DISEASES L - OF THE INTESTINES A TEXT-BOOK FOR PEACTITIONEKS AND STUDENTS OF MEDICINE MAX EINHORN, M.D. PROFESSOR OF MEDICINE AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL, AND VISITING PHYSICIAN AT THE GERMAN DISPENSARY, NEW YORK NEW YORK WILLIAM WOOD AND COMPANY MDCCCC COPYRIGHT, 1900 BY WILLIAM WOOD AND COMPANY TO MY ESTEEMED FRIEND AND TEACHER ERNST VON LEYDEX, M.D. PROFESSOR OF MEDICINE IN THE UNIVERSITY OF BERLIN THIS BOOK IS RESPECTFULLY DEDICATED PREFACE. THIS treatise is a continuation of my work on " Diseases of the Stomach," the two together comprising the princi- pal disorders of the digestive tract. In discussing the subject of the intestinal affections an effort has been made to follow the same lines laid down in my book on the stomach. The practical points regarding diagnosis and treatment are always placed in the foreground. Although our knowledge of diseases of the intestines has not made such rapid progress as that of morbid conditions of the stomach, much has likewise been achieved in this field. Surgery has made many successful advances. The elucidation of the intimate relation existing between func- tional disturbances of the stomach and of the intestines also marks an important step forward, especially as to therapy. While there are many excellent works on intestinal dis- eases by German authors, the more recent English litera- ture contains no monographs on this important subject. The medical encyclopedias, it is true, contain very instruc- tive contributions on this topic, and among these Ewald's vi PREFACE. treatise on diseases of the intestines in the " Twentieth Cen- tury Practice of Medicine " is a most valuable acquisition. The present volume, it is hoped, will to a certain extent fill the void in American literature of a monograph on the affections of this portion of the digestive tract. The writer desires to express his indebtedness to Nothnagel, Rosen- heim, Boas, Fleischer, Ewald, Pick, Fowler, Treves, and Allingham, whose works have been frequently consulted. He trusts that this book will prove of practical utility to the practitioner, and if it will aid him in more successfully treating this class of cases, the author's effort will be more than recompensed. MAX EINHORN. NEW YORK, April, 1900. CONTENTS. CHAPTER I. ANATOMY AND PHYSIOLOGY. PAOK Anatomy, 1 The Intestinal Canal (Intestinum) 1 The Duodenum. . 1 The Small Intestine, .4 Structure of the Small Intestine, . . . 6 The Large Intestine or Large Bowel (Intestinum Crassum), . 11 Histology of the Large Bowel, . . .17 Physiology, ... 18 1. The Secretory Function or the Chemical Processes in the Intestines 18 2. Absorption. ....... . 24 3. Motion 28 CHAPTER II. METHODS OF EXAMINATION AND TREATMENT. Examination 32 Interrogation, .... 32 Inspection, ... 34 Proctoscopy, 37 Palpation, ... . ... 40 Percussion. . . . . .... 44 Auscultation, . .... 45 Inflation of the Intestine with Carbonic Acid Gas or Air, . 45 Injection of Water per Anum, ....... 48 Lavuge of the Bowel 48 Examination of the Faeces, 49 Treatment .... 74 Diet, 74 Mechanical Procedures, . .... 78 Injections 78 Massage and Gymnastic Exercises, 80 viii CONTENTS. PAGE Mechanical Procedures: Hydrotherapy, . * 80 Electricity, ... .... 81 CHAPTER III. ACUTE AND CHRONIC INTESTINAL CATARRH. Acute Intestinal Catarrh, .... ... 83 Synonyms, .... . Definition .83 Etiology, 83 Morbid Anatomy, . 85 Symptomatology, ......... 86 General Subjective Symptoms, 87 Objective Symptoms, Fever 89 Localization of the Catarrhal Process 89 Duration, 90 Diagnosis, .......... 91 Prognosis, .91 Treatment, 91 Chronic Intestinal Catarrh, 94 Synonyms, 94 Definition, 94 Etiology, . 94 Morbid Anatomy, . . 95 Symptomatology .98 Objective Symptoms, 99 Course, . . 103 Diagnosis, . . . 103 Prognosis, 104 Treatment, . 105 Hydrotherapeutic Measures, 106 Mineral Waters, 107 Medicaments, 107 CHAPTER IV. DYSENTERY. Dysentery, 110 Synonyms, . 110 Definition, 110 Etiology, . . 110 Morbid Anatomy, . . 115 CONTENTS. ix PAGE Dysentery : Symptomatology of Acute Dysentery, 119 Symptomatology of Chronic Dysentery, . . . . 122 Course, ... 123 Complications, .......... 123 Diagnosis, . . 125 Prognosis, . * 125 Treatment of Acute Dysentery, . . . . . 125 Treatment of Chronic Dysentery, 126 CHAPTER V. ULCEBS OF THE INTESTINES. 1. Duodenal Ulcer, 128 Synonyms, 128 Definition 128 Etiology, . . .128 Morbid Anatomy . . 129 Situation of the Ulcer 130 Symptomatology, . . . . . . . 131 Course, 133 Diagnosis, . . . 133 Prognosis, ........... 134 Treatment, 134 -2. Kmbolic and Thrombotic Ulcers, 135 Pathological Changes 135 Symptoms, 136 Diagnosis, 138 Prognosis. .......... 138^ Treatment . . .139 :?. Amyloid Ulcers, . 140 Diagnosis, 141 4. Tuberculous Ulcers, . . 141 .">. Syphilitic Ulcers, 144 6. Toxic Ulcers, 145 Symptomatology, 145 Diagnosis, 147 Prognosis, .......... 148 Treatment 148 CHAPTER VI. NEOPLASMS OF THE INTESTINE. Malignant Growths, 150 Cancer, . . . . . . . . . . .150 x CONTENTS. PAGE Cancer . Defitiition, 150 Etiology 150 Location, 151 Morbid Anatomy 152 Symptomatology, 154 Course .*.... 163 Diagnosis 163 Prognosis, .......... 164 Treatment 164 Sarcoma and Lympho-Sarcoma, 166 Benign Tumors of the Intestine, 167 CHAPTER VII. HEMORRHOIDS. Hemorrhoids .... .169 Synonyms, ... 169 Definition. 169 Etiology .169 Morbid Anatomy 171 Symptomatology, ....... .174 Diagnosis. 179 Prognosis. .......... 180 Treatment 180 Radical, .... 185 Complications 189 Prolapse of the Rectum 189 Fissure of the Anus, 193 CHAPTER VIII. APPENDICITIS. Appendicitis 196 Synonyms, 196 Definition 196 General Remarks, 196 Etiology "197 Morbid Anatomy 202 Symptomatology 206 Course 2ox Diagnosis, 214 Differential Diagnosis 215 Prognosis, 216 CONTENTS. XI PAGE Appendicitis: Treatment, 218 Medical 218 Surgical, 221 CHAPTER IX. INTESTINAL OBSTRUCTION. Introductory Remarks, ......... 226 Acute Intestinal Obstruction, . . . . . . . . 227 Synonyms, 227 Definition, 227 Etiology, , . . . . .227 Compression of the Intestine, 227 Strangulation by Adhesions, 228 Strangulation by Meckel's Diverticulum, . . . 230 Volvulus 232 Obturations 233 Intussusception, 234 Pathological Changes, . . 236 Symptomatology 238 Objective Signs, 245 Course 247 Diagnosis, 249 Prognosis, .......... 258 Treatment 258 Medical, 258 Surgical, 266 Chronic Intestinal Obstruction, 268 Etiology 268 Symptomatology, 269 Complications 276 Course and Prognosis, 277 Diagnosis, . . 277 Treatment, 278 Operative Intervention, 280 CHAPTER X. NERVOUS AFFECTIONS OF THE INTESTINES. General Remarks 282 Motor Neuroses of the Intestines, 284 Diarrhoea 284 Etiology and Symptomatology, 284 Diagnosis 289 xii CONTENTS. PAGE Diarrhoea : Prognosis, 289 Treatment, 289 Constipation, 291 Synonyms, ......... 291 Definition, ... 291 General Remarks 291 Etiology, 292 Symptomatology, 297 Diagnosis, 302 Prognosis, 304 Treatment, 304 .Moral, 305 Dietetic 305 Mechanical 306 CHAPTER XL NERVOUS AFFECTIONS OF THE INTESTINES. Motor Neuroses (Continued), 314 Paralysis of the Intestines, 314 Diagnosis, 315 Treatment, 315 Proctospasmus, or Spasm of the Rectum, 316 Diagnosis, . 317 Treatment 317 Paresis and Paralysis of the Sphincters of the Anus, . . 317 Diagnosis 318 Prognosis .318 Treatment, . . ' 318 Peristaltic Restlessness of the Intestines, 319 Definition 319 Etiology and Symptomatology, 319 Diagnosis 320 Prognosis, 320 Treatment, 320 Mi'teorism, 321 Etiology, 321 Symptomatology 322 Diagnosis 323 Prognosis 323 Treatment, 323 Sensory Neuroses of the Intestines, :!'.M Enteralgia, 326 CONTENTS. xni PAGK Enteralgia: Synouj-ms. . 326 Definition 326 Etiology, 326 Symptomatology, 32? Diagnosis . . . 329 Prognosis, .......... 330 Treatment, 330 Hypogastric Neuralgia, . . . . . . . . 332 Treatment, . . . . . . . . .332 Hyperaesthesia, Panesthesia, and Anaesthesia of the Intestine, 333 Treatment 334 Secretory Neuroses of the Intestines 335 Membranous Enteritis, 335 Synonyms, 335 Definition 335 History, 335 Etiology. . . . . . . . . . .339 Symptomatology, 341 Diagnosis 343 Treatment. . .344 Intestinal Neurasthenia 34? Diagnosis 348 Treatment 348 CHAPTER XII. INTESTINAL PARASITES. General Remarks 349 Protozoa, . . .349 Amu>ba> 349 Sporozoa 350 Infusoria 350 Vermes 351 Cestodes (Tape Worms) 351 General Remarks 351 Taenia Solium. ......... 354 Tsenia Saginata or Mediocanellata 355 Bothrioceplmlus Latus. Taenia Lata, or Pig Head, . . 35? Taenia Nana 358 Ta'nia Cucumerina 358 Taeiiia Flavopunctata or Taeuia Diminuta, . . . 359 Treatment 359 Trematodes (Fluke Worms) 362 CONTENTS. PAGE Trematodes (Fluke Worms): Distoma Hepaticum or Liver Fluke 362 Distoma Lanceolatum, 363 Distoma Hsematobium or Bilharzia Haematobia, . 364 Nematodes (Round Worms) 365 Ascaris Lumbricoides (Common Spool or Hound Worm), . 365 Diagnosis 367 Symptoms, . 367 Prophylaxis 368 Treatment, .368 Ascaris Mystax, 369 Oxyuris Vermicularis, Awltail, Seat or Pin Worm, Maggot or Thread Worm .369 Symptoms, 370 Diagnosis 371 Prophylaxis, 371 Treatment 371 Anchylostoma Duodenale, Dochmius Duodenalis, or Stron- gylus Duodenalis 372 Symptoms, 374 Course, 375 Diagnosis, 375 Treatment, 376 Anguillula Stercoralis, 376 Anguillula Intestinal is. :};} Trichocephalus Dispar, Whip Worm, . . . 377 Symptoms, 377 Diagnosis, 377 Trichina Spiralis, 379 Prophylaxis, 380 Treatment, . . 380 DISEASES OF THE INTESTINES. CHAPTER I. ANATOMY AND PHYSIOLOGY. ANATOMY. The Intestinal' Canal (Intestinum). THE intestinal canal may be divided into two parts, the small intestine and the large intestine (Fig. 1). The small intestine (intestinum tenue) is about seven to eight metres long, the first portion being called the duodenum, the sec- ond the jejunum, and the third the ileum. With the ex- ception of the duodenum the small intestine lies for the most part inside the more fixed portion of the large intes- tine and is connected to the posterior abdominal wall by the mesentery. This broad membrane extends from above downward and from left to right, from the end of the duo- denum above to the ileocsecal valve below, enclosing the jejunum and ileum along the whole of their extent. The Duodenum. The duodenum, so called on account of its length (being about twelve inches long), is, unlike the other parts of the small intestine, very definite in position and extent. It is that part which is not suspended by the mesentery. It is, further, the most fixed as well as the widest part of the small intestine, measuring one and one-half to two inches 2 DISEASES OF THE INTESTINES. in diameter. It has a curved shape, somewhat resembling that of a horseshoe. It surrounds the pancreas and is divided into four parts : 1. The superior horizontal portion (pars horizontalis superior) begins at the pylorus, lying at the level of the first lumbar vertebra, and runs slightly upward and back- ward toward the right until it reaches the right side of the vertebral column. It ends at the neck of the gall bladder, and is the most movable of the four portions. It is cov- ered by the two layers of the peritoneum which are contin- ued from the stomach, and by these it is completely sur- rounded. Above it lie the liver (quadrate lobe) and the gall bladder, below it is the pancreas, and behind it are the common bile duct and hepatic vessels. 2. The descending portion of the duodenum, beginning at the neck of the gall bladder, is about twice as long as the first portion, and runs almost vertically to the second or third lumbar vertebra. It lies to the right of the lumbar vertebrae, and touches the right kidney. In front of it and crossing it almost at a right angle, runs the transverse colon. It is more fixed than the first portion. On its left side is the pancreas, and the common bile duct a little more posteriorly. Into this part of the bowel, and at its inner and back part, but four inches from the pylorus, the common bile duct and pancreatic duct enter. The portion at which these ducts enter, occasionally forms a small sinus (diverticulum or ampulla Vateri). 3. The third part or the transverse portion is the longest, measuring about five inches. It extends from the base of the second or third lumbar vertebra on the right side obliquely across the spine to the upper part of the left side, ascending a little on its waj r . In front of it is found the lower layer of the transverse mesocolon. The superior ANATOMY. mesenteric vessels cross this part of the duodenum, running between it and the pancreas in order to reach the mesentery. This portion is in relation with the pancreas and superior 13 FIG. 1. The Intestine, as Seen from the Front, after Removing the Omentum (Testut). 1, Abdominal wall ; 2, wall of the thorax ; 3, oesophagus; 3', cardia ; 4, stomach ; 4', pylorus; 5, duodenum; ti, pancreas; 7, liver; 8, gall bladder; 9, gastrohepatic liga- ment; 10, rjght kidney and its suprarenal capsule; 11, small intestine; 12, terminal portion of the ilenm : 13, oiwum : 13', its appendix ; 14. ascending colon ; 15, transverse colon ; 16, descending colon ; 17, ileopelvic colon ; 18, bladder ; 19, parietal peritoneum ; 20, spleen : 21, diaphragm ; 22, thoracic aorta. mesenteric artery above, with the vena cava, aorta, and crura of the diaphragm behind. It is the most fixed por- tion of the duodenum. 4 DISEASES OF THE INTESTINES. 4. The fourth part of the duodenum or second ascending portion ascends vertically at the left side of the spine. It is abodt one inch long and forms the end of the duodenum. It is firmly fixed in its place by the musculus suspensorius duodeni, the latter being the name of the fibrous band, containing some plain muscular fibres which descend to the vertical part of the duodenum from the left crus of the diaphragm and the tissues about the coeliac axis. It ter- minates at this point in the jejunum, forming the -flexura duodenojejunalis at a place situated to the left of the sec- ond lumbar vertebra. The Small Intestine. The small intestine which forms the continuation of the duodenum is composed of the jejunum and ileum. There is really no marked structural difference between the two, and it is therefore hardly possible to determine where one ends and the other begins. As a rule, the upper two-fifths are designated as the jejunum and the lower three-fifths as the ileum. The jejuno-ileum fills the greater part of the abdomen. It occupies the umbilical, hypogastric, iliac, and lumbar regions, and is more or less encircled by the large intestine. The coils formed by the jejunum and ileum are very movable and completely invested by the peritoneum. They are supported and attached to the pos- terior parietes by the mesentery. The latter extends from the end of the duodenum to the ileocsecal junction. The point at which the mesentery is attached above is on a level with the lower border of the pancreas and just lo the left of the vertebral bodies. From this point of insertion the mesentery follows an oblique line running downward and to the right, crossing the great vessels and ending in the iliac fossa. The length of the mesentery from the spine ANATOMY. 5 to the intestines varies in different parts of the canal, its average being eight to nine inches. It soon attains its full length, and within one inch of the end of the duodenum is already six inches long. The small intestine hangs on the mesentery in the form of coils, and the folds which the mesentery forms may be compared to those of a fan. The small intestine including the duodenum has an aver- age length of about twenty feet. The calibre of the small intestine is larger at its upper end and gradually dimin- ishes in size until its entrance into the large bowel. Thus at the beginning the jejunum has a calibre of 17.5 cm., the ileum at its beginning of 11.5 cm., and at its end 9.5 cm. The ileum passes perpendicularly into the ascending part of the larger bowel just above the caecum, its mucosa forming a double valve, called valvula Bauhini. The jejuno- ileum is the most movable part of the intestinal tract. Wherever a free space is left it occupies it. It is therefore most often met with in hernias. During gravidity or when a tumor or ascites exists in the abdomen the small intes- tine moves up higher and thus escapes compression. The small intestine receives its blood supply from the abdominal aorta. The arteria gastroduodenalis, a branch of the arteria hepatica, supplies the upper part of the duo- denum; the lower part of the duodenum and the jejunum and ileum are supplied by the arteria mesenterica superior. The latter vessel branches off into a fine net of numerous small vessels which run through the intestinal wall. The end ramifications penetrate the submucosa and here again form a net. From the latter the finest ramifications pene- trate the mucosa and form a capillarj- system of the villi and glands. The venous blood flows partly into the vena gastrica superior, partly into the vena mesenterica superior, and empties itself iuto the vena porta. The lymphatics 6 DISEASES OF THE INTESTINES. form a continuous series which is divided into two sets, that of the mucous membrane and that of the muscular coat. The lymph vessels of both sets form a copious plexus. They run between the two folds of the mesentery and end in the mesenteric lacteals. They are provided with valves which prevent the current from flowing back- ward, the direction of which is into the truncus lymphati- cus intestinalis and finally into the thoracic duct. The nerves of the small intestine originate principally from the plexus mesentericus superior or the sympathetic. The duodenum is supplied by the plexus hepaticus, a branch of the plexus co3liacus. The abdominal part of the vagus, namely, the plexus gastricus, anterior and posterior, also supplies the small intestine with nerves. The nerves, which are mostly non-medullary, enter the intestinal wall in connection with the branches of the arteria mesenterica superior and form a subserous net. They then penetrate the long muscular fibres and form between these and the circular muscular fibres ramifications which consist of nu- merous groups of multi polar cells (plexus mesentericus seu Auerbachii) ; fine branches of nerves arising here sup- ply the muscularis. Others penetrate the circularis, reach the submucosa, and form the submucous nerve plexus, containing small groups of ganglion cells (Meissner's nerve plexus) ; fine ramifications also supply the muscularis mu- COSSB, the muscles of the villi, and end in the remaining part of the mucosa. Stricture of the Small Intestine. The small intestine is composed of four principal coats: the serous, muscular, submucous, and mucous (Fig. 2). The serous coat is formed by the visceral layer of the peri- toneum. The muscular coat consists of an internal circular ANATOMY. 7 and an external longitudinal layer (Fig. 3). The former is usually considerably thicker than the latter. They both .-,, a Fin. 2. Longitudinal Cross-section through the Wall of the Small Intestine (Ileum). Solitary lymph nodules (nodulus lymphaticus solitarius). Intestinal glands (Lieber- kuehni) (Toldt). n. The mucous layer; /*. the muscularis mucosae ; c, the submucous layer; , intestinal villi ; c, a solitary lymph nodule. 10 DISEASES OF THE INTESTINES. advances. They are situated beneath the mucous mem- brane and embedded in the submucous tissue. Each gland is a branched and convoluted tube lined with col- umnar epithelium. In structure they are very similar to the pyloric glands of the stomach, but are more branched and convoluted, and their ducts are longer. The duct of each gland passes through the muscularis mucosje and opens on the surface of the mucous membrane. Solitary follicles or glands are found scat- tered throughout the mu- cous membrane of the small intestine. They are most numerous in the lower part of the ileum. Each one has a diameter of from 3 to 6 mm. The structure of the solitary follicle is similar to that of the lymph nodes and consists of a dense reti- form tissue packed with lymph corpuscles and permeated by fine capillaries. There are no ducts. The interspaces of the retiform tissue are continuous with lar- ger lymph spaces at the base of the gland, by which they communicate with the lacteal system. The base of the nodules is in the submucous tissue. It penetrates the muscularis mucosae and enters the mucous membrane form- ing a slight projection of its epithelial layer. The solitary follicles are the breeding place of the lymph cells. They FIG. 6. Ileum Partly Opt-ned (Toldt). Solitary lymph nodules; h, serosa; mucpsa. ANATOMY. 11 are met with in two conditions, namely, either scattered singly, in which case they are termed glandulse solitaries (Fig. 6), or aggregated in groups varying from one to three FIG. 7. Peyer's Patch (Noduli Lymphatic! Aggregati) In the Ileum (Toldt). a, Peyer's patch ; It, solitary lymph nodules. inches in length and about one-half inch in width. The surface of the solitary follicles is free from villi. Chiefly of an oval form, their long axis is parallel with that of the intestine. In this state they are called glandule agminate or Peyer's patches or plaques (Fig. 7). They are almost always placed opposite the attachment of the mesentery. Peyer's patches number about twenty to twenty -eight. In some cases they are already found in the jejunum, but they are most prevalent in the ileum. The Large Intestine or Large Bowel (Intestinum Crassum). The large intestine extends from the termination of the ileum to the anus. It is about five to six feet in length. Its calibre decreases from beginning to end except at the ampulla of the rectum where it is larger. It measures 28.5 cm. in circumference at the junction of colon and cse- 12 DISEASES OF THE INTESTINES. cum, 20.5 cm. at the end of the ascending portion, 14.5 cm. in the descending portion. The large intestine is divided into the caecum, colon, and rectum. With the exception of the rectum it possesses three tseniae, these being groups of non- striated muscu- lar fibres run- ning lengthwise with the lumen of the intestine. Between the tfenire the walls are somewhat sacculated. The circular muscu- lar ti b r e s are also accumulat- ed in spots. leaving short intervals be- tween each other, thus forming c o n - strictions and expansions (haustra coli) across the intestine (Fig. 8). The large bowel is further characterized by appendices epiploicae, external pouches, formed by the peritoneal cov- ering containing fat. The caecum is the head of the colon or that part of the large bowel situated below the mouth of the ileum (Fig. 9). It lies in the right iliac fossa and is FIG. 8. The Large Bowel Partly Opened along the Mesen- tery (Toldt). a. Free taenia; /), ta-nia mesocolica; c, appendices epiplolcae ; d, the raucosa ; e, the semllunar folds of the colon ; /, the mesocolon. ANATOMY. 13 completely covered by the peritoneum. In the filled con- dition it touches the anterior abdominal wall. Starting from the inner and back portion of the caecum lies the pro- cessus vermiformis or appendix, forming a narrow, some- what bent, blind-ending tube. The appendix is mpvable and has its own a mesentery (mes- /j enteriolum). Its length varies between 2 and 20 cm. and its width between 0.5 and 1 cm. The appendix opens into the caecum (ostium processus vermi- formis), occa- sionally form- ing a crescentic fold (v a 1 v u 1 a processus v e r - miformis). In man it consti- tutes an entirely fuuctionless or- gan which occa- sionally gives rise to manifold ailments. The appendix has no fixed position. J. D. Bryant 1 found it most often "inward," then "behind the caecum," "downward and inward," "into the true pelvis." ' J. D. Bryant : Annals of Surgery, February, 1893, p. 164. FIG. 9. Section of the Caecum and Ileum, showing the En- trance of the Latter into the Caecum (Toldt). a. The semilunar folds of the colon ; b, c, the ileocaecal valves (b, the upper, and c. the lower one) ; d, the end portion of the ileum ; c, the posterior ileocaecal valve ; /, the appen- dicular valve ; y, the appendix. 14 DISEASES OF THE INTESTINES. Without distinct demarcation the caecum merges into the ascending colon. It passes vertically above the crest of the ileum and runs along the posterior abdominal muscles and the lower part of the right kidney. At this point just in front of the kidney and immediately beneath the liver the colon bends toward the left of the flexura coli dextra. The ascending colon is posteriorly adherent through con- nective tissue with the parts just mentioned, while the peritoneum covers only its anterior and partly also its lat- eral surfaces. In close proximity to its median wall lies the ascending part of the duodenum. Beginning at the flexura coli dextra the colon runs across the abdominal cavity from right to left (transverse colon), forming the longest segment of the large intestine. It passes from the hepatic flexure in the right hypochondrium transversely and slightly upward from right to left along the anterio'r abdominal wall to the splenic flexure in the left hypochon- drium. This part of the colon is the most movable. It has a very long mesentery, called the transverse meso- colon. The usual position of the transverse colon corre- sponds to a line separating the umbilical and epigastric regions. It is in relation by its upper surface with the lower part of the liver and gall bladder, the greater curva- ture of the stomach and the lower end of the spleen ; by its under surface with the small intestine ; by its anterior surface with the great omentum and abdominal wall; by its posterior surface with the transverse mesocolon ; on the right side with the second part of the duodenum, and on the left besides the latter with some convolutions of the small intestine. The transverse colon does not form a straight line con- necting the right and left flexures, but is about twice as long as this line and therofore forms several curves. In ANATOMY. iJ the left hypochondrium especially, there is an S-shaped coil. The latter tills out the free space in the left hypo- chondrium which is left by the stomach in its various states of fulness. Beginning at the flexura coli sinistra the descending colon runs downward in front of the left kidney and the quadratus lumborum and iliac muscles un- til it reaches the left iliac fossa. The descending colon runs just in the opposite direction to the ascending colon, and like this is only partly covered \)y the peritoneum. The descending colon passes into the sigmoid colon or flexure (S Romanum), commencing above the iliac crest and ending below in the rectum at the brim of the true pelvis opposite the left sacro-iliac articulation. It is gen- erally described as an S-shaped curve having an upper colic rim turned toward Poupart's ligament and the lower rectal rim, hanging down into the true pelvis. It has a complete peritoneal covering or mesentery. This part of the bowel is very movable, and its calibre is the narrowest of that of the large bowel. The sigmoid flexure continues into the rectum, forming the terminal portion cf the intes- tinal tube. It runs, coming from the left, in front of the os sacrum down to the bottom of the small pelvis. Only the upper half of the rectum is invested completely with peritoneum (mesorectum) and is attached to the sacral ver- tebra. The lower half passes between the organs occupy- ing the pelvic floor, being adherent to them by connective tissue. It now runs posteriorly along the os coccyx and terminates in the anus. This part has an incomplete peri- toneal covering (plica Douglasii) lying anteriorly and turn- ing backward in order to ascend either over the vagina or the bladder (excavatio recto-uterina, excavatio rectovesica- lis). Below this point the rectum has very little mobility as it is covered all around bv connective tissue. The en- 16 DISEASES OF THE INTESTINES. tire rectum is about 18 to 22 cm. long. Its calibre varies. It is widest at the apex of the prostate, forming the am- pulla of the rectum. The longitudinal muscular fibres of the rectum are not arranged in teeniae as in the colon, but pass all around the lumen. The circular muscular fibres become more dense from above downward and increase to such a degree at the anal opening that they here form a thick ring (nmsculus sphincter ani internus). A short distance above this mus- cle there is also an accumulation of circular muscular fibres (musculus sphincter ani tertius). At the anus the walls of the rectum are connected with striated muscular fibres (sphincter ani externus and levator ani), which are both of importance in the act of defecation. The colon is supplied by the three arterise colicse, branches of the arteria mesenterica superior and arteria mesenterica inferior. The arteria colica sinistra origi- nates from the arteria mesenterica inferior, while the ar- teria colica media and superior are tributaries of the arteria mesenterica superior. The veins accompany the artery and empty partly into the vena mesenterica superior, partly into the vena mesenterica inferior. The lymphatics of the colon are numerous and lie below the glands and all through the submucosa. The plexus mesentericus supe- rior, a branch of the plexus coeliacus, provides the nervous supply of the caecum, ascending colon, and the right half of the transverse colon. The plexus mesentericus inferior, a branch of the plexus aorticus abdominalis, supplies the left half of the transverse colon, the descending colon, and the sigmoid flexure. The rectum is supplied by the arteriae haemorrhoidales superior, media, and inferiores, branches of the arteria mesenterica inferior and arteria pudenda communis. The ANATOMY. 17 venous blood of the rectum is carried to the vense hsemor- rhoidales principally into the vena mesenterica inferior, thus emptying into the vena portarum, partly, however, into the vena iliaca interna. In this way there is a sepa- rate communication (outside of the portal circulation) with the remaining vessels of the abdomen. The lymphatics of the rectum form a wide net, running partly to the glands lying behind the rectum, partly to the plexus lumbalis sinister. The nerves supplying the rectum originate from the sympathetic, being branches of the plexus mesenteri- cus inferior, the plexus sacralis (nervi hsemorrhoidales in- ferior and medii), and the plexus hypogastricus superior. Histology of the Large Bowel. The large bowel consists, like the small bowel, of four coats: the serosa, muscularis, submucosa, and mucosa. The structure "of these four coats corresponds to that of the small intestine, except that the longitudinal muscular fibres are arranged in three groups (tgenise) running along the wall, as mentioned above. The mucosa of the large bowel differs from that of the small intestine in that there is an absence of the folds of Kerkring and of the villi. Lieberkiihn's glands are here somewhat longer and some- times curved. The mucous membrane of the rectum is thicker, more red, and succulent than that of the colon. There are nu- merous folds. One conspicuous fold is found 6 to 7 cm. above the anus (plica transversalis recti). In the neigh- borhood of the anus the folds take a longitudinal direc- tion, and are called columns Morgagnii seu recti. The lower region of the rectum contains the epithelial cells of the rectum, pavement-like epithelium, forming a gradual 18 DISEASES OF THE INTESTINES. transition from the mucous membrane of the digestive tract to that of the external skin. The upper portion of the rectum corresponds exactly to that of the colon. PHYSIOLOGY. The intestines are entrusted with the important office of digesting the food which has not been acted upon by the stomach, of absorbing it, and finally of eliminating the undigested remnants. In order to fulfil this object they have three functions, the secretory, absorbent, and motor. All these functions are supervised by ganglion ic cells and nerves, the latter also transmitting sensory impressions. 1. The Secretory Function or the Chemical Processes in the Intestines. As is well known, the intestinal secretion consists, first, of the bile; secondly, the pancreatic juice ; and thirdly, the intestinal juice proper (succus entericus). The composi- tion of each of these and their properties may be found in the text-books on physiology, and also briefly in my book on " The Diseases of the Stomach. " It will not be amiss, however, to describe here more fully their joint action in the intestinal canal. The effect of each of the digestive juices is influenced by that of the others. For this reason the chemical processes in the intestines are quite complicated. The carbohy- drates, whose conversion into maltose by the ptyalin has been checked in the stomach by the free hydrochloric acid, are now, after reaching the intestines, further changed by the diastase of the pancreatic secretion into maltose, which is further converted into glucose. Cane sugar is likewise converted into grape sugar, while milk sugar, according to PHYSIOLOGY. 19 Voit and Lusk, 1 remains unchanged. The finer parts of the cellulose also undergo some changes, but their ulti- mate products are not known. It is certain, however, that under the influence of micro-organisms they partly undergo fermentation, giving rise to the formation of marsh gas, acetic acid, and butyric acid. The pancreatic juice forms the principal factor of all the digestive processes in the intestinal canal. Besides its ac- tion upon the carbohydrates through its diastatic ferment, it acts upon fats by means of the steapsin and upon al- bumiuates by means of the trypsin ferment. According to Nencki 2 and Rachf ord, 3 the fat-splitting action of the pancreas is greatly increased by the presence of bile. The splitting of the fats into fatty acids and glycerin is of greatest importance for absorption. The fatty acids com- bine with the alkalies of the intestinal and pancreatic juices and form soaps which are either absorbed as such or promote the absorption of fats. There is no doubt that the greater amount of fats taken in with the nourish- ment is absorbed as a fine emulsion in the formation of which the soaps take part. These processes of fat emulsi- fication, by the action either of the pancreatic juice or of soaps, take place only in alkaline media. If the intestinal contents are acid, emulsification does not occur, or does so only at those places at which the fat comes in contact with an alkaline secretion covering the mucous membrane. Ac- cording to Claude Bernard 4 and Dastre, 6 the action of bile greatly increases the emulsifying property of the pancre- 1 Lusk : Zeitschr. f. Biologie, Bd. 28. p. 275. " Nencki : Arch. f. experimentelle Path. u. Pharm., Bd. 20. 3 Rachford Journal of Physiology, vol. 12. 4 Claude Bernard : " Le9ons de physiologie experimentale, " 2d edi- tion. 1865. 5 Dastre : Arch, de Physiologie, Tome 2, p. 315. 20 DISEASES OF THE INTESTINES. atic juice. While the bile exerts a deleterious influence upon the action of pepsin in artificial solutions, its pres- ence in the stomach does not seem to have any inhibitory effect. The bile exerts an influence upon the digestion of the albuminates in the intestines by precipitating the pep- sin in tho acid gastric contents. It thus destroys the ac- tion of the pepsin. This precipitate, formed by the gas- tric contents and the bile, is soon dissolved, partly through the intervention of freshly secreted bile in abundance, partly through the sodium chloride which arises after the neutralization of the gastric juice by the alkalies present. The action of the bile upon the pancreatic digestion of al- bumin is not deleterious, and may have a beneficial effect in the presence of organic acids which, as a rule, exist in the upper parts of the small intestine. Aside from the chemical processes caused by the enzymes in the intestines there also exist fermentative and putre- factive changes produced by micro-organisms. These are but very slight in the upper part of the intestine and increase in intensity toward the end of the small intestine and in the greater part of the large bowel, while they again decrease in the lower part of the bowel and in the rectum. According to Macfadyen, Nencki, and Sieber, 1 who have repeatedly analyzed the intestinal contents of a man with a fistula situated near the end of the ileum, only fermen- tative processes take place within the small intestine. The contents obtained in this case had a golden-yellow color and showed an acid reaction, the acidity amounting to one per mille. As a rule, they were odorless. The principal elements of the acidity consisted of acetic, lactic, and paralactic acids, volatile fatty acids, succinic acid, and 1 Macfadyen, M. Nencki und N. Sieber : Arch. f. experimentelle Pathol. u. Pharm., Bd. 28, p. 311. PHYSIOLOGY. 21 biliary acids; albumin, peptone, mucin, dextrin, sugar, and alcohol were present; leucin and ty rosin, however, were absent. Thus, according to these authors, fermenta- tive processes in the small intestine result merely from the action of microbes upon carbohydrates, which ac- tion ultimately leads to the formation of ethyl alcohol and the organic acids just mentioned. The latter pre- vent the putrefaction of albuminates within the small in- testine and also partly check the decomposition of the carbohy drates. The putrefaction of the albuminates takes place in the large intestine, the contents there having an alkaline reac- tion. The decomposition of the albuminates by the putre- factive processes caused by micro-organisms goes much further than that by the pancreatic digestion. The pan- creatic digestion of the albuminates gives rise to albumoses and peptones, lysin, lysatinin, proteinchromogeu, amido- acids, and ammonia. In the putrefaction of the albumin- ates at first the same products are formed, but the decom- position advances still further and generates a host of new products: indol, skatol, paracresol, phenol, phenyl-propi- onic acid and phenyl-acetic acid, para-oxyphenyl-acetic acid, hydroparacumaric acid, volatile fatW acids, carbon dioxide, hydrogen, marsh gas, methyl mercaptan, and sul- phuretted hydrogen. In the putrefaction of gluten neither ty rosin nor indol is formed while glycocoll is developed. Of the products of decomposition just named some are of great importance, as they are eliminated by way of the urine after their absorption from the intestinal wall. Some of them, as for instance the oxy-acids, appear unchanged in the urine, others (like the phenols) after further oxidation, and still others (like indol and skatol) after combination with ethereal sulphuric acids. The presence of ethereal 22 DISEASES OF THE INTESTINES. sulphuric acids in the urine is thus to a certain extent an indication of the amount of putrefaction going on in the intestine. The putrefactive processes in the intestine relate not only to the ingested food but also to the secretions rich in albuminates. Thus Miiller ' observed that Cetti during his fasting period first showed a diminution of the amount of indican in the urine which entirely disappeared on the third day. The phenol elimination was also at first diminished, but beginning from the fifth day of fasting it commenced to increase, and on the eighth or ninth day reached an amount which was three to seven times that of a mai: under ordinary conditions. The putrefactive processes within the intestines, how- ever, do not reach that height which they attain outside of the body. Thus, for instance, the fresh contents of the large bowel do not present so fetid an odor as a pancreatic infusion or decomposing albumin would reveal after long standing. The putrefaction within the intestine is partly checked by several factors : 1. Carbohydrates as such exert an inhibitory influence upon putrefaction (Hirschler 2 ); the organic acids which develop during their fermentation also partly check putre- faction. Of other foods, milk and kumyss, according to Schmitz, 3 likewise lessen the processes of bacterial de- composition, this effect being due to the presence of lactose and also of lactic acid. 2. The bile exerts a decidedly anti-putrefactive action. As shown by Liudberger 4 and Limbourg, b albumin to which bile is added does not decompose so thoroughly as 1 Miiller: Berl. klin. Wochenschr. , 1887. No. 24. * Hirschler : Zeitschr. f. physiol. Chemie, Bd. 10. p. 306. 3 Schmitz : Zeitschr. f. physiol. Chemie, Bd. 17, p. 401. 4 Lindberger : Maly's Jahresber. , Bd. 14, p. 334. 5 Limbourg : Zeitschr. f. physiol. Chemie, Bd. 13. PHYSIOLOGY. 23 without it. The biliary acids, moreover, inhibit putrefac- tion through their acid elements. 3. Absorption. The rapid absorption of fluids from the intestinal wall and the forward motion of the contents do not permit the putrefactive processes to get the upper hand. These fermentative and putrefactive processes taking place within the intestines serve to augment the various means at the disposal of the organism to utilize or to break up into simpler components the more complex groups of various food substances. In the normal state these putre- factive processes are most probably checked before any deleterious substances can be developed. The intestinal contents on their long way from the duo- denum to the anus show the presence of different gases. These consist of traces of oxygen and a larger amount of nitrogen ; the latter is derived either from swallowed air which has come from the stomach, or from pure nitrogen which has been diffused from the tissues through the in- testinal walls. Carbonic-acid gas is present which has been developed through neutralization of the acid gastric con- tents by the pancreatic and intestinal juices, and also from the butyric and lactic acid fermentation of the carbohy- drates. Hydrogen is found in larger amounts after a milk diet and only in small quantities after a pure meat diet. Methyl mercaptan and sulphuretted hydrogen are present in traces, and undoubtedly owe their origin to the albumin. Marsh/ gas likewise results from the decomposition of albumin, but it is also evolved from the fermentation of carbohydrates, especially of cellulose. These different gases are formed and absorbed all along the intestinal walls, and most probably help to mix the contents and thus facilitate absorption. If present in too large quanti- ties, they are easily passed through the rectum ; occasion- 24 DISEASES OF THE INTESTINES. ally some of the gases contained in the upper part of the small intestine may be eructated by way of the stomach through the mouth. In passing through the large bowel the intestinal con- tents become thickened through the rapid absorption of the fluids, and at last are eliminated as fecal matter. This (faeces) comprises the remnants of the undigested material, excretory products of the intestines, and a host of micro- organisms. The quantity of fecal matter within twenty- four hours varies greatly according to the mode of nourish- ment. Thus after a mixed diet it amounts usually to from 120 to 150 gm. After a vegetable diet, however, the quan- tity, according to Voit, 1 reached 333 gm. The reaction of the faeces is varied. Often it is found acid in their inner parts, while the outer surface shows an alkaline reaction. Their peculiar odor is principally due to Brieger's skatol, but 'also to indol and other substances. Their color is usually of a light or dark brown, according to the charac- ter of the nourishment. 2. Absorption. The object of digestion is to dissolve and partially change the food substances into such combinations as can be assimilated by the blood. Before assimilation can be effected absorption must take place. The main place for the absorption of nutritive material is the small intestine. It will be best to describe the process of absorption of the different food materials separately. (a) The proteids are usually changed into albumoses and peptones before their absorption. Albumen as such, however, is also liable to be absorbed, although not so quickly as when its change into peptone has been accom- 1 Voit: Zeitschr. f. physiol. Chemie, Bd. 13. PHYSIOLOGY. 25 plisbed. The absorption of albumoses and peptones takes place through the intestinal wall by way of the capillaries of the blood-vessels and not through the lacteals. Thus Munk and Rosenstein ' observed in a patient with a lymph fistula that after a meal rich in albuminous food the lymph did not contain more proteids than before the meal. The peptones and albumoses do not reach the blood current as such, but are previously reconverted into albumin. This fact has been clearly shown by the experiments of Ludwig and Salvioli. 2 These investigators tied a resected intesti- nal coil at both ends and injected into its lumen a solution of peptone, while the coil was kept alive with defibrinated blood. Although the peptone entirely disappeared from the intestinal coil, the blood did not contain even traces of peptone. It therefore must have become changed into another substance. This change of the peptones into al- buminates before reaching the blood is of teleological im- portance. For, as has been shown by Schmidt-Muhlheim 3 and others, peptone introduced into the circulating blood is soon eliminated with the urine. Where the change of the peptones into albuminates takes place and by what mechanism are not as yet certain. Some seem to believe that the epithelial cells of the intestinal walls perform this office, others that the leucocytes are the means of its con- version. The absorption of the albuminates appears to be more complete as regards animal than vegetable food. The reason for this is that the cellulose surrounding the legu- men partly renders its absorption more difficult. Again, the peristalsis being greater after vegetable food, the iutes- 1 Munk and Rosenstein : Virchow's Arch., Bd. 123. 8 Ludwig and Salvioli : Du Bois-Reymond's Arch., 1880, Suppl. 3 Schraidt-Miihlheim : Du Bois-Reymond's Arch., 1880. 26 DISEASES OP THE INTESTINES. tinal contents pass through the canal quicker, and thus less of the albumen is utilized. And again, according to Hammarsten, ' a part of the nitrogenous substances of the plant proteids appears to be indigestible. (b) The carbohydrates are absorbed principally as raono- saccharides. Glucose, laevulose, and galactose are absorbed as such. Cane sugar and maltose are ordinarily changed first into glucose and Isevulose. According to Voit and Lusk, sugar of milk is not converted, and is either partly absorbed as such or else undergoes lactic-acid fermenta- tion. The different kinds of sugar are absorbed through the capillaries of the villi and thus reach the circulation. They enter the liver through the vena porta and are here retained in great part as glycogen. In case, however, a large quantity of sugar is at once absorbed, it may occa- sionally reach the lacteals and thus enter the blood current outside of the liver. In such instances sugar appears in the urine, a condition which is known as alimentary glyco- suria. The introduction of larger quantities of sugar into the intestinal tract occasionally gives rise to diarrhoea. Carbohydrates, however, even in large amounts in the form of starch, will be absorbed without difficulty and without giving rise.to any trouble. (c) The fats. In the absorption of fats their emulsifica- tion seems to be of greatest importance. Although a small part is absorbed in the form of soaps, the greatest quan- tity of fat is taken up in the form of an emulsion. The latter comprises not only neutral fats but also fatty acids. These, however, undergo a change into neutral fats after their absorption from the intestinal walls. It is generally accepted that fats after their absorption from the intestinal 1 Olof Hammarsten : " Lehrbuch der physiologischen Chemie, " Wies- baden, 1895, p. 293. PHYSIOLOGY. 27 wall directly reach the lymphatics and thus enter the tho- racic duct, whence they afterward find their way into the blood current. In a girl with a lymph fistula Munk and Rosenstein found that sixty per cent of the ingested fat appeared in the lymph. After giving the patient erucic acid (a fatty acid foreign to the organism) they could dis- cover thirty-seven per cent of this particular substance in the form of neutral fats. Thus it appears to be proven that while the proteids and carbohydrates after their ab- sorption directly reach the blood current, as mentioned above, the fats are an exception and directly enter the lac- teals. The ultimate way in which absorption takes place is not as yet known. It must, however, be accepted that the epithelial cells of the intestinal wall cause this process by some specific action. The absorptive property of the small intestine for fat is very great. According to Rub- ner, 1 a man can absorb over 300 gm. of fat per day. Not all kinds of fat, however, have the same coefficient of as- similation. Thus fats with a low melting-point (olive oil, goose fat, butter, etc.) are absorbed more quickly than those with a high melting-point (mutton fat and stearin). Moreover, free fats, like butter and lard, are assimilated more quickly and thoroughly than bacon, in which the fat is surrounded by connective tissue. Besides the above-named three groups of food sub- stances, water and different salts which are kept in solu- tion are very quickly and thoroughly absorbed all along the intestinal tract. Aside from the salts, other soluble substances of the secretory juices are also absorbed. Thus the urine contains traces of pepsin and also urobilin, which shows that the biliary products must have been absorbed and eliminated through the urine. According 1 Kubner : Zeitschr. f. Biologic, Bd. 15. 28 DISEASES OF THE INTESTINES. to Schiff, 1 the bile is absorbed from the small intestine and reaches the liver with the blood current in order to be eliminated again by this organ from the blood. The pancreatic juice being the principal factor in the di- gestion of the different kinds of food, it appears of interest to ascertain how much of these foods will be absorbed after the pancreas has been excluded from participation in the act of digestion. Minkowski and Abelmann a experimented on dogs by extirpating the pancreas, and found that forty- four per cent of the proteids and from fifty -seven to seventy- one per cent of carbohydrates (amylaceous food) were ab- sorbed, while the fats remained totally unabsorbed. The fat contained in milk, being emulsified, however, was absorbed to the extent of from twenty-eight to fifty-three per cent. While the main place at which the absorption occurs is the small intestine, the large bowel is also able to serve- in this capacity. Thus aside from the absorption of fluids and salts which normally takes place in this organ, albu- minates and carbohydrates can be absorbed in consider- able amounts, and fats in small quantities. This function of the large bowel is of great practical importance, as it is utilized in some conditions for nourishing purposes (rectal alimentation). 3. Motion. The motor function or peristalsis of the intestine has for its objects the thorough mixture of the contents and their propulsion through the entire canal until their final exit through the anus. Nothnagel ' and Braam-Houk- 1 Schiff : Pflttger's Arch., Bd. 3. * Abelmann : "Ueber die Ausnutzung der Nahrungsstoffe nach Pan- kreasexstirpation. " Inaug. Dissert., Dorpat, 1890. 3 H. Nothnagel: "Beitrage zur Physiologic und Pathologic des Darms, " Berlin, 1884. PHYSIOLOGY. 29 geest ' have studied the process of intestinal peristalsis in animals. After laparotomy the latter were kept in a bath of physiological salt-water solution of 38 C., and the mo- tions of the intestines were investigated. Three types of intestinal peristalsis were discerned: 1. The ordinary peristaltic motion. The intestinal tract con- tracts at a certain point and thereafter relaxes. The con- traction is carried with moderate rapidity for a certain length contiguously in the direction toward the anus and the contents are pushed forward. 2. Oscillating motions. An intestinal coil is here moved to and fro all along its mesentery without any particular contraction at any point. The contents are not propelled, but simply mixed up dur- ing these motions. 3. Kotary motions. A filled intesti- nal coil experiences a circular constriction which is rapidly carried over the intestine for the length of about 20 cm. This is exactly the same process as described under 1, but executed in a violent manner. "NVhile the first two types of intestinal peristalsis are purely physiological, the third type is partly pathological. It is met with only when the contents are mixed with a great deal of gas. Thus, after indiscretions in diet, we often feel this kind of rapid motion going along with a gurgling sound (tormina intestinorum). This type is ob- served only in the small intestine, but never in the large bowel. The small intestine manifests much quicker peristalsis than the large bowel, the motions of which are very slow. Here the haustra during the act of peristalsis contract and then protrude in regular order. The small intestine while empty does not show any motion whatever, but after the entrance of chyme into the duodenum intestinal peristalsis 1 Braam-Houkgeest : Pfliiger's Arch., Bd. 7, p. 266. 30 DISEASES OF THE INTESTINES. begins. It is not, however, transmitted down to the Bau- hinian valve without interruption, but stops as a rule at a certain distance from its starting-point (about 20 cm.). After an intermission of some duration it begins again. Thus one or more intestinal segments may be in a state of peristalsis while other parts of the intestine in between are at rest. The time for the arrival of the first particles of chyme from the duodenum into the caecum is about two hours. But, of course, the intestinal peristalsis must con- tinue until the stomach has expelled the last portions of the chyme, that is to say, within about two hours after the stomach has become empty the small intestine as a rule will also be found free of contents. The forward motion of the contents in the large bowel is a very slow one in- deed. It takes as a rule from twenty to twenty -four hours for the fecal matter to move from the caecum to the rec- tum. Antiperistalsis, or reversed motion of the large bowel and the small intestine, beginning at the anus and extend- ing upward, has never been seen by Nothnagel in physio- logical conditions. The process of peristalsis is controlled by nervous influ- ences. Auerbach's and Meissner's plexus most probably contain automatic nerve centres for this act. But there are also other centrally located nervous agencies. Thus after great mental excitement diarrhoea very often results, showing that the intestinal peristalsis must have been greatly increased through the influence of the brain. There are also numerous nerves which supervise the motor function of the entire intestinal tract. Pfliiger ' has shown that the splanchnic nerve contains inhibitory fibres for the 1 Pflliger: "Ueber das Hemmungs- und Nervensystem fur die peri- staltischen Bewegungen der Gedarme, " Berlin. 1857. PHYSIOLOGY. 31 intestinal peristalsis. According to Ehrmann, 1 accelerat- ing and inhibitory fibres supervising intestinal peristalsis are contained in the vagus as well as in the splachnicus, but they have a varied function according to the way they ond, whether in the longitudinal or in the circular muscles. The longitudinal muscles are stimulated by the splanchnic and paralyzed by the vagus. The circular muscles, on the other hand, are stimulated by the vagus and paralyzed by the splanchnic. Normally the chyme acts as a stimulus on the intestinal canal and provokes peristalsis (through the influence of the nerves). Too cold drinks, indigestible food, organic acids (present in too large amount) may often cause an increased peristalsis and thus produce diarrhoea. Toxic substances which are ingested or developed from unwholesome food may have the same effect. 1 Ehrmann : Wiener med. Jahrbilcher, 1885. CHAPTER II. METHODS OF EXAMINATION AND TREATMENT. EXAMINATION. Interrogation. THE examination begins with a thorough interrogation of the patient. Before starting with the narration of the present ailment a general outline of previous sicknesses is of value. Diseases which involve the intestinal canal, like typhoid fever, dysentery, and the like, are of special impor- tance, as they are liable to be etiological factors in the de- velopment of consecutive ailments. The mode of living, with regard to habits (drinking, smoking, etc. ), should also be inquired into. The patient is then asked to describe his present com- plaint. He should state the time when the trouble began and its nature. If the chief complaint refers to pains, it is necessary to inquire as to their location and character. Pains felt in the neighborhood of the navel usually origi- nate in the small intestine ; those experienced in the right iliac region often emanate from the appendix ; while those in the left iliac region and in and about the rectum have their starting-point in the sigmoid flexure and in the lower portion of the rectum. Are the pains of long duration or do they last only a very short while, a few seconds or min- utes? The former variety is usually caused either by an affection of the sensory nerves of the intestines or by some organic lesion, like ulcers, etc. The latter variety, to which EXAMINATION. 33 the name colic is applied, is due to a strong spasmodic contraction of a certain part of the bowel. Colicky pains are often followed and relieved by the passing of flatus or of fecal matter. Occasionally these pains also shift from one place of the abdomen to another, and the route of their travel is distinctly felt by the patient. Abnormal sensations, a feeling of heat or cold may also be experienced over a certain area of the abdomen. A fre- quent or constant desire for an evacuation (tenesmus) is encountered in dysentery and in many affections of the rectum. It is also advisable to inquire whether the pains and abnormal sensations appear at a certain period of the day or at a certain time after meals (soon after eating or three to four hours later), or whether they are experienced at night or especially in the early morning hours. The condition of the bowels should always be described in detail. Do the bowels act regularly and is the evacua- tion of sufficient quantity ? What is its consistency? Is the stool of sausage-shape and pliable, or is it hard or very soft, mushy, watery? What is its color? Is it dark brown or light yellow or clay-colored or black? Is there an ad- mixture of mucus or blood? If there is constipation, in- quire whether the bowels move without any cathartics after a period of constipation of a few days, and if not, whether mild aperients are sufficient to cause an evacuation, or whether a strong drastic remedy is necessary. Does the constipation alternate with periods of normal movements or with periods of diarrhoea? Are the periods of constipa- tion, if cathartics are not resorted to, accompanied by any marked symptoms (headaches, dizziness, anorexia, etc.) or not? If there is diarrhoea, the patient should state how many movements a day he has. Is he disturbed during the night, or is the diarrhoea confined principally to the 3 34 DISEASES OP THE INTESTINES. morning hours? Does the diarrhoea alternate with periods of constipation ; does it disappear after a change of climate, or is it aggravated by mental excitement? Is there a feel- ing of exhaustion in connection with it? Is the abdomen filled up with gas (meteorism)? Does this phenomenon pertain to a special part of the abdomen (the upper or lower region, right or left side), or does it extend over the entire abdomen? A feeling of tension in the abdomen with frequent passing of wind, belching, and flatus, is com- monly designated as flatulency. It is necessary to inquire whether this symptom is present principally at a certain time of the day or continuously. Absence of flatus is of significance if it occurs in conjunction with obstinate con- stipation, otherwise it is of no consequence. In all intestinal disorders it is necessary to inquire as to the state of the stomach. The latter organ being in direct communication with the intestines, it will often be subject to disturbances in intestinal affections. Com- plaints of a bad taste and smell in the mouth are often made, principally in constipation. Anorexia and nausea are present in the most varied intestinal disorders. Vom- iting frequently occurs in intestinal obstruction. Inspection. Inspection of the abdomen is best made in good daylight with the patient in the recumbent posture, but should also be completed by inspection in the standing position. The condition of the skin of the abdomen is first examined. Sometimes striae or scar-like lines running parallel to each other over some part of the abdomen (especially the lower part) , and presenting either a silvery hue or, if not old, a rather reddish tinge, are observed ; these are always signs of a very marked former disteution of the abdominal pari- EXAMINATION. 35 etes. Thus they are found after frequent pregnancies, also after the removal of rapidly developing abdominal tumors, or after tapping for ascites. These striae persist long after the disappearance of the conditions which caused their development. Distention of the abdominal veins, giving them a bluish hue, is observed whenever the return flow of the venous blood of the lower extremities is retarded either by in- creased iutra-abdominal pressure (ascites, tumors of the abdomen) or by thrombosis or compression of the iliac vein or of the vena cava inferior. Cirrhosis of the liver and compression of the portal vein often produce the same result. In the latter condition there is an extensive forma- tion of veins over the navel which is commonly called caput Medusae. After observing the appearance of the skin, the shape of the abdomen is then minutely considered. In normal conditions, in grown people, the abdomen and the chest are on the same level in the recumbent position. In small children the abdomen as a rule is somewhat more prominent than the thorax. In very old age the abdomen appears somewhat sunken. The greatest degree of a re- tracted or trough-shaped abdomen is found in stricture of the oesophagus or cardia, in basilar meningitis, and in lead poisoning. Long-continued inanition, no matter of what origin, also causes this phenomenon. Protrusion of the abdomen occurs either over a definite area or over the entire surface. The abdomen may pre- sent the shape of a round hemisphere or of a flattened one if there is an accumulation of air and gas in the intestines (intestinal meteorism). This occurs principally in atonic conditions of the intestines and in hysteria. A uniform protrusion of the abdomen or a general bloated condition is present in general peritonitis, occasionally also in pro- 36 DISEASES OF THE INTESTINES. nounced atony of the intestines. In case of ascites, no matter to what cause it is due (tumors, cirrhosis of the liver, nephritis, etc.), the abdomen is also more or less evenly protuberant above, while the lower parts bulge out somewhat in the recumbent position. This is caused by the accumulation of fluid in the lower portions of the ab- dominal cavity. Change of posture alters the shape of the abdomen. This applies to the early period of ascites, during which the abdominal cavity is not yet filled to its maximum ; later, when this is the case, the abdomen ap- pears uniformly enlarged, and there is no bulging out of any particular portion. Change of position then no longer alters its shape. Protrusion of a certain part of the abdomen is noticed in many cases of neoplasm, sometimes in fecal concretions, and occasionally in appendicular abscesses. In umbilical hernia a small, more or less roundish protrusion is noticed in the region of the navel. In diastasis of the rectus ab- dominis muscles there appears in the middle line of the abdomen a long protrusion of sausage shape consisting of prolapsed intestine. Sometimes there is a pronounced protrusion of this area owing to the escape of a large mass of the bowel through the gap in the muscles. In patients with thin abdominal walls very small sau- sage-shaped prominences are occasionally visible which quickly change their configuration, appearing now in one place and now in another. This phenomenon is caused by peristaltic contractions of the small intestine. As a rule, they are not associated with pain and do not denote a mor- bid condition. Sometimes similar peristaltic waves in the small intestine appear periodically and annoy the patient. Here they may be caused by nervous influences. Peri- staltic contractions of the small intestine appearing in a EXAMINATION. 37 violent manner and caused by a stenosis or an obstruction of the intestinal lumen are usually much more pronounced, that is, the prominences are much higher and involve larger areas of intestine, the waves moving with greater rapidity and strength and being accompanied by intense pain. Visible peristaltic contractions of the large bowel FIG. 10. Sims' Rectal Speculum. FIG. 11. Allingham's Rectal Speculum. are ordinarily met with only in cases of partial or total intestinal obstruction. Inspection of the anal region is best made when the pa- tient lies on his side with his back toward the examiner. The buttocks are held apart with the hands, and thus thor- ough inspection of the anus is rendered possible. Piles, fissures, fistulse may thus be discovered. Proctoscopy. In order to inspect the anus internally and also the rectum it is necessary to introduce a speculum. This method of inspecting the rectum is called proctoscopy. Of the many specula devised for this purpose I would mention those of Sims, Allingham, and Kelly as the most practical (see Figs. 10, 11, 12). Kelly's speculum, which 38 DISEASES OP THE INTESTINES. consists of a hollow metallic tube provided with an obtu- rator, is best suited for this purpose. Before inserting the instrument it must be thoroughly smeared with sweet oil or vaseline. In cases in which the rectal region is inflamed or ulcerated, it is necessary, in order to avoid too much pain, to induce anaesthesia of these parts by painting them with a ten-per-cent cocaine solution or by the introduction JOHN REYNDER yCO. NSW YORK. FIG. 12. Kelly's Rectal Speculum. of a suppository of opium with belladonna or of cocaine. It is hardly necessary to say that endoscopy of the rectum must not be performed until after a thorough evacuation of the bowels. It is best to wash out the gut before examin- ing with the speculum. When the speculum is in position a portion of the rectal mucosa becomes visible when good light is thrown into the endoscopic tube. The source of light is immaterial, although it is best to have electric light. Usually a small electric lamp with a reflecting mir- ror fastened to the head of the examiner best serves the purpose. The higher up the bowel has to be examined the longer the speculum must be. After the full insertion of the instrument the highest portion of the bowel is first EXAMINATION. 39 examined, and while gradually drawing out the speculum the entire area of the bowel through which it passes will be brought into view. Small ulcers, atrophic and congested conditions can thus be easily recognized and malignant growths detected at an early period. TrcDisillumination. Transillumination of the bowel was first suggested by myself ' and later practised principally by Heryng and Reichmann." After a thorough cleansing of the bowel by means of high irrigation about one quart of water is injected and an electric illuminator (very similar in construction to the gastrodiaphane) is inserted into the rectum. The examination must be made in a dark room. By gradually pushing up the instrument successive portions of the bowel may be transilluminated. This method, how- ever, has not as yet proven to be of any practical value. Roentgen Rays. The examination of the colon by means of Roentgen rays seems to be somewhat more promising. A soft-rubber Tectal tube through which a flexible wire passes is introduced into the bowel as high up as possible and the patient exposed to the Roentgen apparatus. The wire within the tube becomes visible as a shadow, and thus marks the course of the bowel in which it lies. Inasmuch as it is hardly possible to insert an instrument higher up than the sigmoid flexure, the following procedure for the Roentgen examination appears to be of greater value : The bowel is filled with two quarts of water in which 60 gm. (2 ounces) of subnitrate of bismuth are suspended by means of a starch solution. This mixture penetrates almost the entire colon, and thus the position of the large bowel can be determined by the Roentgen rays. 1 Max Einhorn . " Die Gastrodiaphanie. " New-Yorker medicinische Monatsschrift, November, 1889. 2 Heryng und Reichmann : Therapeutische Monatshefte, 1892. 40 DISEASES OF THE INTESTINES. Palpation. Palpation is the most important procedure available among the methods of examination in abdominal diseases. It is best performed in the recumbent position of the patient, the head being slightly raised and the abdominal muscles relaxed as much as possible. In order to effect this the room must be of a comfortable temperature and the hands of the examiner warm. If the patient is fidgety and contracts his abdominal walls, it is necessary to talk to him and to draw his attention away from the exam- ination. I have often noticed a great relaxation of the muscles during an expiration following a deep inspira- tion. Whenever, therefore, it is difficult to obtain relaxa- tion of the abdomen I tell the patient to take a deep inspiration and then make use of the following period of expiration for palpation. If all these means fail to relax the abdominal muscles, palpation may be tried in a warm tub bath, as first recommended by Chlapowski, or under chloroform narcosis. In cases of great diagnostic impor- tance the latter method is certainly preferable. In palpat- ing the abdomen it is advisable first to examine with the entire palm of the hand, applying very little pressure, thus determining the state and consistency of the abdomen. The hand may thus be passed over the entire abdominal surface from one place to another. This having been done, palpation is then performed with a trifle more pressure, the finger tips being used for this purpose. The latter procedure serves for exploring a more circumscribed area. Finally, deep palpation is practised for which considerable pressure may be required. Palpation aids us in discovering the position of some of the abdominal organs. With regard to the intestine the EXAMINATION. 41 following portions are often accessible to this method of ex- amination : the csecuni and part of the ascending colon, the transverse colon, and the sigmoid flexure. In some in- stances the descending colon above the sigmoid flexure can also be palpated, especially if it is filled with hard scybala. The jejunum and ileum filling most of the lower part of the abdominal cavity (from the navel downward) cannot nor- mally be separately- outlined. For the detection of tumors in the abdomen palpation is of great service. By means of it we gain information with regard to their size, shape, and consistency. An uneven protuberant surface is characteristic of malignant growths, while an even surface is more often found in benign neo- plasms or in intussusception. A fecal tumor can be recog- nized by indentations made by pressure with the fingers. Sometimes after such pressure it is possible to notice for a moment, when raising the finger, a slipping off of the in- testinal wall from the fecal mass. This phenomenon, first described by Gersuny ' under the name of " Klebesymptom, " I have observed quite frequently and consider of practical value. Another important object of palpation is to ascertain whether there is tenderness or pain on pressure. While strong pressure exerted upon the intestine through the ab- dominal wall eve'u normally elicits an unpleasant sensation, there is, however, no distinct pain connected with thio act. Tenderness on slight pressure is often present in inflam- matory conditions of the bowels and also in ulcerative processes. A circumscribed pain on pressure is present in the appendicular region (McBurney's point) in appen- dicitis, especially in % the acute form. In chronic appendi- citis the pain may be elicited only upon very strong press- 1 Gersuny : Wiener klinische Wochenschrift, 1896, No. 40. 42 DISEASES OF THE INTESTINES. FULL SIZE JOHN RBTffDKRSCO. KKW YORK. FIG. 13. Finger Cot. ure. In ulcerations of the bowel there may be also one or several circumscribed areas very painful to pressure. In pains due to a purely nervous affection of the bowel pressure may afford relief. If a mere touching of the ab- domen elicits pain, it is a sign either of an extensive inflam- matory process with- in the bowel or of peritonitis. Palpation in the form of tapping oc- casionally produces a splashing sound (clapotage) over some portions of the bowel. The splashing sound can be elicited over the colon only when it is filled with liquid or semi-liquid matter and gas. It can be discovered off and on either in the caecum and in the portion of the bowel im- mediately above it or in the sigmoid flexure. In the small intestine clapotage can be obtained only in the dilated portion of the gut above a stricture. Boas J first suggested the method of filling up the bowel with from 500 to 600 c.c. of water and then examining for the splashing sound along the colon. When the patient has been thus pre- pared, clapotage can be produced in the sigmoid flex- ure ; and by having the patient turn on his right side, it can occasionally be produced in the transverse colon, and finally in the cfecal region. In cases of atony of the bowel Boas was able to evoke the splashing sound even after the injection of only 200 to 300 c.c. of water. Frieden- i 1 Boas : ' " Diagnostik und Therapie der Magenkrankheiten, " Theil i., 1897, 4te Auflage, p. 105. EXAMINATION. 43 wald ' lias also practised the same method with advan- tage. Whenever the splashing sound can be produced in the colon it serves the purpose of determining the situa- tion of this organ. The rectum is best palpated with the index finger well oiled or smeared with vaseline or encased in a rubber cot (Fig. 13) and anointed in the same way. The condition of the anus and the lower portion of the rectum can be advantageously investigated with the finger. The examination may be made either in the recumbent posture of the patient, in the side or knee- elbow position, or in the standing po- sition. In the latter instance it is well to have the patient exert down- ward pressure upon the rectum. Hemorrhoids, polypi, and malignant growths can thus be occasionally dis- covered. In cases in which there is a suspicion of malignant growths in- volving portions of the colon not ac- cessible either to palpation by the finger or inspection with the procto- scope, examination with the entire hand in chloroform narcosis can be tried as first practised by Simon. 2 After dilating the anal sphincters, the entire right hand and the arm are inserted into the bowel through the anus, and thus the higher portions of the 1 J. Friedenwald : Medical News, 1894. * Simon Verhandlungen der deutscben Gesellsch. f. Chirurgie, 1871, and Deutsche Klinik 1^72 FiG.l-ki. FIG. 15. FIG. 14b. FIGS. 14a and 146. Cylin- drical Bougies. FIG. 15. Olive-Point Bou- gie. 44 DISEASES OF THE INTESTINES. colon palpated with the fingers. This method can be recr om mended only in cases of extreme importance, as such an examination is liable to produce unpleasant symptoms, as, for instance, incontinence of the rectum, tearing of the mucous membrane, etc. Palpation of the rectum by means of sounds is performed whenever there is suspicion of a stricture involving por- tions of the bowel not accessible to examination by the fin- ger. For this purpose either bougies (see Figs. 14 and 15), or, still better, rectal tubes of various calibre may be employed. Kuhn ' has recently recommended the use of tubes provided with a metal spiral. He believes that these penetrate the colon farther up without bending. His statements have, however, not as yet been corroborated. Percussion. Percussion is of less importance than palpation. In many instances it serves to confirm the results obtained by the latter. In percussing the intestines it is best to use the fingers. It should be done rather gently. Mild percussion permits the discernment of slight differences of sound much better than strong percussion. As is well known, percussion over empty intestinal coils or those filled with gas or air gives a tympanitic sound which is louder over the large than over the small bowel. Intestinal coils filled with liquid or solid substances give dulness. In meteorism of'the intestines percussion will elicit a tym- panitic sound of a deeper pitch than normally, and there will be besides some areas of dulness over the abdomen. The region of the liver and spleen will here show normal conditions with regard to the percussion sounds. Meteor- ism of the abdomen as a result of perforation will manifest 1 Kuhn : Deutsche med. Wochenschr., 1897, Nos. 36 and 37. EXAMINATION. 45 an evenly diffused tympauitic sound all over the abdomi- nal cavity. Usually the dulness over the region of the liver and spleen will have disappeared. In ascites percus- sion will reveal an area of duluess in the lower parts of the abdomen, and there will be a change in the character of the sound on altering the position of the patient. Tumors of the intestine give dulness on percussion. Fecal accu- mulations and appendicular abscesses will also manifest dulness on percussion. Auscultation. Auscultation is not of great significance in diseases of the intestine. Palpation of intestinal coils with the application of moderate pressure may elicit either a gur- gling noise or a friction sound. The latter was formerly believed to be pathognomonic of typhoid fever. Of late, however, it has been recognized that this sign is found in many other conditions. At the time of active peristalsis all kinds of gurgling sounds are heard within the intestine (borborygmi), which, however, are not of much impor- tance. In chronic stenosis of the intestine very loud noises are at times heard, caused by the sudden passage of liquid and gaseous contents through the stricture under great pressure. In the latter affection splashing sounds can also be easily produced over the enlarged bowel above the stric- ture. Often a tympanitic sound of a metallic character can be heard. Inflation of the Intestine with Carbonic Acid Gas or Air. Inflation of the intestine is one of the most important diagnostic procedures. Von Ziemssen, 1 who first intro- duced this method of examination, injected successively 1 Von Ziemssen : Deutsches Archiv f. klinische Medicin, 1883, Bd. 33, S. 235. 46 DISEASES OF THE INTESTINES. into the bowel two solutions, one containing tartaric acid, the other bicarbonate of sodium in water. The carbonic acid gas developing fills the large bowel, which can then be recognized by the tympanitic percussion sound, or, in rare instances, by inspection. Schnetter, 1 of New York, suggested filling the bowel with carbonic acid gas by means of a tube attached to an inverted siphon containing soda- water, the valve of which is pressed. Here the carbonic acid gas runs into the bowel without any admixture of water. Rosenbach " made use of liquefied carbon dioxide from a sparklet. Instead of the latter Runeberg 3 recom- mended inflation of the intestines by means of air. This is best done by a rectal tube to which a compressible air suction bulb is attached. The advantage this method offers consists in the possibility of regulating the amount of the introduced air. In order to be able to measure the amount of insufflated air, Damsch 4 has recommended the employ- ment of a syringe of known capacity. An ordinary bicycle pump can be used for this purpose, the rectal tube being attached to it. Inflation of the bowel is of importance in detecting a stenosis of this organ. Under ordinary conditions the injected air evenly distends the entire colon, as can be proven by inspection and percussion. In case there is a stenosis in the large intestine the air will distend prin- cipally that portion of the bowel below the stricture, while that above will remain unchanged. It is thus possible to recognize the seat of a constriction. The significance of this diagnostic means, however, is confined merely to strictures 'Schnetter: Deutsches Archiv f. klinische Medicin, 1884, Bd. 34 8. 638. *O. Rosenbach: Berliner klinische Wochenschrift, 1889, No. 28. 'Runeberg: Deutsches Archiv f. klinische Medicin. Bd. 34, S. 460. 4 Damsch: Berliner klinische Wochenschrift, 1889, No. 75. EXAMINATION. 47 of a high degree, while a beginning stenosis of the bowel cannot be thus recognized, as the air will pass through it. The position of the colon can be ascertained by this pro- cedure. Normally the transverse colon is situated some- what above the navel, while in cases of enteroptosis it may be found about a hand's width above the symphysis. Inflation of the colon is also of importance in the differential diagnosis of abdominal tumors. As is well known, tumors of the intestine will become more distinct after inflation of the bowel with air, while tumors of the kidney, of retroperitoneal glands, and of the spine tend to recede. According to Minkowski, ' abdominal tumors after filling the colon with air or water are usually slightly shifted in the direction of the organ to which they be- long. Inflation of the bowel with air impregnated with ether has been suggested by Dr. Sutton 2 as a means of recog- nizing intestinal perforation. For this purpose he makes use of a bottle filled with two drachms of ether. The bot- tle is provided with a perforated rubber cork to which are attached two rubber tubes provided with stopcocks. One of these is then attached to a bicycle pump and the other to an ordinary rectal tube. The air pumped into the bowel must pass through the bottle containing ether and thus takes up the ether vapors. In case of perforation of the bowel, the ether quickly escapes through the opening into the abdominal cavity and equally distends it; while, if there is no perforation, the bowel, first the large and later the small intestine, becomes filled with air and ether; ulti- mately the ether reaches the stomach and is usually eruc- 1 Minkowski : Berliner klinische Wochenschrift. 1888, No. 31. 2 E. M. Sutton: "Diagnosis of Intestinal Perforations by Means of Ether Inflation per Rectum." Journal of the Am. Med. Assn., Decem- ber 30th, 1899. 48 DISEASES OF THE INTESTINES. tated. The ether can then be recognized by its charac- teristic odor. It seems that this procedure is especially useful in gunshot wounds of the abdomen. Injection of Water per Anum. This is done by means of a rectal tube and a fountain syringe provided with a scale indicating the amount of water used. In case of stricture, especially of the lower portion of the colon, the quantity of water which can be injected is not great, while ordinarily from three to five quarts of water can be poured in. Inasmuch as even nor- mally some people are not able to hold large amounts of water in the bowels without experiencing considerable dis- comfort, the quantity of fluid which can be injected with- out pain is not of great diagnostic value. Filling up the bowel with water can also be made use of for the determi- nation of the position of the colon, as this organ will then give a dull sound. For this purpose, however, the proced- ure in question is not so good as the above-described method of inflation with air. Lavage of (he Bowel. Lavage of the bowel in a similar manner as performed in the stomach has been recommended by Boas ' for di- agnostic purposes. It is best performed in the lateral posture of the patient after an evacuation of the bowels. The same apparatus as for gastric lavage may be used here. The rectal tube, which represents the stomach tube employed in gastric lavage, is attacjied to a long piece of rubber tubing provided with a big funnel. The rectal tube is inserted as high up in the bowel as possible and then the water is poured in until the patient begins to 1 J. Boas: Deutsche Aerzte-Zeitung, 1895. Nos 2 and 3. EXAMINATION. 49 feel some discomfort. As soon as this is the case the fun- nel is lowered and thus the water returns. The latter is now subjected to a thorough examination. Normally the returning water appears pretty clear or slightly turbid by the admixture of small particles of mucus, epithelial cells, and fecal matter. In catarrh of the large bowel a consid- erable quantity of mucus is found. Ulcerative processes accompanied by hemorrhages or by suppuration are often recognized by the admixture of either pus or blood in the wash-water. Occasionally exfoliated pieces of intestinal mucosa are found in the wash-water, and a microscopical examination of them may be of diagnostic importance. Examination of the Fceces. The examination of the faeces is of much service in dis- eases of the intestine. The faeces represent the end pro- duct of the digestive act, consisting of residue unsuitable for further assimilation. It is evident that a thorough knowledge of the dejecta will throw light upon the nature of the activity of the intestines. The normal faeces consist of changed and unchanged remnants of food, bacteria, traces of digestive juices, epi- thelial cells, and salts. The quantity of the faeces for twenty-four hours varies greatly with the kind of food taken. In a mixed diet it usually amounts to from four to seven ounces. The color of the faeces is usually dark brown owing to changed bile pigment, the bilirubin having be- come changed in the intestine into urobilin. The diet has great influence upon the color of the faeces. Meat pro- duces a dark brown, milk a light yellow color, cacao a more or less brownish-red, huckleberries and claret a dirty black-brown color with a greenish hue. The salts of iron and manganese give rise to a darker color than the usual 50 DISEASES OF THE INTESTINES. one, while bismuth produces a more or less blackish color. According to Quincke, 1 all these metals are reduced to oxydule combinations which are responsible for these colors, while the former belief that these metals formed sulphides is not correct. Calomel frequently produces a greenish hue, while senna, santonin, gamboge, and rhubarb give rise to an intensely yellow color. The faeces are normally somewhat soft in consistency and have a sausage shape. In abnormal conditions the con- sistency may be changed in two directions. The dejecta may be greatly hardened and appear in small balls, or in the form of very thin cylinders. On the other hand, the stools may be abnormally mushy or even liquid. The hardened stools which occasionally show grooved impres- sions from the taenia coli bear testimony to their long sojourn in the intestine, thus being exsiccated from the complete absorption of water. They are, however, by no means characteristic of a stenosis of the intestine. Very soft dejecta may be either watery, as for instance in cholera nostras or asiatica, or they are mixed with mucus which can be easily seen when pouring the dejecta into a glass and inverting it, when the mucus as a rule adheres to the surface of the vessel. Odor. The characteristic odor of the faeces is normally caused by skatol and also to a less degree by indol. The fecal odor may be increased whenever the faeces have been retained much longer than normally in the intestine. On the other hand, faeces occasionally present very little or no odor when their sojourn in the intestine has been very short. As a good instance of the latter variety the so- called rice-water movements in cholera nostras and cholera asiatica may be mentioned. Movements with a fetid odor 1 Quincke : Mttnchner medizinischs Wocbenschrift, 1896, No. 36. EXAMINATION 51 occur principally in malignant growths of the large bowel accompanied by ulcerative processes. Remnants of Food in the Fceces. Undigested remnants of food, macroscopically visible, occur in the faeces. Nor- mally, however, only small particles of vegetable sub- stances, like potatoes, asparagus, spinach, peas, etc., are found, while remnants of meat can never be discovered with the naked eye. In case particles of meat are visible, it in- dicates a severe lesion of the intestinal tract. If large amounts of undigested food (even vegetable matter) are present in the faeces, it is also an indication of an existing severe lesion. Abnormal admixtures frequently occur in the faeces, and are occasionally of great diagnostic importance. Thus, blood may be found either in its fresh condition (red) or it may be very dark but not coagulated. In both instances the blood comes from the lower portions of the large bowel. Sometimes the blood appears in a more changed and de- composed form, giving the faeces the appearance of tar. In this instance it originates from the higher portions of the bowels or from the stomach. An admixture of pus in the dejecta which can be macro- scopically recognized occurs only in instances in which pus exists in the lower portions of the large intestine. For if there is pus present in the higher portions of the bowel, it is usually changed before its exit in such a manner that it cannot be detected unless the amount is very consider- able. Fragments of tumor (polypi or torn off particles of can- cer) are occasionally found in the dejecta. A thorough examination of these may be of great help in the diagnosis. Mucus, although a normal constituent of the faeces, can- not be discovered in large amounts under physiological 52 DISEASES OP THE INTESTINES. conditions. Macroscopically visible mucus may exist in the following forms : (1) It may surround the fecal matter in the form of a glassy layer. This usually indicates a diseased condition of the lower portion of the bowel. (2) The mucus may appear in the form of membranes and may be evacuated either alone or after a fecal vacuation. This often occurs in membranous enteritis. (3) The mucus may appear in a mushy movement having a yellowish coloration and be well mixed with faeces. If a glass rod is dipped into such an evacuation the mucus adheres to it. (4) The mucus exists in small particles visible with the naked eye and floating in the watery dejecta. All these varieties of mucus with the exception of (2) indicate the presence of a catarrhal condition of the intestine. Intestinal parasites also occur in the faeces, and their discovery may elucidate the diagnosis. Chemical Examination of the Faeces. The reaction of the faeces is normally neutral or slightly alkaline. Under a diet rich in vegetables, however, it is slightly acid. In cases in which there is an occlusion of the bile duct so that it does not empty into the intestines the reaction is strongly acid. The test for the reaction is best made by means of litmus paper. The reaction at the surface of the fecal mat- ter may be different from that in the interior. It is there- fore best to test both. The amount of acidity or alkalinity of the faeces can be determined by mixing 10 to 20 c.c. of the fresh fecal matter with about 100 c.c. of distilled water. A drop of a phenol- phthalein solution is added and as much of a decinormal solution of either sodium hydrate or sulphuric acid until the red color appears, or if the alkalinity has to be deter- mined, disappears. The reaction of the faeces is, however, not of much diagnostic value. EXAMINATION. 53 Tests for Mucin. According to Hoppe-Seyler, mucin forms one of the principal constituents of the faeces. In order to test for it the faeces are thoroughly mixed with water and an equal volume of milk of lime, allowing the mixture to stand for several hours. It is then filtered. Acetic acid is now added to the filtrate. In the presence of mucin a precipitate forms. In case particles of sus- pected mucus are visible within the faeces, they can be examined separately in the following manner : A small flake of the mucus is dissolved in a weak solution of potassium or sodium hydrate, and acetic acid added. If the precipi- tate remains uudissolved after the addition of the acetic acid in excess, it proves the presence of mucin. Inasmuch as nucleoalbumiu also gives the reaction just described, the positive proof that the precipitate is due to mucin is afforded by heating it in a diluted mineral acid to the boil- ing-point. If mucin is present the heated solution will contain a substance reducing copper oxide. Another very useful test for the presence of mucin consists in staining the flake of fecal matter resembling mucus with a weak triacid solution (Ehrlich). The presence of mucus pro- duces a green color, while if the flake consists of albumin, a red color arises. This test, first described by Pariser, 1 I have found of practical value. Albumin. In. order to examine the faeces for albumin, they are treated repeatedly with water slightly acidified with acetic acid. The watery extract is filtered several times and the filtrate examined for albumin according to the methods used in examinations of the urine for this substance. The addition of acetic acid and potassium ferro- cyanide, however, is best suited for this purpose. Under normal conditions there is no albumin present in the faeces. 1 Pariser : Deutsche medicinische Wochenschrift, 1893, No. 41. 54 DISEASES OF THE INTESTINES. Von Jaksch ' found it present in typhoid fever, in isolated cases of acute enteritis, and in chlorosis. Propeptone and Peptone. After the test for albumin has been made with negative result, the watery extract of the faeces is treated with phosphotungstic acid, the precipi- tate diluted with water and sodium hydrate and a small amount of a weak solution of sulphate of copper added. A purplish-red color (biuret test) shows the presence of both propeptones and peptones. If it is desirable to ascer- tain the presence of peptones separately it is necessary to first precipitate the propeptone by the addition of a large amount of ammonium sulphate. In normal dejecta Von Jaksch never encountered peptone. Pathologically he found it in typhoid fever, dysentery, tuberculous ulcer of the intestine, and in perforation peritonitis. Carbohydrates. In order to test for the presence of car- bohydrates, the faeces are subjected to distillation. The residue is extracted with alcohol and ether ; the extract is then boiled with water, filtered, and again boiled with the addition of dilute sulphuric acid. This solution is then subjected to Trommer's or Nylander's test for the presence of reducing substances. In order to ascertain whether starch is present the watery extract of the ffeces is examined with Lugol's solu- tion, the presence of starch producing a blue color. If the dejecta be examined for the presence of sugar, then a watery extract of the fecal matter can be directly tested with the usual sugar reagents. Normally neither starch nor its derivatives (sugar) are found. Schmidt' suggested testing the watery extract of the fecal matter with regard to the amount of gas developing 1 Von Jaksch : " Klinische Diagnostik. " 7 Ad. Schmidt : Berliner klinische Wochenschrift, 1898, No. 41. EXAMINATION. 55 through fermentation. For this purpose Schmidt puts the watery extract of the faeces into fermentation tubes (similar to the fermentation saccharometer) and keeps them at blood temperature. The greater the amount of gases developing in the cylindrical part of the tube, the greater the evidence of disturbances within the intestine. The greater propor- tion of the gas consists of carbonic acid and is due to its formation from the carbohj'drates existing in the fecal matter. In order to be able to judge more accurately from this test, Schmidt examined his patients after a certain diet which they had been taking for several days. It con- sisted of 1,560 c.c. of milk, four eggs, three zwieback, one plate of barley soup, one plate of flour soup, and one cup of bouillon a day. While Schmidt asserts that whenever a considerable amount of gas is found in the fermentation tube this indicates a real disturbance of the intestine, S. Basch, ' who has made a thorough study of Schmidt's method in a considerable number of cases, is of the opinion that on the one hand a considerable amount of gas may be found in cases without any apparent intestinal lesion, and, on the other hand, grave disturbances of the intestine may show a total absence of gas. Inasmuch as Schmidt's fer- mentation method is certainly complicated and its results are not of great diagnostic value, I do not believe that it will ever come into practical use. Fat. The presence of neutral fat and fatty acids is de- termined in the following manner : The faeces are treated with a considerable amount of ether ; the latter is separated and evaporated in a water bath. The fat if present then remains and is visible. In order to show the presence of 1 S. Basch " Welche klinische Bedeutung bezeichnet die Schrnidt'sche Giihrungsprobe der Faeces?" Zeitsckrift f. klin. Med., Bd. 37, Heft 5 and 6. 56 DISEASES OF THE INTESTINES. soaps which do not dissolve in ether, another portion of fecal matter is iirst treated with acids which split up the soaps and then extracted with ether. The quantitative de- termination of the amount of fat and of its different com- ponents is somewhat complicated and of not much service clinically. Those interested in the subject may look up Von Noorden's "Beitrage zur Lehre voin Stoff wechsel, " Heft I., p. 109, Berlin, 1892. Normally fat is never per- ceptible macroscopically in the faeces unless after the in- gestion of very large quantities. It may then be visible in small portions of pea size. Pathologically fat may exist in very large quantities in the fecal matter and give it a grayish silvery appearance, the so-called fatty stools. This normally occurs in diseases of the pancreas, and also whenever the absorption by the lymphatics is greatly dis- turbed. Blood. Fresh blood from the lower portion of the intes- tine, and also from the higher portions of the bowel if pres- ent in large amount, is easily recognized by its macroscopic appearance. Often the microscope will reveal well-pre- served red and white blood corpuscles. Sometimes, how- ever, the blood is changed to such a degree that it is not easily recognized. Here various tests are required in order to prove its existence, the same procedures being used as for the discovery of blood in the gastric contents. The haemiu test which is chiefly used is made as follows : A small particle especially suspected of containing blood is dried and powdered and a portion of it put on a slide. A trace of sodium chloride is now added and a drop of glacial acetic acid poured over it and thoroughly mixed. A cover- glass is now put over it, the specimen is slowly heated, and after cooling examined with the microscope. The presence of hsematin crystals shows that there was blood. EXAMINATION. 57 Bile Pigment. Under normal conditions no unchaoged bile pigment is found in the faeces. In catarrhal conditions of the small intestine it has been frequently detected. The presence of bile pigment is ascertained in the following manner : A particle of highly colored fecal matter is brought into contact with a drop of fuming nitric acid. The yellow color usually passes through the various colors of the spec- trum red, violet to green. In some instances a green discoloration appears at once. The test for biliary pigment may also be made as follows: The faeces if liquid are filtered through filter paper, and if not liquid a watery mixture is made and filtered. When the filter paper is dry a few drops of nitric acid are poured on it. The colors just mentioned appear in the form of rings, if bile pigment is present. Still another test is as follows : A small quan- tity of the fluid dejecta is treated with a concentrated watery solution of sublimate. If the faeces contain biliary pigments in considerable quantity, the entire mixture turns green. If, however, the biliary pigment is adherent to cer- tain small fecal particles then these alone turn green. Biliary Acids. Whenever biliary pigments appear in the dejecta, biliary acids, as a rule, accompany them. The presence of biliary acids is best revealed by Pettenkofer's test, and is made as follows: A small quantity of fecal matter is thoroughly treated with alcohol, which is then evaporated. To the residue a weak watery solution of bi- carbonate of sodium is added, and to this mixture a small quantity of cane sugar and a few drops of sulphuric acid. When biliary acids are present a characteristic red or pink color arises. Urobilin. Normally the biliary pigment within the in- testinal tract becomes changed into urobiliu, which is the principal factor of the characteristic brownish color of the 58 DISEASES OF THE INTESTINES. fceces. The best test for the presence of urobilin is Fleischer's ' procedure which is as follows: A small quan- tity of faeces is put into a test tube and a small amount of alcohol with a few drops of hydrochloric or acetic acid added ; the mixture is then left undisturbed for a short time. The presence of urobilin produces a yellow or brown color, the latter, if present in large amount. If the alcohol is now poured out and a few drops of sodium hydrate added, as well as a small quantity of a chloride-of- zinc solution, there appears, according to the amount of urobilin, a more or less greenish fluorescence in direct rays of light, while in transmitted light the fluid appears pink or yellowish-red. If the watery extract of faeces to which some ammonia has been added is filtered and chloride of zinc added, the presence of urobilin produces a pinkish-red precipitate. If this precipitate is filtered under addition of alcohol containing some ammonia there appears a more or less greenish fluorescence (Schmidt's 2 test). A small piece of fecal matter is treated with a concentrated watery solution of sublimate and thoroughly mixed with a glass rod. The presence of urobilin gives rise either imme- diately or a little later to a pinkish-red color, while biliver- din, if present, produces a greenish color. Normally urobilin is present in the fseces. Its absence is observed only in pathological conditions. Acholic Stool. The acholic stool presents a grayish- white, ashy gray, or clay color. It is usually of a soft salve- like consistency. It occurs (1) in conditions in which there is a total absence of bile in the intestine, and (2) whenever the absorption of fat is greatly impaired. Until very recently the grayish- white color has been generally 1 R. Fleischer : " Krankheiten des Darms. " p. 1160, Wiesbaden, 1896. *A. Schmidt. Verhandlungen des Congresses f. Innere Med., 1895. EXAMINATION. 59 ascribed to the absence of biliary pigments and their modi- fications (urobilin) , but Fleischer and Bunge ' have conclu- sively shown that the whitish color may be observed in faeces containing urobilin, the color being due to the pres- ence of large amounts of fat. In the latter instance the stool, after being treated with large amounts of ether, thus separating the contained fat, assumes a brownish color. This I can confirm also from my own experience. Ferments. In order to ascertain the existence of fer- ments in the fneces a glycerin extract of them may be made or the fecal matter may be directly mixed with water con- taining a small proportion of thymol, and filtered. The filtrate, or the glycerin extract, can now be directly tested for the presence or absence of the different ferments, tryp- sin and diastase. In order to test for trypsin the fecal filtrate is made alkaline by the addition of bicarbonate of sodium and a few flakes of fibrin are added. The solution is kept at blood temperature for a few hours and then tested with potassium hydrate and a weak solution of sulphate of copper. If trypsin is present, a pinkish-red color will arise in consequence of the peptone which has formed (biuret test). In order to test for diastase, a few cubic centimetres of the filtrate are mixed with about half the amount of a starch solution and kept at blood temperature for half an hour. The mixture is now subjected to Fehling's or Trommer's test for the presence of sugar. Normally, as a rule, these ferments are absent, but in pathological condi- tions, especially in diarrhoea, they are frequently found. Concretions. The faeces occasionally contain concretions which may be of diagnostic importance. In order to de- tect them, especially if they are small, the faeces must be 'Bunge: "Lebrbuch der phys. u. pathol. Chemie, " Leipsic, 1887, p. 192. 60 DISEASES OF THE INTESTINES. thoroughly mixed with warm water and poured through a large sieve. While the fecal matter is 011 the sieve some more water is added and the mass constantly stirred with a wooden stick. Any concretions present will thus be dis- covered remaining on the surface of the sieve. The following different qoncretions may be met with in the faeces : (1) Gall stones ; (2) pancreatic calculi ; (3) en- teroliths ; (4) coproliths ; (5) foreign bodies. Biliary calculi are easily recognized when they attain considerable size. When they are very small, however, their recognition is somewhat more difficult. The princi- pal constituents of biliary calculi are cholesterin and bile pigment in conjunction with lime. The small concretions (sand) suspected to be of biliary origin should be examined in the following way : About 2 gm. of the mass is well powdered and treated with 20 c.c. of ether, thoroughly mixed and filtered, the nitrate evaporated and tested for the presence of cholesterin in the following manner : (a) Part of the residue is dissolved in hot alcohol and put aside on a porcelain dish for spontane- ous evaporation. The precipitate is examined under the microscope. Crystals of rhomboid shape with a ragged edge are characteristic of cholesterin. (/>) Another por- tion of the residue is directly put on a slide, a drop of concentrated sulphuric acid added, and covered with a cover-glass. The cholesterin crystals assume a carmine color at their margins. If now a drop of Lugol's solution is added a violet color arises, (c) Another portion of the residue is treated with hydrochloric acid and a trace of chloride of iron and evaporated. If cholesterin is present a blue color arises. The residue of the original ether mix- ture is treated with diluted hydrochloric acid, heated, and extracted with chloroform after it has cooled off. The EXAMINATION. 61 chloroform extract is now tested with Mellin's reaction (fuming nitric acid). The presence of bile pigment pro- duces the well-known change of colors. Pancreatic Calculi. Pancreatic calculi usually have a rough surface, are brittle, and may be faceted. They are soluble in chloroform and produce on evaporation an aro- matic odor (Minich 1 )- Bile pigment and cholesterin are absent. Enterolitlis or calculi formed in the small intestine usu- ally consist principally of inorganic salts (lime, magnesia). They are light in color and ordinarily of small size. They occasionally form after an extensive use of mineral medica- ments (lime, magnesia, etc.). They hardly ever give rise to intestinal obstruction. Coproliths or fecal calculi are found in the large bowel, principally in places in which there is a retardation in the passage of the faeces. Thus they are encountered in the csecuin, in the appendix, in sacculations of the colon, and in the rectum. The coproliths are of stony hardness and of sausage shape. They usually show on section concen- tric rings. Occasionally they attain considerable size and may give rise to obstruction of the bowel. Foreign Bodies. Foreign bodies which have been swal- lowed ma}' pass through the entire intestinal tract and be eliminated in the faeces. Thus pieces of bone, coins, mar- bles, needles, and all kinds of foreign substances may be found in the stools. In rare instances concretions of shellac are discovered in the stools of patients who have drunk furniture polish, the shellac forming concretions after the absorption of the alcohol. Hair balls may be found in patients who habitually bite off and swallow hair. 1 Minich: Berliner klin. Wochenschrift, 1894. No. 8. 62 DISEASES OF THE INTESTINES. Microscopical Examination. The microscopical examination of the faeces is occasionally of assistance in establishing the diagnosis. With Ewald ' I do not think it necessary to examine microscopically the faeces of every patient presenting intestinal symptoms. In FIG. 16. Normal Faeces, showing a few Fat Crystals and Fat Globules ; Digested Muscle and Epithelial Cells ; Micro-organisms. cases, however, in which the diagnosis is not quite clear and the symptoms point to an intestinal lesion, a micro- scopical examination of the faeces should be made. Diarrhceal stools may be examined under the microscope 1 C. A. Ewald: "Diseases of the Intestines." Twentieth Century Practice of Medicine, vol. ix.. p. 113. EXAMINATION. 63 without any further preparation. Solid fecal matter is examined by taking a small particle of the faeces, putting it on a slide, and mixing it thoroughly with a drop of physi- ological salt solution. In order to avoid the unpleasant odor, a small amount of a watery one-per-cent formalin solution may be first added to the fecal matter. The micro- FIG. 17. Normal Fasces showing Detritus, Plant Cells, Digested Muscle Fibres, Bacteria. scopic picture of the normal fseces varies greatly according to the diet. In people living on a meat diet no vegetable residue will be seen, while there will be no remnants of meat in people subsisting on an exclusively vegetable diet. In case of a mixed diet there will be remnants of both in the stool. A mixed diet will reveal the following appear- 64 DISEASES OF THE INTESTINES. auces: There will be a large number of plant cells, the remnants of various vegetables and fruits. They are usu- ally of considerable size, present peculiar shapes, and can be easily differentiated from animal cells (Figs. 16, 17, 18, 19). The peels of pears and apples and of prunes com- monly pass out in the stool entirely unchanged. Notwith- Fio. 18. Different Varieties of Vegetable Cells found In Normal Faeces. standing the presence of these plant cells in the stools starch, as a rule, is absent. Thus the microscopical speci- men when stained with Lugol's solution will show no blue color. If, however, starch appears in a stool in well-pre- served granules, it is always pathological, indicating de- ficient digestion. Minute fragments of meat are found EXAMINATION. 65 in small quantity in the stools. Although considerably changed the muscles can be recognized as such, and the transverse markings can often be noticed. Frequently they present a yellowish tinge from biliary pigment. Connec- tive-tissue fibres and also elastic fibres are occasionally met FIG. 19. Stool of an Hysterical Patient who Simulated Passing of Large Quantities of Mucous Membranes in the Faeces. The membranes under the microscope showed the structure of common tissue paper ; a few plant cells, epithelial cells, and fat crystals were also present. with, both being quite resistant to the action of the diges- tive juices. The presence of numerous pieces of meat in the stool is pathological. Fat. Microscopically fat can be detected in the faeces in the form of colorless small globules which may exist in 66 DISEASES OF THE INTESTINES. large numbers after an excessive milk diet or in the shape of small needle-shaped crystals, or again in the form of sheaves. The small crystals of needle shape usually occur singly, and consist mostly of fatty acids, while the sheaves consist of fatty soaps. The fatty-acid crystals melt and disappear when heated, while the soaps remain unchanged. Ether likewise causes a disappearance of the fatty acids, while the soaps remain unchanged. Bieder ' suggests the use of the dye stuff Sudan II. (C^H.^O) in a concentrated alcoholic solution for the differentiation of the fats. This dye stains plain fat bright red, while crystals of fatty acid and of lime and magnesia soaps remain unchanged. While normally these different forms of fat appear in very scanty amounts in the faeces, they may be found considerably in- creased under pathological conditions (affections of the liver, pancreas, and acute enteritis). Crystals. Besides the crystals of fatt} r acids and their soaps the following crystals are met with in the faeces: oxalate of lime appears in the well-known envelope form of varying size, especially after a diet consisting principally of vegetables. Calcium carbonate occasionally occurs iu the form of amorphous granules or dumbbell-shaped crystals. Neutral phosphate of calcium and ammonio-magnesium phosphate crystals are often present and can be readily rec- ognized, the former occurring in more or less well-defined wedge-shaped crystals collected into rosettes, the latter pre- senting the well-known coffin shape. They are soluble in acetic acid. All the crystals just mentioned are found in normal as well as in pathological faeces, and have no diag- nostic importance. Bismuth crystals: when bismuth is internally administered it is usually found in the faeces in 1 Rieder : Deutsches Archiv fiir klin. Med., 1898, Bd. 59, Heft 3 and 4. p. 444. EXAMINATION. 67 rhomboid crystals of a dark-brown or almost black color (Fig. 20). Hsematoidin crystals are occasionally encoun- tered in severe catarrhal conditions of the intestines or shortly after intestinal hemorrhages have taken place. They occur in small amorphous particles of an orange or FIG. 20. Specimen of Stool of Mrs. W., living on Milk Diet and taking Bismuth and Magnesia. Bismuth and magnesia crystals, some fat globules and detritus. No muscle or plant cells. ruby red color, or in crystals of the rhombic system. Charcot-Leyden crystals of spermiu phosphate, having the shape of grains of oats, are occasionally met with in the faeces and are of diagnostic importance. According to Leichtenstern, ' these crystals are very frequently found in 1 Leichtenstern : Deutsche raed. Wochenschrift, 1892, No. 25. 68 DISEASES OF THE INTESTINES. the fceces whenever intestinal parasites (helminthiasis) exist. These crystals, however, occur also in other patho- logical conditions as in typhoid fever, dysentery, tubercu- losis of the lungs. In rare instances the Charcot-Leyden crystals are absent in cases of helminthiasis. When they FIG. 21. Specimen of Stool of Mrs. V., with Chronic Intestinal Catarrh. Groups of epi- thelial cells ; detritus : a few muscle cells, partly digested ; plant cells ; bacteria ; yeast cells. occur, however, they are an indication that the stools should be carefully watched for the presence of intestinal worms. Elements Derived from the Intestinal Wall. Epithelial cells and also goblet cells occur occasionally in the faeces, but only in scanty number (Fig. 21). They are very sel- EXAMINATION. 69 doin unchanged with a distinctly visible nucleus; usually they appear in a metamorphosed condition without any perceptible nucleus. Larger accumulations of epithelial cells may be found in desquamative catarrhal conditions of the intestines. FIG. 22. Stool of Patient L , with Acute Dysentery. Pus cells In considerable number; occasional epithelia ; mucus ; detritus. Blood. Blood in the f races is occasionally easily recog- nized under the microscope, both red and white blood cor- puscles being present. This, however, is the fact only in hemorrhages of the lower portion of the rectum. In hem- orrhages originating in the upper portion of the large bowel or in the small intestine, the blood cells are usually 70 DISEASES OF THE INTESTINES. already greatly changed and not to be recognized as such microscopically . Pus. Pus corpuscles in the dejecta occur in ulcerative processes of the intestines or whenever an abscess has discharged its contents into the bowel. Besides these two conditions, it is also met with in dysentery. The pus Ho. 3 L Stool of Patient H., wiin Chronic Dysentery, during an Acute Exacerbation. Highly magnified. Amoetwe; red and white Wood celte ; crystals of fat and ammonio- magnesium phosphate; plant and muscles cells ; detritus. corpuscles are then distinctly visible under the microscope (Figs. 22, 23, 24). [For the beautiful execution of the above drawings I am indebted to Dr. C. A. Elsberg of this city.] Mucus. Mucus is frequently seen in the dejecta under the microscope. It is recognized by its thread-like ap- EXAMINATION. 71 pearance (Fig. 25). Occasionally it is also amorphous. Thionin colors mucus reddish-violet, while it stains other proteid substances bine. Mucus is often present in ca- tarrhal conditions of the intestine and also in membranous enteritis. Pieces of Tumors. In rare instances a small fragment of FIG. 2L From tbe Same Patient, a Few Days Later. Highly magnified. Amoebse: fitt in globules and ciystals ; a few red and white blood corpuscles: muscles eeOs: detri- tus: bacteria. tumor may be found in the dejecta. Under the microscope the structure of the mass will be seen and its character de- termined. The result of such an examination may be of great diagnostic importance. Uici-o-organisms. Numerous micro-organisms are found 72 DISEASES OF THE INTESTINES. in the faeces normally as well as pathologically. Their number averages in daily evacuations fifty -three milliards. Sometimes they may reach as high a figure as four hundred milliards. Beginning with the stomach the number of micro-organisms steadily increases all through the intesti- nal tract down to the large bowel, where the maximum is FIG. 25. Specimen of the Stool of Mrs. J. B., Suffering from Intestinal Catarrh. Mucus all over the field of vision ; a few plant cells and muscle cells, and an occasional fat crystal. reached. The micro-organisms appear to be intimately connected with the physiological processes of digestion. This is true notwithstanding the valuable investigations of Nencki, Macfadyen, and Sieber, 1 and Thierfelder and Nut- Nencki, Macfadyen, und Sieber: Archiv f. experimentelle Patho- logic u. Pharmakologie, Bd. 28, S. 301. EXAMINATION. 73 tal, 1 which have shown that normal digestion is possible even without bacteria. Pathologically various kinds of bacteria play a very important part. Besides certain spe- cies of pathogenic bacteria, the micro-organisms normally sojourning in the intestine occasionally assume morbific properties. The different varieties of micro-organisms in the intes- tinal tract have been thoroughly studied by Mannaberg, 2 who found fourteen different species of bacilli, nine species of micrococci, and four species of schizomycetes. Of the latter saccharonij^ces cerevisise are most frequently encoun- tered in the faeces. They are found in groups forming three or four buds, and assume a mahogany color when treated with Lugol's solution. Of the bacteria and cocci the following deserve special mention : The bacterium coll commune, first described by Esche- rich, 3 occurs in the form of thin or thick rods being about 0.4 ;>. in length. Some show motile power. They are well stained by the ordinary anilin dyes and decolorized by Gram's solution. Their colonies growing upon gelatin re- semble those of the bacillus of typhoid fever. The bacterium lactic aerogenes (Escherich) greatly re- sembles the bacterium coli commune. It is frequently found in the stools of infants, and is now and then met with in those of adults. It is found in thick rods frequently lying in pairs. They are non-motile and have the property of causing fermentation of milk, producing coagulation and formation of gas within sixty hours. 1 Thierfelder u. Nuttal . Zeitschrift f. phys. Chemie, Bd. 21, S. 109, u. Bd. 22, S. 62. 8 Mannaberg : " Die Bacterien des Darms " Nothnagel 's Erkrankun- gen des Darms, Wien, 1895. 3 Escherich : "Beitrage zur Kenntniss der Darmbacterien. " Milnch- ener med. Wochenschr. , 1886, No i., 43-45. 74 DISEASES OP THE INTESTINES. Bacillus putrificus coli (Bienstock 1 ) forms slender rods 3 A* in length. This bacillus energetically decomposes proteid substances in presence of air under the formation of ammonia, amin bases, fatty acids, tyrosin, phenol, indol. While all the above-mentioned micro-organisms give a mahogany or brown color with solutions of iodine, there are a few varieties which give a blue color with this sub- stance. To the latter belongs the bacillus butyricus de- scribed by Nothnagel. 2 It is rod-shaped, 3 to 10 AI long and 1 A< thick. It is often lemon-shaped. This bacillus is anaerobic an(J produces fermentation of starch, sugar, and cellulose, forming butyric acid and gas. The bacillus butyricus is often found in pathological conditions of the intestine, but occurs in small numbers also in normal faeces. Of the pathogenic micro-organisms, cholera, typhoid, and tubercle bacilli are found in the fseces. The cholera and typhoid bacilli causing infectious diseases do not belong, strictly speaking, to the micro-organisms producing dis- eases of the intestine alone. The tubercle bacilli, occasion- ally producing intestinal tuberculosis, are recognized in the fseces by the same methods which are employed in the examination of the sputum. TREATMENT. Diet. The principles of diet are fully described in my book on the stomach. Here I will add a few remarks referring to the dietetic treatment of intestinal diseases. As in the case of the stomach, acute intestinal disorders lasting a 1 B. Bienstock : " Ueber die Bacterien der Faeces. " Zeitschr. f . klin. Med., Bd. 8. 1884. *H. Nothnagel : "Die normal in dem Menschendarm vorkommenden niedersten (pflanzlichen) Organismen." Zeitschr. f. klin. Med., Bd. 3, 1881. TREATMENT. 75 few days or weeks must be managed according to the prin- ciple of rest. Very scanty and light foods (mostly liquid) should be given. In chronic ailments of the intestines the principle of rest may also be utilized occasionally for a short time, while as a general rule we should bear in mind the necessity of introducing sufficient quantities of food and gradually accustoming the intestinal tract to the ordi- nary foods. In some instances it is possible to exert a wholesome influence upon the disturbances of the intestine by appro- priate dietetic measures. This applies especially to dis- orders accompanied by constipation or by diarrhoea. I. Articles of diet which increase tjie intestinal peristalsis or " laxative foods" are the following: Most fruits, both* raw and cooked, and fruit juices increase the peristalsis in consequence of the organic acids which they contain, as apples, pears, plums, peaches, strawberries, gooseberries, dates, and figs. Most salads and garden vegetables also increase peristalsis, firstly, owing to the large amount of water they contain, and secondly, owing to the consider- able residue which is left undigested, as, for instance, melons, cucumbers, tomatoes, pumpkins, all kinds of cab- bage. By many of the latter foods the peristaltic action of the intestine is also increased on account of the forma- tion of acid and gaseous products. Fresh beer, cider, bonny -clabber, and kumyss act in a similar manner. Cold drinks of plain water or carbonated water act as mild ape- rients in some instances. Here a reflex action upon in- testinal peristalsis due to irritation must be assumed, for often a movement of the bowels follows very soon (a quar- ter of an hour to one hour) after drinking. II. Articles of diet which iliniinMi //"' infcttfrnal peri- stalsis or "constipating foods": (1) All substances con- 76 DISEASES OF THE INTESTINES. taining a considerable portion of astringent agents, par- ticularly tannic acid, as, for instance, dried bilberries, French red wines (particularly San Rafael wines), tea, ca- cao, the acorn preparations like acorn coffee, acorn cacao. (2) Foods which have a mucilaginous character and thus somewhat allay irritation also have a slightly constipating effect: sago, tapioca, barley, rice. (3) Foods which leave no residue whatever or very little residue, and thus exert no irritation. To these belong egg water (prepared by dis- solving the white of an egg in some water), scraped raw meat, mutton broth. Some foods manifest different action in different individ- uals. Thus, for instance, milk is constipating in one per- son and laxative in another, while in still others it has no special effect upon intestinal peristalsis. Most foods have no marked influence upon the intestinal peristalsis. To these belong most kinds of meat and fish not too highly seasoned, the various meat powders, and most artificial foods like meat peptone and nutrose, eucasiu, somatose, sanose, eggs prepared in different ways, well- baked bread, wheaten or rye bread, crackers, zwieback, fats in small amounts, especially butter. The preparation of the foods has an important bearing with regard to its action upon the intestinal peristalsis. The finer the foods are the less irritating they will act, and the coarser the particles the greater the irritation they produce upon the intestinal muscular layer. Highly seasoned foods also act as a stimulant of the peristalsis. In some severe conditions of the intestines the ordinary way of ingestion of food must be avoided for a short period. Here artificial feeding is employed. Artificial feeding can be done in two different ways: rectal alimentation and subcutaneous alimentation. TREATMENT. 77 1. Rectal Alimentation. The rectum and the greater part of the large bowel should be emptied if possible be- fore injecting the feeding enema. The latter is best accom- plished by using a fountain syringe and a soft-rubber tube which is introduced for about five to seven inches into the rectum. The quantity of the feeding enema may be be- tween five and ten ounces. As feeding enemas the follow- ing substances are used : () The different kinds of pep- tones and propeptones in the market of which about two to three ounces can be dissolved in six to eight ounces of water. The different beef juices may also be dissolved in water and injected in corresponding quantities, (b) The milk and egg enemas. These are mostly used. Their composition is as follows : Six to seven ounces of milk, one or two raw eggs well beaten up, one teaspoonful of powdered sugar, and the point of a kuifeful of salt. The addition of pancreatin (one tube of Fairchild pancreatiu to one enema) will facilitate assimilation, (c) Meat-pan- creas enema. Leube ' employs enemas consisting of well- chopped meat mixed with fresh pancreas. Besides these food enemas injections of water, into the bowel are made in order to increase the amount of fluid in the system. These injections of water for the purpose of ab- sorption are of great importance. Usually saline solutions are employed in quantities varying from one pint to one quart. The nutritive enema should be given three or four times in twenty-four hours, and the water enemas for ab- sorption once or twice a day. 2. Subcutaneous Alimentation. In diseases of the intes- tine special conditions are met with in which neither the ordinary way of feeding nor rectal alimentation is possible. 'Leube: Leyden's "Handbuch der Ernahrungstherapie. " Bd. i., p. 508, Leipsic, 1897. 78 DISEASES OF THE INTESTINES. Here an attempt must be made to introduce nourishment subcutaneously. Most food substances cannot be intro- duced under the skin without inflicting more or less injury. Two substances only form an exception and are of practical value : (a) Olive oil. This can be injected subcutaneously to the amount of one ounce twice or three times a day. It is hardly necessary to say that the oil as well as the syringe used for this purpose should be thoroughly sterilized. A large-sized Pravaz syringe is employed, and but little pressure exerted while injecting. This precaution is neces- sary in order to obviate any traumatism (tearing) of the tis- sues. The best place for the injection is the thigh, (b) Water. A saline solution is subcutaneously injected in amounts varying from one pint to a quart. This serves to increase the amount of fluid in the system. The injection is made by means of the fountain syringe to the end of which an aspirating needle is attached. The same pre- cautions as above are necessary. The saline injection may be employed twice or three times a day if necessary. Mechanical Procedures. Injections. Injections into the bowel in the form of clys- ters were used for curative purposes even in old times. The regular syringe with its stiff end may, if forcibly in- serted, give rise to damage of the rectum. For this reason nowadays a soft-rubber rectal tube is employed, to which a fountain or Davidson syringe or any form of syringe can be attached. The tube being flexible cannot injure the in- testinal walls. It can also be introduced higher up than the ordinary hard-rubber end pieces of the fountain syringe. Instead of the fountain syringe a funnel apparatus similar to the one used in gastric lavage may be employed. For washing out the bowel Leube-Rosenthal's appliance for TREATMENT. 79 washing out the stomach can be used to advantage. For irrigation of the bowel Kemp's hard-rubber rectal double- current irrigator can be conveniently employed (Fig. 26). These injections into the bowel are made for various purposes : 1. To produce an evacuation. About a quart of luke- warm water to which a teaspoonful of salt is added can be employed, or a piece of soap dissolved in the same FIG. 36. Dr. E. C.Kemp's Rectal Irrigator (New Model). Outer tube of hard-rubber; central tube of metal. Hard-rubber flange, protecting sphincter from transmission of heat through the metal parts. Amount of water. As a rule, it is not advisable to intro- duce larger quantities of water than these as they distend the bowel too much. In greatly atonic conditions, how- ever, in which a quart of water may be inefficient, an injection of from two to three quarts will be required. In- jections of oil (olive oil or sesame oil) in quantities varying from half a pint to one pint have been recommended by Fleiner. ' According to this writer the oil should be in- jected at blood temperature into the rectum when retiring and be retained over night. While olive oil was used as a laxative injection long ago by Habershon " and others, we owe its methodical use to Fleiner, to whom is also due the credit for having promulgated the method. Small injec- tions of glycerin (one or two drachms) in about an ounce Kleiner: "Ueber die Bebandlung der Constipation." Berl. klin. Wochenschr. , 1893, Nos. 3 and 4. 2 Habershon "Diseases of the Abdomen," London, 1862. 80 DISEASES OF THE INTESTINES. of water can also be advantageously employed for produc- ing an evacuation of the bowels. 2. Injections may be resorted to either to strengthen the tonicity of the bowel, in which case plain very cold water in amounts of from one to two quarts can be em- ployed, or for medicinal purposes, i.e., for applying cer- tain medicaments directly to the intestinal mucosa. The drugs most frequently used for this purpose are nitrate of silver, taniiic acid, subnitrate of bismuth, as astringents; thymol, hydrogen peroxide, boracic acid, essence of pep- permint, as disinfectants. Massage and Gymnastic Exercises. Massage is frequently employed in functional diseases of the intestine. Its field of usefulness lies principally in neurotic and atonic condi- tions. Massage should be applied by well-trained and experienced persons. Abdominal massage requires great care, as too rough manipulation is liable to do great harm. Gymnastic exercises and sports are well adapted to stimu- late and strengthen the muscles of the abdomen as well as those of the intestine. Ewald particularly recommends rowing in boats with sliding seats as an exercise which gives definite results in chronic intestinal torpidity. Golf, billiards, horseback riding, bicycle riding, walking may also be included among the exercises contributing to a ton- ing up of the system. Hydrotherapy. Moist applications in the form of either Priessnitz's compresses or poultices are often of benefit. Priessnitz's compresses are stimulating, while the warm fomentations serve as a sedative. The latter are applied to allay pain, the heat producing a temporary paralysis of the superficial sensory nerves. Instead of either cold or warm compresses a rubber bag filled with either cold or hot water may be applied. When warm applications are TREATMENT. 81 required they can also be used in the form of the Japanese box. Sitz baths of various temperatures may be employed. A shower bath, especially over the abdomen, of cold or warm water or of alternating cold and warm water, is also of benefit. Many of these procedures may be combined with massage, and in this way the curative action is enhanced. Electricity. The f ara- dic, galvanic, or frauk- linic currents are em- ployed. All these three can be used percuta- neously; the first two also intrarectally. The faradic current is mostly applied in atonic condi- tions of the bowel with the object of stimulating the motor function of the intestines. The galvanic current i s principally employed in painful intestinal affections of neurotic char- acter. The franklinic or static current may be advan- tageous^ used in both conditions. For the intrarectal application of the current I use an electrode which in prin- ciple is very similar to that of Boudet ' and consists of a perforated hard-rubber end piece in which is lodged a metallic button connected by means of a wire with the bat- tery. To the upper end of the hard-rubber piece is at- tached a soft-rubber tube leading to an irrigator and pro- 1 Boudet: Cited after A. Mathieu : "Treatment of Diseases of the Stomach and Intestines, " New York, 1894, p. 171. 6 FKJ. 27.-Rectal Electrode. 82 DISEASES OF THE INTESTINES. vided with a stopcock (see Fig. 27). Proceed as follows: The irrigator is filled with water at blood temperature. The hard-rubber piece, or the rectal electrode, is smeared with vaseline and introduced into the rectum. Another plate electrode is moistened and placed over the abdomen, the stopcock partly opened, and the current applied. The water running from the end piece of the electrode into the bowel carries the electricity along with it. The electrical application should last from five to ten minutes, the amount of water used varies from ten to fifteen ounces. The outflow of the water can be regulated by the stopcock arrangement. I have applied both the faradic and gal- vanic currents with this apparatus and found it very con- venient. The faradic current may be applied as strong as the patient can bear, while the galvanic current should be used with the negative pole in the rectum, the intensity of current ranging from eight to fifteen milliamperes. CHAPTER III. ACUTE AND CHRONIC INTESTINAL CATARRH. ACUTE INTESTINAL CATARRH. Synonyms: Enteritis acuta; Catarrhus intestinalis acu- tus ; Acute diarrhoea ; Cholera nostras. Definition, An inflammatory affection of the intestines characterized by a sudden development of pains and more or less loose movements. Etiology. Acute intestinal catarrh is one of the most frequent diseases. "While it occurs more often in infants and children it is found in persons of all ages. The affection may attack the entire intestinal tract or may be limited to a part of it. Thus we may have a duo- denitis, jejunitis, ileitis, typhlitis, colitis, and proctitis (inflammation of the rectum) . With regard to frequency the colon is most often affected. According to Woodward, ' an inflammation of the small intestine alone hardly ever exists, a portion of the large bowel always being affected. Intestinal catarrh is either primary (idiopathic) or second- ary when occurring as a sequel of other diseases. Acute enteritis may be due to a number of causes : 1 . It may result from the iugestion of heavy indigestible food, ice-cold drinks, and tainted meat or fish, unripe fruit, stale or sour beer, bad water. 2. Good food and drink taken in unusually large quanti- ties may also produce this condition. Woodward : "The Medical aud Surgical History of the War of the Rebellion, " vol. i , part 2. 84 DISEASES OF THE INTESTINES. 3. A host of organic and inorganic substances may chem- ically irritate the intestinal nmcosa and cause inflammation. All the drastic remedies, like croton oil, colocynth, jalap, etc., belong to these organic irritating substances; of the inorganic may be mentioned tartar emetic, arsenic, lead, sulphate of copper, all the mercurial preparations, concen- trated acids, and strong, caustic alkalies. 4. Enteritis may be caused by mechanical irritants. Thus hardened sdybala, biliary calculi, enteroliths, or foreign bodies which have been swallowed, like large ker- nels of fruit or coins, may evoke inflammation. The catarrh accompanying intestinal worms may also be placed in this group. 5. Intestinal catarrh is very often due to variations in temperature or to catching cold. It seems that the dispo- sition to this agent varies in different individuals. Thus some people get an attack of diarrhoea if they sleep uncov- ered during the summer and a drop in temperature occurs, the colder atmosphere affecting the abdomen. Others, again, are attacked with diarrhoea whenever they get their feet wet. How the influence of cold acts in causing the enteritis is difficult to say. Some writers believe that the sudden change in the circulation of the blood caused by the cold is the principal factor; others again explain it on the ground of a more favorable development of micro- organisms during the change of temperature. 6. Auto-intoxication. Poisonous substances may develop in the intestinal tract and cause diarrhoea. The enteritis following large burns of the skin belongs to this group. Here the poisonous substance is probably formed at the site of the burned skin and carried by the blood current into the intestinal tract. Secondary catarrh of the intestine occurs in almost all ACUTE INTESTINAL CATARRH. 85 acute infectious diseases in the same way as gastric catarrh. It is further found accompanying heart, kidney, and liver diseases, tuberculosis, diabetes, etc. Most organic dis- eases of the bowels are associated with intestinal catarrh, as cancer of the intestines, volvulus, iuvaginatiou, peri- tonitis, thrombosis. In this class of cases, however, the intestinal, catarrh is of little importance compared with the primary affection. Morbid Aiwiomy. The anatomical changes found in au- topsies are not always very well marked, and there is cer- tainly no exact relation between the intensity of the clinical symptoms and the severity of the pathological processes discovered. The mucous membrane of the affected part of the intestine appears reddened either over its entire ex- tent or only in spots. This red color is more pronounced around the follicles and patches, at the apex of the folds and of the villi. If the process is intense, extravasations of blood may be found. The mucous membrane appears swollen, sometimes oedematous, often it is covered with tenacious mucus. The villi and the solitary follicles are succulent and appear as whitish, small prominences sur- rounded by a red stratum (enteritis follicularis seu nodu- laris). If the process continues, these gray areas may rupture, and thus give rise to ulcerative lesions (follicular ulcers) . Catarrhal ulcers also exist, however, caused by the loss in some places of the protective epithelial covering of the mucosa. Through extension of the inflammation in width and depth irregular losses of substance with under- mined edges are produced. Inflammatory irritation in the neighborhood of these defects may give rise to polypoid growths, especially when the process has run a protracted course. Microscopically the vessels of the mucosa and sub- 86 DISEASES OF THE INTESTINES. mucosa appear in a more or less congested state. Small extravasations often exist between the glands of Lieber- kuehn. The spaces between the glands are frequently widened and filled with an abundant accumulation of round cells. The epithelium of the mucosa has mostly disap- peared, especially in the large bowel. But according to Nothnagel this may be a post-mortem phenomenon and not always the result of inflammation. Desquamative processes in the epithelial layer, however, occur during life caused by the catarrhal affection, for the changed eroded epithelial cells are found in the mucus voided with the stool. The glands often appear altered with regard to their contour, being wider at their fundus and much narrower at their mouth, frequently presenting a flask shape. The sub- mucous tissue is usually somewhat hyperplastic, otherwise not much changed. The muscular and serous coats are not affected. Symptomatology. Intestinal catarrh usually manifests itself through a feeling of fulness in the lower part of the abdomen, colicky pains appearing from time to time, and diarrhoea. As a rule, no fever is present except in cases of a severe type. The number of the stools and their quality vary a great deal. In mild cases there may be only two or three movements in twenty-four hours; in severer cases fifteen to twenty diarrhceal evacuations. The first passage as a rule still contains normal fecal matter in its first por- tion, while the second part is of a mushy character. The next movements are semi-fluid, and at last entirely liquid dejecta may appear. The first stool still has a brown color and the characteristic fecal odor, while the following evac- uations present a slightly yellowish color or even a grayish appearance, occasionally resembling rice-water. The latter are sometimes devoid of fecal odor, have an acid reaction, ACUTE INTESTINAL CATARRH. 87 and show a foamy surface. Mucus is almost always pres- ent. The fecal matter in its yellow parts contains, as a rule, unchanged biliary substances which give a charac- teristic Gmelin reaction. Microscopically undigested food particles may be discovered in larger than normal amounts; thus meat fibres and well-preserved granules of starch may be observed. A host of micro-organisms, epithelial cells, sometimes in contiguous groups, and mucus are found. Very seldom and only in severer cases small amounts of pus and red blood corpuscles may be dis- covered. Chemically peptones and sugar may be found in the dejecta. General Subjective Symptoms. Aside from the diarrhceal movements and the unpleasant sensations consisting in a feeling of pressure and fulness in the abdomen mentioned above, there may in light cases be perfect euphoria ; usu- ally a feeling of weakness exists which is especially marked in the lower extremities. A feeling of dizziness and slight nausea often also appear, especially shortly before and during evacuations. Vomiting may also occur, as a rule, in cases in which the stomach is likewise affected or when the process of inflammation is of a severer type (cholera nos- tras). Tenesmus is frequently present, if the process is in the lower part of the colon, even if not especially pro- nounced. This seems to be the result of the irritating action of the dejecta upon the rectum. The general symptoms above described are much more pronounced in children and very old people. Here the appearance of collapse (cold extremities, blue lips, and apathy) is not very rare. Marshall Hall ' has described a condition under the name of acute hydrocephaloid disease 1 Marshall Hall : " Diseases and Derangements cf the Nervous Sys- tem, "London, 1841, p. 153. 88 DISEASES OF THE INTESTINES. which occurs in weak children with acute enteritis. The hydrocephaloid appears in consequence of severe attacks of gastro-enteritis with a temperature of 104-106 F. There is sudden collapse. While the body is hot, the extremi- ties become ice cold, the fontanelles sink in, the pulse becomes considerably accelerated, soft, and often irregular. In this condition the little patient lies apathetic unless suddenly disturbed with colicky pains when he utters a cry. The pupils do not react alike and the conjunctival reflex may be absent. Sometimes paralysis of the rectum is present, which I have seen in one case. In this condi- tion the patient often dies within a short time from paraly- sis of the heart. Objective Symptoms. The physical examination of the abdomen occasionally reveals on inspection a bloated con- dition and some spots tender to pressure. As a rule, the lower part of the abdomen, particularly the immediate neighborhood of the navel, is slightly painful on palpation. Occasionally there may be found a decided tenderness, either in the right or in the left iliac region. Sometimes this tenderness may be quite pronounced in a line running across the abdomen between the margins of the false ribs (transverse colon). Palpation often elicits gurgling sounds caused by intestinal coils distended with gas and fluid con- tents. This phenomenon is most frequently observed in both iliac regions. In patients with thin abdominal walls peristaltic move- ments of the small intestines may be visible either sponta- neously or after palpatory examination. The urine is voided in small quantities, is concentrated, and of ten shows Eosenbach's reaction (Burgundy red color after boiling with nitric acid), and also contains indicau (this especially if the process involves the small intestine). ACUTE INTESTINAL CATARRH. 89 Casts and small amounts of albumin are sometimes found in the urine, especially in severer cases (Fischl '). Fevw. In the greater number of instances there is no rise of temperature during the course of this affection. In some cases, however, fever is quite a prominent symptom, and the disease may commence with violent chills and a marked elevation of temperature (104) . The temperature may either fall suddenly on the next day or after the lapse of a few days, but it does not show that regular steady rise which is characteristic of typhoid fever. Fever is espe- cially met with in those cases of acute enteritis which are caused most probably by infection (either pathogenic micro- organisms or tainted food) . Localization of the Catarrhal Process. In order to find out what part of the bowels is especially affected the fol- lowing points are of value : A duodenitis may be recognized if the above symptoms are accompanied by icterus. Intestinal catarrh attended with a constant painful sensation in the right epigastric region, which, besides, is also tender to pressure, indicates more or less a continuation of the catarrhal process from the stomach to "the duodenum. Pains appearing in the same region after extensive burns of the skin also point to a duodenal affection, even if there be no icterus. Jejuiiitis alone or jejunitis and ileitis without any affec- tion of the large bowel can be diagnosed only with diffi- culty, for the principal symptom of enteritis (namely, that of diarrhoea) is as a rule absent. Small amounts of mucus well mixed with fecal matter, a considerable quantity of undi- gested food particles, and epithelial cells tinged with yellow bile pigment in the fseces, point to a catarrhal condition of the small intestine. Indicauuria is also often present. 'Fischl: Prager Vierteljahresscbr., 1878, Bd. 139, p. 27. 90 DISEASES OF THE INTESTINES. Acute colitis is characterized by painful sensations and a greater tenderness on pressure over the entire colon. The stools are diarrhoeal and contain large quantities of mucus. The latter as well as the fecal matter may contain undecomposed biliary pigment. Sigmoiditis, described by Mayor 1 and later by Boas 2 and Mathews, 3 means an in- flammatory process involving the sigmoid flexure, and is recognized by special tenderness on palpation of this por- tion of the bowel, intense backache, and a frequent dis- position to go to stool. Proctitis, or inflammation of the rectum, is characterized by severe tenesmus and colicky pains in the left iliac fossa. The patients have a constant desire to go to the closet, but at each time void only small quantities of fecal matter under the greatest pains. The scybala are surrounded by a layer of mucus which may be tinged with blood. Occa- sionally the mucous membrane of the rectum prolapses during defecation. It then appears intensely dark red and is extremely painful to the touch. Even if not prolapsed, a digital rectal examination is attended with much pain. The mucous membrane of the rectum feels hot and the ex- amining finger on removal sometimes showS traces of blood. Duration. The duration of acute enteritis varies consid- erably. Mild cases improve in about two to five days, while those of a severer type may last about two weeks. After recovery from acute enteritis the intestinal tract remains quite sensitive for a long time. If no attention is paid to this condition and gross errors of diet are com- mitted, relapses are liable to occur. Several relapses may 1 A. Mayor: Revue med. de la Suisse Romande, 1893, No. 4. 9 J. Boas : "Krankheiten des Darms, " ii., p. 513. 3 Mathews : " Disease in the Sigmoid Flexure. " The American Med- ical Quarterly, June, 1899. ACUTE INTESTINAL CATARRH. 91 also follow each other and ultimately cause a chronic en- teritis. Diagnosis. As a rule the recognition of acute enteritis is very easy. The characteristic diarrhoea, the admixture of mucus in the dejecta, the fact that a dietetic error has been committed, or that the abdomen (or other parts of the body) has been exposed to cold, will all indicate the nature of the affection. The localization of the process, whether affecting more or less the entire intestinal tract or only certain parts, is more difficult, and the important points of differentiation have already been given above. Frequent vomiting and very pronounced general symptoms (espe- cially collapse) point to cholera nostras, which is the most severe form of acute enteritis. If the diarrhrea is accom- panied by high fever, urinary casts, and pains in the mus- cles and joints, then the assumption of an acute enteritis of an infectious type is justified. Prognosis. The prognosis of acute enteritis is, as a rule, good, the disease tending to recovery in a very short time. In children, however, and very old and weakened persons, the course of the disease is sometimes not so favorable and may lead to collapse and even to death. Treatment. In mild cases of acute enteritis no medicinal treatment will be necessary. Abstinence from food for one or two days, allowing the patient to take only weak tea, a small quantity of bouillon, and some boiled water may suf- fice to check the attack. Sometimes, however, especially if the attack of enteritis has been caused by dietetic errors, and fulness of the abdomen and frequent colicky pains in- dicating that irritating substances are lodged within the intestines are present, a good old-fashioned drastic is in place. Thus castor oil about one ounce may be given or calomel 0.6 (gr. x.), the latter being preferable in cases 92 DISEASES OF THE INTESTINES. of a probably infectious nature. If there is no fever and the symptoms are mild, then the patients may be up and about, although it is always advisable for them to keep quiet more or less. In cases of a severer type, and especially those with fever, the patients should stay in bed until the symptoms are entirely subdued. If the diarrhoea shows no signs of abating after a day or two, or if the symptoms occur so frequently as to be debilitating, then an opiate is in place. Tincture of opium, seven drops every three hours, or co- deine, 0.02 or 0.03 (gr. -4) also every three hours, may be given. Frequently the combination of an opiate with subnitrate of bismuth and chalk or with tannigen may be useful. Thtfs I often prescribe the following powders : $ Bism. subnitr 6.0 (3 iss.) Cret. pulv 3.0 (gr. xlv.) Cod. pbosph 0.1 (gr. iss. ) Eheosacch. menth. pip 5.0 (gr. Ixxv. ) Misce f. pulv. Div. in p. seq. No. x. S. One powder three or four times a day. Or $ Morph. muriat 0.1 (gr. iss. ) Tannigen, Eheosacch. menth. pip aa 5.0 (gr. Ixxv.) Misce f. p. Div. in p. seq. No. x. S. One powder three times daily. Calumba, cascarilla, catechu, kino, may also be employed, twenty to thirty drops of the tinctures being given about three times daily. Another useful remedy is dermatol, which may be administered in doses of 0.5 gm. (gr. viii.) three times daily. In cases in which the entire colon or its lower part is affected, irrigation of the bowels with astringent solutions is of great benefit. This may be done with a solution containing nitrate of silver, 0.3 (gr. v.) ACUTE INTESTINAL CATARRH. 93 to 1,000 (one quart) water, or tannic acid, 2 to 5 gm. (30 to 80 grains) to 1,000 water, or liquor ferri sesqui- chlor. 2 : 1,000. It is best to inject these solutions after a previous washing out of the. bowel with plain water or soon after a movement. The astringent solution should be allowed to remain for about five to ten minutes, but in case the patient is not able to retain it for even so short a time, fifteen to twenty drops of tincture of opium may be added to the injection. This, as a rule, lessens the irrita- tion of the rectum and the patient is thus able to hold the enema longer. The temperature of the water should be tepid. All the above-mentioned astringent remedies have also slight antiseptic qualities. In cases, however, in which the fermentative processes within the bowels are especially pronounced, the following stronger antifermen- tative substances may be used for irrigation : salicylic acid, 2 : 1,000 water, or salicylate of sodium, 10.0 ( 3 iiss.) : 1,000; boracic acid, 5.0 : 1,000; creolin, 1.0 (gr. xv.) : 1,000.' If pains are present a warm poultice or a hot-water bag over the abdomen is very beneficial. Cold drinks should be forbidden. Warm teas, fennel or camomile, are useful; on the second or third day the pa- tient can be nourished with soups or gruels (barley, rice, oatmeal soup cooked with or without milk) ; water soup (stale bread softened in hot water with the addition of a little butter and salt) and hot spiced claret are then in place. A little later toasted bread, crackers, soft-boiled eggs may be added to the diet ; still later, scraped meat, lamb chops, tenderloin steak, bread and butter. As soon as the diarrhoea has entirely stopped we may allow mashed or baked potatoes in addition to the other articles. For quite a while after an attack of enteritis the patient has to 94 DISEASES OF THE INTESTINES. be careful with vegetables and especially fruits. The first he may begin to take in small portions soon after an at- tack, while the latter should be avoided for a somewhat longer time. In secondary enteritis the principal primary affection must be considered first. Thus enteritis accompanying malaria will be best remedied by quinine. Enteritis ac- companying affections of the lung, heart, or liver must be treated after due attention has been given to the primary affection. CHRONIC INTESTINAL CATARRH. Synonyms. Enteritis chronica; Chronic catarrh of the bowels. Definition. An affection characterized by a chronic inflammation of the intestinal mucosa, giving rise to vari- ous disturbances in the function of the bowels. Etiology. Chronic intestinal catarrh may arise either from a severe acute enteritis which shows no tendency to a cure, or (most often) from repeated attacks of acute enter- itis following each other at short intervals before the bow- els have had a chance to recover fully. This often occurs in patients who do not pay sufficient attention to their apparently slight trouble and disregard the dietetic rules prescribed by the physician. The direct factors causing chronic enteritis are the same as those of the acute condi- tion. Like acute enteritis, chronic intestinal catarrh may be divided into a primary and a secondary form, the pri- mary being idiopathic, while the secondary appears in connection with affections predisposing to this condition. Thus diseases of the lungs, especially tuberculosis, affec- tions of the heart, liver, and kidneys, and diabetes are often accompanied by chronic intestinal catarrh. Intestinal CHRONIC INTESTINAL CATARRH. 95 parasites, round worms, tapeworms, etc., are quite often the cause of a secondary chronic enteritis, due to the irri- tation of the intestinal mucosa which they evoke. Morbid Anatomy. The anatomical changes in chronic intestinal catarrh are similar to those of the acute condition and are characterized by hypereemia, swelling, and in- creased secretion of the mucous membrane. However, instead of the bright red or intensely dark red color seen in acute catarrh, the mucosa in the chronic form presents a grayish brown-red tint. The blood-vessels are greatly dis- tended, and often curved into a serpentine shape. In cases of long duration the intestinal mucosa frequently appears of a slate color intermingled with black pigment (changed red blood pigment which has escaped from the blood-ves- sels). These black dots are often found accumulated at the tips of the villi and also in the immediate neighborhood of the lymph follicles and of the glands of Lieberkuehn. The surface of the mucosa is as a rule covered with a viscid and transparent mucus. The epithelial cells are cloudy, in a condition of fatty degeneration, and partly desquamated. The interstitial tissue is infiltrated with cellular elements. The glands themselves are of irregular shape, sometimes elongated and tortuous, occasionally much smaller than normally. In cases in which there is an interstitial tissue proliferation, a constriction around the neck of a gland arises, As a consequence there is retention of the glandular secretion, and ultimately a cyst may develop. Hyperplastic processes around the inflamed area very often lead to the formation of polypi. The latter as a rule consist of muscular and fibrous tissues and con- tain no glands. Exceptionally polypoid excrescences may appear on the intestinal mucosa (especially in the colon), which consist of a real proliferation of the intestinal mu- 96 DISEASES OF THE INTESTINES. cosa containing glands. An excellent instance of this rare occurrence has been described by Woodward. ' In some of the most advanced cases, atrophy of the mucosa may be present. As in the stomach, this process may arise from two entirely different conditions. In the one the process originates in the glandular tissue ; the lat- ter becoming inflamed, the seat of fatty degeneration, and ultimately atrophied. In the second group the process leading to atrophy originates from an interstitial tissue proliferation; the connective tissue becoming hypertro- phied, compresses the glands, and, gaining the upper hand, ultimate!}* leads to their entire disappearance. These atrophic processes, as a rule, do not extend over the entire intestine, but more often involve certain parts. Thus, the caecum and its immediate neighborhood have often been found in this state, even in persons who ap- parently during life had no intestinal affection (Noth- nagel). Large portions of the small and large intestines or the entire intestinal tract are but rarely found atro- phied, more often in children than in grown-up persons. Ewald " mentions that he has observed this rare condition in six autopsies in adults. They all had suffered during life from pernicious anaemia and gastro-intestinal disturb- ances. " Both the hyperplastic and atrophic processes, as a rule, are not limited to the intestinal mucosa alone, but also in- volve the neighboring structures (the submucosa and the muscularis). Thus in the hyperplastic form the thickness of the wall of the small intestine may be increased to six times its normal size, while the large bowel may become 1 Woodward : L. c. C. A. Ewald-. " Diseases of the Intestines. " Twentieth Century Practice of Medicine, vol. ix. , p. 127. CHRONIC INTESTINAL CATARRH. 97 three times as thick as normally. In atrophy of the intes- tine there is also a degeneration of the muscles. The gan- glionic cells of the Meissner and Auerbach plexus have been found in a state of fatty degeneration, smaller and lessened in number in the atrophic form ( Jiirgens ' and Sasaki *) . Whether these changes in the nervous tissue are the cause or the result of this general intestinal atrophy is as yet not known. Several varieties of ulcerative processes exist complicat- ing chronic intestinal catarrh. Some ulcerations arise in consequence of superficial erosions of the mucosa, which do not heal. The defect, once produced, gradually grows deeper. Several superficial ulcers adjacent to each other may grow larger and unite. Thus a considerable irregu- lar ulceration develops. The ulcerative process increasing in depth maj^ lead to a secondary phlegmonous inflamma- tion of the submucosa, and ultimately to perforation of the intestinal walls. Another danger lies in the ulcerative process involving a blood-vessel which may cause hemor- rhage. If the perforation through the intestinal walls oc- curs rapidly, fatal peritonitis results ; but if the perforative process develops slowly, then agglutination takes place and a localized peritonitis with or without the formation of a fecal abscess follows. These eventualities are", how- ever, rare. Generally the ulcerations either remain un- changed (not progressing) for a long period of time or they cicatrize. In the latter event strictures of the intestinal lumen may occasionally develop. Follicular enteritis is also occasionally the cause of the formation of an ulcer. The lymph nodules swell up to pea size, soften, and burst. A small ulcer thus arises. As a 1 Jiirgens: Berl. klin. Wochensch., 1892, p. 357. 2 Sasaki ; Virch. Arch., Bd. 96, p. 387. 7 98 DISEASES OF THE INTESTINES. rule, healing takes place, the mucosa of the immediate neigh- borhood extending over and gradually overlapping the de- fect. Sometimes, however, the ulcerative area is covered with a layer of mucus secreted by the goblet cells of the neighboring glands. From time to time the accumulated mucus is removed from the defect and appears in the dejecta in form of particles resembling sago. Extensive ulcerations are seldom met with in chronic enteritis. Most often they occur in the enteritis accompanying pulmonary tubercu- losis. Symptomatology. Chronic intestinal catarrh may occa- sionally exist without giving rise to any subjective com- plaints. As a rule, however, there is a feeling of discom- fort and sometimes of slight pains in the abdomen. These abnormal sensations may be especially marked some time after the ingestion of food or shortly before the evacua- tions. In some cases, again, these annoying sensations appear early in the morning, about an hour or two before rising. Borborygmi often occur; occasionally there is a feeling of tension or of bloating in the abdomen, which may be relieved by the passing of flatus. The latter symp- tom may be so constant and annoying that the patient is afraid to appear in society or may be hindered in his voca- tion. An accumulation of gases in the intestine, especially in the colon, may sometimes exert pressure upon the dia- phragm and give rise to asthmatic complaints, palpitations of the heart and angina pectoris, congestion of the head and vertigo. Belching or passing of wind alleviates these symptoms or entirely removes them. Colicky pains sometimes appear and are of short dura- tion. Severe pains, however, are almost always ab- sent. If the catarrh has lasted for some time, then symptoms CHRONIC INTESTINAL CATARRH. 99 relating to the general state of health often appear. Thus the patient may feel weak, show a disinclination to work, be irritable and somewhat melancholic. Some patients greatly lose in flesh, and present an appearance of suffer- ing, have cold extremities and a slow pulse. Headaches, nausea, and anorexia are also often met with. Whether these symptoms are due to auto-intoxication as some, especially of the French writers, assume (Bouchard ') is very difficult to state. It is, however, certain that this theory does not apply to all cases of this kind. Gastric symptoms (nausea, anorexia, etc.) are as a rule met with only in cases in which the small intestine is affected. If the catarrh is limited to the large bowel these symptoms are usually absent. Objective Symptoms. In some cases the abdomen is bloated, especially shortly after meals, and somewhat ten- der to pressure. There may be tenderness all along the colon ; occasionally the ascending colon can be felt as a sausage-like body containing hard masses, which change their shape upon digital pressure, or this part of the colon is filled with gas and liquids and a splashing sound can then be easily evoked. Similar phenomena may be ob- served also in the descending part of the colon (S Boma- num) in the left iliac fossa. Tenderness along the colon upon pressure is often found ; usually the pains are felt just beneath the area where the pressure is exerted; some- times, however, the pain appears in a more remote spot. Thus, for instance, upon pressing upon the ascending co- lon in the right iliac fossa, pain is felt across the abdomen in a line lying horizontally at two fingers' width above the navel (trans verse colon). Intestinal peristalsis may be observed in persons with thin abdominal walls, especially 1 Bouchard : "Lecoussur les Auto-intoxications," Paris, 1887. 100 DISEASES OF THE INTESTINES. after a palpatory examination. All these signs, however, are occasionally absent. In the symptomatology of the chronic intestinal catarrh the character and frequency of the stools are of greatest importance. While in acute intestinal catarrh diarrhoea is almost a constant characteristic symptom, there is much variation in the frequency of the dejecta in the chronic form. With regard to this point Nothnagel divides cases of chronic intestinal catarrh into the four following groups : 1. Cases characterized by pronounced constipation. An evacuation appears only once in two, three, or four days ; sometimes only with the aid of cathartics. The fecal mat- ter is usually hard. As a cause of the constipation, Noth- nagel assumes a decreased activity of the automatic nervous apparatus of the intestines, this being the result of the ca- tarrhal process. 2. Cases in which constipation and diarrhoea constantly alternate. For two or three days there may be a daily evacuation of very hard dejecta. On the following day there may be four to six very thin or mushy movements mixed with mucus, accompanied by violent pains, and then again constipation for a day or two, etc. Or there may be quite normal evacuations (once daily) for a few days in succession and then again four to seven diarrhoeal move- ments in one day, and after this constipation. The prin- cipal feature of these cases is the constipation, but the excitability of the nervous apparatus being quite good, the decomposed stagnant contents often cause increased peristalsis and diarrhoea. Sometimes these alternating periods of constipation and diarrhoea continue for a long time. Thus the patient may be constipated for four or five weeks, or even for a few months, and then again the diarrhoea may set in, lasting several weeks or months. CHRONIC INTESTINAL CATARRH. 101 3. In a very limited number of cases there is a daily evacuation, which is usually not formed and mushy. 4. Cases in which there are for months several diarrhceal evacuations daily. The dejecta as a rule show the biliary reaction, or they may contain yellow fragments of mucus, yellow tinged epithelia, and round cells. In these cases the catarrhal process affects not only the large bowel but also the small intestine. The absorption suffers and there are more abnormal products in the contents (acids), which give rise to increased peristalsis in the small as well as large bowel. Besides these typical cases there are some in which the nervous element plays a part in combination with the ca- tarrhal process. Thus there are patients who are molested with diarrhceal movements only during the night or in the early morning hours (morning diarrhoea of Delafield 1 ), while they feel well during the remainder of the day. The quality of the dejecta in those cases in which there is constipation is almost normal, with the only exception that there is an admixture of mucus. Nothnagel considers this point the most important in the recognition of a catarrhal condition of the intestine. The mucus may be absent in rare instances in which the scybala are small and the layer of mucus within the intestine is very tough and adherent, so that the fecal matter cannot carry it along in its passage. The quantity of mucus varies greatly. While in most cases only small particles of mucus are found, there are some in which a considerable amount may be passed. Large amounts of mucus without fecal matter are often found in enteritis membranacea, less frequently in chronic enteritis. 'F. Delafield : Medical Record, May llth, 1895. 102 DISEASES OF THE INTESTINES. In cases in which the dejecta are more or less thin, mushy or water} 7 , the fecal matter has a light color, brown- ish-yellow or grayish-yellow, and may at times be very poor in biliary matters. In these instances, undigested food particles are easily found. Thus small particles of meat or starchy food may be discovered. The microscopical examination of the dejecta is often very useful, for even in cases in which macroscopically nothing abnormal can be discovered, the microscope may reveal considerable amounts of undigested meat fibres, starch granules, and fat globules. Such substances, if fre- quently present, indicate that the catarrhal affection is principally within the small intestine. The microscope here further shows the presence of epithelial cells, some- times of a yellow color and mostly in a shrivelled condi- tion and embedded in mucus. According to Rosenheim, ' chemical examinations of the dejecta have no practical value in this affection. The reac- tion with regard to litmus varies greatly and is dependent upon the frequency of the stools and the quality of the in- gested food. As a rule, however, an alkaline reaction is found. The degree of fermentative processes in the intestines may be gauged by the intensity of the feeling of tension in the abdomen, the frequency of flatus, and the condition of the dejecta. The latter may present a very fetid odor and a foamy surface. If the movements are diarrhceal, a fer- mentation tube may be filled with the liquid contents and kept at blood temperature for a few hours ; the amount of gas developed in the tube will indicate the degree of fer- mentation. The character of the urine is also of impor- 1 Tbeodor Rosenheim: "Pathologic und Therapie der Krankheiten des Darms, " Wien und Leipzig, 189? CHRONIC INTESTINAL CATARRH. 103 tance with regard to this point. In conditions in which there is considerable fermentation and absorption of de- composed products within the small intestine, it usually gives a more or less strong indican reaction and also a decided Rosenbach reaction (Burgundy red color after boiling and the addition of nitric acid). Chronic enteritis complicated with catarrhal ulcers mani- fests itself by more frequent attacks of diarrhoea, admix- ture of blood or pus in the dejecta, and pain. All these symptoms are especially apt to be present if the lower part of the intestinal tract is affected ; if the ulcer is in the small intestine, diarrhoea is often absent, nor need there be any signs of blood or pus in the dejecta. Atrophic processes may also accompany the enteritis. If these involve only a small part of the intestinal tract, no symptoms whatever. may result; if, however, larger parts of the small intestine are affected, the absorption of food is greatly impaired and then severe symptoms occur. Diarrhoea without passage of mucus and accompanied by a gradual but steady loss in weight is present, as are oc- casional symptoms of pernicious anaemia. This condition is found much oftcner in infancy than in later life. Course. As a rule chronic enteritis is a very tedious affection. It may last many years, even until the end of life. The intensity of the symptoms varies a great deal, and there may be periods of apparent perfect euphoria. There always remains, however, a decided weakness of the intestine, which is easily upset by slight errors in diet, which in healthy persons would be harmless. Diagnosis. The diagnosis of chronic enteritis is made if there are abnormal sensations within the abdomen, ac- companied by irregularity of the bowels and the presence of mucus in the stools. Habitual constipation can be ea- 104 DISEASES OF THE INTESTINES. sily differentiated from enteritis : (1) by the absence of mu- cus ; (2) by the fact that it does not so easily nor so com- pletely respond to mild cathartics. Malignant growths are often accompanied by enteritis, and thus the symp- toms of the latter often give rise to mistakes. A longer period of observation, however, will aid in arriving at a correct diagnosis. In case of a neoplasm symptoms of cachexia will not fail to appear nor will the accompanying enteritis be so readily alleviated as if it were the only affection. In ulcer of the intestine pains predominate and are a marked feature. Constipation and diarrhoea depend- ent upon disease of the stomach will be recognized : (1) by the absence of mucus in the stools ; and (2) by an examina- tion of the gastric contents. They will readily yield to treatment directed toward the gastric disorder. With regard to the localization of the process, the fol- lowing is of importance: Chronic inflammation confined to the small intestine is usually accompanied by gastric symptoms, constipation, and the presence of small parti- cles of mucus in the stools, having a yellow tinge and being well mixed with the dejecta. If the large bowel alone is involved (colitis), there is constipation with the presence of more or less mucus of a grayish color, either covering the entire fecal mass or appearing here and there on its sur- face. Occasionally, especially if the lower part of the bowel is affected, the mucus appears at the end of the de- fecation and is then voided without any admixture of fecal matter. If the inflammatory process involves both the small and the large intestines, constant diarrhrea is a pre- dominant feature. The mucus found in the dejecta has a yellowish color; besides considerable quantities of undi- gested food are discovered in the fecal matter. Prognosis. The prognosis of chronic enteritis depends CHRONIC INTESTINAL CATARRH. 105 upon the intensity of the symptoms, the duration of the disease, and also. greatly upon the age and the constitution of the patient. In infancy and in old age chronic catarrh of the intestines must be considered a grave affection. The same applies to persons with a weakened constitution (tuberculosis, cardiac or other important lesions). A chronic enteritis of intense type which has lasted a long period of time is hardly ever cured perfectly. There may be improvements in the condition of the patient, but re- lapses are sure to follow soon. Cases of a mild nature, how- ever, often end in recovery, especially under an appropriate treatment. In old age a complete cure rarely takes place. If atrophy of the intestines has developed, then the condi- tion is very unfavorable, the patient succumbing after a period of about twelve to eighteen months. Treatment. As in the treatment of chronic gastric ca- tarrh, and perhaps in a still greater degree, hygienic and dietetic measures here play the chief part. It will be at first important to regulate the mode of living of the patient not too much work, not too great business strain, plenty of outdoor life and exercise, regularity of meals. Expo- sure to cold should be carefully avoided. The patient should dress warmly, especially the abdomen and feet (flan- nel bandage around the abdomen), and should be particu- larly careful not to get his feet wet. In rainy weather shoes with thick soles or rubbers should be worn. With regard to diet the following rules are of value : the meals should be taken frequently and in small portions. Indigestible sub- stances should be avoided. Sufficient nourishment should be given, and care taken that there is an increase rather than a decrease in weight. In cases of diarrhoea the fol- lowing should be forbidden : acid or sweet wines, all mine- ral waters charged with carbonic-acid gas, lemonade, all 106 DISEASES OF THE INTESTINES. kinds of fruits, salads, all kinds of cabbage including cauli- flower, rye bread, and pastries. Give eggs (soft-boiled or scrambled), light meats, especially sweetbread, calf's brain, spring chicken, steak, lamb chops, oysters, lean fish, white bread well baked or toasted, fresh butter, cream soups, bouillon, rice, sago, macaroni, mashed or baked potatoes, milk, cacao, tea. Kumyss, matzoon, ginger ale, good claret or Tokay may also be allowed. As a rule noth- ing should be taken in large portions, and the drinks should be warm or cool (temperature of the room), but not cold. Large amounts of liquids should be avoided. Patient with very severe symptoms (frequent diarrhoea, intense pains, great weakness) must be kept abed for a short time and put on a rigorous diet at first, as in cases of acute ente- ritis. Upon improvement of the condition the dietetic rules described above should be followed. In cases attended with constipation the diet may be more liberal. Besides all the articles of food mentioned in the diarrhoeal group, light fruits, as oranges, grapes, ripe pears, and green vegetables, green peas, cauliflower may be added. The ingestion of large amounts of starchy foods, easily assimilated fats, butter, cream, and of fluids is very beneficial. The more indigestible articles of food, like bran breads (pumpernickel), sausages, lobster salad, mayonnaise dressings, cabbage, cucumbers, etc., should be avoided. Beer, ale, Rhine wine taken moderately are permissible. Hydrotherapeutic Measures. Incases of diarrhoea warm mineral baths or baths with the addition of pine needle extract and mud and bran baths are favorable. Cold baths should be avoided. A cold sponge bath, however, or a cold shower on the back may be serviceable in chronic en- teritis with nervous symptoms. A Priessnitz (wet pack) CHRONIC INTESTINAL CATARRH. 107 over the abdomen may be advantageously used over night. Cold sitz baths and cold showers over the abdomen are also often beneficial. Mineral Waters. According to Nothnagel chronic enteri- tis is sometimes greatly improved, and even perfectly cured, by a methodical course of drinking certain mineral waters. Such a cure can best be carried out at the mineral springs themselves. For here the patients not only take the waters in the right way, but also observe the necessary rules of diet and are besides kept free from their business cares. Carlsbad is to be regarded as the best place in cases of chronic enteritis in which the diarrhoea is a prominent fea- ture; Vichy comes next. For cases of chronic enteritis with constipation Marienbad seems to be very useful ; the same applies to Saratoga (Hawthorn and Congress Springs). For cases in which neither constipation nor diarrhoea plays a prominent part Kissingen or Homburg may be recommended. Chronic enteritis accompanied by anaemia may be benefited at the watering-places of Fran- zensbad and Elster. The Carlsbad water should be taken in small quantities, about a wiueglassful twice daily ; in some cases even smaller amounts (25 to 50 gm.) three to five times daily. In cases which have been benefited by a drinking cure in Carlsbad, Nothnagel suggests having these patients use at home the Carlsbad waters in a similar manner as at this resort, four times a year for an entire month. Nothnagel says : " The chronic condition requires a chronic treatment." Medicaments. Strong cathartics should be avoided in the treatment of the constipation. Here some articles of diet which moderately increase the intestinal peristalsis may be first tried buttermilk, a glass of cold water, stewed fruits, and the like. If these fail, small amounts 108 DISEASES OF THE INTESTINES. of rhubarb, fluid extract of cascara sagrada, podophyllin may be used. Of greater value, however, are rectal injec- tions either of plain water or with the addition of some soap or salt (a teaspoonful to a quart) or Carlsbad water. Enemas of olive oil, as first recommended by Habershon and later by Kussmaul and Fleiner, may also be advan- tageously used. The oil enemas should, however, be given in small quantities (half a pint to a pint) and be re- tained over night in the bowels. The frequent use of calo- mel, castor oil, and jalap should be forbidden. The diarrhoea is best treated either by large doses of subnitrate of bismuth or salicylate of bismuth (1 to 2 gm., gr. xv. -xxx.) three times daily, or some of the drugs con- taining tannic acid as their principal ingredient (calumba, cascarilla, rhattania, catechu, kino, lig. campechianum, fructus myrtili). Weber ' recommends the following pre- scription : ^ Extr. monesiae, Extr. calumbse aa 15.0 (|ss.) Extr. gent, et pulv. liq q.s. Ut f. pil. cxx. 8. Three times daily two to four pills. I very frequently give fluid extract of condurango and fluid extract of calumba of each twenty drops three times daily. Dermatol (subgallate of bismuth) seems to be quite beneficial in cases in which the formation of gas is a predominant feature. It may be given in doses of half a gram (gr. viii.) three times daily. For the same condition salicylate of bismuth, benzonaphthol, and creosote in small doses may be given. Tannigen and tanalbin may be used in doses of 0.5 to 1 gm. (gr. viii.-xvi.) three times daily, the first being preferable. Both substances seem to less- en fermentation, and by their astringent qualities exert a 1 L. Weber : New-Yorker medicinische Monatsschrift, 1892. CHRONIC INTESTINAL CATARRH. 109 beneficial influence upon the healing-process. They may therefore be given continuously for a long period of time. Cases accompanied by pains will require an opiate (mor- phine, or still better codeine), with or without the addition of belladonna extract. In chronic proctitis suppositories of opium and belladonna extract with cacao butter are indi- cated. Small enemas of starch solution with an opiate are also useful here. It is of course to be understood that the administration of opiates will have to be limited to a short period of time. CHAPTER IV. DYSENTEKY. Synonyms. Enteritis crouposa et necrotica; Amoebic dysentery. Definition. An infectious disease characterized by spe- cific ulcerations of the large intestine, giving rise to fre- quent bloody, mucous, or purulent dejections accompanied by tenesmus and general symptoms. Etiology. Dysentery occurs under three different condi- tions : (1) As a disease principally during the warm season in temperate climates, appearing in local epidemics; (2) endemic in hot climates ; (3) epidemic at certain times in all latitudes, being quickly disseminated, and also sporadic. While the endemic zone of dysentery is limited to places lying south of the fortieth degree of latitude, epidemics of the disease have occurred in almost every part of the globe. Dysentery is one of the oldest diseases known. ' It was observed by Hippocrates and well described by Are- taeus and Celsus. Aretaeus already recognized the ulcera- tion of the intestines in dysentery. Various causes have been adduced to explain the origin of the disease, and meteorological influences have been held responsible for its prevalence in local epidemics. The endemic dysentery of the tropics was generally ascribed to the combined action of heat and of the miasm of swamps. Sudden exposure to cold, eating of bad and spoiled food, and the use of stagnant or marshy water were all believed DYSENTERY. Ill to be factors in producing dysentery. It is only within recent years that its infectious and also contagious char- acter has been recognized. Sodre ' says : " A careful etio- logical study shows that dysentery in whatever latitude it be observed is always due to the action of the same exciting cause, that it starts and is propagated always under the influence of infection and contagion, and that it should be included in the group of parasitic diseases." The exciting cause of dysentery often lies in the soil, in circumscribed foci of infection. These foci are represented by marshes and bogs which receive the drainage from dung heaps and cesspools, or by a soil impregnated with human dejec- tions. The contagious character of dysentery is best shown by the following report of Dr. Beauchef.' This writer states that the French ship Loreit, anchored on the west coast of Africa, was in the best possible sanitary condition, not one of the crew being ill. She was then ordered to transport to Gorea the sailors of the sloop of war Eagle, among whom were twenty-nine dysenteric patients. A few days afterward, while on the high sea, dysentery spread among the crew of the Loreit and ceased only after all the patients had been landed at Gorea. Among the causes which contribute to diffuse the dysen- teric contagion and to produce the disease in an epidemic form the following may be mentioned : Crowding together of individuals, the vicissitudes of war, bodily privation, chiefly hunger. These factors are frequently found asso- ciated in times of war when epidemics of dysentery have often appeared, causing great ravages. Since bacteria have been found to play an important 1 A. Sodre : " Dysentery, " Twentieth Century Practice of Medicine, vol. xvi. , p. 241. 1 Beaucbef : Cited after Sodre, loc. cit. 112 DISEASES OF THE INTESTINES. part in the etiology of infectious diseases, many investi- gators have tried to discover the particular micro-organism producing dysentery. Various bacilli and cocci have been described and hejd responsible as etiological factors, but their relative significance has not been determined. As early as 1859, however, Lambl l called attention to the pres- ence of amoebae in the intestinal contents. He found them in the stools of a child suffering from dysentery. Loesch, 2 in 1875, observed amoebae in the dejecta of a patient suffer- ing from chronic dysentery. He was the first to attribute the disease to this micro-organism. He also succeeded in experimentally producing a dysentery -like disease in a dog to which he had administered rectal injections of fecal matter containing amoebae. The observations of Loesch have been confirmed by Koch, 3 who, while investi- gating dysentery in Egypt, found in post-mortem examina- tions numerous amoebae in the intestine at the base of the ulcers. The next important contribution on this subject was made by Kartulis, 4 who, while practising in Alex- andria, had an opportunity to observe several hundreds of cases of dysentery. In more than five hundred post-mor- tem examinations he found the amoebae constantly in the faeces and on the surface of the ulcers, and in the abscesses of the intestine as well as of the liver. In other affections of the intestines Kartulis failed to detect the amoebae para- sites. He also succeeded in cultivating them in infusions of sterilized dry straw, and twice produced dysentery in 1 Lambl : " Beobachtungen und Studien aus dem Franz- Josef -Kinder- Spital, " 1860. 8 Loesch : "Massenhafte Entwickelung von Amoeben im Dickdarm. " Virch. Arch , Bd. Ixv. 3 Koch : Cited after Sodre, loc. cit. 4 Kartulis : " Zur Aetiologie der Dysenterie in Aegypten. " Virch. Arch., Bd. 105, 1885. DYSENTERY. 113 cats by inoculation with these cultures. Kartulis, there- fore, declared the amoebae to be the true etiological factor of dysentery. Yery soon afterward observations of a similar character were made both abroad and here. Thus Quincke and Roos,' Hlava," Massaiutiu, 3 Nasse,* and others abroad, and Osier, 5 Stengel/ Musser, 7 Eichberg, 8 Stockton,' Council- man and Lafleur, 10 and Harris " of this country have also described cases of dysentery with the presence of the amoebae parasites. The theory of the amoebic origin of dysentery has been dis- puted by some writers, for they have found this micro-or- ganism in the faeces in other intestinal disorders and, in some instances, even in the stools of healthy persons. Thus Schuberg ia says : " The abundance of amoebae in dysentery is the effect and not the cause of the disease, the ulcerative lesions affording this habitual denizen of the intestines more favorable conditions for its development." The con- sensus of opinion, however, is that while harmless amoebae may occur in the intestinal tract, there exists a pathogenic variety of this organism which is specific for dysentery. For this reason Councilman and Lafleur proposed the name I Quincke und Roos: Berl. klin. Wochenschr., 1893. Hlava : Centralbl. fur Bacteriologie, 1887. Massaiutin : Ibid. 4 Nasse : Deutsche med. "Wochenschr.. 1891. 5 Osier : Bulletin of the Johns Hopkins Hospital, 1890. 6 Stengel : Medical News, November 15th, 1890. : Musser: University Med. Magazine, December, 1890. 8 Eichberg: Medical News, August 22d, 1891. ' 9 Stockton : International Clinics, 1894. i. 1(1 W. J. Councilman and H. A. Lafleur : u Amoebic Dysentery." Johns Hopkins Hospital Reports, vol. ii., Xos. 7-9, 1891, p. 395. II K. F. Harris: "Amoebic Dysenteuy. " American Journal of the Medical Sciences, 1898, p. 384. 18 Schuberg : Centralbl. fur Bakteriologie. 1893. 8 114 DISEASES OF THE INTESTINES. of amoebae dysenteriae for this special variety. The pres- ence of the amoebae in the contents of abscesses of the liver, which are so often met with in dysentery according to Sodre, constitutes a powerful argument in favor of the amoebic etiology of the disease. It is generally believed that the amoebae enter the system along with the food or drink. Sodre believes that they can be taken in with the air. Certain waters, however, ap- parently constitute the principal means of propagation of these amoebae. Thus, Barthelemy ' relates that the troops when operating on the shore of the Oueme, whose clear run- ning water was filtered in Chamberland filters before being used, were in good health and free from dysentery ; when, however, the army moved away from the Oueme in the direction of Abomey they were compelled to use unfiltered swampy water. From that moment dysentery made its appearance. Fitz and Gerry 8 described a case of dysen- tery with the presence of amoebae in the stools and found the same micro-organisms in a cistern, the water of which the patients constantly used. Age does not seem to have any influence upon the disease. Statistically a greater number of cases is found among adults, as these are more exposed to the morbific causes. Both sexes are equally predisposed to dysentery, and no race enjoys immunity from it. One attack does not confer immunity against others. Persons who suffer from want of food or who live on food of bad ffuality are most liable to contract the disease. Harris says: "Dysentery is a disease pre-eminently of the poor, and is almost always associated with filth, bad hygienic surroundings, and lack of proper food." This statement, however, is somewhat 1 Barthelemy . " Medical Report of the War of Dahomey " J Fitz and Gerry : Cited after Sodre, loc. cit. DYSENTERY. 115 too categorical, and I fully agree with Sodre, who remarks that dysentery is observed also in persons of the wealthier class, who live on the best food and are surrounded with every comfort. Nevertheless, it must be admitted that it is most frequent among the poor, and chiefly among people who live under bad hygienic conditions. JUorbid Anatomy. In acute dysentery the large intestine is almost always found in a thickened condition. This thickening involves all the intestinal coats, but is most marked in the subnmcosa. Sometimes the latter layer alone is involved. The mucosa, when washed with water, presents a bright red, at some places dark red color. The folds of the mucosa are much more voluminous than nor- mally, and thus present considerable prominences. Small red nodules of various size are also seen scattered over the mucous membrane. Besides these nodules more or less numerous ulcers are found. These vary greatly in size (from a pinhead to two inches long) and also in depth, some being superficial, others quite deep. The ulcers are situated chiefly on the folds of the mucosa. Ordinarily they are oblong and lie transversely to the long axis of the bowel. Sometimes they are circular, sinuous, or ir- regular. Councilman and Lafleur have described on the surface of the mucosa sharply outlined projecting nodular thicken- ings, in which are observed cavities filled with a gelatinous mass communicating with the surface of the mucous mem- brane by small openings, frequently not larger thaii the head of a pin. These writers have also pointed out as characteristic of the dysenteric ulcers their undermined edges. The disease process in dysentery, according to Councilman and Lafleur, is essentially one of advancing infiltration and softening of the submucous and iuteruius- 116 DISEASES OF THE INTESTINES. cular tissue with subsequent necrosis of the overlying tissue. The amoebae reach the submucosa without injur- ing the mucous membrane. Here the essential changes are first produced, and the mucous membrane is interfered with later. The mucosa becomes cedematous and ruptures after a while, forming an ulcer. Harris described two anatomical forms of ulcers found in dysentery. In the first form, which is encountered most frequently and can be considered as the typical intestinal lesion of the disease, changes in the submucosa r^ay be traced in advance of the surface ulceration for quite a dis- tance, thus undermining the comparatively healthy mucosa above. In the second form the ulcers increase in size by gradual softening and breaking down at the surface, never by necrosis and sloughing of the underlying tissue. Ulcers of the second category occasionally do not penetrate deeper than half-way through the mucosa. Generally they extend into the submucosa. They never contain amoebae. The lesions described are usually found throughout the entire large bowel, but as a rule they do not extend beyond the ileocaecal valve. In a comparatively small number of cases the small intestine is also involved, principally the ileum. In some instances gangrene of the intestine is found. Many authors even describe a gangrenous form of dysen- tery. Sodre, however, does not regard the gangrene as a lesion brought on by the amoebae dysenteric, but by the action of bacteria foreign to the dysenteric process. Ac- cording to this author gangrene is a complication of dysen- tery, but not a specific lesion. In this complicated form, besides the ulcers described above, there exist others of a gangrenous character. The gangrenous process may also extend beyond the ulcers. On the brownish-red mucosa DYSENTERY. 117 gangrenous patches of a dark color and of various size are seen. In this condition the mucosa may be detached over a considerable area and eliminated with the dejections. In chronic dysentery the intestine is pale with slate col- ored spots. Its walls are thickened. The mucosa presents a pale rosy or slate color. Ulcers in different stages of development are encountered. Often the ulcers occur in groups separated from each other by more or less extensive healthy areas of intestine. Sometimes in certain portions of the intestines the ulcers become confluent. Dysenteric ulcers may be round, elliptical, or serpentine in form and usually have thickened and callous edges. In the neighbor- hood of the ulcers, there is no hypersemia or cedema, al- though an increase of fibrous tissue is noted. Undermined ulcers undergoing a process of repair are also found. The mucosa glands are found dilated and filled with mucus. In some places glandular cysts of considerable size are encoun- tered, in others the glands have almost disappeared, and only traces of them are left. The mucosa is thickened and filled with round cells. The submucosa is likewise thick- ened and in some places oedematous. Dense fibrous tissue is found almost all over in this layer, predominating, how- ever, at the location of the cicatrices and of ulcers in the process of repair. In both the chronic and the acute form of dysentery, but principally in the latter, besides the lesion of the intes- tines described above, the liver is frequently found dis- eased. In dysentery complicated with gangrene this organ is usually greatly increased in volume, tumefied, soft, and friable. The cross-section presents a dark color inter- spersed with yellowish spots. The latter are usually some- what raised above the surface. On microscopical examina- tion the hepatic cells show a large amount of fat ; besides, 118 DISEASES OF THE INTESTINES. small round abscesses are found around the capillaries, which are most probably due to emboli. Aside from these very small pus collections of pysemic origin, other abscesses are found which differ from these by their size and the nature of their contents. They are the so-called dysenteric abscesses of the liver, and are most often encountered in acute dysentery without gangrene. The dysenteric abscesses vary greatly in size from a few lines to several inches. They are situated chiefly in the right lobe of the liver near the surface. Often several are found together. The contents of these abscesses vary greatly. In the most recent, the abscess does not empty itself on section. A small amount of glairy, semi-trans- parent fluid exudes and leaves behind an irregular sponge- like mass, the fluid being apparently held in the meshes. In the older abscesses the contents are more fluid, the latter having a greenish opaque color. In these are suspended some solid masses of tissue. In some instances the con- tents are brownish or streaked with brownish-red from admixture of blood. Microscopical examination of the con- tents of the abscesses reveals the presence of a few pus cells, a large quantity of fatty granules, necrotic hepatic cells, a few blood corpuscles, a great number of amoebae (see Fig. 28), and sometimes micrococci and bacilli. Ac- cording to Councilman and Lafleur, there is no definite abscess-wall, the liver tissue passes gradually into the abscess, and the contour of the edge is very irregular, sometimes extending into the liver for a distance of several nodules. The abscess may penetrate the capsule of the liver and either open externally or it may burst into some of the adjacent organs, as, for instance, the lungs, the stomach, the intestines, or the peritoneal cavity. Most often, however, it bursts into the lungs. DYSENTERY. 119 Symptomatology of Acute Dysentery. The disease may begin suddenly without any premonitory symptoms, or after a few clays of general malaise, loss of appetite, and irregularity of the bowels, the patient is attacked with abdominal colic and diarrhoea. These symptoms are usually accompanied by chills, vague pains through the body, and fever. The stools, at first abundant and watery, very soon become scanty, mucous, and usually contain FIG. 28. Amoebae from an Abscess of the Liver. X 750. (Sodre 1 .) blood. Gastric disturbances are present in almost all cases: anorexia, nausea, often vomiting. The principal features of dysentery are the characteristic stools, the abdominal pains, and tenesmus. 1. Stools. The evacuations increase in frequency, oc- curring from twenty to twenty -seven times during the twenty-four hours. The calls to stool are usually preceded by rumbling and colicky pains, and are followed by strain- ing and tene&mus. While during the first and perhaps the second day of the disease the motions are copious, they soon become scanty. The patient is then able to expel but a small quantity, about a teaspoonful of mucus mixed with blood, after painful efforts. Occasionally a few small pieces of fecal matter are passed. The dejecta o<.v;:sion- ally change their character with regard to frequency as 120 DISEASES OF THE INTESTINES. well as consistency. Intermissions and exacerbations of the diarrhoea are sometimes observed in the coarse of the disease. The mucus in the stools is almost always mixed with blood. In some cases the dejecta are hemorrhagic, that is, consist of almost pure blood, either red and fluid or dark and coagulated. In dysentery complicated with gangrene the stools are serous, of a dark reddish-brown color, and contain, in addition to finely divided mem- branous threads, large and thick masses of necrotic tissue of a gray or black color. The gangrenous dejecta have an intensely offensive odor. In many instances the stool con- tains no' bile. Amoebae are almost always found in the dysenteric stools, especially if the lesions are quite extensive. In examining the faeces for amoebae it is well to use some precaution. If possible the examination should be made immediately after the dejecta have been passed. If this be impossible, the stool should be preserved in a clean vessel and kept in a warm place until the examination is made. The amoebae are from 12 to 36 *. in diameter, and when alive frequently change their shape by contracting some part of their bodies in order to move about. The body of these micro-organisms consists of an outer clear homogeneous substance or ectosarc and an inner highly refractive mass or eudosarc. Within the latter are usually found some bacteria, sometimes changed red blood corpuscles, and a few quite large vacuoles. The amoebae, when outside of the intestinal tract, die very quickly, especially if they are kept in a cool place. When dead, these organisms generally show a round or almost round configuration. (2) Abdominal pain. Abdominal pains exist with greater or less severity in almost every case. The pains may be experienced continuously, or principally before an evacu- DYSENTERY 121 ation. Most often they are located in the umbilical region and in the left iliac fossa, bat sometimes they exist in the right iliac fossa and may then almost simulate an attack of appendicitis. The pains may be so severe that the patient is forced to lie perfectly still for fear of increasing them. Pressure exerted on the large intestine as a rule provokes more or less intense pain. According to Dutrouleau, ' in some very grave cases there is a total absence of colic during the entire course of the disease. (3) Tenesmus. Rectal tenesmus, consisting at first in painful sensations of pressure and constriction and later in an intense desire to go to stool, is encountered very fre- quently. In grave cases of dysentery the tenesmus may exist almost uninterruptedly. Off and on the patient suc- ceeds in expelling a small amount of fecal matter or slime or merely gas, and then feels relieved for a short while. Very soon, however, the pains in the anal region return with the same severity. When the tenesmus is very severe it may be accompanied by dysuria or strangury. In this condi- tion the patient presents a pitiable appearance. His straining is frequently agonizing and occasionally accom- panied by fainting. Besides the three cardinal symptoms of dysentery just ribed, other symptoms are often encountered." Fever may be present, especially in the severer form of the dis- ease. It may occur in the form of chills, when the disease is first ushered in. As a rule, the fever is not very high and shows an irregular course. Gastric symptoms are often present. They consist in intense anorexia, nausea, vomiting, and pain in the epigastric region. The general condition is more or less affected according to the severity 1 Dutrouleau : " Traite des Maladies des Europeens dans lea pays bauds, " Paris, 1868. 122 DISEASES OF THE INTESTINES. i of the disease. In grave cases prostration is marked, the skin is dry, the features are altered, and the extremities sometimes cold. The pulse is small and rapid. Some- times cerebral disorders, stupor, drowsiness, even delirium, are encountered. Dutrouleau and others divide cases of acute dysentery into three groups: Cases of a mild character, those of medium intensity, and those of a severe type. In the mild form, there exist only local symptoms which are usually not very intense. In the form of medium intensity, the local symptoms are more accentuated and general symp- toms are encountered. In the severe form, there are fever, intense pain, very bloody stools, great prostration, and in- tolerable tent-sums. Symptomatology of Chronic Dysentery. Chronic dysen- tery develops either after several attacks of the acute form or directly from the first acute attack, which after some periods of improvement persists to a greater or less extent. Cases of chronic dysentery are also divided into three categories : (1) The mild form. The general nutrition is not inter- fered with. The patients usually complain of slight con- stipation interrupted by light attacks of diarrhoea. Tenes- mus is either entirely absent or present in a very slight degree. Even during the attacks of diarrhoea the passages are, as a rule, not bloody. (2) Form of mediant intensity. Here slight gastric symp- toms are present, like anorexia, belching, etc. The gen- eral condition is interfered with to a considerable extent. There are almost always periods of intermission and exac- erbation of the disease. The patient may have regular movements or be slightly constipated, for a period varying from a week to ten days, but soou diarrhoea appears and lasts DYSENTERY. 123 for four or five days. The stools are then watery, contain mucus, and occasionally a little blood. Slight colicky paiiis are present, as well as moderate teuesmus and a sen- sation of heat or burning in the rectum. (3) The severe form. General nutrition is greatly im- paired. The patient becomes emaciated, pronounced gas- tric symptoms are present: anorexia, a bad taste in the mouth, often nausea, occasionally vomiting. As a rule, there is persistent diarrhoea, and the dejecta present a mu- cous or nmco-sauguineous character. Colicky pains in the abdomen and pronounced tenesmus are present. In some cases, however, the diarrhoea alternates with short periods of constipation lasting two or three days. The patient usually feels very weak and is obliged to stay abed a great deal of the 'time. Course. The course of acute dysentery is very indefinite. Sometimes the disease terminates in recovery in eight to fifteen days; sometimes in one to three months ; sometimes again death occurs a few days after the commencement of the disease. Again, a case of dysentery may at first be mild, but later assume a dangerous character, and even terminate fatally. Intermissions and exacerbations are often encoun- tered in this disease. When dysentery becomes chronic its duration varies greatly, often depending upon the severity of each particular case. Thus, it may last five to six mouths or many years. Even in the chronic form recovery is not entirely impossible. Co)nj>U<'((fio)i$. The course of the disease is occasionally motlinVd by various complications. Peritonitis often re- sults from an extension of the ulcerative process from the iutestiual wall to the peritoneum. Perforation of the intestine may occur in a similar way, and is observed principally in gangrenous dysentery. Sudden death is 124 DISEASES OF THE INTESTINES. occasionally observed in such an event. In acute as well as in chronic dysentery severe hemorrhages from the bowel may take place. The loss of blood ma} r be so great even as to cause death. Thrombosis of the femoral artery as well as of the venous sinuses of the brain has been observed by Laveran l as a complication of dysentery. A patient of mine with acute dysentery, apparently on the road to im- provement, suddenly one day developed a paralysis of the upper and lower right extremities. He later lost con- sciousnes and died about forty-eight hours after the first signs of paralysis. Here most probably thrombosis of some brain vessels took place. The most frequent complication of dysentery is abscess of the liver. In the majority of instances it is observed in convalescence from acute dysentery or during the evolu- tion of chronic dysentery. The symptoms of the forma- tion of an abscess in the liver are : fever of an irregular character, occasionally chills and pain in the hepatic region which may radiate to the right shoulder. The physical examination often reveals some enlargement of the liver. In the event of a liver abscess opening into the lungs, there is persistent cough and sometimes expectoration of a reddish-brown fluid containing amoebae. Abscess of the liver is more frequently encountered in tropical regions than here. The course of such an abscess is very irregular. Sometimes it progresses rapidly, at other times it shows periods of intermissions and exacerbations. The large abscesses of the liver, if not operated upon, usually termi- nate in death. Rarely recovery may follow the opening of the abscess into a neighboring organ. 1 Laveran : " De la phlebite, de la thrombose et des paralysies comme complications de la dysenteric. " Archives de Medecine militaire, 1885. DYSENTERY. 125 Di(i(/)ioti)fi. The diagnosis of acute dysentery is usually very easy. The symptoms above described, being ordi- narily present, cannot fail to indicate the disease. The most reliable evidence is afforded by the character of the dejecta, the presence of mucus, an admixture of blood and pus corpuscles. Appendicitis is occasionally simulated by dysentery if the pains involve principally the appendicular region. Usually, however, it will be found that, besides the tenderness over the appendix, there are also similar areas of pain over other portions of the large bowel, espe- cially in the left iliac fossa. Besides, the character of the stool will help to reveal the true condition. The diagnosis of chronic dysenterj' is usually somewhat more difficult. Repeated examinations of the faeces will, as a rule, reveal the presence of amoebae at one time or another and thus aid in discovering the disease. Many diseases of the rectum, as for instance proctitis, rectal polypus, and cancer, often present symptoms similar to those of chronic dysentery. A careful local examination, however, will clear up the diagnosis without difficulty. Prognosis. Dysentery must always be considered a quite serious disease. Even the mild form is at times liable to assume a dangerous character. On the whole dysentery must be regarded as a treacherous and insidi- ous malady. In general it must be said that cases of sporadic dysentery or of the epidemic form appearing in the cold and temperate zones take a much milder course and thus present a more favorable prognosis than does the endemic dysentery of hot climates. These remarks apply to both acute and chronic dysentery. Treatment of Acute Dysentery. The patient must be kept abed and put on a diet consisting of liquid food (milk and strained barley water, bouillon, bouillon with egg, egg 126 DISEASES OF THE INTESTINES. water, tea). Ipecacuanha has been found of great benefit in this disease. It may be given, according to Sodre, in the following combination : Powdered ipecacuanha 0.1 (gr. ij.) Powdered opium 0.02 (gr. ) Calomel 0.05 (gr. f) In capsules, one to be taken every two hours. In case the evacuations contain very small quantities of fecal matter, it is best to give a cathartic, as a large dose of castor oil (one to two tablespoonfuls) or sodium or mag- nesium sulphate one teaspoonful twice during the day. The purgative, however, should be administered only on the first or second day of the disease, and not be kept up for a long time. In order to allay the pains, hot poultices are applied over the abdomen and opium is administered. Thus, Dover's powder may be given in three-grain doses every two or three hours. This medicament may also be combined with salol, subnitrate of bismuth, tannigen, tannalbin, etc. The tenesmus, if severe, must be subdued by suppositories containing opium and belladonna, and by washing out the bowel with a quart of water containing a tea- spoonful of essence of peppermint, which can be done once or twice in twenty -four hours. Astringent solutions have been recommended as injections for the large bowel. They are not, however, of great benefit in acute dysenter} r . Besides the points just mentioned, the condition of the patient must be carefully watched and every complication treated by itself. The high fever may necessitate the use of an antipyretic ; the weak action of the heart aualeptic drugs, etc. As soon as the severe symptoms are allayed and the patient is on the way to recovery the diet can be cautiously increased. Treatment of Chronic Dysentery. If the patient is living DYSENTERY. 127 in an endemic centre of dysentery, it is best to send him to another climate. The hygienic surroundings of the patient should be carefully selected. The food should be well pre- pared. The patient should eat often, not too much at a time, and should avoid all coarse and highly seasoned sub- stances. Tannigen gr. viii. three times daily or benzo- naphthol in the same dose, or subnitrate of bismuth gr. xxx. t.i.d., can be advantageously given. Sometimes these drugs are combined with codeine or opium. Here local remedies play a prominent part. Loesch was the first to recommend injections into the bowel of solution of quinine (1 : 5,000) ; tannic acid, nitrate of silver, permanganate of potassium have also been employed in clysters with good results. Harris very recently recommended the use of hy- drogen dioxide. The ordinary commercial hydrogen diox- ide is diluted from four to eight times with water and the solution injected. About a quart is injected twice daily for about a week and then gradually decreased. Harris has seen very good results from this mode of treatment. In cases in which there is an exacerbation of the disorder, the same mode of treatment may be required as in acute dys- entery. CHAPTER V. ULCEKS OF THE INTESTINES. 1. DUODENAL ULCER. Synonyms. Round duodenal ulcer; Ulcus duodeni pep- ticum (Leube). Definition. A defect in the mucous membrane of the duodenum. Etiology. The etiology of duodenal ulcer corresponds with that of gastric ulcer. It is undoubtedly caused, as in the stomach, by the action of the acid gastric juice upon the duodenal mucosa, the vitality and nutrition of which have been previously impaired. Such conditions occur as a result of circulatory derangements of various kinds. Thus, affections of the lungs and heart or of the liver, an atheromatous state of the duodenal artery may be the positive factors in disturbing the circulation of the mucous membrane. Burns of the skin are an etiological factor which, while not operative in gastric ulcer, is of great im- portance in duodenal ulcer. After extensive scaldiugs of the skin, quite often one or several duodenal ulcers ap- pear. According to Mayer ' these ulcers develop from seven to fourteen days after the burn, very seldom much sooner. The primary cause of these ulcers is not yet known. The toxic theory which is the most plausible has been discussed above. Duodenal ulcer is much less frequent than gastric ulcer. 1 Mayer . Annal. de la Soc. de Med. d'Anvers, 1865. DUODENAL ULCER. 129 Willigk ' found it twice in sixteen hundred autopsies. Ac- cording to this writer, there are thirty-eight gastric ulcers to one duodenal ulcer. According to Starke, 2 however, the ratio is twelve to one. Kraus 3 found that the fre- quency of duodenal ulcers varies in different countries in a similar manner as does gastric ulcer, the northwestern part of Europe having the highest percentage, while it is but rarely met with in the eastern part. In Kraus' expe- rience duodenal ulcer most frequently occurs in persons between thirty and sixty years of age. Next in frequency comes the very early age (one to ten, and especially in- fancy). This is another point of difference between gas- tric and duodenal ulcers, for the former hardly ever occur in children. With regard to the distribution of duodenal ulcer among the sexes, Kraus found it much more preva- lent among the male than among the female sex, the rela- tion being ten to one. According to Lebert/ however, the proportion is only four to one. This again is another point of difference in the etiology of duodenal and gastric ulcers, for the latter, as is well known, are much more fre- quently encountered in women than in men (two to one). Morbid Anatomy . A duodenal ulcer resembles in most particulars a gastric ulcer. It is a defect of the mucous membrane having an oblong and oval contour and extend- ing into the depth of the mucosa in form of a terrace or funnel. The ulcer presents an irregular shape only in those instances in which several ulcers have coalesced, thus forming one large defect. The size of the ulcer varies from that of a lentil up to that of a dollar. The margins 1 Willigk : Prager Vi^rteljahresschr., 1833. 2 Starke : Deutsche Klinik, 1870. 8 J. Kraus: "Das perforirende Geschwiir des Duodenum," Berlin, 1865. 4 Lebert : "Die Krankheiten des Magens," 1878. 9 130 DISEASES OF THE INTESTINES. are usually smooth and overlapping, the latter being espe- cially the case in chronic affections. The base of the ulcer is formed either by thin layers of the remaining intestinal wall, or, if perforation has taken place, by adhesions with neighboring organs. Situation of the Ulcer. Ordinarily the ulcer is found in the ascending or the upper horizontal part of the duodenum, much more rarely in the descending part, and only excep- tionally in the lower horizontal section. As a rule it is situated immediately behind the pyloric fold, rarely at some distant point. If the ulcer is situated in the descend- ing part of the duodenum, especially in the immediate neighborhood of the diverticulum Vateri, it may cause through cicatricial strictures important complications in- volving the pancreatic and biliary outlets. As a rule there is one duodenal ulcer, exceptionally there are two or four. In the latter instance the ulcers may be found in different stages of development : in the initial stage, in that of commencing cicatrization, or fully cicatrized. The cicatricial process may lead to manifold complications. A stenosis of the duodenum just behind the pylorus or at some distance may result, and create exactly the same dis- turbances of the stomach as are found in cicatricial stenosis of the pylorus itself. I had the opportunity of observing two cases of this kind. In both the diagnosis of a benign stricture of the pylorus had been made and the patients subjected to operation. At the laparotomy the stricture was found in the duodenum, in one case immediately behind the pylorus and in the other at some distance therefrom. Sometimes the ulcer progresses quickly and leads to per- foration into the peritoneal cavity. Deatli from shock or from diffuse peritonitis then occurs. If there is a slow extension of the ulcer, it often gives rise to circumscribed DUODENAL ULCER. 131 peritonitis, usually with adhesions to neighboring organs. If the ulcer perforates after adhesions have been formed, it usually leads to an encapsuled purulent peritonitis. The ulcerative process may occasionally extend to contiguous parts with the formation of ulcers in the liver, gall bladder, or other neighboring organs. The development of a cancer at the base of a duodenal ulcer has also been observed by Eichhorst ' and Ewald. 2 Symptomatology. Occasionally there may be no symp- toms whatever during life and the duodenal ulcer may not be discovered until at the autopsy. Sometimes there are no symptoms at first, then suddenly the disease manifests itself by a severe and dangerous hemorrhage or by a fatal perforation. In the majority of cases, however, there are pronounced manifestations during the existence of a duo- denal ulcer. Most frequently pains are present, usually to the right of the linea alba, extending up to the right parasternal line in the region below the liver. These pains usually appear from half an hour to two or three hours after meals ; as a rule they do not radiate to the back but rather somewhat downward in the abdominal cavity . While the pyloric region is often found slightly painful on press- ure, there is no circumscribed area in the epigastrium intensely painful on deep palpation as in ulcer of the stomach. In rare instances the pains are felt by the patient in the epigastric region, which may also show tenderness on pressure. Dyspeptic symptoms, as for instance loss of appetite, nausea, fulness in the epigastric region, are as a rule absent. Vomiting is likewise a rare occurrence in simple duodenal ulcer, which has not gone on to a partial stenosis of the intestinal lumen. 1 Eichhorst : Zeitschr. f . klin. Medicin, Bd. 14, p. 522. 2 C. A. Ewald : Berl. klin. Wochenschr. , 1886. 132 DISEASES OF THE INTESTINES. Hemorrhages as the consequence of an erosion of a more or less large blood-vessel, through the progressing necrotic process, occur in about thirty per cent of duodenal ulcers. The blood is frequently voided with the stools (melaeua) which appear dark red or tarry. Occasionally, however, there may be vomiting of blood (hsematemesis), in connec- tion with the melsena or without it. If the hemorrhage is very great the patient may bleed to death. This, however, is rare ; as a rule the patients recuperate from the loss of blood in about the same time as they do from a gastric hemorrhage. Constipation is often present. The general condition of the patient is usually good and there may be no loss in flesh. Perforation is quite a frequent event in duodenal ulcer. The symptoms will differ according to whether perforation has taken place before or after adhesions have been formed. In the former instance perforation leads to a general peri- tonitis, ending fatally in eighteen to thirty hours. Rarely the course is more protracted when the inflammatory proc- ess of the peritoneum has not assumed large dimensions and has become quickly localized through the formation of adhesions in the neighborhood. The perforation mani- fests itself by a sudden appearance of intense pains in the abdominal cavity, by the usual signs of a general collapse (cold extremities, very quick pulse), and by a swelling of the abdomen. The patient presents an expression of ex- treme anguish and maintains a rigid attitude often with the legs flexed, being afraid even to stir. The abdomen is painful to the slightest touch. Nausea and constant sin- gultus soon appear. Sometimes the patient is greatly tormented with vomiting. A few hours later, in addition to these symptoms, the area of liver dulness may be found DUODENAL ULCER. 133 absent in consequence of the escaped gas which has accumu- lated above its surface and has pressed it down. Dyspnoea and coma ultimately set in and the patient succumbs. If perforation has taken place after adhesions have been formed, the same complications occur as in ulcer of the stomach under similar conditions. The duodenal ulcer often heals and there is a complete disappearance of all the morbid symptoms. Sometimes the cicatrix leads to a stric- ture of the duodenal lumen and then gives rise to ischo- chymia. Course. The duodenal ulcer has, as a rule, a very pro- tracted course. In some instances a perfect cure may be established without any ill consequences. In the majority, however, complications are common. Hemorrhages, ob- struction of the duodenal lumen in consequence of the stenosis and perforation are often observed. Diagnosis. The diagnosis of a duodenal ulcer can be made with certainty only in a very few instances. Most often only a probable diagnosis will be possible. A duo- denal ulcer can be diagnosed with certainty if the symp- toms of ulceration follow within a short period after exten- sive scalding of the skin has taken place. The sudden development of icterus in a case presenting symptoms of gastric ulcer speaks with a certain amount of probability for a duodenal ulcer if gall stones can be excluded. The points which indicate a probable location of the ulcer within the duodenum are the following: 1. The pains usually appear from half an hour to three hours after the ingestion of food and are situated most often to the right of the linea alba in the pyloric region. They never radiate to the back. 2. Repeated attacks of melsena, either not as- sociated with hfematemesis or in which the latter was only slight compared with the melsena. 3. Most of the patients 134 DISEASES OF THE INTESTINES. are men presenting a healthy appearance. 4. Perforation is a frequent occurrence in duodenal ulcer, while it is very rare in the course of gastric ulcer. If all these points are found associated, then a probable diagnosis of duodenal ulcer may be made, otherwise it is uncertain. With regard to the differential diagnosis between ulcer of the stomach and that of the duodenum, Leube ' stated that in the latter the gastric contents show a normal degree of acidity, while in gastric ulcer, as a rule, hyperchlorhy- dria prevails. This point, however, is not of much value, for on the one hand cases of gastric ulcer are found with a lessened degree of secretion, and on the other hand duodenal ulcer may be attended with hyperchlorhydria. In the two cases of duodenal ulcers mentioned above which had been operated upon, the condition of the gastric juice in one was normal, while the other showed intense hj'perchlor- hydria. The differential diagnosis between ulcer and can- cer of the duodenum is the same as that between ulcer and cancer of the stomach or pylorus. Prognosis. The prognosis of duodenal ulcer is almost always quite serious, as complete recovery is very rare. Relapses after apparent perfect recovery often occur. The sequelae to which the cicatrizing process may give rise, namely, obstruction of the duodenal lumen, must also be taken into consideration, and the possibility of death from perforation should never be forgotten. Another danger lies in the formation of a cancerous growth on the base of the ulcer. Treatment. On the whole the treatment must be con- ducted on the same line as that of ulcer of the stomach. 'Leube: von Ziemssen's "Handbuch der speciellen Pathologie und Therapie, " Bd. vii., Abth. 2. -"Die Krankheiten des Magens und Darms, " Leipzig, 1876. EMBOLIC AND THROMBOTIC ULCERS. 135 In some cases the advisability of operative intervention must be considered. Cases in which a duodenal ulcer can be diagnosed with great probability and in which hemor- rhages have recurred several times may perhaps be sub- jected to a gastro-euterostomy during the period of com- parative euphoria. For by this procedure the duodenum is relieved of a great deal of irritation caused by the pas- sage of the chyme, and the ulcer is thus given a better chance to heal. Cases in which the cicatrix has led to a partial stenosis of the duodenal lumen should certainly be operated upon, pyloroplasty or gastro-enterostomy being selected. 2. EMBOLIC AND THROMBOTIC ULCERS. This group of ulcers resembles the duodenal ulcer in that disturbances of the circulation are the exciting causes. These ulcers are of very rare occurrence. Embolic ulcers were first described by Pareuski. ' They originate in con- sequence of emboli which are carried into the fine branches of the intestinal arteries, either from some abscess cavity or from a focus of atheroma or endarteritis. The pathological changes of the intestine after such an occurrence are slight if a very small vessel, a capillary or an arteriole, has been occluded. In case the embolus is of an infectious nature, infiltration and formation of pus soon develop, and the process may quickly penetrate down to the serosa and infect the peritoneal cavity. It may also rapidly reach the intestinal lumen and thus produce an ulcer. In the infectious cases the fatal issue often ensues so quickly that there is hardly time for a complete forma- tion of the ulcer. In such instances only the initial stages of the ulcerative process can be discovered. Fine nodules 1 Parenski : Wiener med. Jahrbucher, 1876, Heft 3. 136 DISEASES OP THE INTESTINES. will be noticed in the intestinal wall originating from the submucosa and consisting of accumulations of round cells in the centre of which are very small blood-vessels. The symptoms of these embolic ulcers are the same as those caused by other ulcerative processes of the intestines, namely, severe pain which may be of a colicky nature, tenderness on pressure over the abdomen, and diarrhosa with more or less bloody admixture. If these symptoms are present and embolic processes can be discovered in other organs, then the diagnosis of embolic ulcer of the intestine is probable. The clinical symptoms and the anatomical changes re- sulting from the obstruction of a very small blood-vessel of the intestines are comparatively slight, compared to those which rapidly appear if the embolus has entered the arteria mesaraica superior. This affection is extremely rare ; only nineteen cases have been described in literature. The emboli which have been found in the arteria mesaraica superior itself or in its branches could be traced to the left heart or to the aorta, which was the seat of excres- cences due to endocarditis or atheroma. There is either a total obstruction of the entire mesaraic artery or several larger and numerous smaller branches of this vessel are occluded. The changes which frequently result after the embolus has excluded the organ from circulation are hem- orrhagic infarcts and necrosis with partial peritonitis. According to Litten,' after an occlusion of the arteria mesaraica superior or its branches, the intestine is deprived of all arterial blood, there being no vicarious blood current from any anastomoses of these vessels. The arteria mesa- raica superior, although it forms anatomical anastomoses, 1 Litten : " Ueber die Folgen dcs Verschlusses der Arteria mesaraica superior." Virchow's Arch., Bd. 63. EMBOLIC AND THROMBOTIC ULCERS. 137 acts functionally like a terminal artery. The reason of this is that the anastomosing vessels are of a very small calibre and pursue a very long course, and hence the mesenteric arteries are not able sufficiently to supply with blood the region deprived of its circulation. The pathological cJianges which appear after the occlusion of this artery consist of venous hypenemia, hemorrhagic extravasations, redema, and necrosis. In that part of the mesentery and intestine which was supplied by this oc- cluded vessel, the smaller arteries branching off from the latter are contracted and empty, while the veins of the serosa and mesentery are overfilled with blood. The mucous membrane appears dark red ; the entire intestinal wall is oedematous and swollen ; small hemorrhages exist all over the mucous membrane and in the mesentery ; and the intestinal canal contains extravasated blood either fresh or tarry looking. If the process has lasted for some time, necrotic changes soon appear and the mucosa presents a dirty brownish-green appearance and may be wiped off from the other layers like a slimy coating. The serous layer may be the seat of inflammation not only over the involved intestinal segment, but also over other still healthy intestinal coils, the latter being agglutinated and covered with a deposit of fibrin. In the peritoneal cavity there may be a bloody fluid or a purulent exudation. The clinical symptoms of an embolus of the superior mesenteric artery have been best described by Gerhardt ' and Kussmaul." They are not always alike, and two groups of cases may be easily discerned. In the one, being 1 Gerhardt : " Embolie der Arterii mesenteries. " WQrzburger nied. Zeitschr., 1863, Bd. iv. * Kussmaul : " Zur Embolie der Artcrise mesentericse. " Wiirzburger med. Zeitschr, 1864, Bd. v. 138 DISEASES OF THE INTESTINES. the larger, an intestinal hemorrhage is the feature most marked, in the other the affection presents the picture of intestinal occlusion with or without any signs of perito- nitis. As a rule the disease sets in suddenly with violent colicky pains involving the entire abdomen or some por- tion of it, usually in the neighborhood of the navel. Soon the pains grow diffused and there is an extreme ten- derness on pressure over the abdomen. Sometimes the pain is accompanied by vomiting ; in rare instances, how- ever, the pain may be entirely absent. Such a case has been mentioned by Nothnagel. Intestinal hemorrhage, which is the chief symptom, soon occurs. As a rule sev- eral bloody stools appear in succession, which have a dark, almost black, brown or tarry appearance and occasionally a very fetid odor. The blood of the hemorrhage, how- ever, is not always necessarily voided per rectum, for it may remain in the intestinal canal. The symptoms, how- ever, which characterize a profuse intestinal hemorrhage (falling of the body temperature and collapse) will never be missing. In the second group of cases there are merely signs of an acute intestinal occlusion ; pains, constipation, and peritonitis being the only symptoms. The diagnosis of this affection can be made, according to Kussmaul and Gerhardt, in cases in which the source of the embolus can be determined. An intestinal hemorrhage occurs (for which no primary lesion exists), colicky pains of great violence and later a tympanitic swelling of the abdomen and exudations make their appearance. The diagnosis can be possibly made only if all the just men- tioned points exist. Otherwise, especially if the intestinal hemorrhage is missing, the diagnosis cannot be made during life. The prognosis of this affection is very grave. As a rule EMBOLIC AND THROMBOTIC ULCERS. 139 it ends fatally. It appears, however, according to Vir- chow, that in rare instances a recovery is possible after long illness, a collateral circulation having slowly devel- oped. With regard to treatment, there is no special indication for this affection. The symptoms will have to be treated as such. Embolus of the inferior mesaraic artery is a very rare oc- currence. Two cases have been described by Hegar ' and Gerhardt. The prominent symptoms are violent colicky pains, tenesmus, and bloody stools. The mucous mem- brane of the small intestine remains normal, while that of the colon, S romanum, and rectum becomes intensely red, succulent, and contains effusions of blood here and there. Severe anatomical lesions of the intestines, however, are absent, for the circulation is quite quickly re-established through anastomosis with the superior mesenteric artery and with the rectal arteries of the hypogastric vessel. Similar to the lesions of the embolic process of the superior mesaraic artery are the consequences which result from a thrombus within the mesenteric veins or the portal vein. A few cases of this nature have recently been ob- served by Pilliet, 2 Grawitz, 3 and Eisenlohr. 4 The clin- ical picture of these cases is as follows : There appear sud- denly violent colicky pains in the abdomen. The latter swells up and grows intensely painful on pressure. Often vomiting is present, occasionally haematemesis. There 1 Hegar: "Embolie der Lungenarterie und der Arteria mesaraica in- ferior." Virchow's Arch., Bd. 93. 7 Pilliet : "Thromboses des veines mesaraiques. " ProgrSs raed., 1890. No. 25. 3 Grawitz : " Ein Fall von Embolie der Arteria mesaraica superior. " Virchow's Arch., Bd. 110. 4 Eisenlohr: "Zur Thrombose der Mesenterialvenen. " Jahrbticher der Hamburger Staatskraukenanstalten, 1890. 140 DISEASES OP THE INTESTINES. may be constipation or very frequent diarrhoeal and bloody movements. Accompanying these symptoms there is al- ways collapse. The course is also a very rapid one, the fatal end appearing after two or three days. This affection is liable to occur in advanced pulmonary tuberculosis, in highly marasmic conditions like the malarial cachexia, then as a consequence of pressure of the portal vein, in cirrhosis and cancer of the liver. All abdominal neoplasms may likewise produce a thrombotic condition of the veins by pressure. The same ma}' happen in chronic peritonitis by the formation of constricting cicatricial tissue. Similar processes also arise whenever the intestine experiences pressure or incarceration at a circumscribed spot. The venous circulation becomes obstructed by the pressure, while the arterial blood supply owing to its elastic walls remains undisturbed. In consequence of the lacking out- flow of the blood, hypersemia appears, then follow hem- orrhagic infarcts, and lastly necrosis. As the symptoms and treatment of the following classes of intestinal ulcers are identical, we shall discuss them together later on, after having first given the etiological and anatomical features of each separately. 3. AMYLOID ULCERS. Amyloid processes within the intestine were first de- scribed by Virchow ' in 1855. The amyloid changes start in the walls of the small blood-vessels (capillaries and the finest arteries, occasionally also the veins). At first the vessels of the mucosa alone are affected, but afterward the process may extend through the submucosa and even through the entire intestinal wall down to the 1 R. Virchow: "Ueber den Gang der amyloiden Degeneration." Virchow's Arch., Bd. 8. TUBERCULOUS ULCERS. 141 serous layer. The amyloid degeneration may also involve the muscularis inucosae, or even fhe entire muscular layer of the intestinal walls. The amyloid degeneration of the blood-vessels makes them friable, thereby often leading to necrotic processes with the formation of small ulcers. Amyloid changes are found more often in the small intes- tine than in the large bowel. The mucous membrane of the affected part has a waxy and pale appearance. The villi are missing here and there. The diagnosis can be positively made by means of the characteristic color tests. A solution of iodine poured over the suspected area gives a brownish-red color which be- comes violet or blue after the addition of sulphuric acid ; a solution of methyl violet produces a bright pink color. We have reason to suspect amyloid processes within the intestine in conditions which are known to be often asso- ciated with this process, as tuberculosis, syphilis, leukae- mia. Especially is this true if amyloid degeneration is detected in other organs (spleen and liver) as shown by their enlargement, and besides there are signs of chronic diarrhoea and insufficient intestinal absorption. There are, however, no positive means of establishing the diagnosis of amyloid degeneration of the intestine during life. 4. TUBERCULOUS ULCERS. Tuberculosis of the intestines is of very frequent occur- rence. While it usually appears in phthisical patients, there are also cases of an undoubted primary intestinal tuberculosis. According to Frerichs,' a tuberculous affec- tion of the ileum is found in eighty per cent of the cases of chronic pulmonary phthisis. Bayle in 1810 was the first 1 E. Frerichs : "Beitrage zur Lebre von der Tuberculose, " Marburg. 1882. 142 DISEASES OF THE INTESTINES. to observe the occurrence and frequency of tuberculous ul- cers of the intestine. The seat of these ulcers is princi- pally in the ileum, especially in its lower portion. They may extend from this point downward over the colon to the rectum or upward over the entire ileum, jejunum, and even the duodenum. The development of the ulcer takes place in the following way: In one of the solitary follicles a miliary tubercle forms by extensive accumulation of cells, the latter swell up; after a time a caseous degeneration appears in the centre and the swollen follicle bursts; thus a small pea- sized ulcer is formed. In the same way tuberculous proc- esses may develop in the agminated follicles and also lead to the formation of ulcers. But whereas Peyer's patches are equally affected in their entirety in typhoid fever and intestinal catarrh, in tuberculosis the infiltrations are con- fined only to several follicles of the group, while others be- longing to the same patch remain intact. The ulcar enlarges either by spreading directly at the periphery or by the coalition of several defects. As a rule the extension of ulcers into the deeper layers proceeds in a line transversely to the intestinal lumen corresponding to the direction of the vessels supplying the bowels. Thus in the small intestine the ulcer spreads in a line parallel with the valvulse conniventes, and thus may form a circu- lar defect over the entire lumen of the intestine, trans- versely to its longitudinal axis (the so-called tuberculous girdle ulcer). There exist, however, ulcers of an oblong or entirely irregular shape. With regard to the depth of the ulcer it usually penetrates to the muscularis and re- mains at a standstill there. Small tuberculous foci, how- ever, are often met with within the latter, usually connected with the lacteals. Sometimes a destruction of the mus- TUBERCULOUS ULCERS. 143 cular layers is also present and the ulcer may advance down to the serosa and may even perforate into the peri- toneal cavity. The fully developed large tuberculous ulcer has an irreg- ular shape, and mostly a bright red margin, being partly smooth, partly overlapping, sometimes undermined. Ita base is pultaceous, consisting partly of decomposed tissue, partly of swollen remnants of the mucosa. Tuberculous in- filtrations are noticeable here and there at the base as well as at the margin. The surroundings of the ulcer often show catarrhal changes. The serosa over it is usually in a state of chronic inflammation, being reddened, thick- ened, and surrounded with fibrinous exudations. Some- times there are agglutinations with other intestinal coils, the omentum, or other immediately adjacent organs. The frequency of these peritonitic adhesions explains why per- forations of tuberculous ulcers within the intestine are comparatively so rare. Tuberculous ulcers very rarely show a tendency to heal, the process as a rule progressing steadily and leading to the formation of new nodules in the neighborhood of the margin. In very few instances, however, cicatrization of the ulcers takes place. The latter, when occurring in ul- cers of girdle shape, may produce a stenosis of the intes- tinal lumen. Tuberculous ulcers are very rarely primary, that is to say, developing in the intestines without a previous tuber- culous affection existing in other organs. In most instances they are secondary and are met with in patients who are in a more or less advanced stage of pulmonary tuberculosis. The ultimate cause of tuberculous processes in the intes- tine is Koch's tubercle bacillus. The latter may be car- ried into the intestinal canal with the sputum which 144 DISEASES OF THE INTESTINES. phthisical patients swallow, or it may also, in rare in- stances, be ingested directly with the food. Thus, meat and milk of tuberculous cows may cause primary tubercu- losis of the intestine. This condition is specially frequent in infants on account of their being fed with milk either from phthisical nurses or tuberculous cows. 5. SYPHILITIC ULCERS. Syphilitic ulcers of the intestines are quite rare. In the small intestine they are mostly met with in the new-born. Here the ulcers are found either singly or in great num- bers over the entire small intestine. They originate in the lymphatic apparatus of the mucosa and submucosa, first forming gummata within the intestinal walls, which after- ward undergo rupture. Syphilitic ulcers of the small in- testine have also been observed in adult life (Klebs, ' Birch- Hirschfeld 9 ). Of greater clinical importance are the acquired syphi- litic ulcers which often occur principally in the lower part of the colon and the rectum, including the anus (most frequently the lower part of the rectum a few centimetres above the anus is affected). We may have primary ulcers of the rectum through direct infection after a preternatural coitus. These are observed principally in men and are located in the median line of the anus. They are character- ized by a hard base, sharp margins, and bacon-like appear- ance. We may also have secondary ulcers due to constitu- tional syphilis. Condylomata and gummata may undergo degenerative changes and form ulcers, which by their cica- trization very often give rise to the development of stric- 1 Klebs: "Handbuch der pathologischen Anatomie," Berlin, 1868. 8 Birch-Hirschfeld : " Lehrbuch der pathologischen Anatomic, " Leip- zig, 1887. TOXIC ULCERS. 145 tures of the rectum. The latter variety is much more fre- quently found in women than in men. Among two hundred and nineteen patients with constricting rectal ulcers Poelchen ' found one hundred and ninety women. This author, however, correctly remarks that not all these ulcers resulting in stricture are due to syphilis. In a great many instances their origin is attributable to a gonorrhceal affec- tion of the Bartholinian glands which ultimately through infection leads to destructive processes within the rectum. Some of these ulcers may also result from traumatic causes, such as the frequent use of clysters or hard fecal matter irritating the mucous membrane. 6. TOXIC ULCERS. Under the term toxic ulcers of the intestine are under- stood defects which develop in consequence of abnormal (toxic) products contained in the blood. Thus intestinal ulcers occur in severe forms of nephritis, especially when they are complicated with ursemic symptoms. In leukaemia and scurvy such ulcers are also met with. Intestinal ulcers arising in cases of poisoning with mercury likewise belong to this group. The ulcerative process in all these cases is best explained as due to necrosis in consequence of the altered condition of the blood. Symptomatology. The symptoms which accompany ulcers of the intestines vary greatly. In the following we shall enumerate all the symptoms which may be met with in these conditions. 1. Diarrhoea. Frequent loose movements are often pres- ent, especially if the ulcer is situated in the lower part of the large bowel. Ulcerations of the small intestines, 1 Poelchen : " Zur Aetiologie der stricturirendeu Mastdartnge- schwiire. " Virchow's Arch., Bd. 127. 10 DISEASES OP THE DfTESTTNEBL and the upper end of the laige bowel do not cause diarrhoea, m>l there is some other complicating affection (a > *frr r ***l condition of the bowels or an amyloid state). Bat even if the nicer is situated in the lower part of the colon, diarrhoea may be absent in rare instances. 2. The occurrence of Hood or pus in the, dejecta. Blood may be voided with the stools in consequence of a small hemorrhage of the ulcerated intestine. If there is no gas- tric nicer, and other symptoms point toward intestinal nicer, the presence of blood will help to make the diagnosis more probable. But it is by no means a positive sign, for, on the one hand, an intestinal nicer may exist without any hemorrhages, and, on the other hand, intestinal hemor- rhages may occur from other causes than ulcer. The presence of pus in the stools seems to have much greater importance. According to Xothnagel, real pus (numerous round cells) in -the faeces is one of the most valuable signs of nlceration of the intestines. It is to be understood that pus may also be present in ulcerative processes accom- panying neoplasms of the intestines and in abscesses which open into the intestine. The latter two conditions will have to be excluded before we can infer the existence of an intestinal ulcer from this symptom. The amount of pus in true nlcerations of the intestines is, as a rule, very small, and it is necessary to examine the dejecta quite thoroughly in order to find it While the presence of pus is so important a symptom in intestinal ulcer, its absence by no means speaks against it. For there may be no for- mation of pus at the site of the ulcerative spot, or the pus may be changed to such a degree that it is no longer recog- nizable, especially if the ulcer is situated high up in the 3. The existence of tubercle bacilli in the dejecta is of INTEST1XAL ULCERS. 147 great importance in cases in which pulmonary tubercu- losis can be excluded, since they then show primary intes- tinal tuberculosis. The absence of the tubercle bacilli does not speak against the presence of ulcerative areas in the intestines, nor does their presence positively indicate a tuberculous affection of the intestine when pulmonary tuber- culosis exists, for these microbes are then usually derived from the sputa which have been swallowed and carried down with the passages. 4. Pains. If pains exist in the abdomen in a more or less circumscribed spot for a long period of time, and if these pains are increased on pressure, they are prob- ably due to an ulcer in the intestines. The absence of this symptom, however, speaks in no way against an ulcer, nor is its presence an absolute positive symptom for ulcer. The general state of the system need not be disturbed, if the ulcers are only few in number and very small. If their number, however, is great and their siae extensive, so that a large part of the intestinal tract is involved in the nlcerative process, then nutritive disturbances will manifest themselves and marked emaciation take place. Diagnosis. As may be seen from the description of the symptoms, the diagnosis of ulcer of the intestines is, as a rule, quite difficult. Their existence may be suspected whenever there is diarrhosa of a severe nature and more or less intense pain over a certain fixed region of the abdomen extending over a great period of time. A positive diag- nosis ran be made only in the following instances: 1. If necrotic pieces of the intestinal mncosa or pus appear in the stools (in the latter instance the perforation of an abscess into the intestine has to be excluded). 2. The more or tees frequent appearance of small amounts 148 DISEASES OF THE INTESTINES. of blood quite changed in the stool, if ulcer of the stomach or vicarious bleeding can be excluded. 3. Diarrhoea and the constant appearance of tubercle bacilli in the stools, when pulmonary tuberculosis can be excluded. This points to the presence of tuberculous proc- esses (ulcers) in the intestine. 4. If the ulcers are situated in the lower part of the colon or rectum and are accessible to a direct visual examination. x'he nature of the ulcers (whether catarrhal, tuberculous, syphilitic, or toxic) must be elucidated by a thorough knowledge of the history of the case and the results of an accurate examination of the patient. Prognosis. The prognosis of intestinal ulcers will de- pend largely upon their number, size, and nature. A few small catarrhal ulcers will heal quickly without any further trouble. Amyloid ulcers hardly ever show a tendency to heal. Tuberculous ulcerations occasionally are amenable to treatment, still more so are the syphilitic ulcers. Very extensive ulcerations, no matter of what nature, are very dangerous to life. Treatment. In the treatment of intestinal ulcers the etiological factors play the greatest part. Thus, in tu- berculous ulcers general hygienic rules will have to be observed. An out-of-door mode of living, and, if pos- sible, in the mountains, should be recommended. Guai- acol carbonate, creosote, ichthalbin are of value. In syphilitic ulcers general anti-syphilitic treatment should be instituted : inunctions with mercury, or injections of sublimate or calomel, or the administration of large doses of potassium iodide. In toxic ulcers (as those due to uraemia and mercurial poisoning) the treatment must be directed against the primary trouble. Besides the etio- logical therapy, intestinal ulcers require specific and INTESTINAL ULCERS. 149 symptomatic treatment. The treatment directed to the healing of the ulcers is very successful if the latter are situ- ated in the rectum or in the lower part of the colon, while this object can hardly be attained if they exist high up in the colon or in the small intestine. In the former instance the ulcers, if accessible to view, may be directly treated by the application of a strong solution of nitrate of silver or pro- targol. If not visible but situated in the colon, injections of a 0.2 to 1 per cent, solution of nitrate of silver or of tannic acid of the same strength into the bowels are of value. If the ulcers are situated in the small intestine, large doses of subnitrateof bismuth (1 to 2 gm. [gr. xv. to xxx.] three times a day) may be tried. The symptoms which accom- pany the ulcer and vary from time to time will have to be treated as such. Diarrhoea, hemorrhage, and pain must be combated with the customary remedies. Most patients should be kept abed for some time. The application of a hot-water bag or a wet pack over the abdomen is very beneficial. The diet should contain nourishing but easily digestible arid non-irritating food. Thus, milk, kumyss, matzoon, eggs beaten up in milk, soft-boiled eggs, farina, oat meal cooked in milk, mutton broth, chicken soup, scraped beef, calf's brain, sweetbreads, cacao, tea, and toast may be given. CHAPTER VI. NEOPLASMS OF THE INTESTINE. MALIGNANT GROWTHS. Cancer. Definition. An epithelial neoplasm of the intestinal walls. Etiology. The etiology of intestinal cancer, like that of cancerous disease of other organs, is still unknown. The traumatic theory (repeated irritation of one particular area) appears quite plausible with reference to this organ. As will be seen later, this malady occurs much more fre- quently in those parts of the bowels in which the passage of fecal matter is more apt to be retarded, and in conse- quence to cause irritation. With regard to sex, it is generally accepted that intqs- tinal cancer occurs somewhat oftener in men than in women. With reference to age it is chiefly met with during the period from forty to sixty-five years. Cancer of the intes- tine is occasionally found also in young people, this hap- pening much more commonly than cancer of the stomach or of other organs. Nothnagel ' has observed cancer of the caecum in a twelve-year-old boy, and Schoening 2 reports two cases of rectal cancer in girls seventeen years old. 1 H. Nothnagel. "Die Erkraukungen des Darms und des Perito- neum, " Wien, 1898. 'Schoening: Deutsche Zeitschr. f. Chirurgie, Bd. xxii., 1885. MALIGNANT GROWTHS. 151 According to Maydl, ' the total number of intestinal cancers occurring from the first to the thirtieth year amounts to oue-seventh of the entire number of cases. Location. With regard to location the frequency of the affection in the different portions of the bowel varies. The frequency gradually increases the lower down the growth is situated, beginning with the jejunum and ending with the rectum. Among one hundred and sixty autopsies on cases of cancer of the different organs, Maydl found in one hundred cancerous disease of the bowels. In one hundred and ten autopsies of patients suffering from intestinal cancer, Bryant 2 found, the neoplasm located six times within the small intestine, seven times in the caecal and ileo- csecal regions, nineteen times in the transverse colon, includ- ing the hepatic and splenic flexures, seventy-eight times in the sigmoid flexure and rectum. Maydl gives the follow- ing locations of the tumor in one hundred autopsies : Two in the duodenum, four in the ileum (none in the jejunum), forty-six in the large bowel (in the vermiform process, one; caecum, nine ; ascending colon, six ; colon seventeen ; sig- moid flexure, thirteen), and forty-eight in the rectum. As regards cases observed during life, Maydl gives the follow- ing figures : During twelve years there were in the Wiener Allgemeines Krankenhaus 246,827 patients. Among these there were 6,287 patients with cancer. Among the latter there were 254 cases of cancer of the bowels, and in 224 of these the neoplasm was in the rectum. This certainly shows the great predilection of intestinal cancer for the rectum. Intestinal cancers are almost always primary. It is exceptional for cancer of the bowels to develop by way of metastasis. It is obvious, however, that cancer in this 1 Maydl : "Ueber den Darmkrebs, " Wien, 1883. * Joseph D. Bryant : Annals of Surgery, February, 1893. 152 DISEASES OF THE INTESTINES. region may develop secondarily as a result of direct exten- sion of the cancerous process from a contiguous organ. This often occurs in cancer of the stomach, gall bladder, or pancreas. Intestinal cancer often gives rise to metasta- ses in other organs. According to Miiller, ' these are more frequently met with in cancer of the small intestine than in that of the large bowel. The lymphatic glands are also often secondarily affected. Those in the neighborhood of the neoplasm show a greater tendency to become cancer- ous than those farther off. Morbid Anatomy . All varieties of cancer are found in the intestines. Most frequently, however, the cylindrical epithelial-celled carcinoma, having a glandular structure (adeno-carcinoma), is encountered. The latter takes its origin in the epithelial cells of the follicles of Lieberkuehn. Colloid carcinoma is quite often found in the rectum, while melano-carcinoma is here quite rare. Occasionally the pavement-celled carcinoma (epithelioma cancroid) is met with, especially in the lower part of the rectum, starting principally from the anus. It often involves the perineum and the vagina. The neoplasm varies in consistency according as connec- tive tissue or cells predominate. If the former is the prin- cipal element, then the tumor presents a hard consistency (as hard as cartilage) and is termed scirrhus. In case the latter are more abundant, then it is less firm, occasionally soft and succulent. The colloid cancer as a rule contains a brownish, somewhat viscid fluid. The scirrhus shows a greater tendency toward partial necrosis in its central part. It often forms a carcinomatous ulcer. The primary intestinal cancer frequently shows a ten- 9 Max M filler -. "Beitrage zur Kenntniss der Metastasenbildung ma- ligner Tumoren. " Inaugural-Dissertation, Bern, 1892. MALIGNANT GROWTHS. 153, dency to extend in a circular direction perpendicularly to the lumen of the bowel. Stenosis of the intestinal canal is very often the result of this circumstance. In case the stricture is of marked degree, the intestine above the stric- tured spot becomes greatly distended through stagnating fecal matter and gas. The bowels working hard to over- come the obstacle show thickened walls due to hypertrophy of the muscles. The irritating and stagnating contents in the dilated part of the intestine give rise to catarrhal in- flammation and also to ulcers. If the stenosis has become still more pronounced, the dilatation of the intestine above it may be so excessive that a rupture of its walls ultimately occurs. Below the stricture the intestinal wall appears thinner, and if the stricture is so narrow that no contents pass downward, it appears empty and contracted. Occa- sionally the neoplasm constricting the intestinal lumen begins to break down and ulcerate, and this partly removes the occlusion of the intestinal canal. This, however, does not last long, for as a rule the cancer shows a tendency to grow again and to fill up the defect. Thus the free lumen of the bowel is very soon again occluded. This partial necrotic process will also often cause more or less hemorrhage through erosion of the smaller blood- vessels. In case a larger artery or vein opens, a severe hemorrhage with fatal issue may result. Cancer of the bowel often involves, besides the mucosa and submucosa, the muscularis and even the serosa. In the latter event perforation occurs in rare instances before adhesions have had time to form, and may result in fatal general peritonitis. In most instances, however, adhe- sions have formed around the involved area, and thus the perforation causes merely a circumscribed peritonitis. Even without the occurrence of perforation the cancer may 154 DISEASES OF THE INTESTINES. progress from the serous layer to the peritoneum and lead to a carcinomatous peritonitis, which is often accompanied by a hemorrhagic exudation. Another series of grave complications is caused by the extension of the cancerous process to a neighboring organ which has previously be- come agglutinated to the bowel. The process of disinte- gration in the cancerous growth then often establishes an ab- normal communication between the bowel and other organs. Thus fistulous openings may occur between colon and stomach, between rectum and bladder, between rectum and vagina, between rectum and uterus, between large and small bowels, or a direct fistulous opening may form from the bowel through the abdominal wall. Symptomatology. Cancer of the bowel develops quite slowly and insidiously, and in most instances at the begin- ning gives rise to hardly any symptoms at all. For this reason it can never be detected at this time; later, how- ever, general and local symptoms manifest themselves. While the general symptoms are common to all cancers of the small and large bowels, the local symptoms will differ according to the location of the tumor, and it will therefore be necessary to consider the different portions of the intes- tinal tract separately. A. General Symptoms. The general symptoms of cancer of the bowel are those found in malignant growths of other organs. Of these anaemia and cachexia are the most impor- tant. Usually both are present at the same time. Some- times one is more pronounced than the other. In some in- stances a general weakness, pallor, and emaciation are the first indications of a severe affection. There may be as yet no local symptoms whatever or a very slight degree of con- stipation and scarcely noticeable sensation of discomfort in the abdomen. Loss of appetite and slight dyspeptic sy mp- MALIGNANT GROWTHS. 155 toms are often encountered. Fever is occasionally met with, which is due to a suppurative process and absorption of pyogenic matter into the blood. The neoplasm often gives rise to disturbances in neighboring organs by constricting or dragging upon them. Thus radiating pains from com- pression of nerves may arise and in the same manner dis- turbances of circulation. (Edema of the lower extremities is often encountered, which after lasting for weeks and months may occasionally disappear shortly before death. Symptoms of chronic intestinal obstruction are often pres- ent. They develop either gradually, the constipation in- creasing more and more, or they may appear more abruptly. The bowels, while formerly more or less regular, suddenly cease to move, and even strong cathartics are of no avail. The clinical features of cancerous obstruction of the bowel are not different from stenosis of the intestine caused by other processes, which are described in Chapter IX. Such a sudden attack of obstruction of the bowel may ter- minate fatally in a few days ; sometimes, however, after a total occlusion of the bowels, life continues much longer. Thus fecal retention of forty-four days' duration, without even fecal vomiting, is mentioned by Heusgen, ' and an- other case of eighty -eight days' duration has been reported by Cooper-Forster. ' Diarrhoea is frequently present in cancer of the bowels. This often serves partly to overcome the beginning obstruction of the intestinal lumen. In some cases diarrhoea alternates with constipation. In the latter instance the stools often bear signs of having passed a strictured spot. They may appear in the shape of a tape or in the form of small, hard balls. These characteristics of the evacuation are, however, by no means a positive 1 Heusgeu : Deutsche med. Wochenschr. , 1877. 9 Cooper-Forster : Medical Times arid Gazette, September, 1867. 156 DISEASES OF THE INTESTINES. proof of a real stricture, for they are also met with in merely neurotic conditions. The stools often contain an admixture of mucus, blood, or pus. In case the progress of the necrosis of the neoplasm is pronounced, the stools during that period have a very offensive, almost unbear- able odor. In rare instances particles of tumor may be discovered in the dejecta, which show under the micro- scope the exact nature of the neoplasm. If these particles are of a large size (cherry or walnut) they will be easily discovered in the stools ; but if they are minute, a thor- ough examination of the fecal matter will be necessary in order to find them. Washing out of the bowels will often be helpful to discover such minute pieces of the growth, in case the latter is situated in the colon. While all of the above symptoms are of great value, they are unimportant compared with the physical signs of a tumor. Its presence in a doubtful case in most instances helps to clear up the diagnosis. The tumor is often easily palpable and bears the general characteristics of a cancer- ous growth. It is hard and presents an uneven nodular surface. Its size varies greatly, being often that of a wal- nut and occasionally that of an apple or still larger. In the latter instance the mere inspection of the abdomen may already show the presence of the tumor. In autopsies the neoplasm is frequently found much smaller than it ap- peared to be during life. The cause of this is the hyper- trophy which occurs in the walls of the bowel above the tumor, together with the accumulation of fecal matter at the same place. The tumor is usually situated in the lower half of the abdomen, principally in the left iliac re- gion, not only because this part of the intestine is so often affected, but also because a neoplasm of other parts of the bowel, if not fixed by adhesions, is as a rule dragged down MALIGNANT GROWTHS. 157 by its own weight into this region. Intestinal neoplasms as a rule show a high degree of mobility. Often they can be moved with the hand in all directions in the abdominal cavity. The only exceptions to this rule are tumors of the duodenum, the sigmoid flexure, and the caecum, which are more or less fixed. With regard to the detection of the tumor a thorough palpation of the abdomen (if the abdominal walls are very rigid, under ether or chloroform narcosis) is necessary. A digital examination of the rectum, and, in women, of both rectum and vagina, will in most instances be required. A bimanual examination will also be found useful. In case the affected area in the rectum is not accessible to digital examination, inspection of this organ and in some instances a manual examination under anaesthesia with the whole hand must be resorted to. When the disease is fully developed, peritonitis (either circumscribed or general) often appears as a complication. It may be simply caused by the inflammatory processes accompanying the neoplasm or be of a real cancerous na- ture. While at first it is impossible to differentiate these two conditions, later on it is as a rule not difficult to deter- mine which of the two is present. The discovery of a hemorrhagic exudation and of a few nodules under the abdominal wall will indicate that a cancerous affection of the peritoneum is present. An acute perforation peritoni- tis is much more rare-and leads to shock and sudden death, or in the presence of adhesions to grave complications in consequence of fecal abscesses. If the perforation occurs into adherent neighboring organs, new communications may be formed between them and the intestine ; they ag- gravate the condition and are of great clinical importance. The following communications are frequently met with : 158 DISEASES OF THE INTESTINES. 1. Fistula between stomach and colon. The fistulous opening may freely communicate with both cavities or only in one direction on account of the formation of a valve. If the passage has the direction from the stomach into the colon, symptoms of lientery develop, and undigested and unchanged foods, as for instance pieces of meat, potatoes, spinach, and the like, appear in more or less large quanti- ties in the stools ; often diarrhoea manifests itself shortly after a meal and examination of the evacuation shows numerous particles of food from the last meal. Lavage of the stomach performed in such a case will often show that the liquid has escaped from the stomach in consider- able quantity and may occasionally be voided by the rec- tum. The admixture of some coloring matter to the water used for lavage will facilitate the recognition of this condi- tion. If the communication has a direction in the oppo- site way, namely, from the colon into the stomach, there will be an appearance of fecal matter in the latter. In that event the gastric contents always contain decomposed and fetid material, and vomiting of fecal matter is fre- quently the result. Inflating the colon with air will often cause a filling up of the stomach with this gas, and again irrigation of the bowel -with water (either clear or stained) will be followed by its appearance in the stomach, which may be easily discovered by introducing a tube into this organ and evacuating the gastric contents. If the fistulous opening has a free communication in both directions, then symptoms of lientery and fecal vomiting may be present at the same time or they may appear alternately. 2. In case of a communication between rectum and blad- der, small particles of fecal matter and gas appear in the latter organ and may be voided through the urethra. They give rise to a putrid cystitis. Occasionally urine may pass MALIGNANT GROWTHS. 159 from the bladder into the rectum and be discharged with the stools. The recognition of the latter condition is, however, more difficult. 3. Communications between the rectum and uterus or rn'jina are also met with and give rise to the passage of fecal matter through these organs. 4. A Jistulous opening may exist between the bowel and the abdominal icall. This fistula may discharge externally a putrid secretion having a fetid odor and containing par- ticles of fecal matter or chyle, depending upon its location, whether in the large or small intestine. All these fistulous communications appear as a rule in the last stages of the disease. They are, hewever, by no means characteristic of cancer of the intestine, for they may also, but very rarely, develop in consequence of other ulcerative processes in the bowel (tubercles). Again they may be a result of a cancerous growth in the stomach in- volving secondarily the intestinal tract. The urine does not show anything characteristic of can- cer. However, it often contains large amounts of indican ; acetone and diacetic acid have also been occasionally met with. B. Symptoms Due to the Location of the Neoplasm. (a) Cancer of the duodenum. In the duodenum the neoplasm almost always causes gastric symptoms similar in nature to those of cancer of the pylorus. Thus anorexia, pains, vomiting, and dilatation of the stomach will be the pre- dominatjug features. If the tumor is situated near the pylorus in the superior horizontal portion of the duode- num it will be quite movable, and a differential diagnosis between cancer of the pylorus and that of the beginning of the duodenum will hardly ever be possible during life. In case the neoplasm is situated in the descending part of the 160 DISEASES OF THE INTESTINES. duodenum, in the immediate neighborhood of Vater's papilla, icterus is often encountered. In such cases the initial symptoms may be jaundice and sometimes chills. The icterus may remain stationary or vary in intensity from time to time according to the degree of the obstruc- tion of the duct caused by the neoplasm. Ulceration of the tumor may for a while open a passage for the bile and the jaundice 'may then temporarily disappear. If the cancer is located below Vater's papilla, especially in the inferior horizontal part, the gastric contents will frequently show the presence of a large amount of bile. In the latter two instances the tumor, if accessible to palpation, is not mov- able. On acoount of its deep situation it can frequently not be discovered. (b) Cancer of the small intestine. According to the re- gion in which the neoplasm is situated, whether at the beginning of the jejunum or in the lower parts of the ileum, gastric or intestinal symptoms will- predominate. There may be anorexia and vomiting, or, on the other hand, good appetite and apparently good stomach diges- tion, but obstinate constipation. The tumor is often acces- sible to palpation, and is as a rule very movable. (c) Cancer of the large bowel. Pains are frequently en- countered at a localized spot in the region of the large bowel. They may exist before a tumor can be palpated and may be felt either in its immediate neighborhood or in almost exactly opposite portions of the colon. Thus cancer of the caecum may give rise to pain in the sigmoid flexure, and vice versa. These pains are rarely severe ; as a rule they consist merely in a sensation of discomfort or in a feeling of tension. Besides these uncomfortable sen- sations of a more or less permanent nature, there may be more or less frequent attacks of colic. In the latter in- MALIGNANT GROWTHS. 161 stance there may be violent excruciating pains in^ the ab- domen, which may be relieved after passing of flatus or after a diarrhceal movement. The attacks of colic are fre- quently caused by the commencing obstruction of the in- testine, and therefore become gradually aggravated in na- ture. They may lead at last to a total obstruction and be the immediate cause of death. Constipation is one of the foremost symptoms of a neoplasm of the large bowel. It is encountered in the great majority of cases; in some in- stances it forms the first symptoms of the disease ; at first it may be slight in nature, but becomes steadily more ob- stinate. Ten or twenty days may pass without a sponta- neous evacuation, and even cathartics are very slow in their action. The constipation as a rule is accompanied by the usual symptoms resulting from it, tension and fulness in the abdomen, poor appetite, occasionally pains. The con- stipation may at times disappear and give place to a pe- riod of diarrhoea. In some instances diarrhoeal evacu- ations may exist for many weeks, and they may be the predominating feature of the disease. (d) Cancer of the rectum. The symptoms met with in cancer of the rectum resemble more or less those of a neo- plasm of the upper portion of the large bowel. Here, how- ever, the diagnosis can be made with greater ease and cer- tainty. In most instances rectal cancer can be discovered by a digital examination of the rectum. By means of the latter we may discover a mass lying right beneath the mu- cous membrane of the rectum, over which the mucosa can be slightly moved or not at all if it is adherent. The sur- face may feel uneven and somewhat hard. Sometimes the finger encounters a constriction through which it cannot easily pass ; the tissues here present the same character- istics as just described. Occasionally an ulcerated area 11 162 DISEASES OF THE INTESTINES. can be discovered on the surface of the neoplasm. In can- cer of the rectum situated high up (not accessible to digital examination), several clinicians have advised examination with the whole hand passed through the rectum. This, however, can be done only under chloroform narcosis and is not free from danger. Such an examination may in rare instances cause rupture of the intestinal wall as stated by Volkmann. ' Inspection of the rectum by means of Kelt's speculum can be easily performed and aids us in discover- ing a neoplasm situated quite high up in the rectum, even if not accessible to digital examination. The latter instru- ment may also be used in neoplasms of the lowest part of the bowel, although its use here is not of much impor- tance, as the palpating finger gives us enough certainty in making the diagnosis. Cancer of the rectum is as a rule accompanied by severer pains than that of the large bowel. These as a rule are local in character. They often radiate toward the caecum and the lower lumbar region, toward the bladder and geni- tal organs, and sometimes in the direction of the sciatic nerves. In case the neoplasm involves the anus, there is an exacerbation of the pain at each evacuation. Tenesmus is constantly present in the latter instance. If such a neo- plasm of the lower parts of the rectum becomes ulcerated, the tortures of the afflicted person can hardly be described. The patient as a rule is afraid of having an evacuation, and tries to keep it back as long as possible. At last there is a movement containing fecal matter, mucus, blood, and sometimes pus, under most excruciating pains. Leube has directed attention to the fact that hemor- rhoids are frequently associated with the neoplasm of the 1 Volkmann : "Ueber den Mastdarmkrebs. " Volkmann's Sammlung klin. Vortraege, No. 131. MALIGNANT GROWTHS. 163 rectum. This is of importance, as it shows that the pres- ence of hemorrhoids should not lead one to abstain from digital rectal examination. If a patient has complained of constipation for a short period (a few months) and hemor- rhoids have developed during this time, the latter are rather indicative of a more serious condition, and a digital examination of the rectum should always be undertaken under such circumstances. Course. An uncomplicated intestinal cancer may last for years. Frequently, however, the time is much shorter. Many complications are liable to occur hemorrhages, per- foration peritonitis, rupture of the intestines, ileus, auto- intoxication, extension of the cancer to other organs, and metastases. On account of these many possibilities the life of the patient may be shortened, and it is hardly pos- sible to foresee its duration. In some instances a condi- tion of coma (coma carcinomatosum) appears quite earl}'. It is generally assumed that the latter is due to auto-intoxi- cation, either by the products of decomposition of the in- testinal contents or by the toxins of the cancer. Ewald in such a case succeeded in isolating a body from the urine belonging to the group of diamins. In cancer of the duodenum the general nutrition suffers very early and ex- tensively, and for this reason the duration of life is short. In cancer of the rectum nutrition is well maintained for a long period, and for this reason the duration of life in the absence of complications is quite long (about four years). In case anaemia of a high degree supervenes, a marasmic thrombosis may develop and the patient may die in conse- quence of an embolus of the lungs. If intestinal cancer is unattended with complications, death often results in con- sequence of general exhaustion. Diagnosis. The diagnosis of intestinal cancer can be 164 DISEASES OF THE INTESTINES. made with certainty in the following instances: 1. If by abdominal or rectal palpation a tumor can be detected which is situated in the small or large bowel, and accom- panied by symptoms of cachexia and disturbances of defe- cation. 2. The presence of a tumor as just described, and the discovery of small particles of the neoplasm in the evacuation giving microscopically the appearance of a can- cerous growth. 3. Gradually increasing disturbances of the bowel for a few months in a heretofore healthy person, accompanied by cachexia and symptoms of a beginning or already developed stricture of the bowels and the presence of a small particle of growth in the stools, giving as above microscopically the picture of cancer. If there is no tumor and if nothing cancerous is found in the stools, the diagnosis can never be made with cer- tainty. A probable diagnosis of intestinal cancer will have to be made if cachexia is present, together with symptoms of gradually developing intestinal disturbances, indicating the beginning of an obstruction of the bowel, in a middle-aged or elderly person who has been well up to a few months before. Prognosis. The prognosis of intestinal cancer is always unfavorable. Unless an early operation and total ex- cision of the growth is resorted to, a fatal issue is sure to follow, although the exact duration of life can hardly be predicted, the latter depending upon subsequent complica- tions. Treatment. A cure is possible only by a total and thor- ough removal of the growth. We must therefore always endeavor to make the diagnosis as early as possible and advise an immediate operation whenever feasible. Cancer of the rectum can be recognized quite early and resection of the neoplasm is here followed by brilliant results. If MALIGNANT GROWTHS. 165 the tumor is located farther up in the large bowel or in the small intestine, then the results of an operation are not so promising, for here the recognition of the growth is pos- sible only at an advanced period, and by that time often adhesions with other organs and cancerous infection of the glands have already taken place. Excision of the tumor and resection of the intestine in the neighborhood of the neoplasm with an end-to-end anastomosis should be prac- tised whenever feasible. In case, however, total resection is impossible, an entero-enterostomy or entero-colostomy, or if the cancer is situated in the rectum, a colostomy (ar- tificial anus) will be of benefit. These operations are pal- liative in nature and prolong life, at the same time making it more comfortable. They are intended to allay the symp- toms of obstruction and to carry the fecal matter over a new route, not passing through and thus not irritating the cancerous area. In some instances of inoperable cancer of the rectum curettage followed by the application of the thermo-cautery is of benefit for a short period. Aside from these surgical means the treatment should be symptomatic. The diet should consist of foods con- taining plenty of nourishment but very little indigestible residue, thus forming only a small quantity of fecal mat- ter. If there is stagnation of the intestinal contents, cathartics will have to be given in order to liquefy the fecal matter. This can be done by means of castor oil, rhubarb, magnesium sulphate, and so on. If the neoplasm is located in the large bowel, irrigations with warm oil or water are preferable. The pains should be allayed by means of warm baths and cataplasms, but if these fail, by narcotic remedies, such as morphine, opium, codeine, or belladonna; suppositories being here most suitable. Eventual complications should be treated as such. 166 DISEASES OP THE INTESTINES. Sarcoma and Lympho-Sarcoma. Sarcoma of the intestine is a much rarer affection than cancer. According to Kundrat, ' in the Wiener Allgemeine Krankenhaus between the years 1882 to 1893 there were 2,125 autopsies on cases of cancer. Of this number 243 were cancers of the intestines. In the same period of time there were 274 necropsies on patients with sarcoma, of which 3 were located in the intestines. Among 61 lympho- sarcomata 9 were in the intestines. On the whole the symptomatology of these malignant neoplasms coincides with that of cancer of the intestines. There are, however, a few points in which they differ from intestinal cancer.' While carcinoma is most frequently found in the lower portions of the large bowel, sarcoma shows a greater predi- lection for the small intestine and the upper portion of the large bowel. Thus, according to Nothnagel, among 9 cases of sarcoma of the intestines 1 was located in the duode- num, 3 in the jejunum, 3 in the ileum, and 2 in the caecum. Sarcoma of the intestines shows very rapid progress, and metastases in other organs are very early found. The duration of life is much shorter than in cancer, being in most cases about but nine months. There is only one in- stance mentioned in literature in which a patient lived one and three-quarter years after the first appearance of symp- toms. Symptoms of obstruction which are so frequently found in cancer of the intestines are very rarely if ever met with in sarcoma. The tumor as a rule extends over a large part of the intestines, but does not occlude the canal. Cachexia and anaemia belong to the early symptoms, and are much more pronounced than in cancer. The progno- 1 Kundrat : Gerhardt's " Handbuch der Kinderkrankheiten, " Bd. iv., 2te Abtheilung, Tubingen, 1880. BENIGN TUMORS. 167 sis of this form of tumor of the intestines is absolutely fatal. Even in cases in which an operation is performed quite earl}', it is as a rule not of much benefit on account of the numerous metastases which develop so early ; and on this account Madelung ' even hesitates to advise surgi- cal interference. BENIGN TUMORS OF THE INTESTINE. Of the benignant neoplasms the following forms are occasionally met with in the intestine: adenoma, fibro- ma, lipoma, myoma, angioma, and cyst. These growths are termed polypi if they have a pedicle. Occasionally they have a large base and form only a small prominence over the surface. The polypi are usually of small size, that of a cherry or plum ; rarely they are larger, pear-sized or greater still. As a rule they are covered with normal mucous membrane. Although they are found almost every- where in the intestinal tract, they occur most frequently in the rectum (according to Rosenheim in eighty per cent). Among the benign tumors the adenomata are most fre- quently met with. They arise from the mucosa, have a typical acinous structure, and are attached to the mucous membrane either by a broad base or by a pedicle. In the latter instance they form polypoid excrescences which may cover long distances of the intestinal canal, existing in large numbers. Ewald refers to a specimen in his possession in which the inner wall of the colon was covered from the splenic curvature to the sigmoid flexure with such numer- ous polypi that they projected from the mucous membrane like tassels from a ribbon. The whole specimen looked somewhat like a gigantic bunch of grapes. The polypi are most often met with in children from the fourth to the 1 Madelung : Centralbl. f. Chirurgie, 1892, No. 30. 168 DISEASES OP THE INTESTINES. seventh year, although they also occur in grown-up per- sons. With regard to symptoms the benign tumors located in the upper parts of the intestinal tract cause hardly any disturbances ' at all. Sometimes, however, especially if they are present in larger numbers, they may give rise to hemorrhages and catarrhal affections. On account of their small size and soft consistency it is almost impossible to discover them by palpation through the abdominal wall. In very rare instances they may give rise to serious symp- toms by occluding the intestinal lumen or by causing in- vagination. The benign tumors located in the rectum more frequently give rise to disturbances. Thus tenesmus and difficult defecation are often met with; hemorrhages also occur frequently. Sometimes such a polypus, if situ- ated near the anus, may protrude through this opening during defecation and give rise to severe pains. Occasion- ally a polypus is torn off from the intestinal wall and passed with the stools. In such an event the symptoms, if there have been any, suddenly disappear. Whenever these tumors are situated in the lower rec- tum they are accessible to direct examination and treat- ment. The latter consists in removing them by galvano- cautery or by direct surgical measures. CHAPTER VII. HEMORRHOIDS. Synonyms : Phlebectasia hemorrhoidalis. Piles. Definition. Diffuse or circumscribed varicose dilata- tions of the hemorrhoidal veins situated either in the sub- cutaneous tissue of the external surface of the anus or in the submucous tissue of the lower portion of the rectum. Etiology. The affection under consideration is quite frequently met with. It occurs more often in men than in women and very rarely in children. While in olden times it was believed that hemorrhoids were due to a faulty state of the general circulation or dyscrasia, it is now generally ac- cepted that they are the result of merely local disturbances. The development of hemorrhoidal varices takes place in the same manner as that of varices of other regions of the body, principally by mechanical influences. The reason why these phlebectases are formed so often in the hemor- rhoidal plexus is as follows: 1. The hemorrhoidal veins occupy a low position of the body, no matter whether in the standing or in the recumbent posture. 2. They are often unduly compressed by the contraction of the muscles situated in the lower end of the rectum and by fecal masses accumulated here. The circulation is thus at certain times obstructed or altogether arrested. 3. The hemorrhoidal veins are not provided with valves, and thus blood which has passed through them can be easily forced back. 4. The rental veins are the remotest branches of the portal 170 DISEASES OF THE INTESTINES. vein in which there is normally but a low degree of pres- sure, and in which circulation is easily retarded by dis- turbances of the liver. As all these factors exist even under normal conditions it is readil}' conceivable that phlebectases are found in the majority of people; usually, however, they do not reach a marked development, and for this reason do not give rise to complaints. All conditions which tend to produce lasting hyperaemia of the lower portion of the rectum give rise to the develop- ment of hemorrhoids. Too prolonged sedentary or stand- ing occupations predispose to them. In this way hemor- rhoids occur in clerks, students, some artisans, for instance, shoemakers, tailors, and cavalrymen, seamstresses and washwomen, etc. High livers and people who are used to strongly seasoned or fatty foods also often suffer from piles on account of the great fulness of the portal circula- tion under these conditions. Habitual constipation also favors their development. The use of strong cathartics like aloes, colocynth, gamboge, etc., irritates the large bowel in a marked degree and often gives rise to hemor- rhoids. Diseases of the uterus which lead to an enlarge- ment of this organ and also pregnancy are predisposing causes. In a similar way affections of the prostate and tumors of the bladder as well as of other organs situated in the small pelvis often produce hemorrhoids. All dis- eases of the liver which are accompanied by a congestive state of the portal circulation exert a direct influence upon their formation. Diseases of the heart and lungs fre- quently cause congestion of the inferior vena cava and indirectly also of the rectal veins, thus predisposing to the affection under consideration. Hemorrhoids are most frequently developed between the ages of thirty and fifty years. They are extremely rare HEMORRHOIDS. 171 in infants and children. With regard to frequency the male sex seems to be more often afflicted than the female. Some races show a special predisposition to this disease, depending most probably upon their mode of living and their diet. Whether heredity plays a part in the develop- ment of hemorrhoids is yet unsettled. Morbid Anatomy. In some instances the hemorrhoidal veins are evenly dilated and can be noticed as bluish-red and tortuous vessels encircling the external anal opening. At the same time there may be no special varicose swell- ings; more frequently, however, besides the general con- gested condition of the veins there are isolated varicose protrusions which may range in size from a pea to a wal- nut. They vary greatly in shape: sometimes they are round, sometimes flat, sometimes again irregular. Their size greatly changes from time to time in the same person. After defecation as a rule they grow smaller. Internal hemorrhoids appear as soft nodules of a bluish hue and have thin walls. They often develop to a considerable size and make defecation difficult. As a rule, hemorrhoids occur as multiple nodules, which may cover the mucous membrane at different places, or they may encircle the external surface of the anus, or be situated above the inter- nal sphincter. Internal and external hemorrhoids may also be present at the same time. Thus Cruveilhier ' de- scribed a case in which there existed a wreath of external hemorrhoids around the anal opening, another above the in- ternal sphincter, and a third a few centimetres farther up. External hemorrhoids are at first covered with normal epidermis which can be moved over them. Later, how- ever, through inflammatory processes the cutis becomes adherent to the varicose nodule. At the same time the 1 Cruveilhier : "Traite d'anatomie pathologique generate, " 1849. 172 DISEASES OF THE INTESTINES. skin covering the nodule grows thinner through the steady pressure to which it is subjected, and it may reach a point when it breaks open after a forced defecation. The same remarks also apply to internal hemorrhoids in which the cutaneous covering of external hemorrhoids is represented by the mucous membrane of the bowel. This also be- comes adherent, thinned, and may ultimately rupture. Internal piles are best divided, according to Allingham,' into the three following varieties : 1. Capillary Piles. These present small, florid, rasp- berry-looking tumors or rather vascular areas upon the mucous membrane, having a granular spongy surface and bleeding on the slightest touch; they are often situated rather high in the bowel ; in structure they consist almost entirely of hypertrophic capillary vessels and spongy con- nective tissue. They resemble arterial naevi very closely, indeed, in their microscopical structure, except that they are covered externally by a very much thinner membrane and consequently are readily made to bleed. 2. Arterial Piles. These appear as tumors varying in size, sessile or somewhat pedunculated, attaining sometimes very considerable dimensions, glistening or slightly villous on their surface, slippery to the touch, hard and vascular with an artery often as large as the radial entering their upper part. When they are villous on their surface, they bleed very freely and for some reason or other have formed and grown very rapidly. On dissecting one of these tumors one will find that it consists of numerous arteries and veins frequently anastomosing, tortuous, and sometimes dilated into pouches, and of a stroma of cell growth and connective tissue, the latter most abundant. 'William Allingham and Herbert W. Allingham: "The Diagnosis and Treatment of Diseases of the Rectum. " London, 1896, p. 113. HEMORRHOIDS. 173 3. Venous Piles. In these the venous system predomi- nates. The tumors are often very large and are sometimes the size of a hen's egg. They are bluish or livid in color. The surface may be smooth and shiny or pseudocutaneous. External and internal piles often present themselves as nodules situated closely to each other and sometimes coa- lescing ; thus larger tumors arise. In these hemorrhoidal varices important structural changes frequently take place. While at first soft, they may grow quite hard by the for- mation of blood clots or by a process of calcification. In- flammatory processes in the neighboring tissue have a tendency to increase their size and to make them more firm. Internal piles are often pushed downward during the act of defecation. In this manner the mucous membrane of the base of the tumor is subjected to greater traction, and thus ultimate^ a pedicle is formed. Such nodules pro- vided with more or less long pedicles and situated near the internal sphincter very frequently slip out from the anus at each defecation. When, however, they are not especially large, they spontaneously return into the rectum after defecation is finished. If they are of considerable size, it sometimes happens that they become incarcerated by the external sphincter, and if not carefully replaced, inflammation may develop and give rise to intense pains. Occasionally they may even become gangrenous and ulti- mately drop off. In some instances hemorrhoids undergo retrograde changes, become smaller, and even disappear entirely. Flaps of skin hanging near the anus and pre- senting a brownish color are often the remnants of pre- vious piles. External piles sometimes give rise to the formation of warts and their surface assumes an uneven and wrinkled appearance. Internal hemorrhoids are often 174 DISEASES OF THE INTESTINES. complicated by inflammatory processes of the neighboring tissues. Such processes give rise to the formation of ul- cers, proctitis, and periproctitis. In the latter instance an abscess may be formed, which may open either exter- nally or internally, sometimes both ways. Thus a com- plete rectal fistula originates. In internal hemorrhoids the mucous membrane of the rectum almost always exhibits the signs of a chronic ca- tarrh. Its surface is swollen, succulent, and often covered with a thick layer of mucus. Occasionally there may be some pus. The proctitis accompanying piles may be either the cause or the sequel of the latter ; sometimes, however, both may be due to some other factor. Symptomatology. Most of the symptoms produced by hemorrhoids are generally of a local character. They greatly vary in the different varieties of piles. In the early stage of external pile there occur off and on, espe- cially after indiscretions in eating and drinking (princi- pally effervescent wines or strong alcoholic beverages), attacks caused by an increased congestion of the hemor- rhoids. These attacks may be described as follows: A sensation of fulness or clogging and slight pulsation in the anus are felt by the patient. Moderate constipation exists, compelling the patient to strain more than ordinarily. Itching of the anal region and the perineum frequently annoy the patient, especially soon after retiring, and may keep him awake for quite some time. On awaking in the morning the patient finds the anus tender and swollen, and after a movement a few stains of blood are discov- ered on the paper. Such an attack will, as a rule, pass off very quickly if the patient lives rationally and avoids the predisposing causes ; if not, the attack will quickly recur with greater intensity and gradually assume a severer type. HEMORRHOIDS. 175 External piles may become swollen and cedematous, and are then extremely painful to touch. Sometimes there may be ulceration, or suppuration may take place and small painful fistulae may form. The venous tumors now and then irritate the sphincter and levator ani muscles and produce spasm of the latter. The piles are then occasion- ally drawn up into the anus and pinched by the latter. This causes a great deal of pain and keeps the patient awake during the night. A feeling of throbbing and a sensation as of a foreign body in the anus exist. A fre- quent desire for defecation is thereby produced and the patient, as a rule, is inclined to attempt to expel the for- eign body by forcible straining, which of course only aggravates the pain. Under these circumstances the patient can hardly sit down nor can he walk about com- fortably, and on coughing and sneezing experiences great suffering on account of the constriction of the involved diseased parts. During a movement of the bowe^and for some hours afterward the pains are greatly increased. The patient is unable to attend to his daily occupation. General symptoms like fever, anorexia, dizziness, 'severe constipation, may accompany the local manifestations. Of the internal hemorrhoids, the capillary variety, being small and only slightly elevated above the mucous surface, gives rise to scarcely any trouble. As a rule, there is no pain. Occasional!}', however, ulceration takes place which may cause considerable suffering. Arterial and venous hemorrhoids give rise to many more symptoms. In case the sphincter muscles are relaxed, the hemorrhoids often protrude on the slightest exertion. This also often occurs at stool. At first they spontane- ously return within the sphincter after the bowels have moved or whenever the exertion has ceased. Later in the 176 DISEASES OF THE INTESTINES. course of the disease, however, the patient is compelled to return them with the finger. In still more advanced cases they never remain long within the sphincter and pro- trude very often whenever the least exertion is made. In this manner the hemorrhoids cause much discomfort. They also discharge a gummy acrid mucus which keeps the parts constantly moist and leads to excoriations around the anus, and also favors the development of cutaneous excrescences. Patients with fully developed internal hem- orrhoids experience a great deal of suffering during defe- cation. They also feel quite uncomfortable for some time afterward, occasionally to such a degree that they have to lie down. When walking they are always conscious of the fact that they have an anus. In other instances in which the sphincter ani is strong and tight, the piles in coming down become nipped and their return is rendered difficult and painful. The ymptom from which the hemorrhoids originally derived their name, namely, hemorrhage, is common to all varieties of piles, although it is by no means constant. In many instances it is absent, or it does not play any essen- tial part, especially in external piles. In some patients a more or less considerable hemorrhage takes place at cer- tain intervals, appearing periodically, occasionally with great regularity. A few premonitory signs, consisting in painful sensations in the back and around the anus, con- stipation, and other indefinite nervous symptoms usually precede for a few days the beginning hemorrhage. The blood as a rule then appears at first in small quantities gradually increases in amount, and the hemorrhage stops on the fifth or sixth day after its commencement. Physi- cians in olden times and some of the laity even nowadays looked upon the hemorrhage as an important event, free- HEMORRHOIDS. 177 ing the system of vicious material. This is the reason why formerly the hemorrhoidal bleeding was termed the golden flow. Nowadays we do not attach any particular import- ance to these hemorrhages. Their regularity or the perio- dicity of their appearance is simply attributable to the fact that the time necesary for the filling up of the nodules until they rupture is usually- of the same length. In some instances there are transient hemorrhages, last- ing a shorter or longer period. Ordinarily the patients feel relieved after the bleeding ; occasionally they remain quite well for a long time, sometimes for a year or two, until there is suddenly a new hemorrhage. In the latter case the hemorrhage is commonly caused by some unusual oc- currence ; thus, a very copious meal, a long ride on horse- back, or an excess in venery may bring it on. In another class of patients there may be continuous small hemorrhages. These occur more frequently in cases of capillary hemorrhoids. The quantity of blood lost at each action of the bowel is small, but being steady it be- comes a serious strain upon the patient's constitution and may give rise to severe forms of anaemia and even per- nicious anaemia. The blood discharged from piles is either of a bright red or a dark brown color, depending upon its origin from arteries or veins. It is characteristic of hemorrhoidal hemorrhages that the blood usually appears in a liquid, non-coagulated state, covering the fecal matter, but not mixed with it. If the hemorrhage is very copious, uncon- sciousness may result combined with symptoms of pro- found collapse. This, however, happens very rarely. Ac- companying the local manifestations, especially if the latter are of a high degree, there may be varied general symp- toms. Thus dyspnoea, palpitations of the heart, angina 12 178 DISEASES OF THE INTESTINES. pectoris, irregular heart action, hiccough, headaches, gid- diness, dizziness, buzzing in the ears, and cloudy vision may be present. Often a despondent feeling and a condi- tion resembling hypochondria is met with. Anorexia, nausea, belching, and constipation also often occur. The general symptoms are especially marked if incarceration of internal piles within the sphincter has taken place. In case the swelling of the hemorrhoids is so extensive that a reposition cannot be quickly effected, there may be pres- ent besides the local pains high fever and signs of col- lapse. If the incarceration lasts a long period, the hem- orrhoids may become gangrenous and either fall off, accompanied by profuse hemorrhage, or, although rarely, give rise to septic and peritonitic conditions. In most instances after a falling off of the hemorrhoid a sponta- neous cure takes place. Some cases of hemorrhoids are complicated with catarrn of the rectum (proctitis). In such instances the stools reveal the presence of a considerable quantity of mucus, occasionally even of pus.. Sometimes the mucous or mu- co-purulent fluid admixed with the faeces may be tinged with blood. These cases are often accompanied by a paretic condition of the sphincters, which allow the secre- tion to dribble from the anus. This gives rise to excoria- tions and inflammation of the anus and the neighboring tissues. In the course of the proctitis prolonged tenesmus may appear at times. If the inflammation extends into the rectal cellular tissue, it may lead to the formation of ab- scesses which may empty into or outside the bowels. This is the most frequent way in which fistulae are produced. Disturbances of the adjacent organs are also occasion- ally met with in cases of piles. Thus ischuria, stranguria, hemorrhages from the bladder, hemorrhages from the va- HEMORRHOIDS. 179 gina, and catarrbal conditions of the latter are encoun- tered. Diagnosis. The diagnosis of hemorrhoids as a rule is easy. External piles are found by inspection of the anus, the patient lying on his side with the thighs drawn up. The buttocks are pushed aside with the hands, and the patient is instructed to strain in a similar manner as when having a stool. Nodules of a reddish-bluish tinge will be noticed in the immediate vicinity of the anus or partly within it. It is characteristic of hemorrhoidal nodules to increase in size during a period of constipation, and to diminish after an efficient evacuation of the bowels. Condylomata and small skin tags around the anus can be easily differentiated from piles. Condylomata, as a rule, encircle the anus and are present also on other parts of the body, especially on the scrotum. Besides, there will be a previous history of syphilis, and occasionally other lue- tic manifestations. The cutaneous tags present more the appearance of whitish-looking skin, never change in size, and do not bleed when punctured, while hemorrhoids bleed profusely on puncture. The diagnosis of internal hemorrhoids can be made by a digital examination or by this in connection with the in- spection of the lower portion of the rectum by means of a speculum. The characteristics of internal piles are similar to those of external hemorrhoids. They can be easily differentiated from polypi by means of puncture with the needle. Polypi do not bleed when punctured. Besides, polypi are usually found in children, while hemorrhoids occur with greatest frequency in the advanced period of life. Carcinoma of the rectum will rarely give rise to mistakes, the tumor usually presenting a much harder consistency 180 DISEASES OP THE INTESTINES. than hemorrhoids. As a rule, there will also be other signs of a malignant trouble, cachexia, etc. It is needless to say that cancer of the rectum may be combined with hemorrhoids. As a matter of fact, it very often gives rise to their development, and the discovery of piles which have formed within a short period of time should indeed rouse the suspicion of cancer of the rectum. Prognosis. The prognosis of external as well as internal piles is as a rule favorable. They generally exist for a long time, not infrequently throughout life. They hardly ever endanger life, unless some grave complications (incar- ceration of the hemorrhoids or gangrenous processes or very profuse hemorrhages) supervene. Hemorrhoids are liable to recede or even to disappear entirely, especially if the factors producing them have been eliminated. Treatment. A rational mode of living is of the greatest importance. Patients with hemorrhoids should have plenty of outdoor exercise, should partake of food with moderation, should avoid all excesses in baccho and in venere, and should endeavor to have a daily evacuation of the bowels. Any condition causing venous hyperaemia of the rectum must be removed. Thus vocations requiring constant sitting, or constant standing, or horseback riding should be entirely or partly given up. With regard to diet the following general rules may be given: Patients with hemorrhoids should avoid copious meals. They should rather eat often and sparingly. Fish, fresh, well-cooked vegetables, and ripe fruit should form a considerable part of their diet. Alcoholic beverages, strong coffee, and highly seasoned dishes should be avoided. The different kinds of cheese, very coarse brown bread, cabbage, peas, and beans are best eliminated from the diet. Salads, potatoes, beets, spinach, asparagus, cauliflower, are, how- HEMORRHOIDS. 181 ever, rather of benefit if taken in small quantities, as these articles make the intestinal contents more liquid. Stewed fruits and also raw fruit, as for instance apples, pears, prunes, oranges, grapes, are useful. As a beverage, plain water, best taken between meals in the quantity of a pint, is most beneficial. In some instances, especially in anae- mic patients, buttermilk in the same quantity may be taken instead of water. A small amount of light beer is permissible in some cases. With reference to hygiene or prophylactic measures it is of importance for the patients to have plenty of outdoor exercise, especially walking. The exercise, however, should not be continued to over-fatigue. Gymnastic exercises at home, sawing or chopping wood, and the like, and also massage are best adapted for this purpose. The patients should wash the affected part in the morning and evening with cool water. They should sit on caned chairs, not on upholstered ones, and should sleep on a mattress. The patient should have a good evacuation of the bowels daily. In case this does not occur, it will be of the great- est importance to secure it by the different therapeutic measures at our disposal (see Chapter X., on constipa- tion). As a rule, however, powerful laxative and drastic, remedies should be avoided. The frequent use of injec- tions had also best be omitted. The purgatives most adapted for these patients are the saline ones, sulphur and rhubarb drugs. Thus compound licorice powder, a tea- spoonful in the evening, or sulph. depur., potas. bitartrat. ua, also one teaspoonful in the evening. Rhubarb in the form of tincture or in substance 0.5 to 1 gm., taken once or twice daily, is also advantageous for a prolonged use. The waters of Carlsbad, Kissingen, Marienbad, Tarasp, Saratoga, will also be of benefit, especially if taken at the 182 DISEASES OF THE INTESTINES. watering-places themselves in connection with a prescribed diet. If the hemorrhoids have already attained consider- able size, local remedies will often be required. Local Treatment. The irritation or the rubbing of the piles against each other or against the skin must be pre- vented. For this purpose covering the piles with a small piece of smooth and clean cotton is of benefit ; still better, however, for this purpose is cotton moistened in olive oil or covered with vaseline or a soft salve (Hebra's ointment or ointments of zinc, lead, boracic acid) . If the piles are inflamed, it is best to first paint them a few times with the following solution : $ Potas. iodidi 2.0 ( 3 ss. ) lodi puri 0.2 (gr. iiiss. ) Glycerin 40.0 ( 3 x.) before applying the ointment. After a movement the anus and the piles should be first washed with cool water and then wiped off with soft cotton or linen. This must be done very gently. Persons suffering with annoying tenes- inus after defecation should accustom themselves to go to stool before retiring. The recumbent position which the patients are thus able to assume soon after the passage affords them decided relief. If there are pains in the rectum caused by a mere hyper- aesthesia of the mucous membrane, an injection of one to two teaspoonfuls of warm olive oil or of the same quantity of warm water into the bowel will exert a favorable influ- ence. If this fails, or in cases in which the pains are caused by a superficial excoriation of the piles, it is best to apply an ointment containing some narcotic after an evacuation of the bowels, and sometimes even during the intervals. The following salve, recommended by Eosen- heim, is very appropriate : HEMORRHOIDS. 183 $ Lanolin 20.0 ( 3 v. ) Bism. subnitr 2.0 ( 3 ss.) Extr. opii 0.3 (gr. v. ) M. f. uugt. In place of the ointment the piles may be painted with a solution containing equal parts of fluid extracts of opium and belladonna, or with a two-per-cent cocaine solution. Suppositories containing opium, belladonna, or cocaine are also effectual. Internal piles prolapsing through the anus should be pushed back by the patient after anointing them with olive oil or with vaseline. In case the reposition is not easy, painting of the piles with a two-per-cent cocaine solution will after a while lessen the sensitiveness and thus make re- position possible. In some obstinate cases the patient must be narcotized in order to accomplish this. If the incarcerat- ed piles have already become gangrenous, the pains usually grow less. In order to arrest the necrotic process it is advisable to dust the affected area with an antiseptic powder (dermatol) and to cover it with dry gauze. The pile usu- ally falls off spontaneously and the wound heals of itself. The inflammatory processes in piles require special treatment in the stage of exacerbation (general antiphlo- gistic remedies) . Thus rest in bed on the side, applica- tion of cold in the form of an icebag or a Priessnitz poultice, occasional!}'* leeches in the neighborhood of the anus, not on the piles themselves. Application of cold lead water is also useful. In case there are signs pointing to the forma- tion of pus or the development of a septic process, surgical intervention is imperative. An incision into the hardened piles followed by thorough extirpation is essential. Inas- much as such an operation must be done under chloroform narcosis, the radical removal of the entire hemorrhoidal area is therefore best performed at the same time. t 184 DISEASES OF THE INTESTINES. Hemorrhoidal hemorrhages, if not extensive, and if occur- ring at long intervals, will hardly require any therapeutic measures. If, however, the quantity of blood is quite con- siderable or if the hemorrhage is protracted, the following means should be employed : An icebag should be applied to the anus for several hours, or in case the hemorrhage results from internal piles, a cylindrical piece of ice is pushed up into the anus and replaced every half-hour. The rectal refrigerator may likewise be used with benefit. Very cold injections are also useful. In cases with very frequent hemorrhages injections of water, to winch an as- tringent remedy has been added, are beneficial. Thus a two-per-ceut solution of tannic acid or of alum, or a 0.3- per-cent solution of acetate of lead may be applied. The following ointment, first suggested by Kossobudskj,' may also be applied in these cases : ^Chrysarobin 0.8 (gr. xiij.) lodoform 0. 3 (gr. v.) Extr. bellad 0. 6 (gr. x.) Vaselini 15.0 ( ss.) M. f. ungt. This salve not only checks the hemorrhage, but has also an excellent effect in reducing the size of the pile. In in- ternal hemorrhoids the following suppository may be used for the same purpose : % Chrysarobin 0. 1 (gr. if) Acidi tannici 0. 1 (gr. if) lodoform ' 0.2 (gr. Extr. opii 0.02 (gr. i) Ol. theobrom 2.0 ( 3 ss.) M. f. Suppository. S. One suppository in the evening. 1 Kossobudskj : Centralblatt fur Chirurgie, 1889. HEMORRHOIDS. 185 Radical Treatment. 1. Dilatation of the Sphincters. Ver- neuil ' was the first to recommend dilatation of the sphinc- ters as a cure for piles. This treatment is based upon the idea that the spasm of the sphincter is thereby stopped, that the bowels act more freely and the pressure upon the venous blood-vessels is relieved. The dilatation of the sphincters may be accomplished gradually by introducing, specula into the rectum, taking a larger size each time, which proce.dure occupies several weeks, or it may be done in one sitting (the so-called forcible dilatation). In the latter instance, however, chloroform narcosis is necessary. Complete dilatation is effected, according to Allingham, in the following way : The patient being fully under the influ- ence of ether or chloroform, both thumbs must be inserted into the rectum, which is to be dilated gradualh', first in the antero-posterior and afterward in the opposite direc- tion. The amount of force used must be sufficient to over- come the spasm thoroughly. This manipulation must be continued until the sphincter muscles yield, as if reduced to a really pulpy condition. Care must be taken to act high enough up in the rectum so as to include the whole of the sphincter. The result is that the state of contrac- tion is abolished and no spasm can occur. In fact, for the time being, as in any other stretched muscle, paralysis re- sults. With great gentleness the desired effect may be ac- complished without tearing the mucous membrane. But some extravasation is usually noted around the anus for a few days. After this an opium suppository is kept in the rectum and the patient is placed in bed in a recumbent position. Dilatation of the sphincters may be recom- mended in the early stage of hemorrhoids, especially in cases combined with constipation ; further in hemorrhoids 1 Verneuil : Gazette des hop. , 1884, 1887. 186 DISEASES OF THE INTESTINES. during pregnancy or occurring in persons greatly debili- tated by other grave diseases. 2. Carbolic-Acid Injections. Pooley , ' Kelsey , 3 Koux, 3 and Lange 4 have recommended injections of carbolic acid into the piles in order to produce shrinking. This method is per- missible only if the hemorrhoids are not inflamed. Proceed as follows: The piles are first thoroughly cleansed and dried, then covered with iodoforrn salve. In order to lessen the pains a few drops of a one-per-cent cocaine so- lution may first be used subcutaneously. Then three to five drops of either of the two following solutions are in- jected into the centre of each pile: (1) Carbolic acidl, gly- cerin 3; (2) Carbolic acid 1, glycerin 3, distilled water 3. The injection is made with the common Pravaz syringe, but care must be taken that none of the solution drips from the needle, so as to avoid cauterizing the mucous mem- brane. Several piles can be treated at the same sitting. It is advisable, however, not to make the injections ofteuer than about once a week. This procedure if carefully done is not dangerous nor painful, and often effects shrinking or even disappearance of quite considerable hemorrhoidal nodules. 3. Cauterization with Fuming Nitric Acid. Houston," of Dublin, was the first to recommend cauterization of piles with fuming nitric acid. This may be done in the follow- ing manner : After thorough cleansing and drying of the anus and the surrounding parts, the entire area is covered 1 J. H. Pooley : "Injection of Carbolic Acid in Hemorrhoids." To- ledo Med. and Surg. Journal, November, 1877, No. 11. * Charles B. Kelsey : " The Treatment of Hemorrhoids. " Medical Record, 1886, vol. ii., p. 141. 3 Roux : "Behandlung der Hamorrhoiden." Therap. Monatshefte, 1895, p. 124. 4 F. Lange : Centralblatt fur Chirurgie, 1887, No. 25. Beilage, p. 70. 1 Houston : Dublin Journal of Medicine, 1844. HEMORRHOIDS. 187 with a thick layer of vaseline excepting the pile which is to be treated. The latter is then painted with nitric acid by means of a small stick of wood or a glass rod. Special care must be taken that the acid reaches no other spot. After the nodule has assumed a grayish-green color it is carefully dried, smeared with vaseline, and pushed back into the rectum. This method is best adapted for smaller nodules, especially if they have a wide base. Sometimes a second cauterization is necessary, which may be done after an interval of about five days or a week. Instead of nitric acid other cauterizing substances may be used, and Allingham has recommended concentrated carbolic acid as especial^ efficient for this purpose. 4. Ligature. Cooper ' recommended the ligature of hem- orrhoids iii order to cut them off from the circulation and thus destroy them. Salmon 2 has improved this method by making an incision before applying the ligature. Ac- cording to this writer, the operation is performed in the following manner : The patient is placed on the right side on a. hard couch and is completely anesthetized. The sphincter muscles are then gently but completely dilated. The hemorrhoids, one by one, are then drawn down with a pronged hook fork ; by means of sharp scissors the pile is separated from its connections with the muscular and sub- mucous tissues upon which it rests. The cut is best made in the sulcus or white mark which is seen where the skin meets the mucous membrane. This incision is made in a direction parallel to the bowel and carried to such a dis- tance that the pile is left connected by an isthmus of vessels and mucous membrane only. A well-waxed, strong, thin, aseptic silk ligature is now placed at the bottom of the deep 1 Cited from Alliugbarn, loc, cit. 4 Ibid. 188 DISEASES OP THE INTESTINES. groove which has been made, and the ligature is tied right at the neck of the tumor as tightly as possible. When all the hemorrhoids have thus been ligated, they should be returned within the sphincter. A small piece of absor- bent cotton saturated with iodoform ointment is now placed into the bowel and a pad of cotton applied over the anus. 5. Crushing. Crushing of piles has been suggested by Pollock and the method further improved by Allingham, ' who devised a very ingenious apparatus for this purpose, namely, the "screw-crushing instrument." The operation begins with the dilatation of the sphincters. The hemor- rhoid is then drawn into the screw-crusher by means of a hook, and this being intrusted to an assistant the bar is pushed up and screwed home as tightly as possible. The pile should be crushed longitudinally and not transversely. The projecting portion of the pile is cut off with the knife or scissors and the pressure kept up for about one minute. According to Allingham crushing is a very satisfactory method of removing internal piles. 6. Thermo-ccudery (Paqueliri) and Galvano-cautefry. Lan- genbeck introduced the method of operating upon piles by means of thermo-cautery. Each pile is seized with a volsellum forceps and drawn well down. The clamp is then applied so as to embrace its base. The portion above the clamp is cut off with a pair of scissors and the cautery- iron, heated to a dull red heat, is repeatedly applied to the stump until all the vessels are well seared. Instead of using the Paquelin, galvano-cautery may be applied for the removal of hemorrhoids, the technique being identical with the former. Bardeleben and also Ko- senheim strongly recommend the latter method. 1 Allingham : "Diseases of the Rectum," 1896, p. 153. HEMORRHOIDS. 189 7. Extirpation of Hemomhoids, followed by Suture. This method was first introduced by von Esmarch ' in Germany and by Whitehead in England. It is not, however, exten- sively used as it is quite complicated, besides giving rise to many disagreeable complications. Thus Alliugham has noticed the following sequels of such an operation : 1 . Anal stricture. 2. Loss of sensation and control over the anus. 3. Irritation of the mucous membrane due to fre- quent discharges of mucus and at times accompanied by bleeding. After any of the above-named operations it was customary to employ an astringent in order to prevent a movement of the bowels for a few days. Contrary to this method E. Graser 2 is of the opinion that such patients are better off when having a free movement shortly after the operation. He administers soon after its performance a small dose of castor oil and instructs the patient to have an evacuation while in a warm sitz bath. Cleansing of the anus is very easily obtained in this manner. After an antiseptic wash- ing a piece of cotton or linen, thickly smeared with an ointment, is introduced into the rectum. This procedure has usually to be performed once daily. According to Graser, the patients if thus treated are almost without pain, and are able to get up and be out of bed five or seven days after the operation. For some time after its perform- ance it is advisable to have the patient introduce bougies of varying size into the rectum in order to prevent the for- mation of a stricture. Complications. Prolapse of the Rectum. Prolapse of the rectum is a frequent complication of hemorrhoids, although 'von Esmarch: "Die Kraukheiten des Mastdarms und Afters," Stuttgart, 1887. * E. Graser : Penzoldt u. Stiii/ing. " Handbuch d. Therapie, " Bd. iv., p. 634. 190 DISEASES OP THE INTESTINES. it may also occur alone. The prolapse may involve either the mucous membrane alone or all the coats of the rectum. In the latter instance this condition is also called proci- dentia recti. Outside of the anus there is a protrusion of the mucous membrane in its entire circumference. An internal prolapse of the rectum may also occur, which con- sists in the descent of the upper part of the rectum through the lower part, but not appearing outside the anus. This corresponds rather to an intussusception. A relaxation of the ligaments which serve to keep the rectum in its place is often the cause of this malady. Weakness and paralysis of the sphincter ani muscles are also predisposing factors. Prolapse of the rectum is frequently found in debilitated children, especially if an intestinal catarrh is present, for these little patients go to stool too often and usually strain too much and for too long a time. These conditions weaken the muscular apparatus of the anus, and thus a prolapse of the rectum easily arises. In elderly people, in patients suffering from affections of the bladder or from severe constipation and internal hemorrhoids, and in women who have gone through many pregnancies in quick suc- cession, prolapse of the rectum is also a frequent oc- currence. The symptoms are as follows : If the prolapse is only of a moderate degree, there appears in the act of defecation a protrusion of the rectum outside the anus, one or one and a half inches in length, the mucosa looking -quite red and puckered. In the more advanced stage the bulged out rectum resembles a large tumor with a star-like opening at its centre, while the color is pale or bluish-red. In children the mass generally protrudes only 011 going to stool, but in adults it is constantly down' or comes down on the slightest exertion, and therefore may become ulcer- HEMORRHOIDS. 191 ated or inflamed. In old cases of prolapse incontinence of faeces is also frequently present. The diagnosis of prolapse of the rectum is easily made from the above-mentioned appearances. Internal prolapse is net so easily diagnosed, as the mass never appears out- side the anus. This condition can be recognized only by means of a digital examination of the rectum. The finger introduced into the bowel is first kept close to the anterior or posterior wall, and is passed up until it meets with an ob- struction (i.e., it has passed into the cul-de-sac). Then the finger is slightly withdrawn and the centre of the gut examined until an orifice is found into which the finger or a bougie may be passed for some inches high up into the rectum. If the intussusception is rather far up in the rec- tum, the patient should bear down during the examination. With regard to treatment it is of importance to eliminate all the conditions which were predisposing factors for the prolapse. Extreme cleanliness, especially after defecation, should be observed. The reposition of the prolapse should, be performed in the most careful manner. It is best done in the knee-elbow posture. If a considerable portion of the bowel has come down, a large flexible bougie may be passed into the bowel in such a manner as to carry before it the upper part of the descended gut. General taxis should at the same time be used, and in this way the mass can generally be returned. In cases in which the prolapse occurs quite frequently, even during a walk, a rectal sup- porter, as suggested by von Esmarch, should be worn by the patient. It consists of a soft-rubber ball .attached to the anus by means of a belt and a T bandage. The palliative treatment which is especially successful in children is as follows : All sources of irritation should be re- moved and tho general health strengthened. Straining at 192 DISEASES OF THE INTESTINES. stool should be strongly forbidden and a mild laxative remedy given. After a movement of the bowels the pro- truded part should be well washed with cold water and pushed back into the anus by gentle pressure. After this procedure the patient should remain in a recumbent position for half an hour or so, best lying on the abdomen. If these means alone are not sufficient, the following more radical measures will have to be adopted : Cauterization of the pro- lapsed part with fuming nitric acid or with the thermo-cau- tery under chloroform narcosis is often of great benefit. Care should be taken while cauterizing not to touch the verge of the anus or the skin. After this the prolapsed part should be well oiled and returned. Instead of nitric acid Allingham uses the acid nitrate of mercury. These cauterizing methods have the disadvantage of often producing strictures of the rectum. For this reason a num- ber of surgical operations have been devised. Thus exci- sion of triangular or elliptical portions of the mucous mem- brane, bringing the edges together with sutures, has been practised. Extirpation of the entire prolapsed portion was first advocated by Treves.' F. Lange," of New York, has described a new operation, serving the purpose of reduc- ing the calibre of the rectum and at the same time produc- ing a narrow muscular ring. The patient is placed in the genu-pectoral position, an incision is made from the lower part of the sacrum down to the anus, until the posterior wall of the rectum is reached ; the coccyx is then removed. The object in view is to narrow the gut as high as possible and to lessen the impediments to the action of the levator ani. The calibre of the rectum is lessened by introducing buried etage sutures of iodoforrned catgut, which do not 1 Treves : Lancet. 1890, vol. 1. * F. Lange : Annals of Surgery, vol. v., p. 497. HEMORRHOIDS. 193 perforate the entire thickness of the gut. The first rows are inserted near the middle line and form a fold in the posterior walls which protrudes into the bowel. In this manner the more lateral portions of the gut are brought into position without causing too much tension. Similar sutures are applied to unite the cut surfaces of the levator ani and sphincter externus, which had been previously dis- sected in order to lay bare the posterior wall of the rectum. The cavity thus formed is filled up with iodoform gauze and the flaps of integument are united with sutures. Another very efficient operation has been suggested by Allingham and consists in making a small incision through the anterior abdominal wall on the left side, just above the outer third of Poupart's ligament, then introducing the fingers into the abdomen, catching hold of the rectum and pulling it up. After it has been drawn as high up as pos- sible, silk threads are passed through the mesentery and the latter is fastened to the abdominal wall. Fissure of the Anus. Another affection which very fre- quently occurs in connection with hemorrhoids is anal fis- sure. The latter consists of an oblong tear of the mucosa of the anus and gives rise to severe pain and spasmodic contractions of the sphincters. Fissures or ulcers of the anus vary in depth and size. Some are mere abrasions of the mucous membrane, others are quite large and deep so that the muscular fibres are laid bare. The edges of the fissure may be in a healthy state or they may be inflamed, callous, and indurated. Fissure of the anus is usually caused by an injurj^ or tearing of the mucous membrane at the verge of the anus. This may result either from ex- cessive straining or from the passage of very dry hard scybala. The affection is more often found in women than in men. The posterior portion of the anus is the point of 13 194 DISEASES OF THE INTESTINES. predilection, although the fissure may occur at any other place. It is usually situated parallel to the external sphinc- ter, although in some instances it may lie higher up, par- allel to the internal sphincter or even above it. The symptoms consist in intense pains in the rectum on defecation, sometimes persisting afterward. The pains are often of a very excruciating character. The size of the fis- sure does not seem to be of so much importance with regard to the severity of the pain as its position. A small crack situated at the anal orifice over the external sphincter and involving the skin causes much greater pain than a large ulcer situated higher up in the rectum. There may also be a discharge of blood and pus. The diagnosis of anal fissure is made by the symptoms just mentioned and by local examinations. The patient lying on his left side should be told to bear down, and the anus opened with forefinger and thumb as gently as pos- sible. An elongated club-shaped ulcer will be seen within the orifice. Its floor may be very red and inflamed, or if the ulcer is of long standing, of a grayish color, with well- defined and hard edges. Often the introduction of the fin- ger into the anus is so painful that before making the ex- amination a suppository containing one grain of cocaine has to be applied. Sometimes even this procedure is in- sufficient, and then chloroform anaesthesia will be required. For a fissure situated higher up above the internal sphinc- ter examination with the speculum will have to be made. Fissures of recent origin can often be cured without any operation. Rest in the recumbent position should be adopted as much as possible. Mild laxatives are to be recommended, but no drastic remedies employed. If the patient can manage to have a movement at night time lie- fore retiring, it will be of advantage. Locally, the fissure HEMORRHOIDS. 195 should be touched off and on with a ten-per-cent solution of cocaine or with a ten-per-cent solution of nitrate of sil- ver. Still better is the application of the following salve recommended by Allingham : IJ Hydrarg. subchlor gr. iv. Pulv. opii gr. ij. Extr. bellad gr. ij. Ung. sambuci 3 i. M. f. ung. If these palliative remedies are not sufficient, a free incision through the fissure should be made. The cut should be rather deep and should reach the sphincter muscles. CHAPTER VIII. APPENDICITIS. Synonyms: Scolecoiditis ; Perityphlitis ; Paratyphlitis ; Appendicular inflammation. Definition. Inflammation of the appendix, characterized by localized pains, commonly fever and digestive disturb- ances. General Remarks. The inflammatory lesions involving the right iliac region were formerly designated as typhlitis (inflammation of the caecum itself), perityphlitis (inflam- mation of the peritoneal covering of the caecum), and para- typhlitis (inflammation of the retro-peritoneal connective tissue of the caecum). Grisolle ' was the first to maintain that inflammation of the caecum could hardly give rise to such grave lesions as are found in the right iliac fossa, for even ulcerations of the caecum and colon do not, as a rule, show any tendency to extend into the neighboring connec- tive tissue. He ascribed the above conditions to an inflam- mation of the appendix, which organ shows a tendency to perforate and to lead to abscesses in the right iliac fossa as verified by post-mortem examinations. The possibility of a stercoral typhlitis (inflammation of the caecum as the result of accumulated fecal matter) which was formerly generally accepted, is now held by but very few writers, 1 Grisolle : " Tumeurs Phlegmoneuses des Fosses Iliaques. " Archives de Medecine, 1839. APPENDICITIS. 197 as for instance, Lennander. 1 Sahli, 3 Nothnagel, 3 Fow- ler, 4 Sonnenburg, 5 and others deny its existence. The teachings of Grisolle found further support through the brilliant investigations of Reginald Fitz 6 of Boston, Sands, 7 McBurney, 8 Weir, 9 Bull, 10 and Fowler of New York, were supplemented by the observations of Sonnen- burg, Sahli, Rotter," Roux, 12 Talamon, 13 and others, and are now generally accepted. Eiiology. In former years much importance was at- tributed to the occurrence of foreign bodies like cherry stones, grape seeds, lemon and orange pits, date kernels, fish bones, pins, etc., within the appendix as causative fac- tors of the inflammatory suppurative process. According to Fowler, the belief that the disease is frequently due to the engaging of foreign bodies in the cavity of the organ is based to a large extent upon purely speculative or imagi- nary conditions or erroneous observations. In a very large number of cases of this disease upon which he operated Fowler found but in two instances any body other thac soft fecal masses which could be considered as being in 1 Lennander : "Ueber Appendicitis, " Wien, 1895. 2 Sahli : "Ueber das Wesen und die Behandlung der Perityphliti- den. " Correspondenzbl. f. Schweizer Aerzte, Basel, 1892. 3 Nothnagel : " Krankheiten des Darms, " Wien, 1898. 4 George R. Fowler: "A Treatise on Appendicitis, " Philadelphia, 1894. 5 Sonnenburg : "Pathologie und Therapie der Perityphlitis, " Leip- zig, 1895. * Reginald Fitz : American Journal of the Medical Sciences, 1886 ; and New York Medical Journal, 1888. I Sands : New York Medical Journal, 1888, p. 197-205, 607. 8 Charles McBurney : Annals of Surgery, 1891 ; Medical Record, 1892. 9 Robert F. Weir: Medical Record and Medical News, 1887-1892. 10 W. T. Bull : Medical Record, 1894. II Rotter : "Ueber Perityphlitis, " Berlin, 1897. 12 Roux : Revue de Medecine de la Suisse romande, 1890, 1891, 1892. 13 Talamon: "Appendicite et Perityphlite, " Paris, 1892. 198 DISEASES OF THE INTESTINES. any seuae foreign. The fecal concretions within the ap- pendix are now looked upon as of no importance whatever with regard to the causation of the disease, as they are also accidentally encountered in perfectly normal appendices. The opinion generally prevails that the inflammation is caused by micro-organisms which are conveyed to the in- terior of the organ in the fecal matter. According to Nothnagel, however, fecal concretions play a prominent part in lesions leading to perforation of the appendix. Movable kidney has been assumed to be a predisposing factor in the development of appendicitis by Carl Beck ' and Edebohls." The much greater frequency of movable kidney in the female and the comparative infrequency of appendicitis in the latter as compared with the male sex seems to speak somewhat against this view. Actinomycosis, tuberculous and typhoid ulcers are pre- disposing causes of the disease. Occlusion of the lumen of the appendix, either partial or complete, is likewise a pre- disposing factor. These occlusions may be the result of former inflammatory lesions, but are most frequently due to the retrograde changes which this organ is gradually undergoing in the process of evolution. According to Kib- bert 3 and Zuckerkandl/ the appendix is found obliterated in about twenty-five per cent of all living persons. Both these writers ascribe this condition not to inflammatory diseases, but to the progress of evolution which takes place in the appendix. This view is supported by the fact that 'Carl Beck: "Appendicitis." Volkmann's Samralung klinischer VortrSge, No. 221, Leipzig, 1898. * George M. Edebohls : Medical Record. 1898. z Ribbert : " Beitrilge zur normalen und pathologischen Anatomic des Wurmfortsatzes. " Virch. Arch., Bd. 132. 4 E. Zuckerkandl : "Ueber die Obliteration des Wurmfortsatzes beim Menschen, " Wiesbaden, 1894. APPENDICITIS. 199 obliteration of the appendix is found with gradually in- creasing frequency in more advanced age. Thus Kibbert found obliteration of the appendix in fifty per cent of per- sons above sixty years of age. Why the appendix should be the seat of disease so very much more frequently than other parts of the intestine is a question which cannot be so easily answered. The fact that the appendix is a rudimentarj" organ in which proc- esses of evolution are even normally discoverable makes it probable that it is imbued with less resistance against dis- ease-producing agents. The comparatively narrow lumen of the appendix and Gerlach's valve make the emptying of tli is little canal a difficult matter. This, in connection with the scantiness of circular muscular fibres in the walls of the appendix explains the slowness with which substances within the appendicular cavity are emptied into the intes- tine. Stagnation of contents in this organ is certainly a predisposing factor for disease. The abundance of ade- noid tissue in the appendix has been believed by some writers to be a predisposing cause of disease. Bacterial infections here take place in a similar manner as in the tonsils, and Sahli speaks by way of comparison of an an-: gina of the appendix. Fowler and Van Cott ' believe that the vascular arrangement of the appendix (scantiness of blood supply, the main vessels being almost end arteries) is responsible to a great extent for the frequency of dis- ease in this organ. Some of the blood-vessels and nerves are primarily affected, and the nutrition of the appendix being thus disturbed, diseases of an infective character easily take place. Another predisposing cause of appen- dicitis is displacement and malformation of the appendix. While all the above-mentioned factors may predispose 1 Van Cott-Fowler : "Treatise on Appendicitis." 200 DISEASES OF THE INTESTINES. the appendix to disease, the real cause of the latter must be looked for in a bacterial invasion. Talamon was the first to lay stress upon the importance of microbes in ap- pendicitis. Nowadays all writers coincide with this view. Thus Tavel, 1 Hodenpyl, 2 Fowler, Wilson, 3 Barbacci, 4 and others ascribe a very important part to the bacillus coli communis (Escherich), which is almost always encoun- tered in lesions of the appendix, either in the exudate, pus, or the walls of the appendix itself. Other micro-organ- isms are, however, frequently found either in connection with the bacterium coli commune or alone. Thus strepto- coccus pyogenes, pneumococcus, staphylococcus pyogenes aureus, bacterium lactis, bacillus pyocyaneus and pyogenes foetidus, proteus vulgaris, and others have been encoun- tered. In most cases probably a mixed infection (several varieties of micro-organisms) takes place. The bacterium coli commune, however, is most frequently found, as it has a greater resisting-power and in the course of its growth usually causes disappearance of the other micro-organ- isms. Sex and age seem to play an important part in regard to the distribution of the disease. The male sex is much more frequently affected than the female. Thus, Sonnenburg reports 130 cases 77 males, 53 females. Rotter " 68 " - 44 " 24 Nothnagel " 130 " 105 " 25 " Bamberger 5 " 73 " 54 " 19 1 Tavel und Lanz : " Ueber die Aetiologie der Peritonitis. " Mitthei- lungen aus Kliniken und Instituten der Schweiz, Basel, 1893. 5 Hodenpyl : " On the Etiology of Appendicitis. " New York Medi- cal Journal, 1893. 3 E. Wilson : Cited after Fowler. 4 Barbacci : Lo sperimentale, 1893, fasc. 4. 6 Bamberger : " Die Entzttndungen der rechten Fossa iliaca. " Wiener rued. Wocbenschr. , 1853. APPENDICITIS. 20* Volz ' reports 59 cases 45 males, 14 females. Mattel-stock 4 " l',030 " 733 " 297 " This preponderance of the male sex is already found in early life. Thus Matterstock observed 72 cases of appen- dicitis in early life (seven months to fifteen years), and among this number were 51 male children and 21 girls. The greater frequency of appendicitis in the male sex is explained by Van Cott as due to the circumstance that the appendix of the male has a less abundant blood supply than that of the female ; for in the latter there is a col- lateral circulation derived from the sexual apparatus. With regard to age all writers agree that appendicitis is most frequently encountered between the tenth and thir- tieth years. It occurs less frequently in the first decade of life and in the thirtieth to fortieth years, and is quite rare in advanced age. The following table is submitted with a view of showing the frequency of appendicitis in the different decades of life as recorded by several eminent writers : Ages. Fitz. Matter-stock. Nothnagel. Total number 228 22 86 65 34 8 11 1 1 474 46 143 158 72 30 18 5 2 129 1 44 57 14 7 4 2 1 to 10 10 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 70 to 80 The frequency of appendicitis in relation to other dis- eases can be studied from the report of the autopsies made 1 Ad. Volz : "Die durcb Kothsteine bedingte Perforation des Wurm- fortsatzes, etc., " Karlsruhe. 1846. .Afatterstock : "Perityphlitis. " Gerhardt's Handbuch der Kinder- krank., Tubingen, 1880. 202 DISEASES OF THE INTESTINES. in the pathological institute of the Wiener Allgemeiue Krankenhaus between 1870 and 1896. According to Noth- nagel, the total number of autopsies was 44,940. Among these the number of cases dying from appendicitis amounted to 148. The percentage of appendicitis, therefore, was 0.32. With regard to sex there were 107 males (72.3 per cent) and 41 females (27.7 per cent). The actual fre- quency of appendicitis among the living, however, is much greater than appears from these numbers, which relate only to cases which have resulted fatally. Morbid Anatomy. The pathological anatomy of appen- dicitis has been thoroughly studied recently, not only in autopsies but principally in operative cases. In the latter an insight is permitted into the changes which take place early in the disease. Fowler distinguishes four stages of anatomical lesions according to the spread of the morbid process involving the different tissues of the appendix. In the first stage (endo-appeudicitis) more or less intense in- flammation of the mucous and submucous layers takes place. The second stage (parietal appendicitis) consists in an inflammatory process involving the interstitial or intermuscular structure of the body of the appendix. The third stage (peri-appendicitis) means an inflammatory proc- ess involving all the layers of the appendix, the peritoneum included. The fourth stage (para-appendicitis) consists in lesions involving the appendix and the neighboring tissues. This process is most often accompanied with suppurative inflammations of the connective tissue adjacent to that por- tion of the appendix which is not covered with perito- neum. According to Fowler, the above described stages are not essentially different processes but further developments of one and the same lesion. APPENDICITIS. 203 Riedel, ' Notlmagel, and others distinguish two different types of appendicitis which are of great clinical importance. They are the following : 1. Catarrlml appendicitis (e)tdo-appendicitis) . Here in the acute form the inucosa of the appendix is swollen and red- dened, the subrnucosa is engorged and filled with round cells. The follicles are distinctly swollen. The appendix appears swollen and more rigid, and its lumen is filled with thick yellowish contents, mostly mucus; sometimes the latter may be mixed with fecal matter. Occasionally there are fecal concretions. Often ecchymoses of the mucosa occur, leading sometimes to superficial defects (erosions). All these lesions may entirely disappear after the acute at- tack is over, and thus a perfect cure may be established. This, however, is possible only if there is no occlusion of the lumen of the appendix and the inflammatory products can be emptied into the caecum. In the large majority of cases of catarrhal appendicitis the cure is not a perfect one and chronic appendicitis is the result. In this stage the mucosa of the appendix presents a slate-gray appearance. It is filled with accumu- lations of round cells; at the same time proliferation of connective tissue and occasionally blood pigment are found. The submucosa and muscularis may show no changes whatever, although as a rule they are hypertrophied. The latter condition is probably due to stricture of the lumen of the appendix and consecutive muscular (compensatory) hypertrophy. The chronic form of appendicitis, owing to suppurative processes of the mucous membrane, occasion- ally leads to a total destruction of the mucosa, and an ob- literation of the lumen of the appendix. This condition is 1 Riedel : " Ueber die Friihoperation bei Appendicitis purulenta seu gangraenosa." Berl. kliu. Wocheuschr., 1899, Nos. 33 and 34. 204 DISEASES OF THE INTESTINES. very similar to obliteration of the lumen due to the involu- tion processes which have been mentioned above. The appendix then forms a solid membranous band of uniform thickness or with a few small protrusions. As a rule it is found embedded in peritonitic adhesions. Sometimes primary slight lesions of the appendix lead to complications, especially if a stricture is present. Thus an accumulation of secretion within the occluded appen- dicular cavity may take place and give rise to the forma- tion of a cyst. Such cysts occur, varying in size from a cherry to a fist. Guttmann ' observed a cyst of the appen- dix fourteen centimetres (five and a half inches) long and twenty-one centimetres (eight and a quarter inches) wide. The contents of such a cyst are either of a watery mucous character or gelatinous. If ulceration takes place in the occluded appendicular cavity, it may give rise to the formation of a small abscess (py-appendix or empyema processus vermiformis). In these cases the purulent process may penetrate the wall of the appendix and lead to perforation. A timely opera- tion in many instances prevents such an outcome. 2. The severe form of appendicitis (apptiK/irlfiK ulcerosa et (jdiH/nt'iioHt, appendicitis perforativa). In this group the bacterial infection is of a much more virulent nature than in the catarrhal form. The inflammation originating in the mucosa of the appendix at once involves all its lay- ers, including the serosa. Necrobiotic processes and for- mation of pus take place quite early. The peritoneum is also very soon involved, either in the immediate neighbor- hood of the appendix or in its entirety. Ulcerations and gangrenous processes may lead to the destruction of a 1 P. Guttmann : Verliaudlungen des Vereins fi'ir innere Medicin zu Berlin, 1883-84, p. 301. APPENDICITIS. 205 part of the appendix, thus causing perforation, or to a total necrosis of the entire appendix. As a result of this proc- ess the latter may be cast off from the caecum and be found free in the peritoneal cavity or embedded in pus. The way in which the peritoneum is involved is quite variable. There may be an adhesive type of peritonitis leading to a matted and agglutinated condition of the ap- pendix, or a circumscribed or diffuse peritonitis without adhesions. The contents of the appendix may be emptied into the abdominal cavity or hemmed in by adhesions. The size, location, and direction of the abscess differ greatly. The location and length of the appendix and the portion perforated play an important part in this respect. In the great majority of cases the abscess is at first intra- peritoneal, but very soon extends toward the surface or above or below Poupart's ligament. Again it may pene- trate into the bladder, vagina, small intestine, or rectum. In some instances it reaches the diaphragm and from there perforates into the pleural cavity. In some very grave cases there is no abscess but a dit- fuse peritonitis. Here we often meet with a paretic con- dition of the intestine, the latter being filled with gas ; the serous layer is shiny and red, while there is an absence of any exudation. In other cases a small quantity of a purely serous or bloody serous exudation is found. The condi- tion just described may be discovered either in operations undertaken very early or at autopsies in cases which ter- minate fatally at the beginning of the disease. In still an- other group of cases which is a comparatively very small one, the general peritonitis may assume a more protracted and chronic form. In these cases mattings and adhesions are formed over more or less large areas of the abdominal cavity, and in these accumulations of pus may be found. 206 DISEASES OF THE INTESTINES. Appendicitis due to tuberculosis is of comparatively rare occurrence and shows a great tendency to the formation of fistulee. Recently actinomycosis has been found to be the cause of some cases of appendicitis with the formation of abscesses. In these cases the actinomycosis fungi can easily be demonstrated. Symptomatology. In describing the symptomatology of appendicitis it will again be best to differentiate the two forms already mentioned above, namely, the catarrhal and the severe form. 1. Catarrhal or aido-appendicitis. An attack of appendi- citis is usually characterized by a sudden appearance of pain in the abdominal cavity, which at first may be dif- fused or in the region of the navel, but very soon is local- ized in the right iliac region. A moderate rise of temper- ature is very frequently present. Slight gastric symptoms, nausea, and sometimes vomiting often occur, but are, as a rule, only transient. The pains usually increase in inten- sity, and the patient assumes a fixed position with the legs flexed. Any change in the position or any movement of the thighs increases the pain. Examination by palpation shows extreme tenderness on pressure of the right iliac re- gion, more especially at McBurney's point, while the rest of the abdomen can be examined by pressure without giv- ing rise to the slightest pain. While the pains are gener- ally continuous, they may show periods of exacerbation. The latter, according to Nothnagel, are most probably due to a spastic contraction of the muscles of the appendix. The term " appendicular colic " has been given by Tala- mon to the same condition. Talamon, however, assumed that the colic is always due to an attempt of the appendix to rid itself of a fecal concretion. Inasmuch as operations for appendicitis have often been performed during the at- APPENDICITIS. 207 tack of colic and no fecal concretions whatever found in the appendix, and inasmuch as coproliths have been found in cases in which no colic whatever existed, this theory cannot be maintained. In some cases there is an area of resistance in the right iliac region. If the latter be due to an accumulation of fecal matter in the caecum, the tumor can be slightly moved and its shape changed by pressure. In a few of the cases of catarrhal appendicitis the resistance is due to an inflam- matory swollen (serous) condition of the appendix and of the neighboring organs. In this instance the tumor is not circumscribed but rather diffuse, immovable, and its shape unaffected by pressure. In comparatively few cases can the appendix be directly palpated. It then appears as an elongated round body of the size of the little finger, and is very painful on pressure. The examination of the appendix itself, whenever this is possible, is certainly of the utmost importance for diagno- sis. Edebohls ' deserves much credit for having cultivated and perfected the method of examining the appendix by palpation. According to Edebohls, this examination is best done as follows : The patient lies upon his back with the legs comfortably flexed. The physician standing at the patient's right begins to search for the appendix by apply- ing two, three, or four fingers of his right hand, palmar surface downward, almost flatly upon the abdomen at or near the umbilicus ; while now he draws the examining fin- gers over the abdomen in a straight line from the umbili- cus to the anterior superior spine of the right ilium, he notes successively the character of the various structures as they come beneath and escape from the fingers passing over them. In doing this the pressure exerted must be 1 Edebohls : American Journal of the Medical Sciences, May, 1894. 208 DISEASES OF THE INTESTINES. strong enough to recognize distinctly along the whole route traversed by the examining fingers the resistant sur- face of the posterior abdominal wall and of the pelvic brim. Only in this way can we positively feel the normal or slightly enlarged appendix. Pressure short of this must necessarih r fail. R. T. Morris ' suggests for Edebohls' method of palpating the use of three right-hand fingers to feel with and three left-hand fingers placed upon these to press with. The fingers that are to do the feeling are pressed by means of the three others down to the border of the right rectus ab- dominalis muscle at the level of the navel and slowly drawn toward the examiner. I have found both these methods very useful in detecting the position and size of the ap- pendix. The temperature is usually but slightly raised, some- times even normal. The pulse likewise is either normal or but moderately accelerated. Constipation is often present, but seems to be rather the result of the inflammatory condition of the appendix than its cause, as was formerly believed. In a comparatively small number of cases diarrhoea is present during the at- tack of appendicitis. Course. An acute attack of catarrhal appendicitis may last from two to three days to two to three weeks. After this variable period of sickness the symptoms either en- tirely disappear or persist in a slight degree. With regard to the further development the following classes must be distinguished: 1. There may be complete recovery without any further trouble. 2. The patient may entirely recover from the present attack, but have a return of the disease after a variable period of time (from a few weeks, a few 1 R. T. Morris: " Lectures on Appendicitis," New York, 1899, p. 45. APPENDICITIS. 209 months to a year or two) " recurrent appendicitis. " 3. The symptoms may not completely disappear but may persist for many weeks and the patient may remain in a lingering condition "subacute or chronic appendicitis." The first class of perfect recoveries is comparatively small. In this group there is either an obliteration of the appen- dix or the catarrhal process may have subsided completely without having left behind any lesions. The second class of recurrent appendicitis comprises the majority of the cases. In these a chronic catarrhal condition of the mu- cosa of the appendix may persist without manifesting symptoms until a new invasion of micro-organisms gives rise to an acute exacerbation of the process, or strictures of the lumen of the appendix may have formed as a conse- quence of the acute attack and thus become the cause of renewed disturbances later on. In the third category the catarrhal appendicitis has led to severe anatomical lesions. There may be a considerable thickening of the appendix wall including the serosa. The appendicular lumen may show ulceratious, strictures, or 'bends. There may also be an accumulation of pus (py-appendix). 2. The severe form of appendicitis (appendicitis nujynira- tiva or perforans). The disease usually begins quite sud- denly in the midst of perfect health ; rarely it is preceded by slight digestive disturbances. The patient is seized with violent pains in the abdomen. These are felt at first either over the entire abdomen, in the epigastric region, or on the left side of the abdomen, but very soon they settle in the right iliac region. The pains are of an intense charac- ter, and occasionally are accompanied by paroxysms dur- ing which they are almost unbearable. Any motion in- creases the pain. The patient lies perfectly motionless and breathes superficially. The appearance is that of a 14 210 DISEASES OF THE INTESTINES. very sick person, the countenance manifests great suffer- ing and anxiety. The temperature is usually considerably increased and continues so during the first days of the dis- ease. The pulse is accelerated. Occasionally it is of small calibre, easily compressible, and at times irregular. The latter phenomena are found principally in critical conditions. A very frequent pulse and a comparative^ low degree of fever are also considered bad omens. There is always complete anorexia and great thirst, the tongue is dry and thickly coated, the bowels, as a rule, are con- stipated. In rare instances there is diarrhoea. Accord- ing to Nothnagel, vomiting is present in almost three- quarters of the cases. It usually appears right at the commencement of the disease and lasts only a short time. In exceptional instances it persists for several days. The vomited matter consists of gastric contents, mucus, and bile. In very grave cases it exceptionally assumes a fecu- lent character. The vomiting is occasionally accompanied by hiccoughs. Both these phenomena are very annoying and at the same time increase the pain through the mo- tions evoked by them. In many of the cases, soon after the commencement of the disease a tumor begins to form in the right iliac re- gion. At first a rigidity of the muscles in this region is noted; later on a distinct resistance over an area of egg size may be found. The tumor is either circumscribed and sharply defined, or it is diffuse and connected with the neighboring tissues. The skin over the tumor is as a rule easily movable, while the latter is immovable. The tumor generally consists of a purulent exudation in and around the appendix and congested portions of the intes- tines, occasionally of the omentum, and of a purulent infil- tration of the abdominal wall itself. In some instances APPENDICITIS. 211 the size of the tumor is considerably increased by an ac- cumulation of fecal matter in the caecum. The tumor may be discovered by palpation and sometimes by percussion. Fluctuation is present only in very extensive abscesses. Its absence does not signify the absence of pus. The re- sistance as a rule increases either very slowly or quite rapidly. In rare instances, namely in those in which the abscess is surrounded by a firm capsule, it may remain unchanged for a long time. The abscess occasionally in- volves the muscles and even the skin lying above it. The latter becomes infiltrated and oedematous, and in rare in- stances the abscess may spontaneously open through the skin. Occasionally the resistance disappears entirely when the purulent exudation has descended into the deeper parts. In such an event, by an examination through the rectum, and in females through the vagina, the exudation may be discovered filling Douglas' space. In cases in which there is an extensive inflammation of the peritoneum accompanied by a considerable quantity of pus, severe pains in urination appear quite early, after two or three days (Fleischer). On this account the patients are often rather afraid to urinate. In the same cases there may also be parsesthesia and anaesthesia in the limbs, or obstinate erections of the penis, or a drawing up of the right testicle. These symptoms all show that the accumu- lation of pus presses upon the nerves of the sacral plexus. The further course of the disease will largely depend u ix)ii the way in which the newly formed pus around the appendix acts. Often it leads to a perforation of the ap- pendix. Sometimes the abscess forms adhesions and is encapsuled. Sometimes, again, the abscess penetrates into the peritoneal cavity and gives rise to diffuse septic or fibrino-purulent peritonitis. 212 DISEASES OF THE INTESTINES. Perforation of the tqypendix which occurs quite fre- quently in this class of cases is accompanied, according to Souuenburg, by the following symptoms: The disease begins with febrile and marked symptoms ; violent pains in the abdomen appearing either suddenly or after a short period of slight uneasiness and concentrating very quickly in the right side ; vomiting accompanied by diarrhoea and in other cases by constipation; small and frequent pulse; fever commencing with chills and quickly rising; pro- nounced tympanites; general appearance extremely bad; slight cyanosis and perspiration ; a distinct area of resist- ance over or around the affected spot. While all these symptoms are certainly found in cases of perforation of the appendix, they can by no means be absolutely relied upon ; for they may exist in the same manner without a perforation taking place, and, on the other hand, the lat- ter event may occur without any of the above-mentioned symptoms being present. For these reasons Boas ' is re- luctant to make the diagnosis of perforative appendicitis, and contents himself with determining the presence of purulent appendicitis. Perforation peritonitis most often appears between the second and fourth days of the disease (Fitz). The danger of a penetration of pus into the free peritoneal cavity less- ens with the length of time the disease has lasted, on ac- count of the formation of adhesions. On the other hand, numerous other perilous events may take place. In some cases a few days after the commencement of the disease there is a subsidence of the most important symptoms (pains, fever, etc.), while in others they persist with undi- minished severity. Even in the first class, however, the 1 J. Boas: "Diagnostik und Therapie der Darmkraukheiteu, "Leip- zig, 1899. APPENDICITIS. 213 amelioration rarely persists, for pretty soon afterward the pains reappear and the fever recurs, and in connection with these symptoms the inflammation increases and the pus augments. Periods of improvement and exacerbation of the condition may alternate for quite a while until at last either recovery or a fatal issue ensues. A spontaneous cure or recovery without surgical inter- vention may occur in one of the following ways : 1. The abscess may become encapsulated, the pus losing its virulence and becoming absorbed. In such an event the tumor disappears and the patient is either definitely or ap- parently cured ; for dangers to life remain after such a cure in consequence of the remnants of the abscess and of the adhesions formed among the intestines. " The occurrence of a sudden bursting of the abscess," using Ewald's words, " hangs like the sword of Damocles over the head of the patient as long as there is still pus present. " In seemingly perfect health a fatal peritonitis may thus occur in patients who had previously suffered from an attack of appendicitis. 2. A cure may be established by the opening of the abscess into adjacent hollow viscera. Thus the abscess may open into the csecum, colon, small intestine, bladder, vagina, or pelvis of the kidney. This favorable issue is, however, rare. 3. The abscess may find its way externally by ruptur- ing spontaneously through the skin. Sometimes, however, the pus burrows into other organs ; thus it may reach the diaphragm (subphrenic abscess), and sometimes even force its way through into the pleural cavity and perhaps the lungs. But even from these places the pus may be evacu- ated spontaneously, principally through rupture into a bronchus and its expulsion during a coughing spell. In a large number of cases peritonitis and septicaemia 214 DISEASES OF THE INTESTINES. terminate the life of the patient; in others after recovery there are frequently grave recurrences of the disease. Diagnosis. Catarrhal appendicitis can be diagnosed if there is a sudden onset of pain in the right abdominal cav- ity, principally in the region of the appendix, combined usually with a slight rise of temperature and some light gastric symptoms (nausea, anorexia, vomiting). The grave form of the disease or purulent appendicitis shows the same manifestations, only of a much severer type. Besides there are always present signs of serious illness. The patient is very pale and manifests an anxious ap- pearance. Chills are frequently present and the tempera- ture shows a certain irregularity in its course. There may be a marked rise in temperature after it has been quite low or almost normal for a time. The presence of a tumor in the right iliac region is of great importance in the diagnosis of appendicitis, although this symptom is frequently absent. In order to recognize the nature of the tumor with regard to its contents, espe- cially whether pus is present or not, Sahli first suggested the use of an exploratory puncture. If pus can be aspi- rated through the needle, then an abscess is positively present. Although many physicians make use of this method even nowadays, as for instance Ley den, 1 Noth- nagel, Penzoldt," Fleischer, Boas, and others, most of the surgeons are decidedly opposed to this diagnostic measure (Fowler, Treves, 3 Sonnenburg, and others). In this coun- try the consensus of opinion is against the use of explom- tory puncture, for its employment adds a new element of >E. von Leyden: Berl. klin. Wochensckr. , 1889, No. 31. 8 Penzoldt: "Behandlung der Erkrankungen des Darms. " Pen- zoldt-Stintzing's "Handbuch der speciellen Therapie innerer Krank- heiten, " Jena, 1896. 3 Treves : " On Peritonitis." British Medical Journal, 1894. APPENDICITIS. 215 danger to the case, while its results, especially if negative, are unreliable. While appendicitis can usually be diagnosed without difficulty, in some instances its recognition is quite diffi- cult. In cases in which the appendix is abnormally situ- ated, as for instance in the left iliac region or in the upper part of the right abdominal cavity, the diagnosis of appen- dicitis' will hardly be possible. Differential Diagnosis. The following conditions may at times be confounded with appendicitis, namely, biliary, renal, and intestinal colic. The following points will serve as a guide in making a correct diagnosis. In biliary colic the pains are referred by the patient to the right abdominal cavity, radiating to the back and up to the shoulders. Pal- pation shows a painful area situated immediately below the right margin of the ribs ; occasionally jaundice is present. In kidney colic (right side) the pain is felt by the patient in the right lumbar region, radiating toward the bladder. There is generally a frequent desire for micturition and slight burning in the urethra. The urine ma}" show the presence of mucus, sometimes of blood and pus cells. In intestinal colic the pain may be referred to the right iliac region, but, as a rule, it is relieved very soon after the passage of flatus. In contradistinction to these three con- ditions the pain in appendicitis is referred to the right iliac region, where it remains localized, does not disappear upon passage of flatus, does not radiate to the shoulder and but very rarely to the bladder, while there is also great tenderness and pain upon pressure at McBurney's point. No jaundice is present and the urine is normal. In women the differential diagnosis between appendici- tis and a right-sided salpiugitis is not always easily made. A thorough examination through the vagina, however, will 216 DISEASES OP THE INTESTINES. in most instances enable us to decide as to the true condi- tion. If the appendix is situated in the small pelvis and has given rise to the formation of an abscess in this local- ity the decision of the question whether the abscess is due to appendicitis or to oophoritis is extremely difficult and sometimes even impossible. Typhoid fever in exceptional cases may simulate an appendicitis ; the presence or absence of Widal's reaction will serve to differentiate the former. Prognosis. Catarrhal appendicitis affords in most in- stances a favorable prognosis as regards to life. With ref- erence to complete recovery, however, the outlook is by no means bright, for the liability to recurrence of the disease is very great. Inasmuch as an apparently mild form of appendicitis may all of a sudden change its character and assume alarming features, the prognosis should always be made with a certain reserve, even in this class. The purulent form of appendicitis must be regarded as a very serious disease and gives quite an unfavorable prognosis unless timely surgical intervention is adopted. The intensity of the symptoms in purulent appendicitis is by no means a correct measure of the gravity of the dis- ease. Experience shows that cases with violent symp- toms, very high fever, and intense pains, etc. , occasionally recover within a few days, the pus rupturing iuto the intes- tine, while apparently mild cases after a few days of sick- ness suddenly develop symptoms of a general septic peri- tonitis with a fatal issue. Diffuse peritonitis is liable to occur between the second and fourth days of sickness, but even later the patient is subjected to numerous risks. Grave complications may suddenly develop even in a pa- tient who is apparently progressing nicely and already convalescent-. Thus purulent appendicitis may give rise to pyopneumothorax, empyema, or purulent pericarditis, APPENDICITIS. 217 and these complications may result in a fatal issue. The prognosis of perforating appendicitis is decidedly less fa- vorable than that of a simple empyema of the appencjix, as in the former septicaemia is liable to occur. After having described the numerous dangers present in the severe form of appendicitis it is consoling to say that spontaneous recoveries are, notwithstanding this, in the majority. With regard to the frequency of spontaneous recoveries Nothnagel gives the following statistics : Among 130 hospital patients he observed 85 complete recoveries, 4 deaths without operation, 30 partial recoveries, and 11 cures after operation. The large number of cases reported by Sahli is also very important in this connection. This author reports the results in 7,213 cases of appendicitis ; 473 cases were operated upon, while 6,740 received only medical treatment. Among the latter 6,194 recovered (91.2 per cent) while 591 (8.8 per cent) died. Sahli further states that of the 4,593 cases which had not been operated upon and in which inquiries had been made with regard to recurrence of appendicitis, 3,635 were cured without any recurrence. Nothnagel says that circumscribed appendicitis is cura- ble in the large majority of cases, and that about eighty per cent recover under simple medical treatment. Among the rest there are still some that can be cured by means of operative procedures. Careful watching of the pa- tient and timely surgical intervention in proper cases may reduce the number of deaths from appendicitis to perhaps five per cent or three per cent. It is, however, impossible entirely to avoid fatal issues, even with the greatest and strictest watchfulness. Aside from accidental complications and from rare cases in which a correct diag- nosis is hardly to be made, there remain instances in which 218 DISEASES OF THE INTESTINES. the peritoneum is diffusely affected quite early without presenting any symptoms. These are the cases which make the prognosis unfavorable and they form the great- est contingent of deaths among patients with appendicitis. The acute septic form with perforation of the appendix is the most dangerous, while the progressive suppurative form is comparatively favorable. Treatment. With reference to prophylaxis the swallow- ing of fruit pits, of very small bones, and coarse, indi- gestible matter in the food was formerly strictly forbidden. Nowadays, however, we know that the above-named sub- stances play no part whatever in the etiology of appendi- citis. Kegulation of the bowels or, more practically speak- ing, correcting constipation has been believed to be of importance in preventing appendicitis. This maxim can likewise not be maintained on the ground of recent re- searches. Regularity of the bowels is in itself of impor- tance, and hence it will be advisable to pay attention to this factor. The only means we possess of preventing an attack of appendicitis is the removal of the appendix. While this suggestion is not generally practicable, for it requires an operation which is not entirely without risk, it may, however, be carried out in cases requiring a lap- arotomy for other diseases, provided that this additional operation does not demand too much time. The medical treatment of appendicitis consists in abso- lute rest of the entire body, especially of the intestinal tract, and in appropriate diet. The patient must be kept strictly abed from the commencement of the disease until it is entirely over. He should not be permitted to leave the bed for a moment. He must lie perfectly quiet ; even turning from one side to the other should be avoided, or if done, performed with the greatest care. In taking nour- APPENDICITIS. 219 ishinent the head may be slightly raised ; the urine should be voided in a glass, and an evacuation of the bowels should take place in a bed-pan. During this act the pa- tient must be forbidden to strain or exert himself in any way. The utensils needed must be handled by the nurse, who must also attend to the cleansing of the patient. The principle of rest must also be applied with reference to diet. During the first few days of illness there should be either total abstinence from food (only small quantities of water being given now and then), or liquid food in small portions. Thus strained barley water, or this with the addition of a little milk, oatmeal water and rice water given in the same way, chicken soup, very weak tea. In the very severe forms of appendicitis, especially when per- foration has taken place, or when symptoms of ileus and fecal vomiting are present, absolute abstinence from food and also drink is necessary. In accordance with Penzoldt, Ewald, and Boas, rectal feeding appears to me to be con- traindicated in these cases and the only way of supplying the organism with nutritive material is a subcutaneous injection of saline solutions, sugar solutions, and also per- haps small subcutaneous injections of olive oil. Small pieces of ice may from time to time be given to the patient. He must, however, keep the ice in his mouth until it melts before swallowing. This often alleviates the nausea and retching. The first two or three days of sick- ness being over, the patient may be allowed to have milk, an egg beaten up in bouillon or milk, in addition to the above- named food. The diet should be kept up in this way until the pains and fever have entirely disappeared. At this pe- riod soft-boiled eggs, crackers, small portions of meat (squab) or chopped beef may be given, and still later mashed potatoes, bread and butter, and light vegetables added. 220 DISEASES OF THE INTESTINES. Medicaments. The use of cathartics is mentioned here only in order to condemn it. Even injections into the bowels should not be administered too frequently nor in large quantities. A small enema of one-half to one pint of water or one-half pint of olive oil may occasionally be given. The remedy par excellence in the treatment of appendici- tis is opium. Its use was originally recommended by Eng- lish physicians (Graves, Stokes) and later by French clin- icians (Petriquin, Grisolle); in Germany this remedy found a fervent advocate in Volz and in America in Alonzo Clark. During the last decade the administration of opium has met with great opposition especially on the part of many surgeons. Their reasons against the use of this remedy are, first, that opium masks the true picture of the disease, and secondly, that it gives rise to paralysis of the intestines. Some of the foremost clinicians, Nothnagel, Penzoldt, Ewald, Sahli, Boas, and others, are even nowadays en- thusiastic admirers of the opium treatment. The prin- cipal element of importance of opium as a remedy is its action in lessening or arresting the peristalsis of the in- testine, and besides in alleviating pain. I myself have always used and still use the opium treatment with great satisfaction. It is of course understood that the opium should be given only in sufficient amount to allay the pain, while excessive doses should be avoided. As soon as the active stage of the disease is passed, the opium must be entirely discontinued. The best way of administering it is that suggested by Sahli . Ten or fifteen drops of tinc- ture of opium are at first given every hour until there is a decided subsidence of the pain. Then five to six drops are given every two or three hours until the pains disap- pear completely. As soon as there is an exacerbation an- other large dose is administered, but if the patient is entirely APPENDICITIS. 221 free from pain 110 opium is given. If the administration of the drug excites nausea or vomiting, it may be given in the form of a suppository : % Extr. opii 0.05 Ol. theobrom , 1.00 M. f. supp. One suppository every four hours until subsi- dence of pain. Or belladonna extract, 0.005-0.01 gm., may be added to the opium in the same suppository. Boas recommends the administration of opium subcuta- neously. (Extr. opii aquosi sterilis. 0.3 to 10.0 water; 1 Pravaz syringe [1 gni.] three times daily.) In cases in which the pains are very intense and a quick action is desired, morphine may be administered subcuta- neously in doses of gr. to ^. The action of this remedy is, however, not so satisfactory as that of opium, as it has but a very slight influence in diminishing the peristalsis. When morphine is used, opium should be given in addition. Poultices. The application of ice over the painful area is often beneficial at the beginning of the disease, espe- cially if the temperature is quite high and symptoms of peritoneal irritation are present. If the patient, however, complains of great discomfort from the application of ice, it must be discontinued. In the latter instance a cold Priessnitz poultice may be tried. Cases not accompanied by high fever often derive great relief from the application of a hot-water bag or plain warm poultices. The latter are especially to be recommended in that form of appendi- citis which is called append icular colic of Talamon. Surgical Treatment. The question of operation in ap- pendicitis is a very live one nowadays and is being every- where discussed. The medical profession has not yet come to a unanimous conclusion in regard to it. Surgical treat- 222 DISEASES OF THE INTESTINES. merit of appendicitis originated in this country, Dr. Regi- nald Fitz of Boston having done the first operation for this purpose, and it has been practised and perfected here more than anywhere else. It is therefore quite natural that we find many more advocates of surgical intervention in America than abroad. As a general rule the majority of sur- geons frequently recommend operative intervention, while the larger number of physicians reserve -the surgical treat- ment only for a small number of grave cases of appendicitis. Fowler, Morris, Beck, Deaver, Murphy, and others in this country and Legueu ' in France urge surgical treat- ment in every case of appendicitis. Legueu says : " Ap- pendicitis belongs to surgery." . . . "There is no medi- cal treatment of appendicitis." . . . "Every appendicitis must be operated earl}*." C. Beck 2 expresses himself in the following manner : " No matter how mild the clini- cal picture of appendicitis appears, even if it promises a quick temporary recovery, the operation is always justi- fied. Inasmuch as the gravity of infection can never be esti- mated at the beginning, it appears wiser to look upon every case of appendicitis as serious. Of two evils one should choose the lesser, and the lesser one here means opera- tion." In his article Beck makes the two following asser- tions : " 1. Appendicitis is a surgical disease and should be treated surgically as soon as diagnosed. 2. So long as no physician is able to estimate the gravity of the bacterial infection at the commencement of the disease or to foresee the course which the appendicitis will pursue, whether mild or grave, the safest treatment consists in the early removal of the appendix." 'Felix Legueu: "Traitment de 1'Appendicite. " Suite de Mono- graphics Cliniques, 1899, No. 80. ; C. Beck : "Appendicitis. " Volkmann's Sammlung klinischer Vor- trage, No. 221, Sept.. 1898. APPENDICITIS. 223 Many surgeons, even in this country, however, do not take so radical a view as the above writers. Thus Willy Meyer,' Charles McBurney, W. T. Bull, A. J. McCosh and F. Hawkes, 2 and others do not recommend the early opera- tion in milder forms of appendicitis. McCosh and Hawkes express themselves in the following manner with regard to the necessity of operative interference : " When the presence of pus is assured, the sooner operation is done the better. Also there are cases which begin and continue for twenty - four or forty-eight hours with such severity that a judicious mind must conclude that operation is demanded. So in the chronic and relapsing cases where the symptoms have con- tinued for months with such severity and have recurred so frequently as to subject the patient to a life of semi-in- validism, no wise surgeon can counsel any other plan of treatment than removal of the diseased appendix. Likewise when the patient has suffered from three or more attacks the offending organ should be removed, for other attacks will in all probability follow. The same indication for operation also exists in our opinion if a patient has suf- fered from two attacks within a year or even two years." ..." The view which we take is that operation is not necessary in every case of appendicitis. We believe that not infrequently patients recover, and recover permanent!}', from one attack of appendicitis, and that in a certain num- ber of cases, provided a careful watch is kept, operation is not necessary. On the other hand, we acknowledge that many cases which did not appear to be serious have been allowed to die when they might have been saved l>y opera- tion." 1 Willy Meyer : "When Shall we Operate for Appendicitis?" Medi- cal Record, February 29. 1896. s A. J. McCosh and F. Hawkes : " The Surgical Treatment for Appen- dicitis. " The American Journal of the Medical Sciences, May, 1897. 224 DISEASES OF THE INTESTINES. Willy Meyer, who was among the first to recommend the removal of the appendix during the free interval, comes to the following conclusions in his paper already men- tioned: "1. In case of diffuse perforative appendicitis the operation must always be done at once. 2. In cases of acute appendicitis the patient always needs careful obser- vation. If the pulse goes above 116 and 120 and has a tendency to stay there, the indication for an operation is given. In cases of doubt the operation is better than waiting. In cases of subacute attacks of appendicitis, also after the first severe attack from which the patient recovers without immediate operation, the appendix should be re- moved. The appendix once inflamed has to be looked upon as a diseased organ which is very apt to give repeated and more serious, even fatal, trouble in the future." Among the German surgeons Sonnenburg, and especially Riedel, ' are advocates of early surgical intervention in the grave forms of appendicitis. Riedel says : " As soon as the temperature reaches 101, the pulse 100, the immediate removal of the appendix is indicated. ... A tumor which has developed, accompanied by fever and an acceleration of the pulse, is always an indication for immediate opera- tion." R. Stein 2 and Henry J. Wolf, 3 in papers read quite recently before the German Medical Society of New York, urged early surgical intervention in all the graver forms of appendicitis. With Penzoldt, Nothnagel, Ewald, Boas, and others I would give the following indications for surgical interven- tion in this disease : 'Riedel: "Ueber die sog. Frilhoperation bei Appendicitis puru lenta resp. gangraenosa." Berliner klinische Wochenschrift, 1899, 33 und 34. *R. Stein: Deutsche med. Wochenschr., 1899, p. 440. 3 H. J. Wolf: New Yorker medicinische Monatsschrift, 1899. APPENDICITIS. 225 1. Diffuse peritonitis in consequence of perforation of the appendix demands immediate operation. As a rule the following symptoms will be found : Sunken and drawn fea- tures, cyanosis, a small and very frequent pulse, an increase of the painful area, often also a bloated condition of the abdomen. 2. Whenever an appendicular abscess showing fluctua- tion is present, an operation should be performed. 3. If the protracted course of the disease points to the existence of an abscess, giving rise to slight septic symp- toms, an operation should be undertaken. While in these three groups there can be no hesita- tion in recommending the operation, in the following groups the necessity of surgical intervention must be con- sidered and decided in each individual case. 4. (a) If the rational treatment does not produce any im- provement in the course of three to five days, the symptoms persisting in undiminished severity or becoming even more pronounced, an operation may be resorted to. (b) A sud- den rise of temperature lasting over twenty-four hours, after the first few days of sickness, is also an indication for operation, (c) A very frequent pulse, not corresponding to the degree of fever, is another symptom which justifies the consideration of an operation, (c/) If the tumor con- tinues to increase in size after the fifth day of sickness, an operative treatment should be considered. 5. The removal of the appendix should be undertaken: (a) In all cases of appendicitis in which after recovery the pain in the right iliac region persists for a long time (sev- eral months) ; (b) in recurrent appendicitis if the attacks have been quite severe or if they have followed each other at short intervals. 15 CHAPTER IX. INTESTINAL OBSTKUCTION. (Acute and Chronic.) Introductory Remarks. By intestinal obstruction is un- derstood a great variety of conditions which, although unlike in character, have yet the common feature of me- chanically causing an obstruction to the passage of con- tents along the intestine. Leichtenstern ' distinguishes the following three groups with regard to the causation of the intestinal obstruction : 1. Occlusion* due to pressure from without or com- pression of the intestinal lumen in the full sense of the word. To this group belong incarcerations of the intes- tines in apertures, in slits, and in hernial openings; strangulation by pseudo-ligaments, the vermiform proc- ess, and diverticula ; compression by tumors, by the mes- entery, or by displaced abdominal organs. Rotations of the intestinal tube around its axis (torsions) and forma- tion of knots also belong to this category. 2. Occlusion from within the intestinal lumen (obtura- tion). The obturation may be produced either by gall stones, enteroliths, foreign bodies, hardened fecal masses, or by neoplasms of considerable size, especially polypi. Intussusception (involution of one coil of the bowel into another) also belongs to this class. 'Leichtenstern: " Verengerungen, Verschliessungen und Lagever- Snderungen des Danns." Ziemssen's " Handbuch der speciellen Patho- logie und Therapie," B'd. vii., Leipzig, 1878. ACUTE OBSTRUCTION. 227 3. Occlusions which originate from factors within the intestinal wall and causing narrowing of the lumen either directly or indirectly. Constriction may occur either in circular form (strictures) or as a result of flexions. Ob- structions developing after chronic peritonitis, distortions, and angular bends of the intestine, cicatricial stenoses as well as those produced by neoplasms, belong to this class. Notwithstanding the diversity and great multiplicity of the anatomical factors causing stenoses and obstructions of the intestines, the clinical picture and the consecutive le- sions which they evoke greatly resemble each other. It will therefore perhaps be practical to give first the clinical picture of complete obstruction of the bowels (ileus) and of stenosis of the intestine, and then to discuss the differ- ent anatomical causes and also the differential diagnosis. ACUTE INTESTINAL OBSTRUCTION. Synonyms. Ileus, miserere, passio iliaca. Definition. An acute stoppage of the passage of the in- testinal contents. This may be caused either by a me- chanical occlusion at a certain part of the intestinal canal (mechanical ileus) or by an entire absence of motor power in a portion of the bowel (dynamic or paralytic ileus) or sometimes by both (mechano-dynamic ileus). Etiology. The etiology of ileus is quite complicated, and it will be best to analyze separately the different factors producing it. Compression of the Intestines. Compression of the in- testines can occur: (1) by strangulation through adhesions, bends or pseudo-ligaments, by Meckel's diverticulum, by normal structures abnormally attached, by slits and aper- 228 DISEASES OF THE INTESTINES. tures in the mesentery and omentum, and by incarcerations into hernise; (2) by torsions (volvulus) ; and (3) by tumors from without. The primary factor in producing isolated adhesions (bands or pseudo-ligaments) is a preceding localized peri- tonitis. In some cases these bands may have been con- genital and due to intra-uterine peritonitis. The band may have the form of a firm fibrous cord or it may be very slender and may appear as a tough, rigid thread. Occa- sionally it may be of comparatively large size. Seldom the constricting ligament has the appearance of an actual band, having a width of half an inch or more. The strangulation of the intestine by an isolated peritoneal adhesion takes place in two ways : first, the intestine may be strangulated under the band as beneath a shallow and narrow arch; secondly, it may become snared and con- stricted by a noose or knot formed by the false ligament itself. Strangulation from bands occurs when these are com- paratively short and tightly stretched over a firm surface. The arch beneath which the implicated bowel passes is usually large enough to admit one to three fingers. Stran- gulation by a noose or knot requires the presence of a long false ligament which must lie loose and free in the abdom- inal cavity, being attached only at its two ends. The most common way in which a coil of intestine becomes snared is where a lax band forms a ring or spiral between its fixed points. Through this ring a loop of the small intestine slips ; the protrusion becoming larger the implicated coil cannot free itself from the noose and is strangulated. Strangulation by the formation of a knot is described by Leichtenstern in the following manner : " There are several kinds of this knotting. The most frequent is the follow- ing : A long and loose ligament is fastened at one end to ACUTE OBSTRUCTION. 229 a loop of the small intestine, and hangs in the form of a simple coil (Fig. 29); if the top of the intestinal loop passes directly through the coil a simple knot is formed about the piece of the intestine, as is shown in Fig. 30. It is evident that the same result can be produced by the FIG. 30. FIG. 31. FIG. 32. FIG. 29. PIGS. 29-32. Types of Constricting Peritonitic Bands. (After Leichtenstern and Treves.) coil being drawn over the top of and around the intestinal loop. Another and rarer form of knot is produced as fol- lows : A long and perfectly loose false ligament forms a simple coil between its points of attachment. If now one leg of the so-called primary noose passes through it we have a knot like that shown in Fig. 31, and if now the 230 DISEASES OF THE INTESTINES. intestinal loop passes directly through (Fig. 32), it be- comes firmly caught and strangulated. A common char- acteristic of all described knots is that when the strangu- lated intestine is freed, the ligament can immediately be drawn out straight." Strangulation by Meckel's Diverticulum. Meckel's diver- ticulum is due to the persistence or incomplete oblitera- tion of the vitelline duct. Most commonly it exists as a blind tube, given off from the ileum. Its length is about three inches. As a rule, it is cylindrical in shape, with a conical extremity. Occasionally it presents a globular shape and is then called "clubbed." Meckel's diverticle is always single and is attached to the ileum one to three feet above the ileo-cgecal valve. As a rule, the end of the diverticulum is free. In some instances it is attached to the umbilicus or to the abdominal wall. Sometimes the end attached to the abdominal parietes may give way and form fresh adhesions with some points of the peritoneal surface. The latter occurrence is of great importance with reference to strangulation of the intestine, which frequently takes place under these conditions. By means of the new adhesion of the diverticulnm a loop is formed in which some portion of the intestine is liable to engage. Another possibility for strangulation by the diverticulum is afforded when its end is free and club-shaped. The diverticulum forms a ring into which its own free end projects. A loop of the intestine entering the centre of this ring may push the clubbed end of the process before it and so tie the knot, thus leading to obstruction. Again the diverticulum may surround the pedicle of an intestinal loop in such a way as to encircle it with a single knot (see Figs. 33, 34, 35). In a similar manner as Meckel's diverticulum some nor- mal structures may act when they are abnormally attached. ACUTE OBSTRUCTION. 231 I Thus the vermiform appendix may become adherent to some point of the neighboring peritoneum and so form an arch under which a loop of the in- FIG - ^ f Fl - 3 *- testine may b e strangulated. The Fallopian tube may likewise become adherent to the adjacent peritoneum situ- ated in the iliac fossa and thus form an arch in- to which a por- tion of the intes- tine may slip and become incarcer- ated. Other in- ternal organs ab- normally at- tached may form similar traps for intestinal stran- gulation. Of great clini- cal importance is the strangulation of the intestine in slits and apertures of the mesentery or omentum. These may be either congenital or of traumatic origin. Similar to the action of slits in the production of strangulation are also the various internal herniae (her- nia duodeno-jejunalis, hernia retroperitonealis anterior, FIG. 35. - FIGS. 3^-35. Knotting of a Meckel's Divertlculum which has a Button-like Swelling of its Extremity. (Treves.) 232 DISEASES OP THE INTESTINES. hernia intrasigmoida, hernia bursse omentalis, formed by the foramen of Winslow, diaphragmatic hernia). In all these cases the mechanism of the obstruction is as follows : A coil of gut may be driven with sudden severe force beneath the band or through an aperture and become practically strangulated at once, as is often the case in strangulated hernia. There being no natural force to drive the coil out of its place of imprisonment, it remains firmly gripped. In other cases the involved intestine may not be strangulated at first, but the band pressing upon the mes- enteric vessels produces a congestion in the implicated coils, which become engorged and distended by an in- creased accumulation of gas, and thus complete strangu- lation is the result. In other cases, again, the final cause of a strangulation is a twisting of the bowel. All the va- rieties of intestinal strangulation just mentioned occur in the small intestine, the lower portion of the ileum being principally affected, less frequently its upper portion or the jejunum. The occlusion may in some cases be due to kinking of the intestine through a band attached to the bowel and dragging upon it. Adhesions may also obstruct the bowel, compressing its lumen. This occurs when false mem- branes are situated around the bowel and have undergone shrinking. They then compress the intestine seriously and narrow its lumen. The same process of shrinking may also effect an obstruction of the bowel if it takes place in the mesentery after inflammation. Volvulus. By the term volvulus is understood an obstruc- tion of the bowel by a twist about its mesentery, or its own axis, or the intertwining of an intestinal coil within another. Twisting of the bowel occurs most often in the sigmoid flexure. The usual cause of this trouble is chronic consti- ACUTE OBSTRUCTION. 233 pation, for in this condition the flexure fs more or less constantly distended. Its walls become partly paralyzed and hang down into the pelvis, like an inert heavy mass, being filled with fecal matter. Traction is thereby exerted upon the mesocolon and a loop is soon formed. A twist- ing of the latter is brought about either by some displace- ment of the bowel or by a sudden change in the position of the body. The ascending colon, caecum, and the small intestine may also be affected in the same manner, al- though less frequently. Intertwining of the intestine is here more often met with. Obturations of the Intestine. Intestinal occlusion often takes place in consequence of obturation of the lumen of the gut through foreign bodies lodging therein. Accumu- lations of fecal matter may give rise to such an occurrence. The hard fecal tumor is then situated either in the caecum or in the colic or sigmoid flexures. In these cases chronic constipation has existed for a long time. Gall stones, although rarely, give rise to intestinal oc- clusion. In order to do this they must be of considerable size. " The puzzle as to how the camel could go through the eye of the needle, i.e., how these enormous gall stones could reach the bowel, has been solved, by the assumption on fair evidence that an ulcerative process opens the way from the gall bladder to the bowel, though doubtless very large stones occasionally find their passage through the ducts" (E. D. Ferguson 1 ). In a similar manner enteroliths may also cause obstruc- tion of the bowel. This happens especially if an entero- lith situated in an intestinal diverticulum has been dis- lodged and found its way into the canal of the gut. 1 E. D. Ferguson : Transactions of the New York State Medical Association, 1898, p. 233. 234 DISEASES OF THE INTESTINES. Foreign bodies which have been accidentally or inten- tionally swallowed may under favorable conditions reach some part of the bowel and here obstruct the lumen. This will occur if the foreign body is of considerable size, or if it is not smooth but provided with sharp points. The latter catch in a fold of mucous membrane and prevent its further passage. The most varied substances have thus been found to be the cause of intestinal obstruction : mar- bles, stones, coins, glass stoppers, corks, spoons, knives, forks, keys, needles, pins, buttons, false teeth with the plate. Kernels of fruit like cherries, prunes, etc., may accumulate in the bowel and by means of fecal matter be kept together, forming a large conglomeration, completely obstructing the canal. Recently Murphy's button has also been found in a few instances to cause obstruction of the bowel. Intestinal parasites (tapeworms, ascaris lumbricoides) , if present in large numbers, may also form a mass obstruct- ing the canal. This occurs especially after a vermifuge has been administered and the dead parasites have re- mained within the canal. Similar to the action of foreign bodies are also tumors (polypi, fibroma, myoma, etc.) connected by a pedicle with the intestinal wall, filling up its lumen. Intussusception. Intussusception or invagination means the prolapse of one part of the intestine into the lumen of an immediately adjoining part. An intussusception shows in a vertical section six layers of intestine, three on either side of the central canal, which are more or less parallel to one another. The arrangement of the layers is such that mucous membrane is in contact with mucous membrane, and peritoneum with peritoneum. On transverse section the invaginated mass shows three concentric rings of bowel. ACUTE OBSTRUCTION. 235 The external of the three layers is called the intussusci- piens, the sheath, or the receiving layer. The innermost cylinder is called the entering layer and the middle one the returning layer. The latter two together form the intus- susceptum. The neck of the intussusceptum is at its up- per part where the returning layer joins the sheath. In case the intussusception lasts for some time the se- rous surfaces of the gut touching each other may become glued together and ultimately adherent. This will prevent the disengagement of the invaginated portion, while its fur- ther passage into the other bowel will not be interfered with. The mesentery always participates in the invagiua- tion and becomes more or less compressed and wedged in by the sheath. The whole mass of a simple intussuscep- tion may in its turn become invaginated and give five in- stead of three coats, or even seven if the process is re- peated, so that the upper edge of the intussuscipiens is rolled over like a cuff. These double and triple intussus- ceptions are comparatively rare. With regard to the mechanism of intussusception Noth- nagel's experiments on animals have proven of greatest value. According to this writer intussusception may be due either to a localized spastic contraction of a portion of the bowel or to a total paralysis. The normal gut im- mediatety below the contracted part slips upward to a slight extent over this strongly contracted and greatly narrowed portion, and imagination is thus produced. Again if a segment of the bowel is paralyzed, the gut lying immedi- ately below it, on contraction will slip into the paralyzed portion and thus an invagiuatiou may arise. Intussusception may take place at any point within the entire small and large intestines. Over fifty per cent of the cases consist of the imagination of the ileum into the 236 DISEASES OF THE INTESTINES. colon. With regard to the remote cause of intussuscep- tion Treves ' has examined a number of reported cases and found it in one hundred examples of intussusception dis- tributed as follows : 1. No evident exciting cause 62 per cent. 2. Diarrhoea, dysentery, enteritis, marked irregularity of the bowels 8 " 3. Polypi 5 " 4. Ingesta 5 " 5. Injuries and exposure to cold 5 - 6. Certain acute and chronic ailments which may or may not have had a concern in the etiology, such as typhoid fever, whooping-cough, measles, scarlet fever, smallpox, cholera, and hernia ; with these may be included pregnancy and labor 15 a Total 100 This clinical form of intussusception must not be con- founded with agonal i)itussusceptio)i, which, as the term indicates, occurs shortly before death and is purely of anatomical importance. The agoual form of intussuscep- tion is sometimes found multiple and is met with fre- quently at autopsies of children who have died from affec- tions of the brain. Patholoyical Clianges. The lesions which are encountered in acute ileus, no matter what be its origin, are the follow- ing: The intestinal coils above the occluded part of the bowels present a quite different appearance from those below. The former are distended, filled with gas and ill- smelling feculent contents; and this ectatic condition is the more pronounced the nearer they are situated to the occluded part. If the occlusion lies in the jejunum or ileum, the distention will involve the entire upper portion of the small intestine and also the stomach. If, however, the stoppage is situated within the colon, the dilatation 'Treves: "Intestinal Obstruction," p. 211. ACUTE OBSTRUCTION. 237 will at first occupy that portion of the colon situated be- tween the ileocaecal valve and the obtruded spot, while the small intestine may remain unchanged, the ileocsecal valve acting in its usual way and thus preventing an over- flow of the contents of the colon into the small intestine. Under such circumstances the dilated portion of the colon may attain considerable size, resembling almost the stom- ach. After the condition has lasted a few days, however, the ileocaecal valve ceases to functionate and now the con- tents of the colon overflow the small intestine and the stomach and these organs become also overfilled and dis- tended. The portion of the intestine situated below the occlusion is empty and contracted. The intestinal coils above the occluded spot are usually engaged in very active peristaltic movements, which repre- sent an attempt of nature to overcome the obstacle. After these peristaltic motions have lasted a few days, a paralytic state of the intestines supervenes. The intestinal niucosa situated near the occlusion is subjected to great mechanical and chemical irritations due to the constant presence of considerable amounts of decomposed material, and thus grows intensely inflamed. Often ulcers develop which may penetrate the wall of the bowel and cause fatal peritonitis. In rare instances after such a perforation, adhesion to neighboring intes- tinal coils may occur and give rise to fecal abscesses and abnormal communications between different intestinal segments. By means of a similar process an opening may be established between the intestine and the abdominal walls in such a manner that the fecal matter finds an exit here (anus praeternaturalis). Localized or general peritonitis is thus often present in cases of intestinal obstruction. Serous, bloody, or puru- 238 DISEASES OF THE INTESTINES. lent exudation is frequently found in the abdominal cav- ity. The anatomical lesions are most pronounced in the immediate vicinity of the occluded intestine. This is due not only to the stoppage of the intestinal contents but also to interference with the circulation of the gut produced by the same factors which have caused the obstruction. Nu- merous large and small mesenteric veins become com- pressed, thus causing congestion and hemorrhages. The intestinal walls appear infiltrated with blood, showing ec- chymoses at various places, and may even appear dark red. In the neighborhood of the occlusion the intestine may be covered with black curdled blood in the form of a membrane. Its walls become brittle and gangrenous. Symptomatology. The symptoms of acute intestinal ob- struction appear either suddenly or after slight disturb- ances have existed for a few days, as for instance diar- rhoea, constipation, feeling of uneasiness. In some instances the history of an exciting cause is given. Thus a severe blow on the abdomen, violent bodily exertion, a cold, a too copious meal, or a strong laxative. The patients are first seized with violent abdominal pains, sometimes of a crampy character. The pain may be felt at first at a certain definite spot within the abdo- men, while later it becomes more diffuse. In other in- stances the patient is unable to localize the pains dis- tinctly. Occasionally the area around the navel is given as the seat of the pains, while in other cases they are re- ferred to the entire abdomen. The pain usually exists un- interruptedly, though it may show exacerbations from time to time. Soon after the occurrence of these colicky pains eructations of gas and then vomiting appear. At the be- ginning gastric contents are ejected, later bile, and finally offensive feculent material is brought up. The latter usu- ACUTE OBSTRUCTION. 239 ally has a yellowish-brown color, is liquid, and contains only very fine, small, solid particles suspended in the fluid. At this period the eructated gases have a fetid odor and hiccough almost constantly distresses the patient. After the act of vomiting the patient may feel somewhat relieved for a short while, but soon there is a return of the severe symptoms. Almost simultaneously with vomiting, meteorism of the abdomen ensues. The passage from the rectum is entirely stopped and there is no evacuation either of fecal matter or of flatus. The meteorism may involve either a certain region of the abdomen or the entire cavity. The tympani- tes gradually increases and a feeling of tension becomes more and more pronounced. The diaphragm is soon pushed upward by intestinal coils filled with gas in such a manner that the liver dulness may be absent from the entire right thoracic cavity. Dyspnoea supervenes; the breathing becomes accelerated and superficial, assuming the thoracic type. The pulse is small and frequent. The extremities are cold, the skin is covered with perspiration, the face is pale, bearing the expression of utmost anguish, the eyes are sunken, dryness of ihe throat and extreme thirst exist, and the patient is barely able to use his voice. These extremely painful and tormenting symptoms persist and the patient succumbs unless there is a change in the course of the disease remaining conscious until the end. After having given a general description of the clinical picture of ileus it will not be amiss to discuss each symp- tom separately. 1. Pains. Pain, the most constant and conspicuous symptom of intestinal obstruction, depends upon several conditions. It is usually due, first, to the injury inflicted on the peritoneum and the intestinal walls in consequence 240 DISEASES OF THE INTESTINES. of the strangulation; secondly, especially at a somewhat later period, to the tumultuous and increased irregular peristaltic movement of the intestines. These movements above the site of obstruction are of a very intense charac- ter and produce " colic " as well as exacerbations of the pains which occur at certain intervals. The intensity of the pain depends upon the degree of excitability of the individual, upon the state of the sensorium, upon the ex- tent of the intestine and peritoneum involved, and upon the severity of the occluding lesion and the rapidity of its occurrence. Later on the pain is influenced by the dis- tention of the gut and by the presence or absence of peri- tonitis. At the commencement of the disease the pain is fre- quently not aggravated and sometimes relieved by press- ure. Later, however, the pain is considerably increased by even slight pressure, the cause of this being the pres- ence of peritonitis. According to Treves, 1 the pain is constant, although liable to periodical exacerbations in cases of complete ob- struction. In cases in which the obstruction is but par- tial the pain is distinctly intermittent, and the patient experiences intervals between attacks of pains during which he is free from suffering. The pain as a rule grows more intense with the progress of the disease. There may be, however, a diminution in the severity of the pain for a short period before a fatal issue, caused by a collapse, paralysis of the intestine, rupture or perforation of the bowel, or by a diminished activity of the sensorium. Treves has pointed out that no matter in what part of the small intestine the obstruction is situated, the pain arising therefrom is usually referred to the region of the umbilicus. P. Treves: "Intestinal Obstruction," Philadelphia, 1884. ACUTE OBSTRUCTION. 241 If the obstruction is localized in the large bowel, then the pain may be experienced, especially at the beginning of the disease, at the seat of the lesion.; later, however, the pain may assume a more diffused character or may be fait at other regions of the abdomen. This is the reason why only the initial pain is of some diagnostic significance with regard to the seat of the lesion. 2. Vomiting. Vomiting is almost always present. At the beginning of the disease it is of reflex origin due to the irritation of the peritoneum ; later on it must be as- cribed principally to the irregular, strong, peristaltic con- tractions of the intestines. The appearance of fecal vom- iting was believed by the old writers to be a sign that the obstruction was situated in the large bowel. Nowadays, however, it is generally known that this symptom is often present in cases in which the obstruction is situated in the ileum or even in the jejunum. The reason of absence of putrefactive processes in the intestinal contents normally is the rapidity with which they are moved farther on along the canal until they reach the large bowel. In obstruction, however, the peristaltic contractions are much slower and thus putrefactive processes develop even in the small bowel. In order to explain the mechanism of stercoraceous vom- iting a reversed peristaltic or antiperistaltic motion of the intestines was formerly assumed. Of late, however, the mechanism of fecal vomiting as expounded by Hagueuot ' as early as 1713, is now generally accepted. According to this author, stercoraceous vomiting takes place in the fol- lowing manner : Above the occluded intestine there is an accumulation of more or less liquid intestinal contents in 1 Haguenot : "Memoire sur les Mouvernents des Intestius dans la Passion Iliaque. " Histoire de 1' Academic Royale des Sciences, Paris. 1713. 16 242 DISEASES OP THE INTESTINES. considerable quantity; the bowels being distended with large amounts of gas are under constant pressure, which is increased after each inspiration and especially after energetic contraction of the abdominal muscles, occur- ring for instance during the act of vomiting. Under the influence of pressure the stagnant liquid contents are re- gurgitated from above the occluded spot into places in which there is less resistance and thus reach the duo- denum and the stomach. Here they irritate the mucous membrane and cause vomiting. This theory is perfectly in accord with the circumstance that in stercoraceous vomiting mostly liquid or sometimes semi-liquid contents are evacuated, but never solid fecal matter ; for even in obstruction of the colon the fluid will be moved farther upward while solid particles will remain in the lower portion of the bowel. Vomiting of formed fecal matter is a very rare occurrence, and must be ascribed to an existing fistulous opening between the colon and stomach. 3. Constipation. Constipation almost always exists and is very obstinate. After injections, very rarely spontane- ously, there may be a slight movement of the bowel con- sisting of the fecal matter lodged below the occluded spot. In some rare instances a catarrhal condition may exist in the segment of the bowel below the obstruction, and the patient then may rather have diarrhoea combined with tenesmus. Of greater significance than the absence of stools is the inability to pass wind through the anus. The passage of flatus is a sure sign that the permeability of the intestine has been re-established. 4. Meteorism. Meteorism is the result of increased for- mation of gas developing in consequence of putrefactive processes as well as of diminished absorption. According to Zuntz, the absorption of intestinal gases into the blood ACUTE OBSTRUCTION. 243 takes place only when the circulation is in good working order. Meteorism thus indirectly points to a disturbed circulation which is often found in cases of incarcerations. If meteorism is absent the absorption of gases must be assumed to take place as rapidly as their formation. Me- teorism may be at first present at a certain circumscribed spot of the abdomen and later become more diffuse. If the place at which it first appears can be distinctly defined, this is of diagnostic importance with regard to the location of the occlusion. If the occlusion is in the large bowel the portion situated between it and the ileocaecal valve will become considera- bly distended with gas. Thus a protrusion of the right side of the abdomen will be noticed when the obstruction is at the right flexure. If the obstacle is situated in the rectum there is at first a protrusion of the left side of the abdomen and later the tympanites will involve the portion of the abdomen situated above the navel (course of the transverse colon) . In some instances, however, obstruction of the rectum may be acompanied by more or less general meteorism. This is especially the case after the disease has lasted some time ; for then, as a rule, the resistance of the ileocaecal valve is overcome by the gas pressure and it remains more or less patent in such a way that the gases easily penetrate the small intestine. In occlusions affecting the duodenum or the upper part of the jejunum the meteorism as a rule involves the upper half of the abdomen, and remains confined to this area. After vomiting there is usually a perceptible decrease of the protrusion for a short while. If the meteorism has lasted for some time and is in- tense, the abdomen assumes a barrel shape. This is espe- cially found in cases in which the distended intestinal coils 244 DISEASES OF THE INTESTINES. are already paralyzed. The accumulation of gas can now go on without encountering much resistance and thus do great harm. The diaphragm is then pushed upward. The lungs as well as .the heart become compressed. Stomach, liver, and bladder are compressed by the intestinal coils filled with gas lying upon them. In a similar manner the large veins (vena cava, vena portae, etc.) are subjected to the same disturbance. Thus the function of many impor- tant vital organs is interfered with and impaired to such a de- gree, if this condition persists, that a fatal issue may occur. 5. Collapse. The diverse symptoms of shock which ap- pear in a marked degree in cases of ileus must be ascribed to the sudden damage inflicted upon the peritoneum and intestinal wall by the strangulating agent. The mechani- cal irritation involves first the splanchnic nerves, and through them the circulatory apparatus. As a conse- quence there are a lowering of the temperature of the sur- face, cold sweats, lividity of the extremities, anaemia of the brain, and a small and rapid pulse. The degree of the collapse depends upon the disposition of the patient, upon the suddenness of the strangulation, and upon the amount of peritoneum or of intestine involved in the lesion. The gravest amount of shock is met with in cases in which a considerable segment of the intestine is suddenly strangu- lated and an injury thus abruptly inflicted upon an exten- sive nerve area. As a rule, the shock met with in cases of obstruction of the small intestine is much more pronounced than in cases in which the obstruction is situated in the large bowel. The reason for this is the greater supply of nerves and the greater activity of the small intestine as compared with the large bowel. The nerves of the small intestine are also more directly associated with the great sympathetic ganglia of the abdomen. ACUTE OBSTRUCTION. 245 6. The Decrease of the Amount of Fluid in the Blood. In intimate connection with the disturbance of the nerves and circulator}' functions just described is the decrease in the amount of fluid in the blood. This is due to increased secretion in the intestine with absence of absorption, to vomiting, and to increased perspiration. As a consequence there exist dryness of the tongue and a tormenting thirst; the urine is also passed only in small quantities, and in some instances there may even be anuria. Certain symptoms which occur bat rarely and also be- long more or less to this group are cramps, tetanus, coma, delirium, fever. Whether these symptoms are due to auto-intoxication or to other factors (especially the dry con- dition of the blood) is as yet not settled. C'ij^cilct Signs. inspection reveals eitnei ~. svmmetri- cal fulness of the abdomen (sometimes barrel shaped) or a protrusion of certain parts. Thus, as mentioned above, the upper part of the abdomen is protruded when the oc- clusion involves the duodenum or the upper part of the jejunum. The right iliac region is intensely tympanitic if the occlusion involves the hepatic flexure, while the left iliac region is the seat of the protrusion if the occlusion involves some portion of. the descending colon. After the disease has existed for some days there is as a rule a gen- eral marked swelling of the abdomen. Palpation reveals in some cases a circumscribed area which is painful on pressure and thus serves to localize the seat of the disease. This is especially the case very soon after the onset of the symptoms. In the larger num- ber of cases, however, there is a special tenderness either in the region of the navel alone or over the entire abdomen. In comparatively few cases will palpation reveal a tumor situated deeply within the abdomen and in direct connec- 246 DISEASES OF THE INTESTINES. tion with the site of obstruction. This occurs especially in intussusception, strangulation, in occlusions due to com- pression by tumors, and in fecal impaction. After a thor- ough palpation of the abdomen a digital examination of the rectum and also of the vagina should be performed. It is hardly necessary to add that a thorough examination should be made of any existing hernia which may be the seat of incarceration. By means of auscultation either from a distance or in the immediate neighborhood of the abdomen we are often enabled to judge about the state of the intestinal peristal- sis ; for when the latter takes place in a violent manner splashing and gurgling noises are always audible. Percussion is usually of great importance. In general meteorism it permits us to judge of the position of the dia- phragm and liver. If percussion shows a change in char- acter over a certain region of the abdomen during a period of a few minutes, it follows that the condition of an intes- tinal coil lying beneath has undergone some change in its state of fulness, and thus indicates that the bowel is still in active peristalsis. Auscultation and percussion may be used conjointly and serve the same purpose. In case no change whatever is noted on percussion for a very long period of time, there is a suspicion that paralysis of the bowels exists. The liver dulness will be found either partly or entirely absent in almost all cases of perforation, but in Some rare instances even without perforation. In the latter event we must assume that intestinal coils filled with gas are lying above the liver. I have observed such a case with recovery during the last year. Sometimes per- cussion may help to discover existing exudation, dulness being found in the lower part of the abdomen. Examination of the vomited matter will show the pres- ACUTE OBSTRUCTION. 247 ence or absence of fecal elements. The urine is scanty, very concentrated, often contains albumin, and almost al- ways shows an increase of indican and phenol. Kosen- bach's reaction is almost always present. Course. The course of an acute obstruction will depend first upon its location, and secondly upon its nature. The higher up in the intestine the obstruction is situated the more rapid as a rule is the course of the disease. Volvu- lus and strangulation of the intestine are generally accom- panied by a more violent course than is obturation by for- eign bodies. The duration of the disease is not always the same. In some instances the patient dies very soon, a few hours or a day or two after the commencement of the obstruction, of shock and paralysis of the heart. In other instances the disease lasts several days or even a week. In intussusception the duration of the disease is longer, several weeks, showing periods of exacerbations and remissions. If the patient recovers from the collapse and there is a spontaneous re-establishment of the patency of the in- testinal lumen (i.e., the obstruction is relieved, which may happen in cases of invagination, torsion, and obturation by foreign bodies), there is at first as a rule a passage of flatus, which may be followed by a fecal movement of offensive odor. In case of invagination there is often some blood in the evacuation. All the symptoms which have previously existed begin to abate, the fecal vomiting ceases, the meteorism becomes less, and the patient gradually re- covers from his severe illness. In cases in which the intes- tinal obstruction has led to considerable anatomical changes within the lumen of the bowel (ulcers, gangrenous proc- esses, adhesions), after a period of comparative euphoria, symptoms of chronic intestinal obstruction may develop. 248 DISEASES OF THE INTESTINES. In the greater number of cases of acute intestinal ob- struction the latter persists, and the patient, if not oper- ated upon, generally dies of diffuse peritonitis, with or without perforation of the intestines. Even without per- foration, peritonitis may readily develop in consequence of the paralytic state of the intestine; for, according to B6n- necken, ' bacteria can easily penetrate the intestinal wall as soon as the latter is in a paralyzed condition and thus give rise to inflammation of the peritoneum. Circumscribed peritonitis around the occluded part need not give distinct symptoms. General peritonitis, however, always enhances the alarming symptoms already existing. Thus the meteorism increases; the dyspnoea, hiccough, and vomiting become more violent, the pains unendur- able ; the heart begins to give out and pronounced collapse appears. Generally there is a rise of temperature and frequently a fluid exudation within the abdomen is dis- coverable. If perforation of the intestine has taken place, the symptoms just described appear still earlier and with more violence. The abdomen becomes more or less rounded and the diaphragm is pushed upward in the high- est degree. The liver dulness disappears and the pains be- come excruciating. The shock may be so great that the patient becomes unconscious and remains so until death brings relief. Complications appearing during the disease may also be the cause of death. Thus deglutition pneumonia (Schluck- pneumonie) which occasionally occurs by aspiration into the lungs of gastric and intestinal contents during the act of vomiting, or septicaemia in consequence of intestinal per- foration, may develop with embolic processes in the lungs, liver, and other organs. In exceptional cases there occurs 1 Bonnecken : Virchow's Arcbiv, Bd. 120. ACUTE OBSTRUCTION. 249 an adhesion of the occluded intestinal coils to the anterior abdominal wall, and after the gangrenous destruction of the latter as well as of parts of the gut, an anus praeter- uaturalis develops, or a fistulous opening between two por- tions of the intestines, or again a fistula of the intestine into the bladder, uterus, vagina, or stomach. Diagnosis. The diagnosis must deal with the following three points : A. Recognition of the intestinal obstruction. B. Its seat. C. Its etiological factor. A. Recognition of the Intestinal Obstruction. The recog- nition of an acute intestinal obstruction is not difficult if the syinptoiiis described above are present in a marked degree. Thus total absence of passage of fecal matter and flatus combined with symptoms of collapse, meteorism, pains, and fecal vomiting will permit a positive diagnosis of intestinal obstruction. In many instances, however, only a few of the symptoms mentioned are present, and then the diagnosis is quite difficult. The symptom of the great- est diagnostic value is fecal vomiting, although even this alone does not always warrant the diagnosis of obstruction, for it also occurs in intestinal paralysis. The latter con- dition must be especially borne in mind in cases in which there has been a history either of contusion of the ab- domen or of a reposition of incarcerated hernia shortly before the appearance of the disease. The fecal vomiting of hysterics can also be easily recognized, as there are always symptoms present which indicate the true condi- tion. The greatest difficulty in diagnosis lies in the differenti- ation between intestinal obstruction and diffuse peritonitis, especially if the latter accompanies appendicitis. All the symptoms characteristic of intestinal obstruction may oc- cur also in peritonitis. A thorough consideration of all 250 DISEASES OP THE INTESTINES. the symptoms and their differentiation in these two dis- eases will, however, permit a decision. The following points will serve as a guide in this connec- tion : In acute peritonitis there is a rise of temperature at the beginning of the disease, while in intestinal obstruction there is at first no fever or even a subnormal temperature. There are exceptions, however, and a general peritonitis of a grave nature may run its course without any fever but with symptoms of collapse. The pains on pressure over the abdomen are much more intense in peritonitis ; in intesti- nal occlusion the spontaneous pain may occasionally even be relieved by pressure. Fecal vomiting is of compara- tively rare occurrence in peritonitis, and if present it usu- ally appears later than in intestinal obstruction. The me- teorism is diffuse in peritonitis right from the start. It thus causes a general distention of the abdominal parietes. In obstruction the accumulation of gas is at first less pro- nounced, circumscribed, and increases gradually. In peri- tonitis the abdomen becomes tense from the first, while in obstruction, at the commencement at least, it is as a rule soft. The existence of an exudation speaks in favor of general peritonitis. In peritonitis accompanying appen- dicitis there will be besides the above symptoms the phe- nomena characteristic of the latter disease. In some in- stances, however, the differentiation between peritonitis and obstruction will hardly be possible and mistakes are liable to occur. Acute intestinal obstruction is occasional^ simulated by poisoning with arsenic and also by a very severe attack of cholera. In the former condition there will be a history of poisoning, and in the latter the presence of cholera ba- cilli in the dejecta will clear up the diagnosis. In rare instances a severe attack of biliary colic or of renal colic ACUTE OBSTRUCTION. 251 may in some respects resemble intestinal obstruction. A thorough examination, however, will always reveal the true condition. In biliary colic as a rule there is swelling of the liver and sometimes jaundice; in renal colic the pains radiate from the kidney to the bladder, there is a burning sensation during urination, and the urine often contains mucus and occasionally a few pus corpuscles or blood cells. Intestinal colic resulting from chronic lead poisoning occa- v sionally simulates true obstruction of the bowels. The anamnesis, however, will show that we have to deal with lead poisoning. Besides, in these cases there is, as a rule, a more or less sunken condition of the abdomen. Simple intestinal colic (of nervous origin) will hardly ever give rise to mistakes in the diagnosis, as the clinical picture is less severe and the disease quickly subsides. B. Location of the Obstruction. The location of the seat of the obstruction is not merely of theoretical value, but of great practical importance, for this decides the question as to where abdominal incision should be made in cases of operation. It will be useful to discuss first at what point of the abdomen the obstruction is situated, and secondly, what particular portion of the bowel it involves. 1. The point at which the patient first experiences pain is significant in case he is able to locate it definitely. In many instances, however, the pain is not experienced in one circumscribed spot, and is often located diffusely in the neighborhood of the navel. The presence of a tensely tympanitic intestinal coil, which does not change its con- figuration and thus makes the abdominal wall protrude asymmetrically, is of great importance; for, according to Yon Wahl, such a coil is often found above the occluded segment of intestine. Strong peristaltic contractions run- ning in the same direction over a certain region of the ab- 252 DISEASES OF THE INTESTINES. domen, especially if they return periodically and always in the same area, will serve to locate the place at which the obstruction is situated. For these peristaltic waves pass along the intestine down to the seat of the obstruc- tion, which they are unable to overcome. Palpation of the abdomen occasionally reveals the pres- ence of a sausage-like tumor. This occurs especially in cases of intussusception. If such a tumor is present, the location of the obstruction is certainly easy. A thorough examination of all hernial openings will occasionally re- veal an incarceration of the intestine and also show the site of the lesion. If there is no hernia the examination must be continued through the vagina and through the rec- tum. The exploration through the vagina will show whether the pelvic organs are normal, and if not, whether a tumor or?^i.i8.*ino > from the genital organs ^ c expressing the in- testines. Digital examination of the rectum will enable us to discover a stricture, an intussusception, or a tumor of the lower portion of the bowel. In some cases a thorough examination of the entire rectum and the descending colon may be undertaken with the whole hand under chloroform narcosis, according to the method of Simon. In cases of intussusception involving the sigmoid flexure and rectum, the anus often remains open (paralysis of the sphincters) and there appears an involuntary evacuation of a muco- bloody fluid from time to time. 2. Determination of the Portion of the Intestinal Tract in ivhich the Obstruction is Situated. Small Intestine. If the obstruction is situated in the small intestine all the symp- toms (pains, vomiting, collapse) are, as a rule, much more intense and appear sooner than in obstruction of the large bowel. Soon after the commencement of the disease, there is copious vomiting which may become fecal after a short ACUTE OBSTRUCTION. 253 period. The meteorism at the beginning is localized in the upper part of the abdomen, while the lower part remains unchanged. Pronounced visible peristaltic waves in the small intestine also point to an occlusion situated within the latter. Jaffe ' was the first to show that obstruction of the small intestine gives rise to pronounced iudicanuria. As early as the second or third day of the obstruction, indicau can be found in the urine in large quantities. In obstruction of the large bowel there is as a rule no iudicanuria, and if it appears it does so only later in the disease, on the sixth or seventh day. The higher up in the intestinal tract the obstruction is situated, the sooner and the more frequently anuria may appear. Injections of water into the bowel may secure a fecal evacuation. The colon can also be filled with a large amount of water or gas. If the obstruction is situated within the duodenum or in the upper part of the jejunum, it can often be easily recog- nized. Obstruction of the duodenum above Vater's papilla will manifest the same symptoms as acute dilatation of the stomach in consequence of a stricture. There will be ischo- chyinia and continuous vomiting of chyme. An obstruc- tion situated within the duodenum below Vater's papilla will give rise to vomiting of large quantities of pure bile. The vomited matter may contain acids from admixture of gastric juice. It is never fecal in character. The gastric region is protuberant but sinks in after a spell of vomiting. If the obstruction is situated within the beginning of the jejunum the vomiting assumes at first a greenish hue (de- composed bile) which may be followed by the vomiting of pure unchanged yellow bile. Occasionally the vomited matter assumes a fecal character. Ol>structious situated 1 Jaffe : Centralbl. f. die med. Wissenschaften, 1872. 254 DISEASES OF THE INTESTINES. within the duodenum or at the beginning of the jejunum, as a rule, are unaccompanied with indicanuria. Obstmction of the Large Bowel. The symptoms here are usually less violent and appear a little later than in the obstruction of the small intestine. Fecal vomiting often appears long after the establishment of the occlusion, and it may even be absent if the obstacle is situated at the beginning of the descending colon or lower down. The meteorism is in most instances limited to the lower parts of the abdomen and also to the lumbar regions. In occlu- sion of the descending colon it may be noticeable that at first there is a protrusion in the left iliac region, afterward a protrusion of the transverse colon, and ultimately the as- cending colon will also become tympanitic. As mentioned above, indicanuria will be absent during the first five or six days of illness. With regard to the determination of the occlusion within the lower parts of the colon, Brinton's ' method , already in use over fifty years ago, is very valuable. It consists in filling up the bowel with water through the rectum. If not more than half a quart can be injected, the obstruction must be situated in the upper part of the rectum. If one to two quarts can be injected, the obstruction must be situ- ated above the sigmoid flexure, in the descending colon, or still higher. In case obstruction is situated in the as- cending colon four quarts or still more can be injected and retained in the bowel. Insufflation of air or carbonic acid gas into the rectum will also occasionally show the seat of the obstruction, if the latter is situated in the descending or the transverse colon, as there will be a filling up with gas of the free portion of the bowel up to the obstructed point. When the obstruction is located beyond the trans- 1 Brinton : "On Intestinal Obstruction, " London, 1867. ACUTE OBSTRUCTION. 255 verse colon, however, it will not permit of distinct recog- nition by this method. C. Recognition of the Different Foi'ms of Acute Obstruction. If the diagnosis of acute obstruction of the bowels is not always easy, the recognition of the special anatomical lesion underlying it is still more difficult. In many in- stances an exact anatomical diagnosis will not be possible and we will have to be satisfied with a probable conjecture. In some cases, however, the exact determination of the etiological factor underlying the obstruction will be possi- ble. The following groups of acute obstruction of the bowels can be clinically differentiated : 1. Acute Incarceration of the bowels in hernias (also in- ternal hernias, in slits of the omentum, mesentery, or di- verticula), in strangulation by bands or twists of the bowel, is most frequent between the ages of twenty and forty. It occurs more often in males than in females. There is often a previous history of peritonitis, of hernia, or of acci- dents (contusions). The onset of the disease is sudden. The pains are severe. Vomiting is present from the start, becoming stercoraceous later on. Collapse is marked. Tenesmus is absent. Physical examination of the abdo- men gives, as a rule, negative results. 2. Volvulus most often involves the sigmoid flexure and can then be easily recognized. Volvulus of the small in- testine, which occurs very rarely, cannot be differentiated clinically from incarceration. The rotation of the bowel around its axis is either complete (360) or incomplete (half rotation, 180). In the first instance there is total occlusion, while in the latter the intestinal lumen is at first partially pervious. Volvulus is more common in males than in females in the proportion of four to one, and occurs principally late in life, usually between forty and sixty. 256 DISEASES OF THE INTESTINES. There is usually an antecedent history of chronic constipa- tion. The onset of the disease is sudden. The pain ordi- narily is intermittent. Vomiting may be absent at first and later on occurs intermittently. Constipation is almost ab- solute and grows worse after the use of aperients. There is pronounced meteorism. The sigmoid flexure can oc- casionally be felt as a tumor. Only moderate amounts of water can be injected into the rectum. 3. Intussusception occurs very frequently in early child- hood. The onset is sudden, the pains appear early, are colicky in character and come in paroxysms. There are marked tenesmus and bloody evacuations. The collapse is not pronounced. The invaginated coil may be acces- sible to palpation and then appears in the form of a tumor of egg-size or somewhat larger, this occurring in about fifty per cent of the cases. Meteorism develops in con- junction with peritonitis. 4. Obturation of the Intestine by Gall Stones, EnterolitltH, or Foreign Bodies. Obstruction by gall stones occurs chiefly in women and is more frequent at an advanced age. A pre- vious history of gall stones or a preceding attack of jaun- dice, pains in the region of the liver, and swelling of this organ are points which aid in the diagnosis. Obstruction by gall stones usually occurs in the small intestine; the symptoms, as a rule, are less severe than in other forms of ileus. The collapse is not pronounced or may be en- tirely absent. Flatus may occasionally be passed, copious vomiting of bile may be present. If the gall stone is situ- ated in the lower portion of the ileum the vomiting may later become stercoraceous. Occasionally the stones can be palpated through the abdomen and- felt as a hard mass. Meteorism is generally not highly developed. In some instances there is diarrhoea with admixture of blood, the ACUTE OBSTRUCTION. 257 latter being due to abrasions of the intestinal mucosa pro- duced by friction of rough gall stones. The recognition of an enterolith as the cause of obstruc- tion is very difficult and possible only when small frag- ments of a fecal calculus have previously been found in the dejecta. The seat of obstruction is as a rule then in the large bowel, the latter being the place where enteroliths develop. Obstruction by foreign bodies will be recognized by the previous history ; often also, especially if they are of a metallic nature, by a Roentgen picture. An accumulation of cherry pits or plum stones may also cause an obstruc- tion and will likewise be recognized by the previous history and by the presence of some of them in the de- jecta. Hardened fecal matter will very rarely give the picture of obstruction. This will occur only in very weakened in- dividuals and in persons with spinal trouble. In these cases the rectum and colon will be found filled with greatly hardened scybala. If a stricture or a tumor exists within the intestine and narrows its lumen, an accumulation of fecal matter above the stricture gives rise to acute ob- struction. 5. Dynamic Ileus. Obstruction due to paralysis of a segment of the bowel can be recognized only with great difficulty. Often there has been a preceding laparotomy or some operation on the genital organs in the female or a history of a replaced hernia. With regard to the recognition of the different forms of intestinal obstruction the following table, which gives the frequency of the principal symptoms in the various forms of obstruction, may be of assistance. Among two hundred and ninety-five cases of acute ob- 17 258 DISEASES OF THE INTESTINES. struction of the bowels collected in literature and minutely examined by E. Fitz ' of Boston, the symptoms were as follows with regard to the different groups of obstruction : Strangu- la tii Hi. Per Cent. Intussus- ception. Per Cent. Twist. Per Cent. Gall Stones. Per Cent. Stricture or Tumor. Per Cent. Pain 82 70 60 83 60 Nausea and vomiting Fecal vomiting 69 47 75 13 37 15 74 61 80 33 Tympanites ". 56 33 55 56 66 Tumor 10 69 13 27 Visible coils 11 7 20 Prognosis. The prognosis of acute obstruction of the bowel is very serious. According to Curschmann/ only thirty to thirty-five patients out of one hundred recover from this disease. As a rule ileus caused by coprostasis or by obturation with gall stones and foreign bodies gives the best prognosis. Then come volvulus and intussuscep- tion, while incarceration gives the worst prognosis. If in the course of ileus deglutition pneumonia or diffuse peri- tonitis or perforation of the bowel develops, then the case is well-nigh hopeless. Operative intervention, especially in cases in which the seat of the intestinal occlusion is known, improves the prognosis considerably, but only if it is resorted to early. Later, when the complications just mentioned arise, not much can be expected from an opera- tion. Treatment. A. Medical Treatment. Absolute rest is of the great- est importance. The patient should be kept in bed and told to avoid any abrupt motions. He should not be 1 R. Fitz : " Transactions of the Congress of Physicians and Sur- geons, " vol. i., 1888. * Curschmann : " Die Behandlung des Ileus. " Congress fur innere Medicin, Wiesbaden, 1889. ACUTE OBSTRUCTION. 259 allowed to go to the water-closet, but should use a bed- pan. With Treves, Graser, 1 and others I am for absolute rest of the stomach and intestines, i.e., no food whatever should be given to patients suffering from acute obstruc- tion of the bowels. If there is great thirst a teaspoonful of hot water or very weak tea may be given every half-hour or hour or a small piece of ice may be held in the mouth until it melts, but the water should not be swallowed. Neither should any stimulants like wine, champagne, or whiskey be given by the mouth. In obstruction of the small intestine small quantities of a saline solution (about seven to twelve ounces) may be injected into the bowel several times during the day. If the sickness lasts several days, nutritive enemas consisting of milk and egg or of a peptone solution may be given in the same way. If, however, the patient is not able to retain the enema, considerable quantities of saline solution must be injected either subcutaneously or intra- venously. All writers agree that no cathartic remedies whatever should be used, as they increase the peristalsis and there- by may cause great harm. A cathartic should be per- mitted only in cases in which the obstruction is positively due either to gall stpnes or hardened fecal masses or in dynamic ileus. It is, however, of benefit to evacuate the lower parts of the bowel by means of an enema. This cleans out the rectum, diminishes the feeling of tension to a slight extent, and prepares the bowel for the nutrient " enemas. The administration of opium plays a principal part. It 'Graser: "Behandlung der Darmverengerung und des Darmver- schlusses." Penzoldt-Stintzing's "Handbuch der speciellen Tberapie innerer Krankheiten, " Jena, 1896. 260 DISEASES OF THE INTESTINES. is indicated not only as a means of allaying pain but for its soothing action upon the intestinal peristalsis. The arrest of the latter may have a direct curative effect, since it may promote a return of the partly incarcerated or in- vaginated or slightly twisted coil to its normal position. In order to secure a prompt action of the drug it is best to first give a hypodermic injection of morphine, one-sixth to one-fourth of a grain. A short time afterward a sup- pository of two-thirds of a grain of opium is administered and repeated every three or four hours until the pains are kept in abeyance. In cases in which the vomiting is not so marked, opium may be given in the form of the tincture fifteen to twenty drops every three to four hours. It is hardly necessary to say that the opiates should not be used too lavishly. Only so much should be administered as is absolutely necessary for relieving the pain and quieting the violent peristalsis of the intestine. Given in this way, opium not only acts as a sedative but also as a stimulant on the heart. Patients in deep collapse very soon after an injection of morphine become warm, show a better pulse and a more normal temperature. The only disadvantage of opium is that it slightly masks the true picture of the disease. It is therefore best whenever possible first to make an exact diagnosis by thorough examination of the abdominal viscera by palpation, auscultation, etc., before administering it. If the symptoms- of the disease persist after the admin- istration of opium, especially if the tension of the abdomen is not relieved and no flatus is passed, it is well to dis- continue the remedy for a certain period of time. This will enable the physician to judge the situation critical^. As a further sedative agent applications of poultices can be considered. A hot-water bag, a hot plate wrapped up ACUTE OBSTRUCTION. 261 in flannel, or a Japanese warm box, wet packs (Priessnitz) are useful. If there are signs of peritoneal inflammation, applications of ice or of very cold poultices are prefer- able. Lavage of the stomach was first recommended in this disease by Kussmaul and Cahn. 1 This procedure is of benefit if the obstruction is situated high up in the small intestine. It empties the stomach, relieves the vomiting, and also decreases the abdominal tension. There is no doubt that this therapeutic measure is sometimes crowned with success in appropriate cases. As a striking instance of the efficacy of this mode of treatment the following case may be reported : E. K., thirty -five years old, had always been well, when he suddenly became critically ill with violent abdominal pains and constant vomiting. For three days there was no evacuation of the bowels nor was the patient able to pass any flatus. On examination I found his abdomen considerably distended and tense. The stomach could be mapped out and was considerably dilated, the greater cur- vature extending a hand's width below the navel. On pal- pation there was considerable tenderness all over the abdomen. The pulse was quite frequent (110) and weak, temperature 96.5 in the mouth, the extremities were cold. The face showed an expression of great suffering. There were almost continuous hiccough and now and then vomit- ing of a watery, turbid, somewhat brownish-looking liquid with fecal odor. On introducing the tube over a quart of liquid of the same character was obtained. The stomach was then washed out with several quarts of water until the fluid returned quite clear. The patient felt somewhat re- lieved. The vomiting stopped and on the following day there was a spontaneous evacuation of the bowels. The patient was now able to pass flatus, the disteutiou sub- 1 Kussmaul -Cahn : "Heilung von Ileus durch Magenausspiilung. " Berl. klin. Wochenschr. , 1884, Nos. 42 and 43. 262 DISEASES OF THE INTESTINES. sided, and he gradually recuperated. For the sake of com- pleteness I would add that besides washing out the stomach, the treatment consisted in the administration of opium suppositories. Lavage of the Bowel. Injections of large amounts of water into the bowel under considerable pressure are also occasionally of benefit, especially in cases of intussuscep- tion of the colon or when a foreign body or hardened fecal matter is the cause of the obstruction within the large bowel. According to Treves, it is desirable to use this procedure after anaesthetizing the patient. A considerable quantity of water (varying according to the age of the pa- tient from half a pint to three quarts) is introduced into the bowel by means of an ordinary fountain syringe. The fluid is allowed to remain in the colon for at least ten min- utes. While injecting the water it is best to have the pa- tient in such a position that his head is lowered and his pelvis is raised. While the irrigation of the bowels is going on the physician should hold his hand upon the patient's abdomen and in this way notice any change which may occur. In intussusception when the tumor can be felt the latter will in some instances suddenly disappear, giving way to the pressure of the water. Too great force, however, should never be used, as this may bring on rup- ture of the bowels. Instead of water, injections of warm olive oil, which were first recommended by Kussmaul and Fleiner, may be used in the same way. Dr. Klubbe ' has related three cases of cure by means of this method. Inflation of the Bowel with Air or Certain Gases in Cases of Imagination. Trastour 2 recommended inflation 1 Klubbe : British Medical Journal, November 6th, 1897. 2 Trastour : Bulletin General de Therapie, 1874, p. 107. ACUTE OBSTRUCTION. 263 of the bowel with air by means of a common bellows, to which an India-rubber nozzle and rectal tube had been attached. The forcible filling up of the bowel with air is capable of producing the same effect as the injection of water and may free the invaginated portion. Von Ziems- seu ' has recommended the use of carbonic-acid gas, while Senn 2 suggested hydrogen gas. Carbonic-acid gas is best used in the form of "sparklets," as suggested by Dr. A. Rose 3 of New York. Care must be taken not to fill up the bowel too quickly and too forcibly. Massage. Massage has been recommended by several writers. Its use, however, is not entirely harmless. It can be of benefit only in cases of obstruction by gall stones and fecal matter, but even in these cases extreme care in its use is necessary. Electricity. Electricity has especially been recom- mended by Boudet. Among seventy cases of ileus Boudet 4 had fifty-three recoveries by this method. The faradic or galvanic current may be used. In the application of the faradic current one metal electrode of cone shape is in- serted into the rectum while another large plate electrode is kept over the abdomen for about ten to twenty minutes. In using the galvanic current it is necessary to have a special rectal electrode, which is constructed in such a way that water running through it forms the conductor, so as to avoid burning the mucosa. The other electrode is placed over the abdomen. The negative pole should be inside. The strength of the current should vary from ten to fifteen milliamperes. The duration of the treatment should be twenty to twenty-five minutes. 1 Von Ziemssen Archiv fiir klinische Medizin. Bd. 33. Heft 3 and 4. *Nic. Senn : "Intestinal Surgery, " Chicago. 1889, p. 244. J A. Rose : New YorkMed. Journal. 1900, i., p. 47. 4 Boudet; Progres Medical, February 7th and 14th, 1885. 264 DISEASES OF THE Electricity will be of special value in obstruction due to hardened fecal matter or in the paralytic form of ileus, while in incarceration it is rather contraindicated. Puncture. Puncture of the distended bowel has recently been recommended anew by Curschmann,' von Ziemssen, and others. According to Curschmanu, puncture of the intestine is performed in the following way : A long aspi- rator needle of thin calibre (like that of a Pravaz syringe) provided with a stopcock is thrust into the abdomen over a prominent coil of the intestine. A piece of rubber tub- ing is then connected with the outer end of the needle ; the free end of the latter is inserted into a bottle filled with water, which is turned upside down in a basin likewise filled with water'. The stopcock of the aspirating needle is now opened and the gas escaping from the intestinal coil appears in bubbles rising to the upper part of the bottle, displacing the water. There is no doubt that con- siderable temporary relief can be afforded by this mode of procedure, as it lessens the feeling of tension. Occasion- ally it may also have a direct curative result. Thus Curschmann reports three cures by this method. Punc- ture, however, is not entirely free from danger. In cases in which the intestine is already partly paralyzed, the opening after the withdrawal of the needle may not entirely close and intestinal gases and contents may continue to ooze out and cause peritonitis. Most surgeons of note are against this procedure, as it lacks precision and is not free from danger. Thus Treves, ' Kocher, ' and Graser 4 are all opposed to its employment. 1 Curschmann Deutsche med. Wochenschrift, 1887, No. 21. 2 Treves: "Intestinal Obstruction, " New York, 1899,^). 471. 3 Kocher: "Mittheilungen aus den Grenzgebieten der Medizin," 1898. Bd. 4, p. 2. 4 Graser. Penzoldt-Stinzing's "Handbuch, " Bd. 4, p. 562. ACUTE OBSTRUCTION. 265 Sad experiences with puncture have been reported by Freutzel, 1 Fiirbringer, 2 Hoffmann, Korte, 3 and Graser. The latter observed the appearance of fecal matter and consecutive peritonitis from such an opening. He con- siders puncture permissible only if the patient absolutely refuses an operation. 3fercni-t/ (Jlercuritts Vivus). The internal administration of pure mercury in tables poonful doses was highly es- teemed as a remedy for ileus by the old physicians. When all resources had been exhausted without success, mercury was given as an ultimum refugium. Even nowadays many physicians are convinced of its efficacy. The use of mer- cury in incarceration, strangulation of the bowel by twists or bands, intussusception, is not permissible, as it does real harm. In ileus in consequence of coprostasis or in dynamic ileus, mercury may be employed if all other rem- edies have proven futile. Its effect consists in the pene- tration of the mercury into the accumulated fecal matter, thus softening it. All the enumerated internal methods of treatment must be applied, first, in cases in which the obstruction is due either to gall stones or to foreign bodies or fecal accumu- lation or volvulus of the sigmoid flexure ; secondly, in cases iu which the exact diagnosis as to the kind of obstruction is not settled, and which are not of a very severe type. In all other varieties of intestinal obstruction and even in the types just mentioned, after the failure of the medicinal measures at hand, an operation should be resorted to. 1 Frentzel : Deutsche Zeitschr. f Chirurgie, Bd. 33. 8 Fiirbringer : Verhandl. des 8ten Congresses f. innere Medicin, 1889. :: Korte : Ibidem. 266 DISEASES OF THE INTESTINES. B. Surgical Treatment. Treves, the greatest authority on intestinal obstruction, says: "There is one measure for the treatment of acute intestinal obstruction, and that is by means of laparotomy. The operation should be performed at the earliest possible moment, as soon indeed as the diagnosis is reasonably clear. In case of acute abdominal trouble in which the diagnosis is not clear, the better and safer course is to operate." This view is now generally accepted by physi- cians as well as surgeons. As mentioned above, obturation, ileus, and volvulus of the sigmoid flexure are the only groups of intestinal ob- struction in which medical treatment plays a prominent part. The importance of an early operation has been shown by Naunyn, who found that among two hundred and eighty -eight cases of ileus operated upon, the results were the more favorable the earlier recourse was had to surgical intervention. In those cases in which the operation was performed during the first two days of sickness recovery took place in seventy-five per cent. During the third day and still later there were only thirty -five to forty per cent of recoveries. A similar view is expressed by Gibson, ' who dealt par- ticularly with acute intussusception. Among one hundred and forty-nine cases of this affection he found an average mortality of fifty -three per cent. The first and second days showed mortality inferior to the general mortality, while the four succeeding days showed a steadily increasing mor- tality, in each instance greater than the average. With regard to treatment by inflation of the bowels by enemata 1 C. L. Gibson : "Mortality and Treatment of Acute Intussusception, with Table of 239 Cases. " Medical Record. July 17th, 1897. ACUTE OBSTRUCTION. 267 of fluids (or air) Gibson says: "It is probably not an ex- aggeration to say that if all cases of intussusception were treated on the onset, or say within forty -eight hours, by abdominal section, without any previous attempt at re- duction, the mortality, while still considerable, would in all probability be very much less than the present figures." Gibson believes that injections should" be tried only on the first or at the latest on the second day. In the discussion on intestinal obstruction which took place at the New York State Medical Association, ' all the speakers (Parker Syms, E. D. Ferguson, George D. Stew- art, J. "W. Gouley, J. D. Rushmore, LeRoy J. Brooks, John F. Erdmann, Fred. H. Wiggin, and H. O. Marcy) were in favor of surgical treatment and for early interven- tion. J. D. Rushmore says:* "I have no hesitation in affirming that in competent hands operation for intestinal obstruction would not have a mortality above twenty per cent. In my personal experience, including over one hun- dred and ten operations, the mortality has been nearly forty per cent. In the last thirty cases there have been six deaths." Wiggin 3 considers that operations performed within the first forty -eight hours will give a mortality of 22.2 per cent. Inasmuch as the question of operation has to be dealt with in each case of intestinal obstruction, it is advisable to have the opinion and advice of an expert surgeon right at the start of the disease. The physician and surgeon should act together, the first watching the symptoms carefully and making the diagnosis, the second prepared to resort to surgical intervention as soon as it is demanded. 1 Transactions of the New York State Medical Association, 1898. 2 J. D. Rushmore: Ibidem. S F H. Wiggin: Da Costa's "Modern Surgery," p. 644. 268 DISEASES OF THE INTESTINES. In this way the number of recoveries will be greater in the future than it has been in the past. The operation consists in making an abdominal incision, finding the seat of the lesion, and removing the obstacle if possible. If not, an enterostomy is performed in the most distended coil of intestine which is then attached to the abdominal wall. The fecal matter and the gases thus find an outlet through this opening. Enterostomy is also re- quired in all cases in which the portions of the intestine are already found gangrenous. Treves says that this oper- ation (enterostomy) could be avoided in acute intestinal obstruction if the abdomen were opened at the very earliest possible moment. Every hour delayed adds to the grav- ity of the case. " The earlier the operation the less the need for enterostomy. Laparotomy should be performed at an early enough period to render an opening into the bowel unnecessary." CHRONIC INTESTINAL OBSTRUCTION. Etiology. Chronic intestinal obstruction may be caused by the same factors which produce acute ileus if they do not occlude the entire lumen of the bowel but leave part of the canal open. Besides, obstruction of the intestine is frequently occasioned by strictures resulting from preced- ing ulcers or from new growths. The latter, benign as well as malignant, are liable to give rise to occlusion even if they do not occupy the entire circumference of the bowel, by simply obtruding part of the canal at the site of their greatest development. Strictures caused by ulcers much more frequently involve the large than the small intestine. According to Treves, they are found six times as often in the large bowel as in the small one. While formerly dysentery was believed to be the cause of a CHRONIC OBSTRUCTION. 269 large number of these intestinal strictures, Woodward ' has shown that this view is not supported by facts. Among the many autopsies on patients with chronic dysentery which the latter had an opportunity to observe, there was not one case of dysenteric stricture of the intestine. Nothnagel agrees with Woodward. On the other hand, tuberculous ulcers of the intestine which were regarded as only rare causes of intestinal stricture have recently been found to produce strictures quite frequently. Koenig 2 laid stress upon the frequency of constricting tuberculosis of the intestines. The latter mav exist even if tuberculosis in other organs is absent. Ulcers of typhoid fever very rarely if ever cause strictures, and this also applies to the small follicular ulcers. Syphilitic ulcers on the contrary produce strictures quite often. All kinds of strictures are met with most frequently in the lower portion of the colon, principally in the rectum. Sometimes they lie just above the anal region and can then be very easily discovered. Symptomatology. The symptoms and the course of the disease vary considerably, and greatly depend upon the cause of the obstruction. Thus, clinically, the benign growths must be differentiated from the malignant ones (in which the obstruction is caused by cancer). The pic- ture which the intestinal obstruction as such produces will, however, be pretty much the same. A stenosis which is not very much pronounced may give rise to no symp- toms whatever. It is therefore quite evident that the dis- ease may exist for some length of time before manifesting its presence. In typical cases of chronic intestinal obstruction the onset is slow and insidious. The patient at first notices 1 Woodward : Loc. cit. * Koenig : Deutsche Zeitscbrift filr Chirurgie, 1891. 270 DISEASES OF THE INTESTINES. slight digestive disturbances, some discomfort in the abdomen which gradually changes into real pain, and slight constipation. The latter as a rule quickly becomes worse. Mild aperients which a short while before were efficient refuse to act, and the patient is obliged to resort to stronger cathartics ; at times even these will fail to work. Frequently constipation suddenly alternates with an attack of severe diarrhoea, which may last several days and be followed by another period of obstinate constipation. In some instances the color and form of the fecal matter will be an indication of the seat of the stenosis. It is gener- ally believed that pipestem-like or tape-like motions indi- cate a stricture in the colon. According to Treves, ' how- ever, this sign is of very little value, as in the great majority of cases the sphincter muscle is the originator of these peculiar shapes. Diarrhrea may also occasionally occur. It is sometimes quite obstinate, especially if the stenosis is situated in the large bowel. An admixture of blood or pus in the dejecta is occasionally met with and is due to ulcerative processes taking place at the seat of the stricture or immediately above it. Vomiting is not a very marked feature at first, but later on occurs more frequently. When the obstruction, how- ever, becomes complete, vomiting is a prominent symp- tom and may assume a stercoraceous character. The situation of the obstruction has much influence upon the clinical picture of the disease. If the stenosis is situ- ated in the duodenum above Vater's papilla, the symptoms will resemble those of stricture of the pylorus. Ischochy- mia, vomiting, nausea will be the prominent features. A stenosis of the duodenum below Vater's papilla, although presenting symptoms similar to those of stricture of the 1 Treves : Loc. cit. , p. 395. CHRONIC OBSTRUCTION. 271 pylorus, will be recogiiized by the more or less constant pres- ence of large amounts of bile in the stomach. The farther down in the small intestine the obstruction is situated, the less pronounced are the gastric symptoms and the more marked the intestinal manifestations (less vomiting or nausea, more constipation, colicky pains). If the stenosis is situated in the lower portion of the ileum or in the colon no gastric symptoms are as a rule present. The appetite is good, there is no nausea, and the principal features are obstinate constipation, sometimes alternating with diar- rhoea and frequent attacks of colicky pains. Condition of the Abdomen. The abdomen may present a normal appearance when the stenosis is situated in the upper portion of the small intestine, although in some of these cases there may be a protrusion of the upper part of the abdomen. If the site of obstruction is in the lower portion of the small intestine or in the large bowel, then some distentiou of the abdomen is usually noticeable, espe- cially after the disease has advanced considerably. Above the obstruction there is always distention and hypertro- phy of the bowel. The latter is a manifestation of the attempt which nature makes in order to overcome the diffi- culty. The intestines above the stenosis act with greater force in order to propel the contents through the narrow passage. The contraction of the bowel above the affected area often assumes a tetanic type and is then painful. Such violent tetanic contractions are often visible through the abdominal wall, and by propelling large amounts of liquids and gases through the narrowed lumen, give rise to gur- gling and bubbling sounds audible at a distance. Treves thus describes the picture which this violent peristalsis manifests : " The surface of the abdomen becomes uneven, 272 DISEASES OF THE INTESTINES. a rounded elevation appears in one place and depressions appear in another. They produce an aspect comparable to that of a relief map of a hilly country. Slowly the hill-like elevation sinks and vanishes and out of the shallow valley appear fresh eminences which rise up and move along beneath the skin. The movements are slow and attended by colicky pains, and by more or less of rumbling and gurgling sounds." . . . "The same coil appears again and again and can often be quite definitely recognized. Although as a rule the contracting coils of the small intestine are of considerably smaller size than those of the large bowel, occasionally even the small intes- tine may assume such dimensions that it cannot be differ- entiated from the large bowel." Meteorism is often present. If the obstruction is situ- ated in the lower portion of the colon or in the rectum, the meteorism is at first restricted to the large bowel, the dis- tention then being pronounced along the course of the colon at both sides of the abdominal wall and in the epigastric region. The lower part of the abdomen and also the re- gion of the navel may be free from meteorism. If the stricture is situated in the lower portion of the ileum or caecum, the lumbar regions of the abdomen are quite lax, while the distention is more or less pronounced in the me- sogastric and hypogastric regions. After having described the symptoms of chronic intesti- nal obstruction in a general way it will be useful to point out separately the characteristics of some special forms which occur more or less frequently. Chronic intussusception may develop either after an acute attack or begin slowly and insidiously without at first giv- ing rise to any marked symptoms. It is most frequently found in the ileo-csecal portion. Pain occurs during the CHRONIC OBSTRUCTION. 273 progress of the disease and is usually of a paroxysmal character. Attacks of pain may appear several times a day or once in twenty-four hours. Occasionally days and even weeks elapse between the paroxysms. As a rule the intervals between the attacks grow shorter as the disease advances. In some cases there is almost continuous suffer- ing with occasional exacerbations. Vomiting seldom oc- curs and is certainly not a marked feature. A tendency to diarrhoea very often exists. The bowels may be normal or constipated for a while and then become loose, or there may be persistent diarrhoea. Blood is very often passed with the stools and tenesmus is occasionally present. On examination of the abdomen by palpation a tumor is . found in almost half of the cases. The nature of the tumor corresponds to that found in acute intussusception de- scribed above. Occasionally a tumor can be felt in the rec- tum when the intussusception involves the lower portion of the large bowel. In rare instances the invaginated portion is separated from the bowel by necrotic processes, and may then appear in the movement. While this event may in rare instances lead to perfect recovery (the other portions of the bowel growing together and the lumen thus being restored), in the greater majority it causes death through perforation, rupture of the intestinal walls, and general peritonitis. Chronic Obstruction Due to Fecal Accumulation. This variety of intestinal obstruction is more common in fe- males than in males and is usually met with in more ad- vanced age and in patients suffering from hysteria and brain troubles. As a rule, the patients have already long before been subject to habitual constipation ; usually many days elapse without an evacuation of the bowels. From time to time enormous quantities of fecal matter are passed 18 274 DISEASES OF THE INTESTINES. by artificial means. Later on the symptoms of constipa- tion grow more intense. The abdomen becomes distended and it is much more difficult to secure an evacuation even by artificial means. As a rule the patient is tormented by eructations and flatulence. His appetite is poor ; he has a bad taste in his mouth and frequently his breath has an unpleasant odor. Headache, vertigo, and a general tired feeling are often encountered. These symptoms, as well as the marked unhealthy ap- pearance of the skin, are most probably due to intestinal auto-intoxication. Certain chromogens, the products of decomposition, are absorbed from the bowel and give rise to this peculiar discoloration of the skin. The conjunctivas also are often yellow. A further symptom due most prob- ably to the same process of auto-intoxication is the rise of temperature which is often present. If the distention of the abdomen is very marked, a feeling of oppression in the chest and palpitations of the heart are experienced. Fecal accumulation sometimes causes pressure upon the lumbar or sacral nerves and gives rise to discomfort in the genital organs or to pain in the thigh radiating down the entire leg. Distended coils may be visible through the abdomen and there may be much rumbling and gur- gling heard after constipation has lasted a long period. This symptom is, however, not so marked here as in cases of stricture of the intestine. Vomiting may occur and even become stercoraceous. Slight colicky pains are felt over the abdomen, but as a rule they are not intense. The symptoms having advanced to an extreme degree, re- lief may ensue either spontaneously or after resort to differ- ent procedures which serve to evacuate the bowels. Occa- sionally, however, an evacuation of the bowel cannot be obtained and the patient develops all the symptoms of an CHRONIC OBSTRUCTION. . 275 unyielding obstruction which may be fatal. Often there are attacks of obstruction following each other at certain intervals. The narrowed lumen of the bowel most prob- ably becomes entirely occluded or blocked by a piece of hard fecal matter, which completely fills it and cannot move in either direction. Sometimes the abrupt stoppage may be due to some bending or kinking of the distended bowel. In almost all cases of obstruction by fecal masses a tumor can be palpated usually in some portion of the colon. The tumor is caused by the fecal accumulation. The caecum, the hepatic and the sigmoid flexures are the places where the tumor is most often encountered. Such a fecal tumor feels hard and uneven ; sometimes it has a globular shape. . As a rule it is not painful on pressure. Sometimes it is possible to change the shape of the tumor by pressure. This is the best proof of its fecal character. Sometimes, however, pressure does not give rise to any change in the configuration of the mass if the fecal matter is very hard. The best sign of its fecal nature is the change in form after repeated irrigations of the bowel. In some rare instances the fecal accumulation occupies the greater part of the abdominal cavity and gives the impression of one immense tumor of very hard consist- ency. I have seen two such cases in patients suffering from grave melancholia. Here also after repeated irriga- tions of the bowel and administration of cathartics the tu- mor gradually becomes smaller and ultimately disappears. Stricture of the Rectum. In this condition as a rule there are at first merely symptoms of constipation ; later on these become more obstinate, requiring stronger cathartics. The patient now begins to complain of congestion of the head, anorexia, nausea, cold feet, and sometimes of disagreeable 276 DISEASES OF THE INTESTINES. sensations in his limbs ; still later there is diarrhoea which may persist as such or alternate with constipation. Off and on muco-purulent material appears with the dejecta. A burning sensation is often felt in the rectum, and tenes- mus is frequently present. Hemorrhoids and prolapse of the rectum often accompany the stricture. Digital examination of the rectum often reveals a ste- nosed area in its lower part. The finger is either not able to pass any farther than a few centimetres (five to six) above the anus or it meets with a resistance which it can overcome. Contrary to spasm of the rectum which yields completely after the finger has succeeded in passing the constriction, in stricture of the rectum the pressure of the narrowed lumen exerted upon the finger remains constantly the same. Most of the strictures are situated about five to six centi- metres above the anus, seldom higher up. In the latter in- stance the examination must be made with a bougie or with a rubber tube which is not too soft. In order to determine the exact nature of the stricture it is always best to make a visual examination of the rectum by means of a specu- lum. Complication. No matter to what cause the intestinal obstruction is due, in the protracted course of the disease several complications are liable to occur, although here less often than in acute obstruction. Above the stenosed area ulcerations of the bowel may take place and perfora- tion may occur, giving rise to general peritonitis. Occa- sionally circumscribed peritonitis may ensue in a similar manner and lead to an abscess surrounded by adhesions. Such an abscess may rupture through the abdominal wall and under favorable conditions (if communicating with the intestinal lumen) form a fecal fistula. In many in- CHRONIC OBSTRUCTION 277 stances the patients gradually waste away and die in con- sequence of thrombosis of the crural vein and decubitus. Course and Prognosis. The duration of chronic intestinal obstruction depends largely upon the nature of the partic- ular affection and upon the degree of the obstruction. If there are no complications and the patients lead a perfectly ra- tional life (with regard to diet and treatment) the condition may last a number of years. In other cases the symptoms of intestinal obstruction rapidly progress and life is then of short duration unless something radical is done. Diagnosis. The diagnosis of chronic intestinal obstruction is warranted by the presence of gradually increasing symptoms of constipation, and attacks of intestinal colic with a temporary stoppage of the bowels follow- ing each other at not too great intervals. The acute attack of obstruction in these cases of chronic intestinal stenosis is as a rule much milder than in acute occlusion of the bowel not due to a chronic con- dition. In the chronic form there is either no collapse at all or it is but slightly marked. Increased intestinal peri- stalsis is often encountered in the chronic form, especially FIG. 36. Patient M. with Chronic Intestinal Stenosis (Stricture of I>fvi-ny the situation of the pain which often corresponds to the location of the affected organ. Besides, other symptoms are usually pres- ent which are characteristic of the latter (icterus, strangury). Prognosis. The prognosis of intestinal colic is almost always good with regard to life, for the attack usually ends in recovery. Exceptional cases of death have, however, been observed by Oppolzer 1 and Wertheimer. 2 Treatment. The treatment consists, first, in measures 1 Oppolzer: Wiener meu. Wochenschr., 1867. * Wertheimer: Deutsches Arch. f. klin. Mediciu, 1866, Bd. 1. ENTERALGIA. 331 directed toward the removal of the cause, and secondly, toward tlie relief of the pain. In most cases of intestinal colic a thorough evacuation of the bowels is of benefit. For this purpose injections of a considerable quantity of water (one to two quarts) or of olive oil (one-half to one pint) are very serviceable. Mild cathartic remedies, cas- tor-oil, calomel, and the like, may also be administered. In cases in which worms have been found a vermifuge must be given with the cathartic. If meteorism is quite pro- nounced massage of the abdomen may be tried. If the colic is due to an error in diet, the latter must be strictly regulated. If due to a general cold, hot beverages (tea, infusions of camomile and of peppermint), hot poultices over the abdomen are of value. In nervous enteralgia occurring in patients suffering from hysteria and neurasthenia the treatment should be directed toward the improvement of the latter conditions. Climate, electricity, massage, and hydrotherapy play a predominant part here. The following symptomatic measures which serve to subdue the pains are of great importance : If the colicky pains are quite severe, the administration of an efficient dose of an opiate is indicated. Tincture of opium may be given in doses of fifteen or twenty drops, or opium ex- tract, 0.03 to 0.05; or morphine, 0.01 to 0.015, may be in- jected subcutaneously. Even in cases in which the colic is due to a retention of fecal matter, the narcotics just mentioned are indicated, for they relieve the spastic con- tractions of the intestines. During a severe attack of intestinal colic the diet should consist principally of liquids, small quantities of milk ami broth being given at frequent intervals (about every two hours) . If the attacks recur quite often, the application 332 DISEASES OF THE INTESTINES. of the galvanic current (one electrode within the rectum, negative pole, the other over the abdomen) is sometimes of benefit. Hypogastric Neuralgia. (Neuralgia hypogastrica, Romberg. 1 ) Enteralgia limited to the lower portion of the large bowel is termed hypogastric neuralgia. In this condition there exist disagreeable, sometimes painful sensations in the lower region of the abdomen and in the lower parts of the back, accompanied by a violent feeling of pressure in the rectum and sometimes also in the bladder. In female patients the same sensation may also extend to the uterus and vagina. Sometimes the patient also complains of painful sensations in the perineum and the thighs. Per- sons suffering from hemorrhoids and women afflicted with nervous and uterine troubles are principally liable to suffer from this condition. This form of neuralgia is also fre- quently found in diabetic patients. Sometimes the pa- tients have the sensation as if a foreign body were in the rectum. The treatment resembles very much that of intestinal colic. The original trouble predisposing to hypogastric neuralgia should always be first treated. If congested piles are present, application of leeches about the anus and warm sitz baths must be recommended. If the pains are violent, suppositories of opium alone or with bella- donna should be used. The diet should be a bland one and the bowels should be carefully regulated. 1 Romberg : "Lehrbuch der Nervenkrankheiten," Berlin. HYPER^STHESIA. 333 Hypercesthesia, Parcesthesia, and Anaesthesia of the Intestine. While in the normal state no disagreeable sensations are manifested during the act of intestinal digestion and defe- cation, in some cases of neurasthenia or hysteria we inetet with exceptions to this rule. Thus, even without apparent anatomical lesions of the intestine, there may be 'a sensa- tion of pressure, fulness, of pinching, of heat or cold in the lower region of the abdomen a few hours after the inges- tion of food. The same sensations may also occasionally appear without the patient having eaten anything, after bodily exertion and excitements, especially after sexual intercourse. The rectum and the anus are particularly liable to be the seat of abnormal sensations. Pliysiologicall} r a feel- ing of fulness is experienced in the rectum when the fecal mass has accumulated in this locality. In case of neuras- thenia a sensation of fulness with an inclination to go to stool may appear, even when the rectum is entirely empty. Sometimes a feeling of pressure or weakness in the anal region may be present; sometimes the patient may be tormented by a constant burning or itching in the 'same region. The act of defecation may be accompanied by erections, sometimes by a feeling of uneasiness; quite often a feeling of extreme fatigue after defecation is ex- perienced. Anaesthesia of the rectum is observed in the same class of patients. The sensation of fulness in the rectum, which causes the desire for defecation, is then absent ; there is, therefore, never a desire for evacuation. In very pronounced cases of rectal anesthesia it may occur that even the pas- sage of fecal matter through the anus is not felt. Such a 334 DISEASES OF THE INTESTINES. high degree of anaesthesia, however, is met with only in pa- tients with spinal and brain troubles and in very old and decrepit individuals. Paralysis of the sphincters, which has been described above, may occasionally accompany the anaesthesia of the rectum and thus aggravate the latter. In such instances involuntary evacuations of the bowels take place without the patient's knowledge. He becomes aware of this fact only after Ms clothes have been soiled and by the fecal odor. In the treatment of these abnormal sensations within the intestines attention must be directed toward the improve- FIG. 37. Rectal Obturator. ment of the general condition, thus raising the nervous tone of the organism. Hydrotherapeutic measures and climatic influences are of the greatest importance. While dietetic measures as such are without much influence upon the nervous disturbances which appear during the intesti- nal digestion, spicy food and alcoholic beverages should, notwithstanding, be forbidden and an essentially vege- tarian regimen recommended. The abnormal sensations within the rectum and anus may be improved by cooling rectal douches, by sitz baths, and also by rectal galvani- zation. In cases of anaesthesia of the rectum a cleansing enema in the morning will remove the fecal matter and thus be beneficial during the day. Patients suffering from the MEMBRANOUS. ENTERITIS. 335 severer forms of anaesthesia should wear a rectal obturator held in place by means of a T-bandage during the day (Fig. 37). SECRETORY NEUROSES OF THE INTESTINES. Although there is no doubt that secretory nerves exist in the intestines for it has been shown that the entrance of food into the stomach is immediately followed by secre- tion not only in the small intestine but also in distant parts of the large bowel still we are yet very far from the knowledge of their exact location. Nervous diarrho3a, which has been described under the motor neuroses, is often accompanied also by an increased flow of intestinal juice. Conditions in which there is a lessened secretion of intestinal juice are not yet positively known. It may be that they exist in cases of constipation, being perhaps the cause of the latter in some instances. While, however, in the disturbances just mentioned the increase or decrease of intestinal secretion is a mere hypothesis, one affection of the intestines exists in which increased secretion is posi- tively found. This is the so-called membranous enteritis. Membranous En feriti*. Synonyms. Mucous Colic; Tubular Diarrho3a; Mem- branous Diarrhoea. Definition. By membranous enteritis is understood an affection in which more or less large pieces of mucus (usu- ally ribbon-like) are passed periodically with the faeces. History. This affection seems to have been familiar to the medical world for several centuries. Paulus JSgineta, ' in speaking of the passage of the inner membrane of the 1 Paulus ^Egineta Cited from Da Costa, American Journal of the Medical Sciences, 1871, p. 321. 336 DISEASES OF THE INTESTINES. intestine, has certainly dealt with cases of membranous enteritis, and erred only in the explanation of these masses. Sennertius and Morgagni ' recognized these membranes as mucus, which had been inspissated and moulded in the intestine. Mason Good " was the first to describe this affection un- der the name of "tubular diarrhrea," which name has also been accepted by Woodward. 3 The latter author adds that in case the membranes in a given instance have no tubu- lar form, the expression " membranous diarrhoea " is suit- able. F. Siredey 4 contributed a very valuable paper in 1869 in reference to the knowledge of this affection. He de- scribed one case of mucous discharge in a man and six cases in women, and arrived at the conclusion that in some instances these mucous discharges occur in patients whose intestinal tract does not reveal any organic lesion whatever. For this reason Siredey regards this affection as an in- testinal neurosis, occurring principally in hypochondriacs and hysterics. Whitehead B describes this affection under the name of "mucous disease," cites the entire old literature, and gives detailed rules with regard to treatment and diet. He says: "Exercise, short of fatigue, should be taken daily. 1 Sennertius and Morgagni : Cited from J. G. Woodward, " The Medical and Surgical History of the War of the Rebellion, " 1879, part ii., vol. i., p. 363. 2 Mason Good : "The Study of Medicine," cl. 1, ord. 1, species 7, vol. i., Philadelphia. 1825, p. 162. 8 Woodward : Loc. cit. 4 Siredey, F. : " Note pour servir si 1' etude des concretions muqueuses membraniformes de 1'intestin. " Union med., Nos. 7-9, 1869. 5 Whitehead, W. : "Mucous Disease." British Medical Journal, February 11, 1871, p. 140. MEMBRANOUS ENTERITIS. 337 The diet is perhaps the point of all others where the great- est mistake is made. An idea, strongly felt by the patient, that a great amount of strengthening food is required, leads to the further exhaustion of an already enfeebled digestion. Impress upon the patients the fact that it is the quantity absorbed which means strength, and not the bulk swallowed, and it is possible to check the error they are so anxious to commit. Certain articles of diet should be strictly interdicted, the chief of which are the follow- ing : Liquid food, excepting milk, aggravates in the major- ity of cases every symptom; sugar is invariably hurtful; tea, coffee, and alcohol Burgundy being the only wine from which I have ever derived benefit vegetables, and fruit also prove injurious." Cruveilhier ' and Laboulbeue 2 discuss this ailment under the term "pseudo-membranous enteritis." One of the best papers upon this disease was written by Da Costa, 3 who called it "membranous enteritis." This author gave a full description of this affection, recognized its nervous character, furnished several detailed cases, and put particular stress upon dietetic treatment. Da, Costa permits eggs, milk, bread, and solid food, which is better borne than liquids; tea, coffee, and alcoholic stimulants are to be permitted only in very small quantities. As re- gards vegetables, we must observe whether they pass un- changed in the stools. Fresh meat juice is serviceable; from an exclusive milk diet, even faithfully carried out, he has seen no good. Furthermore, Da Costa recommends that great attention be paid to the action of the skin, and 1 Cruveilhier : Anat. path, gen., t. ii. s Laboulbene : " Recherches sur les affections pseudomembraneuses, " 1861. 3 J. M. Da Costa : " Membranous Enteritis. " American Journal of the Medical Sciences, 1871, p. 321. 22 338 DISEASES OP THE INTESTINES. believes baths followed by systematic friction to be very useful. Daily moderate exercise is advocated, particularly in cool weather, and if possible an occasional trip to the mountains and living out of doors in the bracing mountain air. Everything that can be done to invigorate the diges- tive and nervous systems forms the essential part of the therapeutics. A few years later there appeared an article by Edwards, 1 who coincided with Da Costa' s views in most points, being, however, much stricter with regard to diet. He says: "Easily digested or "even predigested food should be supplied, and care should be taken that undigested particles of food are not irritating the intestinal canal." Ley den, 2 in 1882, directed attention to membranous en- teritis in Germany, where also very soon appeared ex- haustive publications on this subject. Nothnagel 8 sug- gested the name "colica mucosa," in order to show that a true enteritis need not exist in these cases and that the disease really is a mucous colic. Eothmanu 4 was the first to publish a case of membranous enteritis complicated with cancer of the skull in which an autopsy was made. By means of Weigert's stain, or rather by Ehrlich-Hoy- er's thionin (a specific stain for mucus), double-stained specimens could be obtained, which showed the presence of large quantities of mucus on the surface of the large bowel in the glandular tubules. 1 Edwards : American Journal of the Medical Sciences, April, 1888, p. 329. 1 E. Leyden : Verhandl. d. Vereins f. innere Medicin in Berlin, Deutsche med. Wochenschr. , 1882, Nos. 3.6 and 17. 3 Nothnagel : " Colica mucosa. " Beitriige zur Physiologic und Pathologic des Darms, " 12tes Capitel, 1884. 4 Max Rothmann : "Ueber Enteritis membranacea. " Deutsche med. Wochenschr., 1893, p. 999. MEMBRANOUS ENTERITIS. 339 Ewald, 1 Boas, 2 Kittagawa, 3 Pariser, 4 and others have added further contributions. Ewald laid stress on a ptosis of the colon, Boas on atony of this organ as important factors in this affection. Etiology. Most authors agree that membranous enteritis is quite a rare affection ; it occurs much- more frequently in women than in men (children being only exceptionally affected). That the nervous element (hysteria, neurasthenia) plays a great role in the origin of this trouble, no one can doubt, and W. Mendelson 5 is right when he asserts that neuras- thenia is not absent in any of his cases. Mendelson goes too far, however, when he says : " I believe that the reverse of the proposition may also as confidently be affirmed namely, that if neurasthenic patients be closely questioned, very few will be found who have not had at some time re- peated characteristic passages of stringy mucus, associated with abdominal pains." Membranous enteritis is found in nervous individuals (possibly the affection as such adds much to their neurasthenia) ; but only a small fraction of the great mass of neurasthenics is afflicted with this ailment. With regard to the frequency of membranous enteritis, 1 examined my private patients of the year 1897 relative to its presence, and take the following data from my day- book. The total number of patients was 1,315772 men, 543 women. Twenty of these patients suffered from mem- 1 C. A. Ewald: " Membranous or Mucous Enteritis. " Twentieth Century Practice of Medicine, vol. ix., p. 265. - J. Boas : Deutsche med. Wochenschr. , 1893, No. 41. 3 O. Kittagawa: "Beitrage zur Kenntniss der Enteritis membrana- cea." Zeitschr. f. klin. Medicin, 1891. 4 Pariser: Deutsche med. Wochenschr., 1893, No. 41. 5 Walter Mendelson : " Mucous Colitis a Functional Neurosis. " Medical Record, January 30, 1897. 340 DISEASES OP THE INTESTINES. branous enteritis two men aud eighteen women. The frequency of membranous enteritis among sufferers from digestive disorders expressed in percentages is, in men, 0.25 per cent; and in women, 3.31 per cent. Among these twenty patients, twelve had enteroptosis in a pronounced degree. Ewald has already pointed out that a prolapse of the colon is frequently found in patients with mem- branous enteritis. My own observations fully confirm this statement, for with the prolapse of the stomach descent of the colon naturally must be presupposed. It appears that enteroptosis certainly creates a fruitful soil for the devel- opment of membranous enteritis, although it does not di- rectly cause it. Enteroptosis is, as is well knowu, very frequent, while membranous enteritis is rare in compari- son with the former. There must, therefore, be still other factors which are of importance in the causation of mem- branous enteritis. With reference to gastric secretion and the motor func- tion of the stomach in this disease, I ' have made examina- tions on twelve cases and found the following two points most conspicuous : 1. The motor function (prochoresis) of the stomach- judged from the amount of contents found one hour after the test breakfast was increased in eight cases and n< >r- mal in the four remaining. 2. Five cases presented a typical achylia gastrica. Considering the comparative infrequency of achylia gas- trica, which hardly amounts to two. or three per cent of the digestive disorders, this large proportion of achylia in pa- tients with membranous enteritis namely, five in twelve is certainly noteworthy. 1 Max Einhorn : * Membranous Enteritis. " Medical Record, January 28, 1899. MEMBRANOUS ENTERITIS. 341 Three cases of membranous enteritis with normal acid- ity revealed, besides the increased prochoresis, still another feature in common with achylia namely, the extraordi- narily small amount of fluid surrounding the scarcely changed particles of roll, one hour after the test breakfast. Although this symptom may occasionally be met with in other cases than achylia, it is nevertheless, as a whole, characteristic of this affection. Therefore we are justified in making the following statement : In many cases of mem- branous enteritis typical achylia is present, in some it is lacking, but even then some features characteristic to achy- lia are encountered. In membranous enteritis achylia thus plays a great part. Whether one condition causes the other, or one and the same factor (nervous influences) cre- ates both, is difficult to say. The latter, however, is more plausible. Symptomatology. The disease is characterized by at- tacks of rather violent colicky pains in the abdomen, which are followed by the passage of mucous masses with the stools. The mucus may be voided either alone, without any admixture of fecal matter, or it forms a considerable part of the evacuation. Usually the attack is preceded by a period of obstinate constipation, and often followed by diarrhoea lasting a few days, and sometimes accompanied by tenesmus. Gastric symptoms as loss of appetite, fre- quent belching, now and again a burning sensation at the pit of the stomach are generally quite pronounced during the attack. Vomiting may occasionally appear, while fever is, as a rule, absent. The attack lasts three to seven days, and then the pains subside, the diarrhoea ceases, and eu- phoria reappears. More or less constipation, however, and some other dyspeptic as well as nervous symptoms persist. These free intervals last various periods of time 342 DISEASES OF THE INTESTINES. (four weeks to five or six months). In rare instances the mucous discharges may be present continuously. With reference to the mucous masses, they present a grayish-white appearance, seldom yellowish, and have either a ribbon-like or membranous form; at times the pieces are several feet Ipng ; ordinarily, however, they are considerably smaller. Complete moulds of the intestinal lumen have been observed by several authors, and Ley den not unjustly has compared this process with that of croup of the larynx. As already stated by Cornil, 1 the false membranes consist of mucus, mixed with dried-up epithe- lial ovoid cells, which arise from a mucous metamorphosis of the cylindrical cells or the leucocytes. Nothnagel and others have proven the mucous nature of these dis- charges. As suggested by Pariser, the mucous nature of these masses can be demonstrated by treating them, first, with sublimate alcohol, and then staining them with Ehrlich's triacid solution. A green color appears, which indicates mucus (fibrin treated in the same manner assumes a red color). Judging from my experience it is unnecessary to dip these membranes first into sublimate alcohol, as the same result will follow when they are put directly into the weak triacid solution. Microscopically this substance re- veals a somewhat fibrillary nature, and contains many shrivelled cells, so called by Nothnagel. Micro-organisms are found admixed, although they do not seem to play any important part in this affection. In two of my cases mi- croscopically single-celled corpuscles were found in these masses, having a distinct nucleus and a tail-like process. The accompanying drawing shows these corpuscles {Fig. 38). These are most probably metamorphosed goblet cells. 1 Cornil : Cited from Siredey. See above. MEMBRANOUS ENTERITIS. 343 Diagnosis. The diagnosis of membranous enteritis is, as a whole, simple when the above-mentioned character- istic symptoms, including the mucous discharges, are pres- ent. It is, however, necessary to be careful not to mis- take for mucus other substances admixed in the faeces, FIG. 38. Microscopical Picture of Mucous Masses Found In the Evacuation of Mrs. I*, Showing Numerous Cells Having a Nucleus and a Tail-like Process. which occasionally resemble shreds of mucous membrane as, for instance, the fibre of an orange, tendons, pieces of tapeworm. A microscopical examination will guard against all such errors. This affection will hardly be confounded with real intes- tinal catarrh, as it presents an entirely different picture and only occasionally may have an abundant secretion of mucus in common with mucous colic. There are, however, 344 DISEASES OF THE INTESTINES. cases of chronic intestinal catarrh which are complicated with membranous enteritis that is, having typical attacks of mucous colic. The following case presents an instance of this kind : Miss L. N , twenty-eight years old, had diarrhoea eleven years ago for quite a while, which disappeared after two or three months. The patient was then well until four years ago, when she again began to be troubled with diarrhoea. Soon periods of obstinate constipation ap- peared, which alternated with diarrhosa. The patient re- ports having occasionally observed mucus in the passages ; at times (about every five or six weeks) there appear abdominal pains for about one or two hours, followed by an evacuation of pure mucus, the quantity being one to two tablespoonfuls. The appetite was always good. Now and again there was belching. The patient lost about twenty- five pounds in weight. Sleep is undisturbed, only at times restless for a few days. Her strength greatly failed. Pal- pation of the abdomen reveals spots sensitive to pres- sure in the entire course of the colon. The examination of the faeces in the free interval shows small quantities of mucus well mixed with the fecal matter. The mucous masses voided after an attack of pains are free from fecal matter, appearing grayish-white and staining green when treated with Ehrlich's triacid solution. Treatment. Diet plays the principal part in the treat- ment of membranous enteritis. While the older writers laid stress on scanty light food, it is now generally ac- cepted that abundant nutrition is of the greatest value. That a fluid diet is unsuitable, the older authors have al- ready been cognizant of (Da Costa, TVhitehead, Siredey), and this axiom holds good in its entirety even to-day. Eecently von Noorden ' advised a very coarse diet, being 1 C. von Noorden : " Ueber die Behandlung der Colica mucosa. " Zeitschr. f. practiscbe Aerzte, 1898, No. 1. V MEMBRANOUS ENTERITIS. 345 guided by the idea that the intestinal tract should be exer- cised and strengthened by increased work. He recom- mends per day half a pound of bread containing plenty of chaff, leguminous vegetables, garden vegetables rich in cellulose, fruits with small pits and coarse skin, as cur- rants, gooseberries, grapes 1 these being foods rich in un- digestible material, thus forming much ballast for the bowel. Among fifteen patients subjected to this treatment by von Noorden, seven were permanently cured, seven im- proved, and one was unchanged. This method has certainly much in its favor ; it may be better, however, not to institute this diet abruptly, as sug- gested by von Noorden, but rather gradually. I, for my part, for some years past have seen to it that my patients partook of an abundant and nutritious diet, without, however, advising substances that were too coarse. As a whole, I recommend ample food and try to keep the patients on a mixed diet containing plenty of vegetables. In patients who have lived on a strict diet (as for instance milk diet or beef and hot water), I arrange the change gradually. The principle here is the same as stated by von Noorden, only not carried to such an extreme. It ap- pears sufficient if the intestines of the patient with mem- branous enteritis are trained to master the foods customary in healthy persons, and the accomplishment of this object is all that is required. If we subsequently see that the organism amply fulfils its work, a few less digestible foods may then be added. It is not necessary to recommend these immediately from the start, nor are they important for the cure. With regard to therapeusis, two phases will have to be considered the treatment during the attack and the treat- ment during the interval. In severe attacks, rest in bed, 346 DISEASES OF THE INTESTINES. warm poultices over the abdomen, a cleansing enema (of ordinary warm water with the addition of some common table salt or essence of peppermint one teaspoonful to a quart), and afterward the administration *of codeine or opium, with or without belladonna, are of value. As long as the pains last it is necessary to give light food (small quantities frequently) . In mild attacks a stay abed may not be requisite, nor the administration of an analgesic remedy, and the diet may be the same as during the in- terval. In the interval free from pains the treatment consists in a methodical application of olive-oil enemas, as suggested by Kussmaul and Fleiner. 1 These enemas are injected into the bowel at night, at blood temperature, the quantity being two hundred and fifty to five hundred cubic centimetres. The patient is then instructed to try and retain the oil in the bowel during the night. The patients seldom assert that they are disturbed in their sleep by these injections and have to answer nature's call. In such an instance the quantity of oil may be reduced to one hundred and fifty or one hundred cubic centimetres. The oil should be injected every night for three weeks; then every other night for three weeks, and twice weekly for four weeks ; finally, once weekly for five or six months. Besides, patients must accustom themselves to a regular morning evacuation, by promptly visiting the closet every day at the same hour in the morning. Next to abundant nourishment the methodical oil cure is of the greatest importance in the treatment of this affection, and the results achieved are, according to my experience, very satisfactory. The administration of oil injections in membranous enteritis is mentioned here and 1 Fleiner . Berliner klin. Wochenschr. , 1893, No. 3. INTESTINAL NEURASTHENIA. 347 there in recent literature, especially by Ewald, but its value must be placed much higher than heretofore. The oil has not only a favorable influence upon the constipa- tion which is always present in this malady, but at the same time also effects a diminution or a disappearance of the mucous discharges. How the oil brings this about is difficult to say. The favorable effect may perhaps be ex- plained by the circumstance that by means of the oil the intestine is not left in an empty condition during the night, and thereby a spasmodic contraction is avoided, which must be regarded as one, of the principal factors in the formation of mucus. It is evident, according to my statement with regard to the etiology, that enteroptosis and anomalies of the gas- tric functions (principally achylia) exist in a large number of these cases. It will, therefore, be necessary to bear these points in mind and to treat the cases accordingly. The neurotic symptoms present in these cases should not be neglected in the general plan of treatment. "We shall have to pay attention to a regular hygienic mode of living and ample physical exercise. In suitable cases occasional hydrotherapeutic measures will be of value. The tonic remedies, like iron, arsenic, etc., will also prove beneficial. Intestinal Neurasthenia. The various intestinal neuroses have been separately described. In practice combinations of different neuroses ' frequently occur. Following Rosenheim we designate such cases as intestinal neurasthenia. The appetite as a rule is good and the symptoms usually appear during the pe- riod when intestinal digestion takes place. The symptoms generally develop one to three hours after meals and consist in a feeling of pressure, tension, and sometimes of griping 348 DISEASES OF THE INTESTINES. in the abdomen. Occasional!}' there may be a sensation of nausea, at times an evacuation of the bowels accompa- nied with painful sensations in the abdomen and in the anus. Sometimes palpitation of the heart occurs, some- times again a sensation of flashes of heat or of cold extend- ing upward. As a rule, the patients feel worse when rest- ing, especially in the recumbent position, than when walking about. After a period of one or two hours the symptoms usually disappear, to return again later on after a meal. Constipation is as a rule associated with this condition. The quality of the food does not seem to exert much influence upon the symptoms, although the latter are more marked after heavier meals. In a few instances, es- pecially when the pains play a predominant part and bor- borygmi occur, diarrhoea is encountered. In these cases the diarrhoea appears in the middle of the night or toward early morning, and disturbs the patient's sleep. It is of diagnostic importance that the pains do not in any way depend upon the quality of the food. Indigestible foods, even taken in considerable quantity, are occasionally well borne, while at other times a small meal, consisting of the lightest food, causes severe symptoms. Intestinal neuras- thenia is sometimes associated with gastric neurasthenia and completes the picture of the other. In making the diagnosis of intestinal neurasthenia ana- tomical lesions of the intestines must first be excluded. The treatment consists in hygienic measures which serve to tone up the system, in ample feeding, and in the admin- istration of the bromides, occasionally in conjunction with iron and arsenic. With regard to diet all foods are al- lowed excepting indigestible substances, and a preponder- ance of vegetable food is to be recommended. CHAPTER XII. INTESTINAL PAEASITES. General Remarks. Most of the animal parasites found in man inhabit the intestinal canal. Leuckart ' estimates the number of varieties at about fifty. Not all parasites, however, produce morbid conditions. Comparatively few of them evoke a pathological state, either in the intestine by their direct presence, or in the blood by the formation of toxic products which are absorbed- and reach the circu- lation. The intestinal parasites are detected by repeat- edly examining the stools. They may be seen or their presence may be assumed from the discovery of their ova (the latter referring to the helminths). There are no char- acteristic symptoms which would be encountered only in morbid conditions due to animal parasites. The diagno- sis, therefore, must be made by directly discovering them or their eggs in the dejecta. It will always be wise to look for worms in cases in which gastric and intestinal symp- toms of a functional character exist, accompanied or not by anaemia and certain neuropathic affections. The intes- tinal parasites are divided into two large groups: (1) Pro- tozoa. (2) Vermes. I. PROTOZOA. Amoebce. Besides dysenteric amoebae which have been described above, a similar variety is occasionally encountered giving 'Leuckart: "Die inenschlichen Parasiten," Leipzig, 1886, Bd. ii. 350 DISEASES OF THE INTESTINES. rise to no symptoms whatever or sometimes to slight at- tacks of diarrhoea. Sporozoa. Among the sporozoa coccidia are occasionally found in the stools. This organism is egg-shaped, provided with a thin shell, 0.02 mm. long, and contains in its interior a large number of nuclei usually arranged in groups. The coccidia do not seem to have any pathological bearing. Infusoria. To these belong cercomonas intestinalis, trichomonas intestinalis, and paramaecium coli. All of them are found principally in conditions in which diarrhoea is the fore- most symptom. The cercomonas intestinalis is pear-shaped, has a distinct nucleus and eight flagellse. The head portion of the body tapers obliquely and presents a depression (Fig. 39). It is not believed to have a direct pathogenic significance. Sf FIG. 39. Cercomonas Intestinalis (Da- FIG. 40. Trichomonas Intestinalis (Zun- vaine). ker). It is assumed, however, that this micro-organism is liable to prolong pre-existing catarrhal affections of the intestine. Trichomonas intestinalis presents the same features as the cercomonas and can be distinguished from the latter by its somewhat greater size and the row of fine cilia upon the periphery of its body (Fig. 40). In fresh dejecta this mi- cro-organism moves around very actively. Zunker ' found 'Zunker: Deutsclie Zeitschr. f pniktisc-lie Medicin, 1878, No. 1. TAPE WORMS. 351 it principally in mushy dejecta having a brownish-yellow color and a somewhat putrid odor. Paramcecium (or balantidium} coli is egg-shaped, 0.1 mm. long and covered with fine cilia, the latter being densely grouped about the mouth, while but few of them surround the anus. In the interior of this or- ganism are found a nucleus and two contractible vesicles, besides fat drop- lets, starchy particles, etc. (Fig. 41). The balantidium coli was first de- scribed by Malmsten ' in 1857. In the fresh stools the balantidium moves about very rapidly, but it dies as early as one-half an hour to two hours after the dejecta have been passed. Like the cercomonas, the paramsecium coli is believed to keep up conditions of diarrhoea. The treatment directed against these infusoria consists in intestinal irriga- tion with watery solutions of tannic acid, boracic acid, thymol, or quinine. II. VERMES. Cestodes (Tape Worms'). General Remarks. In describing the disorders caused by tapeworms it is best to include the teenia solium, tamia mediocanellata, and bothriocephalus latus. The symptoms produced by these three different entozoa are almost identical. In some instances the tapeworm is domiciled in the intestine for a long period of time with- out manifesting any symptoms. The host may enjoy per- 1 Malmsteu: Yin-how's Aivhiv. lid. xii. FIG. 41. Balantidium Coll (Claus). a. Mouth : 1>. nucleus ; r, a granule of starch which has been ingested ; d, a for- eign body in the process of being expelled. Highly magnified. 352 DISEASES OF THE INTESTINES. feet health and only after noticing segments of taenia in the dejecta does he become conscious of his uninvited guest. In other instances the worm produces intestinal as well as general disturbances. A feeling of pressure at the pit of the stomach and pains at different points of the abdomen may be present. Bulimia is frequently encountered. Anorexia and anorexia alternating with bulimia are also occasionally observed. Nausea, even vomiting, may be present, especially in the morning. The bowels are usu- ally constipated. In a few instances, however, there is persistent diarrhoea. Besides these gastro-intestinal symptoms there may be present various disturbances of the nervous system or of the blood; dizziness, headache, fainting spells, convul- sions, epilepsy, various forms of parsesthesia of the ex- tremities. Some patients, again, look very bad and be- come emaciated, notwithstanding that they take sufficient quantities of food. The anaemic condition is occasionally very marked. The patient feels extremeh r weak, suffers from palpitation of the heart, is hardly able to walk, and is subject to fainting spells. In this serious form of aure- mia oedema of the feet and eyelids may exist as well as hemorrhages from the mucous membranes. The micro- scopical examination of the blood in these instances reveals poikilocytosis and also nucleated red blood corpuscles, thus demonstrating the existence of a progressive per- nicious anaemia. The grave condition just described has been observed only in the presence of bothriocephalus latus but not of the other varieties of tapeworms. The proof that the symptoms described are produced by the tapeworm is found in the circumstance that they disappear entirely after the removal of the parasite. None of the above symptoms, however, permits the diag- TAPE WORMS. 353 nosis of tapeworm, for they are found also when it is not present. The diagnosis can be made only by the discov- ery of either segments of the parasite or their eggs in the stools. The tapeworm has a head or scolex, which may remain alive for years, even when separated from the other part of the body, an oblong neck and detachable segments (proglottides). The latter vary in size and in configura- tion the farther away from the head they are situated. They possess the power of moving. The tapeworm is a flat worm devoid of mouth or intestine. It grows by alter- nate generation through the germination of a pear-shaped primary host (head) and remains united with the latter for a considerable time as a long band-shaped colony. Each member of the colony forms a sexually active individual. The proglottides increase in size the more distant they are from the head. The tapeworm is an hermaphrodite. It is provided on its head with four sucking discs, by means of Avhich it is enabled to attach itself to the intestinal mu- cosa. It derives its nourishment by means of pores from the intestinal chyme. The older proglottides contain a large number of fructified eggs. The la.tter are off and on emptied into the intestinal canal and then appear in the dejecta. The ovum contains an embryo which requires for its de- velopment an intermediary host. After reaching the stom- ach of the intermediary host the envelope of the ovum is dissolved by the gastric juice. The embryo is now set free and finds its way either by the lymphatics or by the blood-vessels to some place (usually the muscles) where it settles. Here it surrounds itself with a sac, which later on may become surrounded with a calcareous deposit. In this condition the embryo is called cvsticercus or measle. 23 354 DISEASES OF THE INTESTINES. When the measle again reaches the stomach of a new host it then opens and its scolex advances into the small in- testine, where it develops into a full-grown taenia. Tcmia Solium. Taenia solium, or the armed tapeworm, when fully developed, is from two to three metres long. Its head is of pinhead size and spherical in shape. It has four cuplike suckers, in the middle of which is situated the rostellum, the latter being surrounded with a large number of hooks (Fig. 42). These are arranged in two rows and number from twenty-four to twenty-six. Succeeding the head is a filiform neck, almost an inch long. Commencing at a certain distance from the head the body is di- vided into segments. The mature proglottides PIG. 42. Head of Tsenla Solium with Pro- truding Rostellum. Magnified 50 diameters. (Zlegler.) FIG. 43. Half Developed and Fully Matured Segments. Natural size. (Leuckart.) are 1 to 1.5 cm. long and 6 mm. wide. The genital open- ing is situated at the side near the posterior border of the uegment (Fig. 43). The uterus forms a straight median tube, giving off at right angles five to seven branches on TJ3NIA SAGINATA. 355 each side. These branches are undivided at first, but to- ward the periphery ramify in the form of a tuft (Fig. 44). The eggs are round and provided with a thick shell. Tsenia solium inhabits the small intestine of human beings. The further development of the embryo into A FIG. 44. Taenia Solium. Showing two proglottides. A, A, pores. (Huber.) measles occurs in the intermediary host, the pig, in which condition they reach the human system and are trans- formed into mature tseuias. Earely the measles (cysto- cercus cellulosae) are found in men, in which instance they occur in various organs, brain, eye, skin, etc. The grav- ity of the disease which they produce depends upon the importance of the organ they involve. Tf&nia Saginata or Mecliocanellata.T}iis tapeworm is the one most frequently observed in America as well as abroad. The tsenia saginata is much longer, thicker, and wider than tsenia solium. The head is 2.5 mm. large, has four large sucking-discs but no rostellum, and is often pigmented (Fig. 45). The length of the worm is 4 to 5 metres, the proglottides are unusually thick, the widest being in the middle. The mature segments occasionally attain a length of 2.5 cm. The uterus lies in the middle of the segment and gives off numerous branches on both sides (about twenty on each side (Fig. 46). The genital opening is situated on the side below the middle. The 356 DISEASES OF THE INTESTINES. eggs have an elliptical shape, a brownish color, and a con- tour exhibiting radiating streaks. The taenia sagiuata inhabits the small intestine of man. Its measles occur in beef, as has been demonstrated by rf I I II ~ s * Huber ' and Leuckart. These measles are usually smaller than those of taenia solium. Human beings acquire this Twentieth Century Practice of Medicine, " vol. viii. , p. 1 Huber: 570. BOTHRIOCEPHALUS LATUS. 357 tsenia by the consumption of raw beef. The measles have not as yet been found in man. Bothriocephalas Latns, Tcenia Lata or Pig Head, This tapeworm is the longest. It measures from five to eight metres. The head is elongated, of almond shape, being about 2.5 mm. in length (Fig. 47). It has two lengthy big grooves on its flat surface (Fig. 48). The neck is nar- row, about 2 cm. long. The body is thin and flat like a ribbon, excepting the central part of the segments which FIG. 46. The Uterus and its Branches in a Segment of Tsenia Saginata. Enlarged 3 diameters. CHuber.) project somewhat outward. The genital openings are on the flat surface in the middle, the female very close to the male. The uterus has a special opening and four to six visible uterine convolutions on each side, which look al- most like a rosette. The eggs are oval, round, with a thin membrane and a lid (Fig. 49). They measure 0.07 mm. in length and 0.04 in width. The measle of bothriocephalus latus occurs principally in fish, especially in pike, turbot, perch, and trout. The ta?nia lata lives in the small intestine of man, but is also, though rarely, found in dogs. In the northeast- ern part of Europe, Holland, Switzerland, and Japan this tapeworm is very prevalent. In America it occurs but in- 358 DISEASES OF THE INTESTINES. frequently. As stated above, among the symptoms pro- duced by bothriocephalus anaemia is often observed. Aside from the three tape- worms just described there exist a few more varieties which are only rarely met in human beings. They are : (1) Tcenia Nana. This is the smallest tapeworm found in man. It measures 10 to 15 mm. in length and may have one hun- dred and ninety segments. The head has four sucking - discs, a rostellum, twenty - four to twenty-eight hooklets in a sin- gle row. The proglottides are short and broad; the genital openings are on one side. This tapeworm has been ob- served principally iu Egypt and Italy in children. It usually occurs in large numbers in the small intestine, from forty to even five thousand. The symp- toms produced by this tapeworm are mostly nervous disturbances, fainting spells, occasionally even epilepsy. (2) Tu'nia Cucmnerina. This small cucumber-shaped tapeworm occurs frequently in the intestine of the dog, but has also been found, although rarely, in small children. The tapeworm is 10 to 40 cm. FIG. 47. Bothriocephalus Latus. Natural size. (Leuckart.) TAPE WORMS. 359 long and about 3 mm. wide. The measle of this tsenia inhabits the flea. (3) Tcenia Flavo-Punctata or Tcenia Diminuta. This parasite is 2 to 6 cm. long and 3.5 mm. wide. Its head is very small, club-shaped, and provided with sucking- discs. The measle infests the caterpillar and cocoon of I FIG. 48. FIG. 49. FIG. 48. Head of Bothriocephalus Latus. Magnified. (Heller.) FIG. 49. Eggs of Botbriocepbalus. (Krabbe.) asopia famialis and in the coleoptera axispinosa. This tapeworm has been observed in man only a few times. (4) Bothriocephalus Cordatm. This tapeworm resembles in all particulars the bothriocephalus latus except that it is much shorter and that the head merges into the proglot- tides directly without an intermediary neck. It occurs in the intestine of men and dogs in Greenland. The list of the tapeworms enumerated above is not com- plete, for there exist the taenia madagascariensis, bothrio- cephalus liguloides, and others, but as 'these do not occur in Europe or America a description of them does not ap- pear to be of practical interest. Treatment. Prophylaxis. In order to escape infection with tapeworm it is necessary to abstain from raw or me- dium done meats, including fish. The sanitary inspection 360 DISEASES OF THE INTESTINES. of the meat' is no absolute guarantee that it is free of measles. Thorough boiling or broiling of the meat de- stroys the cysticerci and thus the danger is avoided. In order to diminish the spread of tapeworm it is advisable to free the patient of the worms and thoroughly to destroy them as soon as possible after they have left the intestine. Whoever examines the proglottides or the ova should care- fully wash and disinfect his hands immediately afterward in order to avoid auto-infection. The direct treatment of the tapeworm consists in meas- ures to expel it from the intestinal canal. This is accom- plished by emptying the bowels previously and giving a vermifuge afterward. The treatment is carried out in the following way : For about two days before giving the ver- mifuge the patient is kept on a scanty diet, consisting cf some milk, meat and broth, very little bread or none at all. A laxative (calomel eight to ten grains or castor oil one tablespoonful) is given once a day. On the evening preceding the administration of the vermifuge the patient should have no supper or should take only salt herrings with onions. On the following morning a cup of coffee or tea is given. Half an hour to one hour later the vermifuge is administered. Among the drugs for the removal of the tapeworms the following are the most efficient : Male-fern extract is given in doses of 6 to 10 gin. ( 3 iss.- iiss.), as for instance: $ Extr. filicis mar. aether 8.0 ( 3 ij.) Syr. simpl 40.0 ( i*) S. To be taken iu ten minutes. The dose of male-fern should never be very high and should not exceed 10 gm. ( 3 iiss.), as symptoms of intoxi- cation have frequently been observed. Pomegranate root is also au efficient remedy, espe- TAPE WORMS. 361 cially if it is fresh. It may be given in an infusion of the bark, three ounces of which are macerated in ten ounces of water and then reduced to one-half by evaporation. The entire quantity is then taken within half an hour. Pelletierine, the active principle of pomegranate root, may also be used in doses of five to eight grains. Flores koosso, about 20 to 30 gin. ( 3 v. to f i. ) of the blossoms are thoroughly mixed in sugar water or lemon- ade and should be taken within one-half or one hour, or IJ Flores koosso, Mellis despumati aa 3 v. (20 gm.) Fiat electuarium. S. To be taken in two portions. Kamala may also be employed in doses of 10 gm. C 3 iiss.) mixed in aqua foeniculi or in wine and taken in the same way.__ Turpentine 30 to 60 gm. ( 3 i.-ii.) may be given in cap- sules. After this medicament one or two glassfuls of milk should be taken. Pumpkin seeds (semina cucurbitse) may be administered in doses of 120 gm. ( iiv.), thoroughly mixed with the same amount of grape sugar. Cocoanut has also been recommended for this purpose. The milk and albumin of an entire nut should be consumed within one hour. Naphthalin in doses of 0.6 to 2.0 gm. (gr. x.-xxx.) may be given in capsules. Salol 3 gm. (gr. xlv.) in capsules may also be advanta- geously employed. One or two hours after the administration of the vermi- fuge a cathartic should be given, usually about two table- spoonfuls of castor oil, or citrate of magnesia one to two teaspoonfuls. The resulting evacuation must be thor- 362 DISEASES OF THE INTESTINES. oughly examined and the tapeworm looked for, especially its head. Children require a correspondingly smaller dose of the above remedies, according to their age. Patients who are debilitated, or have intestinal disorders or organic lesions of the digestive tract, should not be subjected to this treat- ment, nor should it be employed shortly after typhoid fever or other grave diseases. In these conditions it is necessary to postpone the treatment until a more oppor- tune time. Trematodes (Fluke Woi-ms). The trematodes are solid worms of a tongue or leaf They possess a clinging apparatus in the form of FIG. 50. Dtetoma Hepatioum. with Male and Female Sexual Apparatus. CLeuckart,) Magnified 2M> diameters. oral and ventral sucking-cups varying in number. Some- times they are also provided with hook or clasp like pro- jections for this purpose. The intestinal canal is without any anus and is split like a fork nearly throughout its extent. The fluke worms are mpstly hermaphroditic. To these belong : Dlstoma Hcjif!rn,n or Liver Fluke. This parasite has a leaf shape, is 22 mm. long and 12 mm. wide. The ceph- alic end projects like a beak and bears a small cuplike DISTOMA LAXCEOLATUM. 363 sucker, in which the mouth is located. Close behind this on the ventral surface is a second suction cup and between the two lies the sexual orifice. The uterus consists of a FIG. 51. Eggs of Dlstoma Hepaticum. (Leuckart.) Magnified 200 diameters. convoluted bulb-shaped bag, situated behind the posterior sucker. On each side of the body lie the ovisacs and be- tween them the much branched testicular canals (see Fig. 50). The eggs are oval, 0.13 mm. long and 0.08 mm. wide. They have a brownish color and are provided with a lid (Fig. 51). The liver fluke is rare in man, though frequently found in ruminating animals. It inhabits the biliary ducts and is occasionally found in the intestine and in the inferior vena cava. The symptoms which it produces are varied: jaundice, enlargement of the liver, diarrhoaa, hemorrhages. FIG. 52. Dlstoma Lanceolatum with its Inner Organs. (Leuckart.) Magnified 10 diameu-rs. Most probably the liver fluke reaches the intestinal canal by means of impure water or vegetables. Distoma lanceolatum is 8 to 9 mm. long and 2 to 2.5 mm. wide. It has a lancet shape and the head portion is not specially marked off from the body (Fig. 52). The eggs 364 DISEASES OF THE INTESTINES. are considerably smaller than those of distoma hepaticum, being only 0.04 mm. long (Fig. 53). With regard to its occurrence and symptoms it resembles the liver fluke. Distoma hcematobium or JSilharzia hcematobia is fre- quently found in hot climates, especially in Egypt. In FIG. 53. Egg of Distoma Lanceolatum Shortly After the Formation of a Shell. (Leuck- art.) Magnified 400 diameters. the United States and in Europe it is very rarely found. This parasite has separate sexes. The male is from 12 to 14 mm. long. Its body is smooth, but in its posterior portion rolled up into a tube, which serves for the recep- tion of the female (canalis gynaecophorus) (Figs. 54 and 55). The female is from 16 to 19 mm. long and almost FIG. 54. FIG. ;V>. FIG. 54. Distoma Haematobium. (Leuckart.) Male and .female, the latter in the ca- nalis gynaecophorus of the former. Magnined 10 diameters. FIG. 55. Eggs of Distoma Haematobium. (Leuckart.) a. Egg with terminal spine; b, egg with lateral spine. Magnined 150 diameters. cylindrical. The sexual opening lies in both sexes close behind the ventral sucker. The distoma haematobium ROUND WORMS. 365 finds its way into the intestinal canal of man and then reaches the portal circulation, where it develops. In the intestinal canal it has been encountered very rarely, in which case ulcerations of the intestinal mucosa were pres- ent. It frequently causes haematuria and great cachexia, terminating fatally in some instances. As regards treatment, the removal of these fluke worms must be undertaken in identically the same manner as that of the tapeworms described above. Nematodes (Round Wo)*ms). The round worms which occur as parasites have a slen- der, cylindrical, sometimes filiform body, with neither segments nor appendages. The integument is thick and elastic. The oral opening is at one extremity and provided with either soft or hornlike lips. The alimentary canal extends throughout the entire body cavity, terminating in an opening upon the ventral side at a short distance from the posterior extremity. The sexual organs and their ori- fices lie on the ventral surface. The female aperture is located at about the middle of the body ; in the male the sexual orifice is situated close to the anus. The males are usually much smaller than the females. Ascaris Lumbricoides (Common Spool or Hound Worm). This worm is one of the most frequently observed para- sites in man. The round worm has a light brown or red- dish color and a cylindrical shape. The male is 20 cm. and the female 30 cm. long. The posterior extremity of the male is bent in the form of a hook and provided with two spicules or chitinous processes. The mouth is sur- rounded by three muscular lips provided with very fine teeth. The sexual opening of the female lies anterior to the middle of the body (Fig. 56). The eggs when ripe 366 DISEASES OF THE INTESTINES. FIG. 56. Ascaris Lumbrtcoides. (Perls. ) A, Female ; JB, male. (Natural size.) At a Is the female sexual orifice ; c, the two splcules of the male ; ft. head extremity (magnified) of the worm, with the three lips. have a double shell and around this is an albumi- nous envelope which is ir- regularly shaped, and studded with excrescences (Fig. 57). The long di- ameter of the egg is about 0.05 mm. The round worm pos- sesses a strong odoriferous principle which is very perceptible even after the worm has been carefully washed. According t o Huber, ' this substance may occasion urticaria in persons predisposed to this eruption. It is not im- probable that certain of the symptoms of ascariasis are due to the action of the same element. The principal habitat of ascaris lumbricoides is the small intestine of man. It develops here often in large numbers, fifty to one hun- dred and more occurring together. The mode of transmission, according to 1 Huber: "Twentieth Century Practice of Medicine, " vol. viii., p. 583. ASCARIS LUMBRICOIDES. 367 FIG. 57. Egg of As- carls Lumbricoides (Leuckart) with Shell and Albuminous En- velope. Magnified 300 diameters. Leuckart, Grassi, ' and Lutz/ is by ingestion of the eggs of the ascaris, there being no intermediate host. The full development of the round worm from the egg to its period of sexual maturity requires ten to twelve weeks. Infection usually takes place by eggs existing in the soil near dwell- ing-places, in the drinking-water, and also in some foods, principally salads and fruits. Ascaris lumbricoides is most frequently found in children three to twelve years old, the poorer classes showing a larger percentage than the well-to-do. In grown persons the worm is not so frequent. The female sex is more frequently infected than the male. The diagnosis of ascariasis is made by the detection of the worm in the fecal matter, or of its eggs, which are easily recognized. Symptoms. Ascariasis may exist without giving rise to any symptoms whatever. Occasionally, however, there are various disturbances : anorexia, nausea, irregularity of the bowel, meteorism, an irregular pulse; in children black rings around the eyes, much nervousness, even convul- sions. In rare instances progressive anaemia has been ob- served (Leichtenstern). Anatomically hypenemia of the intestinal wall has been frequently found, erosions are rare. Itching of the nose is often present in ascariasis and may be due to the odoriferous principle. The round-worm is liable to wander and may then give rise to severe complications. In several instances it has 1 Grassi: Centralbl. f. BuctiTiologie und Parasitenkunde, 1887. 4 Adolf I,ut/: " Klinisclu's iibcr Parusitcn di-s Mcnschen und der Haustbieie." Ceiitralbl. f. Bacteriologie, 1889. 368 DISEASES OF THE INTESTINES. been found in the bile duct, in the gall bladder, and even in the liver, producing abscesses and even a fatal issue. The worm occasionally migrates into the stomach and pro- duces pain and often vomiting. In the latter act it is often expelled from the mouth. Occasionally it ascends the oesophagus and enters the larynx, causing asphyxia, and, in rare instances, even death. It has also been found in hernial sacs and in the peritoneal cavity, but it is gen- erally believed that it cannot penetrate through the healthy intestinal wall. Obstruction of the bowels by a conglomeration of ascarides has also been thought pos- sible ; its real occurrence, however, is denied by Leichten- stern. ' Prophylaxis requires total destruction of all the eggs of the ascaris passed with the fecal matter of the patient. The grounds near dwellings should be kept perfectly clean and the hands should be frequently washed. All foods should be protected against a possible infection. Treatment. The treatment consists in freeing the pa- tient from the worms. This is done in a similar manner as in the case of tapeworms. The intestinal tract is kept partially empty for a day or two before the administration of the anthelmintic. The most efficient remedy for this pur- pose is santonin, which is given in a dose of 0.02 to 0.06 gm. (gr. -i.) twice or four times a day. Then a purgative remedy is given. Some combine the santonin with the purgative and give them together. Thus santonin 0.2 (gr. iiiss.), castor oil 60 gm. ( 3 ii.), twice or three times daily one teaspoonful for small children, a dessertspoonful for larger children, and one tablespoonful for grown people. 1 Leichtenstern : " Verengerungen, Verschliessungen und Lageveran- derungen des Darms. " von Ziemssen's Ilaiiulmrli der spec. Path, und Thcrapie, Bd. vii., Abtli. '2. OXYURIS VERMICULARIS. 369 The santonin may also be given in combination with cal- omel; thus 3 Calomel 0.05 to 0.1 (gr. i.-ij.) Santoniii 0.02 (gr. ) T. d. No. ix. S. One powder three times daily. Flores cinse, the plant from which santonin is obtained, may also be administered in doses of 0.5 to 2 gra. as powders or as an electuary, with the addition of jalap, 0.1 to 0.2 gm. Chenopodium or wormseed is also a popular remedy, the powdered seeds being given in doses of 1 to 2 gm. (gr. xv. -xxx.), or the volatile oil in five to ten drop doses. Thymol has also been recommended in doses of 0.5 to 2 gm. (gr. vii.-xxx. ) in twenty-four hours. It may be given in gelatin capsules. Irrigation of the bowels with water to which three to five drops of benzene have been added has likewise been suggested, but does not appear as bene- ficial as santonin. Ascaris Mystax. A round-worm resembling ascaris lum- bricoides but much smaller and somewhat thinner. This parasite frequently occurs in animals, principally in cats, but has been discovered very rarely in man. No symp- toms whatever have been observed. Oxyuris Vermicularis, Aivltail, Seat or Pin Worm, Mag- got or Thread Worm. This parasite is white and filiform, 4 to 12 mm. long and 0.2 to 0.6 mm. thick (Fig. 58). The males are much smaller than the females. The oxyuris has three small knoblike lips. The female possesses two uteri passing backward and forward from the end of the vagina. The opening of the latter is situated above the middle of the body. The eggs are 0.05 mm. long and 0.02 wide. The contents are granular and the shell appears white. 24 370 DISEASES OF THE INTESTINES. Infection takes place when the eggs of oxyuris reach the stomach. Here the shell opens and the embryo migrates into the small intestine (Fig. 59). After fructi- fication has taken place the females usually begin to wander along the in- testinal canal. 'In the cascum they generally make quite a long sojourn until the eggs are almost ripe. Then they again begin to pass down- ward. According t o Leichtenstern, Lutz, and Huber, the females do not pass their eggs within the intestinal canal. As a rule they first leave the bowel and then deposit the eggs. For this reason the fecal matter usually does not contain any eggs. The symptoms which are most frequently observed con- sist in pronounced pruritus ani due to the irritation pro- duced by the passing of the parasites out from the rectum. Frequentlj r the itching annoys the patient as soon as he retires. Various nervous symptoms are occasionally ob- served: anorexia, nausea, dizziness, palpitation of the heart, pollutions and spermatorrhoea in the male ; besides diarrhoea occasionally occurs. Pronounced anaemia is en- countered, although rarely. In rare instances the para- sites reach the vagina and cause irritation there. Nymph- omania has then been observed. Infection probably occurs through direct conveyance of FIG. 58. Oxyuris Vermicularis : o, natural size : b, head ; c, tall, magnified ; <./. head greatly magnified. OXYURIS VERMICULARIS. 371 the eggs by the unwashed hands of the host. It is also possible that ova dried by the sun exist on fruit, radishes, or salads, in which state they may be carried into the stomach. The diagnosis of the thread worm is made by inspection of the anal region and by the finding of the oxyuris. With regard to prophylaxis extreme cleanliness is of the greatest importance. Fruits should be thoroughly cleaned and then peeled before they are eaten. The eating uten- sils of a person infected with oxyuris should never be used by another, unless they have been thoroughly disinfected. The same applies to the clothes. Sleeping with an infected person should be forbidden, and even touching his hands FIG. 59. Development of Oxyuris Vermieularls. (Heller.) a-e. Segmentation of the yolk; /, ovum containing tadpole-shaped embryo, seen from the side; 0, abdominal view of the same ; 7i, ovum with worm-shaped embryo; i, embryo escaping from the shell ; 7f, free embryo capable of motion. requires immediate washing, as otherwise infection may take place. Treatment. Santonin is the principal remedy for com- bating oxyuriasis. It is given in the same way as de- 372 DISEASES OF THE INTESTINES. scribed in the treatment of ascaris lumbricoides. Here, however, irrigations of the bowel with water and the addi- tion of a few drops of benzene or thymol or vinegar (three to four tablespoonsful to a quart), or of sapo medicatus in a one-half to one-per-cent solution may be advantageously used. The anal region should be thoroughly cleansed. If the pruritus ani is quite intense, application to the anal region and rectum of unguentum hydrarg. cinerei or the use of a suppository of ung. hydrarg. cinerei 1 gm., in cacao butter 2 gm. will afford relief. Anchylostoma Duodenale. Dochmius Duodenalis or Stron- gylus Duodenal^. This important parasite was first de- scribed by Dubini ' in 1838. Bilharz a and Griesinger 3 recognized this parasite as the cause of the Egyptian chlorosis. Some time afterward the anchylostoma was observed in severe cases of anaemia among workmen in tunnels and brickmakers. The anchylostoma duodenale is cylindrical in shape, 0.5 to 1 mm. thick and 6 to 18 mm. long. It is yellowish or grayish-white in color, with translucent edges. The male is much shorter than the female. The cephalic end is curved toward the dorsal surface and is provided with an oral capsule at the margin of which there are six hooklike teeth. Further within the capsule there are three sharp chitinous processes (Figs. 60 and 61). The male is more slender and transparent than the female. Its head end is bent backward. The tail end appears somewhat swollen, containing the bursa copulatrix, and is much more curved than the head. In the female the caudal end is pointed and armed with an awl-like prong; the genital opening 1 Angelo Dubini: Gaz. med. Lombard., 1843. 2 Bilharz : Wiener med. Wochensehr. , 1856. 3 Griesinger: Arch. f. physiolog. Ileilkunde, 1854. AXCHYLOSTOMA DUODENALE. FIG. 61. Cephalic End of Anchylostoma Duo- denale. (Schultheiss.) a. Mouth-capsule ; b, teeth of ventral border ; c, teeth of dorsal border; d, buccal cavity: e, skin-sac on ventral side of head ; /, muscular layer ; g, dorsal groove ; /i, oesophagus. FIG. 62. Eggs of Anchylostoma Duodenale. (Perroncito and Schulthelss.) a, b, c, d, Different stages of cleavage : c, f, eggs with embryos. Magnified 200 diameters. FIG. 60. Male of Anchylostoma Duodenale. (Schulthelss.) a. Head with mouth-cap- sule ; b, oesophagus ; r, intestine ; d, anal glands ; e, cervical glands ; /, skin ; g, muscular layer ; h, porus excretorius : i. triple bursa : A', ribs of the bursa ; ?, testicu- lar canal; m, vesicula seminalis; i, ductus ejaculatorius ; o, groove of latter : p, penis ; q, sheath of penis. Magnified 30 diameters. 374 DISEASES OF THE INTESTINES. lies behind the centre of the body. The eggs are oval, 0.06 mm. in length and 0.03 mm. in width (Fig. 62). The habitat of the anchylostoma is the duodenum, the jejunum, and the upper part of the ileum. Here the worm attaches itself to the intestinal mucosa and feeds by suck- ing the blood of his host. According to Leichtensteru, ' active migration of the worm begins at the time of the first copulation in the fifth week. Young worms change their place quite frequently and hence give rise to repeated hem- orrhages. Colic, and acute anaemia are encountered at an early period after infection. Under favorable conditions the eggs develop outside of the body into rhabditis-like larvae, becoming enclosed in a protecting envelope or encysted. In this stage the larvae may be carried along with the dust and contaminate fruit and water. On reaching the small intestine they develop into mature worms. This parasite is always encountered in great numbers if present in the intestines. Leichten- stern never found them in a smaller number than one hundred, but sometimes their total reached three thou- sand. The symptoms produced by anchylostoma consist of gas- tralgia, nausea, occasionally vomiting, constipation, rarely diarrhoea, and severe anaemia, the latter becoming progres- sively worse. The patient with anchylostoma does not greatly emaciate, but becomes pale, extremely weak, and suffers from dizziness and shortness of breath after the slightest exertion. His extremities are cold, slight hemor- rhages occur frequently, and oedema of the ankles devel- ops. A systolic murmur may be heard at the apex of the heart, the pulse is accelerated, and fever may be present 1 Leichtenstern : Centralbl. f . kliu. Medicin, 1885, and Deutsche med. Wochenschr., 1885, 1886, 1887. ANCHYLOSTOMA DUODENALE. 375 toward evening. An inclination to eat earth (geophagia) is not rarely observed. The dejecta are of a brownish color, although admixture of blood cannot ' be recognized macroscopically. Micro- scopically Charcot-Ley den's crystals, as well as the eggs of the parasites, are often found in the stools. The urine rarely contains albumin, but frequently indican. The con- dition of the blood resembles that found in pernicious amemia : enormous decrease of the red blood corpuscles, poikilocytosis, nucleated red blood corpuscles, and a slight increase of the leukocytes, especially of the eosinophile cells. Anatomically the mucosa of the small intestine is found greatly congested and ecchymoses are visible here and there. Peyer's patches and the solitary follicles are often swollen. The heart is found hypertrophied and dilated, the liver and spleen may be diminished in size, normal, or in an amyloid condition. The same can be said of the kidneys. There is no doubt that the principal deleterious action of the anchylostoma consists in the profuse loss of blood caused by the parasites. Whether some toxic sub- stances generated by them participate in producing the grave symptoms is questionable. The course of the disease is protracted and its severity depends greatly upon the number of parasites present. If the latter is great, the disease may progress quickly and the patient succumb with the symptoms of general dropsy, dj'spnoea, and heart failure or pulmonary oedema. If the number of the parasites is small, the patient may live many years and ultimately recover entirely. Recovery is also possible by successful expulsion of the parasites from the intestinal tract. The diagnosis of auchylostomiasis is made by the pres- 376 DISEASES OF THE INTESTINES. ence of the symptoms of anaemia in conjunction with the discovery of the anchylostoma eggs in the dejecta. With regard to prophylaxis the above given rules for the prevention of the round- and thread-worms are also applicable here. Extreme cleanliness of the body and of the food is of greatest importance. The treatment consists in the ad- ministration of extract of male-fern, which should be employed in the same manner as described above for the tapeworm disease. Anguillula Stercoralis. This nema- tode is 0.8 to 1.2 mm. long, the male shorter than the female (Fig. 63;. The male is indigenous in Cochin China and Italy. In the latter coun- try it often occurs simultaneously with anchylostoma. If the worms exist in large numbers they may produce patho- logical conditions. According to Golgi and Monti, 1 the anguillula stercoralis penetrates into Lieberkuehn's crypts and there deposits its eggs and young. Anguillula intent inalw, which is 2.25 mm. long, belongs to the same variety as anguillula stercoralis and is found under the same conditions. Only the female of this worm is known. The eggs develop in the intestinal canal and exhibit only the first stages of segmentation at the time of their passage with the faeces. 1 Golgi e Monti: Arch, per le science rued., 1886, No. 3. FIG. 63. Female of An- guillula Stercoralis, wit li Egfre and Embryos. (Perronclto.) Magni- fied 85 diameters. TRICHOCEPHALUS DISPAR. 377 TricJiocephalns Disbar. IFJiip-Worm. This parasite is quite common, but comparatively harmless. Its habitat is the caecum and the neighboring section of the intestine. It lives upon blood which it abstracts from the intestinal mucosa. This parasite is 4-5 cm. long, the male being smaller than the female. The head end, which is about three-fifths of the entire length, is drawn out into a fine thread; the tail end is not so thin, being up to 1 mm. in thickness (Fig. 64). The male has a spiral body from the end of which the spicule projects. The body of the fe- male is straight and terminates in a blunt extremity. The FIG. 64. Trtchocephalus Dispar. (Heller.) o, FIG. 65. Ova of Trichocephalus Female . b, male. Natural size. Dispar In Process of Develop- ment. CHuber.) ova are almost lemon-shaped, dark brown in color, 0.05 mm. in diameter (Fig. 65). The number of eggs in a sin- gle female was estimated by Leuckart at 58,000. They are hatched out very slowly. Leuckart asserts that the dispersion of the eggs and con- sequent spread of infection may readily occur through wind, rain, or dust, and that the eggs may be ingested with fruit and salads. The number of these worms found in one patient is usually small, from six to twenty. The symptoms are but very slight, occasionally diarrhoea exists, sometimes there are some reflex nervous conditions. The diagnosis can usually be easily made from the shape of the ova. The passage of the living worms in the stools occurs but rarely. 378 DISEASES OP THE INTESTINES. PLATE I. TRICHINA SPIRALIS (Huber). TRICHINA SPIRALIS. 379 With regard to treatment Lufcz recommends the admin- istration of thymol; Mosler ' and Peiper 2 employ rectal irrigation of water, to which a few drops of benzene have been added. Extract of male-fern may also be used inter- nally. Trichina Spiralis. The trichina spiralis was discovered by Paget, 3 but its pathological importance was first recog- nized *by Zenker. 4 This .parasite is observed in two forms, the trichina of the intestine and the trichina of the muscles (see Plate I.). The trichina reaches the stomach through the ingestion of pork containing encapsulated trichinae. In the stomach the capsule opens about three to four hours after the inges- 1 Mosler: " Darminf usion. " Real- Encyclopadie der gesammten Heil- kunde, Bd. v. 2 Peiper : " Helminthen. " Real -Encyclopadie der gesammten Heil- kumU-, Bd. ix. 3 Paget, cited after Huber : " Twentieth Century Practice of Medi- cine, " vol. viii., p. 608. 4 Zenker: Deutsches Arch, fur klin. Medicin, i., 1866. EXPLANATION OF PLATE I. FIG. 1. Muscle Trichina Enclosed in a Fully Developed Cyst. X 240. Cy, cyst; Bg, connective-tissue envelope ; Ffc, fat globules. FIG. 2. The Same Removed from the Cyst. X 400. Oe, (Esophagus ; Zk, cell bodies ; I/, side lines : Or, ovary : Ch.D, chyle duct. FIG. 3. Part of the Ovary. X 600. Is readily distinguished from the testicle by the varying size of the germ cells. FIG. 4. Male Intestinal Trichina. X 100. T, Testicle ; d ej, ejaculatory duct ; Zk, cell bodies. FIG. 5. Female Intestinal Trichina. X 90. Ov, ovary ; E, embryos ; Oe, genital opening from which the embryos escape. FIG. B. Free Embryo. X 400. O, mouth ; A, anus. FIG. 7. Embryo About Three Days After Having Entered the Muscle Fibre. MF, normal muscle fibre. FIG. 8. Muscle Trichina, About Six Days Old, in the Greatly Swollen Sarcolemma Sheath Traversed by Capillary Vessels, Cap. FIG. 9.-Muscle Trichina, Four Weeks old. Enclosed in a Capsule, Cj/vl, within the sarcolemma sheath. Sfr ; Bk, connective-tissue capsule in process of active growth ; fc, nuclei ; 3/F. contents of the sarcolemma sheath at each pole of the capsule. FIG. 10. Muscle Trichina with Calcilied Capsule. F/c, Fat globules. 380 DISEASES OF THE INTESTINES. tion of the meat and the embryos rapidly develop. At the end of thirty to forty hours fructification of the young par- asites takes place. The intestinal trichinae are visible with the naked eye, the females being 3 to 4 mm. long and the males half this size. The caudal extremity is thicker than the head end. Five days after fecundation the females give birth to living young ones. The young brood wanders directly frdm the intestine of the host into his muscles. Here they further develop. In this condition they give rise to a febrile dis- ease accompanied by severe muscular symptoms which may lead to death. Sometimes the trichinae become en- capsulated. The symptoms vary according to the number of worms which have been ingested. Gastro-intestinal dis- turbances usually appear on the second or third day after the ingestion of the contaminated meat. Vomiting, diar- rhoea, colic often appear. The disease known as trichinosis, which depends upon the further development of the young embryos in the mus- cles of the host, is not within the scope of this book, and we refer to this parasite only as far as its occurrence in the intestines is concerned. With regard to prophylaxis pork should never be eaten raw. The treatment after the iugestion of trichinous meat consists in the employment of lavage of the stomach, if the physician is called early enough after the meal. In addition a vermifuge and cathartic rem- edy should be given immediately. INDEX. ABELMANN, 22 Absorption as a function of the bowel, 24 Acholic stool, 58 Adenoma of the intestines, 167 .Kirineta, Paulus, 335 Albumin in the faeces, 53 Albuminates, putrefaction of, in the large intestine, 21 Alimentation, rectal, 77 subcutaneous, 77 Allingham, 37, 172, 185, 188 Allingham's rectal speculum, 37 Amceba, 349 Amoebic dysentery, 110 Amyloid ulcers, 140 Anacker, 311 Anaesthesia of the intestine, 333 of the rectum, 333 treatment, 334 Anatomy of the intestine, 1 Anchylostoma duodenale, 372 course, 375 diagnosis, 375 prophylaxis, 376 symptoms, 374 treatment. :??<> Angioma of the intestines, 167 Anguillula intcstinalis, 376 stercoralis, 376 Antiperistalsis of the intestine, 30 Anus, anatomy of the, 16 fissure of the, 193 Appendicitis, 196 Appendicitis, definition, 196 diagnosis, 214 differential diagnosis, 215 etiology, 197 general remarks, 196 morbid anatomy, 202 prognosis, 216 symptomatology, 206 synonyms, 196 treatment, 218 catarrhal, 202 indications for operation, 226 perforativa, 204 severe form, 204 ulcerosa et gangraenosa, 204 Appendicular inflammation, 196 Appendix vermiformis, 13 Areta3us, 110 Ascariasis, diagnosis, 367 prophylaxis. 368 symptoms, 367 treatment, 368 Ascaris lumbrieoides, 365 ' mystax, 369 Atony of the bowel, 291 Auscultation, 45 Awl-tail, 369 BALANTIIHI M coli, 351 Bambcrger, 200 Barbacci, 200 Barthelemy, 114 Bnseh. 55 Bauhln's valve, 13 Bavle. 141 382 INDEX. Beauchef, 111 Beck, Carl, 198, 222 Benign tumors of the intestines, 167 Bernard, Claude, 19 Bienstock, 74 Bile pigment in the faeces, 57 Bilharz, 372 Bilharzia haematobia, 364 Biliary acids in the faeces, 57 BSrch-Hirschfeld, 144 Blood in the faeces, 56 Boas, J., 42, 48, 90, 212, 214, 219, 220, 221, 224, 339 Bftnnecken, 248 Borborygmi, 45 Bothriocephalus cordatus, 359 latus, 357 Bouchard, 99, 298 Boudet, 81, 263, 309 Bougies, rectal, 43 Bowel, atony of the, 291 Brahm-Houkgeest, 28, 283 Brinton, 254 Brooks, LeRoy J., 267 Brunner's glands, 9 Brunton, 324 Bryant, J. D., 13, 151 Bull, W. T., 197, 223 Bunge, 59 M, anatomy of the, 12 Calm, 261 Cancer of the duodenum, symp- toms, 159 of the intestine, 150 course, 163 definition, 150 diagnosis, 163 etiology, 150 location, 151 morbid anatomy, 152 prognosis, 164 symptomatology, 154 treatment, 164 Cancer of the large bowel, syhip- toms, 160 of the rectum, symptoms, 161 of the small intestines, symp- toms, 160 Carbohydrates in the faeces, 54 Carbolic-acid injections in hemor- rhoids, 186 Cash, 324 Catarrh, acute intestinal, 83 chronic, of the bowels, 94 Cauterization in hemorrhoids, 186 Celsus, 110 Cercomonas intestiualis, 350 Cestodes, 351 Charcot, 286 Chlapowski, 40 Cholera nostras, 83 Clapotage, 42 Clark, Alonzo, 220, 302 Colic, intestinal, 326 mucous, 335 Colitis, acute, 90 Colon, anatomy of the, 11 ascending, 14 descending, 15 transverse, 14 Compression of the intestine, 227 Concretfons in the faeces, 59 Constipation, 291 definition, 291 dependent upon other dis- eases, 296 diagnosis, 302 etiology, 292 habitual, 291 prognosis, 304 prophylaxis, 304 symptomatology 297, synonyms. 291 treatment, 304 dietetic. 30.") mechanical, 306 moral, 305 Cooper, 187 INDEX 383 Cooper-Forster, 155 Cornil, 342 Councilman, 113, 115, 118 Crude, 279 Crushing in the treatment of hemorrhoids, 188 Cruveilhier, 171, 337 Curschmann, 258, 264 Cysts of the intestines, 167 DA COSTA, 337, 338, 344 Damsch, 46 Dastre, 19 Dravcr, 222 Demant, 282 Delafield, F. , 101 Diarrho?a, 284 acute, 83 diagnosis, 289 dyspeptic, 287 etiology, 284, 288 membranous, 335 morning, 101 nervous, 284 prognosis, 289 stercoral, 288 symptomatology, 284, 288 treatment, 289 tubular, 335 Diet, 74 Dilatation of the sphincters in the treatment of hemorrhoids, 185 Distoma ha?matobium, 364 hepaticum, 362 lanceolatum, 363 Dochmius duodeualis, 372 Douglas' fold, 15 Doumer, 309 Dubini, 372 Duuin, 294 Duodenal ulcer. 128 course, 133 definition, 128 diagnosis, 133 etiology, 128 Duodenal ulcer, morbid anatomy, 129 prognosis, 134 symptomatology, 131 synonyms, 128 treatment, 134 Duodenitis, acute, 89 Duodenum, anatomy of the, 1 Dutrouleau, 121 Dynamic ileus, 257 Dysentery, 110 amoebic, 110 complications, 123 course, 123 definition, 110 diagnosis, 125 etiology, 110 morbid anatomy, 115 prognosis, 125 symptomatology, 119 synonyms, 110 treatment, 125 Dyspeptic diarrhoea, 287 EDEBOHLS, 198, 207, 208 Edwards, 338 Ehrlich, 338, 342 Ehrmann, 31 Eichberg, 113 Eichhorst, 131 Eisenlohr, 139 Electricity in intestinal obstruc- tion, 263 in the treatment of constipa- tion, 308 in the treatment of disease, 81 Elsberg, C. A., 70 Embolic ulcers, 135 Embolus of the arteria mesaraica superior, 136 of the inferior mesaraic artery, 139 Endo-appendicitis, 203 Enemata in the treatment of con- stipation, 310 384 INDEX. Enteralgia, 326 definition, 326 diagnosis, 329 etiology, 326 prognosis, 330 symptomatology, 327 synonyms, 326 treatment, 330 Enteritis, acute, 83 chronic, 94 crouposa, 110 membranous, 335 necrotica, 110 Enterospasmus, 295 Erdmann, John F., 267 Escherich, 73, 200 Esmarch, 189 Ewald, C. A.. 62, 96, 131, 219, 220, 224, 339, 340 Examination, methods of, 32 Extirpation of hemorrhoids, 189 FAECES, abnormal admixtures in the, 51 albumin in the, 53 bile pigment in the, 57 biliary acids in the, 57 blood in the, 56 carbohydrates in the, 54 chemical examination of the, 52 concretions in the, 59 examination of the, 49 fat in the, 55 ferments in the, 59 fragments of tumor in the, 51 micro-organisms in the, 71 microscopical examination of the. 62 mucin in the, 53 odor, 50 peptone in the, 54 propeptone in the, 54 pus in the, 51 reaction of the, 52 Freces, remnants of food in the, 51 Fat in the faeces, 55 Fecal accumulation as a cause of chronic obstruction, 273 fever, 302 tumors complicating constipa- tion, 300 Ferguson, E. D , 233, 267 Fermentation test, Schmidt's, 55 Ferments in the faeces, 59 of the pancreas, 19 Fever, fecal, 302 Fibroma of the intestines, 167 Finger cot, 42 Fischel, 286 Fischl, 89 Fissure of the anus, 193 Fitz, Reginald, 114, 197, 222, 258 Flatau, 312 Flatulency, 321 Fleiner, 79, 262, 311, 346 Fleischer, 59, 214, 282 Fluke worms, 362 Foreign bodies, obturation by, 234 Fowler, 197, 199, 200, 202, 214, 222 Frentzel, 265 Firrichs, 141 Frirdcinvald, J., 43 Fi'irl tringer, 265 GALL stones, obturation by, 233 Galvano-cautery in the treatment of hemorrhoids, 188 Gerhardt, 137 (Jerry. 114 (Jrrsuny. 41 Gibson, C. L., 266 Glycerin injections in the treat- ment of constipation, 311 Golgi. :;:'> Good, Mason, 336 Goulry. J. W., 267 Graser, 189, 259, 264, 265 Grasse, 367 Graves, vi-jn INDEX. 385 Grawitz, 139 Grit-singer, 372 Grisolle, 196, 197, 220 Guttmann, P., 204 G} r mnastic exercises in the treat ment of constipation, 308 exercises in the treatment of disease, 80 HABEKSHON, 79, 300 Habitual constipation, 291 Hackel, 309 Haguenot, 241 Hall, Marshall. 87 Hammarsten, 26 Harris, 113, 114, 116, 127 Haustra coli, 12 Hawkes, F., 223 Hegar, 139 Hemorrhoids, 169 complications, 189 definition, 169 diagnosis, 179 etiology, 169 morbid anatomy, 171 prognosis, 180 symptomatology, 174 % synonyms, 169 treatment, 180 radical, 185 Heurot, 314 Heryng, 39 Heusgeu, 155 Hippocrates, 110 Hirschler, 2 '2 Hlava, 113 Hodenpyl, 200 Hoffmann, 265 Houston. 186 Hoyer, 338 Huber, 356, 366, 370 Hydrocephaloid, acute, 87 Hydrotherapy, 80 in the treatment of constipa- tion, 309 25 Hypersesthesia of the intestine, 333 Hypogastric neuralgia, 332 treatment, 332 II.EO-C.ECAL valve, 13 Ileum, anatomy of the, 4 Ileus, 227 dynamic, 257 Illoway, 307 Incarceration, acute, 255 Inflation of the bowel with air in intestinal obstruction, 262 of the intestine, 45 Infusoria, 350 Injection of water per anum for examination, 48 Injections as a method of treat- ment, 78 in the treatment of constipa- tion, 310 Inspection, 34 Interrogation, 32 Intestinal catarrh, acute, 83 definition, 83 diagnosis, 91 duration, 90 etiology, 83 localization, 89 morbid anatomy, 85 prognosis, 91 symptomatology, 86 synonyms, 83 treatment, 91 catarrh, chronic, 94 course, 103 definition, 94 diagnosis, 103 etiology, 94 morbid anatomy, 95 symptomatology, 98 synonyms, 94 treatment, 105 colic, 326 neurasthenia, 347 diagnosis, 348 386 INDEX. Intestinal neurasthenia, treatment, 848 obstruction, 2'J6 obstruction, acute, 226 course, 247 definition, 227 diagnosis, 249 ctii logy, 227 location of the obstruc tiou, 251 objective signs, 245 pathological changes, 236 recognition, 249 recognition of the differ- ent forms, 255 symptomatology, 238 synonyms, 227 treatment, 258 treatment, medical, 258 treatment, surgical, 266 obstruction, chronic. 268 complications, 276 course, 277 diagnosis, 277 etiology, 268 prognosis, 277 symptomatology, 269 treatment, 278 treatment, surgical, 280 parasites, 349 vertigo, 301 Intestine, anatomy of the, 1 anaesthesia of the, 3:5:5 compression of the, 227 hypersrsthesia of the, 333 obturation of the. 233, 25H parsesthesia of the, 333 strangulation of the, 228 Intestines, motor neuroses of the, 284 neoplasms of the, 150 nervous affections of the, 282 classification. 283 paralysis of the. 314 diagnosis. 315 Intestines, paralysis of the-, treat- ment, 315 peristaltic restlessness of the, 319 secretory neuroses of the, 335 sensory neuroses of the, 326 ulcers of* the, 128 Intussusception, 234, 256 agonal, 23r> Irrigator, Kemp's rectal, 79 JAFFE, 253 v. Jaksch, 54 Jejuuitis, acute, 89 Jejunum, anatomy of the, 4 Jill-gens. 97 KAIIX, Arthur, 308 Kartulis, 112, 113 Kelly, 37 Kelly's rectal speculum, 38 Keteey, 186 Kemp's rectal irrigator, 79 Kerkring's valves, 8 Kittagawa, 339 Kli-bs. 144 Klerrfperer, 310. 311 Klubbe, 262 Koch. 112 Koclier, 264 Koenig, 269 Korte. 265 Kossnhudskj, 184 Knius. 12!) Kuhn. 44 Kundnit. !<><> Kussmaul. 137, 261. 262, 309, 811. 846 Latleur. 113, 115. US Lambl, 112 Lange, F., 186. 192 LaiiL'enhcck. 1HN INDEX. 387 Large bowel, physiology of the, 18 structure of the, 17 intestine, anatomy of the, 11 Lavage of the bowel, 48 in intestinal obstruction, 262 of the stomach" iu intestinal obstruction, 201 Laveran, 124 Legueu, F., 222 Leichtenstern, 67, 226, 228, 295, 367, 5M5M. 370, 874 Lemazurier, 800 Lenancler, 197 Leube, 77, 134, 301 Leubuscher, 309 Leuckart, 356, 367, 377 Levi, 300 v. Leyden, 214, 338, 342 Lieberkiihn's glands, 9 Ligature in hemorrhoids, 187 Limbourg, 22 Lindberger, 22 Lipoma of the intestines, 167 Litten, 136 Liver fluke, 362 Loesch, 112 Ludwig, 25 Lusk, 19, 26 Lutz, 367, 370, 379 Lympho-sarcoma of the intestines, 'l66 MACFADYEN, 20, 72 Madelung, 167 Malmsten, 851 , Marcy, H. O., 267 Matterstock. 201 Maggot-worm, 369 Mannaberg, 73 Massage in intestinal obstruction, 263 in the treatment of const ipa- Hon. 8d(i Massage in the treatment of dis- ease, 80 Massaiutin, 118 Massloff , 282 Mathews. 90 Mayer. 128 Mayor, A., 90 McBurney, 41, 197. 223 McCosh, A. J., 223 Meckel's diverticulum, strangula- tion by, 230 Membranous diarrhoea, 835 enteritis, 835 definition, 385 diagnosis, 343 etiology, 339 history, 335 symptomatology, 841 synonyms. 335 treatment, 844 Mendelson, Walter, 339 Mercury, metallic, in intestinal obstruction, 265 Meteorism, 821 diagnosis. 323 etiology, 821 prognosis, 823 symptomatology, 322 treatment, 323 Meydl, 151 Meyer, Willy, 223, 224 Micro-organisms in the fa?ces, 71 Miller. 22 Minich, (il Minkowski, 28, 47 Miserere, 227 Monti, 376 Moreau, 282 Morgagni, 336 Morris, R. T., 208, 222 Mosler, 379 Motion of the intestine, 28 Mucin iu the faeces, 53 Mucous colic, 335 Miiller. Max. 152 388 INDEX. Munk, 25, 27 Murphy, 222, 280 Murphy's button, obturation by, 234 Musser, 113 Myoma of the intestines, 167 NASSE, 113 Nematodes, 365 Nencki, 19, 20, 72 Neoplasms of the intestines, 150 Nervous affections of the intes- tines, 282 diarrhoea, 284 Neuralgia, hypogastric, 332 mesenterica, 326 Neurasthenia, intestinal, 347 Neuroses of the intestines, motor, 284 secretory, 335 sensory, 325 v. Noorden, C., 56, 344, 345 Nothnagel, 28, 30, 74, 138, 150, 166, 197, 202, 214, 217, 220, 224, 235, 269, 283, 285, 294, 302, 338, 342 Nuttal, 72 OBSTIPATIO, 291 Obstruction, intestinal, 226 Obturation of the intestine, 233, 256 Oil injections in the treatment of Constipation, 311 Opium in intestinal obstruction, 259 Oppolzer, 330 Osier, 113 Oxyuris vermicularis, 369 diagnosis, 371 prophylaxis, 371 symptomatology, 370 treatment, 371 PAGET, :'>7'.t Palpation, 40 Pancreatic juice, digestive power of, 19 Paraesthesia of the intestine, 333 Paralysis of the intestines, 314 of the sphincters of the anus, 317 diagnosis, 318 prognosis, 318 treatment, 318 Parama'cium coli, 351 Parasites, intestinal, 349 Paratyphlitis, 196 Parenski, 135 Paresis of the sphincters of the anus, 317 Pariser, 53, 339, 342 Passio iliaca, 227 Pean, 280 Peiper, 379 Penzoldt, 214, 219, 220/224 Peptone in the faeces, 54 Percussion, 44 Peristalsis of the intestine, 28 Peristaltic restlessness of the in- testines, 319 definition, 319 diagnosis, 320 etiology, 319 symptomatology, 319 treatment, :!',>< Perityphlitis, 196 Petriquin, 220 Pettenkofer, 57 Peyer, 285 Peyer's patches, 11 Phlebectasia hemorrlioidalis. 169 Pighead, 357 Piles, 169 arterial, 172 capillary, 172 venous, !?:{ Pilliet, 139 Pin-worm, 369 INDEX. 389 Plica Oouglasii, 15 Poclchcn, 145 Polypi of tin- intestines, 167 Pooley, 186 Proctitis, 90 Proctoscopy, 37 Proctospasmus, 316 diagnosis, 317 treatment, 317 Prolapse of the rectum, 189 Propeptone in the faeces, 54 Proto/oa, 349 Puncture of the bowel in intestinal obstruction, 264 Purgatives in the treatment of constipation, 312 Putrefaction of albuminates in the large intestine, 21 Qt IN( KK. 50, 113, 282 RACHKOKU, 19 Rectal alimentation, 77 bougies, 43 electrode, 81 specula, 37 Rectum, aiitL-sthesia of the, 333 anatomy of the, 15 prolapse of the, 189 Reichmann, 39 Ribbert. 198 Riedel, 202, 224 Riedeiy 66 Roentgen rays in examination of the bowel, 39 Romberg, 332 Rose. A., 2i:5, 307 Kosenbach, 46, 247 Roscnheim, 102, 167, 308, 315, 319. :3. 347 Roscnsicin, 25, 27 Ross, 113 Rothmann, 338 Rotter, 197 Round-worms, 365 Roux, 186, 197 Rubner, 27 Ruedi, 297 Runeberg, 46 Rushmore, J. D., 267 SAHLI, 197, 217, 220, 307, 324 Salmon, 187 Salvioli. 25 Sands, 197 Sarcoma of the intestines, 166 Sasaki, 97 Schiff, 28 Schmidt, 54, 58 Schmidt's fermentation test, 55 Schmidt-Miihlheim, 25 Schmitz, 22 Schnetter, 46 Schoening, 150 Schuberg, 113 Scolecoiditis, 196 Seat-worm, 369 Secretory function of the intes- tines, 18 neuroses of the intestines, 335 Senator, 302 Semi. 263 Sennertius, 336 Sieber, 20, 72 * Sigmoid flexure of the colon, 15 Simon. 43 Sims. 37 Sims' rectal speculum, 37 Si i vi Icy, F., 336, 344 Small intestine, anatomy of the, 4 structure of the, 6 Sodiv, Ill, 116, 126 Solitary follicles of the intestines, 10 Sonnenburg, 197, 214, 224 Spasm of the rectum, 316 Spasmodic contraction of the bowel. OJ)5 Specula, rectal, 37 Spool-worm, 365 390 INDEX. Sporozoa, 350 S romanum, 15 Starke, 129 Stein, R, 234 Stengel, 113 Stercoral diarrhoea, 288 Stewart, 267 Stockton, 113 Stokes, 220 Stool, acholic, 58 Strangulation of the intestine, 228 Stricture of the rectum as a cause of chronic obstruction, 275 Strongylus duodenalis, 372 Subcutaneous alimentation, 77 Sutton, E. M., 47 Syms, Parker, 267 Syphilitic ulcers, 144 T.ENIA cucumerina, 358 diminuta, 359 flavopunctata, 359 lata, 357 mediocauellata, 355 nana, 358 saginata, 355 solium, 354 Taenise of the large intestine, 12 Talamon, 197 Tapeworms, 351 prophylaxis, 359 treatment, 359 Tavel, 200 Thermocautery in the treatment of hemorrhoids, 188 Thierfelder, 72 Thread-worm, 369 Thrombotic ulcers, 135 Thrombus of the mesenteric veins, 139 Toxic ulcers, 145 Transilluminatiou of the bowel, 39 Trastour, 262 Treatment, methods of, 74 Trematodes, 362 Trematodes, treatment, 365 Treves, 192, 214, 236, 240. 259. 262, 264, 266, 268, 270, 271, 281 Trichina spiralis, 379 symptoms, 380 Trichinosis, 380 prophylaxis, 380 treatment, 380 Trichocephalus dispar, 377 diagnosis, 377 symptoms, 377 treatment, 379 Trichomonas intestinalis, 350 Trousseau, 284 Tuberculous ulcers, 141 Tubular diarrhoea, 335 Tympanites, 321 ULCER, duodenal, 128 Ulcers, amyloid, 140 embolic, 135 of the intestines, 128 syphilitic, 144 thrombotic, 135 toxic, 145 tuberculous, 141 Urobilin in the fteces, 57 VALVE, ileo-ctecal, 13 of Bauhin, 13 Valvulse conniventes Kcrkringi, 8 Van Cott, 199, 201 Vennes, 351 Vermiform appendix, 13 Verneuil, 185 Vertigo, intestinal, 301 Virclunv, 140 Voit, 19, 24, 2 Volkmann, 162 Volvulus, 232, 255 Volz, 201, 220 WALLACE' 319 Weber, L.. His Wr inert, 338 INDEX. 391 197 Woodward, *3, 96, 269, 292, Wertheimer, 330 336 Whfp-worm. 377 Worms, intestinal, 351 Whin-head, 189, 336, 344 Wiiririn, Fred. H., 267 ZENKER, 379 Willigk, 129 Ziemssen, 45, 263, 264 Wilson, 200 Zuckerkandl, 198 Wolf, H. J., 224 Zunker, 350 WI liOO E35d 1900 Eihorn, Max x Diseases of the intestines. MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 A 000 421 703