.c.) or more, being retained over night; or the addition of olive oil to the enema, mild cathartics, such as cascara, rhubarb, syrup of figs, phenolphthalein, 890 DISEASES OF THE STOMACH AND INTESTINES regulin, the mineral oils, and occasionally sulphate of magnesia or Apenta water, are of service. Under Chronic Constipation numerous remedies are described. Enteroclysis (recurrent) is valuable in many cases. Massage, vibratory massage, and electricity are of service only in cases due to fecal accumulation. If diarrhea is present, unless the patient is weakened thereby, it should not be checked. In the latter event mild preparations, such as bismuth subnitrate, chalk mixture, or chalk and catechu, are preferable to opiates. If there are small diarrheal movements, evidently a diarrhea associated with constipation, then a dose of castor oil, laxol, or a saline cathartic is indicated. For Colic Attack and Peristaltic Movements. Hot applications to the abdomen are indicated and a recurrent irrigation of normal saline solution at 115 to i2oF. is of value, to be given for ten to twenty minutes. The latter removes gas and clears the bowels. Enemata also can be administered. Tincture of belladonna, 10 minims (0.59), once or twice, is of use to allay spasm, or by suppository, extract of belladonna, y to y$ grain (0.016-0.024). Opium I avoid if possible, and then only % to y grain (0.008-0.016) of morphin or codein by hypodermic. It should be given only to allay severe pain. For vomiting and distention lavage is indicated. Cerium oxalate with bismuth and soda will check vomiting, also i minim (0.059) doses of Fowler's solution of arsenic every hour for four doses. Cocain, which has been suggested, is a dangerous and pernicious drug. I have seen complete collapse after its use in as small doses as ^{ grain (0.006). Lavage is of special value in temporarily allaying symptoms if the stenosis is in the small intestine. If there is chronic fecal impaction, our first efforts should always be directed from below. Hardened scybalae should be removed from the rectum by the finger, oil injections, and, later, by soapsuds enemata and recurrent rectal irrigations. Olive oil can be given by mouth. Later, cathartics, massage, electricity, and vibratory massage are of service. Electric enteroclysis I have found useful in obstinate cases of fecal impaction. Tincture of belladonna, 10 gtts. (0.59) three or four times a day, and strychnin, ^ grain (0.002) t.i.d., are of value. Eserin sulphate, Hoo to 3^0 grain (0.00065-0.00108), may be required. Mild cases of rectal stricture, providing they are not malignant, can be benefited by dilatation for ten to fifteen minutes every two to three days with different sized bougies. Operation on the stricture may be necessary in some cases. Thiosinamin can first be tried, injected into the bowel or by hypodermic. Dose, > to ij grains (0.033-0.1); or by hypodermic, i grain (0.065), m *5 P er cent, alcohol solution or 10 per cent, glycerinated solution. INTESTINAL OBSTRUCTION ACUTE AND CHRONIC 891 Operation. Most types of chronic intestinal obstruction grow worse, except those due to fecal impaction. In mild types of rectal stricture local dilatation may be palliative and keep the patient comfortable. Malignant growths must be extirpated as soon as possible. Stric- tures must be treated according to their location in the rectum, by divi- sion and dilatation or by resection. In other regions, enteroplasty, splitting the gut parallel to its axis, at the same time dividing the stricture and uniting the incision transversely, has been successful. Complete excision may be necessary, with or without employing Murphy's button to unite the ends. Anastomosis of the bowel above to that portion lying below the stricture may be required. In stricture of the colon in cases quite prostrated, a simple colotomy above the point of stenosis is indicated. Local anesthesia may even be employed. Adhesions should be severed and tumors compressing the bowel re- moved. If the chronic obstruction be due to any of the causes which may also produce acute obstruction, appropriate surgical measures are indicated. Early operation is preferable in most cases of chronic obstruction. In acute obstruction engrafted on chronic stenosis there should be immediate resort to surgery. CHAPTER XXXIV VAGOTONIA SYMPATHETICOTONIA VISCERAL CRISES IN THE ERYTHEMA GROUP UMBILICAL DYSPEPSIA VAGOTONIA AND SYMPATHETICOTONIA. THEIR RELATION TO GASTRO -INTESTINAL SYMPTOMS IN the study of functional disturbances of the gastro-intestinal tract there has been considerable difference of opinion. Some believe an anatomical basis to be the source of these abnormalities, for example that ulcer is the cause of hyperacidity, or hypersecretion; others that pure gastric-intestinal neuroses are fairly common, though in some cases they are one of the symptoms of hysteria or neurasthenia. They may also undoubtedly be reflex from disease of some other organ. Pure neuroses of the gastro-intestinal tract are, in my opinion, extremely rare. Eppinger 1 and Hess in their recent studies of the "Vegetative Nervous System," hold that a certain constitutional defect exists in some persons, which manifests itself in disturbances of the autonomic or sympathetic systems. The conditions are known as Vagotonia and Sympatheticotonia. Under the term "Vegetative Nervous System" are included all those nerve fibers which go to organs having smooth muscles, such as the intes- tines, blood-vessels, gland-ducts and skin and also certain cross-striated muscles such as the heart, the beginning and end of the alimentary canal and the muscles of the genital organs. Excepting the heart, these muscles are functionally similar to smooth muscles. The autonomic (para-sympathetic) nerves supply the glands and vaso- dilators of the head and also enter the ciliary ganglia and serve definite functions in the eyes. The vagus, one of the most important of the autonomic group, supplies the heart, bronchi, esophagus, stomach, pancreas and intestines; while the nerves from the sacral segment, con- tained in the pelvic nerve, supply the descending colon, sigmoid, anus, bladder and genital apparatus. The vegetative organs are supplied by nerves both from the sym- pathetic and autonomic (para-sympathetic) systems. Anatomically the only exceptions are the sweat glands, pilomotor muscles and vascular muscles of the viscera which are supplied by fibers from the sympathetic cord. The sweat glands, though apparently supplied by the sympathetic, react to autonomic poisons and the sympatheticotonic adrenalin (epine- phrin), a stimulant of the sympathetic system, abolishes their secretion and does not increase it as one would expect. Pharmacological tests enable us to differentiate these two systems. Adrenalin is known to act solely upon the sympathetic system and its action is similar to that of electrical stimulation of the sympathetic fibers. 1 Kraus and Jelliffe, Journal Nervous and Mental Diseases, March, 1914, et al. 892 VAGOTONIA SYMPATHETICOTONIA 893 Certain drugs exclusively influence the autonomic (para-sympathetic) system, as atropin, pilocarpin, physostigmin and muscarin. The last three stimulate the autonomic fibers, while atropin prevents many of the effects which would be caused by stimulation of these fibers, and counter- acts to a certain degree, the effects produced by pilocarpin, muscarin and physostigmin. The sweat glands as noted are an exception. The two nervous systems sympathetic and autonomic (para-sym- pathetic) are antagonistic in their action. The pharmaco-dynamic examination of the functions of the vegetative nervous system have been developed by Eppinger and Hess for clinical purposes. They interpreted the symptoms of some of these cases, as produced by irritability of the autonomic nervous system. These patients responded strongly to pilocarpin and atropin. These were those who, under hypodermics of epinephrin (adrenalin) exhibit the phenomena of stimulation of the sympathetic system, but who were not suscep- tible to the action of pilocarpin and atropin. These observers assumed two systems, of diseases or dispositions, the vagotonic and the sym- patheticotonic. It has been found, however, that in some cases pilocarpin and atro- pin as well as epinephrin produces strong reactions in the same person. Age. Vagotonia particularly occurs more frequently in youth. Etiology. For the explanation of these disturbances of the vegetative nervous system numerous causes have been given. The neurologists believe that constitutional inferiority is the chief factor and that if these patients receive early proper treatment by psychotherapy, the progressive development of vagotonia, or sympatheticotonia with resulting finally or- ganic changes may often be prevented. Physical, or mental shock, many toxins and the organs of internal secretions exercise marked influence on the vegetative nervous system. The so-called chromaffin (adrenalin-pro- ducing cells) accompany the sympathetic in its course, and adrenalin exer- cises a continuous influence on the sympathetic. It is believed probable that there is a physiological "autonomin" which stimulates the autonomic system though it is not as yet known. Hemmeter 1 calls to our attention that cases of enlarged thyroid occur where parts of the thyroid were found to be normal, the symptoms not being relieved by thyroidectomy and that undoubtedly neuroses of the ductless glands may occur from overexcitability of the vegetative nervous system, and their excessive secretion in turn overstimulating this system, either the autonomic or sympathetic portion, produce a vicious circle. He holds, therefore, that so-called "organ neuroses" (ductless gland neu- roses) may be factors. The autonomic and sympathetic systems also may be morbidly irritable in one and the same person; hence the strict division into the separate pathological conditions of vagotonia and sympathet- icotonia is not always possible. For example in Basedow's disease one may find both systems in the same person may be overactive, or one may predominate. Hemmeter believes that the patient may himself concentrate his at- tention upon some special organ, in which there may, or may not be some 1 X. Y. Med. Jour., Jan. 17, 1914. 894 DISEASES OF THE STOMACH AND INTESTINES disturbance, and in the latter event these organs respond more readily to autonomic or sympathetic irritation. Defective development of the adrenals, with enlarged thymus and the lymphatic constitution, probably have a relationship to the production of vagotonia. Moreover we find that vagotonia is often associated with enteroptosis. Relation of Intestinal Intoxications to Vagotonia. In conclusion it is interesting to observe that many of the symptoms associated with severe vagus irritations (vagotonia) occur in most cases of meat or sausage poisoning, such as bradycardia, low blood pressure, diarrhea, sweating, vomiting, contraction of the pupils, etc., an example of subinfection not auto-intoxication. Eppinger 1 and Guttman, on the other hand, referring to the symptoms of spastic constipation and its complications, believe there is a close relationship between general intoxications and intestinal derange- ments and that such disturbances are not limited to damage to the in- testines by poisons introduced from without, but may be produced by substances originating in the intestinal tract. For example, the relief of constipation would be followed by a disappearance of autonomic irrita- tion with resulting symptoms such as hyperacidity, hyper mo tility, gastric spasm (pyloric), bradycardia, extrasystoles, etc. These investigators turned their attention to the intestinal tract to search for the hormone controlling the autonomous system. Barger and Dale have isolated from ergotoxin beta-imidazolylethylamin, amido-acid base, apparently identical with lustidin, a product of protein decomposition and of putre- faction. Beta-imidazolylethylamin, also called lustamin, produces a number of disturbances very similar to those following the application of poisons which are known to be typical irritants of the autonomous system. Paraoxyphenylethylamin another base was isolated from ergo tin. This, also named tyramin, is derived from the decomposition of tyrosin. It is said to possess some chemical properties similar to suprarenal extract and some functional characteristic like it. Both poisons also originate during putrefaction. Barger and Dale have also isolated lustamin from normal (not living) intestinal mucosa. Eppinger and Gutman carried out further investigations of the characteristics and significance of amino-acid bases in the stools of normal and abnormal cases, and also subsequently isolated the bases described by Barger. They found a skin reaction much resembling urticaria occur with beta-imidazolylethylamin which was suggestive. In animals, lustamin produces symptoms much like that of bronchial asthma in human beings. They ascribe the origin of the poisons they discovered in the intestinal canal to bacterial activity, and consider the probability that these bases, originating within the intestinal canal having properties similar to the hormones, are distributed to the organism and exert their influence on the vegetative system. Symptoms of Vagotonia. These patients may be of either sex and young, or of middle age. They present at least some of the following group of symptoms: Stomach or intestinal disturbances; fear of heart 1 Med. Rec., "Intestinal Intoxication," Aug. 2> 1914. VAGOTONIA SYMPATHETICOTONIA 895 disease; neurasthenia; alternate flushing and pallor of the face, blotchy areas of redness on the arms and trunk; bluish redness of the hands, cyanotic and becoming pale when stroked, cold and damp to the feel and the palms thickened. Perspiration readily occurs on the head, face, back and feet. Widening of palpebral fissure, so that the eyes appear large, glistening and almost like exophthalmos; constitutional inferiority with thick nose and lips, enlarged cervical glands, acne and other skin eruptions; conjunctivae red or pale, shortsightedness, convergent strabismus, no Moebius sign (i.e., no weakness in muscular convergence). V. Gaefe's sign present (formerly considered pathognomonic to Grave's disease); salivation, fissured tongue, arched palate, enlarged uvula; adenoids, naso- pharyngeal catarrh; pharynx and larynx anesthetic (contrast to irritability elsewhere) so instrumentation is easy. Voice is hoarse, respirations shallow and diminished in frequency; bradycardia or Erben's phenomenon (transition from tachycardia to bradycardia when kneeling), arrhythmias, respiratory changes in the pulse, sticking of food in the esophagus, fulness, distention, acid retching, heart burn, appetite usually good; bowels fre- quently sluggish, stools few with diminished bulk though diarrhea occurs; sigmoid distended with feces; mild anginoid attacks or laryngismus or bronchial asthma, urine in small amounts, acid, and highly colored. Stigmata of Vagotonia. Among these are dermography, the Aschner reflex (pressure on eyeball produces bradycardia); Erben's phenomenon (bradycardia on kneeling when pulse was previously rapid) ; Chovostek's sign (increase in mechanical excitability of the motor nerves, as a tap over the facial causes constriction of muscles supplied by it), tremors of lids, increased tendon reflexes and activity of cremasteric and abdominal muscle reflexes; as a further test atropin markedly affects the eyes and yet ameli- orates symptoms, while after pilocarpin injections the stomach contracts, hyperacidity occurs, also stool takes form as found with spastic constipa- tion, there are eosinophilia and symptoms resembling pylorospasm, cardiospasm, asthma, hypersecretion, gall-stone, colic, etc., from which Eppinger attributes to vagotonia. Gastro-intestinal symptoms as follows: rumbling and pains after eating, increased peristalsis demonstrated by tf-rays, spasmodic hour-glass contraction, cardiospasm, pyloric spasm, hyperacidity, hypersecretion, hyperesthesia, gastric ulcer (from local spasm with hyperacidity), spasm affecting the gall-bladder, nervous diarrheas (' 'neurogenic"). Some of diarrheas in Basedow's disease belong to vagotonia and possibly with tuberculosis, leukemia and lympho-sarcoma (Eppinger); acid jejunal diarrhea, mucous colitis; eosinophilic catarrh (mucous catarrh plus eosinophilia); spastic catarrh, hypermobility with diarrhea ; spastic constipation and spasm of the sphincter ani. Enteroptosis often occurs in association with vagotonia or sympatheticotonia or irrita- bility of both systems. A poly neuritis affecting the occipital, trigeminus intercostal and nerves of the arms and back, also the crural and sciatic nerves has been described by von Noorden. The pains are wandering in character and there may be tender points in their course. The pains may affect the muscles or even the joints but there are no swelling or redness and pains occur early in the morning ^on first movements and later disappear. In association there are marked indicanuria hyper- 896 DISEASES OF THE STOMACH AND INTESTINES acidity, retention of feces in the sigmoid with a sensitive point (S. point) over it, level of McBurney's point; on the left side, however; occasionally diarrhea, urticaria, dermography and other symptoms of vagotonia. There is slight temperature. This polyneuritis is believed to be due to intestinal toxemia (putrefaction). Symptoms of Sympatheticotonia. There may be mydriasis, tachy- cardia, constriction of the vessels with resulting cold hands and feet, mottling or a red nose, hyperesthesia, great susceptibility to temperature changes, numbness, sensation of pins and needles, deficiency of perspira- tion, gooseflesh, perverse skin reaction (a condition of pallor in response to shock), intermittent pulse, transitory attacks of high blood pressure, pulsation of abdominal aorta, transitory vertigo, nasal hemorrhage or catarrh, hemorrhoids, increased climacteric disturbances. Among the gastro-intestinal disturbances are dry mouth (dimunition of saliva), increased gag reflex, though tube can readily be passed on account of relaxed esophagus; cardia relaxed so regurgitation occurs; atony of the stomach with delayed emptying, or atonic dilatation; splashing sound readily produced; hydrochloric acid diminished; pancreatic secretion lessened, motility and secretory activity of intestines diminished, atonic constipation. Hence gastro-intestinal functions are diminished in their activity. It will be readily seen that vagotonia or sympatheticotonia, singly or together in alternation, may explain many of our so-called gastro- intestinal neuroses. Treatment. Psychotherapy would be of value in the early stages, in order to divert attention from the particular organ complained of by the patient. With the vagotonics atropin and adrenalin have proved of service, atropin being of particular value in reducing spasm and dimin- ishing secretion atropin gr. Hoo to ^ t.i.d., sometimes the dosage must be pushed higher. Occasionally tinct. belladonna gtts. x, three or four times daily or ext. belladonna gr. % t.i.d. may be substituted. Adren- alin chloride (i : 1000) 10 to 15 drops by hypodermic acts in these cases by stimulating the sympathetic. Three or four doses may be used daily, particularly valuable in asthma. In cases of sympatheticotonia pilocarpin gr. J{ t.i.d. to increase gastric or pancreatic secretion, or physostigmin gr. ^ 00 to ^ t.i.d. for intestinal atony, for example. Enteroptosis, chronic intestinal putrefac- tion and other special conditions should be treated appropriately. In conclusion the writer wishes to express his appreciation to Smith Ely Jelliffe for much valuable material in his description of these conditions. VISCERAL CRISES IN THE ERYTHEMA GROUP In the study of these conditions one notes that they merely describe another phase of instability of the vegetative nervous system and may really be classified under Vagotonia and Sympatheticotonia. Under "Differential Diagnosis in Appendicitis" the writer refers to various types of erythema, urticaria, angioneurotic edema and Henoch's purpura producing visceral lesions with symptoms, simulating appendicitis. VAGOTONIA SYMPATHETICOTONIA 897 In addition nausea, vomiting, diarrhea and hemorrhages from the mucous membranes, melena, etc., may occur. The attacks have also been mistaken for intussusception and when operated upon there has been found an acute sero-hemorrhagic infiltration of a limited area of the stomach or intestine, resembling angioneurotic edema. Enlargement of the spleen is usually present in these cases and albuminuria and acute nephritis may occur and prove a serious complication. Osier 1 classifies the group as follows: Cases of pure angioneurotic edema," cases in which urticaria is the associated skin lesion; Henoch's purpura with arthrites, purpura or erythema and colic ; cases with ery- thema multiforme, with or without edema and frequently with redness or purpura; cases with recurrent colic, and nothing else determinable, it may recur some years before the skin lesion appears. Etiology. Members of certain families are predisposed to these con- ditions and Osier has traced heredity to angioneurotic edema through five generations. Attacks recur and one can frequently find in the history, evidences of instability of the vasomotor mechanism or as Solis-Cohen terms it "vasomotor ataxia" such as dermographia, transient skin erup- tions, asthmatic attacks, hay-fever, arthritic attacks, repeated hemor- rhages from apparently unknown causes, hysteria, hyperidrosis, drug idiosyncrasies, migraine, vertigo, visual disturbances, polyuria, etc. The exciting cause of the attack may be from cold or emotion and in many cases from the gastro-intestinal tract. Thus some have an idiosyncrasy to strawberries and shellfish. Undoubtedly in many of these cases an idiosyncrasy to protein absorption, with parenteral digestion with toxin elimination (anaphylaxis), is responsible. Symptoms. The description of these cases would place them chiefly under vagotonia with occasionally symptoms of sympatheticotonia. They usually show an unstable vasomotor system and suffer from dermographia, skin mottling, rapid or irregular heart action, or palpitation or intermit- tent tachycardia or functional murmurs may be present. In some cases there may be tremulousness of the lids, widening of the commissure of the eyelids, and dilatation of the pupils which react to light, but with wide oscillation. The character of 'the eruption may vary; thus purpura, at times measles may be simulated, or there may be erythema with urti- caria, or nodules with dark centers. The eruptions, however, are rather constant in their distribution over the extensor surfaces of the hips, knees, ankles and elbows. Angioneurotic edema may be limited in extent. Some cases show only recurring attacks of colic and no skin eruption for several years. The colic attacks often come at intervals of a month or so, and tend to recur. A chill may accompany the attack. The pain is extremely severe, in some cases beginning in the epigastrium and becom- ing diffuse, while in others it may be confined to the lower segment of the abdomen. Some resemble biliary or renal colic, though radiation of of the pain is not common. Nausea, vomiting of food, or clear or greenish or bloody fluid, together with diarrhea with melena, preceded by constipa- tion, quite often accompany the colic attack. The patient may appear quite ill. There may be rigidity and tenderness over the colon, appendix, 1 Johns Hopkins Hosp. Bull., vol. xv, p. 260. 57 DISEASES OF THE STOMACH AND INTESTINES in the epigastric region, or in all three. The writer 1 has already referred to a case of acidosis and indicanuria from dietetic indiscretions with an erythematous eruption and angioneurotic edema of the ascending colon and cecum simulating appendicitis. The abdomen is often decidedly retracted and distention is rare. At times a mass can be felt which opera- tion during the crisis has demonstrated to be a swollen portion of the intestine, operation having been performed through mistake in diagnosis. The intestinal wall for several inches in some of these cases was swollen and edematous, the last part of the ileum being most frequently involved, the peritoneal coat congested and studded with petechiae and ecchymotic areas. A small amount of fluid was found in the peritoneal cavity. It was clear in some cases and turbid or bloody in others. One operator reports a case in which the intestines were pale and in spasmodic contraction. The abdomen has been opened between attacks and the organs appeared normal. The spleen is quite frequently moderately enlarged; usually a moderate leukocytosis 14,000 or thereabouts is present. With hemorrhagic cases coagulation time is slow. Albuminuria with blood and casts, hemorrhage into the mucous membranes and retina and arthritis may occur. Severe acute nephritis may cause a fatal termination and there may be no edema with it. Pleu- risy, pericarditis, endocarditis and pneumonia may complicate. In- tussusception and perforation of the f undus of the stomach (from necrotic foci from purpura) have been reported. Other crises such as hemiplegia, monoplegia, asphasia, swelling of the fauces and pharynx, edema of the glottis and asthma may occur. Diagnosis. One must exclude erythemas secondary to organic diseases such as cardiac disease, liver cirrhosis, cholelithiasis, nephritis, etc. The family and personal history with physical examinations generally give us the required information. In the colic cases with no eruption, the diagnosis is more difficult. In the cases simulating appendicitis abdominal retraction is more often present, while with appendicitis there is more often distention. Tenderness and rigidity are more marked with appendicitis and melena occurs quite frequently with the visceral crises. Treatment. Arsenic and iron are of value to prove the general con- dition of these cases. Idiosyncrasies as to certain foods should be investigated. Monobromate of camphor can also be employed. Atropin or adrena- lin are indicated for the vagotonia, and the usual treatment of sym-r patheticotonia if such is present. In cases from protein absorption, hexamethylin gr. 5 to 10 t.i.d. abolition of the objectionable proteid and correction of the gastro-intestinal functions and of the chronic intestinal putrefaction are indicated. Sour milks are of service. In hemorrhagic cases lactate calcium gr. x, fo*ur to six times daily with 10 per cent, gelatin, or horse serum by mouth or human serum by hypodermic or direct infusion are indicated. Rest in bed and milk diet are useful for the nephritis. 1 Amer. Jour. Med. Sci., February, 1894, cvii, 145. VAGOTONIA SYMPATHETICOTONIA 899 UMBILICAL DYSPEPSIA Aaron 1 reports a condition which he denominates umbilical dyspepsia resulting from a congenital defect in the abdominal parietes preventing closure of the umbilical canal. The defect is at the opening for the omphalomesenteric duct and the urachus. It is not a true umbilical hernia. The opening may be so small at first as to escape notice. Symptoms. There are symptoms of nervous dyspepsia due to in- creased irritability of the autonomic nervous system. Symptoms may be absent for days and then recur from some trivial cause. Appetite is capricious; at times coarse food may be taken with impunity, while an ordinary diet may be rejected. There are fulness of the head, headache, inability to work, vertigo, depression and lassitude. There may be heaviness immediately after eating, or uneasy sensations one to two hours later. The discomfort does not depend on the quantity or quality of food. Constipation is usually present and the nutrition generally good. If the subjective symptoms become severe, loss of weight results from refusal to take sufficient nourishment. Physical Examination. Deep palpation with the fingers over the umbilicus elicits severe pain. It may radiate, or be referred to a distant part of the abdomen. When pressure ceases, the pain stops. In more advanced cases the separation at the umbilicus can be determined. The stomach may possess normal functions but hyperacidity is more usually present. Treatment. Bring the edges of the congenital opening as closely to- gether as possible with adhesive strapping preferably a strip 2 inches wide and long enough to extend 2^ to 4 inches on either side of the umbilical opening. Cleanse the abdomen first with soap, water and alcohol, and clean the umbilicus. Hair should be shaved off. The treatment should be continued from 4 to 10 weeks. Ether or oil of wintergreen aid in removal of plaster. Elastic abdominal support is a useful adjunct. Treat the hyperacidity if present by appropriate remedies, and vagotonia by belladonna or atropin. The bromids are useful. Stomachics may be required. Nourishing food should be administered, such as butter, cream, milk, eggs, etc. It would seem to the author that surgical procedure might in some cases be necessary. ^our. A. M. A., May 13, 1916. CHAPTER XXXV NERVOUS DISEASES OF THE INTESTINES UNDER this heading are included those conditions due to perversion of the innervation of the intestines independent of anatomic lesions of the intestinal wall or of distant organs. In many cases the neurotic manifestations in the intestines are an in- dependent manifestation of some general neurosis, such as of neurasthenia, hysteria, or hypochondriasis. Some few cases result, purely from func- tional perversion of the intestinal nerves. Vagotonia and sympathetico- tonia may explain some of these conditions. Intestinal neuroses may be divided into motor, sensory, and secretory. They often exist in combination. Psychic influences, such as fear, fright, worry, and anxiety, may be causes, as may reflexes from some diseased organs, such as the stomach or genito-urinary tract. The nerve-centers influencing peristalsis, Meissner's and Auerbach's plexuses, have been described in the chapter on Physiology of Digestion, Part I, under Nervous Control of Peristalsis. Secretion seems to be dependent to a great extent upon the ganglionic plexus. Moreau 1 ligated an intestinal coil and severed all the nerves passing to it. In a few hours it was filled with fluid, showing amylolytic qualities and containing albumin. After ingestion of food into the stomach, secretion takes place in the lower part of the intestines before the arrival of the chyme. This was demonstrated by Quincke and Demant. Vasomotor filaments exist in the intestines as stimulation of the splanchnic causes contraction, and its section causes dilatation of the intestinal blood-vessels. They are also concerned with absorption. Sensory filaments exist in the intestines, since stimuli of greater in- tensity than normal, such as the ingestion of beans or cabbage, may give rise to sensations of pain or pressure. Kast and Meltzer 2 have demon- strated experimentally that the sensation of pain exists in the intestines, and that laparotomy, under cocain, causes anesthesia of the intestines through the cocain being carried by the blood. MOTOR NEUROSES OF THE INTESTINES Peristaltic Unrest (Tormina Intestinorum). This condition consists in marked rotary or rolling movements of the intestines, so that they frequently become visible. It is usually seen in patients with hysteria or hypochondriasis. Occasionally it is an independent affection. It is almost exclusively seen in the small intestine. 1 Centralbl. fur die Med. Wissensch. 186, No. 14. 2 Med. Rec., Dec. 29, 1906. NERVOUS DISEASES OF THE INTESTINES 901 Peristaltic restlessness, which accompanies complete or incomplete occlusion of the intestines, is not included herein. There is not the peculiar stiffening of the intestinal coils, as is present with stenosis, and other symptoms of that condition are absent. Occasionally the condi- tion occurs in persons presenting no other nervous symptoms, as after the ingestion of highly spiced or indigestible foods, after the excessive use of tobacco, mental excitement, or too much brain work. Clinically, there are rolling, gurgling, squelching noises in the abdomen of varying intensity. They can often be heard at some distance and are a source of mortification to the patient. Pain, as a rule, is not present. The movements of the intestines may occasionally become visible and palpable. Eructations sometimes occur when peristaltic unrest of the stomach is associated. Attacks occur at irregular intervals and may take place during menstruation. Diagnosis. Stenosis of the bowel must be excluded. The nervous type of peristaltic restlessness of the intestines is readily recognized. Prognosis is favorable. Treatment. This should be directed toward the tone of the nervous system. Heat externally applied and the drinking of hot water during the attack are of value. Spicy and indigestible food should be excluded. Priessnitz compresses should be applied to the abdomen at night. The bromids, valerian, and asafetida are useful. Arsenic alone or combined with iron should be employed in anemia. If there is any disturbance of the bowels (diarrhea or constipation) it should be properly regulated. Rarely a small dose of opiate, alone or combined with belladonna, is required. If the attacks occur at night, chloral hydrate, 15 grains (i.o) or veronal, 7^ grains (0.5), sulphonal or trional, 10 grains (0.6), may be necessary. Electricity and massage have been recommended. Change of climate is beneficial. Nervous Diarrhea. These exaggerated peristaltic movements occur not only in the small, but also in the large intestine. They may be limited to the colon in some cases. There is an increased transudation of fluid due to nervous influences. The reader should refer to a description of this condition under Diarrhea. Spastic constipation, due to local enterospasm and also spasm of the sphincter, sometimes occurs in neuropathic, hypo- chondriac, or hysteric subjects. These conditions are described under Constipation. Paralysis of the Intestines. Paralysis resulting from a mechanical obstacle to the passage of the intestinal contents has been described. Primary paralysis of the intestines without any organic obstacle will itself cause symptoms of obstruction. The reader is further referred to Dynamic Ileus. There are several forms of this condition: i. An intestinal coil may become paralyzed after forced reposition of a hernia or after incar- ceration; it may be due to direct traumatism, to abdominal operation, or to inflammation or ulcerative processes of the intestines. 2. It may result from reflex irritation. of the inhibitory nerves of the Q02 DISEASES OF THE STOMACH AND INTESTINES muscular coats of the intestines, especially where there is injury or inflammation which does not necessarily involve the bowel. Toxemia may be a factor. Contusion of the testicles, abdominal abscess, anesthesia, uremia, etc., are causes. 3. Neuroses, melancholia, hypochondria, or affections of the nervous system, such as meningitis, brain tumors, tabes, myelitis, etc., are also causes. Atony of the intestines, leading to coprostasis, has been sug- gested as a cause of intestinal paralysis. It would seem that the symp- toms are produced by occlusion. Intestinal atony is really a subparetic condition, and the nervous type is described under Chronic Constipation. Meteorism in hysteria is probably due to sudden paresis of the muscular coat of the bowel. See Meteorism. Treatment. Removal of fecal impaction by the fingers if present, enemata of soapsuds, i quart (liter), containing olive oil, 8 ounces (250 c.c.), and glycerin, i ounce (30.0), electric enteroclysis, enteroclysis, simple enemata, massage, and electricity are useful. With fecal impaction, liquid mercury, 10 to 20 ounces (300.0-600.0), given through a stomach-tube, is of value. It might otherwise enter the larynx. Various cathartics, such as castor oil, i to 2 ounces (30.0-60.0); olive oil, 1 4 ounces (128.0); physostigmin sulphate, >f 00 to J^ grain (0.0006-0.001), may be em- ployed. Lavage, followed by the administration of the cathartic through the stomach-tube, is useful. For further treatment, the methods pursued in Dynamic Ileus should be consulted. Paralysis of the Sphincters. It occurs as one of the symptoms of rectal affections. Tenesmus may lead to exhaustion. Ulceration and infiltration of the rectum at times involve the sphincters, interfering with their function or destroying it. Improper methods of operations on the rectum may cause paralysis. Accumulation of feces may impair the tone of the muscles. Diseases of the brain and spinal cord may cause paralysis of the sphincters. 77 may be a pure neurosis. Some patients are not able to keep the rectum tightly closed and a small amount of discharge continually escapes. In others involuntary movements occur after excitement, exertion, or during urination, there being only a partial paresis. With complete paralysis, flatus and feces escape involuntarily, even when resting. With paralysis resulting from proctitis, hemorrhoids, stricture, etc., there is a continuous dripping of mucous secretion which irritates the skin. Diagnosis. The anus appears patulous and several fingers can be introduced into the rectum without resistance. To diagnose purely nervous paralysis, anatomic lesions must be excluded by means of examination with~U speculum. Prognosis. This depends upon the cause in the pure neuroses it is favorable. Treatment. Thorough evacuation of the bowels, preferably by enemata twice daily, is important. The addition of alum, i dram to i pint (4.0-500 c.c.) of water by enema, is useful. If due to nervous con- 1 Large doses of olive oil, 5 vi-viii, and mineral oil, 5ii~iv, through a duodenal tube are useful. NERVOUS DISEASES OF THE INTESTINES 903 ditions, electricity and massage, especially local vibrations, as suggested by the late J. P. Tuttle, are beneficial. Tonics, such as iron and arsenic, are useful. Strychnin, %o to i^o grain (0.001-0.0015) by hypodermic into the anal folds, has been recommended by Rosenheim. General improvement of the nervous system and at times change of scene are indicated. Occasionally difficulty in urination and straining may cause paresis of the sphincter. Catheterization will improve this condition. In the cases in which the nervous condition is not responsible, but some anatomic lesion, appropriate treatment is indicated. SENSORY NEUROSIS OF THE INTESTINES I agree with Riegel that true colic is not a sensory neurosis. I have called attention to the fact that the pain of colic is produced by tetanic contractions of the intestinal muscles, and that it is a secondary symptom. Hyperesthesia of the Intestines. Under normal conditions digestion is carried on without producing any sensation whatever. In cases of neurasthenia, hysteria, and hypochondriasis the patient may be conscious of abnormal sensations in the intestines after the ingestion of food. They may occasionally appear after violent emotion or shock. These sensations consist in a feeling of fulness, stabbing, burning, tearing, and as if the ingesta were moving about in the abdomen. Occasionally delusions may develop. In some there is local hyperesthesia, especially in the rectum. There is a feeling of tenesmus or fulness, as if some foreign material were impacted therein, though the rectum is normal and contains no fecal matter. In others, pressure and weakness occur in this region, or there is burning, tickling, itching, stabbing, or a cutting feeling, at times combined with voluptuous sensations. Anesthesia of the Rectum. In these patients the desire for defecation is absent. In pronounced cases movement may occur without being felt. Such conditions are met with only in patients with spinal and brain trouble, or in the old and decrepit. Paralysis of the sphincters may occasionally accompany this condition. Treatment. This must be directed toward the improvement of the nervous condition. Change of climate and hydrotherapy are valuable. Highly spiced food, alcohol, and red meats should be forbidden. Abnormal sensations in the rectum may be improved by cold rectal douches, sitz-baths, the cold prostatic cooler, such as I advocated in the treament of hemorrhoids, and by rectal galvanization. With rectal anesthesia cleansing enemata are useful. It may be necessary to wear a rectal obturator (Fig. 363) to prevent soiling. Nervous Enteralgia (Neuralgia Mesenterica). Aside from enteralgia due to irritating factors, it may result from a perverted state of the sensory intestinal nerves. This condition is not due to spasm of the intestinal muscles, like colic, but to a neuralgic affection of the bowels. It appears as a primary affection and is found in patients troubled with hysteria, neurasthenia, or spinal difficulty. It may occasionally be reflex, 904 DISEASES OF THE STOMACH AND INTESTINES from abnormal conditions of the kidneys, bladder, uterus, ovaries, and liver. It may occur as a neuralgic condition even after the removal of some primary cause in the intestines. The first symptom is pain, which usually begins in the umbilical region, mild at first, but gradually increas- ing in intensity. It may radiate in various directions. Pressure over the abdomen and the passage of flatus usually relieve the pain. It may be of a cutting or stabbing type, and may even produce shock or syncope. The bowels may be nearly normal or constipated. Appetite and digestion may be good. Palpitation, dyspnea, strangury, etc., may occur. Neuralgic attacks can occur in lead-poisoning without the true spasm. Hemmeter has reported three cases of gouty neuralgia of the intestines. Romberg holds that the abnormal crisis of tabes dorsalis is due to nervous enteralgia. Examination of the symptoms demonstrates that true colic is present. The Romberg symptom, Argyll-Robertson pupil, and absence of patellar reflexes are diagnostic of syphilis, also the presence of the Wassermann reaction. FIG. 363. Rectal obturator. Eypogastric Neuralgia (Romberg). In some cases of tabes there is a purely local form of neuralgia, limited to the rectum. The attacks are characterized by violent tenesmus, paroxysms of pain, a feeling as if a red-hot iron were inserted in the rectum, and occasionally diarrhea. This condition is also frequently found in diabetes and in women having uterine trouble, piles, or who are neurasthenic. The picture presented by nervous enteralgia, on the other hand, as Riegel remarks, may occupy an intermediate position between peritonitis and colic pseudoperitonitis. Violent attacks of pain occur in the abdomen at short intervals. Associated with this is frequently pronounced collapse, wich great abdominal tenderness 1 on light pressure. Vomiting, which is usually present in peritonitis, is always absent in these cases. The skin of the abdomen is generally hyperalgesic. The functions of the intestines and stomach between attacks are undisturbed, and the patients feel perfectly well. Treatment. This should be directed toward improvement of the hysteria and neurasthenia. Change of climate, hydrotherapy, massage, electricity, and moral treatment are of service. Arsenic is valuable. The bowels should be kept regular and a simple diet advised. 1 There is no true tenderness on deep pressure, and muscular rigidity is absent. NERVOUS DISEASES OF THE INTESTINES 905 With neuralgia hypogastrica, if there is local disturbance, this should be treated. Warm sitz-baths and hot enemata are useful. Occasionally an opium-and-belladonna suppository may be required. Tabes should receive treatment. SECRETORY NEUROSES OF THE INTESTINES Though secretion. in the intestines immediately follows the entrance of food into the stomach, thus demonstrating the presence of secretory nerves in the intestines, we still have little knowledge of the subject. Nervous diarrhea, which has been described as a motor neurosis, is often accompanied by art increased flow of intestinal juice. Increased intestinal secretion is found in membranous enteritis, though I do not consider this disease a pure neurosis of secretion. INTESTINAL NEURASTHENIA Combinations of the intestinal neuroses frequently occur. Rosen- heim designates such cases as intestinal neurasthenia. The appetite is good and the symptoms usually appear when intestinal digestion takes place about two to three hours after meals. There are pressure, tension, and griping in the abdomen. Occasionally there is nausea, and at times an evacuation of the bowels occurs accom- panied with painful sensations in the abdomen and anus. Palpitation occurs at times; sometimes flashes of heat or cold. Generally the patient feels worse when resting in the recumbent position than when walking about. The symptoms usually disappear in a couple of hours to return later after a meal. Constipation usually is present. The quality of the food does not exert any influence on the symptoms^ Borborygmi and diarrhea occasionally are present, and the latter in the middle of the night or in the early morning. Indigestible foods are often well borne, while at other times small meals consisting of light food cause severe symptoms. Gastric neurasthenia is sometimes associated. This condition is found among the hysteric and neurasthenic. Diagnosis. Anatomic lesions causing these symptoms, intestinal dyspepsia, and enteroptosis must be excluded. Treatment. The general nervous condition must be toned up; iron, arsenic, strychnin, and the bromids are indicated, and ample feeding is required. Indigestible substances should be avoided, also red meats, to lessen the nervous irritability. The sour milks, such as bacillac, matzoon, kefir, etc., are of value. MUCOUS COLIC (MEMBRANOUS ENTERITIS) Among the best-known synonyms for mucous colic are mucous colitis, membranous colitis, membranous or pseudomembranous enteritis, and tubular diarrhea. In all, there are about twenty-five names for this condition. History. Although no distinct accounts of this disease occur in the writings of the ancients, yet there may be detected some of its peculiar 906 DISEASES OF THE STOMACH AND INTESTINES features in the description of certain pathologic conditions grouped under diarrhea, dysentery, etc. J. Mason Good, in 1825, was the first to classify the disease, calling it tubular diarrhea. Woodward described it in the "Medical and Surgical History of the War of the Rebellion." Siredy contributed a valuable paper in 1869. DaCosta, in 1871, described the nervous elements of the disease, stating that the condition is not a true inflammation. Leyden's work, in 1882, gave further stimulus to investiga- tion, especially regarding the character of the dejecta. Nothnagel sug- gested the name "mucous colic," in order to show that a true enteritis need not exist. Mucous colic is, therefore, an entity, and may be defined as a "condition characterized by the excessi\e production of mucus in the colon, by attacks of painful spasms of varying degrees of severity and frequency, accompanied or followed by the expulsion of mucus in gelatinous masses, or in the form of tubular casts, or in tape-like pieces or strings, and, furthermore, characterized by anomalies of the gastro-intestinal functions and by various nervous symptoms." Age and Sex. It is a comparatively rare affection, occurring most frequently in women from twenty to forty, frequently in middle life. A few cases occur late in life and rarely in children. Boas reports one in early infancy. About 75 to 85 per cent, occur in women. Etiology. Space will allow me to mention only a few of the chief investigators. Among the various theories regarding the etiology, we may mention the following: 1. Neurasthenia is the prime factor mucous colic is a secretory neurosis. Among the advocates of this view are notably DaCosta, Siredy, and W. Mendelson, of New York City. Eppinger and Hess hold it as a neurosis, particularly since with spastic constipation, they find in many cases the masses of stool covered with mucus, suggesting increased secretory activity. They impute these conditions to vagotonia. 2. The anatomic origin. Ewald lays stress on ptosis of the colon; Boas, on atony; Glenard, on splanchnoptosis. 3. Partly nervous and partly anatomic origin. Mathieu considers it a hypersecretion of mucus in patients of a neuro-arthritic type, who suffer from enteroptosis, intestinal sand being present. Hemmeter believes that often there is some connection with arthritis. Von Noorden lays stress on long-continued constipation in nervous subjects. Einhorn places it among the neuroses, but finds that it is associated in many cases with Glenard's disease (with gastroptosis and enteroptosis), and that achylia gastrica is present in many patients. 4. Tumors, adhesions, enlarged prostate, and various other factors are given. The late J. P. Tuttle believes mucous colic due to organic causes. Roger traces the cause to the liver, believing there is an anti- coagulant in healthy bile, and when its production is interfered^with by visceral ptosis, abnormal accumulation of mucus begins. Nepper 1 also imputes the condition to disturbance of the biliary functions. 1 Mucomembranous Colitis, its Causes and Mechanism, New York Med. Jour., May 23, 1908. NERVOUS DISEASES OF THE INTESTINES 907 Pathology. Necropsies are rare unless death results from some intercurrent disease. Autopsies in the cases of O. Rothmann, Osier (Edwards), and Weigert demonstrate that no inflammatory condition existed in the colon. There was simply hypersecretion of mucus. The consensus of opinion is that no inflammation exists. On the other hand, M. Rothmann reports one case and Hemmeter two cases in which, in ad- dition, some catarrhal inflammation was present. Nothnagel explains this unquestionably by the fact that there are two classes of cases, one in which there is the pure "mucous colic," with hypersecretion of mucus; and the second class, in which the mucous colic is engrafted on a catarrhal colitis. I have noted, in my own experience, that the catar- rhal colitis may be of such a mild type that attention may readily be di- verted from it on account of the predominance of the symptoms of the mucous colic. The mucus may be passed in the form of long, thin bands, ribbon- like or in the shape of a tapeworm ; they may be tubular or form a cast of the intestines; in some cases these are of considerable length, several feet; the mucus may be in jelly-like masses or even in shreds, occasionally streaked with blood. This discharge should be carefully differentiated from fascia, tendons, the membranes of oranges, etc. After first treating with sublimated alcohol and then staining with Ehrlich's triacid solution, a green color occurs with mucus, of which this discharge consists; with fibrin it turns red. The color of the membranes in mucous colic is or- dinarily grayish, though they may be translucent or even transparent. Microscopically, the membrane consists of a structureless matrix, with columnar epithelium scattered therein; its chief constituent is mucus. Symptoms. These patients are markedly neurasthenic and morbidly self-conscious; in appearance they are usually emaciated, with a history generally of considerable loss of weight. There has been obstinate constipation of long duration, with an occasional intermittent diarrhea. Palpitation, dizziness, disturbances of the genito-urinary system, hysteric symptoms, anemia, headache, and gastric disturbances of various types are present. On palpation of the abdomen sensitive points will often be detected. Patients give a history of a sudden attack of acute abdominal pain like severe colic, and the abdomen may become swollen and tense. At this time the nervous symptoms become extremely aggravated. Finally, the passage of the mucous masses described occurs spontaneously, with great staining or with artificial aid. These attacks occur with varying frequency and severity. Between the attacks the nervous condition of the patient may be slightly improved. This is the type of uncomplicated (pure) mucous colic. Nothnagel describes a second type of enteritis membranacea which is engrafted on a colitis. He notes two classes of cases: (a) That in which the severe cramp-like attacks are absent; the patient passes mucus continuously, with occasional tube-casts a cystic colitis (Abercrombie's case), as shown at autopsy. This is not a true mucous colic. (b) A class in which mucous colic is engrafted on a chronic catarrhal DISEASES OF THE STOMACH AND INTESTINES colitis the latter due in this case to adhesions from recurrent appendicitis. There were small amounts of mucus passed at frequent intervals with occasional attacks of mucous colic. Operation relieved both conditions at first, but the mucous colic later returned. I have had such a patient under treatment; the appendix had been removed and adhesions broken up. The patient improved for a time, but later relapsed. I found enteroptosis associated with gastroptosis. I applied Rose's belt and instituted treatment. Improvement imme- diately followed, with ultimate cure. Researches. For some years the author has carried on investigations in gastroptosis and enteroptosis at the Manhattan State Hospital, as well as other institutions, and also into the etiology of mucous colic, 1 and he is thoroughly convinced that enteroptosis is a factor in mucous colic. In Fig. 364 is illustrated ptosis of the colon, narrowed at one point and sacculated above this. Gastroptosis is associated with it. This misplacement of the colon undoubtedly favors circulatory and, hence, secretory changes in the sacculated portion of the colon. Fecal accumulation is also favored, a further cause of irritation. Absorption, with resulting auto- intoxication and nervous disturbances folio wing the same, can thus readily result. Naturally, a patient of nervous temperament, and there are undoubtedly many such, may be more Fig. 364. Mucous colic: markedly affected, but I do not believe that \ Presence of gastroptosis (G) ., . . n ,, r even of a mild degree, as neurasthenia per se will cause that peculiar demonstrable by gastrodi- entity known as mucous colic any more than it ^fl cause gonorrhea. There must be other aphany shows (E) is present enteroptosis also, enter- , - . optosis with sacculation and factors. narrowing at ST; passive We know that mucous colic occurs in (sacculated) portion of colon; ptosis, and Boas that atony, of the colon are mucous colic attacks occur as important factors, and Einhorn finds a large percentage of patients with mucous colic that have enteroptosis associated with gastroptosis and achylia gastrica. I believe that mucous colic has as its chief etiologic factor ptosis of the colon with associated gastroptosis. I have had under observation a patient with typic attacks of mucous colic which began one month after confinement. She had enteroptosis and gastroptosis (Landau's disease) due to insufficient support of the abdomen after the birth of her child. She was not neurasthenic, and was only nervous at the time of her attack. A specimen of the mucus passed by this patient was about 12 inches long, flat, and tape-like, and gave the typic reaction to the mucin test; no fibrin was present. To my knowledge, this is the first case of mucous 1 Amer. Med., vol. ix, No. 9, pp. 349-354, March 4, 905. NERVOUS DISEASES OF THE INTESTINES 909 colic that has been reported without the usual accompaniment of neurasthenia, and it substantiates my views. In addition, in nine cases of mucous colic which I have carefully examined since I began these special investigations, I have found in every case varying degrees of gastroptosis with its asso- ciated enteroptosis. In four cases there was hyperacidity; two cases, anacidity; three cases, achylia gastrica. Since the publication of the above article the author has investigated many more cases, all of which substantiated this view. In the newborn and in young children, in whom several cases of mucous colic have been reported, neurasthenia surely cannot be claimed as a cause of the condition. As before stated, visceral ptosis may be present and the patient be in perfect health; but some contributory factor, local irritation, anemia, or intercurrent disease may destroy the equilibrium, and gastro-intestinal disturbances, constipation, etc., may result, and finally, mucous colic. On the other hand, gastro-intestinal ptosis may be brought about by loss of weight or other factors mentioned under Etiology of Gastroptosis, and mucous colic finally result. Enterop- tosis is not invariably productive of mucous colic, any more than is typhoid always complicated by hemorrhage or perforation. Enteroptosis with associated gastroptosis with gastro-intestinal dis- turbances I consider factors in the production of mucous colic, and the neurasthenia the result of auto-intoxication. In effect, it may be con- sidered as one of the manifestations of Glenard's disease. Other con- tributory factors, such as rectal irritation, associated colitis, etc., will be referred to under Treatment. In a paper entitled "A Consideration of the Etiology of Mucous Colitis," by John A. Lichty, 2 there are reported 21 cases of mucous colitis; ptosis of the viscera was demonstrated in 1 6 cases; the other patients were seen before the author's attention had been directed to splanchnoptosis. He states that it is a well-known fact that not infrequently during the examination of a patient a condition of ptosis is found without any symptoms referring to it. In such cases there has been established what may be called a condition of perfect com- pensation, and physiologic function has not been disturbed. When, however, this compensation is lost or disturbed, the symptom-complex of mucous colitis appears. He notes a lithemic condition in several patients notably one having had several attacks of acute articular rheu- matism. The gastric secretion was studied in eight patients in four it was hyperacid; in two, normal; in one, hypo-acid, and in one, achylic. G. H. Koehler 3 reports a case of mucous colic clearly dependent on gastroptosis. Prognosis. These cases require tact and patience and most of them are of long duration. With perseverance, I believe them to be curable Treatment. This may be summarized as follows: During the attack, rest in bed; the application of heat to the abdomen by flax-seed poultices, turpentine stupes, or hot pepper poultices -i dram (4.0) red pepper to i pint (500 c.c.) of boiling water a flannel being wrung out therein, 1 Med. News, Aug. 6, 1904; Amer. Med., March 4, 1905. 2 Amer. Med., Aug. 6, 1902. 3 Med. Sent., June, 1909, Portland, Oregon. DISEASES OF THE STOMACH AND INTESTINES covered with oiled silk, and applied to the abdomen. Dry heat, by means of a hot- water bag, salt-bag, or light tinplate (pie plate), heated in the oven and covered with flannel, may be employed. Spice poultices are of service. Moist heat, however, seems best. The greatest relief to the cramps and bearing-down pains is afforded by enteroclysis by recurrent irrigation with normal saline solution at 110 to i2oF., oil of peppermint, 5 to 15 minims (0.296-0.888) to the quart (liter), may be added. Several gallons should be employed once or twice in twenty-four hours, and no fluid should be left in the bowel after irriga- tion, lest further cramps ensue. High enemata of warm olive oil -i pint to i quart (500 c.c. to i liter) are also of service, as they aid in relieving spasm just as does the internal administration of olive oil in spasm or stenosis of the pylorus. Hot saline rectal injections containing 2 to 4 ounces (60.0-125.0) of milk of asafetida may be employed. Diet. Fluid diet, milk, sour milk, broths, soups, etc., should be enjoined during an acute attack. Medication. Tincture of belladonna in doses of 10 gtts every three or four hours, and pushing even to physiologic symptoms, has given me the best results in the treatment of spasm, and increased secretion of mucus. Atropin gr. >{ 00 to 3- > three to four times daily may give better results. Occasionally it may be necessary to employ codein in 0.016 to 0.03 gram (%-}>i gr.) doses, or even morphin, 0.008 to 0.016 gram (j-^ gr.), in conditions of extreme pain. Tf the acute attack is rather prolonged, the internal administration of valerianates or of asafetida, and the addition of milk of asafetida to the enema may prove to be of value. Between attacks I apply proper abdominal support. For this purpose a silk elastic abdominal supporter, the Van Valzah-Hayes support, Gallant's or La Grecque corset, or Rose's adhesive plaster belt can be used. Rose's belt has the advantage of simplicity and it cannot slip or become displaced. My great object is to "put on fat" in all cases, and as ptosis of the colon of the stomach are great factors in the disease, the increase of intra-abdominal tension should be secured by this means. The belt is an aid in the relief of the functional disorders of the stomach incident to the gastroptosis. If the patient objects to the plaster, then the silk abdominal supporter may be employed, or Lane's spring pad in the male. In exceptional cases it may be necessary to resort to the rest cure, asso- ciated with hydrotherapy and electrotherapeutics. Under such condi- tions we may increase the weight by following out Russell's method, such as he first instituted at the Post-Graduate Hospital in the treatment of tuberculosis. It was advocated by me in cases of gastroptosis. Regard- ing the constipation, the Kussmaul-Fleiner method of injecting into the rectum nightly or every other night warm olive oil, to be retained all night, is of great value. At the beginning one may employ a few ounces, increasing it to i pint (500 c.c.) or even i quart (liter). The patient should be taught regular habits in attempting bowel movement. A glass of hot or cold water administered an hour before breakfast is valuable as an adjunct. Fluidextract of cascara sagrada or the compound cascara tablets have been found serviceable, and in some cases sodium phosphate NERVOUS DISEASES OF THE INTESTINES 911 administered in the morning is of value, or regulin, or the mineral oils or olive oil. Other remedies, as suggested under Chronic Constipation, can be employed. A thorough bowel action should be secured daily. Massage of the bowel may be employed, massage with a cannon-ball, or vibratory massage. Sensitive areas must be avoided. These methods can be used while Rose's belt is in situ. Enteroclysis several times a week with normal saline solution is useful, since it promotes intestinal peristalsis, prevents the accumulation of mucus, and lessens the chances of spasmodic attacks. With obstinate constipation electric saline enteroclysis is of value. In addition I some- times employ baths, abdominal compresses, and electricity. Fig. 365. Rose's dry carbonic acid gas bath. The carbonic acid bath (Nauheim) is of value in improving the circu- lation. For the nervous conditions the same bath (Triton salts) has proved of service. The late Achilles Rose has devised a simple method for administering the dry gas bath without the patient being obliged to disrobe (Fig. 365). Rose has recently improved on the dry bath apparatus, so it is possible to enter it on the floor level without climbing up steps. The tank is filled w r ith gas and the patient sits therein. The height to which the gas rises is estimated by means of a burning candle, which goes out when the gas reaches that point. I have secured at least one brilliant result in the treatment of mucous colic by inflation of the colon with CO 2 gas, as advocated by Dr. Rose. The method seems in some cases to improve the local circulatory condi- 912 DISEASES OF THE STOMACH AND INTESTINES tions in the colon, just as it affects the peripheral circulation when the bath is given. I believe it worthy of trial as an adjunct to the other treatment. It merely requires a bottle with a large mouth. A glass tube passes through the cork. To this tube is attached a piece of rubber tubing with a rectal tip. From ^ to i dram (2.0-4.0) each of bicarbonate of soda and tartaric acid are placed in the bottle, which is then filled two-thirds with water. The CO 2 gas is thus generated, and the bottle being elevated slightly above the rectum, the gas is allowed to flow in until slight dis- tention is observed. This procedure can be carried out every other day. Rose's COz bottle is illustrated in this volume. I have referred to certain mixed cases in which there was a catarrhal colitis with a mucous colic later engrafted upon it. Among such we can classify those that may apparently be caused by excessive bicycling or horseback .riding, enlarged prostate, uterine fibroids, adhesions from appendicitis, etc. In some of these conditions a local congestion of the rectum or sigmoid can be detected, and careful investigation will demon- strate that the attack first starts as a simple proctitis or colitis. Consti- pation has been previously present. Subsequent auto-intoxication, nervous symptoms, and mucous colic result. I believe that careful exami- nation will reveal that these patients have had an existing ptosis of stomach and colon, quiescent, with no resulting symptoms, but as a result of irritation causing favorable conditions, mucous colic develops. The correction of such sources of irritation is undoubtedly rational, and will thus readily explain the improvement which at all times occurs after operative procedure, as in the chronic appendicitis case with colitis and mucous colic previously described. The existence of the "mixed cases" will undoubtedly "clear up "the hitherto apparently diverse opinions as regards the etiology of this disease. In such cases, with a coexisting catarrhal colitis, irrigation with nitrate of silver, 1.3 to 2 grams (20-30 grains) to 2 quarts of water, and followed by saline solution, or argyrol or protargol 1-2,000, or with resorcin, 0.65 to 1.3 gram (10-20 grains) in 2 quarts, or with listerin, borolyptol, gly- cothymolin, 4 to 8 grams (1-2 drams) to 2 quarts, or with gomenol, 4 grams (i dram) in the same quantity of water, may prove to be of ser- vice. I have often found enteroclysis with demulcents, such as weak flaxseed tea, or 6 to 8 ounces (185-259 c.c.) of a saturated solution of gum arabic added to 2 quarts (liters) of warm water, of value. In pure mucous colic I employ only normal saline solution or the demulcents for removal of the mucus, since the conditions is due to hypersecretion and not to inflammation. I should avoid silver irriga- tions in such cases, since I have already referred to the fact that irriga- tions of silver, tannin, alum, etc., can produce an artificial hypersecretion. Small doses of olive oil or of castor oil, in capsules, seem of value for con- stipation, and improve the tone of the mucous membrane of the intestines, providing they do not increase the patient's dyspeptic symptoms. Extract of nux vomica, K grain (0.016), or strychnin, % Q grain (0.00108) t.i.d., is of service in increasing the tone of the gastro-intestinal NERVOUS DISEASES OF THE INTESTINES 913 tract and the general muscular system. Resorcin, 5 grains (0.3), or sodium benzoate, 5 to 10 grains (0.3-0.6), or bismuth salicylate, 5 to 10 grains (0.3-0.6), should be given if there is much gastro-intestinal fermentation. The use of the following, suggested by W. H. Thomson in the mixed cases for the treatment of catarrh, gives good results: J$. Silver nitrate 0.32 gm. (gr. v); Resin of turpentine 8.0 gm. (3ij); Potash solution 4.0 gm. (3j)- Pulverized licorice, q. s. to make pills soft. M. Divide into 60 pills. Sig. Three pills t.i.d. Copper sulphate, y grain (0.016) t.i.d., may be substituted later; Fowler's solution of arsenic in i-minim (0.06 c.c.) doses t.i.d. has also been found useful in these mixed cases. General Treatment. Exercise 1 and outdoor life, as golf, etc., to strengthen the abdominal muscles, are important. During winter weather fencing is useful. The general nervous system must be toned up and anemia should be corrected. Iron tropon is easy to assimilate. An excellent combination is a fresh Blaud's pill (iron), 5 grains (0.32 grams), made soft with honey; in each pill is incorporated 2 minims (0.118) Fowler's solution of arsenic, and extract of nux vomica % grain (0.008 gram), or sod. arsen., ^ grain (0.00108), with % grain (0.00108 gram) of strychnin. The glycerophosphates or phosphorus compounds are of value for the nervous conditions. Hydrotherapy, massage, and electro- therapy may be used. Diet. As before noted, fluid diet, milk, koumiss, bacillac, fermillac, lactone-buttermilk, broths, gruels, etc., with the addition of somatose or liquid peptonoids, should be used during the attacks. Between attacks, Von Noorden advocates a very coarse diet (bread containing plenty of chaff, vegetables rich in cellulose, fruits with skins, etc.), to form ballast for the bowel. He claims excellent results. It is my custom to determine the condition of the stomach. Like Einhorn, I have found cases of achylia gastrica in mucous colic, but more cases of hyperchlorhydria and a few of hypochlorhydria. These special conditions should be treated in each individual case and appropriate diet instituted. Stomachics and dilute hydrochloric acid should be given when there is deficiency of HC1, and alkalis if there is hyperacidity (see Hyperchlorhydria, Achylia Gastrica, etc.). We should, however, give our patient abundant nutrition. Cod- liver oil and fats, such as Russell's emulsion, cream, 2 etc., are of value when they can be assimilated. The addition of healthy fat, with increase in weight, means the cure of our patient. Surgery. Some writers, notably Hale White, have recommended a right inguinal colotomy to give rest to the colon in certain intractable cases. This would not relieve the ptosis, however. In severe cases one might resort to shortening the suspensory ligaments of the stomach and colon. Gastropexy and colopexy might be performed, but to my mind it is 1 Exercise should not be sufficiently active to cause loss of weight, as the object is to increase the latter. 2 Butter is indicated in considerable quantity. 58 914 DISEASES OF THE STOMACH AND INTESTINES always objectionable to suture a viscus to the abdominal wall. If there is hepatoptosis, Elliot's operation for support of the liver might be insti- tuted at the same time. These procedures will aid in the support of the floating kidney if such be present. Nephropexy, I believe, is rarely indi- cated when it is a part of general ptosis, unless there be some evidence of nephritis or interference with its functions. Some recommend a "revi- sion" (tightening) of the abdominal muscles (recti) by means of suturing, so as to relieve the muscular relaxation. This last procedure, as advocated by R. T. Moris, I consider preferable. I believe that resort to surgery is rarely required except in the most obstinate cases, and only after at least two years' continuous medical treatment, with failure to secure cure or comparative comfort for the patient. CHAPTER XXXVI OBESITY OBESITY may be defined as a disorder of metabolism characterized by an excessive deposit of fat in the tissues of the body. Etiology. It results from inadequate oxidation of the food, in associa- tion with incomplete combustion, or with excessive absorption of the fat- producing materials. Both factors may be concerned in the process. Excessive intake of food is not always a cause, as frequently stout persons are light eaters, while in others excessive eating may produce increase in weight. There is evidently an hereditary tendency and some races are prone to it and it is more likely to affect -women, and to appear after middle life. It occurs in children from improper feeding and in such is at times associated with rickets. Sedentary life tends to produce it, as does also the excessive use of alcohol, particularly malt beverages such as beer. Gout has been considered a factor. Fat metabolism is under the control of the internal secretions. It is interesting to observe the deposition of fat in connection with processes with which the internal secretions are concerned; thus fat deposits at puberty, during pregnancy, lactation and at the menopause. Obesity frequently follows castration. It is believed that some cases of extreme obesity in young persons result from hypopituitarism, as there is an increased tolerance for carbohydrates with the adipose condition. Sudden access of extreme adipose is probably dependent in part at least upon perversion of some of the internal secretions. Fat may be derived from any of the three classes of food. Symptoms. Women usually consult the physician for this condition, chiefly on account of loss of good looks, or inconvenience produced by their bulk, in walking for example. The round face, double chin and great girth are familiar objects. Some obese individuals may be quite vigorous and active. Many, however, suffer from shortness of breath, particularly on exertion, such as climbing stairs; heart action may be disturbed and walking is difficult. Digestive disturbances may occur, and the bowels may be constipated. The liver may become enlarged. Sexual disturbances among women may be aggravated and intertrigo may occur where two skin surfaces are" in apposition such as in the groin and about the breasts. In young persons there may be an uncontrollable desire to sleep in the day time. Prognosis. This is usually good unless fatty degeneration of the heart, liver, etc., occur with their associated symptoms. Treatment. Prevention. Considerable may be done in the way of prevention. Thus the starches and fats should be markedly reduced, candy and soda water should be cut off, and sugar reduced to a minimum, one lump of sugar to a cup of tea for example. Pastry and sweet desserts should be forbidden fruit is preferable as a dessert, with occasionally a small custard sweetened with saccharin or a small quantity of "poor man's rice pudding." 915 91 6 DISEASES OF THE STOMACH AND INTESTINES Regular exercise in the open air should be enjoined, in an adult begin- ning at i to 2 miles and increasing to 3 to 5 miles daily in fine weather. In bad weather, the use of exercising machines or walking about the room with windows open and massage are all of value. Cold salt baths if the reaction is good, or hot alkaline baths every other day may be of service. If at any time the patient feel a little weak during the treatment, the diet is increased. Diet for Reduction of Obesity. Various systems have been suggested. Banting's is probably one of the best known. He eliminates carbohy-* drates and fats from the diet, allows a considerable amount of proteid in the form of lean meat, and permits green vegetables. Water and alcoholic drinks are not forbidden. The amount of food is greatly reduced. Oertel reduces the amount of ingested fluids, allowing in all daily about 36 ounces of liquid including the amount taken with the solid food only about a pint of pure water is given daily, the balance of liquid as tea, etc. Free perspiration is promoted by bathing (by Turkish baths in some cases) or occasionally by the use of pilocarpin. The bowels are kept open. The diet consisting largely of proteids is as follows: Breakfast. Cup of coffee or tea with a little milk, in all 6 ounces, bread, 3 ounces. Lunch. Three to 4 ounces of soup, 7 to 8 ounces roast beef, veal, poultry or game, salad or light vegetable, a little fish, i ounce of bread or farina pudding; 3 to 6 ounces of fruit. No water at this meal. In hot weather 6 ounces of light wine in some cases. Afternoon. Six ounces of tea or coffee and an equal amount of water. Occa- sionally as an extra an ounce of bread. Supper. One or two soft boiled eggs; an ounce of bread; in some cases a small piece of cheese, salad and fruit, 6 to 8 ounces of wine with 4 to 5 ounces of water. Graduated exercise (walking) should be taken, not on the level, but up hills of various grades. The distance should be gradually increased. Ebstein restricts the quantity of food ingested, but allows fats and carbohydrates in considerable amount but forbids sweets and potatoes. Von Noorden's diet is as follows: Breakfast, 8.00 A. M. 80 gm. lean cold meat; 25 gm. bread; one cup tea with spoonful of milk, no sugar. 10.00 A. M. One egg. 12.00 noon. Cup of strong meat broth, i. oo P. M. Small plate meat soup flavored with vegetables; 150 gm. lean meat (one or two varieties) partly flesh, partly fish; 100 gm. potatoes; salad; 100 gm. fresh fruit or compote without sugar. 4.00 P. M. 200 gm. fresh fruit. 6.00 P.M. Quarter of a liter of milk, with tea if desired. 8.00 P.M. 125 gm. cold meat weighed raw and grilled, and eaten with pickles or radishes and salad; 30 gm. graham bread and 2 to 3 spoonfuls of cooked fruit without sugar. Von Noorden believes additional small feedings should be given to prevent the tendency to weakness. He allows twice daily a glass of wine; mineral water, weak tea or lemonade is not limited at the meal time, or between meals. Occasionally a "hunger day" is given. OBESITY 917 Dujardin-Beaumetz recommends as follows: Breakfast 7.00 A. M. Bread 614 drams; cold meat without fat, i2y- drams; 6 ounces of weak tea. Luncheon 12.00 noon. Bread izy^ drams preferably the crust; meat 3 ounces or two eggs; green vegetables 3 ounces; salad; 3 drams cheese; cooked fruit for dessert. Dinner 7.00 A.M. No soup; dry bread 12^ drams; meat3 ounces including vege- tables, salad, cheese and fruit as at luncheon. The fluids are reduced and pastry and sweets are forbidden. Starches are cut down to a minimum and half a glass of light white wine is allowed with luncheon and dinner. Alka- line waters can be taken as may also a small cup of black coffee after dinner. In place of taking fluid at meals, he holds it is better to omit them and two hours after eating take a glass of white wine mixed with two parts of water or a large cup of weak tea without sugar. Occasionally it may be necessary to give small quantities of suitable food between meals to prevent weakness. The writer believes restriction of liquid as extensively as advocated by Oertel often does positive harm. In his own experience he knows of a case who thus first produced hyperacidity and gravel and later nephritis resulted with a fatal issue. Von Noorden's diet seems far too rich in protein, placing too much work on the excretory organs. Precautions. There are certain definite precautions to be taken in the attempt at fat reduction. In extremely severe cases, it is better for the patient for a time at least should be in a hospital under the care of a com- petent nurse. This is particularly true if the patient be very short of breath, or have fatty accumulation about the heart or fatty degeneration and suffer from cardiac asthma, dizziness, bronchitis, etc. From the diminution of the diet, some patients may complain of weakness, in which event more calories must be added in the form preferably of carbohydrates and fats. At the time of change of diet, there may be at first no loss of weight but even a slight gain. Too rapid loss of weight 1 is to be avoided. The writer is perfectly satisfied if he can reduce the patient about 2 to 3 pounds a week. At this rate of reduction, weakness is not as a rule com- plained of. Rapid reduction will also often produce marked facial wrinkles and seriously damage the personal appearance. Author's Diet. The writer cuts down markedly, fats, starches, and sugars. One should vary the diet in each case and feed rather by the "scales," causing a reduction in weight of about 2 to 3 pounds weekly. Individual cases can assimilate more carbohydrates and fats than others without increasing in weight. The patient should be weighed at least twice to three times weekly when an ambulant case, and always in the same weight clothes. In hospital cases I weigh them daily. Here are two sample diets for individual cases. Diet i Diet 2 (more restricted) Breakfast. One to two soft boiled eggs. 8.00 A.M. Zoolak and Vichy (equal parts) 8.00 A. M. Cup of tea with a little milk or mixed, one to two glasses (5 v i each cup of coffee (weak) sweetened with sac- glass) one to two whole wheat crackers; charin. Total, 6 ounces tea or coffee. one apple, or fruit only. One to two whole wheat crackers (Wheats- worth for example), i glass water, 5 y i 1 Acidosis the writer believes may result from too rapid fat reduction and too marked restriction of diet in some patients. The urine should be frequently examined during reduction cure. 918 DISEASES OF THE STOMACH AND INTESTINES drunk slowly, no butler, i orange or apple. 10.00 A.M. Water 8 to 1 2 ounces or Vichy 10.00 A.M. Water 8-12 or same one day and Kissingen the next, same amount Vichy or Kissingen. amount, i.oo P.M. No soup, no butter. Fish (boil- i.oo p. M. Plate of broiled rice (loogm.). ed, broiled or baked). loogm. (3 ounces). Small piece of fish (75 gm.) one Spinach 100 gm. (small dish). One whole wheat biscuit; fresh cooked fruit to two whole wheat crackers. One (no sugar). Tea 5 v i ( n <> sugar) but poached egg (no toast) fruit cooked with- saccharin and a little milk. out sugar. Tea vi (no sugar) sweetened with saccharin with a little milk. 3.30 P. M. Water, Vichy, or Kissingen, 3.30 p. M. Same liquids as diet i. 8-12. 6.30 P. M. Meat (hot or cold lean), two 6.30 p. M. Chops, small chicken, etc., chops or steak, chicken, turkey or duck but only too gm. One whole wheat about 150 gm.; one to two whole wheat cracker; spinach 100 gm.; lettuce, crackers; spinach zoo gm.; no butter, pickles, radishes; cooked fruit (no lettuce, pickles or radishes, black coffee, sugar). small cup, water 5 iv, compote or stewed fruits (no sugar). 9-9.30 P. M. Water, etc., 57~ 12 as at 3.30 9-9-30 P. M. Same liquids as diet i. P. M. No wine is given. It is possible to substitute another carbohydrate for rice, such as potato or some cereal. If the patient feels weak or is losing too rapidly, more carbohydrate and fat (butter) should be added to the diet. It can be used between meals. If indicanuria is present red meat should be cut out and the putrefactive condition receive appropriate treatment. Baths. The hot mineral baths (various alkaline salts) advocated, seem to act chiefly in the production of sweating. Some cases cannot undergo depressing treatment by the hot baths. Ordinarily duration of hot baths should be eight to fifteen minutes depending on the pulse and given daily or every other day. Several pounds of salt (5 lb.), or 3 pounds washing soda to the baths may be used. Some cases do well with the Turkish bath but with circulatory disturbances present, it should not be employed. The artificial Nauheim baths (Triton salts) are of value for the latter class. Exercise. To reduce the waist-line, extension of the arms above the head, holding the arms and knees stiff and flexing the hips, bending for- ward and endeavoring to touch the toes with the fingers, 15 to 25 move- ments A. M. and p. M. are of service. Dorsal posture with thigh flexion and leg extended may also be tried. Graded exercise should be given commencing at i-mile walk per day and gradually increasing to 2 to 3 to 5 miles daily. Horseback, bicycling, and gymnastics may be required. Massage and vibratory massage are of service. The bowels should be kept open for which purpose Carlsbad salts, phosphate of soda, and magnesium or sodium sulphate are useful. The spa treatment at Carlsbad or Marienbad may be advisable in some cases as the systematic mode of life enjoined at these resorts is most valuable. The daily quantity of urine should be watched carefully and if neces- sary additional water be given to preserve the normal secretion. Many of these patients are anemic and require iron. OBESITY 919 An excellent pill is 1^ Blauds iron pill gr. v. 1 Sod. arsen gr. Ho J Make salt with honey; silver coat. Sig. One t.i.d. after meals. If the circulation is poor, gr. ^ strychnin t.i.d. can be added. Thyroid extract (dried) gr. 3 to 5 t.i.d. may be useful if cautiously employed, in some cases. The detoxicated thyroid made by Burroughs and Wellcome or thyroidin, a French preparation are suggested. Pituitary gland extracts have also been employed. Phytolacca and many other preparations advocated, only act through disturbing the appetite and producing purgation. lodin with the alkaline iodids have been suggested. CHAPTER XXXVII INTESTINAL PARASITES MOST of the animal parasites that occur in mankind inhabit the intes- tinal canal. There are about fifty varieties, but all do not produce morbid conditions. Some cause a pathologic state locally in the intestines or by their toxins in the blood. There are no absolutely characteristic symptoms produced by these parasites, but they are detected by dis- covering either them or, in the case of worms, their ova in the stools. Gastro-intestinal disturbances, with or without anemia and with nervous symptoms, may result from their presence. There are two chief groups the protozoa and the vermes. In passing, it is interesting to note that certain fungi have spread from the mouth to the lungs, in some cases causing symptoms resembling tuberculosis. Thus, Castellani 1 has reported tropical bronchomycosis with the o'idium albicans and saccharomyces fungi, found in the sputum in such cases. PROTOZOA Amebae In addition to the dysenteric amebae which have been described, amebae differing slightly in certain characteristics from the dysenteric variety have been reported. They are said to give rise to no symptoms or at times to slight diarrhea. Musgrave is skeptical as regards the existence of non-pathogenic amebae. Sporozoa Coccidia are occasionally found in the stools. These are egg shaped, provided with a thin shell, are about 0.02 mm. long, containing in the interior a large number of nuclei, usually arranged in groups. They do not seem to have a pathologic bearing. Internal Psorospermiasis Psorosperms have" been found in the liver, spleen, kidneys, and ileum, producing a disease similar to that in rabbits. One patient, notably referred to by Osier, 2 was thought to be suffering from typhoid fever. The patient had diarrhea and enlarged liver and spleen. Masses resembling tubercles in the liver, spleen, and ileum were found to contain coccidia. Infusoria Cercomonas intestinalis is pear shaped, has a distinct nucleus, and eight flagellae. The head tapers obliquely and has a depression (Fig. 366). 1 Philippine Jour, of Sci., July, 1910. 2 Prac. Med., 1906. 920 INTESTINAL PARASITES 921 It is believed that this organism is liable to prolong existing catarrhal affection of the intestines. Fig. 366. Cercomonas intestinalis: A, larger, B, smaller, variety (Davaine). Trichomonas intestinalis is distinguished from the former by its greater size and the row of fine cilia on its periphery (Fig. 367). In fresh dejecta it shows active movements. Zunker 1 reports it in mushy dejecta 2 of yellowish-brown color and putrid odor. Dalley 3 reports a case Fig. 367. Trichomonas intestinalis (after Zunker). of gangrene of the lung in which traumatism of the chest was a factor. Numberous trichomonas actively motile were found in the sputum. Balantidium (Paramcecium) Coli. The body is oval shaped, measur- ing from 0.07 to o.i mm. in length, by 0.05 to 0.07 mm. in breadth (Fig. 368). The anterior end is slightly truncated, with a short peristome, generally funnel shaped, and opens externally near the anterior pole. When feeding it opens out and broadens, so one can see it is a mouth which leads to a gullet and not a simple furrow. The left border has long cilia, while the rest of the mouth is destitute of them. The surface of the cortical layer is surrounded by a cuticle covered with cilia. The interior structure consists of granular sub- stance. It contains a nucleus and contractile vacuoles. Fat and starch granules and, occasionally, red and white corpuscles may be found within 'the granular substance. The posterior end is rounded and contains the anus. Par- ticles may be observed to pass from it. The parasite can change its shape and possesses both forward and rotary motion, production occurs by division, budding, and conjugation. The balantidium is a parasite of the colon and cecum of the hog. Human infection probably occurs most frequently through the infusorium entering its host in the encapsulated state. When hog feces are dried and broken up, the encysted forms are scattered about and come in contact with the food or drinking-water. The parasite has been found in the city of London 1 Deuts. Zeits. f. Praktish. Medicin, 1878, No. i. 2 Lynch (N. Y. Med. Jour., May i, 1915) reports mild enteritis with intermittent diarrhea. Infection occurs from active forms from dejecta of rabbits and encysted forms from human beings. Infection per orem or rectum. Dysenteric diarrhea may occur (Rhamy, Jour. Amer. Med. Assoc., April 15, 1916) with death even. 3 Jour. Amer. Med. Assoc., Oct. 15, 1910. Fig. 368. Ba- lantidium coli (Malmsten). Re- 922 DISEASES OF THE STOMACH AND INTESTINES in the drinking-water. The disease frequently occurs after the preparation of sausage or the ingestion of uncooked sausage-meat. Malmsten first described the disease in 1857. Fig. 369. Balantidium cbli: Parasite more highly magnified, showing flagella (Strong). Musgrave has written on the subject, and for the most complete de- scription the reader should refer to R. P. Strong's 1 article, "The Clinical Fig. 370. Balantidium coli: A parasite passing through the walls of a gland of Lieberkiihn, rupturing the basement membrane. The parasite shows the striation referred to in the text (Strong). and Pathologic Significance of Balantidium Coli." He tabulates 117 cases. Brewer 2 reports a case occurring in a child aged five years in the Philippines. Other intestinal parasites were also present. 1 Bureau of Government Laboratories, Manila, Dec., 1904, No. 26. 2 N. Y. Med. Jour., June 18, 1910. INTESTINAL PARASITES 923 The balantidia frequently exist alone, though sometimes other para- sites, such as Bothriocephalus latus, Ascaris lumbricoides, Trichocephalus dispar, etc., may be associated. Bowman 1 reports cases. Harlow Brooks 2 found balantidia the cause of an epidemic of diarrhea among the orang-outangs in the New York Zoological Park. The lesions found in human beings seem to be an ulcerative colitis (Figs. 369-371), with the infection in the large intestine. In some cases there were swelling of the lymphatics of the mesentery and mesocolic glands and chronic adhesive peritonitis. Pulmonary, cardiac, renal, and cerebral complications may occur. Symptoms. The presence of Balantidia coli in the stools is usually associated with diarrhea; the feces are liquid, often contain mucus, some- times undigested food, and frequently blood. Diarrhea is persistent Fig. 371. Balantidium coli. The early lesions of the mucosa, consisting of des- quamation of epithelial cells of the glands, round-celled infiltration, etc. About a dozen parasites may be counted in this field (Strong). until treatment is directed against the parasite. Colic is frequent, nausea and vomiting may occur. The abdomen may be swollen. It is often painful on pressure along the colon, and on palpation the latter may feel thickened. Tenesmus is common. In chronic cases there are weakness, exhaustion, and emaciation; more or less anemia and edema of the feet and ankles. In the fresh stools the balantidia move about rapidly, but die in from one-half hour to two hours after the dejecta have been passed. Only two cases are reported in children; 25 per cent, of cases give the history of association with or caring for pigs or having eaten or prepared fresh sausage. Eosinophilia is present locally in the intestines and also in the blood. The temperature may be subnormal or at times of considerable height. 1 Jour. Amer. Med. Assoc., Dec. 2, 1911. 2 N. Y. University Bull, of Med. Sci., Jan., 1902. 924 DISEASES OF THE STOMACH AND INTESTINES The disease has been found in Germany, Sweden, Russia, France, the United States, and the Philippines. Balantidia probably occur more frequently than we suppose. The mortality was 30 per cent., but depended somewhat on the presence of other diseases which were associated in many of the fatal cases reported. In 33 per cent, there were cures, and improvement in the other cases. Treatment. 1 The following solutions for topical irrigations or enemata have been suggested: Ems 1 salt, by water enemata, 15 grains (i.o) are added to 1500 c.c. (i% quarts) of water, followed by quinin enemata, i quart (liter) of 1 1750 or i : 500 strength. Others suggest calomel, 2 grains (o.i) t.i.d. for two days only, or naphthalin, 5 grains (0.3) t.i.d., daily by mouth, with tannic acid, i dram to i pint (4.0-500 c.c.) of water, by injection, every day. Acetic acid enemata acetic acid, 50 grains (3.3) to 2 quarts (liters) of water at 37C. once or twice a day, with tannic acid 5 grains (0.3) t.i.d., by mouth, proved useful in some cases. Another combination is salicylic acid, 15 grains (i.o), and sodium sulphate, ^ ounce (16.0), morning and night, by mouth, with enemata twice a day of salicylic acid,(i :iooo), or salol, by mouth, 5 grains (0.3), four or five times a day, with salicylic acid (i :iooo), or boracic acid ene- mata i dram (4.0) to the quart (liter) of water, are suggested. Sodium bicarbonate (2 per cent.) enemata, followed by a salicylic acid (i : 2000-1 : 1000) enema, with salol, 5 grains (0.3), and tannalbin, 5 to 10 grains (0.3-0.6), by mouth, each several times a day, have given good results. Thymol (i : 2500), acetozone (i : 1000), quinin bisulphate (i : 500), administered by enema or irrigation, as in dysentery, with the use of salol and tannin preparations by mouth, are valuable. One might also administer small quantities of acetozone (i : 1000) by mouth. VERMES Cestodes (Tapeworms) ; Hydatid Disease. The adult parasites live in the small intestine of man; the larval forms, in the muscles and other organs. The most important varieties of tapeworms found in human beings are the Taenia solium, Tgenia mediocanellata, and the Bothriocephalus latus. The symptoms produced by these varieties of tapeworms are about identical, except in the case of the bothriocephalus, which at times gives special symptoms. The parasites are found at all ages, are not uncommon in children, and occasionally are found in sucklings. They may cause no disturbance, and one may only learn of their presence by noting segments of the tenia in the dejecta. Eosinophilia is present. In other cases there may be general as well as intestinal disturbances. There may be pressure in the pit of the stomach, abdominal pains, 1 For Trichomonas. Ipecac, emetin by hypo, and thymol, with enteroclysis with i per cent, hexamethylenamin solution and 5 per cent, argyrol applied to rectal ulcers. INTESTINAL PARASITES 925 ravenous appetite (bulimia), nausea, at times loss of appetite, occa- sionally vomiting. Diarrhea is sometimes present or there may be constipation. In women and nervous patients we may see mental depression and even hypochondria. There may be dizziness, headache, fainting spells, chorea, convulsions, and even epileptic attacks. Some patients may emaciate, feel weak, and suffer from palpitation. The bothriocephalus may cause a severe and even fatal anemia (per- nicious), with poikilocytosis and nucleated red blood-corpuscles; and with it there may be edema of the feet and eyelids and hemorrhages from the mucous membranes. The metabolic products of this worm probably have a hemolytic action. The diagnosis can only be made by discovery of the segments of the parasites or their eggs in the stools. General Description of the Tapeworm. It has a scolex or head, which may live for years even when detached from the rest of the body, an ob- long neck, and detachable segments (proglottides). These vary in size and shape and possess the power of motion. The worm is flat and devoid of mouth or intestines. It grows by alternate generation through ger- mination of a pear-shaped primary host (head), and remains united to the latter for a time as a colony of band-like shape. Each segment forms a sexually active individual. The proglottides gradually increase in size as they become more distant from the head, and then diminish again toward the extremity. The tapeworm is an hermaphrodite. On its head are four sucking disks, by which it attaches itself to the mucosa of the intestines. By means of pores it derives its nourishment from the chyme. The older proglottides contain many fructified eggs. These are emptied at intervals into the intestinal canal and appear in the dejecta. The ovum contains an embryo, which requires for its development an intermediary host. After reaching the stomach the envelope is dissolved by the gastric juice. The embryo is set free and finds its way by the lymphatics or blood-vessels to some place (usually the muscles) where it settles. It here surrounds itself with a sac, which may later be surrounded by a calcareous deposit. In this condition it is called a cysticercus or measle. When the measle reaches the stomach of a new host it opens, and its scolex enters into the small intestine, where it develops into a full- grown tapeworm. Tcenia Solium. Armed tapeworm or pork tapeworm. This is not common to North America, but more frequent in Europe and Asia. When mature it is from 6 to 12 feet (2-4 meters) or more long. The head is smaller than the head of a pin, spheric, and provided with four sucking disks, in the middle of which is the rostellum and a double row of hooklets, from twenty-four to twenty-six in number, and hence is called the armed tapeworm (Fig. 372). The neck is narrow and thread-like, nearly i inch long. The body is divided into segments, which possess both male and female generative organs, and at about the four hundred and fiftieth they become mature 926 DISEASES OF THE STOMACH AND INTESTINES and contain ripe ova. The segments are about i cm. in length and from 7 to 8 mm. wide. The worm attains its full growth in about three to three and a half months, about which time the segments are con- tinuously shed and appear in the stool. The uterus forms a straight median tube in each segment, giving off five to seven branches on each side. The branches are undivided at first, but finally ramify as a tuft (Fig. 373). The eggs are rounded and provided with a thick shell (Fig. 374). Rarely the cysticerci (measles) are found in man, as in the muscles, brain, eye, and skin. Fig. 372. Head of Taenia solium, rostellum with hooks; suckers (Mosler and Peiper). Fig. 373. Mature segments of Taenia solium; proglottides; uterus and branches (Mosler and Peiper). In the muscular system they cause pain, numbness, weakness, and symptoms a little like peripheral neuritis. In the ventricles of the brain irritative symptoms may result. In one case diabetic symptoms were reported. They can be recognized in the eye. Taenia solium was formerly believed to exist alone, but several have been found together. Tcenia saginata, or mediocanellata, the unarmed or beef tapeworm. Fig. 374. Eggs of Taenia solium, showing thick shell (Mosler and Peiper). This is the most common form seen in America as well as abroad. It is longer, thicker, and wider than the Taenia solium. It may attain a length of 15 to 20 feet (approximately 4^ to 6 meters) or more. The head measures over 2 mm. in breadth, has four large sucking disks, but no booklets and no rostellum (Fig. 375). It is square shaped. The ripe segments are from 17 to 18 mm. in length and from 8 to 10 mm. in breadth. The uterus consists of a median stem, with from about twenty to thirty-five lateral branches (Fig. 376). Malformations of the INTESTINAL PARASITES 927 Tsenia saglnata have been reported. MacCallun 1 refers to an interesting case showing lateral splitting of the segments. The ova are larger and the shell thicker, and possibly slightly more elliptic, but the two forms are difficult to distinguish by their ova. The measles (cysticerci) occur in beef and are smaller than those of the Taenia solium. Human beings acquire this worm by the consumption of raw beef. Fig. 377. Bothriocephalus latus: c, a, Head; b, neck (Blanchard). Fig. 375. Scolex of Taenia saginata (M osier and Peiper). LH3 V Fig. 376. Segments of Taenia saginata (Mosler and Peiper). Fig. 378. Bothriocephalus latus (Eich- horst). Bothriocephalus Latus (Taenia Lata, or Pig Head). This is found in certain districts bordering on the Baltic Sea, in Holland, Switzerland, and Japan. A few cases have occurred in the United States, believed generally to have been imported. The parasite is large and long, measuring 25 to 30 feet or, more ap- proximately, 7^ to 9 meters. 1 Med. Rec., Mar. 23, 1912. 928 DISEASES OF THE STOMACH AND INTESTINES The head is elongated, almond shaped, being about 2 mm. long and i mm. broad; it has two grooves, probably suckers, on its flat surface (Fig- 377). It has no booklets. The neck is narrow and short, about 2 cm. in length, and passes at once into the body segment. The body is thin and flat (Fig. 378). The full-grown proglottides are nearly square and show the sexual organs in the center. The uterus presents as a median dark line, with four to six lateral branches, looking like a star or rosette. The eggs are oval, round, with a thin membrane and a lid (Fig. 379). They measure 0.07 mm. long and 0.04 mm. in width. The larvae develop in the peritoneum and muscles of pike especially, and of fish such as the turbot, perch, and trout. Infection occurs through eating insufficiently cooked fish. Taenia lata occur in the small intestine of men and rarely in dogs. A severe and even fatal form of anemia may result from this worm. There are a few rare forms of tapeworms occasionally found in human beings. Tcenia nana (Hymenolepsis nana) occurs chiefly in Italy, occasionally in Egypt. It is the smallest tapeworm found in man, measuring 10 to 15 mm. long, and may have nearly two hundred segments. The head has four sucking disks, a rostellum, and about twenty-four booklets in a single row. Proglottides are short and broad. It is found more frequently in children, and occurs in large numbers in the small intestine. Nervous disturbances, fainting spells, Fig. 379. Eggs of Bpthriocephalus an d even epileptiform attacks are pro- latus (Mosler and PeiperJ. , , ^, , duced thereby. The Davainea Madagascariensis (Taenia Madagascar iensis) is a rare form of this worm. Tcenia cucumerina (Elliptica, or Dipylidium Caninum). This is small, of cucumber shape, occurs frequently in the intestines of the dog, and has been found in small children. The larvae develop in the lice and fleas of the dog. The worm is 10 to 40 cm. long and about 3 mm. wide. Tcenia Flavopunctata (Hymenolepsis Diminuta). This has been met with in about 12 cases. The worm is 2 to 6 cm. long and about 3 mm. wide. Its head is small, club shaped, and provided with sucking disks. It is common in rats. The larvae 'develop in Lepidoptera and in beetles. Bothriocephalus Cordatus. This tapeworm resembles the Bothrio- cephalus latus, except that it is shorter and the head merges into the proglottides without an intervening neck. It occurs in the intestines of men and dogs in Greenland. Other types of tapeworms occur, but they are excessively rare and not found in Europe or America. Echinococci are the larvae of the Taenia echinococcus of the "dog. The latter is a tiny cestode 4 or 5 mm. long, consisting of three or four segments, of which the terminal one alone is mature. The head is small, provided with four sucking disks, and a rostellum with a double row of booklets. INTESTINAL PARASITES 929 As a result of the ingestion of these parasites, cysts develop in various parts of the human organism, as in the liver, muscles, etc. These cysts contain scolices, the head of the taenia presenting four sucking disks and a circle of hooklets. Cysts have been passed per rectum. The disease is common to Ice- land, not uncommon in Europe, but rare in this country. The reader is referred to Echinococcus Disease in any work on Practice of Medicine. Treatment of Tapeworms. To escape infection avoid raw or medium- done meats, pork, and fish. One should not trust to meat inspection alone. Thorough cooking of the meat is the only guarantee of extinction of the cysticerci. All worms or fragments removed should be destroyed by burning, and if one handles the proglottides or ova, the hands should immediately be disinfected; also the stools. For about two days before administering a vermifuge the patient should be kept on a scanty diet, consisting of broths, soups or milk, with a few crackers. The night before, no food; and in the morning a cup of tea or coffee, followed in about an hour by the vermifuge. Calomel, 5 grains (0.3), castor oil, ^ to i ounce (15.0-30.0), or a saline cathartic should be given daily for a couple of days previously. Male fern is considered quite efficient. Extract of filix mas, ethereal, i> to 2^ drams (6.0-10.0), mixed with simple syrup; follow in a couple of hours by a saline cathartic or castor oil. The following have also been suggested: Oleoresin aspidii (male fern), > to i dram (2.0-4.0), in capsules, coated with keratin; a few hours later castor oil, i ounce (30.0). Filicic acid (filmaron), an amorphous principle from root of male fern, insoluble in water. It should not be administered in fatty oils or alcohol, as they dissolve it and it is toxic. Give in capsules, 7^ to 15 grains (0.5-1.0); follow by a saline purgative (not castor oil). Pomegranate root is efficient, given as an infusion of the bark; 3 ounces are macerated in 10 ounces of water and then reduced to one-half by evaporation. The entire quantity is taken in divided doses within an hour or more. It is effective, though sometimes producing colic. The active principle of the root, pelletierin, 4 to 7^2 grains (0.25- 0.5), in sweetened water, to which tannin, 5 grains (0.3), can be added may be given as a substitute. These remedies are followed in a couple of hours by a purge. Pelletierin tannate can be secured and given in the same dose. Pumpkin seeds (Semina cucurbitae), 3 or 4 ounces (90.0-125.0), should be bruised and macerated for twelve to fourteen hours.; then mixed with a little grape-sugar, diluted with milk, i pint (500 c.c.), and take in two doses about half an hour apart; then follow in two hours by castor oil. Turpentine, Oleum terebinthinae (spirits of turpentine), i ounce (30.0), in honey or with sugar, follow with a glass or two of milk; and two hours later a cathartic. I have found pine-needle oil (Gardner's), i to 2 drams (4.0-8.0), also efficacious. Cusso (kousso). Cusso pulv., H ounce (16.0) with mel depuratum (honey), ^ ounce (16.0), is useful. 59 930 DISEASES OF THE STOMACH AND INTESTINES Or cusso can be mixed with sugar, water, or lemonade, and taken in divided doses within an hour. Though cusso is cathartic, it is preferable to follow in two hours with a dose of castor oil. Kamala. Pulv. kamala, i to 2 drams (4.0-8.0), suspended in syrup or in wine. This preparation is purgative and may cause griping, nausea, and vomiting. The dose should be distributed over an hour. Castor oil may be given later. Cocoanut has been recommended as a vermifuge; the milk and al- bumin of an entire nut should be taken within an hour. Naphthalin, in capsules, 10 to 30 grains (0.6-2.0), in divided doses, within a few hours, is another vermifuge. Salol, 45 grains (3.0), in capsules, in divided doses, has been recom- mended. A combination of these remedies is often effective. Thus: take % ounce (16.0) of an infusion of pomegranate seeds; pumpkin seeds, i ounce (30.0); pulverized ergot, i dram (4.0), and boiling water 10 ounces (300 c.c. approximately). Make an emulsion of male fern i dram (4.0) ethereal extract with acacia powder. Mix the emulsion and infusion and take fasting at 9 A. M. Follow a couple of hours later with castor oil or a saline cathartic. Osier recommends the addition of croton oil, 2 minims (0.118), to the above, but I think this rather too active treatment. Male fern, pumpkin seed, pomegranate, and turpentine are the best remedies. About two hours after the vermifuge a cathartic, such as citrate of magnesia, i to 2 drams (4.0-8.0), or magnesium sulphate, larger doses, or some other saline cathartic, or castor oil, i to 2 ounces (30.0-60.0), should be given. The head of the tapeworm should be looked for, as the parasite will regrow if this is not removed. In some cases this is difficult to find. Children require proportionately smaller doses, according to their age. Care must be exercised with patients who are debilitated, recently con- valescent from typhoid, or have severe intestinal disorders. It may be necessary to postpone treatment. Trematodes (Fluke Worms) ; Distomiasis. Flukes are found in the lungs, liver, small intestine, and in the blood; in the latter case affecting chiefly the urinary system and the rectum. The trematodes are solid worms of leaf or tongue shape. They possess a clinging apparatus in the form of oral and ventral sucking cups, which vary in number. Sometimes they also have hook or clasp-like projections. The intestinal canal is without an anus and is split like a fork. They are generally hermaphroditic. Flukes are found in China, Japan, India, Egypt, Arabia, and Persia, and imported cases have been found in Canada and the United States. They have been found in the cat, dog, and hog in this country. Five species of liver fluke are known to occur in man. The Distoma conjuncture, the Indian liver fluke, usually described, the Distoma lancea- tum (lancet fluke), and the Distoma sinensis are the most frequent occurring in the liver, the last being most important. The Fasciola hepatica, common to ruminants, and the Opisthorchis INTESTINAL PARASITES 931 (Distoma) felineus, occurring in Prussia and Siberia, and found in cats in Nebraska, are the other varieties. In general, we may say the liver fluke is of leaf shape. It may vary in length from 10 to 20 mm. by 2 to 5 to 10 mm. broad. The cephalic end Fig. 380. Distoma hepaticum, with male and female sexual apparatus; X 2^ (Leuckart). projects like a beak and has a small cup-like sucker, in which lies the mouth. Behind this, on the ventral surface, is a second cup, and between the two is a special orifice. The uterus appears as a convoluted bag behind the posterior sucker. On each side of the body are the ovisacs and the branched testicular canals (Fig. 380). The eggs are oval, 25 to 30 ju long by 15 to 1 7 IJL broad, of brown color, with a sharply denned operculum (lid) (Fig. 381). The Distoma lanceolatum, another variety of liver fluke, has a lancet shape and the head is not especially marked off from the body (Fig. 382). The eggs are rather small, 0.04 mm. long (Fig. 383). Young children suffer more frequently from liver fluke; sometimes whole families or villages are attacked. Fig. 381. Eggs of Distoma There is an irregular diarrhea; there may hepaticum and Distoma lanceo- . T ,, T r ,. latum, moderately magnified or may not be blood. The liver enlarges. (Heller). There are often pain and an intermittent jaundice, but not much fever. Anasarca and ascites come on later. The ova of the parasite are found in the stool. Intestinal Distomiasis. In India the Distoma fasciolopsis has been found in a number of cases in the small intestine, with diarrheal symptoms. Fig. 382. Distoma lanceolatum with its inner organs; X 10 (Leuckart). Hemic Distomiasis; Distoma Hcematobium; Bilharziasis; Schistosoma H&matobium; Bilharzia Hamatobia. Endemic hematuria, particularly in Egypt, had been known for many years, when in 1851 Bilharz dis- 932 DISEASES OF THE STOMACH AND INTESTINES covered the parasite of the disease. The blood fluke prevails in South Africa (the Transvaal); in North Africa, especially in Egypt; in Arabia, Persia, and the west coast of India. It is prevalent in Japan. It has Fig. 383.- of Distoma lanceolatum shortly after the formation of a shell; X 400 (Leuckart). been observed in Porto Rico and in the Philippines. It has been reported 104 times on the Isthmus of Panama according to statistical records from the Chief Sanitary Office from 1904-1909 inclusive. It has also occurred in Antigua, Trinidad, Demarara, Barbadoes. Jamaica, and Dutch Guiana. Brayton 1 reports several interest- ing cases from the Ancon Hospital on the Isthmus. The disease is rare in the United States, only seven cases having been reported, In addition, seven cases occurred among the Boers who were on exhibition in this country after the African War. The first case of rectal infection reported in the United States was in a German, who evidently contracted the disease in Brazil and who was Fig. 384. Male and female of Bilhar- zia hsematobia (Loos). Fig. 385. Eggs of Distomum hsema- tobium (Bilharzia haematobia), length, 0.12 mm.; breadth, 0.05 mm.: a, Egg with lateral spine; fc, egg with terminal spine; X 150 (after Bilharz). treated at the German Hospital. He suffered from mixed infection Strongyloides intestinalis, Trichocephalus, and Schistosoma haematobium, reported by L. Blumgart, 2 of New York. 1 Jour. Amer. Med. Assoc., April 30, 1910. 2 Med. Rec., April 6, 1907. INTESTINAL PARASITES 933 The Schistosoma has separate sexes and carries the female in a gyneco- phorous canal. The male is from 12 to 14 mm. long. Its body has ciliated warts on the integument, but otherwise is smooth, and in the pos- terior portion is rolled up into a tube, which serves for the reception of the female (Fig. 384). There is a sucker at the anterior end and a second one posterior to it on the ventral surface. The female is from 16 to 18 mm. long and nearly cylindric. The eggs have a terminal or lateral spine (Fig. 385). The trematode is most abundant in the blood of the portal system, while the ova lodge in the capillaries, especially of the bladder, urinary organs, rectum, and lungs. In the stools of the case reported the spine was placed laterally on the ova. Infection is now considered to take place in two ways either by the gastro-intestinal tract, through infected food or water, or through the skin by bathing in infected streams. The parasite reaches the portal system, where it develops. The males, bearing the females, creep to various parts, particularly the bladder and rectum. The eggs are laid in the tissues, but wander like other sharp foreign bodies, and escape with the urine and f eces. The eggs in the tissues cause irritation, fibroid changes, and papillomata in the bladder and rectum. Hematuria and bladder irritation, chronic cystitis, tenesmus, mucus and blood in the stools, ulcerative proctitis, calculi in the kidney and bladder, peri-urethral abscess and perineal fistula, vaginitis, inflammation of the ureters and seminal vesicles may all occur. Bilharzial colitis has been reported. In the lungs the blocking of blood-vessels from the ova and the surrounding infiltration give rise to deposits which may be mistaken for tuberculosis. Cirrhosis of the liver and biliary calculi may be caused by the presence of the parasite. Anemia is present and eosinophilia is quite marked. In 1904 there was described a new blood fluke, Schistosoma Cattoi, or Japanicum, found in Japan. It lives chiefly in the vessels of the ali- mentary canal and ulcerative lesions are found therein. The ova appear in the feces. Katsurada has studied numerous cases. This condition is known in Japan as the "Katayama disease," from the name of a town in which it is quite prevalent. Catto described certain bodies he found in a Chinaman in 1904, and the new fluke is sometimes called by his name. Paul G. Woolley 1 has reported a case occurring in the Philippines, and has given an excellent description of the disease. The worms are characterized by the absence of ciliated warts on the integument, which are a feature of the Schistosoma, hcematobium. The worm averages 10.43 mm - l n g- The eggs are smaller, brown in color, have blunter ends, and no spine. Katsurada gives the most definite reports of the disease "Katayama," according to Woolley: "Defective physical developments is the rule in the affected children. Diarrhea is usually the first symptom to be noted, while anemia and ascites generally follow later; the most striking feature is the shape as- 1 Philippine Jour, of Sci., Jan., 1906, vol. i, Xo. i. 934 DISEASES OF THE STOMACH AND INTESTINES sumed by the trunk. The hypogastric region seems to shrink, while the epigastric enlarges, a transverse furrow forming directly above the um- bilicus, so that the general appearance of the abdominal region is that of an inverted gourd. Dilatation of the epigastric region and of the lower part of the thorax were noted even in patients whose liver and spleen were not much enlarged. The commonest symptoms are an initial increase in the size of the liver, followed by a decrease, a secondary enlargement of the spleen, a mucosanguineous diarrhea, severe attacks of ascites, and progressive anemia." Katsurada found the ova of the parasite under discussion and also those of Trichocephalus dispar, Uncinaria, and Ascaris lumbricoides in the stools of his patients. The rectum and appendix were the parts chiefly affected, but the ova were found in the subperitoneal layer, the submucosa, and mucosa, es- Fig. 386. Schistosoma Japanicum. Ova in mucosa and submucosa of large intestine. Shows atrophic and infiltrated condition of mucosa. Hematoxylin (Woolley). pecially in necrotic areas, from the cecum to the anus. Adult trematodes were found in the blood-vessels. In Woolley 's case there were also amebae and the ova of the uncinaria; but in the fibroid tissue of the submucosa of the large intestine there were many ova of the Schistosoma Japanicum surrounded by round-cell infiltration (Fig. 386). A type of cirrhosis was produced in the liver. Splenomegaly, ascites, dysentery (specific), and possibly Jacksonian epilepsy may be produced by these trematodes. The disease is probably water-borne, originating in rice-fields or irrigated gardens, from human fertilizer. Infection may occur through the skin or by the gastro-intestinal canal. Treatment. The extract of the male fern is recommended for dis- tomiasis and the treatment as of tapeworm. Nothing has been found for the treatment of the parasite in the blood. The author would suggest the trial of urotropin, 1 10 grains (10.6), and sodium benzoate, 10 grains 1 Hexamethylenamin in same dosage may be substituted. INTESTINAL PARASITES 935 (0.6), four to six times a day. The latter lessens the irritation of the urotropin (hexamethylenamin) . The inflammation of the bladder, colon, and rectum should be treated as indicated by irrigation, etc. Solutions, as described under Proctitis and Colitis, can be employed for the latter complications. Nematodes (Round Worms). Round worms have a slender, cylindric, at times a filiform body, with neither segments nor appendages. The integument is thick and elastic. The mouth is at one extremity and furnished with either soft or horn-like lips. The alimentary canal extends through the entire body and terminates in an opening on the ventral side near the posterior extremity. The sexual organs and their orifices are on the ventral surface. The female aperture is at the middle of the body, while in the male the sexual orifice is near the anus. The males are usually smaller than the females. Ascaris Lumbricoides (Round or Spool Worm). This is one of the common parasites observed in man. It is cylindric in shape, pointed at both ends, and of a yellowish-brown or slightly reddish color. It varies from 4 to 12 inches (10-30 cm.) in length, the female being as large as 12 inches (30 cm.), while the male is only one-half or two-thirds the length, 8 inches (20 cm.), and frequently much smaller. The posterior extremity of the male is bent in the shape of a hook and furnished with two spicules or chitinous processes (Fig. 387). The mouth has three muscular lips provided with very fine teeth. The worm is transversely striated and has four longitudinal bands. The sexual opening of the female is anterior to the middle of the body. The eggs when ripe have a double shell, and around this is an albuminous envelope, irregular in shape, studded with excrescences (Fig. 388). The long diameter of the ovum is about 0.075 mm< an d 0.058 mm. in width. Atypic (unfertilized) eggs have been described by O. T. Logan 1 of China. When taken from the uterus it has not the typic thick shell but is granular, elliptic, and enclosed in a delicate membrane (Fig. 389). In the feces, the yolk is not finely granular, but coarsely globular; the albuminous coat is less voluminous and projects from the shell like blunt saw teeth. The unfertilized egg 2 is longer and narrower than the fertilized egg and markedly elliptic, with a tendency to flatten at one or both ends. It is occasionally oval, but never round. An irritating, odoriferous substance is formed by the round worm. Huber 3 states that it may occasion urticaria in those predisposed to this symptom. Peiper suggests that the nervous symptoms, sometimes resembling meningitis, may be due to this poison; and Chaufard and Marie report fever, intestinal symptoms, diarrhea of intermittent character and foul breath, so-called typholumbricosis, in connection with these worms. The fever may continue for a month or more. The parasitic life history is direct, by ingestion of the ova, with no intermediate host. The parasite occupies the upper part of the small intestine. Usually not more than one or two are present, but they may occur in enormous numbers. 1 N. Y. Med. Jour., Dec. 21, 1907. 2 Ibid., Aug. 19, 1905 (Wellman) ; Reference Handbook Med. Sci., p. 502. 3 Twentieth Century Practice of Medicine, vol. viii, p. 583. 936 DISEASES OF THE STOMACH AND INTESTINES Infection usually takes place by eggs in the soil near dwellings, in the drinking-water, and especially in raw foods, such as salads and fruits. These worms occur more frequently in children from three to twelve years of age and in the poorer class. They are not so frequent in adults. Fe- males seem more frequently infected. Migration. The worms may crawl into the stomach, whence they may be ejected by vomiting; or they may pass through the esophagus and enter the pharynx, whence they may be withdrawn. The worm has entered the larynx and has produced fatal asphyxia, or into the trachea and lungs and caused gangrene. They have passed through the Eu- stachian tube and appeared at the external meatus. They have been found in the bile-ducts, pancreatic duct, the gall-bladder, and even in the liver, where they produced fatal abscess. They have entered hernial sacs, Fig. 388. Eggs of Ascaris lumbricoides, double shell; albuminous envelope, magni- fied (Hosier and Peiper). Fig. 387. Ascaris lumbricoides: a, Body, b, head; c, eggs (after v. Jacksch). Fig. 389. Unfertilized egg of Ascaris lumbricoides; X 500 (Logan). perforated intestinal ulcer, and some claim even the healthy bowel wall has been perforated by them. Appendicitis has been attributed to the ascaris; and obstruction of the bowel has been produced by a large mass of ascarides. Symptoms. They may produce no symptoms. In children, irri- tability, restlessness, picking at the nose, grinding the teeth, twitchings or convulsions, have been attributed to them. Anorexia, nausea, irregular bowel action, meteorism, irregular pulse, and black rings around the eyes may also occur. In rare instances progressive anemia has been ob- served. Itching of the nose may be present. The worms probably produce local hyperemia of the intestinal walls. Hemorrhage from the bowel, simulating an occult ulcer, may be pro- duced by a lumbricoid worm. The following interesting case is reported INTESTINAL PARASITES 937 to me by H. D. Meeker. The possibility of hemorrhage from an occult duodenal ulcer was suggested. The author was present during part of the operation and examined the worm. Mrs. L. P. consulted me in April, 1911, for irregular bleeding from the bowel. She gave the following history: Age twenty-five years, housewife, married four and a half years, no children, family history negative. She could recall no serious illness of any sort. Four years ago a slight bleeding from the bowel was noticed, a few weeks later a second hemorrhage occurred, and the patient purchased medicine for piles. There was no pain associated with the attacks. The hemorrhages continued at intervals of one to six weeks, the amount of blood varying from a mere trace to nearly a quart in twenty-four hours. The blood was always dark in color and usually clotted. The pa- tient, after several weeks of treatment by her family physician, was sent to a Boston hospital where she remained a month without apparent benefit. She then went to Baltimore to live, where she received both private and hospital treatment. Not finding relief at the hands of the various internists, she sought help from Christian Science with equally disappointing results. The day prior to admission to the Red Cross Hospital the patient had passed approximately 20 ounces of blood-clots. She was anemic, her blood count showing3, 500,000 red blood-corpuscles. Hemoglobin, 70 per cent. Aside from an indefinite tenderness of the abdomen, she gave no sub- jective symptoms, appetite and digestion had always been good, bowels inclined to be loose. Stomach washings and examination of the stools were negative so far as throwing light on the cause of the condition was concerned. The sigmoidoscope revealed a healthy intestinal mucosa. In view of the negative, subjective and objective symptoms, and yet persistent bleeding, exploratory laparotomy was proposed and welcomed by the patient. A small right Battle incision was made in the mid-abdomen, permitting exploration in both directions. All the abdominal viscera were examined and found normal with the exception of the ileum as hereafter described. The small gut was examined inch by inch and appeared normal up to a point about 5 feet from the ileocecal valve where an area about 5 feet long was found deeply injected. At the mesenteric border the condition of the tissue sugggested a healed ulcer. Another in- jected area was found 2 feet nearer the valve about 6 inches in length. Within this area doubled on itself, was felt a moving worm. The intestine was opened after observing the usual protective technic, and the worm extracted. A small bleeding was observed at the mesenteric attachment of the gut, this was excised, and the opening into the ileum closed. No other pathological condition of the abdominal contents was observed. The worm was of the Ascaris lumbricoid family, a male measuring nji inches. The patient made a prompt recovery. She has been seen at intervals of two weeks and up to the present writing has had no further bleeding. Her hemoglobin has increased 10 per cent. A second blood count has not been taken. Eosinophilia was never present at any time nor were any ova or other intestinal parasites discovered. The various hemor- rhages which occurred for a period of four years were evidently due to perforations of the gut vessels by a single male worm. Chronic intestinal obstruction, gradually becoming acute, may be caused by a large mass of the ascaris lumbricoides. Such a case has been described under Acute Intestinal Obstruction. Allen 1 of Hannadam, Persia, describes an interesting case of intra- abdominal abscess apparently due to the ascaris. Enterospasm from ascarides has been reported by Schaal and Swain. 2 In case of the former laparotomy was performed for suspected perforation of gastric ulcer. Diagnosis. This is made by the detection of the worm or of its ova in the stools. Treatment. The stools should be disinfected by carbolic (5 per cent.) 1 Journal A. M. A.. June 21, 1913. 2 Miinchener medizinische Wochenschrift, Sept. 26, 1912, lix, No. 48. 938 DISEASES OF THE STOMACH AND INTESTINES or bichlorid (i : 1000) solution to destroy the ova. The hands should be disinfected and all food protected against infection. It is preferable to administer a simple saline cathartic for a couple of days and keep the patient on a light diet before administering the anthelmintic. Santonin is the best remedy. It can be given mixed with sugar in doses of ^ to % grain (0.022-0.032) for a child, and 2 to 3 grains (0.13 0.194) for an adult, followed by calomel or a saline purge. It can be administered in divided doses; thus, santonin, i grain (0.06), three or four times a day, followed by a purge; or santonin, 3^ grains (0.2), with castor oil, 2 ounces (60.0); give i teaspoonful for a small child; Fig. 390. Oxyuris vermicularis: Female, enlarged (Mosler and Peiper). i dessertspoonful for a larger child; i tablespoonful for an adult, two or three times daily (Einhorn). Santonin, y z grain (0.022); hydrargyrum choridum mite, i to 2 grains (0.065-0.13). Give one powder t.i.d. Yellow vision (xanthopsia) occasionally follows the use of santonin. Chenopodium (powdered seeds), in doses of 15 to 30 grains (1.0-2.0), or oleum chenopodii, 2 to 10 minims (0.118-0.592), followed by a cathartic, have been employed. Thymol, 7% to 30 grains (0.5-2.0), given in capsules in divided doses and followed by a saline cathartic, has been recommended. Fig. 391. Oxyuris vermicularis, natural size: i, Female; 2, males; 3, ovum, magnified (Vierordt). Enteroclysls with water, to which a few drops of benzine are added, has been suggested; but I scarcely see the benefit, as the habitat of the worms is in the small intestine. Ascaris Mystax. This is a round worm resembling the ascaris lum- bricoides, but smaller and thinner. It is found chiefly in cats and rarely in man. No special symptoms result. Oxyuris Vermicularis (Thread-worm; Pin-worm; Seat-worm; Awl- tail; Maggot-worm). This parasite occupies the rectum and colon. It is white and filiform. The male measures about 4 mm. (y 6 inch) in length and the female about 10 mm. (% inch) (Figs. 390 and 391). It has three small nob- INTESTINAL PARASITES 939 like lips. The female has two uteri, passing backward and forward from the end of the vagina. The opening of the latter is situated above the middle of the body. The eggs are 0.05 mm. long and about 0.02 mm. wide, with granular contents and white shell (Figs. 391 and 392). Huber and others claim that they are generally deposited outside the body, so that feces rarely contain them; while Osier holds that they are usually found in the feces in large numbers. These worms occur at any age, though most commonly in children. The worms are found in the feces, at the anus, or in the vagina. Infection takes place through drinking-water or through salads, radishes, fruits, etc., the ova being dried upon them, or through the un- washed hands of the host. The eggs of the oxyuris reach the stomach, when the shell opens and the embryo migrates into the small intestine. After fructification the females pass along the canal to the cecum, where they remain until the eggs are ripe, and then pass on downward, chiefly to the sigmoid and Fig. 392. Segmentation and development of embryo of Oxyuris vermicularis (Heller). rectum. The oxyuris may traverse the intestinal wall and have been found in the peritoneal cavity, where they may form verminous tubercles in Douglas' fossa or perirectal abscesses. Symptoms. The oxyuris produce great irritation and itching around the anus, particularly at night. The pruritis ani is pronounced. The patient becomes nervous and irritable, sleep is disturbed. There may be anorexia, nausea, dizziness, palpitation, pollutions in the male, oc- casionally diarrhea, and at times anemia. Sometimes the parasites enter the vagina and cause irritation, or nymphomania. Diagnosis. The worms are easily detected in the feces and are readily diagnosed by their appearance and location through inspection of the anus. Treatment. Cleanliness of the hands of the infected person and dis- infection of stool, clothes, and bedclothes are important. Sleeping with an infected case should be forbidden. Raw fruits should be cleaned and peeled, salads, etc., thoroughly washed. One should not eat out of the same vessels as the patient. 940 DISEASES OF THE STOMACH AND INTESTINES Santonin, administered by the same method as for ascaris, is an ex- cellent remedy. Local treatment by enemata of water, i quart (liter) containing 5 to 10 minims (0.296-0.592) of benzine, or vinegar ij-^ to 2 ounces (45.0-60.0), or thymol (i : 2500) by enema, or fluidextractof quassia, 10 to 30 minims (0.2921.704) to the quart; or soak a quassia cup in water for half an hour and inject quassia water, i pint (500 c.c.). An enema of spirits (oil) of turpentine, i dram (4.0) to i pint (500 c.c.) of water, is of value. These injections should be given with hips elevated and retained fora short period. Cold injections of strong salt water are of service in children. Carbolic acid I believe unsafe. Injections of limewater are of use. Blackwash calomel, i dram (4.0); lime-water, i pint (500 c.c.) locally, externally; lead-and-opium lotion, unguentum belladonna, vase- lin, or 1$. Unguent, belladonnae 3ij (8.0); Tr. aconite radix 3ss (2.0); Zinc oxid gr. xv (i.o); Unguent, aq. rosae q.s. 5 j (30.0). M. Sig. Ft. ung. External use to anus. Cocain, J grain (0.32), can be added to this. These preparations lessen itching. The saline enemata, given frequently, are of use. Ankylostoma (Anchylostoma) Duodenale; Uncinariasis ; Hook-worm Disease; Miner's Anemia; Egyptian Chlorosis; Dochmius Duodenalis or Strongylus Duodenalis. In 1843 Dubini first described this parasite in man. Griesinger, in 1854, demonstrated it as the cause of Egyptian chlorosis. Subsequently it was described in the tunnel workers of St. Gothard, and it is now recognized as an important cause of tropical anemia and of the anemia of miners, brick workers, and tunnel workers. It is interesting to note that as far back as 1886, the late Prof essor Joseph Leidy reports in an article entitled "Remarks on Parasites and Scorpions," May 5, 1886, his discovery of true ankylostoma duodenale infesting a cat. He refers to the probability that some of the cases of supposed pernicious anemia found in America are due to this parasite. Leidy's researches are to be found at the Smithsonian Institution. Incidence. This parasite is widely spread in tropical and subtropical countries, and is one of the most fatal of parasitic diseases. In Porto Rico, in 1903, 5736 deaths out of a total of 23,433 were from anemia due to uncinariasis, as shown by the Anemia Commission in the report issued by Ashford, King and Igaravidez. In Porto Rico, Colombia, Dutch Guiana and Ceylon about 90 per cent, of the population were in former years infected by this parasite. A summary of ten years' campaign against hookworm disease is reported by these authors. 1 Stiles has demon- strated that the disease is endemic in many places, and is the cause of the common anemia in the Southern States. Harlow Brooks 2 reports a case of hookworm infection endemic in New York. This patient had been working on the reservoir at Brewster, 1 Jour. Amer. Med. Assoc., May 28, 1910. - Med. Rec., Jan. 29, 1910. INTESTINAL PARASITES 941 N. Y. He was of Irish-American extraction. A number of his asso- ciates were Italians recently arrived in this country. The European form of the worm was found in this patient's stools. Stiles 1 has ex- amined the pupils of eight schools, 1306 children inspected, and classified 55.9 per cent, as "suspects" as regards hookworm disease in Southern Florida. He believes the condition lamentably common in the South. Wells 2 investigating uncinariasis in the State of Georgia, finds, exclusive of the large towns, about 24 per cent, of the total white population have uncinariasis. Infection seemed to be confined chiefly to those between five and twenty-seven years of age, and the parasites may live in the intestines from two to twelve years. Bass 3 has reported a large number of cases in the country population of Mississippi. Uncinariasis has been found among the miners in Pennsyl- vania and has been reported in Texas, Missouri, Arkansas and Oklahoma. Gunn 4 reported in 1905 about 60 cases of imported hookworm disease in the state of California. Sprague and Endicott have reported the occur- rence of this disease in Jackson, Amador Co., in the same state, and Gunn 5 more recently reports a large series of cases of hookworm disease in the mines of California, and on investigation finds the disease is endemic in certain mines, hookworm embryos being demonstrated in the earth removed from these mines. The condition is also found in Nevada and probably exists in many other mines in the United States. Unsanitary conditions in the mines are undoubtedly responsible. In many of them there are no privy facilities underground. The severest infection occurs from the light sandy soil of the coastal plains. It occurs frequently in the agricultural districts. From 1910 to 1913 examination of 415,000 school children in 413 counties of n Southern States revealed an infection of 43 per cent. Of over 700,000 persons of all ages, 35 per cent, were infected. Protection against this infection is, therefore, of interest on the economic as well as on the humanitarian side. Ford 6 reports a case of hookworm disease in Kansas. It is not uncommon in the Philippines. Chamberlain 1 reports a sta- tistical study of hookworm among the whites in the Philippines, and Castellani and Chalmers in the July issue of the same Journal, intestinal flagellates occurring with hookworm. The disease is prevalent among the miners of Germany and Austro-Hungary and also in Westphalia. The anemia of the Cornish miners has been shown to be due to hookworm. In Egypt the disease is very prevalent. Parasite. The worm is a strongyle, closely allied to the sclerostoma, which causes verminous aneurysms and colic in the horse, and to the gapeworm of fowls. There are two forms the Anchylostoma duodenale and the Uncinaria americana or Necator americanus described by Stiles. They have the same general characteristics, there being certain differences in the arrangement of the teeth, etc. 1 Public Health Reports, March 25, 1910. 2 Jour. Amer. Med. Assoc., June 4, 1910. 3 Ibid., July 21, 1906. 4 California State Jour. Med., April and Aug., 1905. 6 Jour. Amer. Med. Assoc., Jan. 28, 1910. 6 Jour. Amer. Med. Assoc., May 28, 1910. 7 Philippine Jour, of Sci., Aug., 1910. 942 DISEASES OF THE STOMACH AND INTESTINES The worm is cylindric in shape, about 0.5 to i mm. thick. The males are from 7 to n mm. in length, the females 10 to 18 mm. The American worm is the longer. The worm is yellowish or grayish-white in color, with translucent edges. The head is curved toward the dorsal Fig. 393. Ankylostomum duodenale: a, Male (natural size); b, female (natural size); c, male (enlarged); d, female (enlarged); e, head;/, eggs (after v. Jaksch). surface and the mouth is provided with a heavy armature of hook-like teeth, with which they pierce the mucosa. There is a strong muscular esophagus. The male has a prominent caudal expansion or bursa (Fig- 393)- Fig. 394. Posterior extremity of female Uncinaria Americana, viewed ventro- lateraUy, showing anal opening expanded: a, a, Anal papillae, showing small chitinous tips (A. J. Smith). In the female the caudal end is pointed and armed with an awl-like prong (Fig. 394). The female worms number about four to one. The eggs are oval, 64 to 76 n long by 36 ju wide (Fig. 395) in the American form. They are laid in segmentation. The development is direct, without an intermediate host. The European eggs are smaller. Some- INTESTINAL PARASITES 943 times as many as 2,000,000 eggs are found in one stool. They do not hatch in the intestines. Sometimes they are not readily found in the microscopic field and centrifuging the specimen may be necessary. Bass affirms that more than 7 per cent, of females out of 247 whom he dissected failed to produce ova. He maintains that during the latter third of their existence, they cease to lay eggs. If this observation is substantiated, in some cases individuals may be harboring the worm, though no ova can be found in their stools. The embryo lives in the water or moist ground and passes through the rhabditiform stage. Larvae may live for months in the mud and water of the mines. They may be taken into the body by drinking water, with the dirt from the hands of the miners and tunnel workers, or in the soil eaten by the earth feeders, the geophagi. They may be carried in the dust and contaminate green vegetables and fruit. Uncinarial Dermatitis. Ashford and King 1 refer to the fact that in Porto Rico infections through the mouth are rare, and that fully 96 per cent, of the patients have suffered from ground-itch ("Mazamorra"), or dew-itch, due to invasion of the skin 2 by these larva. The well shod were never affected. Various stages of dermatitis occur, and even obstinate ulcers of the leg, in the lower third especially. These were called " tropical " or "syphilitic" by the ignorant. Next in fre- quency to infection through the skin of the feet are the hands and arms as the route of entrance. Loos demonstrated that embryo worms enter the skin, the lymph-channels, egg showing three cells is a lateral and then the veins, and are carried by the ^ w r ^ found 6 in A^T'feces^f veins to the right side of the heart and lungs, patients, and give a positive di- and then pass up through the trachea into agnosis of infection. Greatly the pharynx and are swallowed. Ashford enlarged (aft( further believes that skin infections can take place without manifest dermatitis, from experiments on animals. Skin infection is probably very frequent. Infection is more common in summer than winter, in part probably due to the fact that greater protection is afforded the lower limbs during the cold or rainy season. Immunity. Some whites, and especially the negro race and Asiatics, enjoy considerable immunity to this disease. One may find a large number of ova in the stools, and yet there may be few or no symptoms. Usually the greater the infection, the more acute the onset and course of the disease. The adult worm lives in the small intestine; more are found in the jejunum; many in the duodenum; and rarely in the ileum or colon. 1 Uncinariasis, Jour. Amer. Med. Assoc., Aug. 10, 1907. 3 The skin eruption known as "bunches," occurring in the Cornish miners is probably due to the entrance of these worms (Haldane). Fig. 395. Four eggs of the New World hookworm (Unci- naria Americana), in the one-, two-, and four-cell stages. The 944 DISEASES OF THE STOMACH AND INTESTINES Symptoms. Chronic Cases. It is interesting to note the retarding of mental and physical development of children infected with this parasite. In cases reported by Ferrell 1 malaria and tuberculosis have been diag- nosed, when eventually the emaciation, anemia and loss of strength were found to be due to hookworm infection. Many of the infected children have a prominent abdomen (pot belly), the chest is flat and the shoulder- blades stand out prominently suggesting "angel wings" and are denomi- nated this type of shoulder-blade; even in the less severe types of cases, these patients become somewhat weak and anemic, unable to properly perform the physical or mental labor and the disease thus affects their wage-earning capacity, so that from an economic standpoint as well such infections are a serious menace to the prosperity of a community. In the early stage of more acute cases there may be gastro-intestinal symp- toms, such as pains in the epigastrium (gastralgia), tenderness in the right hypochondrium, nausea, occasionally vomiting, constipation, rarely diarrhea. Pain in the sternum and chest, slight breathlessness on exer- tion, and palpitation. A temperature of 37.5 to 38.5C. (99.5-io3.5F.) is not uncommon. The patient feels unable to work; gradually anemia becomes manifest, the fever disappears, hemoglobin steadily diminishes. Headache, vertigo, tinnitus aurium, hemic murmurs, weakening of the pulse, and dyspnea follow. The pains in the sternum become quite severe, debility and mental hebetude increase; patellar reflexes are diminished or even lost. Impotence or amenorrhea may be present. In this advanced condition the skin is of a dirty muddy hue, at times waxy white. In the Southern States it is known as the "Florida com- plexion." The eyes are dull, heavy, lack luster, and have a blank stare. Children are interfered with in their growth and become stunted and ill developed. The circulatory system becomes more profoundly affected; the heart, at first slightly hypertrophied, now becomes dilated and broken compensation ensues. There are edema of the feet and legs, puffiness, of the face and a general anasarca, with pericardial, pleural, and peritoneal effusions. The patient is bedridden and gradually passes away in a semisomnolent condition. Acute cardiac dilatation, cerebral effusion, or violent diarrhea may be terminal events. Osier holds that the liver and spleen become enlarged, but this does not correspond to the findings of Ashford and King. The hemoglobin may fall below 30 per cent, and sometimes even to 8 per cent., and some of these latter have recovered under appropriate treatment. Eskridge 2 reports a case of Ainhum complicating uncinariasis. Morbid Anatomy. Autopsies (Ashford and King). Muscles are often brownish gray, friable and atrophied. Skin and subcutaneous tissue pale and sodden with fluid. Serous effusion generally present in the pleurae and pericardium, sometimes in the cerebral ventricles. Ascites marked. Lungs. Edema and passive congestion. Liver. Never normal; once was increased in size; never diminished; fatty degeneration often present; connective- tissue increase is not a feature. 1 Journal A. M. A., June 20, 1914. 2 Med. Rec., Sept. 17, 1910. INTESTINAL PARASITES 945 Kidneys. Chronic parenchymatous or chronic diffuse nephritis. As a rule, there was little connective-tissue increase. Stomach. Uncinariae are occasionally found in the stomach and even adherent to its walls. Chronic gastritis is common. Intestines. The jejunum contained most of the uncinariae, some unat- tached and others attached to the mucosa. The balance were mostly found in the first part of the duodenum, a few in the ileum, and none in the coon. The intestinal lesion is confined to the mucosa, there being a tiny superficial erosion about 0.5 mm. (li inch) in diameter, and not a deep ulcer. They are usually not red and are difficult to find, except with a hand lens. The duodenum and especially the jejunum are the seat of a chronic intestinal catarrh. The dejecta are often of brownish color. Microscopically, eggs of the parasites and at times Charcot-Leyden's crystals are found in the stools. Spleen. This is frequently found reduced in size, soft, and has a wrinkled capsule. There was a paucity of lymphoid elements. Hemolymph Glands. In the region of the abdominal aorta, especially near the bifurcation, enlarged glands of dull reddish hue were noted. There was no surrounding trace of inflammation. Microscopic examina- tion showed they were hemalymph glands of the type described as splenolymph. Bone-marrow. Changes such as occur in pernicious anemia; also eosinophilous cells. Anemia. Blood. The findings vary from a diminution of hemoglobin and red cells to those of pernicious anemia. The hemoglobin is usually relatively lower in uncinariasis; as low as 15 to 20 per cent, in severe cases is not uncommon, 8 per cent, having been registered. Polychromatophilia, and in severe cases poikilocytosis, with macro- cytes, and microytes, occur. Normoblasts and megoblasts were not uncommon, but the latter were in the minority. Erythrocytes averaged 2,406,416 per cubic millimeter, the lowest 754,000; average hemoglobin slightly over 40 per cent. Osier reports marked leukocytosis in his cases. Some observers hold that leukocytosis is generally due to complications; while Ashford and King find no constant leukocytosis, but that it is present at times in acute cases, while in chronic cases there is apt to be leukopenia. There seemed to be a tendency of the leukocytes to degenerate. Eosinophilia is of importance. Boycott and Haldane hold it is present in 94 per cent, of cases, and at times it is quite high. Ashford and King call especial attention to the fact that in the most serious cases it is liable to be absent, and that it is chiefly of prognostic importance. Very chronic cases of severe type, poor resisting power, and lack of blood regeneration, they state, rarely show eosinophilia, or only to a slight degree; that a rise of eosinophilia is of good prognostic significance; that a fall, with lack of improvement in the symptoms, is not a good omen. They hold that good resistance to the toxin of uncinariae is expressed by eosinophilia. An inter- esting case of fatal acute hook-worm infection with purpura is reported by Boiling Lee and Harlow Brooks. 1 Eosinophilia was absent probably 1 Med. Rec., May 14, 1910. 60 946 DISEASES OF THE STOMACH AND INTESTINES by reason of the severe character of the infection and the slight body resistance to it. Diagnosis. By the finding of the eggs'and parasites in the stool. It is well to examine the stools after a dose of thymol, followed by a saline cathartic. Stiles suggests placing a small bit of feces on a white blotting paper when a microscopic examination cannot be made. In about an hour there is a blood-red or reddish-brown stain suggestive of blood. The worms to the naked eye are about % inch long, of the diameter of a pin, with one end sharply recurved. Eosinophilia is suggestive. The microscopic examination of the stool will settle the diagnosis. It is interesting to note that other intestinal parasites or their ova may be found in addition to the hook-worm. Charcot-Leyden's crystals in the stool are also suggestive. Prognosis. This is good if the condition is detected early, but is bad in the advanced cases. Prophylaxis. In camps or mines, proper sanitary regulations, such as the correct location of the latrines, etc., are important. In regions where this infection is endemic, new miners should be inspected, and infected cases should be pronounced free from the disease before being allowed to resume work. The feet and legs should be protected from the soil (should not be bare) and the hands properly scrubbed before eating. The stools of infected patients should be disinfected with bichlorid of mercury (i : 1000) or carbolic acid (i : 20) solution. Raw fruits and vegetables, such as apples, lettuce, etc., should be properly cleaned, and should preferably be avoided if there are many cases of ankylostomiasis. Treatment. Filix mas, thymol, and betanaphtol are the best drugs. The ethereal extract of filix mas, same dosage as for tape-worms, and then the solid extract were tried in Porto Rico, but they seemed to be of no value. Ashford believes that possibly the preparation deteriorates in warm climates. In the early stage of emigration (uncinarial dermatitis) the author suggests the possible value of hexamethylenamin, 10 grains (0.6), with same quantity of sodium benzoate, four to eight times a day. Thymol proved to be the best remedy. The day previous the patient abstains from solid food and at night is given 25.0 grams sodium sulphate or any good saline cathartic; the next morning, if free bowel action, on an average about 30 grains (2.0)- of thymol should be given in capsules, and an equal dose two hours later, followed in a couple of hours by another saline cathartic. This procedure should be kept up once a week, until no ova are found. Smaller, occasionally even larger, or more frequent doses may be required. It is generally advised that oily cathartics, such as castor oil and also alcohol should not be taken directly after the thymol. Dizziness or slight collapse may follow the use of thymol. Epigastric pain, nausea, vomiting, tremors, twitchings, convulsions, and severe collapse, pulmonary congestion and fatty degeneration of the liver result from thymol poison- ing. Ashford mentions cases who have taken alcohol for these conditions with no deleterious effect. INTESTINAL PARASITES 947 Occasionally thymol, when given pulverized in capsules, may pass through in a hard stony mass, with no effect on the parasites. Lindeman 1 recommends triturating the thymol crystals with equal parts of milk- sugar and placing the mixture in cachets which are softened to the con- sistency of a raw oyster before administering. The sugar of milk is dis- solved and the thymol is well distributed over the small intestine. An equal quantity of powdered sugar or creta preparata (precipitated car- bonate of chalk) has also been suggested as a valuable combination with the thymol. Lindeman believes that intestinal catarrh, rapid peristalsis from intestinal erosions, and especially dilatation of the stomach, with gastroptosis, which latter condition he believes frequent, as many of these patients are pot-bellied, that these conditions interfere with the thymol coming in contact with the parasite. With ectasy, the drug would lie too long in the stomach and part be absorbed. It is, therefore, recom- mended that the patient lie on the right side after ingestion of the thymol, so the stomach can readily empty itself. The following dosage is outlined by the State Board of Health of Florida. Under 5 years of age Up to 8 grains. 5 to 10 years of age 5 to 15 grains. 10 to 15 years of age 15 to 30 grains. 15 to 20 years of age. 30 to 45 grains. 20 to 60 years of age 45 to 60 grains. Over 60 years of age 45 grains. One should also consider the weight of the child, and also in all cases the condition of the heart and the degree of debility. Bozzolo administers much larger adult doses of thymol 12 grams in divided doses 2 grams every two hours, and claims the. best results. He administers a small dose of strong wine or alcohol after each dose of thymol and had no bad results, no poisoning and no other phenomena beyond giddiness or sleepiness, with dark urine. Betanaphtol, 15 grains (i.o), and two hours later the same dosage, administered like thymol, have been employed. It is somewhat irritating to the kidneys; is an excellent anthelmintic, but not quite as safe as thymol nor as efficacious. Ashford and King hold that hemoglobin increased more rapidly under the use of iron, but that the return to normal came about as surely with- out it, after the use of thymol. They used Blaud's pills in obstinate cases. Iron and arsenic I believe valuable accessories. 1$. Blaud's pill (iron) (made fresh) gr. v. (0.3) ; Sod. arsen gr. J^ (0.0013). M. One pill. Sig. One t.i.d. Blaud's iron pill, 5 to 10 grains (0.3-0.6), or iron tropon can be used, combined with Fowler's solution of arsenic, 5 minims (0.274), t.i.d.; or atoxyl, % grain (0.02), by hypodermic every other day. A subsequent high enema of thymol, i quart (liter), i : 2500, might be of value in aiding their destruction after the worms have passed into the large intestine. 1 Jour. Amer. Med. Assoc., May 28, 1910. 948 DISEASES OF THE STOMACH AND INTESTINES Autogenous Vaccine in Ankylostomiasis.- Recent observations sug- gest that the hookworm itself is not always exclusively responsible for the symptoms found in hookworm infection, since different types of fever and intestinal putrefactive processes are very marked in ankylostomiasis. R. G. Archibald ascribes the evidences of toxemia, unaccounted for by the hookworm, to absorption of poisonous products of certain intestinal bacteria, who immediately improved after the administration of an autogenous vaccine prepared from a coliform organism isolated from the stools. He suggests use of autogenous vaccines prepared from the stool previous to the administration of the anthelmintic These cases seem to the author an associated bacillus coli infection. I have previously recommended the use of hexamethylenamin for ankylostomiasis. Strongyloides Intestinalis. Under this name we now include the small nematode worms found in the feces and formerly de- scribed as Anguillata stercoralis, Anguillata in- testinalis, and Rhabdonema intestinale. The parasite occurs abundantly in the stools of the endemic diarrhea of hot countries, and has been described by the French in the diarrhea of Cochin-China. It has been found in Manila by Strong. W. S. Thayer reported three cases from Osier's clinic. It has occurred in Italy. Blumgart 1 reports their larvae in a case and refers to reports of five additional cases, and to the fact that Southern physicians refer to other cases, so that the disease is probably more widespread than is supposed. The worms are said to occupy all parts of the intestines, and have even been found in the biliary and pan- creatic ducts. The female is from i to 2.20 mm. long and ao4 to O-O3 mm . ^de (Fig. 396). The mouth . , ,. . ,. . 6 ov . , has three distinct hps, continuous with a triangu- lar esophagus, which after narrowing dilates again into a second ovoid enlargement, which is followed by intestines. The esophagus is one-fourth the length of the body. It has a double uterus, each horn of which contains from three to six segmentary ova which escape through the vulva. The intestinal tract is bordered by fine granulations. Eggs are elliptic, with a thin, clear yellow shell, with granular contents about 0.0x5675 by 0.0375 mm. They hatch quickly, so are rare in the stools. They occur chiefly in the duodenum and jejunum, but have been found in the stomach and other parts of the intestines. The source of infection has been attributed to contaminated food or drinking water and also to the entrance of the parasite through the skin. Symptoms. They are usually more of chronic diarrhea than of 1 Med. Rec., April 6, 1907. Fig. 396. Strongyloides intestinalis and stercoralis: i, Larva (Anguillula intesti- nalis); 2, male Anguillula ster- coralis; 3, female Anguillula stercoralis (after Perroncito). INTESTINAL PARASITES 949 dysentery. There are at first mild dyspeptic symptoms, eructations, anorexia, and a diarrhea of moderate intenstity, with soft and pasty stools, three or four a day, often in the early morning hours. The attacks are sometimes dysenteric, with mucus and blood; in other cases they are more choleraic, the dejecta consisting of liquid yellow material; while vomiting, cyanosis, and collapse may occur. Emaciation and prostration may be present. Anemia though pres- ent, is, as a rule, not very severe. Intercurrent dysentery is not uncommon, also headache, vertigo, tinnitus, aurium, and prostration. In India, Powell found this parasite in over 75 per cent, of the cases of anemia. In incomplicated cases a high grade of leukocytosis may be present. There is eosinophilia. Some patients complain of difficult breathing and of painful deglutition and Strong describes a peculiar facial expression which is characteristic. A general toxemia may be produced by the toxins of these parasites. Moss 1 reports an unusual case of long duration, suffering from attacks of dyspnea, cyanosis, frequent and painful urination, burning sensations of the buttocks and thighs, emacia- tion, quite marked anemia and sphincteric spasm. Eosinophilia was over 12 per cent. The case resulted fatally. Fig. 397. Trichocephalus dispar: a, Fe- ' Fig. 398. Egg of Trichocephalus male; b, male (natural size) (Heller). dispar, moderately enlarged (Heller). Treatment, Rest and liquid diet. Male fern, ethereal extract, 12 to 30 grams divided in three doses during the morning and repeated daily, have been used by the Italians. Thymol has been quite successful, by the method described. Large quantities of olive oil have seemed to give good results in some cases. Trichocephalus Dispar (Whip-worm). This parasite is found in the cecum and large intestine of man. It measures from 4 to 5 cm. long, the male being smaller than the female. It is readily recognized by the peculiar differences between the anterior and posterior portions. The anterior forms three-fifths of the body, is thin and hair-like; the tail end of the female is more conic and thicker, terminating in a blunt extremity; while that of the male is rolled like a spring (Fig. 397). The ovum is lemon shaped, dark brown, 0.05 mm. in length, and provided with button-like projections (Fig. 398). The number of worms is variable, as many as a thousand having been counted; often only 10 to 20 are found. In parts of Europe particularly in Italy they are very common, but not so in the United States. 2 Symptoms. Profound anemia with diarrhea have occurred from 1 N. Y. Med. Jour., May 23, 1914. - The writer has seen two cases in New York City recently and several from Cuba and Central America. There were no symptoms imputed to the parasites. 95 DISEASES OF THE STOMACH AND INTESTINES them. Many worms may be present without producing symptoms; occasionally diarrhea and nervous symptoms occur, and enteritis has been reported as due to this parasite. Dysentery, aphonia, perityphlitis and ^omiting of blood have been reported. 1 Diagnosis. This can be made from the peculiar ova. Living worms are rare in the stool. Treatment. Thymol, as previously described. Extract of male fern may be employed. High enemata of warm water, i quart (liter), containing 5 to 10 drops of benzin, may be of service. Trichina Spiralis (Trichiniasis). The trichina in its adult condition lives in the small intestine. The embryos pass from the intestines and reach the voluntary muscles, where they become encapsulated larvze. Muscle Trichina. Tiedemann, in 1822, described the ovoid cysts in human muscle. Owen named the parasite. Leidy, in 1845, described it in the pig. In 1860, Zenker discovered in a girl both the intestinal and muscle forms, and established their connection with the specific symptoms. Fig. 399. Trichina spiralis (greatly enlarged): a, Female; b, male; c, embryo (after Heller). Incidence. Man is infected by eating the raw or not completely cooked flesh of trichinous hogs, which contain encapsulated trichinae. The capsules are digested in the stomach and the trichinae set free. They pass into the small intestine, and about the third day become sexually mature. On the sixth or seventh day the embryos are fully developed. The young produced by each trichina (female) have been estimated at several hundred. The female worm penetrates the intestinal wall and the embryos are probably discharged directly into the lymph-spaces, and thence into the venous system, whence they reach the muscles; and in about two weeks they develop into the full-grown muscle form. A myositis is produced and they may become encapsulated. The trichinae may live therein for many years. Calcification may occur about them. One must remember that in the hog the capsule does not readily become calcified, so that the parasites are not as readily visible as in man. More- over, an apparently healthy looking animal may be suffering from trichiniasis. Children seem to suffer slightly from the disease. Van Cott 2 holds 1 Mellon, Med. Rec., Aug. 21, 1915. 2 Journal A. M. A., Feb. 28, 1914. INTESTINAL PARASITES 951 that the small quantity of infected meat ingested in children explains their mild attacks. The intestinal trichina are visible to the naked eye white glistening worms 3 to 4 mm. long; and the male half this size, with two little projections from the hind end. The caudal extremity is thicker than the head Fg- 399)- The muscle trichina is 0.6 to i mm. long and coiled in the capsule. It has a pointed head and rounded tail (Fig. 400). The dead parasites are probably usually dissolved in the small intestine and dead or living appear to be rarely found in the stool. The embryos are exceptionally discharged into the lumen of the gut. TrichineUa Spiralis in the Human Blood. Herrick and T. Janeway 1 have demonstrated the TrichineUa spiralis in the human blood, and E. Packard 2 reports finding an embryo of the TrichineUa spiralis in the blood of a patient and within a short period larger embryos in the muscle, not yet encysted (Figs. 401 and 402). I'lg. 400. Fresh muscle trich- inae (Mosler and Peiper). Fig. 401. Trichinella spiralis in blood ( X 500) (Packard). Trichinae in the Cerebrospinal Fluid. Van Cott 3 and Lintz discovered living trichinae in the cerebrospinal fluid by lumbar puncture. No 1 Arch. Int. Med.j 1909, iii, 263. 2 Jour. Amer. Med. Assoc., April 16, 1910. 3 Journal A. M. A., Feb. 28, 1914. 952 DISEASES OF THE STOMACH AND INTESTINES trichinae were found in the blood of this patient and they were believed to be probably present in the nerve tissue and to be derived in the spinal fluid from that source. Bloch 1 also reports a case and Lintz, 2 3 cases. Development of Toxins. Flury 3 has demonstrated that poisonous products arise in connection with the evolution of the trichinae just as certain other intestinal parasites liberate toxic substances. Chemical products also arise from the invaded and damaged muscle tissue. The trichinae infected muscle cells are profoundly altered, there being an undue accumulation of certain purin compounds. Trichinosed muscle contains highly active poisons which can provoke rigor and tonus and Fig. 402. Trichinella spiralis found in muscle five days after embryo was found in blood (X about 250) (Packard). derivatives of the guanidin series may produce nervous symptoms. Flury 4 has initiated and imitated varied symptoms of trichinosis in animals by feeding them with the toxic extracts of trichinosed flesh. Herrick 5 believes the fever due to parenteral introduction of alien protein material. Symptoms. As a rule, a few days after eating the infected flesh gastro-intestinal disturbances occur, such as pain in the abdomen, anorexia, vomiting, and severe diarrhea. The attack may resemble cholera nostras or even typhoid fever. Invasion symptoms usually occur between the seventh and tenth days or, occasionally, not until the end of two v/eeks. There may be fever, intermittent or remittent, even to 102 to io4F. Chills are not common. 1 Ibid, Dec. 18, 1915. 2 Ibid, June 10, 1916. 3 Arch. f. exper. Path. u. Pharmakol., 1913, Ixxiii, 164 and 214. 4 Arch. f. exper. Path. u. Pharmakol, 1913, Ixvii, 294. 5 Journal A.M. A., Nov. 27, 1915 INTESTINAL PARASITES 953 Pain occurs in the muscles on pressure and movement, also swelling of the muscles. There may be difficulty in chewing and swallowing. Respiration may be painful. Dyspnea may be present from involvement of the intercostal muscles and diaphragm. Edema of the face, especially about the eyes, is an important symptom. Sweating, itching, and urticaria occur. There may be capillary hemorrhages. The general nutrition is disturbed and the patient becomes anemic and emaciated. In cases with severe infection, there may be delirium, tremor, and dry tongue, sug- gestive of typhoid fever. Bronchitis, pleurisy, pneumonia, polyuria, or albuminuria may occur. No splenic enlargement. Diazo reaction positive. In Van Cott's cases, there were headaches, loss of patellar reflex, and sometimes the loss of Achilles tendon reflex, with Kernig's sign present almost invariably and a rigid neck. Dilatation of the pupils was marked in the fatal cases and was present from the beginning of the disease. Differential Diagnosis. Trichinosis has been mistaken for typhoid fever and for articular or muscular rheumatism, multiple neuritis, or cholera morbus. With typhoid there is leukopenia, the presence of the Widal reaction, enlarged spleen, and the typhoid temperature. The typhoid bacilli are also present in the blood and stools. With nephritis, there are edema, gastro-intestinal symptoms, and urinary findings of such but no eosinophilia. With cerebrospinal meningitis we have positive Kernig's sign, exagger- ated knee-jerks, Achilles tendon reflex but no eosinophilia, while with trichinosis there are Kernig's sign, loss of patellar reflex, absence of Achilles tendon reflex, eosinophilia and the muscle symptoms. Leukocytosis, especially marked eosinophilia, is an aid to the diagnosis of trichinosis. There is often secondary anemia. Charcot-Leyden crystals occur in the stools. Eosinophilia, edema of the eyelids, dyspnea, swelling, and tension of the muscles are at once suggestive. The presence of trichinae in the stools and muscles is conclusive. The muscle can be incised under cocain injection and the cyst examined. The disease has proved fatal in a number of cases. Prognosis. This depends on the intensity of the infection. Mild cases may recover in two weeks. The mortality has ranged as high as 30 per cent. Early diarrhea is favorable to evacuate the infected pork. Prophylaxis. Pork, such as ham, sausage, etc., should always be thoroughly cooked before eating. Proper inspection of hogs is important. Treatment. Immediate lavage, if infected pork is suspected and the case is seen early. Evacuation of the bowel by calomel, 10 grains (0.6), or a saline cathartic. Thymol, santonin, male fern, kamala, and turpen- tine, have all been recommended as vermifuges in the early stage but have not proved particularly satisfactory. Colonic irrigations with various anthelmintics, irrigation with weak benzin, etc., would not reach the small intestine. Van Cott has experimented with salvarsan and neo- salvarsan injections with apparently no beneficial results. Glycerin in large doses internally is said to be destructive of the worm. Later, the treatment is symptomatic and the strength is to be supported. Hexa- 954 DISEASES OF THE STOMACH AND INTESTINES methylenamin in lo-grain (0.6) doses six to eight times a day, I believe of value during the early stages. It is preferable to combine it with equal doses of sodium benzoate. In view of the presence of the parasite in the blood and spinal fluid, this method seems particularly logical. The writer has secured an excellent result by the use of hexamethyl- enamin in a recent case. Picric acid, J^ to 2 grains (0.03-0.1) dissolved in alcoholic solution and well diluted, has been recommended to destroy the larval forms circulat- ing in the blood. It is very bitter and liable to cause gastro-intestinal irritation. Quinin has also been recommended. I do not advise their use. PART IV DISEASES OF THE PANCREAS CHAPTER XXXVIII THE PANCREAS AND ITS ANOMALIES SURGICAL RELATIONS THE greater part of the pancreas is located in the epigastrium (Fig. 403), but a portion of the body and tail extend in to the lefthypochondrium, and the head may project into the umbilical region. The organ lies about Fig. 403. Surface marking of the pancreas. 3 inches above the umbilicus, midway between the navel and ensiform appendix, the body corresponding to the level of the first lumbar vertebra. To expose the pancreas one must detach the stomach from the great omentum and turn it upward. The pancreas is a long, pink, cream-colored 955 956 DISEASES OF THE STOMACH AND INTESTINES gland, which stretches transversely across the posterior abdominal wall from the concavity of the duodenum to the lower and inner border of the spleen (Fig. 404). When fresh, its consistency is firm and its appearance is lobulated. It varies in length from 5 to 6 inches (12 to 15 cm.). Its weight averages from 2.25 to 3.5 ounces (66 to 102 gm.). The enlarged right extremity, or "head," extends downward and to the left, and lies in the concavity of the duodenum, in contact with its second and third parts. This portion is enlarged, bulbous, and lies opposite the second and upper part of the third lumbar vertebra. The short constricted part, or "neck," arises from the upper and anterior part of the head. It runs upward and slightly forward, and then to the Inferior vena cava Aorta Stomach Left adrenai Right adrenal Right kidney Spleen Kidney Colon Fig. 404. Diagram showing the relations of the pancreas (Robson and Cammidge). left for about an inch, where it merges into the body of the gland. This last, which is the longest section, runs backward and to the left at the level of the first lumbar vertebra. The pointed left extremity ("tail") is least firmly attached, and it merges gradually into the body. To the left of the head, in contact with the neck, is a deep groove, the "incisura pancreatis," in which lie the superior mesenteric vessels; a short process of the head, the "uncinate," projects behind and to the left of the vessels along the third part of the duodenum, deepening the groove in which they lie. Occasionally this process lies separate and is known as the "lesser pancreas." The anterior aspect of the head is in contact with the commencement of the transverse colon. The liver overlaps the pancreas. The lower part of the head anteriorly is covered by peritoneum reflected from the THE PANCREAS AXU ITS ANOMALIES SURGICAL RELATIONS 957 lower surface of the colon, and which enters into the formation of the greater sac of the peritoneum. This part is in contact with the small intestine. The posterior surface of the head has no peritoneal coat, and lies in front of the inferior vena cava, the left renal vein, and the aorta. The common bile-duct is in a groove or canal on this surface. Anteriorly, and to the right, the neck is in contact with the first part of the duodenum, and with the pylorus when the stomach is distended. Behind, and to the left, there is a groove in which are the terminations of the superior mesenteric veins and splenic veins. The body has three surfaces. Its anterior surface is concave, looking upward and forward. The lesser sac of the peritoneum separates it from the stomach. Where the body joins the neck there is often a prominence the "omental tuberosity" so called from its contact with the small omentum when the stomach is distended. The posterior surface looks backward and lies upon the aorta, the origin of the superior mesenteric artery, the pillars of the diaphragm, the splenic artery and vein, the left kidney and renal vessels, and the left suprarenal capsule. The splenic vessels run along its upper border in a single groove or, at times, in separate grooves. The posterior surface has no peritoneal covering, and is connected to the abdominal wall and adjacent organs by areolar tissue. The inferior surface looks downward and slightly forward. At the right end it rests on the duodencjejunal flexure. The middle part is covered by jejunum. This surface is invested by peritoneum derived from the descending layer of the transverse mesocolon. With gastroptosis, the pancreas may at times be felt in a space between the edge of the liver and the lesser curvature of the stomach. The tail is in contact with the lower part of the inner surface of the spleen, but occasionally a portion of the mesentery, containing a lymph- nodule, intervenes. Blood-supply. Arteries. The hepatic branch of the celiac axis, the inferior pancreaticoduodenal branch of the superior mesenteric, the superior pancreaticoduodenal artery (a branch of the gastroduodenal), and branches of the splenic and of the hepatic arteries supply the pancreas. Veins. These are tributaries of the splenic and superior mesenteric veins, the anterosuperior pancreaticoduodenal vein, which enters the superior mesenteric vein; the posterior pancreaticoduodenal vein, which empties into the portal vein; a number of small tributaries enter the splenic vein, and small veins from the head and neck, which run into the portal vein. Lymphatics. This system enters into glands located on the head of the pancreas, in the hilum of the spleen, and along the superior mesenteric vessels. Nerves. The vagi supply the cerebrospinal fibers, and the solar plexus the sympathetic fibers. They accompany the arteries through the celiac, splenic, and superior mesenteric plexuses, traverse the substance of the gland in company with the ducts, and terminate in plexuses around the acini, sending fibers to the secreting cells. The nerve-fibers are chiefly non-medullated, and have minute visceral sympathetic ganglia. 958 DISEASES OF THE STOMACH AND INTESTINES Small nerve-cells are also found near the distribution of the nerve-fibers to the alveoli. Peritoneum. The transverse mesocolon is attached to the anterior border of the pancreas, from the neck to the tail. The anterior layer passes upward and backward over the superior surface, forming the pos- terior wall of the lesser peritoneal cavity. The posterior layer passes downward and backward along the inferior surface to form the greater peritoneal sac. At the neck and on the head anteriorly the two layers of peritoneum have separate lines of attachment, so that there is a space devoid of peritoneal covering, which is separated from the colon by areolar tissue. In some cases the transverse mesocolon is continued as far as the hepatic flexure, in which event the head and neck are com- pletely invested. The posterior surface of the pancreas is uncovered by peritoneum. Ducts of the Pancreas. The pancreas has two ducts opening sepa- rately into the duodenum. The duct of Wirsung, the chief one, commences in the tail from the union of the small branches and gradually increases in size, passing through the body of the gland from left to right. It passes downward and backward through the neck into the head of the organ, where it lies nearer the posterior surface, and is in relation with the com- mon bile-duct, beside which it runs into the duodenum. The two ducts pierce the second part of the duodenum obliquely, about 3 to 4 inches (8 to 12 cm.) below the pylorus, and afterward unite to form a common channel, the "ampulla" or "diverticulum of Vater," which opens by an orifice into the gut. This last is situated on a papilla-like fold of the mucous membrane, called the "papilla or caruncula major." Above it there is a small fold of mucous membrane, which must be raised in order that the orifice may be seen. Running downward from the caruncle there is a small vertical fold known as the "frenum carunculae" or "plica longitudinalis." The diverticulum of Vater is oval or triangular, having the duodenal orifice at its apex, and its base at the openings of the two ducts. Its average length is only 3.9 mm., though Testut believes it to be longer, from 6 to 7 mm., and rarely as much as n mm. The orifice of the diverticulum of Vater is the narrowest part of the biliary channel, only averaging 2.5 mm. According to Oddi, a thin layer of unstriped muscle- fiber surrounds the ampulla and the terminations of the ducts, forming a sphincter. The duct of Santorini (ductus pancreaticus accessorius) drains a large part of the head of the pancreas. It anastomoses near the neck with the duct of Wirsung, is apparently a branch of this larger duct, and usually increases in size as it approaches it. The duct of Santorini diminishes in size as it approaches the duodenum and opens into the latter on a small papilla, the "caruncula minor," % to i inch above and ventral to the "papilla major." Opie finds, in more than half the cases, that the orifice of the duct of Santorini is obliterated, or so constructed that it cannot assume the function of the larger duct when the latter is occluded. The main and accessory ducts communicate with each other by branches of varying size. THE PANCREAS AND ITS ANOMALIES SURGICAL RELATIONS 959 ANATOMIC ANOMALIES OF THE PANCREAS Depending upon alterations of the usual process of development various anomalies may occur in the pancreas. The tail of the pancreas has occasionally been bifid. Pancreas divisum is due to an absence of lobules of parenchyma about the duct of Wirsung or its branches for a short distance, so that a division of the gland into two parts may result. Pancreas Minus. There is a supernumerary lobule or lobe present in the head of the gland, separated by a constriction. It cannot be classed as an accessory pancreas, as it is merely a part of the pancreas which is separated from the remainder by a depression more marked than usual. The portion of the head lying behind the mesenteric vessels is an ex- ample. It forms the lesser pancreas (pancreas parvum). Annular Pancreas. In rare cases the whole circumference of the duodenum is enclosed in a ring of pancreatic tissue. It may be congenital or a result of invasion of the head of the gland by a growth or from inflam- matory changes. It may cause partial obstruction with dilatation of the duodenum above the point of constriction, and usually dilatation of the stomach with hypertrophy of its wall. The patient suffers from symptoms similar to pyloric stenosis. Pancreas Accessorium (Aberrant Pancreas). An accessory pancreas is a mass of pancreatic tissue entirely separated from the pancreas and having a duct of its own. Possibly such isolated masses of gland tissue may vicariously assume the function of the main organ when diseased, and they may cause diverticula or hernise of the wall of the intestines. Opie 1 reports 10 cases in 1800 autopsies, which he divides into two groups, those lying above the pancreas, in the duodenum and stomach, and those below, in the duodenum and jejunum. Accessory pancreas has also been found in the ileum in an umbilical fistula, in the mesentery of the duodenum, and in the fat of the great omentum. The aberrant pancreas averages i cm. in diameter, though it has been found as large as 4.5 cm. More than one accessory gland may occur in the same person. About one-third of these glands are situated in the wall of the stomach in the submucosa near the pylorus, and about two- thirds occur in the intestinal wall. In the latter they are more frequent in the muscular layer, though they are also found in the submucosa. The tissue of the aberrant gland does not differ in histologic features from that of the pancreas. Among the pathologic changes affecting accessory pancreatic tissue are fat necrosis, chronic interstitial inflammation, and malignant growth. There are a number of cases recorded in which accessory pancreas is associated with a diverticulum of the intestine occurring in the jejunum ileum, duodenum, and once even in the stomach. Such diverticula usually occur in children from less than a year old to those of fourteen years. Intestinal obstruction, acute intraperitoneal 1 J. B. Lippincott, Diseases of the Pancreas. 960 DISEASES OF THE STOMACH AND INTESTINES inflammation, hernia, into the pancreas, both with and without hemorrhagic necrosis, have all resulted from these diverticula. Other Anomalies of the Pancreas. The pancreas may fall forward, or there may be a congenital displacement of the head of the gland associated with gastroptosis. Wandering spleen may drag the tail of the pancreas into an abnormal position. The pancreas has been pushed down by tight lacing, and has been forced upward by retroperitoneal tumors and aneurysms of adjacent vessels. A movable pancreas in a man, resulting from a fall, has been reported by Dabrzyki, which gave rise to symptoms resembling those of movable kidney. It has also been met with in hernial sacs in umbilical hernia (both congenital and acquired). Luther reports it in diaphragmatic hernia, and in one case it had passed through a rent in the diaphragm into the thoracic cavity. Anatomic Variations of the Pancreatic Ducts and Common Bile- ducts. Variations in these ducts have an important bearing upon the pathology of the pancreas, and especially on pancreatitis. Common Bile-duct. The common bile-duct is divided into four portions: the supraduodenal, the retroduodenal, the pancreatic, and the intraparietal or interstitial portion, which last is contained in the wall of the duodenum. The pancreatic portion, which chiefly concerns us, is from 20 to 25 mm. long, and extends fromxthe lower border of the first part of the duo- denum to where it penetrates the second part of this viscus. It is closely applied anteriorly to the posterior surface of the head of the pancreas. It is estimated that in from 62 to 75 per cent, of cases this portion of the common duct is completely embraced, by the head of the gland and that it runs in a deep groove in the remainder. It is evident that when the duct passes through the substance of the gland that a swelling, or interstitial inflammation of the head of the pancreas, may compress and even lead to the occlusion of the common bile-duct. Variations in the Ampulla of Vater and Terminations of the Ducts. Normally, the common bile-ducts and duct of Wirsung empty into the ampulla. The pancreatic and common ducts may join a little distance from the duodenum, the ampulla be absent, and the united ducts open into the duodenum by a small flat, oval orifice; or the ducts may open into a concave fossa in the duodenal wall; or the caruncle is well developed, but the ampulla is absent, and the two ducts open side by side. Opie found this latter arrangement in about n per cent, of cases. Rarely the common duct unites with the duct of Santorini. The bile-duct may open by a circular orifice and the pancreatic duct embrace the bile-duct like a gutter and have an orifice of cresentic shape. Variations in the Pancreatic Ducts. Opie investigated a series of 100 cases and found both ducts present, though one may have been partially obliterated, or so small that it was demonstrated with difficulty. In 89 per cent, the duct of Wirsung is the main excretory channel of the pancreas, and in 21 per cent, the duct of Santorini was obliterated near its termination. THE PANCREAS AND ITS ANOMALIES SURGICAL RELATIONS 961 Opie found that in 48 cases out of 100 it was possible to inject fluid at low pressure through the lesser papilla into the duct of Santorini. After numerous experiments he concluded that in more than half of all cases the lesser duct is obliterated at its orifice, or so constructed that it cannot assume the function of the larger duct when the latter is occluded. The varying relations of the duct of Santorini to the duct of Wirsung are shown in Fig. 405. w _ Fig. 405. Diagram to show the variations in the ducts of Wirsung (W) and San- torini (S). Broken lines, in the plane of the interlobular fissure (after Opie). It must be remembered that the duct of Santorini, even if patent, may be compressed by a gall-stone passing down the pancreatic portion of the common bile-duct. Three ducts have been found, the additional one being an accessory pancreatic duct opening into the ampulla of Vater. SURGICAL RELATIONS As the head of the pancreas is in intimate relation with the duodenum, disease of the gland may readily invade the small intestine, or the converse 61 962 DISEASES OF THE STOMACH AND INTESTINES may happen. Cancer of the head of the pancreas has obliterated the duo- denum to such an extent as to call for a gastro-enterostomy. Malignant growth of the duodenum may invade the pancreas and, finally, give rise to diabetes. Cysts or tumors of the pancreas may compress the duodenum, or the latter may be involved in a pancreatic abscess which may discharge into the gut. The stomach lies in front of the pancreas, so that the latter is liable to invasion from ulcer or cancer of the former. Adhesions between the pancreas and stomach, no matter which organ is the source of the trouble, may produce symptoms when the stomach is distended with food, owing to the limitation of the movements of the latter organ, and pain may also result from interference with its peristalsis. When the pancreas is invaded by or becomes adherent to a malignant growth of the stomach, this increases the danger of operation on the stomach and renders the return of the disease more probable after removal. In 100 cases of pyloric cancer, Fenwick found the pancreas adherent in six. With cancer at the cardia, out of 100 cases the pancreas was ad herent in 16, and when the cancer was present in the lesser curvature or posterior wall, the pancreas was adherent in 19. Chronic gastric ulcer, when situated posteriorly, may become adherent to the pancreas and may cause pancreatitis or even produce a pancreatic abscess. The latter may burst into the stomach and discharge therein, producing at the same time an acute gastritis. On account of the retroperitoneal position of the pancreas, in case of suppurative pancreatitis, pus may burrow upward to the diaphragm and downward toward the left iliac fossa. Pus in some cases may be reached from the right or left loin, from the left iliac fossa, or between ribs, if it presents as a subdiaphragmatic abscess. The anterior surface of the pancreas projects into the lesser sac of the peritoneum, being covered by its posterior layer. This cavity may be invaded in inflammatory conditions or from an injury to the gland. When filled with fluids it may be mistaken for a true pancreatic cyst. Tumors of the tail of the pancreas and pancreatic cysts in this region are more readily extirpated than when in other regions, as they are less closely connected with great vessels. The tail of the gland serves as a pedicle. Section and closure of the pancreatic duct results in chronic inflammation of the parenchyma, which is tributary to the occluded duct, and, hence, injury to the pancreas is greatest in proportion to the nearness of the traumatism to the duodenum. As the pancreas lies at the back of the abdominal cavity, operation upon it is not particularly easy, and various routes are adopted according to indications. One must also remember its relations to the vena cava, the aorta, celiac plexus, spleen, the left suprarenal capsule, the left kidney, portal vein, the common bile-duct, and middle colic artery. The usual method to expose the pancreas is through the gastrocolic ligament, entering the lesser peritoneal cavity between the stomach and transverse colon. If the stomach has sunk downward and the lesion is near the upper border of the pancreas, incision may be made through the gastrohepatic omentum. THE PANCREAS AND ITS ANOMALIES SURGICAL RELATIONS 963 In some cases one may push up the omentum and transverse colon and reach the pancreas by incision through the lower layer of the mesocolon. One may reach the head of the pancreas for the purpose of pancreatic lithotomy or to examine that part, by incising the peritoneal covering of the duodenum and forcing a way along its side to the head of the pancreas. To reach the posterior surface of the head of the gland in order to expose the pancreatic portion of the common bile-duct one can detach the duodenum from the abdominal wall and lift it inward, separating it from the front of the kidney. Under some conditions extraperitoneal operation may be employed; thus, an abscess of the tail has been opened through the left lumbar region, and a cyst projecting to the right from the head of the pancreas has been opened in the right lumbar region. CHAPTER XXXIX HISTOLOGY OF THE PANCREAS PHYSIOLOGY THE pancreas consists of lobules held together by connective tissue. It is composed of branching ducts, terminating in acini that are round or oval (Maziarski). 1 The acini about the terminal ducts are grouped together to form primary lobules from i to 2.5 mm. in diameter. These last are not so regularly arranged or so clearly defined from each other by connective tissue as in animals, and may be indistinctly marked off, and even, in places, fuse with each other. An island of Langerhans is often situated in the middle of the lobule. Numerous primary lobules fuse together to form larger secondary lobules, which last are separated by wide bands of loose areolar tissue, in which are contained the larger ducts, the blood-vessels, and the nerves. They give to the gland its lobulated appearance. They vary in width from 2 to 6 mm. The arteries and veins lying side by side do not accompany the ducts. Numerous secondary lobules grouped together form tertiary lobules. They represent the largest subdivisions on the surface of the gland. Connective-tissue Framework. The arrangement of the connective- tissue framework of the pancreas is important, in view of the changes which occur as a result of chronic inflammation. The surface of the gland has no capsule, but is covered by a thin coat of connective tissue. Within the substance of the organ the connective tissue is arranged in an inter- lobular framework which separates the lobes and lobules, and also an intralobular network of fine fibrils which pass between the individual acini and form a plexus. The interlacing fibers form a reticulated basement- membrane which supports the alveolar cells (Fig. 406). Near the islands of Langerhans the processes between the alveoli become thicker and form septa which run into the capsule of the island. A small amount of elastic tissue is mixed with the fibrous framework, chiefly in the interlobular regions. The ducts throughout are surrounded by a fine network of elastic fibers. The connective tissue contains some fat and connective-tissue cells. Mast cells are found in the interlobular framework. Cells with polygonal or elongated nuclei lie in the interalveolar connective tissue. The lobules do not have a definite hilus, but the blood-vessels and ducts enter separately. Ducts. The duct of Wirsung while passing through the gland gives off lateral branches, most numerous on its upper and lower aspect, which usually enter the main channel obliquely. The branches subdivide and give off lateral twigs, which ultimately penetrate the tertiary lobules. 1 Anat. Hefte, 1901, Hfte, Iviii, 171. 964 HISTOLOGY OF THE PANCREAS PHYSIOLOGY 965 The pancreatic ducts and their large branches have a wall of connective tissue containing both white and elastic fibers, and lined by columnar cells. Some believe these cells discharge a secretion which mixes with that of the alveoli. In the wall of the duct of Wirsung there are structures having the character of mucous glands. The medium-sized ducts within the secondary lobules have little connective tissue in their walls, and are lined by cubic or low cylindric cells; the smallest ducts, about which the acini are grouped, are formed by a layer of flat epithelium with a large oval nucleus. They appear spindle shaped on longitudinal section. Island Fig. 406. Piece digestion of a human pancreas, showing the limiting membrane of a lobule and the reticulated basement-membranes of the alveoli. In the center is an island of Langerhans with its capsule of trabeculae (X 26) (after Flint). Acini. The shape of the acini varies in different animals. In the human pancreas they are round or oval, and at times have a lobed surface. They do not branch. The cells forming an acinus are shaped like a truncated pyramid with the apex toward the lumen of the acinus (Fig. 407). They constitute the secreting cells. The apical zone contains refractive zymogen granules. There is a basal zone, which is homogeenous except for striations parallel with the long axis of the cell. The granules of the apical zone stain with certain acid dyes, while the protoplasm of the base stains deeply with hematoxylin. There is a nucleus situated near the base of the cell. It is a spheric or, occasionally, oval, and has a well-defined nuclear membrane. There is usually a large nucleolus. The centro-acinar cells lie in the acini in contact with the apices of the secreting cells. They are fusiform, occasionally flat, and may have short projections penetrating between the secreting cells. The protoplasm is nearly homogeneous and the nucleus is small, oval, and rich in chroma- tin. These cells resemble those of the terminal ducts, with which they seem to be continuous. There are at times scattered fat drops in the acini. 9 66 DISEASES OF THE STOMACH AND INTESTINES Changes with Secretion. Haidenhain 1 has demonstrated in dogs that changes occur in the cells of the acini during the period of active secretion of the pancreas. From six to ten hours after a full meal the inner zone, which contains the granules, decreases in size until it occupies only the tip of the cell. The outer zone increases in height, but not as rapidly in proportion as the inner zone decreases, hence, the cell becomes smaller. From the tenth to the twentieth hour after food the cell increases in volume, the apical zone increases in size through accumulation of granules, and the basal zone diminishes in size. In the active or "discharged" gland the granules are comparatively scanty, while in the resting stage they are abundant, and the precursor of trypsin is abundant in the gland of a fasting animal. Outer zone of secretory cells Connective tissue -- Larger glands, duct - Centro-acinal cell Centro-acinal cell Intermediate tubule - Inner granular zone of secre- tory cells Fig. 407. From section through human pancreas; X 450 (sublimate) (Bohm and Davidoff). Islands of Langerhans. These structures (Fig. 408), also known as the interacinar islands, are usually round or oval, and their outlines are frequently denned by a circle of thin connective tissue. In others the shape is less clearly defined. Their size may be from 75 to 175 microns in diameter and occasionally as large as 0.5 mm. DeWitt 2 estimates that their tissue constitutes from ^"25 to ^5 of the total volume of the pancreas. Opie 3 finds that the islands of Langerhans are more numerous in the splenic end or tail; in all, slightly less than three and a half times more numerous in these regions than in other parts of the pancreas. Position of the Islands. This is not constant, though they are most frequently situated in the center of a lobule. 1 Arch. f. d. ges. Physiol., 1875, x, 557. 2 Jour, of Exper. Med., 1906, viii, 193. 3 Johns Hopkins Bulletin, 1900, xi, 205. HISTOLOGY OF THE PANCREAS PHYSIOLOGY 967 Cells of the Island of Langerhans. The cells are polygonal, and are smaller than those of the acini. They have a large round or an oval nucleus, with several nucleoli. The cell body is usually well defined. They are unstained by nuclear dyes, unlike the secreting cells of the acini, while with eosin their protoplasm stains a bright pink. The nuclei vary in size, and occasionally very large nuclei are found, larger than the adjacent cells. The cells lie in columns, between which there are anastomosing capillaries, though at times they are packed together, and the nuclei lie side by side. Fat droplets are found in the islands of Langerhans. Fig. 408. Island of Langerhans of the human pancreas (Opie, "Diseases of the Pancreas"). The protoplasm of the cells of the island is not entirely homogeneous but contains small granules, staining with eosin, safranin, gentian violet, and f uchsin. Lane 1 has demonstrated two varieties of cells, one soluble and the other fixed by Miiller's fluid with bichlorid. Blood-vessels. The capillaries of the island form a glomerulus of tortuous vessels (Fig. 409) which freely anastomose. A single afferent vessel does not enter the glomerulus, as it does in the kidney. There are numerous anastomoses, so that the network within the island is continuous with the capillaries between the acini. There is no evidence in the human subject that there is any connection between the islands and the duct system of the gland. Opie holds that there is no proof that any transition occurs from acini into islands of Langerhans. 1 Amer. Jour, of Anat., 1907, vii, 409. 968 DISEASES OF THE STOMACH AND INTESTINES Intralobular Framework. The connective tissue between the acini near the islands of Langerhans becomes thicker, and forms septa which run into the capsule of the island. The capsule is composed of many small fibers, which are connected on the one side with the alveolar network, and on the other with septa, which stretch across the space within the island, subdividing it into small lacunae, and which act as a support for its cells. In the human subject the age and the condition of the body seem to be the chief factors in determining the amount of intra-insular connective tissue. DeWitt shows that in the pancreas of the newborn infant there is no connective tissue in the islands; in a four-year-old child there is a delicate Fig. 409. Blood-vessels of the pancreas injected in order to show the glomerular arrangement of capillaries in the islands of Langerhans (Opie, "Diseases of the Pan- creas"). capsule and sheaths surrounding the blood-vessels; while in the adult the condition was found as described. The increase accompanying advancing age suggests the condition of fibrosis, which occurs in other organs under similar conditions. Function of the Islands of Langerhans. On account of the intimate relation of the columns of the epithelial cells of the islands to the capillary network, it is believed the islands furnish some substance to the blood, known as the "internal secretion of the pancreas." A study of the pathologic changes associated with diabetes mellitus has shown that the islands of Langerhans control the assimilation of sugar. HISTOLOGY OF THE PANCREAS PHYSIOLOGY 969 PHYSIOLOGY OF THE PANCREAS The Pancreatic Juice. The pancreatic juice is a clear, watery, alka- line fluid, without odor, with a specific gravity of 1.0075 to 1.0098. It consists of approximately 98.5 water and 1.5 solids. One-third to two- thirds of the solids are ash. It contains a small amount of coagulable protein and enzymes, which play an important part in the digestion of protein, carbohydrates, and fat. The gland is inactive when fasting. Secretion begins directly after a meal and reaches its maximum within three hours. The quantity and character of the pancreatic juice depends on the character of the food. Meat causes a rapid secretion of a juice poor in solids, while bread, a slower secretion, but in greater quantity. Milk produces the flow of a small amount of concentrated juice with a low alkalinity. Cause of Pancreatic Secretion. Bayliss 1 and Starling, isolating a loop of the jejunum and severing all its nerve connections, the blood- vessels only remaining, demonstrated that the introduction of hydro- chloric acid into the loop produced an abundant flow of pancreatic juice. Evidently some chemic substance which was transported by the blood from the loop to the pancreas caused the secretion. Acid introduced into the circulation did not excite secretion, and hence it was evident that acid, introduced into the intestines caused the mucosa of that viscus to elaborate some substance which was absorbed by the blood, was carried to the pancreas, and thus excited its activity. Moreover, the epithelial cells of the intestinal mucosa treated with the acid, yielded an extract which, when it was introduced into the circulation, caused an active flow of the pancreatic juice. They named this substance "secretin." As an extract of the cells alone, when injected into the circulation, did not produce pancreatic secretion, it was evident that the acid activated some substance in the cells. They called this "prosecretin." The acid evidently converted the prosecretin into secretin, which last was carried by the circulation and excited the pancreas into activity. Pawlow believed that nervous mechanism, stimulation of the vagus, has a direct influence on pancreatic secretion. Other theories have also been advanced, but the work of Bayliss and Starling is considered con- clusive. Fats and soaps also stimulate pancreatic secretion, but their action is less marked. Holsti 2 through experiments on a man with pancreatic fistula has demonstrated that a psychic secretion of pancreatic juice occurs, just as it does with the gastric juice, though it plays a less prominent part. The psychic secretion of the pancreas independent of gastric causes lasts about half an hour. The epithelial cells of the duodenum and of the jejunum chiefly contain prosecretin. Wertheimer 3 and Lepage found that the acid caused the greatest flow of pancreatic secretion when it was introduced into the duodenum; a less intense flow, lower in the small intestine, and that it disappeared when the lower part of the ileum was reached. Secretin is 1 Jour, of Physiol., 1902, xxviii, 325; 1903, xxiv, 174. 2 Deutsch Arch. f. klin. Med., 1913, cxi, 48. 3 Jour, de Physical et de Patholgen, 1901, iii, 335. 970 believed to influence not only the pancreatic but the gastric glands (through gastrin) and to stimulate the functional activity of the liver and jejunum. Some hold that a hormone is also produced by the spleen which also stimulates the digestive glands. The Ferments. The three chief ferments of the pancreas are trypsin, amylopsin, and steapsin. Some claim there is a lab ferment, on account of the ability of the pancreatic juice to coagulate casein, while others impute this action to the trypsin. Other observers believe there is a "lactase ferment," because of its supposed power of splitting milk-sugar into galactose and dextrose. Nucleate. Nucleic acid is, for the great part, precipitated in the stomach and dissolved in the intestines. This solution of the nucleic acid, which is caused by the pancreatic juice, is attributed to a pancreatic enzyme, "nuclease." 1 Others believe it to be simply a property of trypsin. Trypsin. Trypsin does not exist as such in the secreting glands of the pancreas, and extracts of the fresh glands do not act upon protein. It is believed that the pancreas contains trypsinogen, since the juice which is obtained from the pancreatic duct after the use of secretin contains this enzyme. The intestinal juice (succus entericus) contains an enzyme "enterokinase," which transforms the inactive trypsinogen into active trypsin. Pawlow, on the other hand, claims that the pancreatic juice of a dog fed on a meat diet contains trypsin. Trypsin is a proteolytic ferment, and not only forms albumoses and peptones from protein, but the action is more prolonged, so that they are transformed into amino-acids. The action is most powerful in a weakly alkaline solution, but it will act in a neutral or even faint acid medium. Free mineral acids destroy the ferment. Organic acids are less harmful. Collagen, the constituent of connective tissue, is not acted on by pancreatic juice unless it has been previously boiled with water or has been acted on by dilute acid, hence, connective tissue is not digested if the stomach has been removed or if the secretion of the acid of that organ is interfered with. Gelatin is converted into gelatin peptones and elastin is dissolved. Mucin and nucleoproteins, after preliminary cleavage, undergo digestive changes. Starling has shown in the fasting animal that a mixture of the pancreatic juice with the intestinal secretions may give rise to inflamma- tion and erosions of the intestinal wall. In the case of pancreatic fistula similar effects on the skin are produced. Steapsin. The digestion of fat is peculiarly a function of^the pancreas. Neutral fats, we must remember, owing to a gastric lipase ferment, undergo slow changes in the stomach, and fine emulsions, as occurring in the yolk of eggs and milk, are more completely digested. This is of importance in the case of infants before the lipolytic function of the pancreas is developed, and also in adults whose pancreas is diseased. Steapsin, the fat-splitting enzyme of the pancreas, acts in an alkaline, neutral, or acid reaction. It splits neutral fats into fatty acids and 1 Umber, Zeit. f. klin. Med., 1901, xliii, 282. HISTOLOGY OF THE PANCREAS PHYSIOLOGY 971 glycerin. When an alkali is present, the fatty acids form soluble alkaline soaps. These, together with the glycerin, are absorbed by the epithelial cells of the walls of the intestines, within which they are synthesized to form neutral fat. Steapsin can also decompose a number of esters of fatty acids, such as ethyl-butyrate, and the latter can be used as a test for the presence of the fat-splitting enzyme. The amount of acid formed measures its activity. The action of the enzyme is reversible. 1 Bile increases the activity of the fat-splitting enzyme several times. Its method of action is unknown. Amylopsin. This is an amylolytic enzyme which converts starch into dextrin, and, finally, into maltose. Little, if any, dextrose is formed from starch, and invertin is not produced. Amylopsin acts in the presence of a weak acid and is somewhat inhibited by a weak alkali. Amylopsin is not present in the pancreas of the new-born infant, and does not appear until "more than a month after birth. Autodigestion of the Pancreas. Self-digestion of the pancreas after death of the subject occurs in about 50 per cent, of cases. It is attributed to the proteolytic enzyme. 1 Kastle and Lovenhart, Amer. Chem. Jour., 1901, xxiv, 491. CHAPTER XL METHODS OF DIAGNOSIS IN PANCREATIC DISEASE TESTING THE FUNCTIONS OF THE PANCREAS THE pancreas has two secretions, an internal and an external. The former passes into the blood and is concerned with the metabolism of sugar. It also appears to have an antagonistic influence on the secretion of the adrenals, as Loewi has shown by experiment that, in dogs whose pancreas had been removed, dilatation of the pupil took place after instilla- tion of adrenalin into the eye. The external secretion, which contains the proteolytic, fat-splitting, and amylolitic ferments (and, as some believe, a lab ferment and nuclease), will first be referred to in this chapter. In order to properly test the digestive capacity of the pancreatic juice, and to arrive at some definite conclusion as to whether this organ is suffering from a temporary disturbance of one or more of its functions, or whether there is permanent disability, i.e., a diseased condition, the author believes that numerous factors must be taken into consideration, and that the diagnosis must often be made by the process of exclusion. Temporary Disturbances of Function. In acute febrile conditions, in typhoid fever, for example, there is a disturbance of all the digestive secre- tions, salivary, stomach, liver, intestine, and pancreas. As a result, the digestive function of the pancreas is diminished. This has been previously referred to by the author under Typhoid Fever, and is, from his viewpoint, a scientific reason for the avoidance of excessive forced feeding, 4500 to 5500 calories, during the active stage of this disease. Duodenitis may complicate the typhoid. There may be temporary disturbances of the pancreas for any one or for all of the functions, to which reference is made under Intestinal Dyspepsia. Catarrh of the duodenum may temporarily disturb the functions of the pancreas by interference with the formation of its activating prosecretin, or its conversion into secretin, and it also interferes with elimination of the enterokinase which activates the trypsinogen. The catarrh may spread into the common bile-duct and into the pancreatic duct; in the latter instance interfering with the pancreatic secretion, and also partially or completely block the common duct. Obstruction of the pancreatic duct, from the pressure of tumors or from calculi in the common duct, or similar conditions affecting the pancreatic ducts, are the most frequent causes which may give rise to a more or less complete absence of the pancreatic secretion from the intestine. Atrophy, fatty degeneration, or sclerosis of the pancreas may result. With interference with the biliary excretion, the digestion of fat would be markedly diminished and the pancreas might be involved. A negative sublimate test would suggest that suppression of bile was the cause. This further shows the necessity of care in diagnosis. Anemia, 972 METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 973 nervous exhaustion, fright, grief, mental overwork, worry or fatigue from excessive muscular work, or sexual excess, Herter gives as further causes of temporary disturbance of the pancreatic secretion. With chronic duodenitis, which extends into the ducts, permanent damage to the pancreas may result. Other Conditions Obscuring the Diagnosis. With tuberculosis of the intestines and peritoneum, sprue, and amyloid disease, fat absorption is impaired, and these facts must be held in consideration. Enterocolitis with diarrhea, the use of purgatives, and excesses in diet in reference to meat, fats,, and carbohydrates, must also be considered. The gastric secretion under certain conditions influences fat digestion when the fat is contained in meat. For example, collagen, the chief constituent of con- nective tissue, is not acted on by the pancreatic juice unless previously boiled with water or unless it has been acted on by an acid. Deficiency or absence of hydrochloric acid in the stomach, therefore, may cause the appearance of an abnormal quantity of fat in the feces. On the other hand, fats and soaps stimulate pancreatic secretion to a certain degree, and this undoubtedly accounts for the fact that in achylia gastrica, with the absence of hydrochloric acid, nutrition may be improved by the adminis- tration of fats, such as cream, butter, milk, etc. Therefore, in testing the digestive capacity of the pancreatic juice, these facts may be taken into careful consideration. At the end of the chapter the author recommends the methods which he considers most practical. There are two methods of obtaining the pancreatic ferments, the direct and the indirect. Direct Methods. Boas has obtained the duodenal contents by passing the stomach-tube into the empty stomach and massaging near the duodenal region, thus forcing the juice into the stomach; while Hemmeter and Kuhn have passed the stomach-tube directly into the duodenum. These procedures are uncertain. Einhorn has employed the duodenal bucket and has also endeavored to catheterize the duodenum. They are impractical. There are two methods more recently introduced by which it is possible to secure in some cases, but not in all, the duodenal contents. There are two instruments reported almost synchronously, the duodenal tube of M. Gross 1 and the duodenal pump of Einhorn. 2 The Gross Tube. This instrument is depicted in Fig. 410. It consists of a perforated round metal ball about twice the size of a pea, to which is attached a thin rubber tube 0.2 cm. in diameter and 125 cm. in length, marked every 10 cm. To this is attached a glass receptacle (bulb), which is connected by a length of tubing with a mouth-piece, which the operator can use to aspirate, or to which an aspirating bulb can be attached. Gross recommends the following method: 3 "Test-meal. The patient is given in the morning a tumbler (250 c.c.) of milk and water, equal parts. This mixture does not cause a great flow 1 N. Y. Med. Jour., Jan. 8. 1910. 2 Med. Rec., Jan. 15, 1910. 3 Jour. Amer. Med. Assoc., April 23, 1910. 974 DISEASES OF THE STOMACH AND INTESTINES of hydrochloric acid and contains sufficient fat to stimulate the pancreatic secretion. Half an hour later introduce the duodenal tube. " Technic. The patient swallows the ball and tube, previously wet in water, until the mark 45 cm. reaches the lips. Then blow lightly through the tube into the stomach, so as to smooth the tube out and that it will hang freely in the cavity. The patient should then lie down and slowly turn over on the right side, in which position, after a few minutes, the tube is allowed to glide down through the mouth without swallowing, following the pull of the ball, until the mark 60 cm. has been reached. After five or ten minutes the first aspiration may be made, which usually shows contents of a slightly yellow tint. The patient, with the mouth still partly open, should not make any swallowing movements. Gradually the tube will be drawn down to the 65 or 70 cm. mark. "A second aspiration is then made, and usually a yellowish fluid, free from casein, will be aspirated, giving a weakly acid or acid reaction. Fig. 410. Gross duodenal tube. One should wait a little longer and, after several aspirations, the yellow aqueous contents of the duodenum will usually be secured, giving a neutral or alkaline reaction, and at times a greenish-yellow fluorescence." Precautions. Occasionally the aspirated fluid remains acid, probably due to hyperchlorhydria, and, therefore, neutralization of duodenal con- tents may occur lower down. As a check, give a cup of coffee with the tube in place. Aspiration should be performed, and if the fluid is still green, the contents are duodenal. This may be proved by withdrawing the tube a short distance and reaspirating, when the coffee will appear. Gross holds that unless there is a mechanical obstacle at the pylorus, it is usually possible to pass through the pylorus with the tube and into the duodenum within an hour. 1 Einhorn's Duodenal Pump. This instrument, similar in principle to the one already described, is readily understood from the illustration (Fig. 411). It has three markings 40 cm. (cardia), 56 cm. (the pylorus), and 70 1 N. Y. Med. Jour., July 9, 1910. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 975 and 80 cm. distance from the capsule. The duodenal contents are aspirated out by the syringe, the cock turned, and they are then ejected into a vessel, and so on. It is to be noted that Einhorn 1 now suggests in many cases that the tube be inserted on retiring at night and be left thus for some hours before attempting aspiration. The patient in the fasting condition drinks a cup of tea with sugar and without milk, and then about one-half to three-quarters of an hour later the capsule and tube are lubricated in water and gradually swallowed, the effort being aided by drinking about half a glass of water. In some cases 200 c.c. milk, bouillon and raw eggs are given one to two hours before aspiration. To be sure that the capsule has entered the stomach and is not kinked, one can aspirate and determine the presence of gastric con- tents. A syringeful of water is then forced through the tube and then one of air, and the tube is then shut off by the stop-cock and the thread hitched over one ear. The patient should not close the lips or teeth and should read for about an hour. Fig. 411. Einhorn's duodenal pump: a, Metal capsule, lower half provided with numerous holes, the upper half communicating with tube 6; I, II, III, marks of I = 40, II = 56, III = 70 cm. from capsule; c, rubber band with silk attached to end of tubing, which can be placed over the ear of the patient; d, three-way stop-cock; e, collapsible connecting tube;/, aspirating syringe. When the tube reaches the mark 70 cm. at the lips, aspiration is attempted. If the capsule is in the duodenum, on aspirating one generally obtains a golden-yellow watery liquid of alkaline reaction, somewhat viscid in consistency. Einhorn 2 now recommends, as soon as the flow commences, that the piston of the syringe be removed and the barrel be kept low, so as to siphon out the fluid. At times one does not obtain the duodenal contents, as the tube may coil in the stomach. If acid gastric contents are obtained, withdraw the tube to the 56-cm. mark, wash it out with water, and then blow in air, and in half an hour try again. When the tube lies in the stomach, it does not collapse on aspiration; when it lies in the duodenum, it collapses and aspiration is slower. As a further test, one can give the patient a little milk with the tube in place, and if the capsule lies in the duodenum no milk will appear. r. Jour. Med. Sci., October, 1914, No. 4, vol. cxlviii. - Jour. Amer. Med. Assoc., July 2, 1910, vol. TV, pp. 6-8. 976 DISEASES OF THE STOMACH AND INTESTINES Palefoki has also devised a duodenal tube, an improvement on those described. There are others also reported. The writer finds these methods of obtaining the duodenal contents are by no means always successful. I have succeeded in entering the duodenum in a little over an hour's time in a patient with normal gastric motility, but on other occasions have been obliged to wait a number of hours. Patients who have an irritable pharynx and esophagus will not retain the instrument for the time necessary to secure the duodenal contents. In cases where there is pyloric stenosis, even of no marked degree, in the atonic dilatation of the stomach, and often in atony of the stomach, the procedure may prove a failure. With normal conditions of the stomach it may sometimes be unsuccessful, or only a drop or two or no contents be extracted, even when the tube is apparently in the duodenum. Moreover, the pancreatic ferments are active, even in very small quantities, and as long as there is any pancreatic tissue functionating and the possibility of its escape into duodenum, one would expect to secure the reactions due to their presence. This last view is referred to by Deaver. 1 The mere presence of the ferments, therefore, is not conclusive that there is no pancreatitis. Einhorn states, however, that if one of the fer- ments is persistently absent it usually 2 indicates chronic pancreatitis. He does not claim it invariably does so. The Schmidt-Strassburger diet might show marked deficiency in pan- creatic function for an average diet, while the direct test indicated the pancreatic ferments to be present. The writer believes the tests of the intestinal functions should be used in every case. EXAMINATION OF THE DUODENAL CONTENTS Bile-pigment. Add i c.c. of fuming nitric acid to i c.c. of the duo- denal contents in a test-tube and note if Gmelin's reaction occurs. With sufficient bile, the juice turns green. The following simple tests are suggested by Einhorn for the ferments: 3 Steapsin. Take i drop of neutral milk, 2 drops of water, and 2 to 3 drops of the duodenal contents, which should be neutralized if the reac- tion is acid, and add a small piece of blue litmus-agar. Place this in a small test-tube and keep it at blood temperature. If steapsin is present the agar piece turns red in twenty to thirty minutes, owing to the develop- ment of fatty acids. The writer finds an excellent incubator is a Thermos bottle containing water at 99 to iooF., in which the corked test-tube can be placed. - Nile-blue sulphate has been advocated by Lohrisch as a specific stain for fat in the examination of feces and gastric contents. Neutral fats assume a red color, while fatty acids become blue. Employ olive oil. 25 gm. 1 Ibid., April 15, 1911. 2 N. Y. Med. Jour., Oct. 18, 1913. 3 Am. Jour. Med. Sci., October, 1914, No. 4. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 977 Agar-agar, 2 gm. Sol. nile-blue sulphate (i :2OOo), add 100 gm. The olive oil nile-blue tube which has a violet tint becomes blue when steapsin is present. It otherwise remains unchanged or becomes slightly purple. The amount of agar column in millimeters turning blue represents the approximate quantity of the fat-splitting ferment. These tubes can be prepared in any laboratory or can be secured from Eimer and Amend. They are recommended by Einhorn. He suggests 1 specially prepared tubes of agar powder but they possess no advantages. Trypsin. If the fluid (duodenal) is acid, neutralize it and place in it a small piece of white of a hard-boiled egg. Keep it a few hours at blood temperature. If trypsin is present, the albumin disappears. Amylopsin. To test for diastase, use a boiled starch solution or starch- paper. Either mix the duodenal contents with equal parts of starch solution or insert in it a strip of starch test-paper, and leave it at blood temperature. In half an hour to an hour add a weak iodin solution, and if dextrin is present, the starch solution or paper turns blue; if erythro- dextrin is present, we have a red color. One must always note with litmus-paper the reaction of the duodenal contents. It is usually alkaline, though occasionally HC1 is present, giving an acid reaction. Gross 2 recommends the following, though more complicated tests are suggested: Amylopsin. A quantity of a i per cent, aqueous solution of Kahl- baum's soluble starch is heated in the incubator to 55C.; also a number of empty test-tubes are heated up; 5 c.c. of the heated starch is put in a hot tube, 4 drops of duodenal juice are added, and the tube shaken for about a minute; ^ c.c. of a 25oth normal iodin solution is then added. This normal iodin solution consists of an aqueous solution of equal parts of iodin, iodid of soda, potassium iodid, and ammonium iodid, i : 250. If no amylopsin is present, the solution becomes blue; or green if bile is present ; if traces of amylopsin are present, it turns blue violet ; if marked traces, then red violet; if the quantity is normal, then pale pink; and if an excess, then it is colorless. If to this solution Fehling's alkaline solution is added, it will become colorless. On the addition of Fehling's copper solution on boiling, the sugar reaction occurs, if such is present. Steapsin. Melt some fresh butter and abstract the clean, pure fat mixture with a little o.i per cent, aqueous carbonate of potash and phenolphthalein solution, and then shake and titrate with liquor sodae until a distinct red coloration remains. This solution is then heated in the incubator to 55C. Then 5 c.c. of this is shaken with 5 drops of intestinal juice in a heated test-tube. If there are normal quantities of steapsin, the red color will disappear in from two to five minutes. The quantity of active steapsin can be estimated from the rapidity of this discoloration. 1 Med. Rec., Oct. 12, 1912. - Med. Rec., May 21, 1910; Ibid., Nov. 12, 1910. 62 978 DISEASES OF THE STOMACH AND INTESTINES Trypsin. Mix a solution of 0.07 per cent, copper sulphate and o.i per cent, sodium carbonate with a few drops of Fehling's alkaline solution and a 5 per thousand of casein. Heat this in an incubator to 5 5C. Shake up 5 c.c. of this with 5 drops of the duodenal contents. The color is at first blue or green if bile is present. Depending on the quantity of trypsin, it will become more or less red violet, and after a few minutes, pink. Indirect Methods of Obtaining the Ferments. Pawlow 1 discovered that if he administered oil, to dogs having a gastric fistula, within one or two hours he was able to obtain an emulsion containing bile and pancreatic juice due to the regurgitation of the duodenal contents into the stomach. Boldyreff 2 used a combination of fatty acid in oil and secured a regurgitated fluid containing trypsin. Levinsky 3 advises giving half a teaspoon of magnesia usta twenty minutes before the oil, and a second dose twenty minutes after, to neutralize the acidity of the stomach contents. This is the method that is usually employed. The technic is as follows: First determine the acidity of the gastric juice and if free hydro- chloric acid is present; then on an empty stomach one-half teaspoon of magnesia usta is given in water, and this is followed in twenty minutes to half an hour by 200 c.c. of olive oil, and twenty minutes later by another half teaspoon of magnesia usta. Three-quarters of an hour later the stomach should be aspirated, and the fluid, which is often greenish yellow, should be placed in a separating funnel. The oil rises to the surface. The lower part of the fluid is tested for trypsin and the other ferments. Abderhalden and Schittenhelm, 4 in order to determine the presence" of trypsin, advise the use of the polypeptid, glycyltyrosin. This optically active peptid cannot be split by pepsin, but is acted on by trypsin, the tyrosin crystallizing out. They have also employed a solution of silk peptone, which contains 40 per cent, tyrosin, and observe the rotation of light by the polariscope. The author believes the simpler methods to determine the presence of the ferments to be preferable for the general practitioner. Securing the Ferments from the Feces. The O. Gross 5 method is usually employed. He recommends a high protein diet for two to three days previous to the test, and a mild saline purgative the morning of the day when the test is to be made, so as to hurry the stool through the intestinal tract, that there may be less loss of ferment by bacterial action. The stool should be examined as soon as possible. A solution of ]4 gram of casein (Grubler) is dissolved in i liter of sodium carbonate solution (i : 1000). A portion of the stool is rubbed up with three times the amount of soda solution and filtered; 10 c.c. of this filtrate are placed in a small flask with 100 c.c. of the casein soda solution, and a little chloroform is added. The mixture is then put 1 Arbeit der Verdauungsdriisen, Wiesbaden, 1898, pp. 159-161. 2 Report of International Physiolog. Congress, Brussels, 1904. 3 Deutsche Medezin Wochenschr., 1907, p. 403. 4 Zeitschr. fur Physiolog. Chemie., Ixi, p. 421, 1909. 5 Deut. Med. Woch., 1909, Nr. 16. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 979 in the incubator at 38C., and after four and eight hours respectively is tested by taking out 10 c.c. and adding to it with care, drop by drop, a i per cent, acetic acid solution. If the solution is clear, the casein has been digested; if it becomes cloudy, the flask is put back into the incubator and tested again after twelve, fourteen, and twenty-four hours. At the end of this time, if no digestion has taken place (if the solution is still cloudy), trypsin is absent or very markedly diminished. Frank recommends the use of the Berkfeldt filter under pressure before this test, in order to insure a clear filtrate, but it is difficult to clean, and some of the ferment is liable to be lost. When we estimate the value of the casein method we must remember that the erepsin in the intestinal juice and bacterial action have some digestive effect on this product. Attempts have been made by Schitten- helm 1 and Frank to isolate erepsin. Muller's Serum Plate Method for Trypsin. This method 2 is as follows: A glycerin injection is first given to empty the lower bowel. The patient is then given a test-meal of 150 grams of meat and 150 grams of potato gruel, and several hours later a strong laxative is given. If the stool which results is thick, rub it up with glycerin water (10 in 1000). If it is acid or neutral, render it alkaline with soda. Small drops of the feces are then placed on the surface of a serum plate. This last consists of a Petri dish covered with a fairly thick, layer of coagulated blood-serum. This is then placed in an incubator at 50 to 6oC. If an active proteolytic ferment is present, small depressions soon appear in the serum due to digestion by the enzyme. In the absence of the ferment no depressions occur. The ferment contained in leukocytes will produce pitting of the plate, so that if pus or blood are present in the stool the specimen should be discarded. If large quantities of fat are present, it may interfere with the test. The fat should be first removed by shaking out with ether. Schmidt's Nuclei Test. Adolf Schmidt 3 introduced a test which depends on the power of the pancreatic juice to dissolve the nuclei con- tained in meat. Small pieces of meat are hardened in absolute alcohol and enclosed in small gauze bags. These are soaked in water for some hours and then swallowed. The stool is searched for the bags, and the contents are frozen, cut, and then stained with hematoxin, and examined for the presence of nuclei. If they are not found, one presumes the pancreatic juice has digested them. If they are present, it is assumed that the juice is absent. There is a question as to how much the digestion of the nuclei is affected by erepsin, and Klieneberger 4 states that nuclei have been found intact when the pancreas was not involved. Einhorn disputes the test. Moreover, in cases of diarrhea the bags may pass through so quicky that the pancreatic juice has no chance to act, and in cases of marked intestinal putrefaction the nuclei may be destroyed. 1 Zentralblatt der Gesamt. Physiol. und Pathol. des Stoffwechsels, 1909, Nr. 23. 2 Medizin. Klinik, 1909, Nr. 16, p. 573. 3 Deut. Med. Woch., 1899, Nr. 49, p. 811. 4 Medizenische Klinik, 1910, p. 89. 980 DISEASES OF THE STOMACH AND INTESTINES Sahli's Test. 1 He employs a gelatin capsule hardened with formol and containing 0.5 gm. of iodoform, or one with 0.25 gm. of salol. The capsule is given with the Ewald test-meal, and normally iodin can be recovered in the saliva, or salicyluric acid (from the salol) in the urine in four to six hours. A strip of starch-paper moistened with the saliva and touched with fuming nitric acid gives a violet or blue color for iodin from the iodoform capsule. The urine tested with neutral ferric chlorid solution gives a violet color when the salol test is used. Sahli prefers the salol test. Two or three of the salol capsules are given. One should be sure of the condition of the motor function of the stomach, and this should be first investigated. Absorption from the intestines would be interfered with by a catarrhal condition, and in case of diarrhea the capsule may pass through unchanged. All these conditions must be considered. Sodium Fluorid Fibrin Test. This method, devised by Huber and Arthur, 2 consists in soaking strips of fibrin in a 2 per cent, solution of sodium fluorid for twenty-four hours at 4oC. The material to be tested is then diluted with an equal amount of the sodium fluorid solu- tion, and the whole is digested for a considerable time at 4oC. If trypsin is present, crystals of tyrosin appear. THE FATS IN THE FECES Normally, little more than 5 to 10 per cent, of fat escapes absorp- tion. Impaired assimilation of fats and proteins is more readily recog- nized than alterations affecting the digestion of the carbohydrates. Experiments on animals have demonstrated that extirpation complete or partial or destruction of the pancreas is attended by a defective absorption of fat, except of the emulsified fat of milk, in which case a greater proportion was assimilated. Similar disturbances of digestion occur in human cases, where the pancreas has been partially destroyed by chronic inflammation, by cysts, and by new growths. Occlusion of the duct caused by calculi or by tumor, followed by degenerative changes in the gland, may produce the same effect. Opie 3 shows that even when the duct of Wirsung is obstructed the pan- creatic juice may reach the intestine through the duct of Santorini in about three-fourths of all individuals, and that often digestion proceeds with no manifest impairment. In estimating whether a true fatty stool (steatorrhea) is present, one must exclude the acholic stool due to the absence of bile-pigment. The acholic stool is grayish white, ash gray, or of clay color, due to the absence of bile-pigment. Dilute fecal matter added to a strong solu- tion of bichlorid of mercury is colored red when unchanged bile-pigment is present. A negative sublimate test suggests the suppression of bile through occlusion of the bile-duct. There is considerable fat in the acholic stool, seen microscopically as needle-shaped crystals or in sheaves of crystals, or, at times, in fat-droplets. Owing to the absence of bile from the in- 1 Lehrbuch der Klinischen Untesruchungs Methoden, 1909, p. 570. 2 Arch, de Physiologic, 1898, p. 622. 3 Disease of the Pancreas. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 981 testinal tract, the emulsifying power of the pancreatic juice is diminished and excess of fat appears. Moreover, an abnormal quantity of fat may appear in the stools of healthy individuals after the ingestion of great quantities of fat. The stool may also be devoid of color or grayish white where there is no jaundice and no occlusion of the bile-ducts, with stercobilin present and large quantities of fat, in conditions where the absorption of fat is impaired, such as with tuberculosis of the intestines and tuberculosis of the mesen- teric glands. Fat may also appear in excess in the stools in extensive catarrh of the intestines and in conditions accompanied by active peristal- sis. Only in the absence of the above conditions is the presence of excessive fat in the stools an aid to the diagnosis of pancreatic disease. Steatorrhea. This term is strictly applied to those cases in which the fat is discharged in the feces as an oily yellow fluid, or in isolated masses, visible to the naked eye. Opie states there are some cases of pancreatic disease in which the feces are clay colored or grayish white, frequently with a metallic or asbestos-like appearance, and that the increased quantity of fat can be demonstrated only by microscopic or chemic examination. These stools contain fatty acids, neutral fats, and soaps. Steatorrhea may follow the loss of pancreatic secretion, and Fitz demonstrates its diagnostic value when it is present. Up to 1903 he collected only 29 cases in which there were fatty stools in patients in whom there was conclusive evidence of pancreatic disease. Theodor Brugsch 1 states that in pancreatic disease, without jaundice, the average loss of fat is 64 per cent.; with mild jaundice associated, the loss is 72 per cent. While in cases in which the bile is completely shut off, the loss of fat is 87 per cent. A case of carcinoma has been reported by Robson in which 93 per cent, of the dried feces was fat, and with chronic pancreatitis the fat per cent, has been as high as 80 to 82. With pancreatic disease, observers report a great reduction in split fat. Fr. Miiller 2 states that in normal feces from 20 to 30 per cent, of the fat is neutral fat, while from 70 to 80 per cent, is split fat, in the form of fatty acids and soaps. With pancreatic disease, the feces, on the other hand, may contain a diminished proportion of split fat, although the total fat may not be increased. Fitz has collected seven cases of pancreatic disease without jaundice in which there was no Steatorrhea. The proportion of neutral fat was normal or less than normal in only one case, while in the rest it averaged 56.84 per cent. One must remember that cases of undoubted pancreatic disease occur in which there is no marked loss of fat, so that the absence of Steatorrhea does not exclude pancreatic disease. The author has already referred to the fact that though disease of the pancreas is present, that even with closure of the duct of Wirsung, a iLehrbuch Klinischer Untersuchungs Methoden, 1909, p. 371. 2 Zeit. fur Klin. Med., xii, p. 51, 1887. 982 DISEASES OF THE STOMACH AND INTESTINES patent duct of Santorini may allow the escape of pancreatic juice into the intestines. Early in the stages of the disease, little change will occur in the fat content of the stool, and if little fat be ingested by the patient or milk be taken, in which form the emulsified fat is readily absorbed, no noticeable difference would occur. Some have also offered the theory that there is an increase in the activity of the stomach lipase. One must consider all these possibilities, and hence early diagnosis is often difficult and frequently impossible. In order to estimate the amount of fat in the stools, it is necessary to employ a test-meal containing known amounts of fat. One can employ the Schmidt-Strassburger test-diet or Steele's modification, as under Testing the Intestinal Functions, or that recommended by Brugsch, which consists of 2 liters of milk, 150 grams of white bread, and 50 to loo grams of butter. With this meal a capsule of carmine is given to identify the resulting stool. It would seem best to divide this into two or even three meals. The characteristics of a fatty stool have already been described. Robson and Cammidge describe a special method of their own for determining the fat in the feces. Their technic is as follows: Fig. 412. Schmidt-Stokes milk-tube (Robson and Cammidge). "They employ two dry, clean Schmidt-Stokes milk tubes, which they label 'A' and 'B' (Fig. 412). Each is provided with a 10 c.c. mark. About > 2 gram of finely powdered feces, which have been dried on a water- bath, is introduced into the lower bulb of each tube. "The residue, on the watch-glass used for weighing and on the sides of the short funnel through which the powder is poured into the tubes, is washed down by a fine jet from a wash bottle, which for A tube contains hydrochloric acid (i 13), and for B tube, plain water. "The sides of the tubes are also washed until all is collected in the lower bulbs, and the tubes are each filled with solution to the 10 c.c. mark. "Tube A is then heated in boiling water for twenty minutes, rotating it occasionally so as to thoroughly mix its contents. After it is cooled, both tubes are filled to the 50 c.c. mark with ether. They are then tightly corked and inverted about forty times, so that all the material runs from bulb to bulb at each turn. Each tube is then rotated between the hands and then allowed to stand for half an hour or more, so that the solid residue may collect in the lower bulbs. The upper layers of ether in the tubes should be clear and free from solid particles. "Draw off from each tube 20 c.c. of the ethereal extract with a pipet, and place each in a CO 2 flask of known weight, also noting the amount of ether left in the two tubes. "The ether in each flask is then evaporated, the residue dried on a water-bath, and the flasks are again weighed. METHODS OF DIAGNOSIS . IN PANCREATIC DISEASE 983 "From the amount of extract yielded by the 20 c.c. of ether, and the quantity of ether left in the tubes, the total amount yielded by the weight of dried feces used may be calculated, and from this the percentage in the stool may be determined. "The result from tube A gives the total fat in the feces, i.e., neutral fats, free fatty acids, and combined fatty acids or soaps; since the latter are decomposed by boiling with hydrochloric acid and are thus rendered soluble. "The residue from B tube represents the neutral fats and fatty acids, as the soaps are undissolved by the ether. "The difference between the two gives the proportion of saponified fat. Other substances in the feces are negligible. For convenience we may say tube A gives the total fat, tube B, the 'neutral fat,' and the difference between the two, the 'fatty acid.' "Robson recommends testing the solid residue of tube B for ster- cobilin. The contents of B are filtered off, then extracted with acid alcohol, the extract neutralized with ammonia, and then mixed with a quantity of 10 per cent, zinc acetate in alcohol. The precipitate is re- moved by filtration and the clear filtrate examined through a lens against a black background. "A green fluorescence indicates the presence of stercobilin. The intensity of the color varies with the amount of the pigment." The total absence of pancreatic juice and bile, however, does not always put an end to the fat-splitting process in the intestines; by the organisms of the colon group fats are converted into glycerin and fatty acids in the lower part of the small intestine. Absorption will be dimin- ished, and they will be largely excreted in the feces. The appearance of a larger proportion of saponified fat in the stools than would be expected in some cases of severe pancreatic disease, is probably explained in this way. The author has already referred to the influence of simple biliary obstruction, defective gastric digestion, excess of fat in the diet, disease of the intestinal mucosa, intestinal tuberculosis, tubercular peritonitis, etc., which would all influence the excretion of fat, and which must be excluded. Color of the Stool in Steatorrhea. The white appearance of the feces due to diminution or exclusion of the pancreatic secretion from the intestines can be attributed chiefly to the presence of excess of fat, especially the crystalline fatty acids. It is believed to be partly due to the reducing action of bacteria growing anerobically in an acid medium. Miiller has attributed it chiefly to the absence of bile through the blocking of the biliary passage. When such occurs it would be a contributory factor, but it can be demonstrated that bile is present in some cases. THE USE OF PANCREATIC ENZYMES AS AN AID TO DIAGNOSIS; PANCREATIC INFANTILISM In the case of animals in whom the pancreas has been removed, it was found possible to increase the assimilation of fats and proteins by the administration of fresh pancreas. 9 8 4 DISEASES OF THE STOMACH AND INTESTINES Pancreatic Infantilism. Bramwell 1 describes a case in which he believed that retarded development was due to deficient pancreatic action. The patient, eighteen years of age, had suffered from diarrhea for nine years, and there was arrested development after the age of eleven. There were disappearance of diarrhea and a rapid increase in weight after the administration of a glycerin extract of the pancreas. Thompson 2 and Rentoul 3 record similar instances, though Herter is inclined to attribute them to chronic intestinal putrefaction. In this connection the author refers his reader to a case of infantilism with hypochlorhydria and chronic intestinal putrefaction under the section Fig. 413. Microscopic characters of the residues met with in the stools in cases of pancreatic disease and biliary obstruction: a, Striated muscle- fibres; b, fat globules; c, free fatty acid crystals; d, combined fatty acid (soap) crystals (Robson and Cam- midge). "Hypochlorhydria." The treatment for the condition is fully described in that article. Robson and Cammidge report a case of chronic pancreatitis demon- strated by operation, in which after the administration of "pancreon" the neutral fat was diminished over 40 per cent., and the fatty acid in- creased ii per cent, in the stools. The use of pancreatic extract might, therefore, be of some aid to diagnosis, especially if improvement in the stools, with diminished fat excretion, resulted therefrom. This would suggest at once pancreatic deficiency. Azotorrhea. The presence of unaltered muscle-fibers in the feces is significant of disturbance of protein digestion. Fitz 4 found only eight cases in which this occurred in pancreatic disease. 1 Scottish Med. and Surg. Jour., 1904, xiv, 321. - Robson and Cammidge. 3 Brit. Med. Jour., 1904, ii, ion. 4 Trans. Cong, of Amer. Phys. and Surg., 1903, vi, 36. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 985 Examination should be made under the microscope, where the muscle- fiber is readily recognized (Fig. 413). Rarely, undigested muscle can be detected in the stool with the naked eye. In forming proper judgment, one must exclude an excessive meat diet, and also cases in which for any reason there is increased peristalsis, as in intestinal catarrh, or intestinal putrefaction with secondary diarrhea. In such event, the contents are hurried through the intestines before they can be digested. The stomach, moreover, digests the connective tissue of meat, and deficient gastric digestion would lead to imperfect digestion of muscle, since the meat fibers, under such conditions entering the intestines, bound together by connective tissue, would be attacked less rapidly by the pancreatic juice. Undigested meat fibers would thus readily pass through the intestinal canal. Nitrogen in the Feces. Under normal conditions only 5 to 6 per cent, of nitrogen is lost in the feces. In a case of pancreatic diabetes, Hirschfeld 1 recovered 32 per cent, of the nitrogen ingested with the food. In pancreatic disease without jaundice, 2 the loss of nitrogen is 21 per cent. ; while if jaundice is present, it may reach 33 per cent. CARBOHYDRATES IN THE STOOL. PANCREATIC DIASTATIC FERMENTS Though extirpation of the pancreas in animals causes disturbance of the digestion of the carbohydrates, so that an increased proportion of starch ingested reappears with the feces, Opie holds that the determination of the undigested carbohydrates in the human being acquires no signifi- cance for the diagnosis of pancreatic disease. Robson and Cammidge find that though in some instances of pan- creatic disease a larger proportion of carbohydrates than normal is found in the feces, this is not constant even in marked cases. The fact that the patient, in spite of an abundant carbohydrate diet, loses weight, points to a diminished assimilation of carbohydrates in excess of the conditions indicated by the feces, and hence the figures given by analysis of the stool are not the true index of the loss of carbohydrates to the organism. The difference between the quantity assimilated and that found in the stools is probably explained by bacterial action. The influence of a pathologic condition of the fecal flora (see Testing the Intestinal Functions) must also be considered. Hyperchlorhydria would be productive of fermentation of the carbohydrates in the stomach, and catarrh of the intestines would have an influence. One is, therefore, compelled to arrive at definite conclusions after a process of careful elimination. Wohlgemuth 3 introduced the method of estimating the diastatic ferments in the feces. Wynhausen 4 employs the following method: "Five c.c. of a i per cent, solution of soluble starch (Kahlbaum) 1 Zeit. f. Klin. Med., 1891, xiv, 294. 2 Lyle, N. Y. Med. Jour., May 28, 1910. 3 Zeitschr. fur Biochemie, ix, 1908. ( Berlin. Klin. Woch., July, 1909, p. 1406. 986 DISEASES OF THE STOMACH AND INTESTINES are each placed in several test-tubes of the same size, and graduated quantities of the filtrate of a thin stool are added to each. The tubes are placed in an incubator at 4oC. for twenty-four hours. At the end of this period they are filled to within a finger-breadth of the top with distilled water. To each is then added i drop of one-tenth normal solution of iodin and the resulting color is noted. If the starch is un- digested, a blue color results; if erythrodextrin is present, it is red; if complete digestion has occurred (achroodextrin), the solution is colorless. "To calculate the amount of ferment, if i c.c. of the filtrate digests , i c.c. of soluble starch (Kahlbaum) in twenty-four hours at 38C., the filtrate has a concentration of one diastatic unit. If one-tenth of i c.c. of the filtrate is added to 5 c.c. of the starch solution, and the mixture is colorless on adding i drop of the decinormal iodin solution, digestion has taken place. Therefore, i c.c. of the filtrate added to i c.c. of the starch solution equals 10 X 5 or 50 units." Wynhausen believes the normal number of units should be about 500 to 600, or even up to 2000. If the total number of units is as low as 50 to 60, there is an interference with the flow of pancreatic juice. Lyle shows that considerable caution must be exercised in this estimation, as the units may be only 60, with a normal evacuation, and in the same case, after a dose of Carlsbad salts, be increased to 600. The method of producing the stool must, therefore, be considered. Fedeli 1 and Romani describe the following method for estimating the diastatic function of the pancreas: "To i c.c. of saliva add 5 c.c. of the patient's gastric juice. Shake the mixture, and in half an hour add sufficient of a i per cent, sodium carbonate solution to render it slightly alkaline. To this add 20 c.c. of a 10 per cent, starch paste and place in a thermostat at 37C. for two hours, shaking it repeatedly. - "Estimate the amount of sugar formed. "Then add 10 c.c. of an aqueous solution v i : 4) of feces to the above, and leave in an incubator for twelve hours, when the sugar formed is again estimated. The difference between the two quantities of sugar represents the degree of pancreatic diastatic function." GENERAL CHARACTER OF THE STOOL With advanced pancreatic disease the stools are frequently bulky, soft, white, and usually have an acid reaction and a peculiar odor. This appearance does not always occur, however. There is an abnormal quantity of undigested material, especially of fat, and also marked fermentation is present. Reaction of the Stool. Out of 80 cases of pancreatic disease reported by Robson and Cammidge, the fresh feces had an acid reaction in 58 patients; in 16 they were neutral or amphoteric, and in 6 they were alkaline. Jaundice appeared to exert little effect on the reaction of the stools when the pancreas was also diseased. With jaundice without pancreatic 1 Riforma Medica. Sept. 20, 1909. . METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 987 disease, and in patients where calculi were present in the biliary passages, but no bile-pigment in the urine, the stools were usually alkaline. The peculiar sour odor of the stools in pancreatic cases is probably due to the free fatty acids. In the fatty stools of jaundice Strassburger noted a diminution in the number of bacteria, and probably there is a lessened degree of intestinal putrefaction in these cases, even though the bile is believed to possess antiseptic properties. If, however, the amount of protein is increased, putrefaction may occur as a result of affections of the pancreas or intestines, and the feces may become alkaline. Enteritis or chronic colitis, which may be associated with pancreatic disease, may account in some for the alkaline reaction of the stool. CHANGES IN THE URINE IN PANCREATIC DISEASE Indicanuria. Opposing theories are held as to the relation of pancreatic disease to indicanuria. . Herter believes that since a reduced secretion of pancreatic juice is followed by an impaired digestion of proteins, the latter are liable to be attacked by bacteria, the urine showing the signs of intestinal putrefac- tion (indicanuria), holding that on exclusion of the bile and pancreatic juice there is an excess of indican, and that the ethereal sulphates are increased, their proportion to preformed sulphates rising to i :6 or even i : i ; while the normal proportion is i : 10. Other observers believe that absence of indican and a diminution of ethereal sulphates are an indication of pancreatic disease. One may say that diminished secretion of the pancreas provides conditions under which putrefaction may occur. Robson believes that the presence of indicanuria and an excess of ethereal sulphates in the urine probably shows an associated enteritis. Bile in the Urine. Diseased conditions of the pancreas, or chole- lithiasis which may obstruct the passage of bile into the intestines, may produce jaundice, and the appearance of bile in the urine. The latter may in some cases be of a deep yellow or brown color, and gives the reaction for bile-pigment. Bilious urine and jaundice are not constantly found. Urobilin. If the bile is completely shut off from the intestines, no urobilin is found in the urine. When urobilin is present in the urine, there is some escape of bile into the intestines, even though there is an apparently complete obstruction of the duct. Azoturia. An increased excretion of nitrogen compounds in the urine is believed to result from disturbances of intestinal digestion, and to be closely related to putrefactive changes in the intestines. This condition is not constant in diseases of the pancreas, though it does occur with diabetes. In many cases of pancreatitis the excretion of urea is not excessive and the total nitrogen is within normal limits. Phosphates. These are stated by some to be increased in diseases of the pancreas, but there is probably no marked variation. This is true also of the chlorids. Acetonuria. Experimentally, extirpation of the pancreas in animals may result in the appearance of acetone, diacetic acrd. and, at times, of DISEASES OF THE STOMApH AND INTESTINES /8-oxy butyric acid in the urine. Acetone and diacetic acid have been found in the urine in a large percentage of cases of acute pancreatitis, and in nearly one- third of the cases of chronic pancreatitis and of malignant growth which have been examined for these bodies. Acetone bodies occur with diabetes, with wasting diseases, in postanesthetic poisoning, with gastro-intestinal diseases, with the cyclic vomiting of children, with the toxemic vomiting of pregnancy, with puerperal eclampsia, with phos- phorous-poisoning, with acute yellow atrophy of the liver and other dis- eases of that organ, with fevers, with scurvy, starvation (especially in women and children), etc. Carbohydrate starvation may also produce acidosis. The condition is not idiopathic to pancreatic diseases or to pancreatic diabetes. It is now believed that the acetone bodies are formed chiefly from the storage fats within the system, and not within the intestinal tract. Calcium Oxalate. These crystals have been found in many cases of chronic pancreatitis, and diabetes has been occasionally observed to follow long-continued oxaluria. Part of the calcium oxalate is undoubtedly derived from the food, and oxaluria- may be the direct result of intestinal fermentation. The writer believes it has no significance as to pancreatic disease. Carbohydrates. Alimentary Glycosuria. The liver is limited in its ability to transform glucose into glycogen, and if an excess of sugar is absorbed from the alimentary tract the quantity of sugar in the blood is increased and is, consequently, excreted in the urine (alimentary gly- cosuria). A normal person can assimilate from 1 50 to 250 grams of glucose after fasting. Therefore, Kraus advises giving 100 grams of dextrose (grape-sugar) in 250 c.c. of tea or water two hours after breakfast, on the fasting stomach, and testing the urine for sugar two or three hours later. If this is found, there is a possibility of pancreatic disease, showing the metabolic function of the pancreas is at fault. Temporary glycosuria occurs with a variety of injuries or operations on the nervous system, with neurasthenia, traumatic neurosis, some forms of mental debility, after the use of large quantities of carbohy- drates, acute febrile conditions, alcoholism, with exophthalmic goiter, acute diseases of the brain and meninges, mania, paralysis, and, in some cases, with cirrhosis of the liver. It is present with asphyxiation, carbon monoxid poisoning, after an excessive dose of morphin, curare, etc. It shows pancreatic disease to be present in about 65 per cent, of cases. Persistent glycosuria is suggestive of diabetes. Fehling's test will disclose the presence of sugar. The Carnmidge Pancreatic Reaction. This reaction consists in the demonstration in the urine, when treated by a special chemic procedure, of certain crystals of a definite morphology and a certain characteristic solubility. Their composition is unknown, according, to Carnmidge, though the substance on hydrolysis yields a body giving the reactions of pentose, probably an osazone. The specific reaction that is secured is believed to be due to an inflammation of the pancreas. It has also been found in a percentage of cases of carcinoma of the pancreas, due to an inflammatory zone about the neoplasm. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 989 The "A-reaction" and, later, a differential test, the "B-reaction," were first employed. It was found that errors in technic were apt to occur, and that much depended on the individual equation. The "improved" or "C-reaction" is now employed. The technic of C-reaction, as described by Cammidge, is as follows: "The urine should be freed from albumin by boiling with acetic acid and from sugar by fermentation, when they are present. Then filter it several times through the same paper. A specimen of the twenty-four- hour urine should be employed, though the mixed night and morning specimen can be used. "Forty c.c. of the clear filtrate are mixed with 2 c.c. of strong hydro- chloric acid (sp. gr. 1.16), and the mixture is gently boiled on a sand-bath in a small flask which is fitted with a funnel condenser. The flask is cooled in a stream of water and the contents made up to 40 c.c. with cold distilled water. Then 8 grams of lead carbonate are slowly added to neutralize the excess of acid, and the solution should be allowed to stand a few minutes. It is again cooled in running water and filtered through a well-moistened and close-grained filter-paper until the contents are perfectly clear. Several filtrations may be required. "The acid filtrate is shaken well with 8 grams of tribasic lead acetate and the resulting precipitate filtered out. A clear filtrate should be secured, filtering being performed several times if necessary. "The excess of lead in solution is removed by a stream of sulphuretted hydrogen or, preferably, the filtrate is shaken well with 4 grams of powdered sodium sulphate, and the mixture then heated to the boiling- point. It is then cooled to as low a temperature as possible in a stream of running water and the white lead sulphate precipitate is filtered out. "Ten c.c. of the clear, transparent filtrate are diluted up to 17 c.c. with distilled water, and to it are added 2 grams of sodium acetate, 0.8 grams of phenylhydrazin hydrochlorate, and i c.c. of a 50 per cent, acetic acid. This is placed in a small flask with a funnel condenser and boiled in a sandbath for ten minutes. It is filtered while hot through a small filter-paper moistened with hot water into a test-tube provided with a 15 c.c. mark. If the filtrate falls short of the 15 c.c. mark, it is made up to this point by the addition of hot distilled water, and the mixture is stirred with a glass rod. In well-marked cases of pancreatic inflamma- tion a light yellow flocculent precipitate should appear in a few hours, but in less marked cases it may be necessary to leave the preparation over night." Under the microscope the precipitate is found to consist of long, flexible, light yellow and hair-like crystals, arranged in delicate sheaves (Fig. 414), which disappear in ten to fifteen seconds when irrigated with a 33 per cent, solution of sulphuric acid A microscopic examination must always be made. Cammidge recommends a control experiment to exclude traces of sugar which may be undetected by the ordinary tests. He treats 40 c.c. of urine in the same way as just described, only that it is not boiled with hydrochloric acid. 9QO DISEASES OF THE STOMACH AND INTESTINES The urine should be fresh, and if alkaline should be acidified with hydrochloric acid before testing. Dextrose, when present, should be removed by fermentation after the urine has been boiled with the hydrochloric acid, and the excess neutralized. If calcium chlorid has been given, which is advocated in all pancreatic cases before operation, it interferes with the test. Robson and Cammidge 1 report the reaction positive in every case of acute and chronic pancreatitis 67 cases in all; and that in 16 cases of carcinoma it was found in 4 (25 per cent.). In 50 normal cases it was absent, while in 117 cases of gall-stones, etc., with no pancreatic disease, it was present only four times. In 75 per cent, of diabetics there was a positive result. Fig 414. Improved or C- ("pancreatic") reaction crystals from a case of chronic pancreatitis with gall-stones in the common bile-duct ( X 200) (Robson and Cam- midge). Opie 2 states that the pancreatic reaction has been obtained in a large number of cases in which pancreatic disease has been demon- strated or suspected; but the reaction may occur without pancreatic disease and is sometimes absent when a lesion of the gland is present. There have been various reports both for and against this reaction. 1 Deaver 3 reports 154 reactions, and, more recently, 197 additional cases, and now summarizes 351 in all. 4 In all the cases in which the condition of the pancreas was accurately determined by Deaver at the time of operation, the pancreatic reaction was obtained, on an average, only two and a half times as frequently when the pancreas was affected as when it was not. Recently he finds 1 The Pancreas. 2 Disease of the Pancreas, 1910. 3 Amer. Jour. Med. Sci., Dec., 1910. * Jour. Amer. Med. Assoc., April 15, 1911. METHODS OF DIAGNOSIS IN PANCREATIC DISEASE 991 only about 25 per cent, positive reactions corresponding to operative findings. 1 Later reports 2 state he has been unable to derive any assistance from this reaction. Roper and Stillman 3 carried out a series of studies on the Cammidge reaction, and found that results varied in the same patient, apparently due to accidental occurrences. They conclude that the C-reaction of Cammidge does not rest on a sound scientific basis. The author has tested the reaction in a number of patients. In a recent case, for example, of far-advanced chronic pancreatitis with marked steatorrhea, repeated examinations showed a negative Cam- midge. He must confess that he has been disappointed in his results secured as an aid to diagnosis. He rarely employs it and is skeptical as to its value. Other Urinary Tests in Pancreatic Disease. Wohlgemuth has advised estimating the diastatic ferment in the urine as a means of diagnosis of pancreatitis. He suggests in a suspected case that the urine should be examined daily, and a decided increase in the diastatic ferments should be regarded as indicating an interference to the flow of the pancreatic juice. If i c.c. of urine digests i c.c. of soluble starch (Kahlbaum) in twenty- four hours at 38C. ; this urine has a diastatic concentration of one diastatic unit. The formula for y c.c. of urine and s. c.c. of starch is - - X 5 (i c.c. y c.c. J starch) = diastatic unit. Fat-splitting Ferment. Opie 4 found in one case of acute pancreatitis with fat necrosis evidence of a fat-splitting enzyme in the urine. Hewlett 5 has also demonstrated experimentally that an injury to the pancreas may cause a fat-splitting enzyme to appear in the urine. In subacute and chronic pancreatitis Robson and Cammidge found no fat- splitting enzyme present. Lipuria. Bowditch and Clark describe the appearance of fat-lobules in the urine in cases of cancer of the pancreas. They have also been found in acute pancreatitis, and Robson reports them in one case of chronic pancreatitis. Lipuria at times occurs with diabetes mellitus. It has been found in other conditions and is not diagnostic of pancreatic disease. THE BLOOD IN DISEASES OF THE PANCREAS In the more chronic and more advanced cases there is generally a secondary anemia, with reduction in the red cells. The hemoglobin does not seem to suffer a proportional decrease with the red cells and the hemoglobin index may even be quite high. Often the ratio of the leu- 1 Ibid., July i, 1911. 2 N. Y. Med. Jour., Mar. 23, 1912. 3 Arch, of Int. Med., Feb., 1911, pp. 252-258. 4 Johns Hopkins Hosp. Bull., 1902, xiii, 117; also Kastle and Loevenhart, Amer. Chem. Jour., 1900, xxiv, No. 16. 3 Jour, of Med. Research, 1904, xi, 377. 9Q2 DISEASES OF THE STOMACH AXD INTESTINES kocytes is unaltered, though Woolsey has reported leukocyte counts from 17,600 to 39,000 in three cases of acute pancreatitis. The polynuclears should also be determined in acute inflammation. Pancreatic Hemolysin. Friedeman 1 has demonstrated the presence of a strongly active autohemolysin in the pancreatic juice, and that when this enters the circulation through tissue destruction it brings about the same results as other hemolytic substances. In some pancreatic affec- tions there is a tendency to general hemorrhage; thus, in cancer of .the head of the pancreas, in pancreatitis with jaundice (believed to be partly due to cholemia), and also in pancreatitis without jaundice. Coagulation of the Blood. The coagulation time of the blood is increased. This feature is of considerable importance, as severe postopera- tive hemorrhage may occur in cases in which the pancreas is involved. The writer believes the determination of the coagulation time of the blood may in some cases be of assistance in diagnosis. Conclusions. The author would first recommend that in every case of suspected pancreatic disease the functions of the stomach, both motor and secretory, should be examined, so that the digestive function of this organ can be taken into consideration in making one's deductions. The general test of the intestinal functions, as previously described, by the Schmidt-Strassburger diet, should then be made. This demon- strates whether or not a catarrhal condition of the intestine is present; the presence or absence of bile, the influence of the fecal flora, fermenta- tion and putrefactive conditions, and a general idea of the quantity of fat present, muscle-fibers, starch, etc., by microscopic examination This alone will give pretty thorough information as to disturbance of the pancreatic functions. Reduction of split fat is significant. For the general practitioner, the Boldyreff method of securing the pancreatic juice is the most simple and is to be recommended. Tests can then be made for trypsin, amylopsin, and steapsin. The urine should always be examined for sugar. The Cammidge reaction may be tested for as routine, though its value is doubtful. Im- provement in the fecal findings after administration of pancreatic extract is also suggestive. The blood examination should be made and the rapidity of blood-clotting determined. These methods of examination, when employed in association with the clinical symptoms, will be of most service. In acute conditions par- ticularly, and even with suspected chronic pancreatitis, the urine should be examined for colon bacilli, and if such are present, proper treatment instituted. The writer later reports a chronic pancreatitis with colon bacillus infection. The other methods described are of chief interest to the specialist. 1 Deut. Mediz Wochenschr., 1907. CHAPTER XLI GENERAL SYMPTOMS AND DIAGNOSIS OF PANCREATIC DISEASE ONE might suppose that on account of the important part that the pancreas takes in the digestive processes in the intestines, and its influence on the metabolism of the body, that any deviation from the normal would produce such functional disturbances that a diagnosis of pan- creatic disease would be easy. On account of the fulminating symptoms, an acute disturbance of the pancreas is much more readily diagnosed than the chronic conditions. Unfortunately, the pancreas is seldom diseased without the involvement of some of the other organs. Thus, cholelithiasis, gastro-intestinal catarrh, or catarrh of the biliary and pancreatic ducts may coexist; or tumors or ulcers of the stomach or duodenum may in- volve the pancreas. Affections of the liver, lymphatic glands, or colon may also produce disease of the pancreas. One must further remember that the stomach can care for the pro- teins to a certain extent, that the salivary and intestinal glands can digest starches, and that the bile and intestinal juice can emulsify fat; further- more, the intestinal bacteria can break down various food stuffs, and thus interfere with the pathologic changes in the stools, such as would be expected in disease of the pancreas. When the duct of Wirsung is obstructed, in a number of cases the pancreatic secretion may escape through the duct of Santorini, and, moreover, a considerable portion of the pancreas may be diseased, and yet a sufficient part remain healthy and so carry on the functions of the organ. Sometimes, though the pancreas may be primarily at fault, the most prominent symptoms may be produced by an organ that is secondarily involved. For example, marked jaundice and distention of the gall-bladder may result from a cancer of the head of the pancreas pressing on the common bile-duct, or from pres- sure contraction of a chronic pancreatitis. Moreover, as in a recent case of the author's, a pancreatic tumor may compress the intestines and produce intestinal obstruction, or may press upon the neighboring ganglia and cause such excruciating pain that it mimics that of an aneurysm or of spinal disease. All these factors must be held in consideration. Anamnesis. A careful history of the case is of great importance. Some patients may give a history of habits of eating or drinking which might set up an inflammation of the stomach and duodenum; in others there may be a history of infectious conditions which are liable to be followed by disease of the biliary passages; or there may be a preceding history of disease of the bile-ducts or gall-bladder, with, in some cases, attacks of biliary colic. Males, moreover, seem to be more liable to pancreatic disease. 63 993 994 DISEASES OF THE STOMACH AND INTESTINES PHYSICAL SIGNS Presence of Tumor. The position of the pancreas, lying behind the stomach, renders it unfavorable for palpation, and often, especially in stout persons, it cannot be felt at all. If the patient is very thin and the stomach is empty and the abdominal muscles are relaxed, especially in the case of gastroptosis, it may be often defined. Frequently in acute and chronic inflammation, and even in the case of abscess of the pancreas, it is impossible to determine enlargement of the pancreas. In the acute cases, pain and rigidity in the epigastrium often interfere with the determination of a mass, but the acute fulminating attack and the epigastric peritonitis are themselves suggestive. Robson claims that in many cases a distinct swelling can be felt due to the enlarged pancreas, with an effusion of blood, inflammatory fluid, and matted omentum. Korte describes three cases in which the mass was palpable between the stomach and colon. With chronic pancreatitis, in three cases only, in very thin patients, was Deaver 1 able to palpate the swollen head of the pancreas. Palpation he found of most value to exclude other abdominal conditions. With cancer of the head of the pancreas, the only tumor usually felt is due to the enlarged gall-bladder. Occasionally, tumor of the body, tail, and, at times, some growths of the head of the pancreas can be distinguished by palpation. The writer has recently determined one such by palpation. By inflating the stomach with carbonic acid gas or with air the relation of this organ to the tumor can be made out. The inflated stomach separates the mass from the liver. Unless the stomach is empty, there is resonance on percussion over the growth, with communicated non- expansile pulsation, and a slight movement on deep inspiration. Infla- tion of the colon may also aid at times in localizing the mass. With cyst of the pancreas, the presence of a tumor may be for a time the only symptom. Its position depends on from what part of the pancreas it originates. It is found in various situations, which are described under Cyst of the Pancreas. The absence of tumor does not prove that disease of the pancreas is not present. If the tumor or enlargement of the organ can be positively determined, in connection with other symptoms, it affords valuable evidence of a lesion of the pancreas. Pain. Pain in acute pancreatitis is one of the important symptoms. It appears suddenly and is intense in character. It may be colicky, then diminish and disappear, and return later (paroxysmal). It may at times be continuous. It is usually located in the epigastrium, above the umbilicus, and may pass from the median line along the course of the pancreas. Opie notes cases in which the pain is most severe in the hypochondriac regions or even below the umbilicus. In the cases of chronic pancreatitis reported by Deaver 2 pain was the leading and most constant symptom, being absent in only three cases. It 1 Jour. Amer. Med. Assoc., April 15, 1911. 2 Jour. Amer. Med. Assoc., April 15, 1911. GENERAL SYMPTOMS AND DIAGNOSIS OF PANCREATIC DISEASE 995 varied from a dull discomfort, fulness, or oppression in the epigastrium to an ache or a sharp, lancinating, colicky pain, much like gall-stone colic. In the cases of colicky pain he found the gall-bladder usually also diseased. In many cases of chronic pancreatitis, especially in the early stages, pain may be absent or scarcely noticed. There is no definite relation to eating or to particular articles of food in the production of the pain. In this it differs from the pain produced with gastric or duodenal ulcer, and thus may be of some aid in differential diagnosis. The carbohydrates in some cases seem to cause the most digestive disturbances, and Sailer has found that the administration of glucose to test the limit of assimilation to be particularly distressing. Intestinal fermentation is undoubtedly the cause of this feature. With malignant disease of the pancreas, pain may be absent in some cases and present in others. The pain may be very severe, due to pressure on or involvement of the ganglia or adjacent organs, such as the stomach and duodenum. On the other hand, the writer has recently seen a large carcinoma of the outer third of the pancreas, involving the stomach also, in which all symptoms pointed to gradually increasing stenosis of the bowel. Operation demonstrated pressure stenosis of the transverse colon. The patient had no pain from the tumor, which was readily palpable, and only suffered from cramps when attempting to have a bowel action, with dyspeptic disturbances and progressive loss of weight. Pancreatic cysts are sometimes painless, though pain is present in some cases. With abscess of the pancreas, pain is frequently present, but not invariably so. Calculus of the pancreas may exist for years without any pain. If the calculus progresses to the orifice of the pancreatic duct or becomes impacted in the ampulla of Vater, severe paroxysmal pain may occur which resembles gall-stone colic, and jaundice may be associated. The pain may become continuous. It may occur in the epigastrium or radiate to either side of the thorax. With disease of the pancreas, the pain may radiate to the left, to between the scapulae or under the left scapula. When it radiates to the right it resembles gall-bladder pain. The pain may also radiate to the cardiac region and resemble that of angina pectoris. Pain can scarcely be called pathognomonic of any particular type of pancreatic disease, except in the case of acute pancreatitis. Tenderness. With acute pancreatitis there is excessive tenderness on pressure in the epigastric region, most marked at Robson's point (Fig. 415), about ij^ inches above and slightly to the right of the umbilicus which is accompanied by muscular rigidity of the recti. At times the tenderness may extend along the course of the pancreas, and Fitz has noted additional sensitive points in the abdomen, probably due to the areas of fat necrosis. With chronic pancreatitis tenderness may be absent, though in the more advanced cases it may be present. Deaver's patients were operated upon during or just after some exacerbation of the symptoms, and there 99 6 DISEASES OF THE STOMACH AND INTESTINES was some degree of tenderness in most of them. His findings were variable as to location, tenderness, being present below both costal margins, more frequently to the right, in the mid-epigastrium, at Robson's point, and in one case general. Rigidity. Rigidity was also variable, there being more cases in the right hypochondrium, some in the midepigastrium, and in some there was moderate distention. Tenderness is, as a rule, absent in malignant disease of the pancreas, unless from pressure or involvement of the nerve plexuses or of adjacent organs. Fig. 415. Most frequent site of the tender spot in inflammatory affections of the pancreas ("Robson's point"). With pancreatic abscess tenderness is often present, but it may be absent, and with pancreatic cysts tenderness is more usually absent. With calculus of the pancreatic duct tenderness is often absent, unless the calculus becomes impacted in the ampulla, when tenderness may be associated with the attacks of paroxysmal pain. SYMPTOMS Nausea and Vomiting. With acute pancreatitis (hemorrhagic or gangrenous) vomiting is a prominent symptom. It is frequently so violent and obstinate as to suggest intestinal obstruction. The vomiting is not GENERAL SYMPTOMS AND DIAGNOSIS OF PANCREATIC DISEASE 997 stercoraceous, and there is no visible peristalsis of the intestines, such as occur with acute obstruction. In other types of pancreatic disease, vomiting has usually been con- sidered not a common symptom, and when it occurs it is often due to disturbances of the stomach or duodenum. Opie reports four cases of persistent vomiting associated with chronic interlobular pancreatitis. The history in all afforded evidence of gastric or gastro-intestinal disease, and indicated some relationship between these disturbances and the chronic lesion of the pancreas. Deaver 1 reports 21 cases of chronic pancreatitis having attacks in which vomiting figured, and 10 more who were nauseated, and holds that in the more severe types of chronic pancreatitis nausea or vomiting may occur in attacks at variable intervals. When vomiting occurs, it is not particularly characteristic, though it may contain mucus and bile. If an abscess of the pancreas has ruptured into the stomach, pus and altered blood may be vomited up. Vomiting of Blood. With acute pancreatitis, altered blood ll co fee- ground" or so-called "black" vomit may be vomited up. This may occur quite early in association with the tendency to general hemorrhage. 2 The vomiting of blood with this hemorrhagic diathesis, occurs chiefly with acute pancreatitis, in pancreatitis associated with jaunidce, and also in cancer of the pancreas, though also in other types of pancreatic disease. Jaundice. Acute hemorrhagic pancreatitis may be accompanied by a slight jaundice if a small gall-stone is impacted in the outlet of the ampulla of Vater. There is a well-known relation between gall-stone disease and disease of the pancreas. The relation of the common bile- duct to the head of the pancreas is the determining factor in many cases as to the appearance or absence of jaundice; in about 38 per cent, of cases the common duct lies behind the head of the pancreas, so that pancreatitis, either acute or chronic, or even cancer of the pancreas, may run its course without the appearance of jaundice. In about 62 per cent, of cases the common duct is situated in a deep groove or is imbedded in the head of the pancreas, so that either pancreatitis or a new growth will compress the bile-duct and lead to jaundice. Robson reports that in 62 per cent, of cases of chronic pancreatitis with cholelithiasis bile-pigments were found in the urine before opera- tion, while in 38 per cent, neither jaundice nor bile-pigment was present. In the case of chronic pancreatitis without cholelithiasis in 16 per cent, there was jaundice, due either to an ascending catarrh of the duodenum or to compression of the common duct. In Beaver's patients with chronic pancreatitis jaundice was present in 24 and absent in 14. Jaundice may be preceded by pain, as in gall-stone colic, though usually it is less severe, unless a stone is passing through theduct. Jaundice is not a constant symptom. Marked jaundice with a dis- tended gall-bladder is significant of cancer of the head of the pancreas. Jaundice in these cases develops slowly but steadily, and usually with- out pain. The patient's skin, as the cachexia increases, may become of a 'Jour. Amer. Med. Assoc., April 15, 1911. - Intestinal hemorrhage with melena, hemorrhages from the nasopharynx and sub- cutaneous hemorrhage may occur. Q98 DISEASES OF THE STOMACH AND INTESTINES slaty appearance, a "black jaundice," instead of the saffron yellow of cholelithiasis. With advanced chronic pancreatitis jaundice may occur. When a gall-stone in the common duct is the cause of the jaundice, the gall- bladder is usually contracted, and often cannot be felt (Courvoisier's rule). Emaciation. Emaciation as a symptom does not figure in acute inflammation of the pancreas, since the attack is fulminating in character and of short duration. In the typic chronic inflammation, in carcinoma or cyst of the pancreas, and in diabetes of pancreatic origin, emaciation is often a prominent symptom. The loss of weight is frequently marked. Due to disturbance of the pancreatic function, digestion is impaired and rapid loss of weight may result. It is sometimes difficult to differentiate between chronic pancreatitis of a severe type, with rapid loss of weight, and carcinoma of the pancreas. Loss of strength may accompany the loss of weight. This is par- ticularly true in cases of severe chronic pancreatitis with associated jaundice, and also in cancer of the pancreas. Temperature. In acute hemorrhagic pancreatitis the temperature may be normal or subnormal; while with acute gangrenous and acute suppurative pancreatitis the temperature may be considerable. In the last, it is frequently irregular and may run a septic type. With acute pancreatic catarrh the temperature resembles that of infective cholangitis. With abscess formation there may be a persistent temperature of 100 to io3F., with rigors associated. With cancer of the pancreas the temperature is usually subnormal, though occasionally fever from asso- ciated complications may result. Cysts and calculus, as a rule, are not accompanied by fever. With chronic pancreatitis the temperature, as a ride, is normal, but fever may occur during the exacerbation of the disease. Dyspepsia and Disturbance of Appetite. There may be anorexia, a sensation of fulness after eating, flatulence with eructations, heart- burn, nausea, and distaste for fats and meat. Sometimes the adminis- tration of pancreatic extracts markedly relieves these symptoms. Hemorrhage. Reference has already been made to the hemorrhagic tendency which is found with inflammatory disease and malignant growths of the pancreas. Bleeding may occur, not only at and after operation, but at other times, and may manifest itself by hemorrhage from the mucous surfaces, stomach, intestines, etc., and into the skin or subcutaneous tissues. Blood. The blood frequently shows a secondary anemia, and leuko- cytosis and increase in polynuclears may occur with the acute attacks. Clotting may be delayed. Pressure Symptoms. With disease of the pancreas ascites may at times occur due to tumor pressure on the portal vein, and edema of the lower limbs from pressure on the inferior vena cava. Enlargement of the spleen and hemorrhoids may also result from pressure on the portal vein. Occasionally the duodenum is partially or completely surrounded by the- head of the pancreas, and malignant disease or inflammation of the pancreas may obstruct the passage of the gastric contents and produce GENERAL SYMPTOMS AND DIAGNOSIS OF PANCREATIC DISEASE 999 dilatation of the stomach with vomiting. Obstruction of the transverse colon occurred from pancreatic cancer in a case of the author's. Cysts or new growths of the pancreas may displace the stomach, duodenum, or colon. The stomach, depending on the position of the cyst, may be pushed up under the diaphragm or down below the umbilicus. Distention of the gall-bladder with associated jaundice may result from cancer of the head of the pancreas, and also from chronic pancreatitis, when the common duct passes through the head of the organ. Occasion- ally the hepatic duct is pressed upon by a prolongation of the diseased pancreas, so there may be jaundice without distention of the gall-bladder. If a pancreatic cyst presses upward against the diaphragm, it may cause dyspnea, and this may also be produced by secondary effusion into the lesser peritoneal sac. Hydronephrosis may occasionally be caused by pressure of pancreatic tumors on the ureter, and either pressure on or involvement of the solar plexus may cause pain. Liver. The liver is occasionally enlarged (cirrhosis), with diabetes. General Circulation. Symptoms of severe shock occur with acute pancreatitis, and the pulse becomes so rapid and feeble that cyanosis results. Bowels. With acute pancreatitis there is obstinate constipation. With pancreatic disease of a chronic type, constipation is a frequent symptom; rarely, diarrhea. The frequent soft, bulky movements, greasy and of pale color, described as characteristic of pancreatic disease of the more chronic type, are found in the most advanced cases and not in the earlier stages of the diseased pancreas. Steatorrhea. The microscopic appearance of fat in the stools is a valuable adjunct in determining disease of the pancreas. One must determine whether the clay-colored stool is due to the presence of excess of fat or fatty acids, or to absence of bile from the intestinal tract. The presence or absence of stercobilin in the stool will determine this last feature. In health the unabsorbed fecal fats consist approximately of 20 to 30 per cent, neutral fat, and from 70 to 80 per cent, of split fat (fatty acids and soaps). In cases of pancreatic disease, even though the total percentage of fecal fat in some cases may not be increased above the normal, the ratio of split fat to the neutral fat is always decreased. Katz has asserted that a diminution of the split fat below 70 per cent, of the total fecal fat signifies disease of the pancreas, except in nursing infants and patients with diarrhea. Robson and Cammidge hold that in chronic pancreatitis the total amount of unabsorbed fat may reach 50 to 60 per cent., and even to 75 to 90 per cent., with malignant disease of the organ. Normal stools have, however, been found with cases of pancreatic disease, so that negative findings as to Steatorrhea or split fat may not be conclusive. Positive results are very suggestive. Azotorrhea. The presence of muscle-fibers in the feces is not as constant a symptom. Sialorrhcea Pancreatica. An increased flow of saliva has been noted by a few observers in disease of the pancreas, especially in cases of pan- creatic calculi and in cysts. As an aid to diagnosis it cannot be relied on. Glvcosuria should be tested for. 1000 DISEASES OF THE STOMACH AND INTESTINES The author has recommended the most practical tests for diagnosis at the end of the section entitled "Methods of Diagnosis in Pancreatic Disease." Fat Necrosis. The discovery of fat necrosis by the surgeon on opening the abdomen should be an indication for exploration of the pancreas. CHAPTER XLII INJURIES OF THE PANCREAS CLASSIFICATION OF ACUTE AND CHRONIC INFLAMMATION OF THE PANCREAS- CATARRH OF THE PANCREAS INJURIES OF THE PANCREAS ON account of its relation to other important viscera, it is rare for the pancreas alone to be damaged by direct violence without associated injury to other organs. Injuries of the pancreas comprise laceration due to direct violence, bullet wounds, and penetrating wounds. Laceration due to Direct Violence. In the majority of cases the force which produces the injury has been directed from before backward in the epigastrium, and lacerations of other organs, such as of the liver, kidney, duodenum, jejunum, spleen, or fractured ribs, have been asso- ciated. In such cases the hemorrhage from the other injured organs has recently been so severe that the injury to the pancreas has often been overlooked. Rarely, the pancreas alone may be lacerated. Etiology. Falls, a blow, a kick, crushing between two vehicles, or the passage of a vehicle over the abdomen are the most frequent causes of laceration. Sometimes the injury (blow) may be apparently slight. Symptoms. In some cases after severe injury, shock and the immediate symptoms of internal hemorrhage may occur, and operation will alone determine the character of the injury. In others, there may be only a slight hemorrhage into the pancreas as a result of the injury, and shortly acute pancreatitis follows; or the patient may slowly recover from the blow, shock pass off, and within a few days to a few weeks an abdominal tumor may. appear. In this event laceration of the posterior layer of the lesser peritoneal sac has occurred, and blood and the pancreatic secre- tion are poured into the lesser peritoneal cavity; adhesions close the foramen of Winslow and a pseudocyst of the pancreas results. It occupies the epigastric, umbilical, and left hypochondriac regions, as a rule. The stomach and transverse colon usually lie in front, and the descending colon behind and to the left. Treatment. The immediate shock 1 should at first receive treatment, and as soon as reaction occurs, immediate laparotomy should be under- taken and an attempt be made to secure the bleeding points. Suture of the torn pancreas should be performed. If other viscera are lacerated the condition is complicated, but repair should be undertaken. In cases of acute pancreatitis following hemorrhage due to traumatism, incision and drainage of the pancreas are indicated, and when a pseudocyst of the pancreas forms subsequent to injury it should be incised and drained. 1 Application of heat, hot saline enema, morphin >4 grain, strychnin ^$o grain and camphor (in sterile almond oil) 10 grains by hypodermic are indicated. IOO2 DISEASES OF THE STOMACH AND INTESTINES Bullet Wounds of the Pancreas. In the majority of instances other viscera have also been perforated as well as the pancreas. President McKinley, for example, was wounded in the stomach, pancreas, and left kidney. Rarely, the lesser omentum and pancreas may alone be injured. Symptoms. There are no symptoms pathognomonic to a wound of the pancreas. The probable Bourse of the bullet is the only guide. When the stomach and lesser omentum are found to be wounded, particular examination of the pancreas should be made. The only symp- toms are of shock and hemorrhage taken in association with the visible perforating wound. Treatment. Shock should be treated. 1 Operation is indicated. Bleed- ing points should be tied. The injured organ should be sutured and proper drainage instituted. Penetrating Wounds of the Pancreas. Penetrating wounds of the pancreas have been reported as a result of stabs with a knife or bayonet. In some cases the pancreas protruded, and was either returned or the projecting portion resected. These cases recovered. Injuries of other viscera were associated. Symptoms. They consist of shock and internal hemorrhage. Treatment. This is the same as that described for gunshot wound. As a result of injuries to the pancreas, acute pancreatitis (hemor- rhagic), a pseudocyst of the pancreas, a true pancreatic cyst, abscess of the pancreas, protrusion of the pancreas, and prolapse of the pancreas may occur. CLASSIFICATION OF ACUTE AND CHRONIC INFLAMMATION OF THE PANCREAS Undoubtedly, inflammatory affections of the pancreas are much more frequent than were formerly supposed. We owe much to the surgeons who have demonstrated the frequency of pancreatic disease, and its particularly close association with disease of the gall-bladder. As far back as 1672 Tulpius described a diffuse abscess of the pancreas, and Baillie, in 1799, a hard pancreas, evidently a case of chronic inter- stitial pancreatitis. In 1804 Portal described a case of acute suppurative pancreatitis, and Percival, in 1818, one of pancreatic abscess with jaundice. In 1879 Balzer first described acute pancreatitis with fat necrosis. Fitz first placed inflammatory diseases of the pancreas on a practical basis, and Robson, chronic pancreatitis and the relation of gall-stone disease to disease of the pancreas. Classification. From a pathologic standpoint the writer believes that Robson 's classification of pancreatic inflammation is the best: (1) Catarrhal inflammations acute, chronic, suppurative, and pancreolytic catarrh. (2) Parenchymatous inflammations comprise acute hemorrhagic pancreatitis: ultra-acute, in which profuse hemorrhage precedes inflam- mation; acute, in which inflammation precedes hemorrhage; gangrenous pancreatitis; suppurative pancreatitis (diffuse or circumscribed). Chronic inflammation comprises interstitial pancreatitis of the interlobular or interacinar type, and cirrhosis of the pancreas. 1 Hemorrhage is temporarily treated as " under hemorrhage of gastric ulcer." ACUTE AND CHRONIC INFLAMMATION OF THE PANCREAS IOC>3 Etiology of Pancreatitis. Among the predisposing causes of pan- creatitis are obstruction in the ducts or papilla of Vater resulting from gall-stones, duodenal catarrh, pancreatic calculi, cancer of the head of the pancreas or of the papilla, ulcer of the duodenum with cicatricial stenosis of the papilla, and lumbricoid worms. Injuries to the epigastrium or a wound may produce pancreatitis. Among other predisposing causes are hemorrhage into the pancreas, general diseases, such as typhoid, influenza, and mumps, anatomic peculiarities in the pancreas or its ducts, atheroma or fatty degeneration of the blood-vessels, back pressure from diseases of the heart and lungs, and new growths, notably cancer. Among the exciting causes are infection from the blood, as from syphilis or pyemia, or extension from the duodenum, as with gall-stone obstruc- tion or from gastroduodenal or duodenal catarrh; or from adjacent organs, as from gastric or duodenal ulcer, or cancer of these viscera eroding the pancreas. Tuberculosis may be a cause of infection, and alcohol may be productive of pancreatitis, though such has been disputed. Bacterial infection has been disputed in its causal relation to pan- creatitis, though colon bacilli, streptococci, staphylococci, etc., have been found, and are believed by many to be secondary invaders of injured tissue. The author particularly believes the colon bacillus to be a factor in some cases, either from a general infection, or through the duodenum, and later reports a case of advanced chronic pancreatitis with colon b. bacilluria. Since the ducts of the pancreas open into the duodenum, which always contains bacteria, it is evident that infection can readily occur from this viscus. The close relation of the pancreatic to the common bile-duct is also a prominent factor. With the lodgment of a calculus in the common bile-duct, an infective cholangitis may follow. If a stone passes down into the pancreatic portion of the common duct, the duct of Wirsung may be compressed, and the secretion of the pancreas may be dammed back. This retained secretion may, in turn, become infected, and a catarrhal inflammation of the pancreas result. Even if the stone ulti- mately passes, the congested and swollen pancreas may keep up pressure on the common duct and cause a persistence of the jaundice. With persistent jaundice, due supposedly to extension into the common bile-duct from a duodenal catarrh, probably the pancreatic duct is involved in many cases. With persistent obstruction from a gall-stone a suppurative inflamma- tion of the pancreatic and common bile-ducts may ensue, and if this continues, abscess of the liver and pancreas may follow. With the milder type of infective catarrh an interstitial pancreatitis may result. This type is usually of the interlobular variety, but later the islands of Langerhans may become affected and diabetes result. If the opening of the ampulla of Vater into the intestine is obstructed by a gall-stone (Fig. 416) the common bile-duct and duct of Wirsung become a single channel, and acute hemorrhagic pancreatitis may result from the entrance of bile into the pancreas. From the above observations it is evident that gall-stones in the common duct and in the ampulla are the most frequent causes of the various forms of pancreatitis. IOO4 DISEASES OF THE STOMACH AND INTESTINES In a certain percentage of cases, however, the bile-duct and duct of Wirsung open by separate orifices into the duodenum (Fig. 416(6), while in others the duct of Santorini is the chief outlet of the pancreas or is of sufficient size to take on the functions of the duct of Wirsung, if the latter becomes obstructed. In the case of injury (traumatism) to the pancreas, it is believed that the secretion of the gland may act on the walls of the blood-vessels and produce further hemorrhage, and infection from the duodenum may be an additional factor in causing an acute inflammation. Hemorrhage into the pancreas may also arise from diseased blood- vessels, and the injection of mercury in a syphilitic subject has been reported as producing acute pancreatitis, resulting possibly from increased secretion and congestion of the gland. Syphilis alone, however, may be a factor. Infection of the biliary passages by the typhoid bacilli is not an infre- quent occurrence, and in one case they were proved to be the factor in pancreatic catarrh. Probably influenza and some of the other infectious diseases may cause pancreatitis. Pancreatitis has been reported in a number of cases occurring as a complica- tion of mumps. Out of 652 cases treated at the military hospital of Val de Grace, Simonin reports 10 cases, or 1.3 per cent., in which symptoms of pancreatitis oc- curred from the first to the twelfth days of the disease, and which lasted from two to seven days. The chief symptoms were epigastric pain and tenderness associated with nausea and vomiting. Jacob re- ports a case in which a tender swelling was found in the epigastric region (an enlarged pancreas); and Lemoine and Lapasset describe a case occurring on the fifteenth day in which autopsy showed an acute inflammation of the pancreas. Epigastric pain, jaundice, and hematemesis were the chief symptoms. With pyemia, one has the general symptoms of the disease with the additional epigastric pain, tenderness, etc., when the pancreas is involved. Syphilis may affect the pancreas as a tertiary lesion (gumma) or it may be congenital. It causes an interlobular interstitial pancreatitis. Ulcera- tion of the stomach or duodenum may spread to the pancreas and may produce suppuration in that organ. The relation of alcohol to the pro- duction of cirrhosis of the pancreas has been questioned. It has been found in association with cirrhosis of the liver, and the writer sees no particular reason why this factor should not be identical. Of course, abuse of alcohol may produce a gastro-intestinal catarrh, which, by exten- sion, might be the cause of the chronic pancreatitis. Arteriosclerosis, the result of alcohol, might again be the cause of pancreatic involvement. a b Fig. 416. a, Diagram to show how a small gall-stone may obstruct the papilla, and, if the ampulla of Vater be very large, may convert the common bile-duct and duct of Wirsung into one canal, thus pre- disposing to acute pancreatitis, b, Diagram to show a method of ter- mination of the ducts which will not predispose to pancreatitis (Opie). CATARRH OF THE PANCREAS IOO5 Cirrhosis of the pancreas, usually resulting in a fatal diabetes, in some cases undoubtedly results from a catarrh of the ducts of long duration, which first produces an interlobular and later an interacinar pancreatitis. Unquestionably, arteriosclerosis may be a cause of chronic pancreatitis. FUNCTIONAL DISTURBANCE OF THE PANCREAS Pancreatic Achylia Adolf Schmidt refers to a secretory disturbance of the pancreas which occurs in the course of gastrogenic intestinal dyspepsia resulting from achylia gastrica. He holds that ferment tests of the feces alone are of little value, but that the stools should be examined and that they contain undigested nuclei and show creatorrhea and a less marked steatorrhea in these cases. A careful, examination of the gastric functions, the author believes should be made, as in his opinion a positive diagnosis of achylia gastrica can be made only by this method. There is a mild form of acute (or rather subacute) pancreatitis which may occur as a complication of disease of the bile passages and is dis- tinguished from pancreatic achylia by an onset with pain, slight fever, steatorrhea marked, but an absence of creatorrhea. The condition is believed to be due to the relative absence of bile, which is the chief activator of lipase. Unquestionably with acute infectious diseases such as typhoid, etc., there are disturbances of the pancreatic functions with diminution of its digestive capacity Disturbances of the gastric secretion is also associated. CATARRH OF THE PANCREAS Acute Catarrh of the Pancreas. This type of pancreatitis resembles infective cholangitis, with which it is usually associated, and is generally due to a stone in the common bile-duct or diverticulum of Vater, with incomplete obstruction. The process is undoubtedly one 6f extension into the pancreatic duct. The writer does not believe that infective cholangitis and acute catarrhal pancreatitis can be differentiated, and thinks that the latter is a sequel to the former. The symptoms of infective cholangitis are: Variations in the intensity of the jaundice, which is of long duration, usually over a year; the liver may be of normal size or slightly enlarged; the gall-bladder is not distended; the spleen is enlarged; there is no ascites; bile may be present in the feces continuously or occa- sionally; and at times there may be ague-like paroxysms, with chilly fever and sweating (the hepatic intermittent fever of Charcot). On these occasions there may be colicky pains and the jaundice deepens, and often nausea and vomiting are present. The chills are often quite severe and the temperature may rise to 103 to io5F. Between attacks the temperature is normal. Though this condition may continue for years without suppuration within the ducts, the process is one of infec- tion, and operative procedure is indicated, i.e., the removal of the impacted stone. The infective cholangitis and acute catarrh of the pancreas are together cured by this method. 1006 DISEASES OF THE STOMACH AND INTESTINES Chronic Catarrh of the Pancreas. The possibility of diagnosing chronic catarrh of the pancreas is at present a matter of much dispute. Curtin 1 believes that there is little evidence that it is an inflammatory process. Lando 2 holds that stagnation of the pancreatic secretion within the acini may produce chronic interstitial pancreatitis. Robson 3 and Cammidge believe that chronic catarrh of the pancreas can usually be diagnosed by digestive and metabolic symptoms and by swelling of the gland, and that the symptoms and physical signs resemble in a mild degree those of chronic pancreatitis. Etiology. The most frequent cause of chronic catarrh of the pancreas the writer believes to be a gastroduodenitis or duodenitis. These condi- tions may be either acute or chronic, and as a result an infection of low grade may occur, both of the common bile-duct and of the duct of Wirsung. While a catarrhal condition of the duodenum exists, as can be determined by the microscopic appearance of mucus from the small intestine, "test- ing the intestinal functions" will be of value chiefly to show the catarrh. This last will interfere with the secretion of the prosecretin and entero- kinase, and, even if the pancreatic duct were not involved, or to a slight extent, and the common bile-duct were chiefly affected, the functions of the pancreas would be interfered with. After the mucus has disappeared from the stools and jaundice still persists, if then one finds the pancreatic functions markedly disturbed, the assumption of catarrh of the pancreatic duct is a fair one. Moreover, persistent jaundice following the history of a gastro-intestinal or intestinal catarrh shows that the common bile- duct is involved, and probably the pancreatic duct. Treatment. The general medical treatment is that of duodenal jaundice (see Intestinal Catarrh). This may be continued for the chronic condition, and if failure results, cholecystotomy or cholecysten- terostomy may be performed, which will relieve the catarrh of the common bile-duct and take off pressure from the pancreatic duct. The other most common cause of chronic pancreatic catarrh is an impacted stone in the pancreatic portion of the common bile-duct, which presses on the pancreatic duct, or a stone in the ampulla. The obstruction is usually partial, and the grade of infection producing a chronic catarrh is low. The history is one of gall-stone attack, followed by jaundice. In some cases the pancreatic functions may be disturbed. One must remember that in some the duct of Santorini may take on in part the function of the inflamed duct of Wirsung, so that the examination of the pan- creatic functions may not afford information. Furthermore, the repeated passage of gall-stones through the common duct may set up a catarrhal condition which may extend to the pancreatic ducts. Regarding the determination of pancreatic "enlargement in chronic catarrh of the pancreas the author is very skeptical. The removal of the impacted stone affords relief both to the catarrh of the common bile-duct and to that of the pancreatic duct. 1 Phila. Hosp. Rep., 1902, v. 2 Zeit. f. Heilk., 1906, Hft. i. 3 The Pancreas: Its Surgery and Pathology. CATARRH OF THE PANCREAS 1007 In a large percentage of cases the absolute determination and early diagnosis of chronic catarrh of the pancreatic duct is an impossibility. Its probability can be reasoned out, and the treatment is fortunately the same as that of chronic catarrh of the common bile-duct. Suppurative Catarrh of the Pancreas. This disease bears the same relation to catarrh of the pancreas as does suppurative cholangitis to simple catarrhal jaundice. Suppurative cholangitis and suppurative catarrh of the pancreas are usually associated. Etiology. The usual cause of this disease are gall-stones. One can explain that the same cause may produce in one case a simple catarrh and in another suppuration, on the ground that in suppurative cases there must be a high grade of infection with a lowered resistance on the part of the patient. Abscesses of the liver, gall-bladder, and pancreas are usually present. Symptoms. In the milder cases the symptoms are septicemic, in some those of a local abscess of the pancreas, and in the more severe cases they are pyemic. The preliminary history is one of attacks of gall-stones with sub- sequent jaundice, enlarged liver, tenderness and pain in the epigastrium and right hypochondrium, muscular rigidity, frequently a mass in these regions, irregular septic temperature, chills, sweating, leukocytosis, and increased polynuclears. Cammidge found his urine reaction in one of these cases of septicemic type. Occasionally, suppurative catarrh of the pancreas may assume a subacute form and end in a single pancreatic abscess with the symptoms associated therewith. Even after drainage of simple abscess of the pan- creas, interstitial pancreatitis may occur and ultimately lead to the death of the patient. CHAPTER XLIII ACUTE PANCREATITIS CHRONIC PANCREATITIS ACUTE PANCREATITIS THE best classification of acute inflammation of the pancreas has been made by Fitz: 1 1. Hemorrhagic pancreatitis, or hemorrhagic necrosis of the pan- creas (Opie). 2. Gangrenous pancreatitis. 3. Suppurative pancreatitis. Gangrenous pancreatitis, though due to other conditions, is usually the result of hemorrhagic pancreatitis, and in about 50 per cent, of cases recorded there is evidence of previous hemorrhage in the gland. The symptoms of the two conditions resemble each other, but with gangrenous inflammation the disease is of longer duration. Disseminated fat necrosis is present with both the hemorrhagic and gangrenous types. Suppurative pancreatitis results from hemorrhagic necrosis of the pancreas, necrotic tissue being particularly susceptible to bacterial infection. Pancreatic abscess also occurs in association with cholelithiasis through ascending infection from the intestinal tract, or from Suppurative cholangitis, carcinoma, compressing the pancreatic duct, pancreatic calculi, perforating ulcer in an adjacent organ, and traumatism. Fat necrosis is uncommon with Suppurative inflammation of the pancreas It is interesting to note that an acute interstitial inflammation of the pancreas without suppuration (acute interstitial pancreatitis) may oc- casionally occur. Acute Hemorrhagic Pancreatitis (Synonyms. Hemorrhagic Necrosis of the Pancreas Opie) This lesion has really not the characteristics of an inflammatory process. There is a primary necrosis of the parenchyma of the pancreas, and the only inflammatory changes which occur are at the margin of the necrotic tissue. It should properly be called "hemorrhagic necrosis of the pancreas." Fat necrosis which accompanies it has been demonstrated as due to the fat-splitting enzyme of the pancreatic juice. Pancreatic Hemorrhage. Hemorrhage into the substance of the pancreas may be due to a variety of causes. It may accompany tumors or may occur in pancreatic cysts, or with purpura, eclampsia, and the acute infectious diseases. Such cases have nothing in common with hemorrhagic pancreatic necrosis. Experimental Hemorrhagic Necrosis of the Pancreas. Hemor- rhagic pancreatitis has been experimentally produced on dogs by the 1 Acute Pancreatitis, Med. Rec., xxxv, 197, 225, 253, 1889. 1008 Fig. 417. Pancreas and adjacent tissues from a case of acute hemorrhagic pan- creatitis with fat necrosis (St. Bartholomew's Hospital Museum). ACUTE PANCREATITIS CHRONIC PANCREATITIS 1 009 injection of various substances into the duct of Wirsung, such as the deliquescent chlorid of zinc, artificial gastric juice, papain, the diphtheria toxin, hydrochloric acid, nitric and chromic acid, 1 suspensions of bacteria, etc. Bile 2 injected into the pancreatic duct almost uniformly produced the same results. Flexner 3 demonstrated that the Production of the lesion may be at- tributed to the bile salts. Occurrence. Hemorrhagic necrosis of the pancreas is found more frequently in men than in women. Peiser 4 tabulated 121 cases of hemor- rhagic and gangrenous pancreatitis, of which 79 occurred in men and 42 in women. Korte 5 collected 37 cases of the hemorrhagic type in males and 4 in females. In cases with gangrenous pancreatitis, 21 were in males and 19 in females. Individuals who are apparently in good health are not infrequently attacked, and fat patients are believed to be particularly susceptible. Age. Hemorrhagic necrosis of the pancreas and gangrenous pan- creatitis occur usually between twenty and sixty years of age. Etiology. Bacterial Infection. Opie 6 holds that no relation between hemorrhagic necrosis of the pancreas and bacterial invasion has been demonstrated. Welch 7 believes that the organisms penetrate the tissue subsequent to the production of the lesion. Various investigators have found the colon bacillus, the pneumo- coccus, streptococci, staphylococci and other bacteria in acute hemor- rhagic pancreatitis. Most agree that, as the findings are inconstant and as the necrotic parenchyma may contain no microorganisms they are secondary invaders of the injured tissue. In view of gall-bladder infection produced by the colon bacillus, the author believes that in some instances the colon bacillus may, in part, be responsible for this type of acute pancreatitis. It has been recently demonstrated that certain living pathogenic organisms, especially of the typhoid and B. coli group, are capable of activating the proteolytic pancreatic enzyme and the autogestive action of the enzymes or damaged tissue is a factor. It is further interesting to note that in an autopsy of one of Robson's 8 cases, performed three hours after death, subsequent to operation for acute hemorrhagic pancreatitis, blood-cultures contained the bacillus coli communis, as did also the pancreas. Cholelithiasis. There is a close relationship between cholelithiasis and acute pancreatitis. Egdahl has found that out of 105 cases of acute pancreatitis, cholelithiasis was present in 42 per cent. This is probably a minimum percentage. The calculus is sufficiently large to occlude the opening of the ampulla of Vater into the duodenum, and yet so small that it will not fill up the ampulla and will not obstruct the orifices 1 Contributions to the Science of Medicine, Johns Hopkins Hosp. Rep., 1900, ix, 793. 2 Opie, Bull, of Johns Hopkins Hosp., 1901, xii, 182. 3 Jour, of Exper. Med., 1906, viii, 167. 4 Deutsche Zeit. f. Chir., 1902, Ixv, 302. 6 Chirurg. Krankheit, des Pancreas, Deutsche Chirurg., Stuttgart, 1898. 6 Disease of the Pancreas. 7 Med. News, 1891, lix, 669. 8 The Pancreas (Robson and Cammidge), p. 392. 64 IOIO DISEASES OF THE STOMACH AND INTESTINES of the common bile-duct and of the duct of Wirsung. These two ducts are converetd into a continuous closed channel, and the bile entering the pancreas through its duct produces a hemorrhagic necrosis of the gland. In only a little more than three out of ten persons is the size of the diver- ticulum of Vater such that the stone will block the opening into the duodenum and yet not obstruct the duct openings. In i out of 10 cases the bile-duct joins the smaller pancreatic duct, and, furthermore, in some ' cases the duct of Santorini is the chief duct of the pancreas. In other cases the common duct and duct of Wirsung enter the bowel separately. These facts explain the comparative rarity of hemorrhagic necrosis of the pan- creas when compared with the frequency of cholelithiasis. Opie reports eight cases of hemorrhagic necrosis of the pancreas, in which gall-stones were present in five. Fig. 418. Areas of fat necrosis in the mesenteric and oraental fat and in the abdominal wall in a case of acute hemorrhagic pancreatitis (Fison). Penetration of the Duodenal Contents into the Pancreatic Ducts. In about one out of ten persons the duct of Santorini is the larger, and is the chief outlet of the gland. Probably a duct of this type can be the port of entry of the duodenal contents. Catarrhal duodenitis, which preponderates in males, may pass by regurgitation directly into the pancreatic duct. It might render the orifice of the duct larger and less competent to assert the valvular action and might be a factor in producing acute pancreatitis. The Lymphatics. The lymphatic system of the gall-bladder directly anastomoses with that of the pancreas, and may therefore be a source of infection in the production of acute pancreatitis. Deaver 1 holds that the 1 Journal A. M. A., Jan. 4, 1913. ACUTE PANCREATITIS CHRONIC PANCREATITIS IOII lymphatics may carry the infection and reports two cases of acute appen- dicitis followed by infection of the pancreas. Traumatic Necrosis. A blow, an injury to the abdomen in the epi- gastric region, or a stab- wound may produce hemorrhage into the pan- creas. Crushing of the gland, associated with occlusion of the vessels (venous thrombosis), together with an escape of the pancreatic juice into the damaged area, may be subsequently followed by hemorrhagic necrosis. Alcoholism and diabetes have by some been considered factors in the production of this type of acute pancreatitis. Parturition has been mentioned as a cause, the pancreas being affected in a similar way as the kidneys and liver by the toxemias of pregnancy. .,.** V Fig. 419. Hemorrhagic necrosis of the pancreas, showing abrupt transition from normal to necrotic tissue. At the margin of the living tissue are red blood-corpuscles, leukocytes, and fibrin (Opie, "Diseases of the Pancreas"). The theory has been advanced that the pancreatic necrosis may result from embolism of the giant cells of the placenta. Undoubtedly the major number of cases of hemorrhagic necrosis of the pancreas can be imputed to a gall-stone impacted in the mouth of the ampulla of Vater. Pathology. The pancreas is enlarged, firm, and generally covered by clotted, black-red blood (Fig. 417). There is blood-stained fluid in the lesser peritoneal cavity, and frequently blood infiltrates the tissues about the pancreas. Fat necrosis always accompanies it (Fig. 418). Usually the entire organ is not affected, and there may be areas of normal parenchyma. There is coagulation necrosis in the diseased areas, involving the 1012 DISEASES OF THE STOMACH AND INTESTINES epithelial cells, interstitial tissue, and the blood-vessels. There is an abrupt transition from the necrosed area to living tissue, and there is a line of demarcation, a narrow zone, which contains fragments of nuclei, red blood-cells, polynuclear leukocytes, and fibrin (Fig. 419). Acute inflammation is not always present. There is hyaline thrombo- sis of the capillaries within the tissue which is in contact with the necrotic area. In some cases hemorrhage may be a slight feature and necrosis the chief lesion, with a few hemorrhagic areas. Complete recovery may occur, and the necrotic area become absorbed and replaced by fibrous tissue. After healing of the pancreatic lesion, the lesser peritoneal cavity may still contain opaque fluid and necrotic particles, and the pancreas be covered by black, altered blood. As gangrenous pancreatitis is a progressive stage of the acute hemor- rhagic type, it will be next described, and the symptoms of both conditions will be given later. Gangrenous Pancreatitis Stage of Gangrene. Etiology. This condition is usually a sequel of hemorrhagic necrosis of the pancreas should the patient survive a sufficient period of time. Perforating ulcer of the stomach, intestines, or biliary tract, or even extension of a cholangitis through the pancreatic duct, may be causes. Traumatism may first produce a hemorrhagic necrosis of the pancreas with subsequent gangrene. Pathology. The pancreas is usually swollen, dark red, or red-gray, or slate colored, generally foul smelling, and is often surrounded by a thin greenish or dark-colored purulent fluid. It may lie free in the cavity of the omentum, which last is distended with ill-smelling bloody or blackish fluid. In some cases in about a week or ten days the pancreas may be dry, firm, and of dark-brown color, covered by altered blood. In the paren- chyma of the gland yellow spots of softening may alternate with areas of hemorrhage. In others, in about two weeks the pancreas may appear a black, soft, friable mass, and the cavity of the lesser omentum contain chocolate- colored fluid with blackish clots. The gangrenous condition of the gland is produced by the invasion of bacteria, which produce these changes in a necrotic gland containing extravasation of blood. Suppuration with or without perforation of the gastro-intestinal tract is a secondary condition. The microscopic appearance of gangrene is quite typic. Disseminated fat necrosis is present. Accumulation of Fluid in the Lesser Peritoneal Cavity. With these types of acute pancreatitis there is accumulation of fluid in the lesser peritoneal cavity. The foramen of Winslow is closed by adhesions. The fluid usually contains the products of pancreatic secretion. The contents may at first be sterile, but later become infected from the gangren- ous pancreas. The bacillus coli, bacillus lactis aerogenes, bacillus proteus vulgaris, and streptococcus pyogenes have been found in this sac. ACUTE PANCREATITIS CHRONIC PANCREATITIS 1013 An abscess may form, the wall of which is blackish or gray," and consists chiefly of necrotic fat. The contained fluid may be brown or gray in color, and contain soft, greasy, necrotic material. Through erosion the abdominal wall in the left lumbar region may be perforated, or perforation into the general peritoneal cavity may occur. A sub- diaphragmatic abscess may form, and the diaphragm may be perforated with a resulting empyema. Perforation of the stomach, duodenum, or transverse colon may take place, and the discharge of necrotic pan- creatic tissue from the bowel has been recorded. Symptoms of Acute Pancreatitis (Hemorrhagic and Gangrenous) Symptoms of Hemorrhagic Necrosis. The patient may have been previously healthy or a sufferer from occasional attacks of indigestion. In some there may be a history of gall-stone attack. Suddenly there is an intense pain in the upper abdomen, the epigastric region, followed by vomiting, more or less obstinate in character, and severe collapse, which has in a few hours even caused death in some cases reported. The pain, which is very intense, never wholly subsides, and is paroxysmal and increases on movement. If the condition persists for a longer period, in the course of twenty-four hours there is an epigastric swelling, tympanitic or resistant, with tenderness on pressure, which is present from above the umbilicus to the ensiform process and over the pancreas. The tenderness may be most marked at Robson's point. Obstinate consti- pation occurs, though the obstruction is not absolute, as flatus occasion- ally passes and a large enema may secure a movement. A normal or, usually, subnormal temperature is present in the very acute cases. If the case survives several days there may be irregular temperature, or occasionally it may be high. The pulse is rapid and small and cyanosis may result, both of the face and abdominal wall particularly (Halsted). The aspect is anxious and the face pinched. An epigastric peritonitis is present at first, which later may become general, and general disten- tion occur. Tender spots are also often present throughout the abdo- men. They are believed to lie over the areas of fat necrosis. Jaun- dice may be present, at first slight, which may later deepen. The vomitus may consist, first, of food; later, of bile, and, finally, of black altered blood. Hemorrhage may also occur from the other mucous surfaces, the intestines, subcutaneously, and into the skin. Death usually occurs on the second to fifth day, though a fatal issue may take place within a few hours. Delirium may occur before death. This condition may be mistaken for intestinal obstruction, but stercoraceous vomiting and visible peristalsis of the intestines are absent, which occur in the latter. On laparotomy, areas of fat necrosis are visible, which are at once suggestive of the condition. Subacute Pancreatitis. The writer has recently seen a case in which there was an acute attack of pain, apparently from a gall-stone; tenderness over the pancreas and common duct; vomiting of blood and passage of blood in the stools; no jaundice and no shock of marked degree. Recovery ensued. The stone evidently escaped into the gut. 1014 DISEASES OF THE STOMACH AND INTESTINES Symptoms of Gangrene of the Pancreas. With this condition the violent symptoms of an acute hemorrhagic pancreatitis, which may precede it, may diminish in their severity, or the symptoms of the onset may be less severe in character. The patient survives the more acute attack and the condition is more chronic. Opportunity is given for bacterial invasion and subsequent gangrene. The pain is localized in the epigastric region and vomiting may occur at intervals. Symptoms pointing to suppuration eventually give evidence that infection has occurred. There are frequently an irregular temperature and chills. Diarrhea may later be present. An ill-defined tumor may at times be felt above the umbilicus, due to accumulation of fluid in the lesser peri- toneal cavity, or to hemorrhagic purulent fluid about the pancreas. The mass is generally situated in the epigastrium, and extends toward the spleen. Inflation of the stomach and colon may aid in locating its posi- tion. The stomach separates the tumor from the liver, and, when inflated, covers it. At times erosion of tissue over the left kidney occurs, and there may be a swelling below the left costal margin as far as the iliac crest. The gangrenous type of pancreatitis may be prolonged for several weeks or longer. Considerable loss of weight may occur in these cases when prolonged. In both these types of acute pancreatitis, digestive disturbances, such as have been described under the General Symptoms of Diseases of the Pancreas, may occur. Seldom is there such destruction of the pancreas that its functional activity is entirely destroyed. Sugar is rarely present; fatty stools are rare. Leukocytosis. Leukocytosis may be present during the first few days of the attack of hemorrhagic necrosis of the pancreas. It is not always present, however. With gangrenous pancreatitis, leukocytosis may vary from 15,000 to 40,000. It may diminish, and there may even be leukopenia before death. Increased polynuclears occur with leukocy- tosis. Blood clotting is delayed. Diagnosis and Differential Diagnosis. The anamnesis, the symp- toms of acute epigastric peritonitis, pain, vomiting and collapse, and the fulminating character of the attack are at once suggestive. The writer believes that determination of the pancreatic functions, the Cammidge reaction, etc., are of no practical assistance. The condition is acute, and radical procedure is indicated, with no delay. Laparotomy reveals fat necrosis, which is diagnostic in connection with the symptoms. With intestinal obstruction there are stercoraceous vomiting and intestinal paralysis; no flatus is passed. With perforation of duodenal or gastric ulcer the history, gravitation of the contents toward the pelvis the general peritonitis and the absence of liver dulness are serviceable data. With phlegmonous cholecystitis the swelling and tenderness usually first lie below the right costal margin, tenderness is to the right (over Murphy's point) i.e. the gall-bladder. Pain passes through to the back and right shoulder. Determination of the gall-bladder zone (Head) is of service. With appendicitis epigastric pain may first be present, but tenderness ACUTE PANCREATITIS CHRONIC PANCREATITIS 101$ at McBurney's point and muscular rigidity over tne appendix are present. Head's zone for the appendix is also diagnostic. Treatment. Collapse must receive treatment at once and the acute pain must be relieved, which is in itself a serious factor in producing the shock. Morphin, y to Y 2 grain (0.015-0.03), may be given by hypo- dermic injection, and strychnin, ^ grain (0.002), camphor oil, 5 grains (0.3) camphor in 15 minims (i.o) of sterile olive oil or almond oil, should be administered. Hypodermoclysis may be indicated. Vomiting should be relieved by lavage. Hot saline enemata, i pint to i quart (500-1000 c.c.) each, at i2oF., may be given for shock. A nutritive enema may be added, and in the latter 20 grains of lactate of calcium should be given to overcome the hemorrhagic tendency. Chlorid or, preferably, lactate of calcium, 60 to 90 grains (i-iM drams) daily, should be given in divided doses, 15 grains (i.o) at a time, by enema, both before and after opera- tion, in the latter event for ten days. In a recent case with hematemesis and inability to retain the enema, 10 grains (0.6) of lactate of calcium were dissolved in 5 ounces of water and i-dram doses of this solution given by mouth every one-half to one-quarter hour with success. This was repeated several times daily. Proctoclysis with the addition of cal- cium lactate 5* to the solution is also valuable. Human blood-serum 20 c.c. may also be injected hypodermically, if necessary, to combat the hemorrhagic tendency, or horse serum by mouth. Continuous entero- clysis with hot saline at i2oF. will both relieve distention and stimulate the patient. Recourse to laparotomy is indicated as soon as the shock is relieved. Incision is made in the median line or over the 'most prom- inent part of the tumor, if such can be determined. On opening the ab- domen the presence of fat necrosis is at once diagnostic of pancreatic involvement. The cavity of the lesser peritoneum is then entered through the gastrocolic ligament, and fluid and necrotic material, if present, are evacuated. The pancreas should also be drained. The operator should determine the condition of the bile-passages, and if the shock of the operation be not dangerously increased by further procedure, gall-stones, if present, should be removed from the gall-bladder and any impacted stone from the common duct. If prolongation of the operation seem inadvisable, the gall-bladder should be drained, and by a subsequent operation the stones removed therefrom and the impacted stone cleared from the ampulla. Subsequent to operation on the pancreas, during the drainage period, severe hemorrhage from the wound, due to erosion of the larger blood-vessels from the glandular secretion of the pancreas, has been reported. Korte has seen some 44 cases of hemorrhage from this cause and reports six deaths from such occurring from eleven to thirty- four days after operation. Proctoclysis subsequent to operation is of value for the sepsis and lactate of calcium should be continued to check hemorrhagic tendency by hastening blood clotting. Suppurative Pancreatitis Pathology. The pancreas is enlarged. There may be a diffuse suppurative process of the gland, or multiple small abscesses, in which I0l6 DISEASES OF THE STOMACH AND INTESTINES the process is more acute, or there may be a single abscess of the pancreas (subacute pancreatitis Robson), a less acute process, and which may even be of considerable duration. Rarely, there may be an acute interstitial pancreatitis without suppuration an intermediary stage. Etiology. Suppurative pancreatitis may be secondary to hemor- rhagic necrosis of the pancreas, or quite frequently result from ascending infection of the pancreatic duct. It may occur in association with chole- lithiasis by occlusion of the duct of Wirsung by a calculus lodged in the diverticulum of Vater. Suppurative cholangitis or cyst of the pancreas may be followed by suppuration. Pancreatic calculi, carcinoma compressing the pancreatic duct, carcinoma of the diverticulum of Vater, or ulceration of neighboring organs may produce abscess of the pancreas. Traumatism and digestive dis- turbances have been considered factors. Bacterial Infection. Among the microorganisms isolated from abscess of the pancreas are Bacillus coli, pyogenic cocci, proteus vulgaris, and diplococcus lanceolatus. Colon bacillus infection the author believes to be a possible etiologic factor. Fat necrosis rarely accompanies Suppurative pancreatitis. Sequelae of Suppurative Pancreatitis. Infection of the lesser peritoneal cavity is frequent. Perforation into the general peritoneum may result. The abscess has ruptured into the stomach, with resulting vomiting of pus, or has perforated the bowel, with discharge of pus therefrom. Throm- bosis, with infection of the splenic and portal veins and metastatic abscess of the liver, may occur. The pus may burrow into the right loin and be mistaken for a perirenal abscess. It may find its way into the left iliac region or form a subphrenic abscess. It may burrow between the liver and stomach, or reach the surface above or below the latter, or pass into either loin or into the pelvis, or into the left broad ligament. Even with proper drainage, chronic interstitial oancreatitis may result, from which the patient may succumb. Symptoms of Suppurative Pancreatitis/ If this condition results from hemorrhagic necrosis of the pancreas, cholelithiasis, pancreatic cyst, or pancreatic lithiasis, its symptoms are modified by the preceding condition. In about 50 per cent, of the cases there are first a sudden onset, with intense epigastric pain, vomiting and collapse, the symptoms of hemorrhagic pancreatitis, of which suppurative pancreatitis may be a sequel. The severity of the symptoms then lessens and the course becomes chronic. In others there may be a more or less sudden onset with severe pain, vomiting, and constipation, but collapse is not a marked symptom and, as a rule, is absent. The upper region of the abdomen in these cases does not become as rapidly distended, and vomiting is less severe. In others the onset is gradual and the symptoms are less severe. The abdominal pain may be little more than discomfort and gastric disturbances occur at times. In some cases a history of intermittent attacks of pain, at first without and later with jaundice, may be elicited, due to gall-stones, and in others, symptoms of infective cholangitis, with rigors, intermittent fever, and deepening of the jaundice. ACUTE PANCREATITIS CHRONIC PANCREATITIS Thayer 1 reports a case of jaundice due to pressure of a pancreatic abscess on the common bile-duct in which carcinoma was suspected. Tenderness over the pancreas is usually well marked, and in about one-fourth of the cases a palpable tumor can be determined. This is more frequently due to accumulation of inflammatory products within the lesser peritoneal cavity than to a palpable pancreas. Constipation may be followed by diarrhea, which may be fetid in character if pus or blood are present in the stools. Fatty stools may occasionally be observed or impaired absorption of fat may at times be determined. Robson believes that fat and undigested muscle-fibers are usually present in the stools, and Opie, that they rarely occur. Glycosuria is rare. The writer believes that fat in the stools and glycosuria are rare oc- currences. In the subacute or chronic type of case the pulse is not seri- ously affected. In many cases there is fever, reaching up to io5F., with recurring chills. The morning temperature may be normal. Leu- kocytosis is present and increased polynuclears. There is a gradual loss of flesh and the patient becomes more feeble. Albuminuria is quite frequently present. Robson holds that the Cammidge reaction is, as a rule, well marked. The author believes it may be tried, but doubts its diagnostic value. Suppurative pancreatitis with single abscess formation tends to take a chronic course, from one to even eleven months. With diffuse suppura- tion, liver abscess may be associated and the symptoms may be pyemic. There may be evidence of abscess formation in the regions described under Sequelas of Suppurative Pancreatitis. Rarely, there is no elevation of temperature, and when, in addition, the mass cannot be palpated, pancreatic abscess cannot be determined. Diagnosis. Early occurrence of fever, with chills, epigastric tender- ness, pain and swelling, and leukocytosis, suggests pancreatic abscess. When it follows hemorrhagic necrosis of the pancreas the diagnosis is more difficult, since when this condition reaches the stage of gangrene, abscess of the lesser peritoneum may also be present, as it is also in suppurative pancreatitis. A chronic course, however, suggests suppuration. Fat necrosis is also usually absent. Treatment. During the acute stage the treatment of vomiting, collapse, and distention are the same as with the other types of acute pancreatitis already described. Enemata of soapsuds, with i dram of spirits of turpentine, or enteroclysis at 120 F aid in relieving distention. Calomel is of value to empty the bowel during the constipated stage, and can be given in a dose of 5 grains (0.3), or it may be administered in small doses as an intestinal antiseptic, in either case to be followed by a saline cathartic. Lactate of calcium, 60 grains (4.0), should be given daily in divided doses before and after operation to prevent hemorrhage, or, if such is occurring. The urine should be examined for colon bacilli and urotropin 2 and benzoate of soda, 80 grains (5.3) each, should be given by enema in divided doses daily if such are present. 1 Amer. Med., 1902, 341. He.xamethylenamin may be substituted. I0l8 DISEASED OF THE STOMACH AND INTESTINES Early operation with drainage of the abscess is indicated; also the removal of biliary or pancreatic calculi if such are present. CHRONIC PANCREATITIS In undertaking to give the reader a clear and concise conception of chronic interstitial pancreatitis, so that he may readily be enabled to diagnose this condition, the writer, in the present state of our medical knowledge, is confronted by an almost impossible task. Though the study of this lesion or, rather, of one particular type of it, has contributed important facts to our knowledge of diabetes mellitus, yet chronic pan- creatitis of another anatomic type, at times difficult to diagnose as a result of various factors, may occur. The symptoms appearing with the primary disease, such as inflammatory conditions of the gall-bladder, duodenum, etc., which may stand in a direct causative relation to the chronic pancreatitis, may greatly obscure the diagnosis. One must frequently arrive at the latter by the process of exclusion. It may simulate biliary, duodenal or gastric disease or chronic appendicitis with symptoms referred to the upper abdomen, and differentiation may be possible only at operation. Chronic inflammation of the pancreas may be present, and, on account of anatomic peculiarities of the gland found in a percentage of cases, the disease may become well advanced before disturbances of the pancreatic functions can be determined. Opie, in fact, holds the view that "the lesion is seldom associated with such definite symptoms as to be recognized during life, and that, even at autopsy, the condition is frequently overlooked." Robson and Cammidge, on the contrary, believe that "from examina- tion of the patient, the history of the case, and the results of chemic and microscopic examination of the excreta, a correct opinion may be formed in a large majority of instances." These represent extreme views. The writer believes that in many cases the diagnosis of chronic pancreatitis is possible, while in other instances, especially in the early cases, our present medical knowledge is not sufficiently advanced to permit accurate determination of this lesion. The diagnosis in a well advanced case of chronic pancreatitis is frequently not particularly difficult. Sex. In 30 of Opie's 1 cases, 17 occurred in males and 13 in females; while in Deaver's 2 patients, 22 were males and 16 females. Bohm reports 65 per cent, males and 35 per cent, females. The disease, therefore, preponderates in the male sex. The relation of sex to chronic pancreatitis, as compared with chole- lithiasis, is reversed, biliary affections preponderating in the female. Age. Opie has collected 30 cases from the age of ten to eighty years. Twenty, or two-thirds, occurred between forty and sixty years. These included postmortem records. Deaver reports 34 cases, in which four were under thirty years of age and the balance between thirty and sixty years. Two-thirds of these cases occurred between forty and sixty years. All but one were operative. 1 Disease bf the Pancreas. 2 Jour. Amer. Med. Assoc., April 15, 1911; ibid., July i, 1911. ACUTE PANCREATITIS CHRONIC PANCREATITIS IOIQ Etiology. In about one-half to two-thirds of all cases of chronic pan- creatic, cholecystitis and cholelithiasis are found to be the exciting causes. Deaver found disease of the gall-bladder or ducts in 65 per cent., and one-half had gall-stones at operation; Mayo found gall-stones in 81 per cent.; Robson, in 60 per cent. A large calculus in the diverticulum of Vater or in the common duct above its junction with the pancreatic duct may compress the latter and cause chronic inflammation of the pancreas. Bacterial infection (ascend- ing infection) of the duct of Wirsung is probably a factor. A small calculus in the orifice of the diverticulum of Vater usually produces acute pancreatitis. Flexner reports from his experiments that when the position of the bile is modified by a diminution of its salts or by an increase of colloid material, its entrance into the pancreatic duct is likely to set up a chronic pancreatitis, while fresh unaltered bile sets up acute changes. Small stones sometimes cause chronic pancreatitis, so that modified bile in these cases has probably been diverted into the duct. Wm. J. Mayo 1 finds that cholecystitis without stones or jaundice is responsible for chronic pancreatitis and advises removal of the gall- bladder for this condition. Malignant Growths. A growth compressing or invading the pancreas may produce chronic pancreatitis; it may either compress the duct of Wirsung or obstruct the ampulla or papilla, interfering with the flow of pancreatic secretion. Infection from an ulcerated surface may be a factor. The pancreas may be invaded by a carcinoma of the stomach, with resulting local or diffuse interstitial inflammation. Impacted pancreatic calculus, stenosis of the duodenal orifice of the gland following ulceration, and hydatid membrane obstructing the opening are reported as causes. Ascending Infection from the Duodenum. Chronic pancreatitis may result from extension of a duodenal catarrh into the pancreatic duct. Associated bacterial infection is a factor even when the ducts are blocked by calculi. In the latter event, bacteria may enter along the walls of the inflamed duct through the lymphatics or blood-stream. Infectious Diseases and from Adjacent Organs. Chronic pancreatitis may occasionally occur as a sequel to typhoid fever, mumps, influenza, and other zymotic diseases. Extension of the inflammatory process from an adjacent organ, as in a case of gastric ulcer or carcinoma of the pylorus, may produce it. Among other causes are arteriosclerosis and chronic passive congestion of the pancreas, due to chronic diseases of the heart, lungs, and liver. The action of toxic substances in the blood may produce a chronic pancreatitis, notably tuberculosis, syphilis, and alcohol. Chronic pancreatitis is quite frequently associated with cirrhosis of the liver. In 30 of Opie's cases of chronic pancreatitis, cirrhosis of the liver was present in eight. Lefas 2 and Opie 3 find that chronic pancreatitis may accompany either 1 Amer. Jour. Med. Science, April, 1914- 2 Arch. gen. de. Med., 1900, U. S., Hi, 539. 3 Disease of the Pancreas. 1020 DISEASES OF THE STOMACH AND INTESTINES the atrophic form of cirrhosis of the liver (Laennec's) or the hypertrophic form. In the former case the type of pancreatitis is intralobular (inter- acinar), and the weight of that organ is increased, while in the latter case the interlobular type occurs, and there is no increase in the volume of the pancreas. Cirrhosis of the liver and interacinar pancreatitis are associated with diabetes mellitus with hemachromatosis. The writer has recently reported a case of undoubted chronic pan- cr*eatitis with marked colon b. bacilluria. He believes the colon bacillus responsible in some cases. This patient had steatorrhea. Pathology. There are two types, of chronic interstitial inflammation of the pancreas the interlobular and the interacinar. Chronic Interlobular Pancreatitis. Etiology. This type is most fre- quently due to obstruction of the pancreatic duct or to ascending infection along the duct. Fig. 420. Chronic interstitial pancreatitis of the interlobular variety (Santos). The interlobular tissue is the site of the chief change, and the gland is dense, hard, and the surface is nodular or granular. The tissue on section is compact and homogeneous, the areolar tissue being replaced by scar-like bands. Occasionally the gross appearance may be little altered, so that the lesion can only be recognized under the microscope. Considerable fat may infiltrate the newly formed tissue, and small foci of fat necrosis may be present. Coarse glands of fibrous tissue separate the lobules of the parenchyma; and lymphoid cells, plasma cells, and eosinophiles are present in the interstitial tissue. The chief increase of fibrous tissue is between the lobules. Acini, with atrophied nuclei and dilated laminae, are at times separated by new tissue. The islands of Langerhans are unaltered (Fig. 420). When the case is far advanced, the pancreas may become densely ACUTE PANCREATITIS CHRONIC PANCREATITIS IO2I sclerotic, fibrous tissue replacing the gland tissue to a great extent, there remaining small masses of the parenchyma embedded in fibrous tissue. The islands of Langerhans are unchanged, being frequently the only remains of the parenchyma, lying amid sclerotic bands. They are resistant to the sclerotic process, and only suffer in extreme cases when the acini are nearly completely replaced by fibrous tissue. Chronic Interacinar Pancreatitis. With this type of pancreatitis there is a diffuse increase of the interacinar stroma, and the organ is tougfi, rather than hard, and the surface is smooth. It is characterized by newly formed tissue within the lobules (intralobular) (Fig. 421). The lesion is irregular in its distribution. There is thickening at one point of the connective-tissue network supporting the acini, while in other F> /e3NS ^YJ' ^Mviv* F'^1888 Fig. 42 1/ Chronic interstitial pancreatitis of interacinar type showing the invasion of Langerhans by the inflammatory process (Opie). regions there are compact bands or masses of stroma. The interlobular tissue is not entirely unaffected, but its proliferation is not constant and is inconspicuous. The lobules are not accentuated, but the interlobular boundaries are obscured by strands of new tissue. The new growth invades the islands of Langerhans. They are almost constantly surrounded by fibrous tissue, forming a capsule which separates them from the adjacent acini, which last are separated from each other. There is proliferation of interstitial tissue about the capillaries of the islands, which forms coarse strands between the columns of cells. In the early stages there is an accumulation of lymphoid cells in and about the islands. In some instances this type of inflammation (sclerosis) is almost entirely limited to the islands of Langerhans. 1022 DISEASES OF THE STOMACH AND INTESTINES Interacinar pancreatitis is much less common than the intralobular form, and the former condition has direct association with diabetes mellitus. Lipomatosis (infiltration with adipose tissue) occurs in association with chronic interstitial inflammation of the pancreas in both types of this lesion. Symptoms. In many cases the diagnosis of chronic pancreatitis is impossible, particularly in the early stages of the interlobular type of the disease, and at times, even when the lesion is fairly well marked, sufficient of the normal parenchyma remains for the organ to partially perform its functions. The anamnesis is often of considerable value, in arriving at a definite conclusion. A history of bad habits of eating or drinking, with resulting chronic inflammatory conditions of the stomach and duodenum, or of infectious diseases, which are likely to be followed by disease of the biliary passages, or a history pointing to attacks of gall-stones or impacted gall- stone with cholangitis and intermittent fever, would be suggestive of the probability of secondary involvement of the pancreas. In some cases chronic pancreatitis may exactly simulate this last condition, and the writer will describe a case simulating duodenal ulcer with pyloric stenosis. On the other hand, when with a history as described above there follow, progressive loss of weight, jaundice which tends to persist, though at times it may intermit, disturbances of the digestive functions, pain or aching in the epigastrium, or a sense of discomfort, an excess of unabsorbed fecal fat, or an undue amount of unsplit fat in the feces, epigastric tenderness, and fulness in this region with or without a swelling of the pancreas, a diagnosis of chronic pancreatitis can be made with certainty. The Cammidge reaction, the writer believes, is not always present, and he, at present writing, is very doubtful as to its value. Jaundice, however, is not always present. Chronic Pancreatitis Simulating Gastric or Duodenal Ulcer with Pyloric Stenosis. Recently the writer examined a patient, a girl of twenty-six years, with a history of gastric disturbances of three years' duration; pain after eating, more frequently after several hours; occa- sional vomiting; history of apparent occasional attacks of coffee-ground hematemesis. Patient anemic. Total acidity, 60+ ; free HC1, 30+; combined HC1, 25+. No pus, no occult blood detected in gastric con- tents. Stool showed some disturbance of intestinal digestion, but nothing typical of chronic pancreatitis. There was local tenderness in one point in the epigastrium. Stomach lies with lower border at umbilicus. The writer believed the case one of pyloric obstruction (partial), due probably to duodenal ulcer. Operation by John Connors disclosed a dilated stomach; no ulcer of stomach or duodenum; a partial stenosis of the duodenum from enlarged head of the pancreas; the entire pancreas showed evidences of chronic pancreatitis, no gall-stones in common duct or gall-bladder, but the latter was filled with very thick inspissated bile. The gall-bladder was drained. At present writing, several weeks since operation, there are no gastric disturbances. Whether the head of the pancreas will become smaller, with no subsequent symp- toms, or whether the condition later progresses, time alone will determine. ACUTE PANCREATITIS CHRONIC PANCREATITIS 1023 On the other hand, in Fig. 422 is demonstrated an early case of evi- dently commencing chronic pancreatitis due to gall-stones. The patient is suffering from chronic toxemia (biliary) though no jaundice at the present time. She has hyperchlorhydria of rather mild type with gastric symptoms. The gall-bladder and appendix are both sensitive to pressure. There are a large number of fatty acid crystals in the stool and incomplete absorption of the products of fat digestion. The urine shows a trace of bile, indicanuria, a trace of albumin and a few casts. Operation to be immediate. As Deaver justly remarks, the diagnosis is most frequently made in those who are driven to surgical intervention on account of rather an active type of symptoms. It seems best to take up the latter separately. F FIG. 422. Mrs. K. Author's case at Manhattan State Hospital, Wards Island. Gall-stones at + + . Hyperchlorhydria; trace of bile in urine. Radiography by D. J. Kelliher. No jaundice at time of radiograph; conjunctiva? clear. Patient has had attacks of jaundice. Gall-bladder tender. Chronic appendicitis. Stool shows a large number of fatty acid crystals and incomplete absorption of products of fat digestion. Early stage of chronic pancreatitis. To be operated immediately. Bile passes into intestines at present time in most part, though slight absorption of same. The onset of the symptoms may be apparently sudden, due to an exacerbation, or they may be gradual. Pain. Pain is usually present during an exacerbation, varying from a dull ache or discomfort to that of a lancinating or colicky type. In the latter instance, calculi are probably responsible in most cases. In many, the pain is in the epigastric region, though it may radiate to the back in the midscapular region. Occasionally it radiates to the right, and it may start beneath the right or left costal margin. There appears to be no definite relation of the time of eating or the character of the food to the commencement of the pain, and this may be sometimes of service in differentiating pancreatic pain from that of gastric or duodenal ulcer. Nausea and Vomiting. Nausea or vomiting, or both conditions in association, occur quite frequently in attacks. With nausea there may 1024 DISEASES OF THE STOMACH AND INTESTINES be anorexia, offensive eructations, heart-burn, flatulency, and distaste for fats or meat. Carbohydrates seem to cause in some the most disturbance. Sailer states that the administration of a large amount of glucose is particularly distressing to these patients. Opie has called attention to persistent vomiting 1 in some cases of chronic interlobular pancreatitis. It seemed to indicate a relationship between gastro-intestinal disturbance and a chronic pancreatitis. Gastritis, or gastroduodenitis may be associated with chronic pan- creatitis, and in some cases these factors may be the cause of the vomiting. Vomiting also occurs with biliary catarrh. The vomiting of chronic pancreatitis is not characteristic, though it may contain mucus and bile, and eructations of distressing character may be present. Jaundice. Jaundice is another important symptom. In Beaver's 2 cases it was present in 24 patients at the time of operation and absent in 14. In about two-thirds of all cases the common bile-duct passes through the head of the pancreas, so that an inflammation of this part of the organ will interfere with the free exit of bile. Undoubtedly, many cases of so-called catarrhal jaundice can be so explained. On the other hand, a great degree of inflammation of the pancreas may be present, with no jaundice, when the duct does not pass through the head of the gland. A certain percentage of jaundice cases may be due to obstruction from a calculus, or to extension from a catarrhal duodenitis. In some cases the jaundice may come on without pain, and it may be continuous. In others, rapid wasting and loss of strength are associated with the jaundice, so that malignant disease of the pancreas may be simulated. On operation the head of the pancreas may be so hard and nodular as to resemble carcinoma on palpation. Occasionally the neighboring glands may also be enlarged, so that the simulation is complete. More frequently, jaundice is preceded by pain, sometimes like that of gall-stone colic when such is present, or at other times the pain may be less severe and not colicky. Pain, intermittent jaundice, and attacks of fever (Charcot's hepatic intermittent fever) may occur, and yet no stone be found at operation. Possibly it has escaped from the duct, though this simulation of gall-stone attack may occur with chronic pancreatitis. The jaundice may vary from a slight tinge to black jaundice. Opie holds the view that in most cases jaundice is due to cholelithiasis or some other hepatic disease, preceding or accompanying the chronic pancreatitis. Digestive Symptoms. With serious disturbance of the pancreatic func- tions there are loss of weight and impairment of appetite. The appetite may persist in some cases. In some there is no disgust for meat. The loss of weight and strength, especially in the cases with jaundice, may be so rapid as to simulate cancer. In ordinary cases marked wasting does not occur. Temperature. The temperature is usually normal in prolonged cases, but fever may be present during an exacerbation of the disease. In the 1 Vomiting of blood, with hemorrhage from the intestines and other mucus mem- branes is of bad prognosis. 2 Jour. Amer. Med. Assoc., April 15, 1911. ACUTE PANCREATITIS CHRONIC PANCREATITIS 102$ cases coming to the surgeon to secure relief, fever has been usually present, sometimes varying from 99 to io3F. With an associated cholangitis, fever, chills, and sweating occur. Bowels. The bowels are, as a rule, constipated and flatulence is present. In a few cases there is diarrhea. Only with advanced pancreatitis do we have the frequent pale, offensive, greasy, and bulky movements (steatorrhea). Physical Examination. Physical examination may afford no positive information, but may aid in excluding other abdominal conditions. Epi- gastric tenderness and muscular rigidity of the recti in this region may be present during an exacerbation of the disease. When present, it is impossible to detect a mass except possibly under anesthesia. At other times, in patients with thin abdominal walls, or when ptosis of the colon or stomach are present, it may be possible to palpate the enlarged head of the pancreas; but in the majority of cases it cannot be done. When a mass can be palpated, its relation to the stomach and colon can be determined by inflating the stomach with air or with carbonic acid gas. Resonance on percussion from the overlying stomach, slight movement on deep inspiration, and communicated non-expansile pulsation are character- istic of the mass (enlarged pancreas). The relation of the tumor to the transverse colon can be determined by inflating the colon with air or carbonic acid gas. Tenderness. Tenderness in the epigastrium is sometimes present, though in some cases it may not be marked. It may be absent. Tender- ness may be over Mayo Robson's point (above and a little to the right of the umbilicus) or in the midepigastrium. In a number of cases it has been found beneath the right costal margin, but associated disease of the gall-bladder probaby accounted for this. Occasionally tenderness is found beneath the left costal margin, and rarely it may be general. If found over the head of the pancreas it is of value. Muscular Rigidity. This occurs in the epigastrium, though in some cases it may be found in the right hypochondrium, over the gall-bladder. It may be absent. Gall-bladder. In the chronic cases of long duration a distended gall- bladder may be found, such as occurs with carcinoma of the head of the pancreas. With jaundice due to stone in the common duct the gall-bladder is nearly always contracted. Liver. The liver is found enlarged in some patients. The association of hypertrophic cirrhosis of the liver with interlobular pancreatitis has already been noted. The Blood. The blood quite frequently shows a secondary anemia which is seldom grave, the hemoglobin also being moderately reduced. Leukocytosis is usually absent except during the acute exacerbation, when it is moderate and there is increase in the polynuclears. The coagulation period should be tested, as it is frequently delayed. When atrophic cirrhosis of the liver and arteriosclerosis accompany diabetes mellitus, the latter condition is due to the interacinar form of chronic pancreatitis. Diabetes with hemachromatosis results from chronic interacinar pancreatitis. One may say that glycosuria and other symp- 65 1026 DISEASES OF THE STOMACH AND INTESTINES toms of diabetes mellitus are distinctive of chronic interacinar pancreatitis. Temporary glycosuria may occur during an exacerbation of pancreatitis. Gastric Analysis. 1 Deaver reports in his cases that there is usually subacidity and no further abnormality. The writer found mild hyper- chlorhydria in an incipient case. Stools. Examination of the stools may give important information. In some instances they are clay colored. One must determine to what extent absence of bile influences this condition, and the test for stercobilin must be carried out. Generally the color is due to excess of fat. In cases of chronic pancreatic disease the total amount of unabsorbed fat may reach 50 to 60 per cent., and up to 90 per cent, with malignant disease of the gland. Miiller finds that, though the total per cent, of fecal fat may not be above normal, yet the proportion of split fat is always decreased, averaging about 40 per cent, of the total fat. Katz holds that a diminution of the split fat below 70 per cent, of the total fecal fat signifies disease of the pancreas, except in nursing infants and in patients with severe diarrhea. Steatorrhea is present only in the most advanced cases. Excess of muscle-fibers in the stools is very rare. In the early case noted above, there were incomplete absorption of the products of fat digestion and a large number of fatty acid crystals. Cammidge Reaction. The Cammidge reaction in the urine, in 5 $ cases of chronic pancreatitis confirmed by Deaver 2 at operation, was present in 1 8 cases (32 per cent.). In other series the ratio was not as good one-fifth of the cases positive in pancreatitis as compared with one-sixth positive when no pancreatitis was present; and in summing up all cases in which the condition of the pancreas was determined at operation, Deaver found the pancreatic reaction was obtained about two and a half times as frequently when the pancreas was diseased as when it was not. This does not correspond to the reports of Robson and Cammidge. According to Deaver, in a recent series, 3 he found it present in 25 per cent. Later reports by Deaver 4 with an experience of over 500 cases state that he has been unable to derive any assistance from this reaction. The writer is very dubious of the value of the Cammidge reaction. Only recently, in an undoubted case of advanced pancreatitis with steatorrhea, repeated tests were negative. The urine should be tested for bile and sugar. Sugar may appear during an exacerbation of an attack and clear up later. Per- sistent glycosuria suggests diabetes. Under Testing the Pancreatic Func- tions the most desirable methods are described, and those the author pre- fers are referred to at the end of that chapter, notably the general method of Testing the Intestinal Functions. A marked hemorrhagic tendency is of serious import and may show the approach of a fatal termination. Differential Diagnosis. With cancer of the head of the pancreas the onset is generally gradual and painless, and the age of the patient is usually over forty years. Jaundice 5 appears, which is absolute. The 1 Hypoacidity and achylia occur in advanced cases. 2 Jour. Amer. Med. Assoc., April 15, 1911. 3 Ibid., July i, 1911. * 4 N. Y. Med. Jour., Mar. 23, 1912. 5 The writer reports carcinoma of the tail of the pancreas, with no jaundice and pressure stenosis of the colon with cachexia. ACUTE PANCREATITIS CHRONIC PANCREATITIS 1027 gall-bladder is generally distended, but is not tender. The liver enlarges from bile stasis, but there are no nodules. Occasionally there is a meta- static tumor of the inner side of the gall-bladder. The loss of weight and strength is rapid and anemia increases. Fever is generally absent and the pulse is slow and feeble. Ascites with edema of the lower limbs may occur late in the disease. Carcinoma is sometimes difficult to differentiate from severe chronic pancreatitis with jaundice. The course of carcinoma is more rapid and the history short. Cammidge holds that the pancreatic reaction in the urine occurs in about 25 per cent, of cases of cancer; undigested fat is present in the feces in some cases, of which only a small proportion consists of fatty acids. When the carcinomatous growth lies in the common bile-duct above the opening of the pancreatic duct, the loss of flesh and strength are not as apt to be as rapid. Syphilis. This should be excluded by testing for the Wassermann or Noguchi reaction. Cancer of the Liver. With this condition there is an irregular enlarge- ment of the organ, and it is nodular to the feel. There are a rapid loss of weight and strength, the jaundice is less intense, and there are no fever or paroxysmal pains. Gall-stones. With gall-stones there is a long history of spasmodic pains without jaundice, the pain commencing in the right hypochondrium and radiating to the right shoulder-blade, as a rule. Later, attacks of pain occur, followed by jaundice, and often recurrent pains, with increased jaundice and with chills and intermittent fever. Head's zone for the gall- bladder is present. In the active stage there is leukocytosis with increase in the poly nucl ears. The tenderness with gall-stones is over the gall-bladder, and fre- quently lower down in the case of pancreatitis and nearer the middle line. Robson holds that the Cammidge reaction and examination of the stools are of service to exclude pancreatitis. Frequently the two conditions gall-stones and chronic pancreatitis are associated, and operation alone will determine the presence of the latter. The writer has already referred to the fact that in some cases, chronic pancreatitis presents symptoms of gall-stones alone. Removal of an impacted stone and drainage of the gall-bladder will at times cure the chronic pancreatitis. The #-rays will usually determine the presence of gall-stones either by the direct method or by the presence of deformity of the duodenum. In Fig. 422 gall-stones are demonstrated to be the cause of the incipient pancreatitis. With catarrh of the bile-ducts there is at times a history of chronic gastroduodenitis, though it may be of pancreatic origin. The jaundice and loss of flesh come on without pain. With chronic appendicitis, the determination of the sensitive appendix at McBurney's point or Morris' point and of the appendix Head zone are of value. Prognosis. If the diagnosis be made sufficiently early, free drainage of the biliary tract, and hence of the pancreas, may result in cure. The disease may progress for months or even for years, and the well- marked cases may eventually die from asthenia, diabetes, or the hemor- rhagic diathesis. A hemorrhagic tendency is of bad prognostic import. 1028 DISEASES OF THE STOMACH AND INTESTINES Commencing glycosuria, intermitting but increasing in frequency, is suggestive of commencing interacinar involvement; and persistent glycosuria, of diabetes. Treatment. Medicinal. If gastro-intestinal catarrh is present, proper dietetic measures should be undertaken and the usual treatment accorded to these conditions. For attacks of gall-stones, olive oil, the salicylates, probilin pills, etc., may be administered. Duodenal or gastric ulcer, alcoholism, syphilis, or arteriosclerosis should receive appropriate treatment if they are be- lieved to be factors. Wet packs, rest in bed, the sparing use of carbo- hydrates, and the administration of the pancreatic extracts, as holadin gr. v t.i.d. and secretin 1 gr. i t.i.d., to stimulate pancreatic secretion should be tried. Mild mercurial purges may be indicated. In all cases, whether or not hemorrhage has occurred for several days before any operation, chlorid, or preferably, lactate of calcium, 60 grains (4.0) a day in divided doses, should be given. It should be continued a week after operation or until normal blood clotting time is present and may be given by rectum by enema or proctoclysis if indicated. Human serum may be injected hypodermically if hemorrhage occur. Surgery. For ulcer of the stomach or duodenum if these are factors gastro-enterostomy may be required. Free drainage of the biliary tract and, through this, drainage of the pancreatic ducts will in many cases enable the pancreas to cast off the infection and resume its normal func- tions. Gall-stones should be removed from the gall-bladder and the common bile-duct as well, and the head of the pancreas should be thor- oughly explored, and any calculus lying therein or in the pancreatic duct should be removed. Cholecystotomy or, in some cases, cholecystenterostomy (establishing an artificial opening between the gall-bladder and duodenum) afford the best method of drainage. Junction of the gall-bladder with the colon, the writer believes, increases the liability of infection. The writer's case, with colon b. bacilluria, received hexamethlyenamin and sodium benzoate 60 grs. each daily and the usual treatment of colon bacillus infection as described in that section. Diet. If temporary glycosuria or diabetes mellitus be present, appro- priate diet should be instituted. With the interlobular type of pancreatitis fats should be given in the form of emulsions and milk is of great value. Feeding should be forced by repeated small meals and general nutrition should be improved. The bowels should be regulated to one movement daily and diarrhea checked. 1 Prosecretin, grs. 3 t.i.d. may be substituted. CHAPTER XLIV FAT NECROSIS TUBERCULOSIS SYPHILIS PANCREATIC CALCULI FAT NECROSIS BALSER 1 first directed attention to this condition. In several autopsies he observed in the fat about the pancreas, small white opaque areas, which subsequently were demonstrated to be composed of necrotic fat cells. One occasionally finds these minute foci limited to fat within or upon the pancreas, but usually the process is disseminated. Location and Appearance of Fat Necrosis. Fat necrosis is of impor- tance to the surgeon, as it indicates disease of the pancreas. When the abdomen is opened, the omentum, and at times other fat, is found to be studded with small round oval areas, opaque, white or yellow in color, in contrast to the translucent golden yellow color of normal fat. Occasionally each area of necrotic fat is surrounded by a narrow hemorrhagic zone. The lesions are usually most marked near the pancreas, and are generally limited to the fat of the abdominal cavity. Two cases of fat necrosis in the subcutaneous tissue of the abdomen have been reported by Hause- mann. 2 Areas of fat necrosis have been found in the mesentery, in the subperitoneal fat of the abdominal wall, in the subpericardial and subpleural fat, and in the pericardial fat. Occurrence. Fat necrosis associated with pancreatic disease has been frequently noted in stout patients, in fact in about 50 per cent, of cases. In the majority it is found with hemorrhagic necrosis or gangrene of the pancreas, is rare with suppurative pancreatitis, and occasionally occurs with chronic pancreatitis. It may be present with pancreatic calculi, cyst of the pancreas, and with gall-stones or carcinoma which close the pancreatic duct. Fat necrosis with acute hemorrhagic pancreatitis is depicted under that subject. Pathology. The changes in the fat cells are due to splitting of the neutral fat into fatty acid and glycerin. The fatty acids are deposited in needle-like crystals in the cells. The latter lose their nuclei and are necrotic. The soluble glycerin is absorbed. The fatty acids subsequently unite with calcium and form irregular or globular masses of lime salts. The outline of the cells is more or less preserved. It has been demonstrated by Benda 3 that acetate of copper will com- bine with the fatty acid in the necrotic fat, and will produce a greenish- blue compound, and that calcium salts, are less markedly stained, while 1 Ueber Fettnekrose, Virchow's Archiv, 1882, xc, 520. 2 Berliner Med. Gesellsch. Sitzung vom 4 Dec., 1889; Berliner Klin. Woch., 1889, xxv, 1115. 3 Virchow's Archiv, 1900, clxi, 194. 1029 1030 DISEASES OF THE STOMACH AND INTESTINES neutral fats are unchanged. It is thus possible to demonstrate areas of necrosis which are not visible to the eye. A half-saturated solution of acetate of copper is employed for this test. The foci of fat necrosis may disappear entirely. This has been demonstrated by subsequent operation on patients in whom they were formerly observed. Etiology of Fat Necrosis. Some have attempted to impute the occurrence of fat necrosis to the action of microorganisms, since the colon bacillus and various micrococci have been found. The invasion of the fat by these bacteria is believed to be secondary. The products of the pancreas are the active cause of fat necrosis. Flexner, 1 Opie, 2 and others have demonstrated on animals that when conditions were produced which afforded opportunity for the escape of pancreatic secretion into the tissues surrounding the gland, fat necrosis resulted. It has been concluded that fat necrosis is produced by the fat-splitting ferment of the pancreatic juice. Flexner 3 has demonstrated that necrotic fat tissue in the human being contains an enzyme which can split up neutral butter fat and set free fatty acids. Some have claimed that fat necrosis may occur without lesion of the pancreas. A case associated with duodenal ulcer is reported in this volume. The presence of an aberrant pancreas may explain some cases. Fat necrosis without the association of pancreatic disease is a rare occurrence. Occasionally (postmortem) minute foci of fat necrosis are found in and upon the pancreas. The treatment of fat necrosis when determined at operation is that of the pancreatic disease upon which it depends. TUBERCULOSIS OF THE PANCREAS Tuberculosis of the pancreas occurs, as a rule, in connection with tuberculosis of other organs, and the blood-vessels usually furnish the channel by which the bacilli are distributed to the gland. In 12 out of 1 28 autopsies with tuberculosis in other regions, Krudewetzky 4 found miliary tubercles of the pancreas, of which six were in children in 18 cases of acute miliary tuberculosis. The tubercles usually lie within the lobules, and less frequently in the interlobular tissue. They rapidly undergo caseation. In cases of chronic tuberculosis large tubercles occasionally occur. , Multiple small tuberculous deposits are found irregularly scattered through the pancreas, or several large masses, which may caseate and form cavities that open into the stomach, or some adjacent organ. A small tuberculous lymphatic gland has been removed from the head of 1 Contributions to the Science of Medicine, Johns Hopkins Hosp. Reports, 1900, ix, 850. 2 The Pancreas. 3 Jour, of Exper. Med., 1897, ii, 413. 4 Zeit. f. Heilk., 1892, xiii, 101. PANCREATIC CALCULI 1031 the pancreas. Tuberculosis of the pancreas may occur by extension from neighboring organs. Primary tuberculosis of the pancreas, though rare, has been reported by Mayo, 1 Aran, 2 and Chvostek. 3 Symptoms. Pain in the epigastrium, vomiting, local tenderness, and, at times, jaundice may be present. A palpable tumor just above the umbilicus was found by Mayo in one case. Functional disturbances of the organ may also occur. The diagnosis is probable from the usual association of the process elsewhere. SYPHILIS Congenital Syphilitic Pancreatitis. Attention was first called to the frequency of congenital syphilis of the pancreas by the investigations of Birch-Hirschfeld, 4 who found it in that organ in 13 out of 23 children, and in another series in 29 out of 124 syphilitics. The pancreas would seem to be affected in about 22 to 23 per cent, of all cases of syphilis of the newborn. Pathology. The pancreas is enlarged and firm, and there is a diffuse interstitial pancreatitis with proliferation of interlobular and interacinar tissue which penetrates between the cells of the acini. This is followed by destruction of the parenchyma, which last probably atrophies. There is a syphilitic peri-arteritis. The islands of Langerhans are not invaded by the new growth of interstitial tissue. Small gummata (syphilitic necrosis) are occasionally found in the newly formed stroma. Acquired Syphilis. Gummata and syphilitic induration, resembling syphilitic cirrhosis of the liver, may occur. The bands of tissue are irregular, scar-like, and differ from the diffuse increase of tissue, such as occurs with the interlobular or interacinar types of chronic pancreatitis. Symptoms. Usually one finds associated symptoms of the tertiary stage in these acquired cases. These may be disturbances of the pan- creatic functions, evidences of chronic pancreatitis, and, at times, diabetes. Diagnosis. The Wassermann or Noguchi reactions should be tested for in addition to a careful anamnesis and examination. Treatment. This should be as of syphilis mercury and iodids or, preferably, "606" or neosalvarsan should be injected, followed by mer- cury and the iodides. PANCREATIC CALCULI Pancreatic calculi are rare, and among 1500 autopsies at the Johns Hopkins Hospital only two cases were discovered. The earliest report of this condition is by Panarol and Galea in the year 1667. Guidiceandra, in 1896, records 48 cases; and in 1903 Oser states that there were only 70 cases reported. Lazarus has since collected 80 cases. Mayo and Robson have reported others since that date. 1 Cited by Senn, Outlines of Human Pathology. 2 Ibid. 8 Wiener med. Blatter, 1879, ii, 791. 4 Gerhardt's Handbuch d. Kinde.rkrankheiten, iv., Abt., 753, Tubingen, 1880. 1032 DISEASES OF THE STOMACH AND INTESTINES Occurrence. Pancreatic calculi are more common in men than in women. Lazarus 1 collected 57 cases, of which 47 occurred in men and 10 in women. Age. Thirty-seven of these cases were in patients between thirty and forty years of age. Pathology. Calculi are not found in the healthy pancreas, and prob- ably these pancreatic concretions are a result of catarrh of the ducts, with stagnation of secretion, with which bacterial infection is associated. The concretions in the ducts may be like sand, but generally there are one or more small stones. As many as one hundred have been re- ported. The ducts may be lined with calcareous material, so as to com- pletely or nearly close their lumen. Usually the calculi consist of calcium carbonate or calcium phos- phate, though a case has been reported which contained cholesterin in considerable amount, and another which consisted chiefly of calcium oxalate. Biliary calculi at times make their way into the pancreatic duct, and this has resulted in suppuration. A pancreatic calculus which lodges at the duodenal end of the pancreatic duct may be stained with bile- pigments and be covered with a layer of cholesterin. The duct of Wir- sung is narrowest where it passes through the wall of the duodenum, and calculi have a tendency to lodge above this point, The outflow of the pancreatic secretion may be entirely obstructed, and the duct may become dilated above the point of obstruction. True cysts rarely result, but they have been reported. Obstruction of the duct by calculi is usually associated with bacterial infection, and produces the most advanced type of sclerosis. The Bacillus coli has been found in two calculi. The chronic inflammation is of the interlobular type, and the islands of Langerhans are usually not affected. They may finally become involved in the advanced sclerosis. Pancreatic calculi are opaque to the re-rays, and we thus have a means of diagnosing their presence and of differentiating them from biliary calculi, which are not readily seen and may not even be visible in a rontgenograph. The presence of the Cammidge reaction, when such is present, Robson believes, will confirm the diagnosis by demonstrating the associated chronic pancreatitis. The stones are round, oval or elongated, and usually smooth. They may occur in all parts of the ducts, though they are found most frequently in the head of the pancreas. They may also be branched. One stone has been recorded measuring 2% by ^ inch, weighing 200 grains, and a second one weighing 20 ounces. They are pale in color, but may be white, or when near the common duct may be covered with cholesterin and stained with bile. Obstruction to the flow of the pancreatic juice from an impacted calculus may cause escape of the secretion into the tissues, so that fat necrosis results. A pancreatic calculus in the diverticulum of Vater may occlude the common bile-duct and cause jaundice. Ulceration of the 1 Beitrag zur Pathologic und Therapie der Pankreaserkrankungen mit bensonderer Berucksichtigung der Cysten und Steine, Berlin, 1904. PANCREATIC CALCULI 1033 mucosa of the duct may be caused by an impacted calculus, and pancreatic abscess result. Etiology. The writer has already referred to the fact that obstruction to the outflow of the pancreatic juice with associated bacterial infection are probably factors. Various forms of bacteria have been found within the calculi. Cholelithiasis may occur in association with pancreatic lithiasis, and the former may produce obstruction of the pancreatic duct and favor stasis. Pancreatic calculi are sometimes found in pancreatic cysts, possibly resulting from the retained secretion. Symptoms. Pancreatic calculi have been found on autopsy in persons who have never suffered with symptoms that could be referred to the pancreas. In some the symptoms may be vague. The presence of a cyst, a secondary abscess, and the degree of advancement of the chronic pancreatitis modify the symptoms. There is often pain in the epigastrium, which may be slight but continuous, or it may be paroxysmal, resembling biliary colic; sometimes it is agonizing in character, and may be associated with vomiting, hiccup, cold sweats, and collapse; chills and fever may at times 'occur. The attacks may be brought on by exertion, or they may be irregular, occurring at any time, day or night. The pain frequently comes on in sharp, colicky attacks, less severe than gall-stones, and may radiate toward the inferior angle of the left scapula. A sensation of soreness or stiffness is sometimes noticed for several days after an attack. Fragments of stone may subsequently be found in the stool, which, when analyzed, consist chiefly of carbonate or phosphate of calcium. In one case of Kinnicutt's 1 the pain began in the back and then ran around the right side along the lower intercostal spaces, while in another case the pain began between the scapulae and ran through not around the body into the epigastrium, where it became localized to the right of the middle line. The localization of the pain, though more frequently to the left, is not always characteristic. Jaundice, which occurs with pancreatic calculi, may be due to as- sociated gall-stones, but a pancreatic calculus may occlude the common bile-duct and thus produce it. Lancereaux records glycosuria in 12 out of 40 cases of pancreatic calculi. Sugar may be observed at intervals. Diabetes mellitus or glycosuria accompany pancreatic lithiasis with a fair degree of frequency, and Lazarus has found one of these conditions present in 36 out of 80 cases. The disturbance of carbohydrate metabolism is not produced by the occlusion of the ducts, but by the chronic interlobular pancreatitis, and it occurs only when this condition is so far advanced that the islands of Langerhans are involved. Alimentary glycosuria indicates a less advanced stage of the pan- creatitis. Steatorrhea, when it is present, is an aid to diagnosis. It has been re- corded in only 10 out of 80 cases. Even if there is no apparent excess of fat, microscopically, in the stool, there may be deficient fat splitting of ingested fats into fatty acids and soaps, and an excess of neutral fat may be found. 1 Trans. Assoc. Amer. Phys., 1902, xvii, 81. 1034 DISEASES OF THE STOMACH AND INTESTINES Azotorrhea is less frequently found. Suppuration, as already noted, may occur as a complication of pan- creatic calculus. The hemorrhagic tendency 1 may occur with pancreatic calculi, especially with advanced chronic pancreatitis. Diagnosis. Pancreatic calculi are more opaque for x-rays than are gall-stones, and this fact proves of value for diagnosis. The analysis of the calculus, calcium carbonate or phosphate, when present in the stools, is also of use. Glycosuria, when present, even though temporarily so, is significant, and also deficient splitting of the ingested fats into fatty acids and soaps. Robson and Cammidge set much store by the pancreatic reaction of the urine, which they believe usually to be present, but the writer believes it uncertain. The location of the pain and the direction of its radiation in some cases proves of service. Treatment. Lazarus recommends that secretion be increased by the administration of large quantities of water, and especially to acidify it with carbonic acid gas or weak acids. Pancreatic secretion may be increased by the injection hypodermically of pilocarpin, >f 00 grain (0.0006), and Eichhorst reports a favorable result. This method may be dangerous, particularly if there is obstruction in the duct. Possibly prosecretin, 3 grains (0.5), which is less active and a normal excitant, three times a day, might be of service. Morphin, % to % grain (0.0075-0.0022), may be administered by hypodermic for the acute attacks of pain; heat should be applied to the epigastrium, and shock be treated in the usual method, if such be present. A hot bath is useful, as in attacks of renal or biliary colic. Surgery. In several cases pancreatic calculi have been successfully removed by operation through incision in the duodenum or, preferably, by pancreolithotomy. It is indicated to explore the gall-bladder and common bile-duct and remove calculi, if present. If there is hemorrhage from the gastro- intestinal tract or subcutaneous or nasal hemorrhage, and, in any event for several days before operation and for at least a week thereafter, calcium lactate should be administered in divided doses, 60 to 90 grains (4.0-6.0) per day by mouth or by rectum, if there is vomiting. Hypo- dermic injection of normal human serum, or horse serum by mouth, may be further indicated for hemorrhage. 1 Hemorrhage from the stomach, intestines and from other mucous membranes and also into the skin and subcutaneous tissues. CHAPTER XLV CYSTS OF THE PANCREAS NEOPLASMS CYSTS CYSTS of the pancreas, though not frequent, must be considered in the diagnosis of cysts of the abdomen, since they occur in various regions, and may simulate other diseases. About 173 cases of operation on cysts of the pancreas have been recorded. Hale White states that in nearly 6000 autopsies at Guy's Hospital from 1883 to 1894 only four cases of pancreatic cyst were found, one of which was a hydatid cyst. The simplest classification is as follows: 1. True cysts of the pancreas. 2. Pseudocysts. 3. Hydatid cysts. i. Among the true cysts we have: (a) Retention cysts, due to obstruction of the outflow of the pan- creatic secretion, with resulting dilatation of the ducts of the acini. (b) Proliferation cysts, or cystic neoplasms. These are cystic tumors, due to spontaneous proliferation of the epithelial elements of the gland, with accumulation of fluid in the cavities which are so formed. They may be simple, such as cystadenomata; or malignant, cystic epitheliomata or carcinomata. (c) Congenital cystic disease of the pancreas is exceedingly rare. Retention Cysts. Etiology. Partial or intermittent occlusion of the pancreatic duct favors the formation of retention cysts of the pancreas. The outflow of pancreatic secretion may be interfered with by ob- struction of the excretory duct, or by compression from without and obstruction within it. Compression of the pancreatic ducts by tumors, by gall-stones, or closure by a pancreatic calculus, or by a large calculus in the diverticulum of Vater, tumors in the bile-passages or duodenum, swollen lymphatic glands pressing on the duct, adhesions or intestinal parasites in the pan- creatic duct, may be causes. Frequently no cystic formation results, but sometimes cysts are found. Chronic pancreatitis is believed to be the most common cause of retention cysts. Occlusion of the ducts is followed by interlobular pancreatitis, which, when far advanced, may cause diabetes mellitus. Retention cysts are frequently quite small, and may not cause symp- toms. There may be a beaded or rosary-like dilatation of the pancreatic duct, which has been described as "ranula pancreatica," or multiple cysts of small size containing opaque thick fluid, "acne pancreatica," or a single cystic dilatation as large as a man's fist. 1036 DISEASES OF THE STOMACH AND INTESTINES They are occasionally multiple two of equal size, unilocular or multilocular. One cyst may have several small cysts attached to its walls. When a cyst enlarges it destroys the substance of the gland, and, at the same time, interstitial inflammation is produced in the adjacent gland- tissue. The cyst may become pedunculated. Retention cysts of large size have been reported containing 15 to 20 quarts (liters) of fluid. The wall of the cyst is composed of dense fibrous tissue with few cells, and may be 3 to 4 mm. thick. Occasionally the wall is thin. Large blood-vessels often traverse the outer surface. The inner surface consists of an epithelial lining of a single layer of cylindric cells, which may be flattened by pressure. It is sometimes smooth and shining, and free from epithelium. In some cases the cyst lining may have ridges or septa; the remains of other cysts or clotted blood may be found therein adherent to the surface. Portions of pancreatic tissue are sometimes embedded in their walls. Proliferation Cysts, or Cystic Neoplasms of the Pancreas. Many of these tumors are on the border-line between proliferating cystoma and cystic carcinoma, and only the subsequent course of the tumor will indi- cate to which class it belongs. They are characterized by irregular gland-like growths below the epithelial lining of the cyst and by the presence of papillary projections from the cyst lining. There are two types the cystadenoma and the epitheliomata cysticum. The simple proliferation cyst (cystadenoma) is usually multilocular, has a lining of columnar epithelium, which sometimes dips down into the wall of the cyst, and at times covers polypoid masses, which projects into its cavity. These cysts are more common in the tail of the pancreas, and often their contents are blood stained. Rarely cystic tumors of the pancreas are malignant (the cystic epi- thelioma). Hartmann 1 described one in the tail of the pancreas which was accompanied by metastases in the liver. Sotti, under the name of adenocystoma papilliferum, described a tumor of the pancreas with metastases in the lymphatic glands and lungs. The malignant form is usually multilocular, with patches of carcino- matous tissue in its walls. In some cases chocolate-colored fluid is contained in the cyst. Met- astatic deposits occur in the liver, pancreatic glands, duodenum, and in other organs, rendering the tumor inoperable. Congenital cystic disease of the pancreas is exceedingly rare. Robson and Moynihan refer to three cases, resembling that met with in other organs. Hydatid cysts of the pancreas seldom occur resembling the lesion met with in the liver. Evacuation and drainage are indicated. Pseudocysts of the Pancreas. Pseudocysts constitute a large pro- portion of cases reported as pancreatic cysts. They may be found within the substance of the pancreas, but the greatest number of pseudocysts are 1 Cong, franc de Chir., 1891, v, 618. CYSTS OF THE PANCREAS NEOPLASMS formed in contact with the gland, particularly in the lesser peritoneal cavity, as a result of injury to the pancreas. Blood and pancreatic juice escaping into the lesser cavity set up a mild form of peritonitis, which closes the foramen of Winslow and produces a tumor which is difficult to differentiate from a true cyst. Enzymes similar to those of the pancreatic juice have been found in traumatic cysts. Fig. 423 is shown the method of the origin. Pseudocysts within the pancreas containing blood have been believed to be the result of hemorrhage into the organ. The wall of these cysts is formed by dense connective tissue. There is no epithelial lining to the cyst, but this does not always determine the nature of the lesion since the epithelial lining may be destroyed by the pancreatic juice. Pancreas Lesser peritoneal sac Stomach Colon Small intestine Fig. 423. Diagram to show the method of origin of a pseudocyst of the pancreas (Robson and Cammidge). Etiology. In 33 out of 117 cases of pancreatic cyst, Korte has found that traumatism to the abdomen preceded the appearance of a palpable tumor. Lazarus has collected eight more cases. Among the various injuries to the epigastric region are the kick of a horse or compression between car buffers. Indirect force may produce it also, such as a violent fall, by tearing the pancreas. These traumatic pseudocysts usually contain blood, though only clear fluid be present. Hemorrhagic necrosis of the pancreas may be the direct cause of pseudo- cysts. A number of such cases have been reported, the patient having recovered from the attack of acute pancreatitis, with the subsequent appearance of the cyst. 1038 DISEASES OF THE STOMACH AND INTESTINES Sex. The greater portion of the traumatic pseudocysts occur in males, who are most exposed to injury, while true cysts occur more frequently in females. Cystic Contents. The fluid in the pancreatic cysts and pseudocysts may furnish little evidence as to their origin. Blood is generally present. The fluid is frequently reddish brown; it may be coffee-colored, yellow, greenish, milky, black, or bright red from recent hemorrhage. After absorption of the blood, traumatic cysts may contain clear fluid. The contents are sometimes viscid, more or less turbid, and mucin has been demonstrated therein. The specific gravity varies from 1.007 to 1.028, and the reaction is generally alkaline, rarely neutral, and still more rarely acid. Sugar is seldom met with. Albumin is present. Under the microscope, red blood- cells, fat-cells, epithelial cells, crystals of fatty acids, leukocytes, necrotic tissue at times, at times cholesterin, and, rarely, leucin and tyrosin are present. One or more of the pancreatic enzymes can frequently be demonstrated in these cysts. Proteolytic, lipolytic, and diastatic enzymes have been found in the fluid of abdominal cysts which did not originate from the pancreas, and cysts of the pancreas may show no activity of these enzymes. Nevertheless, if a cyst contains fluid which can digest coagulated egg- albumen or split starch, it is probable that it originates from the pancreas. Symptoms. In studying the symptoms of the pancreatic cyst one must consider the possible cause from which the cyst may develop, the general symptoms, both subjective and objective, the physical signs of the tumor, and, finally, the pressure symptoms which may result from its presence. There may be a history of previous traumatism in the epigastrium or of an attack of hemorrhagic necrosis of the pa"ncreas, subsequently fol- lowed by the development of a tumor, or of previous attacks pointing to pancreatic calculi, or disturbances suggestive of a chronic pancreatitis. The Rontgen rays may be of service in determining the presence or absence of pancreatic calculi, also the examination of the stool. The last may also demonstrate disturbance of the pancreatic functions. On the other hand, cases do occur which have existed for a long time and present few or no symptoms except the presence of the tumor. As regards general symptoms, pain in the epigastrium or just above the umbilicus may be present, and may occur even when the cyst is not palpable. There may be colicky paroxysms, varying in location and intensity, sometimes there is no pain whatever. Vomiting may occur, associated with the acute attacks or pain, or the cyst may be bound to the stomach by adhesions and produce gastric disturbance. Constipation is usually present. Bulky pale motions are rare and only occur with advanced pancreatitis. The cyst may compress the lumen of the intes- tines and produce intestinal obstruction. Jaundice does not occur as frequently with pancreatitis cyst as it does with carcinoma, because the former is less frequently in the head of the gland. In some cases disturbances of digestion referable to a diminution of the flow of pancreatic juice into the intestines occur. Fitz has found only CYSTS OF THE PANCREAS NEOPLASMS 1039 two cases of steatorrhea with cyst of the pancreas, and only two in which there were undigested muscle-fibers in the feces. These last conditions show advanced destruction of the gland. Glycosuria is associated with them. Glycosuria and diabetes mellitus follow severe chronic inflammation of the pancreas, which last is produced by a cyst occluding the ducts. Diabetes was present in only 9 out of 134 cases which were collected by Oser. Alimentary glycosuria has been reported. Emaciation is a frequent symptom, and in some cases cannot apparently be explained as due to disturbances of pancreatic digestion. The patient frequently rapidly regains weight after drainage of the cystic contents. Robson and Cammidge report marked pancreatic reaction in the urine. The writer believes this of no value. Pressure Symptoms. Among the symptoms due to pressure of the cyst are: Dilatation of the superficial branches of the portal vein, ascites from pressure on the portal vein, or edema of the lower extremities from pressure on the inferior vena cava. In two cases the right ureter has been obstructed. Dyspnea may result from pressure on the diaphragm or from distention of the abdominal cavity. Rarely, intestinal obstruction may result from pressure. Physical Signs of Pancreatic Cysts. The cyst is usually spheric and the surface is smooth. It may be as large as a human head, and may even fill the entire abdominal cavity from the ensif orm cartilage to the symphysis. Usually fluctuation can be felt, but at times the sac is so tense that it appears to be a solid growth. The tumor is often situated in the middle line between the ensiform cartilage and the umbilicus. It may cause a round protrusion of the abdominal wall; in many instances the greater part of the cyst lies to the left of the median line, and in a few cases it was found on the right side. Occasionally cysts have extended to below the umbilicus. Usually these cysts exhibit little mobility unless they are in contact with the diaphragm, in which case they move with respiration. When they are situated in the tail of the pancreas they may be freely movable. If the cyst is in contact with the aorta, pulsation may be transmitted, but it disappears when the patient is in the knee-chest position. The relation of the different parts of the pancreas from which the cyst originates to adjacent organs determines the physical signs. The relation of the cyst to the stomach and colon can be defined after artificial distention of these organs with carbonic acid gas or with air. Korte studied 133 cases of pancreatic cyst which were operated upon, and classified the positions which they occupied. Pancreatic cysts usually project from the anterior surface of the pancreas into the lesser peritoneal cavity and push the stomach upward. They are covered by the gastrocolic omentum (Fig. 424). Small cysts lie behind the stomach. Cases have been reported in which the cyst arises from the upper border of the pancreas, and makes its way between the stomach and liver, being covered by the gastrohepatic omentum (Fig. 425). The dulness of the tumor is continuous with the dulness of liver. Inflation of the stomach will cover the dull area of the tumor. 1040 DISEASES OF THE STOMACH AND INTESTINES In some the cyst grows between the two layers of mesocolon, and the cyst projects upon the upper surface of the mesocolon and lies between the stomach and colon (Fig. 426). Occasionally, the cyst may project on the under surface of the meso- colon and the transverse colon lie above it (Fig. 427) or the colon may cross the summit of the cyst (Fig. 428). The cyst may pass into the right hypochondrium and simulate an enlarged gall-bladder, or right renal, or suprarenal, cyst. It may make its way into the right or left lumbar region and simulate a cyst of the kidney; or it may pass forward to the right and beneath the hepatic Fig. 424. A cyst projecting from the ventral surface of the pancreas into the bursa omentalis. The stomach is in front of the cyst and with its growth is pushed upward; the transverse colon is below it; M, stomach; C, transverse colon; P, pancreas; M.t., transverse mesocolon. flexure of the colon and resemble a tumor of the kidney, cecum, or ascend- ing colon. In some instances it burrows between the layers of the mesentery, simulating a mesenteric cyst, or may pass to the left and resemble a left renal or ovarian cyst, or a cyst of the spleen or left lobe of the liver. It has also simulated a tumor of the descending colon or of the small intestine. Accumulation of fluid in the lesser peritoneal cavity (pseudocyst) may closely resemble the true pancreatic cyst. A cyst may pass through the foramen of Winslow into the general peritoneal cavity, or may rupture into the peritoneal cavity as the result of injury produced by a blow or fall. The spontaneous disappearance of a cyst without intraperitoneal CYSTS OF THE PANCREAS NEOPLASMS IO4I P.C Fig. 425. Pancreatic cyst between liver and stomach (Robson and Cammidge): L, Liver; P.C, pancreatic cyst; S, stomach; C, colon. P.c Fig. 426. Pancreatic cyst between stomach and colon (Robson and Cammidge): L, Liver; 5, Stomach; P. C, pancreatic cyst; C, colon. 66 1042 DISEASES OF THE STOMACH AND INTESTINES P.C Fig. 427. Pancreatic cyst below the transverse colon:/,, Liver; S, Stomach; C, colon; P. C, pancreatic cyst (Robson and Cammidge). FIG. 428. A pancreatic cyst (T) which has penetrated between the folds of the transverse mesocolon (M.t.) and projects equally upon the upper and lower surface. The stomach is above the cyst and the transverse colon crosses it. CYSTS OF THE PANCREAS NEOPLASMS 1043 rupture has been reported in association with diarrhea. The contents probably entered the intestine. Bull 1 and Parsons report such cases. Diarrhea occurred at the time of the disappearance. Possibly one of the pancreatic ducts communicated with the cyst. Diagnosis. A round fluctuating tumor lying in the epigastrium, especially when ike greater part is to the left of the median line, is suggestive of a pancreatic cyst. Most frequently the cyst lies between the stomach and transverse colon. The stomach usually partially covers it. Even when the cyst occupies the more uncommon position between the stomach and liver, percussion of the cyst while inflating the stomach is of value, since tumor gradually becomes covered as the stomach distends. Cysts of the liver and spleen or a distended gall-bladder remain superficial, and are not pushed back and covered by the distending stomach. Mesenteric cysts usually lie near the umbilicus and are freely movable. Pancreatic cysts may appear in this region, but generally there is no mobility. At times the pancreatic cyst may extend as far as the pelvis. The history of the cyst as first commencing in the epigastrium may be of service; also inflation of the colon may aid in the determination of its relations, and bimanual examination of the vagina and rectum may ex- clude its connection with the uterus and ovaries. The disappearance of the tumor is more suggestive of hydronephrosis. Exploratory aspiration of the cystic tumor the writer believes danger- ous. It may damage the viscera or cause extravasation of the cystic contents. The history is of great value in many cases. The Cammidge reaction may be tested, though the writer has no faith in the procedure. The pancreatic functions should be investigated and the urine examined for sugar. These factors are an aid to diagnosis. The contents of the cyst should be tested for enzymes after evacuation by operation. Treatment. Surgical treatment is alone of service. Aspiration is dangerous for the purpose of diagnosis. Incision and drainage is the operation of choice; extirpation is more dangerous, and in many cases is impossible. Description of the surgical procedures has no place in this volume. It is recommended to administer a diet to lessen the flow of pancreatic juice, thus, bread and milk, with the administration of small doses of sodium carbonate, 5 to 10 grains (0.32-0.65) t.i.d., are excellent. Others advise a diabetic diet and the use of the same drug. As in all cases of pancreatic disease, chlorid or, preferably, lactateof calcium, i dram (4.0) in divided doses, should be administered for a week before and after operation. In the latter event it can be given for a time by rectum by enema or proctoclysis. Human serum may be used by hypodermic, and the calcium salts, 60 to 90 grains (4.0-6.0) daily, by mouth, if hemorrhage occur at any time during the course of the disease. Mayo Robson records 160 cases of pancreatic cyst which have been operated. Of these, there were 20 deaths subsequent to operation, and 8 deaths later from diabetes or other complications. Of 138 cases treated 1 N. Y! Med. Jour., 1887, xlvi, 376. 1044 DISEASES OF THE STOMACH AND INTESTINES by incision and drainage, death occurred in 16. Among 15 cases in whom complete excision was practised, 3 died. Partial excision in 7 cases re- sulted in i death. Korte collected 102 cases, of which 101 were treated by incision and drainage, with only 4 deaths. NEOPLASMS Tumors of the pancreas are not a very common occurrence, and are most frequently of a malignant nature. The solid growths met with in the pancreas are carcinoma, sarcoma, adenoma, and lymphoma. Segre, 1 in 11,472 autopsies, reports 127 cases of carcinoma and two of sarcoma. Benign tumors are less common. Carcinoma Carcinoma is the most common of the new growths found in the pancreas. Probably some cases reported as cancer of the liver were cases of primary carcinoma of the pancreas, with secondary nodules in the liver. Formerly cancer was considered the most common lesion affecting the pancreas, but chronic interstitial pancreatitis was undoubtedly mistaken for it in many instances. Age. Carcinoma usually occurs after forty years of age, though a case in a patient aged thirty-two has been reported, and rarely it has occurred in childhood. Bourke 2 reports a case in a patient twenty-two years old. Sex. Carcinoma is more frequent in males. In 108 cases 3 there were 69 in men and 39 in women. Situation of Tumor. Carcinoma is most frequently situated in the head of the gland. It was involved in about 62 per cent, of the cases recorded: in 5.5 per cent, the tail was affected; in 3.5 per cent., the body; and there was a diffuse growth in 29 per cent. The duct of Wirsung was obliterated in 55 out of 66 cases, and dilated beyond the point of stricture in about one- third of the cases. Among 57 cases collected by Segre, the tumor was situated in the head of the gland in 35 cases; in the body, twice; in the tail, once, and the entire gland was affected in 19 cases. Out of 113 cases reported by Miraillie, primary carcinoma of the head of the pancreas was present in 82. Oser states that there is secondary carcinomatous involvement of the pancreas in more than 10 per cent, of cases of primary carcinoma of the stomach. Metastasis also takes place from carcinoma of other organs. Frequency. Out of 53,000 autopsies, Roswell Park reports 226 cases of primary malignant disease of the pancreas. Secondary growths of the pancreas are much more common. Eppinger reports, in 1314 autopsies, 19 cases of cancerous involvement of the pancreas. Only two of these were primary cancer of the- pancreas. There were 308 cancers in various organs . 1 Annual Univ. de Med. et Chir., 1888. 2 Journal A. M. A., Mar. 14, 1914. 3 Miraillie, Gaz. des H6p., 1893, Ixvi, 889. CYSTS OF THE PANCREAS NEOPLASMS 1045 Morbid Anatomy. Carcinoma of the pancreas begins either in the glandular epithelium or in the cells of the excretory ducts. In the former instance it is of the spheroid type, and in the latter usually columnar. Spheroid-celled carcinoma is the more common and usually of the scirrhous type, and is composed of firm, fibrous nodules. Occasion- ally it is encephaloid, soft, and cellular. Colloid carcinoma has been observed. Roux 1 described a cystic epithelioma, and Sotti a malignant adenocys- toma with metastases in the lymphatic glands and lungs. Secondary deposits are most common in the liver, but may be found anywhere. A variety of carcinoma characterized by great irregularity in the size and shape of its cells, and believed to originate in the island of Langer- hans, has been described by Hiller and Goodall. Secondary interstitial pancreatitis is present in some cases, and occasionally small cysts may occur. Carcinomatous growths of the pancreas are usually of small size (5 to 10 cm. in diameter), but occasionally they are quite large. When the tumor invades adjacent organs, such as the liver, bile-passages, stomach, and duodenum, the origin of the primary growth may be in doubt. Effects of Adhesions and Pressure. Adhesions may be formed be- tween the tumor and adjacent organs, and various lesions may result from pressure. Thus, occlusion of the duodenum or pylorus may cause dilata- tion of the stomach, or the stomach may be compressed against the abdominal wall, or compression of the transverse colon may cause in- testinal obstruction. Obstruction of the bile-duct with dilatation of the gall-bladder is common. Pressure on the left ureter may cause hydronephrosis, or on the portal vein may produce ascites. Edema of the lower extremities may follow pressure on the vena cava. The tumor tissue may invade the stomach or duodenum, and perforation of these viscera may occur. The pancreas may be secondarily invaded from the stomach or duodenum. Symptoms.- The symptoms of carcinoma of the pancreas are modified by the position of the growth and by the degree of chronic pancreatitis which is sometimes associated with it. In the largest percentage of cases of cancer of the pancreas the head of the gland is involved. The earliest symptoms are rapid loss of weight and strength, with loss of appetite, discomfort after eating, and distaste for meat. Nausea and vomiting may occur; constipation is most frequently present, though occasionally there may be diarrhea. In the earlier stages the movements may be normal. Cachexia is rapid, jaundice soon appears, and is pro- gressive. The skin may become dark, almost black in color, or in some cases like the yellow color from gall-stones; the gall-bladder enlarges and is readily recognizable and the liver swells. There are intense prostration and weakness. Pain, particularly in the early stages, is at times absent. 1 Cancer et Kystes du Pancreas, Paris, 1891. 1046 DISEASES OF THE STOMACH AND INTESTINES The writer has recently seen a large carcinoma of the outer third of the body, with no pain whatever. It may, when the tumor rapidly increases, be quite intense from pressure on the celiac ganglion or on adjacent nerve- trunks, and may radiate to the back or shoulders. Occasionally, there may be colicky pain due to occlusion of the pancreatic duct, which may resemble the colic of pancreatic lithiasis or colicky pains from pressure on the common bile-duct resembling biliary colic. The stool is pale in color after the appearance of the jaundice and bile is found in the urine. The obstruction of the common bile-duct is usually complete and the feces contain no stercobilin. With scirrhous cancer of the head of the pancreas often the tumor cannot be felt; in about one-fourth or one-fifth of the cases the cancerous mass is palpable, usually in the epigastric region, more rarely in the right or left hypochondrium. Usually the mass is immovable, unless lying in the tail of the pancreas. Occasionally it moves with respiration or trans- mits the pulsation of the aorta. There is frequently absence of free HC1 in the stomach contents, as may occur with cancer situated in oilier organs. This finding does not, therefore, always determine involvement of the stomach. Excessive vomiting with dilatation of the stomach may result from carcinomatous involvement of the pyloric end of that organ or of the duodenum. Adhesions may cause similar symptoms. Occasionally, there may be no enlargement of the gall-bladder if the cystic or hepatic duct alone are involved by the growth, or if the gall-bladder be obliterated by previous inflammation. In some instances steatorrhea or disturbances in the ratio of neutral fats and combined fatty acids are present, and rarely un- digested muscle-fibers are found in the stool. Bulky stools may occa- sionally be present. Alimentary glycosuria has been observed, and diabetes mellitus when there is great involvement of the pancreas, and particularly with a complicating interacinar pancreatitis. If the tumor lies near the tail of the pancreas, there is no jaundice. In some cases where the body or tail of the organ are involved there may be tenderness at Robson's point as with chronic pancreatitis. Intestinal obstruction (chronic), even merging into the acute, may result from pressure on the transverse colon or ileum. The writer re- cently has been a case of chronic intestinal obstruction caused by pressure from carcinoma of the outer third of the body of the pancreas. There was no jaundice. H. Haubold found this condition on operation. Ascites, swelling of the spleen, hemorrhoids, dropsy of the lower limbs, and hy- dronephrosis may result from pressure. Perforation of adjacent viscera may occur. Chylous ascites due to perforation or rupture of the thoracic duct has been reported. There is frequently a marked hemorrhagic tendency, particularly in the cases of cancer of the head of the pancreas with jaundice. Hemorrhage may occur from the nose, mouth, stomach, intestines, and subcutaneously. Persistent bleeding or oozing is liable to occur, both at and subsequent to operation. Cammidge states the C-reaction (Cammidge) is present in about 25 per cent, of all cases and the A-reaction in most cases. The writer is skeptical as to the value of these reactions, CYSTS OF THE PANCREAS NEOPLASMS 1047 Examination of the stool, the urine, and testing the pancreatic functions are an aid to diagnosis. Diagnosis. Rapid emaciation, progressive weakness, increasing ane- mia, jaundice becoming very intense, dilatation of the gall-bladder, and epigastric tumor (not always present) are significant of carcinoma of the head of the pancreas; glycosuria and, occasionally, steatorrhea are confirmatory when present. The patient is usually over forty. The course is very rapid, not over a year, and after the onset of jaundice, only six to eight months; on distending the stomach with air or carbonic acid gas, the tumor, if present, disappears. The temperature is subnormal. Symptoms from pressure, such as anasarca, etc., occur in some cases. With cancer of the outer part of the body of the pancreas there are no jaun- dice and no dilatation of gall-bladder. Loewis' Test. The instillation of 3 or 4 drops of adrenalin chlorid (1:1000) into the conjunctival sac causes mydriasis in patients suffer- ing from pancreatic disease. This test depends on the diminution or absence of the island of Langerhans hormone, so that there is increased excitability of the sympathetic system due to an excess of the antag- onistic adrenal hormone. When this does not take place following the instillation, it is presumed that the pancreatic hormone is present. Crohn 1 holds that the absence of bile, or pancreatic ferments on duo- denal aspiration determines the diagnosis of new growth in this region. Cholelithiasis. There is a preliminary history of gall-stone attacks; the jaundice comes on after an attack of pain and is sudden. Remissions of jaundice sometimes occur: the impacted calculi may produce intense jaundice. Some bile usually escapes past the gall-stones into the intestines, and stercobilin is present in the stools. The bile is likely to become infected, and ague-like paroxysms occur with an irregular temperature. There is no distended gall-bladder, but there is a rigid right rectus muscle. There is frequently a tender point above and to the right of the umbilicus, and there may be pain which passes to the midscapular region or beneath the right shoulder-blade. As a rule, the liver is not enlarged with cholelithiasis, though it may be enlarged and tender in an acute attack. This history is long. Chronic Pancreatitis. With chronic pancreatitis the history is long, the jaundice is, as a rule, not complete, and may be slight or absent; infection of the pancreatic duct and infective cholangitis are often present, as shown by occasional chills and temperature. The loss of flesh is less marked. Only after a long period (much longer than one can live with cancer} may there be anasarca or enlargement of the abdominal veins. There is a history of attacks of pain and local tenderness may be present. At operation for gall-stones, when enlargement of the head of the pancreas can be felt in a patient before middle life, or there are adhesions of long standing, and the history is long, the disease is apt to be chronic pancreatitis. Someimes enlarged glands are found with this condition, but they are apt to be discrete, while with cancer they are usually confluent. The loss of flesh and strength is less marked, and 1 Amer. Jour. Med. Science, Dec., 1914 1048 DISEASES OF THE STOMACH AND INTESTINES the gall-bladder is seldom distended though rarely it is enlarged. Anemia is less marked. Cancer of the common bile-duct is rare and is usually associated with gall-stones. If the papilla .is involved, the symptoms cannot be distinguished from cancer of the head of the pancreas. If the cancer lie above the opening of the pancreatic duct into the ampulla, the pancreatic functions will not be so markedly disturbed and the loss of flesh will not be so rapid. Tumor. Tumor of the pancreas is usually less movable than tumors of the pylorus or colon, and its position does not change, as do tumors of these organs when distended with carbonic acid gas or air. It is found in about one-fifth of the cases, and lies in the epigastrium usually, though occasionally in the right or left hypochondrium. Carcinoma of the pan- creas can be at times determined by inflation of the stomach and colon, since the pancreatic tumor becomes covered by the distended organs. Cancer of the Liver. With cancer of the liver the jaundice is absent or less intense and the liver soon enlarges. Irregular nodules can be felt on the surface and edges. Cachexia is marked. Syphilis can be excluded by the Wassermann or Noguchi's tests. Cancer of the Pylorus. Cancer of the pylorus 1 can be diagnosed by the usual methods, but sometimes both pancreas and stomach are involved. Cammidge sets great store on his urinary test as an aid to diagnosis, but the writer has not been impressed as to its value. Treatment. In the earlier stages, when doubt arises as to whether the condition be one of chronic pancreatitis or carcinoma, exploration is indicated, with drainage of the gall-bladder, if such be required. Obstruction of the bowel or pyloric orifice of the stomach, when oc- curring, must necessarily be relieved to prolong life. When the carcinoma involves the head of the pancreas, life is not prolonged by operation to any extent, and the writer believes operative procedure to be useless. If the growth involve the tail of the gland and there are no metastases and only a few enlarged glands, a partial pancreatectomy may be indicated. So far the results of operation for carcinoma of the pancreas have been exceedingly bad, and life does not seem to be prolonged to any extent. Medical treatment must be symptomatic, morphin for pain, if such occur. Chlorid or lactate of calcium, 60 to 90 grains (4.0-6.0) per day or human serum injections for hemorrhage; holadin, pancreon tablets, liquor pancreaticus, or one of the preparations of the pancreatic ferments to aid digestion, secretin gr. i t.i.d. or prosecretion gr. 3 t.i.d., to stimu- late pancreatic secretion and the usual treatment of symptoms. The bowels should be properly regulated. Sarcoma of the Pancreas Primary sarcoma of the pancreas is a very rare disease. Out of 11,492 autopsies Segre found this condition only twice, and Hale White only one case in 6708 autopsies. Kakels 2 collected 21 cases, among which 10 only were believed to be primary. 1 The #-rays are of value in determining malignancy of the pylorus, by demon- strating the presence of deformity, or obstruction. 2 Amer. Jour. Med. Sci., 1902, cxxiii, 471. CYSTS OF THE PANCREAS NEOPLASMS 1049 Fibrosarcoma, medullary sarcoma, mixed-cell sarcoma, lympho- sarcoma, spindle-celled sarcoma, and angiosarcoma have been described. Sarcomatous degeneration of an ecchinococcus cysts of the tail of the pancreas has also been reported successfully removed by operation. Age of the Patient. The age of the patients vary from four to seventy years. The period of life may, therefore, not be significant for diagnosis. Symptoms. Rapid loss of flesh and strength, and the symptoms de- scribed under Carcinoma may occur. Secondary sarcoma of the pancreas is not uncommon. It occurs most frequently as a lymphosarcoma arising from a primary sarcoma of the duodenum, mediastinum, or abdominal lymph-glands. Secondary mel- anotic sarcoma of the pancreas has also been described, the primary growth being situated in the eye. Diagnosis. The general course of the disease resembles carcinoma of the pancreas, though the tumor may grow more rapidly. Treatment. The medical treatment should be symptomatic. Sur- gical procedure results unfavorably, though exploration for diagnosis may be necessary. Coley's erysipelas toxins may be tried. Adenoma of the Pancreas Cystic adenomata have been described. Simple adenoma may origf inate from the epithelium of the duct, the gland acini, or an island o- Langerhans. Fibro-adenoma has been reported. Nicholls describes a tumor consisting of a stroma of connective tissue arranged in irregular alveoli which contained cells of a glandular type, probably arising from an island of Langerhans. One case of fibro-adenoma of the head of the pancreas has been reported by Biondi, 1 which was palpable and caused jaundice. Recovery followed removal. Small tawny, yellow tumors have been described which histologically resembled an island of Langerhans. Symptoms. No characteristic symptoms are produced except from pressure on the ducts or adjacent organs, and the presence of a palpable tumor. Treatment. Attempt should be made to extirpate the tumor by operation. Lymphadenoma. Lymphadenoma of the pancreas is extremely rare. Only two cases are referred to, which were met with in patients who died from Hodgkin's disease. 1 Riforma Med., 1896, ii, 97. CHAPTER XL VI DEGENERATIVE CHANGES OF THE PANCREAS THE PANCREAS AND DIABETES HEMOCHROMATOSIS DEGENERATIVE CHANGES OF THE PANCREAS DEGENERATIVE changes occurring in the liver, kidneys, and other parenchymatous organs may also affect the pancreas. Like other organs, the pancreas may diminish in size and weight as the years advance, or theTsame condition may result from chronic diseases or from marasmus; senile atrophy is accompanied in many instances by sclerotic changes in the blood-vessels, or it may be the result of malnutrition, such as occurs with chronic wasting diseases. Atrophy of the pancreas is met with in a considerable number of dia- betics, and the cause of both conditions is usually a chronic interstitial pancreatitis. Opie shows there are cases of diabetes in which the pancreas were markedly diminished in size, though no changes could be observed in the structure of the glands. Possibly this condition is congenital, and at some period of life the pancreas is so small that it cannot fulfil the demands made upon it, so diabetes results. Another condition believed to be due to congenital pancreatic deficiency was first described by Byron Bramwell as "pancreatic infantilism." Secondary atrophic changes may occur in the pancreas as the result of pressure from aneurysm, and new growths or chronic interstitial inflammation which accompanies pancreatic calculi, pancreatic cysts, hemorrhage, or abscess. The pancreas may undergo fatty, hyaline, or amyloid degeneration, and focal necrosis. Fatty Degeneration. Etiology. The prolonged use of alcohol usually produces an excess of fat or fatty degeneration in the islands of Langer- hans. Fatty degeneration is caused most frequently by inflammation of the pancreas, but it may occur with infectious diseases, toxemias, or from poisoning by phosphorus or the mineral acids, or be associated with pancreatic lithiasis. In extreme cases the entire organ may be transformed into a mass of fatty tissue, and the pancreas is yellow or yellowish white, soft, and larger than normal. On section the gland is lobulated and consists of masses of fat, separated by strands of fibrous tissue in which the remains of the larger ducts and remnants of the gland structure are embedded. The epithelium contains numerous fat globules and the interstitial tissue is edematous. Amyloid Degeneration. Amyloid degeneration occurs with a similar condition in other organs, and is associated with the same causes as the cachectic state, particularly when due to prolonged suppuration; tuber- 1050 THE PANCREAS AND DIABETES 1051 culous bone diseases; less frequently pulmonary tuberculosis; tertiary syphilis; the cancerous cachexia; rickets; protracted convalescence from acute infectious diseases; and chronic enterocolitis. It does not attain the severity such as is seen in the liver, spleen, and kidneys. The application of iodin to the pancreas turns the area of amyloid degeneration a dark brown. Metachromatic stains, such as gentian violet or methyl green, may be used to demonstrate the amyloid condition. Hyaline Degeneration. This form of degeneration exhibits a special tendency to attack the inter acinar islands ofLangerhans, and generally leaves the secreting parenchyma unaffected. Diabetes is particularly associated with it. Pathology. There is first an increase in size of the cells of the islands of Langerhans and an alteration of their protoplasm. The nuclei disap- pear with the death of the cells and the cell protoplasm finally becomes homogeneous. Small masses of hyaline matter fuse together and form larger collections. The hyaline material may occupy nearly tne entire area of the island and only a few epithelial cells be present. The island appears as a circumscribed hyaline structure of homogeneous material in a series of broken, twisted columns, between which lie capillary walls. The lumen of the blood-vessels is patent and red blood-corpuscles are visible between the hyaline masses. It is usually accompanied by chronic interacinar pancreatitis, though the increase in interstitial tissue is sometimes slight. Arteriosclerosis 'has been present in a number of cases. The hyaline material stains deeply with eosin, picric acid, and other acid dyes, and shows little affinity to nuclear stains. It does not give the amyloid reaction. Similar hyaline degeneration is not present in the other organs. Focal Necrosis. In a case of diabetes reported by Opie there was present a lesion of the pancreas, resembling the focal coagulation necrosis observed in the liver in typhoid fever and like infections. It affected both the islands of Langerhans and also the parenchyma. The process is acute, but there is a commencing chronic proliferation of interstitial tissue replacing the defects caused by destruction of the cells. Focal necrosis of the pancreas has been found in a number of cases associated with lobar pneumonia and other infections. THE PANCREAS AND DIABETES The writer has already referred to the fact that the islands of Langer- hans produce an internal secretion which influences carbohydrate metabo- lism, and disease of the islands will produce diabetes mellitus. Opie 1 reports findings in 288 cases of diabetes mellitus: interacinar pancreatitis in 43.4 per cent. (125 cases); interlobular pancreatitis (13 cases) ; atrophy (65 cases); lipomatosis (18 cases); while calculi, cyst, carcinoma, and focal necrosis were found in a few others. There were a few cases with lesions of the islands of Langerhans, such as hyaline degeneration, sclerosis, 1 Diseases of the Pancreas. 1052 DISEASES OF THE STOMACH AND INTESTINES adenoma, and hypertrophy with normal parenchyma. There were 34 cases of diabetes with a normal pancreas and five cases with normal parenchyma, but the islands reduced in number. Cecil 1 found lesions of the islands of Langerhans in 79 (88 per cent.) of 90 cases of diabetes. The changes which destroy the islands of Langerhans, especially interacinar pancreatitis and hyaline degeneration, are almost constantly accompanied by diabetes, while the lesions which destroy the parenchyma and invade the islands of Langerhans only when the lesion is far advanced, such as in the case of interlobular pancreatitis, pancreatic calculi, and carcinoma, are usually not accompanied by diabetes. Acute lesions of the pancreas, such as acute pancreatitis (hemorrhagic necrosis) or suppuration, rarely cause glycosuria, since usually sufficiently healthy parenchyma remains to prevent its onset. In a small percentage of cases of diabetes mellitus (6.6 per cent.) of those reported by Cecil no abnormality of the pancreas was found. Changes in the central nervous system, the liver, and the kidneys have been followed by glycosuria, and even by diabetes, and diabetes has also accompanied exophthalmic goiter and acromegaly. Arteriosclerosis is present in a large number of diabetics due to its production of interstitial pancreatitis. The close association between cirrhosis of the liver and diabetes has often been observed, the latter in the majority of cases the result of chronic interstitial pancreatitis, both the cirrhosis and pancreatitis usually being the result of the same factor, alcohol, for example. Higgins 2 and Ogden found glycosuria in 9.3 per cent, of 212 cases of traumatism affecting the head, and in 21.9 per cent, out of 45 cases of fractured skull. Diabetes is occasionally associated with tabes or with multiple sclerosis or tumors of the medulla. A renal diabetes has been suspected, and Klemperer 3 has described a case of diabetes associated with nephritis. Among other conditions with which diabetes has been associated are myxedema, disease of the adrenals, and acromegaly. Glycosuria has been observed to follow the use of thyroid extract, and it has been sug- gested that glycosuria occurring with exophthalmic goiter is referable to abnormal activity of the thyroid. In many cases, diabetes, which is associated with arteriosclerosis, cirrhosis of the liver, hemochromatosis, Graves' disease, and acromegaly, is secondary to a pancreatitis which accompanies these diseases. In about 12 per cent, of all cases, diabetes is unaccompanied by a lesion of the islands of Langerhans, and diabetes with a normal pancreas usually occurs during the early period of life, most frequently before the age of thirty. Diabetes which occurs during middle life and later can generally be referred to a lesion of the pancreas. Interacinar pancreatitis is responsible for about two-thirds of the cases of diabetes after forty years of age. Though alimentary glycosuria may occur without pancreatic disease, 1 Ibid. 2 Boston Med. and Surg. Jour., 1895, cxxxii, 197. 3 Berliner Klin. Woch., 1896, xxxiii, 571. HEMOCHROMATOSIS 1053 with hysteria and other neuroses, from the administration of excessive sugar or starchy products, etc., its persistence suggests the existence of a pancreatic lesion. HEMOCHROMATOSIS Von Recklinghausen, 1 under the term "hemochromatosis," describes a condition of pigmentation affecting various organs. He believes the brown pigment is derived from the hemoglobin of the blood. There is an iron-containing pigment, "hemosiderin," in the epithelial cells of the various glands, chiefly the liver and pancreas. There is also an iron- free pigment, "hemofusan," in the muscle-cells of the gastro-intestinal tract, also in the muscle-cells of the blood and lymph-vessels, and connec- tive-tissue cells. Cirrhosis of the liver is associated with the pigmentation. Bronzed Diabetes. Hanot 2 and Chauffard describe a closely related condition of diabetes mellitus associated with hypertrophic cirrhosis of the liver and bronze-like pigmentation of the skin, "diabete bronze." The diabetes is rapidly fatal. Associated with it is an hypertrophic. cirrhosis of the liver, and bronzing of the skin is present in the majority of cases. Etiology. The pigment deposited in the liver and other organs is undoubtedly derived from the hemoglobin in the blood. In many cases it has been accompanied by conditions causing an active destruction of the red blood-cells, such as morbus maculosus, the hemorrhagic dia- thesis, etc. It is believed that phagocytosis of the red blood-corpuscles by the parenchymatous cells of various organs takes part in the process. Chronic interstitial pancreatitis of the interacinar variety has been reported in these cases, as well as hypertrophic cirrhosis of the liver. 'Tagebl. d. 62 Versamml. deutsch. Naturforsher v. Aertze in Heidelberg, 1889, 324. 2 Rev. de Med., 1882, ii, 385. INDEX ABDERHALDEX test, Van Slyke's modi- fication of, in gastric cancer, 341 Abderhalden and Schittenhelm's method of testing for trypsin, 978 Abdomen, anatomic landmarks, 65 auscultation, 73 barrel-shaped, 67 in chronic intestinal obstruction, 884 examination, 65 in hot baths, 69 technic, 66 inflammatory lesions of, diverticulitis and, differentiation, 856 inspection, 66 palpation, 67 bimanual method, 69 Boston's double method, 69 method of, 67 reinforced, 68 percussion of, 70 protrusion in intestinal diseases, 516 topographic anatomy, 65, 74 Abdominal cavity, sounds in, 73 examination, preparation of patient, 66 muscles, functions, 444 pressure in gastroptosis, increase, 464 soreness in amebic dysentery, 683 support in gastroptosis, 462 wall, superficial reflexes of, in appendi- citis, 813 Aberrant pancreas, 959 Abscess in acute appendicitis, 816 in diverticulitis, 853, 854 ischiorectal, 798 liver, in amebic dysentery, 675 diagnosis, 676 phj'sical signs, 676 symptoms, 676 treatment, 692 of rectum, 797 superficial, 797 of stomach, 246. See also Gastritis, phlcgmonous. pelvic, 798 subphrenic, terminations of, 288 Absorption from intestines, 41 protein, 573 Acetic acid in gastric contents, 150 Acetonuria in pancreatic disease, 987 intestinal, 500 classification, 580 Achlorhydria, 383 diagnosis, 386 diet in, 385 etiology, 383 Achlorhydria, haemorrhagica gastrica, 269 bacteriology, 271 blood in, 272 cancer and, differentiation, 273 chronic erosions and, differentia- tion, 273 chronic gastritis and, differentia- tion, 253, 273 diagnosis, 272 diet in, 274 duodenal ulcer and, differentiation, 751 etiology, 269 gastric analysis in, 271 ulcer and, differentiation, 272 lavage in, 275 microscopic examination, 270 morbid anatomy, 270 occult blood in, 272 prognosis, 273 symptoms, 272 treatment, 274 medication in, 385, 386 treatment, 386 Acholic feces, 536 Achylia gastrica, 262 absorption in, 265 age in, 263 cancer of stomach and, differentiation, 266 chronic gastritis and, differentiation, 253 course, 265 diagnosis, 265, 266 differential, 239 diet in, 194, 267 etiology, 263 gastralgia and, differentiation, 477 gastric analysis in, 265 gastric cancer and, differentiation, 349 history, 262 intestinal irrigation in, 269 morbid anatomy, 263 motor function in, 265 prognosis, 265 putrefaction in, treatment, 269 symptoms, 263 temporary, 262 treatment, 266, 628 pancreatic, 1005 Acid gastritis, 248 duodenal ulcer and, differentiation, 75i poisoning, antidotes for, 245 Acidosis, intestinal, 580 classification, 580 1055 1056 INDEX Acini of pancreas, 965 Acne pancreatica, 1035 rosacea, stomach functions in, 506 simplex, stomach functions in, 506 Adenocarcinoma of stomach, 324 Adenocystoma papilliferum of pancreas, 1036 Adenoma of intestines, 779 of pancreas, 1049 Adhesions, colonic, 641 Adnexa, uterine, Head's zones for, 833 Aerophagia, 485, 487, 585 Agar-agar in constipation, 621 Air inflation of intestines, 529 of stomach, 96 swallowing, 585 Akoria, 472 Akoric dyspepsia, 591 Albumin, absorption of, 42 in feces, 535 Alcohol as food, 189 in typhoid fever, 716 poisoning, antidotes for, 245 Algesimeter, Boas', 91 Alimentary gastrosuccorrhea, 396 Alimentation, duodenal, 190 rectal, 191 Alkalis in gastrosuccorrhea continua chronica, 395 Allingham's operation for hemorrhoids, 793 Allotriophagia, 472 Aloes in constipation, 622 Aloin test for occult blood, 161 Amebas, 920 Amebic appendicitis, 681 dysentery, 668. See also Dysentery, amebic. Amebiosis, intestinal, 668. See also Dysentery, amebic. Amoeba dysenteriae, 668 encysted, 670 Ampulla of Vater, 958 variations, 960 Amyloid degeneration of pancreas, 1050 Amylopsin, 39, 971 examination for, 977 in gastric contents, 158 Amyxorrhcea gastrica, 280 Anadenia ventriculi, 249, 250, 262. See also Achylia gastrica. Anchylostoma duodenale, 941. See also Uncinariasis. Anematose, Fairchild's, 191 Anemia, grave, in carcinoma ventriculi without palpable tumor, 345 in gastric cancer, 330 treatment, 303 in uncinariasis, 945 miners ','940 stomach functions in, 503 Anesthesia of rectum, 903 Aneurysm of celiac axis, cancer of pylorus and, differentiation, 347 stomach functions in, 504 Angioma of intestines, 780 Anguillata intestinalis, 948 Anguillata stercoralis, 948 Angulations, colonic, 641 Angustatio ventriculi, 437 Ankylostoma duodenale, 940 Annular pancreas, 959 Anorexia in cancer of stomach, 329 nervosa, 472 transitory, 472 Antidotes for poisoning, 245 Antimony poisoning, antidotes for, 245 Antiperistaltic restlessness of stomach, 481 Antitryptic reaction of blood in gastric cancer, 339 Antityphoid vaccination, 707 in childhood, 707 Antrum cardiacum, 437 Anuria in acute ectasy of stomach, 410 Anus, fissure of, in hemorrhoids, 796 hygiene of, in hemorrhoids, 787 Apepsinia, 151 Appendices epiploicas of large intestine, 29 Appendicitis, 801 acute, abscess in, 816 black vomit in, 815 diagnosis, 825 diet in, 836 fecal accumulation in, 836 fulminating type, 817 hyperinosis in, 818 indications for operation, 837 in infants and children, 811 Lanz's point in, 812 lavage in, 836 leukocytosis in, 818 McBurney's point in, 812 Meltzer's method of palpation in, 814 Morris' point in, 812 muscular rigidity in, 811 pain in, 811 percussion in, 815 rectal examination in, 815 remote effects, 821 superficial reflexes of abdominal walls in, 813 symptoms, 810 temperature in, 815 tenderness on pressure in, 811 treatment, 835 tumefaction in, 816 tumor in, 815 age and, 805 amebic, 68 1 bacteria causing, 802 Blumberg's sign in, 813 bowels in, 815 catarrhal, acute, 805 simple acute, 806 chronic, 80 1, 805, 822 Bastedo's method of testing for, 814 blood-clotting time, 823 diagnosis, 825 x-T&y, 825 diet in, 836 duodenal ulcer and, differentiation, 75 Edebohls' palpation in, 823 INDEX 1057 Appendicitis, classification, 809 claudicans, 822 constipation as cause of, 803 diagnosis, differential, 826 diet in, 836 diffuse acute, 805 etiology, 802 foreign bodies as cause, 804 gangrenous, 805, 808 gastro-intestinal symptoms in, 815 Head's zones in diagnosis, 828 intestinal parasites as cause, 803 myalgia and, differentiation, 827 non-suppurative acute, 805, 807 obliterative, 806 perforative, 808 perforation in simple duodenal ulcer and, differentiation, 744 prognosis, 834, 835 protective, 808, 809, 824 purulent, 805, 807 Rovsing- Chase method of palpation in, 814 sex and, 805 suppurative, 805 acute, 807 syncongestive, 809 treatment, 835 vaginal examination in, 815 varieties, 805 with extrinsic infection, 809 with intrinsic infection, 809 Appendicostomy in amebic dysentery, 692 Appendicular colic, 811 Appendix, vermiform, 29 blood-supply, 802 cancer of, 776 primary, 776 fibroid degeneration, 809 harmful involution, 808, 824 Head's zones in affections of, 833 inflammation, 801 intussusception, 870 palpation, 811 peculiarities, 802 position, 80 1 Appetite, disturbance of, in pancreatic diseases, 998 juice, 35 perversion of, 472 Arsenic in gastric cancer, 358 poisoning, antidotes for, 245 Arterial hemorrhoids, 783 Arteries of cecum, 31 of colon, 31 of rectum, 31 of stomach, 20 Arteriosclerosis, stomach functions in, 506 visceral, 588 Arthritis deformans, stomach functions in, SOS Ascans lumbricoides, 935 diagnosis, 937 intestinal obstruction by, differentia- tion, 877 migration, 936 symptoms, 936 67 Ascaris lumbricoides, treatment, 937 mystax, 938 Aspirating bulb, Boas', 140 tube, 139 Ewald's, 139 Aspiration, intermittent, fractional study of gastric digestion by, 137 of gastric contents, 139 Boas' bulb for, 140 Boas' method, 141 Ewald-Boas expression method, 141 Ewald's tube for, 139 Kemp's method, 142 position of patient and operator, 141 Asthma, dyspeptic, 499 treatment, 500 Atonia gastrica, 399, 442. See also Gastroptosis. Atonic constipation, 611 ectasy of stomach, 416 Atony of stomach, 398, 485 acute, 398 in pneumonia, 407 treatment, 399 chronic, 399 diet in, 400 electricity in, 401 etiology, 399 medication in, 400 physical examination, 399 prognosis, 400 symptoms, 399 treatment, 400, 401 vibratory massage in, 400 of third degree, 442. See also Gastrop- tosis, with hyperchlorhydria, 375 Atrophic gastritis, 249, 262. See also Achylia gastrica. Atrophy of gastric mucosa, 250, 262. See also Achylia gastrica. of mucosa in chronic enteritis, 653 of stomach, 250, 262. See also Achylia gastrica. Auerbach's plexus, 24 Auscultation in intestinal disease, 527 of abdomen, 73 of esophagus, 5 1 Auscultatory inflation of colon, 527 percussion in intestinal diseases, 526 of liver, 77 of stomach, 92 scratch method, 94, 95 Autodigestion of pancreas, 971 Autogenous vaccines in typhoid fever, 718 Auto-intoxication, 571 hydrogen sulphid, 583 in constipation, 615 Autolysin treatment of gastric cancer, 359 Auto- massage in constipation, 619 Autonomin, 893 Aversion to food, 472 Awl-tail, 938 Azotorrhea, 984 in pancreatic diseases, 999 Azoturia in pancreatic disease, 987 1058 INDEX BACILLARY dysentery, 692. See also Dyseniefy, bacillary. Bacilluria in typhoid fever, treatment, 717 Bacillus bifidus, 40 Boas-Oppler in feces in gastric cancer, 342 in gastric cancer, 338 contents, 166 coli, 40 as cause of wound infection, 601 infections, as cause of cholecystitis, 599 as cause of choroiditis, 600 as cause of intra-abdominal tumors, 600 as cause of pelvic exudate, 600 diagnosis, 607 general, 601 method, 595 of Jddneys, 594, 596 in chronic interstitial nephritis, 599 . in pyelitis, 598 in typhoid fever, 598 reaction of urine in, 596, 607 subphrenic abscess from, 602 symptoms, 596 treatment, 607 types, 595 dysenteriae, 693 enteritidis, 706 faecalis alcaligenes, 706 lactis aerogenes, 40, 41 paratyphoid, 706 paratyphosus, 718 tubercle in feces in intestinal ulcer, 761 typhosus, 700 distribution in body, 701 outside body, 701 Bacteria in gastric juice, 34 in mouth, 34 in small intestine, 34 in stomach, 34 of intestine, 40 Balantidium coli, 921 diarrhea from, 923 treatment, 924 Balloon man, 593 Ballottement, suprahepatic, 78 Banti's disease, duodenal ulcer and, dif- ferentiation, 752 Bassler's method of drainage in ectasy of stomach, 412 stomach electrode, 218 Bastedo's method of testing for chronic appendicitis, 814 Baths in obesity, 918 in typhoid fever, 712 Bath-tub, portable, 713 Beans, cooking of, 187 protein in, 187 Beef extracts, effect on flow of gastric juice, 35 tapeworm, 926 Beef-juice, 188 Beef- tea, 188 Belching, 487 in chronic gastritis, treatment, 259 nervous, 487 Belt, Kilmer's, 231-233, 234 Rose's adhesive plaster, 226, 227 rosewater adhesive, 230, 234 Benedict's effervescent test for gastric acidity, 374 Benzidin test for blood in gastric contents and stool, 159 paper, 159 Beyea's operation for gastroptosis, 467 Bile, function of, 38 in gastric contents, 158 in vomit, 157 Bile-ducts, common, anatomic variations, 960 Bile-pigment, acute enteritis and, 648 examination for, 976 in feces, 536 sublimate test for, 549 Bilharzia haematobia, 931 Bilharziasis, 931 treatment, 934 Biliary acids in feces, 536 colic, hyperchlorhydria and, differentia- tion, 376 Bilinuria in pancreatic diseases, 987 Bismuth in acute enteritis, 650 in bacillary dysentery, 697 in chronic enteritis, 662 subnitrate in x-ray examination of in- testines, 528 Bite block for esophagoscopy, 102 Bladder in typhoid fever, 702 Blenorrhcea intestinalis, 657 Blood, antitryptic reaction of, in cancer, 339 coagulation, in pancreatic diseases, 992 diarrhea from irritants in, 626 examination in simple duodenal ulcer, 739 fluke, 930 in achlorhydria haemorrhagica gastrica. 272 in acute appendicitis, 818 in cancer of stomach, 330 in chronic pancreatitis, 1025 in feces, 533, 535 benzidin test for, 159 in intestinal ulcer, 761 in gastric cancer, 338 contents, 159 benzidin test for, 159 ulcer, 286 in pancreatic disease, 091, 998 in typhoid fever, 705 in vomit, 157 occult, in hyperchlorhydria, 376 test for, 1 60 Trichinella spiralis in, 951 vomiting of, in pancreatic diseases, 997 Blood-clotting time in chronic appendi- citis, 823 Blood-vessels of intestines, diseases of, 763 of islands of Langerhans, 967 of stomach, 20 INDEX Elumberg's sign in appendicitis, 813 Boas' algesimeter, 91 aspirating bulb, 140 method of aspiration of gastric contents, 141 point in abdominal palpation, 68 test-breakfast, 137 test for free hydrochloric acid, 144 for lactic acid, 149 Boas-Ewald expression method of aspi- rating gastric contents, 141 test-breakfast, 137 Boas and Moerner's test for free hydro- chloric acid, 153 Boas-Oppler bacilli in feces in gastric can- cer, 342 cancer, 338 contents, 166 Bone-marrow in typhoid fever, 702 Bonninger's diagnosis of gastric ulcer, 289 Boston's method of double palpation, 69 Bothriocephalus cordatus, 928 latus, 924, 927 Botulism, 582 Bougie, cylindric, 524 soft rectal, 524 Brand treatment of typhoid, 712 Brewer's point, 87 Brill's disease, 720. See also Typhus, mild endemic. Bronchoscopy, thimble gag or bite block for, 102 Bronzed diabetes, 1053 Broths, soy, 180 Brunner's glands, 27 Brunning's modification of Killian's eso- phagoscope, 103, 104 Bubbling sounds of stomach, 97 Bulimia, 470 treatment, 471 Bullet wounds of pancreas, 1002 Bunches, 943 CACHEXIA, diverticula of intestines and, 847 in gastric cancer, 330 Calcium oxalate in urine in pancreatic diseases, 988 Calculi in feces, 539 pancreatic, 1031 age and, 1032 diagnosis, 1034 Rontgen ray, 1032 etiology, 1033 in feces, 539 jaundice in, 1033 occurrence, 1032 pain in, 1033 pathology, 1032 symptoms, 1033 treatment, 1034 surgical, 1034 Calomel in acute enteritis, 649 Calorie, 172 ( large, 172 small, 172 table, Chittenden's, 175 Calorie, value of food, 172 determination, 183 of protein, 173 Cammidge reaction in chronic pancreatitis 1026 pancreatic, 988 Cancer atrophicans, 325 of appendix, primary, 776 of body of stomach, 335 of cardia, 333 dysphagia in, 333 esophageal examination in, 333 physical examination in 333 spasm of esophagus in, 334 of colon, cancer of pancreas and, differ- entiation, 1048 of duodenum, 772 of esophagus, 63 early diagnosis, 64 symptoms, 63 treatment, 64 of gall-bladder, gastric cancer and, dif- ferentiation, 349 . of intestines, 767 benign, 779 colic in, 774 constipation in, 774 course, 777 diagnosis, 777 by Rontgen rays, 777 differential, 775 diet in, 778 etiology, 767 feces in, 770, 775 morbid anatomy, 768 mobility of tumor in, 771 pain in, 774 prognosis, 777 pus in feces in, 775 situation, 768 symptoms, 770 due to position, 772 general, 770 local, 774 treatment, 777 tumor in, 775 of liver, cancer of pancreas and, dif- ferentiation, 1048 chronic pancreatitis and, differentia- tion, 1027 of pancreas, age and, 1044 cancer of colon and, differentiation, 1048 of liver and, differentiation, 1048 of pylorus and, differentiation, 1048 cholelithiasis and, differentiation, 1047 chronic pancreatitis and, differ- entiation, 1047 diagnosis, 1047 effects of adhesions and pressure, 1045 frequency, 1044 hemorrhage in, 1046 intestinal obstruction in, 1046 morbid anatomy, 1045 obstruction of bile-ducts with dilata- tion of gall-bladder in, 1045 io6o INDEX Cancer of pancreas, pain in, 1045 sex and, 1044 situation, 1044 symptoms, 1045 treatment, 1048 of pylorus, 125, 334 aneurysm of celiac axis and, differ- entiation, 347 cancer of pancreas and, differentia- tion, 1048 of rectum, 776 hemorrhoids and, differentiation, 786 treatment, 786 of small intestine, 774 of stomach, 320 achlorhydria haemorrhagica gastrica and, differentiation, 273 achylia gastrica and, differentiation, 266, 349 adhesions and, differentiation, 350 age and, 320 anemia in, 330 anorexia in, 329 anticancer globulins in, 359 antitryptic reaction of blood in. 339 arsenic in, 358 autolysin treatment, 359 benign stenosis and, differentiation, 34.8 blood in, 330, 338 Boas-Oppler bacilli in, 338 in feces in, 342 cachexia in, 330 care of bowels in, 363 chronic gastritis, and, differentiation, ?53. 349 classification of cases, 328 colloid, 325 coma in, 332 condurango in, 358 constipation in, 332 dangers of non-radical operation, 323 diagnosis, 338, 344 differential, 344 laboratory, 335 Rontgen rays in, 342 diagnostic points, 348 diet in, 193, 355 drugs for, 358 duration, 350 edema in, 332 engrafted on ulcer, 347 enlarged lymph-glands and, differ- entiation, 349 etiology, 321 exploratory laparotomy in, 352 exudates and, differentiation, 350 fibrous, 324 fluoroscopy for determination of, 1 29 frequency, 320 gall-bladder cancer and, differentia- tion, 349 gastralgia and, differentiation, 477 gastric cancer and, differentiation, 349 contents in, 335 ulcer and, differentiation, 348 Cancer of stomach, gastritis and, 322 gastro-enterostomy for, 355 gastrostomy for, 355 glycyltryptophan test for, 338 grave anemia in, pernicious anemia and, differentiation, 345 hemolysis as diagnostic method in, i, 34 i hemorrhage in, 329 heredity and, 321 hydrochloric acid in, 336 inflation in, 331 injections of cancer residue in, 359 inspection, 330 lactic acid in, 337 leukocytosis in, 330 location, 326 loss of appetite in, 329 loss of weight in, 330 Mayo's partial gastrectomy for, 353, 354 medullary, 324 mesenteric growths and, differentia- tion, 350 metastases in, 326, 332 methylene blue in, 359 morbid anatomy, 324 multiple neuritis in, 332 nervous dyspepsia and, differentia- tion, 497 pain in, 328 palliative operation, 355 palpation in, 331 percussion in, 331 perforation in, 326, 332 peritoneal growths and, differentia- tion, 350 prognosis, 350 pus in, 338 race and, 321 radical operation, 353 radiologic findings in, 344 rectal examination in, 338 respiratory motility in, 331 Rontgen-ray diagnosis of, 1 25 filling defects in, 126 Salomen's test in, 341 scirrhous, 324 sclerosis and, differentiation, 345 secondary changes in mucous mem- brane, 325 sex and, 321 silica metabolism in, 341 skin reaction in, 340 Smithies' percussion sign in, 331 sodium iodid in, 358 symptoms, 327 due to location, 333 general, 327 syphilis and, differentiation, 345 syphilitic cirrhosis of liver and, dif- fentiation, 346 stenosis of pylorus and, differentia- tion, 346 temperature in, 332 test-breakfast in, 336 tetany in, 332 INDEX 1061 Cancer of stomach, thiosinamin in, 358 thrombosis in, 332 thymus extract in, 361 thyroid extract in, 361 transillumination in, 332 traumatism in etiology, 321 treatment, 351 autolysin, 359 drug, 358 medical, 355 of constipation in, 363 of diarrhea in, 363 of ectasia in, 362 of hemorrhage in, 362 of pain in, 362 of vomiting in, 362 radium, 357 Rontgen rays in, 356 surgical, 351 trypsin, 359 vaccine, 359, 361 with body fluids of recovered case, 361 Tremoliere's solution in, 362 trypsin treatment, 359 tryptophan test in, 338 tumor in, 330 types of growth, 325 ulcer in etiology of, 322 urinary methylene-blue reaction in, .341 urine in, 332 vaccine treatment, 359, 361 Van Slyke's modification of Abderhal- den test in, 341 varieties, 324 vomiting in, 329 Wolff- Junghans test in, 341 secondary to diverticulitis, 853 Cancerous ulcers of intestines, 759 Canine hunger, 490 Cannon-ball massage in constipation, 618, 619 Cap, duodenal, 114 Capillary hemorrhoids, 783 Caput coli, 28, 29 medusae, 66 Carbohydrates, absorption of, 42 in feces, 535, 985 in nuts, 178 in urine in pancreatic diseases, 988 Carbolic acid injection for hemorrhoids, 792 poisoning antidotes for, 245 Carbonic acid gas bath in mucous colic, 91 1 for tenesmus in amebic dysentery, 691 inflation of intestines, 529 of stomach with, 95 Carcinoma. See Cancer. ventriculi without palpable tumor, grave anemia in, 345 Cardia, cancer, 333. See also Cancer of Car dia. insufficiency, 487 spasm of, 485 stenosis of, treatment, 363 Cardiac glands of stomach, 20 orifice of stomach, 17 Cardialgia, 475 Cardioptosis, 460 Cardiospasm, 62, 485. See also Cardio- spasmus. Cardiospasmus, 485 diagnosis, 486 etiology, 485 in simple duodenal ulcer, 741 prognosis, 486 symptoms, 485 treatment, 59, 486 surgical, 487 x-ray examination in, 58 Carriers of dysentery bacilli, treatment, 699 typhoid fever, 708, 717 Caruncula major of pancreas, 958 minor of pancreas, 958 Cascara sagrada in constipation, 621 Casein test for pepsin, 152 Catarrh, drunkard's, 248 intestinal, 643. See also Enteritis. , of pancreas, 1005 acute, 1005 chronic, 1006 suppurative, 1007 of stomach, 236. See also Gastritis. Catarrhal appendicitis, acute, 805 simple acute, 806 ulcer of intestine, 758 Catarrhus atrophicans, 262. See also Achylia gastrica. intestinalis, 643 acutus, 643 Caustic alkalis, antidotes for, 245 Cecostomy in modified cecostomy, 692 Cecum, 29 arterial supply, 31 lymphatics, 31 movable, 639 nerves, 31 Celiac axis, aneurysm, cancer of pylorus and, differentiation, 347 Cercomonas intestinalis, 920 Cerebrospinal fluid, trichinae in, 951 Cestodes, 924 Chambers' portable bath-tub, 713 Chauffard's method of percussion for hydatid cyst of liver, 78 Chest, inspection of, 49 Chewing cud, 490 Chittenden's caloric table, 175 sample dietary, 152 Chlorosis, Egyptian, 940 stomach functions in, 503 Cholecystitis, diagnosis of, by Rontgen rays, 132 from Bacillus coli infections, 599 Cholecystotomy in chronic pancreatitis, 1028 Cholelithiasis and acute hemorrhagic pan- creatitis, relation, 1009 cancer of pancreas and, differentiation, 1047 duodenal ulcer and, differentiation, 751 1062 INDEX Cholera nostras, 643 Chorea, acute ectasy of stomach in, 406 Choroiditis from Bacillus coli infection, 600 Churning, haustral, 44 Chvostek's symptom in gastric tetany, 434 Chyme in duodenum, propulsion of, 44 Chymosinogen, 153 Circulation in pancreatic diseases, 999 Circulatory changes in typhoid fever, 702 Cirrhosis of liver, gastric ulcer and, differ- entiation, 294 syphilitic, gastric cancer and, differ- entiation, 346 of stomach, syphilitic, 511 ventriculi, 249, 250 Clamp and cautery treatment of hemor- rhoids, 793 Clapotage in intestinal diseases, 523 Cohnheim modification of benzidin blood test, 159 stomach stiffenings of, 67 Cold applications to stomach, 224 Coley's toxins in gastric cancer, 361 Colic, 587 appendicular, 811 fecal, 614 in cancer of intestines, 774 in chronic intestinal obstruction, treat- ment, 890 intestinal, 587. See also Enteralgia. mucous, 905 abdominal support in, 910 age and, 906 carbonic acid gas bath in, 911 constipation in, treatment, 910 cramps in, treatment, 910 diet in, 910, 913 enteroclysis in, 91 1 enteroptosis and, 908 etiology, 906 exercise in, 913 history, 905 in children, 909 in newborn, 909 medication in, 910 mixed, treatment, 912 pathology, 907 prognosis, 909 researches, 908 sex and, 906 symptoms, 907 treatment, 909 general, 913 surgical, 913 Colitis, acute, acute enteritis with, 648 chronic, 652. See also Enteritis, chronic. in typhoid fever, treatment, 717 membranous, 905. See also Colic, mu- cous. mucous, 905. See also Colic, mucous. ulcerative, 758 Collapse in duodenal ulcer, 753 in gastric ulcer, treatment, 298 in intestinal obstruction, 873 Colon, adhesions, 641 angulations, 641 Colon, arterial supply, 31 ascending, 29 bacillus, infections by, 594. See also Bacillus coli, infections by. corded, in chronic dilatation of duode- num, 636 descending, 30 dilatation, 592 distal, movements of, 44 inflation, auscultatory, 527 with water, 531 location of, with Rontgen ray, 529 lymphatics, 31 nerves, 31 proximal, movements of, 44 transverse, 30 position of, 19 Colonic massage bags, 565 nebulizer, 565, 566 Colon-tube, 555 Coma in cancer of stomach, 332 Compress, Priessnitz's, 224 Compression of intestines, 860 mechanism, 863 Concretions in feces, 538 Condurango in gastric cancer, 358 Condyloma, hemorrhoids and, differentia- tion, 786 Constipatio alvi, 609 Constipation, 609 agar-agar in, 621 aloes in, 622 as cause of appendicitis, 803 atonic, 611 auto-intoxication in, 615 auto-massage in, 619 cannon-ball massage in, 619 cascara sagrada in, 621 diagnosis, 616 diet in, 617 electricity in, 619 enteroclysis in, 620 etiology, 609 fecal colic in, 614 treatment, 623 fever in, 615 tumor in, 614 treatment, 623 foods, causing, 569 fragmentary, 613 glycerin injections in, 621 gymnastic exercises in, 619 habitual, 609 hemorrhoids and, 784 hydrotherapy in, 620 in atonic ectasy of stomach, treatment, 43 in cancer of intestines, 774 of stomach, 332 in chronic atony of stomach, treatment, 401 enteritis, 658 gastritis, treatment, 260 intestinal obstruction, 885 in gastric cancer, treatment, 363 in gastroptosis, treatment, 467 in hemorrhoids, treatment, 787 INDEX 1063 Constipation in mucous colic, treatment, 910 in volvulus, 866 injections in, 620 intestinal diverticula and, 848 sapremia in, 613 massage in, 618 medication in, 621 mineral oil treatment, 621 obstinate, 615 olive oil in, 617, 621 orthopedics in, 621 physical treatment, 618 podophyllin in, 622 predisposing causes, 6n prognosis, 616 prophylaxis, 616 regulin in, 621 rhubarb in, 622 saline laxatives in, 623 spastic, 61 2 sweet oil injection in, 620 symptoms, 613 nervous, 615 tamarinds in, 622 termination, 614 training of patient, 617 treatment, 616 vibratory massage in, 619 Constitutional diseases, intestinal ulcers in, 759 Contact ulcer of duodenum, 732 Convulsions in chronic ectasy of stomach, 435 Copper poisoning, antidotes for, 245 Coproliths in feces, 539 Coprostasis in acute ectasy of stomach, 408 Corde colique transverse in enteroptosis, 444 Corrosive sublimate, antidotes for, 245 Corset for abdominal support, 235 Gallant, 462 La Grecque, 462, 463 proper method of adjusting, 462 Van Orden, 463 Counterirritation, 225 Cruveilhier's disease, 277. See also Ulcer of stomach. Crystals in feces, 540 Cud, chewing, 490 Curtis spring pad, 235 Curvature, greater, of stomach, 18 lesser, of stomach, 18 Cutaneous burns, intestinal ulcers from, 754' Cyanosis enterogenic, 583 treatment, 583 Cyclic vomiting in children, 492 Cynorexia, 470 Cystadenoma of pancreas, 1036 Cystic epithelioma of pancreas, 1036 tumors of pancreas, 1036 Cysts of pancreas, 1035 classification, 1035 contents, 1038 diagnosis, 1043 emaciation in, 1039 Cysts of pancreas, etiology, 1035, 1037 hydatid, 1036 physical signs, 1039 pressure symptoms, 1039 proliferation, 1036 retention, 1035 Rontgen rays in, 1038 symptoms, 1038 treatment, 1043 true, 1035 DAVAINEA Madagascariensis, 928 Dawbarn's method of lavage, 205 Ddbove's meat powder, 189, 268 Decubital ulcers of intestines, 758 Degeneration, amyloid, of pancreas, 1050 fatty, of pancreas, 1050 hyaline, of pancreas, 1051 Degenerative changes of pancreas, 1050 Deglutition sounds of stomach, 99 Dehio's method of determining position of stomach, 92, 135 Dermatitis, uncinarial, 943 See also Uncinarial dermatitis. Dew-itch, 943 Diab&te bronze, 1053 Diabetes, bronzed, 1053 pancreas and, relation, 1051 stomach functions in, 505 Diaphragm, eventration of, 441 Diaphragmatic hernia, 439, 862 acquired, 440 congenital, 440 diagnosis, 440 differential, 441 paradoxic expiratory displacement in, 440 physical signs, 862 prognosis, 441 Rontgen rays in, 440 symptoms, 440 treatment, 441 Diarrhea, 624 acute, 643 cathartica, 625 1 classification, 625 due to irritation of bowel contents, 625 dyspeptica, 625 treatment, 628 entozoica, 626 from balantidium coli, 923 treatment, 924 from exposure to cold and wet, 627 from intestinal parasites, treatment, 628 from irritants transmitted in blood, 626, 628 gastrica, 625 treatment, 628 in chronic enteritis, 658 intestinal obstruction, 885 in gastric cancer, treatment, 363 in intestinal ulcer, 760 in typhoid fever, treatment, 715 nervous, 626, 901 treatment, 628 stercoral, treatment, 628 stercoralis, 626 1064 INDEX Diarrhea stercoralis, treatment, 628 treatment, 627 tubular, 905 Diastase in feces, test for, 537 Diastatic ferments, pancreatic, 985 Diazo-reaction in typhoid fever, 705 Diet, 172 after gastro-enterostomy, 194 before gastro-enterostomy, 194 for reduction in obesity, 916 general rules of, 189 in achlorhydria haemorrhagica gastrica, 274 in achylia gastrica, 194, 267 in acute appendicitis, 836 enteritis, 652 stomach disease, 192 in atonic ectasy of stomach, 425-427 in bacillary dysentery, 699 in cancer of stomach. 193 in chronic amebic dysentery, 690 atony of stomach, 400 diseases of stomach, 193 entertis, 659 gastritis, 194, 256 intestinal obstruction, 889 pancreatitis, 1028 in constipation, 617 in disease, 192 in duodenal ulcer, 753 in ectasia, 194 in gastric cancer, 355 ulcer, 302 in gastroptosis, 194 in gastrosuccorrhea continua chronica, 394 in health, 172 ; in hemorrhoids, 786 in hyperchlorhydria, 377, 379 in indolic indicanuria, 577 in intestinal cancer, 778 diseases, 568 in mucous colic, 910, 913 in nervous dyspepsia, 194 in senile dyspepsia, 591 in simple acute gastritis, 241, 242 in typhoid fever, 708 in ulcer of stomach, 193 postoperative, 195 scales, 185, 186 Leube-'s 186 Dietary, Chittenden's sample, 152 Diet-lists, von Noor den's 183-185 Dietl's crisis in gastroptosis, treatment, 466 in nephroptosis, 446, 459 Dieulafoy's ulcer of stomach, 314 Diffuse appendicitis, acute, 805 Digestibility of food, 186 Digestion, enteral, 42 ferments of, 33 intestinal, 38 parenteral, 42 physiology, 33 Dilatation, diffuse, of esophagus, 54 x-ray examination, 57 of colon, 592 Dilatation of duodenum, chronic, 634 classification, 635 corded colon in, 636 determination, 636 pressure paradox in, 636 treatment, 636 of esophagus, diffuse, without anatomic stenosis, 62 symptoms, 63 treatment, 63 of sphincters for hemorrhoids, 791 of stomach, acute, 401. See also Ectasy of stomach. Diminished peristole, 398. See also Atony of stomach. Diphtheritic dysentery, 666, 695 Dipping, 69 Dipylidium caninum, 928 Disinfection in typhoid fever, 708 Dislocation of stomach, 439 Distoma conjunctum, 930 felineus, 931 hematobium, 931 hepaticum, 931 lanceatum, 930 lanceolatum, 931 sinensis, 930 Distomiasis, 930 hemic, 931 treatment, 934 intestinal, 931 Diverticula, Meckel's, 24, 843 diseases of, 839, 856. See also Diver- ticulitis. inflammation of, 857 strangulation by, 86 1 of esophagus, 56, 57 stenosis of esophagus and, differentia- tion, 52 of intestines, 842 absence of fat and,. 847 acquired, 843 cachexia and, 847 congenital, 842 connective tissue around vessels and, 849 constipation and, 848 etiology, 847 false, 842 flatulence and, 848 intestinal wall and, 847 muscular deficiency of gut wall, 849 obesity and, 847 occurrence, 845 perforation in, 852 pressure from within intestines and, 848 relation of, to points of entry of vessels through gut walls, 848 secondary pathologic processes in, 840 sex and, 847 sigmoid flexure and, 848 size, 846 of vessels and, 848 true, 842 of Vater, 958 INDEX 106^ Diverticulitis, 839 ' abscess in, 853, 854 acute, 851 adhesions in, 852 carcinoma secondary to, 853 chronic, 851 clinical aspects, 854 diagnosis, 856 differential, 854 Rontgen ray, 855 etiology, 847 foreign bodies in, 853 gangrenous, 851 history, 839 inflammatory lesions of abdomen and, differentiation, 856 intestinal obstruction and, differentia- tion, 855 left-sided tumor in, 854 mesenteritis in, chronic, 853 metastatic suppuration in, 853 perforation in, 852 of hernial sac in, 853 peritonitis, from, local chronic, 853 perforative, 852 sigmoiditis and, differentiation, 855 symptoms, 851 submucous fistula? in, 853 treatment, 856 vesicocolic fistula and, differentiation, 855 Diverticulum. See Diverticula. Dochmius duodenalis, 940 Douche in stomach diseases, 225 stomach, 211. See also Stomach douche. Douleur thoracique in volvulus of stomach, 442 Drain-trap stomach, 37 Dripping sounds of stomach, 99 Duct of Santorini, 958 Ducts of pancreas, 958 of Wirsung, 958 Ductus pancreaticus accessorius, 058 Dujardin-Beaumetz diet in obesity, 917 Dulness, hepatic, 77 Duodenal alimentation, 190 cap, 114 deformity of, 119 dilated, 129 motility, 37 motor function, 36 shape, 37 feeding in gastric ulcer, 301 regurgitation from fatty foods, 482 ulcer, 724. See also Ulcer, duodenal. Duodenitis, catarrhal, acute hemorrhagic pancreatitis and, 1010 with jaundice, treatment, 651 Duodenoscope, Kemp's inflating, 105-108 sterilization, 108 uses of, 1 08 Duodenum, anatomy, 22 ascending part, 22 cancer of, 772 chronic dilatation, 634. See also Dila- tation, chronic, of duodenum. chyme in, propulsion of, 44 Duodenum, constriction of, from abnormal folds of anterior mesogastrium, 748 contents, examination, 976 descending part, 22 direct lavage of, 552 Head's zones for, 830 stricture of, ulcer of duodenum and, differentiation, 749 superior horizontal part, 22 transverse part, 22 Dynamic ileus, 871 intestinal obstruction by, differentia- tion, 877 Dysentery, 666 amebic, abdominal soreness in, 683 acute, 679 feces in, 679 ipecac in, 686 pain in, 679 tenesmus in, 679 treatment, 685 internal, 685 local, 688 adhesive peritonitis in, 682 after-effects, 683 appendicostomy in, 692 carriers of, 687 cecostomy in, 692 Gant's modified, 692 chronic, 679 diet in, 690 treatment, 690 surgical, 691 circulatory system in, 680 classic ulcers in, 672 cold water irrigation in, 689 complicating bacteria in, 677 complications, 68 1 definition, 668 diagnosis, 683 differential, 682 emetin in, 687 healing process in, 673 in aged, 680 in children, 680 intestinal parasites in, 677 intestines in, 670 irrigation in, 689 latent infection, 678 leukocytes in, 680 liver abscess in, 675 treatment, 692 location of lesions, 674 microscopic pathology, 675 nervous system in, 682 pains in, 678, 680, 681 pathology, 670 prognosis, 683 prophylaxis, 684 source of infection, 668 splenic abscess in, 677 sprue after, 683 subacute, 678 symptoms, 677 temperature in, 680 tenesmus in, 680 io66 INDEX Dysentery, amebic, treatment, 684 local, 688 medical, 604 ulceration in, 670 undermined ulcers in, 672 bacillary, 692 acute, diet in, 699 treatment, 698 bacillus dysenteriae as cause, 693 bismuth treatment, 697 chronic, diet in, 699 treatment, 698 clinical types, 695 complications, 696 definition, 692 etiology, 692 ipecac treatment, 696 irrigation in, 698 medication in, 696 morbid anatomy, 694 prognosis, 696 prophylaxis, 696 serum therapy in, 699 symptoms, 694 tenesmus in, treatment, 698 treatment, 696 bacilli carriers, treatment, 699 catarrhal, acute, 695 classification, 667 climatic location, 667 diphtheritic, 666, 695 location of lesions in, 670 predisposing causes, 667 pre-ulceration stage, 670 Dyspepsia, akoric, 591 chronic, 248. See also Gastritis, chronic. gastric acute, 236. See also Gastritis simple acute. hyperkoric, 591 in pancreatic diseases, 998 intestinal, 570 chronic enteritis and, differentiation, 656 treatment, 571 nervous, 496 chronic gastritis and, differentiation, 497 course, 497 . diagnosis, 497 differential, 497 diet in, 194 etiology, 496 gastric cancer and, differentiation, 497 juice in, 496 ulcer and, differentiation, 497 neurasthenia gastrica and, differentia- tion, 49) symptoms, 496 treatment, 497 senile, 590 diagnosis, 591 diet in, 591 exercise in, 591 gastric analysis in, 590 intestinal functions in, 590 symptoms, 590 treatment, 591 Dyspepsia, umbilical, 899 Dyspeptic asthma, 499 Dysphagia, 485 in cancer of cardia, 333 EAR diseases, stomach functions in, 506 Echinococci, 928 Ectasia, diet in, 194 in gastric cancer, treatment, 362 ventriculi, 414 Ectasy, gastrosuccprrhea continua chron- ica and, differentiation, 393 of pylorus, stenotic, symptoms, 420 of stomach, acquired, treatment, 431 acute, 401 age in etiology of, 404 anuria in, 410 cardiac symptoms with, 406 character of vomitus, 410 clinical types, 405 coprostasis in, 408 diagnosis, 411 drainage in, 412 duodenal stenosis with motor dis- turbances and, 754 duodenum in, 411 duration of attacks, 410 etiology, 404 from obstruction of transverse duo- denum, 403 in epilepsy, 406 in migraine, 406 in simple duodenal ulcer, 741 in tetany, 406 in typhoid fever, 407 lavage in, 412 mechanism of production, 402 medication in, 413 microscopic examination, 411 morbid anatomy, 411 operations in, 414 pain in, 410 percussion in, 410 peristalsis in, 410 physical signs, 410 postural treatment, 413 prognosis, 411 pseudo-angina with, 406 sex in etiology, 404 splashing sound in, 410 symptoms, 408 tenderness in, 410 treatment, 412 vomiting in, 409 atonic, 416 constipation in, treatment, 430 course, 419 diagnosis, differential, 423 diet, 425-427 electricity in, 428 etiology, 416 fermentation in, treatment, 430 gastric analysis in, 419 tetany in, treatment, 430 gastroplication in, 431 gastrosuccorrhea in, treatment, 430 hydrotherapy in, 428 INDEX 1067 Ectasy of stomach, atonic, in epilepsy, 417 in insane, 417 lavage in, 428 local treatment, 428 massage in, 429 mechanic support in, 427 Rose's plaster belt in, 428 stomach douche in, 429 spray in, 429 surgical treatment, 430 symptoms, 418 treatment, 425 benign, gastric contents in, 422 treatment, 431 chronic, 414 complications, 433 convulsions in, 435 diagnosis, differential, 416 epilepsy in, 435 tetany in, 433. See also Tetany in eclasy of stomach. treatment, 425 congenital, treatment, 431 malignant, treatment, 433 medication in, 429 obstructive, 419. See also Ectasy of stomach, stenotic. onset, 409 prophylaxis, 412 types, 401 stenotic, 89, 416, 419 acquired, 419 congenital, 419 treatment, 421 diagnosis, 422, 423 differential, 423 etiology, 419 inflation, 424 inspection, 422 malignant, 421 gastric contents in, 422 motor functions in, 424 palpation, 423 pathology, 420 percussion, 422 special type, 421 test-breakfast in, 424 transillumination, 424 treatment, 431 vomiting in, treatment, 432 ar-rays in, 424 Eczema, stomach functions in, 506 Edebohls' palpation in chronic appendi- citis, 823 Edema in cancer of stomach, 332 Egyptian chlorosis, 940 Ehrlich's diazo-reaction in typhoid fever, 705 Kinhorn's bead test for intestinal motor functions, 543 >i benzidin test paper, 159 deglutible electrode, 217 disease, 317. See also Erosions of stom- ach, chronic. duodenal feeding, 190 pump for obtaining pancreatic fer- ments, 974, 975 Einhorn's esophagoscope, 99 gastric spray, 214 stamper test for gastric ulcer, 295 gastrodiaphane, 109 gastrograph, 171 meat powder, 268 methods of recognizing gastric ulcer, 294, 295 pyloric dilator for pylorospasmus, 484 radiodiaphane, 134 stomach powder-blower, 215 stool sieve, 538 technic of transillumination of intes- tines, 528 thread impregnation test for gastric ulcer, 294 treatment of gastric ulcer, 301 Electricity in atonic ectasy of stomach, 429 in chronic atony of stomach, 401 gastritis, 255 in constipation, 619 gastroptosis, 465 in hyperchlorhydria, 382 in intestinal diseases, 566 in stomach diseases, 216 combined with vibratory massage, 222 high-frequency currents, 219 indications, 219 intragastric method, 216 percutaneous method, 216 static method, 219 triphase method, 219 Turck's gyromele, 219 with roller massage and heat, 223, 224 intrarectal, 567 Electrode, Einhorn's deglutible, 217 Lockwood's, 217 stomach, Bassler's, 218 Elsberg and Neuhof 's method of diagnosis by Head's zones, 828 Emaciation in pancreatic cyst, 1039 diseases, 998 Embolic intestinal ulcers, 755 Embolism of inferior mesenteric artery, 756 of mesenteric arteries, 763 clinical symptoms, 764 diagnosis, 756 etiology, 763 prognosis, 756 Emetin in amebic dysentery, 687 Endo-appendicitis, 806 Enema, 553, 554 high, with colon- tube, 554 in chronic enteritis, 66 1 uses, 553 value, 563 Enteral digestion, 42 Enteralgia, 587 diagnosis, 588 etiology, 587 nervous, 903 prognosis, 588 symptoms, 587 treatment, 588 io68 INDEX Enteritis, acute, 643 acute colitis with, 648 bile-pigment and, 648 bismuth in, 650 calomel in, 649 crypts of Lieberkuhn in, 645 diagnosis, to localize lesion, 648 diet in, 652 duration, 649 enteroclysis in, 650 etiology, 643 fermentation in, treatment, 651 fever in, 647 heat in, 650 localization, 647 microscopic anatomy, 645 morbid anatomy, 644 opiates in, 650 physical signs, 646, 647, 755 prognosis, 649 prophylaxis, 649 symptoms, 645, 654 subjective, 645 treatment, 649 urine in, 647 chronic, 652 atrophy in, 653 bismuth in, 662 chronic catarrhal colitis in, 655 constipation in, 658 treatment, 66 1 course, 657 degeneration of muscular coats in, 6S4 diagnosis, 656 differential, 658 diarrhea in, 658 diet in, 659 enema in, 661 etiology, 652 feces in, 655 hydrotherapy in, 660 hypertrophy in, 653 intestinal dyspepsia and, differentia- tion, 656 massage in, 660 medication in, 661 mineral waters in, 660 morbid anatomy, 653 mucus in feces in, 656 prognosis, 658 rectal examination in, 653, 658 treatment, 659 local, 662 surgical, 663 ulceration in, 654 chronica, 652 atrophicans, 674 cystica, 653 follicularis seu nodularis, 645" membranacea, 656 membranous, 905. See also Colic, mu- cous. phlegmonous, 665 polyposa, 653 pseudomembranous, 905 purulent, 665 Enteroclysis, double-current, 555 without bed-pan, 560 in acute enteritis, 650 in constipation, 620 in mucous colic, 911 in simple acute gastritis, 240, 241 value, 563 Enterocolitis, chronic, 652 Enterogenic cyanosis, 583 treatment, 583 Enterokinase, 40, 970 Enteroliths, 871 in feces, 539 intestinal obstruction by, differentia- tion, 876 Enteroptosis, 448, 592. See also Gastrop- tosis. mucous colic and, 908 Rontgen-ray for determining, 124 Epilepsy, acute ectasy of stomach in, 406, 41? in chronic ectasy of stomach, 435 Epithelial cells in gastric contents, 167 Epithelioma of pancreas, cystic, 1036 of stomach, 324 Epithelium in feces, 541 Erb's sign in gastric tetany, 434 Erepsin, 40, 42 of stomach, 315 acute, 315 bismuth treatment, 317 chronic, 315 emaciation in, 316 etiology, 316 gastric analysis in, 317 pains in, 316 pathology, 316 prognosis, 317 symptoms, 316 treatment, 317 weakness in, 316 hemorrhagic, 315 nitrate of silver treatment, 317 Eructation, 487 Erythema, stomach functions in, 507 Erythrocytes in feces, 541 Esculin in gastrodiaphany, no Esophageal bougie, 50 diseases, examination, 50 orifice of stomach, 17 sounds, use of, 55 Esophagitis, acute, 60 chronic, 60 Esophagoplasty in cancer of esophagus, 64 Esophagoscope, Einhorn's, 99 Jackson's, 102 Killian's, Brunning's modification, 103, 104 Lewisohn's, 102 Esophagpscopy, 99 contraindications for, 104 correct position for, 101, 102 for foreign bodies, 103, 104 in cancer of esophagus, 64 indications for, 104 Jackson's instruments for, 102 Roser position for, 101, 102 INDEX 1069 Esophagoscopy, technic, 100 thimble gag or bite block for, i~2 Esophagus, auscultation of, 51 benign growths of, 65 cancer, of, 63. See also Cancer of esoph- agus. dilatation of, diffuse, 54 without anatomic stenosis, 62 symptoms, 63 *-ray examination, 57 diverticulum of, 56, 57 stenosis of esophagus and, differentia- tion, 52 examination of, 50 instrumental, 51 foreign bodies in, 59 palpation of, 50 paralysis of, syphilitic, 62 perforation of, 61 Rontgen rays in diagnosis of diseases of, JI 3 spasm of, in gastric cancer, 334 splashing sound in, 51 stenosis of, diverticulum of esophagus and, differentiation, 52 stricture of, 62 benign, .examination in, 54 thiosinamm in, 59 treatment, 59 malignant, examination in, 55 ulcers of, 61. See also Ulcer of esoph- agus. *-ray examination, 56 Etat mamelonne, 249 Eventration of diaphragm, 441 Ewald's aspirating tube, 139 test-meal, 136 treatment of gastric ulcer, 301 Ewald and Boas' expression method of aspirating gastric contents, 141 test-breakfast, 137 Ewald and Siever's salol test of motor power of stomach, 1 70 Examination, physical, general methods, 49 Exercise in gastroptosis, 463 in intestinal diseases, 566 in mucous colic, 913 in obesity, 918 in senile dyspepsia, 591 open-air, in obesity, 916 Exulceratio simplex, 314 Eye diseases, stomach functions in, 506 FABER and Penzoldt's test for absorptive power of stomach, 168 Fairchild's anematose, 191 Fan-douche, 225 Fasciola hepatica, 930 Fasting stomach. See Stomach, fasting. Fat, 1 88 absence of, diverticula of intestines and, 847 absorption, 42 effect of extirpation of pancreas on, 980 Fat in feces, 535, 539 in diseases of pancreas, 981 Robson and Cammidge's test for, 981 necrosis in pancreatic diseases, 1000 of appendix, appearance, 1029 of pancreas, 1029 etiology, 1030 location, 1029 pathology, 1029 treatment, 1030 Fats in feces, 980 Fat-splitting ferment in urine. in pancreatic diseases, 991 Fatty degeneration of pancreas, 1050 feces, 537 Fecal colic, 614 fever, 615 tumors, 614 Feces, accumulation, chronic intestinal obstruction from, 887 in acute appendicitis, 836 intestinal obstruction by, differentia- tion, 877 acoholic, 536 albumin in, 535 bile-pigment in, 536 sublimate test for, 549 biliary acids in, 536 blood in, 533, 535 in intestinal ulcer, 761 Boas-Oppler bacilli in, in gastric cancer, .342 calculi in, 539 carbohydrates in, 535, 985 chemic examination, 534 color of, in steatorrhea, 983 colorless, 536 concretions in, 538 coproliths in, 539 crystals in, 540 diastase in, test for, 537 diastatic ferments in, Wynhausen's test for, 985 Einhorn's sieve for, 538 enteroliths in, 539 epithelium in, 541 examination, 532 after test-diet, results, 551 bacteriologic, from test-diet, 547 chemic, 534 after test-diet, 549 for parasitic ova, 542 from test-diet, 545-551 macroscopic, 533, 545 after test-diet, 545 fat in, 535, 539, 980 in diseases of pancreas, 981 Robson and Cammidge's test, 982 fatty, 537 fermentation test for, 549 ferments in, 537 food remnants in, 533 foreign bodies in, 539 gas fermentation in, 535 in acute amebic dysentery, 679 1070 INDEX Feces in chronic enteritis, 655 pancreatitis, 1026 in intestinal cancer, 770, 775 in pancreatic disease, character, 986 reaction, 986 indol in, test for, 550 intestinal parasites in, 534 macroscopic findings, 533 masses, intestinal obstruction from, 871 microorganisms in, 542 microscopic examination, 539 mucus in, 533, 541 examining separate particles, 535 in chronic enteritis, 656 in intestinal ulcer, 761 nitrogen in, 985 normal reaction, 534 odor, 533 pancreatic calculi in, 539 ferments in, obtaining, 978 Gross' method, 978 pea-soup, in typhoid, 704 peptone in, 535 propeptone in, 535 pus in, 533, 541 in intestinal cancer, 775 ulcer, 761 putrefactive products in, test for, 550 red blood cells in, 541 tissue shreds in, in intestinal ulcer, 761 tubercle bacilli in, in intestinal ulcer, 761 tumor fragments in, 541 quantity of, 41 reaction of, 41 skatol in, tests for, 550 starch in, 535 stercobilin in, 536 sugar in, 535 test for mucin in, 534 trypsin in, test for, 537 urobilin in, 536 Fedeli and Romani's method for estimat- ing diastatic function of pan- creas, 986 Feeding after gastro-enterostomy, 194 before gastro-enterostomy, 194 duodenal, 190 forced, 208 method for sparing stomach, 189 postoperative, 195 rectal, 191 Fermentation in acute gastritis, treatment, 651 in atonic ectasy of stomach, treatment, 430 in chronic gastritis, treatment, 259 in small intestine, 41 test for feces, 549 Ferments in feces, 537 of digestion, 33 of intestine organized, 40 of pancreatic juice, 39 pancreatic, 970. See also Pancreatic ferments. . Fever, fecal, 615 in acute enteritis, 647 in intestinal ulcer, 761 Fibro-adenoma of pancreas, 1049 Fibroid degeneration of vermiform appen- dix, 809 Fibroma of intestines, 780 Fibromyoma of intestines, 780 Fish-hook stomach, 37, 120, 121, 455 Fissure of anus in hemorrhoids, 796 Fistula in ano, 799 submucous, in diverticulitis, 853 vesicocolic, diverticulitis and, differen- tiations, 855 Fitz's classification of acute pancreatitis, 1008 Flank tympanites, 874 Flatulence, 584 diverticula of intestines and, 848 Flatus in proctoclysis, 564 Fleisher's test for urobilin in feces, 536 Fletcherism, 174 Flicking percussion, 72 Floating kidney, 445. See also Nephrop- tosis. liver, 459 spleen, 82 Fluke worms, 930 Fluorescein in gastrodiaphany, in Fluorescent media for gastrodiaphany, no Fluoroscopy for determining cancer of stomach, 129 Focal necrosis of pancreas, 1051 Follicles, solitary, of small intestine, 27 Follicular ulcers of intestines, 758 Food, aversion to, 472 chemic composition of, 181-183 constipating, 569 determination of caloric value, 183 digestibility, 186 effect of seasoning, 569 fatty, duodenal regurgitation from, 402 idiosyncrasies to, 474 in vomit, 156 insalivation of, 174 laxative, 568 mastication of, 174 potential energy of, 174 proprietary, list, 189 regurgitation, 489 remnants in feces, 533 Foreign bodies as cause of appendicitis, 804 esophagoscopy for, 103 in diverticulitis, 853 in esophagus, 59 in feces, 539 in stomach, 367 treatment, 369 intestinal obstruction by, 871 differentiation, 877 treatment, 88 1 Fore-stomach, 437 Fragmentary constipation, 613 Fremitus, hydatid, transthoracic, 78 Frenum carunculae of pancreas, 958 Friedlieb's apparatus for lavage, 204 method of lavage, 203 Fundus glands of stomach, 20 of stomach, 17 Funnel method of lavage, 196 INDEX GALACTOSE, absorption of, 42 Gallant corset, 462 Gall-bladder, acute perforation of, perfora- tion in simple duodenal ulcer and, differentiation, 745 cancer of, gastric cancer and, differen- tiation, 349 distended, movable kidney and, dif- ferentiation, 87 Head's zones for, 831 in chronic pancreatitis, 1025 in typhoid fever, 702 ' palpation of, 76 percussion of, 77 physical examination, 75 symptoms in gastroptosis, 460 Gall-stones, chronic pancreatitis and, dif- ferentiation, 1027 diagnosis of, by Rontgen rays, 132 gastralgia and, differentiation, 478 intestinal obstruction by, differentiation, 876 ulceration of, into duodenum, duodenal ulcer and, differentiation, 751 Galvanization, direct, in gastrosuccorrhea continua chronica, 396 Gangrenous appendicitis, 808 pancreatitis, 1012 accumulation of fluid in lesser peri- toneal cavity, 1012 diagnosis, 1014 differential, 1014 etiology, 1012 leukocytosis in, 1014 pathology, 1012 symptoms, 1013, 1014 treatment, 1015 Gant's examining speculum, 520 hinged speculum, 520 modified cecostomy in amebic dysen- tery, 692 water infiltration treatment of hemor- rhoids, 793 Gas cysts of intestines, 781 fermentation in feces, 535 of gastric contents, 156 Gastralgia, 475 achylia gastrica and, differentiation, 477 as neurosis, 476 cancer of stomach and, differentiation, .477 chronic gastritis and, differentiation, 477 diagnosis, differential, 477 duration, 476 etiology, 476 from cerebral disease, 476 from malarial infection, 476 from spinal disease, 476 gall-stones and, differentiation, 478 gastric ulcer and, differentiation, 477 hyperchlorhydria and, differentiation, 477 hypersecretion and, differentiation, 477 intercostal neuralgia and, differentia- tion, 478 intestinal colic and, differentiation, 478 Gastralgia, myalgia and, differentiation, 477 nervous, gastric cancer and, differentia- tion, 349 hyperchlorhydria and, differentiation. 376 originating in stomach, 476 perigastritis and, differentiation, 478 prognosis, 477 pyloric stenosis and, differentiation, 477 reflex causes, 476 renal calculi and, differentiation, 478 rheumatism and, differentiation, 477 sex in etiology, 476 symptoms, 476 tabes and, differentiation, 477 treatment, 478 Gastralgokenosis, 479 Gastrectasy, 414 Gastrectomy, partial, for cancer, 353, 354 Gastric analysis in achlorhydria haemor- rhagica gastrica, 271 cancer, vomitus in, 335 catarrh. See Gastritis. contents, abnormal constituents of, 158 amylopsin in, 158 aspiration of, 139. See also Aspira- tion of gastric contents. contraindications to, 138 bile in, 1 58 blood in, 159. See also Blood. Boas-Oppler bacilli in, 166 epithelial cells in, 167 examination, 143 microscopic, 163 gases in, 156 gastric mucosa fragments in, 167 Gunzburg's test for, 155 in chronic gastritis, 251 intestinal juice in, 158 Megastoma entericum in, 164 microscopic examination, 165 mold in, 167 treatment, 168 mucus in, 158 Oldium albicans in, 167 Penicillium glaucum in, 167 pepsin in, 150. See also Pepsin. peptone in, 150 propeptone in, 150 reaction, 144 rennet in, 152. See also Rennet. Sahli's desmoid test of, 155 sarcinae in, 166 Strep to thrix Foersteri in, 167 Trichomonas hominis in, 164 trypsin in, 158 tumor particles in, 167 volatile acids in, 150 yeast in, 166 crises cf tabes, 512 erosions, 315 hemorrhage. See Hemorrhage. insufficiency, 399 juice, 33 bacteria in, 34 chronic continuous secretion of, 391 1072 INDEX Gastric juice, continuous secretion, 386. See also Gastrosuccorrhea . effect of beef extracts on flow, 35 of meat juice on flow, 35 excessive flow, 386. See also Gastro- succorrhea. hydrochloric acid in, 33. See also Hydrochloric acid. in nervous dyspepsia, 496 in periodic vomiting, 492 intermittent secretion, 387 periodic continuous flow, 387 quantity secreted, 35 secretion of, 35 effect of nervous influences on, 35 of sham feeding on, 35 mucosa, atrophy of, 250, 262. See also Achylia gastrica. fragments in gastric contents, 167 neuroses, chronic gastritis and, differ- entiation, 253 secretion, microscopic examination, 163 tetany in atonic ectasy of stomach, treatment, 430 ulcer, 277. See also Ulcer of stomach. achlorhydria haemorrhagica gastrica and, differentiation, 272 Gastrin, 35 Gastritis, acid, 248 duodenal ulcer and, differentiation, 7Si hyperchlorhydria and, differentiation, 376 acute, 236 atrophic, 249, 262. See also Achylia gastrica. cancer of stomach and, 322 chronic, 236, 248 absorption in, 252 achlorhydria haemorrhagica gastrica and, differentiation, 253, 273 achylia gastrica and, differentiation, 253 alkaline-saline waters in, 257 belching in, treatment, 259 cancer and, differentiation, 253 catarrhal, 248 classification, 248 constipation in, treatment, 260 course, 252 definition, 248 diagnosis, 251 differential, 252 diet in, 194, 256 electricity in, 255 etiology, 248 fermentation in, treatment, 259 gastralgia and, differentiation, 477 gastric cancer and, differentiation, 349 contents in, 25 1 neuroses and, differentiation, 253 hygiene, 254 inspection, 251 lavage in, 255 massage in, 255 medication in, 258 Gastritis, chronic, microscopic examina- tion in, 252 morbid anatomy, 249 motor function in, 252 nausea in, treatment, 259 nervous dyspepsia and, differentia- tion, 497 symptoms in, treatment, 260 palpation, 251 percussion, 251 physical examination, 251 prognosis, 253 prophylaxis, 254 saline waters in, 257 smoking in, 257 splashing sound in, 251 stomachics in, 259 symptoms, 258 treatment, 253 local, 254 medicinal, 258 ulcer and, differentiation, 253 urine in, 251 vomiting in, treatment, 259 hyperpeptica, 248 hypersthenic, 248 phlegmonosa, 246 phlegmonous, 246 age of occurrence, 247 diagnosis, 247 duration, 247 etiology, 246 morbid anatomy, 247 symptoms, 247 treatment, 248 polyposa, 249 simple acute, diagnosis, 238 diet in, 241, 242 duration, 238 enteroclysis in, 240, 241 etiology, 236 beat in, 240 jaundice in, treatment, 240 microscopic anatomy, 237 morbid anatomy, 237 nausea in, treatment, 239 physical examination in, 238 prophylaxis, 239 pyrosis in, treatment, 239 symptoms, 238 treatment, 239, 241 urine in, 238 vomiting in, treatment, 239 toxic, 243 anatomy, 243 diagnosis, 244 etiology, 243 prognosis, 244 symptoms, 243 treatment, 244 Gastrodiaphane, Einhorn's, IOQ Kemp's circumscribing, IOQ, no Lockwood's, 109 Gastrodiaphany, 109, 135 esculin in, no fluorescent media for, no fluorescin in, in INDEX 1073 Gastrodiaphany glycerin in, in in gastroptosis, 112, 449 technic, 112 Gastrodynia, 475 Gastro-enterostomy, feeding before and after, 194 for cancer, 355 Gastrofaradization, 218 Gastrogalvanization, 218 Gastrograph, Einhorn's, 171 Gastro-intestinal hemorrhage, occult, phe- nolphthalein test for, 160 symptoms in appendicitis, 815 Gastrojejunal ulcer following gastric ulcer, treatment, 312 Gastroptosis, 89, 442 abdominal support in, 462 after confinement, 447 age in, 447 anatomic considerations, 443 belt test in, 461 Beyea's operation for, 467 complications in, treatment, 467 constipation in, treatment, 467 crescentic, 451 definition, 442 diagnosis, 90, 460 diet in, 194 Dietl's crisis in, treatment, 466 electricity in, 465 elevation of foot of bed in, 466 exercise in, 463 existing, treatment, 462 gall-bladder symptoms in, 460 gastric analysis in, 449 gastrodiaphany in, 112, 449 Glenard's belt-test in, 461 theory of, 443 gymnastics in, 463 hydrotherapy in, 466 increase of abdominal pressure, 464 inflation in, 449 inspection, 449 Kilmer's belt in, 463 large intestine in, 455 lengthening of stomach in, 451 massage in, 464 motor functions in, 450 palpation in, 449 percussion in, 449 physical examination, 449 prognosis, 461 prophylaxis, 461 Rontgen ray for determining, 124, 126, 461 Rose's adhesive plaster belt in, 461, 462 Russell's treatment, 465 sex in, 447 small intestine in, 450 splashing sounds in, 449 symptoms, 447 treatment, 461 surgical, 467 Van Valzah-Hayes belt in, 463 with hyperchlorhydria, 376 Gastroscope, Jackson's, 105 68 Gastroscope, Kemp's inflating, 105-108 sterilization, 108 uses of, 108 Gastroscopy, 104 Gastrospasmus, 475 Gastrostomy for cancer, 355 in cancer of esophagus, 64 in perforation of esophagus, 62 Gastrosuccorrhea, 238, 386 alimentary, 396 etiology, 397 symptoms, 397 treatment, 397 chronic, 391 classification, 386 continua chronica, 391 alkalis in, 395 diagnosis, 392 differential, 393 diet in, 394 direct galvanization, in, 396 ectasy and, differentiation, 393 etiology, 391 frequency, 391 gastric ulcer and differentiation, 393 hyperchlorhydria with dilatation and, differentiation, 393 hypersecretion in, treatment, 395 lavage in, 395, 396 medication in, 395 pain in, treatment, 395, 396 palpation in, 392 prognosis, 394 prophylaxis in, 394 symptoms, 392 treatment, 394 peripdica, 387 diagnosis, 388 etiology, 387 gastric contents in, 388 history, 387 lavage in, 389 prognosis, 389 prophylaxis, 389 symptoms, 387 treatment, 389 of pain in, 389 of thirst in, 390 of vomiting in, 389 vomitus in, 388 hyperchlorhydria and, differentiation, 376 in atonic ectasy of stomach, treatment, 43 Gastroxynsis, 386. See also Gastrosucor- rhea. Gavage, 208 Gelatin in hyperchlorhydria, 378 in intestinal diseases, 569 in typhoid fever, 710 treatment of gastric ulcer, 306 Germain See's test-meal, 137 Gersuny's adhesion symptom in fecal tumor, 615 of fecal tumor, 522 symptom, 70 1074 INDEX Gl6nard's belt test in gastroptosis, 461 disease, 442. See also Gastroptosis. theory of gastroptosis, 443 Glucose, absorption of, 42 Glycerin in gastrodiaphany, in injections in constipation, 621 Glycosuria, alimentary, in pancreatic dis- eases, 988 Glycyltryptophan test in cancer of stom- ach, 338 Gonorrheal ulcer of intestines, 759 Gout, stomach functions in, 505 Grip, stomach functions in, 505 Gross' double-current stomach douche, 212 method of obtaining pancreatic methods from feces, 978 tube for obtaining pancreatic ferments, .973, 974 Ground-itch, 943 Gruel flour, soy, 179 Gruels, soy, 180 Giinzburg's test for free hydrochloric acid, 144 for gastric contents, 155 Gurgling sound of stomach, 99 Gymnastics in constipation, 619 in gastroptosis, 463 in intestinal diseases, 566 Gyromele, 565 Turck's 219, 220 HABITUAL constipation, 609 Haggard, 190 Hammer, percussion, 71 Hart's diet scales, 185 Haustral churning, 44 Hayes' methods of determining chronic duodenal dilatation, 636 Headache in hyperchlorhydria, 373 in typhoid fever, treatment, 717 Head's zones, Elsberg and Neuhof's method of diagnosis by, 828 in affections of appendix, 633 of duodenum, 830 of ^gall-bladder, 831 ofiintestines, 833 of kidney, 832 of liver, 831 of stomach, 830 of ureter, 832 of uterus and adnexa, 833 of vermiform appendix, 833 diagnosis of appendicitis, 828 in ileocecal tuberculosis, 833 Health, diet in, 172 Heart lesions, stomach functions in, 504 stimulants in typhoid fever, 715 Heartburn, 489 Heat in acute enteritis, 650 in simple acute gastritis, 240 moist, 224 unit, 172 Hematemesis. See Hemorrhage. Hemic distomiasis, 931 treatment, 934 Hemin crystals, Teichmann's test for, 162 Hemin crystals, Stozyzowski's modifica- tion, 162 Hemmeter-Moritz test for motor power, 171 Hemochromatosis, 1053 of pancreas, 1053 Hemofusan, 1053 Hemolysin, pancreatic, 992 Hemolysis as diagnostic method in gastric cancer, 340 Hemorrhage, gastro-intestinal occult, phe- nolphthalein test for, 160 in cancer of pancreas, 1046 in duodenal ulcer, Kemp's treatment, 752 in gastric cancer, 329 treatment, 362 ulcer, 284 serum treatment, 297 treatment, 296, 306 in hemorrhoids, 785 in pancreatic diseases, 998 in simple duodenal ulcer, 740 in typhoid fever, death from, 702 treatment, 715 intestinal, 724 Of stomach, 276 causes, 276 prognosis, 277 symptoms, 277 treatment, 277 pancreatic, 1008 Hemorrhagic necrosis of pancreas, 1008 pancreatitis, acute, 1008 age and, 1009 catarrhal duodenitis and, 1010 cholelithiasis and, relation, 1009 etiology, 1009 lymphatics in, 1010 occurrence, 1009 pathology, ion penetration of duodenal contents into pancreatic ducts, 1010 traumatic necrosis and, ion diagnosis, 1014 differential, 1014 epigastric peritonitis in, 1013 experimental, 1008 leukocytosis in, 1014 symptoms, 1013 treatment, 1015 Hemorrhoids, 782 age and, 783 anal fissure in, 796 anatomy, 782 arterial, 783 bowels in, 787 cancer and, differentiation, 786 capillary, 783 carbolic acid injection for, 792 cauterizing with fuming nitric acid, 792 clamp and cautery treatment, 793 complications, 793 condyloma and, differentiation, 786 constipation and, 784 treatment, 787 crushing of, 793 INDEX Hemorrhoids, diagnosis, 786 diet in, 786 dilatation of sphincters in, 791 etiology, 783 external, anatomy, 782 symptoms, 784 treatment, 788 extirpation of, 793 Gant's water infiltration method, 793 hemorrhage in, 785 treatment, 790 hygiene of anus in, 787 internal, anatomy, 782 symptoms, 785 Kemp's ice tube for, 788 soft rubber rectal bag for, 789 tube for, 788 ligature of, 792, 793 proctitis in, 797 prognosis, 786 prolapse of rectum in, 793 treatment, 795 prolapsed, treatment, 790 sex and. 783 suture of, 793 symptoms, 784, 785 tenesmus in, 785 treatment, radical, 791 ulcerated, treatment, 790 venous, 783 Whitehead's operation for, 793 Hemosiderin, 1053 Hepatic flexure of ascending colon, 29 Hernia, diaphragmatic, 439, 862. See also Diaphragmatic hernia. physical signs, 862 from strangulation, internal, 860, 86 1 mechanism, 863 perforation of sac, in diverticulitis, 853 Hexamethylenamin in duodenitis with jaundice, 651 High-frequency current in stomach dis- ease, 219 Hirschsprung's disease, 592 History of patient, 46 Hodenpyl's treatment of gastric cancer, 361 Hoffmann's sign in gastric tetany, 434 Hook-worm disease, 940. See also Unci- tiariasis. Hormones, 35 Hort's theory of gastric ulcer, 279 Hot applications, continuous steam coil for, 225 in stomach diseases, 224 baths, abdominal examination in. 69 Hour-glass stom?ch, 437 acquired, etiology, 437 congenital, 437 hypotonic, 439 Rontgen rays for determining, 123, 438 spastic, 439 symptoms, 437 Woltler's signs in, 438 Houston's valves, 32 Hunger, canine, 470 Hyaline degeneration of pancreas, 1051 Hydatid cyst of liver, Chauffard's method of percussion for, 78 of pancreas, 1036 disease, 924 fremitus, transthoracic, 78 Hydrochlorhydria, nutrition in, 373 Hydrochloric acid, 33 combined, Topfer's test for, 146 deficit, determination, 154 free, Boas' test for, 144 Giinzburg's test for, 144 Kemp's test for, 147 Mintz's test for, 153 phloroglucin-vanillin test for, 144 resorcin-sugar test for, 144 RiegePs test for, 154 tests for, 144, 153 Topfer's test for, 145, 146 tropaolin oo test for, 153 in gastric cancer, 336 Hydrogen sulphid auto-intoxication, 583 Hydrotheropy in atonic ectasy of stomach, 428 in chronic enteritis, 660 in constipation, 620 in gastroptosis, 466 in intestinal diseases, 566 local, 224 Hydrothionemia, 583 Hymenolepis diminuta, 928 nana, 928 Hypanakinesis ventriculi, 485 Hyperaciditas hydrochlorica, 370 Hyperacidity, 370. See also Hyperchlor- hydria. Hyperanakinesis ventriculi, 479, 485 Hyperchlorhydria, 370 absorption in, 374 acid gastritis and, differentiation, 376 alcohol in, 378 appetite in, 373 atony with, 375 Benedict's test for, 374 biliary colic and, differentiation, 376 bowels in, 373 care of, 383 complications, 375 course, 374 diagnosis, 375 differential, 376 diet in, 377, 379 dilatation with, 375 duodenal ulcer and, differentiation, 750 electricity in, 382 etiology, 371 frequency, 371 gastralgia and, differentiation, 477 gastric contents in, 373 ulcer and, 281, 283, 286 differentiation, 376 gastrosuccorrhea and, differentiation, 376 gelatin in, 378 headache in, 373 in duodenal ulcer, treatment, 753 magnesia in, 380 1076 INDEX Hyperchlorhydria, medication in, 380 microscopic pus in, 376 motor function in, 374 movable kidney complicating, 376 nervous gastralgia and, differentiation, 376 nervous symptoms in, 373 occult blood in, 376 olive oil in, 378 pain in, 375 palpation in, 373 pathology, 375 percussion in, 373 physical examination in, 373 prognosis, 375 removal of causes, 376 symptoms, 372 thirst in, 373 treatment, 376 urine in, 373 with atonic dilatation, gastrosuccorrhea continua chronica and, differen- tiation, 393 with gastroptosis, 376 Hyperesthesia of intestines, 903 of stomach, 474 Hyperinosis in acute appendicitis, 818 Hyperkinesis, 479 Hyperkoric dyspepsia, 591 Hypermotility of stomach, 479 Hyperorexia, 470 Hyperpepsinia, 151 Hyperperistalsis, Rontgen ray for deter- mining, 126 Hypersecretion, 386. See also Gastrosuc- corrhea. gastralgia and, differentiation, 477 in gastrosuccorrhea continua chronica, treatment, 395 intermittent, 387 Hypertrophy of mucosa in chronic enter- itis. 653 Hypochlorhydria, 383 diagnosis, 386 diet in, 385 etiology, 383 medication in, 386 treatment, 386 Hypodermoclysis, 192, 565 Hypogastric neuralgia, 904 Hypoleukocytosis in typhoid fever, 705 Hypopepsinia, 151 Hypotonic hour-glass stomach, 439 IDIOPATHIC nervous vomiting, 494 Idiosyncrasies to food, 474 Heac phlegmon, 801 Ileaca-ileocolic intussusception, 868 Ileocecal intussusception, 867 tuberculosis, Head's zones in, 833 valve, functions, 640 incompetence, 640 etiology, 640 palpation method of determining, 636 symptoms, 641 treatment, 641 Ileocolic intussusception, 867 Ileum, anatomy, 23 Ileus, 859. See also Intestinal obstruction. dynamic, 871 Incisura pancreatis, 956 Incontinence of pylorus, 481 Indicanuria, causes, 41 indolic, 574 etiology, 574 medication in, 577 treatment, 577 in pancreatic disease, 987 test for, 576 Indol in feces, test for, 550 Indolic indicanuria, 574. See also In- dicanuria, indolic. diet in, 577 intestinal putrefaction with saccharo- butyric type, 578 Infantilism, pancreatic, 984, 1050 Infarction of intestines, 763 Infectious diseases, acute, intestinal ulcers in, 759 Inflation of colon, auscultatory, 527 with water, 531 of intestines, uses, 531 with air, 529 with carbonic acid gas, 529 of stomach, 135 with air, 96 with carbonic acid gas, 95 with water, 96 Infusion, rectal, 565 Infusoria, 920 Ingesta, examination of, 143 Insalivation of food, 174 Insanity, atonic ectasy of stomach in, 417 Insomnia in typhoid fever, treatment, 717 Inspection, general, 49 of abdomen, 66 of chest, 49 of intestines, 517 of kidney, 84 of liver, 76 of neck, 50 of oral cavity, 49 of pharynx, 50 of rectum, 517 of spleen, 80 of stomach, 135 of tongue, 49 of tonsils, 50 of uvula, 50 Insufficiency, gastric, 309 motor, 399 of cardia, 487 of stomach, 481 Interacinar islands of pancreas, 966. See also Islands of Langerhans. Internal secretion of pancreas, 968 Interrogation of patient, 46 Intestinal acetonuria, 580 classification, 580 acidosis, 580 classification, 580 amebiosis, 668. See also Dysentery, amebic. INDEX 1077 Intestinal catarrh, 643. See also Enteritis. colic, 587 gastralgia and, differentiation, 478 digestion, 38 distomiasis, 931 dyspepsia, 570 treatment, 571 hemorrhage, 724 intoxications, relation to vagotonia, 894 irrigation in achylia gastrica, 269 juice, 40 in gastric contents, 158 myiasis, 760 neurasthenia, 905 obstruction, acute, 859 acute peritonitis and, differentia- tion, 878 . auscultation in, 874 by Ascaris lumbricoides, differen- tiation, 877 by compression, 863 by dynamic ileus, differentiation, 877 by enteroliths, 871 differentiation, 876 by fecal accumulation, differentia- tion, 877 by fecal masses, 871 by foreign bodies, 871 differentiation, 877 by gall-stones, differentiation, 876 by intussusception, 867. See also Intussusception. differentiation, 876 by volvulus, 865 differentiation, 875 collapse in, 873 course, 878 diagnosis, 873 differential, 78 between forms of, 875 between obstruction of small and large intestine, 875 etiology, 860 from chronic obstruction, 872 from dynamic ileus, 871 general consideration, 859 inspection in, 873 ladder pattern, 874 lavage in, 882 meteorism in, 873 palpation in, 874 paralytic, 871 , pathology, 872 percussion in, 874 prognosis, 879 symptoms, 872 treatment, 879 medical, 879 surgical, 881 vomiting in, 873 by adhesions, 861 by bands, 861 by compression, 86 1 by foreign bodies, treatment, 881 by internal hernia, 860, 861 Intestinal obstruction by strangulation from internal herniae, 861 through slits and apertures, 86 1 chronic, 883 acute obstruction engrafted on, 872 anatomy, 884 barrel-shaped abdomen in, 884 bowels in, 889 colic in, treatment, 890 complications, 888 4 constipation in, 885 course, 889 diagnosis, 888 diarrhea in, 885 diet in, 889 etiology, 883 from fecal accumulation, 887 from rectal stricture, 888 inspection in, 886 location, 884, 885 pain in, 885 peristaltic unrest in, treatment, 890 prognosis, 889 Rontgen rays in, 886 surgical treatment, 891 symptoms, 885 treatment, 889 tympanites in, 886 diverticulitis and, differentiation, 855 from strangulation of Meckel's diver- ticulum, 861 in cancer of pancreas, 1046 pain, 587. See also Enteralgia. parasites, 920 as cause of appendicitis, 803 in amebic dysentery, 677 in feces, 534 paresis, 871 putrefaction, chronic, 573 combined indolic and saccharobutyric type, 578 sand, 593 sapremia, 613 splash, stomach splash and, differentia- tion, 98 stasis, chronic, 630. See also Stasis, chronic intestinal. trichinae, 951 tuberculosis, 757 Intestines, absorption from, 41 adenoma, 779 anatomy, 22 angioma of, 780 anomalies in position and form, 592 bacteria of, 40 blood-vessels, diseases of, 763 compression, 860 mechanism, 863 digestion in, 38 diseases of, 515 auscultation in, 527 auscultatory percussion in, 526 clapotage in, 523 diet in, 568 electricity in, 566 exercise in, 566 gelatin in, 569 1078 INDEX Intestines, diseases of, gymnastics in, 566 massage in, 566 mechanical support in, 566 inspection in, 516 palpation in, 521 percussion, 525 protrusion of abdomen in, 516 special interrogation of patient in, 515 splashing sound in, 523 succussion.in, 523 vaginal examination in, 524 diverticula of, 842. See also Diver- ticula of intestines. ferments of, organized, 40 fibroma of, 780 fibromyoma of, 780 functions, in senile dyspepsia, 590 motor, 43 test-diet for, 544 testing, 543 gas in, 584. See also Tympanites. cyst of, 781 Head's zones in affections of, 833 hyperesthesia of, 903 in amebic dysentery, 670 in typhoid fever, 701 infarction, 763 inflation, uses, 531 with air, 529 with carbonic acid gas, 529 irrigation, 552. See also Irrigation of intestines. large, absorption in, 43 anatomy of, 28 appendices epiploicae, 29 histology of, 32 motor functions, 44 pendulum movements, 44 lavage for diagnosis, 532 lipoma of, 780 lymphosarcoma of, 778 treatment, 779 motor function, 43 neuroses of, 900 myoma of, 780 neoplasms, 767. See also Cancer of intestines. nervous diseases, 900 neuroses of, secretory, 905 sensory, 903 obstruction of 859. See also Intestinal obstruction. obturation of, 870 oscillating movements, 43 paralysis, 901 palpation, 521 papilloma of, 780 peristalsis in, 43 nervous control, 45 physical examination, 515 Rontgen rays in examination of, 528 rotary movements, 43 sarcoma of, 778 small, arterial supply, 24 bacteria in, 34 coats of, 24 fermentation in, 41 Intestines, small, lymphatics of, 24 microscopic anatomy, 26 motor function, 43 mucous coat, 25 muscular coat, 24 nerves of, 24 serous coat, 24 solitary follicles, 27 structure of, 24 submucous coat, 25 veins of, 24 villi of, 26 volvulus of, 865 strangulation. See Strangulation. transillumination, 528 tumors of, 767. See also Cancer of in- testines. ulcers of, 724 volvulus, 865. See also Volvulus. Intra-abdominal pressure, maintenance, 445 tumors from colon bacillus infections, 600 Intragastric method of applying elec- tricity in stomach diseases, 216 Intrarectal electricity, 567 Intussusception, 867 age and, 869 causes, 869 diagnosis, 870 differential, 876 duration, 870 frequency, 868 ileaca-ileocolic, 868 ileocecal, 867 intestinal obstruction from, treatment, 88 1 mechanism, 868 of appendix, 870 pain in, 869 situation, 869 symptoms, 869 tumor in, 869 Imagination, 867. See also Intussuscep- tion. Invertin, 40 lodin poisoning, antidotes for, 245 lodipin test for motor power, 171 lodoform poisoning, antidotes for, 245 Ipecac in acute amebic dysentery, 686 in treatment of bacillary dysentery, 696 Iron test for occult blood, 161 Irrigation in bacillary dysentery, 698 of intestines by patient, 562 double-current, 555 position of patient, 558 precautions before inserting tube, 557 rotation method, 559 solutions employed in, 561 uses, 553 value, 563 with single tube, 554 Irrigator, rectal, Kemp's flexible recurrent, 556 Kemp's glass, 556 Ischio-rectal abscess, 798 Ischochymia, 414 INDEX 1079 Island of Langerhans blood-vessels, 967 cells, 967 function, 968 intralobular framework, 968 position, 966 JACKSON'S esophagoscope, 102 gastroscope, 105 instruments for esophagoscopy, 102 membrane, 637 Rontgen rays in, 638 symptoms, 638 treatment, 639 Jacoby-Solms test for pepsin, 151 Jaundice, duodenitis with, treatment, 651 in chronic appendicitis, 1024 gastritis, treatment, 259 in pancreatic calculi, 1033 diseases, 997 in simple acute gastritis, treatment, 240 duodenal ulcer, 741 Jejunal ulcer, 313. See also Ulcer, jejunal. gastric ulcer after, treatment, 312 prognosis, 314 Jejunum, anatomy, 23 Juvenile vomiting, 494 KATAYAMA disease, 933 Kelly's proctoscope, 518 rectal speculum, short, 517 standard, 517 sigmoid speculum, 518 Kelsey's rectal speculum, 519 Kemp's circumscribing gastrodiaphane, 109, no diet in obesity, 917 table in gastric ulcer, 305 esophageal bougie, 51 flexible recurrent rectal irrigator, 556 glass rectal irrigator, 556 ice tube for hemorrhoids, 788 inflating gastroscope and duodenoscope, 105-108 method of aspirating gastric contents, 142 prostatic cooler, 788 rectal irrigator, 557 soft rubber rectal bag for hemorrhoids, 789 stomach-whistle, 97 test for free hydrochloric acid, 147 test-supper for motor power, 169 treatment of amebic dysentery, 690 of gastric ulcer, 298 of hemorrhage in acute duodenal ulcer, 752 of typhoid fever, 710 tube for hemorrhoids, 788 vacuum bottle method of proctoclysis, 564 Kerkring, valvulae conniventes of, 25 Kidney, acute unilateral septic infarcts from, 599 Bacillus coli infections of, 594, 596 in chronic interstitial nephritis, 599 in pyelitis, 598 in typhoid fever, 598 Kidney diseases, stomach functions in, 504 Head's zones for, 832 in typhoid fever, 702 inspection, 84 movable, 85 distended gall-bladder and, differentiation, 87 with hyperchlorhydria, 376 palpation, 84 percussion of, 87 physical examination, 84 surface relations, 83 topography, 83 Killian's esophagoscope, Brunning's modi- fication, 103 Kilmer's belt, 231-233, 234 in gastroptosis, 463 Kissing ulcer of duodenum, 732 Klemperer's oil test for motor power, 171 test-meal, 137 Kliinge's aloin test for occult blood, 161 Knapp's director for lavage, 207, 209 method of examination of stomach, 90 of inspecting liver, 75 LACERATION of pancreas due to direct violence, 1001 Lactase ferment, 970 Lactic acid, Boas' test for, 149 in gastric cancer, 337 quantitative estimation of, 150 Uffelmann's test for, 148 modified, 148 Lactose, 40 Ladder pattern of acute intestinal obstruc- tion, 874 La Grecque corset, 462, 463 Landau's disease, 447 Lane's abdominal supporter, 235 definition of chronic intestinal stasis, 630 kinks, 609, 631 Langerhans, islands of, 966. See also Islands of Langerhans. Lanz's point in appendicitis, 812 Lavage, 196 by single operator, 200,201 by two nurses, 202, 203 contraindications, 211 dangers of, 196 Dawbarn's method, 205 Friedlieb's apparatus, 204 method, 203 funnel method, 196 in achlorhydria haemorrhagica gastrica, 275 in acute ectasy of stomach, 412 intestinal obstruction, 882 in appendicitis, 836 in atonic ectasy of stomach, 428 in chronic gastritis, 255 in gastric ulcer, 297 in gastrosuccorrhea continua periodica, 39 in office practice, 197 in toxic gastritis, 244 indications for, 208 io8o INDEX Lavage, Knapp's director for, 207, 209 Leube-Rosenthal method, 205 mouth-gag in, 206 of duodenum, direct, 552 of intestines for diagnosis, 532 position of operator, 198, 199 of patient, 198 stomach-tube for, selection, 197 technic, 198 208 testing tube for, 197 through nostril, 207, 210 with glass Y or T, 205 with patient lying on back, 206 Laxative foods, 568 Lead poisoning, antidotes for, 245 Lee's cholera table, 555 Legumes, cooking of, 187 Lenhartz's treatment of gastric ulcer, 301 Leube's diet scale, 186 meat pancreas, 191 sound method for determining posi- tion of stomach, 97 test-meal, for motor power, 169 Leube-Rosenthal meat solution, 189 method of lavage, 205 Leube-Ziemssen rest-cure in gastric ulcer, 300 Leukocytosis in acute appendicitis, 818 in gangrenous pancreatitis, 1014 in gastric cancer, 330 in hemorrhagic pancreatitis, 1014 Leukopenia in typhoid fever, 705 Levulose, absorption of, 42 Lewisohn's esophagoscope, 102 Lieberkiihn's crypts, 26 in acute enteritis, 645 Ligature of hemorrhoids, 792 Lipase, 34 Lipoma of intestines, 780 Lipuria in pancreatic diseases, 991 Liver abscess in amebic dysentery, 675 delimitation of, 74 diseases, stomach functions in, 504 dulness, 77 floating, 459 fluke, 930 functions, testing, 549 Head's zones for, 831 hydatid cyst of, Chauffard's method of percussion for, 78 in chronic pancreatitis, 1025 in pancreatic diseases, 999 in typhoid fever, 702 inspection, 75 movable, 459 palpation, 76 percussion, 77 auscultatory, 77 physical examination, 75 spilling, 76 syphilitic cirrhosis of, gastric cancer and, differentiation, 346 Lock wood's electrode, 217 gastrodiaphane, 109 Loewis test for pancreatic disease, 1047 Lymphadenoma of pancreas, 1049 Lymphatics of cecum, 31 of colon, 31 of rectum, 32 of small intestines, 24 of stomach, 21 Lymph glands, enlarged, gastric cancer and, differentiation, 349 Lymphosarcoma of intestines, 778 treatment, 779 MAGGOT-worm, 938 Magnesia in hyperchlorhydria, 380 Malacia, 472 Malaria, gastralgia from, 476 stomach functions in, 505 Maltose, 40 Massage, 221 bags, colonic, 565 cannon-ball in constipation, 619 in atonic ectasy of stomach, 429 in chronic enteritis, 660 gastritis, 255 in constipation, 618 in gastroptosis, 464 in intestinal diseases, 566 in nephroptosis, 466 roller, 223, 224 tapotement in, 221 vibratory, 221 combined with electricity, 222 in chronic atony of stomach, 400 in constipation, 619 Mastication, 174 Mathieu-Remond test for motor power of stomach, 170 Mayo's partial gastrectomy for gastric cancer, 353 Mazamorra, 943 McBurney's point in appendicitis, 812 Meat juice, effect on flow of gastric juice, 35 pancreas, Leube's, 191 powder, Debove's, 189, 268 Einhorn's, 268 solution, Leube-Rosenthal, 189 Mechanical support, 225 Meckel's diverticulum, 24, 843 diseases of, 839. See also Diver- ticulitis. Megalogastria, 415, 437 Megastoma entericum in gastric contents, 164 Meissner's plexus, 24 Meltzer's method of palpation in appendi- citis, 814 Membrane, Jackson's, 637 Membranes, pericolic, 639 Membranous colitis, 905 enteritis, 905. See also Colic, mucous. Mercury poisoning, antidotes for, 245 Merycism, 490 Mesenteric artery, embolism of, 763. See also Embolism 0} mesenteric arteries. inferior, embolism, 756 thrombosis, 756 superior, occlusion of, 764 INDEX 1081 Mesenteric glands in typhoid fever, 702 veins, embolism of, 763 thrombosis of, 763. See also Throm- bosis of mcsenteric veins. Mesenteritis, chronic, in diverticulitis, 853 Mesentery, growths of, gastric cancer and, differentiation, 350 Mesogastrium, anterior, constriction of duodenum from abnormal folds of, 748 Mesorectum, 31 Meteorism, 584. See also Tympanites. in acute intestinal obstruction, 873 in volvulus, 866 Methylene-blue in gastric cancer, 359 reaction of urine in gastric cancer, 341 Mett's test for pepsin, 152 Microgastria, 437 Microorganisms in feces, 542 Migrane acute ectasy of stomach in, 406 Milk, digestibility of, 187 in typhoid fever, 709, 712 Milk-sugar, absorption of, 42 Mineral oil, absorption of, 43 Miner's anemia, 940 Mintz's test for free hydrochloric acid, 153 Miserere, 859 Moerner and Boas' test for free hydro- chloric acid, 153 Mold in gastric contents, 167 treatment, 168 Morgagni, columns of, 32 Moritz-Hemmeter test for motor power, 171 Morris' point in appendicitis, 812 Motility of duodenal cap, 37 of stomach, 37 Motor function of duodenal cap, 36 of intestine, 43 of large intestines, 44 of small intestine, 43 of stomach, 36. See also Stomach, functions of, motor insufficiency, 399 of first degree, 399 of second degree, 414 relative, 416 neuroses of intestines, 900 Mouth, bacteria in, 34 pemphigus, stomach functions in, 507 Mouth-gag in lavage, 206 Movable cecum, 639 kidney, 445. See also Sephroptosis. liver, 459 Mucin, test for, in feces, 534 Mucinase, 39 Mucous coat of small intestine, 25 of stomach, 20 colic, 905. See also Colic, mucous. colitis, 905. See also Colic, mucous. glands of stomach, 20 Mucus in feces, 533, 541 examining separate particles, 535 in chronic enteritis, 656 in intestinal ulcer, 761 in gastric contents, 158 in vomit, 157 Mucus, microscopic examination, 163 Muffins, soy, 180 Miiller's serum plate method of examina- tion for trypsin, 979 Mumps complicating pancreatitis, 1004 Murphy's drop-method of proctoclysis, 563 Muscular coat of small intestine. 24 of stomach, 19 Muscle trichinae, 951 Musser's method of inflation of colon, 527 Myalgia, appendicitis and, differentiation, 827 gastralgia and, differentiation, 477 Myasthenia ventriculi, 399 Myiasis, intestinal, 760 Myoma of intestines, 780 NAUHEIM bath in typhoid fever, 713 Nausea due to abnormal sensations, 474 in chronic gastritis, treatment, 259 pancreatitis, 1023 in pancreatic diseases, 996 in simple acute gastritis, treatment, 239 Nebulizer, colonic, 565, 566 Neck, inspection of, 50 Necrosis, fat, in pancreatic diseases, 1900 of pancreas, focal, 1051 hemorrhagic, 1008 traumatic, acute hemorrhagic pancrea- titis and, i on Needle douche, intestinal, 565 Nematodes, 935 Neoplasms. See Tuniors. Nephritis, chronic interstitial, Bacillus coli infections of kidneys in, 599 Nephroptosis, 445, 455 degrees of, 456, 457 Dietl's crisis in, 446, 459 etiology, 446 massage in, 466 Nerves of cecum, 31 of colon, 31 of rectum, 32 of small intestines, 24 of stomach, 22 Nervous control of peristalsis, 45 diarrhea, 626, 901 treatment, 628 diseases of intestines, 900 dyspepsia, 496. See also Dyspepsia, nervous. enteralgia, 903 influences, effect on secretion of gastric juice, 35 symptoms in typhoid fever, 703 in typhoid fever, treatment, 717 Neuhof and Elsberg's method of diagnosis by Head's zones, 828 Neuralgia, hypogastric, 904 intercostal, gastralgia and, differentia- tion, 478 mesenterica, 903 of stomach, 475 Neurasthenia gastrica, 496. See also Dys- pepsia, nervous. nervous dyspepsia and, differentia- tion, 497 1082 INDEX Neurasthemia, intestinal, 905 Neuritis in typhoid fever, 705 multiple, in gastric cancer, 332 Neuroses, motor, of intestines, goo of intestines, sensory, 903, 905 of stomach, 469, 495 classification, 469 etiology, 469 motor, 479 peculiarities, 469 sensory, 470, 474 Nitric acid, fuming, cauterizing with, in hemorrhoids, 792 Nitrogen, excessive secretion of, 175 in feces, 985 Non-suppurative appendicitis, acute, 805 Nose diseases, stomach functions in, 506 Nuclease, 970 pancreatic, 40 Nutrition, in intestinal ulcer, 761 parenteral, 192 Nuts, carbohydrates in, 178 OBESITY, 915 baths in, 918 diet for reduction in, 916 diverticula of intestines and, 847 exercises in, 918 open-air exercise in, 916 prevention, 915 sex and, 915 symptoms, 915 treatment, precautions in, 917 Obliterative appendicitis, 806 Obstipatio alvi, 609 Obturation of intestines, 870 Obturator, rectal, 904 Occlusion of superior mesenteric artery, 764 Occult blood in achlorhydria haemor- rhagica gastrica, 272 iron test for, 161 Kliinge's aloin test for, 161 test for, 1 60 hemorrhage in gastric ulcer, 284 Odor of feces, 533 Oidium albicans in gastric contents, 167 . Olive oil, 1 88 hypodermoclysis, 192 in constipation, 617, 621 in hyperchlorhydria, 378 Omentum, greater, 19 lesser, 19 tuberosity of, 957 Opiates in acute enteritis, 650 ; Opisthorchis felineus, 930 Oral cavity, inspection, 49 Orthopedic methods in constipation, 621 treatment of stomach diseases, 225 Osseous system in typhoid fever, 702, 705 Oxyuris vermicularis, 938 diagnosis, 939 symptoms, 939 treatment, 939 PAIN from adhesions in gastric ulcer, treatment, 309 Pain in acute amebic dysentery, 679 ectasy of stomach, 410 in amebic dysentery, 678, 680, 681 in cancer of intestines, 774 of pancreas, 1045 of stomach, 328 in chronic gastric erosions, 316 intestinal obstruction, 885 pancreatitis, 1023 in gastric cancer, treatment, 362 ulcer, 284, 285 treatment, 307 in gastrosuccorrhea continua chronica, treatment, 395, 396 periodica, treatment, 389 in hyperchlorhydria, 375 in intestinal ulcer, 761 in intussusception, 869 in pancreatic calculus, 1033 diseases, 994 in simple duodenal ulcer, 736 in volvulus, 866 intestinal, 587. See also Enteralgia. Palpation, Meltzer's method in appendi- citis, 814 of abdomen, 67 of esophagus, 50 of gall-bladder, 76 of intestines, 521 of kidney, 84 of liver, 76 of recti muscles, 69 of rectum, 524 by sounds, 525 of spleen, 80 of stomach, 9, 135 of vermiform appendix, 811 Rovsing-Chase method, in appendicitis, 814 Pancreas, aberrant, 959 accessorium, 959 acini, 965 adenocystoma papilliferum of, 1036 adeaoma, 1049 amyloid degeneration of, 1050 annular, 959 anomalies, 955, 959, 960 arteries, 957 autodigestion, 971 blood-supply, 957 body, 957 bullet wounds of, 1002 cancer of, 1044. See also Cancer of pancreas. caruncula major of, 958 minor of, 958 catarrh, 1005 acute, 1005 chronic, 1006 suppurative, 1007 changes in cells of acini with active secretion, 966 connective-tissue framework, 964 cystadenoma of, 1036 cystic disease, 1036 epithelioma of, 1036 tumors of, 1036 INDEX I08 3 Pancreas cysts, 1035. See also Cysts of pancreas. degenerative changes, 1050 diabetes and, 1051 diastatic function, Fedeli and Romani's test for, 986 diseases, 955 acetonuria in, 987 alimentary glycosuria in, 988 anamnesis, 993 azotorrhea, 999 azoturia in, 987 bile in urine in, 987 blood coagulation in, 992 blood in, 991, 998 bowels in, 999 calcium oxalate in urine in, 988 carbohydrates in urine in, 988 circulation in, 999 diagnosis, 993 conditions obscuring, 973 use of enzymes in, 983 disturbance of appetite in, 998 dyspepsia in, 998 emaciation in, 998 fat necrosis in, 1000 fat-splitting ferment in urine in, 991 feces in, character, 986 reaction, 986 hemorrhage in, 998 history of case, 993 indicanuria in, 987 jaundice in, 997 lipuria in, 991 liver in, 999 Loewis test, 1047 methods of diagnosis, 972 nausea in, 996 pain in, 994 phosphaturia in, 987 physical signs, 994 pressure symptoms in, 998 rigidity in, 996 Sahli's test in, 980 Schmidt's nuclei test, 979 sodium fluorid fibrin test in, 980 steatorrhea in, 999 symptoms, 993, 996 temperature in, 998 tenderness in, 995 tumor in, 994 urinary tests in, 991 urine in, changes, 987 urobilin in urine in, 987 vomiting in, 996 of blood in, 997 divisum, 959 ducts, 958 anatomic variations, 960 histology, 964 terminations, 960 variations, 960 extirpation of, effect on fat absorption, 980 fat necrosis of, 1029 fatty degeneration of, 1050 fibro-adenoma, 1049 Pancreas, focal necrosis, 1051 frenum carunculae, 958 functional disturbances of, 1005 functions, temporary disturbances, 972 testing, 972 head, 956 hemorrhagic necrosis, 1008 histology, 964 hyaline degeneration, 1051 inflammation, acute and chronic, classi- fication, 1 002 injuries, 1001 interacinar islands, 966. See also Islands of Langerhans. internal secretion, 968 laceration due to direct violence, 1001 lesser, 956 lymphadenoma, 1049 lymphatics, 957 meat, Leube's, 191 minus, 959 neck, 956 nerves, 957 papilla major, 958 parvum, 959 penetrating wounds of, 1002 peritoneum, 958 physiology, 964, 969 plica longitudinalis, 958 pseudocysts of, 1036 sarcoma, 1048 surgical relations, 955, 961 syphilis, 1031 acquired, 1031 tail, 956, 957 topography of, 79 tuberculosis of, 1030 tumors of, 1044 uncinate process, 956 veins, 957 Pancreatic achylia, 1005 calculus, 1031. See also Calculus pan- creatic. ferments, 970 diastatic, 985 direct methods of obtaining, 973 Einhorn's pump for, 974 Gross' method, 973 in feces, obtaining, 978 indirect methods of obtaining, 978 use of, in diagnosis, 983 hemolysin, 992 hemorrhage, 1008 infantilism, 984, 1050 juice, 969 cause, 969 ferments of, 39 function of, 39 reaction, Cammidge, 988 Pancreatitis, acute, 1008 Fitz's classification, 1008 hemorrhagic, 1008. See also Hemor- rhagic pancreatitis. perforation in simple duodenal ulcer and, differentiation, 745 suppurative, 1015. See also Supptira- tive pancreatitis. 1084 INDKX Pancreatitis, chronic, 1018 age and, 1018 anamnesis, 1022 ascending infection from duodenum as cause, 1019 blood in, 1025 bowels in, 1025 calculus as cause, 1019 Cammidge reaction in, 1026 cancer of pancreas and, differentia- tion, 1047 cholecystotomy, 1028 diagnosis, differential, 1026 diet in, 1028 digestive symptoms, 1024 duodenal ulcer and, differentiation, 75i etiology, 1019 feces in, 1026 gall-bladder in, 1025 gall-stones and, differentiation, 1027 gastric analysis in, 1026 infectious diseases as cause, 1019 interacinar, 1021 interlobular, 1020 etiology, 1020 jaundice, 1024 liver in, 1025 malignant growths as cause, 1019 medicinal treatment, 1028 muscular rigidity in, 1025 nausea in, 1023 pain in, 1023 pathology, 1020 physical examination, in, 1025 sex and, 1018 simulating gastric or duodenal ulcer with pyloric stenosis, 1022 surgical treatment, 1028 symptoms, 1022 syphilis and, differentiation, 1027 temperature, 1024 tenderness in, 1025 treatment, 1028 vomiting in, 1023 congenital syphilitic, 1031 etiology, 1003 gangrenous, acute, 1012. See also Gangrenous pancreatitis. mumps complicating, 1004 subacute, 1013 Papilla major of pancreas, 958 Papilloma of intestines, 780 Paralysis of esophagus, syphilitic, 62 of intestines, 901 of sphincters, 902 Paramoecium coli, 921 Parasecretion, 386. See also Gastrosuc- corrhea. Parasites in vomit, 157 intestinal, 920 Parasitic ova, examination of feces for, 542 Paratyphlitis, 801 Paratyphoid bacillus, 706 fever, 718 complications, 720 Paratyphoid fever, course, 720 diagnosis, 720 etiology, 718 incubation period, 719 mode of infection, 719 pathology, 719 prognosis, 720 treatment, 720 Parenteral digestion, 42 nutrition, 192 Paresis, intestinal, 871 Parorexia, 472 Passio iliaca, 859 Patient, examination of, 49 history of, 46 interrogation of, 46 special, in diseases of intestines, 515 Peanut butter, 187 Pea sausage, 187 Pea-soup feces in typhoid, 704 Pellagra, stomach functions in, 503 Pelvic abscess, 798 exudate from colon bacillus infection, 600 Pemphigus of mouth, stomach functions in, 57 Pendulum movements of large intestine, 44 Penetrating wounds of pancreas, 1002 Penicillium glaucum in gastric contents, 167 Pengoldt and Fabers test for absorptive power of stomach, 168 Pepsin, casein test for, 152 in gastric contents, 150 Mett's test for, 152 ricin test for, 150 Pepsinia, normal, 151 Pepsi nogen, 34 Peptic ulcer, 277. See also Ulcer of stomach. Peptone in feces, 535 in gastric contents, 150 Percussion, flicking, 72 hammer, 71 light, 71 of abdomen, 70 of gall-bladder, 77 of kidney, 87 of liver, 77 of spleen, 81 of stomach, 91, 135 auscultatory, 92 scratch method,, 94, 95 piano, 71 simple method, 71 Percutaneous method of applying electric- ity in stomach diseases, 216 Perforation in diverticulitis, 852 in intestinal ulcer, 761 in simple duodenal ulcer, 742. See also Ulcer, duodenal, simple, perfora- tion in. in typhoid fever, 702 treatment, 715 of esophagus, 61 of hernial sac in diverticulitis, 853 INDEX I08 5 Perforative appendicitis, 808 Pericolic membranes, 639 Peri colitis, 637 Peridiverticulitis, 839. See also Diver- ticulitis. Perigastric adhesions, perigastritis with, 319 Rontgen rays in determination of, 1 29 indirect method, 132 Perigastritis, gastralgia and, differentia- tion, 478 with adhesions, 318 diagnosis, 319 treatment, 319 Perisigmoiditis, 839. See also Diverticu- lilis. Peristalsis, diagnostic value of, 67 intestinal, 43 nervous control, 45 visible, 67 Peristaltic restlessness of stomach, 480 unrest, 900 diagnostic value, 67 Peristole, diminished, 398. See also A tony of stomach. Peritoneal coat of stomach, 19 Peritoneum, growths of, gastric cancer and, differentiation, 350 of pancreas, 958 Peritonitis, acute, intestinal obstruction and, differentiation, 878 adhesive, in amebic dysentery, 682 epigastric, in hemorrhagic pancreatitis, 1013 in typhoid fever, treatment, 715 local chronic, from diverticulitis, 853 perforative, diverticulitis and, differen- tiation, 855 in diverticulitis, 852 Perityphlitis, 801 Perversion of appetite, 472 Petroleum, absorption of, 43 Peyer's patches, 27 Phantom tumor, 73, 585 Pharynx, inspection of, 50 Phenolphthalein test for occult hemor- rhage, 160 Phlebectasia hemorrhoidalis, 782 Phlegmon, ileac, 801 Phlegmonous enteritis, 665 gastritis, 246. See also Gastritis, phleg- monous. Phloroglucin-vanillin test for free hydro- chloric acid, 144 Phosphaturia in pancreatic disease, 987 Phosphorus poisoning, antidotes for, 245 Phthisis ventriculi, 249, 250, 262. See also Achylia gastrica. Physical examination, general methods, 49 Phytin of whole wheat, properties, 178 Piano percussion, 71 Pica, 472 Pig-head tapeworm, 927 Piles, 782. See also Hemorrhoids. Pine-apple, food value of, 178 Pin-worm, 938 Plexus, Auerbach's, 24 Meissner's, 24 Plica longitudinalis of pancreas, 958 Plu miner's differential * diagnosis of esophageal stenosis and diverticu- lum, 52 Pneumatosis, 485, 495 cystoides intestinorum hominis, 781 Pneumonia, acute atony of stomach in, 407 Podophyllin in constipation, 622 Poisons, antidotes for, 245 Polyadenoma of stomach, 305. See also Stomach, polyadenoma. Polyadenome en Nappe, 366 Polyphagia, 472 Polyposis gastrica, 365. See also Stom- ach, polyadenoma. intestinalis adenomatosa, 780 Pork tapeworm, 925 Portal vein, thrombosis, 763, 766 Postoperative feeding, 195 Powder-blower, stomach, 214 Pressure paradox in chronic dilatation of duodenum, 636 Priessnitz's compress, 224 Probilin pills, 241 Proctitis, 663 classification, 663 digital examination in, 664 etiology, 663 in hemorrhoids, 797 pathology, 663 symptoms, 663 treatment, 664 Proctoclysis, 553, 563 bottle, heat-retaining, 563 flatus in, 564 in typhoid fever, 714 speed of, 565 vacuum bottle for, 563 Proctoscope, Kelly's, 518 Tuttle's pneumatic, 518 Proctoscopy, 517 Proctosigmoidoscope, Tuttle's pneu- matic, 521 Proctospasmus, 612 Prolapse of rectum in hemorrhoids, 793 treatment, 795 of stomach, 89. See also Gastroptosis. Propeptone in feces, 535 in gastric contents, 150 Prosecretin, 40, 969 Protective appendicitis, 808, 809, 824 Protein absorption, 573 in beans, 187 diet, 175 metabolism, 175 Protozoa, 920 Protrusion of umbilicus, diagnostic value, 67 Pruritus ani, 799 Pseudo-angina with acute ectasy of stomach, 406 Pseudocysts of pancreas, 1036 Pseudomembranous enteritis, 905 Psoriasis, stomach functions in, 507 io86 INDEX Psorospermiasis, 920 Ptyalin, 33 Pulse in typhoid fever, 703 Purulent appendicitis, 805, 807 enteritis, 665 Pus in feces, 533, 541 in intestinal cancer, 775 ulcer, 761 gastric cancer, 338 in vomit, 157 microscopic, in hyperchlorhydria, 376 Putrefaction, intestinal chronic, 573 combined indolic and saccharobuty- ric, 578 saccharobutyric type, 578 Putrefactive products in feces, tests for, 550 Pyelitis, Bacillus coli infections of kid- neys in, 598 Pyemia after typhoid fever, 705 Pyloric glands of stomach, 20 Pylorospasmus, 482 Einhorn's pyloric dilator for, 484 Rontgen rays in, 484 symptoms, 483 treatment, 484 surgical, 484 Pylorus, 17 congenital narrowing, 437 incontinence of, 481 insufficiency, 481 snail-form, in gastric ulcer, 290 spasm, 482 stenosis of, laparotomy in, 351 syphilitic, 509 gastric cancer and, differentiation, 346 Pyrosis, 489 in simple acute gastritis, treatment, 239 RADIODIAPHANE, 134 Radium introducer, 357 photographs of stomach, 135 transillumination of stomach, 134 treatment of gastric cancer, 357 Ranula pancreatica, 1035 Raspberry tongue, 50 Rectal alimentation, 191 examination, digital, 69 infusion, 565 irrigator, Kemp's, 557 obturator, 904 Recti muscles, palpation of, 69 Rectum, 31 abscess of, 797 superficial, 797 anesthesia of, 903 arterial supply, 31 cancer of, 776 examination, in appendicitis, 815 in chronic enteritis, 653, 658 inspection, 517 lymphatics, 32 nerves, 32 palpation, 524 by sounds, 525 prolapse, in hemorrhoids, 793 Rectum, prolapse, treatment, 795 veins, 31 Recurrent vomiting in children, 492 Reduction in obesity, diet for, 916 Reflex vomiting, 494 Reflexes in typhoid fever, 703 Regulin in constipation, 621 Regurgitation, duodenal, from fatty food, 482 of food, 489 Reichmann's disease, 386, 391. See also Gastrosuccorrhea. method of examining contents of fasting stomach, 157 rod, 94 Renal calculi, gastralgia and, differentia- tion, 478 insufficiency in typhoid fever, treat- ment, 717 Rennet, 152 absence of, 152 deficient, 152 normal, 152 Rennet-zymogen, 34, 153 Resorcin-sugar test for free hydrochloric acid, 144 Respiratory organs in typhoid fever, 702 Retention cysts of pancreas, 1035 Rhabdonema intestinale, 948 Rheumatism, gastralgia and, differentia- tion, 477 Rhubarb in constipation, 622 Ricin test for pepsin, 151 Riegel's test-dinner, 136 test for free hydrochloric acid, 154 Rigidity in pancreatic diseases, 996 muscular in chronic pancreatitis, 1025 Ringing sounds of stomach, 99 Roberts' rectal speculum, glass, 518 sphincter dilator, 791 Robson and Cammidge's test for fat in feces, 982 classification of acute and chronic in- flammation of pancreas, 1002 Rod, Reichmann's, 94 Rogers' red dots in amebic dysentery, 670, 672 Roller massage, 223, 224 Rontgeno-cinematographic method of di- agnosis, 113 Rontgen-ray diagnosis of cancer of stom- ach, 125 of chronic appendicitis, 825 findings in duodenal ulcer, 118-124 for detecting foreign bodies in stomach, 113 of gastric ulcer, 289 of hour-glass stomach, 123 in gastric ulcer, 114-118 for determining gall-stones, 132 gastroptosis, 124, 126 hyperistalsis, 126 perigastric adhesions, 129 indirect method, 132 position of stomach, 123 for enteroptosis, 124 in chronic intestinal obstruction, 886 INDEX 1087 Rontgen-ray in determining diseases of stomach, 135 in diagnosis of cancer of stomach, filling defects in, 126 of cholecystitis, 132 of diseases of esophagus, 113, 114 of stomach, 113 technic, 114 of diverticulitis, 855 of gastric cancer, 342 of intestinal cancer, 777 of pancreatic calculi, 1032 of stomach diseases, 135 in diaphragmatic hernia, 440 in examination of esophagus, 56 of intestines, 528 in gastric syphilis, 510 ulcer, 289 in gastroptosis, 461 in hour-glass stomach, 438 in Jackson's membrane, 638 in jejunal ulcer, 313 in pylorospasmus, 484 in simple duodenal ulcer, 736 in stenotic ectasy of stomach, 424 in treatment of gastric cancer, 356 ulcer, 309 location of colon with, 529 physiologic investigations with, 529 Rosenthal-Leube's method of lavage, 205 Roser position for esophagoscopy, 101, 102 Rose's adhesive plaster belt, 226-229 in atonic ectasy of stomach, 428 in gastroptosis, 461, 462 method of making, 228-230 carbonic acid gas generator, 530 Rosewater adhesive belt, 230, 234 Rotation method of intestinal irrigation, 5 69 Round worm, 935 Rovsing-Chase method of palpation in appendicitis, 814 Rumination, 490 Russell's treatment of gastroptosis, 405 SACCHAROBUTYRIC type of intestinal putre- faction, 578 indolic type with, 578 Sago grains in chronic enteritis, 654 Sahli's desmoid test of gastric juice, 155 test in diseases of pancreas, 980 Salol test of motor power of stomach, 1 70 Salomen's test in cancer of stomach, 341 Sand, intestinal, 593 Santorini, duct of, 958 Sapremia, intestinal, 613 Sarcinse in gastric contents, 166 Sarcoma of intestines, 778 of pancreas, 1048 of stomach, 363 average duration, 364 gastric analysis in, 364 symptoms, 364 treatment, 364 Scale, diet, 185, 186 Leube's diet, 186 Schistosoma haematobium, 931 Schmidt-Stokes milk-tube, 982 Schmidt-Strassburger fermentation test of feces, 549 test-diet to determine intestinal func- tions, 544 Schmidt's test for nuclei, 979 treatment of gastric ulcer, 304 Sclerosis of stomach, gastric cancer and, differentiation, 345 ventriculi, 249, 250 Scolecoiditis, 801 Seat-worm, 938 Secretin, 969 Secretogogues, 35 Secretory neuroses of intestines, 905 Senator's treatment in gastric ulcer, 304 Senile dyspepsia, 590. See also Dyspepsia, senile. Sensations within stomach, 473 Septicemia after typhoid fever, 705 Serous coat of small intestine, 24 Serum therapy in bacillary dysentery, 699 Sham feeding, effect on secretion of gastric juice, 35 Sialorrhcea pancreatica, 999 Siever and Ewald's salol test of motor power of stomach, 170 Sigmoid flexure, 31 dilated, 641 diverticula of intestines and, 848 volvulus of, 865 Sigmoiditis, 839. See also Diverticulitis. diverticulitis and, differentiation, 855 Sigmoidoscope, Strauss', 519, 522 Tuttle's, 519 Sigmoidoscopy, 517, 519, 522 Silica metabolism in gastric cancer, 341" Silver nitrate poisoning, antidotes for, 245 Sims' rectal speculum, 519 Singultus gastricus nervosus, 488 Sippy's treatment of gastric ulcer, 304 Sitophobia, 475 Siturgy, 473 Sizzling sounds in stomach, 97, 99 Skatol in feces, test for, 550 Skin diseases, stomach functions in, 506 Smithies' percussion sign in gastric cancer, 33i Smoking in chronic gastritis, 257 Sodium benzoate in duodenitis with jaun- dice, 651 fluorid fibrin test in diseases of pancreas, 980 iodid in gastric cancer, 358 Solitary follicles of small intestine, 27 Solms-Jacoby test for pepsin, 151 Sounds, esophageal, use of, 55 splashing, in esophagus, 51 Soy bean, 179 flour, 179 broths, 1 80 gruels, 1 80 muffins, 180 Spasm of cardia, 485 of pylorus, 482 of sphincter ani, 612 treatment, 624 io88 INDEX * Spastic constipation, 612 hour-glass stomach, 439 Spectroscopic blood-examination, clinical, technic, 584 Speculum, Kelly's sigmoid, 518 rectal, Gant's examining, 520 hinged, 520 Kelly's short, 517 standard, 517 Kelsey's, 519 Roberts' glass, 518 Sims', 519 Sphincter ani dilatation for hemorrhoids, 791 internal, 31 paralysis, 903 spasm, 612 treatment, 624 antri, 37 Spider gall-bladder adhesions, gastric ulcer and, differentiation, 294 Spilling, 69 liver, 76 spleen, 80 Splanchnoptosis, 422. See also Gastrop- tosis. Splashing sounds in acute ectasy of stom- ach, 410 in esophagus, 51 in gastroptosis, 449 in hyperchlorhydria, 373 in intestinal diseases, 523 of stomach, 98, 135. Spleen, abscess in, in amebic dysentery, 677 acute enlargement, 82 dulness, 82 floating, 82 in typhoid fever, 707 inspection of, 80 movable, 460 palpation, 80 percussion of, 81 physical examination, 80 spilling, 80 topography of, 80 Splenic flexure of transverse colon, 30 Sponging in typhoid fever, 712 Spool worm, 935 Sporozoa, 920 Spray, gastric, 214. See also Stomach spray. Sprue after amebic dysentery, 683 Starch, digested, examination of, 153 in feces, 535 Stasis, chronic intestinal, 630 etiology, 631 treatment, 633 Static electricity in stomach diseases, 219 Steapsin, 39, 970 examination for, 976, 977 in gastric contents, 158 Steatorrhea, 537, 981 color of feces in, 983 in pancreatic diseases, 999 Steele's diet to test intestinal functions, 544 Stenosis, duodenal, with motor disturb- ances and dilatation of stomach, treatment, 754 of cardia, treatment, 363 of esophagus, diverticulum of esophagus and, differentiation, 52 of pylorus, gastralgia and, differentia- tion, 477 laparotomy in, 351 syphilitic, 509 gastric cancer and, differentiation, 346 of stomach, gastric cancer and, differ- entiation, 348 Stenotic ectasia of stomach, 419 Stercobilin in feces, 536 Stercoral ulcer of intestines, 758 Stereoradiography in diseases of stomach, 114 Stewart's method of continuous intestinal irrigation, 559 Stomach, abnormal sensations in, 474 abscess of, 246. See also Gastritis, phlegmonous. absorptive function, determination, 168 acute diseases of, diet in, 192 adenocarcinoma of, 324 anatomy, 17 anomalies in position and form, 437 antiperistaltic restlessness of, 481 arteries, 20 atony, 398, 485. [See also Atony of stomach. atrophy of, 250, 262. See also Achylia gastrica. auscultatory percussion of, 92 stratch method, 94, 95 bacteria in, 34 blood-vessels, 20 bubbling sounds in, 97 cancer of, 320. See also Cancer of stomach. capacity, 19 cardiac glands, 20 orifice, 17 catarrh of, 236. See also Gastritis. chronic diseases of, diet in, 193 cirrhosis, syphilitic, 511 coats, 19 contents, analysis, in chronic pancre- atitis, 1026 in senile dyspepsia, 590 in simple duodenal ulcer, 739 cul-de-sac of, greater, 17 deglutition sounds of, 99 determining lower margin of, 97 position of, DeMo's method, 135 digestion, fractional study, by inter- mittent aspiration, 137 dilatation, 401. See also Ectasy of stomach. diseases, 89 cold applications in, 224 counterirritation in, 225 douche in, 225 electricity in, 216. See also Elec- tricity in stomach diseases. INDEX 1089 Stomach diseases, hot applications in, 224 hydrotherapy in, 224 moist heat in, 224 orthopedic treatment, 225 Rontgen rays in diagnosis of, 135 dislocation, 439 douche, 211 alternate hot and cold, 213 bulb-compression method, 212 double-current, 212 Gross' double current, 212 in atonic ectasy of stomach, 429 medication by, 212 technic, 212 temperature of fluid, 212 Y-method, 212 drain-trap, 37 dripping sounds, 99 ectasy, 401. See also Ectasy of stom- ach. electrode, Bassler's 218 epithelioma of, 324 erosions, 315 esophageal orifice, 17 examination, Knapp's method, 90 preparation of patient, 90 fasting, examination of contents, 157 Reichmann's method of examining contents, 157 fish-hook, 37, 120, 121, 455 fore-, 437 foreign bodies in, 367 Rontgen rays for detecting, 113 functional diseases, 370 functions, examination, 136 eye diseases in, 506 heart lesions in, 504 in acne rosacea, 506 in acne simplex, 506 in acute febrile diseases, 501 in anemia, 503 in aneurysm, 504 in arteriosclerosis, 506 in arthritis deformans, 505 in chlorosis, 503 in chronic febrile diseases, 502 in diabetes, 505 in ear diseases, 506 in eczema, 506 in erythema, 507 in gout, 505 in grip, 505 in kidney diseases, 504 in liver diseases, 504 in malaria, 505 in nose diseases, 506 in pellagra, 503 in pemphigus of mouth, 507 in psoriasis, 507 in pulmonary tuberculosis, 502 in skin diseases, 506 in throat diseases, 506 in urticaria, 507 motor, 36, 169 Ewald and Siever's test, 170 Hemmeter-Moritz test, 171 iodipin test for, 171 69 Stomach functions, motor, Klemperer's oil test for, 171 Mathieu-Rmond test, 170 salol test of, 170 test-breakfast for, 169 test-meal for, 169 test-supper for, 169 tests for, 169 sensation, 136 fundus, 17 glands, 20 gastralgia originating in, 476 gastric insufficiency, 399 glands, 20 greater curvature, 18, 89 gurgling sound of, 99 Head's zones for, 830 hemorrhage, 250. See also Hemorrltage of stomach. hour-glass, 437. See also Hour-glass stomach. in gastric ulcer, 118 Rontgen rays for determining, 1 23 hyperesthesia of, 474 hypermotility of, 479 inflammation of, suppurative, 246. See also Gastritis, phlegmonous. inflation of, 135 with air, 96 with water, 96 with carbonic acid gas, 95 inspection of, 90, 135 lavage, 196. See also Lavage. lesser curvature, 18 lymphatics, 21 massage, 221. See also Massage. methods of physical examination, 89 motility, 37 motor insufficiency, 399 of first degree, 399 of second degree, 414 mucous coat, 20 glands, 20 multiple polypi of, undergoing malignant changes, 363 muscular coat, 19 nerves, 22 nervous affections, 469 neuralgia of, 475 neuroses, 469. See also Neuroses of stomach. secretory, 495 normal capacity, 415 palpation of, 91, 135 percussion of, 91, 135 peristaltic action of, 169 restlessness of, 480 peritoneal coat, 19 polyadenoma, 365 age in, 365 diagnosis, 366 etiology, 365 location, 366 pathology, 365 symptoms, 366 treatment, 366 position, 17 IOQO INDEX Stomach position, determining, 94-98 Dehio's method, 96 Leube's sound method, 97 Rontgen rays for, 123 powder-blower, 214 Einhorn's, 215 prolapse, 89. See also Gastroptosis. pulsation in, 474 pylpric glands, 20 radium photographs of, 135 transillumination of, 134 resonance, dorsal nucleus of, 92 ringing sounds of, 99 Rontgen rays in diagnosis of diseases of, "3 sarcoma of, 363. See also Sarcoma of stomach. secretion, examination of, 136 sensations within, 473 shape, 37 sizzling sounds in, 97, 99 snail form, 116 sparing, method of feeding for, 189 spasm, 475 intestinal splash and, differentiation, 98 splashing sounds of, 98, 135 spray, 214 Einhorn's tube for, 214 in atonic ectasy of stomach, 429 gastrosuccorrhea continua chronica, . 396 indications for, 208 technic, 214- stenosis, gastric cancer and, differentia- tion, 348 stiff enings of Cohnheim, 67 stricture, diet in, 193 structure, 19 submucous coat, 20 succussion sound of, 99 supermotility, 479 syphilis, 508 Rontgen rays in, 510 transillumination, 109 treatment, local, 196 tuberculosis, anatomic types, 507 tumors, 363 apparent, 344, 366 benign, 365 differential diagnosis, 94 syphilitic, 509 ulcer, 277. See also Ulcer of stomach. deformity of contour in, 117 hour-glass contraction in, 118 ulceration of, superficial, 314 undershot, 116 veins, 21 vertical, 451 volume, 18 volvulus of, 441 water-trap, 37, 456, 457 weak, 236 Stomachics in chronic gastritis, 259 Stomach-tube for lavage, selection, 197 Stomach- whistle, Kemp's, 97 Stools. See Feces, Stozyzowski's modification of Teichmann's test for hemin crystals, 162 Strangulation by herniae, internal, 860, 86 1 by Meckel's diverticulum, 86 1 clinical symptoms, 864 herniaform internal, mechanism, 863 through apertures, 86 1 through slits, 86 1 Strassburger's fermentation tube, 549 Strauss' mixing funnel, 149 sigmoidoscope, 519, 522 Strawberry tongue, 50 Streptothrix Foersteri in gastric contents, 167 Strictureof duodenum, duodenal ulcer and, differentiation, 749 of esophagus, 62 benign, examination, 54 thiosinamin in, 59 treatment, 59 malignant, examination, 55 of rectum, chronic intestinal obstruc- tion from, 888 of stomach, diet in, 193 Strongyloides intestinalis, 948 Strongylus duodenalis, 940 Subacute pancreatitis, 1013 Subinfection, 571 Sublimate test for bile-pigment in feces, 549 Submucous coat of small intestine, 25 of stomach, 20 Subphrenic abscess from co on bacillus infection, 602 terminations of, 288 Succus entericus, 40 Succussion sound in intestinal diseases, 523 sound of stomach, 99 Sugar, absorption of, 42 in feces, 535 milk-, absorption of, 42 Superacidity, 370 Supermotility of stomach, 479 Supporter, Lane's abdominal, 235 Suppurative appendicitis, 805 acute, 807 diagnosis, 1017 etiology, 1016 pathology, 1015 sequelae, 1016 symptoms, 1016 treatment, 1017 Suprahepatic ballottement, 78 Sutton's method of intestinal inflation, . 53i Sweet oil injection in constipation, 620 Sympatheticotonia, 892 etiology, 893 symptoms, 896 treatment, 896 Syncongestive appendicitis, 809 Syphilis, chronic pancreatitis and, differ- entiation, 1027 gastric cancer and, differentiation, 345 of pancreas, 1031 acquired, 1031 INDEX 1091 Syphilis of stomach, 508 Rontgen rays in, 510 Syphilitic cirrhosis of stomach, 511 pancreatitis, congenital, 1031 paralysis of esophagus, 62 stenosis of pylorus, 509 tumor of stomach, 509 ulcers of intestines, 759 of stomach, 509 TABES, gastralgia and, differentiation, 477 gastric crises of, 512 Taenia cucumerina, 928 echinococcus, 928 elliptica, 928 flavopunctata, 928 lata, 927 Madagascariensis, 928 mediocanellata, 924 nana, 928 saginata, 926 solium, 924, 925 Tamarinds in constipation, 622 Tapotement in massage, 221 Tapeworm, 924 armed, 925 beef, 926 description, 925 pig-head, 927 pork, 925 treatment, 929 unarmed, 926 Tapping in massage, 221 Tartar emetic poisoning, antidotes for, 245 Tea in test- meal, 138 Teichmann's test for hemin crystals, 162 Stozyzowski's modification, 162 Temperature in acute appendicitis, 815 in chronic pancreatitis, 1024 in gastric cancer, 332 in pancreatic diseases, 998 in typhoid fever, 703, 712 Tenderness in chronic pancreatitis, 1025 in pancreatic diseases, 995 Tenesmus in acute amebic dysentery, 679 in amebic dysentery, 680 carbonic acid gas for, 691 in bacillary dysentery, treatment, 698 in hemorrhoids, 785 Test-breakfast, Boas', 137 Ewald and Boas', 137 for motor power, 169 in gastric cancer, 336 in stenotic ectasy of stomach, 424 Test-diet, examination of feces after, 545- 5Si Test-dinner, Riegel's, 136 Test-meal, 136 dry, 137 Ewald's, 136 Germain SeVs, 137 Klemperer's, 137 Leube's, for motor power, 169 making diagnosis from, 138 precautions before, 138 tea in, 138 Test-supper for motor power, 169 Tetany, acute ectasy of stomach in, 406 gastrosuccorrhea continua chronica and, differentiation, 394 in ectasy of stomach, 433 Chvostek's symptom, 434 diagnosis, 434 Erb's sign in, 434 etiology, 433 frequency, 434 Hoffmann's sign in, 434 pathology, 433 prognosis, 434 symptoms, 434 treatment, 434 Trousseau's symptom, 433 in gastric cancer, 332 tetany, Erb's sign in, 434 in simple duodenal ulcer, 741 Thimble gag for esophagoscopy, 102 Thiosinamin in benign stricture of eso- phagus, 59 in gastric cancer, 358 Thirst in gastric ulcer, treatment 287 in gastrosuccorrhea continua periodica, treatment, 390 Thoracic disease, acute, perforation in simple duodenal ulcer and, diff- erentiation, 741 Thread-worm, 938 Throat diseases, stomach functions in, 506 Thrombosis in cancer of stomach, 332 in typhoid fever, 705 of inferior mesenteric artery, 756 of mesenteric arteries, 763 clinical symptoms, 756 diagnosis, 756 etiology, 763 prognosis, 756 veins, 763 etiology, 763 treatment, 766 Thrombotic intestinal ulcers, 755 Thymol in uncinariasis, 947 Thymus extract in gastric cancer, 361 Thyroid extract in gastric cancer, 361 Tongue, inspection of, 49 raspberry, 50 strawberry, 50 Tonsils, inspection of, 50 Topfer's test for combined hydrochloric acid, 146 for free hydrochloric acid, 145, 146 for total hydrochloric acid, 146 Tormina intestinorum, 900 ventriculi nervosa, 480 Toxic gastritis, 243. See also Gastritis, toxic. ulcers of intestines, 759 Transillumination in gastric cancer, 332 of intestines, 528 of stomach, 109 radium, 134 Traube's space, 19 Trematodes, 930 Tremoliere's solution for hemorrhage in amebic dysentery, 691 in gastric cancer, 362 IOQ2 INDEX Trichina spiralis, 950 in cerebrospinal fluid, 951 in muscle, 950 toxins from, 952 Trichinella spiralis in blood, 951 Trichiniasis, 950 differential diagnosis, 953 incidence, 950 prognosis, 953 prophylaxis, 953 symptoms, 952 treatment, 953 Trichocephalus dispar, 949 Trichomonas hominis in gastric contents, 164 intestinalis, 921 Triphase method of applying electricity in stomach diseases, 219 Tropaolin oo test for free hydrochloric acid, 153 Trousseau's symptom in gastric tetany, 434 Trypsin, 39, 970 examination for, 977 978 Muller's serum plate method, 979 in feces, test for, 537 in gastric contents, 158 treatment of gastric cancer, 359 Tryptophan test in gastric cancer, 338 Tubercle bacilli in feces in intestinal ulcer, 761 Tubercular ulcers of intestines, secondary, 757 Tuberculosis, ileocecal, Head's zones in, .833 intestinal, 757 of pancreas, 1030 of stomach, anatomic types, 507 pulmonary, stomach functions in, 502 Tuberculous diaphragmatic pleurisy, gas- tric ulcer and, differentiation, 294 Tubular diarrhea, 905 Tumors, fecal, 614 fragments in feces, 541 in intussusception, 869 left-sided, in diverticulitis, 854 of intestines, 767 benign, 779 of pancreas, 1036, 1044 of stomach, 363. See also Stomach, tumors of. phantom, 73, 585 Tiirck's colonic nebulizer, 565, 566 double-current needle douche for sig- moid, 565 gyromele, 219, 220 Tuttle's pneumatic proctosigmoidoscope, S2i sigmoidoscope, 519 Tympanites, 584 etiology, 584 in typhoid fever, treatment, 714 flank, 874 hystericus, 585 in chronic intestinal obstruction, 886 nervous, 585 prognosis, 586 Tympanites, symptoms, 585 treatment, 586 Typhlitis, 801 Typhoid fever, 700 acute ectasy of stomach in alcohol in, 716 autogenous vaccines in, 718 bacilluria in, treatment, 717 Bacillus coli infections of kidneys in, .598 bacillus typhosus as cause, 700 baths in, 712 bladder in, 702 blood in, 705 bone-marrow in, 702 bowels in, 712 Brand treatment, 712 carriers, 708, 717 chart, 703 chronic distribution, 708 circulatory changes in, 702 colitis in, treatment, 717 convalescence, 717 diagnosis, 705 diarrhea in, treatment, 715 diet in, 708 disinfection in, 708 Ehrlich's diazo-reaction in, 705 etiology, 700 from infected oysters, 707 gall-bladder in, 702 gelatin in, 710 headache in, treatment, 717 healing of intestines in, 702 heart stimulants in, 715 hemorrhage in, death from, 702 treatment, 715 history, 700 hypoleukocytosis in, 705 immunity to, 700 insomnia in, treatment, 717 intestinal hyperplasia in, 701 intestines in, 701 irrigation in, 710 kidneys in, 702 leukopenia in, 705 liver in, 702 mesenteric glands in, 702 milk in 709, 712 modes of conveyance, 701 modes of onset, 704 morbid anatomy, 701 mortality in, 706 necrosis in, 702 nervous symptoms in, 703 treatment, 717 neuritis in, 705 osseous system in, 702, 705 pea-soup feces in, 704 perforation in, 702 symptoms, 705 J treatment, 715 peritonitis in, treatment, 715 precautions in, 708 proctoclysis in, 714 prognosis, 706 prophylaxis, 706 INDEX 1093 Typhoid fever, pulse in, 703 pyemia after, 705 reflexes in, 703 renal insufficiency in, treatment, 717 respiratory organs in, 702 septicemia after, 705 spleen in, 702 sponging in, 712 symptoms, 703 temperature in, 703, 712 thrombosis in, 705 treatment, 708 medicinal, 713 tympanites in, treatment, 714 ulceration in, 702 vaccination against, 707 vaccine therapy in, 713 voluntary muscles in, 703 Widal's reaction in, 706 Typhus, mild endemic, 720 complications, 721 diagnosis, 721 etiology, 721 history, 720 incubation period, 721 method of transmission, 721 prognosis, 723 symptoms, 721 treatment, 723 UFFELMANN'S test for lactic acid, 148 modified, 148 Ulcer, cancerous, of intestines, 757 catarrhal, of intestine, 758 classic or undermined in amebic dysen- tery, 672 decubital, of intestines, 758 duodenal, 724 acute, 735 chronic, 725, 735 gastric ulcer and, differentiation, 294 perforating, 725 Rontgen-ray findings in, 118-124 round, 725 simple, 725 achlorhydria hsemorrhagica gas- trica and, differentiations, 751 acid gastritis and, differentiation, 7Si age and, 727 Band's disease and, differentiation, 752 blood examination in, 739 bowels in, 739 cardiospasm in, 741 characteristics, 728 cholelithiasis and, differentiation, 7Si chronic appendicitis and, differen- tiation, 750 pancreatitis and, differentiation, 75i perforation in, treatment, 754 clinical aspects, 734 collapse in, treatment, 753 complications, 732 contact, 732 Ulcer, duodenal, simple, diagnosis, 750 differential, 748 diet in, 753 etiology, 725 frequency, 726 gastric ulcer and, differentiation, 750 hemorrhage, 740 Kemp's treatment, 752 treatment, 752 hyperchlorhydria and, differentia- tion, 750 hyperchlorhydria in, treatment, 753 jaundice in, 741 kissing, 732 medical treatment, 753 number, 732 pain in, 736 pathology, 728 perforation in, 742 acute pancreatitis and, differ- entiation, 745 perforation of gall-bladder and, differentiation, 745 thoracic disease and, differen- tiation, 746 chronic, 747 perforation in gastric ulcer and, differentiation, 744 subacute, 747. symptoms, 743 treatment, 746 prognosis, 752 recurrences, 732 Rontgen rays in, 736 sex and, 728 site, 731 stomach contents in, 739 dilatation in, 741 stricture of duodenum and, differ- entiation, 749 surgical treatment, 753 symptoms, 735, 736 tetany in, 741 treatment, 752 ulceration of gall-stone into duo- denum and, differentiation, 751 embolic, of intestines, 755 follicular, of intestines, 758 gonorrheal, of intestines, 759 jejunal, 313 etiology, 313 symptoms, 313 treatment, 314 z-rays in, 313 of esophagus, 61 diagnosis,'6i etiology, 61 symptoms, 61 treatment, 62 of intestines, 724 blood in, 761 feces in, 761 cancerous, 757 catarrhal, 758 decubital, 758 diarrhea in, 760 embolic, 755 1094 INDEX Ulcer of intestines, fever in, 761 follicular, 758 from cutaneous burns, 754 general nutrition in, 761 gonorrheal, 759 mucus in feces in, 761 pain in, 761 perforation in, 761 pus in feces in, 761 stercoral, 758 symptoms, 760 syphilitic, 759 thrombotic, 755 tissue threads in feces in, 761 toxic, 759 treatment, 762 tubercle bacilli in feces in, 761 tubercular, secondary, 757 of stomach, 277 age in etiology, 278 anemia in etiology, 279 treatment, 303 blood in, 286 bowels in, care, 307 cancer and, differentiation, 348 engrafted on, 347 changes in shape of stomach, 326 chlorosis in etiology, 279 chronic gastritis and, differentiation 353 cirrhosis of liver and, differentiation, 294 collapse in, treatment, 298 complications, 286 conditions simulating, 290 course, 295 diagnosis, 288, 291, 293 Bonninger's method, 289 x-ray, 289 diet in, 193, 302 Dieulafoy's, 314 duodenal feeding in, 301 ulcer and, differentiation, 294, 750 Einhorn's treatment, 301 etiology, 277, 278 Ewald's treatment, 301 excision, 312 extent, 282 frequency, 278 gastralgia and, differentiation, 477 gastric contents in, 285 gastrojejunal ulcer following, treat- ment, 312 gastrosuccorhea continua chronica and, differentiation, 393 gelatin treatment, 306 geographic distribution, 277 hemorrhage in, 284 serum treatment, 297 treatment, 296, 306 operative, 309 Hort's theory of, 279 hyperchlorhydria and, 281, 283, 286 differentiation, 376 hypersecretion in, treatment, 309 in acute infectious diseases, 759 in constitutional diseases, 759 Ulcer of stomach, in etiology of cancer, 322 jejunal ulcer after, treatment. 3 1 2 Kemp's diet table, 305 treatment, 298 lavage in, 297 Lenhartz's treatment, 301 Leube-Ziemssen rest-cure in, 300 location, 282, 294 microscopic anatomy, 281 morbid anatomy, 281 motor function in, 285 nervous dyspepsia and, differentia- tion, 497 number, 282 occult hemorrhage in, 284 occupation in etiology, 278 pain in, 284, 285, 289 from adhesions in, treatment, 309 treatment, 307 perforation in, 287 treatment, 309 simple duodenal ulcer and, differen- tiation, 744 physical signs in, 288 with little air present, 288 with much air present, 288 postmortem distribution, 277 precancerous stage, operation in, 352- prognosis, 295 progress, 283 pyloric obstruction, surgical treat- ment, 312 Rontgen ray findings in, 114-118 Senator's treatment, 304 sex in etiology, 278 shallow, bismuth or barium patch on, 116 Sippy's treatment, 304 snail-form pylorus in, 290 spider gall-bladder adhesions and, differentiation, 294 stenosis with dilatation in, treatment, 308 surgical treatment, 309 symptoms, 283 syphilitic, 509 thirst in, treatment, 297 traumatism in etiology, 278 treatment, 296 tuberculous diaphragmatic pleurisy and, differentiation, 294 urine in, 286 vomiting in, treatment, 309 Weinland's theory of, 279 z-rays in, 288 in diagnosis, 289 in treatment, 309 peptic, 277. See also Ulcer of stomach. perforating gastric, 277. See also Ulcer of stomach. stercoral, of intestines, 758 syphilitic, of intestines, 759 thrombotic, of intestines, 755 toxic, of intestines, 759 Ulcerative colitis, 758 Ulceration in amebic dysentery, 672 of stomach, superficial, 314 INDEX 1095 Ulcus carcinomatosum, 734 duodeni pepticum, 725 ventriculi, 277. See also Ulcer of slow - ach. Umbilical dyspepsia, 899 Umbilicus, protrusion of, diagnostic value, 6? Uncinaria americana, 941 Uncinariasis, 940 incidence, 940 parasite of, 941 Uncinarial dermatitis, 943 anemia in, 945 autogenous vaccine in, 948 diagnosis, 946 immunity, 943 morbid anatomy, 944 prognosis, 946 prophylaxis, 946 symptoms, 944 thymol in, 947 treatment, 946 Urine in pancreatic diseases, 987 Urobilinuria in pancreatic disease, 987 Ureter, Head's zones for, 832 Urine in acute enteritis, 647 in cancer of stomach, 332 in chronic gastritis, 251 in gastric ulcer, 286 in hyperchlorhydria, 373 in simple acute gastritis, 238 reaction, in Bacillus coli infections, 596, 607 Urobilin in feces, 536 Urticaria, stomach functions in, 507 Uterus, Head's zones for, 833 Uvula, inspection of, 50 VACCINATION, antityphoid, 707 Vaccines, autogenous in typhoid fever, 718 in uncinariasis, 948 therapy in typhoid fever, 713 Vacuum bottle for proctoclysis, 563 Vaginal examination, digital, 69 in appendicitis, 815 in rectal diseases, 524 Vagotonia, 892 age and, 892 etiology, 893 relation of intestinal intoxications to, 894 stigmata of, 895 symptoms, 894 treatment, 896 Valvula Bauhini, 24 Valvulse conniventes of Kerkring, 25 Van Deen's test for occult blood, Weber's modification, 160 Van Orden corset, 463 Van Slyke's modification of Abderhalden's test in gastric cancer, 341 Van Valzah-Hayes belt in gastroptosis, 463 Vater's ampulla, 958 variations, 960 Vedee vibrator, 222 Veins of rectum, 31 Veins of small intestine, 24 of stomach, 21 Venous hemorrhoids, 783 Vermes, 924 Vermiform appendix, 29. See also Ap- pendix, vermiform. Vesicocolic fistula, diverticulitis and, diff- erentiation, 855 Vibrator, Vedee, 222 Vibratory massage in chronic atony of stomach, 400 in constipation, 619 of stomach, 221 Villi of small intestines, 26 Visceral arteriosclerosis, 588 crises in erythema group, 896 diagnosis, 898 etiology, 897 symptoms, 896 treatment, 898 Visceroptosis, 442. See also Gaslroptosis. Volatile acids in gastric contents, 150 Voluntary muscles in typhoid fever, 703 Volvulus, 865 age and, 866 anatomy, 866 constipation in, 866 course, 867 diagnosis, differential, 875 etiology, 865 frequency, 866 mechanics, 865 meteorism in, 866 of sigmoid flexure, 865 of small intestine, 865 of stomach, 441 diagnosis, differential, 442 etiology, 442 symptoms, 442 treatment, 442 pain in, 866 sex and, 866 symptoms, 866 Vomit, bile in, 157 blood in, 157 examination of, 156 food in, 156 mucus in, 157 parasites in, 157 pus in, 157 black, in appendicitis, 815 Vomiting, cyclic, in children, 492 diagnosis, 493 etiology, 492 prognosis, 493 symptoms, 492 treatment, 493 delayed in acute atony of stomach, 398 idiopathic nervous, 494 in acute ecstasy of stomach, 409 intestinal obstruction, 873 in chronic gastritis, treatment, 259 pancreatitis, 1023 in gastric cancer, 329 treatment, 362 ulcer, treatment, 309 in pancreatic diseases, 996 1096 INDEX Vomiting in simple acute gastritis, treat- ment, 239 in stenotic ectasy of stomach, treatment, 432 juvenile, 494 nervous, 490 characteristics, 491 treatment, 491 periodic, 491 in children, 492 recurrent, in children, 492 reflex, 494 Vomito negro appendiculaire, 815 Vomitus in gastric cancer, 335 in gastrosuccorrhea continua periodica, 388 nervosa, 490 Von Noorden's diet in obesity, 916 diet-lists, 183-185 WATER as food, 189 infiltration treatment of hemorrhoids, Gant's 793 inflation of colon with, 531 of stomach, 96 Water-trap stomach, 37, 456, 457 \Veber's modification of Van Deen's test for occult blood, 160 W'einland's theory of gastric ulcer, 279 Whip-worm, 949 Whistle, stomach, Kemp's, 97 Whitehead's operation for hemorrhoids, 793 Widal's reaction in typhoid fever, 706 Winterberg method of determining num- ber of bacteria in feces, 548 Wirsung's duct, 958 Wolff's artificial Carlsbad mixture, 258, 38i Wolff-Junghans test in gastric cancer, 34i Wolfler's signs in hour-glass stomach, 438 Worm, fluke, 930 hook-, 940 maggot-, 938 pin-, 938 round, 935 seat, 938 spool, 935 thread-, 938 whip-, 949 Wound infection with colon bacillus, 601 Wynhausen's method of determining dia- static ferments in feces, 985 X-RAYS. See Rontgen rays. YEAST in gastric contents, 166 ZIEMSSEN-LEUBE rest-cure in gastric ulcer, 3o Zinc salts, poisoning with, antidotes for, 245 Zones, Head's. See Head's zones. Zymogen rennet, 153 SAUNDERS' BOOKS on Nervous and Mental Diseases, Children, Hygiene, and Medical Jurisprudence W. B. SAUNDERS COMPANY WEST WASHINGTON SQUARE PHILADELPHIA 9, HENRIETTA STREET COVENT GARDEN, LONDON Dercum's Mental Diseases Clinical Manual of Mental Diseases. By FRANCIS X. DERCUM, PH. D., M. D., Professor of Nervous and Mental Diseases at Jefferson Medical College, Philadelphia. Octavo of 425 pages. Cloth, $3.00 net. TWO PRINTINGS IN FIVE MONTHS This is a book really useful to the family physician a book that tells you definitely how to diagnose, how to treat either at home or in an institution all classes of mental diseases. First, Dr. Dercum takes up the various primary forms of mental disease, giving emphasis to those you meet in your daily practice as general practitioner delirium, confusion, stupor. Then melancholia, mania, the insanities of early life, paranoia, the neurasthenic-neuropathic disorders, and the dementias follow. The mental disturbances of the infections (syphilis, tubercu- losis, malaria, pellagra, rheumatic fever, etc.), the various forms of intoxicational insanities, those due to metabolic disorders, visceral disease, diseases of the nervous system are all given you and from your viewpoint. An important sec- tion is that devoted to the insanities of pregnancy. An entire part is devoted to the psychologic interpretations of symptoms as evolved by Freud and his disciples. You get a full discussion of the role of dreams. The Medical World ' This book gives just the information necessary, and gives it in a style studiously adapted to the needs of the general physician." SAUNDERS' BOOKS ON Church and Peterson's Nervous anc Mental Diseases Nervous and Mental Diseases. By ARCHIBALD CHURCH, M. D., Professor of Nervous and Mental Diseases and Medical Jurisprudence, Northwestern University Medical School, Chicago ; and FREDERICK PETERSON, M. D., formerly Professor of Psychiatry at the College of Physicians and Surgeons, N. Y. Handsome octavo, 944 pages; 350 illustrations. Cloth, $5.00 net; Half Morocco, $6.50 net. EIGHTH EDITION For this new (8tJi) edition this standard work has undergone a thorough re- vision. Vertigo and its labyrinthine relations, as developed by Barany, has received careful consideration; much new matter has been added to the section on Infantile Paralysis; syphilis of the nervous system has been brought into accord with recent epoch-making discoveries. Throughout, references to the new inves- tigations of the spinal fluid, and the relation of spinal fluid changes to the various organic diseases of the brain and cord have been introduced. The bearing of internal secretion upon nervous disorders has been brought right down to date. Tetany has been given its place among nervous diseases associated with glandular disorder. Altogether over 300 interpolations and alterations have been made. It is more than ever the standard. American Journal of the Medical Sciences " This edition has been revised, new illustrations added, and some new matter, and really is two books. . . . The descriptions of disease are clear, directions as to treatment definite, and disputed matters and theories are omitted. Altogether it is a most useful text-book." Serology of Nervous and Mental Diseases. By D. M. KAPLAN, M. D., Director of Clinical and Research Laboratories, Neurological Institute, New York City. Octavo of 346 pages, illustrated. Cloth, $3.50 net. This is an entirely new work, giving you the indications, centra-indications, preparation of patients, technic, after-phenomena, after-care, and disposal of the fluids obtained by lumbar puncture. You get a full discussion of the serology of all nervous and mental diseases of non-luettc etiology (including disorders of internal secretion), and of every type of luetic nervous and mental disease, giv- ing the Wassermann reaction in detail, the use of salvarsan and neosaivarsan, etc. MENTAL DISEASES AND HYGIENE Herrick's Neurology Introduction to Neurology. By C. JUDSON HERRICK, PH. D., Pro- fessor of Neurology in the University of Chicago. 1 2mo of 360 pages, illustrated. Cloth, $1.75 net. RECENTLY ISSUED Professor Herrick's new work will aid the student to organize his knowledge and appreciate the significance of the nervous system as a mechanism right at the beginning of his study. It is sufficiently elementary to be used by students of elementary psychology in colleges and normal schools, by students of general zoology and comparative anatomy in college classes, and by medical students as a guide and key to the interpretation of the larger works on neurology. Brill's Psychanalysis second Edition Psychanalysis : Its Theories and Practical Application. By A. A. BRILL, PH. B., M. D., Clinical Assistant in Neurology at Columbia University Medical School. Octavo of 392 pages. Cloth, $3.25 net. To the general practitioner, who first sees these "borderline" cases (the neuroses and the psychoses), as well as to those specially interested in neurologic work, Dr. Brill's work will prove most valuable. Dr. Brill has had wide clinical experience, both in America and in Europe. The results of this experience you get in this book. Here you get the practical application of all Freud's theories and from the pen of a man thoroughly competent to write. Hunt's Diagnostic Symptoms of Nervous Diseases Diagnostic Symptoms of Nervous Diseases. By EDWARD L. HUNT, M. D., formerly Instructor in Neurology and Assistant Chief of Clinic, College of Physicians and Surgeons, New York. I2mo of 229 pages, illustrated. Cloth, $1.50 net. Stiles on the Nervous System The Nervous System and its Conservation. By PERCY G. STILES, Instructor in Physiology at Harvard University. I2tno of 230 pages, illustrated. Cloth, $1.25 net SAUNDERS' BOOKS ON American Illustrated Dictionary New (8th) Edition 1500 New Words The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred branches; with over 100 new and elaborate tables and many hand- some illustrations. By W. A. NEWMAN BORLAND, M. D. Large octavo, 1137 pages, bound in full flexible leather, $4. 50 net ; with thumb index, $5.00 net The American Illustrated Medical Dictionary defines hundreds of terms not defined in any other dictionary bar none. It gives the capitalization and pro- nunciation of all words. It makes a feature of the derivation or etymology of the words. Every word has a separate paragraph, thus making it easy to find a word quickly. The tables of arteries, muscles, nerves, veins, etc., are of the greatest help in assembling anatomic facts. Every word is given its definition a definition that defines in the fewest possible words. Howard A. Kelly, M. D., Johns Hopkins University, Baltimore. " The American Illustrated Dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." Owen's Treatment of Emergencies The Treatment of Emergencies. By HUBLEY R. OWEN, M. D., Surgeon to the Philadelphia General Hospital. I2mo of 350 pages, with 249 illustrations. Just Issued. Dr. Owen's book is a complete treatment of emergencies. It gives you not only the actual technic of the procedures, but, what is equally important, the un- derlying principles of the treatments, and the reason why a particular method is advised. . You. get treatments of fractures, of contusions, of wounds. Particularly strong is the chapter on gun-shot wounds, which gives the new treatments that the great European War has developed. You get the principles of hemorrhage, to- gether with its constitutional and local treatments. You get chapters on sprains, strains, dislocations, burns, sunburn, chilblain, asphyxiation, convulsions, hysteria, apoplexy, exhaustion, opium poisoning, uremia, electric shock, bandages, and a complete discussion of artificial respiration, including mechanical devices. DISEASES OF CHILDREN. Kerley's Pediatrics Practice of Pediatrics. By CHARLES GILMORE KERLEY, M. 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Dr. A. D. Black&der, Me Gill University, Montreal " Dr. Kerley is a pediatrician of large experience who thinks for himself and is never con- tent to accept, without testing, the experiences or statements of previous writers. His book has a very definite value." Handler's The Expectant Mother Just Out This is decidedly a book for the woman preparing for childbirth. It has chapters on menstruation, nourishment of mother during pregnancy, nausea, care of breasts, examination of urine, preparations for labor, care of mother and child after delivery, twilight sleep, and dozens of other matters of great interest to the expectant mother. i2mo of 213 pajjes. illustrated. By S. WVLLIS HANDLER, M. D., Professor of Diseases of Women, New York Post-Graduate Medical School and Hospital. Cloth, $1.25 net. Winslow's Prevention of Disease Just Ready This book is a practical guide for the layman, giving him briefly the means to avoid the various diseases described. The chapters on diet, exercise, tea, coffee, and alcohol are of special interest, as is that on the prevention of cancer. There are chapters on the prevention of malaria, colds, constipation, obesity, nervous disorders, tuberculosis, etc. The work is a record of twenty-five years' active practice. i2mo of 348 pages, illustrated. By KENELM WINTSLOW, M. D., formerly Assistant Professor of Com- parative Therapeutics, Harvard University. Cloth, $1.75 net. Kerr's Diagnostics of Children's Diseases Dr. Kerr's work is written absolutely for the general practitioner to aid him in diagnosing disease in his child patients. He approaches his subject as the child is approached in the sick-room. It is strictly a clinical work a first aid in the diagnosis of disease in children. Octavo of 542 pages, illustrated. By LE GRAND KERR, M. D., Professor of Diseases of Children in the Brooklyn Postgraduate Medical School. Brooklyn. Cloth, $5.00 net; Half Morocco, $6.50 net. SAUNDERS' BOOKS ON Hill and Gerstley's Infant Feeding Ready soon CLINICAL LECTURES IN INFANT FEEDING. By LEWIS WEBB HILL, M. D., Alumni Assistant in Pediatrics, Harvard Medical School, and JESSE R. GERSTLEY, M. D., Clinical Assistant in Pediatrics, North- western University Medical School. 12 mo of 300 pages, illustrated. In these clinics you are given the full details of the Boston method of infant feeding as developed by Dr. Rotch, and of the Chicago method. You are given the theory, use in both normal and abnormal cases, exact quantities and percentages, and concrete clinical examples. The book is equivalent to a postgraduate course in infant feeding. It brings these two systems right to your door. Abt's Preparation of Infants' Foods Ready soon THE PREPARATION OF INFANTS' FOODS. By ISAAC A. ABT, M. D., Professor of Diseases of Children, Northwestern University Medical School. i2mo of 100 pages. This is a practical guide for infant feeding, giving to young mothers, nurses, and caretakers minute directions on the preparation of food for infants and young children. You get weights and measures; the mineral constituents and caloric values of foods. You get such practical material as diet-lists for constipation in older children, an outline of a plan for feeding babies, care of nipples and bottles, etc., and a great host of recipes for beverages of all kinds, milk preparations, soups and broths, puddings and cereal preparations, custards, eggs, vegetables, fruits, meats, sea foods, and breads. Aikens' Home Nurse's Hand-Book New HOME NURSE'S HAND-BOOK. By CHARLOTTE A. AIKENS. i2mo of 303 pages, illustrated. Cloth, $1.50 net. The point about this work is this : It tells you and shows you just how to do those little but important things often omitted from other nursing books. "Home Treat- ments" and "Points to be Remembered" terse, crisp reminders stand out as par- ticularly practical. Just the book for those who have the home-care of the sick. Galbraith's Personal Hygiene for Women PERSONAL HYGIENE AND PHYSICAL TRAINING FOR WOMEN. By ANNA M. GALBRAITH, M. D., Fellow New York Academy of Medicine. i amo of 393 pages, with original illustrations. Cloth, $2.25 net. " It contains just the sort of information which is very greatly needed by the weaker K. Its illustrations are excellent." Dietetic and Hygienic Gazette. sex. Galbraith's Four Epochs of Woman's Life THE FOUR EPOCHS OF WOMAN'S LIFE. By ANNA M. GALBRAITH, M.D. With an Introductory Note by JOHN H. MUSSER, M. D., Uni- versity of Pennsylvania, i amo of 296 pages. Cloth, $1.50 net. " We do not as a rule care for medical books written for the instruction of the public ; but we must admit that the advice in Dr. Galbraith's work is, in the main, wise and whole- some." Birmingham Medical Review. CHILDREN AND HYGIENE Griffith's Care of the Baby The Care of the Baby. By J. P. CROZER GRIFFITH, M. D., Professor of Pediatrics in the University of Pennsylvania. I2mo of 455 pages, illustrated. Cloth, $1.50 net. THE NEW (6th) EDITION The author has endeavored to furnish a reliable guide for mothers. He has made his statements plain and easily understood, so that the volume will be of service to mothers and nurses. New York Medical Journal "We are confident if this Itttle work could find its va/ into the hands of every trained nurse and of every mother, infant mortality would be lessened by at least fifty per cent." Grulee's Infant Feeding Infant Feeding. By CLIFFORD G. GRULEE, M. D., Assistant Pro- fessor of Pediatrics at Rush Medical College. Octavo of 3 16 pages, illus- trated, including 8 in colors. Cloth, $3.00 net. NEW (2d) EDITION Dr. Grulee tells you how to feed the infant. He tells you and shows by clear illustrations the technic of giving the child the breast. Then artificial feeding is thoughtfully presented, including a number of simple formulas. The colored illus- trations showing the actual shapes and appearances of stools are extremely valuable. Ruhrah's Diseases of Children A Manual of Diseases of Children. By JOHN RUHRAH, M. D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. I2mo of 552 pages, fully illustrated. Flexible leather, $2.75 net. FOURTH EDITION In revising this work for the fourth edition Dr. Ruhrah has carefully in- corporated all the latest knowledge on the subject. All the important facts are given concisely and explicitly, the therapeutics of infancy and childhood being outlined very carefully and clearly. There are also directions for dosage and prescribing, and many useful prescriptions are included. American Journal of the Medical Sciences " Treatment has been satisfactorily covered, being quite in accord with the best teaching, yet withal broadly general and 'free from stock prescriptions." SAUNDERS' BOOKS ON Reefer's Military Hygiene Military Hygiene and Sanitation. By LIEUT.-COL. FRANK R. KEEPER, Professor of Military Hygiene, United States Military Academy, West Point. I2mo of 305 pages, illustrated. Cloth, $1.50 net. ILLUSTRATED This is a concise, though complete text-book on this subject, containing chapters on the care of troops, recruits and recruiting, personal hygiene, physical training, preventable diseases, clothing, equipment, water-supply, foods and their preparation, hygiene and sanitation of posts and barracks, the troopship, hygiene and sanitation of marches, camps, and battlefields, disposal of wastes, tropical and arctic service, venereal diseases, alcohol and other narcotics, and a glossary. Bergey's Hygiene The Principles of Hygiene : A Practical Manual for Students, Physicians, and Health Officers. By D. H. BERGEY, A. M., M. D., Assistant Professor of Bacteriology in the University of Pennsylvania. Octavo volume of 531 pages, illustrated. Cloth, $3.00 net. FIFTH EDITION This book is intended to meet the needs of students of medicine in the acquirement of a knowledge of those principles upon which modern hygienic practises are based, and to aid physicians and health officers in familiarizing themselves with the advances made in hygiene and sanitation in recent years. This fifth edition has been very carefully revised, and much new matter added, so as to include the most recent advancements. Buffalo .Medical Journal ' It will be found of value to the practitioner of medicine and the practical sanitarian ; and students of architecture, who need to consider problems of heating, lighting, ventilation, water supply, and sewage disposal, may consult it with profit." Pyle's Personal Hygiene The New (6th) Edition A MANUAL OF PERSONAL HYGIENE : Proper Living upon a Physiologic Basis. By Eminent Specialists. Edited by WALTER L. PYLE, A. M., M. D., Assistant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 541 pages, fully illustrated. Cloth, $1.50 net. The book has been thoroughly revised for this new edition, and a new chapter on Food Adulteration by DR. HARVEY W. WILEY added. There are important chapters on Domestic Hygiene and Home Gymnastics, Hydrotherapy, Mechanotherapy, and First Aid Measures. " The work has been excellently done, there is no undue repetition, and the writers have succeeded unusually well in presenting facts of practical significance based on sound knowledge." Boston Medical and Surgical Journal. LEGAL MEDICINE Bohm and Painter's Massage Massage. By MAX BOHM, M. D., of Berlin, Germany. Edited, with an Introduction, by CHARLES F. PAINTER, M, D., Professor of Orthopedic Sur- gery at Tufts College Medical School, Boston. Octavo of 91 pages, with 97 practical illustrations. Cloth, $1.75 net. Draper's Legal Medicine A Text-Book of Legal Medicine. By FRANK WINTHROP DRAPER, A. M., M. D., Late Professor of Legal Medicine in Harvard University, Boston. Octavo of 573 pages, illustrated. Cloth, #4.00 net ; Half Morocco, $5.50 net Golebiewski and Bailey's Accident Diseases Atlas and Epitome of Diseases Caused by Accidents. By DR. ED. GOLEBIEWSKI, of Berlin. Edited, with additions, by PEARCE BAILEY, M. D., Consulting Neurologist to St. Luke's Hospital, New York. With 71 colored illustrations on 40 plates, 143 text illustrations, and 549 pages of text. Cloth, $4.00 net. In Saunders 1 Hand-Atlas Series. Hofmann and Peterson's Legal Medicine Atlas of Legal Medicine. By DR. E. VON HOFMANN, of Vienna. Edited by FREDERICK PETERSON, M. D., Professor of Psychiatry in the College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates and 193 half-tone illustrations. Cloth, $3.50 net. Jakob and Fisher's Nervous System Atlas and Epitome of the Nervous System and its Diseases. By PROFESSOR DR. CHR. JAKOB, of Erlangen. Edited, with additions, by ED- WARD D. FISHER, M. D., University and Bellevue Hospital Medical College. With 83 plates and copious text. Cloth, $3.50 net. Spear's Nervous Diseases Just out A Manual of Nervous Diseases. By IRVING J. SPEAR, M. D,. Professor of Neurology at the University of Maryland, Baltimore. 1 2mo of 660 pages, illustrated. Cloth, $2.75 net. This is a comprehensive digest, supplying the means to a clear understanding of neurology, and robbing that subject of much of its difficulty. You are given, first, a brief description of the practical anatomy and physiology, with those facts and theories that bear on the mechanism of organic nervous diseases. Then pathology is given, the simpler diseases being considered first, gradually preparing the reader to grasp the more difficult ones. The descriptions are clear and brief, di/erential diagnoses and treatments being brought out very definitely. Only the most recent accepted facts have been considered. For the treatments recommended, no special apparatus is required beyond a galvanic and faradic battery; they demand no special training, and they are easily remembered. io SAUNDERS' BOOKS ON CHILDREN. American Pocket Dictionary New (9th) Edition AMERICAN POCKET MEDICAL DICTIONARY. Edited by W. A. NEW- MAN BORLAND, M. D., Editor "American Illustrated Medical Dic- tionary." Containing the pronunciation and definition of the principal words used in medicine and kindred sciences, with 75 extensive tables. With 693 pages. Flexible leather, with gold edges, $1.25 net; with patent thumb index, $1.50 net. " I can recommend it to our students without reserve." J. H. HOLLAND, M. D., Dean of the Jefferson Medical College, Philadelphia. Morrow's Immediate Care of Injured second Edition IMMEDIATE CARE OF THE INJURED. By ALBERT S. MORROW, M. D., Adjunct Professor of Surgery at the New York Polyclinic. Octavo of 360 pages, with 242 illustrations. Cloth, $2.50 net. Dr. Morrow's book on emergency procedures is written in a definite and decisive style, the reader being told just what to do in every emergency. It is a practical book for every day use, and the large number of excellent illustrations can not but make the treatment to be pursued in any case clear and intelligible. Physicians and nurses will find it indispensibJe. Powell's Diseases of Children Third Edition, Revbed ESSENTIALS OF THE DISEASES OF CHILDREN. By WILLIAM M. POWELL, M. D. Revised by ALFRED HAND, JR., A. B., M. D., Dispensary Physician and Pathologist to the Children's Hospital, Philadelphia. i2mo volume of 259 pages. Cloth, $1.25 net. In Saunders* Question- Compend Series. Shaw on Nervous Diseases and Insanity Fifth Edition ESSENTIALS OF NERVOUS DISEASES AND INSANITY: Their Symptoms and Treatment. A Manual for Students and Practitioners. By the late JOHN C. SHAW, M. D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital, New York. i2mo of 204 pages, illustrated. Cloth, $1.25 net. In Saunders 1 Question- Com- pend Series. " Clearly and intelligently written ; we have noted few inaccuracies and several sug- gestive points. Some affections unmentioned in many of the large text-books are noted.' Boston Medical and Surgical Journal. Brady's Personal Health just out PERSONAL HEALTH: A Doctor Book for Discriminating People. By WILLIAM BRADY, M.D., Elmira, N. Y. i2mo of 406 pages. Cloth, $i.5onet. Hecker, Trumpp, and Abt on Children ATLAS AND EPITOME OF DISEASES OF CHILDREN. By DR. R. HECKER and DR. J. TRUMPP, of Munich. Edited, with additions, by ISAAC A. ABT, M.D., Assistant Professor of Diseases of Children, Rush Medical College, Chicago. With 48 colored plates, 144 text-cuts, and 453 pages of text. Cloth, $5.00 net. The many excellent lithographic plates represent cases seen in the authors' clinics, and have been selected with great care, keeping constantly in mind the practical needs of the general practitioner. These beautiful pictures are so true to nature that their study is equivalent to actual clinical observation. The editor, Dr. Isaac A. Abt, has added all new methods of treatment. Date Due FF.R-I 1 1979 ' REC'D PRINTED IN U.S.A. CAT. NO. 24 161 124 7 WI 100 K32d 1917 Kemp, Robert Coleman Diseases of the stomach, intestines, and pancreas WI 100 K32d 1917 fKemp, Robert Coleman Diseases of the stomach, intestines, and pancreas MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664